The management of a person with haemophilia who has a fixed flexed hip and intractable pain

The clinical picture of a fixed flexed hip associated with pain in a person with haemophilia is suggestive of a haemorrhage in that area. Sonography facilitates differentiation between a haemarthrosis, intraperitoneal haemorrhage, subperiosteal bleed, a bleed into the soft tissue around the hip joint or a psoas haematoma. All these aforementioned causes may result in the same clinical presentation. Two cases are described in which coxhaemarthrosis resulted in a flexion contracture of the joint associated with severe intractable pain. Narcotic drugs failed to alleviate the severe pain. Joint aspiration produced dramatic pain relief and early joint rehabilitation.     

Sonography for hip joint effusion in adults with hip pain

OBJECTIVE: To study the prevalence of ultrasonic hip joint effusion and its relation with clinical, radiological and laboratory (ESR) findings in adults with hip pain. METHODS: Patients (n = 224) aged 50 years or older with hip pain, referred by the general practitioner for radiological investigation, underwent a standardised examination. The distance between the ventral capsule and the femoral neck, an increase in which represents joint effusion, was measured sonographically. Joint effusion was defined in three different ways: "effusion" according to Koski's definition, "major effusion", and "asymmetrical effusion" based on only individual side differences. RESULTS: "Effusion" was present in 80 (38%), "major effusion" in 20 (9%), and "asymmetrical effusion" in 47 (22%) patients. Pain in the groin or medial thigh, pain aggravated by lying on the side, decreased extension/internal rotation/abduction/flexion, painful external rotation, and pain on palpation in the groin showed a significant relation (adjusted for age and radiological osteoarthritis of the hip) with ultrasonic hip joint effusion. "Major effusion" showed a significant relation with an increased ESR. When patients with bilateral pain and increased ESR were excluded, a side difference in the range of motion of extension of the hip was shown to be a good predictor for "asymmetrical effusion" (positive predictive value: 71%, negative predictive value: 80%). CONCLUSION: This study showed a relatively high prevalence of ultrasonic joint effusion in adults with hip pain in general practice. Furthermore the results indicate a relation between joint effusion and clinical signs.     

Joint-pain comorbidity, health status, and medication use in hip and knee osteoarthritis: a cross-sectional study

Objective

To determine the prevalence of joint‐pain comorbidities in individuals with hip or knee osteoarthritis (OA) and to assess the differences in the characteristics of people with and without joint‐pain comorbidities.

Methods

In this cross‐sectional study, individuals referred to secondary care for treatment of hip/knee OA completed questionnaires to determine sociodemographic characteristics, disease‐related outcomes, and joint‐pain comorbidities. Joint‐pain comorbidity was defined as pain perceived in a joint, other than the index joint, for more than half of the days in the preceding month. To compare differences in patient‐ and disease‐related characteristics between participants with and without joint‐pain comorbidities, we performed analyses of covariance and logistic regression.

Results

A total of 401 individuals, 117 with hip OA and 284 with knee OA, returned the questionnaire (82% response rate); the mean ± SD age was 58 ± 13 years and 58% of the responders were women. Fifty‐eight percent of the participants reported symptoms in ≥1 other joint. Participants with joint‐pain comorbidities were more likely to be women, less educated, and have more medical comorbidities. Individuals with joint‐pain comorbidities reported unfavorable outcomes on pain, functioning, fatigue, distress, and health‐related quality of life compared with patients without joint‐pain comorbidities (P < 0.001 for all). Moreover, use of nonsteroidal antiinflammatory drugs (P = 0.038), opioids (P = 0.010), and supplements (P = 0.019) was higher in the group with joint‐pain comorbidities.

Conclusion

Our results indicate that individuals with joint‐pain comorbidities represent a clinically relevant and large subgroup of people with OA of the knee or hip. We recommend addressing joint‐pain comorbidities in both research and clinical practice.     

