European Radiology

, Volume 29, Issue 3, pp 1258–1266 | Cite as

Comparison of radiographs, tomosynthesis and CT with metal artifact reduction for the detection of hip prosthetic loosening

  • Romain GilletEmail author
  • Pedro Teixeira
  • Chloé Bonarelli
  • Henry Coudane
  • François Sirveaux
  • Mathias Louis
  • Alain Blum



To evaluate the diagnostic performance of digital tomosynthesis (DTS) for the diagnosis of hip prosthesis loosening (PL) compared with conventional radiographs and CT with metal artifact reduction (CT-MAR).


Forty-nine patients with painful hip prosthesis were prospectively included and underwent anteroposterior and lateral radiographs, anteroposterior DTS and CT-MAR of the hip. This study was approved by the local ethics committee, and all patients signed an informed consent form. Images were evaluated independently by two radiologists. Periprosthetic radiolucent lines wider than 2 mm found in two or more Gruen or De Lee and Charnley zones were considered diagnostic of PL. All cases of PL were confirmed surgically. Patients with a stable radiological follow-up for at least 1 year with an alternative cause for the symptoms or with no surgical evidence of PL were considered PL negative.


There were 21 cases of PL, 9 unilateral and 12 bilateral. For both the acetabular and femoral sides, DTS had a specificity for PL detection similar to that of conventional radiographs and CT-MAR (98.5–100%, 96.9%–100% and 96.9–95.4% respectively for both readers) and a sensitivity similar to conventional radiographs (39.9–45.4% versus 33.3–51.5% for both readers) but lower than CT-MAR (84.85% for both readers). The interobserver agreement was 0.84 for CT-MAR, 0.53 for DTS and 0.39 for conventional radiographs.


DTS has a similar diagnostic performance to radiographs for the diagnosis of PL with a better interobserver agreement. The sensitivity however remains lower than that of CT-MAR.

Key Points

• Plain radiograph is still the first imaging step when hip prosthesis loosening is suspected.

• Interobserver agreement is better with digital tomosynthesis than radiographs.

• Sensitivity of CT with state-of-the-art metal artifact reduction is superior to that of digital tomosynthesis.


Prosthesis loosening Diagnostic techniques and procedures Hip replacement arthroplasty Interobserver variation Tomography, x-ray computed 



Body-mass index


Computed tomography with metal artifact reduction algorithms


Digital tomosynthesis


Prosthesis loosening


Radiolucent zones






Total hip arthroplasty



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is Prof. Alain Blum.

Conflict of interest

The authors of this manuscript declare relationships with the following companies: non-remunerated research contract with Toshiba Medical Systems for the development and clinical testing of post processing tools for MSK CT (Prof. Alain Blum and Prof. Pedro Augusto Teixeira). The other authors have no potential conflicts of interest to disclose.

Statistics and biometry

One of the authors has significant statistical expertise (Dr. Romain Gillet).

