hip injection techniques

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Doctodd

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brushing up......not a common procedure for me and not one i ever did in residency, but it has been increasing in frequency for me. Most recently i had a big ortho group who is testing me out send me a patient with concomitant spine pathology and they were unclear on if the hip was the pain generator. He was a previous patient of theirs who had the opposite hip replaced a few years ago. I looked at algos' website and the bullseye is about midfemoral head. I was taught to do them laterally to directly reach the joint space. About algos' pics(which may be Rheum journal pics....not sure), it seems like even though it is much lower than the weightbearing surface, i guess enough injectate gets there anyway?...that is my question. Who does hip injections laterally and who does it differently?

correct me if im wrong....comments? By the way, the patient had a sacralization/fusion of the upper SI joint which is where he correlated his pain when the needle hit it and i injected. Post procedure he was doing well. Follow up in 2 weeks. So i think his pain is NOT hip related. And hip had minimal DJD on plain films and under my fluoro.

T
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Lateral to anterolateral approach. Depends on size of patient.
I use a 25G 3.5" Quincke, AP fluoroscopy, contrast arthrogram.
Anywhere from halfway down the femoral neck to the head. The needle does not go into joint space between the head and the acetabulum as this is a synovial joint with a capsule that reflects as far inferior as the base of the femoral neck. Equate this with a knee injection using a superolateral approach and in thin patients a 1/2 " needle will access the subcapsular space. I inject contrast and if I see the arthrogram (rather than a local collection of contrast), I change syringes and put in the cocktail.
 
I do a lot of these for my ortho group - diagnostic, therapeutic and pre-MRI. I use an anterolateral approach. I line it up in a far oblique, guide the needle (22g 3.5") to the joint, then go to AP and get it in. 1-2 cc contrast will usually acumulate either in the joint space or around the femoral neck in a circular pattern.
 
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Ultrasound guidance is a nice tool for intra articular hip injections. Smith and Hurdle describe a nice technique in the Archives of Physical Medicine and Rehabilitation from Feb '06. Basically, visualize the femoral head/neck junction longitudinally to the femoral neck, guide the needle down to the junction, pop through the ileofemoral ligament, and inject a few cc's of local which is anechoic, confirm the placement and then inject medication, contrast etc., and watch the capsule distend.
 
i have found myself doing more hip injections lately - primarily because the IR guys don't want to do them for the orthos anymore - i guess not enough money to warrant their time/effort.

I use a 25 gauge 3.5 quinke - patient is supine - my view is slightly oblique - use a touch of contrast and then about 20mg of triamcinolone and 1.5-2ml of lido...

the orthos are now asking me to do more and more iliopsoas tendon injections for their hip replacements - ie: patient still has hip pain after total hip but x-ray shows good placement and no lucency, etc... so far i have only 2 or 3 patients who have been blown away by the results -- the rest usually are like : "it's a bit better"... i do those AP through the groin
 
caedmon said:
Ultrasound guidance is a nice tool for intra articular hip injections. Smith and Hurdle describe a nice technique in the Archives of Physical Medicine and Rehabilitation from Feb '06. Basically, visualize the femoral head/neck junction longitudinally to the femoral neck, guide the needle down to the junction, pop through the ileofemoral ligament, and inject a few cc's of local which is anechoic, confirm the placement and then inject medication, contrast etc., and watch the capsule distend.
Click to expand...
If you have a c-arm, why bother with U/S?
 
I don't have either. Hopefully one day I'll have both. Some arguments would be ease of use (roll machine into patient room and go) and no radiation exposure.
 
Doctodd said:
brushing up......not a common procedure for me and not one i ever did in residency, but it has been increasing in frequency for me. Most recently i had a big ortho group who is testing me out send me a patient with concomitant spine pathology and they were unclear on if the hip was the pain generator. He was a previous patient of theirs who had the opposite hip replaced a few years ago. I looked at algos' website and the bullseye is about midfemoral head. I was taught to do them laterally to directly reach the joint space. About algos' pics(which may be Rheum journal pics....not sure), it seems like even though it is much lower than the weightbearing surface, i guess enough injectate gets there anyway?...that is my question. Who does hip injections laterally and who does it differently?

correct me if im wrong....comments? By the way, the patient had a sacralization/fusion of the upper SI joint which is where he correlated his pain when the needle hit it and i injected. Post procedure he was doing well. Follow up in 2 weeks. So i think his pain is NOT hip related. And hip had minimal DJD on plain films and under my fluoro.

T
Click to expand...

I go straight AP, right between IT line and femoral head, right down to the os. There is usually some relocating secondary to the tight capsule, or if you are too lateral. I also use ultrasound, which is easy on thin patients, but difficult on obese, unless you have a curved probe. I still prefer c-arm to a larger patient to confirm capsular flow. Of course, holding the pannus back can get cumbersome as well no matter which method you use! This injection in an ASC is becoming extinct due to the reimbursement, and that is why anes. does not want to do them...
 
Put the patient in the supine position & prep the groin.

