Arch Orthop Trauma Surg (2014) 134:99–101 DOI 10.1007/s00402-013-1887-2
HIP ARTHROPLASTY
Pubic ramus convexity or ballooning: a sentinel sign for severe periacetabular osteolysis in total hip arthroplasty Daniel Mandziak · Steffen Breusch
Received: 31 October 2013 / Published online: 13 November 2013 © Springer-Verlag Berlin Heidelberg 2013
Abstract Osteolysis is a significant long-term problem in hip arthroplasty. Plain radiographs are the routine investigation of choice for monitoring hip arthroplasty patients; however, the recognition of clinically significant osteolysis can be challenging. We present two case reports of arthroplasty patients with ballooning and expansion of the superior pubic ramus with loss of the normal concavity of the ilio-pectineal line. Both patients subsequently displayed massive pubic osteolysis at the time of revision surgery. We suggest that the presence of convexity of the ilio-pectineal line/superior pubic ramus indicates established pelvic osteolysis.
[4]. Computed tomography is a more sensitive means of detecting osteolysis, but its routine use is not usually required and certainly has cost implications. We describe two cases with expansion and ballooning of the superior pubic ramus adjacent to hip arthroplasty with medial convexity of the ilio-pectineal line and propose this as a simple radiographic finding representing significant pubic osteolysis.
Case studies Case 1
Keywords Hip · Acetabular · Arthroplasty · Replacement · Osteolysis · Pubic
Background Osteolysis related to particulate debris is a well-described long-term problem in hip arthroplasty, and is one of the most common reasons for revision surgery. Significant periacetabular lysis from an adjacent hip arthroplasty is not easily diagnosed on plain radiographs [1–3] However, despite plain radiographs being the routine investigation of choice for monitoring and assessing arthroplasty patients, the recognition of clinically significant osteolysis can be challenging even for experienced surgeons [4, 5]. Osteolysis often remains clinically silent until bone loss reaches an advanced stage with associated implant migration or failure D. Mandziak (*) · S. Breusch Department of Orthopaedic Surgery, New Royal Infirmary of Edinburgh, Little France, EH16 4SU Edinburgh, Scotland, UK e-mail: [email protected]
A 63-year-old man with no comorbidities presented with painful osteoarthritis in his left knee. He had undergone a right hip resurfacing arthroplasty (Depuy, Warsaw, IN) performed for osteoarthritis seven years before. The initial arthroplasty and recovery had been uneventful. He was asymptomatic regarding his right hip and reported functioning well with no pain or limitations to his activities. On further questioning, elevated Cobalt and Chrome serum levels (23 μg/L) had been detected 3 years postoperatively as part of a Depuy screening programme, but no further action was taken at the time. Routine surveillance radiographs of the pelvis revealed expansion and convexity of the right superior pubic ramus (Fig. 1). Metal suppression magnetic resonance imaging further displayed evidence of superior pubic ramus ballooning. Revision surgery was recommended. At surgery, significant metallosis was noted, and a well-fixed uncemented shell was removed using the explant system (Zimmer, Warsaw, IN). Massive pubic osteolysis and superior posterior granulomatous lesions were encountered, which were successfully bone grafted from the resected head/neck remnant and proximal femoral cancellous bone.
13
100
Arch Orthop Trauma Surg (2014) 134:99–101
Fig. 1 Plain radiograph of right hip resurfacing arthroplasty at 7 years postoperatively, displaying expansion and convexity of right superior pubic ramus Fig. 2 Left hybrid hip arthroplasty at 9 years postoperatively, displaying mid-stem fracture and expansion of left superior pubic ramus
Histological analysis confirmed inflammatory changes with severe metallosis. Case 2 A 59-year-old woman presented with a 3 months history of deteriorating left thigh pain. Her left hybrid total hip arthroplasty (Exeter stem, Stryker, Mahwah, NJ; Reflection cup, Smith & Nephew, London, UK) was initially performed 9 years prior for pain related to osteoarthritis, with an uneventful postoperative recovery. There was no history of rheumatoid arthritis, steroid use, hip infection or neoplasm. Subsequent plain radiographs of the left hip showed a cemented stem with mid-stem implant breakage. Ballooning and expansion of the superior pubic ramus were noted (Figs. 2, 3). Further imaging was not performed preoperatively. Revision surgery was undertaken, revealing massive lysis and expansion involving the superior pubic ramus, which was filled with an inflammatory soft tissue membrane. Osteolysis also involved the proximal femoral metaphysis, contributing to lack of cement mantle support and stem fracture.
