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Painful Infection at the Site of Hip Prosthesis: CT Imaging¹

¹ From the Departments of Radiology (C.C., M.P.S., P.T.) and Orthopaedics (P.M.), Hôpital Lapeyronie, 371 avenue du Doyen Gaston Giraud, 34295 Montpellier Cedex 5, France; and the Department of Radiology, Hôpital Caremeau, Nimes, France (V.H., F.M.L.). Received June 4, 2001; revision requested July 2; revision received November 14; accepted January 7, 2002. Address correspondence to C.C. (e-mail: c-cyteval @chu-montpellier.fr).

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
PURPOSE: To prospectively determine the accuracy of computed tomography (CT) in the detection of painful infection at the site of hip prosthesis before surgery.

MATERIALS AND METHODS: Helical CT examinations of hip prostheses were prospectively performed before surgery after a standard clinical and radiologic examination of 65 patients. CT scans and conventional radiographs were reviewed for periprosthetic bone abnormalities, and CT scans were reviewed for periprosthetic soft-tissue abnormalities (joint distention, fluid-filled bursae, and fluid collection in muscles and perimuscular fat). Patients subsequently underwent revision arthroplasty within 1 month, and infection was diagnosed in 12 (19%) patients.

RESULTS: Infection was detected clinically in 25% of patients. Periprosthetic bone abnormalities did not allow differentiation of infection from complications not related to sepsis, except for periostitis, with 100% specificity but only 16% sensitivity. Soft-tissue findings were accurate for detection of infection, with 100% sensitivity and 87% specificity. Fluid collection in muscles and perimuscular fat had a 100% positive predictive value, and absence of joint distention had a 96% negative predictive value.

CONCLUSION: CT is accurate in the diagnosis of painful infection at the site of a hip prosthesis on the basis of soft-tissue findings, whereas periprosthetic bone abnormalities are not useful.

© RSNA, 2002

Index terms: Hip, CT, 44.12111, 44.12115 • Hip, infection, 44.20 • Hip, prostheses, 44.454

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Pain is a frequent symptom after total hip replacement, occurring in as many as 20% of patients (1). Local complications associated with a hip prosthesis include infection, mechanical loosening, heterotopic bone formation, prosthetic and periprosthetic fractures, acetabular malposition, and foreign-body reaction to polyethylene debris (2). Such complications are common sources of patient morbidity and often necessitate revision arthroplastic surgery. Appropriate management of such cases hinges partly on distinguishing patients with infection from those with other causes of postoperative pain, chiefly aseptic loosening. Preoperative diagnosis of infection is important, because revision arthroplasty requires excision of all infected tissue and cement, which may be difficult and time consuming (3). In addition, a strict operating-room disinfection protocol is essential to prevent nosocomial infection from airborne contamination.

Clinical diagnosis is often difficult, and no specific hematologic tests are available for the diagnosis of infected hip prosthesis, although white blood cell count and erythrocyte sedimentation rate may help determine diagnosis. Furthermore, there is currently no consensus concerning the best imaging approach. Conventional radiography (4), nuclear medicine examinations with bone and gallium scanning (5,6), arthrography (7–9), and magnetic resonance (MR) imaging (10) have been proposed to evaluate hip prosthesis for the presence of infection, but they all have limitations. Tigges et al (11) have emphasized the difficulty of differentiating infection from mechanical loosening, as both conditions produce nonfocal lucencies on radiographs. In addition, imaging-guided joint aspiration is considered by Tigges et al (7) to be of some value.

Although detail on computed tomographic (CT) scans is degraded by metal artifacts, study findings have shown that it is possible to depict a hip prosthesis (12–14).

Furthermore, CT is widely known to be accurate in the depiction of soft-tissue abnormalities, particularly in infection (15), and could be of some interest in the diagnosis of hip prosthetic complications, particularly infection. To our knowledge, however, there are no data available about the potential of CT to help distinguish sepsis from complications of noninfected prosthesis.

The purpose of this prospective study was to determine the accuracy of CT in the detection of painful infection at the site of a hip prosthesis before surgery.

	MATERIALS AND METHODS

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Study Population
During 3 years (January 1997 to January 2000), 73 consecutive patients scheduled for surgical revision for painful hip prosthesis were prospectively included in the CT study. Our institutional review board did not require its approval or patient informed consent. Eight patients with a recent history of prosthetic dislocation were excluded, since there was no doubt about the cause of pain. Sixty-five patients (39 men, 26 women; age range, 33–94 years; mean age, 65 years) with pain at the site of total hip arthroplasty were examined. The duration of implantation ranged from 3 months to 30 years (mean, 9 years). Pain was present in all patients; clinical findings consistent with infection were present in 10 patients and included previous infection of hip prosthesis (three patients), rest pain or night pain (six patients), fever (one patient), induration (one patient), and erythema or discharge at inspection (two patients).

