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Leal J, Holland CT, Cochrane NH, Seyler TM, Jiranek WA, Wellman SS, Bolognesi MP, Ryan SP. The relationship between pseudotumours and infected complications in patients who have undergone metal-on-metal total hip arthroplasty. Bone Joint J 2024; 106-B:555-564. [PMID: 38821507 DOI: 10.1302/0301-620x.106b6.bjj-2023-1370.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Aims This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. Methods A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years' clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. Results The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Conclusion Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low.
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Affiliation(s)
- Justin Leal
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | | | - Niall H Cochrane
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
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Daher J, Desai B, Nammour M, Warren M, Chimento G. Long-term Follow-up on Revisions of a Recalled Large Head Metal-on-metal Hip Prosthesis: A Single Surgeon Series. Arthroplast Today 2023; 22:101163. [PMID: 37521732 PMCID: PMC10374868 DOI: 10.1016/j.artd.2023.101163] [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] [Received: 11/17/2022] [Revised: 03/29/2023] [Accepted: 05/14/2023] [Indexed: 08/01/2023] Open
Abstract
Background In 2010, a recall was issued for a specific monoblock large head metal-on-metal (MoM) hip prosthesis due to short-term revision rates of 12%-13% (articular surface replacement, DePuy Orthopaedics, Inc., Warsaw, IN). High complication, infection, and rerevision rates for revised MoM implants have been reported. The purpose of the study is to report long-term outcomes and trend metal ion levels of this recalled MoM prosthesis from a single surgeon series. Methods Retrospective chart review was performed on all patients that underwent revision of large MoM hip replacements between 2010 and 2015. Pre- and post-revision Harris Hip Score (HHS), cup abduction angles, anteversion angles, and cup sizes were compared. Survivorship and HHS were the primary outcomes measured; serum cobalt and chromium levels were secondary outcomes. Multivariate linear regression was used to examine the correlation between prerevision serum metal ion levels and HHS. Results A total of 24 hips (21 patients) met inclusion criteria. Mean time to revision was 4.12 years ± 1.1. Mean follow-up was 10.0 years (7-11.9 years). Mean HHS increased significantly after revision from 48.5 to 89.5 (P < .001). Higher prerevision cobalt levels were correlated with lower prerevision HHS (cobalt R = 0.25; chromium R = 0.3160). There was no correlation with prerevision cobalt (P = .2671) or chromium (P = .3160) with postrevision HHS. Most recent metal ion testing revealed a significant decrease in both cobalt (P = .0084) and chromium (P = .0115). Survival rate is 100%. Conclusions Our study showed excellent survivorship and outcomes at 10 years. There were no failures for any reason including infection. This differs from previous studies and confirms excellent long-term results are possible with revision of this recalled MoM implant.
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Affiliation(s)
- Jimmy Daher
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Bhumit Desai
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA, USA
- Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA
| | - Michael Nammour
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - Michael Warren
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA, USA
| | - George Chimento
- Department of Orthopaedic Surgery, Ochsner Medical Center, New Orleans, LA, USA
- Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA
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Semaan DJ, Rutledge-Jukes H, Berend KR, Lombardi AV, Adams JB, Crawford DA. Survivorship of a Metal-on-Metal Total Hip Implant With Modular Titanium Adapter. J Arthroplasty 2022; 37:S560-S565. [PMID: 35219576 DOI: 10.1016/j.arth.2022.01.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/05/2022] [Accepted: 01/19/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Use of metal-on-metal (MoM) articulations in total hip arthroplasty (THA) has sharply declined due to high failure rates from metal-related complications. Although certain MoM designs have demonstrated only 46% survival, not all MoM designs have performed the same. The purpose of this study is to evaluate mid-term to long-term survival of a specific MoM implant with a modular titanium taper adapter. METHODS A retrospective review was performed on all patients who underwent primary THA at our center with the M2a-Magnum system (Zimmer Biomet, Warsaw, IN). Of 829 patients (956 hips) identified, 754 patients (869 hips) met inclusion criteria of signed research consent, minimum 2-year follow-up, and/or any revision surgery. RESULTS Mean follow-up was 11.0 years (range 2-16; ±3.5). Mean cup angle of inclination was 42.8° (range 24°-70°, ±6.3°), with 88.0% reconstructed within the 40° ± 10° safe zone. There were 64 revisions (7.36%): 7 (0.81%) septic and 57 (6.56%) aseptic. Of those, 32 (3.68%) were adverse reactions to metal debris. Kaplan-Meier survival free of revision for all causes was 88.6% at 16 years (95% confidence interval 86.8-90.4). Univariate analysis of risk factors for all-cause, aseptic, and adverse reaction to metal debris revision found no relationship with female gender, age ≥65 years, body mass index >30 kg/m2, higher activity level, or inclination angle outlier. CONCLUSION The results of this study demonstrate a more favorable mid-term to long-term survivorship with this specific MoM implant compared to other designs. Although our institution no longer performs MoM THA, further investigation into differences in MoM implant designs is warranted.
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Affiliation(s)
- Derek J Semaan
- Joint Implant Surgeons Inc, New Albany, OH; White Fence Surgical Suites, New Albany, OH; Mount Carmel Health System, New Albany, OH
| | | | - Keith R Berend
- Joint Implant Surgeons Inc, New Albany, OH; White Fence Surgical Suites, New Albany, OH; Mount Carmel Health System, New Albany, OH
| | - Adolph V Lombardi
- Joint Implant Surgeons Inc, New Albany, OH; White Fence Surgical Suites, New Albany, OH; Mount Carmel Health System, New Albany, OH; Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, Ohio
| | | | - David A Crawford
- Joint Implant Surgeons Inc, New Albany, OH; White Fence Surgical Suites, New Albany, OH; Mount Carmel Health System, New Albany, OH
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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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Lepri AC, Villano M, Matassi F, Carulli C, Innocenti M, Civinini R. "Anterolateral" approach to the hip: a systematic review of the correct definition of terms. Hip Int 2020; 30:13-19. [PMID: 33267690 DOI: 10.1177/1120700020966800] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The Watson-Jones interval plane between tensor fascia lata (TFL) and the gluteus medius (GM) has come back into fashion in the past few years - Röttinger described the anterolateral minimal invasive approach (ALMI) for use in total hip replacement, in which the standard Watson-Jones interval was used, but with a completely intermuscular plane. However, the term anterolateral is often still utilised to describe intramuscular approaches in which the GM was violated, thus creating a potential misunderstanding in the literature. Accordingly, we have designed a study to answer the following questions: (1) are there articles in the recent literature that use the term "anterolateral" to describe different approaches; (2) which would be the correct description of the anterolateral approach? METHODS We did a systematic review of the literature based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, to look for peer reviewed papers of any evidence level focusing on the definition of anterolateral approach; MEDLINE and EMBASE were searched. RESULTS 73 manuscripts met the criteria of the systematic search. 53 papers (72.6%) reported the term anterolateral approach to describe a complete intermuscular approach between the interval between GM and TFL. Nonetheless, in the remaining 20 papers (27.4%) the term anterolateral was used to describe intramuscular approaches in which the gluteus medius was violated. CONCLUSION In about 1 out of 4 papers in the recent literature, the term anterolateral was utilised to describe approaches that are completely different both in terms of anatomy and function.
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Affiliation(s)
- Andrea Cozzi Lepri
- Department of Health Sciences, Orthopaedic Unit, University of Florence, Italy
| | - Marco Villano
- Department of Health Sciences, Orthopaedic Unit, University of Florence, Italy
| | - Fabrizio Matassi
- Department of Health Sciences, Orthopaedic Unit, University of Florence, Italy
| | - Christian Carulli
- Department of Health Sciences, Orthopaedic Unit, University of Florence, Italy
| | - Massimo Innocenti
- Department of Health Sciences, Orthopaedic Unit, University of Florence, Italy
| | - Roberto Civinini
- Department of Health Sciences, Orthopaedic Unit, University of Florence, Italy
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Metal-on-Metal Total Hip Revisions: Pearls and Pitfalls. J Arthroplasty 2020; 35:S68-S72. [PMID: 32081501 DOI: 10.1016/j.arth.2020.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND At the turn of the 21st century, there was a re-emergence of metal-on-metal (MoM) articulation with 35% of all total hip arthroplasty implants having MoM articulation. Approximately 10 years after its peak use, MoM articulation began to decrease dramatically as revisions became more apparent because of adverse reaction to metal debris. Today, there are surveillance guidelines and reconstructive clinical pearls a surgeon should recognize. METHODS This article gives a literature-based overview of clinical pearls and discusses how to avoid pitfalls when performing revision of a metal-on-metal total hip arthroplasty. RESULTS Patients with MoM can be risk-stratified based on symptom, implant, and testing variables. Those patients who are symptomatic and/or develop adverse reaction to metal debris with local tissue destruction will require a revision. The revision of MoM can be challenging due to bone and soft tissue destruction. Constraint may be needed in cases of abductor deficiency. CONCLUSION Although MoM implants for THA have declined significantly, surgeons are still faced with the revision burden from a decade of high use. Risk stratification tools are available to aid in revision decision making, and the surgeon should be prepared to address the challenges these revisions present.
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Sagoo NS, Sharma R, Johnson CS, Stephenson K, Aya KL. Pseudotumor in the Setting of Metal-on-Metal Total Hip Arthroplasty. Cureus 2020; 12:e8255. [PMID: 35509374 PMCID: PMC9062588 DOI: 10.7759/cureus.8255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/23/2020] [Indexed: 12/17/2022] Open
Abstract
Metal-on-metal (MoM) hip resurfacing/replacement is a highly discussed topic in arthropathy, and the impact of its complications is still being elucidated. We report the case of a patient who presented with severe stomach pain due to a symptomatic psoas fluid collection that was later shown to communicate with a MoM total hip prosthesis. A MoM pseudotumor presenting as persistent stomach pain due to an aseptic psoas fluid collection is a rare complication. The case may support an earlier diagnosis in at-risk patients, and it outlines a suggested workup and treatment plan.
