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Meier MP, Hawellek T, Lehmann W, von Lewinski G. [Tips and tricks of cement removal in the case of revision surgery]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:176-184. [PMID: 37855912 PMCID: PMC10896878 DOI: 10.1007/s00132-023-04453-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND In Germany, current revision rates after arthroplasty range between 28-37%. In particular, remaining cement residues are causative for additional revision surgery after periprosthetic joint infection, which is why complete cement removal is of high importance. However, the removal of remaining cement residues often confronts the surgeon with technical challenges. Complication-free and complete cement removal requires extensive preoperative preparation in order to develop the best possible surgical strategy. TREATMENT Special instrument sets to facilitate cement removal in revision cases are available from various manufacturers. In addition to endoluminal approaches, access enhancements such as extended osteotomies exist to facilitate complete cement removal. Finally, the surgeon should be able to give the indication for an intraoperative procedural change after a defined time interval.
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Affiliation(s)
- Marc-Pascal Meier
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| | - Thelonius Hawellek
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Wolfgang Lehmann
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Gabriela von Lewinski
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
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2
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Weissman BN, Palestro CJ, Fox MG, Bell AM, Blankenbaker DG, Frick MA, Jawetz ST, Kuo PH, Said N, Stensby JD, Subhas N, Tynus KM, Walker EA, Kransdorf MJ. ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty. J Am Coll Radiol 2023; 20:S413-S432. [PMID: 38040462 DOI: 10.1016/j.jacr.2023.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
This article reviews evidence for performing various imaging studies in patients with total hip prostheses. Routine follow-up is generally performed with radiography. Radiographs are also usually the initial imaging modality for patients with symptoms related to the prosthesis. Following acute injury with pain, noncontrast CT may add information to radiographic examination regarding the presence and location of a fracture, component stability, and bone stock. Image-guided joint aspiration, noncontrast MRI, and white blood cell scan and sulfur colloid scan of the hip, are usually appropriate studies for patients suspected of having periprosthetic infection. For evaluation of component loosening, wear, and/or osteolysis, noncontrast CT or MRI are usually appropriate studies. Noncontrast MRI is usually appropriate for identifying adverse reaction to metal debris related to metal-on-metal articulations. For assessing patients after hip arthroplasty, who have trochanteric pain and nondiagnostic radiographs, ultrasound, or MRI are usually appropriate studies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | | | | | - Angela M Bell
- Rush University Medical Center, Chicago, Illinois; American College of Physicians
| | - Donna G Blankenbaker
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - Phillip H Kuo
- University of Arizona, Tucson, Arizona; Commission on Nuclear Medicine and Molecular Imaging
| | - Nicholas Said
- Duke University Medical Center, Durham, North Carolina
| | | | | | - Katherine M Tynus
- Northwestern Memorial Hospital, Chicago, Illinois; American College of Physicians
| | - Eric A Walker
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania; Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Mikkelsen RT, Schou M, Torfing T, Graumann O, Overgaard S, Varnum C. Sensitivity and specificity for detecting pseudotumors in patients with hip resurfacing arthroplasty, metal-on-metal or metal-on-polyethylene total hip arthroplasty-MRI versus ultrasonography performed by an orthopedic surgery resident. Acta Radiol Open 2023; 12:20584601231152396. [PMID: 36776533 PMCID: PMC9909072 DOI: 10.1177/20584601231152396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 04/02/2023] [Indexed: 02/10/2023] Open
Abstract
Background Metal artifact reduction sequence magnetic resonance imaging (MRI) scan is a common method to detect adverse reaction to metal debris in total hip arthroplasty (THA). It might be quicker and cheaper if ultrasonography (US) could screen for the need for an MRI. However, both require trained personnel. Purpose We aimed to investigate the sensitivity and specificity of US for detecting pseudotumors (PT) when performed by an orthopedic surgery resident compared to MRI. We also investigated the sensitivity and specificity of US to detect PTs in obese and non-obese patients. Material and methods We examined 205 patients with hip resurfacing arthroplasty, metal-on-metal or metal-on-polyethylene THA with both MRI and US. US was performed by an orthopedic surgery resident who was trained according to a standardized training program in musculoskeletal US. Results from MRI were used as gold standard. Results US had a sensitivity of 0.92 (95% CI 0.81-0.98) and specificity of 0.94 (95% CI 0.89-0.97) for detecting PT. It had a positive predictive value of 0.84 (95% CI 0.73-0.91) and a negative predictive value of 0.97 (95% CI 0.93-0.99). US performed similarly in obese and non-obese patients. Conclusions US had a high sensitivity and specificity for detecting PT when performed by an orthopedic surgery resident. Trained orthopedic surgeons could screen for the need of an MRI scan when searching PTs.
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Affiliation(s)
- Rasmus T Mikkelsen
- Department of Orthopedic Surgery, Lillebaelt Hospital, Vejle, Denmark,Department of Regional Health Research, Faculty of Health Science, University of Southern Denmark, Odense, Denmark,Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark,Rasmus T Mikkelsen, Lillebaelt Hospital, Department of Orthopedic Surgery, Beriderbakken 4 7100, Vejle, Denmark.
| | - Martin Schou
- Department of Emergency Medicine, Holbaek Hospital, Holbaek, Denmark
| | - Trine Torfing
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Ole Graumann
- Department of Radiology, Odense University Hospital, Odense, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Søren Overgaard
- Department of Orthopedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark,Department of Clinical Research, University of Southern Denmark, Odense, Denmark,Department of Orthopaedic Surgery and Traumatology, Copenhagen University Hospital, Bispebjerg, Denmark,University of Copenhagen, Department of Clinical Medicine, Faculty of Health and Medical Sciences, Kobenhavn, Denmark
| | - Claus Varnum
- Department of Orthopedic Surgery, Lillebaelt Hospital, Vejle, Denmark,Department of Regional Health Research, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
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4
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[Strategies for stem revision : Surgery planning, implant removal and reimplantation]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:21-34. [PMID: 35802156 PMCID: PMC9842594 DOI: 10.1007/s00132-022-04277-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PLANNING Femoral revision represents a challenging procedure in its surgical planning and technical execution. The results are mainly dependent on the bone loss present, the quality of the implant removal and the choice of revision system. Patient-specific factors such as age, comorbidities, bone quality or even the localization of the cement have a decisive influence on the surgical strategy. Appropriate preoperative preparation, including the presence of the necessary special instruments, which are essential for gentle implant removal, is indispensable to achieve the best possible result. THERAPY A bone-sparing implant removal can be particularly challenging, especially in the case of well-fixed stems and cement residues, which may extend far beyond the isthmus. In such situations, a transfemoral approach should be considered. Cementless reimplantation using modular or non-modular titanium stems is currently the preferred treatment of choice for most revisions. In elderly, low-demand patients or with poor bone quality, cemented revision remains a good alternative treatment option.
