Injection therapy (IT) for the treatment of joint pain has ... · treatment of joint pain has been...
Transcript of Injection therapy (IT) for the treatment of joint pain has ... · treatment of joint pain has been...
1. Introduction
Ian Reilly FCPodS DMS
Consultant Podiatric Surgeon
� Injection therapy (IT) for the
treatment of joint pain has been
performed for many years using
different substances� Compounds such as sodium bicarbonate,
potassium phosphate and procaine have been used
from the first half of the twentieth century▪ Miller JH, White J, Norton TH. The value of intra-articular injections in osteoarthritis of
the knee. Journal of Bone and Joint Surgery 1958; 40B: 636-643)
� Hollander et al reported the use of
hydrocortisone and cortisone in 1951 with
further reports produced by Bornstein
and Fallet, and Lambelet (cited by Miller
et al)� Hollander JL, Brown EM Jr, Jessar R, Brown C. Hydrocortisone and cortisone
injected into arthritic joints; comparative effects of and use of hydrocortisone as
a local antiarthritic agent. J Am Med Assoc. 1951; 147: 1629-35.
� Even though injectable steroids have
been around for more than 50 years,
there is a paucity of (good) evidence
regarding their use� The challenge is to apply what evidence is
available appropriately in a safe and effective
manner
� Hyaluronate, alcohol, prolotherapy, needling
“The right medicine,in the right quantity,
in the right place,at the right time”.
David Lannik MD, 2005.
1. Introduction
� Diagnostic value� Pain relief� Aspiration
� Therapeutic value� Definitive treatment� To provide a pain-free window for some
other (curative) therapy)� To provide episodic pain and symptom
relief
Reduce pain
Improve mobility
Improve function
First, Do No Harm
Intra-articular
Peri-articular
Soft tissue (ST)
1. Introduction
� Chemically, they are derived from
cholesterol and all the molecules share a
common chemical structure
� Physiologically, the glucocorticoids have a
wide range of actions as glucocorticoid
receptors are found in a wide range of tissues
� As well as anti-inflammatory and
immunosuppressive actions, they affect
carbohydrate, protein and lipid metabolism, the
cardiovascular and the central nervous systems
� Corticosteroids are injected locally for an
anti-inflammatory effect
Phospholipids
Arachidonic Acid
Thromboxane A2Prostaglandins
Endoperoxides
Prostacyclins
Leukotrienes
COX I/II
Phospholipase A2
NSAIDsNSAIDs
Steroids
Cell Injury
� Triamcinolone acetonide � Adcortyl 10mg/ml
� Kenalog 40mg/ml � Net price 1ml vial = £1.49
� Methylprednisolone acetate� Depo-Medrone 40mg/ml
� Net price 1ml = £2.87
� (also 2/3mL) � Net price with lidocaine = £3.28
� Betamethasone phosphate� Betnesol 4mg/ml
� Net price 1ml amp = £1.17 � Hydrocortisone acetate
� Hydrocortistab 25mg/ml
� Net price 1ml amp = £5.72
�Diagnostic
�Therapeutic ?
�Both?Explain to your patient in advance of the possible outcomes and your subsequent strategy
�Plantar fasciitis
�Morton's neuroma
�Hallux limitus
1. Introduction
Injections will
not benefit
everyone!
Diagnosis
Knowledge of anatomy
Treatment algorithms
Technique
Drug choice
Dosage
� Diagnosis� An inaccurate diagnosis is
made
� Knowledge of anatomy� The drug is put into the wrong
tissue
� Treatment algorithms� Steroid therapy is used
inappropriately
� Treatment is aimed at
alleviating the symptoms without addressing the
underlying cause
� Technique� Poor technique allows the
spread of drugs into adjacent
tissues
� Injections are given too
frequently
� Little regard is given to
aftercare
� Drug choice� An inappropriate drug is
chosen
� Dosage � Too little or too large a dose is
given
� Soft tissue injection� If the patient is pregnant or breastfeeding
� Overlying soft tissue infection, cellulitis or dermatitis
� A viral infection or TB
� Bacteremia
� A known hypersensitivity to any of the constituent agent
� Lack of response after two injections
� Severe coagulopathy
� Anticoagulant therapy (relative contraindication)
� Intra-articular injections
� As for soft tissue, and:
� No more than 3 injections per year in
weightbearing joint
� Unstable joints
� Inaccessible joints
� Joint prosthesis
� Osteochondral fracture
1. Select the patient
2. Prepare the injection site
3. Prepare the injection
4. Give the injection
5. Record drugs/dose/batch No’s
6. Give aftercare advice
1. Introduction
� Do you have a clear diagnosis?
� Is injection therapy the best treatment?
… at this point in the treatment pathway
� Discuss all the options
� Are there any contraindications?
