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A Comparison of Radiographic and Scintigraphic Techniques to Assess Aseptic Loosening of the Acetabular Component in a Total Hip Replacement
Olivier P.P. Temmerman, MD1; Pieter G.H.M. Raijmakers, MD, PhD1; Erik F.L. David, MD1; Rik Pijpers, MD, PhD1; Marinus A. Molenaar, MD, PhD1; Otto S. Hoekstra, MD, PhD1; Johannes Berkhof, PhD1; Rado A. Manoliu, MD, PhD1; Gerrit J.J. Teule, MD, PhD1; Ide C. Heyligers, MD, PhD2
1 Departments of Nuclear Medicine (O.P.P.T., P.G.H.M.R., R.P., O.S.H., and G.J.J.T.), Orthopaedic Surgery (O.P.P.T.), Clinical Epidemiology and Biostatistics (O.S.H. and J.B.), and Radiology (E.F.L.D., M.A.M., and R.A.M.), VU University Medical Centre, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands. E-mail address for O.P.P. Temmerman: opp.temmerman@vumc.nl.
2 Department of Orthopaedic Surgery, Atrium Medical Centre, Henri Dunantstraat 5, 6401CX Heerlen, The Netherlands
View Disclosures and Other Information
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the Dutch Health Care Insurance Board (00155). None of the authors received 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.
Investigation performed at the VU University Medical Centre, Amsterdam, The Netherlands

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Nov 01;86(11):2456-2463
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Background: The diagnosis of a loose total hip prosthesis is often established with use of radiographic and nuclear medicine techniques, but there is controversy about the relative utility of plain radiography, subtraction arthrography, nuclear arthrography, and bone scintigraphy. In this retrospective study, we evaluated the sensitivity, specificity, and interobserver reliability of these imaging modalities in patients suspected of having aseptic loosening of the acetabular component.

Methods: From 1994 to 1999, eighty-six consecutive patients with pain after a total hip arthroplasty were evaluated for possible loosening of the components. The imaging evaluation included plain radiography followed by a one-day protocol that included bone scintigraphy, subtraction arthrography, and nuclear arthrography. For this study, two experienced nuclear medicine physicians and two experienced radiologists, all of whom were blinded with respect to the clinical pretest data and the clinical outcome, retrospectively interpreted the diagnostic images. The sensitivity and the specificity of each imaging modality were established by comparing the findings obtained with each technique with those found at surgery or during the subsequent clinical course of the patient. Interobserver variability was determined with the intraclass correlation coefficient.

Results: Plain radiography had a sensitivity of 85% (95% confidence interval, 71 to 94) and a specificity of 85% (95% confidence interval, 66 to 96) in detecting aseptic loosening of the acetabular component, but it had only fair interobserver variability (intraclass correlation coefficient, 0.37). For subtraction arthrography, the sensitivity was 72% (95% confidence interval, 57 to 84), the specificity was 70% (95% confidence interval, 50 to 86), and there was good interobserver variability (intraclass correlation coefficient, 0.71). For nuclear arthrography, the sensitivity was 57% (95% confidence interval, 41 to 71), the specificity was 67% (95% confidence interval, 46 to 84), and there was fair interobserver variability (intraclass correlation coefficient, 0.24). For bone scintigraphy, the sensitivity was 83% (95% confidence interval, 69 to 92), the specificity was 67% (95% confidence interval, 46 to 84), and there was moderate interobserver variability (intraclass correlation coefficient, 0.43).

Conclusions: Plain radiography had the highest diagnostic accuracy in the evaluation of aseptic loosening of the acetabular component. The diagnostic accuracy was increased when plain radiography was combined with bone scintigraphy or subtraction arthrography. However, we found considerable interobserver variability in image interpretation, even with experienced radiologists and nuclear medicine physicians.

Level of Evidence: Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients [with universally applied reference "gold" standard]). See Instructions to Authors for a complete description of levels of evidence.

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    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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