Skeletal Radiology (2023) 52:2259–2270

https://doi.org/10.1007/s00256-022-04270-8

REVIEW ARTICLE

Osteoarthritis of the hip: is radiography still needed?

Charbel Mourad1 · Bruno Vande Berg2

Received: 2 October 2022 / Revised: 12 November 2022 / Accepted: 18 November 2022 / Published online: 20 December 2022
© The Author(s) 2022

Abstract
Diagnosis of hip osteoarthritis (OA) is based on clinical arguments, and medical imaging is obtained to confirm the diagnosis
and rule out other possible sources of pain. Conventional radiographs are recommended as the first line imaging modal-
ity to investigate chronic hip pain. They should be obtained in a rigorous technique that includes an antero-posterior (AP)
radiograph of the pelvis. The choice of the appropriate lateral view depends on the clinical indication, Lequesne’s false
profile being valuable in the assessment of OA. Magnetic resonance imaging (MRI) is more sensitive to detect joint effu-
sion/synovitis, cartilage, labral, and bone marrow lesions. However, structural joint changes are frequent in asymptomatic
population and neither radiographs nor MRI have shown a good correlation with pain and functional impairment. MRI
seems to be more suitable than radiographs as a biomarker for clinical trials addressing early OA. The absence of a validated
MR biomarker of early OA, together with issues related to machine availability and MRI protocol repeatability, prevent the
widespread use of MRI in clinical trials.

Keywords Hip · Conventional radiography · Osteoarthritis · MRI

Abbreviations OA  Osteoarthritis
AP  Antero-posterior WB  Weight-bearing
BME Bone marrow edema-like
CR Conventional radiography
FAI Femoro-acetabular impingement Introduction
JSN Joint space narrowing
JSW Joint space width Hip osteoarthritis (OA) is a highly prevalent and disabling
MRI Magnetic resonance imaging disorder that affects elderly but also young patients with a
nWB  Non-weight-bearing high socio-economic burden [1–7]. In patients with clini-
cally suspected hip OA, medical imaging contributes to
Key points confirm the diagnosis and rule out alternative diagnoses by
• In clinical practice, radiographs are still recommended as first demonstrating cartilage lesions and associated structural
line imaging modality for clinically suspected hip osteoarthritis. changes [8]. For decades, conventional radiography (CR) has
• MRI shows structural lesions of the cartilage, bone and soft been used to support the clinical diagnosis of hip OA. Over
tissues and is possibly more suitable than radiographs to be used
as a biomarker. the years, magnetic resonance imaging (MRI) emerged as
• Development and validation of disease modifying drugs and a powerful imaging modality to detect cartilage lesions and
interventions could alter current imaging strategies. structural changes of the hip joint. The current special issue
• Absence of validated diagnostic criteria for early-stage hip OA, of Skeletal Radiology granted us the opportunity to address
and dissociation between pain, physical examination and imaging
findings in hip OA remain challenging. a fundamental question: is radiography still needed to diag-
nose hip OA? Which imaging modality should be used to
* Charbel Mourad diagnose stage and quantify hip OA in clinical practice, in
Charbel.j.mourad@hotmail.com clinical trials and in research? After a brief review on classi-
1
Department of Diagnostic and Interventional Radiology,
fications and diagnostic criteria, the current narrative article
Hôpital Libanais Geitaoui CHU, Beyrouth 1100, Achrafieh, will summarize strengths and weaknesses of CR and MRI
Lebanon to diagnose hip OA and will propose perspectives on the
2
Department of Radiology, Cliniques CHC Montlégia, use of medical imaging. This review article also highlights
Boulevard Patience Et Beaujonc 2, 4000 Liège, Belgium

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2260 Skeletal Radiology (2023) 52:2259–2270

Fig. 1  A 21-year-old man with

moderate left hip pain and
osteoarthritis secondary to fem-
oro-acetabular impingement.
A AP radiograph demonstrates
lateral joint space narrowing
(arrows), subchondral sclerosis
of the acetabular roof (asterisk)
and femoral head osteophytes
(arrowheads). B The 45° Dunn
lateral view demonstrates Cam
deformity at the head-neck
junction (arrow)

