False-positive radionuclide arthroscintigraphy with a porous-coated total hip prosthesis.

The evaluation of a painful hip prosthesis for suspected loosening frequently requires a multi-modality approach. Radionuclide arthroscintigraphy is a valuable adjunct to contrast arthrography, demonstrating greater sensitivity than contrast arthrography in detecting loosening of the femoral component of the prosthesis. Despite its reliability in the evaluation of cemented hip prostheses, the value of arthroscintigraphy in patients with uncemented or porous-coated prostheses is undetermined. The case of a false-positive radionuclide arthroscintigram in a patient with an uncemented prosthesis is reported. The literature is briefly examined, and the potential implications regarding interpretation of arthroscintigraphy in patients with porous-coated prostheses are discussed.     

Arthroscintigraphic evaluation of the painful total hip prosthesis

Arthroscintigraphy was performed in 19 patients with a painful total hip prosthesis by injecting both Tc-99m sulfur colloid and iodinated radiographic contrast material intra-articularly. Scintigraphic and radiographic results correlated exactly in 15 patients, with one false-negative scintigram, one false-positive scintigram, and one false-negative arthrogram. One patient was evaluated by scintigraphy alone. Although arthroscintigraphy is potentially more sensitive than conventional arthrography in the detection of femoral component loosening, acetabular component loosening cannot be evaluated by scintigraphy alone. A combination of scintigraphy and conventional arthrography appears to be the most accurate imaging method in the evaluation of hip prosthesis loosening.     

Radiography, radionuclide imaging, and arthrography in the evaluation of total hip and knee replacement

Twenty patients with 21 total joint replacements including 17 hips and 4 knees were studied by plain film radiography, radionuclide imaging, and subtraction arthrography to evaluate these procedures for assessing prosthetic complications. Surgery was performed in 14 patients and confirmed loosening of 8 femoral and 7 acetabular hip prosthesis components and 1 femoral and 4 tibial knee prosthesis components. Plain films suggested loosening of only 9 hip components and no knee components. In contrast, radionuclide imaging and subtraction arthrography were considerably more effective in demonstrating loosening as well as other causes of the painful total joint prosthesis.     

Radiological evaluation of painful total hip replacement

Ninety-four cases of clinically failed, cemented, total hip prostheses requiring surgery were reviewed to determine the accuracy of preoperative plain radiography, culture of aspirated fluid, arthrography, and bone scanning. When radiopaque cement had been used to embed the prosthesis, plain radiography was highly accurate in detecting a loose femoral component, less so in detecting a loose acetabular component. Culture of aspirated fluid was accurate in diagnosing infection. A positive arthrogram identified loosening with good accuracy; however, a negative arthrogram did not reliably exclude loosening. 99mTc bone scans frequently differentiated loosening from loosening with infection. The suggested sequence of diagnostic tests is plain radiography followed by bone scanning. If the bone scan shows diffuse augmented uptake, culture of aspirated fluid followed by arthrography is indicated.     

Loose hip prosthesis. Appearance in radionuclide arthrography

Radionuclide arthrography has been found to be valuable in the diagnosis of a loose hip prosthesis. The appearance of one normal case with no loosening and two abnormal cases with loosening of femoral and acetabular components are described. To diagnose this difficult problem, radionuclide arthrography should be used more frequently.     

Arthrography in total hip prosthesis complications.

Previous reports have stressed the value of hip arthrography primarily in determining the presence of loosening of the total hip prosthesis. Although loosening is a common complication and frequently associated with infection, other complications producing a painful hip prosthesis exist and are demonstrable by arthrography. Since the etiologies of these are as diversely different as the treatment, the hip arthrogram is advocated as an integral part of the diagnostic approach to the patient with a painful hip prosthesis in order to assess the specific complication and determine the therapeutic approach.     

Lymphatic opacification in the prosthetic hip

A retrospective analysis of 52 patients with hip pain following total hip replacement was made. Each of them was evaluated by plain radiographs, technetium 99m pyrophosphate scans, arthrography with plain film subtraction technique, and culture of joint fluid. In 30 cases there was evidence of prosthetic loosening, and in 21 of these lymphangeal opacification during arthrography was seen. In 15 cases with lymphongeal opacification the diagnosis of prosthetic loosening was subsequently confirmed by prosthetic revision. In none of the 22 cases in which no evidence of prosthetic loosening was seen was there lymphatic opacification. It is concluded that lymphatic opacification during arthrography for pain following total hip prosthesis is a valuable ancillary sign of loosening.     

