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Reito A, Lainiala O, Berryman F, Dunlop DJ, Eskelinen A, Matharu GS. Long-term changes in blood metal ion levels in patients with hip resurfacing implants: implications for patient surveillance after 10 years follow-up. Hip Int 2023; 33:864-871. [PMID: 35848136 DOI: 10.1177/11207000221104396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Studies investigating changes in blood metal ion levels during the second decade of the implant lifetime in MoM hip resurfacing patients are scarce. METHODS Patients implanted with either Birmingham Hip Resurfacing (BHR) or Articular Surface Replacement (ASR) hip resurfacings with >10 years follow-up and repeated blood metal ion measurements were identified at 2 large specialist European arthroplasty centres. After excluding patients with initial metal ion levels >7 ppb, the proportion of patients with an increase in blood metal ion levels above previously validated implant-specific thresholds (cobalt 2.15 ppb for unilateral implants, cobalt or chromium 5.5 ppb for bilateral) was assessed. RESULTS We included 2743 blood metal ion measurements from 457 BHR patients (555 hips) and 216 ASR patients (263 hips). Of patients with initial metal ion levels below implant specific thresholds, increases in cobalt or chromium level, respectively, to above these thresholds during the second decade were seen as follows: unilateral BHR (cobalt = 15.6%), unilateral ASR (cobalt = 13.8%), bilateral BHR (cobalt = 8.2%, chromium = 11.8%), bilateral ASR (cobalt = 8.5%, chromium = 4.3%). Measurement-to-measurement changes exceeding +2.15 ppb or +5.5 ppb were, however, uncommon during the second decade. Subgroup results with small diameter (<50 mm) implants were similar. CONCLUSIONS We recommend less frequent blood metal ion measurements are needed (every 3 to 5 years) for hip resurfacing patients if initial values were below 7ppb.
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Affiliation(s)
- Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | | | | | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, Tampere, Finland and Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | - Gulraj S Matharu
- The Royal Orthopaedic Hospital, Birmingham, UK
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Level 1 Learning and Research Building, Southmead Hospital, Westbury-on-Trym, Bristol, BS10 5NB, UK
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Mok JM, Poelstra K, Ammar K, McGirt M, Cormier J, Hart R, Bauman J, Cowart P, Sheth I, Singh P, Yadav J. Characterization of ion release from a novel biomaterial, Molybdenum-47.5Rhenium, in physiologic environments. Spine J 2023; 23:900-911. [PMID: 36706920 DOI: 10.1016/j.spinee.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 01/02/2023] [Accepted: 01/18/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND CONTEXT Metals from spinal implants are released into surrounding tissues by various mechanisms. Metal ion release has been associated with clinical implant failure, osteolysis, and remote site accumulation with adverse events. Significant corrosion and associated metal ion release has been described with currently used spinal implant alloys. A novel metal alloy, Molybdenum-47.5Rhenium alloy (MoRe®), was approved for use in medical implants in 2019 by the FDA. PURPOSE To evaluate the metal ion release profile of MoRe alloy after immersion in both a stable physiologic, as well as in an inflammatory environment. STUDY DESIGN In vitro study. METHODS The ion release profile of the MoRe alloy was comprehensively evaluated in-vitro after prolonged immersion in physiologic and inflammatory environments. Ion concentration analyses were then conducted using inductively coupled plasma-mass spectrometry (ICP-MS) methods. Comparative testing of titanium (Ti-6Al-4V) and cobalt chromium (Co-28Cr-6Mo) was also performed. RESULTS Under baseline physiologic conditions, the MoRe alloy demonstrates very low molybdenum and rhenium ion release rates throughout the 30-day test period. During the first time interval (day 0-1), low levels of molybdenum and rhenium ions are detected (<0.3 μg/cm2 day) followed by a rapid reduction in the ion release rates to <0.05 μg/cm2 day during the second time interval (days 1-3) followed by a further reduction to very low steady-state rates <0.01 μg/cm2 day during the third time interval (days 3-7), which were maintained through 30 days. In the inflammatory condition (H2O2 solution), there was a transient increase in the release of molybdenum and rhenium ions, followed by a return to baseline ion release rates (days 2-4), with a further reduction to low steady-state rates of ∼0.01 μg/cm2 day (days 4-8). The measured molybdenum and rhenium ion release rates in both steady state (<0.01 μg/cm2 day), and inflammatory environments (0.01 μg/cm2 day) were far below the established FDA-permitted daily exposure (PDE) of 1,900 μg/cm2 day for molybdenum and 4,400 μg/cm2 day for rhenium. In contrast, titanium and cobalt chromium approached or exceeded their established PDE values in an inflammatory environment. CONCLUSIONS The novel biomaterial MoRe demonstrated a lower metal ion release profile in both a physiologic and inflammatory environment and was well below the established PDE. Comparative testing of the cobalt-chromium and titanium alloys found higher levels of ion release in the inflammatory environment that exceeded the PDE for cobalt and vanadium.
