Laboratory Studies

Laboratory evaluation prior to any surgical intervention should include a complete blood count (CBC), coagulation studies, and routine chemistries. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are useful, especially in excluding indolent infection. In cases where infection is a serious consideration, preoperative aspiration may also prove helpful in further evaluation.

Radiography

Standard anteroposterior (AP) hip and pelvis views and frog-leg lateral views are central to the evaluation of acetabular wear in total hip arthroplasty (THA). Most information can be gathered from these views. Serial radiography over time confers additional information regarding wear and prosthetic loosening.

In the setting of significant osteolysis, additional views may be helpful in defining the extent of these lesions and the extent of any bony deficiencies. These include Judet oblique views to evaluate the integrity of both the anterior and posterior columns and the false profile view and sitting lateral view.

Derbyshire et al described a two-dimensional (2D) radiographic wear measurement system that enables the low wear of highly cross-linked polyethylene cups to be accurately measured from standard pelvis radiographs.^[23]

Computed Tomography

Computed tomography (CT) may provide supplemental information regarding the pelvis and help differentiate contained bony deficiencies from significant pelvic discontinuity.

Devane et al described a computer-assisted method that uses models of the patient's bones and components built from a single CT scan to measure migration and polyethylene wear.^[24]

Bone Scanning

Although bone scintigraphy has been available for more than 30 years, it plays a limited role in the evaluation of a painful hip prosthesis. The main determinants of technetium (Tc)-99m methylene diphosphate (MDP) tracer uptake in bone are blood flow and metabolic bone activity. Increased tracer uptake may be observed for 12-24 months after implantation of a total hip prosthesis because of bone remodeling.

The appearance of abnormal uptake surrounding a painful prosthesis has been used to differentiate loosening from infection. Loose prostheses tend to show increased uptake in the trochanters, at the stem tip, and possibly the acetabular shell. Bone scintigraphy is sensitive for infection but lacks specificity.^[25]

Gallium scanning may be useful in the assessment of infection. Gallium binds to serum transferrin and carries an accuracy of 75% in detecting a periprosthetic infection. It has more intense uptake than Tc-99m MDP, and combining these tests may be effective in the evaluation of a painful prosthesis.

Indium-labeled white blood cells (WBCs) accumulate in the region of infection because of chemotaxis. Mixed WBC lines are used in the preparation and may account for the similar sensitivity for acute and chronic infections of 82%.

Treatment & Management

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Media Gallery

Acetabular wear in total hip arthroplasty. Cementless total hip arthroplasty in a 60-year-old woman with osteoarthritis.
Acetabular wear in total hip arthroplasty. Woman who underwent cementless total hip arthroplasty for osteoarthritis at age 60 years, 6 years following the index arthroplasty. This image demonstrates eccentric polyethylene wear, osteolysis, and a protrusio defect. The stem appears to be well fixed.
Acetabular wear in total hip arthroplasty. Lateral radiograph of the left hip of woman who underwent cementless total hip arthroplasty for osteoarthritis at age 60 years, 6 years following the index arthroplasty. She has eccentric polyethylene wear, osteolysis, and a protrusio defect. The stem is well fixed.
Acetabular wear in total hip arthroplasty. Intraoperative photograph of retrieved specimens at the time of revision arthroplasty. The specimens demonstrate both mode 1 and mode 2 wear.
Acetabular wear in total hip arthroplasty. Intraoperative photograph of retrieved specimens at the time of revision arthroplasty. The specimens demonstrate both mode 1 and mode 2 wear.

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Author

Hari P Bezwada, MD Staff Physician, Department of Orthopedic Surgery, Drexel University College of Medicine

Hari P Bezwada, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pennsylvania Orthopaedic Society

Disclosure: Nothing to disclose.

Coauthor(s)

David G Nazarian, MD Assistant Clinical Professor, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine

David G Nazarian, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Robert E Booth, Jr, MD Medical Director of Total Knee Replacement and Revision, Jefferson Health 3B Orthopaedics

Robert E Booth, Jr, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, The Knee Society

Disclosure: Received consulting fee from Zimmer for consulting. for: Zimmer Biomet.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

B Sonny Bal, MD, JD, PhD, MBA CEO and President, SINTX Technologies, Salt Lake City, UT

B Sonny Bal, MD, JD, PhD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SINTX Technologies.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University Grossman School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

Jegan Krishnan, MBBS, FRACS, PhD Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Flinders Private Hospital

Jegan Krishnan, MBBS, FRACS, PhD is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.