Arthrocentesis Presentation Katie Krimetz Core Surgery

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

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Arthrocentesis Presentation Katie Krimetz Core Surgery

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

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