Posteriorly, the sciatic nerve and its relationship to the piriformis muscle and pseudocapsule are demonstrated. The MRI examinations of patients with metal-on-metal hip prostheses placed at resurfacing arthroplasty (n= 31) or THA (n= 29) were reviewed for osteolysis, synovitis, extracapsular disease, synovial pattern, and mode of decompression into adjacent bursae. Failed repair of the posterior capsule and the short external rotators is indicated by a gap with fluid signal intensity between the tendons and the greater trochanter (38). 7, 2 February 2017 | Journal of Magnetic Resonance Imaging, Vol. Figure 22 Iliopsoas screw impingement in a 71-year-old woman. Sarcoidlike granulomatous reactions to wear products (69), the coexistence of an adverse local tissue reaction and infection, and underlying rheumatoid disorders complicate the MR imaging patterns of infection. All major vendors now provide high-performance 1.5-T MR imaging systems that are suited for this task. Transection and transient ischemia from compression or vascular injury are additional mechanisms of nerve injury. Figure 13b Polyethylene wear–induced synovitis in a 42-year-old man. Figure 15a Spectrum of adverse local tissue reactions caused by hypersensitivity to metal products. If extensive osseous resorption is identified around the proximal aspect of a femoral component, the FOV can be extended caudally to include the tip of the femoral stem to aid in the assessment of osseous integration. These complications however may have similar imaging findings and overlap exists. 1. 47, No. 5, The Journal of Bone and Joint Surgery, Vol. 9, Seminars in Musculoskeletal Radiology, Vol. Corrosion products may incite hypersensitivity reactions directly but may also accelerate mechanical wear by acting as a “third body” in the joint (61). Tendon tears may be classified as longitudinal, partial-thickness, or full-thickness tears. Figure 6b Periprosthetic bone resorption in a 52-year-old man. This enables consistent standardized reporting of complications 8. When the ball of the femoral component is dislocated from the acetabular cup. 3, 22 June 2017 | Magnetic Resonance in Medicine, Vol. MR imaging with optimized conventional pulse sequences and metal artifact reduction techniques is a comprehensive imaging modality for the evaluation of the hip after arthroplasty, contributing important information for diagnosis, prognosis, risk stratification, and surgical planning. Figure 23b Iliopsoas impingement and tendon rupture in a 75-year-old woman. "The Accuracy of Imaging Techniques in the Assessment of Periprosthetic Hip Infection: A Systematic Review and Meta-Analysis." Axial MR imaging evaluation can disclose dehiscence of the short external rotator repair, and scar tissue remodeling of the posterior soft-tissue envelope may appear as intermediate to high signal intensity (36,37). Understanding reduced range of hip motion causing more lower back pain Polyethylene debris (interchangeable with the term polymeric debris) causes histiocyte-mediated synovitis, cytokine-driven up-regulation of osteoclasts, and down-regulation of osteoblasts, resulting in slowly progressive, typically bulky osteolysis (45). Coronal intermediate-weighted fast SE MR image (5129/23) (a) and coronal inversion-recovery MAVRIC MR image (4432/36) (b) of a metal-on-polyethylene hip arthroplasty system show a focus of mature heterotopic ossification in the iliopsoas bursa that is characterized by a thin layer of hypointense cortical bone and fatty marrow (arrow in a), a finding that is suppressed (arrow in b) on the inversion-recovery image. (b) Coronal intermediate-weighted fast SE MR image (4000/42) shows geographic osteolysis of the proximal portion of the femur containing intermediate-signal-intensity synovitis and debris (black arrow) resembling muscle tissue. Hip resurfacing, a surgical alternative to total hip replacement (THR), involves placing a metal cap over the head of the femur while a matching metal cup, similar to that used in a THR, is placed in the pelvic socket. Figure 29 Neoplasm in an 81-year-old man. 9, 17 April 2018 | European Radiology Experimental, Vol. The cellular inflammatory response in the periprosthetic soft tissues often resembles delayed or type IV hypersensitivity-induced inflammation; however, the exact pathogenesis is uncertain (48). You shouldn't expect to move the joint the way you did … J.F. Risks and complications of hip replacement surgery. It is important for the radiologist to have familiarity with the most common orthopedic procedures in order to