Differential Diagnosis Of Hip Pain Research Articles

CT-guided infiltration of the ischiofemoral space in young patients with ischiofemoral impingement is an effective diagnostic tool.

To present our technique of diagnostic CT-guided ischiofemoral space injection and report on pain response, complications, and associated imaging findings in young patients with ischiofemoral impingement (IFI). Retrospective case series of patients with a clinical diagnosis of IFI that underwent CT-guided IFS injection with local anesthetic in a prone position with the feet in maximum internal rotation between 06/2019 and 04/2021. The response was evaluated using maximum subjective pain evaluation on a 0-10 visual analog scale (VAS) during a standardized pre- and postinterventional clinical examination. Patient charts and radiographic imaging data were reviewed to report associated imaging findings and subsequent surgeries. Eleven patients (13 hips, 9 females) with a median age of 31 years (interquartile range; IQR: 25-37 years) were included. Median baseline VAS was 7 points (IQR: 5-8) with a pain reduction of 5 points (IQR: 5-7 points, p = 0.001) after the injection. One patient reported transient ischial nerve paresthesia, otherwise, no complications occurred. Quadratus femoris muscle edema was present in 85% (11 of 13 hips). Excessively high femoral torsion (11/13 hips, 85%) and cam deformities (8/13 hips, 62%) were the most common osseous deformities. Eight of 13 hips (62%) underwent subsequent surgery for IFI. CT-guided diagnostic injection of the ischiofemoral space is safe and feasible. In young IFI patients, diagnostic IFS injections have the potential to improve the differential diagnosis of hip pain and to inform decision-making with regard to a possible benefit of joint-preserving hip surgery. In young patients with hip pain, diagnosis of IFI can be challenging due to concomitant pathologies. Furthermore, surgical treatment in these patients is controversial. In this context, CT-guided diagnostic infiltrations of the ischiofemoral space may facilitate not only the initial diagnosis of IFI, but could also improve surgical decision-making. CT-guided diagnostic injection of local anesthetic in the ischiofemoral space is safe. In young patients with IFI, it leads to subjective pain reduction. In young patients with concomitant osseous deformities, it may improve surgical decision-making.

The Role of Ultrasonography in Hip Impingement Syndromes: A Narrative Review.

Hip pain is indubitably a frequent clinical problem deriving from copious etiologies. Hip impingement syndromes are one of the most prevalent causes of persistent groin pain, especially in young and active patients. Diligent imaging of the hip region is indispensable to discern femoroacetabular impingement, as the differential diagnosis of hip pain can be exceedingly arduous. Despite hip radiography being plain and broadly attainable, it offers narrow information concerning soft tissue pathologies around the hip joint (extra-articular hip impingement syndromes). Magnetic resonance imaging and arthrography remain the gold standard examination for detecting intra-articular pathologies; however, they are widely considered expensive, time-consuming and characterized by confined. Consequently, ultrasonography has emerged as an alternative valuable diagnostic tool for distinguishing the underlying abnormalities that trigger femoroacetabular impingement. Proper hip ultrasound examination provides dynamic assessment, while also beneficial for guided intervention around the hip joint. Ultrasound hip examination is exacting due to its complex regional anatomy and deep location. It is capable of providing detailed information about various hip quadrants. An adept operator can identify both intra-articular and extra-articular pathologies. In addition, with ultrasonography, hip injections have been rendered relatively undemanding, aiding in therapeutic and diagnostic purposes. This paper aims to provide a succinct and compendious review of the existing literature, accentuating the crucial role of ultrasonography in diagnosing hip impingement syndromes and determining whether an additional examination is required regarding distinguishing between intra-articular and extra-articular syndromes.

