Unlock Your Hip Flexors

Unlock Your Hip Flexors

Unlock Your Hip Flexors is a program that gives the user a practical, easy-to-follow, natural method of releasing tight hip Flexors. Its aim is to help the user get the desired result within 60 days at 10-15 minutes per day. Naturally, the hip flexors are not meant to be tight. When they become tight, the user needs a way to make them loosen up. Unlock Your Hip Flexor has been programmed in such a way that it will help the user in doing just that. The plan was not created to be a quick fix. In fact, it will take the user close to 60 days to solve this problem and it is hard; yet the easiest as well the only that have been known to successfully help in the loosening of tightened hip flexors. The methods employed in this program are natural ones that have been proven by many specials. The system comes with bonus E-books Unlock Your Tight Hamstrings (The Key To A Healthy Back And Perfect Posture) and The 7-Day Anti-Inflammatory Diet (Automatically Heal Your Body With The Right Foods). There various exercises that can be done at home are recorded in a video format and are so easy that you will only get a difficult one after you have agreed to proceed to the next stage. Read more here...

Unlock Your Hip Flexors Summary


4.8 stars out of 135 votes

Contents: Ebooks, Training Program
Author: Mike Westerdal
Official Website: www.unlockmyhips.com
Price: $19.00

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My Unlock Your Hip Flexors Review

Highly Recommended

All of the information that the author discovered has been compiled into a downloadable ebook so that purchasers of Unlock Your Hip Flexors can begin putting the methods it teaches to use as soon as possible.

This ebook does what it says, and you can read all the claims at his official website. I highly recommend getting this book.

Symptomatic Hip Joint Disease

Symptomatic hip joint disease is usually confused with upper lumbar radiculopathy as the hip can refer pain down the anterior thigh to the knee and occasionally further. Variable pain locations may also include the groin, buttock, or other areas in the thigh. The severity of arthritis demonstrated on x-ray only roughly correlates with pain which can be severe and often at night. Hip motion asymmetry is often diagnostic as is Trendelenberg gait, Faber's test, or Stinchfield's test compared to the well leg.46

Concentric Narrowing Of Hip Joint

Sacroiliac Joints Sclerosis Iliac

Fig. 10.35A, B Concentric hip joint narrowing with axial migration of the femoral head in advanced rheumatoid arthritis. A Anteroposterior radiograph of the right hip in a 44-year-old male shows typical concentric narrowing and axial femoral head migration (arrow). B Anterior pinhole scan reveals intense concentric tracer uptake with axial migration of the femoral head (arrow) Fig. 10.35A, B Concentric hip joint narrowing with axial migration of the femoral head in advanced rheumatoid arthritis. A Anteroposterior radiograph of the right hip in a 44-year-old male shows typical concentric narrowing and axial femoral head migration (arrow). B Anterior pinhole scan reveals intense concentric tracer uptake with axial migration of the femoral head (arrow)

Right Iliopsoas Bursogram With Depomedrol And Ropivacaine

Iliopsoas Tendonitis

Iliopsoas Bursography Iliopsoas bursography has been successfully used to diagnose iliopsoas tendon snapping syndrome.42 The examination is considered diagnostic of iliopsoas snapping syndrome if a jerking motion of the iliopsoas tendon is observed fluoroscopically as the patient reproduces the snapping or popping sensation. In our institution, this procedure has been replaced with ultrasound. Ultrasound has proven successful in a relatively recent report of a small group of patients examined for iliopsoas snapping syndrome43 and has been useful in our clinical practice. Ultrasound has the advantages of being noninvasive, lacks ionizing radiation, and allows concomitant evaluation of the contralateral side. The technique for iliopsoas bursography (Figure 4.6) is similar to that of a fluoroscopically guided hip injection. With the patient on the fluoroscopic table in the supine position, a skin mark is placed directly anterior to the middle of the femoral neck. Using sterile technique...

Inflammation of the hip joint Inflammation of the hip

Inflammation Hip Joint

I Inflammation of the Hip Joint Fig. 8.55a An inflammatory process, either rheumatic or infectious, is the cause for this acute joint condition. The cartilage in the hip joint has been destroyed completely and everywhere. There are no osteophytes at all. The acute phase of the arthritis has passed the bone is already remodeling with reactive sclerosis. b On this radiograph of the hip, the trabeculae of the femoral head are seen to run through into the acetabulum with no joint space discernible except in the medial periphery of the joint. This hip joint has become fused ankylosed in a late and final phase of the arthritis. Fig. 8.55a An inflammatory process, either rheumatic or infectious, is the cause for this acute joint condition. The cartilage in the hip joint has been destroyed completely and everywhere. There are no osteophytes at all. The acute phase of the arthritis has passed the bone is already remodeling with reactive sclerosis. b On this radiograph of the hip, the...

Hip Joint Effusion

Sonography has been proven to be an accurate method for diagnosing a hip effusion in children, and its use in the diagnosis of pediatric joint effusions and septic arthritis is now commonplace 2 . In contrast, sonography is not widely used to detect hip joint effusions in adults, with both sonography and fluoroscopically guided aspiration being used for this purpose. Several authors have reported successful use of sonography to detect an effusion in the native adult hip 3 and to assess for a septic joint 4 . Sonography has also been used to assess joint effusion after hip arthroplasty 5 . The main sonographic finding for hip joint effusion in the native adult hip is anterior capsule distension of 7 mm or more and 1 mm or more, and greater distention of the symptomatic hip when compared with the asymptomatic hip 4 . In the postoperative hip, anterior pseudocapsule distension of 3.2 mm or more at the proximal anterior femoral cortex indicates an infected hip prosthesis 5 . Although...

Nelda Fish Oil to Relieve Pain

Back in 1980, at age sixty-three, Nelda was displaying all the signs of rheumatoid arthritis. Her fingers, which hurt all the time, were becoming red and deformed. She was taking prescription pain relievers six to eight times daily, and her family physician was suggesting that it might be better to replace her right knee and left hip joints. Nelda was also taking nitroglycerin for her heart and a blood pressure-lowering medication.

Establishing Primary Explant Cultures

Transfer tissue, removed at surgery or biopsy, into a sterile container with PBS or serum-free medium (SFM) for transport to the laboratory with minimal delay, preferably on the same day (see Note 6). An excellent source is the upper femur of patients undergoing total hip replacement surgery for osteoarthritis. Cancel-lous bone that would otherwise be discarded is removed from this site prior to the insertion of the femoral prosthesis. The tissue obtained is remote from the hip joint itself, and thus from the site of pathology, and is free of contaminating soft tissue (see Note 7).

Effect of Scoliosis Osteoarthritis Osteophytes Surgery and Fracture on BMD in the Proximal Femur

Structural changes and artifacts that interfere with DXA proximal femoral BMD measurements occur less often than at the spine. Osteoarthritic change in the hip joint may cause thickening of the medial cortex and hypertrophy of the trabeculae in the femoral neck, which may increase the BMD in the femoral neck and Ward's area (36). The trochanteric region is not apparently affected by such change and has been recommended as the preferred site to evaluate in patients with osteoarthritis of the hip (37). Osteophytes in the proximal femur are apparently much less common than osteophytes in the lumbar spine (19). They also appear to have little effect on the bone densities measured in the proximal femur. In patients with scoliosis, however, lower bone densities have been reported on the side of the convexity (38). If a worst-case measurement is desired, the bone density in the proximal femur should be measured in the femur on the side of the convexity. Proximal femur fracture and surgically...

Anterior Muscles Of The Spine

Anterior Scalene Mri

The anterior flexors of the spine in the lumbar region are the psoas major and minor muscles and the iliacus. These muscles are often described as muscles of the posterior abdominal wall, but they attach directly to the spine and have a direct effect on the position of the spine. The psoas major arises from the sides of the bodies of T12-L4, the intervertebral discs between the bones, and the transverse processes of all lumbar vertebrae. The muscle crosses the pelvic brim under the inguinal ligament and, after passing anterior to the capsule of the hip joint, attaches distally to the lesser trochanter of the femur. The psoas minor arises from the sides of the bodies of T12 and L1 and the intervening disc and attaches distally to the pectin pubis and the iliopubic eminence. The iliacus arises from the inner lip of the iliac crest, the upper two thirds of the iliac fossa, and the superolateral part of the sacrum. Its muscle fibers blend with those of the psoas major to insert on the...

MRI of the Painful Hip in Athletes

Female Hip Mri

Hip pain is a common complaint in athletes, and may result from an acute injury or from chronic, repetitive trauma 1-3 . Osseous injuries involving the proximal femur or adjacent acetabulum represent one important subset. Soft-tissue injuries about the hip are varied, including those involving the musculotendinous unit and those specifically localized to entheses, or tendon insertions upon bone. A number of bursae about the hip may result in hip pain in the athlete. Finally, increasing emphasis has recently focused on injuries within the hip joint capsule, including the articular cartilage and the fi-brocartilaginous labrum. Specific underlying anatomic conditions may predispose to labral and hyaline cartilage injury at the hip in the athlete, including femoracetabular impingement (FAI) 4-6 and developmental dysplasia of the hip (DDH) 7-9 . Fig. 5. Professional basketball player with groin pain. (A) Axial T2, fat-suppressed image reveals edema in the adductor brevis (arrow) adjacent...

