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admin | Treatment For Hip Flexor Strain | 19.11.2013
Early hip arthritis in a young patient remains a challenging problem for joint replacement surgeons (Figure 9-1). Hemiarthroplasty has been shown to result in persistent pain, early component loosening, and loss of acetabular bone stock. The treatment of severe hip arthritis in a young patient should alleviate current symptoms yet allow future surgical options. Three surgical techniques are commonly performed today for hip arthrodesis: cobra head plate, anterior plating, and dual plating. Is there value in the results of orthopedic studies performed using data from large-scale databases? We present the case of a patient who, after undergoing unilateral total hip arthroplasty (THA), achieved pain reduction in the contralateral hip accompanied by restoration of the radiographic joint space. JavaScript is currently disabled, this site works much better if you enable JavaScript in your browser. Complete Health AcupunctureAcupuncture and Massage eliminate your pain, stress and anxiety. As I look at the patient, I notice that his standing posture is not exactly consistent with hip pain yet he favors his right side while walking. I guess that the patient originally went straight to X-Ray without meaningful observation or examination. My doctor friend’s son was a medical student at the University of Chicago and interned at a large Manhattan hospital. AbstractThere is a need for an effective and noninvasive treatment for intractable bone marrow edema syndrome of the hip. Treatment options for very young patients with end-stage disease consist of delaying surgery, total hip replacement, resurfacing arthroplasty, hemiarthroplasty, femoral osteotomy, hip resection, or hip fusion.
Hip resection eliminates the potential for wear-induced osteolysis but results in a limb that is shortened, has decreased strength, and requires increased expenditure of energy for ambulation. Total hip arthroplasty undoubtedly returns patients to a higher functional level with near immediate pain relief. This option is considered less frequently today as the long-term outcomes of total hip arthroplasty improve.
A successful surgical result requires not only for the hip to fuse but requires the fusion to occur in an appropriate position without violation of the abductor musculature.
The cobra head plate, originally described by Schneider, is a technique that involves release of the abductors from the iliac crest to accommodate a cobra-shaped plate. In my practice, I advocate the use of hip arthrodesis in patients under the age of 25 who are employed in manual labor or in patients with recalcitrant infection in a native hip.
We conducted gait analysis to clarify the dynamic factors affecting the natural course of osteoarthritis (OA). This diagnosis is complete with X-Rays and report which states there is mild osteoarthritis in the hip. While there certainly is arthritis in the hip (X-rays cannot lie), it is most likely not the cause of pain.
Forty-six patients with intractable bone marrow edema syndrome of the hip were retrospectively studied to compare the short-term clinical effects of treatment with high-energy extracorporeal shock wave therapy vs femoral head core decompression. Each of these treatment modalities has perceived and realized advantages along with accompanying disadvantages. Patient is employed in construction and had no clinical or radiographic evidence of low back, ipsilateral knee, or contralateral hip pain. Patients with a resection have significant limitations in their daily activities, and this option is considered unacceptable for most patients. However, failure rates of 30% to 40% have been observed in this cohort of patient at short- to mid-term follow-up. However, a well-performed arthrodesis can provide dramatic pain relief, allow patients to return to high-level activities, and can be converted to a successful total hip arthroplasty in the future. The optimal position of the hip following an arthrodesis is 20 to 30 degrees of hip flexion, 5 degrees of adduction, and 5 to 10 degrees of external rotation. In addition, a pelvic osteotomy is performed to improve the contact area of the femoral head on the pelvis. This procedure is performed through an anterior Smith-Peterson approach with the patient in a supine position. Candidates for hip fusion must not describe pain or have radiographic evidence of arthritis in their low back, contralateral hip, or ipsilateral knee. Our findings revealed that the patient walked with exaggerated adduction of the hip following the contralateral THA, causing substantial regeneration of joint loading. He is being medically treated for this and is also self treating himself with expensive supplements. Upon examining the patient in the prone position, I observe that his lower back muscles are very contracted.
