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      Hybrid SPECT/CT for the assessment of a painful hip after uncemented total hip arthroplasty

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          Abstract

          Background

          The diagnosis of hip pain after total hip replacement (THR) represents a highly challenging question that is of increasing concern to orthopedic surgeons. This retrospective study assesses bone scintigraphy with Hybrid SPECT/CT for the diagnosis of painful THR in a selected cohort of patients.

          Methods

          Bone SPECT/CT datasets of 23 patients (mean age 68.9 years) with a painful hip after THR were evaluated. Selection of the patients required an inconclusive radiograph, normal serum levels of inflammatory parameters (CRP and ESR) or a negative aspiration of the hip joint prior to the examination. The standard of reference was established by an interdisciplinary adjudication-panel using all imaging data and clinical follow-up data (>12 month). Pathological and physiological uptake patterns were defined and applied.

          Results

          The cause of pain in this study group could be determined in 18 out of 23 cases. Reasons were aseptic loosening (n = 5), spine-related (n = 5), heterotopic ossification (n = 5), neuronal (n = 1), septic loosening (n = 1) and periprosthetic stress fracture (n = 1). In (n = 5) cases the cause of hip pain could not be identified. SPECT/CT imaging correctly identified the cause of pain in (n = 13) cases, in which the integrated CT-information led to the correct diagnosis in (n = 4) cases, mainly through superior anatomic correlation. Loosening was correctly assessed in all cases with a definite diagnosis.

          Conclusions

          SPECT/CT of THA reliably detects or rules out loosening and provides valuable information about heterotopic ossifications. Furthermore differential diagnoses may be detected with a whole-body scan and mechanical or osseous failure is covered by CT-imaging. SPECT/CT holds great potential for imaging-based assessment of painful prostheses.

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          Most cited references 31

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          Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002.

          The purpose of this study was to quantify the procedural rate and revision burden of total hip and knee arthroplasty in the United States and to determine if the age or gender-based procedural rates and overall revision burden are changing over time. The National Hospital Discharge Survey (NHDS) for 1990 through 2002 was used in conjunction with United States Census data to quantify the rates of primary and revision arthroplasty as a function of age and gender within the United States with use of methodology published by the American Academy of Orthopaedic Surgeons. Poisson regression analysis was used to evaluate the procedural rate and to determine year-to-year trends in primary and revision arthroplasty rates as a function of both age and gender. Both the number and the rate of total hip and knee arthroplasties (particularly knee arthroplasties) increased steadily between 1990 and 2002. Over the thirteen years, the rate of primary total hip arthroplasties per 100,000 persons increased by approximately 50%, whereas the corresponding rate of primary total knee arthroplasties almost tripled. The rate of revision total hip arthroplasties increased by 3.7 procedures per 100,000 persons per decade, and that of revision total knee arthroplasties, by 5.4 procedures per 100,000 persons per decade. However, the mean revision burden of 17.5% for total hip arthroplasty was more than twice that for total knee arthroplasty (8.2%), and this did not change substantially over time. The number and prevalence of primary hip and knee replacements increased substantially in the United States between 1990 and 2002, but the trend was considerably more pronounced for primary total knee arthroplasty. The reported prevalence trends have important ramifications with regard to the number of joint replacements expected to be performed by orthopaedic surgeons in the future. Because the revision burden has been relatively constant over time, we can expect that a greater number of primary replacements will result in a greater number of revisions unless some limiting mechanism can be successfully implemented to reduce the future revision burden.
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            Dislocations after total hip-replacement arthroplasties.

            In a series of 300 total hip replacements, nine (3 per cent) dislocated. Precise measurements of the orientation of the acetabular cup were made and it was found that anterior dislocations were associated with increased acetabular-component anteversion. There was no significant correlation between cup-orientation angle and posterior dislocation. The dislocation rate for cup orientation with anteversion of 15 +/- 10 degrees and lateral opening of 40 +/- 10 degrees was 1.5 per cent, while outside this "safe" range the dislocation rate was 6.1 per cent. Other factors that were documented include time after surgery (with the greatest risk in the first thirty days) and surgical history (with a greater risk in hips that have had prior surgery).
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              "Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening.

              In view of the increasing incidence of stem-type femoral component loosening, a detailed retrospective radiographic zonal analysis of 389 total hip replacements indicated a 19.5% incidence (76 hips) of radiological evidences of mechanical looseness, i.e., fractured acrylic cement and/or a radiolucent gap at the stem-cement or cement-bone interfaces. Detailed serial radiographic examination demonstrated progressive loosening in 56 of the 76 hips and these were categorized into mechanical modes of failure. The 4 modes of failure characterizing stem-type component progressive loosening mechanisms consisted of stem pistoning within the acrylic (3.3%), cement-embedded stem pistoning with the femur (5.1%), medial midstem pivot (2.5%), calcar pivot (0.7%) and bending (fatigue) cantilever (3.3%).
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                Author and article information

                Contributors
                o.dobrindt@gmail.com
                holger.amthauer@med.ovgu.de
                alexander.krueger@med.ovgu.de
                juri.ruf@uniklinik-freiburg.de
                heiko.wissel@med.ovgu.de
                oliver.grosser@med.ovgu.de
                max.seidensticker@med.ovgu.de
                christoph.lohmann@med.ovgu.de
                Journal
                BMC Med Imaging
                BMC Med Imaging
                BMC Medical Imaging
                BioMed Central (London )
                1471-2342
                2 June 2015
                2 June 2015
                2015
                : 15
                Affiliations
                [ ]Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Magdeburg A.ö.R., Otto-von-Guericke Universität, Leipziger Straße 44, 39120 Magdeburg, Germany
                [ ]Charité - Universitätsmedizin, Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charitéplatz 1, 10117 Berlin, Germany
                [ ]Orthopädische Universitätsklinik, Universitätsklinikum Magdeburg A.ö.R., Otto-von-Guericke Universität, Leipziger Straße 44, 39120 Magdeburg, Germany
                [ ]Universitätsklinikum Freiburg, Klinik für Nuklearmedizin, Hugstetter Straße 55, 79106 Freiburg, Germany
                Article
                56
                10.1186/s12880-015-0056-1
                4459070
                26033371
                © Dobrindt et al. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Categories
                Research Article
                Custom metadata
                © The Author(s) 2015

                Radiology & Imaging

                total hip arthroplasty, spect/ct, thr, hip pain, loosening

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