Metal Hip Resurfacing Research Articles

SURVIVORSHIP OF CURRENTLY AVAILABLE METAL-ON-METAL HIP RESURFACING IN MALES UNDER 55 YEARS OF AGE: A MATCHED NJR SURVIVORSHIP ANALYSIS

The 22 year survivorship of metal on metal hip resurfacing arthroplasty (RSA) is reported to be 94.3% with expert surgeons, in males with head sizes greater than 48mm. The 2023 National Joint Registry (NJR) report estimates survivorship of all RSA at 19 years to be 85%. This estimate includes all designs, head sizes and females. Our aim was to estimate the survivorship of RSA currently available for implantation (males only, head size >48mm, MatOrtho Adept or Smith and Nephew Birmingham Hip Resurfacing (BHR)) in those under 55 years, performed by all surgeons, compared to conventional THR.We performed a retrospective analysis of the NJR. We included all males under 55 years who had undergone BHR or Adept RSA with head size greater than 48mm. Propensity score matching was used to produce two comparable groups of patients for RSA or conventional THR. We matched in a 3:1 ratio (THR:RSA) using sex, ASA, BMI group, age at primary procedure, surgeon volume, diagnosis and surgeon grade as covariates. The primary analysis was survivorship at 18 years. Time-to-revision was assessed using Kaplan-Meier curves. Cox's proportional hazard models were used to investigate between group differences.4839 RSA were available for analysis. After matching the RSA and THR groups were well balanced in terms of covariates. Survivorship at 18 years was 93.7% (95% CI 89.9,96.2) in the RSA group and 93.9% (90.5,96.0) in the THR group. Despite these similar estimates the adjusted hazard ratio was 1.40 (95% CI 1.18, 1.67 p<0.001) in favour of THR.Survivorship of the currently available RSA in males under 55 was 93.7% at 18 years, however THR survivorship was superior to RSA. These results, generalisable to UK practice, should be set against perceived benefits in functional status offered in RSA when counselling patients.

Histiocytic lymphadenopathy secondary to metallosis following endoprosthetic replacement in osteosarcoma patient – a potential diagnostic pitfall

We present the case of a 43-year old patient with inguinal lymphadenopathy 22 years after distal femoral resection for osteosarcoma with cemented distal femoral replacement reconstruction. Seven years after initial distal femoral resection patient underwent metal on metal hip resurfacing arthroplasty on the affected side. Twenty years after distal femoral replacement and 13 years after metal on metal hip resurfacing procedure, the patient underwent left inguinal lymph­adenectomy for an enlarged mass of inguinal lymph nodes on suspicion for a sarcoma recurrence. On microscopic ex­amination, excised lymph nodes were massively infiltrated with macrophages and multinucleated giant cells with focal asteroid bodies. An examination in polarized light revealed numerous metal particles; immunohistochemical stainings confirmed reactive character of changes, and florid metal-related sinus histiocytosis was finally diagnosed. Microscopic assessment of lymph nodes in the course of malignancy is a standard procedure; we present a rare case of non-neoplastic lymph node enlargement due to the late onset of metallosis, which might be a diagnostic challenge.

Evaluation and treatment of the painful hip resurfacing

Hip resurfacing arthroplasty (HRA) can have unique failure mechanisms not commonly seen with traditional metal on polyethylene total hip replacements (THRs) due to the shape and fixation of the implants, interaction of the bone with the implants, biomechanics of the joint, and the metal-on-metal (MOM) articulation. As such, one should be aware of the most common mechanisms for pain in a hip resurfacing to be able to evaluate the problem with the proper imaging and laboratory studies. Besides the usual causes of pain in a hip arthroplasty such as infection, hip flexor tendonitis, and implant loosening, there can also be bone-to-implant impingement, synovitis from metal debris, and immunologic reaction to metal debris. Thus, the diagnosis of problems in a metal on metal hip resurfacing is aided by the use of diagnostic modalities such as metal ion measurement and metal artifact reduction imaging techniques. The treatment of such problems can consist of a revision to a stemmed THR, either by revising the femoral component only, or performing a revision of both components.

