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Agarwala S, Vijayvargiya M. Predictive factors affecting long-term survivorship of ASR metal-on-metal total hip arthroplasty. SICOT J 2021; 7:51. [PMID: 34668856 PMCID: PMC8527991 DOI: 10.1051/sicotj/2021040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/14/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION We present the outcome of 154 ASR (Articular Surface Replacement) hips performed at the P.D Hinduja Hospital and Medical Research Centre in terms of revision rate, metal ion levels, and factors affecting survivorship. Further, determined the importance of serial metal ion estimation over single value with poorly functioning arthroplasties. METHODS A retrospective study of 154 ASR arthroplasties (136 patients) performed from April 2005 till March 2010 was conducted. Ninety-seven patients were available for final analysis. All patients were assessed for symptoms, radiographs, blood metal (chromium and cobalt), metal artefact reduction sequence (MARS), magnetic resonance imaging (MRI), and computerized tomography (CT). RESULTS Female gender, smaller femoral head, patients with a rising level of metal ion levels were more likely to have revision surgery. However, abnormal acetabular inclination/anteversion was not associated with the occurrence of raised metal ion levels, ARMD (adverse reaction to metal debris) or revision surgery. Patients with raised metal ion levels were more likely to have periprosthetic lucency, ARMD, and revision surgery. Median metal levels increased initially for the first three years. Still, patients who required revision surgery continued to have a metal ion rise until the point when revision surgery was performed. In contrast, patients who had a fall in metal ion levels did not require revision. CONCLUSION A single metal ion value is less predictive of failing arthroplasties; instead, a rising trend of metal ion levels can better delineate arthroplasties which will require revision. ASR hips whose blood ion levels fell after an initial rise and showed a declining trend did well.
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Affiliation(s)
- Sanjay Agarwala
- Chief of Surgery and Director Professional Services, P.D Hinduja Hospital and Medical Research Centre, 400016 Mumbai, India
| | - Mayank Vijayvargiya
- Junior Consultant, Department of Orthopedics, P.D Hinduja Hospital and Medical Research Centre, 400016 Mumbai, India
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Dias Corpa Tardelli J, Bolfarini C, Cândido Dos Reis A. Comparative analysis of corrosion resistance between beta titanium and Ti-6Al-4V alloys: A systematic review. J Trace Elem Med Biol 2020; 62:126618. [PMID: 32663743 DOI: 10.1016/j.jtemb.2020.126618] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/19/2020] [Accepted: 07/08/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND The knowledge of the electrochemical property (corrosion resistance) of beta titanium alloys compared to Ti-6Al-4 V for implants is relevant because of the potential cytotoxic effects that the released ions could cause to long-term health. OBJECTIVES The objective of this systematic review was to seek information on the electrochemical properties (corrosion resistance) of beta titanium alloys compared to Ti-6Al-4 V since the awareness of the electrochemical behavior of the implant surface in the medium is essential for the best indication of the alloys or compositional changes, which may promote benefits to bone-implant interaction in all areas that this procedure is required. METHODS The PubMed, LILACS, COCHRANE Library, and Science Direct databases were electronically searched for the terms: dental implants AND beta-titanium AND Ti-6Al-4 V AND electrochemical technics. The inclusion criteria were research articles that studied beta-titanium compared to Ti-6Al-4 V using electrochemical techniques in electrolytes of chemical composition similar to body fluid, published in English, between 2000 and 2020. Articles that did not compare the corrosion resistance of these alloys in electrolytes similar to body fluids were excluded. RESULTS A total of 189 articles were restored and selected by title and/or abstract according to the inclusion and exclusion criteria, which resulted in 15 articles that were reduced to 8 after read in full. The studies in vitro evaluated the corrosion resistance in electrolytes Hank, Ringer, SBF, and 0.9 % NaCl, between beta titanium alloys, obtained by arc fusion or bars stock, and Ti-6Al-4 V, for dental or biomedical implants submitted to surface treatments by heat treatment, plasma electrolytic oxidation (PEO), alkaline treatment, and thermomechanical. CONCLUSION The evaluated literature allowed to determine that 1) The oxides Nb2O 5, Ta2O 5, and ZrO2 have higher stability and protection quality than that of TiO2 modified by the oxides of Al and V; 2) A higher modulus of elasticity of the Ti-6Al-4 V alloy favors protection against corrosion by maintaining a thicker and more firmly adhered oxide layer; 3) The increase in the thickness of the Ti alloys superficial layer contributes to the improvement of the corrosion resistance.
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Affiliation(s)
- Juliana Dias Corpa Tardelli
- Department of Dental Materials and Prosthesis, School of Dentistry of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil.
| | - Claudemiro Bolfarini
- Department of Materials Engineering, Federal University of São Carlos (UFSCAR), São Carlos, SP, Brazil.
| | - Andréa Cândido Dos Reis
- Department of Dental Materials and Prosthesis, School of Dentistry of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, SP, Brazil.
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D'Angelo F, Tanas D, Gallazzi E, Zagra L. Adverse reaction to metal debris after small-head diameter metal-on-metal total hip arthroplasty: an increasing concern. Hip Int 2018; 28:35-42. [PMID: 30755124 DOI: 10.1177/1120700018812993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION: Failures due to adverse reaction to metal debris (ARMD) have become an area of common focus among surgeons performing hip replacements. Several authors have reported data on the prevalence of these masses, in both symptomatic and asymptomatic patients after either large-diameter head metal-on-metal (MoM) total hip arthroplasty (THA) or hip resurfacing arthroplasty, with a large variability of rate. To our knowledge, few data are reported on the association of this lesion with the use of small-head diameter MoM. METHODS: 15 hips that were revised for ARMD in small-head MoM THA were included in this study. We focused our attention on the difficulties of diagnosis and treatment and also on the histologic aspects of the harvested pathologic tissue. RESULTS: The histological examination of our cases showed a presence of lymphocytic infiltrate suggesting a delayed hypersensitivity reaction to the metal of type IV (ALVAL), but different from each other in term of the prevalence of the cellular component. Osteolysis and severe soft tissue damage were also observed. Revision resulted in remission of the lesion and successful implant. CONCLUSIONS: Our observation suggests that the evidence of ARMD should be considered even in case of small-head MoM arthroplasty and therefore these patients should be followed scrupulously with 2nd level diagnostic tools such as magnetic resonance imaging with metal artifact reduction sequence (MARS-MRI) and metal ion levels at least once. Further investigations are necessary to establish the real prevalence of this phenomenon in the whole population of small-head MoM THAs.
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Affiliation(s)
- Fabio D'Angelo
- 1 Department of Biotechnologies and Life Sciences, Division of Orthopaedics and Traumatology, University of Insubria, Italy
| | - Davide Tanas
- 1 Department of Biotechnologies and Life Sciences, Division of Orthopaedics and Traumatology, University of Insubria, Italy
| | - Enrico Gallazzi
- 2 Hip Department, I.R.C.C.S. Galeazzi Orthopaedic Institute, Milan, Italy
| | - Luigi Zagra
- 3 IRCCS Istituto Ortopedico Galeazzi, Hip Department, Milan, Italy
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Kilb BKJ, Kurmis AP, Parry M, Sherwood K, Keown P, Masri BA, Duncan CP, Garbuz DS. Frank Stinchfield Award: Identification of the At-risk Genotype for Development of Pseudotumors Around Metal-on-metal THAs. Clin Orthop Relat Res 2018; 476. [PMID: 29529651 PMCID: PMC6259707 DOI: 10.1007/s11999.0000000000000028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Once touted as the future of hip arthroplasty, metal-on-metal (MoM) bearing surfaces have fallen sharply from favor with the emergence of a strong body of evidence demonstrating unacceptably high premature implant failure rates. The previously unpredictable development of adverse local tissue reactions (ALTRs) has been a substantive contributor to this. Although the underlying pathophysiology of these so-called "pseudotumors" is now well understood, the fundamental predisposing patient risk factors have remained elusive. QUESTIONS/PURPOSES The aim of this research, as a clinical-genotype correlation analysis, was to identify specific alleles (genes) associated with the development of ALTRs in patients with in situ MoM THAs. METHODS A case-control study of patients who received a large-head, primary MoM THA between 2005 and 2008 was performed with a minimum followup of 5 years. Twenty-six patients who had undergone revision of a primary MoM THA secondary to symptomatic ALTRs were recruited. The mean timeframe from primary MoM THA to symptomatic revision was 5.5 years (range, 1-10 years). Twenty-eight control subjects were randomly selected asymptomatic patients with no evidence of ALTRs on protocol-specific screening. Baseline demographics and high-resolution genotype (human leukocyte antigen [HLA] Class II) were collected for all patients. Cohorts were similar with respect to age at the time of primary MoM THA (mean, 54.8 versus 54.9 years, p = 0.95) and serum cobalt (mean, 5.5 versus 8.5 μg/L, p = 0.09) and chromium concentrations (mean, 2.9 versus 4.2 μg/L, p = 0.27). The association between genotype and revision surgery secondary to ALTRs was determined with gender as a covariate. RESULTS The prevalence of the risk genotype was 30% (16 of 54) among the entire cohort. Adjusting for sex, the odds of revision were 6.1 times greater among patients with the risk genotype present than among patients without (95% confidence interval [CI], 1.5-25.4; p = 0.01). Among females, the specificity of the risk genotype was 1.0 (95% CIexact, 0.5-1.0; pexact = 0.03), and for males, it was 0.8 (95% CIexact, 0.6-0.9; pexact < 0.01). CONCLUSIONS The findings of this study suggest that, among patients with a primary MoM THA, allelic variation within the HLA Class II loci may be a strong, independent risk factor associated with the need for subsequent revision surgery secondary to pseudotumor formation. CLINICAL RELEVANCE Given the hypothesis-generating nature of this novel undertaking, confirmatory prospective clinical studies are required to further elucidate this correlation and to explore the clinical utility of targeted genetic screening in this specific population. This research may, however, represent a key missing piece in the puzzle that is metal ion-induced pseudotumor formation.
