Orthopedics

Feature Article 

Initial Experiences With a New MRI Scoring System for Differentiating Advanced Femoral Osteonecrosis From Tubercular Arthritis

Vasanthakumar Venugopal, MD; Alex Daniel Prabhu, MD; Ishrat Afshan, MD; Mehvash Haider, MD; Ekram Ullah, MD

Abstract

The purpose of this study was to formulate a magnetic resonance imaging–based scoring system for differentiating tuberculous arthritis from advanced osteonecrosis of the femoral head. Magnetic resonance imaging findings in 18 hips with tuberculous arthritis and 36 hips with advanced osteonecrosis of the femoral head were reviewed retrospectively. Confirmation of tuberculous arthritis was based on enzyme-linked immunosorbent assay and/or synovial biopsy. Osteonecrosis was confirmed either by histopathology or eventual radiographic evidence on follow-up. The findings were analyzed with an emphasis on the changes in femoral head marrow, joint cavity, synovium, acetabulum, and contrast enhancement patterns. A score of 2 was assigned for the presence of each of the following: T2 hyperintensity of the femoral head, synovial hypertrophy, articular cartilage erosion, unilateral involvement of the femoral head, acetabular edema/sclerosis, and enhancement of the involved head. A score of 1 was assigned for each of the following: joint effusion, edema of adjacent marrow, and enhancement of adjacent soft tissue. A cutoff value of 10 of 15 points was considered to be positive for tuberculous arthritis. Sixteen of 18 cases of tuberculous arthritis were correctly identifiable on the basis of this scoring system. The 2 remaining cases had a score of 9. No case of osteonecrosis of the femoral head scored more than 9. A score of 10 for a positive diagnosis of tuberculous arthritis had a sensitivity of 88.89% and specificity of 100%. Positive and negative predictive values were 1 and 0.94, respectively. Statistical significance for each of the parameters and the entire model was established with logistic regression analysis. This new scoring system is effective in solving the imaging dilemma pertinent to endemic regions.

The authors are from the Department of Radiodiagnosis (VV, IA, EU), Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh; the Department of Radiodiagnosis (ADP), Chettinad Medical College Hospital and Research Centre, Chennai; and the Department of Microbiology (MH), Hamdard Institute of Medical Sciences and Research, New Delhi, India.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Vasanthakumar Venugopal, MD, Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India 202002 ( vasanthdrv@gmail.com).

Received: May 23, 2013
Accepted: March 04, 2014

Abstract

The purpose of this study was to formulate a magnetic resonance imaging–based scoring system for differentiating tuberculous arthritis from advanced osteonecrosis of the femoral head. Magnetic resonance imaging findings in 18 hips with tuberculous arthritis and 36 hips with advanced osteonecrosis of the femoral head were reviewed retrospectively. Confirmation of tuberculous arthritis was based on enzyme-linked immunosorbent assay and/or synovial biopsy. Osteonecrosis was confirmed either by histopathology or eventual radiographic evidence on follow-up. The findings were analyzed with an emphasis on the changes in femoral head marrow, joint cavity, synovium, acetabulum, and contrast enhancement patterns. A score of 2 was assigned for the presence of each of the following: T2 hyperintensity of the femoral head, synovial hypertrophy, articular cartilage erosion, unilateral involvement of the femoral head, acetabular edema/sclerosis, and enhancement of the involved head. A score of 1 was assigned for each of the following: joint effusion, edema of adjacent marrow, and enhancement of adjacent soft tissue. A cutoff value of 10 of 15 points was considered to be positive for tuberculous arthritis. Sixteen of 18 cases of tuberculous arthritis were correctly identifiable on the basis of this scoring system. The 2 remaining cases had a score of 9. No case of osteonecrosis of the femoral head scored more than 9. A score of 10 for a positive diagnosis of tuberculous arthritis had a sensitivity of 88.89% and specificity of 100%. Positive and negative predictive values were 1 and 0.94, respectively. Statistical significance for each of the parameters and the entire model was established with logistic regression analysis. This new scoring system is effective in solving the imaging dilemma pertinent to endemic regions.

The authors are from the Department of Radiodiagnosis (VV, IA, EU), Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh; the Department of Radiodiagnosis (ADP), Chettinad Medical College Hospital and Research Centre, Chennai; and the Department of Microbiology (MH), Hamdard Institute of Medical Sciences and Research, New Delhi, India.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Vasanthakumar Venugopal, MD, Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India 202002 ( vasanthdrv@gmail.com).

