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How to Image Metal-on-Metal Prostheses and Their Complications

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M u s c u l o s k e l e t a l I m a g i n g • R ev i ew
Metal-on-Metal Prostheses
Musculoskeletal Imaging
Simon Ostlere1
Ostlere S
How to Image Metal-on-Metal
Prostheses and Their Complications
OBJECTIVE. Metal-on-metal arthroplasty is a durable alternative to traditional metalon-polyethylene total hip replacement for young active patients. Although midterm results
for resurfacing arthroplasty are reasonable, there is increasing recognition of the problem of
metal-induced periprosthetic reactive masses.
CONCLUSION. Imaging plays an important role in the investigation of symptomatic metal-on-metal arthroplasty. Radiographs will identify fracture and loosening, but cross-В­
sectional imaging is required to diagnose and stage periprosthetic reactive masses.
Keywords: arthroplasty, complications, hip, imaging,
metal-on-metal prostheses, prostheses, resurfacing,
total hip replacement
Received March 8, 2011; accepted after revision
May 5, 2011.
Department of Radiology, Nuffield Orthopaedic Centre,
Windmill Rd, Oxford OX3 7LD, United Kingdom. Address
correspondence to S. Ostlere (
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В© American Roentgen Ray Society
558 he first documented metal-onmetal arthroplasty was performed
in the 1930s. The stainless steel
prosthesis used in a small number
of patients failed because of poor fixation and
wear [1]. Twenty years later, reasonable results
were reported with the McKee-Farrar cobaltchromium-molybdenum metal-on-metal total
hip replacement (THR), with loosening of the
acetabular component being the main cause of
failure [2, 3]. The successful introduction of a
metal-on-polyethylene prosthesis by Charnley
in the 1960s resulted in a temporary lull in interest in metal-on-metal arthroplasty. However,
it became clear that the long-term results of
metal-on-polyethylene THR in young patients
were unsatisfactory [4], thus leading to a resurgence of research activity in metal-on-metal
technology over the past 20 years and the development of a successful resurfacing design.
Metal-on-metal arthroplasty is an attractive alternative to conventional metal-onpolyethylene THR for young active patients.
The primary problem with metal-on-polyethylene THR in this age group is the high
rate of revision as a result of bone lysis secondary to excessive wear of the polyethylene
liner [5, 6]. This high rate of revision is not
only because these patients have a longer life
expectancy but also because they are more
active, resulting in higher rates of polyethylene wear. Metal-on-metal designs were developed to overcome the problem of excessive polyethylene wear. The metal bearings
are durable and produce a relatively low level
of wear particles that, in theory, should re-
duce the risk of foreign-body reaction, thus
increasing the chances of long-term survival
of the prosthesis.
Metal-on-metal THR using a conventional femoral stem has been available for many
years, but the resurfacing design has more recently garnered substantial market share. Resurfacing has the major advantage of sparing
the native femoral neck. The initial resurfacing designs in the 1970s using either Teflonon-Teflon (fluorine-containing resins, DuPont) or metal-on-polyethylene did not fare
well [7, 8]. In the 1990s metal-on-metal designs were developed, but failure rates were
initially unacceptable [9, 10]. Further refinements in the manufacturing process and instrumentation have led to the current generation of resurfacing devices, which have
become a popular choice for young patients.
The results of the initially published outcome studies for modern resurfacing arthroplasty were encouraging, but recently
concerns over the incidence of periprosthetic metal-induced reactive masses have
emerged. Aseptic loosening, infection, and
femoral neck fracture are other complications that have been recorded. This article
reviews the role of imaging in the diagnosis
and management of complications related to
metal-on-metal arthroplasty.
Types of Prostheses
Metal-on-metal prosthesis may have a conventional THR or resurfacing design (Fig. 1).
Metal-on-metal THR has a standard femoral
stem and a range of femoral head sizes. Some
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Metal-on-Metal Prostheses
newer designs of THRs and all resurfacing
prostheses use a larger femoral head that articulates with a thin acetabular metal shell.
