Hip Joint Injection

Other Names

• Hip Joint Injection
• Ultrasound Guided Hip Joint Injection
• Hip Arthrocentesis
• Hip Aspiration

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Background

Illustration of the bony hip anatomy

Key Points

• Transducer: low frequency, curvilinear array
• Needle: 3.5 inch, 20-22 gauge spinal (in most patients)
• Recommend long axis, in plane approach

Anatomy of the Hip Joint

• Ball and socket synovial joint
• Formed by the acetabulum (socket within the ileum) and femoral head (ball)
• Thick capsule is formed by 3 major ligaments: iliofemoral, ischiofemoral and pubofemoral
• The femoral neurovascular bundle descends through the femoral triangle medial to the joint

Palpation vs Ultrasound Guided

• Should not be performed with palpation guidance
• A systemic review and meta-analysis found that ultrasound guidance is 100% accuracy compared to 72% accuracy with landmark based approach
• Note: CT, Fluoroscopy can also be used but are not reviewed here

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Indications

• Hip Osteoarthritis
• Diagnostic to help determine source of pain

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

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Demonstration of the long axis, in plane approach

Needle and probe position (A), ultrasound view with needle (B) and illustration of long axis, in plane approach

Short axis, in plane approach. (A) Shows needle and probe position, (B) shows needle trajectory (white arrow)

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 20-22 gauge, 3.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Transducer: low frequency, curvilinear array
• Approach to finding the hip joint
  • Begin with the probe in short axis over the femoral shaft
  • Slide proximally until the greater trochanter comes into view laterally
  • Rotate the medial side of the probe into the axis of the femoral neck
  • Slide the probe super medially along the femoral neck
  • This should bring the head of the femur and acetabulum into view

Technique: Long Axis, In Plane (recommended technique)

• Patient Position
  • Supine
  • Can place pillow under knee to relax muscles of the hip
• Transducer position
  • Long axis to the neck of the femur
• Needle Approach/ Orientation
  • In plane
  • Infero-lateral to supero-medial
• Target
  • Anterior capsule: hip joint, head of femur, or proximal neck
• Pearls and Pitfalls
  • Can rotate to long axis once needle is at target
  • Consider identifyig the lateral circumflex femoral artery, it is often in the way
  • Find the neurovascular bundle medially for orientation and safety
  • Needle visualization can be challenging in larger patients

Technique: Short Axis, In Plane

• Patient Position
  • Supine
  • Can place pillow under knee to relax muscles of the hip
• Transducer position
  • Short axis to the neck of the femur
• Needle Approach/ Orientation
  • In plane
  • Lateral-to-medial
• Target
  • Anterior capsule: hip joint, head of femur, or proximal neck
• Pearls and Pitfalls
  • Might be easier in patients with larger body habitus

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Aftercare

• No significant restrictions
• Can augment with ice, NSAIDS

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Complications

• Skin: Subcutaneous fat atrophy, skin atrophy, skin depigmentation
• Painful local reaction
• Infection
• Hyperglycemia
• Tendon, nerve or blood vessel injury

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See Also

Internal

• Procedures Main
• Ultrasound Main
• Hip Pain Main

External

• https://www.sportsmedreview.com/blog/fluoroscopy-vs-ultrasound-guidance-for-corticosteroid-injections-of-the-hip/

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