Discussion
trauma, lightheadedness, vasovagal symptoms, pain
SECONDARY OSTEOARTHRITIS, EVENT, COMPLICATION, SECONDARY, LEAKAGE
From this study, using the three approaches, namely anterior, anterolateral, and proximal anterolateral approaches for fluoroscopy-guided intra-articular hip injection, the overall successful intra-articular hip injection in a single attempt is 83%, with the anterior approach in 80%, anterolateral approach in 80%, and proximal anterolateral approach in 90%, we did not find the statistically significant differences between three approaches. The VAS during local anesthetic injection, VAS during intra-articular injection, radiation doses, radiation time of exposure, and the post-injection mHHS were similar in all three approaches without significant differences between groups.The accuracy rate in our study is 100% (including 83% single attempt, and 17% multiple attempts) intra-articular injection in all approaches during the use of fluoroscopic guidance and controlled injection. After the tip of the needle reached the femoral head-neck area, we found the contrast within the hip joint capsule in all patients, we could not observe any extra-articular leakage of the radio-opaque media. Compared to the previous study on the accuracy of each approach which reported a 93For the secondary outcome, we report no statistically significant difference in pain using a visual analog scale (VAS), both during local anesthetic injection and intra-articular hip injection between the three approaches, with the mean VAS of about 4 on both procedures. Even though the data focusing on pain during the procedure have not yet been previously reported, from the result of our study which showed a similar level of pain in all approaches, we can conclude that pain should not be a factor when considering the intra-articular hip injection approaches. Additionally, we’ve found no statistically significant difference in radiation exposure between the approaches. The average radiation doses (anterior of 0.56 ± 0.31, anterolateral of 0.53 ± 0.49, and proximal anterolateral of 0.49 ± 0.28 mGy) were less than another studyThroughout our study, we’ve only experienced one complication from ninety patients, which accounts for 1.1%. Details on the event were as follows, the patient was 29 years 29-year-old man diagnosed with secondary osteoarthritis of the right hip after trauma, he was allocated to the PAL injection group, and during the procedure, he experienced lightheadedness with normal vital signs and oxygen saturation. The symptoms recovered spontaneously after resting for 2 minutes, thus the symptom was considered to be caused by vasovagal symptoms. Following 2 weeks, the patient returned for follow-up with an improvement in mHHS from 58.3 pre-injection to 82.5 post-injection, no further complication was recorded. There were no serious complicationsComparing the pre-injection mHHS with post-injection mHHS, there was no statistically significant difference between the three groups. However, comparing the pre-injection score with post-injection mHHS in the same group, we reported a significant improvement in post-injection mHHS in all three groups. The results represent the improvement in very short-term outcomes of successful intra-articular steroid injection of the hip despite the approach being used. We did not evaluate the outcomes of longer follow-up because of the natural history of the intra-articular steroid injection that mainly affected only about 6–12 weeks after injectionHip injection using anatomic landmarks without ultrasonographic or radiographic assistance is useful and provides acceptable accuracyOur study is the first study to compare the efficacy between three commonly used techniques for intra-articular hip injection. No study compared the safety and outcomes of each injection approach. Additionally, all operating procedures were performed by a single fellowship-trained surgeon in hip arthroscopy, and the operative setting was standardized in every patient therefore the errors and variations in the injection techniques were minimized in our study.Our study is not without limitations, however. Due to the single well-trained performer in our study, our result may not be generalizable to a general orthopedic surgeon or general practitioners, however in providing detailed instruction on the operative setting and procedure we used in this study, we believed that similar result could be achieved even with less experienced practitioners. Furthermore, our study has a small sample size, which might not represent the general population, and has low power to detect the statistical significance. The very short-term outcomes were evaluated that could not evaluate the effect of each approach in terms of medium- to long-term therapeutic outcomes. Finally, the non-blind nature of our study design could cause bias in the outcome measure.