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11/21/20171

Knee Injections for Osteoarthritis

Brian Feeley, MDSports Medicine and Shoulder Surgery

UC San Francisco

Outline

Indications for Injections/Aspirations

Injectable medications

Outcomes (covered previously)

How to do a knee injection easily


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Indications for knee aspiration/injection

Diagnostic

• Effusion, especially atraumatic

• Send for cell count, differential, crystals +/- gram stain and culture

Therapeutic

• Osteoarthritis

• Crystal arthropathy

• Inflammatory arthritis

Case 1

42 year old male, BMI 38, comes in with a 3 day history of increased right knee pain and swelling. He thinks he might have had a fall a week ago, but doesn’t remember pain. He has bought a cane and presents with a noticeable limp and large effusion.

• On exam, he has a moderately red joint, and cannot straighten past 10 degrees

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Audience Participation

What is your most likely diagnosis?

1. Acute ACL tear

2. Acute meniscus tear

3. Arthritis

4. Gout

5. Septic Arthritis

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Indications for Aspiration

Rule out septic arthritis

Establish diagnosis of gout

Traumatic etiology (bloody aspiration)

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Results:Yellow fluid58 K WBC65 PMN


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How to interpret aspiration results

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Case 2

55 year old computer scientist with 3 weeks of knee pain and swelling. He has a history of 2 meniscus debridements, and was told he had some mild arthritis 5 years ago at his last surgery. He has a trip in 2 weeks to Istanbul (not Constantinople) and wants to feel good for the trip, so is asking for an injection (also he has a lot of questions).

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Contraindications to steroid injection

Joint infection

Hemarthrosis

Overlying cellulitis

Fracture

Prosthetic joint

Relative contraindications to steroid injection

Corticosteroid injection within past 3-4 months

Coagulopathy

Poorly controlled diabetes


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What is your preferred steroid injection?

1. Depomedrol

2. Betamethasone

3. Kenalog

4. Triamcinolone

5. I don’t do injections

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Corticosteroid injections for knee osteoarthritis


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Corticosteroids: mechanism of action

Anti-inflammatory

Probably inhibit COX-2 and phospholipase-A2, both inflammatory mediators

Goldman: Goldman’s Cecil Medicine, 24th Ed, ch 34 –Immunosuppressing Drugs. Accessed via MD Consult 1/6/2013.

Anesthetic injections cause cell death

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Increased chondrocyte death:Longer duration

More acidic (lidocaine)More concentrated


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Intraarticular corticosteroid for knee OA: American Academy of OrthopaedicSurgeons 2013

Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2nd EditionAmerican Academy of Orthopaedic Surgeons 2013.www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Accessed 11/13/15.

Appropriate treatment

Quality of evidence: Good

Clinically significant short-term pain relief

Consider other options for longer duration pain relief

Intraarticular corticosteroid for knee OA: Osteoarthritis Research Society International 2014

McAlindon TE et al. OARSI Guidelines for the Non-Surgical Management of Knee Osteoarthritis. Osteoarthritis and Cartilage 2014.


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2-year RCT

Patients with knee OA (mild-moderate)

Q3 month triamcinolone or saline knee injection under ultrasound x 2 years

Annual knee MRI, WOMAC q 3 months

140 randomized patients

• Mean age 58 years

• 54% women

Sig more cartilage loss in triamcinolone group compared to saline group

No sig difference in pain between groups


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Risks of steroid injection in the knee Diabetics: increased blood sugar, 300 mg/dl starting as early as 2 hours after, lasting 5 days

(controversial)

Facial flushing: 10% with Kenalog

• 19-36 hours post-injection

Skin or fat atrophy

Post-injection steroid flare: 1-10%

• Synovitis in response to injected crystals

• Within hours - 48 hours post-injection

• More common in soft tissue injections (20% of trigger points) than intra-articular injections

Septic arthritis: 1/3000-1/50,000

• 1-2 days after injectionHabib GS. Clin Rheumatol, 2009.

UpToDate, “Joint aspiration or injection in adults,” 2010.

Intra-articular corticosteroid injections: take home points

Short-term pain relief (6 weeks average)

Small effect on function

No evidence for long-term pain relief

Clinical effect independent of degree of inflammation present

• Don’t need to restrict injection just to those with effusion

Frequency: general practice once every 3-4 months max

• Concern for cartilage toxicity if given q 3 months x 2 years


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Case 3

62 year old male presents with progressive knee pain and a known history of arthritis. He has had NSAIDS, PT, and steroid injections. The last 3 steroid injections haven’t worked as well and he would like to try something different but doesn’t feel ready for surgery.

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What would you recommend?

1. Repeat steroid injection

2. Hyaluronic acid injection

3. PRP injection

4. Stem cell injection

5. Knee replacement

6. Meniscus debridement

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Series of 1 to 5 injections

Thought to decrease pain

May work better for patients without an effusion

May work better for mild to moderate arthritis

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Viscosupplementation

“The experts achieved unanimous agreement in favor of the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to surgery in advanced hip OA; VS is a well-tolerated treatment of knee and other joints OA”

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TConclusions—The year of a TKA, 25% of OA costs are to HA injectionsMost patients try everything the year before TKA (steroid, meds, HA, and


Medicare claims database of 255,000 patients

What is the cost of a stem cell injection to the knee?

1. $100

2. $1000

3. $2500

4. $5000

5. $10000

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V

$500-$1800 per treatment (often recommended to have 3 treatments)No studies have shown marked improvementsNo change in natural historyVery few studies show significant complications

Washington Post 2017

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Take home points—non steroid injections

Hyaluronic acid injections have limited efficacy but low side effects

PRP has limited efficacy but is somewhat expensive

There is no data for stem cell treatments and they are very expensive

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How to do a knee injection

Keep your supplies simple!

• 2 alcohol swabs

• Bandaid

• Cold spray

• Injection (mixed together) 19-22 ga needle

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Where do you like to inject the knee?

1. Superolateral

2. Superomedial

3. Anteromedial

4. Anterolateral

5. Stop asking me if I inject knees!

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Superolateral approachPatient supine (no peeking)

Extend knee

Bump under knee so flexed 10-20 degrees

Superior border patella

Lateral border patella

1cm above

Mark with syringe cover or tip of pen


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Why Superolateral?

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71%

75%

93%


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Why superolateral?

Thank you

Questions?

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