Metal-on-metal Total Hip Arthroplasty Research Articles

The relationship between pseudotumours and infected complications in patients who have undergone metal-on-metal total hip arthroplasty.

This study aims to assess the relationship between history of pseudotumour formation secondary to metal-on-metal (MoM) implants and periprosthetic joint infection (PJI) rate, as well as establish ESR and CRP thresholds that are suggestive of infection in these patients. We hypothesized that patients with a pseudotumour were at increased risk of infection. A total of 1,171 total hip arthroplasty (THA) patients with MoM articulations from August 2000 to March 2014 were retrospectively identified. Of those, 328 patients underwent metal artefact reduction sequence MRI and had minimum two years' clinical follow-up, and met our inclusion criteria. Data collected included demographic details, surgical indication, laterality, implants used, history of pseudotumour, and their corresponding preoperative ESR (mm/hr) and CRP (mg/dl) levels. Multivariate logistic regression modelling was used to evaluate PJI and history of pseudotumour, and receiver operating characteristic curves were created to assess the diagnostic capabilities of ESR and CRP to determine the presence of infection in patients undergoing revision surgery. The rate of PJI for all identified MoM THAs was 3.5% (41/1,171), with a mean follow-up of 10.9 years (2.0 to 20.4). Of the patients included in the final cohort, 8.2% (27/328) had PJI, with a mean follow-up of 12.2 years (2.3 to 20.4). Among this cohort, 31.1% (102/328) had a history of pseudotumour. The rate of PJI in these patients was 14.7% (15/102), which was greater than those without pseudotumour, 5.3% (12/226) (p = 0.008). Additionally, logistic regression analysis showed an association between history of pseudotumour and PJI (odds ratio 4.36 (95% confidence interval 1.77 to 11.3); p = 0.002). Optimal diagnostic cutoffs for PJI in patients with history of pseudotumour versus those without were 33.1 mm/hr and 24.5 mm/hr for ESR and 7.37 mg/dl and 1.88 mg/dl for CRP, respectively. Patients with history of pseudotumour secondary to MoM THA had a higher likelihood of infection than those without. While suspicion of infection should be high for these patients, ESR and CRP cutoffs published by the European Bone and Joint Infection Society may not be appropriate for patients with a history of pseudotumour, as ESR and CRP levels suggestive of PJI are likely to be higher than for those without a pseudotumour. Additional investigation, such as aspiration, is highly recommended for these patients unless clinical suspicion and laboratory markers are low.

Long-Term Outcome of Metal-on-Metal Total Hip Arthroplasty with Modular Neck Stem.

Background: This study aimed to report the long-term outcomes of total hip arthroplasty (THA) using a Conserve Plus (Wright Medical, Japan) metal-on-metal (MoM) acetabular prosthesis with a modular neck stem. Methods: This study enrolled 50 patients (10 men and 40 women; mean age, 65.8 (39-87) years) who underwent primary THA using a Conserve Plus MoM acetabular prosthesis with a modular neck stem. The preoperative diagnosis in most patients was osteoarthritis. Clinical function of hip joint outcomes was investigated using the Japanese Orthopedic Association (JOA) hip score preoperatively and at the final follow-up. The perfect JOA hip score was 100, while the worst score was 0. Radiological analyses were evaluated during the final follow-up visit. Magnetic resonance imaging (MRI) images were evaluated to screen for pseudotumors in 43 hips postoperatively. Results: Six patients did not visit before their 10-year follow-up for unknown reasons. Therefore, 44 patients were evaluated at a mean of 11-years of follow-up (10-12 years). The mean (±SD) preoperative JOA hip score of 44.2 (±15.5) improved significantly to 85.1 (±12.9) postoperatively at the final follow-up (n = 36 hips, excluding eight revision cases). One patient underwent femoral fixation for a periprosthetic fracture due to trauma that occurred 4 years postoperatively. Spot welds were identified in 93.2% (41/44 hips) of cases. Severe (third- and fourth-degree) stress shielding was identified in 40.9% (18/44 hips) of cases. Twenty-two patients (51.2%) had pseudotumors attributable to MoM articulation based on MRI results, 2 to 10 years after arthroplasty. Three hips showed cup osteolysis (7%) and three showed trochanteric region osteolysis (7%). There were seven cup and/or three stem revisions for aseptic loosening and/or osteolysis at 4 months (with trauma) and 3.3 to 11 years (with pseudotumor) postoperatively. The Kaplan-Meier survivorship for the THA construct in this group was constant at 93.0% and 75.9% at 10 and 12 years after arthroplasty, respectively. The rates of survivorship of revision and loss of follow-up at 10 and 12 years were 83.9% and 66.8%, respectively. Conclusions: In summary, we reported on the long-term treatment results of MoM THA, precautions based on our cohort's findings, and the measures taken to address these issues, such as revision replacement and its outcomes. Clinical scores revealed good outcomes during the mean 11-year follow-up period. However, the prevalence of pseudotumors (PTs) was 51.2%. Some cases required revisions even after the 10 years following surgery. This is because in MoM THA, PT occurrence increases over time, and as a result, there were cases in which revised THA was required even after 10 years.

