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Arthrocentesis Presentation Katie Krimetz Core Surgery

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Aug, 2009 - A presentation given during my surgery rotation; reviews arthrocentesis procedures and landmarks

Aug, 2009 - A presentation given during my surgery rotation; reviews arthrocentesis procedures and landmarks

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  • 1. Arthrocentesis
    Katie Krimetz
    Western University, College of Veterinary Medicine
    4th Year Core Surgery Rotation
    Veterinary Specialty Hospital, San Diego
    8/28/09
  • 2. OutlineArthrocentesis
    Case Presentation
    Importance
    Which Cases
    Technique for Collection
    Which Joint(s)
    Analysis
    References
  • 3. Case PresentationDr. Jackson, 8/7/09
    Subjective
    “Bear,” 8 years, M(N), Golden Retriever
    Left hind limb lameness, duration: 4 days
    Hx: “ligament wrap” sx done April 2009
    Objective
    PE: Left hind limb – joint effusion, pain, medially luxating patella
    Assessment
    Prior L-CrCL tear
    Sx: lateral fabellar/extracapsular technique  “Ligament wrap”
    Grade 3/4 MPL
    OVERVIEW
    Image: http://farm2.static.flickr.com/1265/1187377381_e92ef2cd93.jpg?v=0
  • 10. Case Presentation“Bear,” 8 years, M(N), Golden Retriever – Dx: MPL, L-CrCL
    Plan
    Radiographs - Effusion noted
    Surgical correction of MPL
    Lateral imbrication
    Recession block trochleoplasty
    Medial releasing desmotomy
    +/- TPLO
    Intra-Operatively
    Joint effusion, synovitis
    Cytology: suppurative inflammation
    Patellar realignment achieved once excess joint fluid was removed
    Trochlear ridge appeared smooth and deep
    Implant from previous CrCL correction was removed
    Closed suction drain placed
    OVERVIEW
    Image: http://www.acvs.org/
  • 17. Importance of Arthrocentesis
    Assess historical and current joint status
    Clinical Examination
    Obvious signs
    Septic arthritis
    Rheumatoid arthritis
    Subtle Changes
    Systemic lupus erythematosus
    Idiopathic polyarthritis type I
    Etiologies of Disease
    Cranial cruciate rupture, 2° to immune-mediated polyarthritis (3)
    OVERVIEW
  • Which Cases
    Differentiating
    Osteoarthritis vs inflammation vs infection vs other
    Cytology (total white cell count)
    Protein analysis
    Mucin clot test
    Doubt in a lameness diagnosis
    More than one joint affected
    Immune mediated polyarthritis
    Usually affects smaller joints (carpus, tarsus) (3)
    Clinical Signs
    Joint effusion/swollen joint/pain
    Pyrexia of unknown origin (4)
    Monitoring response to therapy
    Infective arthritis
    Immune mediated polyarthritis
    OVERVIEW
  • Technique for Collection
    Aseptic Conditions
    Surgical skin preparation
    Sterile gloves worn
    Equipment
    Syringes
    1 to 6 ml
    Sufficient negative pressure
    Needles
    20-25g hypodermic
    1-2.5” long for proximal joints, 5/8-1” for distal joints
    Glass Slides
    Tubes
    EDTA – for preserving cells
    Sterile tubes/Culture medium – for culture
    OVERVIEW
    Image: http://www.vetmed.wsu.edu/resources/Techniques/images/arthro_carpus.jpg
  • 36. Technique for Collection
    Restraint and lateral recumbency
    Sedation
    Local anesthesia
    Short-acting anesthetics
    Assessment
    Volume
    Viscosity
    Color
    Appearance
    Analysis of fluid
    OVERVIEW
  • Technique for Collection
    Smears
    Push or pull smears slowly  thin smears
    Air dried
    Rapidly to reduce cell shrinkage and artifacts (3)
    Artifacts: (3)
    Lytic neutrophils  mimics degenerative changes in infections
    Vacuolated synovial cells  mimics osteoarthritis
    Staining
    Romanowsky-type stain
    Diff-Quik
    Wright’s Stain
    Giemsa Stain
    Cultures
    OVERVIEW
  • Technique for Collection
    Avoiding vessels and nerves, boney protuberances will be the most reliable landmarks
    Caution with osteophytes
    Introduce needle into joint, and apply negative pressure
    If no fluid is aspirated, release pressure, and redirect
    After successful aspiration, release pressure, and remove needle from joint
    OVERVIEW
  • Technique for Collection
    Scapulohumeral Joint
    6ml syringe
    1.5-2” needle, 20-21g
    Main landmark:
    Acromion process (4)
    Insert needle distal to the
