Joint injection

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Joint injection
Hip joint injection by anterior longitudinal approach.jpg
Ultrasound-guided hip joint injection: A skin mark is made to mark the optimal point of entry for the needle.[1]
Specialtyorthopedics

In medicine, a joint injection (intra-articular injection) is a procedure used in the treatment of inflammatory joint conditions, such as rheumatoid arthritis, psoriatic arthritis, gout, tendinitis, bursitis, Carpal Tunnel Syndrome,[2] and occasionally osteoarthritis.[3][4] A hypodermic needle is injected into the affected joint where it delivers a dose of any one of many anti-inflammatory agents, the most common of which are corticosteroids. Hyaluronic acid, because of its high viscosity, is sometimes used to replace bursa fluids.[4] The technique may be used to also withdraw excess fluid from the joint.[3]

Efficacy in osteoarthritis[edit]

In osteoarthritis, joint injection of glucocorticoids (such as hydrocortisone) leads to short term pain relief that may last between a few weeks and a few months.[5] Injections of hyaluronic acid have not produced improvement compared to placebo for knee arthritis,[6][7] but did increase risk of further pain.[6] In ankle osteoarthritis, evidence is unclear.[8] The effectiveness of injections of platelet-rich plasma is unclear; there are suggestions that such injections improve function but not pain, and are associated with increased risk.[vague][9][10]

A 2015 Cochrane review found that intra-articular corticosteroid injections of the knee did not benefit quality of life and had no effect on knee joint space; clinical effects one to six weeks after injection could not be determined clearly due to poor study quality.[11] Another 2015 study reported negative effects of intra-articular corticosteroid injections at higher doses,[12] and a 2017 trial showed reduction in cartilage thickness with intra-articular triamcinolone every 12 weeks for 2 years compared to placebo.[13] A 2018 study found that intra-articular triamcinolone is associated with an increase in intraocular pressure.[14]

Ultrasound-guided[edit]

Usual standards for musculoskeletal interventional procedures apply include review of previous imaging, informed consent and appropriate local anesthetic. The use of a high-frequency (> 10 MHz) linear array transducer is recommended, but lower-frequency curvilinear probes may be occasionally required to visualize deep structures in larger patients. A preliminary diagnostic sonographic examination, including color Doppler of the area to be punctured is necessary to define the relationship of adjacent neurovascular structures.[1]

Injections should be performed with adherence to aseptic technique although this varies between institutions and radiologists attributable to resources, training, perceived risk and experience. In a survey of 250 health professionals in the United Kingdom, 43.5% believed infection rates were < 1/1000 following intra-articular injections, 33.0% perceived rates were < 1/100, and 2.6% perceived the risk as negligible.[1] Sterile preparation of the entire injection field, including adjacent skin where the gel and probe are applied, is recommended. Areas of superficial infection such as cellulitis or abscess should be avoided to prevent deeper spread.[1]

After planning a safe route of access, a line parallel to the long axis of the transducer is drawn on the skin adjacent to the end of transducer where the needle will be introduced. Once the patient’s skin is sterilized and initial needle entry is made adjacent to the mark, the probe can be returned quickly to the same location and orientation by aligning to the skin mark. The needle is directed toward the intended target by a freehand technique. The needle size, length and type should be selected based on the site, depth and patient’s body habitus. 22–24G needles are sufficed for most injections.[1]

As an example, ultrasound-guided hip joint injection can be considered when symptoms persist despite initial treatment options such as activity modification, analgesia and physical therapy.[1]

References[edit]

  1. ^ a b c d e f Initially largely copied from: Yeap, Phey Ming; Robinson, Philip (2017). "Ultrasound Diagnostic and Therapeutic Injections of the Hip and Groin". Journal of the Belgian Society of Radiology. 101 (S2). doi:10.5334/jbr-btr.1371. ISSN 2514-8281.
    Creative Commons Attribution 4.0 International License (CC-BY 4.0)
  2. ^ "Carpal Tunnel Review". JohnDRhoads. 25 July 2013. Archived from the original on 30 July 2013. Retrieved 25 July 2013.
  3. ^ a b "intraarticular injection - definition". TheFreeDictionary.com. Farlex. 2010. Retrieved 9 June 2010.
  4. ^ a b Wen, Dennis Y (1 August 2000). "Intra-articular Hyaluronic Acid Injections for Knee Osteoarthritis". American Academy of Family Physicians. Retrieved 9 June 2010.
  5. ^ Arroll B, Goodyear-Smith F (April 2004). "Corticosteroid injections for osteoarthritis of the knee: meta-analysis". BMJ. 328 (7444): 869. doi:10.1136/bmj.38039.573970.7C. PMC 387479. PMID 15039276.
  6. ^ a b Rutjes AW, Jüni P, da Costa BR, Trelle S, Nüesch E, Reichenbach S (August 2012). "Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis". Annals of Internal Medicine. 157 (3): 180–91. doi:10.7326/0003-4819-157-3-201208070-00473. PMID 22868835.
  7. ^ Jevsevar D, Donnelly P, Brown GA, Cummins DS (December 2015). "Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence". The Journal of Bone and Joint Surgery. American Volume. 97 (24): 2047–60. doi:10.2106/jbjs.n.00743. PMID 26677239.
  8. ^ Witteveen AG, Hofstad CJ, Kerkhoffs GM (October 2015). "Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle". The Cochrane Database of Systematic Reviews. 10 (10): CD010643. doi:10.1002/14651858.CD010643.pub2. PMID 26475434. It is unclear if there is a benefit or harm for HA as treatment for ankle OA
  9. ^ Khoshbin A, Leroux T, Wasserstein D, Marks P, Theodoropoulos J, Ogilvie-Harris D, Gandhi R, Takhar K, Lum G, Chahal J (December 2013). "The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis". Arthroscopy. 29 (12): 2037–48. doi:10.1016/j.arthro.2013.09.006. PMID 24286802.
  10. ^ Rodriguez-Merchan EC (September 2013). "Intraarticular Injections of Platelet-rich Plasma (PRP) in the Management of Knee Osteoarthritis". The Archives of Bone and Joint Surgery. 1 (1): 5–8. PMC 4151401. PMID 25207275.
  11. ^ Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, da Costa BR (October 2015). "Intra-articular corticosteroid for knee osteoarthritis". The Cochrane Database of Systematic Reviews (10): CD005328. doi:10.1002/14651858.CD005328.pub3. PMID 26490760.
  12. ^ Wernecke C, Braun HJ, Dragoo JL (May 2015). "The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review". Orthopaedic Journal of Sports Medicine. 3 (5): 2325967115581163. doi:10.1177/2325967115581163. PMC 4622344. PMID 26674652.
  13. ^ McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ (May 2017). "Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial". JAMA. 317 (19): 1967–1975. doi:10.1001/jama.2017.5283. PMC 5815012. PMID 28510679.
  14. ^ Taliaferro K, Crawford A, Jabara J, Lynch J, Jung E, Zvirbulis R, Banka T (9 March 2018). "Intraocular Pressure Increases After Intraarticular Knee Injection With Triamcinolone but Not Hyaluronic Acid" (Epub abstract ahead of print). Clinical Orthopaedics and Related Research (Level-II therapeutic study). 476 (7): 1420–1425. doi:10.1007/s11999.0000000000000261. ISSN 1528-1132. LCCN 53007647. OCLC 01554937. PMID 29533245. Retrieved 8 April 2018 – via ResearchGate.