Knee Joint Injection Research Articles

Histaminergic Pharmacology Modulates the Analgesic and Antiedematogenic Effects of Spinally Injected Morphine.

Histamine receptors are known to participate in spinal cord nociceptive transmission, and previous studies have suggested that histaminergic receptors are involved in the analgesic effects of morphine. Herein, we investigated the effect of intrathecal injection of histaminergic agonists and antagonists in a model of acute articular inflammation and their interaction with morphine. After carrageenan injection in the right knee joint, articular incapacitation was measured hourly, for up to 6 hours, by the paw elevation time during 1-minute periods of stimulated walking. Inflammatory edema was also assessed hourly by determining an increase in articular diameter. Spinal treatments were administered 20 minutes before knee-joint carrageenan injection and were compared with the saline-treated control group. Intrathecally injected histamine increased incapacitation and articular edema, whereas the H1R antagonist, cetirizine, decreased both parameters. The H3R agonist, immepip, decreased both incapacitation and edema, but the H3R antagonist, thioperamide, increased both incapacitation and edema. Morphine inhibited both incapacitation and edema. Furthermore, combining a subeffective dose of morphine with cetirizine or immepip potentiated the analgesic and antiedematogenic effect. Histamine seems to act at the spinal level via H1 and H3 receptors to modulate acute arthritis in rats. An H1R antagonist and H3R agonist were found to potentiate the analgesic and antiedematogenic effects of morphine, suggesting that histaminergic and opioid spinal systems may be explored for means of improving analgesia, as well as peripheral anti-inflammatory effects.

Synovial macrophages promote TGF-Β signaling but protect against influx of S100A8/S100A9-producing cells after intra-articular injections of oxidized low-density lipoproteins

Purpose: In previous studies we found that synovial macrophages regulate joint pathology during experimental osteoarthritis (OA) and, more recently, we found that high systemic levels of LDL aggravate joint pathology during experimental OA with synovitis. LDL in inflamed synovium is oxidized and taken-up by macrophages via scavenger receptors, leading to an activated macrophage phenotype. In this study, we investigate whether direct injection of oxLDL into a normal murine knee joint induces joint pathology and elucidate the role of synovial macrophages in that process. Methods: Knee joints of C57BL/6 mice were injected at five consecutive days with 6 μL (1.2 mg/mL) oxLDL, LDL, or an equal volume of vehicle (PBS). This same procedure was done in mice which were depleted of synovial macrophages by intra-articular injection of clodronate liposomes seven days prior to the (ox)LDL or vehicle injections. Joint pathology was investigated by immunohistochemistry and FACS analysis, and RNA expression and protein production by synovium were determined using RT-PCR and luminex, respectively. Active TGF-β was measured using a functional CAGA-luciferase assay. Data are depicted as mean±standard deviation. Results: LDL and oxLDL injection in naïve knee joints did not increase synovial thickening, or production of pro-inflammatory factors (IL-1β, IL-6 and S100A8/9) compared to vehicle injection. Levels of active TGF-β in synovial wash-outs was, however, significantly increased by 33% (from 84.7 ng/mL/g synovium±14.4 to 113.0 ng/mL/g synovium±33.3; p<0.05). Immunohistochemistry of total knee joints showed that oxLDL injection decreased formation of aggrecanase-induced neo-epitopes (NITEGE) compared with vehicle injections (3.6 times; p<0.05). In contrast, repeated injections of oxLDL in macrophage-depleted knee joints led to a 3.1 fold increase of synovial thickening, compared with injection of vehicle (p<0.01), while LDL injections did not alter synovial thickening. Protein and RNA levels of chemokines CCL2 (Mcp-1) and CCL3 (Mip-1α) were significantly upregulated in macrophage-depleted joints after oxLDL injections (6.7 fold and 4.6 fold, respectively; p<0.01). FACS-analyses revealed increased presence of monocytes and polymorphonuclear granulocytes (PMN) in the synovium, which was confirmed with immunohistochemical staining for NIMP.R14. Also protein levels of S100A8/A9, markers for inflammation, were significantly increased in synovial wash-outs of oxLDL injected joints, compared with LDL (fold increase 5.6; p<0.05) or vehicle (fold increase 8.3; p<0.01) injection, as was NITEGE expression (fold increase 1.92; p<0.05). Interestingly, no raise in active TGF-β was measured in these macrophage-depleted joints. Conclusions: Synovial macrophages promote anabolic effects after oxLDL injections in knee joints, supporting earlier studies which show increased ectopic bone formation during LDL-rich conditions in experimental osteoarthritis. In absence of synovial macrophages, however, oxLDL induces monocyte and PMN influx, production of pro-inflammatory mediators and aggrecanase activity, thereby increasing catabolic activity.

