Approach to Aspiration and Injections ACR Virtual Rheumatology Practicum

Approach to Aspiration and Injections

ACR Virtual Rheumatology Practicum

Jul 2020

Kenneth S. O'Rourke, MD Rheumatology Associates Portland, Maine

Division Director Rheumatology

Founding Member Carolinas Fellows Collaborative

Arthrocentesis - O'Rourke Pg 2 Approach to Aspiration and Injections

NB: This presentation will deal primarily with the technical aspects of injections. For a discussion on the indications and efficacy of these procedures, the learner may consider the following: • Roberts WN: Primer: pitfalls of aspiration and injection. Nat Clin Pract Rheum (2007) 3:464-72 • Philpose J, Baker K, O'Rourke KS, Deodhar A: Joint aspiration and injection: mastering the basics. J Musculoskel Med 28(6):216- 22,2011 (http://nwprimarycare.com/Journal%20Articles/joint%20aspiration%20&%20inj%20basics.pdf) • Evans CH et al: Progress in intra-articular therapy. Nat Rev Rheumatol (2014) 10:11-22 • Garg N et al: Intra-articular and soft tissue injections, a systematic review of relative efficacy of various corticosteroids. Clin Rheumatol (2014) 33(12):1695-706 • McAlindon TE et al: Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis. A randomized clinical trial. JAMA (2017) 317:1967-75

I. What Comes Out A. Synovial fluid (tables adapted in part from Gatter RA, A Practical Handbook of Joint Fluid Analysis, Philadelphia: Lea & Febiger, 1984; see also Shmerling RH, et al: JAMA 264:1009-14, 1990, and Margaretten ME, et al: JAMA. 2007;297:1478-88) 1. Characteristics (note below in table: the rule of 2's)

Normal Noninflammatory Inflammatory Septic Color transparent transparent translucent-opaque opaque Viscosity very high high low variable WBC/cubic mm < 200 200-2,000 > 2,000 > 50,000 % PMN < 75 (<25) < 75 (<25) > 75 (> 50) > 75

Examples OA, AVN, HOA RA, crystal, SpA bacterial CTDs, serum sickness infection;

concentrated crystals; Estimating WBC: 1 WBC/hpf using 40x objective ~ 500 WBC/mm3 ‘pseudoseptic’ (eg RA, ReA, PsA) Hemorrhagic synovial fluid: trauma with or without fracture, Charcot joint, hemorrhagic diathesis, tumor

Synovial fluid eosinophilia: infrequent, generally not associated with peripheral eosinophilia, and most cases had a benign course (Rheumatology 52:346-51, 2013)

Synovial fluid in potential septic arthritis: Margaretten et al (JAMA. 297:1478-88, 2007) performed a meta-analysis of published articles to determine the accuracy and precision of clinical findings, including synovial fluid, for the diagnosis of monoarticular, nongonococcal bacterial arthritis. Prior to receiving the results of synovial fluid gram stain and culture, the synovial fluid WBC and %polys had the best utility to identify septic arthritis. The following table is adapted from their study: Summary Publications Sensitivity Specificity Likelihood Ratio (95% CI) Study Reviewed % % Positive Negative Synovial Fluid WBC >100k 4 29 99 28 (12-66) 0.71 (0.64-0.79) WBC >50k 4 62 92 7.7 (5.7-11) 0.42 (0.34-0.51) WBC >25k 4 77 73 2.9 (2.5-3.4) 0.32 (0.23-0.43) Polys > 90% 3 73 79 3.4 (2.8-4.2) 0.34 (0.25-0.47) Low glucose 3 51 85 3.4 (2.2-5.1) 0.58 (0.44-0.76) Protein >3 gm/dl 2 48 46 0.90 (0.61-1.3) 1.1 (0.76-1.6) LDH >250 U/L 2 100 51 1.9 (1.5-2.5) 0.10 (0.00-1.6) Serum WBC > 10k 1 90 36 1.4 (1.1-1.8) 0.28 (0.07-1.1) ESR > 30 mm/hr 1 95 29 1.3 (1.1-1.8) 0.17 (0.20-1.3) CRP > 100 mg/L 1 77 53 1.6 (1.1-2.5) 044 (0.24-0.82) Physical exam Fever 1 46 31 0.67 (0.43-1) 1.7 (1-3) Arthrocentesis - O'Rourke Pg 3 Synovial fluid in potential septic arthritis, prosthetic joint: Note that the synovial fluid WBC threshold levels for consideration of septic arthritis change when one is evaluating fluid aspirated from a prosthetic joint. Data in the table below, and a more detailed discussion on prosthetic joint infection can be found in: Tande AJ, Patel R: Prosthetic joint infection. Clin Microbiol Rev 2014; 27:302-345 Pubs Sens Spec Likelihood Ratio (95% CI) Rev’d % % Positive Negative

Native Joint (JAMA 297: 1478-88, 2007) WBC >100k 4 29 99 28 (12-66) 0.71 (0.64-0.79) WBC >50k 4 62 92 7.7 (5.7-11) 0.42 (0.34-0.51) WBC >25k 4 77 73 2.9 (2.5-3.4) 0.32 (0.23-0.43) Polys > 90% 3 73 79 3.4 (2.8-4.2) 0.34 (0.25-0.47)

Prosthetic Joint Knee (Am J Med 117: 556-62, 2004; PROSPECTIVE, n = 133, (aseptic 99, PJI 34), revision TKA) WBC > 1700 94 88 8.0 (5-13) 0.1 (0.0-0.3) WBC > 50k 21 100 (infinity) 0.8 (0.7-0.9) Polys > 65% 97 98 48 (12-190) 0.0 (0.0-0.2)

Knee (J Bone Jt Surg Am 90: 1637-43, 2008; RETROSPECTIVE, n = 429, (aseptic 161, PJI 268), revision TKA) WBC > 1100 91 88 7.6 * 0.1 * Polys > 64% 95 95 17.9 * 0.1 *

Hip (J Bone Jt Surg Am 90:1869-75, 2008; PROSPECTIVE, n=201 (aseptic 146, PJI 55) revision THA) WBC > 4200 84 93 12 * 0.2 * Polys > 80% 84 82 4.7 * 0.2 * *calculated

Recent studies using test strips as an adjunct for suspecting septic arthritis: • Omar M et al (J Bone Joint Surg Am 2014; 96:2032) applied centrifuged synovial fluid supernatant from the joints of consecutive cases of atraumatic joint effusion presenting to an emergency department to the leukocyte esterase (LE) and glucose (GLC) test pads of a colorimetric strip that is usually used for urine analysis:

Synovial fluid gram stain/culture were compared to the strip findings as noted below: LE ++ or +++ LE ++ or +++ and GLC − Sensitivity† (%) 94.7 (74.0 to 99.9) 89.5 (66.9 to 98.7) Specificity† (%) 73.2 (64.7 to 80.7) 99.2 (95.7 to 99.9) Positive predictive value† (%) 34.6 (22.0 to 49.1) 94.4 (72.7 to 99.9) Negative predictive value† (%) 98.9 (94.2 to 99.9) 98.4 (94.5 to 99.8) Positive likelihood ratio 3.54 114

Negative likelihood ratio 0.08 0.11 † estimate (95% confidence intervals)

Arthrocentesis - O'Rourke Pg 4 • Mortazavi SMJ et al (J Pediatr Orthop 2019; epub) in a prospective study of children <18 yo suspected of hip or knee septic arthritis (n = 25), applied the supernatant from spun synovial fluid (acquired at operative arthrotomy or arthrocentesis) to the LE pad, and comparing results to synovial fluid gram stain/culture or the presence of purulent synovial fluid. A LE pad result of ++ or +++ had a positive likelihood ration of 5.88, and a negative likelihood ratio of 0.

