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## Complete Summary

#### GUIDELINE TITLE

Imaging after total hip arthroplasty (THA).

#### BIBLIOGRAPHIC SOURCE(S)

Weissman BN, Dalinka MK, Alazraki N, Daffner RH, DeSmet AA, El-Khoury
GY, Kneeland JB, Manaster BJ, Pavlov H, Rubin DA, Steinbach LS, Haralson
RH III, Expert Panel on Musculoskeletal Imaging. Imaging after total hip
arthroplasty (THA). \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 8 p. \[51 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Keats TE, Dalinka MK,
Alazraki N, Berquist TH, Daffner RH, DeSmet AA, el-Khoury GY, Goergen
TG, Manaster BJ, Newberg A, Pavlov H, Schweitzer ME, Haralson RH 3rd,
McCabe JB. Hip arthroplasty\--radiography procedure recommendations.
American College of Radiology. ACR Appropriateness Criteria. Radiology.
2000 Jun;215 Suppl:389-90.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [May 23, 2007, Gadolinium-based Contrast
    Agents](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Gadolinium):
    The addition of a boxed warning and new warnings about the risk of
    nephrogenic systemic fibrosis (NSF) to the full prescribing
    information for all gadolinium-based contrast agents (GBCAs).

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Total hip arthroplasty (THA)

#### GUIDELINE CATEGORY

Evaluation

#### CLINICAL SPECIALTY

Orthopedic Surgery\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of radiologic procedures for imaging
after total hip arthroplasty (THA)

#### TARGET POPULATION

Patients who have had total hip arthroplasty (THA)

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray

2.  Radiostereogrammetry

3.  Nuclear medicine

    -   Bone scan

    -   Bone/gallium scan

    -   White blood cell scan, Indium-111

4.  Dual energy x-ray absorptiometry

5.  Computed tomography

6.  Quantitative computed tomography

7.  Magnetic resonance imaging

8.  Aspiration, image-guided

9.  Aspiration/arthrography

10. Ciprofloxacin (infection) imaging

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in follow-up evaluation

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of recent
peer-reviewed medical journals, and the major applicable articles were
identified and collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Imaging After Total Hip Arthroplasty (THA)**

**Variant 1: Follow-up of the asymptomatic patient with a THA.**

  -----------------------------------------------------------------------------
  **Radiologic Exam       **Appropriateness   **Comments**
  Procedure**             Rating**            
  ----------------------- ------------------- ---------------------------------
  X-ray, hip              9                    

  Radiostereogrammetry,   1                    
  hip                                         

  NUC, bone scan          1                    

  NUC, bone/gallium scan  1                    

  DXA, hip                1                    

  CT, hip                 1                    

  QCT, hip                1                    

  MRI, hip                1                    

  ***Appropriateness                          
  Criteria Scale*\                            
  1 2 3 4 5 6 7 8 9\                          
  1 = Least appropriate 9                     
  = Most appropriate**                        
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Evaluating patients with a painful primary THA \--
suspected loosening and/or wear.**

  -----------------------------------------------------------------------------
  **Radiologic Exam       **Appropriateness   **Comments**
  Procedure**             Rating**            
  ----------------------- ------------------- ---------------------------------
  X-ray, hip              9                    

  CT, hip                 5                   For planning, if osteolysis is
                                              suspected or assessment of bone
                                              stock is needed. May be useful to
                                              see subtle wear. With
                                              multidetector, thin section CT,
                                              this study is providing more
                                              information.

  Aspiration, hips,       5                   Arthrography may be done to
  image-guided                                evaluate loosening. Injection of
                                              anesthetic may be helpful to
                                              localize the source of pain.

  NUC, bone/gallium scan  2                    

  DXA, hip                1                    

  Radiostereogrammetry,   1                    
  hip                                         

  QCT, hip                1                    

  MRI, hip                1                   Recent data suggests it may be
                                              helpful in certain cases.