Safety of bathing on the day of knee joint injection

Safety of bathing on the day of knee joint injection

Cationic PLGA/Eudragit RL nanoparticles for increasing retention time in synovial cavity after intra-articular injection in knee joint.

Positively surface-charged poly(lactide-co-glycolide) (PLGA)/Eudragit RL nanoparticles (NPs) were designed to increase retention time and sustain release profile in joints after intra-articular injection, by forming micrometer-sized electrostatic aggregates with hyaluronic acid, an endogenous anionic polysaccharide found in high amounts in synovial fluid. The cationic NPs consisting of PLGA, Eudragit RL, and polyvinyl alcohol were fabricated by solvent evaporation technique. The NPs were 170.1 nm in size, with a zeta potential of 21.3 mV in phosphate-buffered saline. Hyperspectral imaging (CytoViva®) revealed the formation of the micrometer-sized filamentous aggregates upon admixing, due to electrostatic interaction between NPs and the polysaccharides. NPs loaded with a fluorescent probe (1,1′-dioctadecyl-3,3,3′,3′ tetramethylindotricarbocyanine iodide, DiR) displayed a significantly improved retention time in the knee joint, with over 50% preservation of the fluorescent signal 28 days after injection. When DiR solution was injected intra-articularly, the fluorescence levels rapidly decreased to 30% of the initial concentration within 3 days in mice. From these findings, we suggest that PLGA-based cationic NPs could be a promising tool for prolonged delivery of therapeutic agents in joints selectively.

Comparative study of the physicochemical indexes and clinical effects of platelet-rich plasma and sodium hyaluronate on knee osteoarthritis treatment

Objective To compare the clinical effect of platelet rich plasma and sodium hyaluronate in the treatment of knee osteoarthritis. Methods According to the different treatment methods,100 patients with knee osteoarthritis were divided into the control group(for treatment of platelet rich plasma)and study group(for treatment of sodium hyaluronate), each group 50 cases.The treatment effect would be compared between two groups, and the patients were scored knee joint active function using Lysholms score standard, using visual analogue score method on patients with knee joint pain. Results The excellent and good rate had no significant difference between the study group (98.0%)and control group(94.0%)(P> 0.05); The knee joint activity of study group(76.81±9.24) was significantly better than that of the control group(60.46±7.41),the difference was statistically significant(t=- 9.76,P<0.05);the knee joint pain degree of the study group(1.91±0.88)was lower than that of the control group(3.58±0.85),the difference was statistically significant(t= 9.65,P<0.05). Conclusion Platelet rich plasma and the knee joint injection of sodium hyaluronate in the treatment of osteoarthritis were able to effectively alleviate knee joint pain, activity limitation and other clinical symptoms, improve the curative rate, but the treatment effect of sodium hyaluronate is more remarkable, which is worthy of promotion. Key words: Blood proteins; Glass sodium; Osteoarthritis; Injections, intra-articular

