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REVIEW ARTICLE

Ultrasound-Guided Interventional Procedures in Pain Medicine

A Review of Anatomy, Sonoanatomy, and Procedures. Part IV: Hip

Philip W.H. Peng, MBBS, FRCPC, Founder (Pain Medicine)

Abstract: Ultrasound-guided injection in pain medicine is emerging as a popular technique for pain intervention. It can be applied for the in- tervention procedures in the hip region. The objectives of this review article were to review the relevant anatomy and sonoanatomy of the hip joint and the trochanteric bursae, to describe the techniques for ultrasound-guided injections, and to examine the ef cacy and accuracy of such injections.

(Reg Anesth Pain Med 2013;38: 264273)

H ip pain can be a manifestation of a broad range of intra- articular or extra-articular pathologies. 1,2 Of those, osteoar-

thritis of the hip and greater trochanteric pain syndrome (GTPS) are the 2 conditions commonly referred to an anesthesiologist or pain specialist for injections. Osteoarthritis is the most common joint disorder in the United States and is the leading cause of disability in the elderly. Radiographic evidence of osteoarthritis of the hip is present in about 5% of the population older than

65 years. 3,4 However, not all patients with radiographic evidence of osteoarthritis have symptoms. According to the National Center for Health Statistics, the Healthcare Cost and Utilization Project estimated that nearly 368,000 total hip replacements were per- formed in 2004, costing the nation approximately $5.3 billion. 5 Greater trochanteric pain syndrome affects approximately 18% of the adults in community settings 6 and 0.2% of the patient population in the primary care setting. The prevalence increases in patients with musculoskeletal low-back pain and in women. 6 9 This review focuses only on these 2 causes of hip pain, as they reect the common reasons for the referral to anesthesiol- ogists. The rst objective of this review was to describe and summarize the anatomy and sonoanatomy of hip structures rel- evant to these hip pain conditions. The second objective was to examine the feasibility, accuracy, and effectiveness of the injec- tions to these structures as well as the injection techniques.

7

METHODS

A literature search of the MEDLINE database was per- formed from January 1980 to December 2012 using the search

From the Department of Anesthesia and Pain Management, University Health Network, University of Toronto, Toronto, Ontario, Canada. Accepted for publication March 10, 2013. Address correspondence to: Philip W. H. Peng, MBBS, FRCPC, Founder (Pain Medicine), Department of Anesthesia and Pain Management, University Health Network, University of Toronto, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8 (e-mail: Philip.peng@uhn.on.ca). Source of funding: Institutional. The author received equipment support from SonoSite Canada. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal s Web site (www.rapm.org). Copyright © 2013 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0b013e318291c8ed

terms ultrasound,” “ultrasound-guided,” “ pain management,and different hip structures relevant to this review, such as hip,” “hip joint,” “ trochanteric bursa,and greater trochanter pain syndrome.Only literature published in English was included.

DISCUSSION

Anatomy

The anatomy of the hip region has been detailed in many excellent textbooks. In this review, we focus on the anatomy that is pertinent to the understanding of the injection of the hip joint and the pathophysiology of GTPS. The hip is a synovial ball-and-socket joint formed by the articulation of the femoral head and the acetabulum. The ace- tabular socket is formed at the junction of the ilium, ischium, and pubis and is augmented by the acetabular labrum, a bro- cartilaginous ring attached directly to the rim of the acetabulum (Fig. 1). This labrum increases the depth and surface of the ac- etabular cavity, optimizing the congruity between acetabulum and the femoral head. At any position of hip motion, approxi- mately 40% of the articular surface of the femoral head is cov- ered by the acetabulum. 10 Along with the strong capsule and several powerful para-articular ligaments, this structural ar- rangement confers stability to the hip joint.

