State ofthe Art

William F. Conway, MD, PhD William

#{149} G. Totty, MD Kevin
#{149} W. McEnery, MD

CT and MR Imaging ofthe Hip

B EFORE the 1970s, musculoskeletal ation of dysplastic hips, and assess- reduce image noise, we suggest use of
radiology relied on plain radiog- ment for hip prosthesis revisions as a field of view that includes the entire
raphy, tomography, and bone scintig- well as evaluation for creation of cus- pelvis. The larger field of view also
raphy to make diagnoses and to stage tom-made prostheses. CT can also be enables detection of unsuspected frac-
lesions. Since that time, the introduc- useful as a secondary imaging modal- tures, particularly within the sacrum,
tion of first computed tomography ity for assessment of atypical osseous which can alter patient care manage-
(CT) and then magnetic resonance lesions with or without calcification. ment. In some patients, especially
(MR) imaging has substantially broad- The availability of helical (spiral) CT those with a large body habitus, 2 sec-
ened the capabilities of the musculo- provides the radiologist with an en- onds or longer for image acquisition
skeletal radiologist. This is particu- hanced method to efficiently perform in conventional CT may be necessary
larly true in the area of hip imaging, diagnostic CT examinations that are to ensure adequate image quality.
where CT has proved invaluable in optimal for multiplanar and three- With improvements in CT tube
the assessment of such things as trauma dimensional reconstructions. technology and advances in computer
and congenital abnormalities and where ‘ capabilities, acquisition of helical CT
MR imaging is currently the modality of scans is now possible for 30 seconds
Helical CT
choice (following plain radiography) for or more. This time frame of 30 sec-
avascular necrosis (AVN. The purpose , . Helical (spiral) CT provides the ra- onds is important, since a suggested
of this article is to review recent devel- diologist with enhanced capabilities protocol for scanning of the hip and
opments in cross-sectional imaging of over those reported previously with acetabulum is to use a 3-mm/sec table
the hip, concentrating on the techniques conventional CT. The two main ad- speed with 3-mm section collimation.
and indications for both CT and MR vantages provided by helical CT are A 30-second examination at a 3-mm
imaging. efficiency of examination and reduced table increment provides for 9 cm of
radiation dose necessary for an ex- imaging coverage, which is adequate
amination optimized for multiplanar to image the entire acetabulum and
CT OF THE HIP
or three-dimensional reconstructions. femoral heads. Although 5-mm colli-
CT is the preferred modality for A typical helical CT examination of mation may be adequate for three-
assessment of osseous-based abnor- the hip requires approximately 30-40 dimensional imaging, it is suggested
malities of the hip. CT is a mature seconds of scanning. Although helical that 3-mm collimation images should
technology, with its use in normal CT of the chest or abdomen requires be created with the helical data set at
anatomy and developmental stages of relatively fast table speeds to effec- 2-mm increments to optimize the im-
the hip well established (1-3). Specific tively image the area of interest, it can age data set for both multiplanar and
indications for CT of the hip include utilize much slower table speeds (2-3 three-dimensional reconstructions.
trauma, pre- and postoperative evalu- mm/sec) to image the hip and other The proposed acetabulum protocol
joints. Unlike conventional CT, over- optimizes visualization of hip articu-
lapping image sections are created lations. However, some orthopedic
without the need for overlapping ra- surgeons prefer to visualize the entire
Index terms: Bone marrow, diseases, 44.20 diation exposures. This is particularly pelvis when evaluating cases of ac-
Hip, CT, 44.12115 Hip, dysplasia,
#{149} 442.146, important in hip imaging, especially etabular trauma. Newer models of
442.159 Hip, fracture,
#{149} 441.41 Hip,
#{149} necrosis,
in the pediatric population, given the helical scanners have the added capa-
442.44 S Hip, MR. 44.121413, 44.121415 State
#{149}
proximity of gonadal tissue to the bility that allows acquisition of con-
of art reviews
area of clinical interest. For assess- secutive scans with different scan col-
Radiology 1996; 198:297-307 ment of acute hip trauma, helical CT limations but without an interscan
provides an effective method to effi- time delay. With these newer helical
ciently perform a diagnostic examina- scanners, we recommend 3-mm colli-
t From the Department of Radiology, Medical tion even in the potentially clinically mation through the acetabulum and
unstable patient. then, if desired, we suggest continu-
University of South Carolina, 171 Ashley Ave.
Charleston, SC 29425 (W.F.C.); and the Maffinck- Reports of helical CT have noted a ing the scanning with either 5- or
rodt Institute ofRadiology, St Louis, Mo (W.G.T., limitation in the milliamperes pro-
K.W.M.). Receivedjuly 25, 1994; revision requested vided for imaging (4,5). On most CT
September 6; revision received August 2, 1995; ac-
cepted August 25. Address reprint requests to
scanners, the milliamperes setting is
W.F.C. limited to the same value as that ob- Abbreviations: AVN = avascular necrosis,
, RSNA, 1996 tamable with dynamic scanning. To STIR = short-inversion-time inversion recovery.

