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Pearce O, Matharu GS, Bolland BJ. Predictive Factors for Revision and Survivorship Analysis of a Prevalent 36-mm Metal-on-Metal Total Hip Replacement System: A Large Single-Center Retrospective Cohort Study. J Arthroplasty 2021; 36:1380-1387. [PMID: 33189496 DOI: 10.1016/j.arth.2020.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/11/2020] [Accepted: 10/15/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To our knowledge, this is the largest single-center cohort of the 36-mm Corail-Pinnacle metal-on-metal total hip replacements system, aiming to determine 10-year survivorship and identify predictors of revision. We further assessed year of implantation given reports of manufacturing variations affecting shells made after 2006 predisposing these components to increasing wear. METHODS All Corail-Pinnacle 36-mm metal-on-metal hips implanted in a single center (2005-2012). The effect of patient and implant-related variables, and year of implantation on revision risk was assessed using Kaplan-Meier, Cox regression, and interrupted time series analysis. RESULTS In total, 1212 metal-on-metal total hip replacements were implanted with a 10-year survival rate of 83.4% (95% confidence interval [CI] = 81.3-85.5). Mean follow-up duration was 7.3 years with 61% of patients reaching a minimum of 7 years of follow-up. One hundred nineteen patients required revision surgery (9.8%). Univariate analysis identified female gender (hazard ratio [HR] = 1.608, CI = 1.093-2.364, P = .016), age at implantation (HR = 0.982, CI = 0.968-0.997, P = .019), smaller 50-mm to 54-mm cup diameter (HR = 1.527, CI = 1.026-2.274, P = .037), and high-offset stems (HR = 2.573, CI = 1.619-4.089, P < .001) as predictors of revision. Multivariate modeling confirmed female gender and high-offset stems as significant predictors of revision. For components implanted after 2007, the number of revisions showed no statistically significant step increase compared to pre-2007 implantation. CONCLUSION We observed a high 10-year failure rate (16.6%) with this implant, mostly due to adverse reaction to metal debris. Female gender and high femoral offset stems were significant predictors for all-cause revision. Year of implantation was not significantly associated with an increasing number of revisions from 2007 onwards, although further studies to validate the impact of manufacturing discrepancies are recommended.
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Affiliation(s)
- Oliver Pearce
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom
| | - Gulraj S Matharu
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Ben J Bolland
- Department of Orthopaedic Surgery, Musgrove Park Hospital, Taunton, United Kingdom
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Jiao X, Li Z, An S, Huang J, Yang G, Zhao Y, Shen J, Chu Y, Yang CC, Cao G. An elderly female with adult-onset Still's disease initially misdiagnosed as prosthetic joint infection after total knee arthroplasty: lessons in differential diagnosis and treatment. BMC Geriatr 2020; 20:512. [PMID: 33246419 PMCID: PMC7694938 DOI: 10.1186/s12877-020-01925-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High fever, knee swelling and pain after knee arthroplasty are often considered as symptoms of acute prosthetic joint infection. However, similar symptoms can also present as primary manifestations of adult-onset Still's disease, which creates some interference in differential diagnosis. To our knowledge, this is the first published case of misdiagnosis of adult Still's disease after total knee arthroplasty, who was initially misdiagnosed as an prosthetic joint infection due to the above-mentioned symptoms. The symptoms of the knee infection was not relieve after several revisions and continous antibiotic treatment. Finally, after several consultations and repeated evaluation it was diagnosed as adult-onset Still's disease. CASE PRESENTATION A 77-year-old female who underwent bilateral total knee arthroplasty 6 years ago was admitted to our hospital with high fever, right knee effusion and painful knee. Based on the results of joint fluid aspiration and culture, we treated the right knee as acute hematogenous prosthetic joint infection. After three debridement and revision surgeries, the patient's symptoms continued to persist. Subsequent manifestations of other symptoms such as typical rash and sore throat and laboratory examination suggested the possibility of adult-onset Still's disease. So she underwent diagnostic steroid hormone therapy at the recommendation of a rheumatologist, and a final revision was performed after symptom was controlled. At the one-year follow-up, the patient's symptoms completely resolved and the knee revision was functioning well. CONCLUSIONS When joint swelling and pain occurs after knee arthroplasty, the possibility of joint infection should not only be considered, but rheumatic autoimmune diseases should also be differentiated. Because the manifestations of joint infection and rheumatic immune disease sometimes overlap highly, when reasonable treatment over a period of time fails to relieve symptoms and signs, we should notice subtle differences in symptoms and laborotary tests and look for other diagnostic possibilities in time.
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Affiliation(s)
- Xufeng Jiao
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Zheng Li
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Shuai An
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Jiang Huang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Guangzhong Yang
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Yi Zhao
- Department of Rheumatology and Immunology, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Jianghua Shen
- Department of Pharmacy, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Yanqi Chu
- Department of Pharmacy, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Charlie C Yang
- Colorado Joint Replacement, 2535 S Downing Street, Suite 100, Denver, CO, 80210, USA
| | - Guanglei Cao
- Department of Orthopedics, Xuanwu Hospital Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.
