External snapping hip syndrome is associated with an increased femoral offset

Background External snapping hip syndrome (ESH) is postulated to be one of the causes of greater trochanteric pain syndrome, which also includes greater trochanteric bursitis and tendinopathy or tears of the hip abductor mechanism. However, it was not yet described what kind of bony morphology can cause the snapping and whether symptomatic and asymptomatic individuals have different imaging features. Purpose It was the purpose of this study to look for predisposing morphological factors for ESH and to differentiate between painful and asymptomatic snapping. Methods A consecutive cohort with ESH and available magnetic resonance imaging (MRI) between 2014 and 2019 was identified. The control group consisted of patients that underwent corrective osteotomies around the knee for mechanical axis correction and never complained of hip symptoms nor had undergone previous hip procedures. The following parameters were blindly assessed for determination of risk factors for ESH: CCD (corpus collum diaphysis) angle; femoral and global offset; femoral antetorsion; functional femoral antetorsion; translation of the greater trochanter (GT); posterior tilt of the GT; pelvic width/anterior pelvic length; intertrochanteric width. Hip and pelvic offset indexes were calculated as ratios of femoral/global offset and intertrochanteric/pelvic width, respectively. For the comparison of symptomatic and asymptomatic snapping, the following soft-tissue signs were investigated: presence of trochanteric bursitis or gluteal tendinopathy; presence of surface bony irregularities on trochanter major and ITB (Iliotibial band) thickness. Results A total of 31 hips with ESH were identified. The control group (n = 29) consisted of patients matched on both age (± 1) and gender. Multiple regression analysis determined an increased hip offset index to be independent predictor of ESH (r = + 0.283, p = 0.025), most likely due to the higher femoral offset in the ESH group (p = 0.031). Pearson correlation analysis could not identify any significant secondary factors. No differences were found between painful and asymptomatic snapping on MRI. Conclusions A high hip offset index was found as an independent predictor for external snapping hip in our cohort, mainly due to increased femoral offset. No imaging soft-tissue related differences could be outlined between symptomatic and asymptomatic external snapping. Level of evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00590.

Neglected tuberculous trochanteric bursitis in an adolescent girl: A case report and literature review

Tuberculous trochanteric bursitis (TTB) is an extremely rare form of extrapulmonary tuberculosis. Due to a low clinical suspicion and poor collaboration among medical professionals, the diagnosis of TTB can be often delayed. In this report, we describe a case of neglected TTB in an adolescent girl that initially presented with right thigh swelling and fluctuance. The patient underwent repeated unsuccessful surgical treatment; however, dull pain and periodic wound drainage remained for eight years. Complete excision of fistula and trochanteric bursa and one year of oral antituberculous drug therapy led to complete recovery. This case report highlights tuberculosis as a diagnostic challenge, when rare localizations are affected. In addition, this report addresses several diagnostic pitfalls and reviews the literature regarding TTB in adolescent patients. Orthopedic surgeons need to consider TTB, when swelling, fluctuance or repeated wound drainage are present on the thigh.

AB0504 TOPOGRAPHY OF 18F-FDG PET/CT INFLAMMATORY SITES IN SPONDYLOARTHRITIS IN COMPARISON TO POLYMYALGIA RHEUMATICA AND TO PATIENTS WITHOUT INFLAMMATORY RHEUMATIC DISEASE

Background:Spondyloarthritis (SpA) is a common inflammatory rheumatism, characterized by axial and/or peripheral enthesitis. The positron emission tomography (PET/CT) allows the detection of inflammation.Objectives:Our objective was to study the rhizomelic fixation with 18F-FDG (18-Fluorine deoxyglucose) PET/CT in SpA, compared to a Polymyalgia Rheumatica (PMR) group and to a control without rheumatological manifestationsMethods:Monocentric and retrospective study, including patients who have benefited from PET/CT. 2 groups of patients, with SpA on the one hand, and PMR on the other hand, fulfilling standard diagnostic criteria. A third group of controls (CN) benefiting from PET/CT in the context of assessment of a neoplasia. The rhizomelic fixations were evaluated according to the average of semi-quantitative scores. This in different rhizomelic sites, articular (gleno-humeral, coxo-femoral) and extra-articular (sub acromial (BSAD), trochanteric bursitis).Results:147 patients were included: 44 SpA, 50 PMR, and 53 CN. The rhizomelic fixations were significantly lower in SpA compared to PMR: on the pelvic girdle [0.31(0.7) vs 1.15(1.04), p=1.2*10-10], the scapular girdle [0.15(0.44) vs. 1.35(1.2), p=7.09*10-15], the hip joints [0.27(0.62) vs 1.16(1.16), p=1.6*10-5], glenohumeral joints [0.18(0.49) vs. 1.71(1.04), p=4.75*10-12], the trochanteric bursae [0.36(0.77) vs 1.14(0.91), p=3.54*10-6], BSADs [0.11(0.38) vs. 0.98(1.24),p=4.63*10-5], or overall rhizomelic fixation. [0.23(0.59) vs. 1.26(1.14), p= 4.47*10-24]. The fixation was also significantly lower for SpA compared to CN, in trochanters [0.36(0.77) vs 0.58(0.68),p=3.54*10-6], at the glenohumeral joints [0.18(0.49) vs 0.58(0.66),p=3.27*10-5], pelvic girdle [0.31(0.7) vs. 0.49(0.67),p=0.0028] and scapular girdle [0.15(0.44) vs. 0.41(0.66), p=7.09*10-15] and on the global overall rhizomelic fixation [0.23(0.59) vs. 0.49(0.67), p=1.22*10-6].Conclusion:Our study is the first to study the rhizomelic fixations with 18f-FDG in SpA, compared to another rheumatism inflammatory and controls. We found a lower fixation in SpA compared to PMR, confirming the major and specific rhizomelic fixation of PMR. We found a lower fixing of SpA compared to CN, without anatomical, articular or extra-articular systematization. SpA seems to be a condition with low uptake on 18f-FDG PET/CT, particularly at the rhizomelic level, compared to PMR and controls.Disclosure of Interests:None declared.

