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Davis TP. Metal-on-Metal Hip Arthroplasty: A Comprehensive Review of the Current Literature. Cureus 2023; 15:e48238. [PMID: 37929272 PMCID: PMC10624517 DOI: 10.7759/cureus.48238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 11/07/2023] Open
Abstract
Metal-on-metal (MoM) total hip arthroplasty has been widely used since the end of the 20th century, although rates have now decreased due to concerns regarding adverse reactions and failure rates. The MoM implant has been replaced with other materials, such as ceramic-on-ceramic (CoC) and metal-on-polyethylene (MoP). This literature review looks at the past and present use of MoM prostheses to assess whether the turn away from MoM use is justified. Online literature searches were performed on PubMed, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), and Web of Science online databases using the search terms "MoM and (ARMD and ALVAL)" (ARMD: adverse reaction to metal debris; ALVAL: aseptic lymphocyte-dominant vasculitis-associated lesion). A total of 64 relevant titles were included in the review. Although risk factors for adverse reactions and the causes of ARMD are generally agreed upon, more work is required to further understand the specific thresholds of blood metal ion levels that can be used to consistently identify ARMD and excessive metal wear-debris in patients who have not had their MoM implants revised. Metal-on-metal devices are not an acceptable option for total hip arthroplasties (THAs) in their current formulation due to the high rate and risk of ARMD. Some MoM hip resurfacing operations are appropriate for very carefully selected patients who are fully aware of the risks posed by the implant. It is recommended that device-specific thresholds for metal ion levels be developed to identify patients at risk of ARMD locally and systemically while using auxiliary tools to assist diagnosis, such as metal artefact reduction sequences (MARS)-MRI and hip scoring tools. Further work should investigate device-specific blood metal ion levels, the systemic effects of raised metal ion concentrations secondary to MoM arthroprosthetic wear, and the potential risks of ARMD caused by wear from tapered stems (including the implications this has for patients with CoC and MoP prostheses).
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Affiliation(s)
- Timothy P Davis
- Department of Anatomy, University of Nottingham Medical School, Nottingham, GBR
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2
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Reito A, Lainiala O, Berryman F, Dunlop DJ, Eskelinen A, Matharu GS. Long-term changes in blood metal ion levels in patients with hip resurfacing implants: implications for patient surveillance after 10 years follow-up. Hip Int 2023; 33:864-871. [PMID: 35848136 DOI: 10.1177/11207000221104396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies investigating changes in blood metal ion levels during the second decade of the implant lifetime in MoM hip resurfacing patients are scarce. METHODS Patients implanted with either Birmingham Hip Resurfacing (BHR) or Articular Surface Replacement (ASR) hip resurfacings with >10 years follow-up and repeated blood metal ion measurements were identified at 2 large specialist European arthroplasty centres. After excluding patients with initial metal ion levels >7 ppb, the proportion of patients with an increase in blood metal ion levels above previously validated implant-specific thresholds (cobalt 2.15 ppb for unilateral implants, cobalt or chromium 5.5 ppb for bilateral) was assessed. RESULTS We included 2743 blood metal ion measurements from 457 BHR patients (555 hips) and 216 ASR patients (263 hips). Of patients with initial metal ion levels below implant specific thresholds, increases in cobalt or chromium level, respectively, to above these thresholds during the second decade were seen as follows: unilateral BHR (cobalt = 15.6%), unilateral ASR (cobalt = 13.8%), bilateral BHR (cobalt = 8.2%, chromium = 11.8%), bilateral ASR (cobalt = 8.5%, chromium = 4.3%). Measurement-to-measurement changes exceeding +2.15 ppb or +5.5 ppb were, however, uncommon during the second decade. Subgroup results with small diameter (<50 mm) implants were similar. CONCLUSIONS We recommend less frequent blood metal ion measurements are needed (every 3 to 5 years) for hip resurfacing patients if initial values were below 7ppb.
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Affiliation(s)
- Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | | | | | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, Tampere, Finland and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | - Gulraj S Matharu
- The Royal Orthopaedic Hospital, Birmingham, UK
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, UK
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Holappa E, Kettunen J, Miettinen H, Kröger H, Miettinen S. Long-term survival analysis of cementless large-diameter head metal-on-metal total hip arthroplasty. Arch Orthop Trauma Surg 2023; 143:4437-4446. [PMID: 36197490 PMCID: PMC10293397 DOI: 10.1007/s00402-022-04633-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 09/18/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The aim of this retrospective study was to study the long-term survival and reasons for revisions of a single-type, large-diameter head (LDH) metal-on-metal (MoM) implant. A special study interest was to find the threshold level for revision in terms of adverse reaction to metal debris (ARMD). MATERIALS AND METHODS In this cohort study, we retrospectively reviewed 234 patients (253 hips) who received 38 mm head size LDH MoM total hip arthroplasties (THAs) between 01 January 2004 and 31 December 2009 at our institution. Patient symptoms, conventional radiographs, magnetic resonance imaging (MRI) findings and whole blood metal ions were studied. RESULTS The median follow-up time was 11.5 years. The Kaplan-Meier cumulative survival estimate of the implant was 89.6% at 10 years and 82.9% at 14.6 years. Overall, 34/253 (13.4%) hips were revised during the follow-up period and of these; 19/34 (55.9%) were revised due to ARMD. The prevalence of ARMD was 12.4% (29/234 patients). CONCLUSIONS The survival of the implant was on a moderate level as the 10-year cumulative survival rate was 89.6%. The exact threshold level for ARMD revision cannot be determined due to multiple variables affecting factors in re-operation decision-making.
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Affiliation(s)
- Elli Holappa
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
| | - Jukka Kettunen
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, PO Box 1777, 70211, Kuopio, Finland
| | - Hannu Miettinen
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, PO Box 1777, 70211, Kuopio, Finland
| | - Heikki Kröger
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, PO Box 1777, 70211, Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
| | - Simo Miettinen
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, PO Box 1777, 70211, Kuopio, Finland.
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland.
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Lass R, Bechler U, Springer B, Rueckl K, Hanreich C, Boettner F. Midterm results of the Birmingham hip resurfacing: a single-surgeon series. Arch Orthop Trauma Surg 2023; 143:1041-1048. [PMID: 35076766 DOI: 10.1007/s00402-021-04305-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/04/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Birmingham hip resurfacing (BHR) is readily used as alternative to total hip replacement in younger patients. The current study aims to compare outcomes in terms of adverse local tissue reactions (ALTR), elevated metal ion levels and survival rates between low-risk (femoral component size ≥ 48 mm) and high-risk (femoral component size < 48 mm) BHR patients at a minimum 5-year follow-up (FU). MATERIALS AND METHODS We report the minimum 5-year, single surgeon outcome results of 183 BHRs, performed between 2007 and 2012. 154 patients, 18 women (20 hips) and 136 men (163 hips) were included in the study. Patients were grouped in 149 low-risk cases (femoral component size ≥ 48 mm) and in 34 high-risk cases (18 female/12 male) patients with a femoral head size < 48 mm). RESULTS At a minimum of 5-years FU time, 91% of the patients were available for FU. The overall survival rate was 91.8%. There were five revisions (survival rate 96.6%) in the low-risk group and ten revisions (survival rate 70.6%) in the high-risk group. In the low-risk group, six patients (6.5%) showed elevated metal ion levels (> 7 μg/l), compared to five patients (20.8%) in the high risk-group (p = 0.03). CONCLUSION Including the surgeon's initial learning curve, the BHR shows very good mid-term survival rates in the low-risk group but should, as previously demonstrated, not be considered for patients with less than 48 mm femoral head size. LEVEL OF EVIDENCE Level III: retrospective cohort study.
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Affiliation(s)
- Richard Lass
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics and Traumatology, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ulrich Bechler
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernhard Springer
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, 535 East 70th Street, New York, NY, 10021, USA
- Department of Orthopedics and Traumatology, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Kilian Rueckl
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, 535 East 70th Street, New York, NY, 10021, USA
- Orthopedic Clinic König-Ludwig-Haus, University of Wuerzburg, Würzburg, Germany
| | - Carola Hanreich
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, 535 East 70th Street, New York, NY, 10021, USA
| | - Friedrich Boettner
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, 535 East 70th Street, New York, NY, 10021, USA.
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Nandra RS, Ahmed U, Berryman F, Brash L, Dunlop DJ, Matharu GS. How much does a Medical and Healthcare Products Regulatory Agency medical device alert for metal-on-metal hip arthroplasty patients really cost? Hip Int 2022; 32:493-500. [PMID: 33445979 PMCID: PMC9203671 DOI: 10.1177/1120700020983297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Many worldwide regulatory authorities recommend regular surveillance of metal-on-metal hip arthroplasty patients given high failure rates. However, concerns have been raised about whether such regular surveillance, which includes asymptomatic patients, is evidence-based and cost-effective. We determined: (1) the cost of implementing the 2015 MHRA surveillance in "at-risk" Birmingham Hip Resurfacing (BHR) patients; and (2) how many asymptomatic hips with adverse reactions to metal debris (ARMD) would have been missed without patient recall. METHODS All BHR patients eligible for the 2015 MHRA recall (all females, and males with head sizes ⩽46 mm, regardless of symptoms) at one centre were invited for review (hips = 707; patients = 593). All patients were investigated (Oxford Hip Score, radiographs, blood metal ions, and targeted cross-sectional imaging) and managed accordingly. Surveillance costs were calculated using finance department data. RESULTS The surveillance cost £105,921.79 (range £147.76-£257.50/patient). Radiographs (£39,598) and nurse practitioner time/assistance (£23,618) accounted for 60% of overall costs. 31 hips had ARMD on imaging (12 revised; 19 under surveillance). All revisions were symptomatic. 7 hips with ARMD under surveillance were asymptomatic and remain under regular review. The number needed to treat to avoid missing one asymptomatic ARMD case was 101 patients, representing a cost of £18,041 to avoid one asymptomatic case. CONCLUSIONS Implementing MHRA surveillance for "at-risk" BHR patients was extremely costly. The risk of asymptomatic ARMD was low with the BHR (1%), suggesting recommended follow-up in asymptomatic patients is not cost efficient. This raises concerns about the increasingly intensive surveillance recommended in the 2017 MHRA guidance for metal-on-metal hip patients.
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Affiliation(s)
| | - Usman Ahmed
- The Royal Orthopaedic Hospital, Birmingham, UK
| | | | | | | | - Gulraj S Matharu
- The Royal Orthopaedic Hospital, Birmingham, UK,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, UK,Gulraj S Matharu, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB, UK.
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PIETILÄINEN S, LINNOVAARA A, VENÄLÄINEN MS, MÄNTYMÄKI H, LAAKSONEN I, LANKINEN P, MÄKELÄ KT. Median 10-year whole blood metal ion levels and clinical outcome of ReCap-M2a-Magnum metal-on-metal total hip arthroplasty. Acta Orthop 2022; 93:444-450. [PMID: 35438184 PMCID: PMC9017114 DOI: 10.2340/17453674.2022.2510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE We have previously reported that the whole blood (WB) chromium (Cr) and cobalt (Co) ion levels decrease in the short term after ReCap-M2a-Magnum large-diameter head (LDH) metal-on-metal (MoM) total hip arthroplasty (THA). This study reports long-term metal ion levels and clinical outcomes after ReCap-Magnum THA. PATIENTS AND METHODS ReCap-M2a-Magnum LDH THA was used in 1,450 patients in our hospital district from 2005 to 2012. Median follow-up time was 10 years. 991 patients had 2 or more metal ion measurements. The median measurement interval was 4 years. Individual metal ion change was assessed using logarithmic metal ion values in a random coefficient model. Kaplan-Meier survival estimates were calculated for revision surgery for any reason for revision, and separately for metal-related adverse events (metal ions above safe upper limit [SUL], revision due to ARMD, or pseudotumor). RESULTS Geometric mean of Cr decreased from 1.8 ppb (geometric standard deviation [GSD] 1.8) to 1.0 ppb (GSD 2.8, p < 0.001). The Co levels decreased from 1.7 ppb (GSD 2.4) to 1.4 ppb (GSD 2.8, p < 0.001). The hip-specific survival was 85% for revision due to any reason at 14 years and the hip-specific survival for any metal-related adverse event was 69% at 14 years. INTERPRETATION WB Cr and Co levels continued to decrease in the long-term follow-up of ReCap-M2a-Magnum THA patients. The amount of metal-related adverse events was rather high, but revision surgery was seldom required. We suggest that after 10 years from the implantation a 5-year measurement interval may be sufficient for asymptomatic ReCap-M2a-Magnum patients.
