Orthopedic Appliances and Prostheses

Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 16 – Orthopedic Appliances and Prostheses

Chapter 16
Orthopedic Appliances and Prostheses
Thomas H. Berquist
Internal Fixation Systems


FIGURE 16-1 Screws. (A) Fully threaded cortical and partially threaded cancellous screws (courtesy of Zimmer, Warsaw, IN). (B) Interference screws. Anteroposterior (AP) (C) and lateral (D)
radiographs of the knee after anterior cruciate ligament repair. The
interference screws secure the bone plugs at the ends of the tendon


FIGURE 16-2 Soft tissue anchors. (A) Revo cancellous screw and suture for anchoring soft tissues (courtesy of Linvatec, Largo, FL). (B) Shoulder radiograph after rotator cuff repair using soft tissue anchors. One of the anchors (arrow) has pulled out.


FIGURE 16-3 Plate and screw fixation. (A)
Straight dynamic compression plates (1), one-third tubular plate (3),
T-buttress (4), and L-buttress plates (5), cloverleaf plate (olecranon
fixation) (6), spoon plate (7), and condylar buttress plate (distal
femur) (8). (B) Midhumeral fracture internally fixed with a dynamic compression plate and cortical screws. (C,D) Tibial plateau fracture reduced using a T-buttress plate, and proximal cancellous (arrowheads) and distal cortical screws.


FIGURE 16-4 Dynamic compression screw. (A) Dynamic compression screws with side plates of different lengths and femoral neck angles. (B) Intertrochanteric fracture reduced using a dynamic hip screw and four-hole side plate with cortical screws.


FIGURE 16-5 Intramedullary nails. Solid (A) and hollow (B) intramedullary nails with proximal and distal holes for screws. AP (B) and lateral (C)
radiographs of a midtibial fracture with static (screws at both ends)
intramedullary nail fixation. The fracture margins are sclerotic (arrow) because of delayed union.
FIGURE 16-6 Implant failure. AP radiograph of the right femur with fracture of the side plate and several screws.


Suggested Reading
Behrens F. A primer of fixation devices and configurations. Clin Orthop 1989;24:5–14.
Berquist TH, Broderson MP. General orthopedic fixation devices. In: Berquist TH, ed. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995:45–108.


External Fixation Systems


FIGURE 16-7 Fisher external fixation. (A) Fisher fixation system. (B) Radiograph of a refractured femur reduced using Fisher external fixation.


FIGURE 16-8 Colles fracture with external fixation. The system (arrowhead) allows wrist motion. Posteroanterior PA (A) and lateral (B) radiographs showing external fixation of a Colles fracture. Note the proximal pin (open arrow) has fractured the distal cortex.
Suggested Reading
Behrens F. General theory and principles of external fixation. Clin Orthop 1989;241:15–23.
Berquist TH, Broderson MP. General orthopedic fixation devices. In: Berquist TH, ed. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995:45–108.




FIGURE 16-9 Traction. (A) Thomas splint for lower extremity traction (courtesy of Zimmer, Warsaw, IN). AP (B) and lateral (C) radiographs of a supracondylar femur fracture treated in traction. There are two threaded traction pins in the upper tibia.
Suggested Reading
Berquist TH, Brodersen MP. General orthopedic fixation devices. In: Berquist TH, ed. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995:45–108.


Spinal Instrumentation: Long Segment Instrumentation


FIGURE 16-10 Posterior long segment instrumentation. (A,B) Luque instrumentation. (A) Smooth Luque rods, sublaminar wires, and proximal and distal “H” bars (arrowheads). (B) PA radiograph with multiple Luque rods, sublaminar wires, and proximal and distal cross links (arrowheads). (C,D) Cotrel-Dubousset instrumentation. (C) Diamond-point surface rods with hooks and cross links. (D) PA radiograph after Cotrel-Dubousset instrumentation.


FIGURE 16-11 Rod fracture. AP radiograph of fracture of Luque rods caused by pseudarthrosis.
Suggested Reading
Dawson EG, Clader TJ, Bassett LW. A comparison of different methods used to diagnose pseudarthrosis. J Bone Joint Surg 1985;67A:1153–1159.
Ohashi K, Bennet DL, Restrepo JM, et al. Orthopedic hardware complications diagnosed with multidetector row CT. Radiology 2005;237:570–577.


