Hip Pain

Anatomie de la hanche

Hip pain, that is to say, a secondary pain arthropathy coxofemoral, may correspond to very many etiologies.

Before searching for, we must affirm the hip causing the pain, which is not always easy.

DIAGNOSTIC:

Physical examination:

Examination:

He specifies :

– Installation mode of pain: gradual or abrupt, post-traumatic;

– The topography of pain and radiation: usually with inguinal irradiation at the front of the thigh to the knee, rarely lateral (trochanteric) or posterior (buttocks). Isolated knee pain and reveals a hip disease is as classic as deceptive always evaluate hip in the exploration of a knee pain;

– The schedule of pain: mechanical or inflammatory;

– The intensity and the evolving profile, sensitivity to treatment;

– The functional consequences: reduced scope of work, lameness, stiffness, insomnia, use of a cane, etc., of the parameters evaluated by algofunctional Lequesne index for hip disease (Table I);

– History, general symptoms (weight loss, fever, etc.), the symptoms at bay.

Physical examination:

The clinical examination is always bilateral and comparison.

The patient standing and walking, we look lameness, vicious attitude of the hip (shortening, flexion, rotation), a pelvic tilt, painful exacerbation at OLB.

Lying on the patient, a search:

– Has a myotrophie quadriceps;

– A vicious attitude in flexion contracture, a shortening of the lower limb;

– The painful spots in the groin or trochanteric pressure;

– A limitation of passive motion amplitudes, the normal values are: 130 ° flexion and 15 ° in extension (supine patient ventral) 45 ° abduction and 30 ° adduction, 45 ° external rotation and 30 ° internal rotation;

– A clinostatic syndrome: inability to take off the leg extension of the plane of supine bed, almost pathognomonic of acetabular pathology (usually malignant).

Imaging tests:

Standard radiology:

It allows most often to confirm the existence of a hip disease and to clarify the etiology.

Two effects are sufficient: face basin snapshot standing with internal rotation of the lower limbs to 30 ° and the Lequesne false profile, which is a real hip profile (the surgical profile does not allow the study of the joint coxofemoral but the femoral neck). Coxométrique an assessment can usefully complement the standard radiological assessment.

Other imaging tests:

They are justified when the clinical impression is for a hip disease but the standard radiology is still contributory.

Can be performed:

– A bone scan with technetium 99, very sensitive but not specific;

– An opaque arthrography, readily coupled to a scanner, which provides the best condition of cartilage surfaces and allows the detection of intra-articular radiolucent foreign bodies;

– Especially an MRI exam widely the most sensitive and most specific for the etiological diagnosis of hip disease.

Table I. algofunctional Lequesne index

Table I. algofunctional Lequesne index

Other tests:

They are especially relevant for the diagnosis of the etiology of a hip disease:

– The usual biology boils first line in search of inflammation (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP]);

– Ultrasound-guided puncture of synovial effusion demonstrated by MRI may be useful to clarify the mechanical nature of the hip disease or inflammatory;

– Multiple diagnostic tests can be requested as part of the workup.

Differential diagnosis:

Numerous diseases can possibly do wrong to evoke a hip disease:

– Neurological disorders: L3 or L4 especially cruralgie but obturator neuralgia (L2), sciatica L5 (classical “inguinal arrow”) or MERALGIA PARAESTHETICA (fémorocutanée neuralgia).

The pain of projected lower lumbar facet joint origin are very common;

– Neighbourhood bone diseases (stress fracture, Looser-Milkman crack, crack pagetic, bone metastasis, etc.) that may affect the shutter frame, head, neck or diaphyseal femur, acetabulum;

– Periarticular tendon pathologies: mainly tendonitis (or tendinobursite) of the gluteus medius and also the adductor tendinitis (and groin), tendonitis and iliopsoas that of the previous law;

– Other neighborhood conditions: inguinal and femoral hernia, lymphadenopathy, sacroiliac joint disease, pelvic tumor, etc.

ETIOLOGY:

In practice, the diagnosis of hip disease being discussed by the clinical examination, research on etiology is based primarily on the results of standard radiology.

Normal radiographs:

Mechanical look hip disease with VS / normal CRP:

We must mention several diagnoses, a stage still infraradiologique beginner.

Osteoarthritis:

Osteoarthritis may be symptomatic without initial radiological translation, apart from moderate and considered commonplace osteophytes.

In the rapidly destructive hip osteoarthritis, pain, happy intense and sudden onset, before the pinch coxa vara: value of MRI and even arthrography, to demonstrate a joint effusion and incipient lesions Chondrolysis .

