Ultrasound-guided Hip Injections Research Articles

Comparison of Pain With Ultrasound-Guided Intra-Articular Hip Injections With and Without Prior Subcutaneous Local Anesthesia.

To compare pain levels of intra-articular hip steroid injections performed with and without prior subcutaneous local anesthesia (LA) injection. Randomized prospective study. University-based musculoskeletal clinic. Forty-one adult patients undergoing a first-time ultrasound-guided unilateral intra-articular hip steroid injection. Subjects were randomized into 1 of 2 groups: intra-articular hip injection with prior subcutaneous LA with 2 mL of lidocaine 1% (With LA) or hip injection without prior subcutaneous LA (Without LA). Visual analog scale (VAS) pain scores (0-100) were collected before and after each injection. Visual analog scale pain score for the intra-articular hip injection. Of the 41 total subjects, 18 were randomized to the Without LA group and 23 to the With LA group. There was no significant difference in baseline (preprocedure) VAS scores between the Without LA (mean ± SD = 39.2 ± 27.2) and With LA (41.2 ± 24.0) groups (P = 0.864). The mean ± SD VAS score for the subcutaneous LA injection in the With LA group was 20.4 ± 16.1. There was no significant difference in VAS scores for the intra-articular hip injection between the Without LA (48.5 ± 27.7) and With LA (39.5 ± 25.7) groups (P = 0.232). Subcutaneous injection of lidocaine before an intra-articular hip injection did not significantly decrease pain from the intra-articular hip injection. Providers may perform intra-articular hip injections with a 22-gauge 3.5-inch spinal needle without the need for an extra subcutaneous LA injection.

Ultrasound-Guided Hip Injections with High Density Hyaluronic Acid: Outcome at One Year Follow Up.

Background: The ultrasound-guided viscosupplementation of the hip joint with hyaluronic acid (HA) is considered a standard procedure among the conservative treatments for hip arthritis. The aim of this study was to evaluate the clinical benefit and the incidence of adverse events of the technique in an observational study at one year follow up. Methods: We evaluated a consecutive series of 85 patients with a diagnosis of symptomatic arthritis who underwent intra-articular ultrasound-guided hyaluronic acid injections. The scales used for evaluation were modified Harris Hip Score (mHHS), WOMAC (Western Ontario and McMaster University), and Hip Outcome Score (HOS) with subscale Sport (HOSs), for pain the Visual Analogic Scale (VAS). The patients were classified according to Tonnis' radiological classification of arthritis (range 0-3): 20 patients (grade 0), 32 (grade 1), 18 (grade 2), 15 (grade 3). Results: At last follow up, all the scales increased: mHHS from 59.35 to 82.1, HOS from 69.45 to 78.53, HOss from 47.4 to 58.11, VAS from 6.09 to 3.97, WOMAC from 33.2 to 31.5 (p < 0.05 for all the parameters); the results were elaborated with GraphPad Prism v5.0 (Prism Software La Jolla, CA, USA) using Wilcoxon's test. A total of 13 patients out of 85 needed arthroplasty, all classified as Tonnis grade 3. No serious adverse events were noted due to the procedure. Conclusions: Based on our findings, indication for the use of hyaluronic acid is limited to patients with mild to moderate arthritis. Patients in advanced arthritis refusing replacement surgery and asking for this treatment should be informed about the poor results of the technique even in the short term.

The cost-effectiveness of adding an ultrasound corticosteroid and local anaesthetic injection to advice and education for hip osteoarthritis

Abstract Objectives Evidence for the comparative cost-effectiveness of intra-articular corticosteroid injection in people with hip osteoarthritis (OA) remains unclear. This study investigated the cost-effectiveness of best current treatment (BCT), comprising advice and education, with BCT plus a single ultrasound-guided intra-articular hip injection of 40 mg triamcinolone acetonide and 4 ml 1% lidocaine hydrochloride (BCT+US-T). Methods A trial-based cost–utility analysis of BCT+US-T compared with BCT was undertaken over 6 months. Patient-level cost data were obtained, and effectiveness was measured in terms of quality-adjusted life years (QALYs), allowing the calculation of cost per QALY gained from a UK National Health Service (NHS) perspective. Results BCT+US-T was associated with lower mean NHS costs (BCT+US-T minus BCT: −£161.6; 95% CI: −£583.95, £54.18) and small but significantly higher mean QALYs than BCT alone over 6 months (BCT+US-T minus BCT: 0.0487; 95% CI: 0.0091, 0.0886). In the base case, BCT+US-T was the most cost-effective and dominated BCT alone. Differences in total costs were driven by number of visits to NHS consultants, private physiotherapists and chiropractors, and hip surgery, which were more common with BCT alone than BCT+US-T. Conclusion Intra-articular corticosteroid injection plus BCT (BCT+US-T) for patients with hip OA results in lower costs and better outcomes, and is highly cost-effective, compared with BCT alone. Trial registration EudraCT: 2014-003412-37 (8 August 2015) and registered with Current Controlled Trials: ISRCTN 50550256 (28 July 2015). Trial protocol Full details of the trial protocol can be found in the Supplementary Appendix, available with the full text of this article at https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-018-2153-0, doi: doi.org/10.1186/s12891-018-2153-0.

