Knee joint aspiration and injection are performed to aid in diagnosis and treatment of knee joint diseases. The knee joint is the most common and the easiest joint for the physician to aspirate. One approach involves insertion of a needle 1 cm above and 1 cm lateral to the superior lateral aspect of the patella at a degree angle. Local corticosteroid injections can provide significant relief and often ameliorate acute exacerbations of knee osteoarthritis associated with significant effusions.
Among the indications for arthrocentesis are crystal-induced arthropathy, hemarthrosis, unexplained joint effusion, and symptomatic relief of a large effusion. Contraindications include bacteremia, inaccessible joints, joint prosthesis, and overlying infection in the soft tissue. Large effusions can recur and may require repeat aspiration. Anti-inflammatory medications may prove beneficial in reducing joint inflammation and fluid accumulations. Knee joint aspiration and injection are performed to establish a diagnosis, relieve discomfort, drain off infected fluid, or instill medication.
Because prompt treatment of a joint infection can preserve the joint integrity, any unexplained monarthritis should be considered for arthrocentesis Table 1. Arthrocentesis also may help distinguish the inflammatory arthropathies from the crystal arthritides or osteoarthritis. If a hemarthrosis is discovered after trauma, it can indicate the presence of a fracture or other anatomic disruption. The knee is the most common and the easiest joint for the physician to aspirate.
It was chosen for discussion here because of the frequent clinical problems associated with this joint. The indications, complications, and pitfalls for knee arthrocentesis generally can be applied to other joints Tables 2 and 3.
Many of the principles of needle aspiration and injection also can be used for soft tissue disorders, such as bursitis or tendinitis. An effusion of the knee often produces detectable suprapatellar or parapatellar swelling. Large effusions can produce ballottement of the patella. Medial or lateral approaches to the knee can be selected; some investigators advocate the medial approach when the effusion is small and the lateral approach with larger effusions.
The knee generally is easiest to aspirate when the patient is supine and the knee is extended. Corticosteroids are believed to modify the vascular inflammatory response to injury, inhibit destructive enzymes, and restrict the action of inflammatory cells. Intrasynovial steroid administration is designed to maximize local benefits and minimize systemic adverse effects. There is no convincing evidence that corticosteroids modify rheumatic joint destruction, and steroid injections in patients with rheumatoid arthritis should be considered ancillary to rest, physical therapy, nonsteroidal anti-inflammatory drugs NSAIDs , or disease-modifying antirheumatic drugs.
Judicious use of corticosteroids rarely produces significant adverse effects. The introduction of infection after injection is believed to occur in less than 1 in 10, procedures. The concept of steroid arthropathy is largely based on studies in subprimate animal models, and it is an unusual occurrence in humans if the number of injections is limited to three to four per year in weight-bearing joints. More conservative researchers have even advocated limiting knee injections to three or four over an individual's lifetime.
Clothing is removed from over the affected joint. The patient is placed in the supine position, and the knee is extended some physicians prefer to have the knee bent to 90 degrees. An absorbent pad is placed beneath the knee. Hemostat for stabilizing the needle when exchanging the medication syringe for the aspiration syringe. The patient is supine on the table with the knee extended some physicians prefer that the knee be bent to 90 degrees.
Some physicians prefer the medial approach for smaller effusions, but the lateral approach will be discussed here. The knee is examined to determine the amount of joint fluid present and to check for overlying cellulitis or coexisting pathology in the joint or surrounding tissues. The superior lateral aspect of the patella is palpated. The skin is marked with a pen, one fingerbreadth above and one fingerbreadth lateral to this site. This location provides the most direct access to the synovium.
The skin is washed with povidone-iodine solution. The physician should be gloved, although there is no consensus as to whether sterile gloves must be used. A gauge, 1-inch needle is attached to a 5- to mL syringe, depending on the anticipated amount of fluid present for removal. The needle is inserted through stretched skin. Some physicians administer lidocaine Xylocaine into the skin, but stretching the pain fibers in the skin with the nondominant hand can also reduce needle-insertion discomfort.
The needle is directed at a degree angle distally and 45 degrees into the knee, tilted below the patella Figure 1. Using the nondominant hand to compress the opposite side of the joint or the patella may aid in arthrocentesis. Once the syringe has filled, a hemostat can be placed on the hub of the needle. With the needle stabilized with the hemostat, the syringe can be disconnected and the fluid sent for studies. Care should be taken not to touch the needle tip against the joint surfaces when removing the syringe.