Reliability of a Novel Scoring System for MRI Assessment of Severity in Gluteal Tendinopathy: The Melbourne Hip MRI Score

Background: Gluteal tendinopathy is commonly reported in the literature, but there is a need for a validated magnetic resonance imaging (MRI)-based scoring system to grade the severity of the tendinopathy. Purpose: To use intra- and interobserver reliability to validate a new scoring system, the Melbourne Hip MRI (MHIP) score, for assessing the severity of gluteal tendinopathy. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The MHIP score assesses gluteal tendinopathy according to each 1 of 5 categories: (1) extent of tendon pathology (maximum 5 points); (2) muscle atrophy (maximum 4 points); (3) trochanteric bursitis (maximum 4 points); (4) cortical irregularity (maximum 3 points); and (5) bone marrow edema (maximum 1 point), with an overall range of 0 to 17 (most severe). A total of 41 deidentified MRI scans from 40 patients diagnosed with gluteal tendinopathy (mean baseline age, 57.44 ± 25.26 years; 4 male, 36 female) were read and graded according to MHIP criteria by 2 experienced musculoskeletal radiologists. The radiologists were blinded to previous reports, and the scans were read twice within a 2-month period. Statistical analysis using the intraclass correlation coefficient (ICC) was used to determine intra- and interobserver reliability and mean/range for the MHIP scores. Results: Of a total of 123 readings, the mean MHIP score (±SD) was 3.93 ± 2.24 (range, 0-17 points). The MHIP score demonstrated excellent reliability for determining the severity of gluteal tendinopathy on MRI. The ICC for intra- and interobserver reliability was 0.81 (95% CI, 0.67-0.89) and 0.78 (95% CI, 0.62-0.87), respectively. Conclusion: The MHIP score had excellent intra- and interobserver reliability in scoring gluteal tendinopathy. This score allows gluteal tendon pathology to be graded prior to treatment and to be used for standardized comparisons between results in future research undertaking radiological review of gluteal tendinopathy.

Prognostic factors of trochanteric bursitis in surgical-staged patients: a prospective study

Background: Trochanteric bursitis or greater trochanteric pain syndrome is a common disorder and frequent cause of lateral hip pain. It can lead to severe functional impairment with increase morbidity and poor quality of life. The purpose of the current study was to identify and evaluate relationship between health-related factors, as prognostic indicators, and clinical outcomes. Methods: A single-centre, prospective study was conducted and 60 patients (62 hips) were included with a minimum 12 months of follow-up. Clinical outcomes were evaluated using Hip Outcome Scale, Single Assessment Numeric Evaluation and Visual Analogue Scale. Radiological assessments and health-related factors were documented in an attempt to understand their validity as predictors of clinical outcomes. Complications and recurrence rates were also analyzed. Results: Univariate model revealed that an increased BMI ( p = 0.001; OR = 1.05; 95% CI, 1.02–1.07); number of previous corticosteroid infiltrations ( p = 0.001; OR = 1.28, 95% CI, 1.11–1.48); longer time from symptom onset to surgery ( p = 0.001; OR = 1.19; 95% CI, 1.12–1.28); smoker status ( p = 0.001; OR 11.2; 95% CI, 3.30–44.2); and the presence of prior lumbosacral fusion (LSF) ( p = 0.001; OR 13.8; 95% CI, 2.96–101); were prognostic factors predisposing for poor clinical outcomes. Among prognostic health-related factors were medical comorbidities such as emotional distress ( p < 0.001; OR 26.1; 95% CI, 5.71–192); fibromyalgia ( p = 0.026; OR 3.56; 95% CI, 1.16–11.7); and hyporthyroidism ( p = 0.005, OR = 6.55, 95% CI, 1.73–28.7). Conclusions: Better overall physical function was predicted by lower number of corticosteroid infiltrations, shorter time span from symptom onset to surgery, non-smoker status and the absence of prior lumbosacral fusion. Obesity, smoking, the presence of emotional distress, fibromyalgia and hypothyroidism seem to increase the risk of poor clinical outcomes. A proper selection and/or correction of modifiable prognostic factors could reduce the incidence of endoscopic treatment failure and, as a consequence, improve patient outcomes and quality of life. However, future efforts should focus on experimental and randomised studies to fully determine these associations.

