Clinical Orthopaedics and Related Research®

, Volume 472, Issue 2, pp 417–423 | Cite as

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

  • Donald S. GarbuzEmail author
  • Brian A. Hargreaves
  • Clive P. Duncan
  • Bassam A. Masri
  • David R. Wilson
  • Bruce B. Forster
Symposium: 2013 Hip Society Proceedings



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.


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.


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.


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%.


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.


Positive Predictive Value Negative Predictive Value Metal Artifact Artifact Reduction Negative Ultrasound 
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 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.


  1. 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.PubMedCrossRefGoogle Scholar
  2. 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.PubMedGoogle Scholar
  3. 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.PubMedCrossRefGoogle Scholar
  4. 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.PubMedCrossRefGoogle Scholar
  5. 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.PubMedCrossRefGoogle Scholar
  6. 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. 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.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 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.PubMedCrossRefGoogle Scholar
  9. 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.PubMedCrossRefGoogle Scholar
  10. 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.PubMedCrossRefGoogle Scholar
  11. 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.PubMedCrossRefGoogle Scholar
  12. 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.PubMedCrossRefGoogle Scholar
  13. 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.PubMedCrossRefGoogle Scholar
  14. 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.PubMedCrossRefGoogle Scholar
  15. 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.PubMedGoogle Scholar
  16. 16.
    Hayter CL, Potter HG, Su EP. Imaging of metal-on-metal hip resurfacing. Orthop Clin North Am. 2011;42:195–205, viii.PubMedCrossRefGoogle Scholar
  17. 17.
    Hennekins CH, Buring JE. Epidemiology in Medicine. Boston, MA: Little, Brown and Co; 1987.Google Scholar
  18. 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.PubMedCrossRefGoogle Scholar
  19. 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.PubMedCrossRefGoogle Scholar
  20. 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.PubMedCrossRefGoogle Scholar
  21. 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.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 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.PubMedCrossRefGoogle Scholar
  23. 23.
    Medicines and Healthcare products Regulatory Agency. MDA/2010/033 Medical Device Alert: all metal-on-metal (MoM) hip replacements. Available at: Accessed February 13, 2012.
  24. 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.PubMedCrossRefGoogle Scholar
  25. 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.PubMedCrossRefGoogle Scholar
  26. 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.PubMedCrossRefGoogle Scholar
  27. 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.PubMedCrossRefGoogle Scholar
  28. 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.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Donald S. Garbuz
    • 1
    Email author
  • Brian A. Hargreaves
    • 2
  • Clive P. Duncan
    • 1
  • Bassam A. Masri
    • 1
  • David R. Wilson
    • 1
  • Bruce B. Forster
    • 3
  1. 1.Division of Lower Limb Reconstruction and Oncology, Department of OrthopaedicsUniversity of British ColumbiaVancouverCanada
  2. 2.Department of RadiologyStanford University Lucas Center for ImagingStanfordUSA
  3. 3.Department of RadiologyUniversity of British ColumbiaVancouverCanada

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