Arthroscopic findings of a diagnostic dilemma- hip pathology with normal imaging

Abstract

Background: Patients with groin, hip and pelvic pain but normal findings on MRI and minimal changes on x-ray can be a diagnostic problem. This paper looks at the arthroscopic findings of patients who have had hip pain and a positive response to an intra-articular anaesthetic but have non-contributory imaging. We hypothesized that standard MRI's were missing significant pathology and if there was a response to intra-articular local anaesthesia, pathology found during arthroscopy was likely.

Methods: A retrospective review of all hip arthroscopies performed from March 2011 to January 2015 by two orthopaedic surgeons specializing in hip arthroscopy was conducted to identify patients with clinically suspected intra-articular hip pathology despite a normal MRI report and X-ray. Clinical suspicion of intra-articular hip pathology was confirmed with a positive response to a fluoroscopically guided intra-articular injection of local anaesthetic and corticosteroid. Pathologic findings were collated from the standardised operative notes.

Results: Fifty-three hip arthroscopies performed in 51 patients met the inclusion criteria from a total of 1348 hip arthroscopies performed over a 46-month period. All but one of the 53 (98%) hips had arthroscopically confirmed pathology. Mean patient age was 32.5 years [15 to 67 years] with 40 (78%) females and 11 (22%) males. 92.5% of the hips (49/53) were FADIR (flexion, adduction and internal rotation) positive on clinical examination, giving this test a positive predictive value of 98% (95% CI: 89.31 to 99.67%) for intra-articular pathology.

Conclusions: In patients with a normal MRI without contrast and a positive response (relief of pain) to an intra-articular injection that failed conservative management, there is a 98% chance of intra-articular hip pathology being discovered on hip arthroscopy.

Keywords: Hip arthroscopy; Image-guided injection; Intra-articular hip pathology; Magnetic resonance imaging.

Fig. 1

Combinations of Intra-Articular Pathology Defined at Time of Arthroscopy for Individual Patients. The most frequent pathology combination was a ligamentum teres (LT) tear with associated chondral damage, which was seen as a combination in 21 hips (40%). A combination of all 3 pathologies (LT tear, labral tear and chondral damage) co-existed in 12 hips (23%; also see Table 3 and Additional file 2)

Fig. 2

Total Proportions of Intra-Articular Pathology Identified Arthroscopically. The most common pathology arthroscopically diagnosed in patients with normal imaging was a tear of the ligamentum teres (89% of hips), followed by chondral damage (66%). Labral tears were seen in 20 hips (38%)