Skip to main content
NCBI home page
The Journal of Bone and Joint Surgery. American Volume logoLink to The Journal of Bone and Joint Surgery. American Volume
. 2012 Nov 21;94(22):2097–2105.

Monitoring and Risk of Progression of Osteolysis After Total Hip Arthroplasty

Michael D Ries 1, Thomas M Link 2
PMCID: PMC3497905  PMID: 23310970

Osteolytic lesions may develop after total hip arthroplasty from a biologic reaction to particulate debris. Loss of bone results from osteoclastic resorption and can be seen on radiographs as cystic lesions or radiolucent regions in proximity to the femoral and acetabular components. Osteolysis may be associated with pain, particularly if bone loss results in decreased mechanical support for the prosthetic components and implant loosening. However, osteolysis may also be asymptomatic and only detected with radiographic or other imaging modalities.

Radiographs

Osteolytic lesions usually appear on radiographs as well-demarcated, scalloped areas of bone loss. Osteolysis can be differentiated from bone loss resulting from stress-shielding, which causes more diffuse trabecular thinning. Stress-shielding is also typically associated with an area of sclerosis and cortical thickening below the area of osteopenia or trabecular thinning. Osteolytic lesions may mimic bone loss due to infection, which should be considered in the differential diagnosis.

Since radiographs show a two-dimensional image of a three-dimensional structure, anteroposterior and lateral views should be made to provide the most accurate assessment of the lesion size and location. Radiographs are useful as a screening tool to detect osteolysis, but may not accurately delineate the lesion size. Shon et al., using radiographs to detect periacetabular osteolysis in comparison with computed tomography (CT), found a sensitivity of only 57.6% but a specificity of 92.9%1. The use of oblique radiographs increased the sensitivity to 64% without changing the specificity. Other authors have similarly observed a higher specificity than sensitivity with use of radiographs to assess osteolysis2,3.

Cross-Sectional Imaging

CT or magnetic resonance imaging (MRI) can be used to supplement the information obtained from radiographs. These imaging modalities can provide cross-sectional images of the osteolytic lesions, and are indicated when radiographs do not provide adequate visualization of the lesion size, location, or progression for clinical decision making. MRI and CT images can be distorted by metal artifact from the adjacent prosthetic components. However, the use of metal artifact reduction protocols permits better visualization of the periprosthetic bone and soft tissues than with conventional CT or MRI protocols. CT is faster, and acceptable visualization of osteolytic lesions is achieved by modifying standard CT protocols. MRI requires more challenging protocol changes or use of new sequences, which are not uniformly available. In general, if we are more concerned with an osteolytic lesion without soft-tissue extension, we make a CT scan; if the lesion is primarily in soft tissue or involves soft-tissue extension of an osteolytic lesion, then we prefer MRI.

Acetabular Lesions

Acetabular osteolytic lesions typically develop around the dome or screw-holes of the acetabular component and in proximity to the cup rim, where particulate debris from the bearing surface tends to migrate4,5 (Fig. 1). The location and size of the defects affects treatment. Medial acetabular defects, which do not compromise the osseous support around the periphery of the cup, can be effectively treated with revision to a cementless hemispheric component with screw fixation and medial acetabular bone-grafting (Fig. 2). Although the cup shown in Figure 2 was well fixed, symptoms of hip pain occurred in association with osteolysis. This is likely related to synovitis and effusion that can develop in response to ultra-high molecular-weight polyethylene (UHMWPE) wear debris. If the shell is well fixed and in good position, liner exchange and bone-grafting of the osteolytic lesions is an attractive alternative to cup revision since this does not risk further bone loss during acetabular component removal6.

Fig. 1.

Fig. 1

Open in a new tab

Anteroposterior radiograph demonstrates an osteolytic lesion around a screw and dome hole (arrows).

Fig. 2.

