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Micu A, Micu MC, Bodozs G, Duțu AG. To stop or not to stop novel oral anticoagulants prior to performing joint interventional maneuvers? Evidence from a prospective study that the therapy can be maintained. Clin Rheumatol 2024:10.1007/s10067-024-07048-6. [PMID: 39008221 DOI: 10.1007/s10067-024-07048-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/09/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024]
Abstract
Anticoagulation is common in patients undergoing routine musculoskeletal interventional maneuvers. Previous retrospective studies have established the safety of continuing anticoagulation with novel oral anticoagulants (NOACs) when performing this kind of interventions. Indeed, ultrasound (US)-guided interventional maneuvers have shown a superior safety profile compared to blind anatomical maneuvers. To evaluate prospectively the periprocedural bleeding events in NOAC-anticoagulated patients undergoing interventional articular or periarticular procedures. Consecutive patients diagnosed with inflammatory or degenerative rheumatologic pathology requiring interventional maneuvers were prospectively recruited. Group 1 was treated with NOACs, group 2 was treated with vitamin K antagonists, and group 3 was not anticoagulated. Prior to the international maneuver, NOAC therapy was continuously administered, in regimens dictated by the underlying anticoagulation indication. Demographics, comorbidities, laboratory parameters, locally administered medication (corticosteroids or viscosupplementation), interventional maneuver location, needle size, and local bleeding events were recorded. Post-procedural control was performed at 30 min, 48 h, and 7 days. No articular/periarticular bleeding event occurred in patients treated with NOACs, regardless of their type and dosage, locally administered medication, needle size, location, and number of interventions per individual. Several patients in all groups developed small superficial ecchymoses at the injection site. Our results suggest that NOACs are safe to be used in a continuous regimen prior to US-guided injections, even as dual antithrombotic therapy (in combination with aspirin). The use of lower gauge needles, chosen for viscosupplementation therapy, was not burdened with adverse effects on the procedural outcome. Key Points • Currently, no prospective studies have been performed to establish the safety of continuous NOAC anticoagulation when performing routine intra- or periarticular interventional maneuvers. • The study offers an extensive view on a wide spectrum of intra- and periarticular interventional maneuvers including anatomic targets and needle sizes that were not previously assessed. • The study offers a perspective into performing repetitive maneuvers in the same patient, both over a short time and at longer intervals. • The zero periprocedural bleeding risk observed in our study may reassure practitioners and suggest that US-guided interventional therapeutic interventions are safe in patients treated with a continuous regimen of different NOACs.
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Affiliation(s)
- A Micu
- "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
| | - M C Micu
- Rheumatology Division, Rehabilitation Clinical Hospital Cluj-Napoca, Viilor str. No 46-50, 400347, Cluj-Napoca, Romania.
| | - G Bodozs
- Laboratory Unit, Rehabilitation Clinical Hospital Cluj-Napoca, Cluj-Napoca, Romania
| | - A G Duțu
- Department of Medical Biochemistry, "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania
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McCrum C, Furner R, Grainger S. Peri-procedural management and incidence of bleeding events following musculoskeletal injections or aspirations in people on oral anticoagulation and antiplatelet therapy. Musculoskeletal Care 2023; 21:702-712. [PMID: 36806477 DOI: 10.1002/msc.1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 01/24/2023] [Accepted: 02/01/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Corticosteroid injections and aspirations are common interventions for managing musculoskeletal and inflammatory conditions. However, there remains limited safety evidence to support injection decisions and peri-procedural management in people on anti-thrombotics, particularly for direct oral anticoagulants (DOACs). OBJECTIVES To investigate peri-procedural management and bleeding complications following musculoskeletal injections or aspirations with anti-thrombotic medication use. DESIGN A prospective observational study was undertaken (October 2018-December 2020) in Orthopaedics, Rheumatology and Radiology specialities in two large UK healthcare providers. Data collection involved weekly identification of musculoskeletal procedures, emergency attendance or admission within 30 days and follow-up questionnaires sent within 2 weeks post-procedure. Descriptive statistics were used to analyse anticoagulant/anti-platelet use, peri-procedural management and bleeding complications. RESULTS Of 5080 procedures, 237 of 1338 responses reported antithrombotic use: warfarin (n = 36), DOACs (n = 75) and antiplatelets (n = 126). There were no self-report or electronic identification of clinically significant bleeding events/complications. Only local bruising was reported (8.6% vs. 0.2% with non-use), and only with medication continuation or international normalised ratio (INR) levels ≥3.8 or unknown. Only 3/72 DOAC use was interrupted. CONCLUSIONS In this study, no clinically significant bleeding events or complications were reported or identified following musculoskeletal injections or aspirations, with only localised bruising reported. It was not universal practice to check INR levels and DOAC interruption was uncommon. Findings add evidence that musculoskeletal procedures appear to be low risk procedures for bleeding complications with antithrombotic continuation and when INR levels within lower target range. Research on intra-articular or soft tissue iatrogenic consequences would add to risk/benefit evaluations.
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Affiliation(s)
- Carol McCrum
- Research Centre for Health Professions, University of Brighton, Eastbourne, UK
- East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
- Rheumatology Department, Canberra Health Service, Canberra, Australian Capital Territory, Australia
| | - Rosie Furner
- East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
| | - Sally Grainger
- East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
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Conrozier T, Diraçoglù D, Monfort J, Chevalier X, Bard H, Baron D, Jerosch J, Migliore A, Richette P, Henrotin Y. EUROVISCO Good Practice Recommendations for a First Viscosupplementation in Patients with Knee Osteoarthritis. Cartilage 2023; 14:125-135. [PMID: 36443990 PMCID: PMC10416196 DOI: 10.1177/19476035221138958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Viscosupplementation (VS) with hyaluronic acid is widely used in the management of knee osteoarthritis. There is no clear recommendation on the decision-making to achieve VS. DESIGN Based on extensive research of the literature and expert opinion, the members of the EUROVISCO (European Viscosupplementation Consensus Group) task force were asked to give their degree of agreement with 60 issues, using a Delphi method. RESULTS The expert panel achieved unanimous agreement in favor of the following statements: It is recommended to assess pain on a visual or 10-point numeric scale before considering VS. VS can be considered for patients with pain scores between 3 and 8. A standard x-ray must be obtained before the decision of VS. If the x-ray is normal, osteoarthritis must be confirmed by MRI or computed tomography (CT) arthrogram before considering VS. The aims of VS are relieving pain, improving function, and reducing non-steroidal anti-inflammatory drug (NSAID) consumption. The use of VS must not be considered for treating an osteoarthritis flare. VS can be envisaged as a first-line pharmacological treatment in patients having a contra-indication to NSAIDs or analgesics. VS can be considered in patients with contra-indications to arthroplasty. In the case of severe comorbidities (diabetes, hypertension, gastrointestinal disorders, renal failure), VS can avoid the use of potentially dangerous treatments. VS can be considered in patients receiving antiplatelet agents, vitamin K antagonists, and direct factor Xa or thrombin inhibitors. Five other statements obtained a high level of consensus. CONCLUSION These recommendations, illustrated in a decision algorithm, have been established to help practitioners in the decision-making of knee VS.
