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Indications
Injection Indications:
Knee Osteoarthritis
Gouty Arthritis affecting the knee
Pseudogout affecting the knee
Noninfectious inflammatory arthritis
Drainage Indications:
Evaluation of effusion
Symptomatic relief of a large effusion
Crystal-induced arthropathy
Hemarthrosis
Limiting damage from an infectious process
Unexplained joint effusion
Unexplained monarthritis
Contraindications
Relative contraindications:
Severe immunodeficiency
Anticoagulant therapy
Poor response to prior injection
Multiple prior injections
Uncontrolled diabetes (>8.0)
Absolute Contraindications:
Presence of fracture or tumor
Adjacent osteomyelitis
Bacteremia
Hemarthrosis
Within days of joint replacement surgery
Infectious arthritis
Joint prosthesis
Overlying infection in the soft tissues
Severe coagulopathy
Severe overlying dermatitis
Periarticular cellulitis
Injection Supplies
Betadyne / Alcohol Swabs
Sterile gauze / Sterile Band-aid
Cold Spray / Hemostat
Needle: 1.5 inch 25-27 (injection), 18-20 (aspiration)
Syringe: 10 ml (injection) or 30-60 ml (aspiration)
Corticosteroids:
Betamethasone (Celestone) 2 ml of 6 mg/ml
Methylprednisolone (Depo-Medrol): 2 ml of 40 mg/ml
Anesthetic:
Lidocaine 1%: 4 to 7 ml
Bupivacaine 0.25% or 0.5%: 4 to 7 ml
Ropivacaine 0.75%: 4 to 7 ml
Injection / Drainage Procedure
Step 1: Draw up medication (anesthetic BEFORE steroid)
Step 2: Choose Injection / Drainage Approach
"Lateral Suprapatellar Approach"
Palpate superior-lateral aspect of the patella
One fingerbreadth lateral to superolateral aspect
Mark the skin
Needle angle of 45 degrees inferiomedially and
perpendicular to the coronal axis of the knee
"Lateral Midpatellar Approach"
Palpate lateral facet of the patella
One fingerbreadth lateral to the lateral facet
Mark the skin
Needle angle kept parallel to the floor and
perpendicular to the coronal axis of the knee
"Anteriolateral Parapatellar Approach"
"Anteriomedial Parapatellar Approach"
Patient sits with knee flexed at 90 degrees
Allow fluid to settle into dependent position
One fingerbreadth inferior to the inferior pole of the patella
One figerbreadth medial or lateral to the inferior pole
Mark the skin
Needle angle kept parallel to the floor and
angled 30 degrees to the intracondylar notch
Step 3: Sterile Preparation
Step 4: Cold Spray
Step 5: Drain / Inject
Step 6: Bandage
Step 7: Post Injection Instructions
Dominic King D.O.
References
Pfenninger (1994) Procedures, p. 1036-54
Cardone (2003) Am Fam Physician 67(10):2147-52
Zuber (2002) Am Fam Physician 66(8):1497-1500
Overall potency (equivalent dosages)
High potency
Betamethasone 0.6 to 0.75 mg
Dexamethasone 0.75 mg
Medium potency
Methylprednisolone 4 mg
Triamcinolone 4 mg
Prednisolone 5 mg
Prednisone 5 mg
Low potency
Hydrocortisone 20 mg
Cortisone 25 mg
Relative anti-inflammatory potency
High anti-inflammatory potency
Betamethasone 20-30
Dexamethasone 20-30
Medium anti-inflammatory potency
Methylprednisolone 5
Triamcinolone 5
Prednisolone 4
Prednisone 4
Low anti-inflammatory potency
Hydrocortisone 1
Cortisone 0.8
Half Life
Long half-life (36-54 hours)
Betamethasone
Dexamethasone
Medium half-life (18-36 hours)
Methylprednisolone
Prednisolone
Prednisone
Triamcinolone
Short half-life (8-12 hours)
Cortisone
Hydrocortisone