Intra Artikular

Injection
to Treat Joint
Disorder
Lita Diah
Rheumatology Division
Internal Medicine Department
Airlangga Medical School- Dr Soetomo Hospital
 What is Intra articular
Injection
• Intra articular injection is particularly given to
people who have acute or chronic pain in joints,
which does not subside with oral medication for
pain or inflammation.
• The joints in which the injection can be given are
knees, shoulder, hips, spine, joints of hands and
feet and sometimes even between breastbone
and ribs.
 Conditions related
Intra-Articular injection
• Intra-articular peripheral joint injections
recommended to patients who have not had
success with mild analgesics and NSAIDs.
• To treat patients who may not be suitable
candidates for surgery because of potential
health conditions.
• physicians routinely perform intra-articular
peripheral joint injections to treat inflammatory
conditions in a variety of joints.
 What Is Intra Articular
Injection?
• an injection given in a joint to treat
pathology knee conditions
• In the procedure, the affected joint is
injected with a hypodermic needle,
through which anti-inflammatory agents
• This procedure is also used to remove
extra fluid from the joint.
 How Does Intra Articular
Injection Work?
• reduce inflammation : macrophages, mast cells,
lymphocytes, inflammation mediators like
interleukin-1, prostaglandins and leukotrienes.
• non-inflammatory condition like osteoarthritis
helps prevent degradation of cartilage.
• Hyaluronan can be used with the injection to
lubricate the joint and improve the motion
range. It is usually done when there is cartilage
damage or reduced synovial fluid
Radiology OA
 Homeostasis OA
• ↓ Viskosity HA1

• Chondroprotective effect
HA ↓2

• Inflammation synovial ,
increase permeability,
activity proinflamation ↑,
synovitis 2

• Breakdown cartilage,
cysta subchondral 3
1. Balazs EA, Denlinger JL. J. Rheumatol 1993;20(Suppl 39):3-9.
2. Pelletier JP, Martel-Pelletier J. J Rheumatol 1993;20(Suppl 39):19-24.
3. Abatangelo G et al. Clin Orthop 1989;241:278-85.
 Therapeutic of Hyaluronic Acid (HA)
• HA preparations have a short half – life;
therefore and have the long term effects
• The term biosupplementation is the
restoration of joint rheology, anti –
inflammatory and anti – nociceptive effects,
normalization of endogenous hyaluronic acid
synthesis, and chondroprotection.
 Therapeutic of Hyaluronic Acid (HA)
Hyaluronan (HA) is a high molecular weight non-sulfated
glycosaminoglycan.
It is produced by hyalocytes of the synovial membrane
and is present basically in synovial fluid, vitreous humor
and skin.
Substantial evidence shows that reactive oxygen species
(ROS) are responsible for HA degradation in inflammatory
diseases, such as osteoarthritis, rheumatoid arthritis or
chronic hepatitis.
 Therapeutic of Hyaluronic Acid (HA)
• HA involvement in activation and modulation of the
inflammatory response includes its antioxidant
scavenging activity towards ROS, such as hydroxyl
radical species (OH).
• In vitro protection of HA against radical
depolymerization has been achieved by some drugs,
mostly antioxidants and/or free-radical scavengers.
• Mannitol, thiourea, propofol have an antioxidant
activity by scavenging .Several studies have evidenced
the role its in the protection of HA against ROS.
Mechanism of action of intra-articular
steroid injections
• anti-inflammatory properties in celullar level
• highly lipophilic, bind to the cell’s nucleus,
• influence altering transcription.
• reduce the number of lymphocytes,
macrophages, and mast cells
• reduces phagocytosis, lysosomal enzyme
• decreased of inflammatory mediators such as
interleukin-1, leukotrienes, and prostaglandins
• pain symptoms often are improved.
 Why local injection?
• Hollander introduced local corticosteroid
injection therapy for treatment of
inflammatory arthritis in 1951 ( 100.000
injection, 4000 patient), improved joint pain
• Reported medical benefits of intra-articular
injection because they are injected locally
• Avoid the systemic effects of oral steroids,
including muscle weakness, skin thinning,
peptic ulceration, and induced diabetes.
 Equipment
• All needles and syringes must be of single-use
disposable Have available 1 ml, 2 ml, 5 ml, 10 ml
and 20 ml sterile syringes; 50 ml syringe for
aspiration
• Needles Use a large bore, such as 21G, sterile in-
date needle for drawing up the drugs.The size of the
infiltrating needle depends on the size of the
individual patient
• successfully infiltrate deep structures such as the
hip joint or psoas bursa. It is better to use a longer
needle
 Aseptic Technique
• Remove watches and jewelry
• Mark injection site with closed end of sterile needle
guard, then discard
• Clean injection site with appropriate cleanser allow 1 min
• Wash hands for 1 min; dry with disposable paper towel
• Use pre-packed, in-date, sterile disposable needles and
syringes
• Use single-dose ampoules or vials, then discard them
• Do not touch skin after marking and cleansing the
injection site
• When injecting joints, aspirate to check that any fluid
does not look infected
 Comfortable
• Maintain a calm confident approach throughout the
procedure and keep a conversation going.
• Avoid letting the needle-phobic patient see the
needle
• Three simple rules helps to make the procedure
relatively painless:
strongly stretch skin between finger and thumb
hold needle close to and perpendicular to skin
insert needle rapidly just into epidermis.
 Injection Techniques
• Injection site clearly identified
• Immediate injection site cleaned with alcohol swab
• Use of local anesthetic on skin / subcutaneous tissues
overlying the injection site optionalDo not inject
directly into tendon or ligament
• Reposition needle if resistance encountered
• Aspirate to avoid intravascular deposition of medicine
• Immediate injection site cleaned with alcohol swab
 Contraindication
• Overlying cellulitis*
• Severe coagulopathy
• Anticoagulant therapy
• Septic effusion
• More than three injections per year in a weight-bearing joint
• Lack of response after two to four injections
• Bacteremia*
• Unstable joints
• Inaccessible joints (i.e. facet joints of spine)
• Joint prosthesis*
• Evidence of surrounding osteoporosis
• Recent intra-articular joint osteoporosis
• History of allergy or anaphylaxis to injectable pharmaceuticals
 Post-Injection Care
• Pain relief following joint or soft tissue
injection with local anesthetic may indicate
appropriate structure infiltrated.
• Avoid poly-injection syndrome
• Not be performed more than three times per
year
• Separated by six or more weeks.
 Efficacy study about HA
• Meta – analysis, 5257 participants
• 40 Randomized Controlled Trials (Curran, 2010; National
Collaborating Center for Chronic Conditions at the Royal
College of Physicians, 2008).
• These studies were performed single or double – blind,
with different types of hyaluronic acid (low and high
molecular weight) against placebo.
• The number of injections ranged from 3 to 5 weekly
• The percentages of improvement from baseline, in all the
outcome, were 28 % to 54 % for pain, and 9 % to 32 %
for function, and were similar in the trials where low
molecular weight or high molecular weight
Thank You