Introduction
Hip pain is a common pathology in the orthopedic surgeon’s office and should be determined as part of the initial diagnosis if it is of intra-articular, extra-articular, or referred origin to the hip. Pain in this region can occur in all age groups and be produced by multiple causes such as septic arthritis in a pediatric patient, a labral injury secondary to sports in a young person, or osteoarthritis in an elderly patient. Because of this, diagnosis is essential to decide the appropriate treatment. There are various diagnostic methods as well as safe and reproducible techniques for its performance, one of which is arthrocentesis1,2.
The hip is a deep joint, surrounded by various structures, which could be the source of pain but are also susceptible to injury during an invasive procedure such as a puncture. Diagnosis of pain can be difficult for the inexperienced orthopedist, as can perform procedures without skill or knowledge of anatomy. A useful and frequently used method for its study is arthrocentesis which has two main indications: Diagnostic and therapeutic3,4.
As a diagnostic procedure, it is used for obtaining samples for cytochemical study or culture, and in imaging for infiltration of contrast medium; and as therapeutic for drug infiltration5,6. Among these, the use of corticosteroids, viscosupplementation, or platelet-rich plasma for local action stands out in the management of symptoms of incipient osteoarthritis or acute monoarthritis7,8.
Different techniques have been reported to puncture the joint, from those based on anatomical references to those guided by fluoroscopy, ultrasound, or axial tomography9,10.
Leopold et al. reported the efficacy of two landmark-guided arthrocentesis techniques in a cadaveric study using 30 fresh-frozen specimens. By taking into account the neurovascular structures, they demonstrated that the anterior approach was safer for hip infiltration. The lateral approach was 20% more effective in drug storage within the hip joint space (60% and 80% respectively)11.
The aim of this article is to describe a safe and reproducible technique to perform fluoroscopy-guided hip arthrocentesis.
Materials and methods
A retrospective study was carried out reviewing the cases in which hip puncture was performed by the same surgeon in a period between January 2000 and December 2020 in 56 patients with painful hip patho logy. In 31 cases due to suspected infection to obtain a sample prior to revision surgery, 13 cases as part of the preoperative protocol for total hip arthroplasty due to the presence of osteosynthesis material due to previous fractures, 28 cases for infiltration of contrast medium for studies of image and 12 cases for intra-articular infiltration.
Technique description
- The procedure is performed in a fluoroscopy room (Fig. 1). The equipment required to perform this technique consists of aseptic material, sterile fields, sterile gown and gloves, a spinal needle, contrast medium for local injection, lidocaine with 2% epinephrine, and sterile gauze.
- The patient is placed in the supine position. Asepsis and placement of sterile fields are performed.
- After the preparation and dressing of the region, the safety zone for the puncture is identified, delimited by the anterior superior iliac spine, the lateral inguinal fold, and the upper edge of the greater trochanter. The hip is identified on an Antero-Posterior view with low-dose pulse fluoroscopy by placing a ring forceps on the anterior surface of the groin at the point to be punctured (Fig. 2).
- The greater trochanter is identified by palpation. The femoral artery pulse is identified and the puncture site is delimited 3 cm lateral to it on the femoral neck area.
- In an oblique direction from lateral to medial toward the femoral neck midway between the area of the femoral vessels and the greater trochanter, two milliliters of local anesthetic are infiltrated into the skin with the spinal needle over the anterior border of the greater trochanter (Fig. 3).
- The spinal needle is advanced in the direction of the superolateral rim of the acetabulum, guided by fluoroscopic vision until it is located in the middle third of the femoral neck into the space between the rim of the acetabulum and the lateral femoral head (Fig. 4).
- Confirm the intra-articular position of the needle tip by injecting contrast medium. In this position, the extraction of synovial fluid or the infiltration of the contrast medium or selected drugs is performed (Fig. 5).
- The spinal needle is withdrawn, and a disposable dressing is placed over the puncture site.
Figure 1. Fluoroscopy room with radiolucent table.
