Síndrome de pinzamiento isquiofemoral: a propósito de una serie de 5 casos / Ischiofemoral impingement syndrome: A five-case series report

El dolor glúteo es un motivo frecuente de consulta médica en la práctica clínica diaria. Las causas son muy variadas, pudiendo encontrar entre aquellas que forman parte de su diagnóstico diferencial el síndrome de pinzamiento isquiofemoral. Este, incluido actualmente dentro de los síndromes de glúteo profundo, es consecuencia del atrapamiento de las estructuras neuromusculares englobadas entre el trocánter menor y la tuberosidad isquiática, lo que ocasiona un cuadro de dolor en la raíz del miembro inferior, con irradiación hacia el muslo o hacia la región glútea, y mala tolerancia a la deambulación y a la sedestación. La prueba diagnóstica fundamental es la resonancia magnética de cadera, y su manejo suele ser médico inicialmente. A pesar de no ser una entidad frecuente en las consultas de reumatología, tener esta patología en mente ayuda a mejorar su pronóstico, al poder ofrecer un tratamiento adecuado y precoz.(AU)

Gluteal pain is a frequent cause of medical attention in the daily clinical practice. It can be caused by multiple pathologies, being ischiofemoral impingement syndrome among those included in its differential diagnosis. Encompassed within the deep gluteal syndromes, this entity occurs as a consequence of the entrapment of the neuromuscular structures between the lesser femoral trochanter and the ischial tuberosity, causing pain in the root of the lower limb, with irradiation towards the thigh or the gluteal region and poor tolerance to deambulation and sedestation. The magnetic resonance imaging of the hip is fundamental for its diagnosis, and its management consists on medical treatment at onset. Despite not being a frequent diagnosis in the clinical practice in rheumatology, keeping it in mind helps improving its prognosis by establishing an early and adequate treatment.(AU)

Dual-Energy X-Ray Absorptiometry Does Not Confirm Validity of the Craig's Test.

The Craig's test is a clinical assessment used to quantify femoral version. The validity of the Craig's test has been called into question due to instances where the test exhibits relatively poor correlation with three-dimensional imaging. Our study purpose was to use dual-energy X-ray absorptiometry (DXA) to indirectly assess the validity of the Craig's test. Twenty-three volunteers (n = 46; each hip analyzed separately) received two hip DXA scans using two different methods of positioning. During the first scan, a standard-sized wedge, the conventional tool of hip positioning for DXA scans, was used to fixate the legs without regard for individual levels of femoral version. For the second scan, the participants' hips were manually positioned according to their degree of femoral version determined by the Craig's test. We hypothesized that the bone mineral density (BMD) values from the customized positions would be lower due to the X-ray beams hitting the femoral neck perpendicularly. A paired t-test revealed weak evidence of a difference between BMD readings of the conventional and customized positions (p-value = 0.065); moreover, contrary to our hypothesis, the BMD readings obtained in the standard position were lower than those obtained in the customized position, albeit not significantly. Our findings suggest that the Craig's test is not a valid clinical assessment of true femoral version. A secondary conclusion is that the widespread use of the standard wedge for hip positioning during DXA scans is a better option than trying to find a customized position that is based on findings of the Craig's test.

Bilateral hip DXA Reporting: 2023 Official Positions of the International Society for Clinical Densitometry.

INTRODUCTION: This position development conference (PDC) Task Force examined the use and reporting of bilateral hip bone mineral density (BMD) measurements. This was deemed appropriate as increased availability of Dual-energy X-ray Absorptiometry (DXA) technology offering bilateral hip measurement resulted in more routine clinical use. The International Society for Clinical Densitometry Official Positions accept bilateral hip BMD measurement for clinical use but currently do not include recommendations for reporting those studies. METHODS: Four key questions regarding bilateral hip reporting were proposed by the PDC Steering Committee. Relevant literature was identified using PubMed. Questions included whether bilateral hip measurements are appropriate for diagnostic classification or monitoring, as well as which bilateral hip regions of interest should be reported for diagnosis and monitoring. Additionally, the appropriate nomenclature for bilateral hip acquisition was defined. RESULTS: The literature review demonstrated that bilateral hip measurement is appropriate and diagnostic classification should be based on the lowest T-score at the right or left side femoral neck or total hip; the mean T-score should not be used for diagnostic purposes. Mean bilateral total hip is preferred for BMD monitoring. The terms hip, or total hip were deemed appropriate nomenclature instead of femur or total proximal femur. CONCLUSION: Bilateral hip acquisition is clinically appropriate and reporting and nomenclature standards are offered herein when a bilateral hip study is acquired. In terms of future research, the impact of discordant hips on diagnosis and monitoring was identified as a significant knowledge gap.

