What is the Diagnostic Accuracy of MRI for Component Loosening in THA?
What is the Diagnostic Accuracy of MRI for Component Loosening in THA?
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DOI：
10.1097/corr.0000000000000772
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发表时间：
2019-09-01
影响因子：
4.2
通讯作者：
Potter, Hollis G.
中科院分区：
文献类型：
--
作者：
Burge, Alissa J.;Konin, Gabrielle P.;Potter, Hollis G.
背景 种植体松动是全髋关节置换术后再次手术的常见原因。尽管放射线照片对整合的评估相对不敏感，但放射线平片一直是评估松动的默认方式；横截面模式可以提供更详细的评估，但传统上会受到与金属相关的伪影的影响。我们试图确定 MRI 是否能够可靠地检测髋关节置换术后患者经手术确认的部件松动。问题/目的 (1) 使用 MRI（具有多采集可变共振图像组合，[MAVRIC]）评估植入物集成是否可以在读者之间重复？ (2) 以术中评估为金标准，使用 MAVRIC 进行 MRI 评估组件松动的敏感性和特异性如何？ (3) 与 X 线照片相比，MAVRIC MRI 对于手术证实的部件松动的敏感性和特异性如何？方法 2012 年至 2017 年间，1 个机构对 2582 例 THA 进行了翻修。其中 219 人接受了 MAVRIC 术前 MRI 检查。在此期间，获得 MRI 的最常见指示是评估潜在的局部组织不良反应。外科医生决定进行修复是基于他们对临床、影像和实验室检查结果的总体评估，MRI 结果被认为有助于做出修复的决定，这通常发生在召回的植入物中。在接受 MRI 的 THA 中，本研究纳入了 212 例，其中 7 例因手术记录不明确 (5) 和 MRI 质量过低 (2) 而被排除。使用标准化关节成形术成像方案以 1.5T 进行 MRI，包括 MARS（金属伪影减少测序）和 MAVRIC 技术。两名接受过肌肉骨骼专科培训的独立读者（一名有 26 年经验，另一名有 5 年经验）对手术结果不知情，根据 Gruen 区和组件松动（定义为组件周围整合的完全圆周损失）对 57 个髋关节的子集进行了植入物整合评分，以评估观察者间的可靠性。第三位对影像学结果不知情的研究者审查了手术记录，以了解外科医生对术中松动评估的详细信息。结果 Gwet 一致性系数 (AC) 用于描述观察者间的一致性；这些与 Cohen 的 kappa 类似，但更能抵抗某些悖论，例如在性状流行率非常高或非常低的情况下出乎意料的低值，或者读者之间在边际计数上的良好一致性。 MRI 上的所有髋臼区和所有股骨 Gruen 区显示出几乎完美的观察者间一致性 (AC(2) = 0.81-1.0)，而髋臼假体松动的整体评估显示出完美的一致性 (AC(1) = 1.0)，股骨假体松动的评估显示出近乎完美的一致性 (AC(1) = 0.98)。 MRI 对髋臼假体松动的敏感性和特异性分别为 83% (95% CI, 65-96) 和 98% (95% CI, 97-100)，对股骨假体松动的敏感性和特异性分别为 75% (95% CI, 55-94) 和 100% (95% CI, 100-100)。 X 光片显示髋臼假体松动的敏感性和特异性分别为 26% (95% CI, 12-47) 和 100% (95% CI, 96-100)，股骨假体松动的敏感性和特异性分别为 20% (95% CI, 9-47) 和 100% (95% CI, 100-100)。结论 MRI 可以提供可重复的评估植入物整合和 在单一机构接受翻修 THA 的患者中，对于经手术证实的种植体松动，其敏感性比 X 线照片更高。其他多机构研究可能会更深入地了解这些发现的普遍性。
Background Implant loosening is a common cause of reoperation after THA. Plain radiographs have been the default modality to evaluate loosening, although radio-graphs provide a relatively insensitive assessment of integration; cross-sectional modalities may provide a more detailed evaluation but traditionally have suffered from metal-related artifacts. We sought to determine whether MRI is capable of reliably detecting operatively confirmed component loosening in patients after hip arthroplasty.Questions/purposes (1) Is assessing implant integration using MRI (with multiacquisition variable resonance image combination, [MAVRIC]) repeatable between readers? (2) What is the sensitivity and specificity of MRI with MAVRIC to evaluate component loosening, using intraoperative assessment as a gold standard? (3) How does the sensitivity and specificity of MRI with MAVRIC for surgically confirmed component loosening compare with those of radiographs?Methods Between 2012 and 2017, 2582 THAs underwent revision at one institution. Of those, 219 had a preoperative MRI with MAVRIC. During that period, the most common indication for obtaining an MRI was evaluation of potential adverse local tissue reaction. The surgeons' decision to proceed with revision was based on their overall assessment of clinical, imaging, and laboratory findings, with MRI findings cited as contributing to the decision to revise commonly occurring in the setting of recalled implants. Of the THAs that underwent MRI, 212 were included in this study, while seven were excluded due to equivocal operative notes (5) and excessively poor quality MRI (2). MRI was performed at 1.5T using a standardized arthroplasty imaging protocol, including MARS (metal artifact reduction sequencing) and MAVRIC techniques. Two independent musculoskeletal fellowship-trained readers (one with 26 and one with 5 years of experience) blinded to operative findings scored a subset of 57 hips for implant integration based on Gruen zone and component loosening (defined as complete circumferential loss of integration around a component) to evaluate interobserver reliability. A third investigator blinded to imaging findings reviewed operative notes for details on the surgeon's assessment of intraoperative loosening.Results Gwet's agreement coefficients (AC) were used to describe interobserver agreement; these are similar to Cohen's kappa but are more resistant to certain paradoxes, such as unexpectedly low values in the setting of very high or low trait prevalence, or good agreement between readers on marginal counts. Almost perfect interobserver agreement (AC(2) = 0.81-1.0) was demonstrated for all acetabular zones and all femoral Gruen zones on MRI, while perfect (AC(1) = 1.0) agreement was demonstrated for the overall assessment of acetabular component loosening and near perfect agreement was shown for the assessment of femoral component loosening (AC(1) = 0.98). MRI demonstrated a sensitivity and specificity of 83% (95% CI, 65-96) and 98% (95% CI, 97-100), respectively, for acetabular component loosening and 75% (95% CI, 55-94) and 100% (95% CI, 100-100), respectively, for femoral component loosening. Radiographs demonstrated a sensitivity and specificity of 26% (95% CI, 12-47) and 100% (95% CI, 96-100), respectively, for acetabular component loosening and 20% (95% CI, 9-47) and 100% (95% CI, 100-100), respectively, for femoral component loosening.Conclusion MRI may provide a repeatable assessment of implant integration and demonstrated greater sensitivity than radiographs for surgically confirmed implant loosening in patients undergoing revision THA at a single institution. Additional multi-institutional studies may provide more insight into the generalizability of these findings.