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
Evidence Based References
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Evidence based references
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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
Outline of Workshop

Didactics

Procedure pearls

Anatomy review

Clinical Issues and technique review

Surface anatomy

Present evidence based best practices
Current status of how we do and teach
arthrocentesis and injection therapy
Dangers of “Evidence
based Medicine”
Analytic rubric
Procedure distilled into discrete steps:
1. Patient counseling
2. Patient preparation
1.
5. Able to verbalize anatomy and
Discuss reasons for doing
the procedure
2.
Discuss details of doing the
procedure
mark appropriate location
6. Patient positioned properly for
site of procedure
3.
Discuss potential side effects 7. Skin cleansed properly
4.
Inquire about potential
contra-indications
8. Appropriate application of
anesthesia
Analytic rubric continued
3. Needle insertion
4. Post-procedure wrap-up
9. Choose appropriate needle
13. Skin re-cleansed if necessary,
and syringe for procedure
10. Needle inserted at
appropriate angle/depth
11. Needle/syringe stabilized
during procedure
12. Aseptic technique
site bandaged
14. Post-procedure counseling
provided
15. Sharps disposed of properly
16. Operator showed concern for
patient comfort
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
Procedure Pearls
Textbook complications of arthrocentesis &
injection therapy; How much should we worry?
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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
Textbook contraindications to injecting
corticosteroids into joints and soft tissue

Infection or suspected infection around the joint

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Hypersensitivity to injectables


Avoid injecting through psoriatic plaque
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
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
How often can we inject a knee?
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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
Steroid injection into hip prior to THA
Chitre 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
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
Arthrocentesis and anticoagulation?
Ahmed and Gertner Am J Med 2012


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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
Complication
INR >2
N=456
INR < 2
N=184
Early Bleeding
1 (0.2%)
0
Late Bleeding
0
0
Infection
1 (0.2%)
0
Pain
3 (0.7%)
0
Comparisons between groups NS
Patient with bleeding also had pain
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:


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Conventional syringe or
Reciprocating procedure device
Pain measured on 10 cm VAS (0 no pain; 10 unbearable pain)
Conventional syringe
Reciprocating syringe
49
50
Pain w/o anesthesia
9.22
9.39
NS
Pain of anesthesia
6.18
3.96
.006
Pain after anesthesia
4.10
1.84
.003
100%
100%
NA
# of subjects
% Pt wanting anesthesia
P
Benefit of buffering lidocaine

Lidocaine maintained at acidic pH to increase shelf life; pH 6.2
preventing photodegradation/aldehyde formation; lidocaineepinephrine 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
Pain scores on VAS following intradermal infiltration
of unbuffered and buffered local anesthesia
6
Unbuffered
Buffered
5
4
3
2
1
6.21
0
7.22
Lidocaine
5.98
7.16
Lidocaine with Epi
Cristoph et al. Ann Emerg Med 1988;17:117-120
6.18
7.20
Mepivacaine
pH noted
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
Dual Injector
Three Way Stop Cock
Simkin Method
New ways of doing
procedures
Reciprocating Procedure Device
Which is he best corticosteroid
preparation?
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Triamcinolone (Aristospan, Kenalog) - easily goes
through 26-30 gauge needles,
Methylprednisone Acetate (Depomedrol) floculant, may require larger than 30 gauge
needle.
Betamethasone Acetate (Celestone Soluspan) 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
Pyne D, et al Clin Rheumatol 2004;23:116-120
In 2 small trials of TCA vs MPA in RA, TCA lasted
Can we mix anesthetic and steroids?

