Background: The evaluation of periprosthetic osteolysis in patients who have had a total hip arthroplasty is challenging, and traditional imaging techniques, including magnetic resonance imaging and computerized tomography, are limited by metallic artifact. The purpose of the present study was to investigate the use of modified magnetic resonance imaging techniques involving commercially available software to visualize periprosthetic soft tissues, to define the bone-implant interface, and to detect the location and extent of osteolysis. Methods: Twenty-eight hips in twenty-seven patients were examined to assess the extent of osteolysis (nineteen hips), enigmatic pain (five), heterotopic ossification (two), suspected tumor (one), or femoral nerve palsy (one). The results were correlated with conventional radiographic findings as well as with intraoperative findings (when available). Results: Magnetic resonance imaging demonstrated the bone-implant interface and the surrounding soft-tissue envelope in all hips. Radiographs consistently underestimated the extent and location of acetabular osteolysis when compared with magnetic resonance imaging. Magnetic resonance imaging also disclosed radiographically occult extraosseous soft-tissue deposits that were similar in signal intensity to areas of osteolysis, demonstrated the relationship of these deposits to adjacent neurovascular structures, and allowed further visualization of hypertrophic synovial deposits that accompanied the bone resorption in twenty-five of the twenty-eight hips. Conclusions: Magnetic resonance imaging is effective for the assessment of the periprosthetic soft tissues in pa-NOTE: The authors thank Drs. Mathias Bostrom, Robert L. Buly, and Steven B. Haas for providing case material. We also acknowledge

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Modular augmented stems of a constrained condylar knee implant are intended to improve tibial fixation under increased varus/valgus loads, but conflicting studies have not yet indicated the factors determining stem usage and performance. To address this, we combined a paired-tibiae, cadaveric experiment of unstemmed and stemmed tibial components with specimen-specific computational models. We hypothesized that the stem would improve implant stability by decreasing implant motion and compressive strains in the proximal cancellous bone due to load transfer by the stem. The models also would indicate the important factors governing stem performance. Large variations of the displacements arose because of loading and biologic variability indicating the inconclusive effects of a stem. Despite these variations, the models showed that a stem augment consistently decreased the strains (30%-50%) in the bone beneath the tray. In tibiae of sufficient stiffness, the supporting cancellous bone did not approach yield, suggesting that a stem augment may not always be necessary. On the other hand, tibial specimens with reduced bone quality and lower stiffness benefited from a stem augment that transferred load to the distal cortical bone. Therefore, patient selection and proper sizing of the implant were identified as important factors in the analyses.

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Revision total hip arthroplasty remains one of the most challenging procedures for the orthopaedic surgeon. The number and complexity of revision cases is likely to increase dramatically in the upcoming years as the population ages. Thorough preoperative planning is crucial to minimize operating room time and maximize patient outcome. While templating the radiographs and selecting the implants remain critical components of the preoperative process, other elements include a thorough history and physical examination, proper radiographic evaluation, assessment of bone deficiencies, medical clearance, assessment of infection, choice of anesthesia, blood management, preparation for prevention of heterotopic ossification, and frank discussion with the patient about outcome. The above steps in the preoperative process are discussed with illustrative case studies, experience of the authors, and review of the literature.