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Affiliation(s)
- James M Mok
- NorthShore University Health System, 9600 Gross Point Rd Suite 1200, Skokie, IL 60076, USA.
| | - Kornelis Poelstra
- Nevada Spine Clinic-Allegiant Spine Institute, President-The Robotic Spine Institute of Las Vegas, 7140 Smoke Ranch Rd, Las Vegas, NV 89128, USA
| | - Kevin Ammar
- Neurosurgical and Spine Institute, 4 E Jackson Blvd, Savannah, GA 31405, USA
| | - Matthew McGirt
- Carolina Neurosurgery & Spine Associates, 225 Baldwin Avenue, Charlotte, NC 28204, USA
| | - Jason Cormier
- Acadiana Neurosurgery, 118 rue Fontaine, Lafayette, LA 70508, USA
| | - Robert Hart
- Spine Specialists at SNI, 550 17th Ave Suite 500, Seattle, WA 98122, USA
| | - Jordan Bauman
- MiRus, LLC, 755 W. Oak Parkway Suite 100, Marietta, GA 30062, USA
| | - Pam Cowart
- MiRus, LLC, 755 W. Oak Parkway Suite 100, Marietta, GA 30062, USA
| | - Ishan Sheth
- School of Computer Science, Georgia Institute of Technology, 266 Ferst Dr NW, Atlanta, GA 30332, USA
| | - Preet Singh
- School of Materials Science and Engineering, Georgia Institute of Technology, 771 Ferst Dr, Erskine Love Building, Atlanta, GA 30332-0245, USA
| | - Jay Yadav
- MiRus, LLC, 755 W. Oak Parkway Suite 100, Marietta, GA 30062, USA
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Wan ZY, Shan H, Liu TF, Song F, Zhang J, Liu ZH, Ma KL, Wang HQ. Emerging Issues Questioning the Current Treatment Strategies for Lumbar Disc Herniation. Front Surg 2022; 9:814531. [PMID: 35419406 PMCID: PMC8999845 DOI: 10.3389/fsurg.2022.814531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 03/04/2022] [Indexed: 11/26/2022] Open
Abstract
Lumbar disc herniation is among the common phenotypes of degenerative lumbar spine diseases, significantly affecting patients' quality of life. The practice pattern is diverse. Choosing conservative measures or surgical treatments is still controversial in some areas. For those who have failed conservative treatment, surgery with or without instrumentation is recommended, causing significant expenditures and frustrating complications, that should not be ignored. In the article, we performed a literature review and summarized the evidence by subheadings to unravel the cons of surgical intervention for lumbar disc herniation. There are tetrad critical issues about surgical treatment of lumbar disc herniation, i.e., favorable natural history, insufficient evidence in a recommendation of fusion surgery for patients, metallosis, and implant removal. Firstly, accumulating evidence reveals immune privilege and auto-immunity hallmarks of human lumbar discs within the closed niche. Progenitor cells within human discs further expand the capacity with the endogenous repair. Clinical watchful follow-up studies with repeated diagnostic imaging reveal spontaneous resolution for lumbar disc herniation, even calcified tissues. Secondly, emerging evidence indicates long-term complications of lumbar fusion, such as adjacent segment disease, pseudarthrosis, implant failure, and sagittal spinal imbalance, which get increasing attention. Thirdly, systemic and local reactions (metallosis) for metal instrumentation have been noted with long-term health concerns and toxicity. Fourthly, the indications and timing for spinal implant removal have not reached a consensus. Other challenging issues include postoperative lumbar stiffness. The review provided evidence from a negative perspective for surgeons and patients who attempt to choose surgical treatment. Collectively, the emerging underlying evidence questions the benefits of traditional surgery for patients with lumbar disc herniation. Therefore, the long-term effects of surgery should be closely observed. Surgical decisions should be made prudently for each patient.