Received: May 23, 2013
Accepted: March 04, 2014

Approximately 2% to 5% of all tuberculous lesions involve the skeletal system.1 Tuberculosis of the hip constitutes approximately 40% of all cases of skeletal tuberculosis.1,2 The hip joint is the second most common site of bone involvement after the spine.1–4 Musculoskeletal spread of tuberculosis is usually hematogenous, secondary to primary focus elsewhere. The classical radiographic presentation of tuberculous hip is described by the Phemister triad, which includes severe periarticular osteoporosis, peripherally located osseous erosions, and gradual joint space narrowing. The current authors have encountered myriad radiological findings due to advanced stages of disease and noncompliance with treatment leading to partially treated cases.

Osteonecrosis of the femoral head is a well-described entity that in advanced cases can cause collapse of the femoral head, severe joint space narrowing, and secondary osteoarthritic changes.5,6 In tropical regions, tuberculous arthritis of the hip is a close clinical and radiological mimic of advanced osteonecrosis of the femoral head. Although a sizeable volume of literature describes the role of magnetic resonance imaging (MRI) in the diagnosis of osteonecrosis of the femoral head, to the best of the authors’ knowledge, no study has been published on the differentiation of osteonecrosis of the femoral head from tuberculous arthritis on the basis of MRI findings.

The authors devised a scoring system based on certain MRI criteria to differentiate advanced osteonecrosis of the femoral head from tuberculous arthritis of the hip joint. Each of these criteria was allotted a score based on its combined sensitivity, specificity, and statistical significance to differentiate the 2 entities. The pathological basis of choosing these findings as criteria and their individual and combined significance are explored in this study.

Materials and Methods

This was a retrospective study and was exempted from institutional review board approval. Using hospital records, the authors reviewed the data from cases of advanced osteonecrosis of the femoral head and tuberculous arthritis treated between December 2008 and December 2009. Included were confirmed cases of tuberculosis and osteonecrosis with chronic hip pain and radiographic evidence of femoral head collapse that had undergone MRI evaluation. Suspected cases of tuberculous arthritis were confirmed by enzyme-linked immunosorbent assay (ELISA) or synovial biopsy, and cases of osteonecrosis of the femoral head were confirmed by either histopathology (n=24) or eventual radiographic evidence on follow-up (n=12). Histopathological classification of osteonecrosis was based on Arlet and Durroux classification.7 Only type 2 or higher Arlet and Durroux lesions were included in the study.

There were 16 cases of tuberculous arthritis and 22 cases of osteonecrosis of the femoral head fulfilling the inclusion criteria. Two patients with tuberculous arthritis and 14 patients with osteonecrosis of the femoral head had bilateral disease. All patients had undergone MRI examination on a 1.5-T superconducting system (Magnetom Avanto; Siemens, Erlangen, Germany). The patients’ MRIs were retrieved from the authors’ database. Magnetic resonance image findings in 18 hips with tuberculous arthritis and 36 hips with advanced osteonecrosis of the femoral head were reviewed by 2 radiologists (V.V., I.A.) independently. They were blinded to the histopathological findings in these cases.

Certain imaging findings pertinent to the pathogenesis of both entities were identified and evaluated for their weight in disease prediction. These findings included hyperintense areas of the femoral head on T2-weighted sequences, hypertrophy of the synovium, articular cartilage erosion, unilateral involvement of the femoral head, acetabular involvement in the form of edema or sclerosis, joint effusion, and adjacent bone marrow edema. Two findings on the post-contrast sequences—enhancement of the femoral head lesion and enhancement of adjacent soft tissue—were also included.

Results

This retrospective study included 54 hips in 38 patients (22 males and 16 females). Eighteen hips had tuberculous arthritis and 36 hips had advanced osteonecrosis of the femoral head. Mean patient age was 26.3 years (range, 11–48 years) in the osteonecrosis group and 28 years (range, 14–50 years) in the tuberculous arthritis group. Magnetic resonance imaging findings are summarized in Table 1.

