Clinical Orthopaedics and Related Research®

, Volume 468, Issue 2, pp 480–490

A Three-dimensional Method for Evaluating Changes in Acetabular Osteolytic Lesions in Response to Treatment

  • Hiroshi Egawa
  • Henry Ho
  • Cathy Huynh
  • Robert H. HopperJr.
  • C. Anderson EnghJr.
  • Charles A. Engh
Symposium: Papers Presented at the Hip Society Meetings 2009


The treatment of asymptomatic osteolysis among well-fixed cementless cups remains controversial. To compare the effectiveness of different treatment strategies, an objective technique for evaluating bone remodeling would be useful. By matching and comparing serial CT images with the aid of a computer-assisted imaging program, we developed a method to evaluate three-dimensional mineralization changes within osteolytic defects. Preoperative, immediate postoperative, and followup CT images were normalized based on a phantom with known densities and matched using image registration so that the same region could be analyzed on each image. New bone mineralization within the preoperative osteolytic lesion volume was quantified based on a patient-specific trabecular bone density threshold. As a pilot study, we applied this technique in 10 patients treated by polyethylene liner exchange with débridement and grafting of periacetabular osteolytic lesions using a calcium sulfate bone graft substitute. Relative to the preoperative osteolytic lesion volume, an average of 43% (range, 8%–72%) of each defect was filled with graft at revision. After resorption of the graft, an average of 24% (range, 9%–44%) of the original defect volume demonstrated evidence of new mineralization at 1-year followup. The amount of new mineralization was directly proportional (r2 = 0.70) to the defect filling achieved at revision. CT-based image analysis offers an objective method for quantifying three-dimensional bone remodeling and can be used to evaluate the effectiveness of osteolysis treatment strategies.

Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Beaulé PE, LeDuff MJ, Dorey FJ, Amstutz HC. Fate of cementless acetabular components retained during revision total hip arthroplasty. J Bone Joint Surg Am. 2003;85:2288–2293.PubMedGoogle Scholar
  2. 2.
    Berry DJ. Periprosthetic fractures associated with osteolysis: a problem on the rise. J Arthroplasty. 2003;18(3 Suppl 1):107–111.CrossRefPubMedGoogle Scholar
  3. 3.
    Borrelli J Jr, Prickett WD, Ricci WM. Treatment of nonunions and osseous defects with bone graft and calcium sulfate. Clin Orthop Relat Res. 2003;411:245–254.CrossRefPubMedGoogle Scholar
  4. 4.
    Boucher HR, Lynch C, Young AM, Engh CA Jr, Engh C Sr. Dislocation after polyethylene liner exchange in total hip arthroplasty. J Arthroplasty. 2003;18:654–657.CrossRefPubMedGoogle Scholar
  5. 5.
    Chang JD, Yoo JH, Hur M, Lee SS, Chung YK, Lee CJ. Revision total hip arthroplasty for pelvic osteolysis with well-fixed cementless cup. J Arthroplasty. 2007;22:987–992.CrossRefPubMedGoogle Scholar
  6. 6.
    Chatoo M, Parfitt J, Pearse MF. Periprosthetic acetabular fracture associated with extensive osteolysis. J Arthroplasty. 1998;13:843–845.CrossRefPubMedGoogle Scholar
  7. 7.
    Chiang PP, Burke DW, Freiberg AA, Rubash HE. Osteolysis of the pelvis: evaluation and treatment. Clin Orthop Relat Res. 2003;417:164–174.PubMedGoogle Scholar
  8. 8.
    Claus AM, Totterman SM, Sychterz CJ, Tamez-Pena JG, Looney RJ, Engh CA. Computed tomography to assess pelvis osteolysis after total hip replacement. Clin Orthop Relat Res. 2004;422:167–174.CrossRefPubMedGoogle Scholar
  9. 9.
    Claus AM, Walde TA, Leung SB, Wolf RL, Engh CA Sr. Management of patients with acetabular socket wear and pelvic osteolysis. J Arthroplasty. 2003;18(Suppl 1):112–117.CrossRefPubMedGoogle Scholar
  10. 10.
    Deheshi BM, Allen DJ, Kim PR. Treatment of retroacetabular osteolysis with calcium sulfate and retention of original components. J Arthroplasty. 2008;23:1240.e9–1240.e12.CrossRefGoogle Scholar
  11. 11.
    Engh CA, Engh CA Jr, Claus A. The relationship between lysis and loosening in failed anatomic medullary locking components. Orthopedics. 2001;24:855–856.PubMedGoogle Scholar
  12. 12.
    Engh CA Jr, Egawa H, Beykirch SE, Hopper RH Jr, Engh CA. The quality of osteolysis grafting with cementless acetabular component retention. Clin Orthop Relat Res. 2007;465:150–154.PubMedGoogle Scholar
  13. 13.
    Etienne G, Bezwada HP, Hungerford DS, Mont MA. The incorporation of morselized bone grafts in cementless acetabular revisions. Clin Orthop Relat Res. 2004;428:241–246.CrossRefPubMedGoogle Scholar
  14. 14.
    Griffin WL, Fehring TK, Mason JB, McCoy TH, Odum S, Terefenko CS. Early morbidity of modular exchange for polyethylene wear and osteolysis. J Arthroplasty. 2004;19(7 Suppl 2):61–66.CrossRefPubMedGoogle Scholar
  15. 15.
    Helfet DL, Ali A. Periprosthetic fractures of the acetabulum. Instr Course Lect. 2004;53:93–98.PubMedGoogle Scholar
  16. 16.
    Hozack WJ, Mesa JJ, Carey C, Rothman RH. Relationship between polyethylene wear, pelvic osteolysis, and clinical symptomatology in patients with cementless acetabular components: a framework for decision making. J Arthroplasty. 1996;11:769–772.CrossRefPubMedGoogle Scholar
  17. 17.
    Kelly CM, Wilkins RM. Treatment of benign bone lesions with an injectable calcium sulfate-based bone graft substitute. Orthopedics. 2004;27(1 Suppl):s131–s135.PubMedGoogle Scholar
  18. 18.
    Kelly CM, Wilkins RM, Gitelis S, Hartjen C, Watson JT, Kim PT. The use of a surgical grade calcium sulfate as a bone graft substitute: results of a multicenter trial. Clin Orthop Relat Res. 2001;382:42–50.CrossRefPubMedGoogle Scholar
  19. 19.
    Kitamura N, Leung SB, Engh CA Sr. Characteristics of pelvic osteolysis on computed tomography after total hip arthroplasty. Clin Orthop Relat Res. 2005;441:291–297.CrossRefPubMedGoogle Scholar
  20. 20.