Prostheses with a larger head are more stable,
almost eliminating the risk of dislocation. Despite the increased surface area, metal wear is
no greater than with prostheses with smaller
heads, reportedly because the precision engineering allows formation of a lubricating film
of fluid that protects the surfaces during rapid
movement of the joint [11].
With the resurfacing design, the acetabular component is uncemented and the femoral component is cemented. The femoral
component caps the prepared femoral head,
thus conserving the native femoral neck. If
the prosthesis fails, then revision is relatively
straightforward because femoral bone stock
is preserved and a primary femoral component can be used. Improved stability and
mobility are cited as additional advantages,
but there is only weak evidence that resurfacing arthroplasty is associated with higher postoperative activity than conventional
THR [12]. The main disadvantages of resurfacing arthroplasty are the lack of long-term
outcome data, the risk of femoral neck fracture, and the potential adverse effects of metal wear particles and metal ions. Compared
with conventional THR surgery, the surgery
is more challenging and the component position is more critical.
Conventional metal-on-metal THR has a
long track record, but results are mixed [13,
14]. Acceptable serum ion levels [15] and
good survivorship results at 10 years have
been seen with well-established designs [16,
17], whereas newer models of metal-on-metal THR using large heads have a higher failure rate [18]. With modular metal-on-metal
THR designs, local corrosion at the headneck junction is a well-recognized problem
[19, 20]. In one design, high failure rates
were caused by corrosion of the cemented
cobalt-chromium femoral stem at the interface, with the cement resulting in large, cystic metal-induced reactive masses [14].
Long-term outcomes for the current generation of resurfacing devices are not available, but short- and medium-term results are
encouraging [21–23]. However, recent data
indicate that the overall revision rate for resurfacing may exceed that of conventional
THR and that the revision rate in women is
nearly twice that in men, raising concerns regarding the safety of resurfacing arthroplas-
ty in women [18, 24]. The difference in revision rates between the sexes is likely to be
because females are more susceptible to periarticular metal-induced reactive masses. The
susceptibility of females for this complication
is thought to be primarily because of excess
wear related to the smaller cup size used in females, but metal hypersensitivity may also be
a factor [25]. An additional concern is that initial data suggest that the outcome of revision
arthroplasty performed for failed resurfacing
is disappointing and the need for rerevision is
surprisingly high [26, 27].
There is considerable variation in outcome between designs and some of the poor-В­
performing devices have been withdrawn
from the market. Recently the United Kingdom Medicines and Healthcare Products Regulatory Agency issued a report recommending close clinical and imaging monitoring of
all patients with metal-on-metal prostheses
[28]. The resulting interest from the media and
lawyers has somewhat tempered the enthusiasm for metal-on-metal arthroplasty, particularly for use in women [29–32]. The outcome
data support the use of resurfacing devices in
young men but surgeons should be cautious in
recommending the prosthesis to women.
In addition to the local effect of metal particles, there has been some concern regarding
the safety of persistently high systemic levels of metal ions and metal particles. However, there is no evidence to date that the levels
of ions or particles generated by a good-functioning metal-on-metal prosthesis is associated with any adverse systemic effects [33].
Radiography is routinely used to check the
postoperative state of prostheses. In the symptomatic hip, complications may be identified
on radiography but often cross-sectional imaging is required because radiography frequently shows normal findings in cases of a
reactive mass.
Normal Radiographic Appearances of Metalon-Metal Hip Prostheses
The position of the prosthesis components
on postoperative radiographs has a bearing on the risk of developing complications,
particularly for designs with large-diameter
femoral heads. The recommended range of
cup inclination is 35–55° and of cup anteversion, 10–30° [34]. The femoral component
should be placed in an anatomic position
[35]. A varus position should be avoided.
The position of the resurfacing femoral stem
should be central in the femoral neck on the
frontal view, but the position seen on the lateral view is thought to be less critical (Fig.
