[PPT] - Outline Knee Shoulder and Knee Injections Indications for PowerPoint Presentation

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Shoulder and Knee Injections

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

Outline

Knee
Indications for Injections/Aspirations
Outcomes
How to do a knee injection easily
Shoulder
Indications for Injections/Aspirations
Outcomes
How to do a shoulder injection easily

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

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

f questions). He wants to know if injections are safe—he had one

6 months ago and another one 3 years ago.

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What defines too many injections?

A. 3 injections in one anatomic site within 1 year
B. 3 injections anywhere in the body within 1 year
C. 3 injections in one anatomic site within a lifetime
D. 3 injections anywhere in the body within a lifetime
E. 6 injections into any space with articular cartilage

3 i n j e c t i

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. 3 i n j e c t i

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s a n y . . . 3 i n j e c t i

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. 3 i n j e c t i

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s a n y . . . 6 i n j e c t i

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. . 67% 10% 16% 0% 7%

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

What is your preferred steroid injection?

A. Depomedrol
B. Betamethasone
C. Kenalog
D. Triamcinolone
E. I don’t do injections

D e p

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s 8% 3% 13% 13% 63%

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Corticosteroid injections for musculoskeletal conditions 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

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

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.

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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.

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
Significantly more cartilage loss in triamcinolone

group compared to saline group

No significant difference in pain between groups at

2 years

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.

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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

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.

What would you recommend?

A. Repeat steroid injection
B. Hyaluronic acid injection
C. PRP injection
D. Stem cell injection
E. Knee replacement
F. Meniscus debridement

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K n e e r e p l a c e m e n t M e n i s c u s d e b r i . . .

31% 38% 2% 26% 0% 3%

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

Viscosupplementation

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“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”

Viscosupplementation

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 PT) 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 PT)

Viscosupplementation

Medicare claims database of 255,000 patients

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

A. $100 B. $1000 C. $2500 D. $5000 E. $10000

$ 1 $ 1 $ 2 5 $ 5 $ 1 0% 11% 24% 34% 30%

$500 No studies have shown marked improvements No change in natural history Very few studies show significant complications $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

How to do a knee injection

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

Where do you like to inject the knee?

A. Superolateral
B. Superomedial
C. Anteromedial
D. Anterolateral
E. Stop asking me if I inject knees!

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a s k i n g m e i f . . . 14% 5% 15% 44% 22%

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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

Why Superolateral?

71% 75% 93%

Why superolateral?

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Shoulder Injections Where should an injection go to treat frozen shoulder?

A. Subacromial space
B. Bicipital groove
C. Glenohumeral joint
D. All of the above

Subacromial space Bicipital groove Glenohumeral joint All of the above

53% 11% 34% 1%

Shoulder Injections

Multiple spaces within the shoulder to inject
Subacromial space—rotator cuff pathology
Glenohumeral joint—Frozen Shoulder/Shoulder OA
AC joint—AC joint OA
Bicipital Groove—Bicipital tendonitis

Evidence for glenohumeral injections for frozen shoulder

Gyftopoulos et al AJR 2018
Image guided injections were more cost effective in treatment
f frozen shoulder
Sinha et al Shoulder Elbow 2017
Image guided hydrodilation was more effective than PT alone
Sun et al AJSM 2017
Meta-analysis showed intra-articular injection was safe,

effective in the treatment of frozen shoulder

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Subacromial shoulder injections

Steroid injections
PRP

42 year old male with a 4 month history of pain at night, pain with overhead activity, and difficulty doing

exercises. He has a positive Neer, positive Hawkins test,

and no weakness on exam. MRI shows supraspinatus

tendonopathy. What would you do?
A. Home exercise program
B. PT
C. PT and NSAIDS for 4 weeks
D. PT and subacromial injection of steroid
E. PT and subacromial injection of PRP
F. Referral for subacromial injection

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1% 6% 4% 0% 71% 17%

Evidence for steroid injections for impingement

Rhon et al. Annals of Internal Medicine 2014

Randomized 104 patients to injection vs PT
Both groups got better
No side effects
Lower health care resources used in the injection group

Evidence for steroid injections for impingement

Min et al. JSES 2013

Randomized NSAID injection vs steroid injection in 32

patients

Both groups improved
More improvement at 1 month in the NSAID in ROM and VAS

as well as shoulder function tests, did not meet MCID between groups

SLIDE 11

11 Arroll, BJGP, 2005

Meta analysis of 7 studies
Good evidence that steroid injection improves symptoms for up

to 9 months

NNT: 3.3
RR: 3.3

Evidence for steroid injections for impingement Do I Need Imaging for a Subacromial Injection?

Bhayana et al J Clin Ortho Trauma 2018

60 patients, randomized to landmark vs ultrasound
US 100% accurate; landmark 93.3% accurate
Both groups had equal benefit at 1 week, 3 week, 3 month time points

“Although US guided injections have a higher accuracy in the subacromial space, There is no difference in terms of clinical outcomes or safe profile of either

Method. Therefore, US guided injections seem to be

Compared to equally efficacious and cost effective landmark injections.” “Although US guided injections have a higher accuracy in the subacromial space, There is no difference in terms of clinical outcomes or safe profile of either

Method. Therefore, US guided injections seem to be unjuitifed when

Compared to equally efficacious and cost effective landmark injections.”

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12 What about PRP for tendonopathy/PTRCT? Randomized patients with partial tears to steroid vs PRP injection Both groups got better PRP slightly better than steroid at 12 weeks No difference at 6 months No difference in MRI findings at 6 months Randomized patients with partial tears to steroid vs PRP injection Both groups got better PRP slightly better than steroid at 12 weeks No difference at 6 months No difference in MRI findings at 6 months EJOST 2016 Slight improvement with PRP at 3 months, no difference at 6 months Slight improvement with PRP at 3 months, no difference at 6 months KSSTA 2015 What about PRP for tendonopathy/PTRCT? AJSM, 2013 No difference between exercise And PRP injections at 1 year No difference between exercise And PRP injections at 1 year What about PRP for tendonopathy/PTRCT?

Say et al J Ortho Surg 2016
Non randomized steroid vs PRP
Steroid injections doing significantly better at 6 week and 6

months What about PRP for tendonopathy/PTRCT? “Steroid injection was more effective than PRP injection for impingement.”

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How do to a steroid injection in the subacromial space

Same set up as knee
Have the patient face away from you, sitting up
Find posterolateral tip of the acromion, go just anterior to

this (lateral approach) Marder et al JBJS 2012.

92% accurate lateral; 56% posterior, 83% anterior
Go 1 cm down, aim towards collarbone