  NUC, bone scan          No consensus        May help determine if one or both
                                              components are loose or if other
                                              abnormalities are present. Varies
                                              by institution.

  ***Appropriateness                          
  Criteria Scale*\                            
  1 2 3 4 5 6 7 8 9\                          
  1 = Least appropriate 9                     
  = Most appropriate**                        
  -----------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Evaluating patients with a painful primary THA \--
suspected infection.**

  --------------------------------------------------------------------------------
  **Radiologic Exam          **Appropriateness   **Comments**
  Procedure**                Rating**            
  -------------------------- ------------------- ---------------------------------
  X-ray, hips                9                    

  Aspiration/arthrography,   9                   Should be first exam following
  hips                                           radiographs. Other studies may be
                                                 helpful but not indicated
                                                 routinely. Arthrography may
                                                 document collections.

  NUC, bone scan             3                   Sensitive but not specific enough
                                                 to be used as the sole procedure.

  NUC, bone, Gallium scan    3                   If bone scan is abnormal, gallium
                                                 can follow to suggest infection.

  NUC, WBC scan, Indium-111  3                   WBC scan can be done without bone
                                                 scan to diagnose infection, or
                                                 can follow bone scan.

  Ciprofloxacin (infection)  3                    
  imaging                                        

  CT, hip                    1                   Usually not indicated. Only if
                                                 soft tissue abscesses suspected.

  MRI, hip                   1                   Currently being investigated.

  ***Appropriateness                             
  Criteria Scale*\                               
  1 2 3 4 5 6 7 8 9\                             
  1 = Least appropriate 9 =                      
  Most appropriate**                             
  --------------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Symptoms**

Ninety percent of patients have good or excellent results after THA.
Those with persistent postoperative pain after cemented prostheses may
have had the incorrect diagnosis made originally, have infection, or,
less commonly, have heterotopic bone formation. Studies of patients with
uncemented prostheses indicate that pain occurring after an asymptomatic
period suggests possible loosening. While patients with loosening or
infection usually (but not always) have pain, those with particle
disease and resulting osteolysis may be asymptomatic.

**Imaging Techniques**

Radiographs shortly after surgery are recommended as a baseline for
future evaluation and are particularly important after revision surgery.
The schedule for obtaining radiographs is uncertain and depends on the
presence or absence of symptoms. The NIH consensus panel indicates that
\"appropriate x-ray examination\" is required throughout life with
periodic examination, perhaps at 5-year intervals, after the first 5
years. A review of 18,486 primary total hip arthroplasties in patients
with osteoarthritis found radiological follow-up in order to monitor
component loosening to be unnecessary in asymptomatic patients in the
first five postoperative years. In asymptomatic patients with bone
ingrowth prostheses, radiography may also be useful to gauge fixation
early in the postoperative course. They are also helpful in identifying
bone loss from aggressive granulomatous disease, although the
sensitivity of radiographs in detecting osteolysis is limited. Since
this complication occurs most often several years postoperatively, one
study recommends radiographs in asymptomatic patients beginning 3 years
after surgery.

All symptomatic patients should undergo radiography. Availability of old
radiographs to compare to new ones facilitates the diagnosis of subtle
changes such as may occur in loosening or in particle disease, or of
rapid changes such as may occur with infection.

*Roentgen Stereophotogrammetric Analysis*

Roentgen stereophotogrammetric analysis (radiostereometry) is a
technique that utilizes three components to achieve highly accurate
measurements of component position. First, opaque reference markers are
placed in the bone near the prosthesis (usually at the time of surgery).
Second, two radiographs are obtained simultaneously using two
radiographic tubes that are angled to each other. Third, a calibration
cage is placed beneath the table. Sophisticated mathematical analysis is
then performed. One study investigated the accuracy of this technique by
performing duplicate measurements. The 99% confidence limits were 0.16
mm for proximal to distal translation, 0.3 degree for anterior posterior
rotation, 0.8 degree or rotation about the longitudinal axis
(anteversion-retroversion), and 0.34 degree for varus/valgus tilt.
Radiostereometry has been used for the early detection of component
migration and prosthetic wear. Because of its complexity, however, this
test remains largely a research method.