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Affiliation(s)
- Sakari PIETILÄINEN
- Department of Orthopaedics and Traumatology, Turku University Hospital,Department of Orthopaedics and Traumatology, Vaasa Central Hospital
| | - Axel LINNOVAARA
- Department of Orthopaedics and Traumatology, Vaasa Central Hospital
| | - Mikko S VENÄLÄINEN
- Turku Bioscience Centre, University of Turku and Åbo Akademi University,Turku University Hospital, Division of Medical Imaging, Department of Medical Physics, Turku
| | - Heikki MÄNTYMÄKI
- Department of Orthopaedics, Tampere University Hospital, Tampere
| | - Inari LAAKSONEN
- Department of Orthopaedics and Traumatology, Turku University Hospital,University of Turku
| | - Petteri LANKINEN
- Department of Orthopaedics and Traumatology, Turku University Hospital,University of Turku,Satasairaala Central Hospital, Satakunta Hospital District, Pori, Finland
| | - Keijo T MÄKELÄ
- Department of Orthopaedics and Traumatology, Turku University Hospital,University of Turku
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CASTAGNINI F, MONTALTI M, CATERNICCHIA F, TASSINARI E, BORDINI B, MARIOTTI F, TRAINA F. Outcomes of metal-on-metal hip arthroplasties surveillance in a tertiary center. MINERVA ORTHOPEDICS 2022. [DOI: 10.23736/s2784-8469.20.04092-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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8
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Zhang W, Wang C, Zhu W, Liu F, Liu Y. Ferrostatin-1 alleviates cytotoxicity of cobalt nanoparticles by inhibiting ferroptosis. Bioengineered 2022; 13:6163-6172. [PMID: 35200065 PMCID: PMC9208497 DOI: 10.1080/21655979.2022.2042143] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cobalt is the main component of metal prostheses in hip arthroplasty. Studies have shown that metal particles mainly composed of cobalt nanoparticles (CoNPs) can cause systemic and local toxic reactions due to various physical and chemical factors. Therefore, elucidating the underlying mechanisms of metal prosthesis action, coupled with identification of effective detoxification drugs are imperative to minimizing postoperative complications and prolonging the service life of these clinical tools. In this study, we treated Balb/3T3 mouse fibroblast cell line with CoNPs and ferrostatin-1, then measured cell viability via the CCK-8 assay. Next, we determined levels of reactive oxygen species (ROS), malondialdehyde (MDA), glutathione (GSH), cobalt and iron contents, as well as glutathione peroxidase 4 (GPX4), and solute carrier family 7 member 11 (SLC7A11) expression in each group. Finally, we employed transmission electron microscopy (TEM) to detect changes in the ultrastructure of each group of cells. Exposure of cells to CoNPs significantly suppressed their viability, and downregulated expression of GSH, GPX4, and SLC7A11 proteins. Conversely, this treatment mediated a significant increase in ROS, MDA, cobalt, and iron levels in the cells. TEM images revealed a marked increase in density of the mitochondrial membrane of cells in the CoNPs group, while the outer membrane was broken. Notably, treatment with ferroptosis inhibitor Ferrostatin-1 alleviated the cytotoxic response caused by CoNPs. These findings suggest that CoNP-induced cytotoxicity may be closely related to ferroptosis, indicating that inhibition of ferroptosis is a potential therapeutic strategy for reducing CoNP toxicity.
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Affiliation(s)
- Weinan Zhang
- Department of Orthopaedics, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Chen Wang
- Department of Orthopaedics, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Wenfeng Zhu
- Department of Orthopaedics, The Sixth Affiliated Hospital of Nantong University, Yancheng, Jiangsu Province, China
| | - Fan Liu
- Department of Orthopaedics, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
| | - Yake Liu
- Department of Orthopaedics, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province, China
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PIETILÄINEN S, SMEDBERG E, LAAKSONEN I, VENÄLÄINEN MS, LANKINEN P, MÄKELÄ KT. Repeated metal ion measurements and long-term outcome of Durom/MMC total hip arthroplasty. Acta Orthop 2022; 93:241-248. [PMID: 35043969 PMCID: PMC8788692 DOI: 10.2340/17453674.2022.1444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Data regarding long-term behavior of metal ion levels in metal-on-metal total hip arthroplasty (MoM THA) patients is scarce. Therefore, we assessed whether there is any change in whole blood (WB) chromium (Cr), and cobalt (Co) ion measurements in Durom and MMC MoM THA patients over time. The secondary aim was to report the clinical outcomes using these devices in a single district. Patients and methods - Durom and MMC cups were used in 249 MoM THAs from 2005 to 2011 in our district. Median follow-up time was 12 years for Durom THA (interquartile range [IQR] = 3) and 9 years for MMC THA (IQR = 1). A random coefficient model was used to compare individual differences in repeated WB Cr and Co ion measurements. The Kaplan-Meier estimator was used to analyze implant survival with any reason for revision as the endpoint. Results - Geometric means of Cr in Durom THA and MMC THA patients decreased from 2.2 ppb (geometric standard deviation [SD] = 1.9) to 1.5 ppb (geometric SD = 2.5, p< 0.001) and from 1.8 ppb (geometric SD = 1.8) to 1.1 ppb (geometric SD = 2.8, p = 0.01) respectively. The geometric means of Co values remained unchanged. The 10-year survival of Durom THA was 82%, and that of MMC THA 89% for any revision reason as endpoint. Interpretation - WB Cr levels decreased over time, and Co levels remained unchanged at long-term follow-up. Despite this we recommend continuing the follow-up of these devices due to relatively low implant survival.
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Affiliation(s)
- Sakari PIETILÄINEN
- Department of Orthopaedics and Traumatology, Turku University Hospital,University of Turku
| | | | - Inari LAAKSONEN
- Department of Orthopaedics and Traumatology, Turku University Hospital,University of Turku
| | - Mikko S VENÄLÄINEN
- Turku Bioscience Centre, University of Turku and Åbo Akademi University,Division of Medical Imaging, Department of Medical Physics, Turku University Hospital, Turku
| | - Petteri LANKINEN
- Department of Orthopaedics and Traumatology, Turku University Hospital,University of Turku,Department of Administration, Satakunta Central Hospital, Pori, Finland
| | - Keijo T MÄKELÄ
- Department of Orthopaedics and Traumatology, Turku University Hospital,University of Turku
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van der Weegen W, Hoekstra H, Brakel K, Sijbesma T. Limited need for screening of metal-on-metal hip resurfacing patients beyond 10 years of follow-up. Hip Int 2022; 32:106-112. [PMID: 32340491 DOI: 10.1177/1120700020917939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND National and international guidelines lack consistency on how to screen metal-on-metal (MoM) hip arthroplasty patients for adverse reactions to metal debris (ARMD). Long-term outcomes of MoM hip arthroplasty are scarce, hindering further development of such guidelines. We present the clinical, radiological and ARMD status of 158 cases of hip resurfacing with >10 years follow-up. METHODS A prospective analysis of a cohort of 298 consecutive hip resurfacing procedures was performed at a single institution. All patients underwent MARS-MRI scanning for pseudotumour screening at least once, regardless of symptoms. Implant survival and reasons for revision were analysed for all patients. Clinical, radiological and MARS-MRI results were analysed for 158 unrevised procedures with >10 years follow-up. RESULTS The implant survival was 85.9% at 14.5 years (95% CI, 81.9-90.6) with revision for all causes as endpoint and 92.3% with MoM disease-related revisions excluded (95% CI, 88.2-95.0). Of the 158 cases with >10 years follow-up, 1 had elevated metal ion levels, 29 had a stable C1 pseudotumour and 6 a stable C2 pseudotumour. All pseudotumours were observed within 3 years after initiating our intensified ARMD screening (2011), with no new pseudotumours observed after that period. CONCLUSIONS We suggest that follow-up of MoM hip resurfacing patients beyond 10 years after surgery can be done with large intervals (i.e. every 5 years), and only earlier if a patient becomes symptomatic.
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Affiliation(s)
| | - Henk Hoekstra
- Department of Orthopaedic Surgery, St. Anna Hospital, Geldrop, The Netherlands
| | - Koen Brakel
- Department of Radiology, St. Anna Hospital, Geldrop, The Netherlands
| | - Thea Sijbesma
- Department of Orthopaedic Surgery, St. Anna Hospital, Geldrop, The Netherlands
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11
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Whole blood chromium concentration is very rarely elevated independently of whole blood cobalt. Sci Rep 2021; 11:12352. [PMID: 34117287 PMCID: PMC8196186 DOI: 10.1038/s41598-021-91512-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 05/19/2021] [Indexed: 11/21/2022] Open
Abstract
Due to the risk of adverse reactions to metal debris resulting from increased wear of the arthroplasty more than one million metal-on-metal (MoM) hip replacements worldwide are in active follow-up. Follow-up usually includes measurement of both whole blood cobalt (Co) and chromium (Cr) concentrations. Our experience is that Cr is seldom independently elevated. We wanted to ascertain whether blood Cr measurements could be omitted from follow-up protocols without lowering the quality of follow-up. We identified 8438 whole blood Co and Cr measurements performed without or prior to revision surgery. When the cut-off levels 5 µg/L and 7 µg/L were used, Cr was independently elevated in only 0.5% (95% confidence interval, CI, 0.3 to 0.6) and 0.2% (CI 0.1 to 0.3) of the measurements. The models with continuous variables showed that the higher the blood metal concentrations are the lower the percentage of measurements with Cr higher than Co. Our results suggest that whole blood Cr is very rarely independently elevated and therefore the authorities should consider omitting Cr measurements from their screening guidelines of MoM hip replacements. We believe this change in practice would simplify follow-up and lead to cost savings without decreasing the quality of follow-up.
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12
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Pearce O, Matharu GS, Bolland BJ. Predictive Factors for Revision and Survivorship Analysis of a Prevalent 36-mm Metal-on-Metal Total Hip Replacement System: A Large Single-Center Retrospective Cohort Study. J Arthroplasty 2021; 36:1380-1387. [PMID: 33189496 DOI: 10.1016/j.arth.2020.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/11/2020] [Accepted: 10/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To our knowledge, this is the largest single-center cohort of the 36-mm Corail-Pinnacle metal-on-metal total hip replacements system, aiming to determine 10-year survivorship and identify predictors of revision. We further assessed year of implantation given reports of manufacturing variations affecting shells made after 2006 predisposing these components to increasing wear. METHODS All Corail-Pinnacle 36-mm metal-on-metal hips implanted in a single center (2005-2012). The effect of patient and implant-related variables, and year of implantation on revision risk was assessed using Kaplan-Meier, Cox regression, and interrupted time series analysis. RESULTS In total, 1212 metal-on-metal total hip replacements were implanted with a 10-year survival rate of 83.4% (95% confidence interval [CI] = 81.3-85.5). Mean follow-up duration was 7.3 years with 61% of patients reaching a minimum of 7 years of follow-up. One hundred nineteen patients required revision surgery (9.8%). Univariate analysis identified female gender (hazard ratio [HR] = 1.608, CI = 1.093-2.364, P = .016), age at implantation (HR = 0.982, CI = 0.968-0.997, P = .019), smaller 50-mm to 54-mm cup diameter (HR = 1.527, CI = 1.026-2.274, P = .037), and high-offset stems (HR = 2.573, CI = 1.619-4.089, P < .001) as predictors of revision. Multivariate modeling confirmed female gender and high-offset stems as significant predictors of revision. For components implanted after 2007, the number of revisions showed no statistically significant step increase compared to pre-2007 implantation. CONCLUSION We observed a high 10-year failure rate (16.6%) with this implant, mostly due to adverse reaction to metal debris. Female gender and high femoral offset stems were significant predictors for all-cause revision. Year of implantation was not significantly associated with an increasing number of revisions from 2007 onwards, although further studies to validate the impact of manufacturing discrepancies are recommended.