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Engh CA, McAsey CJ, Cororaton AD, Ho H, Hopper RH. Have newer bearing surfaces changed expectations regarding the longevity of total hip arthroplasty? Bone Joint J 2020; 102-B:105-111. [PMID: 32600211 DOI: 10.1302/0301-620x.102b7.bjj-2019-1545.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The purpose of this study is to examine six types of bearing surfaces implanted at a single institution over three decades to determine whether the reasons for revision vary among the groups and how long it takes to identify differences in survival. METHODS We considered six cohorts that included a total of 1,707 primary hips done between 1982 and 2010. These included 223 conventional polyethylene sterilized with γ irradiation in air (CPE-GA), 114 conventional polyethylene sterilized with gas plasma (CPE-GP), 116 crosslinked polyethylene (XLPE), 1,083 metal-on-metal (MOM), 90 ceramic-on-ceramic (COC), and 81 surface arthroplasties (SAs). With the exception of the COC, all other groups used cobalt-chromium (CoCr) femoral heads. The mean follow-up was 10 (0.008 to 35) years. Descriptive statistics with revisions per 100 component years (re/100 yr) and survival analysis with revision for any reason as the endpoint were used to compare bearing surfaces. RESULTS XLPE liners demonstrated a lower cumulative incidence of revision at 15 years compared to the CPE-GA and CPE-GP groups owing to the absence of wear-related revisions (4% for XLPE vs 18%, p = 0.02, and 15%, p = 0.003, respectively). Revisions for adverse local tissue reactions occurred exclusively among the MOM (0.8 re/100 year) and SA groups (0.1 re/100 year). The revision rate for instability was lower among hips with 36 mm and larger head sizes compared to smaller head sizes (0.2% vs 2%, p < 0.001). CONCLUSION The introduction of XLPE has eliminated wear-related revisions through 15-year follow-up compared to CPE-GP and CPE-GA. Dislocation incidence has been reduced with the introduction of larger diameter heads but remains a persistent concern. The potential for adverse local tissue reactions with MOM requires continued follow-up. Cite this article: Bone Joint J 2020;102-B(7 Supple B):105-111.
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Affiliation(s)
- Charles A Engh
- Inova Mount Vernon Joint Replacement Center, Alexandria, Virginia, USA.,Anderson Orthopaedic Research Institute, Alexandria, Virginia, USA
| | - Craig J McAsey
- Inova Mount Vernon Joint Replacement Center, Alexandria, Virginia, USA.,Anderson Orthopaedic Research Institute, Alexandria, Virginia, USA
| | | | - Henry Ho
- Anderson Orthopaedic Research Institute, Alexandria, Virginia, USA
| | - Robert H Hopper
- Anderson Orthopaedic Research Institute, Alexandria, Virginia, USA
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What Is the Risk of THA Revision for ARMD in Patients with Non-metal-on-metal Bearings? A Study from the Australian National Joint Replacement Registry. Clin Orthop Relat Res 2020; 478:1244-1253. [PMID: 32345846 PMCID: PMC7319380 DOI: 10.1097/corr.0000000000001277] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are increasing reports of corrosion between the femoral head and trunnion in primary conventional THA, resulting in metal particulate release often termed trunnionosis. There may be heightened awareness of this condition because of severe soft-tissue reactions initially thought to be solely attributable to prostheses with a metal-on-metal (MoM) bearing surface. It is unclear what percentage of revisions for THA with non-MoM bearing surfaces can be attributed to trunnionosis and to what extent adverse reaction to metal debris (ARMD) seen with MoM bearings may also be seen with other bearing surfaces in THA. QUESTIONS/PURPOSES We analyzed data from a large national registry to ask: (1) What is the revision risk for the indication of ARMD in patients with conventional THA and modern non-MoM bearing surfaces such as metal or ceramic-on-cross-linked polyethylene (XLPE) or ceramic-on-ceramic? (2) What prosthesis factors are associated with an increased risk of such revision? (3) What is the relative revision risk for ARMD in THAs with large-head MoM bearings, small-head MoM bearings, and non-MoM modern bearing surfaces? METHODS The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) longitudinally maintains data on all primary and revision joint arthroplasties, with nearly 100% capture. The study population included all THAs using modern bearing surfaces (defined as metal or ceramic heads-on-XLPE and ceramic-on-ceramic bearing couples) revised because of ARMD between September 1999 and December 2018. Prostheses with modular necks were excluded. The cumulative percent revision (CPR) because of ARMD was determined. The study group consisted of 350,027 THAs with a modern bearing surface, 15,184 THAs with a large-head MoM bearing (≥ 36 mm), and 5474 THAs with a small head MoM bearing (≤ 32 mm). The patients in the group who received the modern bearing surfaces were slightly older than the patients in the groups who received the large- and small-head bearing surfaces, with a mean age 68 years (SD 12) versus a mean age 63 years (SD 12), and a mean age 62 years (SD 11), respectively. There was a higher proportion of women in the modern bearing surface group; 55% (193,312 of 350,027), compared with 43% (6497 of 15,184) in the large-head MoM group and 50% (2716 of 5474) in the small-head MoM group. The outcome measure was the CPR, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the first revision for ARMD at 17 years. Hazard ratios (HR) from Cox proportional hazards models, adjusting for age and sex, were performed to compare the revision rates among groups. The registry defines a revision as a reoperation of a previous hip arthroplasty in which one or more of the prosthetic components is replaced or removed, or one or more components is added. RESULTS The CPR for ARMD for patients with a modern bearing surface at 17 years was 0.1% (95% confidence interval 0.0 to 0.1). After controlling for age and sex, we found that cobalt chrome heads, two specific prostheses (Accolade® I and M/L Taper), and head sizes ≥ 36 mm were associated with an increased risk of revision for ARMD. Metal-on-XLPE had a higher risk of revision for ARMD than ceramic-on-ceramic or ceramic-on-XLPE (HR 3.4 [95% CI 1.9 to 6.0]; p < 0.001). The Accolade 1 and the M/L Taper stems had a higher risk of revision than all other stems (HR, 8.3 [95% CI 4.7 to 14.7]; p < 0.001 and HR 14.4 [95% CI 6.0 to 34.6]; p < 0.001, respectively). Femoral stems with head sizes ≥ 36 mm had a higher rate of revision for ARMD than stems with head sizes ≤ 32 mm (HR 3.2 [95% CI 1.9 to 5.3]; p < 0.001).Large-head MoM bearings had a greater increase in revision for ARMD compared with modern bearing surfaces. The CPR for patients with a large-head MoM bearing at 17 years for ARMD was 15.5% (95% CI 14.5 to 16.6) and it was 0.1% for modern bearing surfaces (HR 340 [95% CI 264.2 to 438.0]; p < 0.001). Modern bearing surfaces likewise had a lower HR for revision for ARMD than did THAs with small-head MoM bearings, which had a 0.9% (95% CI 0.7 to 1.4) CPR compared with modern bearings from 0 to 9 years (HR 10.5 [95% CI 6.2 to 17.7]; p < 0.001). CONCLUSIONS The revision risk for ARMD with modern bearing surfaces in THA is low. The Accolade 1 and the M/L Taper stem have a higher risk of revision for ARMD and cobalt-chrome heads, and head sizes ≥ 36 mm have a higher rate of revision than ≤ 32 mm head sizes. ARMD is a rare failure mode for THA with non-MoM bearings, but in patients presenting with unexplained pain with no other obvious cause, this diagnosis should be considered and investigated further. LEVEL OF EVIDENCE Level III, therapeutic study.