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Affiliation(s)
- Brett K J Kilb
- B. K. J. Kilb, A. P. Kurmis, M. Parry, B. A. Masri, C. P. Duncan, D. S., Garbuz Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada K. Sherwood, P. Keown Department of Pathology (&) Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada P. Keown, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada A. P. Kurmis, Discipline of Medical Specialties, University of Adelaide, Adelaide, SA, Australia
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Granchi D, Savarino LM, Ciapetti G, Baldini N. Biological effects of metal degradation in hip arthroplasties. Crit Rev Toxicol 2017; 48:170-193. [PMID: 29130357 DOI: 10.1080/10408444.2017.1392927] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.
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Affiliation(s)
- Donatella Granchi
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Lucia Maria Savarino
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Gabriela Ciapetti
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Nicola Baldini
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy.,b Department of Biomedical and Neuromotor Science , University of Bologna , Bologna , Italy
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Equal Primary Fixation of Resurfacing Stem, but Inferior Cup Fixation With Anterolateral vs Posterior Surgical Approach. A 2-Year Blinded Randomized Radiostereometric and Dual-energy X-Ray Absorptiometry Study of Metal-on-Metal Hip Resurfacing Arthroplasty. J Arthroplasty 2017. [PMID: 28641972 DOI: 10.1016/j.arth.2017.05.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The anterolateral (AntLat) surgical approach may spare the blood supply to the femoral head and improve the accuracy of cup positioning in metal-on-metal hip resurfacing arthroplasty. Thereby, potentially lessen complications such as avascular head necrosis, femoral neck narrowing and fracture, improve implant fixation, and lessen periprosthetic bone mineral density (BMD) loss. METHODS Between November 2008 and January 2012, a randomized clinical trial was performed at Aarhus University Hospital. A total of 49 patients (28 males) were allocated to metal-on-metal hip resurfacing arthroplasty by the AntLat (n = 25) or the posterior (Post; n = 24) surgical approach. Patients were followed with radiostereometric analysis, measurements of periprosthetic BMD, clinical outcome scores of Harris hip score and visual analogue scale, serum metal ions, and conventional radiographs. RESULTS At 3 months, cups in the AntLat group had higher total translations of mean 1.00 ± 0.70 mm vs mean 0.64 ± 0.45 mm in the post group (P = .04), and higher total rotations of mean 2.44° ± 1.36° vs mean 1.39° ± 1.17° in the Post group (P = .002). All migrations of cup and stem were similar at 1 and 2 years postoperative (P > .07). At 1 year, periprosthetic BMD since postoperative at the medial side of the stem was reduced to mean 98.45% ± 8.57% in the AntLat group, and increased to mean 105.57% ± 11.07% in the Post group (P = .02), but measurements were comparable at 2 years (P = .05). CONCLUSION Cups inserted by the AntLat approach migrated more until 3 months postoperative. This illustrates a less good primary cup fixation with the AntLat approach; however, all cups were well-fixed after 3 months' follow-up indicating a good secondary fixation.
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Amstutz HC, Le Duff MJ, Bhaurla SK. Risk factors for wear-related failures after hip resurfacing in patients with a low contact patch to rim distance. Bone Joint J 2017; 99-B:865-871. [PMID: 28663390 DOI: 10.1302/0301-620x.99b7.bjj-2016-1369.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 03/22/2017] [Indexed: 11/05/2022]
Abstract
Aims A contact patch to rim (CPR) distance of < 10 mm has been associated with edge-loading and excessive wear. However, not all arthroplasties with a low CPR distance show problems with wear. Therefore, CPR distance may not be the only variable affecting the post-operative metal ion concentrations. Patients and Methods We used multiple logistic regression to determine what variables differed between the patients who had high and low cobalt (CoS) and chromium (CrS) serum ion concentrations within a cohort of patients with low (< 10 mm) CPR distances. A total of 56 patients treated with unilateral hip resurfacing arthroplasty (HRA) had CoS and CrS ion studies performed more than one year after surgery. The mean age of the patients at the time of surgery was 51.7 years (29 to 70), with 38 women (68%) and 18 men (32%). Results It was seen that 47 patients had low ion levels (< 7µg/L) and nine had high ion levels (≥ 7µg/L). We found increased risks of high wear with decreasing CPR distance. Conclusion The use of CPR distance measurements to predict hips at risk for elevated wear is needed for all patients with HRA. We recommend that patients with low CPR distances have at least one serum ion study performed while patients with CPR distance > 10 mm do not need routine ion studies. We believe that patients with low CPR distance and low ions do not need repeat ion studies unless the patient becomes symptomatic or has substantial radiographic changes. Cite this article: Bone Joint J 2017;99-B:865–71.
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Affiliation(s)
- H. C. Amstutz
- St. Vincent Medical Center, 2200
West Third Street, Suite 400, Los
Angeles, California 90057, USA
| | - M. J. Le Duff
- St. Vincent Medical Center, 2200
West Third Street, Suite 400, Los
Angeles, California 90057, USA
| | - S. K. Bhaurla
- St. Vincent Medical Center, 2200
West Third Street, Suite 400, Los
Angeles, California 90057, USA
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Galea VP, Laaksonen I, Matuszak SJ, Connelly JW, Muratoglu O, Malchau H. Mid-term changes in blood metal ion levels after Articular Surface Replacement arthroplasty of the hip. Bone Joint J 2017; 99-B:33-40. [PMID: 28363892 DOI: 10.1302/0301-620x.99b4.bjj-2016-1250.r1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/04/2017] [Indexed: 11/05/2022]
Abstract
AIMS Our first aim was to determine whether there are significant changes in the level of metal ions in the blood at mid-term follow-up, in patients with an Articular Surface Replacement (ASR) arthroplasty. Secondly, we sought to identify risk factors for any increases. PATIENTS AND METHODS The study involved 435 patients who underwent unilateral, metal-on-metal (MoM) hip resurfacing (HRA) or total hip arthroplasty (THA). These patients all had one measurement of the level of metal ions in the blood before seven years had passed post-operatively (early evaluation) and one after seven years had passed post-operatively (mid-term evaluation). Changes in ion levels were tested using a Wilcoxon signed-rank test. We identified subgroups at the highest risk of increase using a multivariable linear logistic regression model. RESULTS There were significant increases in the levels of metal ions for patients who underwent both MoM HRA (Chromium (Cr): 0.5 parts per billion (ppb); Cobalt (Co): 1.1 ppb) and MoM THA (Cr: 0.5 ppb; Co: 0.7 ppb). In a multivariable model considering MoM HRAs, the change in the levels of metal ions was influenced by female gender (Co: Odds Ratio (OR) 1.42; p = 0.002 and Cr: OR 1.08; p = 0.006). The change was found to be irrespective of the initial level for the MoM HRAs, whereas there was a negative relationship between the initial level and the change in the level for those with a MoM THA (Co: OR -0.43; p < 0.001 and Cr: OR -0.14; p = 0.033). CONCLUSION The levels of metal ions in the blood increase significantly over the period until mid-term follow-up in patients with both a MoM HRA and those with a MoM THA. We recommend that the levels of metal ions be measured most frequently for women with a MoM HRA. While those with a MoM THA appear to stabilise at a certain level, the accuracy of this trend is not yet clear. Vigilant follow-up is still recommended. Cite this article: Bone Joint J 2017;99-B(4 Supple B):33-40.
