“plain radiograph and mr evaluation of painful hip...
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.
“PLAIN RADIOGRAPH AND MR
EVALUATION OF PAINFUL HIP JOINT”
BY
Dr. PRUDHVINATH REDDY .A. M.B.B.S.
Dissertation submitted to the
Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.
In Partial fulfillment of the requirements for the degree of
DOCTOR OF MEDICINE
IN RADIO-DIAGNOSIS
Under the guidance of Dr. JEEVIKA M.U. M.D.,
PROFESSOR
DEPARTMENT OF RADIO-DIAGNOSIS J.J.M. MEDICAL COLLEGE
DAVANGERE – 577 004.
2013
vi
ACKNOWLEDGEMENT
It is most appropriate that I begin by expressing my undying gratitude to
the ALMIGHTY GOD for giving me the strength both mentally and physically
to complete this task.
It gives me immense pleasure to express my deepest gratitude and
sincere thanks to my teacher and guide Dr. JEEVIKA M.U. M.D., Professor,
Department of Radio-Diagnosis, J.J.M. Medical College, Davangere for her
guidance, valuable advice, constant support and encouragement during the
entire course of the study, which helped me to complete my dissertation work.
I am indebted to Dr. J. PRAMOD SETTY M.D., Professor and Head,
Department of Radio-Diagnosis, J.J.M. Medical College, Davangere, for
preparing me for this task, guiding me with his superb talent and professional
expertise, showing great care and attention to details and without his
supervision and guidance this dissertation would have been impossible.
My special thanks and gratitude to Dr. K.N. SHIVAMURTHY M.D.,
D.M.R.D., Dr. KIRAN KUMAR .S. HEGDE M.D., Dr. BHAGYAVATHI
M.D., Dr. NAVEEN .S. MARALAHALLI M.D., and Dr. SIDDESH M.D.,
for their timely suggestions and constant encouragement.
My sincere thanks to Dr. MANJUNATH ALUR M.D., Principal
Dr. GURUPADAPPA, Director of Post Graduate studies, J.J.M. Medical
College, Davangere for their constant help and inspiration.
viii
LIST OF ABBREVATIONS USED
AP view : Antero-posterior view
AVN : Avascular necrosis
DDH : Developmental dysplasia of hip
FSE : Fast spin echo
GRE : Gradient echo
JRA : Juvenile rheumatoid arthritis
LCP : Legg-Calve-Perthes
mFFE : Multiecho fast field echo
MRI : Magnetic resonance imaging
OA : Osteoarthritis
PD : Proton density
STIR : Short tau inversion recovery
TB HIP : Tuberculosis of hip
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ABSTRACT
Background and Objectives:
Hip joint pain is a common complaint in the present day practice and
could be due to various reasons, as the investigations are invariably used to
come to a diagnosis of the cause of pain. Plain radiographs are used as primary
investigation followed by MRI which is a valuable tool in the evaluation of hip
disorders, because it enables accurate assessment of articular cartilage,
epiphyses, joint fluid, bone marrow and extra-articular soft tissues that can be
affected by hip disease. MR imaging is the modality of choice when clinical
examination is suspect for hip disease and plain radiographs are normal or
equivocal. Early diagnosis and treatment is important in many of the disorders.
Materials and Methods:
A prospective cross sectional study is done on a total of 50 patients
including both the sexes and of all age groups who presented with hip joint
pain and subsequently underwent plain radiographs followed by MRI of the hip
joint. The data is analysed and the findings on plain radiographs correlated with
that of MRI.
Results:
Of the 50 cases the males (70%) are commonly affected than females
(30%). Majority of the patients fall under the age group of 31-40 years (28%).
In our study we find the commonest pathology for the hip joint pain is AVN of
femoral head 16 cases (32%), followed by joint effusion 12 cases(24%),
Osteoarthritis 10 cases(20%), TB hip 6 cases (12%), Perthes 2 cases (4%),
DDH 2 cases (4%) and metastatic disease 2cases (4%). Out of 16 cases of AVN
only 4 (25%) cases are detected on plain radiograph where as all the 16 cases
(100%) are diagnosed on MRI. Similarly out of 12 cases diagnosed as joint
effusion only 4cases (33%) are detected on plain radiograph, but all the 12
cases (100%) are detected on MRI. Rest of the pathologies are detected 100%
both on X-ray and MRI however, MRI helps in better delineation of articular
cartilage, epiphyses and extra articular soft tissue abnormalities.
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Conclusion:
The hip is a stable, major weight-bearing joint with significant mobility.
In adults, hip pain may be caused by intraarticular disorders such as avascular
necrosis, arthritis, joint effusion, tuberculosis and metastatic disease. In
children common pathologies include DDH, Perthes disease and infections like
tuberculosis.
Plain radiography is a widely established, economical investigation
readily available in all kinds of health setups for imaging the hip joint. Plain
film radiography is used in the initial evaluation of any cause of hip pain. Plain
film may not detect early pathologies like AVN, also cannot accurately
characterize the articular cartilage pathology and soft tissue involvement.
MRI of the hips should be performed early in patients with persistent
pain and negative radiography findings. MR imaging is a valuable tool in the
evaluation of hip disorders because it enables assessment of articular cartilage,
epiphyses, joint fluid, bone marrow and extra-articular soft tissues structures
that can be affected by hip disease. MRI is an imaging technique that does not
require exposure to radiation. MR imaging is the modality of choice when
clinical examination is suspect for hip disease and plain radiographs are normal
or equivocal. Early diagnosis and treatment is important in many of the
disorders.
Key words: Plain radiograph, MRI, Hip joint, Tuberculosis of hip, Bone
marrow edema, Arthritis, Perthes disease, DDH, Avascular necrosis of hip.
xi
TABLE OF CONTENTS
TOPICS PAGE NO.
1. INTRODUCTION 01
2. OBJECTIVES 04
3. REVIEW OF LITERATURE 05
4. METHODOLOGY 47
5. PHOTOGRAPHS 50-56
6. RESULTS 57
7. DISCUSSION 70
8. CONCLUSION 79
9. SUMMARY 81
10. BIBLIOGRAPHY 83
11. ANNEXURES
• PROFORMA 90
• INFORMED CONSENT 92
• MASTER CHART 93
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LIST OF TABLES
SL. NO. TABLES PAGE
1 Sex distribution 57
2 Age wise distribution 58
3 Pathology 59
4 AVN 60
5 X-ray findings 60
6 MRI Findings 60
7 Joint effusion 62
8 On MRI joint effusion 62
9 X-ray findings 64
10 MRI findings 64
11 TB hip joint 65
12 X-ray findings 66
13 MRI findings 66
14 X-ray findings 67
15 MRI findings 67
16 X-ray findings 68
17 MRI findings 68
18 X-ray findings – Metastasis 69
19 MRI findings – Metastasis 69
xiii
LIST OF GRAPHS
SL. NO. LIST OF GRAPHS PAGE NO.
1 SEX DISTRIBUTION 57
2 AGE WISE DISTRIBUTION 58
3 AVN ON X-RAY 61
4 AVN ON MRI 61
5 JOINT EFFUSION ON X-RAY 62
6 JOINT EFFUSION ON MRI 62
7 OSTEO ARTHRITIS 63
8 TB HIP JOINT 65
9 PERTHE'S 67
10 DDH 68
11 METASTASIS 69
xiv
LIST OF PHOTOGRAPHS
SL. NO. PHOTOGRAPHS PAGE
NO 1 Hip joint 14 2 Articular surfaces 14 3 Ilio-femoral and ischio-femoral ligaments 15 4 Ischio-femoral ligament 16 5 Ilio-femoral and pubo-femoral ligament 17 6 Acetabulum 18
7 Transverse acetabular ligament and ligament of head of femur 19
8 Synovial membrane 20 9 Blood supply to the head of the femur 21 10 Cruciate anastomosis 21 11 Anteroposterior radiograph of the pelvis 25 12 Frog-leg lateral radiograph of the pelvis 25 13 AP radiograph showing major trabeculae 26
14 AP radiograph of pelvis showing iliopectineal line (large white arrow) and ilioischial line (small white arrow) 27
15 The anterior (black arrow) and posterior (white arrow) walls of the acetabulum 27
16 The gluteus minimus fat stripe (small white arrow), obturator internus fat stripe (large white arrow), and iliopsoas fat stripe(black arrow)
29
17 STIR coronal image showing bilateral normal hip joints 30 18 PD sagittal image of normal hip joint 30 19 T2W axial image showing normal hip joints bilaterally 31
20 T2W and STIR coronal images demonstrating Conversion to yellow marrow in apo- / epiphysis of the femur in 1styear
31
21 FICAT and ARLET classification of AVN of femoral head 33 22 Diagram of hip joint as seen on frontal radiograph of pelvis 41
23 Diagram demonstrating the Shenton line, Perkin line, Hilgenreiner line and acetabular index in normal Hip and Dislocated hip
43
1
INTRODUCTION
Imaging of the hip was among the earliest reported applications of
musculoskeletal magnetic resonance (MR) imaging. MR imaging is a valuable
tool in the evaluation of hip disorders because it enables assessment of articular
structures, extra-articular soft tissues, and the osseous structures that can be
affected by hip disease1. In the setting of chronic hip pain, a normal-appearing
radiograph, a nonspecific history and clinical findings can be a difficult
diagnostic dilemma. Trauma, infection, arthritis, avascular necrosis, tumor, and
hip dysplasia can all manifest with extremely subtle radiographic
abnormalities.
The principal benefit of the true coronal and axial planes is that they
provide symmetric, bilateral images, which can be important in the diagnosis
and can greatly accelerate the time required to evaluate both hips. Normal hip
anatomy can be routinely demonstrated on coronal and axial MR images. The
femoral head and neck and the intertrochanteric region are best appreciated on
coronal MR images. Axial MR images provide good visualization of the
articular space, hip musculature, and supporting ligaments2.
The diagnostic role of MR imaging in the evaluation of AVN is
evolving. MR imaging is performed to detect AVN in its early stages, thus
allowing early treatment and prevention of subsequent bone destruction. MR
imaging has been shown to be the most sensitive modality for imaging AVN.
Screening of asymptomatic, high-risk patients may enable early intervention.
The principal role of MR imaging is in establishing the diagnosis of AVN in
symptomatic patients before radiographic changes become apparently visible.
2
MR imaging is becoming increasingly useful in the diagnosis and
management of pediatric hip disorders. MR imaging offers several advantages
that are especially important in the pediatric population. Because much of the
pediatric hip is cartilaginous, it is often not optimally imaged with other
modalities such as plain radiography, ultrasound (US) (after 6 months of age),
and computed tomography (CT). MR imaging is unique in its ability to depict
cartilage and is, therefore, especially efficacious in the evaluation of the
pediatric hip2.
A major concern in the juvenile hip is normal development, which is
dependent on proper seating of the femoral head in the acetabulum. The
position and shape of the femoral head should be precisely assessed with
multiplanar MR imaging. Also, changes in bone marrow can be directly
visualized with MR imaging; this is not possible with CT or US.
MR imaging has played an increasingly important role in the evaluation
of the arthritides. The most common form of arthritis in children is juvenile
rheumatoid arthritis (JRA). MR imaging is uniquely capable of depicting the
soft-tissue abnormalities that occur in JRA, including synovial inflammation,
joint effusion, and articular cartilage destruction.
In sarcoidosis patients with musculoskeletal complaints, MRI reveals
marrow and soft-tissue lesions that are occult or underestimated on
radiographs.
Most disorders classified as dysplasia can be readily diagnosed with
plain radiography; thus, MR imaging is rarely employed in the routine work-up
of patients with bone dysplasias.
3
MR imaging can be useful in the evaluation of a variety of hip disorders.
We believe that attention to the details of MR examination technique and
imaging protocol is essential for maximizing the diagnostic potential of MR
imaging in the work-up of hip disease. Specific protocols that incorporate
surface coil imaging, oblique image acquisition, and alternative pulse
sequences are the foundation for successful hip studies. The use of GRE
sequences is essential in the evaluation of cartilaginous disorders, particularly
in pediatric hip disease2.
Currently, high-resolution direct MR imaging of the hip provides the
best means for evaluating intra-articular pathology. However, radiography
remains important for the diagnosis of subtle bony irregularities associated
with femoroacetabular impingement. Therefore, a comprehensive imaging
strategy requires conventional radiographs and MRI to evaluate intra- and
extra-articular sources of pain.
4
OBJECTIVES OF THE STUDY
• To estimate the role of MRI in early evaluation of painful hip joints with
subtle plain radiographic findings.
• To establish a differential diagnosis of the various painful hip joint
conditions on MRI.
