901 - Ultrasound Guided Lateral Approach Hip Injection in Clinical Practice

Case Diagnosis: Hip osteoarthritis with lateral approach injection

Case Description: 75-year-old obese female in inpatient rehabilitation after stroke developed refractory right groin pain exacerbated by hip flexion, which interfered with therapies. Imaging revealed prominent laterally projecting osteophyte, potentially causing femoroacetabular impingement syndrome. Pain management was consulted for corticosteroid injection. Lateral approach was favored over traditional anterior approach due to excessive anterior thigh tissue. She was positioned in left lateral decubitus position. Hip joint was visualized using a curvilinear probe over the greater trochanter. The needle was advanced perpendicular to the table and into the hip joint at the femoral head/neck junction under ultrasound guidance. Approximately 2mL of 1% lidocaine was injected for local anesthesia followed by 2mL 1% lidocaine and 40mg Kenalog. There were no complications, and the patient reported 100% pain relief.

Discussions:

Potential generators of generalized hip pain include intra-articular hip structures, extra-articular hip structures, or referred pain from lumbar spine, pelvic floor etc. Steroid injection is both diagnostic and therapeutic. Conventionally, the anterior approach is used, but with lateral approach the center of the acetabulum is approximately midway relative to the anteroposterior dimension of the thigh, allowing for needle penetration to the center of the hip joint avoiding the labrum. This reduces risk of neurovascular insult to lateral circumflex femoral artery and its branches making this approach safer in anticoagulated patients. It's also easier in obese patients with pannus obscuring anterior approach. Furthermore, this technique mitigates risk of contamination secondary to elevated concentration of bacteria native to the inguinal region. Additionally, this approach should be considered in patients with hip flexor spasticity or contractures that would make anterior approach precarious.

Conclusions:

This is the first publication to describe the lateral approach in clinical practice. This approach should especially be considered for anticoagulated patients, obese patients, and those with hip flexor spasticity or contractures.