Fig. 2

Open in a new tab

Anteroposterior radiograph demonstrates a large osteolytic defect in the medial aspect of the acetabulum in a patient who developed hip pain in association with osteolysis. However, the superior bone stock (area between the arrows) was well maintained. Revision was performed to treat symptomatic osteolysis and prevent further bone loss with a cementless cup, screw fixation, and morselized bone-grafting in the medial acetabular defect.

Superior or posterior acetabular defects that may compromise mechanical support for the acetabular component in weight-bearing regions should be treated surgically (Fig. 3). In comparison with the osteolytic lesion shown in Figure 2, which is a large medial acetabular defect with relative preservation of superior supporting bone, the lesion shown in Figure 3 illustrates marked narrowing of the superior supporting bone stock. The lesion shown in Figure 3 should be treated urgently, whereas surgical treatment of the lesion shown in Figure 2 could be delayed if necessary. Osteolysis leading to further loss of superior or posterior bone stock can result in massive segmental bone loss and requires more extensive revision procedures with use of metal augments or structural bone grafts to restore mechanical support of the acetabular component.

Fig. 3.

Fig. 3

Open in a new tab

Anteroposterior radiograph demonstrates osteolysis in the medial aspect of the acetabulum extending into the superior bone stock. The cup was well fixed with bone ingrowth. A narrow pillar of bone remains (between arrows) providing fixation for the cup (Reproduced, with permission of Elsevier, from: Bozic KJ, Ries MD. Wear and osteolysis in total hip arthroplasty. Sem Arthroplasty.2005;16:142-52. Copyright 2005. http://www.sciencedirect.com/science/journal/10454527).

The decision to treat osteolytic lesions around well-fixed acetabular components surgically or to observe them is made on the basis of the presence or absence of symptoms, as well as the size, location, and rate of progression of the defect. However, the relative urgency of surgical treatment is based on the potential adverse consequences of nonoperative treatment. Two types of catastrophic clinical problems can be encountered with prolonged observation of osteolytic periacetabular defects. These are (1) loss of superior supporting bone resulting in a segmental acetabular bone defect, which converts a contained or cavitary bone defect into a more severe, uncontained segmental defect, and (2) loss of anterior and posterior column support, which results in a pelvic discontinuity (Figs. 4-A and 4-B).

Fig. 4-A. An active fifty-one-year-old woman with rheumatoid arthritis who presented with hip pain twenty years after total hip arthroplasty.

Fig. 4-A

Open in a new tab

Anteroposterior pelvic radiograph of the left hip shows extensive osteolysis with massive superior segmental acetabular bone loss (arrows), resulting in implant loosening, superior migration of the acetabular component, and pelvic discontinuity.

Fig. 4-B. An active fifty-one-year-old woman with rheumatoid arthritis who presented with hip pain twenty years after total hip arthroplasty.

Fig. 4-B

Open in a new tab

An axial CT section just proximal to the acetabular component demonstrates cavitary and cortical anterior column bone loss.

Superior supporting bone stock can be visualized on an anteroposterior radiograph (Figs. 2 and 3), while visualization of the osseous support of the posterior and anterior columns can be obscured by the metallic acetabular shell and may not be visualized well on an anteroposterior radiograph. Use of Judet radiographs and CT or MRI should be considered to assess the integrity of the posterior and anterior columns. For patients at risk of developing loss of superior or posterior osseous support of the acetabular cup or development of pelvic discontinuity, surgical treatment is indicated.

Femoral Lesions

Femoral lesions typically occur in proximity to the bearing surface along the calcar or greater trochanter. Trochanteric lesions may compromise the mechanical integrity of the greater trochanter, leading to fracture and loss of hip abductor muscle function (Fig. 5). Progressive osteolysis of the greater trochanter, which weakens the bone and may lead to a fracture, is an indication for femoral head and acetabular liner exchange with bone-grafting of the osteolytic lesion. If a fracture of the greater trochanter occurs and it is nondisplaced, nonoperative treatment can result in healing.

Fig. 5.