the importance of rigorous acquisition and reading of hip than 2 mm on AP pelvic radiographs [18–20] (Fig. 3). The
radiographic and MR images. Imaging of femoro-acetabular clinical course of hip OA is usually slow and pain fluctuates
impingement (FAI) and advanced quantitative MR tech- over the years with no or minor radiological changes over
niques for the cartilage are out of the scope of this article and time [21] (Fig. 4). Rapidly destructive hip OA is uncommon
will be addressed separately in this Skeletal Radiology issue. and is defined by the development of complete loss of radio-
logical JSW or severe bone attrition on CR within 12 months
after symptoms onset [22–24] (Fig. 5). All these classifica-
Classification systems of hip osteoarthritis tion systems and threshold values are open for discussion,
but they rely on good clinical practice standards for which
Hip OA can be classified according to its etiology, time preservative hip surgery should not be performed after
of onset, severity, and clinical course. In primary hip OA, 50 years of age or when the radiological JSW is < 2 mm.
cartilage degradation can either be idiopathic or develop in
association with dynamic conflict between the articular sur-
faces, the FAI syndrome [9–11] (Fig. 1). In secondary hip Clinical diagnosis of hip osteoarthritis
OA, joint degradation results from preexisting conditions
including developmental hip dysplasia, growth-associated Clinical history
disorders, fracture, femoral head osteonecrosis and inflam-
matory or metabolic synovial disorders [10, 12–17] (Fig. 2). Typically, OA-associated hip pain evolves over time with
Early-onset and late-onset disease develop either before or initial intermittent activity-related or weight-bearing pain
after 50 years of age [2]. Early-stage and late-stage OA differ followed by constant pain, limited range of motion, and
according to the absence or presence of radiological struc- altered gait. Several population- or OA-based cohort studies
tural changes with a joint space width (JSW) of more or less have shown that, on average, there is little to no progression

Fig. 2  Secondary hip osteo-

arthritis. A AP radiograph of
the left hip in an 8-year-old
boy with Legg-Calvé-Perthes
disease showing sclerosis of the
femoral head epiphysis (aster-
isk) and cystic changes of the
metaphysis (arrow). B Follow-
up AP radiograph of the same
patient at the age of 23 years
showing secondary osteoarthri-
tis with abnormal femoral head
contours, articular incongruity,
and joint space narrowing

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Skeletal Radiology (2023) 52:2259–2270 2261

Fig. 3  A 38-year-old woman

with right hip pain and osteoar-
thritis. A Anteroposterior radio-
graph shows cortical buttressing
(arrow) with a preserved joint
space width (Kellgren 1). B
Lequesne false profile shows
narrowing of the antero-
superior joint space (arrows).
C Transverse T1 and D sagittal
intermediate-weighted fat
suppressed MR arthrography
images after intra-articular
contrast injection show full-
thickness cartilage substance
loss in the anterior (arrows in
C) and superior (arrows in D)
aspect of the joint space, with
subchondral cyst-like changes
(asterisks in D)

Fig. 4  Non-evolutive osteo-

arthritis of the left hip in a
62-year-old man with limited
range of motion but no hip pain.
A AP radiograph of the left
hip demonstrates lateral joint
space narrowing (arrows) and
marginal osteophytes (arrow-
heads). B Follow-up radiograph
after 10 years demonstrates no
significant change in joint space
narrowing. Outcome prediction
on radiographs is unreliable.
Note that the area underneath
the osteophyte (asterisk) does
not correspond to the articular
joint space

of complaints during a 10-year follow-up period [21, 25] Hip Physical examination
pain can be localized anteriorly, laterally or posteriorly but
it may also be referred in the groin, the buttock, the thigh or Physical examination remains one of the most valuable
the knee. A major clinical challenge is to recognize articular tools physicians can use to diagnose hip OA. Upright and
hip pain from peri-articular or non-hip-related pain [26–31]. supine exam tests as well as provocative maneuvers have

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2262 Skeletal Radiology (2023) 52:2259–2270

Fig. 5  65-year-old man with

rapidly destructive osteoarthri-
tis. A AP radiograph of the right
hip obtained at onset of symp-
toms shows early osteophytes
(arrowheads) but no joint space
narrowing. B AP radiograph
obtained 3 months later shows
complete joint space narrowing
(arrows) with deformity of the
femoral head (arrowhead) and
subchondral sclerosis (asterisk).

