An MRI is not necessary, it does not contribute anything.

It is a coxarthrosis. The surgical criteria depends on the patient's symptoms and failure of medical treatment. No medication slows down or modifies the course of the disease. An MRI is not necessary, it does not contribute anything. Treatment is medical and sequential, starting with the first analgesic step of the WHO.

You evaluate a 66-year-old patient with groin pain accentuated by prolonged standing for a few days per month. A plain radiograph of the hips shows narrowing of the femoroacetabular joint space, sclerosis and ostephytes.

I make the diagnosis of coxarthrosis and send to the traumatologist to place a hip prosthesis.

Start treatment with weak opioids that have shown evidence in stopping the progression of the disease.

Treatment with paracetamol, explaining that the evolution is very variable and the surgical indication depends on the functionality and pain control.

Because of the radiological features described, I need a hip MRI before making a therapeutic decision.

[Coxarthroses].

Osteoarthritis of the hip is a frequent disease affecting 2 to 4% adults. The main symptoms are inguinal pain, hip movement limitation and thigh muscular atrophy. The diagnosis is usually made of on antero-posterior radiograph of the pelvis and Lequesne's lateral view that show joint space narrowing and osteophytosis. There is no correlation between radiographic lesions and clinical symptoms. The mean rate of joint space narrowing progression was shown to be of about 0.30 mm/year but inter-patients variations are very large. The evolution is more sever in older patients and when there is no osteophyte. New imaging techniques are necessary only if diagnosis is impossible on standard radiographs but not for the surgical decision. The treatment of hip osteoarthritis requires analgesic, NSAIDs and symptomatic slow actin drugs for osteoarthritis. Total hip arthroplasty is necessary when medical treatment is non effective on pain and disability.

Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers.

Making an accurate preoperative diagnosis is critical to optimizing outcomes after hip arthroscopy. A detailed history, thorough physical examination, imaging studies, and diagnostic injections must all be considered in the decision-making process. In today's health care climate, it is imperative to obtain essential and indicated preoperative information while being mindful of health care dollars. Magnetic resonance imaging (MRI) of the hip has been shown to be a highly sensitive modality for hip and pelvis disorders. However, it is critical to recognize that acetabular labral tears and other hip pathology are highly prevalent in an asymptomatic young adult population. There are certainly situations when an MRI should be obtained (suspected arthritic symptoms, avascular necrosis, synovial disorders, uncommon osseous tumors); however, these patients generally present with atypical symptoms. In addition, obtaining an MRI can delay surgical intervention, which has been shown to lead to inferior outcomes in prior studies. MRI is not imperative when patients present with typical intermittent, deep anterior, lateral, groin pain with prolonged sitting, twisting and pivoting, and transitioning from sitting to standing. The typical physical examination includes positive hip impingement testing (FADIR / anterior impingement test) that recreates the patients presenting complaints. Appropriate imaging includes plain radiographs revealing adequate acetabular coverage (not significantly dysplastic) or acetabular overcoverage (pincer-type femoracetabular impingement), cam-type femoracetabular impingement, and well-maintained joint space on all views, including a false profile radiograph to further evaluate the anterior joint space. Finally, a diagnostic injection can be invaluable to further confirm the hip joint proper as the source of pain. If all of the above criteria are met, I strongly believe an MRI is unlikely to alter the surgical decision-making process. In the end, the treating clinician should determine when an MRI is necessary based on the presenting symptoms and examination, rather than insurers applying a blanket requirement for preauthorization. This physician autonomy would ultimately lead to more efficient and cost-effective patient care. Medicine is an art, and unjustified handcuffing of the artist without evidence could result in inferior results.

Magnetic resonance imaging of the hip: poor cost utility for treatment of adult patients with hip pain.

Although MRI is frequently used to diagnose conditions affecting the hip, its cost-effectiveness has not been defined. We performed this retrospective study to determine for patients 40 to 80 years old: (1) the differences in hip MRI indications between orthopaedic and nonorthopaedic practitioners; (2) the clinical indications that most commonly influence treatment decisions; (3) the likelihood that hip MRI influences treatment decisions separate from plain radiographs; and (4) the cost of obtaining hip MRI studies that influence treatment decisions (impact studies). We retrospectively assessed 218 consecutive hip MRI studies (213 patients) at one institution over a 5-year interval. Medical records, plain radiographs, and MRI studies were reviewed to determine how frequently individual MRI findings determined treatment recommendations (impact study). The cost estimate of an impact study was calculated from the product of institutional MRI unit cost (USD 436) and the proportion of impact studies relative to all studies obtained either for a specific indication or by an orthopaedic/nonorthopaedic clinician. Nonorthopaedic clinicians more frequently ordered hip MRI without a clinical diagnosis (72% versus 30%, p < 0.01), before plain radiographs (29% versus 3%, p < 0.001), and with less frequent impact on treatment (6% versus 15%, p < 0.05). Hip MRI most frequently influenced treatment when assessing for a tumor (58%, p < 0.001) or infection (40%, p < 0.001) and least frequently when assessing for pain (1%, p < 0.002). Hip MRI impacted a treatment decision independent of plain radiographic findings in only 7% of studies (3% surgical, 4% nonsurgical). Hip MRI cost was least when assessing for a neoplasm (USD 750) and greatest when assessing undefined hip pain (USD 59,000). The cost of obtaining an impact study was also less when the ordering clinician was an orthopaedic clinician (USD 2800) than a nonorthopaedic clinician (USD 7800). Although MRI can be valuable for diagnosing or staging specific conditions, it is not cost-effective as a screening tool for hip pain that is not supported by history, clinical examination, and plain radiographic findings in patients between 40 and 80 years of age. Level IV, economic and decision analysis study. See Instructions for Authors for a complete description of levels of evidence.

Fate of very small asymptomatic stage-I osteonecrotic lesions of the hip.