Aseptic necrosis of the femoral head:

Aseptic necrosis of the femoral head is typically manifested by a sudden onset of pain, very debilitating to the charging and sometimes insomniante. The standard radiology is long delayed relative to the clinic. At this point infraradiologique, bone scintigraphy is already revealing evocative, very early, localized uptake of the femoral head.MRI confirmed osteonecrosis, with superior picture polar receiver, limited by a hypointense rim on T1. The rest of the head is occupied by a spinal cord edema, hypointense T1 and T2 hyperintensity.

Table II. Causes of aseptic osteonecrosis of the femoral head.

Table II. Causes of aseptic osteonecrosis of the femoral head.

The identification of identical anomalies on the contralateral hip is common, despite the absence of symptoms. The discovery of osteonecrosis of the femoral head imposes the search for an etiology or predisposing factors (Table II). In most cases, however, no specific etiology is not found. The course is variable, sometimes with favorable interruption necrotic process, but, usually, it is more or less rapidly towards the formation of secondary osteoarthritis.

CRPS:

Algodystrophy hip is rare. It is manifested by progressive worsening of pain, mechanical rhythm, with lameness and sometimes severe functional impairment. It may follow trauma or a neurological accident, but appears most often idiopathic. In women, a dystrophy can occur in end of pregnancy (3rd quarter), with gradual recovery in the weeks following childbirth.

Initially, radiology is normal (and may remain so throughout evolution), but MRI is very early contribution: hypointense on T1 and T2 hyperintensity in the acetabulum, the femoral head and neck, extending quite widely to the shaft without escrow image. Synovial effusion is common.

A scintigraphic uptake is also early detected, without specificity.

Stress fractures:

Stress fractures (or fatigue) of the femoral neck and branches ilio and ischio, as cracks of Looser-Milkman ostéomalaciques, are also cause mechanical pain occurring upon loading, with significant lameness or waddling gait.The standard radiology frankly is offset from the clinic, the first visible abnormalities often corresponding to callus formation. Diagnosis, strongly suggested by intense uptake in scintigraphy, is then confirmed by the scanner, which can visualize the fracture, or MRI that highlights the importance of bone marrow edema périfracturaire.

Pathology of synovium:

Pathologies of the synovium are rare and are the cause of mechanical pain and blocking phenomena. These must be alert and realize arthrography (useful ment completed a scanner) in search of “intra-articular foreign bodies” of synovial origin, reflecting a pathological proliferation: chondromatose, villonodular synovitis, Benin synovialome or synovial sarcoma. MRI may also be contributory.

Tendinobursite gluteus medius:

Tendinitis of the gluteus medius (or tendinobursite trochanteric) is a common cause of pain without specific regional radiological translation. For the record, the finding of tendon calcifications péritrochantériennes is extremely commonplace, without any clinical tendinitis, and the lack of visible calcifications should not question the diagnosis of tendinitis. This is manifested by mechanical pain on the outer side of the hip, extending to the lateral side of the thigh to the knee, even in the leg (pseudosciatique L5), awkward walking and climbing stairs, and sometimes insomniantes in lateral recumbency.

On examination, we reproduce the pain trochanteric pressure, thwarted abduction of the thigh is painful but the mobility of the hip, albeit painful, is retained.

MRI can reveal, firstly, the normality of the joint itself, and secondly, a signal on T2 in the thickness of inflammatory tendon or liquid (bursitis).

Treatment consists of local infiltrations of cortisone.

Hip disease inflammatory appearance and / or VS / high CRP:

It should again remove algodystrophy, hip osteoarthritis (mainly in its destructive fast form) or tendinobursite gluteus medius, which may be of an inflammatory nature, with insomniante pain.

But it especially appropriate to seek a beginner hip disease of inflammatory nature, too recent to have a radiological translation.

Coxites:

The coxites share common clinical characteristics: rhythm of inflammatory pain, fever (inconstant), rapid aggravation of inflammatory synovial fluid formula.

* Infectious Coxites to banal germs:

They result in major pain and lameness in a septic context clearly (high fever, chills, general inflammatory syndrome).Radiographic abnormalities are often delayed compared with the clinical and diagnosis based on bacteriological samples, including puncture of a joint effusion identified by ultrasound or MRI.

* Tubercular hip disease (or sciatica):

It has a much more chronic course, with, again, a constant radiological delay.

Diagnosis is based on isolation of the bacillus after culturing synovial fluid or synovial biopsy fragment, whose histological study may also be contributory.

The diagnosis of tuberculous trochantérite evoked in MRI, is also affirmed by the discovery of the tubercle bacillus or histological abnormalities characteristic (granuloma with caseous necrosis).

* Coxites rheumatic:

They can be integrated in a context of known chronic inflammatory disease, especially rheumatoid arthritis, psoriatic arthritis and spondyloarthritis or more rarely reveal. In 50% of cases, the functional prognosis of rheumatic coxites is poor, especially if they complete a spinal involvement in a context of spondyloarthritis.

