Adverse Reaction To Metal Debris Research Articles

Quantification and severity grading of femoral vessel compression by adverse reactions to metal debris in metal-on-metal total hip arthroplasty.

Metal-on-metal (MoM) total hip arthroplasty (THA) may cause adverse reactions to metal debris (ARMD). ARMD causing femoral vessel compression with serious complications has been described in case reports, but the rate of compression by ARMD is not known. This study aims to investigate the rate, and quantify the severity, of femoral vessel compression in MoM hips with ARMD lesions. Patients under surveillance for MoM THA investigated with MRI were studied. In patients with confirmed ARMD, femoral artery (FA) and vein (FV) diameters were measured at the point of maximal compression and compared to contralateral vessels. The primary outcome measure was presence or absence of compression. Cases were then classified by compression ratios. Secondary outcome measures were rates of deep vein thrombosis, revision surgery and time to ARMD from index procedure. MRI scans for 436 patients with MoM THA were screened. Of these, 211/436 (48.4%) showed evidence of ARMD. Measurements were obtained on 133/211 (63.0%) patients. The FV was compressed in 102/133 (76.7%) and FA in 58/133 (43.6%), while 31/133 (23.3%) patients had no compression. In FVs, 42 demonstrated mild compression, 39 moderate and 21 severe. In FAs, none were severely compressed, 6 were moderate and 52 showed mild compression. There were 3 DVT cases, 2 in patients with moderate FV compression and 1 in patients without FV compression. Revision rates were highest in patients with severe FV compression (14/21, 66.7%). The mean time for MRI-diagnosed ARMD from index procedure was 8 years and 1 month (range 11 months-14.5 years). Extra-luminal compression of the femoral vessels was found in >75% of patients with ARMD. Although it is not clear whether revision for femoral vessel compression is required, quantification of FV compression may be useful for surgeons and radiologists considering revision for ARMD.

Long-term survival analysis of cementless large-diameter head metal-on-metal total hip arthroplasty

IntroductionThe aim of this retrospective study was to study the long-term survival and reasons for revisions of a single-type, large-diameter head (LDH) metal-on-metal (MoM) implant. A special study interest was to find the threshold level for revision in terms of adverse reaction to metal debris (ARMD).Materials and MethodsIn this cohort study, we retrospectively reviewed 234 patients (253 hips) who received 38 mm head size LDH MoM total hip arthroplasties (THAs) between 01 January 2004 and 31 December 2009 at our institution. Patient symptoms, conventional radiographs, magnetic resonance imaging (MRI) findings and whole blood metal ions were studied.ResultsThe median follow-up time was 11.5 years. The Kaplan–Meier cumulative survival estimate of the implant was 89.6% at 10 years and 82.9% at 14.6 years. Overall, 34/253 (13.4%) hips were revised during the follow-up period and of these; 19/34 (55.9%) were revised due to ARMD. The prevalence of ARMD was 12.4% (29/234 patients).ConclusionsThe survival of the implant was on a moderate level as the 10-year cumulative survival rate was 89.6%. The exact threshold level for ARMD revision cannot be determined due to multiple variables affecting factors in re-operation decision-making.

Research progress on the revision of Metal-on-Metal hip arthroplasty due to adverse reactions to metal debris

The choice of friction interface has always been a controversial topic in hip arthroplasty. Although the metal-on-metal (MoM) interface has gradually faded out of our vision, its revision is a clinical difficulty. Adverse reactions to metal debris (ARMD) is the most common indication for MoM hip arthroplasty revision, and the clinical results of hip arthroplasty due to ARMD are not satisfactory. At present, the indications and suggestions for revision of ARMD are not uniform. In this article, the clinical diagnosis, indications of revision, risk factors of prognosis, intraoperative suggestions and reasons for revision of ARMD were summarized. This article briefly introduces the diagnosis and treatment strategies and precautions of hip arthroplasty due to ARMD, in order to provide reference for such patients in clinical practice.

Adverse Tissue Reactions and Metal Ion Behavior After Small-Head Metasul Hip Arthroplasty: A Long-Term Follow-Up Study.