been developed to increase the likelihood that presenting allows a comparative analysis of both hips, which enhances
symptoms originate from the hip joint [32–35]. Unfor- the detection of subtle bone and joint abnormalities [8,
tunately, the accuracy of these tests varies with a wide 40–43]. The pelvic AP radiograph should also be used to
range of sensitivity and specificity [33]. For example, the assess FAI-associated features since pelvic positioning can
flexion-abduction and external rotation test had a sensitiv- be controlled on the AP pelvic radiograph but not on the AP
ity ranging from 41 to 97% and a specificity ranging from hip radiograph [44]. There is no clear consensus whether
18 to 100% [36]. Therefore, the specific application and the JSW is better evaluated on weight-bearing (WB) or
interpretation of these clinical tests must be integrated in non-weight-bearing (nWB) AP pelvic radiographs [45–48].
the context of the patient’s history. The WB radiograph evaluates the pelvis in its anatomical
position with a decrease in acetabular coverage and
increase in posterior pelvic tilt in comparison to the nWB
pelvic radiograph [49]. The WB radiograph has an overall
Biological tests decrease in image quality with a higher radiation dose, is
less reproducible and does not provide additional joint space
Routine blood tests play little diagnostic role in hip OA, narrowing (JSN) than nWB radiographs, except in severe
but they contribute to rule out alternative diagnoses. The acetabular dysplasia and advanced OA [18, 50–52].
American College of Rheumatology criteria provide a set of Lateral radiographs of the hip can be obtained with
clinical, laboratory, and/or radiographic features to identify different degrees of pelvic rotation, hip abduction and
patients with OA and to distinguish them from patients with flexion [40–42]. They provide variable lateral views of
other diseases [37]. Many biological markers may be altered the proximal femur [42, 53]. In the setting of early-onset
in severe hip OA as in inflammatory or immune-mediated hip OA, the 45° Dunn lateral view offers the better view
articular disorders, but their use remains limited to research of the femoral-neck junction to measure Cam-associated
setting and are not used in clinical practice [38, 39]. features [44, 54, 55] (Fig. 1). The off-lateral view or false
profile of Lequesne is the unique radiograph that provides
an evaluation of the hip joint in a physiological position
in a near sagittal plane [56, 57] enabling to assess anterior
Radiological diagnosis of hip osteoarthritis acetabular coverage and anterior or posterior JSW [58]
(Fig. 6). The off-lateral view enables to detect more hips
Radiographic hip examination with JSN than the AP pelvic radiograph alone [58, 59].

Radiological workup of the hip includes at least an Normal hip radiograph

antero-posterior (AP) radiograph of the pelvis and a
lateral radiograph of the hip. The pelvic radiograph Radiographs of a normal hip joint may demonstrate some
provides an overview of the entire pelvic girdle and cortical irregularities and labral ossifications that should

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Fig. 6  Value of Lequesne’s

false profile view in a 65-year-
old man with mild hip pain
after walking. A AP and B
Lauenstein lateral radiographs
demonstrate almost normal joint
space and osteophytes (arrow-
heads). C Lequesne’s false
profile demonstrates almost
50% joint space narrowing in
the anterior aspect of the joint
(arrows) that cannot be seen on
the other radiographs

not be confused with OA-related structural bone changes and repeatability in the assessment of absent, possible, or
[41, 60, 61]. The radiographic JSW corresponds to the definite JSN has been consistently demonstrated but the
distance between the acetabular roof and the femoral reproducibility can be influenced by methodological features
head, reflecting the combined thickness of the acetabular [48, 67–70].
and femoral head cartilages [62]. Normal JSW varies from JSW can be reliably measured by using manual or com-
2 to 7 mm among individuals with limited variability puter-assisted methods, providing a continuous variable for
(< 1 mm) between both hips of the same individual [63]. cartilage evaluation [67, 69, 71]. JSW shows important inter-
The distance between the fovea capitis and the teardrop individual variations that limit its value to compare patients
does not reflect articular cartilage thickness [62]. On a [63]. Serial JSW measurement can be used to track cartilage
normal pelvic radiograph, the lateral JSW is larger than changes over time, and disease progression was defined as
or equivalent to the medial JSW in 85% and 15% of cases, loss of JSW of ≥ 0.5–0.6 mm/year [48, 69, 72, 73]. JSW
respectively [60]. The lateral JSW should not be thinner change over time seems to better correlate with hip symp-
than the medial JSW except in arched acetabular roof and toms than absolute JSW [67, 71, 73].
in ossified labrum [60]. On the Lequesne false profile
view, the anterior JSW should always be larger than the
posterior JSW [57, 64]. Radiographic structural changes

