Date post: | 20-Jan-2016 |
Category: |
Documents |
Upload: | alfred-bailey |
View: | 213 times |
Download: | 0 times |
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 LondonInstitute of Orthopedics & Musculoskeletal Science,
Royal National OrthopedicHospital, United Kingdom
OPTIMIZING ULTRASOUND OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
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
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
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).
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
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
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
- 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.
Aims | Background | Scan Protocol | Pathology | Summary
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
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
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).
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Abductor Muscle Atrophy
Aims | Background | Scan Protocol | Pathology| Summary
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.
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Abductor Muscle Atrophy
Aims | Background | Scan Protocol | Pathology| Summary
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.
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Abductor Muscle Atrophy
Aims | Background | Scan Protocol | Pathology| Summary
MARS MRI Ultrasound
GMed
GMin
GMed
GMin
Atrophy No Atrophy (Grade 3) (Grade 0)
[R] [L] [R] [L]
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Tendinous Pathology
Aims | Background | Scan Protocol | Pathology| Summary
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
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Tendinous Pathology
Aims | Background | Scan Protocol | Pathology| Summary
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
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Pseudotumours
Aims | Background | Scan Protocol | Pathology| Summary
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).
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Pseudotumours
Aims | Background | Scan Protocol | Pathology| Summary
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.
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Pseudotumours
Aims | Background | Scan Protocol | Pathology| Summary
TYPE 1 LESION
Thin walled.
Simple internal fluid echotexture.
Seen during bursitis (of the iliopsoas or trochanteric bursa).
Greater Trochanter
Lateral Scan Cranial
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Pseudotumours
Aims | Background | Scan Protocol | Pathology| Summary
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
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Pseudotumours
Aims | Background | Scan Protocol | Pathology| Summary
MARS MRI Ultrasound
TYPE 2 ANTERIOR LESION
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
Pseudotumours
Aims | Background | Scan Protocol | Pathology| Summary
TYPE 3 LESION
Complex lesions.
Solid internal
echotexture.
Anterior Scan Cranial
Femoral Head
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
OPTIMIZING ULTRASOUND (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
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.
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):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 (US) OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach
OPTIMIZING ULTRASOUND OF THE PAINFUL HIP ARTHROPLASTY: Demonstrating a Novel Protocolized Approach