Focal And Multifocal Limb Neuropathy

Segmental Demyelination

The onset of the neuropathy is acute or subacute. The patient complains of numbness or pain of the anterior aspect of the thigh, often of the burning type and worse at night. Difficulty in walking and climbing stairs occurs because of weakness of the quadriceps and iliopsoas muscles. Muscle wasting is also an early and common phenomenon, which is often easier to palpate than to observe in fatter patients. The patellar reflex is decreased or more often abolished. The syndrome progresses during weeks or months in most cases, then stabilizes and spontaneous pains decrease, sometimes rapidly. In many instances, as in those originally reported, there is no any marked or sensory loss, as emphasized by Garland (22) who found inconstant extensor plantar response and

Dancing and Bone Chi Kung

The smooth functioning of the hip joints is crucial in the whole Chi transmission process. The Chi which comes from below has to travel upward. Breathing into the hip joints and the sockets and sending love into the bones and bringing the inward smile into them helps this process. The hip joints play a critical role as conveyors of the upward Chi flow from the earth, and if our body is well aligned, it can then further travel upwards.

Are there any medications that I should adjust or stop taking while Im being treated for osteoporosis

Weight-lifting can be very tricky, particularly if you are loading on the weights. If you are beginning a weight-lifting program at a fitness club, get instructions on how to use the machines that target certain muscle groups. You will want to make sure that you are using the correct technique before you add more weight. As we age, the knee joint deteriorates faster because it has had a lifetime of absorbing the greatest weight of any joints compared to its size. While hip joints are absorbing your weight as well, they are larger joints that can distribute your weight over your pelvic bones.

Doctors Dilemma

One of the success stories in medical treatment, is the increasing use of surgical repair and replacement of parts. We have long been familiar with dental care, in which cavities in teeth are filled, abscesses can be treated by antibiotics, with or without tooth extraction, and false teeth can be provided as required. Comparable intervention in other parts of the body has been developed much more slowly. However, partially blocked coronary arteries are now commonly treated by bypass surgery, hip-joints are often replaced with mechanical substitutes and cataracts are replaced with implants. In addition, organ transplantation has become common, particularly kidney transplants, but also those of heart or liver. These treatments are expensive, and with regard to organ transplantation, there is an ongoing shortage of donors. Another problem is the need to prevent rejection of foreign tissue, so patients have to take drugs to suppress the immune system for the rest of their lives. This can,...

Skeletal Evidence of Knee Injury and Stress

Semitendinosus Gracilis

The tendons of the sartorius, gracilis, and semitendinosus muscles come together as the pes anserinus tendon group. Here the large distal retinacular portion of the vastus medialis is also evident (illustration by the author, reproduced with permission from ref. 1 Hughston Sports Medicine Foundation, Inc., Columbus, Georgia). Fig. 17. The tendons of the sartorius, gracilis, and semitendinosus muscles come together as the pes anserinus tendon group. Here the large distal retinacular portion of the vastus medialis is also evident (illustration by the author, reproduced with permission from ref. 1 Hughston Sports Medicine Foundation, Inc., Columbus, Georgia).

Differential Diagnosis of the Painful

Anterior Soft Tissues Neck

The rectus tendon insertion on the pubis seems to be the primary site of pathology. Most patients describe a hyperextension injury in association with hyperabduction of the thigh. The location of the pain suggests that the injury involves both the rectus abdominis and adductor longus muscles. Other tendinous insertion sites on the pubic bone may also be involved. MRI findings in athletic pubalgia are often nonspecific. On the other hand, 12 of patients have MRI findings which clearly indicate a problem at the rectus insertion site. The relatively small incidence of a specific diagnosis by imaging studies suggests that the problem may be an attenuation of the muscle or tendon due to repeated microtrauma. The MRI finding of adductor longus inflammation is consistent with athletic pubalgia. Inflammatory involvement of the hip joint may also be caused by rheumatoid arthritis. cian.16-18 Extra-articular snapping of the hip joint can be caused by the following The iliopsoas tendon as it...

Infection of bones and joints

Septic arthritis is a medical emergency if good joint function is to be retained. Staphylococcus aureus is the commonest pathogen, but a very wide range of bacteria may be involved including streptococci coliforms and Neisseria. Aspiration of the joint allows specific microbiological diagnosis, differentiation from noninfectious causes such as crystal synovitis, and has therapeutic benefit, e.g. for the hip joint where formal drainage is recommended. Initial therapy is as for chronic osteomyelitis.

Prepatellar And Pes Anserine Bursitis

Patellofemoral Osteoarthritis

Pes anserine bursitis is an inflammation of the conjoined insertion of the sar-torius, gracilis, and semitendinosus muscle tendons along the proximal medial aspect of the tibia 24 . This entity is commonly associated with degenerative joint disease of the knee, but can also be seen in younger, active individuals who engage in sports requiring frequent side-to-side movements. The most specific physical exam finding is pain over the proximal anterior medial tibia where the conjoined tendons insert. On T1WI, there is usually a low intensity fluid collection in the region of the pes anserinus along the medial tibial meta-physis, which shows relatively high homogeneous signal on T2WI (Fig. 7).

Transient Tenosynovitis of the

Transient Toxic Synovitis

If the peripheral WBC and ESR are substantially elevated and a hip effusion is noted on the radiograph, a diagnostic arthrocentesis should be performed to exclude suppurative arthritis. Consideration should be given to open irrigation of the hip joint in the operating room by an orthopedic consultant after obtaining samples of synovial fluid for laboratory studies (Gram stain, aerobic and anaerobic cultures, and acid-fast bacilli stain and culture). The synovial fluid in transient tenosynovitis of the hip is clearly transudative, will have negative stains for microorganisms, and will yield sterile cultures.

Imaging of a Painful

Evaluating Mri Arthrogram

The imaging workup of the patient with hip pain should begin with plain or routine radiographs of the pelvis and hips. Certainly, by obtaining an anteroposterior view of the pelvis, as well as a lateral radiograph (true lateral, frog lateral, or Lowenstein view) one can readily compare the right and left hips, and therefore a built-in comparison is available for the radiologist and orthopedist. The diagnosis in many cases is obvious if the patient has had recent trauma, then one evaluates the alignment of the bones. The acetabular lines should be carefully scrutinized. The addition of oblique views of the affected hip may be necessary to evaluate the anterior and posterior columns of the acetabulum. If an acetabular fracture is identified, a CT scan is suggested to assess the position of the fracture fragments and to exclude intra-articular loose bodies. The CT is often vital for operative planning. If the trauma is repetitive and a stress or fatigue fracture is being considered,...

Pyogenic Arthritis Pyarthrosis

Acetabulum And Hemorrhagic Fluid

Fig. 8.10 A, B Protrusio acetabuli complicating an advanced hip joint pyarthrosis and concurrent osteomyelitis in the innominate bone. A Anteroposterior radiograph reveals mottled lysis in the supra-acetabular bone with acetabular protrusion (white arrow). The articular space is completely closed at the centromedial aspect (arrowheads). B Anterior pinhole scintigraph of the left hip in a 60-year-old woman with pyarthrosis shows extremely intense tracer uptake in the hip joint and supra-acetabular bone (arrows). There is minimal bulging of the pelvic border, the sign of early acetabular protrusion or pathological fracture (middle arrow). Fig. 8.10 A, B Protrusio acetabuli complicating an advanced hip joint pyarthrosis and concurrent osteomyelitis in the innominate bone. A Anteroposterior radiograph reveals mottled lysis in the supra-acetabular bone with acetabular protrusion (white arrow). The articular space is completely closed at the centromedial aspect (arrowheads). B Anterior...

Rheumatoid Synovial Impingement

Chronic synovial thickening can also occur in the hips of patients with rheumatoid arthritis and other conditions that cause chronic synovial inflammation. In a burned out stage of any inflammatory disease, the synovium can become thick and redundant. This excess scar tissue can impinge at the articular-synovial junction in the hip joint, resulting in mechanical

Acetabular Reconstruction Fixation Methods in Simple Fracture Patterns

An important aspect of acetabular fracture surgery should be the establishment of expectations for both the surgeon and the patient. Surgeons should be expected to have dedication to improving their skills and be diligent about analyzing and monitoring their own results, in an effort to learn, and improve, their outcomes. Acetabular surgery is one of the more intensive and complex surgeries performed in orthopedics. This includes but is not limited to the complexity of the surgical dissection, the significant risk of neurovascular and or visceral injury, and the three-dimensional challenge of reducing and fixing the fracture itself. So, prior to embarking on such an endeavor, and during their careers managing acetabular fractures, surgeons should make efforts to learn from their own experiences as well as those of others. The patient's expectations should also be established. They should be informed that even in the hands of subject-matter experts, the outcomes are not uniformly...

Evaluation and Diagnosis

The diagnosis of a hip joint infection can in most cases be gleaned from the history, physical examination, laboratory tests, and plain radiographs. The suspected diagnosis is then best confirmed by aspiration and culture of the joint. In situ ations where the clinical presentation is consistent with a hip joint infection despite nondiagnostic radiographic studies and negative cultures, a synovial biopsy is indicated. This situation may arise when acute pain occurs in the face of a preexisting degenerative condition. Exacerbation of pain in hips with osteoarthritis, avascular necrosis, and inflamatory arthritides can all present with these symptoms, and it is of the utmost importance to rule out infection so that expedient treatment can be provided. Biopsy of the synovial tissue can be performed either via CT guidance or using arthroscopic techniques. In this situation, hip arthroscopy not only provides synovial tissue for culture and pathologic analysis, but also allows visualization...

