Ultrasound-Guided Intra-Articular Injection of the Hip: The Nashville Sound

Injection of the Hip With Hyaluronic Acid Under Distraction Plus Neurectomy of the Femoral and Obturator Nerve

The hip is the location for many disorders, such as osteoarthritis, femoroacetabular impingement syndrome, avascular necrosis of the hip, and cartilage injuries, all of which cause chronic pain, disability, and limitation. It is estimated that 10% of the population ≥40 years of age will present with hip pain. The line of treatment goes from nonsteroidal anti-inflammatory drugs, physical therapy, lifestyle modification, intra-articular injections, and hip surgery. This will depend on the pathology, age, lifestyle, and sport activity of each patient. Currently, hip joint intra-articular injections represent a viable option for those patients who are not candidates for surgery or simply those who do not want surgery. Among the controversial indications for a hip injection is moderate-to-severe arthritis (grades III and IV). Hip injections are considered a diagnostic and therapeutic procedure, with a sensitivity of 87% and specificity of 100% reported, and will differentiate between an intra-articular pathology versus an extra-articular pathology and a neuropathic pain arising from the lumbar spine. Radiofrequency nerve ablation or neurectomy of the femoral and obturator nerve has been implemented more frequently not only for patients with mild-to-moderate osteoarthritis but also in those who present with femoroacetabular impingement syndrome and cartilage lesions who do not wish to undergo surgery.

Understanding the Learning Curve of Carpal Tunnel Release With Ultrasound Guidance: A Review

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy and can be treated through carpal tunnel release (CTR) if nonoperative treatments fail. CTR can be performed through a variety of techniques, including traditional open, mini-open, endoscopic, and CTR with ultrasound guidance (CTR-US). The evidence on endoscopic CTR is mixed, due to a higher potential for nerve injury with endoscopic CTR compared to traditional open CTR. CTR-US offers the potential advantage of allowing the visualization of all key anatomical structures, combined with a very small incision and minimal soft tissue insult. As with any ultrasonographic technique or procedure, the learning curve needs to be considered for any provider considering adopting CTR-US. However, literature on ultrasound use around the wrist, including early evidence on the learning curve of CTR-US specifically, demonstrates this skill can be learned relatively quickly by providers with a wide range of prior experience in ultrasound and CTR. Overall, there is a need for high-quality studies comparing different CTR techniques, particularly CTR-US, as it offers the potential for considerable cost savings.

The Influence of Body Mass Index on Radiation Dose and Exposure Time in Fluoroscopic Guided Hip Injections - A Comparative Analysis of Two Approaches

Objectives

Intra-articular hip injections (IHI) are routinely performed for both diagnostic and therapeutic purposes. The procedure can be performed via either an anterior or a lateral approach with fluoroscopic guidance being widely practised. There is a risk of radiation exposure associated with fluoroscopy assisted IHI. This may be influenced either by the surgical approach or the patient's body mass index (BMI) or both. This study was undertaken to compare the relationships of the respective approaches to BMI, fluoroscopic exposure time (FET) and radiation dose (RD).

Methods

A retrospective study was conducted comprising 74 patients who underwent IHI with 37 patients in each group (anterior and lateral). Patients were assessed pre-operatively and post operatively for any complications. The intra-operative radiation dose, fluoroscopic exposure time and BMI data were collected and analyzed.

Results

The mean age of the patients in anterior and lateral groups was 61.18±14.08 and 67.21±14.39 years respectively. No complications were noted in either group. However, there was a significant increase in FET (P=0.002) and RD (P<0.001) in patients with BMI ≥ 30. In the lateral group, this trend was markedly noted with increase in FET (P<0.001) and RD (P<0.001) in patients with BMI ≥ 30. On the other hand, in the anterior group there was no statistically significant increase in FET (P=0.155) and only a moderate increase in RD (P=0.020) in patients with BMI ≥ 30.

Conclusion

Both anterior and lateral approaches to fluoroscopic guided IHI are equally safe in terms of complications involved. There is statistically significant increase in both radiation dose and fluoroscopic exposure time in patients with BMI ≥ 30. This is more pronounced in lateral approach. The anterior approach is most effective in reducing both radiation dose and fluoroscopic exposure time, more so in patients with BMI of 30 and above.