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Affiliation(s)
- Oliver Pearce
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom
| | - Gulraj S Matharu
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ben J Bolland
- Department of Orthopaedic Surgery, Musgrove Park Hospital, Taunton, United Kingdom
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Pogliacomi F, Schiavi P, Calderazzi F, Leigheb M, Domenichini M, Pedrazzini A, Ceccarelli F, Vaienti E. Is there a relation between clinical scores and serum ion levels after MoM-THA? One year results in 383 implants. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020014. [PMID: 33559629 PMCID: PMC7944688 DOI: 10.23750/abm.v91i14-s.10955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 11/15/2020] [Indexed: 12/14/2022]
Abstract
Background and aim of the work: Adverse reaction to metal debris is the major cause of the high revision rates of metal on metal hip implants with femoral head size ≥ 36mm. Health authorities recommend regular surveillance even for asymptomatic individuals. The main investigations used are Co+ and Cr+ serum levels, x-rays and, eventually, ultrasound and MARS-MRI. Clinic is also assessed. The aim of this study is to identify if there is a relation between ion levels and the clinical scores in order to evaluate the outcome and plan the correct management after this type of implant. Methods: 383 subjects were included and divided in 3 groups (serum ion levels >, < and >60 µg/L). Co+, Cr+, HHS and OHS results of 1 year (2017) were analysed in order to show a correlation between ion levels and clinical scores. Results: Clinical scores were similar in group 1 and 2. Differences were observed comparing the group 1 and 2 with group 3 for both variables. Discussion and Conclusions: Surveillance algorithms have been introduced by health authorities. Nevertheless, the indication to revision surgery is not simple especially in those cases in which a discrepancy between clinic and investigations is present. In this study clinical scores seem to be less important than ion levels in the evaluation of outcomes and in order to plan the correct management in the majority of cases. Larger studies are needed to highlight the real importance of clinical scores in the decision making after these type of implants.
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Affiliation(s)
- Francesco Pogliacomi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Paolo Schiavi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Filippo Calderazzi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Massimiliano Leigheb
- Department of Health Sciences, University of Eastern Piedmont (UPO) Orthopaedics and Traumatology Unit, "Maggiore della Carità" Hospital, Novara, Italy.
| | - Marco Domenichini
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | | | - Francesco Ceccarelli
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Enrico Vaienti
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
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Dell'Isola A, Castagnini F, Bordini B, Montalti M, Rolli M, Traina F. Metal on metal hip arthroplasty surveillance at a tertiary centre: design, patients' adherence, and cost analysis. INTERNATIONAL ORTHOPAEDICS 2020; 44:1943-1949. [PMID: 32642825 DOI: 10.1007/s00264-020-04618-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Metal-on-metal (MOM) bearings may carry higher than expected revision rates and serious complications: an appropriate surveillance may be advocated. Aims of this paper were to (1) present the biennial experience of MOM surveillance in a tertiary centre, (2) describe the patients' adherence to monitoring, and (3) analyze the costs of the surveillance METHODS: The design of MOM surveillance was developed according to the guidelines of the Italian Society of Orthopaedics and Traumatology. The adherence to every follow-up was expressed as raw numbers and percentages. A cost analysis (direct and indirect costs) was conducted and projected in a five year time span. RESULTS About 61.1% of patients adhered to the first step of the surveillance, and 13.5% answered to a specific questionnaire about MOM implant. About 36.2% of the patients participated for the annual follow-up, and 18.1% entered the six month follow-up program. Of the implants, 2.5% required a revision. A two year surveillance costs €45,520.30, €236,443.98 (57.7%) including revisions. Five-year projected costs will be €23.113,64 (5.6%). Hospital indirect costs, including personnel working days, were €150,392.30 (36.7%). The estimated economic burden for seven years will be €409,949.92 (direct € 259,557.62, indirect €150,392.30). CONCLUSION Patients' adherence to MOM surveillance is modest and the rate of dropouts seems not to stop over the time. Most of the expenses are due to revision surgeries, as well as indirect costs. Economy of scale may be suggested to reduce the costs, involving as much MOM population as possible.
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Affiliation(s)
- Alfredo Dell'Isola
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136, Bologna, Italy
| | - Francesco Castagnini
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy.
| | - Barbara Bordini
- Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136, Bologna, Italy
| | - Maurizio Montalti
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Maurizia Rolli
- IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
| | - Francesco Traina
- Ortopedia-Traumatologia e Chirurgia protesica e dei reimpianti d'anca e di ginocchio, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli 1, 40136, Bologna, Italy
- DIBINEM, University of Bologna, Bologna, Italy
- University of Messina, Messina, Italy
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Pietiläinen S, Mäntymäki H, Vahlberg T, Reito A, Eskelinen A, Lankinen P, Mäkelä K. Repeated cobalt and chromium ion measurements in patients with bilateral large-diameter head metal-on-metal ReCap-M2A-Magnum total hip replacement. Acta Orthop 2020; 91:378-382. [PMID: 32285731 PMCID: PMC8023891 DOI: 10.1080/17453674.2020.1751940] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Whole-blood (WB) chromium (Cr) and cobalt (Co) measurements are vital in the follow-up of metal-on-metal total hip replacement (MoM THR) patients. We examined whether there is a substantial change in repeated WB, Co, and Cr levels in patients with bilateral ReCap-M2A-Magnum THR. We also specified the number of patients exceeding the safe upper limit (SUL) of WB Co and Cr in the repeated measurement.Patients and methods - We identified 141 patients with bilateral ReCap-M2A-Magnum THR operated in our institution. 61 patients had repeated WB metal ion measurements with bilateral MoM implants still in situ in the second measurement. The mean time elapsing from the first measurement (initial measurement) to the second (control measurement) was 1.9 years (SD = 0.6, range 0.2-3.5). We used earlier established SUL levels for bilateral implants by Van Der Straeten et al. (2013).Results - The median (range) Co and Cr values decreased in the repeated measurement from 2.7 (0.6-25) to 2.1 (0.5-21) and 2.6 (0.8-14) to 2.1 (0.5-18) respectively. In 13% of the patients Co levels exceeded the SUL in the initial measurement and the proportion remained constant, at 13%, in the repeated measurement. In 5% of the patients, Cr levels were above SUL in the initial measurement and an equal 5% in the control measurement.Interpretation - Repeated WB metal ion levels did not increase in patients with bilateral ReCap-M2A-Magnum THR with a mean 1.9-year measurement interval. Long-term development of WB metal ion levels is still unclear in these patients.
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Affiliation(s)
- Sakari Pietiläinen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku
| | - Heikki Mäntymäki
- Department of Orthopaedics, Tampere University Hospital and University of Turku
| | | | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | - Petteri Lankinen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku
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Affatato S, Castiello E, Amendola L, Comitini S, Prudhon JL, Tigani D. Revision of a Monoblock Metal-on-Metal Cup Using a Dual Mobility Component: Is It a Reasonable Option? MATERIALS (BASEL, SWITZERLAND) 2020; 13:ma13092040. [PMID: 32349434 PMCID: PMC7254332 DOI: 10.3390/ma13092040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 06/11/2023]
Abstract
Revision of large-diameter, monoblock acetabular components for both hip resurfacing arthroplasty and metal-on-metal (MoM) total hip arthroplasty (THA) is correlated to a high amount of complications. For this reason, performing a limited revision by conversion to a dual mobility (DM) without acetabular component exchange has been proposed in order to limit these complications. Although DM bearing offers an easy solution avoiding the intraoperative and time-associated complications, concern about polyethylene wear and stability remains due to the difference regarding the design, the coverage angle and the clearance of the two implants. In order to evaluate the performance of this new solution with the new material to prevent the possibility of failure it is essential to conduct a review of the literature A qualitative systematic review of the literature has been conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, EMBASE, Google Scholar, and Scopus for English and French articles between January 2000 and October 2019 was performed, with the primary objective of finding articles about dual mobility bearing coupling with large metal-on-metal cup in the case of hip revision procedure. Various combinations of the key words were used in the search strategy. Thirteen articles with DM bearing mated with MoM cup were analyzed. Of the 130 hip revisions selected, with a follow-up from 6 to 53 months, there were a total of 14 with complications (10.77%): four true dislocations (3.08%); six intra-prosthetic dislocations (IPD, 4.6%), two of which presented plastic deformation and polyethylene wear; four other complications (3.08%), included a cup osteolysis, a clicking noise, a superficial infection and a periprosthetic fracture. All the mentioned true dislocations occurred during the first month while IPDs appeared during the first two years from the index revision. In conclusion, according to the literature analyzed, we can stress that the concerns and doubts about mating a DM bearing with large MoM cup cannot be dissolved. It has been pointed out that a DM bearing is not designed for a MoM cup; it is not mechanically tested on MoM cups, which presents different clearance and coverage angles. Predictable complications may occur, such as IPD, polyethylene wear and true dislocation. These complications have been reported at an even higher rate than they were in the eighties, when the first generation of DM implants were of a lower quality of polyethylene and the characteristic of the design was less optimal than modern ones.
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Affiliation(s)
- Saverio Affatato
- Laboratorio di Tecnologia Medica, IRCCS – Istituto Ortopedico Rizzoli, 40100 Bologna, Italy
| | - Emanuela Castiello
- Unità Operativa Complessa di Ortopedia e Traumatologia, Ospedale Maggiore, 40100 Bologna, Italy; (E.C.); (L.A.); (S.C.); (D.T.)
| | - Luca Amendola
- Unità Operativa Complessa di Ortopedia e Traumatologia, Ospedale Maggiore, 40100 Bologna, Italy; (E.C.); (L.A.); (S.C.); (D.T.)
| | - Saverio Comitini
- Unità Operativa Complessa di Ortopedia e Traumatologia, Ospedale Maggiore, 40100 Bologna, Italy; (E.C.); (L.A.); (S.C.); (D.T.)
| | | | - Domenico Tigani
- Unità Operativa Complessa di Ortopedia e Traumatologia, Ospedale Maggiore, 40100 Bologna, Italy; (E.C.); (L.A.); (S.C.); (D.T.)
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Matharu GS, Berryman F, Dunlop DJ, Revell MP, Judge A, Murray DW, Pandit HG. No Threshold Exists for Recommending Revision Surgery in Metal-on-Metal Hip Arthroplasty Patients With Adverse Reactions to Metal Debris: A Retrospective Cohort Study of 346 Revisions. J Arthroplasty 2019; 34:1483-1491. [PMID: 30992241 PMCID: PMC6590389 DOI: 10.1016/j.arth.2019.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 02/28/2019] [Accepted: 03/06/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Surgeons currently have difficulty when managing metal-on-metal hip arthroplasty (MoMHA) patients with adverse reactions to metal debris (ARMD). This stems from a lack of evidence, which is emphasized by the variability in the recommendations proposed by different worldwide regulatory authorities for considering MoMHA revision surgery. We investigated predictors of poor outcomes following MoMHA revision surgery performed for ARMD to help inform the revision threshold and type of reconstruction. METHODS We retrospectively studied 346 MoMHA revisions for ARMD performed at 2 European centers. Preoperative (metal ions/imaging) and intraoperative (findings, components removed/implanted) factors were used to predict poor outcomes. Poor outcomes were postoperative complications (including re-revision), 90-day mortality, and poor Oxford Hip Score. RESULTS Poor outcomes occurred in 38.5%. Shorter time (under 4 years) to revision surgery was the only preoperative predictor of poor outcomes (odds ratio [OR] = 2.12, confidence interval [CI] = 1.00-4.46). Prerevision metal ions and imaging did not influence outcomes. Single-component revisions (vs all-component revisions) increased the risk of poor outcomes (OR = 2.99, CI = 1.50-5.97). Intraoperative modifiable factors reducing the risk of poor outcomes included the posterior approach (OR = 0.22, CI = 0.10-0.49), revision head sizes ≥36 mm (vs <36 mm: OR = 0.37, CI = 0.18-0.77), ceramic-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.30, CI = 0.14-0.66), and metal-on-polyethylene revision bearings (OR vs ceramic-on-ceramic = 0.37, CI = 0.17-0.83). CONCLUSION No threshold exists for recommending revision in MoMHA patients with ARMD. However postrevision outcomes were surgeon modifiable. Optimal outcomes may be achieved if surgeons use the posterior approach, revise all MoMHA components, and use ≥36 mm ceramic-on-polyethylene or metal-on-polyethylene articulations.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom; Research Department, The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Fiona Berryman
- Research Department, The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - David J Dunlop
- Research Department, The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Matthew P Revell
- Research Department, The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, United Kingdom
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18
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Mäntymäki H, Lankinen P, Vahlberg T, Reito A, Eskelinen A, Mäkelä K. Repeated cobalt and chromium ion measurements in patients with large-diameter head metal-on-metal ReCap-M2A-Magnum total hip replacement. Acta Orthop 2019; 90:243-248. [PMID: 30945585 PMCID: PMC6534222 DOI: 10.1080/17453674.2019.1595469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Whole blood (WB) cobalt (Co) and chromium (Cr) ion levels have a major role in the follow-up of metal-on-metal total hip replacement (MoM THR). We investigated, first, if there was a change in WB Co or Cr levels over repeated measurements in patients with ReCap-M2A-Magnum THR, and, second, determined how many patients had WB Co or Cr levels that exceeded the safe upper limits (SUL) in the repeated whole blood metal ion assessment. Patients and methods - A Recap-M2A-Magnum THR was used in 1,329 operations (1,188 patients) at our institution between 2005 and 2012. We identified all patients (n = 319) with unilateral ReCap-M2A-Magnum implants who had undergone at least 2 repeated metal ion measurements with the first blood sample taken mean 5.5 years (1.8-9.3) after surgery and the second taken mean 2 years (0.5-3) after the first. Results - The median WB Co and Cr ion levels decreased in repeated measurements from 1.40 (0.40-63) ppb to 1.10 (0.20-68) ppb and from 1.60 (0.60-13.0) ppb to 1.10 (0.30-19.0) ppb, respectively. 7% of the Co ion values exceeded SUL at the initial measurement, and 7% at the control measurement. The proportion of Cr ion values exceeding the safe upper limit (SUL) decreased during the measurement interval from 5% to 4%. Interpretation - Repeated metal ion measurements in unilateral ReCap-M2A-Magnum patients in a mean 2-year time interval did not show any increase. Long-term ion levels are, however, not yet known.