I then recall that the patient’s standing posture is consistent with unilateral psoas contraction and the whole symptomology is consistent with unilateral psoas contraction. The diagnosis is one of exclusion together with the presence of typical magnetic resonance imaging (MRI) findings. Increased rates of bearing surface wear, osteolysis, and aseptic loosening have been demonstrated in the younger, more active patient following total hip arthroplasty. Delaying surgical intervention in patients with end-stage arthritis eliminates the concerns for bearing surface wear but requires patients to lead a more sedentary lifestyle. Male patients with unilateral hip disease requiring total hip replacement secondary to osteonecrosis or osteoarthritis appear to be at the greatest risk of early failure. As with all surgical techniques, the results of hip arthrodesis are heavily dependent on the surgical technique chosen to perform the arthrodesis and an appropriate surgical candidate.


While fusion rates of 94% to 100% have been shown, this technique results in damage to the abductor musculature, which can be problematic should conversion to a total hip arthroplasty be attempted in the future. I recommend total hip arthroplasty in young patients who are not employed in manual labor or who exhibit any of the contraindications above.
Yet the patient’s pain is still there after four months, he walks with difficulty and has a hard time climbing stairs. As I palpate his back and hip area he states that most of his pain is in the front, not at the side or the back.
An MRI scan is the most specific diagnostic modality in the early diagnosis of bone marrow edema syndrome of the hip because it highlights its characteristic appearance.2Clinical symptoms are characterized by acute and worsening hip pain that typically resolves spontaneously in approximately 6 to 9 months.
The need for future revision surgery with the associated bone loss is a concern in patients expected to have 40 to 60 years of remaining life.
Patients with an arthritic hip also describe increased fatigue, weight gain, and decreased quality of life. Alternative bearing surfaces and newer implant designs are now available and may offer improved results. The ideal person to consider a hip arthrodesis today includes a young patient with isolated unilateral hip arthritis ideally secondary to primary or post-traumatic degenerative arthritis. Depending on the patient’s occupation, increased hip flexion may be considered if the patient spends a larger proportion of time in a sitting position, while less hip flexion should be considered in a patient that stands the majority of the day (manual laborer).
Anterior plating is a surgical technique that avoids damage to the hip abductor musculature and allows the fusion to occur with the patient in the supine position.
I believe that hip pain in the young patient can be eliminated for several decades and that an excellent result from a total hip replacement can be expected in the future if these indications are followed and a surgical technique that does not violate the abductors is chosen.
Patients who underwent extracorporeal shock wave therapy also resumed daily activities significantly earlier.
Treatment usually consists of avoiding load on the hips as well as the use of nonsteroidal anti-inflammatory drugs, bisphosphonates, and prostacyclin, which can improve local hemodynamic characteristics.1,2 Unfortunately, in some cases, conservative treatment approaches do not relieve symptoms. Hip resurfacing is an attractive option for younger patients; however, poorer long-term results have been observed in patients with avascular necrosis. Patients should not have accompanying lumbar spine disease, ipsilateral knee pain, or contralateral hip pain. Despite optimal hip positioning, several authors have reported low back pain and ipsilateral knee pain in greater than half the patients at long-term follow-up. Matta has reported on this technique in which an anterior Smith-Peterson approach is used and a compression plate is placed on the pelvic brim lateral to the sacroiliac joint and posterosuperior iliac spine (Figure 9-2).
In these cases, the disease becomes protracted and intractable, causing a great deal of discomfort.
These anatomic locations have been shown in follow-up studies to have accelerated degenerative changes once the hip is fused. A lag screw can also be placed from the lateral trochanteric area into the superior acetabulum and subsequently into the femoral head. Young patients with a septic process or patients who have failed other hip procedures can also be considered candidates for an arthrodesis. Fusion rates of greater than 80% have been reported, and the results of total hip arthroplasty following this procedure are similar to a previously nonoperated hip.
Hospital costs were significantly lower with extracorporeal shock wave therapy compared with femoral head core decompression.