Fig. 5

Open in a new tab

Anteroposterior radiograph of the right hip of a sixty-two-year-old woman, made fourteen years after total hip arthroplasty when she presented with lateral hip pain and abductor weakness resulting from trochanteric osteolysis and spontaneous fracture of the greater trochanter.

Wear debris that reaches the distal femoral component along the bone-implant interface or the so-called effective joint space may lead to the development of periprosthetic femoral fracture7. Osteolysis that compromises the structural integrity of the femoral cortex in proximity to the stem tip, where stress transfer from the implant to bone is high, is a particular risk factor for fracture at or near the stem tip. We consider osteolysis that results in narrowing the thickness of one femoral cortex to one-half or less than its normal width in proximity to the stem tip to be a substantial risk for periprosthetic femoral fracture and an indication for surgery (Fig. 6).

Fig. 6.

Fig. 6

Open in a new tab

Anteroposterior radiograph of the right hip of a sixty-eight-year-old man, made twelve years after a total hip arthroplasty, who developed osteolysis around a cementless femoral stem. An area of cortical thinning and expansion of the medial femoral diaphysis at the stem tip represents a stress-riser that can lead to periprosthetic fracture.

The rate of development and progression of osteolytic lesions is variable. The relative rate of osteolytic progression is evaluated most effectively when viewed on serial radiographic examinations (Figs. 7-A and 7-B). When an osteolytic lesion that may increase in size and could lead to periprosthetic fracture or loss of structural support for the prosthetic components is detected radiographically, we make a follow-up radiograph four months later and a subsequent radiograph four to six months after the second radiograph to determine the relative rate of progression or stability of the lesion.

Fig. 7-A. An active fifty-seven-year-old woman who had bilateral total hip arthroplasty.

Fig. 7-A

Open in a new tab

Anteroposterior radiograph, made nine years postoperatively, demonstrates small trochanteric osteolytic lesions (arrows).

Fig. 7-B. An active fifty-seven-year-old woman who had bilateral total hip arthroplasty.

Fig. 7-B

Open in a new tab

Fourteen years after the bilateral total hip arthroplasty, the patient remained active and asymptomatic, but the left trochanteric lesion had increased in size and a medial acetabular lesion had developed (arrows).

Computed Tomography

Most CT scanners are now multidetector CT scanners and provide three-dimensional volumetric datasets that can be reconstructed in any imaging plane; coronal and sagittal reformations are standard, but three-dimensional reformations, maximum intensity projections, and other, more sophisticated image reconstructions may be made. CT images are grossly distorted around cobalt-chromium and stainless-steel implants, whereas artifacts around titanium implants are relatively mild.

Various techniques are available to suppress metal artifacts with use of CT imaging. In a standard clinical setting, use of a multidetector CT scanner and an increase in exposure dose (milliampere-seconds [mAs]) have been advocated8. In addition, higher peak voltage (kilovolt peak [kVp]) and narrower collimation have been used with smooth or standard reconstruction filters and thicker reconstructed sections to reduce metal artifacts8-10. Also, an extended CT scale, which allows an expansion of the Hounsfield scale from a standard maximum window of 4000 HU to 40,000 HU, is available on some scanners. This technique makes use of the fact that metals have high linear attenuation coefficients that lie outside the normal range of reconstructed CT numbers; most metallic implants are in the range of 8000 to 20,000 HU, whereas the standard upper limit of CT scanners is 4096 HU11. More advanced techniques use complicated image data processing algorithms by ignoring or interpolating the metallic objects in the raw data12. These techniques, however, are research applications and not established in clinical routine.

CT scans with metal artifact reduction techniques have been used successfully to quantitate the size of periacetabular osteolytic lesions13-16. Howie et al. used CT to assess osteolytic lesions after total hip arthroplasty and found considerable variation in the rate of progression of osteolysis17. Factors associated with progression of the lesions included high wear rate, high patient activity level, large-diameter heads, and a lesion size of >10 cm3. However, in comparison with radiographs, the use of CT is associated with increased radiation exposure and cost. Therefore, CT scanning should generally be used in addition to radiographs when indicated to better delineate the extent and location of bone loss.