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Affiliation(s)
- V P Galea
- Massachusetts General Hospital, Harris Orthopaedic Laboratory, 55 Fruit St. GRJ 1231, Boston, MA 02114, USA
| | - I Laaksonen
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - S J Matuszak
- Massachusetts General Hospital, Harris Orthopaedic Laboratory, 55 Fruit St. GRJ 1231, Boston, MA 02114, USA
| | - J W Connelly
- Massachusetts General Hospital, Harris Orthopaedic Laboratory, 55 Fruit St. GRJ 1231, Boston, MA 02114, USA
| | - O Muratoglu
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - H Malchau
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
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The value of serial metal ion levels in following up patients with metal-on-metal hip arthroplasty. Hip Int 2017; 27:14-20. [PMID: 28106230 DOI: 10.5301/hipint.5000432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND The sensitivity of cobalt (Co) and chromium (Cr) ion-levels in detecting poorly performing metal-on-metal hip implants is low. This study proposes that serial changes in ion-levels are a more accurate marker of arthroplasties at risk. METHODS Serial metal ion-levels and implant data of 285 patients with ASR resurfacing or replacement were studied. Patient and implant characteristics were analysed using univariate and multivariate analyses. RESULTS 111 (39%) had revision surgery. Time since index surgery (p<0.001), acetabular inclination (p<0.001), their interaction (p<0.001) and femoral head size (p = 0.01) were significant variables. Head size (≤51 mm) had lower Co and Cr levels (p = 0.01). Cr/Co showed marginal decrease over time in the unrevised group and no decrease prerevision. CONCLUSIONS Repeated measurement of ion-levels were higher in the revision group suggesting that serial measurements rather than absolute values may have a role to play in predicting implant failure.
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Ohtsuru T, Morita Y, Murata Y, Shimamoto S, Munakata Y, Kato Y. Blood metal ion concentrations in metal-on-metal total hip arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:527-532. [PMID: 28217831 DOI: 10.1007/s00590-017-1931-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/07/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The hip placement with a metal-on-metal (MOM) bearing has been used for both surface replacement and total hip arthroplasty (THA). Use of MOM bearing for hip replacement reduces the wear compared to conventional bearings. METHODS We prospectively assessed 30 patients who underwent unilateral MOM THA. A control group of 30 patients who underwent metal-on-polyethylene THA using the implants as the other group, except for bearing, were accessed. Blood samples were collected preoperatively and at 3- , 6- , 9- , 12- , 15- , 18- , and 24-month intervals. Changes in mean blood metal ion concentration were compared between the MOM and metal-on-polyethylene groups. RESULTS A statistically significant positive correlation was observed between blood cobalt and chromium concentrations in all of the patients. The mean blood ion concentrations of the MOM were significantly higher than those of the metal-on-polyethylene. A statistically significant negative correlation was found between maximum blood cobalt concentration and cup version angle. The maximum blood chromium concentrations in the patients who had larger cup version angles were more likely to decrease. CONCLUSIONS We considered that cup version angle is one of the factors that have the greatest effect on blood metal ion concentration, and the target cup version angle that did not induce an increase in blood metal ion concentrations was approximately 20°.
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Affiliation(s)
- Tadahiko Ohtsuru
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan.
| | - Yuji Morita
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
| | - Yasuaki Murata
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
| | - Shuji Shimamoto
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
| | - Yutaro Munakata
- Department of Orthopedic Surgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku Ward, Tokyo, 162-8666, Japan
| | - Yoshiharu Kato
- Kita Shinagawa 3rd Hospital, 3-3-7 Kita-shinagawa, Shinagawa Ward, Tokyo, 140-0001, Japan
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Sassoon AA, Barrack RL. Pseudotumour formation and subsequent resolution in metal-on-metal total hip arthroplasty following revision: Instructional review and an illustrative case report with revision using a dual mobility design. Bone Joint J 2017; 98-B:736-40. [PMID: 27235513 DOI: 10.1302/0301-620x.98b6.36908] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 01/26/2016] [Indexed: 12/13/2022]
Abstract
The use of large-diameter metal-on-metal (MoM) components in total hip arthroplasty (THA) is associated with an increased risk of early failure due to adverse local tissue reaction to metal debris (ARMD) in response to the release of metal ions from the bearing couple and/or head-neck taper corrosion. The aim of this paper was to present a review of the incidence and natural history of ARMD and the forms of treatment, with a focus on the need for and extent of resection or debulking of the pseudotumour. An illustrative case report is presented of a patient with an intra-pelvic pseudotumour associated with a large diameter MoM THA, which was treated successfully with revision of the bearing surface to a dual mobility couple and retention of the well-fixed acetabular and femoral components. The pseudotumour was left in situ Resolution of the intra-pelvic mass and normalisation of metal ion levels was observed seven months post-operatively. Cite this article: Bone Joint J 2016;98-B:736-40.
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Affiliation(s)
- A A Sassoon
- University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - R L Barrack
- Washington University, 4921 Parkview Place, St. Louis, MO 63110, USA
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Outcomes of the Recalled Articular Surface Replacement Metal-on-Metal Hip Implant System: A Systematic Review. J Arthroplasty 2017; 32:341-346. [PMID: 27546469 DOI: 10.1016/j.arth.2016.06.060] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 06/05/2016] [Accepted: 06/27/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The aim of this review was to synthesize the main findings of clinical studies that have evaluated outcomes of the articular surface replacement (ASR) Hip System. METHODS We performed a systematic literature search to identify all articles published between January 2008 and June 2015 that included ASR hip resurfacing arthroplasty (ASR HRA) or ASR total hip arthroplasty (ASR XL THA) outcomes according to the PRISMA statement. RESULTS A total of 56 studies were assessed. The prevalence of adverse local tissue reactions (ALTRs) and revision rates were found to be high. ALTR prevalence varied from 12.5% to 69% (mean, 33.5%). Mean revision rate for any reason at 4-year to 7-year follow-up was 13.8% (range, 5.6%-31%) for ASR HRA and 14.5% (range, 0%-37%) for ASR XL THA. Femoral head size <53 mm was found to correlate with higher blood metal ion levels. Femoral head size >44 mm was not associated with higher ALTR prevalence or revision rates in ASR XL THA. High blood metal ion levels (>7 μg/L Co, >7 μg/L Cr) were associated with higher failure rates and bearing-related complications. The role of cup positioning was found to be controversial. CONCLUSION ALTR prevalence and failure rates were high. High blood metal ion levels were a risk factor for ALTR and failure. Surprisingly, the role of cup positioning and large femoral head size in ASR XL THA were controversial. These findings should be considered in the clinical follow-up and risk stratification of patients with the ASR Hip System.
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Huang GY, Zhao GL, Xia J, Wei YB, Wang SQ, Wu JG. An Alternative Intraoperative Radiographic Method for Optimizing Cup Inclination during Total Hip Arthroplasty. Orthop Surg 2016; 8:345-51. [PMID: 27627718 DOI: 10.1111/os.12272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/16/2016] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE During total hip arthroplasty (THA), the location of the acetabular prosthesis is very important for guaranteeing successful surgery. However, this remains a challenge for many surgeons. This study aimed to investigate the feasibility of using the intraoperative fluoroscopic iliopubic tangential angle (IPTA) to determine the valgus angles of acetabular prostheses. METHODS In the first stage, the IPTA and valgus angles of native acetabula were defined and measured in 102 THAs obtained from the picture archiving and communication systems of our hospital. Obturator foramen morphology was also measured and divided into groups according to the axial length ratio. Correlations between obturator foramen morphology and IPTA and valgus angles of native acetabula were then determined. In the second stage, angular differences (angle θ) between the IPTA and valgus angles of native acetabula were measured during unilateral THA in 136 patients to determine whether this is a stable value that could be used as a reference for placement of acetabular prostheses. Postoperative data such as Harris Hip Score (HHS) scores and complications were collected and evaluated. RESULTS The average IPTA at the apex of the true acetabulum was 58.8° ± 4.1°. The average valgus angle of native acetabula was 43.1° ± 3.9° and angle θ was 15.7° ± 1.3°. Obturator foramen morphology was divided into five groups according to the axial length ratio. IPTA was closely related to obturator foramen morphology (Pearson r = 0.489, P ≈ 0.000). Angle θ was stable and independent of obturator foramen morphology. When the IPTA and angle θ were used as references for placing acetabular prostheses in 136 THAs, the average postoperative valgus angles of acetabular prostheses was 45.13° ± 4.07° and the good-to-excellent rate was 97.05%. There were no short-term complications such as fracture, dislocation or infection. The average HHS score 6 months after surgery was 37.2 higher than the preoperative score, this difference being significant (P < 0.01). Neither infection nor dislocation was found 6 months after surgery. CONCLUSIONS The IPTA (at the apex of the true acetabulum) and angle θ (obtained by intraoperative fluoroscopy) are consistent in determining the postoperative valgus angle of acetabular prosthesis during THA. Thus, IPTA and angle θ are of value in guiding placement of acetabular prostheses; in particular, this method can facilitate the learning of young surgeons.
