Hip Injections Research Articles

Silicone‐induced granulomas and renal failure

AbstractThe use of liquid silicone for soft tissue augmentation has been in practice for the last 40 years. Initially thought to be inert, provoking little local and no systemic response, liquid silicone was extensively used for cosmetic sub‐cutaneous augmentation. With its rampant and unregulated use, however, this substance has become implicated in a variety of adverse reactions, some of which occur months to years after initial exposure. We report the case of a male‐to‐female transsexual patient who had received liquid silicone hip injections for cosmetic augmentation. Years after receiving these injections she developed silicone‐induced granulomas causing hypercalcemia and subsequent renal failure. We discuss the controversy over the use of liquid silicone for soft tissue augmentation. In addition, the pathophysiology of granulomatous disease causing hypercalcemia and treatment options for sili‐cone‐induced granulomas is discussed.

Accuracy of Diagnostic Injection in Differentiating Source of Atypical Hip Pain

It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinicoradiological features, and concomitant hip and lumbar spine arthritis. The purpose of this study is to present our experience using the response resulting from a combined anesthetic-steroid hip injection for treatment selection in these patients. A retrospective analysis of 204 consecutive diagnostic hip injections was undertaken. Patient charts were scrutinized for outcomes of injection and treatment. Our findings suggest that the relief of symptoms following injection of local anesthetic and steroid into the hip joint has a sensitivity of 91.5%, specificity and positive predictive value of 100%, and negative predictive value of 84.6% for response to total hip arthroplasty. We thereby believe that this is a reliable test with low morbidity and can predict the potential benefit of total hip arthroplasty in this diagnostically challenging group of patients.

Accuracy of Intra-Articular Anesthetic and Steroid Hip Injection in Differentiating Pain Source in Patients with Atypical Hip and Lower Extremity Pain

Accuracy of Intra-Articular Anesthetic and Steroid Hip Injection in Differentiating Pain Source in Patients with Atypical Hip and Lower Extremity Pain

The Diagnostic Validity of Hip Provocation Maneuvers to Detect Intra-Articular Hip Pathology

To determine which hip provocation maneuvers best predict the presence of an intra-articular hip pathology. Prospective diagnostic study. Musculoskeletal clinic at a university-based multispecialty group practice. Fifty subjects referred for intra-articular hip injection under fluoroscopic guidance. Subjects were examined with 4 pain provocation maneuvers before and after anesthetic intra-articular hip injection administered under fluoroscopic guidance. Presence of intra-articular hip pain generator was confirmed by > or =80% improvement on visual analog scale after intra-articular hip injection. The most sensitive tests were flexion abduction external rotation (FABER) test and internal rotation over pressure (IROP) maneuver. For the FABER test, sensitivity was 0.82 (95% CI 0.57-0.96); sensitivity for the IROP maneuver was 0.91 (95% CI 0.68-0.99). The most specific test was the Stinchfield maneuver, with specificity at 0.32 (95% CI 0.14-0.55). FABER and IROP had the highest positive predictive value, with 0.46 (95% CI 0.28-0.65) and 0.47 (95% CI 0.29-0.64), respectively. IROP had the highest negative predictive value at 0.71 (95% CI 0.25-0.98). IROP and FABER may be worthwhile components of the clinical evaluation of hip pain to determine intra-articular hip pathology. These tests are nonspecific and therefore not necessarily negative in the absence of intra-articular hip pathology. These hip provocation maneuvers are a useful part of an evaluation that includes history, further examination findings, and other diagnostic studies.

Evaluation of Needle Positioning During Blind Intra-Articular Hip Injections for Osteoarthritis: Fluoroscopy Versus Arthrography

