The Art of a good Injection”

Report
“The Art of the Injection”
By Jon C. Brillhart PA-C
Daivd Lannik MD
Portsmouth Orthopedics, Inc
Joint Injection Challenge
The art of good injection therapy is to
place the appropriate amount of the
appropriate medication into the exact
site of the affected tissue.
“The right medicine”,
“in the right quantity”,
“given in the right stop”,
“at the right time”.
Quoted from David Lannik MD, 2005.
Rational for injections


Diagnostic
1.) Joint Aspiration (confirm nature fluid)
2.) Provide symptom relief of affected body
part.
Therapeutic
1.) Increase mobility and decrease pain.
Indications for Diagnostic
and Therapeutic Injections
Soft Tissue conditions
 Bursitis
 Tendonitis or tendinosis
 Trigger points
 Ganglion cysts
 Neuromas
 Entrapment syndromes
 Fasciitis
Indications for Diagnostic
and Therapeutic Injections
Joint Conditions
 Effusion of unknown origin or
suspected infection.
 Crystalloid arthropathies
 Synovitis
 Inflammatory arthritis
 Advanced osteoarthritis
Absolute and Relative
Contraindications to Therapeutic
Joint and Soft Tissue Injections
Absolute contraindications
 Local cellulitis
 Septic arthritis
 Acute fracture
 Bacteremia
 Joint prosthesis
 Achilles or patella teninopathies
 History of allergy or anaphylaxis to injectable
constituents
Absolute and Relative Contraindications
to Therapeutic Joint and Soft Tissue
Injections
Relative contraindications
 Minimal relief after two previous injections
 Underlying coagulopathy
 Anticoagulation therapy
(avoid soft tissue injection)
 Evidence of surrounding joint osteoporosis
 Anatomically inaccessible joints
 Uncontrolled diabetes mellitus
Top Six Injections
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Chronic subdeltoid bursitis
Shoulder capsulitis
Knee osteoarthritis
Tennis elbow
Trapezio metacarpel joint OA
Plantar fasciitis
General guidelines

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Check patient’s allergies
Don’t forget “the patient” (discuss the
procedure in patient friendly terms, side
effects, what to expect, etc).
Obtain informed consent! (verbal vs written)
Place patient in comfortable position that
allows easy access to area injected.
Take time to identify structure being
injected by locating pertinent anatomical
landmarks.
Be empathetic, and reassure patient.
Document, Document, Document!!!
Equipment

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
Safety (oxygen, anaphylaxis kit,
crash cart, msds)
Appropriate needles and syringes
Medication with “in date” expirations!
Skin preparation
The skin should be prepared with
providone-iodine or similar antiseptic
solution. (Alcohol)
The risk of infection with use of alcohol
skin preparation alone is reportedly
estimated at 1 in 10,000.
Corticosteroids
Synthetic analogues of the adrenal
glucocorticocoid hormone “cortisol”
(hydrocortisone) with is secreted by
the innermost layer (zona reticularis)
of the adrenal cortex.
*Suppress inflammation (RA, PA, Gout).
*Suppress inflammatory flares
(OA/DJD).
Corticosteroid Agents by Relative Potencies, Duration, and Dose
Agent
Potency
Duration
Dose/Site
Hydrocortisone acetate
Low
Short
10 to 25 mg
for
soft tissue
and
small joints
50 mg large
joints
Intermediate
Intermediate
2 to 10 mg
for
soft tissue
and
small joints
10 to 80 mg
for
large joints
High
Long
0.5 to 3 mg
for
soft tissue
and small
joints
2 to 4 mg
large joints
High
Long
1 to 3 mg for
soft tissue
and small
joints
2 to 6 mg
large joints
(Hydrocortone)
Methylprednisolone
(Depo Medrol)
Triamcinolone
(Aristocort)
Dexamethasone sodium
(Decadron)
Betametasone sodium
phosphate and acetate
(Celestone Soluspan)
Recommended maximum
dosages and volumes for joint
injections
Site
Shoulder
Elbow
Wrist, Thumb
Fingers
Hip
Knee
Ankle, foot
Toes
Dosage
30 mg
20 mg
10 mg
5 mg
40 mg
40 mg
20 mg
10 mg
Volume
10 ml
5 ml
2 ml
1 ml
5 ml
10 ml
5 ml
1ml
Side-effects of steroid
injection therapy
Systemic side-effects
 Facial flushing
 Menstrual irregularity
 Impaired diabetic control
 Emotional upset
 Hypothalmic – pituitary axis
suppression
 Fall in ESR/CRP
 Anaphylaxis
Local side-effects
 Post injection flare of pain
 Skin depigmentation
 Subcutaneous atrophy
 Bleeding / bruising
 Steroid “chalk”
 Soft-tissue calcification
 Steroid arthropathy
 Tendon rupture or atrophy
 Joint / soft-tissue infection
Local Anesthetics
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Provide pain relief
May help to differentiate between local
and referred pain.
Provide fluid volume to the injection
Help distribute corticosteroid in large
joints
May be short or long acting
Rule of….
Use more concentrated solutions (ie
2%) of lidocaine hydrochloride for
small joints that require small injection
volumes. (MCPJ)
Conversely, use a less concentrated (ie
1%) lidocaine hydrochloride for large
joints that need increased volume.
(Knee)
Warning!!!
Never use epinephrine /
lidocaine solution on ears,
nose, fingers and toes!!!
Onset, Duration, and toxicity of
local anesthetics
Drug
Lidocaine
1%
2%
Onset
Duration
Max Vol
1-2 Min
1-2 Min
~ 1 Hour
~ 1 Hour
20 ml
10 ml
Bupivacaine
0.25%
30 Min
8 hours
60 ml
0.50%
8 Hours
30 ml
30 Min
CHANGES ASSOCIATED WITH
OSTEOARTHRITIS
 Joint injury or deformity1
 Imbalance of biosynthesis and

