2 thoughts on “Hip joint aspiration technique_ Rare “reply all””
avneesh.chhabra
Thank you, Brian!
Agree need to go to 18G and more in inferomedial recess of joint if not getting anything.
Nice video! You are looking wonderful.
Couple of more pearls-
* esp for hip replacement, we do some aspirations under CT guidance with metal reduction to be 100% sure that we are not missing a deep pocket, which may not be seen on US.
* One can use this beautiful vaccum assisted biopsy needle (angiotech- french needle) for synovial biopsy- it produces nice 15-16G cores- it locks with vacuum and one can aspirate fluid and great cores. I also use it for sensitive areas where one couldn’t use spring guided- e.g. bone lesion in long bone due to small space via bonopty outer needle, and face biopsy etc. This was brought to us by Jon Lewin, prev JHU chair to Hopkins and we also used it for MR guided biopsies.
I don’t typically reply to the whole group, but this is a good opportunity to share a technique that I’m hoping is widespread, but does not seem so in my experience.
Faroogh,
I advocate a larger gauge needle and use 20G or 18G, usually 3.5in spinal. 22G isn’t big enough and will yield dry taps at a greater rate.
If there is a large effusion, portable technique is critical, or when the fluid is decompressing into adjacent bursae or juxta-articular soft tissues, then US is great. With US for the hip I’m in long axis anterior hip, aiming for the anterior neck recess, approaching from caudal to cranial.
Fluoro guidance is my preference in all other cases using a technique described in this article by Eric Brandser (attached). He described this technique for aspirations for total hips, and using his technique my dry taps on total hips is extremely rare (a handful in 15 years) . I use the same technique in native hips with the intention to obtain fluid from the dependent portion of the joint. It should be made clear that a dry tap does not exclude infection in any joint. In the hip, infected fluid commonly decompresses into the IP bursa and in smaller joints (elbow commonly in my experience) the synovitis associated with infection overtakes the volume of the joint and becomes thickened and boggy and the amount of actual fluid is small.
US is less useful when trying to access that deep dependent portion of the joint because you lose the visualization of the needle. Fluoro much better for this technique.
Your success in any aspiration (abscess, hematoma, bakers, ganglion etc.) under any imaging guidance, will be increased by using the aspiration technique that I describe in this video (not to oversell this but I tell my residents and fellows that it will “change your life”…and it has… I have much more money, met and married the love of my life and have 2 lovely little girls since I learned this technique as a resident 20 years ago from IR Jedi Dr. Chuck Ray, who trained me at University of Colorado and now is the Chair at University of Illinois Chicago).
Almost all syringes will lock at the top end of their volume of aspiration. I will place the needle deep to the hip joint capsule (or anywhere else), lock the syringe in aspiration (harder to lock the larger the syringe and the more aspiration force produced), and then slowly withdraw the needle into the deep portion of the joint with the syringe locked in aspiration. This takes a little practice to lock these syringes in place while not manipulating the needle position, but it frees your hands up to manipulate the syringe while holding the US probe with the other hand. If using fluoro the second hand is free to high-five the patient, snap your fingers rhythmically, or drink a cup of coffee.
Here is the link to a video I just recorded in my study. Excuse the multiple chins I have accumulated since the pandemic started. They say quarantine creates drunks, chunks, or hunks, and I have checked off two of those boxes.
I use 22G 3” to 3.5” spinal needle
LAX curvilinear preferred but sometimes I only have a linear probe available which will work unless patient is very large.
Cindy J. Chang M.D., FACSM, FAMSSM
UCSF Clinical Professor
Fellowship Program Director, Primary Care Sports Medicine
Depts. of Orthopaedics and Family & Community Medicine
Past President, American Medical Society for Sports Medicine
Team Physician, UC-Berkeley
University Health Services, Specialty Clinic
Ph: 510-643-7177
Fax: 510-643-9790
Preferred gender pronouns: she/her/hers
cjchang
Agree. Sorry I misread the aspiration…absolutely would use larger gauge as discussed below.
I do not use Fluoro. Just MSKUS.
so appreciate the reply from Brian!!!
Cindy J. Chang M.D., FACSM, FAMSSM
UCSF Clinical Professor
Fellowship Program Director, Primary Care Sports Medicine
Depts. of Orthopaedics and Family & Community Medicine
Past President, American Medical Society for Sports Medicine
Team Physician, UC-Berkeley
University Health Services, Specialty Clinic
Ph: 510-643-7177
Fax: 510-643-9790
Thank you, Brian!
Agree need to go to 18G and more in inferomedial recess of joint if not getting anything.
Nice video! You are looking wonderful.