Dıraçoğlu D, Alptekin K, Dikici F, Balcı Hİ, Özçakar L, Aksoy C. Evaluation of needle positioning during blind intra-articular hip injections for osteoarthritis: fluoroscopy versus arthrography. Objective To evaluate needle positioning during blind/anatomically referenced hip joint injections for osteoarthritis (OA). Design Experimental clinical study. Setting Operating theater of a university hospital. Participants Patients (N=16) (10 women, 6 men), who were diagnosed as having OA according to the American College of Rheumatology criteria and whose radiologic grades were II or III according to Kellgren-Lawrence. Interventions Three bilateral and 13 unilateral hip injections were performed (3 times at 1-week intervals). After it was presumed blindly that the needle was within the joint, the location of the needle was checked with backflow technique and fluoroscopy. Entrance to the joint cavity was also ensured by reconfirmation with contrast medium, and the procedure was then terminated with hyaluronic acid injection. Main Outcome Measures Assessment of blind needle placement into the hip joint by using backflow technique, fluoroscopic images, and contrast enhancement. Results The location of the needle was fluoroscopically confirmed to be at the proper position in 38 (66.7%) of the 57 blind interventions. Furthermore, in 29 (76.3%) of those 38 interventions, localization of the intra-articular needle could be confirmed by intra-articular contrast uptake. Overall, 29 of 57 (50.9%) blind interventions exhibited intra-articular contrast enhancement. Backflow was not observed in 23 (79.3%) of these 29 interventions. Five (17.9%) of 28 interventions with no contrast uptake showed backflow. Conclusions In light of our results, we suggest that blind injection of the osteoarthritic hip joint can be inaccurate even with careful technique. Further, the backflow method does not appear to be reliable, and guidance during the injection seems to be necessary.

A Review of Viscosupplementation for Osteoarthritis of the Hip and a Description of an Ultrasound-Guided Hip Injection Technique

Viscosupplementation of the hip for symptomatic osteoarthritis appears to be safe and effective in more than 25 yr of use in Europe. More than 11 studies suggest that viscosupplementation in the hip is as effective as viscosupplementation in the knee. It appears to be a safe and reasonable alternative to nonsteroidal antiinflammatory drugs or intra-articular steroids for the treatment of osteoarthritis pain. Viscosupplementation in the hip may delay the need for hip replacement surgery. Viscosupplementation in the hip appears to work better in patients with fewer radiographic changes of osteoarthritis. Placement of viscosupplement in the hip under real-time ultrasound or fluoroscopic guidance is safe and well tolerated. Hip joint communication with the iliopsoas bursa may be a factor in studies of the effectiveness of viscosupplementation in the hip.

Ultrasound-guided injections of the knee and hip joints

Intra-articular knee and hip injections have been a mainstay for the treatment of peripheral joint pain. Although these injections are routinely performed using a blind technique, when compared with fluoroscopically guided injections, reported accuracy of needle placement is highly variable. Ultrasound (US)-guided injections provide a reasonable alternative for ensuring accurate, intra-articular needle placement, without the risks associated with radiation exposure from fluoroscopy. This article presents suitable techniques for performing US-guided intra-articular knee and hip injections. With appropriate training, it would be feasible for physicians to incorporate US-guided injections into their clinical practices.

Knee vs hip single-joint intra-articular hyaluronic acid injection in patients with both hip and knee osteoarthritis: a pilot study

This paper aims to compare the results of single-joint knee vs hip hyaluronic acid (HA) injections in patients with osteoarthritis (OA) involving both the knee and hip joints. Thirty-eight patients who were diagnosed to have both hip and knee OA were enrolled. Patients were divided into two groups to receive HA injection three times at 1-week intervals either to the hip or knee joints. Pain level during activities and rest was measured by using visual analog scale (VAS). Western Ontario and McMaster University Osteoarthritis Index (WOMAC 5-point Likert 3.0) was also used prior to the injections and 1 month after the 3rd injection. In the knee injection group, the intragroup analysis revealed significant improvements in VAS activity pain, VAS rest pain, and WOMAC pain values following injection when compared with preinjection values, while no significant difference was detected in WOMAC stiffness, WOMAC physical function, and WOMAC total values. In the hip injection group, VAS activity pain, VAS rest pain, WOMAC pain, WOMAC stiffness, WOMAC physical function, and WOMAC total values showed significant improvement after the injection when compared with preinjection values. Although statistically not significant (p > 0.05), the comparison of the differences (preinjection-postinjection) between the groups demonstrated higher values in the hip injection group. We imply that intra-articular single-joint HA injections either to the knee or hip joints in OA patients with involvement of both of these joints are effective with regard to pain and functional status.

