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) 2 ml of 6 mg/ml
    2. Methylprednisolone (Depo-Medrol): 2 ml of 40 mg/ml
  4. Anesthetic
    1. Lidocaine 1%: 5 to 7 ml or
    2. Bupivacaine 0.25% or 0.5%: 5 to 7 ml

IV. Technique

  1. Images
    1. OrthoKneeInjectSuperior.jpg
  2. Patient position
    1. Patient supine with knee in slight flexion
    2. Prop up knee on towel roll in popliteal space
  3. Sterilize local skin with Betadine or Hibiclens
  4. 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 edge
        2. One fingerbreadth lateral to Patella edge
      3. Needle Insertion
        1. Angle needle 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 hitting 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
  5. 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

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