Evaluation of diagnostic imaging modalities for complications after total hip arthroplasty

Michalis Sarantis, Vasileios S Nikolaou, Loukia Fragkopoulou, Konstantinos Kokkinis


Hip replacement surgery has evolved in line with advancements in implant technology and quality of surgical technique. Radiographs remains first imaging technique used for patient evaluation followed by ultrasonography, computed tomography, magnetic resonance imaging, arthrography, aspiration and nuclear scan techniques. Mechanical loosening, polyethylene wear–induced osteolysis, adverse local tissue reaction due to metal wear debris, infection, fractures, heterotopic ossification, tendinopathy and nerve damage are common causes of painful hip arthroplasty. The radiologist must effectively detect critical concerns with imaging tools while also remaining up to date on additional complications related with advances in surgical technique, implant design, and innovative materials. The present study reviews extensively the clinical and imaging modalities that can be used to better detect complications after hip arthroplasty replacement.


hip arthroplasty; imaging; postoperative complications; radiography

Full Text:



Lee K, Goodman S. Current state and future of joint replacements in the hip and knee. Expert Rev Med Devices. 2008;5(3):383-393.

Mulcahy H, Chew F. Current Concepts of Hip Arthroplasty for Radiologists: Part 1, Features and Radiographic Assessment. American Journal of Roentgenology. 2012;199(3):559-569.

Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91(1):128-133.

Lin EC. Radiation risk from medical imaging. Mayo Clin Proc. 2010;85(12):1142-1146.

Ilchmann T, Lüem M, Pannhorst S, Clauss M. Acetabular polyethylene wear volume after hip replacement: Reliability of volume calculations from plain radiographs. Wear. 2012;282-283:69-75.

Maruyama M, Tensho K, Wakabayashi S, Hisa K. Standing versus supine radiographs to evaluate femoral head penetration in the polyethylene liner after total hip arthroplasty. J Arthroplasty. 2014;29(12):2415-2419.

Barrack RL, Burnett SJ. Preoperative planning for revision total hip arthroplasty. J Bone Joint Surg Am. 2005;87(12):2800-2811.

Pessis E, Campagna R, Sverzut J et al. Virtual Monochromatic Spectral Imaging with Fast Kilovoltage Switching: Reduction of Metal Artifacts at CT. RadioGraphics. 2013;33(2):573-583. doi:10.1148/rg.332125124

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;84(4):609-614.

Roth TD, Maertz NA, Parr JA, Buckwalter KA, Choplin RH. CT of the hip prosthesis: appearance of components, fixation, and complications. Radiographics. 2012;32(4):1089-1107.

Goldvasser D, Noz ME, Maguire GQ Jr, Olivecrona H, Bragdon CR, Malchau H. A new technique for measuring wear in total hip arthroplasty using computed tomography. J Arthroplasty. 2012;27(9):1636-1640.e1.

Bamberg F, Dierks A, Nikolaou K, Reiser MF, Becker CR, Johnson TR. Metal artifact reduction by dual energy computed tomography using monoenergetic extrapolation. Eur Radiol. 2011;21(7):1424-1429.

Kress AM, Schmidt R, Vogel T, Nowak TE, Forst R, Mueller LA. Quantitative computed tomography-assisted osteodensitometry of the pelvis after press-fit cup fixation: a prospective ten-year follow-up. J Bone Joint Surg Am. 2011;93(12):1152-1157.

Pitto RP, Mueller LA, Reilly K, Schmidt R, Munro J. Quantitative computer-assisted osteodensitometry in total hip arthroplasty. Int Orthop. 2007;31(4):431-438.

Chang SD, Lee MJ, Munk PL, Janzen DL, MacKay A, Xiang QS. MRI of spinal hardware: comparison of conventional T1-weighted sequence with a new metal artifact reduction sequence. Skeletal Radiol. 2001;30(4):213-218.

Kolind SH, MacKay AL, Munk PL, Xiang QS. Quantitative evaluation of metal artifact reduction techniques. J Magn Reson Imaging. 2004;20(3):487-495.

Olsen RV, Munk PL, Lee MJ, et al. Metal artifact reduction sequence: early clinical applications. Radiographics. 2000;20(3):699-712.

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;86(9):1947-1954.

