Tendons in the way of my hips

[manowar rules]

Hi guys,

I've had an issue lately where, when doing intra-articular hip injections, my contrast initially lights up tendon in the distribution of the proximal rectus femoris. Sometimes it takes a fair amount of redirecting to get away from it. I usually approach the joint this way (these aren't my images, I stole them from the internet)

but have had this issue coming from superolateral as wel

Anyone have any idea what I'm doing wrong and how I can avoid this? I didn't have this issue in fellowship where I took a more direct approach, but now I'm more cognizant of avoiding femoral stuff and the abdomen. Thanks!

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[Doctodd]

It happens.....change depth as well as redirect. Some are difficult even if done the same way.

 

[cowboydoc]

I aim for the point between those two needle tips and use about 25 degrees of obliquity, which seems to minimize the soft tissue to traverse. There is often some movement needed to optimize intra-articular flow pattern. I err towards staying on the neck, as the capsule translates far laterally on the neck of the femur. I see no reason to put The needle right on the femoral head.

 

[oreosandsake]

the iliopsoas tendon runs right over the head, and neck of the femur. rectus is actually much more superficial (right under the skin)

you are injecting into that. you need to really make contact with os, after going through the ischiofemoral ligament. if you are superficial to the ligament, you also will light up the psoas tendon.

 

[Taus]

As above- pop through soft tissue until os is clearly contacted. Takes a little force. I go to lateral head neck junction. If initial contrast is in soft tissue just push harder on needle and re inject.

 

[painfree23]

Sometimes when I have trouble , I go for "10 o clock" bullseye onto the R femoral head.
"2 oclock " for Left.
Decent results.

 

[manowar rules]

Ok thanks! I do like the idea of injecting further down on the neck, I seemed to have less trouble when I did that

 

[BobBarker]

Gas man drive needle to bone. Gas man get halo of contrast. Gas man happy with that. Gas man not understand physiatrist talk.

 

[Ligament]

From the looks of it, in the top image, they are injecting into the retinaculum of Weitbrecht, not the hip. Is this the pattern you are seeing?

 

[clubdeac]

From the looks of it, in the top image, they are injecting into the retinaculum of Weitbrecht, not the hip. Is this the pattern you are seeing?

Whoa what is this retinaculum you speak of?? I've had that top contrast pattern before and usually accept it as intra-articular. But to answer your question manowar, even after doing this 9 years sometimes I'll have a perfect approach and placement and I'll get a linear pattern even after touching os. Usually if I redirect more inferiorly onto the femoral neck and retry I'll get a good intra-articular pattern

 

[oreosandsake]

learn the anatomy of all the layers you are entering through (with ultrasound) and you'll understand why you get these patterns...

 

[manowar rules]

Gas man drive needle to bone. Gas man get halo of contrast. Gas man happy with that. Gas man not understand physiatrist talk.

Haha this is pretty hilarious, and on some level true
Yeah for the record I do u/s guided hip injections as well, as tolerated by BMI. Granted I may not have a thorough understanding of muscle layer depth. I was puzzled why I would be getting tendon near os on the superolateral portion of the hip, as my understanding is that the iliopsoas usually lay more inferomedial. Thanks!

 

[SSdoc33]

they both look intra-articular to me.

 

[painfree23]

Do you bill 20610+fluoro for hip injections under fluoro or do you do 27093??

 

[oreosandsake]

That video should work.

The layers immediately overlying the neck are the psoas tendon and iliacus muscle before it turns into tendon. The cartoon drawings in netters don't represent it well... they always draw it going more medial (yes it does attach to the lesser trochanter) but that may be to show the head of the femur behind it. Take a look on MRI

 

[painfree23]

Do you bill 20610+fluoro for hip injections under fluoro or do you do 27093??

Bump

 

[DODOCSS]

20610 + 77002