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Affiliation(s)
- Gang-Yong Huang
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Guang-Lei Zhao
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun Xia
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China.
| | - Yi-Bing Wei
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Si-Qun Wang
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian-Guo Wu
- Division of Orthopaedic Surgery, Huashan Hospital, Fudan University, Shanghai, China
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Lainiala OS, Moilanen TPS, Hart AJ, Huhtala HSA, Sabah SA, Eskelinen AP. Higher Blood Cobalt and Chromium Levels in Patients With Unilateral Metal-on-Metal Total Hip Arthroplasties Compared to Hip Resurfacings. J Arthroplasty 2016; 31:1261-1266. [PMID: 26775067 DOI: 10.1016/j.arth.2015.11.045] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/12/2015] [Accepted: 11/30/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Adverse soft tissue reactions in metal-on-metal (MoM) hip replacements are associated with cobalt (Co) and chromium (Cr) ions in blood. We report the prevalence and risk factors for elevated blood Co and Cr levels in patients with a unilateral MoM hip. METHODS From a single institution, blood Co and Cr levels were analyzed in 1748 patients (692 hip resurfacings and 1056 total hip arthroplasties [THAs]). Concentrations exceeding 7 ppb were considered elevated, and the risk factors for elevated levels were calculated with binary logistic regression. RESULTS Elevated blood metal ion levels were more common in MoM THA than in resurfacing patients (17.4% vs 5.9%, P < .001), and in 5 of the 7 THA brands, more than 20% of patients had elevated metal ion concentrations, whereas the proportion was less than 10% in all hip resurfacings. In resurfacings, small femoral head (odds ratio [OR] 1.30 per millimeter decrease [CI, 1.12-1.49]), high acetabular inclination (OR 1.15 per degree increase [CI 1.09-1.22]), and young age (OR 1.05 per year decrease [1.02-1.10]) were independent risk factors for elevated ions. In the THA group, female gender (OR 2.04 [CI 1.35-3.06]), longer time between surgery and ion measurement (OR 1.19 per year increase [CI 1.05-1.34]), and large headsize (OR 1.07 per millimeter increase [CI 1.01-1.13]) were risk factors for elevated ions. CONCLUSION Given the high percentage of elevated levels, the systematic surveillance of especially large diameter MoM THAs seems justified.
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Affiliation(s)
| | | | - Alister J Hart
- University College London and the Royal National Orthopaedic Hospital, London, UK
| | | | - Shiraz A Sabah
- University College London and the Royal National Orthopaedic Hospital, London, UK
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Hip Resurfacing Implant Orientation Analysis: A Comparison of a Computer-Added Design Technique and Computed Tomography. J Arthroplasty 2016; 31:501-5. [PMID: 26427940 DOI: 10.1016/j.arth.2015.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/25/2015] [Accepted: 08/31/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Accurate acetabular component orientation in hip resurfacing is mandatory. The aim of this study is to analyze if interpretation of pelvic radiographs with computer-added design (CAD) software is comparable to computed tomography (CT) in measurement of acetabular anteversion and inclination of a Birmingham Hip Resurfacing (BHR) hip. METHODS A consecutive series of 49 patients (50 hips) who underwent hip resurfacing arthroplasty between 2005 and 2007 with the BHR system were retrospectively included. The surgical procedure was performed by 1 orthopedic surgeon in the beginning of his learning curve. Computer-added design software was used to measure acetabular component orientation on an anteroposterior pelvic radiograph. These measurements were compared with CT measurements. We calculated the correlation between the CAD software and CT analysis. The degree of underestimation or overestimation was determined, and a Bland-Altman plot was created to visualize the agreement between CAD software and CT results. RESULTS We analyzed 50 BHR hips with mean inclination of 54.6° and 55.6° and mean anteversion of 24.8° and 13.3° measured by CT and CAD, respectively. Pearson correlation coefficient for inclination was 0.69 (P < .001) and for anteversion 0.81 (P < .001). Computer-added design showed a mean underestimated anteversion of 11.6° (P < .001). There was no significant underestimation or overestimation of inclination with CAD analysis compared to CT measurements. CONCLUSION The CAD software is useful to assess acetabular inclination in hip resurfacing but underestimates anteversion.
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What are the predictors and prevalence of pseudotumor and elevated metal ions after large-diameter metal-on-metal THA? Clin Orthop Relat Res 2015; 473:477-84. [PMID: 25085361 PMCID: PMC4294930 DOI: 10.1007/s11999-014-3824-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Soft tissue masses, or "pseudotumors," around metal-on-metal total hip arthroplasty (MoM THA) have been reported frequently; however, their prevalence remains unknown. Several risk factors, including elevated metal ion levels, have been associated with the presence of pseudotumor, although this remains controversial. QUESTIONS/PURPOSES The goals of this study were to (1) determine the prevalence of pseudotumors after large-diameter head MoM THA; (2) identify risk factors associated with pseudotumor formation and elevated metal ion levels; and (3) determine the early failure rate of large-diameter MoM THA. METHODS Between December 2005 and November 2012, 258 hips (215 patients) underwent large-diameter head primary MoM THA at our institution. Clinical followup was obtained in 235 hips (91%). Using an inclusion criteria of a minimum followup of 1 year, a subset of 191 hips (mean followup, 4 years; range, 1-7 years) was recruited for high-resolution ultrasound screening for the presence of pseudotumor. Whole blood cobalt and chromium ion levels, UCLA activity level, WOMAC score, patient demographics as well as surgical, implant, and radiographic data were collected. Bivariate correlations and multivariate log-linear regression models were used to compare the presence of pseudotumor and elevated metal ions with all other factors. RESULTS Ultrasound detected a solid, cystic, or mixed mass in 20% hips (38 of 191). No correlation was found between the presence of pseudotumor and any risk factor that we examined. After controlling for confounding variables, elevated cobalt ions were correlated (p<0.001, R=0.50, R2=0.25) with smaller femoral head size, the presence of bilateral MoM THA, and female sex. Elevated chromium ions were correlated (p<0.001, R=0.59, R2=0.34) with smaller femoral head size, presence of bilateral MoM THA, and lower body mass index. The overall survival of MoM THA was 96% at a mean followup of 4.5 years (range, 2-8 years). CONCLUSIONS With the numbers available, we found no associations between the presence of pseudotumor and the potential risk factors we analyzed, including elevated metal ion levels. Further work is needed to explain why larger femoral head sizes resulted in lower metal ion levels despite being associated with higher early failure rates in joint registry data. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Metal ion levels and revision rates in metal-on-metal hip resurfacing arthroplasty: a comparative study. Hip Int 2014; 24:123-8. [PMID: 24500833 DOI: 10.5301/hipint.5000113] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/25/2013] [Indexed: 02/04/2023]
Abstract
Metal-on-metal (MoM) bearings in hip surgery are related to increased blood levels of metal ions. The nature of the relationship between ion levels and failure is still not fully understood. This study compares three cohorts of patients, 120 patients in each cohort, treated with a hip resurfacing arthroplasty, grouped by brand and diameter of femoral component on average four years postoperatively: Birmingham Hip Resurfacing ≥50 mm, Durom resurfacing ≥50 mm and Durom resurfacing <50 mm. The median blood ion levels of cobalt and chromium were significantly lower in the cohort with the large Durom resurfacing than the other two cohorts (P<0.05). The large BHR and large Durom HRA had revision rates of 3.3%. The small Durom HRA had a revision rate of 8.3%. Elevated blood ion levels can indicate a failing MoM bearing. The large BHR and large Durom HRA have similar revision rates yet the large Durom HRA had significantly lower metal ion levels. When similar ion levels were reported for BHR and small Durom the latter had significantly higher revision rates. This suggests ion levels do not absolutely predict the rate of HRA failure. Since MoM generation of metal ions is not the sole reason of failure, regular clinical and radiographic follow-up should also be in place for patients with these joints.