Persistent Hip Pain In A Football Player

HISTORY: 22 y/o male FB player with 3 week history of intermittent R hip flexor pain, worse with hip internal rotation and flexion. No acute trauma. He underwent an intra-articular injection with lidocaine, bupivacaine and depomedrol with aspiration of clear, synovial fluid. Immediately post injection, he had resolved hip joint pain, but c/o deep persistent 1/10 pain over hip flexors. Over 7 days hip flexor pain worsened from 4 to 9/10, with stiffness, worse with hip extension. No F/C, N/T, weakness, back, testicular or urinary pain, B/B incontinence, or GI sx. PHYSICAL EXAMINATION: Heart, lungs and abd exam WNL. (+) Trendelenburg gait. TTP along and inferior to R inguinal ligament. Hip was painful with int. rotation, & passive, active and resisted hip flexion. No pelvic or leg length asymmetry. No pain over the pubis or with valsalva. No palpable hernia. DIFFERENTIAL DIAGNOSIS: 1) Hip Flexor Strain 2) Femoral acetabular impingement 3) Labral Tear SECONDARY: 4) Psoas Abscess 5) Septic Arthritis 6) Femoral Neck Stress Fracture 7) Iliopsoas Bursitis TEST AND RESULTS: 1) AP pelvis and R hip false profile view: a. Mild FAI with decreased anterior femoral head/neck offset. b. Small fibro-cystic lesion, ant-lateral neck of the femur. 2) IA Hip Injection a. Aspiration of 3 ml of clear synovial fluid with 7 to 0/10 pain reduction in hip pain. b. Neg Gram stain & cx. 3) WBC 17.1, 83.6% PMN's, CRP 15.1, ESR 25 4) Hip MRI w/o contrast: a. Complex heterogeneous fluid in psoas muscle to the illiacus (abscess vs hematoma). b. Decreased femoral head/neck offset, no labral tear 5) U/S guided aspiration of fluid collection in the illiacus done before antibiotics. a) 50ml of opaque, light brown, purulent material. Culture negative. 6) I&D of psoas/ illiacus fluid collection with placement of penrose drain. a. Gram stain neg but culture positive for methicillin sensitive staph aureus (MSSA). 7) Blood culture neg x 2 FINAL WORKING DIAGNOSIS: 1) Iliacus and Psoas Abscess 2) Femoral Acetabular Impingement TREATMENT AND OUTCOMES: 1) Piperacillin/Tazobactam and Vancomycin IV started, then Nafcillin IV for 2 weeks via PICC line after cx's positive for MSSA. On completion of IV therapy, he was treated with Dicloxacillin PO for 10 days. 2) Held from play for 6 weeks until full, pain free ROM, no pain with hip flexion, weight bearing, or sport-specific motions.

Greater Trochanteric Pain Syndrome: A Review of Anatomy, Diagnosis and Treatment

Greater trochanteric pain syndrome (GTPS) is a term used to describe chronic pain overlying the lateral aspect of the hip. This regional pain syndrome, once described as trochanteric bursitis, often mimics pain generated from other sources, including, but not limited to myofascial pain, degenerative joint disease, and spinal pathology. The incidence of greater trochanteric pain is reported to be approximately 1.8 patients per 1000 per year with the prevalence being higher in women, and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity. Symptoms of GTPS consist of persistent pain in the lateral hip radiating along the lateral aspect of the thigh to the knee and occasionally below the knee and/or buttock. Physical examination reveals point tenderness in the posterolateral area of the greater trochanter. Most cases of GTPS are self-limited with conservative measures, such as physical therapy, weight loss, nonsteroidal antiinflammatory drugs and behavior modification, providing resolution of symptoms. Other treatment modalities include bursa or lateral hip injections performed with corticosteroid and local anesthetic. More invasive surgical interventions have anecdotally been reported to provide pain relief when conservative treatment modalities fail.

An Inexpensive and Accurate Method for Hip Injections Without the Use of Imaging

Intraarticular injections of the hip have traditionally required sonographic or fluoroscopic guidance assistance. Previous studies report high failure rates with injections based solely on anatomic landmarks. To examine the accuracy of a lateral injection technique in osteoarthritic patients without using image assistance. This study was conducted in the operating room in 40 consecutive patients about to undergo total hip arthroplasty. Before sedation, each patient was positioned in a lateral decubitus position. Under sterile conditions, methylene blue dye was injected through an 18G spinal needle that was inserted 1 cm proximal to the midline of the greater trochanter, and directed toward the superolateral aspect of the femoral neck, according to preoperative hip x-rays. Accuracy was assessed intraoperatively by examining the joint and surrounding tissues for the presence of dye. Injections were successful in 6 of the first 10 (60%) patients and in 25 of the remaining 30 (83.3%) patients. Overall, injections were successful in 31 of 40 (77.5%) patients with disseminated dye solely in the intracapsular space. In all 9 unsuccessful injections, the dye was located distal to the joint, along with the more lateral aspect of the femoral neck. Accuracy of injections, to the hip joint, based on anatomic landmarks and preoperative x-rays is similar to those documented for knee injections in the literature. When unsuccessful, the injected material was not found close to neurovascular structures. This technique has an acceptable learning curve and can be used safely in a standard office setting.