ObjectiveTo investigate the long‐term survivorship, incidence of adverse reactions to metal debris (ARMD), and metal ion behavior in patients who underwent small‐head Metasul metal‐on‐metal (MoM) total hip arthroplasty (THA).MethodsBetween February 1998 and September 2003, a retrospective study was performed on 43 consecutive patients (43 hips) who underwent unilateral cementless Metasul MoM THAs at our institution. Of them, 35 patients (nine males and 26 females) who were available for follow‐up more than 15 years after THA were enrolled in this study and underwent metal artifact reduction sequence magnetic resonance imaging (MARS‐MRI) to identify ARMD. The mean age at surgery of the patients was 59.7 years old (range, 31–83). Clinical and radiographic outcomes were evaluated retrospectively. Clinical examinations were conducted using the Harris Hip Score (HHS). Serum cobalt (Co) and chromium (Cr) ion levels and Co/Cr ratio were assessed at different postoperative periods of <5, 5–10, 11–14, and ≥15 years.ResultsThe mean follow‐up period for the 35 patients included was 18.1 years (range, 15–22). The mean HHS significantly improved from 44.6 ± 11.3 points preoperatively to 89.4 ± 7.9 points at the final follow‐up (P < 0.0001). ARMD was found in 20% of the patients using MARS‐MRI. No signs of stem loosening were found clinically or radiographically, whereas cup loosening and ARMD were observed in three patients (9%), for whom revision THAs were performed. The Kaplan–Meier survival rates with revision for any reason as the endpoint were 90.9% at 5 years, 84.8% at 10 years, 84.8% at 15 years (95% CI, 67.1–93.6), and 70.3% at 20 years (95% CI, 43.6–87.0). The survival rates with revision for ARMD as the endpoint were 100% at 5 years, 96.6% at 10 years, 96.6% at 15 years (95% CI, 77.2–99.7), and 80.1% at 20 years (95% CI, 45.3–95.2). Serum Co ion level peaked at 5–10 years after THA, which was significantly higher than that <5 years; however, it decreased to the initial level after 15 years. In contrast, serum Cr ion level significantly increased at 5–10 years and then remained almost constant. Significant differences in Cr ion levels (1.0 vs 2.0 μg/L, P = 0.024) and Co/Cr ratio (1.3 vs 0.9, P = 0.037) were found between non‐ARMD and ARMD patients at >11 years postoperatively.ConclusionOur results suggest that increased Cr ion levels and decreased Co/Cr ratio may be signs of ARMD in patients who underwent small‐head Metasul MoM THA.

Metal-on-Metal Total Hip Arthroplasty: Current Recommendations and Lessons Learned

Metal-on-metal (MoM) hip arthroplasty was re-popularized in the 1990s to resolve osteolysis and wear associated with metal-on-polyethylene products. Despite early success, registries began reporting high failure rates due to adverse reactions to metal debris (ARMD), manifesting as pseudotumors, hip effusions and osteolysis. Evaluation includes clinical exam, advanced imaging, and blood metal ions and infectious markers. This review provides physicians with an evidence-based update on the 1) clinical workup and management of patients with existing MoM implants, 2) risk and prognostic factors associated with suboptimal results and 3) the precipitating events and lessons learned applicable to future orthopedic prosthesis.

Comparison of the long-term cause of failure and survivorship of four hundred and twenty seven metal-on-metal hip arthroplasties: resurfacing versus large head total hip arthroplasty

IntroductionComparison of mid- to long-term cause of failure and survivorship of metal-on-metal (MoM) resurfacing hip arthroplasty (RHA) and large head total hip arthroplasty (THA) remains sparse. This study aimed to identify and compare the cause of failure and survivorship of MoM RHA and THA at a minimum ten year follow-up.MethodsFour hundred twenty-seven MoM hip arthroplasties (286 THA and 141 RHA) were retrospectively analyzed at a mean follow-up of 13 ± three years. Causes of failure were reported as MoM specific (i.e., adverse reaction to metal debris (ARMD) and painful hip with ion elevation) or MoM non-specific (i.e., fracture, infection, and dislocation). Chromium (Cr) and cobalt (Co) ion levels and Co/Cr ratio were compared. Survivorship was compared according to the cause of failure with revision as the endpoint.ResultsThe rate of ARMD was significantly higher in THA (OR = 2.9 [95%-CI: 1–7]; p = 0.02). No significant difference was detected in failure rate due to other causes between the two groups (p = 0.2–0.9). Ion levels and Co/Cr ratio were both significantly higher in THA (p < 0.01). Survivorship was significantly lower in THA compared to RHA at ten years [89% (95%-CI: 85%–91%) vs 96% (95%-CI: 91%–98%); p = 0.01] and 15 years [73% (95%-CI: 67%–78%) vs 83% (95%-CI: 73%–90%); p = 0.01].ConclusionRHA survivorship was significantly higher at any time point. Failure rate due to ARMD was significantly higher in THA while no significant difference in other causes of failure was observed between the two groups. This result emphasizes the role of fretting corrosion at the head-neck junction (i.e., trunnionosis) with significantly higher ion levels and Co/Cr ratio dissociation in THA.

