Hi OCADers!
I have a protocol question for the group.
For hip MRI arthrograms, in addition to dedicated imaging of the injected
hip, are you doing limited images of the bilateral hips and bilateral knees
to calculate femoral anteversion? If so, are you doing this for all
patients? Have your surgeons requested this?
The idea is that abnormal femoral anteversion can predispose to labral
tear, and more importantly, repairing the labral tear but not correcting
the rotational pathology may be bad form. The limited MRI images typically
take less than 5 minutes.
Simple yes/no or any comments are appreciated. I will share the responses.
Thanks!
Emad Allam
Loyola University Medical Center
Our hip preservation protocol included
4view hips- AP pelvis, Dunn, frogleg and false profile
Hip MRA with 3D and radial recons
3D CT of hip and knee for version assessment with VR segmentation and radial recons
New protocol as MRA doesnt add anything – as of 2022
4view hips- AP pelvis, Dunn, frogleg and false profile
Hip MRI with 3D and radial recons (no more arthrograms)
3D CT of hip and knee for version assessment with VR segmentation and radial recons
plus/minus MRN LS plexus is complicated history/bilateral hip pain/back pain
Here are the videos for recons if interested
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines, Blvd. Dallas, Tx-75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
EXTERNAL MAIL
Hi OCADers!
I have a protocol question for the group.
For hip MRI arthrograms, in addition to dedicated imaging of the injected hip, are you doing limited images of the bilateral hips and bilateral knees to calculate femoral anteversion? If so, are you doing this for all patients? Have your surgeons requested this?
The idea is that abnormal femoral anteversion can predispose to labral tear, and more importantly, repairing the labral tear but not correcting the rotational pathology may be bad form. The limited MRI images typically take less than 5 minutes.
Simple yes/no or any comments are appreciated. I will share the responses.
Thanks!
Emad Allam
Loyola University Medical Center
Thanks for your responses to this protocol question. Always appreciate the
input from this great group.
There were 11 responses (not including myself). Mixed responses, likely
reflecting heterogeneity of surgeon preference and patient population. 7
said no to MR anteversion measurements, although some of these will do CT
(CT in all cases or only in certain situations/if ordered by surgeon). 4
said yes to MR anteversion measurements, although some of these only apply
to certain protocols/if ordered by surgeon.
Dr. Chhabra, thanks for your protocol and videos as always. Will be great
to see the comparative data on your new non-arthrogram 3D MRI protocol –
always pushing the envelope!
Some other comments:
“T1/Stir coronal pelvis, all hip pain is not from the hip
Scout axial pelvis and knees axial sequences, easy to do, lots of
beneficial info
Have asked techs to do it on all hips, hit or miss if it gets done
Seeing the anteversion/ Angles requested more and more by hip surgeons
Uptick in requests for off/on track measurements on shoulders
Orthopedics must be reading the literature”
“At the group I am now at, we do not do that and have not been asked to do
it. We read for several different ortho groups, too.
“On a related note, there was that recent Vancouver talk about hip
preservation and during the comments, several surgeons spoke. I recall one
in particular saying that he wasn’t sure about all the version stuff and it
was a hard sell with young patients to say they would fix the labrum and
the cam and then break the bone, reset and hope for good heal. He said
most patients want to proceed with the less invasive labral repair and not
fix version. Another talked about how he was unsure how much good this
does as he said most do not return to same level of play.”
“We have bilateral hip/knee sequences to calculate femoral version on our
FAI arthrogram protocol that’s used for young adult cases where labral
pathology or FAI is the principal query.
Outside the FAI population, our routine hip protocol (with or without
arthrogram) does not include a femoral anteversion assessment.
If a patient had a MR arthrogram or adequate 3T hip MRI without the version
sequences performed at St Elsewhere and ends up in the hands of our local
FAI surgeons, the surgeon may ask us to do the femoral version assessment
by CT.”
“Yes, only for the specific patients requested by the hip surgeons.”
“Yes we do this routinely in all hip arthrograms. Our surgeons request it.”
“We don’t do additional images during hip arthrogram.
If they want to measure anteversion they can order a separate CT or MR
exam.”
“No, our surgeons like this via CT so we do both a CT and MR preop.”
Here at Loyola, we do femoral anteversion measurements on all hip
arthrograms. From one of our hip surgeons here at Loyola:
“I definitely appreciate the femoral anteversion measurements and the
protocols you have been using. Typically, acetabular retroversion is
considered a greater harbinger for femoroacetabular impingement and labral
pain, but femoral anteversion still plays a part. If they demonstrate > 30
degrees in the femur, I’ll usually suggest a derotational osteotomy rather
than a simple arthroscopy. Otherwise, I focus on a proper
osteochondroplasty to remove the bony impingement.”