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Carulli C, Sani G, Matassi F, Civinini R, Innocenti M. A Mid- to Long-Term Follow-Up Experience with a Specific Metal-on-Metal Total Hip Arthroplasty Design. JOINTS 2020; 7:91-97. [PMID: 34195536 PMCID: PMC8236331 DOI: 10.1055/s-0040-1710388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 04/04/2020] [Indexed: 11/09/2022]
Abstract
Purrpose
Metal-on-metal (MoM) total hip arthroplasty (THA) has been a subject of recent discussion and concern due to the early failures caused by local and systemic adverse reactions related to specific designs. The aim of this study is to analyze the outcomes and survival rates of a single brand of MoM implants implanted in a consecutive series of patients at a single institution.
Methods
Between 2007 and 2012, 116 (118 hips) patients were evaluated at a mean follow-up of 6.6 years after primary THA. The diagnosis leading to surgery was osteoarthritis (80 patients) and proximal femoral fracture (36 patients). A single design of THA was implanted. All patients were evaluated before surgery and postoperatively at 1, 3, 6, and 12 months by clinical scores and radiographic studies. The data analysis was made using Student's
t
-test.
Results
The minimum follow-up was of 4 years, with a mean follow-up of 6.6 years. Two aseptic loosenings of the acetabular component were recorded (one per group), which were not associated with local or systemic complications related to metal ion release. Both were revised by an isolated acetabular cup substitution with metal-on-polyethylene couplings. Nonprogressive radiolucency lines < 2 mm in zone 2 were observed in other six patients around the acetabular component without clinical manifestation (four in the arthritis group and two in the fracture group). Postoperative Harris Hip Score and SF-36 (36-Item Short Form Survey) score improved in both groups.
Conclusion
Despite several MoM implants showing early complications and failures, a specific MoM design may be associated with good clinical results at a mid- to long-term follow-up.
Level of Evidence
This is a therapeutic case series, Level 4 study.
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Affiliation(s)
| | - Giacomo Sani
- Orthopaedic Clinic, University of Florence, Florence, Italy
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6
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Arnholt CM, White JB, Lowell JA, Perkins MR, Mihalko WM, Kurtz SM. Postmortem Retrieval Analysis of Metallosis and Periprosthetic Tissue Metal Concentrations in Total Knee Arthroplasty. J Arthroplasty 2020; 35:569-578. [PMID: 31699531 DOI: 10.1016/j.arth.2019.08.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/03/2019] [Accepted: 08/14/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to determine the preferred sampling location for tissue analysis in total knee arthroplasty (TKA) and to evaluate metal concentrations, inflammatory cytokines, component damage, and tissue metallosis. METHODS Twenty TKA systems were collected at necropsy along with tissue samples from 5 distinct locations. Inductively coupled plasma mass spectrometry (ICP-MS) analysis was performed to determine cobalt (Co), chromium (Cr), and titanium (Ti) concentrations. Synovial fluid cytokine analysis was preformed using a Magnetic Luminex Screening Assay. Femoral components were assesed for damage and tissues were visually scored for metallosis. RESULTS The median metal concentrations were 16 ppb for Co, 46 ppb for Cr, and 9.8 ppb for Ti. There was no association between the tissue collection site and the metal concentration for Co (P = .979), Cr (P = .712), or Ti (P = .854). Twelve of 20 of the necropsy-retrieved TKAs had metallosis, but there was no correlation between Co (P = .48), Cr (P = .89), or Ti (P = .60) concentration and metallosis. Increased Co was associated with decreased tumor necrosis factor alpha (ρ = -0.56, P = .01) and interleukin 1 beta (ρ = -0.48, P = .03). Increased Cr was associated with decreased tumor necrosis factor alpha (ρ= -0.47, P = .03), interleukin 6 (ρ= -0.43, P = .04), and macrophage inflammatory protein 3 alpha (ρ= -0.47, P = .03). CONCLUSION We observed elevated Co, Cr, and Ti concentrations in tissue from necropsy-retrieved TKA. Our findings did not support the hypothesis that tissue metal concentrations were associated with inflammatory cytokines. The results of this research will be useful for the design of future prospective studies.
