Editing Joint injection

{{Short description|Method of delivering drugs into a joint}}
{{Infobox medical intervention
| name         = Joint injection
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| image        = Hip joint injection by anterior longitudinal approach.jpg
| caption      = [[Ultrasound-guided hip joint injection]]: A skin mark is made to mark the optimal point of entry for the needle.<ref name="YeapRobinson2017"/>
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| specialty    = [[orthopedics]]
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In [[medicine]], a '''joint injection''' ('''intra-articular injection''') is a procedure used in the treatment of [[inflammation|inflammatory joint conditions]], such as [[rheumatoid arthritis]], [[psoriatic arthritis]], [[gout]], [[tendinitis]], [[bursitis]], [[Carpal Tunnel Syndrome]],<ref name="CarpalTunnelReview.com">{{cite web|url=http://www.carpaltunnelreview.com|title=Carpal Tunnel Review|date=25 July 2013|publisher=JohnDRhoads|access-date=25 July 2013|url-status=dead|archive-url=https://web.archive.org/web/20130730124449/http://carpaltunnelreview.com/|archive-date=30 July 2013}}</ref> and occasionally [[osteoarthritis]].<ref name="freedict">{{cite web |url=http://medical-dictionary.thefreedictionary.com/intraarticular+injection |title=intraarticular injection - definition |year=2010 |work=[[TheFreeDictionary.com]] |publisher=Farlex |access-date=9 June 2010}}</ref><ref name="Wen2000">{{cite journal|url=http://www.aafp.org/afp/20000801/565.html|title=Intra-articular Hyaluronic Acid Injections for Knee Osteoarthritis|last=Wen|first=Dennis Y|journal=American Family Physician|date=1 August 2000|volume=62|issue=3|pages=565–70, 572|publisher=American Academy of Family Physicians|pmid=10950213|access-date=9 June 2010|archive-date=24 June 2011|archive-url=https://web.archive.org/web/20110624000820/http://www.aafp.org/afp/20000801/565.html|url-status=dead}}</ref> 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 [[corticosteroid]]s. [[Hyaluronic acid]], because of its high [[viscosity]], is sometimes used to replace [[Bursa (anatomy)|bursa]] fluids.<ref name="Wen2000" /> The technique may be used to also withdraw excess fluid from the joint.<ref name="freedict" />
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==Efficacy in osteoarthritis==
In [[osteoarthritis]], joint injection of [[glucocorticoid]]s (such as [[hydrocortisone]]) leads to short term pain relief that may last between a few weeks and a few months.<ref>{{cite journal | vauthors = Arroll B, Goodyear-Smith F | title = Corticosteroid injections for osteoarthritis of the knee: meta-analysis | journal = BMJ | volume = 328 | issue = 7444 | pages = 869 | date = April 2004 | pmid = 15039276 | pmc = 387479 | doi = 10.1136/bmj.38039.573970.7C }}</ref> Injections of [[hyaluronic acid]] have not produced improvement compared to placebo for knee arthritis,<ref name=Rutjes12>{{cite journal | vauthors = Rutjes AW, Jüni P, da Costa BR, Trelle S, Nüesch E, Reichenbach S | title = Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis | journal = Annals of Internal Medicine | volume = 157 | issue = 3 | pages = 180–91 | date = August 2012 | pmid = 22868835 | doi = 10.7326/0003-4819-157-3-201208070-00473 | s2cid = 5660398 }}</ref><ref>{{cite journal | vauthors = Jevsevar D, Donnelly P, Brown GA, Cummins DS | title = Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence | journal = The Journal of Bone and Joint Surgery. American Volume | volume = 97 | issue = 24 | pages = 2047–60 | date = December 2015 | pmid = 26677239 | doi = 10.2106/jbjs.n.00743 }}</ref> but did increase risk of further pain.<ref name=Rutjes12/> In ankle osteoarthritis, evidence is unclear.<ref>{{cite journal | vauthors = Witteveen AG, Hofstad CJ, Kerkhoffs GM | title = Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle | journal = The Cochrane Database of Systematic Reviews | volume = 2015 | issue = 10 | pages = CD010643 | date = October 2015 | pmid = 26475434 | doi = 10.1002/14651858.CD010643.pub2 | pmc = 9254328 | quote = It is unclear if there is a benefit or harm for HA as treatment for ankle OA }}</ref> 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|date=May 2015}}<ref>{{cite journal | vauthors = Khoshbin A, Leroux T, Wasserstein D, Marks P, Theodoropoulos J, Ogilvie-Harris D, Gandhi R, Takhar K, Lum G, Chahal J | title = The efficacy of platelet-rich plasma in the treatment of symptomatic knee osteoarthritis: a systematic review with quantitative synthesis | journal = Arthroscopy | volume = 29 | issue = 12 | pages = 2037–48 | date = December 2013 | pmid = 24286802 | doi = 10.1016/j.arthro.2013.09.006 }}</ref><ref>{{cite journal | vauthors = Rodriguez-Merchan EC | title = Intraarticular Injections of Platelet-rich Plasma (PRP) in the Management of Knee Osteoarthritis | journal = The Archives of Bone and Joint Surgery | volume = 1 | issue = 1 | pages = 5–8 | date = September 2013 | pmid = 25207275 | pmc = 4151401 }}</ref>

