Abstract

Objectives: In this systematic review, we discuss the literature regarding the accuracy and efficacy of ultrasound (US)-, fluoroscopy (FL)-, and landmark (LM)-guided intra-articular hip injections.

Materials and methods: A systematic review was performed following the Cochrane process from April 2023 to August 2023 utilizing PubMed, Embase, Web of Science, and Scopus databases. Branched logic was used to include any articles that were published prior to April 2023 containing the key terms “hip” AND “ultrasound” AND “injections”. Two authors screened studies for eligibility, and any disagreements were resolved through discussion with a third reviewer. Risk-of-bias assessments were performed.

Results: A total of five studies were included in the review. Individual studies demonstrated amounted to 100% (17/17) versus 85.4% (53/62) versus 70% (52/74) for US-, FL- and LM-guided intra-articular injections/arthrocentesis, respectively. All studies, except for one, addressing either the injection accuracy or improvement in pain showed improved outcomes in the US-guided injection/aspiration groups.

Conclusion: This systematic review provides preliminary evidence for slightly better accuracy with US-guided intra-articular hip injections/arthrocentesis versus FL- or LM-guided intra-articular hip injections/aspirations. It contributes to the current literature by evaluating multiple measurable outcomes, including procedural accuracy, changes in pain scores, patient-reported procedural discomfort, and improvements in range of motion.

Introduction

Intra-articular hip pain is common in both athletes and aging adults.[1] In athletes, intra-articular hip pain is usually due to femoroacetabular impingement, labral tears, or chondral defects. Meanwhile, in older adults, osteoarthritis is most common.[1] Conservative treatment measures which can be considered for these patients include medication, physiotherapy, and injections.[2] Intra-articular hip injections can be done via anatomic landmark (LM), fluoroscopy (FL), or ultrasound (US) guidance. Previous studies have evaluated the accuracy of US-guided injections compared to anatomic LM guidance. [3] However, there is no study comparing FL, US, and anatomic LM guidance on the accuracy and efficacy of pain improvement in intra-articular hip injection.

In this review, we discuss the accuracy and efficacy of US-, LM-, and FL-guided intra-articular hip injections to help synthesize the existing literature on evidence for accuracy and efficacy of these three injection methods.

Material and Methods

Search strategy

A systematic review was done following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane process from April 2023 to August 2023. Review guidelines were established prior to performing the literature review. This was performed using multiple databases (PubMed, Embase, Web of Science, and Scopus) for English published articles prior to April 2023. Branched logic was used to include articles containing terms regarding the hip (“hip” OR “hip joint” OR “hip pathology” OR “femoroacetabular impingement” OR “labral tear” OR “acetabulum” OR “hip injuries” OR “hip osteoarthritis”) AND ultrasound (“ultrasonography” OR “interventional ultrasonography” OR “ultrasound” OR “ultrasound-guided”) AND injections (“injections” OR “intra-articular injections” OR “ultrasoundguided injection” OR “hip injection” OR “saline solution” OR “placebo” OR local anesthetics” OR “hyaluronic acid” OR “orthobiologics” OR “platelet-rich plasma” OR “mesenchymal stem cells” OR “adipose tissue” OR “MFAT” OR “botulinum toxins” OR “palpation” OR “anatomic landmarks” OR “physical therapy modalities” OR “fluoroscopic guidance”. Two authors screened the studies for eligibility, and any disagreement was resolved through discussion with a third reviewer.

Outcome measures

The main outcome for this systematic review was to evaluate the accuracy of each intervention arm. Secondary outcomes were to evaluate for efficacy of each treatment arm in relieving pain. The efficacy of each treatment was evaluated as a secondary measure, since pain relief as the measure of efficacy of the injection was not standardized across every study included. Due to the limited number of studies that evaluated two different injection modalities, a decision was made to prioritize the evaluation of injection accuracy. Some studies measured accuracy by needle placement or by location of contrast as seen on imaging or on cadaver dissection.

Data abstraction

Data abstraction was completed by a standardized approach for each study. In the data abstraction, the following fields were included when appropriate: first author, study objective, study design, country location of the study, age in terms of years of the participants, eligibility criteria outlined by the study, number of cases and controls, results, and conclusions of the study. Conclusions of these studies could include accuracy of the injection, convenience of the intervention, pain improvement, injection related pain, change in range of motion, or presence of extravasation of the injection dye.