The prognosis for a patient with osteonecrosis of the hip is generally considered to be worse if a large volume of the femoral head is involved, the patient is symptomatic, and the stage of the lesion is advanced. In 1990, we began a prospective study to detect collapse in asymptomatic hips with a very small stage-I osteonecrotic lesion in the femoral head. We hypothesized that such patients would have a favorable prognosis. These hips were followed for a minimum of ten years after the diagnosis. A small asymptomatic stage-I osteonecrotic lesion (not seen on plain radiographs) was diagnosed with magnetic resonance imaging in forty patients (forty hips) contralateral to a hip with symptomatic osteonecrosis. The criterion for inclusion in the study was a lesion with a volume of <5 cm(3) involving <10% of the volume of the femoral head. Plain radiographs were made annually in six different projections for all patients. At the most recent follow-up evaluation (average, eleven years), patients with a symptomatic hip but without evidence of collapse on plain radiographs underwent a computerized tomography scan. Thirty-five (88%) of the forty hips became symptomatic, and twenty-nine (73%) demonstrated collapse. The mean interval between the diagnosis and the first symptoms was eighty months. Symptoms always preceded collapse by at least six months. The mean interval between the diagnosis and the collapse was ninety-two months (range, seventy-two to 140 months). The diagnosis of collapse could be made on only one or two of the six radiographic views obtained for each patient at each evaluation. The diagnosis of collapse for two patients was made only on a computerized tomography scan at the most recent follow-up evaluation. At the time of final follow-up, the twenty-nine hips with collapse had symptoms of intractable pain and required surgery. This study confirms that the diagnosis of collapse is difficult in hips with a very small stage-I osteonecrotic lesion. Multiple radiographic views and computerized tomography scans may be required to demonstrate small areas of collapse. Clinical and radiographic signs of progression of the disease in asymptomatic hips with a very small asymptomatic lesion progress more slowly than do those signs in hips with a large symptomatic stage-II lesion. Because hips with a small area of osteonecrosis do collapse in a large percentage of patients, such patients should be followed carefully over a long period of time. Prognostic study, Level I-1 (prospective study). See Instructions to Authors for a complete description of levels of evidence.

Differential diagnosis and early management of rapidly progressing hip pain in a 59-year-old male.

Rapidly progressing degeneration of the hip joint is an uncommon condition presenting to physical therapy. Differential diagnosis can often be difficult, as clinical and radiographic findings do not always coincide leaving clinicians with difficult decision making regarding course of treatment. The purpose of this case report was to describe the differential diagnosis and early management of a patient with rapidly progressing hip pain. A 59-year-old male with a complicated medical history was referred with a diagnosis of severe bilateral hip osteoarthritis. Clinical presentation of insidious onset, severe bilateral groin and anterior thigh pain with rapid progression of functional decline lead to the differential diagnosis of bilateral avascular necrosis. The patient received seven manual physical therapy sessions over the course of one month. During this time, the patient's Lower Extremity Functional Scale score worsened from 33 to 21. The persistence of the patient's painful symptoms and continued functional decline helped determine cessation of manual therapy and referral back to his GP for further diagnostic testing and eventual correct diagnosis. This case highlights the importance of monitoring patient prognosis using outcome measures leading to a change in patient management strategies.

[Imaging of chronic hip pain in adults].

Adult hip pathologies are mainly represented by the degenerative disease, so called "osteoarthrosis, or more precisely coxarthrosis". The means of imaging are exposed, according to their specific value: X Rays (measurement of the characteristic angles of the adult hip), Arthrography, CT Scanner, Arthro-CT Scanner, MRI, Bone Scintigraphy, Ultrasonography. Clinical findings differentiate a mechanical syndrome and an inflammatory syndrome. The coxarthrosis is the most frequent, under two forms: primary (idiopathic) coxarthrosis and secondary coxarthrosis. Primary (idiopathic) coxarthrosis has a localised narrowing of the joint space, osteophyte formation, subchondral sclerosis, cyst formation. The destruction progresses slowly, in 10 to 15 years leading to a complete destruction. Bilaterality is frequent. it is treated with total hip prosthesis. There is a rapid form (1 to 2 years) (Postel's Disease). Secondary coxarthrosis occurs after architectural vice, chondral diseases, lack of balance between the size of the head and the acetabulum as in the case of previous fracture or dislocation, avascular bone necrosis of the head of the femur, Paget's disease. Calcium pyrophosphate Deposition disease (CPPD) involves mostly aged women, and also leads to cox-arthrosis. Avascular bone necrosis of the head of the femur involves young adults. Bilateral involvement are frequent. MRI is the most sensitive and the most specific means of early diagnosis, The area of bone necrosis appears as well defined modifications of the upper head of the femur, precisely surrounded by a low signal intensity line on both Ti and T2 weighted imaging. MRI shows articular effusion, bone marrow edema. Scintigraphy gives early findings which are a characteristic, but non specific, hot spot. CT scanner is used for hip destruction evaluation. o Algodystrophy: transient osteoporosis of the hip has a cyclic course, lasting 3 to 9 months. MRI shows an inflammatory pattern in the area of the process(dark in Ti and white in T2, with positive Gadolinium response). Scintigraphy is positive. Staphylococcus location in the hip can be acute or chronic. MRI shows joint effusion, cystic formation and subchondral non specific modifications. Tuberculosis of the hip joint is relatively rare. Greater trochanteric tuberculous involvement is possible under special contexts. Chronic Inflammatory diseases are represented by Rheumatoid Arthritis, Spondylarthritis and other chronic inflammatory diseases. Synovial tumors such as Pigmented Villo Nodular Synovitis, Primary Osteochondromatosis, synovial sarcoma have special presentations. The subchondral bone can be involved by amorphous depositions such as in tophaceous gout, different varieties of lipidosis, amyloidosis, reticulo histiocytosis. Pen arthropathies are enthesopathies in the anterior rectus tendon, calcifying tendonitis (not to be confused with calcifying soft tissue tumor/chondrosarcoma). The pelvis bone and the femur are involved by primary and secondary tumors or by insufficiency fractures which can mislead to hip pathologies.

Idiopathic chondrolysis of hip in children: New proposal and implication for radiological staging.

Our objective was to evaluate the radiological appearances in different stages of idiopathic chondrolysis of hip (ICH) which will be helpful in the early diagnosis and guiding appropriate treatment for this condition to prevent progression of disease. We evaluated 14 patients of ICH in varying stages: Stage 1 (<in</i = 9), Stage 2 (<in</i = 3), Stage 3 (<in</i = 2). Average age at presentation was 10-11 years. Plain radiograph and magnetic resonance imaging (MRI) was done in all these patients. In the current study, we have attempted to stage ICH based on the radiological progression of the disease, where MRI was used as the primary tool. Stage 1 showed a wedge-shaped hyperintensity in T2 weighted (T2W) and hypointensity in T1 weighted (T1W) images involving the middle one-third of the femoral head and it is the earliest and characteristic finding in MRI. Associated findings like joint space narrowing, synovial hypertrophy with joint effusion may also be observed. Stage 2 showed acetabular edema in the affected hip in addition to the above-mentioned findings. Stage 3 showed more extensive involvement of femoral head and acetabulum, with collapse of the femoral head, degenerative changes in hip, early osteoporotic changes, and ultimately loss of joint space. Imaging-based staging system proves very useful in the early diagnosis, staging, and assessing the prognosis of ICH.