• To assess the severity and extent of the underlying lesion in various
conditions of painful hip joint.
5
REVIEW OF LITERATURE
Thirty-four patients who complained of hip pain were studied
consecutively. After clinical assessment of possible hip disease, plain
radiograph and MRI study of both hips were performed. Unilateral hip
involvement was identified in 31 patients (91.2%), and bilateral hip
involvement was found in three patients (8.8%), with a total of 37 hips
evaluated by MRI. The final diagnoses in our patients were: reactive arthritis
(1), transient osteoporosis (7), avascular necrosis (10), osteoarthritis (2),
tuberculous arthritis (4), septic arthritis (2), osteomyelitis (2), sickle cell
anemia (2), lymphocytic leukemia (1), and femoral stress fracture (3). Bone
marrow edema affecting the hip is neither a specific MR imaging finding nor a
specific diagnosis and may be encountered in a variety of hip disorders due to
different etiologies. MR imaging is the modality of choice when clinical
examination is suspect for hip disease and plain radiographs are normal or
equivocal. Early diagnosis and treatment is important in many of the disorders3.
Thirty-six hips were studied because of significant hip pain.
Radiography of the hip showed subtle changes. Twenty-nine hips had a single
lesion, including: infection (one), fracture (eight), avascular necrosis of the
femur (two), or contralateral hip (four), transient osteoporosis (six),
osteoporosis (one), post-irradiation myositis (one), metastasis (four), and
synovitis (two). Twenty-six lesions (89.6%) appeared normal on the
radiographs of the hip, while three lesions (10.4%) showed only osteoporotic
change. Another seven hips had more than one lesion, including: avascular
necrosis and fracture (four), fracture foci (two), and metastasis and fracture
(two). Radiography of the hip showed either a negative finding or detected only
6
a single lesion, missing other important pathologic foci. MRI is extremely
sensitive to alterations in the bone marrow that may represent pathology occult
to plain radiography of the hips. For diagnosis and treatment planning, MRI of
the hips should be performed early in patients with persistent pain and negative
radiography findings4.
In a study, both a limited and a full hip MR examination were performed
prospectively in 179 hips in 92 patients with clinical suspicion of femoral head
osteonecrosis. The percentage of involvement of the femoral head weight-
bearing surface was evaluated subsequently for osteonecrosis-positive hips on
both sets of images. Agreement between the limited and full examinations for
presence of osteonecrosis was 98.9% (177 of 179 cases; k, 0.97). Forty-six
(92%) of 50 patients with femoral head osteonecrosis at both examinations
were placed in the appropriate quartile of percentage of femoral head weight-
bearing surface involvement by both readers (weighted k, 0.94). There was
excellent agreement between the full and screening MR examinations for both
detection of and determining the extent of osteonecrosis. The time and potential
cost reduction achieved with a limited examination may allow introduction of
MR imaging earlier in the diagnosis of femoral head osteonecrosis, as well as
its more widespread use in patient care5.
MR images in 36 hips with documented avascular necrosis and 80 hips
without evidence of joint disease were studied to determine the amount and
appearance of fluid in the joint. All MRI examinations were done on a 1.5-T
machine and included coronal images made with relative T2 weighting
(repetition times = 2000-2500 msec, echo delays = 60-100 msec). The amount
of joint fluid, which had an intense signal higher than that of fat was graded
7
from 0 to 3 and analyzed with respect to the patient's age and radiographic
stage of avascular necrosis. Joint fluid, was seen in 84% of presumed normal
hips. Only four (5%) of 80 had enough fluid to surround the femoral neck
(grade 2), and none had sufficient fluid to distend the joint capsule (grade 3). In
comparison, 21 (58%) of 36 hips with avascular necrosis had grade-2 or grade-
3 effusions (p less than 0.005), and some fluid was seen in all. Grade-3
effusions were seen in seven (50%) of 14 hips with flattening of the femoral
head, compared with only one (5%) of 20 in which the femoral contour was
normal. It is concluded that small amounts of fluid are present in both normal
hips and those with avascular necrosis. In avascular necrosis, increased joint
fluid may be present before radiographic abnormalities occur, but it is greatest
after there is flattening of the femoral head. MRI is a highly sensitive method
for detecting fluid in the hip joint6.
In a study to determine the occurrence of bone marrow edema and joint
effusion and their relationship to pain in patients with osteonecrosis of the
femoral head on the basis of MR imaging. There were 71 patients with
osteonecrosis of the femoral head based on characteristic radiographic and MR
imaging findings. Both hips were affected with osteonecrosis in 39 patients,
whereas only one hip was involved in 31 patients. We evaluated a total of 110
hips in this study, of which 98 were painful. We staged osteonecrosis of the
femoral head, using the classification of Steinberg et al. The 31 unaffected hips
served as controls. Bone marrow edema and joint fluid were evaluated on MR
images. Bone marrow edema, was defined as an ill-defined area of low signal
intensity on Tl-weighted images with corresponding high signal intensity on
T2-weighted or inversion recovery images localizing to the femoral head, neck
8
and intertrochanteric region. The amount of joint fluid was graded from 0 to
3.The peak of bone marrow edema occurred in stage III disease (72%); its odds
ratio was seven times greater than that for stage I osteonecrotic hips. Effusions
of a grade greater than or equal to 2 were seen most often in stage III disease
(92%), compared with 10% in the control hips. With an effusion, bone marrow
edema was 12.6 times greater when the hip was painful than when it was not.
Both bone marrow edema and joint effusions existed with a peak occurrence in
stage III disease. Bone marrow edema seems to have a stronger association
with pain than that of joint effusion in osteonecrosis of the femoral head7.
In 12 children with advanced Legg-Calve'-Perthes disease,
multipositional MR imaging and conventional arthrography were compared in
the assessment of containment, femoroacetabular congruency, and femoral head
deformity. MR imaging correlated well with arthrography for overall subjective
assessment of severity of disease (r 0.71, P .01), with good interobserver
agreement (0.65P.001). MR images demonstrated all cases of hinge abduction
shown arthrographically. MR imaging correlated well with arthrography in the
objective evaluation of joint fluid and lateral subluxation (r 0.80, P 0.01). MR
imaging was comparable to arthrography for demonstration of femoral head
containment and congruency of the articular surfaces of the hip. In the
evaluation of deformity, it performed well8.
The efficacy of magnetic resonance imaging (MRI) in the assessment of
pediatric hip disease was tested by scanning the hips of 24 children (30 scans).
Twelve patients with Legg-Calve-Perthes disease (17 hips) showed
characteristic areas of low-intensity signal representative of necrotic areas of
the capital epiphysis. Abnormal scans were also obtained on patients with
9
transient synovitis, avascular necrosis secondary to steroids, epiphyseal
dysplasia, and multiple osteochondromatosis. MRI accurately shows articular
cartilage, femoral head shape, quality of containment, and areas of necrosis in
pediatric hips. The extent of involvement and revascularization can be
identified in Legg-Calve-Perthes disease9.
Twenty-six patients aged 1.6 to 15.2 years (mean: 6.5 years) were
clinically selected for the study; at clinics, all patients had persistent hip pain
after 10 days' therapy. All patients were examined with radiography, US and
MRI at 0.5 T. SE Tl-weighted sequences, with and without fat suppression
(FS), SE T2-weighted and gradient echo (GE) Tl-weighted-like (Tl*) sequences
were acquired on the coronal plane. Slices were 5 and 3 mm thick on SE and
GE Tl* sequences, respectively. Morphology and signal intensity of epiphysis,
growth plate and metaphysis were prospectively studied with MRI. Clinical
and/or imaging follow-up (3 months) was the reference standard in our study.
Final diagnoses were: no evidence of alteration (n = 3), transient synovitis (n =
6), rheumatic fever (n = 3), Perthes' disease (n = 7), Meyer's dysplasia
(dysplasia epiphysealiscapitisfemoris, DECF) (n = 2), early slipped capital
femoral epiphysis (n = 2), incomplete fracture (n = 1), extraarticular cause of
pain (muscular abscess, osteomyelitis) (n = 2). In 23 of 26 patients MRI
confirmed clinical, radiographic and US findings. MRI was particularly helpful
in making an unquestionable diagnosis in the other 3 cases; in a patient with
suspected slipped capital femoral epiphysis MRI revealed an incomplete
fracture, in a patient with suspected Meyer's dysplasia MRI revealed early
Perthes' disease and finally in a patient with suspected transient synovitis MRI
revealed Perthes' disease. To conclude, MRI allows the condition causing
10
persistent hip pain to be assessed and accurately depicted, integrating clinical,
radiographic and US findings and in some cases also changing diagnosis and
therapy10.
Fifty nine children were examined by MR, including 31 with Perthes'
disease, 7 with subluxating Perthes' disease and 12 with hip pain of unknown
origin; the results were compared with conventional radiological findings. MR
was superior for the early recognition and for the exact determination of the
extent and localization of juvenile femoral epiphyseal necrosis. It was also of
great help in differential diagnosis. It appears to be a suitable method for
judging the effect of therapy at an early stage11.
The MRI findings in nine patients with septic arthritis and 11 with
transient synovitis were reviewed retrospectively. The MRI findings were
analyzed with emphasis on the grade of joint effusion, alterations in signal
intensity in the soft tissues and bone marrow, and the presence of decreased
perfusion at the femoral head. Low signal intensity on fat-suppressed
gadolinium-enhanced Tl-weighted coronal MRI suggesting decreased perfusion
at the femoral head of the affected hip joint was seen in eight of nine patients
with septic arthritis and in two of 11 patients with transient synovitis.
Statistically reliable differences (p = 0.005) were found between the two
groups. Alterations in signal intensity in the bone marrow were seen in three
patients with septic arthritis but in none of the patients with transient synovitis.
Decreased perfusion on fat-suppressed gadolinium-enhanced coronal T1-
weighted MRI was seen in the six patients with septic arthritis who did not
have alterations in signal intensity involving the bone marrow. Decreased
perfusion at the femoral epiphysis on fat-suppressed gadolinium-enhanced
11
coronal T1-weighted MRI is useful for differentiating septic arthritis from
transient synovitis12.
Clinical findings and MR images of 49 patients with transient synovitis
(male/female 36/13, mean age 6.1 years) and 18 patients with septic arthritis
(male/female 10/8, mean age 4.9 years) were retrospectively reviewed. MR
findings of transient synovitis were symptomatic joint effusion, synovial
enhancement, contralateral joint effusion, synovial thickening, and signal
intensity (SI) alterations and enhancement in surrounding soft tissue. Among
these, SI alterations and enhancement in bone marrow and soft tissue,
contralateral joint effusion, and synovial thickening were statistically
significant MR findings in differentiating transient synovitis from septic
arthritis. The statistically significant MR findings in transient synovitis are
contralateral (asymptomatic) joint effusions and the absence of SI
abnormalities of the bone marrow. It is less common to have SI alterations and
contrast enhancement of the soft tissues. The statistically significant MR
findings in septic arthritis are SI alterations of the bone marrow, and SI
alterations and contrast enhancement of the soft tissue. Ipsilateral effusion and
synovial thickening and enhancement are present in both diseases13.
The results of magnetic resonance (MR) imaging in six patients with
transient osteoporosis of the hip were reviewed. Short TR/TE (repetition
time/echo time) images demonstrated diffusely decreased signal intensity in the
femoral head and intracapsular region of the femoral neck. Increased signal
intensity was noted with progressive T2 weighting. Bone biopsies were
performed in four patients. Histologic findings were nonspecific and included
fat necrosis, marrow edema, increased bone resorption, and reactive bone
12
formation. Repeat MR scans in two patients, performed six and eight months
after the initial scans, showed an almost complete return to normal marrow
signal. All patients became asymptomatic without bony deformity. In the
appropriate clinical setting, MR scanning can aid in the diagnosis of transient
osteoporosis as the cause of a painful hip14.
In the first phase of the study by Robinson HJ Jr et.al, forty-eight
patients (ninety-six hips) who were at high risk for avascular necrosis were
studied. Abnormal patterns on magnetic resonance imaging, consistent with
those seen in necrosis, were found in all hips that were suspected of having
Ficat Stage-2 or 3 changes on the basis of radiographic evidence of the disease.
