Gonadal shielding should not be used for any studies of the pelvis for bilateral hip evaluation.

EMBASE Search Strategy

(exp hip disease/ or exp hip osteoarthritis/ or exp hip injury/ or exp hip osteotomy/ or exp congenital hip dislocation/ or exp hip pain/ or exp hip distractor/ or exp hip radiography/ or exp hip arthroscopy/ or exp hip surgery/ or exp “Hip Disability and Osteoarthritis Outcome Score”/ or exp hip dislocation. Or exp hip fracture/ or exp hip dysplasia/ or exp hip contracture/ or exp hip/ or exp hip malformation/ or exp hip arthroplasty/ or exp femoroacetabular impingement/ or exp femur head/ or femur/ or exp femur malformation) AND (exp arthroscopy/ or exp hip arthroscopy/ or arthroscopy.mp.) AND (exp learning curve/ or exp learning/ or exp clinical competence/ or competence or exp experience or exp adverse outcome or exp treatment outcome/ or exp motor performance/ or exp complication/ or exp postoperative complication/)

Radiography examinations

The effectiveness of patient shielding in radiography examinations is summarized in Table 4. In-plane and out-of-plane shielding was also found to be used for this modality. Many reports conclude that gonad shielding for head/neck/shoulder and extremities radiography can be safely abandoned as the X-ray field is far from the sensitive organs [6–11,15]. Regarding, abdomen/pelvis radiography, shielding depends on patient gender with in-plane shielding being applied for female patients and out-of-plane shielding for male patients. For pelvic and hip radiography of female patients the shielding happens to be in the X-ray field then AEC cannot be used as the shielding will increase the exposure parameters considering the density of the irradiated structure. Moreover, the positioning of the shielding for ovaries it’s not an easy task, indeed their position is generally unknown. If the shielding is placed, it is not is usually placed centrally above the pubic symphysis; however, according to more recent studies on the ovaries location, the shielding must be positioned laterally [49]. This information makes ovaries shielding use during pelvis and hip radiographies practically impossible, as the shielding will hide the anatomical region of interest. For the male patient there should be no particular problems, as the gonad shielding is positioned under the pubic symphysis and thus, the shielding should be out but rather close to the acquisition plane. According to a study by Lee et al., pelvic shields were misplaced in 49% of anteroposterior and 63% of frog lateral radiographs and shielding was misplaced for both girls and boys on frog lateral radiographs (misplacement for girls: 76% vs 51% for boys) [50]. Moreover, a review that focused on gonad shieling during pelvic radiography showed that shielding for male patients is controversial and stressed out that the current practice of gonad shielding during female pelvic radiography should be no longer considered as an effective method to reduce radiation exposure [16]. Larson et al. proposed posterior-anterior (PA) radiographs instead of anteroposterior (AP) that can significantly reduce exposure to the testes, thyroid, and breast for all routine screening radiographs [51].

Snapping iliopsoas tendon (internal snapping hip)

The normal iliopsoas tendon glides smoothly over the pelvic brim during hip rotation.15 Sonography has demonstrated a snapping or abnormal jerky movement of the iliopsoas tendon in the snapping hip.123 Sonography has emerged as the preferred technique for examining the iliopsoas tendon because it allows both static and dynamic evaluation of the soft tissues around the hip joint.116,119,123 Sonography also provides an accurate method for injection into the iliopsoas bursa. However, because sonography may not allow accurate evaluation of intra-articular pathologic conditions, some combination of radiography, hip arthrography, CT, or MR imaging is still recommended if an intra-articular cause for hip pain is suspected.123

Although iliopsoas tendinopathy and bursitis can be seen,120 sonographic signs of tendinopathy are not a common feature of a snapping iliopsoas tendon.72,116 When it does occur, iliopsoas bursitis and tendinitis are interrelated in the sense that inflammation of one will often result in inflammation of the other due to their close proximity.120

An accurate diagnosis of the cause of painful snapping hip is essential for deciding on the appropriate treatment. The cause for an individual’s hip pain may not be identified until after iliopsoas bursa injection confirms pain relief. Treatment options for the painful snapping iliopsoas tendon include nonoperative management (rest, analgesics, and physical therapy), injection of corticosteroids and anesthetic agents into the iliopsoas bursa (Fig. 21), and surgery.15,121,124–126

Case 2

Patient 2 is the second child of healthy nonconsanguineous parents. She was born at 40 weeks by vaginal delivery after an uneventful pregnancy. No perinatal complications were reported. Left palpebral ptosis was noticed at birth. At 3 months of age, congenital hip dislocation was diagnosed and treated successfully with harness. At the age of 1 year, she was admitted to our department due to the acute onset of left faciobrachiocrural hemiparesis and seizure. On physical examination, additional mild left facial hypoplasia associated with congenital third cranial nerve palsy moderate global developmental delay were depicted. No other dysmorphic features or cutaneous hemangiomas were noted.

An urgent MRI of the brain revealed an acute ischemic infarct in the right middle cerebral artery territory. Asymmetric hypoplasia affecting the left side of the midbrain and pons also was noted (Figure 3A–C). MRA and digital subtraction angiography depicted several vascular anomalies involving both the anterior and posterior circulation, including multiple narrowing of the ICAs with bilateral extensive quasi-MMD and reduced flow in the left middle cerebral artery (Figure 4). Findings on cardiac and abdominal ultrasound scans were normal. Hip radiography revealed hypoplasia of the left femoral cephalic and greater trochanter nucleus. The array-CGH was normal.

