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ARE YOU PREPARED?

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TASK BASED LEARNING CASE 2

Adi, Afiq, Amni, Azfar, Rachel & Sufian

18 June 2009

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HISTORY

A 46 year old man was complaining of bilateral hip pain on walking for the past one year. The pain was initially mild but the last two months it is getting worse especially to the right side.

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Where is the origin of pain?

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ANATOMY OF THE HIP JOINT

A multiaxial ball and socket

synovial joint between the head of the femur and the acetabulum.

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-Acetabulum -Femoral head: semispherical, covered with articular cartilage- connected by ligament of head of femur

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Acetabulum

-Acetabular labrum deepens the socket. -Acetabular notch bridged by the transverse ligament of the acetabulum.

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Fibrous Capsule

Formed by: external fibrous layer & internal synovialmembrane.

1. Proximal attachment - encircles rim of acetabulum 2. Distal Attachment

a. anterior - greater trochanter, intertrochanteric line b. posterior - neck of femur (capsule incomplete posteriorly )

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Intrinsic Ligaments

•Anterior: iliofemoral ligament (Bigelow ligament)prevent hyperextension

•Medial: pubofemoral ligament. Prevent overabduction

•Posterior: ischiofemoral ligamentLimits medial rotation

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Blood Supply

•Medial and lateral circumflex artery (femoral artery)•Artery to head of femur (obturator artery)

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Muscles of Hip Joint

Hip flexors: Iliopsoas, sartorious, Rectus femoris

Abductors: Gluteus medius (inserts into greater trochanter)

Adductors: Adductor brevis/longus/magnus, Gracilis, Pectineus

Extensors: Hamstrings, Gluteus maximus (Inserts into the gluteal tuberosity and joins tensor fascia lata distally to form the iliotibial tract.)

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Nerve Supply

•Flexors: femoral nerve•Lateral rotators: Obturator nerve and nerve to quadratus femoris•Adductors: superior gluteal nerve

AETIOLOGY CAUSES OF CHRONIC JOINT PAIN

A 46 year old man was complaining bilateral hip pain on walking for the past one year.

• Hip osteonecrosis • Osteroarthritis• Rheumatoid arthritis• Ankylosing spondylitis • Tuberculosis of the hip• Gout of the hip (uncommon) • Osteochondritis (Perthe’s disease of the

hip)• Bone tumor

1.Hip osteonecrosis • Disease process that results in focal areas of

bone death within femoral head.• AKA. Avascular necrosis (AVN) - impairs the blood

supply to bone.(head of femur) cause collapse and flattening of the bone at the end epiphysis region.

• Usually affects people between 30 and 50 years of age.

• Clinical features:– Aching pain in the groin – Pain with movement of the hip accompanied with

stiffness. (Restricted movement)– Nearby joint may be swollen– Local tenderness maybe present – Difficulty walking or limp – Usually bilateral.

2.Osteroarthritis• Non-inflammatory degenerative joint disease

characterized by the breakdown of the joint's cartilage.• There is progressive softening and disintegration of

articular cartilage accompanied by new growth of cartilage and bone at the joint margins(osteophytes) and capsular fibrosis

• Described as ‘Wear & Tear’ arthritis• Common in elderly (>60 yo) and usually unilateral.• Clinical features:

– Pain at the affected joint that starts insidiously and increases slowly over months or years.

– Aggravated by exertion and relieved by rest.– Stiffness after periods of rest.– Swelling and fixed flexion deformity with loss of mobility and

muscle wasting.– Shortening of the affected limb.– Abnormal gait

• Antalgic gait – walking so that the load of the hip joint is reduced

3.Rheumatoid arthritis

• It is involve the small joint with the hallmark of the disease is progressive bone destruction on both sides of the joint without any reactive osteophyte formation.