Toms AP, Smith-Bateman C, Malcolm PN, Cahir J, Graves M. Optimization of metal artefact reduction (MAR) sequences for MRI of total hip prostheses. Clin Radiol. 2010;65(6):447-452.

Sutter R, Ulbrich EJ, Jellus V, Nittka M, Pfirrmann CW. Reduction of metal artifacts in patients with total hip arthroplasty with slice-encoding metal artifact correction and view-angle tilting MR imaging. Radiology. 2012;265(1):204-214.

Albanese CV, Santori FS, Pavan L, Learmonth ID, Passariello R. Periprosthetic DXA after total hip arthroplasty with short vs. ultra-short custom-made femoral stems: 37 patients followed for 3 years. Acta Orthop. 2009;80(3):291-297.

Love C, Marwin SE, Palestro CJ. Nuclear medicine and the infected joint replacement. Semin Nucl Med. 2009;39(1):66-78.

Palestro CJ, Love C, Tronco GG, Tomas MB, Rini JN. Combined labeled leukocyte and technetium 99m sulfur colloid bone marrow imaging for diagnosing musculoskeletal infection. Radiographics. 2006;26(3):859-870.

Reinartz P. FDG-PET in patients with painful hip and knee arthroplasty: technical breakthrough or just more of the same. Q J Nucl Med Mol Imaging. 2009;53(1):41-50.

Even-Sapir E, Mishani E, Flusser G, Metser U. 18F-Fluoride positron emission tomography and positron emission tomography/computed tomography. Semin Nucl Med. 2007;37(6):462-469.

Ullmark G, Nilsson O, Maripuu E, Sörensen J. Analysis of bone mineralization on uncemented femoral stems by [18F]-fluoride-PET: a randomized clinical study of 16 hips in 8 patients. Acta Orthop. 2013;84(2):138-144.

Kobayashi N, Inaba Y, Choe H, et al. Use of F-18 fluoride PET to differentiate septic from aseptic loosening in total hip arthroplasty patients. Clin Nucl Med. 2011;36(11):e156-e161.

Douis H, Dunlop DJ, Pearson AM, O’Hara JN, James SL. The role of ultrasound in the assessment of post-operative complications following hip arthroplasty. Skeletal Radiol. 2012;41(9):1035-1046.

Mulhall KJ, Masterson E, Burke TE. Routine recovery room radiographs after total hip arthroplasty: ineffective for screening and unsuitable as baseline for longitudinal follow-up evaluation. J Arthroplasty. 2004;19(3):313-317.

Ndu A, Jegede K, Bohl DD, Keggi K, Grauer JN. Recovery room radiographs after total hip arthroplasty: tradition vs utility?. J Arthroplasty. 2012;27(6):1051-1056.

Australian Orthopedic Association. Arthroplasty Society of Australia. Available via http://www.aoa.org.au/docs/subspecialties/arthposfollow_200812.pdf?sfvrsn=2. Published 2022. Accessed May 9, 2022.

Bolz KM, Crawford RW, Donnelly B, Whitehouse SL, Graves N. The cost-effectiveness of routine follow-up after primary total hip arthroplasty. J Arthroplasty. 2010;25(2):191-196.

FDA Safety Communication: Metal-on-Metal Hip Implants. 2013; Available via http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm335775.htm. Published 2016. Accessed September 30, 2015.

Stulberg SD, Wixson RL, Adams AD, Hendrix RW, Bernfield JB. Monitoring pelvic osteolysis following total hip replacement surgery: an algorithm for surveillance. J Bone Joint Surg Am. 2002;84-A Suppl 2:116-122.

Cooper HJ, Ranawat AS, Potter HG, Foo LF, Koob TW, Ranawat CS. Early reactive synovitis and osteolysis after total hip arthroplasty. Clin Orthop Relat Res. 2010;468(12):3278-3285.

Mistry A, Cahir J, Donell ST, Nolan J, Toms AP. MRI of asymptomatic patients with metal-on-metal and polyethylene-on-metal total hip arthroplasties. Clin Radiol. 2011;66(6):540-545.

Utz JA, Lull RJ, Galvin EG. Asymptomatic total hip prosthesis: natural history determined using Tc-99m MDP bone scans. Radiology. 1986;161(2):509-512.

