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Imaging evaluation of the painful hip in adults

Imaging evaluation of the painful hip in adults
Literature review current through: Jan 2024.
This topic last updated: Apr 20, 2023.

INTRODUCTION — The hip is a stable, major weightbearing joint with significant mobility. Hip pain has different etiologies in adults and children. In adults, hip pain may be caused by intraarticular disorders such as avascular necrosis (AVN), arthritis, loose bodies, labral tears; periarticular pathology such as tendinitis and bursitis; or extraarticular conditions such as referred pain from lumbar spine, as well as sacroiliac joint and nerve entrapment syndromes.

Imaging modalities used to evaluate adults with hip pain and the appropriateness of particular exams in different clinical scenarios will be reviewed here. The history and physical examination, which are necessary to develop a differential diagnosis prior to the selection of imaging tests; a general review of imaging tests that are used in the evaluation of bone and joint pain; and imaging modalities used to evaluate the hip in children are presented separately. (See "Approach to the adult with unspecified hip pain" and "Imaging techniques for evaluation of the painful joint" and "Radiologic evaluation of the hip in infants, children, and adolescents".)

TYPES OF IMAGING EXAMS — The modalities available for evaluation of the hip include:

Plain film radiography — Plain film radiography of the hip is used in the initial evaluation of any cause of hip pain, including trauma and sports injuries, suspected avascular necrosis (AVN), arthritis, hip arthroplasty, infection, dysplasia, tumor, and microinstability [1]. Plain film can also identify causes of referred hip pain, such as sacroiliitis. Plain film may not detect or accurately characterize some hip fractures and bone marrow edema associated with early AVN or early osteomyelitis.

Computerized tomography — Computerized tomography (CT) of the hip without contrast is most useful in the setting of trauma, for preoperative planning, and for evaluation and guiding percutaneous biopsy of tumors. Intravenous contrast is administered for evaluating a septic joint or a soft tissue abscess.

In traumatic injuries, CT is used to detect intraarticular extension of a fracture, acetabular fracture, pelvic ring and sacral fractures, and intraarticular loose bodies.

CT is also used for preoperative evaluation of hip fractures, pre- and postoperative evaluation of hip dysplasia, and hip arthroplasty.

In the setting of bone tumor, CT is useful for evaluation of tumor matrix and for detection of cortical thinning or cortical destruction. CT is valuable in guidance for biopsy or ablation of certain tumors such as osteoid osteoma.

CT may not detect trabecular bone injuries, which may be present in femoral neck insufficiency fractures in osteoporotic patients, and will not demonstrate the bone marrow edema of early AVN and early osteomyelitis.

Magnetic resonance imaging — Magnetic resonance imaging (MRI) of the hip accurately evaluates the bone marrow, joint space, neurovascular structures, and soft tissues. Intravenous contrast is usually not administered except for evaluation of soft tissue and bone tumors or vascular malformations. MRI is the modality of choice for suspected femoral fracture not demonstrated radiographically, osteochondral injuries, muscle injuries, joint effusion, early diagnosis and staging of AVN, iliopsoas and greater trochanteric pain syndrome (formerly trochanteric bursitis), evaluation of infection, and tumor. More unusual disease entities such as pigmented villonodular synovitis and synovial osteochondromatosis can be diagnosed with MRI. Administration of gadolinium-containing MRI contrast agents should be avoided in patients with severely impaired renal function (eg, estimated glomerular filtration rate <15 to 30 mL/min).

If gadolinium-based imaging must be performed in a patient with moderately to severely impaired renal function, there may be a role for dialysis to reduce the risk of development of nephrogenic systemic fibrosis (NFS). Approaches to prevention of NFS are discussed separately. (See "Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy in advanced kidney disease", section on 'Prevention'.)

Radionuclide Tc-99m bone scan — Radionuclide Tc-99m (technetium methylene diphosphonate) bone scan can be performed as a whole-body exam or as a focused exam of the hip. It is reserved for suspected fracture or AVN not demonstrated by plain film radiography when MRI is not available or is contraindicated (eg, pacemaker, aneurysm clip). Bone scan is also indicated in the evaluation of metastatic disease, as well as prosthetic device loosening or infection. Radionuclide bone scan can survey a large area when performed as a whole-body exam; however, it is often nonspecific.

Ultrasound — Ultrasound (US) of the hip is readily available even at the bedside, allows dynamic evaluation of the tendons and muscles, and does not involve ionizing radiation; however, diagnostic performance is highly variable and operator- and patient-dependent. Hip effusions and bursal or periarticular fluid collections are readily identified. US is useful for guiding hip aspiration [2], injection of anesthetics and steroids into the hip joint or bursae, and soft tissue biopsies. (See "Musculoskeletal ultrasonography: Clinical applications" and 'Image-guided injection with anesthetic and/or steroid' below.)

In the appropriate clinical setting, US can be used to identify soft tissue hematoma and partial or complete muscle tears. Another indication for US is dynamic evaluation of the snapping iliopsoas syndrome [2,3].

Conventional plain film arthrography — The imaging indications for conventional plain film hip arthrography are now limited due to the increased use of MR hip arthrography, which visualizes joint anatomy as well as bone and surrounding soft tissues. However, limited conventional arthrography is useful to confirm intraarticular needle placement when hip aspiration is indicated for joint fluid analysis (eg, when septic arthritis or crystal induced synovitis is suspected). Aspiration and arthrography are also warranted when there is clinical suspicion of a prosthetic hip infection.

Image-guided injection with anesthetic and/or steroid — Injection with anesthetic and/or steroid under fluoroscopic guidance is reserved for cases when imaging is inconclusive or demonstrates mild osteoarthritis (OA) and when referred pain is clinically suspected. Persistent pain, despite the injection of a local anesthetic, reduces the likelihood that hip pathology is the cause of pain and may obviate the need for further diagnostic imaging of the hip [4]. Such injections are usually performed in addition to conventional hip arthrography and aspiration. Therapeutic injection of glucocorticoids into the hip joint can be done for acute and chronic inflammation associated with various arthritides [5].

