Episode 38 – Hip Ultrasound, Aspiration, and Injection

Seriously.

No really, we’re serious.  We understand that most of you practice in the ED and you may not be that excited about hip ultrasound, but trust us, this is pretty cool.  And if for no other reason, you should download because it’s Mark Goodman again.  Yeah, the guy that looks like Val Kilmer, but is way more smooth.  So go ahead…..expand your horizons.

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  • James Miller

    November 15, 2012, 10:17 pm

    Great Podcast!! Thank you!! Are any of you concerned about the use of bupivicaine intra-articularly? There have been reports of chondrolysis particularly in the shoulder and ankle joint following infusion of bupivicane in post operative patients. One of our orhopedic surgeons unfortunately had this complication himself requiring a shoulder replacement surgery. These cases have mainly been after 24-72 hr infusions but have prompted a warning from the FDA on this use. Some of our orthopedic colleagues have extapolated this data into the joint injection category and no longer use bupivicaine in the joint. There are animal studies suggesting that bupivicaine is toxic to the cartilage.

    • Hildy

      November 20, 2012, 5:26 am

      Thanks, this is great!

      James: one of my attendings was thinking that as well as a directly toxic effect, there may be an acute Charcot-joint effect leading to the destruction. There are many reports of chondrolysis in the knee as well.

      • Mark Goodman

        November 20, 2012, 5:01 pm

        James,
        Thanks for bringing up a interesting and contentious point. The literature shows that lidocaine or bupivacaine intra-articularly is associated with a toxic effect on chondrocytes in bovine and human models. The debate is if a single dose causes clinically significant toxicity to chondrocytes. Chu in 2008 looked at the effect of bupivacaine on cartilage and found and dose and time related toxic effect. They stated “Because of the expected dilutional effects of synovial absorption, intra-articular effusion and arthroscopic lavage fluids, these results give insight into why the long- term clinical use of bupivacaine as a single intra-articular injection has not been associated with chondrolysis”. Like you said, the main concern for chondrotoxic effects are from prolonged absorption due to continuous infusions, usually after surgery. Karpie in 2007 found a decrease in bovine chondrocyte viability after exposure to lidocaine. Dragoo in 2012 found that 1% lidocaine was worse than bupivicane or ropivacaine, neither of which showed significant decrease in chondrocyte viability compared to control after a single exposure. There are plenty of ortopods and sports med docs still using lidocaine and bupivacaine for all of their joint injections. Not to say that this is the right thing to do, just that you are likely not outside the standard of care by doing so. The argument that I have heard supporting the continued use of lidocaine and bupivacaine is that in a joint with severe OA the chondrocytes are already toast. The cartilage is not coming back, so you don’t have much to lose. So here is how I interpret and use this data:
        - In my Sports Med clinic I use ropivacaine when possible (a national shortage has made this difficult). I did not mention this in the podcast because I have not had much success getting it in my ED, and I think the jury is still out as to if it matters for a single injection.
        - I will only inject a joint with steroid/ local a couple times per year
        - When consenting the patient for an injection I discuss the risk of chondrotoxicity

        I hope this helps. Happy ultrasounding.

        Mark

        • James Miller

          November 20, 2012, 7:45 pm

          Mark, thanks for the detailed response. You are the MSK master!!

  • Mark Goodman

    November 20, 2012, 5:04 pm

    One correction on the podcast. The size of needle you are going to want is a 22g 3.5 inch spinal needle. Consider using a 5 inch 22g on larger patients. This will give you a easier time with needle visualization because your angle will not be as steep.

    Mark

  • Matt Dawson

    November 20, 2012, 9:06 pm

    Posted for Mark in response to a tweet by Casey Parker:

    Casey,
    Thanks for the question. The normal range for the adult is 5-7 mm measuring the anterior joint recess (that includes both layers of the capsule and the fluid in between). Each layer of the hip capsule (anterior and posterior) should be about 2- 4mm thick and up to 2mm of fluid in the recess is physiologic. In peds the numbers are >5mm total or greater than 2mm difference between sides. One of the great things with MSK ultrasound is to be able to compare with the normal side. Significant asymmetry in the adult or peds should get you thinking of an effusion.

    Mark

  • Eric

    December 26, 2012, 10:57 am

    Excited to try this and not wait for an ortho consult