Palpate the femoral pulse and stay 2-3 cm away from it with anything sharp.

Using an AP view put a needle on the femoral neck near the femoral head, then pull back 1-2 mm.

Inject contrast. Inject medicine. Take the needle out.

No rocket science needed.



.
 
PMR 4 MSK said:
I do a lot of these for my ortho group - diagnostic, therapeutic and pre-MRI. I use an anterolateral approach. I line it up in a far oblique, guide the needle (22g 3.5") to the joint, then go to AP and get it in. 1-2 cc contrast will usually acumulate either in the joint space or around the femoral neck in a circular pattern.
Click to expand...
Just out of curiosity, why the need for a 22? Admittedly, in the typical New Orleans size patient, a 22g 6" needle may be required. We actually also have 4 11/16" 25g for the moderately obese (read virtually everyone down here), but a 22g seems like an unnecessarily large bore (now just wait for a few minutes, and Steve will come back and describe me with those same terms) unless you have a good deal of tissue to to get through, and are concerned about losing thrust (OK Steve, have fun with that one too).
 
ampaphb said:
Just out of curiosity, why the need for a 22? Admittedly, in the typical New Orleans size patient, a 22g 6" needle may be required. We actually also have 4 11/16" 25g for the moderately obese (read virtually everyone down here), but a 22g seems like an unnecessarily large bore (now just wait for a few minutes, and Steve will come back and describe me with those same terms) unless you have a good deal of tissue to to get through, and are concerned about losing thrust (OK Steve, have fun with that one too).
Click to expand...

Sorry it took me so long, I was transitioning between a lunch lecture and a dinner lecture.

Yes you are a large bore (but not that the good way). No pain no gain?
I'd prefer a 25G for less procedural discomfort. Devil's advocate could say the 22G allows more rapid instillation of medication.

Either is fine- if it is my hip, I'll take a FGCE anterolateral approach with a 25G.
 
anybody try the 27 gauges???

the IR guys at my old place had a few 27 gauges - but can't find them commercially for what i want to do (ie: > 3-5 inches)... of course instillation is tough especially w/ contrast or particulate-steroids - but would love to try them on a few procedures... if you know where to get them please let me know
 
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Tenesma said:
anybody try the 27 gauges???

the IR guys at my old place had a few 27 gauges - but can't find them commercially for what i want to do (ie: > 3-5 inches)... of course instillation is tough especially w/ contrast or particulate-steroids - but would love to try them on a few procedures... if you know where to get them please let me know
Click to expand...
We use 27g 3 1/2" needles only for our myelograms, and get them from the local Becton Dickenson rep (ours is out of Lafayette, LA, but you can get them from any BD rep)

Re-order number is 405081
 
ampaphb said:
Just out of curiosity, why the need for a 22? Admittedly, in the typical New Orleans size patient, a 22g 6" needle may be required. We actually also have 4 11/16" 25g for the moderately obese (read virtually everyone down here), but a 22g seems like an unnecessarily large bore (now just wait for a few minutes, and Steve will come back and describe me with those same terms) unless you have a good deal of tissue to to get through, and are concerned about losing thrust (OK Steve, have fun with that one too).
Click to expand...

Bad habit maybe? Some of the guys around me do most everything 17 guage. Just what I'm used to. I use 25 g in the clinic much more. Probably should use them more under fluoro, but the nurses always have my table set up with a 22 g.
 
i tend to use 22s only for ugly SI joints - i tend to get better results compared to 25s ---- otherwise everything else is a 25g unless they are obese... whenever I look at an MRI I always measure skin to epidural space and add 1.5cm... if it looks like it is going to require 5-7 inch needles then the chart gets a special asterix... that way the procedure nurses know

all interlaminar ESIs are done with 22g unless obese then i use a 20g....

ampa thanks for 27 info
 
do you find you can get a reliable loss of resistance with a 22g? i would think a larger gauge needle would be more reliable for interlaminars.
 
i usually use a hanging-drop technique with the 22gauges - sometimes saline LOR

i was actually surprised by my difficulties recently when i had to use a 19gauge Tuohy... it was the only needle i had access to for some god-saken reason without having to delay the case by 30 minutes -

after getting so used to LOR with a 22 gauge it felt like i was getting LOR ALL THE TIME with the 19gauge - it is interesting how your body adapts.

but the fast way is to line up the needle in AP view - advance it about 3-4 centimeters *unless they are fat - in which case i advance it about 5-7 cm) - double check that you are still not swerving away - then go lateral - eyeball the distance to the epidural space - then advance until you are close to the epidural space - then start using your LOR techniques what ever they may be - and it should be fine regardless of gauge -

OF COURSE a 22 gauge causes less spinal headaches than a 17g :) and is a lot less uncomfortable for the patient...
 
SSdoc33 said:
do you find you can get a reliable loss of resistance with a 22g? i would think a larger gauge needle would be more reliable for interlaminars.
Click to expand...

Similar to what Tenesma says, it's all what you get used to. I have no problem with LOR on TLESI with a 22g 3.5 or 5"
 
What's a lateral?