Osteoid osteomas of the hip: a well-recognized entity with a proclivity for misdiagnosis

ObjectivesThe diagnosis of osteoid osteomas (OO) about the hip can be challenging as presenting symptoms can mimic other, more common, periarticular pathologies. Our aims were to identify the most common misdiagnoses and treatments, mean delay in diagnosis, characteristic imaging features and provide tips for avoiding diagnostic imaging pitfalls for patients with OO of the hip.MethodsWe identified 33 patients (34 tumors) with OO about the hip who were referred for radiofrequency ablation between 1998 and 2020. Imaging studies reviewed included radiographs (n = 29), CT (n = 34), and MRI (n = 26).ResultsThe most common initial diagnoses were femoral neck stress fracture (n = 8), femoroacetabular impingement (FAI) (n = 7), and malignant tumor or infection (n = 4). The mean time from symptom onset to diagnosis of OO was 15 months (range, 0.4–84). The mean time from initial incorrect diagnosis to OO diagnosis was 9 months (range, 0–46).ConclusionsThe diagnosis of OO of the hip is challenging, with up to 70% of cases initially misdiagnosed as a femoral neck stress fracture, FAI, bone tumor, or other joint pathology in our series. Consideration of OO in the differential diagnosis of hip pain in adolescent patients and awareness of the characteristic imaging findings are critical for making an accurate diagnosis.Key Points• The diagnosis of osteoid osteoma of the hip can be challenging, as demonstrated by long delays in time to initial diagnosis and high rates of misdiagnoses which can lead to inappropriate interventions.• Familiarity with the spectrum of imaging features of OO, especially on MRI, is imperative given the increase in the utilization of this modality for the evaluation of young patients with hip pain and FAI.• Consideration of OO in the differential diagnosis of hip pain in adolescent patients and awareness of the characteristic imaging findings, including bone marrow edema and the utility of CT, are critical for making a timely and accurate diagnosis.

Differential diagnosis of hip pain in children referred to a specialist bone tumour service.

To determine the differential diagnosis of bone lesions causing hip pain in children and the association between radiographic features of aggression and MRI appearances with final diagnosis. Retrospective review of children with hip pain referred to a specialist musculoskeletal oncology service between September 2018 and December 2020. Patient demographics, lesion location, the radiographic and MRI features, and the final diagnosis, which was made either by image-guided biopsy, surgical curettage or based on typical imaging features were recorded. Statistical analysis examined the association between the Lodwick-Madewell score (determined from available radiographs) and MRI findings with final diagnosis. Fifty-nine patients were included, 40 males and 19 females with mean age 10.9 years, (range 3-16 years). Final diagnoses were based on histology in 24 (40.7%) cases and imaging in 35 (59.3%) cases. Eighteen lesions (30.5%) were classed as non-neoplastic, 31 (52.5%) as benign and 10 (16.9%) as malignant, of which four were primary bone sarcomas. There was a significant association between the Lodwick-Madewell score and final diagnosis (p < 0.001). On MRI, bone marrow oedema, presence of a focal lesion, bone expansion and the presence of an extraosseous mass were all significantly associated with final diagnostic classification. The differential diagnosis of hip pain in children presenting to a bone tumour service is wide. Most cases are due to benign or non-neoplastic conditions, with only 10 out of 59 children having a malignant lesion. Radiography complemented by MRI plays a major role in differentiating non-neoplastic, benign neoplastic and malignant lesions and in determining the requirement for needle biopsy. This is the first study to consider how imaging features relate to diagnosis in suspected paediatric hip tumours. Use of this information can help in determining which cases should undergo needle biopsy.

Transitory bone marrow oedema of the hip in pregnant patient with antiphospholipid syndrome: A case report

BackgroundTransient bone marrow oedema (BMO) of the hip presents with pain, is diagnosed by magnetic resonance imaging (MRI), and usually resolves within 6 months. Risk factors include pregnancy. Avascular necrosis of bone and an association with BMO are among the less common presentations of antiphospholipid syndrome (APS). Aim of the workTo present a young Croatian female APS patient who developed transient BMO during pregnancy which spontaneously resolved postpartum. Case reportAfter developing left leg deep vein thrombosis and positive lupus anticoagulant at 22 years old, the patient was diagnosed with primary APS. Antinuclear antibody was borderline, but classification criteria for SLE were not fulfilled. She had an early missed abortion during her first pregnancy while receiving low-weight molecular heparin (LWMH) (enoxaparin 40 mg), and her second pregnancy was to term with LWMH, aspirin, and hydroxychloroquine 200 mg daily. During the third trimester of this pregnancy, she developed excruciating bilateral hip pain to the point she could barely walk. Based on an MRI scan, the patient was diagnosed with bilateral BMO of the femoral head. The condition improved and resolved within four months with conservative treatment postpartum, as confirmed by followup MRI. ConclusionConsidering that pregnancy and APS are risk factors for BMO, both played a role in the development of BMO and the severity of presentation. This case report presents a differential diagnosis of hip pain in pregnant patients, especially with APS. Although APS is commonly associated with AVN, it may also be associated with transient BMO.