Distribution of MRI Findings Among Hips With Tuberculous Arthritis and Osteonecrosis of the Femoral Head

Table 1:

Distribution of MRI Findings Among Hips With Tuberculous Arthritis and Osteonecrosis of the Femoral Head

Signal intensity change pertinent to the diagnosis of tuberculous arthritis was defined as poorly demarcated areas of diffuse or patchy hypointense areas on T1-weighted images or as hyperintense areas on T2-weighted images in the subchondral region (Figures 1A2A, 3A). Such signal intensity changes in the femoral head were seen in 89% (16 of 18) of tuberculous hips and 17% (6 of 36) of osteonecrotic hips. The difference was statistically significant (P<.001).

Axial T2-weighted magnetic resonance imaging sequence showing a hyperintense lesion surrounded by a sclerotic rim within the right femoral head. The left femoral head is normal (A). Post-contrast fat-saturated T1-weighted image of the same patient showing ipsilateral synovial hypertrophy and enhancement (B). Patchy intralesional enhancement seen at a higher level on post-contrast sequences of the same patient. Synovial biopsy of this patient was suggestive of tuberculous arthritis (C).

Figure 1:

Axial T2-weighted magnetic resonance imaging sequence showing a hyperintense lesion surrounded by a sclerotic rim within the right femoral head. The left femoral head is normal (A). Post-contrast fat-saturated T1-weighted image of the same patient showing ipsilateral synovial hypertrophy and enhancement (B). Patchy intralesional enhancement seen at a higher level on post-contrast sequences of the same patient. Synovial biopsy of this patient was suggestive of tuberculous arthritis (C).

Axial T2-weighted magnetic resonance image of an 18-year-old man showing ill-defined hyper-intense areas in the right femoral head extending up to the neck region. Note the opposite femoral head showing hypointense foci (A). Post-contrast axial and coronal images showing patchy intralesional and peripheral enhancement within the right femoral head. The left femoral head shows just peripheral or marginal zone enhancement. This type of enhancement was considered negative according to the authors’ criteria, whereas the patchy enhancement seen on the right side was considered positive. Also note the intensely enhancing hypertrophied synovium on both sides (B). Post-contrast axial and coronal images showing patchy intralesional and peripheral enhancement within the right femoral head. The left femoral head shows just peripheral or marginal zone enhancement. This type of enhancement was considered negative according to the authors’ criteria, whereas the patchy enhancement seen on the right side was considered positive. Also note the intensely enhancing hypertrophied synovium on both sides (C). Histological photograph of Arlet and Durroux type 5 osteonecrosis showing a layer of viable bone on the surface of necrotic bone (hematoxylin and eosin, original magnification ×100) (D).

Figure 2:

Axial T2-weighted magnetic resonance image of an 18-year-old man showing ill-defined hyper-intense areas in the right femoral head extending up to the neck region. Note the opposite femoral head showing hypointense foci (A). Post-contrast axial and coronal images showing patchy intralesional and peripheral enhancement within the right femoral head. The left femoral head shows just peripheral or marginal zone enhancement. This type of enhancement was considered negative according to the authors’ criteria, whereas the patchy enhancement seen on the right side was considered positive. Also note the intensely enhancing hypertrophied synovium on both sides (B). Post-contrast axial and coronal images showing patchy intralesional and peripheral enhancement within the right femoral head. The left femoral head shows just peripheral or marginal zone enhancement. This type of enhancement was considered negative according to the authors’ criteria, whereas the patchy enhancement seen on the right side was considered positive. Also note the intensely enhancing hypertrophied synovium on both sides (C). Histological photograph of Arlet and Durroux type 5 osteonecrosis showing a layer of viable bone on the surface of necrotic bone (hematoxylin and eosin, original magnification ×100) (D).

Axial T2-weighted magnetic resonance image in a patient with tuberculous arthritis showing hyperintensity involving the anterior cortex of the right femoral head. Hyperintensity is also seen within the joint space (A). Coronal (B) and sagittal (C) post-contrast images in the same patient showing collapse of the femoral head, erosion of the articular cartilage, and homogeneous intralesional enhancement on the right side. The T2 hyperintensity is enhanced, suggesting synovial hypertrophy. Also seen is patchy enhancement involving the ipsilateral acetabulum.

Figure 3:

Axial T2-weighted magnetic resonance image in a patient with tuberculous arthritis showing hyperintensity involving the anterior cortex of the right femoral head. Hyperintensity is also seen within the joint space (A). Coronal (B) and sagittal (C) post-contrast images in the same patient showing collapse of the femoral head, erosion of the articular cartilage, and homogeneous intralesional enhancement on the right side. The T2 hyperintensity is enhanced, suggesting synovial hypertrophy. Also seen is patchy enhancement involving the ipsilateral acetabulum.

