US-Guided Interventional Procedures for Total Hip Arthroplasty

Abstract

In patients with total hip arthroplasty (THA) with recurrent pain, symptoms may be caused by several conditions involving not just the joint, but also the surrounding soft tissues including tendons, muscles, bursae, and peripheral nerves. US and US-guided interventional procedures are important tools in the diagnostic work-up of patients with painful THA given that it is possible to reach a prompt diagnosis both directly identifying the pathological changes of periprosthetic structures and indirectly evaluating the response and pain relief to local injection of anesthetics under US monitoring. Then, US guidance can be used for the aspiration of fluid from the joint or periarticular collections, or alternatively to follow the biopsy needle to collect samples for culture analysis in the suspicion of prosthetic joint infection. Furthermore, US-guided percutaneous interventions may be used to treat several conditions with well-established minimally invasive procedures that involve injections of corticosteroid, local anesthetics, and platelet-rich plasma or other autologous products. In this review, we will discuss the clinical and technical applications of US-guided percutaneous interventional procedures in painful THA that can be used in routine daily practice for diagnostic and therapeutic purposes.

Keywords: arthroplasty; aspiration; corticosteroid; guidance; hip; iliopsoas; intervention; lidocaine; trochanter; ultrasound.

Figure 1

US-guided joint aspiration. (a) US image with convex probe on the long axis of the prosthetic neck and the needle (arrows) introduced with caudocranial approach to reach the prosthesis surrounded by effusion (asterisks); (b) six milliliters of synovial fluid has been collected in the syringe. F—femur; N—prosthetic neck; C—prosthetic cup; A—acetabulum.

Figure 2

US-guided periprosthetic biopsy. Ultrasound in the long axis (a) and short axis (b) of the THA showing the hypoechoic synovium (asterisks) surrounding the prosthesis. The needle (arrows) is introduced from the lateral aspect of the hip (c), with the in-plane technique, with a perpendicular direction compared to the classical joint aspiration, advancing horizontally to be tangent to the prosthetic neck. N—prosthetic neck, F—femur; C—prosthetic cup.

Figure 3

US-guided iliopsoas bursa injection. (a) The iliopsoas tendon (T) is scanned in the short axis at the acetabulum level; (b) the needle (arrows) is introduced laterally to reach the inferior part of the tendon; (c) once the target has been reached, the solution can be injected distending the iliopsoas bursa (asterisks). T—iliopsoas tendon; A—acetabulum; C—prosthetic cup.

Figure 4

US-guided trochanteric injection. (a) US image shows the trochanteric bursa distended by effusion (asterisks); (b) when the bursa is distended, it is an easy target for the procedure, introducing the needle (arrows) with the in-plane approach into the bursa under US monitoring.

Figure 5

US-guided injection of the LFCN. (a) The LFCN (arrowhead) is identified in the short axis superficial to the sartorius muscle (S), sliding the probe distal to the anterior superior iliac spine and the needle (arrows) is introduced with an in-plane lateral to medial approach, placing the tip just below the nerve. (b) The mixture of local anesthetic and corticosteroid can be injected, monitoring the spread of the solution (asterisk) around the nerve.