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• prospective

• diagnostic study

• performed at one institution


  1. 1.
    Nemes S, Gordon M, Rogmark C, Rolfson O (2014) Projections of total hip replacement in Sweden from 2013 to 2030. Acta Orthop 85:238–243Google Scholar
  2. 2.
    Labek G, Thaler M, Janda W, Agreiter M, Stöckl B (2011) Revision rates after total joint replacement: cumulative results from worldwide joint register datasets. J Bone Joint Surg Br 93:293–297Google Scholar
  3. 3.
    Delaunay C, Hamadouche M, Girard J, Duhamel A; SoFCOT Group (2013) What are the causes for failures of primary hip arthroplasties in France? Clin Orthop Relat Res 471:3863–3869Google Scholar
  4. 4.
    Duffy PJ, Masri BA, Garbuz DS, Duncan CP (2005) Evaluation of patients with pain following total hip replacement. J Bone Joint Surg Am 87:2565–2575Google Scholar
  5. 5.
    Patel AR, Sweeney P, Ochenjele G, Wixson R, Stulberg SD, Puri LM (2015) Radiographically silent loosening of the acetabular component in hip arthroplasty. Am J Orthop (Belle Mead NJ) 44:406–410Google Scholar
  6. 6.
    Eklund K, Jonsson K, Lindblom G et al (2004) Are digital images good enough? A comparative study of conventional film-screen vs digital radiographs on printed images of total hip replacement. Eur Radiol 14:865–869Google Scholar
  7. 7.
    Claus AM, Engh CA Jr, Sychterz CJ, Xenos JS, Orishimo KF, Engh CA Sr (2003) Radiographic definition of pelvic osteolysis following total hip arthroplasty. J Bone Joint Surg Am 85:1519–1526Google Scholar
  8. 8.
    Blum A, Meyer JB, Raymond A et al (2016) CT of hip prosthesis: new techniques and new paradigms. Diagn Interv Imaging 97:725–733Google Scholar
  9. 9.
    Gondim Teixeira PA, Meyer JB, Baumann C et al (2014) Total hip prosthesis CT with single-energy projection-based metallic artifact reduction: impact on the visualization of specific periprosthetic soft tissue structures. Skeletal Radiol 43:1237–1246Google Scholar
  10. 10.
    Roth TD, Maertz NA, Parr JA, Buckwalter KA, Choplin RH (2012) CT of the hip prosthesis: appearance of components, fixation, and complications. Radiographics 32:1089–1107Google Scholar
  11. 11.
    Chen Z, Pandit H, Taylor A, Gill H, Murray D, Ostlere S (2011) Metal-on-metal hip resurfacings—a radiological perspective. Eur Radiol 21:485–491Google Scholar
  12. 12.
    Laukamp KR, Lennartz S, Neuhaus VF et al (2018) CT metal artifacts in patients with total hip replacements: for artifact reduction monoenergetic reconstructions and post-processing algorithms are both efficient but not similar. Eur Radiol.
  13. 13.
    Lee YH, Park KK, Song HT, Kim S, Suh JS (2012) Metal artefact reduction in gemstone spectral imaging dual-energy CT with and without metal artefact reduction software. Eur Radiol 22:1331–1340Google Scholar
  14. 14.
    West AT, Marshall TJ, Bearcroft PW (2009) CT of the musculoskeletal system: what is left is the days of MRI? Eur Radiol 19:152–164Google Scholar
  15. 15.
    Agten CA, Sutter R, Dora C, Pfirrmann CW (2017) MR imaging of soft tissue alterations after total hip arthroplasty: comparison of classic surgical approaches. Eur Radiol 27:1312–1321Google Scholar
  16. 16.
    Kretzschmar M, Nardo L, Han MM et al (2015) Metal artefact suppression at 3 T MRI: comparison of MAVRIC-SL with conventional fast spin echo sequences in patients with hip joint arthroplasty. Eur Radiol 25:2403–2411Google Scholar
  17. 17.
    Fritz J, Lurie B, Miller TT, Potter HG (2014) MR imaging of hip arthroplasty implants. Radiographics 34:E106–E132Google Scholar
  18. 18.
    Fritz J, Lurie B, Miller TT (2013) Imaging of hip arthroplasty. Semin Musculoskelet Radiol 17:316–327Google Scholar
  19. 19.
    Blum A, Noël A, Regent D, Villani N, Gillet R, Gondim Teixeira P (2018) Tomosynthesis in musculoskeletal pathology. Diagn Interv Imaging 99:423–441Google Scholar
  20. 20.
    Machida H, Yuhara T, Tamura M et al (2016) Whole-body clinical applications of digital tomosynthesis. Radiographics 36:735–750Google Scholar
  21. 21.
    Geijer M, Gunnlaugsson E, Götestrand S, Weber L, Geijer H (2017) Tomosynthesis of the thoracic spine: added value in diagnosing vertebral fractures in the elderly. Eur Radiol 27:491–497Google Scholar
  22. 22.
    Gomi T, Hirano H (2008) Clinical potential of digital linear tomosynthesis imaging of total joint arthroplasty. J Digit Imaging 21:312–322Google Scholar
  23. 23.
    Gomi T, Hirano H, Umeda T (2009) Evaluation of the X-ray digital linear tomosynthesis reconstruction processing method for metal artifact reduction. Comput Med Imaging Graph 33:267–274Google Scholar
  24. 24.
    Gomi T, Sakai R, Goto M, Watanabe Y, Takeda T, Umeda T (2016) Comparison of reconstruction algorithms for decreasing the exposure dose during digital tomosynthesis for arthroplasty: a phantom study. J Digit Imaging 29:488–495Google Scholar
  25. 25.
    Guo S, Tang H, Zhou Y, Huang Y, Shao H, Yang D (2017) Accuracy of digital tomosynthesis with metal artifact reduction for detecting osteointegration in cementless hip arthroplasty. J Arthroplasty.
  26. 26.
    Göthlin JH, Geijer M (2013) The utility of digital linear tomosynthesis imaging of total hip joint arthroplasty with suspicion of loosening: a prospective study in 40 patients. Biomed Res Int 2013:1–6Google Scholar
  27. 27.