Spinal Instrumentation: Short Segment Instrumentation


FIGURE 16-12 Trauma: fracture/dislocation at T12. AP (A) and lateral (B)
radiographs showing reduction using Isola rods, with pedicle screws at
L1 and L2 and hooks proximally. Generally, fixation should include two
to three vertebrae above and below the injury.


FIGURE 16-13 Vertebral body replacement. AP (A) and lateral (B) radiographs showing a titanium interbody cage and anterior vertebral body screws and rods (Kenada device) for fixation.


FIGURE 16-14 Pedicle screw complications. Axial CT image (A) demonstrating good positioning of pedicle screws in the pedicle and body (thick arrows) of L5. AP radiograph after myelography (B) demonstrates rod and pedicle screw instrumentation from L3 to the sacrum. Coronal CT image (C) shows the lower right pedicle screw extending into the foramen (arrow).


FIGURE 16-15 AP (A) and lateral (B)
radiographs with plate and pedicle screw instrumentation posteriorly
and a bone graft in the L4–5 disc. The graft has displaced posteriorly (arrow) into the spinal canal resulting in neurologic deficit.
Suggested Reading
D, Bauer TW, Lieberman IH, et al. Lumbar intervertebral body fusion
cages: Histologic evaluation of clinically failed cages retrieved from
humans. J Bone Joint Surg 2004;86A:70–79.
Tropiano P, Huang RC, Girardi FP, et al. Lumbar total disc replacement. J Bone Joint Surg 2006;88A:50–64.
West JL, Ogilvie JW, Bradford DS. Complications of the variable plate pedicle screw fixation. Spine 1991;16:576–579.


Shoulder Arthroplasty


FIGURE 16-16 Shoulder arthroplasty components. (A) Fenlin total shoulder system. Cobalt-chromium-molybdenum humeral components with three proximal fins and holes (arrowheads)
for soft tissue attachment. Modular heads are on top and barbed keel
glenoid components are below (courtesy of Zimmer, Warsaw, IN). (B) Total shoulder II with four stem configurations and an all-polyethylene glenoid component (curved arrow). (Courtesy of Zimmer, Warsaw, IN.)


FIGURE 16-17 Hemiarthroplasty. AP radiographs showing a modular DePuy humeral component. There is no glenoid component.


FIGURE 16-18 Delta III inverted shoulder prosthesis for patients with severe rotator cuff deficiency. (A) Photograph of the components with the ball on the glenoid side (DePuy France, Saint Priest CEDEX, France). (B) AP radiograph after placement of a Delta system.


FIGURE 16-19 Glenoid component loosening. (A) Fluoroscopically positioned AP radiograph showing a cemented glenoid component (arrowheads) with no lucency. (B) Fluoroscopically positioned radiograph showing wide lucent lines at the bone–cement interface (arrowheads) of the polyethylene glenoid component caused by loosening.


FIGURE 16-20
Loose, infected humeral component. AP radiograph showing wide irregular
lucency about the cement with a distal cement fracture (arrow) caused by loosening. There is diffuse periostitis and cortical destruction caused by infection.
Suggested Reading
Craig EV. Total shoulder replacement. Orthopedics 1988;11:125–136.
M, Siegal S, Pupello D, et al. The reverse shoulder prosthesis for
glenohumeral arthritis associated with severe rotator cuff deficiency. J Bone Joint Surg 2005;87A:1697–1705.


Elbow Arthroplasty


FIGURE 16-21 (A) Coonrad-Morrey elbow prosthesis with polyethylene hinge, beaded stems, and anterior extension on the humeral component (arrow). AP (B) and lateral (C) radiographs of a Coonrad-Morrey arthroplasty.


FIGURE 16-22 Loose implant. AP (A) and lateral (B) radiographs showing a grossly loose ulnar component caused by toggling.
Suggested Reading
Cooney WP. Elbow arthroplasty: Historical perspective and current concepts. In: Morrey BF, ed. The elbow and its disorders, 3rd ed. Philadelphia: WB Saunders; 2000:583–601.
Morrey BF. Complication of elbow replacement surgery. In: Morrey BF, ed. The elbow and its disorders, 3rd ed. Philadelphia: WB Saunders; 2000:667–677.