Emergency nursing in Ghana: Outcomes after a five year pilot program

and Pharmacy School (FMP) and State University Hospital (HUEH) have not been able to provide this from year to year. The University of California Haiti Initiative (UCHI) hopes to implement a collaborative rheumatologic training program between the University of California Los Angeles (UCLA) and UEH, in attempt to rebuild medical and teaching capacity in rheumatology. Structure/Method/Design: Dr. Belliot, a Haitian Internist at UEH, was selected by UEH FMP administration to complete a five week observership atUCLA inAugust 2014,where she learned rheumatologic physical exams, joint injections, and principles of rheumatic disease. She is currently completing one year of clinical training at UEH and will manage rheumatology patients under the supervision of Dr. Rebecca Gordon (UCLA) via telecommunications, and on-the-groundbyDr. Else Chalumeau (HUEH Chief of Internal Medicine). From November 2014eOctober 2015,Dr. Belliot will be assessed regularly on theoretical knowledge and clinical skills periodically upon visits to HUEH by Dr. Gordon. We are building a network by recruiting rheumatologists worldwidewho can both deliver lectures at distance and visitDr.Belliot to co-host rheumatology weeks where patients will be seen at higher volume. Subsequent years will be dedicated to teaching methodologies and epidemiologic research. Outcomes & Evaluation: Dr. Belliot is currently managing 17 patients: 2 systemic lupus erythematosus (SLE), 7 rheumatoid arthritis (RA), and 8 osteoarthritis. Her SLE patients are improving with no renal involvement. All knee joint injections have been performed successfully to date. Her first clinical evaluation will occur in January 2015 by Dr. Gordon and Dr. Chalumeau. Written examinations are under development. We are keeping record of: 1) Number of outpatient rheumatology clinics held at HUEH 2) Number of patients seen at the rheumatology outpatient clinic 3) Number of inpatient rheumatology consults delivered 4) Increased availability of antirheumatic drugs at HUEH 5) Number of lectures delivered at HUEH Before-and-after comparisons of patient volume will be used to assess impact after the 3rd quarter (8-month mark). Going Forward: Grow network of mentoring rheumatologists worldwide Build laboratory capacity at HUEH Advocate for essential rheumatology drugs to be incorporated in the national essential medicines list (NEML). Conduct secondary analysis of hospital records. Funding: International League of Associations for Rheumatology DirectRelief. Abstract #: 01ETC007

Intra-articular intervention by hyaluronic acid for knee osteoarthritis can modify locomotor pattern of muscle activity

To evaluate the muscle activation pattern of lower extremities can be modified by intraarticular injection of hyaluronic acid( IAHA). Twenty-three subjects with knee OA and 14 age-matched non-knee OA control subjects were recruited from an outpatient clinic. Three-dimensional gait analysis with using the MA- 100 EMG system was applied to measure the muscles activities. The quadriceps (QUA), hamstrings (HAM), tibialis anterior (TA), and medial gastrocnemius (MG) muscles were selected for this study. For the knee OA group, bilateral IA knee joint injections with HA were performed. During the stance phase of gait cycle, the quadriceps, hamstring, and tibialis anterior muscles had longer muscle contraction duration in the knee OA patients as compared with the control group. The muscle activities of quadriceps, hamstrings, tibialis anterior, and medial gastrocnemius muscles recovered to a pattern similar to the control group after the completion of IA HA injections in knee OA patients. The H/Q ratio improved significantly after the IA HA injections, and also lasted up to a period of six months (p<0.01). IA HA is an available treatment option as it effectively decreases co-contraction and improves motor activity of the lower extremity muscles. The improved muscle activities lasted up to a period up to six months.

Comparison between needles with knee joint injection for the osteoarthritis of the knee joint

Comparison between needles with knee joint injection for the osteoarthritis of the knee joint

Aspiration and Injection of the Knee Joint: Approach Portal

Aspiration and injection of the knee joint is a commonly performed medical procedure. Injection of corticosteroid for the treatment of osteoarthritis is the most common reason for knee joint injection, and is performed as an office procedure. Debate exists among practitioners as to the 'best' approach portal for knee injection. This paper examines the various approach portals for injection and/or aspiration of the knee joint, as well as the accuracy of each approach. Searches were made of electronic databases, and appropriate papers were identified and hand-searched. Although there is some evidence that particular approach portals may be more efficacious in the presence of specific knee joint pathologies, generally, in experienced hands, it is of no clinical consequence as to which approach portal is utilised for aspiration or injection of the knee joint. No approach portal is 100% accurate, and the accuracy of injection of the knee joint may be enhanced by the use of techniques such as ultrasound. Practitioners are reminded that they should continuously refine and practice their preferred technique. Knee joint aspiration and injection is a common, simple, and generally safe office procedure.