I,ii 297
8-mm table speed (collimation) to ob- with these techniques. Surface ren- dures (32) (Fig 2) and assessment of
tam diagnostic images of the remain- denng allows a detailed view of the postoperative results (33-35). The use
ing pelvis to include the iliac wings. bone contours. Fractures may be seen of three-dimensional imaging allows
This combination of high- and lower- as contour discontinuities that are direct assessment of the amount of
resolution imaging provides an opti- accentuated through light-source ma- anterior and posterior acetabular coy-
mal image data set for diagnosis and nipulation. Surface-rendering is sensi- erage, which may be difficult for the
reconstruction of the entire pelvis. tive for detection of fractures that dis- radiologist or orthopedic surgeon to
rupt the cortical surface. However, assess with plain radiography or ap-
surface rendering does not easily de- preciate on axial CT images (36). In
pict fractures that are nondisplaced or the skeletally immature patient, given
Trauma
nonperpendicular to the scanning the presence of nonossified cartilage
In the assessment of trauma, the plane (24). and the lack of radiation exposure,
role of CT is to allow accurate defini- Volume-rendering techniques pro- MR imaging may be more beneficial
tion of the extent of fractures, particu- vide a more realistic representation of (31). However, we know of no corn-
larly of the acetabulum (Fig la, ib), anatomic structures. However, there parative study of these modalities in
and to depict interarticular fragments are instances in which the superimpo- the pediatric population.
that are not visualized at radiogra- sition of structures and the relatively In the postoperative pediatric pa-
phy. It is well accepted plain that
ra- smooth rendering of bone surface tient, CT is often the preferred method
diography underestimates the extent make this technique less than optimal for evaluation of hip reduction, given
of acetabular fractures (6-9). Occult for fracture detection (25). For frac- the presence of a spica cast, which
fractures associated with hip disloca- ture detection, it has been demon- makes assessment difficult with plain
tions can be detected with CT (10), strated that surface rendering is the radiography and may preclude visu-
including fractures of the femoral preferred three-dimensional tech- alization with either MR imaging or
head (11) and unsuspected fractures nique (26). In the context of clinical US (37). As the pediatric postopera-
of the posterior acetabular rim, which imaging, it is unusual when either tive assessment only requires limited
cause instability (12). CT also can be surface or volumetric three-dimen- visualization of alignment, pediatric
useful in postoperative assessment sional images serve as the primary protocols that involve reduced doses
(13), including cases of nonunion of means of fracture detection, with con- are employed without a compromise
reduced fragments (14). ventional axial CT images reviewed in in diagnostic information (38).
The use of multiplanar and three- conjunction with three-dimensional The main benefit of CT scanning in
dimensional reconstructions in the and multiplanar images. the assessment of hip dysplasia is its
assessment of complex trauma has Holographic presentations of image capability in enabling exact quantifi-
been investigated (15-19). Several in- data represent a third technique for cation of preoperative appearance
vestigators have noted the utility of the postprocessing of CT image data and postoperative improvement. Al-
CT with reconstructions, which af- (Fig le). With this method, CT image though CT is not necessary for preop-
fects positive patient outcomes by data serve to create a hologram image erative assessment of every patient, it
providing information that alters the that is displayed by using a specially can be useful in selected complex
plan for surgical treatment (20-22) designed view box. Anecdotal evi- cases in which exact determination of
both in the adult and pediatric popu- dence indicates that the technique hip involvement is not possible with
lations (23). Of importance, these may be as sensitive as three-dimen- routine radiography.
postprocessed images provide addi- sional imaging in the presentation On standard pelvic radiographs,
tional information without additional of acetabular fractures (27). To our the center-edge angle, measured as
radiation dose for the patient. knowledge, articles regarding the the angle formed by a line drawn
There are two basic methods used evaluation of this technique have yet from the superior acetabular rim to
to create three-dimensional recon- to appear. the center of the femoral head and
structions: surface (Fig ic) and volu- the horizontal axis of the pelvis, is the
metric (Fig id) renderings. With standard measurement for assessment
Developmental Dysplasia
surface-shading techniques, the corn- of developmental dysplasia. How-
of the Hip
puter presents the image data refer- ever, CT of the hip provides precise
encing distance from the observer to a A second area in which CT remains information that may be difficult to
given surface point as a color value, a useful diagnostic tool is in the as- abstract from radiographic examina-
traditionally gray-scale. Manipulation sessment of developmental dysplasia tions. Standard CT protocols allow
of the simulated “light source” en- of the hip (congenital hip dyspla- images to be obtained with the child
hances visualization of surface fea- sia) (28-30). Although plain radiogra- positioned in a frog-leg position. CT
tures. Volume-rendering techniques phy and ultrasound (US) are the stan- scanning allows differentiation of lat-
entail much more complex image ma- dard imaging modalities used for eral from posterior hip dislocations
nipulation in assigning different opti- assessment of hip dysplasia, CT can (31). Acetabular angles have been de-
cal transparencies or colors to distinct provide precise information with fined that provide precise character-
areas of attenuation of tissue. The regard to the reduction of the hip ization of hip dysplasia. Acetabular
image is manipulated by highlighting within the acetabulum (31) in compli- anteversion is measured by determin-
specific areas of tissue attenuation. cated cases and in the postoperative ing the angle of the anterior and pos-
With visualization of a typical frac- period. tenor acetabular rim relative to the
ture, CT attenuation values that cor- In the skeletally mature patient, vertical axis of the pelvis (Fig 2c). Al-
respond to those of bone are high- axial CT supplemented with multipla- though some authors have noted an
lighted and areas of soft-tissue atten- nar and three-dimensional images increased acetabular anteversion in
uation are rendered transparent. provides the orthopedic surgeon with hip dysplasia (32), others have noted
In assessment of trauma, there are valuable information with regard to that similar acetabular version mea-
inherent strengths and weaknesses appropriate surgical corrective proce- surements are obtained in healthy

