Imaging of Juvenile Hip Conditions Predisposing to Premature Osteoarthritis - PowerPoint Presentation

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Imaging of Juvenile Hip Conditions Predisposing to Premature Osteoarthritis - PPT Presentation

Carl Kraus MD Rama S Ayyala MD Jonathan K Kazam MD Tony T Wong MD Presented as an educational exhibit at the 2016 RSNA Annual Meeting MK235EDX Address correspondence to Tony T Wong MD ID: 815401

hip femoral line head femoral hip head line imaging weighted years arrow acetabular impingement appearance

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Slide1

Imaging of Juvenile Hip Conditions Predisposing to Premature Osteoarthritis

Carl Kraus, MD, Rama S. Ayyala, MD, Jonathan K. Kazam, MD, Tony T. Wong, MD

Presented as an educational exhibit at the 2016 RSNA Annual Meeting, MK235-ED-X

Address correspondence to:Tony T. Wong, MDDepartment of Radiology New York Presbyterian Hospital/Columbia University Medical Center630 W 168th St, MC-28, New York, NY 10032ttw2105@cumc.columbia.edu

All authors have disclosed no relevant relationships

An earlier incorrect version of this presentation appeared online. This presentation was

corrected on December 21, 2017.

Slide2

Background

Osteoarthritis of the hip is a major cause of morbidity and mortality in the United States affecting more than 54 million adults.

Causes of Hip OsteoarthritisJuvenile Prearthritic ConditionsDevelopmental dysplasia of the hip (DDH)Legg-Calvé-Perthes disease (LCP)Slipped capital femoral epiphysis (SCFE)Proximal femoral focal deficiency (PFFD)Femoroacetabular impingement (FAI)Other CausesCoxa valga and varaInfection

Trauma (eg, hip dislocation, pelvic fractures)Systemic disease (eg, rheumatoid arthritis)Imaging is important for diagnosis of the prearthritic

conditions and to evaluate their long-term complications.

Total costs associated with arthritis and related conditions are approximately $128 billion per year.

Slide3

Learning Objectives

Review hip embryology and developmentDiscuss epidemiology, clinical information, imaging, and treatment of juvenile

prearthritic hip conditions (DDH, LCP, SCFE, PFFD, FAI)Identify long-term complications of these conditions

Slide4

Hip Embryology and Development

Fetal

4 weeks: Limb buds form8 weeks: Cartilaginous model for the acetabulum and femur form11 weeks: Infantile configuration of the acetabulum and femoral head form16 weeks: Femoral ossification is complete to the level of the greater trochanterInfancyFemur forms by appositional growth from defined growth zones Longitudinal growth plate (red arrow) Trochanteric growth plate (yellow arrow) Femoral neck isthmus (green arrow)

ChildhoodAcetabulum grows appositionally through the articular cartilage (arrowheads) and interstitially through the triradiate cartilage (

star

Reciprocal interactions between the acetabulum and the femoral head are essential for proper structure and function in adulthood.

Ossified bone

Growth cartilage

Slide5

Developmental Dysplasia of the Hip

Background

A spectrum of abnormalities present at birth or during infancy, which range from mild acetabular dysplasia to hip subluxation or dislocation.EpidemiologyIncidence: 1–66 per 1000 live births

Risk factors for development - Female sex (6:1 female-to-male ratio) - Breech presentation - Family history of DDHBilateral in 33% of patientsClinical Information

Abnormal neonatal examination

Barlow maneuver

- Clunk with posterior-directed pressure with hips adducted and flexed

Ortolani maneuver

- Clunk with hip abduction in flexed position

Galeazzi test

- Limb length discrepancy with differential knee height

Slide6

Developmental Dysplasia of the Hip

Imaging Appearance—Ultrasonography (US)

Imaging modality of choice for DDH evaluation (sensitivity, 88.5%; specificity, 96.7%)Performed after 4–6 weeks of age (may be falsely positive earlier because of ligamentous laxity from maternal hormones)

Coronal view

Transverse view (hip flexed to 90

)

