Understanding Orthopedic Hardware - not just screws and

wires!

Poster No.: C-1951

Congress: ECR 2014
Type: Educational Exhibit
Authors: F. M. G. S. Pereira da Silva, H. Donato, P. Donato, F. Caseiro
Alves; Coimbra/PT
Keywords: Musculoskeletal bone, Musculoskeletal joint, Conventional
radiography, CT, Surgery, Trauma, Arthritides
DOI: 10.1594/ecr2014/C-1951

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Page 1 of 77
Learning objectives

1. To review commonly found orthopedic hardware

2. To review basic biomechanical theories that give rational support to surgical
approaches and the use of that material
3. To review and illustrate commonly found pathologies and complications
associated with the use of orthopedic hardware

Background

Orthopedic material is increasingly common due to advances in trauma treatment and to

the successful joint replacement in an aging of the population.

Due to this, the number of people carrying an articular prostheses is steadily increasing
not only in hospital but also in ambulatory and primary care practices, leading to this
being a common finding in imaging studies.

Therefore, it is essential for a radiologist to acquire further knowledge of their use in order
to provide a meaningful report.

Radiologists provide critical support for attending physicians. Before intervention,

by providing the most accurate diagnosis. After intervention, by evaluating possible
complications that may jeopardize an satisfactory outcome or that may require treatment.

It is difficult for the Radiologist to know all brands and types of material used on different
orthopedic surgeries.

We will focus essentially on illustrating the most commonly used material, their rationale
and try to explain why they actually work or why they may fail.

Findings and procedure details

THE HARDWARE ITSELF

Page 2 of 77
Bones - or joints - kept fixated for some time will eventually consolidate into either
arthrodesis or fracture healing.

Hardware provides temporary support by stabilizing and diverging forces from the area.
Hardware is not adequate for long term stability - when consolidation or arthrodesis does
not occur, with time, any material will eventually fail - like a paper clip being bent multiple
times.

When consolidation does occur, most hardware is no longer necessary, and is left in
place (unless it causes symptoms).

Articular replacements also have their limitations and limited lifespan, having been
developed and used in order to provide better functional performance than the patients
own diseased joint. Many complications may be radiologically assessed.

APROACHING AN IMAGING STUDY

Paying attention to the clinical information and communication with the attending
physician is, as always, beneficial as many procedures and clinical doubts are specific
to the context.

When assessing an radiograph, the "rules of two" are always a wise starting point.

• two views
• two joints (above and below the injury)
• two sides (for comparison)
• two occasions (may need a follow up x-ray)

Orthopedic hardware has in most instances two reasons for being used

• As articular -or bone - prosthesis

• Fixation devices as in fracture healing

Articular prosthesis are designed to provide movement to diseased joints. The most
common are knee and hip prosthesis. However, many other joints may be submitted
do arthroplasties for different pathologies - degenerative, inflamatory or neoplastic
processes.

(Fig. 1 on page 42 / Fig. 2 on page 42 / Fig. 3 on page 43 / Fig. 4 on page 44)

Page 3 of 77
Fig. 3: Patient with an extensive osteosarcoma of the left thigh. Digital topogram (top,
left) 3D reconstruction (top, middle) and axial CT (top right) show a aggressive looking
lesion with osteoid matrix. Bottom shows AP and lateral radiograph 1 year follow-up
post-op finding where a whole femoral replacement placed with a total knee prosthesis.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

When hardware is used as fixation devices, what the referring physicians is hoping to
see is the fixation and healing. (Fig. 8 on page )

Page 4 of 77
Fig. 8: Left hip radiograph shows an oblique fracture in the proximal femur diaphysis.
On the right, it is possible to see a bone callus with bone remodelling. A hook plate with
cerclage wires were used to reduce the fracture.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

The hardware itself may fracture (Fig. 5 on page 47 / Fig. 6 on page 48 ), disengage
(Fig. 7 on page 45) or loosen (Fig. 9 on page 71).

Page 5 of 77
Fig. 9: 22 year old male, previously submitted to a knee resection due to sarcoma. A
fully constrained knee prosthesis with an extended femoral component is seen. The
femoral component shows bone resoption in a windshield wiper pattern, with regular
contours, indicating a mechanical loosening
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Differences in the stress distribution after fixation predispose to fractures. ( Fig. 8 on page
).

Page 6 of 77
Fig. 8: Left hip radiograph shows an oblique fracture in the proximal femur diaphysis.
On the right, it is possible to see a bone callus with bone remodelling. A hook plate with
cerclage wires were used to reduce the fracture.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

It is may be difficult to differentiate on imaging alone infection from loosening. A

windishield wiper, or pistoning lucent areas may sugest an mechanical cause. Periosteal
reaction or wider lytic areas may be a finding sugestive of infectious ethiology of the
orthopedica material.