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Dogma about not
“mixing” local
anesthetic with
steroids especially
methylprednisolone;
74% of us do mix
Percent drug remaining after time noted by HPLC
Formula 1
Triamcinolone
Bupivicaine
Iohexol
4 hours
93%
101
103
24 hours
97
99
101
Formula 2
Triamcinolone
Lidocaine
Iohexol
Preservative parabens
may cause steroid to
appear flocculant
4 hours
85
101
91
24 hours
85
101
97
Formula 3
Methylprednisolone
Bupivicaine
Iohexol
HPLC study to
determine stability of
mixed contents for
epidural injections
4 hours
88
103
104
24 hours
86
103
98
Formula 4
Methylprednisolone
Lidocaine
Iohexol
4 hours
101
102
98
Conclusion: mix away!
24 hours
98
99
93
Shat et al. BJ Radiology 2009;82:109-111
Stored at 370
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
Joint position and intra-articular pressure:
Maximum joint volume between 30-450 of flexion
Hochberg et al. Rheumatology 3rd edition
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
BBC Joint

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
Convex vs Concave Joint Surfaces
Electronic Textbook of Hand Surgery www.eatonhand.com
Carpus
Direction
of Needle
Convex
Concave
Ulna
Radius
Radius
Ulna
Making your own polarizing
microscope
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
Scope and Kit
Placing Polarizer and Analyzer
Crystals
Shoulder
Subacromial Region
Shoulder Anatomy
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Osseous
structures
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Scapula
Scapular spine
Acromium
Glenoid
Coracoid
Clavicle
Humerus
Shoulder Anatomy

Important muscles
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Important joints
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Deltoid
Rotator Cuff
Scapular stabilizers
Glenohumeral
Acromioclavivular
“Scapulothoracic”
Other

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Redundant capsule
Subdeltoid bursa
Glenohumeral Joint: Circle of Stability
Long head of
biceps tendon
Note pear shaped glenoid that allows humeral
head to be depressed by RTC muscles
Shoulder Joint Capsule
Capsule distended
Grays Anatomy
Suggested X-rays:
Internal rotation
External rotation
Axillary view
External rotation view
Mike Richardson, M.D.
Axillary view
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
AC Joint OA
10
4
Bicepital Tendonitis
RA/OA/RSD/PMR
3
1 each
Anderson, Kaye. West J Med 1983; 138:268
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 vs impairment 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
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
Lateral Subacromial
Injection

Lateral

Palpate AC joint

Identify acromion

1 cm below acromion;
angle under AC joint
Subacromial Injection:
Lateral vs Posterolateral
Note how patient is
elevating arm?
Injection + exercise vs exercise alone for RTC
tendonitis
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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
Crawshaw et al BMJ 2010
 One-third of exercise only patients go on to injection
Do repeated injections lead to RTC tears?
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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:
0-2 injections
3 or more
65 (50.8%)
48 (47%)
Partial thickness
12
21
Full thickness
50
24
Massive tear
3
3
RTC tears

Conclusion: repeated injections NOT associated with RTC
tears

Ann
R Coll Surg Engl 2009; 91: 414–
More full thickness tears in fewer injection
group??
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
1.
2.
3.
4.

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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;22:521-5
Knee
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
Menisci
Bursae
ACL
Menisci
PCL
Infrapatellar Fat Pad
Joint Capsule
Patella,
Lateral
Patellar Groove
(Femoral Sulcus)
Femoral
Condyles
MultiMedia Group, used with permission
Note “keel” of the patella
Purpose of patella?
Shape of Patella
Axial View of Knee
Visible Human
Lateral
Medial
Suprapatella
Lateral
Medial
Lateral
Medial
Lateral
Medial
Lateral
Medial
Midpatella
Lateral
Medial
Lateral
Medial
Reasons to aspirate or inject a knee

Aspirate

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
Inject



Confirm inflammatory arthritis/crystalline arthritis
R/O septic arthritis (knee most affected joint)
Relieve pressure in OA/inflammatory arthritis
Treat inflammatory arthritis with IA steroids
Inject steroids/hyaluronic acid for OA
Equipment

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
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21-22 gauge needle for aspiration (18??)
25 gauge to inject only
20-40 mg of triamcinolone or depomedrol
Like celestone soluspan for gouty arthritis when available
Knee approaches