Lee YK, Kim TY, Ha YC, Kang BJ, Koo KH. Radiological measurement of femoral stem version using a modified Budin method. Bone Joint J. 2013;95-B(7):877-880.

McArthur B, Cross M, Geatrakas C, Mayman D, Ghelman B. Measuring acetabular component version after THA: CT or plain radiograph?. Clin Orthop Relat Res. 2012;470(10):2810-2818.

Loftus M, Ma Y, Ghelman B. Acetabular Version Measurement in Total Hip Arthroplasty: the Impact of Inclination and the Value of Multi-Planar CT Reformation. HSS J. 2015;11(1):65-70.

Ong KL, Kurtz SM, Lau E, Bozic KJ, Berry DJ, Parvizi J. Prosthetic joint infection risk after total hip arthroplasty in the Medicare population. J Arthroplasty. 2009;24(6 Suppl):105-109.

Parvizi J, Gehrke T; International Consensus Group on Periprosthetic Joint Infection. Definition of periprosthetic joint infection. J Arthroplasty. 2014;29(7):1331.

Tigges S, Stiles RG, Roberson JR. Appearance of septic hip prostheses on plain radiographs. AJR Am J Roentgenol. 1994;163(2):377-380.

Cyteval C, Hamm V, Sarrabère MP, Lopez FM, Maury P, Taourel P. Painful infection at the site of hip prosthesis: CT imaging. Radiology. 2002;224(2):477-483.

Tomas X, Bori G, Garcia S, et al. Accuracy of CT-guided joint aspiration in patients with suspected infection status post-total hip arthroplasty. Skeletal Radiol. 2011;40(1):57-64.

Aliprandi A, Sconfienza LM, Randelli F, Bandirali M, Di Leo G, Sardanelli F. Magnetic resonance imaging of painful total hip replacement: detection and characterisation of periprosthetic fluid collection and interobserver reproducibility. Radiol Med. 2012;117(1):85-95.

Love C, Marwin SE, Tomas MB, et al. Diagnosing infection in the failed joint replacement: a comparison of coincidence detection 18F-FDG and 111In-labeled leukocyte/99mTc-sulfur colloid marrow imaging. J Nucl Med. 2004;45(11):1864-1871.

Nagoya S, Kaya M, Sasaki M, Tateda K, Yamashita T. Diagnosis of peri-prosthetic infection at the hip using triple-phase bone scintigraphy. J Bone Joint Surg Br. 2008;90(2):140-144.

Reinartz P, Mumme T, Hermanns B, et al. Radionuclide imaging of the painful hip arthroplasty: positron-emission tomography versus triple-phase bone scanning. J Bone Joint Surg Br. 2005;87(4):465-470.

Stumpe KD, Nötzli HP, Zanetti M, et al. FDG PET for differentiation of infection and aseptic loosening in total hip replacements: comparison with conventional radiography and three-phase bone scintigraphy. Radiology. 2004;231(2):333-341.

Gómez-Luzuriaga MA, Galán V, Villar JM. Scintigraphy with Tc, Ga and In in painful total hip prostheses. Int Orthop. 1988;12(2):163-167.

American Academy of Orthopaedic Surgeons. The Diagnosis of Periprosthetic Joint Infections of the Hip and Knee Guidline and Evidence Report. Available via http://www.aaos.org/research/guidelines/PJIguideline.pdf. Published 2022. Accessed May 9, 2022.

Chryssikos T, Parvizi J, Ghanem E, Newberg A, Zhuang H, Alavi A. FDG-PET imaging can diagnose periprosthetic infection of the hip. Clin Orthop Relat Res. 2008;466(6):1338-1342.

Zhuang H, Duarte PS, Pourdehnad M, et al. The promising role of 18F-FDG PET in detecting infected lower limb prosthesis implants. J Nucl Med. 2001;42(1):44-48.

García-Barrecheguren E, Rodríguez Fraile M, Toledo Santana G, Valentí Nín JR, Richter Echevarría JA. La 18FDG-PET: una nueva aproximación diagnóstica en la infección protésica de cadera [FDG-PET: a new diagnostic approach in hip prosthetic replacement]. Rev Esp Med Nucl. 2007;26(4):208-220.

