Intra-Articular Hip Injections in Obese Patients

[DOctorJay]

The $ is in the 99204, not the 20610 +77002. Hip inj takes maybe 10 seconds. This shouldn’t displace a spine inj. Just added on to what’s already there. If there is some arbitrary max number on your schedule, then that’s stupid. Same with shoulders, get, ac, etc

Joints get double booked with an RFA or something else in my practice. Would rather do it myself than have the pt get an injection with the PA in IR.

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[DOctorJay]

The $ is in the 99204, not the 20610 +77002. Hip inj takes maybe 10 seconds. This shouldn’t displace a spine inj. Just added on to what’s already there. If there is some arbitrary max number on your schedule, then that’s stupid. Same with shoulders, get, ac, etc

2 99214s are now worth more than a 99244 or 99204 in wrvu crumb land

 

[buddababa]

You do all prone? I kind of like this idea. I switched to doing shoulder prone. Contrast looks like the same ring around femoral neck?

hips 100% prone now, shoulders usually supine because of patient comfort, i do shoulder's prone if i'm adding on a procedure that requires a posterior appraoch

 

[specepic]

Agree.

Speaking of my ortho partners, one of them does his hips under ultrasound, and I’ve repeated several and they did great after x ray guided IA hip injections.

Suspect operator error

 

[cowboydoc]

Suspect operator error

This. I think I’ve done 4-5 hips under fluoro after failure with U/S. About half have responded to subsequent fluoro. I probably do 5-7 hips with U/S per week x10 years.

I explain I’m ~95% accurate with U/S vs. 99% with fluoro.

 

[specepic]

I do supine only for both USGI or fluoro

pillow under knees for comfort

large curved probe in parasagittal plane for USGI. 22G 3.5". visualize anterior circumflex artery to avoid it (AVN risk). Lido with 25G 2" first

if BMI > 40 then most likely fluoro although I have done many USGI hips and can usually get there regardless. Need to visualize tip under capsule at head/neck junction

If the 3.5" will not reach then I will r/s for fluoro day

c-arm angled to avoid NVB (oblique to affected side and tilted to feet ). land at head/neck junction. never an issue that I can recall. rare use of 5" spinal for BMI >50

pt or staff to hold pannus

 

[lobelsteve]

100% supine, 100% fluoro. Once a week patient or nurse retracts a pannus.
Rarely need a 22g6". Whole thing takes 60 seconds and is painless.
Start over femur at level of GT, work superiomedially to neck/head jcn.

 

[Painologist]

Am I the only one who does hip injections with the lateral approach? Much easier and obese doesn't matter much, other than them having to lie on the side.

 

[sloh]

It's funny how just putting these patients on GLP-1 agonists would be the magical fix for the discussion going on in this thread, including their pain.

 

[PainMD23]

I switched to Prone about 10 years ago due to the pannus / groin infection issue. My ICU experience taught me femoral lines weren't always the most sterile option. Plenty of M.O. patients in my area.

Patient placed prone. AP fluoro view identifying the acetabulum. Prep overlying greater trochanter. 5 or 7" 22g spinal needle. Skin entry 1-2 cm superior to greater trochanter. Then, under AP view, angle 45 deg caudad and medial, towards junction of femoral head and neck (same needle target as supine AP view). Using this approach, you avoid the sciatic nerve. Contrast to confirm arthrogram / joint entry. Inject steroid mixture.

Advantages with this technique include: We do most of our fluoro blocks prone, so the anatomy is easily identified. Sterility. Ease of technique. Avoid sciatic nerve and vascular bundle. Avoid femoral vasculature. Comfortable for patient. Quick. No guessing like U/S-- contrast is definitive. 77002 typically pays for the image guidance.

Disadvantages: need to get comfortable with an out of plane / non-gunbarrel approach to the joint. This is going to take 5-10 injections to get your speed / technique down.

 

[runfastnow]

Great thread for tips, etc. My two cents.

I've switched to lateral 99% of time. Never get complaints of pain, zero neuro-vascular issues, etc. Normally longer to get patient on/off table than anything else.

- Usually 5-10 degrees to the feet + 5-15 degrees oblique to line up the femoral heads (if THA on opposite side cheat the oblique 5 degrees off to one side so you can see the target). My XR tech has been trained to do this while I'm drawing meds.
- Skin prep
- 25g 3.5" middle of femoral head, coaxial to bone in about 2 sec.
- Move to lateral while hooking up some contrast.
- Inject

 

[Ducttape]

anyone care to post images?

