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Particle disease: total hip replacement
With particle disease progression, osteolysis ensues, and osteolysis is the most frequent serious complication in patients following hip arthroplasty. Bone resorption that occurs in osteolysis may be visible on plain films, though plain radiographs are less sensitive than MR and the sensitivity of plain radiographs is more dependent upon lesion location than is MR. Osteolysis may occur anywhere along the “effective joint space” of the hip, that is, the entire region surrounding the joint into which particles may migrate and contact bone16. As a result, osteolysis may be seen anywhere from the superior acetabulum to the distal tip of the prosthesis. On MR images, osteolysis has an intermediate signal intensity appearance, similar to or slightly brighter than skeletal muscle, on both T1- and T2-weighted images. A low signal intensity rim which outlines the lesion is typical (6a). Infection or malignancy, in distinction, is more hyperintense on T2-weighted images and a low signal intensity rim would not be expected. Osteolysis may also result in cortical expansion and disruption, and extraosseous deposits of similar signal intensity may be seen in such cases. Extraosseous components may result in symptoms due to compression of adjacent neural structures (7a,8a).
X-rays showed significant osteolysis of the proximal femur, distal to the greater trochanter of his left hip (). Despite the bone loss, the stem appeared to still be solid. In addition, significant wear of the left cup was observed. It was anticipated that the progressive wear of the polyethylene cup would induce small particle disease involving the greater and lesser trochanter areas. X-rays had been taken 5 years prior to evaluate the aging arthroplasty. Comparison to the current x-rays () revealed that the particle disease had expanded and significantly increased the endosteal lytic zone, it was also evident that the ceramic head had penetrated deeper into the acetabulum. The right hip was not radiologically or symptomatically threatened at the presented time. To avoid impending femoral fracture or avulsion of the greater trochanter from lytic bone loss, revision of the left hip was scheduled.
Particle Disease Hip Replacement Ct | Orthopedic Doctors
Abductor tendon avulsion is a known cause of recurrent pain and/or dysfunction in patients following hip arthroplasty, particularly when an anterolateral approach is utilized22. Fluid collections are often present in association with these abductor avulsions (15a). These collections tend to be of pure fluid signal and lack a low signal intensity rim. Their typical location at the site of abductor avulsion provides another clue to the etiology. It should be noted, however, that particle disease including pseudotumors may coexist with abductor tendon avulsions following hip arthroplasty.
With regard to pseudotumors, which often have a predominantly fluid-signal appearance, there are two important alternative diagnostic alternatives that should be considered. Infection is a known complication in patients following hip arthroplasty, and infection can of course cause large fluid collections/abscesses to form in the region of the prosthesis. On MR images, infected fluid collections tend to be less well defined than pseudotumors, and they lack a low signal intensity rim (14a). Soft-tissue edema may be seen with either infection or pseudotumor, but extensive, ill-defined perifascial fluid is more suggestive of infection.
distinguish small particle disease from ..
The majority of complications related to failure of total hip arthroplasties are thought to be related to particle disease. Particle disease refers to the reaction that occurs in response to small particles of debris that are released due to wear of arthroplasty components. In hip arthroplasty patients, this reaction can occur due to particles of metal, polyethylene, and/or cement. The presence of these microscopic particles within the joint leads to a cellular response primarily from macrophages. Inflammatory cells infiltrate the synovium, resulting in synovial hypertrophy and effusions13. The macrophages are unable to digest the particles, and as a result inflammatory cytokines and growth factors are released. A complex physiologic response ensues which may lead to bone resorption (osteolysis), primarily by osteoclasts14.
The earliest MR finding that results from particle disease is the presence of a joint effusion due to reactive synovitis (5a), and reactive synovitis in these patients may occur before symptoms arise15. MR images in affected patients may reveal capsular thickening and the presence of low signal intensity debris within the joint, though normal fluid signal intensity of the effusion may also be found. Unfortunately, visualization of the joint itself is perhaps the most challenging area for MR imaging following hip arthroplasty, as metal artifact tends to be greatest about the spherical femoral head component of the arthroplasty, and artifact in this region is even more pronounced with metal on metal cobalt-chrome prostheses. As a result, small effusions that do not distend the joint may be missed early in the course of particle disease.
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to distinguish small particle disease from ..
The most frequent abnormality that affects the long term viability of a total hip arthroplasty is osteolysis2,3. Osteolyis is but one manifestation of particle disease, a complex response to the microdebris that is generated in arthroplasty patients. Plain radiographs have traditionally been the mainstay for the assessment of osteolysis, and remain the current clinical standard. Yet plain films are known to underestimate the existence and extent of osteolysis, and detection of osteolysis on plain films is influenced by lesion size and location4. Computed tomography (CT) with newer metal artifact reduction techniques can effectively detect osteolysis, but CT lacks the soft tissue contrast of MR, and serial CT evaluations have the potential of subjecting the patient to a hazardous amount of ionizing radiation. MR, with proper technique, has been found to be the most sensitive imaging test for the detection of osteolysis5. In addition, MR’s superior soft tissue contrast, multiplanar capability, and lack of ionizing radiation make it ideally suited for the evaluation of numerous other entities that may account for pain in a patient who has undergone hip arthroplasty.
After total hip replacement or hip resurfacing, particle ..
For reasons including particle disease, revision of total hip replacements generally occur upon indication of a painful loose prosthesis. Davis et al. () used the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) questionnaire to grade pain and function pre- and 2-year-postoperatively. The study reported that a higher pain level and number of comorbidities before the surgery predicted poorer outcomes at 24 month post-surgical follow-up. Patients with better preoperative WOMAC pain and function scores had better scores postoperatively, suggesting the benefit of performing total hip revision not only to relieve current symptoms, but to reduce the chance that pain and function will worsen while waiting for surgery. In this case, loosening was first noticed by the patient through instability and loss of gait control and later confirmed through radiography. If surgery had waited until higher levels of pain were expressed to maximize the life of the original device, more serious complications may have occurred. By performing the revision more complicated surgeries with worse outcomes, potentially for failure due to fracture, are avoided. The use of allograft is shown as an effective way to support components threatened with osteolysis. Donor bone in combination with biocompatible cement can greatly reduce the potential for injury and pain due to lytic bone loss.
Prosthesis Types Total Hip Hemi Revision ..
A 67 year-old male with right foot drop and leg weakness years following placement of a right hip arthroplasty. Fast spin echo T1-weighted images demonstrate particle disease that markedly expands and destroys the medial acetabular wall (arrows) on (left) coronal and (right) axial views.
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