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School of MRI 2016 Advanced MR Imaging of the Musculoskeletal System
November 10-12, 2016 Menton/FR
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Apostolos Karantanas
Professor of RadiologyUniversity of Crete
akarantanas@gmail.com
HIP-PELVIS
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AIMS
1. How I perform, read and report a hip exam
2. Labral anatomy and pathology
3. Femoroacetabular impingement (& extraarticular)
4. Bone marrow edema: The many facesESMRMB
Pulse sequences
T1-w TSE coronal
Turbo STIR coronal
PD/T2-w TSE/FS axial
PD-w TSE/FS sagittal
FS 3D-T1 GRE or FS PD-w, oblique axial
MR scanner 1.5-3T, Phased array coil
1. MR technique and reporting
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3T
Better SNR and contrast resolution at the same acquisition time
Less MR arthrograms
Courtesy: Eracleous, CY
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Reporting:
1. Overall appearance of hip joints. Congenital dysplasia?
2. Femoral head sphericity
3. Articular cartilage
4. Labra: compare with clinical symptoms and physical examination
5. Bone marrow: exclude AVN, TOH. Quick look at SI joints.
6. Soft tissues: tendons, bursae, muscles (piriformis - quadratus femoris)
X-rays: Coverage: CE angle
Acetabular version: “8” sign
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• 0.8ml Gd-DTPA in 100ml normal saline
• 12ml of this solution are mixed to 5ml of non-
ionic iodinated contrast and 2ml lidocaine 1%
• 8-15 ml of solution, fluoroscopy, 22G needle
• MR arthrography within 30min
MR arthrography
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T1-w TSE+FS
single side, small FOV/high resolution
axial, sagittal, coronal,
oblique axial
Single axial PD-w TSE/FS
both sides
MR arthrography
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FAI
Trauma: acute, overuse
DDH
SFCE, LPC, OA, iliopsoas impingement
Labral pathology
Blenkenbaker DG, Tuite MJ. Magn Reson Imaging Clin N Am 2013
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Labral tear IIIAMRa
Labral tear IIAMRa
Windsurfing 20 y/o,m Mountain skiing 32 y/o, f
Plain MRI: sens 30%, acc 36%MR arthro: sens> 90%, acc> 91%, specificity ~100%
Czerny, Radiology 1996Freedman BA, et al. Artrhoscopy 2006
Toomayan GA, et al. AJR 2006
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Deficient acetabular coverage of the FH
hip instability OA
Anterolateral migration of the FH chronic stresses
at the acetabular rim
Enlarged labrum initially maintains the FH within the joint
Chronic shear stress labral tear
Developmental Dysplasia of the Hip
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Center-edge angle:
Quantifies coverage of the femoral head by the acetabulum
Abnormal <25° adults,
<20° children and adolescents
DDH
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CT/MRI measurements
Dysplastic AASA<50o m, PASA<90o
Normal
63o m, 64o f
105o
49f
42o
100o
105o
45o
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Overview Labra
Significant anatomic variation – age related changes
Tears cause hip mechanical pain MR arthro
Match the clinical info with lido-related pain reduction
Labral cysts: with/without tears, often related to DDH
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3. Impingement meaning
A painful syndrome due to abnormal contact of two
distinct anatomic structures at motion
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Impingement syndromes
Intra-articular
• Femoroacetabular
• Cam type
• Pincer type
• DDH
Extra-articular
• Ischiofemoral
• Snapping internal type
• Iliopsoas imp. S.
• Snapping extenral type
• Iliotibial band imp. S.
• SubspineESMRMB
• Predictor of early onset hip OA
• Wagner S, et al. Osteoarthritis Cartilage 2003
• Ganz R, et al. Clin Orthop 2003
• Beck M, et al. J Bone Joint Surg Br 2005
• Patterns of labral and chondral injury from FAI
appear to be unique to its distinct type
• Lavigne M, et al. Clin Orthop 2004
Established knowledge FAI
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CAM FAI“Pistol grip” deformity
Abnormal FH-neck offset associated with FAI
Premature OA
MR artrhography
AS acetabular cartilage degeneration-tear
AS labral tear
Abnomral alpha angle
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How to use alpha angle?
