Knee Injections for Osteoarthritis Brian Feeley, MD Sports Medicine - PDF document

Knee Injections for Osteoarthritis Brian Feeley, MD Sports Medicine and Shoulder Surgery UC San Francisco Outline  Indications for Injections/Aspirations  Injectable medications  Outcomes (covered previously)  How to do a knee injection easily 1 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Indications for knee aspiration/injection  Diagnostic • Effusion, especially atraumatic • Send for cell count, differential, crystals +/- gram stain and culture  Therapeutic • Osteoarthritis • Crystal arthropathy • Inflammatory arthritis Case 1  42 year old male, BMI 38, comes in with a 3 day history of increased right knee pain and swelling. He thinks he might have had a fall a week ago, but doesn’t remember pain. He has bought a cane and presents with a noticeable limp and large effusion. • On exam, he has a moderately red joint, and cannot straighten past 10 degrees 4 11/21/2017 2 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Audience Participation  What is your most likely diagnosis? 1. Acute ACL tear 2. Acute meniscus tear 3. Arthritis 4. Gout 5. Septic Arthritis 5 11/21/2017 Indications for Aspiration  Rule out septic arthritis  Establish diagnosis of gout  Traumatic etiology (bloody aspiration) Results: Yellow fluid 58 K WBC 65 PMN 6 11/21/2017 3 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

How to interpret aspiration results 7 11/21/2017 Case 2  55 year old computer scientist with 3 weeks of knee pain and swelling. He has a history of 2 meniscus debridements, and was told he had some mild arthritis 5 years ago at his last surgery. He has a trip in 2 weeks to Istanbul (not Constantinople) and wants to feel good for the trip, so is asking for an injection (also he has a lot of questions). 8 11/21/2017 4 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Contraindications to steroid injection  Joint infection  Hemarthrosis  Overlying cellulitis  Fracture  Prosthetic joint Relative contraindications to steroid injection  Corticosteroid injection within past 3-4 months  Coagulopathy  Poorly controlled diabetes 5 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

What is your preferred steroid injection? 1. Depomedrol 2. Betamethasone 3. Kenalog 4. Triamcinolone 5. I don’t do injections 11 11/21/2017 Corticosteroid injections for knee osteoarthritis 6 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Corticosteroids: mechanism of action  Anti-inflammatory  Probably inhibit COX-2 and phospholipase-A2, both inflammatory mediators Goldman: Goldman’s Cecil Medicine, 24 th Ed, ch 34 – Immunosuppressing Drugs. Accessed via MD Consult 1/6/2013. Anesthetic injections cause cell death Increased chondrocyte death: Longer duration More acidic (lidocaine) More concentrated 14 11/21/2017 7 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Intraarticular corticosteroid for knee OA: American Academy of Orthopaedic Surgeons 2013 Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2 nd Edition American Academy of Orthopaedic Surgeons 2013. www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed 11/13/15. Intraarticular corticosteroid for knee OA: Osteoarthritis Research Society International 2014  Appropriate treatment  Quality of evidence: Good  Clinically significant short-term pain relief  Consider other options for longer duration pain relief McAlindon TE et al. OARSI Guidelines for the Non-Surgical Management of Knee Osteoarthritis. Osteoarthritis and Cartilage 2014. 8 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

 2-year RCT  Patients with knee OA (mild-moderate)  Q3 month triamcinolone or saline knee injection under ultrasound x 2 years  Annual knee MRI, WOMAC q 3 months  140 randomized patients • Mean age 58 years • 54% women  Sig more cartilage loss in triamcinolone group compared to saline group  No sig difference in pain between groups 9 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Risks of steroid injection in the knee  Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after, lasting 5 days (controversial)  Facial flushing: 10% with Kenalog • 19-36 hours post-injection  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. Intra-articular corticosteroid injections: take home points  Short-term pain relief (6 weeks average)  Small effect on function  No evidence for long-term pain relief  Clinical effect independent of degree of inflammation present • Don’t need to restrict injection just to those with effusion  Frequency: general practice once every 3-4 months max • Concern for cartilage toxicity if given q 3 months x 2 years 10 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Case 3  62 year old male presents with progressive knee pain and a known history of arthritis. He has had NSAIDS, PT, and steroid injections. The last 3 steroid injections haven’t worked as well and he would like to try something different but doesn’t feel ready for surgery. 21 11/21/2017 What would you recommend? 1. Repeat steroid injection 2. Hyaluronic acid injection 3. PRP injection 4. Stem cell injection 5. Knee replacement 6. Meniscus debridement 22 11/21/2017 11 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Viscosupplementation  Series of 1 to 5 injections  Thought to decrease pain  May work better for patients without an effusion  May work better for mild to moderate arthritis 23 11/21/2017 Viscosupplementation  “The experts achieved unanimous agreement in favor of the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to surgery in advanced hip OA; VS is a well-tolerated treatment of knee and other joints OA” 24 12 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Viscosupplementation Medicare claims database of 255,000 patients Conclusions— T The year of a TKA, 25% of OA costs are to HA injections Most patients try everything the year before TKA (steroid, meds, HA, and 25 11/21/2017 What is the cost of a stem cell injection to the knee? 1. $100 2. $1000 3. $2500 4. $5000 5. $10000 26 11/21/2017 13 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Washington Post 2017 $500-$1800 per treatment (often recommended to have 3 treatments) No studies have shown marked improvements No change in natural history V Very few studies show significant complications 27 11/21/2017 28 11/21/2017 14 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Take home points—non steroid injections  Hyaluronic acid injections have limited efficacy but low side effects  PRP has limited efficacy but is somewhat expensive  There is no data for stem cell treatments and they are very expensive 29 11/21/2017 How to do a knee injection  Keep your supplies simple! • 2 alcohol swabs • Bandaid • Cold spray • Injection (mixed together) 19-22 ga needle 30 11/21/2017 15 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Where do you like to inject the knee? 1. Superolateral 2. Superomedial 3. Anteromedial 4. Anterolateral 5. Stop asking me if I inject knees! 31 11/21/2017 Superolateral approach  Patient supine (no peeking)  Extend knee  Bump under knee so flexed 10-20 degrees  Superior border patella  Lateral border patella  1cm above  Mark with syringe cover or tip of pen 16 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

33 11/21/2017 Why Superolateral? 93% 71% 75% 34 11/21/2017 17 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]

Why superolateral? Thank you  Questions? 36 11/21/2017 18 11/21/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]