298 Radiology
#{149} February 1996
 b.
Figure 1. Anterior and posterior column acetabular fracture in a 35-year-old man who was
involved in a motor vehicle accident. (a) Anteroposterior pelvis radiograph demonstrates frac-
ture involvement of the acetabulum of which the inner wall is medially displaced. The frac-
ture extends into the ilium. Oblique views (not shown) demonstrated extension into both the
anterior and posterior column. (b) Axial CT images demonstrate fracture involvement of the
anterior and posterior column and clearly quantify extension into the ilium. Postprocessed
images are obtained from the original CT image data set projecting the pelvis in the antero-
posterior view. Conventional CT images were obtained with a 3-mm increment. (c) Three-
d. dimensional surface, (d) three-dimensional translucent volumetric, and (e) hologram image
rendering. Although c does not demonstrate the fracture to great advantage in the anteropos-
tenor projection, d and e provide clear visualization of the displaced medial acetabular wall. (Clini-
cal images courtesy of Douglas D. Robertson, MD, Mallinckrodt Institute of Radiology, St Louis, Mo.)

relative to the horizontal axis of the revision can provide useful informa-
pelvis. A normal anterior angle is tion regarding the position of the ex-
greater than 50#{176},
and a normal poste- isting acetabular components relative
nor angle is greater than 90#{176}
(33). to pelvic vasculature, particularly if
These angles are reduced in develop- there is associated protrusion or
mental dysplasia, which reflects de- known intrapelvic fixation screws
creased acetabular support. (41,42).

e. Preoperative Evaluation MR IMAGING OF THE HIP

for Arthroplasty
MR imaging has achieved wide ac-
In the correction of adult dysplastic ceptance as a technique used in the
volunteers compared with those in hips or in revisions of previous hip evaluation of pathologic processes in
patients with known dysplastic hips arthroplasty, custom-made prostheses and about the hip. This acceptance
(33). Femoral anteversion can also be are often necessary. Production of was initially due to its high sensitivity
directly measured on CT images by anatomic models from the CT image and specificity in detection of avas-
determining the angle of the central data has been described (39). These cular necrosis (AVN) of the femoral
axis of the femoral neck relative to the models assist the surgeon in preop- head (43-47). Since then, however,
vertical axis of the pelvis (Fig 2d). This erative planning and enable produc- MR imaging has also proved effica-
angle is increased in developmental tion of a custom-made prosthesis for cious in the evaluation of primary
dysplasia, but there is overlap with selected patients. The greater cost of musculoskeletal tumors (48,49), ar-
healthy patients. these custom-made prostheses com- thropathies (50,51), trauma (52,53),
Acetabular sector angle measure- pared with that of standard prosthe- marrow replacement processes
ments are more specific to the pres- ses currently limits their use to cases (43,44), and osteomyelitis (54,55).
ence of hip dysplasia (Fig 2e). Ante- in which a standard prosthesis is in-
nor and posterior sector angles reflect adequate because of the severity or
Technique
the degree of both anterior and poste- complexity of the deformity. Axial CT
nor acetabular support. The sector image data have also been employed Although MR imaging of the hips
angles are determined by measure- to create mathematic models of the should be individualized to the clini-
ment of the angle drawn between the hip to allow for improvements in cal question asked, most studies are
center of the femoral head and the standard prosthesis design (40). In initially performed with the body coil
anterior and posterior acetabular rim addition, CT evaluation before hip in the coronal projection, a view eas-

Volume 198 Number

#{149} 2 Radiology 299
#{149}
a.

b. c.

a.
d. e.
Figure 2. Bilateral developmental dysplasia of the hip in a 27-year-old woman. Spiral CT was
performed with 3-mm table speed and 3-mm collimation; images were created at 2-mm incre-
ments. (a) Axial CT images demonstrate typical changes of hip dysplasia, including a mis-
shaped acetabulum. (b) Coronal CT images reveal orientation of femurs within the acetabu-
lum. Subchondral cysts are present in both hips. (c) Measurement of acetabular version
demonstrates a measurement (200) similar to a normal example (22#{176}).
(d) Measurement of
femoral version demonstrates an increased angle of 27#{176}.
(e) Measurement of acetabular sector
angles demonstrates reduction in the anterior angle of 19#{176}
(normal example, 64#{176})
and the pos-
tenor angle of 73#{176} (normal example, 106#{176}).
AASA = anterior acetabular sector angle, PASA =
posterior acetabular sector angle.