Relationship between the Hip Abductor Muscles and Abduction Strength in Patients with Hip Osteoarthritis.

This study aimed to determine which muscle the gluteus maximus, gluteus medius, gluteus minimus (Gmin), or tensor fasciae latae (TFL) contributes most to hip abduction strength and to identify effective sites for cross-sectional area (CSA) Gmin and TFL measurement in hip osteoarthritis (OAhip) patients. Twenty-eight patients with OAhip were included. The muscle CSA and volume were determined using magnetic resonance imaging. Peak isometric strength was determined using hand-held dynamometry. Muscle volumes were normalized to the total muscle volume of hip abductors. Multiple regression analysis was performed. The difference between the CSA of Gmin and TFL was calculated, and correlations with volume and muscle strength were determined. Gmin volume was related to abductor muscle strength (p=0.042). The peak CSA of the Gmin correlated with muscle volume and strength. The CSA of the TFL correlated with volume, with no difference between the CSA of the most protruding part of the lesser trochanter and peak CSA. Gmin volume was strongly related to abductor muscle strength. Peak CSA is a useful parameter for assessing the CSA of the Gmin among patients with OAhip. The CSA of the TFL should be measured at the most protruding part of the lesser trochanter.

Evaluation of paediatric hip pain.

Hip pain in a child can pose a diagnostic conundrum. In most cases, the cause of a painful hip is often attributed to trauma, but a number of these cases will be atraumatic. The main entities to consider are inflammatory, infective and neoplastic causes. Pathologies such as avascular necrosis and slipped upper femoral epiphysis can also present in a similar manner. A detailed history and clinical examination are crucial in narrowing down the differential diagnosis. In addition, understanding the most appropriate imaging modalities and the characteristic radiological findings is key in ensuring timely treatment and management. This article reviews the various disease processes in children who present with hip pain and outlines the most appropriate assessment and imaging modalities that will aid diagnosis.

Imaging of common hip pathologies in runners.

Running is an increasingly popular sport and form of exercise. Because of the importance of the hip in the biomechanics involved with running, forming the primary connection between the axial and appendicular skeleton of the lower extremities, accurate diagnosis and reporting of hip pathology are vital for appropriate management. This review provides an overview of the most common hip pathologies and injuries encountered in runners. Radiologic studies, primarily conventional radiography and magnetic resonance imaging (MRI) provide useful diagnostic information and should be used in combination with clinical findings to help guide therapeutic management.

Update on contribution of hip labral tears to hip pain: A narrative review.

Hip labral tears are found in 22-55% of individuals with hip pain, but labral tears without cysts are usually not responsible for hip pain, which originates mostly from other structures than the torn labrum, like osteochondral, but also tendinous injuries (rectus femoris, gluteus minimus, iliopsoas) or capsulo-ligamentous tears (iliofemoral ligaments, ligament teres). Those lesions are mainly the consequences of underlying unrecognized functional acetabular dysplasia, and/or femoroacetabular impingements. Although the early repair of labral tears in young sportsmen induces a marked and lasting relief, and might delay the onset of osteoarthritis, the microinstability fostered by labral damages seems less important than underlying dysplasias/impingements. This narrative review details recent findings on: (i) the various mechanisms of pain associated with labral tears; (ii) few evidence for hip microinstability induced by isolated labral tears; (iii) how to best detect labral tears, both clinically (including through IROP test) and on imaging (MRI, MRA, computed tomography arthrography, ultrasound). Some authors suggested to use pull-out tests during surgery, but pulling of hips do not seem to increase much diagnostic performances of ultrasounds. Ultrasound-guided intra-articular and peri-articular injections may tell how often hip pain is exclusively induced by peri-capsular injuries secondary to the acetabular dysplasia/femoro-acetabular impingements already responsible for labral tears. Further works could tell whether labral repair, tendinous debridement, plication of capsule, and/or focal denervation, may induce lasting reliefs of pain induced by the chronic contraction of surrounding muscles (rectus femoris, gluteus minimus, psoas), whose deep aponeuroses mix with the superficial fibres of the thick hip capsule.