Labral Injuries Clinical Correlations Etiology and Classification

Femoral Head With Arthritis

As noted above, the acetabular labrum is a fibrocartilaginous structure attached to the rim of the acetabulum that provides additional surface area for the articulation with the femoral head. The labrum exists at the anterior, superior (lateral), and posterior margins of the acetabulum and is absent inferiorly in the cotyloid fossa, at which point it attaches to the transverse acetabular ligament. Pathology of the labrum including tears, hypertrophy, and instability is perhaps the most common finding on arthroscopic evaluation of the hip joint. At a minimum of 2 years from hip arthroscopy, patient results were directly correlated with the stage of labral injury. There was one stage 0 lesion and 10 stage 1 labral lesions. All but one of these patients had a good to excellent result (91 ). This single patient required an iliopsoas release with V-Y lengthening of the iliotibial band 9 months after ar- throscopy for recurrent painful snapping hip. In addition, there were 11 patients with...

Pigmented Villonodular Synovitis

Pigmented villonodular synovitis (PVNS) is a nonneoplastic proliferative disorder that can affect any synovial-lined structure, including bursae, tendons, and joints. PVNS is most commonly reported in the knee, but also occurs in the hip joint. The process occurs most frequently in the third or fourth decades of life, with no sex predilection,68 and should be considered in the differential diagnosis for all young patients presenting with uncharacteristic clinical and or radiographic features suggestive of early hip degeneration.69 In the hip, PVNS most commonly presents in a monoarticular distribution, but bilateral hip involvement has been reported.70 The etiology and pathogenesis remain obscure and undefined the most widely accepted theories attribute this disorder to a chronic inflammatory response or a benign but locally aggressive condition of fibrohistiocytic origin.68,71 At the cellular level, PVNS is characterized by hypervascular proliferative syn- PVNS has been described in...

Synovial Chondromatosis Osteochondromatosis

Loose Bodies Synovial Chondromatosis

When this condition involves the hip joint there are usually long delays in accurate diagnosis and initiation of treatment because of its insidious clinical presentation. Symptoms include the onset of dull aching pain, catching or locking sensations, and mild restriction of motion. Compounding the delay in diagnosis, plain roentgenograms demonstrate the presence of periarticular loose bodies in only 50 of the cases, because calcification within the loose bodies is not consistent.13,18 Zwas et al described a case of hip joint synovial chondromatosis that initially presented with normal radiographs and a bone scan suggestive of a destructive, reactive articular process or late manifestation of femoral head avas- The loose bodies associated with synovial chondromatosis osteochondromatosis, when small and cartilaginous, can be found in a joint with little articular destruction, while large ossified bodies may result in destructive pressure erosions of the femoral head and neck.19 Although...

Lij clinical orthopaedic examination

Hemivertebra Pes

Conditions associated with total hip joint replacement 1 72 This condition occurs in the perinatal period and involves displacement of the femoral head relative to the acetabulum if untreated it disrupts the normal development of the hip joint. The term 'congenital dislocation of the hip' (CDH). now less frequently used, is for the main part virtually synonymous. Note, however, that the contraction 'DDH' may be somewhat confusingly used for 'developmental dysplasia of the hip'. Staphylococcus is the organism most frequently responsible for acute infections in the hip joint. The infection is bloodborne and the diagnosis seldom difficult. The onset is rapid, with high fever and toxaemia. All In secondary osteoarthritis a younger age group is generally involved than in the case of primary osteoarthritis. In the young patient, where it is thought desirable to avoid the uncertain long-term morbidity of total hip replacement, a hip joint fusion may be considered in unilateral cases. Where...

Treatment Of Acetabular Injuries

The goals of managing patients with acetabular fractures are to restore the congruity of the articular surface, minimize pain, and improve long-term function (47). In the elderly, special considerations should be given to those presenting with significant medical problems, osteopenic bone, and patients who also present with concurrent femoral head fractures or those who also present with moderate or severe arthritis of the hip joint. These orthopedic comorbid factors may result in a treatment that may need to be tailored to the specific needs of that patient.

Open Reduction Internal Fixation

In those patients sustaining fractures from low-energy traumas, age-related bone loss or bone loss occurring secondary to osteoporosis will result in diminished bone stock. This is seen at the microstructural level, resulting in a reduction in the bone mineral density and a change in the trabecular orientation of the bone. Studies have demonstrated that these structural changes narrow the tolerable loading directions of the bone, increasing the risk of a fracture (74,75). In addition, these patients may also have already have pre-existing arthritis of the hip so that the additional insult of an acetabular fracture may produce displaced, unrecognizable fracture patterns with severe comminution, erosion of the articular surfaces, and associated fractures of the femoral head (65,73) (Fig. 8A-F). The combination of the four factors of osteoporosis, comminution, associated head fractures, and arthritis may ultimately produce bone that does not allow any anchorage of the fixation devices,...

Delayed Total Hip Arthroplasty

Knowing that these orthopedic and medical complications can occur may persuade surgeons to perform an open reduction of the fracture in an attempt to minimize late complications. Unfortunately, as just described, the fixation may fail or be inadequate, resulting in collapse of the joint, producing a malunion or nonunion of the acetabulum, contributing to disuse osteoporosis, producing heterotopic bone, and resulting in the development soft tissue contractures about the hip joint (60,72). Therefore, if late arthroplasty is to be considered as the treatment for these patients, it should be reserved as salvage for those who have developed symptomatic posttraumatic arthritis of the hip and have failed an attempt at conservative care (Fig. 9A-C). Regardless of conflicting reports as to whether cemented or cementless arthroplasties are better for these patients, some things are certain. Operative times, blood loss, transfusion requirements will be increased, and the difficulty in performing...

Acute Total Hip Arthroplasty

A suggested option is to combine procedures in an attempt to improve function and decrease morbidity. A combined approach, consisting of stabilization of the acetabular fracture along with immediate application of a total hip arthroplasty, has certain advantages (9,19,64,65,96). First, fixing the acetabular fracture stability to the pelvis allows a solid base to be built for the placement of a total hip. Second, fixing the fracture may help prevent the development of severe deformity of the pelvis and avoid the development of a nonunion. Last, it should be remembered that, since the goal is a rigid and stable fixation of the fracture, an anatomic reduction of the acetabulum is not necessary for success of this technique. Once the acetabular fracture has been stabilized, then the application of an acute arthroplasty of the hip can be performed (Fig. 10A-F). A combined approach, however, is not recommended for all elderly patients. Indeed, most elderly patients with acetabular fractures...

Surgical Intervention

In common with many elective surgical interventions, a stepwise approach is often employed in the treatment of OA. The procedures are site specific and in the first instance often involve a combined diagnostic therapeutic joint injection. In the hip, a radiolucent dye is injected into the hip joint under fluoroscopic guidance to confirm successful needle position. A mixture made up of a local anesthetic and a steroid is then injected. If the pain is truly due to isolated hip disease, the patient will be free of pain in minutes, due to the local anesthetic effect, with the steroid component producing symptomatic relief often over several months. many elderly patients were also excluded from surgery as the complication rate was thought to be unacceptably high. Since the early 1990s there has been phenomenal progress in terms of operative techniques, implant design, and orthopaedic anesthesia. There are now many different designs of prostheses that can be safely and reliably utilized in...

Gene Therapy for Autoimmune Diseases

In animal models, pDNA constructs with the encoding anti-inflammatory cytokine genes for IL-10 (54), IL-4 (55), and TGF j31 (56) were injected into either tibialis anterior or rectus femoris muscles in nonobese diabetic (NOD) mouse against autoimmune diabetic disease. Although there was no marked decrease in severity of insulitis, the diabetes was reduced in NOD mice injected with IL10 compared with nontreated NOD mice. In another experiment, treatment of autoimmunity prone NOD mice with pCMV-TGF-j31 (57) resulted in considerable elevation of TGF-p 1 level in the plasma. The increased levels of exerted various immunosuppressive effects such as there was suppression of de-layed-type hypersensitivity (DTH) and prevention of insulitic and diabetic incidence in this kind of mice. TGF- 31, IL-4, and IFN-y gene coding plasmid vectors were also injected IM to rodent models for treatingexperimental allergic encephalomyelitis (EAE) (57), systemic lupus erythematosus (SLE) (58), colitis (59),...

Common Conditions Causing Low Back Pain

Usually pain and paresthesias are more conspicuous than weakness, although weakness can be severe with anterior root compression. Despite overlapping effects, one finds S1 lesions to weaken plantar (dorsi) flexors L5, extensors of ankle and big toe L4, ankle evertors L3, knee extensors L2, thigh adductors and L1, hip flexors.

Rotator Cuff Injuries

As a non-weight-bearing area, the true glenohumeral joint is subject to less mechanical stress than the lower extremity. When arthritic changes occur, there may have been a prior local injury. Inflammatory arthritis, with erosive changes of the glenohumeral joint and joint effusion, may occur, especially with severe rheumatoid arthritis.12 Treatment for any degenerative arthritis is primarily aimed at relief of pain and inflammation. Surgical intervention with joint replacement is possible, but functional results are not as satisfactory as with knee and hip joint replacement, and the major goal should be relief of pain.

