Acute Hip Pain Research Articles

Osteonecrosis of the hip treated with core decompression: a case report

Osteonecrosis is a disease of impaired blood flow affecting mainly young people in their third ,fourth or fifth decades. It leads to collapse of the femoral head necessitating Total hip replacement. A 44 year old female presented at Kenyatta National Hospital,Nairobi, Kenya. in 2006 where she was managed by the authors with acute right hip pain and thigh pain. Early osteonecrosis(FICAT stage II), was diagnosed with the aid of MRI and core decompression by three small diameter (3.2mm) drillings was performed. Follow-up at five years shows a radiological regression of the lesion.

Acute Hip Pain In A High School Kicker

Acute Hip Pain In A High School Kicker

Transient synovitis of the hip: Ultrasound appearance. Mini-pictorial essay

We describe the ultrasound (US) appearance of transient synovitis. Transient synovitis of the hip typically occurs in 3 to 8-year-old children. The onset is clinically characterized by acute hip pain and limp with limited joint mobility, and the leg is usually held in a position of flexion and external rotation to avoid pain. US image is characterized by joint effusion in the hip joint anterior recess, as described in the literature. Our experience confirms the importance of the technique with which the US examination is performed. In order to obtain the best diagnostic information the hip must be examined with the patient in the supine position and the hip joint in a neutral position (abduction of the hip with extension and slight external rotation) by means of an anterior approach along the long axis of the femoral neck in the parasagittal plane.

Monoarticular Pseudogout of the Hip: A Case Report

Monoarticular pseudogout is a rare cause of acute hip pain, and may mimic hip joint infection. We present a case of monoarticular pseudogout in an 85-year-old woman. Diagnosis was confirmed with hip joint aspiration and crystal analysis. The patient was treated with intra-articular corticosteroids, and her symptoms resolved.

Hip Pain as Initial Presentation for Varicella-Zoster Infection in an Adolescent Male

Hip pain and varicella infections are common diagnoses affecting children and adolescents. Hip pain in childhood can be a challenging presenting complaint for the pediatrician or orthopedic physician. The differential diagnosis is broad, and ranges from benign conditions, such as transient synovitis and muscle strains, to more serious infections or malignancies. Acute hip pain is usually referred to an orthopedic surgeon, and the principal concern is to distinguish infection of the hip joint or pelvis from an irritable hip or musculoskeletal pain. The Varicella-zoster virus, a member of the herpes virus family, often presents as a generalized, pruritic, vesicular rash. The primary infection is commonly known as chickenpox. The prevalence of varicella infections has decreased significantly over the past decade with use of the varicella vaccine. Reactivation of varicella infection, or herpes zoster, in patients younger than 20 years is seen in only 68 per 100,000 people. Hip pain as the presenting symptom for onset of a herpes zoster infection is rare. This article presents a case of herpes zoster infection with initial presentation of hip pain in a 13-year-old boy. This case highlights the difficulty in diagnosing atraumatic joint pain in the pediatric population. The clinical importance of a thoughtful differential diagnosis, and the necessity of close follow-up by a pediatrician and/or orthopedic surgeon until there is a confirmed diagnosis cannot be overstated.

Subchondral stress fracture of femoral head in a healthy adult

Subchondral fracture of the femoral head is an uncommon entity and usually occurs as an insufficiency fracture associated with poor bone quality or as a fatigue fracture in young military recruits. This condition should be considered in the differential diagnosis of acute hip pain in young patients along with transient osteoporosis and avascular necrosis of the hip. We report a case of acute onset hip pain in an asymptomatic healthy adult in which the diagnosis was made by magnetic resonance imaging and the patient responded well to conservative treatment.