Contrast and nuclear arthrography in loosening of the uncemented hip prosthesis

The recent popularity of ingrowth or uncemented hip arthroplasties has presented problems in the radiographic diagnosis of loosening because there is no longer a cement interface in which lucencies may be seen. We evaluated a combination of positive contrast and nuclear arthrography to see whether these studies could accurately detect loosening of uncemented femoral components of hip prostheses. We performed routine contrast and nuclear arthrography in 21 patients with ingrowth total hip arthroplasties or bipolar endoprostheses. The results were surgically confirmed in 12 patients. The contrast arthrogram was true positive in 5 and false negative in 5. There were no false positives and 2 true negatives. The nuclear arthrogram was true positive in 7 patients, false negative in 3, and true negative in 2. Taken together, there was only 1 patient in whom both contrast and nuclear arthrography were false negative, and there were no false positives. Thus, when either contrast or nuclear arthrography is positive, the sensitivity of the combined procedures is 90%; when both studies are negative, the specificity is 100%. The combination of contrast and nuclear arthrography is an accurate method of determining loosening of the femoral component of an uncemented hip arthroplasty or bipolar endoprosthesis in the patient with postoperative hip pain.     

保留股骨颈型人工全髋关节置换术92例

目的探讨保留股骨颈型人工全髋关节置换术的疗效。方法 2000年9月—2010年9月,我科开展保留股骨颈型人工全髋关节置换术92例(104髋),其中男50例,女42例,年龄20～65岁。结果本组经过0.5～10年随访,92例人工全髋关节置换术后,髋关节功能良好。影像学检查显示人工髋关节位置良好,假体无松动和下沉。结论保留股骨颈型人工全髋关节置换符合股骨近端生理顺应性,能防止股骨近端骨质疏松引起假体松动和下沉。     

K-edge digital subtraction arthrography of the painful hip prosthesis: a feasibility study

K-edge energy subtraction radiography is a method for detecting the presence of iodinated contrast material by subtracting two digital radiographs produced by X-ray beams with energies above and below the iodine K edge. We performed a feasibility study on the application of K-edge energy digital subtraction arthrography (KEDSA) to painful hip prostheses. During arthrography, loosening of the prosthesis is implied if contrast material is seen dissecting around the prosthesis, an often difficult detection task because of adjacent prosthesis metal or cement. In conventional arthrography a preliminary mask image is thus used from which films obtained after injection of iodinated contrast material are subtracted. Movement by the patient during this process may preclude subsequent subtraction. With KEDSA, since multiple image pairs may be obtained after the injection of contrast material, the problem of patient motion is virtually eliminated. A conventional X-ray tube operating between 55 and 65 kVp was alternately filtered by iodine and cerium filters to produce the KEDSA images. The apparatus was capable of producing a subtracted image within 3 sec. The technique was applied to phantoms and to six patients immediately after hip arthrography that had been positive for prosthesis loosening. Although of lower spatial resolution, the KEDSA images were, in all cases, positive for loosening in a pattern consistent with the conventional arthrographic images. KEDSA was shown to be successful in detecting extraarticular contrast material. During a single study, subtraction in various imaging planes as well as postexercise subtraction imaging can be accomplished-techniques not heretofore possible in routine subtraction arthrography.     

Focal lytic lesions associated with femoral stem loosening in total hip prosthesis

Focal lytic lesions may occur in the proximal femur associated with loosening of the femoral component of a total hip prosthesis. During long-term follow-up of 62 patients with total hip prostheses, five such lesions developed. Histologically the lesions appear to be a histiocytic response to fragmented methylmethacrylate. Radiographically the lesions may suggest infection or neoplasm. Pathologic fracture may occur through large lesions. Experience in one case suggests that thorough removal of the tissue at the time of revision may be necessary to prevent recurrence. The recent reports of several malignant neoplasms developing in association with the femoral components of total hip replacements makes recognition of these benign focal lytic lesions even more important.     