The joint capsule surrounds the outer surface of the labrum and inserts distally to the intertrochanteric region and posterior aspect of the femoral neck. The anterior joint capsule is com- posed of 2 layers, anterior and posterior, that are separated by the anterior recess of the joint space (Fig. 2). Each layer is of considerable thickness (2 4 mm) and lined by only a minute sy- novial membrane. 11 The anterior layer runs caudally and inserts on the intertrochanteric line, where it blends with the perios- teum. Many bers are re ected upward, covering the femoral neck, to form the posterior layer of the joint capsule, which ends at the caudal edge of the articular cartilage of the femoral head. The trochanters (greater and lesser) and the lateral third of the posterior femoral neck are extra-articular. 10 The capsule has several thickenings, including the longitu- dinally oriented iliofemoral, ischiofemoral, and pubofemoral extracapsular ligaments (Fig. 1). The ligamentum teres femoris, an intracapsular ligament, is attached to the acetabular notch and a depression on the femoral head called the fovea capitis. 12 The structures in the anterior hip regions from medial to lateral are the following: pectineus muscle, femoral neurovascular bun- dle, iliopsoas muscle and tendon, and sartorius and rectus femoris muscles (Fig. 3 and see Video, Supplemental Digital Content 1, http://links.lww.com/AAP/A72, which shows layer by layer the muscles in the anterior hip region [reproduced with permission from Ultrasound for Regional Anesthesia, Ultra- sound for Regional Anesthesia, www.usra.ca]). A good knowledge of the anatomy of the lateral hip region is instrumental to the understanding of the GTPS. The bony sur- face of the greater trochanter (GT) consists of 4 facets: anterior,

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Regional Anesthesia and Pain Medicine Volume 38, Number 4, July-August 2013

Ultrasound in Pain Medicine/Hip

Number 4, July-August 2013 Ultrasound in Pain Medicine/Hip FIGURE 1. Front view of hip joint, the

FIGURE 1. Front view of hip joint, the labrum (left), and the hip ligaments. Ischiofemoral ligament cannot be seen from this view because of the posterior location. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

lateral, superoposterior, and posterior (Fig. 4 and Video, Sup- plemental Digital Content 2, http://links.lww.com/AAP/A73, which shows the 4 facets in the GT in a 3-dimensional view [reproduced with permission from Ultrasound for Regional An-

esthesia, www.usra.ca]).

and anterior and posterior tendons of the gluteus medius insert into the anterior, lateral, and superoposterior facets, respec- tively. There is no tendon attached to the posterior facet. Be- tween the posterior facet and gluteus maximus muscle, the subgluteal maximus bursa (SMaB) can be found. The muscles in the lateral region are divided into 2 layers. The origins and the insertions of those muscles are summarized in Table 1. The supercial layer, from anterior to posterior, is formed by the tensor fascia lata and gluteus maximus muscle. The trian- gular interval between these 2 muscles is lled with fascia lata overlying the gluteus medius muscle (Fig. 5). This supercial layer is also called deltoid of the hip joint,reminiscent of

13

The tendons of the gluteus minimus

” reminiscent of 13 The tendons of the gluteus minimus FIGURE 2. Figure shows the anterior

FIGURE 2. Figure shows the anterior synovial recess (***). Under

normal circumstances, the amount of

is kept at a

demonstration. Reproduced with permission from Ultrasound

for Regional Anesthesia, www.usra.ca.

synovial uid in the

recess

minimum. This

gure

shows a hip

with effusion for

© 2013 American Society of Regional Anesthesia and Pain Medicine

American Society of Regional Anesthesia and Pain Medicine FIGURE 3. Muscles (M) around hip joint. The

FIGURE 3. Muscles (M) around hip joint. The femoral head and neck (in dotted line) and the schematic of femoral neurovascular bundle are shown here for reference. V indicates femoral vein; A, femoral artery; N, femoral nerve. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

