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To the Editor:

The art of arthrocentesis is an essential element in every rheumatologic practice. Diagnostic aspirations retain a central position in the recognition of microcrystalline arthritides and septic arthritis. Therapeutic arthrocenteses relieve the discomfort of high-pressure effusions, permit effective debulking of large fluid collections, and provide essential access for articular administration of corticosteroids. All of these facts are axiomatic.

In practice, however, arthrocentesis is sometimes more challenging than it is in theory. One practical problem lies in the need for more than one syringe. Large effusions may require syringe changes even when the (in our hands) clumsy 60-ml variety is in use. A hemostat clamped to the needle shaft at the entry site helps to alleviate the in and out “pistoning” of needle position that fatigue and impatience may easily induce. It does nothing, however, to eliminate the awkward and distasteful scene of synovial fluid flowing out of the needle hub, down the patient's leg, and onto the examining table as one syringe is disconnected and the next is put in place. By using a 3-way stopcock, this situation can be avoided, because a simple flip of the device's lever will seal the needle end and preserve sterility as well as appropriate decorum.

A second relevant situation occurs when a diagnostic (or therapeutic) aspiration is performed in conjunction with a therapeutic injection. In that case, the syringe with the injectate is connected to the open port, the aspirate is obtained, and the 3-way stopcock's switch is flipped to permit the injection while the system remains entirely closed and no syringes are exchanged (Figure 1). One minor caveat is that the aspirating syringe must be disconnected before the specimen of synovial fluid is expelled for diagnostic studies. Inadvertent emptying through the stopcock and/or needle may contaminate the aspirate with the injectate. In that case, the presence of crystalline corticosteroids will greatly confound the subsequent microscopic examination.

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Figure 1. Demonstration of 3-way stopcock method for aspiration and injection. A, Aspirating an inflamed olecranon bursa with the injection syringe in place. B, Injecting the bursa after flipping the 3-way stopcock.

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Although we are not aware of a previously published report of this practice, we make no claim of primacy in its use. Any method this simple must have occurred to others and may be widely used elsewhere. However, we continue to encounter colleagues who are unfamiliar with the technique, and we offer this brief description to encourage its wider application.

Peter A. Simkin MD*, Gregory C. Gardner MD*, * University of Washington, Seattle, WA