… absolute or relative
� Warn about side effects
� Record that this has been done
� Information to be given to the patient should
include:� The diagnosis and nature of their condition
� The details of proposed treatment and the alternatives
� The nature and effects of drugs to be given
� The most likely possible side effects and incidence
� The likely benefits
� Your plans for follow-up and after care
� Position the patient
� Mark the site
� Swab the skin and
allow to dry
� Iodine for joint
injections
� Cotton wool and
plaster at hand
MARK A CROSS CLEANSE THE CENTRE
Mark the site
� Decide the dose and volume
� Wash and dry hands
� Open vials/swab bungs
� Draw up the steroid
� Dilute with local anesthetic: 50/50, depending
on local guidelines
� Change the needle after drawing up
solution(s)
Hand washing and skin
disinfection is important –
do it in front of the patient
Simon AC (2004) Hand
hygiene, the crusade of the infection control specialist.
Alcohol-based handrub: the solution! : Acta Clin Belg. 2004
Jul-Aug;59(4):189-93.
1. Introduction
� White 19g
� Green 21g
� Blue 23g
� Orange 25g
� Grey 27g
1. Introduction
�Clinician preference (strength/dose)
� Soft tissue:
▪Methylprednisolone
▪ Hydrocortisone
� Joints:
▪ Triamcinolone
40mg triamcinolone
40mg methyl-prednisolone
6mg beta-methasone
4 mg dexa-methasone
�Diagnosis
�Analgesia
�Dilution
�Distension
� Diagnosis: this helps confirm the placement of the solution and the diagnosis
� Analgesia: although temporary, a reduction in pain will make the whole process less painful for the patient, may help break the pain cycle and may reduce the post-injection flare
� Dilution: an increased volume of solution helps spread the active drug where a larger joint is being injected
� Distension: large volumes of injected solution may help break down adhesions
� Patient consent – can be oral or written, but must be informed� Use (non-sterile) gloves; gowns are not required
� Keep talking to the patient – let them know what to expect
� Apply strong skin traction using a non-touch technique� Insert the needle rapidly and perpendicularly to the skin
� Attempt to aspirate
� Inject joints and bursae as a bolus; entheses with a peppering technique� Withdraw needle gently and keep the plunger depressed to prevent
suction of the steroid back into the syringe
� Compress the site with cotton wool to prevent capillary leakage along the needle tract
� Dispose of sharps safely
� Apply a dressing
1. Introduction
� The injection can
be painful – we
are often
injecting into a
hot spot (PMT)
� Be aware of
patient
apprehension
� Technique used
� Aseptic
� Drugs
� Name of drug
� Dose
� Batch number
� Expiry date
� Information sheet
� Warnings given
� “You should try and rest for
the first 2-3 days after the
injection and avoid any
activities that normally
make your symptoms
worse”
�... Treatment
�... Surgery
�... Injection
�... Etc...!
1. Introduction
Bugger!
You will see complications!� Use:
� 2.5 mL syringe
� 23/25 g needle (to inject with)
� 20-40 mg of methyl-pred or hydrocortisone
� Palpate the hot spot and mark
� Inject from a medial approach (… or plantar)
� Work the needle progressively deeper
� Look for needle paraesthesia – and go gently
� Aspirate
� Inject – peppering technique
1. Introduction
Patient education, PT, OT, BMI, exercise, etc
Surgery
Paracetamol
OTC NSAIDs
Rx NSAIDs
Creamer P et al, Lancet 1997;350:503-508
Joint
Injections
Fre
qu
ency
Difficu
lty
� Use:
� 2.5 mL syringe
� 21g needle (to draw up with) / 23/25g needle (to inject with)
� 20-40 mg of triamcinolone (or methyl-prednisolone)
� Palpate the joint line� Distract and plantarflex the toe – the joint line may pucker (if there
minimal dorsal arthrosis)
� You may be able to palpate this
� Start dorso-medially (DM): insert the needle away from EHL
� Medial and dorso-lateral (DL) approaches can be tried if the DM approach is difficult
� If you do go DL, remember the EHB tendon
� Ensure you are in the joint (given the length of the needle)
� Remember the curvature of the joint: damage from the needle tip can aggravate the pain
1. Introduction
1. Introduction
� Use:
� 2.5 mL syringe
� 23/25 g needle (to inject with)
� 20-40 mg of methyl-pred or hydrocortisone� Palpate the IM space� Mark up or visualise the MPJs� Hold the needle lightly at 90 degrees to the skin� Look for needle paraesthesia – deep – and go gently� Inject in-between and distal to the MPJs� Remember the plantar surface of the skin… the patient may
feel pin-prick sensation plantarly and falsely think this is from the neuroma (causing lipo-hypotrophy)
� Talk to the patient… they may JUMP!
1. An accurate diagnosis
2. Good judgement
3. Technical skills
As a basis, sound (3D) anatomical
knowledge is crucial
� …… is just the
beginning !
� "Education is a
progressive
discovery of our
own ignorance."
▪ Will Durant
� Foot and Ankle
Injection
Techniques: A
Practical Guide
� Stuart Metcalfe, Ian
Reilly. 2010
1. Introduction
FIN
Questions???