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Functional Medicine®

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Functional Medicine Explained

Diagnosis of Hip Complaints: Arthritis & Neoplasms Part I | El Paso, TX.

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Degenerative Joint Disease (DJD)

Macroscopic & Microscopic Appearance of Normal vs. Damaged Articular Hyaline Cartilage by DJD

Hip Osteoarthritis (OA) aka Osteoarthrosis

  • Symptomatic and potentially disabling DJD
  • Progressive damage and loss of the articular cartilage causing denudation and eburnation of articular bone
  • Cystic changes, osteophytes, and gradual joint destruction
  • Develops d/t repeated joint loading and microtrauma
  • Obesity, metabolic/genetic factors
  • Secondary Causes: trauma, FAI syndrome, osteonecrosis, pyrophosphate crystal deposition, previous inflammatory arthritis, Slipped Capital Femoral Epiphysis, Leg-Calves-Perthes disease in children, etc.
  • Hip OA, 2nd m/c after knee OA. Women>men
  • 88-100 symptomatic cases per 100000

Radiography is the Modality of Choice for the Dx and Grading of DJD

  • Special imaging is not required unless other complicating factors exist
  • The acetabular-femoral joint is divided into superior, axial and medial compartments/spaces
  • Normal joint space at the superior compartment should be 3-4-mm on the AP hip/pelvis view
  • Understanding the pattern of hip joint narrowing/migration helps with the DDx of DJD vs. Inflammatory arthritis
  • In DJD, m/c hip narrowing is superior-lateral (non-uniform) vs. inflammatory axial (uniform)

AP Hip Radiograph Demonstrates DJD

  • With a non-uniform loss of joint space (superior migration), large subcortical cysts and subchondral sclerosis
  • Radiographic features:
  • Like with any DJD changes: radiography will reveal L.O.S.S.
  • L: loss of joint space (non-uniform or asymmetrical)
  • O: osteophytes aka bony proliferation/spurs
  • S: Subchondral sclerosis/thickening
  • S: Subcortical aka subchondral cysts “geodes.”
  • Hip migration is m/c superior resulting in a “tilt deformity.”

Radiographic Presentation of Hip OA May Vary Depending On Severity

  • Mild OA: mild reduction of joint space often w/o marked osteophytes and cystic changes
  • During further changes, collar osteophytes may affect femoral head-neck junction with more significant joint space loss and subchondral bone sclerosis (eburnation)
  • Cyst formation will often occur along the acetabular and femoral head subarticular/subchondral bone “geodes” and usually filled with joint fluid and some intra-articular gas
  • Subchondral cysts may occasionally be very large and DDx from neoplasms or infection or other pathology

Coronal Reconstructed CT Slices in Bone Window

  • Note moderate joint narrowing that appears non-uniform
  • Sub-chondral cysts formation (geodes) are noted along the acetabular and femoral head subchondral bone
  • Other features include collar osteophytes along head-neck junction
  • Dx: DJD of moderate intensity
  • Referral to the Orthopedic surgeon will be helpful for this patient

AP Pelvis (below the first image), AP Hip Spot (below the second image) CT Coronal Slice

  • Note multiple subchondral cysts, severe non-uniform joint narrowing (superior-lateral) and subchondral sclerosis with osteophytes
  • Advanced hip arthrosis

Severe DJD, Left Hip

  • When reading radiological reports pay particular attention to the grading of hip OA
  • Most severe (advanced) OA cases require total hip arthroplasty (THA)
  • Refer your patients to the Orthopedic surgeon for a consultation
  • Most mild cases are a good candidate for conservative care

Hip Arthroplasty aka Hip Replacement

  • Can be total or hemiarthroplasty
  • THA can be metal on metal, metal on polyethylene and ceramic on ceramic
  • A hybrid acetabular component with polyethylene and metal backing is also used (above right image)
  • THA can be cemented (above right image) and non-cemented (above-left image)
  • Non-cemented arthroplasty is used on younger patients utilizing porous metallic parts allowing good fusion and bone ingrowth into the prosthesis

Failed THA May Develop

  • Most develop within the first year and require revision
  • Femoral stem may fracture (above left)
  • Postsurgical infection (above right)
  • Fracture adjacent to the prosthesis (stress riser)
  • Particle disease

Femoroacetabular Impingement Syndrome

  • (FAI): abnormality of normal morphology of the hip leading to eventual  cartilage damage and premature DJD
  • Clinically: hip/groin pain aggravated by sitting (e.g., hip flexed & externally rotated). Activity related pain on axial loading esp. with hip flexion (e.g., walking uphill)
  • Pincer-type acetabulum: > in middle age women potentially  many causes
  • CAM-type deformity: > in men in 20-50 m/c 30s
  • Mixed type (pincer-CAM) is most frequent
  • Up until the 90s, FAI was not well-recognized

FAI Syndrome

  • CAM-type FAI syndrome
  • Radiography can be a reliable Dx tool
  • X-radiography findings: osseous bump on the lateral aspect of femoral head-neck junction. Pistol-grip deformity. Loss of normal head sphericity. Associated features: os acetabule, synovial herniation pit (Pit’s pit). Evidence of DJD in advanced cases
  • MRI and MR arthrography (most accurate Dx of labral tear) can aid the diagnosis of labral tear and other changes of FAI
  • Referral to the Orthopedic surgeon is necessary to prevent DJD progression and repair labral abnormalities. Late Dx may lead to irreversible changes of DJD

AP Pelvis: B/L CAM-type FAI syndrome

Pincer-Type FAI with Acetabula Over-Coverage

  • Key radiographic signs: “Cross-over sign” and abnormal center-edge and Alfa-angle evaluation methods

Dx of FAI

  • Center-edge angle (above the first image) and Alfa-angle (above the second image)
  • B/L CAM-type FAI with os acetabule (above right image)

MR Arthrography

Hip Pelvis Arthritis & Neoplasms

Dr. Alex Jimenez D.C.,C.C.S.T

Welcome-Bienvenido's to our blog. We focus on treating severe spinal disabilities and injuries. We also treat Sciatica, Neck and Back Pain, Whiplash, Headaches, Knee Injuries, Sport Injuries, Dizziness, Poor Sleep, Arthritis. We use advanced proven therapies focused on optimal mobility, health, fitness, and structural conditioning. We use Individualized Diet Plans, Specialized Chiropractic Techniques, Mobility-Agility Training, Adapted Cross-Fit Protocols and the "PUSH System" to treat patients suffering from various injuries and health problems. If you would like to learn more about a Doctor of Chiropractic who uses advanced progressive techniques to facilitate complete physical health, please connect with me. We a focus on simplicity to help restore mobility and recovery. I'd love to see you. Connect!

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