the deltoid muscle of the shoulder. The iliotibial (IT) tract is a thickening of the fascia lata commencing at the level of GT, where three-fourths of gluteus maximus muscle and tensor fas- cia lata insert into it. The IT tract passes along the posterolateral aspect of the thigh and inserts in the Gerdys tubercle of tibia. The deep layer comprises gluteus medius and minimus muscles. The anterior two-thirds of gluteus medius muscle des- cends distally and forms a tendon that inserts into the inferior aspect of the lateral facet of the GT. The posterior portion of the muscle gives rise to a strong tendon, which inserts into the posterosuperior facet (Fig. 4). The gluteus minimus tendon inserts onto the anterior facet of the GT. The tendons of gluteus minimus and medius can be considered the rotator cuffs of the hip joint, analogous to the shoulder joint. In both situations, the tendons are covered with bursa against friction (Table 2). The similarities between the 2 regions are important in the un- derstanding of the pathophysiology of GTPS. 14 19 In the lateral hip region, 3 groups of bursae are described consistently: the SMaB, the subgluteal medius bursa, and the subgluteal minimus bursa. 8,9,20,21 The function of the bursae is to serve as a cushion against friction between tendons and fas- cia lata. The SMaB is situated lateral to the GT, deep to the fascia lata, gluteus maximus muscle, and its tendon. Contrary to the belief of a single bursa, the SMaB is typically subdivided into up to 4 separate bursae. The deep SMaB bursa, often referred as the trochanteric bursa,is the largest and most consistent among these subdivisions (Fig. 6A and Video, Supplemental Digital Content 3, http://links.lww.com/AAP/A74, which shows layer by layer the 3 groups of subgluteal bursae in the lateral hip region [reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca]). Other SMaBs are the su- per cial subgluteal maximus, secondary deep subgluteal maxi- mus, and gluteofemoral bursae (Fig. 6B). The subgluteal medius bursa is associated with the anterosuperior portion of the GT separating the gluteus medius tendon from either the distal insertion of gluteus minimus and/or the lateral anterior surface of the GT (Figs. 6C, D; Video 3). The subgluteus mini- mus bursa lies deep to the gluteus minimus insertion on the an- terior aspect of the GT, in close proximity to the inferior

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Peng

Regional Anesthesia and Pain Medicine Volume 38, Number 4, July-August 2013

Pain Medicine • Volume 38, Number 4, July-August 2013 FIGURE 4. Figure shows the 4 facets

FIGURE 4. Figure shows the 4 facets of great trochanter. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

insertion of the hip joint capsule into the base of the femoral neck (Fig. 6E; Video 3).

Patient Selection

Intra-articular hip injection is considered for the manage- ment of a wide variety of hip disorders, including osteoarthritis, rheumatoid arthritis, and acetabular labral tears. 22,23 Osteoar- thritis is the most common joint disorder. Not all patients with

radiographic evidence of osteoarthritis are symptomatic. 4 Patients with osteoarthritis of the hip classically present with anterior or inguinal pain that increases with joint movement and is relieved, although incompletely, with rest. Although pain arising from the osteoarthritis of the hip can occur at night, hip pain at night may instead re ect tumors, infection, chronic in- ammatory arthritis, or crystal-induced arthropathies. Physical examination is important to rule out other causes of hip pain or pain referred from the spine. Patients indicated for intra-articular

TABLE 1. Origin and Insertion of the Muscles in the Lateral Hip Region

Muscle

Origin

Insertion

Gluteus maximus

Outer surface of ilium behind the posterior gluteal line, adjacent posterior surface of the sacrum and coccyx and sacrotuberous ligament Outer edge of the iliac crest between ASIS and the iliac tubercle Outer surface of ilium, between iliac crest and posterior and middle gluteal line Outer surface of ilium between middle and inferior gluteal line

Majority inserted into the IT band, some to the gluteal tuberosity of the femur

Tensor fascia lata Gluteus medius

IT band Anterior tendon to lateral facet and posterior tendon to superoposterior facet of GT Anterior facet of GT

Gluteus minimus

ASIS indicates anterior superior iliac spine.

Regional Anesthesia and Pain Medicine Volume 38, Number 4, July-August 2013

Ultrasound in Pain Medicine/Hip

Number 4, July-August 2013 Ultrasound in Pain Medicine/Hip FIGURE 5. Figure shows the muscles and fascia

FIGURE 5. Figure shows the muscles and fascia in the lateral hip region. Reproduced with permission from USRA.

injection are those with moderate to severe pain and disability, with poor response to conservative management, and those not a surgical candidate either because of age or comorbidity. 4,23 Injected medications may include corticosteroids, local anes- thetics, and viscosupplements (VSs). Evaluation of the patient with GTPS reveals patient with lateral hip pain, distinct tenderness about the GT (jump sign), Trendelenburg sign, positive Ober test, and Patrick-Faber test (exion, abduction, and external rotation). There is a paucity of physical signs that are highly specic to GTPS, and the specic- ity and sensitivity of these clinical features mentioned above have not been validated. 9 Both magnetic resonance imaging and ultrasound are very useful in the evaluation of the gluteal ten- dinopathy, tendon tears, or presence of bursitis. 8,9,24

