Live On Screen: Knee Injections ABCs of Musculoskeletal Care - - PowerPoint PPT Presentation

12/11/2015 1

Live On Screen: Knee Injections ABCs of Musculoskeletal Care

Carlin Senter, MD Primary Care Sports Medicine Departments of Medicine and Orthopaedics

December 11, 2015

I have no disclosures.

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

12/11/2015 2 Indications for aspiration in knee OA patient

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 200-2000 WBC/mm3

Synovial fluid analysis

WBC count <25,000 25,000 50,000 100,000 (+) Likelihood ratio for septic joint 0.32 2.9 7.7 28

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

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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 College of Rheumatology 2012

Hochberg MC et al. ACR Recommendations for the Nonpharmacologic and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care & Research 2012.

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.

Contraindications to steroid injection

Joint infection Fracture Prosthetic joint Hemarthrosis (theoretically higher risk of infection) Soft tissue infection overlying joint

12/11/2015 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 19-36 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 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

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

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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

Hunter DJ. N Engl J Med 2015;372:1040-1047.

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) Gelber AC. In the clinic. Osteoarthritis. Ann Intern Med. 2014 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

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. 2015 May 29.

Performing a knee aspiration and injection

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Knee injection Injection set-up bucket

Betadine Ethyl chloride Alcohol swabs 4x4 guaze Bandaids

Injection prep Needles, syringes, meds

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Aspiration Corticosteroids 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 Avoid swimming, hot tub, bath x 24 hours

• Let injection site heal

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My current knee injection steps

1. Patient supine with bump under knee so knee flexed 20-30° 2. 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

Knee injection