    acromion process, directed
    perpendicular and
    slightly dorsomedial
    Withdraw slightly and aim
    more distally or proximally
    Gentle traction and abduction
    of limb may help
    OVERVIEW
    Image: Reference 2
  • 61. Technique for Collection
    Elbow Joint
    6 ml syringe
    1-1.5” needle, 21-23g
    Main landmark:
    Lateral epicondyle,
    olecranon, and
    epicondylar crest (4)
    Flex elbow to 45°
    Insert needle level with and perpendicular to the lateral epicondyle
    Direct distomedially to epicondylar crest, along anconeal process
    OVERVIEW
    Image: Reference 2
  • 68. Technique for Collection
    Carpal Joint (radiocarpal and middle carpal)
    3ml syringe
    5/8” needle, 23-25g
    Main landmark:
    Radius, radiocarpal
    bone, and 2nd and 3rd
    carpal bones
    Flex carpus to 90°
    Insert needle
    perpendicular to skin
    Avoid neurovascular bundle on dorsal surface
    OVERVIEW
    Image: Reference 2
  • 75. Technique for Collection
    Coxofemoral Joint
    6-12ml syringe
    2.5” needle, 20g
    Main landmark: Greater trochanter (4)
    Abduct and internally rotate hip
    Insert needle from craniodorsal to greater trochanter
    Angle needle medially and caudoventrally
    OVERVIEW
    Image: Reference 2
  • 82. Technique for Collection
    Stifle Joint
    6ml syringe
    1-1.5” needle, 21g
    Main landmarks:
    Patella, patella ligament,
    and tibial tuberosity (4)
    Partially flex the stifle
    Insert needle lateral to
    patellar ligament, halfway
    between the patella and tibial tuberosity
    Angle needle caudomedially
    OVERVIEW
    Image: Reference 2
  • 89. Technique for Collection
    Tarsal Joint
    1-6ml syringe
    5/8” needle, 23g
    Main landmark:
    Malleolus of the fibula,
    calcaneous, tibia
    Flex the joint
    Insert needle medially to
    the lateral malleolus of the
    fibula, parallel with the calcaneous
    Advance the needle medially and distally
    OVERVIEW
    Image: Reference 2
  • 96. Which Joint to Sample
    Determined by:
    Clinical signs
    Volume of synovial fluid needed
    Normal large joints may only provide 0.25-0.5ml of synovial fluid
    Large sites
    Stifle
    Shoulder
    Smaller sites
    Distal joints
    elbow, carpus, tarsus
    OVERVIEW
  • Analysis of Synovial Fluid
    Assessment: Volume, Viscosity, Color, Appearance/Transparency
    Nucleated Cell Count
    Total Cell Count
    Differential
    Culture
    Protein
    Mucin Clot Test
    OVERVIEW
  • Analysis of Synovial FluidAssessment
    Assessment of NORMAL fluid (syn-ovum)
    Volume
    Normal joints have 0.1-1.0ml
    Viscosity – Hyaluronic acid (mucin)
    High viscosity
    “Viscoelastic” behavior (3)
    Settled: thick/solid  shaken: becomes liquid (8)
    Color
    Colorless or slightly yellow
    Red streak of blood – likely contamination (3)
    Appearance
    Clear
    OVERVIEW
    Image: http://startswithabang.com/wp-content/uploads/2008/05/a_raw-egg.jpg
  • 115. Analysis of Synovial FluidAssessment
    Assessment of Synovial Fluid
    Hemarthrosis (recent hemorrhage)
    Red color
    Etiologies: intra-articular injury (fracture, ligament rupture), recent surgery/arthrocentesis, uncommon in hemorrhagic disorders
    Hemoglobin removed within 2-4 weeks (3)
    May become orange or yellow in color
    Inflammation/Increased nucleated cellularity
    Changes appearance  cloudy/turbid
    Color may be white-yellow or grey-red (3)
    OVERVIEW
  • Analysis of Synovial FluidNucleated Cell Count
    Nucleated Cell Count
    Laboratories require 0.25ml (6)
    Nucleated cell count will be based on amount of blood contamination
    Can always look for hemosiderin-laden macrophages and erythrophagocytosis
    Indicates hemorrhage, not iatrogenic (8)
    Normal joint fluid – 1-3 cells/hpf (6)
    Large mononuclear cells – 60-90% (3)
    Synovial cells and macrophages, Normal: <10% vacuolated
    Lymphocytes – 3-30% (3)
    Neutrophils are rare - <5% (3)
    Palisades or windrowing often seen – reflects viscosity (3)
    Background staining – pink granular material (hyaluronan)
    At 40x, each nucleated cell represents approx. 1000 cells/µl (8)
    OVERVIEW
  • Normal Synovial Fluid
    Large mononuclear cell
    Image: Reference 2
  • 128. Osteoarthritis
    Normal, slightly, and markedly increased cell counts may be seen
    Neutrophils – 2-4%