2). The pin should not impinge on the cortex.
A surrounding thin lucency and focal sclerosis at the tip of the stem are features seen
in asymptomatic patients [22] (Fig. 3). Occasionally there is notching of the superior
Fig. 1—Normal radiographic appearances of metal-on-metal prostheses.
A and B, Radiographs show resurfacing arthroplasty (A) and hip replacement with large-diameter femoral head (B).
AJR:197, September 2011559
femoral neck because of either inadvertent
extension of the reaming required to prepare
the femoral head or impingement against the
acetabular rim [36] (Fig. 4). Notching is usually an insignificant finding, although some
investigators have suggested that notching
may increase the risk of fracture [35]. A
minor degree of femoral neck thinning is a
common finding on follow-up radiographs
of asymptomatic hips, but this finding is also
associated with a reactive mass [37–39].
Fig. 2—Lateral radiograph shows acceptable angulation of femoral pin in patient who underwent resurfacing hip replacement.
Fig. 3—Resurfacing hip replacement. Radiograph
shows minor lucency and sclerosis around tip of
femoral stem.
Fig. 4—Notching of superolateral aspect of femoral neck in 54-year-old woman who underwent resurfacing hip
A, Early postoperative radiograph shows defect (arrow) in superior cortex of femoral neck.
B, Follow-up radiograph shows defect has healed.
Fig. 5—64-year-old woman with resurfacing arthroplasty.
A, Standard T1-weighted MR image of resurfacing replacement shows troublesome metal artifact.
B, T1-weighted metal artifact–reducing sequence shows reduction in extent of artifact at expense of some
blurring of image.
Reducing Metal Artifact on MRI
When MRI is performed in this setting, optimum parameters should be used to reduce
the effect of metal artifact. Artifact-reducing
sequences will vary somewhat among MRI
scanner manufacturers. The artifacts from
embedded metal devices are caused by metal-В­
induced local inhomogeneity of the magnet
field. Gradient-echo imaging and spectral
fat-suppression techniques should be avoided because they are susceptible to artifacts
related to field inhomogeneity. MRI parameters should be optimized to reduce metal artifact as much as possible while maintaining
adequate image quality. Reducing the time of
dephasing improves the artifact and can be
achieved by using fast spin echo with a long
echo-train and short TE, increasing the readout bandwidth and image matrix, and reducing slice thickness. Most of the artifact reduction may be achieved with bandwidth values
and matrix sizes in the mid range. Further
increases in these values will result in an increase in noise for little reward [40]. The other popular technique in clinical use is view
angle tilting; this technique uses a gradient in
the slice select direction during readout, resulting in the affected signals being projected into the correct pixel. However, this advantage is at the expense of image blurring [41]
(Fig. 5).
Complications of Metal-on-Metal Arthroplasty
Proper positioning of the components is
important in minimizing the degree of metal
wear particularly with prostheses with largediameter heads. A vertical cup may result in
edge loading in which the area that is normally subjected to the highest loads extends
beyond the contour of the acetabular cup resulting in excessive loading at the edge of
the cup [42] (Fig. 6). In the case of resurfacing arthroplasty, an excessively horizontal cup or insufficient anteversion can result in impingement causing subluxation of
the femoral head, leading to edge loading
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Fig. 6—Resurfacing hip replacement. Radiograph
shows excessive abduction of acetabular cup.
and increased wear [43]. Poor positioning of
the femoral component is unusual and rarely contributes to failure of the prosthesis. If
components are in an adverse position, the
patient warrants close observation. In these
cases, serum cobalt and chrome ion measurements may be helpful to predict which
prostheses are likely to fail [44].
Loosening—Loosening of the components
in the absence of a reactive mass is unusual
[31]. The uncemented acetabular component
may rarely suffer mechanical loosening that is
sometimes associated with debonding of the
porous coating [45]. Lucency around and migration of the component are signs of loosening [31] (Fig. 7). Review of old radiographs is
important to detect minor degrees of migration and progressive lucency.