Ischium

Labrum

Femoral

head

Ilium

Acetabular

roof

Triradiate

cartilage

Femoral

head

Femoral

shaft

Labrum

Slide7

Developmental Dysplasia of the Hip

Imaging Appearance—US

αAlpha angle = 75°

Alpha angle = 35°

How to measure alpha angle

Obtain coronal US image

Identify center of femoral head (white circle)

Draw line parallel to the ilium (

red

)

Draw line through the roof of the acetabulum (

green

)

Normal alpha angle greater than 60°

Normal Hip

Dysplastic Hip

Slide8

Developmental Dysplasia of the Hip

Imaging Appearance—Radiographs

Normal location of the femoral head (dotted circle) is within the inferomedial quadrant formed by the intersection of Hilgenreiner and Perkin lines.

Hilgenreiner

line

Drawn horizontally through the superior aspect of both

triradiate

cartilage

Perkin line

Drawn perpendicular to

Hilgenreiner

line, intersecting the lateral most aspect of the acetabular roof

Acetabular line:

Drawn connecting the superolateral acetabular roof to the ipsilateral

triradiate

cartilage (angle formed with horizontal line should be less than 30°)

Shenton arc:

Curvilinear line drawn connecting the obturator foramen and the medial aspect of the proximal femoral metaphysis (line should be smooth and uninterrupted)

Neutral frontal radiographs are obtained after 6 months of age (when femoral heads are ossified).

Dysplastic

Normal

Slide9

Developmental Dysplasia of the Hip

Treatment

Majority of cases treated nonoperativelyWith early diagnosis, treatment success rate is approximately 95%.Pavlik harness—maintains abduction and external rotationSurgical treatment reserved for refractory disease or late diagnosesOpen reduction and spica castPeriactebular osteotomycorrect shallow acetabulum

Derotational femoral varus osteotomy—improve femoral head coverage

Periacetabular osteotomy

Derotational

osteotomy: Removed bone (green triangle) resulting in improved femoral head coverage (red arcs).

Slide10

Developmental Dysplasia of the Hip

Long-term ComplicationsMagnetic resonance (MR) arthrograms obtained 12 years later in a 15-year-old adolescent girl (same patient) with hip pain. Note dysmorphic femoral head shape and undercoverage (star), torn hypertrophied labrum (arrow), and paralabral cyst (arrowhead).

Anteroposterior radiograph in a 3-year-old girl with mild hip dysplasia shows small femoral head (star) and shallow acetabulum (arrow).

Early-onset arthritis

Labral hypertrophy and tear

FAI

Coronal T1-weighted fat-saturated

Coronal proton-density–weighted

Slide11

Developmental Dysplasia of the Hip

Long-term Complications

17 months old 4 years old

6 years old 12 years oldSerial radiographs in a female child with treated DDH demonstrate progressive deformity and early-onset arthritis despite multiple femoral and pelvic osteotomies.

Slide12

Legg-Calvé-Perthes

Disease BackgroundIdiopathic avascular necrosis of the femoral head epiphysis

EpidemiologyMale-to-female ratio: 4:1Peak incidence between 4 and 8 years old10% successive bilateral involvement-Usually at different stagesClinical InformationCommonly manifests as painful limpTrauma may be inciting factor that unmasks or accentuates chronic pain.60%–70% heal without functional impairment at maturityBetter prognosis for presentation at age younger than 6 years and less resultant femoral head flattening

Slide13

Legg-Calvé-Perthes

Disease Imaging Appearance—RadiographsWaldenstr

öm stages of PerthesStage 1 InitialStage 2 FragmentationStage 4 HealedStage 3 Reossification

Periarticular osteoporosis → Small and dense femoral ossification center → Early lateral displacement of epiphysis and medial joint widening → Subchondral fracture crescent sign (arrow)

More lateral extrusion (double-headed arrow) with epiphyseal flattening, fragmentation, sclerosis, and areas of resorption (arrowheads)

New bone formation (curved arrow)

