Joint aspiration or injection in adults: Technique and indications
- W Neal Roberts, Jr, MD
W Neal Roberts, Jr, MD
- Chief of Rheumatology
- University of Lousiville
- Section Editor
- Daniel E Furst, MD
Daniel E Furst, MD
- Section Editor — Treatment Issues in Rheumatology
- Professor of Rheumatology, University of Washington, Seattle
- Professor of Rheumatology, Washington University of Florence, Florence, Italy
- Professor of Rheumatology, University of California in Los Angeles (Emeritus)
- Director of Research, Pacific
A needle is inserted into a joint for two main indications: aspiration of fluid (arthrocentesis) for diagnosis or for relief of pressure, or injection of medications. In practical terms, most injections into joints consist of a glucocorticoid, a local anesthetic, or a combination of the two. Occasionally saline is injected into the joint to diagnose a joint injury.
This topic will review the basic technique of inserting a needle into a joint and the main indications for intraarticular steroid injections. The same techniques apply for injection of the less commonly used hyaluronate viscosupplementation agents into knees, hips, and perhaps shoulders.
The choice of injectable glucocorticoid and whether it should be combined with a local anesthetic, the frequency of injection, and potential complications that can occur are discussed separately (see "Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?" and "Joint aspiration or injection in adults: Complications"). The injection of saline (ie, saline load test), used to diagnose traumatic arthrotomy, is also discussed elsewhere. (See "Severe extremity injury in the adult patient", section on 'Soft tissue and bone assessment'.)
INDICATIONS FOR ASPIRATION OR INJECTION
There are a number of indications, both diagnostic and therapeutic, for joint aspiration or injection (table 1). Arthrocentesis and synovial fluid analysis are important in the evaluation of a patient who has an effusion or signs suggesting inflammation within the joint. (See "Overview of monoarthritis in adults".)
The two most important indications for diagnosis are:
- Meenagh GK, Patton J, Kynes C, Wright GD. A randomised controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis. Ann Rheum Dis 2004; 63:1260.
- Stahl S, Karsh-Zafrir I, Ratzon N, Rosenberg N. Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints. J Clin Rheumatol 2005; 11:299.
- Mankin HJ, Conger KA. The acute effects of intra-articular hydrocortisone on articular cartilage in rabbits. J Bone Joint Surg Am 1966; 48:1383.
- Behrens F, Shepard N, Mitchell N. Alterations of rabbit articular cartilage by intra-articular injections of glucocorticoids. J Bone Joint Surg Am 1975; 57:70.
- Hill DJ. Effects of cortisol on cell proliferation and proteoglycan synthesis and degradation in cartilage zones of the calf costochondral growth plate in vitro with and without rat plasma somatomedin activity. J Endocrinol 1981; 88:425.
- Moskowitz RW, Davis W, Sammarco J, et al. Experimentally induced corticosteroid arthropathy. Arthritis Rheum 1970; 13:236.
- Salter RB, Gross A, Hall JH. Hydrocortisone arthropathy--an experimental investigation. Can Med Assoc J 1967; 97:374.
- Pond MJ, Nuki G. Experimentally-induced osteoarthritis in the dog. Ann Rheum Dis 1973; 32:387.
- Pelletier JP, Martel-Pelletier J. Protective effects of corticosteroids on cartilage lesions and osteophyte formation in the Pond-Nuki dog model of osteoarthritis. Arthritis Rheum 1989; 32:181.
- Pelletier JP, Martel-Pelletier J. Cartilage degradation by neutral proteoglycanases in experimental osteoarthritis. Suppression by steroids. Arthritis Rheum 1985; 28:1393.
- Pelletier JP, Martel-Pelletier J, Altman RD, et al. Collagenolytic activity and collagen matrix breakdown of the articular cartilage in the Pond-Nuki dog model of osteoarthritis. Arthritis Rheum 1983; 26:866.
- Williams JM, Brandt KD. Iodoacetate causes osteoarthritis in guinea pigs. Anat Rec 1982; 202:204A.
- Williams JM, Brandt KD. Triamcinolone hexacetonide protects against fibrillation and osteophyte formation following chemically induced articular cartilage damage. Arthritis Rheum 1985; 28:1267.
- Pelletier JP, Mineau F, Raynauld JP, et al. Intraarticular injections with methylprednisolone acetate reduce osteoarthritic lesions in parallel with chondrocyte stromelysin synthesis in experimental osteoarthritis. Arthritis Rheum 1994; 37:414.
- Driban J, Lavalley MP, Price LL, et al. Intraarticular corticosteroids are safe and have no effect on structural progression of synovitic knee OA: A 2-year randomized controlled trial of 3-monthly triamcinolone hexacetonide. American College of Rheumatology meeting abstracts, September 29, 2015, San Francisco, CA 2015.