Discussion There is a paucity of literature describing pubic lysis in the setting of implant-related periacetabular osteolysis. The plain radiographic findings of isolated pubic osteolysis have previously been reported with relation to trauma or osteopenic changes in elderly females, which may mimic benign neoplastic lesions [6]. Radiographic features in these cases are described as well-circumscribed lytic defects [6]. Patterns of implant-related osteolysis differ with regard to acetabular component fixation. Cemented sockets initially
13
Fig. 3 Magnified view of left hip arthroplasty showing ballooning and expansion of superior pubic ramus, with convexity of iliopectineal line
tend to show a linear pattern of osteolysis in DeLee and Charnley zone 3 [7], but may progress to include the entire cement-bone interface region. Cementless sockets show an expansile pattern of lysis beginning at the implant-bone interface and ballooning outwards, with some areas of the implant surface remaining well-fixed [2, 8]. The osteolytic lesions communicate with the joint space and may be demarcated by a sclerotic margin. [2, 9]. Osteolytic defects within the pelvis are difficult to assess intraoperatively with a retained cementless acetabular component [8]. Periacetabular osteolysis is notable in its difficulty to diagnose based on traditional plain radiographs. In a study of 206 hips at a mean of 10 years post hip arthroplasty, Sandgren [1] reported detection of osteolytic lesions in only 7 % of cases with digital radiography, compared to
101
Arch Orthop Trauma Surg (2014) 134:99–101
86 % of cases with computed tomography. In a cadaveric pelvic model, Safir et al. [4] reported that ten arthroplasty surgeons were unable to accurately quantify bone defects less than 50 % based on plain radiographs, though accuracy increased as defects became more severe. Furthermore, large defects tended to be underestimated by around 30 %. Numerous studies have shown that computed tomography is more sensitive than plain radiographs for evaluating osteolysis [1, 3, 5, 10]. Computed tomography is not indicated in most cases of long-term hip arthroplasty assessment, but may have value in a carefully selected subgroup of patients based on clinical or plain radiographic signs.
Conclusions Periacetabular osteolysis related to hip arthroplasty is difficult to diagnose on plain radiographs. To our knowledge, superior pubic ramus ballooning has not been described as a sentinel sign for periacetabular osteolysis. In case of ballooning, the diagnosis seems obvious. The more subtle, sign however, seems to be the loss of the normal concavity of the ilio-pectineal line. We suggest that the presence of convexity of the ilio-pectineal line/superior pubic ramus indicates established pelvic osteolysis. Its presence should alert towards the possibility of implant failure even in the presence of a well-fixed acetabular component. Imaging such as computed tomography or MRI should be considered for further assessment and planning of revision surgery.
References 1. Sandgren B, Crafoord J, Garellick G, Carlsson L, Weidenhielm L, Olivecrona H (2013) Computed tomography vs digital radiography assessment for detection of osteolysis in asymptomatic patients with uncemented cups. J Arthroplasty 28(9):1608–1613 2. Maloney WJ, Peters P, Engh CA, Chandler H (1993) Severe osteolysis of the pelvis in association with acetabular replacement without cement. J Bone Jt Surg (Am) 75:1627–1635 3. Puri L, Wixson RL, Stern SH, Kohli J, Hendrix RW, Stulberg SD (2002) Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty. J Bone Jt Surg A 84(4):609–614 4. Safir O, Lin C, Kosashvili Y, Mayne IP, Gross AE, Backstein D (2012) Limitations of conventional radiographs in the assessment of acetabular defects following total hip arthroplasty. Can J Surg 55(6):401–407 5. Stulberg SD, Wixson RL, Adams AD, Hendrix RW, Bemfield JB (2002) Monitoring pelvic osteolysis following total hip replacement surgery: an algorithm for surveillance. J Bone Jt Surg A 84(Suppl):116–122 6. McCarthy B, Dorfman H (1990) Pubic osteolysis—A benign lesion of the pelvis closely mimicking a malignant neoplasm. Clin Orthop Relat Res 251:300–307 7. DeLee JG, Charnley J (1976) Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res 121:20–32 8. Chiang PP, Burke DW, Freiberg AA, Rubash HE (2003) Osteolysis of the pelvis. Clin Orthop Relat Res 417:164–174 9. Kitamura N, Leung SB, Engh CA (2005) Characteristics of pelvic osteolysis on computed tomography after total hip arthroplasty. Clin Orthop Relat Res 441:291–297 10. Garcia-Cimbrelo E, Tapia M, Martin-Hervas C (2007) Multislice computed tomography for evaluating acetabular defects in revision THA. Clin Orthop Relat Res 463:138–143
Conflict of interest Both authors have no conflicts of interest to declare.
