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Our Approach to Knee Injections

Joint injections and musculoskeletal (MSK) injections are increasingly common in Calgary and indeed, across North America.  At both Elite Sport Performance as well as our private Knee Clinic, we utilize various injections when clinically indicated.  Joint and musculoskeletal injections can be done either blind or with the benefit of image guidance.  Various studies purport that blind injections into a joint have an accuracy of somewhere around 63% to 75%, while image-guided joint injections enjoy an accuracy of between 95% and 99%.  Unsurprisingly then, the popularity of image-guided joint injections is increasing.  There are still some ‘old-school’ physicians who claim to be able to do a blind injection with a high degree of accuracy, but the statistics do not support this approach.

 

When performing an image guided injection, the practitioner has the option of using a diagnostic ultrasound or a much more expensive piece of equipment called a fluoroscope.  A fluoroscope is effectively a live x-ray exposing the patient to a not-insignificant degree of radiation.  Diagnostic ultrasound, on the other hand, is non-irradiating.  With respect to fluoroscope-guided procedures, a small amount of dye is typically injected so that the physician can confirm that the needle placement is correct.  This is in part necessary because the fluoroscope does not show in great detail the soft tissues in the area in question.  Diagnostic ultrasound, on the other hand, does not require any dye injection and shows in considerable detail the soft tissues surrounding the target to the injective.

 

There is another less palatable reason for a doctor to use a fluoroscope for image guidance rather than a diagnostic ultrasound, and that is the ability to bill Alberta Health Services for a ‘surgical procedure’ for even the most basic injection.  This billing code allows the physician to bill Alberta Health Services over $600 for simply turning on the fluoroscope when a much less expensive, less dangerous ultrasound option exists.  Diagnostic ultrasound procedures are billed at a dramatically lower rate to Alberta Health and can also be utilized within a truly private clinic.  Compounding the disparity between these two procedures is the timeliness with which they can be done.  Image-guided joint injection by a physician using a fluoroscope currently is accompanied by a wait of weeks to months within the city of Calgary.  The same image-guided joint injection using a diagnostic ultrasound can often be done within one or two days.  This represents a significant cost-savings of time for a patient looking to have a procedure done sooner rather than later.  This timeliness, along with the different ethical approach in billing Alberta Health Services so much money for a simple procedure, is why there is quite a difference in pricing for certain injections within the city.

 

Ultimately, it is the patient’s prerogative which route they choose to take,  but consider asking the clinic which method of image guidance they use and ask yourself if costing the public system more than $600 extra really represents good value for you, your family, or your community.  Paying a little bit extra to have the procedure done privately in a timely fashion, using a non-irradiating guidance such as diagnostic ultrasound, can allow you to feel better both physically and morally.  For more information regarding this topic or to learn more about any of the injections that we offer within our clinic, please reach out at (403) 689-9889 or reception@kneeclinic.ca.

Inflammation and OA

Osteoarthritis (OA) was previously considered non-inflammatory. It is now well recognized that inflammatory mediators are produced and can be measured in joint fluids of patients with OA. This inflammation is a major risk factor in cartilage loss, pain, swelling, and stiffness. When management and treatment of OA consists of anti-inflammatory components, patients can improve their function and decrease pain levels. Platelet-rich plasma (PRP) is a cell therapy, that uses one’s own blood through joint injections, to reduce inflammation. Platelets are a high source of concentrated growth factors and inflammatory mediators. Platelets in PRP release many types of anti-inflammatory proteins that signal cells that lead to suppression of inflammation in OA.

 

Goldring and Otero. Inflammation in Osteoarthritis. Curr Opin Rheumatol. 2011; 23

Xie et al. Biology of platelet-rich plasma and its clinical application in cartilage repair. Arthritis Res Ther. 2014; 16

Platelet Rich Plasma (PRP): How does it work?

Platelet rich plasma, commonly called PRP, has been promoted widely as a potential treatment for helping injured musculoskeletal tissues to heal.  Platelet rich plasma contains high concentrations of several growth factors.   Platelet rich plasma has been used worldwide for multiple indications of knee pain, most commonly accelerate ligament healing or to augment tissue repair.  The mechanism of action of PRP is well understood, with ongoing research being done to further refine when and how PRP injections can be performed for maximal efficacy.  There are myriad ways in which PRP can help joint osteoarthritis, including the anabolic effects of the growth factors found within PRP.  There is a well-documented anti-inflammatory effect as well as cell proliferation and scaffolding to help create tissue remodeling.  PRP has also been found to improve tissue stiffness, making cartilage more resilient to future wear and tear.

The philosophy behind using platelet rich plasma to augment tissue healing is based upon growth factors that are present in an individual’s own blood.  Platelets naturally gravitate toward an injured area of the body and the alpha granules, which contain the growth factors, are released by the platelets.  For platelet rich plasma, blood is drawn from a patient and the platelets are spun down with a centrifuge to much higher levels than are normally seen in a person’s own blood.  These concentrated platelets are then injected into the injured or surgically repaired area.

Over the last few years, platelet rich plasma has emerged as an accessible and relatively inexpensive source of growth factors to treat musculoskeletal injuries.  PRP contains growth factors that are very important for musculoskeletal healing, such as TGF-beta, platelet-derived growth factor (PDGF) insulin-like growth factor (IGF-I) in fibroblast growth factor (FGF).  The growth factor concentration in platelets, coupled with the normal platelets that are present in blood, are sufficient to yield increases of measurable growth factors in the blood to help reduce knee pain.  Laboratory studies have confirmed that PRP has beneficial effects on ligament fibroblast migration and the differentiation and production of collagen.  This means that it assists with healing knee pain.  In addition to the effects of the growth factors directly on healing, platelet rich plasma has also been reported to enhance the gene expression of important healing factors.

The future of PRP is encouraging.  Using the patient’s own growth factors and platelets is cost effective and research does indicate that it facilitates repairs in both basic science and animal models.  While ongoing studies are still required, it is widely believed that the use of biologic agents to enhance healing is the next major breakthrough in sports medicine for treating knee pain.

(Source: Steadman Phillipon Research Institute via drrobertlaprademd.com website).