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joint aspiration (arthrocentesis)

Indications: 1) pain relief 2) diagnostic a) no history of trauma 1] septic arthritis 2] crystal-induced arthritis 3] rheumatic arthritis b) joint injury or activity-related 1] intra-articular fracture 2] ligamentous tear 3] synovial or capsular tear Contraindications: 1) absolute a) localized abscess or cellulitis at site of injection b) active Herpes simplex virus (HSV) or tuberculosis infection 2) relative a) bleeding diathesis b) anticoagulant therapy - anticoagulation is not a contraindication [2] - safe in patients receiving direct oral anticoagulant therapy; - no need to withhold anticoagulation before procedure [4] c) bacteremia d) joint prosthesis (infected prosthesis is exception) Procedure: Preparation: 1) obtain informed consent 2) identify landmarks 3) wide-field skin cleaning 4) sterile glove 5) sterile drape may be indicated 6) consider ultrasound guidance [5] Precautions: 1) withdraw needle to subcutaneous tissue prior to redirecting needle 2) avoid removing the needle completely & redirecting Aspiration by joint: 1) glenohumeral joint aspiration a) locate inferolateral border of coracoid process, the anterior border of the acromion, & the medial border of the humeral head b) insert 4 cm, 22 gauge needle in space between inferolateral border of coracoid & humeral head, direct posteriorly toward glenoid rim c) aspirate fluid for laboratory studies 2) radiohumeral joint aspiration a) elbow flexed 90 degrees with hand pronated b) locate space between distal lateral epicondyle & proximal tip of olecranon process of radial head c) insert 4 cm, 22 gauge needle at a 90 degree angle to skin, direct medially & posterior d) aspirate fluid for laboratory studies 3) knee a) patient supine with leg extended b) locate space between the superolateral border of the patella & the lateral femoral epicondyle c) insert 4 cm, 20 gauge needle (for septic joint, use 18 gauge needle) parallel to floor in space 1 cm lateral to the patellar border, direct towards under surface of patella, with the quadriceps relaxed, patella may be lifted to facilitate insertion, d) aspirate fluid for laboratory studies e) knee may have as much as 50-75 mL of fluid, have 2 35 cc syringes available for aspiration of fluid 4) ankle a) patient supine, leg fully extended, foot partially plantar flexed b) locate joint line, 1 cm superior to the line joining the inferior borders of the malleoli, locate from medial to lateral the tibialis anterior tendon, the tendon to the extensor hallucis longus & the anterior tibial artery c) insert a 4 cm, 22 gauge needle along the joint line, avoiding the artery & tendons (lateral to the artery seems easiest), direct needle superiorly 2-3 cm into the joint space d) aspirate fluid for laboratory analysis Laboratory: 1) cell count with differential 2) Gram stain, culture & sensitivity - gram stain negative in 20% of septic arthritis, especially common with gram-negative organisms 3) crystal analysis under polarized light a) urate: needle-shaped, negative birefringence b) calcium pyrophosphate: rhomboid-shaped, positive birefringence c) hydroxyapatite (basic calcium phosphate) 4) serum glucose & joint fluid glucose 5) 'string test': Normal fluid when gently pushed from syringe will form a 5-10 cm 'string'. With infection, the 'string' will be shorter 6) tubes: red top & lavender top Radiology: - ultrasound guidance may improve success rate & avoid unnecessary joint aspirations [5] Differential diagnosis: 1) Bloody effusion: - traumatic injury - Charcot joint - tumor - sickle cell joints 2) Fat Droplets: intra-articular fracture 3) Purulent effusion: a) septic arthritis - bacterial (including tuberculosis) - fungal b) > 80,000 WBC/mm3 c) > 90% neutrophils d) joint glucose < 50% of serum glucose 4) Inflammatory effusion: a) etiology - rheumatoid arthritis - gout - pseudogout - viral arthritis b) joint fluid - 1000-50,000 WBC/mm3 - 30-50% lymphocytes - 50-70% neutrophils 5) crystal examination: a) uric acid (gout) - rods or needles - negatively birefringent (yellow) under polarized light b) calcium pyrophosphate dihydrate (pseudogout) - rods, rectangles, or rhomboids - weakly positive birefringent (blue) under polarized light Complications: 1) seizures from local anesthetic: - IV diazepam should be available 2) subcutaneous swelling & pain after procedure: - ice may attenuate 3) post procedural infection 4) damage to tendons Management: - empiric antibiotic therapy while awaiting culture results - ceftriaxone & vancomycin

Related

gout infectious arthritis (septic arthritis) pseudogout [calcium pyrophosphate dihydrate crystal deposition] or CPPD disease rheumatoid arthritis (RA)

Specific

joint aspiration/injection traumatic tap

General

clinical procedure

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 779-781
  2. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
  3. Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Best Pract Res Clin Rheumatol. 2013 Apr;27(2):137-69 PMID: 23731929
  4. Yui JC, Preskill C, Greenlund LS. Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc 2017 Aug; 92:1223 PMID: 28778256 http://www.mayoclinicproceedings.org/article/S0025-6196(17)30310-5/fulltext
  5. Gibbons RC, Zanaboni A, Genninger J, Costantino TG. Ultrasound-versus landmark-guided medium-sized joint arthrocentesis: A randomized clinical trial. Acad Emerg Med 2022 Feb; 29:159 PMID: 34608713 https://onlinelibrary.wiley.com/doi/10.1111/acem.14396