Intra-articular T2-weighted or short tau inversion recovery sequence hyperintensity showing enhancement on post-contrast sequences was considered to represent synovial hypertrophy. Synovial hypertrophy was present in all cases of tuberculous arthritis (n=18), thus making it the most sensitive finding (Figures 1B, 3B, 3C). It was also observed in 42% (15 of 36) of osteonecrotic hips (P=.002) (Figures 2B, 4B).

Sagittal T2-weighted magnetic resonance imaging sequence in a patient with osteonecrosis of the femoral head showing the classic double-line sign surrounding a focal hypointense geographical lesion (A). Post-contrast coronal image in the same patient showing peripheral marginal zone enhancement on both sides with a subchondral nonenhancing avascular area. Bilateral synovial enhancement is also seen (B).

Figure 4:

Sagittal T2-weighted magnetic resonance imaging sequence in a patient with osteonecrosis of the femoral head showing the classic double-line sign surrounding a focal hypointense geographical lesion (A). Post-contrast coronal image in the same patient showing peripheral marginal zone enhancement on both sides with a subchondral nonenhancing avascular area. Bilateral synovial enhancement is also seen (B).

Articular cartilage erosion is visualized as a well-delineated defect causing disruption of normal cartilage lining of the joint (Figure 3B). It was observed in 89% (16 of 18) of tuberculous hips and in 25% (9 of 36) of osteonecrotic hips (P<.001).

Unilateral involvement is more common in tuberculous arthritis (Figure 3A). There were 14 (78%) patients with unilateral tuberculous arthritis in this study. Unilaterality in advanced osteonecrosis is uncommon and limited to patients with previous traumatic injury to the hip joint. It was observed in only 8 (22%) cases of osteonecrosis. The difference was statistically significant (P<.001).

The acetabulum was considered to be involved in the presence of any of the following findings: hyperintensity or hypointensity of acetabular marrow on T2-weighted sequences, enhancement on post-contrast sequences, and the presence of severe degenerative changes. Acetabular involvement was seen in 83% (15 of 18) of tuberculous hips (Figure 3C) and 39% (14 of 36) of osteonecrotic hips (P<.001).

Two types of post-contrast enhancement patterns were identified: diffuse homogenous (Figure 3C) or patchy intra-lesional enhancement and peripheral marginal zone enhancement (Figures 2B, 4B). The intralesional patterns of enhancement were considered positive for tuberculous arthritis and were given a score of 2. The marginal zone enhancement was given no score because it is more suggestive of osteonecrosis of the femoral head.

Diffuse intralesional enhancement was seen in 11 cases of tuberculous arthritis, and patchy intralesional enhancement was seen in 6 cases. Only 1 osteonecrotic hip demonstrated patchy intralesional enhancement. The rest of the osteonecrotic hips (n=35) showed marginal zone enhancement.

Joint effusion and adjacent soft tissue enhancement were present in 78% (n=28; P=.014) and 14% (n=5; P=.013) of osteonecrotic hips, respectively (Figure 2C). Both joint effusion and adjacent soft tissue enhancement were present in 44% (n=8) of tuberculous hips.

Adjacent bone marrow edema was the only finding whose statistical significance could not be established (P=.74). It was observed in 89% (n=16) and 92% (n=33) of tuberculous and osteonecrotic hips, respectively.

A significant difference in the frequency of distribution (P<.05) between the 2 subsets was observed with all findings included in the scoring system except for bone marrow edema. The P values for the findings are shown in Table 1.

Based on the P values, a decision was made to allot a score of 2 for the presence of findings whose P value was less than .01 and to allot a score of 1 for the presence of findings whose P value was greater than .01. Thus, 6 findings—T2-weighted hyperintensity, articular cartilage erosion, acetabular involvement, unilaterality of disease, synovial hypertrophy, and post-contrast enhancement of the femoral head—were given a score of 2 for their presence. Three findings—joint effusion, adjacent soft tissue enhancement, and bone marrow edema—were given a score of 1 for their presence. Negative findings were given a score of 0. The total score was calculated by adding the individual scores for positive findings. The maximum possible score was 15.