Ultrasonographic evidence of hip synovitis in patients with rheumatoid arthritis

One hundred non-operated hip joints in 50 adult patients with active rheumatoid polyarthritis were examined by ultrasonography as well as by clinical methods and X-ray. In 15 hip joints in 11 patients, ultrasonography indicated intra-articular effusion (a distance between the joint capsule and bone of more than 7 mm in 14 and a difference between the two sides of more than 1.5 mm for one hip). There were no subjective symptoms associated with five of these hip joints, the X-ray findings were normal for 11 hips, and careful clinical examination showed normal findings for one hip joint. The routine clinical examination used in the hospital had revealed pathological findings in only two of these hip joints. It is concluded that ultrasonography may reveal intra-articular effusion or synovitis in clinically and radiologically apparently normal hip joints of patients with active rheumatoid arthritis. The increase in pain and restricted motion was statistically significant in the hips for which ultrasonography indicated intra-articular effusion. Hips that appear pathological in ultrasonography are thus synovitis, and do not fall within the range of normal variation for healthy hip joints.     

Manual therapy in osteoarthritis of the hip: outcome in subgroups of patients

OBJECTIVE: To investigate whether manual therapy has particular benefit in subgroups of patients defined on the basis of hip function, range of joint motion, pain and radiological deterioration. METHODS: The study was performed in the out-patient clinic of physical therapy of a large hospital. Data on 109 patients with OA of the hip (clinical ACR criteria) participating in a randomized clinical trial on the effects of manual therapy were used. The outcomes for hip function (Harris hip score), range of joint motion (ROM) and pain (VAS) were compared for specific subgroups. Subgroups were assigned by the median split method. The interaction effect between subgroup and treatment was tested using multiple regression analysis. RESULTS: No differences were observed in the effect of manual therapy in specific subgroups of patients defined on the basis of baseline levels of hip function, pain and ROM. On the basis of radiological grading of osteoarthritis (OA), we found that patients with severe radiological grading of OA had significantly worse outcome on ROM as a result of manual therapy than patients with mild or moderate radiological grading of OA. CONCLUSION: A significant interaction effect was found for only 1 out of 12 hypotheses investigated. Therefore, we conclude that there is no evidence for the particular benefit of manual therapy in subgroups of patients.     

Giant iliopectineal bursitis presenting as neuropathy and severe edema of the lower limb: case illustration and review of the literature

We report a 61-year-old woman with rheumatoid arthritis (RA: Steinblocker stage III, class 3) who developed severe swelling and neuropathy of the right lower limb caused by an iliopectineal bursa associated with destruction of the hip joint. Physical examination revealed an inguinal mass and groin pain. X-ray examination indicated destruction of the hip joint. Contrast-enhanced computed tomography showed the bursa connected with the hip joint and a markedly compressed external iliac vein among the inguinal ligament, pubis, and bursa. The patient underwent partial synovial resection and total hip arthroplasty for recovery of hip function, and this led to successful resolution of the symptoms and bursa. We present the characteristic images from this case and review all previously reported cases of RA iliopsoas bursitis causing leg swelling or neuropathy, and summarize the background. Since this lesion may cause various symptoms, clinical awareness that iliopsoas bursitis may present with unique clinical symptoms may aid correct diagnosis.     

Joint space narrowing and relationship with symptoms and signs in adults consulting for hip pain in primary care

OBJECTIVE: To study whether clinical symptoms and signs can predict radiological osteoarthritis (OA) of the hip in primary care patients with hip pain. METHODS: Consecutive patients (n = 220) aged 50 years or older consulting the general practitioner for hip pain and referred for radiological investigation underwent a standardized history, radiological, laboratory, and physical examination. Radiological OA was confirmed with joint space < or = 2.5 mm. Additionally, a more stringent definition was used (< or = 1.5 mm). The relationship between radiological OA and possible clinical symptoms/signs of OA was tested. Combinations of clinical symptoms/signs that had shown an independent relationship with radiological OA in multivariate analyses were tested for their predictive value. RESULTS: Radiological OA (joint space < or = 2.5 mm) of the (more) symptomatic hip was present in 35.5% of the study population and more severe OA (joint space < or = 1.5 mm) in 11.4%. Presence of 4 specific symptoms/signs from history and examination showed a positive predictive value (PPV) of 73% (specificity 91%, sensitivity 45%) for radiological OA. When 5 specific symptoms/signs were present, the PPV for the more severe radiological OA was 82% (specificity 98%, sensitivity 72%), and when 6 or 7 specific symptoms/signs were present the PPV was 100% (specificity 100%, sensitivity 40% and 8%, respectively). Negative predictive values were high for almost all combinations. CONCLUSION: In primary care patients with hip pain, clinical symptoms and signs can to a moderate extent predict radiological OA and to a large extent more severe radiological OA.     

