12/11/2015 I have no disclosures. Live On Screen: Knee Injections ABCs of Musculoskeletal Care Carlin Senter, MD Primary Care Sports Medicine Departments of Medicine and Orthopaedics December 11, 2015 Objectives 1. Indications for knee aspiration 2. Risks and benefits of steroid injections for knee 3. How to perform a knee aspiration and injection Knee aspiration 4. Practice 1
12/11/2015 Indications for aspiration in knee OA patient Synovial fluid analysis WBC count <25,000 25,000 50,000 100,000 � If joint effusion and (+) 0.32 2.9 7.7 28 1. Diagnostic uncertainty Likelihood 2. New pattern of large volume swelling ratio for 3. Red or hot joint septic joint � Send fluid for cell count, differential, crystals, gram stain, culture PMNs > 75% � bacterial infection � If OA � WBC 200-2000 WBC/mm 3 Eosinophils in fluid � parasitic infection, allergy, neoplasm, or Lyme disease Why aspirate the effusion before injection? � Clinically • Decreased pain and stiffness because effusion gone • More effect of steroid because not diluted by effusion Knee injections • Inspect fluid for inflammation/infection, send to lab if question • Confirms that injxn was intra-articular 1. Corticosteroid � Significantly greater improvement in VAS for patients who had joint 2. Hyaluronic acid aspirated at time of injection in knee OA patients (Gaffney K et al, Ann Rheum Dis, 1995.) 3. Platelet rich plasma � Reduction in relapse for 6 months after injection in RA patients (Weitoft T et al, Ann Rheum Dis, 2000.) 2
12/11/2015 Intraarticular corticosteroid for knee OA: Intraarticular corticosteroid for knee OA: American College of Rheumatology 2012 American Academy of Orthopaedic Surgeons 2013 � Benefits > risks if patient has inadequate response to intermittent dosing of OTC such as ‒ APAP ‒ NSAIDs ‒ Nutritional supplements (glucosamine, chondroitin sulfate) Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2 nd Edition Hochberg MC et al. ACR Recommendations for the Nonpharmacologic and American Academy of Orthopaedic Surgeons 2013. www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Accessed 11/13/15. Care & Research 2012. Intraarticular corticosteroid for knee OA: Contraindications to steroid injection Osteoarthritis Research Society International 2014 � Joint infection � Appropriate treatment � Fracture � Quality of evidence: Good � Prosthetic joint � Clinically significant short-term pain relief � Hemarthrosis (theoretically higher risk of � Consider other options for longer duration pain relief infection) � Soft tissue infection overlying joint McAlindon TE et al. OARSI Guidelines for the Non-Surgical Management of Knee Osteoarthritis. Osteoarthritis and Cartilage 2014. 3
12/11/2015 Relative contraindications to steroid injection Risks of steroid injection in the knee � Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after x 5 days � Corticosteroid injection within past 4 months � Suppression of hypothalamic pituitary adrenal axis, mild x 1-3 days post � Coagulopathy (ok if on warfarin but check injection recent INR, make sure not >> 3) � Facial flushing: 10% with Kenalog x 19-36 hours post-injection � Skin or fat atrophy � Poorly controlled diabetes � Post-injection steroid flare: 1-10% • Synovitis in response to injected crystals • Within 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: Knee OA: cutting edge treatments? take home points � Good short-term pain relief (6 weeks average) � Hyaluronic acid � No significant effect on function � Platelet rich plasma � 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 with more than 4/year 4
12/11/2015 Hyaluronic acid Hyaluronic acid injections � No data for 1 brand name over another � Can provide pain relief for longer than steroid (5-13 weeks) � High molecular-weight polysaccharide in the cartilage and synovial fluid � Evidence is heterogeneous � Provides lubrication and acts as shock absorber in the joint (adult � Significant placebo response knee normally has 2ml HA) � Risk = 1-3% pseudoseptic reaction � Knee OA: decreased amt of HA in the joint � reduced � Less likely to benefit viscoelasticity of the synovial fluid • > 65 yrs old � Injections • Severe joint space narrowing • Theoretically reestablish joint homeostasis via increased joint � “Uncertain” recommendation from OARSI 2014 production of HA after the injection has left the joint � No specific recommendation ACR 2012 • Proposed anti-inflammatory, analgesic effects � “Cannot recommend” (strength of recommendation = strong) AAOS 2013 • ? Protects cartilage � Recommend (AMSSM 2015) Hunter DJ. N Engl J Med 2015;372:1040-1047. Gelber AC. In the clinic. Osteoarthritis. Ann Intern Med. 2014 Jul 1;161(1):ITC1-16. Platelet rich plasma (PRP) injections � Data heterogeneous • Different preparations of PRP Performing a knee aspiration and • Different injection protocols injection � More benefit in more mild disease � Potential to relieve pain x 12 months � More data needed Campbell KA et al. Does Intra-articular Platelet-Rich Plasma Injection Provide Clinically Superior Outcomes Compared With Other Therapies in the Treatment of Knee Osteoarthritis? A Systematic Review of Overlapping Meta-analyses. Arthroscopy. 2015 May 29. 5
12/11/2015 Knee injection Injection set-up bucket � Betadine � Ethyl chloride � Alcohol swabs � 4x4 guaze � Bandaids Injection prep Needles, syringes, meds 6
12/11/2015 Aspiration Corticosteroids Superolateral approach Post-injection patient instructions � Rest: no definitive evidence-based recommendation � Patient supine • Recommendations in literature vary � Extend knee ‒ No restrictions � Bump under knee so ‒ Bed rest x 24 hours flexed 10-20 degrees ‒ Light activity x 7 days, no weight bearing exercise � Superior border patella � Avoid swimming, hot tub, bath x 24 hours � Lateral border patella • Let injection site heal � 1cm below � Mark with syringe cover or tip of pen 7
12/11/2015 My current knee injection steps Knee injection 1. Patient supine with bump under knee so knee flexed 20-30° 2. Mark injection site (superior lateral) 3. Betadine x 3 4. Alcohol x 1 5. Ethyl chloride for skin anesthesia 6. Alcohol again 7. 22g needle attached to 10cc syringe containing 5cc of 1% lidocaine without epi 8. Slowly advance and inject lidocaine, 1mm at a time 9. Feel resistance give when in joint 10. Aspirate, make sure fluid straw-colored and clear 11. Keep needle in place, switch syringe 12. Inject 1cc of 40mg triamcinolone 8
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