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DOI:10.2214/AJR.07.2080
AJR 2007; 189:437-445
© American Roentgen Ray Society


Original Research

Septic Arthritis Versus Transient Synovitis of the Hip: Gadolinium-Enhanced MRI Finding of Decreased Perfusion at the Femoral Epiphysis

Kyu-Sung Kwack1, Jae Hyun Cho1, Jei Hee Lee1, Jae Ho Cho2, Ki Keun Oh3 and Sun Yong Kim1

1 Department of Radiology, Ajou University Medical Center, Wonchun Dong, Yongtong Gu, Suwon 442-721, Republic of Korea.
2 Department of Orthopaedic Surgery, Ajou University Medical Center, Suwon, South Korea.
3 Department of Radiology, Yonsei University College of Medicine, Seoul, Korea.

Received December 10, 2006; accepted after revision February 26, 2007.

 
Address correspondence to J. H. Cho (choj{at}ajou.ac.kr).


Abstract
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
OBJECTIVE. The purpose of this study was to identify differences in the MRI findings of septic arthritis and transient synovitis in patients with nontraumatic acute hip pain and hip effusion.

MATERIALS AND METHODS. The MRI findings in nine patients with septic arthritis and 11 with transient synovitis were reviewed retrospectively. This study was approved by our institutional review board. The diagnoses were based on findings at physical examination, laboratory studies, and joint aspiration and bacteriologic study. The MRI findings were analyzed with emphasis on the grade of joint effusion, alterations in signal intensity in the soft tissues and bone marrow, and the presence of decreased perfusion at the femoral head.

RESULTS. Low signal intensity on fat-suppressed gadolinium-enhanced T1-weighted coronal MRI suggesting decreased perfusion at the femoral head of the affected hip joint was seen in eight of nine patients with septic arthritis and in two of 11 patients with transient synovitis. Statistically reliable differences (p = 0.005) were found between the two groups. Alterations in signal intensity in the bone marrow were seen in three patients with septic arthritis but in none of the patients with transient synovitis. Decreased perfusion on fat-suppressed gadolinium-enhanced coronal T1-weighted MRI was seen in the six patients with septic arthritis who did not have alterations in signal intensity involving the bone marrow.

CONCLUSION. Decreased perfusion at the femoral epiphysis on fat-suppressed gadolinium-enhanced coronal T1-weighted MRI is useful for differentiating septic arthritis from transient synovitis.

Keywords: hip • MRI • septic arthritis • transient synovitis


Introduction
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Septic arthritis and transient synovitis are the two most common diseases among young patients with acute hip pain [1, 2]. However, these two diseases have similar early symptoms: spontaneous onset of progressive hip, groin, or thigh pain; limp or inability to bear weight; fever; and irritability [3-5]. Transient synovitis, a self-limited disease with no known long-term sequelae, is managed with oral analgesics and observation [2, 6]. Septic arthritis of the hip necessitates emergency surgical drainage and concomitant administration of IV antibiotics [2, 7-9]. Transient synovitis of the hip is common among children but can also develop in adults [5, 7, 10-13].

Various clinical, laboratory, and radiographic criteria are used to differentiate septic arthritis from transient synovitis, but no absolute values are sufficient for definitive diagnosis of either condition [2, 5]. MRI has become increasingly important in evaluating musculoskeletal infections in children [14-17]. MRI should aid in the differential diagnosis of these two diseases. While reviewing the MRI results of patients with hip pain, we suspected that a hip affected by sepsis had decreased perfusion in the femoral head, whereas a hip affected by transient synovitis did not. Therefore, we performed a retrospective review of hip MRI of patients with proven septic hip and transient synovitis to evaluate the decrease in perfusion of the femoral head and to find radiologic features that differentiate these two diseases.


Materials and Methods
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Patients
A PACS search with the keywords "septic arthritis" and "transient synovitis" in the history fields was conducted to find the medical records of patients who had undergone hip MRI for acute hip pain at our tertiary care hospital between August 2003 and August 2006. Twenty cases of a final diagnosis of transient synovitis or septic arthritis of the hip were collected and reviewed retrospectively in terms of patient age, sex, disease history, clinical findings, radiographic findings on MRI, laboratory studies, and the results of arthrocentesis. Patients with trauma, later development of rheumatologic disease, avascular necrosis of the femoral head, or Legg-Calvé-Perthes disease were excluded. Our study included nine patients (five men and boys, four women and girls; mean age, 13 years; range, 10 months-48 years) with septic arthritis and 11 patients (six boys and men, five women and girls; mean age, 5 years 3 months; range, 12 months-9 years) with transient synovitis. The mean interval between symptom onset and MRI was 12 days (range, 2-33 days) for patients with transient synovitis and 14.3 days (range, 7-20 days) for patients with septic arthritis.

