Ultrasound-Guided Intra-Articular Knee Injection in an Obese Patient

Abstract

A 35-yr-old woman was referred to our outpatient clinic for a right intra-articular knee aspiration and injection. She had a medical history notable for lymphedema and morbid obesity (Fig. 1). Her body mass index was recently calculated at greater than 60 kg/m(2). She had a history of four previous nonguided knee joint injections performed elsewhere that provided no significant improvement in pain. On physical examination, it was difficult to localize common knee joint bony landmarks, including the medial and lateral borders of the patella (Fig. 2). Consequently we opted to utilize ultrasound guidance for the knee joint injection via the technique described herein.

American Medical Society for Sports Medicine (AMSSM) Position Statement: Interventional Musculoskeletal Ultrasound in Sports Medicine

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint.…”

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint. Thirty‐five percent (20/57) of the studies evaluated knee injections [8‐10,13,15,16,19‐23,26,31,32,36,37,48,52,56,57], 46% (26/57) evaluated glenohumeral (GH) joint injections [5,7,8,10,11,15‐17,24‐26,28,29,31,38‐40,42,43,46,47,49,52,54,60,61], 21% (12/57) evaluated hip injections [8,12,27,30,33,35,41,44,45,50,52,59,62], and 4% (2/57) evaluated sacroiliac (SI) joint injections [18,34].…”

“…The results of the studies investigating major joint injection accuracy are summarized in Table 1. The level of evidence for a majority of the studies evaluating major joint USGI accuracy (15/23 [65%]) [5,8,9,15,16,18,20,21,23,27,30,32,34,36‐39,41,42,44‐46,49] or LMGI accuracy (28/28 [100%]) [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61] were level 1 or 2. The mean accuracy of GH, hip, and knee joint USGIs in studies with level 1 or 2 evidence ranged from 91%‐100% [5,8,9,15,18,21,23,32,36‐39,42,46,49], whereas the mean accuracy of LMGIs were between 64% and 81% [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61].…”

American Medical Society for Sports Medicine (AMSSM) Position Statement: Interventional Musculoskeletal Ultrasound in Sports Medicine

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint.…”

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint. Thirty‐five percent (20/57) of the studies evaluated knee injections [8‐10,13,15,16,19‐23,26,31,32,36,37,48,52,56,57], 46% (26/57) evaluated glenohumeral (GH) joint injections [5,7,8,10,11,15‐17,24‐26,28,29,31,38‐40,42,43,46,47,49,52,54,60,61], 21% (12/57) evaluated hip injections [8,12,27,30,33,35,41,44,45,50,52,59,62], and 4% (2/57) evaluated sacroiliac (SI) joint injections [18,34].…”

“…The results of the studies investigating major joint injection accuracy are summarized in Table 1. The level of evidence for a majority of the studies evaluating major joint USGI accuracy (15/23 [65%]) [5,8,9,15,16,18,20,21,23,27,30,32,34,36‐39,41,42,44‐46,49] or LMGI accuracy (28/28 [100%]) [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61] were level 1 or 2. The mean accuracy of GH, hip, and knee joint USGIs in studies with level 1 or 2 evidence ranged from 91%‐100% [5,8,9,15,18,21,23,32,36‐39,42,46,49], whereas the mean accuracy of LMGIs were between 64% and 81% [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61].…”

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

“…The level of evidence for a majority of the studies evaluating major joint USGI accuracy (15/23 (65%))5 8 9 15 16 18 20 21 23 27 30 32 34 36–39 41 42 44–46 49 or LMGI accuracy (28/28 (100%))5 7 9–13 17 19 21–26 28 31 32 36–38 40 43 47 48 50 60 61 were level 1 or 2. The mean accuracy of GH, hip and knee joint USGIs in studies with level 1 or 2 evidence ranged from 91% to 100%,5 8 9 15 18 21 23 32 36–39 42 46 49 whereas the mean accuracy of LMGIs were between 64% and 81% 5 7 9–13 17 19 21–26 28 31 32 36–38 40 43 47 48 50 60 61.…”

Clinical examination, ultrasound assessment and aspiration of knee effusion in primary knee osteoarthritis patients

“…Therefore, the use of long, lengthened needles on obese patients could improve aspiration success. In this context, Hurdle et al [ 32 ], successfully used a 22-gauge/ 3.5-inch spinal needle to aspirate SF from the knee of a morbidly obese patient under US guidance. Therefore, we hypothesized that the long, lengthened needles may have contributed to the success of aspiration in obese patients and those with mild knee effusion.…”

American Medical Society for Sports Medicine (AMSSM) Position Statement: Interventional Musculoskeletal Ultrasound in Sports Medicine

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint.…”

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint. Thirty‐five percent (20/57) of the studies evaluated knee injections [8‐10,13,15,16,19‐23,26,31,32,36,37,48,52,56,57], 46% (26/57) evaluated glenohumeral (GH) joint injections [5,7,8,10,11,15‐17,24‐26,28,29,31,38‐40,42,43,46,47,49,52,54,60,61], 21% (12/57) evaluated hip injections [8,12,27,30,33,35,41,44,45,50,52,59,62], and 4% (2/57) evaluated sacroiliac (SI) joint injections [18,34].…”

