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1
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Bateman EA, Fortin CD, Guo M. Musculoskeletal mimics of lumbosacral radiculopathy. Muscle Nerve 2025; 71:816-832. [PMID: 38726566 PMCID: PMC11998970 DOI: 10.1002/mus.28106] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 04/14/2024] [Accepted: 04/23/2024] [Indexed: 04/16/2025]
Abstract
Electrodiagnostic evaluations are commonly requested for patients with suspected radiculopathy. Understanding lower extremity musculoskeletal conditions is essential for electrodiagnostic medicine specialists, as musculoskeletal disorders often mimic or coexist with radiculopathy. This review delineates radicular pain from other types originating from the lumbosacral spine and describes musculoskeletal conditions frequently mimicking radiculopathy, such as those that cause radiating pain and sensorimotor dysfunction. In clinical evaluation, a history of pain radiating along a specific dermatomal territory with associated sensory disturbance suggests radiculopathy. Physical examination findings consistent with radiculopathy include myotomal weakness, depressed or absent muscle stretch reflexes, focal atrophy along a discrete nerve root territory, and potentially positive dural tension maneuvers like the straight leg raise. However, electrodiagnostic medicine specialists must be knowledgeable of musculoskeletal mimics, which may manifest as incomplete radiation within or beyond a dermatomal territory, non-radiating pain, tenderness, and give-way weakness, in the context of a normal neurological examination. A systematic approach to musculoskeletal examination is vital, and this review focuses on high-yield physical examination maneuvers and diagnostic investigations to differentiate between musculoskeletal conditions and radiculopathy. This approach ensures accurate diagnoses, promotes resource stewardship, enhances patient satisfaction, and optimizes care delivery. Musculoskeletal conditions resembling L1 to S4 radiculopathy are reviewed, emphasizing their distinctive features in history, physical examination, and diagnostic investigation. Among the more than 30 musculoskeletal disorders reviewed are hip and knee osteoarthritis, lumbar facet syndrome, myofascial pain syndrome, greater trochanteric pain syndrome, and plantar fasciitis.
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Affiliation(s)
- Emma A. Bateman
- Parkwood Institute Research, Parkwood Institute, St Joseph's Health Care LondonLondonCanada
- Department of Physical Medicine and RehabilitationWestern UniversityLondonCanada
| | - Christian D. Fortin
- Division of Physical Medicine & Rehabilitation, Faculty of MedicineUniversity of TorontoTorontoCanada
- Hennick Bridgepoint HospitalSinai HealthTorontoCanada
| | - Meiqi Guo
- Division of Physical Medicine & Rehabilitation, Faculty of MedicineUniversity of TorontoTorontoCanada
- Toronto Rehabilitation Institute, University Health NetworkTorontoCanada
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2
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Samet JD, Alizai H, Chalian M, Costelloe C, Deshmukh S, Kalia V, Kamel S, Mhuircheartaigh JN, Saade J, Walker E, Wessell D, Fayad LM. Society of skeletal radiology position paper - recommendations for contrast use in musculoskeletal MRI: when is non-contrast imaging enough? Skeletal Radiol 2024; 53:99-115. [PMID: 37300709 DOI: 10.1007/s00256-023-04367-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023]
Abstract
The following White Paper will discuss the appropriateness of gadolinium administration in MRI for musculoskeletal indications. Musculoskeletal radiologists should consider the potential risks involved and practice the judicious use of intravenous contrast, restricting administration to cases where there is demonstrable added value. Specific nuances of when contrast is or is not recommended are discussed in detail and listed in table format. Briefly, contrast is recommended for bone and soft tissue lesions. For infection, contrast is reserved for chronic or complex cases. In rheumatology, contrast is recommended for early detection but not for advanced arthritis. Contrast is not recommended for sports injuries, routine MRI neurography, implants/hardware, or spine imaging, but is helpful in complex and post-operative cases.
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Affiliation(s)
- Jonathan D Samet
- Ann & Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, USA.
| | - Hamza Alizai
- CHOP Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Majid Chalian
- Department of Radiology, University of Washington, Seattle, USA
| | | | | | - Vivek Kalia
- Children's Scottish Rite Hospital, Dallas, USA
| | - Sarah Kamel
- Thomas Jefferson University Hospital, Philadelphia, USA
| | | | - Jimmy Saade
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, USA
| | - Eric Walker
- Penn State Health Milton S Hershey Medical Center, Hershey, USA
| | - Daniel Wessell
- Mayo Clinic Jacksonville Campus: Mayo Clinic in Florida, Jacksonville, USA
| | - Laura M Fayad
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, USA.
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3
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Jordan E, Varady NH, Hosseinzadeh S, Smith S, Chen AF, Mont M, Iorio R. Femoral Head Osteonecrosis: Computed Tomography Not Needed to Identify Collapse When Using the Association Research Circulation Osseous Staging System. Arthroplast Today 2023; 24:101244. [PMID: 37867923 PMCID: PMC10585620 DOI: 10.1016/j.artd.2023.101244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/14/2023] [Indexed: 10/24/2023] Open
Abstract
Background The 2019 Revised Association Research Circulation Osseous (ARCO) Staging Criteria for Osteonecrosis of the Femoral Head (ONFH) only requires plain radiographs and magnetic resonance imaging (MRI) to diagnose and stage ONFH; however, the effectiveness of the 2019 ARCO criteria in the absence of computed tomography (CT) scans has not been investigated. Therefore, the purpose of this study was to evaluate whether CT scanning is a necessary modality for diagnosing/staging ONFH using the ARCO staging system. More specifically, do CT scans help differentiate pre- and post-collapse lesions more than MRI scans? Methods A study was conducted on 228 ONFH patients diagnosed between January 1, 2008, and December 31, 2018, at a single academic medical center. CT and MRI scans were reviewed by the senior author and other contributors. The ONFH classification was compared between the 2 scans to determine if CT scans were able to further differentiate staging of collapsed lesions vs MRI scans. Results A diagnosis of ONFH was made by MRI first in 57% (129/228) while 21% (48/228) used MRI and CT simultaneously. Only 22% (51/228) of cases were diagnosed by CT scans first. There were no cases where collapse was found by a CT scan that were not diagnosed by standard x-rays and/or MRIs. Conclusions CT scans are not a useful adjunct for diagnosing or treating ONFH and are not necessary if MRI is ordered when using the Revised ARCO Staging System for ONFH diagnosis.
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Affiliation(s)
- Eric Jordan
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Nathan H. Varady
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Shayan Hosseinzadeh
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Stacy Smith
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Antonia F. Chen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michael Mont
- Department of Orthopaedic Surgery, Rubin Institute for Advanced Ortho, Baltimore, MD, USA
| | - Richard Iorio
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
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Wang DD, Bora VG, Beauvais DH. Traumatic Obturator Hip Dislocation in a 9-Year-Old Girl: A Case Report. JBJS Case Connect 2023; 13:01709767-202306000-00021. [PMID: 37146164 DOI: 10.2106/jbjs.cc.22.00795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
CASE We present a case of traumatic anterior obturator hip dislocation in a pediatric patient with a focus on acute management of this injury. The orthopaedic team successfully performed closed reduction of this injury on an emergent basis, and the patient had minimal issues with ambulation and pain at subsequent follow-up. CONCLUSION Pediatric traumatic hip dislocations are rare injuries with potentially devastating sequelae, particularly if diagnosis and treatment are delayed. Proper technique during closed reduction is essential. Be prepared for potential emergent open reduction. Two years of postinjury follow-up is recommended to monitor for signs of femoral head osteonecrosis.
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Affiliation(s)
| | | | - Dorothy H Beauvais
- Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
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5
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Chen Y, Miao Y, Liu K, Xue F, Zhu B, Zhang C, Li G. Evolutionary course of the femoral head osteonecrosis: Histopathological - radiologic characteristics and clinical staging systems. J Orthop Translat 2022; 32:28-40. [PMID: 35591937 PMCID: PMC9072800 DOI: 10.1016/j.jot.2021.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023] Open
Abstract
Osteonecrosis of the femoral head (ONFH) is a recalcitrant ischemic disorder, which could be classified into two major categories: traumatic and nontraumatic. Regardless of different risk factors, it has been testified that ONFH results from primitive vascular problems, leading to temporary or permanent loss of blood supply to bone tissue. Histopathological and microarchitectural alterations ensues, which is a gradual evolutionary process involving bone marrow and osteocyte necrosis, progressive destruction of subchondral bone, unsuccessful reparative process, and eventual articular collapse and degenerative arthritis. Based on the imaging features of ONFH, different classification systems have been developed to evaluate the severity and prognosis of the disease, which is pivotal for implementation of treatment strategy, especially the joint-preserving surgery. However, patients classified with the same severity stage, especially in the peri-collapse stage, sometimes responded differently after similar joint-preserving surgery. The unusual phenomenon may be attributed to the limitation of the current imaging classification systems, which might underestimate the disease severity, especially when referring to the early stages. In this review, we briefly summarize the etiology and pathogenesis of ONFH. The imaging features and staging classification systems of ONFH are also described. More importantly, we focus on histopathological and microstructural alterations of the femoral head, and provide an overview of their essential contribution to ONFH progression. Given the observation of discordance between imaging characteristics and histopathological alterations, a substantial amount of research on the relationship between imaging and histopathological features is required to further modify and revise the current wide-accepted classification systems.