Diagnosis
In eight cases of septic arthritis, the diagnosis was made when a bacterial culture after arthrocentesis had a positive result. In the other case, the diagnosis was based on the presence of purulent synovial fluid and a high WBC count [2, 5]. Arthrocentesis was performed on all patients with septic arthritis. The diagnosis of true septic arthritis (eight patients) was made when a patient had a positive result of joint fluid culture or a joint fluid WBC count of at least 50,000 cells/µL with positive results of blood cultures [5, 18]. The diagnosis of presumed septic arthritis (one patient) was made when a patient had a joint fluid WBC count of at least 50,000 cells/µL with negative results of cultures of joint aspirate and blood [5, 18].

Synovial fluid was cultured for four of the 11 patients with transient synovitis, and all culture results were negative. Arthrocentesis was not performed in seven patients with transient synovitis. The diagnosis of transient synovitis (11 patients) was made when the patient had a joint fluid WBC count less than 50,000 cells/µL with negative culture results, symptom resolution with conservative treatment, and no further development of disease documented in the medical records.

MRI
One of two 1.5-T MRI units (Signa, GE Healthcare) was used for hip MRI. Whether a body or a head coil was used depended on the patient's size. The following imaging parameters were used: TR/TE, 400-800/9-14 for T1-weighted spin-echo imaging, 3,500-4,000/65-75 (effective) with an echo-train length of 8 for T2-weighted fast spin-echo imaging, and 400-800/9-14 for gadolinium-enhanced T1-weighted spin-echo imaging. A fat-suppression technique based on frequency-selective excitation was used for T2-weighted fast spin-echo imaging and gadolinium-enhanced T1-weighted spin-echo imaging. For both T1- and T2-weighted images the parameters were a 3.0- to 7.0-mm section thickness with 0- to 2.5-mm intersection gap, 2-4 signals acquired, and a 256 x 192 or 256 x 256 matrix. The field of view was 180-340 mm depending on body size and section planes. Axial and coronal images were obtained with each pulse sequence. Axial and coronal T1-weighted spin-echo images were obtained after IV administration of gadopentetate dimeglumine (Magnevist, Schering) 0.1 mmol/L per kilogram of body weight. In our study, MRI was performed before arthrocentesis in all cases. Contrast-enhanced MRI was started 1 minute after contrast administration, and acquisition of coronal T1-weighted spin-echo images was started within 5 minutes (mean, 2.6 minutes) after contrast administration in all cases.

Two musculoskeletal radiologists blinded to the diagnoses retrospectively evaluated the MRI results in consensus regarding the grade of joint effusion, presence of synovial thickening, alterations in signal intensity of soft tissue and bone marrow in the affected hip joint, and decreased femoral head perfusion in each pulse sequence. Joint effusion was classified according to the system of Lee et al. [17] and Mitchell et al. [19]: 0, no effusion; 1, minimal effusion; 2, effusion surrounding the femoral neck; 3, distention of the capsular recesses. Synovial thickening and decreased femoral head perfusion of the affected hip were compared with the findings in the contralateral hip.

Statistical Analysis
Fisher's exact test and the Mann-Whitney U test were used for the statistical analysis. Receiver operating characteristic curves were obtained for decreased perfusion (SPSS 12.0.0).


Results
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Decreased Perfusion at Femoral Epiphysis on Fat-Suppressed Contrast-Enhanced T1-Weighted Images
Decreased perfusion at the femoral head was seen on fat-suppressed gadolinium-enhanced T1-weighted images in eight (89%) of nine patients with septic arthritis (Figs. 1A, 1B, 1C, 2A, 2B, 2C, 2D and 3A, 3B, 3C) but in only two (18%) of 11 patients with transient synovitis (Fig. 4A, 4B, 4C, 4D). The difference was significant (p = 0.005). The sensitivity and specificity for the diagnosis of septic hip were 89% and 82%, respectively.


Figure 1
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Fig. 1A —9-year-old girl with septic arthritis of right hip. Coronal T1-weighted spin-echo MR image (TR/TE, 617/14) shows no abnormal signal intensity in bone marrow.

