Clinical Review

Imaging for Nonarthritic Hip Pathology

Am J Orthop. 2017 January;46(1):17-22

References

1. McCall DA, Safran MR. MRI and arthroscopy correlations of the hip: a case-based approach. Instr Course Lect . 2012;61:327-344.

2. Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med . 2012;40(12):2720-2724.

3. Campbell SE. Radiography of the hip: lines, signs, and patterns of disease. Semin Roentgenol . 2005;40(3):290-319.

4. Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am . 2008;90(suppl 4):47-66.

5. Malviya A, Raza A, Witt JD. Reliability in the diagnosis of femoroacetabular impingement and dysplasia among hip surgeons: role of surgeon volume and experience. Hip Int . 2016;26(3):284-289.

6. Nepple JJ, Martel JM, Kim YJ, Zaltz I, Clohisy JC, Group AS. Do plain radiographs correlate with CT for imaging of cam-type femoroacetabular impingement? Clin Orthop Relat Res . 2012;470(12):3313-3320.

7. Kosuge D, Cordier T, Solomon LB, Howie DW. Dilemmas in imaging for peri-acetabular osteotomy: the influence of patient position and imaging technique on the radiological features of hip dysplasia. Bone Joint J . 2014;96(9):1155-1160.

9. Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Clin Orthop Relat Res . 2003;(407):241-248.

10. Griffin JW, Weber AE, Kuhns B, Lewis P, Nho SJ. Imaging in hip arthroscopy for femoroacetabular impingement: a comprehensive approach. Clin Sports Med . 2016;35(3):331-344.

11. Nepple JJ, Lehmann CL, Ross JR, Schoenecker PL, Clohisy JC. Coxa profunda is not a useful radiographic parameter for diagnosing pincer-type femoroacetabular impingement. J Bone Joint Surg Am . 2013;95(5):417-423.

12. Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br . 1999;81(2):281-288.

13. Dunn DM. Anteversion of the neck of the femur; a method of measurement. J Bone Joint Surg Br . 1952;34(2):181-186.

14. Meyer DC, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Orthop Relat Res . 2006;(445):181-185.

15. Hellman MD, Mascarenhas R, Gupta A, et al. The false-profile view may be used to identify cam morphology. Arthroscopy . 2015;31(9):1728-1732.

16. Barton C, Salineros MJ, Rakhra KS, Beaulé PE. Validity of the alpha angle measurement on plain radiographs in the evaluation of cam-type femoroacetabular impingement. Clin Orthop Relat Res . 2011;469(2):464-469.

17. Nepple JJ, Carlisle JC, Nunley RM, Clohisy JC. Clinical and radiographic predictors of intra-articular hip disease in arthroscopy. Am J Sports Med . 2011;39(2):296-303.

18. Murphy SB, Ganz R, Muller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am . 1995;77(7):985-989.

19. Mast NH, Impellizzeri F, Keller S, Leunig M. Reliability and agreement of measures used in radiographic evaluation of the adult hip. Clin Orthop Relat Res . 2011;469(1):188-199.

20. Monazzam S, Bomar JD, Cidambi K, Kruk P, Hosalkar H. Lateral center-edge angle on conventional radiography and computed tomography. Clin Orthop Relat Res . 2013;471(7):2233-2237.

21. Weber AE, Jacobson JA, Bedi A. A review of imaging modalities for the hip. Curr Rev Musculoskelet Med . 2013;6(3):226-234.

22. Bencardino JT, Palmer WE. Imaging of hip disorders in athletes. Radiol Clin North Am . 2002;40(2):267-287, vi-vii.

23. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med . 2004;32(7):1668-1674.

24. Mintz DN, Hooper T, Connell D, Buly R, Padgett DE, Potter HG. Magnetic resonance imaging of the hip: detection of labral and chondral abnormalities using noncontrast imaging. Arthroscopy . 2005;21(4):385-393.

25. Blankenbaker DG, De Smet AA, Keene JS, Fine JP. Classification and localization of acetabular labral tears. Skeletal Radiol . 2007;36(5):391-397.

26. Aydingöz U, Oztürk MH. MR imaging of the acetabular labrum: a comparative study of both hips in 180 asymptomatic volunteers. Eur Radiol . 2001;11(4):567-574.