For the presence of 2 major criteria (arterial anomalies and brain structural abnormalities) but no hemangioma, the patient was diagnosed with possible PHACE syndrome and was treated conservatively with aspirin (5 mg/kg/day) and levetiracetam (15 mg/kg/day), with improvement of the left-sided hemiparesis and good seizure control. At that time, the parents refused the surgical treatments. Follow-up brain MRI and MRA studies performed at the age of 1.7 and 2.7 years revealed progressive occlusion of the right ICA and reduced arterial blood flow signal into the distal branches of the left middle cerebral artery with markedly increased moyamoya collateralization (Figure 5A and B). New focal white matter lesions were detected in the left frontal lobe, in watershed arterial territories (Figure 3D–F). Findings of a neurologic examination revealed worsening of neurologic symptoms due to the appearance of headaches and pyramidal signs in the right lower limb. The neuropsychological evaluation demonstrated severe developmental delay. The EEG showed bilateral spike and slow-wave complexes, emanating primarily from the right frontal cortex. Considered the neurologic worsening, the progression of intracranial arterial stenosis and the EEG pattern, we decided to perform a left unilateral indirect revascularization using EDAS to preserve the brain perfusion in the less-affected hemisphere, as previously described.18

She tolerated the procedures well and did not have any complications in the postoperative period. At last follow-up, performed at 3.10 years of age, complete resolution of headaches and right pyramidal signs was noted, whereas mild left hemiparesis persisted. Improvement in the cognitive performances also was depicted on Griffiths Mental Development Scales. MRI of the brain did not show new ischemic infarcts, whereas MRA of the brain and perfusion studies revealed development of abundant collateral vessels at the synangiosis sites (Figure 5C and D), with improved perfusion in the left cerebral hemisphere. The EEG showed an improvement of the anomalies in the left hemisphere.

What is the role of radiography in follow-up assessment and disease management?

Once radiographic sacroiliitis is evident on pelvic radiography, there is no purpose to further evaluation of the SIJ. But it has been proposed by ASAS that spinal radiography be considered a core outcome domain for the assessment of disease-controlling anti-rheumatic therapy in patients with SpA [41]. Hip radiography was also placed on the research agenda as a possible outcome domain for disease-modifying therapies. Plain radiography can show a variety of features in the spine. In spinal vertebrae the earliest feature is the loss of the cortex at the corner of the vertebral body giving the appearance of an erosion. Bone remodelling and new bone formation lead to the radiographic appearance of squaring and sclerosis at the vertebral corner. Further new bone formation from the vertebral corner across the disc space to the adjacent vertebral corner or syndesmophyte may ultimately lead to complete ankylosis. This occurs not only at the vertebral rim but also in the interior of the disc. Spondylodiscitis is radiographically evident as disruption and loss of the vertebral endplate. Facet joint abnormalities consist of erosions, loss of joint space, and ankylosis. They are not readily visible in the thoracic spine because of overlapping structures. They are visible on lateral radiographs of the cervical spine and it has been shown that structural changes of joints space narrowing and fusion can be reliably detected [42]. Assessment of facet joints in the lumbar spine requires oblique views. Systematic prospective radiographic studies are limited but clinical observations indicate that abnormalities typically originate in the lumbar spine and ascend cranially although the cervical spine may be preferentially affected in some patients. Typical features occur relatively late in the course of the disease and are in general not contributory to the diagnosis. In a cross-sectional cohort of patients with AS and a mean disease duration of almost 12 years, more than 60% of patients had features attributable to AS on their spinal radiographs, but only a minority had syndesmophytes extending over multiple vertebrae [43]. A ‘bamboo spine’, which reflects an end-stage of spinal AS, was observed in less than 5%. Radiographic abnormalities are associated with impaired spinal mobility [44]. The relationship is not linear and the association increases with increasing level of ankylosis.

The pace of radiographic progression in terms of new bone formation as detected by syndesmophytes and ankylosis is variable but only about 20% of patients show progression over 2 years [45–47]. Moreover, until recently there was minimal evidence that any therapeutic approach had disease-modifying potential. Consequently, there has been little interest in the radiographic assessment of the spine for follow-up and disease management. But there is now evidence from two recent studies that continuous use of NSAIDs may prevent the development of new bone in patients at risk of progression because of elevated acute phase reactants or the presence of baseline syndesmophytes [48,49]. This may particularly impact the approach to treatment of patients who may be symptomatically well controlled on minimal or discontinuous NSAID therapy but who show evidence of radiographic progression. Since NSAID therapy may be associated with gastrointestinal, cardiovascular, and renal morbidity, appropriate patient selection for long-term continuous therapy is essential. Consequently, there may now be justifiable grounds to monitor progression with spinal radiography, particularly if the patient has elevated acute phase reactants and evidence of new bone formation on the spinal radiograph. But this should not be done within a time frame that is shorter than 2 years since this is the minimum period that must elapse before radiographic progression can be reliably detected [43].

Lower extremity