Intra-Articular Hip Injections in Obese Patients

[po_boy]

How do you all approach intra-articular hip injections in obese/morbidly obese patients?

Tape/ have someone retract the pannus, and go AP?

I feel like it's difficult to retract all of the pannus in these patients, and it doesn't feel right to stick a needle through some of the pannus in AP...

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[SSdoc33]

How do you all approach intra-articular hip injections in obese/morbidly obese patients?

Tape/ have someone retract the pannus, and go AP?

I feel like it's difficult to retract all of the pannus in these patients, and it doesn't feel right to stick a needle through some of the pannus in AP...

have the MA pull back the pannus, use a 5 or 7 inch needle. it shouldnt be a problem.

 

[po_boy]

have the MA pull back the pannus, use a 5 or 7 inch needle. it shouldnt be a problem.

Do you use AP approach? Or come in lateral?

 

[SSdoc33]

I never come in AP anyway. Start at the mid inter trochanteric line and follow the neck and hit os at junction of head and neck. You start inches lateral to the neurovascular bundle. Piece of cake

 

[callmeanesthesia]

I have the patient retract their own pannus. 10 degrees oblique which is what I always do anyway. 5” needle if necessary.

 

[knoxdoc]

... and don't forget to scrub away all the sub-pannicular candida. Then spend the next two weeks wondering if you seeded the joint. Its all well worth the $46.

 

[RoloTomassi]

... and don't forget to scrub away all the sub-pannicular candida. Then spend the next two weeks wondering if you seeded the joint. Its all well worth the $46.

This post elicited unpleasant olfactory memories

 

[Laryngospasm]

Hip injections are basically charity work at this point

 

[Agast]

Fat squeeze I have the patient retract their own pannus. 10 degrees oblique which is what I always do anyway. 5” needle if necessary.

“Here, hold this”

 

[Taus]

Can do it prone. Same technique. No pannus unless the backfat is exceptional

 

[DoYouEvenLiftBro]

Can do it prone. Same technique. No pannus unless the backfat is exceptional

If they’re that big, a 7 inch might not even reach them sometimes from a posterior approach

 

[Taus]

If they’re that big, a 7 inch might not even reach them sometimes from a posterior approach

I’d rather press down to hub a 7 inch posteriorly than retract a pannus and wipe away cottage cheese.

 

[BobBarker]

 

[Tboned]

If they’re that big, a 7 inch might not even reach them sometimes from a posterior approach

Jeez, I live in the Midwest and have never had to bust out a 7” for a hip, have for LTFESI though

 

[CleanUp]

Contrarian stance - I don’t offer it to these patients unless they understand the point is to get them moving more. We all know an injection won’t move the needle. I refer them to bariatric medicine. They come back after losing some pounds. We build momentum. I gain their trust because every pain physician before them just injected them. Then I take care of their knee and back pain. They tell their friends and family. These people come to me already knowing the deal. The follow up visits are social ones and quite enjoyable.

 

[drg123]

Lateral approach is helpful here.

 

[Taus]

All joking aside…. Prone approach is very easy on these patients. Target same as in AP. Lateral head/neck junction. Granted, I send most hips to sports med to do under ultrasound and my practice is 99% spine. You lose money every time you displace a spine injection from your schedule if otherwise full. I only get the ones where they can’t see/reach target due to body habitus….. Id seriously take hubbing a 7” straight down than deal with all that comes w pannus retraction, sterility concerns, stink, out of plane trajectory despite max pannus retraction, etc.

 

[Status Sciaticus]

Lateral approach is helpful here.
View attachment 385713

which book is this?
It looks like the furman layout.

 

[buddababa]

Just do it prone. I find a lot more comfort for the patients, my outcome is the same when I went the anterior traditional approach.

 

[BobBarker]

Sciatic nerve not in the way with prone?

 

[BobBarker]

 

[Agast]

Lateral approach is helpful here.
View attachment 385713

That looks a little high, wonder what the contrast spread looks like

 

[Taus]

Target in white. We come much closer to nerves on spinal injections so not really concerned. Not all that different from neurovasc bundle anteriorly

 

[BobBarker]

That is interesting. The new doctor in my office does his gt bursa injections in the area marked in blue. He is somewhat intentionally getting iliofemoral ligament also.

 

[Doctodd]

I’ll do it once…..45 degrees from
Inferolateral aporoach starting distal of femoral neck, and have patient hold their own pannus. Always with fluoro.

 

[RoloTomassi]

Just do it prone. I find a lot more comfort for the patients, my outcome is the same when I went the anterior traditional approach.

You do all prone? I kind of like this idea. I switched to doing shoulder prone. Contrast looks like the same ring around femoral neck?

 

[Ronin1]

I send all knee/hip/shoulder joints to the sports guys. They like them and send me enough RFAs to more than make up for the minimal reimbursement

 

[GlowInTheDark]

I always do lateral. Thick or thin. Target the 2-3/9-10 o’clock position of the femoral head. Takes about 30 seconds

 

[Taus]

You do all prone? I kind of like this idea. I switched to doing shoulder prone. Contrast looks like the same ring around femoral neck?

Yep, looks same

 

[RoloTomassi]

Yep, looks same

Nice, no risk of femoral vessels, not all up in their business. Will try

 

[Scottie_Dog]

I don’t understand the appeal of doing hip injections with lateral approach. Setup can be extremely difficult and the hips are typically superimposed. Drop a needle down in ap, supine or prone, doesn’t matter. Whole procedure takes less than a minute.

