Hip pain rating after preforming MRI with gadolinium arthrography and intra-articular lidocaine

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1 Hip pain rating after preforming MRI with gadolinium arthrography and intra-articular lidocaine Poster No.: C-1352 Congress: ECR 2014 Type: Scientific Exhibit Authors: J. García Yavar, J. Cabezudo, S. Allodi de la Hoz, P Gamo Villegas, C. del Riego Fernandez-Nespral, S. Santos Magadán ; Madrid/ES, Mostoles/ES, Fuenlabrada (Madrid)/ES, 4 Fuenlabrada/ES Keywords: Outcomes, Inflammation, Epidemiology, Diagnostic procedure, Contrast agent-other, Arthrography, MR, Fluoroscopy, Conventional radiography, Pelvis, Musculoskeletal joint, Musculoskeletal bone DOI: /ecr2014/C-1352 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 33

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3 Aims and objectives In recent years, a strong relationship has been described between femoroacetabular impingement, hip pain and the origin of osteoarthritis in young adults. This syndrome is characterized by the presence of structural alterations at the level of the femoral head-neck transition or at the level of the femoroacetabular anterior-superior flange, creating a problem of space in certain positions of the hip. There are three basic mechanisms of femoroacetabular impingement production: - Type CAM -> The sphericity of the femoral head is altered by the presence of a bony prominence (hump) in the transition between the head and the neck. Fig 1, 2 - Type Pincer -> The sphericity of the femoral head is normal but the femoral neck hits the labrum because of a prominent acetabular wall. Figure 3, 4 - Mixed Type -> A combination of both mechanisms. In up to 70% of the cases we can see this combination with a slight predominance of one of them. The patient refers slow start pain, located in inguinal region, greater trochanter, gluteal or irradiated to the knee. The pain is intermittent and increases after prolonged sitting, minor trauma or long marches. On physical examination, the discomfort can be reproduced by specific tests such as: - Impingement Test. Fig 5 - FABER maneuver (forced abduction and external rotation) Fig 6, 7 The specific pain of the coxofemoral joint may appear on a hip without structural alteration (acetabular labrum injury, chondral defects, etc.) or with structural alterations (type CAM, Pincer or Mixed Impingement, Developmental dysplasia, etc.) The main objective of this work is to correlate the clinical findings in the femoroacetabular impingement with the findings visualized in MR arthrography of the hip, using the intraarticular administration of lidocaine and performing maneuvers that evoke pain before and after administration. Images for this section: Page 3 of 33

4 Fig. 1: : Type CAM Impingement: Side Giba (pistol grip deformity) visible in the AP Page 4 of 33

5 Fig. 2: Type CAM Impingement: anterosuperior Giba visible on the axial plane. Page 5 of 33

6 Fig. 3: Type Pincer Impingement: anterosuperior acetabular retroversion (sign of the loop) Page 6 of 33

7 Fig. 4: Type Pincer Impingement: back focal overwrap. Prominent posterior wall. Page 7 of 33

8 Fig. 5: Impingement Test: pain on flexion maneuver in 90 internal rotation and hip adduction (more specific maneuver for labral injury) Page 8 of 33

9 Fig. 6: F.A.B.E.R. Maneuver (forced abduction and external rotation): In supine position, the affected leg is placed in flexion, abduction and external rotation while the contralateral pelvis is attached. The distance between the knee and the edge of the table is measured. Page 9 of 33

10 Fig. 7: F.A.B.E.R. Maneuver (forced abduction and external rotation): In supine position, the affected leg is placed in flexion, abduction and external rotation while the contralateral pelvis is attached. The distance between the knee and the edge of the table is measured. Page 10 of 33

11 Methods and materials A retrospective study of the findings displayed in MR arthrography of 30 patients who had symptoms of impingement is performed. During the medical visit (pre-test), exercises are performed to evoke pain and quantified by VAS scale. Fig 8 The maneuvers are: - Test of Impingement: pain on flexion maneuver in 90 with internal rotation and hip adduction (more specific maneuver for labral injury). Fig 5 - F.A.B.E.R. Maneuver (forced abduction and external rotation): In supine position, the affected leg is placed in flexion, abduction and external rotation while the contralateral pelvis is attached. The distance between the knee and the edge of the table is measured. Fig 6, 7 Then a 20ml syringe is prepared containing this solution: ml of Gadolinium. - 2 ml Lidocaine. - 5 ml of iodinated contrast ml of saline. Fig 9 The patient should be in supine position with the leg in slight internal rotation which allows positioning the femoral neck in the coronal plane and facilitates puncture. Fig 10 Using fluoroscopy, the puncture site is located by a metal marker (anterior aspect of the femoral head-neck junction). Fig 11, 13 With a permanent marker the puncture site is marked on the skin (we recommend not to puncture at the dot marked on the skin because it leaves a permanent mark). A careful cleaning of the puncture area is performed. A 22G spinal needle is used and it is introduced until it contact with the femoral head. In our center we use a 3-step key extender which is connected to the needle and the syringe to administer intra-articular contrast. This way the contrast injection is performed more comfortably. Then, by fluoroscopy, we verified if the contrast is placed intraarticular so we can go on injecting the solution. Fig 12, 14 Finally we quantified by VAS scale the pain after the procedure. Fig 8 After the findings on MRI Arthrogram it was found that some patients had more than one pathology. When this occurred, the patients were included in both groups so the results may overlap. Page 11 of 33

