Injections are Cost Ineffective! What a Waste of Time! Just Operate! - - PowerPoint PPT Presentation

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Injections are Cost Ineffective! What a Waste of Time! Just Operate! - - PowerPoint PPT Presentation

Dec 21, 2022 206 likes •353 views

Injections are Cost Ineffective! What a Waste of Time! Just Operate! Benjamin G. Domb, M.D. Medical Director, American Hip Institute Director of Orthopedics, Adventist Hinsdale Hospital Ajay C. Lall, M.D. American Hip Institute Hinsdale

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SLIDE 1

Hinsdale Orthopaedics

Injections are Cost Ineffective! What a Waste of Time! Just Operate!

Benjamin G. Domb, M.D.

Medical Director, American Hip Institute Director of Orthopedics, Adventist Hinsdale Hospital

Ajay C. Lall, M.D.

American Hip Institute

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SLIDE 2

Hinsdale Orthopaedics

Disclosures

  • American Hip Institutea, AANA Learning

Center Committeea, Adventist Hinsdale Hospitalc, Arthroscopy Journala, Amplitudec, Arthrexb,c,d, DJO Globald, Medactab,c, Orthomericad, Strykerb,c

  • a – boardmember; b – research support; c – consulting; d – royalty; e - stockholder
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SLIDE 3

Hinsdale Orthopaedics

Hip Pain

  • Diagnostic Challenge
  • Pain Generator…
  • Hip
  • Lumbar Spine
  • Knee
  • Bowel / Bladder / Reproductive

Organs

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SLIDE 4

Hinsdale Orthopaedics

Hip Pain

  • Diagnostic Challenge
  • History & Physical
  • X-ray
  • Sensitivities depend on projection

(Domayer et al Radiol 2011)

  • MRA
  • High sensitivity, moderate

specificity

  • Tendency to over-diagnose Labral

pathology

(Freedman et al Arthroscopy 2006)

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SLIDE 5

Hinsdale Orthopaedics

Injections

  • Diagnostic / Therapeutic / Prognostic
  • Intra-articular
  • FAI
  • Labral pathology
  • Chondral pathology / OA
  • Extra-articular
  • Bursae
  • Abductors
  • IT Band
  • Iliopsoas
  • Abdominal aponeurosis
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SLIDE 6

Hinsdale Orthopaedics

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SLIDE 7

Hinsdale Orthopaedics

Role for Diagnostic Injection

  • When you are not sure

whether the pain is coming from within the hip joint!

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SLIDE 8

Hinsdale Orthopaedics

Physical Examination

“The diagnostic gold standard

is still the history and physical.”

Frank Jobe, M.D.

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SLIDE 9

Hinsdale Orthopaedics

Injections

  • Therapeutic
  • Krych et al KSSTA 2014
  • Freehand U/S or Fluoroscopic guidance
  • 40mg methylprednisolone or 40mg/mL triamcinolone
  • r 6mg/mL betamethasone + local anesthetic

** IAHI of steroid injection has limited therapeutic benefit

  • 37% diminished pain at 2 weeks
  • 6% sustained relief at 6 weeks
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SLIDE 10

Hinsdale Orthopaedics

Injections

  • Prognostic
  • Ayeni et al KSSTA 2014
  • Fluoroscopic guidance
  • 0.25% bupivicaine + 40mg methylprednisolone
  • Pain diary 2 weeks post IA inj
  • Compared mHHS pre-op to 6 mo post-op

** Negative response to IAHI may predict poor outcomes after FAI surgery

– No long term f/u to assess non-operative mgmt

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SLIDE 11

Hinsdale Orthopaedics

Injections

  • Limitations of the evidence
  • Small # observational studies
  • Diverse patient populations with varying severity
  • f hip pathology
  • Lack of control groups
  • Heterogeneity of injections
  • Lack of long term follow-up
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SLIDE 12

Hinsdale Orthopaedics

Role for Diagnostic Injection

  • In the minority of cases when you are not

sure whether the pain is coming from within the hip joint!

  • But…
  • With a good history and physical exam, we

can establish the source of pain in the majority of cases

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SLIDE 13

Hinsdale Orthopaedics

SUMMARY

Role for diagnostic injections in diagnostic mysteries Lack of high-quality research to support IA injection prior to all hip arthroscopy History / Physical / Imaging is enough in experienced hands, in most cases

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SLIDE 14

Hinsdale Orthopaedics

Thank You

www.AmericanHipInstitute.org