The symptomatic hip in childhood: scintigraphic findings in the presence of a normal radiograph

The principal causes in children of a nonacute painful hip are Perthes disease and synovitis (irritable hip). The ^99mTc methylene diphosphonate (MDP) bone scan appearances in Perthes disease are well-known; in synovitis, the hip may show a diffuse increase in activity or may be normal. The significance of bone scintigraphy in the clinical setting of non-acute hip symptoms with normal skeletal radiography has been evaluated in 36 symptomatic children. The mean duration of symptoms prior to scan was 3 months (range 1 week-17 months). On the basis of final diagnosis, established by clinical findings, bone scan, X-ray and follow-up, the children were divided into two groups: synovitis or Perthes disease. Of the 33 scans in the 32 children with synovitis, 18 were normal and 15 showed diffusely increased activity on the painful side. All four patients with Perthes disease had focal femoral head abnormalities in the painful hip. Of the 18 children with normal scans, none went on to develop a skeletal disorder. In children with hip pain of over 1 week's duration, the main value of the bone scan is the early detection of Perthes disease. Diffuse increased activity on the painful side suggests synovitis. A normal scan virtually excludes significant skeletal abnormality.     

Isotope scanning in the “irritable hip syndrome”

A study of isotope scanning in children with irritable hip syndrome has demonstrated its role as a discriminator between Perthes disease and transient synovitis. Three children with normal radiographs had Perthes changes on scanning and went on to develop X-ray changes. An anatomical and pathological basis for the scan abnormalities is suggested.     

Sport bei Hüftgelenkserkrankungen im Kindes- und Jugendalter

Children and adolescents suffering from hip disorders are often compromised in their physical activity and sports. The typical hip diseases in this age group are hip dysplasia, Perthes disease, Slipped Capital Femoral Epiphysis and transient synovitis of the hip. On the one hand athletic overuse can provoke hip symptoms and on the other hand sports activities need to be restricted in ongoing or past hip diseases. It is important to follow patients until growth arrest to recognize and possibly treat secondary hip deformities and early osteoarthritis.     

Perthes disease

The Legg-Calve-Perthes disease is an idiopathic avascular necrosis of the hip during early childhood. It is characterized by different stages with the main risk of persisting hip deformation, dysfunction of the joint movement, and the potential for early osteoarthritis. For the evaluation of prognosis and therapy planning patients age and extent of the necrotic area of the epiphysis are important factors. For an early diagnosis and sufficient therapy all radiological efforts have to be performed. MR imaging is an ideal method for the assessment of osteonecrotic changes of the Morbus Perthes. Compared to plain radiography by MR imaging pathologic alterations can be detected earlier and with higher specificity. However, conventional radiograms have to be still used as basic imaging modality. Nowadays x-rays and MR imaging should be the main methods for the evaluation of children suffering from Perthes disease.     

Compensatory sagittal plane ankle gait mechanics: Are they present in patients with a weak or stiff hip?

IntroductionSimulations suggest that subjects with reduced hip range of motion (ROM) and/or weakness can achieve more normal walking mechanics through compensations at the ankle. The aims of this study were to assess whether subjects with reduced hip ROM (Stiff hip) or hip flexor weakness (Weak hip) exhibit ankle compensations during walking and investigate redistribution of power in the lower extremity joints.MethodsRetrospective gait data were reviewed (IRB-approved hip registry). Preoperative kinematic/kinetic walking data were collected in patients with: adolescent hip dysplasia (AHD), femoral acetabular impingement (FAI), and Legg-Calvé Perthes disease (Perthes). AHD patients with significantly weak hip flexors on their affected side were included (Weak hip group). The Gait Profile Score (GPS) was calculated on the affected side of the FAI and Perthes groups to identify patients who had a Stiff hip. Patients who had undergone a hip arthrodesis (Fusion) were also included (Stiff hip group). Ankle kinematics/kinetics were compared to healthy participants (Control). The total positive work of sagittal plane hip, knee and ankle power were compared along with the distribution of power.ResultsPatients in the Weak/Stiff hip groups did not walk with greater ankle plantarflexion, peak push-off power or positive ankle work on their affected sides compared to Control. Ankle work contribution (percentage of total positive work) on the affected or unaffected sides was greater in the Perthes and Hip Fusion patients compared to Control. Significant gait abnormalities on the unaffected side were observed.ConclusionsPatients with a weak or stiff hip did exhibit altered ankle mechanics during walking. Greater percent ankle work contribution appeared to correspond with hip stiffness. In patients with hip pathology the redistribution of power among the lower extremity joints can highlight the importance of preserving ankle function.     

