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Ultrasound of the Hip: Anatomy, Pathology, and Procedures

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Ultrasound of the Hip: Anatomy, Pathology, and Procedures Ultrasound of the Hip: Anatomy, Outline Pathology, and Procedures • Hip Joint – Native hip Jon A. Jacobson, M.D. – Arthroplasty Professor of Radiology • Greater Trochanter Director, Division of Musculoskeletal Radiology – Tendon abnormalities University of Michigan – Bursal pathology • Snapping Hip Hip: anterior recess Hip: anterior recess • Anterior and posterior layers – Fibrous tissue + minute layer of synovium – Hyperechoic Radiology – Each 2 - 4 mm thick 1999; 210:499 Anterior Posterior Femur Hip Joint Hip Effusion: • Separation of anterior and posterior layers1 • Capsule distention at femoral neck > 7 mm or difference of 1 mm from opposite side2 • Extension & abduction improves H 3 A visualization Neck • Do not internally rotate hip: capsule thickens 1Radiology 1999; 210:449 2 Sagittal-oblique Scand J Rheumatology 1989; 18:113 3Acta Radiologica 1997; 38:867 1 Hip Joint: septic effusion Hip Effusion: misconception • It is incorrect to assume that joint fluid may not be seen anterior due to gravity • Native hip: joint fluid distributes around * femoral neck • In no cases was fluid only seen posterior FH * Neck • Exception: after hip surgery * * Long Axis Moss et al. Radiology 1998; 208:43 Hip Effusion: Joint injection • Anterior recess • Cannot predict infection by ultrasound • In plane • Negative power color * • Transducer: Doppler does not – Parallel to femoral neck exclude infection* Head * – Consider curvilinear • Guided aspiration • Needle: distal to Neck proximal • 97% accuracy1 F * AJR 1998; 206:731 1Smith J. J Ultrasound Med 2009; 28:329 Joint injection Joint Injection • Transducer: in plane • Femoral neck target – Lateral to medial • Preferred over aiming – Horizontal and parallel N for femoral head to sound beam • Allows higher injection volumes • Less extra-articular contrast From Kantarci F et al. Skeletal Radiol 2013; 42:37. F H Courtesy of Mark Cresswell, Vancouver N 2 Pigmented Villonodular Juvenile Rheumatoid Arthritis Synovitis Head Head Erosion Hip Labrum Labral Tear Femoroacetabular Impingement • Normal: – Hyperechoic, triangular • Pincer-type: deep acetabulum • Degeneration: hypoechoic Acetab • Cam-type • Tear: anterior Femoral – Broad irregular femoral neck Head – Anechoic cleft – Possible cortical irregularity at US – Sensitivity 82%, specificity • Associated with anterior labrum tear 60%, accuracy 80%* • Consider dynamic evaluation Chondrocalcinosis Detachment Radiology 2005; 236:588 *Jin W et al. J Ultrasound Med 2012; 31:439 Labral Tear and Paralabral Cyst Hip Arthroplasty: • Associated with labral tear – Full-thickness or detachment • Prosthesis identifiable • Anechoic to hypoechoic • Multilocular • May use sonography to guide hip aspiration • Most useful: non-communicating abscess, bursitis, incision infection Courtesy of D. Fessell, Ann Arbor, MI 3 Total Hip Hip Arthroplasty: Arthroplasty: • Ultrasound cannot differentiate small effusion • Metal components from post-op change1 demonstrate posterior • Suspect infection: reverberation A Acet Femur – Pseudocapsule > 3.2 mm: 2 • Artifact occurs deep to H Neck suspect infection prosthesis away from > 3.2 – Extra-articular fluid Head mm fluid collection (unlike collection MRI, CT) – Not visualized with Neck arthrography if non- communication 1Weybright PN et al. AJR 2003; 181:215 2AJR 1994; 163:381 Hip Arthroplasty: infection Hip Arthroplasty: infection Superior Inferior Femur Native Coronal Radiograph Femur Teaching Point: Always screen soft tissues about an arthroplasty Sagittal prior to fluoroscopic joint aspiration Metal-on-Metal Arthroplasty: pseudotumor Iliopsoas Bursa • Hip joint communication in 10% – Increased with hip joint pathology Troch – After joint replacement Cup • May extend cephalad into abdomen • May be mistaken for psoas abscess Neck Cup – Look for hip joint communication Anterior Lateral Radiology 1995; 197:853 4 Iliopsoas Bursal Fluid Iliopsoas Bursa • Oblique-axial plane: – Superior to femoral head – Lateral to medial – Inject between tendon and ilium1 • Pain relief = successful iliopsoas surgical release2 IP 1Dauffenbach J et al. Femoral J Ultrasound Med 2014; Head 33:405 I 2Blankenbaker DG et al. Ilium