The Emerging Era of Interventional Imaging in Rheumatology: An Overview During the Coronavirus Disease-2019 (COVID-19) Pandemic

Imaging has long been taking its place in the diagnosis, monitor, and prognosis of rheumatic diseases. It plays a vital role in the appraisal of treatment. Key progress in the clinical practice of rheumatology is the innovation of advanced imaging modalities; such as musculoskeletal ultrasound (MSUS), computerized tomography (CT) and magnetic resonance imaging (MRI). These modalities introduced a promising noninvasive method for visualizing bone and soft tissues to enable an improved diagnosis. The use of MSUS in rheumatology is considered a landmark in the evolution of the specialty and its ease of use and many applications in rheumatic diseases make it a forerunner instrument in the practice. The use of MSUS among rheumatologists must parallel the development rate of the excellence revealed in the specialty. Moreover, innovative interventional imaging in rheumatology (III-R) is gaining fame and key roles in the near future for a comprehensive management of rheumatic diseases with precision. This review article throws light on the emergence of these robust innovations that may reshape the guidelines and practice in rheumatology, in particular, efforts to enhance best practice during the coronavirus disease 2019 (COVID-19) pandemic are endorsed.

Utility of Ultrasound-Guided Anesthetic Intra-articular Injection to Estimate the Outcome of Hip Arthroscopy in Patients with Femoroacetabular Impingement Syndrome

Objective

To investigate the effectiveness of ultrasound (US) guided intra‐hip joint injection to estimate the outcome of hip arthroscopy in patients with femoroacetabular impingement (FAI) syndrome.

Methods

Patients with FAI syndrome (n = 60) were prospectively enrolled in our study. Before hip arthroscopy, a mix of 4 mL 2% lidocaine and 4 mL 1% ropivacaine were injected into the hip joint under the guidance of US. The clinical efficacy of the intra‐articular injection was evaluated by comparing the visual analog scale (VAS) and international hip outcome tool 12 (iHOT‐12) results before and after the injection. The outcome of hip arthroscopy was evaluated by iHOT‐12, the modified Harris hip score (MHHS), and the patient's satisfaction 12 months after the operation. The outcome of intra‐articular injection and hip arthroscopy were compared. Factors related to the outcomes of hip arthroscopy were evaluated. The correlation between the efficacy of intra‐hip joint injection and arthroscopy was evaluated.

Results

The VAS of patients decreased from 11.3 ± 7.7 to 3.3 ± 4.5, and the iHOT‐12 increased from 52.1 ± 23.2 to 84.1 ± 18.1 after intra‐articular injection (all P < 0.001). The iHOT‐12 score increased from 52.1 ± 23.2 to 78.9 ± 19.2, and the MHHS increased from 66.5 ± 6.8 to 81.6 ± 8.1 after hip arthroscopy (all P < 0.001). The satisfaction rate of arthroscopy, including very satisfied and effective patients, was 93.3%. Multi‐variable logistic regression showed that only iHOT‐12 improved value after injection was included in the regression formula of satisfaction, with the β of −0.154, standard error of 0.071, Wald value of 4.720, and OR of 0.857 (95%CI 0.746–0.985) (P = 0.03). Significant correlation was detected between iHOT‐12 scores after intra‐articular anesthesia and at 12 months after arthroscopy (r = 0.784, P < 0.001). So was the iHOT‐12 improved value (r = 0.781, P < 0.001) and the iHOT‐12 improved ratio (r = 0.848, P < 0.001). If we had performed arthroscopy only on patients with post‐injection iHOT‐12 score improvement ≥10, the satisfaction rate of arthroscopy would have increased to 96.6%.

Conclusions

US‐guided intra‐hip joint injection may provide a feasible way to estimate the outcome of hip arthroscopy in patients with FAI syndrome, and could be used as a method for indication selection of hip arthroscopy.

Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome

PURPOSE

To use a prospectively collected database to internally validate a previously published intraoperative classification system by determining its utility in improving patient-reported outcome scores (PROS).

