Journal of Hip Preservation Surgery Vol. 0, No. 0, pp. 1–6 doi: 10.1093/jhps/hny013 Research article Efficacy of a non-image-guided diagnostic hip injection in patients with clinical and radiographic evidence of intra-articular hip pathology 1 2 3 Matthew J. Kraeutler , Tigran Garabekyan , Matthew J. Fioravanti , 4 3 David A. Young and Omer Mei-Dan * Department of Orthopaedic Surgery, Seton Hall-Hackensack Meridian School of Medicine, South Orange, NJ 07079, USA, Southern California Hip Institute, North Hollywood, CA 91602, USA, Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO 80045, USA and Melbourne Orthopaedic Group, Melbourne, Australia *Correspondence to: O. Mei-Dan. E-mail: firstname.lastname@example.org Submitted 5 December 2017; revised version accepted 9 April 2018 ABSTRACT The purpose of this study was to determine the likelihood of pain relief, as a measure of accurate diagnosis of intra-articular hip pathology and correct needle placement, with a non-image-guided intra-articular hip injection per- formed bedside in the clinic. A retrospective study of prospectively collected data was performed in a consecutive cohort of patients diagnosed with symptomatic intra-articular hip pathology who underwent a non-image-guided intra-articular injection in the clinic. All patients had clinical and radiographic evidence of hip impingement, hip in- stability, chondrolabral pathology, or other causes of intra-articular hip pain. A previously described technique for a non-image-guided hip injection was performed using 7–10 ml of 1% lidocaine for diagnostic evaluation with some patients receiving 2 ml of Kenalog -40 if clinically indicated. Ten minutes following each injection, the patient was asked to report the percent improvement in pain (from 0 to 100%) while physical examination and provocative tests were repeated. The ﬁnal study cohort comprised 142 patients (161 injections). In three cases, patients were either unable to assess or quantify any change in pain level 10 min following the injection. In the remaining 158 hip injec- tions, pain relief was noted in 156 cases (156/158, 98.7%), with at least 70% improvement in pain level noted in 152 cases (152/158, 96.2%). Average pain relief among all 158 injections was 896 16%. A non-image-guided diag- nostic intra-articular hip injection yields reliable short-term pain relief, simultaneously endorsing accurate diagnosis of hip pathology and intra-articular needle placement. these injections are more commonly performed under INTRODUCTION fluoroscopy guidance by a radiologist, with confirmation Non-image-guided intra-articular injections have been provided by the intra-articular positioning of radiopaque described for the shoulder , knee  and ankle . By contrast material . Recently, however, non-image- using palpation of anatomic landmarks, these injections guided techniques have been described for the hip using can achieve a high level of accuracy, be convenient and be anatomic landmarks and palpation [9–12]. The purpose of cost-effective, allowing physicians to perform diagnostic this study was to determine the likelihood of pain relief, as and therapeutic injections in the clinic rather than referring the patient to a radiologist . Intra-articular hip injec- a measure of accurate diagnosis of intra-articular hip path- tions are typically performed using ultrasound or fluoro- ology and correct needle placement, with a non-image- scopic guidance [5–8]. Ultrasound-guided hip injections guided intra-articular hip injection performed bedside in may be performed in the orthopaedic clinic , though the clinic. V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact email@example.com Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hny013/4992276 by Ed 'DeepDyve' Gillespie user on 12 July 2018 2 M. J. Kraeutler et al. MATERIALS AND METHODS After Institutional Review Board approval was obtained, the authors performed a single-center retrospective analysis of prospectively collected data from a consecutive cohort of patients undergoing a non-image-guided intra-articular injection in the clinic. Patients included were injected with lidocaine for diagnostic purposes, or with lidocaine and tri- amcinolone for diagnostic and/or therapeutic purposes. Inclusion criteria for patients selected for this study were a painful hip joint during comprehensive physical examin- ation whereby several pain sources were established and there was a need to differentiate between them, atypical hip pain (posterior or lateral only), and/or need for tem- porary treatment of hip pain in the form of steroid injec- tion. Patients who had undergone prior total hip arthroplasty, hip resurfacing, or other open hip or pelvic Fig. 1. Injection technique. A point was marked by the respective