Couple of more pearls-
* esp for hip replacement, we do some aspirations under CT guidance with metal reduction to be 100% sure that we are not missing a deep pocket, which may not be seen on US.
* One can use this beautiful vaccum assisted biopsy needle (angiotech- french needle) for synovial biopsy- it produces nice 15-16G cores- it locks with vacuum and one can aspirate fluid and great cores. I also use it for sensitive areas where one couldn’t use spring guided- e.g. bone lesion in long bone due to small space via bonopty outer needle, and face biopsy etc. This was brought to us by Jon Lewin, prev JHU chair to Hopkins and we also used it for MR guided biopsies.
Best!
AC
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I don’t typically reply to the whole group, but this is a good opportunity to share a technique that I’m hoping is widespread, but does not seem so in my experience.
Faroogh,
I advocate a larger gauge needle and use 20G or 18G, usually 3.5in spinal. 22G isn’t big enough and will yield dry taps at a greater rate.
If there is a large effusion, portable technique is critical, or when the fluid is decompressing into adjacent bursae or juxta-articular soft tissues, then US is great. With US for the hip I’m in long axis anterior hip, aiming for the anterior neck recess, approaching from caudal to cranial.
Fluoro guidance is my preference in all other cases using a technique described in this article by Eric Brandser (attached). He described this technique for aspirations for total hips, and using his technique my dry taps on total hips is extremely rare (a handful in 15 years) . I use the same technique in native hips with the intention to obtain fluid from the dependent portion of the joint. It should be made clear that a dry tap does not exclude infection in any joint. In the hip, infected fluid commonly decompresses into the IP bursa and in smaller joints (elbow commonly in my experience) the synovitis associated with infection overtakes the volume of the joint and becomes thickened and boggy and the amount of actual fluid is small.
US is less useful when trying to access that deep dependent portion of the joint because you lose the visualization of the needle. Fluoro much better for this technique.
Your success in any aspiration (abscess, hematoma, bakers, ganglion etc.) under any imaging guidance, will be increased by using the aspiration technique that I describe in this video (not to oversell this but I tell my residents and fellows that it will “change your life”…and it has… I have much more money, met and married the love of my life and have 2 lovely little girls since I learned this technique as a resident 20 years ago from IR Jedi Dr. Chuck Ray, who trained me at University of Colorado and now is the Chair at University of Illinois Chicago).
Almost all syringes will lock at the top end of their volume of aspiration. I will place the needle deep to the hip joint capsule (or anywhere else), lock the syringe in aspiration (harder to lock the larger the syringe and the more aspiration force produced), and then slowly withdraw the needle into the deep portion of the joint with the syringe locked in aspiration. This takes a little practice to lock these syringes in place while not manipulating the needle position, but it frees your hands up to manipulate the syringe while holding the US probe with the other hand. If using fluoro the second hand is free to high-five the patient, snap your fingers rhythmically, or drink a cup of coffee.
Here is the link to a video I just recorded in my study. Excuse the multiple chins I have accumulated since the pandemic started. They say quarantine creates drunks, chunks, or hunks, and I have checked off two of those boxes.
share.icloud.com/photos/0iBcujn8T0gFGmCvm-sxqca0A
Hope this helps. This combination of techniques will give you the best chances of success for aspiration of any type.
Cheers,
Brian Petersen, MD
MSK Radiologist
Chair, Inland Imaging LLC
801 S. Stevens #N3 | Spokane, WA. 99204
Tel: 509.363.7788 | Fax: 509.363.7064|
I use 22G 3” to 3.5” spinal needle
LAX curvilinear preferred but sometimes I only have a linear probe available which will work unless patient is very large.
Cindy J. Chang M.D., FACSM, FAMSSM
UCSF Clinical Professor
Fellowship Program Director, Primary Care Sports Medicine
Depts. of Orthopaedics and Family & Community Medicine
Past President, American Medical Society for Sports Medicine
Team Physician, UC-Berkeley
University Health Services, Specialty Clinic
Ph: 510-643-7177
Fax: 510-643-9790
Preferred gender pronouns: she/her/hers
Agree. Sorry I misread the aspiration…absolutely would use larger gauge as discussed below.
I do not use Fluoro. Just MSKUS.
so appreciate the reply from Brian!!!
Cindy J. Chang M.D., FACSM, FAMSSM
UCSF Clinical Professor
Fellowship Program Director, Primary Care Sports Medicine
Depts. of Orthopaedics and Family & Community Medicine
Past President, American Medical Society for Sports Medicine
Team Physician, UC-Berkeley
University Health Services, Specialty Clinic
Ph: 510-643-7177
Fax: 510-643-9790
Preferred gender pronouns: she/her/hers