Magnetic resonance arthrography — MR arthrography of the hip with intraarticular gadolinium administration best delineates the joint anatomy, including the acetabular labrum, articular cartilage, and ligamentum teres, and detects loose bodies. MR arthrography is used in cases of hip pain that may involve any of the above-mentioned structures. Administration of gadolinium-containing MRI contrast agents should be avoided in patients with severely impaired renal function (eg, estimated glomerular filtration rate less than 15 to 30 mL/min). See Gadoteridol drug information.

Computerized tomography arthrography — CT arthrography of the hip with intraarticular iodinated contrast is used in cases where the use of MR arthrography is contraindicated (eg, pacemaker, aneurysm clip).

IMAGING EXAMS FOR SPECIFIC CLINICAL SETTINGS — As noted in the introduction, imaging evaluation of the hip is directed by the history and physical examination findings. (See "Approach to the adult with unspecified hip pain".)

Major categories of hip pathology include trauma, sports-related injuries, the bone marrow edema syndrome, osteonecrosis (avascular necrosis [AVN]), arthritis, the greater trochanteric pain syndrome, infection, tumor, and hip arthroplasty. Less common entities such as femoroacetabular impingement syndrome, nerve entrapment syndromes, and snapping hip syndrome are briefly addressed. Imaging in the evaluation of pediatric hip pain is presented in the context of individual disorders. A list of some entities that affect the hip in children of various ages is presented separately. (See "Radiologic evaluation of the hip in infants, children, and adolescents".)

Acute hip trauma — Acute hip trauma is initially evaluated with plain film radiographs. Patients with a history of trauma for whom there is a high clinical index of suspicion of fracture, which is not apparent on plain radiographs, should be assessed further with computed tomography (CT) or magnetic resonance imaging (MRI), depending on the type of fracture suspected. The American College of Radiology has published appropriateness criteria for evaluation of acute hip pain with suspected fracture [6].

Plain film radiography – Plain film radiography is the initial imaging exam obtained for trauma or suspected fracture involving the hip and pelvis. Most fractures of the pelvis and hip joint, avulsion injuries, and dislocations will be identified on plain film. However, fractures involving the acetabulum, pelvic ring, or sacrum are occasionally difficult to detect on plain film radiography, and CT is recommended. Likewise, nondisplaced fractures, insufficiency fractures, or stress/incomplete fractures of the femoral neck may not be seen on plain film, and MRI is recommended (image 1 and image 2). These advanced imaging modalities are indicated if the clinical suspicion remains high despite negative plain film radiography.

CT – CT has several indications in the evaluation of hip fractures and dislocation. CT is indicated in clinically suspected acetabular, pelvic ring, and sacral fractures not seen on plain radiographs. CT can demonstrate the cortical break, intraarticular loose bodies, fracture alignment, and underlying pathological bone. CT with multiplanar reconstruction is used for preoperative planning of hip fractures and assessment of nonunion femoral fracture [7].

CT is valuable in assessing the direction of the hip dislocation when plain film is not conclusive, evaluating the extent of injury, and in treatment planning. In posterior hip dislocation, CT shows the associated posterior acetabular wall fractures, intraarticular loose bodies, or other mechanical blocks, which may interfere with closed reduction or result in instability after reduction [8]. CT is also indicated after closed reduction of all hip dislocations to assess for associated fractures, residual subluxation, and osteochondral fragments [9,10].

CT may not detect trabecular bone injuries seen in insufficiency fractures of the femoral neck; these are best detected by MRI.

MRI – MRI is indicated for detection of radiographically occult fractures, such as stress and insufficiency fractures of the femoral neck, intertrochanteric fractures, and subtrochanteric fractures (image 1 and image 2) [11-13]. Pelvic MRI evaluation will show any additional pelvic insufficiency fractures (image 3), avulsion fractures, bone contusions, and muscle and sciatic nerve injury [11,12,14]. MRI will demonstrate the full extent of a fracture, such as a greater trochanteric fracture, which may appear simple on plain radiography, to determine if surgical intervention is needed [15,16].

Accuracy of MRI for detecting occult hip fracture is reported to be 100 percent [14], which can be achieved using T1-weighted coronal sequence alone [13]. However, for early detection of associated edema and soft tissue injury, a fluid sensitive sequence is required.

In the follow-up of femoral neck fracture and dislocation, MRI performed at three months is useful in detecting AVN, which is a potential complication from damage to the circumflex femoral artery [11].

Radionuclide Tc-99m bone scan – Radionuclide Tc-99m (technetium methylene diphosphonate) bone scan is indicated in cases with suspected fracture and negative radiographs when MRI or CT is not available. The bone scan usually becomes positive within six hours; however, in older or osteopenic patients, there may be a delay of 48 hours after injury [17]. Sacral fractures have a characteristic appearance on bone scan and can be accurately diagnosed.

MR arthrography – MR arthrography is indicated in the setting of persistent pain and clinical suspicion of acetabular labral tear, ligamentous or capsular injury, intraarticular loose bodies, and chondral injuries. MR arthrography can detect stability of an osteochondral lesion, which can affect management.

Ultrasound (US) – In the appropriate clinical setting, US can identify soft tissue hematoma, as well as partial or complete muscle and tendon tear [18]. US can also detect cortical fractures [19].

Hip imaging in sports medicine — Plain film radiographs are used initially to evaluate patients with subacute or chronic hip pain. Radionuclide scanning, CT, and MRI are all more sensitive than plain radiographs for the detection of stress fractures of the hip or pelvis, particularly during the first few weeks following the onset of pain. MRI is indicated for evaluation of soft tissue injuries. MR arthrography is indicated for evaluation of articular and osteochondral injuries. The American College of Radiology has published appropriateness criteria for evaluation of soft tissue abnormalities encountered in athletic activities, such as tendonitis or tendon tears, muscle injuries, nerve injuries, and athletic pubalgia [20], and also for evaluation of articular cartilage and osteochondral injuries [21].

Plain film radiography – Plain film radiography detects fracture, dislocation, avulsion injuries of the ischium, iliac spines, and iliac crest, as well as of the greater and lesser trochanters.

Premature osteoarthritis (OA) of the symphysis pubis and sacroiliac joints, which is encountered in marathon runners, skiers, and soccer players, is detected.