Digital subtraction arthrography in preoperative evaluation of painful total hip arthroplasty

 Objective. The objective of this clinical study was to define the diagnostic value of plain radiography, digital subtraction arthrography and two-phase bone scintigraphy in patients with clinically loose or infected hip prostheses. Design. Digital subtraction arthrograms, scintigrams and plain radiographs of 70 consecutive patients who underwent revision hip arthroplasty were scored individually and in masked fashion for the presence or absence of features indicating loosening of femoral and/or acetabular components. The operative findings acted as the gold standard. Results. Digital subtraction arthrography was best (P<0.001) for predicting a loose acetabular component, while no significant additional predictive value was found for plain radiographs (P=0.24) and scintigraphy (P=0.27). Digital subtraction arthrography was also the most important modality for predicting a loose femoral component (P=0.001), while the plain radiograph was of significant (P=0.04) additional value and scintigraphy was of no additional value (P=0.13) on multivariate analysis. Conclusion. Digital subtraction arthrography gives the best results in the prediction of loosening of acetabular and femoral components. Plain radiographs give additional information on loosening of the femoral component, but scintigraphy offers no additional advantage.     

Imaging of hip arthroplasty

The imaging evaluation of the prosthetic hip begins with radiography, but arthrography, aspiration, scintigraphy, sonography, CT and MR imaging all have roles in the evaluation of the painful prosthesis. This article will review the appearance of normal hip arthroplasty including hemiarthroplasty, total arthroplasty, and hip resurfacing, as well as the appearances of potential complications such as aseptic loosening and osteolysis, dislocation, infection, periprosthetic fracture, hardware failure, and soft tissue abnormalities.     

Radiophosphate evaluation of loose hip prostheses

There were 23 patients who had revisions of their failed hip arthroplasties and a prior radiophosphate assessment of the joint components. In this selected group of patients the true positive incidence of abnormal scintigraphic findings for femoral component loosening was 19 out of 20 (95%) and the true negative incidence was two out of two by the criteria adopted. The true positive incidence of such findings, indicating acetabular component loosening, was seven out of seven, and the true negative was nine out of 10. Some of these patients also had contrast arthrography and the incidences of true positive and true negative findings for femoral component loosening were seven out of 15 (47%) and one out of one, respectively. Prediction of the status of the acetabulum was poorer using this technique with true positive and true negative incidences of four out of nine and two out of five, respectively.     

Colour Doppler ultrasound assessment of well-functioning mature arteriovenous fistulas for haemodialysis access

OBJECTIVE: To summarize and compare the diagnostic accuracy of contrast and subtraction arthrography in the assessment of aseptic loosening of total hip arthroplasties. DESIGN: This meta-analysis was performed using methods described by the Cochrane Methods Group on Systematic Reviews of Screening and Diagnostic Tests. We included original, English-language papers published between January 1975 to October 2004 that examined contrast-enhanced arthrography with or without subtraction for diagnosis of loosening of total hip prostheses. A qualitative and quantitative analysis was performed by two investigators. RESULTS: With regard to the acetabular component, pooled sensitivity and specificity for contrast arthrography was 70% (95% confidence interval, 52-84) and 74% (95% CI, 53-87), respectively. Subtraction arthrography had a significantly higher sensitivity of 89% (95% CI, 84-93) (p=0.01), with a similar specificity of 76% (95% CI, 68-82). For the femoral component, pooled sensitivity and specificity for contrast arthrography were 63% (95% CI, 53-72) and 78% (95% CI, 68-86). Pooled estimates for subtraction arthrography revealed a significantly higher sensitivity of 86% (95% CI, 74-93) (p=0.003). Specificity was 85% (95% CI, 77-91) and was similar to the data of contrast arthrography (p=0.23). CONCLUSION: Using the present data we found that the subtraction arthrography is a sensitive technique for detection of loosening of total hip prostheses, offering added value over contrast arthrography, especially for evaluation of the femoral component.     

Evaluation of metallic osseous implants with nuclear medicine

Nuclear medicine has proven to have a valuable role in the evaluation of osseous metallic implants, particularly with joint prostheses, but can assist with evaluation of other appliances as well. The nuclear arthrogram has become an invaluable adjunct to simultaneously performed radiographic contrast arthrography. This application has been best evaluated in what is one of the most common of orthopedic prosthesis problems, namely, loosening of total hip prostheses. Experience indicates that both sensitivity and specificity of loosening of the femoral component can be increased to over 90% through combined use of nuclear with radiographic contrast arthrography. Furthermore the combination of routine skeletal scintimaging with the nuclear arthrogram adds a significant dimension to precise localizing of the nuclear arthrographics agent In-111 chloride. Nuclear medicine also plays an important role in further evaluating the presence of infection associated with metallic implants with In-111 WBC preparations being superior to Ga-67 as the radiopharmaceutical tracer. Infection has been detected with a sensitivity of 73% and a specificity of 93% in our series using combined In-111 WBC and simultaneous skeletal imaging with conventional Tc-99m MDP. Acute infections are more readily identifiable than chronic in association with prostheses.     