b.
Figure 3. Class A AVN of the right hip in a
65-year-old man with no predisposing factors
for AVN. (a) Coronal Ti-weighted MR image
(600/15 [repetition time msec/echo time msec])
shows a well-demarcated area in the weight-
bearing portion of the femoral head. Signal in-
tensity (arrowhead) equal to that surrounding
normal marrow is inside the peripheral rim
ofdecreased signal intensity. (b) Axial T2-
weighted MR image (2,500/80) shows an area
ily correlated with standard hip radio- ence suggests that MR imaging of
within the circumscribing double-line sign,
graphs and bone scintigraphs. Other joints, with use of dilute gadopen- which has signal intensity (arrow) equal to that
projections and surface coils may be tetate dimeglumine injected directly surrounding normal marrow. The double-line
added to demonstrate, with high spa- into the joint, may be helpful for sign (arrowheads) is the concentric low- and
hal resolution, specific anatomic struc- evaluation of the acetabular labrum high-signal-intensity lines that surround the
central area of osteonecrosis.
hires and pathologic processes. In (Petersilge C, MD, oral communica-
general, standard Ti- and T2-weighted tion, 1995).
spin-echo sequences are recommended
for imaging. Fat-saturation techniques tion of blood flow to the femoral capi-
Osteonecrosis
may also be utilized to decrease the tal epiphysis (43,56,57).
high signal intensity of normal fat The most frequent indication for Histologically, bone marrow is corn-
and enhance the visualization of ab- MR imaging of the hip is undoubt- posed of three separate cell types:
normal tissue and edema within the edly evaluation for possible AVN of hematopoietic cells, osteocytes, and
marrow and soft tissues (43,44). In our the femoral head. Femoral AVN is the marrow fat cells (44). When these cells
experience, gradient echo sequences end result of a wide variety of dis- are exposed to an ischemic insult,
provide little, if any, additional infor- similar conditions, ranging from they die at different rates. Hemato-
marion and therefore are not used for trauma to steroid use, in which the poietic cells tend to die within 6-12
evaluation of the hip. Recent experi- common final stages involve interrup- hours after the insult, whereas osteo-

300 Radiology
#{149} February 1996
 characteristics in the central avascular
portion of theabnormal fernoral head
(Fig 4). The authors of this classifica-
hon scheme also found a correlation
between the MR imaging dasses and
the Steinberg radiographic stages (59).
MR imaging dasses A and B were found
to correspond primarily to Steinberg
stages 1 and 2, whereas MR imaging
classes C and D corresponded to Stein-
a. b.
berg stages 3-5. Thus, Mitchell classes A
Figure 4. Class D AVN of the right femoral head in a 42-year-old man with a long history of
steroid use. Coronal Ti-weighted MR image (600/15) shows a well-circumscribed area of de-
and B are considered to represent earlier
creased signal intensity (arrowhead) in the weight-bearing portion of the right femoral head. and less severe stages of disease than
Incidentally noted is a similar area within the left femoral head. (b) Coronal T2-weighted MR stages C and D. Unfortunately, it has
image (2,700/90) of the well-circumscribed area in the right femoral head shows decreased been our experience that many patients
signal intensity (arrowhead). Incidentally noted is a similar area within the left femoral head. with AVN demonstrate heterogeneous
MR imaging signal intensity characteris-
tics within the femoral heads, which
predudes definitive placement into one
of the four Mitchell dasses (Fig 5).
Surgical management of AVN of
the femoral head (core decompression
with or without bone grafting) is most
effective when performed in the earli-
est stages of disease before articular
collapse necessitates a salvage proce-
dure such as total hip arthroplasty.
Beltran et al (60) demonstrated core
decompression as most successful in
patients in whom MR imaging dem-
onstrated less than 25% involvement
of the femoral head with AVN (suc-
cess indicated by failure of the ferno-
ral head to subsequently collapse).
a. b.
When greater than 50% of the ferno-
Figure 5. Mixed class, idiopathic AVN of the right hip in a 42-year-old man. (a) Coronal Ti-
ral head was involved with AVN, col-
weighted MR image (500/10) shows a well-circumscribed area of decreased signal intensity lapse occurred in a very large per-
(arrowhead) within the weight-bearing portion of the femoral head. (b) Coronal T2-weighted centage. Because of this finding, the
MR image (2,700/90) of the inferior portion of the circumscribed area of AVN shows high sig- authors suggested imaging the femo-
nal intensity equivalent to that seen with fluid (arrow). The superior portion shows decreased ral head in two orthogonal planes to
signal intensity (arrowhead). This latter area represents class D disease, whereas the inferior better estimate the percentage of
aspect of this area of AVN actually represents class C disease.
femoral head involvement with AVN.
We routinely follow this recommen-
dation when AVN is found in the
cytes die within 12-48 hours. Marrow nal-intensity peripheral band on both coronal plane.
fat cells are more resistant to ischemia Ti- and T2-weighted images usually MR imaging has proved to be ex-
and die approximately 5 days after demarcates the area of AVN from sur- tremely sensitive for detection of
the insult (58). MR imaging depiction rounding normal marrow (46). In 80% AVN of the hip when compared with
of osteonecrosis of the hip depends of cases of AVN, there is a charactens- other modalities (bone scintigraphy
on change in the normally high signal tic “double-line” sign on T2-weighted and CT) (61). There are some excep-
intensity of marrow on Ti-weighted images, which represents concentric, tions to this generalization, and those
images and the intermediate signal low- and high-signal intensity rims usually involve very early stages of
intensity on T2-weighted images. that surround the area of marrow sig- AVN. Figure 6 compares the temporal
These signal intensity characteristics nal intensity change (Fig 3) (20). Within appearance of AVN on bone scinti-
have been thought to be due to the the area circumscribed by the double grams and MR images. With bone
presence of marrow fat. Although the line, signal intensity is determined by scintigraphy, early stages of AVN are
histologic definition of osteonecrosis the material that replaces the marrow depicted as a cold spot within the
requires death of osteocytes (empty fat. femoral head. The cold spot is due to
lacunae), the MR imaging changes in Categorization of the marrow the ischemia to the affected area,
osteonecrosis reflect the death and changes that occur during osteone- which prevents delivery of radiophar-
replacement of marrow fat cells. Thus, crosis has resulted in the most ac- maceuticals. As the disease progresses
the normal high signal intensity of cepted MR imaging classification and bone remodeling begins, the cold
marrow on Ti- and intermediate sig- system for AVN (46). The Mitchell spot becomes a hot spot. There is a
nal intensity on T2-weighted images classification system correlates MR period of time, however, between
change in the presence of osteonecro- imaging appearances with histo- these two phases of the disease (the
sis to a usually well-circumscribed pathologic features (Table). Classes crossover point) when scintigraphy
region of marrow signal intensity A-D are identified on the basis of Ti- actually can produce a false-negative
within the femoral head. A low-sig- and T2-weighted signal intensity result (58).

