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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-

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Presentation on theme: "1 The following presentation was given at the Radiological Society of North America (RSNA) in 2012 Multimodality Assessment of Metal-on-"— Presentation transcript:

1 1 The following presentation was given at the Radiological Society of North America (RSNA) in 2012 Multimodality Assessment of Metal-on- Metal Hip Arthroplasties 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 Disclosures Dr. K. Satchithananda Dr. K. Satchithananda – Johnson & Johnson Committee Member Introduction | Plain Radiographs | MARS MRI | SPECT-CT

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

4 Metal-on-metal hip arthroplasty First popular design introduced by McKee in 1951 First popular design introduced by McKee in 1951 Failure through aseptic loosening due to high torque Failure through aseptic loosening due to high torque Superseded by Charnley low- friction arthroplasty Superseded by Charnley low- friction arthroplasty Introduction | Plain Radiographs | MARS MRI | SPECT-CT

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

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

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

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

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

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

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

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

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

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

15 Malposition Retroverted acetabular component Retroverted acetabular component

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

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

18 Aseptic loosening Femoral component Femoral component

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

20 Dislocation

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

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

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

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

25 Metal-artifact reduction sequence MRI Imperial Classification Imperial Classification Lesion category WallContentsShape Class 1Thin walled Fluid like: T1 hypo / T2 hyper Flat with walls mainly in apposition Class 2A Thick walled or irregular Fluid like: T1 hypo / T2 hyper Not flat and >50% of the walls are not in apposition Class 2B Thick walled or irregular Atypical fluid: T1 hyper / T2 variable Any size Class 3SolidMixed signalAny size Hart, AJ. JBJS(Am). 2012; 94(4): Introduction | Plain Radiographs | MARS MRI | SPECT-CT

26 Pseudotumors Imperial Type 1 Pseudotumor Imperial Type 1 Pseudotumor Cor STIR Introduction | Plain Radiographs | MARS MRI | SPECT-CT

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

28 Pseudotumors Imperial Type 2B Pseudotumor Imperial Type 2B Pseudotumor Ax T2W Ax T1WAx T2W Introduction | Plain Radiographs | MARS MRI | SPECT-CT

29 Pseudotumors Imperial Type 3 Pseudotumor Imperial Type 3 Pseudotumor Ax T1WCor T1W Introduction | Plain Radiographs | MARS MRI | SPECT-CT

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

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

32 Periprosthetic hip musculature Grading Grading – Assessed on T1W images – Compared to contralateral side GradeComment 0Normal 1≤30% decrease in muscle size % fatty change with decrease in muscle mass 3>70% fatty change with an 80% decrease in size Bal, BS. Instr Course Lec : Introduction | Plain Radiographs | MARS MRI | SPECT-CT

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

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

35 Tendinopathy Abductor tendon avulsion due to soft tissue lesion Abductor tendon avulsion due to soft tissue lesion Ax T1W TSE P2Cor STIR Introduction | Plain Radiographs | MARS MRI | SPECT-CT

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

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

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

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

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

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

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

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


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