Techniques of Insertion and Early Clinical Impressions with a Short Curved Tissue Sparing Implant for Total Hip Arthroplasty (The French Experience)

Background: Total hip arthroplasty (THA) is one of the most effective orthopedic procedures, providing consistently high success rates across all population segments as measured by pain relief, improved function, and patient satisfaction. However clinical outcomes have been less favorable in young active patients, that lead to the re-development of metal on metal hip resurfacing (HR), with the most successful being the Birmingham Hip Replacement (BHR) introduced in 1997. Evolving complications due to increased metal ion debris has lead to a great reduction of use for all metal on metal (MOM) HR designs, leading many surgeons and patients to look for an alternative surgical selection. This search has focused on the development and use of short stems for THA. One such style of short stems is curved neck preserving designs. This paper will review our French experience with one of those designs.Materials and Methods: This is a retrospective review of four surgeons series of a short curved tissue sparing cementless femoral implant (TSI™ Hip Stem, Signature Orthopaedics) for THA. The femoral component was used with two different cementless acetabular styles (Mathys RM Pressfit, and Zimmer Biomet Allofit®). Results on the cups will not be revived in this paper. 150 TSI™ Stems by four surgeons at the same institution utilizing the posterior surgical approach since September 2016. 40% women, average age 66 years with extremes of 27 to 78 years. 10 cases of dysplastic hips, 6 cases of aseptic osteonecrosis, 1 fracture, 1 rheumatoid coxitis, and the rest primary coxathosis, with 7 patients operated on both hips at the same time. 23.3 % have been Dorr type A canal shape.Results: There has been no aseptic loosing, three femoral components have been explanted due to postoperative infection. There was one intra-operative femoral distal fracture in a Dorr type A bone profile during stem insertion. One posterior dislocation; there has been two patients with thigh pain with pathological bone scan, and one with low back pain and no leg length discrepancies greater than plus or minus 5 mm.Conclusion: This short curved tissue sparing implant has demonstrated excellent initial short-term results, with excellent implant stability, excellent medial calcar bone remodeling with one dislocated stem, two thigh pain and one patient with low back pain. One distal intra-operative fracture in a Dorr type A bone. This has now been addressed with the use of distal sizing gauges and the use of flexible reamers to open the distal canal prior to stem insertion. Removal of the infected stems demonstrated implant stability with early bone attachment in the proximal porous surface. The high neck resection allows for ease of revision and conversion implanting a new primary conventional length cementless stem design.There is a short but definitive learning curve in fitting the implant to the femoral neck versus the standard metaphyseal and diaphyseal conventional style stems.

Metal on Metal Hip Resurfacing in Patients 45 Years of Age and Younger at Minimum 5-Year Follow-Up

BackgroundMetal on metal hip resurfacing (MoM-HR) is an alternative to total hip arthroplasty in young and active patients. The purpose was to determine the survivorship of MoM-HR procedures performed in patients aged 45 years and younger assessing patient-reported outcome measures (PROMs) at minimum 5-year follow-up. MethodsAll 217 patients equal to or younger than 45 years of age at the time of surgical intervention presenting to our center with MoM-HR between May 2002 and May 2011 were prospectively followed. Baseline demographic data, preoperative and postoperative radiographic measurements, and validated PROMs were obtained (Hip Disability and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and University of California, Los Angeles Activity Score). Survivorship was calculated using Kaplan-Meier analysis, and risk factors for failure were identified using multivariate regression analysis. ResultsThe overall survivorship excluding septic failures was 94.6% and 93.8% at 5 and 10 years, respectively. Aseptic loosening of the acetabular component was the most common mode of failure (11/20 cases). Gender, head size, and acetabular abduction angle had no significant effect on survivorship. Significant improvements in PROMs were seen for Hip Disability and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Osteoarthritis Index, and University of California, Los Angeles Activity Scale (P < .001). ConclusionThis study indicates that MoM-HR is a suitable option for young individuals, as demonstrated through improved functional scores and low revision rates. The survivorship of HR in the younger than 45 age-group was similar to that of total hip arthroplasty, as well as HR in older patients. Given the proposed benefits of HR, this procedure may be viewed as a viable option in patients aged younger than 45 years.

