Ultrasound-guided hip joint injection

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Anterior longitudinal approach. An arrow parallel to the long axis of the transducer is drawn on the skin adjacent to the end of transducer where the needle will be introduced. Hip joint injection by anterior longitudinal approach.jpg
Anterior longitudinal approach. An arrow parallel to the long axis of the transducer is drawn on the skin adjacent to the end of transducer where the needle will be introduced.

Ultrasound-guided hip joint injection is a joint injection in the hip, assisted by medical ultrasound. Hip and groin pain often presents a diagnostic and therapeutic challenge. The differential diagnosis is extensive, comprising intra-articular and extra-articular pathology and referred pain from lumbar spine, knee and elsewhere in the pelvis. Various ultrasound-guided techniques have been described in the hip and groin region for diagnostic and therapeutic purposes. Ultrasound has many advantages over other imaging modalities, including portability, lack of ionizing radiation and real-time visualization of soft tissues and neurovascular structures. Many studies have demonstrated the safety, accuracy and efficacy of ultrasound-guided techniques, [2] although there is lack of standardization regarding the injectates used and long-term benefit remains uncertain. [1]

Contents

Introduction

The hip and groin are sites of multiple injuries and inflammatory conditions, including intra-articular and extra-articular pathology, giving rise to an extensive differential diagnosis for hip and groin pain. Pain originating from different anatomical areas such as lumbar spine, knee and pelvis can also be referred to the hip and groin. Often, patients with hip conditions have concomitant knee or spine conditions, which may present difficult therapeutic and diagnostic dilemmas. Given the complexity of hip and groin anatomy and clinical conditions, imaging-guided injections are useful both for the diagnostic workup and treatment. The main advantages of ultrasound-guided injection are its safety, portability and lack of ionising radiation. Injectates can include corticosteroid, local anaesthetic, platelet-rich plasma (PRP), viscosupplement and dextrose prolotherapy. [1]

The total volume injected is usually 6–7ml. [1]

General principles for ultrasound-guided injection

Usual standards for musculoskeletal interventional procedures apply include review of previous imaging, informed consent and appropriate local anesthetic. The use of a high-frequency (> 10 MHz) linear array transducer is recommended, but lower-frequency curvilinear probes may be occasionally required to visualize deep structures in larger patients. A preliminary diagnostic sonographic examination, including color Doppler of the area to be punctured is necessary to define the relationship of adjacent neurovascular structures. [1]

Injections should be performed with adherence to aseptic technique although this varies between institutions and radiologists attributable to resources, training, perceived risk and experience. In a survey of 250 health professionals in the United Kingdom, 43.5% believed infection rates were < 1/1000 following intra-articular injections, 33.0% perceived rates were < 1/100, and 2.6% perceived the risk as negligible. [1] Sterile preparation of the entire injection field, including adjacent skin where the gel and probe are applied, is recommended. Areas of superficial infection such as cellulitis or abscess should be avoided to prevent deeper spread. [1]

Before sterile preparation, the procedure often begins with a preliminary sonography in order to determine a safe route of access. At this point, an evaluate may also be performed over the joint area for any joint effusion, or any thickening or hyperemia of the joint capsule. A line parallel to the long axis of the transducer can be drawn on the skin adjacent to the end of transducer in order to mark where the needle will be introduced. [1]

Once the patient’s skin is sterilized and initial needle entry is made adjacent to the mark, the probe can be returned quickly to the same location and orientation by aligning to the skin mark. The needle is directed toward the intended target by a freehand technique. The needle size, length and type should be selected based on the site, depth and patient’s body habitus. 22–24G needles are sufficed for most injections. [1]

The risk of clinically significant bleeding is minimal, so coagulation tests are not needed before the procedure. It can for example be performed during chronic warfarin therapy with therapeutic coagulation levels. [3]

