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Techniques in Regional Anesthesia and Pain Management (2009) 13, 191-197

Ultrasound-guided injections of the knee and hip joints

Peter H. Cheng, DO,a Helen J. Kim, MD, MPH,a Einar Ottestad, MD,b Samer Narouze, MD, MScc
From the aDepartment of Anesthesiology, Division of Interventional Pain Management, Kaiser Permanente Hospital, Riverside, California; b Department of Anesthesiology, Division of Pain Management, Stanford University Hospital, Stanford, California; and the c Pain Management Department, Cleveland Clinic, Cleveland, Ohio. KEYWORDS:
Ultrasound-guided blocks; Musculoskeletal ultrasound; Knee injection; Hip injection Intra-articular knee and hip injections have been a mainstay for the treatment of peripheral joint pain. Although these injections are routinely performed using a blind technique, when compared with uoroscopically guided injections, reported accuracy of needle placement is highly variable. Ultrasound (US)-guided injections provide a reasonable alternative for ensuring accurate, intra-articular needle placement, without the risks associated with radiation exposure from uoroscopy. This article presents suitable techniques for performing US-guided intra-articular knee and hip injections. With appropriate training, it would be feasible for physicians to incorporate US-guided injections into their clinical practices. 2009 Elsevier Inc. All rights reserved.

Ultrasonography is an invaluable tool in the diagnosis and treatment of disorders of the musculoskeletal system. Although ultrasound (US) has been used for diagnostic purposes for the last 30 years,1 the use of this imaging modality for guiding joint injections is a new and emerging eld. Knee and hip pain are common complaints, particularly prevalent in the elderly population, with about 30% of adults 65 years of age and over reporting knee pain or stiffness in the past 20 days and 15% reporting hip pain or stiffness.2 According to the National Center for Health Statistics, the Healthcare Cost and Utilization Project (HCUP) estimated that, in 2003, knee replacement surgery cost the nation approximately $11.9 billion and hip replacement $12.3 billion. Due to the growing numbers of those aficted with knee and hip pathology, it is important that physicians
Address reprint requests and correspondence: Peter H. Cheng, DO, Department of Anesthesiology, Division of Interventional Pain Management, Kaiser Permanente Hospital, 10800 Magnolia Avenue, Riverside, CA 92505. E-mail address: 1084-208X/$ -see front matter 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2009.06.022

have a safe and reliable method for treating the pain associated with these joint disorders. This paper will rst provide an anatomical overview of the knee and hip joint. Next, advantages as well as limitations of US-guided joint injections will be discussed. Finally, techniques describing US-guided knee and hip injections will be presented.

Anatomy of the knee joint

The largest joint of the body, the knee is a synovial hinge joint consisting of four bones: the femur, patella, tibia, and bula.3 Articular cartilage envelops the ends of the tibia and femur, as well as the underside of the patella. The knee joint is surrounded by a thick capsule and lined with a synovial membrane that secretes synovial uid to reduce friction and facilitate movement.3 Four strong ligaments (anterior cruciate, posterior cruciate, lateral collateral, medial collateral) connect the ends of the bones and serve to stabilize the knee. There are two menisci that are located between the femur


Techniques in Regional Anesthesia and Pain Management, Vol 13, No 3, July 2009 reported accuracy of nonimage-guided injections has been highly variable. In a study of 156 knees from 78 fresh cadavers, Esenyel and coworkers demonstrated that the anterolateral approach showed the highest accuracy rate (85%), followed by the lateral mid patellar (76%), anteromedial (75%), and medial midpatellar (56%). However, no statistical signicance was found among the rst three.11 Even in situations where the injection is preceded by aspiration of joint uid through the same needle, it is still possible for the injectate to be placed outside the joint.12 There are several advantages to treating a pathologic knee with the aid of sonography. First, US can be used as an extension of the physical examination and aid in the accurate diagnosis of arthritis. Several papers have discussed the wide spectrum of pathologic ndings characteristic of RA and OA that can be visualized under US.8,13,14 In general, OA is initially characterized by a loss of sharp contour and variations in the echogenicity of the cartilage matrix. As the disease progresses, there is asymmetric narrowing of the cartilaginous layer. Early bone changes in the OA joint are seen as a hyperechoic signal where the joint capsule attaches to the bony cartilaginous margin, and this correlates with the eventual appearance of osteophytes detected on conventional radiography.14 Secondly, US can guide the accurate placement of the therapeutic material into the knee. Qvistgaard and coworkers undertook a study where a total of 184 injections were performed in 37 patients with knee OA by using a technique where 0.5-1 mL of atmospheric air was injected into the joint cavity to verify positioning. In knee joints, the injected air will move to the suprapatellar bursa, thus making it visible. The authors were able to visualize the diffusion of air into the suprapatellar bursa in all cases.15 This would be particularly useful for small or poorly accessible joints, or in the case of obese patients, where typical bony landmarks may be difcult to palpate. Third, sonography can potentially be used to evaluate the outcome of the procedures and monitor effectiveness of the treatment.14 Substantial relief can be obtained with therapeutic knee injections, but often these injections may be deemed unsuc-