• Starts in the synovium and is mainly “inflammatory”.• Usually bilateral in affecting many joints.• Common in women in child bearing age• Usually develops in middle age, but may occur in the 20s and

30s.• Clinical features:

– Pain and swelling in the groin comes on insidiously.– Has difficulty getting into or out of a chair.– Movement from the bed maybe painful– Limp– Morning stiffness.– Wasting of the buttock and thigh is often marked.– The limb is usually held in external rotation and fixed flexion.– All movements are restricted and painful.

4.Ankylosing spondylitis

• This is generalized chronic inflammatory disease but mainly seen in the spine and scroiliac joints that may involve of the hip joint.

• It is a complete fusion results in a complete rigidity of the spine, a condition known as “bamboo spine” or “poker back”.

• Involved bilaterally.• Usually - Male > female and affects at the age of 15 – 25

years old• Clinical features:

– Persistent backache and stiffness of the spine.– Often worse in the early morning or after inactivity.– Pain at the peripheral joints ( More common).– All movements are diminished– May go on to complete ankylosis.– Swollen and tender at the affected joints and sometimes complaint of

painful heels.– General fatigue and loss of weight.– Ocular inflammation with causing eye pain and photophobia.

5.Tuberculosis of the hip

• The disease may start as a synovitis, or as an osteomyelitis in one of the adjacent bones.

• Usually unilateral.• Affects at the young age and children.• Clinical features:– Pain in the hip– Limp– Muscle wasting– Limited joint movement and painful– Limb shortening and deformity– Neglected cases a cold abscess in the thigh or

buttock

6.Osteochondritis • There is compression, fragmentation or separation of a

small segment of bone, usually at the bone end involving the attached articular surface where the cartilage and bone in a joint is inflamed. ( features of ischaemic necrosis)

• Common in boys at the age of 5 – 10 yo. ( Children and adolescent).

• Clinical features:– Joint pain– Limited range of motion– Stiffness– Tenderness is sharply localised- Crushing osteochondritis– Feel of excessive pull by a large tendon – Pulling

osteochondritis.– Intermittent pain, swelling and joint effusion – shearing

osteochondritis.

7.Bone tumors

• Which can be used for both benign and malignant abnormal growths found in bone, but is most commonly used for primary tumors of bone, such as osteosarcoma.

• Common in elderly (>60 yo) and usually unilateral and causing pathological fracture.

• Clinical features:– Loss of sensation due to nerve compression– Poor blood circulation– Pain and accompanied with tenderness and

swelling at the affected joint.

Bone TumorsBenign Malignant

Fibrogenic Simple cyst Aneurysmal bone cyst Fibrous dysplasiaFibrous cortical defect

Malignant fibrous Hystiocytoma Fibrosarcoma

Chondrogenic

Enchondroma Priosteal chondromaOsteochondroma Chondromyxoid fibroma chondroblastoma

Chondrosarcoma

Osteogenic Osteoid osteoma Osteoblastoma Ossifying fibroma

Osteosarcoma

Unknown Ewing’s synovial sarcoma

Bone marrow

Myeloma (Multiple myeloma)Lymphoma

8. Trauma- Articular destruction

• More common fracture is in the proximal end of the femur (the long bone running through the thigh), near the hip joint.

• More frequently related with the osteoporotic factors in pathological fracture.

• Common in old age. (>55yo)• Most hip fractures in people with normal bone are the

result of high-energy trauma such as car accidents.• Clinical features:

– Pain at the affected joint– Swelling and tenderness– Short limb at the affected region – Limb length discrepancy– Can be bilateral or unilateral joint pain – depending on type of

trauma and fracture.– Stiffness and decreased range of mortion.

CAUSES OF UNILATERAL AND BILATERAL HIP JOINT PAIN.UNILATERAL BILATERAL

•Trauma•Bone tumors•Osteochondritis•Tuberculosis of the hip•Osteoarthritis

•Hip osteonecrosis ( Avascular necrosis)•Ankylosing spondylitis•Rheumatoid arthritis

ACUTE JOINT PAIN

• Hip fracture• Hip dislocation ( Posterior dislocation)• Septic arhtritis • Trochanteric bursitis• Infective tendonitis.

