Hip Joint Injection

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Hip Joint Injection
Indication	Diagnostic injection, arthropathy, MR arthrogram
Syringe	5 mL
Needle	22-gauge Quincke needle
Steroid	optional 40mg triamcinolone acetonide
Local	5mL 1% lidocaine

Indications

• Pain - arthropathy i.e. osteoarthritis
• Diagnostic injection
• MRI: labral injury

Contraindications

• Absolute: anaphylaxis to contrast/ injectates, active local/ systemic infection
• Relative, bleeding diathesis, recent injection with steroid in same/ other body parts (anaesthetic arthrogram), unable to remain still for the procedure

Equipment

• ultrasound machine, sterile probe cover and a skin marker (ultrasound)
• skin marker, a metal rod for marking and short connecting tube (fluoroscopy)
• skin cleaning product
• sterile drape
• sterile field and tray for sharps
• syringe selection i.e. 10mL, 5mL and 20mL
• larger bore drawing up needle
• needle to administer local anaesthetic i.e. 25-gauge needle
• needle to cannulate the joint i.e. 22-gauge needle Quincke needle
• injectants i.e. local anaesthetics, iodinated contrast, corticosteroid preparation
• sterile gauze
• adhesive dressing

Technique

Ultrasound Guided

• optimise patient positioning by laying them flat and supine on the bed, with a bolster on the lateral aspect of the ipsilateral foot, holding it in internal rotation
• using ultrasound, identify the anterior hip joint in a longitudinal plane; parallel to the long axis of the femoral neck, and then optimise imaging and mark the skin entry point at the end of the probe 1
• clean skin and draw up appropriate medications
• consider local anaesthesia along the proposed needle path
• under ultrasound guidance insert the needle in-plane with the probe in a caudal-cranial direction targeting the head-neck junction of the femur and reach bone
• administer arthrogram injectate under direct visualisation
• remove the needle and apply dressing as required

Fluoroscopy Guided

• optimise patient positioning by laying them flat and supine on the bed, with a small bolster under the knee and a further bolster on the ipsilateral foot to keep it in internal rotation
• optimise imaging field and using the metal rod mark the skin at the target entry point; both ‘eye of the needle’ and oblique needle techniques are used and the lateral femoral neck is the target 2
• clean skin and draw up appropriate medications
• consider local anaesthesia along the proposed needle path
• under fluoroscopic guidance insert a needle targeting the lateral femoral neck and reach bone
• check an intra-articular needle tip position with a small amount of iodinated contrast via connection tubing and save a post-injection image/ video run
• administer arthrogram injectate
• remove the needle and apply dressing as required

Landmark Guided

Not recommended.

Complications

Initial injections can be extra-articular but if the needle is repositioned before giving the injectate this often has no effect. Excess extra-articular solution may distort an MRI arthrogram, especially if the MRI injectate is outside of the joint. The most serious complication is an infection causing septic arthritis. A steroid flare after injection can occur but symptoms will resolve after 1 - 2 days. Injections should be postponed if there are signs and/or symptoms of local and/ or systemic infection. Fat necrosis causing skin dimpling and skin discolouration can occur due to steroid leaking into the surrounding soft tissues 3, although less common in deeper injections.

References

Part or all of this article or section is derived from Hip joint injection (technique) by Dr Dai Roberts et al., used under CC BY-NC-SA 3.0