Lateral Hip Pain: Relation to Greater Trochanteric Pain Syndrome.

The purpose of this article is to provide a synopsis of the current medical understanding of lateral hip pain, highlighting greater trochanteric pain syndrome (GTPS) and its relation to lateral hip pain. Common causes of lateral hip pain, GTPS as a cause of lateral hip pain, prevalence of GTPS, clinical presentation of GTPS, associated risk factors, history and physical examination, laboratory testing, diagnostic imaging, and treatment options are described. A quiz serves to assist readers in their understanding of the presented material.

Towards defining muscular regions of interest from axial magnetic resonance imaging with anatomical cross-reference: a scoping review of lateral hip musculature.

BACKGROUND: Measures of hip muscle morphology and composition (e.g., muscle size and fatty infiltration) are possible with magnetic resonance imaging (MRI). Standardised protocols or guidelines do not exist for evaluation of hip muscle characteristics, hindering reliable and valid inter-study analysis. This scoping review aimed to collate and synthesise MRI methods for measuring lateral hip muscle size and fatty infiltration to inform the future development of standardised protocols. METHODS: Five electronic databases (Medline, CINAHL, Embase, SportsDISCUS and AMED) were searched. Healthy or musculoskeletal pain populations that used MRI to assess lateral hip muscle size and fatty infiltration were included. Lateral hip muscles of interest included tensor fascia late (TFL), gluteus maximus, gluteus medius, and gluteus minimus. Data on MRI parameters, axial slice location, muscle size and fatty infiltrate measures were collected and analysed. Cross referencing for anatomical locations were made between MRI axial slice and E-12 anatomical plastinate sections. RESULTS: From 2684 identified publications, 78 studies contributed data on volume (n = 31), cross sectional area (CSA) (n = 24), and fatty infiltration (n = 40). Heterogeneity was observed for MRI parameters and anatomical boundaries scrutinizing hip muscle size and fatty infiltration. Seven single level axial slices were identified that provided consistent CSA measurement, including three for both gluteus maximus and TFL, and four for both gluteus medius and minimus. For assessment of fatty infiltration, six axial slice locations were identified including two for TFL, and four for each of the gluteal muscles. CONCLUSIONS: Several consistent anatomical levels were identified for single axial MR slice to facilitate muscle size and fatty infiltration muscle measures at the hip, providing the basis for reliable and accurate data synthesis and improvements in the validity of future between studies analyses. This work establishes the platform for standardised methods for the MRI assessment of lateral hip musculature and will aid in the examination of musculoskeletal conditions around the hip joint. Further studies into whole muscle measures are required to further optimise methodological parameters for hip muscle assessment.

Dígito pélvico como hallazgo incidental y posibles diagnósticos diferenciales / Pelvic digit as an incidental finding and possible differential diagnoses

El dígito pélvico es un tipo de anomalía congénita benigna poco frecuente, que se localiza en la región coxofemoral, en relación con el ilion.A pesar de que suele ser asintomático, es importante conocer su existencia, así como los posibles diagnósticos diferenciales, ya que se puede encontrar como un hallazgo incidental en la radiografía simple.Se presenta el caso de un hombre, de 58 años, que acude a su médico de Atención Primaria (AP) por artralgias generalizadas, quien observa en la radiografía simple de cadera un hallazgo inusual, por lo que interconsulta al servicio de Radiodiagnóstico, donde se realiza el diagnóstico de dígito pélvico.(AU)

The pelvic digit is a rare benign congenital abnormality, located in the hip region, in regard to the ilium.Although usually asymptomatic, it is important to be aware of its existence as well as the possible differential diagnoses since it can be found as an incidental finding on plain x-ray.We report the case of a 58-year-old man who presented to his primary care physician because of generalized arthralgia. He observed an unusual finding on plain x-ray of the hip, whereby he consulted the radiology department, where pelvic digit was diagnosed.(AU)

Double diapering facilitates hip maturation in newborns.