* Coxites microcrystalline:

They are dominated by chondrocalcinosis, having radiological stigmas are fickle.

The identification of calcium pyrophosphate microcrystals is possible in the synovial effusion. Other microcrystals may be responsible (uric acid, hydroxyapatite).

Osteoid osteoma of the femoral neck:

The osteoid osteoma of the femoral neck, benign tumor in young patients, is particularly by the occurrence of electively night pain, typically enhanced by Aspirin. The standard radiology is usually normal and the identification of the nidus is based on the achievement of various tests: bone scintigraphy (uptake puncture) CT and MRI.

The therapeutic sanction is always surgical.

Pathological radiographs:

Hip disease mechanical pace, with VS / normal CRP:

Osteoarthritis:

This is the etiology most banal, it combines a variable radiographic osteophytes topography, before the joint space usually localized and polar superolateral, and acetabular sclerosis, in which can appear geodes of hypertension. In the rapidly destructive hip osteoarthritis, pinching, worth more than 50% of the spacing in less than 6 months, largely above osteophytes.

* Treatment of osteoarthritis:

Medical treatment is as long as possible (especially before age 60), and when surgical pain and / or functional impairment become incompatible with a normal life. Crucially, the therapeutic indications should not be based on the degree of radiological destruction, but only on clinical criteria (no radio-clinical parallelism).

Medical treatment:

The medical treatment is intended only to reduce pain. If osteoarthritis secondary to hip dysplasia, it should not delay surgical correction of any anatomical abnormalities.

Medical treatment involves:

– Some lifestyle and dietary rules, designed to reduce pain and slow the destruction:

– Reduction of overweight;

– Use of a cane, on the side opposite the painful hip, and use of high seats;

– Eviction steps and stations standing too long and traumatic sports, focusing on “soft” sports (swimming or cycling).

– Of the analgesics and / or a nti-inflammatory drugs (NSAIDs) to reduce pain and maintain some autonomy. Adding antiarthrosic symptomatic treatment of slow action, such as avocado and soybean unsaponifiables, chondroitin sulfate, diacerein and glucosamine, can be interesting. These Aasal have not really demonstrated a structural effect, but can reduce the consumption of analgesics and NSAIDs. They should be prescribed for at least six months, warning the patient that the effect is delayed by at least two months.

– Corticosteroids for arthrography infiltration (performed under image intensifier) sometimes have a brilliant precedent efficiency, as well as local injections of hyaluronic acid.

– Physical therapy aims to maintain trophicity periarticular muscles (quadriceps and glutes primarily) to preserve joint mobility and to fight against the vicious attitudes (flexion).

– The crenotherapy can have interesting analgesic effects.

Surgical treatment:

For secondary osteoarthritis unevolved or localized, conservative surgical procedures designed to correct existing anatomical abnormalities (bone block correcting an acetabular failure, varus osteotomy correcting a coxa valga).

In case of advanced osteoarthritis and inefficiency of medical treatment, the treatment is based on the establishment of a total hip replacement.

Two inorganic elements mounted one upon the pelvic bone and the other on the femur, constituting a new joint. The metal-plastic torque is superior to metal-on-metal used once, and currently more than twenty different models are available, with a current life expectancy of law prostheses twenty years.

Aseptic necrosis of the femoral head:

It typically combines a discrete and limited sclerosis of the head, typically triangular upper outer base, loss of sphericity of the head with classic hook “stair step in” and an image “eggshell”, corresponding to overcoming the cortical bone cancellous bone underlying necrotic and collapsed. However, there is no pinching of coxa vara spaced, or osteophytes, or injury to the acetabulum. Belatedly, the remodeling of the femoral head are the source of secondary osteoarthritis.

Hip dystrophy:

It can, like any disease location, translate radiologically by a homogeneous demineralization or more typically mottled (or speckled) on the femoral head and the acetabulum adjacent. However, there is no joint space narrowing or osteophytes or sclerosis.

Other etiologies:

Chondromatose the synovium becomes visible in standard radiology when there is “ossification” of one or more chondromas (osteochondromatosis).

Other mechanical hip disease can be revealed by the standard radiographs: hip disease pagetic (acetabular protrusion), osteochondritis dissecans, arthropathy of tabes (exceptional).

Hip disease inflammatory speed and / or high ESR and CRP:

Infectious and rheumatic coxites result radiologically by a global joint space narrowing, a souschondrale demineralization and bone erosions, without osteophytes or sclerosis. The anomalies occur particularly fast in infectious coxites pyogenic. In acute coxite chondrocalcinosis, a calcic edging end highlighting the cartilage contours is possible, but calcium inlays are much rarer than hip knee, wrist or the pubic symphysis.

Other causes of coxofemoral region inflammatory look of pain can be detected by radiological examinations: metastases, myeloma locations, primary malignancy (osteosarcoma, chondrosarcoma).