There are at least 4 different routes utilized to enter
the knee joint

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Medial mid-patellar
Lateral supra-patellar
Anteromedial or anterolateral
Lateral mid-patellar
Each route has their proponents but it is important to
be be familiar with several as some patients will not
be easily approached via your most comfortable
route
Medial knee approach
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Medial approach is particularly
useful when there is a small
effusion
Identify the superior and
inferior poles of the patella
Mark a location 1/3-1/2 down
from the superior pole and just
below the medial margin of the
patella
Angle needle slightly inferior
and a bit superior to miss the
patellar keel
Make sure you look at the
patient’s foot; the needle
should be generally
perpendicular to the foot
Courtney & Doherty: Best Practice &
Research Clinical Rheumatology. 2009
Superolateral knee approach

This approach is
useful for large
effusions

Mark the area
where the
superior and
lateral margins of
the patella meet

Angle the needle
down and
medially into the
joint space
Courtney & Doherty: Best Practice &
Research Clinical Rheumatology. 2009
Anterior approaches
for knee injections

This approach can be
done from either the
medial or lateral
surface

Identify the patellar
ligament then the tibial
plateau

Generally there is a
“soft spot” that
identifies the area
adjacent to the
ligament and just
above the tibial plateau

Angle the needle
toward the center of the
Patella
Medial
edge of
patellar
ligament
Tibial
plateau
Anterior approach
“Soft spot”
 Needle directed toward center of knee
 Not recommended for aspiration

Lateral Midpatellar Approach




John Clark MD, PhD
Remember MRI scan
Suggest inserting
needle no further than
1/2 the way down the
lateral patellar margin
Tissue to traverse is thin
laterally and can use 1”
needle in normal sized
person
John Clark is using
butterfly needle in this
picture
Bilateral knee effusions
Note loss of medial concavity and bulging suprapatellar pouch
Anesthesia with 1-2% lidocaine without epinephrine
(what is wrong with this picture?)
Note marks on knee
Aspiration with 21-22 gauge needle and 20-30 cc syringe
Using mosquito clamp to change from aspiration to
injection syringe
Injecting with 40 mg of triamcinolone or depomedrol +/mixed with small amount of local anesthetic
Clean, bandage, bed rest x 24 hr
Accuracy of knee injection into non-effused joints
by location of injection

240 knee injected for OA done by one orthopaedic
surgeon into knees without effusions

Three approaches; anteromedial, anterolateral, and
lateral mid-patellar

Placement of injected material confirmed by fluoroscopy

Accuracy:

Anteromedial: 60/80 in joint space (75% accuracy)

Anterolateral: 57/80 in joint space (71% accuracy)

Lateral mid-patellar: 74/80 in joint space (93% accuracy)
Jackson et al. JBJS 2002;84-A:1522-27
Aspirate or not aspirate RA knee before steroid
injection?

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191 swollen RA knees randomized to receive 20 mg of
triamcinolone following:
 Complete aspiration of fluid
 No aspiration of fluid
Followed 6 mo primary end point recurrent knee swelling
Groups balanced with regard to gender, medications,
prednisone use, ESR etc.
Primary end point:


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Relapses in 23% of aspirated knees
Relapses in 47% of non-aspirated knees (p = .001)
Medications changed in similar % of pts during study
period
Weitoft & Uddenfeldt. Ann Rheum Dis 2000; 59:233
Should an RA knee be rested following injection?


Old dogma: bed for 2-3 days and then use crutches for 2-3 wks
Chakravarty et al Br J Rheum 1994




Randomized 91 Pts with inflammatory knee arthritis to 24 hr of in
hospital rest or usual activity after 40 mg of triamcinolone
hexacetonide & 2 cc of lignocaine in knees aspirated to dryness
VAS pain, knee circumference, 50 foot walk time, CRP followed at
3, 6, 12 and 24 months
Results - both improved at 3 wks; RG showed
highly significant improvement through 24 wks
compared to NRG in all of the study variables;
8 NRG & 2 RG Pts required reinjection
Conclusion - 24 hr of bed rest
improves clinical outcome for inflammatory
arthritis patients (OA pts as well?)
Conclusion

Make sure our patients are well informed about
the procedure process

If unsure, review basic anatomy before
procedure

Be careful but remember that serious adverse
events are very rare

Evidence based approach will hopefully turn a
“wild west” approach to arthrocentesis and
injection into a more orderly process!