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Soliman SB, Davis JJ, Muh SJ, Vohra ST, Patel A, van Holsbeeck MT. Ultrasound evaluations and guided procedures of the painful joint arthroplasty. Skeletal Radiol 2022; 51:2105-2120. [PMID: 35624311 DOI: 10.1007/s00256-022-04080-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/22/2022] [Accepted: 05/22/2022] [Indexed: 02/02/2023]
Abstract
The purpose of this article is to describe the use of ultrasound for the diagnosis and treatment of painful joint arthroplasty. Ultrasound plays a crucial role in the diagnosis of the painful joint arthroplasty, especially given its unique dynamic capabilities, convenience, and high resolution. Ultrasound guidance is also instrumental for procedures in both diagnosing and in select cases, treating the painful joint arthroplasty. Topics to be discussed in this article include trends in arthroplasty placement, benefits of the use of ultrasound overall, and ultrasound evaluation of periprosthetic joint infections. We will also review the sonographic findings with dissociated/displaced components and adverse reaction to metallic debris including metallosis, trunnionosis, and metal-on-metal pseudotumors. Additionally, we will discuss ultrasound evaluation of tendon pathologies with arthroplasties, including dynamic maneuvers to evaluate for tendon impingement/snapping. Finally, we will cover ultrasound-guided joint arthroplasty injection indications and precautions. KEY POINTS: • Ultrasound is preferred over MRI in patients with joint arthroplasty and plays a crucial role in diagnosis, especially given its unique dynamic capabilities, convenience and high resolution. • It is especially beneficial for US-guided aspiration in periprosthetic joint infections; effectively used to evaluate periprosthetic fluid collections, facilitating differentiation between abscesses and aseptic collections, and tracking sinus tracts. • Recently, the diagnosis of periprosthetic joint infections has shifted focus to biomarkers in the periprosthetic fluid, specifically α-defensin, which has a high sensitivity and specificity for diagnosing infection. • Cutibacterium acnes is a major pathogen responsible for shoulder arthroplasty infections, often presenting with normal laboratory values and since slow growing, must be kept for a minimum of 14 days.
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Affiliation(s)
- Steven B Soliman
- Division of Musculoskeletal Radiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA.
| | - Jason J Davis
- Division of Orthopedic Surgery, Department of Orthopedics, Henry Ford Hospital, Detroit, MI, USA
| | - Stephanie J Muh
- Division of Orthopedic Surgery, Department of Orthopedics, Henry Ford Hospital, Detroit, MI, USA
| | - Saifuddin T Vohra
- Division of Musculoskeletal Radiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
| | - Ashish Patel
- Division of Musculoskeletal Imaging, Department of Radiology, Vanderbilt University, Nashville, TN, USA
| | - Marnix T van Holsbeeck
- Division of Musculoskeletal Radiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA
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Nandra RS, Ahmed U, Berryman F, Brash L, Dunlop DJ, Matharu GS. How much does a Medical and Healthcare Products Regulatory Agency medical device alert for metal-on-metal hip arthroplasty patients really cost? Hip Int 2022; 32:493-500. [PMID: 33445979 PMCID: PMC9203671 DOI: 10.1177/1120700020983297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many worldwide regulatory authorities recommend regular surveillance of metal-on-metal hip arthroplasty patients given high failure rates. However, concerns have been raised about whether such regular surveillance, which includes asymptomatic patients, is evidence-based and cost-effective. We determined: (1) the cost of implementing the 2015 MHRA surveillance in "at-risk" Birmingham Hip Resurfacing (BHR) patients; and (2) how many asymptomatic hips with adverse reactions to metal debris (ARMD) would have been missed without patient recall. METHODS All BHR patients eligible for the 2015 MHRA recall (all females, and males with head sizes ⩽46 mm, regardless of symptoms) at one centre were invited for review (hips = 707; patients = 593). All patients were investigated (Oxford Hip Score, radiographs, blood metal ions, and targeted cross-sectional imaging) and managed accordingly. Surveillance costs were calculated using finance department data. RESULTS The surveillance cost £105,921.79 (range £147.76-£257.50/patient). Radiographs (£39,598) and nurse practitioner time/assistance (£23,618) accounted for 60% of overall costs. 31 hips had ARMD on imaging (12 revised; 19 under surveillance). All revisions were symptomatic. 7 hips with ARMD under surveillance were asymptomatic and remain under regular review. The number needed to treat to avoid missing one asymptomatic ARMD case was 101 patients, representing a cost of £18,041 to avoid one asymptomatic case. CONCLUSIONS Implementing MHRA surveillance for "at-risk" BHR patients was extremely costly. The risk of asymptomatic ARMD was low with the BHR (1%), suggesting recommended follow-up in asymptomatic patients is not cost efficient. This raises concerns about the increasingly intensive surveillance recommended in the 2017 MHRA guidance for metal-on-metal hip patients.
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Affiliation(s)
| | - Usman Ahmed
- The Royal Orthopaedic Hospital, Birmingham, UK
| | | | | | | | - Gulraj S Matharu
- The Royal Orthopaedic Hospital, Birmingham, UK,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK,Gulraj S Matharu, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.
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7
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Takahashi T, Thaker S, Lettieri G, Redmond A, Backhouse MR, Stone M, Pandit H, O'Connor P. Reliability of slice-encoding for metal artefact correction (SEMAC) MRI to identify prosthesis loosening in patients with painful total hip arthroplasty - a single centre, prospective, surgical validation study. Br J Radiol 2022; 95:20210940. [PMID: 35148205 PMCID: PMC9153704 DOI: 10.1259/bjr.20210940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To validate reliability of slice-encoding for metal artefact correction (SEMAC)-MRI findings in prosthesis loosening detection by comparing them to surgical outcomes (gold standard) in symptomatic patients following hip arthroplasties. To evaluate periprosthetic anatomical structures in symptomatic patients to identify an alternative cause of hip symptoms. METHODS We prospectively followed 47 symptomatic patients (55 hips, 39 painful hips - group P and 16 control hips - group C) at our institution from 2011 to 2016. We acquired 1.5 T MRI conventional and SEMAC-MRI images for all patients. Two consultants scored MRI for osteolysis and marrow oedema zone-wise using predefined signal characteristics and settled scoring variations by consensus. We used Spearman Rank-Order Correlation for correlation analysis and used OMERACT (Outcome Measures in Rheumatology) filter pillars to validate SEMAC-MRI findings. RESULTS Eleven patients needed revision surgery, all from group P. None from group C required revision surgery. Remaining 28 hips in the group P were managed conservatively pain completely resolved in 21 hips, eight hips had trochanteric bursitis, eight had extraarticular cause and the remaining five hips had spontaneous pain resolution. We found moderate-to-weak correlation between SEMAC-MRI findings for prosthesis loosening and revision surgery outcomes. Sensitivity, Specificity, PPV and NPV in Group P were (72.7, 64.3, 44.4, 85.7%) in T1W-SEMAC, (90.9, 46.4, 40.0, 92.9%) in STIR-SEMAC and (36.3, 78.5, 40.0, 75.8%) in PDW-SEMAC. CONCLUSION Negative SEMAC-MRI results can effectively exclude prosthesis loosening confirmed on revision surgery and SEMAC-MRI can detect alternative cause of hip pain accurately. ADVANCES IN KNOWLEDGE Negative SEMAC-MRI in painful THA patients can effectively exclude prosthesis loosening as a cause.
