Knee Joint Injection

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Knee Joint Injection
Syringe 10mL
Needle 20-27g
Injectate Options Steroid, hyaluronic acid, PRP, dextrose
Steroid 0.5-2mL of steroid (e.g. 20-40mg triamcinolone)
Local 5-10mL of 1% lidocaine or 0.25% to 0.5% bupivacaine
Volume 5-10mL

Anatomy

Indications

Contraindications

Infection, uncontrolled coagulopathy, joint prosthesis, poor response to previous injections. Allergy to eggs or feathers is a relative contraindication to hyaluronic acid.

Pre-procedural Evaluation

Injectate

A variety of options exist for injectates - steroid, visco-supplementation, platelet rich plasma, stem cells, and dextrose prolotherapy.

Equipment

Technique

Ultrasound Guided

Fluoroscopy Guided

Landmark Guided

  • Protective gloves and use sterile technique.
  • Position: Lie supine with the knee slightly flexed, supported underneath with a rolled towel or cushion.
  • Palpate and identify the borders of the patella and mark the entry site
  • Clean the skin
  • Draw up the injectate mixture.
  • Optional infiltration of skin with 3-5mL local anaesthetic with 27-30g needle.
  • Use a 20-27 gauge 1 inch needle on a 10 ml syringe to enter the joint.
  • Approach
    • Lateral: Enter the skin 1 cm superior and 1 cm lateral to the superior lateral aspect of the patella; direct the needle at a 45° angle, tilting below the patella, and aim toward the middle of the medial side of the joint
    • Medial: Enter the medial aspect of the knee at the middle of the patella, aiming toward the lateral midpole.
    • Anterior: The patient's knee should be flexed 90°; keeping the needle parallel to the tibial plateau, enter just medial or lateral to the patellar tendon
  • May feel a "pop" when penetrating the joint capsule. Flow of the injection should not meet resistance.
  • Change the path of the needle slightly if injecting the medication is difficult; the needle may be within a fat pad or thick synovium.
  • Redirect or withdraw the needle if severe pain occurs; the needle may be hitting the cartilaginous surface.
  • Apply a bandage after withdrawing the needle.

Complications

Repetitive intra-articular corticosteroid injections may cause accelerated cartilage loss. McAlindon evaluated triamcinolone vs saline repeated every 12 weeks for 2 years in 141 patients with knee osteoarthritis. The steroid group had greater cartilage loss (-0.21 mm vs -0.10mm), and no significant difference in pain. There was a small increase in HbA1c levels in the steroid group. The steroid group had 5 complications, and the saline group had 3.[1]

Other complications include bleeding, infection (1:10,000), postinjection flare (1%-2%), no response, non-sustained response, temporary glucose elevated. Allergic reactions are rare.

Specific to hyaluronic acid is that it can more frequently cause pain and can cause a large joint effusion, rash, and itching.

Aftercare

Rest the knee, avoid strenuous activity for 48 hours, shower/bathe as normal. Post-injection flares can be treated with ice and NSAIDs. Safety netting for injection.

Videos

See Also

External Links

References

  1. McAlindon et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA 2017. 317:1967-1975. PMID: 28510679. DOI. Full Text.

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