Apply Evidence Based Medicine to Arthrocentesis Skills: Shoulder and Knee

1. Apply Evidence Based Medicine to Arthrocentesis Skills:Shoulder and Knee Gregory C. Gardner, MD, FACP Gilliland-Henderson Professor of Medicine University of Washington, Seattle, WA

2. Evidence Based References • Evidence based references • Courtney and Doherty. Best Practice & Research Clinical Rheumatology 2009; 23:161–192 (2013 update) • Crawshaw DP et al. Exercise therapy after corticosteroid injection for moderate to severe shoulder pain. BMJ 2010;340:c3037 doi:10.1136/bmj.c3037 • Raynauld JP, et al. Safety and efficacy of long-term intraarticular steroid injections for osteoarthritis of the knee. Arthritis Rheum 2003;48:370-377 • Habib GS, et al. Local effectes of intra-articular corticosteroids. Clin Rheumatol 2010;29:347-356 • Gardner GC. Teaching arthrocentesis and injection techniques: what is the best way to get our point across. J Rheumatol 2007 vol. 34 (7) pp. 1448-1450

3. Outline of Workshop • Didactics • Procedure pearls • Anatomy review • Clinical Issues and technique review • Surface anatomy • Present evidence based best practices

4. Current status of how we do and teacharthrocentesis and injection therapy

5. Dangers of “Evidence based Medicine”

6. 1. Patient counseling Discuss reasons for doing the procedure Discuss details of doing the procedure Discuss potential side effects Inquire about potential contra-indications 2. Patient preparation Able to verbalize anatomy and mark appropriate location Patient positioned properly for site of procedure Skin cleansed properly Appropriate application of anesthesia Analytic rubricProcedure distilled into discrete steps:

7. 3. Needle insertion Choose appropriate needle and syringe for procedure Needle inserted at appropriate angle/depth Needle/syringe stabilized during procedure Aseptic technique 4. Post-procedure wrap-up Skin re-cleansed if necessary, site bandaged Post-procedure counseling provided Sharps disposed of properly Operator showed concern for patient comfort Analytic rubric continued

8. Utility of Rubric • Framework for teaching arthrocentesis skills • Can be used to think about and applying evidenced-based principles • Useful as assessment tool for physicians in training • Useful as a documentation of procedure competency

9. Procedure Pearls

10. Textbook complications of arthrocentesis & injection therapy; How much should we worry? • Charcot arthropathy – very rare; why would it develop and how often can we safely inject an joint? • Periarticular calcifications – 4% give or take may develop • Infection – very rare (TBD) • Post-injection synovitis – uncommon; 6-12 hrs following procedure and resolves in 48 hrs • Tendon rupture – rare; avoid injecting tendon especially high tension tendons i.e. Achilles • Skin depigmentation – 5%; may develop 8 wks after injection and resolve by 16 wks • Subcutaneous fat atrophy – up to 8%; avoid placing corticosteroid in subcutaneous fat • Other – AVN, hyperglycemia, flushing

11. Textbook contraindications to injecting corticosteroids into joints and soft tissue • Infection or suspected infection around the joint • Avoid injecting through psoriatic plaque • Hypersensitivity to injectables • Most “hypersensitivity” is to epinephrine; no need to use • Upcoming surgery on the joint • TBD • Suspected intra-articular fracture/joint instability • Anticoagulation • Caution not contraindication; TBD

12. Joint procedures and infection • Seror et al Rheumatology 1999 • Retrospective study involving 69 French rheumatologists • Mean number of years in practice 20.9 • Mean number of corticosteroid injections per year 809 • Total injections 1,160,000 in 20 years with 15 instances of post injection infection • Overall rate of infection was 1/77,300 • When pre-packaged CS syringes used: 1/162,000 • When multi-dose vial used: 1/21,000 (7.7 X higher!) • 1/4.6 rheumatologists had post-injection septic complication over 20 years

13. How often can we inject a knee? • 68 knee OA pts randomized to either saline or 40 mg of triamcinolone acetate injections every 3 months for 2 years • Double blind study • After 2 years of therapy, no difference in joint space width between groups (figure) • Joint pain at night and stiffness significantly better for steroid group using AUC analysis at 2 years • Conclusion: • JS not affected • Clinical improvement especially at 1 year, less apparent at 2 yrs • No significant SE Raynauld et al. Arthritis Rheum 2003;48:370

14. Steroid injection into hip prior to THAChitre et al. JBJS 2007 • 99 pts had received steroid/local anesthetic into hip joint 4 to 50 mo prior to THA; mean 18 mo • Follow-up 25.8 mo post-surgery with range 9-78 mo • NO instances of post-operative joint infection or sepsis occurred • Similar data from Sankar et al and Sreekumar et al in the hip and Desai et al in the knee • Data from McIntosh et al raise concern about infection if given within 6 weeks of surgery (trend but NS) McIntosh et al. Clin Orthop Relat Res 2006