The Effects of Ultrasound-Guided Intra-Articular Injections with Hyaluronic Acid and Corticosteroids in Patients with Hip Osteoarthritis: A Long-Term Real-World Analysis.

Intra-articular (IA) ultrasound-guided hip injections are currently considered a cornerstone of the conservative management of symptomatic hip osteoarthritis (HOA), although their effect on clinical outcomes has not been fully elucidated.The purpose of this study is to investigate the effectiveness of ultrasound-guided IA hip injections of hyaluronic acid (HA) with or without corticosteroids (CS) on pain relief and functional improvement in patients with HOA. In total, 167 patients with HOA were assessed at baseline (T0) and 12 months after injection (T1) using the VAS and GLFS scores. The sample consisted mainly of female subjects (58.1%), presenting an average age of 70.6 ± 12.2 years and grade 3 HOA (63.9%) according to the Kellgren-Lawrence classification. Most of the patients (76.2%) underwent unilateral hip injection with a combination of medium-high molecular weight HA (1500-2000 kDa) and CS. At T1, lower use of anti-inflammatory drugs, an increase in the consumption of chondroprotectors, and an overall reduction of instrumental physical therapies and therapeutic exercise were recorded. In addition, a statistically significant intragroup and between-group decrease observed at T1 for both the VAS and GLFS. Study results suggested that intra-articular hip injections with HA alone and with CS could represent a useful therapeutic tool for pain reduction and functional improvement for patients with hip osteoarthritis.

Is intra-articular injection of autologous micro-fragmented adipose tissue effective in hip osteoarthritis? A three year follow-up

BackgroundRecently, increased attention on regenerative medicine and biological injective treatments have been proposed to restore native cartilage. Micro-fragmented adipose tissue (MFAT) has been studied for its anti-inflammatory, paracrine, and immunomodulatory effects. The long-term effects of MFAT are still poorly understood: the aim of the present study is to demonstrate how hip articular injections with autologous MFAT can have an impact on clinical outcomes.MethodsSeventy-one consecutive patients affected by early hip osteoarthritis underwent an ultrasound-guided hip injection of autologous MFAT between June 2017 and December 2018. Patients were divided into four groups according to the Oxford Hip Score. All patients received 4 mL of autologous micro-fragmented adipose tissue under an ultrasound guide. A clinical evaluation was done between 29 and 41 months after the initial treatment. During this follow-up period, we recorded any new treatment the patients had done, whether that be injection or arthroplasty surgery.ResultsThe study included 55 patients. Out of 55 patients, 28 saw benefits and were in no need of further treatment. Moreover, the score between the beginning and control increased by 6.9 points. Ten patients underwent a new articular injection: the mean time between the two injections was 635.7 ± 180 days. Seventeen patients underwent total hip replacement: the mean period between the autologous MFAT injection and the surgery was 495 days.ConclusionThis study found that intra-articular injections with autologous MFAT achieve beneficial clinical results in patients affected by early to moderate hip osteoarthritis, with an OHS between 48 and 30. Furthermore, these subjects are the ideal patients for whom this treatment obtains good clinical results.

Hybrid Hyaluronic Acid versus High Molecular Weight Hyaluronic Acid for the Treatment of Hip Osteoarthritis in Overweight/Obese Patients.