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How do metal ion levels change over time in hip resurfacing patients? A cohort study. ScientificWorldJournal 2014; 2014:291925. [PMID: 25580456 PMCID: PMC4279264 DOI: 10.1155/2014/291925] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/27/2014] [Indexed: 01/15/2023] Open
Abstract
Metal-on-metal hip resurfacing (MOM-HR) is offered as an alternative to traditional hip arthroplasty for young, active adults with advanced osteoarthritis. Nevertheless, concerns remain regarding wear and corrosion of the bearing surfaces and the resulting increase in metal ion levels. We evaluated three cohorts of patients with Birmingham hip resurfacing (BHR) at an average follow-up of 2, 5, and 9 years. We asked whether there would be differences in ion levels between the cohorts and inside the gender. Nineteen patients were prospectively analyzed. The correlation with clinical-radiographic data was also performed. Chromium, cobalt, nickel, and molybdenum concentrations were measured by atomic absorption spectrophotometry.
Chromium and cobalt levels demonstrated a tendency to decrease over time. Such tendency was present only in females. An inverse correlation between chromium, implant size, and Harris hip score was present at short term; it disappeared over time together with the decreased ion levels. The prospective analysis showed that, although metal ion levels remained fairly constant within each patient, there was a relatively large variation between subjects, so mean data in this scenario must be interpreted with caution.
The chronic high exposure should be carefully considered during implant selection, particularly in young subjects, and a stricter monitoring is mandatory.
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Assessment of Patients with a DePuy ASR Metal-on-Metal Hip Replacement: Results of Applying the Guidelines of the Spanish Society of Hip Surgery in a Tertiary Referral Hospital. Adv Orthop 2014; 2014:982523. [PMID: 25431677 PMCID: PMC4241718 DOI: 10.1155/2014/982523] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 10/21/2014] [Indexed: 12/12/2022] Open
Abstract
The prognosis associated with the DePuy ASR hip cup is poor and varies according to the series. This implant was withdrawn from use in 2010 and all patients needed to be assessed. We present the results of the assessment of our patients treated with this device, according to the Spanish Society of Hip Surgery (SECCA) algorithm published in 2011. This retrospective study evaluates 83 consecutive ASR cups, followed up at a mean of 2.9 years. Serum levels of chromium and cobalt, as well as the acetabular abduction angle, were determined in order to assess their possible correlation with failure, defined as the need for revision surgery. The mean Harris Hip Score was 83.2 (range 42–97). Eight arthroplasties (13.3%) required revision due to persistent pain and/or elevated serum levels of chromium/cobalt. All the cups had a correct abduction angle, and there was no correlation between elevated serum levels of metal ions and implant failure. Since two previous ASR implants were exchanged previously to the recall, the revision rate for ASR cups in our centre is 18.2% at 2.9 years.
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20
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Implication of femoral stem on performance of articular surface replacement (ASR) XL total hip arthroplasty. J Arthroplasty 2014; 29:2127-35. [PMID: 25108735 DOI: 10.1016/j.arth.2014.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 06/14/2014] [Accepted: 06/29/2014] [Indexed: 02/01/2023] Open
Abstract
Taper junctions of large diameter metal-on-metal femoral heads and femoral stems were described as metal ion generator due to accelerated wear and corrosion. However, literature about the Articular Surface Replacement (ASR) total hip arthroplasty (THA) invariably deals with stems manufactured by DePuy Orthopedics (Warsaw, IN, USA). Nothing is known whether different stems with common 12/14 mm tapers affect failure rate or ion release. 99 ASR THA (88 patients) implanted with CoxaFit or ARGE Geradschaft stems (K-Implant, Hannover, Germany) were retrospectively analyzed. After a mean follow-up of 3.5 years revision rate was 24.5%, mostly due to adverse reaction to metal debris (ARMD). CT scan revealed component loosening in 10.3% and pseudotumoral lesions in 12.6%. Elevated ion concentrations (>7 μg/l) were found in 38.6%.
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21
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Tai SM, Millard N, Munir S, Jenabzadeh AR, Walter LR, Walter WL. Two-year serum metal ion levels in minimally invasive total conservative hip resurfacing: preliminary results of a prospective study. ANZ J Surg 2014; 85:164-8. [PMID: 25288230 DOI: 10.1111/ans.12868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Metal-on-metal (MoM) hip resurfacings have been associated with the potential development of metallic debris and its associated pathology. Serum cobalt and chromium levels are a reliable surrogate marker of wear rates in MoM bearings. The aim of the study was to examine the trend in serum metal ion levels in the initial 2-year post-operative period following implantation of the minimally invasive total conservative hip MoM hip resurfacing and to determine whether head size, acetabular component orientation, clinical outcome scores or post-operative range of movement would affect these levels. METHODS In this prospective cohort study, serum cobalt and chromium ion levels were measured pre- and post-operatively in 25 patients who underwent minimally invasive total conservative hip MoM hip resurfacing. The results were correlated with acetabular component orientation, head size, outcome scores and post-operative range of movement. RESULTS The mean serum cobalt and chromium levels at 2 years were 1.2 ppb (0.4-4.4 ppb) and 2.1 ppb (0.7-5.7 ppb). The mean cup inclination was 43° (30°-60°) and anteversion was 18° (1°-47°). There was no clear relationship between serum ions and acetabular component orientation, outcome scores or range of movement. Patients with a head size ≤52 mm had significantly higher metal ion levels (cobalt P = 0.02, chromium P = 0.045). CONCLUSION Our preliminary results show all patients had cobalt and chromium levels below those indicating a high-risk implant, suggesting successful early outcome from minimally invasive total conservative hip resurfacing surgery.
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Affiliation(s)
- Stephen M Tai
- Mater Clinic, Specialist Orthopaedic Group, Sydney, New South Wales, Australia
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22
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Hjorth MH, Søballe K, Jakobsen SS, Lorenzen ND, Mechlenburg I, Stilling M. No association between serum metal ions and implant fixation in large-head metal-on-metal total hip arthroplasty. Acta Orthop 2014; 85:355-62. [PMID: 24847790 PMCID: PMC4105765 DOI: 10.3109/17453674.2014.922731] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The mechanism of failure of metal-on-metal (MoM) total hip arthroplasty (THA) has been related to a high rate of metal wear debris, which is partly generated from the head-trunnion interface. However, it is not known whether implant fixation is affected by metal wear debris. PATIENTS AND METHODS 49 cases of MoM THA in 41 patients (10 women) with a mean age of 52 (28-68) years were followed with stereoradiographs after surgery and at 1, 2, and 5 years to analyze implant migration by radiostereometric analysis (RSA). Patients also participated in a 5- to 7-year follow-up with measurement of serum metal ions, questionnaires (Oxford hip score (OHS) and Harris hip score (HHS)), and measurement of cup and stem positions and systemic bone mineral density. RESULTS At 1-2 years, mean total translation (TT) was 0.04 mm (95% CI: -0.07 to 0.14; p = 0.5) for the stems; at 2-5 years, mean TT was 0.13 mm (95% CI: -0.25 to -0.01; p = 0.03), but within the precision limit of the method. For the cups, there was no statistically significant TT or total rotation (TR) at 1-2 and 2-5 years. At 2-5 years, we found 4 cups and 5 stems with TT migrations exceeding the precision limit of the method. There was an association between cup migration and total OHS < 40 (4 patients, 4 hips; p = 0.04), but there were no statistically significant associations between cup or stem migration and T-scores < -1 (n = 10), cup and stem positions, or elevated serum metal ion levels (> 7µg/L (4 patients, 6 hips)). INTERPRETATION Most cups and stems were well-fixed at 1-5 years. However, at 2-5 years, 4 cups and 5 stems had TT migrations above the precision limits, but these patients had serum metal ion levels similar to those of patients without measurable migrations, and they were pain-free. Patients with serum metal ion levels > 7 µg/L had migrations similar to those in patients with serum metal ion levels < 7 µg/L. Metal wear debris does not appear to influence the fixation of hip components in large-head MoM articulations at medium-term follow-up.