15. Best way of cleansing the skin? • Current evidence based guidelines for inserting IV catheters suggests the following is best practice according to EPIC 2, a mega- systematic review of best practices for prevention of catheter associated infections • Decontaminate the skin site with a single patient use application of alcoholic chlorhexidine gluconate solution (preferably 2% chlorhexidine gluconate in 70% isopropyl alcohol) prior to the insertion of a central venous access device. (Class A) • Use a single patient use application of alcoholic povidone-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter (Class D) Journal of Hospital Infection (2007) 65S, S1–S64

16. Arthrocentesis and anticoagulation?Ahmed and Gertner Am J Med 2012 • Retrospective review of complication in 640 arthrocentesis in 514 anticoagulated patients • Compared the incidence of significant bleeding in patients by INR (>2 or < 2) • Conclusion: no need to reduce anticoagulation level prior to procedures Comparisons between groups NS Patient with bleeding also had pain

17. Should I use anesthesia prior to a procedure? • Park et al Rheumatol International 2009 • 99 patients underwent 2 arthrocenteses • One without and one with anesthesia • Procedures performed with: • Conventional syringe or • Reciprocating procedure device • Pain measured on 10 cm VAS (0 no pain; 10 unbearable pain)

18. Benefit of buffering lidocaine • Lidocaine maintained at acidic pH to increase shelf life; pH 6.2 preventing photodegradation/aldehyde formation; lidocaine-epinephrine has even lower pH (5.98) • Sodium bicarbonate neutralizes pH (7.2) but does not affect onset of action; increases efficacy via increasing uncharged form of drug • Buffering: 1 part (1mEq/ml) sodium bicarbonate to 10 parts lidocaine • Consistent literature favoring buffering: • Vasectomy • Bone marrow Bx • IV cannula insertion • Laceration repair • Etc.. Cristoph et al. Ann Emerg Med 1988;17:117-120

19. Pain scores on VAS following intradermal infiltration of unbuffered and buffered local anesthesia Pain on VAS 6.21 7.22 5.98 7.16 6.18 7.20 pH noted Cristoph et al. Ann Emerg Med 1988;17:117-120

20. Needles: Primum non nocere or Gardner’s rule 23 “use the smallest needle necessary to get the job done” 25 Gauge 22 Gauge 18 Gauge 18 gauge in articular cartilage John Clark, MD, PhD

21. New ways of doing procedures Dual Injector Three Way Stop Cock Simkin Method Reciprocating Procedure Device

22. Which is he best corticosteroid preparation? • Triamcinolone (Aristospan, Kenalog) - easily goes through 26-30 gauge needles, • Methylprednisone Acetate (Depomedrol) -floculant, may require larger than 30 gauge needle. • Betamethasone Acetate (CelestoneSoluspan) - mixture of short and long acting preparation • Dexamethasone Acetate (Decadron-LA) - Long acting, frequently mixed with Decadron for short and long acting combination • Only head to head trial of TCA 20 mg vs MPA 40 mg in knee OA - TCA better pain relief, MPA lasted longer • In 2 small trials of TCA vs MPA in RA, TCA lasted longer Pyne D, et al Clin Rheumatol 2004;23:116-120

23. Can we mix anesthetic and steroids? Percent drug remaining after time noted by HPLC • Dogma about not “mixing” local anesthetic with steroids especially methylprednisolone; 74% of us do mix • Preservative parabens may cause steroid to appear flocculant • HPLC study to determine stability of mixed contents for epidural injections • Conclusion: mix away! Shat et al. BJ Radiology 2009;82:109-111 Stored at 370

24. Why do patients with acute onset joint effusions keep their joint at 30-450 of flexion? Boyles Law of course! Boyles Law: Pressure is inversely proportional to volume when temperature is constant in a closed system pV=C www.grc.nasa.gov/WWW/K-12/airplane/aboyle.html

25. Joint position and intra-articular pressure:Maximum joint volume between 30-450 of flexion Hochberg et al. Rheumatology 3rd edition

26. Practice Point:Three causes of severe joint pain • There are three causes of joint pain so severe that the patient will guard the joint and protect against movement • BUGS • BLOOD • CRYSTALS • Patients hold their joint 300 of flexion as this represents maximum joint volume; flexion or extension results in reduced volume thus increased pressure • Slowly developing joint effusions allow time for the capsule to distend and thus do not cause the same degree of pain BBC Joint