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Affiliation(s)
- Navraj S Sagoo
- Orthopedic Surgery, The University of Texas Medical Branch at Galveston, Galveston, USA
| | - Ruhi Sharma
- Orthopedic Surgery, Ross University School of Medicine, Bridgetown, BRB
| | - Connor S Johnson
- Orthopedic Surgery, The University of Texas Medical Branch at Galveston, Galveston, USA
| | - Kelly Stephenson
- Orthopedic Surgery, The University of Texas Medical Branch at Galveston, Galveston, USA
| | - Kessiena L Aya
- Orthopedic Surgery and Rehabilitation, The University of Texas Medical Branch at Galveston, Galveston, USA
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8
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Lubchak VV, Sivkov VS, Tsybin AV, Denisov AO, Maligin RV, Shubnyakov MI. [Mid-term and long-term results of metal-on-metal total hip arthroplasty]. Khirurgiia (Mosk) 2019:55-61. [PMID: 31626240 DOI: 10.17116/hirurgia201910155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess mid-term and long-term results of metal-on-metal total hip arthroplasty. MATERIAL AND METHODS There were 349 operations for the period 2006-2012 in our clinic. Sixty-four patients underwent a full examination. All patients underwent X-ray examination of the pelvis, MRI of hip joint with metal artifact reduction sequence (MARS). The concentration of cobalt and chromium metal ions was determined in blood serum. Each patient completed a questionnaire (Harris, Oxford, Womac, SF-36). 'Survival' of endoprostheses was calculated using the Kaplan-Meier method. RESULTS According to the Oxford scale, 76.6% of patients had excellent clinical and functional outcomes, 10.9% - good, 9.4% - satisfactory, 3.1% - unsatisfactory. According to the Harris scale, 57.9% of patients had excellent results, 15.6% - good, 7.8% - satisfactory, 18.7% - unsatisfactory. Inclination less than 45 degrees was noted in 77.2% of acetabular components. It is optimal installation angle. According to MRI data, effusion was the main type of periprosthetic changes (16 cases). There were no periprosthetic changes in 33 cases. Pseudotumor was diagnosed in 5 cases. Mean concentrations of cobalt and chromium ions were 1.27 (13.57-0.12) and 0.59 (0.4-0.87) µg/l, respectively. Normal concentration of chromium ions was observed in all cases. Kaplan-Meier survival rate of endoprostheses was 89% (80-97%). CONCLUSION There was no correlation between female sex, young age of patients and incidence of complications. It is necessary to exclude pseudotumor in case of pain syndrome and no signs of aseptic loosening of the components of the endoprosthesis.
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Affiliation(s)
- V V Lubchak
- Vreden Russian Institute of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - V S Sivkov
- Vreden Russian Institute of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - A V Tsybin
- Vreden Russian Institute of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - A O Denisov
- Vreden Russian Institute of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - R V Maligin
- Vreden Russian Institute of Traumatology and Orthopedics, Saint-Petersburg, Russia
| | - M I Shubnyakov
- Vreden Russian Institute of Traumatology and Orthopedics, Saint-Petersburg, Russia
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Crawford DA, Adams JB, Morris MJ, Berend KR, Lombardi AV. Revision of Failed Metal-on-Metal Total Hip Arthroplasty: Midterm Outcomes of 203 Consecutive Cases. J Arthroplasty 2019; 34:1755-1760. [PMID: 31053470 DOI: 10.1016/j.arth.2019.04.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 03/27/2019] [Accepted: 04/08/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Metal-on-metal (MoM) revisions have shown high rates of complications from aseptic loosening, deep infection, and dislocation. The purpose of this study is to report on outcomes and complications of a large consecutive series of patients who were revised for failed MoM total hip arthroplasty (THA). METHODS We evaluated 188 patients (203 hips) who underwent revisions of failed MoM THA. Mean age at the revision was 60 years old. Gender was female in 112 hips (55%) and male in 91 hips (45%). Mean interval to failure after primary THA was 4.9 years (range, 0-18 years). The acetabular component was revised in 183 cases (92%). Clinical outcomes assessed included pain score and Harris hip score. RESULTS Mean follow-up from revision was 4.2 years. Harris hip score improved from 53.6 pre-revision to 73.5 at most recent follow-up (P < .001). Pain level significantly improved from 17.2 pre-revision to 32.8 post-revision (P < .001). Reoperations occurred in 28 (14%) hips. Re-revision was required in 16 hips (7.9%). The most common reasons for re-revision were aseptic loosening (5), dislocation (3), infection (2), and iliopsoas tendonitis (2). Re-revision was significantly higher in cases of pseudotumor. There was no difference in survival with ultraporous cups. Three hips required re-revision to custom triflange components. All-cause survival was 90.5% at 4.2 years. Metal ion levels significantly declined after revision. CONCLUSION Revisions of failed MoM THA showed improvements in clinical outcomes, but present significant surgical challenges and complications especially in cases with soft tissue damage and pseudotumor.
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Affiliation(s)
| | | | - Michael J Morris
- Joint Implant Surgeons, Inc, New Albany, OH; Mount Carmel Health System, New Albany, OH
| | - Keith R Berend
- Joint Implant Surgeons, Inc, New Albany, OH; Mount Carmel Health System, New Albany, OH
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc, New Albany, OH; Mount Carmel Health System, New Albany, OH; Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH
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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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11
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Grote CW, Cowan PC, Anderson DW, Templeton KJ. Pseudotumor from Metal-on-Metal Total Hip Arthroplasty Causing Unilateral Leg Edema: Case Presentation and Literature Review. Biores Open Access 2018; 7:33-38. [PMID: 29607251 PMCID: PMC5870059 DOI: 10.1089/biores.2017.0035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Metal-on-metal (MoM) total hip arthroplasty (THA) can be associated with adverse metal reactions, including pseudotumors. This case report describes a 58-year-old female with an MoM THA-related pseudotumor that caused unilateral leg edema from compression of her external iliac vein. After thorough preoperative workup to rule out infection and deep vein thrombosis and consultation with a vascular surgeon, the patient underwent revision THA and excision of her pseudotumor. She had complete resolution of her swelling at 4 years after surgery. Review of all available case reports for this rare complication revealed that almost all patients were female. All patients underwent revision THA, with resolution of their symptoms. Literature review demonstrates that women are disproportionally affected by complications associated with MoM THA. We recommend close monitoring of patients with MoM THA, particularly women, for development of adverse metal reactions.
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Affiliation(s)
- Caleb W Grote
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
| | - Paul C Cowan
- Department of Orthopedic Surgery, Drisko, Fee and Parkins, Kansas City, Missouri
| | - David W Anderson
- Department of Orthopedic Surgery, Kansas City Joint Replacement at Menorah Medical Center, Overland Park, Kansas
| | - Kimberly J Templeton
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas
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12
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Goodnough LH, Bala A, Huddleston J, Goodman SB, Maloney WJ, Amanatullah DF. Metal-on-metal total hip arthroplasty is not associated with cardiac disease. Bone Joint J 2018; 100-B:28-32. [PMID: 29305447 DOI: 10.1302/0301-620x.100b1.bjj-2017-0366.r1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Many case reports and small studies have suggested that cobalt ions are a potential cause of cardiac complications, specifically cardiomyopathy, after metal-on-metal (MoM) total hip arthroplasty (THA). The impact of metal ions on the incidence of cardiac disease after MoM THA has not been evaluated in large studies. The aim of this study was to compare the rate of onset of new cardiac symptoms in patients who have undergone MoM THA with those who have undergone metal-on-polyethylene (MoP) THA. PATIENTS AND METHODS Data were extracted from the Standard Analytics Files database for patients who underwent MoM THA between 2005 and 2012. Bearing surface was selected using International Classification of Diseases ninth revision codes. Patients with a minimum five-year follow-up were selected. An age and gender-matched cohort of patients who underwent MoP THA served as a comparison group. New diagnoses of cardiac disease were collected during the follow-up period. Comorbidities and demographics were identified and routine descriptive statistics were used. RESULTS We identified 29 483 patients who underwent MoM THA and 24 175 matched patients who underwent MoP THA. Both groups had a mean Charlson comorbidity index score of 4. There were no statistically significant differences in 30 of 31 pre-existing comorbidities. Patients undergoing MoM THA had a slightly lower incidence of cardiac failure compared with those undergoing MoP THA at three years (6.60% versus 7.06%, odds ratio (OR) 0.93, 95% confidence interval (CI) 0.87 to 0.99) and four years (8.73% versus 9.49%, OR 0.91, 95% CI 0.86 to 0.97) postoperatively, with no difference in the incidence of new cardiac failure in between the groups at five years. There was no statistically significant difference in the incidence of arrhythmia, myocardial infarction and cardiomyopathy at any time between the two groups. CONCLUSION MoM THA is not associated with cardiac complications. Initial reports may have represented individual instances of cardiac disease in patients with a failing MoM articulation rather than an emerging epidemiological trend. Cite this article: Bone Joint J 2018;100-B:28-32.