Treatment and Outcome

Joint fluid can usually be drained by aspirating it through a needle. This may need to be repeated if the fluid reaccumulates. The number of white blood cells in the synovial fluid decreases as the infection responds to treatment. completely draining a joint using a needle can sometimes be difficult because the fluid is thick and accumulates in pockets. If this happens arthroscopy is often performed to drain the fluid. Because draining the hip joint through a needle is difficult, surgical drainage is usually performed, either directly or by arthroscopy. The outcome of septic arthritis varies a lot depending on the causative organism, how long the infection has been present, and the response to

Patients and Methods

Between 1972 and 1979, 128 patients with idiopathic ONFH underwent osteotomy in our department. Fifteen hips of 9 patients, who had been visiting our outpatient office and had their living hip joints more than 25 years after operation, were examined. The hips were separated into two groups (Table 1). One group includes the hips that had advanced or terminal osteoarthritis (OA) at the last follow-up. Another group includes those that had no OA or early OA. Age at operation and period after operation were similar in both the groups. Clinical scores were assessed according to the hip scoring system by the Japanese Orthopaedic Association. a In the clinical scoring system for hip joints developed by the Japanese Orthopaedic Association, the maximum score is 100 points

Twenty Years of Experience with the Bernese Periacetabular Osteotomy for Residual Acetabular Dysplasia

Residual acetabular dysplasia is known as the most frequent cause of early osteoarthritis of the hip. The degeneration starts with overload of the rim, leading to a variety of pathologies. This change may cause the femoral head to migrate further out of the socket, resulting in a loss of congruity and generating even higher pressure point loading, which finally leads to rapid destruction of the joint. It is well accepted today that the surgical increase of the load transmission area can slow down this process of destruction and postpone total hip replacement (THR) substantially. Among the different techniques available, reorientation procedures allow for the most physiological correction of the joint mechanics. Our proposition is a reorientation procedure, which was first executed in 1984. Techniques and results have been published on several occasions. Under the name of the Bernese periacetabular osteotomy, the technique has gained popularity, especially in North America....

Mr Evaluation Of The

Acetabular labral tears have become a commonly recognized source of intra-articular hip pain that affects athletes and nonathletes alike. Although strongly associated with athletes performing twisting pelvic motions and rotations of the hip that occur in sports like soccer, golf, football, ballet, and hockey athletes in all major sports (and even minor ones such as skateboarding and Olympic yachting) have been affected 38 . Many tour-level professional golfers have undergone successful hip surgery for labral pathology with return to previous level of play and sometimes beyond prior performances (Marc J. Philipponm, personal communication). As stated earlier, direct MR arthrography is the best imaging modality for evaluation of underlying intra-articular disorders. Interpretation should not only include labral evaluation, but also evaluation of chondral, capsular, bony, ligamentum teres, and adjacent extra-articular (iliopsoas, rectus femoris, pubic symphysis) abnormalities (Fig. 10)....

Additional considerations in site selection for diagnosis

In the proximal femur, the total hip, femoral neck, and trochanter are all useful sites. The proximal femur is less affected by dystrophic changes than the PA spine, but it is not entirely free of such affects. Although the hip joint itself is not measured in a DXA proximal femur study, severe osteoarthritis of the hip joint can affect the bone density of the proximal femur (39,40). Therefore, if severe unilateral osteoarthritis is known or suspected, the proximal femur on the unaffected side should be measured. If this is not possible, the trochanteric region becomes the preferable region of interest in the proximal femur as the effects of osteoarthritis of the hip joint are most notable in the femoral neck and Ward's area, both of which are included in the total hip region of interest.

And Contraindications

The indications for HA without traction do not differ from those described for the traction technique. The traction and nontraction techniques should be combined to allow a complete diagnostic inspection of the hip joint. Performing HA solely as a nondistraction method should be limited to children and situations in adults in which distraction is not sufficient to introduce instruments into the central compartment of the hip. with other hip arthroscopists,55,56 who have performed HA in children with septic arthritis and Perthes disease, reveal that a traction table is not necessary in patients younger than 12 to 14 years. Soft tissues, including the hip joint capsule and pericapsular ligaments, are so lax at this age that HA can be performed solely as a combination of nontraction and manual traction. A minimum distraction of the central compartment of the hip of about 8 to 10 mm should be confirmed under fluoroscopy before placement of the first portal. In patients with osteoarthritis...

Radiographic and Other Studies

Quick and easy method of evaluating for joint effusion, particularly in the hip joint. C. Carefully evaluate hip joint. Remember that referred pain to the knee may originate in the hip. Permanent damage may result from increased pressure within the joint capsule. Consider DDH in younger kids, LCPD in school-age boys, SCFE in overweight adolescents, and septic arthritis in everyone (medical emergency). VIII. Teaching Pearl Answer. The anterior branch of the obturator nerve passes close to the hip joint and, if irritated, may send a painful sensation to the medial side of the knee.

Keith R Berend and Thomas Parker Vail

The appropriate application of hip arthroscopy to pediatric conditions requires a broad understanding of children's hip problems. In the end, the success of a hip arthroscopy in treating a pediatric hip condition depends as much on an accurate anatomic diagnosis as it does on technique. A dense constellation of intraarticular and extraarticular anatomic structures exists in close proximity to the hip joint. As such, multiple intraarticular and extraarticular pathologic conditions ranging from developmental to traumatic to infectious can be responsible for hip pain in the young active patient. Indeed, many of these conditions are specific to children and skeletally immature young adults. Traumatic etiologies include apophyseal injury, labral tears, chondral injury with or without loose body formation, and even hip dislo-cation.1-4 Legg-Calve-Perthes disease (LCP), slipped capital femoral epiphysis (SCFE), osteomyelitis, pyarthrosis, psoas compartment abscess, transient synovitis,...

Faint Tracer In L2 Vertebra

Enthesopathy Calcaneus

Fig. 11.17A, B Osteophytes or whiskers in the hip joint in Reiter's syndrome. A Anteroposterior radiograph of the right hip in a 28-year-old man with Reiter's syndrome shows shaggy bone excrescences in the femoral neck and the acetabular margin (arrowheads). Bone trabeculae appear coarsened and the joint space is moderately narrowed. B Anterior pinhole scintigraph shows necklacelike tracer uptake in the femoral neck and the acetabular margin (arrowheads) Fig. 11.17A, B Osteophytes or whiskers in the hip joint in Reiter's syndrome. A Anteroposterior radiograph of the right hip in a 28-year-old man with Reiter's syndrome shows shaggy bone excrescences in the femoral neck and the acetabular margin (arrowheads). Bone trabeculae appear coarsened and the joint space is moderately narrowed. B Anterior pinhole scintigraph shows necklacelike tracer uptake in the femoral neck and the acetabular margin (arrowheads)

Vascularity Related Osteoporosis

Rsd Radiographs

Fig. 14.8A, B Avascular osteonecrosis in alcoholics. A Anteroposterior radiograph of the left hip in a 36-year-old man with chronic alcoholism shows admixture of irregular bony condensation and lucency, deformity (curved arrow), and marked flattening of the head (open arrows). The hip joint is narrowed and the acetabular fossa deepened due to advanced secondary osteoarthritis. B Anterior pinhole scintigraph reveals intense tracer uptake in the femoral neck and narrowed joint with markedly collapsed head (open arrow) Fig. 14.8A, B Avascular osteonecrosis in alcoholics. A Anteroposterior radiograph of the left hip in a 36-year-old man with chronic alcoholism shows admixture of irregular bony condensation and lucency, deformity (curved arrow), and marked flattening of the head (open arrows). The hip joint is narrowed and the acetabular fossa deepened due to advanced secondary osteoarthritis. B Anterior pinhole scintigraph reveals intense tracer uptake in the femoral neck and narrowed...

Inflammatory Synovitis Rheumatoid Arthritis

Die Spirale

The hip joint, because of its anatomic location and in accessibility, has not commonly been treated with synovectomy, and very little published information exists to support or refute the arthroscopic procedure in this location. The few reports that exist include only small numbers of patients, and focus on the JRA population. Open synovectomy of the hip in rheumatoid arthritis has been reported, usually as part of a larger series including multiple joints, and the results have been difficult to interpret. Albright et al, in a series of nine hips (five patients with JRA) treated with subtotal and complete synovectomy, showed symptomatic improvement and preserved joint motion in four of five patients. They concluded that synovectomy of the hip may be useful for progressive hip involvement in younger patients whose skeletal immaturity contraindicates major reconstructive procedures.63 Hol-gersson et al, also in a pediatric population with JRA, showed that arthroscopic intervention may...

Synovial and Intra Articular Pathology

The hip joint, a diarthrodial or synovial joint, under normal conditions can function under very high loads and stresses for seven to eight decades. The thick, fibrous joint capsule encloses the metabolically active synovial connective tissue in an environment that nourishes and protects the articular cartilage. A highly permeable vascular capillary system invests the synovium and functions to produce synovial fluid, a plasma ultrafiltrate that sustains and lubricates the avascular cartilage. The synovium is also immunologically active and harbors cells capable of phagocytosis for removal of cell degradation products from the joint and joint fluid. The syn-ovium plays a critical role in maintaining the balance between physiological processes and pathological changes, and its proper function is essential for long-term joint durability. When aging or a pathological condition alters the function of the synovial lining, biochemical or biomechanical breakdown of the articular cartilage may...