Reconstitution of femoral head with or without residual deformity

Slide14

Legg-Calvé-Perthes

Disease Imaging Appearance—RadiographsStulberg

classification: Assess for risk of developing osteoarthritis in the future1. Normally contoured femoral head2. Spherical femoral head with coxa magna, short femoral neck, and/or steep acetabulum3. Ovoid femoral head with coxa magna, short femoral neck, and/or steep acetabulum4. Flattened femoral head with abnormal femoral neck and abnormal acetabulum5. Flattened femoral head with normal neck and normal acetabulum

Stage 1

Stage 2

Stage 3

Stage 4

Stage 5

Normal Mild arthritis Moderate arthritis Severe arthritis

Slide15

Legg-Calvé-Perthes

DiseaseAvascular PhaseNecrotic portions of femoral head - Low T1 signal intensity

- Variable T2 signal intensity (high initially from edema then low with advanced necrosis)Partial or complete nonenhancement of epiphysisSubchondral collapseJoint effusion with synovitisRevascularization and Reparative PhaseVariable epiphyseal signal abnormality reflecting different areas of residual necrosis and revascularizationMay see epiphyseal hyperenhancementMetaphyseal cysts and edemaPhyseal undulationJoint effusion with synovitis Imaging Appearance—MR Imaging

MR images in a 2-year-old boy in the avascular phase. Note marked flattening of femoral head epiphysis and nonenhancement (arrows).Coronal postcontrast T1-weighted fat-saturated

Coronal T1-weighted

MR images in a 7-year-old boy in the revascularization phase show mixed epiphyseal signal intensity (arrowheads), metaphyseal cyst and edema (arrow), and effusion (curved arrow).

Coronal T2-weighted fat-saturated

Coronal T1-weighted

Slide16

Legg-Calvé-Perthes

Disease Treatment

Treatment is dependent on age, degree of femoral head involvement, and stage of disease.Age younger than 6 years: Nonsurgical with motion restriction and altered weight bearingAge older than 8 years Early stage: Femoral or pelvic osteotomies to improve femoral head containment Late stage: Osteotomies and possible external fixation with distraction to offload hipOlder adolescents: May be treated similar to adult avascular necrosis with core decompression and vascularized bone graft or total hip arthroplastyFemoral varus osteotomyAcetabular innominate osteotomy

Core decompression and vascularized fibular graft

Distraction with external fixator

Slide17

Legg-Calvé-Perthes

Disease Long-term Complications

Early-onset arthritis—most common complicationLabral tearsOsteochondral lesions and intra-articular bodiesFAIPhyseal barsStulberg Stage 4MR arthrograms obtained 4 years after radiograph in an 18-year-old man with chronic hip pain. Note acetabular cartilage delamination (arrowheads), osteochondral fragmentation (bracket), subchondral cysts and edema (curved arrow), and anterosuperior labral tear (straight arrow).

Sagittal T1-weighted fat-suppressedCoronal proton-density–weighted

Slide18

Legg-Calvé-Perthes

Disease Long-term Complications

Frontal radiographs at 5-year follow-up in a boy who underwent acetabular and femoral osteotomies. Note ovoid femoral head with loss of sphericity. MR arthrograms obtained at 14 years old. Note osteochondral lesion in the femoral head with disruption of subchondral bone plate and tiny subchondral cysts (arrows).

9 years old14 years old Sagittal T1-weighted fat-saturated

Sagittal T1-weighted fat-saturated

Slide19

Slipped Capital Femoral Epiphysis

Background

Fracture through the proximal femoral physis due to mechanical shear forcesEpidemiologyMost common hip disorder in adolescence

Peak ages: 12 years in girls and 14 years in boysMale-to-female ratio: 2.5:1African-American–to-white ratio: 4:1Bilateral in 10%Other side often involved within 2 years of first side

Clinical Information

Adolescent with limp and hip pain

Often no trauma history

Obesity is strong risk factor

May have predisposing metabolic abnormality such as hypo- or hyperparathyroidism and renal failure

