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British Journal of Radiology 75 (2002),229-233 © 2002 The British Institute of Radiology

Full Paper

The role of MRI in the evaluation of hip joint disease in clinical subtypes of juvenile idiopathic arthritis

M I Argyropoulou 1 S L Fanis 1 T Xenakis 2 S C Efremidis 1 and A Siamopoulou 3

Departments of 1 Radiology, 2 Orthopaedics and 3 Paediatrics, University of Ioannina, 45110 Ioannina, Greece


   Abstract
Top
 Abstract
Introduction
 Subjects and methods
 Results
 Discussion
 References
 
The purpose of this study was to evaluate the role of MRI in the assessment of hip joint involvement in clinical subtypes of juvenile idiopathic arthritis (JIA). 28 patients (mean age 12.5 years) with JIA (oligoarthritis 8, polyarthritis 13, systemic arthritis 7) were examined with T2 weighted turbo spin echo and T1 weighted spin echo (plain and contrast enhanced) sequences. The severity of joint involvement was evaluated using an MR grading score: grade 1=no contrast enhancement; grade 2=focal synovial contrast enhancement; grade 3=diffuse synovial contrast enhancement; grade 4=grade 3+diffuse synovial thickening; grade 5=grade 4+villonodular synovial thickening; and grade 6=grade 5+cartilage and subchondral bone erosions. MRI was abnormal in 57.1% of cases (25% of oligoarthritis, 53.8% of polyarthritis and 100% of systemic arthritis). Clinical examination was positive in 32.1% of cases and was associated with higher MR grades (mean 4.6, SD 1.34) compared with a negative clinical examination, which was associated with lower MR grades (mean 1.78, SD 1.13) (p<0.001). Patients with active disease (mean grade 3.9, SD 2) had higher MR grades than those with inactive disease (mean grade 2.1, SD 1.4) (p<0.01). The MR grades were different in the three clinical subtypes: oligoarticular (mean 1.5, SD 1.06); polyarticular (mean 2.38, SD 1.55); and systemic (mean 4.85, SD 1.21) (F:12.3, p<0.001), with a significant difference between systemic arthritis and oligoarthritis, and between systemic arthritis and polyarthritis (p<0.001). MRI of the hip might be considered for inclusion in the study protocol of patients with JIA since it reveals joint involvement at early stages and provides a detailed evaluation of the extent of joint disease.


   Introduction
Top
 Abstract
 Introduction
Subjects and methods
 Results
 Discussion
 References
 
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory multisystem disease with prominent joint manifestations [1–4]. Joint involvement starts with synovitis, which progresses to synovial hyperplasia and formation of pannus, a highly cellular inflammatory tissue [5–7]. Pannus erodes cartilage and bone, leading to articular destruction and ankylosis [2, 6]. Active joint synovitis is evaluated by clinical examination. Early detection is important to assess the extent of disease and to adapt treatment appropriately [2]. Hip joint involvement is frequent and may occur early in the course of the disease [8, 9]. However, since the hip is not a superficial joint, clinical evaluation of synovitis is difficult [1, 5]. Late detection of hip joint disease often results in the development of serious disability in children with JIA [8]. Imaging techniques such as radiography and ultrasound have been used for the evaluation of hip joint involvement. Radiography depict bone erosions and growth disturbances, which represent advanced stages of the disease [2, 10]. Ultrasound examination, although depicting the synovium and, when coupled to color Doppler, assessing tissue vascularity [8], visualizes only the anterior aspect of the articulation [2]. Previous studies in patients with JIA have demonstrated that MRI reveals early joint involvement by demonstrating contrast enhancement of the inflammatory synovium [7, 10, 11]. However, there are only few studies of the hip joint with a small number of patients [2, 3, 5, 12]. Since JIA is a heterogeneous clinical entity classified into subtypes that differ in clinical expression and prognosis [13], the purpose of the present study was to evaluate the role of MRI in the assessment of hip joint involvement in the different clinical subtypes of JIA.


