Scientific Article   |    
Radiographic Definition of Pelvic Osteolysis Following Total Hip Arthroplasty
Alexandra M. Claus, MD, PhD; C. Anderson Engh, Jr, MD; Christi J. Sychterz, MS; John S. Xenos, MD; Karl F. Orishimo, MS; Charles A. Engh, Sr., MD
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Investigation performed at the Anderson Orthopaedic Research Institute, Alexandria, Virginia

Alexandra M. Claus, MD, PhD
Orthopädische Universitätsklinik Mannheim, Fakultät für Klinische Medizin der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3 68167 Mannheim, Germany. E-mail address: alexandra_claus@t-online.de

C. Anderson Engh Jr., MD
Christi J. Sychterz, MS
Karl F. Orishimo, MS
Charles A. Engh Sr., MD
Anderson Orthopaedic Research Institute, P.O. Box 7088, Alexandria, VA 22307

John S. Xenos, MD
Department of Orthopaedics, Walter Reed Army Medical Center, 6900 Georgia Avenue, Washington, DC 20307

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. The Anderson Orthopaedic Research Institute acknowledges the INOVA Health Care System, our hospital base, for the general support of our research endeavors. The nature of this study was not influenced by this support.

J Bone Joint Surg Am, 2003 Aug 01;85(8):1519-1526
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Background: Radiographs are the standard clinical tool used to monitor patients with pelvic osteolysis after total hip arthroplasty; however, previous reports have questioned the value and accuracy of this method. With use of a cadaveric model, we investigated the accuracy of radiographs in determining the location and size of periacetabular osteolysis.

Methods: We implanted total hip arthroplasty components in eight cadaveric hips and made four radiographs of each hip from different views. We then removed the components and created two pelvic defects in each hip. We measured the volume of each defect, reimplanted the components, and made another set of radiographs. The defects were then enlarged two more times, with the volume measured and another set of radiographs made each time. In total, 128 radiographs were made of forty-eight lesions. An orthopaedist who was blinded to the location of the lesions assessed the radiographs with regard to the presence and size of osteolytic lesions.

Results: The overall sensitivity for the detection of osteolysis on a single radiograph was 41.5%, and the overall specificity was 93.0%. Sensitivity was dependent on the location and size of the lesions but not on the radiographic view. Sensitivity ranged from 72% for lesions in the ilium to =15% for lesions in the ischium and acetabular rim. The detection rate for lesions with a volume of >10 cm 3 was significantly higher than that for smaller lesions (p < 0.001). When all four radiographic views of one lesion were analyzed together, sensitivity increased to 73.6%. Despite the low sensitivity, specificity remained high, indicating that once osteolysis is evident radiographically, the likelihood that a lesion truly exists is high. Additionally, we found that the extent of osteolysis was substantially underestimated on radiographs.

Conclusions: The use of radiographs to assess and monitor osteolysis has both limitations and merits. Using multiple views, an experienced orthopaedist identified only 73.6% of pelvic lesions. However, once a pelvic osteolytic lesion is evident radiographically, the likelihood that it truly exists is high.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Alexandra M. Claus
    Posted on August 27, 2003
    Dr. Claus responds to Dr. Marya
    Orthopaedische Klinik Mannheim, Klinische Fakultaet der Universitaet Heidelberg, Theodor-Kutzer Ufer

    Dear Sir,

    Thank you for your interest in our study that assessed the accuracy and value of radiographs in detecting pelvic osteolysis.

    It is well recognized that the diagnosis of pelvic osteolysis following total hip replacement is difficult and it was the intent of our study to demonstrate and quantify the merits as well as the limitations of standard radiographs in the detection of periacetabular osteolysis.

    In our Discussion we noted that CT scans might represent an alternative method to detect osteolysis. However, we did not suggest that CT scans be performed for regular follow-up of patients with total hip replacement for several reasons.

    First, despite an encouraging report {1}, the accuracy of computed tomography in identifying periacetabular lesions has yet to be determined. Second, we share your concern that regular CT scans expose the patient to high radiation. Additionally, the routine use of CT scans represents a cost-benefit dilemma because an effective therapy for pelvic osteolysis in the setting of stable implants is not yet known. There is an ongoing discussion about potential surveillance and treatment algorithms [2, 3, 4].

    Based on our current knowledge we recommend using multiple radiographic views--an AP pelvic view, an anteroposterior femoral view of the affected hip and 45° iliac and obturator oblique views for follow-ups.

    When assessing these views for the presence of osteolysis, the reviewer must be aware that identification of an osteolytic lesion in any view, no matter what the other views show and no matter how small the lesion is, establishes the likelihood that osteolysis is present. Using this radiographic protocol, 75% of all lesions can be detected, but some lesions,particularly those located in the posterior column of the acetabulum, may go undetected.

    If the radiographs indicate the presence of extensive periacetabular bone loss in the presence of a stable cup, or the surgeon decides to perform revision surgery, one might then consider performing a CT scan to obtain a three- dimensional understanding of the extent of bone loss as a preparation for revision surgery. However, streak artifacts caused by a metal implant may limit the effectiveness of CT. The use of MRI to evaluate pelvic osteolysis in the presence of a stable implant is also affected by implant artifacts and its use for this indication is under current investigation [5].

    We hope we have addressed your concerns regarding the problem of detecting periacetabular osteolysis using radiographs.


    Alexandra M. Claus, MD., PhD

    1. Puri L, Wixson RL, Stern SH, Kohli J, Hendrix RW, Stulberg SD

    Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty.

    J Bone Joint Surg Am. 2002 Apr;84-A(4):609-14

    2. Stulberg SD, Wixson RL, Adams AD, Hendrix RW, Bernfield JB

    Monitoring pelvic osteolysis following total hip replacement surgery: an algorithm for surveillance

    J Bone Joint Surg Am. 2002;84-A Suppl 2:116-22.

    3. Claus AM, Walde TA, Leung SB, Wolf RL, Engh CA Sr

    Management of patients with acetabular socket wear and pelvic osteolysis

    J Arthroplasty. 2003 Apr;18(3 Suppl 1):112-7

    4. Maloney WJ, Paprosky W, Engh CA, Rubash H

    Surgical treatment of pelvic osteolysis

    Clin Orthop. 2001 Dec;(393):78-84.

    5. Sofka CM, Potter HG

    MR imaging of joint arthroplasty

    Semin Musculoskelet Radiol. 2002 Mar;6(1):79-85

    K.M. Marya
    Posted on August 19, 2003
    Problems with using CT scans to evaluate osteolysis
    Department of Orthopaedics, SSR Medical College, Mauritius

    Dear Sir That aseptic loosening and osteolysis form an important reason of deterioration in functional outcome after a THA is well recognised. In the normal course of clinical follow-up, radiographs in two views are all that is done at centers that are not teaching and/or research oriented.

    This article again emphasizes that plain radiographs alone cannot be relied upon in areas where either the geometry of bone is complex (as in the pelvis) or in areas where overlapping shadows exist. But, at the same time, it is really not financially (or ethically) viable to expose all such patients to the high radiation of a CT scan.

    The study, though, has clearly demonstrated the unreliability of plain X- ray in detecting osteolytic changes. Itleaves one to ponder what protocol to follow when one does not have an access to a CT or when one is not ethically prompted to expose a patient to an unnecessary radiation hazard. Multiple X-ray exposure versus CT is not what is the dilemma. The issue is the the cost-benefit dilemma of exposing patients to increased radiation to try to establish a diagnosis.

    Claus et al might wish to propose alternate strategies to evaluate the possiblity of osteolysis. I would invite their comments regarding this issue.

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