Myocardial Structure, Function, and Tissue Characterisation by Cardiac Magnetic Resonance in Asymptomatic Patients with Metal on Metal Hip Resurfacing

Myocardial Structure, Function, and Tissue Characterisation by Cardiac Magnetic Resonance in Asymptomatic Patients with Metal on Metal Hip Resurfacing

Personalized Medicine for Metal on Metal Hip Resurfacing: Predictors for the 10 Years Success of the Birmingham Hip Resurfacing

Background: Metal-on-metal hip resurfacing arthroplasty was introduced to preserve patients’ bone and facilitate revision surgery. This prospective cohort study aims to determine a prognostic model (OsBHR) to predict which patient and surgeon related factors predict better long term implant survival for the Birmingham Hip Resurfacing (BHR). Methods: Between 1997 and 2002, details of 4490 patients (4945 hips) treated by hip resurfacing arthroplasty using the BHR prosthesis were entered in a prospective international registry and available for analysis. Implant survival was determined using the Kaplan-Meier estimator and a shared frailty proportional hazard model was used to determine predictors of implant revision. Results: prognostic equation suggested a minimum diameter of 50 mm should be used for male and 52 mm for female patients to ensure a minimum 10-year survival rate of 95% for in procedures performed by an average surgeon. Conclusion: Implant survival at ten years and beyond strongly depends on component size and gender, varies between surgeons but is little affected by patient age. The OsBHR predictor allows a personalized estimated survival at ten years based on pre-operative variables.

P33 In-stent restenosis: the potential role of tribocorrosion

In the aftermath of the metal hip resurfacing scandal, the role of tribocorrosion products in pathological processes has been scrutinised. Recently, studies have shown that stents undergo corrosion and fatigue-based fracture in vivo, releasing metal ions and particulates into surrounding tissues; however the processes are not fully understood. Despite advances in biomaterials and stent design, in-stent restenosis remains a significant clinical problem, accounting for an approximate 20% failure rate. The aim of this study is to generate physiologically comparable tribocorrosion products and investigate their possible role in restenosis. Smooth muscle cells (SMCs) were explanted from saphenous vein tissue from patients undergoing coronary artery bypass surgery. Concentrations of heavy metal chloride salts representing corrosion products of common stent alloys (Co, Cr, Mo, Ni) were prepared to determine their effect on cell viability (MTT assay). Concentrations of chloride salt solutions were confirmed with ICP-MS. Cobalt ions induced a reduction in cell viability in a concentration-dependent manner by 50% at 300 ppm (p Galvanostatic potentiometry tests can be used to generate heavy metal ions electrochemically with corrosive processes. This study aims to compare the current approach of metal ion standards to tribocorrosion debris. A fretting wear rig will generate these and be tested using neo-intimal formation in an organ culture of human saphenous vein to investigate their potential effects on in-stent restenosis.

Migration pattern of a cobalt-chrome monoblock acetabular component after metal-on-metal hip resurfacing.