The dual plating technique is frequently used when patients exhibit poor bone stock, avascular bone, or are noncompliant. With the patient in a lateral position, a modified lateral approach is performed where a trochanteric osteotomy is used to elevate the abductor musculature. On magnetic resonance imaging (MRI), bone marrow edema improved in all patients during the follow-up period. A lateral plate is secured to the lateral aspect of the femur and just anterior to the greater sciatic notch on the pelvis. After extracorporeal shock wave therapy, all patients remained pain-free and had normal findings on posttreatment radiographs and MRI scans. The anterior superior iliac spine (ASIS) is then removed and a second plate is contoured and then secured distal to the ASIS and along the anterior femur before the trochanteric osteotomy is reattached. Extracorporeal shock wave therapy appears to be a valid, reliable, and noninvasive tool for rapidly resolving intractable bone marrow edema syndrome of the hip, and it has a low complication rate and relatively low cost compared with other conservative and surgical treatment approaches. The duration of conservative treatment before extracorporeal shock wave therapy is at least 3 months. The diagnosis was based on typical clinical findings, recurring severe hip pain, and bone marrow edema on MRI (a hypointense area on T1-weighted sequences and a hyperintense area on T2-weighted sequences), after exclusion of the differential diagnoses for bone marrow edema.9The two treatment groups included patients with both unilateral and bilateral lesions (Table 1). In the nonoperative group, patients underwent high-energy extracorporeal shock wave therapy, as shown in Figure 1. The operative group was surgically treated with femoral head core decompression with a lateral approach to the hip.
Under fluoroscopy, a K-wire was introduced 2 to 5 cm inferior to the greater trochanter, then drilled at least 10 times into the affected part of the femoral head in a radial fashion.
Patients were evaluated both before and after treatment with a visual analog scale, Harris Hip Score, and MRI (to assess bone marrow edema).
Using a radiation dosimeter (ALOKA PDM-112; ALOKA Co, Ltd, Tokyo, Japan), measurements were carried out with tissue-equivalent anthropomorphic phantoms to quantitatively determine radiation exposure at various locations from the C-arm for both treatment procedures. On follow-up examination 6 months after treatment, a history was taken with regard to pain before and after treatment. Harris Hip Scores and a visual analog scale were used to assess functional and health status on the day of examination. Pelvic radiographs and lateral views of the affected hip were obtained to exclude avascular necrosis and other pathology.


Clinical assessment included pain history, severity and duration of symptoms, the progress of treatment, intraoperative fluoroscopy radiation dose, operative time, hospital costs, time when symptoms disappeared, and MRI findings.
Shock waves were focused around (on the margins of) the femoral head under radiographic guidance. The treatment area was prepared with a coupling gel to minimize the loss of shock wave energy at the interface between the head of the device and the skin.All extracorporeal shock wave therapy procedures were performed once without general or regional anesthesia by experienced physicians.
After extracorporeal shock wave therapy, patients were instructed to walk on crutches and to avoid bearing weight on the affected limb for 4 to 6 weeks. All patients received alendronate sodium tablets (70 mg orally weekly for 14 days) and alprostadil (10 ?g intravenously guttae quaque die for 14 days).Statistical AnalysisPreoperative visual analog scale scores, intraoperative fluoroscopy radiation dose, operative time, hospital costs, postoperative visual analog scale scores, postoperative Harris Hip Scores, and time when symptoms disappeared were compared between treatment groups with Student’s t test for independent samples. Mean values were determined for all patients, and 95% confidence intervals were determined. All retrospectively collected data assessing pain relief were dichotomized using 6 months of impairment as the cutoff point. Hospital costs were significantly lower in the extracorporeal shock wave therapy group compared with the femoral head core decompression group for both unilateral and bilateral lesions. Only minor complications occurred after therapy, such as transient soft tissue swelling or minor bruising. In the femoral head core decompression group, there were 3 cases of local hematoma formation and there was 1 case of poor wound healing. No infection, bone fractures, or sympathetic atrophy occurred.Case ReportsPatient 1A 36-year-old saleswoman had bone marrow edema syndrome of the right hip.