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Affiliation(s)
- L H Goodnough
- Stanford University, 450 Broadway Street, Redwood City, California, 94063, USA
| | - A Bala
- Stanford University, 450 Broadway Street, Redwood City, California, 94063, USA
| | - J Huddleston
- Stanford University, 450 Broadway Street, Redwood City, California, 94063, USA
| | - S B Goodman
- Stanford University, 450 Broadway Street, Redwood City, California, 94063, USA
| | - W J Maloney
- Stanford University, 450 Broadway Street, Redwood City, California, 94063, USA
| | - D F Amanatullah
- Stanford University, 450 Broadway Street, Redwood City, California, 94063, USA
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Charette RS, Neuwirth AL, Nelson CL. Arthroprosthetic cobaltism associated with cardiomyopathy. Arthroplast Today 2017; 3:225-228. [PMID: 29204485 PMCID: PMC5712038 DOI: 10.1016/j.artd.2016.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/25/2016] [Accepted: 11/14/2016] [Indexed: 12/12/2022] Open
Abstract
Systemic cobaltism related to metal-on-metal total hip arthroplasty has been published in case reports and series with effects on the cardiac, neurologic, endocrine, and immunologic systems. This case report presents a 46-year-old male who underwent bilateral metal-on-metal total hip arthroplasty and subsequently developed cardiomyopathy requiring left ventricular assist device implantation. Intervention with bilateral revision to non-cobalt-containing implants resulted in improved cardiac function. This case report will alert clinicians to the presentation of this rare but devastating complication while also displaying improvement following revision total hip arthroplasty. It is our hope this case will aid in early recognition and intervention of this condition.
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Affiliation(s)
- Ryan S. Charette
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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14
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Does a micro-grooved trunnion stem surface finish improve fixation and reduce fretting wear at the taper junction of total hip replacements? A finite element evaluation. J Biomech 2017; 63:47-54. [DOI: 10.1016/j.jbiomech.2017.07.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 07/27/2017] [Accepted: 07/29/2017] [Indexed: 11/30/2022]
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15
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Carlson BC, Bryan AJ, Carrillo-Villamizar NT, Sierra RJ. The Utility of Metal Ion Trends in Predicting Revision in Metal-on-Metal Total Hip Arthroplasty. J Arthroplasty 2017; 32:S214-S219. [PMID: 28320566 DOI: 10.1016/j.arth.2017.02.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/03/2017] [Accepted: 02/11/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is a paucity of data examining metal ion levels over time. METHODS We retrospectively reviewed 59 patients (69 hips) with an articular surface replacement total hip arthroplasty. We reviewed prerevision cobalt and chromium concentrations over time. RESULTS Seventy-one percent of patients who were revised and had multiple ion measurements (12/17) demonstrated increasing cobalt ion levels or elevated ion levels over time. There was a trend toward an elevated risk of revision for increasing cobalt and chromium levels starting at 12 and 4 ppb, respectively; this was significant for chromium levels above 7 ppb (hazard ratio 22.35, P = .001). Similarly, there was a trend toward an elevated risk of pseudotumor formation for increasing cobalt and chromium levels starting at 5 and 2.5 ppb, respectively; this was significant for cobalt levels above 7 ppb (hazard ratio 6.88, P = .027). CONCLUSION In this paper, cobalt and chromium levels levels above 5 and 2.5 ppb started to demonstrate an increased risk of ARMD, and should be considered as a lower cutoff for discussion with patients about the potential for future revision.
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Affiliation(s)
- Bayard C Carlson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew J Bryan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Rafael J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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16
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Small SR, Meding JB, Oja JW, Lakstins KS, Gehron DJ, Rogge RD, Buckley CA. Shell design and reaming technique affect deformation in mobile-bearing total hip arthroplasty acetabular components. Proc Inst Mech Eng H 2017; 231:691-698. [DOI: 10.1177/0954411917701952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Press-fit acetabular components are susceptible to rim deformation. The inherent variability within acetabular reaming techniques may generate increased press-fit and, subsequently, additional component deformation. The purpose of this study was to analyze the insertion and deformation characteristics of acetabular components designed for dual-mobility systems based on component design, size, and reaming technique. Shell deformation was quantified in a validated worst-case scenario foam pinch model. Thin-walled, one-piece, and modular dual-mobility shells of varying size were implanted in under- and over-reamed cavities with insertion force measured and shell deformation assessed using digital image correlation. Increased shell size resulted in larger rim deformation in one-piece components, with a reduction in press-fit by 1 mm resulting in up to 48% reduction in insertion forces and between 23% and 51% reduction in shell deformation. Lower insertion forces and deformations were observed in modular components. Variability in acetabular reaming plays a significant role in the ease of implantation and component deformation in total hip arthroplasty. Modular components are less susceptible to deformation than thin-walled monoblock shells. Care should be taken to avoid excessive under-reaming, particularly in the scenario of large shell size and high-density patient bone stock.
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Affiliation(s)
| | | | - Jordan W Oja
- Department of Biology & Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN, USA
| | - Katherine S Lakstins
- Department of Biology & Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN, USA
| | - Danielle J Gehron
- Department of Biology & Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN, USA
| | - Renee D Rogge
- Department of Biology & Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN, USA
| | - Christine A Buckley
- Department of Biology & Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN, USA
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17
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Zagra L, Caboni E. Total hip arthroplasty instability treatment without dual mobility cups: brief overview and experience of other options. INTERNATIONAL ORTHOPAEDICS 2017; 41:661-668. [DOI: 10.1007/s00264-016-3383-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 12/19/2016] [Indexed: 01/02/2023]
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18
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Liow MHL, Dimitriou D, Tsai TY, Kwon YM. Preoperative Risk Factors Associated With Poor Outcomes of Revision Surgery for "Pseudotumors" in Patients With Metal-on-Metal Hip Arthroplasty. J Arthroplasty 2016; 31:2835-2842. [PMID: 27387480 DOI: 10.1016/j.arth.2016.05.034] [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: 03/21/2016] [Revised: 05/02/2016] [Accepted: 05/17/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision surgery of failed metal-on-metal (MoM) total hip arthroplasty (THA) for adverse tissue reaction (pseudotumor) can be challenging as a consequence of soft tissue and muscle necrosis. The aims of this study were to (1) report the revision outcomes of patients who underwent revision surgery for failed MoM hip arthroplasty due to symptomatic pseudotumor and (2) identify preoperative risk factors associated with revision outcomes. METHODS Between January 2011 and January 2013, a total of 102 consecutive large head MoM hip arthroplasties in 97 patients (male: 62, female: 35), who underwent revision surgery were identified from the database of a multidisciplinary referral center. RESULTS At minimum follow-up of 2 years (range: 26-52 months), at least one complication had occurred in 14 of 102 revisions (14%). Prerevision radiographic loosening (P = .01), magnetic resonance imaging (MRI) findings of solid lesions with abductor deficiency on MRI (P < .001), and intraoperative grading of adverse tissue reactions (P = .05) were correlated with post-revision complications. The reoperation rate of revised MoM THA was 7% (7 of 102 hips). Implant survivorship was 88% at 3 years. Metal ion levels declined in most patients after removal of MoM articulation. CONCLUSION Revision outcomes of revision surgery for failed MoM THA due to symptomatic pseudotumor demonstrated 14% complication rate and 7% re-revision rate at 30-month follow-up. Our study identified prerevision radiographic loosening, solid lesions/abductor deficiency on MRI, and high grade intraoperative tissue damage as risk factors associated with poorer revision outcomes. This provides clinically useful information for preoperative planning and perioperative counseling of MoM THA patients undergoing revision surgery.
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Affiliation(s)
- Ming Han Lincoln Liow
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dimitris Dimitriou
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsung-Yuan Tsai
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Young-Min Kwon
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Is Metal-On-Metal Total Hip Arthroplasty Associated With Neurotoxicity? J Arthroplasty 2016; 31:233-236.e1. [PMID: 27118351 DOI: 10.1016/j.arth.2016.03.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 03/07/2016] [Accepted: 03/17/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Isolated case reports in the literature describe systemic neurologic side effects associated with metal-on-metal (MOM) bearing surfaces, yet the incidence of these effects have not been evaluated beyond individual cases. The purpose of this study was to compare new diagnoses of these side effects described in isolated cases in large patient cohorts of MOM vs metal on polyethylene (MOP). METHODS We queried the entire Medicare database from 2005 to 2012. Total hip arthroplasty (THA) and bearing surface were determined using International Classification of Diseases, 9th revision procedure codes. Patients with 5-year follow-up were selected. Using International Classification of Diseases, 9th revision codes, we identified new diagnoses of previously reported neurologic side effects: peripheral neuropathy, sensorineural hearing loss, visual impairment, paresthesias, tinnitus, and vertigo. Comorbidities and demographics were collected. Odds ratios, CIs, and P values were calculated. RESULTS Overall, 29,483 MOM THAs and 23,587 age- and gender-matched MOP THAs were identified. The average Charlson Comorbidity Index was 5 for both groups. MOM and MOP patients had 26 of 30 identical prevalence of Elixhauser-measure comorbidities. There was no statistically significant difference in new diagnoses of any of the side effects at any time point between the 2 groups over 5 years. CONCLUSION This study represents, to our knowledge, the first longitudinal analysis of systemic neurotoxicity after THA in a large cohort of patients. The results of our study suggest that on the large scale, neurologic side effects previously described do not occur as a common attributable complication. Rather, these cases may be due to individual patient hypersensitivity to metal ions.