Utility of synovial fluid alpha-defensin in the evaluation of suspected septic arthritis • Others have looked at synovial fluid levels of alpha-defensin as an aid to diagnose infection, specifically prosthetic joint infection. The alpha-defensin protein is an antimicrobial peptide that is naturally released by neutrophils responding to a pathogen in the synovial fluid. (See Deirmengian C, et al: Clin Orthop Relat Res 2015; 473:198-203)

2. Crystal characteristics

Crystal Brightness Morphology Size estimate/comments Negative birefringence MSU strong rod/needle, spherule up to 40 µm (maltese cross *) cholesterol weak plates (notched corners) 5-40 µm betamethasone strong rod 10-20 µm; confused with MSU acetate triamcinolone strong rod 15-60 µm; confused with MSU hexacetonide Positive birefringence CPPD weak rod, rhomboid up to 40 µm calcium oxalate variable/weak tetrahedron, rod lithium heparin weak polymorphic 2-5 µm nail polish strong rod 5-10 µm immersion oil strong polymorphic 1-5 µm prednisone TBA strong pleomorphic, branched confused with CPPD lipid inclusions in WBC maltese cross * liquid lipid maltese cross * talc maltese cross * Charcot-Leyden weak hexagonal bipyramid from crystallized eosinophil lysophospholipase (Arthritis Rheum 24:1591, 1981) Birefringent axis unclear methylprednisolone strong acetate triamcinolone strong acetate Cannot be seen with a compensated, polarized microscope Basic calcium phosphates (e.g., hydroxyapatite)

* in MSU spherules, axis of the yellow triangles of cross are parallel with compensator axis; in talc and lipid, the blue triangle axis is parallel

Arthrocentesis - O'Rourke Pg 5 Timing of synovial fluid evaluation for crystals • Synovial fluid must be evaluated promptly (within a couple of hours). Delay in fluid evaluation was been associated with a fall in synovial fluid WBC, fewer CPPD crystals (far more so than fall in MSU crystals), and the development of new crystal artifacts (Arthritis Rheum 32:271, 1989) • A more recent study (J Clin Rheumatol 19:241, 2013) suggested that crystal identification could be safely performed up to 3 days after arthrocentesis, whether synovial fluid (SF) was refrigerated (40C/39.20F) or at a stable room temperature (200C/680F). However, the 75 consecutive, uncentrifuged SF samples had to contain at least 5 mL (submitted native or in tubes with EDTA anticoagulant), and only 27 samples contained crystals (16 monosodium urate, 6 calcium pyrophosphate 5 both).

Utility of centrifugation (cytospin technique) • Examination of synovial fluid sediment following centrifugation may enhance crystal detection (particularly CPPD crystals) by elevating cell and crystal count per high power field (Theiler G, et al: Rheumatol Int 34:137-139, 2014)

B. Bursal fluid (table adapted from Zimmermann B, et al:Semin Arthritis Rheum 24:391, 1995, and Raddatz DA: J Rheumatol 14:1160, 1987):

Nonseptic Septic bursal fluid WBC/cubic mm, range 90-11,000 350-395,000 %PMN 0-90 50-100 gram stain positive 0 15-100%

C. Sympathetic effusion (Strickland RW, et al: Arthritis Rheum (1985) 28:941; Tan IJ and Barlow JL: ACR Open Rheumatol (2019) 1(1): 37-42) • A transudative, noninflammatory effusion in a synovial-lined space contiguous to another inflamed joint, bursa or other inflamed/infected tissue space, presumably a reactive phenomenon in response to inflammation. • Sympathetic effusions are reported to have good viscosity, negative gram stain, WBC/cubic mm from 200-3,000, and %PMN of 6-57%. • Proposed Tan diagnostic criteria (ref above): -- Clinical features (fulfill all) 1. Monoarticular 2. Joint or bursal inflammation on exam (must have pain and swelling, may have warmth and or erythema) 3. Acute onset (within hours to <7 days, up to weeks in some) 4. Cannot be explained by other disorder -- Synovial fluid (fulfill all) 1. WBC/cubic mm may range from <200 up to <2000 2. Culture negative 3. No crystals -- Adjacent pathologic process in same limb present (contiguous, adjacent or close anatomic proximity) Definite: all 3 categories met Probable: clinical + synovial fluid features met

Arthrocentesis - O'Rourke Pg 6 II. What Goes In A. Corticosteroids (non-fluorinated: less cutaneous side effects; fluorinated: longer depot half-life)

relative single solubility anti-inflam equivalent Steroid (proprietary name) mg/ml sizes dose? (%wt/vol) potency dose, mg Non-fluorinated Hydrocortisone acetate 50 5 ml no 0.002 1 20 (Hydrocortone) Hydrocortisone TBA Methylprednisolone acetate 20, 40, 80 1 ml yes 0.001 5 4 (Depo-Medrol) Prednisolone tebutate 20 1, 5 ml yes 0.001 4 5 (Hydeltra TBA, Predalone TBA, Prednisol TBA) Fluorinated Betamethasone sodium 3 5 ml no 25 0.75 phosphate and acetate suspension (Celestone Soluspan) Dexamethasone sodium 4, 10 1, 5, 25 ml yes 0.01 25 0.75 phosphate (Decadron) Triamcinolone acetonide 10, 40 1, 5 ml yes 0.004 5 4 (Kenalog) Triamcinolone diacetate 40 1, 5 ml yes 5 4 (Aristocort Forte) Triamcinolone hexacetonide 5, 20 1, 5 ml yes 0.0002 5 4 (Aristospan) Triamcinolone acetonide extended 32 mg powder yes 5 4 release microspheres (Zilretta) for reconstitution There is a paucity of data comparing relative efficacy of various corticosteroid preparations. A limited number of studies favored triamcinolone hexacetonide over t. acetonide, methylprednisolone and betamethasone (Clin Rheumatol (2014) Mar 21. [Epub ahead of print] PMID: 24651914). Triamcinolone acetonide ER microspheres is only FDA approved for a single dose (see The Medical Letter, (2018) 60 (1554): 142-145)

B. Saline For tidal joint/bursa irrigation (see Ike RW: J Rheumatol 19:772, 1992). Must use large-bore needle (14G) or similar-sized blunt trocar with side port windows. Primarily for the knee; reported volumes vary, but 1 litre seems to be the minimum for total irrigation.

C. Viscosupplements: Post-injection pain 1-27%. Uncommon post-injection acute painful effusions (synovial WBC up to 100,000), starting within hours, lasts several hours but usually not more than 48 hrs, and uncommon with initial injections. Isolated reports of acute gout and pseudogout after injections. Inject with a 18-21 gauge needle to avoid fractionating the product.

