USD guided Hip Injection

[sevoflurane]

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Had a 3 hour Tennis Match last week and really did a number on my Left Hip. @ this point I can't walk more than 15 minutes before it starts seriously acting up (weight bearing). A little tender to palpation along the greater troch + deep and dull pain around the joint area itself. Heading out to the caribbean in a week and want these sypmtoms controlled.

My wife and I are pretty slick with USD, and these injections appear to be super easy. So I'm debating weather to have her do a hip injection.

[YOUTUBE]http://www.youtube.com/watch?v=6DLrkFZW8uI[/YOUTUBE]

What do you guys like to use in your cocktail for hip injections? I'll be asking my pain and orthopod buddies what they use, but just curious as to what others are using.

3 ccs' of .5% rop + 50-80mg of triamcinolone sound about right?

Any other thoughts?

Thanks.

 

[sevoflurane]

anybody using sodium hyaluronate?

 

[PMR2008]

Just use Lidocaine first to see if hip joint is the pain generator(labrial tear). Other things you might want to consider are Gluteus Medius Tendinitis/tear and or Trochanteric Bursitis.

 

[lobelsteve]

6cc 0.25% bupi and 2cc (12mg) Celestone.

Or for the fancy folks, 6cc Synvisc.

I use fluoro and contrast for hips. I use US for CRL.

 

[DOctorJay]

unless you're having groin pain it's probably not intra-articular hip pathology. would agree with PMR2008 on glut medius tendinopathy or troch bursa if you were doing a lot of running.

we do USGI of the hip with a 22 gauge spinal needle after anesthetizing the track with 0.5% lidocaine. injectate is typically 4cc of 0.25% bup with 40 mg triam.

 

[Ducttape]

I take it the original poster realizes that none of us are giving him any recommendations on what to do, only what they do for their own patients...

 

[specepic]

can anyone explain to me why they are choosing Bup or anything other than Lido for the joint cocktail? While the evidence is not robust it does suggest Bup is more toxic. I am surprised SL is using Bup for joints. So Bup gives you a few more hours of numbing, what is the upside? I have deleted Bup from all my procedures except MBB.

Hip joint: Lido 1% with Triam 40mg, total of 5 mls. 22G spinal. US all the way unless BMI >45.

I would start with an XR, if a pt similar to you had a robust joint space an PE neg. for joint (fairly pain free IR, neg scour, neg figure 4), would concentrate on bursa, etc.

 

[PMR2008]

I take it the original poster realizes that none of us are giving him any recommendations on what to do, only what they do for their own patients...

Correct. The recommendations are for future patients. OP see someone you trust and have them examine you before you exposure yourself to unnecessary procedures and tests.

 

[bedrock]

ditto regarding marcaine-

There is no valid clinical reason I can think of to justify putting marcaine inside a joint (outside of surgical anesthesia), due to higher risk of joint toxicity.

Kinda surprised that folks at Mayo would still be doing that

 

[PMR2008]

ditto regarding marcaine-

There is no valid clinical reason I can think of to justify putting marcaine inside a joint (outside of surgical anesthesia), due to higher risk of joint toxicity.

Kinda surprised that folks at Mayo would still be doing that

1+
We use Lidocaine and Ropivacaine

 

[Ligament]

Ropivacaine is great but crazy expensive

 

[emd123]

can anyone explain to me why they are choosing Bup or anything other than Lido for the joint cocktail? While the evidence is not robust it does suggest Bup is more toxic. I am surprised SL is using Bup for joints. So Bup gives you a few more hours of numbing, what is the upside? I have deleted Bup from all my procedures except MBB.

Hip joint: Lido 1% with Triam 40mg, total of 5 mls. 22G spinal. US all the way unless BMI >45.

I would start with an XR, if a pt similar to you had a robust joint space an PE neg. for joint (fairly pain free IR, neg scour, neg figure 4), would concentrate on bursa, etc.

I believe that data came from bupivicaine continuos intra-articular infusions. I don't recall any evidence of significant bupivicaine toxicity from one injection last I looked at this, but I could be wrong. Also, I believe there's some data that the other local anesthetics can be toxic to cartilage also, but mainly continuos infusion. I'm too tired right now to post any links. Maybe tomorrow.

Also, wasn't the last word that ropi, despite being formulated for less cardiotoxicity has never actually been shown to be less cardio toxic?

 

[DOctorJay]

Has bup been proven to damage chondrocytes in HUMANS? If so I'd like to see the study.

I'm in Pain fellowship now, in PMR res we did these with lido, Rads and the guru use ropiv.

 

[Ducttape]

for those who are claiming that lido is the drug to use, please remember that experimental studies on animal models also suggest that lidocaine poses risks...

 

[PMR2008]

Has bup been proven to damage chondrocytes in HUMANS? If so I'd like to see the study.

