Disclosures None How to Do a Knee Injection UCSF Primary Care - - PowerPoint PPT Presentation

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How to Do a Knee Injection

UCSF Primary Care Sports Medicine Conference 2018 Carlin Senter, MD Associate Professor Co-Director UCSF Sports Concussion Program Primary Care Sports Medicine University of California San Francisco

Disclosures

None

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Procedural learning

Learn Learn See See Practice Practice Prove Prove Do Do

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Sawyer T et al, “Learn, See, Practice, Prove, Do, Maintain: An Evidence-Based Pedagogical Framework for Procedural Training in Medicine. Acad Med. 2015;90:1025-1033.

Workshop objectives

• 1. Knowledge

1.Indications and contraindications for knee steroid injection 2.Risks and benefits of knee aspiration and injection 3.Post procedure instructions 4.Materials needed for procedure

• 2. Skills

1.Consent 2.Sterility 3.Positioning 4.Entry site 5.Needle technique

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Indications for knee aspiration/injection

• Diagnostic
• Effusion, esp atraumatic
• Send for cell count, differential, crystals +/- gram stain and

culture

• Therapeutic
• Osteoarthritis
• Crystal arthropathy
• Inflammatory arthritis

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

Risks of steroid injection in the knee

• Diabetics: increased blood sugar, 300 mg/dl starting as early

as 2 hours after, lasting 5 days

• 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.

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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.)

Aspiration/injection supplies

• Betadine swab x 3
• Ethyl chloride spray
• Alcohol swabs x 6
• 4x4 gauze x 1
• Bandaid x 1

Needles, syringes, meds Aspiration

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Superolateral approach

• Patient supine
• Extend knee
• Bump under knee so flexed

10-20 degrees

• Superior border patella
• Lateral border patella
• 1cm below
• Mark with syringe cover or

tip of pen

Post-injection patient instructions

• 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
• I recommend no strenuous activity x 7 days
• Avoid swimming, hot tub, bath x 24 hours
• Let injection site heal

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

Knee injection practice

Category Elements to Complete Errors N = 0 Y = 1 Description of Errors Sterility No touch technique Gloves on Positioning Supine Knee extended with bump underneath Patella mobile/quad relaxed ID Entry Site Site at superior lateral border patella Verification of entry site by partner Does not ask for verification = 1 Adequately marks entry site Skin Sterile Prep (3 betadine swabs used) (Let betadine dry) (Alcohol swab to clean entry site) Ethyl chloride on entry site Needle Technique Holds the needle like a pen/dart Non-dominant hand tilting patella laterally Needle Insertion Pace of needle insertion slow, steady (injecting lidocaine as going) Too fast = 1; Too slow = 1 Angle of entry Would I intervene at this point? Y = 1 or N = 0 Redirection (if needed) Follow verbal instructions of preceptor? N = 1 Y = 0 Sheer underlying structures with redirection? Y = 1 N = 0 *multiple points possible Aspiration prior to injection of medication Preceptor asks: "What would you do to confirm that you are now in the joint space?" Aspiration prior to injection Y = 0, N = 1 If direction required by preceptor = 1 (Smooth switch of lidocaine syringe for steroid syringe and injection of steroid) Needle Extraction Pace slow and steady Gauze ready and put over the site

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Carlin Senter, MD Associate Professor Primary Care Sports Medicine UCSF Medicine and Orthpaedics Carlin.Senter@ucsf.edu

Thank you!