Figure 2. After skin asepsis and sterile field placement, the hip is identified under fluoroscopic control and anteroposterior projection.
Figure 3. Skin infiltration with local anesthetic.
Figure 4. Position of the needle before the infiltration of contrast medium under fluoroscopic vision.
Figure 5. The intraarticular position of the needle tip is confirmed by infiltrating contrast medium.
Results
Fifty-six punctures were performed in Fifty-three patients. In patients with previous hip arthroplasty with suspected infection, 31 patients were studied, (20 women and 11 men) with an age range between 31 and 89 years. In 22 cases, (39%) the infection process was confirmed by obtaining suspicious fluid. In all cases, a cytochemical study and cultures were carried out, without achieving the identification of pathogens in 8 cases (36.3%). In six cases, aseptic loosening was diagnosed, and revision surgery was performed at a time without an infection protocol.
Thirteen patients (six women and seven men) with an age range between 31 and 69 years were studied before primary arthroplasty due to the presence of osteosynthesis material five in the acetabulum and eight in the proximal femur with a diagnosis of post-traumatic osteoarthritis in five cases, avascular necrosis in four (two men and two women) and four due to failed osteosynthesis, (one intramedullary nail and three with dynamic compression system).
Therapeutic puncture for infiltration was performed on 12 patients, (six men and six women), all aged between 50 and 60 years with a diagnosis of Grade I-II osteoarthritis. In eight cases, a combination of steroids and lidocaine was infiltrated, and in four, viscosupplementation with hyaluronic acid; of this group of 12 patients, 8 (66%) persisted with pain and ended up in total hip replacement within 2 years.
As complications of the procedure, an infection at the puncture site was identified in 1 case (1.2%) that resolved with antibiotics for 2 weeks, extra-articular placement of contrast medium in 2 cases (2.4%), and residual pain in 3 cases (3.6%). No other complications were identified.
Discussion
Hip arthrocentesis allows the visualization of intra-articular structures in imaging studies, the obtaining of synovial fluid samples to confirm diagnoses, as well as the intra-articular infiltration of drugs. Despite being a commonly used method, there is no consensus in the literature. How it should be performed, so in this paper, we propose a simple, safe, and reproducible method that allows this procedure to be performed safely and effectively.
There are different reference methods for performing hip arthrocentesis, among which the use of anatomical marks on the skin, ultrasonography-guided, and oriented under fluoroscopic vision stand out. The main disadvantage of the first is that there is a greater risk of injuring the neurovascular structures close to the puncture site (femoral nerve and artery) as well as the impossibility of having a 100% reliable means to establish the intraarticular location of the tip of the needle12.
Different studies have shown the success of arthrocentesis when using ultrasound and fluoroscope-guided puncture; however, we must consider that these studies have been carried out by teams with training in hip ultrasound, a situation that is not easily reproduced in all hospitals. Ultrasound-guided hip puncture has gained popularity in the past 5 years due to the easy access of this equipment, even in the doctor’s office, and the lower exposure to radiation, the disadvantage is the training required and its costs13–16. The use of guided arthrocentesis under fluoroscopic control is recommended as a diagnostic and/or therapeutic method in hip pathology by the orthopedic surgeon.
Conclusion
The examples described here demonstrate the viability of the well-established procedure of hip arthrocentesis in the hands of an experienced orthopedic surgeon. This approach enables prompt identification and treatment of the patient with hip pain in a manner comparable to the workup of other painful monoarthropathies. The anterior approach, guided by fluoroscopy, results in a safe and effective mean for achieving intraarticular needle placement within the hip.
Funding
The authors declare that they have not received funding.
Conflicts of interest
The authors declare no conflicts of interest.
Ethical disclosures
Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.
Confidentiality of data. The authors declare that they have followed the protocols of their work center on the publication of patient data.
Right to privacy and informed consent. The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.
Use of artificial intelligence for generating text. The authors declare that they have not used any type of generative artificial intelligence for the writing of this manuscript nor for the creation of images, graphics, tables, or their corresponding captions.
