Intraarticular Hip Injection—Anterior Approach: Ultrasound Guidance

Abstract

Ultrasound can be used to identify and aspirate joint effusions as well as ensure the needle is not embedded within the redundant hip capsule. Ultrasound also allows for the direct visualization of capsular distention as the injectate enters the joint space. An in-plane technique with out-of-plane confirmation will be described. Live fluoroscopy with contrast visualization should be considered to avoid vascular uptake.

Keywords

Circumflex artery, Femoro-acetabular joint, Hip, Injection, labrum, osteoarthritis, Ultrasound

Note: Please see pages ii , iii for a list of anatomic terms/abbreviations used throughout this book.

Ultrasound can be used to identify and aspirate joint effusions as well as ensure the needle is not embedded within the redundant hip capsule. Ultrasound also allows for the direct visualization of capsular distention as the injectate enters the joint space. An in-plane technique with out-of-plane confirmation will be described. Live fluoroscopy with contrast visualization should be considered to avoid vascular uptake.

In this chapter, we describe an anterior approach with the patient in a supine position. Primary safety considerations include avoiding the femoral nerve, artery, and vein, which lie anterior to the medial aspect of the femoro-acetabular joint. Additionally, branches of the lateral circumflex femoral artery course along the anterior intertrochanteric line and femoral neck, some of which anastomose with the medial circumflex femoral artery, therefore, contributing blood supply to the femoral neck and head. Theoretically, occlusion of these vessels could cause avascular necrosis.

In-Plane Technique ( Fig. 35C.1 )

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Supine patient.

Fig. 35C.1

A, Room, interventionalist, transducer, and US unit setup for intraarticular hip injection.
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Interventionalist on patient’s ipsilateral side ( Fig. 35C.1A ).
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Ultrasound image contralateral to the interventionalist and in line with transducer (see Fig. 35C.1A and Chapter 4 ).
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Identify the femoral artery and vein in a short axis view.
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Begin distally with femur in short axis, track proximally to the femoral neck.
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Translate medially to the head–neck junction.
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Rotate transducer (initially toward the umbilicus) to optimize the capsule’s anterior recess, directly superior to the femoral head–neck junction ( Fig. 35C.1B,C,D ).
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Consider internally and externally rotating thigh passively relative to the acetabulum to confirm the location and to identify effusions if present.
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With the transducer still in the long axis to the femoral neck and head, insert needle from an inferolateral to superomedial direction toward the femoral head–neck junction.
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While visualizing the needle tip in a long axis view, advance until the needle tip is advanced through the capsule ( Fig. 35C.1B,C ) .