*Dynamic Computed Tomography*

Dynamic computed tomography is performed by obtaining CT slices through
the collar of the prosthesis and the femoral condyles with the leg in
maximum internal and external rotation. Change in relative position has
been shown in one series to correlate with loosening at surgery.

*Bone Scintigraphy*

Bone scintigraphic appearances after total hip arthroplasty are varied,
reflecting the stress on the adjacent bone as well as any complications
that occur. One study of asymptomatic cemented total hip prostheses
indicated that persistent increased uptake could be seen at the tip of
the femoral stem in about 10% of patients at 1 to 3 years after surgery;
at the greater trochanter in 20%; and at the acetabulum in 12% at 2
years. The femoral shaft uptake decreased by 9 months after surgery.
These authors recommend that a baseline bone scan be obtained between 9
and 12 months after surgery.

Normal bone scan appearances after uncemented total hip replacements
depend on the type of prosthetic components used. One group of
investigators examined 25 asymptomatic prostheses serially for two years
after THA and found that bone phase images showed uptake at the tip of
each prosthesis at some time during the study. Increased blood flow or
focal blood pool activity should suggest a complication. Uptake at the
area distal to the tip or along the lateral tip increased in some cases
in the 12 to 24 month follow-up. Indium-111 WBC scanning also showed
increased activity at the tip of the prosthesis in 80% of uncomplicated
uncemented prostheses. These authors noted that baseline three-phase
bone scans and In-111 WBC scans are of value.

**Evaluation of Patient with Suspected Infection**

Infection occurs in 1-2% of primary total hip arthroplasties and is even
more frequent after revision procedures. Approximately one third of
infections develop in the first 3 months, another one third within the
first year, and another one third more than 1 year after surgery.
Loosening occurring within the first 2 years after surgery suggests
infection. Infection of failed hip prostheses may be underestimated
since organisms may reside in a biofilm. As summarized in one report, no
test is perfectly sensitive and specific for the diagnosis. This
includes radiography. One study evaluated radiographs of 20 infected
THAs and found half to be normal.

*Computed Tomography*

Prospective evaluation of patients with painful total hip arthroplasties
using helical CT has shown that periosteal new bone formation was always
associated with infection (100% specificity) but had only 16%
sensitivity. Soft tissue findings were more accurate. Fluid collections
in muscles and perimuscular fat had a 100% positive predictive value and
the absence of joint distension a 96% negative predictive value.

*Ultrasonography*

Ultrasonographic findings may suggest infection after THA. One study
found that a thick capsule (3.2 mm bone capsule distance) was 100%
sensitive for the diagnosis but not entirely specific (74%). The
combination of intraarticular effusion with extraarticular extension was
indicative of infection.

*Joint Aspiration*

Joint aspiration, although not perfect, is \"perhaps the most useful
investigative tool for definitive confirmation of the presence or
absence of infection.\" The sensitivity of preoperative aspiration
ranges from 50-93% and the specificity from 82-97%. Thus, both false
positive and false negative studies occur. Debate remains regarding the
indications for arthrography. Some investigators indicate that
aspiration may be particularly useful when there is no clinical
suspicion of infection, while others suggest aspiration when there is an
elevated erythrocyte sedimentation rate or C-reactive protein or
clinical suspicion remains.

*Magnetic Resonance Imaging*

Magnetic resonance imaging (MRI) has demonstrated a peripherally
enhancing juxta-articular fluid collection connecting to the implant in
a patient with periprosthetic infection.

*Technetium-99m Bone Scan*

Technetium-99m bone scans are thought to be sensitive but not specific
for postoperative infection. One study noted that a positive bone scan
strongly suggests loosening or infection, while a negative scan does not
exclude these abnormalities. Another study found that a negative bone
scan makes infection very unlikely. The pattern of bone scan uptake is
probably unreliable in differentiating infection from loosening.

