Minimalinvasive treatment of hip joint arthrosis Maybe, you have already noticed the following cases histories in your practice: A patient came for treatment of a lumbar prolapsed intervertebral disc. After successfully applying the periduralcatheter-therapy according to Salim and treating the sacrodyny by CT-controlled iliosacral joints injections, the patient further complains about pain in the area of hip joint radiating into the leg. A hip joint arthrosis wasn t diagnosed yet. Does a connection exist there? The pathogenesis of hip joint arthrosis is well known. Favoured by overload, by malposition, by alterations due to former injuries, by inflammation or endochondral dysostotsis the nutrition of cartilage will be damaged and the elasticity and stability will be reduced. Later, parts of the cartilage will become necrotic. The stimulus of inflammation will lead to spreading of little vessels into this region and to building of connective tissue and later to conversion to bone tissue. Ostoephytes will occur. Due to the atrophy of the stressed bone, shape alterations will develop. The irritation of synovialis can cause the development of intra-articular effusion. The patient will complain about increasing pain and later about reduced motility. The hip joint movements are always combined with the movement of spine and of pelvis axis. Vice versa, changes in spine motility and spine-pelvis- axis will lead to more stress of hip and iliosacral joints. To a patient with prolapsed intervertebral disc the spinal symptoms of the respective spinal nerve will come to the fore. He will automatically move in malposition to reduce pain. The pain induced malposition will cause an irregular weight distribution and will lead to overload of one hip joint. But another mechanism is important, too: The hip joint and the respective muscles are innervated by plexus lumbalis (L4- L5) and by plexus sacralis (S1-S2). These nerves also give supplying braches to the iliosacral joint. Due to a prolapsed intervertebral disc the iliosacral joint will be stressed and the supplying nerves will tend to irritation and intumescence. This leads to co-reaction of the hip joint, which is supplied by the same spinal nerves. The damaged supplying nerve will cause an irritation of synovialis, a
reduced production of synovial fluid and an increased friction of articular facets. The inflammation stimulus will promote the progress of arthrosis. This process will usually run over years. After the occurring of the first complaints, the detection of radiographic alterations will last one up to eight years. In this interval the patient often has passed an odyssey. Symptoms and examination results Typical symptoms in the first stadium are pain in the hip and the gluteus region, maybe irradiating into the leg. These pains are getting stronger after longer sitting position or after getting up in the morning. Many patients complain about spasm in the calf or in the foot. Others suffer from dysaesthesia. The last is able to become so strong that the patient has to stop walking or a certain movement (DD claudicatio spinalis). Examination shows strong tenderness in the iliosacral and hip joint. The therapy opportunities ranges from conservative therapy including nonsteroid antirheumatics, physical and physiotherapeutic treatment, via neural therapy up to surgical operation. The interval from the beginning of complaints to the surgical intervention runs over many years, in which the patient s quality of life is considerably restricted. Intra-articular injections with local anaesthesia and cortisone crystal suspension are already known and practised. They interrupt the chronic pain status and reduce inflammatory reactions. But it is important to apply hyaluronic-acid-gel as synovial fluid surrogate, additionally. This gel will bring a long term improvement for the joint function, because the cortisone will lead to a membrane stabilisation and to a reduction of synovial fluid production. Further more, the combination of hip and iliosacral joint therapy with S2 nerve blocking is absolutely necessary to obtain a long term success..
Procedure The joint will be treated by CT controlled hip joint infiltration added by anabolic apply of synovial fluid surrogate. This therapy is combined with iliosacral joint injection inclusive S2 blocking. The patient will be in prone position on the CT table. In the CT scan two heights will be marked, the region of hip and of the iliosacral joint. Fig.1: CT scan of the iliosacral and the hip joint Fig.2: Marking the puncture points on the patient s back and hip area After careful disinfection the first injection needle will be placed into the iliosacral joint, the second needle into the hip joint. After positioning of each needle a little amount of contrast medium will be given. The next CT scan shows whether the injection needles and the contrast medium are in the right position or not. Fig.3: the correct position of the needle in the iliosacral joint gap Fig.4: the exact needle position and right contrast medium distribution The contrast medium will have to distribute in the hip and iliosacral joint gap and pass out along the S2 spinal nerve root. Maybe it will be necessary to correct the needles.
