What is the procedure note for an intra-articular knee injection?

From the Guidelines

A knee injection procedure note should document the entire process of administering an intra-articular injection to the knee joint, including patient identification, date, indication, informed consent, pre-procedure assessment, medication injected, approach used, patient positioning, sterile technique, needle size, confirmation of proper placement, and post-procedure instructions, as recommended by the most recent EULAR guidelines 1.

Key Components of the Procedure Note

• Patient's identifying information, date of procedure, and indication for injection (such as osteoarthritis, inflammatory arthritis, or joint effusion) should be documented.
• Informed consent should be obtained and documented according to local habits, as emphasized in the EULAR recommendations 1.
• The knee being injected (right, left, or bilateral) and pre-procedure assessment, including examination findings, should be recorded.
• The medication injected, typically a corticosteroid (such as methylprednisolone 40-80mg or triamcinolone 40mg) often combined with a local anesthetic (like lidocaine 1% 2-5ml), should be noted.
• The specific approach used (medial, lateral, or anterolateral), patient positioning (usually seated with knee flexed at 90 degrees), and sterile technique details, including skin preparation with chlorhexidine or betadine, should be documented.
• The needle size (typically 18-22 gauge), confirmation of proper placement (such as aspiration of synovial fluid if present), and any fluid characteristics if aspirated should be recorded.
• Post-procedure instructions given to the patient, immediate post-injection assessment, and any complications should be concluded, as recommended by the EULAR guidelines 1.

Importance of Documentation

This documentation is essential for medical records, continuity of care, and to establish medical necessity for billing purposes, as highlighted in the AAOS clinical practice guideline summary 1.

Recent Guidelines and Recommendations

The most recent EULAR recommendations 1 and AAOS clinical practice guideline summary 1 should be consulted for the latest guidance on knee injection procedures.

Patient-Centered Care

Patient-centered outcomes, such as benefits, harms, preferences, and implications for self-management, should be considered when performing knee injections, as emphasized in the EULAR recommendations 1.

From the FDA Drug Label

For treatment of joints, the usual intra-articular injection technique should be followed If an excessive amount of synovial fluid is present in the joint, some, but not all, should be aspirated to aid in the relief of pain and to prevent undue dilution of the steroid. With intra-articular administration, prior use of a local anesthetic may often be desirable Care should be taken with this kind of injection, particularly in the deltoid region, to avoid injecting the suspension into the tissues surrounding the site, since this may lead to tissue atrophy.

The procedure note for a knee injection with triamcinolone should include:

• Using the usual intra-articular injection technique
• Aspirating some of the synovial fluid if present in excess
• Considering the use of a local anesthetic
• Avoiding injection into surrounding tissues to prevent atrophy 2

From the Research

Procedure Note for Knee Injection

• The procedure for knee injection typically involves the use of intraarticular corticosteroid injections, such as triamcinolone hexacetonide, for the management of arthritic knee pain 3.
• The evidence supports the use of intraarticular corticosteroid injections for rheumatoid arthritis, osteoarthritis, and juvenile idiopathic arthritis, with significant pain relief and functional improvement for months up to 1 year after the injection 3.
• Intraarticular injection of hyaluronic acid may provide longer pain relief than steroid injection in osteoarthritis, and is also effective for rheumatoid arthritis knee pain 3, 4.
• The choice of injection material and technique may depend on the specific condition being treated, as well as the patient's individual needs and medical history.

Injection Materials and Techniques

• Triamcinolone hexacetonide is a commonly used intraarticular corticosteroid injection, which has been shown to be effective in reducing arthritic knee pain 3, 5.
• Hyaluronic acid injections, such as Synvisc-One, have also been shown to be effective in reducing pain and improving function in patients with osteoarthritis and other conditions 4, 6.
• The use of ultrasound guidance for intraarticular injections has been shown to improve the accuracy and effectiveness of the procedure 7.

Patient Selection and Follow-up

• Patients with mild to moderate osteoarthritis, as well as those with rheumatoid arthritis and other conditions, may be candidates for knee injection therapy 3, 7.
• Follow-up care and monitoring are important to assess the effectiveness of the injection and to manage any potential side effects or complications 7, 6.