Complications and re-revisions after revisions of 528 metal-on-metal hips because of adverse reaction to metal debris

Case report: Formation and recurrence of inflammatory pseudotumor after metal-on-metal hip arthroplasty

The metal-on-metal (MoM) artificial hip joint is a prosthesis used in early hip arthroplasty, particularly for hip resurfacing and total hip arthroplasty. However, abrasion and corrosion of MoM bearings result in the production of metal ions, such as cobalt and chromium, thereby inducing several complications such as inflammatory pseudotumor, aseptic inflammation, and allergy to metal ions (delayed type IV hypersensitivity). In this case report, we present a patient who was hospitalized for recurrence of a mass in the right inguinal area. In 2010, the patient underwent right MoM total hip arthroplasty for right femoral head necrosis and exhibited a good postoperative recovery. In 2019, the patient experienced pain in the right hip with activity limitation without any evident triggers, and a palpable mass was observed in the right inguinal area. A large periprosthetic mass was resected under general anesthesia, and the patient recovered well after the operation. Based on post-surgery imaging and pathological examinations, the mass was diagnosed as a periprosthetic inflammatory pseudotumor. In 2021, the inflammatory pseudotumor recurred at the same site. He then underwent right total hip revision surgery under epidural anesthesia and recovered well after surgery. No recurrence was noted at moderate follow-up. The incidence of inflammatory pseudotumors is high in MoM hip arthroplasty. Early revision is necessary in patients who meet the indications for revision, while regular postoperative follow-up is crucial.

Trunnionosis in Metal-on-Polyethylene Total Hip Arthroplasty With Periprosthetic Infection: A Case Report

A 67-year-old man who underwent right hemiarthroplasty and left total hip arthroplasty (THA) experienced left hip pain two years previously. No previous diagnosis was made at other hospitals. Radiography revealed left hip trunnionosis because of stem-neck shortening, with periprosthetic joint infection (PJI) spreading to both hips. Bilateral revision THA was performed, but the treatment was difficult due to the delayed diagnosis, necessitating the extraction of the well-fixed stem for PJI. Trunnionosis is caused by implant-related, surgical, and patient factors, and early diagnosis is important because of its association with PJI. Furthermore, even implants with few reports of trunnionosis can lead to this complication. Surgeons should always consider that performing THA using a large-diameter head predisposes the patient to trunnionosis.

Sensitivity and specificity for detecting pseudotumors in patients with hip resurfacing arthroplasty, metal-on-metal or metal-on-polyethylene total hip arthroplasty-MRI versus ultrasonography performed by an orthopedic surgery resident

Background

Metal artifact reduction sequence magnetic resonance imaging (MRI) scan is a common method to detect adverse reaction to metal debris in total hip arthroplasty (THA). It might be quicker and cheaper if ultrasonography (US) could screen for the need for an MRI. However, both require trained personnel.

Purpose

We aimed to investigate the sensitivity and specificity of US for detecting pseudotumors (PT) when performed by an orthopedic surgery resident compared to MRI. We also investigated the sensitivity and specificity of US to detect PTs in obese and non-obese patients.

Material and methods

We examined 205 patients with hip resurfacing arthroplasty, metal-on-metal or metal-on-polyethylene THA with both MRI and US. US was performed by an orthopedic surgery resident who was trained according to a standardized training program in musculoskeletal US. Results from MRI were used as gold standard.

Results

US had a sensitivity of 0.92 (95% CI 0.81-0.98) and specificity of 0.94 (95% CI 0.89-0.97) for detecting PT. It had a positive predictive value of 0.84 (95% CI 0.73-0.91) and a negative predictive value of 0.97 (95% CI 0.93-0.99). US performed similarly in obese and non-obese patients.

Conclusions

US had a high sensitivity and specificity for detecting PT when performed by an orthopedic surgery resident. Trained orthopedic surgeons could screen for the need of an MRI scan when searching PTs.

[Postoperative outcomes and survival rates after aseptic revision total hip arthroplasty : What can patients expect from revision surgery?]

BACKGROUND

In 2020, more than 14,000 aseptic revision procedures for total hip arthroplasty (THA) were registered in Germany. Patient expectations of revision hip arthroplasty are not substantially different from expectations of primary hip replacement.

OUTCOME

However, revision surgery is associated with increased complication rates and a higher proportion of dissatisfied patients. In particular, poorer postoperative function and mobility as well as increased pain levels following revision THA have been described compared to the outcome after primary THA. Quality of life and return-to-work can also be impaired.