Safe Upper Limits of Serum Cobalt and Chromium Levels for a Metal-on-Metal Total Hip Bearing: A 10-Year Follow-Up Study

BackgroundLong-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. MethodsOne 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. ResultsUnivariate 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. ConclusionGuidelines 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.

How much does a Medical and Healthcare Products Regulatory Agency medical device alert for metal-on-metal hip arthroplasty patients really cost?

Background:Many worldwide regulatory authorities recommend regular surveillance of metal-on-metal hip arthroplasty patients given high failure rates. However, concerns have been raised about whether such regular surveillance, which includes asymptomatic patients, is evidence-based and cost-effective. We determined: (1) the cost of implementing the 2015 MHRA surveillance in “at-risk” Birmingham Hip Resurfacing (BHR) patients; and (2) how many asymptomatic hips with adverse reactions to metal debris (ARMD) would have been missed without patient recall.Methods:All BHR patients eligible for the 2015 MHRA recall (all females, and males with head sizes ⩽46 mm, regardless of symptoms) at one centre were invited for review (hips = 707; patients = 593). All patients were investigated (Oxford Hip Score, radiographs, blood metal ions, and targeted cross-sectional imaging) and managed accordingly. Surveillance costs were calculated using finance department data.Results:The surveillance cost £105,921.79 (range £147.76–£257.50/patient). Radiographs (£39,598) and nurse practitioner time/assistance (£23,618) accounted for 60% of overall costs. 31 hips had ARMD on imaging (12 revised; 19 under surveillance). All revisions were symptomatic. 7 hips with ARMD under surveillance were asymptomatic and remain under regular review. The number needed to treat to avoid missing one asymptomatic ARMD case was 101 patients, representing a cost of £18,041 to avoid one asymptomatic case.Conclusions:Implementing MHRA surveillance for “at-risk” BHR patients was extremely costly. The risk of asymptomatic ARMD was low with the BHR (1%), suggesting recommended follow-up in asymptomatic patients is not cost efficient. This raises concerns about the increasingly intensive surveillance recommended in the 2017 MHRA guidance for metal-on-metal hip patients.

It's worth cleaning – The examination of the female taper could identify a particular cause of trunnionosis at revision 16 years after total hip arthroplasty

Adverse reaction to metal debris (ARMD) is an issue in metal-on-metal (MoM) total hip replacements (THR). It mainly affects large-head MoM THR, whereas 28–32 mm MoM pairings are associated with low long-term revision rates. However, the bearing surface is not necessarily the only cause of metal debris. This report documents with advanced analysis of the retrievals a particular cause of trunnionosis in late failure of a small diameter MoM THR and illustrates the importance of cleaning of the taper when seating the head in THR. A 65-year-old patient was revised due to ARMD 16 years after small diameter MoM THR. Debridement and exchange of the inlay and the head had been performed through an anterior approach. While the cup and the outer surface of the head were accessible to direct analysis by an optical coordinate measuring machine, the female taper had to be analysed indirectly by measuring an imprint. Wear from the cup and the head was within expected low ranges. The analysis of the female taper identified bone fragments, which contributed to trunnionosis. Failure due to ARMD after MoM THR is not necessarily caused by the bearing, but can be due to trunnionosis. Bone fragments within the taper contact in this case highlight the importance of meticulous cleaning of the taper before seating the head, to avoid trunnionosis.

Predictive factors affecting long-term survivorship of ASR metal-on-metal total hip arthroplasty.