- Roberts WN, Babcock EA, Breitbach SA, et al. Corticosteroid injection in rheumatoid arthritis does not increase rate of total joint arthroplasty. J Rheumatol 1996; 23:1001.
- Emkey RD, Lindsay R, Lyssy J, et al. The systemic effect of intraarticular administration of corticosteroid on markers of bone formation and bone resorption in patients with rheumatoid arthritis. Arthritis Rheum 1996; 39:277.
- Hørslev-Petersen K, Hetland ML, Ørnbjerg LM, et al. Clinical and radiographic outcome of a treat-to-target strategy using methotrexate and intra-articular glucocorticoids with or without adalimumab induction: a 2-year investigator-initiated, double-blinded, randomised, controlled trial (OPERA). Ann Rheum Dis 2016; 75:1645.
- Geirsson AJ, Statkevicius S, Víkingsson A. Septic arthritis in Iceland 1990-2002: increasing incidence due to iatrogenic infections. Ann Rheum Dis 2008; 67:638.
- Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intraarticular injections? J Rheumatol 2009; 36:1892.
- Cunnington J, Marshall N, Hide G, et al. A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum 2010; 62:1862.
- Charalambous CP, Tryfonidis M, Sadiq S, et al. Septic arthritis following intra-articular steroid injection of the knee--a survey of current practice regarding antiseptic technique used during intra-articular steroid injection of the knee. Clin Rheumatol 2003; 22:386.
- Mimoz O, Karim A, Mercat A, et al. Chlorhexidine compared with povidone-iodine as skin preparation before blood culture. A randomized, controlled trial. Ann Intern Med 1999; 131:834.
- Polishchuk D, Gehrmann R, Tan V. Skin sterility after application of ethyl chloride spray. J Bone Joint Surg Am 2012; 94:118.
- Kirschke DL, Jones TF, Stratton CW, et al. Outbreak of joint and soft-tissue infections associated with injections from a multiple-dose medication vial. Clin Infect Dis 2003; 36:1369.
- Mattner F, Gastmeier P. Bacterial contamination of multiple-dose vials: a prevalence study. Am J Infect Control 2004; 32:12.
- Motamedifar M, Askarian M. The prevalence of multidose vial contamination by aerobic bacteria in a major teaching hospital, Shiraz, Iran, 2006. Am J Infect Control 2009; 37:773.
- Schaefer MK, Shehab N, Perz JF. Calling it 'multidose' doesn't make it so: inappropriate sharing and contamination of parenteral medication vials. Am J Infect Control 2010; 38:580.
- Weitoft T, Uddenfeldt P. Importance of synovial fluid aspiration when injecting intra-articular corticosteroids. Ann Rheum Dis 2000; 59:233.
- Thumboo J, O'Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum 1998; 41:736.
- Salvati G, Punzi L, Pianon M, et al. [Frequency of the bleeding risk in patients receiving warfarin submitted to arthrocentesis of the knee]. Reumatismo 2003; 55:159.
- Ahmed I, Gertner E. Safety of arthrocentesis and joint injection in patients receiving anticoagulation at therapeutic levels. Am J Med 2012; 125:265.
- Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med 2003; 163:901.
- Wise, CM. Aspiration and injection of joints in soft tissue. In: Textbook of Rheumatology, 8th Edition, Firestein, G, Budd, R, Harris, T, et al. (Eds), WB Saunders, Philadelphia 2009. p.721.
- Strobel G, Schwarz R, Heppt P, et al. [Use of an improved transmission ultrasound camera for diagnosis of rheumatic joint diseases]. Z Rheumatol 1993; 52:114.
- Hirsch G, O'Neill T, Kitas G, Klocke R. Distribution of effusion in knee arthritis as measured by high-resolution ultrasound. Clin Rheumatol 2012; 31:1243.
- INDICATIONS FOR ASPIRATION OR INJECTION
- PATIENT EDUCATION
- TECHNIQUE OF ARTHROCENTESIS
- Needle size
- Syringe size
- Removing hair at the aspiration site
- Sterile preparation
- - Skin preparation
- - Single versus multidose medication vials
- Local anesthesia
- Switching syringes
- Approach to the patient on anticoagulants
- ANATOMIC APPROACHES TO SPECIFIC JOINTS AND BURSAE
- Elbow (lateral epicondyle)
- Subacromial bursa
- Trochanteric bursa
- Sternoclavicular joint
- Hip aspiration
- DIFFICULT SITES TO ACCESS
- Dry taps
- SUMMARY AND RECOMMENDATIONS