Curriculum Vitae:

dr. Laniyati Hamijoyo SpPD-KR. M.Kes

•Staf pengajar Divisi Reumatologi Departemen Ilmu

Penyakit Dalam FK UNPAD/ RS Hasan Sadikin Bandung
Pendidikan:

1994 : FK Universitas Atma Jaya, Jakarta

1996 : Internship di CWZ Nijmegen-Netherland

2005 : Spesialis Penyakit Dalam FK.UNPAD, Bandung

2005 : Magister kesehatan FK. UNPAD, Bandung

2007 : Subspesialisasi Reumatologi di Univ.Santo Tomas Manila

2008 : Adaptasi Konsultan Reumatologi FKUI,Jakarta

Organisasi: Anggota:

IRA, PAPDI, PRA, IDI, APLAR

+

Workshop:

Injeksi Intra artikular Lutut and Bahu

Laniyati Hamijoyo
Divisi Reumatologi Departemen Ilmu Penyakit
Dalam FK UNPAD/ RS Hasan Sadikin Bandung
+
Workshop

 Cases

 Aspiration of Knee joint

 Intraarticular Injection of Knee Joint
 Injection of Shoulder Joint
+

Kasus
+
Nyeri lutut dan efusi
Kasus 1  Nyeri dan bengkak
sejak 2 hari yang lalu
 Bapak S, 62 th, BB 65 kg
 Trauma (-)

 PF: efusi dan hangat

 TD 140/99 mmHg

 Diagnosis?
+
Harus bagaimana?
+ Anamnesis
Assessment of Acute pain
• Characterizing and quantifying the pain
• Achieve diagnosis of pain and underlying
disorder
• Identify co morbid conditions

• History of past illness/ previous event

• History of family
• History of treatment
+
Characterizing the pain

History taking

Pattern : onset, duration, frequency

Area : location, topography
Intensity: level
Nature : description, history of
similar episodes,
intervention & what helped
Pain assessment tools
+
Musculoskeletal examination

 Inspection: look for redness,

swelling, deformity
 Palpation : Test for warmness
Test for deep/ superficial
muscle tenderness
 Range of motion
“CDR” Jurus untuk membuat diagnosis
+
Nyeri Muskuloskeletal

Anamnesis & PF
Non-artikular Artikular
Akut Kronis
Tendonitis
Bursitis Inflamasi
Ada Tdk ada/ Minima
Poliartritis OA
Monoartritis
Gout
Melibatkan tlg belakang
Artritis septik
Trauma Prominent Minimal/None
AS, PsA* RA, Viral*,
* Manifestasi ekstraartikular: rash, demam
SLE* ReA*
+
Laboratory test

 Hb 13.2 g/dl

 L 10.800

 Ureum 34 mg/dl,

 kreatinin= 2.3 mg/dl (eGFR 30.6 ml/mnt)

 SGOT/SGPT normal

 Cholesterol 254 mg/dl

 HDL 30 mg/dl LDL 198 mg/dl

 Triglyceride 248mg/dl

 Serum Uric acid: 10.3 mg/dl

+
Diagnosis:
 Acute gouty arthritis

COMORBIDITY:

 Chronic kidney disease

 Hypertension

 Dyslipidemia
+
Persiapan aspirasi
 Informed consent

 Persiapan alat
 Alat:
 Persiapan pasien  spuit 10 cc
 Spuit 5 cc
 Persiapan dokter
 Sarung tangan steril
 Iodine
 Alkohol swab
 Triamcinolone acetate
+
Universal Precaution
+
Lokasi aspirasi
+
Anatomi lutut
+
Efusi sendi lutut
+
Medial approach
+
Lateral approach
+
Aspirasi sendi lutut

Kasus 2 Bapak S, 62 th:

Artocentesis: cairan
sinovium keruh: 52 cc

 Diagnosis?
 Analisis cairan
synovium
 Terapi?
+ 8 important things to remember in GOUT

