Relative radiographic bone density measurement in revision hip arthroplasty and its correlation with qualitative subjective assessment by experienced surgeons

Abstract

BACKGROUND:

Conventional radiography (CR) is the imaging method of choice in monitoring bone remodelling and other stability parameters after total hip arthroplasty (THA). Quantitative roentgen- or computed-tomography-based methods to determine bone density are prone to metal artifacts and often very costly, which is why they are not used as standard in a clinical setting. Since subjective assessment of bone remodelling in CR also has a certain susceptibility to errors, semi-quantitative methods have been developed to help approximate periprosthetic bone density development via CR to open up an additional tool for documentation of radiographic THA follow-up.

OBJECTIVE:

Proof-of-principle of a newly designed imaging-software-aided method to measure relative bone density around the femoral stem in a series of conventional radiographs following THA.

METHODS:

Eighty-six patients with hip modular tapered, fluted titanium stems were selected from the clinical database and series of baseline and postoperative follow-up radiographs were obtained after 24 and 48 weeks. Relative bone densities were measured per Gruen zones G1-7 with the use of an open-source image analysis package (ImageJ) by means of greyscale histograms. In addition, subjective evaluation of selected cases was performed by three independent, blinded orthopedic surgeons. Besides descriptive and nonparametric analyses, intra-class correlation (ICC) was performed and objective and subjective results were compared by linear regression analysis.

RESULTS:

Two individual cases are presented as a proof-of-principle. Increase or decrease of bone density could be measured correctly over time in each case. In a collective analysis there were no significant differences in mean relative bone densities between groups after 24 and 48 weeks, although a positive tendency was visible towards increased bone formation over time. Individual analyses by Gruen zones revealed that some zones, namely the proximal ones (e.g. G6), exhibit a broader scattering than others over time. This could be explained by the design of the evaluated tapered revision stem that achieves distal fixation and allows for proximal micromotion. Correlation analysis with subjective ratings (inter-rater reliability ICC $=$ 0.71) showed a positive correlation with objective results, suggesting a feasibility of the method for clinical use.

CONCLUSIONS:

In conclusion the presented method is an easy and accessible tool to quantify relative bone density changes during THA follow-up. It shows a positive correlation to established subjective assessment of bone remodelling and may therefore serve as a quantitative supplement in clinical documentation.