[The natural course of osteoarthritis of the hip. Indication of conservative treatment in relation to osteophyte formation at the acetabular rim].

One hundred and eighty-five hips from 152 patients with primary or secondary osteoarthritis were studied in an attempt to assess the degrees of hip pain in contrast to radiological and other clinical findings. In 30.8% and 26.4% of the primary and secondary osteoarthritic hips respectively, hip pain showed some gradual decrease as time elapsed. Pain relief probably in association with osteophyte formation at the craniolateral acetabular rim occurred in 62.5% and 33.3% of the primary and secondary osteoarthritic hips respectively. Significant parameters observed in the primary osteoarthritic cases of the decreasing pain group were as follows: A lesser extent of cranial displacement of the femoral head, poor capital drop development, well developed floor osteophyte. On the other hand significant parameters in the decreasing pain group of secondary osteoarthritis were as follows: Well developed floor osteophyte, a small size of cyst in both the femoral head and the acetabulum, few "b" or "d" type of bony sclerosis in the acetabulum. Careful observation of radiographic changes (cyst and sourcil) would be most important, especially in secondary osteoarthritis, to decide the indication of surgery. On the basis of histological studies of osteophyte at the craniolateral acetabular rim obtained at the operation, it was assumed that the osteophyte formation had initiated from metaplasia of the labrum or synovial membrane and progressed by a form of chondral ossification after the process of fibrous tissue formation. A well developed trabecular density in the osteophyte at the craniolateral acetabular rim was determined by the use of Muto digigrammer system, Model G-002.

Reliability of radiographic evaluations of the stage of osteoarthritis of the hip joint and an approach to improve the staging criteria.

A few reports have shown that the reliability of the Japanese Orthopaedic Association stage classification of hip osteoarthritis was not high. The objective of this study was to assess the reliability of the stage classification of coxarthrosis, and to evaluate whether a modification of the classification improves reliability. We retrospectively investigated 200 hips in 100 patients with hip pain. We collected radiographs of their hip joints with the patients in both a supine and a standing position. Four orthopaedic surgeons evaluated the stage of coxarthrosis employing the JOA classification. The percentage of agreement of examiners and the value of the kappa statistic were calculated. Furthermore, to improve the reliability of classification, we modified the classification based on previous reports. Partial narrowing of the joint space and disappearance of the joint space were defined as maintained if it was 2 mm or more, and as the width of the loss of joint space that was 10 mm or more respectively. Using this classification, the same examiners assessed the stage on the same radiographs again three months after the previous evaluation. The percentages of agreement were 28.5% and 27% and the interobserver value of the kappa statistic was 0.45 and 0.44 in supine and standing position respectively. After modification of the classification, the percentages of agreement were 36.5% and 44% and the interobserver value of the kappa statistic was 0.48 and 0.56 in supine and standing positions respectively, and the intraobserver value of the kappa statistic was 0.55. The modification significantly improved the reliability only in the percentage of the agreement for the standing position. This study showed that the reliability of the JOA stage classification of coxarthrosis was not as high as previous reports have showed. Modification of the classification improved interobserver reliability.

[Outcome of hip shelf arthroplasty in adults after a minimum of 15 years of follow-up. Long term results and analysis of failures of 56 dysplastic hips].

The goal of this study was to evaluate late results of hip shelf arthroplasty in adults after a minimum of 15 years follow-up. 65 hip shelf arthroplasty performed for painful hip dysplasia between 1964 and 1977 were studied retrospectively in 1992. These 65 procedures were performed in 57 patients mean aged 32 +/- 14 years [17-56]. Nine patients (9 hips) were excluded (2 deceaded, 5 lost for follow-up, and two reoperated because of severe infection). Consequently, the functional results were evaluated for 56 hips (48 patients). Before surgery, according to Merle d'Aubigné's hip rating system, all the hips were painfull (mean pain score was 2.6 +/- 1.7 [0-5]). On radiography, all the hips had a dysplastic acetabulum and arthritic changes. Arthritic changes were severe in 32 hips (57.1 per cent). The hip shelf arthroplasty was carried out according to Roy-Camille. 10 hips had additional varus femoral osteotomy. The 48 patients (56 hips) included were evaluated by means of Merle d'Aubigné's hip rating system and AP and false lateral weight-bearing Xrays. In 1992, 24 procedures were changed for total hip replacement (THR) (17 before 15 years (early failure) and 7 after 15 years of follow-up (late failure)). These 24 hips were included with their last hip rating observed just before THR. Survival analysis was performed according to Kaplan-Meier using date of revision for THR as end-point. After 16.1 +/- 5.6 years of follow-up the functional score for 56 hips was: excellent in 4 hips, very good in 7 hips, good in 10, satisfactory in 14, poor in 17, and bad in 4. The survival rate established for 65 hips was 60 per cent at 15 years and 40 per cent at 21 years. Only 39 hips shelf arthroplasties were still functional after 15 years (mean follow-up 19.1 +/- 3 years [16-28], but 18 hips (46.1 per cent) were painfree or slightly painful (pain score to 5 or 6). Among these 39 hips, the results were excellent in 4 hips, very good in 7 hips, good in 10, satisfactory in 10, poor in 6, and bad in 2. Arthritic change was the main reason for failures: the Kaplan-Meier survival rate at 21 years was 87 per cent when arthrosis was slight and only 15 per cent and 42 per cent when arthrosis was moderate to severe (p = 0.0001). The adverse effect of arthrosis was promoted by lack of congruency for early failures, and by severity of dysplasia and hip subluxation for late failures. The additional femoral varus osteotomies had no influence on functional or radiographic outcome. Our study indicated that hip shelf arthroplasty performed for painful acetabular dysplasia in adult has a 40 per cent probability survival rate at 21 years. The high rate of revision (42.8 per cent) could be related to the prevalence of severe pre-operative arthrosis. The low rate of lost for follow-up (8.7 per cent) and the long follow-up period (16.1 years) made our conclusion reliable. In spite of a high revision rate we recommend shelf athroplasty to treat acetabular dysplasia in adults. This procedure, very reliable in cases of moderate arthrosis, could be performed in cases of severe arthrosis to delay and make easier THR, but a low survival rate could be expected unless dysplasia, lack of congruency and subluxation were mild.