Assessment of study quality

The Newcastle-Ottawa Quality Assessment Scale (NOS) and the Revised Cochrane Risk-of Bias Tool for Randomized Trials (RoB 2) were utilized to assess the studies included in the systematic review by one reviewer.[4] The quality of observational studies was assessed. The NOS provided a numerical score evaluating a study based on three domains: selection bias, comparability for assessment of confounding, and outcome/exposure. The RoB 2 evaluated the quality of randomized trials.[4] The RoB 2 evaluates the given exposure risk and determines whether a study is at risk of “low”, “some concerns”, or “high risk”.

Results

Overview

Initially, a total of 7,289 articles were identified to include the search terms: 3,135 articles from PubMed, 2,220 articles form Embase, 1,297 articles from Web of Science, 634 articles from Scopus, and three systematic review bibliographies. There were 1,482 duplicate records that were removed prior to screening. Over 5,807 articles were screened across all databases. A total of 5,763 articles were excluded based on their title and abstract. A total of 44 articles underwent a full text review for eligibility. Out of those articles that had a full text review, 39 articles were excluded as they had the wrong intervention, wrong study design (such as case report or case series or open letter to the editor), incomplete data, or did not include a comparison group. Five studies were included for final review after meeting the established criteria (Figure 1, Table 1). However, the review of outcomes such as accuracy, improvement in pain scores, comparison of procedural pain experience, and improvement in range of motion provided preliminary evidence which favored US-guided intra-articular hip injections/arthrocentesis for injection accuracy compared to FL- or anatomic LM-guided intraarticular hip injections/aspirations.

Figure 1. Article selection for systematic review.

Table 1. Article summary

Table 1. Continued

Risk of bias assessment

Out of the five studies, four were assessed using the NOS and one study was assessed using the RoB 2 (Tables 2a, b).

Table 2a. Quality assessment using the Newcastle-Ottawa Quality Assessment scale of included studies

Table 2b. Quality Assessment using the Revised Cochrane Risk-of-Bias Tool for Randomized Trials

Ultrasound vs. Landmark Guidance

Of the five final articles for review, Berona et al.[5] evaluated the efficacy of LM- versus US-guided intra-articular hip arthrocentesis. There were 17 cadaver specimens in which residents from PGY-1 to PGY-4 performed both US- and LM-guided intra-articular arthrocentesis. The rate of success for US-guided hip arthrocentesis and LM-guided hip arthrocentesis was 100% (17/17) and 82% (14/17), respectively in diagnosing and aspirating the joint fluid. There was not a statistically significant difference between anatomic LM- and US-guided intra-articular hip arthrocentesis success (p = 0.08). The NOS for this article developed a composite score of 5. Review of the literature revealed no prior live human study comparing anatomic LM guidance versus US guidance in the diagnosis and arthrocentesis of a hip joint effusion.

Ultrasound vs. Fluoroscopy Guidance

There were three articles that met eligibility criteria that focused on comparing US- and FL-guided intra-articular hip injections.[6-8] One of these articles was a retrospective review, one a single-blind study, and one a prospective comparative study. In Byrd et al.’s study,[6] the patients had significantly lower level of procedural pain experience with US-guided compared to FL-guided injections (p < 0.01) and 98% of patients preferred US-guided intra-articular hip injections over FL-guided ones. Pain was rated from 1 to 10 (1, no pain; 10, very painful). Furtado et al.[7] demonstrated an improvement in pain relief using the Visual Analog Scale (VAS) with both US- vs. FL-guided hip injections (p = 0.75). Neither Byrd et al.[6] and Furtado et al.[7] confirmed that injection accuracy was achieved in their interventions. In Martínez-Martínez et al.’s study,[8] there was no significant difference in the rate of extravasation or intra-articular gas finding between US- and FL-guided intra-articular hip injections (p = 0.41 and p = 0.17, respectively). The NOS composite scores for Byrd et al.[6] and Martínez-Martínez et al.[8] were 4 and 5, respectively. The RoB 2 for Furtado et al.[7] was noted to be of “some concern”.

Fluoroscopy vs. Landmark Guidance

Of the five articles that met eligibility criteria, there was one article that compared the efficacy of FL- and LM-guided intra-articular hip injections.[9] It was an experimental clinical study and evaluated accuracy of the injection by the confirmation of contrast uptake into the joint space. Diraçoğlu et al.[9] reported that the accuracy of intra-articular hip injections was significantly better with FL guidance than LM guidance (76.3% vs. 50.9%, p = 0.02). The NOS composite score was 5.

