The Safety of Continued Oral Anticoagulation Therapy in Joint Injections and Aspirations: A Qualitative Review of the Current Evidence.

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.

The morphology of the medial gastrocnemius in typically developing children and children with spastic hemiplegic cerebral palsy.

We collected 3D ultrasound images of the medial gastrocnemius muscle belly (MG) in 16 children with spastic hemiplegic cerebral palsy (SHCP) (mean age: 7.8 years; range: 4-12) and 15 typically-developing (TD) children (mean age: 9.5 years; range: 4-13). All children with SHCP had limited passive dorsiflexion range on the affected side with the knee extended (mean+/-1SD: -9.3 degrees +/-11.8). Scans were taken of both legs with the ankle joint at its resting angle (RA) and at maximum passive dorsiflexion (MD), with the knee extended. RA and MD were more plantar flexed (p<0.05) in children with SHCP than in TD children. We measured the volumes and lengths of the MG bellies. We also measured the length of muscle fascicles in the mid-portion of the muscle belly and the angle that the fascicles made with the deep aponeurosis of the muscle. Volumes were normalised to the subject's body mass; muscle lengths and fascicle lengths were normalised to the length of the fibula. Normalised MG belly lengths in the paretic limb were shorter than the non-paretic side at MD (p=0.0001) and RA (p=0.0236). Normalised muscle lengths of the paretic limb were shorter than those in TD children at both angles (p=0.0004; p=0.0003). However, normalised fascicle lengths in the non-paretic and paretic limbs were similar to those measured in TD children (p>0.05). When compared to the non-paretic limb, muscle volume was reduced in the paretic limb (p<0.0001), by an average of 28%, and normalised muscle volume in the paretic limb was smaller than in the TD group (p<0.0001). The MG is short and small in the paretic limb of children with SHCP. The altered morphology is not due to a decrease in fascicle length. We suggest that MG deformity in SHCP is caused by lack of cross-sectional growth.