June 14, 2020
Fluoroscopy vs ultrasound Guidance for Corticosteroid Injections of the Hip cover

Fluoroscopy vs Ultrasound Guidance for Corticosteroid Injections of the Hip

Hip pain is a commonly encountered clinical entity. The prevalence of hip osteoarthritis (OA) is estimated to be between 4 and 12% [1]. Hip OA has a significant impact on activities of daily living. Management depends on the severity of changes ranging from physical therapy and oral medications all the way to total hip arthroplasty (THA). Corticosteroid injections (CSI) are a treatment option for patients with mild-to-moderate hip OA and can also be used in patients with severe hip OA waiting for a THA.
Intra-articular injection of steroid for hip joint osteoarthritis has been shown to provide symptomatic relief [2]. Lambert et al showed triamcinolone was superior to saline placebo in an RCT [3]. Safety is also well established [4]. Interestingly, the degree of radiographic arthritis appears to correlate with response to CSI with more advanced changes responding more favorably [5]. Anecdotal, this is probably true to an extent, however severe degenerative joint disease typically does not respond well to CSI. Because the hip joint lays deep in the human body, it should not be injected by palpation. This blog post will briefly compare fluoroscopic guided injections vs ultrasound (US) guided injections.

Landmark

The landmark guided approach is not recommended due to overall poor accuracy, significant potential for neurovascular injury and wide availability of radiologic guidance. Studies have estimated the accuracy of the landmark based approach to be about 72% [11].

Fluoroscopy

fluoroscopic guided injection of the hip example

Image 1. Example of fluoroscopic guided hip injection (courtesy of painsource.com)

Fluoroscopic guidance is known to be effective. Subedi at al performed a single arm study of fluoroscopic guided hip CSI and followed patients’ Oxford hip pain score pre- and 6-8 weeks post-intra-articular injection. They demonstrated a statistically significant increase in the hip pain score confirming the benefit of the CSI. They also found benefit regardless of the severity of arthritis [6].
The biggest concerns with fluoroscopy include radiation exposure and contrast use. Other limitations are that fluoroscopy can not visualize soft tissue structures, is less accessible and compact and requires more resources.

Ultrasound

ultrasound guided injection of the hip

Image 2. Example of ultrasound guided hip injection (courtesy of neupsykey.com)

Ultrasound guidance is also known to be effective. Atchia et al in a double blinded RCT found patients in the US guided CSI arm of the study had significant improvement in pain and function of their hip [8]. Hoeber et al estimated that the ultrasound guided approach accuracy is 100% (95% CI is 98-100%) [11].
The only comparative study was published by Byrd et al titled “Ultrasound-Guided Hip Injections: A Comparative Study With Fluoroscopy-Guided Injections“. He took 50 patients who had undergone fluoroscopy-guided hip CSI and then performed a subsequent US-guided CSI. What he found was in-office ultrasound-guided injections of the hip were more convenient and less painful than fluoroscopy-guided hospital-based injections. He also found that in patients who had undergone both, US guidance was preferred [10].
There appear to be numerous benefits to the use of ultrasound guidance. First, there are no known contraindications. Ultrasound does not produce ionizing radiation or require contrast use. It’s safety is well documented in the literature. Studies of other procedures have shown that US use is associated with less cost than fluoroscopy guidance [13]. Ultrasound machines are compact and accessible. They require less staff, space and resources. Ultrasound also allows the user to visualize neurovascular and other soft tissue structures. Atchia et al has shown training learners and achieving competence is not difficult [9]
Interestingly, Martinez-Martinez et al demonstrated that US can be used to inject contrast into hips for CT Arthrography and MR Arthrography [12].

Conclusion

There are no well designed randomized clinical trials comparing fluoroscopic and ultrasound guidance for hip corticosteroid injections. Both modalities appear to accurately achieve intra-articular access for corticosteroid injections. However, there are multiple distinct advantages to ultrasound guidance listed above. I personally have had several patients tell me they prefer the ultrasound guided approach to fluoroscopy. It’s also worth noting that oftentimes the US-guided injection can be done the same day by the patient’s treating physician rather than having to outsource that procedure to another physician in another department. In summary, given the choice, US guided CSI of the hip should be preferred by both physicians and patients.

References

[1] Lawrence JS, Bremer JM, Bier F. Osteo-arthrosis. Prevalence in the population relationship between symtoms and x-ray changes. Ann Rheum Dis 1966;25:1e24.
[2] Kruse DW. Intraarticular cortisone injection for osteoarthritis of the hip. Is it effective? Is it safe? Curr Rev Musculoskelet Med 2008;1:227e33.
[3] Lambert RG, Hutchings EJ, Grace MG, et al. Steroid injection for osteoarthritis of the hip: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2007;56:2278e87
[4] Kullenberg B, Runesson R, Tuvhag R, et al. Intraarticular cortisone injection: pain relief in osteoarthritis of hip? J Rheumatol 2004;31:2265e8.
[5] Deshmukh AJ, Panagopoulos G, Alizadeh A, et al. Intra-articular hip injection: does pain relief correlate with radiographic severity of osteoarthritis? Skeletal Radiol 2011;40:1449e54. Epub 2011 Feb 18.
[6] Subedi N, Chew NS, Chandramohan M, Scally AJ, Groves C. Effectiveness of fluoroscopy-guided intra-articular steroid injection for hip osteoarthritis. Clin Radiol. 2015;70(11):1276‐1280. doi:10.1016/j.crad.2015.07.002
[7] Smith, Jay, and Mark-Friedrich B. Hurdle. “Office-based ultrasound-guided intra-articular hip injection: technique for physiatric practice.” Archives of physical medicine and rehabilitation 87.2 (2006): 296-298.
[8] Atchia, Ismaël, et al. “Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis.” Annals of the rheumatic diseases 70.1 (2011): 110-116.
[9] Atchia I, Birrell F, Kane D. A modular, fl exible training strategy to achieve competence in diagnostic and interventional musculoskeletal ultrasound in patients
[10] Byrd, JW Thomas, et al. “Ultrasound-guided hip injections: a comparative study with fluoroscopy-guided injections.” Arthroscopy: The Journal of Arthroscopic & Related Surgery 30.1 (2014): 42-46.
[11] Hoeber, Shane, et al. “Ultrasound-guided hip joint injections are more accurate than landmark-guided injections: a systematic review and meta-analysis.” Br J Sports Med 50.7 (2016): 392-396.
[12] Martínez-Martínez, A., et al. “Comparison of ultrasound and fluoroscopic guidance for injection in CT arthrography and MR arthrography of the hip.” Radiología (English Edition) 58.6 (2016): 454-459.
[13]Hudnall, Matthew, et al. “Ultrasound guidance reduces percutaneous nephrolithotomy cost compared to fluoroscopy.” Urology 103 (2017): 52-58.

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