Background: Obesity is the main risk factor for hip osteoarthritis, negatively affecting the outcome of the disease. We evaluated the effectiveness of viscosupplementation with hybrid hyaluronic acid compared to that with high molecular weight hyaluronic acid in overweight/obese patients with hip osteoarthritis (OA). Methods: 80 patients were divided into two groups: a treatment group received two ultrasound-guided intra-articular hip injections of hybrid HA 15 days apart; a control group received a single ultrasound-guided infiltration with medium-high molecular weight hyaluronic acid (1500–2000 kDa). We assessed the pain, functional and cardiovascular capacity of the patients at baseline, after 3 months, and after 6 months of the infiltrative sessions. Results: The treatment group showed greater improvements in the scores on the NRS scale (5.4 ± 0.8 vs. 6.3 ± 0.8; p < 0.05) and in the Lequesne index (11.4 ± 2.6 vs. 13.6 ± 2.7; p < 0.05) and in the distance traveled at 6MWT (238.1 ± 53.9 m vs. 210.7 ± 46.2 m; p = 0.02) both at 3 months (T1) and at 6 months (T2). Conclusions: This study underlines the importance of exploiting the anti-inflammatory, analgesic, and chondrogenic properties of hybrid HA for the treatment of hip OA in overweight/obese patients.

89 Do Corticosteroid and Local Anaesthetic Hip Injections Administered Proximal or Distal to The Zona Orbicularis Have an Effect on Patient Satisfaction?

Abstract Aim Pubofemoral and ischiofemoral ligaments blend to make zona orbicularis. Zonaorbicularis has been suggested to force fluid from peripheral compartment to central compartment in unidirectional flow. This study aims to assess whether injection of corticosteroid with local anaesthetic injected either proximal or distal to the zona orbicularis has effect on patient satisfaction. Method This retrospective study investigated consecutive patients undergoing ultrasound guided hip injections at a single centre in the UK between November 2018 and March 2019. Patients were identified using IMPAX© picture archiving and communications system. Radiographs were assessed to see if radiopaque dye and therefore corticosteroid and local anaesthetic had been injected proximal or distal to the zona orbicularis. Clinic letters were accessed on the electronic patient record and we recorded whether patients had pain relief at 24 hours and 2 weeks following hip injection. Results 133 Patients were identified during the study period, of which 40 were included. At 24 hours post-injection 72% of patients were satisfied and 28% were unsatisfied, for which there was 76% and 70% satisfaction for proximal and distal injections respectively (p = 0.63). At 2 weeks post-injection 45% of patients were satisfied and 55% of patients unsatisfied, for which there was 47% and 44% satisfaction for proximal and distal injections respectively (p = 0.9). Conclusions Overall patient satisfaction is high following hip corticosteroid and local anaesthetic injection. No difference was found between injections proximal and distal to the zona orbicularis. Further research is needed to quantify the association between proximal and distal injections.

Ultrasound and Ultrasound-Guided Hip Injection Have High Accuracy in the Diagnosis of Femoroacetabular Impingement With Atypical Symptoms

To evaluate the diagnostic value of ultrasound and ultrasound-guided hip injection in the diagnosis of femoroacetabular impingement (FAI) with atypical symptoms. We evaluated consecutive patients diagnosed with FAI and with atypical symptoms who underwent ultrasound-guided hip injection between January 2017 and February 2019. All patients underwent systematic physical examination, ultrasound examination, magnetic resonance imaging (MRI) examination, and ultrasound-guided injection before surgery. Patients with positive response to ultrasound-guided hip injection were recommended to undergo arthroscopic surgery to treat intra-articular pathology. Sensitivity, specificity, accuracy, and positive predictive value (PPV) of ultrasound and MRI were calculated by using arthroscopic surgery as the gold standard. The accuracy of ultrasound-guided hip injection was recorded. Preoperative and postoperative patient-reported outcomes included visual analog scale for pain and modified Harris Hip Score. A total of 78 patients with atypical symptoms were diagnosed with FAI. Among these 78 patients, 50 patients had positive responses to injection and 28 patients had negative responses to injection. A total of 36 patients finally underwent arthroscopic surgery. Response to the ultrasound-guided intra-articular injection was 91.7% accurate for detecting the presence of intra-articular abnormality. There were no complications of injection in any of the patients. The sensitivity, PPV, and accuracy by ultrasound diagnosis of cam impingement were 82.9%, 96.7%, and 80.6%, respectively. The sensitivity and accuracy by ultrasound diagnosis of anterosuperior labral tear were both 72.2%. For MRI diagnosis of cam impingement, the sensitivity, PPV and accuracy were 72.2%, 96.3%, and 74.3%, respectively. For MRI diagnosis of labral tear, the sensitivity and accuracy were both 88.9%. Thirty-four patients (94.4%) surpassed the minimal clinically important difference, and 33 patients (91.7%) achieved the patient acceptable symptomatic state. Ultrasound and ultrasound-guided hip injection have high accuracy in the diagnosis of femoroacetabular impingement with atypical symptoms. IV, case series.

