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joint/bursa injection (knee injection, subacromial bursa injection)

Indications: - pain relief: symptom improvement may last 24 weeks [4] number needed to treat 4.4 for 1 to benefit at 16-24 weeks Contraindications: 1) absolute - localized abscess or cellulitis at site of injection - active Herpes simplex virus (HSV) or tuberculosis infection - previous hypersensitivity to injectable anesthetic 2) relative a) bleeding diathesis b) anticoagulant therapy - safe in patients receiving direct oral anticoagulant therapy; - no need to withhold anticoagulation before procedure [8] c) bacteremia d) partial tendon rupture at site of injection e) joint prosthesis Procedure: Preparation: 1) obtain informed consent 2) identify landmarks 3) wide-field skin cleaning 4) sterile glove 5) sterile drape may be indicated Precautions: 1) withdraw needle to subcutaneous tissue prior to redirecting needle 2) avoid removing the needle completely when redirecting 3) no single joint should be injected more that every 3-6 months Injection by joint/bursa/disorder 1) subacromial bursitis a) patient sitting arm at side b) locate subacromial bursa by palpating superiorly along spine of scapula to posterolateral portion of the acromion (acromial angle), superior to the humeral head c) insert 4 cm, 25 gauge needle 1 cm below acromial angle, direct anteromedially, staying close to the inferior border of acromion, insert approximately 2.5 cm, avoid rotator cuff tendon inferiorly d) inject anesthetic (1% lidocaine/0.25% bupivicaine 2-10 mL) & glucocorticoid serially from front to back (connective tissue acts as septae separating space into sections) e) move joint through full range of motion to distribute mixture f) lateral & anterior approaches better than posterior approach [5] 2) lateral epicondylitis a) elbow flexed 90 degrees with hand pronated b) locate point of maximum tenderness near lateral epicondyle c) insert 1 cm, 25 gauge needle into point of maximum tenderness parallel to the tendon d) inject anesthetic (lidocaine 1%, 0.5 mL) & corticosteroid 3) knee (video [11]) a) flex knee 10-15 degrees b) a rolled towel may be place in the popliteal fossa to support the knee & allow the quadriceps to relax c) insert 4 cm 25 gauge needle laterally beneath the patella d) inject anesthetic (lidocaine 1%, 2-4 mL) & corticosteroid Glucocorticoids for joint injection: 1) triamcinolone acetonide or hexacetonide (Kenalog) 40 mg/mL 2) methylprednisolone acetate (Depo-Medrol) 80 mg/mL 3) knee 0.5-1.0 mL (20-40 mg) 3) large joints: 0.25-0.5 mL (10-20 mg) 4) small joints: 0.25 mL (5-10 mg) 5) tendons: 0.1 mL (4 mg) Complications: 1) seizures from local anesthetic: - IV diazepam should be available 2) localized cutaneous depigmentation & atrophy from leaking of injectable steroids onto skin 3) subcutaneous swelling & pain after procedure: - ice may attenuate 4) post procedural infection - knee injections given within 3 months of knee arthroplasty associatated with risk for periprosthetic infection [9] 5) damage to tendons: avoid strenuous activity for 1 week after procedure 6) post-injection steroid flairs 6-12 hours after injection (post-injection synovitis) a) phagocytosis of glucocorticoid ester crystals b) generally resolve in 48-72 hours c) relieved by NSAIDs & ice 7) repeated injections do NOT accelerate joint narrowing [3,4] 8) high dose hip joint injection 80 mg dexamethasone or repeated injections confer a risk of rapidly destruction hip disease [10] - a single hip joint injection of 40 mg triamcinolone confers low risk [10]

Specific

joint aspiration/injection paravertebral facet injection

General

injection

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 779-781
  2. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 506
  3. Journal Watch 23(8):65, 2003 Raynauld J-P et al, Arthritis Rheum 48:370, 2003
  4. Journal Watch 24(11):86, 2004 Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004 Apr 10;328(7444):869. Epub 2004 Mar 23. PMID: 15039276 http://bmj.bmjjournals.com/cgi/content/full/328/7444/869
  5. Marder RA et al. Injection of the subacromial bursa in patients with rotator cuff syndrome: A prospective, randomized study comparing the effectiveness of different routes. J Bone Joint Surg Am 2012 Aug 15; 94:1442 PMID: 22992814 http://jbjs.org/article.aspx?articleid=1306117
  6. Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis. 2009 Dec;68(12):1843-9. PMID: 19054817
  7. Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Best Pract Res Clin Rheumatol. 2013 Apr;27(2):137-69 PMID: 23731929
  8. Yui JC, Preskill C, Greenlund LS. Arthrocentesis and joint injection in patients receiving direct oral anticoagulants. Mayo Clin Proc 2017 Aug; 92:1223 PMID: 28778256 http://www.mayoclinicproceedings.org/article/S0025-6196(17)30310-5/fulltext
  9. Richardson SS, Schairer WW, Sculco TP, Sculco PK. Comparison of infection risk with corticosteroid or hyaluronic acid injection prior to total knee arthroplasty. J Bone Joint Surg Am 2019 Jan 16; 101:112 PMID: 30653040
  10. Okike K, King RK, Merchant JC et al. Rapidly destructive hip disease following intra-articular corticosteroid injection of the hip. J Bone Joint Surg Am 2021 Nov 17; 103:2070. PMID: 34550909 https://journals.lww.com/jbjsjournal/Abstract/2021/11170/Rapidly_Destructive_Hip_Disease_Following.2.aspx
  11. Kelly N In-Office Knee Injection Technique: Tips for Success SANFORD HEALTH - THE UNIVERSITY OF SOUTH DAKOTA SCHOOL OF MEDICINE: ORTHOPAEDICS AND SPORTS MEDICINE. https://www.vumedi.com/video/in-office-knee-injection-technique-tips-for-success/