Stress fractures of the femoral neck are often not visualized in the first two weeks on plain radiographs [22] and, when clinically suspected, should be further evaluated with MRI.

Radionuclide Tc-99m bone scan – Radionuclide bone scan with single photon emission computed tomography (SPECT) is 100 percent sensitive for detecting stress fracture; however, it is not specific since it is also positive in stress reaction [23].

CT – CT demonstrates small avulsion injuries, which may not be visualized on plain film, and the presence of intraarticular extension of fracture. CT is used for preoperative planning of hip fractures.

MRI – MRI detects stress fractures, subtle avulsion injuries, osteochondral injuries, periarticular soft tissue injuries such as muscle strains and contusions (image 4), tendon tears, and sciatic nerve injury. MRI is the modality of choice for early detection of stress fractures, which, in turn, prevents complications such as displacement of tensile fractures [22]. MRI of muscle injury may affect the decision for surgical repair and predict time to recovery [24-26].

MR arthrography – MR arthrography is indicated in evaluation of suspected injuries to the acetabular labrum, ligamentum teres, detection of intraarticular loose bodies, and chondral defects. MR arthrography has 90 percent sensitivity and 91 percent accuracy for the detection of labral tears [27].

Acetabular labral tears — Labral tears are most often posttraumatic in young adults and degenerative in the older population. Plain film radiographs cannot detect damage to the fibrocartilaginous labrum but may reveal osteoarthritic changes resulting from a prior injury. Conventional MRI is not as sensitive as MR arthrography for diagnosing acetabular labral tears [28]. The American College of Radiology has published appropriateness criteria for evaluation of labral tear [29].

Plain film radiography – Radiographs have a low diagnostic yield for labral tears. Plain film findings that indicate sequela of labral tear are premature or rapidly progressing OA.

MRI – Conventional MRI is less sensitive for evaluation of the acetabular labrum than MR arthrography [30].

MR arthrography – MR arthrography is the modality of choice for evaluation of acetabular labral tear. MR arthrography defines the presence, morphology, and articular surface contour of the labrum. MR arthrography shows articular cartilage defects, labral tears (image 5), intraarticular loose bodies, and major abnormalities of the ligamentum teres.

Sensitivity of MR arthrography for detecting labral injuries is over 90 percent, and accuracy is between 88 and 91 percent [27,31].

CT arthrography – CT arthrography (CT arthrography) with intraarticular iodine can replace MR arthrography when there is contraindication for MRI (eg aneurysm clips, certain pacemakers) or when MRI is not available.

Femoroacetabular impingement — Femoroacetabular impingement (FAI) is an important cause of hip pain, and its presence may lead to early OA, particularly in those under age 40. The estimated prevalence is 10 to 15 percent [32,33]. FAI can be caused by a nonspherical femoral head (cam type) or by excessive acetabular covering (pincer type) [34]. Clinical manifestations of FAI are chronic pain, reduced range of motion, and early OA.

Early detection can be made by plain film, CT with three-dimensional (3D) reformation, MRI, or MR arthrography [35-38]. MR arthrography also demonstrates the manifestations of untreated FAI, which include articular cartilage damage and acetabular labral tear. The American College of Radiology has published appropriateness criteria for evaluation of impingement [39]. Treatment of FAI, when indicated, is by open surgical approach or by arthroscopic repair [32]. (See "Approach to hip and groin pain in the athlete and active adult", section on 'Femoroacetabular impingement'.)

Bone marrow edema syndrome — Bone marrow edema syndrome, also referred to as the "transient bone marrow edema syndrome" or as "transient osteoporosis of the hip," was initially described in pregnant women. This disorder of unknown etiology is most commonly seen in middle-aged men presenting with hip pain. Osteopenia may be apparent on plain radiographs, while increased T2 signal in the bone marrow of the femoral head and neck is apparent on MRI. Diffuse rather than focal involvement of the femoral head may help to distinguish this entity from osteonecrosis. (See 'Avascular necrosis' below.)

Pain and osteopenia resolve spontaneously in most cases. Diagnostic imaging is useful primarily to exclude other causes of hip pain [40]. Bone marrow edema syndrome should be considered a marker for potential progression to advanced AVN, and careful follow-up is necessary [41,42]. (See 'Avascular necrosis' below.)

Plain film radiography – Plain film radiography is often negative or may demonstrate osteopenia within four to eight weeks after the onset of hip pain [43]. Osteopenia typically resolves within nine months of symptom onset.

Radionuclide Tc-99m bone scan – Bone scan is more sensitive than plain film for detection of bone marrow edema syndrome. Scintigraphy reveals diffuse and homogeneously increased uptake that involves the femoral head and neck [43]. However, this modality is no longer used since the advent of MRI.

MRI – MRI demonstrates bone marrow edema involving the entire femoral head and neck, with possible extension into the subtrochanteric region and commonly associated joint effusion. This entity can be differentiated from AVN by lack of focal changes of the femoral head on MRI [44,45]. The MRI abnormalities are reversible as early as six weeks after onset of symptoms [46].

Avascular necrosis — The femoral head is the most common location for AVN of bone (also referred to as osteonecrosis), with trauma being the leading cause. Other risk factors include use of glucocorticoids, alcohol abuse, radiation, pancreatitis, and hemoglobinopathies. Non-traumatic cases of AVN are often bilateral. Patients on steroids may have asymptomatic AVN. The clinical and laboratory data are not specific for the diagnosis, and confirmation can be done only by imaging. Early detection and surgical intervention by core decompression can prevent progression to femoral head collapse and the need for total hip arthroplasty [47]. The American College of Radiology has published appropriateness criteria for evaluation of AVN of the hip based upon various clinical presentations [48].

Plain film radiography – Plain film radiography is the first imaging exam recommended for evaluation of suspected AVN. Plain film excludes other causes of hip pain and detects advanced stages of AVN, eliminating the need for further imaging. In addition to the frontal view, the frog leg view is necessary to evaluate the anterosuperior aspect of the femoral head [48]. The sensitivity of plain film radiography for the early stages of AVN is low. Findings seen in later stages of AVN are subchondral sclerosis, progressing to subchondral fracture ("crescent sign") and collapse of the femoral head with secondary OA (image 6).