Evaluation of Hip Pain and Management of Toxic Synovitis in the Ultrasound Era.

The cause of acute onset hip pain in children can be difficult to determine. Once trauma is excluded, the workup revolves around determining whether there is a hip effusion and eliminating orthopedic emergencies. Point-of-care-ultrasound can be used as an adjunct in the workup. In this article, we review (1) differential diagnosis of hip pain, with a focus on toxic synovitis; (2) the evaluation of a hip for the presence of effusion, including the point-of-care ultrasound technique; and (3) the management of toxic synovitis.

Valgus slipped capital femoral epiphysis: a systematic review.

Valgus slipped capital femoral epiphysis (SCFE) is a rare entity which leads to a proximolateral displacement of the hip epiphysis. The literature on valgus SCFE consists of case reports or case series. Since no evidence synthesis has been conducted, a systematic review on all published cases of valgus SCFE was conducted. The search strategy located 27 studies comprising 74 subjects with 96 hips. Demographic results were as follows: female/male ratio was of 1.65, and the mean age at presentation was 13.0 ± 2.54 years. Bilateral cases were recorded in 31.1%. Hip pain was the most frequent symptom followed by limping. The most frequent clinical sign was the limitation of medial internal rotation. Comorbidities were present in 65.6% of patients, mostly as endocrine or metabolic disorders. The mean neck-shaft angle was 149.2 ± 9.2°, the mean physis-shaft angle was 83.3 ± 9.7°, the neck-physis angle was 36.1 ± 21.5°, and the posterior physeal tilt angle was 23 ± 6.07°. The physeal tilt was lateral in 90% of cases. Treatment was based on screws in 70.8% of cases, a femoral osteotomy in 18.75%, and the remaining had a combination of surgical procedures. Two out of the three screw migrations occurred following fixation with more than one screw. All major complications (8.3%) had the potential of developing osteoarthritis in the future. Valgus SCFE entity demonstrates distinctive demographic, clinical and radiological results. This rare entity should be always included in the differential diagnosis of hip pain or limping in children.

Diagnosing Taper Corrosion: When Is It the Taper and When Is It Something Else?

There has been an increasing use of modularity at the head-neck junction in total hip arthroplasty to more closely mimic the native anatomy, allowing for optimal leg length and stability. Corrosion at this junction in metal-on-polyethylene bearings can lead to an adverse local tissue reaction (ALTR). This increasingly prevalent condition should be considered in the differential diagnosis of hip pain and difficulty ambulating. A recent symposium by the American Academy of Hip and Knee Surgeons described the diagnosis, etiology, management, and prevention of taper corrosion. This article describes the history, physical, plain and advanced imaging findings, laboratory tests, and other diagnoses that should be taken into consideration when diagnosing taper corrosion. The presence of ALTR due to taper corrosion can mimic other diagnoses such as periprosthetic joint infection, instability, or aseptic loosening. Serum metal levels have been found to be the most effective screening tool for identifying corrosion, but other common causes of hip pain and difficulty ambulating should always be ruled out with the use of radiographs and common laboratory techniques before diagnosing ALTR due to corrosion.

Clinical presentation of intra-articular osteoid osteoma of the hip and preliminary outcomes after arthroscopic resection: a case series.