Abnormal patterns on magnetic resonance imaging that were characteristic of
avascular necrosis were also observed in 17 per cent of the hips that were
suspected of having Ficat Stage-0 changes and in 64 per cent of those that
showed Stage-1 changes, all with no radiographic changes. In the second phase
of the study, twenty-three of the ninety-six hips that were suspected of having
early-stage necrosis of the femoral head but showed slight or no radiographic
changes were studied by repeat radiographs, Ficat functional evaluations of
bone, core biopsies of the femoral head, and magnetic resonance imaging. Of
the twenty-three hips, eighteen (78 per cent) had positive changes on magnetic
resonance imaging; nineteen (83 per cent) had positive histological evidence of
necrosis; and fourteen (61 per cent) had positive findings by bone-marrow
pressure studies and intramedullary venography. Although false-negative and
false-positive results were observed with magnetic resonance imaging, the
over-all results of this study suggest that magnetic resonance imaging may be
useful for the early diagnosis of avascular necrosis.15
13
Magnetic Resonance Imaging (MRI) and conventional radiographs were
compared in 49 hips with Avascular Necrosis (AVN). MRI detected AVN in
25% of the hips during the preradiological stage of the disease. Both MRI and
conventional radiographs accurately detected AVN in the remaining 75% of
hips. Correlation between the patterns observed with the two techniques
reflected the underlying histopathologic events. The reactive interface between
infarcted bone and viable bone could be identified on MRI as a low signal
intensity (SI) band. On conventional radiographs the reactive interface
appeared as a sclerotic band. The adjacent hyperemic zone was seen on MRI as
a high SI band and as a lucent zone on the plain films. Variations of this pattern
occurred as related to the extent and duration of AVN and to the individual's
ability to mount a healing response. Minor degrees of collapse of the femoral
head were better identified with plain radiographs but MRI demonstrated small
areas of hyperintensity probably corresponding to early subchondral
fractures.16
14
NORMAL ANATOMY OF HIP JOINT
Fig.1 : Hip joint
The hip joint is the uppermost joint of the lower extremity. The hip joint
is a ball and socket joint, with the rounded convex femoral head articulating
with the acetabulum of the hip bone.17 The joint consists of the femur, oscoxae
(hip bone), joint capsule and its corresponding ligaments, tendons and muscles.
Fig. 2: Articular surfaces
Bones:
Iliu
ischium an
Lik
three ligam
pubofemor
the femur j
Fibrous ca
The
ascend alo
both the
anterosupe
hip joint c
fibers form
Proximal:
labrum and
um, Ischium
nd ilium bo
ke all syno
ments that
ral and isc
joined with
apsule of h
e capsule o
ong the nec
femoral he
eriorly, the
onsists of t
m the intern
: attached
d transvers
Fig.3 :
m, Pubis, F
ones.
ovial joints
t reinforce
chiofemora
h the hip b
hip joint:
of hip join
ck as long
ead and n
e region of
two types o
nal part wh
at the mar
se acetabul
: Ilio-femo
15
Femur, Th
s the hip j
e it. The
al. These th
one.
nt is stron
itudinal re
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f maximal
of fibers: C
hile longitu
rgin of ac
ar ligamen
oral and is
e acetabul
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three liga
hree ligam
ng and tou
etinacula, c
capsule o
stress. Gro
Circular an
udinal fiber
etabulum,
nt
chio-femo
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a fibrous j
aments are
ments help
ugh. Anteri
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of the hip
ossly, the f
nd Longitud
rs form the
outer surf
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med by the
oint capsu
e the iliof
keep the h
iorly many
blood ves
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etabular
16
Distal: Attach at the intertrochanteric line (ant.) and medial 1/3 of femoral
neck (post.)
Fig.4: Ischio-femoral ligament
Ligaments of hip joint:
Hip joint consists of five major ligaments as described below.
Iliofemoral ligament: It is like an inverted “Y” in shape and is very strong. It
lies towards the anterior side and is somewhat blended with the capsule of hip
joint. The base of the inverted “Y” is attached to anterior inferior iliac spine.
The two limbs of the inverted “Y” are attached to the upper and lower parts of
intertrochanteric line of femur.
Role: It prevents overextension during standing.
Pubofemoral ligament: It is triangular in shape with its base attached to the
superior ramus of the pubis. The apex is attached below to the lower part of the
intertrochanteric line.
17
Role: It limits extension and abduction.
Ischiofemoral ligament: It is spiral shaped and is attached to the body of
ischium near the acetabular margin. The fibers of this ligament pass upward
and laterally and are attached to the greater trochanter of femur.
Role: It limits extension.
Fig. 5 : Ilio-femoral and pubo-femoral ligament
Transverse acetabular ligament: It is formed by the acetabular labrum as it
bridges the acetabular notch. Thus the notch is converted into a tunnel through
which blood vessels and nerves enter the hip joint.
LigamentumTeres (Ligament of head of femur): It is flat and triangular in
form and is attached through its apex to the fovea capitis (pit in the head of
femur). The base of this ligament is attached to the transverse acetabular
ligament and margins of acetabular notch. This ligament lies within the joint
and is ensheathed by synovial membrane.
Role: It lim
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• Branch from obturator artery (ligament of head of femur)
• Medial and Lateral circumflex femoral artery.
Fig.9 : Blood supply to the head of the femur
Fig.10 : Cruciate anastomosis
22
Lymphatic drainage of hip joint:
The lymph vessels from front aspect drain to the deep inguinal nodes,
while those from the posterior and medial aspects run with the gluteal and
obturator arteries respectively to reach the internal iliac nodes.
Nerve supply of hip joint :
• Femoral nerve: nerve to rectus femoris.
• Obturator nerve: anterior division of lumbar plexus.
• Superior gluteal nerve: nerve to quadratus femoris.
Muscle Groups :
The various muscles which attach to or cover the hip joint generate the
hip’s movement.
• Gluteals: The gluteals are the muscles in buttocks. The gluteals (gluteus
maximus, gluteus minimus and gluteus medius) are the three muscles
attached to back of the pelvis and insert into the greater trochanter of the
femur.
• Quadriceps: The four quadricep muscles (vastus lateralis, medialis,
intermedius and rectus femoris) are located at the front of the femur. All
four attach to the top of the tibia. The rectus femoris originates at the
front of the ilium. The three other quadriceps attach around the greater
trochanter of the femur and just below it.
• Iliopsoas: This is the primary hip flexor muscle. The three parts of the
iliopsoas attach the lower part of the spine and pelvis, then cross the
joint and insert into the lesser trochanter of the femur.
23
• Hamstrings: The three muscles at the back of the thigh are called the
hamstrings. All three attach to the lowest part of the pelvis.
• Groin muscles: The groin or adductor muscles attach to the pubis and
run down the inside of the thigh.
Movements of hip joint:
Hip joint is a ball and socket type of joint, which is very mobile. Its
movements can be classified into the following categories:
• Flexion-Extension
• Adduction-Abduction
• Medial and Lateral Rotation
• Circumduction
Muscles producing movements:
Flexion: The primary muscles of flexion are Psoas major and Iliacus. They are
assisted by pectineus, rectus femoris and sartorius. The adductor longus also
assists in early flexion from full extension.
Extension: It is produced by the Gluteus maximus and hamstring muscles. The
hamstring muscles, which are powerful flexors of the knee, are equally strong
extensors of the hip joint. They largely control the posture of this joint. The
Gluteus maximus only becomes active when the thigh is extended against
resistance for instance in climbing.
Abduction: It is produced primarily by gluteus medius and minimus. Tensor
fasciae latae and sartorius assist them.
24
Adduction: It is produced by adductor longus, adductor brevis and adductor
magnus. The assistors of adduction include pectineus and gracilis.
Medial rotation: It is produced by tensor fasciae latae and anterior fibers of
gluteus minimus and medius. It is relatively weak in strength.
Lateral rotation: It is produced by the obturator muscles, the two gemelli and
quadratus femoris. The assistors include piriformis, gluteus maximus and
sartorius. It is much more powerful as compared to medial rotation.
Circumduction: It is a combination of above movements with all muscles
involved in it.
PLAIN RADIOGRAPHIC ANATOMY:
The complex anatomy of the pelvis and the often subtle but significant
radiographic findings can be challenging to the radiologist. A sound
understanding of the standard radiographic techniques, normal anatomy, and
patterns of disease affecting the pelvis can be helpful in accurate diagnosis.18
Commonly used radiographic projections are, AP view of the hip, and
frog-leg lateral (Dan Miller) view of the hip.
The AP radiograph of the hip (fig.11) is taken with the patient supine,
and both feet in approximately 15° of internal rotation. This reduces the normal
25 to 30° femoral anteversion, allowing better visualization of the femoral
neck.19
The frog leg lateral view (fig.12) is performed with the patient supine,
feet together, and thighs maximally abducted and externally rotated.20 The
radiographic tube is angled 10 to 15° cephalad, directed just above the pubic
symphysis.20 The anterior and posterior aspects of the femoral neck, as well as
25
the lateral aspect of the femoral head, are seen with this projection. The frog
leg lateral view is performed with the patient supine, feet together, and thighs
maximally abducted and externally rotated.20 The radiographic tube is angled
10 to 15° cephalad, directed just above the pubic symphysis.20 The anterior and
posterior aspects of the femoral neck, as well as the lateral aspect of the
femoral head, are seen with this projection.
Fig.11: Anteroposterior radiograph
of the pelvis. Fig.12: Frog-leg lateral radiograph
of the pelvis.
The pelvis is composed of three bones, the ilium, ischium, and pubis, all
of which contribute to the structure of the acetabulum. The ilium is composed
of a body and a large flat portion called the iliac wing.21 The body forms with
the bodies of the ischium and pubis, the roof of the acetabulum.
The pubis is composed of a body and two rami.19 The pubic body fuses
with the iliac and ischial bodies to form the anterior border of the acetabulum.
The proximal femur can be divided into the femoral head, femoral neck,
trochanters, and femoral shaft. The fovea is seen at the medial aspect of the
femoral head.21 The femoral head is normally angulated approximately 125 to
135° with respect to the long axis of the femoral shaft, and anteverted
26
approximately 25 to 30°.21 The major trabeculae of the proximal femur are well
demonstrated on the AP radiograph.19 Long, arc-shaped trabeculae extending
from the femoral head to the intertrochanteric ridge are the principal tensile
trabeculae, while the principal compressive trabeculae are more vertically
oriented, coursing along the medial aspect of the femoral neck.21
Fig. 13 : AP radiograph showing major trabeculae
Lines L :
On the standard AP view of the pelvis, the iliopectineal line (also called
the iliopubic line) extends from the medial border of the iliac wing, along the
superior border of the superior pubic ramus19 to end at the pubic symphysis.
This line is seen as the inner margin of the pelvic ring and defines the anterior
column of the pelvis. This line may be thickened in patients with Paget
disease22.
The ilioischial line also begins at the medial border of the iliac wing and
extends along the medial border of the ischium19 to end at the ischial
tuberosity. This defines the posterior column of the pelvis.
27
The anterior rim of the acetabulum is seen as the more medial of two
obliquely oriented arc-shaped lines on the AP view19. The anterior acetabular
rim is seen well in profile on the 45-degree posterior oblique view19. The
posterior rim of the acetabulum is the more lateral arc-shaped line on the AP
radiograph and is seen well in profile on the 45-degree anterior oblique view.19
The teardrop represents a summation of shadows of the medial
acetabular wall23. Teardrop distance is measured from the lateral edge of the
teardrop and the femoral head. Side-to-side comparison of the teardrop distance
can be useful to evaluate for hip jointeffusion or for hip dysplasia.23
Fig.14: AP radiograph of pelvis showing iliopectineal line (large white arrow) and ilioischial line
(small white arrow)
Fig.15 : The anterior (black arrow) and posterior (white arrow) walls of
the acetabulum
The iliopectineal line (fig.14) is part of the anterior column (large white
arrow); ilioischial line (fig.14) is part of the posterior column (black arrow),
and teardrop appearance (small white arrow).
The anterior (black arrow) and posterior (white arrow) walls of the
acetabulum (fig.15) are noted.
28
Line of Kline is a line drawn along the long axis of the superior aspect
of the femoral neck, which normally will intersect the epiphysis.
The Shenton arc is a smooth curvilinear line connecting the medial
aspect of the femoral neck with the undersurface of the superior pubic ramus.
A horizontal line connecting the triradiate cartilages (Hilgenreiner line)
and a perpendicular to this line through the lateral edge of the acetabulum
(Perkins line) define four quadrants in which, in normal hips, the femoral head
should be in the lower inner quadrant.
Fat Stripes:
Several fat planes can also be seen on the AP radiograph.24 The gluteal
fat stripe (fig.16) is seen as a straight line paralleling the superior aspect of the
femoral neck on a true AP radiograph and represents normal fat between the
gluteus minimus tendon and the ischiofemoral ligament. This line bulges
superiorly in the presence of a hip joint effusion.24
The iliopsoas fat stripe (fig.16) is seen as a lucent line immediately
inferior to the iliopsoas tendon. The obturator fat stripe (fig.16) parallels the
iliopectineal line and is formed by normal pelvic fat adjacent to the obturator
internus muscle.
