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

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 Orthopaedics

Disclosures • American Hip Institute a , AANA Learning Center Committee a , Adventist Hinsdale Hospital c , Arthroscopy Journal a , Amplitude c , Arthrex b,c,d , DJO Global d , Medacta b,c , Orthomerica d , Stryker b,c • a – boardmember; b – research support; c – consulting; d – royalty; e - stockholder Hinsdale Orthopaedics

Hip Pain • Diagnostic Challenge o Pain Generator…  Hip  Lumbar Spine  Knee  Bowel / Bladder / Reproductive Organs Hinsdale Orthopaedics

Hip Pain • Diagnostic Challenge o History & Physical o X-ray  Sensitivities depend on projection (Domayer et al Radiol 2011) o MRA  High sensitivity, moderate specificity  Tendency to over-diagnose Labral pathology (Freedman et al Arthroscopy 2006) Hinsdale Orthopaedics

Injections • Diagnostic / Therapeutic / Prognostic o Intra-articular  FAI  Labral pathology  Chondral pathology / OA o Extra-articular  Bursae  Abductors  IT Band  Iliopsoas  Abdominal aponeurosis Hinsdale Orthopaedics

Hinsdale Orthopaedics

Role for Diagnostic Injection • When you are not sure whether the pain is coming from within the hip joint! Hinsdale Orthopaedics

Physical Examination “ The diagnostic gold standard is still the history and physical.” Frank Jobe, M.D. Hinsdale Orthopaedics

Injections • Therapeutic o Krych et al KSSTA 2014  Freehand U/S or Fluoroscopic guidance  40mg methylprednisolone or 40mg/mL triamcinolone or 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 Hinsdale Orthopaedics

Injections • Prognostic o 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 Hinsdale Orthopaedics

Injections • Limitations of the evidence o Small # observational studies o Diverse patient populations with varying severity of hip pathology o Lack of control groups o Heterogeneity of injections o Lack of long term follow-up 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 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 Hinsdale Orthopaedics

Thank You www.AmericanHipInstitute.org Hinsdale Orthopaedics