title: Grading the severity of soft tissue changes associated with metal-on-metal hip replacements: reliability of an MR grading system.
abstract: BACKGROUND
  Metal-on-metal (MoM) soft tissue reactions or aseptic lymphocytic vasculitis-associated lesions (ALVAL) are being recognised using metal artefact reduction (MAR) MR with increasing frequency following the advent of second generation metal-on-metal bearings, but there is no standardised technique for reporting of MR appearances in this disease. The aim of this study was to measure the reliability of a grading system designed for scoring the severity of MoM disease on MRI.
  
  
  METHODS
  MRI examinations of 73 hips in 59 patients were retrospectively selected and then anonymised, randomised and reviewed by three independent observers (musculoskeletal radiologists). Each MR examination was scored as either A: normal, B: infection, C1: mild MoM disease, C2: moderate MoM disease or C3: severe MoM disease according to pre-defined criteria. Kappa correlation statistics were used to compare the observations.
  
  
  RESULTS
  There was substantial agreement among all three observers; the correlation coefficient between the two most experienced observers was κ = 0.78 [95% confidence intervals (CI): 0.68-0.88] and when compared with the least experienced observer coefficients were κ = 0.69 (95% CI: 0.57-0.80) and κ = 0.66 (95% CI: 0.54-0.78). The strongest correlation occurred for grades A, C2 and C3. The weakest correlations occurred for grades B and C1.
  
  
  CONCLUSIONS
  The grading system described in this study is reliable for evaluating ALVAL in MoM prostheses using MR but is limited in differentiating mild disease from infection.
authors.affiliation: Department of Radiology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Anderson
authors.forename: Andoni Paul
authors.initials: AP
authors.lastname: Toms
authors.forename: John G
authors.initials: JG
authors.lastname: Cahir
authors.forename: Richard W
authors.initials: RW
authors.lastname: Goodwin
authors.forename: James
authors.initials: J
authors.lastname: Wimhurst
authors.forename: John F
authors.initials: JF
authors.lastname: Nolan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects*; D003240:Connective Tissue Diseases / Q000145:classification / Q000175:diagnosis* / Q000209:etiology*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008670:Metals / Q000009:adverse effects*; D008875:Middle Aged; D015588:Observer Variation; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index
chemical_list: D008670:Metals