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6
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Sulewski A, Sieroń D, Szyluk K, Dąbrowski M, Kubaszewski Ł, Lukoszek D, Christe A. Avascular Necrosis Bone Complication after Active COVID-19 Infection: Preliminary Results. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57121311. [PMID: 34946256 PMCID: PMC8709043 DOI: 10.3390/medicina57121311] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/16/2021] [Accepted: 11/26/2021] [Indexed: 12/22/2022]
Abstract
Background and objectives: The course of SARS-CoV-2 (COVID-19) is still under analysis. The majority of complications arising from the infection are related to the respiratory system. The adverse effect of the viral infection on bone and joint tissue has also been observed. Materials and Methods: We present a group of 10 patients with degeneration of large joints and adjacent epiphyses of long bones and the spine, with a background of bone infarctions and avascular necrosis (AVN) immediately after infection with the COVID-19 virus. In MR imaging, changes in the characteristics of AVN were documented. Results: Observation of this group showed a clear correlation among the history of COVID-19 disease in the patients, moderately severe symptoms, high levels of IgG antibodies, and the time of occurrence of joint changes. No other clinically significant complications were observed following COVID-19 infection in the study group. No other risk factors for AVN or autoimmune or degenerative diseases were found in the study group. The group of patients responded well to empirical treatment with steroids, which normalized acute inflammatory symptoms and pain in the joints. Conclusions: During coronavirus (COVID-19) infection, there are complications in the locomotor system, such as microembolism and the formation of AVN; hence, more research is needed.
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Affiliation(s)
- Adam Sulewski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61545 Poznan, Poland; (M.D.); (Ł.K.)
- Correspondence:
| | - Dominik Sieroń
- Division of Magnetic Resonance Imaging, Silesian Center for Heart Diseases, 41800 Zabrze, Poland;
| | - Karol Szyluk
- Department of Physiotherapy, Faculty of Health Sciences in Katowice, Medical University of Silesia in Katowice, 40752 Katowice, Poland;
- I Department of Orthopaedic and Trauma Surgery, District Hospital of Orthopaedics and Trauma Surgery, Bytomska 62 Str., 41940 Piekary Śląskie, Poland
| | - Mikołaj Dąbrowski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61545 Poznan, Poland; (M.D.); (Ł.K.)
| | - Łukasz Kubaszewski
- Adult Spine Orthopaedics Department, Poznan University of Medical Sciences, 61545 Poznan, Poland; (M.D.); (Ł.K.)
| | - Dawid Lukoszek
- Dawid Lukoszek Physiotherapy Osteopathy, 42690 Hanusek, Poland;
| | - Andreas Christe
- Department of Radiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010 Bern, Switzerland;
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Ashikyan O, Wells J, Chhabra A. 3D MRI of the Hip Joint: Technical Considerations, Advantages, Applications, and Current Perspectives. Semin Musculoskelet Radiol 2021; 25:488-500. [PMID: 34547814 DOI: 10.1055/s-0041-1730910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Magnetic resonance imaging (MRI) is a common choice among various imaging modalities for the evaluation of hip conditions. Conventional MRI with two-dimensional acquisitions requires a significant amount of time and is limited by partial-volume artifacts and suboptimal fluid-to-cartilage contrast. Recent hardware and software advances have resulted in development of novel isotropic three-dimensional (3D) single-acquisition protocols that cover the volume of the entire hip and can be reconstructed in arbitrary planes for submillimeter assessment of bony and labro-cartilaginous structures in their planes of orientation. This technique facilitates superior identification of small labral tears and other hip lesions with better correlations with arthroscopy. In this review, we discuss technical details related to 3D MRI of the hip, its advantages, and its role in commonly encountered painful conditions that can be evaluated with great precision using this technology. The entities described are femoroacetabular impingement with acetabular labral tears, acetabular dysplasia, avascular necrosis, regional tendinopathies and tendon tears, bursitis, and other conditions.
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Affiliation(s)
| | - Joel Wells
- Department of Orthopedic Surgery, UT Southwestern, Dallas, Texas
| | - Avneesh Chhabra
- Department of Radiology, UT Southwestern, Dallas, Texas.,Department of Orthopedic Surgery, UT Southwestern, Dallas, Texas
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8
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Singh A. Editorial for "Analysis of MR Signs to Distinguish Between ARCO Stages 2 and 3A in Osteonecrosis of the Femoral Head". J Magn Reson Imaging 2021; 55:618-619. [PMID: 34477266 DOI: 10.1002/jmri.27916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Anup Singh
- Centre for Biomedical Engineering, Indian Institute of Technology Delhi, New Delhi, India
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9
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Shi S, Luo P, Sun L, Zhao Y, Yang X, Xie L, Yu T, Wang Z. Analysis of MR Signs to Distinguish Between ARCO Stages 2 and 3A in Osteonecrosis of the Femoral Head. J Magn Reson Imaging 2021; 55:610-617. [PMID: 34309130 DOI: 10.1002/jmri.27860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/14/2021] [Accepted: 07/14/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND MRI is the most effective diagnostic tool of osteonecrosis of the femoral head (ONFH), especially for early diagnosis, but its detection of subchondral or cortical fractures is less accurate than CT. Therefore, it is difficult to accurately stage ONFH in the peri-collapse period by MRI. PURPOSE To improve the accuracy of MR for distinguishing between Association Research Circulation Osseous (ARCO) stages 2 and 3A in ONFH. STUDY TYPE Retrospective. SUBJECTS One hundred and fifty five cases of ARCO stage 2/3A of ONFH underwent MR examinations, M/F = 72/83. CT was used as reference standard for collapse, which was decided by an orthopedist and a radiologist in consultation. FIELD STRENGTH/SEQUENCE 3 T/axial and coronal T1 -weighted Turbo Spin Echo (T1 W TSE) sequence, axial T2 -weighted fat-saturated (T2 W FS) TSE sequence, and coronal proton density-weighted imaging (PDWI)-FS-Dixon fat/water image. ASSESSMENT Five potential MR signs (the maximum width of the necrotic-viable interface, bone marrow edema (BME), irregular articular surface of the femoral head, T2 heterogeneous high signal, and the absence of a necrotic-viable interface with the morphology of closed loop) were evaluated blindly by five radiologists independently and the total scores of different combinations of MR signs were calculated. STATISTICAL TESTS Mann-Whitney U test and Chi-square test were used to evaluate age, gender, and MR signs differences between the two groups. ROC curve was used to access the distinguishing value of MR signs. The consistency of the five radiologists was analyzed by intraclass correlation coefficient. RESULTS The area under the curve of the combined MR signs 2 for distinguishing between ARCO stages 2 and 3A was the greatest (0.967), sensitivity and specificity were 100.00% and 88.71% respectively, and greater than 1 was the threshold. DATA CONCLUSION Combined MR signs 2 has great values in distinguishing between ARCO stages 2 and 3A in ONFH, thus helping clinical therapy. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Shan Shi
- Department of Radiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China.,Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ping Luo
- Department of Radiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Li Sun
- Department of Radiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yanping Zhao
- Department of Radiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xuedong Yang
- Department of Radiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Limin Xie
- Department of Orthopaedics, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Tong Yu
- Department of Orthopaedics, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Zhenchang Wang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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10
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Boontanapibul K, Huddleston JI, Amanatullah DF, Maloney WJ, Goodman SB. Modified Kerboul Angle Predicts Outcome of Core Decompression With or Without Additional Cell Therapy. J Arthroplasty 2021; 36:1879-1886. [PMID: 33618954 DOI: 10.1016/j.arth.2021.01.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/25/2021] [Accepted: 01/27/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Core decompression is the most common procedure for early-stage osteonecrosis of the femoral head (ONFH). This study investigated outcomes of core decompression with/without bone marrow aspirate concentrate (BMAC), based on the Kerboul combined necrotic angles using magnetic resonance imaging. METHODS We reviewed 66 patients (83 hips) with early ONFH, Association Research Circulation Osseous stages I-IIIa, who underwent core decompression alone (26 patients, 33 hips) or in combination with BMAC (40 patients, 50 hips). Survival rate and progressive collapse were analyzed using the Kaplan-Meier method, and conversion to total hip arthroplasty (THA) was evaluated. Subgroup analyses based on the modified Kerboul angle were performed: grade I (<200°), grade II (200°-249°), grade III (250°-299°), and grade IV (≥300°). RESULTS Mean follow-up was 36 ± 23 months. Femoral head collapse with BMAC (16 hips, 32%) was significantly lower than without BMAC (19 hips, 58%, P = .019). Conversion THA was significantly lower with BMAC (28%) than without (58%, P = .007). Survival rates among groups showed significant differences (P = .017). In grade I, 0/12 hips with BMAC collapsed while 3/9 (33%) without BMAC collapsed (P = .063); in grade II, 2/16 hips (12%) with BMAC collapsed while 7/13 (54%) without BMAC collapsed (P = .023). There was no significant difference in collapse with (64%) or without (82%) BMAC in grade III-IV hips (P = .256). CONCLUSION Core decompression with/without BMAC had a high failure rate, by increasing disease progression and the necessity for THA, for combined necrotic angles >250°. In our study, addition of BMAC had more reliable outcomes than isolated core decompression for precollapse ONFH if the combined necrotic angles were <250°.
