Name: knee arthrocentesis in adults
Uploaded: 2022-02-25T14:00:00
Description: Watch this Scientific Journal Video about Knee Arthrocentesis in Adults at JoVE.com

The authors have no acknowledgments.

This protocol follows the guidelines at BronxCare Health System. A written informed consent is necessary from the patient.
1. Identifying anatomical structures
<ol>
	<li>With the patient supine, carefully palpate the knee to locate the patella and use a skin marker to make marks at the four corners of the patella.</li>
	<li>Place an &#34;X&#34; using a skin marker at a site that is one fingerbreadth superolateral to the patella. Avoid infected skin and visible veins.</li>
	<...

<ol>
	<li>Zhang, Q., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+two+positions+of+knee+arthrocentesis:+how+to+obtain+complete+drainage.">Comparison of two positions of knee arthrocentesis: how to obtain complete drainage.</a> American Journal of Physical Medicine &amp; Rehabilitation. 91 (7), 611-615 (2012).</li><li>Roberts, W. N., Hayes, C. W., Breitbach, S. A., Owen, D. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dry+taps+and+what+to+do+about+them:+a+pictorial+essay+on+failed+arthrocentesis+of+the+knee.">Dry taps and what to do about them: a pictorial essay on failed arthrocentesis of the knee.</a> The American Journal of Medicine. 100 (4), 461-464 (1996).</li><li>Weitoft, T., Uddenfeldt, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Importance+of+synovial+fluid+aspiration+when+injecting+intra-articular+corticosteroids.">Importance of synovial fluid aspiration when injecting intra-articular corticosteroids.</a> Annals of the Rheumatic Diseases. 59 (3), 233-235 (2000).</li><li>Thumboo, J., O'Duffy, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+prospective+study+of+the+safety+of+joint+and+soft+tissue+aspirations+and+injections+in+patients+taking+warfarin+sodium.">A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium.</a> Arthritis and Rheumatism. 41 (4), 736-739 (1998).</li><li>Salvati, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frequency+of+the+bleeding+risk+in+patients+receiving+warfarin+submitted+to+arthrocentesis+of+the+knee.">Frequency of the bleeding risk in patients receiving warfarin submitted to arthrocentesis of the knee.</a> Reumatismo. 55 (3), 159-163 (2003).</li><li>Ahmed, I., Gertner, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+of+arthrocentesis+and+joint+injection+in+patients+receiving+anticoagulation+at+therapeutic+levels.">Safety of arthrocentesis and joint injection in patients receiving anticoagulation at therapeutic levels.</a> The American Journal of Medicine. 125 (3), 265-269 (2012).</li><li>Yui, J. C., Preskill, C., Greenlund, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Arthrocentesis+and+joint+injection+in+patients+receiving+direct+oral+anticoagulants.">Arthrocentesis and joint injection in patients receiving direct oral anticoagulants.</a> Mayo Clinic Proceedings. 92 (8), 1223-1226 (2017).</li><li>Klauser, A. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+indications+for+musculoskeletal+ultrasound:+a+Delphi-based+consensus+paper+of+the+European+Society+of+Musculoskeletal+Radiology.">Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European Society of Musculoskeletal Radiology.</a> European Radiology. 22 (5), 1140-1148 (2012).</li><li>Rolle, N. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extractable+synovial+fluid+in+inflammatory+and+non-inflammatory+arthritis+of+the+knee.">Extractable synovial fluid in inflammatory and non-inflammatory arthritis of the knee.</a> Clinical Rheumatology. 38 (8), 2255-2263 (2019).</li><li>Yaqub, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Can+diagnostic+and+therapeutic+arthrocentesis+be+successfully+performed+in+the+flexed+knee.">Can diagnostic and therapeutic arthrocentesis be successfully performed in the flexed knee.</a> Journal of Clinical Rheumatology: Practical Reports on Rheumatic &amp; Musculoskeletal Diseases. 24 (6), 295-301 (2018).</li><li>Jennings, J. M., Dennis, D. A., Kim, R. H., Miner, T. M., Yang, C. C., McNabb, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=False-positive+cultures+after+native+knee+aspiration:+True+or+false.">False-positive cultures after native knee aspiration: True or false.</a> Clinical Orthopaedics and Related Research. 475 (7), 1840-1843 (2017).</li><li>Massey, P. A., Feibel, B., Thomson, H., Watkins, A., Chauvin, B., Barton, R. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Synovial+fluid+leukocyte+cell+count+before+versus+after+administration+of+antibiotics+in+patients+with+septic+arthritis+of+a+native+joint.">Synovial fluid leukocyte cell count before versus after administration of antibiotics in patients with septic arthritis of a native joint.</a> Journal of Orthopaedic Science: Official Journal of the Japanese Orthopaedic Association. 25 (5), 907-910 (2020).</li><li>Polishchuk, D., Gehrmann, R., Tan, V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Skin+sterility+after+application+of+ethyl+chloride+spray.">Skin sterility after application of ethyl chloride spray.</a> The Journal of Bone and Joint Surgery. 94 (2), 118-120 (2012).</li><li>Liu, K., Ye, L., Sun, W., Hao, L., Luo, Y., Chen, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Does+use+of+lidocaine+affect+culture+of+synovial+fluid+obtained+to+diagnose+periprosthetic+joint+infection+(PJI)?+An+in+vitro+study.">Does use of lidocaine affect culture of synovial fluid obtained to diagnose periprosthetic joint infection (PJI)? An in vitro study.</a> Medical Science Monitor: International Medical Journal of Experimental and Clinical Research. 24, 448-452 (2018).</li><li>Chen, L. X., Clayburne, G., Schumacher, H. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Update+on+identification+of+pathogenic+crystals+in+joint+fluid.">Update on identification of pathogenic crystals in joint fluid.</a> Current Rheumatology Reports. 6 (3), 217-220 (2004).</li><li>Boumans, D., Hettema, M. E., Vonkeman, H. E., Maatman, R. G., Avan de Laar, M. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+added+value+of+synovial+fluid+centrifugation+for+monosodium+urate+and+calcium+pyrophosphate+crystal+detection.">The added value of synovial fluid centrifugation for monosodium urate and calcium pyrophosphate crystal detection.</a> Clinical Rheumatology. 36 (7), 1599-1605 (2017).</li><li>Goldenberg, D. L., Reed, J. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bacterial+arthritis.">Bacterial arthritis.</a> The New England Journal of Medicine. 312 (12), 764-771 (1985).</li><li>Atkins, B. L., Bowler, I. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+diagnosis+of+large+joint+sepsis.">The diagnosis of large joint sepsis.</a> The Journal of Hospital Infection. 40 (4), 263-274 (1998).</li></ol>

