Trochanteric Tenderness Research Articles

Abductor Muscle Function and Trochanteric Tenderness After Hemiarthroplasty for Femoral Neck Fracture

Objectives: To compare the abductor muscle function and trochanteric tenderness in patients operated with hemiarthroplasty using the direct lateral (DL) or posterolateral (PL) approach for displaced femoral neck fracture. Design: Prospective cohort study. Setting: A secondary teaching hospital. Participants: We enrolled 183 hips operated with hemiarthroplasty for displaced femoral neck fracture using the DL or PL approach. Interventions: Preoperatively, we evaluated the Harris hip score (HHS) and European Quality of Life-5 Dimensions (EQ-5D). At 1 year postoperatively, lucid patients were clinically examined to evaluate the Trendelenburg sign, abductor muscle strength with a dynamometer, and trochanteric tenderness with an electronic algometer. The 1-year HHS and EQ-5D were documented. Main Outcome Measures: The primary outcome was the incidence of postoperative Trendelenburg sign, whereas the secondary outcomes included patients' reported limp, abductor muscle strength, trochanteric tenderness, HHS, and EQ-5D. Results: There were 48 patients (24 in the DL group and 24 in the PL group) who attended the 1-year clinical follow-up. The 2 groups were comparable (P > 0.05). The DL group showed a higher incidence of the Trendelenburg sign (9/24 vs. 1/24, P = 0.02) and limp (12/24 vs. 2/24, P = 0.004). Further analysis with logistic regression showed the surgical approach to be the only factor that resulted in the increment. No differences regarding HHS, EQ-5D, abductor muscle strength, algometer pressure pain threshold, and radiologic measurements were found (P > 0.05). Conclusions: The incidence of the Trendelenburg sign and limp were significantly higher in the DL approach although this seemed not to influence abductor muscle strength or the incidence of trochanteric tenderness or compromise the clinical outcome. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Abductor Muscle Function and Trochanteric Tenderness After Hemiarthroplasty for Femoral Neck Fracture

To compare the abductor muscle function and trochanteric tenderness in patients operated with hemiarthroplasty using the direct lateral (DL) or posterolateral (PL) approach for displaced femoral neck fracture. Prospective cohort study. A secondary teaching hospital. We enrolled 183 hips operated with hemiarthroplasty for displaced femoral neck fracture using the DL or PL approach. Preoperatively, we evaluated the Harris hip score (HHS) and European Quality of Life-5 Dimensions (EQ-5D). At 1 year postoperatively, lucid patients were clinically examined to evaluate the Trendelenburg sign, abductor muscle strength with a dynamometer, and trochanteric tenderness with an electronic algometer. The 1-year HHS and EQ-5D were documented. The primary outcome was the incidence of postoperative Trendelenburg sign, whereas the secondary outcomes included patients' reported limp, abductor muscle strength, trochanteric tenderness, HHS, and EQ-5D. There were 48 patients (24 in the DL group and 24 in the PL group) who attended the 1-year clinical follow-up. The 2 groups were comparable (P > 0.05). The DL group showed a higher incidence of the Trendelenburg sign (9/24 vs. 1/24, P = 0.02) and limp (12/24 vs. 2/24, P = 0.004). Further analysis with logistic regression showed the surgical approach to be the only factor that resulted in the increment. No differences regarding HHS, EQ-5D, abductor muscle strength, algometer pressure pain threshold, and radiologic measurements were found (P > 0.05). The incidence of the Trendelenburg sign and limp were significantly higher in the DL approach although this seemed not to influence abductor muscle strength or the incidence of trochanteric tenderness or compromise the clinical outcome. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Bipolar hemiarthroplasty for primary abductor deficiency with femoral neck fracture.

Bipolar hemiarthroplasty for primary abductor deficiency with femoral neck fracture.

The short-term functional and radiological outcome of patients treated with the Synthes proximal femoral nail antirotation (PFNA) for unstable proximal femoral fractures

Between April 2006 and December 2007, 74 patients with unstable proximal femoral fractures were treated with the proximal femoral nail antirotation (PFNA). Follow-up to union was achieved for 55 nails in 52 patients. Fifteen patients (20% of the total) died during the initial 4-month follow-up period. Clinical 4-month follow-up was completed in 83% (45 of 54 patients). Radiological follow-up to union was completed in 96% (52 of 54 patients). The mean age was 78.5 years with 10 males and 44 females. The mean tip apex distance was 22 mm. The mean migration in tip apex distance was 0.8 mm, and no blade cut out was seen. In six patients, the distal locking bolts migrated or became loose. Almost one-third of patients had trochanteric tenderness. The mean visual analogue score (VAS) at follow-up was 3/10. The mobility and social function scores were significantly reduced at follow-up compared to preoperative status (P = 0.001). All domains of short-form 36 (SF36) were low compared to normative data.