METAL-ON-METAL HIP PROSTHESIS: A RETROSPECTIVE STUDY OF 681 IMPLANTS WITH A FOLLOW-UP OF BETWEEN 12 AND 22 YEARS

Previous scientific studies have highlighted how coupling is an important element affecting total hip arthroplasty's survival.This study aims to evaluate whether metal-on-metal (MOM) coupling could be a statistically significant risk factor.The data from the regional joint registry (Registro dell'Impiantologia Protesica Ortopedica, RIPO) was used for analysis. The data collection accuracy of this registry was 97.2% in 2017.We retrospective evaluate all MOM total hip arthroplasties (THAs) implanted in our department between January 01st 2000 and December 31st 2011. We used a control group composed by all other prosthesis implanted in our Department in the same time lapse.We registered 660 MOM THAs. Mean age of patients was 66.9 years. 603 patients have a >36mm head, while 78 a <36 mm one. Neck modularity was present in half of patients. 676 implants were cementless. We registered 69 revisions, especially due to aseptic mobilization (16 THAs), implant breakage (9 THAs) and periprosthetic fracture (6 THAs).The MOM THAs overall Kaplan-Meier survival rate was 87.2 at 15 years, and the difference between MOM THAs and other implants two curves is statistically significant (p<0.05). Male sex is a significant risk factors. Further evaluations are in progress to establish the presence of any additional risk factors. We think weight and/or BMI may be included in this category.Our study confirms the data currently present in the literature regarding a lower survival of metal-on-metal hip prostheses.The male sex is a statistically significant risk factor (p<0.05), while age, head size and modularity of the prosthetic neck are not statistically significant (p>0.05).Any new finds will be presented at the congress venue.

Long-term systemic effects of metal-on-metal hip arthroplasty: a systematic review

Metal-on-metal (MoM) hip arthroplasty has been the subject of extensive research due to concerns regarding adverse reactions to metal debris and implant-related complications. This comprehensive review aimed to synthesize the existing literature on MoM hip arthroplasty outcomes, incorporating diverse study designs and examining various parameters such as histopathological features, blood metal ion concentrations, and implant survival rates. A systematic literature search was conducted across multiple databases up to January 2024, utilizing relevant keywords related to MoM hip arthroplasty. The inclusion criteria covered studies in English, involving human subjects who underwent MoM hip arthroplasty, with a focus on case series, observational studies, cohort studies, and randomized controlled trials. Eighteen studies were included, providing a diverse perspective on MoM hip arthroplasty outcomes. Key outcomes, including greater trochanteric fragmentation, spectrum of changes in adverse reactions to metal debris, peri-implant pseudotumor tissue characteristics, elevated blood cobalt concentrations, and complications associated with large-diameter MoM total hip arthroplasty, were systematically presented. The synthesis of findings revealed the multifaceted nature of MoM hip arthroplasty outcomes. Elevated blood cobalt concentrations emerged as a significant risk factor for early implant failure, while the spectrum of changes in adverse reactions highlighted the complexity of tissue responses. The comprehensive analysis contributes to the understanding of MoM hip arthroplasty outcomes, guiding future research and informing clinical decision-making in orthopedics.