We use CT to better determine if or when surgery is indicated in the treatment of periprosthetic osteolysis. For acetabular lesions, CT is used to assess the integrity of the anterior and posterior columns and the posterior acetabular wall since this area is not well visualized on radiographs. For femoral lesions, CT is helpful in determining the structural integrity of the greater trochanter and femoral diaphysis. CT scanning is also helpful in delineating areas of remaining bone stock when planning surgical reconstruction. CT permits three-dimensional reconstructions, which are typically utilized in planning for the use of custom triflange acetabular components to salvage massive acetabular bone loss and pelvic discontinuity (Figs. 4-A and 4-B).

Magnetic Resonance Imaging

MRI is an attractive alternative to CT since there is no ionizing radiation exposure with MRI. However, metal, particularly cobalt chromium and stainless steel, substantially impacts image quality of MRI scans because of susceptibility artifacts. Factors that affect artifacts on MRI scans include the composition of the metallic implant, the orientation of the implants in relation to the direction of the main magnetic field, the strength of the magnetic field, the pulse sequence type, and other imaging parameters (mainly, voxel size, which is determined by the field of view, image matrix, section thickness, and echo train length)8. To reduce metal artifacts, the use of lower field strength has been recommended as higher field strength increases susceptibility artifacts. Studies have used 0.2 to 0.3-T systems; this, however, impacts image quality because of a low signal-to-noise-ratio, which may produce blurry images, providing limited anatomic detail18. With use of high-field systems, improvement of image quality may be achieved by increasing bandwidth. Also, a small field of view with a high-resolution matrix, thin sections, and high gradient strength can help to reduce metal-related artifacts8. Instead of frequency-selective fat saturation, other techniques of fat saturation such as use of short tau inversion recovery sequences have been recommended. Recently, specific metal suppression sequences have been developed; among these, multi-acquisition with variable resonance image combination (MAVRIC) hybrid sequences have shown promising results in reducing artifacts and providing high-quality images near total joint replacements in a clinical setting19,20 (Figs. 8-A and 8-B).

Fig. 8-A. A forty-seven-year-old woman who had a metal-on-metal resurfacing of the left hip.

Fig. 8-A

Open in a new tab

Anteroposterior radiograph of the pelvis, made five years postoperatively, shows osteolysis superior to the acetabular component (arrow).

Fig. 8-B. A forty-seven-year-old woman who had a metal-on-metal resurfacing of the left hip.

Fig. 8-B

Open in a new tab

Axial fat-saturated metal and fat-suppressed MRI (MAVRIC) scan of the left hip, acquired at the same time, shows osteolytic changes anterior and superior to the acetabular component (arrows).

Potter et al. utilized metal artifact reduction protocols with MRI to assess bone and soft-tissue lesions after total hip arthroplasty21. Osteolysis, synovitis, trochanteric bursitis, and loosening have been effectively visualized on MRI with these techniques (Figs. 8-A and 8-B)22. Walde et al. compared the accuracy of radiographs, CT, and MRI in assessing periacetabular osteolytic lesions using a cadaver model23. The sensitivity for detecting lesions was 51.7% for radiography, 74.7% for CT, and 95.4% for MRI. The sensitivity increased with increasing lesion size for all three methods, and MRI was the most effective in detecting small lesions.

Metal-on-metal resurfacing or total hip arthroplasty can produce both osteolytic lesions in bone and so-called soft-tissue pseudotumors. Pseudotumors, which have been associated with an adverse local tissue reaction, can develop in soft tissue and are not well visualized on radiographs. The pseudotumors may be filled with fluid and are effectively visualized on MRI24 (Fig. 9). Ultrasound is also useful for detecting soft-tissue masses and can help to delineate soft-tissue pseudotumors after metal-on-metal total hip arthroplasty25. However, ultrasound is not effective for detecting osteolytic bone lesions.

