RADIOGRAPH EVALUATION

FOR THA
Dr. Ahmed Altaei
Orthopedic Trainee
Arab Board Of Health Specialty
 SUCCESSFUL RESULT

Post operative increase in harris hip score of > 20 points

Radiographically stable implant

No additional femoral reconstruction

<70 70 – 79 80-89 90 -100

Excellen
Poor Fair Good
t
Marchetti P, Binazzi R, Vaccari V, Girolami M, Morici F,
Impallomeni C, Commessatti M, Silvello L. Long-term
results with cementless Fitek (or Fitmore) cups. J
Arthroplasty. 2005 Sep;20(6):730
Radiographic follow-up of total
hip arthroplasty

Short term Long term

complications complications
• Component • Component
malposition loosening
• Adequacy of • Infection
fixation. • Fracture.
FOLLOW-UP RADIOGRAPHS
Initial (postoperative ) radiographs

• Leg length.
• Acetabular and femoral positioning.
• Cement mantle adequacy.
• Used for reference.

Follow-up radiographs

• Changes in the appearance of the

components and bone (impending failure) .
• Signs of component failure.
RADIOGRAPHIC VIEWS

anteroposterior (AP) pelvic

radiograph
• hips in extension and maximal internal rotation.

Lateral radiograph of the hip .

• Assess AP positioning of femoral components
• Cement mantle
RADIOGRAPHIC VIEWS

White and Dougall

 INITIAL RADIOGRAPH OVERVIEW:
STEP BY STEP APPROACH
Radiograph details
• patient details
2. Acetabular 3. Acetabular
• anteroposterior (AP) and 1. Leg length
lateral views inclination version

5. Femoral stem
inclination
4. Acetabular 6. Femoral stem 7. Femoral stem tip
(varus/valgus
cement mantle version positioning
angulation and AP
angulation)

9. Cement 10. Cement

8. Femoral stem
interdigitation with interdigitation with
cement mantle
bone in acetabulum bone in femur
TYPES OF PROSTHESIS

Cemented

Cementless

Hybrid or reverse
hybrid.
 Exeter cemented
stem (Stryker)

Charnley cemented
stem (Depuy)

Corail cementless
stem (Depuy).
LEG LENGTH INEQUALITY
Mean =
common up to 27%
15.9 mm

50% =1 cm = >1 cm, 15-20%

acceptable = shoe orthosis.

leading causes of
lawsuits in the USA.
LEG LENGTH INEQUALITY

Woolson
ACETABULAR COMPONENT
POSITION

The orientation of the acetabular component

• Inclination
• Anteversion
Acetabular inclination
• angle between the face of the cup and the transverse
axis.
ACETABULAR INCLINATION
ACETABULAR ANTEVERSION

angle between the acetabular axis

and the coronal plane.

Done using a true lateral

radiograph.
AP RADIOGRAPH
Component has a radio-opaque marker wire

• The wire appears as an ellipse on the AP view.

• Measurement of ratios between maximum and minimum
elliptical diameter are input into mathematical tables to
give an anteversion angle.
• Einzel-bild-roentgen-analysis describes an even more
complex method of determining anteversion by comparing
two radiographs and referencing seven points along the
ellipse.

Cementless

• Looking at the inferior and superior edges of the cup; if

sharp this infers no version as the cup is being viewed dead
on, but if rounded some version is present, although this
does not discern between ante- or retroversion.
ACETABULAR ANTEVERSION

McCollum and Grey suggest safe ranges

of inclination between 30-50o and
anteversion of 20-40o.

Biedermann radiological inclination of

45o and anteversion of 15o were
associated with the lowest risk of
dislocation.

D’Lima et al demonstrate best range of

motion acetabular inclination of 45-55o
 FEMORAL STEM POSITION

The aim of femoral stem positioning is to place the stem in a

neutral position within the shaft and allow slight anteversion of
the neck.

varus malpositioning
• 46% failure with 16 year follow-up has been reported for cemented prostheses.
• Loosening of cementless prostheses .