*Gallium-67 Citrate*

Gallium-67 citrate accumulates in areas of infection but also in areas
of new bone formation. Mechanisms of gallium uptake include granulocyte
uptake, direct bacterial uptake, and lactoferrin binding and binding to
bacterial siderophores. False negative scans may occur in patients
treated with antibiotics. A positive gallium scan is very likely to
indicate infection, but a normal scan does not exclude infection
(sensitivity 37%, specificity 100%).

*Indium-111-Labeled White Blood Cells*

Indium-111-labeled WBCs may accumulate at the site of a number of
inflammatory processes, including acute osteomyelitis, acute
exacerbations of chronic osteomyelitis, septic arthritis, abscesses, and
rheumatoid arthritis, but also in heterotopic bone, Paget disease, and
other disorders. The sensitivity of the indium WBC scans for infection
decreases as the chronicity of the infection increases. Sensitivities
for the diagnosis of infection after total joint replacement range from
50-100% and specificities from 45-100%.

In addition to Indium-111, leukocytes may be labeled with Tc-99m
stannous colloid. Tc-99m-labeled leukocyte scanning is less expensive
than Indium-111-labeled leukocyte scintigraphy and has better imaging
characteristics and greater availability. Tc99-m stannous colloid labels
both granulocytes and monocytes, which should offer improved detection
of chronic infections such as those associated with total joint
replacement. The addition of marrow imaging to leukocyte scanning has
improved accuracy to 90%. Delayed Tc99-m leukocyte imaging may be
helpful.

One study noted that until additional studies are done, the routine use
of Indium-111-labeled immunoglobulin-G cannot be recommended.

Tc 99-m-labeled antibiotic (ciprofloxacin) has been used to evaluate
orthopedic infections. This agent should be specific for infection as
opposed to other inflammatory processes, although mild uptake in
noninfective inflammation and foreign body reaction does occur.
Antibiotic treatment may interfere with uptake of this agent. One study
found a sensitivity of 85%, specificity of 92%, and accuracy of 88% in
orthopedic infections (including 18 total hip replacements). This was
compared to 78%, 100%, and 90%, respectively, for the bone gallium
combination. The ciprofloxacin scanning procedure enables studies to be
performed at 1 and 4 hours and with improved resolution in contrast to
the delay for gallium and Indium-111 labeled WBC scanning. Ciprofloxacin
is not taken up in normal bone marrow, and its uptake is independent of
the white blood cell count.

**Evaluation of Patient with Suspected Loosening and/or Wear**

Late aseptic loosening is the most common reason for implant failure.
One study evaluated 18,486 primary cemented, uncemented, and combined
total hip arthroplasties performed for osteoarthritis followed at least
10 years. The prevalence of acetabular loosing ranged from 0.6-13.9% and
of femoral loosening from 1.7-12.5%.

Tc-99m-labeled antigranulocyte antibody Fab\' fragments imaging is a
more readily available, simpler examination than Indium-111-labeled
autologous leukocyte scanning and has replaced that examination in
Europe. A sensitivity of 91% and specificity of 47% have been found for
the diagnosis of infected total hip arthroplasties.

Fluorine 18 FDG PET has been utilized in diagnosing of infection after
joint replacement, but has performed similarly to three-phase bone
scintigraphy.

*Radiographs*

Loosening is usually evaluated on radiographs. However, despite the
presence of radiographic features indicating loosening, symptoms may be
absent. As pointed out in one study, there is discrepancy in the
identification and quantification of lucent zones, which are important
indicators of radiographic loosening.

Roentgen stereogrammetry allows the detection of small changes in
component position. One study found that the magnitude of subsidence in
the first 2 years is a risk factor for subsequent component revision.
Thus, the risk of femoral revision at 5-7 years postoperative was
greater than 50% if subsidence was 1.2 mm or more during the first two
years; the relative risk of revision increased 5.2 times for each mm of
subsidence. One study defined loosening as migration (change in
component position over time) demonstrated at roentgen stereogrammetry.
Patients with migration showed signs of loosening on arthrography,
scintigraphy, or at revision surgery, whereas those without migration
detected with this technique did not demonstrate any evidence of
loosening.