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.

Identification of protective and 'at risk' HLA genotypes for the development of pseudotumours around metal-on-metal hip resurfacings.

Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. 'Controls' were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size. Using a previously-reported ALVAL classification, the majority of pseudotumour-positive caseswere found to have intermediate-grade group 2 (n = 10; 63%) or group 3 (n = 4; 25%) histological findings. Two further patients (13%) had high-grade group 4 lesions. HLA-DQB1*05:03:01 (p = 0.0676) and HLA-DRB1*14:54:01 (p = 0.0676) alleles were significantly associated with a higher risk of pseudotumour formation, while HLA-DQA1*03:01:01 (p = 0.0240), HLA-DRB1*04:04:01 (p = 0.0453), HLA-C*01:02:01 (p = 0.0453), and HLA-B*27:05:02 (p = 0.0855) were noted to confer risk reduction. These findings confirm the association between specific HLA genotypes and the risk of pseudotumour development around MoM hip resurfacings. Specifically, the two 'at risk' alleles (DQB1*05:03:01 and DRB1*14:54:01) may hold clinical value in preoperative screening and prospective surgical decision-making.

Metal-on-Metal Hips: Ten-Year Clinical and Radiographic Outcomes of the ADEPT Metal-on-Metal Hip Resurfacing and Modular Total Hip Arthroplasty.

The aim of this study is to update the 10-year follow-up survivorship and metal ions levels of a cohort of metal-on-metal (MoM) hip resurfacing (HR) and large-diameter-head (LDH) total hip arthroplasty (THA). The study is a retrospective analysis of prospectively collected data that compared the outcomes of 24 MoM HR (21 patients) and 15 (11 patients) modular LHD MoM THA at >10 years follow-up. Baseline characteristics as well as intraoperative and postoperative information were collected, including complications, revisions, clinical and radiographic outcomes, and serum metal ions level (Cobalt, Chromium). Metal ion levels were compared using a two-tailed unpaired t-test and Wilcoxon signed-rank test (jamovi v2.3.3.0, Sydney, NSW, AU). No significant differences were detected in gender, BMI, and ASA score between the two groups. Patients in the modular THA group were significantly older (57 years vs. 46 years; p < 0.05). The HR overall survivorship was 91.7% (22 of 24 hips) with survivorship from implant failure and/or aseptic loosening and/or metal debris related 100% of problems. The modular THA overall survivorship was 86.7% (13 of 15 hips) with survivorship from implant aseptic loosening and metal ions complications of 93.4% (14 of 15 hips). No significant difference was noted when comparing clinical outcomes. Metal ions were significantly lower in the HR group (Co 25.8 nmol/L vs. 89 nmol/L; p < 0.001-Cr 33.5 nmol/L vs. 55.2 nmol/L; p = 0.026). Both implants reported excellent and comparable clinical outcomes at >10 years follow-up. The Adept HR reported remarkable survivorship, in line with the registry data, proving once again its reliability in young active males. The modular LDH THA, despite being discontinued, presented higher reliability and a lower failure rate when compared with similar withdrawn MoM implants. Trunnionosis did not appear to be a significant problem in this particular modular design.

Survival rates of different bearing surfaces with the same model of stem in total hip arthroplasty: predictive factors for revision surgery.

Few studies have examined the survival rates of total hip arthroplasty (THA) with the same femoral stem, and the predictive factors leading to the revision of stemmed metal-on-metal (MoM) THA remain unknown. We determined the long-term survival rate of stemmed MoM THA compared with that of metal-on-polyethylene (MoP) bearing THA, the effect of head size and cup placement angle on revision rate, and predictors of revision. A total of 130 hips in 110 patients who underwent primary THA by the same surgeon were included. M2a-RingLoc with a metal-on-polyethylene bearing (group P, 53 hips), M2a-Taper with MoM bearing (group T, 44 hips), and M2a-Magnum with MoM bearing (group M, 33 hips) were used. The mean age at surgery was 63.1 ± 9.5years, and the mean postoperative follow-up duration was 133.7 ± 39.1months. Whole blood metal ion concentrations were measured preoperatively and postoperatively, and magnetic resonance imaging was performed to identify aseptic local tissue reactions (ALTRs). Kaplan-Meier survivorship analysis and multiple logistic regression analysis were performed. The THA survival rate up to the maximum postoperative follow-up period was 96.2% at 173months, 46.6% at 179months, and 47.8% at 145months in groups P, T, and M, respectively, with revision as the endpoint. The stemmed MoM THA recorded a very low survival rate (p < 0.001). The ALTR rates were 70.5% and 63.6% in groups T and M, respectively. The risk factor for revision was the use of MoM bearing, and there was no difference in the results based on the head size in group M. Cobalt levels continued to increase postoperatively, although they were not accurate predictors of revision. Stemmed MoM THA has a very low survival rate and should be used with caution. It is important to monitor the patient's symptoms and perform appropriate imaging to ensure timely revision.