Receiver operating characteristic curve analysis was performed to suggest an optimal cutoff value for differentiation of tuberculous arthritis from osteonecrosis of the femoral head. The best cutoff point of the total score was taken to achieve the maximal sum of the sensitivity and specificity. A cutoff value of 10 for a positive diagnosis of tuberculous arthritis had a sensitivity of 88.89% and a specificity of 100%. It was more specific than any other possible score. The positive predictive value for this score was 1, and the negative predictive value was 0.94.

The statistical significance of this model as a whole was tested with SPSS version 17 statistical software (SPSS, Inc, Chicago, Illinois). Multivariate logistic regression analysis was performed to assess the statistical significance of the model coefficients for differentiating tuberculous arthritis from osteonecrosis of the femoral head. Omnibus tests and the R2 values of the model proved the model to be statistically significant (Tables 23).

Omnibus Test of Model’s Coefficients

Table 2:

Omnibus Test of Model’s Coefficients

Statistical Significance of the Model

Table 3:

Statistical Significance of the Model

Discussion

Most patients with tuberculous arthritis of the hip have lesions appearing hypointense on T1-weighted sequences and hyperintense on T2-weighted sequences, which simulate the appearance of Mitchell grade C lesions. However, signal intensity pattern within the femoral head in patients with advanced Mitchell grade D osteonecrotic lesions is hypointense on both T1- and T2-weighted sequences (Figure 4A).8 Moreover, advanced osteonecrotic lesions are reported to show considerable inhomogeneity in signal intensity in in vitro imaging studies.8,9 Pathologically, grade D lesions contain an abundance of viable fibrous mesenchymal tissue, acellular fibrosis, and bone sclerosis, whereas grade C lesions contain viable fibrous mesenchymal tissue with dilated vessels, interstitial edema, and cellular components.10 These differences in cellular constituents attribute to their differing imaging appearances. These inconsistencies in imaging findings led the current authors to evaluate other criteria that could help differentiate between these 2 entities.

Synovial hypertrophy is a common pattern observed in hips affected with tuberculous arthritis. However, the association of synovial hypertrophy with osteonecrosis has not been emphasized thus far. The current authors noted synovial hypertrophy in 41% of osteonecrotic hip joints, all of which were in an advanced stage (ie, Steinberg stage IV or higher). The probable pathological explanation for occurrence of synovial hypertrophy in patients with osteonecrosis is chronic irritation due to femoral articular surface collapse or secondary osteoarthritic changes (Figure 2C).11,12 Although synovial hypertrophy could be seen in advanced osteonecrosis, this finding is reported to be more specific for tuberculous arthritis.13

In tuberculous arthritis, the pannus of granulation tissue erodes and destroys cartilage and eventually the bone.1 Articular cartilage erosion in hips with tuberculous arthritis occurs early in the course of disease. In the current series, articular cartilage erosion was found in 88% of hips with tuberculous arthritis (Figure 3B), whereas articular cartilage erosion was seen only in osteonecrotic hips with advanced degenerative changes. Femoral osteonecrosis is initiated by the interruption of blood supply to the femoral head. Although the articular cartilage does not share the same blood supply as the femoral head, it depends on the synovial fluid for most of its nutrition.14 Articular cartilage erosion is not due to vascular causes but rather to weight-bearing forces causing abnormal mechanical stress.

Both synovial hypertrophy and joint effusion show intermediate to high signal intensity on T2-weighted sequences, making differentiation impossible on these sequences alone. Post-contrast sequences show intense enhancement in synovial hypertrophy, unlike effusion, where there will be no enhancement. Joint effusion is seen as a consequence of synovial inflammation in tuberculous arthritis. In osteonecrosis, the secondary degenerative changes act as a synovial irritant and incite pannus formation and hence induce joint effusion.11,12 Joint effusion was noted in 78% of hips with femoral head collapse in the current study. The quantity of effusion increases with advancing stages of the disease.11

Marrow edema is a highly nonspecific finding for any disease entity and has been observed in avascular necrosis, transient osteoporosis, infectious arthritis, inflammatory arthropathy, occult stress fractures, primary bone neoplasms, myeloproliferative disorders, and hemoglobinopathy.13 In tuberculous arthritis, formation of inflammatory infiltrates in the surrounding bone marrow causes the observed edema pattern, whereas in avascular necrosis, the primary mechanism is the abnormal mechanical stress due to abnormal distribution of weight-bearing forces occurring as a consequence of the trabecular fracture in the necrotic area.14 Marrow edema seen in early osteonecrosis is an indicator for potential progression to advanced stages.15

