Efficacy of Intra-articular Steroid Injection in Patients with Femoroacetabular Impingement
A 42-year-old male patient (height 170 cm, weight 63.7 kg) visited our pain clinic with complaint of severe right groin pain. Two years earlier, the patient had been diagnosed with bilateral cam type FAI and underwent arthroscopic surgery in the right hip after hip magnetic resonance imaging which showed fibrocystic change of the right femur and superior labral tear and minimal joint effusion on both hips. The recurrent pain began about 1 year prior to his visit and walking was impossible. The degree of pain was 10/10 on the visual analogue score system (VAS, ranging from 0 = no pain to 10 = absolutely intolerable pain) and the Oxford hip score (OHS, function of hip joint, excellent = below 19, good function = 19-26, fair = 27-33, poor = 33 or more) was 47/60. During the physical examination, the straight leg raising test (SLR) was right 45° and left 80°. The FABER test and anterior impingement test (flexion and internal rotation of knee) were all positive at the right hip. The frog lateral view of the X-ray showed left superior labral calcification and an osteophyte at the right femur neck. In addition, the head-neck offset of the left femur was decreased (). The alpha angle in the translateral view was 78.2° (). The ultrasonographic finding showed mild effusion and capsular thickness. The patient had no previous past medical history and took tramadol 200 mg, NSAIDS 200 mg and gabapentin 600 mg per day. We decided to perform IA steroid injection under C-arm guidance. Written informed consent was received after sufficient explanation about the procedure and related complications. With the patient in the supine position, C-arm fluoroscopy was focused on the hip joint in the anterolateral view. After insertion of a 22 gauge spinal needle, 0.75% ropivacaine 5 ml and triamcinolone 40 mg injection was achieved in the right hip joint (). The patient visited our clinic again checking his VAS, OHS and satisfaction scores (5-point Likert scale; 5 = very satisfied, 4 = somewhat satisfied, 3 = neither satisfied nor dissatisfied, 2 = somewhat dissatisfied, 1 = very dissatisfied) at 2, 4, 8 and 12 weeks after injection (). The patient took NSAIDS 200 mg intermittently during the 12 weeks. Although moderate right hip pain remained, the patient could walk and return to work.\nA 59-year-old female patient (height 161 cm, weight 59 kg) visited our pain clinic with left hip joint pain. The patient had been taking medications for rheumatoid arthritis. The patient had been diagnosed with pincer type FAI about two years prior to her visit. The hip AP (anteroposterior) view of the X-ray showed suspicious FAI, with labral calcification and excessive coverage by the superior margin of both acetabula (). The pain site was in the lateral and subgluteal area of only the left hip joint. The degree of pain was 7/10 on the VAS and the OHS was 26/60. During the physical examination, the SLR was right 90° and left 90°. FABER test was positive on the left side. However, the anterior impingement test was negative for both hips. No abnormality was found in the ultrasonographic image. We decided to perform ultrasound guided IA steroid injection. Written informed consent was received after sufficient explanation of the procedure and related complications. With the patient in the supine position, the hip was internally rotated about 15-20°. An ultrasound convex probe (2-5 MHz, MicroMAXXTM, Sonosite, USA) was aligned with the long axis of the femoral neck, including the acetabulum and the femoral head. A 22 gauge spinal needle was then advanced under direct ultrasonographic guidance into the anterior synovial recess at the junction of the femoral head and neck (). Injection of 0.75% ropivacaine 5 ml and triamcinolone 40 mg in the left hip joint was performed. The patient visited our clinic again checking her VAS, OHS and satisfaction scores at 2, 4, 8 and 12 weeks after injection (). The patient took her previous medications for rheumatoid arthritis during the 12 weeks and additional analgesics were not prescribed. Three months after the injection, the pain in the trochanteric area was partially reduced.\nA 50-year-old male patient (height 175 cm, weight 73 kg) visited our pain clinic with complaint of pain in both hip joints. The pain had been ongoing for one year prior to his visit. The patient had been prescribed NSAIDS and muscle relaxants at a local pain clinic whenever he felt pain. The pain in the right anterior groin area was more severe than that of the left side. Because of the hip pain, the patient could not sit crossed-legged on the floor. The degree of pain was 3/10 on the VAS scale and the OHS was 21/60. During the physical examination, the SLR was right 90° and left 90°. The FABER test and anterior impingement test were positive on both sides. The frog lateral view of the X-ray showed the possibility of mixed type FAI of the right hip (). The head-neck offset of the right femur was decreased and there was excessive coverage by the superior margin of the right acetabulum. The alpha angle in the translateral view was 75.3°. No abnormality was found in the ultrasound image. We performed C-arm fluoroscopy guided injection of 0.75% ropivacaine 5 ml and triamcinolone 40 mg in the right hip joint just like case 1. His symptom was much improved after the injection. The patient visited our clinic again checking his VAS, OHS and satisfaction scores at 2, 4, 8 and 12 weeks after injection (). The patient took NSAIDS 200 mg during the first month after injection and thereafter, was discontinued. The patient could sit crossed-legged on the floor 2 weeks after the injection although mild right hip pain remained.