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Cartilage Lesions in the Hip: Diagnostic Effectiveness of MR Arthrography¹

¹ From the Departments of Radiology (M.R.S., M.Z., J.H.) and Orthopedic Surgery (H.P.N., T.F.W.), Orthopedic University Hospital Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland. From the 2001 RSNA scientific assembly. Received February 1, 2002; revision requested March 25; revision received April 15; accepted June 3. Address correspondence to M.R.S. (e-mail: mariusschmid@hotmail.com).

	ABSTRACT

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PURPOSE: To evaluate the diagnostic performance of magnetic resonance (MR) arthrography in the detection of articular cartilage lesions in patients suspected of having femoroacetabular impingement and/or labral abnormalities.

MATERIALS AND METHODS: Forty-two MR arthrograms obtained in 40 patients with a clinical diagnosis of femoroacetabular impingement and/or labral defect were retrospectively analyzed. Two readers independently interpreted the images for cartilage lesion location, depiction, and characteristics. Within 6 months after MR arthrography, each patient underwent open hip surgery, during which the entire cartilage of the hip joint was inspected. Sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. values were calculated to quantify the level of interobserver agreement.

RESULTS: At surgery, most (37 [88%] of 42) cartilage defects were identified in the anterosuperior part of the acetabulum. In 23 (55%), 12 (29%), 10 (24%), and 10 (24%) hips, lesions were found in the posterosuperior acetabulum, anteroinferior acetabulum, posteroinferior acetabulum, and femoral head, respectively. The sensitivities and specificities of MR arthrographic detection of cartilage damage in all regions combined were 79% (73 of 92 regions) and 77% (91 of 118 regions), respectively, for reader 1 and 50% (46 of 92 regions) and 84% (99 of 118 regions), respectively, for reader 2. At interobserver comparison, agreement was fair ( = 0.31) for detection of cartilage lesions in the femoral head and poor ( 0.2) for detection of lesions in all acetabular regions.

CONCLUSION: Cartilage lesions are common in young and middle-aged patients with femoroacetabular impingement and/or labral abnormalities and are most frequently found in the anterosuperior part of the acetabulum.

© RSNA, 2003

Index terms: Arthritis, degenerative, 442.772 • Cartilage, MR, 442.121411, 442.121412, 442.121415, 442.12143 • Hip, arthrography • Hip, MR, 442.121411, 442.121412, 442.121415, 442.12143 • Magnetic resonance (MR), arthrography, 442.121411, 442.121412, 442.121415, 442.12143

	INTRODUCTION

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In the more recent orthopedic literature (1), femoroacetabular impingement has been described as a major pathogenic factor in primary osteoarthritis of the hip. Femoroacetabular impingement is clinically characterized by painful internal rotation and positive results of the impingement test, during which groin pain is caused by a combined maneuver of 90° flexion, adduction, and internal rotation of the hip. Reduced concavity of the anterior femoral head–neck junction is considered to be the cause of femoroacetabular impingement. With this condition, the abnormal anterior femoral head–neck junction comes into conflict with the anterosuperior acetabular rim. Labral tears and cartilage defects close to the abnormal labrum are commonly found in these joints (1,2). Because the choice of surgical procedure may depend on the presence of articular cartilage lesions, these defects should be diagnosed at preoperative magnetic resonance (MR) imaging.

Both standard MR imaging and MR arthrography are commonly used to diagnose internal derangements of the hip joint (3–5). In the detection of suspected labral tears, MR arthrography appears to be superior to standard MR imaging performed without intraarticular contrast material injection (4,6). Contrary to the extensive evaluations of the articular cartilage of the knee (7–11), relatively few investigations have been focused on the articular cartilage of the hip joint (12,13). The excellent results achieved at imaging of the knee cannot be reproduced easily at imaging of other joints that have thinner cartilage (14).

The purpose of our investigation was to evaluate the diagnostic performance of MR arthrography in the detection of mild to moderate articular cartilage lesions in patients suspected of having femoroacetabular impingement and/or labral abnormalities.

	MATERIALS AND METHODS

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Patients
Between May 1999 and March 2001, a total of 54 hip joints in 52 patients with clinical signs of femoroacetabular impingement and/or labral tear were examined at MR arthrography, and then open hip surgery was performed within 6 months. Twelve cases had to be excluded from our investigation because of either severe cartilage damage (n = 7) that necessitated hip prosthesis or an incomplete description of the articular cartilage in the surgery report (n = 5). Therefore, 42 hip joints (24 left, 18 right) in 40 patients (22 women, 18 men; age range, 19–51 years; mean age, 37 years) were evaluated in this retrospective analysis. Our institutional review board did not require its approval or patient informed consent for this study.