Viscosupplement (Proprietary name) Supplied Dose (following joint aspiration) Hexadecylamide hyaluronan (Hymovis) 24mg/3ml 24mg qwk x2 High-MW hyaluronan (Orthovisc) 30mg/2 ml syr 30mg qwk x3-4 Hylan gel-fluid 20 (Synvisc; Synvisc-One) 16mg/2ml; 48 mg/6 ml 16mg qwk x3; 48mg x1 Hyaluronan hydrogel (Gel-One) 30mg/3ml 30mg x1 Sodium hyaluronate (Euflexa) 20mg/2 ml 20mg qwk x3 Sodium hyaluronate (Hyalgan) 20mg/2 ml 20mg qwk x5 Sodium hyaluronate (Supartz) 25mg/2.5ml 25mg qwk x5 Sodium hyaluronate (Monovisc) 88mg/4ml 88mg x1 Sodium hyaluronate (GelSyn-3) 16.8mg/2ml 16.8mg qwk x3 Sodium hyaluronate (Genvisc 850) 25mg/2.5ml 25mg qwk x5 Sodium hyaluronate (TriVisc) 25mg/3ml 25mg qwk x3 Sodium hyaluronate (Visco-3) 25mg/2.5ml 25mg qwk x3 Stabilized hyaluronic acid (Durolane) 60mg/3ml 60mg x1 (adapted from J Rheumatol (1993) 20(suppl 39):3; Cochrane Database Syst Rev. (2006) Apr 19;(2):CD005321; CMAJ (2005):172 (8) doi:10.1503/cmaj.1041203; The Medical Letter (2018) 60(1554):142-145). Arthrocentesis - O'Rourke Pg 7

D. Synoviorthesis applications Chemicals or radionucleotides, other than corticosteroids, used to perform a "medical synovectomy" 1. Radionucleotides

Radiation source joints reported to have been injected dysprosium-165 knee erbium-169 MCP, PIP gold-198 knee, wrist, elbow, ankle rhenium-186 shoulder, wrist, elbow, hip, ankle yttrium-90 shoulder, elbow, wrist, MCP, PIP, knee, ankle lutetium-177 phosphate-32

2. Noncorticosteroid chemicals and biologic agents – selected agents

Chemical Dose regimen (knee, unless specified) Osmic acid aspirate joint; 5 ml 1-2% lidocaine, then 100-200 mg osmium-tetroxide, then steroid (80 mg prednisolone or 50 mg hydrocortisone); immobilize for 24-48 hrs Nitrogen mustard 0.1-1.0 mg mixed with hydrocortisone or prednisolone; has been used for elbow, ankle, knee, wrist, IP, MCP, MTP Thiotepa dissolve in procaine or water; can combine with steroid; inject 2-5 mg for small joints, 7.5-60 mg for knee Methotrexate 2.5 mg qwk x 2, or 5 mg qwk x 1, or 10 mg qwk x 3, or 20 mg qwk x 1 have all been used Orgotein skin test, then: 2 mg q2wk x 24, or 4 mg qwk x 3-8, or 8 or 16 mg q2wk x 6, or 8 mg qwk x 3, or 16 mg qwk x 2, or 32 mg qwk x 1 have all been Used

Onabotulinumtoxin A see Toxicon (2009) 54:658; also Clinical Trial: NCT01518257

TNF-antogonists etanercept and infliximab: see J Rheumatol (2008)35:584; J Rheumatol (2011) 38:1009; Arthritis Rheum (2009) 61:974

Gene therapy see Hum Gene Ther (2018) 29(1): 2-14

Autologous platelet-rich see Phys Med Rehabil Clin N Am (2016) 27(4): 825-53 plasma

Sodium morrhuate

Rifamycin SV

Aspirin

Collagenase Treatment for Dupuytren contracture

Dextrose solution For prolotherapy (joint, ligament and tendon injections). See Curr Rep (2017) 19(6): 34

Photochemotherapy with see J Rheumatol (1995) 22(1): 29-33 oral 8-methoxypsoralen followed 2 hrs later by intraarticular UVA light by arthroscopy

Selected reference: Cruz-Esteban C, Wilke WS: Non-surgical synovectomy. Bailliere's Clin Rheum 9:787, 1995 Arthrocentesis - O'Rourke Pg 8

III. Technique Issues Common to Arthrocentesis and Soft Tissue/Simple Injections

A. Contraindications – General 1. Absolute: essentially none when there is a strong clinical indication to obtain fluid 2. Relative: bleeding diatheses, coagulopathy/anti-coagulated (see Section M below), periarticular infection/cellulitis, possibly bacteremia, irregular/disrupted skin (e.g., psoriasis)

B. Contraindications to intraarticular corticosteroid injection 1. Infection: septic joint 2. Unstable joint 3. Intraarticular fracture 4. Known drug hypersensitivity 5. Joint prosthesis 6. Inaccessible joint 7. Poor response to previous injection 8. Relative: poorly controlled diabetes

C. Informed consent: potential risks of corticosteroid intraarticular injection

Risk Estimated rate Comments Post injection flare 2% (2-15%) Thought secondary to a steroid crystalline synovitis, as steroid crystals are insoluble in water, ingested by, and of the same size as MSU/CPPD; symptoms start within a few hours and may last as long as 48-72 hours; some may have an effusion, the WBC counts of which have been described to go as high as 100,000; low grade temp and constitutional symptoms possible. Steroid arthropathy 0.8% (?) Instability of weight-bearing joints following excessive injections, secondary to osteonecrosis; based on subprimate animal studies and anecdotal case reports; primate models show no deleterious effects. Septic arthritis 0.0072-0.08% Onset usually delayed 3-4 days after injection. Jts injected infxns Hollander, 1969 250,000 18 0.0072% Gray, 1981 100,000 2 0.002% Seror, 1999. 1,160,000 15 0.0013% Kjaer, 2019 14,118 11 0.08% HPA axis suppression Usually with large mg or multijoint injections; evidenced by improvement of noninjected joints, transient eosinophilia, increased plasma 17-hydroxycorticosteroids, decreased plasma cortisol, worsening of serum glucose control; consider stress dose steroids in applicable situation within one week of large joint injection. Tendon rupture < 1% hands/ Avoid by using small gauge needles that disallow plunger wrists, up to depression when needle tip is intratendinous, and gently 10% achilles/ fill tendon sheaths plantar fascia Cutaneous atrophy, < 1% May reverse over a few months or persist; higher risk of depigmentation with fluorinated steroids, therefore consider nonfluorinated steroids for extraarticular injections Flushing < 1% Of face, neck, trunk; may list minutes to days; higher risk with triamcinolone products. Capsular calcification ? Mainly in IP joints, wherein reported in one series in 30 of 70 jts; may be seen 1-2 yr after injection; asymptomatic Hypersensitivity rxns rare Anaphylactic shock also noted in a single case report

Arthrocentesis - O'Rourke Pg 9 Vasovagal syncope It happens

Bleeding / hemarthrosis rare see Section M re anticoagulated patient

Cartilage / nerve damage With inappropriately long needles, rapid needle insertion

Livedoid dermatitis rare Microembolic obstruction of dermal artery leading to Livedoid lesion and necrotic ulcer (Acta Dermatovenerol Croat (2017) 25(3): 251-3

D. Skin preparation: antiseptics "His wife…would repeatedly pinch the skin overlying the medial compartment of the knee with her fingernails until the skin was broken, and would further abrade the underlying tissue until a path had been cleared into the joint and the fluid liberated….The couple was strongly discouraged from continuing this practice." Cohen PL: Self-arthrocentesis in a man with joint pain. Arthritis Rheum 50:680, 2004.