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Affiliation(s)
- Heikki Mäntymäki
- Department of Orthopaedics, Tampere University Hospital and University of Turku;; ,Correspondence:
| | - Petteri Lankinen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku;;
| | | | - Aleksi Reito
- Coxa Hospital for Joint Replacement and University of Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement and University of Tampere, Finland
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku;;
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Kovochich M, Finley BL, Novick R, Monnot AD, Donovan E, Unice KM, Fung ES, Fung D, Paustenbach DJ. Understanding outcomes and toxicological aspects of second generation metal-on-metal hip implants: a state-of-the-art review. Crit Rev Toxicol 2019; 48:853-901. [DOI: 10.1080/10408444.2018.1563048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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20
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Connelly JW, Galea VP, Laaksonen I, Matuszak SJ, Madanat R, Muratoglu O, Malchau H. Response to Letter to the Editor on "Indications for MARS-MRI in Patients Treated With Articular Surface Replacement XL Total Hip Arthroplasty". J Arthroplasty 2019; 34:606-607. [PMID: 30528135 DOI: 10.1016/j.arth.2018.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- James W Connelly
- Department of Orthopaedic Surgery, Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Vincent P Galea
- Department of Orthopaedic Surgery, Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Inari Laaksonen
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sean J Matuszak
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Rami Madanat
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts; Department of Orthopaedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - Orhun Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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21
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Matharu GS. Letter to the Editor on "Indications for MARS-MRI in Patients Treated With Articular Surface Replacement XL Total Hip Arthroplasty". J Arthroplasty 2019; 34:605-606. [PMID: 30420253 DOI: 10.1016/j.arth.2018.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/08/2018] [Indexed: 02/01/2023] Open
Affiliation(s)
- Gulraj S Matharu
- Musculoskeletal Research Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, United Kingdom; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Marchica D, Gallazzi E, Materazzi G, Battaglia GA, Zagra L. MRI findings, metal ion levels and clinical outcome of a complete series of large metal on metal THA: what's really going on? Hip Int 2018; 28:48-53. [PMID: 30755111 DOI: 10.1177/1120700018813223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION: Metal-on-metal (MoM) large head total hip arthroplasties (THAs) were discontinued early after their introduction because of the high number of failures due to adverse reaction to metal debris (ARMD). Aim of this study is to report the clinical outcome at a mid-term follow-up (FU) of a series of large-head MoM THA. METHODS: In this prospective study, 25 hips (24 patients, 3 males, 21 females, mean age 62.44 years) who have undergone primary THA with large head (diameter ⩾36 mm) MoM prosthesis were evaluated. Each patient underwent a standard follow-up after surgery, that included blood tests with metal ion levels (Co and Cr), x-ray of the pelvis, metal artifact reduction sequence magnetic resonance imaging (MARS-MRI) and clinical evaluation. RESULTS: At an average follow-up of 7.3 years, 4 hips have been surgically reviewed: 2 for causes not related to ARMD (1 heterotopic ossification and 1 periprosthetic fracture); the other 2 on the same patient (bilateral) with ARMD, who was eventually found to be allergic to nickel. Increased metal ions, osteolysis and severe MRI alterations were found in patients with ARMD. Asymptomatic alterations at MRI were found in 8 patients. Harris Hip Score improved after surgery from a mean of 51 points to a mean of 90 points ( p < 0.01). CONCLUSIONS: The findings of this study show that not all the patients with MoM THA will develop clear symptoms of ARMD at mid-term follow-up. Patients should be closely monitored following protocols such as that proposed in the European Consensus Statement.
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Affiliation(s)
- Daniele Marchica
- 1 Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Enrico Gallazzi
- 1 Hip Department, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | | | | | - Luigi Zagra
- 2 IRCCS Istituto Ortopedico Galeazzi, Hip Department, Milan, Italy
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Perino G, Sunitsch S, Huber M, Ramirez D, Gallo J, Vaculova J, Natu S, Kretzer JP, Müller S, Thomas P, Thomsen M, Krukemeyer MG, Resch H, Hügle T, Waldstein W, Böettner F, Gehrke T, Sesselmann S, Rüther W, Xia Z, Purdue E, Krenn V. Diagnostic guidelines for the histological particle algorithm in the periprosthetic neo-synovial tissue. BMC Clin Pathol 2018; 18:7. [PMID: 30158837 PMCID: PMC6109269 DOI: 10.1186/s12907-018-0074-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 08/16/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The identification of implant wear particles and non-implant related particles and the characterization of the inflammatory responses in the periprosthetic neo-synovial membrane, bone, and the synovial-like interface membrane (SLIM) play an important role for the evaluation of clinical outcome, correlation with radiological and implant retrieval studies, and understanding of the biological pathways contributing to implant failures in joint arthroplasty. The purpose of this study is to present a comprehensive histological particle algorithm (HPA) as a practical guide to particle identification at routine light microscopy examination. METHODS The cases used for particle analysis were selected retrospectively from the archives of two institutions and were representative of the implant wear and non-implant related particle spectrum. All particle categories were described according to their size, shape, colour and properties observed at light microscopy, under polarized light, and after histochemical stains when necessary. A unified range of particle size, defined as a measure of length only, is proposed for the wear particles with five classes for polyethylene (PE) particles and four classes for conventional and corrosion metallic particles and ceramic particles. RESULTS All implant wear and non-implant related particles were described and illustrated in detail by category. A particle scoring system for the periprosthetic tissue/SLIM is proposed as follows: 1) Wear particle identification at light microscopy with a two-step analysis at low (× 25, × 40, and × 100) and high magnification (× 200 and × 400); 2) Identification of the predominant wear particle type with size determination; 3) The presence of non-implant related endogenous and/or foreign particles. A guide for a comprehensive pathology report is also provided with sections for macroscopic and microscopic description, and diagnosis. CONCLUSIONS The HPA should be considered a standard for the histological analysis of periprosthetic neo-synovial membrane, bone, and SLIM. It provides a basic, standardized tool for the identification of implant wear and non-implant related particles at routine light microscopy examination and aims at reducing intra-observer and inter-observer variability to provide a common platform for multicentric implant retrieval/radiological/histological studies and valuable data for the risk assessment of implant performance for regional and national implant registries and government agencies.
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Affiliation(s)
- G. Perino
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10023 USA
| | - S. Sunitsch
- Medizinische Universität Graz, Institut für Pathologie, Graz, Austria
| | - M. Huber
- Pathologisch-bakteriologisches Institut, Otto Wagner Spital, Wien, Austria
| | - D. Ramirez
- Department of Pathology and Laboratory Medicine, Hospital for Special Surgery, 535 E 70th Street, New York, NY 10023 USA
| | - J. Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, University Hospital, Palacky University Olomouc, Olomouc, Czech Republic
| | - J. Vaculova
- Department of Pathology, Fakultni Nemocnice Ostrava, Ostrava, Czech Republic
| | - S. Natu
- Department of Pathology, University hospital of North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | - J. P. Kretzer
- Labor für Biomechanik und Implantat-Forschung, Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - S. Müller
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Trier, Germany
| | - P. Thomas
- LMU Klinik, Klinik und Poliklinik für Dermatologie und Allergologie, Munich, Germany
| | - M. Thomsen
- Baden-Baden Klinik, Baden-Baden, Germany
| | | | - H. Resch
- Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Salzburg, Austria
| | - T. Hügle
- Hôpital Orthopédique, Lausanne, Switzerland
| | - W. Waldstein
- Medizinische Universität Wien, AKH-Wien, Universitätsklinik für Orthopädie, Wien, Austria
| | - F. Böettner
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, NY USA
| | - T. Gehrke
- Helios Endo-Klinik, Hamburg, Germany
| | - S. Sesselmann
- Orthopädische Universitätsklinik Erlangen, Erlangen, Germany
| | - W. Rüther
- Klinik und Poliklinik für Orthopädie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Z. Xia
- Centre for Nanohealth, Swansea University Medical School, Singleton Park, Swansea, UK
| | - E. Purdue
- Hospital for Special Surgery, Research Institute, New York, NY USA
| | - V. Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Trier, Germany
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Matharu GS, Eskelinen A, Judge A, Pandit HG, Murray DW. Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris. Acta Orthop 2018; 89:278-288. [PMID: 29493348 PMCID: PMC6055775 DOI: 10.1080/17453674.2018.1440455] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The initial outcomes following metal-on-metal hip arthroplasty (MoMHA) revision surgery performed for adverse reactions to metal debris (ARMD) were poor. Furthermore, robust thresholds for performing ARMD revision are lacking. This article is the second of 2. The first article considered the various investigative modalities used during MoMHA patient surveillance (Matharu et al. 2018a ). The present article aims to provide a clinical update regarding ARMD revision surgery in MoMHA patients (hip resurfacing and large-diameter MoM total hip arthroplasty), with specific focus on the threshold for performing ARMD revision, the surgical strategy, and the outcomes following revision. Results and interpretation - The outcomes following ARMD revision surgery appear to have improved with time for several reasons, among them the introduction of regular patient surveillance and lowering of the threshold for performing revision. Furthermore, registry data suggest that outcomes following ARMD revision are influenced by modifiable factors (type of revision procedure and bearing surface implanted), meaning surgeons could potentially reduce failure rates. However, additional large multi-center studies are needed to develop robust thresholds for performing ARMD revision surgery, which will guide surgeons' treatment of MoMHA patients. The long-term systemic effects of metal ion exposure in patients with these implants must also be investigated, which will help establish whether there are any systemic reasons to recommend revision of MoMHAs.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom,Correspondence:
| | | | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Kutzner I, Hallan G, Høl PJ, Furnes O, Gøthesen Ø, Figved W, Ellison P. Early aseptic loosening of a mobile-bearing total knee replacement. Acta Orthop 2018; 89:77-83. [PMID: 29105532 PMCID: PMC5810837 DOI: 10.1080/17453674.2017.1398012] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/29/2017] [Indexed: 01/31/2023] Open
Abstract
Background and purpose - Registry-based studies have reported an increased risk of aseptic tibial loosening for the cemented Low Contact Stress (LCS) total knee replacement compared with other cemented designs; however, the reasons for this have not been established. We made a retrieval analysis with the aim of identifying the failure mechanism. Patients and methods - We collected implants, cement, tissue, blood, and radiographs from 32 failed LCS Complete cases. Damage to the tibial baseplate and insert was assessed. Exposure to wear products was quantified in 11 cases through analysis of periprosthetic tissue and blood. Implant alignment and bone cement thickness was compared with a control group of 43 non-revised cases. Results - Loosening of the tibial baseplate was the reason for revision in 25 retrievals, occurring at the implant-cement interface in 16 cases. Polishing was observed on the lower surface of the baseplate and correlated to the level of cobalt, chromium, and zirconium in the blood. No evidence of abnormally high polyethylene wear was present. For each 1 mm increase in cement thickness the odds of failure due to aseptic loosening decreased by 61%. Greater varus alignment was associated with a shorter time to failure. The roughness, Ra, of a new LCS baseplate's lower surface was 3.7 (SD 0.7) µm. Interpretation - Debonding of the tibial component at the implant-cement interface was the predominant cause of tibial aseptic loosening. A thin cement layer may partly explain the poor performance. Furthermore, the comparatively low tibial surface roughness and the lack of a keeled stem may have played a role in the failures observed.
