Version May 2024
INTRODUCTION — A needle is inserted into a joint for two main indications: aspiration of fluid (arthrocentesis) for diagnosis or for injection of medications. In practical terms, most injections into joints consist of a glucocorticoid, a local anesthetic, or combinations of the two. Soft tissue and intraarticular glucocorticoid injections are generally safe, but they can result in systemic and local adverse effects.
The complications of joint aspiration or glucocorticoid injection in adults are discussed here. Complications of these procedures in children, more details on septic arthritis and bursitis, and other aspects of joint and soft tissue aspiration and injection are described elsewhere, including:
●Complications of joint aspiration and injection in children (see "Joint aspiration or injection in children: Indications, technique, and complications")
●Septic arthritis and bursitis (see "Septic arthritis in adults" and "Septic bursitis")
●Joint aspiration and injection indications and technique in adults and children (see "Joint aspiration or injection in adults: Technique and indications" and "Joint aspiration or injection in children: Indications, technique, and complications")
●Medication dosing in and frequency of joint and soft tissue injections (see "Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?")
●Synovial fluid analysis (see "Synovial fluid analysis")
●Adverse effects of glucocorticoids (see "Major adverse effects of systemic glucocorticoids")
●Role of injections in treatment of osteoarthritis and rheumatoid arthritis (see "Management of moderate to severe knee osteoarthritis", section on 'Limited role of intraarticular glucocorticoid injections' and "Initial treatment of rheumatoid arthritis in adults", section on 'Intraarticular glucocorticoids')
INFECTIOUS COMPLICATIONS
Septic arthritis — Iatrogenic septic arthritis from a joint procedure is a rare but serious complication that occurs in 1 of every 1000 to 3000 procedures [1,2]. A nationwide study in Iceland using data from all arthrocentesis procedures performed over a 13-year period reported frequency of septic arthritis of 1 of 2600 procedures [1]. Another large registry study of 22,370 procedures found a similar rate of septic arthritis of 1 of 2030 procedures [2].
The rates of iatrogenic infections can be reduced by using appropriate measures when performing joint aspirations or injections [3]. These measures include the following: (See "Joint aspiration or injection in adults: Technique and indications", section on 'Sterile preparation'.)
●Using triple concentric iodine preparation of the skin or chlorhexidine preparation, rather than just alcohol alone
●"No touch" technique if using nonsterile universal precaution gloves
●Single-dose vials when these are available from the institutional supplies (multidose vials are most common in outpatient and office practices)
●Changing to a new needle after drawing up the medication and before injecting it
●Cleaning the tops of the vials with an alcohol swipe prior to drawing up the injection
●Avoiding preparing the syringe many hours, or days, ahead of when it is to be used
Although all needle sizes can theoretically inoculate a joint by depositing a core of tissue within the joint [4], there is some evidence from animal models suggesting that translocation of bacteria is correlated both with needle size and with overlying infected tissue (aspirating through cellulitis) [5]. However, there are no human data to support using a preferred needle size to reduce the risk of translocation of bacteria during joint aspiration. Presumably, aspirating through cellulitis would be less of a concern if the patient has already been established on an antibiotic regimen. In addition, ultrasound guidance may be used to guide aspiration via a route that avoids overlying cellulitis.
A septic joint must be distinguished from postinjection flare (see 'Postinjection flare' below). Clinical features favoring infection include symptoms starting after 48 hours from injection, symptoms lasting longer than 48 hours, a crescendo pattern of pain, redness or drainage around the injection site, and fever or malaise. (See "Septic arthritis in adults".)
There is inconclusive evidence that intraarticular glucocorticoid injection preceding total joint arthroplasty of a large joint will increase the probability of septic joint as a complication of the surgery. This is discussed in detail separately. (See "Intraarticular and soft tissue injections: What agent(s) to inject and how frequently?", section on 'Contraindications'.)
A detailed discussion on the diagnosis and management of septic arthritis can be found elsewhere. (See "Septic arthritis in adults".)
Septic bursitis — The superficial or subcutaneous bursae are predisposed to infection as a result of skin trauma. Septic bursitis can result from direct inoculation due to puncture of the overlying skin during an injection. (See "Septic bursitis".)
