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Chang JS, Haddad FS. Revision total hip arthroplasty for metal-on-metal failure. J Clin Orthop Trauma 2020; 11:9-15. [PMID: 32001977 PMCID: PMC6985013 DOI: 10.1016/j.jcot.2019.09.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/26/2019] [Indexed: 12/12/2022] Open
Abstract
Metal-on-metal (MoM) arthroplasty systems became popular in the early-2000s due to presumed advantages of improved wear characteristics and superior stability. However, subsequent reports of abnormal soft-tissue reactions to MoM implants and national registry data reporting high failure rates raised concerns. Early outcomes of revision total hip arthroplasty (THA) for adverse reaction to metal debris (ARMD) were poor, leading to development of surveillance programs and a trend towards early revision surgery. Patients with MoM arthroplasties require surveillance, comprehensive history and physical examination, imaging with ultrasound or magnetic resonance imaging (MRI), and laboratory evaluation including metal ion levels. Operative strategies for revision THA vary from exchange of modular components to extensive debridement and reconstruction with revision components. Surgeons should be aware of the increased risks of dislocation and infection following revision THA for ARMD. However, there is growing evidence that early revision surgery prior to extensive soft tissue destruction results in improved outcomes and decreased re-operation rates. It is estimated that >1 million MoM articulations have been implanted, with a large proportion still in situ. It is imperative to understand the aetiology, presentation, and management strategies for these patients to optimise their clinical outcomes.
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Affiliation(s)
- Justin S. Chang
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, 250 Euston Road, NW1 2PG, London, UK,Corresponding author.
| | - Fares S. Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, 250 Euston Road, NW1 2PG, London, UK,The Princess Grace Hospital, 42-52 Nottingham Place, W1U 5NY, London, UK
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Park CW, Kim JH, Lim SJ, Moon YW, Park YS. A Minimum of 15-Year Results of Cementless Total Hip Arthroplasty Using a 28-mm Metal-On-Metal Articulation. J Arthroplasty 2019; 34:1387-1394. [PMID: 30930158 DOI: 10.1016/j.arth.2019.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/18/2019] [Accepted: 03/04/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We previously reported unexpected early failures of total hip arthroplasty (THA) utilizing a 28-mm Ultima metal-on-metal (MoM) articulation. However, long-term results of small-diameter MoM THAs still remain unclear. The purpose of this study was to evaluate the clinical and radiographic outcomes of the previously reported cohort at a minimum follow-up of 15 years. METHODS The original cohort consisted of 171 primary THAs (167 patients) using a 28-mm MoM articulation performed between April 2000 and March 2002. Of these, 130 hips (126 patients) were reviewed at an average follow-up of 17.1 (range, 15-18) years. Clinical score, complications, presence of osteolytic lesion, serum metal ion concentrations, and implant survivorships were evaluated. RESULTS The mean Harris Hip Score improved from 44.9 points preoperatively to 90.5 points at the latest follow-up. During the entire period since the original surgery, a total of 5 revisions (3.8%) were associated with adverse reaction to metal debris (ARMD). The last revision surgery for symptomatic ARMD was performed at 6 years postoperatively. The implant survivorships with an end point of revision for aseptic failure and for any reason were 95.4% and 93.8%, respectively. Radiographic osteolytic lesions were detected in 27 hips (20.8%). The average serum metal concentration was 2.50 (range, 0.12-9.86) μg/L for cobalt and 2.81 (range, 0.82-12.3) μg/L for chromium. CONCLUSIONS THA using a 28-mm MoM articulation showed favorable long-term outcomes with a relatively high revision-free survival rate. There was no significant symptomatic ARMD after the last acetabular revision performed at 6 years postoperatively.
