Knee Joint Aspiration and Injection

Am Fam Physician. 2002 Oct 15;66(eight):1497-1501.

  Patient Information Handout

Commodity Sections

  • Abstract
  • Methods and Materials
  • Procedure Description
  • Follow Up
  • Process Pitfalls/Complications
  • Md Training
  • References

Knee joint aspiration and injection are performed to aid in diagnosis and treatment of knee joint diseases. The knee joint is the most common and the easiest articulation for the physician to aspirate. One approach involves insertion of a needle 1 cm in a higher place and ane cm lateral to the superior lateral aspect of the patella at a 45-caste angle. Once the needle has been inserted 1 to 1½ inches, aspiration aided by local compression is performed. Local corticosteroid injections can provide significant relief and often meliorate acute exacerbations of knee osteoarthritis associated with significant effusions. Among the indications for arthrocentesis are crystal-induced arthropathy, hemarthrosis, unexplained joint effusion, and symptomatic relief of a large effusion. Contraindications include bacteremia, inaccessible joints, joint prosthesis, and overlying infection in the soft tissue. Large effusions can recur and may crave echo aspiration. Anti-inflammatory medications may evidence benign in reducing articulation inflammation and fluid accumulations.

Knee joint aspiration and injection are performed to institute a diagnosis, relieve discomfort, drain off infected fluid, or instill medication. Because prompt treatment of a joint infection can preserve the joint integrity, any unexplained monarthritis should be considered for arthrocentesis (Table i).

Arthrocentesis also may help distinguish the inflammatory arthropathies from the crystal arthritides or osteoarthritis. If a hemarthrosis is discovered after trauma, information technology can indicate the presence of a fracture or other anatomic disruption.

The genu is the well-nigh common and the easiest joint for the physician to aspirate. It was chosen for discussion here because of the frequent clinical bug associated with this joint. The indications, complications, and pitfalls for knee arthrocentesis generally can be applied to other joints (Tables 2 and 3). Many of the principles of needle aspiration and injection also tin can be used for soft tissue disorders, such every bit bursitis or tendinitis.

An effusion of the knee joint often produces detectable suprapatellar or parapatellar swelling. Large effusions tin produce ballottement of the patella. Medial or lateral approaches to the human knee can be selected; some investigators advocate the medial approach when the effusion is minor and the lateral approach with larger effusions. The knee more often than not is easiest to aspirate when the patient is supine and the articulatio genus is extended.

Corticosteroids are believed to alter the vascular inflammatory response to injury, inhibit destructive enzymes, and restrict the action of inflammatory cells. Intrasynovial steroid administration is designed to maximize local benefits and minimize systemic adverse effects. Local corticosteroid injections can provide significant relief and often amend acute exacerbations of articulatio genus osteoarthritis associated with significant effusions.

Table 1

Indications for Arthrocentesis

Crystal-induced arthropathy

Hemarthrosis

Limiting joint damage from an infectious process

Symptomatic relief of a large effusion

Unexplained joint effusion

Unexplained monarthritis

There is no convincing evidence that corticosteroids modify rheumatic joint destruction, and steroid injections in patients with rheumatoid arthritis should be considered ancillary to rest, physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), or illness-modifying antirheumatic drugs.

TABLE 2

Contraindications to Intra-articular Injection

Adjacent osteomyelitis

Bacteremia

Hemarthrosis

Impending (scheduled inside days) articulation replacement surgery

Infectious arthritis

Joint prosthesis

Osteochondral fracture

Periarticular cellulitis

Poorly controlled diabetes mellitus

Uncontrolled haemorrhage disorder or coagulopathy

Judicious apply of corticosteroids rarely produces pregnant adverse furnishings. The introduction of infection after injection is believed to occur in less than 1 in 10,000 procedures. The concept of steroid arthropathy is largely based on studies in subprimate animal models, and it is an unusual occurrence in humans if the number of injections is limited to three to 4 per twelvemonth in weight-begetting joints. More bourgeois researchers have even advocated limiting articulatio genus injections to three or iv over an individual'due south lifetime.

Methods and Materials

  • Abstract
  • Methods and Materials
  • Procedure Clarification
  • Follow Up
  • Procedure Pitfalls/Complications
  • Physician Grooming
  • References

PATIENT Preparation

Wear is removed from over the affected joint. The patient is placed in the supine position, and the knee is extended (some physicians prefer to take the knee bent to 90 degrees). An absorptive pad is placed beneath the articulatio genus.

