Knee Injections for Osteoarthritis

Brian Feeley, MD
Sports 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)
Results:
Yellow fluid
58 K WBC
65 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

Increased chondrocyte death:

Longer duration
More acidic (lidocaine)
More concentrated

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 Intraarticular corticosteroid for knee OA:
American Academy of Orthopaedic
Surgeons 2013

Treatment of Osteoarthritis of the Knee Evidence-Based Guideline 2nd Edition

American Academy of Orthopaedic Surgeons 2013.
www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf.
Accessed 11/13/15.

Intraarticular corticosteroid for knee OA:

Osteoarthritis Research Society
International 2014

 Appropriate treatment
 Quality of evidence: Good
 Clinically significant short-term pain relief
 Consider other options for longer duration pain relief

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 injection
Habib 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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 Viscosupplementation

 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

Medicare claims database of 255,000 patients

Conclusions—
T year of a TKA, 25% of OA costs are to HA injections
The
Most patients try everything the year before TKA (steroid, meds,
HA, and

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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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 Washington Post 2017

$500-$1800 per treatment (often recommended to have 3 treatments)

No studies have shown marked improvements
No change in natural history
V few studies show significant complications
Very

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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 approach
 Patient 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?

93%

71%
75%
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 Why superolateral?

Thank you

 Questions?

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