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Multimodality Assessment of Metal-on-Metal Hip Arthroplasties

The following presentation was given at the Radiological Society of North America (RSNA) in 2012. Multimodality Assessment of Metal-on-Metal Hip Arthroplasties. metalions@ucl.ac.uk. Never Miss a Diagnosis Again on Plain Radiographs, MARS MRI and SPECT-CT .

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Multimodality Assessment of Metal-on-Metal Hip Arthroplasties

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  1. The following presentation was given at the Radiological Society of North America (RSNA) in 2012 Multimodality Assessment of Metal-on-Metal Hip Arthroplasties metalions@ucl.ac.uk • Never Miss a Diagnosis Again on Plain Radiographs, MARS MRI and SPECT-CT • Sabah, S. A., Satchithananda, K., Henckel, J., Mitchell, A. W., Barwick, T., Khan, S., Eccles, A., Hirschmann, M., Hart, A. J.

  2. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Disclosures • Dr. K. Satchithananda • Johnson & Johnson Committee Member

  3. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Overview • Introduction to metal-on-metal hip arthroplasty • Assessment of unexplained hip pain • Imaging modalities • Plain radiographs • MARS MRI • SPECT-CT

  4. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Metal-on-metal hip arthroplasty • First popular design introduced by McKee in 1951 • Failure through aseptic loosening due to high torque • Superseded by Charnley low-friction arthroplasty http://global.smith-nephew.com/us/BHR_IF_GEORGE_KENETH_MCKE_15656.htm

  5. Introduction | Plain Radiographs | MARS MRI | SPECT-CT MOM Resurgence • Sold as hip replacements to last a lifetime • Promise of: • Low component wear rate • Femoral bone conservation • Low rate of dislocation • Approaching 1 million MOM hips implanted in US over past decade National Joint Registry for England and Wales 9th Annual Report

  6. Introduction | Plain Radiographs | MARS MRI | SPECT-CT MOM Controversy • Higher failure rates compared to traditional hip types National Joint Registry for England and Wales - 9th Annual Report

  7. Introduction | Plain Radiographs | MARS MRI | SPECT-CT MOM Controversy • Withdrawal of DePuy ASR prosthesis

  8. Introduction | Plain Radiographs | MARS MRI | SPECT-CT MOM Controversy • Concern over soft tissue lesions and raised metal ions

  9. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Reasons for revision • Pain • Aseptic loosening • Infection

  10. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Unexplained hip pain Henderson. JBJS(Br) 2012. 94(B):145-51 MHRA Device Bulletin. MDA/2012/036

  11. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Plain Radiographs Hip resurfacing Total Hip Prosthesis

  12. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Component Orientation • Acetabular inclination Murray, DW. JBJS(Br). 1993; 75-B:228-32. Hart, AJ. HipInt. 2009; 19:323-9

  13. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Malposition • Raised inclination (‘Vertical cup’)

  14. Malposition • Anteverted femoral stem (retroverted femoral component)

  15. Malposition Retrovertedacetabular component

  16. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Impingement

  17. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Periprosthetic fracture Femoral neck fracture

  18. Aseptic loosening • Femoral component

  19. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Aseptic loosening • Gross acetabular loosening

  20. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Dislocation

  21. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Stem Fracture

  22. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Trochanteric resorption

  23. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Metal-artifact reduction sequence MRI • Artifact reduction techniques

  24. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Metal-artifact reduction sequence MRI • Reporting protocol

  25. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Metal-artifact reduction sequence MRI • Imperial Classification Hart, AJ. JBJS(Am). 2012; 94(4):317-325

  26. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Pseudotumors • Imperial Type 1 Pseudotumor CorSTIR

  27. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Pseudotumors • Imperial Type 2A Pseudotumor Ax T2W

  28. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Pseudotumors • Imperial Type 2B Pseudotumor Ax T2W Ax T1W Ax T2W

  29. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Pseudotumors • Imperial Type 3 Pseudotumor Ax T1W Cor T1W

  30. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Pseudotumors • Infected Pseudotumor Ax T2W

  31. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Metal-artifact reduction sequence MRI • Anderson Classification Anderson, H. Skeletal Radiol. 2011. 40:303-307

  32. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Periprosthetic hip musculature • Grading • Assessed on T1W images • Compared to contralateral side Bal, BS. Instr Course Lec. 2008. 56:223-230.

  33. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Periprosthetic hip musculature • Abductor anatomy Minimus Medius Maximus

  34. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Tendinopathy • Pfirrmann system to assess: • Tendon signal • Tendon diameter • Tendon ossification

  35. Introduction | Plain Radiographs | MARS MRI | SPECT-CT Tendinopathy • Abductor tendon avulsion due to soft tissue lesion Ax T1W TSE P2 Cor STIR

  36. Introduction | Plain Radiographs | MARS MRI | SPECT-CT SPECT-CT • Hybrid imaging modality + =

  37. Introduction | Plain Radiographs | MARS MRI | SPECT-CT SPECT-CT • Uses of SPECT-CT • Occult infection • Aseptic loosening • Mechanical symptoms • Localisation of pathology to the hip

  38. Introduction | Plain Radiographs | MARS MRI | SPECT-CT SPECT-CT • Infection • Best seen on early blood pool images

  39. Introduction | Plain Radiographs | MARS MRI | SPECT-CT SPECT-CT • Femoral head loosening • ‘Hotspot’ under component

  40. Introduction | Plain Radiographs | MARS MRI | SPECT-CT SPECT-CT • Stem loosening

  41. Introduction | Plain Radiographs | MARS MRI | SPECT-CT SPECT-CT • Mechanical Symptoms • Eccentric femoral stem • ‘Hotspot’ at tip

  42. Introduction | Plain Radiographs | MARS MRI | SPECT-CT SPECT-CT • Incidental pathologies L5/S1 disc pathologyaccounted for unexplained ‘hip’ pain in this patient

  43. Summary • Multimodality assessment permits diagnosis of unexplained hip pain • We recommend post-op surveillance with plain radiographs and MARS MRI • SPECT-CT for occult infection, aseptic loosening, mechanical symptoms and to localize pathology to hip

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