Imaging & Diagnostics

Diagnosis of Hip Complaints: Arthritis & Neoplasms Part I | El Paso, TX.

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Degenerative Joint Disease (DJD)

Macroscopic & Microscopic Appearance of Normal vs. Damaged Articular Hyaline Cartilage by DJD

Hip Osteoarthritis (OA) aka Osteoarthrosis

  • Symptomatic and potentially disabling DJD
  • Progressive damage and loss of the articular cartilage causing denudation and eburnation of articular bone
  • Cystic changes, osteophytes and gradual joint destruction
  • Develops d/t repeated joint loading and microtrama
  • Obesity, metabolic/genetic factors
  • Secondary Causes: trauma, FAI syndrome, osteonecrosis, pyrophosphate crystal depostion, previous inflammatory arthritis, Slipped Capital Femoral Epiphysis, Leg-Calves-Perthes disease in children etc.
  • Hip OA, 2nd m/c after knee OA. Women>men
  • 88-100 symptomatic cases per 100000

Radiography is the Modality of Choice for the Dx and Grading of DJD

  • Special imaging is not required unless other complicating factors exist
  • Acetabular-femoral joint is divided into superior, axial and medial compartments/spaces
  • Normal joint space at the superior compartment should be 3-4-mm on the AP hip/pelvis view
  • Understanding the pattern of hip joint narrowing/migration helps with the DDx of DJD vs. Inflammatory arthritis
  • In DJD, m/c hip narrowing is superior-lateral (non-uniform) vs. inflammatory axial (uniform)

AP Hip Radiograph Demonstrates DJD

  • With non-uniform loss of joint space (superior migration), large subcortical cysts and subchondral sclerosis
  • Radiographic features:
  • Like with any DJD changes: radiography will reveal L.O.S.S.
  • L: loss of joint space (non-uniform or asymmetrical)
  • O: osteophytes aka bony proliferation/spurs
  • S: Subchondral sclerosis/thickening
  • S: Subcortical aka subchondral cysts “geodes”
  • Hip migration is m/c superior resulting in a “tilt deformity”

Radiographic Presentation of Hip OA May Vary Depending On Severity

  • Mild OA: mild reduction of joint space often w/o marked osteophytes and cystic changes
  • During further changes, collar osteophytes may affect femoral head-neck junction with more significant jint space loss and subchondral bone sclerosis (eburnation)
  • Cyst formation will often occur along the acetabular and femoral head subarticular/subchondral bone “geodes” and usually filled with joint fluid and some intra-articular gas
  • Subchondral cysts may be occasionally very large and DDx from neoplasms or infection or other pahtology

Coronal Reconstructed CT Slices in Bone Window

  • Note moderate joint narrowing that appears non-uniform
  • Sub-chondral cysts formation (geodes) are noted along the acetabular and femoral head subchondral bone
  • Other features include collar osteophytes along head-neck junction
  • Dx: DJD of moderate intensity
  • Referral to the Orthopedic surgeon will be helpful for this patient

AP Pelvis (below first image), AP Hip Spot (below second image) CT Coronal Slice

  • Note multiple subchondral cysts, sever non-uniform joint narrowing (superior-lateral) and subchondral sclerosis with osteophytes
  • Advanced hip arthrosis

Severe DJD, Left Hip

  • When reading radiological reports pay particular attention to grading of hip OA
  • Most severe (advanced) OA cases require total hip arthroplasty (THA)
  • Refer your patients to the Orthopedic surgeon for a consultation
  • Most mild cases are good candidate for conservative care

Hip Arthroplasty aka Hip Replacement

  • Can be total or hemiarthroplasty
  • THA can be metal on metal, metal on polythelen and ceramic on ceramic
  • Hybrid acetabular component with polyethelen and metal backing is also used (above right image)
  • THA can be cemented (above right image) and non-cemented (above left image)
  • Non-cemented arthroplasty is used on younger patients utilizing porous metallic parts allowing good fusion and bone ingrowth into the prosthesis

Failed THA May Develop

  • Most develop within first year and require revision
  • Femoral stem may fracture (above left)
  • Postsurgical infection (above right)
  • Fracture adjacent to prosthesis (stress riser)
  • Particle disease

Femoroacetabular Impingement Syndrome

  • (FAI): abnormality of normal morphology of the hip leading to eventual  cartilage damage and premature DJD
  • Clinically: hip/groin pain aggravated by sitting (e.g. hip flexed & externally rotated). Activity related pain on axial loading esp. with hip flexion (e.g. walking uphill)
  • Pincer type acetabulum: > in middle age women potentially  many causes
  • CAM-type deformity: > in men in 20-50 m/c 30s
  • Mixed type (pincer-CAM) is most frequent
  • Up until the 90s FAI was not well-recongnised

FAI Syndrome

  • CAM-type FAI syndrome
  • Radiography can be a reliable Dx tool
  • X-radiography findings: osseous bump on the lateral aspect of femoral head-neck junction. Pistol-grip deformity. Loss of normal head sphericity. Associated features: os acetabule, synovial herniation pit (Pit’s pit). Evidence of DJD in advanced cases
  • MRI and MR arthrography (most accurate Dx of labral tear) can aid the diagnosis of labral tear and other changes of FAI
  • Referral to the Orthopedic surgeon is necessary to prevent DJD progression and repair labral abnormalities. Late Dx may lead to irreversible changes of DJD

AP Pelvis: B/L CAM-type FAI syndrome

Pincer-Type FAI with Acetabula Over-Coverage

  • Key radiographic signs: “Cross-over sign” and abnormal center-edge and Alfa-angle evaluation methods

Dx of FAI

  • Center-edge angle (above the first image) and Alfa-angle (above the second image)
  • B/L CAM-type FAI with os acetabule (above right image)

MR Arthrography

Hip Pelvis Arthritis & Neoplasms

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email: coach@elpasofunctionalmedicine.com

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