Images in Pain Management
A Modified Approach to Intraarticular Hip Injection
I-Min Su1.2 , Ke-Vin Chang3.4.5 , Po-Kai Wang1.2

1Department of Anesthesiology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan

2School of Medicine, Tzu Chi University, Hualien, Taiwan

3Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan

4Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan

5 Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University, Taipei, Taiwan

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Outline



The intraarticular (IA) hip injection is a common procedure for the treatment of hip joint disorders. It can be used to confirm the pain generator. The hip IA injection can be challenging because of the deep location of the hip joint and the adjacent femoral neurovascular structure. In the past, the landmark-guided method had been widely used for performing this injection. Recently, the following image tools have been applied to guide hip joint injections, such as computed tomography, fluoroscopy, and ultrasound [1]. The ultrasound-guided intervention has emerged as the mainstream because of its accuracy in the visualization of soft tissues and neurovascular structures [2]. Besides, there are advantages such as low cost, no exposure to ionizing radiation, and no need to use contrast agents [3]. There are several approaches regarding ultrasound-guided hip IA injection. The anterior longitudinal approach is commonly used in clinical practice (Figure 1). The needle is introduced from the anterior caudal aspect of the hip joint and advanced into the anterior joint recess at the femoral head-neck junction. In the anterior longitudinal approach, the vascular structure is on the trajectory of the needle track and is hard to avoid.

Herein, we would like to introduce an alternative approach through the short-axis view of the hip joint, where fewer vascular structures are encountered during the injection. We fi rst visualize the hip joint on its long axis to identify the head and neck junction. We use color Doppler to recognize vessels that would potentially be damaged by needles. We introduce the needle from the lateral to the medial aspect to target the head-neck junction (Figure 2). Next, we turn the probe 90° to confirm the needle tip in the anterior joint recess in the longitudinal view (Figure 3). The injectate is then administered to see the distention of the hip joint capsule (Figure 4). In conclusion, the latera-to-medial approach allows physicians to inject the hip joint safely, with a lower risk of vascular injury.

Figure 1. Ultrasound Image of Anterior Hip Joint With Transducer Placed Over Femoral Head-Neck Junction in the Anterior Longitudinal Approach

Figure 2. The Needle Is Inserted in Plane With the Transducer Placed Over Femoral Head-Neck Junction in the Lateral-Medial Approach

Figure 3. The Needle Tip Is Positioned in the Recess Out of Plane With the Transducer Placed Over Femoral Head-Neck Junction in the Longitudinal View

Figure 4. The Joint Capsule Is Distended After Injection


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