The final diagnoses were infection in 12 patients and complications not related to infection in 53 patients; the diagnoses were established on the basis of findings from surgical revision performed within 1 month after CT examination. Infection was diagnosed when the same bacterium was found twice at multiple biopsies of deep tissues performed according to the Kamme and Lindberg method (16). Complications not related to sepsis included aseptic loosening (n = 33), foreign-body reaction to polyethylene debris (n = 9, with aggressive bone granulomatosis [n = 7] and only synovitis [n = 2] revealed with synovial analysis after surgery), acetabular component malposition (n = 6), femoral fractures (n = 3), and heterotopic bone formation (n = 2).

Imaging and Review
Conventional radiography and CT (HiSpeed Advantage; GE Medical Systems, Milwaukee, Wis) were performed in all patients within 1 day. Radiographs consisted of anteroposterior and true lateral views. Helical CT scans (section thickness, 3 mm; pitch, 1.3; and spacing reconstruction, 2.5) were obtained from the top of the acetabulum to the inferior part of the stem for bone analysis. The bone reconstruction algorithm and wide window settings to accentuate the border of bone structures (window width, 2,500–3,000 HU; window center, 500–600 HU) were used to minimize artifacts from a metallic prosthesis. Coronal and sagittal images were reconstructed. A soft-tissue reconstruction algorithm (window width, 700 HU; window center, 100 HU) was applied to analyze periprosthetic soft tissues. No intravenous injection of contrast material was performed.

Radiographs and CT scans were each separately reviewed by two experienced musculoskeletal radiologists (C.C., V.H.), who were blinded to each patient’s clinical history and surgical findings. Findings from each imaging modality were assessed jointly by the two reviewers, and conclusions were drawn with consensus. All radiographs were analyzed according to the criteria of Tigges et al (11), including periostitis, which was defined as a laminated new bone formation, and periprosthetic lucency. Lucency was characterized as focal or nonfocal. Nonfocal lucency was defined as a region of bone loss at least 2 mm wide that occurred at the bone-prosthesis or bone-cement interface and outlined and conformed to the shape of the entire prosthesis. Focal lucency was defined as discrete regions of bone loss that occurred at the bone-prosthesis or bone-cement interface and did not conform to the prosthesis shape. In addition, the position (asymmetric or centered) of the femoral head in the acetabular component was noted.

All CT scans were specifically analyzed for both bone periprosthetic and soft-tissue findings. Bone periprosthetic findings obtained with CT were the same as those obtained with conventional radiography. The soft-tissue abnormalities were joint distention, fluid-filled bursae, and fluid collection in muscles and perimuscular fat. We considered fluid masses within a bursa when the masses extended from the region of the femoral neck to the inguinal ligament and were depicted on the CT scan between the iliopsoas and the pectineus muscles of the iliopsoas bursa, which overlie the greater trochanter and posterior to the femur of the trochanteric bursa (17).

Statistical Analyses
Sensitivity, specificity, accuracy, and predictive values of each radiographic and CT finding in the diagnosis of infection were calculated. We used Fisher exact ² test to assess whether joint infection was significantly associated with the different signs of complication. In addition, we attempted to identify, for each modality, the combination of findings that provided the best tradeoff between specificity and sensitivity.

	RESULTS

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Three (25%) of 12 patients with proven infection and seven (13%) of 53 patients without infection had at least one clinical criterion consistent with infection, which included history of infection (n = 1), fever (n = 1), or hip discharge (n = 1) for the infected group and history of infection (n = 2), rest or night pain (n = 5), and/or hip induration (n = 1) for the noninfected group.

Conventional radiographic findings are summarized in Table 1. For each finding (focal lucency, nonfocal lucency, periostosis, and asymmetric position of the femoral head component), findings from the Fisher exact ² test did not reveal any significant difference between the infected and the noninfected groups. There was no abnormality in 25% of the septic prostheses and in 28% of the noninfected prostheses. The only infection-specific finding was periostitis; however, it was nonsensitive because it was encountered in only two (16%) patients with infection.

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 1a. Staphylococcus aureus infection of the prosthesis in a 54-year-old woman 2 years after hip replacement. (a, b) Plurilamellar periostitis (curved arrows) was shown on (a) a radiograph as focal lucent line (straight arrow) and on (b) a transverse CT scan as a low-attenuation line (straight arrow) at the bone-stem interface.

