Hello,
Thanks for asking your question. Although I am an internal medicine
physician, please see your primary care physician for specific
questions regarding any individual cases – please do not use Google
Answers as a substitute for medical advice. I will be happy to answer
factual medical questions. You asked the following:
"Should I get a bone density scan or MRI/CAT Scan of the hip before I
proceed any further? Is it possible that I could get improvement from
arthroscopic
surgery? Could you tell me how to proceed with this problem and
possible who should examine me?"
Without meeting you, examining you or viewing the X-rays myself, I
cannot address your individual case. What I can do is give a factual
approach to chronic hip pain, as well as present data for the various
diagnostic studies and the studies regarding hip surgery.
Here is some background on the approach to hip pain.
Hip pain is a common symptom with a number of possible causes. In a
survey of 6596 adults ages 60 years and older, 14.3 percent reported
significant hip pain on most days over the past six weeks.
Trochanteric and gluteus medius bursitis, osteoarthritis, and
fractures of the femur are the most common conditions affecting the
hip.
The character and location of pain is the key element in the
differential diagnosis of hip pain. Increased pain with or after use
(particularly with weight-bearing) and improvement with rest is the
hallmark of a structural joint problem, particularly osteoarthritis.
By comparison, constant pain, especially pain at night, suggests an
infectious, inflammatory, or neoplastic process.
Trochanteric bursitis:
As mentioned, inflammation of the trochanteric bursa is one of the
most common causes of hip pain. It is caused by an exaggerated
movement of the gluteus medius tendon and the tensor fascia over the
outer femur. Even subtle gait impairment can increase friction and
pressure over the trochanteric process. Common gait abnormalities that
may result in trochanteric bursitis include lumbosacral spine
stiffness, leg length discrepancy, knee arthritis, and ankle sprain.
Untreated, the normally paper thin bursal wall thickens, fibroses, and
gradually loses its ability to lubricate the outer hip.
Patients typically complain of lateral hip pain, with point tenderness
over the trochanteric bursa. The point of tenderness usually lies
approximately one inch posterior and superior to the greater
trochanter, and is located about three inches deep to the skin.
Hip osteoarthritis:
Osteoarthritis most commonly presents in patients over 40 years of
age. The principle symptom associated with osteoarthritis of the hip
is pain, which is typically exacerbated by activity and relieved by
rest. With more advanced disease, pain may be noted with progressively
less activity, eventually occurring at rest and at night.
Meralgia paresthetica:
The lateral femoral cutaneous nerve, a pure sensory nerve, is
susceptible to compression as it courses from the lumbosacral nerve
plexus, through the abdominal cavity, under the inguinal ligament, and
into the subcutaneous tissue of the thigh. Symptoms range from
numbness and tingling (hypesthesia) to burning pain (paresthesia) over
the upper outer thigh.
Osteonecrosis:
Osteonecrosis, also known as aseptic necrosis, avascular necrosis,
ischemic necrosis, and osteochondritis dessicans, is a pathological
process that has been associated with numerous conditions and
therapeutic interventions. The mechanisms by which this disorder
develops are not fully understood. However, compromise of the bone
vasculature leading to the death of bone and marrow cells, and
ultimate mechanical failure, appear to be common to most proposed
etiologies. The process is most often progressive, resulting in joint
destruction within three to five years if left untreated.
Occult hip fracture:
An occult hip fracture (nondisplaced fracture of the femoral neck) can
be difficult to diagnose. It should be suspected in patients with
severe anterolateral hip tenderness, severe pain with even partial
weight bearing, and intolerance to passive rotation of the hip. (1)
1) Should I get a bone density scan or MRI/CAT scan of the hip?
It would seem that since the plain films were inconclusive, an MRI
would be the next logical step. Bone scan would be reserved if an MRI
is not available. See the detail below. From UptoDate:
Radiography:
A plain radiograph should be performed in patients with acute hip pain
to exclude fracture. Further imaging studies, especially magnetic
resonance imaging (MRI), may be necessary when the history, physical
examination, and plain radiographs are inconclusive. Radionuclide
scans to localize osteoblastic activity or to localize sites of soft
tissue inflammation have largely been supplanted by MRI, especially
when MRI is performed with gadolinium enhancement.