No difference in implant survival between 28-mm M2a RingLoc metal-on-metal and metal-on-polyethylene total hip arthroplasty: results from the Finnish Arthroplasty Register.

Long-term outcome of small head (28 mm) metal-on-metal (MoM) total hip arthroplasty (THA) is available mainly for Metasul devices (Sulzer Medica, Winterthur, Switzerland). Biomet MoM THA was frequently used in Finland. Therefore, we assessed long-term survivorship of the M2a 28-mm RingLoc MoM THA (Biomet, Warsaw, IN, USA) and compared it with the metal-on-polyethylene (MoP) RingLoc THA from the same manufacturer. We conducted a register study based on THAs from the Finnish Arthroplasty Register performed between January 1, 2000 and December 31, 2007. 290 28-mm head M2a MoM THAs and 1,647 28-mm head MoP THAs (reference group) were included. The endpoint was revision for any reason, or revision for aseptic loosening, osteolysis, liner wear, or metallosis as one group. Kaplan-Meier survival estimates were calculated, and revision risks were assessed using a Cox multiple regression model, both with 95% confidence intervals (CI). No difference was found in the 15-year Kaplan-Meier survivorship between the 28-mm head M2a RingLoc MoM THA and the reference group for any reason for revision (87.7% [82.9-92.1] and 83.3% [81.0-85.3], respectively). The adjusted hazard ratio (HR) for any reason for revision for the MoM THA group compared with the reference group was at least equal or better (0.70 [0.48-1.02]). Both groups presented similar survival for revision for aseptic loosening of the cup, osteolysis, liner wear, or metallosis, at 96.2% (92.7-98.0) and 95.4% (93.9-96.5), respectively. In the long-term survival there was no difference between the M2a 28-mm RingLoc MoM THA and 28-mm MoP THA. Further follow-up regimens for M2a 28-mm RingLoc THA patients may be unnecessary, but long-term metal ion and radiological data is needed before any formal suggestions.

Midterm Results of Contemporary Uncemented Total Hip Arthroplasty in Patients 45 Years or Younger.

Total hip arthroplasty (THA) in young patients has varying results, and some reports show inferior results when compared with those of older patients. This study evaluated the outcomes of contemporary uncemented THA in patients 45 years or younger. This was a retrospective review from 2003 to 2015 at an academic institution. Three hundred one uncemented THAs in 232 patients 45 years or younger were evaluated. All patients had a minimum follow-up of 5 years. Ninety-day complications, survivorship free of revision, and dislocations were evaluated. Mean age was 35.7 years, 43.1% of patients were women, and mean follow-up was 9.3 years. Ninety-day complications included 26 emergency department visits, 11 readmissions, 3 revisions, and 3 dislocations. The rate of 10-year survivorship free of revision was 85.5%, and the rate of 10-year survivorship free of aseptic revision was 87.7%. Excluding metal-on-metal (MOM) THAs, 10-year aseptic survivorship was 93.3%. The most common reasons for revision were adverse local tissue reaction after MOM THA (16 hips) and periprosthetic joint infection (6 hips). In a multivariable logistic regression model, sickle cell disease (SCD) and conversion THA were associated with 90-day readmissions. Both MOM THA and SCD were associated with revision (P<.05). Patients who are 45 years or younger undergoing THA (excluding MOM articulation) had a rate of 10-year survival free of aseptic revision of 93.3%. At 9.3 years' mean follow-up, THA in young patients was associated with low revision rates with acceptable risk of prosthetic joint infection and dislocation. Patients with SCD are at increased risk for early readmission and revision at latest follow-up. [Orthopedics. 2023;46(1):e45-e51.].