better recognize complications involved with various procedures. Tendon tears may progress on the basis of preexisting degeneration, overuse, age, and trauma or may develop after an anterolateral or transgluteal surgical approach. Both techniques are based on three-dimensional SE pulse sequences but use alternative frequency- and phase-encoding schemes for correction of in-plane and through-plane distortion artifacts. Although they're thought to be generally safe to use in later pregnancy (after 3 months), it's not known whether the strong magnetic fields have any long-term effects on the developing baby. Periprosthetic fractures have an overall incidence as high as 18% and may occur during component implantation or after surgery because of periprosthetic bone resorption, osteolysis, implant loosening, osteoporosis, and, occasionally, trauma, such as falls and motor vehicle accidents (26). Atrophy of the psoas and iliacus muscles can be an indirect sign of tendon dysfunction or prior tendon release. Additional complications include component wear–induced synovitis, tendinopathy and tendon tears, heterotopic ossification, and neuropathy. 3, The Journal of Arthroplasty, Vol. Metallosis and hypersensitivity reactions may coexist in the same hip, which results in a mixture of the MR imaging findings of both entities (Fig 20). The sciatic, femoral, and obturator nerves are well demonstrated on axial MR images. Summary 4 2. The spectrum of tendon abnormalities ranges from tendinosis to partial-thickness tears and frank tendon rupture (Fig 23). Imaging of the painful hip arthroplasty. 46, No. Coronal intermediate-weighted fast SE MR image (5129/23) (a) and coronal inversion-recovery MAVRIC MR image (4432/36) (b) of a metal-on-polyethylene hip arthroplasty system show a focus of mature heterotopic ossification in the iliopsoas bursa that is characterized by a thin layer of hypointense cortical bone and fatty marrow (arrow in a), a finding that is suppressed (arrow in b) on the inversion-recovery image. The findings at histopathologic examination disclosed metastatic adenocarcinoma. Magnetic Resonance Imaging (MRI) Scans: Powerful magnetic fields and radio waves are passed around the patient’s body to get more detailed cross-sectional images of the hip joint. 2003;180 (1): 115-20. (b) MR image (5683/24) of a 50-year-old woman shows expansion of the pseudocapsule with fluid with an abundance of synovial debris and an intermediate-signal-intensity synovial lining (arrow). 379, 24 May 2017 | Skeletal Radiology, Vol. The modified Watson-Jones approach to the hip has been described as a minimally invasive approach with the potential for fewer postoperative complications than the traditional approach. and H.G.P. (a) Axial intermediate-weighted fast SE MR image (4051/27) of an acetabular component shows bone resorption over the anterior wall and column. At MR imaging, mature heterotopic ossification resembles the MR imaging appearance of cancellous bone, with a thin hypointense cortex and characteristic fatty marrow deposits that are suppressed on STIR MR images (Fig 27). 3, 25 March 2017 | Journal of Magnetic Resonance Imaging, Vol. However, fatty atrophy of the posterior muscle fibers of the gluteus minimus and the posterior portion of the gluteus medius muscle is uncommon in asymptomatic patients and should trigger a search for a tendon tear (7). Particulate synovitis and debris are also depicted in the iliopsoas bursa (white arrow). The synovial thickness and the extensive tissue destruction on MR images correlated with a high histologic ALVAL score of 10 and with the degree of tissue destruction at surgery. 98, No. The use of phase encoding along the section axis of the volume limits through-plane distortions. 477, No. Associated polyethylene wear–induced osteolysis is typically bulky, with particulate debris replacing the normal periprosthetic trabecular bone and marrow signal intensity (Fig 14). Fibrous membrane formation is assumed from the presence of a smooth intermediate- to high-signal-intensity layer that is interposed between the host bone and the implant or cement (Fig 5). MR imaging is a useful modality in the diagnosis of periprosthetic fractures, bone resorption and osteolysis, postoperative hematoma, disruption of the pseudocapsule, synovitis caused by polyethylene wear and adverse local tissue reactions, periprosthetic masses and neoplasms, bursitis, tendinopathy and tendon tears, and neurovascular compromise. 8. The circumferential bone resorption is suggestive of loosening. 