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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

Knee Injection / Drainage

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

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