Applicable evidence of joint puncture.
1.The fluid accumulation in the joint cavity of the extremities must be examined by puncture or drainage, or injected with drugs for treatment.
2.Injecting air or contrast into the joint cavity and performing arthrography to understand the changes in the cartilage or bone end of the joint.
Drug applicability certificate.
It is applicable to the adjunctive treatment of deformed knee arthropathy and shoulder periarthritis.
Intra-articular injection of Spironolactone in the knee joint is suitable for patients in the early and part of the middle stage, and arthroscopic surgery can be performed in another part of the middle stage when it is ineffective. For patients with advanced OA with severe wear of the joint surface and loss of joint space, the best way to inform the patients is to perform artificial knee joint replacement.
The mechanism of action of sodium vitrate injection.
Some scholars have analyzed the synovial fluid of affected joints in patients with osteoarthritis and found that the concentration of vitreous acid in synovial fluid and the viscoelasticity of molecular weight are lower than normal, and the synovial membrane synthesizes low vitreous acid function, which weakens the support and stabilization of synovial cells and collagen fiber scaffold, and the biological function of lubrication and resistance to the action of mechanical force becomes impaired, thus increasing the stress used in articular cartilage and leading to chondrocyte damage.
Pathological changes and causes of osteoarthritis of the knee: The pathological changes of osteoarthritis of the knee are mainly limited, progressive destruction of articular cartilage and the formation of bone redundancy at the joint edges. The causes of these changes are: ① Injury: disturbance of load conduction is the main cause of cartilage damage. In particular, increased load directly damages chondrocytes and increases pressure in the joint cavity, affecting the secretion of synovial fluid, reducing the nutrients available to chondrocytes and aggravating the destruction of chondrocytes. ②Chondral degeneration is related to autoimmunity. ③Oxygen free radicals reduce the secretion of hyaluronic acid and degrade hyaluronic acid molecules causing a decrease in the viscosity of synovial fluid.
The most commonly used drugs in clinical practice are non-steroidal anti-inflammatory analgesics (NSAIDs) and hormones. Both of these drugs have different degrees of adverse effects, and most of them can only provide short-term relief and cannot stop the progression of the disease. The injection of high molecular weight, high concentration and high viscoelasticity of sodium vitrate into the joint cavity can significantly improve the inflammatory response of synovial fluid tissue, increase the content of sodium vitrate in synovial fluid, compensate for the low quality of hyaluronic acid, enhance the viscosity and lubricating function of joint fluid, and also promote the production of high molecular weight hyaluronic acid by synovial cells in the joint, which provides high quality raw material for cartilage repair and promotes the healing of joint cartilage It also provides high quality raw material for cartilage repair, promotes the healing and regeneration of articular cartilage, hinders and delays the degeneration of articular cartilage, prevents the formation of fibrous tissue in joints, and supports the healing process of cartilage and synovial tissue. It helps to relieve pain and increase joint mobility.
Principle of action of sodium vitrate: Sodium vitrate is the main component of synovial fluid and is one of the components of cartilage matrix. It acts as a lubricant in the joint cavity to reduce friction between tissues, and plays an elastic role to cushion the damage to joint cartilage from stress. The injection of high molecular weight, high concentration and high elasticity of sodium vitrate into the joint cavity can significantly improve the inflammatory response of synovial fluid tissue, enhance the viscosity and lubricating function of joint fluid, protect joint cartilage, promote the healing and regeneration of joint cartilage, relieve pain and increase joint mobility. Sodium vitrate molecule has a stabilizing effect on joint pain receptors, while its barrier effect can effectively prevent the diffusion of inflammatory mediators and reduce the stimulation of chemical substances on nociceptive receptors. The protective effect of joint pain is achieved. Another experiment suggests that exogenous hyaluronic acid concentration up to 20 mg/ml can produce endogenous hyaluronic acid in synovial B cells through negative feedback mechanism, which can re-form bright plate like structure on the damaged articular cartilage surface to protect articular cartilage and prevent further damage. This allows for the normal metabolism of articular cartilage and thus the treatment of osteoarthritis.