Antiseptic Comments Alcohol (isopropyl 'swipe') Cheap; results in rapid, large decrease in skin flora; no detergent action, thus less effective on 'dirty' skin. Iodine (Betadine[povidone-iodophor]) Iodophors are water soluble complexes of iodine bound to a carrier chemical; must dry on skin for 1-2 minutes to obtain full advantage of the sustained iodine release. Chlorhexidene (Hibiclens [4% solution Slower acting than alcohol, but binds to skin and provides a of chlorhexidene gluconate]) residual activity; combines the broad antibacterial spectrum of alcohol and iodine with prolonged action of hexachlorophene without the risk. Hexachlorophene (pHisoHex) Does not kill gram negatives nor fungi; can be absorbed; can be toxic ; consider following with alcohol pad swipe References: Laufman H: Current use of skin and wound cleansers and antiseptics. Am J Surg 157:359, 1989 Leclair J: A review of antiseptics. Today's OR Nurse 12(10):25, 1990 Sebben JE: Sterile technique and the prevention of wound infection in office surgery-part II. Dermatol Surg Oncol 15:38, 1989

E. Gloves 1. Mandated by OSHA under Universal Precautions 2. Do not have to be sterile if 'no-touch' procedure followed 3. Come in LATEX-free form for those patients with latex allergy 4. Masks and drapes not indicated unless there is a risk of splash.

F. Anaesthesia 1. Compounds a. Ethyl chloride (100%) fine spray: • Anaesthesia from rapid cooling (5 second spray can reduce skin temp to 5-10 degrees C) - may have an antimicrobial affect as well (Clin Radiol 61:1055, 2006) although this effect not seen with jet spray (Am J Sports Med 16:539, 1988). • End-point for spray application is skin frosting - generally takes no more than 10 seconds b. Procaine: an ester • Less painful than lidocaine • Out of favor due to frequent hypersensitivity reactions to ester compounds (most commonly from PABA, an ester metabolite). Those who are allergic can use lidocaine • Lasts 2-3 hours

Arthrocentesis - O'Rourke Pg 10 c. Lidocaine: an amide • Rapid onset, lasts 1-2 hours • No cross reactivity to ester class anaesthetics • Warming a refrigerated solution will reduce pain with injection (Br J Plastic Surg 46:76, 1993) • Acidic – pH of solutions ~5-7 (to promote solubility and extend shelf life). pH of lidocaine premixed with epinephrine ~ 3.3-5.5 in order to maintain epi stability in solution. Buffering the solution (Emerg Med J 22:188, 2005) with sodium bicarbonate before injection: - can reduce pain - increases the amount of anaesthetic in the un-ionized, active, freely diffusible form, shortening time to anesthetic onset irrespective of anaesthetic concentration (J Am Acad Dermatol 54:128, 2006) - is not affected by presence of epinephrine, nor affect the efficacy of epinephrine - does not risk precipitation of the anaesthetic - does not reduce anaesthetic effect for up to 1 week at room temperature, and 2 weeks in refrigerated storage

doses to buffer 1-2% lidocaine: 1 ml of 8.4% Na Bicarb to 9 ml lidocaine 5 ml of 4.3% Na Bicarb to 30 ml lidocaine

• In a study of 99 patients who received two arthrocentesis each, one without and one with 2% lidocaine local anaesthesia, using either a conventional or a reciprocating procedure device (two syringes mounted on a single platform, controlled single-syringe flow of first lidocaine then a steroid-based injectate), local lidocaine markedly reduced procedural pain, and the pain with lidocaine was far less than procedural pain. (Rheumatol Int 29:271, 2009)

d. Bupivicaine: an amide • Longer acting than lidocaine, lasts 2-5 hours • 4 times as potent as lidocaine (therefore comes in lower prepared concentrations, e.g., 0.25% and 0.5%) • Higher risk for precipitation with buffering, thus use lower bicarb amount to buffer:

dose to buffer 0.25% bupivicaine: 1 ml of 8.4% NaBicarb to 90 ml of bupivicaine

e. Diphenhydramine 1% solution (50 mg of parenteral diphenhydramine [1 ml of standard 5% parenteral solution] with 4 ml sterile normal saline). Although an adequate analgesic, as contrasted against lidocaine diphenhydramine is • Shorter acting • More painful when injected • Causes a local skin reaction and may be sedating

2. Skin/SQ injection during arthrocentesis: optional; can use EMLA cream or disc (lidocaine 2.5% and prilocaine 2.5%) for 30-60 minutes prior, or ethyl chloride spray for skin, or 1-2% lidocaine for skin/SQ. Use of local anesthesia in adults may allow for improved needle localization with better patient tolerance when the target is a deformed joint or soft tissue area wherein the need for redirecting the initial needle track approach may be more likely. Local anesthesia may also provide 1- 2 hours of postprocedure pain relief and may reduce the overall pain of the entire procedure (Rheumatol Int [2009] 29:721).Those eschewing the regular use of local anesthesia prior to joint or soft tissue corticosteroid injection in adults, irrespective of anesthetic delivery, note the following points: minor patient discomfort associated with the procedure in well-trained hands, the added pain that may be associated with an injectable anesthetic, the risk that a bactericidal anesthetic (eg, lidocaine) inadvertently introduced into synovial fluid may contaminate subsequent synovial fluid culture, and the time delay associated with preprocedure anesthesia.

Arthrocentesis - O'Rourke Pg 11

3. Intraarticular/intrabursal/soft tissue injection simultaneous with steroid: optional; can precipate/floculate the steroid in the syringe (the preservative methylparaben is thought to be the precipitant- can be reduced with the use of preservative-free, single-dose lidocaine or bupivacaine)- methylprednisolone (e.g., DepoMedrol) is the worst offender, although efficacy of the injection not reduced; can dilute steroid concentration for extraarticular injections, and deliver the steroid over a larger area; intraarticular use may prophylax against the pain from steroid synovitis.

4. For those with LATEX allergy remove rubber stopper of top of lidocaine bottle before withdrawing liquid

G. Other hardware: 1. Tube for synovial fluid cell count: liquid anticoagulant (EDTA best; lithium heparin: can cause its own crystals), not powdered (undissolved powder may interfere with crystal evaluation) 2. Sterile container for synovial fluid culture 3. Slides and cover slips, nail polish (to seal edges of cover slip, for viewing of synovial fluid at a later time) 4. Hemostat 5. Sterile gauze, bandaid 6. Optional: 3 way stopcock for single-needle-insertion aspiration then injection without breaking needle- syringe continuity (re sterility, and to avoid fluid running out end of needle hub between syringe exchanges) (see Arthritis Rheum 53:627, 2005) 7. Selection of sterile disposable needles:

Diam. Size Generally available Suggested for anaesthesia, Suggested for Gauge in mm lengths, in inches or injection without aspiration routine aspiration 18 1.2 1, 1.5 + 19 1.0 1, 1.5 + 20 0.90 1, 1.5 + 21 0.80 1, 1.5, 2 + 22 0.70 1, 1.5 +/- 23 0.60 3/4, 1, 1.25 +/- small jts 25 0.50 5/8, 7/8, 1, 1.5 + small jts 26 0.45 3/8, 1/2 + 27 0.40 1/2, 1.25, 1.5 + 30 0.30 1/2, 1 +

