Hip injection Fluoro vs US

[nvrsumr]

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Does anyone have a pdf of an article showing similar accuracy of US hip injection and fluoro hip injection?

I have a WC IME doc with his panties in a bunch over me using US.

Thank you in advance

 

[jsaul]

Does anyone have a pdf of an article showing similar accuracy of US hip injection and fluoro hip injection?

I have a WC IME doc with his panties in a bunch over me using US.

Thank you in advance

he is worked up because it is more expensive to use ultrasound versus flouro

 

[nvrsumr]

he is worked up because it is more expensive to use ultrasound versus flouro

Probably. I get worked up over how much I get paid to absorb radiation. Still gonna do with US. Anyone have a good study.

Thank you in advance.

 

[drf]

PM R. 2013 Feb;5(2):129-34. doi: 10.1016/j.pmrj.2012.08.010. Epub 2012 Sep 8.
Intra-articular hip injections using ultrasound guidance: accuracy using a linear array transducer.
Levi DS.
Source
APM Spine and Sports Physicians, 5665 Lowery Road, Norfolk, VA 23502, USA. [email protected]
Abstract
OBJECTIVE:
To describe the accuracy of sonographically guided intra-articular hip injections with a linear array transducer.
DESIGN:
Retrospective review.
SETTING:
Private outpatient clinic.
METHODS:
A single experienced operator performed 11 ultrasound-guided intra-articular hip injections by using a linear array transducer. Intra-articular placement was confirmed with contrast agent and fluoroscopy.
MAIN OUTCOME MEASUREMENTS:
Assessment of injected contrast within the hip joint via fluoroscopic imaging.
RESULTS:
All 11 sonographically guided hip injections were accurately placed within the hip joint by the use of a linear array transducer (100% accuracy).
CONCLUSION:
This retrospective review suggests that physicians who use a linear array transducer can accurately perform intra-articular hip injections in an outpatient setting.
Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.

 

[drf]

J Ultrasound Med. 2009 Mar;28(3):329-35.
Accuracy of sonographically guided intra-articular injections in the native adult hip.
Smith J, Hurdle MF, Weingarten TN.
Source
Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA. [email protected]
Abstract
OBJECTIVE:
The purpose of this study was to determine the accuracy of sonographically guided intra-articular injections performed in the native adult hip using contrast-enhanced fluoroscopy as a reference standard.
METHODS:
Twenty-eight consecutive patients (ages 32-91 years; mean, 68 years) referred to the pain clinic for intra-articular hip injections were recruited to participate. In each case, a 2- to 6-MHz curvilinear array transducer was used to place the needle into the hip joint at the femoral head-neck junction using an oblique sagittal approach. A contrast-enhanced fluoroscopic examination was then completed and assessed by an independent observer to determine needle placement accuracy. Once accurate placement was confirmed, the therapeutic injection proceeded.
RESULTS:
Thirty hip injections were completed in 15 women and 13 men (1 man and 1 woman received bilateral injections). The patients' body mass index (BMI) ranged from 20 to 39 kg/cm(2) (mean, 28 kg/cm(2)) and procedure time from initial scanning to injection averaged 112 seconds (range, 47-187 seconds). Overall, 97% of sonographically placed needles were accurate. The single inaccurate placement resulted from inadvertent needle withdrawal from the joint capsule during connection of the extension tubing for contrast agent injection in a young patient with a BMI of 28 kg/cm(2) and no hip effusion.
CONCLUSIONS:
Sonographic guidance can be used to inject the native adult hip joint with acceptable accuracy. When using the oblique sagittal approach, operators must be aware of the possibility of needle withdrawal from the joint due to the limited intra-articular space within the target region, particularly in the absence of effusion.

 

[drf]