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Affiliation(s)
- Ines Kutzner
- Department of Clinical Medicine, University of Bergen, Norway
- Julius Wolff Institute, Charité—Universitätsmedizin Berlin, Germany
| | - Geir Hallan
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Paul Johan Høl
- Department of Clinical Medicine, University of Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Øystein Gøthesen
- Department of Clinical Medicine, University of Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Haugesund Hospital, Haugesund, Norway
| | - Wender Figved
- Orthopedic Department, Baerum Hospital, Vestre Viken Hospital Trust, Norway
| | - Peter Ellison
- Department of Clinical Medicine, University of Bergen, Norway
- Department of Mechanical Engineering, Imperial College London, UK
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Matharu GS, Judge A, Eskelinen A, Murray DW, Pandit HG. What is appropriate surveillance for metal-on-metal hip arthroplasty patients? Acta Orthop 2018; 89:29-39. [PMID: 29105547 PMCID: PMC5810829 DOI: 10.1080/17453674.2017.1398011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The unexpected high revision rates of large-diameter (femoral head sizes of 36 mm or greater) metal-on-metal hip arthroplasties (MoMHAs) have led to worldwide regulatory authorities recommending regular surveillance, even for asymptomatic individuals. However, these recommendations are not evidence-based and are very costly. The rapidly evolving evidence base requires an update regarding the investigation and management of MoMHA patients. This article is the first of 2 (the second article in this series will consider the threshold for performing revision, and the outcomes following ARMD revision surgery: Matharu et al., Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris: A clinical update. Acta Orthop 2018; in press), and considers the various investigative modalities used during surveillance, with specific focus on blood metal ion sampling and cross-sectional imaging. No single investigation can universally be used during MoMHA patient surveillance. Recent studies have now provided important information on interpreting blood metal ions (effective in identifying patients at low risk of problems), clarifying the roles of cross-sectional imaging (reserve combined ultrasound and MARS-MRI for complex cases), and providing parameters to safely exclude many asymptomatic patients from regular surveillance. This information will be useful when designing future surveillance protocols for MoMHA patients.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK;,Correspondence:
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
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Abstract
BACKGROUND Metal-on-metal hip replacement (MoMHR) revision surgery for adverse reactions to metal debris (ARMD) has been associated with an increased risk of early complications and reoperation and inferior patient-reported outcome scores compared with non-ARMD revisions. As a result, early revision specifically for ARMD with adoption of a lower surgical threshold has been widely recommended with the goal of improving the subsequent prognosis after ARMD revisions. However, no large cohorts have compared the risk of complications and reoperation after MoMHR revision surgery for ARMD (an unanticipated revision indication) with those after non-ARMD revisions (which represent conventional modes of arthroplasty revision). QUESTIONS/PURPOSES (1) Does the risk of intraoperative complications differ between MoMHRs revised for ARMD compared with non-ARMD indications? (2) Do mortality rates differ after MoMHRs revised for ARMD compared with non-ARMD indications? (3) Do rerevision rates differ after MoMHRs revised for ARMD compared with non-ARMD indications? (4) How do implant survival rates differ after MoMHR revision when performed for specific non-ARMD indications compared with ARMD? METHODS This retrospective observational study involved all patients undergoing MoMHR from the National Joint Registry (NJR) for England and Wales subsequently revised for any indication between 2008 and 2014. The NJR achieves high levels of patient consent (93%) and linked procedures (ability to link serial procedures performed on the same patient and hip; 95%). Furthermore, recent validation studies have demonstrated that when revision procedures have been captured within the NJR, the data completion and accuracy were excellent. Revisions for ARMD and non-ARMD indications were matched one to one for multiple potential confounding factors using propensity scores. The propensity score summarizes the many patient and surgical factors that were used in the matching process (including sex, age, type of primary arthroplasty, time to revision surgery, and details about the revision procedure performed such as the approach, specific components revised, femoral head size, bearing surface, and use of bone graft) using one single score for each revised hip. The patient and surgical factors within the ARMD and non-ARMD groups subsequently became much more balanced once the groups had been matched based on the propensity scores. The matched cohort included 2576 MoMHR revisions with each study group including 1288 revisions (mean followup of 3 years for both groups; range, 1-7 years). Intraoperative complications, mortality, and rerevision surgery were compared between matched groups using univariable regression analyses. Implant survival rates in the non-ARMD group were calculated for each specific revision indication with each individual non-ARMD indication subsequently compared with the implant survival rate in the ARMD group using Cox regression analyses. RESULTS There was no difference between the ARMD and non-ARMD MoMHR revisions in terms of intraoperative complications (odds ratio, 0.97; 95% confidence interval [CI], 0.59-1.59; p = 0.900). Mortality rates were lower after ARMD revision compared with non-ARMD revision (hazard ratio [HR], 0.43; CI, 0.21-0.87; p = 0.019); however, there was no difference when revisions performed for infection were excluded from the non-ARMD indication group (HR, 0.69; CI, 0.35-1.37; p = 0.287). Rerevision rates were lower after ARMD revision compared with non-ARMD revision (HR, 0.52; CI, 0.36-0.75; p < 0.001); this difference persisted even after removing revisions performed for infection (HR, 0.59; CI, 0.40-0.89; p = 0.011). Revisions for infection (5-year survivorship = 81%; CI, 55%-93%; p = 0.003) and dislocation/subluxation (5-year survivorship = 82%; CI, 69%-90%; p < 0.001) had the lowest implant survival rates when compared with revisions for ARMD (5-year survivorship = 94%; CI, 92%-96%). CONCLUSIONS Contrary to previous observations, MoMHRs revised for ARMD have approximately half the risk of rerevision compared with non-ARMD revisions. We suspect worldwide regulatory authorities have positively influenced rerevision rates after ARMD revision by recommending that surgeons exercise a lower revision threshold and that such revisions are now being performed at an earlier stage. The high risk of rerevision after MoMHR revision for infection and dislocation is concerning. Infected MoMHR revisions were responsible for the increased mortality risk observed after non-ARMD revision, which parallels findings in non-MoMHR revisions for infection. LEVEL OF EVIDENCE Level III, therapeutic study.
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Risk factors for mid-term revision surgery in patients with articular surface replacement total hip arthroplasty. Hip Int 2018; 28:44-49. [PMID: 28574125 DOI: 10.5301/hipint.5000524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION This study assessed the associations between gender and implant survival, as well as adverse local tissue reaction (ALTR), in patients with articular surface replacement (ASR) XL total hip arthroplasty (THA). Secondly, we sought to report the differences between genders in metal ion levels and patient reported outcome measures (PROMs) in these patients. METHODS 563 unilateral ASR XL THA patients were enrolled in a multicentre follow-up study at a mean of 6.4 years after index surgery. All patients had blood metal ion levels and PROMs obtained annually, and a valid anteroposterior pelvis radiograph. A sub-set of patients from a single centre had annual MRI performed and were analysed for the presence of moderate-to-severe ALTR. RESULTS 60 hips (11%) were revised during the study period. The only variables found to be associated with revision surgery in patients with unilateral THA were VAS pain (hazard ratio [HR], 1.35; p<0.001) and elevated cobalt metal ion levels (HR, 1.05; p<0.001). No variables assessed were found to be associated with prevalence of ALTR. Chromium concentrations were greater in female patients than males, while cobalt levels were similar between genders. Males reported higher HHS, EQ-5D and UCLA scores than females. CONCLUSIONS Both males and females with metal-on-metal THA implants should be followed with equal vigilance as gender does not appear to be associated with poor outcomes, such as revision surgery and presence of ALTR.
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Kiran M, Armstrong C, Shivarathre D, Peter VK. Blood Metal Ion Levels Have Limited Utility in the Surveillance of Asymptomatic Large-Head Metal-on-Metal Total Hip Arthroplasties. J Arthroplasty 2017; 32:3685-3688. [PMID: 28781016 DOI: 10.1016/j.arth.2017.07.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/26/2017] [Accepted: 07/12/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Blood cobalt (Co) and chromium (Cr) ion levels have been used as surveillance tools for adverse reaction to metal debris (ARMD) in metal-on-metal (MoM) articulations with varying thresholds in different countries. The aim of our study is to present the serial 12-year blood Co and Cr levels in a cohort of MoM total hip arthroplasties (THAs) with femoral head size ≥36 mm and analyze their utility in asymptomatic patients at current thresholds. METHODS A total of 256 patients with unilateral MoM THA with femoral head size ≥36 mm were included in this study with data collected prospectively. The implants used were Birmingham hip resurfacing cup-Freeman stem (BHR-F) or an Articular Surface Resurfacing cup-Corail/S-ROM stem. Annual follow-up with blood Co and Cr measurements was done as per Medicines and Healthcare Products Regulatory Agency (MHRA) of the United Kingdom guidelines. Receiver operating characteristic curve was plotted based on the sensitivity and specificity of blood metal ion values to detect ARMD. The metal ion levels in asymptomatic patients were analyzed separately. RESULTS Receiver operating characteristic curves showed poor discriminatory ability for both Co and Cr values in predicting ARMD at 7 μg/L. The sensitivity of Co and Cr was 82.1% and 53.5%, respectively, and their positive predictive values were 43.8% and 67.6%, respectively. After 7 years, there was no significant change in Co values, and there was a decline in Cr value after 9 years in asymptomatic patients. CONCLUSION To the best of our knowledge, this is the first study to describe the behavior of serial blood metal ion levels in asymptomatic large-diameter MoM THA. We suggest that annual blood Co and Cr have limited discriminant capacity in diagnosing the occurrence of metallosis and their measurement beyond 7 years is of limited utility in asymptomatic patients.