MRI – MRI is the most sensitive and specific method for diagnosing and staging AVN (image 7) [49,50]. MRI is recommended when there is a clinical suspicion of AVN but when the plain films are negative or equivocal. When the plain films are positive for AVN in one hip, MRI is indicated for evaluation of the contralateral hip for occult AVN [48]. Limited MRI has the potential of becoming a screening procedure for selected groups of patients at high risk for developing AVN [51].

The sensitivity and specificity of MRI for diagnosing early AVN range from 97 to 100 percent [49]. MRI is less sensitive in detection of subchondral fracture seen in later stage of AVN, which is better detected by CT [52,53].

The classic MRI finding is the "double line sign" at the necrotic-viable bone interface that is present in up to 80 percent of cases [50]. Associated bone marrow edema is frequently limited to the femoral head, as compared with the bone marrow edema syndrome which shows more extensive involvement. As mentioned above, bone marrow edema syndrome should be considered a marker for potential progression to advanced AVN, and careful follow-up is necessary [41,42]. The signal characteristic of the lesion determines the bone viability and, therefore, the stage of the disease [49,54]. A small percentage of AVN cases may have associated acetabular osteonecrosis [55].

In addition to being useful in diagnosis, MRI is valuable in assessing prognosis and postoperative follow-up. The extent of involvement of the weightbearing area of the femoral head by osteonecrosis and the location of the lesion correlate with progression to collapse [49-51,56]. Laterally located lesions have a higher rate of femoral head collapse than centrally or medially located lesions [49-51]. The extent of involvement of the femoral head also correlates with the likelihood of success of early surgical interventions, such as core decompression. As an example, early-stage AVN involving less than 25 percent of the weightbearing portion of the femoral head treated by core decompression did not progress to collapse, whereas 87 percent of the cases involving more than 50 percent of the femoral head proceeded to collapse [50] (see "Treatment of nontraumatic hip osteonecrosis (avascular necrosis of the femoral head) in adults"). In addition, MRI is important in postoperative follow-up of core decompression, by assessing the return of bone viability [50].

Entities that mimic AVN on MRI are subchondral insufficiency fracture and femoral head osteochondral lesion. Subchondral insufficiency fracture is a non-traumatic lesion that occurs in older osteoporotic patients and is typically seen in the superior lateral aspect of the femoral head [57]. Femoral head osteochondral lesion is a posttraumatic lesion that occurs in young athletes in the medial aspect of the femoral head. The history and location helps in differentiating these lesions [58].

Radionuclide Tc-99m bone scan – Radionuclide bone scan is sensitive for detection of early AVN when MRI is not available or is contraindicated. The changes are apparent before the plain film radiography becomes positive. The accuracy of radionuclide bone scan with SPECT for detecting AVN is approximately 78 percent, which increases to 95 percent when SPECT/CT is used for diagnosis [50,59].

CT – CT is not sensitive for detection of early AVN. CT may show the classic "asterisk sign" secondary to condensation of bony trabeculae and sclerosis. CT is more sensitive than MRI in detection of advanced changes of AVN manifested by subchondral fracture and articular collapse [52]. CT is useful in anatomic localization of osteonecrosis, as well as evaluation of secondary OA and the extent of bone deformity, if osteotomy or arthroplasty is planned [50].

Arthritides — This section addresses the major arthritides involving the hip joint, including OA, inflammatory arthritis such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS), and calcium pyrophosphate deposition disease. We will briefly discuss pigmented villonodular synovitis and synovial osteochondromatosis.

Osteoarthritis — OA is the most common arthritis seen in practice. Primary OA has a variety of risk factors, while secondary OA follows an identifiable joint injury or may result from repeated microtrauma, a prior infection, osteonecrosis, crystal disease, or metabolic disorders such as hemochromatosis and ochronosis. Plain film radiography is the initial and is often the only imaging modality needed to diagnose OA and to exclude other causes of hip pain.

Plain film radiography – Plain film radiography is the initial imaging modality of choice for evaluation of all arthritides. Hallmarks of OA of the hip seen in plain film include superolateral joint space narrowing, osteophyte formation, subchondral sclerosis, and cyst formation (image 8).

CT – CT is valuable in the setting of premature OA to detect anatomical abnormalities such as acetabular or femoral dysplasia or femoroacetabular impingement. In advanced OA, CT is used for preoperative planning and prosthesis fitting for total hip arthroplasty. CT can also help in localization of paraarticular calcifications or ossification and detection of loose bodies.

MRI – MRI does not have an established indication in the diagnosis and management of OA [60].

Rheumatoid arthritis — The most common inflammatory arthritis of the hip is RA.

Plain film radiography – Characteristic findings of RA on plain film are bilaterally symmetric and uniform (concentric) joint space narrowing with axial migration, osteoporosis, varying degrees of erosion, and synovial cyst formation, without sclerosis and osteophytes (image 9).

CT – CT demonstrates erosions earlier than plain film; however, CT is not routinely used for evaluation of RA.

MRI – MRI demonstrates the hypertrophied synovium and erosions. Use of MRI has been advocated for early diagnosis of RA in the hands [61], but the usefulness of MRI of the hip in early disease is uncertain.

Ankylosing spondylitis — AS is a chronic inflammatory disease primarily affecting the axial skeleton (spine and sacroiliac joints). The most common nonaxial joint to be involved is the hip.

Plain film radiography – Plain film is the single most important technique for detection, diagnosis, and follow-up of AS affecting the hip. Characteristic findings of AS are bilateral symmetrical loss of joint space with axial migration of the femoral head. Ankylosis (fusion) of the joint may ensue.

CT – CT has limited use for the diagnosis of hip involvement by AS.

MRI – MRI is useful in assessing early cartilage abnormalities and bone marrow edema; however, it is not necessary for diagnosis.

Calcium pyrophosphate deposition disease — Calcium pyrophosphate deposition disease (CPPD) is the most common crystal arthropathy, caused by deposition of calcium pyrophosphate dihydrate crystal in and around the joints that may be apparent on plain film radiographs. The knees, wrists, and hips are the joints most commonly affected by CPPD disease. Fluoroscopically guided joint aspiration may be necessary to obtain synovial fluid to confirm the presence of CPPD crystals and to exclude infection.

