O rthopaedic Summit 2017: Evolving Techniques Las Vegas, Nevada USA Injections are Cost Effective: I inject everyone prior to any arthroscopy! Allston J. Stubbs, M.D., M.B.A. Medical Director Hip Arthroscopy & Associate Professor Department of Orthopaedic Surgery December 5-9, 2017
Disclosure Consultant: Smith & Nephew • Stock: Johnson & Johnson • Research Support: Bauerfeind • Department-Division Support: Smith & Nephew, DePuy-Mitek, Arthex • Boards/Committees: AAOS, ABOS, AOSSM, ISHA, AANA, MASH, ISAKOS, Journal • of Hip Preservation Surgery
Do the Right Thing • Spike Lee Is more than a diagnostic tool, it’s a lifestyle
Plenty of Injection Champions • John Sekiya – AJR Am Journ Roentgenol 2012 • Thomas Byrd – Am J Sports Med 2004 • Carlos Guanche Combined over 50 years of experience!
Why Inject? • Diagnostic – Intraarticular vs Extraarticular – Organic vs Supratentorial – One needs a gold standard test: sensitivity and specificity – MRIs are now ~90% abnormal: high false positive rate • Therapeutic – Expanding options for treatment (not just steroids): local anesthetics, steroids, hyaluronic acid, PRP/ACP, Bone Marrow Aspirate, Amniotic – Patient Satisfaction: Improve treatment timeline – In office imaging: fluoroscopy, ultrasound, nanoscopy, open MRI
What’s the Success Rate of Hip Preservation Surgery? • ~80-85% Good to Excellent in the best of hands • Why not gain every percent you can for your patient?!
The Competition • If you don’t offer injection therapy, someone close to you will or not so close Turner & Knoepfler Cell Stem Cell June 2016
But I hate shots! Needle vs Knife
Winning Technique • Skin desensitization • 27G anesthetic • No pin cushion • Know osteology • Don’t over-fill • Instant cold pack technology • Proactive anti-inflammatory po
Limitations . . . • Time & Organization of work flow • Low wRVU • False negatives • Inflammatory response (Gadolinium worst offender especially with MRI-A) • Infection risk
Best time to initiate • Avoid MRI imaging within 6 weeks • Typically have imaging established before injections • Space out injections 4-6 weeks • Avoid intraarticular injections within 3 months of surgery [Wang Arthroscopy 2017]
Where to put them Our Favorites • Intracapsular • Iliopsoas bursa • Greater trochanteric bursa • Ischiofemoral space • Obturator internus muscle-tendon junction • Pudendal nerve • Lateral femoral cutaneous nerve
In Summary Don’t Left Be Holding the Bag • Make the best decision possible . . .based on injection management • Utilize technology • Inject every time!
Cool Future Hip Meetings Cancun May 2019 www.isakos.org Melbourne October 2018 www.isha.net
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