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Affiliation(s)
- Chan-Woo Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joo-Hwan Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Jae Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young-Wan Moon
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Youn-Soo Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Markel DC, Bergum C, Flynn J, Jackson N, Bou-Akl T, Ren W. Relationship of Blood Metal Ion Levels and Leukocyte Profiles in Patients With Articular Surface Replacement Metal-on-Metal Hip Replacement. Orthopedics 2018; 41:e424-e431. [PMID: 29708567 DOI: 10.3928/01477447-20180409-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/22/2018] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare blood leukocyte profiles and metal ion concentrations between hip resurfacing arthroplasty (articular surface replacement) patients with and without revision. A total of 25 articular surface replacement patients were recruited (10 with stable implants and 15 undergoing revision). Blood concentrations of chromium (Cr) and cobalt (Co) were measured. Flow cytometry was used to quantify the subpopulations of leukocytes, including CD14+ monocytes, CD16+ monocytes, CD3+ T-lymphocytes, CD19+ B-lymphocytes, CD4+ helper T-cells, and CD45+RA memory vs naïve T-cells. Patients undergoing revision had higher blood Co (mean, 10.85 µg/L) and Cr (mean, 3.19 µg/L) levels than patients with stable implants (mean Co, 3.06 µg/L; mean Cr, 1.07 µg/L) (P<.05). The number of CD4+ helper T-cells was higher in patients with stable implants (mean, 842±311 cells/µL) than in patients undergoing revision (mean, 591±208 cells/µL) (P<.05). There was a significant association between total metal ion levels (Co+Cr) and the number of CD14+ monocytes (P=.045) and inflammatory CD16+ monocytes (P=.046). The authors observed that the increase in blood metal ions was associated with an increase in CD16+ monocytes. They believe that continued analysis of blood leukocyte profiles may be helpful in defining differences among failed articular surface replacement, stable articular surface replacement, and failed metal-on-polyethylene implants. [Orthopedics. 2018; 41(3):e424-e431.].
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Reiner T, Do TD, Klotz MC, Hertzsch F, Seelmann K, Gaida MM, Weber MA, Gotterbarm T. MRI Findings in Patients After Small-Head Metal-on-Metal Total Hip Arthroplasty with a Minimum Follow-up of 10 Years. J Bone Joint Surg Am 2017; 99:1540-1546. [PMID: 28926383 DOI: 10.2106/jbjs.16.01021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Concern has been raised about the late onset of adverse reactions to metal debris (ARMD) in patients with a small-head metal-on-metal total hip replacement. The aims of this study were to assess the frequency and characteristic appearance of ARMD in patients with a small-head (28-mm) metal-on-metal total hip replacement and elevated blood ion levels (>1 μg/L) after a minimum follow-up of 10 years and to analyze the possible risk factors associated with the prevalence of these lesions. METHODS In the present study, we used metal artifact reduction sequence magnetic resonance imaging (MARS MRI) to investigate the cases of 53 patients (66 hips) with a small-head (28-mm) metal-on-metal total hip replacement and elevated blood ion levels at a mean follow-up interval of 15.5 years (range, 10.6 to 19.3 years). Whole blood metal ion levels (cobalt and chromium), clinical outcome scores (Harris hip score), and radiographs were obtained for each patient. Tissue samples from patients who had revision surgery were histologically examined. RESULTS MARS MRI revealed ARMD in 27 hips (41%). Most hips with ARMD (67%) were asymptomatic. ARMD were generally small, with a median lesion size of 2.3 cm (range, 0.3 to 71.4 cm) and predominantly cystic in nature. Multivariate regression analysis revealed positive correlation between cobalt ion levels and the presence of ARMD. In this case series, the risk for the development of ARMD was 2.87 times higher for every 1 μg/L increase of blood cobalt ion concentration (95% confidence interval, 1.01 to 8.17; p = 0.048). CONCLUSIONS In this case series, ARMD were seen in 41% of the hips following small-head metal-on-metal total hip arthroplasty at long-term follow-up, and most patients with ARMD were asymptomatic. Blood cobalt ion levels could be identified as a risk factor for ARMD. However, ARMD also occurred in patients with low metal ion levels. Further studies are necessary to investigate the role of ARMD in asymptomatic patients with this bearing type. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Tobias Reiner