MR Arthrography
One milliliter of a local anesthetic agent (mepivacaine hydrochloride 2%, Scandicain; Astra-Zeneca, London, United Kingdom), 1 mL of an iodinated contrast material (iopamidol 200 mg/mL, Iopamiro 200; Bracco, Milan, Italy), and 6–10 mL of a diluted MR contrast material (gadopentetate dimeglumine, Magnevist; Schering, Berlin, Germany) at a concentration of 4 mmol/L were injected into the hip joint with fluoroscopic guidance. MR arthrograms were obtained within 30 minutes after contrast material injection. All examinations were performed with a 1.0-T MR imaging system (Expert; Siemens Medical Solutions, Erlangen, Germany). A flexible wraparound surface coil was used.

The standardized MR imaging protocol included an oblique-coronal (ie, parallel to the axis of the femoral neck) T1-weighted turbo spin-echo sequence without fat saturation (800/12 [repetition time msec/echo time msec], 3-mm section thickness, 0.6-mm intersection gap, echo train length of three, and three acquisitions), an oblique-coronal T1-weighted spin-echo sequence with fat saturation (800/20, 4-mm section thickness, 0.8-mm intersection gap, and one acquisition), a sagittal T1-weighted turbo spin-echo sequence (600/12, 4-mm section thickness, 0.8-mm intersection gap, echo train length of three, and three acquisitions), and an oblique-transverse T1-weighted fat-suppressed fast low-angle shot (FLASH) sequence perpendicular to the femoral neck (400/11, 3-mm section thickness, 0.6-mm intersection gap, 60° flip angle, and two acquisitions). All sequences were performed by using a 16-cm field of view and a 256 x 256 matrix.

MR Arthrogram Interpretation
Two radiologists (J.H., M.Z.) with more than 8 years of experience in musculoskeletal radiology interpreted each MR study independently without knowledge of the clinical or surgical data; however, they were aware of the purpose of this study. In this retrospective analysis, the two readers had to use an identical reporting system that has been used at our institution. Therefore, the horseshoe-shaped articular cartilage of the acetabulum was divided into four regions for this analysis: the anterosuperior (corresponding to the 9 o’clock to 12 o’clock positions in the left hip viewed from the patient’s left), posterosuperior (12 o’clock to 3 o’clock positions), anteroinferior (6 o’clock to 9 o’clock positions), and posteroinferior (3 o’clock to 6 o’clock positions) portions of the acetabulum. The femoral head cartilage was interpreted as one region.

For each region, a diagnosis of present or absent chondral degeneration was made. The readers were asked to note the image characteristics that led to their diagnosis. These criteria included contrast material–filled defect, area of cartilage signal intensity alteration, and secondary signs of osteoarthritis (ie, subchondral sclerosis, subchondral cysts, osteophytes). More than one of these criteria could be named per location.

Surgical Procedure
In all cases, surgery was performed within 6 months after MR arthrography by one orthopedic surgeon (H.P.N.) who specializes in diseases of the hip. During surgery, the greater trochanter with the abductor muscle insertions was temporarily removed and the femoral head was subluxated or dislocated according to the technique described by Ganz et al (2). All cartilage regions of the hip joint and the entire acetabular labrum can be completely inspected during this type of surgery. Cartilage abnormalities were the basis for further surgical decision making. Cartilage debridement and creation of an improved waist at the anterior femoral head–neck junction were performed for mild to moderate cartilage lesions. If cartilage damage was severe, total hip arthroplasty was performed.

Statistical Analysis
One of the authors (M.R.S.) who was not involved in the blinded reading sessions then compared the MR imaging data with the surgery reports. The sensitivity, specificity, accuracy, positive predictive, and negative predictive values of both readers in the MR arthrographic detection of cartilage lesions in all five anatomic regions were calculated. values were calculated to quantify the level of agreement at interobserver comparison (15). values were considered to indicate very good (0.81–1.00), good (0.61–0.80), moderate (0.41–0.60), fair (0.21–0.40), or poor (0–0.20) agreement.

	RESULTS

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At surgery, 92 of the 210 evaluated regions had cartilage defects. These cartilage lesions were located most often in the anterosuperior part of the acetabulum (n = 37), followed by the posterosuperior (n = 23), anteroinferior (n = 12), and posteroinferior (n = 10) parts of the acetabulum. Ten lesions were seen in the femoral head at surgery. In each hip (n = 42), at least one cartilage defect was found in one or both of the superior acetabular (ie, anterosuperior and/or posterosuperior) regions. In all 42 hips, these superior acetabular cartilage lesions were adjacent to the acetabular labrum and associated with labral abnormalities–namely, degeneration, ossification, and/or partial or complete tear of the labrum. Labral tears were found in 28 (67%) of the 42 hips at surgery (Figs 1, 2). The sensitivities, specificities, accuracies, and positive and negative predictive values of the MR arthrographic detection of cartilage abnormalities by both readers are listed in Table 1.

