2017 - Donna Magid, M.D., M.Ed.
FLUOROSCOPIC ‘ARTHROGRAM” (persisting common misnomer)
Hip‘arthrography’ is a vague term used to refer to multiple studies: Injection of Gad or radiographic contrast for MR or CT respectively, aspiration to r/o infection, or injection of Marcaine/steroids to test pain relief. MAKE SURE you know what is really requested.
*ASPIRATION requires culture material; joint fluid (>1 ml in Port-a-Cult); ‘dry taps’ require second attempt, injecting 5-10 cc nonbacteriostatic saline to both(hopefully) loosen up existing fluid and/or wash over affected surfaces before being re-aspirated..
*PAIN studies, inject 7-10 cc of (9 cc’s bupivacaine .5%, up to 2 cc Kenalog 40 (ie max of 80 mg in syringe, meaning less goes into patient—data supports risk of ostenecrosis at +100mg), 4-5 cc sterile water) . Post-injection allow the patient to relax while you clean up the prep tray (remove needles, dispose of betadyne-stained gauze-- pts. mistake it for heme and get light-headed), then assist patient upright, let them sit there a moment to make sure not tachycardic, light-headed, etc (keep hands on pt’s upper arms, make eye contact, size up); assist off table, and ask him/her to ambulate around the room and to report their perception of change (remind them “Better or the same, test has no wrong answers”). Ask them to make note of when, hours or days later, the hip returns to the usual baseline of pain, ‘like you felt yesterday”.
*MR Goal is “1:200” Gad:Dilutant” in syringe—actual concentration at MR once injected depends on how much joint effusion or other injected fluids (ie radiographic contrast from localizing) is already in the joint. About .1 cc Gad (in TB syringe) will be injected into tip of 20 cc syringe holding (7 cc Marcaine, 13 cc sterile water; or all sterile water).
AP view sufficient, if no recent films available. If recent MRI or CT available, check reports/results (is there really a joint effusion? Was fracture, AVN, tumor, found/suspected?)
2) INFORMED CONSENT
Risks include pain, (since you are using a needle); bleeding, infection, or allergy to materials (which are theoretically possible but extremely rare), retained material and non diagnostic tests (everything was performed correctly but the answer is still unclear.
- If marcaine injection add: impaired proprioception/loss of sensation leg and explain they must take extra care ambulating, going over door sills, up steps for a few days ‘as if foot were asleep’; risk of chondrolysis (cartilage damage) which has only been seen in constant infusions post-op. If known cardiac hx consider adding risk of cardiotoxicity which has also only been seen with higher intravascular concentrations, ie highly unlikely from intraarticular injection (but if you hit the femoral vein all bets off…).
- For pain study, explain that pain appearing to be in the hip “may in fact be from the back, SI joint, or knee”; and that this is a test with no “wrong” answers: “You may feel better, worse, or the same; all of which will help your physician figure this out with you”. Patients getting pain relief get only a few hrs (from the anesthesia), or days or even weeks (if steroids kick in over time).
- TIME OUT confirms pt. ID (wrist band), DOB, and joint/side of interest-document on Consent. Patient is asked to tell you name and birth date, while you look at wrist band.
The standard prep tray requires a container of betadine, a small container of alcohol, a twenty-five gauge pale blue skin needle (prefer 1.5 inch to 5/8 inch length), a twenty-gauge 1.5-inch needle, a 16 gauge purple needle, and a twenty gauge (yellow) spinal needle. The purple needle is used to draw up fluids; do not show this to the patient (turn/interpose your back). One five cc syringe (for Lidocaine ; add 2nd syringe if aspirating fluid); a 10 cc syringe for radiographic contrast; a twenty cc syringe and fifty cm tubing for 1:200 Gad contrast.
- If this is a pain study, bupivacaine .5% (~9 cc) (Marcaine or Sensorcaine), Kenalog 40 (2 cc ie 80 mg max; usually comes in 1 cc bottles), sterile water (~5-8 cc) will be needed.
- ‘LABEL’ all syringes; use same sizes for same fluids all the time so middle (10 cc) size syringe w/ tubing always =s radiographic contrast, big (20) one = meds, tiny (5cc) one= lidocaine, every time.
4a) NATIVE HIP
Put on non-sterile gloves. Position patient supine, leg extended (if very uncomfortable small triangle wedge under slightly flexed knees ok), tape toes together (inverted) to keep femoral bundle medial to work field. Approximate starting skin landmark is mid-inguinal fold although some pts’ femoral necks prove to be surprisingly cephalad or caudal to this skin crease.
- OBESE with pannus: desired point likely to be buried in overhanging belly, or in apposed folds of belly and thigh pannus, compromising ability to sterilize and stay sterile. There is a clear plastic band which attaches to the table top which may be big enough for some but not all larger pts. If not, and if pt. seems able/willing, help them position and use their hands (and your nonsterile-gloved hands) to retract their own pannus cephalad and towards other side, just enough to be comfortable and maintainable for ~10 min—and advise them you really need their assistance for optimal and fastest test, thanking them for their help. (Taping the pannus never works.)
- LOCALIZE: If the femoral neck from head-neck junction to inter-trochanteric line were a tic-tac-toe board, you’d want the junction of the outside and middle squares. Use mammo-dot (metal spot), and use an indelible pen to mark the spot.