surgical procedures were excluded. Patients injected with crossing lines coming longitudinally (proximal to distal) from platelet-rich plasma (PRP) or hyaluronic acid (HA), the medial aspect of the ASIS (horizontal line) and transversely wherein lidocaine was not used, were also excluded. (lateral to medial) from 1 cm proximal to the vastus ridge or midway between the tip of the trochanter and the vastus ridge Demographic characteristics including age, sex, height, (vertical line). weight, body mass index (BMI) and lateral center edge angle (LCEA) were recorded for all patients. Injection technique All injections were performed by the senior author (Mei- Dan, Omer) or by a hip preservation fellow under direct supervision of the senior author. The technique used has previously been described . Briefly, prior to each injec- tion, the patient’s anteroposterior (AP) pelvic radiograph was reviewed to determine if any variant anatomy was pre- sent (coxa vara/valga, coxa breva, coxa profunda, variant ilium morphology) and, if so, the injection location was adjusted accordingly as described previously . For ex- ample, in patients with a lateralized anterior superior iliac spine (ASIS), the needle was angled more medially than Fig. 2. Plain radiography (left) and computed tomography normal. (right) images of the anatomic landmarks used during injection Patients were positioned supine on a standard examin- with location of the injection illustrated by a red dot. ation table in the clinic with the hip in a neutral position (0 of flexion/abduction/adduction) and the foot in a neu- spinal needle was inserted directly from anterior to poster- tral position (toes pointing to the ceiling and feet parallel). ior toward the femoral neck from the previously marked Care was taken to ensure that both ASISs were aligned so starting point. Upon palpating the anterior femoral neck that the pelvis was not rotated. A point was marked by the with the tip of the needle, the contralateral hand is utilized respective crossing lines coming longitudinally (proximal to gently internally and externally rotate the leg to attempt to distal) from the medial aspect of the ASIS and trans- to verify correct placement. The plunger on the syringe is versely (lateral to medial) from 1 cm proximal to the vastus then gently depressed while assessing the degree of resist- ridge or midway between the tip of the greater trochanter ance, noting that correct intra-articular placement yields (GT) and the vastus ridge (Figs 1 and 2). The vastus ridge, mild to minimal resistance. If excessive resistance is the most prominent part of the GT, is easily localized by encountered, the contralateral hand is placed behind the internally and externally rotating the hip with the patient lying supine. Using a sterile technique, a volume of 5 ml of patient’s knee and the hip is gently flexed while maintain- lidocaine was injected subcutaneously. Then, a 19-gauge ing the needle apposed to the anterior femoral neck. This Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hny013/4992276 by Ed 'DeepDyve' Gillespie user on 12 July 2018 Efficacy of a non-image-guided diagnostic hip injection 3 maneuver relaxes the anterior capsule, enabling it to be ele- Table I. Patient demographics and baseline vated from the anterior femoral neck periosteum with the characteristics injectate, which consists of 7–10 ml of 1% lidocaine V R Patient variables Value (Xylocaine , lidocaine HCl, Fresenius Kabi USA, LLC, Lake Zurich, IL) with/without 2 ml of Kenalog -40 (triam- No. of patients (hips) 142 (161) cinolone acetonide, Bristol-Myers Squibb, New York City, Age, mean (SD), years 38.8 (14.2) NY). It is important to maintain downward pressure with the needle against the femoral neck as the plunger is Female gender, n hips (%) 120 (74.5) deployed to prevent retraction of the needle into the extra- Height, mean (SD), cm 169.7 (9.1) capsular space due to backpressure from flow. Additionally, Weight, mean (SD), kg 70.9 (14.2) the authors recommend periodically stopping the injection and applying a downward pressure to palpate the femoral BMI, mean (SD), kg m 24.5 (4.2) neck cortex and ensure the needle has not migrated during the injection. Upon completion of the injection, the needle is withdrawn and a sterile dressing is placed after applying 2. Patient’s reported level of pain in the room with 10 s of gentle downward pressure for hemostasis. the surgeon, while performing positions and activities which were known to produce pain on a Clinical diagnosis daily basis (squats, knee to chest, etc.). Clinical diagnoses of bony impingement and/or acetabular 3. In patients where pain was reported to be present dysplasia were determined according to accepted patho- mainly during physical activities, the