Outcomes following a ‘positive’ response to diagnostic intra-articular hip injection for pre-arthritic hip pain based on the level of percent pain improvement

The Role of Fluoroscopically Guided Intra-Articular Hip Injections in Potential Candidates for Hip Arthroscopy: Experience at a UK Tertiary Referral Center Over 34 Months

To determine the prevalence of hip pain (HP) in adolescents in East Germany and to evaluate the potential factors associated with HP. Cross-sectional epidemiological study of a total of 2368 pupils (1137 males, 1231 females; age 14.5+/-0.65, range 13-18 y). Demographic data and information on sports activity and consumption of soft legal drugs were obtained using a questionnaire. Physical examination was carried out by school doctors. Odds ratio (OR [95% confidence interval]) was calculated for common factors associated with HP. The prevalence of adolescents suffering from HP was 6.5% (n=151). Pain episodes were reported as occasional in 3.0%. A total of 69 subjects (2.9%) suffered from permanent pain during physical activity. Permanent pain when at rest was reported in 0.5% (n=12). Female subjects, students attending high school, smoking adolescents and adolescents with a consumption of alcoholic beverages had a significantly higher prevalence of HP. HP was associated with a significantly higher prevalence of low back pain and knee pain. The prevalence of pathological findings of the hip was 2.5% (n=60). Factors significantly associated with HP were: female gender (1.9-fold), attending high school (2.1-fold) and consumption of tobacco (1.6-fold). HP in adolescents seems to be mostly caused by functional disorders. There is a possible association between HP and psychological stress or consumption of legal drugs. Prophylactic measures are necessary in this age group in future.

Femoroacetabular impingement (FAI) is a recently described hip disorder resulting from an abnormal morphology between the proximal femur and acetabulum (socket). It is now recognized as a cause of hip pain in adolescents and young adults, and research has shown that it may also lead to early degenerative changes and osteoarthritis. Femoroacetabular impingement as a cause of precocious hip arthrosis was originally described by Ganz et al. in 2001, and a quick literature search on this topic will confirm that it has become a topic of cutting edge research within the orthopaedic community. The abnormal morphology in FAI results in increased hip contact forces with hip motion, especially flexion. This results in abnormal contact that can lead to acetabular labral tears and cartilaginous injury. Early diagnosis and treatment may possibly delay the future onset of hip arthritis. Although the precise cause of FAI is not well understood, the condition has become increasingly recognized as a cause of hip pain in active adolescents and young adults. The purpose of this article is to outline the history, physical examination and radiographic findings, and current conservative and surgical treatment modalities for FAI.

ABSTRACTThe 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 performed 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 instability, 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 injections, 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 89 ± 16%. A non-image-guided diagnostic intra-articular hip injection yields reliable short-term pain relief, simultaneously endorsing accurate diagnosis of hip pathology and intra-articular needle placement.

Background: Ischiofemoral impingement is an often unrecognized cause of hip pain in adolescents. It is caused by abnormal contact between the proximal femur and the ischium. The aim of our work is to describe clinical presentation, imaging findings and functional outcomes of ischiofemoral impingement in adolescents. Methods: We performed a retrospective study. Clinical files were reviewed (age, sex, type and duration of symptoms and hip physical examination). Imaging findings were evaluated in pelvis radiographs (presence of coxa profunda, acetabular protrusio, Wiberg angle, femoral neck shaft angle and acetabular retroversion) and in MRI (quadratus femoris edema, measurement of ischiofemoral and quadratus femoris space). Lower extremity functional scale (LEFS) were used to measured response to a physiotherapy protocol. Also relapse and time to sports return were recorded. Results: 24 hips, two bilateral in 20 female patients and 2 male patients, with 13 years-old on average (9-18) were obtained. Main symptom was hip pain with latency to consultant of 9 days on average (2-14). All patients practiced school sports, the most frequent was gymnastics. Positive FADIR test, ischiofemoral impingement test and pain on palpation of the ischium and gluteus medius were found in everyone. The median of Wiberg angle was 37º (25-48), femoral shaft angle 138º (128-144), and coxa profunda was present in 5 hips. MRI showed 13 hips with quadratus femoris edema, one with muscle atrophy, ischiofemoral space was 20 mm on average (16-25) and quadratus femoris space 17 mm on average (13-21). Our physiotherapy protocol was followed for all patients with a median of 18 sessions (10-30). LEFS improved from 56.4% (30-93) to 92% (80-100) (p=0,02). Time to turn asymptomatic was 6 months on average (3-13). With 2 years follow up, 2 hips had recurrence of symptoms. Time to sports return was 5 months on average (3-7). Conclusions: Ischiofemoral impingement is cause of hip pain in active female adolescents. X-rays are inespecific and MRI shows typically quadratus femoris edema. Conservative treatment with physiotherapy is an effective method that allows sports return in few months. This is the first report in the literature regards ischiofemoral impingement in pediatric population including results of treatment and return to sports.

