PRINCIPLES OF JOINT AND PERIARTICULAR ASPIRATIONS AND INJECTIONS




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 198 gold (large joints), 90 yttrium (large joints), 186 rhenium (medium-sized joints), 169 erbium (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








































Normal Osteoarthritis Inflammatory Arthritis Septic Arthritis
Gross appearance Clear Clear Cloudy or opaque Opaque
Viscosity High High Low Low
Total synovial fluid WBC/mm 3 < 200 200–1000 1,000–75,000 > 50,000
% Polymorphonuclear cells < 25 < 50 > 50 > 90
Polarizing microscopy Negative Negative Positive for crystals in gout or pseudogout Negative


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.

Only gold members can continue reading. Log In or Register to continue

Mar 11, 2019 | Posted by in RHEUMATOLOGY | Comments Off on PRINCIPLES OF JOINT AND PERIARTICULAR ASPIRATIONS AND INJECTIONS
Premium Wordpress Themes by UFO Themes