Structural effect of avocado/soybean unsaponifiables on joint space loss in osteoarthritis of the hip.

To evaluate the structural effect of avocado/soybean unsaponifiables (ASU) in the treatment of patients with symptomatic osteoarthritis (OA) of the hip. Patients with regular painful primary OA of the hip (European League Against Rheumatism 1980 criteria) and a joint space still > or = 1 mm (Kellgren grade 1 to 3, assessed by an independent observer prior to inclusion) entered a prospective, multicenter, randomized, parallel group, double-blind, placebo-controlled trial of 2 years duration. Patients had at least a 6-month history of regular pain and an algofunctional index (AFI) > or = 4. The primary assessment criterion was a decrease of the joint space width (JSW) on plain anteroposterior radiographs of the pelvis performed in standing position, measured at the narrowest points by 2 independent readers, previously tested and selected and blinded to both the treatment and the time sequence. Secondary criteria were standard clinical outcome measurements (AFI, pain on a visual analog scale, consumption of nonsteroidal antiinflammatory drugs and patient's and investigator's global assessments). One hundred sixty-three patients were included: 102 men and 61 women (mean age 63.2 +/- 8.7 years). A total of 108 patients (72 men and 36 women; mean age 64 +/- 7.9 years) were radiologically evaluable at 23.7 +/- 2.6 months (ASU group; n = 55) and 23.7 +/- 3.2 months (placebo group; n = 53). Overall comparison of the evolution of JSW showed no difference between the ASU and placebo groups, from 2.35 +/- 0.93 to 1.87 +/- 1.10 mm and from 2.5 +/- 0.94 to 1.9 +/- 1.33 mm, respectively (intergroup P value at end point = 0.9). When patients were divided into 2 subgroups according to the median value of the baseline JSW (2.45 mm), the joint space loss in the most severely affected subgroup of patients (baseline JSW < or = median) was significantly greater in the placebo group than in the ASU group: from 1.69 +/- 0.58 to 0.84 +/- 0.77 mm (-0.86 +/- 0.62 mm) and from 1.66 +/- 0.42 to 1.22 +/- 0.7 mm (-0.43 +/- 0.51 mm), respectively (P < 0.01). The JSW decrease was identical, with no difference in ASU and placebo groups, in the less severely affected subgroup of patients (baseline JSW > median). Clinical parameters in the 2 groups did not differ significantly throughout the study. This pilot randomized, double-blind, placebo-controlled trial failed to demonstrate a structural effect of ASU in hip OA. However, in a post-hoc analysis, ASU significantly reduced the progression of joint space loss as compared with placebo in the subgroup of patients with advanced joint space narrowing. These results suggest that ASU could have a structural effect but require confirmation in a larger placebo-controlled study in hip OA.

[Late results of conservative treatment of perthes disease.].

The objective of the submitted work was to assess the long-term prognosis of Perthes disease. From the originally invited 142 patients 72 attended the check-up examination, complete X-ray documentation was assembled only in 32 patients with 38 affected hip joints. The time interval which had elapsed since the onset of the disease was on average 17 years. The authors evaluated the clinical and X-ray picture of the hip joints and assessed retrospectively the affection of the head according to Catterall's method, incl. signs of a head associated with risk. Treatment provided during the sixties and beginning of the seventies did not meet the principles of modern "containment" therapy. It comprised bed rest, application of a plaster spike and aftertreatment with a Thomas splint. During late check-up examinations Wiberg's angle, the epiphyseal index, the index of overlapping of the head, the distance of the head from the floor of the acetabulum and the height of the peak of the greater trochanter above the centre of the head of the femur were assessed. In addition to assessment of these partial X-ray parameters the authors evaluated the spherical properties of the head by Mose's method and subjectively the X-ray picture, using a three grade scale (satisfactory, feasible, poor). In the majority of assessed parameters the authors found a statistically significant correlation with the retrospective classification of the original X-ray pictures classified according to Catterall. The clinical picture was satisfactory in the majority, the authors did not find painful restriction of movement, while almost half the patients reported occasional subjective complaints as regards the hip joint. On the X-ray changes in the overgrowth of the greater trochanter were more marked than changes of the spherical character of the head and the extent of decentering. The follow-up of the group will continue to obtain a longer time interval from the onset of the disease. Key words: Perthes disease, late results, Catterall's classification.

[Coxarthrosis].

Osteoarthritis of the hip joint is a very common disease. There is a minor prevalence of males. By etiology one can distinguish primary (idiopathic) from secondary osteoarthritis. Secondary are due to well-known etiologies as overweight, repetitive traumata, malposture, muscle- and tendon-imbalance etc. Osteoarthritis includes not only cartilage abnormalities, but also such of the subchondral-region, synovialis, synovial fluid and periarticular muscles. The cartilage shows in osteoarthritis typically edema and swelling, defects with tears, fibrillation, and "baldness" and (or) cartilagenous repair-islands and joint space narrowing as well, while subchondrally micro-edema, necrosis, ev. microfractures, "cysts", demineralisation followed by sclerosis, osteophyte-formation and deformity is seen. With conventional radiographs and CT joint space narrowing, subchondral cysts, sclerosis and osteophytes and deformities are well delineated, MRI however allows visualization of subtle bone marrow and cartilage abnormalities. Clinically, the diagnosis of pre-osteoarthritis becomes more and more important. This includes e.g. deformities and malpostures, labrum-pathologies and structural imbalances. There are three prognostic different types of hip-osteoarthritis depending on the migration of the head of the hip joint: the most common are the latero-cranial and the medio-caudal ones, while the central one is found very rarely. Basic imaging method are conventional radiographs, and CT, followed by MRI. The diagnosis of an "activated osteoarthritis" is made by bone-scintigraphy or MRI with i.v. application of contrast-media. The labrum- and cartilage diagnosis should be done with MRI or MR-arthrography. Functional computer-animated analysis will be of great diagnostic value in the near future. MRI indications are differences between clinical results and imaging, missing clinical improvement of an "activated" osteoarthritis under standard therapy, unclear joint-pain and before any arthroscopy.

Prognosis of hip pain in general practice: a prospective followup study.