O04 Clinical and cost-effectiveness of ultrasound-guided intra-articular corticosteroid and local anaesthetic injection for hip OA: a randomised controlled trial (HIT)

Abstract Background Evidence of the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis (OA) is limited. The HIT trial compared the clinical and cost-effectiveness of an ultrasound-guided intra-articular hip injection (USGI) of 40mg triamcinolone acetonide and 4ml 1% lidocaine hydrochloride combined with best current treatment (BCT) with (i) BCT alone (primary objective) and (ii) an USGI of 5ml 1% lidocaine only combined with BCT (EudraCT:2014-003412-37). Methods This was a pragmatic, three-parallel arm, single-blind, randomised controlled trial in adults with moderate-severe painful hip OA recruited from community musculoskeletal services and primary care. Participants were randomised equally to: (1) BCT alone, (2) BCT plus USGI triamcinolone/lidocaine, or (3) BCT plus USGI lidocaine only. Outcomes were collected postally at 2 weeks, 2, 4 and 6 months. The primary outcome was self-reported current hip pain intensity (0-10 numeric rating scale (NRS)) over 6 months (repeated measures analysis). Secondary outcomes included function (WOMAC), and, for cost-utility analysis, general health (EQ-5D-5L) and healthcare utilisation. 204 participants were required to detect a minimum difference of 1 point in mean pain NRS score between arms (1) and (2) with 80% power (5% two-tailed significance level, 15% loss to follow-up). Analysis was by intention-to-treat. Results 199 participants were recruited (43% male, mean age 63 years), 67 to arm (1) and 66 each to arms (2) and (3). Primary outcome completion rates were 95% at 2 weeks, 94% at 2 months, 90% at 4 months, and 89% at 6 months. Greater mean improvement in hip pain intensity (0-10 NRS) over 6 months was seen with BCT plus USGI triamcinolone/lidocaine compared with BCT alone: -1.43 (95%CI -2.15,-0.72). Greater mean improvement in pain intensity was seen at 2 weeks (-3.17; -4.06,-2.28) and 2 months (-1.81;-2.71,-0.92), but not at 4 (-0.86;-1.78,0.05) or 6 months (0.12; -0.80,1.04). Participants treated with BCT plus USGI triamcinolone/lidocaine compared with BCT alone had greater mean improvement in function (WOMAC-F -5.47;(-9.41,-1.53)) over 6 months. There was no statistically significant difference in hip pain intensity over 6 months between BCT plus USGI triamcinolone/lidocaine compared with BCT plus USGI lidocaine (-0.52;-1.21,0.18). There was one possible treatment-related serious adverse event: a participant with no signs of infection at randomisation died from endocarditis four months after USGI triamcinolone/lidocaine. BCT plus USGI triamcinolone/lidocaine was less costly (mean cost difference per participant £-161.59) and associated with significantly higher quality-adjusted life-years (QALYs) than BCT only over 6 months (mean difference 0.0477 (0.0257,0.0699). Conclusion USGI triamcinolone/lidocaine plus BCT leads to greater improvements in pain and function over 6 months in adults with hip OA than BCT alone, and was highly cost-effective. There was no significant difference in hip pain intensity between the groups receiving USGI triamcinolone/lidocaine and USGI lidocaine only, raising the possibility of a degree of placebo effect. Disclosures Z. Paskins None. K. Bromley None. M. Lewis None. G. Hughes None. E. Hughes None. A. Cherrington None. A. Hall None. M. Holden None. R. Oppong None. J. Kigozi None. K. Stevenson None. A. Menon None. P. Roberts None. G. Peat None. C. Jinks None. N.E. Foster None. C.D. Mallen None. E. Roddy None.

Clinical and cost-effectiveness of ultrasound-guided intra-articular corticosteroid and local anaesthetic injection for hip osteoarthritis: a randomised controlled trial (HIT)