There was a follow-up question “how do you measure femoral version? More
specifically, do you use straight axial or oblique axial through the
femoral neck?”
In our case, we do straight axials for simplicity.
There is a great article by Dr. Potter “MRI for the preoperative evaluation
of femoroacetabular impingement” that also describes this. I am not
including the entire article (not sure if allowed), but here is an excerpt:
“Femoral anteversion (antetorsion) is the angle between the femoral neck
and the femoral condyles. This can be calculated by measuring angles on the
straight or oblique axial images of the femoral neck using a correction
factor, taking into account the relative anteversion or retroversion of the
femoral condyles (Fig.11) [53]. Normal femoral anteversion is approximately
12 to 13 degrees [54, 55]. Femoral retroversion or a relative decrease in
femoral anteversion exacerbates the effect of a cam or pincer lesion, as
impingement may occur with only minimal internal rotation and hip flexion.
Increased anteversion results in reduced external rotation, with the
potential for impaction of the femur on the posterior acetabulum.”
If you have any follow-up comments, please feel free to let me know.
Thanks again!
Emad
On Sat, Aug 6, 2022 at 8:18 AM Avneesh Chhabra < Avneesh.Chhabra@utsouthwestern.edu> wrote:
We looked at 200 hip MRIs recently with more than 50% arthrograms
3D MRI picked up 20% more tears. Some multifocal. The tears are also more conspicuous on 3D. That’s why we don’t do MRA anymore. Our surgeon also believes that many labral tears are below 1 cm and they are missed on 2Ds. He asks us routinely do radial MRI recons of 3D seq as well.
Plus one can measure the labral tears easily.
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines, Blvd. Dallas, Tx-75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
Hi folks,
Thanks for your responses to this protocol question. Always appreciate the input from this great group.
There were 11 responses (not including myself). Mixed responses, likely reflecting heterogeneity of surgeon preference and patient population. 7 said no to MR anteversion measurements, although some of these will do CT (CT in all cases or only in certain situations/if ordered by surgeon). 4 said yes to MR anteversion measurements, although some of these only apply to certain protocols/if ordered by surgeon.
Dr. Chhabra, thanks for your protocol and videos as always. Will be great to see the comparative data on your new non-arthrogram 3D MRI protocol – always pushing the envelope!
Some other comments:
“T1/Stir coronal pelvis, all hip pain is not from the hip
Scout axial pelvis and knees axial sequences, easy to do, lots of beneficial info
Have asked techs to do it on all hips, hit or miss if it gets done
Seeing the anteversion/ Angles requested more and more by hip surgeons
Uptick in requests for off/on track measurements on shoulders
Orthopedics must be reading the literature”
“At the group I am now at, we do not do that and have not been asked to do it. We read for several different ortho groups, too.
“On a related note, there was that recent Vancouver talk about hip preservation and during the comments, several surgeons spoke. I recall one in particular saying that he wasn’t sure about all the version stuff and it was a hard sell with young patients to say they would fix the labrum and the cam and then break the bone, reset and hope for good heal. He said most patients want to proceed with the less invasive labral repair and not fix version. Another talked about how he was unsure how much good this does as he said most do not return to same level of play.”
“We have bilateral hip/knee sequences to calculate femoral version on our FAI arthrogram protocol that’s used for young adult cases where labral pathology or FAI is the principal query.
Outside the FAI population, our routine hip protocol (with or without arthrogram) does not include a femoral anteversion assessment.
If a patient had a MR arthrogram or adequate 3T hip MRI without the version sequences performed at St Elsewhere and ends up in the hands of our local FAI surgeons, the surgeon may ask us to do the femoral version assessment by CT.”
“Yes, only for the specific patients requested by the hip surgeons.”
“Yes we do this routinely in all hip arthrograms. Our surgeons request it.”
“We don’t do additional images during hip arthrogram.
If they want to measure anteversion they can order a separate CT or MR exam.”
“No, our surgeons like this via CT so we do both a CT and MR preop.”
Here at Loyola, we do femoral anteversion measurements on all hip arthrograms. From one of our hip surgeons here at Loyola:
“I definitely appreciate the femoral anteversion measurements and the protocols you have been using. Typically, acetabular retroversion is considered a greater harbinger for femoroacetabular impingement and labral pain, but femoral anteversion still plays a part. If they demonstrate > 30 degrees in the femur, I’ll usually suggest a derotational osteotomy rather than a simple arthroscopy. Otherwise, I focus on a proper osteochondroplasty to remove the bony impingement.”
