PRINCIPLES OF JOINT AND PERIARTICULAR ASPIRATIONS AND INJECTIONS

Published on 18/03/2015 by admin

Filed under Rheumatology

Last modified 22/04/2025

Print this page

This article have been viewed 2820 times

10 PRINCIPLES OF JOINT AND PERIARTICULAR ASPIRATIONS AND INJECTIONS

Gillian A. Hawker, Elizabeth Grigoriadis, Adel G. Fam

Indications for Aspiration and Injection of Joints and Periarticular Lesions

Aspiration and injection of joints and periarticular synovium-lined cavities (bursae and tendon sheaths) and injection of soft-tissue lesions (entheses, tendinitis, compression neuropathies, epidural sac) are indicated in the diagnosis and treatment of various musculoskeletal disorders. These are summarized in Table 10-1.

TABLE 10-1 INDICATIONS FOR ASPIRATION AND INJECTION OF JOINTS AND PERIARTICULAR LESIONS

Diagnosis

Diagnostic synovial fluid analysisSeptic arthritis, hemarthrosis, crystal arthritis, differentiation of inflammatory from noninflammatory arthritis

Diagnostic studies

Synovial biopsy

Small-bore needle arthroscopy (needlescope)

Therapy Repeated needle (closed) drainage of septic arthritis Drainage of large hemorrhagic or tense effusions Injection of therapeutic agents IA Corticosteroids Local control of inflammatory synovitis; periarticular lesions; efficacy in OA is less clear IA Hyaluronate Preparations Relief of pain in joints affected by OA IA Radioisotopes Control of chronic synovitis in inflammatory arthritis (radioactive synovectomy) using colloidal ¹⁹⁸gold (large joints), ⁹⁰yttrium (large joints), ¹⁸⁶rhenium (medium-sized joints), ¹⁶⁹erbium (small joints), and 32P chromic phosphate

IA, intraarticular; OA, osteoarthritis

(From Silva M, Luck JV Jr, Siegel ME. 32P chromic phosphate radiosynovectomy for chronic haemophilic synovitis. Haemophilia 2001;7 Suppl 2:40–49.)

Contraindications for Aspiration and Injection of Joints and Periarticular Lesions

The relative contraindications to intraarticular (IA) and periarticular injections of corticosteroids are summarized in Table 10–2. If infection is suspected in the joint, bursa, or tenosynovium, it should be aspirated and the synovial fluid examined for cell count, differential, and culture. In the setting of an inflamed joint, if the clinical diagnosis is unclear, or the aspirated fluid suggests possible infection, the aspirated fluid should be sent for cell count, differential, culture, and polarizing microscopy for crystals (Table 10-3). Intrasynovial corticosteroid injections may exacerbate an infection and are not recommended if there is suspicion of infection. Joint injection is also best avoided if there is bacteremia or infection of the overlying skin or subcutaneous tissue or in the presence of overlying skin lesions, such as extensive psoriatic plaques.

TABLE 10-2 RELATIVE CONTRAINDICATIONS TO INTRAARTICULAR AND PERIARTICULAR CORTICOSTEROID INJECTIONS

Suspected joint infection

Overlying cellulitis or other skin infection

Systemic bacteremia

Thrombocytopenia, bleeding disorders

Prosthetic joints

Osteonecrosis, IA fracture or severely destroyed or unstable joint

Tendon tears and steroid injections near the Achilles tendon

Multiple or high-dose IA steroid injections in patients with uncontrolled diabetes mellitus, hypertension, congestive heart failure, or psychosis

Skin surface area covered by psoriatic plaques

Hypersensitivity to local anesthetic (steroid alone may be used)

Reluctant patient

IA, intraarticular

TABLE 10-3 SYNOVIAL FLUID CHARACTERISTICS IN COMMON KNEE JOINT conditions

Bleeding disorders and severe thrombocytopenia are relative contraindications to joint aspiration. However, if diagnostic aspiration is deemed necessary, needle aspiration may be carried out after an appropriate cover for the bleeding disorder, such as factor VIII administration in a patient with hemophilia. Anticoagulant therapy with warfarin in the therapeutic range is not considered a contraindication to joint aspiration or injection.

Aspiration is recommended if prosthetic joint infection is suspected. However, a steroid injection into a prosthetic joint carries a particularly high risk of infection and is best avoided. Another risk is systemic absorption of a proportion of injected corticosteroid, which can result in worsening of uncontrolled diabetes mellitus, hypertension, congestive heart failure, or psychosis; such injections should be used cautiously in these patients.