Fig. 9.

Fig. 9

Open in a new tab

A sixty-two-year-old woman presented with right hip pain and massive thigh swelling four years after metal-on-metal total hip arthroplasty. Radiographs demonstrated a lucency around the acetabular component without apparent osteolysis. A sagittal T1-weighted MRI scan demonstrates a large soft-tissue cyst originating from the hip joint and extending into the posterior aspect of the thigh (arrows).

Monitoring Osteolysis

Osteolysis is related to many factors, but primarily it is affected by wear volume, which increases with use and patient activity. As expected, younger and more active male patients have a greater risk of developing osteolysis26. It takes time to produce the wear debris, and osteolysis is uncommon before five years after arthroplasty, whereas the risk increases after ten years27. Wear is also affected by the bearing surface materials used. Highly cross-linked UHMWPE wears less, and the risk of osteolysis is less compared with conventional UHMWPE27. UHMWPE that was gamma-irradiated in air was discontinued by most manufacturers in the mid-1990s because of oxidation and increased particle debris generation, and it was replaced with non-gamma-irradiated in air sterilization methods. Many of these implants continue to be in use and may generate higher rates of wear and osteolysis than those with highly cross-linked UHMWPE.

Highly cross-linked UHMWPE has been used in large numbers in total hip arthroplasty for over ten years with excellent clinical results. However, since the long-term results with use of highly cross-linked UHMWPE have not been established, routine monitoring of this patient population for wear and osteolysis is appropriate. Patients at higher risk of developing osteolysis, such as those with non-cross-linked UHMWPE and young, active patients, should be monitored more closely. We recommend that patients have a radiograph of the hip made every two to three years, beginning five years following total hip arthroplasty. If osteolysis is detected, then repeat radiographs at four to six months are helpful to determine the rate of progression of the lesion and if surgical intervention is necessary. If the lesion size and location seen on radiographs suggest that clinical failure of the implant may develop or additional quantitative measurements of the lesion are needed, then CT or MRI scans with metal artifact suppression should be acquired. Once a lesion develops, the rate of progression is best determined with serial radiographs and may require serial CT scans15.

Overview

Osteolysis after total hip arthroplasty develops in response to particulate wear debris and may not be associated with clinical symptoms. Osteolysis is associated with more particulate wear debris and greater wear volume. Wear increases with use and activity of the joint, so patients having longer in vivo use of their total hip replacement are at increased risk of developing osteolysis. Patients with non-cross-linked UHMWPE and younger, more active patients are at greater risk of developing osteolysis.

We recommend routine monitoring for osteolysis at five years after total hip arthroplasty, with a radiograph made every two to three years thereafter. Patients at greater risk of developing osteolysis should be monitored more closely. Once a lesion is seen radiographically, serial radiographs help to determine the relative rate of progression of the lesion. CT with metal artifact reduction can be used effectively to quantitate the lesion size and location. MRI can be used to visualize osteolytic areas as well as soft-tissue pathology. Both MRI and CT with metal artifact reduction protocols have been developed to effectively visualize osteolytic lesions in proximity to total hip arthroplasty implants and to provide supplemental information to radiographs.