Accuracy and outcome of sonographically guided intra-articular sodium hyaluronate injections in patients with osteoarthritis of the hip.
Pourbagher MA, Ozalay M, Pourbagher A.
Source
Department of Radiology, Baskent University, Adana Teaching and Medical Research Center, Yuregir, 01250 Adana, Turkey. [email protected]
Abstract
OBJECTIVE:
The aim of this study was to evaluate the accuracy and outcome of sonographically guided intra-articular sodium hyaluronate injections in patients with osteoarthritis of the hip.
METHODS:
The prospective study involved 10 patients who had the diagnosis of unilateral hip osteoarthritis. The mean age of the patients was 63.2 years (range, 27-80 years). Depending on patient body weight, either a 3.5- to 5-MHz convex transducer or a 5- to 12-MHz linear transducer was used to examine each affected joint. Every subject received 3 injections of sodium hyaluronate, 1 per week for 3 consecutive weeks. With real-time sonographic monitoring, each joint was penetrated with a 20-gauge Chiba needle. Contrast medium was injected initially, and proper intra-articular placement was verified with computed tomography before the hyaluronate injection. Each patient's outcome was assessed on the basis of visual analog scale results and Western Ontario and McMaster Universities osteoarthritis index findings that were recorded before the set of injections and 2, 4, and 6 months after the third injection.
RESULTS:
Computed tomography confirmed accurate placement in all 30 injections in the study. The visual analog scale and the Western Ontario and McMaster Universities osteoarthritis index scores showed that 80% of the patients had less pain in the joint at 6 months after the last injection.
CONCLUSIONS:
Sonographically guided intra-articular injection of sodium hyaluronate for patients with hip osteoarthritis is easy to perform and is a safe, economical, and well-tolerated form of treatment. In contrast to fluoroscopic or computed tomographic guidance, the sonographic technique exposes neither the patient nor the physician to radiation.

 

[specepic]

more expensive??? Minimally or perhaps you are comparing non guided with guided.

Safer (can see anterior circumflex artery)

No radiation

More convenient for pt for those of us w/o in office fluoro

WC IME doc's get things wrong 99% of the time IMO

 

[nvrsumr]

Thank you!

 

[Gauss]

doing at ASC has got to be more expensive than in office US

 

[clubdeac]

I am treating a WC patient with low back pain that radiates into the posterior and anterior hip and thigh. MRI and MR arthrogram of the hip are negative. MRI of the spine shows left L3/4 lateral recess stenosis. I want to do a left L3/4 TFESI. They deny it stating they are only treating his "hip pain". What a bunch of *****s!!

 

[Jcm800]

i have fluoro and U/S in the office, i always go back to fluoro since it is SOOOO easy and virtually 100% accurate. I have gotten better at doing it with U/S, but aside from money, i cant see the advantage. a few little shots of pulsed fluoro is minimal radiation. In my hands, albeit i am not the best at U/S (although getting better) i still prefer fluoro, especially in the fatties.

i would love to be convinced that U/S was better because it was as accurate and safer, but i am not.

 

[drf]

I don't think it is more accurate or safer.

But it works if one doesn't have fluoro.

 

[clubdeac]

I can't imagine that it would be more accurate. How many times have you dropped the needle onto the head/neck junction to only get a blobogram requiring you to reposition a little medial, lateral, inferior or superior. Has happened to me frequently in tight joints. In the US course I attended, the instructor advanced the needle to the fem head/neck junction and said it was as easy as that. Well, from fluoro we all know just b/c you're at the junction doesn't mean you're in.

 

[jsaul]

I can't imagine that it would be more accurate. How many times have you dropped the needle onto the head/neck junction to only get a blobogram requiring you to reposition a little medial, lateral, inferior or superior. Has happened to me frequently in tight joints. In the US course I attended, the instructor advanced the needle to the fem head/neck junction and said it was as easy as that. Well, from fluoro we all know just b/c you're at the junction doesn't mean you're in.

exactly... you guys are tricking yourselves thinking it is easier with ultrasound. it is 100 percent accurate with flouro and quicker with flouro

 

[pmrrmp]

...How many times have you dropped the needle onto the head/neck junction to only get a blobogram requiring you to reposition a little medial, lateral, inferior or superior.

Haha, I like that term, "blobogram."

 

[bedrock]

exactly... you guys are tricking yourselves thinking it is easier with ultrasound. it is 100 percent accurate with flouro and quicker with flouro

Quicker and easier with flouro

I think is it safer with US as you can see the the anterior circumflex artery. No guarantee you can see arterial flow, injecting live under fluoro. And less radiation to you and patient.

Financially its a wash. The extra pay for US guidance is offset by the extra time it takes.

 

[specepic]

I'm sorry to say this folks but if you find US to take longer or be less accurate the problem is with the carpenter not the tool. Come to our AAPMR US course in August and I'll show you why. 😀

Seriously though, I can watch the needle pierce the capsule with US and it is quick with both methods.

I can do it very fast with US no issue, sounds a little d*ickish but perhaps you are doing it wrong or need more practice

If you land head/necak under fluoro and get a blobogram it probably means you have a problem with depth or angle or artifact, all eliminated with US use

If BMI really high I do Fluoro

 

[Jcm800]

repeat this all to me when U/S gets decimated, and it actually pays more with fluoro... I do like not wearing lead and and getting radiated, but i just cant see it.