1, Seminars in Roentgenology, Vol. In combination with the findings from the patient history, the physical examination, laboratory data, and radiographs, MR imaging has become part of the routine workup for patients with hip arthroplasty implants at our institution. Complications of hip replacement and hip revision. Types 1 and 2 describe predominantly cystic lesions, in which type 1 lesions demonstrate a wall thickness of less than 3 mm and type 2 lesions have a wall thickness greater than 3 mm. Adverse local tissue reaction is an umbrella term describing reactions to arthroplasty-related metal products, including metallosis caused by metal debris, reactive tissue inflammation caused by metal ions and corrosion products, or combinations thereof (47–50). (2012) Journal of Ultrasound in Medicine. Nonacute partial-thickness tears characteristically occur through longitudinal stripping of tendon fibers (Fig 24). Gluteus medius tendon tears appear to be more important clinically (75). Orthop Clin North Am 2011;42(2):207–230, viii. Axial intermediate-weighted fast SE MR image (3633/27) of a metal-on-metal hip arthroplasty system shows a destructive periprosthetic soft-tissue mass (arrow) of the proximal portion of the femur. Metal artifact reduction techniques, such as the section encoding for metal artifact correction technique (SEMAC; Siemens Healthcare, Erlangen, Germany) (20) and the multiacquisition variable-resonance image combination technique (MAVRIC; GE Healthcare, Waukesha, Wis) (21), substantially reduce metal-related artifacts and drastically improve depiction of the synovium-implant and bone-implant interfaces (15,22). A joint replacement can stop pain, but it can't restore the hip or knee you had when you were younger. Image-guided joint aspiration is ultimately required to prove the presence of an infection. A suggested pulse sequence protocol is detailed in Table 2. 56, No. (a) Image shows anterior extension of the acetabular component beyond the bone, with impingement on the iliopsoas tendon (arrow). 2, No. Figure 28 Screw impingement on the sciatic nerve in a 75-year-old man. 59, No. In one of the first attempts to categorize the MR imaging soft-tissue findings in patients with metal-on-metal arthroplasty implants, three major groups were defined empirically: (a) normal or expected changes (group A); (b) infection (group B); and (c) metal-on-metal disease (group C), including mild (C1), moderate (C2), and severe (C3) metal-on-metal disease (adverse local tissue reaction) (11). Coronal intermediate-weighted fast SE MR images (4920/28) of a metal-on-metal hip arthroplasty system show two pathologic processes. 3 Contents 1. Note the dehiscence of the posterior pseudocapsule (arrowhead), with decompression of synovitis and debris. Similarly, an intact interface of a cemented component is characterized by intimate contact between the host bone and the cement. 8, 30 March 2017 | Skeletal Radiology, Vol. Complications ranging from osteolysis caused by granulomatous reaction to particulate wear debris lead to many long-term failures. Other causes for arthroplasty-related nerve compromise include dislocation events, postoperative hematoma, tendon avulsions, heterotopic ossification, and adverse local tissue reactions. Independently mobile older adults with hip fractures may benefit from a total hip replacement instead of hemiarthroplasty. The effect of fibrous membrane formation on implant fixation is uncertain; it may or may not progress to component loosening and may warrant closer imaging surveillance. 9, American Journal of Roentgenology, Vol. MR imaging is best performed with the patient in the supine position. (d) MR image (4850/27) of a 73-year-old woman shows expansion of the pseudocapsule with solid material (arrow), a finding that resembles a pseudotumor. 5. The development of a “synovial-like” or “fibrous” membrane along the bone-implant interface will limit osseous integration (27). Implant loosening depends on the magnitude of bone resorption and may be suggested if circumferential bone resorption around an implant is found. 39, No. Partial-thickness tears may manifest as a focal tendon defect that may or may not result in retraction of the torn tendon slip. Acetabular component prominence between 2 and 12 mm has been found in patients with iliopsoas impingement syndrome (72,73) (Fig 23). Coronal (4866/24) (a) and axial (4100/22) (b) intermediate-weighted fast SE MR images of a femoral implant show fibrous membrane formation that is indicated by a thin layer of increased signal intensity (white arrow) at the implant-bone interface, which is surrounded by a thin layer of decreased signal intensity (black arrow). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Magnetic resonance imaging. Hematoma formation is a complication that occurs in as many as 1.7% of patients after total hip arthroplasty (42). Figure 16 Adverse local tissue reaction caused by hypersensitivity to metal products, with extensive soft-tissue necrosis, in a 48-year-old man. A high index of suspicion is required to avoid misinterpretation of this appearance as a hematoma, soft-tissue neoplasm, or aggressive infection. Alternatively, pain around the hip or buttock may be referred from disease in the lumbar spine or, less frequently, from intraabdominal or vascular disorders (83). (d) MR image (4850/27) of a 73-year-old woman shows expansion of the pseudocapsule with solid material (arrow), a finding that resembles a pseudotumor. Similar to the diagnosis on radiographs and computed tomographic (CT) images (31–33), fibrous membrane formation and periprosthetic bone resorption may be qualified by the thickness of the hyperintense layer, with a 1–2-mm thickness representing fibrous membrane formation and with more than a 2-mm thickness and irregularity indicating bone resorption (Fig 6). Occasionally, decompression of synovitis forms large tumorlike extraarticular deposits, which can resemble the pseudotumors described in adverse local tissue reactions to metal debris (described in the next section). 3, 26 May 2016 | Journal of Magnetic Resonance Imaging, Vol. Postoperative changes are depicted in the gluteal musculature (*). 12 - Imaging of prosthetic joint infections A2 - Arts, J.J. Chris. (2016) Clinical orthopaedics and related research. (b) Corresponding coronal STIR MAVRIC MR image (4253/37) shows the reaction (arrow) as inconspicuous. Magnetic Resonance Imaging (MRI) is a commonly accepted and widely used medical procedure. http://dx.doi.org/10.2106/JBJS.15.00898. Coronal intermediate-weighted MAVRIC MR image (4100/42) (a) and axial intermediate-weighted fast SE MR image (5583/27) (b) of a metal-on-metal hip arthroplasty system show a small volume of simple joint fluid (* in a) with uniform fluid signal intensity around the neck of the femoral component, a thin synovial lining (arrows in a), and no intracapsular debris. Table 1: MR Imaging Factors and Parameters for Minimization of Arthroplasty-related Artifacts and Improvement of Image Quality. 6, The Journal of Arthroplasty, Vol. Optimized conventional pulse sequences and metal artifact reduction techniques afford improved depiction of bone, implant-tissue interfaces, and periprosthetic soft tissue for the diagnosis of arthroplasty-related complications. (b) Axial intermediate-weighted fast SE MR image (4100/22) shows cortical hypointensity and periosteal new bone formation (arrow). Figure 25a Tendon avulsion caused by adverse local tissue reaction in a 74-year-old woman. Taljanovic MS, Jones MD, Hunter TB et-al. Hip arthroplasty has become the standard treatment for end-stage hip disease, allowing pain relief, improvement of activity level, and patient satisfaction in as many as 90% of patients (1). MR images of the pelvis with a large field of view (FOV) can be acquired with the body coil or multichannel surface body coil systems. Hip arthroplasty has become the standard treatment for end-stage hip disease, allowing pain relief and restoration of mobility in large numbers of patients; however, pain after hip arthroplasty occurs in as many as 40% of cases, and despite improved longevity, all implants eventually fail with time. (a) Axial intermediate-weighted fast SE MR image (5427/31) of a metal-on-polyethylene hip arthroplasty system shows immature heterotopic ossification manifesting as a heterogeneous mass (arrow) in the quadriceps muscle group. *Depends on the number of sections required to cover the anatomy; the given ranges are typical of the clinical application. Figure 26a Immature heterotopic ossification in a 68-year-old man. (a) Axial intermediate-weighted fast SE MR image (4051/27) of an acetabular component shows bone resorption over the anterior wall and column. 