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Affiliation(s)
- Manish Kiran
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Catherine Armstrong
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Deepak Shivarathre
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
| | - Viju K Peter
- Department of Trauma and Orthopaedics, Royal Liverpool and Broadgreen Hospital, Liverpool, United Kingdom
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Matharu GS, Berryman F, Judge A, Reito A, McConnell J, Lainiala O, Young S, Eskelinen A, Pandit HG, Murray DW. Blood Metal Ion Thresholds to Identify Patients with Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris: An External Multicenter Validation Study of Birmingham Hip Resurfacing and Corail-Pinnacle Implants. J Bone Joint Surg Am 2017; 99:1532-1539. [PMID: 28926382 PMCID: PMC5805279 DOI: 10.2106/jbjs.16.01568] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The authors of recent studies have reported newly devised implant-specific blood metal ion thresholds to predict adverse reactions to metal debris (ARMD) in patients who have undergone unilateral or bilateral metal-on-metal (MoM) hip arthroplasty. These thresholds were most effective for identifying patients at low risk of ARMD. We investigated whether these newly devised blood metal ion thresholds could effectively identify patients at risk of ARMD after MoM hip arthroplasty in an external cohort of patients. METHODS We performed a validation study involving 803 MoM hip arthroplasties (323 unilateral Birmingham Hip Resurfacing [BHR], 93 bilateral BHR, and 294 unilateral Corail-Pinnacle implants) performed in 710 patients at 3 European centers. All patients underwent whole-blood metal ion sampling, and were divided into 2 groups: those with ARMD (leading to revision or identified on imaging; n = 75) and those without ARMD (n = 635). Previously devised implant-specific blood metal ion thresholds (2.15 μg/L of cobalt for unilateral BHR; 5.5 μg/L for the maximum of either cobalt or chromium for bilateral BHR; and 3.57 μg/L of cobalt for unilateral Corail-Pinnacle implants) were applied to the validation cohort, and receiver operating characteristic curve analysis was used to establish the discriminatory characteristics of each threshold. RESULTS The area under the curve, sensitivity, specificity, and positive and negative predictive values for the ability of each implant-specific threshold to distinguish between patients with and without ARMD were, respectively, 89.4% (95% confidence interval [CI] = 82.8% to 96.0%), 78.9%, 86.7%, 44.1%, and 96.9% for unilateral BHR; 89.2% (CI = 81.3% to 97.1%), 70.6%, 86.8%, 54.5%, and 93.0% for bilateral BHR; and 76.9% (CI = 63.9% to 90.0%), 65.0%, 85.4%, 24.5%, and 97.1% for unilateral Corail-Pinnacle implants. Using the implant-specific thresholds, we missed 20 patients with ARMD (2.8% of the patients in this series). We missed more patients with ARMD when we used the fixed thresholds proposed by regulatory authorities: 35 (4.9%) when we used the U.K. threshold of 7 μg/L for both cobalt and chromium (p = 0.0003), 21 (3.0%) when we used the U.S. threshold of 3 μg/L for both cobalt and chromium (p = 1.0), and 46 (6.5%) when we used the U.S. threshold of 10 μg/L for both cobalt and chromium (p < 0.0001). CONCLUSIONS This external multicenter validation study confirmed that patients with blood metal ion levels below new implant-specific thresholds have a low risk of ARMD after MoM hip arthroplasty. Using these implant-specific thresholds, we missed fewer patients with ARMD compared with when the thresholds currently proposed by regulatory authorities were used. We therefore recommend using implant-specific blood metal ion thresholds when managing patients who have undergone MoM hip arthroplasty. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S. Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Fiona Berryman
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | | | - Hemant G. Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Chapel Allerton Hospital, Leeds, United Kingdom
| | - David W. Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Matharu GS, Nandra RS, Berryman F, Judge A, Pynsent PB, Dunlop DJ. Risk factors for failure of the 36 mm metal-on-metal Pinnacle total hip arthroplasty system: a retrospective single-centre cohort study. Bone Joint J 2017; 99-B:592-600. [PMID: 28455467 PMCID: PMC5413867 DOI: 10.1302/0301-620x.99b5.bjj-2016-1232.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022]
Abstract
Aims To determine ten-year failure rates following 36 mm metal-on-metal
(MoM) Pinnacle total hip arthroplasty (THA), and identify predictors
of failure. Patients and Methods We retrospectively assessed a single-centre cohort of 569 primary
36 mm MoM Pinnacle THAs (all Corail stems) followed up since 2012
according to Medicines and Healthcare Products Regulation Agency
recommendations. All-cause failure rates (all-cause revision, and
non-revised cross-sectional imaging failures) were calculated, with predictors
for failure identified using multivariable Cox regression. Results Failure occurred in 97 hips (17.0%). The ten-year cumulative
failure rate was 27.1% (95% confidence interval (CI) 21.6 to 33.7).
Primary implantation from 2006 onwards (hazard ratio (HR) 4.30;
95% CI 1.82 to 10.1; p = 0.001) and bilateral MoM hip arthroplasty
(HR 1.59; 95% CI 1.03 to 2.46; p = 0.037) predicted failure. The
effect of implantation year on failure varied over time. From four
years onwards following surgery, hips implanted since 2006 had significantly
higher failure rates (eight years 28.3%; 95% CI 23.1 to 34.5) compared
with hips implanted before 2006 (eight years 6.3%; 95% CI 2.4 to
15.8) (HR 15.2; 95% CI 2.11 to 110.4; p = 0.007). Conclusion We observed that 36 mm MoM Pinnacle THAs have an unacceptably
high ten-year failure rate, especially if implanted from 2006 onwards
or in bilateral MoM hip patients. Our findings regarding implantation
year and failure support recent concerns about the device manufacturing
process. We recommend all patients undergoing implantation since
2006 and those with bilateral MoM hips undergo regular investigation,
regardless of symptoms. Cite this article: Bone Joint J 2017;99-B:592–600.
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Affiliation(s)
| | - R S Nandra
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
| | - F Berryman
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
| | - A Judge
- University of Oxford, Oxford, OX3 7LD, UK
| | - P B Pynsent
- School of Clinical and Experimental Medicine, University of Birmingham, B15 2TT, UK
| | - D J Dunlop
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
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Robinson DJ, Lee S, Marks P, Schneider ME. Ultrasound Screening for Adverse Local Tissue Reaction after Hip Arthroplasty. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:1549-1556. [PMID: 28411966 DOI: 10.1016/j.ultrasmedbio.2017.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 01/26/2017] [Accepted: 02/01/2017] [Indexed: 06/07/2023]
Abstract
Early detection of adverse local tissue reaction (ALTR) to prosthetic hip wear debris is vital to improve the success of revision surgery. Magnetic resonance imaging with metal artefact reduction sequencing (MARS MRI) is considered the modality of choice to provide cross-sectional imaging of the soft tissues. The areas adjacent to the prosthesis are, however, not readily imaged using these protocols. Ultrasound has also been recommended as an imaging modality in the follow-up of hip replacement surgery. We decided to characterise the typical ultrasound findings in a group of patients undergoing routine biennial review of arthroplastic hips with particular reference to the hip capsule, femoral neck and iliopsoas bursa and tendon adjacent to the implant. Fifty-two patients with a mean (±SD) age of 60.4 (±12) y were prospectively recruited. Twelve patients had bilateral hip prostheses, giving 64 hips for analysis. Mean (±SD) age of the prosthesis in situ was 8.2 (±3.3) y. Data were grouped on the basis of the shape of the iliofemoral ligament. The median (range) maximal anteroposterior synovial thickness was 5 (2-8) mm in the normal concave iliofemoral ligament group and 7 (4-56) mm in the abnormal straight/convex iliofemoral ligament group (p = 0.001). The anteroposterior iliopsoas tendon measurement was 5 (3-8) mm in the normal group and 5 (4-8) mm in the abnormal group (p = 0.065). ALTR development in asymptomatic well-functioning prostheses may be recognised earlier using ultrasound rather than MARS MRI by carefully assessing the shape of the iliofemoral ligament. Ultrasound findings of an abnormal straight or convex ligament may be suggestive of early ALTR and warrant streaming of patients to a more frequent surveillance program.
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Affiliation(s)
- David J Robinson
- Healthcare Imaging Services, The Avenue X-Ray & MRI, The Avenue Hospital, Windsor, Victoria, Australia.
| | - Steven Lee
- Healthcare Imaging Services, The Avenue X-Ray & MRI, The Avenue Hospital, Windsor, Victoria, Australia
| | - Paul Marks
- Imaging Associates Box Hill, Box Hill, Victoria, Australia
| | - Michal E Schneider
- Department of Medical Imaging & Radiation Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
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Xia Z, Ricciardi BF, Liu Z, von Ruhland C, Ward M, Lord A, Hughes L, Goldring SR, Purdue E, Murray D, Perino G. Nano-analyses of wear particles from metal-on-metal and non-metal-on-metal dual modular neck hip arthroplasty. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2017; 13:1205-1217. [DOI: 10.1016/j.nano.2016.11.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 10/30/2016] [Accepted: 11/17/2016] [Indexed: 01/13/2023]
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Matharu GS, Blanshard O, Dhaliwal K, Judge A, Murray DW, Pandit HG. Patient and Radiographic Factors Help to Predict Metal-on-Metal Hip Resurfacings with Evidence of a Pseudotumor. J Bone Joint Surg Am 2017; 99:214-222. [PMID: 28145952 DOI: 10.2106/jbjs.16.00212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The role of radiographs in the follow-up of patients with metal-on-metal hip resurfacing (MoMHR) implants is unclear. We investigated whether a combination of patient and radiographic factors predicted MoMHRs with evidence of a pseudotumor. METHODS We performed a retrospective single-center case-control study of 384 MoMHRs. The pseudotumor group of 130 hips all had evidence of a symptomatic pseudotumor on cross-sectional imaging, with the diagnosis confirmed at revision. The nonpseudotumor group of 254 hips (a subgroup of these hips were previously reported on) all had normal findings on cross-sectional imaging. Radiographs taken immediately prior to revision were assessed in the pseudotumor group and were compared with radiographs taken at the time of normal cross-sectional imaging in the nonpseudotumor group. Two blinded independent observers analyzed the radiographs for signs of failure, with excellent interobserver agreement. Logistic regression modeling identified the patient and radiographic predictors of revision for pseudotumor. RESULTS Hips with a pseudotumor more commonly had abnormal findings on radiographs compared to hips without a pseudotumor (80.0% compared with 63.4%; p = 0.001). Patient and radiographic factors predictive of revision for pseudotumor in the multivariable model were female sex (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.85 to 5.35; p < 0.001), high inclination (OR, 1.04 per degree; 95% CI, 1.01 to 1.07 per degree; p = 0.006), acetabular osteolysis (OR, 5.06; 95% CI, 2.14 to 12.0; p < 0.001), femoral osteolysis (OR, 17.8; 95% CI, 5.09 to 62.2; p < 0.001), and acetabular loosening (OR, 3.35; 95% CI, 1.34 to 8.35; p = 0.009). Factors predictive of not having a pseudotumor were anteversion of ≥5° (5° to <10°: OR, 0.31; 95% CI, 0.12 to 0.77; p = 0.012; and ≥10°: OR, 0.32; 95% CI, 0.15 to 0.70; p = 0.004) and heterotopic ossification (OR, 0.19; 95% CI, 0.05 to 0.72; p = 0.015). The final multivariable model was well calibrated (p = 0.589), with good discriminatory ability (area under the curve = 0.801; sensitivity = 74.4%; specificity = 71.7%). CONCLUSIONS A combination of patient and radiographic factors provided useful information for distinguishing between MoMHRs with and without evidence of a pseudotumor. Surgeons may wish to consider these specific patient and radiographic factors before proceeding with cross-sectional imaging. Radiographs are important when assessing patients with MoMHR implants and should be included in all follow-up protocols. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S Matharu
- 1Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom 2MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom 3Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds, United Kingdom
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Matharu GS, Berryman F, Brash L, Pynsent PB, Dunlop DJ, Treacy RBC. Can blood metal ion levels be used to identify patients with bilateral Birmingham Hip Resurfacings who are at risk of adverse reactions to metal debris? Bone Joint J 2017; 98-B:1455-1462. [PMID: 27803220 DOI: 10.1302/0301-620x.98b11.38042] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 07/29/2016] [Indexed: 11/05/2022]
Abstract
AIMS We investigated whether blood metal ion levels could effectively identify patients with bilateral Birmingham Hip Resurfacing (BHR) implants who have adverse reactions to metal debris (ARMD). PATIENTS AND METHODS Metal ion levels in whole blood were measured in 185 patients with bilateral BHRs. Patients were divided into those with ARMD who either had undergone a revision for ARMD or had ARMD on imaging (n = 30), and those without ARMD (n = 155). Receiver operating characteristic analysis was used to determine the optimal thresholds of blood metal ion levels for identifying patients with ARMD. RESULTS The maximum level of cobalt or chromium ions in the blood was the parameter which produced the highest area under the curve (91.0%). The optimal threshold for distinguishing between patients with and without ARMD was 5.5 µg/l (83.3% sensitivity, 88.4% specificity, 58.1% positive and 96.5% negative predictive values). Similar results were obtained in a subgroup of 111 patients who all underwent cross-sectional imaging. Between 3.2% and 4.3% of patients with ARMD were missed if United Kingdom (7 µg/l) and United States (10 µg/l) authority thresholds were used respectively, compared with 2.7% if our implant specific threshold was used, though these differences did not reach statistical significance (p ≥ 0.248). CONCLUSION Patients with bilateral BHRs who have blood metal ion levels below our implant specific threshold were at low-risk of having ARMD. Cite this article: Bone Joint J 2016;98-B:1455-62.
