Avascular necrosis of left hip

Case contributed by Jack Ren

Presentation

Four year history of multiple sclerosis with multiple courses of methylprednisolone and a recent increase left hip pain.

Patient Data

Age: 47 years
Gender: Female
Modality: X-ray

Pelvis and left hip.

There is mild left sided joint space narrowing with osteophytes including buttressing along the medial neck. Mild left femoral head and neck osteopaenia.

No subchondral lucency or sclerosis of the femoral head. 

The sacroiliac joints and right hip joint are normal.

Initial MRI

Modality: MRI

MRI pelvis and left hip:

Non-contrast study. Images are markedly degraded by motion artefact due to leg spasms and pain. As such, the sequences were also abbreviated.

Abnormal low T1 and high T2 signal within the subchondral weight-bearing aspect of the left femoral head. Although there is some linear low signal at the margin, there is no evidence of subchondral collapse. Abnormality involves approximately 20% of the entire articular surface and more than 50% of the weight-bearing surface of the femoral head.

A moderate joint effusion is also present on this side. Loss of cartilage superiorly with small osteophytes indicates early osteoarthritis. 

The right hip is grossly unremarkable.

Conclusion:

Findings are consistent with avascular necrosis of the left femoral head without subchondral collapse but with early osteoarthritis.

Later MRI

Modality: MRI

There is now more extensive signal abnormality within the left femoral head with a serpiginous contour best seen on the sagittal sequence. The femoral head is flattened but there is no clear collapse. There is progression of the joint space loss and osteophytes in keeping with osteoarthritis. Persisting hip joint effusion.

No evidence of avascular necrosis on the right side.

Case Discussion

Even without a cresent sign or collapse of the femoral head, the presence of osteoarthritis means she is unlikely to do well with core decompression and will likely need a total hip replacement if symptoms are not manageable with conservative therapies.

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Case Information

rID: 29721
Case created: 17th Jun 2014
Last edited: 4th Nov 2015
Inclusion in quiz mode: Excluded

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