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University of Southern Mindanao College of Veterinary Medicine Vet Anat 312 GENERAL VETERINARY MACROSCOPIC ANATOMY Laboratory Exercise

No.8 Arthrocentesis Jean Angelo P. Untal 3-DVM-A July 18, 2012

Introduction Arthrocentesis, or Joint Aspiration is a clinical procedure used for the extraction of synovial fluid from the joints. Arthrocentesis is performed by using a syringe fitted with a sterilised needle that goes straight into the joint capsule from where the fluid is to be extracted. Apart from being used as a diagnostic tool, arthrocentesis is also used for draining out any excess and accumulated synovial fluid in the joints. Accumulated synovial fluid which contains white blood cells can destroy the joint significantly. So, draining off the unwanted fluid would not only alleviate the inflammation of the joint but also reduce pain. Aspiration technique The anterior, lateral, or medial approach may be used to aspirate the hip joint. As the hip joint is deep, aspiration under fluoroscopic guidance helps to assist with intracapsular needle placement. In addition, this technique allows for contrast arthrography to confirm joint penetration in difficult cases. Ultrasound-guided aspiration is a useful technique that is more accessible and avoids radiation exposure in infants and toddlers. In these young patients, sedation may be necessary to perform a useful arthrocentesis.[7] With the patient in the supine position, insert an 18-gauge spinal needle approximately 2 cm distal and 2 cm lateral to the intersection of the femoral artery and the inguinal ligament. Direct the needle posteromedially at an angle of 60 until bone is reached. Confirm the position of the needle using image intensification or ultrasound. A lateral approach also may be used, inserting the needle just anterior and inferior to the tip of the greater trochanter. With the hip internally rotated, advance the needle in a proximal and medial direction toward the femoral neck. In young children, the hip may be aspirated using the adductor, or medial, approach. The hip is flexed and abducted and the needle is placed inferior to the proximal adductor longus tendon, aiming toward

the femoral head. In all techniques, small volumes of dilute radio-opaque dye (or air in the case of infants) may be used to confirm intracapsular needle placement. ANKLE Pathophysiology/epidemiology Eight percent of cases of monoarticular septic arthritis involve the ankle. Septic arthritis of the ankle is associated with a high degree of morbidity and mortality. As is the case with all joints, the most common origin of septic arthritis of the ankle is hematogenous spread. The ankle joint, however, is very susceptible to soft tissue infections in the foot such as cellulitis, tenosynovitis (especially extensortendon sheaths), and abscesses. Incidence of infection increases dramatically in systemic diseases such as RA, systemic lupus erythematosus (SLE), gout, and diabetes mellitus (DM).[16] The most common organisms infecting the ankle joint are S aureus, S epidermidis, and gram-negative organisms. Neisseria gonorrhoeae usually affects the ankle joint as a fleeting migratory polyarthritis and tenosynovitis before it evolves into a persistent monoarthritis or oligoarthritis. Viruses that may be involved include Parvovirus B19, hepatitis B, rubella, and alpha viruses. Procedures Arthrocentesis with a large-bore needle (18- to 20-gauge) should be performed within 12 hours of suggested infection. A Gram stain and culture should be attained, with the caveat that these tests are found to be positive in only 50-70% of cases. The procedure should adhere to strict aseptic technique, and suitable local anesthetics, sedatives, and analgesics should be administered. The insertion point of the needle should be 2.5 cm proximal and 1.3 cm anterior to the tip of the lateral malleolus, just lateral to the peroneus tertius tendon. Surgical treatment Needle aspiration of purulent exudates, 1-2 times a day, is the primary method of drainage. The ankle is a joint amenable to repeated aspirations. However, because the ankle is prone to undergo excessive swelling, fluctuations may be difficult to locate. As is the case with all joints, if signs of local sepsis do not abate and synovial fluid analysis does not move to normal within 2 days after treatment, open surgical drainage is indicated. If the purulent fluid becomes too thick to aspirate, open surgical drainage is indicated. The safest and most successful means to surgically drain the ankle joint is through a posterolateral approach. Place the foot in dorsiflexion, and make an incision 5 cm proximal to the tip of the lateral malleolus just lateral to the Achilles tendon. This incision is extended distally and curves along the superior border of the calcaneus for 2.5 cm. Care must be taken to protect the sural nerve and small saphenous vein.

