Garbage job postings

[oreosandsake]

Pls don’t take these jobs

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[JBM16BYU]

That’s a very specific, limited job description. Just fluoro-guided knees, nothing else…

 

[Agast]

It’s a DME mill. Each patient gets a knee brace and possibly a back brace.

 

[BobBarker]

That is such a crazy job. 50 knee injections a day?

 

[MitchLevi]

How weird is this?

 

[oneforfighting]

There’s a place like this in the Chicago metro. Just fluoro guided knee injections with HA.

Home - Joint Relief Institute

Knee Gel Injections For Knee Pain in Chicago and Minneapolis | Joint Relief Institute

jointreliefinstitute.com

 

[MitchLevi]

Do any of you use guidance for knee injections?

 

[lobelsteve]

Do any of you use guidance for knee injections?

100% of the time.

 

[JBM16BYU]

Do any of you use guidance for knee injections?

I personally use ultrasound every time.

 

[oneforfighting]

Do any of you use guidance for knee injections?

Overkill for most cases. I’ll do fluoro for select cases of severe djd.

 

[BobBarker]

Fluoro for nearly all of my viscos.

 

[A Deep Breath]

I hate the word practitioner, but I hate it even more when it’s used for a physician-only job posting.

 

[DrSpine]

Get paid just to do knee injections? Count me in.

 

[Ducttape]

would you feel the same after doing 50 of those a day, 5 days a week for just $260k a year?

 

[RaceCanyon]

Do any of you use guidance for knee injections?

I always use ultrasound, but I'm a glutton for punishment.

 

[SSdoc33]

Do any of you use guidance for knee injections?

Vast majority i dont

 

[Ferrismonk]

Imaging guidance is standard of care. Whether you use fluoro or ultrasound, you should use imaging guidance.

Ultrasound-Guided Knee Injections Are More Accurate Than Blind Injections: A Systematic Review of Randomized Controlled Trials

To review the current literature to determine which injection technique and needle portal placement provide the greatest accuracy for intra-articular access to the knee.This study followed Preferred Reporting Items and Systematic Reviews and Meta-Analyses ...

www.ncbi.nlm.nih.gov

 

[SSdoc33]

Imaging guidance is standard of care. Whether you use fluoro or ultrasound, you should use imaging guidance.

Ultrasound-Guided Knee Injections Are More Accurate Than Blind Injections: A Systematic Review of Randomized Controlled Trials

To review the current literature to determine which injection technique and needle portal placement provide the greatest accuracy for intra-articular access to the knee.This study followed Preferred Reporting Items and Systematic Reviews and Meta-Analyses ...

www.ncbi.nlm.nih.gov

Is it worth making the patient come back for a separate visit?

 

[MitchLevi]

Is it worth making the patient come back for a separate visit?

Exactly. It's dumb if the pt has a normal BMI.

Even elevated BMI pts are easy depending on the anatomy of the knee.

When my knee injections stop working I'll start using guidance.

 

[SSdoc33]

i will admit that it is probably better and more effective with image guidance. not enough for a separate copay and time off work, etc.

 

[Status Sciaticus]

It’s a DME mill. Each patient gets a knee brace and possibly a back brace.

What kind of justification can you use to prescribe a knee brace after a knee injection?

 

[Agast]

What kind of justification can you use to prescribe a knee brace after a knee injection?

The knee brace is for chronic knee pain, you don’t have to complete a steroid injection first so both can be done on the same day

 

[Status Sciaticus]

The knee brace is for chronic knee pain, you don’t have to complete a steroid injection first so both can be done on the same day

Duly noted, for research.

 

[paindoc007]

When orthos start using it, I will. Until then you’re the pm&r clown who needs an image for a simple knee injection. Belittles our abilities. No thanks

 

[lobelsteve]

When orthos start using it, I will. Until then you’re the pm&r clown who needs an image for a simple knee injection. Belittles our abilities. No thanks

Most of the knees and hips that come to me are sent from orthopedics after they failed injection. The literature is quite clear on success rates with experienced hands using different approaches. None of them are as good as fluoroscopy with air contrast. You’re the clown.

 

[MitchLevi]

When my knee injections stop working I'll do it.