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20
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Treatment of the Failed Modular Neck Stems: Tips and Tricks. J Arthroplasty 2016; 31:1390-4. [PMID: 27113947 DOI: 10.1016/j.arth.2016.01.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 01/26/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Modular femoral components emerged because of the advantages of recreating limb length, offset, and native femoral version in total hip arthroplasty. Despite its potential benefits, the increase in modularity at the head-neck junction can lead to corrosion and subsequently failure of the implant. METHODS We present 3 case examples of patients who underwent revision surgery secondary to corrosion of their modular femoral components. RESULTS Issues addressed include understanding corrosion at the head-neck junction, presentations of adverse local tissue reactions, efficacy of metal ion testing and metal artifact reduction sequence magnetic resonance imaging, and approaches to revision surgery for failed modular neck stems. CONCLUSIONS When revision surgery is indicated for failed modular neck stems, we recommend a thoughtful approach with contemporary extraction techniques and options to enhance stability. Furthermore, long-term follow-up is needed to define the growing effect of modularity in total hip arthroplasty.
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Tsuda K, Haraguchi K, Koyanagi J, Takahashi S, Sugama R, Fujiwara K. A forty millimetre head significantly improves range of motion compared with a twenty eight millimetre head in total hip arthroplasty using a computed tomography-based navigation system. INTERNATIONAL ORTHOPAEDICS 2016; 40:2031-2039. [PMID: 26780716 DOI: 10.1007/s00264-015-3095-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/23/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE Larger-diameter (≥40 mm) femoral heads decrease the incidence of post-operative dislocation in total hip arthroplasty (THA). This study was conducted to discover whether larger-diameter femoral heads result in greater range of motion of the hip with the use of a computed tomography (CT)-based navigation system. METHODS Thirty-nine primary THAs were performed via a posterolateral approach using a CT-based navigation system. The stem was inserted in the femur in line with the original femoral neck anteversion. Considering the range of motion during various daily activities which could occur without impingement, the cup anteversion was decided at 10 ° increments according to the stem anteversion. While the cup inclination was set at 40 ° in order to avoid a high inclination angle to prevent the edge roading between the HXLPE liner and ceramic head. After implantation, trial liners and femoral heads were used with either 28 or 40 mm diameter. Maximal hip flexion, extension, abduction, external rotation in extension at 0° and internal rotation angles in flexion at 90 ° were measured. The differences between the ranges of motion with the 40-mm and 28-mm heads were tested. The results were assessed with paired Student t-tests. RESULTS The ranges of motion in flexion, extension, abduction and internal rotation angles improved significantly with the 40-mm heads compared with the 28-mm heads. The ranges of motion of cases where maximal flexion angle was 90° or less were excluded, improved significantly with the 40 mm heads. CONCLUSIONS We concluded that the larger-diameter 40-mm femoral prosthetic heads result in greater ranges of motion in flexion, extension, abduction and internal rotation.
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Affiliation(s)
- Kosuke Tsuda
- Arthroplasty Center, Osaka General Medical Center, 3-1-56, Bandai-higashi, Sumiyoshi, Osaka, Japan. .,Department of Orthopaedic Surgery, Osaka General Medical Center, 3-1-56, Bandai-higashi, Sumiyoshi, Osaka, Japan.
| | - Keiji Haraguchi
- Arthroplasty Center, Osaka General Medical Center, 3-1-56, Bandai-higashi, Sumiyoshi, Osaka, Japan.,Department of Orthopaedic Surgery, Osaka General Medical Center, 3-1-56, Bandai-higashi, Sumiyoshi, Osaka, Japan
| | - Junichiro Koyanagi
- Arthroplasty Center, Osaka General Medical Center, 3-1-56, Bandai-higashi, Sumiyoshi, Osaka, Japan.,Department of Orthopaedic Surgery, Osaka General Medical Center, 3-1-56, Bandai-higashi, Sumiyoshi, Osaka, Japan
| | - Shintaro Takahashi
- Department of Orthopaedic Surgery, Osaka Rosai Hospital, 1179-3, Nagasone-cho, Kita, Sakai, Osaka, Japan
| | - Ryo Sugama
- Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital, 2-10-39, Shibata, Kita, Osaka, Japan
| | - Keiju Fujiwara
- Department of Orthopaedic Surgery, Osaka General Medical Center, 3-1-56, Bandai-higashi, Sumiyoshi, Osaka, Japan
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22
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Metal-on-Metal Total Hip Arthroplasty: Patient Evaluation and Treatment. J Am Acad Orthop Surg 2015; 23:724-31. [PMID: 26493972 DOI: 10.5435/jaaos-d-14-00183] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 05/10/2015] [Indexed: 02/01/2023] Open
Abstract
Metal-on-metal (MoM) hip articulations were thought to represent a biologic and biomechanically favorable alternative to conventional metal-on-polyethylene total hip arthroplasty implants. However, concerns emerged when registry data reported significantly higher failure rates associated with MoM implants compared with other contemporary hip implants. These high implant failure rates have been attributed to the release of metal particles into the periprosthetic space, creating macroscopic necrosis; corrosive osteolysis; large, sterile hip effusions; and periprosthetic solid and cystic masses (ie, pseudotumors)-a spectrum of findings termed adverse reaction to metal debris. A thorough clinical history and physical examination, along with laboratory data and imaging surveillance of these patients, is critical for appropriate diagnosis and treatment. The decision to perform revision hip arthroplasty of a metal-on-metal implant is multifactorial and should be based on documented, objective clinical indications. A systematic and objective approach to this evaluation and treatment is essential to optimize the care of patients who undergo total hip arthroplasty with MoM implants.
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23
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Lombardi AV, Berend KR, Morris MJ, Adams JB, Sneller MA. Large-diameter metal-on-metal total hip arthroplasty: dislocation infrequent but survivorship poor. Clin Orthop Relat Res 2015; 473:509-20. [PMID: 25367107 PMCID: PMC4294925 DOI: 10.1007/s11999-014-3976-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 09/22/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Use of large-diameter metal-on-metal (MoM) articulations in THA increased, at least in part, because of the possibility of achieving improved joint stability and excellent wear characteristics in vitro. However, there have been subsequent concerning reports with adverse reactions to metal debris (ARMD), pseudotumors, and systemic complications related to metal ions. QUESTIONS/PURPOSES The purpose of this study was to determine at a minimum of 2 years' followup (1) the proportion of patients who experienced a dislocation; (2) the short-term survivorship obtained with these implants; (3) the causes of failure and the proportion of patients who developed ARMD; and (4) whether there were any identifiable risk factors for revision. METHODS We reviewed the results of 1235 patients who underwent 1440 large-diameter MoM primary THAs at our institution using two acetabular devices from a single manufacturer with minimum 2-year followup. Large-diameter MoM devices were used in 48% (1695 of 3567) of primary THAs during the study period. We generally used these implants in younger, more active, higher-demand patients, in patients considered at higher risk of instability, and in patients with adequate bone stock to achieve stable fixation without use of screws. Clinical records and radiographs were reviewed to determine the incidence and etiology of revision. Patients whose hips were revised were compared with those not revised to identify risk factors; Kaplan-Meier survivorship analysis was performed as was multivariate analysis to account for potential confounding variables when evaluating risk factors. Minimum followup was 2 years (average, 7 years; range, 2-12 years); complete followup was available in 85% of hips (1440 of 1695). RESULTS Dislocation occurred in one hip overall (<1%; one of 1440). Kaplan-Meier analysis revealed survival free of component revision was 87% at 12 years (95% confidence interval, 84%-90%). The two most common indications for revision were ARMD (48%; 47 of 108 hips revised) and loosening or failure of ingrowth (31%; 34 of 108). Risk factors for component revision were younger age at surgery (relative risk [RR] 0.98 per each increased year; p=0.02), higher cup angle of inclination (RR 1.03 per each increased degree; p=0.04), and female sex (RR 1.67; p=0.03). CONCLUSIONS Large-diameter MoM THAs are associated with a very low dislocation rate, but failure secondary to ARMD and loosening or lack of ingrowth occur frequently. Patients with MoM THA should be encouraged to return for clinical and radiographic followup, and clinicians should maintain a low threshold to perform a systematic evaluation. Early diagnosis and appropriate treatment are recommended to prevent the damaging effects of advanced ARMD. LEVEL OF EVIDENCE Level IV, Therapeutic study.
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Affiliation(s)
- Adolph V. Lombardi
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA ,The Ohio State University Wexner Medical Center, Columbus, OH USA ,Mount Carmel Health System, New Albany, OH USA
| | - Keith R. Berend
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA ,The Ohio State University Wexner Medical Center, Columbus, OH USA ,Mount Carmel Health System, New Albany, OH USA
| | - Michael J. Morris
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA ,Mount Carmel Health System, New Albany, OH USA
| | - Joanne B. Adams
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
| | - Michael A. Sneller
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA
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Karampinas PK, Evangelopoulos DS, Vlamis J, Nikolopoulos K, Korres DS. Confronting hip resurfacing and big femoral head replacement gait analysis. Orthop Rev (Pavia) 2014; 6:5221. [PMID: 24744841 PMCID: PMC3980157 DOI: 10.4081/or.2014.5221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 02/10/2014] [Indexed: 11/23/2022] Open
Abstract
Improved hip kinematics and bone preservation have been reported after resurfacing total hip replacement (THRS). On the other hand, hip kinematics with standard total hip replacement (THR) is optimized with large diameter femoral heads (BFH-THR). The purpose of this study is to evaluate the functional outcomes of THRS and BFH-THR and correlate these results to bone preservation or the large femoral heads. Thirty-one patients were included in the study. Gait speed, postural balance, proprioception and overall performance. Our results demonstrated a non-statistically significant improvement in gait, postural balance and proprioception in the THRS confronting to BFH-THR group. THRS provide identical outcomes to traditional BFH-THR. The THRS choice as bone preserving procedure in younger patients is still to be evaluated.