patient was morphologic signs and measurements [13, 14]. Suggestive sent to run, walk up and down stairs, etc. after physical examination findings included reduction in hip the injection. flexion and internal rotation range of motion and/or posi- tive impingement and other commonly utilized provoca- tive tests for the hip and pelvis [15–17]. Confirmative Statistical analysis imaging findings of pincer anatomy included acetabular Two-tailed student’s t-tests were used to compare numeric- retroversion (crossover sign or ischial spine sign), LCEA al demographic features as well as the LCEA between exceeding 40 and/or acetabular inclination<0 ; features patients who experienced at least 70% versus less than 70% of cam-femoroacetabular impingement (FAI) included an pain relief. Chi-square tests were used to compare categor- alpha angle exceeding 50 on radial sequences of the ical variables between these two groups. head–neck junction and/or a femoral head–neck offset ratio<0.18 . The diagnosis of symptomatic hip in- RESULTS stability due to acetabular dysplasia was established by a During the study period, 809 injections were performed in clinical history of reported instability, pain, positive find- the clinic by the senior author. After excluding non-intra- ings on provocative hip tests indicating labral tear, meas- articular hip injections and injections of PRP and/or HA urement of LCEA<20 on AP pelvic radiography, without lidocaine, the final study cohort comprised increased acetabular version (>25 ) or femoral torsion 142 patients (161 hips), of whom 120 hips (74.5%) were (>35 ) and magnetic resonance imaging (MRI) findings female. Mean patient age was 38.8 years (SD, 14.2 years). of labral hypertrophy, articular cartilage thickening, or par- Additional demographic characteristics are summarized in tial ligamentum teres tear [19–21]. Table I. In three cases, patients were unable to assess or quantify Evaluation of pain relief any change in overall pain level following the injection. In Ten minutes following each injection, the patient was the remaining 158 hip injections, pain relief was noted in asked to report the percent improvement in pain (from 0 156 cases (156/158, 98.7%), with at least 70% improve- to 100%). Improvement in pain was assessed in three ment in pain level noted in 152 cases (152/158, 96.2%). ways: Average pain relief among these 158 injections was 896 16%. No post-injection hematomas occurred in the 1. Repeated physical examination of the same pro- series. One patient complained of a temporary paresthesia vocative maneuvers that elicited pain and per- formed by the same examiner as prior to of the lateral femoral cutaneous nerve which resolved with- injection. in a couple of days following injection. Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hny013/4992276 by Ed 'DeepDyve' Gillespie user on 12 July 2018 4 M. J. Kraeutler et al. Table II. Group comparisons based on pain relief Table III. Group diagnoses based on pain relief Variable Pain relief 70% Pain relief< 70% P-value Diagnosis Pain relief 70% Pain relief< 70% (n¼ 152) (n ¼ 6) (n ¼ 152) (n¼ 6) Sex, N (%) 114 (75%) 3 (50%) 0.17 Cam-type FAI 48 (32%) 1 (17%) female Pincer-type FAI 16 (11%) 1 (17%) Age (years) 38.1 (13.9) 47.0 (12.7) 0.15 Mixed-type FAI 38 (25%) 1 (17%) Height (cm) 169.7 (9.2) 171.5 (8.8) 0.66 Frank hip dysplasia 10 (6.6%) 0 (0%) Weight (kg) 70.8 (14.1) 73.9 (19.5) 0.72 Borderline hip dysplasia 23 (15%) 1 (17%) BMI (kg m ) 24.5 (4.2) 25.2 (6.9) 0.82 Some patients were diagnosed with concomitant FAI and hip dysplasia. LCEA ( ) 30.0 (7.8) 31.7 (7.3) 0.63 Continuous variables are provided as a mean (SD). evidence of intra-articular hip pathology. This bedside technique, unencumbered by use of image guidance, may be used to endorse suspected intra-articular pathology or In comparing patients who experienced at least 70% provide short-term treatment with the inclusion of steroid pain relief (Group A, n¼ 152 hips) versus those who expe- medication. rienced less than 70% pain relief (Group B, n¼ 6 hips), no The injection technique utilized in this study has been significant differences were found between groups with re- described previously . In a case series of 55 patients gard to gender, age, height, weight, BMI, or LCEA undergoing hip arthroscopy in the supine position, Mei- (Table II). In Group A, a diagnosis of one of the pre- Dan et al.  used the same anatomic landmarks arthritic hip pathologies shown in Table III was made in described in this study to place a 19-gauge spinal needle 115 patients (115/152, 76%), compared with 4 patients in intra-articularly. Accuracy of the needle insertion was Group B (4/6, 67%) (P ¼ 0.62). assessed by direct visualization with the arthroscope. The Among all patients who experienced< 