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Affiliation(s)
- Zhong Y. Wan
- Department of Orthopedics, The Seventh Medical Center of General Hospital of People's Liberation Army (PLA), Beijing, China
| | - Hua Shan
- Institute of Integrative Medicine, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Tang F. Liu
- Institute of Integrative Medicine, Shaanxi University of Chinese Medicine, Xi'an, China
| | - Fang Song
- Department of Stomatology, The Specialty Medical Center Rocket Force of People's Liberation Army (PLA), Beijing, China
| | - Jun Zhang
- Department of Orthopedics, Baoji Central Hospital, Baoji, China
| | - Zhi H. Liu
- Department of Cardiac Surgery, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Kun L. Ma
- Department of Orthopedics, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Hai Q. Wang
- Institute of Integrative Medicine, Shaanxi University of Chinese Medicine, Xi'an, China
- *Correspondence: Hai Q. Wang ;
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Pietiläinen S, Lindström M, Laaksonen I, Venäläinen MS, Lankinen P, Mäkelä KT. Long-term blood metal ion levels and clinical outcome after Birmingham hip arthroplasty. Scand J Surg 2022; 111:14574969211066197. [PMID: 35168442 DOI: 10.1177/14574969211066197] [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: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Our aim was to assess long-term metal ion level changes and clinical outcome in patients with a Birmingham hip arthroplasty. METHODS For the purpose of this study, we identified all BHR hip resurfacing arthroplasty (HRA) and total hip arthroplasty (THA) operations performed in Turku University Hospital. A random coefficient model was used to compare the change between the first and last metal ion measurement. A Kaplan-Meier estimator was used to assess the survivorship of the BHR HRA and BHR THA with metal related adverse events (pseudotumor, elevated metal ions above the safe upper limit, revision due to metallosis), or revision due to any reason as endpoints with 95% confidence intervals (CIs). RESULTS BHR HRA was used in 274 hips (233 patients). In addition, we identified 38 BHR-Synergy THAs (38 patients). Operations were performed between 2003 and 2010. Median follow-up time was 14 years for BHR HRA (range: 0.6-17) and 11 years for BHR THA (range: 4.7-13). In the BHR HRA group, geometric means of Cr and Co levels decreased from 2.1 to 1.6 ppb and 2.4 to 1.5 ppb, respectively, during a 3.0-year measurement interval. Metal ion levels in the BHR THA group did not show notable increase. The survivorship of BHR HRA was 66% in 16 years and 34% for BHR THA at 12 years for any metal-related adverse event. CONCLUSIONS Patients with a Birmingham hip device do not seem to benefit from frequent repeated metal ion measurements. The amount of patients with metal-related adverse events was relatively high, but many of them did not require surgery.
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Affiliation(s)
- Sakari Pietiläinen
- Department of Orthopaedics and Traumatology Turku University Hospital, Luolavuorentie 2, 20701 and University of Turku, Turku, Finland
| | | | - Inari Laaksonen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Mikko S Venäläinen
- Turku Bioscience Centre, University of Turku and Åbo Akademi University and Department of Medical Physics, Division of Medical Imaging, Turku University Hospital, Turku, Finland
| | - Petteri Lankinen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
| | - Keijo T Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku, Turku, Finland
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Perino G, De Martino I, Zhang L, Xia Z, Gallo J, Natu S, Langton D, Huber M, Rakow A, Schoon J, Gomez-Barrena E, Krenn V. The contribution of the histopathological examination to the diagnosis of adverse local tissue reactions in arthroplasty. EFORT Open Rev 2021; 6:399-419. [PMID: 34267931 PMCID: PMC8246109 DOI: 10.1302/2058-5241.6.210013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The histopathological examination of the periprosthetic soft tissue and bone has contributed to the identification and description of the morphological features of adverse local tissue reactions (ALTR)/adverse reactions to metallic debris (ARMD). The need of a uniform vocabulary for all disciplines involved in the diagnosis and management of ALTR/ARMD and of clarification of the parameters used in the semi-quantitative scoring systems for their classification has been considered a pre-requisite for a meaningful interdisciplinary evaluation. This review of key terms used for ALTR/ARMD has resulted in the following outcomes: (a) pseudotumor is a descriptive term for ALTR/ARMD, classifiable in two main types according to its cellular composition defining its clinical course; (b) the substitution of the term metallosis with presence of metallic wear debris, since it cannot be used as a category of implant failure or histological diagnosis; (c) the term aseptic lymphocytic-dominated vasculitis- associated lesion (ALVAL) should be replaced due to the absence of a vasculitis with ALLTR/ALRMD for lymphocytic-predominant and AMLTR/AMRMD for macrophage-predominant reaction. This review of the histopathological classifications of ALTR/ARMD has resulted in the following outcomes: (a) distinction between cell death and tissue necrosis; (b) the association of corrosion metallic debris with adverse local lymphocytic reaction and tissue necrosis; (c) the importance of cell and particle debris for the viscosity and density of the lubricating synovial fluid; (d) a consensus classification of lymphocytic infiltrate in soft tissue and bone marrow; (e) evaluation of the macrophage infiltrate in soft tissues and bone marrow; (f) classification of macrophage induced osteolysis/aseptic loosening as a delayed type of ALTR/ARMD; (g) macrophage motility and migration as possible driving factor for osteolysis; (h) usefulness of the histopathological examination for the natural history of the adverse reactions, radiological correlation, post-marketing surveillance, and implant registries. The review of key terms used for the description and histopathological classification of ALTR/ARMD has resulted in a comprehensive, new standard for all disciplines involved in their diagnosis, clinical management, and long-term clinical follow-up.