Purpose: Evidence of the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis (OA) is limited. The HIT trial compared the clinical and cost-effectiveness of an ultrasound-guided intra-articular hip injection (USGI) of 40mg triamcinolone acetonide and 4ml 1% lidocaine hydrochloride combined with best current treatment (BCT) with (i) BCT alone (primary objective) and (ii) an USGI of 5ml 1% lidocaine only combined with BCT (EudraCT: 2014-003412-37). Methods: This was a pragmatic, three-parallel group, single-blind, randomised controlled trial in adults with moderate to severe painful hip OA recruited from community musculoskeletal services and primary care. Participants were randomised equally to: (1) BCT alone, (2) BCT plus USGI triamcinolone/lidocaine, or (3) BCT plus USGI lidocaine only. BCT comprised written information and individualised advice regarding weight loss, exercise, footwear, walking aids and analgesia. Outcomes were collected postally at 2 weeks, 2, 4 and 6 months. The primary outcome was self-reported current hip pain intensity (0-10 numeric rating scale (NRS)) over 6 months (repeated measures analysis). A wide range of secondary outcomes were measured at each follow-up point including pain and physical function (Western Ontario and McMaster University Arthritis Index, WOMAC), pain self-efficacy, participant’s global impression of change, general health (EQ-5D-5L) and healthcare utilisation. Participants and clinicians were not blind to allocation to BCT alone or injection, however participants randomised to either injection arm were blind to the nature of injection. The research nurse involved in data collection and study statistician were blind to treatment allocation. 204 participants were required to detect a minimum difference of 1 point in mean pain NRS score between arms (1) and (2) with 80% power (5% two-tailed significance level, 15% loss to follow-up). Analysis was by intention-to-treat. To determine the cost-effectiveness of BCT plus USGI triamcinolone/lidocaine compared with BCT alone, a cost-utility analysis was conducted, adopting an NHS perspective. QALYs were calculated over a period of 6 months using the area under the curve approach. Results: 199 participants were recruited (43% male, mean age 63 years), 67 to arm (1) and 66 each to arms (2) and (3). Primary outcome completion rates were 95% at 2 weeks, 94% at 2 months, 90% at 4 months, and 89% at 6 months. Greater mean improvement in hip pain intensity (0-10 NRS) over 6 months was seen with BCT plus USGI triamcinolone/lidocaine compared with BCT alone: -1.43 (95% CI -2.15, -0.72). Greater mean improvement in pain intensity was seen at 2 weeks (-3.17; -4.06, -2.28,) and 2 months (-1.81; -2.71, -0.92,), but not at 4 months (-0.86; -1.78, 0.05) or 6 months (0.12; -0.80, 1.04). Participants treated with BCT plus USGI triamcinolone/lidocaine compared with BCT alone had greater mean improvement in function (WOMAC-F -5.47; (-9.41, -1.53)) and pain self-efficacy (5.87; 2.30, 9.45) over 6 months. More participants reported being completely recovered/much better at 2 months with BCT plus USGI triamcinolone/lidocaine than with BCT alone (45.4% v 6.9%; relative risk=6.7; 2.5, 17.9). There was no statistically significant difference in hip pain intensity over 6 months between BCT plus USGI triamcinolone/lidocaine compared with BCT plus USGI lidocaine only (-0.52; -1.21, 0.18). However, a statistically significant difference was seen in favour of the group receiving USGI triamcinolone/lidocaine in comparison to USGI lidocaine alone for a range of secondary outcome measures, over 6 months (e.g. pain self-efficacy, function, and work presenteeism). There was one possible treatment-related serious adverse event: a participant with no signs of infection at randomisation died from endocarditis four months after USGI triamcinolone/lidocaine. BCT plus USGI triamcinolone/lidocaine was less costly (mean cost difference per participant £-161.59) and associated with significantly higher quality-adjusted life-years (QALYs) than BCT only over 6 months (mean difference 0.0477 (0.0257, 0.0699). Increased number of visits to NHS consultants and hip-related surgery in the BCT only group accounted for the majority of cost difference. Conclusions: USGI triamcinolone/lidocaine combined with BCT leads to greater improvements in pain and function over 6 months in adults with hip OA than BCT alone, and was highly cost-effective. There was no significant difference in hip pain intensity over 6 months between the groups receiving USGI triamcinolone/lidocaine and USGI/lidocaine only raising the possibility of a degree of placebo effect.

The hip injection trial (HIT) nested qualitative study: experiences of living with hip Osteoarthritis and receiving trial treatments.