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Affiliation(s)
| | - Siddharth Thaker
- Chapel Allerton Hospital, Leeds Teaching Hospital NHS Trust, Leeds, UK
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8
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Kavolus JJ, Lazarides AL, Moore C, Seyler TM, Wellman SS, Attarian DE, Bolognesi MP, Alman BA. The Calpain Gene is Correlated With Metal-on-Metal Hip Replacement Failures. J Arthroplasty 2021; 36:236-241.e3. [PMID: 32811707 DOI: 10.1016/j.arth.2020.07.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/18/2020] [Accepted: 07/22/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Metal-on-metal (MOM) total hip arthroplasty is associated with unacceptable failure rates secondary to metal ion reactions. Efforts to identify which patients will go on to failure have been limited; recently, there has been a suggestion for a potential genetic basis for the increased risk of revision in MOM hip replacements (MOMHRs). The purpose of this study is to determine whether certain immunologic genotypes are predictive of the need for revision in patients with MOM total hip implants. METHODS This is a case-control study of all patients undergoing primary MOMHR between September 2002 and January 2012 with a minimum of 5-year follow-up. Our investigational "case" cohort was comprised of patients who underwent revision for MOMHR for a reason other than infection. A single-nucleotide polymorphism (SNP) array analysis was performed to identify a potential genetic basis for failure. RESULTS Thirty-two patients (15 case and 17 control) were included in our analysis. All patients in the revision group had a chief complain of pain; revision patients were more likely to have a posterior approach (P = .01) and larger head size (P = .04) than nonrevision patients. No patient or implant characteristics were independently associated with revision in a multivariate analysis. Patients with SNP kgp9316441 were identified as having an increased odds of revision for MOM failure (P < .001). CONCLUSION This study identified an SNP, kgp9316441, encoding proteins associated with inflammation and macrophage activation. This SNP was associated with significantly increased odds of revision for MOMHR. Future studies are warranted to validate this gene target both in vitro and in vivo. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Joseph J Kavolus
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | | | - Christina Moore
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - David E Attarian
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Benjamin A Alman
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
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Best Practices: Best Imaging Modality for Surveillance of Metal-on-Metal Hip Arthroplasty. AJR Am J Roentgenol 2020; 216:311-317. [PMID: 33325734 DOI: 10.2214/ajr.19.22344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE. Metal-on-metal hip arthroplasty has been shown to result in soft-tissue complications in some patients, making revision surgery necessary. Imaging is critical in the detection and surveillance of soft-tissue complications, which are collectively termed adverse reaction to metal debris (ARMD) and adverse local tissue reaction. Studies have investigated the use of ultrasound, MRI, and CT for detecting ARMD, and each modality has advantages and disadvantages. This article provides evidence-based recommendations for imaging surveillance of ARMD. CONCLUSION. Compared with ultrasound, MRI has been found to be a better imaging modality for surveillance of ARMD. In addition, MRI is not operator dependent, allows visualization of soft-tissue details, and allows more consistent measurement of fluid collections on follow-up examinations. Limitations of ultrasound include operator skill, the inability to visualize osseous structures, and the challenge of visualizing posterior soft tissues for synovitis and fluid collections in larger patients. Finally, CT is only useful for focused evaluation of osteolysis or periprosthetic fracture.
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10
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Metal-on-Metal Total Hip Revisions: Pearls and Pitfalls. J Arthroplasty 2020; 35:S68-S72. [PMID: 32081501 DOI: 10.1016/j.arth.2020.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND At the turn of the 21st century, there was a re-emergence of metal-on-metal (MoM) articulation with 35% of all total hip arthroplasty implants having MoM articulation. Approximately 10 years after its peak use, MoM articulation began to decrease dramatically as revisions became more apparent because of adverse reaction to metal debris. Today, there are surveillance guidelines and reconstructive clinical pearls a surgeon should recognize. METHODS This article gives a literature-based overview of clinical pearls and discusses how to avoid pitfalls when performing revision of a metal-on-metal total hip arthroplasty. RESULTS Patients with MoM can be risk-stratified based on symptom, implant, and testing variables. Those patients who are symptomatic and/or develop adverse reaction to metal debris with local tissue destruction will require a revision. The revision of MoM can be challenging due to bone and soft tissue destruction. Constraint may be needed in cases of abductor deficiency. CONCLUSION Although MoM implants for THA have declined significantly, surgeons are still faced with the revision burden from a decade of high use. Risk stratification tools are available to aid in revision decision making, and the surgeon should be prepared to address the challenges these revisions present.
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Van Der Straeten C, Calistri A, Grammatopoulos G, De Smet K. Radiographic evaluation of hip resurfacing: the role of x-rays in the diagnosis of a problematic resurfaced hip. Hip Int 2020; 30:167-175. [PMID: 31431088 DOI: 10.1177/1120700019836373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Hip resurfacing (HRA) requires a new standardised radiographic evaluation protocol. Evaluation of acetabular components is similar to total hip arthroplasty (THA) but femoral components require different criteria. This study evaluates the efficacy of a new femoral zonal system for radiographic HRA assessment in identifying clinical problems. METHODS A new proximal femoral zonal system divides implant-cement-bone interfaces at head and neck into 7 DeSmet zones. 611 in situ and 100 revised HRA were assessed for component positioning, borderline findings (reactive lines, cortical thickening, cancellous condensation) or sinister findings (lucent lines, bone resorption, osteolysis). Findings were correlated with gender, size, implant survival, clinical scores, metal ions, and adverse soft tissue reactions (ALTR). RESULTS Radiological changes were found in 265 hips (37.3%), 154 sinister (21.7%) and 111 borderline (15.6%). 84% of revisions had sinister findings versus 11.4% of in situ HRA (p < 0.001). The mean number of abnormal acetabular and femoral zones was 3.3 in revised compared to 0.6 in situ HRA (p < 0.001). Sinister findings were associated with female gender, lower clinical scores, smaller sizes or ASR design (all: p < 0.001). Metal ions were higher with sinister (p < 0.001) and borderline (p < 0.01) findings compared to normal radiographs. Pathological findings in ⩾4 zones had a sensitivity of 50% and specificity of 94.2% (AUC = 0.898) in detecting hips with ALTR (odds ratio = 49). CONCLUSION In order to accurately evaluate progressive radiographic changes in HRA, specific zones have been established around the femoral component. There was a high correlation between radiographic findings and outcome measures. 84% of problematic hips and 90.4% of proven ALTR had sinister changes.