Plain film radiography – Plain film radiography is the gold standard in the diagnosis of CPPD. Calcification is seen in the acetabular labrum and/or the cartilage (chondrocalcinosis). Uniform loss of cartilage resulting in axial migration and prominent subchondral cyst formation are seen in later stages.

CT and MRI – CT and MRI are not necessary for diagnosis.

Fluoroscopically guided joint aspiration (arthrocentesis) – Fluoroscopically guided hip aspiration is valuable in the detection of CPPD crystals when the clinical manifestation of pseudogout (acute arthritis) is present and when the plain film is normal. Gram stain and culture of joint fluid is useful in excluding a concomitant joint infection.

Pigmented villonodular synovitis and synovial osteochondromatosis — Pigmented villonodular synovitis (PVNS) and synovial osteochondromatosis are benign proliferative disorders of the synovial lining. PVNS and synovial osteochondromatosis are rare causes of hip pain. The American College of Radiology has published appropriateness criteria for evaluation of hip pigmented villonodular synovitis and synovial osteochondromatosis [62]. (See "Treatment for tenosynovial giant cell tumor and other benign neoplasms affecting soft tissue and bone", section on 'Tenosynovial giant cell tumor'.)

Plain film radiography is the initial imaging exam of choice when either of these disorders is suspected. MRI is the imaging modality of choice for the diagnosis of PVNS and for synovial chondromatosis (in which calcification of the cartilaginous loose bodies is absent).

Plain film radiography – Plain film radiography demonstrates well-defined erosions with a normal joint space [63]. In synovial osteochondromatosis, multiple intraarticular loose bodies are seen [64,65].

Uncalcified cartilaginous loose bodies (synovial chondromatosis) are not visible on plain films but can be detected by CT or MRI.

CT – CT of PVNS demonstrates hyperdense, hemosiderin-laden masses and delineates bone cysts and erosions. CT is also valuable for needle biopsy guidance, when needed, and for preoperative planning. In synovial chondromatosis, CT will show non-calcified intraarticular loose bodies.

MRI – MRI is the modality of choice for PVNS and for synovial chondromatosis with normal plain film (image 10). MRI findings of PVNS are low-signal, nodular intraarticular masses in all sequences from hemosiderin deposition [64,66]. Bony erosions, when present, and extraarticular extension of the lesion are well-demonstrated on MRI. In synovial chondromatosis, MRI shows non-calcified loose bodies and helps in preoperative planning [64,65].

CT arthrography or MR arthrography – Hip arthrography, utilizing either CT or MRI, can be used for better delineation of intraarticular masses.

Greater trochanteric pain syndrome — Greater trochanteric pain syndrome can be due to abductor muscle (gluteus medius and gluteus minimus) tendinopathy and tear and bursitis. Greater trochanteric, ischiogluteal, and iliopsoas bursitis are well-recognized causes of pain in the region of the hip (see "Greater trochanteric pain syndrome (formerly trochanteric bursitis)"). The American College of Radiology has published appropriateness criteria for evaluation of soft tissue abnormalities, including bursitis [20].

Plain film radiography – Plain film radiography is usually not helpful in the diagnosis of greater trochanteric pain syndrome but may help to exclude other pathologies such as fractures. Calcifications may be seen in the bursa or adjacent soft tissues.

MRI – MRI demonstrates fluid collection within the affected bursa in the case of bursitis, as well as abnormal signal or discontinuity within the abductor muscle tendons in the case of tendinitis and tear (image 11).

US – US in trochanteric bursitis shows a distended, fluid-filled bursa. US helps in guidance for fluid aspiration and analysis. US can also detect tendinosis and tendon tears of the abductor muscle tendons [67].

Hip infection and inflammation — Hip infection may present as a radiologic and orthopedic emergency. In the absence of immunosuppression, infection affecting the hip is likely due to bacterial organism (see "Septic arthritis in adults" and "Disseminated gonococcal infection"). Infection around the hip can involve the surrounding soft tissues (cellulitis, abscess, and septic bursitis), the joint (septic arthritis), and the bone (osteomyelitis), which can coexist in advanced cases. The American College of Radiology has published appropriateness criteria for evaluation of suspected osteomyelitis, septic arthritis, or soft tissue infection [68].

Soft tissue infection

Cellulitis – Cellulitis rarely requires imaging for diagnosis. MRI can be useful to exclude associated conditions, such as myositis, abscess, sinus tract, fasciitis, or osteomyelitis. Contrast administration is valuable and highly recommended [69].

Infectious fasciitis – MRI is very sensitive for evaluation of fascial inflammation, evaluating the extent of infection and the presence of abscess or osteomyelitis, but is not specific for necrotizing fasciitis since it does not easily detect a small amount of fascial air. CT may be more useful because of high sensitivity for fascial gas [69].

Abscess – Abscesses can be easily detected with CT or MRI, particularly with the use of intravenous contrast.

Pyomyositis – MRI is highly sensitive for detection of muscle edema and disease progression to abscess, septic arthritis, or osteomyelitis.

Septic bursitis – The greater trochanteric bursa is most frequently involved, followed by iliopsoas bursa. MRI is most sensitive, showing focal fluid signal in the bursal location with thick rim enhancement.

Septic arthritis — Fluoroscopically or ultrasonographically guided needle aspiration of the hip is the most important exam in patients with suspected septic arthritis. Plain film radiography may not reveal any specific abnormalities in early disease but may be helpful in excluding other causes of hip pain. Patients with subacute or chronic infection may warrant MRI evaluation, which can assess for the presence of a joint effusion and juxtaarticular soft tissue and bone involvement. The American College of Radiology has published appropriateness criteria for evaluation of suspected septic arthritis of the hip when the radiographs are positive [70]. (See "Septic arthritis in adults".)

Plain film radiography – Radiographs are normal initially but may show joint space widening secondary to effusion and osteoporosis on both sides of the joint. In the advanced stages, joint destruction with erosive changes and joint space narrowing are seen.