Note: The tip of a 25G or smaller needle, when inadvertently placed in a tendon or ligament, will not allow for depression of the syringe's plunger, providing a negative feedback mechanism

H. Injectate considerations: examples of volumes, steroid concentrations

Adult joint mg triamcinolone product total volumes (steroid + anaesthetic) knee 40-80 up to 10 ml routinely; up to 30-50 with TKI ankle 20-40 1-5 ml shoulder 20-40 up to 10 ml routinely elbow 20-40 1-5 ml wrist 20 1-3 ml subtalar 20-30 1-5 ml IP/MCP/MTP 5-10 0.25-2 ml

Adult bursa mg methylprednisolone acetate* total volumes (steroid + anaesthetic) subacromial 20-40 up to 10 ml routinely greater trochanter 20-40 up to 10 ml routinely pes anserine 10-20 1-5 ml

* e.g., a non-fluorinated steroid for extraarticular/soft tissue injections Arthrocentesis - O'Rourke Pg 12 I. Syringe type 1. Always 'break' the seal on an opened syringe before use, by pulling back on the plunger fully, then pushing it down fully. 2. A newly described, single hand operable 'reciprocating syringe' has been FDA approved (2005). Studies suggest it may reduce procedural-related pain, reduces procedure time, and improve physician satisfaction/performance of arthrocentesis (Ann Rheum Dis, 65:1084, 2006; J Rheumatol 33:771, 2006)

J. Possible sequences of joint or soft tissue injection

1. Double needle serial insertion: injection of a local anaesthetic is followed by instillation of the injectate (eg, corticosteroid alone or mixed with anesthetic) at the target using a separate needle and syringe 2. Single needle insertion: injectate (eg, corticosteroid alone or mixed with anesthetic) is directly injected at the target without separate injectable skin anesthesia or following topical spray anesthetic 3. Single needle insertion beginning with the injection of an anesthetic solution, followed by stabilization of the needle (using sterile glove or hemostat), removal of the syringe, and replacement with a syringe prefilled with injectate for instillation 4. Single needle insertion using the following techniques: o 2 syringes connected by a 3-way stopcock (Arthritis Rheum (2005) 53:627) o 2 syringes connected by a reciprocating syringe mechanism for single-handed operation (J Rheumatol (2006) 41:66)

K. Aspiration of the joint prior to injection 1. One randomized study of intraarticular steroid injection to the knee in patients with RA suggests that aspiration of joint fluid prior to steroid instillation reduces the rate of clinical relapse as compared to steroid injection alone (Ann Rheum Dis 59:233, 2000).

2. Removal of fluid may reduce pain

3. Knee effusion alters quadriceps and hamstring muscle activation during walking in patients with knee OA; aspiration may improve these alterations (see Osteoarthritis Cart 2012;20(9):974-81;Clin Biomech 2014;29:923-9)

L. Joint rest: controversial; older recommendations of 3 wks for UE and 6 wks for LE jt are impractical; but at least one study (Neustadt, in Moskowitz Textbook of Osteoarthritis, 1983) shows better efficacy of LE joint injection with 3 days non-weight bearing followed by 6 wks limited weight bearing. Most practitioners advocate some limited period of rest or reduced activity following joint or soft tissue injection. Postprocedural rest may prolong the benefit from a corticosteroid injection by reducing steroid diffusion from the joint and minimizing leakage of the steroid out of the needle track, both of which may maximize the intra-articular duration of action. Rest may also prevent damage from overuse in those obtaining immediate pain relief. Optimal regimens endorsing the means of rest (eg, bed rest, rigid or flexible fixation) and rest duration unique to each specific joint or soft tissue injection are not well defined, and prospective, randomized studies are few.

M. Special circumstances 1. Pregnancy: fluorinated steroids can cross the placenta, whereas prednisolone is inactivated by placental 11-betadehydrogenase.

2. Anticoagulated patient: • Two small studies (Arthritis Rheum 41:736, 1998 – n= 32; Reumatismo 55:159, 2003 – n= 15) suggest that joint or soft tissue injection and aspirations are of low risk in patients on warfarin with INR < 3.7 and not on a NSAID. • Large, retrospective review of 640 arthrocenteses (knees, shoulders, hips)/514 consecutive pts from 2001-09, all on chronic warfarin. Groups divided between those whose INR was > 2 during the entire periprocedural period (procedures n=456, mean INR 2.7 + 0.03, range 2.0-7.81), or warfarin held 3-5 days and INR < 2 (mean INR 1.6 + 0.02, range 0.93-1.9); there were no differences in demographics between groups. Procedures done by IM or FP, ER physicians, physiatrists, rheumatologists and orthopaedists. There were no differences seen between groups in clinically significant bleeding (early or late), late joint infection, or joint pain that caused a subsequent physician visit (Ahmed I and Gertner E: Safety of arthrocentesis and joint injection in patients receiving anticoagulation at therapeutic levels. Am J Med (2012) 125:265-9) Arthrocentesis - O'Rourke Pg 13 • A cross-sectional study of 901 charts of patients on acenocoumarol who underwent arthrocentesis or joint infiltration between 2009 and 2013, grouped on the basis of having an INR higher or lower than 2.0 (268 and 633, respectively). In terms of rates of early or late bleeding complications, a 0.37% rate of early bleeding complications (< 24hours) was observed in the group of patients with INR<2 and 0.99% in the group of patients with INR≥2 (P=.47). Only one case of late complication was presented by bleeding between 24 hours and 30 days, in the group of patients with INR≥2. (Guillen Astete C, et al: Is it safe to perform joint infiltrations or aspirations in patients anticoagulated with acenocoumarol? Reumatol Clin. 2015 Jan-Feb;11(1):9-11) • Retrospective study in 1050 consecutive procedues (483 unique patients) on direct oral anticoagulants (DOAC) undergoing arthrocentesis/joint injection at a single institution revealed no bleeding complications (Mayo Clin Proc 92:1223-1226, 2017) • Post-procedure pressure over needle puncture site, compression bandage, and/or ice may be required to reduce risk of excessive bleeding. • In a survey of 1018 French rheumatologists there was considerable variation in practice regarding discontinuation of antiplatelet drugs or vitamin K antagonists prior to either intraarticular or subacromial shoulder injections (Joint Bone Spine 75:311, 2008).

3. Hemarthrosis in (children with) hemophilia: intraarticular corticosteroid injection, following pre- treatment with intravenous factor VIII then joint aspiration until clear using small-volume (1-10 mL) saline irrigation (n = 22, 84 joint events involving 32 joints), was safe and associated with joint preservation in this case review study

4. Children: Studies suggest that they are efficacious for JIA (e.g., Arthritis Rheum 41:1210, 1998), and can reduce leg length discrepancy with LE joint injections as contrasted against symptomatic patients not injected (Arthritis Rheum 42:2330, 1999). However, consider: need for sedation.