Wrist Arthroplasty


Complication Incidence
Soft tissue imbalance 20%–35%
Soft tissue contracture 12%
Cement fracture/loosening 4%–30%
Dislocation 4%–10%
Tendon rupture 6%
Component fracture 8%–20%
Nerve compression 2%–3%
Deep infection 1%
Soft tissue imbalance Motion studies
Soft tissue contracture Serial radiographs
Cement fracture/loosening Serial radiographs
Dislocation Serial radiographs
Tendon rupture MRI
Component fracture Serial radiographs
Infection MRI, aspiration
Silicone synovitis MRI with contrast



FIGURE 16-23 Wrist arthroplasty implants. (A)
Meuli implant. The distal cupped component is placed in the second and
third metacarpals (M), and the proximal trunnion stems are in the
radius (R). (From

Beckenbaugh RD. Total joint arthroplasty: the wrist. Mayo Clin Proc 1979;54:513–515.

) (B) Radiograph of the Meuli prosthesis. The distal ulna was resected. Note the second metacarpal stem (arrow) is eroding the cortex. (C) A.M.C. wrist implant. (Courtesy of Howmedica, Rutherford, NJ.) (D) Radiograph of the A.M.C. implant.


FIGURE 16-24 Wrist arthroplasty complications. (A) Loose Meuli metacarpal components with lucency around the second metacarpal stem and cortical breakthrough of the third. (B) Lateral radiograph demonstrating a dorsal dislocation.
Suggested Reading
Beckenbaugh RD. Arthroplasty of the wrist. In: Morrey BF, ed. Reconstructive surgery of the joints, 2nd ed. New York: Churchill Livingstone; 1996:387–410.


Carpal and Thumb Arthroplasties


FIGURE 16-25 Thumb/carpal implants. (A) Radiograph of a medullary stem silicone trapezial implant (arrow). (B,C) Mayo trapeziometacarpal arthroplasty. The center of rotation (+) is at the base of the first metacarpal. (C) Radiograph of the implant in place. (From

Cooney WP, Linscheid RL, Ashew L. Total arthroplasty of the thumb trapeziometacarpal joint. Clin Orthop 1987;320:35–45.



FIGURE 16-26 Silicone-induced osteolysis. (A) Radiograph of the thumb showing bone resorption (osteolysis) around the stem of the implant (arrows). (B) T2-weighted MRI in a different patient with fracture of the silicone implant (arrowhead) and synovitis (short arrow).
Suggested Reading
Cooney WP. Arthroplasty of the thumb axis. In: Morrey BF, ed. Reconstructive surgery of the joints, 2nd ed. New York: Churchill Livingstone; 1996:313–339.
Murray PM, Wood MB. The results of treatment of synovitis of the wrist induced by particles of silicone debris. J Bone Joint Surg 1998;80A:397–406.


Metacarpophalangeal and Interphalangeal Arthroplasty
Complication Incidence Imaging Technique
Silicone fracture 5%–11% Serial radiographs
Loosening 10% Serial radiographs, CT
Heterotopic ossification 27% Serial radiographs
Tendon erosion Unknown MRI
Bone erosion Unknown CT
Silicone synovitis 15%–55% MRI with contrast
CT, computed tomography; MRI, magnetic resonance imaging.


FIGURE 16-27 MCP and proximal interphalangeal implants. (A)
Categories of hand implants: A, resection arthroplasty; B,
interposition arthroplasty; C, condylar replacement; D, ball-and-socket
configuration; E, interlocking hinges; F, flexible Silastic implant.

Berquist TH. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995.

) (B) AP radiograph showing Silastic MCP implants with metal grommets to reduce wear. (C) Lateral radiograph showing Meuli wrist and Mayo interphalangeal joint implants (metal and plastic hinge).


FIGURE 16-28 Complications. (A) PA radiograph showing heterotopic bone (white arrow) and lucency about the distal stem (black arrow) caused by loosening. (B) Failed double-stem silicone implant with erosion through the cortex and a large granuloma (arrow).
Suggested Reading
Carter PR, Benton LJ, Dysert PA. Silicone rubber carpal implant: A study of the incidence of late osseous complications. J Hand Surg 1986;11A:639–644.
Linscheid RL, Dobyns JH. Total joint arthroplasty: The hand. Mayo Clin Proc 1979;54:516–526.
NH, Pessis E, Lecompte M, et al. MR imaging of the metacarpophalangeal
joints of the fingers: Evaluation of 38 patients with chronic
disability. Skel Radiol 2005;34:210–216.