    Tang H, Yang D, Guo S et al (2016) Digital tomosynthesis with metal artifact reduction for assessing cementless hip arthroplasty: a diagnostic cohort study of 48 patients. Skeletal Radiol 45:1523–1532Google Scholar
  28. 28.
    Chang YB, Xu D, Zamyatin AA (2012) Metal artifact reduction algorithm for single energy and dual energy CT scans. In: 2012 IEEE Nuclear Science Symposium and Medical Imaging Conference Record (NSS/MIC), Anaheim, CA, 2012, pp. 3426–3429Google Scholar
  29. 29.
    Christner JA, Kofler JM, McCollough CH (2010) Estimating effective dose for ct using dose–length product compared with using organ doses: consequences of adopting International Commission on Radiological Protection Publication 103 or dual-energy scanning. AJR Am J Roentgenol 194:881–889Google Scholar
  30. 30.
    DeLee JG, Charnley J (1976) Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res 20–32Google Scholar
  31. 31.
    Gruen TA, McNeice G, Amstutz HC (1979) “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 141:17–2723Google Scholar
  32. 32.
    Abrahams JM, Kim YS, Callary SA et al (2017) The diagnostic performance of radiographic criteria to detect aseptic acetabular component loosening after revision total hip arthroplasty. Bone Joint J 99-B:458–464Google Scholar
  33. 33.
    Wu T, Moore RH, Rafferty EA, Kopans DB (2004) A comparison of reconstruction algorithms for breast tomosynthesis. Med Phys 31:2636–2647Google Scholar
  34. 34.
    Mermuys K, De Geeter F, Bacher K et al (2010) Digital Tomosynthesis in the detection of urolithiasis: diagnostic performance and dosimetry compared with digital radiography with MDCT as the reference standard. AJR Am J Roentgenol 195:161–167Google Scholar
  35. 35.
    Ha AS, Lee AY, Hippe DS, Chou SH, Chew FS (2015) Digital tomosynthesis to evaluate fracture healing: prospective comparison with radiography and CT. AJR Am J Roentgenol 205:136–141Google Scholar
  36. 36.
    Simoni P, Gérard L, Kaiser MJ et al (2015) Use of Tomosynthesis for detection of bone erosions of the foot in patients with established rheumatoid arthritis: comparison with radiography and CT. AJR Am J Roentgenol 205:364–370Google Scholar
  37. 37.
    Canella C, Philippe P, Pansini V, Salleron J, Flipo RM, Cotten A (2011) Use of tomosynthesis for erosion evaluation in rheumatoid arthritic hands and wrists. Radiology 258:199–205Google Scholar
  38. 38.
    Ottenin MA, Jacquot A, Grospretre O et al (2012) Evaluation of the diagnostic performance of tomosynthesis in fractures of the wrist. AJR Am J Roentgenol 198:180–186Google Scholar
  39. 39.
    Becker AS, Martini K, Higashigaito K, Guggenberger R, Andreisek G, Frauenfelder T (2017) Dose reduction in tomosynthesis of the wrist. AJR Am J Roentgenol 208:159–164Google Scholar
  40. 40.
    Machida H, Yuhara T, Tamura M et al (2012) Radiation dose of digital tomosynthesis for sinonasal examination: comparison with multi-detector CT. Eur J Radiol 81:1140–1145Google Scholar
  41. 41.
    Lacout A, Thariat J, Hajjam ME, Marcy PY (2013) Insight into osteo-articular digital tomosynthesis: a pictorial essay: osteo-articular digital tomosynthesis. J Med Imaging Radiat Oncol 57:45–49Google Scholar
  42. 42.
    Lombard C, Gervaise A, Villani N et al (2018) The impact of dose reduction in quantitative kinematic CT of ankle joints using a full model-based iterative reconstruction algorithm: a cadaveric study. AJR Am J Roentgenol 210:396–403Google Scholar
  43. 43.
    Gervaise A, Osemont B, Lecocq S et al (2012) CT image quality improvement using adaptive iterative dose reduction with wide-volume acquisition on 320-detector CT. Eur Radiol 22:295–301Google Scholar
  44. 44.
    Gervaise A, Teixeira P, Villani N, Lecocq S, Louis M, Blum A (2013) CT dose optimisation and reduction in osteoarticular disease. Diagn Interv Imaging 94:371–388Google Scholar
  45. 45.
    Gervaise A, Osemont B, Louis M, Lecocq S, Teixeira P, Blum A (2014) Standard dose versus low-dose abdominal and pelvic CT: comparison between filtered back projection versus adaptive iterative dose reduction 3D. Diagn Interv Imaging 95:47–53Google Scholar
  46. 46.
    Kim YS, Abrahams JM, Callary SA et al (2017) Proximal translation of > 1 mm within the first two years of revision total hip arthroplasty correctly predicts whether or not an acetabular component is loose in 80% of cases: a case-control study with confirmed intra-operative outcomes. Bone Joint J 99-B:465–474Google Scholar
  47. 47.
    Hayashi D, Xu L, Gusenburg J et al (2014) Reliability of semiquantitative assessment of osteophytes and subchondral cysts on tomosynthesis images by radiologists with different levels of expertise. Diagn Interv Radiol 20:353–359Google Scholar
  48. 48.
    Tucker L, Gilbert FJ, Astley SM et al (2017) Does reader performance with digital breast tomosynthesis vary according to experience with two-dimensional mammography? Radiology 283:371–380Google Scholar

Copyright information

© European Society of Radiology 2018

Authors and Affiliations

  1. 1.Service d’Imagerie GUILLOZ, Hôpital CentralCHRU de NancyNancyFrance
  2. 2.Service d’Arthroscopie, Traumatologie et Orthopédie de l’Appareil Locomoteur, Hôpital CentralCHRU de NancyNancyFrance
  3. 3.Centre Chirurgical Emile GalléCHRU de NancyNancyFrance

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