There was a follow-up question “how do you measure femoral version? More specifically, do you use straight axial or oblique axial through the femoral neck?”
In our case, we do straight axials for simplicity.
There is a great article by Dr. Potter “MRI for the preoperative evaluation of femoroacetabular impingement” that also describes this. I am not including the entire article (not sure if allowed), but here is an excerpt:
“Femoral anteversion (antetorsion) is the angle between the femoral neck and the femoral condyles. This can be calculated by measuring angles on the straight or oblique axial images of the femoral neck using a correction factor, taking into account the relative anteversion or retroversion of the femoral condyles (Fig.11) [53]. Normal femoral anteversion is approximately 12 to 13 degrees [54, 55]. Femoral retroversion or a relative decrease in femoral anteversion exacerbates the effect of a cam or pincer lesion, as impingement may occur with only minimal internal rotation and hip flexion. Increased anteversion results in reduced external rotation, with the potential for impaction of the femur on the posterior acetabulum.”
If you have any follow-up comments, please feel free to let me know.
Thanks again!
Emad
Dear Emad,
Our hip preservation protocol included
4view hips- AP pelvis, Dunn, frogleg and false profile
Hip MRA with 3D and radial recons
3D CT of hip and knee for version assessment with VR segmentation and radial recons
New protocol as MRA doesnt add anything – as of 2022
4view hips- AP pelvis, Dunn, frogleg and false profile
Hip MRI with 3D and radial recons (no more arthrograms)
3D CT of hip and knee for version assessment with VR segmentation and radial recons
plus/minus MRN LS plexus is complicated history/bilateral hip pain/back pain
Here are the videos for recons if interested
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines, Blvd. Dallas, Tx-75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
EXTERNAL MAIL
Hi OCADers!
I have a protocol question for the group.
For hip MRI arthrograms, in addition to dedicated imaging of the injected hip, are you doing limited images of the bilateral hips and bilateral knees to calculate femoral anteversion? If so, are you doing this for all patients? Have your surgeons requested this?
The idea is that abnormal femoral anteversion can predispose to labral tear, and more importantly, repairing the labral tear but not correcting the rotational pathology may be bad form. The limited MRI images typically take less than 5 minutes.
Simple yes/no or any comments are appreciated. I will share the responses.
Thanks!
Emad Allam
Loyola University Medical Center
Attached are some 2D vs 3D MRI cases (pdf as ppt is too big).
Take home- 3D TSE is excellent with 0.7mm-0.8mm isotropic resolution, shows all labral tears and cartilage defects. I routinely show my fellows (several in this forum) how to make recons, measure the labral tears, and do radials. In fact, we are studying patient outcomes and AI correlations, etc.
If you want to learn more about it-welcome to join our 3D MRI session in ARRS 2023 in Hawaii- we will have several speakers incl. our colleague Dr. Thakur who will be speaking on 3D hip MRI.
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor Radiology & Orthopedic Surgery
Chief, Division of Musculoskeletal Radiology
UT Southwestern Medical Center, Dallas, Tx
5373 Harry Hines Blvd.
Dallas, Tx-75390-9178
Office: 214-648-2122
avneesh.chhabra@utsouthwestern.edu<mailto:avneesh.chhabra@utsouthwestern.edu>
http://www.utsouthwestern.edu<http://www.utsouthwestern.edu/>
________________________________
Sent: Sunday, August 14, 2022 12:23 PM
Cc: OCAD-MSK <ocad-msk@googlegroups.com>
Thanks Emad,
We looked at 200 hip MRIs recently with more than 50% arthrograms
3D MRI picked up 20% more tears. Some multifocal. The tears are also more conspicuous on 3D. That’s why we don’t do MRA anymore. Our surgeon also believes that many labral tears are below 1 cm and they are missed on 2Ds. He asks us routinely do radial MRI recons of 3D seq as well.
Plus one can measure the labral tears easily.
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines, Blvd. Dallas, Tx-75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
Hi folks,
Thanks for your responses to this protocol question. Always appreciate the input from this great group.
There were 11 responses (not including myself). Mixed responses, likely reflecting heterogeneity of surgeon preference and patient population. 7 said no to MR anteversion measurements, although some of these will do CT (CT in all cases or only in certain situations/if ordered by surgeon). 4 said yes to MR anteversion measurements, although some of these only apply to certain protocols/if ordered by surgeon.
Dr. Chhabra, thanks for your protocol and videos as always. Will be great to see the comparative data on your new non-arthrogram 3D MRI protocol – always pushing the envelope!