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Affiliation(s)
- Thierry Conrozier
- Department of Rheumatology, Hôpital Nord Franche-Comté, Belfort, France
| | - Demirhan Diraçoglù
- Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Jordi Monfort
- Servei de Reumatología, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | - Xavier Chevalier
- Department of Rheumatology, Henri Mondor Hospital, Paris XII University, Creteil, France
| | - Hervé Bard
- Rheumatology, Cabinet Médical Vaudoyer, Paris, France
| | - Dominique Baron
- Centre de Réadaptation Fonctionnelle de Lannion-Trestel, Trévou-Tréguignec, France
| | - Jörg Jerosch
- Department of Orthopedic, Johanna Etienne Hospital, Neuss, Germany
| | - Alberto Migliore
- U.O.S. of Rheumatology, Ospedale San Pietro Fatebenefratelli, Rome, Italy
| | - Pascal Richette
- Université Paris Cité, UFR Médicale, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Service de Rhumatologie, Paris, France
| | - Yves Henrotin
- MusculoSKeletal Innovative Research Lab, Université de Liège, CHU Sart Tilman, Liège, Belgium
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Tarar MY, Malik RA, Charalambous CP. Bleeding complications in patients on warfarin undergoing joint injection/aspiration: systematic review and meta-analysis. Rheumatol Int 2023; 43:245-251. [PMID: 36322144 PMCID: PMC9898419 DOI: 10.1007/s00296-022-05232-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/06/2022] [Indexed: 11/07/2022]
Abstract
Steroid injections in joints are commonly administered for the management of inflammatory or degenerative conditions. There is substantial controversy as to whether to continue warfarin when undertaking joint injection or aspiration. To assess the rate of bleeding complications in patients on warfarin undergoing joint injection/aspiration. Systematic review and meta-analysis. A literature search of 3 online databases was conducted by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study that reported bleeding complication rates in adult patients on warfarin undergoing a joint injection/aspiration whilst taking warfarin anticoagulation. Studies reporting on less than 5 patients were excluded. Meta-analysis was conducted using a random effects model. The search of databases resulted in a total of 1547 articles. After screening, 8 articles were deemed suitable for inclusion in the analysis, involving 871 injection/aspiration procedures. There were only 5 reported cases of bleeding. On meta-analysis the estimated bleeding complication rate was 1.5% (95% CI 0.5-4.5%). This meta-analysis shows that it is safe to perform joint injection and aspiration in patients on warfarin without routine prior testing of INR. Level of evidence: Level 4.
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Affiliation(s)
- M Y Tarar
- Blackpool Teaching Hospitals NHS Trust, Blackpool, UK
| | - R A Malik
- Weill Cornell Medicine-Qatar, Doha, Qatar.,University of Manchester, Manchester, UK
| | - C P Charalambous
- Blackpool Teaching Hospitals NHS Trust, Blackpool, UK. .,School of Medicine, University of Central, Lancashire, UK.
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Hashem M. Intraoperative and post-procedural complications and disorders of musculoskeletal system hospitalization profile in England and Wales. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2023. [DOI: 10.1016/j.cegh.2023.101252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
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Labmayr V, Eckhart FJ, Smolle M, Klim S, Fischerauer SF, Bernhardt G, Seibert FJ. [Sterile puncture of large joints]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:65-80. [PMID: 36648491 PMCID: PMC9894986 DOI: 10.1007/s00064-022-00786-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Puncture of large joints is performed for diagnostic purposes on the one hand and for the treatment of joint pathologies on the other. Puncture can be used for rapid pain relief by relieving effusions or intra-articular hematomas. The obtained puncture specimen allows immediate visual assessment and subsequent microscopic-cytological and microbiological evaluation in the laboratory. INDICATIONS The indication for puncture of a large joint is for diagnosis and/or therapy of inflammatory, traumatic or postoperative joint problems. Diagnostic punctures are used to obtain punctate, to differentiate the location of pain or (rarely) to apply contrast medium for magnetic resonance arthrography. Therapeutic punctures allow the injection of drugs or platelet-rich plasma (PRP) as well as the relief or drainage of effusions. CONTRAINDICATIONS If there are inflammatory skin alterations-especially purulent inflammation-joint punctures through these lesions are absolutely contraindicated. Special attention is necessary if the patients are on anticoagulants. SURGICAL TECHNIQUE Absolute sterile handling is mandatory. Unnecessary pain can be avoided by a sterile skin wheal of local anesthesia, safe puncture points, and careful handling of the cannulas. POSTOPERATIVE MANAGEMENT Joint aspiration material has to be handled according to the local, intrahospital rules in a timely manner. Puncture sites are covered with sterile dressings, and if intra-articular medication is administered, the joints have to be passively moved through the range of motion to distribute the medication. Thereafter, compression therapy from distally to proximally while also covering the puncture site avoids recurrence of swelling or hematoma. FACTS If sterile conditions are guaranteed, infections rarely occur (0.04-0.08%, 4-8/10,000 cases). The risk of false-positive detection of microorganisms is extremely low.
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Affiliation(s)
- Viktor Labmayr
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, LKH-Univ. Klinikum Graz, Auenbruggerplatz 5, 8036 Graz, Österreich
| | | | - Maria Smolle
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, LKH-Univ. Klinikum Graz, Auenbruggerplatz 5, 8036 Graz, Österreich
| | - Sebastian Klim
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, LKH-Univ. Klinikum Graz, Auenbruggerplatz 5, 8036 Graz, Österreich
| | - Stefan Franz Fischerauer
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, LKH-Univ. Klinikum Graz, Auenbruggerplatz 5, 8036 Graz, Österreich
| | - Gerwin Bernhardt
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, LKH-Univ. Klinikum Graz, Auenbruggerplatz 5, 8036 Graz, Österreich
| | - Franz Josef Seibert
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, LKH-Univ. Klinikum Graz, Auenbruggerplatz 5, 8036 Graz, Österreich
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McDonald A. Primary Care-Based Interventional Procedures for Chronic Pain. Prim Care 2022; 49:425-437. [DOI: 10.1016/j.pop.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Kotecha J, Gration B, Hunt BJ, Goodman AL, Malaiya R. The Safety of Continued Oral Anticoagulation Therapy in Joint Injections and Aspirations: A Qualitative Review of the Current Evidence. J Clin Rheumatol 2022; 28:223-228. [PMID: 35616509 DOI: 10.1097/rhu.0000000000001856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Performing joint aspirations and injections on patients taking long-term oral anticoagulants poses a clinical conundrum. This review aimed to quantify the safety of performing joint procedures in these patients in terms of bleeding risk. In addition, it aimed to identify, in those receiving vitamin K antagonists, what level of international normalized ratio (INR) is the safest.A review of the medical literature was performed (electronic searches in Ovid [MEDLINE], EMBASE, and the Cochrane Library). English language original reports of patients undergoing joint injections or aspirations performed on anticoagulant therapy, published within the last 10 years, were included.Seven studies met the inclusion criteria. Patients were taking a variety of anticoagulants: warfarin, acenocoumarol, and direct oral anticoagulants. Four cases of hemorrhage were reported after 5427 procedures, over a pooled 32-year period, across 9 centers. The INR values were available for 3 cases with bleeding complications: values were 1.9, 2.3, and 3.4.Authors of all studies concluded that joint injection is safe in patients on anticoagulants. A variety of joints and approaches, reversal, or withholding of anticoagulation and bridging with low molecular weight heparin did not seem to alter bleeding risk. Bleeding complications remained low even in those with renal or hepatic impairment or those taking concomitant antiplatelets.In conclusion, joint aspiration and injection are safe in patients taking anticoagulants. Anticoagulation should not be routinely discontinued in these patients; decisions should be made on a case-by-case basis. Because of low event numbers, a recommended safe maximum INR value for joint procedures cannot be determined.
