Beruflich Dokumente
Kultur Dokumente
METHODS
We performed a literature search of the MEDLINE database
from January 1980 to June 2013 using the search terms knee,
arthritis, ultrasound, pain, and treatment to identify reports of the use of IA injections for the amelioration of knee arthritis, the agents used, and the use of image guidance and their
accuracy and efficacy.
Ligaments
DISCUSSION
Anatomy of Knee Joint and Surrounding Structures
The knee joint is a complex joint consisting of 3 components:
the femorotibial, patellofemoral, and superior tibiofibular joints.
368
The stability of the knee is maintained primarily by 4 ligaments (Fig. 4). Both the anterior and posterior cruciate ligaments
are intracapsular but extrasynovial structures. The anterior cruciate ligament originates from the posteromedial aspect of the lateral femoral condyle and has its attachment to the front of the
intercondylar eminence on the tibia. The stronger posterior cruciate ligament originates from the posterolateral surface of the medial condyle and is attached to the posterior intercondylar fossa
of the tibia. The medial collateral ligament is inserted to the medial epicondyle of the femur and the medial tibial condyle
with the deep fibers attaching to the medial meniscus (Fig. 4).
It is buttressed between the tendons of pes anserinus and
semimembranosus. The lateral collateral ligament spans between
the lateral epicondyle of the femur and the head of the fibula.
Joints
The femorotibial joint is composed of 2 compartments: medial and lateral. The fibrocartilaginous medial and lateral menisci
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
common popliteal cyst (defined as a fluid-filled mass in the popliteal fossa), the terms should not be used synonymously as there
are other causes of popliteal cysts. In adult, almost all Bakers
cysts are secondary, which means that communications exist between the bursae and knee joint.1
Sonoanatomy
The knee may be examined from anterior, medial, lateral, and
posterior surfaces to identify various structures and pathologies. A
linear array transducer at frequencies of 6 to 12 MHz is usually
ideal for the examination of the knee. Higher frequencies are used
to examine the more superficial structures in details.
Anterior Knee
Bursa
Around the knee joint, there are multiple bursae, which serve
to reduce the friction between various structures (bones, tendons,
ligaments, or skin), allowing a smooth and independent gliding
of these structures during joint movements. The anatomical locations of these bursae are summarized in Table 1 and Figure 4. Of
these bursae, the most well-known is the semimembranosus or
semimembranosus-gastrocnemius bursa. Abnormal distension of
this results in Bakers cyst. Although Bakers cyst is the most
FIGURE 1. Anterior view of the thigh and knee. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
2014 American Society of Regional Anesthesia and Pain Medicine
369
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
Medial Knee
Examination is best performed with the patients knee externally rotated while maintaining 20- to 30-degree flexion. Placing
the ultrasound probe over the long axis of medial collateral ligament reveals the superficial layer and the deep meniscofemoral
and meniscotibial components of the ligament (Fig. 9). In general,
the ligament is examined for the entire length and with dynamic
scanning during valgus stress for the possible pathology and assessment of integrity. The medial meniscus appears as a
hyperechoic triangular structure between the femur and tibia
(Fig. 9). Moving the ultrasound probe distally to the AM aspect
of the tibial metaphysis, the tendons of sartorius, gracilis, and
Lateral Knee
Examination of the lateral knee is performed with the patients knee internally rotated while maintaining 20- to 30degree flexion. The ultrasound probe is first placed over the long
axis of iliotibial band, with the distal segment best revealed in the
coronal plane. The iliotibial band is seen as a thin, fibrillar structure that inserts onto the Gerdy tubercle, a bony prominence on
the anterolateral (AL) aspect of the tibial epiphysis (Fig. 10).
The lateral collateral ligament is best examined by placing the
lower part of the ultrasound probe over the fibula head with the
proximal part of probe rotating over the femur. When the probe
is aligned with the ligament, it gives the longest view of the ligament. With a proper scan, the popliteus tendon and the lateral meniscus can be seen (Fig. 10).