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Affiliation(s)
- G S Matharu
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK and Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX3 7LD, UK
| | - F Berryman
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - L Brash
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - P B Pynsent
- University of Birmingham, Birmingham B15 2TT, UK
| | - D J Dunlop
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
| | - R B C Treacy
- The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
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Do cobalt and chromium levels predict osteolysis in metal-on-metal total hip arthroplasty? Arch Orthop Trauma Surg 2016; 136:1657-1662. [PMID: 27631309 DOI: 10.1007/s00402-016-2565-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Serum metal ions are part of the regular follow-up routine of patients with metal-on-metal total hip arthroplasties (MoM-THA). Increased cobalt levels have been suggested to indicate implant failure and corrosion. QUESTIONS (1) Is there a correlation between the size of the osteolysis measured on a CT scan and metal ion levels? (2) Can metal ion levels predict the presence of osteolysis in MoM-THA? (3) Are cobalt and chromium serum levels or the cobalt-chromium-ratio diagnostic for osteolysis? MATERIALS AND METHODS CT scans of patients (n = 75) with a unilateral MoM-THA (Birmingham Hip System, Smith & Nephew, TN, USA) implanted by a single surgeon were reviewed to determine the presence of osteolysis. Statistical analysis was performed to detect its association with metal ion levels at the time of the imaging exam. RESULTS The incidence of osteolysis was the same in men and women (35.6 vs 35.7 %). The cobalt-chromium-ratio correlates with the size of the osteolysis on the CT scan and the femoral component size in the overall study population (p = 0.050, p = 0.001) and in men (p = 0.002, p = 0.001) but not in women (p = 0.312, p = 0.344). The AUC for the cobalt-chromium-ratio to detect osteolysis was 0.613 (p = 0.112) for the overall population, 0.710 for men (p = 0.021) and 0.453 (p = 0.684) for women. The data suggest that a cut off level of 1.71 for the cobalt-chromium-ratio has a sensitivity of 62.5 % and specificity of 72.4 % to identify male patients with osteolysis. CONCLUSIONS The disproportional increase of cobalt over chromium, especially in male patients with large component sizes can not be explained by wear alone and suggests that other processes (corrosion) might contribute to metal ion levels and might be more pronounced in patients with larger component sizes.
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Hussey DK, Madanat R, Donahue GS, Rolfson O, Bragdon CR, Muratoglu OK, Malchau H. Scoring the Current Risk Stratification Guidelines in Follow-up Evaluation of Patients After Metal-on-Metal Hip Arthroplasty: A Proposal for a Metal-on-Metal Risk Score Supporting Clinical Decision-Making. J Bone Joint Surg Am 2016; 98:1905-1912. [PMID: 27852907 DOI: 10.2106/jbjs.15.00685] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the follow-up evaluation of patients with metal-on-metal (MoM) hip replacements, current evidence suggests that orthopaedic surgeons should avoid reliance on any single investigative tool. Current risk stratification guidelines can be difficult to interpret because they do not provide guidance when there are several risk factors in different groups (high and low risk). To improve the clinical utility of risk stratification guidelines, we designed a scoring system to assess the risk of revision. METHODS The study population consisted of 1,709 patients (1,912 hips) enrolled in a multicenter follow-up study of a recalled MoM hip replacement. Eleven scoring criteria were determined on the basis of existing follow-up algorithm recommendations and consisted of patient-related factors, symptoms, clinical status, implant type, metal ion levels, and radiographic imaging results. Forward stepwise logistic regression was conducted to determine the minimum set of predictive variables for the risk of revision and to assign variable weights. The MoM risk score for each hip was then created by averaging the weighted values of each predictive variable. RESULTS Receiver operating characteristic curve analysis yielded good discrimination between all revised and unrevised hips, with an area under the curve of 0.82 (p < 0.001). The odds of revision for the group with a high MoM risk score were increased by 5.8-fold (95% confidence interval [CI], 3.1 to 11.0) relative to the moderate risk group and by 21.8-fold (95% CI, 9.9 to 48.0) compared with the low risk group. CONCLUSIONS Although the use of MoM hip arthroplasty has been limited since 2010, we continue to be faced with the follow-up and risk assessment of thousands of patients who have not had a revision. As more knowledge about risk stratification is gained, the complexity of the algorithms is expected to increase. We propose the use of the MoM risk score as a tool to aid in the clinical decision-making process. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel K Hussey
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Rami Madanat
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Gabrielle S Donahue
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Ola Rolfson
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts.,Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Charles R Bragdon
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts .,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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What is the natural history of asymptomatic pseudotumours in metal-on-metal hip resurfacing patients? Hip Int 2016; 26:522-530. [PMID: 27791239 DOI: 10.5301/hipint.5000387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE We assessed the natural history of asymptomatic pseudotumours associated with metal-on-metal hip resurfacings (MoMHRs), and factors associated with future revision. METHODS In 2007-2008, we identified 25 MoMHRs (21 patients; mean age 59.9 years; 76% female) with asymptomatic pseudotumours. All patients underwent identical initial assessment (ultrasound, blood metal ions, radiographs, Oxford Hip Score [OHS]) and were considered asymptomatic because they denied experiencing hip symptoms, were satisfied with their MoMHR surgery, and had good or excellent OHSs (≥34). In 2012-2013, repeat assessments were performed in all non-revised patients. RESULTS Revision for pseudotumour was performed/recommended in 15 MoMHRs (60%) at a mean 2.7 years (range 0.4-6.4 years) from initial assessment, with 14 developing symptoms before revision. Non-revised MoMHRs (n = 10) underwent repeat ultrasound at a mean 5.1 years (range 4.0-6.5 years) later, with no changes in pseudotumour volume (p = 0.956) or OHS (p = 0.065) between assessments. High blood cobalt (p = 0.0048) and chromium (p = 0.0162), large pseudotumours (p = 0.0458), low OHS (p = 0.0183), and bilateral MoMHRs (p = 0.049) predicted future revision. Patients with blood metal ions above established unilateral/bilateral thresholds and/or initial pseudotumours >30 cm3 had an 86.7% sensitivity, 70.0% specificity, 81.2% positive predictive value, and 77.8% negative predictive value for future revision. CONCLUSIONS MoMHR patients with initially asymptomatic pseudotumours often become symptomatic and require revision. Patients with high blood metal ions and/or pseudotumours >30 cm3 should remain under annual surveillance or be considered for revision (especially in patients also having lower initial OHSs, bilateral MoMHRs, and/or those becoming symptomatic). Less regular surveillance of patients outside these parameters appears acceptable.
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van Lingen CP, Zagra LM, Ettema HB, Verheyen CC. Sequelae of large-head metal-on-metal hip arthroplasties: Current status and future prospects. EFORT Open Rev 2016; 1:345-353. [PMID: 28461912 PMCID: PMC5367524 DOI: 10.1302/2058-5241.1.160014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Large-head metal-on-metal (MoM) bearings were re-popularised in the late 1990s with the introduction of modern hip resurfacing (HR), followed closely by large metal head total hip arthroplasty (THA). A worldwide increase in the use of MoM hip arthroplasty subsequently saw a sharp decline, due to serious complications.MoM was rapidly adopted in the early 2000s until medical device alerts were issued by government regulatory agencies and national and international organisations, leading to post-marketing surveillance and discontinuation of these implants.Guidelines for MoM hip implant follow-up differ considerably between regulatory authorities worldwide; this can in part be attributed to missing or conflicting evidence.The authors consider that the use of large-head MoM THA should be discontinued. MoM HR should be approached with caution and, when considered, should be used only in patients who meet all of the recommended selection criteria, which limits its indications considerably.The phased introduction of new prostheses should be mandatory in future. Close monitoring of outcomes and long-term follow-up is also necessary for the introduction of new prostheses. Cite this article: van Lingen CP, Zagra LM, Ettema HB, Verheyen CC. Sequelae of large-head metal-on-metal hip arthroplasties: current status and future prospects. EFORT Open Rev 2016;1:345-353. DOI: 10.1302/2058-5241.1.160014.
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Affiliation(s)
| | | | - Harmen B. Ettema
- Isala Clinics, Department of Orthopaedic Surgery and Traumatology, Zwolle, The Netherlands
| | - Cees C. Verheyen
- Isala Clinics, Department of Orthopaedic Surgery and Traumatology, Zwolle, The Netherlands
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Matharu GS, Judge A, Murray DW, Pandit HG. Prevalence of and Risk Factors for Hip Resurfacing Revision: A Cohort Study Into the Second Decade After the Operation. J Bone Joint Surg Am 2016; 98:1444-52. [PMID: 27605688 DOI: 10.2106/jbjs.15.01234] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most metal-on-metal hip resurfacing (MoMHR) designs have experienced high short-term failure rates because of pseudotumors. The impact of this complication into the second decade after the procedure is unknown. We investigated (1) the prevalence of, and risk factors for, all-cause and pseudotumor-related revision at up to 15 years following MoMHR and (2) whether risk factors were sex-specific. METHODS This single-center prospective cohort study included 1,429 MoMHRs (1216 patients; 40% female) implanted between 1999 and 2009. Patients were contacted in 2010 and 2012 as per national recommendations. Patients with symptoms related to the hip and/or suboptimal Oxford Hip Scores (≤41 of 48 points) underwent cross-sectional imaging and blood metal-ion sampling. Revision diagnoses were established using operative and histopathological findings. Multivariate Cox proportional hazard models were used to assess the association of predictor variables with the time to all-cause and pseudotumor-related revisions. RESULTS One hundred and eighty MoMHRs (12.6%) were revised for all causes, and 111 (7.8% of the series and 61.7 % of all revisions) were revised because of pseudotumor. Survival analysis showed the 15-year cumulative revision rate for all causes to be 19.5% (95% confidence interval [CI] = 16.2% to 23.2%) and the 15-year rate of revision due to pseudotumor to be 14.0% (95% CI = 11.0% to 17.7%). Small femoral head size (hazard ratio [HR] per 2 mm = 0.92, 95% CI = 0.88 to 0.97; p = 0.003) and certain implant designs (HR = 1.55 to 3.01; p ≤ 0.029) significantly increased the all-cause revision risk. Female sex (HR = 2.03, 95% CI = 1.19 to 3.44; p = 0.009) and young age (HR per year = 0.98, 95% CI = 0.96 to 1.00; p = 0.020) significantly increased the pseudotumor-related revision risk but not the all-cause revision risk. Risk factors for all-cause and pseudotumor-related revision were sex-specific. In females, small femoral head size (p = 0.014) increased the all-cause revision risk, and young age was the only predictor of pseudotumor-related revision (p = 0.019). In males, implant design was the only predictor of all-cause revision (p ≤ 0.015) and pseudotumor-related revision (p = 0.001). CONCLUSIONS The prevalence and rates of revision for all causes and pseudotumor were high at up to 15 years following MoMHR. Predictors of revision differed between all-cause and pseudotumor-related revisions and were sex-specific. These factors must be appropriately weighted when risk-stratifying patients with MoMHRs for surveillance. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
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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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Matharu GS, Pandit HG. The Cobalt-To-Chromium Ratio "May Be" a Key Marker for Adverse Local Tissue Reactions in Metal-On-Metal Hips. J Arthroplasty 2016; 31:1374-1375. [PMID: 26515044 DOI: 10.1016/j.arth.2015.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/28/2015] [Indexed: 02/01/2023] Open
Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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Matharu GS, Mansour R, Dada O, Ostlere S, Pandit HG, Murray DW. Which imaging modality is most effective for identifying pseudotumours in metal-on-metal hip resurfacings requiring revision: ultrasound or MARS-MRI or both? Bone Joint J 2016; 98-B:40-8. [PMID: 26733514 PMCID: PMC4714034 DOI: 10.1302/0301-620x.98b1.36746] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aims The aims of this study were to compare the
diagnostic test characteristics of ultrasound
alone, metal artefact reduction sequence MRI
(MARS-MRI) alone, and ultrasound combined with
MARS-MRI for identifying intra-operative
pseudotumours in metal-on-metal hip resurfacing
(MoMHR) patients undergoing revision surgery. Methods This retrospective diagnostic accuracy study
involved 39 patients (40 MoMHRs). The time between
imaging modalities was a mean of 14.6 days (0 to
90), with imaging performed at a mean of 5.3
months (0.06 to 12) before revision. The
prevalence of intra-operative pseudotumours was
82.5% (n = 33). Results Agreement with the intra-operative findings was
82.5% (n = 33) for ultrasound alone, 87.5%
(n = 35) for MARS-MRI alone, and 92.5%
(n = 37) for ultrasound and MARS-MRI combined. The
diagnostic characteristics for ultrasound alone
and MARS-MRI alone reached similar sensitivities
(90.9% vs 93.9%) and positive
predictive values (PPVs; 88.2% vs
91.2%), but higher specificities (57.1%
vs 42.9%) and negative predictive
values (NPVs; 66.7% vs 50.0%)
were achieved with MARS-MRI. Ultrasound and
MARS-MRI combined produced 100% sensitivity and
100% NPV, whilst maintaining both specificity
(57.1%) and PPV (91.7%). For the identification of a pseudotumour, which
was confirmed at revision surgery, agreement was
substantial for ultrasound and MARS-MRI combined
(κ = 0.69), moderate for MARS-MRI alone
(κ = 0.54), and fair for ultrasound
alone (κ = 0.36). Discussion These findings suggest that ultrasound and/or
MARS-MRI have a role when assessing patients with
a MoMHR, with the choice dependent on local
financial constraints and the availability of
ultrasound expertise. However in patients with a
MoMHR who require revision, combined imaging was
most effective. Take home message: Combined imaging with
ultrasound and MARS-MRI always identified
intra-operative pseudotumours if present.