Hip ultrasound

In newborns, US has an established role in the detection and management of developmental dysplasia of the hip. Later in childhood, when the limping child is a major diagnostic dilemma, US is extremely helpful in the identification of the varied disease processes underlying this condition, as transient synovitis, septic arthritis, Perthes disease and slipped femoral capital epiphysis. In adolescent practicing sporting activities, US is an excellent means to identify apophyseal injures about the pelvic ring, especially when avulsions are undisplaced and difficult-to-see radiographically. Later on, in the adulthood, US is an effective modality to diagnose tendon and muscle injuries about the hip and pelvis, identify effusion or synovitis within the hip joint or its adjacent bursae and guide the treatment of these findings. The aim of this article is to provide a comprehensive review of the most common pathologic conditions about the hip, in which the contribution of US is relevant for the diagnostic work-up.     

Irritable bowel syndrome complaints following the uprising of December 1989 in Romania

Irritable bowel syndrome has a strong psychogenic component. One of its features is the influence of stress on the clinical state. An increased amount of irritable‐bowel‐like symptoms within the first month following the uprising in Romania in December 1989 is reported. These symptoms seem to be related to the impressive amount of stress developed by dramatic events presented live on television and watched by the population. Several new cases as compared to the previous year were also reported by our group for the study of psychogenic factors in irritable bowel syndrome.     

The effects of exercise upon symptoms and quality of life in patients diagnosed with irritable bowel syndrome: a randomised controlled trial

While it seems intuitively appealing to promote participation in regular exercise in the management of irritable bowel syndrome, limited randomised controlled trial evidence exists to support this recommendation. We examined the feasibility and effects of an exercise intervention upon quality of life and irritable bowel symptoms using a randomised controlled trial methodology. Patients with a clinically confirmed diagnosis of irritable bowel syndrome according to Rome II criteria were randomised to either an exercise consultation intervention or usual care for 12 weeks. Outcomes included irritable bowel specific quality of life, symptoms (total symptoms, constipation, diarrhoea and pain) and exercise participation. The recruitment rate of eligible patients identified from hospital records was 18.3 % (56/305). Analyses revealed no differences in quality life scores between groups at 12-week follow-up. The exercise group reported significantly improved symptoms of constipation (mean difference = 10.9, 95 % CI = - 20.1, - 1.6) compared to usual care at follow-up. The intervention group participated in significantly more exercise than usual care at follow-up (mean difference = 21.6, 95 % CI = 9.4, 33.8). Recruitment of eligible patients into this study was possible but rates were low. Findings highlight the possibility that exercise may be an effective intervention for symptom management in patients with irritable bowel syndrome; this may be particularly the case for constipation predominant patients.     

Hip arthroscopy: current indications, treatment options, and management issues

The management of hip injuries in athletes has evolved significantly in the past few years with the advancement of arthroscopic techniques. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in both recreational and elite athletes. Recent advancements in both hip arthroscopy and magnetic resonance imaging have elucidated several sources of intraarticular abnormalities that result in chronic and disabling hip symptoms. Many of these conditions were previously unrecognized and, thus, left untreated. Current indications for hip arthroscopy include the presence of symptomatic acetabular labral tears, hip capsule laxity and instability, chondral lesions, osteochondritis dissecans, ligamentum teres injuries, snapping hip syndrome, iliopsoas bursitis, and loose bodies (for example, synovial chondromatosis). Less common indications include management of osteonecrosis of the femoral head, bony impingment, synovial abnormalities, crystalline hip arthropathy (gout and pseudogout), infection, and posttraumatic intraarticular debris. In rare cases, hip arthroscopy can be used to temporize the symptoms of mild-to-moderate hip osteoarthritis with associated mechanical symptoms. This article discusses the current clinical and radiographic methods to detect early hip joint disease and the current indications and surgical techniques of hip arthroscopy.     