Infection—As with any joint prosthesis,
infection is a recognized complication of
metal-on-metal prostheses. Imaging features
are those of any THR and include a joint effusion, periarticular collections, and sinus
formation. Differentiating infection from a
reactive mass may be difficult on the basis of
imaging criteria alone (Fig. 8).
Fracture—A well-recognized early complication of resurfacing arthroplasty is fracture of the femoral neck, which is usually associated with osteonecrosis of the femoral
head [46] (Fig. 9). The incidence is quoted
as being around 1.5%. Notching of the superior femoral neck (Fig. 4) and varus position
of the femoral component have been implicated as risk factors [8, 47]. Improvements
in surgical technique to minimize any disruption of the capsular vessels may lead to
Fig. 7—Loosening of resurfacing components.
A, Radiograph shows that loose acetabular cup has migrated into vertical position.
B, Radiograph shows that loose femoral component with excessive lucency around femoral stem in 43-year-old
Fig. 8—Infected metal-on-metal total hip replacement in 75-year-old woman.
A and B, T1-weighted (A) and STIR (B) coronal MR images show large periprosthetic collection (arrows). It is
impossible to differentiate infection from reactive lesion on basis of imaging criteria alone, although lack of any
substantial solid component and absence of low signal intensity on STIR sequence favor infection.
a fall in the incidence of this complication
[31]. Occasionally a fracture of the femoral
stem accompanies a loose or fractured femoral component [39, 48–50] (Fig. 10).
Metal-induced reactive mass—The histology findings of periprosthetic tissue obtained
at the time of revision of metal-on-metal implants have been described and labeled “aseptic lymphocyte-dominated vascular-associated lesions” and are compatible with a delayed
hypersensitivity to the metal particles [51].
In patients with periarticular masses, marked
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Fig. 9—Fracture of femoral neck in 64-year-old woman after resurfacing arthroplasty.
A, Radiograph shows femoral component has migrated proximally from femoral stem.
B, Subsequent follow-up radiograph shows displaced fracture.
Fig. 10—Fracture of femoral stem in patient who
underwent resurfacing arthroplasty. Radiograph
shows abnormal alignment of femoral stem (arrow);
this finding indicates there is fracture within cup.
Fig. 11—Proven reactive mass and bone involvement.
A, Radiograph of 57-year-old man who underwent resurfacing arthroplasty shows focal thinning of femoral neck proximally (arrows).
B, Radiograph of 67-year-old woman who underwent resurfacing arthroplasty shows lytic lesion in femoral neck with sclerotic border (arrows).
C, Radiograph of 55-year-old man who underwent resurfacing arthroplasty shows wide lucency around femoral stem.
necrosis is an additional consistent feature
[52]. Necrotic masses related to the use of a
cobalt-chromium alloy in joint replacements,
including metal-on-metal designs, were reported in the early 1970s [53]. In a number
of reports, investigators have described similar lesions related to the current generation of
metal-on-metal prostheses [25, 54–56]. The
formation of a periprosthetic mass is now recognized as being a major cause of revision and
fuels concern regarding the long-term safety
of metal-on-metal prostheses.
These reactive lesions have been termed
“pseudotumors” because they can be predominantly solid lesions with necrosis that macroscopically resemble a malignant neoplasm [25].
The biologic pathway leading to the formation
of these masses is complex. The nanometersized particles are cytotoxic to the macrophages
once ingested by phagocytosis, accounting for
the necrosis seen within the lesions. There are
also histologic features compatible with a type
IV hypersensitivity allergic reaction [57, 58].
The risk factors for developing a reactive
mass are female sex, small prosthetic cup size,
poor positioning of the components, and inadvertent downsizing of the femoral head in
women with high preoperative head-neck diameter ratios [38, 43, 59]. The incidence of
this complication varies depending on the
type of prosthesis used. Large femoral head
metal-on-metal THRs are associated with up
to an 8% failure rate at 5 years [60], whereas more traditional designs with small femo-
ral heads have low levels of wear particles and
low incidence of reactive masses [58]. For resurfacing arthroplasty the incidence of revision performed because of a reactive mass increases with time from surgery and is 4% by 8
years. Women outnumber men by 8 to 1 [59].
