The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee.

Although intraarticular injections are important to the management of rheumatoid arthritis, there are few studies regarding the cost-effectiveness of alternative injection techniques. This randomized controlled study addressed the cost-effectiveness of two different low-cost, anatomic landmark palpation-directed intraarticular injection techniques. Ninety-six symptomatic rheumatoid knees were randomized to two different low-cost, palpation-guided intraarticular injection techniques utilizing (1) a conventional syringe or (2) a mechanical syringe, the RPD (the reciprocating procedure device). Three milliliters of 1% lidocaine were used to anesthetize the synovial membrane, followed by arthrocentesis and hydrodissection, and injection of 80 mg of triamcinolone acetonide utilizing the one-needle two-syringe technique. Baseline pain, procedural pain, aspirated fluid volume, pain at outcome (2 weeks and 6 months), responders, reinjection rates, cost/patient/year, and cost/responder/year were determined. Pain was measured with the 10 cm Visual Analogue Pain Scale (VAS). Both techniques significantly reduced pain scores at outcome from baseline (P < 0.001). The mechanical syringe technique resulted in a greater volume of aspirated fluid (P < 0.01), a 38% reduction in procedural pain (P < 0.001), a 24% reduction in pain scores at outcome (P < 0.03), an increase in the responder rate (P < 0.025), 33% increase in the time to next injection (P < 0.001), 23% ($35 US) reduction in cost/patient/year for a patient treated in a physician office (P < 0.001), 24% reduction ($26 US) in cost/patient/year for a hospital outpatient (P < 0.001), and 51% ($151 US) reduction in cost/responder/year (P < 0.001). The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee can be improved significantly with low-cost alternations in technique.

Does sonographic needle guidance affect the clinical outcome of intraarticular injections?

OBJECTIVE: This randomized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular (IA) joint injections. METHODS: In total, 148 painful joints were randomized to IA triamcinolone acetonide injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed control syringe (the reciprocating device). A one-needle, 2-syringe technique was used, where the first syringe was used to introduce the needle, aspirate any effusion, and anesthetize and dilate the IA space with lidocaine. After IA placement and synovial space dilation were confirmed, a syringe exchange was performed, and corticosteroid was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks), and changes in pain scores were measured with a 0-10 cm visual analog pain scale (VAS). RESULTS: Relative to conventional palpation-guided methods, sonographic guidance resulted in 43.0% reduction in procedural pain (p < 0.001), 58.5% reduction in absolute pain scores at the 2 week outcome (p < 0.001), 75% reduction in significant pain (VAS pain score > or = 5 cm; p < 0.001), 25.6% increase in the responder rate (reduction in VAS score > or = 50% from baseline; p < 0.01), and 62.0% reduction in the nonresponder rate (reduction in VAS score < 50% from baseline; p < 0.01). Sonography also increased detection of effusion by 200% and volume of aspirated fluid by 337%. CONCLUSION: Sonographic needle guidance significantly improves the performance and outcomes of outpatient IA injections in a clinically significant manner.

Syringe size: does it matter in physician-performed procedures?

PURPOSE: We hypothesized that the size of syringe influenced needle control in physician-performed procedures. MATERIALS AND METHODS: Operators were tested for their ability to control a 1-, 3-, 5-, 10-, and 20-mL syringe and equivalent sizes of the new safety device, the reciprocating procedure device (RPD), using the quantitative needle-based displacement method. Three hundred twenty clinical syringe procedures were then randomized to either a 3- or 10-mL conventional syringe or to a 3- or 10-mL RPD. Patient pain was measured with the Visual Analog Pain Scale (VAPS). RESULTS: Increasing syringe size was associated with the undesirable characteristic of unintended forward penetration (loss of control of the needle in the forward direction) (r(2) = 0.97, slope = 2.14, 95% CI: 1.54-2.76, P < 0.002), and unintended retraction (loss of control of the needle in the reverse direction) (r(2) = 0.97, slope 2.15, 95% CI: 1.54-2.76, P < 0.002). In addition, 2-handed operation of a syringe resulted in greater control than 1-handed operation of a syringe (P < 0.001). When 1-handed operation was required, the RPD control syringe reduced unintended penetration by 52.3% (P >or= 0.001), unintended retraction by 56.8% (P >or= 0.001), and patient pain by 54.7% (P >or= 0.001) at each device size. CONCLUSIONS: For greater safety and control when operating the conventional syringe, smaller syringe sizes and 2 hands instead of 1 hand should be used whenever possible. If 1-handed operation of a syringe is necessary, a safety technology like the RPD control syringe should be used.

Patient pain and tissue trauma during syringe procedures: a randomized controlled trial.

OBJECTIVE: To investigate the relationship of needle control to tissue trauma and hemorrhage during syringe procedures. METHODS: Forty-seven subjects with a palpable knee effusion underwent needle and syringe aspiration. Subjects were randomized to the conventional syringe or a safety technology, the reciprocating procedure device (RPD). This trial was registered at clinicaltrials.gov. Pain was measured with the Visual Analog Pain Scale (VAPS). Cell count, crystal examination, culture, and aspirated fluid volume were determined. Red blood cell (RBC) counts were used to measure blood in aspirated fluid. RESULTS: Patient pain during the syringe procedure significantly predicted blood (RBC) in aspirated fluid (r = 0. 53, p = 0.001). When compared to the conventional syringe, the RPD safety device reduced blood in aspirated fluid by 66.7% (RBC, 10(3)/ml: RPD 8.9 +/- 11.4; syringe 26.7 +/- 90.2; p 0.01), reduced patient pain by 73.9% (VAPS: RPD 1.68 +/- 2.34; syringe 6.44 +/- 2.86; p < 0.01), and improved fluid aspirate yield by 132% (aspirate volume: RPD 20.9 +/- 19.7 ml; syringe 9.00 +/- 6.58 ml; p < 0.01). CONCLUSION: Inadequate control of needle and syringe during physician-performed syringe procedures is an important cause of trauma to patient tissues resulting in hemorrhage, increased patient pain, and decreased aspirate yield. The RPD -- a safety device that improves needle control and decreases needle trauma to tissues -- reduces hemorrhage and improves the safety, outcome, and aspirate yield of physician-performed syringe procedures.