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Affiliation(s)
- Panagiotis K Karampinas
- Third Department of Orthopaedic Surgery, University of Athens, KAT Hospital , Athens, Greece
| | | | - John Vlamis
- Third Department of Orthopaedic Surgery, University of Athens, KAT Hospital , Athens, Greece
| | | | - Dimitrios S Korres
- Third Department of Orthopaedic Surgery, University of Athens, KAT Hospital , Athens, Greece
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Li J, Zheng W, Zhao J, Liu D, Xu W. Large diameter metal on metal total hip replacement for femoral neck fractures with neurological conditions: A retrospective assessment. Indian J Orthop 2014; 48:605-11. [PMID: 25404774 PMCID: PMC4232831 DOI: 10.4103/0019-5413.144236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [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 Patients with Parkinson's disease and poliomyelitis can have a femoral neck fracture; yet, the optimal methods of treatment for these hips remains controversial. Many constrained or semi-constrained prostheses, using constrained liners (CLs) with a locking mechanism to capture the femoral head, were used to treat femoral neck fractures in patients with neurological disorders. We retrospectively studied a group of patients with Parkinson's disease and poliomyelitis who sustained femoral neck fractures and were treated by total hip arthroplasty using an L-MoM prosthesis. MATERIALS AND METHODS We retrospectively reviewed 12 hips in 12 patients who underwent large-diameter metal-on-metal (L-MoM) total hip replacement between May 2007 and October 2009. Eight of the 12 patients (8 hips; 66.7%) had Parkinson's disease and 4 patients (4 hips; 33.3%) were affected with poliomyelitis. RESULTS The followup time was 5.2 years (range 3.6-6.0 years). At the latest followup, all the patients showed satisfactory clinical and radiographic results, with pain relief. No complications, such as dislocation or aseptic loosening occurred. CONCLUSION We believe the use of L-MoM can diminish the rate of instability or dislocation, after operation. The L-MoM is an option for patients with Parkinson's disease and poliomyelitis with femoral neck fracture.
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Affiliation(s)
- Jia Li
- Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wei Zheng
- Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jinzhu Zhao
- Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Denghui Liu
- Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Weidong Xu
- Department of Orthopedics, Changhai Hospital, Second Military Medical University, Shanghai, China,Address for correspondence: Prof. Weidong Xu, 168 Changhai Road, Shanghai 200433, China. E-mail:
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Panagiotidou A, Meswania J, Hua J, Muirhead-Allwood S, Hart A, Blunn G. Enhanced wear and corrosion in modular tapers in total hip replacement is associated with the contact area and surface topography. J Orthop Res 2013; 31:2032-9. [PMID: 23966288 DOI: 10.1002/jor.22461] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Accepted: 07/15/2013] [Indexed: 02/04/2023]
Abstract
Widespread concern exists about adverse tissue reactions after metal-on-metal (MoM) total hip replacement (THR). Concerns have also been expressed with wear and corrosion of taper junctions in THR. We report the effect of surface finish and contact area associated with a single combination of materials of modular tapers. In an in vitro test, we investigated the head/neck (CoCrMo/Ti) interface of modular THRs using commercially available heads. Wear and corrosion of taper surfaces was compared following a 10 million loading cycle. Surface parameters and profiles were measured before and after testing. Electrochemical static and dynamic corrosion tests were performed under loaded and non-loaded conditions. After the load test, the surface roughness parameters on the head taper were significantly increased where the head/neck contact area was reduced. Similarly, the surface roughness parameters on the head taper were significantly increased where rough neck tapers were used. Corrosion testing showed breaching of the passive film on the rough but not the smooth neck tapers. Thus, surface area and surface finish are important factors in wear and corrosion at modular interfaces.
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Affiliation(s)
- Anna Panagiotidou
- Institute of Orthopaedics and Musculo-Skeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, United Kingdom
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No difference in gait recovery after THA with different head diameters: a prospective randomized study. Clin Orthop Relat Res 2013; 471:3830-7. [PMID: 23640204 PMCID: PMC3825870 DOI: 10.1007/s11999-013-2926-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Larger femoral heads are commonly presumed to improve joint stability and hip biomechanics; some studies have suggested they may hasten recovery of a normal gait. To our knowledge, no gait analysis studies have compared different size head diameters in THA. QUESTIONS/PURPOSES We compared (1) spatiotemporal gait parameters, (2) kinematic and kinetic gait parameters, and (3) Harris hip scores in patients undergoing THA randomized to receive a 28-, 36-, or ≥ 42-mm bearing couple. We hypothesized a larger femoral head would restore an earlier, more physiologic gait pattern. METHODS This randomized, blinded study involved 60 patients who received the same cementless THA except for the size of the bearing. Inclusion criteria were primary hip arthritis, female sex, and age between 55 and 70 years. Exclusion criteria were other problems influencing walking ability. The patients were randomized into three groups of 20 each (28- and 36-mm ceramic-on-crosslinked polyethylene, ≥ 42-mm metal-on-metal). All patients underwent the same postoperative rehabilitation protocol. Gait evaluation using an optoelectronic system was performed preoperatively and at 2 and 4 months postoperatively. RESULTS With the numbers available, no differences in spatiotemporal gait parameters, kinematic or kinetic gait parameters, or Harris hip scores emerged among the three groups. All variables assessed at 4 months postoperatively showed improvements across all groups, but the differences among them were not significant. CONCLUSIONS The hypothesis that a larger femoral head results in improved early gait performance was not supported by this study.
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28
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Stroh DA, Issa K, Johnson AJ, Delanois RE, Mont MA. Reduced dislocation rates and excellent functional outcomes with large-diameter femoral heads. J Arthroplasty 2013; 28:1415-20. [PMID: 23602233 DOI: 10.1016/j.arth.2012.11.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 11/14/2012] [Accepted: 11/26/2012] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to compare the dislocation rates, functional outcomes, and radiographic results between large- and small-diameter femoral head components. A total of 225 patients (248-hips) who received total hip arthroplasties with large-diameter components (36mm or greater) were compared to 501 patients (559-hips) who received smaller diameter components (less than 36mm). Rates of dislocation and revision, Harris hip score, radiographic findings, and complications were compared between the groups. At a mean follow-up of approximately 5years, a significantly higher rate of dislocation was noted in the small-diameter group (10 of 559) compared to the large-diameter group (0 of 248). The overall implant survivorship, mean Harris hip scores, complication rates, and radiographic outcomes were similar for the two groups. The authors believe that large-diameter components significantly reduced the risk of dislocation in susceptible patients, while preserving good to excellent functional outcomes.
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Affiliation(s)
- D Alex Stroh
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland 21215, USA
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Levy YD, Ezzet KA. Poor short term outcome with a metal-on-metal total hip arthroplasty. J Arthroplasty 2013; 28:1212-7. [PMID: 23538122 DOI: 10.1016/j.arth.2012.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 09/28/2012] [Accepted: 10/09/2012] [Indexed: 02/01/2023] Open
Abstract
Metal-on-metal (MoM) bearings for total hip arthroplasty (THA) have come under scrutiny with reports of high failure rates. Clinical outcome studies with several commercially available MoM THA bearings remain unreported. We evaluated 78 consecutive MoM THAs from a single manufacturer in 68 patients. Sixty-six received cobalt-chrome (CoCr) monoblock and 12 received modular titanium acetabular cups with internal CoCr liners. Femoral components were titanium with modular necks. At average 2.1 years postoperatively, 12 THAs (15.4%) demonstrated aseptic failure (10 revisions, 2 revision recommended). All revised hips demonstrated capsular necrosis with positive histology reaction for aseptic lymphocytic vasculitis-associated lesions/adverse local tissue reactions. Prosthetic instability following revision surgery was relatively common. Female gender was a strong risk factor for failure, though smaller cups were not. Both monoblock and modular components fared poorly. Corrosion was frequently observed around the proximal and distal end of the modular femoral necks.
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Affiliation(s)
- Yadin D Levy
- Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, CA, USA
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Berend KR, Morris MJ, Adams JB, Lombardi AV. Metal-on-metal hip arthroplasty: going, going, gone... - affirms. ACTA ACUST UNITED AC 2013; 94:75-7. [PMID: 23118387 DOI: 10.1302/0301-620x.94b11.30745] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Metal-on-metal hip arthroplasty gained significant favor in the first decade of the millennium. However, the past several years have seen increasing reports of failure, pseudotumor and other adverse reactions. This study presents the results of a single center's 15-year experience with metal-on-metal total hip arthroplasty as strong evidence that metal-on-metal is going, going, gone.
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Affiliation(s)
- K R Berend
- Joint Implant Surgeons, Inc., The Ohio State University, Mount Carmel Health System, 7277 Smith's Mill Road, New Albany 43054, Ohio, USA.
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Abstract
BACKGROUND Dislocation remains common after total hip arthroplasty. Efforts have been made to identify and minimize risk factors. One such factor, jump distance, or the distance the femoral head must travel before dislocating, has been poorly characterized with respect to three-dimensional kinematics. QUESTIONS/PURPOSES We therefore determined: (1) the three-dimensional stability of four different component designs; (2) whether the degree of abduction and anteversion affects the stability; (3) whether pelvic inclination angles affected stability; and (4) which combination of these three factors had the greatest stability. METHODS We created a positionable three-dimensional model of a THA. Acetabular components were modeled in various abduction and anteversion angles and in two different pelvic inclinations which simulate standing and chair-rising activities. RESULTS The posterior horizontal dislocation distance increased as inclination angle and femoral head size increased. The 48-mm resurfacing typically had lower jump distances and was at risk of posterior edge loading at 30° inclination. The highest jump distance for all positions and activities occurred with the dual-mobility bearing. CONCLUSION These findings suggest that monoblock cups require extremely accurate positioning for low dislocation risk and that pelvic orientation may increase dislocation risks. CLINICAL RELEVANCE As a result of the dual-mobility designs having the greatest resistance to dislocation, these cups may be appropriate for patients who are at risk for dislocation in difficult primary situations and in revision hip arthroplasty procedures in which proper component orientation may be less likely to be achieved.