27. Gold GE, Chen CA, Koo S, Hargreaves BA, Bangerter NK. Recent advances in MRI of articular cartilage. AJR Am J Roentgenol . 2009;193(3):628-638.

28. Liong SY, Whitehouse RW. Lower extremity and pelvic stress fractures in athletes. Br J Radiol . 2012;85(1016):1148-1156.

Computed Tomography

The benefits of computed tomography (CT) outweigh the risk of radiation exposure. CT is most useful in characterizing osseous morphology.²¹ In FAI cases, CT can distinguish acetabular version abnormalities from femoral torsion (Figures 7A-7C), entities with very different treatment approaches.²¹

CT of the entire pelvis allows accurate objective measurement of acetabular version. Software advancements provide 3-dimensional reconstructions (Figure 8) and afford better appreciation of symptomatic pathomorphology by patients and more sophisticated measures by surgeons.

Whereas CT reveals osseous structure, magnetic resonance imaging (MRI) demonstrates acuity and response of the osseous structures to the clinical condition (eg, bone marrow edema).

Magnetic Resonance Imaging

MRI is becoming essential in the work-up for nonarthritic hip pain.^11,22 It is used for assessment of osseous, chondral, and musculotendinous soft tissues. Further, it affords appreciation of outside-the-hip-joint pathology that may mimic joint-centered pathology.

MRI techniques range from noncontrast to indirect and direct magnetic resonance arthrography (MRA).²² Indirect MRA is performed with contrast medium administered through an intravenous line. Direct MRA has contrast administered intra-articularly and is more sensitive and specific for labral tears and ligamentous injury.²³ Excellent detection of intra-articular pathology on noncontrast studies questions the need for MRA.²⁴ Nevertheless, direct MRA can also be used as a therapeutic procedure when lidocaine is included in the injected gadolinium.

Labral tears, focal chondral defects, and stress or insufficiency fractures are important differentials in the work-up for nonarthritic hip pain. Over the dysplasia-to-FAI spectrum, MRI distinguishes symptomatic pathoanatomy from asymptomatic anatomical variants by revealing underlying bone edema. Capsule findings should also be considered.²¹The most practical classification of labral tears, proposed by Blankenbaker and colleagues,²⁵ is based on tear type (frayed, unstable, flap), location, and extent. More than half of labral tears occur in the anterosuperior quadrant of the labrum.²⁵

On noncontrast MRI, these tears appear as linear T2 hyperintensity within or through an otherwise homogeneously dark labrum. Accurate findings can be elusive because of variant labral anatomy (Figures 9A, 9B).²⁶Findings regarding the inside of the labrum can be signs of an overlying problem, such as FAI (Figures 10A-10C).

Chondral damage is identified much as labral tears are. With chondral injury, the normal intermediate signal is interrupted by a fluid-intense signal extending to the subchondral bone. A fat-saturated T2or short-tau inversion recovery (STIR) sequence is useful in emphasizing this finding.²⁷

MRI detects osseous pathology from surrounding soft-tissue edema and bone remodeling to stress and fragility fractures. In athletes, the most common fractures are pubic rami, sacral, and apophyseal avulsion fractures.²⁸ In all patients, attention should be given to the lower spine and the proximal femurs. Aside from MRI, nuclear medicine bone scan might also identify active osseous reaction representative of a fracture.

Conclusion

The work-up for nonarthritic hip pain substantiates differential diagnoses. A case’s complexity determines the course of diagnostic imaging. At presentation and at each step in the work-up, it is imperative to evaluate the entire clinical picture. The prudent clinician uses both clinical and radiographic findings to make the diagnosis and direct treatment.

References

1. McCall DA, Safran MR. MRI and arthroscopy correlations of the hip: a case-based approach. Instr Course Lect . 2012;61:327-344.

2. Register B, Pennock AT, Ho CP, Strickland CD, Lawand A, Philippon MJ. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. Am J Sports Med . 2012;40(12):2720-2724.

3. Campbell SE. Radiography of the hip: lines, signs, and patterns of disease. Semin Roentgenol . 2005;40(3):290-319.

4. Clohisy JC, Carlisle JC, Beaulé PE, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am . 2008;90(suppl 4):47-66.

5. Malviya A, Raza A, Witt JD. Reliability in the diagnosis of femoroacetabular impingement and dysplasia among hip surgeons: role of surgeon volume and experience. Hip Int . 2016;26(3):284-289.