Cite this article: EFORT Open Rev 2021;6:399-419. DOI: 10.1302/2058-5241.6.210013
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Affiliation(s)
- Giorgio Perino
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Ivan De Martino
- Division of Orthopaedics and Traumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lingxin Zhang
- Department of Pathology and Laboratory Medicine, Sinai Health System, Toronto, Canada
| | - Zhidao Xia
- Centre for Nanohealth, Swansea University Medical School, Singleton Park, Swansea, UK
| | - Jiri Gallo
- Department of Orthopaedics, Faculty of Medicine and Dentistry, University Hospital, Palacky University Olomouc, Czech Republic
| | - Shonali Natu
- Department of Pathology, University Hospital of North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | - David Langton
- Orthopaedic Department, Freeman Hospital, Newcastle upon Tyne, UK
| | - Monika Huber
- Pathologisch-bakteriologisches Institut, Otto Wagner Spital, Wien, Austria
| | - Anastasia Rakow
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Janosch Schoon
- Department of Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Enrique Gomez-Barrena
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario La Paz-IdiPAZ, Universidad Autónoma de Madrid, Madrid, Spain
| | - Veit Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik-GmbH, Trier, Germany
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6
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Koper MC, Hesseling B, Tuinebreijer WE, van der Linden H, Mathijssen NMC. Safe Upper Limits of Serum Cobalt and Chromium Levels for a Metal-on-Metal Total Hip Bearing: A 10-Year Follow-Up Study. J Arthroplasty 2021; 36:2080-2086. [PMID: 33612330 DOI: 10.1016/j.arth.2021.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/02/2021] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Long-term survival of metal-on-metal (MoM) prostheses and the development of adverse reaction to metal debris (ARMD) around these bearings are still unclear. Serum levels of cobalt (Co) and chromium (Cr) are used as a screening tool to anticipate failure in MoM bearings and detect ARMD. METHODS One hundred sixty primary large head MoM prostheses were followed up for 10 years. To estimate the revision risk, the cumulative incidence function (CIF) was used. Subdistribution hazard modeling was used to investigate the associations between cumulative incidence of revision for ARMD and Co levels, Cr levels, gender, age, head size, and cup inclination. Furthermore, the safe upper limits (SULs) for Co and Cr were determined. RESULTS Univariate analyses showed an increased risk in revision for ARMD in females (subdistribution hazard ratio [sdHR] 3.43, 95% confidence interval [CI] 1.01-11.7, P = .049) and cup inclination angles over 45° (sdHR 4.70, 95% CI 1.63-13.58, P = .004). In addition, a higher last measured Co level (sdHR 1.05, 95% CI 1.03-1.07, P < .001) and last measured Cr level (sdHR 1.21, 95% CI 1.14-1.29, P < .001) were associated with a higher probability of revision for ARMD. We determined our bearing-specific SULs at 4.1 parts per billion (ppb) and 4.2 ppb for Co and Cr, respectively. CONCLUSION Guidelines regarding follow-up and surveillance should include a complete clinical assessment with bearing-specific SULs of serum metal ion levels. For the M2a-Magnum MoM bearing we advise an SUL for Co and Cr levels of 4.1 and 4.2 ppb, respectively.
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Affiliation(s)
- Maarten C Koper
- Department of Orthopedics, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Brechtje Hesseling
- Department of Orthopedics, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Wim E Tuinebreijer
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hans van der Linden
- Department of Orthopedics, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Nina M C Mathijssen
- Department of Orthopedics, Reinier de Graaf Hospital, Delft, The Netherlands
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Hastie GR, Collinson SC, Aqil A, Basu S, Temperley DE, Board TN, Wynn-Jones H. Study to Assess the Rate of Adverse Reaction to Metal Debris in Hip Resurfacing at a Minimum 13-year Follow-up. J Arthroplasty 2021; 36:1055-1059. [PMID: 33183915 DOI: 10.1016/j.arth.2020.09.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Hip Resurfacing (HR), although reducing in popularity, is still used in the younger male population. Excellent medium-term results have been published; however, the use of metal on metal has reduced with increased awareness of adverse reactions to metal debris (ARMD). ARMD has been shown to often be clinically "silent" following large Head MoM total hip replacement (THR). The purpose of our study was to report the incidence of ARMD following HR with a minimum follow-up of 13 years. METHODS We performed a retrospective study of a consecutive series of patients who underwent HR between January 1, 2000 and August 1, 2005. All patients were entered into our hospital MoM hip replacement surveillance program database. Patients were reviewed yearly for symptoms and blood ion levels. Patients had Magnetic Resonance (MR) imaging to assess for ARMD. RESULTS A total of 102 patients with 123 hip replacements were included in the study. Eight hips in 7 patients were revised: two for fracture, one for avascular necrosis, and five for ARMD. A best-case scenario of 109 (93.2%) resurfacings were surviving at 13 years. With regard to the radiological analysis, 34% were found to have ARMD on MR. CONCLUSION While the implant survivorship in our series is acceptable, we found a high incidence of ARMD. Surgeons and patients with or considering a HR should be aware of the risk of ARMD developing. This allows an informed choice as to the best implant for their personal requirement and informs of the potential modes of failure and need for long-term screening.