A syringe filled with corticosteroid medication can then be attached to the needle. For injection, use betamethasone Celestone, 6 mg per mL , 1 mL, mixed with 3 to 5 mL of 1 percent lidocaine. Alternately, methylprednisolone Depo-Medrol, 40 mg per mL , 1 mL, mixed with 3 to 5 mL of 1 percent lidocaine can be used.
After injection of the medication, the needle and syringe are withdrawn. The skin is cleansed, and a bandage is is applied over the needle-puncture site. The patient is warned to avoid forceful activity on the joint while it is anesthetized. After diagnostic arthrocentesis, appropriate intervention usually will be dictated by the results of the fluid analysis.
Joint infections are usually treated aggressively with intravenous antibiotics. An inflammatory arthritis, such as rheumatoid arthritis, can be treated with disease-modifying medications such as methotrexate or penicillamine. Patients with traumatic or bloody effusions may be considered for further orthopedic evaluation. Corticosteroid injections for osteoarthritis often provide a short-lived benefit.
Repeat injections can be considered after six weeks. Large, weight-bearing joints should not be injected more than three times a year. Severe pain during the procedure usually results from the needle coming into contact with the highly innervated cartilaginous surfaces. The needle can be redirected or withdrawn when pain is encountered.
Slow, steady movement of the needle during insertion can prevent damage to the cartilage surface from the needle bevel. Introduction of infection into a joint is a rare event, occurring in less than 0. Severe dermatitis or soft tissue infection overlying a joint is a contraindication for arthrocentesis. Some physicians advocate that steroid injection should not be performed before excluding joint infection. A recognized complication of steroid injections to joints is the postinjection flare.
The flare reaction represents an increase in joint pain occurring in 1 to 2 percent of persons. The steroid crystals can induce an inflammatory synovitis that usually begins about six to 12 hours after the injection. The postinjection flare can present with swelling, tenderness, and warmth over the joint that persists for hours or days. If the patient takes anti-inflammatory medications immediately after the injection, they may reduce or abort this reaction.
Aspiration should be performed to rule out joint sepsis if symptoms persist beyond two to three days. The most serious complication of repeated injections is joint instability from the development of osteonecrosis of juxta-articular bone and weakened capsular ligaments. Although this complication occurs in less than 1 percent of patients, it is recommended that injections be performed no more frequently than every six to eight weeks, and no more than three times per year in weight-bearing joints.
Large effusions from the knee can rapidly re-accumulate. Some physicians advocate placing an elastic wrap around the knee immediately after large effusion drainage. A major disadvantage to intra-articular corticosteroid injections is the short duration of action. The average duration of benefit may be only two to three weeks; however, a small percentage of patients with osteoarthritis may have sustained relief after one or two injections.
The technique described involves insertion of the needle 1 cm above and 1 cm lateral to the superior lateral aspect of the patella. The needle is tilted beneath the patella at a degree angle. The choice of steroid varies. Celestone is one of the more common steroids used. Mix 2 ampoules of Celestone with 3 mls of local anaesthetic lignocaine in a 5ml syringe. Mix using an aseptic technique and use a blue or green 21,23G needle.
The choice of injection portal is either superolateral under the patella with the knee extended or through the inferomedial or inferolateral soft part of the knee with the knee flexed to 90 degrees. Always use an aseptic technique. You do not need to aspirate the knee first unless there is a large effusion. If you do aspirate send the fluid off for culture.
Other parts of the knee which may need to be aspirated or injected include the prepatella bursa. This is superficial to the patella and can be traumatic or infective. If you think it might be infected, aspirate heading straight down toward the patella, not into the knee joint.
You should not be able to go into the joint because you will hit bone first. Other bursae or fluid collections do occur. Aspiration or injection should only be done if you are sure of the diagnosis, otherwise you should seek an orthopaedic opinion. A Bakers cyst is extremely common and should not, as a general rule, be aspirated.
Skip to content. Back to Teaching. Knee Injections. Indications for Local Anaesthetic Alone. Suturing a wound Diagnosis of pain coming from a certain part of the knee, e. This is not common and usually should be done by a surgeon or sports physician. When is it used? Intraarticular Injection. They are also useful in patients who are not medically fit for surgery. How long does it last? Where is it Done? Corticosteroids can be injected into the knee in the office under aseptic conditions.
Suspected infection in the joint Cellulitis Immunosuppression Allergy to local anaesthetic or steroids Joint replacement relative Side effects are rare….
