Arthrocentesis with Intra‑articular Steroid Injection – Evidence‑Based Recommendations

1. Pre‑Procedure Requirements

Obtain and document informed consent that outlines expected benefits (pain relief, reduced inflammation) and quantified risks: infection 0.035%, transient hyperglycaemia in diabetics, and vasovagal reactions 2.6% [Rheumatology Society guideline] 1
Screen for diabetes and advise patients with suboptimal control to monitor blood glucose for days 1–3 after injection because of a transient rise in glycaemia [Rheumatology Society guideline] 2
Confirm the diagnosis and exclude septic arthritis before any steroid administration [Rheumatology Society guideline] 3
Do not withhold the procedure in patients on antithrombotic therapy or with clotting disorders unless the individual bleeding risk is deemed high [Rheumatology Society guideline] 2
Prepare the procedural environment: a clean, quiet, private, well‑lit room; patient positioned on an adjustable couch/examination table that can lie flat; all aseptic supplies and resuscitation equipment (for 2.6% vasovagal reaction risk) readily available [Rheumatology Society guideline] 1
Consider having a second healthcare professional present to assist with safety and documentation [Rheumatology Society guideline] 1

Strict aseptic technique is mandatory; the current incidence of iatrogenic septic arthritis is 0.035% (≈3 per 7 900 procedures) [Rheumatology Society guideline] 1
Wear sterile surgical gloves, prepare the skin with alcohol, iodine, or chlorhexidine, and change needles between medication preparation and joint injection [Rheumatology Society guideline] 1

Offer local anaesthetic to all patients to reduce procedural discomfort and prolong pain relief [Rheumatology Society guideline] 1
Available options:
- Topical (ethyl‑chloride spray or EMLA® cream)
- Infiltrative (injection along the needle tract or subcutaneously)
- Intra‑articular (mixed with the glucocorticoid or administered separately) [Rheumatology Society guideline] 1

Use ultrasound guidance when available to improve needle placement accuracy, especially for deep joints such as the hip and shoulder [Rheumatology Society guideline] 2
Ultrasound‑guided injections increase delivery accuracy, although overall clinical outcomes are comparable to landmark‑guided techniques [Rheumatology Society guideline] 4
For landmark‑guided knee injections, the superolateral approach yields 91 % accuracy (95 % CI 84‑99 %) [Rheumatology Society guideline] 1
Select the optimal entry route for each peripheral joint based on its specific anatomy [Rheumatology Society guideline] 1
Ensure the operator has appropriate training and experience, as expertise markedly influences success rates [Rheumatology Society guideline] 1

Aspirate synovial fluid when present to verify intra‑articular needle position [Rheumatology Society guideline] 1
After confirming placement, inject a long‑acting insoluble glucocorticoid; dosing and technique should be tailored to the specific joint and clinical indication [Rheumatology Society guideline] 5

Advise patients to avoid over‑use of the injected joint for 24 hours after the procedure [Rheumatology Society guideline] 2
Discourage strict immobilisation; gentle range‑of‑motion activities are recommended [Rheumatology Society guideline] 2
For diabetic individuals, reinforce glucose monitoring during days 1‑3 post‑injection [Rheumatology Society guideline] 2
Timing relative to joint replacement: perform the injection ≥ 3 months before a planned arthroplasty; after replacement, obtain surgical team approval before any further injections [Rheumatology Society guideline] 2
Re‑injection decisions should be based on documented benefit from prior injections, patient‑specific factors (e.g., systemic therapy, comorbidities), and the specific steroid preparation used [Rheumatology Society guideline] 2

Never inject steroids without a confirmed appropriate diagnosis and exclusion of septic arthritis [Rheumatology Society guideline] 3
Skipping informed consent is unacceptable; patient surveys highlight its critical importance [Rheumatology Society guideline] 1
Always keep resuscitation equipment at hand because vasovagal reactions occur in 2.6 % of cases [Rheumatology Society guideline] 1
Remember to counsel diabetic patients about the need for post‑injection glucose monitoring [Rheumatology Society guideline] 2
Avoid recommending strict immobilisation after the procedure, as it is not supported by evidence [Rheumatology Society guideline] 2

Steroids must never be administered intra‑articularly without first ruling out septic arthritis; this precaution applies to all post‑injection complications. 6

Superficial vein thrombosis has been reported as a complication of intra‑articular steroid injection; it presents with warmth, redness, and pain along superficial veins and should be investigated with duplex ultrasound when suspected. 6

Aseptic technique is mandatory for every intra‑articular procedure, yet septic arthritis can still occur despite strict asepsis. 6

Rheumatology guidelines advise patients to avoid over‑using the injected joint for at least 24 hours after an uncomplicated injection. 6

If the patient cannot reach the injecting physician within a few hours, they should present to an emergency department for urgent assessment. 6
When symptoms are mild but concerning, the patient should contact the injecting physician’s office promptly and be evaluated within hours. 6
The physician’s office should have the capability to perform joint aspiration when septic arthritis is suspected. 6