Anatomy

The hip joint is a ball-and-socket synovial joint, formed by an articulation between the femur and acetabulum. Intra-articular etiology of hip pain includes osteoarthritis, inflammatory arthropathy, acetabular labral tears and femoro-acetabular impingement. Injection of short and long acting anesthetic agents can be useful in confirming hip pathology and differentiating asymptomatic intra-articular pathology from extra-articular conditions that may be the source of symptoms. Complete relief of hip pain following intra-articular injection of local anaesthetic is associated with good surgical outcome following joint replacement. [1]

Injection approach

Anterior longitudinal approach. The needle is introduced from an inferior and anterior approach, lateral to the femoral neurovascular bundle (arrow). A, acetabulum; H, femoral head; N, femoral neck; double arrow - anterior joint recess. Ultrasonography of hip joint injection by anterior longitudinal approach.jpg
Anterior longitudinal approach. The needle is introduced from an inferior and anterior approach, lateral to the femoral neurovascular bundle (arrow). A, acetabulum; H, femoral head; N, femoral neck; double arrow – anterior joint recess.

Two common anterior approaches are typically used both with the patient lying supine:

Anterolateral approach, here shown as a transverse image. The needle will rest on the femoral head (arrow). A, acetabulum; H, femoral head; N, femoral neck; LAT, lateral; MED, medial. Ultrasonography of hip joint injection by anterolateral approach.jpg
Anterolateral approach, here shown as a transverse image. The needle will rest on the femoral head (arrow). A, acetabulum; H, femoral head; N, femoral neck; LAT, lateral; MED, medial.

Comparison to other methods

Initial treatment options include activity modification, analgesia and physical therapy. When symptoms persist despite these measures, hip injections can be considered. Intra-articular hip injections can be technically challenging due to depth, variable body habitus, and the proximity to the femoral neurovascular bundle. Image guidance is therefore advocated to ensure safe and accurate needle placement. Fluoroscopic-guidance was the mainstay imaging-guidance hip injection, but ultrasound-guidance is becoming increasingly prevalent due to its accuracy with visualization of soft tissue and neurovascular structures, less associated cost and no ionizing radiation exposure or risk of contrast agent reactions. A position statement by the American Medical Society for Sports Medicine reviewed the literature and found several level one studies of ultrasound guided hip injections with a mean accuracy of 99%. In addition, a recent meta-analysis revealed that ultrasound-guided hip joint injections were significantly more accurate than landmark-guided intra-articular hip injections (accuracies were 100%, 95%CI 98–100%; 72%, 95%CI 56–85%, respectively). [1]

To date, many trials examining efficacy of intra-articular corticosteroid injection for osteoarthritis, either under fluoroscopy or ultrasound-guidance, have revealed short-term improvement of hip pain, though no reliable predictors of response to intra-articular corticosteroid injections have been identified. While it has been shown that no significant difference in terms of effectiveness between fluoroscopy and ultrasound-guided corticosteroid hip injection, it has been reported that ultrasound-guided injections were less painful and preferred by patients. [1]

Injectates in osteoarthritis

For pain relief in osteoarthritis, the injectate may be for example:

Efficacy in osteoarthritis

In osteoarthritis, joint injection of glucocorticoids leads to short term pain relief, with onset after 2 to 7 days, [6] that may last between a few weeks and a few months. [7] A local anesthetic reduces pain from 15 to 20 minutes after the injection, and lasts about 4 to 6 hours. [6]

Injections of hyaluronic acid have not produced improvement compared to placebo for knee arthritis, [8] [9] but did increase risk of further pain. [8]

Related Research Articles

<span class="mw-page-title-main">Medical ultrasound</span> Diagnostic and therapeutic technique

Medical ultrasound includes diagnostic techniques using ultrasound, as well as therapeutic applications of ultrasound. In diagnosis, it is used to create an image of internal body structures such as tendons, muscles, joints, blood vessels, and internal organs, to measure some characteristics or to generate an informative audible sound. The usage of ultrasound to produce visual images for medicine is called medical ultrasonography or simply sonography, or echography. The practice of examining pregnant women using ultrasound is called obstetric ultrasonography, and was an early development of clinical ultrasonography. The machine used is called an ultrasound machine, a sonograph or an echograph. The visual image formed using this technique is called an ultrasonogram, a sonogram or an echogram.

