1. University College London
OPTIMIZING ULTRASOUND OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
IA Siddiqui, K Satchithananda, AK Lim, S Sabah, J Henckel, JA Skinner & AJ Hart
University College London
Institute of Orthopedics &
Musculoskeletal Science,
Royal National Orthopedic
Hospital, United Kingdom

2. OPTIMIZING ULTRASOUND OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach

3. Dr K Satchithananda: Johnson & Johnson Committee Member
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Disclosures
Dr K Satchithananda: Johnson & Johnson Committee Member

4. Aims | Background | Scan Protocol | Pathology | Summary
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Aims
To demonstrate a novel method for the assessment of the painful hip arthroplasty using ultrasonography (US).
To illustrate the spectrum of findings on US of the post-arthroplasty hip, with a special focus on metal-on-metal (MOM) implants.
To compare US findings with metal artifact reduction sequence (MARS) MRI.
Aims | Background | Scan Protocol | Pathology | Summary

5. Aims | Background | Scan Protocol | Pathology | Summary
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Background
Hip arthroplasty is used to treat degenerative joint diseases such as osteoarthritis.
However, implants have a finite lifespan often failing with features of pain and muscle weakness.
Causes of pain are broad and difficult to diagnose using clinical examination and radiography alone (Long 212).
Aims | Background | Scan Protocol | Pathology | Summary

6. Aims | Background | Scan Protocol | Pathology | Summary
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Background
Approximately, 1.5 million people have metal-on-metal hips worldwide (FDA 2012).
However, studies have shown a particularly high failure rate (Smith 2012).
Periprosthetic lesion (pseudotumours), joint effusions and musculotendinous pathology are common findings (Sabah 2011).
Aims | Background | Scan Protocol | Pathology | Summary

7. Aims | Background | Scan Protocol | Pathology | Summary
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Background
Guidelines recommend investigation using cross-sectional imaging, such as MARS MRI or Ultrasound (MHRA 2012).
Here we present a systematic approach for US examination of the painful hip arthroplasty.
Aims | Background | Scan Protocol | Pathology | Summary

8. Scan Protocol Overview
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Scan Protocol Overview
① Anterior Scan
- Joint Effusion
- Pseudotumours
② Lateral Scan
- Gluteus Medius & Minimus tendons
③ Lateral Scan
- Gluteus Medius & Minimus Muscle Atrophy
④ Posterior Scan
Use an 18 MHz or 9 MHz linear transducer.
Aims | Background | Scan Protocol | Pathology | Summary

9. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Ultrasound Proforma
A standardized proforma was used to record findings.
Aims | Background | Scan Protocol | Pathology | Summary

11. Abductor Muscle Atrophy
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Abductor Muscle Atrophy
Fatty atrophy of the gluteus medius and minimus muscles causes lateral hip pain and limping.
It is commonly associated with metal-on-metal hips and may be a non-specific marker of hip pathology (Sabah 2011).
Aims | Background | Scan Protocol | Pathology| Summary

12. Abductor Muscle Atrophy
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Abductor Muscle Atrophy
Both hips should be scanned for a comparative assessment of size with the contralateral hip.
Report grading of fatty atrophy as follows:
Grade 0
No change
Grade 1
<30% size reduction or with some fatty replacement
Grade 2
30-70% size reduction with fatty replacement
Grade 3
>70% size reduction with marked fatty replacement
Adapted from: Bal BS, Lowe JA. Muscle damage in minimally invasive total hip arthroplasty: MRI evidence that it is not significant. Instr Course Lect. 2008;57:
Aims | Background | Scan Protocol | Pathology| Summary

13. Abductor Muscle Atrophy
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Abductor Muscle Atrophy
GRADE 0
GMed
GMin
GRADE 1
GMed
GMin
GRADE 2
GMed
GMin
GRADE 3
GMed
GMin
Lateral scans showing sequential loss of muscle architecture and thinning.
Aims | Background | Scan Protocol | Pathology| Summary

14. Abductor Muscle Atrophy
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Abductor Muscle Atrophy
GMed
GMin
Atrophy No Atrophy (Grade 3) (Grade 0)
[R] [L] [R] [L]
MARS MRI Ultrasound
Aims | Background | Scan Protocol | Pathology| Summary

15. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
GMed
GMin
Lateral Scans
 Cranial
Asymptomatic Hip
Gluteal Tendinosis
Ossification GT
Tendinous Pathology
Abductor tendinosis is an extrinsic cause for hip pain.
Tendons will appear hypoechoic and thickened.
Ossification may also be seen during calcific tendinosis.
Aims | Background | Scan Protocol | Pathology| Summary

16. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Tendinous Pathology
Native Femoral Head
Iliopsoas
MOM Femoral Head
Asymptomatic Hip
Iliopsoas Tendinosis
Anterior scan
 Cranial
Iliopsoas tendinosis causes groin pain, often due to impingement.
Tendons will appear hypoechoic and thickened.
However, thinning may be seen in severe cases due to wear (Long 2012).
Aims | Background | Scan Protocol | Pathology| Summary

17. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Pseudotumours
Are solid or cystic lesions associated with the hip prosthesis.
They are commonly found in patients with painful metal-on-metal hips (Pandit 2008).
They represent aseptic lymphocytic vasculitis-associated lesions (ALVALs) during histology (Willert 2005).
Aims | Background | Scan Protocol | Pathology| Summary

18. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Pseudotumours
Report the location (anterior, posterior, medial or lateral), classification (see table) and size (in the anterior-posterior, medial-lateral and cranial- caudal planes) of any periprosthetic lesions.
Type 1
Cystic lesion: internal fluid echo-texture; flat, thin-walled
Type 2
Cystic lesion: internal fluid echo-texture; atypical fluid; irregular thick-walled
Type 3
Solid lesion: complex solid echo-texture
Adapted from: Hart AJ, Satchithananda K, Liddle AD, et al. Pseudotumors in association with well- functioning metal-on-metal hip prostheses: a case-control study using three-dimensional computed tomography and magnetic resonance imaging. J Bone Joint Surg Am. 2012;94(4):
Aims | Background | Scan Protocol | Pathology| Summary

19. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Pseudotumours
TYPE 1 LESION
Thin walled.
Simple internal fluid echotexture.
Seen during bursitis (of the iliopsoas or trochanteric bursa).
Greater Trochanter
Lateral Scan
 Cranial
Aims | Background | Scan Protocol | Pathology| Summary

20. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Pseudotumours
TYPE 2 LESION
Irregular, thickened wall.
Abnormal internal fluid echotexture (due to metal debris).
Often in communication with the joint space.
Femoral Head
Anterior Scan
 Cranial
Aims | Background | Scan Protocol | Pathology| Summary

21. Aims | Background | Scan Protocol | Pathology| Summary
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Pseudotumours
TYPE 2 ANTERIOR LESION
MARS MRI Ultrasound
Aims | Background | Scan Protocol | Pathology| Summary

22. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Pseudotumours
TYPE 3 LESION
Complex lesions.
Solid internal echotexture.
Anterior Scan
 Cranial
Femoral Head
Aims | Background | Scan Protocol | Pathology| Summary

23. Summary OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Summary
A structure approach can optimize US of the symptomatic hip arthroplasty.
There is clear visualization of the periprosthetic tissues (particularly the abductor tendons and effusions) without metal artifact.
US is a screening tool for periprosthetic pseudotumours.
The role of US for muscle atrophy assessment is uncertain.
Aims | Background | Scan Protocol | Pathology| Summary

24. References OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
References
Bal BS, Lowe JA. Muscle damage in minimally invasive total hip arthroplasty: MRI evidence that it is not significant. Instr Course Lect. 2008;57:
FDA: Orthopaedic and Rehabilitation Devices Panel of the Medical Devices Advisory Open Panel Meeting, June [Online] Available from: edicalDevicesAdvisoryCommittee/OrthopaedicandRehabilitationDevicesPanel/ucm htm [Accessed 08/10/2012].
Hart AJ, Satchithananda K, Liddle AD, et al. Pseudotumors in association with well- functioning metal-on-metal hip prostheses: a case-control study using three-dimensional computed tomography and magnetic resonance imaging. J Bone Joint Surg Am ;94(4):
Hayter CL, Potter HG, Su EP. Imaging of metal-on-metal hip resurfacing. Orthop Clin North Am. 2011;42(2): , viii.
Kwon YM, Ostlere SJ, McLardy-Smith P, Athanasou NA, Gill HS, Murray DW. "Asymptomatic" pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplasty. 2011;26(4):

25. OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach
Long SS, Surrey D, Nazarian LN. Common sonographic findings in the painful hip after hip arthroplasty. J Ultrasound Med. 2012;31(2):
MHRA. Medical Device Alert: All metal-on-metal (MoM) hip replacements (MDA/2012/036) [Online] Available from: bs/documents/medicaldevicealert/con pdf [Accessed 08/10/2012].
Nishii T, Sakai T, Takao M, Yoshikawa H, Sugano N. Ultrasound Screening of Periarticular Soft Tissue Abnormality Around Metal-on-Metal Bearings. J Arthroplasty
Pandit H, Glyn-Jones S, McLardy-Smith P, et al. Pseudotumours associated with metal- on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90(7):
Sabah SA, Mitchell AW, Henckel J, Sandison A, Skinner JA, Hart AJ. Magnetic resonance imaging findings in painful metal-on-metal hips: a prospective study. J Arthroplasty. 2011;26(1):71-76, 76 e71-72.
Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW. Failure rates of stemmed metal-on- metal hip replacements: analysis of data from the National Joint Registry of England and Wales. Lancet. 2012;379(9822):
Willert HG, Buchhorn GH, Fayyazi A, et al. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am. 2005;87(1):28-36.

26. OPTIMIZING ULTRASOUND OF THE PAINFUL HIP ARTHROPLASTY:
Demonstrating a Novel Protocolized Approach