In the 1960s, viscoelastic filling therapy was proposed to restore the elasticity and viscosity of synovial fluid by injecting hyaluronic acid into the diseased joint cavity to re-establish the protective effect of hyaluronic acid on articular cartilage, alleviate synovial inflammation, reduce cartilage destruction, and improve clinical symptoms. Hyaluronic acid also plays an important role in the formation of cartilage matrix through the aggregation of proteoglycans. Hyaluronic acid for medical use is purified from chicken crowns and has recently been reported to be effective and safe for pain relief. It should be noted that sodium hyaluronate is suitable for the treatment of early and mild osteoarthritis, while it is less effective in people over 50 years of age, with a disease duration of more than 1 year, obesity, severe joint effusion and X-rays showing advanced hyperplasia and degeneration.
Sodium hyaluronate is a common drug for the clinical treatment of OA, and its effectiveness has been confirmed. Sodium hyaluronate is widely present in human tissues, especially in synovial fluid, and plays a supporting and stabilizing role for synovial cells and collagen fiber scaffolds. Hyaluronic acid preparation is a biological macromolecular substance extracted and refined mainly from the corpus cavernosum and human umbilical cord, and it appears as sodium hyaluronate salt. The sodium hyaluronate solution is highly viscoelastic. In a high shear state (fast motion), the synovial fluid mainly behaves as elastic, and the sodium hyaluronate molecular network stores the amount, which serves the purpose of shock absorption and joint vibration mitigation; in a low shear state (slow motion), the synovial fluid mainly behaves as viscous, and the energy is dissipated through the sodium hyaluronate molecular network, thus playing a lubricating role. By injecting sodium hyaluronate into the joint cavity, it can help restore the rheological properties of synovial fluid and joint tissue matrix – viscoelasticity, relieve synovial inflammation, reduce the exudation of pathological joint fluid and relieve joint pain, as well as improve the intra-articular environment, create conditions for the synthesis of its own high molecular glass acid molecules, reduce the destruction of cartilage and promote the repair of damaged cartilage. Its role in the treatment of OA has been proven in both basic experiments and clinical practice.
Preoperative preparation.
(1) Prepare an 18- to 20-gauge puncture needle and syringe.
(2) After strict local sterilization, the operator holds the syringe in the right hand and fixes the puncture site with the left hand. When the needle enters the joint cavity, the right hand does not move, fixing the needle and syringe, and the left hand draws the syringe barrel spigot to perform operations such as fluid extraction or drug injection.
Puncture method.
The patient is seated with the knee flexed and the lower leg naturally lowered so that the knee joint is relaxed. Sterilize with 2.5% iodine, deiodinate with 75% ethanol, lay a sterile towel, and take the medial or lateral side below the patella as the puncture point. A 5 ml syringe was used to puncture the joint cavity, and there was a breakthrough sensation when puncturing the joint cavity, and there was no resistance to drug injection. If there is joint effusion, withdraw the effusion and slowly inject 10ml of 0.25% lidocaine (containing 5mg of trimethoprim, 0.5mg of trimethoprim in each ml of solution). The treatment plan was adjusted from the third time onwards as follows: intra-articular injection of 2.5 ml of sodium glacial solution and treatment of the surrounding painful points as above, moving the knee joint several times to make full contact with the joint surface, once a week for 5 times.
After routine disinfection, the knee is flexed at 90°, the medial or lateral infrapatellar approach is made, a disposable syringe (5ml size) is punctured into the joint cavity, no blood is drawn back, the joint fluid is extracted as much as possible, and the injection of spironolactone is slowly made, 1 injection/time. After injection, cover the injection eye with a sterile dressing and move the joint passively so that the drug can be evenly distributed in the joint cavity quickly. 1 time/week, alternately inject from the medial and lateral sides, 5 weeks as a course of treatment.
Shoulder arthrocentesis.
The affected limb is mildly abducted and externally rotated, and the elbow joint is in flexed position. The joint cavity is punctured vertically between the humeral tuberosity and the rostral process. It can also be performed from the anterior border of the deltoid muscle below the tip of the rostral process, in a posterior and lateral direction.
The shoulder joint puncture route can be anterior or lateral to the shoulder joint, often at the anterior border of the deltoid muscle. Shoulder joint cavity puncture injection method: take a sitting or supine position, expose the affected shoulder joint, take 1.5~2 cm outside the rostral process and then 1.5~2 cm downward as the puncture point, strictly puncture disinfection laying towel procedure, wear sterile gloves, pay attention to the strict standardized aseptic operation technique, apply a common No. 7 injection needle to puncture the skin vertically, have a sense of falling into the joint cavity, and apply sterile dressing for 24 h after injection.