AimTo investigate the prevalence, characteristics, and risk factors of hip pain in adolescents with cerebral palsy (CP) and compare the findings with those of the same individuals 5 years earlier.MethodSixty‐seven adolescents (28 females, 39 males; mean age 14y 7mo; SD 1y 5mo; range 12–17y) with bilateral CP, in Gross Motor Function Classification System (GMFCS) levels III to V enrolled in a CP surveillance programme were assessed for hip pain. Their caregivers responded to the questions on the intensity and frequency of hip pain from the Child Health Questionnaire (CHQ) (transformed to CHQ hip pain score; 100 indicates no pain). Interference of hip pain with daily activities and sleep was recorded on numeric rating scales. Hip displacement was measured radiographically by the migration percentage.ResultsTwenty‐eight participants had 44 painful hips. Their mean CHQ hip pain score was 40 (SD 21.4; range 10–80). Independent risk factors for hip pain, low CHQ hip pain score, and interference with sleep were severe hip subluxation (migration percentage 50–89%) and GMFCS level V. A migration percentage of 50% to 89% was the only independent risk factor for interference with daily activities. Over 5 years, the number of participants with hip pain increased from 18 to 28, while the mean migration percentage of the most displaced hip was unchanged.InterpretationOur CP hip surveillance programme did not protect the participants against increasing prevalence of hip pain during adolescence. We suggest that surveillance programmes for CP should include guidelines on the characteristics and management of hip pain.What this paper addsHip pain prevalence increased in adolescents over a 5‐year period in a cerebral palsy surveillance programme.Risk factors for hip pain were Gross Motor Function Classification System level V and severe hip subluxation.

ABSTRACTIntra-articular injection of corticosteroid and anesthetic (CSI) is a useful diagnostic tool for hip pain secondary to labral tears or femoroacetabular impingement (FAI). However, the effectiveness of CSI as a stand-alone treatment for hip pain in adolescents is unknown. The purpose of this study is to evaluate the use of CSI for the treatment of hip pain and determine factors that may affect outcomes after injection. Retrospective analysis of 18 patients and 19 hips that underwent fluoroscopic guided hip injection for the treatment of pain at a single institution from 2012 to 2015 was carried out in this study. Mean age at the time of injection was 15.1 years (range 13–17) with mean follow-up of 29.4 months. Fifty-two percent (10/19 hips) went on to surgery after the injection. Average time to surgical conversion was 12.8 months after CSI. Cam or pincer morphologies were present in 90% (9/10 hips) of the operative group. Patients with FAI were more likely to need surgery than patients without bony abnormalities (RR= 10, 95% CI 1.6–64.2, P = 0.0001). There was no difference in the presence of labral tears in the operative and non-operative groups (100% versus 89%, P = 0.47). For adolescents without bony abnormalities, 90% improved with CSI alone and did not require further treatment within 2.4 years. Fluoroscopic guided corticosteroid hip injection may have limited efficacy for the treatment of hip pain secondary to FAI in adolescents. However, for patients without osseous deformity, CSI may offer prolonged improvement of symptoms even in the presence of labral tears.

Management of hip pain in young adults

Background: Femoroacetabular impingement (FAI) is a well-known cause of hip pain in adolescents and young adults. However, the incidence in the general population has not been clearly defined. Purpose: To (1) define the population-based incidence of diagnosis of FAI in patients with hip pain, (2) report the trends in diagnosis of FAI over time, and (3) determine the changes in the rate and type of surgical management over time. Study Design: Cohort study; Level of evidence, 3. Methods: A geographic database was used to identify patients who were 14 to 50 years old with hip pain between the years 2000 and 2016. Chart and radiographic review was performed to determine which patients had FAI. To be included, patients had to have a triad of clinical symptoms, physical examination signs, and imaging findings consistent with FAI. Medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Statistical analysis determined the overall age- and sex-adjusted annual incidence of FAI diagnosis and trends over time. Results: There were 1893 patients evaluated with hip pain, and 716 (38%; 813 hips) had diagnosed FAI. The mean ± SD age was 27.2 ± 8.4 years, and 67% were female. The incidence of FAI diagnosis was 54.4 per 100,000 person-years. Female patients had a higher incidence than male patients (73.2 vs 36.1 per 100,000 person-years; P < .01). Incidence of FAI diagnosis were higher from 2010 to 2016 (72.6 per 100,000 person-years; P < .01) as compared with 2005 to 2009 (45.3) and 2000 to 2004 (40.3). Hip arthroscopy, surgical hip dislocation, and periacetabular osteotomy utilization increased from the 2000-2004 to 2010-2016 periods, respectively: 1 (1%) to 160 (20%; P = .04), 2 (1%) to 37 (5%; P = .01), and 1 (1%) to 22 (3%; P = .58). Conclusion: The overall incidence of FAI diagnosis was 54.4 per 100,000 person-years, and it consistently increased between 2000 and 2016. Female patients had a higher incidence than male patients. The utilization of joint preservation operations, including hip arthroscopy, surgical hip dislocation, and anteverting periacetabular osteotomy, increased over time.