Hip pain in the elderly is the main feature of osteoarthritis of the hip. In this prospective followup study, we wanted to determine which patients with hip pain show disease progression, and what the incidence of total hip replacement (THR) is in this group of patients after 3 and 6 years of followup. Within general practices in the area of Rotterdam (The Netherlands), persons age > or = 50 years with incident hip pain were included. After 3 and 6 years, progression of hip pain was assessed. A total of 224 patients were included. After 3 years disease progressed in 29 (15%) patients and 23 (12%) received a THR. After 6 years disease progressed in 45 (28%) patients and 36 (22%) received a THR. The prognostic variables for a THR after 3 and 6 years related to history taking were age > or = 60 years, morning stiffness, and pain in the groin/medial thigh; variables related to physical examination were decreased extension/adduction, painful internal rotation, and a body mass index < or = 30 kg/m(2); and the variable related to radiologic findings was a Kellgren/Lawrence grade of 2 or higher. In this study population, approximately 12% of patients presenting with hip pain to their general practitioner will undergo a THR within 3 years, and approximately 22% after 6 years. Using the variables obtained from history taking, physical examination, and radiologic findings enables better identification of persons at high risk for a THR.

[Imaging of the hip].

Imaging is fundamental to the diagnosis and therapeutic follow-up of all hip diseases. Despite the advent of extremely sophisticated exploratory methods, the oldest imaging method, straightforward radiography, makes it possible to recognize, locate ans treat the lesion in most cases. Good interpretation of simple antero-posterior and lateral x-ray films therefore is very important. Among the new imaging methods, computerized tomography has brought the third dimension, while ultrasonography and nuclear magnetic resonance have enabled us to visualize cartilages and soft tissues. The contribution to diagnosis and follow-up of these modern methods is considerable, but since we are too near their beginning and since the number of examinations is still too small in many fields, the information they provide must be used with caution. A good knowledge of their principle, advantages and drawbacks should help us to utilize them at best by prescribing only those which are necessary and sufficient for diagnosis and treatment.

[The role of core decompression for the treatment of femoral head avascular necrosis in renal transplant recipients].

Avascular bone necrosis is a relatively rare but significant complication in renal transplant recipients because it causes progressive pain and invalidity. It can be the consequence of the action of numerous causative factors, but it is mostly connected to corticosteroid treatment.The underlying pathophysiologic mechanism is a diminished blood flow to the bone leading to necrosis and bone destruction. During the past 25-years period, 570 renal transplantations and five combined kidney and pancreas transplantations were performed in our centre. A part of the patients was lost to follow-up due to the separation of Croatia from the former Republic of Yugoslavia. After transplantation, we revealed aseptic necrosis of the femoral head in five female patients. All patients had a history of treatment with pulse doses of corticosteroids. At transplantation the average age of the patients was 52.2 yrs (range 46 to 62 yrs), and dialytic treatment before transplantation lasted in average 9.2 yrs (range 2.5 to 21.2 yrs). The period between renal transplantation and the development of clinical signs of avascular bone necrosis lasted in average 1.2 yrs (range 0.3 to 2.3 yrs). We will demonstrate our 62-year old female patient with terminal renal failure caused by post-streptococcal glomerulonephritis, who was treated with peritoneal dialysis 2.5 years before renal transplantation. Twenty months before renal transplantation the patient received pulse doses of corticosteroids, together with immunoglobulins and plasmapheresis, for the treatment of an acute polyradiculoneuritis Guillaine Barré. After transplantation a standard immunosuppressive protocol was applied which included tacrolimus, mycophenolate mofetil, corticosteroids and induction with basiliximab. Four months after transplantation the patient started to feel pain in the right hip after longer standing, in addition to the earlier long-lasting problems caused by bilateral coxarthrosis. The pelvic radiograph showed subchondral radiolucencies in the lateral part of the head circumference spreading into the proximal part of the neck of the right femur, which indicated the presence of aseptic necrosis, but these changes could have also been caused by coxarthrosis. Unexpectedly, magnetic resonance imaging (MRI) did not reveal changes characteristic for avascular bone necrosis. Due to the progressively worsening of pain and the radiographic finding, the patient was submitted to decompression surgery of the femoral head. The surgical procedure was performed under diascopic guidance (C-arm) which allowed the correct positioning of a Kuerschner wire. A cannulated drill (diameter 4.0 mm) was placed over the wire and we performed two drillings of the spongiosis of the femoral head through to the subchondral area. Postoperatively, the patient was soon verticalized and advised to walk with crooks during a period of six weeks. This time is necessary to allow the mineralisation and strengthening of the bone which is now better vascularised. The patient recovered well and had no more pain. In renal transplant recipients it is most important to raise suspicion and verify the presence of avascular bone necrosis early, because timely bone decompression surgery can eliminate pain and cure the patient or it can prevent or delay bone destruction. When clinical signs of avascular bone necrosis arise and radiographic or standard MRI findings are negative, additional investigations (i.e. SPECT or MRI with contrast) should be performed to confirm or exclude the diagnosis. In latter phases of the disease, surgical decompression of the femoral head cannot lead to permanent amelioration, and it is inevitable to perform more invasive surgical procedures like "resurfacing" or bone grafting in younger patients, or the implantation of total hip endoprotheses.

Stress fracture of the femoral neck in a child:  a case report.

A 7-year-old boy developed complaints of pain in the left groin. These complaints started spontaneously. Initial plain radiographs of the pelvis indicated no abnormalities. As the symptoms persisted for 6 weeks, the young patient and his parents visited our institution. Clinical investigation showed a slight extension deficit of the left hip. New radiographs and MRI indicated a fracture line with sclerosis along the inferior border of the left femoral neck. In retrospect, this stress fracture of the femoral neck was also visible on the initial radiographs. Seven months after the onset of complaints in the left groin and prescribed partial weight bearing with crutches, callus formation with consolidation of the femoral neck was observed on radiographs. Eleven months after onset, the patient recovered fully without any residual symptoms. After 21 months, the young patient did not have any complaints or restrictions in physical activity. Because of its highly rare nature, stress fractures of the femoral neck in children are easy to miss initially. This was also applicable in our case. Extensive differential diagnosis of a child with pain in the groin furthermore adds to the difficulty in the diagnosis of a stress fracture of the femoral neck. This case report emphasizes the importance of the evaluation of radiographs and observation in children with hip complaints. Similarly, interdisciplinary consultation and cooperation between the general practitioner, orthopaedic surgeon, radiologist and paediatrician is essential in the diagnosis, evaluation and treatment of these young patients.

[Study of a painful total hip prosthesis].

