全髋关节置换术后影像学评估

Radiologic Assessment of Total Hip Arthroplasty: Loosening Grant Garrigues, Harvard Medical School Gillian Lieberman, MD Grant Garrigues, 2004 Gillian Lieberman, MD March 2004 2 Anatomy www.yoursurgery.com/ProcedureDetails.cfm?BR=5&Proc=27 Liner Calcar Stem Acetabular Component Femoral Component www.hipandkneesurgery.net/hip_op.html Grant Garrigues, 2004 Gillian Lieberman, MD 3 Patient JQ • 67 year-old man • Left THA 10 years ago • Hip/thigh pain Lucencies Density Position PACS, MGH Grant Garrigues, 2004 Gillian Lieberman, MD What do you see? 4 Implant loosening • >500,000 THA and TKA each year in US • 10% are revisions of failed implants • Overall, very successful • Aging population, obesity, more THA, younger patients vs. • Improved surgical technique, implant design, and pharmacotherapy Grant Garrigues, 2004 Gillian Lieberman, MD Bauer TW et al. Skeletal Rad, 1999. 5 Total Hip Complications • Deep Venous Thrombosis (fatal PE, 0.3%) • Nerve Palsies (1.7%) • Vascular Complications (0.25%) • Fracture/Perforations • Dislocation (2-2.5%) • Leg-length Discrepancy • Loosening (10%) • Infection (1-5%) • Heterotopic Ossification (significant, 8%) Short-term Long-term Namba RS et al. Current Ortho, 2003. Grant Garrigues, 2004 Gillian Lieberman, MD 6 Radiologic Assessment • Assessment of long-term complications – Loosening is the most significant • Plain films: great bone/metal visualization • Radiographic features – Peri-implant lucency > 2mm • Describe using Gruen Zones (following slide) – Stress views / Interval change in position Keogh CF et al. AJR 2003. Grant Garrigues, 2004 Gillian Lieberman, MD 7 Gruen Zones Grant Garrigues, 2004 Gillian Lieberman, MD www.orthoteers.co.uk/Nrujp~ij331m/Orththrloosening.htm 8Keogh CF et al. AJR 2003. White LM et al. Radiology 2000. Other Modalities • Arthrography – Effective joint space visualized – Aspirate and Biopsy • CT and MRI – Metal artifact • US and Nuclear medicine – Select applications Keogh CF et al. AJR 2003. Grant Garrigues, 2004 Gillian Lieberman, MD Griffiths HJ et al. Rad Clin 1995. 9 Ddx of Radiographic Loosening • Peri-implant bone loss – Aseptic loosening – Infection – Stress Shielding / Adaptive remodeling – Aging / Osteoporosis • Mechanical Failure – Catastrophic – Interfacial Grant Garrigues, 2004 Gillian Lieberman, MD Bauer TW et al. Skeletal Rad, 1999. Tiggles S et al. AJR, 1994. 10 Aseptic Loosening • Most common cause of TJR failure • Wear debris – Most generated at the articulating surface – Submicron UHMWPE, HA, TiAlV, CoCr particles – Spread throughout the “effective joint space” – Phagocytosed by macrophages • Induces bone resorption (osteolysis) • Formation of fibrous, granulomatous tissue Willert and Semlitsch JBMR 1977. Shanbhag, et al. JOR 1994. Grant Garrigues, 2004 Gillian Lieberman, MD 11 Aseptic Loosening Osteoclast in Howship’s lacuna FBGC with wear debris Interfacial Membrane Bone Resorption Courtesy of Arun Shanbhag, MD Macrophages phagocytose wear debris, leading to two processes. 12 Head displacement: Millions of submicron polyethylene particles created with each step Grant Garrigues, 2004 Gillian Lieberman, MD Courtesy of Ferris Hall, MD 13 Aseptic Loosening • Wear debris is the prevailing theory • Hydrodynamic pressure may also contribute to aseptic loosening – Early loosening from periprosthetic bone loss • Trauma, chemicals, and thermal damage – Joint pressures >700 mmHg • “Pumping action” of loosened implants • May cause aseptic loosening without particles • Similar to mechansim of subchondral cysts in OA Grant Garrigues, 2004 Gillian Lieberman, MD Aspenberg P et al. Acta Ortho 1998. Mjoberg B et al. Ortho 1997. 14 Aseptic Loosening Sequellae • Painful loosening • Revision arthroplasty • Pathologic fractures Osteolysis leading to pathologic avulsion fracture Grant Garrigues, 2004 Gillian Lieberman, MD PACS, MGHBerry DJ J Arthro 2003. 15 Septic Loosening • Less common today – Laminar flow OR – UV lights – Prophylactic Antibiotics • Foreign body nidus – Pathogens adhere to biomaterials – S. epidermidis produces glycocalyx Grant Garrigues, 2004 Gillian Lieberman, MD 16 Septic Loosening • Radiographs mimic aseptic loosening • Dx often with arthrogram and clinical correlation – Peri-implant bone loss – Sinus tracts – Joint fluid aspiration: (culture, gram stain, etc.) – Synovial biopsy • Nuclear Med – Tc-99m nonspecific – In-111 leukocytes preferred Keogh CF et al. AJR, 2003. Griffiths HJ et al. Rad Clin, 1995. Arthrogram: sinus tracts and abcesses Grant Garrigues, 2004 Gillian Lieberman, MD Keogh CF et al. AJR, 2003. 17 Septic Loosening Sequellae • Painful implant loosening • Revision arthroplasty – Sterilize site before reimplantation – Antibiotic impregnated cement spacers • Sepsis, osteomyelitis, sinus tracts Grant Garrigues, 2004 Gillian Lieberman, MD Bauer TW et al. Skeletal Rad, 1999. 