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Affiliation(s)
- Jalpa Kotecha
- From the Weston Education Centre, King's College Hospital
| | - Betty Gration
- Department of Haematology, University College Hospital
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust and King's College London
| | - Anna L Goodman
- Department of Infection, Guy's and St Thomas' NHS Foundation Trust, London
| | - Ritu Malaiya
- Department of Rheumatology, St Helier Hospital, Epsom and St Helier University Hospitals NHS Trust, Epsom, United Kingdom
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Gibbons RC, Zanaboni A, Genninger J, Costantino TG. Ultrasound-versus landmark-guided medium-sized joint arthrocentesis: A randomized clinical trial. Acad Emerg Med 2022; 29:159-163. [PMID: 34608713 DOI: 10.1111/acem.14396] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/20/2021] [Accepted: 09/30/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Arthrocentesis is commonly performed in the emergency department, but success rates vary based on location. Presently, there is a paucity of data assessing the utility of ultrasound-guided (USG) medium-sized joint arthrocentesis. The objective of this study was to compare the success of USG and landmark-guided (LMG) medium-sized joint arthrocentesis. METHODS This was a single-center, prospective, randomized clinical trial (NCT03327584) of a convenience sample of adult patients who presented to an urban, university hospital with > 105,000 visits annually. Patients with a suspected medium-sized joint effusion (defined as elbow, wrist, or ankle) undergoing arthrocentesis were randomized into LMG or USG using the GE Logiq e linear transducer (4-10 MHz). The following patients were excluded: on anticoagulation, with soft tissue infection overlying the joint, or involving an artificial joint. Statistical analysis included the Fisher exact, Mann-Whitney U-test, and t-test. RESULTS Overall, 44 patients were enrolled with 23 patients randomized into the LMG group and 21 patients into the USG arm. USG was significantly better than LMG with an overall success of 94.1% versus 60% for LMG (difference = 34.1%, 95% confidence interval [CI] = 4.90 to 58.83). USG first-pass success was 82.4% versus 46.7% for LMG (difference = 35.7%, 95% CI = 2.76 to 60.37) and a mean of 1.35 attempts versus 2.00 for LMG (difference = 0.65, 95% CI = 0.005 to 1.296). Of the 14 LMG failures, eight had no effusion present on USG crossover. Four patients in the USG group had no effusion present. CONCLUSIONS Ultrasound guidance improved first-pass and overall successful arthrocentesis of medium-sized joint effusions.
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Affiliation(s)
- Ryan C. Gibbons
- Department of Emergency Medicine Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
| | - Allison Zanaboni
- Department of Emergency Medicine SSM St. Mary’s Hospital St. Louis Missouri USA
| | - Jessica Genninger
- Department of Emergency Medicine Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
| | - Thomas G. Costantino
- Department of Emergency Medicine Lewis Katz School of Medicine at Temple University Philadelphia Pennsylvania USA
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Duck H, Tanner S, Zillmer D, Osmon D, Perry K. Value of ultrasound-guided aspiration of hip arthroplasties performed in an orthopedic clinic by orthopedic surgeons. J Bone Jt Infect 2021; 6:393-403. [PMID: 34804774 PMCID: PMC8600464 DOI: 10.5194/jbji-6-393-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/18/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Total joint arthroplasties continue to increase as do periprosthetic joint infections (PJIs). Ultrasound-guided aspiration can yield useful synovial fluid for analysis while avoiding radiation exposure. This study presents a high-yield, ultrasound-guided technique with analysis of aspiration results. Methods: All consecutive ultrasound-guided aspirations of hip arthroplasties performed from May 2016 through to April 2019 were retrospectively reviewed. Patient demographic information, component specifics, presence of draining sinus, and inflammatory markers were recorded. Results of aspiration including volume, appearance, lavage use, synovial fluid differential leukocyte count, synovial neutrophil percent, and culture results were recorded. Surgical results, specimen cultures, and surgeon description of purulence were recorded. Aspiration results were compared to the surgical specimen results in all patients who underwent reoperations. Results: Review of 349 hip aspirations demonstrated accuracy of 87 %, sensitivity of 83 %, specificity of 89 %, positive predictive value of 79 %, and negative predictive value 91 %. Surgical and aspiration cultures matched in 81 % of cases. Bloody aspirates and aspirates obtained after lavage had less accuracy at 69 % and 60 %, respectively. Specificity was 100 % for cultures obtained with lavage and 91 % for bloody aspirates. Synovial leukocyte count and neutrophil percentage was obtained in 85 % of aspirations, and cultures were obtained in 98 % of aspirates. Contamination rate was 2 %. Conclusion: Ultrasound-guided aspirations aid in the diagnosis of PJI. The use of lavage to obtain fluid is helpful when aspiration cultures are positive. Bloody aspirates are less accurate but have high specificity. A low contamination rate and 88 % accuracy results with this meticulous technique.
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Affiliation(s)
- Holly Duck
- Department of Orthopedic Surgery, Mayo Clinic, Rochester MN, USA
| | - Suzanne Tanner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester MN, USA
| | - Debra Zillmer
- Department of Orthopedic Surgery, Mayo Clinic, Rochester MN, USA
| | - Douglas Osmon
- Department of Infectious Diseases, Mayo Clinic, Rochester MN, USA
| | - Kevin Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester MN, USA
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Abstract
Purpose Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain. Methods The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed. Conclusion These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.
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Uson J, Rodriguez-García SC, Castellanos-Moreira R, O'Neill TW, Doherty M, Boesen M, Pandit H, Möller Parera I, Vardanyan V, Terslev L, Kampen WU, D'Agostino MA, Berenbaum F, Nikiphorou E, Pitsillidou IA, de la Torre-Aboki J, Carmona L, Naredo E. EULAR recommendations for intra-articular therapies. Ann Rheum Dis 2021; 80:1299-1305. [PMID: 34035002 PMCID: PMC8458067 DOI: 10.1136/annrheumdis-2021-220266] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 05/08/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To establish evidence-based recommendations to guide health professionals using intra-articular therapies (IAT) in adult patients with peripheral arthropathies. METHODS A multidisciplinary international task force established the objectives, users and scope and the need for background information, including systematic literature reviews) and two surveys addressed to healthcare providers and patients throughout Europe. The evidence was discussed in a face-to-face meeting, recommendations were formulated and subsequently voted for anonymously in a three-round Delphi process to obtain the final agreement. The level of evidence was assigned to each recommendation with the Oxford levels of evidence. RESULTS Recommendations focus on practical aspects to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles and 11 recommendations were established, addressing issues related to patient information, procedure and setting, accuracy, routine and special aseptic care, safety issues and precautions to be addressed in special populations, efficacy and safety of repeated joint injections, use of local anaesthetics and aftercare. CONCLUSION We have developed the first evidence and expert opinion-based recommendations to guide health professionals using IAT. We hope that these recommendations will be included in different educational programmes, used by patient associations and put into practice via scientific societies to help improve uniformity and quality of care when performing IAT in peripheral adult joints.
