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

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

[email protected]

University College LondonInstitute of Orthopedics & Musculoskeletal Science,

Royal National OrthopedicHospital, United Kingdom

DisclosuresDr K Satchithananda: Johnson & Johnson Committee Member

OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach

AimsTo 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


BackgroundHip 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).



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).



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.



Scan Protocol Overview

① Anterior Scan

- Joint Effusion

- Pseudotumours

② Lateral Scan

- Pseudotumours

- Gluteus Medius & Minimus tendons

③ Lateral Scan

- Pseudotumours

- Gluteus Medius & Minimus Muscle

Atrophy

④ Posterior Scan

- Pseudotumours

Use an 18 MHz or 9 MHz linear transducer.



Ultrasound Proforma

A standardized proforma

was used to record findings.



Abductor Muscle Atrophy

Aims | Background | Scan Protocol | Pathology| Summary

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).




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;57:223-229.




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.




MARS MRI Ultrasound

GMed

GMin

GMed

GMin

Atrophy No Atrophy (Grade 3) (Grade 0)

[R] [L] [R] [L]


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.

GMed

GMin

GMed

GMin

GMedGMin

Lateral Scans Cranial

Asymptomatic Hip

Gluteal Tendinosis

Ossification

GT

GT

GT


Tendinous Pathology


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).

Native Femoral Head

IliopsoasIliopsoas

MOM Femoral Head

Asymptomatic Hip

Iliopsoas Tendinosis

Anterior scan Cranial


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).


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 2Cystic 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):317-325.


Pseudotumours


TYPE 1 LESION

Thin walled.

Simple internal fluid echotexture.

Seen during bursitis (of the iliopsoas or trochanteric bursa).

Greater Trochanter

Lateral Scan Cranial


Pseudotumours


TYPE 2 LESION

Irregular, thickened wall.

Abnormal internal fluid

echotexture (due to

metal debris).

Often in communication

with the joint space. Anterior Scan Cranial

Femoral Head


Pseudotumours


MARS MRI Ultrasound

TYPE 2 ANTERIOR LESION


Pseudotumours


TYPE 3 LESION

Complex lesions.

Solid internal

echotexture.

Anterior Scan Cranial

Femoral Head


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.



ReferencesBal BS, Lowe JA. Muscle damage in minimally invasive total hip arthroplasty: MRI evidence that it is not significant. Instr Course Lect. 2008;57:223-229.

FDA: Orthopaedic and Rehabilitation Devices Panel of the Medical Devices Advisory Open Panel Meeting, June 2012 [Online] Available from: http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/OrthopaedicandRehabilitationDevicesPanel/ucm309184.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. 2012;94(4):317-325.

Hayter CL, Potter HG, Su EP. Imaging of metal-on-metal hip resurfacing. Orthop Clin North Am. 2011;42(2):195-205, 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):511-518.


Long SS, Surrey D, Nazarian LN. Common sonographic findings in the painful hip after hip arthroplasty. J Ultrasound Med. 2012;31(2):301-312.

MHRA. Medical Device Alert: All metal-on-metal (MoM) hip replacements (MDA/2012/036) [Online] Available from: http://www.mhra.gov.uk/home/groups/dts-bs/documents/medicaldevicealert/con155767.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. 2011.

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):847-851.

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):1199-1204.

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.


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

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