EQUIPMENT

Sterile Tray for the Procedure

Place the following items on a sterile sheet roofing a Mayo stand up:

Sterile gloves

Sterile fenestrated drape

2 10-mL syringes

2 21-gauge, 1-inch needles

1 inch of 4 × four gauze soaked with povidone-iodine solution (Betadine)

Hemostat (for stabilizing the needle when exchanging the medication syringe for the aspiration syringe)

Sterile bandage

Procedure Description

  • Abstract
  • Methods and Materials
  • Procedure Clarification
  • Follow Upward
  • Procedure Pitfalls/Complications
  • Physician Training
  • References

  1. The patient is supine on the table with the knee extended (some physicians prefer that the knee be bent to 90 degrees). Some physicians prefer the medial approach for smaller effusions, just the lateral approach will exist discussed here. The articulatio genus is examined to make up one's mind the amount of joint fluid present and to bank check for overlying cellulitis or circumstantial pathology in the joint or surrounding tissues.

  2. The superior lateral aspect of the patella is palpated. The pare is marked with a pen, 1 fingerbreadth above and ane fingerbreadth lateral to this site. This location provides the well-nigh direct access to the synovium.

  3. The pare is done with povidone-iodine solution. The physician should be gloved, although at that place is no consensus as to whether sterile gloves must be used. A 21-gauge, 1-inch needle is attached to a 5- to 20-mL syringe, depending on the predictable amount of fluid present for removal.

  4. The needle is inserted through stretched skin. Some physicians administer lidocaine (Xylocaine) into the pare, but stretching the hurting fibers in the skin with the nondominant hand tin can also reduce needle-insertion discomfort. The needle is directed at a 45-degree bending distally and 45 degrees into the knee, tilted beneath the patella (Figure 1).

  5. In one case the needle has been inserted ane to ¼ inches, aspiration is performed, and the syringe should fill with fluid. Using the nondominant hand to compress the opposite side of the articulation or the patella may aid in arthrocentesis.

  6. One time the syringe has filled, a hemostat can be placed on the hub of the needle. With the needle stabilized with the hemostat, the syringe can be disconnected and the fluid sent for studies. Care should exist taken non to touch on the needle tip confronting the joint surfaces when removing the syringe. A syringe filled with corticosteroid medication can and so be fastened to the needle.

  7. For injection, use betamethasone (Celestone, six mg per mL), one mL, mixed with iii to five mL of 1 pct lidocaine. Alternately, methylprednisolone (Depo-Medrol, 40 mg per mL), one mL, mixed with 3 to five mL of i percent lidocaine tin be used. Later on injection of the medication, the needle and syringe are withdrawn.

  8. The skin is cleansed, and a bandage is is applied over the needle-puncture site. The patient is warned to avert forceful activity on the articulation while it is anesthetized.

TABLE 3

Contraindications to Joint Needle Aspiration

Bacteremia

Clinician unfamiliar with beefcake of or approach to the joint

Inaccessible joints

Articulation prosthesis

Overlying infection in the soft tissues

Astringent coagulopathy

Severe overlying dermatitis

Uncooperative patient

Follow Up

  • Abstract
  • Methods and Materials
  • Procedure Description
  • Follow Upwards
  • Process Pitfalls/Complications
  • Md Preparation
  • References

  • Afterward diagnostic arthrocentesis, appropriate intervention usually will exist dictated past the results of the fluid assay. Joint infections are commonly treated aggressively with intravenous antibiotics. An inflammatory arthritis, such as rheumatoid arthritis, can be treated with disease-modifying medications such every bit methotrexate or penicillamine. Patients with traumatic or encarmine effusions may exist considered for farther orthopedic evaluation.

  • Big effusions can recur and may require repeat aspiration. Anti-inflammatory medications may prove beneficial in reducing joint inflammation and fluid accumulations.

  • Corticosteroid injections for osteoarthritis often provide a brusk-lived benefit. Repeat injections can be considered after six weeks. Large, weight-bearing joints should not be injected more than three times a year.

Process Pitfalls/Complications

  • Abstract
  • Methods and Materials
  • Process Description
  • Follow Up
  • Procedure Pitfalls/Complications
  • Medico Grooming
  • References

  • The Patient Complains of Severe Hurting During the Procedure. Severe hurting during the procedure usually results from the needle coming into contact with the highly innervated cartilaginous surfaces. The needle tin can be redirected or withdrawn when hurting is encountered. Dull, steady movement of the needle during insertion can prevent harm to the cartilage surface from the needle bevel.

  • The Patient'southward Effusion Was Sterile, But Became Infected After the Joint Injection. Introduction of infection into a articulation is a rare upshot, occurring in less than 0.01 percent of injections; however, infection can develop when the needle is introduced into the joint through an area of cellulitis. Severe dermatitis or soft tissue infection overlying a articulation is a contraindication for arthrocentesis. Some physicians advocate that steroid injection should not be performed before excluding joint infection.

