Is Fluoroscopy the True Gold Standard for Intra-Articular Joint Injections?

Betsy Divyak, MS, CCC-SLP, PA-S Beverly Speece, PA-C

Introduction Results Discussion Three relevant studies were identified and were evaluated using the Grade of Intra-articular hip joint injections are prescribed for pain, This capstone reviewed the existing evidence comparing the accuracy of Recommendations Assessment Development and Evaluation Scale- GRADE scale. diagnostic joint evaluation, joint fluid analysis, and contrast fluoroscopic guided and ultrasound guided intra-articular hip injections. injection for arthrography. Research has determined that Study/ Number of Medical Diagnosis Outcome Results Study Study Three studies were reviewed, and all received a LOW-grade following image guided hip injections have better accuracy and Study Type participants Measured Conclusion Grade analysis. This was based on study limitations related to sample size, lack outcomes as compared to landmark guided injections. Byrd et al., 50 participants -Osteoarthritis -Pain severity Statistically -A properly trained Low of consistency of injected material between modalities, injection 2014 significant in favor of clinician can perform Historically, fluoroscopy has been the gold standard for -50 fluoroscopic -Femoroacetabular -Patient ultrasound in regard ultrasound guided approach between modalities and lack of randomized sampling. imaging as many radiologists have been educated and guided injections impingement convenience to pain and hip injections with trained in this modality. Recently, ultrasound has become Internal convenience less pain and are the comparative -50 ultrasound -Postop hip pain -Patient preference patient preferred Fluoroscopy: more prevalent within the musculoskeletal community and controlled guided injections 49/50 patient method Advantages: Efficient, low-cost, established method for injections. frequency of use has increased in practice. study -Unexplained hip preference for Radiologist utilizes a “live image” for dynamic and functional assessment pain ultrasound vs. of the joint and structures. At this time, there has been no systematic review comparing fluoroscopic these image modalities in terms of accuracy and outcomes. Furtado et al., 71 total participants Rheumatic -Pain severity No statistical -Patient variables Low 2013 Diseases -Improvement significance for: should be considered Drawback: Exposure to ionizing radiation to patient, radiologist, and -23 for hip analysis Likert scale -Pain when determining support staff, poor resolution of soft tissues or distortion of overlapping Single blind the appropriate -Joint flexion -Improvement Likert controlled scales image modality. anatomy and procedure requires radiology suite requiring an additional Purpose: prospective -Percentage of appointment, adding direct and indirect medical expenses for the change of joint -Joint flexion study -Further research is patient. flexion needed Perform a comprehensive REVIEW of existing Martinez- 58 injections Not reported -Extravasation of No statistical -Both image Low research directly COMPARING the accuracy Martinez et al., contrast from joint significance for: modalities are Ultrasound: 2016 -26 fluoroscopic capsule -Extravasation of adequate for Advantages: Uses high frequency soundwaves to create soft tissue and effectiveness of FLOURSCOPY guided vs guided injections -Amount of air contrast diagnosis on CT or images and prevents exposure to radiation, improved differentiation of ULTRASOUND guided intra-articular HIP Retrospective bubbles introduced - Intra-articular gas MR arthrography comparative -32 ultrasound during injection bubbles soft tissue structures, no risk of allergy to contrast material and can be study guided injections -Further research is INJECTIONS. -CT/MR diagnosis of -Amount of contrast performed within a clinic office visit. needed joint space. needed for diagnosis Drawback: A patient’s high BMI can make differentiation of soft tissue Methods more difficult and effectiveness of ultrasound is highly dependent on its

• PubMed: 47 articles, Cochrane Databases: 6 articles / operator, who require training, accreditation, and skill maintenance. Google Scholar: 45 articles • Search terms: fluoroscopy-guided, ultrasound-guided, sonographic guided, hip injection, intra-articular, arthrogram, Literature hip joint and acetabula femoral joint for all studies published Conclusion between Jan 2000 and May 2019. Review Further research directly comparing the image modalities is recommended and may include: the accuracy of joint injection regarding https://injectionclinic.co.uk/latest-news the approach, anterior or posterior; the efficacy of joint capsule injection; the cost effectiveness of each modality; and patient • Direct comparison between image modalities of fluoroscopy satisfaction in terms of convenience and pain reduction. guided and ultrasound guided intra-articular injection into the hip Inclusion • All hip pathologies were included In the interim, a practicing clinician should be aware of this limited Criteria research and be knowledgeable of the advantages and disadvantages of each image modality as well as be familiar with options provided by their medical facilities and the experience of staff performing the injection.

• Studies comparing specified image modality to landmark or References “blind” injections • Studies of extra-articular joint structures, i.e. greater trochanter Exclusion or piriformis muscle Criteria

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Acknowledgments: Dr. Art Stiennon, Diagnostic Radiologist, Wm. S. Middleton VA. Contact Information: [email protected]