NZRA Position Statement on intra-articular and Soft Tissue Injections

AIM

The purpose of this statement is to comment on current standard practice of intra-articular and soft-tissue steroid injections performed by Rheumatologists in New Zealand.

PREAMBLE

Intra-articular and soft tissue steroid injections will be referred to as “injections” in this statement.

Injections are used frequently by Rheumatologists to assist with management of a number of musculoskeletal conditions. Injections can be effective in controlling symptoms in many conditions and have a low risk of complications including infection [1]. Joint aspiration is also an important procedure for diagnostic purposes for example infection, haemarthrosis and crystal arthritis.

Injections and joint aspiration are performed as a standard out patient office based procedure by Rheumatologists.

Rheumatologists are trained to perform injections during Physician training and particularly during their advanced training. In Rheumatology [2], a “no touch”, “clean” or “aseptic” technique is used widely in New Zealand, Australia and internationally, however no standard definition currently exists [1,3]. Hand preparation with hand washing or use of alcohol, and skin preparation with alcohol appears to be effective preparation for most procedures [1,3].

Use of full surgical gowning, gloves and draping is not standard procedure for injections and would add significant costs to this procedure with no improved outcome for the patient [1,3]. Delays or deferral of injections by such full surgical procedure may result in an adverse outcome for the patient.

Use of sterile equipment is essential [1]. Gloves should be worn to protect the operator from coming into contact with body fluids, if at risk, and need not be sterile if a “no touch” technique is utilised [1,3].

Joint infection after injection is extremely rare and comparable to the rate of sepsis after venipuncture [1]. The current literature does not identify any difference in infection risk in a “clean” technique compared with sterile technique [3].

STATEMENT

The New Zealand Rheumatology Association (NZRA) recognises that injections are important in the management of musculoskeletal conditions including diagnosis and treatment. The NZRA note that informed verbal consent is integral to this treatment. The risks of complications with injection are low. A “no touch” technique is essential. Full surgical sterile procedure is unnecessary.

Bibliography

Courtney, P. and M. Doherty, Joint aspiration and injection and synovial fluid analysis. Best practice & research. Clinical rheumatology, 2009. 23(2): p. 161-192.
PREP Advanced Training Program (2009) Royal Australian College of Physicians webpage Accessed June 7th 2011 from http://www.racp.edu.au/page/specialty/rheumatology
Baima, J. and Z. Isaac, Clean versus sterile technique for common joint injections: a review from the physiatry perspective. Current Reviews in Musculoskeletal Medicine, 2008. 1(2): p. 88-91

Acknowledgement

The NZRA gratefully acknowledges The Australian Rheumatology Association for granting permission for use of the ARA Position Statement on Intra-articular injections and soft tissue injections, on which this Position Statement is based.

Dr Terry Macedo
Dr Simon Stebbings

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