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Affiliation(s)
- Graham R Hastie
- Wigan and Leigh NHS Trust, Wrightington Hospital, Wigan, United Kingdom, WN6 9EP
| | - Sophie C Collinson
- Wigan and Leigh NHS Trust, Wrightington Hospital, Wigan, United Kingdom, WN6 9EP
| | - Adeel Aqil
- Wigan and Leigh NHS Trust, Wrightington Hospital, Wigan, United Kingdom, WN6 9EP
| | - Subhasis Basu
- Wigan and Leigh NHS Trust, Wrightington Hospital, Wigan, United Kingdom, WN6 9EP
| | - David E Temperley
- Wigan and Leigh NHS Trust, Wrightington Hospital, Wigan, United Kingdom, WN6 9EP
| | - Timothy N Board
- Wigan and Leigh NHS Trust, Wrightington Hospital, Wigan, United Kingdom, WN6 9EP
| | - Henry Wynn-Jones
- Wigan and Leigh NHS Trust, Wrightington Hospital, Wigan, United Kingdom, WN6 9EP
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Matharu GS, Berryman F, Dunlop DJ, Judge A, Murray DW, Pandit HG. Has the threshold for revision surgery for adverse reactions to metal debris changed in metal-on-metal hip arthroplasty patients? A cohort study of 239 patients using an adapted risk-stratification algorithm. Acta Orthop 2019; 90:530-536. [PMID: 31496340 PMCID: PMC6844394 DOI: 10.1080/17453674.2019.1659661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - A risk-stratification algorithm for metal-on-metal hip arthroplasty (MoMHA) patients was devised by US experts to help clinicians make management decisions. However, the proposed algorithm did not cover all potential patient or surgical abnormalities. Therefore we adapted the US risk-stratification algorithm in MoMHA patients revised for adverse reactions to metal debris (ARMD) to determine the variability in the revision threshold, and also whether high-risk patients had inferior outcomes following revision.Patients and methods - We analysed 239 MoMHA revisions for ARMD between 2001 and 2016 from 2 centres with pre-revision blood metal ions and imaging. Patients were stratified (low risk, moderate risk, high risk) using pre-revision factors (implant, radiographic, blood metal ions, cross-sectional imaging) by adapting a published algorithm. The risk categories for each factor were assessed against revision year, revision centre, and post-revision outcomes (re-revision surgery, and any poor outcome).Results - Compared with hips revised before 2012, hips revised from 2012 onwards included more high-risk implants (44% vs. 17% pre-2012), high-risk radiographic features (85% vs. 69% pre-2012), and low-risk metal ions (41% vs. 19% pre-2012). 1 centre more frequently revised patients with high-risk implants (48% vs. 14%) and low-risk blood metal ions (45% vs. 15%) compared with the other. All these comparisons were statistically significant (p < 0.05). With the limited sample size available, implant, radiographic, blood metal ion, and cross-sectional imaging risk groups did not statistically significantly affect the rates of re-revision surgery or frequency of poor outcomes post-revision.Interpretation - When applying the adapted risk-stratification algorithm the threshold for ARMD revision changed over time, presumably due to increasing evidence, patient surveillance, and investigation since 2012. Lower blood metal ion thresholds were used from 2012 for ARMD revisions; however, there was evidence that centres attached different importance to metal ions when managing patients. High-risk patients did not have inferior outcomes following ARMD revision.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford;; ,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol;; ,The Royal Orthopaedic Hospital, Birmingham;; ,Correspondence:
| | | | | | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford;; ,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol;;
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford;;
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford;; ,Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital and University of Leeds, Leeds, UK
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9
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Mäntymäki H, Lankinen P, Vahlberg T, Reito A, Eskelinen A, Mäkelä K. Repeated cobalt and chromium ion measurements in patients with large-diameter head metal-on-metal ReCap-M2A-Magnum total hip replacement. Acta Orthop 2019; 90:243-248. [PMID: 30945585 PMCID: PMC6534222 DOI: 10.1080/17453674.2019.1595469] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Whole blood (WB) cobalt (Co) and chromium (Cr) ion levels have a major role in the follow-up of metal-on-metal total hip replacement (MoM THR). We investigated, first, if there was a change in WB Co or Cr levels over repeated measurements in patients with ReCap-M2A-Magnum THR, and, second, determined how many patients had WB Co or Cr levels that exceeded the safe upper limits (SUL) in the repeated whole blood metal ion assessment. Patients and methods - A Recap-M2A-Magnum THR was used in 1,329 operations (1,188 patients) at our institution between 2005 and 2012. We identified all patients (n = 319) with unilateral ReCap-M2A-Magnum implants who had undergone at least 2 repeated metal ion measurements with the first blood sample taken mean 5.5 years (1.8-9.3) after surgery and the second taken mean 2 years (0.5-3) after the first. Results - The median WB Co and Cr ion levels decreased in repeated measurements from 1.40 (0.40-63) ppb to 1.10 (0.20-68) ppb and from 1.60 (0.60-13.0) ppb to 1.10 (0.30-19.0) ppb, respectively. 7% of the Co ion values exceeded SUL at the initial measurement, and 7% at the control measurement. The proportion of Cr ion values exceeding the safe upper limit (SUL) decreased during the measurement interval from 5% to 4%. Interpretation - Repeated metal ion measurements in unilateral ReCap-M2A-Magnum patients in a mean 2-year time interval did not show any increase. Long-term ion levels are, however, not yet known.