NONINFECTIOUS COMPLICATIONS
Technique-related
Bleeding — Local bleeding is uncommon in patients without a bleeding diathesis or who are not on anticoagulation. Holding pressure over the puncture site with sterile gauze is typically sufficient to stop local venous bleeding. A rare complication of hemarthrosis due to an arterioarticular fistula after arthrocentesis has been described [6]. The risk of bleeding complications in patients receiving therapeutic anticoagulation is low and is discussed in detail separately (see "Joint aspiration or injection in adults: Technique and indications", section on 'Approach to the patient on anticoagulants'). Using ultrasound guidance for procedures may decrease the likelihood of bleeding complications, but the rarity of this complication makes it difficult to study [7].
Tendon rupture — Tendon rupture appears to be associated with injections placed directly within tendons and may be accelerated by underlying tendon pathology. Tendon rupture is most commonly encountered when undiluted glucocorticoid is injected near the rotator cuff or near the insertion of the long head of the biceps tendon. This complication may be more common with the posterior approach (which can be directed upward in the direction of the subdeltoid bursae and rotator cuff) than with the anterior approach (which is only intraarticular). (See "Rotator cuff tendinopathy", section on 'Glucocorticoids'.)
Neurovascular damage — Nerve atrophy or necrosis occurs when glucocorticoids enter the nerve sheath directly, an event that usually occurs only with carpal tunnel injections that come quite close to the median nerve. This complication can generally be avoided if the procedure is done by a subspecialist with specific training and knowledge of regional anatomy (eg, a hand surgeon or a rheumatologist). Ultrasound guidance may also be helpful if available. (See "Carpal tunnel syndrome: Treatment and prognosis", section on 'Glucocorticoid injection'.)
Glucocorticoid-associated toxicity
Postinjection flare — Postinjection flare is one of the more common acute side effects of an intraarticular glucocorticoid injection, occurring after approximately 5 percent of injections [8]. It is characterized by a localized inflammatory response that typically occurs and resolves within 48 hours after injection. Postinjection flares are thought to result from a chemical synovitis in response to the crystals in the glucocorticoid solution. Triamcinolone, which is less soluble than the other more commonly used preparations, is associated with more postinjection flares [9,10].
In some cases, the flare can be difficult to distinguish from iatrogenic septic arthritis. One helpful clue is that most iatrogenic joint infections seem to develop clinical signs a bit more slowly than a postinjection flare. In addition, postinjection flares primarily occur with soft tissue, tendon, or trigger point injections, while infections are rare and occur primarily with intraarticular injections.
Facial flushing — Facial flushing after glucocorticoid injection has been reported in as many as 10 percent of patients and is more common in women [8]. The onset of flushing is usually within a few hours after injection and may persist for a few days [11]. Facial flushing may often be described as an "allergic reaction" by some patients but is probably not a true allergy in most patients.
Local skin or fat changes — Skin or fat atrophy and skin hypopigmentation are more commonly observed with injections of superficial structures (eg, ganglia, tendon sheath) but can also occur with deeper injections. Skin or fat atrophy are observed clinically as a depressed area of skin, which may develop weeks or months after the injection. Darkly pigmented skin is more susceptible to hypopigmentation and depigmentation, and patients should be informed of such a potential complication (picture 1).
Osteonecrosis — An uncommon complication of intraarticular glucocorticoids is osteonecrosis (ischemic or avascular necrosis of bone) [12-14]. The risk of this complication is reported to range from less than 0.1 to 3 percent of injected joints [15,16]. However, the former figure seems more consistent with clinical practice. It has been hypothesized that the severity of the underlying joint disease may contribute more to this risk than the injection itself.
Cartilage damage — There is limited evidence suggesting that repeated intraarticular glucocorticoid injections may result in cartilage loss for patients with osteoarthritis [10]:
●In a randomized trial with 140 patients with symptomatic knee osteoarthritis, those who received intraarticular triamcinolone every three months for two years demonstrated greater cartilage volume loss on magnetic resonance imaging (MRI) compared with those who received placebo injections [17].