Furthermore, if neither imaging modality showed a
pseudotumour, one was not found
intra-operatively. Cite this article: Bone Joint
J 2016;98-B:40–8.
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Affiliation(s)
- G S Matharu
- NDORMS and Nuffield Orthopaedic Centre, Oxford, UK
| | - R Mansour
- NDORMS and Nuffield Orthopaedic Centre, Oxford, UK
| | - O Dada
- NDORMS and Nuffield Orthopaedic Centre, Oxford, UK
| | - S Ostlere
- NDORMS and Nuffield Orthopaedic Centre, Oxford, UK
| | - H G Pandit
- NDORMS and Nuffield Orthopaedic Centre, Oxford, UK
| | - D W Murray
- NDORMS and Nuffield Orthopaedic Centre, Oxford, UK
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Matharu GS, Berryman F, Brash L, Pynsent PB, Treacy RBC, Dunlop DJ. The Effectiveness of Blood Metal Ions in Identifying Patients with Unilateral Birmingham Hip Resurfacing and Corail-Pinnacle Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris. J Bone Joint Surg Am 2016; 98:617-26. [PMID: 27098320 DOI: 10.2106/jbjs.15.00340] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND We investigated whether blood metal ions could effectively identify patients with metal-on-metal hip implants with two common designs (Birmingham Hip Resurfacing [BHR] and Corail-Pinnacle) who were at risk of adverse reactions to metal debris. METHODS This single-center, prospective study involved 598 patients with unilateral hip implants (309 patients with the BHR implant and 289 patients with the Corail-Pinnacle implant) undergoing whole blood metal ion sampling at a mean time of 6.9 years. Patients were classified into two groups, one that had adverse reactions to metal debris (those who had to undergo revision for adverse reactions to metal debris or those with adverse reactions to metal debris on imaging; n = 46) and one that did not (n = 552). Three metal ion parameters (cobalt, chromium, and cobalt-chromium ratio) were compared between groups. Optimal metal ion thresholds for identifying patients with adverse reactions to metal debris were determined using receiver operating characteristic analysis. RESULTS All ion parameters were significantly higher (p < 0.0001) in the patients who had adverse reactions to metal debris compared with those who did not. Cobalt maximized the area under the curve for patients with the BHR implant (90.5%) and those with the Corail-Pinnacle implant (79.6%). For patients with the BHR implant, the area under the curve for cobalt was significantly greater than that for the cobalt-chromium ratio (p = 0.0005), but it was not significantly greater than that for chromium (p = 0.8483). For the patients with the Corail-Pinnacle implant, the area under the curve for cobalt was significantly greater than that for chromium (p = 0.0004), but it was similar to that for the cobalt-chromium ratio (p = 0.8139). Optimal blood metal ion thresholds for identifying adverse reactions to metal debris varied between the two different implants. When using cobalt, the optimal threshold for identifying adverse reactions to metal debris was 2.15 μg/L for the BHR group and 3.57 μg/L for the Corail-Pinnacle group. These thresholds had good sensitivities (88.5% for the BHR group and 80.0% for the Corail-Pinnacle group) and specificities (84.5% for the BHR group and 76.2% for the Corail-Pinnacle group), high negative predictive values (98.8% for the BHR group and 98.1% for the Corail-Pinnacle group), and low positive predictive values (34.3% for the BHR group and 20.0% for the Corail-Pinnacle group). The authority thresholds proposed by the United States (3 μg/L and 10 μg/L) and the United Kingdom (7 μg/L) missed more patients with adverse reactions to metal debris at 2.0% to 4.7% (twelve to twenty-eight patients) compared with our implant-specific thresholds at 1.2% (seven patients missed). CONCLUSIONS Patients who underwent metal-on-metal hip arthroplasty performed with unilateral BHR or Corail-Pinnacle implants and who had blood metal ions below our implant-specific thresholds were at low risk of adverse reactions to metal debris. These thresholds could be used to rationalize follow-up resources in asymptomatic patients. Analysis of cobalt alone is acceptable. Implant-specific thresholds were more effective than currently recommended fixed authority thresholds for identifying patients at risk of adverse reactions to metal debris requiring further investigation. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Fiona Berryman
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Lesley Brash
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Paul B Pynsent
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | | | - David J Dunlop
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
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47
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Salvage of Monoblock Metal-on-Metal Acetabular Components Using a Dual-Mobility Bearing. J Arthroplasty 2016; 31:846-9. [PMID: 26404847 DOI: 10.1016/j.arth.2015.08.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 08/17/2015] [Accepted: 08/18/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Large-diameter, monoblock acetabular components have been used for both hip resurfacing arthroplasty and metal-on-metal (MoM) total hip arthroplasty (THA). If revision is required, one solution is to retain the shell and use a dual-mobility bearing. METHODS We reviewed the results of 25 revision THAs including 11 hip resurfacing arthroplasty and 14 MoM THAs where a monoblock acetabular component was mated to a dual-mobility bearing. RESULTS At a mean of 29 months, there was one failure, an intraprosthetic dislocation of the dual-mobility bearing. There was a significant decrease in serum metal ion levels postoperatively. CONCLUSION Retention of a well-fixed, monoblock MoM acetabular shell and mating it to a dual-mobility bearing in the setting of revision surgery seems to be a reasonable, low-morbidity option at short-term follow-up in appropriately positioned cups.
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48
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Reito A, Lainiala O, Elo P, Eskelinen A. Prevalence of Failure due to Adverse Reaction to Metal Debris in Modern, Medium and Large Diameter Metal-on-Metal Hip Replacements--The Effect of Novel Screening Methods: Systematic Review and Metaregression Analysis. PLoS One 2016; 11:e0147872. [PMID: 26930057 PMCID: PMC4773181 DOI: 10.1371/journal.pone.0147872] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/25/2015] [Indexed: 11/18/2022] Open
Abstract
Metal-on-metal (MoM) hip replacements were used for almost a decade before adverse reactions to metal debris (ARMD) were found to be a true clinical problem. Currently, there is a paucity of evidence regarding the usefulness of systematic screening for ARMD. We implemented a systematic review and meta-analysis to establish the prevalence of revision confirmed ARMD stratified by the use of different screening protocols in patients with MoM hip replacements. Five levels of screening were identified: no screening (level 0), targeted blood metal ion measurement and/or cross-sectional imaging (level 1), metal ion measurement without imaging (level 2), metal ion measurement with targeted imaging (level 3) and comprehensive screening (both metal ions and imaging for all; level 4). 122 studies meeting our eligibility criteria were included in analysis. These studies included 144 study arms: 100 study arms with hip resurfacings, 33 study arms with large-diameter MoM total hip replacements (THR), and 11 study arms with medium-diameter MoM THRs. For hip resurfacing, the lowest prevalence of ARMD was seen with level 0 screening (pooled prevalence 0.13%) and the highest with level 4 screening (pooled prevalace 9.49%). Pooled prevalence of ARMD with level 0 screening was 0.29% and with level 4 screening 21.3% in the large-diameter MoM THR group. In metaregression analysis of hip resurfacings, level 4 screening was superior with regard to prevalence of ARMD when compared with other levels. In the large diameter THR group level 4 screening was superior to screening 0,2 and 3. These outcomes were irrespective of follow-up time or study publication year. With hip resurfacings, routine cross-sectional imaging regardless of clinical findings is advisable. It is clear, however, that targeted metal ion measurement and/or imaging is not sufficient in the screening for ARMD in any implant concepts. However, economic aspects should be weighed when choosing the preferred screening level.
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Affiliation(s)
- Aleksi Reito
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
- * E-mail:
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
| | - Petra Elo
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
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49
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The Role of Hip Arthroscopy in Investigating and Managing the Painful Hip Resurfacing Arthroplasty. Arthroscopy 2016; 32:459-466.e1. [PMID: 26553962 DOI: 10.1016/j.arthro.2015.08.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 07/20/2015] [Accepted: 08/11/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the safety and efficacy of hip arthroscopy performed in the peripheral compartment as a diagnostic and therapeutic treatment option for patients with hip pain after hip resurfacing surgery. METHODS Indications for hip arthroscopy after hip resurfacing included patients with a symptomatic hip-resurfaced arthroplasties who did not respond to nonoperative treatment. Patients who underwent a hip arthroscopy after a painful hip resurfacing were included with a minimum of 1 year follow-up. Subgroup analysis was performed according to whether an established diagnosis was made before arthroscopic intervention or not. Subjective measures were based on Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, and results were calculated and analyzed. RESULTS We included 68 patients (26 male [38%] and 42 female [62%]) who underwent subsequent hip arthroscopy from a population of 978 consecutive hip-resurfaced arthroplasties performed between 1999 and 2010. The average age was 58 (range, 37 to 78 years). The mean follow-up after hip arthroscopy was 3.4 years (range, 12 months to 5.8 years). Patients who had an established diagnosis (n = 41) before hip arthroscopy showed statistical improvement in their WOMAC scores (7 to 2, P < .001). Only 3 (7%) of these 41 patients failed and were converted to a total hip replacement (THR); however, patients who did not have an established diagnosis (n = 27) before undergoing hip arthroscopy showed statistical worsening of the WOMAC (15 to 21, P = .002). Ten (37%) of these 27 patients without a diagnosis failed and needed to be converted to a THR. A significant correlation was found between the collections found on ultrasound (psoas bursa and/or in the hip joint) and the need for synovectomy (P = .01). The overall revision rate to THR after hip resurfacing in our group of patients was 1.3% (n = 13). Female patients were more likely to require postresurfacing hip arthroscopy with 42 (60%) female to only 26 (40%) male patients undergoing this procedure. In our study population, 70% (14/21, P < .05) of patients with hip pain caused by severe metal synovial reaction or metal-on-metal reaction were women. A total of 5 (7%) patients had minor-to-mild complications after hip arthroscopy. CONCLUSIONS Hip arthroscopy is a safe surgical treatment option for those patients with a painful hip resurfacing arthroplasty. Having an accurate diagnosis before hip arthroscopy improves the likelihood a good outcome. LEVEL OF EVIDENCE Level IV - therapeutic case series.
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50
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Low AK, Matharu GS, Ostlere SJ, Murray DW, Pandit HG. How Should We Follow-Up Asymptomatic Metal-on-Metal Hip Resurfacing Patients? A Prospective Longitudinal Cohort Study. J Arthroplasty 2016; 31:146-51. [PMID: 26439179 DOI: 10.1016/j.arth.2015.08.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/27/2015] [Accepted: 08/11/2015] [Indexed: 02/01/2023] Open
Abstract
Current surveillance for metal-on-metal hip resurfacing (MoMHR) patients is not evidence based. This study established changes that occurred in 152 asymptomatic MoMHRs using repeat ultrasound and patient-reported outcomes. Factors associated with (1) ultrasound progression and (2) developing new pseudotumors were analyzed. Patients underwent repeat assessments 4.3 years later. Ultrasound progression was observed in 19% (n = 29), with 10% (n = 15) developing new pseudotumors. Key predictors of ultrasound progression included high blood cobalt (P = .00013) and chromium (P = .00065), and high initial ultrasound grade (P = .003) and volume (P = .036). No asymptomatic MoMHRs with initially normal metal ions (<2 μg/L) and normal ultrasounds (33% of cohort) developed new pseudotumors. This patient subgroup does not require repeat follow-up within 5 years.
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Affiliation(s)
- Adrian K Low
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom, OX3 7LD
| | - Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom, OX3 7LD
| | - Simon J Ostlere
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom, OX3 7LD
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom, OX3 7LD
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom, OX3 7LD
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