Disclosures None How to Do a Knee Injection UCSF Primary Care - PowerPoint PPT Presentation

Disclosures None How to Do a Knee Injection UCSF Primary Care Sports Medicine Conference 2018 Carlin Senter, MD Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University of California San Francisco 12/15/20 18 Workshop objectives Procedural learning 1. Knowledge 2. Skills 1.Consent 1.Indications and contraindications for knee 2.Sterility Learn Learn See See Practice Practice Prove Prove Do Do steroid injection 3.Positioning 2.Risks and benefits of knee 4.Entry site aspiration and injection 5.Needle technique 3.Post procedure instructions Sawyer T et al, “Learn, See, Practice, Prove, Do, Maintain: An Evidence-Based Pedagogical Framework for Procedural Training in Medicine. Acad Med. 2015;90:1025-1033. 4.Materials needed for procedure 12/15/20 12/15/2018 18 1

Indications for knee aspiration/injection Contraindications to steroid injection  Joint infection  Diagnostic  Hemarthrosis - Effusion, esp atraumatic  Overlying cellulitis - Send for cell count, differential, crystals +/- gram stain and  Fracture culture  Prosthetic joint  Therapeutic - Osteoarthritis - Crystal arthropathy - Inflammatory arthritis Risks of steroid injection in the knee Relative contraindications to steroid injection  Diabetics: increased blood sugar, 300 mg/dl starting as early  Corticosteroid injection as 2 hours after, lasting 5 days within past 3-4 months  Facial flushing: 10% with Kenalog  Coagulopathy 19-36 hours post-injection -  Poorly controlled diabetes  Skin or fat atrophy  Post-injection steroid flare: 1-10% Synovitis in response to injected crystals - Within hours - 48 hours post-injection - More common in soft tissue injections (20% of trigger points) than - intra-articular injections  Septic arthritis: 1/3000-1/50,000 1-2 days after injection - Habib GS. Clin Rheumatol, 2009. UpToDate, “Joint aspiration or injection in adults,” 2010. 2

Why aspirate the effusion before injection? Aspiration/injection supplies  Betadine swab x 3  Clinically  Ethyl chloride spray - Decreased pain and stiffness because effusion gone  Alcohol swabs x 6 - More effect of steroid because not diluted by effusion  4x4 gauze x 1 - Inspect fluid for inflammation/infection, send to lab if question  Bandaid x 1 - Confirms that injxn was intra-articular  Significantly greater improvement in VAS for patients who had joint aspirated at time of injection in knee OA patients (Gaffney K et al, Ann Rheum Dis, 1995.)  Reduction in relapse for 6 months after injection in RA patients (Weitoft T et al, Ann Rheum Dis, 2000.) Needles, syringes, meds Aspiration 3

Post-injection patient instructions Superolateral approach  Rest: no definitive evidence-based recommendation  Patient supine - Recommendations in literature vary  Extend knee  No restrictions  Bump under knee so flexed  Bed rest x 24 hours 10-20 degrees  Superior border patella  Light activity x 7 days, no weight bearing exercise  Lateral border patella - I recommend no strenuous activity x 7 days  Avoid swimming, hot tub, bath x 24 hours  1cm below  Mark with syringe cover or - Let injection site heal tip of pen Knee injection practice Intra-articular corticosteroid injections: Errors Category Elements to Complete Description of Errors N = 0 Y = 1 take home points Sterility No touch technique 0 Gloves on 0 Positioning Supine 0  Short-term pain relief (6 weeks average) Knee extended with bump underneath 0 Patella mobile/quad relaxed 0 ID Entry Site  Small effect on function Site at superior lateral border patella 0 Verification of entry site by partner 0 Does not ask for verification = 1 Adequately marks entry site 0  No evidence for long-term pain relief Skin Sterile Prep (3 betadine swabs used) 0  Clinical effect independent of degree of inflammation present (Let betadine dry) 0 (Alcohol swab to clean entry site) 0 Ethyl chloride on entry site 0 - Don’t need to restrict injection just to those with effusion Needle Technique Holds the needle like a pen/dart 0 Non-dominant hand tilting patella laterally 0  Frequency: general practice once every 3-4 months max Needle Insertion Pace of needle insertion slow, steady (injecting 0 - Concern for cartilage toxicity if given q 3 months x 2 years lidocaine as going) Too fast = 1; Too slow = 1 Would I intervene at this point? 0 Angle of entry Y = 1 or N = 0 Follow verbal instructions of preceptor? N = 1 Y = 0 Redirection (if needed) 0 Sheer underlying structures with redirection? Y = 1 N = 0 *multiple points possible Preceptor asks: "What would you do to confirm that you are now in the joint space?" Aspiration prior to injection of medication 0 Aspiration prior to injection Y = 0, N = 1 If direction required by preceptor = 1 (Smooth switch of lidocaine syringe for steroid 0 syringe and injection of steroid) Needle Extraction Pace slow and steady 0 Gauze ready and put over the site 0 4

Thank you! Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthpaedics Carlin.Senter@ucsf.edu 5