Femoral anteversion is an important factor in allowing adequate

flexion of the hip(10-15o).

combined femoral and acetabular anteversion angle that is

associated with dislocation. ( combined anteversion angle of
50o).
Femoral stem in slight varus
ASSESSING THE CEMENT MANTLE

Deficient cement mantles = aseptic loosening and failure .

Cement mantle fracture =result of deficiencies = allow wear debris to

migrate along the cement- prosthesis interface and reach the cement-
bone interface= lead to osteolysis and loosening.

cement-bone interface and the cement-prosthesis interface.

Lucent areas around the cement-bone interface are common in both

the acetabular (normally superolateral) and femoral components.
 SYSTEM FOR ASSESSING THE
CEMENT MANTLE

Charnley-Delee
Gruen zones
zones.
OPTIMAL THICKNESS OF THE
CEMENT
Acetabular cement mantle of 3 mm (absolute value) thick gave

• The best strain characteristics

• Reduced the risk cement cracking
• Hence loosening.

78% of components were eccentrically placed with increasing mantle

thickness from zone 1 to 3, and that achieving the ideal acetabular
cement mantle was difficult.

Complete femoral cement mantles of 2-3 mm thickness

Cemente- bone deficiencies in the immediate period postoperatively

may not be the result of loosening, but rather due to not all cancellous
bone having been removed at the time of surgery
 CEMENTLESS COMPONENTS

Alignment of components.

Assessing the initial fixation of cementless

components is more difficult.

Unlikely to show any obvious bony defects

Assessing fixation is really only possible with

serial x-ray follow-up.
 RADIOGRAPHIC FOLLOW-UP

 AP and lateral x-rays at 1 year, 5

years, and each subsequent 5 years
following surgery
1. Wide (>2 mm) radiolucent zone at the cement-bone or metal-bone
interface
2. Progressive radiolucent zone at the metal-cement interface
3. Well delineated radiolucencies at the cement-bone or metal-bone
interface: granulomatous disease
4. Endosteal sclerosis at the tip of the femoral stem (pedestal sign):
undetermined significance, but might indicate loosening if
associated with other signs
5. Progressive metal bead shedding
6. Subsidence of >10 mm/progressive tilting of femoral component
7. Migration of acetabular cup
8. Cement fracture
9. Asymmetric position of the femoral head within the acetabular
component: dislocation/deformity/disruption of the acetabularliner

RED FLAGS FOR COMPONENT FAILURE

 PERIPROSTHETIC LUCENCY
Cemented components
• lucencies are common
• may be normal variations relating to surgical technique in the
case of component-prosthesis interface, or bone reaction to
cement in the case of cement-bone interface.
• Normal lucencies are often found in the proximal lateral aspect
of the stemecement interface (zone 1), and a <2 mm lucency
surrounding the cement mantle running parallel to the stem
(which results from a stable fibrous reaction to the cement).
• Lucencies >2 mm in thickness or progression of defects may be
indicative of loosening or infection
• Well demarcated, progressive areas of lucency at the cement-
bone interface may indicate infection or granulomatous disease
= chronological comparison of films
Charnley (depuy) stem
showing lucencies indicative of
loosening around the cement
bone interface, plus loosening
and migration of acetabular
cup.
PERIPROSTHETIC LUCENCY
CEMENTLESS COMPONENTS

• Lucent areas surrounded by sclerotic lines are characteristic of

femoral cementless stem loosening.
• Lucencies are often less common with acetabular component
loosening, the component seen to migrate first instead.
• Radiolucent lines on plain x-ray are described by Skinner et al as
lucent lines at least 2 mm wide and occupying at least 30% of any one
Gruen zone.
• Previous work has shown that lucencies, radiolucent lines, and
vertical migration are reliable indicators of aseptic loosening.
• Skinner et al also describe the development of asymptomatic non-
progressive lucent lines in some cases.
• A thin line <2 mm surrounding the prosthesis delineated by a
sclerotic margin and non-progressive after 2 years can be considered
normal.
Superolateral lucancydcorail
(depuy) stem. Periacetabular
lucent line.
 MIGRATION OF COMPONENTS
During the first 2 years following surgery it may be normal for some
types of prosthesis to subside.

