Knee Injections for Osteoarthritis Brian Feeley, MD Sports Medicine - - PDF document

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Knee Injections for Osteoarthritis Brian Feeley, MD Sports Medicine - - PDF document

Apr 20, 2023 119 likes •321 views

Knee Injections for Osteoarthritis Brian Feeley, MD Sports Medicine and Shoulder Surgery UC San Francisco Outline Indications for Injections/Aspirations Injectable medications Outcomes (covered previously) How to do a knee

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 11/21/2017 1

Knee Injections for Osteoarthritis

Brian Feeley, MD Sports Medicine and Shoulder Surgery UC San Francisco

Outline

  • Indications for Injections/Aspirations
  • Injectable medications
  • Outcomes (covered previously)
  • How to do a knee injection easily
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Indications for knee aspiration/injection

  • Diagnostic
  • Effusion, especially atraumatic
  • Send for cell count, differential, crystals +/- gram stain and culture
  • Therapeutic
  • Osteoarthritis
  • Crystal arthropathy
  • Inflammatory arthritis

Case 1

  • 42 year old male, BMI 38,

comes in with a 3 day history of increased right knee pain and

  • swelling. He thinks he might

have had a fall a week ago, but doesn’t remember pain. He has bought a cane and presents with a noticeable limp and large effusion.

  • On exam, he has a

moderately red joint, and cannot straighten past 10 degrees

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Audience Participation

  • What is your most likely diagnosis?
  • 1. Acute ACL tear
  • 2. Acute meniscus tear
  • 3. Arthritis
  • 4. Gout
  • 5. Septic Arthritis

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Indications for Aspiration

  • Rule out septic arthritis
  • Establish diagnosis of gout
  • Traumatic etiology (bloody aspiration)

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Results: Yellow fluid 58 K WBC 65 PMN

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How to interpret aspiration results

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Case 2

  • 55 year old computer scientist with 3 weeks of knee pain and swelling. He

has a history of 2 meniscus debridements, and was told he had some mild arthritis 5 years ago at his last surgery. He 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 of questions).

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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
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What is your preferred steroid injection?

  • 1. Depomedrol
  • 2. Betamethasone
  • 3. Kenalog
  • 4. Triamcinolone
  • 5. I don’t do injections

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Corticosteroid injections for knee osteoarthritis

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Corticosteroids: mechanism of action

  • Anti-inflammatory
  • Probably inhibit COX-2 and phospholipase-A2, both inflammatory mediators

Goldman: Goldman’s Cecil Medicine, 24th Ed, ch 34 – Immunosuppressing Drugs. Accessed via MD Consult 1/6/2013.

Anesthetic injections cause cell death

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Increased chondrocyte death: Longer duration More acidic (lidocaine) More concentrated

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Intraarticular corticosteroid for knee OA: American Academy of Orthopaedic Surgeons 2013

Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2nd Edition American Academy of Orthopaedic Surgeons 2013. www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed 11/13/15.

  • Appropriate treatment
  • Quality of evidence: Good
  • Clinically significant short-term pain relief
  • Consider other options for longer duration pain relief

Intraarticular corticosteroid for knee OA: Osteoarthritis Research Society International 2014

McAlindon TE et al. OARSI Guidelines for the Non-Surgical Management of Knee Osteoarthritis. Osteoarthritis and Cartilage 2014.

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  • 2-year RCT
  • 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
  • 140 randomized patients
  • Mean age 58 years
  • 54% women
  • Sig more cartilage loss in triamcinolone group compared

to saline group

  • No sig difference in pain between groups
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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
  • 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.

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
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Case 3

  • 62 year old male presents with

progressive knee pain and a known history of arthritis. He has had NSAIDS, PT, and steroid

  • injections. The last 3 steroid

injections haven’t worked as well and he would like to try something different but doesn’t feel ready for surgery.

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What would you recommend?

  • 1. Repeat steroid injection
  • 2. Hyaluronic acid injection
  • 3. PRP injection
  • 4. Stem cell injection
  • 5. Knee replacement
  • 6. Meniscus debridement

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  • Series of 1 to 5 injections
  • Thought to decrease pain
  • May work better for patients without an effusion
  • May work better for mild to moderate arthritis

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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

  • ther joints OA”

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Viscosupplementation

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T Conclusions— The year of a TKA, 25% of OA costs are to HA injections Most patients try everything the year before TKA (steroid, meds, HA, and

Viscosupplementation

Medicare claims database of 255,000 patients

What is the cost of a stem cell injection to the knee?

  • 1. $100
  • 2. $1000
  • 3. $2500
  • 4. $5000
  • 5. $10000

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V $500-$1800 per treatment (often recommended to have 3 treatments) No studies have shown marked improvements No change in natural history Very few studies show significant complications Washington Post 2017

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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

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How to do a knee injection

  • Keep your supplies simple!
  • 2 alcohol swabs
  • Bandaid
  • Cold spray
  • Injection (mixed together) 19-22 ga needle

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Where do you like to inject the knee?

  • 1. Superolateral
  • 2. Superomedial
  • 3. Anteromedial
  • 4. Anterolateral
  • 5. Stop asking me if I inject knees!

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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
  • f pen
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Why Superolateral?

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71% 75% 93%

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Why superolateral? Thank you

  • Questions?

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