ABSTRACTIntra-articular osteoid osteoma (IAOO) of the hip is a relatively rare diagnosis, but one that can closely mimic symptomatic presentation of femoroacetabular impingement (FAI). Although there are multiple case reports of osteoid osteoma (OO) in the hip, we present the largest case series of hip IAOO treated with hip arthroscopy and discuss limited patient-reported outcomes after treatment with hip arthroscopy. We retrospectively identified patients diagnosed with IAOO of the hip with confirmatory computed tomography, magnetic resonance imaging or biopsy diagnoses of OO. We analyzed lesion location, main presenting symptoms, symptom duration and treatment undertaken. For the patients who underwent hip arthroscopy for treatment of their IAOO, we reviewed patient-reported outcome scores when available.Forty patients with confirmed IAOO were identified. Thirteen underwent excision with hip arthroscopy. The most common presenting symptom was groin pain. In limited patients who had pre- and post-operative outcome scores, we found significant improvements in modified Harris Hip Score (mHHS), Hip Outcome Score-Activity of Daily Living (HOS-ADL) and international Hip Outcomes Tool (iHot33) scores. Compared with patients undergoing hip arthroscopy for FAI alone, baseline mHHS, HOS-ADL, Hip Outcome Score–Sport-Specific Subscale and iHot33 scores were almost identical. We found that the presenting symptoms of hip IAOO closely mimic symptomatic FAI, including groin pain and anterior hip pain, so it is important to keep IAOO of the hip in the differential diagnosis of hip pain. Based on our experience, arthroscopy can be an effective treatment option for excision of intra-articular OO and is especially effective in patients with concomitant FAI in treating both pathologies.

Corrosion of the Head-neck Junction After Total Hip Arthroplasty.

Corrosion of the head-neck junction of implants used in total hip arthroplasty is a complex problem. Clinical severity appears to be multifactorial, and the predictive variables have yet to be consistently identified in the literature. Corrosion should be considered in the differential diagnosis of hip pain following total hip arthroplasty regardless of the type of bearing surface used. The most common presentation, pain followed by instability, is similar to complications associated with metal-on-metal articulations. The diagnosis of implant corrosion of the head-neck junction can be challenging; an infection workup should be performed along with analysis of serum metal ion levels and cross-sectional imaging. In the short term, a well-fixed stem may be retained, and the exchange of an isolated head with a ceramic femoral head seems to be a promising option for certain implants. Further research with longer follow-up is warranted, and high levels of evidence are needed to determine whether this approach is generalizable.

Hip Arthroscopy for Excision of Osteoid Osteoma of Femoral Neck

Osteoid osteoma (OO) is the most commonly seen benign bone-forming lesion. It can occur anywhere, including the metaphyseal regions of small and large bones. We present 2 cases that underwent an arthroscopic technique for removal of OO of the femoral neck. The diagnosis was confirmed by computed tomography in addition to magnetic resonance imaging. The lesions were accessed arthroscopically and excised by unroofing and curettage. The clinical and radiographic findings are presented, along with the surgical management. The patients improved dramatically postoperatively. OO of the femoral neck should be included in the differential diagnosis of hip pain in young patients. Arthroscopic excision and curettage provide a good choice for management, with low morbidity and rapid recovery.

An algorithmic approach to mechanical hip pain.

As our understanding of hip pathology evolves, the focus is shifting toward earlier identification of hip pathology. Therefore, it is vitally important to elucidate intra-articular versus extra-articular pathology of hip pain in every step of the patient encounter: history, physical examination, and imaging. The objective was to address the following research questions: (1) Can an algorithmic approach to physical examination of a painful non-arthritic hip provide a more accurate diagnosis and improved treatment plan? (2) Does an anatomical layered concept of clinical diagnosis improve diagnostic accuracy? (3) What are the diagnostic tools necessary for the accurate application of a four-layer (osteochondral, inert, contractile, and neuromechanical) diagnosis? An unrestricted computerized search of MEDLINE was conducted. Different terms were used in various combinations. An algorithmic approach to physical examination of a painful nonarthritic hip, including history, physical examination (specific tests), and advanced imaging allow for better interpretation of debilitating intra- and extra-articular disorders and their effect on core performance. Additionally, it improves our understanding as to how underlying abnormal joint mechanics may predispose the hip joint and the associated hemipelvis to asymmetric loads. These abnormal joint kinematics (layer I) can lead to cartilage and labral injury (layer II), as well as resultant injury to the musculotendinous (layer III) and neural structures (layer IV) about the hip joint and the hemipelvis. The layer concept is a systematic means of determining which structures about the hip are the source of hip pathology and how to best implement treatment. A clear understanding of the differential diagnosis of hip pain through a detailed and systematic physical examination, diagnostic imaging assessment, and the interpretation of how mechanical factors can result in such a wide range of compensatory injury patterns about the hip can facilitate the diagnosis and treatment recommendations.