We have arrived at several likely causes

of his pain:

• Infective

• Non-infective inflammatory

• Trauma

• Malignant change

Past HistoryWhat other important history that must be looked into in order to arrive at the differential diagnoses?

Past History

• Past medical/surgical history

• Drug history

• Family history

• Personal and Social history

He claimed to have pain after he had renal

transplant for his end stage renal failure done four years ago followed

by taking medication also

What is the most likely etiology of

the pain?Which diagnoses

can be safely discarded from the list of differentials?

What would you look for in physical

examination?

Physical Examination:

• Trendelenburg’s sign was elicited

Movement of right hip joint:• Range from 0 – 90 degrees on flexion, 0 –

30 degrees on external rotation, 0 – 25 degrees on internal rotation.

 Movement of left hip joint:• Range from 0 – 80 degrees on flexion, 0 –

10 degrees on external rotation, 0 – 15 degrees on internal rotation.

What is Trendelenburg test?• It is a simple manoeuvre to evaluate the

strength of the gluteus medius and gluteus minimus muscle. 

• The patient is asked to stand, unassisted on each of the leg in turn.

• While standing on one leg, he or she has to lift the other leg by bending the knee (but not the hip).

• Normally, the weight bearing hip is held stable by hip abductors and the pelvis rises on the unsupported side; if the hip is unstable, or very painful, the pelvis drops on the unsupported side.

Trendelenburg’s sign

• Trendelenburg sign is caused by paralysis of the gluteus medius and minimus muscles. Paralysis may arise due to nerve damage, namely, the superior gluteal nerve.

A positive Trendelenburg sign is found in:• subluxation or dislocation of the hip• abductor weakness• shortening of the femoral neck• any painful hip disorder

Movement

Normal range of movement:• The hip should flex until the thigh

meets the abdomen, 0 - 130°• Internal rotation: 0 – 50°• External rotation 0 – 40°

Movement

Flexion Extension

Movement

Internal RotationFlexion with knees bent

Movement

External rotation

Based on the history and

physical examination, what

is your primary suspicion?

What are the investigations to rule out

the causes of the diseases…

Full blood count- WBC: infection- Hb: Low in Sickle cell disease blood film (target cell

& Howell jolly bodies)

Mantoux test – Suggest TB of the hipESR – Indication for chronic inflammatory diseases. (Ex: RA, SLE, ankylosing spondylitis, long term of

steroid use, inflammatory bowel disease, vasculitis).Immunological test/ANA- Rheumatoid arthritisRenal profile - renal study

Blood investigations done revealed normal level ESR

and white count.

Blood investigations done revealed normal level ESR

and white count.

An x-ray of both hips was taken

An x-ray of both hips was taken

-A radiograph, or x ray, is probably the first test the doctor will recommend.-Evaluation includes and AP view and frog-leg lateral x-rays of hip.

Sign of avascular necrosis on radiograph

- A staging system has been developed by Ficat and Arlet and has been used widely for avascular necrosis.- The classification system of Steinberg et al for radiograph finding proposed a 6 stage classification.

Stage Sign on radiograph Presentation

Stage 0 (preclinical and preradiologic)

Usually no changes noted.Performed to evaluate AVN in the contralateral hip or to exclude other diseases

Early presentation

Stage 1 (preradiologic)

Normal radiographic findings or shows minimal demineralization or blurred trabeculae.

Weeks to a month.Pain (common). Limited range of motion (ROM) .

Stage 2 (reparative)

Diffuse or localized areas of sclerosis, lucencies, or both within the femoral head.

Several month or longerClinical signs persist or worsen.

Stage Sign on radiograph presentation

Stage 3 (early collapse of the femoral head)

Crescent sign (subchondral fracture).

Late sign

Several months up to years.

Stage 4 (progressive degenerative disease)

Marked collapse (Joint space widening) and fracture involving the articular surface.

