Hip/Knee Injection Mr Andrew Armitage Horder 2013.

Hip/Knee Injection

Mr 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 ?