Hip joint injection (technique)

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Hip joint injections can be performed with a variety of image guidance, including fluoroscopy and ultrasound, which are used to administer MRI arthrogram injectate, or a steroid containing anesthetic arthrogram injectate.

Indications

Contra-indications

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

Procedure

The general principles of hip arthrogram injections are to:

  • cannulate the joint
  • confirm an intra-articular position with imaging
  • administer intra-articular injectate. The hip is a medium-sized joint and the injected volume should reflect this.  
Pre-procedural evaluation

Relevant imaging should be reviewed, and the details of the patient confirmed.  The patient should have an opportunity to discuss the risks and benefits and consent obtained.

Risks include:

  • infection
  • bleeding
  • allergy 
  • steroid flare (anesthetic arthrogram)
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 anesthetic i.e. 25-gauge needle
  • needle to cannulate the joint i.e. 22-gauge needle Quincke needle
  • injectants i.e. local anesthetics, iodinated contrast, corticosteroid preparation
  • sterile gauze
  • adhesive dressing
Syringe selection

A suggested syringe and injectate selection for a fluoroscopic-guided MRI arthrogram injection:

  • 10mL mL syringe: 5 mL of local anesthetic i.e. 1% lidocaine
  • 5 mL syringe: 5 mL non-ionic iodinated contrast i.e. iohexol 300
  • 20mL syringe containing: 0.1 mL gadolinium, 9.9 ml 0.9% saline, 5 mL 0.5% ropivacaine, 5 mL iohexol 300

A suggested syringe and injectate selection for a fluoroscopic-guided anesthetic arthrogram injection:

  • 10mL mL syringe: 5 mL of local anesthetic i.e. 1% lidocaine
  • 5 mL syringe: 5 mL non-ionic iodinated contrast i.e. iohexol 300
  • 5 mL syringe: 40mg triamcinolone acetonide (40 mg/1 mL) and 3 mL 0.5% ropivacaine

A suggested syringe and injectate selection for an ultrasound-guided hip MRI arthrogram injection:

  • 5 mL syringe: 5 mL of local anesthetic i.e. 1% lidocaine
  • 20mL syringe containing: 0.1 mL gadolinium, 14.9 ml 0.9% saline, 5 mL 0.5% ropivacaine

A suggested syringe and injectate selection for an ultrasound-guided hip anesthetic arthrogram injection:

  • 5 mL syringe: 5 mL of local anesthetic i.e. 1% lidocaine
  • 5 mL syringe: 40mg triamcinolone acetonide (40 mg/1 mL) and 3 mL 0.5% ropivacaine
Needle selection

The needle needs to be long enough to reach the joint and smaller gauge needles will be less stiff.

Hip: 22-gauge Quincke needle

Technique

Ultrasound 
  • check for allergies and if on blood thinners
  • consent
  • optimize 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 optimize imaging and mark the skin entry point at the end of the probe
  • clean skin and draw up appropriate medications
  • consider local anesthesia 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 visualization
  • remove the needle and apply dressing as required
Fluoroscopy 
  • check for allergies and if on blood thinners
  • consent
  • optimize 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
  • optimize 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
  • clean skin and draw up appropriate medications
  • consider local anesthesia 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

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 , although less common in deeper injections.

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