Unstable hips have high risk of avascular necrosis

Clinical Grading of Stability

Stable: ability to bear weight

Unstable: inability to bear weight

Slide20

Slipped Capital Femoral Epiphysis

Imaging Appearance—Radiographs

Normal Hip

Abnormal signs on anteroposterior viewDecreased epiphyseal height (

yellow double-headed arrow

)

Klein line: Line along the lateral femoral neck does not intersect epiphysis (

red line

)

Capener

triangle: Loss of normal overlap at medial femoral metaphysis and ischium (triangle)

Abnormal Hip

Slide21

Slipped Capital Femoral Epiphysis

Imaging Appearance—Radiographs

Southwick MethodOn frog-leg lateral viewA. Line connecting anterior and posterior physeal marginsB. Line perpendicular to AC. Line parallel to femoral neckLateral epiphyseal-shaft angle (LESA) (red) is angle between B and C. Southwick angle is difference of LESA between affected and unaffected side (>30° difference is abnormal)

Staging of SCFE according to Southwick angle

Grade 1 (mild): 0°–30

Grade 2 (moderate): 30°–50

Grade 3 (severe): >50

Frog-leg lateral

Slide22

Slipped Capital Femoral Epiphysis

Imaging Appearance—MR Imaging

Can be helpful to identify preslip or radiographically occult SCFEFindings include edema and/or widening of the physis with surrounding epiphyseal and metaphyseal marrow edemaMR images in a 12-year-old girl with hip pain show displacement of epiphysis posterior to femoral neck (curved arrow), no intersection at Klein line (dotted line), and physeal edema (arrowheads).

Axial T2-weighted fat-saturated

Coronal T1-weighted

Coronal T2-weighted fat-saturated

Slide23

Slipped Capital Femoral Epiphysis

TreatmentOptions

Pinning—can be done with all stable and unstable slips (usually in situ)Epiphyseal reduction—controversial and reserved for unstable early slips (<24 hours)Proximal femoral osteotomy—correction of chronic deformity from a severe slipContralateral prophylactic pinningcontroversial and considered for high-risk patients (age < 10 years, endocrinopathy, contralateral pain) Serial radiographs in a 9-year-old girl with acute unstable slip.

A, Epiphyseal displacement with physeal widening. B, Reduction and pinning. C, Restricted range of motion requiring valgus osteotomy.Initial presentation

Less than 24 hours later

8 years later

Slide24

Slipped Capital Femoral Epiphysis

Long-term ComplicationsEarly-onset arthritisAvascular necrosis

Labral tears4. FAI5. Limb length discrepancyMR arthrograms in an 18-year-old woman with prior SCFE and hip pain show femoral cam deformity with large alpha angle, early-onset arthritis with apposing cartilage wear (arrowheads), and anterosuperior labral tear (arrow).

= 85°

Axial oblique proton density weighted

Coronal T1-weighted fat-saturated

Sagittal T1-weighted fat-saturated

Slide25

Proximal Focal Femoral Deficiency

Background

Congenital deformity characterized by a shortened femur and varying degrees of femoral head and acetabular deficiencyEpidemiologyIncidence: One in 52,000 live births

Third most common longitudinal lower extremity deficiency Bilateral in 10%–15% Clinical InformationCan often be diagnosed on prenatal US image

Shortening of affected limb(s)

Associated abnormalities: Fibular hemimelia (80%),

tibial

shortening, coxa

vara

, lower extremity contractures, knee ligamentous laxity and/or deficiency, and foot deformities

Slide26

Proximal Focal Femoral Deficiency

Imaging Appearance—RadiographsAitken Classification

ClassFemoral HeadAcetabulumFemoral ShaftAPresentNormalShortened with varus subtrochanteric deformityBPresent, but delayed ossificationMild to moderately dysplasticShortened with proximal bony tuft; no subtrochanteric connection between head and shaft

CAbsent Severe dysplasiaComplete absence of trochanteric area and shorter shaft than B with bony tuftD

Absent

Absent (flat)

Severely short with pointed proximal end and no tuft

Class A

Class B

Class C

Class D

Slide27

Proximal Focal Femoral Deficiency

Imaging Appearance—Radiographs

Frontal pelvic radiograph in a 2-year-old girl with Aitken class A PFFD on the right. Note varus shaft deformity (arrow), shortened femur (bracket), and asymmetrically smaller femoral head (dotted circles).Side-by-side frontal hip radiographs in a 31-year-old woman with bilateral Aitken class C PFFD. Note absence of femoral heads, proximal bony tufts (arrows), shortened femora (brackets), and severely dysplastic acetabuli (dotted lines).