Accuracy of Sonographically Guided Intra-articular Injections in the Native Adult Hip

The purpose of this study was to determine the accuracy of sonographically guided intra-articular injections performed in the native adult hip using contrast-enhanced fluoroscopy as a reference standard. Twenty-eight consecutive patients (ages 32-91 years; mean, 68 years) referred to the pain clinic for intra-articular hip injections were recruited to participate. In each case, a 2- to 6-MHz curvilinear array transducer was used to place the needle into the hip joint at the femoral head-neck junction using an oblique sagittal approach. A contrast-enhanced fluoroscopic examination was then completed and assessed by an independent observer to determine needle placement accuracy. Once accurate placement was confirmed, the therapeutic injection proceeded. Thirty hip injections were completed in 15 women and 13 men (1 man and 1 woman received bilateral injections). The patients' body mass index (BMI) ranged from 20 to 39 kg/cm(2) (mean, 28 kg/cm(2)) and procedure time from initial scanning to injection averaged 112 seconds (range, 47-187 seconds). Overall, 97% of sonographically placed needles were accurate. The single inaccurate placement resulted from inadvertent needle withdrawal from the joint capsule during connection of the extension tubing for contrast agent injection in a young patient with a BMI of 28 kg/cm(2) and no hip effusion. Sonographic guidance can be used to inject the native adult hip joint with acceptable accuracy. When using the oblique sagittal approach, operators must be aware of the possibility of needle withdrawal from the joint due to the limited intra-articular space within the target region, particularly in the absence of effusion.

SymbolDiagnostic Hip Injections: Continuing Evidence Of Value and Safety

Lippincott's Bone and Joint Newsletter: March 2009 - Volume 15 - Issue 3 - p 31-32 doi: 10.1097/01.BONEJ.0000346729.05030.5e

Diagnostic Hip Injections

Diagnostic Hip Injections

The diagnostic value of anaesthetic hip injection in differentiating between hip and spinal pain

This study aimed at investigating the diagnostic value of a local anaesthetic hip injection test to differentiate between hip and spinal pain in patients presenting with concurrent hip and spine pathology. Prospective clinical series. Forty-eight consecutive patients with a diagnostic dilemma of concurrent pathology under the care of one spinal surgeon in one centre were evaluated. The hip injection test involved an intra-articular injection of 0.5% Bupivacaine under fluoroscopic control. Positive response was defined as significant (>70%) or complete relief of pain. A minimal relief (<30%) or no relief of pain was considered a negative response to the injection. Thirty-seven patients reported a positive response to the injection. Of these, 33 (89%) underwent successful hip replacement with complete relief of symptoms. One patient had an unsuccessful hip replacement. Three patients with a positive response declined surgery. Eleven patients had a negative response to the test. Ten of them responded satisfactorily to treatment directed towards their spinal pathology and one patient had a successful hip replacement. The sensitivity of the test was 97% and specificity 91%. There was no complication to the injection in any patient. Local anaesthetic hip injection test is a safe and reliable diagnostic tool in identifying the source of pain in patients with combination of hip and spinal pathology.

Poster 153: Provocation Tests to Detect Intra-Articular Hip Pain

Objective: Determine the sensitivity of 4 provocation maneuvers (FABER, Stinchfield, Scour, and Internal Rotation [IR] of hip Over Pressure) in predicting presence of intra-articular hip pathology. Presence of pathology is confirmed with diagnostic intra-articular hip injection under fluorscopic guidance. We provide preliminary results on 13 patients. Design: Prospective diagnostic clinical study. Setting: Musculoskeletal clinic at university center. Participants: 13 subjects undergoing intra-articular hip injection.

Interventions in Chronic Pain Management. 6. Interventional Approaches to Chronic Pain Management

Overton EA, Kornbluth ID, Saulino MF, Holding MY, Freedman MK. Interventions in chronic pain management. 6. Interventional approaches to chronic pain management. This self-directed learning module highlights strategies for interventional treatments for chronic pain disorders. It is part of the chapter on chronic pain in the Self-Directed Physiatric Education Program for practitioners in physical medicine and rehabilitation. Specifically, the first module reviews an interventional protocol for recalcitrant buttock and hip pain. The protocol includes hip and spinal injections, neuroablative lesioning, and percutaneous epidural neuroplasty. The second module reviews implantable treatments (spinal cord stimulation, implantable pumps) for intractable pain. Overall Article Objective To discuss interventional pain management approaches in the treatment of chronic pain disorders.