Introduction: We present the outcome of 154 ASR (Articular Surface Replacement) hips performed at the P.D Hinduja Hospital and Medical Research Centre in terms of revision rate, metal ion levels, and factors affecting survivorship. Further, determined the importance of serial metal ion estimation over single value with poorly functioning arthroplasties. Methods: A retrospective study of 154 ASR arthroplasties (136 patients) performed from April 2005 till March 2010 was conducted. Ninety-seven patients were available for final analysis. All patients were assessed for symptoms, radiographs, blood metal (chromium and cobalt), metal artefact reduction sequence (MARS), magnetic resonance imaging (MRI), and computerized tomography (CT). Results: Female gender, smaller femoral head, patients with a rising level of metal ion levels were more likely to have revision surgery. However, abnormal acetabular inclination/anteversion was not associated with the occurrence of raised metal ion levels, ARMD (adverse reaction to metal debris) or revision surgery. Patients with raised metal ion levels were more likely to have periprosthetic lucency, ARMD, and revision surgery. Median metal levels increased initially for the first three years. Still, patients who required revision surgery continued to have a metal ion rise until the point when revision surgery was performed. In contrast, patients who had a fall in metal ion levels did not require revision. Conclusion: A single metal ion value is less predictive of failing arthroplasties; instead, a rising trend of metal ion levels can better delineate arthroplasties which will require revision. ASR hips whose blood ion levels fell after an initial rise and showed a declining trend did well.

Catastrophic failure of femoral stem modular junction when combined with metal-on-metal bearing in comparison to ceramic-on-ceramic: A retrospective cohort study

BackgroundMetal ion release from total hip arthroplasty's (THA) metal-on-metal (MoM) bearing surfaces or head-neck modular junction (trunnionosis) has been identified as a major cause of adverse reaction to metal debris (ARMD). No study has compared the effects of these bearing couples when combined with modular neck femoral stems (MNFS) (i.e. did a modular CoCr have a higher effect than large MoM bearings on whole blood ion concentrations and ARMD). Therefore we did a retrospective comparative analysis of prospectively collected data aiming to: (1) assess the difference in metal ion release between a group of MoM and CoC bearings implanted with a non-cemented MNFS; (2) compare the ARMD and the related revision rates between the two bearing types; (3) compare the patients’ HOOS and Harris Hip scores. HypothesisMetal ion levels and complications rate will be higher in MoM group. MethodsThirty hips received the same short MNFS with modular CoCr. Seventeen had CoC bearing (16=36mm) and 13 large diameter head (LDH) MoM bearing (mean=50mm, 44-54mm) Both groups had whole blood Cobalt (Co) and Chromium (Cr) concentrations measurements at last follow up or before revision surgery (if any) and were compared to 41 control individuals without implants. ARMD, revision rates and other complications were censed. Functional outcome differences between operative groups were assessed with HOOS and Harris Hip scores. ResultsMean whole blood Co and Cr were 1.9μg/L (0.1–10.6 min–max) and 1.2μg/L (0.2–4.6 min–max) in the CoC group and 12.7μg/L (2.5–40.7 min–max) and 8.2μg/L (2.8–40.6 min–max) for MoM group. Controls presented whole blood Co and Cr levels of 0.2μg/L (0.04–0.2 min–max) and 0.6μg/L (0.1–0.7 min–max) respectively. CoC had significantly higher whole blood metal ion concentrations than controls, while MoM had significantly higher concentrations than both (p<0.001). MoM had a 9/13 (69%) revision rate due to ARMD (with stem-neck junction corrosion and wear were present in all cases) while the CoC had none. Functional scores at last follow up did not statistically differ between groups (Harris: CoC=94.1±8.4 vs MoM 91.8±14.8 (p=0.22) and CoC HOOS 90.2±10.7 vs 75.6±21.7 (p=0.08)). ConclusionIn our study, MNFS with CoCr modular neck released metal ion systemically, as shown in CoC THAs, but when combined with MoM LDH bearings, that elevation was significantly higher. In MNFS MoM, these high metal ion levels translated into a dramatic ARMD related revision rate where stem-neck junction corrosion and wear were present in all cases. More research is required to understand the effects of MoM bearing on neck-stem junctions, and its mechanisms of corrosion. Level of evidenceIII; retrospective comparative study.

Metal Ion Release, Clinical and Radiological Outcomes in Large Diameter Metal-on-Metal Total Hip Arthroplasty at Long-Term Follow-Up.