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Affiliation(s)
- Jacqueline Uson
- Rheumatology Deptarment, Hospital Universitario Móstoles, Universidad Rey Juan Carlos, Madrid, Spain
| | | | - Raul Castellanos-Moreira
- Rheumatology Department, Centre Sociosanitari Hospital Clínic i Provincial de Barcelona, Barcelona, Spain
| | - Terence W O'Neill
- Arthritis Research UK Centre for Epidemiology, The University of Manchester, Manchester, UK
| | - Michael Doherty
- Acaedemic Rheumatology, University of Nottingham, Nottingham, UK
| | - Mikael Boesen
- Musculoskeletal research Unit, Department of Radiology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Hemant Pandit
- Orthopaedic Surgery, Chapel Allerton Hospital, University of Leeds, Leeds, UK
| | | | - Valentina Vardanyan
- Rheumatology Department, Yerevan State Medical University Named after Mkhitar Heratsi, Yerevan, Armenia
| | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Willm Uwe Kampen
- Nuclear Medicine Spitalerhof, Radiologische Allianz, Hamburg, Germany
| | - Maria-Antonietta D'Agostino
- Rheumatology Department, Università Cattolica del Sacro Cuore, Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
| | | | - Elena Nikiphorou
- Rheumatology Research, Acaedemic Department of Rheumatology, King's College London, London, UK
| | - Irene A Pitsillidou
- EULAR Patient Research Partner, Cyprus League Against Rheumatism, Nicosia, Cyprus
| | | | - Loreto Carmona
- Instituto de Salud Musculoesquelética (INMUSC), Madrid, Spain
| | - Esperanza Naredo
- Rheumatology Department and Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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Cipolletta E, Filippucci E, Incorvaia A, Schettino M, Smerilli G, Di Battista J, Tesei G, Cosatti MA, Di Donato E, Tardella M, Di Matteo A, Di Carlo M, Grassi W. Ultrasound-Guided Procedures in Rheumatology Daily Practice: Feasibility, Accuracy, and Safety Issues. J Clin Rheumatol 2021; 27:226-231. [PMID: 32000229 DOI: 10.1097/rhu.0000000000001298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE The aims of this study were to describe in detail the ultrasound (US)-guided procedures in our daily rheumatology practice, to evaluate the feasibility and accuracy of US-guided procedures, and to test the efficacy of our disinfection protocol in preventing infectious complications. METHODS This was a cross-sectional and monocentric study. Information regarding patients' age, sex, body mass index, rheumatic disease, US pathological findings, aspirated and/or injected anatomical site, US equipment (ie, probe type and frequency), and needle type was consecutively collected for each US-guided procedure in a third-level rheumatology center. RESULTS A total of 643 US-guided procedures were performed, with a mean of 5.2 procedures per working-day. In 94.2% of the patients, only one procedure was carried out, whereas in 5.8%, more than one. The mean time was 7 ± 2.5 minutes. Ultrasound-guided procedures were highly accurate (accuracy rate higher than 95%) and safe (adverse events were reported in 0.8%). Our disinfection protocol was effective in preventing infectious complications. Probes with frequency values between 8 to 13 MHz and 20-, 21-, and 22-gauge needles were the most frequently used at shoulder, knee, wrist, elbow, and ankle level. High-frequency linear probes (ranging between 18 and 22 MHz) and 23- and 25-gauge needles were used for injecting small joints of the hands and feet. Convex low-frequency probe (2-7 MHz) and 18- and 20-gauge needles were the most used for performing hip joint aspirations and/or injections. CONCLUSIONS This study reports useful information for setting up a service providing US-guided procedures in rheumatology and supports the feasibility, accuracy, and safety of US-guided procedures.
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Affiliation(s)
- Edoardo Cipolletta
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Emilio Filippucci
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Antonella Incorvaia
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Martina Schettino
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Gianluca Smerilli
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Jacopo Di Battista
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Giulia Tesei
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Micaela Ana Cosatti
- Rheumatology and Immunology Unit, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno, Buenos Aires, Argentina
| | - Eleonora Di Donato
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Marika Tardella
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | | | - Marco Di Carlo
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
| | - Walter Grassi
- From the Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital Jesi, Ancona
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Tsampras N, Ma K, Arora R, McLeod G, Minchelotti F, Craciunas L. Office hysteroscopy safety and feasibility in women receiving anticoagulation and anti-platelet treatment. Eur J Obstet Gynecol Reprod Biol 2021; 260:110-113. [PMID: 33765478 DOI: 10.1016/j.ejogrb.2021.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES More than 60,000 hysteroscopies are performed every year in the UK for common reasons such as heavy menstrual bleeding (HMB) or postmenopausal bleeding. A significant number of women requiring hysteroscopy receive oral anticoagulants and there is often a reluctance to perform these procedures due to bleeding concerns. STUDY DESIGN We are presenting the first proof of concept cohort of patients undergoing minor hysteroscopic procedures while on anticoagulant or antiplatelet medication. A variety of minor procedures such as cervical dilatation, targeted endometrial biopsies, Pipelle endometrial biopsies and insertion or removal of intrauterine contraceptive devices were performed alongside hysteroscopy. RESULTS Completion of planned procedures was feasible in all women due to minimal bleeding despite the ongoing anticoagulation or anti-platelet treatment. CONCLUSION More research is needed to establish the safety of performing diagnostic and operative hysteroscopies without bridging or interrupting anticoagulation or antiplatelet treatment.
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Affiliation(s)
- Nikolaos Tsampras
- Department of Gynaecology, Manchester University Foundation Trust, Manchester, UK.
| | - Kenneth Ma
- Department of Gynaecology, Manchester University Foundation Trust, Manchester, UK
| | - Rohit Arora
- Department of Gynaecology, Manchester University Foundation Trust, Manchester, UK
| | - Gemma McLeod
- Department of Gynaecology, Manchester University Foundation Trust, Manchester, UK
| | - Flurina Minchelotti
- Department of Gynaecology, Manchester University Foundation Trust, Manchester, UK
| | - Laurentiu Craciunas
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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15
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Abstract
Background: Our study aims to identify any influence that anticoagulation and antiplatelet ("blood thinner") medications have on hand and wrist corticosteroid injection complication rates. Methods: This retrospective chart review looked at patients between the ages of 18 and 89 years who received corticosteroid injections in the hand or wrist between 2013 and 2017, noting anticoagulation and antiplatelet use, demographics, injection placement, and surgical intervention. Results: Only 152 (20.9%) of the 726 diagnoses that were treated needed eventual surgical intervention. There were 12 overall reported complications after 1473 injections (0.8%). There were 6 complications after 433 injections (1.6%) placed in patients on blood thinners and 6 complications after 1040 injections (0.6%) placed in patients not on blood thinners. Conclusions: With the complication rate of corticosteroid injections being so low, even in patients taking "blood thinners," the fear of adverse reactions should not preclude a physician from using this treatment modality to prevent surgical intervention.
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Affiliation(s)
- Ajith Malige
- St. Luke’s University Hospital, Bethlehem, PA, USA
| | - Kristofer S. Matullo
- St. Luke’s University Hospital, Bethlehem, PA, USA,Kristofer S. Matullo, Department of Orthopaedic Surgery, St. Luke’s University Hospital, 801 Ostrum Street, Bethlehem, PA 18015, USA.