Page 7 of 77
Fig. 10: (TOP) Patient with distal femoral fracture submitted to open reduction with
internal fixation with skin incision infection. Note the screw loosening. (MIDDLE) Due
to hemorrhage in the superior lateral genicular artery, the patient was submitted to
angiography with supraselective embolization of microspheres (DOWN) Six months
after surgical removal of the bone graft material, note the extensive and thick periosteal
reaction on the medial aspect of the knee.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT
Other complications are rather material-specific: silicone synovitis, asymmetric wear in
polyethylene prosthesis, metallosis with metal-metal prosthesis.

Page 8 of 77
FIXATION DEVICES

The goal of most instrumentation is to provide proper immobilization and compression.

Failure to do so will make it impossible to have adequate bone healing. It requires that a
"bridge" redirects the force away from the diseased bone .

Fixation devices can be classified into internal or external fixation devices.

INTERNAL FIXATION DEVICES

• Screws
• Plates
• Wires and pins
• Intramedullary rods and nails
• Spinal fixation device

EXTERNAL FIXATION DEVICES

• Fracture fixation
• Bone lenghthning

Page 9 of 77
Fig. 48: AP and lateral wrist radiograph. Distal extremity of the radius fracture, treated
with external fixation (pins placed in the proximal radius and the second metacarpal)
and a single k-wire placed from the radial tuberosity crossing the fracture line.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Screws are one of the most versatile and ubiquous orthopedic material found. (Fig. 11
on page 50)

Screws may be divided into static screws (Fig. 13 on page 50) or dynamic screws
(Fig. 12 on page 72)

Different designs also affect their their function or usual use:

• Cortical screws have fine threads along their shreads and are inserted into
the cortical bone on both ends (Fig. 13 on page 50)
• Cancelous screws have longer threads and larger pitch, making them less
invasive, preserving the normal trabecula and allowing purchase to be
acquired in cancelous bone ( Fig. 14 on page 50 )

Page 10 of 77
 • Lag screws have an unthreaded proximal portion. When tightened, they act
as compression screws by "drawing" the distal fragment closer. ( Fig. 15 on
page 73 )
• Canulated screws have an hollow shaft and may be placed over a guidewire
such as a Kirschner wire, which is minimally traumatic to the bone ( Fig. 15
on page 73 )
• Herbert screws have threads with different pitches. This allows the distal
portion to progress at a different speed than the proximal, allowing segments
to compress ( Fig. 16 on page 74 )

Plates are used not only for stabilization, but may also be used for compression or to
work as a buttress (counter-force).

• Dynamic compression plate compression is provided by eccentric placement

of screws that, when tightened, draw both ends closer together (Fig. 17 on
page 51)
• Reconstruction plates (Fig. 18 on page 52) are often used for pelvic or
calcaneal fractures as they are maleable and able to be molded to irregular
bone surfaces
• Neutralization plates (Fig. 19 on page 53) aredesigned for protecting
surface fractures from axial loading, bending and rotation. Acts as protection
device by allowing the primary fracture fixation to be accomplished with other
devices such as lag screws.
• Butress plates (Fig. 20 on page 54) are used to rigidly hold in place fractures
at the end of long bones, especially at the knee and ankle, where the fracture
site experiences compressive and other distorting forces. The broad end and
the adequate contour at the end of the platemakes it more suitable.
• Hook plate (Fig. 21 on page 55) are sometimes used to treat
acromioclavicular dislocation.

Dynamic hip screws (DHS) are a type of hardware which was specifically designed for
treating hip fractures and is currently a current favourite for treating kind of fracturesas
it provides resistance to bending while allowing progressive impactation along the
lag screw. Used primarily for intertrochanteric fracture, well vascularized zones of the
hip because using it for a more proximal bone might lead to bone ischemia and
osteonecrosis.

Page 11 of 77
Fig. 22: Pelvis AP radiograph shows bilateral Dynamic hip screws (DHS). There is
telescoping on the right (slim arrow) related to impacting of the fracture along the
mechanical axis of the hip. On the left (fat arrow), there is no discernible telescoping of
the lag screw.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

For the most proximal fractures, instead of the DHS, the parallell screws will cause less
trauma to an area with fewer blood supply. If perfectly parallel, the bone will impact just
like with an DHS.

Page 12 of 77
Fig. 23: AP and false profile incidence of the left hip. Three canulated lag screws were
applied to treat a subcapital hip fracture. This patient's left leg had been previously
amputated below the knew (not shown)
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Girdlestone procedure - Pain is generated by the synovium nerves from the articular
capsule being painful. Removing the femoral head and neck is effective alleviating the
pain which is considered by patients an satisfatory results. The leg is shortened at about
3-10 cm.

Page 13 of 77
Page 14 of 77
Fig. 25: AP radiograph of the hip. On the right side, there is complete absence of the
femoral head and neck. The great trochanter "articulates" with the lateral ilium. This is
the typical appearance of a Girdlestone procedure.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

WIRES

Wires are another versatile modality of orthopaedic hardware.

