“ The Art of the Injection”

1. “The Art of theInjection” By Jon C. Brillhart PA-C Daivd Lannik MD Portsmouth Orthopedics, Inc

2. 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.

3. “The right medicine”, “in the right quantity”, “given in the right stop”, “at the right time”. Quoted from David Lannik MD, 2005.

4. 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.

5. Indications for Diagnostic and Therapeutic Injections Soft Tissue conditions • Bursitis • Tendonitis or tendinosis • Trigger points • Ganglion cysts • Neuromas • Entrapment syndromes • Fasciitis

6. Indications for Diagnostic and Therapeutic Injections Joint Conditions • Effusion of unknown origin or suspected infection. • Crystalloid arthropathies • Synovitis • Inflammatory arthritis • Advanced osteoarthritis

7. 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

8. 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

9. Top Six Injections • Chronic subdeltoid bursitis • Shoulder capsulitis • Knee osteoarthritis • Tennis elbow • Trapezio metacarpel joint OA • Plantar fasciitis

10. 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!!!

11. Equipment • Safety (oxygen, anaphylaxis kit, crash cart, msds) • Appropriate needles and syringes • Medication with “in date” expirations!

12. 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.

13. 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).

14. Corticosteroid Agents by Relative Potencies, Duration, and Dose AgentPotencyDurationDose/Site Hydrocortisone acetate Low Short 10 to 25 mg for (Hydrocortone) soft tissue and small joints 50 mg large joints Methylprednisolone Intermediate Intermediate 2 to 10 mg for (Depo Medrol) soft tissue and Triamcinolone small joints (Aristocort) 10 to 80 mg for large joints Dexamethasone sodium High Long 0.5 to 3 mg for (Decadron) soft tissue and small joints 2 to 4 mg large joints Betametasone sodium High Long 1 to 3 mg for soft tissue phosphate and acetate and small joints (Celestone Soluspan) 2 to 6 mg large joints

15. Recommended maximum dosages and volumes for joint injections SiteDosageVolume Shoulder 30 mg 10 ml Elbow 20 mg 5 ml Wrist, Thumb 10 mg 2 ml Fingers 5 mg 1 ml Hip 40 mg 5 ml Knee 40 mg 10 ml Ankle, foot 20 mg 5 ml Toes 10 mg 1ml

16. 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

17. 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

18. 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)

19. Warning!!! Never use epinephrine / lidocaine solution on ears, nose, fingers and toes!!!

20. Onset, Duration, and toxicity of local anesthetics Drug Onset Duration Max Vol Lidocaine 1% 1-2 Min ~ 1 Hour 20 ml 2% 1-2 Min ~ 1 Hour 10 ml Bupivacaine 0.25% 30 Min 8 hours 60 ml 0.50% 30 Min 8 Hours 30ml

21. “A Failure of the Supporting Structure of the Total Organ (Joint)” 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 concentrationand 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.

22. 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?).

23. 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

24. ViscosupplementationBasic Principle 100 0 10 90 20 80 hylan G-F 20MW 6 million 30 70 40 60 Normal % Elasticity % Viscosity 50 50 OA 60 40 30 70 running 80 20 walking jumping 90 10 500,000 HA MW 100 0 0.01 0.1 1 10 20 Frequency (Hz)

25. Types • Synvisc • Hylagan • Orthovisc • Suparz

26. Positioning

27. Successes!

28. 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

29. Overall Response to Hylan G-F 20 Viscosupplementation Much Better 35.0% Better 42.2% Same 21.4% Worse or Much Worse 1.3% 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.

30. 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.

31. Treatment • Who is the best candidate for injection? • When to choose preventive vs operative medicine

32. OsteoarthritisCLINICAL MANAGEMENTOA Treatment Modalities ACR 2000 GUIDELINES – Pharmacologic/Surgical Therapy • Mild to Moderate Pain • Simple analgesics (eg, acetaminophen) • OTC NSAIDs • Topical creams • Moderate to Severe Pain • COX-2–selective inhibitors (CELEBREX) • Rx NSAIDs plus gastro-protective agent Additional Therapies • IA hyaluronans • IA steroids • Tramadol • Opioids Surgical Intervention • Arthoplasty; osteotomy • Total knee replacement Adapted from American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000;43:1905-1915.

33. Questions?

34. Thank you, Have a Blessed Day! & God Bless America!