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 Arthrography 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

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