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Imaging adult hip pain
James F Griffith
Department of Imaging and Interventional Oncology
Prince of Wales Hospital
What’s hip in hip imaging
º  Early onset OA
º  Hip dysplasia
º  Femoroacetabular impingement (FAI)
º  Non-FAI impingem...
Acetabular lines

Sourcil ‘eyebrow’ [Fr]
Acetabulum
‘vinegar bowl’ [Lt]
Hip dysplasia - too shallow

Mild

Moderate

Severe

Acetabulum should cover ~ 80% of the femoral head
Hip dysplasia - too deep

normal

profunda

º  Floor of acetabular fossa extends beyond ilioischial line
Centre-edge (CE) angle

º  Normal centre-edge (CE) angle 25 - 400
º  Abnormal < 200 or > 400

Beltran LS et al AJR 2012
Acetabular index

º  Normal acetabular index 0 -10 degrees
º  Negative value indicates profunda
Acetabular retroversion

Three radiographic signs of acetabular retroversion
Proximal femoral morphology

head-neck junction
‘pistol-grip deformity’

Osseous bump

Os supra-acetabulare

º  These rad...
Femoroacetabular Impingement
(FAI)
º  Not as common in the East
º  Leads to premature labral injury & premature OA
º  C...
Cam-type
Cam-type

α=39°

Normal alpha angle < 550

α=64°
Cam-type

Insert Movie 1

Most severe cam-type deformity at anterosuperior plane →
renewed interest in radial hip imaging ...
Pincher (protrusio)
global overcoverage

Normal

Protrusio
Pincher (retroversion)
Focal overcoverage
Femoral torsion

↓ femoral torsion
Impingement in
internal rotation

↑ femoral torsion
Impingement in
external rotation
Su...
Femoral torsion

Normal femoral torsion = 12- 150

Sutter R et al Radiology 2012
FAI – controversy
º  Very high no. of asymptomatic radiographic deformity
º  Only small number → osteoarthritis

º 
º ...
Pelvic tilt

>Pelvic tilt ↑ acetabular coverage → ↑ likelihood of impingement
Sutter R et al AJR 2013
Morphology – so what ??
Shallow	
  acetabulum	
  	
  

Deep	
  acetabulum	
  

Retroverted	
  acetabulum	
  	
  

Proximal...
Labral tear description

Degenerate

Frayed

Partial thickness

Full thickness
Labral tear description

Degenerate

Frayed
Labral tear description

Partial thickness

Full thickness
Labral / paralabral cyst
Labral tear localisation

12
3
9
6

• Anterior
• Superior
• Posterior

Reverse clock-face
Labral tears

55% tears occur just
between 3 – 12 o’clock
95% occur between
3-12 o’clock & beyond

12
3
Sublabral sulcus in 20%

At anteroinferior & posteroinferior aspects
Iliopsoas impingement

º  Isolated anterior labral tear at 3 o’ clock
º  Considered due to iliopsoas impingement
Blanken...
Articular cartilage

Hip cartilage very thin (3.5mm - 4mm in total)
Articular cartilage

Cartilage delamination
& ligamentum teres tear
Hip Traction

No traction

Traction
Llopis E et al AJR 2008
Arthrography – Yes or No
º  Direct arthrography more sensitive

º  Loose effect of seeing hip joint effusion
º  Moderat...
3.0T	
  or	
  1.5T	
  
Cardiac	
  coil	
  (6	
  element	
  SENSE)	
  
T2	
  SPIR	
  obl	
  cor	
  

PD	
  obl	
  cor	
  

...
Ischiofemoral impingement
º  Impingement of quadratus femoris m.

º  More common in women
º  Deep-seated buttock pain
º...
Ischiofemoral impingement

º  Ischiofemoral distance
º  13.5mm ±5mm in patients vs 23 ±8mm controls
Torriani M et al AJR...
Ischiofemoral impingement

Insert Movie 2
Gr. trochanter - facets
Anterior facet
Gr. trochanter - facets
Lateral
facet
Gr. trochanter - facets
Posterosuperior
& Posterior
facets
Gr. trochanter – tendon insertions
Glut. minimus
Glut medius
Gr. trochanter – tendon insertions
Gr. trochanter – bursa
Glut. Min. bursa
Glut med bursa
Trochanteric
Abductor tendons

Gluteus minimus

Gluteus medius
Abductor tendon tears

Peritendinitis

Gluteus minimus tear
Abductor tendon tears

Gluteus minimus avulsion
Abductor tendinosis & tears

º  Very high % are bilateral & asymptomatic
º  Tears much more likely to be symptom indicat...
45 volunteers (38 years)… 3T MRI
º  69% had labral tears

º  13% has labral / paralabral cysts
º  24% had chondral defe...
Hip imaging is hip!
º  Things might look a bit messy
º  Plenty to be happy about!

Thank you!
Msk imaging adult hip pain j griffith
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Msk imaging adult hip pain j griffith

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Msk imaging adult hip pain j griffith