The collarless, polished, tapered design of stem ( Exeter -Stryker)

specifically designed biomechanically to subside into its cement
mantle utilising the force-cast mechanical principle of fixation.

Subsidence of 1-2 mm is often seen superolaterally

Uncemented stems may also subside during the initial

postoperative months, but any progressive movement beyond 2
years or 10 mm is thought to be abnormal
Exeter stem (stryker) showing
characteristic vertical subsidenced gap
seen at superolateral edge of stem
cement interface.
OTHER BONE REACTION
PHENOMENA
Stress shielding

• Fixation of a prosthesis will alter the forces transmitted

through the acetabulum and proximal femur, and
hence may well lead to areas of abnormal or lessened
bone remodelling hence, stress shielding.
• Certain types of prosthesis transmit force by bypassing
areas of bone, therefore leading to a relative osteopenia
in these areas.
• commonly, this occurs with cementless components in
the superomedial acetabulum and the
proximalemedial femur.
• The process of bone loss relating to stress shielding
generally occurs within the first 2 years following
surgery and implies that the prosthesis is well fixed; the
long term implications are unknown
Cementless cup showing stress shielding superomedially.
Left: immediate postoperative film; right: 2 years
postoperatively.
 SCLEROTIC REACTION

Bony sclerosis can occur surrounding the prosthesis =bone in/on growth.

Spot welds are small areas of sclerosis originating from the endosteal surface
and abutting the femoral stem= strong indicators of stability.

Cortical thickening of the femoral shaft may also occur as a reaction to the stem
at point of contact= indicting good fixation.

A bone pedestal is a transverse sclerotic line below the tip of a cementless stem.
It is sometimes but not always associated with loosening and therefore careful
evaluation and sequential review of follow-up x-rays is advised.
CEMENTLESS STEM SHOWING SPOT WELD (LEFT),
AND PEDESTAL
(RIGHT)
ACETABULAR WEAR

In the assessment of polyethylene acetabular

components, linear wear can be assessed on a plain AP
radiograph.

The thickness of the acetabular component is seen as

symmetrical around the femoral head, with the femoral
head sitting in the centre of the acetabular component.

As the component wears out the femoral head may well

sit asymmetrically within this, indicating wear. This
may be less easy to see in a metal backed cementless
acetabular component.
Cemented acetabular component showing eccentric
positioning of femoral head, indicating linear wear
PERIPROSTHETIC FRACTURE OR
DISLOCATION
important to recognise the unique surgical problem surrounding such
injuries.

Vancouver classification of periprosthetic hip fractures which is helpful in

deciding management.

importance of component position for risk of dislocation.

Recognising a frank total hip arthroplasty dislocation is often easily

apparent clinically and radiologically.

The acetabular liner of a modular acetabular liner can also dislocate and
this may not be as easily identifiable

look for asymmetry between the liner and femoral head.

RADIOGRAPHIC FEATURES NOT TO
MISS
Gross component
malposition

Periprosthetic Lucency >2 mm or

fracture progressive

Dislocation Cement fracture

 MAIN MESSAGES
Have a systematic approach to assessing a radiograph

Be aware of the diversity of implants available

Compare radiographs over time

Do not miss signs of component failure

SELF ASSESSMENT QUESTIONS
(TRUE/FALSE)
The AP pelvic radiograph is taken with the legs in slight external
rotation.

Acetabular inclination angles of >50° are associated with

dislocation.

Charnley and Delee described cement mantle zones surrounding

the femoral prosthesis.

Varus malposition of the femoral stem is associated with

loosening.

Lucent lines surrounding a cementless prosthesis are always

symptomatic and progressive.
THANK YOU