Extracorporeal shock wave therapy, combined with alendronate, produced rapid improvement in both pain and bone marrow edema. The visual analog scale score decreased from 8 points preoperatively to 3 points postoperatively.
The patient was able to walk immediately after extracorporeal shock wave therapy; her pain was significantly alleviated.
Coronal magnetic resonance imaging with 3.0 Tesla T1-weighted image showing a relative regular loss of signal intensity in the right femur (arrow) (B). Axial (B) and coronal (C) magnetic resonance imaging with short-time inversion recovery images showing apparent resolution of the hyperintense bilateral bone marrow edema (arrows).Patient 2A 44-year-old female teacher had bone marrow edema syndrome of the left hip that was completely cured after extra-corporeal shock wave therapy. Posttreatment short-time inversion recovery sequence showing complete resolution (arrow) (C).DiscussionBone marrow edema syndrome is a rare condition of unclear etiology that is characterized by hip pain, limited osteopenia on plain radiography, and characteristic MRI findings. The authors’ study shows that extracorporeal shock wave therapy can relieve a great deal of discomfort for these patients.
Furthermore, mean Harris Hip Scores showed statistically significant improvement from pretreatment values at all follow-up time points in patients treated with extracorporeal shock wave therapy. The clinical improvement observed with extracorporeal shock wave therapy was obvious in most patients after the first week of treatment.
Thus, extracorporeal shock wave therapy can be effective in the management of rapidly developing, intractable bone marrow edema syndrome of the hip. However, the exact mechanism through which extracorporeal shock wave therapy operates remains unknown.
Extracorporeal shock wave therapy produced results comparable to those of femoral head core decompression in bone marrow edema syndrome of the hip. Furthermore, the authors observed a significant reduction in the mean visual analog scale score at short-term follow-up only in the extracorporeal shock wave therapy group. In addition, mean Harris Hip Scores showed statistically significant improvement from pretreatment values at all follow-up time points in the extracorporeal shock wave therapy group. During follow-up, all hips with bone marrow edema syndrome of the hip that were treated with extracorporeal shock wave therapy alone showed visible improvement on radiographs and MRI. The benefits of extracorporeal shock wave therapy are supported by the finding that the grade of patients’ edema did not worsen but rather improved.
Because bone marrow edema syndrome of the hip is relatively uncommon in the author’s setting, it would have been difficult to perform a randomized, controlled trial.
Further studies are needed with larger cohorts of patients using a homogenous classification system and standardized treatment protocols to further assess the efficacy of extracorporeal shock wave therapy in the management of bone marrow edema syndrome of the hip.ConclusionThe findings indicate that extracorporeal shock wave therapy is a valid, reliable, and noninvasive tool for rapidly treating intractable bone marrow edema syndrome of the hip. It has a low complication rate and a relatively low cost compared with other conservative and surgical treatment approaches.
Extracorporeal shock wave therapy is an innovative technology that is applicable to orthopedics, but it is still new. Further studies would be worthwhile because this treatment has the potential to resolve patient suffering quickly.References Baiano C, Romeo A, Zocco A, Chierchia M, Denaro S. Treatment of osteonecrosis of the hip: comparison of extracorporeal shockwave with shock-wave and alendronate. Osteoblasts stimulated with pulsed electromagnetic fields increase HUVEC proliferation via a VEGF-A independent mechanism. Infusion, core decompression, or infusion following core decompression in the treatment of bone edema syndrome and early avascular osteonecrosis of the femoral head.
Extracorporeal shock wave therapy in early osteonecrosis of the femoral head: prospective clinical study with long-term follow-up. Autologous blood and corticosteroid injection and extracoporeal shock wave therapy in the treatment of lateral epicondylitis.
The safety and efficacy of high energy extracorporeal shock wave therapy in active, moderately active, and sedentary patients with chronic plantar fasciitis.



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