AJR 2003; 181:1547-1550
© American Roentgen Ray Society
MRI of Failed Total Hip Replacement Caused by Abductor Muscle Avulsion
Akram Twair1,
Martin Ryan,
Martin O'Connell,
Tom Powell,
John O'Byrne and
Stephen Eustace
1 All authors: Department of Radiology, Master Misericordiae and Cappagh
National Orthopedic Hospital, Finglas, Dublin 11, Ireland.
Received January 8, 2003;
accepted after revision June 26, 2003.
Address correspondence to S. Eustace.
Abstract
OBJECTIVE. Our purpose is to describe the use of MRI and associated
metal artifact reduction techniques to detect abductor muscle avulsion from
the greater trochanter, a complication unusual to the anterolateral approach
for total hip replacement.
CONCLUSION. MRI facilitates the detection of abductor muscle
avulsion in patients who have undergone the anterolateral approach during
total hip replacement. MRI is considered a valuable diagnostic tool when this
condition is suspected.
Introduction
An anterolateral approach as part of total hip replacement is preferred
over the transtrochanteric approach to avoid the complications associated with
the trochanteric osteotomy of nonunion and separation of the greater
trochanter [1]. The
anterolateral approach involves the incision of the gluteus medius, vastus
lateralis, and gluteus minimus muscles to gain access to the joint capsule
without the need for trochanteric osteotomy. These muscles are then reattached
at their trochanteric insertion with excellent postoperative restoration of
abductor muscle function and gait
[2].
After this treatment, patients occasionally present with prosthesis failure
and conventional investigative tests fail to identify a cause
[2–4].
In this report, we describe MRI of abductor muscle avulsion in two of eight
patients with prosthesis failure. In each of the two patients, surgical
reexploration and muscle reattachment were performed with subsequent
improvement in hip function.
Subjects and Methods
Eight patients with clinical prosthesis failure and pain were referred for
MRI. Each patient complained of pain initially attributed to prosthesis
loosening or infection. In each case, review of findings of radiographs,
arthrograms with joint aspiration (seven patients), and scintiscans (seven
patients) was normal. MRI was performed to exclude alternate causes of hip
pain and prosthesis failure including bursitis, postoperative hematoma,
sacroiliitis, deep soft-tissue infection, and potential muscle avulsion.
Each patient was imaged using a 1.5-T Intera scanner (Philips, Best, The
Netherlands). We also used a phased array surface coil and a wide field of
view (25 cm), and each patient underwent coronal and axial T1-weighted,
T2-weighted, and STIR imaging.
In each case, frequency-encoded gradients were oriented to manipulate
artifact away from the tissue of interest. T1-weighted images were acquired
using a turbo spin-echo technique (TR/TEeff, 550/12) with
low–high mapping of k-space, an echotrain length of 4, and an
ultra-short echo spacing. T2-weighted turbo spin-echo images
(TReff/TEeff, 2,500/90) were acquired with an echo-train
length of 24, narrow echo spacing, and linear mapping of k-space. STIR images
(TReff/TEeff, 2,500/40) were acquired using the RARE
platform with an inversion time of 160 msec, an echo-train length of 24, and
linear mapping of k-space.
Results
There were six women and two men, with hip pain for a mean duration of 4
months (range, 9 weeks to 18 months) and a mean onset of 3 years after hip
replacement (range, 9 weeks to 5 years).
In six patients, MRI revealed no significant abnormality. In the other two
patients, both women, 76 and 53 years old, MRI revealed abductor muscle
avulsion. The 76-year-old woman presented with severe left hip pain 9 weeks
after anterolateral approach total hip replacement; the 53-year-old woman
presented 8 months after surgery, complaining of left-sided back pain on
walking. Eighteen months previously the 53-year-old patient had a successful
and uncomplicated right total hip replacement. On examination, both patients
were unable to abduct against gravity (Trendelenberg gait). In each patient,
results of routine blood tests were normal. In the 76-year-old patient, MRI
was undertaken following review of normal radiographs and aspiration
arthrogram. In the 53-year-old patient, MRI was undertaken following review of
normal radiographs. Scintigraphy in this case showed a subtle increase in the
concentration of radiotracer adjacent to the prosthesis attributed to the
recent surgery. In both cases, MRI showed abductor muscle avulsion. Despite
metal-induced susceptibility artifact, coronal images allowed detailed
evaluation of the paraarticular soft tissues in both cases. In the 76-year-old
patient, 9 weeks after surgery, findings of T2-weighted and STIR images showed
avulsion of the glutei and abductors from the greater trochanter with
retraction of the common tendon. At the site of tendon retraction, MRI showed
interposition of fluid with atrophy of the associated muscle belly in the
buttock (Fig. 1A,
1B,
1C). In the 53-year-old
patient, 8 months after surgery, MRI of the pelvis also showed avulsion of the
left glutei from the greater trochanter with interposed fluid (Fig.
2A,
2B,
2C). In this patient, images
showed additional artifacts from her asymptomatic right total hip prosthesis
and revealed normal muscle attachments on the greater trochanter. Both
patients underwent surgical repair. The 76-year-old patient described
immediate postoperative resolution of pain and, after protracted
physiotherapy, showed restoration of abductor function. For the 53-year-old
patient, reexamination at 3 months showed impaired but improved abductor
function.