29
Fig. 16 : The gluteus minimus fat stripe (small white arrow), obturator internus fat stripe (large white arrow), and iliopsoas fat stripe (black
arrow).
MRI OF NORMAL HIP JOINT:
The first decision to make with hip MRI is whether to image both hips
simultaneously or only the symptomatic hip. It is an important decision since it
will influence other decisions such as coil and pulse sequence selection. As a
general guideline, imaging of both hips simultaneously may be appropriate if
one is looking for osteonecrosis (given the frequency of bilateral involvement)
or metastasis.25
When bilateral hip imaging is chosen, the body coil, preferably phase
array, is used. The following set of pulse sequences is recommended: T1-
weighted coronal and fast-spin echo (FSE) T2-weighted or short tau inversion
recovery (STIR) axial. This is done by using a dedicated surface coil, such as a
flexible coil, for better anatomical resolution of small structures such as the
acetabular labrum, or for better evaluation of the articular surfaces or
subchondral area of the femoral head.26
MRI of th
• Cor
Fig.
• Sag
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30
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32
PATHOPHYSIOLOGY
Patterns of Disease:
1. Vascular, Metabolic and Synovial Diseases
2. Degenerative
3. Infections
4. Dysplasias and Congenital Anomalies.
5. Miscellaneous
1. VASCULAR,METABOLIC AND SYNOVIAL DISORDERS:
AVN:
Avascular necrosis of the femoral head (AVN) 28 is an increasingly
common cause of musculoskeletal disability, and it poses a major diagnostic
and therapeutic challenge. Although patients are initially asymptomatic, AVN
usually progresses to joint destruction, usually before the fifth decade29.
Femoral head AVN represents ischemic injury of femoral head. By
convention, the term avascular (ischemic) necrosis generally is applied to areas
of epiphyseal or sub articular involvement, whereas "bone infarct" usually is
reserved for metaphyseal and diaphyseal involvement.
Avascular necrosis is characterized by osseous cell death due to vascular
compromise29. Avascular necrosis of bone results generally from corticosteroid
use, trauma, pancreatitis, alcoholism, radiation, sickle cell disease, infiltrative
diseases (e.g. Gaucher’s disease), and Caisson disease29. The most commonly
affected site is the femoral head and patients usually present with hip and
referred knee pain.
33
Early detection of avascular necrosis of the femoral head allows
conservative treatment to be effective, with alleviation of pain and preservation
of normal joint function. Once subchondral fracture has occurred, more
aggressive therapeutic measurements such as total joint replacement are
necessary, with a significant increase in morbidity.
Plain film radiography :
Using plain film, the sensitivity for detecting early stages of the disease
is as low as 41%30. Plain film does not detect stage 0 and 1 AVN. A delay of 1-
5 years may occur between the onset of symptoms and the appearance of
radiographic abnormalities. Normal radiographic findings do not necessarily
mean that disease is not present. A staging system using radiographic findings
has been developed by Ficat and Arlet and has been used widely for treating
avascular necrosis31. This has been supplanted by the classification system of
Steinberg et al, which incorporates MRI and scintigraphic findings32.
Fig.21 : FICAT and ARLET classification of AVN of femoral head
34
Ficat Classification :
Professor RP Ficat33; Ficat Classification of Osteonecrosis of the Hip
Stage
Stage 0 : Normal hip with contra-lateral disease (Hungerford)
Stage I : Normal radiograph
Diagnosis following MRI, bone scan or histology
Stage II : Radiographic changes of repair (osteoporosis / sclerosis / cysts)
No osteochondral fracture
Head spherical
Stage III : Wedge shaped ↑ density
Mottled osteoporosis
Subchondral lucent line® Crescent sign
Head no longer spherical "out of round"
Usually affects antero-lateral area of femoral head (best seen on
lateral view)
Stage IV : Marked changes with secondary degenerative changes in the joint
Collapse of subchondral bone & severe deformity of the head
Magnetic resonance imaging (MRI) :
Magnetic resonance imaging has recently emerged as the most sensitive,
specific, and widely used diagnostic tool for avascular necrosis of femoral
head. In most reports, MRI can diagnose very early lesions with a greater than
90 percent specificity and sensitivity based on histology or eventual
35
rogression.34,35 Screening of asymptomatic, high-risk patients may enable early
intervention. Imaging findings have been signal-intensity bands or lines within
the femoral head are seen surrounding the area that corresponds to ischemic
bone on T1- and T2-weighted images. The band is thick on T1-weighted
images and is thinner and accompanied by a second, inner band of high signal
intensity on T2-weighted images. The appearance on T2-weighted images is
known as the “double-line sign” and is considered highly specific for AVN.
This band is believed to represent the reactive interface that separates normal
marrow from infarcted marrow. The signal intensity of the central infarcted
bone corresponds to areas of bone necrosis seen at histologic examination.
High signal intensity on T1-weighted images and low signal intensity on T2-
weighted images are seen within areas of necrosis when viable, fatty marrow is
still present with prolonged ischemia and necrosis, the necrotic bone has a
signal intensity pattern resembling that of fluid, with low signal intensity on
T1-weighted images and high signal intensity on T2-weighted images. Finally,
when fibrosis and sclerosis of the involved bone occurs, it is reflected by low
signal intensity on both T1- and T2-weighted images. Secondary signs and
sequelae of AVN can also be seen at MR imaging. Joint effusion or
cartilaginous thinning may be present. Progression of AVN leads to instability
of the femoral head with fragmentation and eventual collapse.
In the early stages of the disease, there may not be any alteration of the
normal signal intensity of the femoral head. The first sign of AVN is
nonspecific: diffuse areas of decreased signal intensity are seen in the normally
high-signal-intensity fatty marrow on T1-weighted images36. This is thought to
36
be due to edema within the marrow. Focal findings along the anterosuperior
aspect of the femoral head are more specific: low-necrotic segment of bone.
MITCHELL’S GRADING:
Class T1 T2 Definition
A Bright intermediate "fat" signal
B Bright Bright "blood" signal
C intermediate bright "fluid or edema" signal
D dark dark "fibrosis" signal
LEGG-CALVE-PERTHES DISEASE :
Legg-Calve-Perthes disease (LCPD)37 is avascular necrosis of the proximal
femoral head resulting from compromise of the tenuous blood supply to this area.
LCPD usually occurs in children aged 4-10 years. The cause is not known. LCPD is
the most common cause of a limp in the 4- to 10-year-old age group, and the classic
presentation has been described as a painless limp. Initial radiographs can be normal,
but radiographic changes can be divided into 5 distinct stages representing a
continuum of the disease process.
• Stage 1 reveals cessation of femoral epiphyseal growth.
• Stage 2 is a subchondral fracture.
• Stage 3 shows resorption.
• Stage 4 demonstrates reossification.
• Stage 5 is the healed or residual stage
37
Although radiography is the primary imaging technique used in the
evaluation of patients with suspected or known LCP disease, MRI may play an
important complimentary role.38 Early diagnosis of LCP disease is important
because it allows prompt initiation of potentially joint-preserving therapies.
MRI depicts the exact extent of femoral head involvement more precisely than
pinhole scintigraphs.
Avascular phase: Proximal femoral epiphyseal MR signal abnormality may be
observed early in the course of LCP disease on unenhanced imaging sequences.
On T1-weighted imaging sequences, the proximal femoral ossific nucleus
typically contains focal or diffuse abnormally low or intermediate signal. T2-
weighted/STIR imaging sequences can show variable signal intensity, including
areas of increased signal thought to represent bone marrow edema.
Revascularization and reparative phase: Revascularized areas of the
proximal femoral epiphysis typically show T2-weighted/STIR signal
hyperintensity. A variety of epiphyseal abnormalities may be observed in the
revascularization and reparative phases of LCP disease. With healing, proximal
femoral epiphyseal height is slowly restored, ossific fragments coalesce, and
mature trabecular bone again constitutes the entire ossific nucleus. After
approximately 6 years, the epiphysis typically again shows normal MR signal
characteristics.
2. DEGENERATIVE:
OSTEOARTHRITIS:
Osteoarthritis39, the most common type of joint disease, is a
heterogeneous group of conditions that result in common histopathologic and
38
radiologic changes.40 It is a degenerative slowly developing disorder that
results from the biochemical breakdown of articular cartilage in the synovial
joints characterized by non-uniform degeneration of articular cartilage and
reparative formation of new bone, which results in stiffness and pain of the
affected joint.
Conventional radiographs remain the criterion standard for the imaging
diagnosis of osteoarthritis. The diagnosis can be made with a high degree of
confidence when joint narrowing, subchondral sclerosis, and osteophyte
formation are seen. Radiographs can depict joint space loss, as well as
subchondral bony sclerosis and cyst formation. In the areas without high
contact pressures, osteophytes can be detected. In the osteoarthritic hip the
superior aspect of the joint is typically the most narrowed; axial and medial
migration of the femoral head is less commonly seen.
The Kellgren and Lawrence grading scale
Grade Severity category Description
0 Normal No features
1 Doubtful Possible narrowing of joint space medially and possible osteophytes around the femoral head
2 Mild Definite narrowing of joint space inferiorly, definite osteophytes, and slight sclerosis
3 Moderate Marked narrowing of joint space, definite osteophytes,
some sclerosis and cyst formation, and deformity of the femoral head and acetabulum
4 Severe Gross loss of joint space with sclerosis and cysts,
marked deformity of femoral head and acetabulum, and large osteophytes
39
Unlike radiography, MRI can depict articular cartilage directly; this
feature of MRI has been the subject of multiple research studies over the past
several years, particularly focusing on the cartilage of the knee. A variety of
pulse sequences have been described, but the most commonly used include
spoiled gradient-recalled echo (SPGR) and fast spin-echo imaging.39
MRI grading41:
Grade Findings
grade 0 Normal
grade 1 inhomogeneous high signal intensity in cartilage (T2WI)
grade 2 In homogeneity with areas of high signal intensity in articular
cartilage (T2WI); indistinct trabaculae or signal intensity loss in femoral head & neck (T1WI)
grade 3 criteria of Stage 1 & 2 plus indistinct zone between femoral head & acetabulum; subchondral signal loss due to bone sclerosis
grade 4 above criteria plus femoral head deformity
3. INFECTIONS:
TUBERCULOUS ARTHRITIS:
Joint involvement in tuberculosis may be secondary to direct invasion
from an adjacent focus of tuberculous osteomyelitis or may result from
hematogenous dissemination. The disease is typically monoarticular and
primarily involves the large weight-bearing joints such as the hip.42
The classical radiological triad includes periarticular osteoporosis,
peripherally located osseous erosion, and gradual diminution of the joint space
(Phemister triad). Relative preservation of joint space is suggestive of
40
tuberculous arthritis. Eventual end result in tuberculous arthritis is fibrous
ankylosis of the joint.31
Occasionally, wedge-shaped areas of necrosis (kissing sequestra) may be
present on both sides of the affected joint.42
Tuli Classification. The Natural History of Tuberculous Arthritis
Progresses through 5 Stages.43
Stage Radiographic findings
Stage I (Synovitis) 1) Soft tissue Swelling
2) Osteopenia
Stage II (early arthritis) 1) Soft tissue swelling
2) Marginal joint erosions
3) Diminution in joint space
Stage III (advanced arthritis) 1) Marginal erosions painless joint
2) Cysts
3) Significant loss of joint space
Stage IV (advanced arthritis) Joint destruction
Stage V (Ankylosis) Ankylosis
MRI identifies the synovial inflammation, joint effusion and erosion of
articular cartilage and bone edema early and easily.44
The early findings on magnetic resonance imaging are nonspecific, and
include a joint effusion, marrow edema, and during the stage of arthritis there
may be abnormalities within the articular cartilage and subchondral bone. If the
diagnosis is made during the stage of synovitis, treatment focuses on gaining or
maintaining motion, relief of weight bearing, and splinting to prevent deformity
(especially flexion).46
41
JOINT EFFUSION:
Fig. 22: Diagram of hip joint as seen on frontal radiograph of pelvis. Note tear drop configuration of anteroposterior portion of acetabulum, fovea centralis and tear drop distance ( arrows). Lateral demarcation is most medial aspect of femoral head.
Medial demarcation is lateral margin of teardrop.