- DOUBLE GLOVE and prep. Prep area with Betadine 3x – spiral out from marked spot to approximately six inch diameter with front and back of each of two-three sponges. While that dries, finish drawing up solutions (keeping activities out of pt’s sight lines—makes them anxious. Turn yr back and move up to pt’s head so they can’t watch) –
- 10 cc radiographic contrast in the 10 cc syringe, add tubing and run contrast to tip before returning to tray);
- 5 cc syringe of lidocaine 2%;
- and for pain studies, bupivacaine (Marcaine or Sensorcaine), approximately 8 cc’s (shoulder unlikely to take more than 7-10 cc, ditto hip, unless either previously dislocated/stretched by big effusions), 1-2 cc Kenalog 40, and ~5 cc H20 in the same syringe. (This last syringe will be cloudy, which helps to distinguish it from the other clear fluids on table—but LABEL).
Drape field, laying long axis of rectangular drape transversely so as to maximize sterile path-length from drape fenestration to you. With pale blue 1.5” twenty five-gauge needle and Lidocaine, raise wheal (quickly) and then go perpendicularly down assertively, compressing soft tissue as you inject to reach as deep as you can with this needle. (Going too slowly increases risk of infiltrating deep soft tissues of anterior thigh, which can anesthetize anterior leg nerves etc and impede ambulation. If you’ve ever had a pt. unable to walk for a week you won’t forget this).
Switch to the 20 gg (yellow) spinal needle, advance straight down with occluder stylet in, until you feel bone. Remove hub, insert tubing tip on 10 cc contrast syringe, get tech ready to fluoro, and give one brief test injection with quick look – intra-articular contrast flows away from needle, usually medially and laterally. If you are sure you are over the mid point of the femoral neck and yet there is no flow (blob hangs at tip), try withdrawing about half a millimeter to see if needle tip opening was occluded in the cambrium/periosteum. Never advance needle without stylus.
Once intra-articular position visually confirmed and documented (capture image for proof):
- PAIN, MR—inject 7-10 cc of (either Pain or Gad mix) as tolerated, watch pt’s face and ask ‘How are you doing?”. Make note of volume used; dictate as “9 cc of (9 cc marcaine .5, 2 cc Kenalog 40, 5 cc sterile water mix) were injected…”
- ASPIRATION- use empty 5 cc syringe to test for possible aspirate once spinal needle intraarticular. If fluid returning, remove as much as possible for culture, Gram, and cell count. If needle is proven intra-articular but no free fluid, inject up to ten cc’s of non-bacteriostatic saline (more if ‘falling in’, ie tolerated in distended capsule) and try again. If this does not produce fluid for culture, “walk” the needle tip gently over a few millimeters of bone. (Cannot culture if much less than1 ml fluid, Port-a-Cult bottle).
- Once the needle is removed, reassure the patient “it will not be going back in”; proceed with cultures. Wipe skin clean with alcohol, briefly check groin for hematoma and intact pulses.
- 1 cc into Portacult bottle with an unused needle (white lab form, Core/Bacteriology Lab) for ‘C&S, Gram stain, aerobic, anaerobic, if more fluid available few cc to purple top for ‘body fluid cell count and diff” (pink stat sheet, for Microbial. Lab).
- TUBES WITH printed PT. LABEL go into main body of plastic specimen bag; paperwork into smaller pouch part of bags. One tube and one form per bag. HAND DELIVER yourself to Labs.
4b) Injecting HIP ARTHROPLASTY
Anterior approach more difficult because needle cannot be visualized against background of metal stem. However, to localize, you can criss-cross two metal clamps, one transversely under and one obliquely on top of, pt: take a Halsted (straight) clamp and slide it under the pt’s hip and gluteal area, perpendicular to the long axis of the patient and the table, so that it cross-hairs the mid femoral neck target. Leave this under the patient for visual checks during procedure. Take a second clamp and place it obliquely over the estimated target area of the anterior groin, and fluoro to establish the mid neck position as above. Proceed with skin mark and procedure as above. The spinal needle should advance until it hits metal, at which point test injection is performed. You may need slightly larger test volume and more pressure; the capsule is small and scarred following surgery. It will also take longer fluoro to confirm visualization of contrast on each side of the neck; flow will not be as apparent as in a native hip but if contrast appears to each side of the metal neck it is intra-articular. Proceed as above, with aspiration, saline, and/or needle tip culture. Be reminded post-op hips, unless grossly infected, rarely have free fluid; rub needle along metal, inject sterile saline. Make note of same on paperwork.
The doctor is not finished until the pt. is returning to dressing room. Pt is NEVER to be alone. Help pt. to sit up and dangle legs over edge, standing directly in front of the patient. KEEP HANDS on upper arms or ready to grab pt if unsteady, watch facial color, eyes, feel pulse: post-procedure vaso-vagal reactions surprisingly common. If they attempt to get off table too fast tell them it’s ‘like steering through a near-miss in your car, you do it perfectly but then when it’s over you get all shaky”. Make a little chit-chat, and then when pt ready help them off table, again be ready to grab --attempts to fall or faint surprisingly common.
If Pain study, ask them to ‘test-drive’ ambulating in room, and see if they can give you preliminary opinion. Advise them to keep track of when any change sets in and how long it lasts “until you feel like you did yesterday”. Also remind them gait and proprioception will be impaired even if they think it isn’t.
If pre MR/CT, pt goes in wheelchair taken by Tech or by you, NOT Escort (too slow).
If Aspiration, advise them “test takes 3-4 days” ("10 or 12" if P.Acnes culture) and that they should call their doctor after that.
Donna Magid MD, M.Ed Comments, queries, corrections: call (410) 428-5530