Commentary Cunningham et al. conducted a cost-effectiveness analysis of the diagnostic process for femoroacetabular impingement (FAI) syndrome. With the tremendous increase of the therapeutic and diagnostic costs of this pathology, the data presented in this study are noteworthy from a clinical and a financial standpoint. The article concludes that advanced imaging, including magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA), are not cost-effective methods when compared with the history and physical examination (H&P) with or without diagnostic hip injection, and thus should not be routinely performed to diagnose FAI. It was suggested that hip MRI and MRA should have a place in the diagnostic algorithm of FAI only in cases of “challenging clinical scenarios.” The use of diagnostic hip injection was proven to be favorable for general practitioners and less useful for hip specialists. FAI syndrome was redefined in an international consensus statement and was endorsed by 25 clinical societies1. Hip pain can be the result of bone lesions and cartilage damage, as well as labral, capsular, and ligamentum teres pathology. Although the H&P and hip radiographs can identify osseous abnormalities, labral or capsular pathology is left undiagnosed, and evaluation of the cartilage is impossible without MRI. With the substantial expansion of hip arthroscopic techniques2, it is possible to address osseous and soft-tissue lesions that, if left untreated, result in deterioration of hip biomechanical function and osteoarthritis3. The novelty of and rapid progression in diagnostic and treatment modalities in hip preservation surgery have resulted in an imbalance of medical knowledge between general practitioners and hip specialists. Cunningham et al. propose that H&P with injection is more likely to be cost effective for general practitioners. Administration of hip injection requires technical expertise since severe damage can occur in the hip when performed inappropriately. The former point is reflected in the results of the study: the willingness to pay (WTP) was $57,000/quality-adjusted life year (QALY) using the injection sensitivity rate in the general practitioner scenario. This amount is almost 50% lower than the accepted WTP threshold in the United States, which is $100,000. The elimination of the use of MRI and MRA in cases of “challenging clinical scenarios” would be reasonable if the level of education was equal between general practitioners and hip specialists because characterizing a clinical scenario as “clinically challenging” relies substantially on clinical expertise, which can differ considerably even among hip specialists. Hip joint ultrasonography in the diagnosis of FAI syndrome has attracted research interest. Ultrasound is less expensive and more accessible than MRI and MRA examination, but diagnostic accuracy depends on the examiner’s skills. Buck et al. reported that the acetabular labrum can be visualized using ultrasound, but only partially4. Evaluation of the interference of the labrum with the other joint structures during hip motion under ultrasound visualization could help to better understand the patient’s symptomatology and aid in preoperative planning. MRI has been used in studies as the gold standard to validate ultrasound for the diagnosis of cam impingement, with promising outcomes4,5, but not enough evidence exists to establish it as a reliable examination to diagnose FAI syndrome. Another advantage of preoperative MRI examination is the detection of occult malignant bone or soft-tissue tumors concomitant with FAI pathology, where arthroscopic hip intervention could cause tissue spread and subsequent metastatic disease. While Cunningham et al. support the reduction of MRI and MRA usage to diagnose FAI syndrome, currently there is no other validated tool to diagnose hip soft-tissue and cartilage lesions. A possible solution to limit the financial burden when diagnosing FAI syndrome would be an increase in training opportunities for health-care professionals to advance their knowledge of FAI syndrome (apart from the cam and pincer mechanisms), with specialized physical examination tests and radiographic views (cross-table lateral, Dunn view, or false-profile view). This would eliminate the need for repeated radiographs by specialized physicians who usually encounter a patient who has been diagnosed with FAI syndrome based on symptomatology, impingement tests, and/or anteroposterior pelvic radiographs. Overuse of MRI and MRA and the associated costs need to be addressed by establishing validated hip-screening protocols to diagnose FAI syndrome. This will bridge the “gap” between general practitioners and hip specialists when diagnosing this disease and prevent the misuse of MRI and MRA and overcharging of the health-care system.

Clinical evaluation of the painful adolescent and young adult hip

Femoroacetabular impingement (FAI) is an abnormality of the hip joint that is increasingly being recognized as a cause of athletic disability and early degenerative hip disease. Despite significant advances in the knowledge of FAI, it remains a frequently unrecognized cause of hip pain in adolescents and young adults among orthopedic providers. The purpose of this article is to present a simple 3-view radiographic approach to young adults with hip pain. The radiographs include a standing anteroposterior view of the pelvis, a cross-table lateral view, and a false profile view. Good quality radiographs showing the common sites of potential impingement combined with a basic understanding of certain radiographic parameters may allow faster diagnosis, eliminate unnecessary studies, and allow earlier referral and management.