Supplementary Material

Supporting Data

Disclosure of Potential Conflicts of Interest

Footnotes

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

References

  • 1.Shon WY, Gupta S, Biswal S, Han SH, Hong SJ, Moon JG. Pelvic osteolysis relationship to radiographs and polyethylene wear. J Arthroplasty. 2009 Aug;24(5):743-50 Epub 2008 Jun 13 [DOI] [PubMed] [Google Scholar]
  • 2.Puri L, Wixson RL, Stern SH, Kohli J, Hendrix RW, Stulberg SD. Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty. J Bone Joint Surg Am. 2002 Apr;84-A(4):609-14 [DOI] [PubMed] [Google Scholar]
  • 3.Kitamura N, Pappedemos PC, Duffy PR, 3rd, Stepniewski AS, Hopper RH, Jr, Engh CA, Jr, Engh CA. The value of anteroposterior pelvic radiographs for evaluating pelvic osteolysis. Clin Orthop Relat Res. 2006 Dec;453:239-45 [DOI] [PubMed] [Google Scholar]
  • 4.Stamenkov RB, Howie DW, Neale SD, McGee MA, Taylor DJ, Findlay DM. Distribution of periacetabular osteolytic lesions varies according to component design. J Arthroplasty. 2010 Sep;25(6):913-9 Epub 2009 Sep 23 [DOI] [PubMed] [Google Scholar]
  • 5.Kitamura N, Naudie DD, Leung SB, Hopper RH, Jr, Engh CA., Sr Diagnostic features of pelvic osteolysis on computed tomography: the importance of communication pathways. J Bone Joint Surg Am. 2005 Jul;87(7):1542-50 [DOI] [PubMed] [Google Scholar]
  • 6.Maloney WJ, Herzwurm P, Paprosky W, Rubash HE, Engh CA. Treatment of pelvic osteolysis associated with a stable acetabular component inserted without cement as part of a total hip replacement. J Bone Joint Surg Am. 1997 Nov;79(11):1628-34 [DOI] [PubMed] [Google Scholar]
  • 7.Schmalzried TP, Jasty M, Harris WH. Periprosthetic bone loss in total hip arthroplasty. Polyethylene wear debris and the concept of the effective joint space. J Bone Joint Surg Am. 1992 Jul;74(6):849-63 [PubMed] [Google Scholar]
  • 8.Lee MJ, Kim S, Lee SA, Song HT, Huh YM, Kim DH, Han SH, Suh JS. Overcoming artifacts from metallic orthopedic implants at high-field-strength MR imaging and multi-detector CT. Radiographics. 2007 May-Jun;27(3):791-803 [DOI] [PubMed] [Google Scholar]
  • 9.Buckwalter KA, Lin C, Ford JM. Managing postoperative artifacts on computed tomography and magnetic resonance imaging. Semin Musculoskelet Radiol. 2011 Sep;15(4):309-19 Epub 2011 Sep 16 [DOI] [PubMed] [Google Scholar]
  • 10.Buckwalter KA. Optimizing imaging techniques in the postoperative patient. Semin Musculoskelet Radiol. 2007 Sep;11(3):261-72 [DOI] [PubMed] [Google Scholar]
  • 11.Link TM, Berning W, Scherf S, Joosten U, Joist A, Engelke K, Daldrup-Link HE. CT of metal implants: reduction of artifacts using an extended CT scale technique. J Comput Assist Tomogr. 2000 Jan-Feb;24(1):165-72 [DOI] [PubMed] [Google Scholar]
  • 12.Prell D, Kyriakou Y, Kachelrie M, Kalender WA. Reducing metal artifacts in computed tomography caused by hip endoprostheses using a physics-based approach. Invest Radiol. 2010 Nov;45(11):747-54 [DOI] [PubMed] [Google Scholar]
  • 13.Puri L, Wixson RL, Stern SH, Kohli J, Hendrix RW, Stulberg SD. Use of helical computed tomography for the assessment of acetabular osteolysis after total hip arthroplasty. J Bone Joint Surg Am. 2002 Apr;84-A(4):609-14 [DOI] [PubMed] [Google Scholar]
