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Subject: Knee Joint Aspiration and Injection
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Sterile gloves are preferred by some; others use nonsterile gloves and a “no touch” sterile technique.
Skin preparation agent: 70% isopropyl alcohol, povidone-iodine (Betadine), or chlorhexidine gluconate with 70% isopropyl alcohol (ChloraPrep) pads or applicator.
Viscosupplementation agent or steroid for injection as indicated, most commonly 40 to 80 mg of methylprednisolone acetate (Solu-Medrol), 10 to 40 mg of triamcinolone hexacetonide (Aristospan), or 10 to 40 mg of triamcinolone acetonide (Kenalog).
Syringe (3 to 10 mL, for administering medication).
Syringe (20 to 60 mL, for aspirating effusion).
One or two 21- to 22- gauge, 1.25-inch needles (to draw up injecting solutions, with the option of a second needle for performing arthrocentesis).
Straight hemostat for stabilizing the needle if planning to aspirate first and then exchange the medication syringe for the aspiration syringe to inject without entering the joint a second time.
1% lidocaine for use as a local anesthetic as needed and for injection with cortico-steroids.
Red-top tube or vial for laboratory analysis and culture swab with medium for testing as indicated.
Diagnostic evaluation of the cause of an effusion or an unexplained monoarthritis
To limit joint damage from infected or inflamed joint fluid by serial removal of fluid
Symptomatic relief by removing a large effusion or treatment of joint pain or inflammation (usually temporary)
Diagnosis or treatment of a crystal-induced arthropathy
Administration of viscous agents for symptomatic improvement of osteoarthritis
Administration of glucocorticoids for symptomatic improvement of osteoarthritis
Bacteremia or cellulitis overlying the joint
Bleeding diathesis or coagulopathy
Injection of steroids if septic arthritis is suspected or present
Clinician is unfamiliar with the correct approach to the joint
Presence of a joint prosthesis
Lack of response to previous injections or aspirations
Steroid injections should usually be limited to three to four times per year
Poorly controlled diabetes or systemic illness (diabetes or illness may be more difficult to control with injection of steroids)
Therapeutic injection for children and conditions other than those listed previously warrant consideration of a specialty evaluation or recommendation
PITFALL: Limit the use of local infiltration to 1 to 2 mL to avoid causing swelling that would distort the usual landmarks and the ability to palpate the joint.
PEARL: Marcaine can be mixed with the lidocaine to extend the anesthetic effect from approximately 1 hour to between 3 and 4 hours.
PITFALL: Some experts recommend a new needle for each multidose vial and for the actual injection as well as using single-dose vials of unpreserved anesthetic to avoid possible precipitation of the steroid due to the preservative.
PITFALL: This can be done without an assistant, but make sure that sterility is maintained and that the needles are securely on the syringes with a Luer lock to prevent leakage or dislodgement but not so tight that they are difficult to remove during the procedure.
PITFALL: The needle tip should pass easily and not touch nearby structures. Touching the needle to any structures within the joint can cause significant discomfort.
PITFALL: Avoid movement of the needle when removing or reapplying a syringe. Movement of the needle is very painful.
PITFALL: This technique is discouraged, because the needle tip may cause damage to the articular surfaces or the menisci. This direct approach may be acceptable when administering therapeutic viscous solutions (e.g., hyaluronic acid), because the knee cartilage has previously received significant wear.
Infection from arthrocentesis is rare and is believed to occur in <1 in 10,000 procedures.
The knee is vulnerable to injury, and strenuous activity should be avoided in the first 24 hours after injection.
Postinjection flare is a worsening of joint pain 12 to 72 hours after a steroid injection; nonsteroidal drugs may help.
Theoretically, steroids may cause degeneration of the articular surface; limit them to three to four injections per year.