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16
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Zandee van Rilland E, Kim S, Ni Mhuircheartaigh J, Shif Y, Kung J, Wu JS. Association of aspirin and other non-steroidal anti-inflammatory drugs with bleeding complications in image-guided musculoskeletal biopsies. Skeletal Radiol 2020; 49:1849-1854. [PMID: 32535773 DOI: 10.1007/s00256-020-03510-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the safety of continuing aspirin and other non-steroidal anti-inflammatory drugs (NSAID) in patients undergoing image-guided musculoskeletal biopsies. MATERIAL AND METHODS Prior to October 2017, patients undergoing image-guided musculoskeletal biopsy had aspirin and NSAIDs withheld for the preceding 5-7 days. The policy changed in October 2017 based on new guidelines from the Society of Interventional Radiology such that aspirin and other NSAIDs were not withheld. A retrospective review of patient records was performed for all biopsies prior to and after the policy change to assess for differences in biopsy-related bleeding complications. Additional clinical and biopsy factors including age, gender, liver disease, coagulopathy, biopsy tissue type, and histological diagnosis were assessed. RESULTS In the pre-policy change group, there were 1853 total biopsies with 43 biopsy-related bleeding complications (2.3%). Within this group, 362 patients were on aspirin with 7 bleeding complications (1.9%) and 260 patients were on NSAIDs with 5 bleeding complications (1.9%). There were 409 total biopsies in the post-policy change group and 7 bleeding complications (1.7%). Within this group, 71 patients were on aspirin with 1 bleeding complication (1.4%). No bleeding complications were recorded in patients on NSAIDs (0%). There was no significant difference in bleeding complication between the pre- and post-policy change groups overall (p = 0.58) and in patients on aspirin (p = 1.00) or other NSAIDs (p = 1.00). CONCLUSION Bleeding complications for musculoskeletal biopsies are rare. Leaving patients on aspirin or other NSAIDs during a musculoskeletal biopsy does not increase the incidence of bleeding complications.
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Affiliation(s)
- Eddy Zandee van Rilland
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Stanley Kim
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | | | - Yuri Shif
- Department of Radiology, St. Luke's Hospital of Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Justin Kung
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA
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17
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Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration. AJR Am J Roentgenol 2020; 215:568-581. [PMID: 32783556 DOI: 10.2214/ajr.20.22773] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this evidence-based review is to equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. CONCLUSION. Septic arthritis is an emergency that can lead to rapidly progressive, irreversible joint damage. Despite the urgency associated with this diagnosis, there remains a lack of consensus regarding many aspects of the management of native and periprosthetic joint infections.
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18
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Jokic A, Milevoj Kopcinovic L, Culej J, Kocijan I, Bozovic M. Laboratory testing of extravascular body fluids: National recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine. Part II - Synovial fluid. Biochem Med (Zagreb) 2020; 30:030501. [PMID: 32774119 PMCID: PMC7394252 DOI: 10.11613/bm.2020.030501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 10/22/2019] [Indexed: 11/01/2022] Open
Abstract
Joint diseases are conditions with an often progressive and generally painful nature affecting the patient's quality of life and, in some cases, requiring a prompt diagnosis in order to start the treatment urgently. Synovial fluid (SF) laboratory testing is an important part of a diagnostic evaluation of patients with joint diseases. Laboratory testing of SF can provide valuable information in establishing the diagnosis, be a part of a patient's follow-up and treatment with the purpose of improving the patient's health and quality of life. Synovial fluid laboratory testing is rarely performed in Croatian medical biochemistry laboratories. Consequently, procedures for SF laboratory testing are poorly harmonized. This document is the second in the series of recommendations prepared by the members of the Working group for extravascular body fluid samples of the Croatian Society of Medical Biochemistry and Laboratory Medicine. It addresses preanalytical, analytical, and postanalytical issues and the clinical significance of tests used in SF laboratory testing with the aim of improving the value of SF laboratory testing in the diagnosis of joint diseases and assisting in the achievement of national harmonization. It is intended for laboratory professionals and all medical personnel involved in synovial fluid collection and testing.
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Affiliation(s)
- Anja Jokic
- Croatian Society of Medical Biochemistry and Laboratory Medicine, Working group for extravascular body fluid samples.,Department of Medical Biochemistry, Haematology and Coagulation with Cytology, University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | - Lara Milevoj Kopcinovic
- Croatian Society of Medical Biochemistry and Laboratory Medicine, Working group for extravascular body fluid samples.,Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Jelena Culej
- Croatian Society of Medical Biochemistry and Laboratory Medicine, Working group for extravascular body fluid samples.,Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Irena Kocijan
- Croatian Society of Medical Biochemistry and Laboratory Medicine, Working group for extravascular body fluid samples.,Medical Biochemistry Laboratory, General hospital Varaždin, Varaždin, Croatia
| | - Marija Bozovic
- Croatian Society of Medical Biochemistry and Laboratory Medicine, Working group for extravascular body fluid samples.,Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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19
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Thiesen DM, Mumin-Gündüz S, Gehrke T, Klaber I, Salber J, Suero E, Citak M. Synchronous Periprosthetic Joint Infections: The Need for All Artificial Joints to Be Aspirated Routinely. J Bone Joint Surg Am 2020; 102:283-291. [PMID: 31855870 DOI: 10.2106/jbjs.19.00835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periprosthetic joint infection (PJI) is a severe complication with increasing incidence. However, we are not aware of any robust data on patients having PJI at the same time in ≥2 joints that had undergone total joint arthroplasty, referred to as synchronous PJI throughout this article. The aims of this study were to investigate the probability of the development of synchronous PJI of another prosthetic joint and to identify possible clinical risk factors for the development of synchronous PJI. In addition, we aimed to determine whether routine aspiration of all other prosthetic joints was warranted after a diagnosis of PJI in a single joint. METHODS A total of 2,532 septic revision procedures were performed during the study period. In the final analysis, 644 patients (26 with synchronous PJI and 618 with non-synchronous PJI) with 1,508 prosthetic joints were included. The mean age (and standard deviation) was 71 ± 9.6 years. Using bivariate analyses, we calculated the odds of synchronous PJI as a function of various demographic and clinical variables. RESULTS A suspicious clinical presentation of the non-primary joint had the strongest association with synchronous PJI (odds ratio [OR], 58.5 [95% confidence interval (CI), 22.4 to 152.8]). Additional associations with synchronous PJI were detected for a history of neoplasia (OR, 12 [95% CI, 3.9 to 37.2]), the use of immune-modulating therapy (OR, 9.5 [95% CI, 3.4 to 26.2]), the presence of systemic inflammatory response syndrome or sepsis (OR, 8.4 [95% CI, 2.8 to 25]), and having ≥3 prosthetic joints (OR, 3.0 [95% CI, 1.37 to 6.64]). CONCLUSIONS Synchronous PJI is a rare but very serious complication and every prosthetic joint should be investigated meticulously. Suspicious clinical presentation, a history of neoplasia, sepsis, immune-modulating therapy, and ≥3 prosthetic joints were identified as risk factors and should increase the physician's vigilance. In the case of PJI, aspiration of each joint that had undergone total joint arthroplasty should be considered. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Darius M Thiesen
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Seval Mumin-Gündüz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany.,Department of Surgery, Ruhr-University Bochum, Bochum, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Ianiv Klaber
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Jochen Salber
- Department of Surgery, Ruhr-University Bochum, Bochum, Germany
| | - Eduardo Suero
- Department of General, Trauma and Reconstructive Surgery, Ludwig Maximilian University of Munich, Munich, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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20
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Patel IJ, Rahim S, Davidson JC, Hanks SE, Tam AL, Walker TG, Wilkins LR, Sarode R, Weinberg I. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions—Part II: Recommendations. J Vasc Interv Radiol 2019; 30:1168-1184.e1. [DOI: 10.1016/j.jvir.2019.04.017] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/10/2019] [Accepted: 04/10/2019] [Indexed: 02/06/2023] Open
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21
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Accelerating recovery from acute hemarthrosis in patients with hemophilia: the role of joint aspiration. Blood Coagul Fibrinolysis 2019; 30:111-119. [PMID: 30958454 DOI: 10.1097/mbc.0000000000000803] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
: Arthrocentesis of an acute hemarthrosis in hemophilia remains a controversial issue. The purpose of this study is to define the role that joint aspiration can play in the recovery from acute hemarthrosis in patients with hemophilia. The study sample included 33 hemophilic patients (55 joints) with acute elbow, knee, and ankle hemarthrosis as confirmed by ultrasonography. Patients were distributed into a treatment group and a control group. Patients in the first group were subjected to joint aspiration, whereas patients in the second were not. Arthrocentesis was carried out immediately after diagnosis of acute hemarthrosis in liquid phase. Patients were infused with the deficient coagulation factor and were instructed to observe relative rest until resolution of hemarthrosis. The following parameters were analyzed: time to full resolution of hemarthrosis (determined by ultrasonography), duration of treatment with the deficient coagulation factor, time to pain relief, time to recovery of prebleed range of motion, and time to resumption of school/work (all of these measured in days). The joints treated with joint aspiration exhibited a significantly faster resolution of bleeding (fewer days). In addition, this group required fewer days of pharmacological treatment, with faster achievement of functional recovery and resumption of school/work activities. No complications were observed. This study shows that joint aspiration under hemostatic cover and in strictly aseptic conditions is a well-tolerated technique that makes the recovery of acute hemarthrosis of hemophilic patients faster.
