Ultrasound-guided hip joint injection

Author: Mikael Häggström

Planning

Choice of modality

Ultrasonography is generally superior for injections in the hip joint, because of portability, lack of ionizing radiation and real-time visualisation of soft tissues and neurovascular structures.

Bleeding

The risk of clinically significant bleeding is minimal, so coagulation tests are not needed before the procedure. It can for example be performed during chronic warfarin therapy with therapeutic coagulation levels.

Transducer choice

Preferably use a high-frequency (> 10 MHz) linear array transducer. A lower-frequency curvilinear probes may occasionally be required in larger patients.

Injectate

The total volume injected is usually 6–7ml.

For pain relief in osteoarthritis, for example:

• Local anesthetic

• 300mg lidocaine (such as 3 ml of 10%)
• 30mg mepivacaine (such as 3 ml of 1% Carbocaine)
• 25mg bupivacaine (such as 5ml of Marcaine 0.5%)

• Glucocorticoid, for example:

• 40mg triamcinolone (such as 1ml of 40 mg/ml)

Patient information

In osteoarthritis patients, at least when not having had repeated injections, inform that the local anesthetic effect will wear off after about 4 to 6 hours, and it will take 2 to 7 days before the glucocorticoid will take effect, so that there may be increased pain in the meantime.

Procedure

• Perform a preliminary sonography, including color Doppler of the area to be punctured, to define the relationship of adjacent neurovascular structures. Preferably, also evaluate the joint area for any joint effusion, or any thickening or hyperemia of the joint capsule.
• Decide which approach to use. Two common anterior approaches are typically used both with the patient lying supine:

Anterior longitudinal approach. An arrow parallel to the long axis of the transducer is drawn on the skin adjacent to the end of transducer where the needle will be introduced.

• The anterior longitudinal approach: the probe is aligned along the long axis of the femoral neck. The needle is introduced from an anteroinferior approach and is passed into the anterior joint recess at the femoral head-neck junction.
• The anterolateral approach, with the ultrasound probe oriented axially and the femoral head and acetabular rim in view. This often shortens the distance from needle skin entry to joint compared to the longitudinal approach making it a useful approach in larger patients. The introduced needle remains lateral to the femoral neurovascular bundle, and the needle is advanced until its tip rests on the femoral head.

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  Anterior longitudinal approach. The needle is introduced from an inferior and anterior approach, lateral to the femoral neurovascular bundle (arrow). A, acetabulum; H, femoral head; N, femoral neck; double arrow – anterior joint recess.

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  Anterolateral approach, here shown as a transverse image. The needle will rest on the femoral head (arrow). A, acetabulum; H, femoral head; N, femoral neck; LAT, lateral; MED, medial.

• Draw a line parallel to the long axis of the transducer, on the skin adjacent to the end of the transducer is where the needle will be introduced.
• Perform sterile preparation of the entire injection field, including adjacent skin where the gel and probe are applied. Areas of superficial infection such as cellulitis or abscess should be avoided to prevent deeper spread.
• Using the previous mark, insert the needle, directed toward the intended target. It can be done by a freehand technique, but a needle guide may be used. Needles with a Birmingham Gauge of 22–24 are sufficed for most injections.

Report

• Contents of injectate.
• Absence of immediate complications, or a description thereof.

A more comprehensive report may also include:

• Even the absence of hip effusion
• Even the absence of joint capsule thickening or hyperemia
• Patient informed about the pharmacodynamics of the injectate.

See also: General notes on reporting