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

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.

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

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.

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

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

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

Absolute and Relative Contraindications to Therapeutic Joint and Soft Tissue Injections 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

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

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!!!

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

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.

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).

Corticosteroid Agents by Relative Potencies, Duration, and Dose Agent Potency Duration Dose/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

Recommended maximum dosages and volumes for joint injections Site Dosage Volume 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

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

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

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)

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

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 30 ml

“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 concentration and average molecular weight of hyaluronic acid in synovial fluid2 “A Failure of the Supporting Structure of the Total Organ (Joint)” 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.

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?).

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 Slide 4 • The joint interior has four tissue elements—articular cartilage, synovial tissue, intra-articular ligaments, and synovial fluid.1 • Synovial fluid (SF) permeates the tissues of the joint and significantly influences the nature of the intercellular matrix around chondrocytes, nociceptors, and synovial cells. 1 • Synovial fluid exhibits marked elastoviscous properties due to its hyaluronan content.1 The properties of the hyaluronan allow SF to dissipate energy through viscous flow or to behave like an elastic body, depending on the force applied to the joint. 1 • The SF in the osteoarthritic joint is considerably different from that of the normal joint. Hyaluronan may be diluted and lower in molecular weight in osteoarthritis. Consequently, elasticity and viscosity are significantly lower.1 1. Balazs EA. The physical properties of synovial fluid and the special role of hyaluronic acid. In: Helfet AJ. Disorders of the Knee. 2nd ed. Philadelphia, Pa: JB Lippincott Company; 1982: 61-74.

Viscosupplementation Basic Principle 100 90 10 Slide 10 • This slide is a graphical illustration of the elastic and viscous behavior of solutions of hyaluronan or hylans. As the frequency of deforming force varies, elastic behavior is increased in relation to viscous behavior. In general, as the frequency or quickness of applied deformation force increases, the more elasticity these solutions exhibit. At a point during normal activities, the behavior of normal synovial fluid crosses over from predominantly viscous to predominantly elastic behavior. SF in the joint of OA patients is generally less elastic than normal SF to the same force. The crossover from viscous to elastic behavior occurs later if at all in osteoarthritic synovial fluid. A purified hyaluronan product with chains of low molecular weight (500,000) shows very little elasticity. Hylan G-F 20, on the other hand, behaves predominantly elastically throughout the range of forces seen with normal movements.1 1. Balazs EA. The physical properties of synovial fluid and the special role of hyaluronic acid. In: Helfet AJ. Disorders of the Knee. 2nd ed. Philadelphia, Pa: JB Lippincott Company; 1983: 61-74. 80 20 hylan G-F 20MW 6 million 70 30 60 Normal 40 % Elasticity % Viscosity 50 OA 50 40 60 30 70 running 20 80 walking jumping 10 90 HA MW 500,000 100 0.01 0.1 1 10 20 Frequency (Hz)

Types Synvisc Hylagan Orthovisc Suparz

Positioning

Successes!

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

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

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.

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

Osteoarthritis CLINICAL MANAGEMENT OA 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.

Questions?

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