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Affiliation(s)
- Krit Boontanapibul
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Redwood City, CA; Department of Orthopaedic Surgery, Chulabhorn International College of Medicine, Thammasat University, Pathum Thani, Thailand
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Redwood City, CA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Redwood City, CA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Redwood City, CA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Redwood City, CA
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11
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Gudmundsson P, Nakonezny PA, Lin J, Owhonda R, Richard H, Wells J. Functional improvement in hip pathology is related to improvement in anxiety, depression, and pain catastrophizing: an intricate link between physical and mental well-being. BMC Musculoskelet Disord 2021; 22:133. [PMID: 33535999 PMCID: PMC7860171 DOI: 10.1186/s12891-021-04001-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/20/2021] [Indexed: 12/13/2022] Open
Abstract
Background Pain catastrophizing, anxiety, and depression are risk factors for poor functional outcomes and worse post-treatment pain that can be treated alongside physical care given to orthopedic patients. While these factors have been shown to be common in patients with hip pathology, there is limited literature that follows these conditions throughout treatment. The purpose of this study was to track psychological factors in patients with various hip pathology to determine if they improved alongside functional measures following treatment. Methods Patients presenting to a specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, depression, and hip function. Pre- and post-treatment assessments were undertaken: Pain Catastrophizing Scale, the Hospital Anxiety Depression Scale, the Hip Outcome Survey, and Hip Disability and Osteoarthritis Outcome Score (HOOS). Patient characteristics were recorded. A correlation analysis, using the Spearman partial correlation coefficient (rs), was conducted to evaluate the relationship between change in psychological factors with change in functional outcomes. Results A total of 201 patients (78 male, 123 female) with a mean age of 53.75 ± 18.97 years were included, with diagnoses of hip dysplasia (n = 35), femoroacetabular impingement (n = 35), lateral trochanteric pain syndrome (n = 9), osteoarthrosis (n = 109), and avascular necrosis of the hip (n = 13). Statistical analysis revealed a significant negative relationship between change in function level (as measured by HOOS ADL) and change in pain catastrophizing (rs = − 0.373, p < 0.0001), depression (rs = − 0.363, p < 0.0001), and anxiety (rs = − 0.264, p = 0.0002). Pain catastrophizing, depression, and anxiety improved with function. Spearman correlation coefficients also revealed that pain catastrophizing, HADS anxiety, and HADS depression improved with improvement in other patient-reported functional outcomes. Conclusions Patients with hip pathology often exhibit pain catastrophizing, anxiety, and depression, but improvements in hip functionality are associated with decreased severity of these psychological comorbidities. Exploring this connection demonstrates the correlation between musculoskeletal impairment and psychosocial outcomes and mental health. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04001-5.
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Affiliation(s)
- Paul Gudmundsson
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Rd, Dallas, TX, 75390, USA
| | - Paul A Nakonezny
- Department of Population and Data Sciences, Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Jason Lin
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Rd, Dallas, TX, 75390, USA
| | - Rebisi Owhonda
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Rd, Dallas, TX, 75390, USA
| | - Heather Richard
- Department of Psychology, TX Scottish Rite Hospital, Dallas, USA
| | - Joel Wells
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Rd, Dallas, TX, 75390, USA.
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12
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Yong KL, El-Haddad C, Pillay S. Progression of knee osteonecrosis on MRI. Radiol Case Rep 2021; 16:678-683. [PMID: 33488898 PMCID: PMC7809248 DOI: 10.1016/j.radcr.2021.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/01/2021] [Accepted: 01/02/2021] [Indexed: 11/25/2022] Open
Abstract
Magnetic resonance imaging (MRI) is regarded as the most specific and sensitive of imaging modalities for the detection and progression of osteonecrosis (ON). We present MRI progression of ON in the knee in a 40-year-old female patient with Sjogren disease-related interstitial nephritis recently initiated on corticosteroids for deteriorating renal function. This case report correlates the degree of surrounding marrow edema with the patient's symptoms.
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Affiliation(s)
- King L Yong
- Radiology Department, Liverpool Hospital, Corner of Elizabeth and Goulburn St, Liverpool, New South Wales 2170, Australia
| | - Carlos El-Haddad
- Rheumatology Department/Osteoporosis Refracture Prevention Service, Liverpool Hospital, Corner of Elizabeth and Goulburn St, Liverpool, New South Wales 2170, Australia
| | - Sugendran Pillay
- Radiology Department, Liverpool Hospital, Corner of Elizabeth and Goulburn St, Liverpool, New South Wales 2170, Australia
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13
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Rossi F, Torri L, Dominietto A, Tagliafico AS. Spectrum of magnetic resonance imaging findings in transplanted multiple myeloma patients with hip/pelvic pain (according to MY-RADS): A single center experience. Eur J Radiol 2020; 130:109154. [PMID: 32629214 DOI: 10.1016/j.ejrad.2020.109154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/05/2020] [Accepted: 06/22/2020] [Indexed: 01/07/2023]
Abstract
PURPOSE The aim of our study is to evaluate the spectrum of MRI findings in transplanted Multiple Myeloma (MM) patients with hip/pelvic pain and to correlate these findings with standard prognostic clinical outcomes. METHODS A retrospective interpretation of the MRI findings of 54 MM patients with hip/pelvic pain were done according to MY-RADS guidelines. MRI findings included: type of bone marrow involvement and incidental findings (osteonecrosis and fractures). Inter- and intra-reader agreement were calculated using Cohen's kappa test. Survival and relapse rates, type of transplantation and days of hospitalization were correlated with MRI findings. RESULTS 1/52 patient presented normal bone marrow pattern, 10/52 focal pattern, 26/52 diffuse pattern and 15/52 mixed. No cases of micronodular was reported. Among the incidental findings, n = 6 osteonecrosis and n = 5 pathological fractures were found, with average length of stay higher. The intra- and inter-reader agreement assessing MY-RADS, were good (k value between 0.61-0.8). Focal pattern was most represented in patients with osteonecrosis and the worst survival rate. Diffuse pattern was most represented in relapses. No statistically significant correlations were found between bone marrow infiltration patterns and the type of transplantation. CONCLUSION MRI can recognize different infiltration patterns and complications in transplanted MM patients with hip/pelvic pain, correlating with clinical parameters.
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Affiliation(s)
- Federica Rossi
- Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy; Department of Experimental Medicine (DIMES), University of Genoa, Genova, Italy.
| | - Lorenzo Torri
- Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy
| | - Alida Dominietto
- Second Division of Hematology and Bone Marrow Transplantation, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Alberto Stefano Tagliafico
- Department of Health Sciences (DISSAL), University of Genoa, Genova, Italy; Department of Radiology, IRCCS San Martino Hospital, Genova, Italy
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Barakat E, Guischer N, Houssiau F, Lecouvet FE. The "birth of death": MRI step-by-step reveals the early appearance of a bone marrow infarct. Acta Radiol Open 2019; 8:2058460119834691. [PMID: 30944730 PMCID: PMC6440034 DOI: 10.1177/2058460119834691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 02/03/2019] [Indexed: 11/24/2022] Open
Abstract
The magnetic resonance imaging (MRI) appearance of an “established” bone marrow infarct is well-known, consisting of an area of preserved bone marrow signal surrounded by a serpiginous line. We report the uncommon observation of the very early phases of appearance of a bone marrow infarct, showing its progressive de novo appearance on MR images paralleling clinical symptoms and high-dose systemic steroid administration in a young female patient, presenting with acute knee pain. The initial knee MR examination performed one week after pain onset showed no abnormality. One week later, a second examination showed subtle ill-defined dotted signal abnormalities of the bone marrow of uncertain significance, of high signal on PDFS sequences. A third MR study obtained again one week later showed more evident findings with confluence of the high signal “dots” into a serpiginous line with a geographical appearance of the lesion, corresponding to the typical MRI presentation of bone marrow infarcts. Follow-up MRI at seven weeks showed definitive stability of this bone marrow infarct. A whole-body MRI performed for whole skeleton screening revealed multiple bone marrow infarcts typical for systemic avascular necrosis. This case represents a novel observation of the “birth” of a bone marrow infarct, from early intriguing changes to its typical ring-shaped appearance on MR images. It also reminds of the key role of MRI for early diagnosis of bone marrow infarcts and illustrates the emerging role of whole-body MRI for the detection of multifocal, asymptomatic skeletal involvement by ischemic lesions in systemic osteonecrosis.
