Sonography of the iliopsoas tendon and injection of the iliopsoas Bursa for diagnosis and management of the painful snapping hip

Objective The purpose of this study was to compare sonographic evaluations of patients referred with suspected snapping of their iliopsoas tendon with the pain relief achieved from anesthetic injection of the iliopsoas bursa, and with the subsequent surgical outcome. This study also assessed the effectiveness of Kenalog injection into the iliopsoas bursa for long-term pain relief.Patients and methods Dynamic and static sonography was performed in 40 patients with clinically diagnosed snapping hips. The iliopsoas bursa was injected with Bupivicaine and Lidocaine in the first 22 patients, and an additional 1 ml Kenalog-40 was added to this mixture in the last 18 patients. We compared the static and dynamic sonographic findings with change in the patients’ level of pain at 2 days after anesthetic injection. The sonographic findings and response to anesthetic injection were also compared to the response to Kenalog injection and the results of any subsequent surgery.Results Static sonography of the iliopsoas tendon was normal in 38 patients, and detected iliopsoas bursitis in one patient and iliopsoas tendinopathy in another. Snapping of the iliopsoas tendon was observed using dynamic sonography in 9 of the 40 patients. Following anesthetic injection of the iliopsoas bursa, 29 patients had complete or partial pain relief, and 11 patients had no pain relief. Eight of the nine patients with a snapping iliopsoas tendon had complete or partial pain relief from the bursal injection. Twelve of the 29 patients with pain relief after anesthetic injection later had an arthroscopic iliopsoas tendon release, and all of these 12 patients had a good postoperative result. Of the 18 patients who had Kenalog-40 injected into the iliopsoas bursa and did not have iliopsoas surgery, 16 had sustained pain relief following the injection.Conclusions Patients with groin pain and a clinically suspected snapping iliopsoas tendon can benefit from injection into the iliopsoas bursa even if the snapping tendon is not visualized sonographically. The use of a corticosteroid may provide long-term pain relief, and pain relief after injection is a predictor of good outcome after surgical release of the iliopsoas tendon.     

Effect of prolonged bed rest on the anterior hip muscles

Prolonged bed rest and inactivity is known to cause muscular atrophy with previous research indicating that muscles involved in joint stabilisation are more susceptible. The anterior hip muscles are important for hip joint function and stability but little is known about the effects of prolonged inactivity on their function. This study investigated the effect of prolonged bed rest on the size of the anterior hip muscles and their pattern of recovery. The effect of resistive vibration exercise (RVE) as a countermeasure to muscle atrophy was also investigated. 12 male participants, randomly assigned to either a control or an exercise group, underwent 8 weeks of bed rest with 6 months follow-up. Changes in muscle cross-sectional area (CSA) of the iliacus, psoas, iliopsoas, sartorius and rectus femoris muscles were measured by magnetic resonance imaging at regular intervals during bed rest and recovery phases. CSAs of iliopsoas and sartorius decreased at the hip joint (p < 0.05) during bed rest but iliacus, psoas, and rectus femoris CSAs were unchanged (p > 0.05). No significant difference was found between the two groups for all muscles (all p > 0.1), suggesting inefficacy of the countermeasure in this sample. These findings suggest that prolonged bed rest can result in the atrophy of specific muscles across the hip joint which may affect its stability and function.     

The painful hip: new concepts

Hip pain is a common condition, and the work-up often includes imaging. This article reviews the normal MR anatomy of the hip and the imaging findings of internal derangements, snapping hip, and femoral acetabular impingement. We will describe the role of MR arthrography in evaluating the patient with suspected labral and articular cartilage abnormalities, as well as the pitfalls in interpretation. We will review the causes of a snapping hip, and the role of sonography in evaluating and guiding treatment of the snapping iliopsoas tendon. We will also review the radiographic and MRI signs of femoroacetabular impingement (FAI), a cause of early degenerative joint disease and hip pain.     