BACKGROUND: Double diapering may help to maintain a baby's hips in flexion and abduction posture, but the efficacy in facilitating hip maturation has never been verified. We investigated whether double diapering results in greater improvement of the alpha angle in newborn babies. METHODS: This prospective study enrolled newborns with Graf type IIa immature hips and assigned them to the double-diaper or single-diaper group by the day of birth in a week. Parents were instructed on proper hip positioning, except for diapering. Change in the alpha angle from newborn to 1 month after birth, rate of improvement to bilateral Graf type I hips in 1 month, and number of ultrasound examinations and orthopaedic clinic visits in the first year were compared between the two groups. RESULTS: Seventy newborns with 102 type IIa hips were included from January to December 2017. They were allocated to the double-diaper group (n = 33) and single-diaper group (n = 37). With a comparable sex ratio, gestational age, and newborn alpha angle, the double-diaper group had a greater increase of alpha angles in 1 month than the single-diaper group (+7.9° vs. +5.2°, t-test, p = 0.011). Twenty-eight babies in the double-diaper group (84.8%) and 20 babies in the single-diaper group (54.1%) improved to having bilateral Graf type I hips (chi-square test, p = 0.006). Under the same clinical management pathway, subsequent clinical visits and hip ultrasounds before 1 year were significantly reduced in the double-diaper group. CONCLUSION: Double diapering enhances hip maturation and reduces clinical costs in newborns with physiological immature hips, but the therapeutic role for hip dysplasia requires further study.

Comparison of magnetic resonance imaging and computed tomography for bone assessment of neurogenic heterotopic ossification of the hip: a preliminary study.

BACKGROUND: Neurogenic heterotopic ossification (NHO) is a frequent complication, often involving the hip. The functional impact may require surgical management and pre-surgical imaging assessment is necessary, usually by computed tomography (CT). We aimed to compare the performances of magnetic resonance imaging (MRI) and CT for bone assessment on pre-surgical imaging of the heterotopic ossifications and their features in NHO of the hip. METHODS: This single-center prospective preliminary study included all patients who underwent surgery for NHO with joint limitation from July 2019 to March 2020. All patients had a CT after biphasic iodinated solution injection and an MRI including T1-weighted, STIR and ZTE sequences. Standardized reports were completed for both exams for each patient, evaluating location, implantation and fragmentation of NHO, relation to the joint capsule and bone mineralization, then were compared. RESULTS: Seven patients from 32 to 70 years old (mean = 50.2 ± 17.2 years) were evaluated. NHO were bilateral in 2 patients, for a total of nine hips: six right hips and three left hips. Observed concordance rates between MRI and CT were, respectively, 94.4% for location, 100% for circumferential extension, 87.3% for implantation 88.9% for fragmentation, 77.8% for relation to the joint capsule and 66.7% for bone mineralization. It was 100% for femoral neck fracture and osteonecrosis of the femoral head. CONCLUSION: This preliminary study suggests that pre-surgical MRI imaging should be considered as effective as CT for bone assessment of NHO and their features. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03832556. Registered February 6, 2019, https://clinicaltrials.gov/ct2/show/NCT03832556 .

Prediction of osteoporosis from simple hip radiography using deep learning algorithm.