Total hip arthroplasty (THA) with metal-on-metal (MoM) bearings have shown problems of biocompatibility linked to metal ion release at the local level causing an adverse reaction to metal debris (ARMD) and at a systemic level. The aim of this study was to evaluate clinical and radiological outcomes, and metal ion concentrations in the blood and urine of patients who underwent THA with the LIMA Met-Met hip system. Patients with ceramic-on-ceramic (CoC) bearings were included as a control group. In this study, 68 patients were enrolled: 34 with MoM THAs and 34 with CoC THAs. Patients were evaluated clinically (Harris Hip Score, SF-36) and radiologically at a median of 7.4 years after surgery. Whole blood and urinary cobalt and chromium levels were also assessed. Both types of implants were comparable in terms of clinical and functional results. Ion levels were significantly higher in the MoM group compared with CoC group 7 years after surgery. No correlations were found between metal ion levels and patient demographics, functional and radiological outcomes, and prosthesis features. Patient monitoring is thus advised to establish if prosthesis revision is necessary, especially in the case of MoM THA.

Early failure for wear after ceramic-on-highly cross-linked polyethylene total hip arthroplasty: a case report

BackgroundHighly cross-linked polyethylene (HXLPE) enhances the anti-wear characteristics of the conventional polyethylene (PE). Early failure for wear after ceramic-on-highly cross-linked polyethylene (CoHXLPE) total hip arthroplasty (THA) is extremely rare.Case presentationWe described the case of a 60-year-old man who underwent right CoHXLPE THA because of the developmental dysplasia hip (DDH) complained pain 32 months after this procedure. Plain radiographs showed that eccentric wear existed at the polyethylene insert. However, the patient refused surgery at that time and did not stop weight-bearing. The right hip pain continued for 7 months. Plain radiographs of the pelvis showed that the HXLPE liner was penetrated and partial inner wall of acetabular shell was worn. Acetabular cup revision was performed, and the ceramic head and HXLPE were exchanged.ConclusionsDifficult reduction during primary THA, especially for DDH, can result in higher abductor tension, which may lead to early eccentric wear of the prosthesis. Whenever eccentric wear of HXLPE liner was found, weight-bearing must be stopped to avoid the accelerated wear and adverse reactions to metal debris (ARMD).

Study to Assess the Rate of Adverse Reaction to Metal Debris in Hip Resurfacing at a Minimum 13-year Follow-up

BackgroundHip 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. MethodsWe 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. ResultsA 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. ConclusionWhile 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.

Results of hydroxyapatite ceramic coated primary femoral stem in revision total hip replacement

The purpose of this study was to assess survival rate, functional and radiological outcomes when using a hydroxyapatite-ceramic fully coated primary femoral stem in revision total hip arthroplasty. Patients who underwent revision total hip arthroplasty using the Furlong hydroxyapatite-ceramic (HAC)-coated (Joint Replacement Instrumentation Ltd., Sheffield, UK) primary stem were retrospectively identified between 2013 and 2017. A total of 30 hips in 27 patients were identified and the mean follow-up duration was 44months. Post-operative radiographs were scrutinized for signs of component loosening by two independent assessors. Patient's functional outcomes were assessed using the Oxford hip score and compared pre- and post-operatively. The prevalence of thigh pain was assessed at the latest follow-up. The most common cause of revision was adverse reactions to metal debris (ARMD) (46.6%). The overall complication rate was 13.3%. Results at final follow-up demonstrated 100% survival rate and no reported incidence of thigh pain. Using paired t test, all patients had a statistically significant (P < 0.05) improvement in post-operative mean Oxford hip score of 35 compared to a mean pre-operative score of 14. Radiographic analysis of the latest follow-up radiographs revealed no signs of component loosening or component subsidence. With a 100% survival rate and excellent reported functional outcomes, we believe that our experience and results support the use of primary cementless stems in selected revision cases.

Limited need for screening of metal-on-metal hip resurfacing patients beyond 10 years of follow-up.

