hip/knee injection

Hip/Knee InjectionMr Andrew Armitage

Horder 2013

Hip injections• Trochanteric Bursitis• Meralgia paraesthetica• Intraarticular - Diagnostic• Target injections - iliopsoas

Trochanteric Bursitis

Trochanteric Bursa

Incidence• 1.8 per 1000 per year• 4th to 6th decade• Women• Obesity• Low Back pain• Osteoarthitis

Causes• Very often no clear cause• Trauma• Microtrauma (overuse)• Osteoarthritis• Post THR• Leg length inequality

Presentation• Patient usually complains of hip pain• Pain over lateral side of hip (over trochanter)• Pain when lying on side• Worse with flexn/extn, increased activity• Not usually in groin• Can radiate down lateral thigh• Post surgery

Differential Diagnosis• Trochanteric bursitis• Snapping Iliotibial band• Back pain / radiation• Hip arthritis• Meralgia Paraesthetica• Gluteus medius inflammation

Investigation• Rareley required initially– Pathognomic-pain over trochanter

– Ultrasound– Hip Xray–MRI

Treatment• Conservative

– NSAID – Analgesia– Reduced activity– Topical anti-inflammatories

• Physiotherapy– Massage– Ultrasound

• ESWT– Shockwave therapy

Treatment• Injection– Local anaesthetic – 10ml 0.5% Marcaine– Steroid - 80 mg depo-medrone– Big needle– Relaxed Patient– Target point– Hit bone

Treatment - outcomes • Conservative

– Majority settle

• Injection– 60 – 90 % success– Can take 4 wks– Can be repeated

• Surgery– Very rarely indicated

Meralgia paraesthtica

• Lateral cutaneous nerve of thigh

• Tinnels • Neuralgic pain

Knee injections• Intraarticular

– Osteoarthritis– Inflammatory disease– Chondromalacia patellae – be carefull

• Extraarticular– Pre-patella neuroma– Pes anserine bursitis– Iliotibial band syndrome– Patella tendonitis– Prepatella bursitis

Intraarticular injections• Steroids – 10ml 0.5% marcaine– 80mg Depomedrone

• Viscosupplementation– Synvisc 1– Durolane

Steroids• Help 50 % with arthritic change• Can take 4-6 wks to have effect• 5-10 % worse short period of time• Tiny risk of infection• Very variable benefit duration• Not if imminent TKR - ^ risk of infection• More benefit with effusion• Very unfit

Viscosupplementation• Variable outcome• Grade 1-2 oa changes• Help 50 -60 %• Can last up to a year• Can be painful• £2-300

Under Patella

Under patella

Arthroscopy portal

Pes anserine bursitisiliotibial band syndrome

• Analgesia• Rest• Physio• Targeted injection

Pre-patella neuroma

• In bursa• Very sensitive • Can feel tissue lump/band• 2ml local and steroid• ? Immediate effect

Pre-Patella bursitis

• Inflammatory• Infective• NSAID/rest/ ? Abs• Generally don’t inject• Occaisionally surgery

Patella Tendonitis

• Rest• Analgesia• Physiotherapy / U/S• Shockwave therapy• Do Not Inject

Questions ?