and tibia that assist the ligaments in stabilization and help distribute the axial load imparted onto the knee.4 The synovial membrane is subdivided into several compartments that communicate.3 Anterosuperiorly, the synovial membrane forms a large recess referred to as the suprapatellar bursa. This bursa is found deep to the tendon of the quadriceps femoris muscle, sandwiched between the anterior suprapatellar fat pad and the deep prefemoral fat pad.5,6 Inferiorly, the synovium is separated from the patellar ligament by the infrapatellar fat pad and referred to as the deep infrapatellar bursa or recess. A supercial infrapatellar bursa lies between the skin and the patellar ligament.4 The arteries supplying the knee form an anastomotic ring surrounding the joint. These include the inferior and superior genicular branches of the popliteal artery, the recurrent branches of the anterior tibial artery, the supreme genicular branch from the supercial femoral artery, and the lateral femoral circumex branch of the deep (profunda) femoral artery.3,7 Sensory articular branches from the obturator, femoral, common peroneal, and tibial nerves provide innervation to the knee joint.3

Advantages compared with traditional blind techniques

Knee pain can affect all age groups and can arise from a multitude of different pathologies. Syndromes of the knee can best be categorized according to the anatomic region of the patients pain (Table 1).8 Although knee pain can originate from diverse origins, management options tend to be similar and include nonpharmacologic measures, medications, injections, and surgery. Of those injections performed, intra-articular knee injections with corticosteroids and viscosupplements, such as Synvisc and Hyalgan, are among the most frequently used interventions and remain a mainstay in the treatment of knee pain secondary to rheumatoid arthritis (RA) and osteoarthritis (OA).9,10 Although intra-articular injections to the knee have long been performed by clinicians using surface landmarks, the
Table 1 Knee syndromes based on anatomic regions Medial compartment Pes anserinus Tendonitis Bursitis Medial collateral ligament (MCL) injuries Medial meniscus injury Osteoarthritis Referred pain

Anterior compartment Patellofemoral syndrome Patella tendinopathy Patellofemoral instability Fat pad impingement Infrapatellar bursitis Synovial plica Prepatellar bursitis Quadriceps tendinitis Osgood-Schlatter disease Sinding-Larsen-Johansson disease Referred pain

Lateral compartment Iliotibial band friction syndrome Biceps femoris tendinitis Superior tibiobular joint sprain Lateral meniscus pathology Osteoarthritis Referred pain

Posterior compartment Knee joint effusion Hamstring tendinitis Popliteus tendinitis Bakers cyst Posterior cruciate ligament (PCL) sprain Referred pain

Cheng et al

US-Guided Injections of the Knee and Hip Joints

193 long as they have been appropriately trained; this would be analogous to the necessary views and diagnostic criteria used to examine the heart with echocardiography.14

cessful due to inaccurate needle placement. Accurate placement will increase the likelihood of an effective knee injection, but would also provide the patient with a higher level of safety in which the procedure is performed. US allows direct visualization of the target in addition to all the relevant anatomical structures of the knee, minimizing risk of nerve injury and hematoma formation by allowing the practitioner to avoid nerves and blood vessels. Spread of the injectate material can clearly be visualized, assuring that the medication is effectively delivered inside the articulation.16 This may also allow quicker placement of the injection and possible reduction in amount of medication, thereby minimizing discomfort and the adverse effects that could be associated with steroids.17

Ultrasound-guided techniques for knee injections

Suprapatellar approach
With the knee exed about 20-30 and supported by a pillow placed in the popliteal space, the linear array transducer (7-12 MHz) is aligned parallel (longitudinal axis) to the tendon of the quadriceps femoris muscle. A linear transducer is recommended because it provides excellent resolution due to higher frequency and allows easier guidance of the needle for in-line injection. The superior pole of the patella, distal femur, suprapatellar fat pad, and the anechoic synovial recess known as the suprapatellar bursa should be identied (Figure 1). If there is difculty locating the su-

