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

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

Trochanteric Bursitis

Trochanteric Bursa

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

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

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

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

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

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

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

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

Meralgia paraesthtica Lateral cutaneous nerve of thigh Tinnels Neuralgic pain

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

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

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

Viscosupplementation Variable outcome Grade 1-2 oa changes Help 50 -60 % Can last up to a year Can be painful £2-300

Under Patella

Under patella

Arthroscopy portal

Pes anserine bursitis iliotibial band syndrome Analgesia Rest Physio Targeted injection

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

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

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

Questions ?