Diagnostic hip injections are often used to confirm intra-articular pathology prior to arthroscopic treatment for femoroacetabular impingement (FAI). However, little is known whether the type of response correlates with the post-operative functional outcomes. The purpose of this study is to document the ability of a diagnostic hip injection to predict short-term functional outcomes following arthroscopic surgical management. A prospective cohort of 52 patients diagnosed with FAI who had an intra-articular hip injection prior to arthroscopic surgery was evaluated. A pain diary was used during the 2 weeks after hip injection to document response. In addition, the modified Harris Hip Score (mHHS) was administered preoperatively and 6 months post-operatively to assess functional outcomes. The relationship between response to an intra-articular hip injection and mHHS scores 6 months after FAI surgery was evaluated. Overall, 42 of 52 (81 %) patients diagnosed with FAI achieved pain relief from the hip injection. Outcomes according to mHHS scores improved significantly at the 6-month follow-up visit (19 points, 95 % CI 15-24, p = 0.001). The therapeutic utility of the hip injection suggested that lack of pain relief predicted a lack of functional improvement following arthroscopic surgery. In this study, the data suggests that a positive response from an intra-articular hip injection is not a strong predictor of short-term functional outcomes following arthroscopic management of FAI. However, a negative response from an intra-articular hip injection may predict a higher likelihood of having a negative result from surgery.

The diagnosis of hip osteoarthritis is often complicated by co-existing pathology in the knee and spine, and mismatch between clinical and radiological signs. Temporary pain relief from a local anaesthetic injection into the hip joint has been reported to help localise symptoms, reducing the risk of unnecessary surgery being performed. We hypothesize that good surgical outcome is predicted by good analgesia following diagnostic injection, and that alternative pathology is present when there is no response to injection. Data were analysed from a prospective database of 163 consecutive patients who underwent diagnostic hip injection for possible osteoarthritis. We recorded result of injection and whether hip arthroplasty was performed. A good outcome to surgery was defined as subsequent pain relief without significant residual symptoms. A total of 138 patients were suitable for inclusion in the study. Fifty-eight patients had hip arthroplasty following a good response to diagnostic injection. Of these 54 had a good outcome following surgery (93%). There was also a quantitative improvement in pain and function in these patients as measured by 1year post-operative and pre-operative Harris hip scores (P < 0.0001). A total of 44/49 patients had no surgery following no response to injection. A clear alternative diagnosis to hip osteoarthritis was made in 40 of these patients (91%). Diagnostic ultrasound-guided local anaesthetic injection of the hip joint is a useful test in confirming hip pathology. Complete relief of hip pain following intracapsular injection of local anaesthetic is associated with good surgical outcome following joint replacement.

IntroductionHip arthroscopy has become increasingly popular over the years, making it a leading treatment for hip pain in adolescents and young adults. The influence of various demographic factors, including insurance status, on hip arthroscopy outcomes remains uncertain. This is important, as insurance status is a known predictor of orthopedic surgical outcomes – patients with public insurance often experience worse results compared to those with commercial coverage. This study utilizes Patient-Reported Outcomes Measurement Information System (PROMIS) data to evaluate the role of insurance type on hip arthroscopy outcomes, aiming to identify at-risk populations and improve healthcare equity.MethodsPatients who underwent hip arthroscopy between 1/1/2015–6/30/2024 at our institution were identified (Current Procedural Terminology codes: 29861, 29862, 29863, 29914, 29915, 29916, and 29999). The patients’ insurance information was obtained, and patients were split into two groups for analysis: Commercial and Medicare/Medicaid. PROMIS scores along the pain interference, physical function, and depression domains were obtained and analyzed between the two groups. Furthermore, demographic information such as gender, age at surgery, and smoking status were analyzed. Surgical procedures and intraoperative findings were also examined between groups.ResultsA total of 333 patients were included in this study and all patients had minimum 1-year follow-up. The two groups split by insurance status yielded 272 patients in the Commercial group and 61 patients in the Medicare/Medicaid group. No significant differences were observed in preoperative demographic variables. The Commercial group had a significantly greater number of femoroplasties performed (P = 0.018). There were significant preoperative and postoperative differences in all PROMIS measures examined (P < 0.05). Both groups showed significant improvement in PROMIS measures, however, there were no significant differences in this improvement (P > 0.05).ConclusionThe most important finding in our study is that regardless of insurance status, our cohort of patients improved with surgery. However, patients with Medicare or Medicaid had worse pre-operative and post-operative depression and pain interference scores compared to patients with Commercial insurance. These findings highlight that although patients with Medicare/Medicaid improve overall, this insurance status may be associated with poorer hip arthroscopy outcomes.