Ultrasound versus other imaging modalities

Certainly, different imaging techniques like uoroscopy, CT, and MRI could be used for knee injections. The introduction of CT and MR arthrography has provided the ability to obtain detailed imaging of the knee and to detect abnormalities with high accuracy.18 However, these imaging techniques are not routinely used for therapeutic knee injections due to high costs, time consumption, and lack of availability of equipment to most clinicians. Sonography, by contrast, is an imaging modality that is particularly wellsuited for the evaluation and treatment of musculoskeletal derangements.8,14,19 One of its greatest advantage is that it works in real time. It permits the continuous monitoring of any procedure, allowing visualization of the needle or instrument used at all times, increasing the safety and accuracy of the procedure. It also allows the evaluation of musculoskeletal injuries that can only be demonstrated with specic types of motion, thereby allowing the clinician to evaluate the area of interest in both static and dynamic states.19 Movement would result in motion artifact or excessive radiation exposure if performed under MR or CT. The US machine is portable, thereby making it readily available. It can be operated at low cost, does not use ionizing radiation, and does not require contrast agents for visualization. Therefore, US can safely be used in the pregnant patient without the risk of teratogenesis, in patients with contraindications to MR imaging such as metallic hardware or pacemakers, or those with contrast agent allergies.

Limitations of ultrasound
Limitations include the skill level of the sonographer conducting the evaluation. A good understanding of the anatomy and features of a normal, healthy joint is required to avoid misinterpretations when scanning a pathologic knee. Standardization in the scanning technique and diagnostic criteria will be necessary to make uniform and consistent assessments of the knee regardless of the US operator as

Figure 1 (A) Knee injection: suprapatellar approach, longitudinal view. The transducer is aligned parallel (longitudinal axis) to the tendon of the quadriceps femoris muscle. (B) Knee injection: suprapatellar approach, longitudinal view. US image.


Techniques in Regional Anesthesia and Pain Management, Vol 13, No 3, July 2009 Because the distance from the skin to the small infrapatellar recess is often deep in large patients, the author nds the curvilinear transducer to be better suited for image guidance. However, the radially directed US beams emanating from a curvilinear transducer may distort the image, especially in the lateral eld. Additionally, as only a very limited percentage of the US beams are perpendicular to the needle at any one time, image guidance and needle visualization are challenging. For these reasons, the author nds the suprapatellar approach to the knee joint injection technically easier.

Figure 2 Knee injection: suprapatellar approach, axial view. US image of the needle entering the suprapatellar bursa.

Anatomy of the hip joint

The hip joint is a synovial ball-and-socket joint that allows free movement in all directions. It is formed by the articulation of the head of the femur and the acetabulum of the pelvis. The acetabular socket is formed at the junction of the ilium, ischium, and pubis and covers the spherical femoral head almost completely, except for a depression called the acetabular notch. The transverse acetabular ligament spans this portion of the acetabulum. The acetabulum is then augmented by the acetabular labrum, a brocartilaginous ring attached directly to the rim of the acetabulum. This labrum increases the depth and surface of the acetabular cavity, thus allowing better congruity between it and the femoral head.21 The joint capsule inserts onto the acetabular rim, and a deep layer of circularly oriented bers known as the zona orbicularis encircles the capsule at the base of the femoral neck. The capsule has several thickenings, including the longitudinally oriented iliofemoral, ischiofemoral, and pubofemoral extracapsular ligaments. The ligamentum teres femoris, an intracapsular ligament, is attached to the acetabular notch and a depression on the femoral head called the fovea capitis.22 The femoral artery courses lateral to the femoral vein in the femoral triangle, which is bordered by the sartorius laterally, the inguinal ligament superiorly, and the adductor longus medially. Over the hip joint, it is separated from the femoral head by the iliopsoas tendon and bursa. It then gives off a branch called the deep femoral artery. This artery gives rise to the medial and lateral circumex arteries, which provide most of the blood supply to the head and neck of the femur. The posterior division of the obturator artery is also important as it gives off a branch that passes through the acetabular notch in the ligamentum teres, which helps protect against avascular necrosis with femoral neck fractures.23 The femoral nerve arises from the L2-L4 spinal nerves, travels with the psoas muscle, courses lateral to the femoral artery in the femoral triangle, and gives several branches that provide sensory innervations to the skin and hip joint, as well as motor supply for the anterior femoral muscles. The lateral femoral cutaneous nerve is a purely sensory nerve that arises from the L2 and L3 spinal nerves, passes