The anterolateral approach to drain the ankle involves longitudinal incisions 5-7.5 cm over the joint and 1.3-2.5 cm anterior to the lateral malleolus. If purulent material persists in the medial aspect of the ankle joint, an anteromedial or posteromedial approach may be performed as well. Arthroscopic debridement and lavage is becoming more common in the treatment of the septic ankle. The ankle is flushed with 8-10 L saline and the drain tubes are left for 36-48 hours. Postoperative treatment includes closing the wound loosely over drains. Because of the narrow confines of the ankle joint, closed suction irrigation is not employed. Arthrotomy for prosthesis removal with meticulous debridement of all cement, abscesses, and devitalized tissues may be necessary, which is then followed by prolonged antibiotics. For chronic persistent infections, excision arthroplasty, which may or may not include fusion, may be indicated. The appropriateness for arthrodesis depends on the extent of infection and the quality of remaining bone stock. Shoulder Pathophysiology/epidemiology Septic arthritis of the shoulder is uncommon, with 10-15% of cases of septic arthritis involving the shoulder. Hematogenous spread or direct inoculation is usually responsible for infection of glenohumeral joint and/or subacromial/subdeltoid bursa and acromioclavicular joint.[18] Septic arthritis is a rare (< 1%) complication of arthroscopic surgery; slightly higher incidence is noted following open procedures including rotator cuff repair, open reduction and internal fixation (ORIF), and arthroplasty. TECHNIQUES Scapulohumeral Joint The patient should be in lateral recumbency with the affected joint uppermost and in partial flexion. The acromion process and supraglenoid tubercle of the scapula and the greater tubercle of the humerus are then identified by palpation. The needle enters the joint from its craniolateral aspect, passing proximal to the lateral aspect of the greater tubercle, lateral to the supraglenoid tubercle, and ventral to the acromion process. In large dogs a 1 1/2-to 2 1/2-inch needle may be needed. Elbow Joint With the patient in lateral recumbency and the affected joint uppermost, the elbow is placed in moderate flexion. The joint is entered from its caudolateral aspect. With the joint in flexion, the lateral epicondyle and lateral condyle of the humerus and olecranon process of the ulna are located. The anconeal process of the ulna lies medial to the lateral humeral condyle with its tip approximately in line with the lateral humeral epicondyle. The needle penetrates the skin at the caudolateral aspect of the olecranon process, adjacent to the triceps tendon, and is directed downward and cranially between the olecranon process and the lateral humeral condyle toward the anconeal process. The needle enters the joint space between the anconeal process and the medial surface of the lateral humeral Condole.

Carpal Joints The carpal joints include the proximal, middle, distal, and intercarpal joint surfaces. The proximal or antebrachiocarpal (radiocarpal) joint is the one most frequently entered for arthrocentesis. The middle carpal joint and the carpometacarpal joints are aspirated less often. Each joint is entered from its dorsal Surface after the joint has been flexed. Major arteries and veins, tendons, and nerves cross the carpus on its dorsal surface. These structures must be avoided when performing arthrocentesis. The cranial superficial antebrachial artery travels from medial to lateral down the distal limb. its main trunk is usually midway between the medial and lateral aspects of the limb, just proximal to the antebrachiocarpal joint. At this point, it branches into the dorsal common digital artery. The vessel and the paralleling accessory cephalic vein can be avoided by passing the aspiration needle into the antebrachiocarpal joint just medial or lateral to the midsagittal plane of the joint. Aspiration of the antebrachiocarpal joint will not be diagnostic for the entire carpal articulation, since this joint does not communicate with the middle carpal and carpometacarpal joints, which are contiguous. Entrance to the middle carpal joint is facilitated by hyperflexion and passage of the needle between the radiocarpal bone and the second and third carpal bones. The carpometacarpal joint space is small and difficult to enter. For this reason and because it communicates with the middle carpal joint, it is rarely aspirated. Phalangeal Joints In humans, the interphalangeal joints are frequently affected by degenerative joint disease and rheumatoid arthritis. While these joints are occasionally affected by similar diseases in the dog and by chronic polyarthritis in the cat, they are aspirated infrequently owing to their small size. Coxofemoral Joint Both lateral and ventral approaches to the hip joint have been described for arthrocentesis. The ventral approach may prove to be easier. With the animal in dorsal recumbency, the femur is abducted and secured in position perpendicular to the long axis of the body, and the easily identified pectineus muscle is palpated. The ventral aspect of the acetabular fossa is located immediately dorsal to the body of the pectineus muscle. The needle is passed in a caudal to cranial direction at a 45 angle to the joint. The needle should pass just caudal to the body of the pectineus muscle, lateral to the ventral acetabular rim, and medial to the femoral head . Some resistance to needle advancement may be felt if the needle passes through the ligament of the head of the femur. The lateral approach is obtained by placing the animal on its side with the affected joint uppermost. Tile limb is grasped at the stifle joint, abducted slightly, and then outwardly rotated. The greater trochanter is identified and the needle is passed just caudal and medial to it. The needle is directed in a caudal to cranial direction toward the hip joint at an angle of approximately 45 . Stifle Joint Owing to its size and ease of entry, the stifle is probably the most frequently aspirated of all the joints. The patient is placed in lateral recumbency with the affected limb uppermost, and the joint is flexed sufficiently to cause tensing of the joint capsule. The needle is passed either medial or lateral to the

patellar ligament and directly obliquely and caudally toward the intercondylar space of the distal femur. Entrance to the joint should be made approximately midway between the distal end of the patella and the proximal articular surface of the tibia .Passing the needle directly through the patellar ligament into the intercondylar space has been described for aspiration of the knee in humans and has been used successfully in the dog and cat as well. Tarsus The talocrural joint may be aspirated from either a dorsal or plantar approach. The easier approach is from the proximal plantar-lateral aspect of the joint. With the patient in lateral recumbency and the affected limb uppermost, the space between the distal fibula and tibia is palpated. The needle is advanced in a dorsomedial and distal direction parallel with the fibular tarsal bone. Moderate joint flexion facilitates entrance into the joint. In the dorsal approach the needle is passed in a plantar direction between the tibia and tibiotarsal bone adjacent to the flexor tendons. As with aspiration of the carpal joints unless there is significant joint effusion quantities of synovial fluid greater than 0.1 ml to 0.2 ml will not be obtained.

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