<!--Intra-articular steroid, reviews and side effects-->
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.<ref>{{cite journal | vauthors = Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, da Costa BR | title = Intra-articular corticosteroid for knee osteoarthritis | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD005328 | date = October 2015 | volume = 2015 | pmid = 26490760 | doi = 10.1002/14651858.CD005328.pub3 | pmc = 8884338 | url = http://boris.unibe.ch/73451/1/J%C3%BCni%20CochraneSystRev%202015.pdf }}</ref> Another 2015 study reported negative effects of intra-articular corticosteroid injections at higher doses,<ref>{{cite journal | vauthors = Wernecke C, Braun HJ, Dragoo JL | title = The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review | journal = Orthopaedic Journal of Sports Medicine | volume = 3 | issue = 5 | pages = 2325967115581163 | date = May 2015 | pmid = 26674652 | pmc = 4622344 | doi = 10.1177/2325967115581163 }}</ref> and a 2017 trial showed reduction in cartilage thickness with intra-articular [[triamcinolone]] every 12 weeks for 2 years compared to placebo.<ref>{{cite journal | vauthors = McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ | title = Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial | journal = JAMA | volume = 317 | issue = 19 | pages = 1967–1975 | date = May 2017 | pmid = 28510679 | pmc = 5815012 | doi = 10.1001/jama.2017.5283 }}</ref> A 2018 study found that intra-articular triamcinolone is associated with an increase in [[intraocular pressure]].<ref>{{cite journal|vauthors=Taliaferro K, Crawford A, Jabara J, Lynch J, Jung E, Zvirbulis R, Banka T|title=Intraocular Pressure Increases After Intraarticular Knee Injection With Triamcinolone but Not Hyaluronic Acid|journal=[[Clinical Orthopaedics and Related Research]]|volume=476|issue=7|pages=1420–1425|type=[[Levels of evidence|Level-II]] therapeutic study|date=9 March 2018|doi=10.1007/s11999.0000000000000261|issn=1528-1132|lccn= 53007647|oclc=01554937|pmid=29533245|pmc=6437574}}</ref>

==Ultrasound-guided==
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.<ref name="YeapRobinson2017">Initially largely copied from: {{cite journal|last1=Yeap|first1=Phey Ming|last2=Robinson|first2=Philip|title=Ultrasound Diagnostic and Therapeutic Injections of the Hip and Groin|journal=Journal of the Belgian Society of Radiology|volume=101|issue=S2|pages=6|year=2017|issn=2514-8281|doi=10.5334/jbr-btr.1371|pmid=30498802|pmc=6251072 |doi-access=free }}<br>[https://creativecommons.org/licenses/by/4.0/ Creative Commons Attribution 4.0 International License (CC-BY 4.0)]</ref>

Injections should be performed with adherence to aseptic technique although this varies between institutions and radiologists attributable to resources, training, perceived risk and experience.<ref>{{Cite journal|last1=Stephens|first1=Mark B.|last2=Beutler|first2=Anthony I.|last3=O'Connor|first3=Francis G.|date=2008|title=Musculoskeletal injections: a review of the evidence|url=https://www.ncbi.nlm.nih.gov/pubmed/18953975|journal=American Family Physician|volume=78|issue=8|pages=971–976|issn=0002-838X|pmid=18953975}}</ref> 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.<ref name="YeapRobinson2017"/> 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.<ref name="YeapRobinson2017"/>

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.<ref name="YeapRobinson2017"/>

As an example, [[ultrasound-guided hip joint injection]]<ref>{{Cite web|title=MSK Ultrasound Guided Injection|url=https://r3medicaltraining.com/events/msk-ultrasound-guided-injection-course/|access-date=2021-05-21|website=R3 Medical Training|language=en-US}}</ref> can be considered when symptoms persist despite initial treatment options such as activity modification, analgesia and physical therapy.<ref name="YeapRobinson2017"/>

==References==
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{{Dosage forms|state=expanded}}

{{DEFAULTSORT:Joint Injection}}
[[Category:Rheumatology]]