Volume 198 Number

#{149} 2 Radiology 301
#{149}
 0 \\

‘5 .,‘, Bone scan

‘5 ,-
\-

Figure 6. Graph depicts the relative tempo-

ral detectability of AVN with bone scintigra-
phy and MR imaging. It also shows that bone
scintigraphy may be able to depict earlier
stages of AVN than routine MR imaging.
Early on, bone scintigraphy actually is posi-
tive for AVN by demonstrating an area of
decreased radiopharmaceutical uptake. As
the disease progresses and bone remodeling
occurs, there is a crossover point between
periods in which bone scintigraphy shows a
“cold spot” and those times in which bone a. b.
scintigraphy demonstrates a “hot spot.” Dur- Figure 7. Sudden onset of right hip pain in a 32-year-old man. TI- and T2-weighted spin-
ing this crossover period, bone scintigraphy echo sequences were normal. (a) Fat-saturation Ti-weighted MR image (60/15) obtained be-
may fail to depict AVN. Standard MR imag- fore intravenous administration of gadopentetate dimeglumine shows the lack of uniform fat
ing may not be able to depict the very early saturation (technical problem). (b) Fat-saturated Ti-weighted MR image (600/15) obtained
stages of AVN; however, once positive, MR after intravenous administration of gadopentetate dimeglumine shows the lateral portion of
imaging findings remain so until AVN is the femoral head and the femoral neck enhance with gadolinium. There is an area on the su-
healed. (Reprinted, with permission, from perior and medial portion of the femoral head that fails to enhance (arrowhead). Subsequent
reference 59.) core biopsy of this area demonstrated AVN. The patient became symptom free but was then
lost to follow-up. (Case courtesy of James B. Vogler, MD, Gainesville, Fla.)

Figure 6 demonstrates that bone

scintigraphy actually may enable de-
tection of AVN earlier than MR imag-
ing. This should not be surprising,
since, as stated earlier, MR imaging
depicts AVN by demonstrating
changes in marrow signal intensity.
Most of the signal intensity of normal
marrow is contributed by the fat cells.
Because fat cells are the most resistant
of the marrow components to isch- a. b.
emia (dying approximately 5 days Figure 8. Transient osteoporosis of the left hip was subsequently diagnosed in a 48-year-old
after the ischemic insult), one would man. (a) Coronal TI-weighted MR image (600/15) shows a diffuse area of decreased signal
expect a delay in the ability of MR intensity that encompasses all of the femoral head and extends into the femoral neck (arrow-
imaging to depict AVN of at least 5 head). (b) Coronal T2-weighted MR image (2,700/90) shows a diffuse area of increased signal
intensity that encompasses the entire femoral head and extends into the femoral neck region
days after the ischemic insult. Once
(arrow). Also noted is a small joint effusion (arrowhead).
findings are positive, however, MR
imaging examination will be positive
for the lifetime of the patient or until
the AVN resolves either spontane- These findings are reminiscent of the postgadolinium STIR or fat-saturation
ously (62) or after treatment. cold spot demonstrated in the early imaging.
Realization of the potential inability stages of AVN by bone scintigraphy.
of standard MR imaging to depict Since this study (63), we have en-
Bone Marrow Edema Pattern
very early stages of osteonecrosis, countered several anecdotal cases of
Nadel et al (63) used a dog model and early stages of AVN that had normal In recent years, a specific MR find-
demonstrated that gadolinium-en- findings on both Ti-and T2-weighted ing in the hips has proved to be both
hanced short-inversion-time inver- spin-echo images but demonstrated confusing and controversial; namely,
sion recovery (STIR) images could areas of decreased enhancement after the “bone marrow edema pattern”
potentially be used to enhance the administration of gadolinium (Fig 7). (64,65). This pattern is characterized
early sensitivity of MR imaging. They Those cases that have progressed to- by diffuse decreased signal intensity
found that although spin-echo and core decompression have yielded his- on Ti-weighted images and increased
STIR images obtained before adminis- tologic results consistent with AVN. signal intensity on T2-weighted im-
tration of gadolinium did not show Although these anecdotal cases are ages, which correspond to an edema-
any short-term changes in the isch- not conclusive proof of the efficacy of like pattern. This pattern involves
emic femoral heads, postgadolinium this technique, we currently recom- much of the femoral head and ex-
images showed an area of decreased mend that patients with a high suspi- tends for a variable distance into the
enhancement that corresponded cion for AVN who have normal TI- femoral neck and intertrochanteric
histologically to the region of AVN. and T2-weighted images undergo regions (Fig 8). Unlike standard AVN