“…The results of the studies investigating major joint injection accuracy are summarized in Table 1. The level of evidence for a majority of the studies evaluating major joint USGI accuracy (15/23 [65%]) [5,8,9,15,16,18,20,21,23,27,30,32,34,36‐39,41,42,44‐46,49] or LMGI accuracy (28/28 [100%]) [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61] were level 1 or 2. The mean accuracy of GH, hip, and knee joint USGIs in studies with level 1 or 2 evidence ranged from 91%‐100% [5,8,9,15,18,21,23,32,36‐39,42,46,49], whereas the mean accuracy of LMGIs were between 64% and 81% [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61].…”

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

“…The level of evidence for a majority of the studies evaluating major joint USGI accuracy (15/23 (65%))5 8 9 15 16 18 20 21 23 27 30 32 34 36–39 41 42 44–46 49 or LMGI accuracy (28/28 (100%))5 7 9–13 17 19 21–26 28 31 32 36–38 40 43 47 48 50 60 61 were level 1 or 2. The mean accuracy of GH, hip and knee joint USGIs in studies with level 1 or 2 evidence ranged from 91% to 100%,5 8 9 15 18 21 23 32 36–39 42 46 49 whereas the mean accuracy of LMGIs were between 64% and 81% 5 7 9–13 17 19 21–26 28 31 32 36–38 40 43 47 48 50 60 61.…”

Clinical examination, ultrasound assessment and aspiration of knee effusion in primary knee osteoarthritis patients

“…Therefore, the use of long, lengthened needles on obese patients could improve aspiration success. In this context, Hurdle et al [ 32 ], successfully used a 22-gauge/ 3.5-inch spinal needle to aspirate SF from the knee of a morbidly obese patient under US guidance. Therefore, we hypothesized that the long, lengthened needles may have contributed to the success of aspiration in obese patients and those with mild knee effusion.…”

American Medical Society for Sports Medicine (AMSSM) Position Statement: Interventional Musculoskeletal Ultrasound in Sports Medicine

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint.…”

“…Fifty‐seven studies assessing injections in major joints were identified (see online supplementary Appendix 1) [5‐61]. A majority of the studies (49/57 [86%]) [6,7,9,11‐13,15,17‐25,27‐30,32‐51,53‐61] evaluated injections in a single joint, whereas 14% (8/57) [5,8,10,16,26,31,52,55] assessed injections in more than one joint. Thirty‐five percent (20/57) of the studies evaluated knee injections [8‐10,13,15,16,19‐23,26,31,32,36,37,48,52,56,57], 46% (26/57) evaluated glenohumeral (GH) joint injections [5,7,8,10,11,15‐17,24‐26,28,29,31,38‐40,42,43,46,47,49,52,54,60,61], 21% (12/57) evaluated hip injections [8,12,27,30,33,35,41,44,45,50,52,59,62], and 4% (2/57) evaluated sacroiliac (SI) joint injections [18,34].…”

“…The results of the studies investigating major joint injection accuracy are summarized in Table 1. The level of evidence for a majority of the studies evaluating major joint USGI accuracy (15/23 [65%]) [5,8,9,15,16,18,20,21,23,27,30,32,34,36‐39,41,42,44‐46,49] or LMGI accuracy (28/28 [100%]) [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61] were level 1 or 2. The mean accuracy of GH, hip, and knee joint USGIs in studies with level 1 or 2 evidence ranged from 91%‐100% [5,8,9,15,18,21,23,32,36‐39,42,46,49], whereas the mean accuracy of LMGIs were between 64% and 81% [5,7,9‐13,17,19,21‐26,28,31,32,36‐38,40,43,47,48,50,60,61].…”

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

“…The level of evidence for a majority of the studies evaluating major joint USGI accuracy (15/23 (65%))5 8 9 15 16 18 20 21 23 27 30 32 34 36–39 41 42 44–46 49 or LMGI accuracy (28/28 (100%))5 7 9–13 17 19 21–26 28 31 32 36–38 40 43 47 48 50 60 61 were level 1 or 2. The mean accuracy of GH, hip and knee joint USGIs in studies with level 1 or 2 evidence ranged from 91% to 100%,5 8 9 15 18 21 23 32 36–39 42 46 49 whereas the mean accuracy of LMGIs were between 64% and 81% 5 7 9–13 17 19 21–26 28 31 32 36–38 40 43 47 48 50 60 61.…”

Clinical examination, ultrasound assessment and aspiration of knee effusion in primary knee osteoarthritis patients

“…Therefore, the use of long, lengthened needles on obese patients could improve aspiration success. In this context, Hurdle et al [ 32 ], successfully used a 22-gauge/ 3.5-inch spinal needle to aspirate SF from the knee of a morbidly obese patient under US guidance. Therefore, we hypothesized that the long, lengthened needles may have contributed to the success of aspiration in obese patients and those with mild knee effusion.…”