 

Figure 2
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Fig. 1B —9-year-old girl with septic arthritis of right hip. Coronal fat-suppressed T2-weighted fast spin-echo MR image (4,000/64) shows grade 2 effusion (arrows) in right hip joint.

 

Figure 3
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Fig. 1C —9-year-old girl with septic arthritis of right hip. Coronal fat-suppressed gadolinium-enhanced T1-weighted spin-echo MR image (550/14) shows low signal intensity (arrow) of right femoral head compared with contralateral femoral head and enhancement of synovial membrane (arrowheads) around right hip joint.

 

Figure 4
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Fig. 2A —11-year-old boy with septic arthritis of right hip. Coronal T1-weighted spin-echo MR image (TR/TE, 450/14) shows no abnormal signal intensity in bone marrow of proximal portion of right femur or in pelvis.

 

Figure 5
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Fig. 2B —11-year-old boy with septic arthritis of right hip. Coronal fat-suppressed T2-weighted fast spin-echo MR image (4,100/66) shows grade 2 effusion (arrows) in right hip joint.

 

Figure 6
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Fig. 2C —11-year-old boy with septic arthritis of right hip. Coronal fat-suppressed gadolinium-enhanced T1-weighted spin-echo MR image (417/14) shows low signal intensity (arrow) of right femoral head compared with left femoral head and no abnormal enhancement of proximal portion of femur or of pelvic bone.

 

Figure 7
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Fig. 2D —11-year-old boy with septic arthritis of right hip. Axial MR image (417/14) shows low signal intensity of femoral epiphysis (arrows) but not as clearly as do coronal images.

 

Figure 8
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Fig. 3A —27-year-old woman with septic arthritis of left hip. Coronal T1-weighted spin-echo MR image (TR/TE, 550/14) shows no abnormal low signal intensity in bone marrow of proximal portion of left femur or of pelvis.

 

Figure 9
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Fig. 3B —27-year-old woman with septic arthritis of left hip. Coronal fat-suppressed T2-weighted fast spin-echo MR image (4,000/67) shows grade 2 effusion (arrows) in left hip joint. Abnormal high signal intensity of either proximal portion of left femur or of pelvis is not evident.

 

Figure 10
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Fig. 3C —27-year-old woman with septic arthritis of left hip. Coronal fat-suppressed gadolinium-enhanced T1-weighted spin-echo MR image (467/14) showed relatively low signal intensity (arrow) of left femoral head compared with right femoral head. Abnormal enhancement of bone marrow is not evident.

 

Figure 11
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Fig. 4A —2-year-old girl with transient synovitis of left hip. Coronal T1-weighted spin-echo MR image (TR/TE, 550/14) shows no abnormal alteration of signal intensity in bone marrow.

 

Figure 12
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Fig. 4B —2-year-old girl with transient synovitis of left hip. Coronal fat-suppressed T2-weighted fast spin-echo MR image (4,100/75) shows grade 3 effusion (arrow) in left hip joint. Abnormal high signal intensity of soft tissue around left hip joint is evident.

 

Figure 13
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Fig. 4C —2-year-old girl with transient synovitis of left hip. Axial fat-suppressed T2-weighted fast spin-echo MR image (4,100/75) shows high signal intensity of soft tissue around proximal portion of left femur (arrows).

 

Figure 14
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Fig. 4D —2-year-old girl with transient synovitis of left hip. Coronal fat-suppressed gadolinium-enhanced T1-weighted spin-echo MR image (500/14) shows lower signal intensity of left femoral head than of right femoral head (arrow). Synovial thickening appears as thicker enhancing rim of synovium (arrowheads).

 
Decreased perfusion of the femoral head was more prominent in the epiphyseal region of the proximal femur and was more easily identified on contrast-enhanced coronal images (Fig. 2A, 2B, 2C, 2D). Among the nine cases of septic arthritis, decreased perfusion at the femoral head was seen in six patients who had no visible alteration in signal intensity of bone marrow (Table 1).


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TABLE 1: Data on Nine Patients with Septic Arthritis

 

Altered Bone Marrow Signal Intensity
Low signal intensity was seen in the bone marrow of the affected hip on unenhanced T1-weighted images, whereas high signal intensity was seen on fat-suppressed T2-weighted images and on contrast-enhanced T1-weighted images. In addition to the change in signal intensity at the femoral head, altered signal intensity was seen in the bone marrow of the proximal femur or pelvic bone of the affected hip in three of the nine patients with septic arthritis (Table 1). No alteration in the signal intensity of bone marrow was seen in the patients with transient synovitis, although the difference between the two groups was not significant (p = 0.074).

