Adverse reaction metal debris (ARMD) after metal-on-metal (MOM) hip replacement: magnetic resonance imaging features with surgical feedback

Transcription

1 Adverse reaction metal debris (ARMD) after metal-on-metal (MOM) hip replacement: magnetic resonance imaging features with surgical feedback Poster No.: C-0533 Congress: ECR 2012 Type: Scientific Paper Authors: P. BRAMBILLA, G. Pezzotta, S. Biancardi, F. Barbieri, R. Ferrari, A. Gianatti, C. C. Castelli, M. Nozza, C. Valentino; Bergamo/IT Keywords: Musculoskeletal joint, MR, Prostheses, Artifacts, Drugs / Reactions DOI: /ecr2012/C-0533 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 13

2 Purpose Several authors have described a spectrum of acute lymphocytic vasculitis-associated lesions (ALVALs) as complication after MOM articulation, manifesting itself as unusual peri-prosthetic soft tissue collection or mass. Pandit et al. [1] reported the presence of non-neoplastic and non-infective masses after MOM hip resurfacing, and this complication was called "pseudotumour". Nowadays the usual term to identify such a complication is Adverse Reaction Metal Debris (ARMD): it is observed not only after metal-on-metal hip resurfacing, but also after MOM total hip replacement (THR) (Figure 1). Magnetic resonance imaging (MRI) has become one of the diagnostic tools to evaluate these complications after hip arthroplasty. The aim of our study is to report MR aspects of periprosthetic ARMD in our patient population, and to correlate imaging findings with surgical revision. Magnetic susceptibility artifacts can nevertheless produce significant degradation of MR images in standard data set. The aim of our study is also to describe MRI tecnique in order to reduce metal susceptibility artifact. Images for this section: Page 2 of 13

3 Fig. 1: Photographs of acetabular and femoral components of MOM prosthesis (a-c). Radiographic aspect of metal-on-metal (MOM) total hip replacement on the right side, versus polyethylene-on-metal (POM) THR on the left side (d). Page 3 of 13

4 Methods and Materials From september 2009 to september 2011 we prospectively studied 14 patients (8 men, 6 women; mean age of 61 years) who had undergone MOM hip resurfacing (one case) or total hip replacement (THR). The mean time between first surgery and MRI observation was 47 months. In subset of this population blood level of chromium-cobalt ions was evaluated (8 patients). Patients were recruited because of symptom complaints and/or elevated chromiumcobalt blood levels. Eleven patients were symptomatic: pain, thigh tenderness and/or lump, clicking. Some of them showed high levels of metal ions in blood samplings (> 7µg/L). We performed MR tests with 1.5 T unit at our Radiology Department, with phased-array 4 elements torso coil. The MRI protocol was as follows: coronal STIR sequence (TR ms, TE ms, TI 150 ms, field of view cm, slice thickness 5-7 mm, matrix 256 x 160, full receiver bandwidth ± 31,25 khz corresponding to 122 Hz/ pixel), T1 weighted Fast Spin Echo sequence (TR ms, TE ms, ETL 3, field of view cm, slice thickness 5-6 mm, matrix 512 x 224, full receiver bandwidth ± khz corresponding to 163 Hz/pixel) and PD-weighted Fast Spin Echo sequence (TR ms, TE 8-10 ms, ETL 11, field of view cm, slice thickness 5-7 mm, matrix 512 x 224, full receiver bandwidth ± 41,73 khz corresponding to 163 Hz/pixel). From september 2011, according to Toms et al. [2], we modified MR data set, in order to balance metal artifact reduction along with signal-to-noise ratio decrease, setting frequency encoding resolution at 256 and full receiver bandwidth at ± 62,5 khz (488 Hz/ pixel). We considered positive the MR tests with evidence of: fluid collection, solid mass, bone marrow oedema. Six patients underwent prosthesis revision to a polyethylene-on-metal (POM) hip replacement; seven are under evaluation awaiting revision. Results Most of the symptomatic patients had periarticular masses at MRI. In 9 cases mass was fluid-like, with high signal intensity and pseudocapsule on STIR and PDw sequences, but also intermediate-high signal on T1w (Figure 2); fluid collections were periarticular, Page 4 of 13