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Affiliation(s)
- Mette Holm Hjorth
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Inger Mechlenburg
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Stilling
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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Matusiewicz H. Potential release of in vivo trace metals from metallic medical implants in the human body: from ions to nanoparticles--a systematic analytical review. Acta Biomater 2014; 10:2379-403. [PMID: 24565531 DOI: 10.1016/j.actbio.2014.02.027] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/04/2013] [Accepted: 02/13/2014] [Indexed: 02/06/2023]
Abstract
Metal ion release from metallic materials, e.g. metallic alloys and pure metals, implanted into the human body in dental and orthopedic surgery is becoming a major cause for concern. This review briefly provides an overview of both metallic alloys and pure metals used in implant materials in dental and orthopedic surgery. Additionally, a short section is dedicated to important biomaterials and their corrosive behavior in both real solutions and various types of media that model human biological fluids and tissues. The present review gives an overview of analytical methods, techniques and different approaches applied to the measurement of in vivo trace metals released into body fluids and tissues from patients carrying metal-on-metal prostheses and metal dental implants. Reference levels of ion concentrations in body fluids and tissues that have been determined by a host of studies are compiled, reviewed and presented in this paper. Finally, a collection of published clinical data on in vivo released trace metals from metallic medical implants is included.
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Vundelinckx BJ, Verhelst LA, De Schepper J. Taper corrosion in modular hip prostheses: analysis of serum metal ions in 19 patients. J Arthroplasty 2013; 28:1218-23. [PMID: 23523216 DOI: 10.1016/j.arth.2013.01.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 12/23/2012] [Accepted: 01/13/2013] [Indexed: 02/01/2023] Open
Abstract
Recently, concerns have been raised about the use of metal-on-metal (MoM) implants. This has led to the recall of several resurfacing and large-diameter total hip arthroplasties (THA). Any MoM interface can be the cause of metal debris and adverse tissue reactions. We analyzed serum metal ions and HOOS scores in 19 of 306 patients treated with a THA with modular neck section. The only MoM interface in this particular implant is the taper between the neck and the stem. The articulating surface consists of a ceramic-on-polyethylene or ceramic-on-ceramic interface. As such, this study looks at the metal ion production from the modular neck section. One of 306 implants needed revision at 52-month follow-up because of an adverse reaction to metal debris (ARMD).
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Affiliation(s)
- Bart J Vundelinckx
- Orthopaedic Surgery and Traumatology, Catholic University of Leuven, Belgium
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Jantzen C, Jørgensen HL, Duus BR, Sporring SL, Lauritzen JB. Chromium and cobalt ion concentrations in blood and serum following various types of metal-on-metal hip arthroplasties: a literature overview. Acta Orthop 2013; 84:229-36. [PMID: 23594249 PMCID: PMC3715816 DOI: 10.3109/17453674.2013.792034] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Widely different metal ion concentrations in blood and serum have been reported with metal-on-metal (MoM) implants. We reviewed the literature on blood and serum ion concentrations of chromium (Cr) and cobalt (Co) following various MoM hip arthroplasties. METHODS Studies were searched for in the Medline database, Embase, and the Cochrane Database of Systematic Reviews. Highest mean or median ion concentrations of Cr and Co after a minimum of 1 year of follow-up were extracted and grouped according to sample- and articulation type, and average values were calculated. RESULTS 43 studies were included and 16 different MoM implants were identified. For the different types of bearings, average ion concentrations and range were calculated from the mean or median ion concentration. The average Cr concentration ranged between 0.5 and 2.5 μg/L in blood and between 0.8 and 5.1 μg/L in serum. For Co, the range was 0.7-3.4 μg/L in blood and 0.3-7.5 μg/L in serum. INTERPRETATION When the average blood ion concentrations calculated for the different implants, together with the concentrations measured in the individual studies, were compared with the upper acceptable limit for Cr and Co in blood, no clear pattern was recognized. Furthermore, we were unable to detect any clear difference in ion concentrations between different types of implants (THA and resurfacing).
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Affiliation(s)
| | - Henrik L Jørgensen
- Clinical Biochemistry, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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A comparison of two resurfacing arthroplasty implants: medium-term clinical and radiographic results. Hip Int 2013; 22:566-73. [PMID: 23100155 DOI: 10.5301/hip.2012.9749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2012] [Indexed: 02/04/2023]
Abstract
The objective of this study was to perform a medium-term analysis comparing the clinical and radiographic outcomes of the CONSERVE® Plus (C+) and Birmingham Hip Resurfacing (BHR) arthroplasty systems. 137 hips were included in each cohort, with a mean follow-up of 60.0 ± 14.2 months and 63.3 ± 3.5 months in the C+ and BHR cohorts respectively. Latest review UCLA and HHS scores showed statistically significant improvements when compared with preoperative scores for both cohorts. UCLA and SF-12 physical component outcome scores were significantly different (p<0.01 and p = 0.04, respectively). Median serum chromium and cobalt levels were significantly increased in the BHR cohort (p = 0.001). Both cohorts demonstrated excellent Kaplan-Meier 5-year survival rates (96.9% in the C+ cohort, and 96.4% in the BHR cohort). Overall both implants appear to perform well in the medium term.
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Yoon JP, Le Duff MJ, Johnson AJ, Takamura KM, Ebramzadeh E, Amstutz HC. Contact patch to rim distance predicts metal ion levels in hip resurfacing. Clin Orthop Relat Res 2013. [PMID: 23184671 PMCID: PMC3613526 DOI: 10.1007/s11999-012-2711-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Component design, size, acetabular orientation, patient gender, and activity level have been suggested as factors leading to elevated metal ion concentrations after-on-metal hip resurfacing arthroplasty (MMHRA). The calculation of the contact patch to rim (CPR) distance integrates component size, design, and acetabular orientation and may be a good predictor of elevated metal ion levels. QUESTIONS/PURPOSES We evaluated the effects and the predictive value of the CPR distance on serum cobalt (CoS) and chromium (CrS) ion levels. METHODS We retrospectively studied 182 patients with Conserve Plus MMHRAs at a minimum of 12 months after surgery (median, 57 months; range, 12-165 months). CoS and CrS levels were analyzed using inductively-coupled plasma mass spectrometry. Multiple logistic regression was performed to determine which if any of the factors related to serum ion levels. RESULTS Patients with CPR distances of 10 mm or less had a 37-fold increased risk of having elevated CoS of 7 μg/L or higher. Similarly, these patients had an 11-fold increased risk of having elevated CrS of 7 μg/L or higher. Sex and University of California Los Angeles activity scores did not influence the postoperative CoS and CrS levels. The negative predictive value for CPR distance less than 10 mm was 99.3% for CoS greater than 7 μg/L and 98.0% for CrS greater than 7 μg/L. CONCLUSIONS Our observations suggest the CPR distance would be a useful indicator to determine which patients are at risk for elevated ion levels. Patients with CPR distances greater than 10 mm need not be monitored unless they become symptomatic.
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Affiliation(s)
- James P. Yoon
- Joint Replacement Institute at St. Vincent Medical Center, 2200 West Third Street, Suite 400, Los Angeles, CA 90057 USA
| | - Michel J. Le Duff
- Joint Replacement Institute at St. Vincent Medical Center, 2200 West Third Street, Suite 400, Los Angeles, CA 90057 USA
| | - Alicia J. Johnson
- Joint Replacement Institute at St. Vincent Medical Center, 2200 West Third Street, Suite 400, Los Angeles, CA 90057 USA
| | - Karren M. Takamura
- Joint Replacement Institute at St. Vincent Medical Center, 2200 West Third Street, Suite 400, Los Angeles, CA 90057 USA
| | - Edward Ebramzadeh
- J. Vernon Luck Sr. MD, Orthopaedic Research Center, Orthopaedic Hospital at UCLA, Los Angeles, CA USA
| | - Harlan C. Amstutz
- Joint Replacement Institute at St. Vincent Medical Center, 2200 West Third Street, Suite 400, Los Angeles, CA 90057 USA
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Westacott DJ, McArthur J, King RJ, Foguet P. Assessment of cup orientation in hip resurfacing: a comparison of TraumaCad and computed tomography. J Orthop Surg Res 2013; 8:8. [PMID: 23577620 PMCID: PMC3637092 DOI: 10.1186/1749-799x-8-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 04/04/2013] [Indexed: 12/28/2022] Open
Abstract
Purpose The orientation of the acetabular component in metal-on-metal hip resurfacing arthroplasty affects wear rate and hence failure. This study aimed to establish if interpretation of pelvic radiographs with TraumaCad software can provide a reliable alternative to CT in measuring the acetabular inclination and version. Methods TraumaCad was used to measure the acetabular orientation on AP pelvis radiographs of 14 painful hip resurfacings. Four orthopaedic surgeons performed each measurement twice. These were compared with measurements taken from CT reformats. The correlation between TraumaCad and CT was calculated, as was the intra- and inter-observer reliability of TraumaCad. Results There is strong correlation between the two techniques for the measurement of inclination and version (p <0.001). Intra- and inter-observer reliability of TraumaCad measurements are good (p <0.001). Mean absolute error for measurement of inclination was 2.1°. TraumaCad underestimated version compared to CT in 93% of cases, by 12.6 degrees on average. Conclusions When assessing acetabular orientation in hip resurfacing, the orthopaedic surgeon may use TraumaCad in the knowledge that it correlates well with CT and has good intra- and inter-observer reliability but underestimates version by 12° on average.