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Affiliation(s)
- Elie Barakat
- Department of Radiology, University of Chicago, Chicago, IL, USA
| | - Nathalie Guischer
- Cliniques universitaires Saint-Luc, Institut de recherche expérimentale et clinique, Université Catholique de Louvain, Louvain, Brussels, Belgium
| | - Frédéric Houssiau
- Cliniques universitaires Saint-Luc, Institut de recherche expérimentale et clinique, Université Catholique de Louvain, Louvain, Brussels, Belgium
| | - Frederic E Lecouvet
- Cliniques universitaires Saint-Luc, Institut de recherche expérimentale et clinique, Université Catholique de Louvain, Louvain, Brussels, Belgium
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15
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Agrawal K, Tripathy SK, Sen RK, Santhosh S, Bhattacharya A. Nuclear medicine imaging in osteonecrosis of hip: Old and current concepts. World J Orthop 2017; 8:747-753. [PMID: 29094004 PMCID: PMC5656489 DOI: 10.5312/wjo.v8.i10.747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 08/02/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
Osteonecrosis (ON) is caused by inadequate blood supply leading to bone death, which results in the collapse of the architectural bony structure. Femoral head is the most common site involved in ON. Magnetic resonance imaging (MRI) is a commonly used imaging modality to detect early ON. When MRI is inconclusive, bone scan is helpful in detecting ON during early phase of the disease. As newer nuclear medicine equipment, like single photon emission computed tomography/computed tomography (CT) and positron emission tomography/CT, are emerging in medical science, we review the role of these imaging modalities in ON of femoral head.
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Affiliation(s)
- Kanhaiyalal Agrawal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Sujit Kumar Tripathy
- Department of Orthopedics, All India Institute of Medical Sciences, Bhubaneswar 751019, India
| | - Ramesh Kumar Sen
- Department of Orthopedics, Fortis Hospital, Mohali, Chandigarh 160162, India
| | - S Santhosh
- Institute of Nuclear Imaging and Molecular Medicine, Tamilnadu Government Multi Super Specialty Hospital, Anna Salai, Chennai, Tamilnadu 600002, India
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16
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Rupasov A, Cain U, Montoya S, Blickman JG. Imaging of Posttraumatic Arthritis, Avascular Necrosis, Septic Arthritis, Complex Regional Pain Syndrome, and Cancer Mimicking Arthritis. Radiol Clin North Am 2017; 55:1111-1130. [PMID: 28774452 DOI: 10.1016/j.rcl.2017.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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17
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Osteonecrosis detected by whole body magnetic resonance in patients with Hodgkin Lymphoma treated by BEACOPP. Eur Radiol 2016; 27:2129-2136. [PMID: 27519911 DOI: 10.1007/s00330-016-4535-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 07/09/2016] [Accepted: 07/27/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The purpose of our retrospective review of prospectively acquired Whole Body Magnetic Resonance (WB-MRI) scans was to assess the incidence of osteonecrosis in patients who received different chemotherapies. METHODS We evaluated the WB-MRI scans performed on 42 patients with Hodgkin Lymphoma treated by three chemotherapy regimens (6ABVD, 2ABVD + 4BEACOPP, 2ABVD + 8BEACOPP), excluding patients with the main risk factors for osteonecrosis. RESULTS Six out of seven patients (86 %) who received eight BEACOPP and one out of five patients (20 %) treated by four BEACOPP presented osteonecrosis, with a statistically significant difference of frequency between the two groups of patients (p < 0.05); no injury has been reported in patients treated by only ABVD. Among a total of 48 osteonecrotic lesions observed, 48 % were detected in the knee; multifocal osteonecrosis were detected in six out of seven patients (86 %). CONCLUSIONS The development of osteonecrosis is strictly related to the chemotherapy protocol adopted and the number of cycles received, with a strong correlation between the dose of corticosteroids included in the BEACOPP scheme and this complication. WB-MRI can be considered as a helpful tool that allows detecting earlier osteonecrotic lesions in patients treated with corticosteroids. KEY POINTS • Osteonecrosis is a possible complication of patients with Lymphoma treated by chemotherapy. • Osteonecrosis is related to the corticosteroids included within the BEACOPP protocol. • WB-MRI allows detecting osteonecrotic lesions in patients treated with corticosteroids.
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18
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Magnetic Resonance Imaging of Nontraumatic Musculoskeletal Emergencies. Magn Reson Imaging Clin N Am 2016; 24:369-89. [DOI: 10.1016/j.mric.2015.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Pitfalls in whole body MRI with diffusion weighted imaging performed on patients with lymphoma: What radiologists should know. Magn Reson Imaging 2016; 34:922-31. [PMID: 27114337 DOI: 10.1016/j.mri.2016.04.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/21/2016] [Accepted: 04/17/2016] [Indexed: 01/15/2023]
Abstract
The technological advances in radiological imaging and the relevance of a diagnostic tool that may reduce radiation-induced long-term effects have led to a widespread use of whole body magnetic resonance imaging (WB-MRI) with diffusion weighted imaging for oncologic patients. A lot of studies demonstrated the feasibility and reliability of WB-MRI as an alternative technique for lymphoma staging and response assessment during and after treatment. In this paper, taking advantage of our 2years of experience using WB-MRI for lymphoma, we discuss the main pitfalls and artifacts radiologists should know examining a WB-MRI performed on this typology of patients in order to avoid images misinterpretation.
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20
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Manenti G, Altobelli S, Pugliese L, Tarantino U. The role of imaging in diagnosis and management of femoral head avascular necrosis. ACTA ACUST UNITED AC 2016; 12:31-8. [PMID: 27134630 DOI: 10.11138/ccmbm/2015.12.3s.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this paper is to critically review the literature documenting the imaging approach in adult Femoral Head Avascular Necrosis (FHAVN). For this purpose we described and evaluated different radiological techniques, such as X-ray, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), and Nuclear Medicine. Plain films are considered the first line imaging technique due to its ability to depict femoral head morphological changes, to its low costs and high availability. CT is not a routinely performed technique, but is useful to rule out the presence of a subchondral fracture when MRI is doubtful or contraindicated. MRI is unanimously considered the gold standard technique in the early stages, being capable to detect bone marrow changes such as edema and sclerosis. It may be useful also to guide treatment and, as CT, it is a validated technique in follow-up of patients with FHAVN. Nuclear medicine imaging is mostly applied in post-operative period to detect graft viability or infective complications. More advanced techniques may be useful in particular conditions but still need to be validated; thus new research trials are desirable. In conclusion, X-ray examination is the first line approach, but lacks of sensitivity in early stage whereas MRI is indicated. CT easily depicts late stage deformation and may decrease MRI false positive results in detecting the subchondral fracture. However, the role of both Nuclear Medicine Imaging and advanced MR techniques in FHAVN still need to be investigated.
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Affiliation(s)
- Guglielmo Manenti
- Department of Diagnostic Imaging and Interventional Radiology, University of Tor Vergata, Rome, Italy
| | - Simone Altobelli
- Department of Diagnostic Imaging and Interventional Radiology, University of Tor Vergata, Rome, Italy
| | - Luca Pugliese
- Department of Diagnostic Imaging and Interventional Radiology, University of Tor Vergata, Rome, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
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Murphey MD, Foreman KL, Klassen-Fischer MK, Fox MG, Chung EM, Kransdorf MJ. From the radiologic pathology archives imaging of osteonecrosis: radiologic-pathologic correlation. Radiographics 2015; 34:1003-28. [PMID: 25019438 DOI: 10.1148/rg.344140019] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Osteonecrosis is common and represents loss of blood supply to a region of bone. Common sites affected include the femoral head, humeral head, knee, femoral/tibial metadiaphysis, scaphoid, lunate, and talus. Symptomatic femoral head osteonecrosis accounts for 10,000-20,000 new cases annually in the United States. In contradistinction, metadiaphyseal osteonecrosis is often occult and asymptomatic. There are numerous causes of osteonecrosis most commonly related to trauma, corticosteroids, and idiopathic. Imaging of osteonecrosis is frequently diagnostic with a serpentine rim of sclerosis on radiographs, photopenia in early disease at bone scintigraphy, and maintained yellow marrow at MR imaging with a serpentine rim of high signal intensity (double-line sign) on images obtained with long repetition time sequences. These radiologic features correspond to the underlying pathology of osseous response to wall off the osteonecrotic process and attempts at repair with vascularized granulation tissue at the reactive interface. The long-term clinical importance of epiphyseal osteonecrosis is almost exclusively based on the likelihood of overlying articular collapse. MR imaging is generally considered the most sensitive and specific imaging modality both for early diagnosis and identifying features that increase the possibility of this complication. Treatment subsequent to articular collapse and development of secondary osteoarthritis typically requires reconstructive surgery. Malignant transformation of osteonecrosis is rare and almost exclusively associated with metadiaphyseal lesions. Imaging features of this dire sequela include aggressive bone destruction about the lesion margin, cortical involvement, and an associated soft-tissue mass. Recognizing the appearance of osteonecrosis, which reflects the underlying pathology, improves radiologic assessment and is important to guide optimal patient management.
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Affiliation(s)
- Mark D Murphey
- From the Departments of Musculoskeletal Imaging (M.D.M., K.L.F., E.M.C.) and Pediatric Imaging (E.M.C.), American Institute for Radiologic Pathology, 1010 Wayne Ave, Suite 320, Silver Spring, MD 20910; Uniformed Services University of the Health Sciences, Bethesda, Md (M.D.M., E.M.C.); Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Md (M.D.M., K.L.F., E.M.C.); Joint Pathology Center, Silver Spring, Md (M.K.K.F.); Department of Radiology, University of Virginia, Charlottesville, Va (M.G.F.); and Mayo Clinic Hospital, Phoenix, Ariz (M.J.K.)