N. Failed Arthrocentesis: Considerations 1. “Dry tap” considerations a. NOT DRY! Could be usable fluid in the needle hub! Spritz/droplet onto a slide at bedside b. Thick fluid / needle gauge too narrow c. Needle into fat pad d. Lumen obstructed by subcutaneous tissue from aspirating before reaching fluid space

Re: Knee 2. An MR study of 5 inflammatory arthritis patients with ‘dry taps’ (Am J Med 100:461, 1996; see also same author at Nat Clin Pract Rheum 3:464-72, 2007) noted possible reasons for this to include: a. large, triangular medial fat pad (suggesting that the lateral approach to the joint should be the preferred route) b. chronically inflamed, thickened synovium having undergone fat replacement (akin to a lipoma arborescens) c. fluid loculated, separated from needle by medial plica when medial approach used d. low fluid volume, or highly viscous fluid too difficult to aspirate e. needle bevel lumen blocked by fat, debris, or skin plug f. mistaken exam findings - fluid not really present

3. Lateral midpatellar location more successful than either anteromedial or anterolateral sites when injecting (viscosupplement) when no effusion present, as determined by contrast injection (J Bone Joint Surg Am 84-A(9):1522-7, 2002)

4. Supine position more likely to yield fluid on aspiration than aspiration with knee flexed (sitting). (Am J Phys Med Rehab 91:611-5, 2012).

5. Intraarticular knee pressure is less when the knee is slightly flexed (eg at least 15 degrees) as contrasted to when the knee is at 0 degrees (see Eyring EJ at el: J Bone Jt Surg Am 46:1235, 1964; and Funk DA et al: Arthroscopy 7:86-90, 1991)

6. Knee synovial fluid volume during arthrocentesis in the flexed position with an external suprapatellar compression device can approach that from aspiration in the extended position from the suprapatellar approach. (Yaqub S et al: J Clin Rheumatol 24: 295-301, 2018) Arthrocentesis - O'Rourke Pg 14 7. Examples of accuracy when guided by body surface landmarks:

Accuracy of Needle Skin Portal for Needle Site Imaging Used to Assess Accuracy Placement by Surface Entry Anatomy, n (%) Subacromial Radiographs with radio-opaque contrast in Anterolateral 15/20 (75) space (Kang injectate Posterior 15/20 (75) 2008) Lateral 12/20 (60)

Subacromial MR with gadolinium in injectate Posterior 13/17 (76) space (Henkus Anteromedial 10/16 (62.5) 2006)

Glenohumeral MR with gadolinium in injectate Anterior 11/41 (26.8) joint (Sethi 2005)

Knee joint Fluoroscopy with radio-opaque contrast in Anterolateral 57/80 (71) (Jackson 2002) injectate Anteromedial 60/80 (75) Lateral midpatellar 74/80 (93)

US-guided procedures Ultrasound guided: systematic review and Knee joint more accurate (risk ratio meta-analysis of controlled trials of knee Various (Wu T, 2016) 1.21, 95% CI: 1.13-1.29, aspiration (9 studies: 7 RCTs, 2 non-RCTs) P < 0.001)

Radiocarpal and Fluoroscopy to define joint lines, marked by Joint Mean distance away 1st MTP ink visible under ultraviolet illumination; from fluoro-identified (Manadan AM, attending rheumatologists (n = 10) marked joint line (range) 2015) their needle insertion site on skin Radiocarpal joint 0.85 cm (0-1.6 cm) 1st MTP 0.33 cm (0-1.3 cm) • See also: Lopes RV et al: Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis. Rheumatology (2008) 47:1792-4

O. Ultrasound Guided Procedures The scope of this presentation does not allow for a comprehensive review of the utility of ultrasound as a tool in the routine performance of arthrocentesis and soft tissue injection procedures. The following are a few selected background readings: 1. Reviews a. Berkoff DJ et al: Clinical utility of ultrasound guidance for intra-articular knee injections: a review. Clin Interven Aging (2012) 7:89-95 b. Schirmer M, et al: Ultrasonography in inflammatory rheumatic disease: an overview. Nat Rev Rheumatol. (2011);7(8):479-88. c. Gilliland Ca et al: Ultrasound versus anatomic guidance for intra-articular and periarticular injection: a systemic review. Phys Sportsmed (2011) 39(3):121-31 d. Kissen EY, et al: Self-directed learning of basic musculoskeletal ultrasound among rheumatologists in the United States. Arthritis Care Res (2010) 62(2):155-60 e. Schmidt WA, Backhaus M: What the practicing rheumatologist needs to know about the technical fundamentals of ultrasonography. Best Pract Res Clin Rheumatol. (2008) 22(6):981-99 f. Backhaus M, et al: Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis (2001) 60:641-9 g. www.ussonar.org or www.msk-uss.org : website home of the Ultrasound School of North American Rheumatologists, a group of ACR members with expertise in musculoskeletal ultrasound offering a course directed at training U.S. rheumatology fellows

Arthrocentesis - O'Rourke Pg 15 2. Injections a. Bruyn GA, Schmidt WA: How to perform ultrasound guided injections. Best Pract Res Clin Rheumatol. (2009) 23(2):269-79 b. Phys Med Rehabil Clin N Am. 2016 Aug;27(3): this volume has multiple articles on US- guided injection: shoulder, elbow, wrist, hand, hip, knee, ankle, foot, tendinopathy, nerve

IV. Trigger Point Injections “Trigger point”: A painful irritative focus in the in a muscle consequent on injury, unaccustomed activity or repetitive use.

• It is the commonest cause of non-articular rheumatic pain - many times misdiagnosed as bursitis, tendonitis, radiculopathy, nerve entrapment syndrome etc. Finding of a single or multiple trigger points should suggest the diagnosis of ‘myofascial pain syndrome’. • Many patients with primary arthritis, tendonitis or bursitis may develop biomechanical imbalance and secondary myofascial pain syndrome.

Clinical characteristics of a trigger point are as follows: 1. Exquisite tenderness in a taut muscle band 2. Referred pain elicited by stimulation of the trigger point 3. Local twitch or contraction of the taut band 4. Reproduction of the patient’s spontaneous pain pattern when stimulated 5. Weakness without atrophy 6. Restricted range of motion

Trigger point injection technique: • Use 3-5 ml of 1% procaine or lidocaine. • Clean the skin with alcohol swab. • 24 to 26 gauge needle inserted only as far as deep dermis. Then advance the needle slowly into the area of trigger point till 1) patient experiences sudden pain often with centrifugal pattern of referral and 2) a feeling of increased resistance to the progression of the needle tip. • In superficial muscles, a transient ‘twitch’ response of the muscle is observed. • Approximately 0.5 cc of fluid is injected and the needle is re-inserted (without leaving the original skin puncture) into the adjacent area of muscle. This ‘peppering’ technique is repeated till no more pain is experienced or till 3-5 ml of total fluid is injected. Several trigger points could be injected at a time – total amount of local anesthetic not to exceed 20 cc. Typically, the beneficial effects of a trigger point injection occur after a lag period of 2-5 days after a temporary increase in pain.

Complications & Side Effects: • From large volumes of local anesthetic: dizziness, tinnitus, muscle fasciculations, bradycardia, hypo/hypertension and rarely convulsions, cardiac arrest. • Anaphylaxis is a rare complication from all anesthetics. • Hematoma, pneumothorax etc., depending on the site of injection.