Zoccali C, Teori G, Salducca N. The role of FDG-PET in distinguishing between septic and aseptic loosening in hip prosthesis: a review of literature. Int Orthop. 2009;33(1):1-5.

Choe H, Inaba Y, Kobayashi N, et al. Use of 18F-fluoride PET to determine the appropriate tissue sampling region for improved sensitivity of tissue examinations in cases of suspected periprosthetic infection after total hip arthroplasty. Acta Orthop. 2011;82(4):427-432.

Gibbon WW, Long G, Barron DA, O’Connor PJ. Complications of orthopedic implants: sonographic evaluation. J Clin Ultrasound. 2002;30(5):288-299.

Williams JL, Norman P, Stockley I. The value of hip aspiration versus tissue biopsy in diagnosing infection before exchange hip arthroplasty surgery. J Arthroplasty. 2004;19(5):582-586.

Temmerman OP, Raijmakers PG, David EF, et al. A comparison of radiographic and scintigraphic techniques to assess aseptic loosening of the acetabular component in a total hip replacement. J Bone Joint Surg Am. 2004;86(11):2456-2463.

Buckwalter KA. Optimizing imaging techniques in the postoperative patient. Semin Musculoskelet Radiol. 2007;11(3):261-272.

Temmerman OP, Raijmakers PG, Deville WL, Berkhof J, Hooft L, Heyligers IC. The use of plain radiography, subtraction arthrography, nuclear arthrography, and bone scintigraphy in the diagnosis of a loose acetabular component of a total hip prosthesis: a systematic review. J Arthroplasty. 2007;22(6):818-827.

Oyen WJ, Lemmens JA, Claessens RA, van Horn JR, Slooff TJ, Corstens FH. Nuclear arthrography: combined scintigraphic and radiographic procedure for diagnosis of total hip prosthesis loosening. J Nucl Med. 1996;37(1):62-70.

Manthey N, Reinhard P, Moog F, Knesewitsch P, Hahn K, Tatsch K. The use of [18 F]fluorodeoxyglucose positron emission tomography to differentiate between synovitis, loosening and infection of hip and knee prostheses. Nucl Med Commun. 2002;23(7):645-653.

Gelderman SJ, Jutte PC, Boellaard R, et al. 18F-FDG-PET uptake in non-infected total hip prostheses. Acta Orthop. 2018;89(6):634-639.

Ostlere S, Soin S. Imaging of prosthetic joints. Imaging. 2003;15(4):270-285. doi:10.1259/img.15.4.150270

Dumbleton JH, Manley MT, Edidin AA. A literature review of the association between wear rate and osteolysis in total hip arthroplasty. J Arthroplasty. 2002;17(5):649-661.

Claus AM, Totterman SM, Sychterz CJ, Tamez-Peña JG, Looney RJ, Engh CA Sr. Computed tomography to assess pelvic lysis after total hip replacement. Clin Orthop Relat Res. 2004;(422):167-174.

Malan DF, Botha CP, Kraaij G, et al. Measuring femoral lesions despite CT metal artefacts: a cadaveric study. Skeletal Radiol. 2012;41(5):547-555.

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;197(3):W405-W411.

Bestic JM, Berquist TH. Current concepts in hip arthroplasty imaging: metal-on-metal prostheses, their complications, and imaging strategies. Semin Roentgenol. 2013;48(2):178-186.

Kwon YM, Ostlere SJ, McLardy-Smith P, Athanasou NA, Gill HS, Murray DW. “Asymptomatic” pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplasty. 2011;26(4):511-518.

Macnair RD, Wynn-Jones H, Wimhurst JA, Toms A, Cahir J. Metal ion levels not sufficient as a screening measure for adverse reactions in metal-on-metal hip arthroplasties. J Arthroplasty. 2013;28(1):78-83.

Ostlere S. How to image metal-on-metal prostheses and their complications. AJR Am J Roentgenol. 2011;197(3):558-567.

Yanny S, Cahir JG, Barker T, et al. MRI of aseptic lymphocytic vasculitis-associated lesions in metal-on-metal hip replacements. AJR Am J Roentgenol. 2012;198(6):1394-1402.

Chang EY, McAnally JL, Van Horne JR, et al. Metal-on-metal total hip arthroplasty: do symptoms correlate with MR imaging findings?. Radiology. 2012;265(3):848-857.