   Subjects and methods
Top
 Abstract
 Introduction
 Subjects and methods
Results
 Discussion
 References
 
28 patients with JIA, diagnosed according to the International League Against Rheumatism criteria [13], were included in this study. The study population consisted of 14 males and 14 females aged from 2–24 years (mean age 12.5 years). 8 patients had oligoarthritis, 13 had polyarthritis and 7 had systemic arthritis. The age at onset ranged from 0.5–14 years (mean 6.5 years, SD 4.5) and the duration of the disease ranged from 1–21 years (mean 6.9 years, SD 4.4). Rheumatoid factor and HLA-B27 were negative in all patients, whereas antinuclear antibody titres were positive in nine patients. Disease activity was evaluated based upon the following: Ritchie articular index [14], swollen joint count, grip strength, pain, duration of early morning stiffness, blood haemoglobin and erythrocyte sedimentation rate measurements. The index of disease activity was evaluated according to a previously described method [15]. Pharmacological treatment consisted of non-steroidal anti-inflammatory drugs (n=23), and/or slow acting antirheumatic drugs (n=17) and/or prednisone (n=11). One patient with oligoarticular disease received no medication at any time. Hip joint involvement was clinically assessed by noting the presence or absence of local pain at rest or movement as well as the degree of motion limitation.

All MR examinations were imaged performed on the same 1.5 T MR unit (Gyroscan ACS NT; Philips Medical Systems, Best, The Netherlands) using a body coil with a 33 cm field of view. Both hip joints were imaged simultaneously by performing scans in the coronal plane. T2 weighted images were obtained first with a turbo spin echo sequence, 4000 ms/120 ms (repetition time (TR)/echo time (TE), 4 mm slice thickness, two excitations, 228x256 imaging matrix and 4 min 30 s total examination time. T1 weighted images were performed with a spin echo 400 ms/12 ms (TR/TE) sequence, 4 mm slice thickness, four excitations, 228x256 imaging matrix and 4 min total examination time, before and immediately after intravenous (iv) administration of 0.1 mmol kg-1 gadopentetate dimeglumine Gd-DTPA (Magnevist; Schering, Berlin, Germany). T1 weighted images before and after contrast medium administration were displayed with the same window and grey scale level. One of the radiologists (MIA) assessed T2 and T1 weighted images, blinded to the patient's clinical evaluation. To evaluate the severity of hip joint involvement, an MR grading score was established: grade 1=no contrast enhancement; grade 2=focal synovial contrast enhancement; grade 3=diffuse synovial contrast enhancement; grade 4=diffuse enhancement with synovial thickening (Figure 1Go); grade 5=diffuse enhancement with villonodular synovial thickening; and grade 6=diffuse enhancement with villonodular synovial thickening associated with cartilage and subchondral bone erosions.



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  		Figure 1. Coronal scan of the hip joints in a patient with grade 4 MR findings. (a) Plain T1 weighted image depicting thickened synovium with intermediate signal intensity. (b) Contrast enhanced T1 weighted image showing diffuse enhancement with synovial thickening.

 
Informed consent was obtained from all subjects as well as the parents of the children included in the study. The study was performed with the approval of the Institutional Review Board.

Statistical analysis
Statistical analysis was performed with SPSS base 7.5 for windows. The normality of distribution of the parameters was assessed using the Kolmogorov–Smirnov test. Unpaired two-tailed Student's t-test was used to study differences in MR grades between patients with active and inactive disease as well as between patients with positive and negative clinical examinations. Differences in MR grades between patients with oligoarticular, polyarticular and systemic forms of the disease were evaluated using one-way analysis of variance (ANOVA) followed by the least significant difference (LSD) test.


   Results
Top
 Abstract
 Introduction
 Subjects and methods
 Results
Discussion
 References
 
The MR examination was abnormal in 16 (57.1%) patients. The distribution per clinical form of JIA is shown in Table 1Go. Involvement of the hips was symmetric in all patients with an abnormal MRI study. Inflammatory tissue exhibited high signal intensity on T2 weighted images. Distinction between inflammatory pannus and joint effusion was precise on contrast enhanced T1 weighted images, without blurring of the synovial limits (Figure 2Go). Patients with active disease showed higher MR grades (mean 3.9, SD 2) than those with inactive disease (mean 2.1, SD 1.4) (p<0.01). The clinical examination of hip joints was abnormal in 9 (32.1%) patients, and patients with a positive clinical examination had higher MR grades (mean 4.6, SD 1.34) compared with those with a negative clinical examination (mean 1.78, SD 1.13) (p<0.001). ANOVA between the three clinical forms of the disease showed that the mean values of the MR grades were different (F:12.3, p<0.001) (Table 2Go). The LSD test showed a statistically significant difference between oligoarthritis and systemic arthritis, and between polyarthritis and systemic arthritis (p<0.001). No statistically significant difference was found between oligoarthritis and polyarthritis.


