Hip joint

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  • 1. MRI OF THE HIP JOINTS. By .Dr/ABD ALLAH NAZEER. MD
  • 2. Indication Hip joint complaint Pain Trauma Swelling Osteoarthritis. Tumours. Miscellaneous
  • 3. Protocol of examination Axial scout Coronal T1, STIR Axial PD, T2 (gradient, T2*) , axial T1 ?! Sagittal T1 or T2 for the diseased hip If contrast is injected [ Axial, Sagittal ,coronal T1 WIs ]
  • 4. MR anatomy  Ball and socket joint  Acetabulum covers 40% of the femoral head  A fibrocartilagenous labrium ↑ the depth of acetabulum  95% of the femoral neck is intraarticular
  • 5. Axial anatomy
  • 6. Coronal anatomy GMe GMi IOb EOb Ad.B Gr Ad. L
  • 7. Items to be evaluated       Avascular necrosis Transient osteoporosis Perthes disease Slipped femoral epiphysis Trauma, muscle injury Miscellaneous     Labral tears Bursitis Loose bodies & chondromatosis Femoral neck antiversion
  • 8. Avascular necrosis The antrolateral aspect of the femoral head is the commonest site, but no specific area is protected MR sensitive 97% specific 98% Causes:  Trauma  Corticosteroids  Sickle cell disease  Alcoholism  Gusher's disease  Radiation  Collagen disease, pancreatitis
  • 9. Avascular necrosis of the right hip grad1111
  • 10. Avascular necrosis CT findings :  Contour irregularities and fissures  Areas of bone sclerosis and porosis  Structural collapse  Osteoartheritic changes
  • 11. Avascular necrosis I Bone marrow edema II Normal marrow + line III VI Fluid signal Bone sclerosis
  • 12. .Stage I versus transient osteoporosis
  • 13. Stage 1 AVN
  • 14. Stage Radiographs Magnetic resonance [ MRI ] Appearance Marrow edema T1 Low T2 I Normal II Osteoporosis Normal Osteosclerosis marrow + line High Intermediate III Sclerosis + Cortical irregularities Fluid signal Low High IV Collapse +OA Bone sclerosis Low Low High Image
  • 15. Stage 11 :] The line is composed of two layers [ double line sign Inner layer of hyperemic granulation tissue and an outer layer of osteoblastic activity
  • 16. :] Stage 11. The line is composed of two layers [ double line sign Inner layer of hyperemic granulation tissue and an outer layer of osteoblastic activity
  • 17. Stage 11
  • 18. Stage 11
  • 19. Stage 11  The size and location of the lesion will affect the prognosis.  Lesions < 25% of the weight bearing area of the femoral head responds well to core decompression  Medially and centrally located lesions have better prognosis  Contrast injection may be used to assess bone viability ?!!
  • 20. Stage 111
  • 21. Stage 11
  • 22. Stage 11
  • 23. Stage 111
  • 24. Stage III
  • 25. Stage III
  • 26. Stage IV
  • 27. Stage III Stage I
  • 28. Osteoarthritis Stage IV
  • 29. Transient osteoporosis Unknown etiology Middle aged over weight males Male : female= 3:1 Usually unilateral [left hip in females] Resolves spontaneously in 6-8 months Pain & limp with no history of trauma
  • 30. Transient osteoporosis X ray Normal or ↓ bone density Bone scan ↑ uptake in the femoral head and neck MRI Bone marrow edema in the head and neck DD AVN, bone infarct, stress fracture Septic arthritis, primary and metastatic tumors
  • 31. Transient osteoporosis
  • 32. Transient osteoporosis  Some cases may demonstrate a line after clearance of edema suggesting that TOH as a precursor of AVN
  • 33. Transient osteoporosis
  • 34. Transient osteoporosis
  • 35. Bilateral Transient osteoporosis
  • 36. Transient osteoporosis 7/9/99 , 9/12/99
  • 37. Transient osteoporosis with follow up
  • 38. Subchondral fracture    In young may be a stress fracture In elderly may be the squeal of osteoporosis Leads to extensive marrow edema which may progress to femoral head collapse and secondary OA  DD include AVN , TOH , Rapidly destructive OA  MR shows a hypo intense line
  • 39. Subchondral fracture
  • 40. Legg- Calve- Perthes diseases  Avascular necrosis of the bony femoral epiphysis  Unknown etiology  Children 4-9 years old boys: girls= 4:1  Children with knee pain must be examined for hip pathology
  • 41. Legg- Calve- Perthes diseases Stages I Anterior aspect of the epiphysis II Anterior aspect of the epiphysis + metaphyseal reaction III All of the epiphysis+ metaphyseal reaction IV Flattening and collapse
  • 42. Early stage I : Fracture with gas
  • 43. Stage 11:
  • 44. 8m 18m 56m Healed epiphyseal changes + residual metaphyseal changes
  • 45. Legg- Calve- Perthes diseases MR value  Morphology and signal characteristics of femoral epiphysis  Normal epiphysis shows bright signal in T1 (Fat marrow)  Intra articular effusion
  • 46. Legg- Calve- Perthes diseases stage 111
  • 47. I Anterior aspect of the epiphysis IV Flattening and collapse Spectrum of Perthes disease
  • 48. Slipped capital femoral epiphysis  SCFE is a childhood disorder of the hip characterized by Posterior inferior displacement of the proximal femoral capital epiphysis  Unknown etiology and the current theory is (trauma, obesity, hormonal disorder)  Bilateral in 20-25% of cases.  Associated avascular necrosis of the in 15%. Classified into mild, moderate and severe according to the degree of slippage or acute and chronic according to the duration of symptoms (acute less than 3 weeks and chronic more than 3 weeks).