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Affiliation(s)
- Christina M Arnholt
- Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA
| | | | - Julie A Lowell
- University of Tennessee Health Science Center, Memphis, TN
| | | | - William M Mihalko
- University of Tennessee Health Science Center, Memphis, TN; Campbell Clinic Orthopaedics, Memphis, TN
| | - Steven M Kurtz
- Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA; Exponent Inc, Philadelphia, PA
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Aboltins CA, Antoci V, Bhattacharyya S, Cross M, Ducheyne P, Freiberg AA, Hailer N, Kay P, Ketonis C, Klement MR, Köse N, Lee M, Mitchell P, Nandi S, Palacio JC, Perry K, Prieto H, Shahi A, Trebše R, Turner D, Wu CT, Yazdi H. Hip and Knee Section, Prevention, Prosthesis Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S309-S320. [PMID: 30348551 DOI: 10.1016/j.arth.2018.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Amanatullah D, Dennis D, Oltra EG, Marcelino Gomes LS, Goodman SB, Hamlin B, Hansen E, Hashemi-Nejad A, Holst DC, Komnos G, Koutalos A, Malizos K, Martinez Pastor JC, McPherson E, Meermans G, Mooney JA, Mortazavi J, Parsa A, Pécora JR, Pereira GA, Martos MS, Shohat N, Shope AJ, Zullo SS. Hip and Knee Section, Diagnosis, Definitions: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S329-S337. [PMID: 30348576 DOI: 10.1016/j.arth.2018.09.044] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Surgical Treatment of Intrapelvic Pseudotumour after Hip Resurfacing Arthroplasty: Case Report and Literature Review. Case Rep Orthop 2018; 2018:3808362. [PMID: 30498612 PMCID: PMC6222224 DOI: 10.1155/2018/3808362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 08/08/2018] [Accepted: 08/15/2018] [Indexed: 12/12/2022] Open
Abstract
Hip replacement is the surgery of the last century due to its impact on the quality of life. A pseudotumour is a rare complication of hip arthroplasty, and it is related to a metal-bearing surface. Pseudotumour is a challenging scenario for hip surgeons due to poor clinical outcomes. The patient consulted for hip pain and paresthesia in the left lower extremity, and analyses showed that the cause was a sizeable intrapelvic pseudotumour. A multidisciplinary team surgery was planned. At first, an infraumbilical approach was made to resect the intrapelvic-retroperitoneum portion of the pseudotumour. Then, a posterolateral hip approach was performed, to resect the remaining portion of the pseudotumour and revision arthroplasty. At five years of follow-up, there are no clinical or imaging signs of recurrence of the pseudotumour. Treatment evidence is limited to a series of cases and expert opinions; we encourage complete resection and revision arthroplasty.
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Arnholt CM, MacDonald DW, Klein GR, Cates HE, Rimnac CM, Kurtz SM, the Implant Research Center Writing Committee, Kocagoz S, Chen AF. What Is the Incidence of Cobalt-Chromium Damage Modes on the Bearing Surface of Contemporary Femoral Component Designs for Total Knee Arthroplasty? J Arthroplasty 2018; 33:3313-3319. [PMID: 29871834 PMCID: PMC6146069 DOI: 10.1016/j.arth.2018.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/25/2018] [Accepted: 05/10/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine the incidence of metal release in contemporary total knee arthroplasty and the patient-related factors associated with this release. METHODS In total, 256 retrieved cobalt-chromium femoral components were collected through a multi-institutional orthopedic implant retrieval program (implanted: 1-15 years). Implants were mainly revised for loosening (84/256), instability (62/256), and infection (46/256). Third-body damage was assessed using a semiquantitative scoring method. Microscale electro-corrosion damage (MECD) was evaluated using digital optical microscopy. Radii of curvature were measured from representative components to calculate anterior-posterior and medial-lateral ratios. Femoral component surface roughness was measured using a white light interferometer. Using a multivariable linear model, associations between damage score, implant, and patient factors were tested. Spearman's ρ correlation tests were performed to determine the association between roughness measurements and damage score. RESULTS Mild to severe damage was observed in 52% (134/256) of the components. In the multivariable linear model, anterior-posterior ratio (β = -8.07; P < .001), loosening (β = -0.52; P = .006), and patient weight (β = 0.01; P = .007) were associated with damage score. Suspected MECD damage was observed in 82% (209/256) of components. The Ra value (ρ = 0.196; P = .002) and Rq value (ρ = 0.157; P = .012) increased as the damage score increased. CONCLUSION The findings of this retrieval study support that similar damage mechanisms exist in contemporary and long-term total knee arthroplasty devices. Additionally, we observed associations between loosening, anterior-posterior conformity, and patient weight with increased surface damage.
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Affiliation(s)
- Christina M. Arnholt
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104
| | - Daniel W. MacDonald
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104
| | - Gregg R. Klein
- Hartzband Center for Hip & Knee Replacement, Paramus, NJ
| | | | - Clare M. Rimnac
- Department of Mechanical and Aerospace Engineering and the Center for the Evaluation of Implant Performance, Case Western Reserve University, 10900 Euclid Ave., Cleveland, Ohio 44106
| | - Steven M. Kurtz
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104,Exponent, Inc., 3440 Market Street, Suite 600, Philadelphia, PA 19104
| | | | - Sevi Kocagoz
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104
| | - Antonia F. Chen
- Brigham and Women’s Hospital, Department of Orthopaedics, Harvard Medical School, Boston, MA 02115
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11
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Urish KL, Hamlin BR, Plakseychuk AY, Levison TJ, Higgs G, Kurtz S, DiGioia AM. Trunnion Failure of the Recalled Low Friction Ion Treatment Cobalt Chromium Alloy Femoral Head. J Arthroplasty 2017; 32:2857-2863. [PMID: 28478184 PMCID: PMC5572503 DOI: 10.1016/j.arth.2017.03.075] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 03/11/2017] [Accepted: 03/31/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Gross trunnion failure (GTF) is a rare complication in total hip arthroplasty (THA) reported across a range of manufacturers. Specific lots of the Stryker low friction ion treatment (LFIT) anatomic cobalt chromium alloy (CoCr) V40 femoral head were recalled in August 2016. In part, the recall was based out of concerns for disassociation of the femoral head from the stem and GTF. METHODS We report on 28 patients (30 implants) with either GTF (n = 18) or head-neck taper corrosion (n = 12) of the LFIT CoCr femoral head and the Accolade titanium-molybdenum-zirconium-iron alloy femoral stems. All these cases were associated with adverse local tissue reactions requiring revision of the THA. RESULTS In our series, a conservative estimate of the incidence of failure was 4.7% (n = 636 total implanted) at 8.0 ± 1.4 years from the index procedure. Failures were associated with a high-offset 127° femoral stem neck angle and increased neck lengths; 43.3% (13 of 30) of the observed failures included implant sizes outside the voluntary recall (27.8% [5 of 18] of the GTF and 75.0% [8 of 12] of the taper corrosion cases). Serum cobalt and chromium levels were elevated (cobalt: 8.4 ± 7.0 μg/mL; chromium: 3.4 ± 3.3 μ/L; cobalt/chromium ratio: 3.7). The metal artifact reduction sequence magnetic resonance imaging demonstrated large cystic fluid collections typical with adverse local tissue reactions. During revision, a pseudotumor was observed in all cases. Pathology suggested a chronic inflammatory response. Impending GTF could be diagnosed based on aspiration of black synovial fluid and an oblique femoral head as compared with the neck taper on radiographs. CONCLUSION In our series of the recalled LFIT CoCr femoral head, the risk of impending GTF or head-neck taper corrosion should be considered as a potential diagnosis in a painful LFIT femoral head and Accolade titanium-molybdenum-zirconium-iron alloy THA with unknown etiology. Almost half of the failures we observed included sizes outside of the voluntary recall.
