INTERESTING IMAGE

Acetabular Impingement on Planar and SPECT Bone Scintigraphy
Kevin P. Banks, MD, and Won S. Song, MD

Abstract: A 37-year-old male presented with 4 months of atraumatic left hip pain. Onset of symptoms began during basic military training and pain was exacerbated by physical activity. Plain film radiographs of the hip were reported as normal. Because of the concern for a potential stress fracture, the patient was referred to nuclear medicine for bone scintigraphy. Planar and SPECT imaging revealed the presence of abnormal scintigraphic activity involving both hips (left greater than right) in a distribution atypical for stress injury and more consistent with bilateral femoral acetabular impingement (FAI). Subsequent MR examination was confirmed the diagnosis. This case illustrates a novel method for evaluating the physiologic process of FAI. Key Words: scintigraphy, hip pain, femoroacetabular impingement (FAI) (Clin Nucl Med 2008;33: 916 –919)
Received for publication January 22, 2008; revision accepted May 19, 2008. From the Departments of Radiology and Nuclear Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas. Reprints: Dr. Kevin P. Banks, MD, Departments of Radiology and Nuclear Medicine, Brooke Army Medical Center, 3851 Roger Brooke Dr, Fort Sam Houston, TX 78234. E-mail: KPBanks@gmail.com. Copyright © 2008 by Lippincott Williams & Wilkins ISSN: 0363-9762/08/3312-0916

REFERENCES
1. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular impingement: radiographic diagnosis—what the radiologist should know. AJR Am J Roentgenol. 2007;188:1540 –1552. 2. James SL, Ali K, Malra F, et al. MRI findings of femoroacetabular impingement. AJR Am J Roentgenol. 2006;187:1412–1419. 3. Murphy S, Tannast M, Kim YJ, et al. Debridement of the adult hip for femoroacetabular impingement. Clin Orthop Relat Res. 2004;429:178 –181. 4. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112–120. 5. Banks KP, Grayson DE. Acetabular retroversion as a rare cause of chronic hip pain: recognition of the “figure-eight” sign. Skeletal Radiol. 2007;36:S108 –S111. 6. Kassarjiau A, Yoon LS, Belzile E, et al. Triad of MR arthrographic findings in patients with cam-type femoroacetabular impingement. Radiology. 2005;236:588 –596. 7. Tong KM, Lee TS, Lin YM, et al. Cam and pincer impingements rarely occur in isolation. Radiology. 2007;244:625– 626. 8. Pfirrmann CW, Mengiardi B, Dora C, et al. Cam and pincer femoroacetabular impingement: characteristic MR arthrographic findings in 50 patients. Radiology. 2006;240:778 –785. 9. Maheshwari AV, Malik A, Dorr LD. Impingement of the native hip joint. J Bone Joint Surg Am. 2007;89:2508 –2518.

916

Clinical Nuclear Medicine • Volume 33, Number 12, December 2008

Clinical Nuclear Medicine • Volume 33, Number 12, December 2008

Physiologic Process of Femoral Acetabular Impingement

FIGURE 1. Planar bone scintigraphy of the hips and pelvis was performed in a 37-year-old male soldier with unremitting left hip pain and an unremarkable radiographic examination. Magnification views in the (A) anterior and (B) posterior positions show abnormal scintigraphic activity involving the superolateral portion of the acetabula bilaterally and the lateral margin of the left femoral head. No abnormal activity is present in the femoral necks or pelvic bones concerning the clinically suspected diagnosis of stress fracture.

FIGURE 2. SPECT bone scintigraphy in the (A) coronal and (B) axial views better depict the abnormal osteoblastic activity involving the superolateral region of the bilateral acetabula (left greater than right) and lateral left femoral head. SPECT images of the femoral necks and pelvic bones were again unremarkable (not shown). Given the age of the patient, absence of trauma, and distribution of findings, entities such as stress fracture, traumatic fracture, tumor, or arthritides were excluded. Femoroacetabular impingement was suggested, and the recommendation was made for further evaluation with magnetic resonance imaging (MRI).

