Snapping Hip and Impingement

Transcription

1 Snapping Hip and Impingement Jon A. Jacobson, M.D. Professor of Radiology Director, Division of Musculoskeletal Radiology University of Michigan Disclosures: Consultant: Bioclinica Advisory Board: GE, Philips Book Royalties: Elsevier Not relevant to this talk Note: all images from the textbook Fundamentals of Musculoskeletal Ultrasound are copyrighted by Elsevier Inc. Outline Femoroacetabular impingement Ischiofemoral impingement Snapping hip syndrome Hip Labrum Normal: Hyperechoic, triangular Degeneration: hypoechoic Tear: anterior Anechoic cleft Sensitivity 82%, specificity 60%, accuracy 80%* Acetab Labral Tear Femoral Head Chondrocalcinosis Detachment *Jin W et al. J Ultrasound Med 2012; 31:439 Labral Tear and Paralabral Cyst Associated with labral tear Full-thickness or detachment Anechoic to hypoechoic Multilocular Femoroacetabular Impingement Pincer-type: deep acetabulum Cam-type Broad irregular femoral neck Possible cortical irregularity at US Associated with anterior labrum tear Consider dynamic evaluation Radiology 2005; 236:588 Courtesy of D. Fessell, Ann Arbor, MI 1

2 CAM Impingement Note: labral tear (yellow arrow) and osseous bump (white arrow) Courtesy of M. van Holsbeeck, Detroit, MI FAI: Ultrasound Ultrasound can demonstrate a bony protuberance and non-spherical head associated with CAM FAI Alpha angle measurements Buck et al.: unreliable Lerch et al.: strong correlation with MRI Buck FM et al. Eur Radiol 2011; 21:167 Lerch S et al. International Orthopaedics 2013; 37:783 Chondrocalcinosis Femoroacetabular Impingement Total Hip Arthroplasty: Metal components demonstrate posterior reverberation Artifact occurs deep to prosthesis away from fluid collection (unlike MRI, CT) Acet H Neck Femur Sagittal-oblique Hip Arthroplasty: Ultrasound cannot differentiate small effusion from post-op change 1 Suspect infection: Pseudocapsule > 3.2 mm: suspect infection 2 Extra-articular fluid collection Not visualized with arthrography if noncommunication A Head Neck > 3.2 mm 1 Weybright PN et al. AJR 2003; 181:215 Arthroplasty Impingement Anterior cup rim impingement Deep to iliopsoas tendon Ultrasound-guided steroid injection can be considered Wank R et al. J Clinical Ultrasound 2004; 32:354. Acet Acetabular Cup Head Neck 2 AJR 1994; 163:381 2

3 Outline Femoroacetabular impingement Ischiofemoral impingement Snapping hip syndrome Sonographic Technique: Hip Posterior Piriformis Superior gemellus Obturator internus Inferior gemellus Obturator externus Quadratus femoris Sciatic nerve From: Philippon et al. Orth J Sports Med 2014 Hip: external rotators P Obturator Internus Ischiofemoral Impingement P QF OI OI I QF GT Femur Axial Quadratus Femoris I GT External impingement Narrowed space between ischial tuberosity and femur Associations: Coxa valga Variations in bone anatomy Hip and pelvis instability Abductor / adductor muscle imbalance Sagittal Femur Axial OE Hernando ML et al. Skeletal Radiology 2016; 45:771. Ischiofemoral Impingement: MRI criteria Narrowed ischiofemoral space: 15 mm or less 77% sens, 81% spec, 78% accurate Narrowed quadriceps femoris muscle space 10 mm or less 79% sens, 74% spec, 77% accurate Abnormal signal of quadriceps femoris muscle Seen in 9% of asymptomatic individuals Hernando ML et al. Skeletal Radiology 2016; 45:771. Normal Impingement Ischiofemoral Impingement Variations exist in ischiofemoral distance: 1 Narrowed with external rotation and adduction Decreased in prone position Increased with hip flexion Ultrasound of ischiofemoral space measurement equal to MRI 2 Ultrasound guided injection of quadriceps femoris: Corticosteroids 3 Botulinum toxin 4 From: 1 Finnoff JT et al. PMR 2017; 9:392 2 Johnson AC et al. Skeletal Radiology 2017; 46:59 3 Backer MW et al. Am J Roentgenol 2014; 203:589 4 Chen Y-T et al. PMR 2018; 10:665 3

4 Outline Femoroacetabular impingement Ischiofemoral impingement Snapping hip syndrome Snapping Hip Syndrome Painful snap with hip motion Intraarticular Extraarticular: Anterior: iliopsoas tendon Lateral: iliotibial tract or gluteus maximus Iliopsoas Complex Snapping Hip Syndrome: iliopsoas Red: psoas major Orange: medial iliacus fibers Purple: lateral iliacus fibers AIIS Ilium From: Guillin R. et al. Eur Rad 2009; 19:995 Image long axis to inguinal ligament superior to femoral head Extension of flexed abducted and externally rotated hip Abrupt movement of iliopsoas as iliacus muscle interposed between tendon and bone moves Deslandes et al. AJR 2008; 190:576 Snapping Hip Syndrome: iliopsoas Snapping Hip Syndrome: iliopsoas 4

5 Snapping Hip: lateral Transverse over greater trochanter Hip external rotation / flexion Abrupt motion of iliotibial tract or gluteus maximus over greater trochanter Maximus Snapping Maximus / Iliotibial Band Iliotibial Band Medius TFL Medius Glut Max PF LF AF: anterior facet LF: lateral facet PF: posterior facet AF Minimus Snapping Maximus / Iliotibial Band Iliotibial Band Medius TFL Maximus Maximus Gmin Snapping Hip Syndrome: iliotibial tract Iliotibial Band Gmax Gmed Gmin Proximal hamstring: at ischial tuberosity Sciatic Nerve SM Conjoined ST-BF Tendon Sacrotuberous Ligament SM Conjoined Biceps Femoris- Semitendinosus: tendinosis Conjoined BF-ST tendon Lateral Transverse Medial Short Axis Semimembranosus 5

6 Conjoined BF-ST Tendon: partial tear Sacrotuberous Ligament Conjoined BF-ST Tendon Snapping Conjoined Long Head Biceps Femoris, Semitendinosus + Sacrotuberous Ligament Sacrotuberous Ligament BF-ST Ischial Tuberosity Semimembranosus SM From: Bierry et al. Radiology 2014; 271:162 Long Axis Spencer-Gardner LS et al. PMR 2015; 7:1102 From Bierry G et al. Radiology 2014;271:162 Take-home points Femoroacetabular impingement: Indirect ultrasound findings Ischiofemoral impingement: US-guided injection Snapping hip: Iliopsoas anatomy review Dynamic evaluation Syllabus on line and other educational material: Twitter 6