302 Radiology
#{149} February 1996
 staging information to allow treat- important for the radiologist to un-
ment planning without further stud- derstand the changes these disease
ies. Scintigraphy remains useful in the processes produce because a patient
evaluation of multifocal and meta- may present with hip pain and dis-
static lesions, as the entire body can ability and undergo MR imaging be-
be surveyed with a single study. Both cause of other suspected diagnoses.
CT and MR imaging may be used to Thus, the radiologist must recognize
a. stage bone neoplasms, although, MR the changes produced by arthritic
imaging has been shown to provide processes to distinguish them from
more accurate and detailed informa- AVN, fractures, and neoplasm.
hon in most cases (49). Osteoarthritis produces characteris-
MR imaging is the primary tool for tic changes on MR images. Cartilage
identification, classification, and stag- thinning can be seen when severe,
ing of soft-tissue neoplasms (48). CT but limited resolution prevents identi-
provides less information but may be fication of early stages of cartilage
useful for identification of subtle soft- loss. MR images usually have lower
b. tissue calcifications missed at radiog- resolution than CT images. Small os-
raphy and MR imaging. For either teophytes, early cartilage loss, and
Figure 9. Severe hip pain in a 67-year-old
man with osteoarthritis. (a) Coronal Ti- bone or soft-tissue tumor evaluation, sclerosis are more difficult to recog-
weighted MR image (500/10) shows spurs MR imaging provides better soft-tis- nize with MR imaging. More severe
along the medial and lateral margins of the sue contrast than other imaging disease, however, can be identified
femoral head (arrows). (b) Coronal 12-weighted methods. The improved contrast (Fig 9). MR imaging, because of its
MR image (2,700/90) shows decreased resolu-
makes abnormalities more conspicu- sensitivity to fluid on T2-weighted
lion, which makes the spurs less visible. A joint
effusion is present (arrow).
ous. Better contrast and the ability to images, allows easy and confident
select any imaging plane allows im- identification of subchondral cysts.
proved definition of tumor margins The ability to image in sagittal and
and identification of the compartmen- coronal planes makes identification
of the hip, there is no demarcation of tal and longitudinal extent of the le- and characterization of these lesions
the region of involvement by the sion. quite easy. Studies are now under
double-line sign. Differential diagno- The appearance of a musculoskel- way to evaluate the ability of high
sis for the bone marrow edema pat- etal neoplasm on MR images varies resolution MR imaging for identifica-
tern includes transient osteoporosis, with tissue type. MR imaging depicts tion of early cartilage thinning and
early stages of AVN, osteomyelitis, pathologic cellular tumors as low sig- small erosions. Such studies may pro-
bone bruise, and infiltrative neoplasm nal intensity on Ti-weighted images, vide a noninvasive method to assess
(64). Many times the latter three enti- similar to that of muscle, and as high progression of the disease and the
ties in the differential diagnosis can be signal intensity on T2-weighted im- success of therapy in osteoarthritis.
distinguished on the basis of clinical ages, generally equal to or greater An MR imaging grading system for
signs and symptoms. The real prob- than that of fat. Fibrotic areas are low osteoarthritis has been suggested (50).
lem is in distinguishing between early in signal intensity on both Ti- and The MR imaging grade correlates well
stages of AVN (a disease that may T2-weighted images, and fat within a with mild disease but poorly with se-
need surgical intervention) and tran- tumor always has signal intensity vere disease. Early osteoarthritis pro-
sient osteoporosis (a disease that is equal to that of subcutaneous fat. duces an irregular, heterogeneous
self-limited and requires no specific Many benign neoplasms can be recog- decrease in signal intensity within the
therapy other than supportive mea- nized with confidence at MR imaging. cartilage on MR images (it is not usu-
sures). Currently, MR imaging ap- Seromas, lymphangiomas, vascular ally seen on CT scans). More severe
pears incapable (at least on a consis- malformations, hematomas, pig- disease produces joint space narrow-
tent basis) of enabling this distinction mented villonodular synovitis, and ing, marginal osteophytes, and sub-
(64). lipomas produce characteristic find- chondral cysts seen with all imaging
ings that allow identification. Other modalities. Bone sclerosis is easily
benign neoplasms are less characteris- seen at radiography and CT but is not
Primary Musculoskeletal
tic and cannot be differentiated from seen as well at MR imaging, where it
Neoplasms
malignant neoplasms with confi- produces a loss of signal intensity in
Musculoskeletal neoplasms are dence. MR imaging does not allow normal marrow fat. Active osteoar-
commonly seen about the hip and histologically specific diagnoses for thritis may produce marrow edema
may manifest as either a paraarticular most malignant tumors, although within the femoral head and acetabu-
mass or a cause of pain in the hip and their aggressive nature can be recog- lum. The edema is seen best by using
leg. Plain radiography remains the nized. Signs of an aggressive growth T2-weighted, STIR, or fat-saturation
primary modality for identification pattern include poorly defined mar- techniques.
and classification of bone tumors. gins with invasion of surrounding Images of the hip have been in-
Bone scintigraphy may be used to tissues and entrapment of nerves and cluded in several studies involving
establish the presence of a bone ab- vessels, rapid growth, and heteroge- the MR appearance of synovial arthn-
normality when radiographs are nor- neous internal signal intensity pattern. tis (5i,66). Early changes are subtle
mal; however, if myeloma is sus- and may include only joint effusions.
pected, a normal bone scan cannot be Later, cartilage erosion, joint space
Arthropathies
used to exclude clinically relevant dis- narrowing, bone erosion, and syno-
ease. If suspicion is high, MR imaging Advanced imaging techniques are vial hypertrophy are identified. Be-
will provide equivalent site-specific seldom used as primary tools in the cause of the cross-sectional nature of
information and add the necessary evaluation of arthritis; however, it is MR imaging, it may allow identifica-