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Chang JS, Haddad FS. Revision total hip arthroplasty for metal-on-metal failure. J Clin Orthop Trauma 2020; 11:9-15. [PMID: 32001977 PMCID: PMC6985013 DOI: 10.1016/j.jcot.2019.09.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022] Open
Abstract
Metal-on-metal (MoM) arthroplasty systems became popular in the early-2000s due to presumed advantages of improved wear characteristics and superior stability. However, subsequent reports of abnormal soft-tissue reactions to MoM implants and national registry data reporting high failure rates raised concerns. Early outcomes of revision total hip arthroplasty (THA) for adverse reaction to metal debris (ARMD) were poor, leading to development of surveillance programs and a trend towards early revision surgery. Patients with MoM arthroplasties require surveillance, comprehensive history and physical examination, imaging with ultrasound or magnetic resonance imaging (MRI), and laboratory evaluation including metal ion levels. Operative strategies for revision THA vary from exchange of modular components to extensive debridement and reconstruction with revision components. Surgeons should be aware of the increased risks of dislocation and infection following revision THA for ARMD. However, there is growing evidence that early revision surgery prior to extensive soft tissue destruction results in improved outcomes and decreased re-operation rates. It is estimated that >1 million MoM articulations have been implanted, with a large proportion still in situ. It is imperative to understand the aetiology, presentation, and management strategies for these patients to optimise their clinical outcomes.
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Affiliation(s)
- Justin S. Chang
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, 250 Euston Road, NW1 2PG, London, UK,Corresponding author.
| | - Fares S. Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, 250 Euston Road, NW1 2PG, London, UK,The Princess Grace Hospital, 42-52 Nottingham Place, W1U 5NY, London, UK
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13
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No Threshold Exists for Recommending Revision Surgery in Metal-on-Metal Hip Arthroplasty Patients With Adverse Reactions to Metal Debris: A Retrospective Cohort Study of 346 Revisions. J Arthroplasty 2019; 34:1483-1491. [PMID: 30992241 PMCID: PMC6590389 DOI: 10.1016/j.arth.2019.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/28/2019] [Accepted: 03/06/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Surgeons currently have difficulty when managing metal-on-metal hip arthroplasty (MoMHA) patients with adverse reactions to metal debris (ARMD). This stems from a lack of evidence, which is emphasized by the variability in the recommendations proposed by different worldwide regulatory authorities for considering MoMHA revision surgery. We investigated predictors of poor outcomes following MoMHA revision surgery performed for ARMD to help inform the revision threshold and type of reconstruction. METHODS We retrospectively studied 346 MoMHA revisions for ARMD performed at 2 European centers. Preoperative (metal ions/imaging) and intraoperative (findings, components removed/implanted) factors were used to predict poor outcomes. Poor outcomes were postoperative complications (including re-revision), 90-day mortality, and poor Oxford Hip Score. RESULTS Poor outcomes occurred in 38.5%. Shorter time (under 4 years) to revision surgery was the only preoperative predictor of poor outcomes (odds ratio [OR] = 2.12, confidence interval [CI] = 1.00-4.46). Prerevision metal ions and imaging did not influence outcomes. Single-component revisions (vs all-component revisions) increased the risk of poor outcomes (OR = 2.99, CI = 1.50-5.97). Intraoperative modifiable factors reducing the risk of poor outcomes included the posterior approach (OR = 0.22, CI = 0.10-0.49), revision head sizes ≥36 mm (vs <36 mm: OR = 0.37, CI = 0.18-0.77), ceramic-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.30, CI = 0.14-0.66), and metal-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.37, CI = 0.17-0.83). CONCLUSION No threshold exists for recommending revision in MoMHA patients with ARMD. However postrevision outcomes were surgeon modifiable. Optimal outcomes may be achieved if surgeons use the posterior approach, revise all MoMHA components, and use ≥36 mm ceramic-on-polyethylene or metal-on-polyethylene articulations.
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Connelly JW, Galea VP, Laaksonen I, Matuszak SJ, Madanat R, Muratoglu O, Malchau H. Indications for MARS-MRI in Patients Treated With Articular Surface Replacement XL Total Hip Arthroplasty. J Arthroplasty 2018; 33:2906-2911. [PMID: 29776852 DOI: 10.1016/j.arth.2018.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to identify which patient and clinical factors are predictive of adverse local tissue reaction (ALTR) and to use these factors to create a highly sensitive algorithm for indicating metal artifact reduction sequence magnetic resonance imaging (MARS-MRI) in Articular Surface Replacement (ASR) XL total hip arthroplasty patients. Our secondary aim was to compare our algorithm to existing national guidelines on when to take MARS-MRI in metal-on-metal total hip arthroplasty patients. METHODS The study consisted of 137 patients treated with unilateral ASR XL implants from a prospective, multicenter study. Patients underwent MARS-MRI regardless of clinical presentation at a mean of 6.2 (range, 3.3-10.4) years from surgery. Univariate and multivariate analyses were conducted to determine which variables were predictive of ALTR. Predictors were used to create an algorithm to indicate MARS-MRI. Finally, we compared our algorithm's ability to detect ALTR to existing guidelines. RESULTS We found a visual analog scale pain score ≥2 (odds ratio [OR] = 2.53; P = .023), high blood cobalt (OR = 1.05; P = .023), and male gender (OR = 2.37; P = .034) to be significant predictors of ALTR presence in our cohort. The resultant algorithm achieved 86.4% sensitivity and 60.2% specificity in detecting ALTR within our cohort. Our algorithm had the highest area under the curve and was the only guideline that was significantly predictive of ALTR (P = .014). CONCLUSION Our algorithm including patient-reported pain and sex-specific cutoffs for blood cobalt levels could predict ALTR and indicate MARS-MRI in our cohort of ASR XL metal-on-metal patients with high sensitivity. LEVEL OF EVIDENCE Level II, diagnostic study.