13
HIP ARTHROPLASTY
Pubic ramus convexity or ballooning: a sentinel sign for severe periacetabular osteolysis in total hip arthroplasty Daniel Mandziak · Steffen Breusch
Received: 31 October 2013 / Published online: 13 November 2013 © Springer-Verlag Berlin Heidelberg 2013
Abstract Osteolysis is a significant long-term problem in hip arthroplasty. Plain radiographs are the routine investigation of choice for monitoring hip arthroplasty patients; however, the recognition of clinically significant osteolysis can be challenging. We present two case reports of arthroplasty patients with ballooning and expansion of the superior pubic ramus with loss of the normal concavity of the ilio-pectineal line. Both patients subsequently displayed massive pubic osteolysis at the time of revision surgery. We suggest that the presence of convexity of the ilio-pectineal line/superior pubic ramus indicates established pelvic osteolysis.
[4]. Computed tomography is a more sensitive means of detecting osteolysis, but its routine use is not usually required and certainly has cost implications. We describe two cases with expansion and ballooning of the superior pubic ramus adjacent to hip arthroplasty with medial convexity of the ilio-pectineal line and propose this as a simple radiographic finding representing significant pubic osteolysis.
Case studies Case 1
Keywords Hip · Acetabular · Arthroplasty · Replacement · Osteolysis · Pubic
Background Osteolysis related to particulate debris is a well-described long-term problem in hip arthroplasty, and is one of the most common reasons for revision surgery. Significant periacetabular lysis from an adjacent hip arthroplasty is not easily diagnosed on plain radiographs [1–3] However, despite plain radiographs being the routine investigation of choice for monitoring and assessing arthroplasty patients, the recognition of clinically significant osteolysis can be challenging even for experienced surgeons [4, 5]. Osteolysis often remains clinically silent until bone loss reaches an advanced stage with associated implant migration or failure D. Mandziak (*) · S. Breusch Department of Orthopaedic Surgery, New Royal Infirmary of Edinburgh, Little France, EH16 4SU Edinburgh, Scotland, UK e-mail: [email protected]
A 63-year-old man with no comorbidities presented with painful osteoarthritis in his left knee. He had undergone a right hip resurfacing arthroplasty (Depuy, Warsaw, IN) performed for osteoarthritis seven years before. The initial arthroplasty and recovery had been uneventful. He was asymptomatic regarding his right hip and reported functioning well with no pain or limitations to his activities. On further questioning, elevated Cobalt and Chrome serum levels (23 μg/L) had been detected 3 years postoperatively as part of a Depuy screening programme, but no further action was taken at the time. Routine surveillance radiographs of the pelvis revealed expansion and convexity of the right superior pubic ramus (Fig. 1). Metal suppression magnetic resonance imaging further displayed evidence of superior pubic ramus ballooning. Revision surgery was recommended. At surgery, significant metallosis was noted, and a well-fixed uncemented shell was removed using the explant system (Zimmer, Warsaw, IN). Massive pubic osteolysis and superior posterior granulomatous lesions were encountered, which were successfully bone grafted from the resected head/neck remnant and proximal femoral cancellous bone.
13
100
Arch Orthop Trauma Surg (2014) 134:99–101
Fig. 1 Plain radiograph of right hip resurfacing arthroplasty at 7 years postoperatively, displaying expansion and convexity of right superior pubic ramus Fig. 2 Left hybrid hip arthroplasty at 9 years postoperatively, displaying mid-stem fracture and expansion of left superior pubic ramus
Histological analysis confirmed inflammatory changes with severe metallosis. Case 2 A 59-year-old woman presented with a 3 months history of deteriorating left thigh pain. Her left hybrid total hip arthroplasty (Exeter stem, Stryker, Mahwah, NJ; Reflection cup, Smith & Nephew, London, UK) was initially performed 9 years prior for pain related to osteoarthritis, with an uneventful postoperative recovery. There was no history of rheumatoid arthritis, steroid use, hip infection or neoplasm. Subsequent plain radiographs of the left hip showed a cemented stem with mid-stem implant breakage. Ballooning and expansion of the superior pubic ramus were noted (Figs. 2, 3). Further imaging was not performed preoperatively. Revision surgery was undertaken, revealing massive lysis and expansion involving the superior pubic ramus, which was filled with an inflammatory soft tissue membrane. Osteolysis also involved the proximal femoral metaphysis, contributing to lack of cement mantle support and stem fracture.