Elbow joint.
The puncture point of the elbow joint is generally between the posterior hawk’s-eye and the humeral epicondyle. In view of the above-mentioned route of the important vascular nerves in the elbow, the puncture and surgical access to the elbow joint are mostly performed on the dorsal and dorsolateral sides of the joint.
The elbow joint is flexed at 90o, immediately proximal to the radial tuberosity, and the needle is inserted anteriorly and inferiorly behind it, where the joint capsule is most superficial and the radial head is palpable. It can also be inserted medially and anteriorly between the tip of the ulnar hawk’s beak and the lateral epicondyle of the humerus. It can also be inserted into the joint cavity anteriorly and inferiorly via the triceps tendon above the ulnar eminence.
Carpal joint.
The carpal puncture point can be on the radial side of the ulnar styloid process at the back of the wrist or between the thumb extensor tendon and the intrinsic extensor tendon of the index finger, either through the ulnar styloid process or below the lateral aspect of the radial styloid process and vertically downward into the needle, preferably on the ulnar side because the radial artery travels distal to the radial styloid process.
Hip joint.
The puncture point of the hip is at the midpoint of the line between the anterior superior iliac spine and the pubic crest, 1 cm lateral to the femoral artery, and the needle is inserted vertically.
At the midpoint of the line connecting the anterior superior iliac spine and pubic symphysis, 2 cm below the inguinal ligament, the lateral aspect of the femoral artery is punctured vertically; it is also advisable to puncture from the superior border of the greater trochanter parallel to the lower extremity and inward and upward through the femoral neck (Figure 9-33).
Knee.
The puncture point of the knee joint can be approximately 1 cm inferior, inferior, superior, or superior to the patella medially.
The intersection of the horizontal line of the superior patellar border with the vertical of the external patellar border is the puncture point, through which the joint cavity is pierced inwardly and inferiorly; the needle can also be inserted posteriorly through either side of the patellar ligament immediately inferior to the patella.
Ankle joint.
The ankle puncture point may be between the anterior tibial tendon and the medial ankle or between the toe extensor tendon and the lateral ankle.
The needle is inserted immediately adjacent to the tip of the outer or inner ankle, and is advanced inward and upward, entering the joint capsule through the ankle between the ankle and the adjacent talus.
Precautions.
(1) All instruments, drugs and operations should be strictly aseptic, otherwise they can cause infection in the joint cavity.
(2) The needle should be inserted while suctioning and drawing, noting whether there is fresh blood flow, if there is, it indicates that the puncture has entered the blood vessel, and the puncture needle should be withdrawn a little and the direction should be changed before continuing to insert the needle. In addition, when the fluid is pumped, the puncture needle is then slightly pierced into a small amount, and the fluid in the joint cavity is pumped out as much as possible. Do not penetrate too deeply to avoid damaging the articular cartilage.
(3) Repeated intra-articular steroid injections can cause joint damage, therefore, no more than three intra-articular steroid injections should be given.
(4) In addition to microscopic examination, bacterial culture and antibiotic sensitivity test, careful visual observation should be done on the extracted fluid to initially determine its properties and give timely treatment. For example, normal synovial fluid is straw yellow, clear and transparent; if it is dark red stale blood, it is often traumatic; if the drawn blood contains fat droplets, it may be an intra-articular fracture; cloudy fluid suggests an infection; if it is pus, the diagnosis of infection is determined no different.
(5) In case of obvious fluid accumulation in the joint cavity, pressure bandage should be applied after puncture and appropriate fixation should be given. The time of re-puncture should be determined according to the amount of fluid accumulation, and usually 2 punctures per week are sufficient.
Therapeutic effect.
It should be clearly explained to the patient that it is a slow-acting drug, and the effect is usually very obvious only after 2 injections. 5 injections are one course of treatment. The effect can last from 6 months to 18 months, or longer, depending on the severity of the disease and the patient’s care of the knee. The pain is significantly reduced or disappears the next day after the injection, and function returns to normal or almost normal.
Side effects.
After the injection, there may be occasional swelling and discomfort, and even some people have more pain and swelling on the night after the injection, usually the reaction will disappear naturally after 1 to 3 days. At the same time, SPECTRO is not a pain reliever, so do not expect pain relief immediately after injection. Itchy skin appears after injection and disappears on its own after 2 to 3 days without treatment.