Cerclage wires are usually placed in circunference to the bone in order to secure the
bone fragments closer together. ( Fig. 24 on page 59 )

Tension band wiring is a techniche which allows the conversion of disctractive forces into
compressive forces. Common aplications are patellar and olecraneum fractures.

Fig. 26: AP knee radiograph and lateral knee radiograph. There is a transverse
patellar fracture treated with Kirschner wires and with tension band wiring. These
transform distraction forces into compressive forces
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

KIRSCHNER WIRES (K-wires) are used for guiding canulated wires, help stabelize and
reduce fractures. They are very versatile and minimally invasive. K-wires can be safelly
placed across physeal plates and across articular surfaces.

Page 15 of 77
RODS AND NAILS

Intramedullary devices marked a great advance in fracture treatment, allowing earlier

weight bearing and less invasive procedures.

Placement of endomedullary devices may require reaming (removal of the medulary

contents) as the excessive pressure caused during rod insertion (hammering) might
shatter the bone or cause fat embolism. Compromising endomedulary circulation makes
it almost essential that skin overlying the fracture is intact - "adequate skin conditions" -
in order to prevent osteonecrosis or osteomyelitis.

Some of these endomedullary devices are composed by long, slender, and rather flexible
metalic rods, such as the Ender Nails ( Fig. 27 on page 61)

Probably the current favourite is the Interlocking Nail. These combine the use of a nail as
well as screws connecting the bone to the nail, allowing earlier weight bearing, Further
advantages are the possible placement with minimal invasion, less soft tissue damage,
better blood supply (mainly periosteal).

Page 16 of 77
Page 17 of 77
Fig. 28: AP (left top) and lateral (left bottom) tibial shaft radiograph immediately post-
op. An intramedullary locking nail was used due to a transverse fracture in the distal
tibial shaft. On the right, there's an AP (bottom) and lateral (top) radiographs 3 months
after surgery, showing callus formation.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Concerning sub-trochanteric hip fractures, these injuries tend to behave mechanically as

a femoral fracture. Sub trochanteric puts substantial stress on the lateral plate. This led
to the development of the special nails such as the Gamma nail.

Fig. 29: AP radiograph of the left hip (first from left); false profile (second from left);
AP and lateral femoral radiograph (third and fourth from left). Patient treated with an
intramedullary locking nail for a subtrocanteric fracture, currently consolidated.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT
If an arthrodesis is the procedure intended, nails and rods may be placed crossing
the articular surfaces along the mechanicl axis, providing a solid support for bone
consolidation to occur.

Page 18 of 77
Page 19 of 77
Fig. 30: AP pangonogram. Transarticular nail was used for joint arthrodesis. The knee
joint line was ressected. The nail is fixated to the tibial and femoral shaft by a screw.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

SPINAL FIXATION DEVICES

Trauma, degenerative diseases and congenital abnormalities are among the most
common reasons for spinal intrumentation.

Fig. 31: TOP: Lateral neck view (lateral, extension, flexion) and AP view. Patient
previously submitted to surgery with occipital plates due to basilary invagination,

Page 20 of 77
posterior luxation of C2. There's an anterolystesis of C6 (grade II) as well as sclerosis
of the vertebral platforms. MIDDLE - T2W and T1W didn't show evident signs of
medullary compromise, even though the patient was symptomatic. BOTTOM - Sagital
reconstruction of CT shows reduction of the lystesis, fixation with plate and screws.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Long-term spinal stability requires fusion between levels. The purpose of spinal
instrumentation is to provide temporary imobilization until the artrodesis is sufficient for
mechanical stability.

Anterior or posterior surgical approaches are possible at all levels. Each level has
particularities that may make one or another favourable regarding the specific clinical
situation.

Fig. 32: TOP swimmer's incidence of the cervical spine and AP incidence of the
cervical spine. Posterior instrumentation with was performed with screws in the lateral
masses, connected with parallel rods. Anteriorly there's a plate and fixating C4-
D1. There is also a bone graft replacing the vertebral bodies. CT scan sagittal MIP
reconstruction (second from left, TOP), sagittal CT reconstruction (third and fourth

Page 21 of 77
from left, top) shows detail of bone graft, the positioning of the articular screws and the
absence of the posterior arches from C5 to C7.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Spinal fusion may be achieved by using wires, screws, rods and plates in order to connect
at least two levels. External fixation devices may also be used, but usually as a temporary
fixation method.

