Chapter 55: Intra-Articular Joint Injections

INTRODUCTION

In the past, the purpose for gaining intra-articular access of joints has been predominant for aspiration of synovial fluid and injection of corticosteroid. Over recent years, other options of intra-articular injections have been emerging, including viscosupplementation as well as biologic therapies such as platelet-rich plasma and stem cell therapy. It is anticipated that many more options will be available in the future and physicians carrying for patients with joint pathologies will want to develop expertise in performing intra-articular injection techniques.

Physicians treating musculoskeletal diseases have been taught an understanding of pathophysiology, functional anatomy, and biomechanics. In addition, physicians need to develop injection experience and a kinesthetic sense of feel as the needle traverses tissue planes and anatomical structures. Physicians who have gained significant fluoroscopic-guided injection experience typically have a much better respect for traversing tissue planes and understanding how a needle behaves when it is guided toward a target. An intra-articular injection is often part of a complex diagnostic and treatment algorithm, and physicians need to have a specific plan as to what will be the next step based on response to the procedure. A patient who benefits for 7 to 14 days may require much more complicated management and planning treatment than the patient who benefits for 6 months after the injection.

Anatomical Landmarks

A key to intra-articular injections is the process of identifying specific anatomical and topographical landmarks. It is recommended to utilize a systematic approach of anatomical landmark localization and skin marking before every procedure. In addition to understanding landmarks, one also needs to have a keen understanding of the anatomy that needs to be avoided during the procedure, such as nerves, vessels, ligaments, tendons, etc.

Selection of needles, medications, and equipments:

• Sterile gloves

• Sterile fenestrated drape

• 4 × 4 gauze soaked with povidone-iodine solution (Betadine)

• 30-gauge 0.5- or 1-in needle for subcutaneous infiltration

• 25-gauge 2-in needle, 25-gauge 3.5-in Quincke needle, 22-gauge 3.5-inch Quincke needle, 22-gauge 5-in Quincke needle

• Quincke needles are styleted, and have a relatively dull tip that does not cut into articular cartilage as readily as a standard sharp beveled needle

• 3-cc syringes

• Hemostat, especially if intra-articular access is for the purpose of aspiration, in order to stabilize the needle to switch syringes.

• Extension tubing to facilitate syringe changes from local anesthetic, to contrast, to injection solution. It also keeps the syringe and hands out of the way of the radiographic picture during fluoroscopic injections.

• Local anesthetic (lidocaine, bupivacaine)

• Proposed injectate (deposteroid, viscosupplement)

• Skin marker

• Radiographic marker for fluoroscopic identification of structures

• Paperclip or similar object for ultrasound identification of structures

Indications

• Symptomatic degenerative shoulder joint disease

• Fluid aspiration for diagnosis and treatment

• Viscosupplementation (not FDA approved)

Contraindications

Contraindications to any intra-articular injection will include:

• Uncooperative or noncompliant patient

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