*Dual Energy X-ray Absorptiometry*

Dual energy x-ray absorptiometry (DXA) scanning of patients with loose
prostheses indicated a decrease in bone mineral density (BMD) in every
Gruen zone in comparison to the opposite unoperated hip. While
comparison to the opposite side may be suboptimal, the pattern of bone
loss differed from that associated with normal remodeling around
successful prostheses.

*Arthrography*

The role of arthrography in documenting loosening of cemented components
has been extensively studied. One group of investigators used refined
criteria, high injection pressure, and subtraction technique and found a
sensitivity of 96% and a specificity of 92% for demonstrating femoral
component loosening and a sensitivity of 97% and a specificity of 68%
for acetabular component loosening. Optimal arthrographic technique is
important to demonstrate loosening.

The efficacy of arthrography in defining loosening of uncemented
components is less well studied and less certain. One study analyzed
contrast arthrography in 12 uncemented femoral components and found a
sensitivity of 50% and a specificity of 100% for loosening evaluated at
surgery. Contrast arthrography in 31 uncemented femoral components in
another study showed a sensitivity of 59% and a specificity of 64%,
lower than the results for cemented femoral components (sensitivity 76%,
specificity 70%).

*Anesthetic*

Intra-articular injection of anesthetic that results in pain relief
indicates an intra-articular cause for the symptoms. One study notes
that pain relief suggests an intra-articular process, while the absence
of pain relief is not helpful.

*Bone Scan*

The absence of increased uptake on bone scan is thought to be strong
evidence against prosthetic complication. One study, however, found that
even the combination of bone scan and radiography was only about 84%
sensitive and 92% specific for loosening in patients without obvious
radiographic loosening.

*Intra-articular Radionuclide*

Injection of intra-articular radionuclide was first used for evaluation
of femoral component loosening, but later procedural changes allowed
both acetabular and femoral components to be evaluated. The procedure is
usually coupled with a bone scan, and the isotope injection is performed
at the time of contrast arthrography. In one series of uncemented
components, this study was 70% sensitive and 100% specific for femoral
loosening with increased sensitivity over the contrast examination. In
another study, the nuclear arthrogram performed better than or equal to
the contrast arthrogram for evaluation of cemented and uncemented
components. The combination of radionuclide and arthrographic procedures
is advantageous. In a small series involving uncemented femoral stems,
the sensitivity of combined exams was 90%, and the specificity was 100%
when both studies were negative.

*Magnetic Resonance Imaging*

Initial investigations have suggested that MRI may also have a role in
the evaluation of prosthetic complications. In one series, MRI
documented femoral component loosening as low signal fluid collections
parallel to the component on fast-spin-echo T1-weighted images.

**Evaluation of Patients with Suspected Stress Shielding**

Bone loss associated with decreased stress occurs around both cemented
and uncemented prostheses. Although these changes may be frequent, they
may not affect the long-term results. Cortical thinning, increased
porosity, and decreased bone density are indicators of stress shielding
on radiographs. Radiographs, however, are insensitive indicators of bone
loss. One study evaluated the ability of three orthopedic surgeons to
agree on the presence of bone loss around prostheses under optimal
radiographic conditions. \"Excellent\" agreement was not achieved until
bone loss averaged 70%.

*Dual-Energy X-ray Absorptiometry*

Dual-energy x-ray absorptiometry has been used to assess periprosthetic
bone density. Reproducibility is severely compromised if identical hip
rotation is not achieved on follow up examinations. One study found
precision of the DXA exam to average 3.8% with a standard deviation of
1.2%. Another study noted that bone loss was obvious on radiographs when
about 35% of bone loss was present on DXA scanning.