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Fig. 1B. —76-year-old woman with clinical abductor failure. Coronal
turbo spin-echo T1-weighted image (TR/TEeff, 550/12; echo-train
length, 4) shows metal artifact (straight arrow) at site of hip
prosthesis. Note avulsion, retraction, and atrophy of left glutei with
interposed hypointense fluid (curved arrow).
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Fig. 1C. —76-year-old woman with clinical abductor failure. Coronal
turbo STIR image (2,500/40; echo-train length, 24) shows hyperintense fluid
(arrow) at site of retraction, confirming abductor avulsion.
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Fig. 2A. —53-year-old woman after bilateral anterolateral approach
total hip replacements. Anteroposterior radiograph of pelvis shows bilateral
total hip replacements in situ without evidence of loosening or infection.
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Fig. 2B. —53-year-old woman after bilateral anterolateral approach
total hip replacements. Coronal turbo spin-echo T1-weighted image
(TR/TEeff, 550/12; echo-train length, 4) shows bilateral metal
artifact at site of prostheses with intact abductors on right (straight
arrow) and avulsed, retracted abductors on left (curved
arrow).
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Fig. 2C. —53-year-old woman after bilateral anterolateral approach
total hip replacements. Coronal turbo STIR image (2,500/40; echo-train length,
6) shows healthy abductors on right, with fluid over left greater trochanter
at site of abductor avulsion (arrow).
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Discussion
Surgical hip replacement involves hip exploration and exposure through
transtrochanteric, posterior, or anterolateral approaches. The
transtrochanteric approach involves trochanteric osteotomy with reattachment
via Kirchner cerclage wire. This approach restores hip abductor function but
may be complicated by wire fracture and trochanteric detachment readily seen
on radiography. The posterior approach involves incision of the glutei, which,
despite repair, leads to posterior joint laxity and both postoperative hip
subluxation and dislocation. To avoid complications inherent in
transtrochanteric and posterior approaches to total hip replacement, many
physicians now advocate an anterolateral approach to expose the hip joint at
the time of surgery [1,
2].
After hip replacement using the anterolateral approach, glutei are
reattached at their insertion on the greater trochanter to restore abductor
function. Recognizing the difficulty of identifying the rare complication of
abductor detachment, some surgeons at the time of reattachment anchor the
glutei tendons to the greater trochanter with metallic clips. Clips are
readily identified on radiographs and allow an indirect appreciation of tendon
integrity at the trochanteric attachment. Because the tendon may detach and
tear at this point without displacement of metallic anchors, identification of
abductor failure is limited even using this technique.
Abductor dysfunction after an anterolateral approach to total hip
replacement may also occur when the superior gluteal nerve is damaged at the
time of surgery [3]. In both
avulsion and superior gluteal nerve palsy, patients present with Trendelenburg
gait and secondary muscle atrophy. Electrophysiologic studies may show
evidence of damage to the superior gluteal nerve but are not widely available
[4,
5]. Muscle avulsion after total
hip replacement cannot be detected on radiography, arthrography, scintigraphy,
or CT. Because of superior soft-tissue resolution, and despite metal artifact,
MRI should be considered the examination of choice when this diagnosis is
suspected.
MRI in patients who have undergone hardware fixation may be limited by
susceptibility-induced loss of signal adjacent to the metallic prosthesis.
Satisfactory reduction in susceptibility artifact, allowing assessment of soft
tissues adjacent to prostheses, may now be achieved by appropriate orientation
of slice-select and frequency-encoded gradients, in conjunction with tissue
excitation using RARE-based sequences
[6,
7]. Artifact reduction is
particularly effective when prostheses are cobalt chrome– or
titanium-based rather than steel-based. Using these techniques, MRI allowed
clear identification of abductor muscle avulsion from the greater trochanteric
attachments in two of eight of our patients despite the presence of steel
components. Although sonography reveals soft tissues and is widely used to
evaluate musculoskeletal ailments, in our experience its ability to confirm
this diagnosis is limited by a lack of discernible landmarks.
White et al. [7] have
described their early experience using MRI to evaluate hip prostheses. Using
RARE-based fast spin-echo imaging, these researchers outlined the use of MRI
to evaluate complications of hip replacement in 11 patients. This process
included mechanical loosening in two patients, giant cell reaction in eight
patients, and infection in one patient. In each of these patients, the
diagnosis was made using conventional techniques before MRI was performed.
Unlike mechanical loosening, infection, or giant cell reaction, abductor
muscle dysfunction cannot be confidently assessed by radiographs,
scintigraphy, or joint aspiration. When it is suspected clinically, the
diagnosis can only ultimately be confirmed by the direct visualization
afforded by MRI.
In summary, integrated use of radiography, joint aspiration arthrography,
and scintigraphy allows accurate assessment of common complications like
loosening and infection after hip replacement. Despite metal artifacts, MRI
should not be overlooked when patients present with abductor failure or
Trendelenburg's symptom after hip replacement, particularly replacement using
the anterolateral approach. In this setting, MRI may show the avulsion of
abductors, facilitating corrective intervention.
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Abstract
Introduction