Posterior Knee
The examination is performed while the patient is prone position with the knee extended. The ultrasound probe is placed on the
posteromedial aspect of the knee over the medial femoral condyle.
The following structures are seen from medial to lateral in shortaxis scan: sartorius, gracilis, semimembranosus, semitendinosus,
FIGURE 2. Lateral view of the knee showed the details of the trilaminar nature of the quadriceps tendon. The insert on the right upper corner
was the expanded view of the rectangle over the quadriceps tendon. Reproduced with permission from Dr Philip Peng from Philip Peng
Educational Series.
370
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
and medial head of gastrocnemius muscle (Fig. 11). The semimembranosus or semimembranosus-gastrocnemius bursa is located
between the tendons of semimembranosus and the medial head of
gastrocnemius. Moving the probe laterally, the short-axis scan of
the popliteal fossa reveals the neurovascular bundle (Fig. 11). Moving the probe further laterally, the biceps femoris muscle and tendon
are examined in the long-axis scan (Fig. 11).
Accuracy
Although the knee IA injections are commonly performed
with landmark-based technique by rheumatologists, orthopedic surgeons, and general practitioners, the accuracy of the landmarkbased technique in clinical studies is approximately 79% (range,
40%100%).3 Three factors influence accuracy: use of image guidance, experience of practitioners, and approach of injection.
Literature supports the superiority of image guidance in
terms of accuracy.4 Comparison studies reveal pooled accuracy
rates of 81.0% and 96.7% for landmark-based versus image guidance (fluoroscopy or ultrasound) techniques, respectively.4 In contrast to fluoroscopy, ultrasound allows the procedure to be
performed in office-based settings. The accuracies of landmarkbased versus ultrasound guidance techniques were also significantly different, 77.8% and 95.8%, respectively.4 Although the
presence of an effusion greatly enhances the accuracy of
landmark-based IA needle placement in the knee,5,6 loss of resistance is not indicative of an IA location. This was supported by a
FIGURE 3. Posterior view of the thigh and knee showed the flexors of the knee. Reproduced with permission from Dr Philip Peng from Philip
Peng Educational Series.
2014 American Society of Regional Anesthesia and Pain Medicine
371
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
significantly better for the junior trainee who performed all the
ultrasound-guided injections (accuracy rates of 83% vs 66% for
ultrasound and landmark-based technique, respectively). Confidence or satisfaction of injection by the practitioner using
landmark-guided technique did not result in a better success rate.9
This is similar to the confidence factor of the practitioner in shoulder injections reviewed previously.10
Accuracy is also influenced by the approaches. When performing landmark-based technique knee injections, there are
generally 6 approaches: superolateral (SL), superomedial, medial
FIGURE 4. Four views of the knee showed the ligaments and bursae. A, Medial view. B, Anterior view. C, Lateral view. D, Posterior view. In the
posterior view, the medial head of gastrocnenimus was removed to reveal the IA structures. F indicates fibula; T, tibia. Reproduced with
permission from Dr Philip Peng from Philip Peng Educational Series.
372
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
Location Between
Pes anserinus
Skin
Quadriceps tendon
Skin
Patella tendon (ligament)
Semimembranosus tendon
Popliteus tendon
FIGURE 5. A, Sonogram of the suprapatellar view of the normal knee. The insert showed the position of the patient and the ultrasound probe.
B, Sonogram of the details of quadriceps tendon. C, Sonogram of the suprapatellar view of a patient with knee effusion. Note the presence
of effusion fluid filling the space between prefemoral fat pad and quadriceps tendon. SPFP indicates suprapatellar fat pad; PFFP, prefemoral fat
pad; P, patella; F, femur. ** indicates the SPR. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
2014 American Society of Regional Anesthesia and Pain Medicine
373
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
FIGURE 6. A and C, Pictures show the position of the ultrasound probes and the manipulation of the patella by the examiner. The patella was
pushed to the medial and lateral sides, respectively in A and C. B and D, The respective sonograms (B and D) show the medial and lateral
views, respectively. MFC indicates medial femoral condyle; LFC, lateral femoral condyle. Stars indicate the Hoffa fat pad; chain of trapezoid
indicates the cartilage. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
were significantly more accurate than MMP approach (accuracy rates of SL, LMP, and MMP were 100%, 95%, and
75%, respectively).