18 Stress Shielding • Loading transferred from bone to stiffer prosthesis Abaqus, www.hks.com/solutions/sol_hip.html Finite Element Analysis Interference Stress Interference + Load Stress Proximal Stress Distal Stress Grant Garrigues, 2004 Gillian Lieberman, MD Friedman RJ et al. JBJS, 1993. 19 Stress Shielding • Stress transferred through stem – Metal is stiffer than bone – Bypasses proximal periprosthetic bone • Resorption of bone around proximal femoral shaft (Wolff’s Law) • More common in uncemented • Increased risk of pathologic fracture Jacobs JJ et al. Ortho Clin 1993. Friedman RJ et al. JBJS, 1993. Grant Garrigues, 2004 Gillian Lieberman, MD Keogh CF et al. AJR 2003. 20 Mechanical Failure • Catastrophic failure is rare – Fractured stem – Shattered Zirconia ceramic heads • Interface failure most common – Cement fatigue fracture – Debonding of cement-implant interface – Porous coating fracture Grant Garrigues, 2004 Gillian Lieberman, MD 21 Mechanical Failure Fractured Stem Grant Garrigues, 2004 Gillian Lieberman, MD Keogh CF et al. AJR 2003. 22 Cement Fracture Debonding: implant- cement interface is disrupted Subsidence: implant slides into medullary canal Grant Garrigues, 2004 Gillian Lieberman, MD Courtesy of Ferris Hall, MDCourtesy of Ferris Hall, MD Cortical Reaction 23 Porous Coating Fatigue Porous coatings, fiber-metal mesh, and other surfaces allow bone in-growth to cementless implants Cross-section through fiber-metal mesh shows bone in-growth Multiple loose beads Grant Garrigues, 2004 Gillian Lieberman, MD PACS, BIDMCPACS, BIDMC 24 Summary: JQ • 67 year-old man • Left THA • Hip/thigh pain •Osteolytic Lesions •Cortical Reaction •Stress Fracture •Volumetric wear •Varus shift •Subsidence PACS, MGH Grant Garrigues, 2004 Gillian Lieberman, MD Aseptic Loosening of uncemented femoral component 25 Other THA Complications • We have discussed loosening, the most common complication of THA, in detail. • Bonus cases of other radiographically assessable complications follow… 26 Grant Garrigues, 2004 Gillian Lieberman, MD Cement Venogram: cement forced into vein before hardening Alastair et al. Brief report: fulminating fat embolism syndrome caused by paradoxical embolism through a patent foramen ovale, NEJM, 1993; 329(13):926-963. Courtesy of Ferris Hall, MD This is a powerful reminder of the possibility of fat emboli forced through bridging veins by manipulation in the meduallary canal. 27 Grant Garrigues, 2004 Gillian Lieberman, MD Courtesy of Ferris Hall, MD Heterotopic ossification: This patient had a h/o spondylitis but any joint procedure has a small chance of this complication 28 References • Aspenberg P, van der Vis H. Fluid pressure may cause periprosthetic osteolysis. Acta Orthop Scand, 1998; 69(1):1-4. • Bauer TW, Schils J. The pathology of total joint arthroplasty. Skeletal Rad, 1999; 28:483-97. • Berry DJ. Periprosthetic fractures associated with osteolysis. J Arthrop, 2003; 18(3, supl.):107-11. • Friedman RJ, et al. Current concepts in orthopaedic biomaterials and implant fixation. JBJS, 1993; 75A(7):1086-109 • Griffiths HJ, et al. “Total hip replacement and other orthopedic hip procedures” in Rad Clinics of N America: Imaging of Orthopedic Hardware, 1995; 33(2):267-87. • Jacobs JJ, Sumner DR, Galante JO. Mechanisms of bone loss associated with total hip replacement. Ortho Clin of N Amer; 1993; 24(4): 583-90. • Keogh CF, et al. Imaging of the painful hip arthroplasty. AJR, 2003; 180:115-20. • Mjoberg B. The theory of early loosening of hip prostheses. Orthopedics, 1997; 20(12):1169-75. • Namba RS, et al. “Adult reconstructive surgery” in Current Diagnosis and Treatment in Orthopaedics, 3rd ed, Skinner HB ed.McGraw-Hill, 2003. • Shanbhag A, et al. J Ortho R, 1994 • Tigges S, et al. Complications of hip arthroplasty causing periprosthetic radiolucency on plain radiographs. AJR, 1994; 162:1387-91. • White LM, et al. Complications of total hip arthroplasty: MR imaging. Radiology, 2000; 215(1):254-62. • Willert and Semlitsch. JBMR, 1997 Grant Garrigues, 2004 Gillian Lieberman, MD 29 Acknowledgements Special Thanks to: • Ferris Hall, MD • Arun Shanbhag, PhD • Harry Rubash, MD • Pamela Lepkowski • Larry Barbaras • Gillian Lieberman, MD Grant Garrigues, 2004 Gillian Lieberman, MD Radiologic Assessment of Total Hip Arthroplasty: Loosening Anatomy Patient JQ Implant loosening Total Hip Complications Radiologic Assessment Gruen Zones Other Modalities Ddx of Radiographic Loosening Aseptic Loosening Aseptic Loosening Slide Number 12 Aseptic Loosening Aseptic Loosening Septic Loosening Septic Loosening Septic Loosening Stress Shielding Stress Shielding Mechanical Failure Mechanical Failure Cement Fracture Porous Coating Fatigue Summary: JQ Other THA Complications Slide Number 26 Slide Number 27 References Acknowledgements