Thanks so much. I'm Ben Wachuku. I'm going to be talking about what to inject in the hip, biologic augmentation, steroid, or HA. I'll try to keep it moving. I know we're behind time. So hip injections are an important part of my clinical practice. Pain on the left shows injection to the front of the hip. Pain on the middle shows paratrochanteric injection. And then pain on the right shows technique for injecting around the hamstring. The talk's going to be focusing primarily on intraarticular steroid injections. So what are our options? Steroid and lidocaine, hyaluronic acid, or HA, pellet-rich plasma, hyaluronic acid and PRP, and then bone marrow aspirate concentrate, or BMAC. So when we think about preoperative injections of steroids into the hip, I would say that this study here, published by myself and Dr. Noh, pretty convincingly suggests that you should think twice before you inject steroid into a hip before FAI surgery. We looked at 1,100 patients who underwent arthroscopic labor repair and femoroplasty. We used a machine learning algorithm, applying the LASSO method, to look to see what were some of the predictors of outcome, specifically achieving the MCID, mammal clinical importance difference. And we found that hip injection across all three outcome measures was a negative predictor of achieving MCID at two-year follow-up, and it was actually the strongest predictor, hypothesis being that hip steroid injection preoperatively can impact the ability of the labrum to heal. Other authors have called into question the role of hip steroid injection in patients preoperative for FAI. Dr. Iaini showed in his study that a positive response from intraarticular hip injection is not a strong predictor of short-term functional outcome. And Dr. Critch and his group showed that hip steroid injections really don't last very long, so calling into question the therapeutic part of diagnostic and therapeutic. So 37% of patients sustained improvement at 14 days. The median improvement was only 10 days. And by six weeks, only 6% of patients had improvement with hip steroid injection. So the conclusion is, in my practice, there is limited role for steroid injection in young patients with FAI. I think that lidocaine injections can be helpful for diagnostic and therapeutic purposes and unfortunately are sometimes required by insurance companies. When you think about biologic augmentation for FAI surgery, I would say that the study up top by Dr. Martin and his group at Mass General provides us one of the strongest evidence to support the role of BMAC for FAI surgery. They looked at patients who underwent hip arthroscopy or labral repair who received BMAC and who didn't receive BMAC. And they looked at outcomes at one and two years, and they found that there was actually no significant difference in patients who received BMAC at one and two years. However, when they did a subgroup analysis, they found that patients who had moderate grade cartilage damage showed significant improvement when they underwent BMAC injection at time of surgery. The findings of their study were replicated by our group at HSS. We did a case control study comparing patients who had tinnitus grade zero versus patients with tinnitus grade one and two who underwent arthroscopic surgery with injection of BMAC. All patients got better, but the group of patients who had essentially arthritis, tinnitus grade one and two, they actually had similar outcomes to the patients with no arthritis, our hypothesis being that the addition of BMAC in the arthritic group led to an equivalency in outcome. What about PRP as a biologic augmentation? Well, the literature really doesn't support that. This early randomized control trial demonstrated, showed that there was no significant improvement with PRP injection at time of surgery. And when outcome was looked at at one, three, six, and 12 months, there was really no significant improvement if patients had PRP done at the time of their hip scope. And then a subsequent systematic review of randomized control trials found three RCTs with 363 hips and similarly showed no significant benefits of PRP injection. So when you think about biologic augmentation for arthroscopic intervention, there's really a limited role for intraoperative PRP injection. But I think BMAC shows good promise, especially in patients who have chondral damage. What about some of the other conditions of the hip? So osteoarthritis and soft tissue problems around the hip. I would say that PRP, platelet-rich plasma, has the best support in patients with mild to moderate osteoarthritis. These figures are from a systematic review published in 2018 and showed that PRP was effective in diminishing pain on the visual analog scale for pain, with peak effects actually at six weeks. There was a gradual return of pain, but even at 12 months, the pain scores were lower than they were pre-injection. So oftentimes in my office, when I give patients PRP, I'll tell them that they can expect maximum benefit for six weeks with a gradual return of pain and potentially needing another PRP injection at six to nine months after the indexing injection. What about hyaluronic acid alone? Well, this is a systematic review that showed that hyaluronic acid in patients who have mild to moderate arthritis can be beneficial. However, when you think about hyaluronic acid in comparison to other interventions like steroid or saline, it doesn't actually have significant benefit. So in my practice, there's really no role for isolated hyaluronic acid injection to the hip. What about HA and PRP together? A lot of providers will do that for the knee, suggesting that HA is a good carrier for PRP. While this study actually shows that there's really no role for that, PRP alone results in better improvements in pain scores, and pain on the right really shows that very well for the VAS for pain. So in my purview, I think that PRP alone is sufficient. And then just some final thoughts on other soft tissue problems. So there's really high level evidence to suggest that PRP is very effective for patients with gluteus tendinopathy and partial thickness tears, similarly for hamstring tendon injuries. Thank you for your attention. Thanks, Ben.

hip injections

intraarticular steroid injections

biologic augmentation

cartilage damage

osteoarthritis