Acute hip pain and inability to ambulate: a rare presentation for perirectal abscess

A patient with acute hip pain out of proportion to physical findings and inability to weight bear despite negative plain films warrants further in-depth evaluation. Correctly diagnosing the cause of hip pain, a common emergency department (ED) complaint, may be a challenge in the geriatric population (Perron A, Miller M, Brady W. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med 2002; 20: 234-7; Cannon J, Silvestri S, Munro M. Imaging choices in occult hip fracture. J Emerg Med 2009; 37: 144-52; Kiu A, Khan S. Radiology of acute hip and femoral injuries. Br J Hosp Med (London) 2010; 71: M22-M24; Zacher J, Gursche A. Regional musculoskeletal conditions: hip pain. Best Pract Res Clin Rheumatol 2003; 17: 71-85). A perirectal abscess as a cause of acute hip pain and inability to ambulate, with gluteus muscle inflammation but no evidence for bone or joint infection, has not been described, to the authors' knowledge. An 82-year-old woman with a history of diabetes, previously ambulatory, presented to the ED after being found on her apartment floor by a visiting health aide, complaining of acute pain in her left hip. Pain was exacerbated by palpation and range of motion testing, and she was unable to bear weight. There was no report of fever, rectal or abdominal pain, bleeding, or painful defecation. Plain films were negative for fracture or lytic lesion. Computerized tomography (CT) of the hip and pelvis was then obtained, which was negative for boney abnormality but revealed a 5-cm ischiorectal abscess with inflammation of the adjacent gluteus muscle. This case illustrates the potentially subtle nature of a deep perirectal abscess in an elderly patient. The CT imaging, useful for investigating the possibility of occult femoral neck fracture, was fortuitous in leading to the diagnosis. One must consider the possibility of visceral processes causing referred pain, when evaluating the patient with an acutely painful hip (Perron A, Miller M, Brady W. Orthopedic pitfalls in the ED: radiographically occult hip fracture. Am J Emerg Med 2002; 20: 234-7; Zacher J, Gursche A. Regional musculoskeletal conditions: hip pain. Best Pract Res Clin Rheumatol 2003; 17: 71-85).

Arthroskopische Therapie eines intraartikulären Tumors am Hüftgelenk

We present the clinical case of an 18-year-old woman who complained of acute hip pain. MRI showed an intra-articular tumor 4 cm in size with osteolysis (18 mm) on the distal region of the femoral head-neck junction. Focal pigmented villonodular synovitis infiltrating the bone was diagnosed. A complete resection of the tumor including the osteolytic area was done by an arthroscopic procedure. There was no sign of relapse after 8 months of follow-up, with no pain and complete function of the hip. Arthroscopic treatment has the advantage of minimal surgical trauma and good mid-term results for treating a focal lesion in selected cases.

Pseudogout Associated Hip Pain in a Patient with HIV Infection

HIV infection is a global pandemic, currently affecting approximately 77,000 people in the UK and 33 million people around the world. The infection has widespread effects on the body and can involve the musculoskeletal system. It is therefore important that orthopaedic surgeons are aware of the condition and its sequelae. We present the case of a 46-year-old man with a 10-year history of HIV who presented with acute hip pain, difficulty weight-bearing, and constitutional symptoms. Following radiological, microbiological, and serological tests a diagnosis of pseudogout was established following microscopic analysis of the hip joint aspirate. The patient's symptoms resolved completely following the joint aspiration and NSAID therapy. Studies have shown a relationship between HIV infection and gout. The virus has also been linked to osteonecrosis, osteopenia, bone and joint tuberculosis, and septic arthritis from rare pathogens. However, it is difficult to fully ascertain whether these conditions are related to the HIV infection itself or the HAART (highly active antiretroviral therapy). There are no previously reported cases of HIV-infected patients with pseudogout. The case is discussed with reference to the literature.

