Clinical Orthopaedics and Related Research®

, Volume 472, Issue 2, pp 471–481 | Cite as

MRI Predicts ALVAL and Tissue Damage in Metal-on-Metal Hip Arthroplasty

  • Danyal H. Nawabi
  • Stephanie Gold
  • Steven Lyman
  • Kara Fields
  • Douglas E. Padgett
  • Hollis G. PotterEmail author
Symposium: Papers Presented at the Annual Meetings of The Hip Society



Adverse local tissue reactions (ALTR) around metal-on-metal (MOM) hip arthroplasties are increasingly being recognized as a cause of failure. These reactions may be associated with intraoperative tissue damage and complication rates as high as 50% after revision. Although MRI can identify ALTR in MOM hips, it is unclear whether the MRI findings predict those at revision surgery.


We therefore (1) identified which MRI characteristics correlated with histologically confirmed ALTR (using the aseptic lymphocytic vasculitis-associated lesions [ALVAL] score) and intraoperative tissue damage and (2) developed a predictive model using modified MRI to detect ALVAL and quantify intraoperative tissue damage.


We retrospectively reviewed 68 patients with failed MOM hip arthroplasties who underwent preoperative MRI and subsequent revision surgery. Images were analyzed to determine synovial volume, osteolysis, and synovial thickness. The ALVAL score was used to grade tissue samples, thus identifying a subset of patients with ALTR. Intraoperative tissue damage was graded using a four-point scale. Random forest analysis determined the sensitivity and specificity of MRI characteristics in detecting ALVAL (score ≥ 5) and intraoperative tissue damage.


Maximal synovial thicknesses and synovial volumes as determined on MRI correlated with the ALVAL score and were higher in cases of severe intraoperative tissue damage. Our MRI predictive model showed sensitivity and specificity of 94% and 87%, respectively, for detecting ALVAL and 90% and 86%, respectively, for quantifying intraoperative tissue damage.


MRI is sensitive and specific in detecting ALVAL and tissue damage in patients with MOM hip implants. MRI can be used as a screening tool to guide surgeons toward timely revision surgery.

Level of Evidence

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.


Synovitis Soft Tissue Edema Neurovascular Compression Random Forest Analysis Severe Tissue Damage 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Alissa Burge MD for assistance with the MRI analysis, Matthew Koff PhD for help with the statistical analysis, and Giorgio Perino MD for grading the histologic samples.


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Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Danyal H. Nawabi
    • 1
  • Stephanie Gold
    • 2
  • Steven Lyman
    • 3
    • 4
  • Kara Fields
    • 3
  • Douglas E. Padgett
    • 1
    • 4
  • Hollis G. Potter
    • 2
    • 4
    Email author
  1. 1.Adult Reconstruction and Joint Replacement Division SurgeryHospital for Special SurgeryNew YorkUSA
  2. 2.Department of Radiology and ImagingHospital for Special SurgeryNew YorkUSA
  3. 3.Epidemiology and Biostatistics CoreHospital for Special SurgeryNew YorkUSA
  4. 4.Weill Cornell Medical College of Cornell UniversityNew YorkUSA

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