 

[Forwho]

When orthos start using it, I will. Until then you’re the pm&r clown who needs an image for a simple knee injection. Belittles our abilities. No thanks

so much wrong said in such few words. first, stop putting orthos on a pedestal. second, didn't realize it took less skill to use ultrasound than without. third, can't tell you how many times i've had to aspirate knees with ultrasound which provides immediate relief when orthos simply just injected blindly before - patients are thankful.

 

[au bon pain]

Pretty impressive amount of Fs given here over a knee injection.

Back to the crap job posting that spawned this; if this it’s really a FT gig spent injecting knees q 3-5 mins and Medicare pts involved I’d hope that doc dresses nicely for when DOJ shows up.

 

[paindoc007]

so much wrong said in such few words. first, stop putting orthos on a pedestal. second, didn't realize it took less skill to use ultrasound than without. third, can't tell you how many times i've had to aspirate knees with ultrasound which provides immediate relief when orthos simply just injected blindly before - patients are thankful.

Not any or all of them, but I’ll put the renowned knee surgeons on a pedestal for knee specific problems, sure. I can’t remember them using imaging for a routine knee inj where I trained, which was Rothman. Maybe Taus or someone can correct me if I’m wrong in that, which is possible. But until those guys do, I’m good.

 

[Dr. Ice]

Not any or all of them, but I’ll put the renowned knee surgeons on a pedestal for knee specific problems, sure. I can’t remember them using imaging for a routine knee inj where I trained, which was Rothman. Maybe Taus or someone can correct me if I’m wrong in that, which is possible. But until those guys do, I’m good.

Surgeons don’t know how to use imaging to do anything. That’s one of the many reasons they don’t do it, that and they hope the shot doesn’t work so they can replace the joint. I’m pretty sure they mostly dump the injectate into the fat pad.

That being said I only use image guidance for fattys and/or people with thick legs

 

[MitchLevi]

It's an inefficient use of your time and minimally increases the likelihood of your success.

A good orthopedic surgeon knows far more than anyone in this forum about pathology of the knee, and if you disagree it's bc you don't work with any.

My knee outcomes are identical to anyone else in this forum.

 

[CleanUp]

Not any or all of them, but I’ll put the renowned knee surgeons on a pedestal for knee specific problems, sure. I can’t remember them using imaging for a routine knee inj where I trained, which was Rothman. Maybe Taus or someone can correct me if I’m wrong in that, which is possible. But until those guys do, I’m good.

Are you anesthesia or PM&R? If the former did you place central lines, a lines, ESP blocks, supraclav infraclav pop/saph?

I check my ego at the door.

Gimme ultrasound.

 

[bedrock]

I have seen orthopedic surgeons miss plenty of knees. You guys give them too much credit.

And are none of you aware of the multiple studies demonstrating an accuracy rate around 80% for blind knee injections?

If you have in office fluoro, it is a no brainer to just do with flouro guidance for accuracy and for the flouro charge. If your staff sets it up, it costs you no time.

If you are ASC based without in office fluoro, that’s where it’s a debate whether or not to use guidance.
Yes, ultrasound is an option, but you don’t get paid the guidance code like with x ray, the machine costs $$$, and it takes longer.

 

[oreosandsake]

I have seen orthopedic surgeons miss plenty of knees. You guys give them too much credit.

And are non3 of you aware of the multiple studies demonstrating an accuracy rate around 80% for blind knee injections?

If you have in office fluoro, it is a no brainer to just do with flouro guidance for accuracy and for the flouro charge. If your staff sets it up, it costs you no time.

If you are ASC based without in office fluoro, that’s where it’s a debate whether or not to use guidance.
Yes, ultrasound is an option, but you don’t get paid the guidance code like with x ray, the machine costs $$$, and it takes longer.

Skilled hands accuracy rate 40 percent
Published data in ortho and sports med hands

Same thing happened when they suggested fluoro for epidurals and the old docs said “didn’t we teach you how to feel LOR…”

 

[Agast]

Orthopedic surgeons aren’t injecting knees, that’s what the PA is for!