Despite being the gold standard for diagnosis of osteoporosis, dual-energy X-ray absorptiometry (DXA) could not be widely used as a screening tool for osteoporosis. This study aimed to predict osteoporosis via simple hip radiography using deep learning algorithm. A total of 1001 datasets of proximal femur DXA with matched same-side cropped simple hip bone radiographic images of female patients aged ≥ 55 years were collected. Of these, 504 patients had osteoporosis (T-score ≤ - 2.5), and 497 patients did not have osteoporosis. The 1001 images were randomly divided into three sets: 800 images for the training, 100 images for the validation, and 101 images for the test. Based on VGG16 equipped with nonlocal neural network, we developed a deep neural network (DNN) model. We calculated the confusion matrix and evaluated the accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We drew the receiver operating characteristic (ROC) curve. A gradient-based class activation map (Grad-CAM) overlapping the original image was also used to visualize the model performance. Additionally, we performed external validation using 117 datasets. Our final DNN model showed an overall accuracy of 81.2%, sensitivity of 91.1%, and specificity of 68.9%. The PPV was 78.5%, and the NPV was 86.1%. The area under the ROC curve value was 0.867, indicating a reasonable performance for screening osteoporosis by simple hip radiography. The external validation set confirmed a model performance with an overall accuracy of 71.8% and an AUC value of 0.700. All Grad-CAM results from both internal and external validation sets appropriately matched the proximal femur cortex and trabecular patterns of the radiographs. The DNN model could be considered as one of the useful screening tools for easy prediction of osteoporosis in the real-world clinical setting.

Four-Year Teriparatide Followed by Denosumab vs. Continuous Denosumab in Glucocorticoid-Induced Osteoporosis Patients With Prior Bisphosphonate Treatment.

Objectives: In our previous 24-month study, we observed that teriparatide had some advantages over denosumab for bone mineral density (BMD) in glucocorticoid-induced osteoporosis (GIO) patients with prior bisphosphonate treatment. We conducted this extension study to investigate whether the advantage of teriparatide obtained in the first 2 years would be maintained after the switch to denosumab. Materials and Methods: We switched patients who had completed 24-month daily teriparatide treatment to denosumab (switch group, n=18) and compared their BMD every 6 months up to 48 months with the group who continued to receive denosumab (denosumab group, n=16). Results: At 48 months, the lumbar spine BMD was significantly increased from baseline in both groups (denosumab: 10.4 ± 8.7%, p<0.001; switch: 14.2 ± 6.8%, p<0.001). However, a significant increase in femoral neck BMD from baseline occurred only in the switch group (11.2 ± 14.6%, p<0.05); denosumab (4.1 ± 10.8%). The total hip BMD increased significantly from baseline in both groups (denosumab: 4.60 ± 7.4%, p<0.05; switch: 7.2 ± 6.9%, p<0.01). Femoral neck BMD was significantly increased in the switch versus the denosumab group (p<0.05). Conclusion: In GIO patients with prior bisphosphonate treatment, the advantage of teriparatide may be maintained after the treatment period. A continuous increase in BMD can be expected with teriparatide followed by denosumab.

The Clinical and MRI Effect of TNF-α Inhibitors in Spondyloarthritis Patients With Hip Involvement: A Real-World Observational Clinical Study.

Objectives: Hip involvement is an important cause of disability and poor prognosis in patients with spondyloarthritis (SpA). Tumor necrosis factor (TNF)-α inhibitor treatment has been demonstrated to be effective in SpA patients with hip arthritis; however, quantitative assessment using MRI in long-term follow-up needs further application and observation. Methods: A total of 239 patients were involved in this study. Methotrexate and sulfasalazine were given as basic treatment. In total, 165 patients received TNF-α inhibitors plus basic treatment, and 74 received basic treatment only, as controls. Clinical symptoms were assessed at baseline and at weeks 12, 24, and 52. MRI performances of hip arthritis, including bone marrow edema (BME) and synovitis, were quantitatively assessed using the Hip Inflammation MRI Scoring System (HIMRISS). Results: The clinical values of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Harris hip score, and Ankylosing Spondylitis Disease Activity Score (ASDAS)-ESR in both groups showed significant clinical remission at week 52 (p < 0.001). However, the change in disease activity levels at week 52 in the control group was significantly worse than in the TNF-α inhibitor group. At week 52, MRI showed a significant remission trend in the TNF-α inhibitor group versus baseline, and total HIMRISS scores were significantly decreased (26.49 ± 10.37 vs. 20.59 ± 9.41, p < 0.001); the control group only had slight improvement (p < 0.05). Conclusions: TNF-α inhibitors could significantly improve clinical and MRI manifestations of hip involvement in patients with SpA. Quantitative MRI assessment combined with clinical assessment can be used to accurately evaluate the treatment effect of TNF-α in SpA patients with hip involvement to help guide targeted treatment.

