Needle touches down on the distal aspect of the femoral head. I put in a drop of contrast and if it washes away I inject contrast under live for 1 to 2 seconds. If I get a classic Saturns ring appearance I switch over and inject the good stuff. Otherwise it’s repositioning the needle. I do a washout of 1 to 2 seconds live to make sure that I’m spreading the contrast and inject it subcapsular.
The problem is, those who aren't good at ultrasound see what they want to see and inject when it looks "good enough". With fluoro, the contrast doesn't lie
100% agree w this. I’ve seen plenty of NP’s and others use “ultrasound guidance” and not get anywhere close to the target location. It sounds like this is what is happening with the hip injection. If ur not using the right probe and the right angle, you will see a moving shadow and assume you are in the joint but may actually not be in the joint. I’ve also seen people use a 3.5 inch needle and think they’re in the capsule and a morbidly obese patient using ultrasound.
I don’t use flouro at all and I never will (was not fellowship trained and not interested in advanced procedures the pain management guys do), but now I’m interested in seeing peripheral joint injections with flouro. At this point, a hip joint injection takes about 10-15 minutes from walking in to walking out of the room (lie down, “drop em”, drape em, find the landmarks and mark em, sterilize and inject). The larger patients def take 15…
I’m in Canton. Swing by and check it out.
Fluoro is definitely easier and superior for hips and shoulders. Arthro grams are always definitive and super satusfying.
I’m around that area once a month. I’m gonna drop by (with way advanced notice) next time I’m there visiting family
I do them in lateral decub position. Line up the target hip within the contralat hip to create bullseye or "circle in circle" picture. Aim for the center of the bullseye. Should put you at the lateral femoral head or head/neck. Injection contrast. Inject injectate. Most of the time don't need lidocaine coming lateral approach. Zero risk of vasculature. Only gets slightly tricky if there is THA on contralat side then just use some fluoro manipulation and some out of plane needle driving to get lined up.
Yes from anterior approach. HN junction is a big area though, and sometimes you have to adjust the needle to get ideal arthrogram (contrast ring around the neck or flow between head and acetabulum) vs a "blob" of contrast which is inadequate. That's where I think it would be interesting to learn from an advanced ultrasonographer, if these two types of contrast patterns can be distinguished on ultrasound.
Really someone needs to do a study where they inject via ultrasound with omnipaque and then take a fluoro shot and compare if the operator can always distinguish intraarticukar versus outside the capsule.
pubmed.ncbi.nlm.nih.gov
pubmed.ncbi.nlm.nih.gov
That second study with US vs flouro for SIJ’s is spot on. I’ve done probably over 200 SIJ’s with ultrasound in the last year and have VERY variable success. I send it over to the pain guys and they use flouro and the pain is all gone (still injecting just the SI joint). I’ve made the argument before that we shouldn’t be doing SIJ’s with ultrasound. I try talking all my patients out of the “I don’t care, I want it now” by telling them it can be from the back, etc etc “and ultrasound is a hit or miss and I would never get an USG CSI in my SIJ”. As someone who’s not a beginner with ultrasound, I disagree when people say ultrasound is even remotely similar to flouro with SIJ injections. I even know guys who try facet joints n things with ultrasound and it drives me crazy…Ultrasound-guided hip injections: a comparative study with fluoroscopy-guided injections - PubMed
Level II, prospective comparative study.
really crappy study.
not blinded.
and the biggest negative is who did the ultrasound injection.
in this study, fluoro was superior to US. but of course, the usual defense will be "well, it has to be done in the hands of an expert ultrasonographer".Success Rate of Intra-articular Sacroiliac Joint Injection: Fluoroscopy vs Ultrasound Guidance-A Cadaveric Study - PubMed
Fluoroscopy clearly showed a higher success rate of intra-articular sacroiliac joint injection.
which kind of sounds like the same talk that PRP can only be done by, um, Dr Centeno to be beneficial......
I always inject both the SIJ and the SIJ ligaments for the reasons you mentioned.
What code to you use beyond 27096? TPI code?
20550
They always pay. I use 59 modifier so 20550-59, and with that modifier they always pay for the second code.
is mod 59 necessary in this instance? i have never used it. just add on
As far as I know.
I target really high. It’s the easier place to see the joint. I go lateral to medial until I find the PSIS and sacrum, look for the triangular appearing ligament between them (long posterior si ligament) and inject there. One of the pain guys told me to inject lower to spread the medication, but I can’t see the landmarks if I move lower…I’m sure there’s expert sonographers that can see and inject towards the middle/bottom, but I can’t. I always inject up higher for sure. I don’t like that injection under ultrasound…