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  		Table 1. Number of cases with abnormal MRI in the three subtypes of disease

 


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  		Figure 2. Coronal MRI of the anterior recess (arrows) of both hip joints. (a) T2 weighted image depicting intraarticular fluid with high signal intensity. (b) Plain T1 weighted image showing the anterior recess of the articulation with intermediate signal intensity. (c) Contrast enhanced T1 weighted image depicting synovial enhancement while the signal intensity of the intraarticular fluid remains low.

 

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  		Table 2. Analysis of variance between the three clinical forms of the disease, showing the difference in mean values of MR grades (F:12.3, p<0.001)

 

   Discussion
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
References
 
JIA is a chronic generalized collagen vascular disease with prominent joint manifestations [1–4]. It is the most common rheumatic disease of childhood. Joint disease starts with acute synovitis, which progressively becomes chronic and leads to the formation of highly cellular inflammatory pannus. The latter erodes bone at the osteochondral junction, invades bone marrow and undermines articular cartilage, spreading across from the edges toward the centre [5–7]. Sometimes pannus erodes through articular cartilage into subchondral bone. The end result of this destructive process may be joint ankylosis [16].

Hip joint involvement occurs in 35–63% of patients and its late detection may be the cause of serious disability [2, 17, 18]. Joint inflammation is clinically assessed by the degree of local swelling, tenderness, and pain at rest and motion [1]. However, since the hip is not a superficial joint, the clinical evaluation for active inflammation is difficult and imaging may be useful in the evaluation of hip joint involvement in JIA.

In the present study, MRI has been used as the imaging modality because it evaluates the whole articulation and depicts in detail the synovium, cartilage and bone [7]. After iv contrast injection, the inflammatory synovium enhances owing to increased tissue perfusion [19]. Contrast enhanced MR scans allow direct visualization of the inflammatory synovium [20]. On delayed post-contrast images, enhancement of the intraarticular fluid occurs owing to diffusion of contrast medium from the hypervascular pannus [7]. Since intraarticular fluid enhancement may cause blurring of synovial limits, early post-contrast imaging is necessary. In the present study, MR images were obtained within minutes of contrast medium injection, and the MR grades were based on the presence and extent of enhancing intraarticular inflammatory tissue. Hip joint involvement was revealed in cases with negative clinical examination, while a positive clinical examination was associated with advanced MR grades. This is in agreement with previous studies reporting that the clinical examination does not always show the real degree of hip joint involvement and may remain negative until advanced stages of the disease [21, 22].

Fedrizzi et al [8], studying patients with JIA, demonstrated that the ultrasound detected abnormalities in the hip joint of asymptomatic patients with normal radiographs. Ultrasound is a good method for evaluating synovial thickening and intraarticular fluid; however, its "diagnostic window’’ is limited to the anterior recess of the hip joint [2]. In the present study, MRI reveals focal inflammatory changes beyond the anterior recess of the articulation.

JIA is a heterogeneous disease classified into subgroups that differ in clinical expression and prognosis. Our study showed differences in the degree of development of inflammatory pannus and joint involvement in the three clinical subtypes of disease. Systemic arthritis was associated with more severe joint disease, followed by polyarthritis, while oligoarthritis was associated with lower MR grades. In a previous study, Murray et al [5] did not find significant differences in the presence of pannus among the clinical subtypes of JIA. This is probably because of the small number of cases included in their study.

In the present study, active disease was associated with higher MR grades suggesting the presence of more pronounced intraarticular inflammatory tissue. This is in accordance with the results of Sugimoto et al [23], who studied the hands of patients with rheumatoid arthritis using MR and demonstrated that the volume of enhancing active pannus alters in the direction indicated by changes in physical and laboratory parameters of general disease activity.

Our findings of symmetric hip joint involvement and of higher frequency of joint disease in systemic arthritis and polyarthritis are consistent with the results of other studies [8, 9, 18, 24, 25].

In conclusion, MRI of the hip plays an important role in the study of patients with JIA as it reveals early joint involvement and evaluates in detail the extent of joint disease. The results of this study suggest that MRI of the hip is a useful method of assessment of patients with JIA.

Received for publication August 29, 2001. Revision received November 12, 2001. Accepted for publication November 21, 2001.


   References
Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 

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