●Another randomized trial with two-year follow-up found no difference in adverse effects when comparing intraarticular glucocorticoids with placebo injections; however, radiography was used to assess progression of osteoarthritis, which is a less sensitive measure of cartilage damage compared with MRI [18].
●A cohort study of 656 patients receiving an average of two injections over five years confirmed that infrequent injection does not raise the rate of total knee replacement or radiographic progression as determined by radiography [19].
In addition, rare cases of rapidly destructive hip disease have been described in association with intraarticular glucocorticoid injections in the hip. A case-control study of patients undergoing hip arthroplasty noted that the rate of developing rapidly destructive hip disease was higher among patients who received intraarticular glucocorticoid injections, and the risk was positively correlated with higher doses of glucocorticoids and a higher number of injections [20]. The role for intraarticular glucocorticoid injections in hip osteoarthritis is discussed in more detail separately. (See "Management of hip osteoarthritis", section on 'Limited role of intraarticular glucocorticoids'.)
It is possible that the risk of joint cartilage damage is comparatively less when glucocorticoid injections are used to control flares of inflammatory arthritis (eg, rheumatoid arthritis), since not treating the underlying disease may also cause cartilage damage. In one small retrospective study, repeated glucocorticoid injection into large joints affected by rheumatoid arthritis did not result in an increased rate of total joint arthroplasty in those joints during long-term follow-up [21].
Systemic effects — Intraarticular glucocorticoids do have some degree of systemic absorption and can therefore cause systemic adverse effects. A more common adverse effect is transient hyperglycemia, which may be problematic for patients with diabetes mellitus (DM). However, patients generally experience higher blood glucose values for one to two days, which rarely poses a significant clinical risk when the DM is well controlled. (See "Comorbidities that impact management of osteoarthritis", section on 'Diabetes mellitus'.)
A rare side effect related to systemic absorption of intraarticular glucocorticoids is suppression of the hypothalamic-pituitary axis [22]. Other rare systemic complications that can be seen are ecchymoses, menstrual irregularity, accelerated cataract formation, and osteoporosis. Bone metabolism markers suggest that bone metabolism recovers completely in one to two weeks after the injection [18,23]. Glucocorticoid-induced osteoporosis is probably not a major concern for the majority of patients who have reasonably long intervals between their injections. (See "Clinical features and evaluation of glucocorticoid-induced osteoporosis" and "Major adverse effects of systemic glucocorticoids".)
Allergic reaction — The incidence of allergic reactions is unknown. Facial flushing may often be misinterpreted as an allergic reaction by some patients. (See 'Facial flushing' above.)
Other — Other rare complications that have been described include dystrophic calcification, Charcot-like arthropathy, or embolia cutis medicamentosa (also known as livedoid dermatitis and Nicolau syndrome).
SUMMARY AND RECOMMENDATIONS
●Infectious complications – Bacteria can be introduced into the joint space or nearby bursae during joint aspiration or injection. Iatrogenic septic arthritis from a joint procedure is a rare but serious complication that occurs in 1 out of every 1000 to 3000 procedures. Infection, rather than the more common postinjection flare, should be suspected if the flare lasts longer than or begins later than 48 hours after injection. Septic bursitis can result from direct inoculation due to puncture of the overlying skin during an injection. (See 'Septic arthritis' above and "Septic arthritis in adults" and "Septic bursitis".)
●Technique-related complications – Noninfectious complications that are directly related to technique include bleeding, tendon rupture, and neurovascular damage. Tendon rupture appears to be associated with injections placed directly within tendons and may be accelerated by underlying tendon pathology. Nerve atrophy or necrosis occurs when glucocorticoids enter the nerve sheath directly, as can happen with carpal tunnel injections. (See 'Tendon rupture' above and 'Neurovascular damage' above.)
●Glucocorticoid-associated adverse effects – Complications of intraarticular glucocorticoid injections related to the medication include postinjection flare, facial flushing, local skin or fat changes, osteonecrosis, cartilage damage, systemic effects (eg, hyperglycemia), allergic reactions, and other rare complications (eg dystrophic calcification, Charcot-like arthropathy, or embolia cutis medicamentosa [also known as livedoid dermatitis and Nicolau syndrome]). (See 'Glucocorticoid-associated toxicity' above.)
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