The presence of excess hip joint fluid is indicative of inflammatory
processes and other joint abnormalities.45 Detection of hip joint effusion in
association with clinical symptoms characteristic of joint inflammation
warrants aspiration for culture to evaluate the possibility of infection. Prompt
diagnosis of such infections is paramount, if the destructive consequences that
often accompany these infections are to be avoided. The teardrop distance is
defined as the distance between the lateral aspect of the teardrop and the most
medial aspect of the femoral head. The value of MR imaging in the diagnosis of
hip joint effusions has recently been documented.
42
4. DYSPLASIAS AND CONGENITAL ANOMALIES:
Developmental dysplasia of the hip (DDH) is a spectrum of disorders
affecting the proximal femur and acetabulum that leads to hip subluxation and
dislocation.47 Early diagnosis and treatment is important because failure to
diagnose DDH in neonates and young infants can result in significant
morbidity.
Plain radiographs of the pelvis are most helpful when significant
ossification of the capital femoral epiphyses has occurred and when adequate
US evaluation cannot be performed.
Line measurements made on the anteroposterior radiograph help in
determining the relationship of the femoral head with the acetabulum.
Hilgenreiner's line48 :
Hilgenreiner's line is drawn horizontally through the superior aspect of
both triradiate cartilages. It should be horizontal, but is mainly used as a
reference for Perkin's line and measurement of the acetabular angle.
Perkin's line :
Perkin's line is drawn perpendicular to Hilgenreiner's line, intersecting
the lateral most aspect of the acetabular roof. The upper femoral epiphysis
should be seen in the inferomedial quadrant (i.e. below Hilgenreiner's line, and
medial to Perkin's line)
Acetabular angle :
The acetabular angle is formed by the intersection between a line drawn
tangential to the acetabular roof and Hilgenreiner's line, forming an acute
angle. It sh
with matur
Shenton's
She
ramus and
proximal f
proximal f
Fig. 23 : D
Plai
radiation,
to interpre
hould be a
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line:
enton's line
d should c
femur as a
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Diagram deand acet
in radiogra
and does n
et before th
approximat
he joint.
e is drawn
continue l
a smooth
to DDH the
emonstratintabular ind
aphy has a
not provide
he capital fe
43
tely 30 deg
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en this line
ng the Shendex in norm
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emoral epip
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Perkin line,d Dislocated
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ogressively
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raphs are d
y reduce
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ionizing
difficult
44
MRI can be useful in the preoperative and postoperative evaluation of a
hip with many complications. MRI can be used to distinguish the labrum,
capsule, and acetabular cartilage. MRI is useful for detecting the complications
of DDH and treatment for DDH, such as avascular necrosis of the femoral head
and joint effusions. MRI can also be used to demonstrate iliopsoas tendon
compression, a thick ligamentum teres, and pulvinar hypertrophy.
5. MISCELLANEOUS:
SLIPPED CAPITAL FEMORAL EPIPHYSIS:
Slipped capital femoral epiphysis (SCFE) is a Salter-Harris type1
fracture through the proximal femoral physis and is the most common
adolescent hip disorder. SCFE is a misleading term because it is actually the
femoral neck metaphysis that displaces with respect to the capital femoral
epiphysis 1. In most cases the femoral head will reside posterior to the femoral
neck.49
The exact etiology of SCFE is unclear. Only in a small number of cases
(<10%) is there a specific traumatic event, such as a fall. In addition to trauma,
suggested causes have included mechanical factors, inflammation, endocrine
and renal disorders, nutritional deficiencies, and radiation therapy. The
combination of abnormal shear forces on the growth plate during rapid growth
at the time of adolescence has been implicated.
There are two radiographic classification systems; the Wilson
classification which is based on the relative displacement of the epiphysis on
the metaphysis, and the Southwick method which is based on the epiphyseal-
45
shaft angle. The term "pre-slip" has been used in radiographically occult cases,
in which physeal and metaphyseal abnormalities may be seen on MR images or
CT11. The earliest evidence of SCFE on MRI is diffuse or globular physeal
widening (E,F)12. Hyperintense signal of the marrow along the physis on T2-
weighted images indicates stress and edema13. Axial and sagittal MR images
are important for identification of any retroversion at the epiphyseal-
metaphyseal junction. Both hips should be included on MRI because of the
high prevalence of bilateral SCFE.
PAGET DISEASE:
Paget disease typically occurs in patients over the age of 50 years and
progresses in three phases—predominately lytic, mixed lytic and sclerotic, and
finally, sclerotic. Increased osteoclastic activity leads to abnormal bone
remodeling. The etiology of Paget disease is unknown, although a viral
etiology is hypothesized. Similar to osteomalacia, Looser’s zones may form,
representing inadequately healed stress fractures.50
Radiography shows typical findings include thickening of the
iliopectineal line in early stages, progressing to patchy sclerosis and lucency in
later stages. Weakening of the pageticacetabular bone may lead to
protrusioacetabuli and insufficiency fracture.51
The MRI signal intensity characteristics in Paget disease are variable,
reflecting the natural course of the disease process in different phases. Because
Paget disease can be confined to one bone or to a portion of one bone,
diagnosis may be challenging. Three major patterns of involvement are
recognized. The most common pattern is dominant signal intensity in the
affected bone similar to that of fat; this pattern of involvement presumably
46
corresponds to long-standing disease and is noted in most patients. The second
most common pattern probably corresponds to the early mixed active phase
when involved bone shows heterogeneous, relatively low T1 signal intensity
and high T2 signal intensity . This pattern of signal intensity alteration, also
referred to as the “speckled” appearance, probably corresponds to the presence
of granulation tissue, hypervascularity, and edema seen in active disease when
abnormal, disorderly bone mineralization is present. The least common pattern
of signal intensity changes is seen in the late blastic inactive phase when the
affected bone shows low signal intensity on both T1- and T2-weighted images,
suggesting the presence of compact bone or fibrous tissue. The preservation of
fatty marrow signal in the affected bone generally excludes diagnosis of
superimposed sarcoma.52
TUMORS:
Generally, conventional radiography is the preliminary evaluation for
suspected primary bone neoplasm.53 This is a critical step in identifying the
initial formation of any potential tumors. However, additional imaging is
usually needed to prevent misinterpretation due to other overlapping structures,
and to assess the extent of the lesion for preoperative or other treatment plans.
MR imaging is excellent in assessing the characteristics of a lesion.54 MRI is
used for evaluation of their intramedullary and soft-tissue extension, articular
extension, and neurovascular bundle involvement. MR imaging usually
presents heterogeneity in the pelvic and proximal femoral region, especially for
older or obese patients. In general, no one technique is recommended for the
evaluation of bone metastases.
47
METHODOLOGY
Source of Data :
The main source of data for the study is patients from the following
teaching Hospital attached to Bapuji Education Association, J.J.M. Medical
College, Davangere.
1. Bapuji Hospital.
2. Chigateri General Hospital.
Appropriate MRI sequences and multiplanar imaging will be performed
for every patient
All patients referred to the department of Radio diagnosis with clinical
history of hip pain in a period of 2 years from October 2011 to October 2013
will be subjected for the study.
Sample size: 50
Duration of study: 2 years
Data Analysis: A cross sectional study is performed and the data is analysed
by Proportions.
Inclusion Criteria:
• The study include patients presenting with acute or chronic hip pain
• Patients of all age groups and both sexes.
48
Exclusion Criteria:
The study will exclude
• Patients with history of acute trauma
• Patient having history of claustrophobia.
• Patient having history of metallic implants insertion, cardiac pacemakers
and metallic foreign body in situ
Technique:
Imaging will be done with 1.5 Tesla Philips Achieva Machine using
abdominal surface coils and spine coils. The following sequences will be
selected as required.
a) TIW coronal - TE(18ms) TR(500-700ms) slice thickness
(1-3mm)
b) T1W axial - TE(18ms) TR(500-700ms) slice thickness(1-3mm)
c) T2W coronal - TE(100ms) TR(1000-1500ms) slice thickness
(1-3mm)
d) T2W axial - TE(100ms) TR(1000-1500ms) slice thickness
(1-3mm)
e) STIR coronal - TE(30ms) TR(2700-6000ms) slice thickness
(3-5mm)
f) PD sagittal - TE(30ms) TR(2300-6500ms) slice thickness
(3-5mm)
g) mFFE axial -TE(9.21ms) TR(500ms) slice thickness(1-3mm)
49
The study is mainly based on investigations as Radiology itself is a tool
of Investigation. The study involves only humans. Informed consent would be
taken after explaining about and before any procedure.
Ethical clearance has been obtained from the Research and Dissertation
Committee/ Ethical Committee of the institution for this study.
A female p
MRI Corofemoral h
CAS
patient aged
Plain
onal STIR imhead, neck a
SE:1 AV
d 28yrs com
n X-Ray sh
mage showiand intertro
w
50
VSCULAR
mplaining ofof left hip
howing norm
ing hyperintochanteric awith abnorm
NECROSI
f left hip paip joint
mal hip joint
tense Bone reas. AVN
mal MRI.
IS OF HIP
in, clinically
ts bilaterally
marrow edstage 1 – no
P JOINT
y suspectin
y
dema involvormal radio
g AVN
ing left graph
A 40 y
A 40 yX-Ray sfemora
MRI CoroMRI as
CASE:2
years old ma
years old mashowing AVal head and o
onal STIR ims CLASS ‘C
2 AVASC
ale patient c
ale patient cVN stage 2 osteoporoti
S
mage showiC’ on right s
51
CULAR NE
complaining
complaining( subchondrc) on right Staging) on
ing bilateralside and CL
gradin
ECROSIS O
g of bilatera
g of bilateraral cystic chside and sta
n left side
l bone marrLASS ‘A’ ong)
OF HIP JO
al hip pain s
al hip pain shanges, irregage 1 or nor
row edema an left side (
OINT
since 6 mon
since 6 mongular contormal (FICA
and it is gra(MITCHEL
nths
nths ur of
AT’S
aded on
LL’S
A 14 ye
MRI Coro
ears male pa
onal STIR i
CASE
atient compl
Plain
image showsuggestiv
52
3: JOIN
lainig acute
movem
n X-Ray app
ws hyperinteve of right h
T EFFUSI
e right hip pents.
pears norma
ense fluid cohip joint eff
ON
ain with res
al
ollection in fusion
stricted righ
the right hip
ht hip
p joint
A 13 ye
Plain xray
MRI coromarrow e
CA
ears old mal
y shows defo
onal STIR iedema of fem
ASE 4: TU
le patient co
ormative sta
image showmur and ac
and fluid p
53
UBERCULO
omplains of history of
age of left hhip joi
ws dislocatiocetabular roopockets sug
OSIS OF H
f chronic leff fever.
hip joint witint.
on of left hipof associategestive of a
HIP JOINT
ft hip pain, l
th complete
p with pseued with edemabscess.
T
limping gait
e dislocation
doarthrosismatous soft
t and
n of left
, bone tissue
A 49 yea
Plain X
MRI Scartilage, csevere joint
ars old male
X-Ray showsdeform
SAGITTAL ytic changet space redu
CASE
e patient co
s severe ostmed femoral
PD and COes in subchouction, irreg
around hi
54
:5 OSTEO
mplaining c
eoarthritis whead with s
ORONAL Sondral regiogular contouip joint with
OARTHRI
chronic righ
with gross rsubchondral
STIR imagesn region of
ur of femorah fatty infilt
TIS
ht hip pain a
reduction ofl cystic chan
s showing lf femoral heal head and tration.
and limping
f joint spacenges
oss of articuad and acetatrophy of
g gait.
e and
ular tabulum, muscles
A 8 ye
Plain X-R
MRI COR
CASE 6
ears old ma
Ray shows dand late
RONAL T2
6: DEVEL
le patient co
displacemeneral to Perki
W image sh
55
LOPMENTA
omplainin o
nt of left femin’s line wit
hows small,epiphy
AL DYSPL
of chronic h
moral epiphyth a broken
, hyperintenyses.
LASIA OF
hip pain with
yses above Shenton’s
nse and disp
HIP
h limping g
the acetabuline.
placed left fe
ait.
ular rim
femoral
A 48 yea
Plain X-Rhead, n
MRI AXIAboth the fem
femoral
CA
ars old mal
Ray shows oneck and tro
AL T2W anmoral headsl articular c
h
ASE:7 MET
e patient ca
osteoblasticchanters wi
nd CORONAs in the formartilage, def
hypointense
56
TASTASIS
ame with co
c metastasisith reduced
norm
AL STIR imm of heterogformed fem
e mass with
TO THE H
mplains of
to the left hjoint spaceal.
mage showsgenously hy
moral head aedematous
HIP JOINT
left hip join
hip joint invand right h
s extensive sypointensityand periartimuscles.