Slide28

Proximal Focal Femoral Deficiency

Imaging Appearance—MR ImagingCan identify presence of femoral head prior to time of ossification to differentiate between Aitken class A and B versus C and D

Also useful for evaluation of acetabular dysplasia, joint congruency, labral hypertrophy, proximal femoral physis, hip impingement, and fibrocartilaginous connection between head and shaft

MR images in a 6-month-old male infant with left PFFD and no femoral head on radiograph. Unossified femoral head is located in the acetabulum (bracket). Tiny ossification center (arrow) is present, though asymmetrically smaller than right side (arrowhead).

Coronal gradient-echo

Sagittal gradient-echo

Slide29

Proximal Focal Femoral Deficiency

Treatment

Individualized goals based on severity of deformity, expected limb length discrepancy (ELLD), and associated abnormalitiesNonsurgical management: mild or bilateral deformitiesSurgical management: staged surgeries to equal limb lengths (less severe deformities with ELLD < 20 cm) or fit for prosthesis (ELLD > 20 cm) 7 months old: Aitken class A PFFD on left side2 years old: Femoral valgus osteotomy, Dega osteotomy in acetabulum

6 years old: Second lengthening osteotomy4 years old: Lengthening osteotomyFemale child at four ages

Slide30

Proximal Focal Femoral Deficiency

Long-term ComplicationsLimb length discrepancy

Hip impingementEarly onset arthritisStanding frontal radiograph in a 10-year-old girl who underwent distal femoral epiphysiodesis on normal right side for limb length discrepancy after multiple left-sided osteotomies.Frog-leg lateral radiographs at 11-year follow-up in female patient with PFFD, fibular hemimelia, and absent foot show greater trochanteric-iliac impingement (arrow) after multiple staged osteotomies and prosthesis placement.1 day old

11 years old

Slide31

Femoroacetabular Impingement

BackgroundEpidemiologyMale-to-female ratio: 14:1 (cam), 1:3 (pincer)

In adolescents, the age range is 13–18 years old.Clinical InformationPain commonly in groin, anterior thigh, and lateral hipCatching or popping may be described when there is associated labral injury.Fifty–fifty insidious versus acute onsetUsually associated with high-demand sports, such as aerobics, dancing, football, and soccerAltered osseous morphology that causes pain because of abnormal contact between the femur and acetabulum during motion

Slide32

Femoroacetabular Impingement

Background

1. Cam typeOsseous prominence at femoral head–neck junction 2. Pincer typeOsseous prominence at acetabulum3. Mixed typeOsseous prominence at both femoral head–neck junction and acetabulum

Normal

Cam

Pincer

Mixed

Slide33

Femoroacetabular Impingement

Cam Deformity in the Adolescent PatientA severe deformity seen as a long-term consequence of one of the previously discussed pediatric hip abnormalities (hip dysplasia, SCFE, and LCP) OR

2. A mild deformity related to an abnormal developmental process that has been linked to vigorous sporting activity Background

Slide34

Femoroacetabular Impingement

Multiple views (anteroposterior, frog-leg lateral, Dunn, and false profile) in a standard impingement series each profile the femoral head–neck junction at a different angle.Cam lesion may be identified on any view but is usually best seen on the frog-leg lateral or Dunn views (yellow dotted line

). Imaging Appearance—Radiographs for Cam AssessmentFrog-leg lateral45° Dunn

Slide35

Femoroacetabular Impingement

Imaging Appearance—Radiographic Adequacy to Assess for Acetabular Pincer

Must be anteroposterior view of pelvis

Coccyx centered with tip 1–3 cm from superior margin of symphysis (double-headed arrow)

Symmetric obturator foramina (black circles)

Symmetric iliac wings (yellow lines)

Slide36

Femoroacetabular Impingement

On anteroposterior view of pelvisNormal: Anterior acetabular wall (red dotted line) is medial to posterior wall (yellow line).