METHODS

Open or endoscopic procedures performed at a single center between February 2008 and March 2018 with minimum 2-year follow-up were reviewed. Patients were prospectively classified intraoperatively as one of five greater trochanteric pain syndrome (GTPS) types according to the Lall GTPS classification system and underwent one of the six following surgical procedures: trochanteric bursectomy (TB, type I); TB with trochanteric micropuncture (type II); endoscopic suture staple repair (type IIIA); endoscopic single row transtendinous repair (type IIIB); open or endoscopic double row repair (type IV); and gluteus maximus/tensor fasciae latae transfers (type V). The following PROS were analyzed to assess the efficacy of treatment and validity of the classification scheme: modified Harris Hip Score (mHHS), Nonarthritic Hip Score, The International Hip Outcome Tool, Hip Outcome Score-Sport-Specific Subscale, and visual analog scale for pain.

RESULTS

In total, 324 patients (287 female, 37 male) underwent surgical management per GTPS classification type: 109 type I; 26 type II; 20 type IIIA; 118 type IIIB; 44 type IV; and 7 type V. The mean age and follow-up time were 51.9 ± 12.5 years and 44.5 ± 20.5 months, respectively. All patients PROS improved from baseline to minimum 2-year follow-up (P < .05). High rates of the minimal clinically important difference for mHHS (70.0-100.0) and Nonarthritic Hip Score (73.1-92.7) and patient acceptable symptomatic state for mHHS (70.0-94.5) and International Hip Outcome Tool (58.1-86.7) were achieved per GTPS type. Patient satisfaction was 7.9/10.

CONCLUSIONS

This validation study supports that the classification system and treatment algorithm for surgical treatment of various GTPS types leads to favorable patient-reported outcomes. These findings provide surgeons with a validated classification system and treatment algorithm to manage peritrochantric pathology diagnosed intraoperatively.

LEVEL OF EVIDENCE

III, prognostic study.

Full-Thickness Gluteus Medius Tears With or Without Concomitant Hip Arthroscopy: Minimum 2-Year Outcomes Using an Open Approach and Contemporary Tendon Repair Techniques

Background:

Gluteus medius (GM) tears are a well-established source of pain and disability. An open approach has been recognized with complete full-thickness and large GM tears, yet the current literature provides few reports on outcomes for this specific situation.

Purpose:

To report and analyze minimum 2-year patient-reported outcomes (PROs) from patients who underwent open GM repair in the setting of a full-thickness tear with or without concomitant hip arthroscopy through use of contemporary tendon repair techniques.

Study Design:

Case series; Level of evidence, 4.

Methods:

Prospectively collected data were retrospectively reviewed for patients who underwent hip preservation surgery and total hip arthroplasty (THA) between April 2008 and May 2017. Patients were included in this study if they underwent open repair of GM full-thickness tears. The exclusion criteria were incomplete follow-up, workers’ compensation status, repair regarding size and pattern of the GM, open repair of partial GM tear, open repair with allograft or autograft augmentation, and/or additional gluteus maximus transfer. Pre- and postoperative PROs for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) score for pain and satisfaction were recorded. Statistical significance was set at P < .05.

Results:

A total of 36 patients were included, of whom 12 received concomitant hip arthroscopy for intra-articular procedures. The mean ± SD age, body mass index, and follow-up time were 65.18 ± 12.69 years, 28.97 ± 4.95 kg/m², and 40.8 ± 26.19 months, respectively. At minimum 2-year follow-up, the following outcome measures improved significantly: mHHS (from 54.72 ± 15.89 to 73.12 ± 19.47; P < .0001), NAHS (from 56.05 ± 12.47 to 75.22 ± 19.15; P < .0001); HOS-SSS (from 20.30 ± 20.21 to 44.23 ± 35.85; P < .0001), and VAS (from 4.95 ± 2.70 to 2.67 ± 2.81; P < .0001). There was 1 (2.8%) conversion to THA at 48 months after the index procedure.

Conclusion:

Patients who underwent open repairs in the setting of full-thickness GM tears via contemporary tendon repair techniques, with or without concomitant hip arthroscopy, achieved favorable results in several PRO scores at minimum 2-year follow-up.