Discussion There is a paucity of literature describing pubic lysis in the setting of implant-related periacetabular osteolysis. The plain radiographic findings of isolated pubic osteolysis have previously been reported with relation to trauma or osteopenic changes in elderly females, which may mimic benign neoplastic lesions [6]. Radiographic features in these cases are described as well-circumscribed lytic defects [6]. Patterns of implant-related osteolysis differ with regard to acetabular component fixation. Cemented sockets initially
13
Fig. 3 Magnified view of left hip arthroplasty showing ballooning and expansion of superior pubic ramus, with convexity of iliopectineal line
tend to show a linear pattern of osteolysis in DeLee and Charnley zone 3 [7], but may progress to include the entire cement-bone interface region. Cementless sockets show an expansile pattern of lysis beginning at the implant-bone interface and ballooning outwards, with some areas of the implant surface remaining well-fixed [2, 8]. The osteolytic lesions communicate with the joint space and may be demarcated by a sclerotic margin. [2, 9]. Osteolytic defects within the pelvis are difficult to assess intraoperatively with a retained cementless acetabular component [8]. Periacetabular osteolysis is notable in its difficulty to diagnose based on traditional plain radiographs. In a study of 206 hips at a mean of 10 years post hip arthroplasty, Sandgren [1] reported detection of osteolytic lesions in only 7 % of cases with digital radiography, compared to
101
Arch Orthop Trauma Surg (2014) 134:99–101
86 % of cases with computed tomography. In a cadaveric pelvic model, Safir et al. [4] reported that ten arthroplasty surgeons were unable to accurately quantify bone defects less than 50 % based on plain radiographs, though accuracy increased as defects became more severe. Furthermore, large defects tended to be underestimated by around 30 %. Numerous studies have shown that computed tomography is more sensitive than plain radiographs for evaluating osteolysis [1, 3, 5, 10]. Computed tomography is not indicated in most cases of long-term hip arthroplasty assessment, but may have value in a carefully selected subgroup of patients based on clinical or plain radiographic signs.
Conclusions Periacetabular osteolysis related to hip arthroplasty is difficult to diagnose on plain radiographs. To our knowledge, superior pubic ramus ballooning has not been described as a sentinel sign for periacetabular osteolysis. In case of ballooning, the diagnosis seems obvious. The more subtle, sign however, seems to be the loss of the normal concavity of the ilio-pectineal line. We suggest that the presence of convexity of the ilio-pectineal line/superior pubic ramus indicates established pelvic osteolysis. Its presence should alert towards the possibility of implant failure even in the presence of a well-fixed acetabular component. Imaging such as computed tomography or MRI should be considered for further assessment and planning of revision surgery.
References 1. Sandgren B, Crafoord J, Garellick G, Carlsson L, Weidenhielm L, Olivecrona H (2013) Computed tomography vs digital radiography assessment for detection of osteolysis in asymptomatic patients with uncemented cups. J Arthroplasty 28(9):1608–1613 2. Maloney WJ, Peters P, Engh CA, Chandler H (1993) Severe osteolysis of the pelvis in association with acetabular replacement without cement. J Bone Jt Surg (Am) 75:1627–1635 3. Puri L, Wixson RL, Stern SH, Kohli J, Hendrix RW, Stulberg SD (2002) Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty. J Bone Jt Surg A 84(4):609–614 4. Safir O, Lin C, Kosashvili Y, Mayne IP, Gross AE, Backstein D (2012) Limitations of conventional radiographs in the assessment of acetabular defects following total hip arthroplasty. Can J Surg 55(6):401–407 5. Stulberg SD, Wixson RL, Adams AD, Hendrix RW, Bemfield JB (2002) Monitoring pelvic osteolysis following total hip replacement surgery: an algorithm for surveillance. J Bone Jt Surg A 84(Suppl):116–122 6. McCarthy B, Dorfman H (1990) Pubic osteolysis—A benign lesion of the pelvis closely mimicking a malignant neoplasm. Clin Orthop Relat Res 251:300–307 7. DeLee JG, Charnley J (1976) Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res 121:20–32 8. Chiang PP, Burke DW, Freiberg AA, Rubash HE (2003) Osteolysis of the pelvis. Clin Orthop Relat Res 417:164–174 9. Kitamura N, Leung SB, Engh CA (2005) Characteristics of pelvic osteolysis on computed tomography after total hip arthroplasty. Clin Orthop Relat Res 441:291–297 10. Garcia-Cimbrelo E, Tapia M, Martin-Hervas C (2007) Multislice computed tomography for evaluating acetabular defects in revision THA. Clin Orthop Relat Res 463:138–143
Conflict of interest Both authors have no conflicts of interest to declare.
13
