Joint injections for GPs

Tonight I an giving a talk to local GPs about injecting joints.

The handout is here which may be of use to any doctors who do this! Its just my opinion on the matter so not to be taken as hard fact...

Here is the text:

Charles Willis-Owen's opinion on injecting knees

I'm not a big enthusiast of injecting arthritic knees with steroid. It is important to consider the risks versus the benefits, and the likely outcome.

Risks: Septic arthritis: When carried out in a sterile environment with no touch aseptic technique the risk of septic arthritis very low perhaps about 1 in 5000. If carried out in a less strict manner the risk can be significantly higher. Septic arthritis is a disaster and a source of much litigation. I see 10 a year. Hence it is important to inject safely and document carefully. Consider those at risk e.g. Diabetics, those on steroids, anti-coagulated.

Steroid Flare: About 1 in 10 injections into a joint can cause a significant steroid flare with transient discomfort lasting a week or more. There seems to be no real rhyme or reason to this, and even if previous injections have been fine it can still occur. This often results in anxiety and additional consultations and out of hours phone calls or trips to A&E.

Delaying joint replacement: There is good evidence that the risk of prosthetic joint infection is increased for 7 months after a steroid injection, therefore most surgeons are not happy to carry out joint replacement within six months of an injection. The risk does decrease with time so some surgeons would carry out surgery after three months. This can be okay if there is a predictable waiting period and if the injection is helpful, but if the injection exacerbates the pain it gives no benefit then it can introduce delay in terms of offering definitive treatment.

Others: Facial flushing, skin depigmentation, fat atrophy, avascular necrosis, anaphylaxis (to PEG).

Benefits: Probably the best outcome one can hope for after a steroid injection for arthritis is three months of symptom relief. At this stage the patient is likely to require an additional consultation and want a further injection, etc etc. Hence injections for arthritis are not a long-term solution!

When injections are appropriate: Palliative treatment – for those unfit for anything more definitive As a diagnostic test – e.g. to demonstrate that pain is coming from that joint In peri-articular tissues, e.g. fatpad, ITB etc. Using viscosupplement (lasts longer =, less risk of infection, does not delay joint replacement)

Injecting safely: Informed consent, blue needle, clean skin of 2 mins with Chlorhexidine, wash hands, no touch technique, ensure it goes into the joint. 0.25% bupivacaine.

Documentation: With informed consent, after cleaning the skin for 2 minutes using alcohol and chlorhexidine, using a 21 gauge needle and an aseptic no touch technique I carefully administered XXXX which clearly went into the joint with no complication and excellent initially local anaesthetic effect.

Fatpad /ITB ? Pes Bursa / Pre pat bursa: Kenalog 40mg – 80mg

OA: Nothing or Durolane 60mg

Posted on Jun 07, 2017

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