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22
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Saboo SS, Lin YC, Juan YH, Patel K, Weaver M, Sodickson A, Khurana B. Magnetic resonance imaging for acute hip pain in the emergency department. Emerg Radiol 2015; 22:409-22. [PMID: 25595215 DOI: 10.1007/s10140-014-1293-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 12/29/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Sachin S Saboo
- Department of Radiology, Brigham and Women's Hospital & Harvard Medical School, Boston, MA, USA,
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Unnecessary magnetic resonance imaging of hips: an economic burden to patients and the healthcare system. J Arthroplasty 2014; 29:1911-4. [PMID: 25012918 DOI: 10.1016/j.arth.2014.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 05/23/2014] [Indexed: 02/01/2023] Open
Abstract
Patients referred to orthopedists for hip pain due to arthritis may already have MRI studies ordered by their referring physicians despite plain radiographs being sufficient in most cases. Hence, we prospectively evaluated every patient referred to our institution during a 36-month period to identify the number of new patients with hip osteoarthritis who had an unnecessary MRI, the additional costs of these MRIs, and the extrapolated cost to the United States healthcare system during the next 10years. Overall, 15.4% of the patients presented with unnecessary MRIs, approximately, 330 to 440.5 million dollars may be spent on unnecessary hip MRIs in this patient population in America. We believe that referring physicians should not simultaneously order a radiograph and an MRI to evaluate hip pain.
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24
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Meier R, Kraus TM, Schaeffeler C, Torka S, Schlitter AM, Specht K, Haller B, Waldt S, Rechl H, Rummeny EJ, Woertler K. Bone marrow oedema on MR imaging indicates ARCO stage 3 disease in patients with AVN of the femoral head. Eur Radiol 2014; 24:2271-8. [DOI: 10.1007/s00330-014-3216-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 04/17/2014] [Accepted: 05/02/2014] [Indexed: 12/13/2022]
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Musculoskeletal manifestations of endocrine disorders. Clin Imaging 2014; 38:384-396. [PMID: 24642251 DOI: 10.1016/j.clinimag.2014.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 02/13/2014] [Accepted: 02/25/2014] [Indexed: 11/21/2022]
Abstract
Endocrine disorders can lead to disturbances in numerous systems within the body, including the musculoskeletal system. Radiological evaluation of these conditions can demonstrate typical appearances of the bones and soft tissues. Knowledge of these patterns can allow the radiologist to suggest a diagnosis that may not be clinically apparent. This review will highlight the typical musculoskeletal findings of acromegaly, hypercortisolism, hyperthyroidism, hypothyroidism, hyperparathyroidism, pseudo- and pseudopseudohypoparathyroidism, and diabetes mellitus. The radiological manifestations of each of these endocrine disorders, along with a brief discussion of the pathophysiology and clinical implications, will be discussed.
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26
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Vaishya R, Nyokabi DN, Vaish A. Bilateral hip arthritis in a case of renal osteodystrophy. BMJ Case Rep 2014; 2014:bcr-2013-201420. [PMID: 24554674 DOI: 10.1136/bcr-2013-201420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Chronic renal disease is often associated with secondary hyperparathyroidism (HPP) and rarely with tertiary HPP. Hip arthritis with protrusio acetabuli, secondary to tertiary HPP, is a rare case scenario and has not been described well in the literature. We present a rare case of bilateral hip arthritis with protrusio acetabuli secondary to renal osteodystrophy due to tertiary HPP. The diagnosis and aetiology of hip arthritis and its treatment have been discussed along with a detailed review of literature of skeletal lesions due to HPP.
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Affiliation(s)
- Raju Vaishya
- Department of Orthopaedic & Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India
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27
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Barille MF, Wu JS, McMahon CJ. Femoral head avascular necrosis: a frequently missed incidental finding on multidetector CT. Clin Radiol 2013; 69:280-5. [PMID: 24295736 DOI: 10.1016/j.crad.2013.10.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 09/26/2013] [Accepted: 10/15/2013] [Indexed: 11/20/2022]
Abstract
AIM To determine the incidence of missed femoral head avascular necrosis (AVN) on pelvic computed tomography (CT) performed for clinical indications other than assessment for AVN. MATERIALS AND METHODS The study was a Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective study. The picture archiving and communication system (PACS) database was queried for patients with diagnosis of femoral head AVN on magnetic resonance imaging (MRI), who also underwent pelvic multidetector CT after or <30 days before the MRI examination. The MRI and CT images of 144 hips of 72 patients (39 patients with reported AVN on MRI and 33 age-matched controls; mean age = 60 years, 28 male, 44 female), were reviewed in consensus by two readers in a randomized, blinded manner. Using MRI-proven CT-visible AVN as a reference standard, the incidence of missed AVN on initial CT interpretation was determined. RESULTS Readers confirmed AVN in 33 patients on the MRI images. Nine hips with AVN underwent joint replacement of the affected joint(s) prior to subsequent CT and were excluded. Forty-three MRI-proven AVN cases in 28 patients (15 bilateral, 13 unilateral) were available for analysis. The study readers diagnosed 35/43 (81%) MRI-proven AVN cases in 22/28 (79%) patients. Four of the 35 (11%) cases of MRI-proven, CT-visible AVN were prospectively reported in 3/22 (14%) patients at initial clinical interpretation, with a miss rate of 89% per hip and 86% per patient. CONCLUSION Multidetector CT has high accuracy for detection of AVN; however, this is frequently missed as an incidental finding (89% missed in the present study). Assessment for signs of femoral AVN should be part of routine search pattern in interpretation of pelvic CT.
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Affiliation(s)
- M F Barille
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, USA
| | - Jim S Wu
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, USA
| | - Colm J McMahon
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, USA.
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Miettunen PM, Lafay-Cousin L, Guilcher GMT, Nettel-Aguirre A, Moorjani V. Widespread osteonecrosis in children with leukemia revealed by whole-body MRI. Clin Orthop Relat Res 2012; 470:3587-95. [PMID: 23008023 PMCID: PMC3492614 DOI: 10.1007/s11999-012-2579-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 08/21/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Confirmation of early long-bone epiphyseal osteonecrosis in pediatric patients with leukemia allows for medical and surgical intervention before articular surface collapse. MRI detects early osteonecrosis, but multiple focused MR images are required to capture all lesions. QUESTIONS/PURPOSES We determined whether whole-body MRI (WB-MRI) could (1) assist in diagnosing long-bone epiphyseal and other osteonecroses, (2) characterize articular surface involvement, and (3) detect preferential sites for osteonecrosis. PATIENTS AND METHODS We retrospectively reviewed prospectively collected data on all 11 pediatric patients newly diagnosed with leukemia who had musculoskeletal pain develop that persisted 4 weeks or more during leukemia treatment. All were screened for osteonecrosis by WB-MRI, which consisted of a one-time scan of the entire body. Osteonecrosis was defined as circumscribed lesions with a distinct rim of low signal intensity in the normally high-intensity marrow on T1-weighted images and high signal intensity in the normally low-intensity marrow on short-tau inversion recovery images. RESULTS WB-MRI confirmed osteonecrosis in nine of 11 patients. All patients had multisite lesions; eight had long-bone epiphyseal lesions, which comprised 66 of 129 (51%) of all lesions. Osteonecrosis involving greater than 50% of the epiphyseal surface was present in 57% of distal femoral and proximal tibial lesions. All humeral and femoral head lesions involved more than 1/3 of the medial surface volume but were asymptomatic. No articular collapse was present. All osteonecrotic lesions were more common in the lower extremities. CONCLUSIONS WB-MRI confirmed early epiphyseal osteonecrosis, with quantification of articular surface involvement. Lower limbs were preferentially affected, but asymptomatic humeral head osteonecrosis was present in five of nine patients. LEVEL OF EVIDENCE Level IV, diagnostic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Paivi Maria Miettunen
- Division of Pediatric Rheumatology, Department of Pediatrics, Alberta Children’s Hospital and University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8 Canada
| | - Lucie Lafay-Cousin
- Division of Pediatric Oncology, Department of Pediatrics, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
| | - Gregory M. T. Guilcher
- Division of Pediatric Oncology, Department of Pediatrics, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
| | - Alberto Nettel-Aguirre
- Departments of Pediatrics and Community Health Sciences, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
| | - Vijay Moorjani
- Department of Diagnostic Imaging, Alberta Children’s Hospital and University of Calgary, Calgary, AB Canada
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Eholié SP, Ouiminga M, Ehui E, Nzunetu G, Ouattara SI, Konan AV, Anglaret X, Bissagnéné E. Avascular osteonecrosis of the femoral head in three West African HIV-infected adults with heterozygous sickle cell disease. Antivir Ther 2010; 14:1011-4. [PMID: 19918106 DOI: 10.3851/imp1398] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Three men (aged 33, 44 and 45 years, CD4(+) T-cell nadir 86 cells/mm(3), 99 cells/mm(3) and 12 cells/mm(3), respectively) were admitted to the Department of Infectious Diseases (Treichville Hospital, Abidjan, Côte d'Ivoire) for hip pain and impaired mobility. Their last available CD4(+) T-cell counts were 243 cells/mm(3), 245 cells/mm(3) and 8 cells/mm(3), respectively. They had all received antiretroviral therapy for >4 years, including lopinavir/ritonavir for >8 months. The other risk factors were hypertriglyceridaemia (n=3), smoking addiction (n=2), alcohol consumption (n=2) and lipodystrophy (n=1). All three patients had heterozygous haemoglobin AS sickle cell disease (percentage of haemoglobin S 41%, 45% and 50%, respectively). The diagnosis of avascular osteonecrosis of the femoral head (unilateral n=2 and bilateral n=1) was documented by CT scan. Only one patient underwent surgical arthroplasty. In resource-limited settings, avascular osteonecrosis is uneasy to diagnose and unlikely to be appropriately treated. Physicians should be aware of its symptoms and risk factors, including HIV infection and antiretroviral therapy. Future studies should explore whether these risk factors might include haemoglobin AS sickle cell disease, a common trait in the West African general population.