• “Moderate evidence that a angle at baseline is
associated with progression of FAI to labral tear”
• “Ro measurements are best used in combination
with pt Hx and clinical findings to determine
prognosis and plan of care”
• Wright AA, et al. J Sci Med Sport 2014
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Herniation pit fibrocystic changes
• 33% Leunig et al, Radiology 05
• 24%, James et al, AJR 06
• 21%, Pfirrmann et al, Radiology 06
• 15%, Gerguis et al, Skeletal Radiol 05
• 5%, Kassarjian et al, Radiology 05
Leunig M, et al. Radiology 05
Pfirrmann CW, et al. Radiology 06
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Pincer FAI
Kassarjian, et al. Radiology 2005
R L
• Repetitive contact anterosuperiorly• Labral degeneration/tear• +/- intralabral cysts or ossification• Acetabular cartilage lesions superiorly, smaller than in CAM• Contre-coup chondral lesions
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To sum up
• FAI: cam -pincer: OA
• Labral and chondral degeneration and tear:
prompt diagnosis
MR arthrographyESMRMB
IFI syndrome
Taneja AK, et al. MRI Clin N Am 13
First described in 1977 (Johnson KA. JBJS Am)
Pain due to narrowing of the space between the l.
trochanter and ischial tuberosity
Entrapment of the quadratus femoris m.
Two types
Primary of congenital
Secondary or acquired
Tumors, hematoma,
apophysitis, myositis
ossificans
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Track athlete, 14fPain 1yBilateral ischiofemoral impingement syndrome
Edema
Weekend athlete, 44f
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Elite athletes
Artistic Gymnastics
62.5%
Asymptomatic !!!!!
Papavasiliou A, Bintoudi A, Karantanas ASkeletal Radiol 2014
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Snapping hip syndrome
• External
• Iliotibial band
• Internal or anterior
• Iliopsoas tendon
48 m, long distance runner, pain right
16 m, elite sailor
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4. What does BME represent?
• Oedema
• Haemorrhage
• Necrosis
• Inflammation
• Better to use the term
Bone marrow “edema-like”
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Bone marrow “oedema”: MRI findings
• Low SI on T1-w
• High SI on FS PD/T2-w, STIR
• Enhancement on fat suppressed T1-w
Impossible with
oedema alone
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TRANSIENT BONE MARROW OEDEMA SYNDROME
(TRANSIENT OSTEOPOROSIS OF THE HIP)
• Acute disabling hip pain - functional disability
• Curtiss-Kincaid, 3d trimester pregnancy (JBJS am 1959)
• TOH introduced by Lequesne (Ann Rheum Dis 1968)
• Wilson: “acute bone marrow edema”, pts (-) X-Rays
(Radiology 1988)
• Middle-aged men - pregnant women (M/F:3-4/1)
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Transient osteoporosis
X-Rays: (+) in 3-8 w from onset
Scintigraphy / MRI: early diagnosis
pain l. hip, 7w
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TRANSIENT BONE MARROW OEDEMA SYNDROME
(TRANSIENT OSTEOPOROSIS OF THE HIP)
• Clinical course: up to 4 to 9 m, rapid aggravation of pain and
functional restriction of the hip during the 1st month after onset
• All cases are self-limited, WB protection, pain killers
• Histology: BME, inflammation, bone desorption and
formation, No necrosis (Berger CE et al. Bone 03; Karantanas AH. Eur Radiol 2007)
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TO hip, 55y male
Malizos KN, Karantanas AH. EJR 04 Peak enhancement > 40s
STIR
T1CE-FS T1
FS T2-w
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Fat-suppressed contrast-enhanced T1-w
“Oedema like” area enhances
Synovitis and joint fluid: constant findings
Transient osteoporosis
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Subchondral lesions
50%
Occult epiphyseal stress or
insufficiency fractures
University of Crete
Transient osteoporosis
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• “sparing” sign
• 90% at diagnosis, disappears with disease progression
• 20% migratory pattern
Transient osteoporosis
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Regional Migratory Osteoporosis
• First described by Duncan in 1969
• Arthralgia migrating in other joints or the same joint
• Weight bearing joints lower appendicular skeleton
• Clinical findings, x rays, MRI: similar to TOH
• Migration proximal to distal, intervals up to 9 months
• All cases transientESMRMB
April 06
June 06
Aug 07
Oct 07
35 male
?? Systemic osteopenia
21/22 males*
* Karantanas AH, et al.
Eur J Radiol 08
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Transient osteoporosis:
early reversible avascular
necrosis??
Definitely not!!!!
TOH is a distinct clinical entity
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Avascular necrosis
Young adults
Deterioration despite treatment
Femoral head common location
Subchondral fractures, progressive arthropathy
following collapse of the articular surface
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Pain and AVN
Marrow oedema
Collapse
Joint effusion
Never before “bands”, result of collapse
T1-w
Symptomatic
Karantanas AH.
Expert Opin Med Diagn. 2013
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We discussed
• 1. How to perform and report a hip MRI exam
• 2. The labral anatomy and pathology
• 3. The FAI and other impingement syndromes
• 4. The many faces of HIP BME syndromesESMRMB
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