Prospective study of sequential technetium-99m phosphate and gallium imaging in painful hip prostheses (comparison of diagnostic modalities)

Twenty-two painful hip prostheses were studied prospectively with plain radiography, aspiration and arthrography, Tc-99m phosphate bone imaging, and gallium imaging to evaluate loosening, infection, or both and to compare the accuracy of these modalities. Fifteen prostheses were revised yielding 14 loose femoral and eight loose acetabular components. Five proved to have infected prostheses. Arthrograms, plain radiographs, and bone scans are highly sensitive in detecting loosening of the femoral component. This study confirmed a previous retrospective study in demonstrating that accuracy of diagnosis of an abnormal acetabular component using all four modalities is less than that for the femoral component. In infected prostheses, phosphate bone imaging showed high sensitivity of a pattern that accurately diagnosed all the infected cases, whereas gallium imaging missed one case.     

The radiology of total hip replacement

The radiology of total hip replacement (THR) and its complications is reviewed in conjunction with a long-term follow-up study on 402 patients with 501 prostheses. The indications, contraindications, biomechanics, and operative management of these patients is discussed. Clinical complications such as deep vein thrombosis, pulmonary embolism, and hemorrhage are mentioned. Postoperative infections including granulomatous pseudotumors, dislocations and fractures, true loosening of the prosthesis, and heterotopic bone formation (HBF) are discussed and illustrated. The importance of differentiating the lucent line from true loosening is stressed. Mechanical and other clinical complications which are largely ignored by radiologists are also discussed. The uses of arthrography and bone scanning are included.     

股骨近段矢状位纵向劈开成形在全髋置换中的应用

目的 总结股骨近段矢状位纵向劈开成形术行全髋置换术治疗髋关节终极疾病合并股骨干骺段狭窄畸形的疗效。 方法 选择2000年1月-2009年12月收治的18例(22髋)髋关节终极疾病合并股骨干骺段狭窄畸形患者,其中男3例,女15例;平均年龄54岁(41～ 75岁)。单髋14例,双髋4例。按Berry分类法,全部患者均被确定为干骺段畸形和大小异常型,其中诊断为发育型(先天性髋关节发育不良)17例,陈旧性髋结核1例。先天性髋关节发育不良者按Crowe等分类法,均被诊断为Ⅳ型。所有患者均采用股骨近段矢状位纵向劈开成形、股骨转子下叠加式缩短截骨和“V”形旋转截骨等手术,并采用标准型股骨柄假体生物学固定。 结果 无感染、脱位、下肢神经牵拉伤,以及股骨近段失控性骨折等并发症。术后X线片示臼杯均位于真臼区,所有股骨柄假体的初始固定质量均优良。所有截骨区在术后3～6个月均获骨性愈合。术后测量显示患肢平均延长3 cm(2.5～3.5 cm)。随访1～10年,平均6年,Harris评分由术前的平均30分改善至术后1年的平均93分。X线片显示无骨溶解,或广泛的X线透亮带、假体进行性下沉、内翻移位等假体松动征。无一例因假体松动或其他原因需行翻修手术者。 结论 髋关节终极疾病合并股骨干骺段狭窄畸形者,采用股骨近段矢状位纵向劈开成形术,并采用标准型股骨柄生物固定假体行全髋置换术治疗可取得满意疗效。     

全髋置换术后首次X线平片在评估假体稳定性中的临床价值

目的研究全髋置换术后首次X线平片在评估假体稳定性中的临床价值。方法初次全髋置换术患者53例,观测术后首次术侧髋关节正位片中假体周围骨质情况、人工髋臼的前倾角和外展角、假体柄位置;与其后1 a内复查片对比,观察假体的变化。结果术后1 a内发生假体不稳定共6髋,其中脱位3髋,假体周围骨折1髋,假体与骨界面之间出现连续宽度大于等于2 mm的透亮线2髋。术后首次X线平片中的假体周围骨质情况、人工髋臼的前倾角和外展角、假体柄位置均与假体稳定性的判断密切相关,P<0.05。结论全髋关节置换术后首次X线平片能预测短期内发生假体不稳定的风险,具有重要的临床价值。