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OSTEOPOROSIS & HIP PAIN
HAZEM ABDELAZEEM
Egypt April 2008
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Osteoporosis appears 1st in Hip
X rays ( Ward triangle)
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X ray diagnosis means 40 % bone
loss
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Bone Densitometry
More sensitive
Part of full 4 sites
diagnosis
Tests at differentproximal femur sites
May be done
bilaterally Indicates Ca ions loss
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Hip pain with decreased bone
density ( Porosis or Malacia)
Osteoporosis may be
Generalised or local
forms
Osteomalacia may bevit D deficiency 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 ofmotion
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Stress fracture
May be at neck,
subtrochanteric or
less common the
head May be uni or bilateral
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Stress fracture
Pain may be due to
microscopic fr or
progressive
deformation
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Combined osteoporosis&malacia
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Impacted fracture neck femur
Pt may be ambulant &
bearing weight with
pain & limping
Xray AP & LAT arenecessary 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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Early internal fixation
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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
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Algodystrophy
Alogodystrophy is a
Neurodystrophic
Disorders
Pain. Swelling.
Trophic changes.
Functional incapacity.
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The term Algodystrophy covers a group of
painful conditions with association of pain,
vasomotor and trophic changes, functional
impairment localized in the distal parts of
the body
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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.
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ESSENTIAL
ALGODYSTROPHY
Unrecognized cause
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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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Disturbance of Bone
RemodellingUnbalanced Cellular Coupling
OsteoblasteXOsteoclast
Result: Localized
trabecular bone loss
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Oedema Pain
Stiffness
NeurovascularVasodilation
ischaemia
Vasospasm
Over sympathetic
tone
Stiffness
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Pathology
Osteoblastic poor activity
Subchondral cortical and
cancellous resprotion
Wide marrow spaces
Micro fractures
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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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Clinical basis & staging
Radiography
Bone scintography
MRI
Densitometry
Lab. work up
Histopathology
Biopsy [core]
Diagnosis
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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
SPONTANEOUS REGRESSION OR
Stage III ( RARE in Hip):
Joints increase in stiffness to fibrous
ankylosis.
Decrease in the pseudoinflammatory signs.
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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 boneresorption
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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.
Psychotherapy.
Surgical treatment.
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Medical Treatment
NSAIDA.
Vasodilators.
Corticosteroids.
Betabolckers.
Calcitonin.
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Calcitonin *In Moderate Cases:
- 100 I.U. every day. For 3months
*In Severe Cases:
- 100 I.U. every day. For 2 to 4 weeks followed
by 100 IU every other day for 2 months.
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Local Injection
Local anaesthetic + hydrocortisone.
Sympathetic ganglion block.
Nerve block.
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Other conservative modalities
Physical and rehabilitation
therapy.
Acupuncture.
Psychotherapy.
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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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Painful focal lesions
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FOCAL LESIONS
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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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Back up slides
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Inflammatory arthritis Morning stiffness or
associated systemicsymptoms
Previous history ofinflammatory arthritis ormultiple joint affection
Limited range of motion andpain with passive motion
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T.B. Hip arthritis
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Trochanteric bursitis
Female:male 4:1, fourth to sixth decade Spontaneous, insidious onset
Point tenderness over greater
trochanter
X-rays may show evidence of aprevious fracture, or metal
implant . There may also be
calcification or shadows
suggesting swelling of the soft
tissues
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MRI
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Hip Synovial affections
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p yAutoimune,metabolic,specific & nonspecific infections
synovitis
Synovial tumors and tumor like (PVNS)
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Pyogenic hip arthritis
Changes in chronic caseEarly No Change
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