Knee arthrocentesis is a bedside or clinic procedure in which a needle is inserted into the joint capsule, and synovial fluid is aspirated. Before attempting an arthrocentesis, knee swelling by history should be confirmed to be an effusion on physical examination. A knee x-ray can reveal an effusion but is not necessary prior to aspiration. If body habitus complicates the physical examination, ultrasonography can be used to confirm effusion size and to direct insertion of the needle for aspiration8</sup...

Arthrocentesis is performed to successfully aspirate synovial fluid from a joint such as a knee, shoulder, elbow, wrist, or ankle. A patient with a newly detected knee effusion can undergo a diagnostic arthrocentesis to determine the nature of the effusion. Before proceeding to attempt an arthrocentesis, knee swelling by history must be confirmed on physical examination to assess whether an effusion exists. With the patient supine, the knees can be compared on inspection to see if the swelling is unilateral. The knee with the effusion may appear larger than the other knee. With a large effusion (at least 20 mL), convexity can be seen proximal to the patella. With a small effusion (5-10 mL), pressing the fluid superolaterally with one hand can allow the other hand to palpate a fluid bulge. Palpating the fluid can help decide if a successful arthrocentesis is probable. In addition to the supine position, arthrocentesis of the knee can also be done on a patient in the sitting position, but there is a higher chance that less synovial fluid would be aspirated1. Synovial fluid from the knee can be aspirated from a medial or lateral approach, but the latter is preferred in complicated circumstances2. A knee effusion is not always tender on exam and thus does not necessarily cause an antalgic gait. An urgent arthrocentesis before antibiotic treatment is indicated if septic arthritis is suspected. An orthopedic surgeon can perform a knee joint aspiration to diagnose a prosthetic joint infection in a patient who had a knee arthroplasty.
In addition to evaluating for infection, arthrocentesis can assist in identifying diagnoses, such as crystal-induced arthritis (gout or pseudogout), rheumatoid arthritis, spondyloarthritis, reactive arthritis, psoriatic arthritis, hemarthrosis, or osteoarthritis. The findings on synovial fluid analysis can lead to the appropriate treatment. In a patient with pain and restricted movement of the knee due to an effusion, aspirating the fluid can improve these symptoms. Furthermore, arthrocentesis of a knee prior to an intra-articular steroid injection has been shown to reduce the risk for arthritis relapse in rheumatoid arthritis3. There is no absolute contraindication to arthrocentesis of a knee, but the needle should be inserted away from any cellulitis to not introduce any infection into the joint. Moreover, arthrocentesis has been shown to be generally safe in patients on anticoagulation with warfarin or direct oral anticoagulants4,5,6,7. With the proper technique and clinical indication, a patient can undergo this procedure with minimal risks.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Alcohol prep pad</td>
			<td>Medline</td>
			<td>MDS090670Z</td>
			<td>sterile 2-ply pad</td>
		</tr>
		<tr>
			<td>Eclipse needle</td>
			<td>BD</td>
			<td>DGW60702</td>
			<td>25G x 5/8&#34;</td>
		</tr>
		<tr>
			<td>Ethyl Chloride instant topical anesthetic spray</td>
			<td>Gebauer&#39;s</td>
			<td>P/N 0386-0008-03</td>
			<td>non-flammable</td>
		</tr>
		<tr>
			<td>Lidocaine HCl injection</td>
			<td>Fresenius Kabi Usa, Llc</td>
			<td>NDC 63323-492-27</td>
			<td>1% single dose vial</td>
		</tr>
		<tr>
			<td>Plastic bandage</td>
			<td>Curad</td>
			<td>CUR02278RB</td>
			<td>4-sided seal</td>
		</tr>
		<tr>
			<td>Plastipak 3 mL syringe</td>
			<td>BD</td>
			<td>309651</td>
			<td>sterile</td>
		</tr>
		<tr>
			<td>Plastipak 5 mL syringe</td>
			<td>BD</td>
			<td>309649</td>
			<td>sterile</td>
		</tr>
		<tr>
			<td>Povidone iodine topical solution</td>
			<td>Major</td>
			<td>NDC 0904-1103-09</td>
			<td>topical antiseptic</td>
		</tr>
		<tr>
			<td>Precision glide needle</td>
			<td>BD</td>
			<td>305196</td>
			<td>18G x 1 1/2&#34;</td>
		</tr>
		<tr>
			<td>Sterile gauze sponge</td>
			<td>CARING</td>
			<td>PRM2208</td>
			<td>2 in. x 2 in.</td>
		</tr>
		<tr>
			<td>Sterile regular tip surgical skin marker</td>
			<td>MEDLINE</td>
			<td>DYNJSM01</td>
			<td></td>
		</tr>
		<tr>
			<td>Surgical gloves</td>
			<td>TRIUMPH</td>
			<td>MSG2265</td>
			<td>sterile &#38; powder-free</td>
		</tr>
	</tbody>
</table>