Patients with bilateral resurfacing hip replacements who develop a reactive mass in
one hip have a 33% chance of having a lesion
on the other side. Reactive masses are undoubtedly underreported because abnormalities are seen on ultrasound in 4% of women
who have been discharged from the care of
surgeons but, on questioning, still have some
symptoms related to their prosthesis [44]. Reactive masses are related to high serum and
joint fluid ion levels, indicating that excessive
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Metal-on-Metal Prostheses
Fig. 12—Bilateral resurfacing arthroplasty complicated by reactive mass in 59-year-old woman.
A and B, T1-weighted (A) and STIR (B) axial MR images. On right, typical anterior solid reactive mass (arrows)
shows low signal intensity on STIR image and intermediate to high signal on T1-weighted image. Smaller lesion
(arrowheads) on left side with signal intensities similar to muscle was initially overlooked.
C, On ultrasound, mass (arrows) on left side is clearly identified lying deep in relation to femoral artery.
Fig. 13—CT scan of 55-year-old woman who underwent resurfacing arthroplasty shows two predominately cystic masses (arrows) lying anterior to hip
Fig. 14—61-year-old woman who underwent metal-on-metal total hip replacement with large-diameter head.
A and B, T1-weighted (A) and T2-weighted (B) axial MR images show anterior (arrows) and lateral (arrowheads), mainly solid, reactive mass with minor central cystic component. Low signal intensity on T2-weighted
image is typical of metal-induced reactive mass.
Fig. 15—55-year-old woman who underwent resurfacing arthroplasty.
A and B, T1-weighted (A) and T2-weighted (B) axial MR images show intrapelvic reactive mass (arrows) lying
within psoas muscle.
Fig. 16—Axial STIR MR image of 68-year-old woman
who underwent resurfacing arthroplasty shows
posterior thin-walled cyst (arrow). Lesion has neck
(arrowhead) that is seen pointing toward posterior
joint space.
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Fig. 17—67-year-old woman who underwent resurfacing arthroplasty.
A–C, T1-weighted coronal MR image (A), STIR coronal MR image (B), and ultrasound image (C) show anterior thick-walled cystic reactive mass (arrows).
Fig. 18—67-year-old man who underwent resurfacing
A and B, T1-weighted axial MR image (A) and ultrasound image (B) of posterior hip show small posterior
thin-walled cyst (arrows) typical of reactive lesion.
GT = greater trochanter.
Fig. 19—Reactive mass that developed after resurfacing arthroplasty in 55-year-old man.
A and B, T1-weighted (A) and STIR (B) coronal MR images show thick-walled cyst (stars) and discrete masses (arrowheads) with very low signal intensity on STIR image
and intermediate to high signal on T1-weighted image. Lesion involves bone (arrows).
C, Extended FOV ultrasound image shows extensive hypoechoic lesion (arrows) lying along lateral border of proximal femur. GT = greater trochanter.
shedding of metal particles is the initiating
process [44]. The frequent finding of bilateral reactive masses in patients with bilateral
resurfacings implies that these patients have
an increased susceptibility to hypersensitivity independent of the degree of wear. How-
ever there is no evidence to show that a preoperative history of metal allergy is a risk
factor. Indeed, in one study the measurement
of lymphocyte proliferation responses to metals was not raised in patients with a reactive
mass [61].
Patients may present with symptoms of a
reactive mass as early as a few months after surgery, but with most patients there is a
delay of several years. Presenting symptoms
include pain, a palpable mass, and femoral
neuropathy [62, 63]. The severity of symp-
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Fig. 20—Reactive mass with femoral neck bone lysis in 55-year-old woman who underwent resurfacing arthroplasty.