Altered Soft-Tissue Signal Intensity
The soft tissues around the affected hip were seen as poorly defined areas of high signal intensity on fat-suppressed T2-weighted images and on contrast-enhanced T1-weighted images. Alterations in soft-tissue signal intensity occurred mainly within the muscles around the affected hip and were seen in six of the nine patients with septic arthritis and in four of the 11 patients with transient synovitis. The difference between the groups was not significant (p =0.370).

Grade of Joint Effusion
Joint effusion was seen on coronal fat-suppressed contrast-enhanced images and was easier to grade on those images (Figs. 4A, 4B, 4C, 4D and 5A, 5B, 5C). Four of the patients with septic arthritis had grade 3 and five had grade 2 joint effusion. Seven of the patients with transient synovitis had grade 3 and four had grade 2 effusion of the affected hip. The difference between the two patient groups was not significant (p = 0.403).


Figure 15
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Fig. 5A —6-year-old girl with transient synovitis of left hip. Coronal T1-weighted spin-echo MR image (TR/TE, 550/14) shows no abnormal alteration of signal intensity in bone marrow in proximal portion of left femur or in pelvis.

 

Figure 16
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Fig. 5B —6-year-old girl with transient synovitis of left hip. Fat-suppressed T2-weighted fast spin-echo MR image (4,000/75) shows grade 2 effusion (arrowheads) in left hip joint. Abnormal high signal intensity is not evident in proximal portion of left femur or in pelvis.

 

Figure 17
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Fig. 5C —6-year-old girl with transient synovitis of left hip. Fat-suppressed gadolinium-enhanced T1-weighted spin-echo MR image (450/14) shows no difference in signal intensity between right femoral head and left femoral head (arrows). Abnormal enhancement of bone marrow is not evident.

 
Synovial Thickening
An enhancing thick rim of inflamed synovial membrane was differentiated from the hypointense effusion on contrast-enhanced images (Fig. 4A, 4B, 4C, 4D). On fat-suppressed contrast-enhanced images, synovial thickening of the affected hip compared with the contralateral hip was seen in five of the nine patients with septic arthritis and in five of the 11 patients with transient synovitis. The difference was not significant (p = 1.000).

Laboratory Studies
In the nine patients with septic arthritis, the mean peripheral WBC count was 14.32 x 109/L (range, 3.44-22.78 x 109/L), the erythrocyte sedimentation rate was 34.3 mm/h (range, 2-74 mm/h), and the C-reactive protein concentration was 6.05 mg/dL (range, 1.02-19.66 mg/dL). In 10 of the patients with transient synovitis, the respective values were 9.2 x 109/L (range, 3.74-19.42 x 109/L), 31.2 mm/h (range, 7-75 mm/h), and 3.07 mg/dL (range, 0.28-12.9 mg/dL). No laboratory examination was performed for the last patient with transient synovitis, who recovered with conservative treatment.


Discussion
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 
Various ways have been reported for differentiating septic arthritis and transient synovitis of the hip [1-3, 5, 10, 17, 18]. Discriminating these two diseases is difficult but important. Several studies [3, 5, 18, 20] have been focused on differentiating septic arthritis from transient synovitis of the hip in children. Kocher et al. [5] used retrospective data to develop a clinical prediction algorithm for differentiating the two conditions. Lee et al. [17] and Jung et al. [1] also reported radiologic findings that differentiated these diseases. Nevertheless, the ability to predict septic arthritis is minimal [2, 5, 10].

An interesting finding in our patients was decreased perfusion at the femoral epiphysis on fat-suppressed contrast-enhanced T1-weighted MRI. These perfusion defects were more prominent in the epiphyseal region and were easier to identify on coronal than on axial images. Lee et al. [17] reported signal intensity alterations in the bone marrow of the affected hip, especially high signal intensity on fat-suppressed contrast-enhanced T2-weighted MRI. In retrospect, the images in that study also showed decreased perfusion at the femoral head, but the authors did not mention this feature. We believe it might have been difficult for the investigators to recognize the finding because only axial plane images were obtained or because the hip joint was evaluated unilaterally.