The Diagnostic Accuracy of a Clinical Examination in Determining Intra-articular Hip Pain for Potential Hip Arthroscopy Candidates

One purpose of this study was to determine whether signs and symptoms could identify when a majority of the hip pain was originating from intra-articular sources in potential arthroscopic surgery candidates. The second purpose was to quantify pain reduction after an anesthetic intra-articular injection in those with potential labral pathology. Subjects with hip pain being evaluated by an orthopaedic surgeon specializing in hip arthroscopy were prospectively enrolled in the study. Clinical examination results were recorded. Sensitivity, specificity, and likelihood ratios were calculated to determine their accuracy in identifying those who would have greater than 50% pain relief from those with 50% pain relief or less. We enrolled 105 subjects in this study. An anesthetic intra-articular injection was performed in 49 potential candidates for arthroscopic surgery (47%). The mean age in these 49 subjects was 42 years (SD, 15 years; range, 18 to 68 years), with 25 men (51%) and 24 women (49%). According to magnetic resonance imaging (MRI) arthrogram, 18 individuals had a definite labral tear, 29 had a possible tear, and 2 had no labral tears. In those with definite tears or possible tears, 39% (n = 7) and 45% (n = 13), respectively, did not achieve a greater than 50% reduction of pain. Groin pain, clicking, pinching pain with sitting, lateral thigh pain, flexion abduction external rotation test, flexion-internal rotation-adduction test, and trochanteric tenderness were not useful in identifying those with greater than 50% pain relief from those with 50% relief or less. The symptoms and signs investigated in this study did not accurately or consistently identify subjects with primary intra-articular pain sources. Furthermore, candidates for hip arthroscopy with a labral tear identified on MRI arthrogram had varied responses to anesthetic intra-articular injection. Therefore all labral tears identified on MRI arthrogram may not be a major contributor to patients' pain complaints, and medical personnel should look for other causes of pain. Level III, diagnostic study of nonconsecutive patients (without consistently applied gold standard).

Leg-length inequality is not associated with greater trochanteric pain syndrome

IntroductionGreater trochanteric pain syndrome (GTPS) is a common condition, the pathogenesis of which is incompletely understood. Although leg-length inequality has been suggested as a potential risk factor for GTPS, this widely held assumption has not been tested.MethodsA cross-sectional analysis of greater trochanteric tenderness to palpation was performed in subjects with complaints of hip pain and no signs of hip osteoarthritis or generalized myofascial tenderness. Subjects were recruited from one clinical center of the Multicenter Osteoarthritis Study, a multicenter population-based study of community-dwelling adults aged 50 to 79 years. Diagnosis of GTPS was based on a standardized physical examination performed by trained examiners, and technicians measured leg length on full-limb anteroposterior radiographs.ResultsA total of 1,482 subjects were eligible for analysis of GTPS and leg length. Subjects' mean ± standard deviation age was 62.4 ± 8.2 years, and 59.8% were female. A total of 372 lower limbs from 271 subjects met the definition for having GTPS. Leg-length inequality (difference ≥ 1 cm) was present in 37 subjects with GTPS and in 163 subjects without GTPS (P = 0.86). Using a variety of definitions of leg-length inequality, including categorical and continuous measures, there was no association of this parameter with the occurrence of GTPS (for example, for ≥ 1 cm leg-length inequality, odds ratio = 1.17 (95% confidence interval = 0.79 to 1.73)). In adjusted analyses, female sex was significantly associated with the presence of GTPS, with an adjusted odds ratio of 3.04 (95% confidence interval = 2.07 to 4.47).ConclusionThe present study found no evidence to support an association between leg-length inequality and greater trochanteric pain syndrome.

The Interrater Reliability of 4 Clinical Tests Used to Assess Individuals With Musculoskeletal Hip Pain