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Affiliation(s)
- James W Connelly
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Vincent P Galea
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Inari Laaksonen
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sean J Matuszak
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Rami Madanat
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Orhun Muratoglu
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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Connelly JW, Galea VP, Matuszak SJ, Madanat R, Muratoglu O, Malchau H. Indications for MARS-MRI in Patients Treated With Metal-on-Metal Hip Resurfacing Arthroplasty. J Arthroplasty 2018; 33:1919-1925. [PMID: 29606289 DOI: 10.1016/j.arth.2018.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/11/2018] [Accepted: 01/13/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Currently, there are no universally accepted guidelines on when to obtain metal artifact reduction sequence magnetic resonance imaging (MARS-MRI) in metal-on-metal (MoM) hip resurfacing arthroplasty (HRA) patients. Our primary aims were to identify which patient and clinical factors are predictive of adverse local tissue reaction (ALTR) and create an algorithm for indicating MARS-MRI in patients with Articular Surface Replacement (ASR) HRA. The secondary aim was to compare our algorithm to existing guidelines on when to perform MARS-MRI in MoM HRA patients. METHODS The study cohort consisted of 182 patients with unilateral ASR HRA from a prospective, multicenter study. Subjects received MARS-MRI at a mean of 7.8 years from surgery, regardless of symptoms. We determined which variables were predictive of ALTR and generated cutoffs for each variable. Finally, we created an algorithm to predict ALTR and indicate MARS-MRI in ASR HRA patients using these cutoffs and compared it to existing guidelines. RESULTS We found high blood cobalt (Co) (odds ratio = 1.070; P = .011) and high blood chromium (Cr) (odds ratio = 1.162; P = .002) to be significant predictors of ALTR presence. Our algorithm using a blood Co cutoff of 1.15 ppb and a Cr cutoff of 1.09 ppb achieved 96.6% sensitivity and 35.3% specificity in predicting ALTR, which outperformed the existing guidelines. CONCLUSION Blood Co and Cr levels are predictive of ALTR in ASR HRA patients. Our algorithm considering blood Co and Cr levels predicts ALTR in ASR HRA patients with higher sensitivity than previously established guidelines.
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Affiliation(s)
- James W Connelly
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA
| | - Vincent P Galea
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA
| | - Sean J Matuszak
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA
| | - Rami Madanat
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Orhun Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA
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Affiliation(s)
- F S Haddad
- NIHR University College London Hospitals Biomedical Research Centre, UK
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Matharu GS, Judge A, Eskelinen A, Murray DW, Pandit HG. What is appropriate surveillance for metal-on-metal hip arthroplasty patients? Acta Orthop 2018; 89:29-39. [PMID: 29105547 PMCID: PMC5810829 DOI: 10.1080/17453674.2017.1398011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The unexpected high revision rates of large-diameter (femoral head sizes of 36 mm or greater) metal-on-metal hip arthroplasties (MoMHAs) have led to worldwide regulatory authorities recommending regular surveillance, even for asymptomatic individuals. However, these recommendations are not evidence-based and are very costly. The rapidly evolving evidence base requires an update regarding the investigation and management of MoMHA patients. This article is the first of 2 (the second article in this series will consider the threshold for performing revision, and the outcomes following ARMD revision surgery: Matharu et al., Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris: A clinical update. Acta Orthop 2018; in press), and considers the various investigative modalities used during surveillance, with specific focus on blood metal ion sampling and cross-sectional imaging. No single investigation can universally be used during MoMHA patient surveillance. Recent studies have now provided important information on interpreting blood metal ions (effective in identifying patients at low risk of problems), clarifying the roles of cross-sectional imaging (reserve combined ultrasound and MARS-MRI for complex cases), and providing parameters to safely exclude many asymptomatic patients from regular surveillance. This information will be useful when designing future surveillance protocols for MoMHA patients.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK;,Correspondence:
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
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Skinner JA, Haddad FS. A new year, but the spectre of metal-on-metal lives on. Bone Joint J 2018; 100-B:1-3. [PMID: 29305442 DOI: 10.1302/0301-620x.100b1.bjj-2017-1462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- J A Skinner
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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Matharu GS, Berryman F, Judge A, Reito A, McConnell J, Lainiala O, Young S, Eskelinen A, Pandit HG, Murray DW. Blood Metal Ion Thresholds to Identify Patients with Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris: An External Multicenter Validation Study of Birmingham Hip Resurfacing and Corail-Pinnacle Implants. J Bone Joint Surg Am 2017; 99:1532-1539. [PMID: 28926382 PMCID: PMC5805279 DOI: 10.2106/jbjs.16.01568] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The authors of recent studies have reported newly devised implant-specific blood metal ion thresholds to predict adverse reactions to metal debris (ARMD) in patients who have undergone unilateral or bilateral metal-on-metal (MoM) hip arthroplasty. These thresholds were most effective for identifying patients at low risk of ARMD. We investigated whether these newly devised blood metal ion thresholds could effectively identify patients at risk of ARMD after MoM hip arthroplasty in an external cohort of patients. METHODS We performed a validation study involving 803 MoM hip arthroplasties (323 unilateral Birmingham Hip Resurfacing [BHR], 93 bilateral BHR, and 294 unilateral Corail-Pinnacle implants) performed in 710 patients at 3 European centers. All patients underwent whole-blood metal ion sampling, and were divided into 2 groups: those with ARMD (leading to revision or identified on imaging; n = 75) and those without ARMD (n = 635). Previously devised implant-specific blood metal ion thresholds (2.15 μg/L of cobalt for unilateral BHR; 5.5 μg/L for the maximum of either cobalt or chromium for bilateral BHR; and 3.57 μg/L of cobalt for unilateral Corail-Pinnacle implants) were applied to the validation cohort, and receiver operating characteristic curve analysis was used to establish the discriminatory characteristics of each threshold. RESULTS The area under the curve, sensitivity, specificity, and positive and negative predictive values for the ability of each implant-specific threshold to distinguish between patients with and without ARMD were, respectively, 89.4% (95% confidence interval [CI] = 82.8% to 96.0%), 78.9%, 86.7%, 44.1%, and 96.9% for unilateral BHR; 89.2% (CI = 81.3% to 97.1%), 70.6%, 86.8%, 54.5%, and 93.0% for bilateral BHR; and 76.9% (CI = 63.9% to 90.0%), 65.0%, 85.4%, 24.5%, and 97.1% for unilateral Corail-Pinnacle implants. Using the implant-specific thresholds, we missed 20 patients with ARMD (2.8% of the patients in this series). We missed more patients with ARMD when we used the fixed thresholds proposed by regulatory authorities: 35 (4.9%) when we used the U.K. threshold of 7 μg/L for both cobalt and chromium (p = 0.0003), 21 (3.0%) when we used the U.S. threshold of 3 μg/L for both cobalt and chromium (p = 1.0), and 46 (6.5%) when we used the U.S. threshold of 10 μg/L for both cobalt and chromium (p < 0.0001). CONCLUSIONS This external multicenter validation study confirmed that patients with blood metal ion levels below new implant-specific thresholds have a low risk of ARMD after MoM hip arthroplasty. Using these implant-specific thresholds, we missed fewer patients with ARMD compared with when the thresholds currently proposed by regulatory authorities were used. We therefore recommend using implant-specific blood metal ion thresholds when managing patients who have undergone MoM hip arthroplasty. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S. Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Fiona Berryman
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | | | - Hemant G. Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Chapel Allerton Hospital, Leeds, United Kingdom
| | - David W. Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Matharu GS, Nandra RS, Berryman F, Judge A, Pynsent PB, Dunlop DJ. Risk factors for failure of the 36 mm metal-on-metal Pinnacle total hip arthroplasty system: a retrospective single-centre cohort study. Bone Joint J 2017; 99-B:592-600. [PMID: 28455467 PMCID: PMC5413867 DOI: 10.1302/0301-620x.99b5.bjj-2016-1232.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022]
Abstract
Aims To determine ten-year failure rates following 36 mm metal-on-metal
(MoM) Pinnacle total hip arthroplasty (THA), and identify predictors
of failure. Patients and Methods We retrospectively assessed a single-centre cohort of 569 primary
36 mm MoM Pinnacle THAs (all Corail stems) followed up since 2012
according to Medicines and Healthcare Products Regulation Agency
recommendations. All-cause failure rates (all-cause revision, and
non-revised cross-sectional imaging failures) were calculated, with predictors
for failure identified using multivariable Cox regression. Results Failure occurred in 97 hips (17.0%). The ten-year cumulative
failure rate was 27.1% (95% confidence interval (CI) 21.6 to 33.7).