Degenerative Disc Disease

Iliopsoas (sometimes, but mainly L2-L3) Iliopsoas (L2-L3) Typically, there is some limitation of neck mobility. Examination of the cranial nerves should be normal, although the jaw jerk may be increased in some cases. Weakness is common in the lower extremities, especially in the iliopsoas, hamstrings, and extensors of the feet and toes. Tone in the lower extremities is spastic, and Babinski's sign may be present. Sensory loss to light touch, vibration, and joint position is sometimes found. The major deficits in lower extremity function are determined by the degree of myelopathy. Findings in the upper extremities vary depending on the level of central canal stenosis and the degree of cervical root involvement. Patients may have mild weakness with brisk reflexes. When roots are compromised, especially in the lower cervical myotomes, atrophy, weakness, and fasciculations may be found, at times mimicking the signs of amyotrophic lateral sclerosis. Sensory loss in the upper extremities...

Hip Zona Orbicularis Mr

Head Localizer

Has the unique ability to demonstrate soft tissue and marrow-based abnormalities that cannot be seen on plain radiographs or CT. The spectrum of pathology of the hip demonstrated with MRI has expanded well beyond detecting osteonecrosis, for which hip MRI gained its initial success. MRI is effective in demonstrating in-traarticular and extraarticular pathology. Extraarticu-lar disorders that are well demonstrated with MRI include muscle injuries,23,24 iliopsoas and trochanteric bursitis,25,26 sacroiliitis, and pelvic neoplasms. Intra-articular hip disorders depicted on MRI include joint effusions,27 osteonecrosis,28,29 stress fractures,30,31 occult fractures,32-35 osteoarthritis, and inflammatory arthropathies.36 Unfortunately, conventional MRI has had poor success with demonstrating articular surface cartilage37 and acetabular labral5 abnormalities. Future development and improvements in MRI technology may lead to successful noninvasive evaluation of these structures.

Hemophilia and Hemosiderotic Synovitis

Acute hemarthrosis is probably the most common type of bleeding in hemophilia patients, with 80 of the cases reported in the knees, elbows, and ankles.88,89 Hemarthrosis affecting the hip joint occurs, but by report not as commonly as it does in the other, more peripheral joints. This can be explained by the hip joint's deep location, and the protection from mild to moderate trauma provided by the thick overlying muscular envelope. This protective anatomy may also make realization of bleeding into the hip joint less likely and more difficult to diagnose. Swelling around the hip and pelvic girdle are clinically difficult to detect, and if mild intracap-sular bleeding has occurred or is occurring, it may be contained and clinically impossible to identify. It has been stated that the chronic synovitis reported in other joints is rarely a problem in the hip for patients with hemophilia.90 In this patient population, which endures and functions with chronic pain, the symptoms in the hip...

Arthroscopic Findings In The Initial Stages Of Hip Osteoarthritis

Osteodistrofia Hipertrofica

The acetabular labrum (Figure 8.7), or labrum gle-noidale, gives permanent stability to the hip joint by deepening the acetabular cavity. The labrum is triangular in cross section with the apex forming the free thin edge. The diameter of this free edge is smaller than its fixed edge and is somewhat less than the maximum diameter of the femoral head. It provides coverage and support to the anterior, superior, and posterior surfaces of the femoral head.

Prosthetic Joint Infection

The prevalence of infection of prosthetic hip joints is 0.5-1.3 . Prosthetic knee joints have a prevalence of infection of 1.3-2.9 . Elbows have an infection rate of approx 9 , whereas that of shoulders, wrist, and ankles is approx 1-2 . From 3550 of the patients with an infected joint present within 3 mo of surgery with increasing pain both at rest and with activity (6). Another 30-35 of the patients present from 3-24 mo postoperatively with joint pain. Infection also may spread hematogenously from a distant focus to the joint as well. The average age of patients with an infected prosthetic hip is 67 yr. Elderly patients frequently have rheumatoid or degenerative joint disease (7). Pressure ulcers and urinary tract infections are particularly likely to occur in the elderly and serve as sources of transient bacteremia, which can seed a prosthetic joint.

Superior Lateral Joint Space Of The

Subchondral Cyst Femoral Head

Loose body in osteoarthritis. Coronal T2-weighted fat-suppressed image of both hips demonstrates a small loose body (arrow) in the medial right hip joint outlined by joint fluid. FIGURE 4.10. Loose body in osteoarthritis. Coronal T2-weighted fat-suppressed image of both hips demonstrates a small loose body (arrow) in the medial right hip joint outlined by joint fluid. Injury of the acetabular labrum is now recognized as an important cause of mechanical hip pain that can be surgically treated with resultant symptomatic relief. Recent interest and efforts directed toward improving our ability to diagnose labral tears has resulted in a growing knowledge of the MRI and MR arthro-graphic appearance of the normal and abnormal labrum.4,5,7-10,12-15,54 Knowledge of the anatomy of the hip capsule, acetabular labrum, and articular cartilage and an understanding of the location and appearance of labral tears are essential to proper diagnosis of labral pathology. The acetabular...

Role Of Hip Arthroscopy In Specific Conditions Of Children And Adolescents

Generous Coverage Femoral Head

Articular and growth plate-related injuries that are peculiar to skeletally immature patients. Likewise, when focusing the discussion to arthroscopy of the hip joint, the indications for and outcomes of the procedure are even less well defined than in the adult. In 1977, Gross noted, in his experience with 32 arthro-scopic hip surgeries in children, that the procedure did not seem to more accurately delineate the diagnosis or add to the therapeutic outcome,26 thus quelling early efforts in the application of this technique to young patients. However, since this early report, there have been renewed interest in and enthusiasm toward minimally invasive alternatives to open surgery on the hip in children with a multitude of diagnoses. The following discussion focuses on some of the more common childhood conditions in which hip arthroscopy does potentially play a beneficial role. the application of arthroscopy to more unusual and less well understood joints such as the pediatric hip...

Synovial fluid analysis See joint aspiration

Advantages of ultrasound compared with other musculoskeletal imaging techniques are that it is quick, widely available, noninvasive, and fairly cheap. it is also very effective when used as a guide to needle placement when taking a biopsy or aspirating a collection of fluid. in musculoskeletal practice, ultrasound is most frequently used to assess tendons. it demonstrates tendinitis, tears, and complete rupture very accurately. At the shoulder, for example, it can also show that the rotator cuff tendons are bunching up as the arm is lifted, thus confirming mechanical impingement. In many countries it has become the imaging modality of choice at the shoulder. Ultrasound is extremely effective at demonstrating bursitis from any cause. increasingly ultrasound is being used to demonstrate joint effusions, and a few rheumatologists even have portable machines in their offices to extend their examination of joints. Ultrasound is particularly helpful in demonstrating effusions in joints that...

Median Nerve Force Tendon

Hemophilia Bone Scan

Spontaneous bleeding into the muscle is common and may involve any muscle, even in the absence of trauma. The forearm, quadriceps, calf, and iliopsoas are most often involved, the latter having particularly insidious clinical presentation (Fig. 5.44). US evaluation performed within 24-48 hours from symptom onset of the hemorrhage may not be indicative, because recent bleeding usually appears hyperechoic, but sometimes may be isoe-choic compared to muscle echogenicity 16 . Later on, the hematoma appears as an anechoic intramuscular area with posterior enhancement. Patient with severe hemophilia. a Transverse non-contrast computed tomography (CT) scan detected an old iliopsoas hemorrhage, evident as an intramuscular area of decreased density (*). b Transverse sonogram in the same patient depicts the echofree appearance of the muscle hemorrhage (*). c Echographic reexamination just after sudden recurrence of pain shows the presence of recent bleeding (empty white arrow), which appears...

Types of Loose Bodies

Rice Bodies Rheumatoid Arthritis

Osteochondritis dissecans (OCD) is a common condition in children, adolescents, and young adults that can affect any diarthrodial joint. In the hip joint, few cases have been reported as isolated lesions on both the acetabular and femoral sides of the joint.7-9 OCD is an osseous lesion with a mechanical or traumatic etiology. The process begins as avas-cular necrosis with secondary involvement of the overlying cartilage the lesion forms a transitional zone that harbors the potential for complete healing or progression to an osseous defect. OCD is distinguished from osteochondral fractures and epiphyseal ossification disturbances by age distribution, localization, and the radiologic and surgical presentation. the appropriate testing, whether CT or MR arthrography. Isolated chondral injuries are less common in the hip than in the shoulder or knee because of the constrained mechanics of the hip joint and the high energy required to cause subluxation or dislocation. The majority of...