0424: Ultrasound in Paediatric Emergency

US is a useful imaging modality in the evaluation of childhood emergencies. Various organs are subjected for emergent US examination such as abdomen, kidney, brain, testis, extremities, and so on. US has many advantages in the evaluation of childhood such as portability, non-invasive, maintaining the environment of babies, and particularly without ionizing radiation. Abdominal conditions includes hypertrophic pyloric stenosis, midgut volvulus, acute appendicitis, or intussusceptions complaining abdominal pain, vomiting or abdominal mass. Renal abnormalities such as acute pyelonephritis, acute renal failure or hematuria can be evaluated with US to exclude hydronephrosis, renal swelling or renal vein thrombosis. US of testis is indicated to exclude hydrocele, testicular torsion, acute epididymitis or evaluation in acute testicular trauma. In the neonatal or early infancy, brain US is useful to evaluate hypoxic ischemic damage, meningitis, hydrocephalus or congenital abnormalities. Acute hip pain or limping gait can be evaluated with US to exclude hip joint effusion or to detect associated bony abnormalities. Hip joint aspiration can be guided by US to exclude septic hip from transient synovitis. Cartilage or bone destruction can be detected with US in case of early infancy prior to plain radiograph-visible ossification. Spinal US can be used to evaluate the level of conus medullaris in the neonate or the evaluation of spinal dysraphism or exclude connection of soft tissue mass with spinal canal. Use of emergent US in various clinical conditions will be discussed.

Open Reduction and Smooth Kirschner Wire Fixation for Unstable Slipped Capital Femoral Epiphysis

Reduction of unstable slipped capital epiphysis has a bad reputation, especially in severe slips. Treatment frequently causes avascular necrosis (AVN). This study analyzes the role of capsulotomy with evacuation of intraarticular fluid and gentle reduction done as an emergency procedure followed by fixation with unthreaded Kirschner wires (K-wires). We treated 64 consecutive cases of unstable slips (37 boys and 27 girls) following the same protocol. Instability was recognized in those children who had experienced a fall or a stumble, followed by acute hip pain, with radiological evidence of capital femoral separation and ultrasonographic evidence of joint effusion. The protocol consisted of capsulotomy, evacuation of intraarticular effusion or hematoma, controlled gentle reduction, and fixation of the reduced physis by smooth K-wires. Surgery was done as an emergency procedure if possible within 24 hours after the onset of acute symptoms. There were 20 mild slips with slip angles less than 31 degrees, 24 moderate with slip angles between 31 and 50 degrees, 20 slips were severe with slip angles between 51 and 90 degrees. In 61 cases, reduction was successful without being followed by AVN. Three patients, 2 girls and 1 boy, developed partial AVN (4.7%). Two avascular necroses occurred in moderate slips, one in a severe slip, and none in the mild slips. The outcome of 60 patients (34 boys and 26 girls) with unstable slips could be evaluated clinically and radiographically with a mean follow-up of 4.9 years (range, 18 months-104 months). The Iowa hip score in these 60 cases reached an average of 94.5 points out of 100. Open reduction and evacuation of intraarticular hemarthrosis or effusion detected by ultrasound and smooth K-wire fixation done as an emergency is a safe and reliable treatment option for unstable slips with a low AVN rate. The severity of the slip does not influence the rate of AVN and the outcome measured by the Iowa hip score.

Postpartum bilateral transient osteoporosis of the hip: MR imaging findings in three cases

Transient osteoporosis of the hip (TOH), associated with pregnancy, is a self-limiting skeletal disorder affecting women, usually in the third trimester, which resolves spontaneously within few months postpartum. Bilateral involvement is rare. Involvement postpartum has not been described. We report three patients with postpartum presentation of bilateral TOH. Three pregnant women who presented with acute bilateral hip pain just after delivering their first child are reported. None of them had any past history of joint problems, recent injury, alcohol abuse or corticosteroid administration. Magnetic resonance (MR) imaging examinations were performed on 1.5-Tesla magnets using standard protocols. Bone marrow oedema, with normal joint space and intact articular surfaces, was depicted in all six hips. MR imaging findings with clinical correlation confirmed the diagnosis of TOH. TOH associated with pregnancy does not necessarily occur in the third trimester of pregnancy and may be bilateral.

Ruptured abdominal aortic aneurysm masquerading as isolated hip pain: an unusual presentation

The rupture of an abdominal aortic aneurysm (AAA) is a catastrophic event. Misdiagnosis by first-contact emergency physicians remains a serious concern. Varied and frequently nonspecific presentations lead to erroneous diagnostic impressions and cause significant delays in definitive intervention. We report the case of a 73-year-old man with a ruptured AAA presenting with isolated acute right hip pain without any classical features such as truncal pain or hypotension. Despite major advances in imaging and definitive treatment, a heightened awareness among emergency physicians remains the only effective means of improving detection and thereby survival.