The 17G has such a loss of resistance, that at some;) training centers, they do not bother with laterals. This is how some people are being trained.

Thn they go out in practice and get a couple wet taps with 20G Tuohys and a glass LOR before realizing the LOR can be subtle and the lateral view is quite useful and takes less time than starting over at an adjacent level. Names witheld upon request.:rolleyes:

I've had patients where a 20G would not make it as it kept deflecting and an 18G or 17G and a mallet were needed. I made up the part about the mallet, I used a large Kelley on the Tuohy to allow greater controlled force to be applied (I snapped the plastic wings right off the little bugger). :D
 
This thread is so far off target. Epidural LOR discussed, misc hip stuff.

Injecting the hip area could mean:

1. IA injection
2. SI injection
3. Bursa Injection
4. Adductor injection
5. Other random injection

FLuoro should be used for IA hip and SIJ
I also use it for GTB when sent to me by Ortho because they failed injection x2. Then I load up the Omnipaque and see whats wrong with the bursa. I'd use US but have not been trained.
 
show me any studies that show that a physical exam is superior to diagnostic injections....
 
Tenesma said:
show me any studies that show that a physical exam is superior to diagnostic injections....
Click to expand...


do a good exam and you wont have to stick 10 different joints to figure out where the problem is.......
 
IMHO

SIJ (majority of positive SIJ provocation tests (Gaenslen, FABER, pelvic distraction or compression, thigh thrust, sacral thrust)
vs
Facet (pain on extension with rotation, pain pattern which matches previously identified referral patterns)
vs
Disc (pain c forward flexion > extension, centralization of radicular s/s c repeated F/E)

may improve your likelihood of identifying the pain generator before proceeding with your intervention.
 
ampaphb said:
IMHO

SIJ (majority of positive SIJ provocation tests (Gaenslen, FABER, pelvic distraction or compression, thigh thrust, sacral thrust)
vs
Facet (pain on extension with rotation, pain pattern which matches previously identified referral patterns)
vs
Disc (pain c forward flexion > extension, centralization of radicular s/s c repeated F/E)

may improve your likelihood of identifying the pain generator before proceeding with your intervention.
Click to expand...

Humble? I'd like to think that with good training we are better than just guessing as to which pain generator to target first. I'm sure I can do it;)

Many factors make us lean one way vs another, but aside from the SIJ work from 1996 and update in 2004, is there any research on what part of demographics, HPI, and exam that makes the logic of pain medicine reproducible?
 
again - is there any data to show that physical exam trumps diagnostic injections for diagnosis?

clearly we rely on our anecdotal experience and what we perceived to be "mechanistic truths" about location of pain... and that continues to guide me - but my challenge still stands.
 
Tenesma said:
again - is there any data to show that physical exam trumps diagnostic injections for diagnosis?

clearly we rely on our anecdotal experience and what we perceived to be "mechanistic truths" about location of pain... and that continues to guide me - but my challenge still stands.
Click to expand...

probably not any good data, because the PE would be compared to the "gold standard," which does not exist, except possibly by anesthetizing the area, and how do you define what the "true" Dx is, except based on Hx and PE to narrow it down, the blocks to confirm and/or treat.
 
tenesma--

if someone with a hip pain has external rotation of 45/45 degrees and internal rotation of 0 degrees

and another person has external rotation of 0 degrees and internal rotation of 45/45 degrees

do they have the same problem?
 
maybe they do - maybe they don't

i have had patients with buttock and calf pain - with an exam suggestive of a radiculitis - and it turned out their back was fine, and they needed a hip replacement...

i have had patients with groin pain that was reproducible with internal rotation of the hip - and after a lumbar facet block were pain free...
 
i would say they absolutely do not have the same problem.

obviously the physiology is different between the two examinations, or the exam would be the same. hip "arthritis" but, in my office anyway, the injection location would be different for each person.

whatever. food for thought.
 
pmrmd said:
i would say they absolutely do not have the same problem.

obviously the physiology is different between the two examinations, or the exam would be the same. hip "arthritis" but, in my office anyway, the injection location would be different for each person.

whatever. food for thought.
Click to expand...
What would the different injections for the two patients you described be? To me, they both seem like perfectly reasonable candidates for intra-articular hip injections as a screening diagnostic tool
 
how do you know the "physiology" is not the same?
 
I remembered learning that OA can effect more than just one part of a joint and this can account for different testing on PE and different HPI for the same diagnosis.

oahip.jpg
 
ampaphb said:
What would the different injections for the two patients you described be? To me, they both seem like perfectly reasonable candidates for intra-articular hip injections as a screening diagnostic tool
Click to expand...

i think the exam shows the patient has an abnormality and in conjunction with the history should give you the diagnosis.

i am talking about the way to treat the hip.
 
pmrmd... i know what you are getting at - but before you embarass yourself, i hope you have data to support diagnostic and therapeutic modalities for what you are hinting at.
 
maybe he just wants to feel like the smartest guy in the room instead of contributing....im fine with that. Some of us have forgotten more than what others know in the first place.
 
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