Primary implantation from 2006 onwards (hazard ratio (HR) 4.30;
95% CI 1.82 to 10.1; p = 0.001) and bilateral MoM hip arthroplasty
(HR 1.59; 95% CI 1.03 to 2.46; p = 0.037) predicted failure. The
effect of implantation year on failure varied over time. From four
years onwards following surgery, hips implanted since 2006 had significantly
higher failure rates (eight years 28.3%; 95% CI 23.1 to 34.5) compared
with hips implanted before 2006 (eight years 6.3%; 95% CI 2.4 to
15.8) (HR 15.2; 95% CI 2.11 to 110.4; p = 0.007). Conclusion We observed that 36 mm MoM Pinnacle THAs have an unacceptably
high ten-year failure rate, especially if implanted from 2006 onwards
or in bilateral MoM hip patients. Our findings regarding implantation
year and failure support recent concerns about the device manufacturing
process. We recommend all patients undergoing implantation since
2006 and those with bilateral MoM hips undergo regular investigation,
regardless of symptoms. Cite this article: Bone Joint J 2017;99-B:592–600.
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Affiliation(s)
| | - R S Nandra
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
| | - F Berryman
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
| | - A Judge
- University of Oxford, Oxford, OX3 7LD, UK
| | - P B Pynsent
- School of Clinical and Experimental Medicine, University of Birmingham, B15 2TT, UK
| | - D J Dunlop
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
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Eltit F, Assiri A, Garbuz D, Duncan C, Masri B, Greidanus N, Bell R, Sharma M, Cox M, Wang R. Adverse reactions to metal on polyethylene implants: Highly destructive lesions related to elevated concentration of cobalt and chromium in synovial fluid. J Biomed Mater Res A 2017; 105:1876-1886. [DOI: 10.1002/jbm.a.36057] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Felipe Eltit
- Department of Materials Engineering; University of British Columbia; Vancouver Canada
- Centre for Hip Health and Mobility, University of British Columbia; Vancouver BC Canada
- Faculty of Dentistry; Finis Terrae University; Chile
| | - Ali Assiri
- Department of Pathology and Laboratory Medicine; University of British Columbia; Vancouver Canada
- Department of Pathology and Laboratory Medicine; King Abdulaziz Medical City; Riyadh Saudi Arabia
| | - Donald Garbuz
- Centre for Hip Health and Mobility, University of British Columbia; Vancouver BC Canada
- Department of Orthopaedics; University of British Columbia; Vancouver Canada
| | - Clive Duncan
- Department of Orthopaedics; University of British Columbia; Vancouver Canada
| | - Bassam Masri
- Centre for Hip Health and Mobility, University of British Columbia; Vancouver BC Canada
- Department of Orthopaedics; University of British Columbia; Vancouver Canada
| | - Nelson Greidanus
- Department of Orthopaedics; University of British Columbia; Vancouver Canada
| | - Robert Bell
- Department of Urologic Sciences; University of British Columbia; Vancouver Canada
| | - Manju Sharma
- Department of Urologic Sciences; University of British Columbia; Vancouver Canada
| | - Michael Cox
- Department of Urologic Sciences; University of British Columbia; Vancouver Canada
| | - Rizhi Wang
- Department of Materials Engineering; University of British Columbia; Vancouver Canada
- Centre for Hip Health and Mobility, University of British Columbia; Vancouver BC Canada
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Matharu GS, Blanshard O, Dhaliwal K, Judge A, Murray DW, Pandit HG. Patient and Radiographic Factors Help to Predict Metal-on-Metal Hip Resurfacings with Evidence of a Pseudotumor. J Bone Joint Surg Am 2017; 99:214-222. [PMID: 28145952 DOI: 10.2106/jbjs.16.00212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The role of radiographs in the follow-up of patients with metal-on-metal hip resurfacing (MoMHR) implants is unclear. We investigated whether a combination of patient and radiographic factors predicted MoMHRs with evidence of a pseudotumor. METHODS We performed a retrospective single-center case-control study of 384 MoMHRs. The pseudotumor group of 130 hips all had evidence of a symptomatic pseudotumor on cross-sectional imaging, with the diagnosis confirmed at revision. The nonpseudotumor group of 254 hips (a subgroup of these hips were previously reported on) all had normal findings on cross-sectional imaging. Radiographs taken immediately prior to revision were assessed in the pseudotumor group and were compared with radiographs taken at the time of normal cross-sectional imaging in the nonpseudotumor group. Two blinded independent observers analyzed the radiographs for signs of failure, with excellent interobserver agreement. Logistic regression modeling identified the patient and radiographic predictors of revision for pseudotumor. RESULTS Hips with a pseudotumor more commonly had abnormal findings on radiographs compared to hips without a pseudotumor (80.0% compared with 63.4%; p = 0.001). Patient and radiographic factors predictive of revision for pseudotumor in the multivariable model were female sex (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.85 to 5.35; p < 0.001), high inclination (OR, 1.04 per degree; 95% CI, 1.01 to 1.07 per degree; p = 0.006), acetabular osteolysis (OR, 5.06; 95% CI, 2.14 to 12.0; p < 0.001), femoral osteolysis (OR, 17.8; 95% CI, 5.09 to 62.2; p < 0.001), and acetabular loosening (OR, 3.35; 95% CI, 1.34 to 8.35; p = 0.009). Factors predictive of not having a pseudotumor were anteversion of ≥5° (5° to <10°: OR, 0.31; 95% CI, 0.12 to 0.77; p = 0.012; and ≥10°: OR, 0.32; 95% CI, 0.15 to 0.70; p = 0.004) and heterotopic ossification (OR, 0.19; 95% CI, 0.05 to 0.72; p = 0.015). The final multivariable model was well calibrated (p = 0.589), with good discriminatory ability (area under the curve = 0.801; sensitivity = 74.4%; specificity = 71.7%). CONCLUSIONS A combination of patient and radiographic factors provided useful information for distinguishing between MoMHRs with and without evidence of a pseudotumor. Surgeons may wish to consider these specific patient and radiographic factors before proceeding with cross-sectional imaging. Radiographs are important when assessing patients with MoMHR implants and should be included in all follow-up protocols. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S Matharu
- 1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom 2MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom 3Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, United Kingdom
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Matharu GS, Berryman F, Brash L, Pynsent PB, Dunlop DJ, Treacy RBC. Can blood metal ion levels be used to identify patients with bilateral Birmingham Hip Resurfacings who are at risk of adverse reactions to metal debris? Bone Joint J 2017; 98-B:1455-1462. [PMID: 27803220 DOI: 10.1302/0301-620x.98b11.38042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 07/29/2016] [Indexed: 11/05/2022]