Increased physical activity severely induces osteoarthritic changes in knee joints with papain induced sulfate-glycosaminoglycan depleted cartilage

IntroductionArticular cartilage needs sulfated-glycosaminoglycans (sGAGs) to withstand high pressures while mechanically loaded. Chondrocyte sGAG synthesis is regulated by exposure to compressive forces. Moderate physical exercise is known to improve cartilage sGAG content and might protect against osteoarthritis (OA). This study investigated whether rat knee joints with sGAG depleted articular cartilage through papain injections might benefit from moderate exercise, or whether this increases the susceptibility for cartilage degeneration.MethodssGAGs were depleted from cartilage through intraarticular papain injections in the left knee joints of 40 Wistar rats; their contralateral joints served as healthy controls. Of the 40 rats included in the study, 20 rats remained sedentary, and the other 20 were subjected to a moderately intense running protocol. Animals were longitudinally monitored for 12 weeks with in vivo micro-computed tomography (μCT) to measure subchondral bone changes and single-photon emission computed tomography (SPECT)/CT to determine synovial macrophage activation. Articular cartilage was analyzed at 6 and 12 weeks with ex vivo contrast-enhanced μCT and histology to measure sGAG content and cartilage thickness.ResultsAll outcome measures were unaffected by moderate exercise in healthy control joints of running animals compared with healthy control joints of sedentary animals. Papain injections in sedentary animals resulted in severe sGAG-depleted cartilage, slight loss of subchondral cortical bone, increased macrophage activation, and osteophyte formation. In running animals, papain-induced sGAG-depleted cartilage showed increased cartilage matrix degradation, sclerotic bone formation, increased macrophage activation, and more osteophyte formation.ConclusionsModerate exercise enhanced OA progression in papain-injected joints and did not protect against development of the disease. This was not restricted to more-extensive cartilage damage, but also resulted in pronounced subchondral sclerosis, synovial macrophage activation, and osteophyte formation.

Optimal Needle Placement for Ultrasound-Guided Knee Joint Injections or Aspirations

Although the inferomedial and inferior midline approaches are commonly used for intra-articular injection or aspiration of the knee joint, they may not be ideal for optimal needle placement. With these approaches, the fat pad may be contacted, which may lead to the injection of medication in the incorrect region, cause severe pain during the injection procedure, or present a false sign of low yield of fluid aspiration. Therefore, the objective of this study was to compare various approaches for knee injection and aspiration to identify the optimal one for needle placement. In this retrospective study, the ultrasound images of bilateral knee joints in 33 consecutive patients with knee pain were studied. This patient population was divided into two groups: Group A with knee effusions (n=10) and Group B without knee effusions (n=23). The results showed that among 90% of patients in Group A and 100% of patients in Group B, the superolateral view allowed visualization of the greatest amount of intra-articular knee fluid and the least amount of fat pad. In conclusion, the ultrasound-guided superolateral approach appears to be an optimal approach for knee intra-articular injection or aspiration compared to the conventional inferomedial and inferior midline approaches.

Anti-nociceptive Effect of Entada Phaseoloides Seeds Formulation after Topical Application in Arthritic Wistar Rats

To study the effect of topical application of different formulations of Entada phaseoloides seeds for analgesic activity in arthritic wistar rats. EP (Entada Phaseoloides) seeds were powdered after removing the shell. Paste was prepared by adding water and ointment with polyethylene glycol (PEG 400) & Carbowax 3350. 32 Wister rats of either sex weighing 150-200 gms were divided into four groups ,Gr-I vehicle, Gr-II EP paste, Gr-III EP Ointment, Gr-IV Diclofenac Sodium Ointment. For induction of arthritis 0.1ml Complete Freund's Adjuvant (CFA) was given by intra-articular injection in left knee joint. Drug treatment was started on the same day by topical application in all groups respectively. Pain threshold for referred pain was measured on Randall Selitto analgesymeter before and after drug treatment. At 0 hours pain threshold of animals from all the groups was approximately similar. Pain threshold in control group was statistically significantly decreased at 72 hours. In comparison with control there was significant (p<0.001) increase in the pain threshold in the EP treated groups after 72 hours. Both the formulations of EP have analgesic activity comparable to Diclofenac sodium.

Corticosteroid injection into the osteoarthritic knee: drug selection, dose, and injection frequency

Although some disagreement exists amongst practitioners as to the efficacy of corticosteroid injection into the osteoarthritic knee, this procedure remains the most common reason to perform knee joint injection. There is disagreement too over the most efficacious corticosteroid for the procedure; the dose required at injection; the frequency, and total quantity of corticosteroid that can be injected into the knee. This paper examines the controversies surrounding the efficacy of corticosteroid injection into the osteoarthritic knee, and attempts to provide guidance as to appropriate corticosteroid selection, dose, and treatment interval. Searches were made of electronic databases, and appropriate papers were identified and hand-searched. Although numerous investigations have been conducted in an attempt to identify the optimal corticosteroid agent, and its optimal dosing regimen for the intra-articular treatment of osteoarthritis, a consensus has not been established. The current recommendations for dosing interval appear to have arisen as a consequence of a misinterpretation of previously published works. This paper recommends that practitioners refine and individually tailor their selection of agent and dosing regimen to patient needs and clinical response.