Purpose: Evidence about the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis (OA) is limited. The HIT trial compared ultrasound-guided intra-articular hip injection (USGI) of triamcinolone acetonide and 1% lidocaine hydrochloride combined with best current treatment (BCT) with (i) BCT alone and (ii) an USGI of 1% lidocaine only combined with BCT (EudraCT: 2014-003412-37). BCT included verbal and written advice on exercise, weight loss and pain management. This nested qualitative study explored participants’ experiences of living with hip OA and of and of the treatment they received. Methods: Semi-structured interviews were completed with purposefully sampled trial participants from each arm after return of their 2-month follow-up questionnaire. Interviewers knew whether participants had received an injection within the trial, but not which injection (to minimise patients becoming un-blinded to treatment allocation). Interviews were recorded, transcribed and analysed thematically. Analysis was undertaken blind to the clinical trial Results to facilitate an interpretive and inductive approach. Sampling ceased on inductive thematic saturation. Results: 34 trial participants were interviewed across all arms (USGI of triamcinolone acetonide and lidocaine plus BCT = 13, BCT alone = 8, USGI of lidocaine plus BCT = 11). Both males and females aged between 53 and 83 years old, with varying levels of pain intensity, functional ability, and pain self-efficacy participated in an interview. Participants described how hip OA impacted on many aspects of their life. It caused pain and physical limitations, restrictions in being able to undertake valued activities, difficulties at work, and lowered mood. It also commonly disrupted sleep. Participants who received BCT alone reported receiving an examination, information/explanation and exercises. Despite this, most felt that they had not received ‘treatment’ per se (e.g. “I don’t feel like I’ve had treatment because I was already doing the exercise anyway and I was taking something to help the pain” #10282), and many reported limited exercise adherence. Participants described little or no benefit from BCT, and thoughts about the future tended to focus on inevitable decline. In contrast, experiences of having an injection were positive overall and participants in both injection groups experienced marked improvements in pain, function and other aspects of life, including sleep. Participants described “getting their life back” and having “a new lease of life”. Perceived benefit appeared greater among those randomised to USGI of triamcinolone acetonide and lidocaine plus BCT, however length of benefit varied in both injection groups. Despite uncertainty about the longer-term benefits of injection and the possibility of having repeated injections, there was more hope and optimism about the future among participants who had received an injection in comparison to those who had received BCT alone. Conclusions: Hip OA is burdensome, affecting many different aspects of life. Participants perceived little or no benefit from BCT alone, but reported marked improvements when combined with an USGI of triamcinolone and lidocaine or lidocaine alone. This complements the clinical trial Results which demonstrated superiority of USGI of triamcinolone and lidocaine plus BCT over 6 months compared with BCT alone, but no significant difference in hip pain intensity between the injection groups. Together these findings raise the possibility of a degree of placebo effect. As participants in BCT reported receiving advice and education but did not feel they had treatment, novel ways to effectively implement self-management may be required. Varying duration of response to injection between individuals, and reported uncertainty regarding effectiveness and safety of future injections, suggest these areas as important for future research.

P130 Qualitative findings from the Hip Injection Trial (HIT): experiences of living with hip osteoarthritis and receiving trial treatments

Abstract Background The HIT trial compared ultrasound-guided intra-articular hip injection (USGI) of triamcinolone acetonide and 1% lidocaine hydrochloride combined with best current treatment (BCT) with (i) BCT alone and (ii) an USGI of 1% lidocaine only combined with BCT (EudraCT: 2014-003412-37). BCT included verbal and written advice on exercise, weight loss and pain management. This nested qualitative study explored participants’ experiences of living with hip osteoarthritis (OA) and of the treatment they received. Methods Semi-structured interviews were completed with purposefully sampled trial participants after 2-month follow-up. Interviewers knew whether participants had received an injection within the trial, but not which injection. Thematic analysis was undertaken blind to the clinical trial results to facilitate an interpretive and inductive approach. Sampling ceased on inductive thematic saturation. Results 34 trial participants were interviewed across all arms (USGI of triamcinolone acetonide and lidocaine plus BCT = 13, BCT alone = 8, USGI of lidocaine plus BCT = 11). Interviewees were males (n = 13) and females, of varying ages (53 - 83 years), with varying self-reported improvement. Participants described how hip OA impacted on many aspects of their life. It caused pain and physical limitations, difficulties at work, lowered mood, and commonly disrupted sleep. Participants who received BCT alone reported receiving an examination, information/explanation and exercises. Despite this, most felt that they had not received ‘treatment’ and reported limited exercise adherence. They described little or no benefit from BCT, and thoughts about the future tended to focus on inevitable decline. In contrast, participants in both injection groups experienced marked improvements in pain and other aspects of life, including sleep. Participants described getting their “life back” and having “a new lease of life”. Perceived benefit appeared greater among those randomised to USGI of triamcinolone acetonide and lidocaine plus BCT, however length of benefit varied in both injection groups. Despite uncertainty about the longer-term benefits of injection and the possibility of having repeated injections, there was more hope and optimism about the future among participants who had received an injection in comparison to those who had received BCT alone. Conclusion Hip OA is burdensome, affecting many different aspects of life. Participants perceived little or no benefit from BCT alone but reported marked improvements when combined with an USGI of triamcinolone and lidocaine or lidocaine alone. This complements the clinical trial results which demonstrated superiority of USGI of triamcinolone and lidocaine plus BCT over 6 months compared with BCT alone, but no significant difference in hip pain intensity between the injection groups. Together these findings raise the possibility of a degree of placebo effect. Varying duration of response to injection between individuals and reported uncertainty regarding effectiveness and safety of future injections, suggest these areas as important for future research. Disclosures M. Holden None. A. Hawarden None. Z. Paskins None. E. Roddy None. C. Mallen None. C. Jinks None.