T
nt since 2 m
volving the
hip joint app
sclerosis invy, destructiocular soft ti
months
femur pears
volving on of left issue
Gen
M
Fem
To
nder
ale
male
otal
30
Table
Graph‐
57
RESUL
e – 1 : Sex
Number o
3
1
5
‐1 : Sex
LTS
distributi
of patients
5
5
50
distribu
ion
70
ution
%
70%
30%
100%
%
%
%
Male
Female
A
0
1
2
3
4
5
6
T
0
2
4
6
8
10
12
14
No.of cases
Age
0-10
1-20
21-30
31-40
41-50
51-60
61-70
Total
0
2
4
6
8
0
2
4
0‐10
4
G
Table –
20‐Nov
6
raph‐2 :
58
2 : Age wi
Number
21‐30 3
11
Age
: Age w
ise distrib
of patient
4
6
11
14
8
5
2
50
31‐40 41‐
14
in years
ise distr
ution
ts
‐50 51‐60
8
5
ribution
%
8%
12%
22%
28%
16%
10%
4%
100%
0 61‐70
2
n
%
%
%
%
%
%
59
Table – 3 : Pathology
Sl. No Pathology Number of patients %
1. AVN 16 32%
2. Joint Effusion 12 24%
3. OA 10 20%
4. TB 6 12%
5. Perthe’s 2 04%
6. DDH 2 04%
7. Metastasis 2 04%
Total 50 100%
Avascular Necrosis of Femoral Head:
Out of 50 cases 16 (32%) cases are diagnosed as AVN of femoral head.
In 16 cases of AVN only 4(25%) cases are detected on X-Ray but, all 16
(100%) cases are detected on MRI. 12 (75%) cases which are normal {stage 1
& stage 2 of FICATS CLASSIFICATION} on X-Ray proved to have AVN on
MRI.
Out of 4(25%) cases which are detected both on X-Ray and MRI 2
(12.25%) cases which are detected as stage 2 on X-Ray { FICATS }shows stage
3 or more on MRI {MITCHELL’S} 2 (12.25%) cases which are detected as
stage 3 on X-Ray { FICATS } shows stage 4 on MRI {MITCHELL’S}
60
Table – 4 : AVN
AVN On X-Ray On MRI
Total 16 4 (25%) 16 (100%)
Table – 5 : X-ray findings
X-Ray findings Number of patients
Percentage % (n=4)
Osteoporosis 4 100
Sclerosis 2 50%
Subchondral cysts 2 50%
Crescent sign/subchondral lucency 2 50%
Altered morphology 2 50%
Table – 6 : MRI Findings
MRI Findings Number of patients
Percentage % (n=16)
Bone marrow edema 13 81
Double line sign 11 68
Subchondral cysts 12 75
Femoral head altered contour 2 12.5
Femoral head fragmentation with collapse 2 12.5
61
25%
75%
Graph‐3 : AVN on X‐Ray
positive
negative
100%
Graph‐4 : AVN on MRI
positive
62
JOINT EFFUSION:
Out of 50 cases 12 (24%) cases show joint effusion.
Out of 12 cases of joint effusion 4 (33%) cases detected on X-Ray. And
all the 12 (100%) cases are positive for joint effusion on MRI.
Findings on X-Ray: widened tear drop distance
Findings on MRI: T2W and STIR hyperintensity within the joint space which is
graded as mild, moderate and severe.
Table – 7 : Joint effusion
Joint effusion Positive on X-Ray Positive on MRI
Total 12 cases 4 cases (33%) 12 (100%)
Table – 8 : On MRI joint effusion
On MRI joint effusion Number of patients Percentage % (n=12)
Mild 6 50
Moderate 5 41.6
severe 1 8.3
33%
77%
Graph‐5 : JOINT EFFUSION ON X‐RAY
Positive
negative
100%
Graph‐ 6 : JOINT EFFUSION ON MRI
POSTIVE
OSTEOAR
Out
detected b
cases show
Out
on MRI. O
stage 3( 2c
(2cases).
0
2
4
6
8
10
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
RTHRITI
t of 50 case
both on pla
wing stage
t of 10 cas
Out of 10 c
cases). On
0
2
4
6
8
On X
4
1
STAGE 1
S:
es 10 (20%
ain radiog
1 on X-Ra
es 3 (30%)
cases detec
MRI stage
X‐Ray
10
Graph‐
4
STA
63
%) cases sh
raphy and
ay shows st
) cases sho
cted on X-R
e 1( 1case)
On MR
10
7 : OSTEO
4
AGE 2
how Osteoa
MRI. But
tage 2 or 3
owing stage
Ray stage
) stage 2( 4
RI
0
O ARTHR
2
3
STAGE 3
arthritis. Al
t, out of 1
on MRI.
e 2 on X-R
1 (4 cases
4cases) sta
RITIS
0
STA
ll the 10 ca
10 cases 3
Ray shows
) stage 2(
ge (3 case
OSTEO ARTH
2
AGE 4
ases are
3 (30%)
stage 3
4cases)
s) stage
HRITIS
XRAY
MRI
64
OSTEOARTHRITIS :
Table – 9 : X-ray findings
X-Ray findings Number of patients
Percentage % (n=10)
possible osteophytes 4 40
Definite osteophytes 4 40
Joint space narrowing 8 80
Sclerosis 6 60
Cyst formation 2 20
Deformation of femoral head 2 20
Table – 10 : MRI findings
MRI Findings Number of patients
Percentage % (n=10)
Articular cartilage T2W high signal 5 50
Indistinct trabeculae/ signal loss in femoral head & neck on T1W 9 90
Indistinct zone between femoral head and acetabulum 3 30
Subchondral signal loss 3 30
Femoral head deformity 2 20
TB OF HI
Out
Out
(100%) ca
case), stag
cases dete
stage 4(2 c
TB H
TO
0
0.5
1
1.5
2
2.5
S
IP JOINT:
t of 50 case
t of 6 Case
ases detect
ge 2(1case
cted on M
cases) & st
IP JOINT
OTAL 6
1 1
STAGE 1
:
es 6 cases
es of TB HI
ed on MR
), stage3(2
MRI shows
tage5(1 cas
Tab
T
1 1
STAGE 2
Gra
65
(12%) show
IP 5(83%)
I. Out of 5
2cases), sta
stage 1( 1
se).
le – 11 : T
ON XR
5 (83%
2
1
STAGE 3
h‐8 : TB
ws TB HIP
) cases dete
5 cases d
age 4 ( 0 )
1case), stag
TB hip join
RAY
%)
0
STAGE
B hip joi
P.
ected on X
etected on
& stage 5
ge2(1 case)
nt
1
2
E 4 STA
nt
X-Ray , whe
n X-Ray st
(1 case). O
), stage 3(
ON MRI
6 (100%)
1
AGE 5
ere as 6
age 1(1
Out of 6
1 case),
X‐RAY
MRI
66
Table – 12 : X-ray findings
X-Ray findings Number of patients
Percentage % (n=5)
Osteopenia 4 80
Joint effusion 1 20
Soft tissue swelling 1 20
Joint erosions and reduction of joint space 3 60
Subchondral cysts 2 40
Joint destruction & bony ankylosis 1 20
Table – 13 : MRI findings
MRI Findings Number of patients
Percentage % (n=6)
Synovial hyperintensity on T2W 1 16.66
Joint effusion 2 33.33
Bone marrow edema 3 50
Subarticular cysts 1 16.66
Joint space reduction 3 50
Joint destruction & bony ankylosis 1 16.66
Soft tissue hyperintensity on T2W 3 50
PERTHE’
Out
detected on
Small epip
Complete
Epiphysea
Bone marr
0
0.5
1
1.5
2
2.5
’S DISEAS
t of 50 cas
n X-Ray(1
X-Ray
physes
resorption
MRI F
l hyperinte
row edema
X‐
SE:
ses 2cases(
00%) and M
Table
findings
of epiphys
Tabl
Findings
ensity on T
2
‐RAY
Gra
67
( 4%) sho
MRI (100%
e – 14 : X-
ses
le – 15 : M
T2W
aph‐9 :
ow Perthe’
%)
-ray findin
Numpa
MRI finding
Numpa
M
Perthe'
’s disease.
ngs
mber of tients
1
1
gs
mber of tients
1
2
2
MRI
s
Both 2 ca
Percent(n=
50
50
Percent(n=
50
10
P
ases are
tage % =2)
0
0
tage % =2)
0
0
Perthe's
DEVELO
Out
X-Ray (10
Epiphyses Epiphyses
Epiphyses
Broken she
Complete
HyperintenDisplaced Bone marrHypointenComplete
0
0.5
1
1.5
2
2.5
PMENTA
t of 50 cas
00%) and M
X-Ra
lateral to Pinferior to
superior to
enton’s lin
femoral he
MRI
nsity of epiepiphyses
row edema nse epiphysdislocation
X
L DYSPLA
ses 2 cases
MRI (100%
Table
ay Finding
Perkin’s lino Hilgenre
o acetabula
ne
ead disloca
Tabl
I Findings
iphyses
ses n of femora
2
X‐RAY
G
68
ASIA OF
s (4%) show
%).
e – 16 : X-
s
ne in’s line
ar rim
ation
e – 17 : M
s
al head
Graph‐10
HIP:
w DDH. B
-ray findin
N
MRI findin
N
0 : DDH
Both 2 case
ngs
Number ofpatients
1 1
1
1
1
ngs
Number ofpatients
1 2 2 1 1
2
MRI
es are dete
f Perce% (n
55
5
5
5
f Perce% (
51555
ected on
entage n=2)
50 50
50
50
50
entage (n=2) 50 00
50 50 50
DDH
METASTA
Out
are detect
osteoblasti
Osteolytic
Osteoblast
Sclerosis
Altered fem
Hyperinten
Hypointen
Altered fem
Soft tissue
0
0.5
1
1.5
2
2.5
ASIS:
t of 50 cas
ted on X-
ic metastas
Ta
X-Ray f
lesions
tic lesions
moral cont
T
MRI Fi
nsity signa
nsity signal
moral cont
e hyperinte
2
X‐R
ses 2 cases
-Ray (100
sis.
able – 18 :
findings
tour
able – 19
indings
al on T2W
l on T2W
tour
nsity signa
2
RAY
Graph
69
( 4%) sho
%) and M
X-ray fin
: MRI fin
al on T2W
h‐11 : M
ows metast
MRI (100%
ndings – M
Numbpati
ndings – M
Numbpati
1
1
1
1
2
MRI
METASTA
tatic diseas
%). Both
Metastasis
ber of ients
1
1
1
1
Metastasis
ber of ients
1
1
1
1
ASIS
se. Both th
the cases
Percenta(n=2
50
50
50
50
Percenta(n=2
50
50
50
50
META
he cases
shows
age % 2)
0
0
0
0
age % 2)
ASTASIS
70
DISCUSSION
Plain radiography is a widely established, economical investigation
readily available in all kinds of health setups for imaging the hip joint. Whereas
MRI is an expensive, not readily available investigation at the level of primary
health care centers.
However, is the non-invasive gold investigation in early diagnosis,
evaluate the extent of pathological involvement more accurately and narrow
down the differential diagnosis.
Our study aims at the early detection of the disease before the
appearance of signs on radiography or in patients having subtle findings on
plain radiography by using MRI that helps the clinician to treat the patient at
the early stages to prevent the further progression of disease.
It also aims at the accurate staging of the disease and assesses the extent
of involvement of the pathology in cases which are already detected on X-Ray,
using MRI to guide the clinician in appropriate treatment according to the stage
of involvement of pathology.
Our discussion also proves MRI as gold standard in evaluation of soft
tissue and articular cartilage which are having limitations for the detection of
pathology on plain radiography.
AVASCULAR NECROSIS OF FEMORAL HEAD:
In our study, AVN of femoral head is the commonest pathology
identified as the cause for painful hip joint.
71
In 16(32%, n=50) cases of AVN diagnosed on MRI only 4 (8%, n=50)
cases are identified on plain radiography.
Out of 4(25%, n=16) cases diagnosed on plain X-Ray 2 (4%, n=16)
cases are showing subchondral cysts, osteoporosis suggestive of stage 1 AVN
(FICATS staging). Other 2 (4% ,n=16) cases are showing crescent sign, altered
head morphology and osteoporosis suggestive of stage 2 AVN (FICATS
staging).
Of 16cases detected on MRI 13(81.25%, n=16) cases show bone marrow
edema, reveals it is the common feature seen and can be detected only on MRI
where X-Ray have its limitation in diagnosing Bone marrow edema.