Ultrasound-Guided Intra-Articular Knee Injection in an Obese Patient

A 35-yr-old woman was referred to our outpatient clinic for a right intra-articular knee aspiration and injection. She had a medical history notable for lymphedema and morbid obesity (Fig. 1). Her body mass index was recently calculated at greater than 60 kg/m(2). She had a history of four previous nonguided knee joint injections performed elsewhere that provided no significant improvement in pain. On physical examination, it was difficult to localize common knee joint bony landmarks, including the medial and lateral borders of the patella (Fig. 2). Consequently we opted to utilize ultrasound guidance for the knee joint injection via the technique described herein.

Comparison of Sonographically Guided Intra‐articular Injections at 3 Different Sites of the Knee

Sonographically guided injections show more accuracy than blind injections, but there are no reports comparing sonographically guided intra-articular injection approaches. This study examined the accuracy of sonographically guided intra-articular injections at 3 different sites of the knee using medial, midlateral, and superolateral portals. Sonographically guided intra-articular injections and radiology evaluations were performed on 126 knees with osteoarthritis (Kellgren-Lawrence grade 2 or 3). Six milliliters of mixed material containing 1% lidocaine (1 mL), 20 mg of triamcinolone (1 mL), and a nonionic contrast agent (4 mL) was injected into the intra-articular space of the knee through the medial, midlateral, and superolateral portals. After the sonographically guided intra-articular injection into the knee joint, a radiographic image was taken to determine whether the injected material had reached the intra-articular space or infiltrated into the soft tissue. Sonographically guided intra-articular injections in the midlateral portal (95%; P < .05) and superolateral portal (100%; P < .05) showed significantly higher accuracy than injections in the medial portal (75%). Sonographically guided intra-articular injections in the midlateral or superolateral portal may increase the accuracy of knee joint injections.

Accuracy of blind versus ultrasound‐guided suprapatellar bursal injection

To compare the accuracy rates between ultrasound (US)-guided and blind knee intra-articular injection via the suprapatellar bursa. Ninety-nine patients with radiographically confirmed knee osteoarthritis (Kellgren/Lawrence grade 2 or 3) without effusion were included. Fifty patients were assigned to the US-guided injection group and 49 to the blind injection group. After a US-guided or blind injection of hyaluronic acid (HA) and contrast dye through the suprapatellar bursa into the knee joint, a radiographic image was obtained in each case to ascertain whether all injected material had reached the intra-articular space. US-guided HA injection exhibited a significantly greater accuracy (48 of 50 knees, 96.0%) than blind injection (41 of 49 knees, 83.7%). Intra-articular injections through the suprapatellar bursa under US guidance increased the accuracy of knee joint injections.

The effect of joint aspiration and corticosteroid injections in osteoarthritis of the knee

To evaluate the benefits of knee joint aspiration and injection in knee osteoarthritis (OA). A retrospective, pilot study involved 110 patients with knee OA from a dedicated OA clinic in a Melbourne tertiary hospital from 2007 to 2009. Only those who had completed two Multiple Attribute Prioritization Tool (MAPT) questionnaires within 6 months of the initial review were included. The MAPT was designed to help prioritise patients on orthopedic waiting lists. Three groups were analyzed: patients who had no corticosteroid injection or aspiration, patients who received corticosteroid injections, and patients who received both joint aspiration with corticosteroid injections. Patients who had both joint aspiration and injection reported an improvement in pain compared with those who had no injection (56.3%vs. 32.2%, P = 0.03). Those who had joint injections also did better than those without injection (62.7%vs. 32.2%, P = 0.001). Reduced analgesia use was noted in 12.5% of patients with aspiration and injection compared with 1.7% with no injection or aspiration (P = 0.03). Improved walking distance was noted in 22.4% of patients who had injections compared with 8.5% of patients with no injections (P = 0.03). No significant differences in MAPT scores among the different treatment groups were noted. This pilot study appears to show a beneficial trend in giving corticosteroid injections and to aspirate the knee in OA patients. Further studies are needed to address the mechanical benefits, quadriceps strengthening and pain reduction with knee aspiration, as well as the effects that different volumes of fluid may have on knee mechanics and symptoms.

