MRI Predicts ALVAL and Tissue Damage in Metal-on-Metal Hip Arthroplasty

Adult Reconstruction and Joint Replacement Division Surgery, Hospital for Special Surgery, New York, NY, USA.
Clinical Orthopaedics and Related Research (Impact Factor: 2.88). 01/2013; 472(2). DOI: 10.1007/s11999-013-2788-y
Source: PubMed

ABSTRACT BACKGROUND: Adverse local tissue reactions (ALTR) around metal-on-metal (MOM) hip arthroplasties are increasingly being recognized as a cause of failure. These reactions may be associated with intraoperative tissue damage and complication rates as high as 50% after revision. Although MRI can identify ALTR in MOM hips, it is unclear whether the MRI findings predict those at revision surgery. QUESTIONS/PURPOSES: We therefore (1) identified which MRI characteristics correlated with histologically confirmed ALTR (using the aseptic lymphocytic vasculitis-associated lesions [ALVAL] score) and intraoperative tissue damage and (2) developed a predictive model using modified MRI to detect ALVAL and quantify intraoperative tissue damage. METHODS: We retrospectively reviewed 68 patients with failed MOM hip arthroplasties who underwent preoperative MRI and subsequent revision surgery. Images were analyzed to determine synovial volume, osteolysis, and synovial thickness. The ALVAL score was used to grade tissue samples, thus identifying a subset of patients with ALTR. Intraoperative tissue damage was graded using a four-point scale. Random forest analysis determined the sensitivity and specificity of MRI characteristics in detecting ALVAL (score ≥ 5) and intraoperative tissue damage. RESULTS: Maximal synovial thicknesses and synovial volumes as determined on MRI correlated with the ALVAL score and were higher in cases of severe intraoperative tissue damage. Our MRI predictive model showed sensitivity and specificity of 94% and 87%, respectively, for detecting ALVAL and 90% and 86%, respectively, for quantifying intraoperative tissue damage. CONCLUSIONS: MRI is sensitive and specific in detecting ALVAL and tissue damage in patients with MOM hip implants. MRI can be used as a screening tool to guide surgeons toward timely revision surgery. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

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    ABSTRACT: Total hip replacement is one of the most successful surgical procedures of the 20th century (World Health Organisation). The success rate is dependent on the chosen endpoint. Evaluation of the outcome in joint replacement surgery has shifted from the revision rate toward patient satisfaction and quality of life. Patient satisfaction is reported to be up to 96% 16 years postoperatively, but the prevalence of groin pain after conventional total hip replacement ranges from 0.4% to 18.3% and activity-limiting thigh pain is still an existing problem linked to the femoral component of uncemented hip replacement in up to 1.9% to 40.9% of cases in some series. The aim of our article is to review the aetiology, diagnostic procedures and treatment of the painful primary total hip replacement. We discuss the most relevant intrinsic and extrinsic aetiological factors responsible for chronic pain after total hip arthroplasty focusing on comparative studies and randomised controlled trials including diagnostics and management. Detailed analysis of history, clinical examination, imaging and laboratory tests are required prior to any revision for painful total hip arthroplasty. Revision surgery without knowing the underlying pathology should be avoided.
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    ABSTRACT: Hip replacements with metal-on-metal components can cause a spectrum of adverse tissue reactions-from benign localized fibrosis and chronic inflammation to delayed hypersensitivity response. In addition to history, physical examination, and relevant laboratory data, imaging plays a critical role in the evaluation of hip arthroplasties. Imaging assessment begins with radiographs and may be followed by ultrasound, computed tomography, or MRI. MRI optimized for metal artifact reduction is the most sensitive and specific imaging modality and is essential in assessing the spectrum of metal-related adverse tissue reactions. In this article, we discuss the history, pathophysiology, and imaging findings of adverse reactions to metal debris. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
    Seminars in musculoskeletal radiology 02/2015; 19(1):21-30. DOI:10.1055/s-0034-1396764 · 0.95 Impact Factor
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    ABSTRACT: Background and purpose — Muscle atrophy is seen in patients with metal-on-metal (MOM) hip implants, probably because of inflammatory destruction of the musculo-tendon junction. However, like pseudotumors, it is unclear when atrophy occurs and whether it progresses with time. Our objective was to determine whether muscle atrophy associated with MOM hip implants progresses with time. Patients and methods — We retrospectively reviewed 74 hips in 56 patients (32 of them women) using serial MRI. Median age was 59 (23–83) years. The median time post-implantation was 83 (35–142) months, and the median interval between scans was 11 months. Hip muscles were scored using the Pfirrmann system. The mean scores for muscle atrophy were compared between the first and second MRI scans. Blood cobalt and chromium concentrations were determined. Results — The median blood cobalt was 6.84 (0.24–90) ppb and median chromium level was 4.42 (0.20–45) ppb. The median Oxford hip score was 34 (5–48). The change in the gluteus minimus mean atrophy score between first and second MRI was 0.12 (p = 0.002). Mean change in the gluteus medius posterior portion (unaffected by surgical approach) was 0.08 (p = 0.01) and mean change in the inferior portion was 0.10 (p = 0.05). Mean pseudotumor grade increased by 0.18 (p = 0.02). Interpretation — Worsening muscle atrophy and worsening pseudotumor grade occur over a 1-year period in a substantial proportion of patients with MOM hip implants. Serial MRI helps to identify those patients who are at risk of developing worsening soft-tissue pathology. These patients should be considered for revision surgery before irreversible muscle destruction occurs.
    Acta Orthopaedica 01/2015; 86(3):1. DOI:10.3109/17453674.2015.1006981 · 2.45 Impact Factor


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Jul 15, 2014