Interventional MSK procedures: the hip

Abstract

Percutaneous musculoskeletal procedures are widely accepted as low invasive, highly effective, efficient and safe methods in a vast amount of hip pathologies either in diagnostic or in therapeutic management. Hip intra-articular injections are used for the symptomatic treatment of osteoarthritis. Peritendinous or intrabursal corticosteroid injections can be used for the symptomatic treatment of greater trochanteric pain syndrome and anterior iliopsoas impingement. In past decades, the role of interventional radiology has rapidly increased in metastatic disease, thanks to the development of many ablative techniques. Image-guided percutaneous ablation of skeletal metastases provides a minimally invasive treatment option that appears to be a safe and effective palliative treatment for localized painful lytic lesion. Methods of tumour destruction based on temperature, such as radiofrequency ablation (RFA) and cryotherapy, are performed for the management of musculoskeletal metastases. MR-guided focused ultrasound surgery provides a non-invasive alternative to these ablative methods. Cementoplasty is now widely used for pain management and consolidation of acetabular metastases and can be combined with RFA. RFA is also used to treat benign tumours, namely osteoid osteomas. New interventional procedures such as percutaneous screw fixation are also proposed to treat non-displaced or minimally displaced acetabular roof fractures.

Figure 1.

Ultrasound-guided hyaluronic acid injection for hip osteoarthritis. Longitudinal ultrasonographic scan below the inguinal ligament of the hip joint. The surfaces of the femoral head and the neck of the femoral bone are noted. The 20-gauge spinal needle is indicated with arrows. The accuracy of the injection is confirmed by direct visualization of a few millilitres of anaesthetic (lidocaine 1%) filling the capsule. Then, the hyaluronic acid is injected.

Figure 2.

Ultrasound-guided peritendinous corticosteroid injection. Tip of 22-gauge spinal needle (arrow) is placed at the surface of the lateral facet insertion of the gluteus medius tendon. Peritendinous corticosteroid injection is performed (arrowhead). Note the cortical irregularities of the surface of the greater trochanter.

Figure 3.

Ultrasound-guided platelet-rich plasma (PRP) injection. Tip of 22-gauge spinal needle (arrow) is placed in the lateral facet insertion of the gluteus medius tendon and intratendinous PRP injection is performed.

Figure 4.

(a, b) Iliopsoas impingement on acetabular component. (a) The injection is made under CT guidance in an extra-articular position at the anterior border of the cup in contact with the iliopsoas. (b) Post procedure CT scan with contrast-medium in the iliopsoas bursa.

Figure 5.

Image of a patient with a painful metastasis of the right iliac bone. The patient is in the prone position. CT scan image shows the multitoned expandable RF electrode deployment (arrow) in the expansive lytic lesion involving gluteal musculature and iliac muscle.

Figure 6.

(a–c) Patient with a painful lytic metastasis of the right acetabulum (a). The patient is in supine position. Under CT guidance, a vertebroplasty needle is advanced into the bone to reach the correct position inside the lesion, then polymethylmethacrylate (PMMA) is injected. (b) Coronal CT image obtained after cement injection shows a slight intra-articular PMMA leak (arrow). (c) Sagittal CT image obtained after cementoplasty shows good lesion filling.

Figure 7.

(a–c) Images in a patient with a painful metastasis with pathological fracture of the left iliac bone. (a) The patient is in the prone position on CT table. Radiofrequency ablation (RFA) is performed by using a multitined expandable RF electrode. (b) Axial CT after the RFA reveals microbubble formation in the treated area. (c) After RFA, bone cement is injected. Axial CT scan demonstrates the good lesion filling.

Figure 8.

(a, b) CT images of a 19-year-old male with an osteoid osteoma of the right acetabulum. The patient is in the supine position. (a) A 22-gauge spinal needle is inserted into the joint and 10 ml of normal saline mixed with contrast medium is infused into the joint space prior to the delivery of RF into the nidus to reduce thermal injury to the cartilage. (b) The straight RF electrode is in place, in the centre of the nidus. The 22-gauge spinal needle filling the capsule is also seen.

Figure 9.

(a, b) Percutaneous screw fixation of an acetabular roof fracture. (a) CT guidance permits the perfect position of the screw which was stopped before perforating distal cortex. (b) Axial CT scan shows the perfect field of view. The procedure is planned so the path of the screw will not injure neuromuscular structures. Courtesy of Dr N Amoretti.