5 peritrochanteric (Figure 3) and along ileopsoas compartment (Figure 4). In two cases the mass a had solid-like appearance with intermediate-low SI on STIR and PDw images and intemediate-high signal intensity on T1w images (Figure 5). In 12 patients there were MR signs of periprosthetic marrow oedema (Figure 6). In 3 patients we did not observe masses, but only marrow oedema signs around the femoral component: in the revised cases the surgeon found little peri-prosthetic tissue not evident at MRI (Figure 7). Images for this section: Fig. 1: Photographs of acetabular and femoral components of MOM prosthesis (a-c). Radiographic aspect of metal-on-metal (MOM) total hip replacement on the right side, versus polyethylene-on-metal (POM) THR on the left side (d). Page 5 of 13

6 Fig. 2: ARMD in a patient with MOM total hip replacement. A periarticular fluid-like mass is evident with intermediate-high signal intensity on coronal STIR images (a), axial PDw sequences (b,c); note intemediate-high signal intensity on T1w sequence (d,e). Page 6 of 13

7 Fig. 3: ARMD in a patient with MOM total hip replacement. A fluid-like collection (arrows) with pseudocapsule (arrowheads) in peri-trochateric location, with high signal intensity on PDw sequence (a) and high signal intensity on T1w sequence (b). Page 7 of 13

8 Fig. 4: ARMD in a patient with MOM total hip replacement. A bilobated fluid collection along ileo-psoas compartment with fluid-like features, high signal intensity on STIR sequence (a) and PDw sequence (b), intermediate signal intensity on T1w images (c) Page 8 of 13

9 Page 9 of 13

10 Fig. 5: ARMD in a patient with MOM total hip replacement. A large mass with solidlike appearance encircles prosthetic neck; the signal intensity is intermediate-low on STIR images (a), and intermediate on PDw (b,c) and T1w sequences (d). At the revision surgery, the orthopedic surgeon found "hepatization" of periarticular tissues, as shown in the intraoperative photographs (e,f) Fig. 6: ARMD in a patient with MOM total hip replacement. A little fluid collection (arrows) along ileo-psoas tendon (a,b). Mild signs of marrow oedema (arrowheads) around the femoral component in sub-trochanteric aspect of femur (c) Page 10 of 13

11 Fig. 7: ARMD in a patient with MOM hip prosthesis. Coronal STIR MRI demonstrate bone marrow oedema and periosteal oedema at proximal femur Page 11 of 13

12 Conclusion ARMD is a relatively recent condition and there is an increasing knowledge and awareness about it, not only among clinicians and regulatory agencies [3], but also among patients. It is necessary that radiologists, not only muscolo-skeletal specialists, but also general radiologists become familiar with this complication, due to the potentially increasing number of patients affected by ARMD. The radiologist has to know the type of implanted prosthesis (POM versus MOM, resurfacing versus THR) and clinical setting. In symptomatic people with MOM prosthesis, MRI can rule out the presence of ARMD. In most cases ARMD has fluid collection appearance, in few cases solid-like or mixed [4-5]. Metallosis does not correlate with ARMD. MRI with dedicated sequences for susceptibility metal artifacts reduction is a safe and diagnostic tool in patients with hip replacement, even though the clear role of the imaging in decision making is still work in progress [6]. References Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CLM, Ostlere S, Athanasou N, Gill HS, Murray DW (2008) Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg 90-B (7): Toms AP, Smith-Bateman C, Malcolm PN, Cahir J, Graves M (2010) Optimization of metal artefact reduction (MAR) sequences for MRI of total hip prostheses. Clin Radiol 65: Medicines and Healthcare products Regulatory Agency (MHRA) WM. Medical device alert: all metal-on-metal (MoM) hip replacements (MDA/2010/033). Available from: Safetywarnings/MedicalDeviceAlerts/CON [Accessed ] Sabah SA, Mitchell AWM, Henckel J, Sandison A, Skinner JA, Hart AJ (2011) Magnetic resonance imaging findings in painful metal-on-metal hips. The Journal of Arthroplasty 26(1):71-76 Toms AP, Marshall TJ, Cahir J, Darrah C, Nolan J, Donell ST, Barker T, Tucker JK (2008) MRI of early symptomatic metal-on-metal total hip arthroplasty: a retrospective review of radiological findings in 20 hips. Clin Radiol 63:49-58 Mistry A, Cahir J, Donell ST, Nolan J, Toms AP (2011) MRI of asymptomatic patients with metal-on-metal and polyethylene-on-metal total hip arthroplasties. Clin Radiol 66: Page 12 of 13

13 Personal Information Paolo Brambilla, MD Department of Diagnostic Imaging, Operative Unit of Radiology, Ospedali Riuniti di Bergamo. Largo Barozzi 1, Bergamo, Italy Page 13 of 13