knee injections for osteoarthritis - ucsfcme.com injections for osteoarthritis ... treatment of...
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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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Viscosupplementation
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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
Viscosupplementation
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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