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Hug KT, Watters TS, Vail TP, Bolognesi MP. The withdrawn ASR™ THA and hip resurfacing systems: how have our patients fared over 1 to 6 years? Clin Orthop Relat Res 2013; 471:430-8. [PMID: 22926492 PMCID: PMC3549196 DOI: 10.1007/s11999-012-2547-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Articular Surface Replacement™ (ASR™) metal-on-metal hip arthroplasty system (DePuy Orthopaedics, Inc, Warsaw, IN, USA) reportedly has a higher than anticipated early failure rate leading to a voluntary recall. This prompted us to evaluate all ASR™ components implanted at our center. QUESTIONS/PURPOSES In all ASR™ components, we reported (1) revision rate, (2) blood metal ion levels, and (3) intraoperative findings for revisions related to adverse reaction to metal debris (ARMD). METHODS We retrospectively reviewed all 172 patients (190 hips) who underwent THA (149 hips) or hip resurfacing (41 hips) with the ASR™ system. We determined failure rates. We obtained blood metal ion concentrations from 93 patients at last followup. We evaluated MRI studies and intraoperative histopathology. Minimum followup was 12 months (mean, 40 months; range, 12-74 months). RESULTS At latest followup, we had revised 24 of 190 hips (13%): in 18 patients with THA and five patients with resurfacing. Mean time to revision was 45 months (range, 12-75 months). Mean blood concentrations were 13 μg/L (range, 0-150 μg/L) for cobalt and 6 μg/L (range, 0-87 μg/L) for chromium. Mean prerevision blood metal ion levels were higher in the revised group (cobalt: 48 μg/L; chromium: 18 μg/L) than in the nonrevised group (cobalt: 5 μg/L; chromium: 2 μg/L). ARMD was present in 14 of the 24 hips revised in this study. CONCLUSIONS Surgeons must have a low threshold for concern for ARMD in patients with ASR™ systems. Blood metal ion levels and MRI can be used to evaluate patients with underperforming implants. Intraoperative histopathologic analysis and joint fluid cytology can help diagnose ARMD at the time of revision. LEVEL OF EVIDENCE Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kevin T. Hug
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 3269, Durham, NC 27710 USA
| | - Tyler S. Watters
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 3269, Durham, NC 27710 USA
| | - Thomas P. Vail
- />Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, CA USA
| | - Michael P. Bolognesi
- />Department of Orthopaedic Surgery, Duke University Medical Center, Box 3269, Durham, NC 27710 USA
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Meding JB, Small SR, Jones ME, Berend ME, Ritter MA. Acetabular cup design influences deformational response in total hip arthroplasty. Clin Orthop Relat Res 2013; 471:403-9. [PMID: 22948528 PMCID: PMC3549190 DOI: 10.1007/s11999-012-2553-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Press-fit acetabular components are susceptible to deformation in an underreamed socket, with excessive deformation of metal-on-metal (MOM) components potentially leading to increased torsional friction and micromotion. Specifically, however, it remains unclear how cup diameter, design, and time from implantation affect shell deformation. QUESTIONS/PURPOSES We asked whether (1) changes in component geometry and material altered maximum shell deformation and (2) time-dependent deformational relaxation processes occurred. METHODS Diametral deformation was quantified after press-fit implantation of metal shells into a previously validated polyurethane model. Experimental groups (n = 6-8) consisted of 48-, 54-, 60-, and 66-mm MOM cups of 6-mm wall thickness, 58-mm cups of 10-mm wall thickness, and CoCrMo and Ti6Al4V 58-mm modular cups. RESULTS Greater cup diameter, thinner wall construction, and Ti6Al4V modular designs generated conditions for maximum shell deformation ranging from 0.047 to 0.267 mm. Relaxation (18%-32%) was observed 120 hours postimplantation in thin-walled and modular designs. CONCLUSIONS Our findings demonstrate a reduction of shell deformation over time and suggest, under physiologic loading, early component deformation varies with design. CLINICAL RELEVANCE Component deformation should be a design consideration regardless of bearing surface. Designs neglecting to adequately address deformational changes in vivo could be susceptible to diminished cup survival, increased wear, and premature revision.
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Affiliation(s)
- John B. Meding
- Joint Replacement Surgeons of Indiana Foundation, Inc, 1199 Hadley Road, Mooresville, IN 46158 USA
| | - Scott R. Small
- Joint Replacement Surgeons of Indiana Foundation, Inc, 1199 Hadley Road, Mooresville, IN 46158 USA
| | - Mary E. Jones
- Department of Applied Biology and Biomedical Engineering, Rose-Hulman Institute of Technology, Terre Haute, IN USA
| | - Michael E. Berend
- Joint Replacement Surgeons of Indiana Foundation, Inc, 1199 Hadley Road, Mooresville, IN 46158 USA
| | - Merrill A. Ritter
- Joint Replacement Surgeons of Indiana Foundation, Inc, 1199 Hadley Road, Mooresville, IN 46158 USA
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Sachde B, Maru ND. Mid-term results of large diameter heads on cross-linked polyethylene liners in total hip replacement. J Clin Orthop Trauma 2012; 3:94-7. [PMID: 26403445 PMCID: PMC3872809 DOI: 10.1016/j.jcot.2012.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 10/09/2012] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Highly cross-linked polyethylene liners in total hip replacement (THR) have allowed the use of larger diameter femoral heads. Larger heads allow for increased range of motion, decreased implant impingement, and protection against dislocation. The purpose of this study is to assess the clinical and radiographic outcomes of patients with large femoral heads THR at 4 years postop. MATERIALS AND METHODS Study includes 28 patients who had a primary THR with a 36 mm larger femoral head were retrospectively for minimum 4 years follow-up. All patients received a cementless acetabular shell and a highly cross-linked polyethylene liner with an inner diameter of 36 mm. The median radiographic follow-up was 4 years (range 2.0-6.0), and patients were assessed clinically by Harris hip score. RESULTS The mean follow-up is minimum 4 years (range 2-6 years) results in all operated patients showed marked improvement in Harris hip score from preoperative mean 49.1 to 89.9 at 4 years or more follow-up. The complications include superficial infection (n = 2). No dislocation, or no osteolysis was seen in the pelvis or proximal femur, and no components failed due to aseptic loosening. There was no evidence of cup migration, screw breakage, or eccentric wear on the liner. CONCLUSION The mid-term results in this series of patients with LDH using 36 mm femoral head articulating with highly cross linked polyethylene showed excellent clinical, and radiological results, in terms of, joint restoration that replicates the natural anatomy, optimized range of motion without impingement & reduced opportunity for postoperative dislocation.
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Affiliation(s)
- Bhavesh Sachde
- Professor and HOD, Orthopedics Department, P.D.U. Medical College and Hospital, Rajkot 360001, India
| | - Nikunj D. Maru
- Assistant Professor, Orthopedics Department, P.D.U. Medical College and Hospital, Rajkot 360001, India,Corresponding author. Tel.: +91 9879681202 (mobile).
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Cross MB, Nam D, Mayman DJ. Ideal femoral head size in total hip arthroplasty balances stability and volumetric wear. HSS J 2012; 8:270-4. [PMID: 24082871 PMCID: PMC3470670 DOI: 10.1007/s11420-012-9287-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 06/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Over the last several years, a trend towards increasing femoral head size in total hip arthroplasty to improve stability and impingement free range of motion has been observed. PURPOSE The specific questions we sought to answer in our review were: (1) What are the potential advantages and disadvantages of metal-on-metal, ceramic-on-ceramic, and metal-on-polyethylene bearings? (2) What is effect that femoral head size has on joint kinematics? (3) What is the effect that large femoral heads have on bearing surface wear? METHODS A PubMed search and a review of 2012 Orthopaedic Research Society abstracts was performed and articles were chosen that directly answered components of the specific aims and that reported outcomes with contemporary implant designs or materials. RESULTS A review of the literature suggests that increasing femoral head size decreases the risk of postoperative dislocation and improves impingement free range of motion; however, volumetric wear increases with large femoral heads on polyethylene and increases corrosion of the stem in large metal-on-metal modular total hip arthroplasty (THA); however, the risk of potentially developing osteolysis or adverse reactions to metal debris respectively is still unknown. Further, the effect of large femoral heads with ceramic-on-ceramic THA is unclear, due to limited availability and published data. CONCLUSIONS Surgeons must balance the benefits of larger head size with the increased risk of volumetric wear when determining the appropriate head size for a given patient.
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Affiliation(s)
- Michael B. Cross
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Denis Nam
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - David J. Mayman
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Werner BC, Brown TE. Instability after total hip arthroplasty. World J Orthop 2012; 3:122-30. [PMID: 22919568 PMCID: PMC3425631 DOI: 10.5312/wjo.v3.i8.122] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 07/01/2012] [Accepted: 08/07/2012] [Indexed: 02/06/2023] Open
Abstract
Instability following total hip arthroplasty (THA) is an unfortunately frequent and serious problem that requires thorough evaluation and preoperative planning before surgical intervention. Prevention through optimal index surgery is of great importance, as the management of an unstable THA is challenging even for an experienced joints surgeon. However, even after well-planned surgery, a significant incidence of recurrent instability still exists. Non-operative management is often successful if the components are well-fixed and correctly positioned in the absence of neurocognitive disorders. If conservative management fails, surgical options include revision of malpositioned components; exchange of modular components such as the femoral head and acetabular liner; bipolar arthroplasty; tripolar arthroplasty; use of a larger femoral head; use of a constrained liner; soft tissue reinforcement and advancement of the greater trochanter.