Both unilateral involvement of the hip joint and acetabular involvement were strongly associated with tuberculous arthritis in this study, whereas bilateral involvement of the hip joint was common in osteonecrosis. On MRI, the typical features of monoarticular involvement, effusion with synovitis, and bone marrow edema on either side of the joint should be considered infective unless proven otherwise. Nontraumatic femoral osteonecrosis are bilateral in 30% to 70% of cases. Cellular events and reactions and pathological mechanisms responsible for the development and progression of vascular diseases are common for both femoral heads.16 Acetabular involvement can occur late in the course of osteonecrosis in Steinberg stage V secondary to the osteoarthritic changes.17

Post-contrast sequences further improved the diagnostic accuracy in the current study. Femoral head lesions in cases of tuberculous arthritis showed a homogenous enhancement pattern, which is secondary to inflammatory infiltrate and hyperemia (Figure 3B). In osteonecrotic hips, peripheral enhancement is noted, which suggests the vascular nature of the reactive interface (Figure 2B). Patchy enhancement of femoral head lesions could be seen due to the amalgamation of cellular and fibrous components.10 The most characteristic gross pathological feature of osteonecrosis is the sclerotic rim that develops at the interface between necrotic and viable bone.5,18 Inside this rim is an advancing front of granulation tissue, hyperemia, and bone resorption. The center of the necrotic segment is not perfused and remains morphologically unchanged until the repair process reaches it or it fractures as a result of mechanical failure.18

Adjacent soft tissue involvement is evaluated on post-contrast sequences because contrast enhancement is particularly useful for distinguishing between abscesses and the surrounding myositis.19 Extra-articular lesions in tuberculous arthritis usually consist of abscesses and tend to have smooth boundaries.20 In this study, mild post-contrast enhancement in adjacent soft tissue was noted in 44% hips with tuberculous arthritis. However, frank abscess formation was not noticed in any case. Mild post-contrast enhancement of adjacent muscles was noticed in only 14% of osteonecrotic hips, which can be secondary to myositis or muscle sprain resulting from advanced osteoarthritic changes.

Differentiating between advanced osteonecrosis of the femoral head and tuberculous arthritis is essential to guide the clinician toward appropriate management. Total hip arthroplasty can be safely performed in both advanced tuberculous arthritis and osteonecrosis of the femoral head to provide symptomatic relief and functional improvement. However, complete curettage and resection of the infected tissue and postoperative antitubercular chemotherapy for a minimum of 1 year are important for preventing reactivations in cases of tuberculous arthritis.21

Conclusion

The authors propose a new scoring system based on MRI-identifiable criteria for differentiating between the 2 mimics of destructive hip joint disease: advanced osteonecrosis of the femoral head and tuberculous arthritis. The main limitation of the current study is that its relevance may be limited to tropical regions with a high prevalence of tuberculosis. However, with the rise of tuberculous-opportunistic infections in AIDS and other immuno-compromised states, the study assumes significance in nontropical regions also. The retrospective design, small sample size, and exclusion of other types of septic arthritis are also limitations. However, large-scale, multicenter, prospective studies are needed to establish the clinical significance of the results.

References

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Distribution of MRI Findings Among Hips With Tuberculous Arthritis and Osteonecrosis of the Femoral Head

Finding No.
P
Tuberculous Arthritis (n=18) Osteonecrosis (n=36)
T2 hyperintensity 16 6 .000
Acetabular involvement 15 14 .000
Synovial hypertrophy 18 15 .002
Articular cartilage erosion 16 9 .000
Unilateral hip involvement 14 8 .000
Enhancement of femoral head lesion 15 1 .000
Joint effusion 8 28 .014
Marrow edema 16 33 .740
Soft tissue enhancement 8 5 .013

Omnibus Test of Model’s Coefficients

Step 1 Chi-square df P
Step 68.744 9 .000
Block 68.744 9 .000
Model 68.744 9 .000

Statistical Significance of the Model

Step −2 Log Likelihood Cox & Snell R2 Nagelkerke R2
1 .000a .720 1.000

10.3928/01477447-20141023-59

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