Acute Fracture of the Acetabulum Secondary to a Convulsive Seizure 3 Years After Total Hip Arthroplasty

While aseptic loosening, osteolysis, and infection are the most common causes of failure after total hip arthroplasty (THA), late hip pain can also be the result of acetabular fracture related to trauma and resultant prosthetic failure. However, atraumatic fracture of the acetabulum around a well-fixed acetabular component is unusual. We present a patient with an acetabular fracture resulting from a generalized convulsive attack 3 years after an uncomplicated primary THA. A 33-year-old man presented with acute left hip pain. He had chronic renal insufficiency and had undergone bilateral THA due to avascular necrosis. The night prior to his admission, he suffered a generalized convulsive attack with severe extremity contractions. Afterwards, he had acute left groin pain and had difficulty walking. Physical examination revealed moderate left hip pain as well as a 1-cm shortening of the affected limb. Radiological examination demonstrated an acetabular fracture with medial wall comminution. The acetabular component had migrated medially and rotated horizontally. Revision of the acetabular component with a reinforcement ring and implantation of a cemented acetabular component was realized. Severe muscle spasms during generalized seizures are known to lead to various musculoskeletal injuries (fractures of the proximal humerus, femur, acetabulum, and dislocation of the shoulder). Seizures could also lead to acute periprosthetic fracture of the acetabulum in patients with osteopenia. Therefore careful reaming is required to avoid overmedialization of the acetabular component in those patients.

The Role of Pelvic Magnetic Resonance in Evaluating Nonhip Sources of Infection in Children With Acute Nontraumatic Hip Pain

The Role of Pelvic Magnetic Resonance in Evaluating Nonhip Sources of Infection in Children With Acute Nontraumatic Hip Pain

Acute isolated acetabular fracture following a game of squash: a case report

Although hip injuries do not account a large amount of the Sports Physician's workload they can result in significant morbidity. We present a case where an acetabular fracture was sustained in a relatively young female while playing squash without any history of fall or injury but was treated successfully non-operatively. Such patients who present with acute hip pain must not be dismissed as simply having a soft tissue injury.

The Activity and Toxicity of Dasatinib in Relapsed or Plateau-Phase Multiple Myeloma.

Dasatinib (Sprycel®) is an orally administered inhibitor of multiple tyrosine kinases, which has been approved for the treatment of CML in chronic phase, accelerated phase or blast phase with resistance or intolerance to prior therapy including imatinib. In vitro studies have demonstrated that dasatinib inhibits the viability of multiple myeloma cell lines. Based on the in vitro activity of dasatinib against multiple myeloma, we initiated an open label, single-arm Phase II trial of dasatinib in relapsed, refractory or plateau-phase multiple myeloma; planned enrollment is 21 patients (pts). Treatment consists of dasatinib 70 mg p.o. twice daily continuously. The primary endpoint of the study is the overall response rate (CR+PR). Secondary endpoints include the time to response, duration of response, time to progression as well as tolerability and safety of dasatinib in this population. To date, 13 pts have been enrolled. The median age is 58 (range 38–76). Stage at diagnosis was: IIA (1 pt), IIIA (11), IIIB (1); 9 pts had IgG paraprotein and 4 had IgA. Median beta2-microglobulin at study entry was 3.2 (range 1.2–13). The median number of prior therapies was 2 (range 1–14); 12 pts had undergone prior autologous stem cell transplant. At enrollment, 7 pts had progressive disease and 6 pts had plateau phase disease, defined as at least 3 months with a stable paraprotein level (±25%) following the most recent therapy. At a median follow-up of 39 days (range 1–134 days), results are as follows: 4 patients have stable disease (SD); 7 patients had progressive disease (PD); 1 pt discontinued therapy due to toxicity (Grade II diarrhea, flushing and fatigue); 1 pt is not yet evaluable for response. Of those who remain on therapy, the median time on therapy is 39 days (range 1–134); 4 of these 5 patients had plateau phase disease at enrollment. Of those who discontinued therapy for PD, median time on therapy was 46 days (range 15–91); 6 of these 8 patients had PD at the time of enrollment. Toxicities have been manageable. Hematologic toxicities were more pronounced in the patients who had cytopenias at baseline. There was 1 episode of Grade III neutropenia, 4 episodes of Grade III anemia, 2 episodes of Grade III thrombocytopenia, and 3 episodes of Grade IV thrombocytopenia. Grade III non-hematologic toxicities have included: pneumonia (3 pts), acute renal failure (2), headache (1), epistaxis (2), febrile neutropenia (1), pulmonary edema (1), GI bleed (1), fatigue (2), hypertension (1), and hip pain (1). There was 1 episode of grade IV hypoglycemia. Enrollment and evaluation of responses/toxicities are ongoing. The protocol is being amended to allow for dose escalation to dasatinib 100 mg b.i.d. for stable disease at 8 weeks on therapy.