- 1Center for Orthopedics, Trauma Surgery and Spinal Cord Injury (T.R., M.C.K., F.H., K.S., and T.G.), and Department of Diagnostic and Interventional Radiology (T.D.D. and M.-A.W.), Heidelberg University Hospital, Heidelberg, Germany 2Institute for Pathology, University of Heidelberg, Heidelberg, Germany
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Madanat R, Hussey DK, Donahue GS, Potter HG, Wallace R, Bragdon CR, Muratoglu OK, Malchau H. The Symmetry of Adverse Local Tissue Reactions in Patients with Bilateral Simultaneous and Sequential ASR Hip Replacement. J Arthroplasty 2015; 30:1794-8. [PMID: 26055146 DOI: 10.1016/j.arth.2015.04.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/13/2015] [Accepted: 04/27/2015] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to evaluate whether patients with bilateral metal-on-metal (MoM) hip replacements have symmetric adverse local tissue reactions (ALTRs) at follow-up. An MRI of both hips was performed at a mean time of six years after surgery in 43 patients. The prevalence and severity of ALTRs were found to be similar in simultaneous hips but differences were observed in sequential hips. The order and timing of sequential hip arthroplasties did not affect the severity of ALTRs. Thus, in addition to metal ion exposure from an earlier MoM implant other factors may also play a role in the progression of ALTRs. Bilateral implants should be given special consideration in risk stratification algorithms for management of patients with MoM hip arthroplasty.
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Affiliation(s)
- Rami Madanat
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Department of Orthopaedic Surgery, Boston, Massachusetts
| | - Daniel K Hussey
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Gabrielle S Donahue
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Hollis G Potter
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, New York
| | | | - Charles R Bragdon
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Department of Orthopaedic Surgery, Boston, Massachusetts
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Department of Orthopaedic Surgery, Boston, Massachusetts
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Department of Orthopaedic Surgery, Boston, Massachusetts
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Briant-Evans TW, Lyle N, Barbur S, Hauptfleisch J, Amess R, Pearce AR, Conn KS, Stranks GJ, Britton JM. A longitudinal study of MARS MRI scanning of soft-tissue lesions around metal-on-metal total hip arthroplasties and disease progression. Bone Joint J 2015; 97-B:1328-37. [DOI: 10.1302/0301-620x.97b10.34131] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the changes seen on serial metal artefact reduction magnetic resonance imaging scans (MARS-MRI) of metal-on-metal total hip arthroplasties (MoM THAs). In total 155 THAs, in 35 male and 100 female patients (mean age 70.4 years, 42 to 91), underwent at least two MRI scans at a mean interval of 14.6 months (2.6 to 57.1), at a mean of 48.2 months (3.5 to 93.3) after primary hip surgery. Scans were graded using a modification of the Oxford classification. Progression of disease was defined as an increase in grade or a minimum 10% increase in fluid lesion volume at second scan. A total of 16 hips (30%) initially classified as ‘normal’ developed an abnormality on the second scan. Of those with ‘isolated trochanteric fluid’ 9 (47%) underwent disease progression, as did 7 (58%) of ‘effusions’. A total of 54 (77%) of hips initially classified as showing adverse reactions to metal debris (ARMD) progressed, with higher rates of progression in higher grades. Disease progression was associated with high blood cobalt levels or an irregular pseudocapsule lining at the initial scan. There was no association with changes in functional scores. Adverse reactions to metal debris in MoM THAs may not be as benign as previous reports have suggested. Close radiological follow-up is recommended, particularly in high-risk groups. Cite this article: Bone Joint J 2015;97-B:1328–37.