Pincer (focal overcoverage): Cranial acetabular retroversion: Anterior acetabular wall is lateral to posterior wall. Imaging Appearance—Radiographs for Pincer Assessment

Anteroposterior

Normal

Pincer

Slide37

Femoroacetabular Impingement

On anteroposterior view of pelvisNormal: Acetabular wall (dotted red line) and femoral head (yellow line

) are lateral to ilioischial line (black line).Pincer (global overcoverage): Coxa profunda: Acetabular wall is medial to ilioischial line. Acetabular protrusio: Acetabular wall and femoral head are medial to ilioischial line. Imaging Appearance—Radiographs for Pincer Assessment

Anteroposterior

Slide38

Femoroacetabular Impingement

Labral TearsAbnormal morphology or increase in signal intensity, contrast material imbibition

Typically in anterosuperior quadrantCartilage AbnormalitiesFocal defects, fissuring, or delaminationTypically adjacent to labral tear Imaging Appearance—MR ImagingMR arthrograms show labral tear with contrast material imbibition (arrows) and paralabral cyst (arrowhead).

Sagittal T1-weighted fat-saturated

Coronal proton-density–weighted

Sagittal T1-weighted

fat-saturated

Coronal T1-weighted fat-

saturated

MR arthrograms show labral tear with contrast material imbibition (arrow) and full-thickness cartilage defect (bracket).

Slide39

Femoroacetabular Impingement

Osseous AbnormalitiesQuantify cam lesion with alpha angle on axial oblique image.

Abnormal alpha angle is greater than 55°. Cysts may be seen at femoral head–neck junction. Imaging Appearance—MR ImagingAlpha angleDraw best-fit circle around the femoral head.Draw line from center of circle bisecting femoral neck.Draw line from center of circle to the portion of neck that exits the circle.

Axial oblique proton-density–weighted

Axial oblique proton-density–

weighted

MR arthrogram shows severe cam deformity from prior SCFE (arrow) and old tracks from prior pinning (arrowheads).

MR arthrogram shows mild cam deformity with small focus of underlying fibrocystic change (arrow).

Slide40

Femoroacetabular Impingement

Treatment

Hip arthroscopyFemoroplasty—cam resectionAcetabuloplasty—pincer resectionLabral repair

Axial oblique proton-

density–weighted

Axial oblique proton-density– weighted

Frog-leg lateral radiographs (top) and MR arthrograms (bottom) in an 18-year-old man after hip arthroscopy show cam resection with interval decrease in alpha angle and restoration of normal femoral head–neck contour (red line).

Slide41

Femoroacetabular Impingement

Long-term Complications

Sagittal T1-weighted fat saturated Coronal proton-density weightedTheorized to be cause of early-onset osteoarthritis in young adultsFrontal radiographs in a 32-year-old man with chronic pain show cam deformity with moderate joint space narrowing requiring total hip arthroplasty 8 months after initial presentation.

MR arthrograms in a 32-year-old man with chronic pain show labral tear (arrows) with arthritis and moderate apposing cartilage wear (arrowheads).

Slide42

Summary

DDH is a spectrum ranging from mild acetabular dysplasia to hip subluxation or dislocation.LCP is idiopathic avascular necrosis of the femoral head epiphysis.

SCFE is a fracture through the proximal femoral physis.FAI is an alteration in osseous morphology that causes abnormal contact in the hip.PFFD is characterized by a shortened femur and varying degrees of femoral head and acetabular deficiency.All of these entities can result in early-onset arthritis because of altered anatomy.Imaging is important for initial diagnosis and to evaluate long-term complications.

Slide43