National and international guidelines lack consistency on how to screen metal-on-metal (MoM) hip arthroplasty patients for adverse reactions to metal debris (ARMD). Long-term outcomes of MoM hip arthroplasty are scarce, hindering further development of such guidelines. We present the clinical, radiological and ARMD status of 158 cases of hip resurfacing with >10 years follow-up. A prospective analysis of a cohort of 298 consecutive hip resurfacing procedures was performed at a single institution. All patients underwent MARS-MRI scanning for pseudotumour screening at least once, regardless of symptoms. Implant survival and reasons for revision were analysed for all patients. Clinical, radiological and MARS-MRI results were analysed for 158 unrevised procedures with >10 years follow-up. The implant survival was 85.9% at 14.5 years (95% CI, 81.9-90.6) with revision for all causes as endpoint and 92.3% with MoM disease-related revisions excluded (95% CI, 88.2-95.0). Of the 158 cases with >10 years follow-up, 1 had elevated metal ion levels, 29 had a stable C1 pseudotumour and 6 a stable C2 pseudotumour. All pseudotumours were observed within 3 years after initiating our intensified ARMD screening (2011), with no new pseudotumours observed after that period. We suggest that follow-up of MoM hip resurfacing patients beyond 10 years after surgery can be done with large intervals (i.e. every 5 years), and only earlier if a patient becomes symptomatic.

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

Background and purpose — There is limited amount of evidence about optimal revision indications, technique, and implants when performing revision surgery for metal-on-metal (MoM) hip replacements due to adverse reaction to metal debris (ARMD). We assessed which factors are related to re-revisions and complications after a revision of MoM hip arthroplasty because of ARMD. We also aimed to provide information on optimal implants for these revisions.Patients and methods — 420 MoM total hip arthroplasties (THA) and 108 MoM hip resurfacings were implanted and later revised at our institution. We used Cox regression to analyze the factors associated with re-revisions and complications after a revision for ARMD.Results — A re-revision was performed on 27 THAs (6%) and 9 resurfacings (8%). The most common indication for re-revision was recurrent dislocation (20 hips, 4%). Complications not leading to re-revision were seen in 21 THAs (5%) and 6 resurfacings (6%). The most common complication was dislocation treated with closed reduction in 13 hips (2%). Use of revision head size > 36mm was associated with decreased risk for dislocations. Presence of pseudotumor, pseudotumor grade, pseudotumor size, or the choice of bearing couple were not observed to affect the risk for re-revision. Non-linear association was observed between preoperative cobalt and risk for re-revision.Interpretation — As dislocation was the most frequent post-revision complication, large head sizes should be used in revisions. Because size or type of pseudotumor were not associated with risk of re-revision, clinicians may have to reconsider, how much weight is put on the imaging findings when deciding whether or not to revise. In our data blood cobalt was associated with risk for re-revision, but this finding needs further assessment.

No radiological and biological sign of trunnionosis with Large Diameter Head Ceramic Bearing Total Hip Arthroplasty after 5 years

BackgroundTrunnionosis of large diameter (LDH) metal-on-metal total hip arthroplasty (THA) was linked to high systemic chromium (Cr) and cobalt (Co) ion levels and local adverse reactions to metal debris (ARMD). The safety of CoC LDH THA is not yet available at mid-term. Measuring whole blood Ti level of ceramic on ceramic (CoC) LDH THA with a titanium (Ti) stem is an indirect way to assess the performance of its head-neck taper modular junction. Therefore, we wanted to determine: (1) if the whole blood Ti ion levels in patients with LDH CoC THA after a minimum of 5 years of implantation is within the expected values for similar well performing Ti THA, (2) if Ti level scientifically increases over time, which would suggest the presence of a progressive modular head/neck junction wear process, (3) if clinical or radiographical manifestations of implant dysfunction are present? HypothesisTi blood levels of LDH CoC THA will indirectly reflect the expected levels due to passive corrosion of the implants and will be stable over time. Patients and methodsWe report the whole blood Ti, Cr, and Co levels at 5years minimum for 57 patients with unilateral primary LDH CoC THA with head sizes ranging from 36 to 48mm using Ti stem and acetabular component. To compare Ti ion levels modification over time, in 25 patients were a previous measurement (1–3years) was available, we compared it to their last follow-up results (>5 years). Mean Ti level in well performing Ti THAs is recognized to be around 2.0 ug/L. Although, there are no universally accepted Ti levels associated with problematic implant, we used safety threshold of 10 ug/L. Clinical and radiological outcomes were recorded at last follow-up. ResultsAt 79 months mean follow-up, all mean Ti levels were 1.9μg/L (min 1.2, max 4.4) and all subject had values below the safety threshold of 10ug/L. In the subgroup of 25 cases with a previous measurement, there was a decrease in mean Ti levels between 20 months and 78 months follow-up (2.2μg/L (1.6–3.9) versus 2.0μg/L (1.4–2.8), p=0.007). No statistically significant relation was observed between Ti level at last FU and bearing diameter (rho=0.046, p=0.0734) or the presence or absence of a Ti adaptor sleeve (p=0.454): 1.94ug/L (min 1.20, max 2.80) versus 1.90ug/L (min 1.20, max 4.40). At last follow up, no patients presented osteolysis signs on radiographs, clinical signs of ARMD or were reoperated. Most patients had excellent clinical with 98% of them reporting minor (29%) or no functional limitation (69%) and 44% perceive their THA as a natural hip joint. However, 3/57patients (5%) temporarily experienced hip squeaking and 18/57 (31%) reported clicking sound. ConclusionWith the tested LDH CoC THA, Ti levels were low and related the uneventful and unavoidable passive corrosion of implant surfaces. Mid-term measurement of Ti in subjects with LDH CoC did not reveal any indirect signs of trunnionosis, which should already be observable by this time. Level of evidenceIV, retrospective study.