Abnormalities of Joint Position

Joint Anomalies

The broad designation of 'muscular imbalance' is meant to include several unrelated disorders, all of which are characterized by incompetence of the muscular function at a given joint. Muscular incompetence, that is, absence, atrophy, fibrosis, flaccidity, or spasticity of a muscle from any cause, results in mal-positioning and impaired development of the bony components of that joint (Dunne and Clarren 1986 Bunch 1977 Baratta et al. 1988 Fidler and Jowett 1976). However, normal growth of the osseous structures at a given joint depends not only on adequacy of the muscular forces applied, but also on proper anatomical positioning and maintenance of the joint activity hence, absence or loss of one of these requirements affects bone growth, resulting in various bone deformities. Deformed bones lead, in turn, to anatomical incongruities at their articulation, further compromising correct bone positioning (Fer-rone 1976). An example of this complex interaction of events is offered by hip...

Indications And Diagnostic Accuracy

Physical examination of the injured hip can be quite vexing, likely because of the complex anatomy both within and surrounding the hip joint. Examination frequently reveals pain in provocative positions, but this is individualized and entirely patient dependent. Reproducible pain with passive flexion and medial or internal rotation of the hip has been identified as predictors of intraarticular pathology.24 This finding has been corroborated in young athletic patients.2 The direction of these provocative maneuvers does not correlate well with the location of labral tears, according to Farjo et al.24 McCarthy noted painful clicks in 56 of patients during a Thomas hip flexion-to-extension test and concluded that this finding had a significant positive correlation with acetabular labral tear on arthroscopic evaluation. He states that pertinent physical findings such as these represent the best predictors of treatable intraarticular pathology.23

Acetabular Labral Lesions Cadaveric Research

Flat Acetabulum

The labrum acts as a stabilizer of the hip joint. But in the dys-plastic hip, it becomes part of the weightbearing surface of the acetabulum. It is postulated that this causes overload of the superior and or anterior labrum in tension and shear, leading to labral injury.19

Legg CalvePerthes Disease Coxa Plana

Severs Disease Ossific Nucleus

The disease process is characterized as an avascular necrosis of the femoral head complicated by subsequent subchondral stress fracture. Resorption of areas of bone within the femoral head (rarefaction) is followed by the laying down of new bone. Collapse and flattening of the femoral head may ensue, along with the potential for subluxation. The result is a painful hip joint associated with restricted range of motion, muscle spasm, and soft tissue contractures.

Problems of the Hip and Lower Extremity

Teste Barlow

Children with TSH present with an ill-defined limp, hip or knee pain, and possibly a low-grade fever. The hip is often held flexed, abducted, and externally rotated to provide for maximum joint volume. A complete blood count may show mild leukocytosis without a left shift. The erythrocyte sedimentation rate (ESR) may be elevated, exceeding 20 mm hour in nearly one third of patients.19 Radiographs may show capsular swelling characterized by increased distance between the medial acetabulum and the ossified part of the femoral head (Fig. 7.5). Ultrasound examination has been used increasingly as a diagnostic tool to detect hip disorders because of its high sensitivity for demonstrating effusion in the hip joint. A septic hip is considered a medical emergency, as surgical drainage of pus soon after onset of symptoms prevents destruction of the femoral head and neck. Accumulating fluid and pus containing destructive enzymes rapidly elevate the intraarticular pressure and permanently injure...

Infection Septic Arthritis

Hip joint infection and septic arthritis, although most common in growing children, is becoming more prevalent in the adult population due to the growing number of elderly, disabled, and immunosuppressed patients, and those with chronic systemic illnesses. The ramifications of sepsis in this major weightbearing joint can result in lifelong disability for a child, and can be responsible for the loss of independence and or demise of an adult if not recognized and treated early. Evrard has reported a 13 incidence of mortality from hip joint infection in the adult.104 This seemingly high mortality rate in adults may be secondary to concurrent medical issues or underlying hip disease that make diagnosis difficult and often impede appropriate, early aggressive surgical treatment. Although the rate of pediatric hip infections is not likely to increase, society's growing elderly, debilitated, and immuno- suppressed population will likely necessitate an increased awareness of hip joint sepsis...

Diagnosis of osteoarthritis of the hip

The patient's posture and gait should be carefully evaluated. The hip joint is palpated to detect signs of local inflammation. Tenderness over the greater trochanter suggests bursitis, while groin tenderness suggests adenopathy, infection or possible neoplasm. Patients with sciatic nerve involvement due to disc disease or osteoarthritis of the spine may describe tenderness over the course of the sciatic nerve. A positive straight leg raising test also suggests sciatica.

TABLE 1321 Causes of Suppurative Arthritis in Children

The pathophysiology of septic arthritis exemplifies the seriousness of the condition and the risks of long-term sequelae. Synovial edema and hyperemia accompany increased secretion of synovial fluid, which may be serosanguinous early on, cloudy, or suppurative with polymorphonuclear (PMN) leukocyte counts ranging from 5000 to 200,000 and exceeding 50,000 pL3 after the earliest stages. Synovial fluid glucose concentration is decreased, and the protein content is elevated. The mucin string is poor to very poor. Within days, the synovial fluid becomes frankly purulent, if it was not so initially. The hyaline articular cartilages degenerate initially at points of contact between opposing articular surfaces. The synovium itself is eventually replaced by granulation tissue, and the infection invades surrounding bone, particularly epiphyseal and metaphyseal bone. Adhesions are created within the joint and restrict motion. Subluxation or dislocation may occur in the setting of marked...

Synovial Abnormalities

The synovium can be the genesis of deep-seated and unremitting hip joint pain. A diverse number of etiologies may initiate synovial irritation. These conditions may be of inflammatory, hematologic, crystalline, collagen disease, mechanical, viral, or tumorous origin. Specific treatment is based upon whether the condition is focal or diffuse, and self-limiting or unremitting in nature. Crystalline diseases such as gout or pseudogout can produce extreme hip joint pain. A joint effusion, best seen on T2 weighted MR scanning, can be accompanied by an elevated or normal serum uric acid level. Joint fluid analysis with polarized-light microscopic verification clinches the diagnosis. At arthroscopy the senior author has witnessed high concentrations of crystals diffusely distributed throughout the synovium as well as embedded within the articular cartilage of the acetabulum. (Figure 6.6.) Arthroscopic treatment consists of copious lavage, mechanical removal of crystals, and synovial biopsy...

When Walking Becomes a Pain

Osteophytes Acetabulum

Fig. 8.53 Osseous protuberances (osteophytes) are seen extending from the acetabular convexity in osteoarthritis of the hip joint. The joint space width is diminished in the zone of weight bearing the neighboring bone is sclerosed. The acetabulum harbors a large synovial cyst. Fig. 8.53 Osseous protuberances (osteophytes) are seen extending from the acetabular convexity in osteoarthritis of the hip joint. The joint space width is diminished in the zone of weight bearing the neighboring bone is sclerosed. The acetabulum harbors a large synovial cyst.

Streptococcus Pneumoniae Arthritis

Joints that are easily reached usually are drained by an arthroscopic procedure, while more deeply situated joints, like the hip joint, are approached by arthrot-omy. Specimens of the synovial fluid or biopsies of synovial membrane for culture and pathology can be taken when the joint is flushed with saline solution. Aspiration of synovial fluid alone is insufficient treatment (Dabney and Bowen, 1995) and may lead to irreversible damage to the affected joint. Morbidity following arthroscopy is considered low while the time to cure the inflammatory response is reduced by the procedure leading to reduced costs with respect to the hospital stay (Smith, 1986). Drainage procedures using silastic drains that will stay in for some time, are not used anymore. When relapse occurs a second arthroscopic drainage may be performed.

Chondral Injuries Of The

As the experience with hip arthroscopy expands, so, too, will the ability to recognize the various injury patterns to the chondral surfaces of the hip. As our understanding of the pathologic processes contributing to chondral injury of the hip joint improves, perhaps we will be able to intervene preventing the progression to osteoarthritis.

Calcium Pyrophosphate Deposition Disease CPPD Chondrocalcinosis

Chondrocalcinosis Arthroscopy

Calcium pyrophosphate deposition disease is the crystalline arthropathy most likely to affect the hip joint.65 The cause of the disease is unknown, but pathologically it results from increased calcium or inorganic phosphate concentrations in hyaline or fibrocartilage that precipitate to form crystals. Chon-drocalcinosis is the descriptive term used to denote the presence of calcium pyrophosphate crystals in cartilage, and although it occurs in the hip it is radiographically difficult to distinguish. (Figure 14.9.) The deposition and shedding of crystals lead to the clinical syndrome of calcium pyrophosphate deposition disease (CPPD), which can result in acute and chronic synovitis. It has been postulated that chronic syn-ovitis secondary to CPPD plays a role in the initiation of hip joint degeneration and osteoarthritis.66 Menkes et al studied the frequency and significance of articular chondrocalcinosis in hip osteoarthritis. Its presence at the time of arthroplasty was found to be...

Mechanical Complications of Obesity Arthritis

Obesity is frequently complicated by degenerative arthritis (DJD). Increased body weight leads to trauma of the weight-bearing joints and speeds the development of osteoarthritis in obesity. Knee and hip joints are particularly affected. However, obese patients have increased DJD of the hands, perhaps due to cytokines produced by adipose tissue, which may damage the cartilage in joints. Flattening of the arc of the planter surface of the feet (flat feet) occurs more frequently in obese people, presumably due to the stress of carrying excess body weight. Flat feet may lead to unsteady gait and aches and pains after walking. Increased fat deposition, particularly in the abdominal region, can change the natural curvature of the spine, causing lordosis and resulting in backache in obese people.

