Skip to main content
SpringerLink
Log in

The John Charnley Award: Diagnostic Accuracy of MRI Versus Ultrasound for Detecting Pseudotumors in Asymptomatic Metal-on-Metal THA

  • Symposium: 2013 Hip Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

The prevalence of pseudotumors in patients with large-head metal-on-metal (MOM) THA has been the subject of implant recalls and warnings from various regulatory agencies. To date, there is no consensus on whether ultrasound or MRI is superior for the detection of pseudotumors.

Questions/purposes

We prospectively compared ultrasound to MRI for pseudotumor detection in an asymptomatic cohort of patients with MOM THAs. We also compared ultrasound to MRI for assessment of pseudotumor growth and progressive soft tissue involvement at a 6-month interval.

Methods

We enrolled 40 patients with large-head MOM THAs in the study. The mean age was 54 years (range, 34–76 years). The mean time from surgery was 54 months (range, 40–81 months). There were 28 men and 12 women. All patients underwent ultrasound and MRI using slice encoding for metal artifact correction. The gold standard was defined as follows: if both ultrasound and MRI agreed, this was interpreted as concordant and the result was considered accurate.

Results

Ultrasound and MRI agreed in 37 of 40 patients (93%). The prevalence of pseudotumors was 31% (12 of 39) in our cohort. Twenty-three of 39 patients (59%) had completely normal tests and four (10%) had simple fluid collections. Ultrasound had a sensitivity of 100% and specificity of 96% while MRI had a sensitivity of 92% and specificity of 100%.

Conclusions

A negative ultrasound rules out pseudotumor in asymptomatic patients as this test is 100% sensitive. Given its lower cost, we recommend ultrasound as the initial screening tool for pseudotumors.

Level of Evidence

Level I, diagnostic study. See the Instructions for Authors for a complete description of levels of evidence.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1A–B

Similar content being viewed by others

References

  1. Anderson H, Toms AP, Cahir JG, Goodwin RW, Wimhurst J, Nolan JF. Grading the severity of soft tissue changes associated with metal-on-metal hip replacements: reliability of an MR grading system. Skeletal Radiol. 2011;40:303–307.

    Article  PubMed  Google Scholar 

  2. Bellamy N, Buchanan W, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or the knee. J Rheumatol. 1988;15:1833–1840.

    CAS  PubMed  Google Scholar 

  3. Berend KR, Morris MJ, Adams JB, Lombardi AV Jr. Metal-on-metal hip arthroplasty: going, going, gone…–affirms. J Bone Joint Surg Br. 2012;94(11 suppl):75–77.

    Article  CAS  PubMed  Google Scholar 

  4. Bosker BH, Ettema HB, Boomsma MF, Kollen BJ, Maas M, Verheyen CC. High incidence of pseudotumour formation after large-diameter metal-on-metal total hip replacement: a prospective cohort study. J Bone Joint Surg Br. 2012;94:755–761.

    Article  CAS  PubMed  Google Scholar 

  5. Bozic KJ, Kurtz S, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. The epidemiology of bearing surface usage in total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91:1614–1620.

    Article  PubMed  Google Scholar 

  6. Canadian Hip Resurfacing Study Group. A survey on the prevalence of pseudotumors with metal-on-metal hip resurfacing in Canadian academic centers. J Bone Joint Surg Am. 2011;93(suppl 2):118–121.

    Google Scholar 

  7. Chen CA, Chen W, Goodman SB, Hargreaves BA, Koch KM, Lu W, Brau AC, Draper CE, Delp SL, Gold GE. New MR imaging methods for metallic implants in the knee: artifact correction and clinical impact. J Magn Reson Imaging. 2011;33:1121–1127.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Cho ZH, Oh CH, Mun CW, Kim YS. Some results of high-flow-velocity NMR imaging using selection gradient. Magn Reson Med. 1986;3:857–862.

    Article  CAS  PubMed  Google Scholar 

  9. Douis H, Dunlop DJ, Pearson AM, O’Hara JN, James SL. The role of ultrasound in the assessment of post-operative complications following hip arthroplasty. Skeletal Radiol. 2012;41:1035–1046.