Pain After Preoperative UltraSound Guided Hip Injections for Total Hip Arthroplasty (PUSH)

Pain After Preoperative UltraSound Guided Hip Injections for Total Hip Arthroplasty (PUSH)

The Safety of Hip Arthroscopy within 3 Months of an Intra-Articular Injection.

Ultrasound-guided intra-articular hip injections have become a mainstay in the diagnosis and treatment of various hip disorders. Concern arises with regard to the chronological proximity of an injection to subsequent arthroscopy. Thus, the purpose of this study was to report the risk of postoperative infections among patients who have undergone an intra-articular corticosteroid injection within 3 months of hip arthroscopy. In-office, ultrasound-guided, intra-articular hip injections were first performed at this center in 2011. Corticosteroid is used for therapeutic purposes in the presence of painful hip conditions to reduce joint symptoms, either to allow for more effective supervised physical therapy or simply as a last line of nonoperative management. A retrospective review of patient records was performed, identifying all patients who had undergone arthroscopy and had received an intra-articular injection of corticosteroid at this institution within 3 months of the surgical procedure. Five hundred patients underwent an ultrasound-guided intra-articular injection of corticosteroid within 3 months of a hip arthroscopy. The mean age was 37.6 years (range, 14 to 74 years), with 112 male patients and 388 female patients. The mean time between the injection and the arthroscopy was 59 days (range, 15 to 92 days). There were no postoperative infections. When both the injection and the procedure are performed in a tertiary referral center, an ultrasound-guided intra-articular injection of corticosteroid within 3 months prior to arthroscopy, at a mean time of 59 days, resulted in no postoperative infections among 500 cases and can represent an acceptably low rate of complication. To our knowledge, this is the largest reported series on this subject. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound-Guided Hip Injections.

The diagnosis of hip pain can be difficult to isolate because the discomfort can originate from several locations and compensatory pain patterns. Pain generators can include the intra- and extra-articular hip structures, the lumbar spine, the pelvic floor, or a combination of these. It can also be referred as pain from the bowel, bladder, or reproductive organs. Injections into and around the hip have become an important part of both diagnostic and nonsurgical treatment algorithm for hip pain. The proximity of the hip to important neurovascular structures, lack of palpable anatomic landmarks, and deep location of targets can make use of ultrasonography-guided injections ideal. These injections have been growing in popularity in the orthopedic community because ultrasonography allows for a real-time visualization of dynamic anatomy without any radiation exposure to the patient and physician. The use of ultrasonography has allowed for in-office image guidance with improved accuracy for more targeted and advanced procedures. The patient's response to these injections can help guide patient selection for surgery and allow for better pain control of the soft-tissue pathology that often accompanies intra-articular pathology. This article highlights the diagnostic and therapeutic value of ultrasonography-guided hip injections for an orthopedic practice. The focus is on sonographic anatomy, introduction to technique, common indications, and pearls and pitfalls of these procedures.

Commentaries on health services research

Commentaries on health services research

A randomised controlled trial of the clinical and cost-effectiveness of ultrasound-guided intra-articular corticosteroid and local anaesthetic injections: the hip injection trial (HIT) protocol