Discussion

In this systematic review, we evaluated the literature offering a comparison between the different image-guided modalities for intra-articular hip injections. Of note, this systematic review is limited by small studies and low quality of the included studies. Nevertheless, it provides preliminary evidence for slightly better accuracy of needle placement with US-guided intra-articular hip injections/arthrocentesis versus FL- or anatomic LM-guided intra-articular hip injections/aspirations. Both FL- and US-guided intra-articular hip injections provided significant pain relief. There is some evidence that procedural pain experienced by the patient decreases during an intra-articular hip injection with US-guidance compared to FL-guidance. Due to the low number of studies that evaluated these outcomes, further research is needed to make a strong conclusion on the superiority of UScompared to FL-guidance. Compared to anatomic LM-guided intra-articular hip injections, both US- and FL-guidance were found to be superior across the individual studies. In comparing success for injection/aspiration for the hip, cumulative accuracies amounted to 100% (17/17) vs. 85.4% (53/62) vs. 70% (52/74) for US-, FL-, and LM-guided hip injections/arthrocentesis, respectively.[6-10] Accuracy was measured across the studies by either contrast within the joint, amount of extravasation into the surrounding muscle, or success in aspiration of fluid from the intra-articular hip joint. For inexperienced clinicians, there is a significant benefit to using image guidance for the hip due to the neurovascular structures within the area, injector comfortability, and accuracy of the needle placement.[5,11,12] Efficacy as a measure of pain relief at Week 4 during follow-up was equivocal between FL- and US-guidance.[6] However, patients reported that US-guidance was significantly more convenient and had less procedural pain compared to FL-guidance for intra-articular hip injection.[7] Although it is too early to make a formal recommendation between FL- and US-guidance for intra-articular hip injections, physicians may consider patient comfort and convenience when choosing an imaging modality.

Due to the rise of orthobiologics and the associated high cost for these interventions, there is an additional growing desire by both patients and providers to ensure accurate placement into the joint space. Providers can select from US, computed tomography, FL, and magnetic resonance imaging for safe and accurate intra-articular hip injections.[13] However, US for intra-articular hip injections confers an advantage over the other imaging modalities in its ability to visualize neurovascular structures, assess muscular architecture, live monitoring of the needle, absence of radiation exposure for the patient and clinician, and convenience to the patient as an in-office procedure.[6,8,14,15] The limitations of US include the training required to achieve proficiency and the financial burden of acquiring the necessary equipment. There is not any current research to suggest that an US-guided injection of the hip is more costeffective for the patient, but typically in-office procedures require less cost than in a procedure suite where FL-guided injections are done. There is also existing research that suggests it is more cost effective for the patient with knee injections to complete their procedure in-office with US guidance than in a procedure suite.[13]

The main limitation to this systematic review is the limited number of studies, the heterogeneity, and the outcomes measurement. Some articles focused on evaluating US versus LM guidance, US versus FL guidance, and some on FL versus LM guidance. Studies included different inclusion/exclusion criteria, different skill levels of proceduralists, and evaluated different outcomes. This heterogeneity makes it more difficult to directly compare efficacy across the interventions. The sample sizes of the studies included were also relatively small. Future prospective, comparative studies comparing these different modalities for intraarticular hip injection are warranted.

In conclusion, this systematic review provides preliminary evidence for slightly better accuracy with US-guided intra-articular hip injections/arthrocentesis versus FL- or LM-guided intra-articular hip injections/aspirations. It contributes to the current literature by evaluating multiple measurable outcomes, including procedural accuracy, changes in pain scores, patient-reported procedural discomfort, and improvements in range of motion.

Citation: Hemeida A, Kasitinon D, Kim L, Williams R, Özçakar L, Jain NB. Accuracy and efficacy of intra-articular hip injections under ultrasound guidance versus landmark and fluoroscopy guided injections: A systematic review. Arch ISPRM 2026;1(2):106-113. https://doi.org/10.5606/ archisprm.2026.10.

D.K., R.W., L.O., and N.J.: Conceptualized and designed the study; D.K., L.O., and N.J.: Developed the search strategy; D.K. and L.K.: Conducted the study selection and data extraction; A.H. and L.K.: Evaluated the risk of bias; A.H.: Performed the analysis and interpretation and wrote the initial draft of the manuscript; D.K.: Contributed to the writing and initial revisions of the manuscript; L.O. and N.J.: Completed the final review.

The authors declare that there are no conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

This research received no specific grant from any funding agency in the public, commercial, or not‑for‑profit sectors.

AI Disclosure
The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.

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