Descriptive and reliability study. To evaluate the interrater reliability of the FABER test, flexion-internal rotation-adduction impingement test, log roll test, and the palpation of the greater trochanter for tenderness. Clinical examination for individuals with musculoskeletal hip pain is believed to provide critical diagnostic information. However, there is very limited information in the literature on the reproducibility of examination techniques for the hip region. Seventy subjects were evaluated prospectively by an orthopaedic surgeon and physical therapist. Subjects had a mean age of 42 years (range 18-76 years; SD 15.4) and included 32 (46%) females and 38 (54%) males. Subject diagnoses were as follows: degenerative joint disease (n=27 [39% of subjects]), labral tear (n=35 [50% of subjects]), femoroacetabular impingement (n=48 [69% of subjects]), capsular laxity (n=28 [40% of subjects]), trochanteric bursitis (n=29 [41% of subjects]), iliopsoas tendonitis (n=10 [14% of subjects]), and adductor strain (n=2 [3% of subjects)]. Subjects could have more than 1 diagnosis. Kappa, prevalence indexes, bias indexes, and maximal attainable kappa were calculated. Kappa (kappa) coefficients with 95% confidence intervals (CI) were as follows: FABER test kappa was 0.63 (95% CI: 0.43-0.83); flexion-internal rotation-adduction impingement test kappa was 0.58 (95% CI: 0.29-0.87); log roll test kappa was 0.61 (95% CI: 0.41-0.81); and greater trochanteric tenderness kappa was 0.66 (95% CI: 0.48-0.84). Bias indexes were low (0.06-0.08) for all 4 tests while prevalence indexes were low (0.03-0.37) for 3 of the 4 tests. The flexion-internal rotation-adduction impingement test had a high prevalence index (0.76), with a higher proportion of positive tests. The kappa values for the FABER test, log roll test, and assessment of greater trochanteric tenderness were greater than 0.40 (fair level of agreement) at a 95% confidence level. The low reliability obtained for the flexion-internal rotation-adduction impingement test may be related to a prevalence concern.

Greater Trochanteric Pain Syndrome: Epidemiology and Associated Factors

Segal NA, Felson DT, Torner JC, Zhu Y, Curtis JR, Niu J, Nevitt MC, for the Multicenter Osteoarthritis (MOST) Study Group. Greater trochanteric pain syndrome: epidemiology and associated features. Objectives To describe the prevalence of greater trochanteric pain syndrome (GTPS); to determine whether GTPS is associated with iliotibial band (ITB) tenderness, knee osteoarthritis (OA), body mass index (BMI), or low back pain (LBP); and to assess whether GTPS is associated with reduced hip internal rotation, physical activity, and mobility. Design Cross-sectional, population-based study. Setting Multicenter observational study. Participants Community-dwelling adults (N=3026) ages 50 to 79 years. Interventions Not applicable. Main Outcome Measures Greater trochanteric tenderness to palpation in subjects with complaints of hip pain and no signs of hip OA or generalized myofascial tenderness. Results The prevalence of unilateral and bilateral GTPS was 15.0% and 8.5% in women and 6.6% and 1.9% men. Odds ratio (OR) for women was 3.37 (95% confidence interval [CI], 2.67−4.25), but age and race were not significantly associated with GTPS. In a multivariate model, adjusting for age, sex, ITB tenderness, ipsilateral and contralateral knee OA, BMI, and LBP, ITB tenderness (OR=1.72; 95% CI, 1.34−2.19), knee OA ipsilaterally (OR=3.47; 95% CI, 2.72−4.42) and contralaterally (OR=1.74; 95% CI, 1.32−2.28), and LBP (OR=2.79; 95% CI, 2.22−3.50) were positively related to GTPS. In this complete model, BMI was not associated with GTPS (OR=1.10; 95% CI, 0.80−1.52 when comparing ≥ 30 with <25kg/m 2). Hip internal rotation range of motion did not differ based on GTPS status. After multivariate adjustment, GTPS did not alter physical activity score, but bilateal GTPS was significantly associated with a higher 20-meter walk time and chair stand time. Conclusions The higher prevalence of GTPS in women and in adults with ITB pain or knee OA indicates that altered lower-limb biomechanics may be related to GTPS. Slower functional performance in those with GTPS suggests that the study of targeted rehabilitation may be useful. A longitudinal study will be necessary to identify causal factors and outcomes of interventions.

The Reliability and Validity of Clinical Tests Used to Assess Individuals with Potential Labral Tears of the Hip (SS-20)