Atrapamiento femoroacetabular

Femoroacetabular impingement (FAI) is a clinical and radiological syndrome resulting from repetitive abutment between the acetabular rim and the femur. This syndrome should be included in the differential diagnosis of hip pain, especially in the young. The most important imaging technique for suspected FAI is standard radiology, but the gold-standard for diagnosis is arthro-magnetic resonance imaging (MRI). The cornerstone of treatment is surgery but outcome depends on several factors such as physical activity, FAI type, disease duration, surgical technique and, especially, whether the cartilage is damaged. For non-prosthetic surgical treatment to be effective, early diagnosis of FAI is essential. Late diagnosis, when hip osteoarthritis is already present, limits surgery to hip replacement.

Bilateral Hip Pain Caused by Adductor Pyomyositis as the Initial Presentation of Chronic Myeloid Leukemia in a 17-Year-Old Child

Pyomyositis is a pyogenic muscular tissue infection mainly occurring in immunocompromised patients. Chronic myeloid leukemia (CML) accounts for only 2-3% of cases of childhood leukemia. Herein, we report on a 17-year-old male with bilateral hip pain caused by adductor pyomyositis before beginning the treatment course of CML. CML was diagnosed by bone marrow chromosome study and was treated initially with imatinib but switched to hydroxyurea 5 days later because of poor cytoreduction response. Subsequently, white blood cell counts decreased gradually; however, the hyperleukocytosis condition resolved very slowly again until we switched back to imatinib use on the 40(th) day of hospitalization. Pyomyositis was diagnosed by magnetic resonance imaging. Oxacillin was administered to cover Staphylococcus aureus, the most common pathogen of pyomyositis. Bilateral hip pain improved within 72 hours after antibiotic usage, but follow-up magnetic resonance imaging after 15 days of treatment revealed well-defined abscess and osteomyelitis of both femoral heads. Abscess incision and drainage were performed, and cultures of the drained pus grew no microorganisms. The patient completed 5 weeks of oxacillin treatment after the operation and recovered with a full range of motion of both hips. There was no residual disability. This is the first report of bilateral hip pain caused by pyomyositis as the initial presentation of CML. Pyomyositis needs to be considered in the differential diagnosis of hip pain in pediatric patients.

Transient Bone Marrow Oedema Syndrome: A Report of Two Cases

Transient bone marrow edema syndrome (TBMES) is a disorder with unknown etiology and must be included in the differential diagnosis of hip pain. TBMES generally has a good prognosis but, it can be result in avascular necrosis (AVN). We present two cases diagnosed with TBMES, one of whom experienced full remission and the other who developed AVN.

Beitrag zur Differentialdiagnose des kindlichen Hüftschmerzes in der MR-Tomographie

The efficiency of spin echo tomography in the differential diagnosis of hip joint pain in children in comparison with other imaging methods was tested in 115 spin echo tomography examinations of 68 patients. By means of the different modes available it was possible to determine joint effusion, necrosed areas and the formation of abscesses with great accuracy. In the case of Legg-Calve-Perthes disease the MRT is especially in the early diagnosis superior to the other Methods, already in the early stage a classification in the four Catterall groups was possible. Furthermore the "head at risk" signs, except the gage-sign, were better to describe by BRI than by conventional x-rays. The MRT allows an exacter staging and a better observation of the course of disease, especially the beginning of the revitalisation of the femora epiphysis in earlier and clearer visible than in other imaging methods. Further diseases like epiphysial dysplasie, specific and unspecific coxitis and slipped capital femora epiphysis were also investigated. We regard spin echo examination in the differential diagnosis of hip pain in children indicated by the following criteria: 1. with over six weeks uncertain differential diagnosis of coxitis fugax and Legg-Calve-Perthes disease 2. with Legg-Calve-Perthes disease in the early stage for therapy option 3. with TBC- and non-TBC-coxitis as a therapy attend and diagnostic measure.

