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Knee Joint Injection

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Other Names

  • Knee Injection
  • Intra-articular knee joint injection
  • Cortisone injection of the knee
  • Knee Arthrocentesis

Background

Lateral knee anatomy[1]

Key Points

  • This injection can be done safely with palpation guidance or ultrasound guidance
  • Transducer: high frequency, linear array
  • US guided approach is optimal in the supra-patellar recess
  • Palpation guided approach is typically easier in the anterolateral joint space
  • Arthrocentesis recommended approach is suprapatellar recess

Anatomy of the Knee Joint

  • Formed by the articulation of the distal femur, proximal tibia, patella
  • Multiple significant static and dynamic stabilizers
  • Suprapatellar recess communicates directly with the joint
  • Injections can occur in either the femorotibial or patellofemoral space

Palpation Guidance vs Ultrasound Guidance

  • This procedure can be safely performed by palpation or ultrasound guidance
  • Jackson et all demonstrated 71-93% accuracy with palpation guided injections[2]
  • Curtis et al demonstrated 100% accuracy with ultrasound guidance, 55% accuracy with palpation guidance[3]
  • Jones et al demonstrated 60% accuracy with palpation guidance[4]
  • We recommend ultrasound guidance when possible to increase accuracy and decrease procedural pain
  • Approach may also depend on injectate
    • For example, corticosteroids are likely efficacious without accurate placement where as viscosupplementation must be intra-articular to work

Indications

Contraindications

  • Absolute
    • Anaphylaxis to injectates
    • Overlying cellulitis, skin lesion or systemic infection
  • Relative
    • Can be treated with less invasive means
    • Tendon tear or rupture
    • Hyperglycemia or poorly controlled diabetes
    • Lack of symptom improvement with previous injection

Procedure

Landmarks and location marked for palpation guided injection[5]
Short axis in plane approach in the suprapatellar recess. (A) Transducer and needle position and (B) Ultrasound view of suprapatellar recess with needle in plane[6]
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Short axis view of the suprapatellar recess with in-plane advancement of the needle tip.
(A) Setup for a right knee sonographically guided, lateral-to-medial, suprapatellar joint recess injection. Proximal is left. (B) Sonographic longitudinal view of an effusion in the suprapatellar joint recess between the suprapatellar fat pad and quadriceps tendon. Note that this is a different orientation from that depicted in Fig. 1A. (C) Sonographic transverse view of a lateral-to-medial injection, in plane with the transducer into the suprapatellar joint recess between the suprapatellar fat pad and prefemoral fat pad. Medial is left. (D) Injectate distending the suprapatellar joint recess. Medial is left. ANT, anterior, FEM, femur, LG, longitudinal; MED, medial; PAT, patella; PF, prefemoral fat pad, QT, quadriceps tendon, SP, suprapatellar fat pad, TR, transverse[7]
Midmedial subtpatellar approach with needle and transducer position[1]
Midmedial subpatellar approach ultrasound view with needle in plane. The needle (N) is being advanced medial to lateral angling deep to the transducer between the patella (p) and the medial femoral condyle (MFC) through the joint capsule (JC) in to the synovial envelope of the knee. Not the hypoechoic signal from the lidocaine pooling under the joint capsule serving as a confirmation of intraarticular penetration.[1]

Equipment

  • Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
  • Gloves
  • Needle: typically 21-25 gauge, 1.5 inch
    • Larger 18 gauge, 3.5 inch for arthrocentesis
  • Syringe: 5-10 mL
    • Larger 20-50 mL syringe for arthrocentesis
  • Gauze
  • Ethyl Chloride
  • Bandage
  • Injectate
    • Local anesthetic
    • Corticosteroid
  • Sterile probe cover

Ultrasound Findings

  • Joint Effusion
    • Most noticeable in the superior lateral portion of the knee in the suprapatellar recess
    • Here the recess bulges superolaterally to e patellofemoral articulation
    • Presents as a hypoechoic fluid below the quadriceps tendon and above the prefemoral at pad
    • Can be seen extending down into the joint space
  • Degenerative findings
    • Osteophytes
    • Meniscal extrusion
    • Capsular deformity
    • Chondromalacia of articular cartilage

Palpation Guided Technique: Femorotibial Approach

  • Patient Position
    • The patient is seated, legs hanging off the examination table
  • Landmarks
    • The lateral compartment approach is the simplest and easiest
    • Identify the lateral tibial plateau, femoral condyle and lateral border of the patella tendon
    • Mark the skin just laterally to the tendon between the femur and tibia
    • Note: the same landmarks can be used to enter from the medial joint space
  • Sterilize the skin
  • Provide cutaneous anesthesia as indicated
  • Ethyl chloride is typically sufficient
  • Injection
    • Prior to injection, use your knees to stabilize the patients leg so they do not flinch
    • Needle and syringe should be roughly parallel to the ground
    • Needle vector should be directed into the popliteal fossa
    • Advance needle approximately 1 inch into joint space, redirection may be required
    • Aspirate to ensure no blood return, then inject
    • Inject and if meeting resistance, pull back needle slowly until injection flows easily
  • After procedure, apply pressure to tamponade any bleeding
  • Apply bandage

Ultrasound Guided Technique: Suprapatellar Recess

  • Patient Position
    • Supine
    • Can place towel roll under affected knee
  • Transducer position
    • Short axis to the distal quadriceps tendon
    • Place over effusion for optimal aspiration/injection
  • Needle Approach/ Orientation
    • In plane
    • Lateral to medial
  • Target
    • Suprapatellar recess
    • Effusion, if present
  • Pearls and Pitfalls
    • Technically more difficult with the presence of an effusion
    • Can use anesthetic or sterile water to "find" and create a window in the recess before injecting

Ultrasound Guided Technique: Mid-medial Subpatellar

  • Patient Position
    • Supine
    • Can place towel roll under affected knee
  • Transducer position
    • Mid-medial patella and medial femoral condyle
  • Needle Approach/ Orientation
    • In plane
    • Medial to lateral
  • Target
    • Synovial envelope under the patella
  • Deep to medial patellar retinaculum
    • Pearls and Pitfalls
    • Can be considered as an alternative in the absence of an effusion
    • Can use local anesthetic to confirm placement, will cause retinaculum to bulge outward
    • Although less common, safe technique as there are no significant structures

Aftercare

  • No major restrictions in most cases
  • Can augment with ice, NSAIDS

Complications

  • Infection
  • Damage to surrounding tissue

See Also

References

  1. ↑ 1.0 1.1 1.2 Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
  2. ↑ Jackson D, Evans N, Thomas B. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am 2002;84:1522–1527.
  3. ↑ Curtiss H, Finnoff J, Peck E. Accuracy of ultrasound-guided and palpation-guided knee injections by an experienced and less experienced injector using a superolateral approach: a cadaveric study. PM R 2011;3:507–515.
  4. ↑ Jones A, Regan M, Ledingham J, et al. Importance of placement of intra-articular steroid injections. BMJ 1993; 307:1329–1330.
  5. ↑ Image courtesy of https://www.aafp.org/
  6. ↑ Image courtesy of https://www.aptivahealth.com/
  7. ↑ Lueders, Daniel R., Jay Smith, and Jacob L. Sellon. "Ultrasound-guided knee procedures." Physical Medicine and Rehabilitation Clinics 27.3 (2016): 631-648.
Created by:
Jesse Fodero on 14 July 2019 20:43:07
Last edited:
7 November 2024 19:57:27
Category:
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