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Affiliation(s)
- Serge P Eholié
- Service des Maladies Infectieuses et Tropicales, CHU de Treichville, Abidjan, Côte d'Ivoire.
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Donmez FY, Basaran C, Ulu EMK, Uyusur A, Tarhan NC, Muhtesem Agildere A. MRI findings in renal transplant recipients with hip and knee pain. Eur J Radiol 2009; 71:536-40. [DOI: 10.1016/j.ejrad.2008.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2008] [Revised: 05/13/2008] [Accepted: 06/03/2008] [Indexed: 10/21/2022]
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Calder JD, Hine AL, Pearse MF, Revell PA. The relationship between osteonecrosis of the proximal femur identified by MRI and lesions proven by histological examination. ACTA ACUST UNITED AC 2008; 90:154-8. [DOI: 10.1302/0301-620x.90b2.19593] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Total hip replacement in patients with advanced osteonecrosis of the femoral head is often complicated by early loosening of the femoral component. Recent evidence has suggested that abnormal bone extending into the proximal femur may be responsible for the early failure of the femoral component. We aimed to identify which patients were at high risk of early failure by evaluating gadolinium-enhanced MR images of histologically-confirmed osteonecrotic lesions beyond the femoral head. Although the MR signal intensity has been shown to correlate well with osteonecrosis in the femoral head, it was found to be relatively insensitive at identifying lesions below the head, with a sensitivity of only 51% and a predictive value of a negative result of only 48%. However, the specificity was 90%, with the predictive value of a positive MRI finding being 86%. Only those patients with osteonecrosis of the femoral head secondary to sickle-cell disease, who are known to be at high risk of early loosening, had changes in the MR signal in the greater trochanter and the femoral shaft. This observation suggests that changes in the MR signal beyond the femoral head may represent osteonecrotic lesions in areas essential for the fixation of the femoral component. Pre-operative identification of such lesions in the neck of the femur may be important when considering hip resurfacing for osteonecrosis of the femoral head, following which early loosening of the femoral component and fracture of the neck are possible complications.
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Affiliation(s)
- J. D. Calder
- Imperial College London, Charing Cross Campus, Reynolds Building, St Dunstan’s Road, London W6 8RP, UK
| | | | - M. F. Pearse
- Department of Orthopaedic Surgery, Central Middlesex Hospital, Acton Lane, London NW10 7NS, UK
| | - P. A. Revell
- University College London, Eastman Dental Institute, 256 Grays Inn Road, London WC1X 8LD, UK
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Age Factors
- Analgesics, Non-Narcotic/administration & dosage
- Analgesics, Non-Narcotic/therapeutic use
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anemia, Sickle Cell/complications
- Anemia, Sickle Cell/diagnosis
- Anemia, Sickle Cell/drug therapy
- Anemia, Sickle Cell/epidemiology
- Anemia, Sickle Cell/genetics
- Anemia, Sickle Cell/physiopathology
- Anemia, Sickle Cell/therapy
- Antibiotic Prophylaxis
- Antisickling Agents/administration & dosage
- Antisickling Agents/therapeutic use
- Blood Transfusion
- Child
- Child, Preschool
- Diagnosis, Differential
- Female
- Genotype
- Hematopoietic Stem Cell Transplantation
- Hospitalization
- Humans
- Hydroxyurea/administration & dosage
- Hydroxyurea/therapeutic use
- Ibuprofen/administration & dosage
- Ibuprofen/therapeutic use
- Immunization
- Infant
- Infant, Newborn
- Male
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain/diagnosis
- Pain/drug therapy
- Pain/etiology
- Pain Measurement
- Penicillins/administration & dosage
- Penicillins/therapeutic use
- Risk Factors
- Stroke/epidemiology
- Stroke/prevention & control
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Rupa Redding-Lallinger
- Division of Hematology/Oncology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
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Ha YC, Jung WH, Kim JR, Seong NH, Kim SY, Koo KH. Prediction of collapse in femoral head osteonecrosis: a modified Kerboul method with use of magnetic resonance images. J Bone Joint Surg Am 2006; 88 Suppl 3:35-40. [PMID: 17079365 DOI: 10.2106/jbjs.f.00535] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The hypothesis that the combined necrotic angle measurement from magnetic resonance imaging scans predicts the subsequent risk of collapse in hips with femoral head necrosis was tested. METHODS Thirty-seven hips with early stage osteonecrosis in thirty-three consecutive patients were investigated. With use of the modified method of Kerboul et al., we measured the arc of the femoral surface involved by necrosis on a midcoronal as well as a midsagittal magnetic resonance image (rather than an anteroposterior and a lateral radiograph) and then calculated the sum of the angles. On the basis of the magnitude of the resulting combined angle, hips were classified into four categories: grade 1 (<200 degrees), grade 2 (200 degrees to 249 degrees), grade 3 (250 degrees to 299 degrees), and grade 4 (>/=300 degrees). After the initial evaluations, the hips were randomly assigned to a core decompression group or a nonoperative group. Patients underwent regular follow-up until femoral head collapse or for a minimum of five years. RESULTS Seven grade-4 hips and sixteen grade-3 hips had development of femoral head collapse by thirty-six months. Six of the nine grade-2 hips and none of the five grade-1 hips collapsed (log-rank test, p < 0.01). None of the four hips with a combined necrotic angle of </=190 degrees (the low-risk group) collapsed, all twenty-five hips with a combined necrotic angle of >/=240 degrees (the high-risk group) collapsed, and four (50%) of the eight hips with a combined necrotic angle between 190 degrees and 240 degrees (the moderate-risk group) collapsed during the study period. CONCLUSIONS The Kerboul combined necrotic angle, as ascertained with use of magnetic resonance imaging scans instead of radiographs, is a good method to assess future collapse in hips with femoral head osteonecrosis. LEVEL OF EVIDENCE Prognostic Level I. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.
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Schneider G, Massmann A, Fries P, Kusma M, Dienst M. Magnetresonanztomographie und -arthrographie des Hüftgelenks. DER ORTHOPADE 2006; 35:22-6, 28-32. [PMID: 16322973 DOI: 10.1007/s00132-005-0890-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Plain film radiographs represent the imaging of choice for the initial evaluation of pathologies of the hip. However, many lesions of the joint itself and surrounding soft tissues are often not visualized by conventional radiographs. Magnetic resonance imaging (MRI) demonstrates most of these pathologies with high sensitivity and specificity. For further assessment of intra-articular lesions such as labral tears, hyaline cartilage lesions, rupture of the ligamentum teres, and loose bodies, direct MR arthrography after intra-articular administration of contrast medium may be indicated. This article summarizes the technical aspects and the most important indications for MRI and MR arthrography of the hip in correlation with typical imaging findings of the most frequent pathologies.
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Affiliation(s)
- G Schneider
- Arbeitsgemeinschaft Kernspintomographie, Klinik für Diagnostische und Interventionelle Radiologie, Universitätskliniken des Saarlandes, Homburg/Saar.
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Abstract
MR imaging of the hip presents technical difficulties seldom encountered when imaging other joints. The imager is responsible for surrounding bony and soft tissue structures susceptible to many maladies that can mimic hip pain related to an intra-articular derangement. The anatomic nature of the hip and pelvis present difficulties with application and use of local receiver coils. A lack of hip joint capaciousness and distensibility presents obstacles to acquiring diagnostic images with direct and indirect arthrography. Imagers must strive to improve diagnostic accuracy and maximize the information provided to referring clinicians in each MR imaging report in order to help choose the most appropriate therapeutic course. In this article, the authors review technical considerations specific to patient subsets and suspected causalgia of pain or dysfunction about the hip.
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Affiliation(s)
- Adam C Zoga
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
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Abstract
MRI has become increasingly helpful in establishing an early diagnosis of avascular necrosis(AVN). AVN often demonstrates a classic pattern on MRI; findings earlier in the course of the disease are less specific. Many pitfalls can complicate interpretation, and a number of pathologic conditions can share features of early AVN on MRI and plain radiographs. These entities should be distinguished from AVN, because treatment and prognosis may differ significantly.
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Affiliation(s)
- Shari M Jackson
- Department of Radiology, Duke University Medical Center, Erwin Road, Durham, NC 27710, USA
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Steinberg ME, Steinberg DR. Classification systems for osteonecrosis: an overview. Orthop Clin North Am 2004; 35:273-83, vii-viii. [PMID: 15271535 DOI: 10.1016/j.ocl.2004.02.005] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Currently a number of classification systems for osteonecrosis are in use. The use of different systems often leads to confusion and makes it difficult to compare the results of different methods of treatment. Because the management of osteonecrosis is determined in large part by the stage of the disease, it is important to use an effective and reliable method of staging and classification. This article provides an overview of the systems most commonly used so the reader can better understand and compare the outcome of studies that report their results using different methods of classification. The essential features of the ideal system are outlined to enable the reader to decide which of the available classification systems best meets these goals.