 

[runfastnow]

 

[Quixotic2501]

I won't belabor the point as many people have already described the technique. Do it lateral. I will second the comment that patients who have had it done anteriorly will comment on how quick and painless the lateral approach is.

 

[SSdoc33]

I won't belabor the point as many people have already described the technique. Do it lateral. I will second the comment that patients who have had it done anteriorly will comment on how quick and painless the lateral approach is.

it is only painful if you spear the femoral nerve. the old teaching where you come straight down in AP medial to the femoral bundle is stupid. any approach other than that one should be fine

better question: what is the best approach for a hip aspiration? where does articular fluid pool?

 

[Doctodd]

there is a nuance to these hip injections.....the contrast has to spread a certain way in the capsule and sometimes you need to pull back 1-2mm to get it. Perfectly visualized in a couple of the pics above. My only variation is that my needle is in line with the femoral neck and aiming superior at 45 degrees.

 

[SpineandWine]

I’ve never tried that.

Are US guided SIJ unreliable?

Likely a moot point as they now don’t pay unless flouro/CT, but regardless I don’t know much about the reliability of US SIJ injections.

No contrast with ultrasound so cannot guarantee arthrogram.
Peri-articular SIJ good success with US

 

[cowboydoc]

No contrast with ultrasound so cannot guarantee arthrogram.
Peri-articular SIJ good success with US

Accuracy of Sacroiliac Injections With Ultrasound Guidance - PubMed

Insurance doesn’t yet agree with DeLuigi.

 

[manowar rules]

I do a bunch of hips as part of an ortho group. I used to do lateral positioning for the massively obese, BMI 50+. But honestly, everyone under our table limit of 450 lbs can be done supine in under 30 seconds

If a pannus must be lifted, the patient gets the honor of carrying out that duty.

 

[bedrock]

I do a bunch of hips as part of an ortho group. I used to do lateral positioning for the massively obese, BMI 50+. But honestly, everyone under our table limit of 450 lbs can be done supine in under 30 seconds

If a pannus must be lifted, the patient gets the honor of carrying out that duty.

I like it.

And honestly the pannus lifting is likely a good psychological reminder that they need to do their part for the hip (lose weight)

 

[SpineandWine]

Accuracy of Sacroiliac Injections With Ultrasound Guidance - PubMed

Insurance doesn’t yet agree with DeLuigi.

I think in right hands, anything can be optimal
Most I’d argue can’t

 

[Taus]

I think in right hands, anything can be optimal
Most I’d argue can’t

If I can stick a needle 100% in the joint under fluoro on AP, oblique, lateral, and not get an clearcut 100% arthrograms with contrast every time…… Ultrasound can shove it

That said, does it make a difference in clinical outcome intra versus peri….?

 

[RoloTomassi]

If I can stick a needle 100% in the joint under fluoro on AP, oblique, lateral, and not get an clearcut 100% arthrograms with contrast every time…… Ultrasound can shove it

That said, doesn’t make a difference in clinical outcome intra versus peri….

Yeah especially when I see PAs use non-spinal needles. Nah, you're not in

 

[SpineandWine]

If I can stick a needle 100% in the joint under fluoro on AP, oblique, lateral, and not get an clearcut 100% arthrograms with contrast every time…… Ultrasound can shove it

That said, doesn’t make a difference in clinical outcome intra versus peri….

Honestly I think it does
I’ve had patients where u didn’t get arthrogram in, 1 month of relief with peri articular
Had arthrogram subsequently with 8-9 mo relief

Anecdotal but there has to be some pathological differentiation between the two people are not doing. That’s why I shoot for arthrogram, once achieved, put 2 ccs in and as I pull back but another 1 cc peri-articular

 

[cowboydoc]

Yeah especially when I see PAs use non-spinal needles. Nah, you're not in

I use a 1.5 25g to anesthetize before using spinal. I think it makes it to the capsule 1/50 times.

 

[Dr. Ice]

If you have fluoro skills, ultrasound for anything bone = not so bueno..generally.

Ultrasound rocks for tendon, soft tissue. I was a non believer until I taught myself and saw the results. But I’m also no fool, cause fluoro was my first friend…

 

[po_boy]

I always do lateral. Thick or thin. Target the 2-3/9-10 o’clock position of the femoral head. Takes about 30 seconds

The picture posted above from Furman shows going essentially dead center

What is everyone's injectate & volume?

 

[manowar rules]

The guy may not have updated his website in the last decade, but I found thepainsource.com website very helpful when I started out doing msk injections under fluoro.

I inject 5cc of bupi or lidocaine with 40mg kenalog into a hip