 Hyperuricemia ≠ Gout
 Treat the acute pain properly
 Don’t start ULT in acute attack, don’t interrupt if patient
has been taking ULT.
 Use prophylaxis for at least 3 months after initiating
gout therapy
 Do not stop gout medication unless
patient is showing evidence of drug
toxicity or adverse reaction
 Goal sUA < 6 and sUA < 5 if tophus (+)
 Encourage vegetable
 Ask your friendly rheumatologist for
help!
+

REVIEW

Injeksi intraartikular dan intralesi

+ INJEKSI intra-artikuler atau Intralesi 25

INJEKSI Sendi, tendon, bursa

Memulihkan keluhan penderita

Mempercepat penyembuhan artritis
Mengurangi kecacatan sendi

1. DIAGNOSTIK :
 Aspirasi cairan sendi
2. TERAPI :
 Membuang kelebihan cairan sendi
 Injeksi obat
 INDIKASI 26

DIAGNOSTIK TERAPI
ASPIRASI SENDI:
 Membuang/mengambil  INJEKSI OBAT
cairan sinovial dianalisa
 TIA nyeri sendi 
 Evaluasi monoartritis akut
 Membedakan artritis
inflamasi /non inflamasi

SYARAT:
ANALISA CAIRAN SENDI INFEKSI SENDI (-)
(lekosit/PMN, gram staining & kultur,
kristal urat/piropospat, kadar glukosa)
 KONTRA INDIKASI
+ TERAPI INJEKSI INTRA-ARTIKULER
27

1. Infeksi lokal

2. Hipersensitivitas

3. Diatesis hemorrhagik

4. Sendi yang tidak stabil

5. Fraktur intra-artikuler

6. Sendi yang tidak dapat dicapai

7. Osteoporosis juxta-artikuler yang berat

8. Kegagalan suntikan terdahulu

9. Tidak ada indikasi yang tepat

10. Lesi yang mungkin tidak berespon terhadap injeksi


Facial flushing
Flare up post injeksi
Atrofi kulit lokasi injeksi
Hipopigmentasi kulit
Infeksi
Perdarahan
KOMPLIKASI 28
Sering dijumpai (40%)
Corticosteroid-induced crystal synovitis (5%)
Pada post injeksi sub kutan bursa : cigarette
paper-like skin, reccurent echymosis, &
chronic pressure pain
Pada inj. Kortikosteroid superfisial
( pada de Quervain tenosynovitis)
Insiden 1 dari 1.000-16.000 (dokter
berpengalaman).
20% penderita artritis septik pernah diinjeksi
IA dalam 3 bulan terakhir
Perdarahan merata curiga: trauma/
gangguan mekanisme perdarahan
Lakukan aspirasi, jangan diinjeksi
 KOMPLIKASI 29

Kerusakan rawan Trauma ujung jarum suntik

sendi
Ruptur Oleh karena prosedur yang tak benar
tendon/ligamen
Artropati Ok injeksi IA yang berlebihan
kortikosteroid ~ Charcot’t like arthropathy

Osteonekrosis Ok injeksi IA yang berlebihan

Kristal sinovitis Ok larutan mikrokristal kortikosteroid

Supresi korteks Jika IA dilakukan > 1-2 x sebulan

adrenal
+

Kasus 2
Kasus 2. Ibu T 65 tahun

 Nyeri lutut
 Nyeri jika bangun dari
duduk, naik tangga
 Kalau jalan tidak begitu
sakit

Dr. Lanny
Osteoarthritis (OA)
 DM, HT, HHD, Decomp FC
2
 Rx/ dexametason + Na
diclofenac
 Riwayat perdarahan
lambung

Kasus 2. Ibu T 65 tahun

+ ACR Pharmacologic recommendations for the
initial management of knee OA 2012

We conditionally recommend that patients with

knee OA should use one of the following:

 Acetaminophen

 Oral NSAIDs
 Topical NSAIDs
 Tramadol

 Intraarticular corticosteroid injections

+ ACR Pharmacologic recommendations for the
initial management of knee OA 2012

We conditionally recommend that patients with

knee OA should not use the following:

 Chondroitin sulfate
 Glucosamine

 Topical capsaicin
We have no recommendations
regarding the use of intraarticular
hyaluronates, duloxetine, and
opioid analgesics
+ Final set of 10 recommondations for knee OA
based on both evidence and expert opinion
1. Combination nonpharmacological + pharmacological treament
2. Tailored according:
a. specific knee risk factors (obesity, mechanical factors, physical
activity)
b. general risk factors (age ,comorbidity, polypharmacy)
c. level of pain intensity and disability
d. sign of inflammation e.g effusion
e. location and degree of structural damage
3. Nonpharmacological treatment (education, exercise, appliances, &
weight )
4. Paracetamol
5. Topical NSAID or Capsaicin
6. NSAID / Selective COX 2 inhibitors or
NSAID + gastroprotective agents (gastrointestinal risk)
7. Opoids
8. SYSADOA (GS,CS, Diacerin, Hyaluronate)
9. I.A. Steroid injection
10. Joint Replacement (refractory pain and disability)
Jordan et al. Ann. Rheum. Dis. 2003; 62:1145-1155
+
Injeksi IA Hyaluronic acid
+

The role of HA
Intraarticular injection
+
synovium

 Normalhuman knee contains about 5-8mg

hyaluronic acid in 2ml of synovial fluid.
 Inarthritic knee the amount of HA is
diminished, reducing the viscoelastic property
of the synovial fluid.
 Thisin turn increases the stress and shear
forces experienced by the articular surface
and may lead to further damage.
+ IAHA: Mechanism of Action

 Increased synovial fluid HA conc.

 Increased cartilage lubrication/elasticity
 Chondrocyte proliferation
 Chondrocyte stimulation  matrix
 Decreased inflammatory mediators
 Inhibition of nociceptors
 MAY BE DISEASE-MODIFYING
Devine, Shaffer. Use of viscosupplementation
for knee osteoarthritis: an update. Curr Sports Med Rep 2011
Indications for
Viscosupplementation in OA
Failureto respond
to conventional
nonpharmacologic
therapy

Inadequate
response to
analgesics
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Injection technic of HA
+
HA Injection

Informed consent
Determine location of injection
Antiseptic and aseptic
Inject the HA
+ Injection location
+
Anatomi lutut
+
Imaging
+
HA injection

Superior lateral Medial

+
Injeksi intraartikular
+
HA injection

Antero-lateral anteromedial
+
+
anatomy
+
+
+

Injeksi shourder
Needle Sizes for Common
Musculoskeletal Injections
+
Shoulder anatomy
+
Shoulder tendon and muscles
+ Anatomy of shoulder
Anterior Shoulder Exam

 Sternoclavicular
joint
 Acromioclavicular
joint
 Glenohumeral
joint
 Biceps tendon
Rotator Cuff Exam

 Supraspinatus
tendon
 Infraspinatus
tendon
 Teres minor tendon
Subdeltoid Bursa Injection

 Localize lateral
midpoint of acromion
 Insert 1 cm distal
 Angle needle upward
Sendi bahu/ glenohumeral… 63
Injeksi sendi bahu
dengan
pendekatan dari
punggung

Identifikasi
dari sudut
posterior
acromion
Injeksi sendi bahu
dengan
pendekatan dari
punggung

Masukan jarum 1-2

cm dari posterior
acromion
Arahkan jarum ke
prosesus coracoid
Injeksi sendi bahu
dengan
pendekatan dari
depan

Identifikasi prosesus
coracoid
Masukan jarum di
lateral dari prosesus
coracoid
Shoulder Joint Injection

 Insert needle 1 cm
below coracoid
process
 Medial to humeral
head
+
Shoulder injections – adverse
effects

 Temporary worsening of
pain
 Flushing
and menstrual
abnormalities
 Steroid atrophy
 Infection?
+
SIMPULAN
Aspirasi dan suntikan Intraartikular atau
intralesi dilakukan sesudai indikasi
Aspirasi cairan sendi :
 Diagnostik
 Terapi

Suntikan intraartikuler :
 Suntikan Hyaluronan I.A.:
 Suntikan Kortikosteroid I.A :
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Terima kasih
+