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Affiliation(s)
- Kenneth L. Urish
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583,Corresponding Author: The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, College of Medicine, University of Pittsburgh, Pittsburgh, PA 15212.
| | - Brian R. Hamlin
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Anton Y. Plakseychuk
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Timothy J. Levison
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
| | - Genymphas Higgs
- Implant Research Center, 3401 Market St., Suite 345, Philadelphia, PA. Phone: 215-901-4520
| | - Steven Kurtz
- Implant Research Center, 3401 Market St., Suite 345, Philadelphia, PA. Phone: 215-901-4520
| | - Anthony M. DiGioia
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212. Phone: 412.736.4261; Fax: 717.531.7583
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Sigmund IK, Holinka J, Gamper J, Staats K, Böhler C, Kubista B, Windhager R. Qualitative α-defensin test (Synovasure) for the diagnosis of periprosthetic infection in revision total joint arthroplasty. Bone Joint J 2017; 99-B:66-72. [PMID: 28053259 DOI: 10.1302/0301-620x.99b1.bjj-2016-0295.r1] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 09/14/2016] [Indexed: 01/03/2023]
Abstract
AIMS The diagnosis of periprosthetic joint infection (PJI) remains demanding due to limitations of all the available diagnostic tests. The synovial fluid marker, α-defensin, is a promising adjunct for the assessment of potential PJI. The purpose of this study was to investigate the qualitative assessment of α-defensin, using Synovasure to detect or exclude periprosthetic infection in total joint arthroplasty. PATIENTS AND METHODS We studied 50 patients (28 women, 22 men, mean age 65 years; 20 to 89) with a clinical indication for revision arthroplasty who met the inclusion criteria of this prospective diagnostic study. The presence of α-defensin was determined using the qualitative Synovasure test and compared with standard diagnostic methods for PJI. Based on modified Musculoskeletal Infection Society (MSIS) criteria, 13 cases were categorised as septic and 36 as aseptic revisions. One test was inconclusive. RESULTS The Synovasure test achieved a sensitivity of 69% and a specificity of 94%. The positive and negative likelihood ratios were 12.46 and 0.33, respectively. A good diagnostic accuracy for PJI, with an area under the curve of 0.82, was demonstrated. Adjusted p-values using the method of Hochberg showed that Synovasure is as good at diagnosing PJI as histology (p = 0.0042) and bacteriology with one positive culture (p = 0.0327). CONCLUSION With its ease of use and rapid results after approximately ten minutes, Synovasure may be a useful adjunct in the diagnosis of PJI. Cite this article: Bone Joint J 2017;99-B:66-72.
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Affiliation(s)
- I K Sigmund
- Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
| | - J Holinka
- Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
| | - J Gamper
- Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
| | - K Staats
- Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
| | - C Böhler
- Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
| | - B Kubista
- Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
| | - R Windhager
- Medical University of Vienna, Spitalgasse 23, 1090 Wien, Austria
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13
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Matharu GS, Pandit HG, Murray DW, Judge A. Adverse reactions to metal debris occur with all types of hip replacement not just metal-on-metal hips: a retrospective observational study of 3340 revisions for adverse reactions to metal debris from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. BMC Musculoskelet Disord 2016; 17:495. [PMID: 27955657 PMCID: PMC5153685 DOI: 10.1186/s12891-016-1329-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/03/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adverse reactions to metal debris (ARMD) have resulted in the high short-term failure rates observed with metal-on-metal hip replacements. ARMD has recently been reported in non-metal-on-metal total hip replacements (non-MoM THRs) in a number of small cohort studies. However the true magnitude of this complication in non-MoM THRs remains unknown. We used a nationwide database to determine the risk of ARMD revision in all non-MoM THRs, and compared patient and surgical factors associated with ARMD revision between non-MoM and MoM hips. METHODS We performed a retrospective observational study using data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. All primary hip replacements undergoing revision surgery for ARMD were included (n = 3,340). ARMD revision risk in non-MoM THRs was compared between different commonly implanted bearing surfaces and femoral head sizes (Chi-squared test). Differences in patient and surgical factors between non-MoM hips and MoM hips revised for ARMD were also analysed (Chi-squared test and unpaired t-test). RESULTS Of all ARMD revisions, 7.5% (n = 249) had non-MoM bearing surfaces. The relative risk of ARMD revision was 2.35 times (95% CI 1.76-3.11) higher in ceramic-on-ceramic bearings compared with hard-on-soft bearings (0.055 vs. 0.024%; p < 0.001), and 2.80 times (95% CI 1.74-4.36) higher in 36 mm metal-on-polyethylene bearings compared to 28 mm and 32 mm metal-on-polyethylene bearings (0.058 vs. 0.021%; p < 0.001). ARMD revisions were performed earlier in non-MoM hips compared to MoM hips (mean 3.6-years vs. 5.6-years; p < 0.0001). Non-MoM hips had more abnormal findings at revision (63.1 vs. 35.7%; p < 0.001), and more intra-operative adverse events (6.4 vs. 1.6%; p < 0.001) compared to MoM hips. CONCLUSIONS Although the overall risk of ARMD revision surgery in non-MoM THRs appears low, this risk is increasing, and is significantly higher in ceramic-on-ceramic THRs and 36 mm metal-on-polyethylene THRs. ARMD may therefore represent a significant clinical problem in non-MoM THRs.