I might do one hip injection a month. Vast majority are done in office under ultrasound. Usually get referrals for hip injections under flouro for patients with large BMI.

 

[bedrock]

Granted, I send most hips to sports med to do under ultrasound and my practice is 99% spine. You lose money every time you displace a spine injection from your schedule if otherwise full.

Agree. I was so into sports as a resident, but much less as an attending. It just doesn’t pay.

Politically, My ortho partners want all the peripheral joints anyway. I generally comply because it keeps them happy and I make way more doing spine procedures, than CS knee injections.

The only peripheral joint/tendon procedures I routinely perform are PRP injections.

 

[RoloTomassi]

I feel like ultrasound hips aren't as effective. Probably operator overconfidence. I only do fluoro and a decent amount who have failed hip US respond when I do fluoro

 

[bedrock]

I feel like ultrasound hips aren't as effective. Probably operator overconfidence. I only do fluoro and a decent amount who have failed hip US respond when I do fluoro

Agree.

Speaking of my ortho partners, one of them does his hips under ultrasound, and I’ve repeated several and they did great after x ray guided IA hip injections.

 

[Doctodd]

Nice, no risk of femoral vessels, not all up in their business. Will try

If you can’t palpate the femoral artery, maybe you shouldnt be doing injections. Contrast should be mandatory.

 

[Taus]

Agree.

Speaking of my ortho partners, one of them does his hips under ultrasound, and I’ve repeated several and they did great after x ray guided IA hip injections.

Not as bad as sij

 

[SgtThunderfistMD]

I don’t understand the appeal of doing hip injections with lateral approach. Setup can be extremely difficult and the hips are typically superimposed. Drop a needle down in ap, supine or prone, doesn’t matter. Whole procedure takes less than a minute.

I might do one hip injection a month. Vast majority are done in office under ultrasound. Usually get referrals for hip injections under flouro for patients with large BMI.

How is the setup difficult? I get to literally tell the patient they can be prone or supine, i dont care. Splash prep just cephalad to trochanteric bursa. One lateral image. Numb and enter while tech spins to AP angle. 3 shots later, I'm landing in the joint. Guarantee I do mine on average less than a minute as well and never once had to even consider retracting pannus, thinking about femoral artery, nerve, vein, etc. Most of my patients who have had it done anterior by the older docs tell me my way is painless in comparison (may just be trying to be nice but I doubt it).

 

[bedrock]

Not as bad as sij

I’ve never tried that.

Are US guided SIJ unreliable?

Likely a moot point as they now don’t pay unless flouro/CT, but regardless I don’t know much about the reliability of US SIJ injections.

 

[GlowInTheDark]

I don’t understand the appeal of doing hip injections with lateral approach. Setup can be extremely difficult and the hips are typically superimposed. Drop a needle down in ap, supine or prone, doesn’t matter. Whole procedure takes less than a minute.

I might do one hip injection a month. Vast majority are done in office under ultrasound. Usually get referrals for hip injections under flouro for patients with large BMI.

Target hip is closer to intensifier and therefore smaller in appearance. Nothing difficult at all.

 

[RoloTomassi]

If you can’t palpate the femoral artery, maybe you shouldnt be doing injections. Contrast should be mandatory.

Yeah maybe I should change careers

 

[DoYouEvenLiftBro]

I feel like ultrasound hips aren't as effective. Probably operator overconfidence. I only do fluoro and a decent amount who have failed hip US respond when I do fluoro

Curved probe, color Doppler on over femoral neck, avoid vessel, numbing needle touch os, inject, see it stay under the capsule, if not redirect. Tougher on fluffy pts.

I do all the mri arthrograms in our group w this method, 100% on the test so far

 

[Laryngospasm]

And to think we used to do transarterial brachial plexus blocks.. good thing everyone’s arm didn’t fall off..

 

[Status Sciaticus]

I send all knee/hip/shoulder joints to the sports guys. They like them and send me enough RFAs to more than make up for the minimal reimbursement

Agree. I was so into sports as a resident, but much less as an attending. It just doesn’t pay.

Politically, My ortho partners want all the peripheral joints anyway. I generally comply because it keeps them happy and I make way more doing spine procedures, than CS knee injections.

The only peripheral joint/tendon procedures I routinely perform are PRP injections.

why do they want to do them if it pays so little?

 

[mdo1738]

which book is this?
It looks like the furman layout.

That’s definitely Furman

 

[Status Sciaticus]

That’s definitely Furman

yeah i didnt see it in the spine atlas. Didnt find a 'joint' atlas so I am wondering which book it was from

 

[bedrock]

why do they want to do them if it pays so little?

They don’t want to take the chance that they miss a surgery on a patient who gets partial relief from a joint injection.

 

[Agast]

I’ve never tried that.

Are US guided SIJ unreliable?

Likely a moot point as they now don’t pay unless flouro/CT, but regardless I don’t know much about the reliability of US SIJ injections.

I was told you cannot bill for ultrasound guided SI joints, that the procedure code implies fluoro was used.

 

[BobBarker]

Yes, I think a US SIJ is billed the same as a TPI with US.

 

[SSdoc33]

The $ is in the 99204, not the 20610 +77002. Hip inj takes maybe 10 seconds. This shouldn’t displace a spine inj. Just added on to what’s already there. If there is some arbitrary max number on your schedule, then that’s stupid. Same with shoulders, get, ac, etc

 

[knoxdoc]

The $ is in the 99204, not the 20610 +77002.

100% true and 100% sad. It's pathetic that it has come to this.