Ultrasound diagnosis of anterior iliopsoas impingement in total hip replacement

Iliopsoas impingement syndrome, an infrequent complication of total hip replacement, has been rarely reported in the radiological literature. It follows chronic friction of the posterior aspect of the iliopsoas muscle and tendon against the acetabular cup, a piece of cement, or cup fixation screws. Clinical findings are non-specific and an imaging modality is required to diagnose the condition. Computed tomography (CT) is considered the gold standard imaging modality in evaluating iliopsoas impingement. We report a case of a patient in which the diagnosis was made by ultrasound and later confirmed by CT.     

MR imaging of the acetabular labrum: a comparative study of both hips in 180 asymptomatic volunteers

The aim of this study was to determine the MR imaging characteristics of normal acetabular labra on both hips. Three hundred sixty acetabular labra on both hips of 180 asymptomatic volunteers were examined on a 0.5-T MR unit utilizing a superficial coil. Received: 10 April 2000 Revised: 30 June 2000 Accepted: 4 July 2000     

Microglandular adenosis of the breast in a BRCA1 mutation carrier: radiological features

Microglandular adenosis is a very uncommon benign proliferative disorder of the breast that may mimic tubular carcinoma radiologically and pathologically. We describe the radiological features of this rare condition in a patient with BRCA 1 mutation. To our knowledge, this is the first case of microglandular adenosis reported in the radiology literature. The relationship between microglandular adenosis and malignancy and the association between BRCA 1 and proliferative benign disorders are also discussed.     

改良髋关节磁共振成像扫描方法在发现骶髂关节病变中的应用价值

目的：通过对髋关节磁共振成像（MRI）冠状位扫描的改良,从而发现骶髂关节病变,弥补临床医生判断失误,提高疾病的检出率。方法对265例申请髋关节MRI检查的患者增加冠状位扫描层数,使每例患者双侧骶髂关节均能大部分显示。结果发现骶髂关节病变的共计20例,发现率为7．5％,年龄11-65岁,其中强直性脊柱炎16例,退行性骨关节炎2例,骶髂关节结核1例,外伤导致骨挫伤1例。结论骶髂关节病变,尤其是强直性脊柱炎是一种以危害年轻人为主的慢性炎性疾病,起病隐匿,临床部分患者以髋关节为主述症状,引起误诊,MRI在检查髋关节时适当在冠状位上增加扫描层数,能发现7．5％的遗漏病变,方法简便易行,值得推广。     

Role of MRI in hip fractures, including stress fractures, occult fractures, avulsion fractures

MR imaging plays a vital role in the diagnosis and management of hip fractures in all age groups, in a large spectrum of patient groups spanning the elderly and sporting population. It allows a confident exclusion of fracture, differentiation of bony from soft tissue injury and an early confident detection of fractures. There is a spectrum of MR findings which in part is dictated by the type and cause of the fracture which the radiologist needs to be familiar with. Judicious but prompt utilisation of MR in patients with suspected hip fractures has a positive therapeutic impact with healthcare cost benefits as well as social care benefits.     

Comparison of MR arthrography with arthroscopy of the hip for the assessment of intra-articular loose bodies

Objective To assess the specificity and sensitivity of MR arthrography of the hip in comparison with arthroscopy for the evaluation of intra-articular loose bodies. Design Over a 3-year period, 81 consecutive patients underwent a total of 82 hip arthroscopies by a single orthopedic surgeon for intractable hip pain. Of the 82 arthroscopies, 70 had pre-operative MR arthrograms. Of these, 57 were available for retrospective review, after which they were compared with the operative notes of the subsequent arthroscopies. Results Of 82 arthroscopies 16 (20%) demonstrated intra-articular loose bodies, while, in the study group, nine of 57 had loose bodies (16%). There was a total of seven discordant cases (five false negatives and two false positives). The sensitivity of MR arthrography for detection of intra-articular loose bodies was 44%, while the specificity was 96%. Conclusion While the specificity of MR arthrography for the detection of intra-articular loose bodies was high (96%), the sensitivity was not nearly as good (44%). Presented at the Special Scientific Section of the ISS in Vancouver, Canada, September 2006.     