Fig. 33: TOP - Open mouth incidence (left) and lateral cervical spine radiograph
show fracture of the base of the odontoid with displacement. An Halo traction vest
was placed. There screws attached to the calvaria and to the thoracic skeleton (right).
Bottom - Definite Fracture fixation was made by placing screws in the lateral masses of
C1 and in the lamina of C2.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Page 22 of 77
Scoliosis led to the development of much of the intrumentation used today. The
Harrington rod was one of the firs methods of spinal intrumentation avaiable. Because
it used distraction forces only on two points, to achieve reduction in smaller Cobb
angles an excessive amount of force had to be used. The following methods of spinal
instrumentation focused on multiple level intrumentation, with hooks, with laminar wires
and later on with pedicular screws.

Fig. 34: LEFT - Idiopathic scoliosis treated with posterior instrumentation. The parallel
rods extends from the cervical spine to the ilium, where a rod is inserted into the ilum.
The rods are interconnected with stabilizing bridge and are fixated t the spine via
hooks. RIGHT - Toracic instrumentation. The parallel rods are connected with two
stabilizing bridges. The rods are fixated to the vertebral column by laminar wires.

Page 23 of 77
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Although diagnosed as a 10º Cobb angle in the coronal plane, the pathological starting
point is a rotation in the vertebral body. Laminar hooks (with compression and distraction
foreces) and wires have a limited control over this rotational component. This fact was
addressed with the use of pedicular screws. These are currently one of the most widely
used (not only for scoliosis) as it allows better control of the vertebral body alignement
and correction of its rotation.

Fig. 35: AP and lateral spine radiograph of the thoracic spine. Compression fracture
of D11. Presence of transpedicular screws connected to a rod system. The rod system
itself is connected by a bridge at T11. Note the presence of radiodence cement in L3.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Hardware positioning in the spine (particularly pedicular screws) is a delicate procedure

and post-op imaging should assess their positioning.

Regarding pedicular screws' positioning, medially there's the spinal cord; laterally the
screw would not provide sufficient purchase and noble structure might be injured.

Page 24 of 77
Caudally and cephalically are the nerve roots, which might cause severe pain and
fuctional compromise.

Fig. 36: Patient submitted to surgery due to spondylolisthesis. LEFT: lateral

incidence radiograph of the lumbar spine; Center and right - CT with axial and sagittal
reconstruction. There are trasn-pedicular screws placed at L5 and S1 levels. The
lamina have been removed. There is also marked sclerosis of the intersomatic
platforms at L5/S1, as well as a "cage" between the somatic levels.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Other types of material such as titanium boxes, bone grafts or even prosthesis have also
been developed.

COMPLICATIONS OF SPINAL SURGERY

The complications that should be carefully assessed are:

• incorrect level submited to surgery

• hematoma
• infection
• instability
• instrument failure (look for attachment sites, junctions, along rigid portion
• stenosis (immediatly above or below the intrumented segments)
• Pseudarthrosis (usually 6-9 months for radiological fusion; 2 years for a
fusion to remodel)

ARTHROPLASTY

Page 25 of 77
Hip and knee replacements are one of the most common procedures today. In 2010, in
the US, there was an average of 1 surgery per thousand of inhabitants, and the double of
knee replacement surgeries. In Europe there has been a steady increase in the number
of this procedures, and probably the demographics are rather similar to the US.

HIP REPLACEMENT

Total hip replacement is an invasive procedure. Other alternatives have been attempted
in order to minimize trauma.

Total hip prothesis is used when the femoral head and the acetabulum have both
pathological changes.

Hip endoprothesis without acetabular component is used when the femoral head alone
is diseased.

Femoral resurfacing are procedures designed to postpone a hip replacement surgery

(Fig. 47 on page 70).

Girdlestone procedure was discusssed above. It is a last resource surgery being used in
most cases for neuropathic or infectious disease.

Complications

1. Heterotopic bone formation

2. Loosening

Page 26 of 77
Fig. 46: AP radiograph shows leg shortening and migration of the femoral component.
There are also radiolucent zones surrowding the acetabular component.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

• Mechanical loosening may appear as pivotting, pistoning

• Plain radiographs may be sufficient in an adequate clinical setting
• Infection is always a major concern when loosening is present. Usually
presents with a more focal bone resoption, increased inflamatory markers
and more precociously.
• 1 year after the surgery MMA usualy contracts, which is not considered a
true loosening.
• A radiolucent line of 1-2 mm, non progressive in following radiographs is
probably not significant.
• MMA may induce marked progressive osteolysis. Distinction from infectious
ethiology is not always easy.

Page 27 of 77
Fig. 37: AP radiograph shows leg shortening, migration of the femoral component with
radiolucent lines. There are also radiolucent zones in the acetabular component. Gruen
(femoral - orange) and DeChaney (acetabular - black)zones may be used for follow up.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

3. Infection

• Most occur in the first 4 months

• Diagnosis may be difficult and may present with a radiologically normal hip.
Resoption and periosteal reaction may be the only findings.
• Fluroscopic guided hip aspiration (2 weeks after antibiotic discontinuation)
with asseptic technique may be performed if inflamatory marker are elevated
or if there is an increased suspection index. Skin flora may confuse results
or (worse) be innoculated.
• Arthrograms are not routinely performed in most settings. They may,
however, provide important informations regarding the fistulous trajects.