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#{149} 2 Radiology 303
#{149}
a.

a.

b.

b.
Figure 12. Non-Hodgkin lymphoma and irregular increased
radionuclide uptake throughout the pelvis in a 40-year-old man.
(a) Axial Ti-weighted MR image (768/i7) shows patchy low-signal-
intensity areas in the left acetabulum (arrowheads) and a broad
C. region of low signal intensity in the right posterior acetabulum and
Figure 10. Right hip pain in an 89-year-old woman with normal ra- ischium (arrow). (b) Axial T2-weighted MR image (2,400/90) shows
diographs after a fall. (a) Coronal Ti-weighted MR image (500/10) that low-signal-intensity areas in the left acetabulum are almost
shows an irregular area of low signal intensity in the greater trochanter invisible. High signal intensity is noted in a portion of the right
(arrow). Fine low-signal-intensity lines extend medially across the posterior acetabular lesion (solid arrow). In addition, intermediate
femoral intertrochanteric zone toward the lesser trochanter (arrow- to high signal intensity is also noted in the obturator internus and
heads). 0,) Axial Ti-weighted MR image (600/15) shows the low-signal- gluteus musculature (open arrows). Tumor involvement was
intensity zone (arrow) crossing posteriorly to involve the lesser trochan- proved with biopsy of both bone and soft tissues.
ter, which causes this injury to be classified as an intertrochanteric
fracture. (c) Coronal STIR image (2,360/19/125 [inversion time]) shows
extensive marrow edema in the greater trochanter and crossing the
femur. There are also extensive signal intensity changes in the sur-
rounding muscular and perimuscular tissues.

tion of small erosions before they can is easily identified at MR imaging.

be seen at radiography. Hypertro- Thus, nondisplaced fractures; stress
phied synovium can be seen within fractures; subtle fractures in severely
and adjacent to the joint and within osteopenic patients; and fractures pri-
bony erosions. By using gadolinium- manly in the axial plane, which are
enhanced sequences, the response of difficult to see at CT, are easily recog-
synovial proliferation to therapy may nized at MR imaging because of the
be assessed (67). change they produce in the marrow
(52,53). Fractures produce low-signal-
intensity lines on all MR images (Fig
Trauma
10). On T2-weighted and STIR im-
Fractures of the pelvis, hip, and ages, the low-signal-intensity line is
proximal femur are usually identified surrounded by a variable amount of
at radiography. As previously dis- high-signal-intensity marrow edema.
cussed, CT can add substantially to Stress fractures may show regions
the assessment of fractures around of only low signal intensity on Ti- Figure 11. Clicking sensation in the left hip
of a 32-year-old woman. Corornal fat-satu-
the hip. Recently, MR imaging has weighted and high signal intensity
rated Ti-weighted MR image (600/15) ob-
been shown to add another dimen- on T2-weighted images (edema).
tamed after intraarticular injection of 1:200
sion to the study of hip trauma. Frac- An area of trauma that, to our dilution of gadopentetate dimeglumine
tures produce an immediate change knowledge, has received little atten- shows a subtle tear in the posterosuperior
in the appearance of marrow, which tion in the orthopedic and radiology acetabular labrum (arrowheads).