  1. 1. Imaging adult hip pain James F Griffith Department of Imaging and Interventional Oncology Prince of Wales Hospital
  2. 2. What’s hip in hip imaging º  Early onset OA º  Hip dysplasia º  Femoroacetabular impingement (FAI) º  Non-FAI impingement syndromes of hip º  Abductor tendon problems (greater trochanteric pain syn.)
  3. 3. Acetabular lines Sourcil ‘eyebrow’ [Fr] Acetabulum ‘vinegar bowl’ [Lt]
  4. 4. Hip dysplasia - too shallow Mild Moderate Severe Acetabulum should cover ~ 80% of the femoral head
  5. 5. Hip dysplasia - too deep normal profunda º  Floor of acetabular fossa extends beyond ilioischial line
  6. 6. Centre-edge (CE) angle º  Normal centre-edge (CE) angle 25 - 400 º  Abnormal < 200 or > 400 Beltran LS et al AJR 2012
  7. 7. Acetabular index º  Normal acetabular index 0 -10 degrees º  Negative value indicates profunda
  8. 8. Acetabular retroversion Three radiographic signs of acetabular retroversion
  9. 9. Proximal femoral morphology head-neck junction ‘pistol-grip deformity’ Osseous bump Os supra-acetabulare º  These radiographic abnormalities are reliable
  10. 10. Femoroacetabular Impingement (FAI) º  Not as common in the East º  Leads to premature labral injury & premature OA º  Cam-type, pincher-type & mixed type
  11. 11. Cam-type
  12. 12. Cam-type α=39° Normal alpha angle < 550 α=64°
  13. 13. Cam-type Insert Movie 1 Most severe cam-type deformity at anterosuperior plane → renewed interest in radial hip imaging (should use 600 as cutoff) Sutter R et al Radiology 2012
  14. 14. Pincher (protrusio) global overcoverage Normal Protrusio
  15. 15. Pincher (retroversion) Focal overcoverage
  16. 16. Femoral torsion ↓ femoral torsion Impingement in internal rotation ↑ femoral torsion Impingement in external rotation Sutter R et al Radiology 2012
  17. 17. Femoral torsion Normal femoral torsion = 12- 150 Sutter R et al Radiology 2012
  18. 18. FAI – controversy º  Very high no. of asymptomatic radiographic deformity º  Only small number → osteoarthritis º  º  º  º  Level of activity clearly important Considerable inherent variability in imaging assessment FAI is a clinical diagnosis “Acetabular ±femoral morphological tendency to FAI” Hartofilakidas G et al JBJS 2011 Hartofilakidis G et al JBJS 2011 deBruin F et al Eur Radiol 2013
  19. 19. Pelvic tilt >Pelvic tilt ↑ acetabular coverage → ↑ likelihood of impingement Sutter R et al AJR 2013
  20. 20. Morphology – so what ?? Shallow  acetabulum     Deep  acetabulum   Retroverted  acetabulum     Proximal  femoral  dysplasia     º  Very little can be done º  Operative success questionable º  Helps to explain symptoms º  Potential for prevention Hip pain, Labral injury Premature OA
  21. 21. Labral tear description Degenerate Frayed Partial thickness Full thickness
  22. 22. Labral tear description Degenerate Frayed
  23. 23. Labral tear description Partial thickness Full thickness
  24. 24. Labral / paralabral cyst
  25. 25. Labral tear localisation 12 3 9 6 • Anterior • Superior • Posterior Reverse clock-face
  26. 26. Labral tears 55% tears occur just between 3 – 12 o’clock 95% occur between 3-12 o’clock & beyond 12 3
  27. 27. Sublabral sulcus in 20% At anteroinferior & posteroinferior aspects
  28. 28. Iliopsoas impingement º  Isolated anterior labral tear at 3 o’ clock º  Considered due to iliopsoas impingement Blankenbaker DG et al AJR 2012
  29. 29. Articular cartilage Hip cartilage very thin (3.5mm - 4mm in total)
  30. 30. Articular cartilage Cartilage delamination & ligamentum teres tear
  31. 31. Hip Traction No traction Traction Llopis E et al AJR 2008
  32. 32. Arthrography – Yes or No º  Direct arthrography more sensitive º  Loose effect of seeing hip joint effusion º  Moderate post-arthropathy pain is common, delayed & lasts~2 days º  Non-invasive → invasive investigation º  Time consuming, ↑ cost, ↓ unit productivity
  33. 33. 3.0T  or  1.5T   Cardiac  coil  (6  element  SENSE)   T2  SPIR  obl  cor   PD  obl  cor   PD  FS  obl  ax   PD  FS  obl  sag   ±  T2  FS    (whole  pelvis)   ±PD  axial  (whole  pelvis)    
  34. 34. Ischiofemoral impingement º  Impingement of quadratus femoris m. º  More common in women º  Deep-seated buttock pain º  Often bilateral, but only one side symptomatic º  Can respond to steroid/ long acting LA injection
  35. 35. Ischiofemoral impingement º  Ischiofemoral distance º  13.5mm ±5mm in patients vs 23 ±8mm controls Torriani M et al AJR 2009
  36. 36. Ischiofemoral impingement Insert Movie 2
  37. 37. Gr. trochanter - facets Anterior facet
  38. 38. Gr. trochanter - facets Lateral facet
  39. 39. Gr. trochanter - facets Posterosuperior & Posterior facets
  40. 40. Gr. trochanter – tendon insertions Glut. minimus Glut medius
  41. 41. Gr. trochanter – tendon insertions
  42. 42. Gr. trochanter – bursa Glut. Min. bursa Glut med bursa Trochanteric
  43. 43. Abductor tendons Gluteus minimus Gluteus medius
  44. 44. Abductor tendon tears Peritendinitis Gluteus minimus tear
  45. 45. Abductor tendon tears Gluteus minimus avulsion
  46. 46. Abductor tendinosis & tears º  Very high % are bilateral & asymptomatic º  Tears much more likely to be symptom indicative Blankenbaker DG et al Skel Radiol 2008
  47. 47. 45 volunteers (38 years)… 3T MRI º  69% had labral tears º  13% has labral / paralabral cysts º  24% had chondral defects º  11% acetabular bone oedema º  22% has fibrocystic change in head/neck region º  20% had osseous bumps º  16% had subchondral cysts º  Overall, 73% has some abnormality Register B et al Amer Jour Sports Med 2013
  48. 48. Hip imaging is hip! º  Things might look a bit messy º  Plenty to be happy about! Thank you!

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