MRI – MRI is very sensitive for detecting joint effusion, destruction of the articular cartilage, and bone marrow edema. Subchondral edema is commonly due to hyperemia; however, the extension of bone marrow edema into the medullary cavity and the degree of change in bone marrow signal intensity are helpful to detect osteomyelitis [69].

CT – CT is indicated when MRI is not available or is contraindicated for evaluation of large joint effusion and femoral head and neck erosion. CT is not sensitive for detecting cartilage destruction in the early stage of septic arthritis.

Radionuclide Tc-99m bone scan – Radionuclide bone scan is used when MRI is not available. Bone scan demonstrates increased uptake in both sides of the joint but is nonspecific.

Fluoroscopically or US-guided joint aspiration – Joint aspiration under fluoroscopic or US guidance is indicated for diagnostic evaluation and therapeutic drainage of septic joint effusion [18].

Osteomyelitis — The most common etiology of osteomyelitis is bacterial infection. Less frequent causes are mycobacterial and fungal organisms such as Candida, Coccidioides, Histoplasma, and Blastomyces species, which are more likely to occur in patients who are immunocompromised or who live in or have traveled to endemic areas. (See "Nonvertebral osteomyelitis in adults: Clinical manifestations and diagnosis" and "Approach to imaging modalities in the setting of suspected nonvertebral osteomyelitis" and "Bone and joint tuberculosis".)

Plain film radiographs may not reveal any abnormality in the first two weeks of bone infection. Early diagnosis is enhanced by use of MRI. Radionuclide bone scanning is an alternative for those with contraindications to MRI.

Plain film radiography – Plain film radiography may take two weeks to demonstrate any abnormality. Findings suspicious of acute osteomyelitis include soft tissue swelling, joint effusion, periarticular osteoporosis, and bone erosion. Periosteal reaction is not commonly seen in infection around the hip, unless the proximal femoral shaft is involved. Chronic osteomyelitis presents with a mixed pattern of lysis, sclerosis, and cortical thickening. Sequestrum formation (necrotic bone), involucrum (thick, irregular periosteal reaction), cloacae (cortical defect), and sinus tract can also be present [71].

Radionuclide Tc-99m bone scan – Radionuclide bone scan is highly sensitive but nonspecific in preexisting bone pathology, joint prostheses, and recent surgery or trauma. In patients without prior bone changes, the 3-phase radionuclide bone scan is 94 percent sensitive and 95 percent specific for osteomyelitis. Normalization of the bone scan after infection may take months, making the diagnosis of chronic osteomyelitis difficult. Imaging with In-111-labeled leukocytes is advocated for detection of osteomyelitis in patients with underlying bone pathology or prosthesis [72].

CT – CT is indicated in chronic osteomyelitis to evaluate the extent of the disease such as sequestrum, involucrum, cloacae, and sinus tract and soft tissue swelling [68,71]. CT cannot assess activity of disease.

MRI – MRI is the most sensitive and specific modality in the diagnosis of early osteomyelitis by showing bone marrow edema (image 12), with accuracy value of over 90 percent [73]. MRI can distinguish between paraarticular soft tissue infection and osteomyelitis. MRI is more valuable than CT in chronic osteomyelitis because it demonstrates activity of the disease.

Bone or soft tissue tumor — Plain film radiography is the first imaging modality employed in patients who present with suspected mass lesions in the region of the hip. Further evaluation of bone tumors is facilitated by CT, while MRI is the modality of choice for evaluation of soft tissue tumors. The American College of Radiology has published appropriateness criteria for evaluation of primary bone tumors and soft tissue masses, based upon clinical and radiographic findings [74,75].

Plain film radiography – Plain film is the initial modality of choice for detection and assessment of the general features of bone tumor. Accuracy of plain film for detection of soft tissue tumors is limited. Plain film is the most valuable method to evaluate the margin characteristic of bone tumor (zone of transition), which is the important distinguishing feature between benign and malignant bone lesions. Plain film radiography also demonstrates the extent of cortical destruction, periosteal reaction, matrix calcifications, and pathological fractures. Certain radiographic patterns, combined with the age of the patient, can be very suggestive of specific tumors.

CT – CT is the best method for detection of lesions not optimally seen by plain film. CT provides better assessment of cortical invasion, pathological fracture, periosteal reaction, matrix mineralization, and detection of cystic or fatty nature of tumor (image 13). CT is used for biopsy guidance and preoperative evaluation. CT is the best imaging technique for identification and localization of the nidus of the osteoid osteoma [74].

MRI – MRI is nonspecific for differentiation of most tumors. MRI is the modality of choice for local staging, for definition of medullary and extracortical spread, and for the delineation of tumor in relation to critical neurovascular structures. The zone of transition, an important feature in plain film imaging, as discussed above, is not valid on MRI. Gadolinium administration is useful to differentiate solid from cystic or necrotic tumor, to evaluate responses to nonsurgical therapy, and to detect tumor recurrence. Gadolinium administration may be useful for differentiation of benign from malignant soft tissue tumors [75]. As noted earlier, administration of gadolinium-containing MRI contrast agents should be avoided in patients with moderately to severely impaired renal function (eg, estimated glomerular filtration rate <15 to 30 mL/min).

If gadolinium-based imaging must be performed in a patient with moderately to severely impaired renal function, there may be a role for dialysis to reduce the risk of development of nephrogenic systemic fibrosis (NFS). Causes and approaches to prevention of NFS are discussed separately. (See "Nephrogenic systemic fibrosis/nephrogenic fibrosing dermopathy in advanced kidney disease", section on 'Prevention'.)

Radionuclide Tc-99m bone scan – The use of radionuclide bone scan for tumor is limited to evaluation of metastatic skeletal involvement (image 14).

Hip arthroplasty — The hip is the most commonly replaced joint. Plain film is the first method in the evaluation of hip arthroplasty; however, CT, MRI, radionuclide scintigraphy, ultrasonography, aspiration, and arthrography all have different roles in the assessment of the painful hip prosthesis [76] (see "Complications of total hip arthroplasty"). The American College of Radiology has published appropriateness criteria for imaging after total hip arthroplasty [77].