V. OSHA Requirements and Other Regulations Certain regulations/forms/protocols should be kept on site, including information on Universal Precautions, OSHA Bloodborne Pathogen Standard, Safety Data Sheets (SDS) of all chemicals (e.g., ethyl chloride, povidone iodine, etc), Personal Protective Equipment list for procedures performed, and exposure control protocols. Beginning 2016, OSHA requirements for SDS met the Globally Harmonized System for Chemical Information and Labeling, with a goal to improve consistency and understandability of information.

Arthrocentesis - O'Rourke Pg 16 VI. Selected References (see text for additional embedded references)

General Gardner GC: Teaching arthrocentesis and injection techniques: what is the best way to get our point across? J Rheumatol 34(7):1576-9, 2007

Philpose J, Baker K, O'Rourke KS, Deodhar A: Joint aspiration and injection: mastering the basics. J Musculoskel Med 28(6):216-22, 2011 (http://nwprimarycare.com/Journal%20Articles/joint%20aspiration%20&%20inj%20basics.pdf)

Roberts WN: Primer: pitfalls of aspiration and injection. Nat Clin Pract Rheum 3:464-72, 2007

Schumacher HR: Aspiration and injection therapies for joints. Arthritis Rheum (Arthritis Care & Research) 49:413, 2003

Thumboo J, O'Duffy JD: A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum 41:736, 1998

Travell JG & Simons DG. Myofascial pain & dysfunction: The trigger point manual. Baltimore: Williams & Wilkins. 1983

Weitoft T and Uddenfeldt P: Importance of synovial fluid aspiration when injecting intra-articular corticosteroids. Ann Rheum Dis 59:233, 2000

Wise C: The rationale use of steroid injections in arthritis and nonarticular musculoskeletal pain syndromes. Bull Rheum Dis 52(1), 2003

Wittich CM et al: Musculoskeletal injection. Mayo Clin Proc 84:831-7, 2009

Anaesthesia and Antiseptics Burney K, Bowker K, Reynolds R, Bradley M: Topical ethyl chloride fine spray. Does it have any antimicrobial activity? Clin Radiol 61: 1055, 2006

Laufman H: Current use of skin and wound cleansers and antiseptics. Am J Surg 157:359, 1989

Leclair J: A review of antiseptics. Today's OR Nurse 12(10):25, 1990

Quaba O, Huntley JS, Bahia H, McKeown DW: A users guide for reducing the pain of local anaesthetic administration. Emerg Med J 22:188, 2005

Sebben JE: Sterile technique and the prevention of wound infection in office surgery-part II. Dermatol Surg Oncol 15:38, 1989

Equipment Draeger HT, et al: A randomised controlled trial of the reciprocating syringe in arthrocentesis. Ann Rheum Dis. 2006 Aug;65(8):1084-7

Nunez SE, Draeger HT, Rivero DP, Kettwich LG; Sibbitt WL, Bankhurst AD: Reduced pain of intraarticular hyaluronate injection with the reciprocating procedure device. J Clin Rheumatol. 13(1):16-9, 2007

Simkin PA, Gardner GC: The 3-way stopcock: a useful adjunct in the practice of arthrocentesis. Arthritis Rheum 53:627, 2005

Sibbitt W, Sibbitt RR, Michael AA, Fu DI, Draeger HT, Twining JM, Bankhurst AD: Physician control of needle and syringe during aspiration-injection procedures with the new reciprocating syringe. J Rheumatol. 33(4):771-8, 2006. Arthrocentesis - O'Rourke Pg 17

Specific Joints Lutt JR, O'Rourke KS, Deodhar A: Aspiration and injection of the elbow and olecranon bursa. J Musculoskel Med 24(8): 352-3, 2007

Lutt JR, O'Rourke KS, Deodhar A: Aspiration and injection of the shoulder joints and subacromial bursa. J Musculoskel Med 24(9): 391-2, 2007

Bilstrom E, O'Rourke KS, Deodhar A: Injection of the carpal and tarsal tunnels. J Musculoskel Med 24(11): 472-4, 2007

Bilstrom E. O'Rourke KS, Deodhar A: Aspiration and injection of the metatarsophalangeal joints. J Musculoskel Med 24(12):517-8, 2007

Bilstrom E, O'Rourke KS, Deodhar A: Injection of the subtalar joint and sinus tarsi. J Musculoskel Med 25(1): 29- 30, 2008

Bloniarz D, O'Rourke KS, Deodhar A: Injection of the wrist and ulnar styloid. J Musculoskel Med 25(4): 188-9, 2008

Bloniarz D, O'Rourke KS, Deodhar A: Injection of the first carpometacarpal joint: the base of the thumb is a common site of osteoarthritis J Musculoskel Med 25(6):295-6, 2008

Bloniarz D, O'Rourke KS, Deodhar A: Injection of the anserine bursa and iliotibial tract. J Musculoskel Med 25(7): 340-1, 2008 Anderson AS, Deodhar A, O'Rourke KS: Aspiration and injection of the knee. J Musculoskel Med 25(10): 470-2, 2008

Bourne R, Deodhar A, O'Rourke KS: Injection therapy for pelvic soft tissue conditions. J Musculoskel Med 26(1): 25-7, 2009

Ramsay O, Deodhar A, O'Rourke KS: Injection and aspiration of finger joints. J Musculoskel Med 26(2):65-6, 2009

Synovial Fluid Gatter RA, A Practical Handbook of Joint Fluid Analysis, Philadelphia: Lea & Febiger, 1984

Margaretten ME, et al: Does this adult patient have septic arthritis? JAMA. 297(13):1478-88, 2007

Raddatz DA: Septic bursitis: presentation, treatment and prognosis J Rheumatol 14:1160, 1987

Shmerling RH, et al: Synovial fluid tests. What should be ordered? JAMA 264:1009-14, 1990

Strickland RW, et al: Sympathetic synovial effusions associated with septic arthritis and bursitis. Arthritis Rheum 28:941, 1985

Zimmermann B, et al: Septic bursitis. Semin Arthritis Rheum 24:391, 1995

VIDEO

Fischer J, et al: Educational quality of YouTube videos on knee arthrocentesis. J Clin Rheumatol 19:373-376, 2013

Thomsen TW, Shen S, Shaffer RW, Setnik GS: Arthrocentesis of the knee. N Engl J Med 354:e19, 2006. Arthrocentesis of the knee on a patient using the medial approach. 7/10/20

Right 1st MTP

© 2005 Kenneth S. O’Rourke, MD 1st MTP joint (e.g., 5/8” 25G): either side of dorsal, midline extensor tendon, aim slightly caudally, applying traction and mild plantar flexion to distract joint. (cadaver photo)

Right 2nd MTP

1 7/10/20

Right ankle (tibiotalar) Tibial ridge

Medial EHL malleolus

Tibialis anterior

© 2005 Kenneth S. O’Rourke, MD Ankle joint (1.5” needle): enter at depression medial to tibialis anterior tendon (have patient dorsiflex ankle to locate), just distal to bony tibial edge of joint line (cadaver photo)

Lateral Right subtalar malleolus

2 7/10/20

Right sinus tarsi

Medial malleolus

Left tarsal tunnel

Tarsal tunnel (1.5” needle): enter at a 20-30 degree angle to the skin at the midpoint of the proximal edge of the flexor retinaculum, aspirate before injecting. (cadaver photo)