I'm in Pain fellowship now, in PMR res we did these with lido, Rads and the guru use ropiv.

http://bja.oxfordjournals.org/content/102/4/439.full

"The effect of bupivacaine on human cartilage has also been analysed. The effects of bupivacaine 0.5%, bupivacaine 0.25%, bupivacaine 0.125%, and saline 0.9% on bovine and human articular chondrocyte cultures were compared. Both bupivacaine 0.5% and bupivacaine 0.25% displayed dose-dependent and time-dependent chondrotoxicity. The toxicity of bupivacaine 0.5% was more marked than bupivacaine 0.25% at all time points. The toxicity of both drugs increased as the duration of exposure increased (from 15 to 60 min) and as the time after exposure increased (from 1 h to 1 week). The effect of bupivacaine 0.125% on bovine and human articular chondrocytes was no different from 0.9% saline. The effects of different concentrations of bupivacaine on bovine articular osteochondral tissue were also compared. "

Chu CR, Izzo NJ, Coyle CH, Papas NE, Logar A. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg Br 2008;90:814-20.

http://www.ncbi.nlm.nih.gov/pubmed/18539679

 

[Ducttape]

http://bja.oxfordjournals.org/content/102/4/439.full

"The effect of bupivacaine on human cartilage has also been analysed. The effects of bupivacaine 0.5%, bupivacaine 0.25%, bupivacaine 0.125%, and saline 0.9% on bovine and human articular chondrocyte cultures were compared. Both bupivacaine 0.5% and bupivacaine 0.25% displayed dose-dependent and time-dependent chondrotoxicity. The toxicity of bupivacaine 0.5% was more marked than bupivacaine 0.25% at all time points. The toxicity of both drugs increased as the duration of exposure increased (from 15 to 60 min) and as the time after exposure increased (from 1 h to 1 week). The effect of bupivacaine 0.125% on bovine and human articular chondrocytes was no different from 0.9% saline. The effects of different concentrations of bupivacaine on bovine articular osteochondral tissue were also compared. "

Chu CR, Izzo NJ, Coyle CH, Papas NE, Logar A. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg Br 2008;90:814-20.

http://www.ncbi.nlm.nih.gov/pubmed/18539679

http://www.ncbi.nlm.nih.gov/pubmed/20194319

dont think you are safe just because you switch to lido...

 

[sevoflurane]

I believe that data came from bupivicaine continuos intra-articular infusions.

No doubt about intra-articular continuous infusions. That was a good way to destroy post-op shoulders about 8-10 years ago.

 

[sevoflurane]

Thanks for the replies folks. 👍

 

[specepic]

as I said the evidence is somewhat questionable and I've read all the studies (it was my fellowship project to study this)

Nevertheless, on par, the studys seem to show that Bup is more toxic than lido but lido is still toxic to a degree

Not sure how a human study would get approved on this Jay

Bottom line, why use Bup if lido works and all you get is a few hours more numb? Ever seen the lawyer websites on Bup?

 

[DOctorJay]

True Spec and I appreciate the article. Why use lido if ropiv is better? I know $$$.

 

[lobelsteve]

Where is the in vivo data on bupi and lido in joints?

In vitro is one thing, in vivo is another.

I think bupi has pain relieving properties independent of its anes effect.

 

[SSdoc33]

.

 

[DOctorJay]

.

it's ok SSdoc33, i'm fine with being "dead wrong" just add something constructive.

and yes my response above is overly simplified.

 

[Gauss]

Chondrolysis of the glenohumeral joint after infusion of bupivacaine through an intra-articular pain pump catheter: a report of 18 cases.

http://www.ncbi.nlm.nih.gov/pubmed/20362823

 

[lobelsteve]

Chondrolysis of the glenohumeral joint after infusion of bupivacaine through an intra-articular pain pump catheter: a report of 18 cases.

http://www.ncbi.nlm.nih.gov/pubmed/20362823

Chondrolysis of the glenohumeral joint after infusion of bupivacaine through an intra-articular pain pump catheter: a report of 18 cases.
Anderson SL, Buchko JZ, Taillon MR, Ernst MA.


METHODS:
A retrospective chart review of 18 patients diagnosed with chondrolysis was carried out. All patients were from 2 experienced orthopaedic surgeons' practices. Details of their clinical course were obtained and summarized. These data were compared with all other arthroscopies completed by the 2 surgeons to determine the incidence of chondrolysis.


CONCLUSIONS:
Although we cannot establish a causal link, the development of glenohumeral chondrolysis may be related to the intra-articular infusion of bupivacaine with epinephrine postoperatively. We thus caution against the use of IAPPCs.


These are not my patients and I am not infusing bupi with epi and using a pump. This is not representative of single shot injection.

 

[lobelsteve]

But better to shut me and the rest of us up by providing more data from the guy who did the studies:

http://www.healio.com/orthopedics/a...ons-of-local-anesthetics-how-much-is-too-much

0.25% at low volumes in single shots may produce some problems 5-10 years down the road, but this is still unknown.