<span class="mw-page-title-main">Knee</span> Leg joint in primates

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

<span class="mw-page-title-main">Osteoarthritis</span> Form of arthritis caused by degeneration of joints

Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the world. The most common symptoms are joint pain and stiffness. Usually the symptoms progress slowly over years. Other symptoms may include joint swelling, decreased range of motion, and, when the back is affected, weakness or numbness of the arms and legs. The most commonly involved joints are the two near the ends of the fingers and the joint at the base of the thumbs, the knee and hip joints, and the joints of the neck and lower back. The symptoms can interfere with work and normal daily activities. Unlike some other types of arthritis, only the joints, not internal organs, are affected.

<span class="mw-page-title-main">Hip replacement</span> Surgery replacing hip joint with prosthetic implant

Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis. Hip replacement surgery can be performed as a total replacement or a hemi/semi(half) replacement. Such joint replacement orthopaedic surgery is generally conducted to relieve arthritis pain or in some hip fractures. A total hip replacement consists of replacing both the acetabulum and the femoral head while hemiarthroplasty generally only replaces the femoral head. Hip replacement is one of the most common orthopaedic operations, though patient satisfaction varies widely. Approximately 58% of total hip replacements are estimated to last 25 years. The average cost of a total hip replacement in 2012 was $40,364 in the United States, and about $7,700 to $12,000 in most European countries.

<span class="mw-page-title-main">Joint injection</span> Method of delivering drugs into a joint

In medicine, a joint injection is a procedure used in the treatment of inflammatory joint conditions, such as rheumatoid arthritis, psoriatic arthritis, gout, tendinitis, bursitis, Carpal Tunnel Syndrome, and occasionally osteoarthritis. A hypodermic needle is injected into the affected joint where it delivers a dose of any one of many anti-inflammatory agents, the most common of which are corticosteroids. Hyaluronic acid, because of its high viscosity, is sometimes used to replace bursa fluids. The technique may be used to also withdraw excess fluid from the joint.

<span class="mw-page-title-main">Hip</span> Anatomical region between the torso and the legs, holding the buttocks and genital region

In vertebrate anatomy, hip refers to either an anatomical region or a joint.

<span class="mw-page-title-main">Nerve block</span> Deliberate inhibition of nerve impulses

Nerve block or regional nerve blockade is any deliberate interruption of signals traveling along a nerve, often for the purpose of pain relief. Local anesthetic nerve block is a short-term block, usually lasting hours or days, involving the injection of an anesthetic, a corticosteroid, and other agents onto or near a nerve. Neurolytic block, the deliberate temporary degeneration of nerve fibers through the application of chemicals, heat, or freezing, produces a block that may persist for weeks, months, or indefinitely. Neurectomy, the cutting through or removal of a nerve or a section of a nerve, usually produces a permanent block. Because neurectomy of a sensory nerve is often followed, months later, by the emergence of new, more intense pain, sensory nerve neurectomy is rarely performed.

<span class="mw-page-title-main">Arthrogram</span>

An arthrogram is a series of images of a joint after injection of a contrast medium, usually done by fluoroscopy or MRI. The injection is normally done under a local anesthetic such as Novocain or lidocaine. The radiologist or radiographer performs the study using fluoroscopy or x-ray to guide the placement of the needle into the joint and then injects around 10 ml of contrast based on age. There is some burning pain from the anesthetic and a painful bubbling feeling in the joint after the contrast is injected. This only lasts 20 – 30 hours until the Contrast is absorbed. During this time, while it is allowed, it is painful to use the limb for around 10 hours. After that the radiologist can more clearly see what is going on under your skin and can get results out within 24 to 48 hours.

<span class="mw-page-title-main">Knee replacement</span> Surgical procedure

Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources. It may also be performed for other knee diseases, such as rheumatoid arthritis. In patients with severe deformity from advanced rheumatoid arthritis, trauma, or long-standing osteoarthritis, the surgery may be more complicated and carry higher risk. Osteoporosis does not typically cause knee pain, deformity, or inflammation, and is not a reason to perform knee replacement.

