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A hip puncture is a procedure in which a doctor removes synovial fluid or a purulent mass from an affected joint. The procedure is typical, like a knee puncture, but due to the presence of muscle overlap and the depth at which the joint is located, the doctor may need the help of additional medical equipment, such as: ultrasound diagnostics, fluoroscopic diagnostics.
Arthrocentesis – (Greek: arthrosis – joint + centesis – puncture) is a clinical procedure using a syringe to collect synovial fluid from the joint capsule. It is also known as a joint tap. Arthrocentesis is used in the diagnosis of gout, arthritis, and synovial infections such as septic arthritis.
Anatomy of Education
The hip joint is a spherical synovial joint: its structure includes the femoral head and the acetabulum. The hip joint is the articulation of the pelvis with the femur, which connects the axial skeleton to the lower limb. In adults, the hip bone is formed by the fusion of several other bones, which occurs towards the end of adolescence. 2 bones of the femur form a bone pelvis together with the sacrum and coccyx and are united in front by the pubic symphysis. The hip joint is a synovial connection between the femoral head and the acetabulum of the pelvis.
The vertical head is formed by three bones of the pelvis. Between them is a Y-shaped cartilaginous growth plate (cartilage) that usually fuses at age 14-16 for a high degree of mobility. Acetabular labrum increases the depth of the joint, thereby increasing the stability of the joint, but causes a decrease in movement in the joint. Compared to the shoulder joint, it allows a smaller range of motion due to the increased depth and contact area, but exhibits much greater stability.
The joint is surrounded by a fibrous capsule that attaches to the acetabulum and then attaches to the proximal femur. The processes of this capsule make up the ileofemoral, ischeofemoral and pubofemoral ligaments.
Indications for use
There are many different indications for this manipulation, they can be divided into two categories – diagnostic and therapeutic.
After the liquid begins to flow into the syringe, the doctor needs to monitor it. He needs to pay attention to the consistency, color, presence of blood or pus. Sometimes novocaine is used for this, which has the property of changing color and viscosity upon contact with foreign biological fluids. Biochemical analysis of the fluid allows you to identify pathologies in the metabolic processes occurring in the capsule. In addition to mechanical, it performs a nutritional function: with its help, the necessary nutrients are delivered to the avascular cartilage.
For diagnostic purposes:
- biochemical analysis of the fluid, as well as a study for the presence of impurities (blood in injuries, or pus in inflammatory processes);
- using x-rays and drugs that help block x-rays, with their help they get very accurate information about meniscus lesions, in this case the drug is injected directly into the joint;
- most of the information can be obtained not from laboratory analysis, but directly during the operation.
Therapeutic operations are performed to pump out exudate, pus, blood impurities from the cavity of the articular sac, which manifest themselves in acute inflammatory processes. In addition, various drugs are administered through the procedure, for example, local anesthesia during surgery and painful manipulations.
In case of inflammation, antibiotics and corticosteroids are administered through a puncture. When hemarthrosis occurs in the joint cavity, hematomas that interfere with motor function and contribute to the development of infection, this pathological condition is eliminated.
There is another indication – for the introduction of oxygen into the articular sac. It is used for degenerative-dystrophic lesions of the musculoskeletal system, articular arthrosis, or as a means of preventing post-traumatic arthrosis. This method has only one strict contraindication – the presence of an acute purulent-inflammatory process at the puncture site. Medical oxygen and a special instrument are used, although other equipment is sometimes used.
Essence of the operation
The joints are punctured with a 10-20 g syringe with a needle 5-6 cm long and 1-2 mm thick. Thin needles are used to inject drugs into the joint when there is no need to take fluid from the inside, which can significantly reduce trauma.
2 mm needles are used for pumping and the risk of clogging with solid particles is reduced.
The doctor is required to perform extremely precise movements. Thus, the needle should not enter the articular sac more than 1-1,5 cm, and the slightest vibration of the tip as it passes through the synovial membrane severely damages it. There is a technique that prevents infection and leakage of the contents of the joint through the hole: the skin must be laid back, which achieves the curvature of the punching cavity. To reduce the risk of developing pathologies, a tight bandage is applied to the leg after a puncture or immobilized with a splint.