    Article  CAS  PubMed  Google Scholar 

  10. Fang CS, Harvie P, Gibbons CL, Whitwell D, Athanasou NA, Ostlere S. The imaging spectrum of peri-articular inflammatory masses following metal-on-metal hip resurfacing. Skeletal Radiol. 2008;37:715–722.

    Article  PubMed  Google Scholar 

  11. Gill IP, Webb J, Sloan K, Beaver RJ. Corrosion at the neck-stem junction as a cause of metal ion release and pseudotumour formation. J Bone Joint Surg Br. 2012;94:895–900.

    Article  CAS  PubMed  Google Scholar 

  12. Glyn-Jones S, Pandit H, Kwon YM, Doll H, Gill HS, Murray DW. Risk factors for inflammatory pseudotumour formation following hip resurfacing. J Bone Joint Surg Br. 2009;91:1566–1574.

    Article  CAS  PubMed  Google Scholar 

  13. Grammatopolous G, Pandit H, Kwon YM, Gundle R, McLardy-Smith P, Beard DJ, Murray DW, Gill HS. Hip resurfacings revised for inflammatory pseudotumour have a poor outcome. J Bone Joint Surg Br. 2009;91:1019–1024.

    Article  CAS  PubMed  Google Scholar 

  14. Hart AJ, Sabah S, Henckel J, Lewis A, Cobb J, Sampson B, Mitchell A, Skinner JA. The painful metal-on-metal hip resurfacing. J Bone Joint Surg Br. 2009;91:738–744.

    Article  CAS  PubMed  Google Scholar 

  15. Hart AJ, Satchithananda K, Liddle AD, Sabah SA, McRobbie D, Henckel J, Cobb JP, Skinner JA, Mitchell AW. 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;94:317–325.

    PubMed  Google Scholar 

  16. Hayter CL, Potter HG, Su EP. Imaging of metal-on-metal hip resurfacing. Orthop Clin North Am. 2011;42:195–205, viii.

    Article  PubMed  Google Scholar 

  17. Hennekins CH, Buring JE. Epidemiology in Medicine. Boston, MA: Little, Brown and Co; 1987.

    Google Scholar 

  18. Koch KM, Lorbiecki JE, Hinks RS, King KF. A multispectral three-dimensional acquisition technique for imaging near metal implants. Magn Reson Med. 2009;61:381–390.

    Article  PubMed  Google Scholar 

  19. Kwon YM, Glyn-Jones S, Simpson DJ, Kamali A, McLardy-Smith P, Gill HS, Murray DW. Analysis of wear of retrieved metal-on-metal hip resurfacing implants revised due to pseudotumours. J Bone Joint Surg Br. 2010;92:356–361.

    Article  PubMed  Google Scholar 

  20. 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;26:511–518.

    Article  PubMed  Google Scholar 

  21. Lu W, Pauly KB, Gold GE, Pauly JM, Hargreaves BA. SEMAC: slice encoding for metal artifact correction in MRI. Magn Reson Med. 2009;62:66–76.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Matthies AK, Skinner JA, Osmani H, Henckel J, Hart AJ. Pseudotumors are common in well-positioned low-wearing metal-on-metal hips. Clin Orthop Relat Res. 2012;470:1895–1906.

    Article  PubMed  Google Scholar 

  23. Medicines and Healthcare products Regulatory Agency. MDA/2010/033 Medical Device Alert: all metal-on-metal (MoM) hip replacements. Available at: http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON079157. Accessed February 13, 2012.

  24. Nishii T, Sakai T, Takao M, Yoshikawa H, Sugano N. Ultrasound screening of periarticular soft tissue abnormality around metal-on-metal bearings. J Arthroplasty. 2012;27:895–900.

    Article  PubMed  Google Scholar 

  25. Olsen RV, Munk PL, Lee MJ, Janzen DL, MacKay AL, Xiang QS, Masri B. Metal artifact reduction sequence: early clinical applications. Radiographics. 2000;20:699–712.

    Article  CAS  PubMed  Google Scholar 

  26. Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CL, Ostlere S, Athanasou N, Gill HS, Murray DW. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90:847–851.