Perthes病17例治疗分析

目的回顾性分析Perthes病治疗的经验,结合系统文献复习,以确定治疗的指征和方法。方法17例(平均6.4岁)Perthes病中,CatterallⅠ型3例,Ⅱ型4例,Ⅲ型7例,Ⅳ型3例。分别采取支具或石膏固定(4例),滑膜切除髓腔减压或植骨(3例),Salter或Chairi截骨治疗(10例)。采用临床和X线片动态随访,按Stulberg标准进行疗效评价。结果术后平均随访24(6~52)个月。4例采用石膏或支具外固定的CatterallⅠ和Ⅱ型病例均取得全优效果;采用滑膜切除髓腔减压或植骨的CatterallⅠ和Ⅱ型病例,2优,1中;采用Salter或Chairi截骨治疗CatterallⅢ和Ⅳ型的10个病例,5优,3良,2中。结论严格应用Perthes病临床分型,选择合适的治疗方法是提高此疾患治愈效果的重要手段。     

Perthes Disease: Returning Children to Sports

The authors provide guidelines for returning children with Perthes disease to sporting activities. They suggest maintenance of hip motion and containment of the femoral head in the acetabulum until the extent of the femoral epiphyseal necrosis can be determined. Swimming and adaptive physical therapy help regain the motion and strengthen the hip abductor muscles. Abduction brace therapy is continued in patients with a risk of femoral head deformity until reossification of the necrotic femoral head begins. Surgical containment, as an alternative to brace therapy, is recommended when an orthosis is not socially tolerated. Once reossification of the femoral head occurs, the patient may begin full activity, but osteochondritis dissecans with an osteocartilaginous loose body should be considered if catching or locking of the hip joint occurs.     

髋臼囊变在强直性脊柱炎髋关节病变早期影像诊断中的价值

目的探讨强直性脊柱炎髋关节病变的X线平片、CT、MRI表现及早期征象。方法从65例强直性脊柱炎髋关节病变中筛选出23例符合入组标准、资料完整、临床证实的强直性脊柱炎髋关节病变患者的X线平片、CT及MRI资料进行分析和研究。结果发现髋臼囊变出现率100%,出现在其他异常征象之前,且能独立出现,并存在于强直性脊柱炎髋关节病变全过程。本组23例中18例髋臼囊变单独存在,而无其他异常征象,其他征象如关节间隙变窄、股骨头囊变等均与髋臼囊变并存,无一单独存在。结论髋臼囊变应该是强直性脊柱炎髋关节病变的早期影像征象,在所有征象中最具特征性,对确定强直性脊柱炎髋关节病变早期诊断有重要价值。     

Rheumatic diseases presenting as sports-related injuries

Most individuals seeking consultation at sports medicine clinics are young, healthy athletes with injuries related to a specific activity. However, these athletes may have other systemic pathologies, such as rheumatic diseases, that may initially mimic sports-related injuries. As rheumatic diseases often affect the musculoskeletal system, they may masquerade as traumatic or mechanical conditions. A systematic review of the literature found numerous case reports of athletes who presented with apparent mechanical low back pain, sciatica pain, hip pain, meniscal tear, ankle sprain, rotator cuff syndrome and stress fractures and who, on further investigation, were found to have manifestations of rheumatic diseases. Common systemic, inflammatory causes of these musculoskeletal complaints include ankylosing spondylitis (AS), gout, chondrocalcinosis, psoriatic enthesopathy and early rheumatoid arthritis (RA). Low back pain is often mechanical among athletes, but cases have been described where spondyloarthritis, especially AS, has been diagnosed. Neck pain, another common mechanical symptom in athletes, can be an atypical presentation of AS or early RA. Hip or groin pain is frequently related to injuries in the hip joint and its surrounding structures. However, differential diagnosis should be made with AS, RA, gout, psudeogout, and less often with haemochromatosis and synovial chondochromatosis. In athletes presenting with peripheral arthropathy, it is mandatory to investigate autoimmune arthritis (AS, RA, juvenile idiopathic arthritis and systemic lupus erythematosus), crystal-induced arthritis, Lyme disease and pigmented villonodular synovitis. Musculoskeletal soft tissue disorders (bursitis, tendinopathies, enthesitis and carpal tunnel syndrome) are a frequent cause of pain and disability in both competitive and recreational athletes, and are related to acute injuries or overuse. However, these disorders may occasionally be a manifestation of RA, spondyloarthritis, gout and pseudogout. Effective management of athletes presenting with musculoskeletal complaints requires a structured history, physical examination, and definitive diagnosis to distinguish soft tissue problems from joint problems and an inflammatory syndrome from a non-inflammatory syndrome. Clues to a systemic inflammatory aetiology may include constitutional symptoms, morning stiffness, elevated acute-phase reactants and progressive symptoms despite modification of physical activity. The mechanism of injury or lack thereof is also a clue to any underlying disease. In these circumstances, more complete workup is reasonable, including radiographs, magnetic resonance imaging and laboratory testing for autoantibodies.     