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degradation in
cartilage,
synovial fluid, bone, muscle,
ligaments1
Inflammation1
Chronic wear and age1
Softening and loss of articular
cartilage1
Decrease in concentration and
average molecular weight of
hyaluronic acid in synovial fluid2
1. Brandt KD. In: Harrison’s Principles of Internal Medicine. 13th ed. New York, NY: McGraw-Hill;
1994:1692-1698.
2. Balazs EA, Denlinger JL. J Rheumatol. 1993;20(suppl 39):3-9.
“A Failure of the Supporting
Structure of the Total Organ (Joint)”
Hyaluronic Acid
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Used to treat OA of the knee
Act as viscoelastic supplements that
replace the diseased synovial fluid of
the osteoarthritic joint
Act as a shock absorber and lubricates
the joint! (How to explain this to pt?).
Synovial Fluid

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Highly influences intercellular
matrices of joint soft tissues
Unique combination of elasticity and
viscosity
Hyaluronan responsible for
elastoviscous properties
Elastoviscosity critical for joint
function
Elastoviscosity reduced in
osteoarthritis
100
0
90
10
80
20
70
30
60
40
50
50
40
60
30
70
running
20
walking
80
jumping
90
10
0
0.01
HA MW
0.1
100
1
Frequency (Hz)
10 20
% Viscosity
% Elasticity
Viscosupplementation
Basic Principle
Types
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Synvisc
Hylagan
Orthovisc
Suparz
Positioning
Successes!
Side Effects
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Mild pain caused by injection, usually
resolve in three days following
injection. (Avoid heat for 24 hours and
strenous / weight bearing activity
after).
Serious allergic reaction. (Egg based).
How to define (Synvisc) pseudo-sepsis
vs injection flare
Overall Response to Hylan G-F 20
Viscosupplementation
Much Better
35.0%
Better
42.2%
Worse or
Much Worse
1.3%
Same
21.4%
Reference: Lussier A, Cividino AA, McFarlane CA, et al. Viscosupplementation with hylan for the
treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol.
1996;23(9):1579-1585.
Reimbusement
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Always be aware of participating
insurance programs.
Seek pre-authorization per insurance
Per Incident “2” guidelines, (would
second visit per mid level be covered?)
Purchasing “off shore”.
FDA vs Morality vs Reality.
Treatment


Who is the best candidate for
injection?
When to choose preventive vs
operative medicine
Osteoarthritis
CLINICAL MANAGEMENT
OA Treatment
Modalities
ACR 2000 GUIDELINES – Pharmacologic/Surgical
Therapy
Mild to Moderate
Pain
 Simple analgesics
(eg, acetaminophen)
 OTC NSAIDs
 Topical creams
Additional
Therapies
 IA
hyaluronans
 IA steroids
 Tramadol
 Opioids
Moderate to Severe
Pain
 COX-2–selective
inhibitors (CELEBREX)
 Rx NSAIDs plus gastroprotective agent
Surgical Intervention
 Arthoplasty; osteotomy
 Total knee replacement
Adapted from American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:1905-1915.
Questions?
Thank you,
Have a Blessed Day!
&
God Bless America!

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