Acetabular Abnormalities

The acetabulum is cartilaginous at birth, with a Y-shaped physeal plate (the triradiate cartilage) located between the ilium, ischium, and pubis. The fully developed acetabulum is a hemispheric cavity made deeper by a bony rim lining its contour, to which is attached a fibrocartilaginous labrum. The smooth, hemispheric head of the femur articulates with the acetabular cavity, to which it is firmly attached by the ligament of the femoral head. The bony surfaces of the femoral head and acetabulum are covered with a layer of articular cartilage. These articular cartilages, together with the intra-articular space, form the hip joint space as seen on frontal radiographs. The joint space can be analyzed in adult by dividing it into three portions, superior, axial, and medial (Arm-buster et al. 1978). The axial and superior joint space should be approximately half the medial joint space.

Transient synovitis of the hip

The important differential diagnosis is septic arthritis. The clinician needs to be sure that it is transient synovitis of the hip that is being treated rather than septic arthritis as the latter condition can rapidly destroy the hip joint if not treated aggressively. Investigations must be performed to exclude septic arthritis and if there is any doubt as to the exact diagnosis, a specimen of hip-joint fluid must be obtained for culture to exclude septic arthritis.

Foveal Distraction Test

The physical examination test recommended for assessing any contracture of the rectus femoris muscle is Ely's test. This assessment is performed by flexing the knee and drawing the lower leg into the thigh. A negative test demonstrates full flexion of the knee to the thigh with no movement in the pelvis. A positive Ely's sign demonstrates that with flexion at the knee, the pelvis will tilt, raising the buttocks from the table.

Chondral Lesions of the Acetabulum or Femoral Head

Chondral lesions are among the most elusive sources of hip joint pain. Because of the more constrained anatomy of the hip compared to the shoulder, until recently these lesions were not believed to exist. Furthering the consternation of both patient and clinician, no currently available radiographic test reliably diagnoses the presence or extent of these lesions.1

Epidemiology And Diagnosis

In the hip, the most common soft-tissue disorders are due to problems associated with the numerous bursae that are found in this region. Trochanteric bursitis is the most prevalent condition and is often associated with other disorders, including osteoarthritis of the same hip, lumbar spondylosis, and RA.168 Since no findings are pathogno-monic of trochanteric bursitis, the diagnosis is generally based on the clinical picture, which includes pain along the lateral side of the upper thigh that is aggravated by activity or lying on the affected side. Physical examination reveals tenderness over the greater trochanter. Less frequent soft-tissue disorders in this area include iliopsoas bursitis, iliogluteal bursitis (weaver's bottom''), and adductor tendinitis, which tends to occur as a sporting injury, particularly in gymnasts and horseback riders.169

Holding Up pattern of tension

Changes in your body, you will notice tension in the back of the neck, under your shoulder blades, lower back, and hip flexors. This combination of tension can easily contribute to lordosis, also known as sway back - misalignment of the spine often responsible for lower back pain.

Septic Arthritis For Femoral Head

Septic arthritis of the hip joint can be a devastating problem, and is primarily a pediatric disease. Septic arthritis of the hip joint develops secondary to hematogenous introduction of bacteria through the synovium, or from the proximal femoral metaphysis. The most common organisms found are group B streptococci, Staph. aureus, Strept. pneumoniae, and H. influenza type B.13 Destruction of articular cartilage may ensue if prompt drainage is not performed. Clinically, the child may present with pain, limp, or refusal to move the affected joint. The pain is usually found on the anterior aspect of the hip joint and may radiate to the knee. The child often holds the hip flexed, externally rotated, and abducted to maximize the joint space. Fever may or may not be present. The goals of treatment of septic arthritis of the hip are decompression of the joint capsule, joint debridement, reduction of bacterial load, and dismantling of loculations. Hip ar-throscopy is an excellent alternative...

Duration and location of pain

Groin pain with radiation into the buttock indicates hip joint dysfunction. Pure buttock or back pain without a groin component is usually back in origin. When patients say their hip hurts, they mostly point to the buttock. Lateral hip pain with radiation to the lateral thigh may be related to greater trochanteric bursitis or abductor tendinitis. Discomfort over the anterior superior iliac spine extending down the anterior thigh is associated with meralgia paresthetica (inflammation of the lateral femoral cutaneous nerve).


Hip joint pain and stiffness accompany osteoarthrosis. Osteophytes are readily visible on radiographic studies. These impinging bony excrescences may contribute to the limited motion present in this disease. While technically possible and appealing, removal of osteophytes per se is not an indication for arthroscopy. These rim protuberances are but the late, bony expression of diffuse joint disease. Articular cartilage involvement that accompanies osteophyte formation is usually full-thickness and exhibits diffuse lesions. McCarthy and Glick have reported a direct correlation between the stage of cartilage loss, especially on the acetabular side, and poor outcome following arthroscopy.3,15


As with the bones, the shape of the joints reflects their function (and their function reflects their shape). Joints come in a spectrum of shapes, depending on the mobility or stability they require. For example, the hip joint is a ball and socket while the knee joint is a hinge. A ball and socket type hip joint confers the greatest mobility in all planes and is useful for activities such changing direction while walking and running (or reaching in various directions to grasp objects, as with the shoulder). A hinge type knee joint provides greater stability and is useful for propelling the body forward (or drawing an object towards the body, as with the elbow). hip joint capsule with synovium (posterior view)

The Lateral Approach

The last decade has seen an evolution in the understanding of the benefits of hip arthroscopy. The technique for lateral positioning was pioneered by Dr James Glick, who became frustrated with difficulties in visualization and instrumentation, particularly in the posterior aspects of the hip joint, using the supine position and anterolateral portal placements.1 Indeed, he experienced several cases in which loose bodies could not be removed from the posterior inferior aspect of the hip joint via the supine approach. Since the introduction of the lateral approach, this surgical approach has gained widespread acceptance by arthro-scopists.1-6 It allows a direct lateral approach to the hip joint, provides reproducible bony landmarks for orientation, and facilitates access and instrumentation of most areas within the hip joint.7


Arthroscopic removal of symptomatic loose bodies from the hip joint has become an accepted treatment option, and the clearest indication for arthroscopic intervention in the hip. Although accepted, the procedure should be used judiciously within its narrowly defined indications, because it is technically difficult, has a steep learning curve, requires specialized equipment, and is not without complication. Removal of loose bodies from an articulation has been effective in relieving mechanical symptoms, but although it makes intuitive sense that loose body removal prevents future joint degeneration, this has been shown only in the posttraumatic situation.3 When hip disease or a pathological condition results in loose body formation, symptomatic improvement can be expected after arthroscopic removal, but the effect on the future of the joint remains dependent on the natural history of the underlying condition. Examples include osteoarthritis, synovial chondromatosis, and avascular...

Jack D McCue

In comparison with lower respiratory tract, urinary tract, and skin and soft tissue infections, infections of bones and joints are relatively uncommon in the elderly, accounting for no more than a few percent of the infectious diseases treated by geriatricians. However, some bone and joint infections disproportionately afflict the elderly, such as osteomyelitis contiguous to pressure ulcers, septic arthritis of joints damaged by rheumatoid arthritis, or periprosthetic hip joint septic arthritis. As is true of many infectious illnesses in the elderly, diagnosis of bone and joint infections may be complicated by subtle, masked, or atypical clinical presentations. The consequences of delay in diagnosis and treatment of these infections, moreover, are no less serious in the elderly than in younger patients, and in the frail elderly inadequate diagnosis and treatment may increase mortality and cause great morbidity. Although definitive antibiotic treatment is similar to that of bone and...

Trendelenburg Test

Trendelenburg Sign

Palpation (1) Place the fingers over the head of the femur below the inguinal ligament, lateral to the femoral artery. Note any tenderness. Now rotate the leg medially and laterally. Crepitus arising in the hip joint may be detected in this way. 9.28. Palpation (2) Palpate the origin of adductor longus. Tenderness occurs here in sports injuries (strain of adductor longus) and in patients developing adductor contractures in osteoarthritis of the hip. 9.29. Palpation (3) Externally rotate the leg and palpate the lesser trochanter. Tenderness occurs here in strains of the iliopsoas as a result of athletic injuries. A loss affecting extension only is often the first detectable sign of an effusion in the hip joint. (2) Repeat the test, this time feeling for flexor (iliopsoas) contraction while making a sudden gentle attempt to extend the hip. 9.59. Trendelenburg's test (3) The test is positive as a result of (A) gluteal paralysis or weakness (e.g. from polio, muscle-wasting disease)...


Dermatome Distribution

(mainly iliopsoas) is controlled by L2.3. Extension of the hip (mainly gluteus maximus and the hamstrings) is controlled by L4.5 (L2.3 also control internal rotation, and L4.5 external rotation of the hip). Motor distribution (A) Above (i.e. proximal to) the inguinal ligament the femoral nerve supplies iliopsoas. (B) Below the inguinal ligament it supplies the quadriceps, sartorius and pectineus. 2.83. Femoral nerve (3) Sites of involvement Closed lesions of the femoral nerve are rare. Damage may occur when a haematoma is formed in the iliacus muscle, causing local pressure. This is seen in haemophilia and in extension injuries of the hip. 2.84. Femoral nerve (4) Tests (A) Test the quadriceps by asking the patient to extend the knee against resistance. (B) Test the iliopsoas (hip flexion against resistance). The response to these tests should determine the level of any lesion. In doubtful cases try to elicit the knee jerk. Observe any quadriceps wasting, and test for loss of sensation...

