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