Bowing-head sign: rare but detectable in pre-catastrophic hip implant failure


Recently, catastrophic failure (i.e., dissociation between the metal femoral head and stem due to stem neck deformation) after total hip arthroplasty (THA) has been reported. Early detection of this complication is very important, because it is accompanied by an increased cobalt concentration in the body, which might influence systemic conditions such as heart failure and immune system diseases. However, early detection of stem neck deformation is considered as difficult. In most cases in the literatures, the diagnosis was made at the time of acute dissociation. We report a case of early detection of stem neck deformation with the ‘Bowing-head sign’ before acute dissociation. The patient is a 71-year old woman complained of a clicking sensation in the right hip during regular follow-up after THA with a 32-mm cobalt/chromium head with polyethylene insert for osteoarthritis performed 7 years previously. The plain radiograph showed that the angle between the metal femoral head and the axis of the stem neck was not perpendicular (‘Bowing-head sign’). Dynamic evaluation under fluoroscopy showed movement of the stem neck in the metal femoral head with hip abduction and adduction. Laboratory data showed abnormal serum cobalt (6.3 μg/L, normal < 1 μg/L) and chromium (3.8 μg/L, normal < 5 μg/L) levels. Considering those radiographic findings, deformation of the stem neck due to trunnionosis was diagnosed, and elective revision surgery was performed without any complications. Plain radiographs after THA should be assessed with attention to this complication, ‘Bowing-head sign’ must not be overlooked.

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We thank Takehisa Matsukawa, Ph.D, and, Ayano Kubota for a measurement of blood metal concentration. We thank Mr. Colin G Murphy for his advice of the title and content of the manuscript.


No funds were received in support of this study. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Correspondence to Yasuhiro Homma.

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Homma, Y., Morikawa, T., Ishii, S. et al. Bowing-head sign: rare but detectable in pre-catastrophic hip implant failure. Arch Orthop Trauma Surg (2020).

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  • Total hip arthroplasty
  • Bowing-head sign
  • Cementles stem
  • Cobalt
  • Dissociation