The authors propose a simple routine survey to be performed in the case of a painful total hip prosthesis which is generally able to define the diagnosis and the prognosis. X-ray films are more valuable by their repetition than by their simple analysis. Certain minor signs can help predict or detect loosening of the prosthesis or other complications, but in the great majority of cases, radiology alone is not sufficient to make the diagnosis, as the films are only able to show clear spaces around the prosthesis, without being able to definitely confirm the aetiopathogenic significance of this sign. In these cases, when the decision has not been taken to re-operate, more sophisticated investigations are required (scintigraphy, dynamic tests, arthrography), although they must be used with caution as very often the clinical findings will have the last word.

Radiographic Prevalence of Sacroiliac Joint Abnormalities and Clinical Outcomes in Patients With Femoroacetabular Impingement Syndrome.

To quantify the prevalence of sacroiliac joint (SIJ) abnormalities in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) by use of various imaging modalities and to compare outcomes based on SIJ abnormalities. Plain radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. The exclusion criteria included patients undergoing bilateral or revision surgery, those with a history of dysplasia, and those with less than 2 years' follow-up. On radiographs, the SIJs were graded using modified New York criteria for spondyloarthropathy. CT and MRI scans were reviewed for joint surface erosion, subchondral sclerosis, joint space narrowing, pseudo-widening, bone marrow edema, and ankylosis. Patients with SIJ abnormalities were matched to patients without SIJ abnormalities in a 1:2 ratio by age and body mass index. Outcomes included the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain, and VAS for satisfaction. Of 1,009 consecutive patients, 743 (73.6%) were included; 187 (25.2%) showed SIJ changes. Of these 187 patients, 164 (87.7%) had changes on plain radiographs, 88 (47.1%) had changes on CT, and 125 (66.8%) had changes on MRI. SIJ changes on any imaging modality were weakly correlated with pain to palpation of the SIJ (r = 0.11, P = .004) on physical examination. Pain to palpation of the SIJ on physical examination (odds ratio [OR], 1.12; P = .031) and a history of SIJ pain (OR, 1.93; P = .018) increased the odds of having an SIJ abnormality on any imaging modality. After matching, patients without SIJ abnormalities had a significantly greater HOS-ADL (95.4 vs 90.6, P = .001), HOS-SS (91.1 vs 77.5, P < .001), and mHHS (91.3 vs 84.5, P < .001) and a significantly lower VAS pain score (10.9 vs 25.7, P < .001) than patients with abnormalities at a mean follow-up of 34.1 ± 9.7 months (range, 24-54 months). Patients without SIJ abnormalities had greater odds of achieving the minimal clinically important difference for the HOS-ADL (OR, 2.91; P = .001) and for the HOS-SS (OR, 2.83; P < .001) but not for the mHHS (OR, 1.73; P = .081). A high prevalence of SIJ abnormalities (25.2%) is seen on imaging in FAIS patients. These patients may show significantly inferior clinical outcomes and persistent postoperative pain after FAIS treatment. The results of this study may allow treating orthopaedic surgeons to better inform patients with SIJ abnormalities that they may not achieve clinically significant outcome improvement after hip arthroscopy. Level III, retrospective comparative study.

[Save the joint? Replace the joint? Long-term results and considerations in the treatment of femur head necroses in adults].

65 patients with necrosis of the femoral head (not caused by a trauma) in 102 hip joints were examined at an average of 9.7 years following first operation: 1st: 30 joints underwent intertrochanteric varus angulation osteotomy (follow up 11.6 y). 12/30 clinically not sufficient, 13/30 radiologically worse, only 2/30 improved range of movement. 2nd: 35 hip joints were treated using an artificial hip replacement (follow up 9.1 y): 77% got loose at an average of 5 years requiring 39 follow-up operations. 3rd: 5 arthrodesis were performed (follow up 11.4 y). 60% delayed nor non bony union. The results indicate a general osteopathy overlapping the size of osteonecrosis, and causing a lot of complications. Various therapeutic concepts should be considered with respect to radiological stage and age of the patient. The results of joint saving operations depend on the ability of the femoral bony structures to react sufficiently.

Treatment of mixed type femoroacetabular impingement using safe surgical hip dislocation in adults.

This study aims to assess the experience gained in a single institution in the treatment of mixed type femoroacetabular impingement (FAI) using safe surgical hip dislocation (SSHD) technique. In this study, 22 hips of 21 patients (7 males, 14 females; mean age 33.8±10.6 years; range 19-52 years) treated by SSHD technique in our clinic between October 2009 and October 2014 were retrospectively evaluated. Preoperative and final Harris hip scores (HHS) and alpha angles were compared. Age, gender, laterality, impingement tests, preoperative HHS, cam and pincer type FAI radiographic indicators and intraoperative articular findings were assessed in terms of their influence to the final functional outcomes. Mean duration of the symptoms was 29.5 months. Groin pain, activated by flexion and internal rotation of the hip, was the main symptom. A radiographic diagnosis of "mixed type FAI" was made in all hips. Mean follow-up duration of 22 hips was 48 months. The difference between the mean preoperative and latest HHS was statistically significant (60.0 vs. 87.6 points, p<0.001). The treatment was considered satisfactory in 17 of 22 hips (77%) having a mean HHS of 95.0 points. Hips having a preoperative HHS of less than 60 points were more prone to unsatisfactory outcome. Among the investigated patient-dependent, clinical, radiographic variables and intraoperative articular findings, coxa profunda sign in a plain radiograph was found correlated with a higher rate of unsatisfactory outcome (p=0.040). Safe surgical hip dislocation procedure has a success rate of 77% after a mean follow-up of four years. Coxa profunda sign is associated with the unsatisfactory clinical outcome. Preoperative HHS of less than 60 points seems to be a negative predictive variable on the clinical outcome.

[S3 Guideline. Part 1: Diagnosis and Differential Diagnosis of Non-Traumatic Adult Femoral Head Necrosis].