Joint distension arthrography for disabling hip pain. A controlled clinical trial

Thirty-eight patients (age 27-73 years) with unilateral hip pain, restricted movement of the hip joint and radiologically no or only slight osteoarthrosis were studied in a double-blind controlled clinical trial. Twenty-one patients received active treatment with hip joint distension arthrography and 17 received placebo treatment. All patients were assessed clinically on entry, the day after and 3 months after treatment. The incidences of subjective improvement were similar in the two groups. Apart from a slight deterioration in the treated group of hip flexion, abduction and lateral rotation at the one-day assessment, neither group showed any change in the registered movements of the hip joint compared with the assessment on entry. The measured intermalleolar distance at maximal straight-leg abduction was the sole variable which tended to increase (p = 0.05) 3 months after active treatment. Thus, the therapeutic effect of a single treatment with joint distension seems to be dubious.     

髋关节液体松解术治疗强直性脊柱炎的疗效观察

目的观察髋关节液体松解术对强直性脊柱炎髋关节活动度的改善及延缓关节间隙变窄的临床疗效。方法将华中科技大学同济医学院附属协和医院风湿免疫科2003—2004年112例强直性脊柱炎患者随机分成对照组(52例)和治疗组(60例),对照组仅使用药物治疗,治疗组在药物治疗基础上加用髋关节液体松解术。比较治疗前后髋关节功能评分、髋关节疼痛评分(VAS评分)、髋关节病变CT分期、炎性指标(C-反应蛋白、血沉)的变化。结果治疗后两组髋关节功能评分及疼痛评分均较治疗前有改善(P均<0.05),而治疗组较对照组改善更显著(P<0.05);两组髋关节病变CT分期在治疗前后均无明显变化,两组之间比较差异亦无显著性意义;炎性指标(C-反应蛋白、血沉)两组均较治疗前有改善(P<0.05),但两组之间比较差异无显著性意义。结论髋关节液体松解术联合药物治疗在减轻强直性脊柱炎患者的关节疼痛和改善关节功能方面优于单用药物治疗。对延缓髋关节变形的作用还需要观察。     

DIFFERENTIAL DIAGNOSIS AND MANAGEMENT OF HIP PAIN IN CHILDHOOD

Hip pain in children is always potentially serious. Differentspecialists see a different spectrum of hip diseases. Acutehip pain is usually referred to the surgeons, and the principalconcern is to distinguish sepsis of the hip joint or pelvicbones from irritable hip: untreated sepsis can destroy the hipwithin days, but its presentation may be atypical or mild andinvestigations misleading. A reliable protocol for the managementof acute hip pain in children is now available. Perthe's diseaseand slipped capital femoral epiphysis is usually evident onthe initial radiograph. Hip disorders with a subacute or chronicpresentation are usually referred to the paediatrician or rheumatologist.If examination shows restriction of hip movement or there areradiographic abnormalities, many will have a serious disorderrequiring long-term management. The diagnosis is often apparenton the initial radiographs, although special imaging techniquesmay be needed. In a monoarticular presentation of juvenile arthritis,the hip radiograph will be normal but the diagnosis evidentfrom other clinical features or blood investigations. Recognitionof non-organic syndromes presenting with hip pain requires theexclusion of organic causes and an alertness to the incongruityof the physical signs. KEY WORDS: Hip, Arthritis, Children, Pain, Septic arthritis, Irritable hip.     