12 The maneouvers preformed (Test of Impingement and FABER maneuver), is not specific for the diagnose of femoroacetabular impingement, been more specific for the evaluation of the sacroiliac joints. This can also be a problem when assessing pain reduction after contrast and lidocaine administration as it is not specific to the impingement. Using the results of the MRI Arthrogram, the patients were divided into the following groups: - Impingement ( CAM / Pincer / Mixed ) - Osteoarthritis - Labrum lesion Pain difference) is calculated (depending on the VAS scale) before and after contrast injection. We study if there are significant differences comparing means using the SPSS program with a T -student for independent samples. Images for this section: Fig. 8: VAS scale (visual analogue scale) Page 12 of 33

13 Fig. 9: Materials for intra-articular injection of contrast. Page 13 of 33

14 Fig. 10: Intraarticular contrast injection guided by fluoroscopy. Step 1: Displaying the correct position of the patient. Page 14 of 33

15 Fig. 11: Intraarticular contrast injection guided by fluoroscopy. Step 2: Location of the puncture site. Page 15 of 33

16 Fig. 12: Intraarticular contrast injection guided by fluoroscopy. Step 3: Confirmation that the contrast is within the intra-articular joint. Page 16 of 33

17 Fig. 13: X-Ray marking the puncture site. Page 17 of 33

18 Fig. 14: X-Ray with intrarticular contrast. Page 18 of 33

19 Results A group of 30 patients with symptoms of impingement were divided according to the findings displayed in MRI Arthrogram. In 17 patients (56.6%) the findings on MRI suggest impingement (CAM / Pincer / Mixed), while in the remaining 13 (43.3% ) there were no clear signs of this disease. Fig.15 Within the impingement group, the EVA difference before and after intra-articular contrast administration was of 2.29, while in the group without this pathology was This difference is not statistically significant (p> 0.05). Fig. 16 These findings confirm the clinical maneuvers for the diagnosis of impingement are nonspecific since there is a 43.3 % of patients with symptoms of impingement that is not confirmed by MRI Arthrogram.. Fig. 21, Fig. 22., Fig. 23 In 10 patients (33.3 %) the findings on MRI suggest osteoarthritis (cartilage lesions), while in the remaining 20 (66.6 %) there were no clear signs of this disease. Fig. 17 Whitin the osteoarthritis group, the EVA difference before and after intra-articular contrast administration was of 2.40, while in the group without this pathology was This difference is not statistically significant (p> 0.05). Fig. 18 In our study, patients with signs of osteoarthritis may also have other pathologies. Fig. 24 In 14 patients (46.6%) the findings on MRI suggest labrum lesion, while in the remaining 16 (53.3%) there were no clear signs of this disease. Fig. 19 Whitin the labrum lesion group, the EVA difference before and after intra-articular contrast administration was of 2.93, while in the group without this pathology was This difference if statistically significant (p < 0.05). Fig. 20 This finding correlates with the described by Ribas et al. referring that In case of positive pain after the "Test of Impingement", the absence of pain when repiting the manuever after the administration of intrarticular contrast with lidocain is diagnostic. Fig. 25, Fig. 26 Images for this section: Page 19 of 33

20 Fig. 15: Patients with findings consistent with Impingement (CAM, Pincer and Mixed) in MRI Arthrogram. Page 20 of 33

21 Fig. 16: VAS differences in patients with Impingement diagnosis by MRI Arthrogram. Page 21 of 33

22 Fig. 17: Patients with findings consistent with osteoarthritis in MRI Arthrogram. Page 22 of 33

23 Fig. 18: VAS differences in patients with osteoarthritis diagnosis by MRI Arthrogram. Page 23 of 33

24 Fig. 19: Patients with findings consistent with labrum injury in MRI Arthrogram. Page 24 of 33

25 Fig. 20: : VAS differences in patients with labrum lesion diagnosis by MRI Arthrogram. Page 25 of 33

26 Fig. 21: Coronal oblique SE, T1, FatSat right. Acetabular Overcoverage. Page 26 of 33

27 Fig. 22: Coronal oblique SE, T1, FatSat left. Chondral lesion and type CAM impingement, labrum without injury. Page 27 of 33

28 Fig. 23: Coronal oblique SE, T1, FatSat left. Impact of the labrum with a small hump at the junction of the femoral head and neck. Page 28 of 33

29 Fig. 24: Coronal oblique SE, T1, FatSat left. Small areas of increased signal in the articular cartilage compatible with cartilage lesions. Page 29 of 33

30 Fig. 25: Coronal oblique SE, T1, FatSat right. Intrarticular contrast between acetabulum and labrum, compatible with labrum lesion. Page 30 of 33

31 Fig. 26: Coronal oblique SE, T1, FatSat right. Hyperintense image located in the superior labrum with intraarticular contrast between the labrum and the acetabulum. Findings correspond to labrum lesion. Page 31 of 33

32 Conclusion Following administration of lidocaine and contrast, we observed that patients had less pain overall. Only in the group labrum ruptura, VAS differences were statistically significant. In the case of impingement and arthrosis, we believe that the sample is too small to observe significant differences. Personal information References References. Fig 27 Images for this section: Fig. 27: References Page 32 of 33

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