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. MR images of acetabular cartilage defect adjacent to complete labral tear in a 32-year-old man. (a) Coronal T1-weighted (800/12), (b) coronal T1-weighted fat-saturated (806/20), and (c) sagittal T1-weighted (600/12) images clearly show the complete labral tear (large arrow in a and b) in the anterosuperior part of the labrum and the adjacent loss of articular cartilage (arrowheads) in the anterior part of the left superior acetabulum. Intact femoral cartilage (small arrows in a and b) in the corresponding area also is seen. The contrast material within the joint space is visible only in the area of cartilage loss.

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. MR images of acetabular cartilage defect adjacent to complete labral tear in a 32-year-old man. (a) Coronal T1-weighted (800/12), (b) coronal T1-weighted fat-saturated (806/20), and (c) sagittal T1-weighted (600/12) images clearly show the complete labral tear (large arrow in a and b) in the anterosuperior part of the labrum and the adjacent loss of articular cartilage (arrowheads) in the anterior part of the left superior acetabulum. Intact femoral cartilage (small arrows in a and b) in the corresponding area also is seen. The contrast material within the joint space is visible only in the area of cartilage loss.

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 1c. MR images of acetabular cartilage defect adjacent to complete labral tear in a 32-year-old man. (a) Coronal T1-weighted (800/12), (b) coronal T1-weighted fat-saturated (806/20), and (c) sagittal T1-weighted (600/12) images clearly show the complete labral tear (large arrow in a and b) in the anterosuperior part of the labrum and the adjacent loss of articular cartilage (arrowheads) in the anterior part of the left superior acetabulum. Intact femoral cartilage (small arrows in a and b) in the corresponding area also is seen. The contrast material within the joint space is visible only in the area of cartilage loss.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 2. Coronal T1-weighted MR image (800/12) obtained in the contralateral hip of the patient in Figure 1 shows an incomplete tear (white arrow) in the anterosuperior part of the labrum and adjacent loss of articular cartilage (arrowhead) in the right acetabulum. Although surgery revealed no cartilage defects in the femoral head, osteophytes (black arrow) can be seen at the superior border of the femoral head-neck junction.

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Oblique-transverse FLASH MR image (400/11, 60° flip angle) shows a small contrast material-filled femoral cartilage defect (arrowheads) in a 42-year-old woman with early osteoarthritis of the right hip joint. Adjacent cartilage (white arrow) has a hypointense signal. Partial detachment of the anteroinferior acetabular labrum (black arrow) without an adjacent cartilage defect also is seen.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 4a. (a, b) Consecutive oblique-transverse FLASH MR images (400/11, 60° flip angle) show signal intensity alterations within the anterior part of the femoral head cartilage (arrows) in a 48-year-old woman. There was no evidence of a defect at surgery. The small amount of contrast material visible in the joint space is caused by a depression of the hyaline cartilage layer and the underlying subchondral bone (arrowheads) and is not related to thinning or defect of the cartilage layer.

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 4b. (a, b) Consecutive oblique-transverse FLASH MR images (400/11, 60° flip angle) show signal intensity alterations within the anterior part of the femoral head cartilage (arrows) in a 48-year-old woman. There was no evidence of a defect at surgery. The small amount of contrast material visible in the joint space is caused by a depression of the hyaline cartilage layer and the underlying subchondral bone (arrowheads) and is not related to thinning or defect of the cartilage layer.

	DISCUSSION

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Almost all previously published studies (7–11) on MR imaging of cartilage have been focused on the knee joint. Various sequences optimized for cartilage imaging, such as T1-weighted fat-suppressed three-dimensional FLASH (16) and spoiled gradient-echo (8) sequences and the T2*-weighted three-dimensional double-echo steady-state (11) sequence, have yielded high sensitivity (75%–85%) and specificity (94%–97%) in the detection of cartilage abnormalities. Although we used a fat-saturated FLASH sequence that is comparable to the sequences used in some of these investigations (8,16), the sensitivity and specificity that we achieved were lower than those reported for the detection of lesions in the knee. These results may be explained, at least in part, by the thinner cartilage in the hip joint compared with the cartilage in the knee (17), especially the posteroinferior part of the acetabulum. Hodler et al (12) observed hip cartilage to be between 1 and 2 mm in diameter both on MR images and at histologic analysis. In contrast, articular cartilage of the knee may be up to 7 mm in diameter, with the highest values in the patella (12,17). The poor sensitivity in the detection of cartilage damage in the posteroinferior part of the acetabulum in our investigation was probably due to the fact that the readers were well aware of this normal variation in cartilage thickness and accordingly raised their threshold for the diagnosis of articular cartilage lesions.