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Affiliation(s)
- T. W. Briant-Evans
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - N. Lyle
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - S. Barbur
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - J. Hauptfleisch
- Derby Teaching Hospital, Uttoxeter
New Road, Derby DE22 3NE, UK
| | - R. Amess
- University of Oxford, Nuffield
Orthopaedic Centre, Windmill Road, Oxford
OX3 7LD, UK
| | - A. R. Pearce
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - K. S. Conn
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - G. J. Stranks
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - J. M. Britton
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
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Muraoka K, Naito M, Nakamura Y, Hagio T, Takano K. Usefulness of ultrasonography for detection of pseudotumors after metal-on-metal total hip arthroplasty. J Arthroplasty 2015; 30:879-84. [PMID: 25540995 DOI: 10.1016/j.arth.2014.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 11/12/2014] [Accepted: 12/02/2014] [Indexed: 02/01/2023] Open
Abstract
We retrospectively analyzed 83 metal-on-metal total hip arthroplasties in 74 patients. Ultrasonography and magnetic resonance imaging (MRI) of each hip were performed to detect abnormal patterns and pseudotumors. We examined the reliability of ultrasonography for detecting pseudotumors in comparison with MRI. We also compared the acetabular component inclination between patients with and without pseudotumors. The mean positive and negative predictive values for pseudotumor detection by ultrasonography were 65% and 91%, respectively. The mean positive and negative likelihood ratios were 5.78 and 0.32, respectively. There was no clear association between pseudotumor presence and acetabular component inclination. We concluded that ultrasonography is a suitable technique to screen for the presence of pseudotumors. We also need to distinguish between bearing-related and taper junction corrosion-related complications.
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Affiliation(s)
- Kunihide Muraoka
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Masatoshi Naito
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Yoshinari Nakamura
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Tomonobu Hagio
- Department of Orthopaedic Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Koichi Takano
- Department of Radiology, Fukuoka University Faculty of Medicine, Fukuoka, Japan
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Hwang KT, Kim YH, Kim YS, Ryu JA. Prevalence of a soft-tissue lesion after small head metal-on-metal total hip replacement: 13- to 19-year follow-up study. Bone Joint J 2015; 96-B:1594-9. [PMID: 25452360 DOI: 10.1302/0301-620x.96b12.33705] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the incidence of soft-tissue lesions after small head metal-on-metal total hip replacement (MoM THR). Between December 1993 and May 1999, 149 patients (195 hips) underwent primary cementless MoM THR. During the follow-up period, three patients (five THRs) died and eight patients (14 THRs) were lost to follow-up. We requested that all patients undergo CT evaluation. After exclusion of five patients (six THRs) who had undergone a revision procedure, and 22 (28 THRs) who were unwilling to take part in this study, 111 patients (142 THRs) were evaluated. There were 63 men (88 THRs) and 48 women (54 THRs) with a mean age of 45.7 years (37 to 56) at the time of surgery. The mean follow-up was 15.4 years (13 to 19). A soft-tissue lesion was defined as an abnormal peri-prosthetic collection of fluid, solid lesion or asymmetrical soft-tissue mass. At final follow-up, soft-tissue lesions were found in relation to 28 THRs (19.7%), including 25 solid and three cystic lesions. They were found in 20 men and eight women; 26 lesions were asymptomatic and two were symptomatic. The mean maximal diameter of the soft-tissue lesion was 42.3 mm (17 to 135). The relatively high rate of soft-tissue lesions observed with small head MoM THR remains a concern.
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Affiliation(s)
- K T Hwang
- Department of Orthopaedic Surgery, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Korea
| | - Y H Kim
- Department of Orthopaedic Surgery, Hanyang University, 153 Gyungchoon-ro, Guri-si, Gyunggi-do 471-701, Korea
| | - Y S Kim
- Department of Orthopaedic Surgery, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-791, Korea
| | - J A Ryu
- Department of Radiology, Hanyang University, 153 Gyungchoon-ro, Guri-si, Gyunggi-do 471-701, Korea
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Matharu GS, Pandit HG, Murray DW, Treacy RBC. The future role of metal-on-metal hip resurfacing. INTERNATIONAL ORTHOPAEDICS 2015; 39:2031-6. [DOI: 10.1007/s00264-015-2692-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 01/24/2015] [Indexed: 10/24/2022]
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Haddad FS. One step at a time. Bone Joint J 2014; 96-B:1573-4. [PMID: 25452356 DOI: 10.1302/0301-620x.96b12.35411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Haddad FS. Further advances in problems relating to arthroplasty surgery: the debate continues. Bone Joint J 2014; 96-B:1141-2. [PMID: 25183581 DOI: 10.1302/0301-620x.96b9.34811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET, UK
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