Abnormal radiographic joint space Structural bone changes on radiographs include subchondral
sclerotic or cystic bone changes and osteophyte formation at
Joint space narrowing (JSN) of the hip is the radiographic the periphery of or at distance from the cartilage-covered
hallmark of late-stage hip OA but is absent in early-stage articular surfaces. Osteophyte formation has received most
hip OA. Several patterns of predominant JSN have been rec- attention in OA and is an important finding in Kellgren-
ognized, most likely reflecting uneven advanced cartilage Lawrence scoring system [74–79]. There is currently no
loss [62, 65, 66]. Predominant lateral or anterior JSN is the accepted or validated definition for early OA [18]. In many
most frequent pattern and is associated with the CAM-type clinical trials, hip OA is defined by a Kellgren-Lawrence
FAI. Predominant medial or posterior JSN is associated with grade ≥ 2 (definite JSN, definite osteophytes, and possible
the Pincer-type FAI [62, 66]. Predominant isolated supero- sclerosis) [74, 75, 80]. The strengths and weaknesses of
medial JSN can occasionally be seen in late-onset OA and these grading systems have been extensively addressed
in some secondary forms of hip OA. Good reproducibility [81, 82].

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2264 Skeletal Radiology (2023) 52:2259–2270

MRI diagnosis of hip osteoarthritis trials and research including (1) Scoring Hip osteoarthritis
with MRI (SHOMRI), (2) Hip OA MRI Scoring System
Hip MRI examination (HOAMS), and (3) Hip Inflammation MRI Scoring System
(HIMRISS) [94, 96–100].
The standard MRI protocol of the hip usually includes fat-
sensitive and fat-saturated fluid-sensitive sequences with the
highest spatial resolution achievable which is higher at 3.0 Strengths and weaknesses of clinical,
than at 1.5 Tesla. Recommended imaging planes vary and radiographic and MRI hip examinations
include standard or oblique coronal, sagittal and transverse in the setting of suspected hip osteoarthritis
planes, radial imaging and 3D imaging [83–85]. Direct hip
traction MR arthrography can also be performed for dedi- Clinical examination
cated cartilage and labrum evaluation but is more invasive
than standard MRI due to the need for articular puncture Clinical examination of the hip of patients with suspected
and hip traction. early-stage hip OA is feasible, available, and repeatable with
a moderate interobserver reproducibility [101]. Its accuracy
MRI of the hip cartilage is acceptable when findings are integrated with past medical
history and present clinical history, in the absence of clinical
In fact, MRI of hip cartilage reached maturity later than that red flags [33, 102]. Exclusion of all red flags is mandatory to
of knee cartilage due to several technical challenges that are accept a presumptive diagnosis of hip OA [45]. A major weak-
specific to the hip. Meta-analyses demonstrated a lower accu- ness of clinical examination is its low sensitivity for detecting
racy of conventional MRI for the detection of cartilage defects early-onset and early-stage hip OA. Clinical examination does
at the hip than at the knee [86, 87]. Technical challenges for not provide any staging system or predictive information but
hip cartilage MRI include (a) deep and eccentric location of can be used to monitor disease progression (Table 1).
the hip, (b) absence of dedicated hip coils (c) thinness of the
hip cartilage, (d) high congruency of the articular surfaces
with no fluid between the two hyaline cartilage surfaces [18, Radiographic examination
88], and (e) complex anatomy with partial volume artifacts.
MRI can demonstrate focal morphological changes of the car- Radiological examination of the hip of patients with sus-
tilage, like signal alteration, substance loss, and delamination, pected OA is feasible, available, and repeatable with an
before radiographic JSN occurs [89, 90] (Fig. 3). Cartilage acceptable moderate interobserver reproducibility [67,
defect may represent early biomarker for OA [89]. Compo- 103]. Despite some variations in radiological practices, the
sitional and quantitative MRI techniques of the cartilage add radiographic technique is well documented and reproduc-
some insights into the sequence and rate of articular cartilage ible among institutions and over time. Long-term follow-
changes at the hip that precede overt hip OA [91]. up radiographs can be compared with initial films. Contra-
indications for pelvic radiographs are negligible. In the
MRI structural changes in hip osteoarthritis setting of hip OA, pelvic radiographs are easily interpreted
by radiologists and clinicians. It yields valuable information
Besides the depiction of hyaline and labral cartilage changes, to differentiate primary from secondary OA and to detect
conventional MRI depicts structural bone changes includ- FAI-associated anatomical features.
ing bone marrow edema (BME)- and sclerosis-like signal Pelvic radiography has poor sensitivity in the detection
changes along with joint effusion and synovitis [89, 92–95]. of many soft tissue, bone, and joint changes [104, 105] and
Osteophytes and subcortical cysts are more conspicuous at therefore has limited value for ruling out alternative disorders.
MRI than at CR because of its multiplanar capacity. MRI, In the setting of hip OA, radiographs are insensitive to com-
a powerful diagnostic tool in OA imaging, has dramatically positional and early structural changes; JSW measurement is
changed our understanding of OA that evolved from a car- insufficient to assess articular cartilage. Deep cartilage defects
tilage-centered disease to a whole joint organ disease. This can be observed at MRI despite normal radiographic JSW
new approach of OA offers potentials for early diagnosis and of that hip [89] (Fig. 3). Given these limitations, CR does
outcome measures for new treatments [90, 94]. However, not fulfill the mandatory requirements to become a valuable
there is currently no accepted or validated definition of hip biomarker of early OA in clinical trials [80, 95, 103, 106].
OA based on MRI [18]. Several semi-quantitative scoring Radiological-clinical discordances have been frequently
systems based on location and severity of articular changes observed; hips with radiographic OA may remain asympto-
have been developed and validated for hip MRI in clinical matic and, conversely, painful hips due to early OA may not
show radiographic signs of OA [107, 108] (Fig. 7). Intensity