Thereafter local anaesthetics and cortisone crystal suspension will be given, additionally hyaluronic-acid gel (Suplasyn) will be injected into the hip joint gap. It is important to reach S2 nerve root, in order to achieve a distribution in the area of plexus sacralis and a nerve blocking and detumescence of the iliosacral joint supplying nerves. A therapy cycle of three interventions in a regular interval of two weeks each should be performed. In each intervention two ampoules of hyaluronic-acid-gel should be given. Results During two years 724 patients had been examined after finishing hip joint therapy. They were summarized in two groups. Group 1: 364 patients had got the CT-controlled hip joint injection combined with iliosacral treatment. Three interventions with regular interval of two weeks each were executed. Lidocain, cortisone crystal suspension and Suplasyn were instilled. Group 2: the other 364 patients received a pure conservative therapy with nonsteroid antirheumatica, physical and physiotherapeutic treatment. The pain intensity was represented in the visual analogue scale (=VAS). The pain before treatment was fixed on 10 of the VAS for all patients (violet column). 10 9 8 7 6 5 4 3 2 1 0 before 1a 1b 2 before after hip injections - group 1a after hip injectionsgroup 1b after conserv. therapy Fig. 5: the average pain intensity before and after treatment
Group 1 was divided in two subgroups: 1a and 1 because of different grades of arthrosis. Group 1a: After hip injections combined with iliosacral treatment 85 per cent of the patients of group 1 obtained a pain intensity of 1, 8 on VAS (dark blue column). Group 1b: 15 per cent of the patients of the first group achieved a pain intensity of 4, 6 on VAS (light blue column). Group 2: After 6 to 8 weeks of conservative treatment the patients still declared a pain intensity of 8, 5 on VAS (pink column). Because of stronger arthrosis the group 1b patients received e second therapy cycle. And so the patients of the group 2 with conservative treatment did. Group 1b: After the second cycle of treatment these patients showed a reduced pain intensity on 2, 4 on VAS (light blue column). Group 2: These patients had conservative therapy further or two months. But just a small pain reduction on 7, 5 on VAS was not noticed (red column). 10 8 6 4 before therapy group 1 b group 2 2 0 before 1b 2 Fig.6: average pain intensity after the second therapy cycle Complications No complications such as intra-articular bleeding, infection, or nerve damage occurred. Discussion Many patients with hip joint problems suffered from this pain for a long time and complained about strong reduce of life quality. After CT controlled hip joint
injection combined with iliosacral joint treatment they noticed a pain free status or a significant pain reduction for the first time since years. The patients with arthrosis of lower grade (group 1a) achieved a success rate of 92 per cent. The group with the higher arthrosis grade obtained after first therapy cycle a pain reduction on 46%. After the second treatment cycle they indicated the pain intensity with 2, 4 on VAS. That means a success rate of 76 %. After four months of therapy the conservative treated group only showed a success of 25 per cent. The persisting pain was represented with 7, 5 on VAS. Conclusions The CT controlled hip joint treatment combined with iliosacral joint injections represents a well applicable outpatient method at minimal risks and great success. In general, three interventions with a regular interval of two weeks each will be sufficient for patients with a lower arthrosis grade. In case of higher grade of degenerative hip joint alterations a second therapy cycle should be performed. Respective to all minimal invasive treatments, the use of CT control gives the opportunity to interventions with high safety. After the first intervention the patient already will feel a significant pain reduction and will notice an increased quality of life. Of course, for hip joint arthroses of highest grade with significant radiographic determined strong alterations a surgical operation is absolutely necessary. The described new method has got a good appropriation with arthroses of low and middle grade. author: Dr. med. Elias Salim, Dr. med. Jana Salim Winterhuder Marktplatz 17 22299 Hamburg Germany Tel.: ++49-40 300 31 202 Fax: ++49-40 300 31 203 e-mail: elias@dr-salim.de Internet: http://www.dr-salim.de