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Affiliation(s)
- Gulraj S. Matharu
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7LD UK
| | - Hemant G. Pandit
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7LD UK
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA UK
| | - David W. Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7LD UK
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7LD UK
- MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD UK
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Ras Sørensen SAL, Jørgensen HL, Sporing SL, Lauritzen JB. Revision rates for metal-on-metal hip resurfacing and metal-on-metal total hip arthroplasty - a systematic review. Hip Int 2016; 26:515-521. [PMID: 27791245 DOI: 10.5301/hipint.5000444] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE To compare revision rates of metal-on-metal (MoM) hip resurfacing (HRS) and MoM total hip arthroplasty (THA), as well as the primary causes for revisions. METHODS The PubMed database was queried for potentially relevant articles addressing MoMTHA and MoMHRS, a total of 51 articles were included. RESULTS The review includes a total number of 5,399 MoMHRS and 3,244 THA prosthesis and the reasons for prosthesis failure were divided into 7 categories and the main causes discussed. The overall MoMTHA revision rate was 4.7% after 6.9 years. MoMHRS revision rate was 5.9% after 5.7 years. The odds ratio was 1.25 (1.03:1.53) 95% CI (p = 0.03) (MoMHRS vs. MoMTHA).The studies of hip prostheses were separated into 2 categories of short- and long-term (more or less than 5 years). Short-term revision rate for MoMTHA was 4.5% after 4.8 years, and for MoMHRS 4.0% after 4.2 years. The odds ratio was 1.09 (0.82:1.43) 95% CI (0 = 0.56) (MoMTHA vs. MoMHRS). Long-term revision rate for MoMTHA was 5.2% after 7.7 years and 8.2% after 7.6 years for MoMHRS. The odds ratio was 1.58 (1.53:1.96) 95% CI (p = 0.0001) (MoMHRS vs. MoMTHA).Revision causes were divided into 7 main categories. The most common cause for revision for both MoMTHA and MoMHRS was loosening 47.6% vs. 37.7%, fracture (MoMTHA 7.69%; MoMHRS 19.62%), metal reactions (MoMTHA 7.69%; MoMHRS 26.92%) infection (MoMTHA 12.08%; MoMHRS 6.54%), instability (MoMTHA 9.13%; MoMHRS 2.69%), manufacturer defect 6.73% for MoMTHA and nonreported for MoMHRS, and miscellaneous (MoMTHA 7.69%; MoMHRS 6.54%) was stated. INTERPRETATION The comparison of MoMHRS and MoMTHA revision rates showed no difference in the short term, however in the longer term, the revision rate of MoMHRS was significantly higher than for MoMTHA. The linear increase in revision rate of MoMHRS may indicate a progression in failure.
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Affiliation(s)
| | - Henrik L Jørgensen
- Department of Clinical Biochemistry, Bispebjerg Hospital, University of Copenhagen, Copenhagen - Denmark
| | - Sune L Sporing
- Department of Orthopaedic Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen - Denmark
| | - Jes B Lauritzen
- Department of Orthopaedic Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen - Denmark
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15
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Metal-on-Metal Total Hip Arthroplasty at Five to Twelve Years Follow-Up: A Concise Follow-Up of a Previous Report. J Arthroplasty 2016; 31:1773-8. [PMID: 27113940 DOI: 10.1016/j.arth.2016.01.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/12/2016] [Accepted: 01/28/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Concern has arisen regarding potential complications with modular metal-on-metal (MoM) acetabular components in total hip arthroplasty. The purpose of this study was to analyze longitudinally the longer term results of a previously reported cohort of patients utilizing a cementless modular acetabular component with a MoM bearing. METHODS One hundred sixty-nine consecutive but selected total hip arthroplasties were performed in 148 patients at 2 institutions using a modular acetabular MoM component. One hundred thirty-nine patients (158 hips) were living at minimum 5 years, 1 patient (1 hip) was lost to follow-up and 8 patients (10 hips) were deceased. Patients were evaluated clinically in terms of revision as well as radiographically. Additional testing (metal ion levels, advanced imaging) was performed when concerns for adverse local tissue reaction (ALTR) arose. RESULTS There were 6 (3.8%) additional hips revised since the prior report for a total of 7 hips (4.4%) revised at 5-12 year follow-up. All newly revised hips (3.8%) demonstrated ALTR. There were 7 (4.7%) additional cases of radiographically detected acetabular osteolysis and 7 (4.7%) cases of femoral osteolysis. CONCLUSION Longitudinal evaluation of a modular MoM bearing surface acetabular component demonstrated increased rates of ALTR and osteolysis at longer duration follow-up. Although greater than 95% of hips in this study performed well at 5-12 years, when comparing the results to metal-on-polyethylene bearings using the same acetabular component, the results were inferior. Longitudinal surveillance is warranted with this design and this bearing surface couple as cases of ALTR and osteolysis increased with longer follow-up.