<span class="mw-page-title-main">Snapping hip syndrome</span> Medical condition

Snapping hip syndrome, also referred to as dancer's hip, is a medical condition characterized by a snapping sensation felt when the hip is flexed and extended. This may be accompanied by a snapping or popping noise and pain or discomfort. Pain often decreases with rest and diminished activity. Snapping hip syndrome is commonly classified by the location of the snapping as either extra-articular or intra-articular.

The knee examination, in medicine and physiotherapy, is performed as part of a physical examination, or when a patient presents with knee pain or a history that suggests a pathology of the knee joint.

<span class="mw-page-title-main">Acetabular labrum</span> Ring of cartilage that surrounds the acetabulum of the hip

The acetabular labrum is a fibrocartilaginous ring which surrounds the circumference of the acetabulum of the hip, deepening the acetabulum. The labrum is attached onto the bony rim and transverse acetabular ligament. It is triangular in cross-section.

<span class="mw-page-title-main">3D ultrasound</span> Rendering technique in medical imaging

3D ultrasound is a medical ultrasound technique, often used in fetal, cardiac, trans-rectal and intra-vascular applications. 3D ultrasound refers specifically to the volume rendering of ultrasound data. When involving a series of 3D volumes collected over time, it can also be referred to as 4D ultrasound or real-time 3D ultrasound.

<span class="mw-page-title-main">Femoroacetabular impingement</span> Medical condition

Femoroacetabular impingement (FAI) is a condition involving one or more anatomical abnormalities of the hip joint, which is a ball and socket joint. It is a common cause of hip pain and discomfort in young and middle-aged adults. It occurs when the ball shaped femoral head contacts the acetabulum abnormally or does not permit a normal range of motion in the acetabular socket. Damage can occur to the articular cartilage, or labral cartilage, or both. The condition may be symptomatic or asymptomatic. It may cause osteoarthritis of the hip. Treatment options range from conservative management to surgery.

<span class="mw-page-title-main">Sacroiliac joint dysfunction</span> Medical condition

The term sacroiliac joint dysfunction refers to abnormal motion in the sacroiliac joint, either too much motion or too little motion, that causes pain in this region.

<span class="mw-page-title-main">Hip arthroscopy</span>

Hip arthroscopy refers to the viewing of the interior of the acetabulofemoral (hip) joint through an arthroscope and the treatment of hip pathology through a minimally invasive approach. This technique is sometimes used to help in the treatment of various joint disorders and has gained popularity because of the small incisions used and shorter recovery times when compared with conventional surgical techniques. Hip arthroscopy was not feasible until recently, new technology in both the tools used and the ability to distract the hip joint has led to a recent surge in the ability to do hip arthroscopy and the popularity of it.

Gene therapy for osteoarthritis is the application of gene therapy to treat osteoarthritis (OA). Unlike pharmacological treatments which are administered locally or systemically as a series of interventions, gene therapy aims to establish sustained therapeutic effect after a single, local injection.

<span class="mw-page-title-main">Hip pain</span>

Pain in the hip is the experience of pain in the muscles or joints in the hip/ pelvic region, a condition commonly arising from any of a number of factors. Sometimes it is closely associated with lower back pain.

<span class="mw-page-title-main">Femoral nerve block</span>

A femoral nerve block is a nerve block that uses local anesthetic to achieve analgesia in the leg. The block works by affecting the femoral nerve.

Radiosynoviorthesis (RSO) is a minimally invasive therapeutic procedure for managing joint inflammation, particularly synovitis associated with osteoarthritis. Radiosynoviorthesis involves the intra-articular injection of radioactive isotopes to specifically treat the inflamed synovial membrane. Synovitis, a hallmark of various joint disorders, including osteoarthritis, manifests as inflammation within the synovial membrane lining the joints. RSO aims to suppress overactive macrophage and synovial cells responsible for the inflammatory response, providing relief from pain and improving joint functionality.

References

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