Hip and Pelvic Problems in Athletes

In the athletic population, the differential diagnosis of hip pain is quite broad and must include intra-articular pathology, extra-articular pathology, and central pubic pain associated with athletic pubalgia. In addition to an appropriately performed history and physical examination, advanced imaging techniques, including magnetic resonance imaging (MRI) and ultrasound, often are required to narrow the differential diagnosis. MRI is an excellent modality to image the pelvis and hip because of its ability to screen the pelvis for other etiologies of pain, its superior soft-tissue contrast, which allows visualization of the articular cartilage, fibrocartilaginous labrum, and myotendinous junctions, and its lack of ionizing radiation. During the last decade, the management of hip injuries has evolved substantially as a result of the advancement in techniques and flexible instrumentation for hip arthroscopy. Currently, a variety of hip pathologies may be addressed arthroscopically, including labral tears, loose bodies, femoroacetabular impingement, coxa saltans, ligamentum teres injuries, and capsular laxity. This article will focus on common etiologies of hip and pelvis pain in the athletic population with an emphasis on the use of hip arthroscopy to treat these disorders.

Hip Arthroscopy in the Athletic Patient: Current Techniques and Spectrum of Disease

Over the last decade, the management of hip injuries has evolved substantially due to the advancement of techniques in arthroscopy and diagnostic tools such as magnetic resonance imaging. Arthroscopy of the hip remains a challenge due to the osseous and soft-tissue constraints of the hip. Currently, various hip lesions, including labral tears, loose bodies, femoroacetabular impingement, coxa saltans (snapping hip syndrome), ligamentum teres injuries, and capsular laxity, can be successfully treated arthroscopically. As continued improvements are made in surgical techniques and in specifically designed instrumentation for the hip, the indications for arthroscopy will continue to increase and arthroscopy of the hip will become a standard procedure performed by an increasing number of orthopaedic surgeons. After reviewing this article, the reader should: (1) have a basic understanding of the intra-articular and extra-articular hip disorders that commonly occur in athletes; (2) be able to generate a differential diagnosis for hip pain; (3) have a basic understanding of the relevant anatomy, patient history, and physical examination findings for an athlete who presents with hip pain; and (4) be able to identify normal and abnormal findings on radiographic and magnetic resonance imaging studies. The differential diagnosis of hip pain in an athletic patient is quite broad (Table I). A complete history and physical examination are necessary in order to determine the source and cause of the pain. It is still common to ascribe hip pain in an athlete to a muscle strain or a soft-tissue contusion. However, hip pain may arise from a number of soft-tissue structures in and around the hip joint, and it is important to be able to differentiate extra-articular from intra-articular abnormalities. The physician should elicit information from the patient with regard to the specific location of the discomfort, the qualitative nature of the discomfort (such as catching, clicking, instability, …

Hip pain in adults: MR imaging appearance of common causes

To determine the exact origin of hip pain can be challenging. Symptoms apparently originating from the hip may arise from the pelvis, the sacroiliac joint, the lumbar spine, periarticular structures such as muscles and bursae, or from unexpected sites such as the abdominal wall, the genitourinary tract, or the retroperitoneal space. This article reviews the differential diagnosis of hip pain arising from the hip and surrounding structures and the role of different imaging methods with emphasis on magnetic resonance imaging where most recent advances have occurred.

Bone marrow edema syndrome of the hip

Bone marrow edema syndrome (BMES) is a rare clinical condition. Its etiology is unknown and it can be seen in different locations. In the case of the hip, avascular necrosis is the main differential diagnosis. To present our experience of BMES of the hip and a review of the literature. Retrospective analysis of clinical records of patients with hip pain that met clinical, radiological, and magnetic resonance imaging criteria for BMES. Clinical outcome and clinical and radiological follow up are presented. Two men and two women (one of them pregnant) aged 42, 48, 36 and 26 years old, fulfilled criteria. Treatment included limited weight bearing, non steroidal antiinflammatory drugs, intranasal calcitonin and physical therapy. Complete remission of symptoms was observed within five to seven months. At an average follow up of 36 months, all patients presented complete function of the hip, returning to their previous activity levels, with no new episodes of BMES. It is important to be aware of this condition as part of the differential diagnosis of hip pain to avoid aggressive and unnecessary diagnostic and therapeutic procedures.