The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip

Clinical criteria for the classification of patients with hip pain associated with osteoarthritis (OA) were developed through a multicenter study. Data from 201 patients who had experienced hip pain for most days of the prior month were analyzed. The comparison group of patients had other causes of hip pain, such as rheumatoid arthritis or spondylarthropathy. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop different sets of criteria to serve different investigative purposes. Multivariate methods included the traditional "number of criteria present" format and "classification tree" techniques. Clinical criteria: A classification tree was developed, without radiographs, for clinical and laboratory criteria or for clinical criteria alone. A patient was classified as having hip OA if pain was present in combination with either 1) hip internal rotation greater than or equal to 15 degrees, pain present on internal rotation of the hip, morning stiffness of the hip for less than or equal to 60 minutes, and age greater than 50 years, or 2) hip internal rotation less than 15 degrees and an erythrocyte sedimentation rate (ESR) less than or equal to 45 mm/hour; if no ESR was obtained, hip flexion less than or equal to 115 degrees was substituted (sensitivity 86%; specificity 75%). Clinical plus radiographic criteria: The traditional format combined pain with at least 2 of the following 3 criteria: osteophytes (femoral or acetabular), joint space narrowing (superior, axial, and/or medial), and ESR less than 20 mm/hour (sensitivity 89%; specificity 91%). The radiographic presence of osteophytes best separated OA patients and controls by the classification tree method (sensitivity 89%; specificity 91%). The "number of criteria present" format yielded criteria and levels of sensitivity and specificity similar to those of the classification tree for the combined clinical and radiographic criteria set. For the clinical criteria set, the classification tree provided much greater specificity. The value of the radiographic presence of an osteophyte in separating patients with OA of the hip from those with hip pain of other causes is emphasized.     

Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial

OBJECTIVE: To determine the effectiveness of a manual therapy program compared with an exercise therapy program in patients with osteoarthritis (OA) of the hip. METHODS: A single-blind, randomized clinical trial of 109 hip OA patients was carried out in the outpatient clinic for physical therapy of a large hospital. The manual therapy program focused on specific manipulations and mobilization of the hip joint. The exercise therapy program focused on active exercises to improve muscle function and joint motion. The treatment period was 5 weeks (9 sessions). The primary outcome was general perceived improvement after treatment. Secondary outcomes included pain, hip function, walking speed, range of motion, and quality of life. RESULTS: Of 109 patients included in the study, 56 were allocated to manual therapy and 53 to exercise therapy. No major differences were found on baseline characteristics between groups. Success rates (primary outcome) after 5 weeks were 81% in the manual therapy group and 50% in the exercise group (odds ratio 1.92, 95% confidence interval 1.30, 2.60). Furthermore, patients in the manual therapy group had significantly better outcomes on pain, stiffness, hip function, and range of motion. Effects of manual therapy on the improvement of pain, hip function, and range of motion endured after 29 weeks. CONCLUSION: The effect of the manual therapy program on hip function is superior to the exercise therapy program in patients with OA of the hip.     

关节镜技术治疗髋关节骨关节炎的疗效

目的 探讨应用关节镜技术治疗髋关节骨关节炎的疗效。方法 采用关节镜技术治疗中老年髋关节骨关节炎23例，男性8例，女性15例。平均年龄61岁（51～67岁）。左侧9例。右侧11例，双侧3例。关节镜下采用等离子刀清理关节内增生、肥厚、充血水肿的滑膜组织、退变的软骨和髋臼盂唇、游离体取出和髋关节灌洗。结果 术后随访23例，平均25个月（6个月至5．5年），髋关节疼痛症状减轻，功能明显改善。VAS评分术前7．6分，术后2．5分。Harrss评分术前46．8分，术后84．6分。结论 关节镜下清理治疗髋关节骨关节炎是一种有效的姑息性手术治疗方法，可减轻症状，延缓病情发展，提高生活质量。     

Transient regional osteoporosis. A study of 56 cases and review of the literature

We describe the clinical features and course of disease in 56 patients (33 men and 23 women) with transient regional osteoporosis. The median age at hospitalization was 48 years. All patients had monoarticular or oligoarticular joint pain that was aggravated by weight bearing. Eighteen also had pain at rest in the involved joints and 6 had nocturnal pain. The joints of the lower extremities were affected in 54 patients; the hip was the most commonly affected joint. There was little evidence of synovitis. Osteoporosis was diagnosed on the basis of characteristic clinical findings and the results of roentgenograms and bone scans. The osteoporosis resolved spontaneously over several months. Treatment consisted of joint protection, initiation of gradual ambulation, and administration of nonsteroidal anti-inflammatory agents. Although its cause is unknown, osteoporosis appears to be a regional rather than a systemic process.     

