1. Arthrocentesis involves the introduction of a needle into a joint space to remove synovial fluid.

2. It is an essential diagnostic technique for the evaluation of arthritis of unknown cause.

3. The presentation of conditions such as septic arthritis and crystalline arthritis may be similar, yet treatment may be different.

4. Arthrocentesis and synovial fluid analysis are important for accurate diagnosis.

5. Arthritis can involve a single joint (monoarthritis) or multiple joints (oligoarthritis).

1. Arthrocentesis is performed for both diagnostic and therapeutic reasons.

2. In the intensive care unit, arthrocentesis is most commonly performed to rule out septic arthritis in a patient with acute monoarthritis or oligoarthritis.

3. Before performing arthrocentesis, one must be certain that true joint space inflammation with effusion is present rather than a periarticular inflammatory process, such as bursitis, tendinitis, or cellulitis.

4. In the knee, the presence of an effusion may be confirmed by the bulge test or patella tap.

a. Bulge test: Milk fluid from the suprapatellar pouch into the joint, slide the hand down the lateral aspect of the joint line, and watch for a bulge medial to the joint.

b. Patellar tap: Apply pressure to the suprapatellar pouch while tapping the patella against the femur to determine if the patella is ballottable, which indicates an effusion.

5. Arthrocentesis with ultrasound guidance for evaluation of the joint and surrounding soft tissues can be performed at the bedside to assess for joint fluid, bursal fluid, or other soft tissue fluid collections such as an abscess. This can allow evaluation of bursal or soft tissue collections that may go undetected by blind aspiration.

6. Arthrocentesis may also be used therapeutically, as in the serial aspiration of a septic joint for drainage and monitoring of the response to treatment.

7. Arthrocentesis allows for therapeutic injection of corticosteroid preparations into the joint space for treatment of various forms of inflammatory and noninflammatory arthritis.

1. Rheumatoid arthritis.

2. Spondyloarthropathies.

a. Psoriatic arthritis.

b. Seronegative spondyloarthropathy.

c. Ankylosing spondylitis.

d. Ulcerative colitis/regional enteritis.

3. Crystal-induced arthritis.

a. Monosodium urate (gout).

b. Calcium pyrophosphate dehydrate (pseudogout).

c. Hydroxyapatite.

4. Infectious arthritis.

a. Bacterial.

b. Mycobacterial.

c. Fungal.

5. Connective tissue diseases.

a. Systemic lupus erythematosus.

b. Vasculitis.

c. Scleroderma.

d. Polymyositis.

6. Hypersensitivity.

a. Serum sickness.

1. Osteoarthritis.

2. Trauma/internal derangement.

3. Avascular necrosis.

4. Hemarthrosis.

5. Malignancy.

6. Benign tumors.

a. Osteochondroma.

b. Pigmented villonodular synovitis.

1. Absolute contraindications to arthrocentesis include infection of the overlying skin or periarticular structures and severe coagulopathy.

2. If septic arthritis is suspected in the presence of severe coagulopathy, efforts to correct the bleeding diathesis should be made before joint aspiration.

3. Although known bacteremia is a contraindication to arthrocentesis given the potential for joint space seeding, joint aspiration is
nonetheless indicated if septic arthritis is the presumed source of the bacteremia.

4. Articular damage and instability constitute relative contraindications to arthrocentesis.

1. Skin preparation.

a. Two percent chlorhexidine and seventy percent isopropyl combination antiseptic or equivalent (ten percent povidone-iodine solution should be used only if the patient has a sensitivity to chlorhexidine).

2. Local anesthesia.

a. 1% Lidocaine; 25-gauge, 1-in. needle; 22-gauge, 1.5-in. needle; and 5-mL syringe.

b. Sterile sponge/cloth.

3. Arthrocentesis.

a. Sterile gloves.

b.

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