The inflammatory pseudotumor formed after metal-on-metal hip arthroplasty

Due to its advantages of low wear, high stability and flexibility, the new generation metal-on-metal hip prosthesis is favored by many patients with hip diseases, especially young patients. However, in recent years, several studies have indicated that adverse reactions to metal debris (ARMD) caused the formation of inflammatory pseudotumor, which ultimately led to a higher revision rate after metal-on-metal hip arthroplasty. This aroused the widespread concern from doctors and patients. Moreover, revision surgery for metal-on-metal hip arthroplasty in the setting of inflammatory pseudotumor is faced with a great risk of failure because of the large defects of bone and surrounding soft tissue and difficulty in removing the original prosthesis and the fixing of the modified prosthesis. Therefore, the use of such products is restricted with caution in their choice. We summarized the recent developments in the research in the risk factors, diagnosis and treatment of inflammatory pseudotumor after metal-on-metal hip arthroplasty. The risk factors for the formation of inflammatory pseudotumor around the hip prosthesis mainly include the increase of metal ion concentration, the position of prosthesis implantation and the patient's own factors. The diagnosis mainly depends on physical examination, imaging examination, laboratory examination, arthroscopy and histological examination. The treatment strategies for clinical symptomatic and asymptomatic patients are also varies. Through the detailed analysis, evaluation and summary of the above contents, we may provide guidance for the selection of hip prosthesis, and lay the foundation for further exploration of the mechanism of inflammatory pseudotumor caused by ARMD.

In vitro evaluation of human myoblast function after exposure to cobalt and chromium ions.

The replacement of a native hip joint by a metal-on-metal prosthesis may induce deleterious inflammatory side effects that are associated with the release of wear particles and metal ions. These events are referred to the adverse reaction to metal debris (ARMD) and the adverse local tissue reaction (ALTR). While wear particles seem involved in ARMD, the role of metal ions in ALTR and their impact on myoblasts, located in the prosthesis vicinity, has not been fully identified. To clarify this issue we investigated, using an in vitro culture system, the effect of cobalt and/or chromium ions (Co2+ and/or Cr3+ ) on human myoblast proliferation, cellular differentiation, and inflammatory marker expression. Freshly isolated human myoblasts were cultured in media supplemented with graded concentrations of Co2+ and/or Cr3+ . Co2+ induced a concentration-dependent decrease of both myoblast viability and myogenic differentiation while Cr3+ did not. Co2+ or Co2+ /Cr3+ also induced the upregulation of ICAM-1, whereas HLA-DR expression was unaffected. Moreover, allogenic monocytes induced the synergistic increase of Co2+ -induced ICAM-1 expression. We also found that Co2+ stabilized HIF-1α and increased TLR4, tumor necrosis factor-alpha (TNF-α), and interleukin 1β (IL-1β) expression in a dose and time-dependent manner in human myoblasts. This study showed that Co2+ , but not Cr3+ , was toxic toward myoblasts and induced, in the surviving cells, expression of inflammatory markers such as ICAM-1, TLR4, TNF-α, and IL-1β. This suggests that Co2+ , most efficiently in the presence of monocytes, may be a key inducer of ALTR, which may, if severe and long-lasting, eventually result in prosthesis loosening.