*Quantitative Computed Tomography*

Quantitative computed tomography (QCT) has demonstrated changes in
acetabular density with time after total hip replacement.

**Particle Disease (Aggressive Granulomatous Disease)**

Localized areas of bone resorption occur around total hip arthroplasties
in response to the release of small particles. The condition may occur
in response to cement and/or polyethylene or metal particles. It is more
frequent after uncemented total hip arthroplasties than cemented ones
and is a more frequent complication than infection, dislocation, or
extensive heterotopic bone formation. Loosening may or may not accompany
the condition.

*Radiographs*

Radiographs are typically the first method of identifying these areas of
bone resorption. One study found the area of the lesions to double in
2.2 years and the number of lesions to increase with time. However,
particularly in the acetabulum, considerable bone loss is necessary
before lesions are identified with certainty.

*Computed Tomography*

Improved CT scanning techniques enable better demonstration of bone
adjacent to prostheses and may find a role for identifying granulomas.
CT scans have helped determine the extent and location of clinically
silent osteolysis. One study suggests a baseline CT scan seven to ten
years after THA; additional follow-up CTs may then be done.

*Magnetic Resonance Imaging*

On MRI, focal periprosthetic intraosseous masses of low T1 and
heterogeneous, largely low to intermediate T2 signal have been described
in cases of aggressive granulomatous disease. Peripheral and some
internal enhancement of these granulomas have been noted after
intravenous gadolinium injection.

**Summary**

A large number of techniques are available for evaluating total hip
arthroplasties. Radiographs, however, remain the standard imaging
modality. Joint aspiration is the best available test for evaluation of
joint infection. CT and MRI hold potential for assessing granulomatous
disease.

**Abbreviations**

-   CT, computed tomography

-   DXA, dual energy x-ray absorptiometry

-   MRI, magnetic resonance imaging

-   NUC, nuclear medicine

-   QCT, quantitative computed tomography

-   WBC, white blood cell

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for imaging after
total hip arthroplasty (THA)

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Weissman BN, Dalinka MK, Alazraki N, Daffner RH, DeSmet AA, El-Khoury
GY, Kneeland JB, Manaster BJ, Pavlov H, Rubin DA, Steinbach LS, Haralson
RH III, Expert Panel on Musculoskeletal Imaging. Imaging after total hip
arthroplasty (THA). \[online publication\]. Reston (VA): American
College of Radiology (ACR); 2005. 8 p. \[51 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1998 (revised 2005)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Musculoskeletal
Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Barbara N. Weissman, MD (*Principal Author*); Murray K.
Dalinka, MD (*Panel Chair*); Naomi Alazraki, MD; Richard H. Daffner, MD;
Arthur A. DeSmet, MD; George Y. El-Khoury, MD; John B. Kneeland, MD;
B.J. Manaster, MD, PhD; Helene Pavlov, MD; David A. Rubin, MD; Lynne S.
Steinbach, MD; Robert H. Haralson III, MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

It updates a previously published version: Keats TE, Dalinka MK,
Alazraki N, Berquist TH, Daffner RH, DeSmet AA, el-Khoury GY, Goergen
TG, Manaster BJ, Newberg A, Pavlov H, Schweitzer ME, Haralson RH 3rd,
McCabe JB. Hip arthroplasty\--radiography procedure recommendations.
American College of Radiology. ACR Appropriateness Criteria. Radiology.
2000 Jun;215 Suppl:389-90.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonMusculoskeletalImaging/ImagingafterTotalHipArthroplastyDoc12.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on February 10, 2006. This
summary was updated by ECRI Institute on May 17, 2007 following the U.S.
Food and Drug Administration (FDA) advisory on Gadolinium-based contrast
agents. This summary was updated by ECRI Institute on June 20, 2007
following the U.S. Food and Drug Administration (FDA) advisory on
gadolinium-based contrast agents.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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Guidelines represented on the NGC Web site are submitted by guideline
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Date Modified: 11/3/2008