Non-traumatic femoral head necrosis (FHN) is primarily a disease of the middle-aged adult. Early diagnosis, at a time with lacking or minimal clinical symptoms, is mandatory to consider conservative therapy or joint preserving operations as a therapeutic option. The new German S3 guideline about diagnosis and therapy of FHN is a cooperative effort of five professional medical societies, overall headed by the Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC). This review (part I/III) cites and explains the statements of the S3 guideline as agreed on the use of imaging methods for diagnosis of FHN. A diagnostic algorithm is presented. FHN clinically has to be considered in case of equivocal pain of a hip joint with a minimum of 6 weeks duration, when risk factors can be revealed, groin pain at clinical investigation, limping, pain or limitation of movement in case of load, and no obvious differential diagnoses. Is an FHN clinically suspected, primarily radiographs of the pelvis ap and a Lauenstein projection of the hip involved should be carried out. When the radiographs are normal, an MRI of the hips should follow routinely. MRI allows the diagnosis of FNH with high accuracy. Furthermore, MRI reveals the site and the size of the necrotic area involved and evaluates the integrity of the joint surface and subchondral fractures. When ARCO stage II (ARCO: Association Research Circulation Osseous) is diagnosed and MRI does not allow one to determine the joint surface with certainty, a CT of the hip joints should be performed. The S3 guideline explains and recommends the use of the ARCO classification. Although, this classification of 1993 is still largely based on radiographs, the pragmatic use of an "extended" version seems reasonable. Today, classical radiographic criteria like impression of the joint surface and subchondral fractures ("crescent sign") are better to be evaluated by MRI, in cases of subtle findings MRI is even surpassed by CT. The extent of the necrosis in the femoral head as well as the size of the surface area involved is best revealed with MRI. Additionally, in the era of cross sectional imaging a stage "0" seems obsolete. The guideline also addresses practically important considerations about the differential diagnosis of misleading MRI findings. This especially holds true for bone marrow oedema in the femoral head which may be misinterpreted. The differentiating features between FHN, transient bone marrow oedema and destructive arthropathy are discussed.

Incidence of Femoroacetabular Impingement and Surgical Management Trends Over Time.

Femoroacetabular impingement (FAI) is a well-known cause of hip pain in adolescents and young adults. However, the incidence in the general population has not been clearly defined. To (1) define the population-based incidence of diagnosis of FAI in patients with hip pain, (2) report the trends in diagnosis of FAI over time, and (3) determine the changes in the rate and type of surgical management over time. Cohort study; Level of evidence, 3. A geographic database was used to identify patients who were 14 to 50 years old with hip pain between the years 2000 and 2016. Chart and radiographic review was performed to determine which patients had FAI. To be included, patients had to have a triad of clinical symptoms, physical examination signs, and imaging findings consistent with FAI. Medical records were reviewed to obtain demographic information, clinical history, physical examination findings, imaging details, and treatment details. Statistical analysis determined the overall age- and sex-adjusted annual incidence of FAI diagnosis and trends over time. There were 1893 patients evaluated with hip pain, and 716 (38%; 813 hips) had diagnosed FAI. The mean ± SD age was 27.2 ± 8.4 years, and 67% were female. The incidence of FAI diagnosis was 54.4 per 100,000 person-years. Female patients had a higher incidence than male patients (73.2 vs 36.1 per 100,000 person-years; <iP</i < .01). Incidence of FAI diagnosis were higher from 2010 to 2016 (72.6 per 100,000 person-years; <iP</i < .01) as compared with 2005 to 2009 (45.3) and 2000 to 2004 (40.3). Hip arthroscopy, surgical hip dislocation, and periacetabular osteotomy utilization increased from the 2000-2004 to 2010-2016 periods, respectively: 1 (1%) to 160 (20%; <iP</i = .04), 2 (1%) to 37 (5%; <iP</i = .01), and 1 (1%) to 22 (3%; <iP</i = .58). The overall incidence of FAI diagnosis was 54.4 per 100,000 person-years, and it consistently increased between 2000 and 2016. Female patients had a higher incidence than male patients. The utilization of joint preservation operations, including hip arthroscopy, surgical hip dislocation, and anteverting periacetabular osteotomy, increased over time.

Strategy and optimization of diagnostic imaging in painful hip in adults.

Diagnostic imaging strategy in painful hip depends on many factors, but in all cases, plain X-ray is the first investigation. It may be sufficient to reach diagnosis and determine treatment options. More effective but more expensive exploration is indicated in two circumstances: when plain X-ray is non-contributive, and when diagnosis has been established but more accurate imaging assessment is needed to guide treatment. Following radiography, the choice of imaging techniques depends not only on the suspected pathology but also on the availability of equipment and its performance. MRI is probably the technique that provides the most comprehensive results; recent improved accessibility has significantly simplified the diagnostic algorithm. CT remains invaluable, and current techniques have reduced patient irradiation to a level similar to that of standard X-ray. Finally, cost is an important consideration in choosing the means of exploration, but the overall financial impact of the various strategies for diagnosis of painful hip is not well established. This article aims to provide a simple and effective diagnostic strategy for the assessment of painful hip, taking account of the clinical situation, and to detail the most typical semiologic patterns of each disease affecting this joint.

Rapidly destructive inflammatory arthritis of the hip.

Rapidly destructive coxarthrosis (RDC) is a rare syndrome that involves aggressive hip joint destruction within 6-12 months of symptom onset with no single diagnostic laboratory, pathological, or radiographic finding. We report an original case of RDC as an initial presentation of seronegative rheumatoid arthritis (RA) in a 57-year-old Caucasian woman presenting with 6 months of progressive right groin pain and no preceding trauma or chronic steroid use. Over 5 months, she was unable to ambulate and plain films showed complete resorption of the right femoral head and erosion of the acetabulum. There were inflammatory features seen on computed tomography (CT) and magnetic resonance imaging (MRI). She required a right total hip arthroplasty, but arthritis in other joints showed improvement with triple disease modifying antirheumatic drugs (DMARD) therapy and almost complete remission with the addition of adalimumab. We contrast our case of RDC as an initial presentation of RA to 8 RDC case reports of patients with established RA. Furthermore, this case highlights the importance of obtaining serial imaging to evaluate a patient with persistent hip symptoms and rapid functional deterioration.

[Long-term development of primary osteochondritis of the hip (Legg-Perthes-Calvé). Apropos of 60 hips with a follow-up of more than 30 years].

This study concerns 60 hips in 57 patients aged between 33 and 56 years with a follow-up of 30 to 44 years since the onset of the disease. The progress of the condition was assessed by objective and subjective clinical criteria and radiographic criteria including roundness of the head, head height, head cover, abnormal head shape and the presence of arthrosis. The main prognostic feature was found to be the eventual shape of the femoral head. Normal heads (7 cases) and round heads with some flattening (20 cases) had few problems at the time of follow-up. Irregular heads (7 cases) and, most of all, very irregular heads (20 cases) progressed badly. Pain was common, often severe and the patients were disabled. Fourteen of them had consulted a doctor and seven had already been treated surgically. Arthrosis as a consequence of osteochondritis seemed to be due to joint incongruence. We consider that the prognosis can be made at the end of the progressive phase of the disease, since remodelling plays no part in the roundness of the head. These findings indicate the need for care in recommending treatment in the residual phase of the disease and suggest that it is difficult to determine what surgical treatment should be considered in adult life.