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Affiliation(s)
- Heikki Mäntymäki
- Department of Orthopaedics, Tampere University Hospital and University of Turku;; ,Correspondence:
| | - Petteri Lankinen
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku;;
| | | | - Aleksi Reito
- Coxa Hospital for Joint Replacement and University of Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement and University of Tampere, Finland
| | - Keijo Mäkelä
- Department of Orthopaedics and Traumatology, Turku University Hospital and University of Turku;;
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Hellman MD, Ford MC, Barrack RL. Is there evidence to support an indication for surface replacement arthroplasty?: a systematic review. Bone Joint J 2019; 101-B:32-40. [PMID: 30648490 DOI: 10.1302/0301-620x.101b1.bjj-2018-0508.r1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Surface replacement arthroplasty (SRA), compared with traditional total hip arthroplasty (THA), is more expensive and carries unique concern related to metal ions production and hypersensitivity. Additionally, SRA is a more demanding procedure with a decreased margin for error compared with THA. To justify its use, SRA must demonstrate comparable component survival and some clinical advantages. We therefore performed a systematic literature review to investigate the differences in complication rates, patient-reported outcomes, stress shielding, and hip biomechanics between SRA and THA. MATERIALS AND METHODS A systematic review of the literature was completed using MEDLINE and EMBASE search engines. Inclusion criteria were level I to level III articles that reported clinical outcomes following primary SRA compared with THA. An initial search yielded 2503 potential articles for inclusion. Exclusion criteria included review articles, level IV or level V evidence, less than one year's follow-up, and previously reported data. In total, 27 articles with 4182 patients were available to analyze. RESULTS Fracture and infection rates were similar between SRA and THA, while dislocation rates were lower in SRA compared with THA. SRA demonstrated equivalent patient-reported outcome scores with greater activity scores and a return to high-level activities compared with THA. SRA more reliably restored native hip joint biomechanics and decreased stress shielding of the proximal femur compared with THA. CONCLUSION In young active men with osteoarthritis, there is evidence that SRA offers some potential advantages over THA, including: improved return to high level activities and sport, restoration of native hip biomechanics, and decreased proximal femoral stress shielding. Continued long-term follow up is required to assess ultimate survivorship of SRA.
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Affiliation(s)
- M D Hellman
- California Orthopedics and Spine, Larkspur, California, USA
| | - M C Ford
- Campbell Clinic Orthopaedics, Germantown, Tennessee, USA
| | - R L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
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11
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Affiliation(s)
- F S Haddad
- NIHR University College London Hospitals Biomedical Research Centre, UK
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12
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Uchihara Y, Grammatopoulos G, Munemoto M, Matharu G, Inagaki Y, Pandit H, Tanaka Y, Athanasou NA. Implant failure in bilateral metal-on-metal hip resurfacing arthroplasties: a clinical and pathological study. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2018; 29:28. [PMID: 29516273 PMCID: PMC5842269 DOI: 10.1007/s10856-018-6037-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/22/2018] [Indexed: 06/13/2023]
Abstract
Metal-on-metal hip resurfacing arthroplasties (MoMHRAs) have a high failure rate due to pseudotumour formation. It is not certain whether pseudotumours in bilateral MoMHRAs form on the basis of an adverse reaction to metal debris (ARMD) that is entirely due to a local innate and adaptive immune response to Cobalt-Chrome (Co-Cr) wear particles. To determine if there is a systemic component to ARMD in bilateral MoMHRAs, we examined the histology of ARMD in unilateral and bilateral MoMHRAs revised for pseudotumour and determined whether implant survival differed between these two groups. Periprosthetic tissue specimens from 119 hips revised for pseudotumour were examined. These were derived from 109 patients including 10 patients with bilateral MoMHRAs and 99 with sunilateral MoMHRAs including a cohort of 20 patients with bilateral MoMHRAs that had undergone only one MoMHRA revision for pseudotumour. The mean time to revision for pseudotumour of unilateral and bilateral MoMHRAs was determined. The histology of periprosthetic tissue was examined for evidence of the innate and adaptive immune response and scored semi-quantitatively. There was no significant difference in histological features of the innate / adaptive response between Group 1 bilateral pseudotumours and Group 2 and Group 3 unilateral pseudotumours. Histological features, including ALVAL scores, were similar in the periprosthetic tissues of right and left hips in Group 1 bilateral MoMHRAs. The mean time to first revision for pseudotumour of bilateral MoMHRAs (6.59 years) was not decreased compared with unilateral MoMHRAs (5.66 years) or bilateral MoMHRAs that had only one revision (7.05 years). Right and left hip pseudotumours in bilateral MoMHRAs exhibit similar histological features of the innate and adaptive immune response. Mean implant survival is not decreased in bilateral compared with unilateral MoMHRA cases. The findings suggest that pseudotumour formation is due more to a local than a systemic innate /adaptive immune response to components of metal wear.