prapatellar bursa, squeezing the quadriceps femoris muscle may distend this synovial recess and enhance visualization. Minimal transducer pressure should be applied on the knee to avoid inadvertently compressing the suprapatellar bursa. Next, the transducer should be rotated to the axial (transverse) plane, remaining superior to the patella. Once again, identify the quadriceps femoris tendon, the suprapatellar fat pad, and the underlying suprapatellar bursa. Find the location of the synovial recess with the largest dimensions, and use this as the target site for the injection. After creating a sterile eld and using sterile technique, a 22-gauge, 3.5-inch spinal needle is advanced in-line to the transducer to enter the suprapatellar recess (Figure 2). Prior to injection, aspirate for synovial uid. Aspiration of synovial uid conrms proper placement of needle. During the injection, a uid jet is observed under US, distending the suprapatellar recess. Use of color Doppler sonography will enhance visualization of the uid jet. Other methods of conrmation described in literature include the injection of 0.5-1 mL of air alone into the intra-articular space15 as well as the injection of 1-2 mL of air with the steroid to produce an audible squishing sound with knee exion and extension.20

Infrapatellar approach
As with the suprapatellar approach, the knee is exed and supported. A linear array transducer is aligned in the longitudinal axis of the patellar ligament between the patella and the tuberosity of the tibia. Deep to the patellar ligament, the infrapatellar fat pad and the underlying infrapatellar recess should be identied. Directing the needle medial or lateral to the patellar ligament with the transducer in the longitudinal axis limits needle visualization as the needle is advanced parallel with the transducer. However, visualization may be enhanced by rotating the needle, injecting a small amount of uid to cause tissue distention, or insonating with color Doppler sonography.

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US-Guided Injections of the Knee and Hip Joints

195 expensive and time-consuming. These techniques expose the patient and staff to radiation, iodinated contrast with associated reactions, and use cumbersome equipment. US allows safe, accurate, and inexpensive joint injections with real-time visualization of soft-tissue structures. Furthermore, US has the ability to visualize joint effusions, the iliopsoas bursa, and the relationship of the femoral vessels to the needle. Pourbagher and coworkers investigated a series of 10 patients who each had 3 sonographically guided intra-articular injections of sodium hyaluronate using an anterior parasagittal approach. Each needle location was conrmed with injection of contrast and CT with a 100% success rate.26 Smith and coworkers used an oblique sagittal approach to sonographically guide the needle into the hip joint. A contrast-enhanced uoroscopic investigation was then done which conrmed correct placement in 29 of 30 injections.23 The inaccurate placement was due to the needle being withdrawn from the joint capsule when connecting extension tubing before injection. They also compared patient body mass index (range 20-39 kg/m2), showing that the technique works for a variety of body types. One benet of uoroscopic and CT-guided injections is the ability to conrm proper needle placement using small amounts of radiopaque contrast. However, Carson and Wong describe a sonographic approach to the hip joint that uses injection of air to conrm intra-articular position of the needle tip.27 Using US, if the air collects in a nondependent fashion along the joint capsule, it is believed to be intraarticular. If it collects around the tip of the needle indicating an extra-articular position, the needle is adjusted. They reported no technical failures or complications to have occurred. Berman and coworkers and Sofka and coworkers reported 800 and 358 sonographically guided hip injections, respectively, with no major complications.28,29 Duc and coworkers reported average elapsed times from skin penetration to injection for uoroscopically guided procedures as 105 and 115 seconds.30 Although the learning curve for sonographically guided hip injections can be steeper than uoroscopically guided injections, Smith and coworkers averaged 112 seconds (range 47-187 seconds). In their experience, operators could become comfortable with the technique after 7-10 procedures.23

medially to the anterior superior iliac spine, and innervates the anterior and lateral portions of the thigh. Posteriorly, the sciatic nerve originates from the L4-S3 spinal nerves, courses deep to gluteal musculature midway between the greater trochanter and the ischial tuberosity, and gives off articular branches to the hip joint as well.21