Complications of Intrasynovial and Periarticular Corticosteroid Injections

The potential complications of IA and intralesional corticosteroid injections are summarized in Table 10-4. The risk of infection after intrasynovial corticosteroid injections is very low; among practicing rheumatologists, one study documented the rate at less than 1 per 75,000 procedures, while a study of primary care practitioners in Britain prospectively documented no infections following 1147 steroid injections. Infection rates can be minimized by observing stringent aseptic “no-touch” techniques and by using sterile disposable needles and syringes and single-dose vials of corticosteroid and lidocaine. Local aspirations and injections can occasionally result in minor hemorrhage in the joint (hemarthrosis) or periarticular tissues (ecchymosis).

TABLE 10-4 COMPLICATIONS OF INTRAARTICULAR AND INTRALESIONAL CORTICOSTEROID INJECTIONS

Introduction of infection

IA or periarticular hemorrhage

Postinjection flare

Destructive arthritis (“steroid arthropathy”) from multiple IA injections into weight-bearing, partially damaged joints

Systemic Effects

Transient facial flush, warmth, and diaphoresis

Worsening of diabetic control, hypertension, heart failure, or psychosis

Suppression of HPA axis

Iatrogenic Cushing syndrome

Local Effects

Leakage of steroid along needle tract

Atrophy of subcutaneous fat, depigmentation, telangiectasia, and periarticular calcifications

Misplaced injections

Tendon rupture, nerve damage, cartilage injury, subcutaneous fat granuloma, and sterile abscess formation

Rare Reactions

Pancreatitis, hypersensitivity reactions, uterine bleeding, central serous chorioretinopathy, posterior subcapsular cataract, osteonecrosis

HPA, hypothalamic–pituitary–adrenal; IA, intraarticular

Postinjection flare is an acute, self-limiting, corticosteroid crystal–induced synovitis that may occur after IA or periarticular injections of insoluble, crystalline, intermediate- or long-acting corticosteroid preparations. It occurs in about 1% to 10% of patients, usually within 12 to 24 hours after injection. The reaction often resolves spontaneously in 48 to 72 hours, and the elbow, wrist, and finger joints are the most commonly affected sites. It is important to caution the patient that the joint may become more painful for up to 48 hours after the injection and that this flare is transient and does not affect the therapeutic outcome.

Repeated IA injection of large doses of corticosteroid into weight-bearing joints (e.g., knee, hip) may very rarely result in joint deterioration, disorganization, and instability that resembles a neuropathic arthropathy. This can be prevented by using small steroid doses and limiting the number of injections into the same joint to fewer than three to four injections per year.

SYSTEMIC EFFECTS

A certain degree of systemic absorption of steroid occurs after local injections. After IA injection, methylprednisolone acetate remains in the plasma for a mean of 16 days. This systemic absorption can result in a transient steroid pulse, with facial flushing, diaphoresis, and sometimes worsening of diabetic control and aggravation of hypertension, heart failure, or psychosis. It can also lead to both Cushing syndrome and suppression of the hypothalamic-pituitary-adrenal (HPA) axis, particularly in those receiving frequent large doses into multiple joints. This complication can be minimized by giving small, infrequent IA doses (fewer than three or four injections per year) and resting the joint for 24 to 48 hours after injection. Activity and exercise have been shown to increase the escape of steroids from the joint.

LOCAL EFFECTS

Leakage of the steroid along the needle tract can lead to atrophy of both skin and subcutaneous fat, depigmentation, telangiectasia, and periarticular calcific deposits of hydroxyapatite crystals. This complication can be prevented by using a small-gauge needle and by applying local pressure for about 30 seconds after withdrawal of the needle.

Misplaced needle injections can lead to tendon rupture—particularly rotator cuff, long biceps, and Achilles tendons—nerve damage, injury of articular cartilage or IA disks, or formation of a sterile subcutaneous abscess or foreign-body granuloma.

Technique of Joint Aspiration and Injection

EQUIPMENT

Aspiration or injection of joints and soft tissues is an outpatient procedure that does not require specialized equipment. The equipment used includes povidone iodine or chlorhexidine, alcohol swabs, gauze pads, 1% or 2% lidocaine, ethyl chloride spray, disposable needles and syringes of various sizes, gloves, a corticosteroid preparation (Table 10-5), prepared small-patch dressing (e.g., Band-Aid), specimen bottles, and forceps.