Surgical indications for treatment for femoroacetabular impingement with surgical hip dislocation.

There is a lack of detailed information about the indications of surgical treatment for femoroacetabular impingement (FAI), particularly using open surgical dislocation. The purpose of this review was to systematically review the reported indications for surgical dislocation of the hip for FAI. Two databases (MEDLINE and EMBASE) were screened for clinical studies involving the treatment for FAI with surgical hip dislocation. We conducted a full-text review and the references for each included paper were hand-searched for other eligible studies. Papers published until September 2011 were included in this review. Two individuals reviewed all identified studies independently, and any disagreement was resolved through consensus. Fifteen studies met the eligibility criteria, which included a total of 822 patients. We identified a lack of consensus for clinical and radiographic indications for surgical hip dislocation to treat FAI. The most common clinical indications reported were clinical symptoms such as hip pain in 10 papers (67 %), a positive impingement sign in 9 papers (60 %), painful/reduced range of motion in 9 papers (60 %), activity-related groin pain in 4 papers (27 %), and non-responsive to non-operative treatment in 4 papers (27 %). The most commonly reported radiographic indicators for surgical hip dislocation were a variety of impingement findings from radiographs in all 15 included papers (100 %), a combination of radiographs and MRA in 5 papers (33 %) or radiographs and MRI in 3 papers (20 %). These results showed that that there was an inconsistency between the clinical and radiographic indications for surgical hip dislocation as a treatment for femoroacetabular impingement. This review suggests that there is a need for the development of standardized clinical and radiological criteria that serve as guidelines for surgical treatment for FAI. Systematic review, Level IV.

Surgical treatment of late developmental displacement of the hip. Results after 33 years.

The outcome of displaced hips treated by Somerville and Scott's method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change. The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.

Juvenile idiopathic arthritis

At the time of receiving a JIA diagnosis, children and their families often have many questions regarding prognosis. Recent therapeutic advances in the management of JIA have made inactive disease and clinical remission achievable goals for the majority of children with access to modern treatments. Clinical remission can be defined as the absence of signs and symptoms of inflammatory disease activity, including extra-articular manifestations of the disease. Differentiating subtypes of JIA helps to target treatment and leads to more positive outcomes, however subtype is not the only predictor of JIA outcome. Poor prognostic factors include arthritis of the hip, cervical spine, ankles or wrists; prolonged elevation of inflammatory markers; and radiographic evidence of joint damage including erosions or joint space narrowing. Patients with RF-positive polyarthritis often have worse outcomes associated with more aggressive disease. Despite this, the probability of this subgroup achieving

The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip.

Clinical criteria for the classification of patients with hip pain associated with osteoarthritis (OA) were developed through a multicenter study. Data from 201 patients who had experienced hip pain for most days of the prior month were analyzed. The comparison group of patients had other causes of hip pain, such as rheumatoid arthritis or spondylarthropathy. Variables from the medical history, physical examination, laboratory tests, and radiographs were used to develop different sets of criteria to serve different investigative purposes. Multivariate methods included the traditional "number of criteria present" format and "classification tree" techniques. Clinical criteria: A classification tree was developed, without radiographs, for clinical and laboratory criteria or for clinical criteria alone. A patient was classified as having hip OA if pain was present in combination with either 1) hip internal rotation greater than or equal to 15 degrees, pain present on internal rotation of the hip, morning stiffness of the hip for less than or equal to 60 minutes, and age greater than 50 years, or 2) hip internal rotation less than 15 degrees and an erythrocyte sedimentation rate (ESR) less than or equal to 45 mm/hour; if no ESR was obtained, hip flexion less than or equal to 115 degrees was substituted (sensitivity 86%; specificity 75%). Clinical plus radiographic criteria: The traditional format combined pain with at least 2 of the following 3 criteria: osteophytes (femoral or acetabular), joint space narrowing (superior, axial, and/or medial), and ESR less than 20 mm/hour (sensitivity 89%; specificity 91%). The radiographic presence of osteophytes best separated OA patients and controls by the classification tree method (sensitivity 89%; specificity 91%). The "number of criteria present" format yielded criteria and levels of sensitivity and specificity similar to those of the classification tree for the combined clinical and radiographic criteria set. For the clinical criteria set, the classification tree provided much greater specificity. The value of the radiographic presence of an osteophyte in separating patients with OA of the hip from those with hip pain of other causes is emphasized.

BILATERAL RAPIDLY DESTRUCTIVE HIP OSTEOARTHRITIS: A CASE REPORT.

Although hip osteoarthritis usually shows a slow progression, a rapidly destructive osteoarthritis is observed in approximately 10% of patients. We aimed to present a case with rapidly destructive osteoarthritis in bilateral hip joints. A 78-year-old male patient was admitted due to pain in hip joints. In examination, hip movements were minimally painful and limited. The patient was able to walk independently with a cane. When he re-applied six months later, hip movements were severely limited and painful. In plain radiographs, while a slight narrowing in hip joint space, sclerosis and minimal osteophyte had been observed at the first administration, extreme narrowing, subluxation, flattening of femoral head, increased sclerosis, resorption in femoral head and acetabulum were detected six months later. We consider that hip osteoarthritis in elderly people should be monitored at frequent intervals in terms of clinic and radiological progression.

A reappraisal of 'analgesic hip'.

Nineteen patients with hip radiographs typical of 'analgesic hip' (rapidly destructive, atrophic arthropathy involving both femoral and acetabular components) have been studied. Women predominated (14:5), and all were elderly (mean age 74 years, range 64-83 years). Destructive hip disease was unilateral in all but one case. The mean interval from symptom onset to typical x ray appearance was short (one year, range three to 24 months), and persistent pain unresponsive to drug therapy was characteristic. Screening showed no metabolic or neurological disease. Contrary to previous reports, non-steroidal anti-inflammatory drugs could not be incriminated in development of the disease. Clinical and radiographic similarity to apatite associated destructive arthritis of other large joints was striking, and occurrence of the latter, uncommon condition in five patients (five shoulders, two knees) suggests that both descriptions represent a common articular response at different joint sites.