Hip Joint Pain Referral Patterns: A Descriptive Study

To determine hip joint pain referral patterns. Retrospective analysis. Setting. Multicenter. Patients. Fifty-one consecutive patients meeting clinical criteria of a symptomatic hip joint. Interventions. Fluoroscopically guided intra-articular hip joint injection. Outcome Measures. Anatomic pain map before hip injection and visual analog scale both before and after hip injection. The hip joint was shown to cause pain in traditionally accepted referral areas to the groin and thigh in 55% and 57% of patients, respectfully. However, pain referral was also seen in the buttock and lower extremity distal to the knee in 71% and 22%, respectively. Foot and knee pain were seen in only 6% and 2% of patients, respectively, while lower lumbar spine referral did not occur. Fourteen pain referral patterns were observed. Buttock pain is the most common pain referral area from a symptomatic hip joint. Traditionally accepted groin and thigh referral areas were less common. Hip joint pain can occasionally refer distally to the foot. Lower lumbar spine referral did not occur.

A modular, flexible training strategy to achieve competence in diagnostic and interventional musculoskeletal ultrasound in patients with hip osteoarthritis

This study sought to establish a model of training and an assessment of competency in musculoskeletal ultrasound (MSUS) diagnosis of hip synovitis and/or effusion and in MSUS-guided injection of the hip. The 'trainee' (no previous experience in MSUS) was trained by an 'expert' [a rheumatologist who is a trainer on the European League Against Rheumatism (EULAR) MSUS course] using a modular approach focused on hip ultrasound only. This consisted of (i) a 1.5 h initial tutorial and practical demonstration and (ii) indirectly supervised non-continuous scanning of 40 hips over 5 h. Competency was assessed in three ways: (i) ability to obtain standard EULAR reference MSUS images of the hip of sufficient image quality, (ii) accuracy in diagnosis of synovitis or hip effusion by measurement of the anterior femur-capsule distance, and (iii) accuracy in ultrasound-guided hip aspiration and injection. After a period of scanning of 75 min (10 hips), the images obtained by the trainee were consistently graded as acceptable for routine clinical use. Next, blinded triplicate measurements of the anterior femur-capsule distance performed by the trainee and expert showed agreement regarding diagnosis of hip effusion (>7 mm thickness) in 16/17 cases of hip arthritis (kappa 0.876). The trainee performed 40 MSUS-guided hip injections (seven directly supervised followed by 33 indirectly supervised). After 10 consecutive MSUS-guided hip injections, the novice achieved a subsequent accuracy rate of 25/26 (96%) confirmed by radiographic localization of radiopaque contrast. Using a modular approach, a learner-centred curriculum and a self-directed learning strategy with a minimum of direct supervision, a trainee achieved competence in MSUS diagnosis of hip effusion/synovitis and in MSUS-guided hip aspiration/injection.

The Safety of Hip Injection with Corticosteroid in the Diagnosis and Treatment of Osteoarthritis

Injection of steroid and local anaesthetic into hip and knee joints has been a recommended treatment for osteoarthritic pain for decades. There have been recent studies showing a higher incidence of infection leading to early revision of joint prostheses in patients who have had corticosteroid injections prior to joint replacement surgery. The aim of our study was to determine if there is any risk of infection in patients undergoing total hip arthroplasty (THA) after a hip joint injection. A retrospective search was conducted using the hospital computer database to identify patients who underwent hip injection and subsequent THA between 2000 and 2004. The study included a review all case notes to specifically identify prosthetic infection or early joint replacement surgery. One hundred and twenty-eight patients had hip joint injections and subsequently underwent successful total hip replacement. In this study there was no evidence of associated risk of prosthetic infection or early revision of total hip arthroplasty after hip joint injection with corticosteroids (average time of follow-up 3.2 years). Hip injection is safe provided a strict aseptic protocol is maintained. The time period of pain relief with hip injection is limited (average 2 months). For diagnostic purposes injections with local anaesthetic only is recommended. A large randomised control study would probably further substantiate these findings.