SURVIVAL RATE

Implant survival is influenced by age, BMI, and comorbidities of the patients, but also by the size and complexity of bone defects, the extent of periprosthetic soft tissue compromise and the choice of revision implant(s). In addition, the number of previous revision surgeries inversely correlates with the survival rates. Previous revisions have been shown to be associated with increased risks of aseptic loosening, instability and periprosthetic infection.

Outcome of revised metal-on-metal hip arthroplasties: a Dutch arthroplasty register study

BACKGROUND

Preliminary results of metal-on-metal (MoM) hip arthroplasty were satisfactory, but since 2004 data showed high failure rates. National joint replacement registries are multi-centre databases comprised of thousands of subjects and implants which allow for identifying variables predictive of implant failure. The aim of the current study was to estimate re-revision rates after revision of a primary MoM hip arthroplasty in the Dutch Arthroplasty Register (LROI) and to assess potential predictor variables of re-revision of these MoM hip arthroplasties.

METHODS

Eligible procedures were those with a revision for any reason except infection, after an initial primary surgery with a hip resurfacing (HRA) or large-head MoM (LH-MoM) total hip arthroplasty (THA). The probability of re-revision for both types of MoM hip arthroplasty over time was estimated using the cumulative incidence function taking mortality as a competing risk into account. A proportional sub-distribution hazards regression model was used to assess potential predictor variables of re-revision of these MoM hip arthroplasties.

RESULTS

A total of 3476 records of revised implants were included, of which 873 (25.2%) were MoM implants. Over the course of follow-up, 101 (11.5%) MoM implants were re-revised. During follow-up 36 (4.3%) patients who received a MoM-implant at primary arthroplasty and a revision afterwards had died. The regression model showed that for primary MoM implants a MoM articulation after revision (HR 2.48; 95% CI 1.53-4.03, p < 0.001), femoral-only revisions (HR 3.20; 95% CI 2.06-4.99, p < 0.001) and periprosthetic fractures (HR 1.98; 95% CI 1.03-3.82, p = 0.042) as reason for the first revision were statistically significant risk factors for re-revision.

CONCLUSION

Both types of large-head MoM hip arthroplasties have shown high revision and re-revision rates; risk factors were identified. The outcome of this study can be helpful in managing expectations of patients and orthopaedic surgeons.

Surgical management of hip prosthetic failure in metallosis: A case series and literature review

Local and remote complications can be observed in hip prosthesis failures associated with metallosis. Structural changes in the periprosthetic bone and soft tissues may not always be precisely assessed preoperatively due to metal artifacts. The unpredictability of the damage extension, potentially leading to complex and insidious surgeries, requires the availability of alternative surgical plan(s) for the reconstruction of the joint. The aim of the study is to present and analyze, with the literature data support, practical tips for the revision of the prosthetic components, the management of ARMD and of intraoperative complications in the unusual scenario of metallosis.

Favourable clinical outcomes following cemented arthroplasty after metal-on-metal total hip replacement: a retrospective study with a mean follow-up of 10 years

BACKGROUND

Given the unexpected high rate of failure following metal-on-metal total hip replacement (MoM-THR), it is expected that more MoM-THR patients will experience revision. The long-term outcomes regarding the primary MoM-THR revised to cemented THR (CTHR) remain controversial. The purpose of this retrospective review was to evaluate the long-term outcomes of patients who underwent conversion from MoM-THR to CTHR.

METHODS

A total of 220 patients (220 hips) who underwent a conversion of primary MoM-THR to CTHR from March 2006 to October 2016 were retrospectively reviewed. The primary outcomes were the functional outcomes assessed using the Harris hip scores (HHS) and major radiographic outcomes. Follow-ups occurred at 3 months, 6 months, 1 year, 2 years, and then every two years after revision.

RESULTS

Mean follow-up was 10.1 years (5-13 years). Distinct improvements were detected in the mean HHS between the preoperative and last follow-up analysis (62.35[±8.49] vs. 84.70[±14.68], respectively, p < 0.001). The key orthopaedic complication rate was 18.2% (27/148). Seven (4.7%) cases experienced a CTHR failure at a mean of 3.4 (±1.2) years after revision MoM-THR, mostly attributed to recurrent dislocation.

CONCLUSION

CTHR might yield an acceptable functional score and a low rate of the key orthopaedic complications.