The purpose of this study was to study the initial fixation and migration pattern of a monoblock acetabular component used for a metal on metal hip resurfacing using Einzel Bild Roentgen Analyse (EBRA). 99 patients with a mean age of 49.6 years (range 28.5-66.3 years) of whom 14 were bilateral underwent a hip resurfacing (Conserve Plus®, MicroPort, Memphis, TN) for a total of 113 resurfacings. Acetabular component orientation was noted with 35 of the 113 components (31.0%) having a lucency &gt;2 mm on the immediate postoperative radiograph. The mean follow-up for our cohort of 113 hips is 50 months (2-79 months). When examining the 2-year migration mark, 37 of the 113 hips exceeded the threshold of 0.5 mm/year with a median total migration of 1.40 mm (range 1.02-4.24). 6 resurfacings underwent revision surgery for aseptic loosening of the acetabular component at a mean time of 43.6 months. Presence of initial lucency (OR 2.29, p = 0.05) was the only significant predictor of migration over threshold at 2-years. Those that had migrated over the threshold (1.0 mm) at 2 years were at significantly greater risk of continued migration at 4 years. The migration pattern of this component raises concerns about long term performance, with postoperative lucencies representing a significant factor for future migration.

Clinical Results of the Conserve Plus Metal on Metal Hip Resurfacing: An Independent Series

The purpose of the present study was to report the clinical and radiographic results of an independent series of the Conserve Plus hip resurfacing. Five hundred forty-eight consecutive hip resurfacings were performed using the Conserve Plus prosthesis in 458 patients (350 males) with a mean age of 48.3years (range 19 to 66). No patients were lost to follow-up. At a mean follow-up of 6.6years (3.9 to 11.9) thirty (5.4%) hips required conversion to a total hip arthroplasty (THA) (20 males, 10 females, mean age=48.3±7.3years). Five-year survival with as revision endpoint was 94.5% (95% CI: 93.5% to 95.5%). This study confirms the good clinical results previously reported with the Conserve Plus hip resurfacing device.

Groin Pain after Metal on Metal Hip Resurfacing: Mid-Term Follow-Up of a Prospective Cohort of Patients

Groin pain after metal on metal hip resurfacing has been previously reported. The purpose of this study was to determine the natural history of a cohort of patients with groin pain after hip resurfacing previously reported on and incidence of revision surgery. Our group previously reported an 18% incidence of groin pain at a mean of 18months post hip resurfacing. This cohort of groin pain patients was prospectively followed. Patients were evaluated using a visual analog pain rating score, the University of California at Los Angeles (UCLA) Physical Activity Index, and the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index. Functional outcome scores were compared from initial to latest follow up using the paired Student's t test. Further diagnostic evaluation and/or intervention or other complication was also recorded. The latest mean follow up from surgery was 63 ± 15months. The mean pain rating, UCLA, and WOMAC scores all improved at latest follow up, although WOMAC score improvement was not statistically significant. Mean pain rating score improved from 5.2 ± 2.0 to 2.5 ± 1.4 (p = 0.0001). UCLA activity score improved from 6.4 ± 2.0 to 6.9 ± 1.6 (p = 0.03). Total WOMAC score improved from 75.6 ± 20.5 to 84.5 ± 14.8 (p = 0.15). Only one patient was revised for an adverse local tissue reaction. Groin pain post hip resurfacing has a multifactorial etiology, and in the vast majority of cases improves over time with no significant functional limitations. However, the surgeon should be aware of the many potential causes, and help minimize the possibility with proper patient selection and surgical technique.

Metallosis, psoas abscess and infected hip prosthesis in a patient with bilateral metal on metal total hip replacement.

Metal on metal hip (MoM) resurfacing / replacement has recently been one of the most discussed topics in orthopaedics. Significant revision rates and complications are associated with MoM. We report a patient presenting with infection of a total hip prosthesis in conjunction with a psoas abscess in which the presentation is complicated by radiological evidence of suspected metallic debris in the lower limb tissues and elevated chromium and cobalt levels, suggestive of metallosis secondary to MoM.