99Tcm-MDP显像用于人工髋关节置换术后关节感染的鉴别诊断

目的 探讨99Tcm-MDP显像用于髋关节置换术后关节感染与无菌性假体松动鉴别诊断的适合方法.方法 回顾性分析2008年2月至2011年8月间74例人工髋关节置换术后出现关节疼痛的患者资料,其中男32例,女42例,年龄(64.3±11.2)岁.所有患者均行99Tcm-MDP血流、血池和骨骼三时相显像及血清C反应蛋白和血红细胞沉降率测定.99Tcm-MDP显像分别以假体周围软组织放射性浓聚、假体周围骨骼放射性浓聚或两者同时存在作为关节感染的诊断依据;无上述阳性表现者即认为关节疼痛由无菌性假体松动所致.依据最终临床诊断,采用x2检验比较99Tcm-MDP显像中骨骼相、血流-血池相、血清学检查结果间诊断效能的差异.结果 74例患者中,有症状关节74个,其中感染关节24个,无菌性假体松动50个.诊断关节感染的灵敏度和特异性:血流-血池相分别为91.7％(22/24)和90.0％ (45/50),骨骼相分别为70.8％ (17/24)和48.0％ (24/50),血清C反应蛋白分别为62.5％ (15/24)和78.0％ (39/50),血红细胞沉降率分别为62.5％ (15/24)和76.0％ (38/50).血流-血池相对假体周围感染诊断的准确性优于单纯骨显像[90.5％ (67/74)和55.4％ (41/74);x2=23.159,P＜0.001],也优于血清C反应蛋白[73.0％(54/74) ;x2 =7.656,P＜0.05]和血红细胞沉降率[71.6％(53/74);x2 =8.633,P＜0.05]检测.结论 在髋关节置换术后关节感染与无菌性假体松动鉴别诊断中,99Tcm-MDP血流-血池相具有较高的临床价值,建议作为常规检查方法.     

股骨头缺血坏死并髂腰肌囊扩张的影像学表现

目的　探讨髂腰肌囊扩张的CT、MRI表现 ,明确其诊断、原因及意义。资料与方法　回顾性分析具有典型影像学表现和 /或经病理或随访证实的 86例 (138髋 )成人股骨头缺血坏死患者的CT和MRI片 ,从中挑选出伴髂腰肌囊扩张者 17例 (18髋 )进行分析。结果　 18髋均为圆形、卵圆形或倒水滴状囊性肿物 ,位于髋关节囊前方 ,髂外或股动静脉后外方和髂腰肌 (腱 )内侧。MR上T1WI呈低信号 ,T2 WI呈高信号 ,T2 WI 脂肪抑制呈明显高信号。CT上为等或略低密度 ,CT值 12～ 4 5HU。 5例增强检查 ,囊壁轻度强化。Ⅱ级关节积液并髂腰肌囊扩张 12髋 ,Ⅲ级关节积液并髂腰肌囊扩张 6髋。Ⅱ级关节积液并髂腰肌囊扩张多于Ⅲ级关节积液 (P <0 .0 0 1)。结论　股骨头坏死并髂腰肌囊扩张见于股骨头缺血坏死中晚期 ,提示临床采取进一步措施     

MR imaging findings in transient osteoporosis of the hip

Purpose: The authors sought to describe the magnetic resonance (MR) imaging findings including perfusion imaging, in association with the course of acute bone marrow oedema syndrome (aBMEs), in a group of patients with acute hip pain and a final diagnosis of transient osteoporosis of the hip (TOH). Materials and methods: From 217 patients referred with a probable diagnosis of avascular necrosis (AVN) of the femoral head, we identified 42 patients who had clinical and radiographic findings not relevant to AVN. MR imaging examinations were performed on a 1.0T scanner. Perfusion imaging was performed in 20 patients. The bone marrow oedema (BME) was classified in four stages. In addition, the presence or absence of oedema in the subchondral area and the presence of other subchondral lesions were recorded. Acetabular bone marrow was also assessed for the presence of oedema. The quantitative measurements included: maximum size of the effusion, percentage of enhancement (PE) and time of peak enhancement of abnormal marrow compared to the first pass, on the perfusion images. Results: Osteopenia was present on plain radiographs in 87% of cases. The most common pattern of BME was extending to the femoral head and neck. Acetabulum was involved in 16.6%. In 22.6% the BME spared the subchondral region of the femoral head. There were two cases (4.7%) with subchondral changes. A joint effusion was noted in 33 of the 42 patients. On perfusion imaging, a delayed peak enhancement was noted in 20 patients between 40 and 65 s after the first pass of contrast. No patient had any evidence of femoral head collapse or change in sphericity on follow-up MRI. None of the patients developed avascular necrosis in a time frame of 18 months from the onset of the acute hip pain. Conclusion: The aBMEs MR imaging pattern varies and is most commonly appearing on X-rays as osteopenia. Absence of subcondral lesions, delayed peak enhancement of the abnormal marrow on perfusion images, and sparing of subchondral zone from marrow oedema are MR imaging findings highly correlated to TOH.     

