Mr Balakumar places significant weight on imaging as part of his assessment process. His view is that if a clinician is considering surgery, there should be convincing imaging to support it. Imaging tells the truth, though it can be misread or misinterpreted, which is why it is always reviewed in the context of a thorough clinical history and examination rather than in isolation.
For hip conditions, Mr Balakumar requests a specific set of standardised X-ray views rather than a generic pelvis X-ray. The views he orders are chosen deliberately to give him the most useful information about the specific anatomy of each patient’s hip. In selected patients he also uses advanced cartilage mapping techniques that are not widely available in Melbourne, which help inform decisions about joint preservation versus joint replacement in cases where the answer is not clear from standard imaging alone.
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Plain X-ray is the most commonly used imaging investigation for hip conditions. It provides clear images of the bony anatomy, allowing assessment of joint space, bone shape and alignment, and the presence of deformity or arthritis.
For hip assessment, Mr Balakumar requests a specific set of standardised X-ray views: a standing AP pelvis, a standing faux profile (a side view of the socket), a Von Rosen view for dysplasia assessment, and a frog lateral view (a side view of the femoral head). These views are chosen to provide the most clinically useful information.
The radiation from a single hip X-ray is similar to background radiation from a short-haul flight to Sydney. Up to 100 chest X-rays per year is considered a safe annual radiation exposure. The cumulative dose from routine orthopaedic follow-up X-rays remains well within safe limits.
CT scanning provides detailed three-dimensional images of the bony anatomy and is particularly useful for assessing complex deformities, planning osteotomy procedures and evaluating implant position after joint replacement.
CT involves more radiation than plain X-ray. A CT scan of the hip and pelvis delivers approximately 10 to 20 times the radiation of a single X-ray, which is roughly equivalent to background radiation from a return flight between Melbourne and New York. It is ordered when the additional information it provides is clinically necessary.
MRI uses a magnetic field and radio waves rather than radiation. It provides detailed images of soft tissues including the labrum, cartilage, tendons and muscles. MRI is used to assess labral tears, cartilage damage, avascular necrosis, stress fractures and soft tissue pathology around the hip.
MRI is widely available in the private setting, though it can be difficult to access in the public hospital system. It does not involve radiation, but is not suitable for patients with pacemakers, certain metal implants or brain coils. It can also cause anxiety in patients who are claustrophobic, as the scan requires lying still in a narrow tunnel for 30 to 60 minutes.
A specialised MRI sequence called dGEMRIC (delayed gadolinium-enhanced MRI of cartilage) provides a quantitative assessment of cartilage health in the hip. It is particularly useful in patients with hip dysplasia or impingement where the decision between joint preservation and joint replacement is not straightforward. This sequence generates a logarithmic curve that gives both Mr Balakumar and the patient a prognostic estimate of the likely success of a joint preservation procedure.
Most of this work was pioneered in the United States and Switzerland. Mr Balakumar uses dGEMRIC in collaboration with radiologists at the Royal Children’s Hospital Melbourne and Melbourne Radiology Clinic for this specific patient population.
A bone scan is a nuclear medicine investigation in which a radioactive marker is used to assess blood flow and bone activity. It has less radiation than a CT scan but more than a plain X-ray. It is particularly useful in children when the location of a problem is not yet clear from other investigations, and in adults when assessing blood supply or the stability of a prosthesis.
No special preparation is required for X-ray or CT. For MRI, you will be asked about any metal implants, pacemakers or devices before the scan. Remove metal jewelry and clothing with metal components. Please bring any previous imaging to your appointment. If having new imaging arranged, attending a centre that provides both the images and a radiology report is helpful.
Mr Balakumar is one of a small number of surgeons in Australia with formal training in both paediatric and adult hip surgery. His fellowship at Harvard’s Children’s Hospital in Boston, under some of the world’s leading specialists in hip preservation, gives him a depth of expertise that is difficult to find in a single practice.
His approach is the same whether the patient is 6 months or 65 years old – thorough assessment, honest options, and no pressure toward surgery until the clinical picture clearly supports it.
(03) 9573 9659