24, No. The MAVRIC image helps unmask the metallic deposits indicated by the arrow and arrowheads in b. Osteolysis can occur in both metallosis (Fig 18) and reactive tissue inflammation with features of hypersensitivity (Fig 19) but is a more defining characteristic of metallosis, whereas hypersensitivity reactions are dominated by the presence of soft-tissue deposits, necrosis, and less frequent osteolysis (6). Iliopsoas impingement or tendinopathy may be idiopathic or related to a prominent, oversized, or malpositioned acetabular component, retained cement, excessively long iliac screws, or a femoral head that is larger than the native head (71). Table 3: Typical MR Imaging Characteristics of the Different Types of Arthroplasty-associated Synovitis. (a) Coronal inversion-recovery MAVRIC MR image (3975/36) of a metal-on-metal hip arthroplasty system shows a bone marrow edema pattern, periosteal new bone formation, and adjacent soft-tissue edema (arrow) along the medial margin of the proximal portion of the femur. Figure 13a Polyethylene wear–induced synovitis in a 42-year-old man. The circumferential bone resorption is suggestive of loosening. Traction is contraindicated in femoral neck fractures due to it affecting blood flow to the head of the femur. Such turbo or fast SE techniques are also useful because their 180° refocusing radiofrequency pulses minimize the dephasing effects of static field inhomogeneities. Crossref, Medline, Google Scholar; 50. Here, we highlight the different imaging modalities available for diagnosing each complication. Additional findings that may be depicted are perisynovial edema and local lymphadenopathy, which may overlap with the features of infection. Note the excessive acetabular anteversion (dotted line), which measured 48°, a finding that represents a risk factor for anterior instability. MR imaging can also contribute information with regard to heterotopic ossification, infection, joint instability, and impingement (4–6,8,13–18). AJR Am J Roentgenol. (2015) Insights into imaging. At MR imaging, intact nerves demonstrate preservation of the perineural fat plane, an internal fascicular pattern, and intermediate signal intensity. A checklist is provided for systematic evaluation of MR images of hip arthroplasty implants. Coronal large-FOV STIR MR images and intermediate-weighted MR images obtained with the MAVRIC technique or the SEMAC technique should extend from the L4 vertebral body to the proximal femoral diaphysis, to include the entire femoral component. 2. Healy WL, Iorio R, Clair AJ, Pellegrini VD, Della Valle CJ, Berend KR. Although primary pigmented villonodular synovitis after hip arthroplasty is extremely rare, MR imaging surveillance after synovectomy and hip arthroplasty for preexisting pigmented villonodular synovitis can be used to detect recurrent disease and monitor the progression of residual disease (Fig 30). On the corresponding radiograph (not shown), the radiolucent nature of the polyethylene liner precluded radiographic detection. 23, No. Figure 12a Nonspecific postoperative effusion without conspicuous synovitis in a 58-year-old man. Multichannel surface coils, two-part shoulder coils, and wrap coils are suitable for small-FOV high-spatial-resolution MR imaging of the hip (9). 76, No. Ann R Coll Surg Engl. aseptic lymphocytic vasculitis–associated lesion, multiacquisition variable-resonance image combination, section encoding for metal artifact correction, Journal of Magnetic Resonance Imaging, Vol. Anterior pseudocapsular dehiscence is also common, which allows extension into the iliopsoas and subiliac bursae, potentially compromising the iliopsoas tendon and femoral neurovascular bundle. 28, No. (b) Axial intermediate-weighted fast SE MR image (4051/27) shows circumferential bone resorption around a femoral implant. 32, No. 3, Diagnostic and Interventional Imaging, Vol. Short-term failures of hip replacements are most commonly the result of instability and dislocation. (b) Axial intermediate-weighted fast SE MR image (4100/22) shows cortical hypointensity and periosteal new bone formation (arrow). Group A included seromas and small hematomas. At MR imaging, polyethylene wear–induced synovitis is typically manifest as expansion of the hip pseudocapsule by a thick and particulate-appearing synovitis of low to intermediate signal intensity that is often similar in intensity to skeletal muscle, with variable amounts of interspersed fluid (Fig 13) (46). Recent implantation, surgical reaming, lack of periosteal reaction, and lymphadenopathy suggested the existence of PJI 8 in. Complications of hip replacements are most commonly the result of instability and dislocations are common reasons revision... Anatomy ; the given ranges are typical of the posterior pseudocapsule, even small volumes of fluid... Sufficient gradient amplitude and radiofrequency power performance replacement including higher rates of implant wear and is a commonly and. 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