knee arthrocentesis in adults

Arthrocentesis of the knee is a procedure in which a needle is inserted into the knee joint, and synovial fluid is aspirated. An arthrocentesis can be diagnostic or therapeutic. Synovial fluid may be removed for testing to determine the nature of the knee effusion. If septic arthritis is suspected, urgent arthrocentesis before initiation of antibiotic treatment is indicated. Moreover, arthrocentesis can also aid in diagnosing crystal-induced arthritis such as gout or pseudogout, or non-inflammatory arthritis such as osteoarthritis. Identifying the cause of the knee effusion can guide treatment. Furthermore, removing fluid from a knee can reduce intraarticular pressure to decrease pain and improve range of motion. There is no absolute contraindication to performing this procedure, but in selecting the needle entry site, an area of skin that is infected should be avoided. Therefore, caution should be exercised when a patient presents with suspected cellulitis over the knee joint to avoid the potential risk of causing iatrogenic septic arthritis. A knee that has undergone arthroplasty should be assessed for arthrocentesis by an orthopedic surgeon. Arthrocentesis of the knee is typically performed with the patient supine. The site for needle insertion is marked, and then the skin is disinfected. After a local anesthetic is administered, a needle is inserted along the pathway that was anesthetized. Synovial fluid is aspirated, and then the needle is withdrawn. Pressure is applied until any bleeding stops. The synovial fluid can be analyzed for infection and inflammation but cannot directly confirm a diagnosis of internal derangement or autoimmune causes of arthritis. In addition to the history and physical examination, laboratory findings and imaging can clarify the etiology of a knee effusion.

A prospective randomized study compared&#160;complete aspiration of synovial fluid from the knee and intra-articular injection with corticosteroid alone. It demonstrated that aspirating as much synovial fluid as possible can reduce the risk for recurrence of arthritic symptoms when treating rheumatoid arthritis patients with intra-articular corticosteroids. Figure 1 shows the reduction in the proportion of relapses in the arthrocentesis group3.
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Watch this Scientific Journal Video about Knee Arthrocentesis in Adults at JoVE.com

Knee Arthrocentesis in Adults

Here the protocol describes arthrocentesis of the knee, a procedure in which a needle is inserted into the knee joint, and synovial fluid is aspirated. Synovial fluid may be removed for testing to determine the nature of the knee effusion. Arthrocentesis of the knee is typically performed with the patient supine.

Arthrocentesis of the knee is a procedure in which a needle is inserted into the knee joint, and synovial fluid is aspirated. An arthrocentesis can be ...

This protocol describes arthrocentesis of the knee, a procedure in which a needle is inserted into the knee joint and synovial fluid is aspirated. An arthrocentesis can be diagnostic or therapeutic. Synovial fluid may be removed for testing to determine the nature of the effusion.Removing fluid from a knee can decrease pain. With the patient in a supine position carefully palpate the knee to locate the patella and use a skin marker to make marks at the four corners of the patella. Place an X using a skin marker at the site that is one finger breath, superolateral to the patella and avoid infected skin and visible veins.If a large effusion is detected on examination and the patella appears to be sitting on fluid, consider a medial approach just posterior to the patella. Clean the selected needle entry site with three iodine soaked, two by two inch gauze sponges. Allow the antiseptic to dry.Place the nondominant hand over the area superomedial to the patella and gently, manually compress the fluid laterally. Insert a 1.5 inch 18 to 22 gauge needle attached to the syringe along the anesthetized pathway. Advance the needle slowly and pull the plunger back gently until the visualization of synovial fluid.If the first syringe fills up and further aspirated fluid is desired, switch to another syringe. Remove the needle and syringe in one smooth withdrawal motion, then place a sterile dressing over the site and apply pressure until any bleeding stops. Once hemostasis is achieved, apply a bandage after wiping the skin marker and iodine off with an alcohol pad.A comparative study of complete aspiration of synovial fluid from the knee and intraarticular injection with corticosteroid alone demonstrated that aspirating as much synovial fluid as possible can reduce the risk for recurrence of arthritic symptoms when treating rheumatoid arthritis patients with intraarticular corticosteroids. A retrospective chart review of arthrocentesis and joint injections comparing the incidence of clinically significant bleeding in patients receiving Warfarin and those whose anticoagulation was adjusted to an international normalized ratio, less than 2.0, did not show a statistically significant difference in bleeding. The most important thing to remember is to advance the needle slowly while pulling the plunger back until synovial fluid is visualized.The hand should be steady. Following this procedure, the synovial fluid can be sent for cell count, crystal, Gram stain and culture. This can help to diagnose the etiology of the knee effusion.This technique enables viewing cells, crystals, or bacteria in the synovial fluid under microscopy to evaluate for inflammation and for infection. By aspirating synovial fluid from the knee, I can alleviate the patient's pain and diagnose the etiology of the swelling. This can help prevent recurrence of the arthritis.

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