Page 28 of 77
Fig. 38: Patient with several previous total hip prosthesis complicated with infection
presented with purulent fistula (yellow arrow)
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

4. Fracture, dislocation

• When identified intraoperativelly, stabilize with wire

• Dislocation may happen post-operativelly due to lax muscles, or due to
loosening of the prosthesis components.

Page 29 of 77
Fig. 39: Pelvis radiogram shows left hip luxation of the femoral component (left)
treated with closed reduction (rigt). There is also bilateral signs of loosening with a
windshield wipring pattern. The acetabular components are rotated.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Normal alignement

• Should be neutral or sligghtly valgus

• Little or no anteversion
• Acetabular component should be 45º with 10º anteversion

Page 30 of 77
Fig. 40
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

5. Metalosis

May occur due to metal wear in metal-metal prothesis. Besides the expected prothesis
wear damage, dissemination of metal debris to regional lymph nodes has been
documented.

The potential development of hypersensitivity reactions, infections, and tumors are a

concern. Within the involved joint, metal debris in the synovial membrane leads to a
diagnostic radiographic appearance, with radiodense material observed at the periphery
of the joint. Arthrocentesis documents the presence of thick, dark gray or black fluid.

Page 31 of 77
Fig. 45: Patient with pancytopenia of undisclosed origin and presence of total hip
prosthesis. There is a dense metal-density area in the right pelvis, also shown in
sagittal ct reconstruction (second from right). Metallosis was suspected. The patient
was submitted to surgery, where it was confirmed a acetabulum perfortion with wear
of the acetabular component. Black fluid was extracted from the pelvis. Revision of
the prosthesis was performed (right). The patient recovered from his cell dyscrasia.
(Courtesy of Dr. Catarina Oliveira and Dr. Pedro Belo Oliveira)
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

TOTAL KNEE ARTHROPLASTY

There are several designs avaiable.

Fully constrained prosthesis were the first type of prosthesis available. Althought they
possess intrinsic stability, they do not reproduce exactly the normal knee rotation and
kinematics, placing an excessive amount of stress in the bone-joint interface, leading
to early loosening. Fully constrained with rotations are still used in older patients, with
massive tumour resection or in revision arthroplasties.

Page 32 of 77
Fig. 9: 22 year old male, previously submitted to a knee resection due to sarcoma. A
fully constrained knee prosthesis with an extended femoral component is seen. The
femoral component shows bone resoption in a windshield wiper pattern, with regular
contours, indicating a mechanical loosening
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

More commonly used are the unconstrained models which allow triplanar motion (flexion,
rotation, distraction).

These have no ligament stability, meaning the joint stability is provided by sparing the
patients own ligaments. As little bone is actually ressected, they are composed by

Page 33 of 77
"resurfacing" components - both a tibial and a femoral one. Some may also possess a
patelar resurfacing component.

Unicompartmental replacements have the advantage of preserving near normal bone

stock, but are less frequently used.

PREOPERTIVE ASSESSMENT

Usually the radiographic assessment should be done with an anteroposterior and lateral
knee incidence, a axial patelar radiograph, a whole leg length radiograph.

Page 34 of 77
Fig. 41: (LEFT) Patient with buttress place on the right tibia due to previous tibial
valgus osteotomy surgery for lower limb alignement. Note the total knee arthroplasty
of the left knee (CENTER) Lower limb mechanical axis placed along the center of the
knee (between the femoral condyles) (RIGHT) Anatomical axis is drawn along femoral
shaft. Angulation with the mechanical axis should be about 7º
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT
Angulation with the femoral mechanical axis is important as this is the best intraopertory
reference aviable.

POST-OPERATIVE ASSESSMENT

Follow-up uses both clinical and radiological aspects of the knee prosthesis.

In 1989, the Knee Society introduced the Total Knee Arthroplasty Radiographic
Evaluation and Scoring System to standardize the radiographic parameters to be
measured when reporting radiographic outcomes of TKA:

• component alignment
• tibial surface coverage
• radiolucencies
• patellar problem list that includes angle of the prosthesis, eccentric
component placement, subluxation, and dislocation

The development of such scoring systems stresses the need for methodical follow up -
quantification of radiolucent areas (in milimeters), the number of lucent areas, the angular
relationships and, very importantly, their evolution are important aspects to pay attention.

Component alignement is an important factor to considerate as mal-alignement is a cause

for instability, loosening and failure.

In a knee AP radiograph, the angle between the femoral anatomical axis and the femoral
component should be about 7º valgus (as previously stated), which would represent a
match with the mechanical axis. On lateral view, the femoral component should be nearly
perpendicular with the femoral mechanical axis and no lucent spot should be seen.