On MRI 11(68.75%, n=16) cases shows double line sign i.e., on T2W
sequences inner bright line representing granulation tissue and outer dark line
suggestive of sclerotic bone.
12 (75%, n=16) cases diagnosed as normal or stage 1 (FICATS) on plain
X-Ray shows stage 1 or 2 changes on MRI.
Of 4(25%, n=16) cases detected on plain X-Ray
2 (12.5%, n=16) cases are staged as stage 1 (FICATS) which shows
stage 3 (MITCHELLS) giving fluid signal intermediate signal on T1W and
T2W shows bright signal.
2(12.5%, n=16) cases which are staged as stage 2 (FICATS) shows stage
4 on MRI (MITCHELLS) giving fibrosis signal, dark on both T1W and T2W
sequences, reveals that MRI evaluates better than X-Ray in staging and assess
the extent of the pathological involvement in already proven cases of AVN on
72
plain radiography that helps in appropriate treatment plan by the clinician
based on the stage of AVN.
Our study is compared to the study done by Robinson HJ Jr. et.al,15 in
which 23 of the 96 hips that were suspected of having early-stage necrosis of
the femoral head but showed slight or no radiographic changes were studied by
repeat radiographs. Of the 23 hips, 18 (78 per cent) had positive changes on
magnetic resonance imaging; In our study out of 16 hips MRI detects 16 cases
(100%), whereas radiography detects only 4 cases (25%).
OSTEOARTHRITIS:
In our study, 10(20%, n=50) cases are diagnosed as osteoarthritis.
All 10 cases are detected both on plain X-Ray and MRI.
Out of 10 cases on plain X-Ray. 4(40%, n=10) cases shows stage 1
(Kellgren and Lawrence staging) that is possible narrowing of joint space and
possible osteophytes.
4(40%, n=10) cases showing stage 2 that is definite narrowing of joint
space inferiorly, minimal sclerosis and osteophytes.
2(20%, n=10) cases showing stage 3 that is marked narrowing of joint
space, definite osteophytes, cyst formation, deformation of femoral head and
acetabulum.
Out of 10 cases detected on MRI. 1 (10%, n=10) case shows stage 1
(Higgs and Aiesen staging) that is inhomogeneous high signal on T2W within
the cartilage.
73
4(40%, n=10) cases show stage 2 that is inhomogeneity of articular
cartilage high signal on T2W sequences and indistinct trabeculae or signal
intensity loss in femoral head & neck on T1w sequences.
3(30%, n=10) cases show stage 3 that is having criteria of stage 1&2 as
mentioned above and indistinct zone between femoral head & acetabulum,
subchondral signal loss due to bone loss.
2(20%, n=10) cases show stage 4 that is criteria of stage 1,2&3 and
showing femoral head deformity.
3 (30%, n=10) cases showing stage 1 on X-Ray shows stage 2 on MRI
3 (30%, n=10) cases showing stage 2 on X-Ray shows stage 3 on MRI
2 (20%, n=10) cases showing stage 3 on X-Ray shows stage 4 on MRI
Thus, MRI reveals better delineation of cartilage destruction and reveals
accurate pathological involvement and staging of osteoarthritis which helps in
appropriate plan of treatment or intervention by the clinician.
JOINT EFFUSION:
In our study 12 (24%, n=50) cases show joint effusion.
All 12 cases are detected on MRI (100%) but only 4(33.33%, n=12)
cases are detected on plain X-Ray.
4(33.33%, n=12) cases diagnosed on plain X-Ray shows widened tear
drop distance.
On MRI joint effusion is seen as high signal intensity within the joint
space both in T2W and STIR sequences suggestive of fluid collection within
the joint space.
74
On MRI it helps better in evaluation of the quantification of the amount
of fluid within the joint and can be graded as minimal, moderate and severe
joint effusion.
On MRI 6(50%, n=12) cases show minimal joint effusion, 5(41.67%,
n=12) cases show moderate joint effusion and 1 (8.33%, n=12) case shows
severe joint effusion.
8(66.67%, n=12) cases diagnosed as normal on plain X-Ray shows
positive for joint effusion on MRI.
Thus, by our study it reveals MRI is more sensitive in detection of joint
effusion particularly in cases where plain radiography shows normal or subtle
changes even in strong clinical suspicion. It also helps better quantification of
joint fluid collection.
TUBERCULOSIS OF HIP JOINT:
In our study 6(12%, n=50) cases are diagnosed as TB hip.
5(83.33%, n=6) cases are diagnosed on plain X-Ray.
All 6 cases are diagnosed on MRI (100%, n=6)
Among which, 1 (16.66%, n=6) case shows only osteopenia, joint
effusion and soft tissue swelling.
1(16.66%, n=6) case shows along with osteopenia, marginal joint
erosions and diminution of joint space.
2(33.33%, n=6) cases show osteopenia, joint erosions, joint space
reduction and subchondral cysts.
1(16.66%, n=6) case shows joint destruction and bony ankylosis.
6(100%, n=6) cases diagnosed on MRI
75
Among which, 1 (16.66%, n=6) case shows only synovial T2W
hyperintensity and joint effusion in the form of high signal intensity within the
joint space in T2W and STIR sequences, that is diagnosed as normal on plain
X-Ray.
It reveals the importance of MRI in early detection of TB where plain
X-Ray remains normal in spite of strong clinical suspicion.
1(16.66%, n=6) case shows synovial hyper intensity, joint effusion and
bone marrow edema as high signal intensity within the marrow on STIR
sequence.
1(16.66%, n=6) case shows sub articular T2 hyper intense cysts and
joint space reduction.
2(33.33%, n=6) cases show joint deformity along with bone marrow
edema, joint space reduction and para articular soft tissue hyperintense signal
on T2W .
1(16.66%, n=6) case shows marked joint destruction and bony ankylosis
seen as hypo intensity on both T1W and T2W and para articular soft tissue
involvement also.
Thus, MRI helps in better delineation of synovial involvement and
detection of joint effusion in early stages of TB Hip where plain X-Ray has
limitation in diagnosis.
MRI also helps in detection of bone marrow edema in early stages of TB
Hip.
76
In diagnosed cases on plain X-Ray, MRI helps in better evaluation of the
extent of the articular cartilage destruction and also para articular soft tissue
involvement.
PERTHES DISEASE:
In our study 2(4%, n=50) cases are diagnosed as Perthes disease.
The 2 cases are diagnosed both on X-Ray and MRI(100%,n=2).
On plain X-Ray
1(50%, n=2) case shows cessation of femoral epiphyseal growth in the
form of small epiphyses.
1(50%, n=2) case shows complete resorption of femoral epiphyses in
healed/residual stage.
On MRI
1(50%,n=2) case showing only cessation of femoral epiphyses growth
on plain X-Ray, shows epiphyseal abnormality in the form of T1
Hypointensity, T2W hyperintensity and bone marrow edema in the form of
STIR hyperintensity and metaphyseal T2W hyperintenities.
Our study is compared to the study done by Toby EB, Koman LA,
Bechtold RE9 in the assessment of pediatric hip disease by scanning the hips of
24 children (30 scans). Twelve patients with Legg-Calvé-Perthes disease (17
hips) showed characteristic areas of low-intensity signal representative of
necrotic areas of the capital epiphysis. In our study both the cases are showing
small epiphyses which are hypointense on T1W and hyperintense on T2W.
77
Thus, MRI helps in better evaluation of femoral epiphyses along with
detection of bone marrow edema on STIR sequence.
DEVELOPMENTAL DYSPLASIA OF HIP (DDH):
In our study 2(4%,n=50) cases are diagnosed as DDH.
2 cases are diagnosed both on plain X-Ray and MRI(100%,n=2).
1(50%,n=2) case shows displacement of femoral epiphyses lateral to the
Perkin’s line but, inferior to the Hilgenrein’s line.
On MRI the same case shows along with the displacement of epiphyses,
hyperintensity of the epiphyses on T2W and bone marrow edema as
hyperintesity on STIR sequence.
1(50%,n=2) case shows complete femoral head dislocation with broken
Shenton’s line and epiphyses displaced superior to the acetabular rim.
On MRI along with the displacement of epiphyses, dislocation of
femoral head it shows small epiphyses and hypointense epiphyses on both T1W
& T2W.
Thus, X-Ray remains as the first line of investigation to diagnose DDH.
However, MRI helps in better evaluation of epiphyses & femoral head
pathological involvement and also to detect associated bone marrow edema,
along with evaluation of displacement of epiphyses and femoral head.
METASTASIS:
In our study 2(4%,n=50) cases of metastasis to the hip joint diagnosed.
2 cases are diagnosed both on plain X-Ray and MRI(100%,n=2).
78
1(50%, n=2) case shows osteolytic lesions in the femoral head on plain
X-Ray.
On MRI it shows altered signal intensity of the femoral head on T2W
sequence.
1(50%, n=2) case shows osteoblastic lesions and sclerosis within the
femoral head on plain X-Ray.
On MRI it shows altered contour of femoral head altered and signal
intensity in the form of hyperintense signal on T2W sequence with associated
para articular soft tissue involvement in the form of hyperintense signal on
T2W sequence.
Thus, MRI lies superiors in the evaluation of metastatic lesions by not
only detecting the abnormal signal intensity lesions, also evaluates the
cartilaginous and the extent of soft tissue involvement accurately, which helps
in the appropriate treatment plan.
79
CONCLUSION
In our study total 50 cases complaining of acute and chronic hip pain
underwent both plain radiography and MRI consecutively. Maximum number
of patients are between the age group of 31-40(28%), followed by the age
group of 21-30(22%). Out of 50 cases 35 (75%) are males and 15(30%) are
females thus, showing male preponderance.
In our study of 50 cases, 16 cases are diagnosed as AVN, 12 cases
showing Joint effusion, 10 cases showing Osteoarthritis, 6 cases as TB Hip, 2
cases as DDH, 2 cases Perthe’s and 2 cases showing Metastatic disease to Hip
joint.
Out of 16 cases diagnosed as AVN only 4(25%) cases are diagnosed on
plain radiography, where as all the 16 cases are diagnosed on MRI which shows
MRI is more sensitive for the detection of AVN even in early stages where
plain radiography shows normal or subtle findings. MRI also helps in detection
of bone marrow edema for which plain radiography shows its limitation in
detection. In proven cases of AVN on plain radiography the MRI helps in
accurate staging of the disease that helps in appropriate treatment plan by the
clinician.
Out of 12 cases showing the joint effusion only 4(33%) cases are
diagnosed on plain radiography showing widened tear drop distance, where as
all the 12 cases (100%) are diagnosed on MRI. Thus, it reveals the higher
sensitivity of MRI in detection of joint effusion.
10 cases are show osteoarthritis though, all the cases are detected both
on plain radiography and MRI, MRI reveals better delineation of cartilage
destruction, accurate pathological involvement and staging of osteoarthritis.
80
6 cases are diagnosed as TB Hip. Plain radiography helps in detection of
obvious findings such as joint space reduction, altered contour of the articular
surface, osteopenia and joint destruction. MRI adds to the findings of the plain
X-Ray by detection of minimal joint fluid collection, hyperintensity of the
articular cartilage which will be the only findings in the very early stage of TB
Hip. MRI also helps in detection of bone marrow edema, better delineation of
the extent of the articular cartilage destructionand proper delineation of the
para articular soft tissue involvement.
2 cases show DDH plain, X-Ray imaginary lines like Perkin’s line,
Hilgenrein’s line and Shenton’s line are highly useful in diagnosing the
displacement of epiphyses and dislocation of Hip joint. 2 other cases show
Perthe’s disease. Even in Perthe’s disease plain radiography helps to detect the
evaluation of cessation of epiphyseal growth in the form of small epiphyses.
Also it helps in evaluation of resorption of femoral head. However, MRI helps
in detection of the early stages of DDH and Perthe’s by showing the
involvement of epiphyses in the form of T2W hyperintensity before the actual
displacement of epiphyses noted. It also helps in evaluation of bone marrow
edema.
2 other cases show metastasis to the Hip joint. Plain X-Ray helps well
defined osteolytic lesions and also osteoblastic lesions. But, MRI helps in the
evaluation of the involvement articular cartilage in the form of T2W
hyperintensity. It also helps in evaluation of soft tissue involvement along with
detection of bone marrow edema.
81
SUMMARY
The hip is a stable, major weight-bearing joint with significant mobility.
Hip pain has different etiologies in adults and children. In adults, hip pain may
be caused by intraarticular disorders such as avascular necrosis, arthritis, joint
effusion, tuberculosis and metastatic disease. In children common pathologies
include DDH, Perthe’s disease and infections like tuberculosis. Imaging
modalities used to evaluate hip pain and the appropriateness of particular
studies in different clinical scenarios should be considered. The history and
physical examination, play a key role to develop a differential diagnosis prior
to the selection of imaging tests.