TABLE 10-5 PREPARATIONS OF INTRAARTICULAR AND PERIARTICULAR CORTICOSTEROIDS

PROCEDURE

Using gloves, the clinician first identifies and marks the needle site with pressure from the cap of the needle and thoroughly cleanses the site with antiseptic solution or alcohol swabs. For local anesthesia, the skin and subcutaneous tissue are infiltrated down to the capsule with 1% or 2% lidocaine without epinephrine, using a small-bore needle. However, experienced physicians may opt to use topical anesthetics or no anesthetic at all; a single, quick needle thrust may be less painful than the local anesthetic when aspirating a joint effusion. With a proper aspiration technique, the needle passes freely through the skin, capsule, and synovial membrane, and a “pop” is felt as it enters the joint. Aspiration of synovial fluid confirms that the needle tip is within the joint space. If the fluid appearance raises any concerns about possible infection, injection should be abandoned and the fluid sent for cell count, differential, and culture. If the needle becomes clogged by fibrin clots, “rice bodies,” or synovial villi, slight rotation or repositioning of the needle or reinjection of a little of the fluid will often help to unclog the needle and allow additional fluid to be aspirated. The aspirating syringe barrel is then detached with the aid of forceps, leaving the needle in place, and the steroid is injected through another syringe. The ease of injection determines whether the needle is in the joint space. If more than gentle pressure on the plunger is required to inject the steroid solution, the needle tip is probably not free in the synovial cavity and should be readjusted. At the end of the procedure, the needle is swiftly withdrawn, light pressure is applied with sterile gauze on the needle site for about 30 seconds, and a sterile Band-Aid is applied for a few hours.

The accuracy of outpatient IA and intralesional injections has recently come under close scrutiny. It is estimated that about 50% of IA and intralesional injections are placed incorrectly. Ultrasonographic or computed tomographic (CT) guidance of IA and periarticular aspirations and injections is particularly useful for injecting deep, inaccessible joints and for aspirating small amounts of fluid (< 5 mm³). The procedure also reduces the risk of injury to articular cartilage, tendons, peripheral nerves, or blood vessels.

FOLLOW-UP CARE

Resting an injected joint for 24 to 48 hours after an injection—particularly large, weight-bearing articulations—has been shown to reduce the escape of steroid from the joint and to improve the antiinflammatory response.

PREPARATIONS OF INTRAARTICULAR AND PERIARTICULAR CORTICOSTEROID INJECTIONS

Corticosteroid preparations are divided into three categories based on potency and approximate duration of action of the drug (Table 10-6; see Table 10-5 also). Hydrocortisone, which can be synthesized, is the natural corticosteroid preparation. Prednisolone is less soluble, and the addition of methyl and acetate groups further reduces its solubility and prolongs its duration of action. The introduction of a fluorine atom to form triamcinolone enhances potency, and the addition of acetonide prolongs the duration of action. Therefore, the ranking order of potency is hydrocortisone, prednisolone salts, and then triamcinolone. Although triamcinolone is a highly effective preparation with a longer duration of action, it causes greater subcutaneous fat atrophy when leaked or injected extraarticularly compared to other steroid preparations. For this reason, use of prednisolone is preferred for periarticular injections.

TABLE 10-6 DOSAGES OF INTRAARTICULAR AND INTRALESIONAL CORTICOSTEROID INJECTIONS

SELECTED READINGS

Berger R.G., Yount N.J. Immediate “steroid flare” from intra-articular triamcinolone hexacetonide injection: Case report and review of the literature. Arthritis Rheum.. 1990;33:1284-1286.

Bernstein R.M. Injections and surgical therapy in chronic pain. Clin. J. Pain. 2001;17:S94-S104.

Bird H.A. Intra-articular and intralesional therapy. In: Hochberg M.C., Silman A.J., Smolen J.S., et al, editors. Rheumatology. third ed. Edinburgh: Mosby; 2003:393-397.

Canoso J.J. Aspiration and injection of joints and periarticular tissues. In: Hochberg M.C., Silman A.J., Smolen J.S., et al, editors. Rheumatology. third ed. Edinburgh: Mosby; 2003:233-244.

Dieppe P.A., Klippel J.H. Aspiration and injection of joints and periarticular tissues. In: Klippel J.H., Dieppe P.A., editors. Practical Rheumatology. first ed. London: Mosby; 1995:111-113.

Fam A.G. The ankle and foot. In: Klippel J.H., Dieppe P.A., editors. Practical Rheumatology. first ed. London: Mosby; 1995:120.

Grassi W., Farina A., Fillippucci E., Cervini C. Sonographically guided procedures in rheumatology. Semin. Arthritis Rheum.. 2001;30:347-353.

Gray R.C., Gottlieb N.L. Intra-articular corticosteroids: An updated assessment. Clin. Orthop.. 1983;177:235-263.

Jones A., Regan M., Ledingham J., et al. Importance of placement of intra-articular steroid injection. Br. Med. J.. 1993;307:1329-1330.

Kumar N., Newman R.J. Complications of intra- and peri-articular steroid injections. Br. J. Gen. Prac. 1999;49:465-466.

Pfenninger J.L. Injections of joints and soft tissues. Part I: General guidelines. Am. Fam. Physician. 1991;44:1196-1202.

Seror P., Pluvinage P., d’Andre F.L., et al. Frequency of sepsis after local corticosteroid injection (an inquiry on 1,160,000 injections in rheumatological private practice in France). Rheumatology (Oxford). 1999;38:1272-1274.

Speed C.A. Corticosteroid injections in tendon lesions. Br. Med. J.. 2001;323:382-386.

Related

Fams Musculoskeletal Examination and Joint Injection Techniques