70% pain relief authors noted 51 accurate needle placements (93%), with (Group B), one patient was diagnosed with concomitant the needle most commonly located near the upper medial cam-type FAI and a hamstring tendon tear prior to injec- femoral head–neck junction. A trend was noted toward a tion, and experienced 50% pain relief with injection. Both significantly lower accurate needle placement in females pathologies were addressed surgically with hip arthroscopy (P ¼ 0.06). Additional reasons for needle misplacement and open hamstring tendon repair, with good outcomes most commonly revolved around variant anatomy, namely noted postoperatively. Similarly, one patient was diagnosed a high-riding greater trochanter, increased femoral version, with concomitant mixed-type FAI and gluteus medius ten- thick adipose tissue around the anatomic landmarks used, dinopathy and experienced 30% pain relief with injection and variant ilium morphology. Finally, in two of the four (though all hip-related pain was relieved). This patient patients requiring more than two attempts at needle place- later underwent hip arthroscopy as well as gluteus medius ment, the patients were considered overweight. repair, with good outcomes noted postoperatively. One pa- In addition to the technique described by Mei-Dan tient was diagnosed with concomitant pincer-type FAI and et al. , Schmidt-Braekling et al.  recently described spine-related pain and experienced 60% pain relief with in- a technique for non-image-guided intra-articular hip injec- jection. One patient experienced 20% pain relief and was tions whereby a line is drawn from the ASIS distal and at a later diagnosed with piriformis syndrome and underwent 45 angle from the greater trochanter. The point of injec- successful piriformis release surgery. Two patients, each of tion is marked approximately 2 cm lateral to the first line whom experienced 0% pain relief, underwent diagnostic in- and the needle is angled 45 medial and proximal. Using a jection to differentiate between an intra-articular source of 25-gauge needle, a subcutaneous injection of 5 ml of 1% pain and spine and sciatic nerve-related pain, respectively. lidocaine is used. This is then replaced with a 22-gauge needle, which is advanced until bony resistance is encoun- DISCUSSION tered. Then, the needle is realigned so that the injection Based on the results of this study, non-image-guided intra- (4 ml of 1% lidocaine, 4 ml of 0.5% Marcaine, 1 ml of articular hip injections can provide substantial pain relief to Kenalog-40) may proceed without resistance. In a retro- the majority of patients who had clinical and radiographic spective case series of 369 intra-articular hip injections in Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hny013/4992276 by Ed 'DeepDyve' Gillespie user on 12 July 2018 Efficacy of a non-image-guided diagnostic hip injection 5 331 patients with hip osteoarthritis or rheumatoid arthritis, for magnetic resonance arthrography. Again, this would the authors found that patients experienced more than save healthcare costs and time for patients and radiologists. 50% pain relief in 304 hip injections (82%). Non- Despite the successful results of non-image-guided responders were found to have a significantly higher BMI intra-articular hip injections in several studies described than responders (P ¼ 0.007). above, previous studies have demonstrated significantly Finally, Ziv et al.  performed a case series of intra- improved accuracy, pain, and/or functional outcomes for articular hip injections in 40 consecutive patients in the image-guided versus palpation-guided injections of the operating room prior to undergoing total hip arthroplasty. knee joint , acromioclavicular joint [22, 23], distal Patients were positioned in the lateral decubitus position radioulnar joint , elbow joint , subacromial space with methylene blue dye injected using an 18-gauge spinal , and the peroneal tendon sheath . However, as needle inserted 1 cm proximal to the midline of the greater mentioned above, image-guided injections come with an trochanter and directed toward the superolateral aspect of increased cost to patients and time lost between presenta- the femoral neck based on preoperative radiographs. tion and established diagnosis, two important parameters Intraoperatively, accuracy of the injection was assessed by that the current technique aims to address. the presence of the dye in the joint and surrounding tis- In the present study, the average pain relief experienced sues. A successful injection was defined as one in which by all patients was 89%, with the majority of patients expe- disseminated dye was found solely in the intracapsular riencing 90–100% pain relief. Lack of complete pain relief space. Overall, injections