Knee Joint Injection

Aka: Knee Joint Injection, Knee Joint Aspiration, Knee Arthrocentesis, Prosthetic Knee Arthrocentesis, Total Knee Arthroplasty Joint Aspiration, Intraarticular Knee Injection

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II. Indication

  1. Aspiration
    1. Knee Effusion of unclear etiology
    2. Evaluation for Septic Knee
  2. Injection (Synvisc or Corticosteroid)
    1. Knee Osteoarthritis
    2. Gouty Arthritis affecting the knee
    3. Pseudogout affecting the knee

III. Preparation

  1. Needle
    1. Gauge: 25-27 (injection), 18-20 (aspiration)
    2. Length: 1.5 inches
  2. Syringe: 10 ml (injection) or 30-60 ml (aspiration)
  3. Corticosteroid options
    1. Betamethasone (Celestone) 1 to 2 ml of 6 mg/ml
    2. Methylprednisolone (Depo-Medrol): 1 to 2 ml of 40 mg/ml
    3. Dexamethasone 8 mg
    4. Triamcinolone 40 mg
  4. Anesthetic: 5 to 7 ml
    1. Lidocaine 1% OR
    2. Bupivacaine 0.25% or 0.5%

IV. Technique: Native Knee

  1. Images
    1. OrthoKneeInjectSuperior.jpg
  2. Patient position
    1. Patient supine with knee in slight flexion (15 to 20 degrees)
    2. Prop up knee on towel roll in popliteal space
  3. Sterilize local skin with Betadine or Hibiclens
  4. Ultrasound guidance (optional)
    1. Linear probe 12 MHz
    2. Place probe at the lateral superior aspect of the Patella (see landmarks below)
    3. Direct probe medially
    4. Target is the suprapatellar pouch
  5. Mark needle insertion site based on approach
    1. Lateral Suprapatellar Approach
      1. Palpate superior-lateral Patella aspect
      2. Mark skin superior and lateral to palpated point
        1. One fingerbreadth above Patella margin
        2. One fingerbreadth lateral to Patella margin
      3. Needle Insertion
        1. Angle needle toward medial knee, 45 degrees distally
        2. Angle needle 45 degrees posteriorly (into knee)
    2. Medial Suprapatellar Approach
      1. Knee flexed 60-90 degrees
      2. Insert needle medial to Patellar tendon
        1. Stay parallel to tibial plateau
      3. Risk of Meniscus Injury
    3. Medial Approach
      1. Risk of needle injury to the medial meniscus (uncommon)
      2. Aspirate first, then inject
    4. Inferior Approach
      1. Patient sits with knee at 90 degrees
        1. Allows fluid to settle into dependent position
        2. May localize small effusion to allow aspiration
      2. Insert needle just medial to inferior Patellar pole (and medial to Patellar tendon)
        1. Direct needle toward the lateral joint line
  6. Aspirate first and then inject
    1. Use first syringe to aspirate joint contents
    2. Use hemostat to detach syringe from needle
    3. Attach syringe with Corticosteroid
    4. Inject Corticosteroid mix into joint

V. Technique: Prosthetic Knee

  1. See Periprosthetic Joint Infection
  2. Indications
    1. Suspected Periprosthetic Joint Infection after total knee arthroplasty (TKA)
  3. Preparation
    1. Patient supine with affected knee in slight flexion
  4. Procedure
    1. Use sterile technique
    2. Ultrasound linear probe
      1. Apply Ultrasound probe sterile cover
      2. Start with probe indicator oriented toward patient's head
      3. Place the probe in the prepatellar fossa
      4. Slide the probe superiorly until the effusion is visible (in the suprapatellar space)
        1. Identify landmarks (Quadriceps femoris tendon, Femur, Fat pad)
      5. Rotate the probe 90 degrees to allow for in-plane needle insertion
    3. Prepare needle insertion site
      1. Chlorhexidine
      2. Inject Local Anesthetic at skin surface (e.g. Lidocaine 1 to 2%)
        1. Avoid injecting into effusion
    4. Insert and advance an aspiration needle toward effusion (e.g. 18 gauge)
      1. Use In-Plane technique to follow the needle tip into effusion
      2. Target effusion will be deep to the quadriceps tendon
  5. References
    1. Voorhees and Riveros (2024) Crit Dec Emerg Med 38(3):22-3

VI. References

  1. Pfenninger (1994) Procedures, p. 1036-54
  2. Cardone (2003) Am Fam Physician 67(10):2147-52 [PubMed]
  3. Webb (2024) Am Fam Physician 109(1): 61-70 [PubMed]
  4. Zuber (2002) Am Fam Physician 66(8):1497-1500 [PubMed]

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