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.

Survivorship of a Metal-on-Metal Total Hip Implant With Modular Titanium Adapter.

Use of metal-on-metal (MoM) articulations in total hip arthroplasty (THA) has sharply declined due to high failure rates from metal-related complications. Although certain MoM designs have demonstrated only 46% survival, not all MoM designs have performed the same. The purpose of this study is to evaluate mid-term to long-term survival of a specific MoM implant with a modular titanium taper adapter. A retrospective review was performed on all patients who underwent primary THA at our center with the M2a-Magnum system (Zimmer Biomet, Warsaw, IN). Of 829 patients (956 hips) identified, 754 patients (869 hips) met inclusion criteria of signed research consent, minimum 2-year follow-up, and/or any revision surgery. Mean follow-up was 11.0 years (range 2-16; ±3.5). Mean cup angle of inclination was 42.8° (range 24°-70°, ±6.3°), with 88.0% reconstructed within the 40° ± 10° safe zone. There were 64 revisions (7.36%): 7 (0.81%) septic and 57 (6.56%) aseptic. Of those, 32 (3.68%) were adverse reactions to metal debris. Kaplan-Meier survival free of revision for all causes was 88.6% at 16 years (95% confidence interval 86.8-90.4). Univariate analysis of risk factors for all-cause, aseptic, and adverse reaction to metal debris revision found no relationship with female gender, age ≥65 years, body mass index >30 kg/m2, higher activity level, or inclination angle outlier. The results of this study demonstrate a more favorable mid-term to long-term survivorship with this specific MoM implant compared to other designs. Although our institution no longer performs MoM THA, further investigation into differences in MoM implant designs is warranted.

Poor Patient Follow-up After Metal-on-Metal Total Hip Arthroplasty.

Routine follow-up approximately every 2 to 5 years after total hip arthroplasty (THA) is a common practice. However, although patients are informed of the importance of follow-up, our mean follow-up rate for patients after standard non-metal-on-metal (MOM) THA is only 19%. The US Food and Drug Administration has released several statements on the importance of follow-up every 2 years after MOM THA. With the potential risks of MOM THA apparently widely known, we report on our ability to obtain timely follow-up at 2 separate centers. Two separate centers performed 570 MOM THA procedures between 2002 and 2010. An attempt was made to reach every patient by either telephone or letter to obtain ion levels, radiographs, and examinations. Repeat telephone calls and/or letters to those not reached were made annually. Patients were told of the unique importance of follow-up at each contact. Of the patients, 43% had not been seen within the past 5 years, and only 26% had been seen within the past 2 years. Only 61% had their first measurement of ion levels, and only 30% of patients had a second set of measurement of ion levels. A total of 48 revisions occurred in this group, and 36 patients died. Despite the apparent widespread dissemination of information regarding the potential risks of MOM THA and concerted efforts to contact patients for follow-up, we have been able to achieve a follow-up rate of only 26%. This rate is only marginally better than the mean follow-up for non-MOM THA in our practices. The implications of this poor follow-up are unknown. [Orthopedics. 2022;45(4):e196-e200.].

Ten-year results of a prospective cohort of large-head metal-on-metal total hip arthroplasty : a concise follow-up of a previous report.

