Roger Dunteman and John F. Sarwark

1. Evaluation of infectious, inflammatory, or metabolic disorders

2. Assessment of reduction and morphology of the cartilaginous femoral epiphysis in hip dysplasia

3. Decompression of significant joint effusions due to septic arthritis, hemarthrosis, or inflammation

4. Injection of therapeutic agents into the joint

1. Soft tissue cellulitis in the path of needle placement

2. Tumor tissue in the path of needle placement

3. Uncontrolled bleeding tendency

1. Obtain anteroposterior (AP) pelvis and lateral hip radiographs.

2. If infection is suspected, send blood for culture, complete blood count (CBC), differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) prior to initiation of antibiotics.

3. Obtain vials for cell count, Gram stain, culture (aerobic, anaerobic, acid-fast bacteria, and fungal), crystal analysis, and chemistry (glucose and protein).

1. Monitored intramuscular or intravenous sedation (preferred) or general anesthesia

2. For local anesthesia, 1% lidocaine can be injected subdermally. Remember lidocaine is bacteriostatic. Do not inject it into the joint.

3. Fluoroscope or fluoroscopy

4. Sterile preps, drapes, and gloves

5. 18 to 20-gauge lumbar puncture needle with stylet to prevent inadvertent breaking or needle plugging

6. Sterile saline (nonbacteriostatic)

7. Two 10-cc syringes

8. Two intravenous extension tubes

9. Cell count and culture tubes (as above)

10. Use diatrizoate sodium (Renograffin) diluted to half-strength as a contrast medium.

1. Use air instead of contrast media to prove that the needle tip needle is in the joint. Extra-articular contrast media will obscure the field.

2. Most contrast media is bactericidal and will reduce the culture’s sensitivity if injected prior to obtaining an adequate fluid sample.

3. Do not judge the presence or absence of infection based on the aspirated fluid’s appearance.

1. Avoid injecting the femoral vessels. Consider marking the vessels with a pen prior to the procedure. Remember the nerve, artery, and vein lie from lateral to medial in the femoral triangle.

2. Avoid injecting the round ligament or the articular cartilage. Using the anterior approach may reduce this possibility.

3. Avoid injecting or traumatizing the physis, especially when using the anterior or lateral approach.