Letters to the Editor

Letters to the Editor

Zoe Paskins, et al. Clinical effectiveness of one ultrasound guided intra-articular corticosteroid and local anaesthetic injection in addition to advice and education for hip osteoarthritis (HIT trial): single blind, parallel group, three arm, randomised controlled trial. MJ 2022;377:e068446.

Abstract

Objective: To compare the clinical effectiveness of adding a single ultrasound guided intra-articular hip injection of corticosteroid and local anaesthetic to advice and education in adults with hip osteoarthritis.

Design: Pragmatic, three arm, parallel group, single blind, randomised controlled trial.

Setting: Two community musculoskeletal services in England.

Participants: 199 adults aged ≥40 years with hip osteoarthritis and at least moderate pain: 67 were randomly assigned to receive advice and education (best current treatment (BCT)), 66 to BCT plus ultrasound guided injection of triamcinolone and lidocaine, and 66 to BCT plus ultrasound guided injection of lidocaine.

Interventions: BCT alone, BCT plus ultrasound guided intra-articular hip injection of 40 mg triamcinolone acetonide and 4 mL 1% lidocaine hydrochloride, or BCT plus ultrasound guided intra-articular hip injection of 5 mL 1% lidocaine. Participants in the ultrasound guided arms were masked to the injection they received.

Main outcome measures: The primary outcome was self-reported current intensity of hip pain (0-10 Numerical Rating Scale) over six months. Outcomes were self-reported at two weeks and at two, four, and six months.

Results: Mean age of the study sample was 62.8 years (standard deviation 10.0) and 113 (57%) were women. Average weighted follow-up rate across time points was 93%. Greater mean improvement in hip pain intensity over six months was reported with BCT plus ultrasound-triamcinolone-lidocaine compared with BCT: mean difference -1.43 (95% confidence interval -2.15 to -0.72), P<0.001; standardised mean difference -0.55 (-0.82 to -0.27). No difference in hip pain intensity over six months was reported between BCT plus ultrasound-triamcinolone-lidocaine compared with BCT plus ultrasound-lidocaine (-0.52 (-1.21 to 0.18)). The presence of ultrasound confirmed synovitis or effusion was associated with significant interaction effect favouring BCT plus ultrasound-triamcinolone-lidocaine (-1.70 (-3.10 to -0.30)). One participant in the BCT plus ultrasound-triamcinolone-lidocaine group with a bioprosthetic aortic valve died from subacute bacterial endocarditis four months after the intervention, deemed possibly related to the trial treatment.

Conclusions: Ultrasound-guided intra-articular hip injection of triamcinolone is a treatment option to add to BCT for people with hip osteoarthritis.

Comments of Dr. Chockalingam

  1. Our incidence of primary OA hip is not as high as in the Caucasian population. This article may not reflect our patient population.
  2. Advanced secondary OA hip is a common presentation in younger patients due to ankylosing spondylitis, AVN hip, and inflammatory arthropathy. These patients often need THR and not injections.
  3. We do use diagnostic injections into the hip to differentiate the pain that is coming from the lumbar spine.
  4. Use of ultrasound vs injection under x-ray control. No specific advantage for USS. Reason: as it is done for diagnostic purposes, it is best done by the Ortho team.
  5. We the Ortho surgeons also have courses to get trained on USS guided injections. We will get trained too soon!
Dr.-S.-Chockalingam

Dr. S. Chockalingam

Senior Consultant, Orthopaedic Surgeon

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