were successful in 31 of 40 after an intra-articular injection of lidocaine may be related patients (77.5%). In all nine unsuccessful injections, dye to extracapsular and surrounding musculature inflamma- was found distal to the hip joint. This is a lower success tion resulting directly or indirectly from the intra-articular rate than that found in the present study, with at least 70% pathology. All six patients who reported less than 70% im- improvement in pain found in 96.2% of patients. provement in their pain following a non-image-guided hip Furthermore, most of the patients in our study who did injection were later confirmed to have an extra-articular not experience significant pain relief with an intra-articular pain source, thereby explaining the incomplete pain relief hip injection were later diagnosed with spinal, hamstring, experienced by these patients. Among these patients, the or gluteal-related pathology as the primary source of their negative or incomplete result of the non-image-guided pain, thereby indicating that an inaccurate injection was intra-articular injection enabled prompt referral to appro- not the reason for their lack of pain relief, thereby possibly priate specialists and/or additional imaging tests and extra- increasing our overall needle placement accuracy rate. articular diagnostic injections to arrive at the correct The non-image-guided hip injections performed in this diagnosis. study were well-tolerated by patients after a local anesthet- The strengths of this study include a large sample size ic injection of lidocaine. These injections provide conveni- of patients undergoing a previously described technique of ence to patients who present with joint or periarticular non-image-guided hip injections performed or supervised pain. Patients may undergo a full assessment (with physical by the same physician in all cases. The limitations of this examination and radiographic imaging) and get confirm- study should also be noted. In particular, this study did not ation of the cause of their pain during one visit with the assess the efficacy of these hip injections based on experi- use of diagnostic local anesthetic injections. Furthermore, ence level, and therefore the results speak only to the clin- in patients who do not experience pain relief with a diag- ical experience of the senior author. On a related note, the nostic hip injection, the provider can immediately prepare surgeon was present in each patient’s clinic room and for further evaluation or diagnostic tests rather than delay- assessed each patient’s pain level following lidocaine injec- ing this process by several days or even weeks. For physi- tion, which could result in a bias in pain reporting. This cians practicing in rural areas, this can yield significant study was not controlled by a placebo group, and therefore savings in both time and monetary cost for patients. When it is possible that some patients could have experienced these injections are performed by a radiologist, it is much pain relief without the needle being within the hip joint. more difficult for the patient to remember the efficacy of However, this is unlikely given that patients treated had a the injection by the time the patient follows up with the positive hip impingement test prior to injection and a surgeon. For team physicians, non-image-guided intra-ar- negative impingement test following injection. The small ticular injections may provide quick and temporary pain re- sample size of patients in Group B (< 70% pain relief lief to allow immediate return to play for athletes. Finally, post-injection) made it difficult to identify significant the use of this non-image-guided technique could also patient factors associated with lack of pain relief. This was translate to injection of gadolinium-based contrast material an inherent limitation given the relatively infrequent Downloaded from https://academic.oup.com/jhps/advance-article-abstract/doi/10.1093/jhps/hny013/4992276 by Ed 'DeepDyve' Gillespie user on 12 July 2018 6 M. J. Kraeutler et al. 11. Schmidt-Braekling T, Waldstein W, Renner L et al. Ultrasound occurrence of a negative injection response. Finally, some and ﬂuoroscopy are unnecessary for injections into the arthritic patients underwent injection with lidocaine only, while hip. Int Orthop 2015; 39: 1495–7. others underwent injection with lidocaine and triamcino- 12. Ziv YB, Kardosh R, Debi R et al. An inexpensive and accurate lone. However, because the primary outcome of this study method for hip injections without the use of imaging. 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Journal of Hip Preservation Surgery – Oxford University Press
Published: May 3, 2018
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