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16
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Langton DJ, Sidaginamale RP, Avery P, Waller S, Tank G, Lord J, Joyce T, Cooke N, Logishetty R, Nargol AVF. Retrospective cohort study of the performance of the Pinnacle metal on metal (MoM) total hip replacement: a single-centre investigation in combination with the findings of a national retrieval centre. BMJ Open 2016; 6:e007847. [PMID: 27130159 PMCID: PMC4853972 DOI: 10.1136/bmjopen-2015-007847] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To determine risk factors for revision in patients implanted with a commonly used metal on metal (MoM) hip replacement. DESIGN Retrospective cohort study in combination with a prospective national retrieval study (Northern Retrieval Registry (NRR)). SETTING Combined orthopaedic unit in combination with the NRR. PARTICIPANTS All patients implanted with a DePuy Pinnacle MoM hip prostheses by the 2 senior authors were invited to attend for a review which included clinical examination, blood metal ion measurements, radiographs and targeted imaging. Explanted components underwent wear analysis using validated methodology and these results were compared with those obtained from the NRR. RESULTS 489 MoM Pinnacle hips were implanted into 434 patients (243 females and 191 males). Of these, 352 patients attended the MoM recall clinics. 64 patients had died during the study period. For the purposes of survival analysis, non-attendees were assumed to have well-functioning prostheses. The mean follow-up of the cohort as a whole was 89 months. 71 hips were revised. Prosthetic survival for the whole cohort was 83.6% (79.9-87.3) at 9 years. The majority of explanted devices exhibited signs of taper junction failure. Risk factors for revision were bilateral MoM prostheses, smaller Pinnacle liners, and implantation in 2006 and later years. A significant number of devices were found to be manufactured out of their specifications. This was confirmed with analysis of the wider data set from the NRR. CONCLUSIONS This device was found to have an unacceptably high revision rate. Bilateral prostheses, those implanted into female patients and devices implanted in later years were found to be at greater risk. A significant number of explanted components were found to be manufactured with bearing diameters outside of the manufacturer's stated tolerances. Our findings highlight the clinical importance of hitherto unrecognised variations in device production.
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Affiliation(s)
| | | | - Peter Avery
- Newcastle University, Newcastle upon Tyne, Newcastle, UK
| | - Sue Waller
- North Tees Nuffield Hospital, Stockton, UK
| | | | | | - Thomas Joyce
- Newcastle University, Newcastle upon Tyne, Newcastle, UK
| | - Nick Cooke
- University Hospital of North Tees, Stockton, UK
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Davis DL, Morrison JJ. Hip Arthroplasty Pseudotumors: Pathogenesis, Imaging, and Clinical Decision Making. J Clin Imaging Sci 2016; 6:17. [PMID: 27195183 PMCID: PMC4863402 DOI: 10.4103/2156-7514.181493] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 04/14/2016] [Indexed: 12/13/2022] Open
Abstract
Pseudotumors are a complication of hip arthroplasty. The goal of this article is to review the clinical presentation, pathogenesis, histology, and the role of diagnostic imaging in clinical decision making for treatment, and surveillance of pseudotumors. We will discuss the multimodal imaging appearances, differential diagnosis, associated complications, treatment, and prognosis of pseudotumors, as an aid to the assessment of orthopedic prostheses at the hip.
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Affiliation(s)
- Derik L Davis
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - James J Morrison
- Dotter Interventional Institute, Oregon Health and Science University, Portland, OR, USA
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18
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Reito A, Lainiala O, Elo P, Eskelinen A. Prevalence of Failure due to Adverse Reaction to Metal Debris in Modern, Medium and Large Diameter Metal-on-Metal Hip Replacements--The Effect of Novel Screening Methods: Systematic Review and Metaregression Analysis. PLoS One 2016; 11:e0147872. [PMID: 26930057 PMCID: PMC4773181 DOI: 10.1371/journal.pone.0147872] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/25/2015] [Indexed: 11/18/2022] Open
Abstract
Metal-on-metal (MoM) hip replacements were used for almost a decade before adverse reactions to metal debris (ARMD) were found to be a true clinical problem. Currently, there is a paucity of evidence regarding the usefulness of systematic screening for ARMD. We implemented a systematic review and meta-analysis to establish the prevalence of revision confirmed ARMD stratified by the use of different screening protocols in patients with MoM hip replacements. Five levels of screening were identified: no screening (level 0), targeted blood metal ion measurement and/or cross-sectional imaging (level 1), metal ion measurement without imaging (level 2), metal ion measurement with targeted imaging (level 3) and comprehensive screening (both metal ions and imaging for all; level 4). 122 studies meeting our eligibility criteria were included in analysis. These studies included 144 study arms: 100 study arms with hip resurfacings, 33 study arms with large-diameter MoM total hip replacements (THR), and 11 study arms with medium-diameter MoM THRs. For hip resurfacing, the lowest prevalence of ARMD was seen with level 0 screening (pooled prevalence 0.13%) and the highest with level 4 screening (pooled prevalace 9.49%). Pooled prevalence of ARMD with level 0 screening was 0.29% and with level 4 screening 21.3% in the large-diameter MoM THR group. In metaregression analysis of hip resurfacings, level 4 screening was superior with regard to prevalence of ARMD when compared with other levels. In the large diameter THR group level 4 screening was superior to screening 0,2 and 3. These outcomes were irrespective of follow-up time or study publication year. With hip resurfacings, routine cross-sectional imaging regardless of clinical findings is advisable. It is clear, however, that targeted metal ion measurement and/or imaging is not sufficient in the screening for ARMD in any implant concepts. However, economic aspects should be weighed when choosing the preferred screening level.
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Affiliation(s)
- Aleksi Reito
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
| | - Olli Lainiala
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
| | - Petra Elo
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, Biokatu 6b, 33900 Tampere, Finland
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19
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Briant-Evans TW, Lyle N, Barbur S, Hauptfleisch J, Amess R, Pearce AR, Conn KS, Stranks GJ, Britton JM. A longitudinal study of MARS MRI scanning of soft-tissue lesions around metal-on-metal total hip arthroplasties and disease progression. Bone Joint J 2015; 97-B:1328-37. [DOI: 10.1302/0301-620x.97b10.34131] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the changes seen on serial metal artefact reduction magnetic resonance imaging scans (MARS-MRI) of metal-on-metal total hip arthroplasties (MoM THAs). In total 155 THAs, in 35 male and 100 female patients (mean age 70.4 years, 42 to 91), underwent at least two MRI scans at a mean interval of 14.6 months (2.6 to 57.1), at a mean of 48.2 months (3.5 to 93.3) after primary hip surgery. Scans were graded using a modification of the Oxford classification. Progression of disease was defined as an increase in grade or a minimum 10% increase in fluid lesion volume at second scan. A total of 16 hips (30%) initially classified as ‘normal’ developed an abnormality on the second scan. Of those with ‘isolated trochanteric fluid’ 9 (47%) underwent disease progression, as did 7 (58%) of ‘effusions’. A total of 54 (77%) of hips initially classified as showing adverse reactions to metal debris (ARMD) progressed, with higher rates of progression in higher grades. Disease progression was associated with high blood cobalt levels or an irregular pseudocapsule lining at the initial scan. There was no association with changes in functional scores. Adverse reactions to metal debris in MoM THAs may not be as benign as previous reports have suggested. Close radiological follow-up is recommended, particularly in high-risk groups. Cite this article: Bone Joint J 2015;97-B:1328–37.