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Stroh A, Naziri Q, Johnson AJ, Mont MA. Dual-mobility bearings: a review of the literature. Expert Rev Med Devices 2012; 9:23-31. [PMID: 22145838 DOI: 10.1586/erd.11.57] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dislocation after total hip arthroplasty remains a major problem and hip instability is the most common reason for revision. These complications are costly to both patients and the healthcare system, and efforts to reduce them have had varied degrees of success. Although there are well documented patient and surgical risk factors for dislocation, the typical surgical solutions offered (constrained liners, large femoral heads) have the drawbacks of reduced range-of-motion and high rates of revision. Dual-mobility prostheses (unconstrained tripolar prostheses) are hip design solutions to dislocation that aim to provide a greater stability with an increased range-of-motion, along with potentially reduced wear. The mean overall dislocation rate from multiple combined studies using dual-mobility prostheses was 0.1% for primary total hip arthroplasty and 3.5% for revisions, compared with 2-7% for standard primary total hip arthroplasties and up to 16% for revisions. Dual-mobility prostheses offer a viable option for treating recurrent dislocation as well as for primary and revision arthroplasty.
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Affiliation(s)
- Alex Stroh
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, MD, USA
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Minimum 5-year results of modular metal-on-metal total hip arthroplasty. J Arthroplasty 2012; 27:545-50. [PMID: 21908166 DOI: 10.1016/j.arth.2011.07.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 07/05/2011] [Indexed: 02/01/2023] Open
Abstract
This study reports minimum 5-year results of 95 hips implanted with a Pinnacle (DePuy, Warsaw, Ind) modular metal-on-metal acetabular prosthesis. Clinical scores such as the Harris Hip and Western Ontario and McMaster Universities Arthritis Index revealed excellent clinical outcomes at mean 6-year follow-up. With the use of large-diameter femoral heads, dislocation was rare, occurring in only 1 hip. Moreover, no acetabular and only 3 femoral osteolytic lesions were detected. Kaplan-Meier survivorship at 7 years after arthroplasty was 97.8% for the total hip arthroplasty construct and 100% for the acetabular shell. No unexplained pain or other complication attributable to wear debris or the metal-on-metal articulation was observed. These findings indicate that total hip arthroplasty with this specific modular metal-on-metal bearing performed well in a high-demand population at midterm follow-up.
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Low incidence of groin pain and early failure with large metal articulation total hip arthroplasty. Clin Orthop Relat Res 2012; 470:388-94. [PMID: 21932102 PMCID: PMC3254765 DOI: 10.1007/s11999-011-2069-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Large-diameter metal-on-metal articulations reportedly improve stability and wear in THAs. However, some reports suggest some patients have unexplained hip and early failures with these implants. Thus, the potential benefits may be offset by these concerns. However, the incidence of these problems is not clearly established. QUESTIONS/PURPOSES We therefore assessed hip pain, function, osteolysis, and complications in patients with large-diameter metal-on-metal THA. PATIENTS AND METHODS We retrospectively reviewed 611 patients who had 681 large-diameter metal-on-metal THAs with the same cup and head design. The average age at operation was 62 years, 53% of the THAs were in men, and the average body mass index was 32 kg/m(2). The diagnosis was osteoarthritis in 92% of the THAs. The minimum followup was 24 months (mean, 37 months; range, 24-60 months). RESULTS Nine of the 611 patients (1.5%) experienced moderate or severe pain in the hip region that we considered to be coming from an extraarticular source in each case. Harris hip scores for pain averaged 42 points. Total Harris hip scores averaged 93 points. Cup abduction averaged 42°, and cup anteversion averaged 26°. There were no infections. Three cups (0.4%) were considered radiographically loose. All were secondary to inadequate seating of the shell. CONCLUSION Our observations suggest with this implant the concerns of higher incidences of groin pain, early failures, and adverse tissue reactions were not confirmed. Early successes or failures with large-diameter metal-on-metal articulations may be implant specific. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Wu PT, Wang CJ, Yen CY, Jian JS, Lai KA. Cementless large-head metal-on-metal total hip arthroplasty in patients younger than 60 years--a multicenter early result. Kaohsiung J Med Sci 2012; 28:30-7. [PMID: 22226059 DOI: 10.1016/j.kjms.2011.06.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 03/22/2011] [Indexed: 10/17/2022] Open
Abstract
Large-head metal-on-metal total hip arthroplasty has the theoretical advantages of less wear and better range of motion than traditional polyethylene bearings and seems to be a better choice for young and active patients. We conducted a retrospective study and reported the early results of using such prostheses in 59 patients (70 hips) with a mean age of 43.1 years (range, 23-59 years) at the time of surgery. Osteonecrosis of the femoral head accounted for most diagnoses. Harris Hip Scores and hip range of motion both significantly improved (p<0.001) at an average follow-up of 32.6 months (range, 24-48 months). Only one intraoperative calcar fissure was encountered, and it was fixated by cerclage wiring; there was no infection, dislocation, or osteolysis around either the cup or the stem at the latest follow-up. A postoperative gap in the acetabular component was noted in 24 hips, with a mean depth of 1.11 mm, but this was not correlated with the functional score (p=0.291). Transient thigh pain, which resolved after 6 months, was observed in six patients but was not related to either the postoperative gap or cup inclination (p=1.000 and p=0.664, respectively). All patients resumed their original jobs and recreational activities with little discomfort. Thus far, large-head metal-on-metal total hip arthroplasty has shown excellent early results. The long-term results and the effects of metal debris and potentially elevated serum metal ion levels require further observation.
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Affiliation(s)
- Po-Ting Wu
- Department of Orthopaedics, National Cheng Kung University Hospital, Tainan, Taiwan
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Moroni A, Nocco E, Hoque M, Diremigio E, Buffoli D, Cantù F, Catalani S, Apostoli P. Cushion bearings versus large diameter head metal-on-metal bearings in total hip arthroplasty: a short-term metal ion study. Arch Orthop Trauma Surg 2012; 132:123-9. [PMID: 21845437 DOI: 10.1007/s00402-011-1364-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Metal-on-metal total hip arthroplasty (MOM THA) has the advantage of replicating the femoral head size, but the postoperative elevation of serum metal ion levels is a cause for concern. Metal-on-polycarbonate-urethane is a new cushion bearing featuring a large diameter metal head coupled with a polycarbonate-urethane liner. AIM The aim of this study was to assess and compare serum cobalt (Co) and chromium (Cr) levels in a group of 15 patients treated with a cushion bearing THA system (Group A) and a group of 15 patients treated with a MOM THA system (Group B) at short-term. At a mean follow-up of 27.3 months (18-35 months), in Group A the median Cr and Co serum levels were significantly lower than in Group B, measuring 0.24 μg/L (0.1-2.1 μg/L) and 0.6 μg/L (0.29-2.3 μg/L) compared to 1.3 μg/L (0.1-9 μg/L, p < 0.001) and 2.9 μg/L (0.85-13.8 μg/L, p < 0.001) respectively. RESULTS All patients demonstrated an excellent clinical result, as shown by the Harris and Oxford hip scores. The cushion bearing THA studied in this paper showed clinical outcomes similar to the MOM THA bearing, with the advantage of no significant metal ion elevation in the serum. CONCLUSION These findings warrant the continued clinical study of compliant bearing options.
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Affiliation(s)
- Antonio Moroni
- School of Sports Science, University of Bologna, Bologna, Italy.
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Swierstra BA, Vervest AMJS, Walenkamp GHIM, Schreurs BW, Spierings PTJ, Heyligers IC, van Susante JLC, Ettema HB, Jansen MJ, Hennis PJ, de Vries J, Muller-Ploeger SB, Pols MA. Dutch guideline on total hip prosthesis. Acta Orthop 2011; 82:567-76. [PMID: 21992086 PMCID: PMC3242953 DOI: 10.3109/17453674.2011.623575] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 04/25/2011] [Indexed: 01/31/2023] Open
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Zywiel MG, Sayeed SA, Johnson AJ, Schmalzried TP, Mont MA. State of the art in hard-on-hard bearings: how did we get here and what have we achieved? Expert Rev Med Devices 2011; 8:187-207. [PMID: 21627555 DOI: 10.1586/erd.10.75] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Total hip arthroplasty has shown excellent results in decreasing pain and improving function in patients with degenerative disease of the hip. Improvements in prosthetic materials, designs and implant fixation have now resulted in wear of the bearing surface being the limitation of this technology, and a number of hard-on-hard couples have been introduced to address this concern. The purpose of this article is to review the origins, development, survival rates and potential advantages and disadvantages of the following hard-on-hard bearings for total hip arthroplasty: metal-on-metal standard total hip arthroplasty; metal-on-metal hip resurfacing arthroplasty, ceramic-on-ceramic total hip arthroplasty; and ceramic-on-metal bearings. Improvements in the manufacturing of metal-on-metal bearings over the past 50 years have resulted in implants that provide low wear rates and allow for the use of large femoral heads. However, concerns remain regarding elevated serum metal ion levels, potential teratogenic effects and potentially devastating adverse local tissue reactions, whose incidence and pathogenesis remains unclear. Modern total hip resurfacing has shown excellent outcomes over 10 years in the hands of experienced surgeons. Current ceramic-on-ceramic bearings have demonstrated excellent survival with exceptionally low wear rates and virtually no local adverse effects. Concerns remain for insertional chipping, in vivo fracture and the variable incidence of squeaking. Contemporary ceramic-on-metal interfaces are in the early stages of clinical use, with little data reported to date. Hard-on-hard bearings for total hip arthroplasty have improved dramatically over the past 50 years. As bearing designs continue to improve with new and modified materials and improved manufacturing techniques, it is likely that the use of hard-on-hard bearings will continue to increase, especially in young and active patients.