BackgroundEvidence on the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis is limited and conflicting. The primary objective of the Hip Injection Trial (HIT) is to compare pain intensity over 6 months, in people with hip OA between those receiving an ultrasound-guided intra-articular hip injection of corticosteroid with 1% lidocaine hydrochloride plus best current treatment with those receiving best current treatment alone. Secondary objectives are to determine specified comparative clinical and cost-effectiveness outcomes, and to explore, in a linked qualitative study, the lived experiences of patients with hip OA and experiences and impact of, ultrasound-guided intra-articular hip injection.MethodsThe HIT trial is a pragmatic, three-parallel group, single-blind, superiority, randomised controlled trial in patients with painful hip OA with a linked qualitative study. The current protocol is described, in addition to details and rationale for amendments since trial registration. 204 patients with moderate-to-severe hip OA will be recruited. Participants are randomised on an equal basis (1:1:1 ratio) to one of three interventions: (1) best current treatment, (2) best current treatment plus ultrasound-guided intra-articular hip injection of corticosteroid (triamcinolone acetonide 40 mg) with 1% lidocaine hydrochloride, or (3) best current treatment plus an ultrasound-guided intra-articular hip injection of 1% lidocaine hydrochloride alone. The primary endpoint is patient-reported hip pain intensity across 2 weeks, 2 months, 4 months and 6 months post-randomisation. Recruitment is over 29 months with a 6-month follow-up period. To address the primary objective, the analysis will compare participants’ ‘average’ follow-up pain NRS scores, based on a random effects linear repeated-measures model. Data on adverse events are collected and reported in accordance with national guidance and reviewed by external monitoring committees. Individual semi-structured interviews are being conducted with up to 30 trial participants across all three arms of the trial.DiscussionTo ensure healthcare services improve outcomes for patients, we need to ensure there is a robust and appropriate evidence-base to support clinical decision making. The HIT trial will answer important questions regarding the clinical and cost-effectiveness of intra-articular corticosteroid injections.Trial registrationISRCTN: 50550256, 28th July 2015.

A Vascular Obstacle in Ultrasound-Guided Hip Joint Injection.

Background:We evaluated the risk of lateral circumflex femoral artery (LCFA) injury during ultrasound-guided intra-articular hip injections.Methods:This study was divided into three parts. (1) Four ultrasound-guided hip injections were performed on human cadavers. With needles in place, tissues were dissected to expose the LCFA. (2) Ultrasound-trained rheumatologists marked a planned needle trajectory from skin to hip joint on live human ultrasound images during an Observed Structured Clinical Examination (OSCE). Doppler was subsequently activated to locate the LCFA, and the distance between trajectory and arterial signal was recorded. (3) Rheumatologists certified in musculoskeletal ultrasound were surveyed about joint injection vascular complications.Results:(1) In one of the four cadaveric dissections, the needle made direct contact with the LCFA. (2) Of 27 OSCE participants, only two activated Doppler before marking simulated hip injection trajectories. Trajectories passed through LCFA Doppler signal in six (22%) cases. Mean minimal distance from trajectory to arterial signal was 4 mm (range, 0–11 mm). (3) Of 62 survey respondents, 24% stated that they did not use Doppler routinely. While none reported bleeding injuries with their patients, 16% knew of a hip injection-related vascular complication performed by another provider.Conclusion:There is a risk of LCFA injury during ultrasound-guided hip joint injection. Routine use of Doppler should be considered in standard hip injection protocols.

Precise patient selection for hip arthroscopy using ultrasound-guided hip injection

Precise patient selection for hip arthroscopy using ultrasound-guided hip injection

Economic Analysis of Accuracy and Cost of Ultrasound-guided Intraarticular Hip Injections

ABSTRACT Background Ultrasonography is an increasingly valuable tool for the diagnosis and treatment of musculoskeletal disorders. In the past, ultrasound has been used for diagnostic purposes, with increasing use of image guidance for joint injections. Hypothesis Ultrasound-guided intraarticular native nontraumatic hip injections are equally as accurate with less cost as other diagnostic imaging modalities including fluoroscopicguided injections. Design This analysis was based on a meta-analysis of the accuracy of the different imaging modalities. Initially a search was performed for intraarticular hip injections in PubMed, EMbasE, and ClinicalTrials.gov. Injection accuracy rates between groups were analyzed via proportional meta-analysis. For the economic analysis, compensation data were determined from estimated charges from Duke University Medical Center. Results Compared with gold standards of accurate injections (such as fluoroscopic and computed tomography-guided injections), ultrasound is 97% as accurate (confidence interval 93%, 99%). based on 2014 reimbursement data, reimbursement for large-joint intraarticular injection averages $61.99 (37.38£, 47.18€) ($49.20–$76.31). Fluoroscopic global reimbursement averages $105.32 (63.51£, 80.13€) ($76.75–$134.72). Ultrasound guidance global reimbursement averages $75.99 (45.86£, 57.83€) ($57.95–$93.15). Conclusion Ultrasound-guided hip injections are an accurate technique for alleviating hip pain at less cost. In an era of increasing concern for health care expenditures, finding an accurate, effective, and cost-friendly alternative has the potential for widespread adaptation and practice. Porras L, boggess b. Economic analysis of accuracy and Cost of Ultrasound-guided Intraarticular Hip Injections. The Duke Orthop J 2016;6(1):35-40.