Abstract
AIMS We investigated whether blood metal ion levels could effectively identify patients with bilateral Birmingham Hip Resurfacing (BHR) implants who have adverse reactions to metal debris (ARMD). PATIENTS AND METHODS Metal ion levels in whole blood were measured in 185 patients with bilateral BHRs. Patients were divided into those with ARMD who either had undergone a revision for ARMD or had ARMD on imaging (n = 30), and those without ARMD (n = 155). Receiver operating characteristic analysis was used to determine the optimal thresholds of blood metal ion levels for identifying patients with ARMD. RESULTS The maximum level of cobalt or chromium ions in the blood was the parameter which produced the highest area under the curve (91.0%). The optimal threshold for distinguishing between patients with and without ARMD was 5.5 µg/l (83.3% sensitivity, 88.4% specificity, 58.1% positive and 96.5% negative predictive values). Similar results were obtained in a subgroup of 111 patients who all underwent cross-sectional imaging. Between 3.2% and 4.3% of patients with ARMD were missed if United Kingdom (7 µg/l) and United States (10 µg/l) authority thresholds were used respectively, compared with 2.7% if our implant specific threshold was used, though these differences did not reach statistical significance (p ≥ 0.248). CONCLUSION Patients with bilateral BHRs who have blood metal ion levels below our implant specific threshold were at low-risk of having ARMD. Cite this article: Bone Joint J 2016;98-B:1455-62.
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Affiliation(s)
- G S Matharu
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK and Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - F Berryman
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - L Brash
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - P B Pynsent
- University of Birmingham, Birmingham B15 2TT, UK
| | - D J Dunlop
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - R B C Treacy
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
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Liow MHL, Dimitriou D, Tsai TY, Kwon YM. Preoperative Risk Factors Associated With Poor Outcomes of Revision Surgery for "Pseudotumors" in Patients With Metal-on-Metal Hip Arthroplasty. J Arthroplasty 2016; 31:2835-2842. [PMID: 27387480 DOI: 10.1016/j.arth.2016.05.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 05/02/2016] [Accepted: 05/17/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision surgery of failed metal-on-metal (MoM) total hip arthroplasty (THA) for adverse tissue reaction (pseudotumor) can be challenging as a consequence of soft tissue and muscle necrosis. The aims of this study were to (1) report the revision outcomes of patients who underwent revision surgery for failed MoM hip arthroplasty due to symptomatic pseudotumor and (2) identify preoperative risk factors associated with revision outcomes. METHODS Between January 2011 and January 2013, a total of 102 consecutive large head MoM hip arthroplasties in 97 patients (male: 62, female: 35), who underwent revision surgery were identified from the database of a multidisciplinary referral center. RESULTS At minimum follow-up of 2 years (range: 26-52 months), at least one complication had occurred in 14 of 102 revisions (14%). Prerevision radiographic loosening (P = .01), magnetic resonance imaging (MRI) findings of solid lesions with abductor deficiency on MRI (P < .001), and intraoperative grading of adverse tissue reactions (P = .05) were correlated with post-revision complications. The reoperation rate of revised MoM THA was 7% (7 of 102 hips). Implant survivorship was 88% at 3 years. Metal ion levels declined in most patients after removal of MoM articulation. CONCLUSION Revision outcomes of revision surgery for failed MoM THA due to symptomatic pseudotumor demonstrated 14% complication rate and 7% re-revision rate at 30-month follow-up. Our study identified prerevision radiographic loosening, solid lesions/abductor deficiency on MRI, and high grade intraoperative tissue damage as risk factors associated with poorer revision outcomes. This provides clinically useful information for preoperative planning and perioperative counseling of MoM THA patients undergoing revision surgery.
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Affiliation(s)
- Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dimitris Dimitriou
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsung-Yuan Tsai
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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What is the natural history of asymptomatic pseudotumours in metal-on-metal hip resurfacing patients? Hip Int 2016; 26:522-530. [PMID: 27791239 DOI: 10.5301/hipint.5000387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE We assessed the natural history of asymptomatic pseudotumours associated with metal-on-metal hip resurfacings (MoMHRs), and factors associated with future revision. METHODS In 2007-2008, we identified 25 MoMHRs (21 patients; mean age 59.9 years; 76% female) with asymptomatic pseudotumours. All patients underwent identical initial assessment (ultrasound, blood metal ions, radiographs, Oxford Hip Score [OHS]) and were considered asymptomatic because they denied experiencing hip symptoms, were satisfied with their MoMHR surgery, and had good or excellent OHSs (≥34). In 2012-2013, repeat assessments were performed in all non-revised patients. RESULTS Revision for pseudotumour was performed/recommended in 15 MoMHRs (60%) at a mean 2.7 years (range 0.4-6.4 years) from initial assessment, with 14 developing symptoms before revision. Non-revised MoMHRs (n = 10) underwent repeat ultrasound at a mean 5.1 years (range 4.0-6.5 years) later, with no changes in pseudotumour volume (p = 0.956) or OHS (p = 0.065) between assessments. High blood cobalt (p = 0.0048) and chromium (p = 0.0162), large pseudotumours (p = 0.0458), low OHS (p = 0.0183), and bilateral MoMHRs (p = 0.049) predicted future revision. Patients with blood metal ions above established unilateral/bilateral thresholds and/or initial pseudotumours >30 cm3 had an 86.7% sensitivity, 70.0% specificity, 81.2% positive predictive value, and 77.8% negative predictive value for future revision. CONCLUSIONS MoMHR patients with initially asymptomatic pseudotumours often become symptomatic and require revision. Patients with high blood metal ions and/or pseudotumours >30 cm3 should remain under annual surveillance or be considered for revision (especially in patients also having lower initial OHSs, bilateral MoMHRs, and/or those becoming symptomatic). Less regular surveillance of patients outside these parameters appears acceptable.