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Affiliation(s)
- Marvin E Steinberg
- Department of Orthopaedic Surgery, School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.
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Lopez-Ben R, Mikuls TR, Moore DS, Julian BA, Bernreuter WK, Elkins M, Saag KG. Incidence of hip osteonecrosis among renal transplantation recipients: a prospective study. Clin Radiol 2004; 59:431-8. [PMID: 15081848 DOI: 10.1016/j.crad.2003.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2003] [Revised: 10/30/2003] [Accepted: 11/03/2003] [Indexed: 01/09/2023]
Abstract
AIM To investigate whether a lessened glucocorticoid cumulative dose would lead to a decreased incidence of femoral head osteonecrosis. METHODS Newly transplanted in-patients (n = 49) underwent hip radiographs and magnetic resonance imaging (MRI) a mean of 17.0+/-4.3 (range 8-29) days after renal transplantation. For the 48 patients without evidence of prevalent osteonecrosis, imaging at a mean of 5.9+/-0.8 (range 4.8-8.7) months after renal transplantation was graded for presence/absence of femoral head osteonecrosis by two blinded radiologists. Sociodemographic and disease characteristics of patients were compared to identify potential associations with incident osteonecrosis. RESULTS At 6-month follow-up, only two patients (4%) had osteonecrosis of the femoral head (three hips). The two primary radiologists had excellent agreement between osteonecrosis diagnosis (kappa coefficient=0.78). Both cases of a definite MRI diagnosis of osteonecrosis occurred in patients who were in the highest tertile of glucocorticoid dosage. CONCLUSION Osteonecrosis was uncommon among a prospective cohort of renal transplant recipients within 6 months after engraftment.
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Affiliation(s)
- R Lopez-Ben
- Departments of Radiology and Medicine, University of Alabama School of Medicine and Hospitals, Birmingham, AL 35249-3408, USA
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Abstract
We report a case of femoral head osteonecrosis that originally was misdiagnosed as a femoral neck stress fracture by plain radiography and magnetic resonance imaging. The correct diagnosis was made using pinhole bone scintigraphy, which revealed a completely cold lesion of the entire femoral head, confirmed by histologic examination. The patient was treated with muscle pedicle bone grafting, and 3 months postoperatively, pinhole bone scintigraphy showed improved vascularity of the femoral head.
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Affiliation(s)
- Taek Rim Yoon
- Department of Orthopaedic Surgery, Chonnam National University Hospital, 8 Hak Dong, Gwangju 501-757, Korea.
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Abstract
MR imaging is the most accurate modality for the diagnosis of AVN, bone marrow edema syndrome, and femoral head insufficiency fractures. When the particular demographics of the patient are considered, the specificity of this examination is high. The reported success rates of joint-sparing operative intervention are variable. When compared with conservative management, the outcome of joint-sparing operative intervention in patients who have early (stage I, II) AVN lesions is improved. This is impetus for screening programs for patients who are known to be at high risk for AVN, such as patients who have undergone renal transplants and others who are on long-term, high-dose corticosteroid treatment. There is strong evidence that bone marrow edema syndrome (TO) is a distinct entity with demonstrable unique histopathology and well-defined demographics. Increased spatial resolution revealed typical subchondral findings of AVN in lesions that were once believed to represent irreversible TO. SIF of the femoral head is a new concept with a seemingly distinct population and with clinical presentation and imaging characteristics that should permit its differentiation from AVN.
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Affiliation(s)
- Rohan M Watson
- Division of Musculoskeletal Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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41
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Assouline-Dayan Y, Chang C, Greenspan A, Shoenfeld Y, Gershwin ME. Pathogenesis and natural history of osteonecrosis. Semin Arthritis Rheum 2003. [PMID: 12430099 DOI: 10.1053/sarh.2002.33724b] [Citation(s) in RCA: 470] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVES Osteonecrosis (avascular necrosis) is a relatively common disorder seen by both rheumatologists and orthopedic surgeons. The vast majority of cases are secondary to trauma. However, for non-traumatic cases, there often remains a diagnostic challenge in defining the cause of bone death. The goal of this article is to review data extensively in the medical literature with respect to the pathogenesis of osteonecrosis, its natural history, and treatment. METHODS A review of 524 studies on osteonecrosis was performed, of which 213 were selected and cited. RESULTS Non-traumatic osteonecrosis has been associated with corticosteroid usage, alcoholism, infections, hyperbaric events, storage disorders, marrow infiltrating diseases, coagulation defects, and some autoimmune diseases. However, a large number of idiopathic cases of osteonecrosis have been described without an obvious etiologic factor. Although corticosteroids can produce osteonecrosis, careful history is always warranted to identify other risk factors. The pathogenesis of non-traumatic osteonecrosis appears to involve vascular compromise, bone and cell death, or defective bone repair as the primary event. Our understanding of the pathogenesis of osteonecrosis is now much better defined and skeletal scintigraphy and magnetic resonance imaging have enhanced diagnosis greatly. Early detection is important because the prognosis depends on the stage and location of the lesion, although the treatment of femoral head osteonecrosis remains primarily a surgical one. CONCLUSIONS Osteonecrosis has been associated with a wide range of conditions. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of steroid usage, especially in conjunction with other illnesses that predispose the patient to osteonecrosis. RELEVANCE A better understanding of the pathophysiology, diagnosis and treatment of osteonecrosis will help the physician determine which patients are at risk for osteonecrosis, facilitating early diagnosis and better treatment options.
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Affiliation(s)
- Yehudith Assouline-Dayan
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Radiology, University of California at Davis, Davis, CA 95616, USA
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Stevens K, Tao C, Lee SU, Salem N, Vandevenne J, Cheng C, Neumann G, Valentin-Opran A, Lang P. Subchondral fractures in osteonecrosis of the femoral head: comparison of radiography, CT, and MR imaging. AJR Am J Roentgenol 2003; 180:363-8. [PMID: 12540435 DOI: 10.2214/ajr.180.2.1800363] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Our objective was to compare the sensitivity of unenhanced radiography, CT, and MR imaging in revealing subchondral fractures. SUBJECTS AND METHODS Forty-five subjects with stage I and stage II osteonecrosis of the femoral head were included in the study as part of a multicenter clinical trial to evaluate the effectiveness of recombinant human bone morphogenetic protein as an adjuvant treatment to core decompression. Patients were evaluated with radiography, CT, and MR imaging 6 and 12 months after surgery. RESULTS At 6 months, 18 fractures were shown on CT scans, but only 12 were detected on radiographs and six, on MR images. At 12 months, 20 subchondral fractures were detected on CT scans, but only 17 were seen on radiographs and 11, on MR images. Compared with CT, MR imaging has a sensitivity and specificity of 38% and 100%, and unenhanced radiography has a sensitivity and specificity of 71% and 97%, respectively. On T2-weighted MR images, the subchondral fractures were visualized as crescentic high-signal-intensity lines, and in all patients, on the corresponding CT scans, the fracture clearly breached the femoral cortex. CONCLUSION CT reveals more subchondral fractures in osteonecrosis of the femoral head than unenhanced radiography or MR imaging. The high-signal-intensity line seen on T2-weighted MR images appears to represent fluid accumulating in the subchondral fracture, which may indicate a breach in the overlying articular cartilage.