The tibial component should be placed perpendicular to the tibial shaft (AP), centered
or slightly posterior to the axis on lateral view. It should slope posteriorly about 10º.
Overhanging of the tibial component may be symptomatic.

Page 35 of 77
The joint line height is determined by measuring the distance from a line passing through
the tibial tubercule (perpendicular to the tibial shaft) to a paralell line passing through the
the tibial plateau.

• best results are obtained when joint line is altered 8 mm or less

The patellar height is measured from the joint line to the lower patellar pole.

• best results are obtained when the patellar height is 10-30 mm

Loosening is believed to be caused by a combination of mechanical stress,

malalignement, osteolysis and poor bone stock. Criteria for diagnosis are

• Increasing radiolucent lines

• component migration
• cement fractures

Page 36 of 77
Page 37 of 77
Fig. 42: AP and lateral knee radiograph (top) with CT reformats (bottom). Constrained
total knee prosthesis. There is a tibial subsidence of the medial component with
deviation the tibial component. Latrally there is loosening of the tibial component. Note
the misalignment of the tibial component with the tibial axis.
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Infection is always a consideration with radiolucent lesions, especially in the first two
years. More commonly they are indolent with mild to moderate disconfort.

Page 38 of 77
Fig. 43: Left knee AP and lateral radiographs 2 months post-op (TOP) and 9
months post-op (BOTTOM). Immediately post-op there is normal relation between
the orthopaedic material and the bones. 9 months after, there are radiolucent line
underneath the tibial plateau and the posteriorly to the femoral component (red arrow).
This patient was submitted to revision arthroplasty due to septic loosening
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

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Fluoroscopic dynamic examination may be helpful in patients with unexplained pain after
TKA and normal radiographs.

Arthrogram with aspiration of knee fluid for culture may also be used. Contrast medium
should not be present in fluid aspiration. In case of dry tap, sterile saline lavage has been
described.

Presence of contrast in periprothesis is diagnosis of loosening.

Extensor mechanism complications account for probably half the causes for
dissatisfaction. Radiographs are instrumental in their diagnosis

Patellar tilt and patellar subluxation are common findings that may imply a tight lateral
retinaculum, a component malrotation or valgus allignment of the extensor mechanism.
Patella alta (due to extensor mechanism rupture) or patella infera (fibrosis in the Hoffa
pad) may also be seen.

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Fig. 44: Bilateral AP radiograph (middle) , left lateral knee radiograph (top) and
axial patellar incidence (bottom). There is a tibial subsidence beneath the medial
component, with loosening (red arrow), which dents the lateral cortical surface of the
tibia (orange arrow)with a valgus deviation. On the axial view, the patelar tilt (green
arrow)
References: Medical Imaging, Faculty of Medicine of Coimbra, University Hospital of
Coimbra - Coimbra/PT

Images for this section:

Fig. 1: LEFT - Sclerosis of the talar dome and posterior body of the talus (white
arrows) relative to the anterior body of the talus. CENTER - Replacement of talar dome
with articular prosthesis. RIGHT - there is anterior migration and lossening of the talar
component of the fracture, which caused signigicant pain

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Fig. 2: Left elbow radiograph. Immediate post-op of a chondrosarcoma resection. A fully
constrained elbow prosthesis was placed

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Fig. 3: Patient with an extensive osteosarcoma of the left thigh. Digital topogram (top,
left) 3D reconstruction (top, middle) and axial CT (top right) show a aggressive looking
lesion with osteoid matrix. Bottom shows AP and lateral radiograph 1 year follow-up post-
op finding where a whole femoral replacement placed with a total knee prosthesis.

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Fig. 4: LEFT - Patient with Rheumatoid arthritis with sclerosis of the glenoid and of
the humeral head, submitted to total shoulder arthropasty (bottom) RIGHT - patient
with secerelly displaced humeral head fracture (top). There is no glenoid damage. A
hemiarthroplasty was performed (bottom).

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Fig. 7: Frontal and lateral radiograph of the lumbar spine. Two parallel rods are seen
longitudinally to the spine and stabilized with wire. There is a laminar hook clearly
disengaged from the rods itself.

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Fig. 48: AP and lateral wrist radiograph. Distal extremity of the radius fracture, treated
with external fixation (pins placed in the proximal radius and the second metacarpal) and
a single k-wire placed from the radial tuberosity crossing the fracture line.

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Fig. 5: Left elbow radiograph, lateral incidence, shows a well aligned radial head
prosthesis. There is a break in the components (red arrow) and there is a smooth bone
resorption in a windshield wiper patern, compatible with loosening

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Fig. 6: PA thoracic spine radiograph. There is a marked thoracolumbar curvature. At the
apex, both rods have broken . There is also disengagement of at least one laminar hook
above.

Fig. 11: Differences in threads diameter, pitch, presence of unthreaded portions allow
them to have diffrenc fucntional uses.