Acute bone marrow edema of the hip: role of MR imaging

Acute bone marrow edema of the hip is a diagnostic challenge for both radiologists and clinicians. Marrow edema is often seen in patients with hip pain and restriction of motion. In patients with acute non-traumatic hip pain, whose radiographs are negative or inconclusive, MR imaging is the imaging study of choice. MR imaging is the most sensitive and specific imaging technique for detecting transient osteoporosis and osteonecrosis, as well as for detecting and staging fractures and microfractures. MR imaging is able to show marrow involvement in various inflammatory disorders and to diagnose reactive marrow edema from femoroacetabular impingment and greater trochanteric pain syndrome. In patients with septic arthritis, it may also depict associated marrow edema and suggest its reactive or infectious origin. For the neoplastic disorders, although plain radiographs should be the initial examination, MR imaging may follow for assessing extension to the surrounding soft tissues and/or associated pathologic fracture, facilitating thus the treatment planning. Computed tomography is more accurate compared with MR imaging in diagnosing intra-articular osteoid osteomas.     

MR-guided direct arthrography of the hip

PURPOSE: To develop an MR-guided technique for direct magnetic resonance arthrography (DMRA) of the hip using a conventional 1.5 Tesla (T) MRI scanner. MATERIALS AND METHODS: Interactive versions of standard single-shot fast spin echo, coherent gradient echo, and fully balanced steady-state free precession sequences were developed, together with the ability to operate the scanner from within the magnet room. Initial optimization was performed using ex vivo animal joints. After informed consent, five patients underwent DMRA using dilute gadolinium as the contrast medium. RESULTS: The procedure was successful in all five patients and diagnostic quality MR arthrography studies were obtained in all cases. The time taken from the initial placement of skin marker to the introduction of contrast medium reduced with successive patients: 26, 22, and 19 min with the final two studies taking 13 min each. CONCLUSION: This work demonstrates the feasibility of performing DMRA using MR guidance, avoiding the need for X-ray fluoroscopy facilities but exploiting the available imaging performance of a high-field closed-bore MR system. The use of an in room control and display system together with interactive fluoroscopic imaging sequences simplifies the positioning of the needle and allows rapid confirmation of an intra-articular injection.     

Lesions of the Achilles tendon: Evaluation with ultrasonography and magnetic resonance imaging

Purpose

This work aims at evaluating the role of ultrasonography and magnetic resonance imaging in the diagnosis of the lesions affecting Achilles tendon of the ankle joint.

Patients and methods

The study is a prospective study of 28 patients. Some of them are complaining of a posterior heel pain, stiffness & a limitation of movements, soft tissue thickness and swollen and ecchymotic ankle. Plain X-ray (anteroposterior and lateral views), ultrasound examination were performed for both ankles of all patients with the patients in a prone position, the Achilles tendon was examined from its musculotendinous junction to its calcaneal insertion in both longitudinal and transverse views. Finally, MRI was performed with the patients in supine position, the foot is dorsiflexed, axial and sagittal T1, T2-weighted images, STIR & proton density were done for all patients.

Results

Out of 28 patients that were examined, the final diagnosis included; eight cases of tendinopathy (five cases peritendinosis, and three cases tendinosis), 16 cases of partial thickness tear (as compared to arthroscope), and four cases of full thickness tear.

