Surgery - Knee Joint Injection Indications • Iniection of corticosteroids are performed to relieve: •Acute attack of crystal arthritis (gout, pseudogout) • Flare of inflammatory arthritis (seronegative arthritis, rheumatoid arthritis, reactive arthritis) • Pain in patients with osteoarthritis. Other substances administered by an intra-articular injection • Yttrium: for chronic monoarticular synovitis • Hyaluronic acid: for pain in patients with osteoarthritis of the knee. Contraindications • Superficial infection or broken skin • Coagulopathy: patients with thrombocytopenia and a high IN should be discussed with a rheumatologist or orthopedic surgeon before a joint injection is attempted • Prosthetic joint. Risks • Discomfort: usually short lived and minor • Septic arthritis: risk is very small (1 in 78,000 in a recent retrospective study from France) • Subcutaneous atrophy: rare but may be permanent • Side effects from systemic absorption of corticosteroids: including facial flushing and transient worsening of diabetic control (uncommon) • Increased pain: this usually lasts for 2-3 days. Procedure Tips • It is good practice to send the joint aspirate for routine crystal study Ch stain, and culture. This establishes if the joint was infected before joins aspiration and corticosteroid injection • Microbiology request forms should provide information on the date, time, and site of joint aspirated. Injecting smaller joints • Hydrocortisone (short acting) should be used for small superficial joints rather than triamcinolone • For MCP joints, 25mg of hydrocortisone and 0.5mL of 2% lidocaine will suffice • Use 23-25G (blue, orange) for small joints such as wrist, MCP. Equipment • Sterile gloves • Isopropyl alcohol swabs • Corticosteroid injection: • Triamcinolone (long acting) for large joints (knee, shoulder) • Lidocaine 1% or 2% • 21G (green) needles • 10mL syringe • 5mL syringe • White-capped universal containers • Elastoplast or cotton wool and sticky tape. Procedure (Medial Approach) • Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent • Position the patient resting on a couch with the leg slightly flexed and supported on a pillow (relaxes quadriceps) • Identify and mark the point of entry just below the midpoint of the patella by indenting the skin with the tip of a syringe • Wash hands and put on the gloves • Draw up 40mg triamcinolone and 2mL of 2% lidocaine • A no-touch technique is essential after cleaning so any mark to identify the point of entry should be made earlier • Wipe the site with alcohol swabs • Attach a 10mL syringe to a green needle • Insert the needle just below the midpoint of patella, aiming behind the patella. Your free hand can apply pressure to move any synovial fluid to the medial side • Intra-articular placement of the needle is confirmed by effortless aspiration of synovial fluid • If the syringe fills up, it can be detached from the needle, the synovial fluid discarded in a specimen pot, and the syringe re-attached to the needle to aspirate more synovial fluid • If there is no suspicion of septic arthritis and, once a significant proportion of synovial fluid has been aspirated, attach the syringe containing a mixture of corticosteroids and lidocaine to the needle • Aspirate a little more to confirm intra-articular, extra-vascular placement and inject the steroid mixture • • If there is any suspicion of septic arthritis, injection of corticosteroids should not be carried out in the same sitting as synovial fluid aspiration: •Signs and symptoms of septic arthritis may be indolent in the immunosuppressed and a high index of suspicion needs to be maintained. The clinical suspicion of septic arthritis is further strengthened by aspirating cloudy or purulent fluid • Withdraw the needle and dress the site with a suitable plaster • Advise the patient to rest the injected area for 24 48 hours. Procedure (Superolateral Approach) For large effusions that distend the suprapatellar pouch. • The needle is introduced above and lateral to the patella at the maximum convexity of the distended pouch • The needle should be aimed inferiorly and medially. Documentation • Date, time, indication, informed consent obtained • Site and approach taken • Aseptic technique used? • How many passes? • Volume and nature of fluid aspirated and tests requested • Type and amount of anaesthetic and steroid used • Any immediate complications • Signature, printed name, and contact details.
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