Another diagnostic problem that is more pronounced in the hip than in other joints is the fact that the acetabular and femoral cartilage surfaces commonly are not differentiated from each other, even at MR arthrography. Traction applied during MR imaging, as performed by Nakanishi et al (3), potentially improves the differentiation between the acetabular and femoral cartilage layers at MR arthrography and thus may improve the detection of cartilage defects. In addition, MR imaging examinations of the knee and other superficially located joints can be performed with dedicated small coils, such as extremity send-receive surface coils. Hip MR imaging examinations, on the other hand, must be performed only with wraparound receive, body array surface, or body coils, the use of which results in a less homogeneous magnetic field and/or a lower signal-to-noise ratio.

Finally, differences in study populations—for example, the patients with severe cartilage damage in the Murphy (11) study versus the patients with mild or moderate cartilage damage in our investigation—may explain the differences in results. This explanation does not always hold true, however: Recht et al (16) evaluated the entire spectrum of cartilage lesions (grades 0–3A) by using a fat-suppressed three-dimensional FLASH sequence without intraarticular contrast agent administration and achieved a sensitivity and specificity of 81% and 97%, respectively.

Establishing a standard of reference for the detection of cartilage damage in the hip joint is difficult because the entire surface of the articular cartilage cannot be inspected during standard surgical procedures. Previously published investigations (12) have involved studies of femoral heads harvested during total hip replacement or cadaveric hips and thus were probably biased owing to the advanced stage of cartilage disease. We were able to use a solid standard of reference in patients without advanced cartilage abnormalities because our hip surgeons dislocate the hip from the acetabulum for certain types of surgery. This procedure has been described in the orthopedic literature by Ganz et al (2) and is technically demanding. Before it is performed, it is important to obtain information regarding the precise diagnosis, including cartilage defects, which have largely increased the clinician’s interest in MR imaging, including MR arthrography of the joint.

One important goal in performing MR imaging is to recognize the cartilage damage that is not seen on radiographs because the cartilage defect either is not extensive enough to cause joint space narrowing that is visible on standard radiographs or is in a position that is not easily depicted on standard radiographs. For instance, posterior and anterior cartilage lesions are not depicted on standard anteroposterior radiographs of the pelvis.

Our study results show, in addition to the moderate sensitivity of MR arthrography in the detection of cartilage damage of the hip joint, that when the diagnosis is based on secondary signs of osteoarthritis, such as subchondral sclerosis, osteophytes, or cysts, the reader tends to overestimate the extent of cartilage damage. In some cases in the present study, large osteophytes without adjacent cartilage damage at MR imaging caused a false-positive interpretation of cartilage defects in the region of the osteophytes (Fig 2). The signal intensity irregularity within the cartilage layer on MR arthrograms could represent an uptake of contrast material within the tissue caused by very early cartilage degeneration, which cannot be seen at surgical inspection of the cartilage surface.

In conclusion, the results of this study demonstrate that cartilage lesions are common in young and middle-aged patients who are suspected of having femoroacetabular impingement and/or labral abnormalities. These defects are most commonly found in the anterosuperior part of the acetabulum. The diagnostic performance of MR arthrography in the detection of articular cartilage damage in the hip joint is inferior to that in the knee joint, presumably because of the relatively thin cartilage in the hip, volume averaging of the cartilage layer with adjacent bone, and intraarticular contrast material due to the spherical shape of the femoral head.

	FOOTNOTES

 
Abbreviation: FLASH = fast low-angle shot

Author contributions: Guarantors of integrity of entire study, M.R.S., J.H.; study concepts, M.R.S., J.H., M.Z.; study design, M.R.S., J.H., M.Z., H.P.N.; literature research, M.R.S.; clinical studies, H.P.N., T.F.W.; data acquisition, M.R.S., T.F.W.; data analysis/interpretation, M.R.S., J.H., M.Z.; statistical analysis, M.R.S., J.H.; manuscript preparation, M.R.S., J.H.; manuscript definition of intellectual content, M.R.S., J.H., H.P.N.; manuscript editing, M.R.S., J.H.; manuscript revision/review, M.R.S., J.H., H.P.N.; manuscript final version approval, all authors.

	REFERENCES

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