  • 49. Slipped capital femoral epiphysis
  • 50. Slipped capital femoral epiphysis
  • 51. Slipped femoral epiphysis with normal marrow signal
  • 52. Muscle sprains I II III Muscle edema with preserved morphology Disruption of up to 50% of muscle fibers with Subacute blood at the site of tear Complete muscle tear ± retraction and atrophy [ best seen in axial images with comparison to normal side ] Grade I muscle sprain of the obturator externus and adductor longus
  • 53. Coronal STIR images show tear at the hamstring muscles at ischial tuberosity.
  • 54. Complete rupture of the quadrates femoris tendon
  • 55. Head rectus femoris head muscle and deep tendon injury.
  • 56. Grade II tear of semitendinosis muscle
  • 57. MR hip arthrogram  Normal saline or Gd -DTPA  Mixing 0.1 ml of Gd with 20 ml saline + 5ml of iodinated contrast + Lidocaine  The joint capacity is 8-20 ml  Surface coil  FOV = 14 -16 CM  Slice thickness 3-5 mm  T1 weighted images without and with fat suppression  Sagittal , coronal and axial oblique should be obtained  STIR images for the whole pelvis should be included  Labral abnormalities  Loose bodies  Osteo – chondral lesions
  • 58. Labral tears  Normal labrum is a triangular low signal structure at the superior and inferior acetabular margins.  Surface coil  MR arthrogram. Labral tears are part of femoroacetabular impingement and can occur  due to trauma or secondary to degeneration.
  • 59. MR arthrogram of the left hip showing an anterior paralabral cyst(arrow) and a complex degenerative tear of the anterior labrum
  • 60. Brusitis  Bursae are sacs of synovial tissue  Prevent friction between bones and soft tissues.  15-20 Bursae around the hip joint  Trochnteric  Ischeo-gluteal  Iliopsoas : the largest in the body  10% - 15% communicate with the joint
  • 61. Sagittal and coronal STIR images show ilioposas bursitis
  • 62. AXIAL CT Scan and axial STIR MRI images show ilioposas bursitis
  • 63. Coronal STIR images show left greater trochanter bursa.
  • 64. Axial images show left greater trochanter bursa
  • 65. Femro - acetabular impingement  Micro trauma from impingement of the femoral head against the acetabulum  Abnormal signal of the acetabular rim and femoral head  Labral tears and cartilage degeneration are seen  Clinically recurrent attacks of severe hip and groin pain  Pain increases by flexion and internal rotation and weight bearing
  • 66. Femro - acetabular impingement
  • 67. Femro - acetabular impingement with avascular head necrosis
  • 68. Effusion, osteoarthritis  Narrowing of the superior joint space  Suprolateral migration of the femur  Osteophytic lipping  Subchondral sclerosis  Subarticular pseudo cysts  Effusion  Vacuum phenomena
  • 69. Osteoarthritis, pseudo-cyst changes, bone marrow edema, synovial profilration , loose body and effusion
  • 70. Loose bodies Etiology  Trauma  Osteoarthritis  PVNS  AVN  Synovial chondromatosis  Arthritis [ gout , septic , rheumatoid,…]
  • 71. Loose bodies/ osteochondromatosis Clinical  Pain  Locking  Clicking  Snapping
  • 72. Synovial osteochondromatosis Metaplasia of subsynovial soft tissues [Affects any joint [ knee , hip , elbow Age incidence 40 years M:F=2:1 Findings  Widening of the joint space  Bone erosions  Intra articular loose bodies  Secondary osteoarthritis changes cartilage formation
  • 73. Synovial osteochondromatosis
  • 74. Synovial osteochondromatosis
  • 75. Types of acetabular of fracture
  • 76. Stress fracture of the femoral neck
  • 77. Femoral neck antiversion angle
  • 78. Femoral neck antiversion angle 0-1 Y 2Y 3 -5 Y = 30 – 50º = 30º = 25º 6- 12 Y = 20º 12- 15 Y = 17º 16-20 Y = 11º 20 Y = 8º