No history of trauma

Supra Patellar Swelling

As the hip is a ball and socket joint, flexion, extension, abduction, adduction, rotation and the combined movement of circumduction are all possible. The actual range changes through life, as does the posture of the joint. As age increases, the first movements to decrease are extension and internal rotation, followed by abduction. The femoral and obturator nerves supply sensory branches to the hip joint and knee joint, explaining the frequency of referred pain from the hip to the knee.

History Of Ps

The syndrome was actually known in 15th century Florence, when hospitals were filled with cases of sciatica, a term used by Hippocratres, Galen, and Dioscorides (ischiatica). Ischiatica originally meant haunches or hip and gave its name to the ischial tuberosity (4), the approximate anatomical location of the pain's origin and its imagined cause in that era. Sacroiliac arthritis and tuberculosis of the iliopsoas muscles were the proposed pathogenetic mechanisms.


Topography of the femoral nerve in relation to components of the iliopsoas muscle in human fetuses. Folia Morphol (Praha) 1991 50(1-2) 91-101. 38 Robinson DE, Ball KE, Webb PJ. Iliopsoas hematoma with femoral neuropathy presenting a diagnostic dilemma after spinal decompression case reports . Spine 2001 26(6) E135-8.


The arthroscope and shaver are positioned within the iliopsoas bursa directly over the lesser trochanter, identifying the fibers of the iliopsoas tendon (IT) at its insertion site. (Courtesy of J.W. Thomas Byrd, MD.) Fig. 11. The arthroscope and shaver are positioned within the iliopsoas bursa directly over the lesser trochanter, identifying the fibers of the iliopsoas tendon (IT) at its insertion site. (Courtesy of J.W. Thomas Byrd, MD.) Fig. 12. An electrocautery device is used to transect the tendinous portion of the iliopsoas (black asterisks) revealing the underlying muscular portion (white asterisk) which is preserved. (Courtesy of J.W. Thomas Byrd, MD.) Fig. 12. An electrocautery device is used to transect the tendinous portion of the iliopsoas (black asterisks) revealing the underlying muscular portion (white asterisk) which is preserved. (Courtesy of J.W. Thomas Byrd, MD.) tered in the lateral aspect of the acetabulum. This is followed by 8 to 10 weeks of protected...


Our population is aging, and the most rapid shift in this age distribution is set to occur as the baby boomers reach their senior years. In the United States alone, the Centers for Disease Control and Prevention estimate that approximately 70 million Americans suffer from arthritis or chronic joint ailments, and, according to the American Academy of Orthopaedic Surgeons, approximately 300,000 hip arthroplasties are performed annually.15,16 Even in absence of arthritis, the hip joint is known to undergo senile changes. An MRI study has demonstrated an increasing incidence of labral pathology with age, even among asymptomatic volunteers.17 An electron microscopy study had documented degenerative labral changes associated with the aging process, and this is consistent with two separate cadaveric studies that showed a 96 preva-


Osteoarthritis, previously known as degenerative joint disease, results from the wear and tear of life. The pressure of gravity and extensive use causes physical damage to the joints and surrounding tissues, leading to pain, tenderness, and swelling. Initially, osteoarthritis is noninflammatory and its onset is subtle and gradual, usually involving one or only a few joints. The joints most often affected are the knee, hip, and hand. Pain is the earliest symptom, usually made worse by repetitive use. Osteoarthritis affects 21 million people in the United States, and the risk of getting it increases with age. Other risk factors include joint trauma, obesity, and repetitive joint use examples of the latter include pitcher's elbow and the hip-joint difficulties that professional dancers develop as they grow old.

JW Thomas Byrd

Following Bozzini's initial design, crude cysto-scopes of various constructs were developed over the ensuing 100 years. All of these were limited by lack of an adequate light source. However, by the early 1900s, electricity was discovered and Edison had invented the incandescent light bulb. This accomplishment opened new horizons in the development of endoscopic instruments. In 1918, Kenji Takagi3 visualized the interior of a cadaveric knee joint with a cys-toscope. The first recorded attempt at arthroscopic visualization of the hip is attributed to Michael S. Burman4 in 1931 (Figures 1.1, 1.2). For his purposes, an arthroscope was constructed by Reinhold Wappler with a diameter of 4 mm, not dissimilar to the dimensions of our current arthroscopes (Figure 1.3). Bur-man used fluid distension for visualization, examining the interior of more than 90 various joints in cadaver specimens, correlating the arthroscopic anatomy with the gross anatomy on subsequent dissection. Twenty of these...

Radiologic Findings

Figure 17-9 demonstrates clinically occult extrapelvic spread in a case of appendicitis in a patient presenting with fever and right hip pain and tenderness. Necrotic cellulitis and interstitial emphysema of the right thigh in this patient progressed via the iliopsoas muscle group from a perforated appendicitis that was not diagnosed antemortem. (a) Destruction of the hip joint due to septic arthritis. (b) Barium enema study shows segmental narrowing of the sigmoid colon due to acute diverticulitis. Barium has entered the hip joint through a fistulous communication. (a) Destruction of the hip joint due to septic arthritis. (b) Barium enema study shows segmental narrowing of the sigmoid colon due to acute diverticulitis. Barium has entered the hip joint through a fistulous communication.

Devon Rex Miositis

Manx Cat Sacrocaudal Dysgenesis

Reconstruction of the damaged ligaments is recommended in these cases, although stabilisation of the joint with cross-pins or a single transarticular pin has been described (Figure 8.3) the pins are removed after 3 weeks. Antebrachiocarpal luxation in the cat is occasionally encountered and is best treated by carpal arthrodesis using a 2.7 2.0 mm hybrid carpal arthrodesis plate (Li et al., 1999). The femoropatellar joint may also luxate secondary to trauma and usually responds to capsular tightening. The patella may also luxate in association with a dislocated hip joint. The tarsocrural joint is commonly luxated or subluxated, often associated with fractures of the medial and or lateral malleoli of the hock (Figure 8.4). Treatment is by fixation of the fractured malleoli, usually by a tension band wiring technique or by reconstructing the collateral ligaments of the hock. Although most ligament tears in cats are associated with major trauma, there is a report suggesting that there may...

Paul L F Giangrande

Hemophilia Bone Marrow Xray

May also occur in the wrist or shoulder. Bleeding into the hip joint is unusual. The affected joint is swollen and warm, and held in a position of flexion (Figure 16.1), with no external discoloration or bruising around the joint. It is unusual for an infant to suffer spontaneous hemarthroses in the first few months of life, and the first joint to be affected tends to be the ankle as the child learns to crawl. The first sign of a hem-arthrosis in an infant will often be obvious discomfort and distress, accompanied by limping or reluctance to use a limb. Recurrent bleeds into a joint lead to synovitis and joint damage resulting in crippling arthritis (Figure 16.2). Bleeding into muscles is also a feature of hemophilia, but this is usually a consequence of direct injury, albeit often minor (Figure 16.3). Fig. 16.3 Magnetic resonance imaging (MRI) scan showing bilateral iliopsoas hemorrhage Fig. 16.3 Magnetic resonance imaging (MRI) scan showing bilateral iliopsoas hemorrhage within the...


The answer is b. (Fauci, 14 e, pp 1904-1906.) Ankylosing spondylitis (Marie-Strumpell arthritis) is a chronic and progressive inflammatory disease that most commonly affects the spinal, sacroiliac, and hip joints. All patients have symptomatic sacroiliitis. Other symptoms may include uveitis and aortitis. Men in the third decade of life are most frequently affected and there is a strong association with HLA-B27 (90 ) in white patients. Patients with advanced disease present with a bent-over posture. A positive Schober test indicates diminished anterior flexion of the lumbar spine. Involvement of the costoveretebral joints limits chest expansion and eye involvement may cause an iritis. Patients with Reiter syndrome may present with a history of conjunctivitis, urethritis, arthritis, and enthesopathy (Achilles tendinitis).

Atrial myxoma

If AVN affects a weight-bearing bone, then avoidance of weight bearing by using crutches in the acute phase protects against loss of normal architecture. If AVN affecting the hip joint is diagnosed before the bone has collapsed, some orthopedic surgeons recommend a surgical approach known as core decompression. The surgery involves drilling into the head of the femur and removing a narrow

Future Directions

17 Cardinal E, Buckwalter KA, Capello WN, et al. US of the snapping iliopsoas tendon. Radiology 1996 198 521-2. 18 Mitchell B, McCrory P, Brukner P, et al. Hip joint pathology clinical presentation and correlation between magnetic resonance arthrography, ultrasound, and arthroscopic findings in 25 consecutive cases. Clin J Sport Med 2003 13 152-6. 43 Takechi H, Nagashima H, Ito S. Intra-articular pressure of the hip joint outside and inside the limbus. Nippon Seikeigeka Gakkai Zasshi 1982 56 529-36. 44 Ferguson SJ, Bryant JT, Ganz R, et al. The influence of the acetabular labrum on hip joint cartilage consolidation a poroelastic finite element model. J Biomech 2000 33 953-60.

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