1. Mr Andrew Armitage Horder 2013
Hip/Knee Injection
Mr Andrew Armitage
Horder 2013

2. Hip injections Trochanteric Bursitis Meralgia paraesthetica
Intraarticular - Diagnostic
Target injections - iliopsoas

3. Trochanteric Bursitis

4. Trochanteric Bursa

5. Incidence 1.8 per 1000 per year 4th to 6th decade Women Obesity
Low Back pain
Osteoarthitis

6. Causes Very often no clear cause Trauma Microtrauma (overuse)
Osteoarthritis
Post THR
Leg length inequality

7. Presentation Patient usually complains of hip pain
Pain over lateral side of hip (over trochanter)
Pain when lying on side
Worse with flexn/extn, increased activity
Not usually in groin
Can radiate down lateral thigh
Post surgery

8. Differential Diagnosis
Trochanteric bursitis
Snapping Iliotibial band
Back pain / radiation
Hip arthritis
Meralgia Paraesthetica
Gluteus medius inflammation

9. Investigation Rareley required initially
Pathognomic-pain over trochanter
Ultrasound
Hip Xray
MRI

10. Treatment Conservative Physiotherapy ESWT NSAID Analgesia
Reduced activity
Topical anti-inflammatories
Physiotherapy
Massage
Ultrasound
ESWT
Shockwave therapy

11. Treatment Injection Local anaesthetic – 10ml 0.5% Marcaine
Steroid - 80 mg depo-medrone
Big needle
Relaxed Patient
Target point
Hit bone

12. Treatment - outcomes Conservative Injection Surgery Majority settle
60 – 90 % success
Can take 4 wks
Can be repeated
Surgery
Very rarely indicated

13. Meralgia paraesthtica
Lateral cutaneous nerve of thigh
Tinnels
Neuralgic pain

14. Knee injections Intraarticular Extraarticular Osteoarthritis
Inflammatory disease
Chondromalacia patellae – be carefull
Extraarticular
Pre-patella neuroma
Pes anserine bursitis
Iliotibial band syndrome
Patella tendonitis
Prepatella bursitis

15. Intraarticular injections
Steroids
10ml 0.5% marcaine
80mg Depomedrone
Viscosupplementation
Synvisc 1
Durolane

16. Steroids Help 50 % with arthritic change
Can take 4-6 wks to have effect
5-10 % worse short period of time
Tiny risk of infection
Very variable benefit duration
Not if imminent TKR - ^ risk of infection
More benefit with effusion
Very unfit

17. Viscosupplementation
Variable outcome
Grade 1-2 oa changes
Help %
Can last up to a year
Can be painful
£2-300

18. Under Patella

19. Under patella

20. Arthroscopy portal

21. Pes anserine bursitis iliotibial band syndrome
Analgesia
Rest
Physio
Targeted injection

22. Pre-patella neuroma In bursa Very sensitive Can feel tissue lump/band
2ml local and steroid
? Immediate effect

23. Pre-Patella bursitis Inflammatory Infective NSAID/rest/ ? Abs
Generally don’t inject
Occaisionally surgery

24. Patella Tendonitis Rest Analgesia Physiotherapy / U/S
Shockwave therapy
Do Not Inject

25. Questions ?