Magnetic resonance imaging:
MRI is the radiographic study of choice for suspected fracture not
demonstrated by plain x-ray, early diagnosis and accurate staging of
osteonecrosis, as well as evaluation for infection and tumor.
Radionuclide bone scan:
Radionuclide bone scan is reserved for suspected fracture or
osteonecrosis not demonstrated by plain film radiography when MRI is
not available. Increased activity is nonspecific and can be seen with
fracture, osteonecrosis, acute and chronic arthritis, and metastatic
bone lesions. (1)
2) Is it possible that I could get improvement from arthroscopic
surgery?
It would depend on what was the cause of your hip pain. I will
outline surgical options for the two more common causes of hip pain:
osteoarthritis and osteonecrosis. From the studies cited, it would
appear that the data is more convincing if the hip pain was caused by
osteoarthritis.
Osteoarthritis:
Surgery should be considered in patients with severe symptomatic OA
who have failed to respond to medical management (including
arthroscopic procedures, if appropriate) and who have marked
limitations in performing the activities of daily living.
Total joint replacement provides marked pain relief and functional
improvement in patients with severe hip or knee OA. In one study by
Kirwin et al (1994) for example, patients undergoing total hip or knee
replacement were followed for up to five years. Most patients with
total hip or knee arthroplasty for severe OA had improvement in pain
which took one year or more to reach a maximal effect; the improvement
was maintained for at least three years. (2)
Osteonecrosis:
The results of total hip arthroplasty for the treatment of
osteonecrosis are inconsistent. Most studies suggest a worse prognosis
in this disease than for other disorders, with failures being three to
four times more common. A retrospective review by Saito et al. (1989),
for example, compared total hip replacement of 29 hips in 23 patients
with osteonecrosis to the same procedure in 63 hips affected by
osteoarthritis. The revision rate was much higher in the osteonecrosis
group (28 versus 6 percent), and the time to revision was an average
of five years earlier in these patients. On the other hand, hip scores
following surgery were significantly better in the osteoarthritis
group. Possible explanations for the higher failure rate in patients
with osteonecrosis include poor bone quality, younger, heavier, and
more active patients, and bilateral disease. (3)
3) Could you tell me how to proceed with this problem and possible who
should examine me?
I cannot comment on your case specifically, but patients with
unrelenting hip pain should be managed by an orthopedic surgeon. From
the data I presented, if the plain X-ray films were non-revealing, an
MRI or bone scan (if MRI was not available) would be a logical next
step in patients with chronic hip pain.
I stress that this answer is not intended as and does not substitute
for medical advice - please see your primary care physician for
further evaluation of your individual case.
Please use any answer clarification before rating this answer. I will
be happy to explain or expand on any issue you may have.
Thanks,
Kevin, M.D.
Internet search strategy:
No internet search engine was used in this research. All sources were
from objective physician-written and peer reviewed sources.
Bibliography:
1) Anderson, B. Evaluation of the adult with hip pain. UptoDate,
2002.
2) Kirwan, JR, HL, Freeman, MA, Snow, S, Young, PJ. Overall long-term
impact of total hip and knee joint replacement surgery on patients
with osteoarthritis and rheumatoid arthritis. Br J Rheumatol 1994;
33:357.
3) Saito, S, Saito, M, Nishina, T, Ohzono, K, et. al. Long-term
results of total hip arthroplasty for osteonecrosis of the femoral
head. Clin Orthop 1989; 244:198.
4) Kalunian, K. et al. Pharmacologic and surgical management of
osteoarthritis. UptoDate, 2002.
5) Donohue, J. Osteonecrosis. UptoDate, 2002.
Links:
MedlinePLUS: Osteonecrosis
http://www.nlm.nih.gov/medlineplus/osteonecrosis.html
MedlinePLUS: Osteoarthritis
http://www.nlm.nih.gov/medlineplus/osteoarthritis.html
MedlinePLUS: Hip injuries and disorders
http://www.nlm.nih.gov/medlineplus/hipinjuriesanddisorders.html |