    Possible to see more
    May be recent trauma, hydroxyapatite/crystal formation, or idiopathic “arthritic flare”
    Mononuclear cells - >10% (3)
    Abundant foamy/vacuolated or phagocytic cytoplasm
    Diagnosis supported by radiography and arthroscopy
    Analysis of Synovial FluidNucleated Cell Count
    OVERVIEW
  • Non-Inflammatory Synovial Fluid
    Degenerative Joint Disease
    Large Mononuclear Cell
    Image: Reference 2
  • 135. Inflammation/Infective Arthritis
    Neutrophils – 95-98%
    Chronic disease (weeks) – 70-95%, may appear degenerate w/ bacteria (3,8)
    Multiple joints affected is rare
    Toxic neutrophils  infective
    Absence does not rule out
    Diagnosis and differentiation made by patient’s history and synovial fluid culture
    Analysis of Synovial FluidNucleated Cell Count
    OVERVIEW
  • Inflammatory Joint Disease
    Septic Arthritis
    Degenerate neutrophil with intracellular bacteria
    Image: Reference 2
  • 142. Immune-Mediated Disease
    Neutrophils – 20-90% (3)
    Non-degenerate
    Proteinacious background may be absent
    More than one joint
    Diagnosis supported by serology for classification and detection of infectious agents (or antibodies)
    Analysis of Synovial FluidNucleated Cell Count
    OVERVIEW
  • Inflammatory Joint Disease
    Non-septic Polyarthritis
    Non-degenerate neutrophil and Lymphocyte
    Image: Reference 2
  • 149. Analysis of Synovial FluidCulture
    Culture
    Should always be performed (6)
    When sepsis is a differential
    When neutrophils >12%
    Common isolates: (3)
    Dogs: Staph. Intermedius, Beta hemolytic Strept., MRSA
    Cats: Pasteurella multocida, Bacteriodesspp., E. coli
    Can be difficult to get successful culture
    Enrichment can help
    Incubate for 24 hours can improve sensitivity (3)
    EDTA may inhibit growth of bacteria
    If storing is required, use sterile tube
    PCR may be used to isolate difficult organisms
    OVERVIEW
  • Analysis of Synovial FluidProtein and Mucin Clot Test
    Protein
    Normal: 1.5-3.0 g/dl (2)
    Elevated: inflammation,
    intra-articular drug
    injections, excess EDTA
    Mucin Clot Test
    Semiquantitative assessment of hyaluronic acid content
    Differentiate effusion from a true decrease in viscosity
    Rarely needed for clinical decisions (3)
    Acetic acid induced precipitation (2)
    4 parts 2.5% acetic acid : 1part joint fluid
    Positive/adequate: tight rope-like clot
    Negative/decreased: rope clot does not form or is friable
    Assessment of viscosity at time of collection is just as informative (6)
    OVERVIEW
    Image: http://www.pathguy.com/lectures/synovflu.gif
  • 162. Still No Diagnosis
    Synovial membrane biopsy
    Exploratory arthrotomy
    Needle biopsy
    Local anesthetic for lameness evaluation (4)
    Contrast radiography (4)
    OVERVIEW
  • References
    Berg, R.I.M.; Sykes, J.E.; Kass, P.H.; Vernau, W. “Effect of Repeated Arthrocentesis on Cytologic Analysis of Synovial Fluid in Dogs” Journal of Veterinary Internal Medicine, April, 2009; 23:814-817
    DeNicola, Dennis; MacWilliams, Pete; Wamsley, Heather. “The Cytological Evaluation of Lumps and Bumps(A Practical Approach to Cytodiagnostics)” Western Veterinary Conference, 2008.
    Innes, John. “Synovial Fluid Analysis – What it Can Do For You.” North American Veterinary Conference, 2007.
    Langley-Hobbs, S.J., MA, BVetMed,m DSAS (O), DECVS, MRCVS. “How I Get Good Joint Taps.” British Small Animal Veterinary Congress, 2007
    MacWilliams, Pete; Wellman, Maxey; Wamsley, Heather. “Synovial Fluid Analysis.” Western Veterinary Conference, 2009.
    Read, Richard, BVSc, PhD., FACVSc. “Arthrocentesis: How, When, Where, and Why?” North American Veterinary Conference, 2006.
    Rochat, Mark C. “Arthrocentesis and Arthroscopy,” Chapter 74, Textbook of Veterinary Internal Medicine, Volume 1. Pages 276-278 Elsevier Saunders, St. Louis Missouri, 2005.
    Wilson, Sherri, DVM, ACVIM. “In-House Joint Fluid Analysis in Dogs and Cats.” VIN Consultant, Animal Critical Care and ER Services, Seattle WA. Updated: 2/19/07
    OVERVIEW
  • Synovial fluid response in disease: dog and cat (Taken directly from Reference #2)
  • 175. Thank You!
    I have truly enjoyed my surgical externship here at VSH, and I am appreciative of the countless experiences and opportunities you have provided for me.
    ~ Katie Krimetz