I'm sorry to say this folks but if you find US to take longer or be less accurate the problem is with the carpenter not the tool. Come to our AAPMR US course in August and I'll show you why. 😀

Seriously though, I can watch the needle pierce the capsule with US and it is quick with both methods.

I can do it very fast with US no issue, sounds a little d*ickish but perhaps you are doing it wrong or need more practice

If you land head/necak under fluoro and get a blobogram it probably means you have a problem with depth or angle or artifact, all eliminated with US use

If BMI really high I do Fluoro

 

[SSdoc33]

I'm sorry to say this folks but if you find US to take longer or be less accurate the problem is with the carpenter not the tool. Come to our AAPMR US course in August and I'll show you why. 😀

Seriously though, I can watch the needle pierce the capsule with US and it is quick with both methods.

I can do it very fast with US no issue, sounds a little d*ickish but perhaps you are doing it wrong or need more practice

If you land head/necak under fluoro and get a blobogram it probably means you have a problem with depth or angle or artifact, all eliminated with US use

If BMI really high I do Fluoro

needle in to needle out takes me 10 seconds for a hip injection. i might sound a little dickish, but maybe you need to get better with the flourroscope.

 

[specepic]

needle in to needle out takes me 10 seconds for a hip injection. i might sound a little dickish, but maybe you need to get better with the flourroscope.

I said they are both fast. The issue people had here was that they felt US was slow. It is not in the right hands.

US works better for me b/c I have it right in the office and my fluoro time at the hosp is wasted with hip inj's, etc.

So, yes, you snd d88kish for not reading my post carefully

 

[specepic]

repeat this all to me when U/S gets decimated, and it actually pays more with fluoro... I do like not wearing lead and and getting radiated, but i just cant see it.

US will take a hit I'm sure but so hasnt fluoro several times over the last few yrs. I'm sure you are aware of the frequent cuts made with fluoro porcedures.

What "can't you see"?

Where I got a little snarky is with the US nay sayers on here who ditch on it b/c they either/or:

- arent good at it
- werent trained properly or at all
- dont know what they are talking about
- dont have a machine

If you like fluoro, fine, nothing wrong with doing a hip under fluoro. But if you are bad at US, dont blame the technology or the machine, or me for that matter.

Cheers

 

[Ligament]

Faster with fluoro, but almost as fast with U/S. I prefer to do it with U/S now.

The exceptions:
1. Horribly arthritic joints easier to do with fluoro
2. Very fat fatties easier with fluoro, if not impossible with portable U/S

One can see the labrum quite clearly with U/S. One can watch the needle tip penetrate the labrum and enter the intra-articular space. Can then watch the injectate flow up and around the femoral head.

 

[specepic]

Faster with fluoro, but almost as fast with U/S. I prefer to do it with U/S now.

The exceptions:
1. Horribly arthritic joints easier to do with fluoro
2. Very fat fatties easier with fluoro, if not impossible with portable U/S

One can see the labrum quite clearly with U/S. One can watch the needle tip penetrate the labrum and enter the intra-articular space. Can then watch the injectate flow up and around the femoral head.

hopefully you mean hip capsule when you say labrum. I don't really see the problem with very arthritic joints as either fluoroscopy or ultrasound technique tends to use the indirect approach of sneaking through the capsule at the head neck junction. that being said, sometimes the landmarks can be more challenging with lots of osteophytes and I think that is what you're getting at and in those cases I certainly agree.

Very much agree with regard to super obese patients, can be very challenging with ultrasound, although I will usually take a look as sometimes these patients have a surprisingly short distance from the skin to the hip capsule and carried her weight elsewhere. ( kind of like that very obese patient where you are sure you will need a 5 inch needle to reach their lumbar spine and it turns out that actually have a "skinny back")

What has been nice about going back and forth between the fluoroscopy and ultrasound is seeing a detailed skin to joint anatomy with ultrasound has helped inform better angle of approach with fluoroscopy. I often see radiologist's take a completely straight up and down anterior/posterior approach to the head neck junction, whereas I tend to use an angled approach, very similar to the angle used for ultrasound even when I do fluoroscopy, which I think gives some extra clearance to the neurovascular bundle among other considerations

 

[lobelsteve]

. I often see radiologist's take a completely straight up and down anterior/posterior approach to the head neck junction, whereas I tend to use an angled approach, very similar to the angle used for ultrasound even when I do fluoroscopy, which I think gives some extra clearance to the neurovascular bundle among other considerations

+1.