27. Convex vs Concave Joint Surfaces Electronic Textbook of Hand Surgery www.eatonhand.com Carpus Direction of Needle Convex Concave Radius Ulna Radius Ulna

28. Making your own polarizing microscope

29. Synovial Fluid Findings Only a small amount of synovial fluid is necessary to make the diagnosis of crystalline forms of arthritis; important to crystal prove at least once

30. Scope and Kit

31. Placing Polarizer and Analyzer

32. Crystals

33. Shoulder Subacromial Region

34. Shoulder Anatomy • Osseous structures • Scapula • Scapular spine • Acromium • Glenoid • Coracoid • Clavicle • Humerus

35. Shoulder Anatomy • Important muscles • Deltoid • Rotator Cuff • Scapular stabilizers • Important joints • Glenohumeral • Acromioclavivular • “Scapulothoracic” • Other • Redundant capsule • Subdeltoid bursa

36. Glenohumeral Joint: Circle of Stability Long head of biceps tendon Note pear shaped glenoid that allows humeral head to be depressed by RTC muscles

37. Shoulder Joint Capsule Capsule distended Grays Anatomy

38. Suggested X-rays: Internal rotation External rotation Axillary view Axillary view External rotation view Mike Richardson, M.D.

39. Dx in 101 Patients with Shoulder Pain Over 18 Months in Internal Medicine Clinic Diagnosis Percent Rotator Cuff Disease 62 Myofascial Pain 22 Adhesive Capsulitis 10 AC Joint OA 4 Bicepital Tendonitis 3 RA/OA/RSD/PMR 1 each Anderson, Kaye. West J Med 1983; 138:268

40. Impingement Syndrome • Impingement is caused by compression of the rotator cuff tendons and subacromial bursa between the greater tubercule of the humerus and the lateral edge of acromion; direct trauma vsimpairment of blood supply? • 3 stages of impingement syndrome described by Neer • Stage 1 - Edema and hemorrhage • Stage 2 - Cuff fibrosis, thickening, and partial cuff tearing • Stage 3 - Full thickness tendon tears, bony changes, and tendon rupture. Neer CS, 2d. Impingement lesions. Clin Orthop 1983; 173:70

41. Posterolateral Injection of the Subacromial Space • Behind humeral head, under the acromium, directed toward the AC joint • 25 gauge, 1 1/2 inch needle • Anesthesia with 3-4 cc 1-2% lidocaine useful as diagnostic test • Inject with 2 cc bupivicaine & 20-40 mg of depomedrol or triamcinalone

42. Lateral Subacromial Injection • Lateral • Palpate AC joint • Identify acromion • 1 cm below acromion; angle under AC joint

43. Subacromial Injection: Lateral vs Posterolateral

44. Note how patient is elevating arm?

45. Injection + exercise vs exercise alone for RTC tendonitis • 227 pts randomized to injection + exercise vs exercise alone for impingement syndrome; mean 16 wks of pain • 20 mg of triamcinolone plus lignocaine • Exercise individualized; attended as many PT sessions as necessary • Outcome: • 1 & 6 wks pain/disability scores significantly better for injection • At 12 & 24 wks NO difference between groups • At later assessments, exercise only group taking more pain meds& 32% were injected at some time between 12 and 52 wks • Conclusion: • Injection therapy provides early pain improvement in impingement syndrome • One-third of exercise only patients go on to injection Crawshaw et al BMJ 2010

46. Do repeated injections lead to RTC tears? • 230 patients who had had an MRI scan for impingement symptoms retrospectively evaluated for frequency of RTC tears by number of subacromial steroid injections • 128 had 0-2 injections, 102 had 3 or more • Exclusions: age > 70, trauma, RA, Diabetes • Results: • Conclusion: repeated injections NOT associated with RTC tears • More full thickness tears in fewer injection group?? Ann R Coll Surg Engl 2009; 91: 414–416

47. Does a corticosteroid injection help in adhesive capsulitis and if so does it matter where we put it? • 191 pts with adhesive capsulitis randomized to 4 groups; all received progressive PT • Subacromial steroid injection (40 mg TCA) • Glenohumeral steroid injection • Combination injection using same total steroid dose • NSAID • At 16 weeks steroid groups significantly less pain and improved motion compared to NSAID only • At 24 weeks no difference b/w groups • Did not matter where the steroid was placed (US guided) Shin SJ, Lee SY. J Shoulder Elbow Surg 2013;22:521-527

48. Knee

49. Knee anatomy • Important points: • Synovial space extends above patella; large target • Synovial space posterior to knee joint as well; may explain why patients have posterior pain with an effusion Gray’s Anatomy

50. Menisci Bursae ACL PCL Infrapatellar Fat Pad Menisci Joint Capsule