Indications for hip joint injections

Joint injections can be useful both diagnostically as well as therapeutically for a variety of disorders, including osteoarthritis, rheumatoid arthritis, and labral tears.23 Osteoarthritis of the hip is a common pathology causing pain and discomfort. Usual radiographic criteria include joint space narrowing, subchondral sclerosis, and osteophytes. However, not all hips show these pathologic changes, and a more specic way to make the diagnosis is useful. Treatment can include intra-articular injections of corticosteroids as well as hyaluronate. Intra-articular injections can also be useful diagnostically to separate intrinsic hip pathology from another source of pain, such as spine degeneration. Crawford and coworkers investigated 42 patients who were being considered for total hip arthroplasty (THA), but in whom the source of pain was uncertain. Of the 33 patients who had pain relief from an intra-articular hip injection, 32 had resolution of pain with a THA. Of the 9 patients who did not have a good response to local anesthetic in the joint, 3 had unsuccessful THAs and the rest have been treated for other pathology, including spine pathology, or still have no diagnosis.24 A similar study showed that 13 of 15 patients status post THA with hip pain who responded to intra-articular hip injections with local anesthetic had loosening of one or both hardware components and beneted from revision surgery.25 Analogous to the knee, viscosupplementation is a treatment technique in which hyaluronate is injected into hip joints to achieve the effects that hyaluronate has in healthy joints.26 In Pourbaghers study of 10 patients, 80% had less pain using the visual analog scale and the Western Ontario and McMaster WOMAC Universities osteoarthritis index scores in the joint 6 months after treatment with sodium hyaluronate. The average visual analogue scale (VAS) decreased from 8.3 to 4.4 at 6 months, and the average WOMAC score decreased from 41.6 to 20.26

Ultrasound-guided technique for hip injection Ultrasound-guided injections

Blind techniques to access the hip joint based on bony anatomy can be difcult and traumatize the femoral neurovascular bundle. Using only surface landmarks, the hip joint is entered only 52% to 80% of the time and may pass within 4.5 mm of the femoral nerve.23 Fluoroscopically guided injections allow easier access to the joint, but still do not visualize the vessels or nerves. CT-guided injections are

Anterior longitudinal approach

US-guided intra-articular injections of the hip have been recently described.23,29,31-33 With the patient in the supine position, the hip is maintained in the neutral position or slight external rotation and exion for better comfort. The author rst insonates with a linear array transducer (7-12 MHz) to identify the supercial neurovascular structures to


Techniques in Regional Anesthesia and Pain Management, Vol 13, No 3, July 2009 identication of the needle tip should be maintained at all times. As the needle is advanced toward the anterior synovial recess, resistance may be felt as it encounters the iliofemoral ligament. Aspirate for synovial uid after popping through the ligament. Minimum resistance to injection should be noted; otherwise the needle may have been incorrectly placed in the periosteum or the iliofemoral ligament. Analogous to the knee injection, injecting 1 mL of air into the synovial recess may help conrm needle placement.15 To avoid inadvertent injury and ensure proper needle placement, the practitioner should see and guide the needle tip and distinguish it from the shaft. Fluid or bubbles may be seen within the anterior synovial recess during injection.

avoid injury during the procedure. In a thin patient, the anterior synovial recess can be adequately visualized with the linear transducer. However, in large patients, the better penetration of the curvilinear transducer (1-5 MHz) is necessary. To identify the anterior synovial recess, the target site of injection, the US probe is aligned parallel to the neck of the femur and lateral to the neurovascular structures identied earlier (Figure 3A). Color Doppler sonography should be used to supplement B mode sonography to exclude any blood vessels overlying the target site. After the skin is prepped to create a sterile eld, a 22-gauge, 3.5-inch spinal needle is introduced in-line to the target site (Figure 3B). To optimize needle visualization, the transducer should be rocked along its longitudinal axis so the US beam is perpendicular to the tip of the needle. Clear

Intra-articular injections provide important diagnostic information that may help identify the etiology of pain and dysfunction as well as provide treatment. However, as a blind procedure, its accuracy is highly variable and subject to inadvertent injury. These problems are more pronounced in the obese patient as palpable landmarks are obscured and the distance from skin to the injection site is greater. For the hip injection, as the neurovascular structure may lie over the hip joint, intravascular or femoral nerve injection may occur. Fluoroscopy, a frequently used imaging modality, can identify proper needle placement but not the soft tissue, including these neurovascular structures. Avoiding the risk of radiation from uoroscopy, US imaging can safely and effectively provide real-time needle guidance for joint injections while avoiding soft tissue trauma.

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Figure 3 (A) Hip injection: anterior longitudinal approach. The transducer is aligned parallel to the neck of the femur. (B) Hip injection: anterior longitudinal approach. US image with representation of needle targeting the anterior synovial recess located at the neck of the femur. (Color version of gure is available online.)