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 1b. Staphylococcus aureus infection of the prosthesis in a 54-year-old woman 2 years after hip replacement. (a, b) Plurilamellar periostitis (curved arrows) was shown on (a) a radiograph as focal lucent line (straight arrow) and on (b) a transverse CT scan as a low-attenuation line (straight arrow) at the bone-stem interface.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Streptococcal infection of the prosthesis in a 43-year-old man 6 months after hip replacement. (a) Transverse CT scan at the joint level shows a nonfocal low-attenuation line (arrows) at the acetabular cement-bone interface. (b) Transverse CT scan of soft tissues shows joint distention (arrows).

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Streptococcal infection of the prosthesis in a 43-year-old man 6 months after hip replacement. (a) Transverse CT scan at the joint level shows a nonfocal low-attenuation line (arrows) at the acetabular cement-bone interface. (b) Transverse CT scan of soft tissues shows joint distention (arrows).

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Streptococcal infection of the prosthesis in a 79-year-old woman 5 years after right hip replacement. Transverse CT scan with soft-tissue reconstruction algorithm shows joint distention (curved arrows) and focal areas of low attenuation in the muscle. Extension into the subcutaneous tissues to the skin was confirmed as an abscess (straight arrows) at surgery.

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 4a. Staphylococcus aureus infection of the prosthesis in a 66-year-old man 20 years after hip replacement. (a, b) Transverse CT scans of soft tissues show (a) distention (arrow) at the joint level and (b) hypoattenuating structure collection (arrows) in the quadriceps muscle.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 4b. Staphylococcus aureus infection of the prosthesis in a 66-year-old man 20 years after hip replacement. (a, b) Transverse CT scans of soft tissues show (a) distention (arrow) at the joint level and (b) hypoattenuating structure collection (arrows) in the quadriceps muscle.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 5a. Foreign-body reaction to polyethylene debris in a 66-year-old man 7 years after hip replacement. (a) Reconstructed coronal CT scan shows asymmetric position of the femoral head (*) in the acetabular component (arrowheads). (b) Transverse CT scan of soft tissues shows fluid-filled psoas bursa (arrow).

View larger version (159K): [in this window] [in a new window] [Download PPT slide]   Figure 5b. Foreign-body reaction to polyethylene debris in a 66-year-old man 7 years after hip replacement. (a) Reconstructed coronal CT scan shows asymmetric position of the femoral head (*) in the acetabular component (arrowheads). (b) Transverse CT scan of soft tissues shows fluid-filled psoas bursa (arrow).

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

Although CT scanning is noninvasive, it has not been popular in the detection of prosthetic complications, because metal in the prosthesis creates many artifacts on reconstructed images. However, newer scanners with improved transformation algorithms and postprocessing techniques have reduced metal artifacts. Many authors have already proposed different techniques to improve readability of CT scans in patients with prostheses, such as multiplanar reconstruction (18) and wide window settings by using the extended CT scale technique to accentuate the border of bone structures (19). The protocol was standardized for all complications of hip prosthesis, and even though more artifacts are found on transverse images with helical than with nonhelical CT scanning (19), coronal and sagittal reconstructions present fewer artifacts.

Robertson et al (20) have proposed generating values for incomplete projection data and iterative deblurring reconstruction. With our protocol, we took into account different improvements to reduce artifacts by increasing the effective energy of the x-ray beam (140 kV, 180 mAs), with use of detail a transformation algorithm, multiplanar reformatting of image data, and maximum window width of 2,500–3,000 HU, according to the CT scale technique (19). Although more artifacts were present in patients with double-hip prostheses or metal-backed acetabular components with our protocol and as was already reported by Robertson et al (20), all scans were considered readable by the two radiologists. Also, each criterion could have been assessed, even though in this study, no interobserver variability was calculated.

The goal of our study was to determine the value of CT to help diagnose infection by assessing the sensitivity and specificity of CT to depict periprosthetic bone and soft-tissue abnormalities and to evaluate its potential role by comparing CT results with clinical and radiographic data. The inclusion of patients without infection allowed us to establish the specificity of the various imaging findings for the diagnosis of infection. The specificity is clearly dependent on the patients without an infected prosthesis. Had we chosen healthy subjects for the noninfected group, it is likely that the specificity of the various imaging findings, particularly the bone findings, would have been higher. Because the control group consisted of patients with pain at the site of a prosthesis, it allowed us to evaluate the specificity of the various imaging findings in actual clinical practice.

Analysis of bone CT findings led to the same conclusions as were drawn in studies that focused on conventional radiographs (21,22): There is a lack of specificity of bone abnormalities in infection diagnosis, since both nonfocal and focal lucencies are commonly encountered in complications of nonseptic hip arthroplasties. Only periostitis was found to be infection specific (100% specificity), but it was not commonly observed (16% sensitivity). Moreover, in 25% of patients with infection, bone appeared normal on both CT scans and radiographs. The lack of accuracy for bone abnormalities on radiographs to diagnose infection has already been demonstrated by Tigges et al (11) who found that infection sometimes does not alter radiographic findings in which nonfocal lucencies mimic aseptic loosening and focal lucencies mimic aggressive granulomatosis.