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22
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Abdel Karim M, Andrawis J, Bengoa F, Bracho C, Compagnoni R, Cross M, Danoff J, Della Valle CJ, Foguet P, Fraguas T, Gehrke T, Goswami K, Guerra E, Ha YC, Klaber I, Komnos G, Lachiewicz P, Lausmann C, Levine B, Leyton-Mange A, McArthur BA, Mihalič R, Neyt J, Nuñez J, Nunziato C, Parvizi J, Perka C, Reisener MJ, Rocha CH, Schweitzer D, Shivji F, Shohat N, Sierra RJ, Suleiman L, Tan TL, Vasquez J, Ward D, Wolf M, Zahar A. Hip and Knee Section, Diagnosis, Algorithm: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S339-S350. [PMID: 30348566 DOI: 10.1016/j.arth.2018.09.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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23
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Joint and soft-tissue injections in rehabilitation inpatients taking direct oral anticoagulants. Int J Rehabil Res 2018; 42:187-189. [PMID: 30507623 DOI: 10.1097/mrr.0000000000000330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The risk for complications associated with joint and soft-tissue injections in patients taking direct oral anticoagulants (DOACs) is not fully understood. In this retrospective evaluation of 445 inpatients in a rehabilitation hospital who received corticosteroid injections, complications were compared in patients on DOACs with those who were not. After a review of all injections, no adverse events of significant bleeding (intra-articular or extra-articular) were observed. These findings suggest no substantial increase in adverse events associated with the use of DOACs when performing joint and soft-tissue injection procedures in inpatient rehabilitation setting.
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24
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Long B, Koyfman A, Gottlieb M. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. West J Emerg Med 2018; 20:331-341. [PMID: 30881554 PMCID: PMC6404712 DOI: 10.5811/westjem.2018.10.40974] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/21/2018] [Accepted: 10/28/2018] [Indexed: 02/06/2023] Open
Abstract
Septic arthritis is a dangerous medical condition associated with significant morbidity and mortality. However, the differential diagnosis can be broad with conditions that mimic this disease and require different evaluation and treatment. This narrative review presents the emergency medicine evaluation and management, as well as important medical conditions that may mimic this disease. Septic arthritis commonly presents with monoarticular joint pain with erythema, warmth, swelling, and pain on palpation and movement. Fever is present in many patients, though most are low grade. Blood testing and imaging may assist with the diagnosis, but the gold standard is joint aspiration. Management includes intravenous antibiotics and orthopedic surgery consult for operative management vs. serial aspirations. Clinicians should consider mimics, such as abscess, avascular necrosis, cellulitis, crystal-induced arthropathies, Lyme disease, malignancy, osteomyelitis, reactive arthritis, rheumatoid arthritis, and transient synovitis. While monoarticular arthritis can be due to septic arthritis, other medical and surgical conditions present similarly and require different management. It is essential for the emergency clinician to be aware how to diagnose and treat these mimics.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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25
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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26
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Ricotta DN, Smith CC, McSparron JI, Chaudhry SI, McDonald FS, Huang GC. When Old Habits Train a New Generation: Findings From a National Survey of Internal Medicine Program Directors on Procedural Training. Am J Med Qual 2017; 33:383-390. [PMID: 29185357 DOI: 10.1177/1062860617743786] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Resident physicians routinely perform bedside procedures that pose substantial risk to patients. However, no standard programmatic approach to supervision and procedural competency assessment among residents currently exists. The authors performed a national survey of internal medicine (IM) program directors to examine procedural assessment and supervision practices of IM residency programs. Procedures chosen were those commonly performed by medicine residents at the bedside. Of the 368 IM programs, 226 (61%) completed the survey. Programs reported the predominant method of training as 171 (74%) apprenticeship and 106 (46%) as module based. The majority of programs used direct observation to attest to competence, with 55% to 62% relying on credentialed residents. Most programs also relied on a minimum number of procedures to determine competence (64%-88%), 72% of which reported 5 procedures (a lapsed historical standard). This national survey demonstrates that procedural assessment practices for IM residents are insufficiently robust and may put patients at undue risk.
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27
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Yui JC, Preskill C, Greenlund LS. Arthrocentesis and Joint Injection in Patients Receiving Direct Oral Anticoagulants. Mayo Clin Proc 2017; 92:1223-1226. [PMID: 28778256 DOI: 10.1016/j.mayocp.2017.04.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 04/05/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
Anticoagulation is common in patients undergoing arthrocentesis and joint injections. Previous studies have established the safety of continuing anticoagulation with warfarin before joint aspirations/injections with only a small increased risk of bleeding, but no data are available regarding the use of direct oral anticoagulants (DOACs) and joint aspirations/injections. The objective of this study was to determine the rate of bleeding complications associated with arthrocentesis and joint injection in patients receiving DOACs. We performed a retrospective review of adult patients at Mayo Clinic in Rochester, Minnesota, who were being treated with DOACs and underwent outpatient joint aspiration and/or injection between October 1, 2010, and October 31, 2016. In 1050 consecutive procedures, there were no bleeding complications. Arthrocentesis and joint injections in patients receiving DOAC therapy are safe procedures, and there is no need to withhold anticoagulation treatment before the procedure.
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Affiliation(s)
- Jennifer C Yui
- Department of Medicine, Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
| | - Carina Preskill
- Department of Medicine, Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN
| | - Laura S Greenlund
- Department of Medicine, Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN.
