Live On Screen: Knee Injections ABCs of Musculoskeletal Care. Knee aspiration. Objectives. I have no disclosures.

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1 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 4. Practice Knee aspiration 1

2 Indications for aspiration in knee OA patient Synovial fluid analysis If joint effusion and 1. Diagnostic uncertainty 2. New pattern of large volume swelling 3. Red or hot joint Send fluid for cell count, differential, crystals, gram stain, culture If OA WBC WBC/mm 3 WBC count <25,000 25,000 50, ,000 (+) Likelihood ratio for septic joint PMNs > 75% bacterial infection 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 Inspect fluid for inflammation/infection, send to lab if question 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.) Knee injections 1. Corticosteroid 2. Hyaluronic acid 3. Platelet rich plasma 2

3 Intraarticular corticosteroid for knee OA: American College of Rheumatology 2012 Benefits > risks if patient has inadequate response to intermittent dosing of OTC such as APAP NSAIDs Nutritional supplements (glucosamine, chondroitin sulfate) Intraarticular corticosteroid for knee OA: American Academy of Orthopaedic Surgeons 2013 Hochberg MC et al. ACR Recommendations for the Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2 nd Edition American Academy of Orthopaedic Surgeons 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 Contraindications to steroid injection Joint infection Fracture Prosthetic joint Hemarthrosis (theoretically higher risk of infection) Soft tissue infection overlying joint McAlindon TE et al. OARSI Guidelines for the Non-Surgical Management of Knee Osteoarthritis. Osteoarthritis and Cartilage

4 Relative contraindications to steroid injection Corticosteroid injection within past 4 months Coagulopathy (ok if on warfarin but check recent INR, make sure not >> 3) Poorly controlled diabetes Risks of steroid injection in the knee Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after x 5 days Suppression of hypothalamic pituitary adrenal axis, mild x 1-3 days post injection Facial flushing: 10% with Kenalog x hours post-injection Skin or fat atrophy 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 intraarticular injections Septic arthritis: 1/3000-1/50, days after injection Habib GS. Clin Rheumatol, UpToDate, Joint aspiration or injection in adults, Intra-articular corticosteroid injections: take home points Good short-term pain relief (6 weeks average) No significant 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 with more than 4/year Knee OA: cutting edge treatments? Hyaluronic acid Platelet rich plasma 4

5 Hyaluronic acid High molecular-weight polysaccharide in the cartilage and synovial fluid Provides lubrication and acts as shock absorber in the joint (adult knee normally has 2ml HA) Knee OA: decreased amt of HA in the joint reduced viscoelasticity of the synovial fluid Injections Theoretically reestablish joint homeostasis via increased joint production of HA after the injection has left the joint Proposed anti-inflammatory, analgesic effects? Protects cartilage Hyaluronic acid injections No data for 1 brand name over another Can provide pain relief for longer than steroid (5-13 weeks) Evidence is heterogeneous Significant placebo response Risk = 1-3% pseudoseptic reaction Less likely to benefit > 65 yrs old Severe joint space narrowing Uncertain recommendation from OARSI 2014 No specific recommendation ACR 2012 Cannot recommend (strength of recommendation = strong) AAOS 2013 Recommend (AMSSM 2015) Hunter DJ. N Engl J Med 2015;372: Gelber AC. In the clinic. Osteoarthritis. Ann Intern Med Jul 1;161(1):ITC1-16. Platelet rich plasma (PRP) injections Data heterogeneous Different preparations of PRP Different injection protocols More benefit in more mild disease Potential to relieve pain x 12 months More data needed Performing a knee aspiration and injection 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 May 29. 5

6 Knee injection Injection set-up bucket Betadine Ethyl chloride Alcohol swabs 4x4 guaze Bandaids Injection prep Needles, syringes, meds 6

7 Aspiration Corticosteroids Superolateral approach Post-injection patient instructions Patient supine Extend knee Bump under knee so flexed degrees Superior border patella Lateral border patella 1cm below Mark with syringe cover or tip of pen Rest: no definitive evidence-based recommendation Recommendations in literature vary No restrictions Bed rest x 24 hours Light activity x 7 days, no weight bearing exercise Avoid swimming, hot tub, bath x 24 hours Let injection site heal 7

8 My current knee injection steps Knee injection 1. Patient supine with bump under knee so knee flexed 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