© 2008 Lippincott Williams & Wilkins

917

Banks and Song

Clinical Nuclear Medicine • Volume 33, Number 12, December 2008

FIGURE 3. A, AP radiograph of the left hip was originally interpreted as normal. B, Focused review after the bone scan reveals a subtle bony prominence of the lateral aspect of the femoral head (arrow) with subchondral lucency and mild irregularity and sclerosis of the superolateral acetabulum. These abnormalities are characteristic for the cam type of femoral acetabular impingement (FAI).1,2 Femoral acetabular impingement has recently been recognized as the most common cause of end-stage osteoarthritis (OA) of the hip in young men and a frequent source of OA in young women.3 Caused by deformity of the femoral head or acetabulum, FAI is usually seen in young, active adults between ages 20 to 50 years and presents with slow onset of groin pain without antecedent trauma.1,2,4 Pain is often exacerbated by activity and/or the sitting position and is associated with a restricted range of motion, particularly flexion, and internal rotation.1 On physical examination, symptoms can usually be reproduced with movements that lead to abutment of the femoral head and neck junction with the anterior acetabular rim. This is done by flexing the hip to 90-degrees and then internally rotating it. If pain is elicited, the maneuver is positive for anterior impingement.5 Two distinct forms of FAI have been described, cam and pincer impingement. The cam type is the femoral form of FAI and is secondary to an aspherical head or osseous prominence at the anterolateral junction of the femoral head and neck, as seen in this patient.6 Young, physically active men are most typically afflicted, with the average age of diagnosis being 32 years.2 Chronic abutment of the abnormally shaped femoral head with the acetabular margin results in shearing forces that lead to chondral and labral injury.2 Because of the mechanism, cartilage damage is commonly focal and quite severe. In reality, the 2 forms are commonly seen in combination.7 The pincer form is the acetabular form of FAI. It is due to over-coverage by the acetabulum. This can be seen with chronic or acquired dysplasias such as acetabular retroversion, acetabuli protrusio or following acetabular reorientation procedures.1,5,6 In contrast to the cam type, the pincer type of FAI is most frequently encountered in middle-aged women.4 Similar to the cam form, recurrent impact between the acetabulum and femoral head yields chondral injury and degeneration of the labrum; however, cartilage damage is more circumferential and less extensive.1,5 Imaging assessment of FAI begins with standard radiographs. Plain films often appear normal; however, close review may reveal some characteristic findings such as a bony prominence on the anterolateral head and neck junction of the femur and degenerative changes of the acetabulum such as subchondral cysts/sclerosis, os acetabuli, or rim ossification.4 FAI is often bilateral but may present asynchronously and therefore, examination of both hips should be considered.1

918

© 2008 Lippincott Williams & Wilkins

Clinical Nuclear Medicine • Volume 33, Number 12, December 2008

Physiologic Process of Femoral Acetabular Impingement

FIGURE 4. MRI of the left hip in the coronal view using (A) short tau inversion recovery (STIR) and (B) fat saturated T2weighted technique confirms subchondral edema in the lateral margin of the femoral head (arrow) and the superolateral margin of the acetabulum (arrowhead). C, Coned-down STIR view shows the adjacent labral tear (dashed arrow), which is also present. This combination of findings is classic MRI features of FAI.2 MRI and MR arthrography have proved to be useful tools in the evaluation of FAI given its excellent soft tissue contrast and resolution. In addition to identifying any underlying predisposing anatomic abnormalities, it can distinguish the early chondral changes and labral injuries before irreversible changes affect the joint.8 The classic triad of features is abnormal headneck morphology, anterosuperior cartilage abnormality, and anterosuperior labral abnormality, which will be seen in the majority of afflicted patients.6 Hip impingement is a mechanical problem, and nonoperative measures will not eliminate the pathomechanics of structural deformities.9 Thus, although modification of activity, restriction of athletic pursuits, and reduction of excessive motion and demand on the hip can be attempted as conservative measures, definitive treatment of FAI is surgical.9 Debridement of the hip may not only relieve symptoms but can also slow or halt the progression of arthrosis.3 It is important to identify the type of FAI because surgical treatment differs for each type. For cam FAI, the surgical goal is to reshape the femoral waist and restore the spherical shape of the femoral head. In instances of pincer FAI, the surgical approach is to reduce acetabular overcoverage by trimming the acetabular rim.8

© 2008 Lippincott Williams & Wilkins

919

Sign up to vote on this title
UsefulNot useful