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Table 1  Strengths and weaknesses of clinical, radiographic and MR MRI examination

examinations of the hip in patients with suspected hip OA based on
authors’ opinions
Hip MRI is worthwhile feasible with some limitations in
Clinical Radio- MRI availability. In the setting of early OA, a high-resolution hip MRI
examination graphs examination is needed and is the most accurate imaging modality
Feasibility to rule out alternative diagnoses and to diagnose and stage hip
Patient acceptability +  +  + +  +  + + OA. Hip MR arthrography with hip traction is more accurate than
Contra-indications − − + standard MRI for the depiction of cartilage changes indicating
Availability +  +  + +  +  + + some limitations in the accuracy of non-arthrographic MRI [113].
Reproducibility +  + +  + + The interpretation of hip MRI by non-expert radiologists and
Short-term repeatability +  +  + +  +  + +  +  + clinicians remains to be validated in the setting of OA. Variations
Long-term repeatability +  + +  +  + + in local radiological equipment and practices may limit its use in
Radiation − + − large multi-center studies. Constant improvement in image quality,
Cost − + +  +  + the availability of new MR sequences and advanced image post-
Comparative hip joint evaluation +  +  + +  +  + + processing might represent a challenge when evaluation long term
Self-confidence of clinicians in NA +  +  + + hip changes at future MRI examinations.
primary interpretation MRI clinical discordances have been seen. Hips with cartilage
Diagnostic performance lesions at MRI may remain asymptomatic, and symptomatic hips
Sensitivity for OA − − +  +  + may show no signs of OA at MRI [114]. OA-related MRI lesions
Specificity for OA + +  +  + +  + can also be observed in asymptomatic volunteers [114, 115].
Negative predictive value for OA − − +  +  + Some hip changes moderately correlate symptoms, including
Positive predictive value for OA + + +  +  + femoral head BME, synovitis/effusion, and muscle atrophy
Focal cartilage lesion − − +  + [93, 116]. The severity of BME could correlate that of pain and
Diffuse cartilage lesion + +  + + number of microfractures [93]. to the best of our knowledge, the
BME − − +  +  + prevalence and rates of progression of hip changes in OA have
Labral tear + − +  + not been established yet at MRI [91]. It is therefore not surprising
Subchondral cyst − + +  +  + that some clinical trial organisators are reluctant in introducing
Osteophytes − +  + +  +  + MRI at inclusion or as a biomarker due to limitations in its
Joint effusion, synovial swelling − − +  +  + interpretation and/or overlapping findings between symptomatic
Quantitative parameters + + +  +  + and asymptomatic hips (Table 1).
Correlation between imaging findings
Pain NA + +  +
Range of motion NA + +  + A plea for CR as first‑line imaging modality
Provocative maneuvers NA − +  + in clinically suspected hip osteoarthritis
Impact on therapeutic decision/management
CAM-associated features + + +  +  + Rising healthcare costs is a major concern in both the politi-
Pincer-associated features + +  + +  +  + cal and medical professions with diagnostic imaging repre-
Femoral torsion − − +  + senting one of the fastest rising cost segments worldwide.
Planning for total hip replace- − +  + − There is a need for value-driven diagnostic algorithms and
ment decreasing unnecessary diagnostic testing that may not alter
the course of patients’ management can efficiently reduce
healthcare costs [117].
In patients aged above 50 years and hip symptoms sug-
of symptoms fairly correlates with radiological staging of gestive of OA, scientific associations recommend to obtain
OA [109, 110]. In addition to these radio-clinical dissocia- pelvic and hip CR as the first-line imaging modality [8,
tions at an early stage, radiographic hip OA progression 27, 45, 102, 118–121]. However, cost-effectiveness stud-
poorly correlates with pain progression [111]. Early radio- ies assessing the value of hip radiographs in patients with
graphic changes also lack predictive values for the develop- suspected hip OA indicated a variable impact on patient’s
ment of clinical hip OA at 5–10 years follow-up in large management. As a matter of fact, a presumptive clinical
patients cohorts [25, 112]. Change in JSW seems to better diagnosis of hip OA could be accepted without requiring
correlate with symptoms than the absolute JSW at a given medical imaging in patients > 50 years without previous
moment (Table 1). relevant medical history as long as symptoms and clinical

