Outline Knee Shoulder and Knee Injections Indications for - PowerPoint PPT Presentation

Outline  Knee Shoulder and Knee Injections • Indications for Injections/Aspirations • Outcomes Brian Feeley, MD • How to do a knee injection easily Sports Medicine and Shoulder Surgery  Shoulder UC San Francisco • Indications for Injections/Aspirations • Outcomes • How to do a shoulder injection easily Indications for knee aspiration/injection Case 1  55 year old computer scientist with 3 weeks of knee pain and swelling. He has a history of 2 meniscus debridements, and was  Diagnostic told he had some mild arthritis 5 years ago at his last surgery. He • Effusion, especially atraumatic 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 • Send for cell count, differential, crystals +/- gram stain and of questions). He wants to know if injections are safe—he had one culture 6 months ago and another one 3 years ago.  Therapeutic • Osteoarthritis • Crystal arthropathy • Inflammatory arthritis 1

Contraindications to steroid injection What defines too many injections? A. 3 injections in one anatomic site within 1 year  Joint infection B. 3 injections anywhere in the body within 1 year  Hemarthrosis C. 3 injections in one anatomic site within a lifetime 67%  Overlying cellulitis D. 3 injections anywhere in the body within a lifetime  Fracture E. 6 injections into any space with articular cartilage  Prosthetic joint 16% 10% 7% 0% . . . . . . o . o . . . . o . . n y n y t n n n i i i s a s a n n s s s o o n n n i i o o t o t i c i c i t t t c e e c c e n j e n j e j i j i j n n n 3 3 i i i 6 3 3 Relative contraindications to steroid injection What is your preferred steroid injection? A. Depomedrol B. Betamethasone  Corticosteroid injection 63% C. Kenalog within past 3-4 months D. Triamcinolone  Coagulopathy E. I don’t do injections  Poorly controlled diabetes 13% 13% 8% 3% l e g e o s n o n n r o l o d a o e s n l i a o t m e h n c e o K i t c j e n p m m e i a D o a i d t r e T t B ’ n o d I 2

Corticosteroid injections for musculoskeletal conditions 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 Intraarticular corticosteroid for knee OA: American Academy of Orthopaedic Surgeons 2013 Increased chondrocyte death: Longer duration More acidic (lidocaine) More concentrated 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. 3

Intraarticular corticosteroid for knee OA: Osteoarthritis Research Society International 2014  Appropriate treatment  Quality of evidence: Good  Clinically significant short-term pain relief  2-year RCT  Consider other options for longer duration pain relief  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 McAlindon TE et al. OARSI Guidelines for the Non-Surgical Management of Knee Osteoarthritis. Osteoarthritis and Cartilage 2014. 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  140 randomized patients  Skin or fat atrophy • Mean age 58 years  Post-injection steroid flare: 1-10% • 54% women • Synovitis in response to injected crystals • Within hours - 48 hours post-injection  Significantly more cartilage loss in triamcinolone group compared to saline group • More common in soft tissue injections (20% of trigger points) than intra- articular injections  No significant difference in pain between groups at 2 years  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. 4

Intra-articular corticosteroid injections: Case 3 take home points  62 year old male presents  Short-term pain relief (6 weeks average) with progressive knee pain and a known history of  Small effect on function arthritis. He has had  No evidence for long-term pain relief NSAIDS, PT, and steroid injections. The last 3  Clinical effect independent of degree of inflammation present steroid injections haven’t • Don’t need to restrict injection just to those with effusion worked as well and he would like to try something  Frequency: general practice once every 3-4 months max different but doesn’t feel ready for surgery. • Concern for cartilage toxicity if given q 3 months x 2 years What would you recommend? Viscosupplementation A. Repeat steroid injection  Series of 1 to 5 injections B. Hyaluronic acid injection 38%  Thought to decrease pain C. PRP injection 31%  May work better for patients without an effusion D. Stem cell injection 26%  May work better for mild to moderate arthritis E. Knee replacement F. Meniscus debridement 3% 2% 0% n n t . . n . o o . . e . n . i i i t t m . i c c . d i d e e e r i b c j j i n n c o a e i a r i d e c P l l p i R l s t n e e s u o P c r c t r a m e s u i e e n l e a n p t e y K e S M H R 5

Viscosupplementation 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” Medicare claims database of 255,000 patients Conclusions— Conclusions The year of a TKA, 25% of OA costs are to HA injections The year of a TKA, 25% of OA costs are to HA injections Most patients try everything the year before TKA (steroid, meds, Most patients try everything the year before TKA (steroid, meds, HA, and PT) HA, and PT) What is the cost of a stem cell injection to the knee? Washington Post 2017 A. $100 B. $1000 34% C. $2500 30% D. $5000 24% $500 $500-$1800 per treatment (often recommended to have 3 treatments) E. $10000 No studies have shown marked improvements No studies have shown marked improvements No change in natural history No change in natural history Very few studies show significant complications Very few studies show significant complications 11% 0% 0 0 0 0 0 0 0 0 0 0 1 0 5 0 0 $ 1 2 5 0 $ $ $ 1 $ 6

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 How to do a knee injection Where do you like to inject the knee? A. Superolateral  Keep your supplies simple! B. Superomedial • 2 alcohol swabs C. Anteromedial • Bandaid D. Anterolateral • Cold spray E. Stop asking me if I inject knees! • Injection (mixed together) 19-22 ga needle 44% 22% 15% 14% 5% l l l l . a a a a . . r i i d d r f e e i t e e t e a m m a m l l o o o o r r g e r r e e e n p p t t i n n k u u A A s S S a p o t S 7

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 Why Superolateral? Why superolateral? 93% 71% 75% 8

Where should an injection go to treat frozen Shoulder Injections shoulder? A. Subacromial space B. Bicipital groove C. Glenohumeral joint D. All of the above 53% 34% 11% 1% Subacromial space Bicipital groove Glenohumeral joint All of the above Evidence for glenohumeral injections for frozen shoulder Shoulder Injections  Gyftopoulos et al AJR 2018  Multiple spaces within the shoulder to inject • Image guided injections were more cost effective in treatment of frozen shoulder • Subacromial space—rotator cuff pathology • Glenohumeral joint—Frozen Shoulder/Shoulder OA  Sinha et al Shoulder Elbow 2017 • AC joint—AC joint OA • Image guided hydrodilation was more effective than PT alone • Bicipital Groove—Bicipital tendonitis  Sun et al AJSM 2017 • Meta-analysis showed intra-articular injection was safe, effective in the treatment of frozen shoulder 9