To prevent complications, the doctor closely monitors healing and recovery, although outpatient treatment and observation of the patient is sometimes possible. It can be performed from the front or from the side.
In the first method, the puncture point is in the middle of a line drawn from the upper edge of the greater trochanter to a point between the middle and inner third inguinal ligament. The needle is inserted in front, runs perpendicular to the upper edge of the femoral head, on the edge of the acetabulum. In the second method, the needle is inserted from the outside, above the top of the greater trochanter, and moves in the frontal plane to the corresponding point on the opposite side.
Patient preparation
The patient should lie on his side, pelvis parallel to the table. The hip joint should be slightly retracted and the thigh rotated medially. The greater trochanter of the femur serves as a guide. Equipment:
- Sterile tray for the procedure.
- Sterile gloves.
- Sterile tight drapery.
- Syringes.
- Needles.
- Gauze soaked in betadine solution.
- Sterile bandage.
Procedure Technique
The accumulation of pathological fluids in the cavity of the hip joint requires a puncture. There are two methods commonly used for hip piercings: anterior and lateral approaches.
Lateral approach – more often used for puncture of the hip joint. This method is usually performed with the patient placed in the supine position. The needle is then inserted in an anterior-posterior direction from a midline point at the tip of the greater trochanter of the femur to a point between the medial and median third of the inguinal ligament.
The needle is extended from the pulsation point in the femoral artery to the medial edge of the sartorius muscle.
Anterior approach – the needle is inserted over the greater trochanter of the hip joint and directed over the head of the femur and when reaching the head of the femur, the direction of the needle to the capsule of the hip joint.
Front approach:
- the femoral artery can be palpated in the femoral triangle and can be used as a guide for hip puncture;
- then you need to feel the femoral pulse in the same way as it leaves the inguinal ligament;
- entry point 2-3 cm to the side of the artery (at the inguinal ligament) and 2-3 cm below the inguinal ligament;
- moving laterally 2-3 cm will also make the entrance site approximately 2-3 cm below the ligament;
- inserting the needle then straight down into the lateral half of the joint cavity.
During severe cases of purulent infection, resection of the femoral head is performed.
Complications of the procedure
Depending on the puncture points and the individual characteristics of the patient’s physique, various complications may occur. If the surgeon is not in the capsule when the contrast dye is injected, then the contrast material will interfere with visualization of the needle. In patients with large hips, the needle may not be long enough to reach the required depth. Care must be taken not to damage the sciatic nerve, which runs near these anatomical structures.
The synovial membrane, which forms the walls of the articular sac, is a delicate tissue, damage to which will be restored over a long time and can cause the development of pathological processes. It is also very vulnerable to germs, so strict antiseptic rules apply. Thus, the surface of the joint is disinfected in two ways: twice with iodine, followed by the treatment of the area with alcohol. Here you need to be careful: iodine penetrating the tip of the needle into the wound can cause a chemical burn of the synovial membrane. Instruments must be sterilized by chemical and thermal methods.
If the articular puncture is performed on an unaffected joint, and the goal is to withdraw fluid, this reduces the already small amount of synovial fluid.
A huge amount of fluid taken can lead to inflammation inside the joint and also to the destruction of cartilage. In addition, due to the negative pressure in the capsule, osmosis from water and other foreign impurities in the synovial fluid occurs through its walls, and, subsequently, a decrease in the amount of this fluid can adversely affect this process.
Complications of puncture: the development of infection in the joint (when moving the needle through the tissues, do not touch with your fingers, but are supported by tweezers); capsule rupture; after the introduction of oxygen may develop: synovitis, subcutaneous emphysema, cerebral embolism.
The impossibility of puncturing the joint can be explained by the presence of a complete synovial septum in the joint (two-chamber joint), hypertrophic folds of the synovial membrane, and the presence of a large thick body in the joint.
A puncture of the hip joint is a manipulation performed by a surgeon, or a traumatologist, in which the doctor inserts a needle into the joint bag. It is carried out for diagnostic or therapeutic purposes in order to reduce the amount of synovial fluid in the capsule. In some cases, this operation is vital and helps to make life easier for many people.
The operation technique differs for different joints due to their structure, the doctor must clearly understand how and where certain tissues, ligaments, bones and many other anatomical formations are located in order to correctly pave the way between them without touching anything superfluous or colliding with the bone.