6. Nepple JJ, Martel JM, Kim YJ, Zaltz I, Clohisy JC, Group AS. Do plain radiographs correlate with CT for imaging of cam-type femoroacetabular impingement? Clin Orthop Relat Res . 2012;470(12):3313-3320.

8. Tannast M, Fritsch S, Zheng G, Siebenrock KA, Steppacher SD. Which radiographic hip parameters do not have to be corrected for pelvic rotation and tilt? Clin Orthop Relat Res . 2015;473(4):1255-1266.

9. Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Clin Orthop Relat Res . 2003;(407):241-248.

10. Griffin JW, Weber AE, Kuhns B, Lewis P, Nho SJ. Imaging in hip arthroscopy for femoroacetabular impingement: a comprehensive approach. Clin Sports Med . 2016;35(3):331-344.

11. Nepple JJ, Lehmann CL, Ross JR, Schoenecker PL, Clohisy JC. Coxa profunda is not a useful radiographic parameter for diagnosing pincer-type femoroacetabular impingement. J Bone Joint Surg Am . 2013;95(5):417-423.

12. Reynolds D, Lucas J, Klaue K. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br . 1999;81(2):281-288.

13. Dunn DM. Anteversion of the neck of the femur; a method of measurement. J Bone Joint Surg Br . 1952;34(2):181-186.

14. Meyer DC, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Orthop Relat Res . 2006;(445):181-185.

15. Hellman MD, Mascarenhas R, Gupta A, et al. The false-profile view may be used to identify cam morphology. Arthroscopy . 2015;31(9):1728-1732.

16. Barton C, Salineros MJ, Rakhra KS, Beaulé PE. Validity of the alpha angle measurement on plain radiographs in the evaluation of cam-type femoroacetabular impingement. Clin Orthop Relat Res . 2011;469(2):464-469.

17. Nepple JJ, Carlisle JC, Nunley RM, Clohisy JC. Clinical and radiographic predictors of intra-articular hip disease in arthroscopy. Am J Sports Med . 2011;39(2):296-303.

18. Murphy SB, Ganz R, Muller ME. The prognosis in untreated dysplasia of the hip. A study of radiographic factors that predict the outcome. J Bone Joint Surg Am . 1995;77(7):985-989.

19. Mast NH, Impellizzeri F, Keller S, Leunig M. Reliability and agreement of measures used in radiographic evaluation of the adult hip. Clin Orthop Relat Res . 2011;469(1):188-199.

20. Monazzam S, Bomar JD, Cidambi K, Kruk P, Hosalkar H. Lateral center-edge angle on conventional radiography and computed tomography. Clin Orthop Relat Res . 2013;471(7):2233-2237.

21. Weber AE, Jacobson JA, Bedi A. A review of imaging modalities for the hip. Curr Rev Musculoskelet Med . 2013;6(3):226-234.

22. Bencardino JT, Palmer WE. Imaging of hip disorders in athletes. Radiol Clin North Am . 2002;40(2):267-287, vi-vii.

23. Byrd JW, Jones KS. Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med . 2004;32(7):1668-1674.

24. Mintz DN, Hooper T, Connell D, Buly R, Padgett DE, Potter HG. Magnetic resonance imaging of the hip: detection of labral and chondral abnormalities using noncontrast imaging. Arthroscopy . 2005;21(4):385-393.

25. Blankenbaker DG, De Smet AA, Keene JS, Fine JP. Classification and localization of acetabular labral tears. Skeletal Radiol . 2007;36(5):391-397.

26. Aydingöz U, Oztürk MH. MR imaging of the acetabular labrum: a comparative study of both hips in 180 asymptomatic volunteers. Eur Radiol . 2001;11(4):567-574.

27. Gold GE, Chen CA, Koo S, Hargreaves BA, Bangerter NK. Recent advances in MRI of articular cartilage. AJR Am J Roentgenol . 2009;193(3):628-638.

28. Liong SY, Whitehouse RW. Lower extremity and pelvic stress fractures in athletes. Br J Radiol . 2012;85(1016):1148-1156.

Imaging for Nonarthritic Hip Pathology

References

Computed Tomography

Magnetic Resonance Imaging

Conclusion

Pages

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