The highly accurate anteriolateral portal for injecting the knee

Abstract

BackgroundThe extended knee lateral midpatellar portal for intraarticular injection of the knee is accurate but is not practical for all patients. We hypothesized that a modified anteriolateral portal where the synovial membrane of the medial femoral condyle is the target would be highly accurate and effective for intraarticular injection of the knee.Methods83 subjects with non-effusive osteoarthritis of the knee were randomized to intraarticular injection using the modified anteriolateral bent knee versus the standard lateral midpatellar portal. After hydrodissection of the synovial membrane with lidocaine using a mechanical syringe (reciprocating procedure device), 80 mg of triamcinolone acetonide were injected into the knee with a 2.0-in (5.1-cm) 21-gauge needle. Baseline pain, procedural pain, and pain at outcome (2 weeks and 6 months) were determined with the 10 cm Visual Analogue Pain Score (VAS). The accuracy of needle placement was determined by sonographic imaging.ResultsThe lateral midpatellar and anteriolateral portals resulted in equivalent clinical outcomes including procedural pain (VAS midpatellar: 4.6 ± 3.1 cm; anteriolateral: 4.8 ± 3.2 cm; p = 0.77), pain at outcome (VAS midpatellar: 2.6 ± 2.8 cm; anteriolateral: 1.7 ± 2.3 cm; p = 0.11), responders (midpatellar: 45%; anteriolateral: 56%; p = 0.33), duration of therapeutic effect (midpatellar: 3.9 ± 2.4 months; anteriolateral: 4.1 ± 2.2 months; p = 0.69), and time to next procedure (midpatellar: 7.3 ± 3.3 months; anteriolateral: 7.7 ± 3.7 months; p = 0.71). The anteriolateral portal was 97% accurate by real-time ultrasound imaging.ConclusionThe modified anteriolateral bent knee portal is an effective, accurate, and equivalent alternative to the standard lateral midpatellar portal for intraarticular injection of the knee.Trial RegistrationClinicalTrials.gov: NCT00651625

Predictors of response to intra-articular steroid injections in knee osteoarthritis--a systematic review

“…Four looked at longer-term effects up to 6–12 months [14, 31, 33, 34]. Five of the 10 RCTs were placebo/controlled trials evaluating steroids such as methylprednisolone acetate (MPA), triamcinolone hexacetonide (TH) and triamcinolone acetonide (TA) against placebo injections.…”

“…In these trials, only the steroid group’s response was used to identify factors predicting response. One RCT [32] compared treatment effects between two types of steroid, MPA and TH, another [33] compared treatment efficacy between tidal irrigation and IASI, two others [13, 34] compared injection techniques and one compared blind and US-guided knee injections [31]. …”

“…When evaluating factors predicting response, outcomes used in the studies were measurement of pain improvement such as change in Western Ontario McMaster Universities index (WOMAC) pain scores [4, 10, 33], VAS pain [5, 8, 21, 31, 32, 34], patient-rated improvement [13] and Osteoarthritis Research Society International (OARSI) response criteria [14]. Table 2 summarizes the main predictor factors and the number of studies that had found null findings or positive or negative direction of response to IASI in knee OA.…”

“…Two other studies investigated whether different injection sites and approaches influenced outcome from IASI [13, 34]. Shah and Wright [13] found no differences in the therapeutic response when 50 mg of hydrocortisone acetate was injected using the infrapatellar or medial knee approach.…”

Intra-Articular Injections for the Treatment of Osteoarthritis: Focus on the Clinical Use of Several Regimens

“…1.). The modified anteriolateral bent knee approach has been reported to be an effective, accurate, and equivalent alternative to the standard lateral midpatellar approach for intraarticular injection of the knee (Chavez-Chiang et al, 2011). Therefore, any of these approaches might be preferred, depending on the experience of the physician.…”