Abdominal pain and bowel dysfunction: the diagnostic role of ultrasonography

PURPOSE: To evaluate the role of intestinal ultrasound (US) in differentiating organic from functional bowel disease. MATERIAL AND METHODS: We examined with abdominal and intestinal US 313 consecutive outpatients presenting abdominal pain and bowel dysfunction, lasting more than 3 months, with no symptoms or signs of alarm and with no previous diagnosis of organic disease. Our population consisted of 191 women and 122 men, with average age at diagnosis of 36.5 years; 236 of these patients had irritable bowel syndrome, 61 Crohn's disease, and 16 ulcerative colitis. Intestinal wall thickness exceeding 7 mm was considered diagnostic for inflammatory bowel diseases. We compared US findings with the diagnosis made with the conventional diagnostic workup of radiological and endoscopic examinations. RESULTS: Sensitivity of intestinal US for diagnosis of inflammatory bowel diseases was 74% and specificity 98% (respectively 84% and 98% for the diagnosis of Crohn's disease and 38% and 98% for ulcerative colitis), and positive and negative predictive values were both 92%; efficacy was also 92%. The likelihood ratio was 35 if US was positive for inflammatory bowel diseases and 0.26 if bowel wall thickness was less than 7 mm. Diagnostic efficacy was 95% for Crohn's disease and 94% for ulcerative colitis. DISCUSSION: Intestinal US proved to be a valuable tool in diagnosing Crohn's disease. As the first step examination US can show the disease site and suggest further instrumental tests. CONCLUSIONS: In our experience intestinal US is an important diagnostic examination for the approach to young patients without symptoms or signs suggestive of organic diseases and can help avoid invasive instrumental examinations.     

伏格特-小柳-原田综合征早期诊断探讨

目的探求伏格特-小柳-原田综合征（Vogt—Koyanagi—Harada syndrome，VKH）综合征临床表现重要特征，提高早期确诊率。方法收集并分析5例10眼VKH综合征患者的临床资料，特别就早期阶段临床症状、相关全身表现及眼底荧光造影（FFA）特征等进行了分析。结果本病早期阶段临床症状和相关全身表现个体差异较大，但FFA具有典型特征。结论早期阶段VKH临床表现缺乏特异性，FFA检查是早期确诊VKH综合征的可靠方法。     

盐酸帕罗西汀对难治性肠易激综合征疗效的影响

目的 探讨盐酸帕罗西汀对难治性肠易激综合征(irritable bowel syndrome,IBS)疗效的影响.方法 124例IBS患者,随机分为常规组和盐酸帕罗西汀组,各62例.常规组口服马来酸曲美布汀0.1 g,3次/d,双歧杆菌活菌胶囊(商品名:培菲康)420 mg,3次/d.盐酸帕罗西汀组在常规组治疗的基础上给予盐酸帕罗西汀20 mg,1次/d,口服.两组疗程均为4周.在治疗前和治疗结束后分别予以焦虑自评量表(SAS)和抑郁自评量表(SDS)测评.观察两组治疗后症状改善情况及有效率.结果 盐酸帕罗西汀组总有效率为96.77%,常规组总有效率为77.42%,两组比较有统计学差异(P<0.01).IBS患者的SAS和SDS治疗前评分与正常人组之间存在显著性差异(P<0.01).盐酸帕罗西汀组患者的SAS和SDS治疗后较治疗前评分有统计学差异(P<0.01),常规组治疗前后SAS和SDS评分无统计学差异(P>0.05).结论 盐酸帕罗西汀对IBS疗效影响较大且能改善患者的情绪状态.     

Three-dimensional delayed gadolinium-enhanced magnetic resonance imaging of hip joint cartilage at 3T: A prospective controlled study

Purpose

To assess acetabular and femoral hip joint cartilage with three-dimensional (3D) delayed gadolinium-enhanced magnetic resonance imaging (dGEMRIC) in patients with degeneration of hip joint cartilage and asymptomatic controls with morphologically normal appearing cartilage.