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28
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Prevalence of Bleeding Complications Following Ultrasound-Guided Botulinum Toxin Injections in Patients on Anticoagulation or Antiplatelet Therapy. PM R 2017. [DOI: 10.1016/j.pmrj.2017.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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29
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Atwell TD, Wennberg PW, McMenomy BP, Murthy NS, Anderson JR, Kriegshauser JS, McKinney JM. Peri-procedural use of anticoagulants in radiology: an evidence-based review. Abdom Radiol (NY) 2017; 42:1556-1565. [PMID: 28070656 DOI: 10.1007/s00261-016-1027-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Peri-procedural anticoagulant management hinges on the balance of hemorrhagic and thrombotic complications. The radiologist is tasked with accurately assessing the hemorrhagic risk for patients undergoing procedures, taking into account procedural bleeding rates, underlying coagulopathy based on lab tests, and use of anticoagulants. The purpose of this article is to provide a contemporary review of commonly used anticoagulants and, incorporating published evidence, review their management related to image-guided procedures.
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30
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Mackenzie DC, McCorvey S. Spontaneous elbow hemarthrosis identified by point-of-care ultrasound. Clin Exp Emerg Med 2017; 4:60-63. [PMID: 28435904 PMCID: PMC5385507 DOI: 10.15441/ceem.16.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/20/2016] [Accepted: 05/10/2016] [Indexed: 12/02/2022] Open
Abstract
Traumatic or spontaneous hemarthroses are an important cause of joint effusions, and can complicate innate or acquired coagulopathies. The elbow is an unusual location for a spontaneous hemarthrosis; we describe a previously unreported case of warfarin-induced spontaneous elbow hemarthrosis, diagnosed by point-of-care ultrasound. On the basis of clinical and ultrasound findings arthrocentesis was deferred, and the patient was successfully treated with warfarin reversal and conservative care. Physical examination is unreliable for the detection of a joint effusion, and misdiagnosis and can lead to unnecessary investigation or resource use. Point-of-care ultrasound allows accurate, prompt, direct visualization of a joint effusion, and non-invasive confirmation of a hemarthrosis. Ultrasound can facilitate accurate diagnosis and characterization of joint effusions to improve the care of patients with coagulopathy.
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Affiliation(s)
- David C Mackenzie
- Department of Emergency Medicine, Maine Medical Center, Portland, ME, USA
| | - Scott McCorvey
- Department of Emergency Medicine, Maine Medical Center, Portland, ME, USA
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McCrum C. Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 2: Clinical and Procedural Considerations. Musculoskeletal Care 2016; 14:252-266. [PMID: 27297723 DOI: 10.1002/msc.1145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection.
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Affiliation(s)
- Carol McCrum
- East Sussex Healthcare NHS Trust, Eastbourne, UK
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Halaszynski TM. Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery. Oral Maxillofac Surg Clin North Am 2016; 28:443-460. [PMID: 27745616 DOI: 10.1016/j.coms.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, 333 Cedar Street, TMP 3 Library, New Haven, CT 203 785-2804, USA.
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Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy. J Clin Anesth 2016; 34:586-99. [PMID: 27687455 DOI: 10.1016/j.jclinane.2016.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 01/10/2023]
Abstract
As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.
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Ponction et infiltration articulaire du genou. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Heron N. Musculoskeletal (MSK) and Sport and Exercise Medicine (SEM) in General Practice (GP): A Novel GP-based MSK and SEM Clinic for Managing Musculoskeletal symptoms in a GP. BMJ QUALITY IMPROVEMENT REPORTS 2016; 4:bmjquality_uu207172.w2905. [PMID: 26733320 PMCID: PMC4645797 DOI: 10.1136/bmjquality.u207172.w2905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 01/23/2015] [Indexed: 12/17/2022]
Abstract
Musculoskeletal (MSK) complaints are common within primary care (1) (2) (3) but some General Practitioners (GPs)/family physicians do not feel comfortable managing these symptoms (3), preferring to refer onto hospital specialists or Integrated Clinical Assessment and Treatment Services (ICATs). Long waiting times for hospital outpatient reviews are a major cause of patient inconvenience and complaints (4). We therefore aimed to establish a GP-ran MSK and sport and exercise medicine (SEM) clinic based within a Belfast GP surgery that would contribute to a sustainable improvement in managing these common conditions within primary care as well as reducing waiting times for patients with these conditions to see a specialist. This shift from hospital-based to community-based management is in-keeping with recent policy changes within the UK health-system, including Transforming Your Care within Northern Ireland (NI) (5). The GP-ran MSK and SEM clinic was held monthly within a Belfast GP practice, staffed by one GP with a specialist interest in MSK and SEM conditions and its performance was reviewed over a three month period. Parameters audited included cases seen, orthopaedic and x-ray referral rates and secondary care referrals comparing the GP practice's performance to the same time period in the previous year as well as patient satisfaction questionnaires.
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Bashir MA, Ray R, Sarda P, Li S, Corbett S. Determination of a safe INR for joint injections in patients taking warfarin. Ann R Coll Surg Engl 2015; 97:589-91. [PMID: 26492905 PMCID: PMC5096611 DOI: 10.1308/rcsann.2015.0044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2015] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION With an increase in life expectancy in 'developed' countries, the number of elderly patients receiving joint injections for arthritis is increasing. There are legitimate concerns about an increased risk of thromboembolism if anticoagulation is stopped or reversed for such an injection. Despite being a common dilemma, the literature on this issue is scarce. METHODS We undertook 2,084 joint injections of the knee and shoulder in 1,714 patients between August 2008 and December 2013. Within this cohort, we noted 41 patients who were taking warfarin and followed them immediately after joint injection in the clinic or radiology department, looking carefully for complications. Then, we sought clinical follow-up, correspondence, and imaging evidence for 4 weeks, looking for complications from these joint injections. We recorded International Normalised Ratio (INR) values before injection. RESULTS No complications were associated with the procedure after any joint injection. The radiologists who undertook ultrasound-guided injections to shoulders re-scanned the joints looking for haemarthroses: they found none. A similar outcome was noted clinically after injections in the outpatient setting. CONCLUSION With a mean INR of 2.77 (range, 1.7-5.5) and a maximum INR within this group of 5.5, joint injections to the shoulder and knee can be undertaken safely in primary or secondary care settings despite the patient taking warfarin.