Uren and Howman-Giles [21] reported that the cold hip sign is often seen on bone scans of patients referred with irritable hip and that this sign is present when fluid under pressure in the hip joint impairs perfusion of the structures in the joint capsule. Avascular necrosis of the femoral head is a well-known complication of septic arthritis. Vidigal et al. [22] found that early diagnosis and management of infection are mandatory in the care of patients with pyogenic arthritis and increased intraarticular hydrostatic pressure and in those with septic thrombosis of the epiphyseal vessels, which can cause avascular necrosis. In evaluation of bone scans, Williamson and Sistrom [23] found femoral and acetabular photopenia associated with septic arthritis of the hip.

Yang et al. [24] reported that decreased enhancement of the femoral head is frequently seen on images of patients with septic arthritis, but they did not find a statistical difference. In our study, eight patients with septic arthritis had decreased perfusion at the femoral head on fat-suppressed contrast-enhanced T1-weighted MRI. Only two of 11 patients with transient synovitis had decreased perfusion. In our study, MRI was started 1 minute after contrast administration, and acquisition of coronal T1-weighted spin-echo images was started within 5 minutes after contrast administration in all cases. All MRIs in our study were performed before arthrocentesis.

The area under the receiver operating characteristic curve for predicting septic arthritis was 0.854. Although two patients in the transient synovitis group had this finding, decreased perfusion at the femoral head is still useful for differentiating septic arthritis and transient synovitis.

Some investigators [25, 26] have reported a relation between Legg-Calvé-Perthes disease and the incidence and causation of transient synovitis. Hochbergs et al. [27] found that the degree and persistence of synovitis on MRI correlated with the extent of epiphyseal necrosis in patients with Legg-Calvé-Perthes disease. Mahnken et al. [28] found various MRI signal intensities in different phases of Legg-Calvé-Perthes disease and found low signal intensity on contrast-enhanced T1-weighted MRI. We postulate that there is a relation between the decreased signal intensity with enhancement at the femoral epiphysis that we observed and perfusion of the femoral head. Kesteris et al. [29] and Wingstrand et al. [30] reported the significance of increased intracapsular pressure related to hip joint effusion in patients with transient synovitis. Those investigators found that radionuclide uptake returned to normal depending on the amount of hip effusion after arthrocentesis. We recommend performing MRI before arthrocentesis in patients with irritable hip because reports [21, 29, 30] suggest that intracapsular pressure, effusion, and impaired perfusion of the hip are related to one another.

Caird et al. [18] and Luhmann et al. [2] isolated various organisms from cultures of patients with confirmed septic arthritis of the hip. These organisms included coagulase-negative staphylococci, Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Streptococcus viridans, Haemophilus influenza type b, Pseudomonas aeruginosa, Micrococcus species, Corynebacterium species, and Abiotrophia species. In our study, one adult with septic arthritis of the hip had decreased perfusion of the femoral epiphysis on MRI, and Candida tropicalis grew on culture of aspirate. C. tropicalis arthritis has been found in patients with hematologic malignant disease, and septic arthritis can be the first sign of C. tropicalis infection [31-34]. Our patient later proved to have hemophagocytic lymphohistiocytosis.

Lee et al. [17] found altered bone marrow signal intensity in six of nine patients with septic arthritis. Although the difference in bone marrow signal intensity between the two groups in our study was not significant (p = 0.074), we observed signal intensity alteration in three of nine patients with septic arthritis. The observed differences between the two groups in numbers of patients with altered soft-tissue signal intensity, grade of effusion, and synovial thickening of the affected hip were not statistically significant in our study, as was true in the study by the Lee et al.

Our study had limitations. It was a retrospective study of a small number of patients. In addition, because our hospital is a tertiary referral center, it was impossible to confirm whether our patients had been treated with oral antibiotics before their arrival at our hospital. Thus we could not exclude the possibility that the culture results were influenced by previous treatment elsewhere.

In conclusion, our study showed the potential usefulness of decreased perfusion at the femoral epiphysis in differentiating septic arthritis of the hip from transient synovitis. This sign may be useful for predicting decreased blood perfusion in patients with irritable hip. We recommend performing coronal T1-weighted MRI immediately after contrast administration to evaluate the difference in blood perfusion between the hips before arthrocentesis. The observation of decreased perfusion at the femoral epiphysis on MRI suggests a need for further evaluation and treatment, including arthrocentesis.


References
Top
Abstract
Introduction
Materials and Methods
Results
Discussion
References
 

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