Transplacental Passage of Metal Ions in Women with Hip Resurfacing: No Teratogenic Effects Observed

Over recent years, hip resurfacing has been performed in young, active patients, including women in their child bearing years. Current work investigating the transplacental passage of metal ions (cobalt and chromium) suggests significant passage of ions across the placenta in mothers with metal on metal hip resurfacing. In vitro studies show that cobalt and chromium can create DNA and chromosome damage in human cells. The consequences of this ion transfer on the child during fetal development and thereafter have not been fully quantified. We report on 3 patients with metal on metal hip resurfacings who had the prosthesis in situ during pregnancy. Our data show that umbilical cord blood chromium levels are under a quarter of the maternal serum levels. Cord blood cobalt levels are approximately half that of maternal blood. All 3 children are healthy. Although there was transplacental passage of ions, there was no significant effect on the child in these cases. We did not show any teratogenic effect of metal ions on the child, and this is consistent with the reported literature.

Hip Resurfacing and Pseudotumour

Metal on metal hip resurfacing has been used widely over the last ten years but there has been recent concern about destructive soft tissue reactions, which have been called pseudotumours by some authors. This has generated considerable controversy. This review explains why pseudotumours occur after resurfacing and how they can be prevented. It also supports the continued use of resurfacing in appropriate patients by appropriately trained surgeons.

Metal on metal hip resurfacing versus uncemented custom total hip replacement - early results

IntroductionThere is no current consensus on the most appropriate prosthesis for treating symptomatic osteoarthritis (OA) of the hip in young, active patients. Modern metal on metal hip resurfacing arthroplasty (HR) has gained popularity as it is theoretically more stable, bone conserving and easier to revise than total hip arthroplasty. Early results of metal on metal resurfacing have been encouraging. We have compared two well matched cohorts of patients with regard to function, pain relief and patient satisfaction.MethodsThis prospective study compares 2 cohorts of young, active patients treated with hip resurfacing (137 patients, 141 hips) and custom uncemented (CADCAM) stems (134 patients, 141 hips). All procedures were performed by a single surgeon. Outcome measures included Oxford, WOMAC and Harris hip scores as well as an activity score. Statistical analysis was performed using the unpaired student's t-test.ResultsOne hundred and thirty four and 137 patients were included in the hip replacement and resurfacing groups respectively. The mean age of these patients was 54.6 years. The mean duration of follow up for the hip resurfacing group was 19.2 months compared to 13.4 months for the total hip replacement group.Pre operative oxford, Harris and WOMAC scores in the THA group were 41.1, 46.4 and 50.9 respectively while the post operative scores were 14.8, 95.8 and 5.0. In the HR group, pre- operative scores were 37.0, 54.1 and 45.9 respectively compared to 15.0, 96.8 and 6.1 post operatively. The degree of improvement was similar in both groups.ConclusionThere was no significant clinical difference between the patients treated with hip resurfacing and total hip arthroplasty in the short term.

Clinical Experience with The Ganz Approach For Metal on Metal Hip Resurfacing

Hip resurfacing arthroplasty has recently gained more attention due to improvements in metallurgy and fixation. Although the posterior approach is the most commonly used, concerns remain in terms of risk of femoral neck fracture secondary to an osteonecrotic event. This study looks at the mid-term results of metal on metal hip resurfacing done by the vascular preserving surgical approach as developed by Ganz.

Total Hip Resurfacing as an Alternative to Total Hip Arthroplasty: Indications and Precautions

The concept of hip resurfacing arthroplasty is not new. Early designs by pioneers including Wagner, Freeman and Charnley failed mainly due to material, design and manufacturing flaws. Modern metal on metal hip resurfacing has become increasingly popular over the last decade however. Good early and intermediate results have been reported in young, active patients using this prosthesis. Theoretical benefits compared to conventional total hip arthroplasty (THA) include bone stock preservation, particularly on the femoral side, improved stability due to the large diameter bearing, improved range of motion and proprioception and technically less difficult revision to a total hip arthroplasty if necessary. This prosthesis must be used with strict indications however as the technique is more demanding than conventional THA and imperfect positioning of either the acetabular or femoral component are associated with complications. Unique complications thought to be due to hypersensitivity reactions have also been reported. This article outlines the evolution of hip resurfacing arthroplasty and discusses new designs, surgical techniques and potential complications, all of which the surgeon needs to be familiar with.

