“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 Chronic subdeltoid bursitis Shoulder capsulitis Knee osteoarthritis Tennis elbow Trapezio metacarpel joint OA Plantar fasciitis General guidelines 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 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 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 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 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 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 Synvisc Hylagan Orthovisc Suparz Positioning Successes! Side Effects 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 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!