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OSTEOPOROSIS &
HIP PAIN
HAZEM ABDELAZEEM
Egypt , April 2009
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AIM
In this presentation we will discuss the
differential diagnosis of some painful
conditions of the hip related to generalisedand local forms of osteoporosis &
osteomalacia
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Osteoporosis appears 1st in Hip
X rays ( Ward triangle)
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Hip pain with decreased bone
density ( Porosis or Malacia) Osteoporosis may be
Generalised or local
forms
Osteomalacia may be vitD deficiency due to
inadequate intake or
other diseases
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Osteomalacia itself is PAINFUL
Associated with
pelvic, femoral &
other long bones
deformities
Vit D deficiency may
be dietary, or
associated with
celiac,hepatic or renaldisease
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Stress fracture
History of overuse or
osteoporosis
Pain with weight-
bearing activity
Antalgic gait
Limited range of
motion
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Stress fracture
May be at neck or
subtrochanteric
regions
May be uni or bilateral
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Stress fracture
Pain may be due to
microscopic fractures
and is associated with
progressive varusdeformation
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Combined osteoporosis&malacia is
common
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Impacted fracture neck femur
Pt may be ambulant &
bearing weight with
pain & limping
Xray AP & LAT are
necessary but may
not show the fr
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CT scan is diagnostic
in cases not seen in
X ray
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Types of stress fractures
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Early internal fixation prevents displacement
, stops the pain and treats the case
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Consequences :Hip fracture
Fall or trauma
followed by inability
to walk Limb externally
rotated, abducted,
and shortened
Pain with any
movement
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Fracture pubic rami
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LOCAL FORMS OFOSTEOPOROSIS
Local osteoporosis is always
painful or is associated with
painful conditions
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Algodystrophy
Alogodystrophy is
a Neurodystrophic
Disorders
Pain.
Swelling.
Trophic changes.
Functionalincapacity.
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Terminology
* Algodystrophy (AD)
Sudecks bone atrophy 1900. Reflex sympathetic dystrophy (RSD).
Decalcifying alogdystrophy.
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Post traumatic painful osteoporosis.
Regional migratory osteoporosis.
Shoulder-hand syndrome. Transient osteoporosis.
Transient osteoporosis with pregnancy
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ESSENTIAL
ALGODYSTROPHY
Unrecognized cause
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The sites most
commonly affected are
the wrist and hand
(28%;, shoulder
(27%), ankle and foot
(24%), knee (10%),
elbow (6%) and hip
(5%).
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Personal Experience
Post traumatic
Pregnancy
Common among
medical professions
Bilaterality &
involvement of two
joints or more
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Pathophysiology
Theories:
Neurovascular dystrophy Bone remodeling
Hormonal regulation
Biomechanical
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Neurovasular Theory
Vicious circle, pain stiffness, fear
over sympathetic tone, vasospasm,
ischemia, vasodilatation, oedema,
pain mediators, etc
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Oedema Pain Stiffness
NeurovascularVasodilation
ischaemia
VasospasmOver
sympathetic tone
Stiffness
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Disturbance of Bone
RemodellingUnbalanced CellularCoupling
OsteoblasteXOsteoclast
Result: Localized
trabecular bone loss
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Pathology
Osteoblastic poor
activity
Subchondral cortical
and cancellous
resprotion
Wide marrow spaces
Micro fractures
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Clinical Picture and stages
Stage I: 2 to 3 months.
* Pain : - Dull - Causalgic
* Vasomotor: - Redness to bluishness.
- Swelling. - Wormth - Oedema.
- *Refrain from movement(Painful)(Pseudoinflammatory signs).
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Clinical Picture and stages
Stage II:
Pain decreases
Trophic changes:
- Skin atrophy. - Atrophic hairs.
- Tappering fingers. - Atrophic nails
- Joints stiffness.
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Clinical Picture and stages
SPONTANEOUSREGRESSION OR
Stage III ( RARE in Hip):
Joints increase in stiffness to fibrous
ankylosis.
Decrease in the pseudoinflammatory signs.
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Clinical basis & staging
Radiography
Bone scintography MRI
Densitometry
Lab. work up
Histopathology
Biopsy [core]
Diagnosis
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Lab:-not constant
Hydroxyprolinuria
increased erosive remodelling
(osteoclast) Osteocalcin level increase
increased osteoblastic activity
ESR normal
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RADIOLOGY: Early X-ray is
negative
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Radiology Diffuse rarifaction,
spotty, patchy,
widened trabeculations
Cortical erosions
Total loss of bone
structure, by moth
eaten appearance
Normal joints
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CT SCAN
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Bone scan inconclusive
Scintography
Hot area
[remodelling
activity]
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Densitometry Weak photon
densitometry image
[ decrease bone
mass]
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MRI
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Core biopsy:
PathologyPeriosteocytic lysis
of cortical and cancellous bone
Foci of remodelling
activity Osteoclastic bone
resorption
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ALGODYSTROPHY VERSUS AVN
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Treatment
The short-term aims of the treatment of
algodystrophy are the following:
To relieve the pain.
To correct or prevent vasomotor disorders.
To prevent bone demoralization.
To prevent trophic change and ankylosis.
To reduce the duration of functional
incapacity.
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Treatment
Medical treatment.
Local injections.
Sympathetic block.
Nerve block.
Physical and
rehabilitation.
Accupuncture.
P
sychotherapy.
Surgical treatment.
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Surgical Treatment
In persistent
Acute
Manifestation
Lumber
Sympathectomy
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Surgical Treatment Persistant cases & when in doubt that it
may be AVN Core decompression may
be done taking also core biopsy
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T.B. Hip arthritis
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Sero positive arthritis
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Rheumatoid arthritis Morning stiffness or
associated systemicsymptoms
Previous history ofinflammatory arthritis or
multiple joint affection Limited range of motion and
pain with passive motion
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Painful focal lesions
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FOCAL LESIONS (eg)
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After excision
Post op recovery
1 Year 2 Years
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CONCLUSION
Osteoporosis is a silent disease
Painful hip associated with osteoporosis
needs special attention Generalized osteoporosis associated with
osteomalacia is painful and leads to
painful conditions
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CONCLUSION
Stress & Impacted fractures has to be
searched for in painful hip conditions
Local forms of osteoporosis are painfuland may prove to be algodystrophy, early
arthritis or focal lesions
Algodystrophy (RSD) should be included
in DD of painful hips in adults & must bedifferentiated from AVN & focal lesions
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THANK YOU
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