Hip Arthroplasty
Complication/Features Incidence Imaging Techniques
Acetabular loosening
Lucent lines >2 mm
Cement fracture
2%–8% Serial radiographs, subtraction arthrograms, PET
Femoral loosening
Varus migration
Cement fracture
Lucent lines >2 mm
Cement voids >50%
6%–18% Serial radiographs, subtraction arthrograms, radionuclide scans, PET
Signs of loosening
Endosteal scalloping
2%–3% Serial radiographs, arthrogram/aspiration, technetium/white blood cell or antigranulocyte antibody scans, PET
Dislocations 3%–4.8% Serial radiographs (usually with early ambulation)
Pseudobursa 43% Subtraction arthrograms
Osteolysis 5%–7% Serial radiographs, CT
Greater trochanteric nonunion/avulsion 5% Serial radiographs
Femoral/acetabular fractures 1%–2% Serial radiographs
PET, positron emission tomography; CT, computed tomography.



FIGURE 16-29 Hip arthroplasty components. (A) Unipolar Moore prosthesis (courtesy of Zimmer, Warsaw, IN). (B) Radiograph of the Moore prosthesis. (C) Photographs of hip systems with (arrowhead) and without collars. (A) Porous-coated anatomic (PCA) with long stem; (B) PCA with medium stem; (C) PCA with short stem; (D) Precision stem with medial collar (arrowhead); (E,F) Precision stems with distal centralizer in F (arrow). Top: 32- and 26-mm heads. Bottom: Acetabular components seen from the attachment side (G–J) and (D) radiograph of a bipolar component. Note the cup (arrow) encloses the head of the femoral component. (From

Berquist TH, ed. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995.

) (E) Radiograph of a total hip arthroplasty with cemented femoral and uncemented acetabular components.



FIGURE 16-30 Normal postoperative features. (A)
AP radiograph showing zones for the acetabular (I–III) and femoral
(1–7) components used to evaluate lucent lines and cement technique.
There are no lucent lines at the bone–cement interface (arrowheads) of the femoral component or metal–bone interface of the acetabular component. (B)
The acetabular component should be angled 45 degrees (35–55 degrees
accepted) to the ischial tuberosity line. This line measures leg length
changes as it intersects the lesser trochanter. Note the irregular
lucency (arrow) indicating a loose right acetabular component. (C)
Lateral radiograph demonstrating the angle formed by the acetabular
component to a vertical line is 15 degrees (normal–neutral to 15



FIGURE 16-31 Hip arthroplasty complications. (A) Radiograph showing a lucent line around the tip of the femoral component (arrow). (B) Subtraction arthrogram showing contrast around the femoral stem (open arrows) and in all three zones of the acetabular component caused by loosening. (C) Infection and loosening. Subtraction arthrogram showing contrast in zones I and III about the acetabular component (open curved arrows) and around the upper femoral component caused by loosening. There is an irregular pseudocapsule and communicating abscess (solid arrows). (D,E) Axial (D) and coronal (E) CT images demonstrate advanced osteolysis about the acetabular components bilaterally. (F)
Radionuclide scan 2 years after surgery (scans can be positive for up
to 1 year) demonstrating intense increased tracer around the femoral
component caused by loosening and infection.


Suggested Reading
Berquist TH. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995:266–351.
DJ, Harmsen WS, Cabanela ME, et al. Twenty-five year survivorship of
two thousand consecutive primary Charnley total hip replacements.
Factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg 2002;84A:171–177.


Knee Arthroplasty


Complication Incidence Imaging Techniques
Extensor mechanism 4%–41% Serial radiographs, flexion extension axial images
Loosening 2%–5% Serial radiographs, radionuclide scans, CT
Deep infection 1%–2.2% Serial radiographs, combined
Technetium/WBC or antigranulocyte antibody scans, PET, joint aspiration
Instability 13% Stress views
Fractures 1.2%–3% Serial radiographs
Polyethylene wear   Serial radiographs, CT
Osteolysis 7% Serial radiographs, CT
Peroneal nerve palsy 1% MRI
Deep venous thrombosis 0.4%–3% Ultrasonography
WBC, white blood cell; PET, positron emission tomography; CT, computed tomography; MRI, magnetic resonance imaging.