304 Radiology
#{149} February 1996
a. b.
Figure 14. Deep decubitus ulcer over the right hip (+) in a 27-year-old paraplegic man. (a) Axial Ti-weighted MR image (600/15) shows de-
creased marrow signal intensity in the proximal femur and acetabulum on the right. The cortex of the right femoral head and acetabulum is
not seen (contrast with the cortex of the ischium and medial wall [arrowheads]). Extensive distortion is noted in the soft tissues associated with
the ulcer. (b) Axial 12-weighted MR image (2,500/90) shows high signal intensity in the acetabulum and femoral head and neck, which consti-
tute an area of low signal intensity on a. Edema surrounds the ulcer.

replacing fat (Fig i2b) (44). Marrow fi- hip and its consequences are most
brosis and sclerotic metastases decrease efficaciously evaluated with CT scan-
signal intensity on both Ti- and T2- ning. Likewise, preoperative planning
weighted images. Subacute hemorrhage and design of total hip revisions and
within the marrow increases signal in- custom-made hip prostheses are best
tensity on both Ti- and T2-weighted accomplished with CT, with or with-
images. Common infiltrative processes out multiplanar and three-dimen-
produce widespread marrow replace- sional reconstruction. The decision of
ment with poorly defined margins. whether to use CT or MR imaging for
More focal processes such as metastases evaluation of trauma is more prob-
and multiple myeloma may produce lematic. Spiral CT adds speed and
multiple, sharply defined foci of marrow permits volumetric acquisition of
Figure 13. Metastatic breast carcinoma and replacement (Fig 13). Separation of me- data, which is extremely useful in the
right hip pain in a 56-year-old man. Coronal tastasis from focal collections of he- acutely injured patient. Spiral CT pro-
Ti-weighted MR image (500/10) shows mul-
matopoietic marrow may be difficult. vides exquisite detail of the osseous
tiple focal low-signal-intensity lesions in the
right hemipelvis and both femurs (arrows).
Schweitzer et al (68) suggest that uni- anatomic structures and the abnor-
form or peripheral ringlike high sig- malities caused by trauma in and
nal intensity strongly suggests metas- about the hip. Nevertheless, MR im-
literature has been detection of dam- tasis while centrally located high signal aging has been shown to add another
age to the acetabular labrum. We and intensity suggests focal marrow (68). dimension to the study of hip trauma.
others (Petersilge C, oral communica- By monitoring changes in marrow
tion, 1995) have found that MR imag- appearance, MR imaging can be used
ing of the joints (with a 200:1 dilution
Osteomyelitis
to detect nondisplaced fractures;
of gadopentetate dimeglumine in- The MR findings of infection in the stress fractures; subtle fractures in
jected directly into the joint, under hip and adjacent bone are sensitive severely osteopenic patients; and frac-
fluoroscopic control) allows superb but relatively nonspecific and must be tures primarily in the axial plane,
detection of even subtle acetabular carefully considered in concert with which can be difficult to visualize at
tears (Fig 11). the clinical picture (54,55). MR imag- CT. In addition, MR imaging of the
ing is useful in answering the clinical joints may be used to recognize even
Marrow Replacement Processes question of whether the patient has subtle injury to the acetabular labrum.
In healthy individuals, the marrow osteomyelitis. It is less useful in differ- As stated earlier, MR imaging has
of the femoral head contains fat, entiating osteomyelitis from diseases proved to be the modality of choice,
which produces high signal intensity such as bone infarction or marrow following plain radiography, for im-
on TI-weighted MR images. Adjacent packing disorders. Initial changes on aging a number of disease processes
marrow in the femoral neck and ac- MR images include marrow edema such as many musculoskeletal tumors,
etabulum contains a mix of fat and and joint effusion. Later, bone erosion marrow replacement processes, and
hematopoietic cells that produces a and destruction are visible. The dis- osteomyelitis (to determine the extent
slightly lower signal intensity on Ti- tinction between paraarticular celluli- of disease and to answer the specific
weighted MR images. Replacement of tis and osteomyelitis can be made question of whether the patient has
the marrow fat by cellular tumor or a with MR images. MR imaging also has osteomyelitis; otherwise, nuclear
cellular marrow packing process de- been useful in defining the extent of medicine studies are advocated). Most
creases signal intensity on Ti-weighted osteomyelitis before surgery (Fig 14). important, as judged by the number
MR images (Fig iii). On T2-weighted of studies ordered, MR imaging has
images, the marrow abnormalities gen- proved to be the modality of choice in
CONCLUSION
erally increase signal intensity, but the AVN and its related diseases. Newer
degree of change varies widely depend- Congenital abnormalities, specifi- developments such as the use of
ing on the exact type of tissue that is cally developmental dysplasia of the gadolinium-enhanced imaging bode

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#{149} 2 Radiology 305
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well for the future prospects of ex- 22. Mandelbaum BR, Magid D, Fishman EK, et Design of custom hip stem prostheses us-
al. Multiplanar computed tomography: a ing three-dimensional CT. J Comput Assist
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