Fig. 13: Detail of a radial fracture treated with compression plate and screws. The screws
are placed securely in the bone. Note how the threads of the screws are placed in cortical
bone on both sides.

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Fig. 14: Left heel lateral radiograph. Fracture was reduced and fixated using three lag
screws. Note how threads are further apart and that the screws are placed in cortical
hole alone.

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Fig. 17: PA and lateral radiographs of the forearm. A radial fracture was submitted to
open reduction with internal fixation. Note the eccentrically placed screws (red mark)

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Fig. 18: Left - AP radiograph of pelvis showing a displaced pelvic fracture. Centre - AP
radiograph and - right - pelvic inlet radiograph showing fixation with two reconstruction
plates used to reduce and fixate the pelvic contour.

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Fig. 19: Left - 3D CT reconstruction of hardware material showing a plate fixated
with screws, fixating in a perpendicular direction to a single screw orientated postero -
inferiorly. Right - A single screw is placed perpendicular to the fracture line, providing a
greater compressive force on the fracture. A neutralization plate provides stabilization
from rotational and other forces.

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Fig. 20: Top-left: AP radiograph of the knee shows oblique fractures of the tibia and fibula.
Top-right and bottom-left shows fracture reduction and fixation with a buttress plate (also
known as "periarticular plates"). Bottom-right shows the formation of bone callus with
radiological consolidation.

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Fig. 21: AP clavicle radiograph. An infra-acromial hook is placed underneath the
acromium, being fixated to the clavicle with hooks.

Fig. 22: Pelvis AP radiograph shows bilateral Dynamic hip screws (DHS). There is
telescoping on the right (slim arrow) related to impacting of the fracture along the

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mechanical axis of the hip. On the left (fat arrow), there is no discernible telescoping of
the lag screw.

Fig. 23: AP and false profile incidence of the left hip. Three canulated lag screws were
applied to treat a subcapital hip fracture. This patient's left leg had been previously
amputated below the knew (not shown)

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Fig. 25: AP radiograph of the hip. On the right side, there is complete absence of the
femoral head and neck. The great trochanter "articulates" with the lateral ilium. This is
the typical appearance of a Girdlestone procedure.

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Fig. 24: AP radiograph of the left hip. This patient was treated with an intramedullary
locking nail also was placed cerclage wires. Many times these are employed to properly
align bone fragments found during surgery.

Fig. 26: AP knee radiograph and lateral knee radiograph. There is a transverse patellar
fracture treated with Kirschner wires and with tension band wiring. These transform
distraction forces into compressive forces

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Fig. 27: AP hip radiograph shows the presence of two enders nais. In the false profile
view (center) there's a radiolucent line in the cortical bone (blue arrow) in as well as
an increase in the density of the cortical bone. Femoral AP radiograph (right) shows a
fracture in the ender nail. This patient had had surgery many years ago.

Fig. 29: AP radiograph of the left hip (first from left); false profile (second from left);
AP and lateral femoral radiograph (third and fourth from left). Patient treated with an
intramedullary locking nail for a subtrocanteric fracture, currently consolidated.

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Fig. 28: AP (left top) and lateral (left bottom) tibial shaft radiograph immediately post-op.
An intramedullary locking nail was used due to a transverse fracture in the distal tibial
shaft. On the right, there's an AP (bottom) and lateral (top) radiographs 3 months after
surgery, showing callus formation.

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Fig. 30: AP pangonogram. Transarticular nail was used for joint arthrodesis. The knee
joint line was ressected. The nail is fixated to the tibial and femoral shaft by a screw.

Fig. 35: AP and lateral spine radiograph of the thoracic spine. Compression fracture of
D11. Presence of transpedicular screws connected to a rod system. The rod system itself
is connected by a bridge at T11. Note the presence of radiodence cement in L3.

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Fig. 33: TOP - Open mouth incidence (left) and lateral cervical spine radiograph show
fracture of the base of the odontoid with displacement. An Halo traction vest was placed.
There screws attached to the calvaria and to the thoracic skeleton (right). Bottom -
Definite Fracture fixation was made by placing screws in the lateral masses of C1 and
in the lamina of C2.

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Fig. 31: TOP: Lateral neck view (lateral, extension, flexion) and AP view. Patient
previously submitted to surgery with occipital plates due to basilary invagination,
posterior luxation of C2. There's an anterolystesis of C6 (grade II) as well as sclerosis
of the vertebral platforms. MIDDLE - T2W and T1W didn't show evident signs of
medullary compromise, even though the patient was symptomatic. BOTTOM - Sagital
reconstruction of CT shows reduction of the lystesis, fixation with plate and screws.

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Fig. 36: Patient submitted to surgery due to spondylolisthesis. LEFT: lateral incidence
radiograph of the lumbar spine; Center and right - CT with axial and sagittal
reconstruction. There are trasn-pedicular screws placed at L5 and S1 levels. The lamina
have been removed. There is also marked sclerosis of the intersomatic platforms at L5/
S1, as well as a "cage" between the somatic levels.