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Fig. 7  Hypothetical Venn diagram illustrating the lack of coherence parameters are present. In OA, discordance between symptoms, clini-
between pain, clinical examination, and imaging findings in patients cal examination, and imaging findings are frequent. In femoral neck
with A presumed hip osteoarthritis and B femoral neck fracture. The fractures, the three parameters are overlapping
shaded area represents the proportion of patients in whom all three

examination at onset and clinical course at follow-up remain from surgery. Cost-effectiveness analysis of hip MRI in the
consistent with this diagnosis [45]. A trend in a more com- setting of FAI will then become mandatory.
prehensive approach of patients with age-associated articular
pain further supports a declining role of medical imaging, in
the absence of red flags at onset and of unexpected clinical Perspectives that would favor the use of MRI
evolution. A recent study demonstrated that psychological as first‑line imaging modality
and behavioral characteristics of patients with hip pain better
correlated with hip pain than any arthroscopically demon- A currently not foreseen increase in MRI equipment avail-
strated hip lesion [122]. To the best of our knowledge, we are ability and decrease in examination time duration and cost
not aware of any validated recommendation proposing hip would be mandatory to significantly change patient’s imag-
MRI as the first imaging modality for suspected hip OA in ing workflow. Currently, in the absence of disease modifying
patients aged >50 years. Cost-effectiveness studies in several drugs, healthcare system efforts focus on tertiary prevention
MSK disorders including OA assessing the value of MRI on of hip OA to soften the clinical and functional consequences
patient management demonstrated a significant increase in and to postpone total hip replacement. Currently, there are no
cost without any therapeutic effect [117, 123]. proven disease modifying drugs approved by the regulatory
In patients aged below 50 years of age and presumed agencies and, therefore, the impact of early detection of OA
hip OA, numerous scientific associations also recommend is limited. The availability of disease modifying drugs and of
to obtain conventional radiographs of the hip as the first- MRI biomarkers that would enable to select patients who are
line imaging modality without any delay [45, 55, 120, 124, likely to benefit from these drugs would definitely support
125]. Studies assessing cost-effectiveness of radiographs are the use of MRI as a screening tool. Cost-effectiveness studies
lacking as hip radiographs are used for patient inclusion. would then be of value once the cost of these disease modify-
Currently, the medical community is still awaiting the multi- ing drugs would be determined. (Tables 2 and 3).
center confirmation that preservative hip surgery in young Currently, hip MRI is considered to be the most sensitive
patients with FAI-related disorders is a disease modifying non-invasive imaging modality that enables to assess local
intervention. In case of reliable positive results, MRI could pre-OA changes and is the best imaging modality to assess
be obtained as second-line imaging modality if MRI yields time- and drug-related changes in radiological studies. How-
independent markers to select patients who would benefit ever, clinical trial organisators are reluctant in including hip

Table 2  Factors that support radiographs as first imaging modality in suspected hip OA
• Lack of availability of disease-modifying drugs
• High prevalence of OA
• Limited diagnostic value of clinical history and examination
• Readability by non-radiologists
• Weaknesses of MRI

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Table 3  Factors that need to be fulfilled before abandoning radiographs as first imaging modality in suspected hip OA

• Availability of disease-modifying drugs

• Validation of long-term results of disease-modifying interventions
• Better availability of MRI (cost, duration, readability)
• Optimized non-contrast enhanced MR images
• Better understanding of mechanisms of pain

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