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Affiliation(s)
- M A Bashir
- Department of Orthopaedics, Guy's and St. Thomas' NHS Foundation Trust, , UK
| | - R Ray
- Department of Orthopaedics, Guy's and St. Thomas' NHS Foundation Trust, , UK
| | - P Sarda
- Department of Orthopaedics, Guy's and St. Thomas' NHS Foundation Trust, , UK
| | - S Li
- Department of Orthopaedics, Guy's and St. Thomas' NHS Foundation Trust, , UK
| | - S Corbett
- Department of Orthopaedics, Guy's and St. Thomas' NHS Foundation Trust, , UK
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Heron N. A 'novel' model for integrating Sport and Exercise Medicine (SEM) and Musculoskeletal (MSK) management into primary care in the UK. BMJ Open Sport Exerc Med 2015; 1:e000027. [PMID: 27900125 PMCID: PMC5117016 DOI: 10.1136/bmjsem-2015-000027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Musculoskeletal (MSK) symptoms are common within primary care but some general practitioners (GPs)/family physicians do not feel comfortable managing these symptoms, preferring to refer onwards. We aimed to establish a reproducible GP-staffed MSK and sport and exercise medicine (SEM) clinic within primary care, in keeping with recent policy changes within the UK health system. METHODS A monthly MSK and SEM clinic was held within a Belfast GP practice, staffed by 1 GP with a specialist interest in MSK/SEM conditions, and its performance was reviewed over two 3-month periods. Parameters audited included diagnoses, patient satisfaction and secondary care referral rates. RESULTS 83 patients, 36 males and 47 females, were reviewed in the clinic and the main presenting joint was the shoulder. Patient self-reported satisfaction with the service was high. Comparing referral rates between August and October 2013 and the same period in 2014, overall referrals from the practice were reduced by 147, orthopaedic and rheumatology referrals were reduced by 2 and 3, while physiotherapy and X-ray referrals were reduced by 47 and 90, respectively. Comparing the referral rates between January and March 2014 and the same period in 2015, overall outpatient referrals were reduced by 152, orthopaedic and rheumatology referrals were reduced by 9 and 4, while physiotherapy and X-ray referrals were reduced by 41 and 3, respectively. DISCUSSION We present a novel, reproducible service model for managing MSK/SEM symptoms in primary care which could be commissioned by local groups. This model can make sound economic sense and deliver high patient satisfaction within primary care, reducing waiting times and the secondary care referral burden.
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Affiliation(s)
- Neil Heron
- Department of General Practice and Primary Care, Queen's University Belfast, Belfast, Northern Ireland; Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland; UKCRC Centre of Excellence for Public Health (NI), Queen's University Belfast, Belfast, Northern Ireland
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Wang DT, Dubois M, Tutton SM. Complications in musculoskeletal intervention: important considerations. Semin Intervent Radiol 2015; 32:163-73. [PMID: 26038623 DOI: 10.1055/s-0035-1549447] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Musculoskeletal (MSK) intervention has proliferated in recent years among various subspecialties in medicine. Despite advancements in image guidance and percutaneous technique, the risk of complication has not been fully eliminated. Overall, complications in MSK interventions are rare, with bleeding and infection the most common encountered. Other complications are even rarer. This article reviews various complications unique to musculoskeletal interventions, assists the reader in understanding where pitfalls lie, and highlights ways to avoid them.
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Affiliation(s)
- David T Wang
- Division of Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Melissa Dubois
- Division of Musculoskeletal Radiology, Froedtert & The Medical College, Milwaukee, Wisconsin
| | - Sean M Tutton
- Division of Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature. Skeletal Radiol 2015; 44:619-27. [PMID: 25433718 DOI: 10.1007/s00256-014-2065-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/11/2014] [Accepted: 11/11/2014] [Indexed: 02/07/2023]
Abstract
This review compiles the current literature on the bleeding risks in common musculoskeletal interventional procedures and attempts to provide guidance for practicing radiologists in making decisions regarding the periprocedural management of patients on antithrombotic therapy. The practitioner must weigh the risk of bleeding if therapy is continued against the possibility a thromboembolic occurring if anticoagulation therapy is withheld or reversed. Unfortunately, there is little empirical data to guide evidence-based decisions for many musculoskeletal interventions. However, a review of the literature shows that for low-risk procedures, such as arthrograms/arthrocenteses or muscle/tendon sheath injections, bleeding risks are sufficiently small that anticoagulants and antiplatelet therapies need not be withheld. Additionally, relatively higher-risk procedures, such as needle biopsies of bone and soft tissue, may be safely performed without holding antithrombotic therapy, provided pre-procedural INR is within therapeutic range. Thus, while a patient's particular clinical circumstances should dictate optimal individualized management, anticoagulation alone is not a general contraindication to most interventional musculoskeletal radiology procedures.
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Abstract
Osteoarthritis is the most frequent joint disorder and substantially affects patient quality of life. As an age-related disease it leads to an increasing financial burden for the healthcare system due to the current demographic changes. Osteoarthritis affects every single tissue in the joint. The identification of the source of disease symptoms is the key to a successful management. Therapeutic approaches include non-pharmacological and pharmacological treatment. Surgery is the therapeutic end stage (e.g. total joint replacement, high tibial osteotomy and arthrodesis). This overview focuses on the pharmacological treatment whereas the clinical manifestations and non-pharmacological approaches are only briefly dealt with.
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Affiliation(s)
- L Wildi
- Rheumaklinik, UniversitätsSpital Zürich, Gloriastr. 25, 8091, Zürich, Schweiz,
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41
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications. Reg Anesth Pain Med 2015; 40:182-212. [DOI: 10.1097/aap.0000000000000223] [Citation(s) in RCA: 195] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Aspiration and injection of joints and periarticular tissue and intralesional therapy. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00069-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Is it safe to perform joint infiltrations or aspirations in patients anticoagulated with acenocoumarol? ACTA ACUST UNITED AC 2014; 11:9-11. [PMID: 24891041 DOI: 10.1016/j.reuma.2014.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 02/19/2014] [Accepted: 03/10/2014] [Indexed: 11/23/2022]
Abstract
The purpose of this study is to determine the rate of bleeding complications in patient's anticoagulated with acenocoumarol according to the international normalized ratio (INR) coagulation index. A cross-sectional study was performed with 901 charts of patients who underwent arthrocentesis or joint infiltration between 2009 and 2013; the charts were grouped on the basis of having an INR higher or lower than 2.0 (268 and 633, respectively). Comparisons were performed in terms of rates of early or late bleeding complications. A 0.37% rate of early bleeding complications (< 24hours) was observed in the group of patients with INR<2 and 0.99% in the group of patients with INR≥2 (P=.47). Only one case of late complication was presented by bleeding between 24 hours and 30 days, in the group of patients with INR≥2. We conclude that oral anticoagulation with acenocoumarol at terapeutical doses does not increase the risk of bleeding joint punctures.
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Feinbloom D. Periprocedural management of antithrombotic therapy in hospitalized patients. J Hosp Med 2014; 9:337-46. [PMID: 24550198 DOI: 10.1002/jhm.2166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/08/2014] [Accepted: 01/15/2014] [Indexed: 11/08/2022]
Abstract
The management of antithrombotic medications in patients requiring invasive procedures is a common problem in hospital medicine, for which there is limited evidence to guide clinical decision making. Existing guidelines do not address many hospital-based procedures and have not kept pace with the introduction of newer antiplatelet and anticoagulant medications. This article provides a conceptual framework for the periprocedural management of antithrombotic therapy, with a focus on the procedures that hospitalists are most likely to perform and the pharmacology of the common and newer antithrombotic medications.
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Affiliation(s)
- David Feinbloom
- Section of Hospital Medicine, Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Abstract
The pharmacological management of osteoarthritis includes pure analgesia, anti-inflammatory drugs and substances supporting tissue maintenance in osteoarthritic joints. The decision for the treatment modality is made depending on the affected joint, the stage of the disease, the extent and frequency of inflammatory flares and the patient risk profile. This article gives an overview of the current treatment modalities including the advantages and disadvantages.
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46
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Conway R, O’Shea FD, Cunnane G, Doran MF. Safety of joint and soft tissue injections in patients on warfarin anticoagulation. Clin Rheumatol 2013; 32:1811-4. [DOI: 10.1007/s10067-013-2350-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Revised: 05/27/2013] [Accepted: 07/25/2013] [Indexed: 10/26/2022]
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