Greater trochanteric pain syndrome: Evaluation and management of a wide spectrum of pathology

Greater trochanteric pain syndrome is a common cause of lateral hip pain, encompassing a spectrum of disorders, including trochanteric bursitis, abductor tendon pathology, and external coxa saltans. Greater trochanteric pain syndrome is primarily a clinical diagnosis, and careful clinical examination is essential for accurate diagnosis and treatment. A thorough history and physical exam may be used to help differentiate greater trochanteric pain syndrome from other common causes of hip pain, including osteoarthritis, femoroacetabular impingement, and lumbar stenosis. Although not required for diagnosis, plain radiographs and magnetic resonance imaging may be useful to exclude alternative pathologies or guide treatment of greater trochanteric pain syndrome. The majority of patients with greater trochanteric pain syndrome respond well to conservative management, including physical therapy, non-steroidal anti-inflammatory drugs, and corticosteroid injections. Operative management is typically indicated in patients with chronic symptoms refractory to conservative therapy. A wide range of surgical options, both open and endoscopic, are available and should be guided by the specific etiology of pain. The purpose of this review is to highlight pertinent clinical and radiographic features used in the diagnosis and management of greater trochanteric pain syndrome. In addition, treatment indications, techniques, and outcomes are described.

Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review

Purpose Recent advances in diagnostic imaging techniques and soft tissue endoscopy now allow for precise diagnosis and management of extra-articular hip pathology. The aim of this scoping review is to present an evidence-based update of the relevant literature focussing only on the pathoanatomy, clinical assessment and the diagnosis of pathology in the peritrochanteric space. Methods A literature search was performed on PubMed to include articles which reported on the anatomy and diagnosis of greater trochanteric pain syndrome, trochanteric bursitis, gluteus medius tears and external snapping hip syndrome. Results A total of 542 studies were identified, of which 49 articles were included for full text analysis for the scoping review. Peritrochanteric space pathology can be broadly classified into (1) greater trochanteric pain syndrome (GTPS), (2) abductor tears and (3) external snapping hip syndrome. Anatomically, gluteus medius, gluteus minimus and tensor fascia lata work in conjunction to abduct and internally rotate the hip. The anterolateral part of the gluteus medius tendon is more prone to tears due to a thin tendinous portion. Increased acetabular anteversion has also been shown to be associated with gluteal and trochanteric bursitis. In terms of clinical examination, tests which were found to be most useful for assisting in the diagnoses of lateral hip pain were the single-leg stance, resisted external derotation of the hip, hip lag sign and the Trendelenburg’s test. Dynamic ultrasound along with guided injections and MRI scan do assist in differentiating the pathology and confirming the diagnosis in patients presenting with lateral hip pain. Finally, the assessment of baseline psychological impairment is essential in this group of patients to ensure outcomes are optimised. Conclusion Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation and management of this cohort of patients. A thorough appreciation of the anatomy of the abductor musculature, specific clinical signs and imaging findings will lead to an appropriate diagnosis being made and management plan instituted. Level of evidence IV.

Treatment of displaced intracapsular fractures of the femoral neck with total hip arthroplasty or hemiarthroplasty

Aims Despite few good-quality studies on the subject, total hip arthroplasty (THA) is increasingly being performed for displaced intracapsular fractures of the neck of femur. We compared outcomes of all patients with displacement of these fractures treated surgically over a ten-year period in one institution. Methods A total of 2,721 patients with intracapsular fractures of the femoral neck treated with either a cemented hemiarthroplasty or a THA at a single centre were retrospectively reviewed. The primary outcomes analyzed were readmission for any reason and revision surgery. We secondarily looked at mortality rates. Results We found no difference in the overall revision rate or rate of infection. However, the rates of readmission due to dislocation, pain, and trochanteric bursitis were significantly higher in the THA group (p = 0.001, p < 0.001, p < 0.001, and p = 0.001, respectively). Conclusion Our study, comparing the outcomes of neck of femur fractures treated with a cemented hemiarthroplasty and THA, revealed the perceived superiority of THA was not borne out by our results. This should be carefully considered before any radical change in practice regarding the use of THA for displaced intracapsular fractures of the femoral neck. Cite this article: Bone Joint J 2020;102-B(6):693–698.