Methods and materials

A total of 40 symptomatic patients (18 males, 22 females; mean age: 32.8 ± 10.2 years, range: 18–57 years) with different hip joint deformities including femoroacetabular impingement (n = 35), residual hip dysplasia (n = 3) and coxa magna due to Legg–Calve–Perthes disease in childhood (n = 2) underwent high-resolution 3D dGEMRIC for the evaluation of acetabular and femoral hip joint cartilage. Thirty-one asymptomatic healthy volunteers (12 males, 19 females; mean age: 24.5 ± 1.8 years, range: 21–29 years) without underlying hip deformities were included as control. MRI was performed at 3 T using a body matrix phased array coil. Region of interest (ROI) analyses for T1_Gd assessment was performed in seven regions in the hip joint, including anterior to superior and posterior regions.

Results

T1_Gd mapping demonstrated the typical pattern of acetabular cartilage consistent with a higher glycosaminoglycan (GAG) content in the main weight-bearing area. T1_Gd values were significantly higher in the control group than in the patient group whereas significant differences in T1_Gd values corresponding to the amount of cartilage damage were noted both in the patient group and in the control group.

Conclusions

Our study demonstrates the potential of high-resolution 3D dGEMRIC at 3 T for separate acetabular and femoral hip joint cartilage assessment in various forms of hip joint deformities.     

A case of non-malignant multifocal lesions on the methyl diphosphonate technetium-99m bone scan with enteropathy. SAPHO syndrome

This is a case of a 24-year-old man with non-malignant multifocal bone lesions on the methyl diphosphonate technetium-99m bone scan, that may represent a variant of synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome. The patient complained for diffuse osseous pain, focused mainly in the hip joints. X-rays of the hips were normal but X-rays of the shoulders showed hyperostosis of the right clavicle with no erosions. SAPHO is a rare syndrome of unknown aetiology with no more than a hundred cases reported during the last 10 years. Its typical form consists of characteristic painful osteoarticular manifestations and dermatological findings. In a variant of this syndrome, such as in our case, dermatological manifestations may be absent, but hyperostosis with osseous hypertrophy and enteropathy are present. No other malignant or benign disease was diagnosed. All routine laboratory tests for an inflammatory rheumatoid disease were negative. Treatment with non steroid anti-inflammatory agents was successful and after six months, there were no clinical symptoms and lesions on the bone scan faded. Four years later the patient remained free from symptoms. We discuss the scintigraphic, radiological laboratory clinical findings, the therapeutic criterion and the exclusion of any malignant or other benign bone disease that suggest the diagnosis of SAPHO syndrome. In conclusion, although we were unable to perform a bone biopsy, we suggest that no other diagnosis but an enteropathic variant of SAPHO syndrome may better describe the above clinical and laboratory findings. Bone scan findings have a principal diagnostic role in SAPHO syndrome.     

MR imaging evaluation of cardiovascular risk in metabolic syndrome

Metabolic syndrome has become an important public health problem and has reached epidemic proportions globally. Metabolic syndrome is characterized by a cluster of metabolic abnormalities in an individual, with insulin resistance as the main characteristic. The major adverse consequence of metabolic syndrome is cardiovascular disease, which is often already present without clinical signs or symptoms. In this early stage of disease, interventions (eg, lifestyle intervention, medication) can be used to prevent further cardiovascular deterioration or even to reverse cardiovascular disease. Therefore, risk stratification on an individual basis and early detection of cardiovascular disease are essential. Magnetic resonance (MR) imaging is a powerful tool for demonstrating cardiovascular risk factors in metabolic syndrome, such as increased fat depots and arterial stiffening. Furthermore, MR imaging is an established modality for the assessment of myocardial function. This review provides a summary of the current MR applications in metabolic syndrome and discusses how these MR techniques can be used to identify subclinical cardiovascular damage.     

The 'cold hip' sign on bone scan. A retrospective review

The "cold hip" sign on bone scan is often seen in patients referred with irritable hip. This sign is due to fluid in the hip joint under pressure causing impaired perfusion of the structures within the joint capsule. In a retrospective review, 22% of patients with this sign on bone scan were found to have septic arthritis at surgery. This fact would appear to justify surgical drainage or aspiration of any hip showing this sign on scan. An attempted follow-up study through the medical records was incomplete because of the short follow-up on most patients. The possibility that temporary impairment of blood supply to the head of the femur causes long-term damage to the hip is unanswered on this study, and a long-term recall follow-up study is underway.