Fractura de liner cerámico en prótesis total de cadera tras traumatismo directo. Una causa poco frecuente de fracaso del componente cerámico / Ceramic liner fracture in total hip replacement after direct trauma. An unsual cause of ceramic component failure

Proponer la centralización del cúbito distal en El desgaste de los materiales tras la artroplastia total de cadera (ATC) es uno de los grandes problemas en el paciente joven. Con el avance en los diseños de las nuevas cerámicas, parece haber disminuido la tasa de desgaste. Sin embargo, existen complicaciones exclusivas del par cerámica-cerámica, como la fractura de los componentes, sien-do la fractura del liner cerámico por traumatismo directo una complicación poco frecuente. Exponemos el caso clínico de un paciente de 41 años de edad que tras ser intervenido de ATC con par de fricción cerámica-cerámica, sufrió un traumatismo de alta energía tras atropello, asociado a fractura del liner cerámico. Se realizó una revisión de la ATC y se recambió el par de fricción a cerámica-politelieno, obteniendo buenos resultados en el postoperatorio, con una puntuación en la escala visual analógica (EVA) de 1, una puntuación en la escala Harris Hip Score de 92,8, una puntuación en la escala Oxford de 44 y una dismetría de 0,5 cm. Además se hizo una comparativa de los resultados obtenidos en nuestro caso clínico con los expuestos en la literatura.(AU)

Wear after total hip arthroplasty (THA) is one of the great problems in young patients. With the advancement in new ceramic designs, the wear rate appears to have decreased. However, there are complications exclusive to the ceramic-ceramic pair, such as component fracture, with the ceramic liner fracture due to direct trauma being a rare complication. We present the clinical case of a 41-year-old patient who, after undergoing THA with a ceramic-ceramic friction pair, suffered a high-energy trauma after being run over, associated with a fracture of the ceramic liner. A revision of the THA was carried out and the friction pair was changed to ceramicolythene, obtaining good results in the postoperative period, with a score on the visual analog scale (VAS) of 1, a score on the Harris Hip Score of 92,8, an Oxford scale score of 44, and a leg length discrepancy of 0.5 cm. In addition, a comparison was made of the results obtained in our clinical case with those reported in the literature.(AU)

MR of tendons about the hip: A study in asymptomatic volunteers.

PURPOSE: Tendon pathology around the hip is a common entity. The aim of this study was to detect tendon abnormalities around the hip in a population of asymptomatic volunteers. MATERIALS AND METHODS: Fifty volunteers (100 hips) referred for non-musculoskeletal conditions were evaluated with an additional coronal STIR-weighted MRI imaging on a 1.5 MR unit. This group was composed of 27 women and 23 men with a mean age of 52 (19-91 years). The images were interpreted independently by 2 musculoskeletal radiologists. All tendons around the hip were given a score from 0 to 4, with a score 0 corresponding to no abnormality, score 1 to signal alteration around the tendon, score 2 to minimal signal abnormality in the tendon, score 3 partial tear and score 4 complete rupture. The trochanteric bursa was also evaluated and its size was measured. It was also given a score from 0 to 3 (0: no abnormality, 1: slight hypersignal, 2: bursitis < 10 mm, 3: bursitis ≥ 10 mm). RESULTS: High intratendinous signal was commonly found at the joined insertion of biceps femoris and semitendinosus (18% L, 20% R), the semimembranosus (24% L, 20% R), gluteus minimus (6% L, 11% R) and rectus femoris (9% L, 3% R). A small trochanteric bursa was seen in 33% of the volunteers on the left side and 32% on the right side. The interobserver correlation was very good with an intraclass correlation coefficient of 0.79 (CI: 0.74-0.85). CONCLUSION: Slight signal alterations might be found in the insertions of the rectus femoris, hamstrings and gluteus minimus tendons. A small to moderate trochanteric bursitis might also be seen. This suggests that care should be taken when interpreting MR scans to attribute symptoms to these findings.