The purpose of this study was to determine the reproducibility and diagnostic accuracy of clinical tests used to examine individuals with potential labral tears of the hip. Specifically, the inter-tester reliability of the FABER, flexion-internal rotation impingement, and log roll tests as well as an assessment for greater trochanteric tenderness was examined. The diagnostic accuracy of the FABER, flexion-internal rotation impingement, flexion-external rotation tests in identifying individuals with a labral tear was also examined. We hypothesized that the four clinical tests would demonstrate moderate agreement (kappa coefficient >.40) in inter-tester reliability assessment. Additionally, we was hypothesized that the clinical tests would demonstrate sensitivity and specificity values >.5 with likelihood ratio for a positive test >1 for diagnosing a labral tear. All patients evaluated by an orthopaedic surgeon specializing in hip arthroscopy for a musculoskeletal hip problem were included in the study. These 85 subjects had a mean age of 41 (range 15-76 SD 14.9) with 40 females and 45 males. 41% of the subjects reported their symptom duration to be 1 year or less while 59% reported their symptom duration to be greater than 1 year. The results of the clinical tests performed by the orthopaedic surgeon were compared to the results obtained by a physical therapist with 15 years experience. Kappa coefficients were calculated to assess inter-tester reliability. As previously documented, the strength of agreement for kappa (κ) was interpreted as follows: ≤ 0=poor, .01-.2=slight, .21-.40 fair, .41-.60=moderate, .61-.80=substantial, .81-.1=almost perfect. The results of the clinical tests were compared to magnetic resonance arthrogram (MRA) results in identifying individuals with a labral tear. Diagnostic accuracy of the clinical test was assessed by calculating sensitivity, specificity, and likelihood ratios. As hypothesized clinical tests had better than moderate agreement with kappa values as follows: Flexion-internal rotation impingement test κ =.69, log roll test κ =.53, greater trochanteric tenderness κ =.72 and FABER test κ =. 45. Diagnostic accuracy of clinical tests in diagnosing individuals with a labral tear was as follows: Flexion-internal rotation impingement test sensitivity =.75, specificity =.07 and a positive likelihood ratio = .81; FABER sensitivity =.65, specificity =.19 and positive likelihood ratio =.80; Flexion with external rotation sensitivity =.29, specificity =.67 and positive likelihood ratio = .89. The flexion-internal rotation impingement test, log roll test and assessment for greater trochanteric tenderness seem to be reliable clinical tests. The reliability of the FABER test seems to less than the other clinical examination tests. While the flexion-internal rotation and FABER had very high sensitivity, the specificity was low. Contrary to this the flexion-external rotation test had low sensitivity but high specificity. Further studies are needed to examine the diagnostic accuracy of these tests when exam findings are clustered together. In conclusion, the results of this study will allow the clinical examination for an individual with a potential labral tear to be more meaningfully interpreted.

Evidence-Based Soft Tissue Rheumatology

Trochanteric bursitis is a term used to name a syndrome that features pain and tenderness over the greater trochanter. Present evidence suggests that in the majority of cases, symptoms result from pathology of the gluteus medius or minimus muscles rather than a bursa. Lower limb length discrepancy, iliotibial band contracture, hip osteoarthritis and lumbar spondylosis are often mentioned, but no proved as predisposing factors. After a lumbar spine or hip and other local pathology have been considered and clinically excluded, the clinical features of the syndrome, ie lateral location of pain plus characteristic trochanteric tenderness are usually sufficient to reach a diagnosis. Most patients with trochanteric bursitis can be successfully treated with a NSAID, physiotherapy plus a local corticosteroid injection. The few refractory cases are often treated surgically. Disappointingly, none of the therapeutic interventions used in trochanteric bursitis have been validly assessed.

人工股関節置換術における前側方アプローチ（Ｈａｒｄｉｎｇｅ法とＤａｌｌ法）の有用性と問題点

Primary total hip arthroplasties were performed on 74 hips between 1998 and2001 at our hospital. We used the Hardinge approach on 36 hips of patients whose age ranged from 46 to 80 years (mean : 63.2 years) and Dall approach on 38 hips of patients whose age ranged from 43 to 76 years (mean : 60.2 years). Postoperative followup was carried out for over one year (mean : Hardinge 24.0 months,Dall 39.4 months).The results revealed trochanteric tenderness in 9 Hardinge hips and 4 Dall hips more than 12 months from operation. Radiological tests indicated abnormal assification in 13 Hardinge hips and seven Dall hips, and abnormal assification with trochanteric tenderness in seven Hardinge hips and one Dall hip during the same period.

Heterotopic ossification after treatment of femoral head osteonecrosis with free vascularized fibular graft

This study evaluated patients with heterotopic ossification after implantation of a free vascularized fibular graft for the treatment of femoral head osteonecrosis. We hypothesized that the osteogenic tendency of these patients might enhance the graft–host union and new bone formation in the femoral head, although the presence of heterotopic ossification might influence adversely the clinical result. Of patients with femoral head osteonecrosis, 32% developed heterotopic ossification after treatment with free vascularized fibular graft. Heterotopic bone formation did not influence the efficacy of the procedure to preserve the hip joint. The radiographic and clinical results and the rate of subsequent total hip arthroplasty were not affected by the heterotopic bone, but local trochanteric tenderness was associated with large heterotopic lesions. Copyright 2003, Elsevier Science (USA). All rights reserved.