The major finding of our study is the reliability of a CT-depicted soft-tissue abnormality in the diagnosis of infection in hip prosthesis. Authors of several studies (23,24) in which arthrography was used indicated that most prosthetic hip infections are characterized by increased joint fluid and periprosthetic collections. van Holsbeeck et al (25), using sonography in a series of 33 symptomatic patients, reported that visualization of intraarticular effusion with extraarticular extension might indicate infection of loosened hip prosthesis. In our study, periprosthetic soft-tissue analysis showed that all patients with infection presented with either joint distention or muscular or perimuscular collection. Fluid collection in muscles and perimuscular fat was specific for sepsis, but it was not very sensitive.

It is likely that the injection of contrast material would have improved the sensitivity of CT in depicting small abnormal soft-tissue foci while facilitating analysis of CT fluid collection. Fluid-filled bursae were detected in patients with infection (five [41%] of 12) or aggressive granulomatosis (three [33%] of nine). We found joint distention to be the most sensitive sign of infection; it was present in 10 of 12 infected hip prostheses. In the two remaining infected prostheses, there was soft-tissue collection in the quadriceps muscle near the periostosis, remote from the joint. The 4% joint distention in patients without infection was due to aggressive granulomatosis. In both cases, the marked asymmetric position of the femoral head in the acetabular component was depicted on CT coronal reconstructions. In a sonographic study of 48 hip arthroplasties, Kesteris et al (26) described aggressive granulomatosis as a cause of effusion in hip prosthesis.

Because of limitations of clinical and radiologic findings in the diagnosis of infected hip prosthesis, examination of patients with pain after total arthroplasty may include arthrography, nuclear medicine evaluation, or hip aspiration. Fluoroscopy-guided aspiration of the prosthetic joint, as determined with a large series, is currently considered to be the most accurate method for diagnosing or excluding periprosthetic infection, with 92.8% sensitivity, 91.7% specificity, and 91.8% accuracy (7). However, routine aspiration of the hip joint before revision arthroplasty remains controversial; it is recommended by some authors (7,8,27), but other authors (28) reserve it for patients suspected of having infection because of the rate of false-positive results.

It is a complicated endeavor to determine which patients will require additional tests after clinical and radiologic examinations. Had we performed a complementary examination only in patients with high clinical and/or radiologic (periostitis) suspicion of infection, we would have missed seven (58%) infectious cases. The findings were obtained in seven noninfected patients, with a positive predictive value of 42% for infection. These findings could be in favor of a systematic approach before revision arthroplasty, including either hip aspiration or CT. Further studies are needed to compare these two modalities in terms of accuracy and cost-effectiveness on the basis of the knowledge that CT has the advantage of being noninvasive and able to reveal signs of other complications (fracture not seen on plain radiographs, acetabular malposition). CT is also able to provide information for spatial analysis of the remaining periprosthetic bone before implantation of a new prosthesis.

In our study, we documented that CT was accurate in the diagnosis of infection in patients scheduled for surgery because of pain at the site of prosthesis. Since the goal was to detect prosthesis-related sepsis before surgery to allow adaptation of the surgical technique, our study was performed only in patients scheduled for surgery. It would now be of interest to perform CT in patients before the final treatment decision is made to investigate the effect of CT on the choice of surgical treatment.

In conclusion, the results of our study indicate that CT is accurate in the detection of painful infection at the site of hip prosthesis on the basis of soft-tissue findings rather than bone periprosthetic abnormalities viewed on CT scans or conventional radiographs. Infected hips show evidence of joint distention or fluid collections around the prosthesis.

	FOOTNOTES

 
Author contributions: Guarantors of integrity of entire study, C.C., P.T.; study concepts and design, C.C., P.T., F.M.L., P.M.; literature research, C.C., V.H.; clinical studies, C.C., V.H., M.P.S.; data acquisition and analysis/interpretation, C.C., V.H., M.P.S.; statistical analysis, C.C., P.T.; manuscript preparation and definition of intellectual content, C.C., V.H., M.P.S.; manuscript editing, C.C.; manuscript revision/review, C.C., F.M.L., P.M., P.T.; manuscript final version approval, all authors.

	REFERENCES

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 

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This Article Abstract Figures Only Full Text (PDF) All Versions of this Article: 2242010989v1 224/2/477    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cyteval, C. Articles by Taourel, P. Search for Related Content PubMed PubMed Citation Articles by Cyteval, C. Articles by Taourel, P.