  • The Patient Complains That the Joint Hurts Much Worse the 24-hour interval Afterward the Injection Than Information technology Did Earlier the Injection. A recognized complication of steroid injections to joints is the postinjection flare. The flare reaction represents an increase in joint hurting occurring in 1 to 2 percent of persons. The steroid crystals can induce an inflammatory synovitis that ordinarily begins about half dozen to 12 hours later on the injection. The postinjection flare can present with swelling, tenderness, and warmth over the joint that persists for hours or days. If the patient takes anti-inflammatory medications immediately after the injection, they may reduce or arrest this reaction. Aspiration should be performed to rule out articulation sepsis if symptoms persist beyond two to three days.

  • The Patient Develops Joint Instability From Repeated Injections. The most serious complication of repeated injections is joint instability from the development of osteonecrosis of juxta-articular bone and weakened capsular ligaments. Although this complication occurs in less than 1 percentage of patients, it is recommended that injections exist performed no more frequently than every vi to eight weeks, and no more than three times per year in weight-bearing joints.

  • A Large Knee Effusion Re-accumulated Right After Being Drained. Large effusions from the knee joint tin can rapidly re-accumulate. Some physicians advocate placing an elastic wrap around the knee immediately after large effusion drainage.

  • The Patient's Hurting Returned Just a Few Weeks After the Injection. A major disadvantage to intra-articular corticosteroid injections is the short duration of action. The average duration of benefit may exist but ii to three weeks; however, a modest percent of patients with osteoarthritis may take sustained relief afterwards one or two injections.

Figure ane.

The technique described involves insertion of the needle 1 cm above and 1 cm lateral to the superior lateral aspect of the patella. The needle is tilted below the patella at a 45-degree angle.

Physician Grooming

  • Abstract
  • Methods and Materials
  • Procedure Description
  • Follow Upward
  • Procedure Pitfalls/Complications
  • Dr. Grooming
  • References

Experience is important for the proper performance of joint aspiration and injection procedures. Physicians skilled in arthrocentesis ordinarily have had the opportunity to gain experience with a rheumatologist or other md who performs many procedures. Each joint has different anatomic landmarks, and novice physicians may demand to review a textbook for approaches to an unfamiliar joint. Although arthrocentesis is a simple technique with minimal risk, physicians should accept assistance or supervision with their first attempts at whatsoever site. Family physicians wanting to perform arthrocentesis on deep joints, such equally the hip or vertebral joints, should obtain extensive training in these college adventure procedures. Additional training in arthrocentesis is available from the American University of Family unit Physicians.

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Adjusted with permission from Zuber TJ. Office procedures. Baltimore: Lippincott Williams & Wilkins, 1999.

Resources

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Anderson LG. Aspirating and injecting the acutely painful joint. Emerg Med. 1991;23:77–94. ...

Brand C. Intra-articular and soft tissue injections. Austr Fam Doctor. 1990;19:671–80.

Goss JA, Adams RF. Local injection of corticosteroids in rheumatic diseases. J Musculoskel Med. 1993;10:83–92.

Grey RG, Gottlieb NL. Intra-articular corticosteroids: an updated assessment. Clin Orthop. 1983;177:235–63.

Hollander JL. Arthrocentesis and intrasynovial therapy. In: McCarty DJ, ed. Arthritis. 9th ed. London: Henry Kimpton, 1979:402–14.

Leversee JH. Aspiration of joints and soft tissue injections. Prim Care. 1986;13:579–99.

Owen DS, Irby R. Intra-articular and soft-tissue aspiration and injection. Clin Rheum Pract. 1986; Mar/April/ May:52–63.

Owen DS, Weiss JJ, Wilke WS. When to aspirate and inject joints. Pat Care. 1990;24:128–45.

Pando JA, Klippel JH. Arthrocentesis and corticosteroid injection: an illustrated guide to technique. Consultant. 1996;36:2137–48.

Stefanich RJ. Intraarticular corticosteroids in treatment of osteoarthritis. Orthop Rev. 1986;fifteen:27–33.

Schumacher HR. Arthrocentesis of the knee. Hosp Med. 1997;33:60–4.

Office Procedures forms on human knee joint aspiration and injection are provided on pages 1503, 1504 and 1507.

This commodity is one in a series adapted from the Academy Collection book Role Procedures, written for family unit physicians, designed to provide the essential details of commonly performed in-role procedures, and published by Lippincott Williams & Wilkins.

Copyright © 2002 by the American Academy of Family unit Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout merely for his or her personal, not-commercial reference. This cloth may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or afterward invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

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