Ultrasound improves accuracy of IA injection, which is important to both outcome and safety. Still, there is some controversy
regarding the effect of imaging method for needle placement
FIGURE 7. Sonogram of both femoral condyles. The picture on the left shows the position of the knee and the ultrasound probe. The hyaline
cartilage was marked with trapezoids. QT indicates quadriceps tendon. *Muscle of vastus medialis. Reproduced with permission from
Dr Philip Peng from Philip Peng Educational Series.
374
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
FIGURE 8. Sonogram of the infrapatellar region. The picture on the left shows the position of the ultrasound probe. The arrow indicates the
patella tendon, and * indicates the Hoffa fat pad. T indicates tibia; TT, tibial tuberosity. Reproduced with permission from Dr Philip Peng
from Philip Peng Educational Series.
FIGURE 9. A, Sonogram of long-axis view of the medial collateral ligament. Open arrowheads indicate superficial layer of the collateral
ligament, which is deep to the superficial fascia (open arrows); closed arrow, the deeper meniscofemoral ligament connecting the
meniscus (*) and the femur (F). B, Sonogram of long-axis view of the pes anserinus complex inserting into the anterolateral aspect of the tibial
metaphysis. At this level, the 3 tendons of sartorius, gracilis, and semitendinosus cannot be differentiated from each other. The lower
diagram is the color Doppler showing the inferior medial genicular artery (dark arrowhead). The inserts show the position of the probe and
patient as well as the corresponding anatomical structures in the sonogram. Note that the leg was externally rotated and rested on a
small pillow. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
2014 American Society of Regional Anesthesia and Pain Medicine
375
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
FIGURE 10. A, Sonogram of the long-axis view of iliotibial band (hyperechoic structures indicated by the arrows) inserting into the
Gerdy tubercle (GT). The GT and the fibula (F) were marked on the skin. B, Sonogram of the long-axis view of lateral collateral ligament
(arrows) inserting into the fibular head. The popliteus tendon (open arrowhead) is seen deep to the collateral ligament at this level and
inserted in the small fossa (closed arrowheads) located on the lateral aspect of the lateral femoral condyle. The insert shows the position
of the probe and the position of the patient. The leg was internally rotated resting on a small pillow. Reproduced with permission from
Dr Philip Peng from Philip Peng Educational Series.
376
improvements met the minimum clinically important improvement thresholds. They showed that the overall improvement (pain
and function outcome) was less than 0.5 meaningfully important
difference units. This suggested a low likelihood that an appreciable number of patients achieved clinically important benefits in
the outcome.39 When the high- and low-molecular-weight HAs
were analyzed separately, they showed that most of the statistically significant outcomes were associated with high-molecular
cross-linked HA (Synvisc), but when compared with midrange
molecular-weight HA, statistical significance was not maintained.
Based on their review method, they did not recommend the use of
HA for knee OA. The strength of this recommendation was strong
and was based on lack of efficacy, not on potential harm
Based on the above information, should we consider knee injection in managing patient with OA of knee? Both injection medications clearly show benefits in terms of pain and function.
However, the clinical benefit of IA corticosteroid is short term.
Literature on viscosupplementation supports improvement in pain
and function as well. The controversy is whether the benefits are
clinically significant. In deciding the management options to patients with knee OA, clinician should balance the benefits and
risks of IA injection with the other conservative and surgical options in the management algorithm.
