Trochanteritis

TROCHANTERITIS (trochanteritis), an inflammatory process in the bone substance of the greater trochanter of the femur. As a separate disease, tuberculous trochanteritis is described almost exclusively. The peculiarity of the localization and course of diseases with an isolated focus in the bones located in immediate proximity to the hip joint, without its involvement in the process, served as the basis for Duplay in 1872 to distinguish these diseases into a group of periostitis. The localization of the tuberculous process in the greater trochanter apparently occurs more often than is described: König observed trochanteritis in only 5 cases out of 185 coxitis; according to the data of the Russian author Dr. Pyrkov, this disease occurs in 5.25% of all bone-joint tuberculosis, and he was able to collect only 84 cases on the material of the Tsustrah sanatorium in Evpatoria. The peculiarity of the course of the tuberculous process with this localization is the languor of clinical manifestations of the disease (Vogt) and the tendency for the lesion to remain a strictly localized process (Oehlecker). Transition to the hip joint is noted in isolated cases (Gangolphe), secondary changes of the hip joint of the type of deformative osteoarthritis with subsequent development of coxa vara have also been described (Baumgartner, Moppert). The isolation of the primary bone focus in trochanteritis can be explained, on the one hand, by the blood supply of the greater trochanter, which, according to the research of Nussbaum, occurs almost exclusively at the expense of the anterior circumflex artery, while the entire articular end of the femur is nourished by the posterior circumflex artery, and on the other hand, by the late formation and connection with the metaphysis of the femur of the ossification center (Rauber). The process usually has a fungoid-destructive character with caseous decay and only in extremely rare cases proceeds in the form of caries sicca. The clinical picture of the disease consists of the following symptoms: pain upon abduction of the thigh, while flexion and extension, as well as loading of the joint (percussion on the heel) do not give pain. The limb is in a position of slight abduction, flexion, and external rotation. The angle of flexion never exceeds 125-135°. Shortening of the limb is always absent. On the outer surface of the thigh, corresponding to the position of the greater trochanter, swelling, pitting, and tenderness upon palpation are noted. In 45% of all cases there is the formation of a tuberculous abscess, which develops in most cases quite quickly, through 4-5 months after the onset of the disease. Sinuses are located on the anterior-outer side of the thigh, which is explained by the presence of a dense intermuscular septum separating the anterior-outer surface of the thigh from the posterior one. On the X-ray, a typical tuberculous focus with indistinct eroded contours, atrophy of the bone tissue, and absence of reactive phenomena from the periosteum is determined. The destructive process mainly involves the lateral surface of the greater trochanter. In differential diagnosis of tuberculous trochanteritis, the following diseases must be kept in mind: bursitis, inflammatory, infectious processes of non-tuberculous origin, neoplasms, and bone cyst (osteodystrophia fibrosa cystica localisata). In bursitis, in addition to negative X-ray data, there is the formation of a large abscess with more clearly expressed fluctuation and abundant purulent content. The typical localization for solitary cyst and sarcoma is the metaphysis of the femur. As a rarity, the development of giant-cell tumor (braune Tumoren) in the area of the greater trochanter is observed, which gives rise to diagnostic errors described in the literature. The characteristic of giant-cell tumor is parchment crunch and a typical X-ray picture indicating the formation of small separate chambers with complete or incomplete septa, swelling of the cortical substance, and absence of osteoporosis of the bones. Tuberculous trochanteritis usually has a benign course; rapid subsidence of the process is noted by Spitzy. Conservative treatment is based on the general principles of treatment of bone-joint tuberculosis in general. In the formation of a sinus, it is necessary to perform puncture in a timely manner to remove pus with subsequent introduction of iodoform emulsion. The presence of an isolated tuberculous focus allows the application of radical operative treatment for tuberculosis of the greater trochanter - removal of all affected bone tissue with subsequent tight suturing of the wound. Inflammatory processes with another etiological moment developing in the area of the greater trochanter belong to the group of acute infectious apophysitis and are caused by various pathogens. Staphylococcal osteomyelitis can proceed both with a violent development of all clinical phenomena and in a subacute form, in which the clinical picture and course of the disease in many ways resemble tuberculous trochanteritis. In addition to bacteriological research data, osteomyelitis is indicated by the formation of large, well-contoured sequestra, the presence of reactive phenomena from the periosteum, and the absence of osteoporosis. In diplococcal infection, for which involvement of the femoral neck is considered typical (Wrede, Kozlovsky), inflammatory foci can also occur in the area of the greater trochanter with the most frequent localization at its base. The disease is observed predominantly in childhood and the lesion often has a multiple character. The typical formation of large perifocal purulent formations and the absence of sequestration is characteristic. On X-rays, the foci appear sufficiently sharply outlined and isolated from the surrounding bone tissue by an osteosclerotic rim. In the formation of an abscess, treatment is operative.