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Affiliation(s)
- Kathryn Stevens
- Department of Radiology, Stanford University Medical Center, 300 Pasteur Drive, Stanford, CA 94305, USA
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Marston SB, Gillingham K, Bailey RF, Cheng EY. Osteonecrosis of the femoral head after solid organ transplantation: a prospective study. J Bone Joint Surg Am 2002; 84:2145-51. [PMID: 12473701 DOI: 10.2106/00004623-200212000-00004] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The reported prevalence of osteonecrosis of the femoral head in patients who have undergone a solid organ transplant has ranged from 3% to 41%. The wide variation is due to the retrospective nature of most studies and the inability to capture data on asymptomatic patients. The primary goals of this study were to determine the true prevalence of osteonecrosis of the femoral head following solid organ transplantation, the time to the development of the osteonecrosis, and whether findings on magnetic resonance imaging precede the onset of symptoms. METHODS Beginning in 1997, patients who had undergone a solid organ transplant were asked to participate in a prospective study in which they would be screened for osteonecrosis of the femoral head. Inclusion criteria included an age of greater than fourteen years, a first-time transplant, and magnetic resonance imaging performed within six months after the transplant. Exclusion criteria were pre-existing osteonecrosis of the femoral head in the hip included in the study, a history of inflammatory arthritis, previous hip surgery, any contraindication to magnetic resonance imaging, a prior organ transplant, prior systemic corticosteroid treatment, and mental health issues preventing adequate follow-up. Screening magnetic resonance imaging was performed every four months. Survivorship analysis was used to determine the prevalence of osteonecrosis of the femoral head. RESULTS Fifty-two patients (103 hips) were enrolled in the study. Their ages ranged from twenty-four to sixty-five years (mean, forty-three years). Sixteen patients were dropped from the study, but the data collected on them before they were dropped were included in the analysis. Osteonecrosis of the femoral head was diagnosed in eight of the 103 hips. Survivorship analysis revealed that, at one year after the transplant, 89% +/- 7% of the hips and 80% +/- 13% of the patients were free of osteonecrosis of the femoral head; thus the prevalence of osteonecrosis one year after transplantation was 11% or 20%, respectively. The mean duration of follow-up of the remaining hips was 2.3 years. In two hips the osteonecrosis of the femoral head was seen on the initial screening magnetic resonance imaging, and in the other six it developed after the initial magnetic resonance imaging revealed negative findings. All cases of osteonecrosis of the femoral head developed within ten months after the transplant. Seven of the eight hips were asymptomatic at the time of diagnosis. There was a significant difference in the one-year osteonecrosis-free survival rate between the patients who were less than forty years old (78%) and those who were at least forty years old (97%) (p = 0.011). Diabetes, smoking, and rejection episodes were not risk factors for osteonecrosis of the femoral head. CONCLUSIONS Our study of patients who had had a solid organ transplant revealed that the true prevalence of osteonecrosis of the femoral head in such patients is lower than that reported in most previous studies, osteonecrosis of the femoral head develops prior to the onset of symptoms, an age of less than forty years is a risk factor for osteonecrosis of the femoral head, and osteonecrosis of the femoral head develops within one year after transplantation. We recommend that magnetic resonance imaging be used to screen for osteonecrosis of the femoral head within one year after transplantation. The utility of additional magnetic resonance imaging after one year has not been established.
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Affiliation(s)
- Scott B Marston
- Department of Orthopaedic Surgery and Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Amrami KK, Askari KS, Pagnano MW, Sundaram M. Radiologic case study. Abrasion chondroplasty mimicking avascular necrosis. Orthopedics 2002; 25:1018, 1107-8. [PMID: 12401005 DOI: 10.3928/0147-7447-20021001-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Arthroscopic abrasion arthroplasty, subchondral drilling, and microfracture continue to be performed with some frequency in younger patients with focal chondral defects and occasionally for patients with moderate degenerative knee arthritis. The plain radiographic appearance after those procedures may mimic avascular necrosis, but MRI is a sensitive method used to exclude the diagnosis of avascular necrosis and evaluate the extent to which fibrocartilaginous repair tissue has formed. When combined with an appropriate clinical history, dedicated articular cartilage imaging sequences improve the sensitivity and specificity that MRI provides in these patients with chondral knee injuries.
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Diagnostic Imaging and the Role of Stage and Lesion Size in Determining Outcome in Osteonecrosis of the Femoral Head. Tech Orthop 2001. [DOI: 10.1097/00013611-200103000-00002] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Sarikaya I, Sarikaya A, Holder LE. The role of single photon emission computed tomography in bone imaging. Semin Nucl Med 2001; 31:3-16. [PMID: 11200204 DOI: 10.1053/snuc.2001.18736] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Single photon emission computed tomography (SPECT) of the bone is the second most frequently performed SPECT examination in routine nuclear medicine practice, with cardiac SPECT being the most frequent. Compared with planar scintigraphy, SPECT increases image contrast and improves lesion detection and localization. Studies have documented the unique diagnostic information provided by SPECT, particularly for avascular necrosis of the femoral head, in patients with back pain, for the differential diagnosis between malignant and benign spinal lesions, in the detection of metastatic cancer in the spine, for the diagnosis of temporomandibular joint internal derangement, and for the evaluation of acute and chronic knee pain. Although less rigorously documented, SPECT is being increasingly used in all types of situations that demand more precise anatomic localization of abnormal tracer uptake. The effectiveness of bone SPECT increases with the selection of the proper collimator, which allows one to acquire adequate counts and minimize the patient-to-detector distance. Low-energy, ultrahigh-resolution or high-resolution collimation is preferred over all-purpose collimators. Multihead gamma cameras can increase the counts obtained or shorten acquisition time, making SPECT acquisitions more practical in busy departments and also increasing image quality compared with single-head cameras. Iterative reconstruction, with the use of ordered subsets estimation maximization, provides better quality images than classical filtered back projection algorithms. Three-dimensional image analysis often aids lesion localization.
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Affiliation(s)
- I Sarikaya
- University of Maryland Medical System, Department of Radiology, Baltimore 21201, USA
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Abstract
Osteonecrosis (avascular necrosis, aseptic necrosis or subchondral avascular necrosis) is not a specific disease entity but the final common pathway of a number of conditions leading to bone death. The main predisposing factors (trauma, glucocorticosteroids, alcoholism and connective tissue disorders) should be carefully sought, but osteonecrosis can also be idiopathic in origin. Its most common localization is to the femoral head, followed by the humeral head, the knee and the small bones of the wrist and foot. New imaging techniques, especially magnetic resonance imaging, have improved the early diagnosis of osteonecrosis as radiographs may be normal in the initial stages. The outcome for the patient is influenced by many factors, the size and localization of the bone necrosis being of primary importance. Early intervention (both surgical and non-surgical) has definitively improved the outcome, but still nearly 50% of cases of femoral head osteonecrosis necessitate arthroplasty. In this chapter, we shall concentrate on patients at high risk of osteonecrosis, on evidence-based diagnosis, especially in the early stages, and on evidence-based treatment suited to the staging system of osteonecrosis.
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Affiliation(s)
- K Pavelka
- Institute of Rheumatology, Charles University, Prague, Czech Republic
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48
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Steinberg ME, Bands RE, Parry S, Hoffman E, Chan T, Hartman KM. Does lesion size affect the outcome in avascular necrosis? Clin Orthop Relat Res 1999. [PMID: 10546624 DOI: 10.1097/00003086-199910000-00033] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The size of the necrotic lesion may be a significant factor in predicting outcome and determining treatment in hips with avascular necrosis. However, to date most reports on the treatment of this condition have not attempted to correlate outcome with lesion size. Seventy-three hips with avascular necrosis were evaluated, 11 in Stage I and 62 in Stage II. All were treated with core decompression and bone grafting. Patients were followed up 2 to 6 years (mean, 39 months). The results were determined by change in Harris hip score, degree of radiographic progression, and the need for total hip replacement. Outcome was correlated with the lesion size, stage, etiology, and other factors. In Stage I, the true three-dimensional size of the lesion was measured with a new technique of quantitative magnetic resonance imaging. In Stage II, measurements were obtained from radiographs using a modular system for quantitative digital analysis. Hips were divided into three groups based on lesion size: Group A, less than 15% of femoral head involvement; Group B, 15% to 30%; and Group C, greater than 30%. There were no significant differences in outcome between Stages I and II and no relationship to etiology or other demographic factors. When correlated with lesion size, radiographs on a 21-point scale showed progression by 1.1, 4.2, and 4.3 points; the Harris hip score showed an improvement of 10.6 and 3.3 points and a loss of 3.6 points; and total hip replacement was required in 7%, 31%, and 33% of Group A, B, and C lesions, respectively. The difference in outcome between small lesions and large or medium lesions was statistically significant, but no significant differences were seen between medium and large lesions. These observations emphasize the importance of lesion size in predicting outcome after core decompression and grafting and possibly after other surgical and nonsurgical methods of managing hips with avascular necrosis. They also encourage the use of methods of evaluation and staging that include a determination of lesion size and stage.
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Affiliation(s)
- M E Steinberg
- The Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia 19104, USA
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Affiliation(s)
- J V Zurlo
- UMDNJ-New Jersey Medical School, Newark, USA
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50
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Koo KH, Dussault RG, Kaplan PA, Ahn IO, Kim R, Devine MJ, Cui Q, Cho SH, Wang GJ. Fatty marrow conversion of the proximal femoral metaphysis in osteonecrotic hips. Clin Orthop Relat Res 1999:159-67. [PMID: 10212609 DOI: 10.1097/00003086-199904000-00021] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
To determine whether fatty marrow conversion of the proximal femoral metaphysis is related to osteonecrosis of the femoral head using a marrow conversion index ([signal intensity of the proximal femoral metaphysis/signal intensity of the greater trochanter] x 100 in T1 weighted magnetic resonance images), a case control study was conducted on 42 osteonecrotic hips in 28 patients. The 28 patients (42 osteonecrotic hips) were matched with 84 control patients (84 normal hips) for gender, age (5-year range), and time of presentation (1-year range). The marrow conversion index was measured in each hip studied. The index was 90.2% (standard deviation, 8.2%) in osteonecrotic hips and 75.1% (standard deviation, 9.1%) in matched controls. By conditional logistic regression, a 5% increase in the index was associated with 3.6 times increase of the odds ratio of osteonecrosis and a 10% increase with a 12.9 times increase of the odds ratio. The marrow conversion index, which reflects the ratio of fatty marrow conversion of the proximal femoral metaphysis to that of the greater trochanter measured on T1 weighted magnetic resonance images, is increased in osteonecrotic hips.
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Affiliation(s)
- K H Koo
- Department of Orthopaedic Surgery, Gyeong-Sang National University School of Medicine, Chinju, South Korea
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