Fig. 32: TOP swimmer's incidence of the cervical spine and AP incidence of the cervical
spine. Posterior instrumentation with was performed with screws in the lateral masses,

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connected with parallel rods. Anteriorly there's a plate and fixating C4-D1. There is also
a bone graft replacing the vertebral bodies. CT scan sagittal MIP reconstruction (second
from left, TOP), sagittal CT reconstruction (third and fourth from left, top) shows detail
of bone graft, the positioning of the articular screws and the absence of the posterior
arches from C5 to C7.

Fig. 34: LEFT - Idiopathic scoliosis treated with posterior instrumentation. The parallel
rods extends from the cervical spine to the ilium, where a rod is inserted into the ilum.
The rods are interconnected with stabilizing bridge and are fixated t the spine via hooks.
RIGHT - Toracic instrumentation. The parallel rods are connected with two stabilizing
bridges. The rods are fixated to the vertebral column by laminar wires.

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Fig. 47: PA hip radiograph showing a right hip resurfacing. There is a metal "cap"
replacing only the femoral head with no endomedullary component. There has been
a slight collapse of the neck with leg shortening, protrusion and sclerosis of the small
trochanter indicating impaction.

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Fig. 9: 22 year old male, previously submitted to a knee resection due to sarcoma. A fully
constrained knee prosthesis with an extended femoral component is seen. The femoral
component shows bone resoption in a windshield wiper pattern, with regular contours,
indicating a mechanical loosening

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Fig. 12: Fibula and tibial fracture. The tibial fracture was reduced with intramedullary nail.
One of the screws is placed ellipse hole in the rod (blue arrow), allowing some degree of
impaction to occur in the weight bearing axis. On the right, bone callus is already formed
(red arrow)

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Fig. 15: (Left) Front knee radiograph shows a not recent inter-condylar fracture which
extended laterally. The condyles were fixated using lag screws (only the distal portion
acquires purchase). (Right) Lateral cervical radiograph. A canulated wire is placed from
the axis body to the odontoid tip. A not recent fracture is seen at the odontoid base.

Fig. 16: PA and lateral (first two from the left) radiograph shows sclerosis and joint space
narrowing between the lunate and capitate. There is also proximal capitate migration into
the space created by the scapholunate dissociation. The third and fourth from the left

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show an scaphoid excision with a four corner fusion achieved by using Herbert screws
to fixate the carpal bones

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Conclusion

The purpose of this review is to raise awareness to the finding of an orthopedic hardware
on an imaging study.

The great part of the Radiologist in the patient care chain lies in describing the significant
findings leading to diagnosis, either pre-operativelly or post-operativelly.

Follow up and sequential imaging is an essential part of this. Knowledge of the

surgical procedure and details of the material used are most helpful in correctly
achieving the diagnosis. When those are not readilly avaible careful descritption of subtle
radiolucencies, misalignements, bone segments connected to the hardware and the
hardware integrity will be a valuable contribution.

Personal information

F. M. G. S. Pereira da Silva - Radiology Resident

H. Donato - Radiology Resident

Professor Paulo Donato - Radiology Specialist

Professor Filipe Caseiro-Alves - Head of the Department

Medical Imaging Department

Faculty of Medicine - University Hospital of Coimbra

Coimbra, PORTUGAL

References

Allen AM, Ward WG, Pope TL, Jr. Imaging of the total knee arthroplasty. Radiologic
Clinics of North America 1995; 33:289-303

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Slone RM, McEnery KW, et al Principles of Spinal instrumentation. Radiologic Clinics of
North America 1995; 33:189-212

Slone RM, McEnery KW, et al Fixation Techniques and instrumentation used in the
cervical spine. Radiologic Clinics of North America 1995; 33:213-232

Slone RM, McEnery KW, et al Fixation Techniques and instrumentation used in

the thoracic, lumar and lumosacral spine. Radiologic Clinics of North America 1995;
33:213-232

Griffiths HJ, Priest DR, et al. Total hip replacement and other Orthopedic Hip procedures.
adiologic Clinics of North America 1995; 33:267-288

Harkess, J; Crockarell. Chapter 3- Arthroplasty of the Hip. Beaty & Canale - Campbell's
Operative Orthopaedics , Twelfth Edition, 158-31. Mosby, 2013

Mihalko WM; Chapter 7 - Arthroplasty of the Knee. Beaty & Canale - Campbell's
Operative Orthopaedics , Twelfth Edition, 376-444. Mosby, 2013

University of Washington - Department of Radiology. Online MSK Textbook -

Orthopedic Hardware. http://www.rad.washington.edu/ academics/ academic-sections/
msk/ teaching-materials/ online-musculoskeletal-radiology-book/ orthopedic-hardware
(6/1/2014)

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