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
FIGURE 11. A, Sonogram showing the various muscles and tendons in the posteromedial region of the knee. Deep to the sartorius
muscle (Sa), the tendon of gracilis (arrow) and saphenous nerve (line arrows) were revealed. Semitendinosus tendon (closed arrowheads)
was seen as a round hyperechoic structure resting on the semimembranosus muscle (SM), similar to a cherry on the cake. B, By moving
the ultrasound lateral to the medial femoral condyle (MC), the medial head of gastrocnemius (GH) and its tendon (asterisk) were
revealed. Between the space between the medial head of gastrocnemius and semimembranosus muscle is the semimembranosus or
semimembranosus-gastrocnemius bursa (outlined by dotted line), which is hypoechoic in normal state because of the apposition of synovial
walls. Because of lack of fluid in normal state, one should apply very light pressure to the ultrasound probe to reveal its presence. The hyaline
cartilage was indicated by white rhombi. C, Sonogram of the central portion of the posterior knee. Color Doppler shows the popliteal
artery (blue structure indicated by the arrow). The sciatic nerve was also revealed posterior to the artery. D, Sonogram of the biceps femoris
in the posterolateral region of the knee. The biceps muscle (BFm) continues as a tendon (arrows) inserting into the fibular head (F) as a clear
hyperechoic structure. * Indicates lateral meniscus; T, tibia. The inserts in each figure show the position of the patient, the position of the
probe, and the anatomical structures corresponding to the sonogram. Reproduced with permission from Dr Philip Peng from Philip Peng
Educational Series.
or viscosupplement is injected following hydrolocation of the location of the needle (avoid injecting into the fat pad).
CONCLUSIONS
Knee IA injections are commonly performed with landmarkbased technique by general practitioners and specialists. The accuracy of IA injection is influenced by 3 factors: use of image
guidance, experience of practitioners, and the approach of injection. Literature supports better accuracy with ultrasound guidance
377
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
FIGURE 12. Diagram shows the various landmark-based approach. The dark dots mark the sites of needle entry; the arrows show the direction
of needle entry. The knee was put in extension for SL, superomedial (SM), LMP, and MMP approaches. The AM and AL approaches are
performed with knee in 90-degree flexion with or without the modification of degree of flexion as suggested by Waddell et al.12 Reproduced
with permission from Dr Philip Peng from Philip Peng Educational Series.
over landmark-based technique. Better experience of the practitioner improves the accuracy of landmark-based technique, but
the use of ultrasound guidance can boost the accuracy of the less experienced. Superolateral approach appears as the most reliable
approach for both the ultrasound-guided or landmark-based techniques. Ultrasound enhances the accuracy of knee IA injection,
378
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
FIGURE 13. Picture shows the injection technique. The ultrasound probe is placed between the patella and quadriceps tendon initially and
then turned 90 degrees upon visualization of the SPR. The needle is then approached from lateral to medial to avoid puncturing the
quadriceps tendon. The needle is indicated by the arrowheads and the SPR by asterisks (****). R indicates retinaculum; Q, quadriceps tendon;
F, femur. Reproduced with permission from Dr Philip Peng from Philip Peng Educational Series.
with the other conservative and surgical options in the management algorithm.
ACKNOWLEDGEMENT
The authors thank Dr Richelle Kruisselbrink for assisting
with the construction of the sonogram.
REFERENCES
1. Fritschy D, Fasel J, Imbert JC, Bianchi S, Verdonk R, Wirth CJ. The
popliteal cyst. Knee Surg Sports Traumatol Arthrosc. 2006;14:623628.
2. Ike RW, Somers EC, Arnold EL, Arnold WJ. Ultrasound of the knee during
voluntary quadriceps contraction: a technique for detecting otherwise
occult effusions. Arthritis Care Res. 2010;62:725729.
16. Koh YG, Jo SB, Kwon OR, et al. Mesenchymal stem cell injections
improve symptoms of knee osteoarthritis. Arthroscopy. 2013;29:748755.