全髋关节翻修术后髋臼旋转中心变化对髋关节稳定性的影响

目的探讨全髋翻修手术前后髋臼旋转中心的变化对髋关节稳定性的影响。方法回顾性分析102例（132髋）全髋关节翻修术患者的临床资料,对比手术前后双髋关节正位片,测量术后髋臼假体的旋转中心与解剖髋臼旋转中心的符合率和再翻修率。结果旋转中心恢复者89髋（67.42%）,未恢复者43髋（32.78%）,术后5 a旋转中心恢复者中因人工髋关节松动、脱位、髋部痛等再行髋关节假体翻修术为6髋（6.74%）,大大低于旋转中心未恢复者11髋（25.58%）,P〈0.01。结论髋臼旋转中心的恢复对人工髋关节翻修术后的关节稳定性产生直接影响。     

Hip joint distension in osteoarthrosis. A triple-blind controlled study comparing the effect of intra-articular indoprofen with placebo

In a triple-blind controlled study, significant pain alleviation (p less than 0.01) was registered in patients with osteoarthrosis (OA) of the hip in the first 24 h after hip joint distension. There was no significant difference between treatment with indoprofen (a new non-steroidal anti-inflammatory drug for intra-articular use) and placebo. Pain relief lasted for at least 12 weeks in approximately half of the patients, in whom a significant increase in joint mobility was registered. Intra-articular indoprofen was not superior to placebo as regards pain relief or increased joint mobility. These findings indicate that the effect of a single hip joint distension in OA is due to a mechanical distension of the joint capsule, perhaps involving disruption of local agglutinations, and not due to suppression of inflammation.     

Pelvic manifestations of diffuse idiopathic skeletal hyperostosis (DISH): are they clinically relevant?

Summary This is a cross-sectional, case-controlled study on the clinical relevance of diffuse idiopathic skeletal hyperostosis (DISH) in relation to the pelvic girdle. Thirty-two rheumatology patients with DISH were compared with 35 dermatology control subjects in respect to the clinical parameters pain and passive hip joint motion in a standardized manner. There were no significant differences between the two groups, indicating no major clinical relevance of DISH in the pelvic region. In a second study, the radiographs of 23 DISH probands were compared blindly with 23 matched controls. The only significant difference was a much higher degree of severe juxtaarticular bone formation in DISH probands. The majority of these spurs proved to be asymptomatic and did not affect the range of passive hip joint mobility. DISH is a frequently seen, often radiologically very impressive phenomenon of little clinical relevance, at least in the pelvic area.     

Bone marrow edema syndromes of the hip: MRI features in different hip disorders

The objectives of this study were to describe the essential magnetic resonance imaging (MRI) features of bone marrow edema syndromes affecting the hip joint. In addition, to evaluate the role of MRI in the assessment of hip joint involvement in different clinical settings that may share similar clinical findings. Thirty-four patients who complained of hip pain were studied consecutively. Of these, 21 were men (61.8%) and 13 were women (38.2%). After clinical assessment of possible hip disease, plain radiograph and MRI study of both hips were performed. The literature was searched using keywords: bone marrow edema, hip, and MRI. All patients had antalgic gait and limping. Initial clinical examination revealed painful limited internal and external rotation of the affected hip/hips suspect for hip disease. Unilateral hip involvement was identified in 31 patients (91.2%), and bilateral hip involvement was found in three patients (8.8%), with a total of 37 hips evaluated by MRI. The final diagnoses in our patients were: reactive arthritis (1), transient osteoporosis (7), avascular necrosis (10), osteoarthritis (2), tuberculous arthritis (4), septic arthritis (2), osteomyelitis (2), sickle cell anemia (2), lymphocytic leukemia (1), and femoral stress fracture (3). Bone marrow edema affecting the hip is neither a specific MR imaging finding nor a specific diagnosis and may be encountered in a variety of hip disorders due to different etiologies. MR imaging is the modality of choice when clinical examination is suspect for hip disease and plain radiographs are normal or equivocal. Early diagnosis and treatment is important in many of the disorders. The literature is reviewed regarding bone marrow edema of the hip.     

Transient osteoporosis of the hip with joint effusion detected by ultrasonography

Summary Three cases of transient osteoporosis of the hip and their ultrasonographic findings are presented. Transient osteoporosis of the hip is an uncommon condition with pain in the hip area and limping. The diagnosis is supported by local radiological osteoporosis and other imaging methods. Exclusion of more common entities is required. Effusion of the hip joint detected by ultrasonography is also related to this condition, which must be taken into account in patients with hip pain.