Thank you for the opportunity to present today. I was tasked to talk about ultrasound-guided injections. We're going to talk about cortisone, PRP, BMAC, and HA. And the main indications for ultrasound-guided injections are interticular pathology, such as femorisotelar impingement, labral or chondral injury, and osteoarthritis. And we can use ultrasound to guide the treatment of multiple injections, such as HA, PRP, or BMAC. And also, very importantly, for diagnosis of intra- versus extra-articular pathology. Some of the advantages of using ultrasound are the location visualization in real time, and also when we're injecting to make sure that the fluid is going wherever we want it to go. The accuracy, we can inject not only the intra-articular pathology or the intra-articular aspect of the joint, but also, if we wanted to, we can guide these injections to the labrum or to the cartilage, if need be. Avoidance of radiation is another feature that is very important in comparison to getting this through a fluoroscopic shot. The main disadvantages are the required training for interpretation of what we see, the equipment expense, and also the time allotment in clinic, because this will disrupt the flow, as they might take 10 to 15 minutes to set up and to do the injection. For the technique, we prefer to use the supine position. The probe position should be in line with the femoral neck, and this will vary depending on if the patient has coxa vera or coxa vulga. We have to see the acetabulum, the labrum, and the femoral head-neck junction, as well as identify the neurovascular structures to make sure that we're not going to produce any iatrogenic damage to the neurovascular structures. This is basically the technique. We have the probe in line with the femoral neck. We clean everything in line to the distal aspect of the probe. We have everything sterile. There's a cover for the probe that will allow us to do this in a sterile fashion, and then we use a spinal needle in line with the femoral neck to try to get this to the femoral head-neck junction. And this is basically what you see. You see the femoral head to your left. You see the neck on the center of the screen, and then you can actually see the capsule quite well. It's important sometimes when we see an image like you see on the right, where there's a lot of fluid inside the joint, probably to drain this before we inject either the cortisone, the PRP, or the BMAC, because that's going to create a significant amount of extra fluid inside the joint. This is what we try to do. Try to come from distal to proximal and hit the femoral neck junction, head-neck junction. If there's no injection, there's no response with the injection, when we have an FAI patient or a labral tear, there's lower surgical satisfaction. So this is something that we can use as a proxy as to whether these patients will improve or not. Cortisone for osteoarthritis has been shown to have beneficial effects after six weeks. We'll use 40 milligrams up to 12 weeks. We'll use 80 milligrams, so it seems to be a dose-dependent response. A systematic review on FAI showed an unclear benefit long-term. 37% had immediate relief, and only 6% had a sustained relief. Satisfaction at one-year post-injection was relatively low, and returned to sport only after surgical manage was achieved. Cortisone for OA, 48%, again, will have immediate relief, defined as within two weeks of the injection. 32% will have continued relief, and 20% will have no relief. 49% of those people had surgery within the next two years. However, the risks for cortisone injections are septic arthritis, just like any other injections. These effects, for example, in people that have diabetes or high blood pressure, and we have to make sure that this is disclosed clearly to patients. Cartage volume loss, fatty atrophy of the tissue, and skin discoloration are some of the risks of using a cortisone injection. In regards to the hyaluronic acid, it has a very potent anti-inflammatory effect. We used to think that this would be a lubricant for the joint, but new studies suggest that it gets cleared out from the joint within 24 hours. However, the anti-inflammatory effect might have a more durable effect than cortisone. It has not been approved by FDA for the hip use, and it's pretty well tolerated by patients. There's a couple of studies that show no difference in pain and function compared to placebo, and there's a second study looking at a prospective cohort of patients showing that there's a decreased pain and improved mobility compared to baseline when using HA. So there's not a lot of evidence in the hip, just like we have in the knee, and therefore more research is warranted in this field. Hip biologics, PRP is probably the main one that people use. You can see here the PRP is extracted from the buffy coat. The closer we get to the red blood cell layer, the more red blood cells, growth factors, and white blood cells that we will have. From the knee literature, we can infer that having too many red blood cells or white blood cells is going to create a significant amount of destruction or degeneration of the knee as well as inflammation with white blood cells, and therefore we try to have a leukocyte-poor PRP for this purpose. And we know also from other studies that the more growth factors that we have, potentially the better effect that they will have. But we know also that these are highly variable, so that's something that we need to take into consideration. We recently published this systematic review with meta-analysis, showing that PRP has a marginal beneficial effect in comparison to control. As well, that's for the treatment of osteoarthritis, but when used as an adjunct for the FAI surgery or for the FAI surgeon that does a labor repair, it does not show a statistically significant difference when using it versus controls. BMAC, the main differences with PRP is probably one of the main questions that we get. And the main difference is that BMAC has higher concentrations of neutrophils, TGF-beta-2-VEGF, and interleukin-1 receptor antagonists, which is probably the main molecule that will cause blockage of interleukin-1 alpha and beta that produce chondrocyte apoptosis and inflammation. Here's John's one randomized clinical trial. This is for the knee, but we can basically extrapolate the results from this from a Mayo Clinic, 25 patients with bilateral OA. BMAC versus saline control, they had similar pain relief. And therefore, as of now, PRP seems to be the best biologic to use because it has a significant amount of evidence, at least in the knee. In conclusion, ultrasound is critical for accuracy of the injection. It has no radiation. It's time efficient in clinic, although you will need to make sure that you have an allotment of 15 to 20 minutes to be able to treat these patients. Excellent diagnostic injection results because it allows us to know if those patients will do well or not with surgery, or if the pain is coming from inside or outside the joint. And we know now that biologics have promising outcomes for the treatment of inflammation, although structural improvement has yet to be proven. Thank you very much.

ultrasound-guided injections

cortisone

PRP

BMAC

HA