Some other comments:
“T1/Stir coronal pelvis, all hip pain is not from the hip
Scout axial pelvis and knees axial sequences, easy to do, lots of beneficial info
Have asked techs to do it on all hips, hit or miss if it gets done
Seeing the anteversion/ Angles requested more and more by hip surgeons
Uptick in requests for off/on track measurements on shoulders
Orthopedics must be reading the literature”
“At the group I am now at, we do not do that and have not been asked to do it. We read for several different ortho groups, too.
“On a related note, there was that recent Vancouver talk about hip preservation and during the comments, several surgeons spoke. I recall one in particular saying that he wasn’t sure about all the version stuff and it was a hard sell with young patients to say they would fix the labrum and the cam and then break the bone, reset and hope for good heal. He said most patients want to proceed with the less invasive labral repair and not fix version. Another talked about how he was unsure how much good this does as he said most do not return to same level of play.”
“We have bilateral hip/knee sequences to calculate femoral version on our FAI arthrogram protocol that’s used for young adult cases where labral pathology or FAI is the principal query.
Outside the FAI population, our routine hip protocol (with or without arthrogram) does not include a femoral anteversion assessment.
If a patient had a MR arthrogram or adequate 3T hip MRI without the version sequences performed at St Elsewhere and ends up in the hands of our local FAI surgeons, the surgeon may ask us to do the femoral version assessment by CT.”
“Yes, only for the specific patients requested by the hip surgeons.”
“Yes we do this routinely in all hip arthrograms. Our surgeons request it.”
“We don’t do additional images during hip arthrogram.
If they want to measure anteversion they can order a separate CT or MR exam.”
“No, our surgeons like this via CT so we do both a CT and MR preop.”
Here at Loyola, we do femoral anteversion measurements on all hip arthrograms. From one of our hip surgeons here at Loyola:
“I definitely appreciate the femoral anteversion measurements and the protocols you have been using. Typically, acetabular retroversion is considered a greater harbinger for femoroacetabular impingement and labral pain, but femoral anteversion still plays a part. If they demonstrate > 30 degrees in the femur, I’ll usually suggest a derotational osteotomy rather than a simple arthroscopy. Otherwise, I focus on a proper osteochondroplasty to remove the bony impingement.”
There was a follow-up question “how do you measure femoral version? More specifically, do you use straight axial or oblique axial through the femoral neck?”
In our case, we do straight axials for simplicity.
There is a great article by Dr. Potter “MRI for the preoperative evaluation of femoroacetabular impingement” that also describes this. I am not including the entire article (not sure if allowed), but here is an excerpt:
“Femoral anteversion (antetorsion) is the angle between the femoral neck and the femoral condyles. This can be calculated by measuring angles on the straight or oblique axial images of the femoral neck using a correction factor, taking into account the relative anteversion or retroversion of the femoral condyles (Fig.11) [53]. Normal femoral anteversion is approximately 12 to 13 degrees [54, 55]. Femoral retroversion or a relative decrease in femoral anteversion exacerbates the effect of a cam or pincer lesion, as impingement may occur with only minimal internal rotation and hip flexion. Increased anteversion results in reduced external rotation, with the potential for impaction of the femur on the posterior acetabulum.”
If you have any follow-up comments, please feel free to let me know.
Thanks again!
Emad
Dear Emad,
Our hip preservation protocol included
4view hips- AP pelvis, Dunn, frogleg and false profile
Hip MRA with 3D and radial recons
3D CT of hip and knee for version assessment with VR segmentation and radial recons
New protocol as MRA doesnt add anything – as of 2022
4view hips- AP pelvis, Dunn, frogleg and false profile
Hip MRI with 3D and radial recons (no more arthrograms)
3D CT of hip and knee for version assessment with VR segmentation and radial recons
plus/minus MRN LS plexus is complicated history/bilateral hip pain/back pain
Here are the videos for recons if interested
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines, Blvd. Dallas, Tx-75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
EXTERNAL MAIL
Hi OCADers!
I have a protocol question for the group.
For hip MRI arthrograms, in addition to dedicated imaging of the injected hip, are you doing limited images of the bilateral hips and bilateral knees to calculate femoral anteversion? If so, are you doing this for all patients? Have your surgeons requested this?
The idea is that abnormal femoral anteversion can predispose to labral tear, and more importantly, repairing the labral tear but not correcting the rotational pathology may be bad form. The limited MRI images typically take less than 5 minutes.
Simple yes/no or any comments are appreciated. I will share the responses.
Thanks!
Emad Allam
Loyola University Medical Center