Sonoanatomy and Injection Technique for Hip Joint

The technique for revealing the anterior recess of hip joint

is anterior oblique sagittal technique; that is, the transducer po-

sition is aligned with the axis of the femoral neck. 25 The patient

is placed in supine position with the hip in neutral position,

and the groin is exposed as medial as pubic symphysis. Either curvilinear or linear probe can be used, but the author prefers

a curvilinear probe as it gives a panoramic view of the anterior

recess and femoral neck even in an obese patient. The rst scan is to locate the femoral neurovascular bundle in the infraingu- inal region (Fig. 7A; Video, Supplemental Digital Content 4, http://links.lww.com/AAP/A75, which shows step-by-step how to obtain the sonoanatomy of the anterior recess [reproduced with permission from Ultrasound for Regional Anesthesia, www.usra. ca]). In this view, the femoral head and acetabulum can usually be seen underneath the iliopsoas muscle and its tendon. The trans- ducer is then rotated to a position coaxial to the femoral neck (Fig. 7B; Video 4). The scan is then optimized in a way such that the following structures can be well dened: femoral head, neck, and joint capsule. A 3.5-in, 22-gauge spinal needle is inserted in-plane from lateral to medial direction. The target is the synovial re- cess underneath the joint capsule between the femoral head and neck (Fig. 8; Video, Supplemental Digital Content 5, http://links.lww.com/AAP/A76, which illustrates step-by-step the injection technique for intra-articular injection of hip [repro- duced with permission from Ultrasound for Regional Anesthe- sia, www.usra.ca]). Before the needle insertion, it is advisable to survey the potential needle path with Doppler scan for any un- suspected vessel (Video 5). The needle is inserted until bone is contacted and is then withdrawn 1 to 2 mm to avoid engaging the needle tip in the posterior capsule. Monitoring the spread of the injectate real time throughout the injection is important to en- sure the injectate is spread within the joint space (Video 5). The medication used is 5 mL of local anesthetic with steroid, such as 2% lidocaine and 40 mg methylprednisolone acetate. Alterna- tively, 5 mL of VS can be injected.

Accuracy and Ef cacy of Intra-articular Injection of Hip

Depending on whether the approach is anterior or lateral, the accuracy of the landmark-based technique ranged from 52% to 80%. 26,27 In addition to the low accuracy, Leopold et al 27 dem- onstrated that the risk of piercing the femoral nerve from the blindanterior approach was 27%, and the needle tips were within 5 mm of the femoral nerve in 60% of the needle

TABLE 2. GTPS: A Bursitis or Rotator Cuff Disease

Shoulder

Hip

Similarity between shoulder and hip anatomy Tendons Bone attachment Impingement Bursa Evidence supporting cuff disease as etiology Bursitis is secondary to initial pathology at tendinous attachments

Evidence of bursitis in GTPS Presence of tendinopathy or tendon tears in GTPS

Supraspinatus Greater tuberosity Coracoacromial arch Subdeltoid, subacromial bursa

Gluteus medius, gluteus minimus Greater trochanter Fascia lata, IT tract Subgluteus maximus bursa

Rationale behind rotator cuff tendonitis, 12,13 supported by radiological evidence 14 Uncommon 15 17 Very common 17

Peng

Regional Anesthesia and Pain Medicine Volume 38, Number 4, July-August 2013

Pain Medicine • Volume 38, Number 4, July-August 2013 FIGURE 6. Figures show the bursae in

FIGURE 6. Figures show the bursae in the lateral hip region layer by layer. Panel B is a close up of panel A. A indicates supercial SMaB; B, deep SMaB; C, secondary deep SMaB; D, gluteofemoral bursa; M, muscle. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

insertions. In contrast, the accuracy of ultrasound-guided injection was 97% to 100%. 25,28 In those studies, contrast-enhanced uo- roscopy 25 or computed tomographic scan 28 was used as the vali- dation tools. For ultrasound-guided injection, the ideal site for needle tip is the junction between the femoral head and neck. 29 Five randomized controlled trials (RCTs) examining the analgesic efcacy of intra-articular hip steroid injection have been published, and all injections were performed under image