I start 2" lateral to any pulsing thingies.

 

[Jcm800]

i have both ultrasound and fluoro in my office, much like some of you. So i can do either, and neither takes me much longer than the other. U/S takes me a bit longer because i put a sterile cover over the probe, etc... but not much longer. But i dont care if it takes me longer to do it U/S, if it is AS good. Even if it takes 5 minutes longer (which is a long time, in the large scheme of things) if i didnt have to wear lead, get radiated, etc, it is worth it to me. if they want to pay me more, even better. But...

I have gotten much better at U/S then previously, but I am still no guru, but this is what i found. Despite being "trained" on how to do a "proper" hip injection, where the guy showing me, who is known to be very good, i was not convinced that you could be positive you are in the right place, ie the comment someone made about the blobogram.

so here is what i did, to prove it to myself, so that i felt confident i was making the decision to use U/S for hips not for money, but for the ease, and the lack of radiation with similar results... I took them in the fluoro room, and i did the injection with U/S, but injected contrast. Got the needle as perfect as i thought it could be, i didnt care how long it took to get the needle perfect. i then took a fluoro shot. 30-50% it was not perfect. I then repositioned, took more shots, still not always perfect. could i be TERRIBLE at U/S and this is ALL ME, possibly, but i doubt it.

point is, Fluoro is ALWAYS perfect. Now two questions 1) Does it matter if its perfect, it might work just as well to be "close", i dont know. i dont think we really know. 2) do you have fluoro in your office. if the answer to #2 is no, i get the use of U/S. I still dont think it is as good, but for a patient it might make sense to get a second goodest injection, instead of dragging them to an ASC for this silly little procedure...

my 2 cents. in conclusion, its possible i suck at U/S hips, but i dont think so. and ultimately, for me, it was more important to always get it right, then the benefits of using U/S when i have my own fluoro. So i give up the extra cash, because for me, its is more important that the injection be perfect EVERY time.

Maybe you all get it perfect every time with U/S, but i would like you guys to try my experiment and report back your HONEST findings...

hopefully you mean hip capsule when you say labrum. I don't really see the problem with very arthritic joints as either fluoroscopy or ultrasound technique tends to use the indirect approach of sneaking through the capsule at the head neck junction. that being said, sometimes the landmarks can be more challenging with lots of osteophytes and I think that is what you're getting at and in those cases I certainly agree.

Very much agree with regard to super obese patients, can be very challenging with ultrasound, although I will usually take a look as sometimes these patients have a surprisingly short distance from the skin to the hip capsule and carried her weight elsewhere. ( kind of like that very obese patient where you are sure you will need a 5 inch needle to reach their lumbar spine and it turns out that actually have a "skinny back")

What has been nice about going back and forth between the fluoroscopy and ultrasound is seeing a detailed skin to joint anatomy with ultrasound has helped inform better angle of approach with fluoroscopy. I often see radiologist's take a completely straight up and down anterior/posterior approach to the head neck junction, whereas I tend to use an angled approach, very similar to the angle used for ultrasound even when I do fluoroscopy, which I think gives some extra clearance to the neurovascular bundle among other considerations

 

[epidural man]

US will take a hit I'm sure but so hasnt fluoro several times over the last few yrs. I'm sure you are aware of the frequent cuts made with fluoro porcedures.

What "can't you see"?

Where I got a little snarky is with the US nay sayers on here who ditch on it b/c they either/or:

- arent good at it
- werent trained properly or at all
- dont know what they are talking about
- dont have a machine

If you like fluoro, fine, nothing wrong with doing a hip under fluoro. But if you are bad at US, dont blame the technology or the machine, or me for that matter.

Cheers

👍

Totally agree. People really like to knock ultrasound...not sure why, never have understood that mentality.

I'm probably as good as most with an ultrasound. I try to use it as much as possible since I do worry about a lifetime of xray exposure (and I work in a system that doesn't worry about reimbursement so that is not my motivation).

However, for many things, like a hip, it is hard to beat fluoro. I have recently wanted to start using US for SI Joint injections...but again, hard to beat fluoro.

The thing about ultrasound, which I can't figure out, is that it is so much more fun and satifsfying then xray. For a hip, when you see the needle pierce the capsule and see it lift with the injection, it is just thrilling. When you look at the piriformis muscle, internally/externally rotate the hip and see the muscle slide along and expand/contract - then see the needle pierce the fibers and expand with your injection - it is just exciting. Too watch your RF needle slip next to the ulnar nerve before you pulse it - is really fun. It's hard to explain the thrill of watching the touhy needle slide under the sciatic nerve, then to watch as you deposit the 8 contact lead there for peripheral stimulation.