3. Daley EL, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the
elbow, knee, and shoulder: does injection site and imaging make a
difference? A systematic review. Am J Sports Med. 2011;39:656662.
17. Sambrook PN, Champion GD, Browne CD, et al. Corticosteroid injection
for osteoarthritis of the knee: peripatellar compared to intra-articular route.
Clin Exp Rheumatol. 1989;7:609613.
4. Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for
intra-articular knee injections: a review. Clin Interv Aging. 2012;7:8995.
5. Glattes RC, Spindler KP, Blanchard GM, Rohmiller MT, McCarty EC,
Block J. A simple, accurate method to confirm placement of intra-articular
knee injection. Am J Sports Med. 2004;32:10291031.
6. Balint PV, Kane D, Hunter J, McInnes IB, Field M, Sturrock RD.
Ultrasound guided versus conventional joint and soft tissue fluid aspiration
in rheumatology practice: a pilot study. J Rheumatol. 2002;29:22092213.
7. Esenyel C, Demirhan M, Esenyel M, et al. Comparison of four different
intra-articular injection sites in the knee: a cadaver study. Knee Surg Sports
Traumatol Arthrosc. 2007;15:573577.
8. Curtiss HM, Finnoff JT, Peck E, Hollman J, Muir J, Smith J. Accuracy of
ultrasound-guided and palpation-guided knee injections by an experienced
and less-experienced injector using a superolateral approach: a cadaveric
study. PM&R. 2011;3:507515.
9. 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;62:18621869.
10. Peng PW, Cheng P. Ultrasound-guided interventional procedures in pain
medicine: a review of anatomy, sonoanatomy, and procedures. Part III:
shoulder. Reg Anesth Pain Med. 2011;36:592605.
11. Hermans J, Bierma-Zeinstra SM, Bos PK, Verhaar JA, Reijman M. The
most accurate approach for intra-articular needle placement in the knee
joint: a systematic review. Semin Arthritis Rheum. 2011;41:106115.
379
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.
Regional Anesthesia and Pain Medicine Volume 39, Number 5, September-October 2014
25. Moorjani GR, Michael AA, Peisajovich A, Park KS, Sibbitt WL Jr,
Bankhurst AD. Patient pain and tissue trauma during syringe procedures: a
randomized controlled trial. J Rheumatol. 2008;35:11241129.
26. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.
Intraarticular corticosteroid for treatment of osteoarthritis of the knee.
Cochrane Database Syst Rev. 2006;2:CD005328.
27. Godwin M, Dawes M. Intra-articular steroid injections for painful knees.
Systematic review with meta-analysis. Can Fam Physician. 2004;50:241248.
28. Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of
the knee: meta-analysis. BMJ. 2004;328:869870.
29. Hepper CT, Halvorson JJ, Duncan ST, Gregory AJ, Dunn WR, Spindler KP.
The efficacy and duration of intraarticular corticosteroid injection for knee
osteoarthritis: a systematic review of level I studies. J Am Acad Orthop
Surg. 2009;17:638646.
30. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis
of the knee: evidence-based guideline: 2013. Available at: http://www.aaos.
org/Research/guidelines/guide.asp. Accessed December 12, 2013.
31. Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G.
Viscosupplementation for the treatment of osteoarthritis of the knee.
Cochrane Database Syst Rev. 2006;2:CD005321.
32. Lundsgaard C, Dufour N, Fallentin E, Winkel P, Gluud C. Intra-articular
sodium hyaluronate 2 mL versus physiological saline 20 mL versus
physiological saline 2 mL for painful knee osteoarthritis: a randomized
clinical trial. Scand J Rheumatol. 2008;37:142150.
33. Huang TL, Chang CC, Lee CH, Chen SC, Lai CH, Tsai CL. Intra-articular
injections of sodium hyaluronate (Hyalgan) in osteoarthritis of the knee. a
380
Copyright 2014 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.