Bilateral Hip Pain in a Child

Abstract

HISTORY: An 8 year old African American male presents with complaint of bilateral hip pain. The pain started 10-14 days ago as a dull ache in both hips, but has progressed in intensity to where he now avoids walking. There was no trauma or recent illnesses. PHYSICAL EXAM: The patient was afebrile with normal vital signs. Significant tenderness was noted over both greater trochanters without swelling or overlying erythema. Active and passive hip range of motion was reduced due to pain. There was no other joint involvement. DIFFERENTIAL DIAGNOSIS: Infection (septic arthritis, osteomyelitis) Transient Synovitis Avascular necrosis Slipped Capital Femoral Epiphysis (SCFE) Malignancy Systemic arthritis Idiopathic chondrolysis of the hip TESTS AND RESULTS: CBC: WBC 14.1, Hemoglobin 9.7 Hematocrit 24.9, and Platelets 768. Hemoglobin electrophoresis: Homozygous sickle cell disease Pelvic radiographs: Bony infarcts in both proximal femurs. In addition, there is minimal irregularity of the lateral left femoral epiphysis. MRI: confirmed the diagnosis of avascular necrosis Joint aspiration: No fluid. FINAL DIAGNOSIS: Bilateral avascular necrosis of the hips secondary to sickle cell disease TREATMENT AND OUTCOMES: Conservative management was initially adopted, which included management of his sickle cell disease, physical therapy, prescription pain medications, and weight bearing restrictions during painful episodes. His course was complicated by progressive joint destruction, leg length discrepancy, and recurrent, often persistent episodes of osteomyelitis. At the age of 18 he underwent his first left hip arthroplasty with temporary PROSTALAC spacer placement. This was subsequently removed after the hip became infected. A total hip replacement was attempted next, but with dense fibrosis and a shortening of the leg, it was difficult to relocate his hip. The patient has been left with a Girdlestone (resection arthroplasty of the hip). He continues to have hip pain. There has been no any other joint replacement.