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Affiliation(s)
- Daniel J Westacott
- Warwick Orthopaedics, University Hospital of Coventry and Warwickshire, Coventry, UK.
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Raghunathan VK, Devey M, Hawkins S, Hails L, Davis SA, Mann S, Chang IT, Ingham E, Malhas A, Vaux DJ, Lane JD, Case CP. Influence of particle size and reactive oxygen species on cobalt chrome nanoparticle-mediated genotoxicity. Biomaterials 2013; 34:3559-70. [PMID: 23433773 DOI: 10.1016/j.biomaterials.2013.01.085] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 01/28/2013] [Indexed: 02/06/2023]
Abstract
Patients with cobalt chrome (CoCr) metal-on-metal (MOM) implants may be exposed to a wide size range of metallic nanoparticles as a result of wear. In this study we have characterised the biological responses of human fibroblasts to two types of synthetically derived CoCr particles [(a) from a tribometer (30 nm) and (b) thermal plasma technology (20, 35, and 80 nm)] in vitro, testing their dependence on nanoparticle size or the generation of oxygen free radicals, or both. Metal ions were released from the surface of nanoparticles, particularly from larger (80 nm) particles generated by thermal plasma technology. Exposure of fibroblasts to these nanoparticles triggered rapid (2 h) generation of reactive oxygen species (ROS) that could be eliminated by inhibition of NADPH oxidase, suggesting that it was mediated by phagocytosis of the particles. The exposure also caused a more prolonged, MitoQ sensitive production of ROS (24 h), suggesting involvement of mitochondria. Consequently, we recorded elevated levels of aneuploidy, chromosome clumping, fragmentation of mitochondria and damage to the cytoskeleton particularly to the microtubule network. Exposure to the nanoparticles resulted in misshapen nuclei, disruption of mature lamin B1 and increased nucleoplasmic bridges, which could be prevented by MitoQ. In addition, increased numbers of micronuclei were observed and these were only partly prevented by MitoQ, and the incidence of micronuclei and ion release from the nanoparticles were positively correlated with nanoparticle size, although the cytogenetic changes, modifications in nuclear shape and the amount of ROS were not. These results suggest that cells exhibit diverse mitochondrial ROS-dependent and independent responses to CoCr particles, and that nanoparticle size and the amount of metal ion released are influential.
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van der Weegen W, Hoekstra HJ, Sijbesma T, Austen S, Poolman RW. Hip resurfacing in a district general hospital: 6-year clinical results using the ReCap hip resurfacing system. BMC Musculoskelet Disord 2012; 13:247. [PMID: 23234268 PMCID: PMC3529103 DOI: 10.1186/1471-2474-13-247] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 12/07/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of our study was to prospectively report the clinical results of 280 consecutive hips (240 patients) who received a ReCap Hip Resurfacing System implant (Biomet Inc., Warsaw, USA) in a single district general hospital. Literature reports a large variation in clinical results between different resurfacing designs and published results using this particular design are scarce. METHODS Mean follow up was 3.3 years (1.0 to 6.3) and four patients were lost to follow-up. All patients were diagnosed with end-stage hip osteoarthritis, their mean age was 54 years and 76.4% of all patients were male. RESULTS There were 16 revisions and four patients reported a Harris Hip Score <70 points at their latest follow up. There were no pending revisions. Kaplan-Meier implant survival probability, with revision for any reason as endpoint, was 93.5% at six years follow-up (95%-CI: 88.8-95.3). There were no revisions for Adverse Reactions to Metal Debris (ARMD) and no indications of ARMD in symptomatic non-revised patients, although diagnostics were limited to ultrasound scans. CONCLUSIONS This independent series confirms that hip resurfacing is a demanding procedure, and that implant survival of the ReCap hip resurfacing system is on a critical level in our series. In non-revised patients, reported outcomes are generally excellent. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00603395.
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Affiliation(s)
- Walter van der Weegen
- Department of Orthopaedic Surgery, St. Anna Hospital, Bogardeind 2, Geldrop, EH, 5664, Netherlands
| | - Henk J Hoekstra
- Department of Orthopaedic Surgery, St. Anna Hospital, Bogardeind 2, Geldrop, EH, 5664, Netherlands
| | - Thea Sijbesma
- Department of Orthopaedic Surgery, St. Anna Hospital, Bogardeind 2, Geldrop, EH, 5664, Netherlands
| | - Shennah Austen
- Department of Orthopaedic Surgery, St. Anna Hospital, Bogardeind 2, Geldrop, EH, 5664, Netherlands
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Verhelst LA, Van der Bracht H, Vanhegan IS, Van Backlé B, De Schepper J. Revising the well-fixed, painful resurfacing using a double-mobility head: a new strategy to address metal-on-metal complications. J Arthroplasty 2012; 27:1857-62. [PMID: 22770851 DOI: 10.1016/j.arth.2012.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 05/06/2012] [Indexed: 02/01/2023] Open
Abstract
Isolated revision of the femoral component of hip resurfacings to metal-on-metal (MoM) total hip arthroplasties has shown inferior results. We present a case series of well-fixed, painful MoM hips with elevated chromium and cobalt levels. An isolated femoral revision using a noncemented femoral component and a double-mobility head was performed. Patients were followed up for 6 months and showed excellent improvements in visual analog score and Hip dysfunction and Osteoarthritis Outcome Score (HOOS). Cobalt and chromium levels dropped at 6 weeks and were normal at 6 months. Although our follow-up is short, we feel that it is important to highlight this as a potential treatment strategy. This revision is less aggressive than traditional methods, eliminates the concerns from MoM bearings, and results in a stable construct.