Accurate intra-articular knee joint injection in the obese? ’Fat Chance!’—A clinical lesson and recommendations for secondary referral

Corticosteroid joint injections are perceived as being an effective treatment for symptomatic knee osteoarthritis, with a very low risk of complications. While the procedure is often performed in secondary care by orthopaedic surgeons and rheumatologists (and trainees in either specialty), the role of general practitioners (GPs) in chronic disease management has long existed with joint injections also frequently performed in primary care. The perception that serious complications from corticosteroid knee joint injections are rare and that their benefits in treating symptomatic knee osteoarthritis significantly outweigh the risks has not been well addressed. We present a case of a 71-year-old obese female who presented to her general practitioner (GP) with worsening left knee pain and radiographic changes consistent with osteoarthritis. She was administered a corticosteroid joint injection, which gave minimal relief, and over the next few days resulted in worsening severe pain, erythema and swelling. She returned to the GP who commenced oral antibiotics and referred her to casualty. A large knee abscess was diagnosed and intravenous antibiotics were commenced. The patient was admitted under the orthopaedic surgeons with her treatment consisting of multiple surgical procedures over a prolonged duration. Although lengthy, her postoperative recovery was unremarkable. Based on this case report and our review of the literature, we highlight the potential complications associated with corticosteroid knee joint injections and suggest certain patients for whom we would recommend secondary referral before any intervention in primary care.

The efficacy, accuracy and complications of corticosteroid injections of the knee joint

Corticosteroid knee injections are being increasingly used in the conservative management of knee osteoarthritis. The procedure is usually performed in secondary care by orthopaedic surgeons and rheumatologists, but as the role of general practitioners in chronic disease management expands, joint injections are now frequently being performed in primary care. It is commonly perceived amongst clinicians that the benefits of corticosteroid knee joint injections in treating symptomatic knee osteoarthritis significantly outweigh the risks of complications. The evidence in the literature for the benefits, accuracy, safety and complications of corticosteroid knee injections in osteoarthritis is reviewed. The perception that serious complications are rare is addressed, and the incidence of infectious complications is estimated. Short-term symptomatic relief is the only evidence-based benefit of corticosteroid injection of an osteoarthritic knee. Accurate intra-articular placement is not achieved in up to 20% of injections and varies considerably with the anatomical approach used. There is no evidence that a medial approach is more accurate. The incidence of serious infectious complications following knee joint injections ranges widely, and may be as high as 1 in 3,000 and potentially far higher in high-risk patients for whom specialist management is advised.

Dependency of nociception facilitation or inhibition after periaqueductal gray matter stimulation on the context

Anxiety and/or fear can alter the nociceptive response in humans and animals. Slight stimulation of the dorsal periaqueductal gray matter (DPAG) produced anxiety/fear-related behaviour and hyponociception in escapable, non-anxiogenic nociceptive models. Our aim was to investigate the role of the DPAG in models of persistent, anxiogenic nociception. GLY (1, 10, 20, and 80 nmol/0.3 μl/60 s) was injected into the DPAG of rats, 5 min before formalin (2%/50 μl) injection either into the knee-joint or hind paw. In the knee-joint incapacitation test, GLY caused hypernociception at lower doses and hyponociception at higher doses. In the paw shacking test, GLY produced only hypernociception with the higher dose. Co-injecting GLY with 7-chlorokynurenic acid (7-CLK) or (+/−)-3-amino-1-hydroxy-2-pyrrolidone (HA-966) completely prevented the GLY effects in incapacitation and paw shacking tests, respectively. GLY injections outside the periaqueductal gray matter (PAG) did not change the nociception. Behavioural analysis indicated that formalin paw injection produced higher stress signals than knee-joint injection, as diminished exploratory behaviour, and stereotypy. The results suggest that activation of the DPAG through the GLY B/NMDA receptor is able to produce either facilitation or inhibition of nociception depending on the nociceptive context.