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Affiliation(s)
- Yoshinubo Uchihara
- Department of Orthopaedic Surgery, Nara Medical University, Shijocho 840, Kashihara, Nara, 634-8522, Japan
| | - George Grammatopoulos
- Nuffield Department of Orthopaedics, Rheumatology and Surgery, Nuffield Orthopaedic Centre, University of Oxford, Headington, Oxford, OX3 7HE, UK.
| | - Mitsuru Munemoto
- Department of Orthopaedic Surgery, Nara Medical University, Shijocho 840, Kashihara, Nara, 634-8522, Japan
| | - Gulraj Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Surgery, Nuffield Orthopaedic Centre, University of Oxford, Headington, Oxford, OX3 7HE, UK
| | - Yusuke Inagaki
- Department of Orthopaedic Surgery, Nara Medical University, Shijocho 840, Kashihara, Nara, 634-8522, Japan
| | - Hemant Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Surgery, Nuffield Orthopaedic Centre, University of Oxford, Headington, Oxford, OX3 7HE, UK
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, Shijocho 840, Kashihara, Nara, 634-8522, Japan
| | - Nick A Athanasou
- Nuffield Department of Orthopaedics, Rheumatology and Surgery, Nuffield Orthopaedic Centre, University of Oxford, Headington, Oxford, OX3 7HE, UK.
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13
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Matharu GS, Judge A, Eskelinen A, Murray DW, Pandit HG. What is appropriate surveillance for metal-on-metal hip arthroplasty patients? Acta Orthop 2018; 89:29-39. [PMID: 29105547 PMCID: PMC5810829 DOI: 10.1080/17453674.2017.1398011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The unexpected high revision rates of large-diameter (femoral head sizes of 36 mm or greater) metal-on-metal hip arthroplasties (MoMHAs) have led to worldwide regulatory authorities recommending regular surveillance, even for asymptomatic individuals. However, these recommendations are not evidence-based and are very costly. The rapidly evolving evidence base requires an update regarding the investigation and management of MoMHA patients. This article is the first of 2 (the second article in this series will consider the threshold for performing revision, and the outcomes following ARMD revision surgery: Matharu et al., Revision surgery of metal-on-metal hip arthroplasties for adverse reactions to metal debris: A clinical update. Acta Orthop 2018; in press), and considers the various investigative modalities used during surveillance, with specific focus on blood metal ion sampling and cross-sectional imaging. No single investigation can universally be used during MoMHA patient surveillance. Recent studies have now provided important information on interpreting blood metal ions (effective in identifying patients at low risk of problems), clarifying the roles of cross-sectional imaging (reserve combined ultrasound and MARS-MRI for complex cases), and providing parameters to safely exclude many asymptomatic patients from regular surveillance. This information will be useful when designing future surveillance protocols for MoMHA patients.
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Affiliation(s)
- Gulraj S Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK;,Correspondence:
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | | | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
| | - Hemant G Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences University of Oxford, Nuffield Orthopaedic Centre, Oxford, UK
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14
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Skinner JA, Haddad FS. A new year, but the spectre of metal-on-metal lives on. Bone Joint J 2018; 100-B:1-3. [PMID: 29305442 DOI: 10.1302/0301-620x.100b1.bjj-2017-1462] [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)
- J A Skinner
- Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA7 4LP, UK
| | - F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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15
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Matharu GS, Berryman F, Judge A, Reito A, McConnell J, Lainiala O, Young S, Eskelinen A, Pandit HG, Murray DW. Blood Metal Ion Thresholds to Identify Patients with Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris: An External Multicenter Validation Study of Birmingham Hip Resurfacing and Corail-Pinnacle Implants. J Bone Joint Surg Am 2017; 99:1532-1539. [PMID: 28926382 PMCID: PMC5805279 DOI: 10.2106/jbjs.16.01568] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The authors of recent studies have reported newly devised implant-specific blood metal ion thresholds to predict adverse reactions to metal debris (ARMD) in patients who have undergone unilateral or bilateral metal-on-metal (MoM) hip arthroplasty. These thresholds were most effective for identifying patients at low risk of ARMD. We investigated whether these newly devised blood metal ion thresholds could effectively identify patients at risk of ARMD after MoM hip arthroplasty in an external cohort of patients. METHODS We performed a validation study involving 803 MoM hip arthroplasties (323 unilateral Birmingham Hip Resurfacing [BHR], 93 bilateral BHR, and 294 unilateral Corail-Pinnacle implants) performed in 710 patients at 3 European centers. All patients underwent whole-blood metal ion sampling, and were divided into 2 groups: those with ARMD (leading to revision or identified on imaging; n = 75) and those without ARMD (n = 635). Previously devised implant-specific blood metal ion thresholds (2.15 μg/L of cobalt for unilateral BHR; 5.5 μg/L for the