Conclusion

Ultrasound is an important complementary diagnostic tool in the diagnosis of lesions of Achilles tendon, it is as good as MRI in the diagnosis of tendinopathy and full thickness tear, however MRI is more superior in the diagnosis of partial thickness tear, and in the differentiation of the different types of tendinopathy.     

Primary synovial osteochondromatosis of the hip: extracapsular patterns of spread

Objective To identify patterns of extracapsular extension of synovial osteochondromatosis of the hip.Design and patients Seven cases of synovial osteochondromatosis of the hip were retrospectively reviewed. Imaging performed included conventional radiography (n=7), arthrography (n=1), CT (n=3) and MR imaging (n=3). Disease extent on imaging was assessed for each patient and the presence of intra-articular effusion, capsular abnormality and osteochondral bodies recorded. The presence and distribution of extra-articular spread was also assessed and correlated with the surgical findings. In all cases diagnosis was confirmed by biopsy, with all patients undergoing tumor resection with or without synovectomy.Results In five cases (5/7) disease extended beyond the hip capsule, while the remaining two cases (2/7) were confined to the hip joint. These findings were confirmed at surgery. Two distinct patterns of extracapsular spread were identified. The first pattern, noted in three cases, involved tumor extension along iliopsoas. The second pattern, noted in five cases, involved tumor extension along the obturator externus fat plane. In three cases both patterns were present.Conclusions Extra-articular spread of synovial osteochondromatosis is common. Patterns of extra-articular spread may be predictable based on involvement of recognized periarticular bursae of the hip joint. Bursal patterns of extra-articular spread include extension into the iliopsoas bursa as well as communication along the obturator externus bursa of the hip.     

暂时性骨质疏松症的MRI表现

目的:探讨暂时性骨质疏松症的MRI表现。方法:对经临床证实的10例暂时性骨质疏松症(TOH)患者的临床及影像学资料进行回顾性分析。10例患者均行MRI平扫,其中5例行MRI增强扫描,4例行CT扫描。10例中男7例,女3例,年龄为25～40岁。结果:10例TOH中,双侧髋关节同时受累2例,单侧受累8例,主要MRI表现为弥漫性骨髓水肿,累及股骨头、颈及转子间,股骨头形态完整,1例可见软骨下应力性骨折,所有病例均无股骨头软骨下骨质缺损;关节囊肿胀和关节积液8髋;MRI增强扫描示病变区呈明显均匀强化。主要CT表现为股骨头骨密度弥漫性减低,骨皮质变薄。治疗5～11个月后患者疼痛症状消失,股骨内MRI信号恢复正常。结论:CT上表现为弥漫性骨质疏松、MRI表现为弥漫性骨髓水肿、缺乏软骨下骨质病变以及均匀一致强化是TOH性特征的影像学表现。     

The advantages of MRI in the detection of occult hip fractures

While the displaced hip fracture can be visualized easily by plain radiography, the non-displaced fracture may be radiographically occult and require different imaging modalities, e.g., MRI for proper visualization. The accuracy of readers and cost advantages of utilizing MRI have not been assessed. Therefore, we undertook a study of these factors. The medical records of all patients who had visited the emergency room from June 2002 until May 2003 with a clinically suspected hip fracture, negative or equivocal plain film and subsequent MRI examination were retrospectively reviewed. Two senior and two junior radiologists independently evaluated both the MR images and radiographs of all 33 patients in a blinded study. One of three possible evaluations was described for the images of each modality: absence, presence or possibility of fracture. The economic consequences of using MRI in the detection of occult hip fractures were calculated. For all four doctors participating in this study, MRI proved to be far more sensitive and specific in the detection of occult hip fractures than radiography. Using the MR images, the senior radiologists identified the occult hip fracture patients with 100% accuracy and were in complete agreement. The agreement between junior and senior radiologists was high (average =0.75). MRI also detected soft tissue injuries in 39% of the patients that could not be identified with radiography. Adoption of the new protocol using MRI saves hospitals from €242 to 627 per patient. By shortening the time to diagnosis and permitting a superior visualization of both bone and soft tissue injuries, MR imaging prevents unnecessary hospitalization and delays in definitive treatment. MR images should be assessed by senior radiologists.