OSTEOPOROSIS & HIP PAIN

HAZEM ABDELAZEEM
Egypt April 2008
Osteoporosis appears 1st in Hip
X rays ( Ward triangle)
X ray diagnosis means 40 % bone
loss
 Bone Densitometry
• More sensitive
• Part of full 4 sites
diagnosis
• Tests at different
proximal femur sites
• May be done
bilaterally
• Indicates Ca ions loss
 Hip pain with decreased bone
density ( Porosis or Malacia)
• Osteoporosis may be
Generalised or local
forms
• Osteomalacia may be
vit D deficiency or
other diseases
Osteomalacia itself is PAINFUL
• Associated with
pelvic, femoral &
other long bones
deformities
• Vit D deficiency may
be dietary, or
associated with
celiac,hepatic or renal
disease
 Stress fracture
• History of overuse
or osteoporosis
• Pain with weight-
bearing activity;
• Antalgic gait
• Limited range of
motion
 Stress fracture
• May be at neck,
subtrochanteric or
less common the
head
• May be uni or bilateral
 Stress fracture
• Pain may be due to
microscopic fr or
progressive
deformation
Combined osteoporosis&malacia
 Impacted fracture neck femur
• Pt may be ambulant &
bearing weight with
pain & limping
• Xray AP & LAT are
necessary but may
not show the fr
• Ct scan is diagnostic
in cases not seen in
X ray
Early internal fixation
 Consequences :Hip fracture

• Fall or trauma
followed by inability
to walk
• Limb externally
rotated, abducted,
and shortened
• Pain with any
movement
Fracture pubic rami
LOCAL FORMS OF
OSTEOPOROSIS
LOCAL OSTEOPOROSIS IS
ALWAYS PAINFUL
 Algodystrophy
• Alogodystrophy is a
Neurodystrophic
Disorders
• Pain.
• Swelling.
Trophic changes.
• Functional
incapacity.
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”
• Terminology
• * Algodystrophy (AD)
• Sudecks bone atrophy 1900.
• Reflex sympathetic dystrophy (RSD).
• Decalcifying alogdystrophy.
• Post traumatic painful osteoporosis.
• Regional migratory osteoporosis.
• Shoulder-hand syndrome.
• Transient osteoporosis.
 ESSENTIAL
ALGODYSTROPHY

Unrecognized cause
 Personal Experience
• Post traumatic
• Pregnancy
• Common among
medical professions
• Bilaterality &
involvement of two
joints or more
 Pathophysiology
• Theories:
• Neurovascular dystrophy

• Bone remodeling
• Hormonal regulation
• Biomechanical
 Disturbance of Bone
Remodelling
Unbalanced Cellular Coupling
• OsteoblasteXOsteoclast

• Result: Localized

trabecular bone loss

 Neurovasular Theory

• Vicious circle, pain stiffness, fear

over sympathetic tone, vasospasm,

ischemia, vasodilatation, oedema,

pain mediators, etc

 •Stiffness
•Oedema •Pain Stiffness

•Vasodilation
Neurovascular
•ischaemia

•Over sympathetic
Vasospasm tone
 Pathology
• Osteoblastic poor
activity
• Subchondral cortical
and cancellous
resprotion
• Wide marrow spaces
• Micro fractures
The sites most commonly

affected are the wrist and

hand (28%;, shoulder

(27%), ankle and foot

(24%), knee (10%), elbow

(6%) and hip (5%).

 Diagnosis
• Clinical basis & staging
• Radiography
• Bone scintography
MRI
 Densitometry
 Lab. work up
 Histopathology
• Biopsy [core]
 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).
 Clinical Picture and stages
• Stage II:
• Pain decreases
• Trophic changes:
- Skin atrophy. - Atrophic hairs.
- Tappering fingers. - Atrophic nails
- Joints stiffness.
 Clinical Picture and stages
• SPONTANEOUS REGRESSION OR
• Stage III ( RARE in Hip):
• Joints increase in stiffness to fibrous
ankylosis.
• Decrease in the pseudoinflammatory signs.
Lab:-
not constant
Hydroxyprolinuria
increased erosive remodelling
(osteoclast) Osteocalcin level increase
increased osteoblastic activity
ESR normal
RADIOLOGY: Early X-ray is
negative
 Radiology
• Diffuse rarifaction,
spotty, patchy,
widened trabeculations
• Cortical erosions
• Total loss of bone
structure, by moth
eaten appearance
• Normal joints
CT SCAN
 Bone scan inconclusive

• Scintography
Hot area
[remodelling
activity]
 Densitometry
• Weak photon

densitometry image

• [ decrease bone

mass]
MRI
 Core biopsy:
• Pathology
Periosteocytic lysis
of cortical and
• cancellous bone
• Foci of remodelling
activity
• Osteoclastic bone
resorption
ALGODYSTROPHY VERSUS AVN
 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.
 Treatment
Medical treatment. Physical and

Local injections. rehabilitation.

Sympathetic block. Accupuncture.

Nerve block. Psychotherapy.

Surgical treatment.
 Medical Treatment
NSAIDA.
 Vasodilators.
 Corticosteroids.
 Betabolckers.
 Calcitonin.
 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.
 Local Injection
• Local anaesthetic + hydrocortisone.

• Sympathetic ganglion block.

• Nerve block.
 Other conservative modalities

• Physical and rehabilitation

therapy.

• Acupuncture.

• Psychotherapy.
 Surgical Treatment
• In persistent
Acute
Manifestation

Lumber
Sympathectomy
 Surgical Treatment
• Persistant cases & when in doubt that it
may be AVN Core decompression may
be done taking also core biopsy
Painful focal lesions
FOCAL LESIONS
 After excision
• Post op recovery

• 1 Year 2 Years
 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
 CONCLUSION
• Stress & Impacted fractures has to be
searched for in painful hip conditions
• Local forms of osteoporosis are painful
and may prove to be algodystrophy or
focal lesions
• Algodystrophy (RSD) should be included
in DD of painful hips in adults & must be
differentiated from AVN & focal lesions
THANK YOU
Back up slides
 Inflammatory arthritis
• Morning stiffness or
associated systemic
symptoms
• Previous history of
inflammatory arthritis or
multiple joint affection
• Limited range of motion and
pain with passive motion
T.B. Hip arthritis
 Trochanteric bursitis
• Female:male 4:1,
• fourth to sixth decade
• Spontaneous, insidious onset

• Point tenderness over greater

trochanter
• X-rays may show evidence of a
previous fracture, or metal
implant . There may also be
calcification or shadows
suggesting swelling of the soft
tissues
MRI
 Hip Synovial affections
Autoimune,metabolic,specific & nonspecific infections
synovitis
Synovial tumors and tumor like (PVNS)
 Pyogenic hip arthritis

Early No Change Changes in chronic case