maximum of either cobalt or chromium for bilateral BHR; and 3.57 μg/L of cobalt for unilateral Corail-Pinnacle implants) were applied to the validation cohort, and receiver operating characteristic curve analysis was used to establish the discriminatory characteristics of each threshold. RESULTS The area under the curve, sensitivity, specificity, and positive and negative predictive values for the ability of each implant-specific threshold to distinguish between patients with and without ARMD were, respectively, 89.4% (95% confidence interval [CI] = 82.8% to 96.0%), 78.9%, 86.7%, 44.1%, and 96.9% for unilateral BHR; 89.2% (CI = 81.3% to 97.1%), 70.6%, 86.8%, 54.5%, and 93.0% for bilateral BHR; and 76.9% (CI = 63.9% to 90.0%), 65.0%, 85.4%, 24.5%, and 97.1% for unilateral Corail-Pinnacle implants. Using the implant-specific thresholds, we missed 20 patients with ARMD (2.8% of the patients in this series). We missed more patients with ARMD when we used the fixed thresholds proposed by regulatory authorities: 35 (4.9%) when we used the U.K. threshold of 7 μg/L for both cobalt and chromium (p = 0.0003), 21 (3.0%) when we used the U.S. threshold of 3 μg/L for both cobalt and chromium (p = 1.0), and 46 (6.5%) when we used the U.S. threshold of 10 μg/L for both cobalt and chromium (p < 0.0001). CONCLUSIONS This external multicenter validation study confirmed that patients with blood metal ion levels below new implant-specific thresholds have a low risk of ARMD after MoM hip arthroplasty. Using these implant-specific thresholds, we missed fewer patients with ARMD compared with when the thresholds currently proposed by regulatory authorities were used. We therefore recommend using implant-specific blood metal ion thresholds when managing patients who have undergone MoM hip arthroplasty. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gulraj S. Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Fiona Berryman
- The Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, United Kingdom
| | - Aleksi Reito
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Tampere, Finland
| | | | | | - Hemant G. Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Chapel Allerton Hospital, Leeds, United Kingdom
| | - David W. Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, United Kingdom
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16
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Matharu GS, Nandra RS, Berryman F, Judge A, Pynsent PB, Dunlop DJ. Risk factors for failure of the 36 mm metal-on-metal Pinnacle total hip arthroplasty system: a retrospective single-centre cohort study. Bone Joint J 2017; 99-B:592-600. [PMID: 28455467 PMCID: PMC5413867 DOI: 10.1302/0301-620x.99b5.bjj-2016-1232.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 12/30/2016] [Indexed: 12/12/2022]
Abstract
Aims To determine ten-year failure rates following 36 mm metal-on-metal
(MoM) Pinnacle total hip arthroplasty (THA), and identify predictors
of failure. Patients and Methods We retrospectively assessed a single-centre cohort of 569 primary
36 mm MoM Pinnacle THAs (all Corail stems) followed up since 2012
according to Medicines and Healthcare Products Regulation Agency
recommendations. All-cause failure rates (all-cause revision, and
non-revised cross-sectional imaging failures) were calculated, with predictors
for failure identified using multivariable Cox regression. Results Failure occurred in 97 hips (17.0%). The ten-year cumulative
failure rate was 27.1% (95% confidence interval (CI) 21.6 to 33.7).
Primary implantation from 2006 onwards (hazard ratio (HR) 4.30;
95% CI 1.82 to 10.1; p = 0.001) and bilateral MoM hip arthroplasty
(HR 1.59; 95% CI 1.03 to 2.46; p = 0.037) predicted failure. The
effect of implantation year on failure varied over time. From four
years onwards following surgery, hips implanted since 2006 had significantly
higher failure rates (eight years 28.3%; 95% CI 23.1 to 34.5) compared
with hips implanted before 2006 (eight years 6.3%; 95% CI 2.4 to
15.8) (HR 15.2; 95% CI 2.11 to 110.4; p = 0.007). Conclusion We observed that 36 mm MoM Pinnacle THAs have an unacceptably
high ten-year failure rate, especially if implanted from 2006 onwards
or in bilateral MoM hip patients. Our findings regarding implantation
year and failure support recent concerns about the device manufacturing
process. We recommend all patients undergoing implantation since
2006 and those with bilateral MoM hips undergo regular investigation,
regardless of symptoms. Cite this article: Bone Joint J 2017;99-B:592–600.
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Affiliation(s)
| | - R S Nandra
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
| | - F Berryman
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
| | - A Judge
- University of Oxford, Oxford, OX3 7LD, UK
| | - P B Pynsent
- School of Clinical and Experimental Medicine, University of Birmingham, B15 2TT, UK
| | - D J Dunlop
- The Royal Orthopaedic Hospital, Birmingham, B31 2AP, UK
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17
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Manktelow ARJ, Gehrke T, Haddad FS. Hip surgery - state of the art: Totally Hip 2017: Gothenburg. Bone Joint J 2017; 99-B:1-2. [PMID: 28363887 DOI: 10.1302/0301-620x.99b4.bjj-2017-0188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 02/14/2017] [Indexed: 11/05/2022]
Affiliation(s)
| | - T Gehrke
- HELIOS ENDO-Klinik Hamburg, Holstenstrasse 2, 22767, Hamburg, Germany
| | - F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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