Four are posi-

guidance (uoroscopy = 3, ultrasound = 2).

tive trials with improvement in pain and functions. 31 33,35 One

possible explanation for the negative study 34 is the potential bias in the study design, as the patients were told that they

30

35

268

would be given priority for surgery if their pain worsened after injection. Current data from available RCTs and other uncon-

trolled studies 30 36 demonstrate strong evidence that steroid in- jection can provide a short-term (1 3 months) reduction in pain. The analgesic ef cacy of VS was recently examined in a systematic review. 37 Although the experience from the 14 case series including 1094 patients supported the analgesic ef cacy of VS in patients with arthritic hip pain, the results from the ran-

domized trials were different. Of 5 randomized trials, 3 included saline as the control, 32,35,38 1 compared VS with local anes-

thetic only,

ferent molecular weights. 40 All of the 3 studies comparing VS

39 and another compared 2 preparations of VS of dif-

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Regional Anesthesia and Pain Medicine Volume 38, Number 4, July-August 2013

Ultrasound in Pain Medicine/Hip

Number 4, July-August 2013 Ultrasound in Pain Medicine/Hip FIGURE 7. A, Sonoanatomy of the infrainguinal hip

FIGURE 7. A, Sonoanatomy of the infrainguinal hip region. The position of the transducer is shown in the insert. A indicates femoral artery; V, femoral vein. B, Sonoanatomy of the anterior hip region when the transducer is placed in the long axis of the femoral neck. The arrowheads indicate the anterior recess. The position of the transducer is shown in the insert. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

with saline did not nd a difference in the analgesic ef cacy between the treatment groups. Therefore, the authors concluded that VS could not be recommended as standard therapy in pa- tients with hip osteoarthritis for wider populations, and there- fore the indications remained a highly individualized matter.

Five retrospective studies have examined the increased in- fection risk of hip replacement following a prior intra-articular

hip injection (Table 3).

that the rates of supercial and deep infection were 30% and 10% compared with 7.5% and 0% of the matched cohort (pa- tients with total hip arthroplasty without prior intra-articular steroid injection). However, subsequent publications did not conrm the increased risk from intra-articular injection. One study suggested that an interval of less than 6 weeks between the injection and hip replacement was a risk factor for deep infection.

The earliest publication 41 revealed

41

45

43

Sonoanatomy and Injection Technique for GTPS

The patient is placed in lateral decubitus position with the injection site as the nondependent side. A linear ultrasound probe is preferred unless the patient is of very high body mass index. The key landmark structures are GT (anterior, lateral, and posterior facet), IT band, gluteus medius, and minimus tendons.

facet), IT band, gluteus medius, and minimus tendons. FIGURE 8. Ultrasonography shows the anterior recess (

FIGURE 8. Ultrasonography shows the anterior recess (*) as the target. Small arrows outline the joint capsule, and arrowheads indicate the needle. The insert shows the position of the transducer and the needle. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

© 2013 American Society of Regional Anesthesia and Pain Medicine

The rst scan is to obtain a transverse view of the GT and the insertion of the gluteus medius tendon (lateral and posterolateral facets) and gluteus minimus tendon (anterior facet). A sharp-pointed ridge separates the anterior and lat- eral facets (Fig. 9; Video, Supplemental Digital Content 6, http://links.lww.com/AAP/A77, which shows step-by-step how to obtain the sonoanatomy of the target for peritendinous injec-