If in doubt, consult the product information sheet. REMEMBER , if you stick a needle into something you think might be infected, send a specimen away for microscopy, culture and sensitivities. Corticosteroid injections are used to relieve symptoms of arthritis in certain joints and are also used to reduce soft tissue inflammation. The appropriate use and knowledge of where and when to inject is extremely important.
Corticosterioids act as an anti-inflammatory medication which can be injected into a joint or around some tendons use with caution around tendons. Corticosteroid is usually mixed with local anaesthetic to reduce pain which is usually only quite mild.
There are multiple indications and we will discuss the most common ones. In general it is used to relieve inflammation of tendons or joints. Intra-articular corticosteroids are primarily used for pain secondary to osteoarthritis but they can also be used in inflammatory conditions such as rheumatoid arthritis. They do not slow down or change the progression of arthritis.
They are generally used in patients with arthritic symptoms who are not symptomatic enough to warrant a total joint replacement. It is also used when trying to delay an inevitable joint replacement. The effects usually take hours to work. For the first day or two there can actually be a slight increase in pain as the corticosteroid starts to work. The effects can last anywhere from a week to 6 months but it is only temporary.
You can repeat the injections if required up to three a year. The choice of steroid varies. Celestone is one of the more common steroids used. Mix 2 ampoules of Celestone with 3 mls of local anaesthetic lignocaine in a 5ml syringe. Mix using an aseptic technique and use a blue or green 21,23G needle. The choice of injection portal is either superolateral under the patella with the knee extended or through the inferomedial or inferolateral soft part of the knee with the knee flexed to 90 degrees.
Always use an aseptic technique. You do not need to aspirate the knee first unless there is a large effusion. If you do aspirate send the fluid off for culture. Other parts of the knee which may need to be aspirated or injected include the prepatella bursa. This is superficial to the patella and can be traumatic or infective. If you think it might be infected, aspirate heading straight down toward the patella, not into the knee joint.
You should not be able to go into the joint because you will hit bone first. Besides, steroids can be injected into different parts of the joint or around the joint depending on the point that is diagnosed with the problem.
Prior to the procedure, the surgeon has to be sure that there is no tear of the rotator cuff, which can be confirmed by investigations such as an MRI scan. However, the injections should not be too frequent as this can increase the risk of a vascular necrosis. The injections are given into the anterior part of the subacromial bursa, while the intra-articular local anesthetic injections are used as a diagnostic test for impingement.
The intra-articular steroid injections are commonly used as a part of the treatment modality for relief from shoulder pain. These steroid injections are successfully used with:. Another key benefit of using the intra-articular steroid injections for shoulder pain is that it is an effective remedy for decreasing pain and swelling quickly.
Patients also prefer to opt for these intra-articular steroid injections in order to delay using steroid pills or arthritis drugs. There are various types of preparation of steroids that have a different duration of effect and action. The guiding principle which determines the effectiveness of each of these preparations is their solubility.
The insoluble preparations are known to have a longer duration of effect and are the most preferred. For the benefit of analysis, here we briefly list each one of the preparations of the intra-articular steroid injections. The duration of effect is usually 6 months. This particular preparation normally has a duration of 3 months. Depo-medrol Methylprednisolone acetate — This is highly soluble and should only be used as a last resort.
The duration of effect in this preparation is only 5 weeks. The subacromial corticosteroid injections for the rotator cuff disease and intra-articular steroid injection for adhesive capsulitis are quite beneficial. However the impact of these injections can be short-lived. Experts suggest that a more extensive research is required to study the efficacy of the corticosteroid injections for shoulder pain.
Intraarticular steroid injections typically take. Clinical Question How effective and injections are insoluble because the steroid injections which all have a chemical called hyaluronan. Common corticosteroids that are used for the use of nonpharmacologic tebutate, hydrocortisone acetate, methylprednisolone acetate, with a bandage, if necessary. Your pain management physician will questions based on their relevance. The preferred steroids for intra articular steroid injection procedure the recovery room area where for the treatment of osteoarthritis. Afterward, bandages will be applied. PARAGRAPHIn certain cases, an anesthesiologist may also be utilized. What are the expected results. You may doze off during. The medication should flow freely what steroid to use and then whether or not to or repositioning of the needle steroid for the intraarticular injection in the proper position.The clinician's thumb is used to gently rock and then stabilize the patella while the needle is inserted underneath the supramedial surface of patella, aimed toward the center of the patella, and then directed slightly posteriorly and inferolaterally into the knee joint. anabolicpharmastore.com › article › technique. Intraarticular Injection. Intra-articular corticosteroids are primarily used for pain secondary to osteoarthritis but they can also be used in inflammatory.