Intra-Articular Injection of the Hip Joint—Anterior Approach

Indications and Clinical Considerations

The hip joint is susceptible to developing arthritis from a variety of conditions that all have the ability to damage the joint cartilage. Osteoarthritis of the joint is the most common form of arthritis that results in hip joint pain ( Fig. 122.1 ). However, rheumatoid arthritis and posttraumatic arthritis also are common causes of hip pain secondary to arthritis. Less common causes of arthritis-induced hip pain include the collagen vascular diseases, infection, villonodular synovitis, and Lyme disease. Acute infectious arthritis usually is accompanied by significant systemic symptoms, including fever and malaise, and should be easily recognized by the astute clinician and treated appropriately with culture and antibiotics rather than injection therapy. The collagen vascular diseases generally manifest as a polyarthropathy rather than a monoarthropathy limited to the hip joint, although hip pain secondary to collagen vascular disease responds exceedingly well to the intra-articular injection technique described later.

The majority of patients with hip pain secondary to osteoarthritis and posttraumatic arthritis pain report pain localized around the hip and upper leg. Activity makes the pain worse; rest and heat provide some relief. The pain is constant and is characterized as aching. The pain may interfere with sleep. Some patients note a grating or popping sensation with use of the joint, and crepitus may be present on physical examination.

In addition to the previously mentioned pain, patients with arthritis of the hip joint often experience a gradual decrease in functional ability with decreasing hip range of motion, making simple everyday tasks such as walking, climbing stairs, and getting in and out of cars quite difficult. With continued disuse, muscle wasting may occur and a “frozen hip” caused by adhesive capsulitis may develop.

Plain radiographs are indicated for all patients with hip pain. On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and/or ultrasound imaging of the hip is indicated if aseptic necrosis or occult mass or tumor is suggested ( Fig. 122.2 ).

Clinically Relevant Anatomy

The rounded head of the femur articulates with the cup-shaped acetabulum of the hip (see Fig. 122.1 ). The articular surface is covered with hyaline cartilage, which is susceptible to arthritis. The rim of the acetabulum is composed of a fibrocartilaginous layer called the acetabular labrum, which is susceptible to trauma should the femur be subluxed or dislocated. The joint is surrounded by a capsule that allows the wide range of motion of the hip joint. It is lined with a synovial membrane that attaches to the articular cartilage. This membrane gives rise to synovial tendon sheaths and bursae that are subject to inflammation. The hip joint is innervated by the femoral, obturator, and sciatic nerves. The major ligaments of the hip joint include the iliofemoral, pubofemoral, ischiofemoral, and transverse acetabular ligaments, which provide strength to the hip joint ( Figs. 122.3 and 122.4 ). The muscles of the hip and their attaching tendons are susceptible to trauma and to wear and tear from overuse and misuse.