Knee Injection

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS

Diagnostic Indications

  • To perform a therapeutic trial to differentiate between various causes of a condition
  • To differentiate an intra-articular from an extra-articular cause of pain symptoms

Therapeutic Indications

  • To inject lidocaine or saline to reduce pain and/or inflammation

Indications for Corticosteroid Use

  • Inflammation due to chronic osteoarthritis
  • Persistent pain despite medical therapy

Indications for Hyaluronic Acid Supplementation

  • Osteoarthritis of the knee
CONTRAINDICATIONS
  • Cellulitis or broken skin over the intended entry site for injection or aspiration
  • Anticoagulant therapy that is not well controlled
  • Severe primary coagulopathy
  • Infected effusion of a bursa or a periarticular structure
  • More than three previous injections in the preceding 12-month period (relative)
  • Lack of response to two or three previous injections (relative)
  • Suspected bacteremia
  • Unstable joints (for steroid injection)
  • Joint prostheses
  • Pregnancy (relative)
EQUIPMENT
  • Gloves (sterile or nonsterile)
  • Sterile drapes (optional)
  • Povidone-iodine wipes or alcohol wipes
  • 20- to 25-gauge, 1½-inch needle for injection, in a size appropriate for the site of injection
    • For injection of the knee joint: 1- to 1½-inch, 20-gauge needle
    • For injection of the prepatellar bursa: 1- to 1½-inch, 20- to 22-gauge needle
    • For injection of a Baker's cyst: 1- to 1½-inch, 20-gauge needle
    • For injection of an anserine bursa: 1½-inch, 22- to 25-gauge needle
  • ½-inch, 30-gauge needle, if skin anesthesia is to be given (usually not needed)
  • Single-dose vials of 1% lidocaine
  • Corticosteroid preparation (relative potencies and common doses)
    • For injection of the knee joint: 5 mL 1% lidocaine and 20 to 80 mg methylprednisolone acetate or equivalent
    • For injection of the prepatellar bursa: 3 mL 1% lidocaine and 20 to 40 mg methylprednisolone acetate or equivalent
    • For injection of a Baker's cyst: 5 mL 1% lidocaine and 20 to 80 mg methylprednisolone acetate or equivalent
    • For injection of an anserine bursa: 3 to 5 mL 1% lidocaine and 20 to 40 mg methylprednisolone acetate or equivalent
  • Hyaluronic acid preparation (if used)
    • Hyalgan: Five injections, 1 week apart
    • Supartz: Five injections, 1 week apart
    • Euflexxa: Three injections, 1 week apart
    • Orthovisc: Three injections, 1 week apart
    • Synvisc: Three injections, 1 week apart
  • Adhesive bandage dressing
ANATOMY

Prepatellar Bursa

  • The prepatellar bursa lies subcutaneously, directly superficial to the patella.

Anserine Bursa

  • The anserine bursa lies beneath the common insertion of the semitendinosus, gracilis, and sartorius tendons on the medial aspect of the tibia.

Baker's cyst (popliteal cyst)

  • The popliteal artery and vein and the tibial and common peroneal nerves traverse the popliteal cavity.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Place a dressing at the injection site for 8 to 12 hours.
  • Advise the patient that it is essential that the affected area be rested.
  • Physical therapy, NSAIDs, and hot or cold compresses all may be indicated.
  • Advise the patient to immediately report if he or she develops fever, chills, or any sign of infection.
  • Reexamine the patient if discomfort from the injection does not resolve within 72 hours.
  • Advise the patient that normal bathing is allowed.
  • Consider prescribing an NSAID.
COMPLICATIONS
  • Injection into a vein or artery
  • Introduction of infection into joint space
  • Trauma to articular cartilage
  • Injury to nearby nerves
  • Subcutaneous fatty atrophy (adverse effects)
  • Adverse drug reaction (adverse effects)
  • Injection of steroid into a septic joint
  • Osteoporosis and cartilage damage
  • Tendon rupture
  • Inappropriate diagnosis
  • Reactions to lidocaine
  • Steroid flare
  • Problems with viscosupplementation injection
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