Avascular necrosis of femoral head

Case contributed by Dr Muhammad Asadullah Munir

Presentation

Young male with known history of steroid therapy for lupus nephritis. Presented with complain of bilateral hip pain and difficulty in movement.

Patient Data

Age: 25 years
Gender: Male

There is evidence of irregular geographic lucencies, representing subchondral cysts, with marginal sclerosis in both femoral heads. Linear subchondral fracture / fissuring is present in both femoral heads associated with mild collapse/flattening . These findings are representing bilateral avascular necrosis of the hip.

There is large geographic marrow abnormality in antero-superior aspect of femoral head on both sides which appear iso to hypointense on T1, hypointense on T2 and showing subtle loss of signal on T1 FAT SAT images. This is surrounded by hypo-intense rim on T1 & T2W images. There is linear subchondral fracture / fissuring in both femoral heads well appreciated on FAT SAT images. Slight contour deformity with mild collapse/flattening is present bilaterally. These findings are representing bilateral avascular necrosis of the hip. This is categorized as stage D according to mitchells classification.

There are mild secondary degenerative changes at right hip joint with small osteophyte is noted along lateral edge of right acetabulum.

Mild to moderate volume effusion is present in both hip joints.
No dislocation is evident.
Imaged both sacro-iliac joints and symphysis pubis appear normal.
Visualized pelvic viscera and bowel loops are normal.
Small volume free fluid is present in the pelvic peritoneal cavity. Diffuse soft tissue edema is present in anterior abdominal wall as well as in the soft tissues of the pelvis and thigh. Diffuse scrotal wall edema is also appreciated. These findings are due to already diagnosed chronic kidney disease.
 

Case Discussion

This is a typical case of bilateral avascular necrosis of hip with characteristic radiographic and MRI findings. The patient had SLE with lupus nephritis and receiving steroid therapy, all of which predispose to AVN. 

The lesion followed signals on MRI suggestive of fibrosis with occasional minute fatty areas, hence classified as Mitchells grade D. Though bone scan was not done, on the basis of current findings this can be categorized as stage III according to FICAT and stage IV-A as per Steinberg classification systems.

 

Case courtesy: Dr. Jaideep Darira (FCPS, EDIR, FRCR)

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