Complications of total hip arthroplasty can be grouped into aseptic loosening and osteolysis, dislocation, infection, periprosthetic fracture, hardware failure, and heterotopic ossification. Heterotopic ossification that occurs in muscle is also known as myositis ossificans. (See "Complications of total hip arthroplasty".)

Serial radiographs are the most important modality in assessing the hip prosthesis. Most management decisions can be made based on serial plain film findings without resorting to more complex imaging [78].

Aseptic loosening and osteolysis — Loosening of hip prosthesis due to mechanical factors (aseptic loosening) is the most common complication leading to revision surgery. Osteolysis is caused by particle disease resulting from wear of the polyethylene (PE) liner of the acetabulum. The PE debris incites a granulomatous reaction in the adjacent bone, resulting in erosion and cyst-like changes in the periprosthetic bone, leading to loosening. In addition, patients can develop cyst-like regions of fluid or soft tissue density material that protrude into the periacetabular region and communicate with the hip joint (pseudomembrane or pseudobursae formation).

Plain film radiography – Plain film radiography is indicated in routine evaluation of the prosthetic hip and for assessing complications of hip arthroplasty. Postoperative radiographic follow-up in asymptomatic patients is routinely recommended at one, three, and five years, and every five years thereafter. In symptomatic patients in whom loosening is suspected, the initial exam should be a plain radiograph. Comparison with prior imaging is of utmost importance. Radiolucent areas greater than 2 mm adjacent to the prosthesis and progressive changes in follow-up radiographs are highly suspicious for loosening (image 15). Other signs of loosening include development of bony sclerosis adjacent to the distal tip of prosthesis (pedestal formation) and evidence of prosthesis movement. Osteolysis related to particle disease is seen as focal, well-defined radiolucencies and smooth endosteal scalloping around the acetabular or femoral component.

CT – Multidetector CT (MDCT) with a special technique to reduce metallic artifact is more sensitive than plain film radiographs for evaluation of the prosthesis. For a cemented acetabular component, the presence of linear radiolucencies more than a few millimeters in width is suggestive of loosening. In a non-cemented acetabular component, large cysts surrounding the acetabular component may indicate particle-induced osteolysis. CT can also visualize the associated pseudomembrane formation and the amount of remaining trabecular bone at the rim of the acetabular component. For the femoral component, CT can visualize subsidence (inferior migration of the femoral stem relative to the shaft) and "bead shedding" [79]. CT can be helpful in evaluating the femoral and acetabular bone stock prior to revision surgery.

MRI – MRI with optimization of image quality for correction of metallic hardware artifact is valuable in differentiating the soft tissue masses surrounding the prosthesis, which can be related to histiocytic osteolysis (particle disease) or infected fluid collections, by demonstrating different signal intensities [80-82].

Conventional plain film arthrography – Arthrography is occasionally performed to evaluate suspected loosening of arthroplasty; however, its accuracy is limited by many false-negatives and false-positives [76]. Arthrography can detect painful pseudobursae formation and can be used for aspiration and injection of local anesthetic or steroid for symptomatic relief.

Ultrasonography – Ultrasonography can detect pseudobursae formation.

Pseudotumors and metal-on-metal resurfacing arthroplasty — In younger patients, hip resurfacing arthroplasty has been utilized as an alternative to conventional arthroplasty. These implants consist of metal-on-metal articulations, leading to small wear particles being released. These particles cause lymphocyte and plasma cell infiltrates, termed aseptic lymphocytic vasculitis-associated lesions. These infiltrates may be associated with periarticular fluid collections or masses, also termed "pseudotumors." Although pseudotumors have been reported most frequently in association with metal-on-metal hip implants, these pseudotumors are simply an additional manifestation of particle disease, and, therefore, they may be seen in hip arthroplasties of any type, including metal-on-polyethylene implants [83]. (See "Complications of total hip arthroplasty", section on 'Sequelae from metal-on-metal wear debris'.)

MRI – Pseudotumors are most commonly located at the posterolateral aspect of the joint, often in continuity with the greater trochanter, and are usually cystic. Anterior lesions may also be seen and are more likely to have solid components. Pseudotumors are contiguous with the joint capsule.

Dislocation — Dislocation is the second most common reason for revision surgery. Dislocation is diagnosed on plain film radiography (image 16). CT can better assess the integrity of the acetabular component (image 17). (See "Complications of total hip arthroplasty", section on 'Dislocation'.)

Infection — Imaging exams for suspected infection of a prosthetic hip may be of value but are usually not diagnostic. A detailed discussion of the imaging modalities that may be used are discussed separately. (See "Prosthetic joint infection: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Radiographic imaging'.)

Periprosthetic fracture — Periprosthetic fracture is more common in the femoral component than the acetabular component and is more common in revision hip than in primary arthroplasty. Periprosthetic fracture can occur during placement of the femoral stem or any time after hip replacement, typically at the level of the tip of the femoral stem. Diagnosis is made by plain film radiography. MRI can also identify associated soft tissue injuries such as avulsion of the abductor muscles from the greater trochanter.

Hardware failure — Hardware failure can affect both the femoral and acetabular components. The stem of the femoral component can break, representing a metal fatigue stress fracture. "Bead shedding" in non-cemented hip prosthesis (dislodgement of the metal spheres sintered to the femoral metal stem) can be visualized as aggregate clumps of beads on CT, indicating hardware failure [79]. The superior aspect of the PE liner of the acetabulum can gradually wear down, resulting in asymmetric superior location of the femoral head within the acetabulum. In addition to gradual wear, the PE liner can break and separate from the metal acetabular shell, resulting in direct contact between the femoral head and acetabular metal component. Anteroposterior radiograph is diagnostic for evaluation of PE liner wear in 95 percent of cases. Arthrography can also show displaced intraarticular pieces of broken PE liner.

Heterotopic calcification — Heterotopic calcification within the soft tissues surrounding the arthroplasty is a more common but less significant complication of total hip replacement, which can be easily diagnosed with plain film radiography.