A, Ultrasound image shows hypoechoic lesion (star) arising from anterior joint space and erosion of femoral neck (arrows). FH = femoral head.
B, Lateral radiograph confirms erosion on anterior femoral neck (arrow).
C, Erosion is not evident on early postoperative lateral radiograph.
toms is very variable. Radiographs usually
show normal findings, but in advanced cases
there may be evidence of bone lysis and signs
of component loosening or femoral neck narrowing [38, 39] (Fig. 11).
Masses can be detected on MRI, CT, and ultrasound. Ultrasound is a useful screening tool
because it is quick, cheap, and is not affected
by artifacts from the metal components. The
anterior, lateral, and posterior aspects of the
hip can be rapidly assessed. In large patients,
sensitivity of ultrasound for reactive masses
is reduced, but with the use of low-frequency
probes, a satisfactory examination is possible
in nearly all cases. Doppler ultrasound usually
shows no or minor intralesional vascularity. On
MRI, the extent of the disease and relationship
of the abnormality to normal structures may be
better appreciated. The solid components will
usually show elements of low signal on T2weighted images reflecting the metal deposition. The fluid contained in cystic lesions may
also show similar signal characteristics [39].
Small lesions lying close to the prosthesis may
be overlooked on MRI but are clearly visible on
ultrasound [39] (Fig. 12). Masses can be identified on CT (Fig. 13), but MRI is preferred on
account of its superior soft-tissue contrast. Our
policy is to use ultrasound as the initial investigation followed by MRI if staging is required.
Lesions may have a variety of appearances. They may be located anteriorly, posteriorly, or laterally or in a combination of these
positions (Figs. 12–19). The lesions may be
solid or cystic. Occasionally it is difficult to
differentiate a solid lesion from a cystic lesion
when the fluid has low signal intensity on fluid-sensitive sequences. There is no evidence
to suggest gadolinium is useful when no lesion is seen on the unenhanced scan. The pau-
city of Doppler signal on ultrasound suggests
that any enhancement would be unimpressive.
Predominantly solid lesions tend to be located anteriorly, usually within the psoas
muscle (Fig. 14). Anterior masses may extend proximally into the pelvis (Fig. 15) and
may involve the femoral nerve or, exceptionally, the external iliac vessels [62, 63]. Predominantly cystic lesions tend to arise from
the posterior joint space and may have thin
or thick walls (Figs. 16–18). Laterally placed
lesions usually involve the trochanteric bursa, which is seen to communicate directly
with the posterior, or less commonly, the anterior joint space (Fig. 19). Careful inspection of the MR images and thorough ultrasound technique are required to identify any
communication of the bursa with the joint
because simple thickening of a noncommunicating trochanteric bursa should not be
labeled as a “reactive mass.” Occasionally
bone involvement is apparent on ultrasound
or MRI (Figs. 19 and 20).
There is no established pathway for the
management of patients with reactive masses. Patients with troublesome symptoms or
larger lesions are candidates for revision. Unfortunately results are poor in the advanced
cases with objective measurements of function being comparable with those recorded
before the primary surgery [26]. There is uncertainty regarding the correct management
of patients with smaller lesions and minor
symptoms because it is not known whether
these lesions are likely to progress.
Metal-on-metal hip replacement is a durable alternative to traditional metal-on-polyethylene THR for young active patients. The
resurfacing design is a relatively recent advance that has the advantage of sparing the
native femoral neck. Although midterm results for resurfacing arthroplasty are reasonable, there is increasing recognition of the
problem of metal-induced periprosthetic reactive masses, particularly in women, raising
concerns that long-term performance may be
less favorable. Imaging plays an important
role in the investigation of the symptomatic metal-on-metal hip replacement. Radiographs will identify fracture and loosening,
but cross-sectional imaging is usually required to diagnose and stage periprosthetic
reactive masses.
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The reader’s attention is directed to the commentary on this article, which appears on the preceding pages.
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