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Hypodermic Needle Separation During Arthrocentesis.

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LETTERS
study of the composition of isolated crystals. J Exp Med
122: 173-180, 1965
14. Goetzl EJ: Modulation of human eosinophil polymorphonuclear leukocyte migration and function. Am J
Pathol 85:419-436, 1976
Hypodermic needle separation during
arthrocentesis
To the Editor:
Numerous complications can result from synovial fluid aspiration or intraarticular corticosteroid
instillation (1-4). This report describes 2 patients in
whom identical technical difficulties developed during
arthrocentesis because of equipment failure. In each
case, the metallic shaft of the needle separated from
the plastic hub when the hypodermic needle was
withdrawn after injection, and the steel fragment remained lodged within the joint and adjacent soft tissue.
Case 1. A 62-year-old woman who had active
seropositive rheumatoid arthritis of 3 years’ duration
complained of progressively severe left shoulder pain
and loss of motion and function despite high-dose
salicylate therapy, intramuscular aurothioglucose injections, and physical therapy. The other peripheral
joints were well-controlled, except for low-grade synovitis of the wrists and several metacarpophalangeal
joints. A microcrystalline corticosteroid ester was
injected into the left shoulder to further suppress
inflammation. After the skin was cleansed with isopropyl alcohol and anesthetized topically with ethyl chloride, a standard brand, I %inch, 22-gauge, disposable
sterile hypodermic needle attached to a 5-cc plastic
syringe filled partially with 1% lidocaine and triamcinolone acetonide (Kenalog-40) was used to enter the
joint cavity via the anterior approach (between coracoid process and humeral head). No resistance or
other difficulties were encountered during joint entry,
and the injectable was expressed without undue pressure. When the procedure had been completed, the
needle and syringe were withdrawn. The needle shaft
was absent, but a portion of it extended past the skin
surface at the site of penetration. A small hemostat
was used to grasp and extract the embedded needle
shaft, which was removed in toto. A photograph of the
fractured needle is shown in Figure IA.
Case 2. A 46-year-old woman with rheumatoid
arthritis of 7 years’ duration had painful boggy synovitis of severai proximal interphalangeal joints of both
1593
hands resulting in inability to clench the fists and
considerable functional disability. Other significant
rheumatologic findings were absent, perhaps because
of disease suppression with ibuprofen and maintenance chrysotherapy (aurothioglucose 50 mg/month).
The skin over the right third proximal interphalangeal
joint was cleaned with isopropyl alcohol and topically
anesthetized with ethyl chloride. To enter the joint
dorsomedially, we used a sterile disposable %-inch,
27-gauge needle attached to a 2%cc sterile disposable
plastic syringe containing a small quantity of 1%
lidocaine and triamcinolone acetonide. After uneventful expression of the injectable and removal of needle
and syringe, a small portion of needle shaft was seen
projecting from the skin at the injection site; extraction
A
B
Figure 1. Photographs of hypodermic needles showing heparation
of the metallic needle shaft from the Dlastic hub.
LETTERS
1594
was accomplished with a hemostat. Inspection of the
hypodermic needle revealed the intact plastic hub
firmly attached to the syringe, indicating that the
metallic needle shaft had separated from the plastic
base (Figure 1 B).
Discussion. Intraarticular fracture of the metallic Parker-Pearson and Polley-Bickel needles during
closed synovial knee biopsy has been described (5,6).
In these cases the intraarticular needle fragments
could not be extracted by external manipulation and
were either left in the joint cavity o r removed by
arthroscopy o r arthrotomy.
Separation of the hypodermic needle shaft from
the hub during arthrocentesis has not been documented in the literature to the best of my knowledge,
and I have observed only 2 such instances after many
thousands of intraarticular injections. Communication
with 2 major United States manufacturers of hypodermic needles has not brought similar cases to light.
However, one company official acknowledged that
complaints about this type of needle separation have
been received rarely, but not during arthrocentesis
(73). Because part of the embedded needle shaft
extended past the skin surface and could be withdrawn
noninvasively, neither patient was injured.
Should other clinicians encounter this problem,
the following precautions are offered: 1) always inspect the needle after arthrocentesis to ascertain that it
is intact; and 2) maintain a hemostat within easy
access to remove the separated needle shaft.
NORMAN
L. GOTTLIEB,MD
Division of Rheumatology
University o j Miami
Miami, FL 33101
I . Hollander JL: Arthrocentesis and intrasynovial therapy,
Arthritis and Allied Conditions. Ninth edition. Edited by
DJ McCarty. Philadelphia, Lea & Febiger, 1979. pp 402414
2. Owen DS Jr: Aspiration and injection of joints and soft
tissues, Textbook of Kheumatology . First edition. Edited
by WN Kelley, ED Hams, S Ruddy. and CB Sledge.
Philadelphia, WB Saunders, 1981, pp 553-567
3. Steinbrocker 0, Neustadt DH: Aspiration and Injection
Therapy in Musculoskeletal Disorders. First edition.
New York, Harper & Row, 1972, pp 1-103.
4. Gray RG, Tenenbaum J , Gottlieb NL: Local corticoste-
5.
6.
7.
8.
roid injection treatment in rheumatic disorders. Semin
Arthritis Rheum 10:231-254, 1981
Bocanegra TS, McClelland JJ, Germain BB et al: Intraarticular fragmentation of a new Parker-Pearson synovial
biopsy needle. J Rheumatol 7:248-250, 1980
Guzman L, Arinoviche R: Intraarticular fracture of synovial biopsy needle. Arthritis Rheum 21:742, 1978
Personal communication from Monoject, Division of
Sherwood Medical, A Brunswick Company, Deland,
Florida
Personal communication from Becton-Dickinson, Rutherford, N J
Optimism-a
cure for quackery?
To the Editor:
The report from the Unproven Remedies Committee (Arthritis and Rheumatism 24: 1188, 1981) reminded me that for more than 20 years we have been
trying to combat quackery in arthritis treatment without much success. The reason may be that the problem
is not one of ignorance, as we once assumed, and
providing information that unorthodox treatments are
ineffective is not the way t o solve it. A patient’s
decision t o try a quack cure is probably not intellectual, based on erroneous facts or incomplete knowledge,
but emotional, prompted by the very human search for
magic o r miracle. As Samuel Johnson remarked of the
widower remarrying, “it represents the triumph of
hope over experience.”
Education and argument have proved ineffective. Behavior modification is what we would like to
achieve, and perhaps we should turn to professionals
skilled in this field for help. Interviews with patients
who have tried unproven remedies to learn why they
took this route might be a good start.
Meanwhile, we can ask ourselves whether in
our contacts with patients, the public, medical students, physicians, and other health perso,nnel, we
convey a spirit of optimism in the prognosis for
rheumatoid arthritis or whether we indicate that the
realities of arthritis treatment are so difficult as to
foster discouragement.
L. A. HEALEY,MD
Seattle. W A
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