Poster 67: Polyradiculopathy Following an Exacerbation of Herpes Zoster Reactivation: A Case Report

Setting: Acute rehabilitation hospital. Patient: A 68-year-old woman with a medical history of liver transplant secondary to hepatitis C, and arthritis for 10 years. Case Description: The patient ambulated with a cane independently prior to entering the emergency department with acute left hip pain; wing radiography determined that she had bilateral avascular necrosis of the hips, with the left hip having collapse and greater involvement. She was simultaneously diagnosed with recurrent herpes zoster and started on intravenous acyclovir.

Septic Arthritis Versus Transient Synovitis of the Hip: Gadolinium-Enhanced MRI Finding of Decreased Perfusion at the Femoral Epiphysis

The purpose of this study was to identify differences in the MRI findings of septic arthritis and transient synovitis in patients with nontraumatic acute hip pain and hip effusion. The MRI findings in nine patients with septic arthritis and 11 with transient synovitis were reviewed retrospectively. This study was approved by our institutional review board. The diagnoses were based on findings at physical examination, laboratory studies, and joint aspiration and bacteriologic study. The MRI findings were analyzed with emphasis on the grade of joint effusion, alterations in signal intensity in the soft tissues and bone marrow, and the presence of decreased perfusion at the femoral head. Low signal intensity on fat-suppressed gadolinium-enhanced T1-weighted coronal MRI suggesting decreased perfusion at the femoral head of the affected hip joint was seen in eight of nine patients with septic arthritis and in two of 11 patients with transient synovitis. Statistically reliable differences (p = 0.005) were found between the two groups. Alterations in signal intensity in the bone marrow were seen in three patients with septic arthritis but in none of the patients with transient synovitis. Decreased perfusion on fat-suppressed gadolinium-enhanced coronal T1-weighted MRI was seen in the six patients with septic arthritis who did not have alterations in signal intensity involving the bone marrow. Decreased perfusion at the femoral epiphysis on fat-suppressed gadolinium-enhanced coronal T1-weighted MRI is useful for differentiating septic arthritis from transient synovitis.

Acute bone marrow edema of the hip: role of MR imaging

Acute bone marrow edema of the hip is a diagnostic challenge for both radiologists and clinicians. Marrow edema is often seen in patients with hip pain and restriction of motion. In patients with acute non-traumatic hip pain, whose radiographs are negative or inconclusive, MR imaging is the imaging study of choice. MR imaging is the most sensitive and specific imaging technique for detecting transient osteoporosis and osteonecrosis, as well as for detecting and staging fractures and microfractures. MR imaging is able to show marrow involvement in various inflammatory disorders and to diagnose reactive marrow edema from femoroacetabular impingment and greater trochanteric pain syndrome. In patients with septic arthritis, it may also depict associated marrow edema and suggest its reactive or infectious origin. For the neoplastic disorders, although plain radiographs should be the initial examination, MR imaging may follow for assessing extension to the surrounding soft tissues and/or associated pathologic fracture, facilitating thus the treatment planning. Computed tomography is more accurate compared with MR imaging in diagnosing intra-articular osteoid osteomas.