Hauptfleisch J, Pandit H, Grammatopoulos G, Gill HS, Murray DW, Ostlere S. A MRI classification of periprosthetic soft tissue masses (pseudotumours) associated with metal-on-metal resurfacing hip arthroplasty. Skeletal Radiol. 2012;41(2):149-155.

Nawabi DH, Gold S, Lyman S, Fields K, Padgett DE, Potter HG. MRI predicts ALVAL and tissue damage in metal-on-metal hip arthroplasty. Clin Orthop Relat Res. 2014;472(2):471-481.

Nishii T, Sakai T, Takao M, Yoshikawa H, Sugano N. Is ultrasound screening reliable for adverse local tissue reaction after hip arthroplasty?. J Arthroplasty. 2014;29(12):2239-2244.

Steinert L, Zanetti M, Hodler J, Pfirrmann CW, Dora C, Saupe N. Are radiographic trochanteric surface irregularities associated with abductor tendon abnormalities?. Radiology. 2010;257(3):754-763.

Pfirrmann CW, Notzli HP, Dora C, Hodler J, Zanetti M. Abductor tendons and muscles assessed at MR imaging after total hip arthroplasty in asymptomatic and symptomatic patients. Radiology. 2005;235(3):969-976.

Ylinen P, Tallroth K, Konttinen YT, Landtman M, Paavilainen T. Arthrography for the diagnosis of abductor avulsion after total hip arthroplasty: a comparison of arthrographic and surgical findings in 33 patients. Acta Orthop. 2007;78(3):340-343.

Lachiewicz PF, Kauk JR. Anterior iliopsoas impingement and tendinitis after total hip arthroplasty. J Am Acad Orthop Surg. 2009;17(6):337-344.

Bancroft LW, Blankenbaker DG. Imaging of the tendons about the pelvis. AJR Am J Roentgenol. 2010;195(3):605-617.

Cyteval C, Sarrabère MP, Cottin A, et al. Iliopsoas impingement on the acetabular component: radiologic and computed tomography findings of a rare hip prosthesis complication in eight cases. J Comput Assist Tomogr. 2003;27(2):183-188.

Adler RS, Buly R, Ambrose R, Sculco T. Diagnostic and therapeutic use of sonography-guided iliopsoas peritendinous injections. AJR Am J Roentgenol. 2005;185(4):940-943.

Khan T, Knowles D. Damage to the superior gluteal nerve during the direct lateral approach to the hip: a cadaveric study. J Arthroplasty. 2007;22(8):1198-1200.

Hayter CL, Koff MF, Potter HG. Magnetic resonance imaging of the postoperative hip. J Magn Reson Imaging. 2012;35(5):1013-1025.

Tagliafico A, Podestà A, Assini A, et al. MR Imaging of total hip arthroplasty: comparison among sequences to study the sciatic nerve at 1.5 T. Magn Reson Imaging. 2010;28(9):1319-1326.

Chhabra A, Flammang A, Andreisek G. Magnetic resonance neurography technique. In: Chhabra A, Andreisek G, eds. Magnetic resonance neurography. New Delhi: Jaypee Brothers Medical Pub.; 2012:10- 23.

Della Valle AG, Ruzo PS, Pavone V, Tolo E, Mintz DN, Salvati EA. Heterotopic ossification after total hip arthroplasty: a critical analysis of the Brooker classification and proposal of a simplified rating system. J Arthroplasty. 2002;17(7):870-875.

Cahir JG, Toms AP, Marshall TJ, Wimhurst J, Nolan J. CT and MRI of hip arthroplasty. Clin Radiol. 2007;62(12):1163-1173.

Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. J Nucl Med. 2002;43(3):346-353.

Popken F, König DP, Tantow M, Rütt J, Kausch T, Peters KM. Ist eine perioperative sonographische Frühdiagnostik heterotoper Ossifikationen nach Alloarthroplastik des Hüftgelenks möglich? [Possibility of sonographic early diagnosis of heterotopic ossifications after total hip-replacement]. Unfallchirurg. 2003;106(1):28-31.

DOI: http://dx.doi.org/10.36162/hjr.v7i4.499


  • There are currently no refbacks.