    Article  CAS  PubMed  Google Scholar 

  27. Sutter R, Ulbrich EJ, Jellus V, Nittka M, Pfirrmann CW. Reduction of metal artifacts in patients with total hip arthroplasty with slice-encoding metal artifact correction and view-angle tilting MR imaging. Radiology. 2012;265:204–214.

    Article  PubMed  Google Scholar 

  28. Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. 2011;93:2164–2171.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Nelson V. Greidanus MD, MPH for contributing patients to the study; Diana Korlaet CRGS, PDDipAppSci (Medical Ultrasound) for performing the ultrasound scans; Hugue A. Ouellette MD, FRCPC, Gordon Andrews MD, FRCPC, and Borys Flak MD, FRCPC for reading the ultrasounds and MR images; Torsten O. Nielsen MD, PhD for his advice pertaining to musculoskeletal pathology; Eric C. Sayre PhD for his help with the statistical analysis; Lorna McLean BA for patient recruitment and data collection; and Daphné Savoy BA for her assistance in the preparation of this manuscript.

Author information

Authors and Affiliations

  1. Division of Lower Limb Reconstruction and Oncology, Department of Orthopaedics, University of British Columbia, Room 3114, 910 West 10th Avenue, Vancouver, British Columbia, Canada, V5Z 4E3

    Donald S. Garbuz MD, MHSc, Clive P. Duncan MD, MSc, Bassam A. Masri MD & David R. Wilson DPhil

  2. Department of Radiology, Stanford University Lucas Center for Imaging, Stanford, CA, USA

    Brian A. Hargreaves PhD

  3. Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada

    Bruce B. Forster MSc, MD

Authors
  1. Donald S. Garbuz MD, MHSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Brian A. Hargreaves PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Clive P. Duncan MD, MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Bassam A. Masri MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. David R. Wilson DPhil
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Bruce B. Forster MSc, MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Donald S. Garbuz MD, MHSc.

Additional information

The institution of one or more of the authors (DSG, CPD, BAM, DRW, BBF) has received, during the study period, funding from Johnson and Johnson (Canada) Inc (Markham, Ontario, Canada), Zimmer, Inc (Warsaw, IN, USA), DePuy Synthes Canada Ltd (Markham, ON, Canada), Stryker Canada (Hamilton, Ontario, Canada), Mako Surgical Corp (Ft Lauderdale, FL, USA), and Bayer Inc (Toronto, Ontario, Canada). The institution of one or more of the authors (BAH) has received, during the study period, funding from GE Healthcare (Waukesha, WI, USA) and the NIH (Bethesda, MD, USA). One of the authors (DSG) certifies that he or she has received or may receive payments or benefits, during the study period, an amount of USD 10,000 to USD 100,000 from Zimmer, Inc. One of the authors (CPD) certifies that he or she has received or may receive payments or benefits, during the study period, an amount of USD 10,000 to USD 100,000 from Zimmer, Inc, and an amount of USD 10,000 to USD 100,000 from DePuy Synthes Canada Ltd. One of the authors (BAM) certifies that he or she has received or may receive payments or benefits, during the study period, an amount of USD 10,000 to USD 100,000 from Zimmer, Inc. The remaining authors (BAH, DFW, BBF) certify that they have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that the human protocol for this investigation was approved by the appropriate ethics committee at his or her institution, that all investigations were conducted in conformity with the ethical principles of research, and that informed consent for participation in the study was obtained.

This work was performed at the Departments of Orthopaedics and Radiology, University of British Columbia (Vancouver, British Columbia, Canada) and at Vancouver General Hospital (Vancouver, British Columbia, Canada).

About this article

Cite this article

Garbuz, D.S., Hargreaves, B.A., Duncan, C.P. et al. The John Charnley Award: Diagnostic Accuracy of MRI Versus Ultrasound for Detecting Pseudotumors in Asymptomatic Metal-on-Metal THA. Clin Orthop Relat Res 472, 417–423 (2014). https://doi.org/10.1007/s11999-013-3181-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-013-3181-6

Keywords

Search

Navigation