  • 14.Egawa H, Ho H, Huynh C, Hopper RH, Jr, Engh CA, Jr, Engh CA. A three-dimensional method for evaluating changes in acetabular osteolytic lesions in response to treatment. Clin Orthop Relat Res. 2010 Feb;468(2):480-90 Epub 2009 Aug 22 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Goosena JHM, Casteleinb RM, Verheyen CCPM. Silent osteolysis associated with an uncemented acetabular component: a monitoring and treatment algorithm. Orthop Trauma. 2005;19(4):288-93 [Google Scholar]
  • 16.Egawa H, Ho H, Hopper RH, Jr, Engh CA, Jr, Engh CA. Computed tomography assessment of pelvic osteolysis and cup-lesion interface involvement with a press-fit porous-coated acetabular cup. J Arthroplasty. 2009 Feb;24(2):233-9 Epub 2008 Apr 8 [DOI] [PubMed] [Google Scholar]
  • 17.Howie DW, Neale SD, Stamenkov R, McGee MA, Taylor DJ, Findlay DM. Progression of acetabular periprosthetic osteolytic lesions measured with computed tomography. J Bone Joint Surg Am. 2007 Aug;89(8):1818-25 [DOI] [PubMed] [Google Scholar]
  • 18.Guermazi A, Miaux Y, Zaim S, Peterfy CG, White D, Genant HK. Metallic artefacts in MR imaging: effects of main field orientation and strength. Clin Radiol. 2003 Apr;58(4):322-8 [DOI] [PubMed] [Google Scholar]
  • 19.Chen CA, Chen W, Goodman SB, Hargreaves BA, Koch KM, Lu W, Brau AC, Draper CE, Delp SL, Gold GE. New MR imaging methods for metallic implants in the knee: artifact correction and clinical impact. J Magn Reson Imaging. 2011 May;33(5):1121-7 doi: 10.1002/jmri.22534 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Hayter CL, Koff MF, Shah P, Koch KM, Miller TT, Potter HG. MRI after arthroplasty: comparison of MAVRIC and conventional fast spin-echo techniques. AJR Am J Roentgenol. 2011 Sep;197(3):W405-11 [DOI] [PubMed] [Google Scholar]
  • 21.Potter HG, Nestor BJ, Sofka CM, Ho ST, Peters LE, Salvati EA. Magnetic resonance imaging after total hip arthroplasty: evaluation of periprosthetic soft tissue. J Bone Joint Surg Am. 2004 Sep;86(9):1947-54 [DOI] [PubMed] [Google Scholar]
  • 22.Cooper HJ, Ranawat AS, Potter HG, Foo LF, Jawetz ST, Ranawat CS. Magnetic resonance imaging in the diagnosis and management of hip pain after total hip arthroplasty. J Arthroplasty. 2009 Aug;24(5):661-7 Epub 2008 Aug 3 [DOI] [PubMed] [Google Scholar]
  • 23.Walde TA, Weiland DE, Leung SB, Kitamura N, Sychterz CJ, Engh CA, Jr, Claus AM, Potter HG, Engh CA., Sr Comparison of CT, MRI, and radiographs in assessing pelvic osteolysis: a cadaveric study. Clin Orthop Relat Res. 2005 Aug;(437):138-44 [DOI] [PubMed] [Google Scholar]
  • 24.Hayter CL, Potter HG, Su EP. Imaging of metal-on-metal hip resurfacing. Orthop Clin North Am. 2011 Apr;42(2):195-205, viii [DOI] [PubMed] [Google Scholar]
  • 25.Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. 2011 Dec 7;93(23):2164-71 [DOI] [PubMed] [Google Scholar]
  • 26.Schmalzried TP, Szuszczewicz ES, Northfield MR, Akizuki KH, Frankel RE, Belcher G, Amstutz HC. Quantitative assessment of walking activity after total hip or knee replacement. J Bone Joint Surg Am. 1998 Jan;80(1):54-9 [PubMed] [Google Scholar]
  • 27.Bitsch RG, Loidolt T, Heisel C, Ball S, Schmalzried TP. Reduction of osteolysis with use of Marathon cross-linked polyethylene. A concise follow-up, at a minimum of five years, of a previous report. J Bone Joint Surg Am. 2008 Jul;90(7):1487-91 [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supporting Data

Disclosure of Potential Conflicts of Interest

Articles from The Journal of Bone and Joint Surgery. American volume are provided here courtesy of Journal of Bone and Joint Surgery, Inc.

RESOURCES