FIGURE 16-32 Knee components. (A) Femoral components for revision (1), cruciate sparing (2), and posterior stabilized with standard (3) and porous coating (4). (B) Tibial component (1) with polyethylene spacer (arrowhead) and augmentation stem for revision (arrow). Conventional tibial component with metal tray (2) and all-polyethylene tibial component (3). (C) All-polyethylene (1) and metal-backed (2) patellar components.


FIGURE 16-33
Normal postoperative appearance and component position. Fluoroscopic
positioning is preferred to evaluate component interfaces. (A)
Standing AP of the knees. Tibial tray should be 90 degrees to the
tibial axis (R = 88 degrees, L = 90 degrees). Angles <90 degrees =
varus; >90 degrees = valgus. Femoral component should be at 98
degrees to the femoral shaft. (B) On the
lateral radiograph, the tibial tray should be 90 degrees to the tibial
axis. <90 degrees = flexion; >90 degrees = extension. The femoral
component should be perpendicular to the femoral axis. The patella
should be 9 to 10 mm above the polyethylene margin (lines, arrows). (C) Normally positioned patella on the sunrise view.


FIGURE 16-34 Complications. Patellar (A) and lateral (B) radiographs of displaced patellar components. (C) Notch view demonstrating a fractured tibial tray (arrow).


FIGURE 16-35 Infection and loosening. (A) Lateral radiograph demonstrating osteolysis in the posterior femur and tibia (arrows). Technetium-99m methylene-diphosphonate (B) and indium-111–labeled leukocyte scans (C) showing increased tracer in the knee caused by infection and loosening.
Suggested Reading
Berquist TH. Imaging atlas of orthopedic appliances and prostheses. New York: Raven Press; 1995:437–539.
S, Mowat F, Ong K, et al. Prevalence of primary revision of total hip
and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg 2005;87A:1487–1497.
Rand JA, Trousdale RT, Ilstrup DM, et al. Factors affecting the durability of primary total knee prostheses. J Bone Joint Surg 2003;85A:259–265.


Ankle Arthroplasty
Complication Incidence Imaging Techniques
Subtalar arthrosis 19% Serial radiographs
Loosening 14%–24% Serial radiographs, CT
Deep infection 1.5%–3% Serial radiographs, radionuclide scans, joint aspiration
Wound healing 3.5%–4% Clinical diagnosis
Polyethylene fracture 4% Serial radiographs
Tibial component fracture 2% Serial radiographs
Impingement 13%–15% Serial radiographs, CT
CT, computed tomography.


FIGURE 16-36 STAR ankle replacement. AP (A) and lateral (B) radiographs of an uncemented STAR total ankle replacement.


FIGURE 16-37 Complications. (A) AP radiograph demonstrating lucent lines (arrowheads) about both components caused by loosening. (B) AP radiograph demonstrating impingement medially and laterally (arrows).
Suggested Reading
Anderson T, Montgomery F, Carlsson A. Uncemented STAR total ankle prostheses. J Bone Joint Surg 2003;85A:1321–1329.
Spirt AA, Assal M, Hansen ST. Complications and failure after total ankle arthroplasty. J Bone Joint Surg 2004;86A:1172–1179.


Metatarsophalangeal Arthroplasty
Complication Imaging Techniques
Ossification about implant Serial radiographs, CT
Implant fracture Serial radiographs, CT
Loss of motion Stress views
Recurrent deformity Serial radiographs
Deep infection Serial radiographs, radionuclide scans, MRI for silicone implants
Stress fractures Serial radiographs, radionuclide scans
Silicone synovitis Serial radiographs, MRI with contrast
CT, computed tomography; MRI, magnetic resonance imaging.


FIGURE 16-38 MTP implants. (A) Swanson Silastic double-stemmed implants with grommets (arrows) to prevent wear. (B) Lateral illustration. (Courtesy of Wright Medical Technology, Arlington, TN.) (C) Standing radiograph of bilateral great toe Silastic implants. Note marginal osteophyte formation.


FIGURE 16-39 Complications. (A) Great toe metal implant system with lucent lines around the components caused by loosening. (B,C) CT images of a loose, fractured (arrowhead) Silastic great toe implant. Standing AP (D) and oblique (E) radiographs showing fragmentation of the Silastic implant with osteolysis resulting from particle disease.


Suggested Reading
Cracchiolo A III, Weltmer JB, Lian G, et al. Arthroplasty of the first metatarsophalangeal joints. J Bone Joint Surg 1992;71A:552–563.

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