    Kitamura N, Pappedemos PC, Duffy PR, Stepniewski AS, Hopper RH, Engh CA Jr, Engh CA. The value of anteroposterior pelvic radiographs for evaluating pelvis osteolysis. Clin Orthop Relat Res. 2006;453:239–245.CrossRefPubMedGoogle Scholar
  21. 21.
    Leopold SS, Jacobs JJ, Rosenberg AG. Cancellous allograft in revision total hip arthroplasty: a clinical review. Clin Orthop Relat Res. 2000;371:86–97.CrossRefPubMedGoogle Scholar
  22. 22.
    Leung S, Naudie D, Kitamura N, Walde T, Engh CA. Computed tomography in the assessment of periacetabular osteolysis. J Bone Joint Surg Am. 2005;87:592–597.CrossRefPubMedGoogle Scholar
  23. 23.
    Lombardi AV Jr, Berend KR. Isolated acetabular liner exchange. J Am Acad Orthop Surg. 2008;16:243–248.PubMedGoogle Scholar
  24. 24.
    Maloney W, Rosenberg A. Implant Wear Symposium 2007 Clinical Work Group. What is the outcome of treatment for osteolysis? J Am Acad Orthop Surg. 2008;16(Suppl 1):S26–S32.PubMedGoogle Scholar
  25. 25.
    Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am. 1997;79:1628–1634.PubMedGoogle Scholar
  26. 26.
    Maloney WJ, Paprosky W, Engh CA Sr, Rubash H. Surgical treatment of pelvic osteolysis. Clin Orthop Relat Res. 2001;393:78–84.CrossRefPubMedGoogle Scholar
  27. 27.
    Mehin R, Yuan X, Haydon C, Rorabeck CH, Bourne RB, McCalden RW, MacDonald SJ. Retroacetabular osteolysis: when to operate? Clin Orthop Relat Res. 2004;428:247–255.CrossRefPubMedGoogle Scholar
  28. 28.
    Mirzayan R, Panossian V, Avedian R, Forrester DM, Menendez LR. The use of calcium sulfate in the treatment of benign bone lesions: a preliminary report. J Bone Joint Surg Am. 2001;83:355–358.CrossRefPubMedGoogle Scholar
  29. 29.
    Naudie DD, Engh CA Sr. Surgical management of polyethylene wear and pelvic osteolysis with modular uncemented acetabular components. J Arthroplasty. 2004;19(Suppl 1):124–129.CrossRefPubMedGoogle Scholar
  30. 30.
    Peters CL, Erickson JA, Dunn HK. Revision of well-fixed cementless acetabular components for polyethylene failure. Clin Orthop Relat Res. 2003;414:129–135.CrossRefPubMedGoogle Scholar
  31. 31.
    Phillips BC, Barnes CL. MIIG HV case analysis. J Surg Orthop Adv. 2008;17:58–61.PubMedGoogle Scholar
  32. 32.
    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;84:609–614.PubMedGoogle Scholar
  33. 33.
    Saleh KJ, Thongtrangan I, Schwarz EM. Osteolysis: medical and surgical approaches. Clin Orthop Relat Res. 2004;427:138–147.CrossRefPubMedGoogle Scholar
  34. 34.
    Sanchez-Sotelo J, McGrory BJ, Berry DJ. Acute periprosthetic fracture of the acetabulum associated with osteolytic pelvic lesions: a report of 3 cases. J Arthroplasty. 2000;15:126–130.CrossRefPubMedGoogle Scholar
  35. 35.
    Schmalzried TP, Fowble VA, Amstutz HC. The fate of pelvic osteolysis after reoperations: no recurrence with lesional treatment. Clin Orthop Relat Res. 1998;350:128–137.CrossRefPubMedGoogle Scholar
  36. 36.
    Stulberg SD, Wixson RL, Adams AD, Hendrix RW, Bernfield JB. Monitoring pelvis osteolysis following total hip replacement surgery: an algorithm for surveillance. J Bone Joint Surg Am. 2002;84:116–122.CrossRefPubMedGoogle Scholar
  37. 37.
    Wright JM, Pellicci PM, Salvati EA, Ghelman B, Roberts MM, Koh JL. Bone density adjacent to press-fit acetabular components: a prospective analysis with quantitative computed tomography. J Bone Joint Surg Am. 2001;83:529–536.CrossRefPubMedGoogle Scholar
  38. 38.
    Yazdi M, Beaulieu L. Artifacts in spiral x-ray CT scanners: problems and solutions. Proc World Acad Sci Eng Technol. 2007;26:376–380.Google Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2009

Authors and Affiliations

  • Hiroshi Egawa
    • 1
  • Henry Ho
    • 1
  • Cathy Huynh
    • 1
  • Robert H. HopperJr.
    • 1
  • C. Anderson EnghJr.
    • 1
  • Charles A. Engh
    • 1
  1. 1.Anderson Orthopaedic Research InstituteAlexandriaUSA

Personalised recommendations