Hip resurfacing arthroplasty for secondary osteoarthritis after developmental dysplasia of hip

To study the clinical results of metal on metal hip resurfacing arthroplasty for developmental dysplasia patients. From March 2005 to December 2006, 34 cases of developmental dysplasia patients (Crowe I, Crowe II) were attempted to have metal on metal hip resurfacing arthroplasty. There were 29 females (32 hips), 5 males (5 hips). The average age was 45 (26 - 57) years old. Radiographic and clinical evaluations were taken at 6 weeks, 3 months, 1 year and then once a year postoperatively. The average Harris score was 35 (25 - 44). Hip flexion was 101 degrees , abduction 24 degrees , adduction 15 degrees . Three patients were turned to total hip arthroplasty during operations. Thirty-one patients (34 hips) received hip resurfacing surgery. These 31 patients were followed for average 21.4 months (12 - 33 months). The average Harris score was 94 (82 - 100) at the latest follow-up, and there was statistical difference compared with the preoperative score (P < 0.01). Hip flexion increased to 133 degrees , abduction to 48 degrees , adduction to 26 degrees . No radiolucency line was found at both acetabular and femoral sides in all the patients. The average abduction angle of acetabular cup was 43 degrees (40 degrees - 53 degrees ), and the average stem shaft angle was 139 degrees (130 degrees - 145 degrees ). The short term result is excellent. While the mid to long term results for hip resurfacing arthroplasty in developmental dysplasia patients are still looking forward, and the meticulous surgical technique and strict patient selection are the key of the good results.

Minimum 4 Year Follow-up Results of Metalon Metal Hip Resurfacing Arthroplasty

Purpose : To report the minimum 4 year follow up results of metal on metal hip resurfacing arthroplasty. Materials and Methods : 39 hips from 36 patients, who received hip resurfacing from November 1998 to September 2001 and were followed up for at least 4 years, were enrolled in this study. The average age was 45 years (28-69 years) and the average follow up period was 51.9 months (48-82 months). A clinical evaluation was performed with the Harris Hip Score and gait analysis postoperatively. A radiologic evaluation was performed regularly after surgery using anteroposterior and lateral simple radiographs. The post-operative cobalt-chrome serum concentration was measured and compared using 21 cases of ceramic-on-ceramic total hip arthroplasty as a control group. Results : The Harris Hip Score improved from 61 points (31-74) preoperatively to 96 points (85-99) postoperatively. There were no cases of acetabular loosening, and the average angle of femoral insert to the shaft was 136˚ with 22 hips (61.1%) being within 130-140˚. The 4 year follow-up survival rate was 97.4%. The serum cobalt and chrome levels were higher than the control group (p＜0.05). Conclusion : Hip resurfacing showed excellent survival rate after a short-term follow-up, but still requires a long-term evaluation with more cases and further metal ion release studies.

Hip resurfacing: Past, present and future

Summary Over the last 10 years hip resurfacing has gained popularity as a surgical alternative to a total hip replacement, for the younger, active patient suffering from arthritis or similar conditions. Hip resurfacing was originally developed over 50 years ago, but was plagued with problems during the early years. By the 1980s the use of hip resurfacing had been discontinued by most surgeons, due to the high failure rate of the prosthesis from wear and tear of the polyethylene cups and aseptic loosening. The purpose of this article is to define hip resurfacing, explain what the procedure entails and to examine the potential benefits, risks and complications of the procedure. The patient's journey from joining the waiting list, through to outpatient follow-up is examined and nursing care described. As metal on metal hip resurfacing is considered to be a fairly new surgical procedure and long-term outcomes are not known, the role of the research nurse in monitoring outcomes for this patient group is also examined.