Segmental flattening of the femoral head

Stage 5 (Degenerative joint disorder)

development of DJD

AP view of bilateral femoral head

Frog-leg lateral X-

ray

The arrow shows crescent sign indicating subchondral fracture

Other investigations to support radiograph

finding?

MRI of bilateral avascular necrosis of the femoral head

Bone scanShows marked increased uptake of radiopharmaceutical in both hips.

CT ScanArrows: clumping and distortion of the central trabeculae representing the asterisk sign

An x-ray of both hips was taken and showed

abnormalities of the femoral head

An x-ray of both hips was taken and showed

abnormalities of the femoral head

What will you think the finding on the radiograph?

History:- Bilateral hip pain on walking for the past one

year- Last two months it is getting worse especially

to the right side.

- Pain on walking & have limitation on squatting.

History:- Bilateral hip pain on walking for the past one

year- Last two months it is getting worse especially

to the right side.

- Pain on walking & have limitation on squatting.

Anteroposterior view of the pelvis in patient with bilateral avascular necrosis of the femoral head

What is the final diagnosis in this case?

- Avascular necrosis of bilateral femoral head secondary to long-term use of oral or intravenous (IV) corticosteroids.

Pathogenesis

• Positive history of renal transplant

• Following the renal transplant, it is imperative that the patient is started on immunosuppressive therapy

• This is to reduce the chances of getting rejection syndrome

• Immunosuppressive drugs consist of steroids

• Fatty metamorphosis of the liver, fat emboli and changes in lipid metabolism induced by corticosteroids are the key events in the occurrence of SION.

• An increase in the average diameter of the marrow fat cells is also an additional factor because in the closed chambers of the bones at risk, this could lead to an increase in tissue pressure and compromise blood supply.

Roles of steroids in this case

Other causes of osteonecrosis?

• Vascular thrombosis

• Vessel damage

• Mechanical defects

• Abnormally shaped cells

• Obstruction to arteriolar and venous flow

• Release of vasoactive factors

• Altered lipid metabolism

• Changes in intraosseous pressure

• Trauma

Avascular Necrosis (Osteonecrosis)

• Consider: Ischemia of the affected bone segment in common sites (femoral head, condyles, head of humerus)

• Consider: Vascular sinusoids have no adventitial layer; patency depends on surrounding marrow

• Local changes > Capillary occlusion > Ischemia > Reactive inflammation > Marrow swelling > Increased Pressure etc

Stages of osteonecrosis

• Stage 1: Bone death without structural change

• Stage 2: Repair and early structural changes

• Stage 3: Major structural failure

• Stage 4: Articular destruction

Management

Management in AVN

• Stage 1 & 2 bone collapse can sometimes be prevented by a combination of weight-relief, splintage and surgical decompression of the bone

• Stage 3 (bone has collapsed) realignment osteotomy, by transferring stress to an undamaged area (may relieve pain & prevent further bone distortion)

• Stage 4 treatment is same for osteoarthritis

Management in OA

• Conservative• Operative/Surgical

Surgical treatment

• Arthroplasty (hip replacement surgery)• Indications:–Unrelieved pain– Progressive disability

• Rehabilitation – to restore the flexibility in the hip & work muscles back into shape

Arthroplasty

Complications of THR

• Intraoperative complications– Perforation or fracture of the femur or

acetabulum

• Sciatic nerve palsy– Usually d/t traction but may cause by direct

injury too

• Post-op dislocation– Rare if the prosthetic components are correctly

placed

• Heterotopic bone formation around the hip– Unknown cause

Cont.

• Aseptic loosening of either the acetabular socket or the femoral stem– Commonest cause of long term failure

• Aggresive osteolysis – May be d/t a severe histiocyte reaction

stimulated by cement, polyethylene or metal particles that find their way into boundary zone

• Infection– Most serious post-op complications– With adequate prophylaxis, the risk should be

<1% (but higher in the very old, rheumatoid disease pt or psoriasis & those in immunosuppresive therapy)