tion of gluteus medius and minimus tendons [reproduced with per- mission from Ultrasound for Regional Anesthesia, www.usra.ca]). The transverse view is useful to differentiate the gluteus ten- dons, but the long-axis view is valuable in revealing the space between the IT band and the gluteus medius tendon. The IT band is a well-de ned hypoechoic layer supercial to the glu- teus medius tendon (Fig. 9; Video 6). Careful examination of the gluteus medius tendon may demonstrate radiological fea- tures suggestive of pathology such as hypoechogenicity, loss of brillary pattern, tear, and the presence of enthesophytes or calci- cations. 46,47 For the gluteus minimus tendon, the transverse view is sufcient to reveal the supercial and deep aspect of the tendon (Fig. 9; Video 6). Most of the GTPS is related to the pathology of gluteus medius tendon, and the target is between the IT band and the gluteus medius tendon. 47 After obtaining a long-axis view of the gluteus medius tendon and IT band, a 22-gauge, 3.5-in spi- nal needle is inserted in-plane toward the caudal direction (Fig. 10). Hydrolocation with normal saline should show the injectate spread between the IT band and gluteus medius ten- don. The injectate is 3 mL of local anesthetic with steroid, such as 0.25% bupivacaine and 40 mg methylprednisolone acetate. Alternatively, a transverse view is obtained, and the needle is inserted in-plane from posterior to anterior. The potential ad- vantage of the latter method is that it allows peritendinous injec- tion of both the anterior and posterior tendons of the gluteus medius muscle. For the gluteus minimus peritendinous injec- tion, the needle is inserted in-plane from posterior to anterior after a transverse view of the tendon is obtained (Fig. 10).

Accuracy and Ef cacy of Injection for GTPS

The landmark-based technique was validated once in the literature. 48 Using bursagram under uoroscopy as the validation tool, the GT was contacted by the needle in only 78%, and the lo- cation of the needle tip was correct in 45% of cases on the rst needle placement. 48 One of the major criticisms is that the bursa is dened by soft-tissue plane. Previous study using x-ray

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Peng

Regional Anesthesia and Pain Medicine Volume 38, Number 4, July-August 2013

TABLE 3. Risk of Injection Following Hip Arthroplasty With Previous Intra-articular Steroid Injection

 

Matching

THR With

Location of

Authors

Study Period

Cohort

Previous Injection

Procedure

Infection

Kaspar and de V de Beer 41 Sreekumar et al 42 McIntosh et al 43 Chitre et al 44 Sankar et al 45

1995

1998

Yes

40

XR

Overall: 30 vs. 7.5% Deep: 10 vs. 0%

1997

2004

Yes

66

XR

NS

1998

2002

Yes

217

XR

NS super cial and deep

1996

2000

No

36

OR

Super cial-1

2002

2009

No

40

OR

Superifcial-1

THR indicates total hip arthroplasty; XR, radiological suite; OR, operating room; NS, no signi cant difference.

to conrm the location of contrast in the subacromial bursa sug- gested that x-ray was unreliable in locating a bursa when the result was validated with cadaver dissection. 49 Not surprisingly, a subsequent multicenter randomized controlled study comparing the uoroscopy-guided and blind steroid injection for the GTPS did not show any analgesia advantage of the image-guided tech- nique over the blind technique. 50 In contrast, ultrasound is a valu- able tool in dening the anatomy and pathology of the gluteal muscles and tendons in the trochanteric region. 46,51,52 At pres- ent, literature on the ultrasound-guided injection for GTPS is

scant, let alone the validation study. Given the simplicity of the landmark-based technique and the lack of literature on the ultrasound-guided technique, the author's rst-line approach is to perform the injection for GTPS with landmark-based tech- nique with the following exceptions: history of previous failed response to landmark-based injection, inability or difculty to de- ne the GT by palpation, or when gluteal minimus tendon is the main pathology. A number of investigations examining the effect of in- jection as the primary treatment modality for GTPS have been

jection as the primary treatment modality for GTPS have been FIGURE 9. A, Ultrasonography shows the

FIGURE 9. A, Ultrasonography shows the junction (* ) between the anterior and lateral facets of the GT (dotted line). The position of the transducer is shown in the insert. B, Ultrasonography shows the gluteus medius tendon in short axis. The position of the transducer shown in the insert is posterior to that shown in A. C, Ultrasonography shows the SMaB. Note that the axis of the transducer is aligned with the long axis of the IT band as shown in the insert. D, Ultrasonography shows the gluteus minimus tendon. Note that the position of the transducer is anterior to that shown in A. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

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Regional Anesthesia and Pain Medicine Volume 38, Number 4, July-August 2013

Ultrasound in Pain Medicine/Hip

Number 4, July-August 2013 Ultrasound in Pain Medicine/Hip FIGURE 10. A, Ultrasonography shows the target for