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Affiliation(s)
- Luk A Verhelst
- AZ Groeninge Kortrijk, Burgemeester Vercruysselaan 5, 8500 Kortrijk, Belgium
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Hartmann A, Lützner J, Kirschner S, Witzleb WC, Günther KP. Do survival rate and serum ion concentrations 10 years after metal-on-metal hip resurfacing provide evidence for continued use? Clin Orthop Relat Res 2012; 470:3118-26. [PMID: 22481276 PMCID: PMC3462856 DOI: 10.1007/s11999-012-2329-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Owing to concerns attributable to problems associated with metal-on-metal bearing surfaces, current evidence for the use of hip resurfacing is unclear. Survival rates reported from registries and individual studies are controversial and the limited long-term studies do not conclusively allow one to judge whether hip resurfacing is still a reasonable alternative to conventional THA. QUESTIONS/PURPOSES We asked whether the long-term survival rate of hip resurfacing is comparable to that of conventional THA and certain factors can be identified that influence serum ion concentration 10 years postoperatively. We specifically assessed (1) the 10-year survivorship in the whole cohort and in male and female patients, (2) serum concentrations of metal ions in patients with hip resurfacing who had not undergone revision surgery, and (3) potential influencing factors on the serum ion concentration. METHODS We retrospectively reviewed our first 95 patients who had 100 hip resurfacings performed from 1998 to 2001. The median age of the patients at surgery was 52 years (range, 28-69 years); 49% were men. We assessed the survival rate (revision for any reason as the end point), radiographic changes, and serum ion concentrations for cobalt, chromium, and molybdenum. The correlations between serum ion concentration and patient-related factors (age, sex, BMI, activity) and implant-related factors (implant size, cup inclination, stem-shaft angle) were investigated. The minimum followup was 9.3 years (mean, 10 years; range, 9.3-10.5 years). RESULTS The 10-year survivorship was 88% for the total cohort. The overall survival rate was greater in men (93%) than in women (84%). Median serum ion levels were 1.9 μg/L for chromium, 1.3 μg/L for cobalt, and 1.6 μg/L for molybdenum. Radiolucent lines around acetabular implants were observed in 4% and femoral neck thinning in 5%. CONCLUSIONS Although our overall failure rate was greater than anticipated, the relatively low serum ion levels and no revisions for pseudotumors in young male patients up to 10 years postoperatively provide some evidence of the suitability of hip resurfacing in this subgroup. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Albrecht Hartmann
- Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr 74, 01307 Dresden, Germany
| | - Jörg Lützner
- Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr 74, 01307 Dresden, Germany
| | - Stephan Kirschner
- Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr 74, 01307 Dresden, Germany
| | | | - Klaus-Peter Günther
- Department of Orthopaedic Surgery, University Hospital Carl Gustav Carus Dresden, Fetscherstr 74, 01307 Dresden, Germany
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Sehatzadeh S, Kaulback K, Levin L. Metal-on-metal hip resurfacing arthroplasty: an analysis of safety and revision rates. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2012; 12:1-63. [PMID: 23074429 PMCID: PMC3440005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Metal-on-metal (MOM) hip resurfacing arthroplasty (HRA) is in clinical use as an appropriate alternative to total hip arthroplasty in young patients. In this technique, a metal cap is placed on the femoral head to cover the damaged surface of the bone and a metal cup is placed in the acetabulum. OBJECTIVES The primary objective of this analysis was to compare the revision rates of MOM HRA using different implants with the benchmark set by the National Institute of Clinical Excellence (NICE). The secondary objective of this analysis was to review the literature regarding adverse biological effects associated with implant material. REVIEW METHODS A literature search was performed on February 13, 2012, to identify studies published from January 1, 2009, to February 13, 2012. RESULTS The revision rates for MOM HRA using 6 different implants were reviewed. The revision rates for MOM HRA with 3 implants met the NICE criteria, i.e., a revision rate of 10% or less at 10 years. Two implants had short-term follow-ups and MOM HRA with one of the implants failed to meet the NICE criteria. Adverse tissue reactions resulting in failure of the implants have been reported by several studies. With a better understanding of the factors that influence the wear rate of the implants, adverse tissue reactions and subsequent implant failure can be minimized. Many authors have suggested that patient selection and surgical technique affect the wear rate and the risk of tissue reactions. The biological effects of high metal ion levels in the blood and urine of patients with MOM HRA implants are not known. Studies have shown an increase in chromosomal aberrations in patients with MOM articulations, but the clinical implications and long-term consequences of this increase are still unknown. Epidemiological studies have shown that patients with MOM HRA implants did not have an overall increase in mortality or risk of cancer. There is insufficient clinical data to confirm the teratogenicity of MOM implants in humans. CONCLUSIONS Metal-on-metal HRA can be beneficial for appropriately selected patients, provided the surgeon has the surgical skills required for performing this procedure.
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Griffin JW, D’Apuzzo M, Browne JA. Management of failed metal-on-metal total hip arthroplasty. World J Orthop 2012; 3:70-4. [PMID: 22720266 PMCID: PMC3377908 DOI: 10.5312/wjo.v3.i6.70] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 05/12/2012] [Accepted: 06/05/2012] [Indexed: 02/06/2023] Open
Abstract
The theoretical advantages of metal-on-metal (MOM) bearing couples in total hip arthroplasty (THA) have been recently balanced by concerns regarding adverse local and systemic effects. Higher than anticipated early revision rates have been reported by several joint registries. Failed MOM hips present with a spectrum of symptoms and findings and traditional methods of failure must be considered in addition to the failure modes that appear to be unique to the MOM bearing couple. Metal hypersensitivity and soft tissue immune reactions remain incompletely understood and require careful ongoing study. The tools available to evaluate MOM THAs and the indications for revision surgery remain to be defined. Outcomes following revision of MOM hips appear to depend on appropriate evaluation, early identification, and appropriate surgical management.
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Chinese experience with metal-on-metal hip resurfacing. J Arthroplasty 2012; 27:968-75. [PMID: 22333868 DOI: 10.1016/j.arth.2011.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 11/21/2011] [Indexed: 02/01/2023] Open
Abstract
The aim of this study was to study the actual clinical and laboratory results of metal-on-metal resurfacing hip arthroplasties by comparing with other implants. A total of 127 cases were operated on at the Department of Orthopaedics of Wuhan Union Hospital from 2005 to 2011. An important cause of failure is the fracture of the femoral neck. The chromium and cobalt levels of resurfacing hip arthroplasty and large-diameter head total hip arthroplasty (THA) are higher than those of a conventional metal-on-polyethylene total hip arthroplasty. There was a high ion level associated with an abduction angle of more than 45° and repetitive extreme hip motion in the 3 revision cases. The findings of this study are novel and quite controversial with that of the previously published literature.
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36
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Moroni A, Nocco E, Hoque M, Diremigio E, Buffoli D, Cantù F, Catalani S, Apostoli P. Cushion bearings versus large diameter head metal-on-metal bearings in total hip arthroplasty: a short-term metal ion study. Arch Orthop Trauma Surg 2012; 132:123-9. [PMID: 21845437 DOI: 10.1007/s00402-011-1364-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Metal-on-metal total hip arthroplasty (MOM THA) has the advantage of replicating the femoral head size, but the postoperative elevation of serum metal ion levels is a cause for concern. Metal-on-polycarbonate-urethane is a new cushion bearing featuring a large diameter metal head coupled with a polycarbonate-urethane liner. AIM The aim of this study was to assess and compare serum cobalt (Co) and chromium (Cr) levels in a group of 15 patients treated with a cushion bearing THA system (Group A) and a group of 15 patients treated with a MOM THA system (Group B) at short-term. At a mean follow-up of 27.3 months (18-35 months), in Group A the median Cr and Co serum levels were significantly lower than in Group B, measuring 0.24 μg/L (0.1-2.1 μg/L) and 0.6 μg/L (0.29-2.3 μg/L) compared to 1.3 μg/L (0.1-9 μg/L, p < 0.001) and 2.9 μg/L (0.85-13.8 μg/L, p < 0.001) respectively. RESULTS All patients demonstrated an excellent clinical result, as shown by the Harris and Oxford hip scores. The cushion bearing THA studied in this paper showed clinical outcomes similar to the MOM THA bearing, with the advantage of no significant metal ion elevation in the serum. CONCLUSION These findings warrant the continued clinical study of compliant bearing options.
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Affiliation(s)
- Antonio Moroni
- School of Sports Science, University of Bologna, Bologna, Italy.
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Hart AJ, Skinner JA, Henckel J, Sampson B, Gordon F. Insufficient acetabular version increases blood metal ion levels after metal-on-metal hip resurfacing. Clin Orthop Relat Res 2011; 469:2590-7. [PMID: 21656317 PMCID: PMC3148360 DOI: 10.1007/s11999-011-1930-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2010] [Accepted: 05/19/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many factors affect the blood metal ion levels after metal-on-metal (MOM) hip arthroplasty. The main surgically adjustable variable is the amount of coverage of the head provided by the cup which is a function of the inclination and version angles. However, most studies have used plain radiographs which have questionable precision and accuracy, particularly for version and large diameter metal heads; further, these studies do not simultaneously assess version and inclination. Thus the relationship between version and blood metal ions levels has not been resolved. QUESTIONS/PURPOSES We determined whether cup inclination and version influence blood metal ion levels while adjusting for age at assessment, gender, body mass index, horizontal femoral offset, head size, manufacturer hip type, and Oxford hip score. PATIENTS AND METHODS We prospectively followed 100 individuals (51 females, 49 males) with unilateral MOM hip resurfacing who underwent clinical assessment, CT scanning, and blood metal ion measurement. Multiple regression analysis was used to determine which variables were predictors of blood metal ion levels and to model the effect of these variables. RESULTS Only cup inclination, version angles, and gender influenced blood cobalt or chromium levels. Cobalt and chromium levels positively correlated with inclination angle and negatively correlated with version angle. The effect of changes in version angle was less than for inclination angle. Based on our observations, we developed a formula to predict the effect of these parameters on metal ion levels. CONCLUSIONS Our data suggest insufficient cup version can cause high blood metal ions after MOM hip arthroplasty. We were unable to show that excessive version caused high levels. LEVEL OF EVIDENCE Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alister J Hart
- Department of Orthopaedic Surgery, Imperial College, Charing Cross Hospital Campus, London SW7 2AZ, UK.
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Haddad FS, Thakrar RR, Hart AJ, Skinner JA, Nargol AVF, Nolan JF, Gill HS, Murray DW, Blom AW, Case CP. Metal-on-metal bearings: the evidence so far. ACTA ACUST UNITED AC 2011; 93:572-9. [PMID: 21511920 DOI: 10.1302/0301-620x.93b4.26429] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.
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Affiliation(s)
- F S Haddad
- Department of Orthopaedics, University College Hospital, 235 Euston Road, London NW1 2BU, UK.
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