Uncommon observation of bifocal giant subchondral cysts in the hip: diagnostic role of CT arthrography and MRI, with pathological correlation

Pauline Gonzalez-Espino, Maïté Van Cauter, Louis Gossing, Christine C. Galant, Souad Acid, Frederic E. Lecouvet

Subchondral cysts (or geodes) are common in osteoarthritis (OA), usually in association with other typical signs, i.e., joint space narrowing, subchondral bone sclerosis, and osteophytosis. However, large lesions without the typical signs of OA or lesions located outside the weight-bearing areas are unusual and may be confused for other conditions, in particular, those of tumoral origin. We report the findings in a 48-year-old man who had been complaining of left buttock pain for 3 years, getting worse over the last year, and an evolutive limited range of motion of the hip. The pain was increased by weight-bearing and was not relieved by nonsteroidal anti-inflammatory drugs. Radiographs and CT showed a large multilocular lytic lesion within the femoral head and a large lytic lesion in the left ilio-ischiatic ramus, raising the question of bifocal tumoral involvement. On MRI, the lesions had low signal intensity on T1- and high signal intensity on T2-weighted MR images, with subtle peripheral enhancement on post-contrast T1-weighted images. CT arthrography, by demonstrating a communication between the femoral head and ischiatic cysts and the joint space allowed us to definitively rule out malignant conditions and to make the diagnosis of subchondral bone cysts. Total hip arthroplasty was performed. Pathological analysis of the resected femoral head and of material obtained at curettage of the ischiatic lesion confirmed the diagnosis of degenerative geodes. This case illustrates an atypical bifocal location of giant subchondral cysts in the hip joint mimicking lytic tumors, in the absence of osteoarthritis or rheumatoid arthritis, and highlights the role of CT arthrography in identifying this condition.