FIGURE 10. A, Ultrasonography shows the target for the peritendinous injection for gluteus medius. The dashed arrow shows the path of the needle inserted in-plane from cephalad to caudal direction. The insert shows the ultrasound probe position. B, Ultrasonography shows the target for the peritendinous injection for gluteus minimus. The dashed arrow shows the path of the needle in plane from posterior to anterior direction. The insert shows the ultrasound probe position. Reproduced with permission from Ultrasound for Regional Anesthesia, www.usra.ca.

published.

domized trials. 50,54,55 In those case series, most of the patients received only a single injection, and the visual analog pain scale was not even used as the outcome measure. The case series showed favorable short-term outcome (3 months) with symp- tom resolution, and the ability to return to activity ranged from 49% to 100% with steroid injection as the primary treatment modality. 53

One randomized trial examined a uoroscopy guided against blind injection without any placebo or nontreatment control. 50 By dening success with a positive categorical out- come (50% pain relief and satisfaction with the results), the outcomes at 3-month assessment were comparable in both groups (41% vs 47% in x-ray and blind group, respectively). Complication is rare and minor. Another large quasi-RCT recruited 229 patients with re- fractory unilateral GTPS sequentially assigned to 1 of the fol- lowing groups: a home training program (group A), a single local corticosteroid injection (group B), or a repetitive low- energy radial shock wave treatment (group C). 54 The response

Most of them are case series, and only 3 are ran-

9,53

© 2013 American Society of Regional Anesthesia and Pain Medicine

was measured on a 6-point Likert scale, and the treatment suc- cess was dened as either completely recovered or much im- proved. Subjects underwent outcome assessments at baseline

and at 1, 4, and 15 months. At 1 month, corticosteroid injec- tion (group B) resulted in the best improvement (success rates were 7%, 75%, and 13% for groups A, B, and C, respectively). However, the success rate of the injection group declined with time and was subsequently superseded by the other 2 groups at

4

and 15 months (success rates were 41%, 51%, and 68% at

4

months and 80%, 48%, and 74% at 15 months for groups A,

B, and C, respectively). Although this study conrmed the short- term analgesic effectiveness of steroid injection, treating physi- cians should be aware of the other conservative measures that could be of benet to those with refractory symptoms from GTPS. Finally, a recent pragmatic, multicenter, open-label ran- domized clinical trial evaluated the effect of corticosteroid

injections compared with expectant treatment (usual care, ie, physiotherapy and analgesic) in patients with GTPS in a pri- mary care setting. 55 One hundred twenty patients were ran- domly allocated to receive either local corticosteroid injections (n = 60) or usual care (n = 60). All patients were followed up for 12 months. At the 3-month follow-up, 34% of the pa- tients in the usual care group had recovered (de ned as totally or strongly recovered) compared with 55% in the injection group (adjusted odds ratio = 2.38; 95% con dence interval [CI], 1.14 5.00; number needed to treat = 5). Reduction in pain severity at rest and on activity was greater in the injection group, with the adjusted difference in pain at rest of 1.18 (95% CI, 0.31 2.05) and in pain with activity of 1.30 (95% CI, 0.322.29). The secondary outcomes (Western Ontario and McMaster Universities Arthritis Index pain and function mea- sures) showed a greater decrease in pain in the injection group as well. At the 12-month follow-up, differences in outcome were no longer present. Aside from a short period with super- cial pain at the site of the injection, no differences in ad- verse events were found. In conclusion, both the case series and randomized trials supported the safety and short-term analgesic efcacy (3 months) of steroid injection for GTPS.

CONCLUSIONS

Intra-articular injection of the hip can be reliably per- formed with ultrasound guidance, targeting the anterior syno- vial recess. In contrast, the landmark-based technique is unreliable and subjects the patient to risk of soft-tissue or nerve injury. The evidence supporting the short-term analgesic ef - cacy of intra-articular steroid injection is strong. However, con- trolled trials did not support the use of VS for hip osteoarthritis. Because current evidence suggests that GTPS is associated with pathology of gluteus medius and minimus tendons, it is rational to direct the steroid injection to the tendons involved. Although the current landmark-based technique is at most mod- estly accurate, it offers an easy bedside method. Ultrasound- guided technique emerges as a rational technique allowing the de nition of the soft tissue involved. However, more studies evaluating the feasibility and ef cacy are required.

ACKNOWLEDGMENTS The author would like to thank Lucy Zhang and Bonnie Tang for their work on the illustrations.

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