Nerve entrapment syndromes — The piriformis syndrome usually is caused by a neuritis of the proximal sciatic nerve. Spasm or contracture of the piriformis muscle can either irritate or compress the proximal sciatic nerve and can mimic discogenic sciatica (pseudosciatica). Hamstring syndrome is caused by tight tendinous structures of the hamstring muscle at its insertion on the ischial tuberosity, causing pain in this area radiating down the back of the thigh. Hip arthroplasty is one of the causes of nerve entrapment syndromes. These syndromes are evaluated by MRI [84,85]. MRI will often show sciatic nerve inflammation in the area of piriformis muscle in the piriformis syndrome and between the semitendinosus and biceps femoris muscles in hamstring syndrome.

Snapping hip syndrome — Snapping hip syndrome is a benign condition that results from slippage of the iliotibial band or gluteus maximus muscle over the greater trochanter (external snapping hip syndrome) or slippage of the iliopsoas tendon over the iliopectineal eminence or the femoral head (internal snapping hip syndrome). Evaluation of the snapping hip syndrome is performed with a combination of plain radiography and ultrasonography [3]. MRI should be reserved for difficult cases [3].

Hip microinstability — Hip microinstability is a relatively new diagnosis defined as persistent excessive hip motion. The most common symptom is hip pain. Diagnostic criteria include patient history, examination, and imaging [86]. Stability of the hip is determined by bony anatomy of the femoral head and acetabulum and by supporting soft tissues, including labrum, ligaments, capsule, and muscles. Etiologic factors include adult hip dysplasia, acetabular labral tears, capsular laxity or injury, connective tissue disorders, muscle dysfunction, iatrogenic, and idiopathic [86,87]. The condition affects younger patients 16 to 50 years old and is more common in females. Treatment is physical therapy, intraarticular corticosteroid injection, or surgical repair of underlying pathology when nonoperative treatment is ineffective [86]. Imaging modalities include plain film radiography and magnetic resonance angiography (MRA). Plain film radiography can identify abnormal shape of the acetabulum and femoroacetabular impingement (cam type: nonspherical femoral head). MRA findings include labral or chondral tears, femoroacetabular cartilage or labral hypertrophy, and capsular thinning [86,87].

SUMMARY AND RECOMMENDATIONS

Selection of modality – The imaging modality used in a given patient depends upon the differential diagnosis that has been developed based upon the history and physical examination. The conditions for which the choice of imaging exam is reviewed here include trauma, sports-related injuries, the bone marrow edema syndrome, osteonecrosis, arthritis, the greater trochanteric pain syndrome, infection, tumor, hip arthroplasty, femoroacetabular impingement syndrome, nerve entrapment syndromes, snapping hip syndrome and hip microinstability. (See appropriate section headings in this topic and appropriate topic reviews.)

Plain radiographs – Plain film radiography of the hip is used in the initial evaluation of any cause of hip pain. Plain films can also identify causes of referred hip pain, such as sacroiliitis, but may not detect or accurately characterize some hip fractures and bone marrow edema associated with early avascular necrosis (AVN) or early osteomyelitis. (See 'Plain film radiography' above.)

Computed tomography – Computed tomography (CT) of the hip without intravenous contrast is most useful in the setting of trauma, for preoperative planning, and for evaluation and guiding percutaneous biopsy of tumors. Intravenous contrast is administered for evaluating a septic joint or a soft tissue abscess.

CT can detect the intraarticular extension of fractures. CT may not detect trabecular bone injuries, which may be present in femoral neck insufficiency fractures in patients who are osteoporotic, and will not demonstrate the bone marrow edema of early osteonecrosis and early osteomyelitis. (See 'Computerized tomography' above.)

Magnetic resonance imaging – Magnetic resonance imaging (MRI) of the hip accurately evaluates the bone marrow, joint space, neurovascular structures, and soft tissues. Intravenous contrast is usually not administered except for evaluation of soft tissue and bone tumors or vascular malformations. MRI is the modality of choice for suspected femoral fracture not demonstrated radiographically, osteochondral injuries, muscle injuries, joint effusion, early diagnosis and staging of AVN, iliopsoas and intertrochanteric bursitis, evaluation of infection, and tumor. (See 'Magnetic resonance imaging' above.)

Bone scan – Radionuclide Tc-99m (technetium methylene diphosphonate) bone scan surveys a large area when performed as a whole-body exam; however, it is often nonspecific. Radionuclide bone scan is reserved for suspected fracture or AVN not demonstrated by plain film radiography when MRI is not available or is contraindicated and in the evaluation of metastatic disease and prosthetic device loosening or infection. (See 'Radionuclide Tc-99m bone scan' above.)

Ultrasound – Ultrasound (US) of the hip is readily available even at the bedside, allows dynamic evaluation of the tendons and muscles, and does not involve ionizing radiation; however, its diagnostic performance is highly variable and operator- and patient-dependent. Hip effusions and bursal or periarticular fluid collections are readily identified. (See 'Ultrasound' above.)

Conventional arthrography – The imaging indications for conventional plain film hip arthrography are now limited due to the increased use of MR arthrography, which visualizes joint anatomy as well as bone and surrounding soft tissues, but may be useful to confirm intraarticular needle placement when hip aspiration is indicated for joint fluid analysis. (See 'Conventional plain film arthrography' above.)

MR arthrography – MR arthrography of the hip with intraarticular gadolinium administration best delineates the joint anatomy, including the acetabular labrum, articular cartilage, and ligamentum teres, and detects loose bodies. Administration of gadolinium-containing MRI contrast agents should be avoided in patients with severely impaired renal function. CT arthrography with intraarticular iodinated contrast is used in cases where the use of MR arthrography is contraindicated. (See 'Computerized tomography arthrography' above and 'Magnetic resonance arthrography' above.)

Hip injection – Injection of the hip with anesthetic and/or steroid under fluoroscopic guidance is reserved for cases when imaging is inconclusive or demonstrates mild osteoarthritis (OA) and when referred pain is clinically suspected. Persistent pain despite the injection of a local anesthetic reduces the likelihood that hip pathology is the cause of pain and may obviate the need for further diagnostic imaging of the hip. (See 'Image-guided injection with anesthetic and/or steroid' above.)

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Topic 1816 Version 29.0

References

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