0:00

<v ->Okay, thank you for the invitation

0:03

and it's an honor to be here

0:06

in this new way of congresses

0:13

and lectures.

0:14

And thank you very much for the invitation, it's an honor.

0:17

And I'd like to thanks to Dr. Mariana Santos

0:20

that helped me to prepare the cases for you all.

0:25

Well, in this first part of the lecture,

0:30

I got two cases

0:35

and they concern about trochanteric pain syndrome

0:40

and they usually are elder women and athletes.

0:46

And bursa is typically not inflamed

0:49

and not a primary cause of symptoms,

0:52

but the underlying pathological conditions are tendonitis

0:57

and tears of the gluteus minimus and medius.

1:01

And there are other less common pathological conditions.

1:07

I will try to show you some of them.

1:10

So this first patient

1:14

is a 49 year old man

1:17

with left hip pain for about six months,

1:22

no history of trauma and no systemic symptoms,

1:28

no fever, no malaise, no (indistinct)

1:32

and just pain.

1:34

We can see here, in the radiographs,

1:40

that there is-

1:43

Oh, sorry.

1:47

Partial destruction of the greater trochanter.

1:53

There's leak areas inside the trochanter

2:01

and we can see calcifications and ossification,

2:05

around the greater trochanter in the soft tissue.

2:10

Probably rest of the destruction of the bone.

2:17

That we can see here.

2:23

In the MRI, that I'll show you next.

2:31

I'll show you the images first, then I'll say my comments.

2:46

I'll let you see the images, then we'll talk a little bit.

3:06

Yeah, still T2 images, (indistinct)

3:26

and plus contrast.

3:38

T2 and plus contrast.

3:51

And in this examination, we can see

3:54

a partial destruction of the greater trochanter.

3:58

There are collection inside the bone

4:02

and edema around this collection.

4:05

We have some destruction of the soft tissue,

4:17

especially

4:21

the gluteus tendons, minimus and medius.

4:27

We can see them here

4:29

and there's a partial (indistinct)

4:33

and we can see the distinction of the bursa

4:40

around the greater trochanter.

4:45

And there's a kind of a

4:54

high signal in T1 images,

4:57

inside suggesting that we have high protein content.

5:04

And we can see in the T2 images...

5:08

Sorry.

5:12

Some debris

5:15

5:18

So the imaging

5:22

is of a bursitis

5:26

and destruction of the bone, like an osteomyelitis,

5:35

but we have osteomyelitis

5:39

in a patient without fever,

5:43

without malaise and with six months of pain.

5:52

Probably we have a low virulence infection.

6:01

So we have a few diagnosis to think

6:05

but there's a bursitis with some debris inside it

6:12

that could be kind of a rice bodies,

6:16

destruction of the bone and low virulence.

6:19

Tuberculosis would be the best diagnosis.

6:26

It was made a biopsy of the bone and the soft tissues,

6:31

and the pathological diagnosis

6:34

was tuberculosis of the greater trochanter

6:37

and tuberculosis bursitis.

6:43

It accounts about 1% of the skeletal tuberculosis

6:49

and tuberculous tendosynovitis is most common

6:53

involving the hand and wrists,

6:57

but tuberculosis bursitis occurs most commonly

7:01

around the hip, in this person.

7:04

So it's not very typical, but it's a very, very nice case.

7:13

Don, do you have any comments?

7:15

<v ->Yeah, I wanna ask you a question, but I have a comment.

7:18

It's interesting to me, we don't see a lot of tuberculosis.

7:23

but I learned a rule, and I think from one of my associates,

7:28

that if I ever saw irregularity of the greater trochanter,

7:33

that one of the things I always have to consider

7:36

is tuberculosis.

7:38

So I've made that diagnosis

7:40

correctly and incorrectly at times.

7:44

The question that I have for you is,

7:47

is there a risk for septic arthritis of the hip

7:51

in these cases?

7:53

And is that a complication that you would be worried about?

7:58

<v ->I would be worried,

8:00

but it's actually not here in this case,

8:03

but the infection's very nearby the capsule

8:07

and the articular space.

8:09

There's some enhancement here.

8:13

I hope it's just reactive,

8:16

but I'm quite sure that if this abscess grows up

8:21

it will get the space

8:27

of the articular space.

8:28

So I'm quite concerned.

8:32

<v ->It's a beautiful case.