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US-Guided Injections of the Knee and Hip Joints

23. Smith J, Hurdle MF, Weingarten TN: Accuracy of sonographically guided intra-articular injections in the native adult hip. J Ultrasound Med 28:329-335, 2009 24. Crawford RW, Gie GA, Ling RSM, et al: Diagnostic value of intraarticular anaesthetic in primary osteoarthritis of the hip. J Bone Joint Surg 80-B:279-281, 1998 25. Crawford RW, Ellis AM, Gie GA, et al: Intra-articular local anaesthesia for pain after hip arthroplasty. J Bone Joint Surg 79-B:796-800, 1997 26. Pourbagher MA, Ozalay M, Pourbagher A: Accuracy and outcome of sonographically guided intra-articular sodium hyaluronate injections in patients with osteoarthritis of the hip. J Ultrasound Med 24:13911395, 2005 27. Carson BW, Wong A: Ultrasonographic guidance for injection of local steroids in the native hip. J Ultrasound Med 18:159-160, 1999 28. Berman L, Fink AM, Wilson D, et al: Technical note: Identifying and aspirating hip effusions. Br J Radiol 68:306-310, 1995 29. Sofka CM, Saboeiro G, Adler RS: Ultrasound-guided adult hip injections. J Vasc Interv Radiol 16:1121-1123, 2005 30. Duc SR, Hodler J, Schmid MR, et al: Prospective evaluation of two different injection techniques for MR arthrography of the hip. Eur Radiol 16:473-478, 2006 31. Caglar-Yagci H, Unsal S, Yagci I, et al: Safety and efcacy of ultrasound guided intra-articular hylan G-F 20 injection in osteoarthritis of the hip: A pilot study. Rheumatol Int 225:341-344, 2005 32. Migliore A, Martin LS, Alimonti A, et al: Efcacy and safety of viscosupplementation by ultrasound guided intra-articular injection in osteoarthritis of the hip. Osteoarthritis Cartilage 11:305-306, 2003 33. Smith J, Hurdle MF: Ofce based ultrasound-guided intra-articular hip injection: Technique for physiatric practice. Arch Phys Med Rehabil 87:296-298, 2006

10. Peterson JJ: Knee injections, in Peterson JJ, Fenton DS, Czervionke LF (eds): Image-Guided Musculoskeletal Intervention. Philadelphia, PA, Saunders Elsevier, 2008, pp 111-135 11. Esenyel C, Demirhan M, Esenyel M, et al: Comparison of four different intra-articular injections sites in the knee: A cadaver study. Knee Surg Sports Traumatol Arthrosc 15:573-577, 2007 12. Jones A, Regan M, Ledingham J, et al: Importance of placement of intra-articular steroid injections. BMJ 307:1329-1330, 1993 13. Grassi W, Filippucci E, Farina A: Ultrasonography in osteoarthritis. Semin Arthritis Rheum 34:19-23, 2005 14. Mller I, Bong D, Naredo E, et al: Ultrasound in the study and monitoring of osteoarthritis. Osteoarthritis Cartilage 16:S4-S7, 2008 15. Qvistgaard E, Kirstoffersen H, Terslev L, et al: Guidance by ultrasound of intra-articular injections in the knee and hip joints. Osteoarthritis Cartilage 9:512-517, 2001 16. del Cura JL: Ultrasound-guided therapeutic procedures in the musculoskeletal system. Curr Probl Diagn Radiol 37:203-218, 2008 17. Louis LJ: Musculoskeletal ultrasound intervention: Principles and advances. Radiol Clin North Am 46:515-533, 2008 18. Coumas JM, Palmer WE: Knee arthrography. Evolution and current status. Radiol Clin North Am 36:703-728, 1998 19. Primack SJ: Musculoskeletal ultrasound. The clinicians perspective. Radiol Clin North Am 37:617-621, 1999 20. Glattes RC, Spinder KP, Blanchard GM, et al: A simple, accurate method to conrm placement of intra-articular knee injection. Am J Sports Med 32:1029-1031, 2004 21. Martinoli C, Bianchi S: Hip, in Baert AL, Knauth M, Sartor K (eds): Ultrasound of the Musculoskeletal System. Heidelberg, Springer-Verlag, 2007, pp 551-610 22. Petersilge CA: Chronic adult hip pain: MR arthrography of the hips. Radiographics 20:S43-S52, 2000 (suppl)