 

[lobelsteve]

I learned imaging on knees the hard way.
Research from Stryker over 10 years ago. Had to use Fluoroscopy to inject their new drug IA. US was not commonly used and saving images for review was not easy enough. SO in our group it fell on me. $1500 per knee (before RVU). Double blind. Needed AP and lat saved images sent in / submitted as part of protocol. It was a BMP product and if IM it went HO. After the first month the study was halted and we did a videoconference. The researchers shared images from all over the country of our air arthrograms. On Ortho who claimed to know fluoroscopy had a pic of his needle superficial to the patella and injected. No bueno. We used air for contrast and it was really cool.

 

[Agast]

Can you post a pic of what air contrast in the knee looks like?

 

[MitchLevi]

Orthopedic surgeons are terrible proceduralists.

They're trying to capture surgical patients in the clinic bc that's how they survive in the partnership comp model.

There's no comparing blind epidurals to blind knee injections. That's just a false equivalency for obvious reasons.

LOL at my blind knee injections being 40% accurate.

 

[lobelsteve]

Can you post a pic of what air contrast in the knee looks like?

 

[rexed]

Most of the knees and hips that come to me are sent from orthopedics after they failed injection. The literature is quite clear on success rates with experience tans using different approaches. None of them are as good as fluoroscopy with air contrast. You’re the clown.

View attachment 378571

Peaked my interest with this technique, found some papers for hip air arthrograms, what's your technique to get images like this in regards to volumes? 2 1-2 cc contrast + 5 cc of air? Also, are you just pulling air from room, using a needle filter? Infection risk? Thanks!

 

[lobelsteve]

Peaked my interest with this technique, found some papers for hip air arthrograms, what's your technique to get images like this in regards to volumes? 2 1-2 cc contrast + 5 cc of air? Also, are you just pulling air from room, using a needle filter? Infection risk? Thanks!

4cc sterile air. No contrast. Sterile Air available vis Steven M. Lobel, MD LLC in my Montana location.

 

[GoBeers]

i still have a hard time believing that people can miss with blind technique (assuming patient's knee is not the size of a tree trunk).

is it that they are just too superficial ?

 

[lobelsteve]

i still have a hard time believing that people can miss with blind technique (assuming patient's knee is not the size of a tree trunk).

is it that they are just too superficial ?

All over the place. Not into capsule. Too proximal. Too lateral.

 

[Status Sciaticus]

Most of the knees and hips that come to me are sent from orthopedics after they failed injection. The literature is quite clear on success rates with experienced hands using different approaches. None of them are as good as fluoroscopy with air contrast. You’re the clown.

are you routinely doing your knees with air injectate on fluoro?

 

[BobBarker]

Fat pad happens all of the time.

 

[lobelsteve]

are you routinely doing your knees with air injectate on fluoro?

All of them.
All hips, knees, IA shoulder, and GTB.
Not for pes or SAB.

 

[Ducttape]

no great studies out there, but some of what i found is that if one is going anteriomedial or anterolateral, the success rate seems to be about as low as 70 and as high as 87%, and going lateral midpatellar is roughly 92%.

for example:

Accuracy of needle placement into the intra-articular space of the knee - PubMed

Using real-time fluoroscopic imaging with contrast material, we demonstrated the difficulty of accurately placing a needle into the intra-articular space of the knee when an effusion is not present. This study revealed that a lateral midpatellar injection (an injection into the patellofemoral...

pubmed.ncbi.nlm.nih.gov

Accuracy of Needle Placement into the Intra-Articular Space of the Knee in Osteoarthritis Patients for Viscosupplementation - PubMed

Study showed that the accuracy of needle placement was higher through Lateral midpatellar than the Anterolateral portal.

pubmed.ncbi.nlm.nih.gov

of these studies, the gold standard to determine if the needle was in the knee was, um, fluoroscopy.

 

[mdo1738]

i still have a hard time believing that people can miss with blind technique (assuming patient's knee is not the size of a tree trunk).

is it that they are just too superficial ?

They certainly do miss a lot. Anytime I see someone who “failed knee injections”, they almost always were done blind by an ortho midlevel. After I explain to them how wildly incompetent of a proceduralist they had, they’ve all trialed one final injection. Used ultrasound guidance and 100% success rate thus far (sample size still low but about 20).