Axial T1w post-gadolinium Skeletal Radiol 2006; 35: 565 Greater Trochanter: gluteal tendons Outline Anterior Lateral Posterior • Hip Joint – Native hip – Arthroplasty • Greater Trochanter – Tendon abnormalities – Bursal pathology • Snapping Hip Gluteus medius (red) Gluteus minimus (blue) Greater Trochanter Greater Trochanter Subgluteus Medius Gluteus Medius Gluteus Bursa Minimus TFL Trochanteric Bursa Glut Subgluteus Max Minimus Bursa LF AF PF AF: anterior facet LF: lateral facet PF: posterior facet FACETS: AF = anterior; LF = lateral; SPF = superoposterior; PF = posterior Pfirrmann et al. Radiology 2001; 221:469 5 Gluteus Minimus and Medius: Long Axis Gluteus Minimus: Long Axis Gluteus Gluteus Medius Minimus Gmed Gmed AF PF Anterior Facet Gluteus Medius: Long Axis Trochanteric Pain Syndrome: Iliotibial • Most commonly caused by gluteus Tract minimus and medius tendon abnormalities1 LF • Trochanteric bursitis: uncommon – 20% of symptomatic patients2 Lateral – Not actually inflamed3 Facet – Not associated with pain4 1Kong A et al. Eur Rad 2007; 17:1772 2Long SS et al. AJR 2013; 201:1083 3Sylva F et al. Clin Rheumatol 2008; 14:82 4Blankenbaker DG et al. Skeletal Radiol 2008; 37:903 Tendinosis: Gluteus Minimus Gluteal Tendon Pathology: • Tendinosis: hypoechoic, no defects • Partial tear: anechoic clefts • Complete tear: discontinuous tendon AF LF • >2 mm cortical irregularity (depth) AF – Associated with tendon tear – Positive predictive value = 90% (xray)* *Steinert et al. Radiology 2010; 257:754 6 Tear: Gluteus Minimus Tendinosis: Gluteus Medius AF LF AF AF LF SPF LF Tear: Gluteus Medius Tear: Gluteus Medius after THA LF SPF AF LF LF LF LF AF AF >2 mm cortical irregularity depth (x-ray) = 90% positive predictive value for gluteus tendon tear Steinert et al. Radiology 2010; 257:754 Post-operative: Gluteus Medius Calcific Tendinosis: Gluteus Medius LF LF AF AF LF SPF LF Long Axis Short Axis 7 Gluteus Medius Fenestration: pelvis • 22 tendons in 21 patients • Gluteus medius (11), hamstring (8), Greater gluteus minimus (2), tensor fascia lata (1) Trochanter Needle • Marked or some improvement: 82% Jacobson JA et al. J Ultrasound Med 2015; 34:2029 Normal Trochanteric Bursal Fluid + Glut Min Tear PRP and Tendon Injection • Gluteal Tendons: greater trochanter AF – Randomized controlled: 30 patients – PRP versus fenestration alone • Significant improvement at weeks 1 and 2 LF AF Glut • Approximately 80% had long term Max PF improvement: up to 1 year follow-up • No difference between treatment groups Jacobson JA et al. J Ultrasound Med 2016; 35:2413 Axial Trochanteric Bursitis Trochanteric Bursa: infection + gas T1w Greater Trochanter 8 Trochanteric Region Bursae Outline • Trochanteric: deep to • Hip Joint gluteus maximus – Native hip • Subgluteus medius – Arthroplasty • Greater Trochanter • Subgluteus minimus LF – Tendon abnormalities • Axial or coronal plane – Bursal pathology PF • Snapping Hip Iliopsoas Complex A Snapping Hip Syndrome AIIS • Painful snap with hip motion A Ilium • Intraarticular B • Extraarticular: – Anterior: iliopsoas tendon – Lateral: iliotibial tract or gluteus maximus Pubis Red: psoas major Femoral Orange: medial iliacus fibers Head Short Axis Purple: lateral iliacus fibers From: Guillin R. et al. Eur Rad 2009; 19:995 Snapping Hip Syndrome: iliopsoas Snapping Hip Syndrome: iliopsoas 1 2 • Image long axis to inguinal ligament superior to femoral head • Extension of flexed abducted and externally rotated hip 3 • Abrupt movement of iliopsoas as iliacus muscle interposed between tendon and bone moves Deslandes et al. AJR 2008; 190:576 Deslandes et al. AJR 2008; 190:576 9 Snapping Hip Syndrome: iliopsoas Snapping Hip: lateral • Transverse over greater trochanter • Hip external rotation / flexion • Abrupt motion of iliotibial tract or gluteus maximus over greater trochanter Snapping Gluteus Maximus / Iliotibial Band Snapping Hip Syndrome: iliotibial tract Gluteus Iliotibial Band Medius TFL Gluteus Maximus Gluteus Maximus Gmin Iliotibial Band Gmax Gmin Gmed Take-home points: • Hip: – Native: focus on anterior recess – Arthroplasty: pseudotumor, iliopsoas bursa • Greater trochanter: – Bursitis uncommon – Tendinosis and tendon tear • Snapping Hip: – Iliopsoas and iliotibial tract/gluteus maximus See www.jacobsonmskus.com for syllabus and other educational material 10.
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