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Matharu GS, Judge A, Murray DW, Pandit HG. Prevalence of and Risk Factors for Hip Resurfacing Revision: A Cohort Study Into the Second Decade After the Operation. J Bone Joint Surg Am 2016; 98:1444-52. [PMID: 27605688 DOI: 10.2106/jbjs.15.01234] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most metal-on-metal hip resurfacing (MoMHR) designs have experienced high short-term failure rates because of pseudotumors. The impact of this complication into the second decade after the procedure is unknown. We investigated (1) the prevalence of, and risk factors for, all-cause and pseudotumor-related revision at up to 15 years following MoMHR and (2) whether risk factors were sex-specific. METHODS This single-center prospective cohort study included 1,429 MoMHRs (1216 patients; 40% female) implanted between 1999 and 2009. Patients were contacted in 2010 and 2012 as per national recommendations. Patients with symptoms related to the hip and/or suboptimal Oxford Hip Scores (≤41 of 48 points) underwent cross-sectional imaging and blood metal-ion sampling. Revision diagnoses were established using operative and histopathological findings. Multivariate Cox proportional hazard models were used to assess the association of predictor variables with the time to all-cause and pseudotumor-related revisions. RESULTS One hundred and eighty MoMHRs (12.6%) were revised for all causes, and 111 (7.8% of the series and 61.7 % of all revisions) were revised because of pseudotumor. Survival analysis showed the 15-year cumulative revision rate for all causes to be 19.5% (95% confidence interval [CI] = 16.2% to 23.2%) and the 15-year rate of revision due to pseudotumor to be 14.0% (95% CI = 11.0% to 17.7%). Small femoral head size (hazard ratio [HR] per 2 mm = 0.92, 95% CI = 0.88 to 0.97; p = 0.003) and certain implant designs (HR = 1.55 to 3.01; p ≤ 0.029) significantly increased the all-cause revision risk. Female sex (HR = 2.03, 95% CI = 1.19 to 3.44; p = 0.009) and young age (HR per year = 0.98, 95% CI = 0.96 to 1.00; p = 0.020) significantly increased the pseudotumor-related revision risk but not the all-cause revision risk. Risk factors for all-cause and pseudotumor-related revision were sex-specific. In females, small femoral head size (p = 0.014) increased the all-cause revision risk, and young age was the only predictor of pseudotumor-related revision (p = 0.019). In males, implant design was the only predictor of all-cause revision (p ≤ 0.015) and pseudotumor-related revision (p = 0.001). CONCLUSIONS The prevalence and rates of revision for all causes and pseudotumor were high at up to 15 years following MoMHR. Predictors of revision differed between all-cause and pseudotumor-related revisions and were sex-specific. These factors must be appropriately weighted when risk-stratifying patients with MoMHRs for surveillance. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
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Blum A, Gondim-Teixeira P, Gabiache E, Roche O, Sirveaux F, Olivier P, Coudane H, Raymond A, Louis M, Grandhaye M, Meyer JB, Mainard D, Molé D. Developments in imaging methods used in hip arthroplasty: A diagnostic algorithm. Diagn Interv Imaging 2016; 97:735-47. [PMID: 27452630 DOI: 10.1016/j.diii.2016.07.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 07/01/2016] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several imaging modalities can be used to diagnose complications of hip prosthesis placement. Despite progress in these imaging techniques, there are, as yet, no guidelines as to their respective indications. METHODS We formed a panel of experts in fields related to prosthesis imaging (radiology, nuclear medicine, orthopedic surgery) and conducted a review of the literature to determine the value of each modality for diagnosing complications following hip replacement. RESULTS Few recent studies have investigated the benefits related to the use of the latest technical developments, and studies comparing different methods are extremely rare. CONCLUSIONS We have developed a diagnostic tree based on the characteristics of each imaging technique and recommend its use. Computed topography was found to be the most versatile and cost-effective imaging solution and therefore a key tool for diagnosing the complications of hip replacement surgery.
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Affiliation(s)
- A Blum
- Service d'imagerie Guilloz, CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | - P Gondim-Teixeira
- Service d'imagerie Guilloz, CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | - E Gabiache
- Service de médecine nucléaire, CHU de Nancy, rue du Morvan, 54511 Vandœuvre-lès-Nancy cedex, France.
| | - O Roche
- Centre chirurgical Émile-Gallé, 49, rue Hermite, 54000 Nancy, France.
| | - F Sirveaux
- Centre chirurgical Émile-Gallé, 49, rue Hermite, 54000 Nancy, France.
| | - P Olivier
- Service de médecine nucléaire, CHU de Nancy, rue du Morvan, 54511 Vandœuvre-lès-Nancy cedex, France.
| | - H Coudane
- Chirurgie traumatologique et arthroscopique de l'appareil locomoteur (ATOL), CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | | | - A Raymond
- Service d'imagerie Guilloz, CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | - M Louis
- Service d'imagerie Guilloz, CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | - M Grandhaye
- Service d'imagerie Guilloz, CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | - J-B Meyer
- Service d'imagerie Guilloz, CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | - D Mainard
- Chirurgie orthopédique et traumatologique (COT), CHU de Nancy, avenue de Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France.
| | - D Molé
- Centre chirurgical Émile-Gallé, 49, rue Hermite, 54000 Nancy, France.
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Affiliation(s)
- F. S. Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET, and NIHR University College London Hospitals Biomedical Research Centre, UK
| | - A. R. J. Manktelow
- Nottingham University Hospitals NHS Trust, City Hospital
Campus, Nottingham, NG5
1PB, UK
| | - J. A. Skinner
- Royal National Orthopaedic Hospital Trust, Brockley
Hill, Stanmore, Middlesex, HA7
4LP, UK
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