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Affiliation(s)
- Michael G Zywiel
- Division of Orthopaedic Surgery, University of Toronto, 100 College Street Room 302, Toronto, Ontario M5G 1L5, Canada
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Steele GD, Fehring TK, Odum SM, Dennos AC, Nadaud MC. Early failure of articular surface replacement XL total hip arthroplasty. J Arthroplasty 2011; 26:14-8. [PMID: 21550764 DOI: 10.1016/j.arth.2011.03.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 03/13/2011] [Indexed: 02/01/2023] Open
Abstract
The ASR (articular surface replacement) XL (DePuy, Warsaw, Ind) metal-on-metal hip arthroplasty offers the advantage of stability and increased motion. However, an alarming number of early failures prompted the evaluation of patients treated with this system. A prospective study of patients who underwent arthroplasty with the ASR XL system was performed. Patients with 2-year follow-up or any revision were included. Failure rates, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, and radiographs were evaluated. Ninety-five patients (105 hips) were included. There were 16 revisions. Thirteen (12%) were aseptic acetabular failures. Eight were revised for aseptic loosening; 4, for metallosis; 1, for malposition; 2, for infection; and 1, for periprosthetic fracture. Mean time to revision was 1.6 years (0.18-3.4 years). The ASR XL with a revision rate of 12% is the second reported 1 piece metal-on-metal system with a significant failure rate at early follow-up. This particular class of implants has inherent design flaws that lead to early failure.
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Queen RM, Watters TS, Abbey AN, Sabesan VJ, Vail TP, Bolognesi MP. Gait symmetry: a comparison of hip resurfacing and jumbo head total hip arthroplasty patients. J Arthroplasty 2011; 26:680-5. [PMID: 20884168 DOI: 10.1016/j.arth.2010.07.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 07/30/2010] [Indexed: 02/01/2023] Open
Abstract
Proponents of large femoral head total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) have touted the potential for restoration of more normal hip kinematics. This study examined 20 patients (10 THA and 10 HRA patients) approximately 18 months after surgery. Subjects were evaluated at a self-selected pace, while bilateral spatial-temporal gait variables, hip flexion/extension kinematics, and ground reaction forces were collected. For both groups, swing time was increased on the surgical side, whereas peak hip flexion, peak extension, and flexion at heel strike were decreased. Peak hip extension and peak vertical ground reaction forces were decreased in THA subjects compared with HRA subjects. After a large-diameter THA or HRA, subjects do not display symmetric gait approximately 18 months postoperatively. Total hip arthroplasty subjects demonstrated restricted hip extension and reduced limb loading when compared with HRA subjects.
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Affiliation(s)
- Robin M Queen
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Lombardi AV, Skeels MD, Berend KR, Adams JB, Franchi OJ. Do large heads enhance stability and restore native anatomy in primary total hip arthroplasty? Clin Orthop Relat Res 2011; 469:1547-53. [PMID: 20953855 PMCID: PMC3094625 DOI: 10.1007/s11999-010-1605-0] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Dislocation remains a serious complication in hip arthroplasty. Resurfacing proponents tout anatomic femoral head restoration as an advantage over total hip arthroplasty. However, advances in bearings have expanded prosthetic head options from traditional sizes of 22, 26, 28, and 32 mm to diameters as large as 60 mm. Large heads reportedly enhance stability owing to increased range of motion before impingement and increased jump distance to subluxation. Available larger diameter material combinations include metal- or ceramic-on-highly crosslinked polyethylene and metal-on-metal, each with distinct advantages and disadvantages. QUESTIONS/PURPOSES We sought to determine (1) if using larger diameter heads has lowered our dislocation rate; and (2) how closely an anatomic metal-on-metal bearing with diameters to 60 mm replicates native femoral head size. METHODS We retrospectively reviewed 2020 primary arthroplasties performed with large heads (≥ 36 mm) in 1748 patients and noted dislocation incidence. In a prospective subset of 89 cases using anatomic heads, native femoral head diameter was measured intraoperatively with calipers by an independent observer and later compared with implanted size. RESULTS One dislocation has occurred in 2020 hips for an incidence of 0.05%. The prosthetic head averaged 0.7 mm larger than the native head with 68 of 89 (76%) reconstructed to within ± 2 mm of native size. CONCLUSIONS Larger diameter heads have contributed to lower dislocation rates and large-diameter metal-on-metal articulation can provide close anatomic restoration in primary THA.
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Affiliation(s)
- Adolph V. Lombardi
- Joint Implant Surgeons, Inc, 7277 Smith’s Mill Road, Suite 200, New Albany, OH 43054 USA ,Department of Orthopaedics and Department of Biomedical Engineering, The Ohio State University, Columbus, OH USA ,Mount Carmel Health System, New Albany, OH USA
| | - Michael D. Skeels
- Albert Einstein College of Medicine, Physical Medicine and Rehabilitation Residency, Bronx, NY USA
| | - Keith R. Berend
- Mount Carmel Health System, New Albany, OH USA ,Joint Implant Surgeons, Inc, New Albany, OH USA ,Department of Orthopaedics, The Ohio State University, Columbus, OH USA
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Amstutz HC, Le Duff MJ, Campbell PA, Wisk LE, Takamura KM. Complications after metal-on-metal hip resurfacing arthroplasty. Orthop Clin North Am 2011; 42:207-30, viii. [PMID: 21435496 DOI: 10.1016/j.ocl.2010.12.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This article determines the incidence and cause of the complications commonly associated with metal-on-metal hip resurfacing implants and the proposed methods to prevent these complications. The literature available in PubMed was reviewed. Complication rates after hip resurfacing are low, and the procedure has shown both safety and efficacy in the hands of surgeons trained in specialized centers. Proper surgical technique can further reduce the incidence of femoral neck fracture, component loosening, and abnormal wear of the prosthesis. A more systematic detection of adverse local tissue reactions is needed to provide accurate assessments of their prevalence.
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Affiliation(s)
- Harlan C Amstutz
- Joint Replacement Institute at Saint Vincent Medical Center, Los Angeles, CA 90057, USA.
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Wehrkamp RA, Rice MS. Long-handled shoehorn length, body mass index, and hip range of motion in healthy female adults. Am J Occup Ther 2011; 64:915-22. [PMID: 21218682 DOI: 10.5014/ajot.2010.09097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We examined the effect that long-handled shoehorn (LHSH) length and body mass index (BMI) have on hip range of motion (ROM) in female adults. Thirty-eight female participants were asked to don a shoe using 18-, 24-, and 30-in. LHSHs. Significant differences in hip flexion were found between the 18- and the 24-in. shoehorns and between the 18- and the 30-in. shoehorns. A significant positive relationship was found between BMI and internal rotation for each of the LHSHs. The results suggest that healthy women with low BMLs using a 24- or 30-in. LHSH have the greatest chance of not violating hip flexion or hip internal rotation ROM precautions. Implications suggest that therapists consider individual BMI and available hip ROM before prescribing an LHSH. A follow-up study is needed involving populations who would likely benefit from using LHSHs.
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Abstract
The effects of elevated levels of metal ions in patients who have undergone metal-on-metal total hip arthroplasty are not fully understood. The effects of femoral head size on serum metal-ion levels have been the subject of conflicting reports, and further investigation is needed to evaluate the impact of acetabular and femoral component alignment. The conduct of clinical trials of metal-on-metal total hip arthroplasties has been inadequate as few investigators have used a randomized controlled design to compare metal-on-metal bearings with other bearing surfaces. Additional clinical research needs to include appropriate validated patient-reported outcome measures, activity monitoring, and health economics.
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Affiliation(s)
- Ajay Malviya
- Department of Orthopaedic Surgery, Freeman Hospital, Newcastle on Tyne NE7 7DN, United Kingdom
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Abstract
Dislocation after total hip arthroplasty (THA) remains a problem despite many advances in technique and prosthetic design over the 5 decades since the introduction of total joint replacement. This article reports the short-term results (1 year of follow-up) of THA in 235 patients who received a large, anatomically sized femoral head (BFH Technology; Wright Medical Technology, Inc, Arlington, Tennessee) with modular necks for hip stability. The prosthesis allows a 6-mm differential between the size of the acetabular component and femoral head size. Patients also received a Conserve monoblock acetabular cup and a Profemur femoral stem (Wright Medical Technology, Inc) implanted without cement. Postoperative clinical evaluations included measurements of Harris Hip Scores and range of motion, along with assessments of pain and function and radiological evaluations. There were no complications (deep venous thrombosis, pulmonary embolism, infection, reoperations) and no dislocations. All clinical evaluations showed statistically significant improvement (P<.001) at 1-year follow-up, and radiographic evaluation has shown no evidence of osteolysis or implant loosening. This study indicates that using a large femoral head may reduce the incidence of dislocation and may enable early return to activities postoperatively. Future evaluations of this patient group will elicit longer-term follow-up data.
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Affiliation(s)
- Milton J Smit
- Oak Orthopedics, 400 S Kennedy Drive, Bradley, IL 60915, USA
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