AimsLarge-diameter metal-on-metal (MoM) total hip arthroplasty (THA) has demonstrated unexpected high failure rates and pseudotumour formation. The purpose of this prospective cohort study is to report ten-year results in order to establish revision rate, prevalence of pseudotumour formation, and relation with whole blood cobalt levels.MethodsAll patients were recalled according to the guidelines of the Dutch Orthopaedic Association. They underwent clinical and radiographical assessments (radiograph and CT scan) of the hip prosthesis and whole blood cobalt ion measurements. Overall, 94 patients (95 hips) fulfilled our requirements for a minimum ten-year follow-up.ResultsMean follow-up was 10.9 years (10 to 12), with a cumulative survival rate of 82.4%. Reason for revision was predominantly pseudotumour formation (68%), apart from loosening, pain, infection, and osteolysis. The prevalence of pseudotumour formation around the prostheses was 41%, while our previous report of this cohort (with a mean follow-up of 3.6 years) revealed a 39% prevalence. The ten-year revision-free survival with pseudotumour was 66.7% and without pseudotumour 92.4% (p < 0.05). There was poor discriminatory ability for cobalt for pseudotumour formation.ConclusionThis prospective study reports a minimum ten-year follow-up of large-head MoM THA. Revision rates are high, with the main reason being the sequelae of pseudotumour formation, which were rarely observed after five years of implantation. Blood ion measurements show limited discriminatory capacity in diagnosing pseudotumour formation. Our results evidence that an early comprehensive follow-up strategy is essential for MoM THA to promptly identify and manage early complications and revise on time. After ten years follow-up, we do not recommend continuing routine CT scanning or whole cobalt blood measurements, but instead enrolling these patients in routine follow-up protocols for THA.Cite this article: Bone Jt Open 2022;3(1):61–67.

Outcome of revised metal-on-metal hip arthroplasties: a Dutch arthroplasty register study.

Preliminary results of metal-on-metal (MoM) hip arthroplasty were satisfactory, but since 2004 data showed high failure rates. National joint replacement registries are multi-centre databases comprised of thousands of subjects and implants which allow for identifying variables predictive of implant failure. The aim of the current study was to estimate re-revision rates after revision of a primary MoM hip arthroplasty in the Dutch Arthroplasty Register (LROI) and to assess potential predictor variables of re-revision of these MoM hip arthroplasties. Eligible procedures were those with a revision for any reason except infection, after an initial primary surgery with a hip resurfacing (HRA) or large-head MoM (LH-MoM) total hip arthroplasty (THA). The probability of re-revision for both types of MoM hip arthroplasty over time was estimated using the cumulative incidence function taking mortality as a competing risk into account. A proportional sub-distribution hazards regression model was used to assess potential predictor variables of re-revision of these MoM hip arthroplasties. A total of 3476 records of revised implants were included, of which 873 (25.2%) were MoM implants. Over the course of follow-up, 101 (11.5%) MoM implants were re-revised. During follow-up 36 (4.3%) patients who received a MoM-implant at primary arthroplasty and a revision afterwards had died. The regression model showed that for primary MoM implants a MoM articulation after revision (HR 2.48; 95% CI 1.53-4.03, p < 0.001), femoral-only revisions (HR 3.20; 95% CI 2.06-4.99, p < 0.001) and periprosthetic fractures (HR 1.98; 95% CI 1.03-3.82, p = 0.042) as reason for the first revision were statistically significant risk factors for re-revision. Both types of large-head MoM hip arthroplasties have shown high revision and re-revision rates; risk factors were identified. The outcome of this study can be helpful in managing expectations of patients and orthopaedic surgeons.

Do cobalt and chromium blood metal ion levels normalize after revision of failed metal-on-metal total hip replacements?

Increased cobalt (Co) and chromium (Cr) serum levels are one reason for revision surgery in metal on metal (MoM) total hip arthroplasty (THA) patients. Dual mobility liners are a simple revision option; however, they preserve the metal shell and stem and it is thereforenot clear if metal ion levels will fully normalize after revision surgery. Between April 2013 and December 2017 25 hips (24 patients) underwent revision from a MoM THA to an off-label dual mobility liner. Five patients were lost to follow-up and one patient refused leaving 18 patients (11 men, 7 female, average age 63.9years) for pre- and postoperative metal ion level blood tests at a minimum follow-up of 2years. Fourteen patients were revised for osteolysis, two for elevated metal ion levels and two for fluid or cysts around the femoral or acetabular component. The average preoperative Co and Cr levels were 8.3µg/l and 5.0µg/l, respectively. At a minimum follow-up of 2years (30-95months), metal ions dropped to 0.8µg/l. Harris Hip Score (HHS), Hip Osteoarthritis Outcome Score (HOOS), Visual Analog Scale (VAS) and the UCLA activity score improved non-significantly from pre- to postoperative. There was one postoperative complication in the study cohort. One patient with persisting pain required revision surgery to a standard acetabular component during the follow-up period. The off-label use of a dual-mobility liner in the current study resulted in normalization of the metal ion levels suggesting that preserving the cobalt-chromium acetabular component has little impact on ion levels. In addition, dual mobility liners have a low complication and revision rate.