Plain radiography is a widely established, economical investigation
readily available in all kinds of health setups for imaging the hip joint. Plain
film radiography is used in the initial evaluation of any cause of hip pain,
including suspected avascular necrosis, arthritis, infection, dysplasia, and
tumor. Plain film may not detect early pathologies like AVN, also cannot
accurately characterize the articular cartilage pathology and soft tissue
involvement.
In the setting of chronic hip pain, a normal-appearing radiograph, a
nonspecific history and clinical findings can be a difficult diagnostic
dilemma.MR imaging is a valuable tool in the evaluation of hip disorders
because it enables assessment of articular structures, extra-articular soft tissues,
and the osseous structures that can be affected by hip disease. MRI is an
imaging technique that does not require exposure to radiation. MRI of the hips
82
should be performed early in patients with persistent pain and negative
radiography findings.
MR imaging is becoming increasingly useful in the diagnosis and
management of pediatric hip disorders. MR imaging offers several advantages
that are especially important in the pediatric population. Because much of the
pediatric hip is cartilaginous, it is often not optimally imaged with plain
radiography. Most disorders classified as dysplasia can be readily diagnosed
with plain radiography; thus, MR imaging is rarely employed in the routine
work-up of patients with bone dysplasias.
MR imaging is performed to detect AVN in its early stages, thus
allowing early treatment and prevention of subsequent bone destruction. MR
imaging has been shown to be the most sensitive modality for imaging
AVN.MR imaging is uniquely capable of depicting the soft-tissue abnormalities
that occur in arthritis, including synovial inflammation, joint effusion, and
articular cartilage destruction.
Joint effusion and synovial proliferation can be identified better by MRI
than by conventional radiography. In proven cases on plain radiography like
Perthe’s and metastatic disease of Hip MRI helps in better staging of the
disease, extent of pathological involvement and soft tissue extension. MRI is
extremely sensitive to alterations in the bone marrow that may represent
pathology occult to plain radiography of the hips.
83
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90
ANNEXURE PROFORMA
Name of the patient:
Age:
Sex:
Complaint:
Side affected: right hip/ left hip
Findings:
1) AVN of femoral head
X-ray: Normal/cysts/osteoporosis/crescent sign/collapsed subchondral bone/altered head morphology/deformed head
MRI: Normal/bone marrow edema/T2W hyperintense cysts/double line sign/crescent sign/joint space narrowing/altered head contour/deformed head
2) JOINT EFFUSION X-ray: Normal/ widened tear drop distance
MRI: Normal/minimal/moderate/severe
3) OSTEOARTHRITIS X-ray: Normal/osteophytes/sclerosis/narrowing of joint space/deformity of femoral head and acetabulum
MRI: Normal/articular cartilage inhomogeneous T2W signal/high signal of femoral head and acetabulum on T2W/signal loss on T1 in femoral head and neck/subchondral signal loss/head deformity.
4) TB HIP X-ray: Normal/Osteopenia/soft tissue swelling/joint effusion/joint erosions/reduced joint space/deformity of femoral head/ankylosis.
MRI: Normal/bone marrow edema/synovial T2 hyperintensity/joint effusion/subarticular T2W hyperintensity cysts/joint space reduction/deformity of joint.
91
5) PERTHE’S DISEASE X-ray: Normal/ Cessation of femoral epiphsyeal growth/Subchondral fracture/resorption/reossification/healed.
MRI: Normal/ bone marrow edema/Femoral epiphyseal abnormality/ Epiphyseal T2 hyperintensity/metaphyseal hyperintensities/joint space narrowing/ altered femoral head contour/ deformity.
6) DDH X-ray: Normal/ displacement of epiphyses inferomedial to Hilgenreiner’s & Perkin’s/lateral displacement/loss of acetabular angle/broken Shenton’s line/complete dislocation of femoral head.
MRI: Normal/displacement of femoral epiphyses/T2W hyperintensity of epiphyses/both T1 & T2W hypointensity of femoral epiphyses/ complete dislocation of femoral head.
7) METASTASIS: X-ray: Normal/osteolytic/osteoblastic/sclerosis/mixed/joint deformity.
MRI: Normal/altered signal in femoral head & acetabulum/altered contour of femoral head/joint deformity/soft tissue abnormality.
92
ANNEXURE – II : INFORMED CONSENT FORM
I …………………………………………….. have been explained in the
language I understand the procedure to be performed on myself / my ward and
the possible risk / adverse effects of contrast media administration, anesthesia
and the procedure. I the undersigned, give the informed consent with full
knowledge of the risks which have been explained to me.
Date : Name :
Signature of patient/Attender :
93
ANNEXURE – II : MASTER CHART
Sl. No. NAME AGE SEX R/L F.HEAD B.M.EDEMA AVN J.EFFUSION OA TB PERTHES DDH METS
X-RAY MRI X-
RAY MRI X-RAY MRI X-
RAY MRI X-RAY MRI XRAY MRI X-
RAY MRI X-RAY MRI X-
RAY MRI
1 PRADEEP SHETTY 28 M L 3 4 0 1 3 4 0 0 0 0 0 0 0 0 0 0 0 0
2 RAJANNA 40 M R 1 3 0 1 1 3 0 0 0 0 0 0 0 0 0 0 0 0
3 RAJANNA 40 M L 3 4 0 1 3 4 0 0 0 0 0 0 0 0 0 0 0 0
4 PANDARINATH 42 M L 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0
5 THIPPESWAMY 40 M R 1 2 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0
6 THIPPESWAMY 40 M L 0 2 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0
7 VEENA 38 F L 2 3 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0
8 HARINI 28 F L 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0
9 UMADEVI 54 F R 0 2 0 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0
10 UMADEVI 54 F L 0 2 0 1 0 2 0 0 0 0 0 0 0 0 0 0 0 0
11 PRAKASH 60 M R 1 2 0 0 1 2 0 0 0 0 0 0 0 0 0 0 0 0
12 SOMESH 40 M L 2 3 0 0 2 3 0 0 0 0 0 0 0 0 0 0 0 0
13 MANJUNATH 52 M L 1 2 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0
14 SHIVA 25 M R 1 3 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0
15 SALEEM 30 M R 2 4 0 0 2 4 0 0 0 0 0 0 0 0 0 0 0 0
16 HONAPPA 45 M R 1 3 0 1 1 3 0 0 0 0 0 0 0 0 0 0 0 0
17 KRISHNAMURTHY 40 M R 1 2 0 1 1 2 0 0 0 0 0 0 0 0 0 0 0 0
18 RAMAPPA 40 M R 1 3 0 1 1 3 0 0 0 0 0 0 0 0 0 0 0 0
19 RAMADEVI 32 F L 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0
20 SUVARNA 35 F L 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
21 SAMIRAN 40 F R 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0
22 VARSHA 28 F L 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
23 REHMAN MALIK 6 M L 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0
24 SHANKAR NAIK 65 M R 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
25 SHANKAR NAIK 65 M L 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
26 SHIVANNA 25 M R 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
27 HANUMANTHAPPA 12 M R 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0
28 HANUMANTHAPPA 12 M L 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0
94
Sl. No. NAME AGE SEX R/L F.HEAD B.M.EDEMA AVN J.EFFUSION OA TB PERTHES DDH METS
X-RAY MRI X-RAY MRI X-RAY MRI X-RAY MRI X-RAY MRI XRAY MRI X-RAY MRI X-RAY MRI X-RAY MRI
29 UMESH 40 M R 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0 0 0
30 RAJANNA 52 M F 0 0 0 0 0 0 1 3 0 0 0 0 0 0 0 0 0 0
31 MUMTAZ 45 M R 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0
32 NAGAPPA 40 M R 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0
33 VEENA 38 F L 0 0 0 0 0 0 0 0 2 3 0 0 0 0 0 0 0 0
34 RAJAPPA 49 M R 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0
35 SWETHA 21 F R 0 0 0 0 0 0 0 0 3 4 0 0 0 0 0 0 0 0
36 KOTRESH 48 M L 0 0 0 0 0 0 0 0 3 4 0 0 0 0 0 0 0 0
37 GAGANDEEP 34 M R 0 0 0 0 0 0 0 0 2 3 0 0 0 0 0 0 0 0
38 GANGA 28 F R 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0
39 MARUTHI 50 M L 0 0 0 0 0 0 0 0 2 3 0 0 0 0 0 0 0 0
40 HASHAM 30 M R 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0 0 0
41 SATISH 28 M L 0 0 0 0 0 0 0 0 2 2 0 0 0 0 0 0 0 0
42 MANJUNAIK 14 M L 0 0 0 0 0 0 0 0 0 0 3 4 0 0 0 0 0 0
43 JAGADISH 13 M R 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0 0 0
44 PARAMESH 16 M R 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0
45 PRAKASH 25 M R 0 0 0 0 0 0 0 0 0 0 2 3 0 0 0 0 0 0
46 LOKESH 13 M L 0 0 0 0 0 0 0 0 0 0 5 5 0 0 0 0 0 0
47 LATHA 20 F R 0 0 0 0 0 0 0 0 0 0 3 4 0 0 0 0 0 0
48 VEENA 38 F L 0 0 0 0 0 0 0 0 0 0 0 0 5 4 0 0 0 0
49 MAHESH 6 M R 0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 0 0 0
50 VITTALA 8 M L 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 3 0 0
51 RAMANAIK 6 M L 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 0 0
52 SHIVAMURTHY 48 M L 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 3
53 GHOUSE MOHIDDIN 64 M R 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1
95
KEY TO MASTERCHART
AVN of femoral head
X-ray
0 Normal
1 Cysts/osteoporosis/
2 Crescent sign, altered head morphology
3 Collapsed subchondral bone deformed head
MRI
0 Normal
1 Fat signal T1 bright T2 intermediate
2 Blood signal T1 bright T2 bright
3 Fluid signal T1 intermediate T2 bright
4 Fibrosis signal T1 dark T2 dark
Bone marrow
0 Normal
1 Edema
Joint effusion
X-ray
0 Normal
1 Widened tear drop distance
MRI
0 Normal
1 Minimal
2 Moderate
3 Severe
Osteoarthritis
X-ray
0 Normal
1 Narrowing of medial joint space
2 1+ osteophytes + slight sclerosis
3 1+ 2+ deformity of femoral head, acetabulum
4 1+2+3+ marked deformity and large osteophytes.
96
MRI
0 Normal
1 Articular cartilage T2 in homogenous signal
2 High T2 signal of articular cartilage and signal loss in head, neck on T1.
3 1 & 2 + subchondral signal loss due to sclerosis
4 1,2 & 3 head deformity
TB Hip
X-ray
X-ray Normal
1 Osteopenia, soft tissue swelling, joint effusion
2 1 + marginal joint erosions + diminution of joint space
3 1, 2+ cysts, significant loss of joint space
4 Joint destruction
5 Ankylosis
MRI
0 Normal
1 Synovial T2 hyperintensity, joint effusion
2 1+ bone marrow edema
3 1, 2+ subarticular T2 hyper intense cysts joint space reduction
4 1+ 2+ 3+ joint deformity
5 1+ 2+ 3+ marked joint destruction
Perthe’s disease
X-ray
0 Normal
1 Cessation of femoral epiphsyeal growth
2 Subchondral fracture
3 Resorption
4 Reossification
5 Healed / residual
97
MRI
0 Normal
1 Femoral epiphyseal abnormality, bone marrow edema
2 Epiphyseal T2 hyperintensity, metaphyseal hyperintensities
3 Abnormal joint space narrowing , altered contour of femoral head, osteophyte formation
4 Joint destruction deformity
DDH
X-ray
0 Normal, epiphyses inferomedial to Hilgenreiner’s & Perkin’s line
1 Displacement femoral epiphyseal laterally
2 Loss of acetabular angle, broken shenton’s line / Epiphyses displaced superiorly at the level of acetabular rim.
3 Femoral head dislocation completely. Epiphyses displaced to acetabular rim.
MRI
0 Normal
1 Displacement of femoral epiphyses
2 Hyperintensity of epiphyses on T2, bone marrow edema
3 Hypointensity of epiphysis on T1, T2 small epiphysis.
4. Complete dislocation of femoral head
Metastasis
X-ray
0 Normal
1 Osteolytic
2 Osteoblastic, sclerosis
3 Mixed
4 2+ deformed head of femur
MRI
0 Normal
1 Altered signal in the head of femur
2 1+ altered contour of head of femur
3 1+ 2+ soft tissue abnormality