Osteoporosis & Hip Pain - Dr Hazem

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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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Stage II:

Pain decreases

Trophic changes:

- Skin atrophy. - Atrophic hairs.

- Tappering fingers. - Atrophic nails

- Joints stiffness.


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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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Osteoporosis & Hip Pain - Dr Hazem