3 7/10/20

Left knee (medial approach) Patella

Knee joint, medial/lateral peripatellar (1.5” needle): knee extended, enter in the depression of the patellar-femoral groove, at the mid-patellar pole, 30-40 degrees from the horizontal, aiming slightly caudal; similar angle for the lateral, mid-patellar approach. (cadaver photo)

Left knee (supralateral approach into suprapatellar pouch)

Patella

© 2005 Kenneth S. O’Rourke, MD Knee joint, supralateral (1.5” needle): enter just supralateral to the intersection of lines drawn from the top and lateral margins of patella, aiming for space under the upper third of patella. (cadaver photo)

4 7/10/20

Patella

Anteromedial

Medial Anterolateral tibial plateau Edges of patellar tendon Knee joint, anterior, knee flexed (1.5” needle): enter in either dimple adjacent to edge of patellar tendon, parallel to tibial plateau, aiming for intercondylar notch. Use small gauge needle to avoid injecting cruciates. (cadaver photo)

Medial tibial plateau

Left pes anserine bursa

Pes anserine bursa (e.g., 1-1.5” needle): enter at 90 degrees to the skin at point of maximal tenderness on flat tibial surface, 1.5-2” inferior to the medial joint line; following anaesthetic, needle to the periosteum, then withdraw 2-3 mm and inject. (cadaver photo)

5 7/10/20

Trochanteric bursa (1.5”, 25G needle [may need up to 3.5” 22G spinal needle]): enter at point of maximal tenderness on trochanteric prominence, 900 to the skin; following anaesthetic, needle to the periosteum, then withdraw 2-3 mm and inject 50-75% of solution, and the remainder fanned posteriorly and distally down the direction of the tensor fascia lata. (cadaver photo)

Left 2nd MCP

© 2005 Kenneth S. O’Rourke, MD MCP joint (1/2 -5/8” needle): either side of dorsal, midline extensor tendon, aim slightly caudally, applying traction and mild flexion to distract joint; using fingers of non-injecting hand palpate for capsular swelling on volar aspect during injection. (cadaver photo)

6 7/10/20

Trigger finger (e.g., 1/2” 26G), palmar approach: enter 30-40 degrees to the skin lateral or medial to the flexor tendon, just proximal to the palmar aspect of the MCP joint (~distal palmar crease), aiming for the tunnel (whose roof is the A1 Flexor tendon pulley). Aspirate for blood, then inject. (cadaver photo) A1 pulley © 2009 Kenneth S. O’Rourke, MD

J Hand Surg (2006) 31:135 (e.g., 1/2” 26G), web space approach: enter parallel to the palmar surface, approximately half-way between the palmar and dorsal surfaces of the hand, aim for the midline of the finger ray, in the tunnel. (cadaver © 2009 Kenneth S. O’Rourke, MD photo)

De Quervain’s tenosynovitis (e.g., 1/2-5/8” 26/27G or 1/2” 26G Abductor pollicis longus needle, on syringe or butterfly): and extensor pollicis direct needle in cephalad brevis tendon sheath direction into tendon sheath, just proximal to radial styloid at junction of tendons. Use fingers to palpate tubular swelling of sheath with injection. Extensor (cadaver photos) pollicis longus © 2009 Kenneth S. O’Rourke, MD

J Occup Environ Med, (1997) 39:990

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Left 1st CMC Extensor Extensor pollicis pollicis brevis longus

© 2005 Kenneth S. O’Rourke, MD !st CMC joint (1/2’ -5/8” 25-27G): enter just proximal to edge of the first metacarpal base, at distal-most end of ‘snuff box’ (with patient’s thumb in active extension, locate joint line by ‘walking down’ midline of patient’s metacarpal with operator’s finger nail to the bony edge; keep finger nail on joint line while patient’s thumb is then passively flexed into palm to open joint space), injecting with thumb passively flexed into palm. (cadaver photo)

Left wrist (ulnocarpal, thru ulnar collateral lig)

© 2005 Kenneth S. O’Rourke, MD Wrist joint, ulnocarpal (e.g., 5/8” 25G): enter in the depression just distal and palmar to the tip of ulnar styloid, aiming slightly cephalad; use small gauge needle to avoid injecting the triangular fibrocartilage complex. (cadaver photo)

8 7/10/20

Lister’s tubercle

Extensor Left wrist pollicis (radiocarpal) longus

© 2005 Kenneth S. O’Rourke, MD Wrist joint, dorsal radiocarpal (e.g., 5/8” 25G): enter 90 degrees to the skin in the depression on the ulnar side of the EPL tendon, just distal to Lister’s tubercle on the dorsum of the distal radius. (cadaver photo)

Right carpal tunnel

Palmaris longus Median nerve

© 2005 Kenneth S. O’Rourke, MD Carpal tunnel (5/8” 25G): enter 30-40 degrees to the skin at the proximal wrist crease, medial to the palmaris longus (bring out tendon, if present, by asking patient to actively make ‘goose head’: straight fingers, flexed at MCPs, with straight thumb opposed to 3rd finger pad), aiming for base of 4th MCP. Aspirate for blood. Redirect tip more medially if median nerve paraesthesias occur during needle insertion. (cadaver photo)

9 7/10/20

Right elbow (ulnohumeral groove)

© 2005 Kenneth S. O’Rourke, MD Elbow joint, ulnohumeral (1.5” needle): with elbow flexed, enter skin in groove, half-way between olecranon and lateral epicondyle, aim for the center-line of the ulna, angling back of syringe slightly up from a plane parallel to the forearm. (cadaver photo)

Right elbow (radiohumeral joint)

10 7/10/20

Right olecranon bursa

Olecranon bursa (1.5” needle): enter bursa via a superficial, anaesthetized subcutaneous tunnel, needle directed cephalad parallel to the forearm. (cadaver photo). Do not aspirate the bursa from the area over the olecranon tip.

Right acromioclavicular joint

11 7/10/20

Acromion Clavicle Spine of scapula Right subacromial space

Subacromial bursa (1.5” needle): enter skin at depression inferior to the edge of the acromion, anywhere from lateral to postero-lateral, angling for space under the acromion (10-20 degrees cephalad); use small gauge needle (e.g., 25G) to avoid injecting the superior aspect of the rotator cuff. (cadaver photo)

Bicipital groove

Bicipital tendinitis (e.g., 1.5” 25G): enter skin at the proximal bicipital groove, adjacent to the long head of the biceps tendon. Tendon is held in groove by an aponeurosis that forms the roof of a tunnel, with the bony groove as the base. Insert the needle to the side of the tendon to the periosteum of the bicipital groove, then back off 2-3mm and inject; use small gauge needle to avoid injecting the biceps long head tendon. (cadaver photo)

12 7/10/20

(spinal needle, to Posterior approach view demonstrate path)

Glenohumeral joint (1.5” needle): standing behind with patient sitting in chair, and finger of non-injecting hand on coracoid process to serve as a target, enter skin at posterior dimple, inferior to where spine of scapula turns anteriorly into the acromion, aiming for the coracoid process. (cadaver photo). In the supine position for anterior (Caldwell) approach, insert needle 1 fingerbreadth (fb) inferior and 1 fb lateral to the coracoid process, aiming slightly laterally and cephalad, toward the posterior dimple described above.