Prevalence of groin pain after primary dual-mobility total hip arthroplasty.

Instability remains a challenging problem following total hip arthroplasty (THA). Dual-mobility (DM) components are used with increasing frequency to mitigate this potential complication. As has been shown with larger metal-on-metal (MoM) THA, the larger size femoral head may pose an increased risk of groin pain. This study aims to evaluate the prevalence of groin pain following primary DM THA compared to other THA constructs. We identified 190 primary THAs (183 patients) performed with DM components at a single academic institution from 2008 to 2017. We retrospectively reviewed standardised patient questionnaires and the electronic medical record to determine the prevalence of groin pain. DM patients were compared to historical controls of 39 MoM hip resurfacing, 26 large-head MoM THA, and 217 conventional THA. Mean age was 64 years, 58% were female, mean body mass index was 30 kg/m2, and mean follow-up was 3.5 years (range 2-8 years). The prevalence of groin pain in patients with DM components was 5%, similar to the prevalence reported by patients with conventional THA (7%). There was a decreased prevalence of groin pain in DM patients compared to hip resurfacing (18%) and MoM THA (15%). Among the 9 DM patients with groin pain, 1 was treated with iliopsoas injection, and 1 underwent radiofrequency ablation of the articular nerve. This study documents a relatively low prevalence of groin pain among primary DM THA patients. This is comparable with historical controls of conventional THA and decreased compared to hip resurfacing and large head MoM THA.

Chromium and cobalt in blood and serum in the surveillance of metal-on-metal hip implants

Objective. The aim of this study is to evaluate the relationship between serum and whole blood chromium and cobalt levels in a group of patients with metal-on metal total hip arthroplasty (Depuy ASR™). A conversion formula was developed to allow adequate evaluation of patients and correctly interpret the measured value. Methods. The authors retrospectively reviewed a series of 150 patients and prospectively analysed 64 patients who satisfied inclusion criteria. We collected data by taking simultaneously sample of chromium and cobalt ionemia from blood and serum.Results. Statistical analyses revealed significant differences between chromium and cobalt values in serum and whole blood (p 0.007), but with a strong positive correlation for both chromium (r 0.927) and cobalt (r 0.935). The authors also calculated a conversion formula to convert whole blood ion levels into serum levels, Cr se = -0.32582 + 1.39018*Cr WB for chromium and Co se = 0.239637 + 0.804279* Co WB, for cobalt. Conclusions. The difference between serum and blood values of chromium and cobalt is highlighted in a strong positive correlation. The development of the conversion formula allows to better interpret laboratory data and improve care and monitoring of patients.

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.

Outcome of revision surgery for adverse local tissue reactions in patients with recalled total hip arthroplasty.

Recalls of total hip arthroplasty (THA) implants, including metal-on-metal (MoM) THA and dual taper stems, due to increased risk of adverse local tissue reaction (ALTR), represent a challenge for both surgeons and patients. This study aims to analyze the revision surgery outcomes for ALTR in patients with recalled THA implants. A total of 118 consecutive patients who underwent revision surgery due to ALTR with recalled THA were analyzed. Sub-group analysis was performed for recalled MoM THAs, head-neck modular stems, and dual taper neck-stems. At a mean follow-up of 6.6years, the complication and reoperation rates of the recalled THAs were 32.2% and 25.4% respectively. The most common post-revision complication was dislocation (16%). Revision of modular taper corrosion THA and high-grade intraoperative tissue damage were risk factors associated with post-revision complications. This study reports high complication and reoperation rates of recalled THAs at mid-term follow-up. The high revision surgery complication rates in both groups suggest the importance of a systematic evaluation of all THA patients with at-risk implants. Level III, case control retrospective analysis.