I think it is true that fluoro is probably often times more accurate, and faster, but there is something about ultrasound guided placement that brings a level of excitement that can't be matched with driving a needle down to OS using a "dot shot" under fluoroscopic guidance and confirming spread with contrast.

 

[specepic]

i have both ultrasound and fluoro in my office, much like some of you. So i can do either, and neither takes me much longer than the other. U/S takes me a bit longer because i put a sterile cover over the probe, etc... but not much longer. But i dont care if it takes me longer to do it U/S, if it is AS good. Even if it takes 5 minutes longer (which is a long time, in the large scheme of things) if i didnt have to wear lead, get radiated, etc, it is worth it to me. if they want to pay me more, even better. But...

I have gotten much better at U/S then previously, but I am still no guru, but this is what i found. Despite being "trained" on how to do a "proper" hip injection, where the guy showing me, who is known to be very good, i was not convinced that you could be positive you are in the right place, ie the comment someone made about the blobogram.

so here is what i did, to prove it to myself, so that i felt confident i was making the decision to use U/S for hips not for money, but for the ease, and the lack of radiation with similar results... I took them in the fluoro room, and i did the injection with U/S, but injected contrast. Got the needle as perfect as i thought it could be, i didnt care how long it took to get the needle perfect. i then took a fluoro shot. 30-50% it was not perfect. I then repositioned, took more shots, still not always perfect. could i be TERRIBLE at U/S and this is ALL ME, possibly, but i doubt it.

point is, Fluoro is ALWAYS perfect. Now two questions 1) Does it matter if its perfect, it might work just as well to be "close", i dont know. i dont think we really know. 2) do you have fluoro in your office. if the answer to #2 is no, i get the use of U/S. I still dont think it is as good, but for a patient it might make sense to get a second goodest injection, instead of dragging them to an ASC for this silly little procedure...

my 2 cents. in conclusion, its possible i suck at U/S hips, but i dont think so. and ultimately, for me, it was more important to always get it right, then the benefits of using U/S when i have my own fluoro. So i give up the extra cash, because for me, its is more important that the injection be perfect EVERY time.

Maybe you all get it perfect every time with U/S, but i would like you guys to try my experiment and report back your HONEST findings...

Pics please

 

[drf]

I learned all my joint injections using US by injecting contrast and taking a pic. I got to at least 5-10 of each joint before i decided I didn't need fluoro anymore. The first few sometimes missed. The last few did not.

There was a nice study I don't remember the journal or author of US guided SIJ. Teaching of residents/fellows etc. the first 30 injections had a success rate of 60%. The last 30 had a success rate of 94%.

Btw I'm not advocating US guided SIJ. It's nice if fluoro is not available or contraindicated for some reason, is all. This is simply an illustration of the learning curve. I can teach a fellow fluoro guided hip in 3 minutes. It takes more than a few injections before they have any idea what is going on with US.

Wait, here it is.

Sacroiliac Joint Injections Performed With Sonographic Guidance
Mehmet Zekai Pekkafalı, MD, Mehmet Zeki Kıralp, MD, Cıhat Çinar Ba ̧sekim, MD, Emir S ̧ ilit, MD, Hakan Mutlu, MD, Ersin Öztürk, MD, E ̧sref Kızılkaya, MD, Hasan Dursun, MD
Objective. To investigate the feasibility and effectiveness of sonographic guidance for therapeutic intra-articular sacroiliac joint injections in patients with sacroiliitis. Methods. Thirty-four consecutive patients with sacroiliitis were enrolled in this study. The synovial portions of 60 sacroiliac joints received injections under sonographic guidance. For treatment, a mixture of a corticosteroid and a local anes- thetic was injected intra-articularly. Fluoroscopic spot images were obtained to assess the accuracy of the sonographically guided technique. Results. Of the 60 sonographically guided injections, 46 (76.7%) were successful (i.e., intra-articular), and 14 (23.3%) were missed. The successful intra-artic- ular injection rate was 60% in the first 30 injections, and it gradually improved, reaching 93.5% in the last 30 injections. The mean procedure time was 9 minutes. Conclusions. Our initial experience sug- gests that sonographically guided therapeutic injections to sacroiliac joints could be valuable alterna- tives to other guidance modalities in patients with sacroiliitis. In the hands of experienced radiologists, this technique is safe, rapid, and reproducible. Key words: intra-articular injection; sacroiliac joint; sonographic guidance.