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Affiliation(s)
- T. W. Briant-Evans
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - N. Lyle
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - S. Barbur
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - J. Hauptfleisch
- Derby Teaching Hospital, Uttoxeter
New Road, Derby DE22 3NE, UK
| | - R. Amess
- University of Oxford, Nuffield
Orthopaedic Centre, Windmill Road, Oxford
OX3 7LD, UK
| | - A. R. Pearce
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - K. S. Conn
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - G. J. Stranks
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
| | - J. M. Britton
- Hampshire Hospitals NHS Foundation Trust, Aldermaston
Rd, Basingstoke, UK
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20
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Alijanipour P, Adeli B, Hansen EN, Chen AF, Parvizi J. Intraoperative Purulence Is Not Reliable for Diagnosing Periprosthetic Joint Infection. J Arthroplasty 2015; 30:1403-6. [PMID: 25817184 DOI: 10.1016/j.arth.2015.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/04/2015] [Accepted: 03/10/2015] [Indexed: 02/01/2023] Open
Abstract
UNLABELLED Purulence, defined as presence of pus, is based on subjective interpretation yet has been considered a definite sign of periprosthetic joint infection (PJI). 583 patients undergoing revision arthroplasty due to presumed PJI were retrospectively studied. PJI definition was independent of purulence, based on the definition of Musculoskeletal Infection Society recently modified by International Consensus Group on PJI. 498 patients fulfilled the criteria for definite PJI and 59 patients were deemed as aseptic. Purulence had sensitivity, specificity, positive and negative predictive values of 0.82, 0.32, 0.91, and 0.17, respectively. Purulence was not correlated with higher culture positivity yet was associated with higher synovial WBC counts (mean of 34.8 versus 5.2×10(3)/μL in patients without purulence [P<0.001]). In the absence of objective definition for purulence and in light of its inadequate test characteristics compared to a multi-criteria definition, purulence cannot serve as a single absolute diagnostic criterion for PJI. LEVEL OF EVIDENCE Level I, Diagnostic Studies.
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Affiliation(s)
- Pouya Alijanipour
- Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital, Philadelphia Pennsylvania
| | - Bahar Adeli
- St. George's University School of Medicine, Apt 1R, Philadelphia, Pennsylvania
| | - Erik N Hansen
- UCSF Department of Orthopaedic Surgery, Division of Adult Reconstructive Surgery, San Francisco, California
| | - Antonia F Chen
- Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital, Philadelphia Pennsylvania
| | - Javad Parvizi
- Rothman Institute of Orthopaedics at Thomas Jefferson University Hospital, Philadelphia Pennsylvania
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21
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Panichkul P, Fricka KB, Hopper RH, Engh CA. Greater Trochanteric Fragmentation After Failed Metal-on-Metal Hip Arthroplasty. Orthopedics 2015; 38:e447-51. [PMID: 25970376 DOI: 10.3928/01477447-20150504-93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 11/04/2014] [Indexed: 02/03/2023]
Abstract
Adverse reaction to metal debris (ARMD) involving the hip joint has emerged as an important reason for failure and revision among patients with metal-on-metal (MOM) hip arthroplasty. To the authors' knowledge, there are no reports of adverse radiographic sequelae in the greater trochanter subsequent to revision for ARMD. The authors describe clinical and radiographic findings in 2 patients who developed greater trochanteric fragmentation 1 to 2 years after conversion of their failed MOM hips to polyethylene bearings. Both patients had solid pseudotumors with tissue necrosis. Several reports describe various clinical features of ARMD. Although poor outcomes have been demonstrated after some MOM revisions, to the authors' knowledge, no reports document greater trochanter fragmentation in ARMD. The current patients highlight the fact that tissue damage occurring with MOM bearing hips can involve bone in addition to soft tissue even after a pseudotumor has been removed and serum metal levels have decreased to normal levels after revision. Unlike the greater trochanteric fractures historically associated with polyethylene wear and osteolysis, no evidence of bone cysts or lesions was found prior to the fractures and neither fracture healed with conservative treatment. For these 2 patients, the authors believe the tissue necrosis included both soft tissue and bone. The necrotic bone resorbed gradually after removal of the MOM bearing, resulting in bone fragmentation with ongoing symptoms. These patients emphasize and remind us that damage is not only limited to soft tissues, but also includes bone. Surgeons should be aware of this radiographic finding and the associated clinical symptoms.
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Abstract
BACKGROUND A relatively high percentage of monoblock metal-on-metal total hip arthroplasties (THAs) undergo early revision. Revision of these THAs poses challenges unique to this implant type. The early complications after these revisions remain unreported as do the clinical and demographic factors associated with these complications. QUESTIONS/PURPOSES We describe (1) the frequency of early complications after revision of monoblock metal-on-metal THA; and (2) the clinical and demographic factors associated with complications. METHODS A review of our institution's total joint registry identified 107 patients who underwent 114 revisions of monoblock metal-on-metal THAs. Mean patient age at revision was 60 years (range, 17-84 years), and 65% of the patients were women. Mean followup after revision was 14 months (range, 0-122 months). Revision diagnoses included metallosis (51%), aseptic loosening (27%), infection (7%), pain (6%), malposition (4%), instability (3%), iliopsoas impingement (2%), and periprosthetic fracture (1%). Major complications (instability, infection, aseptic loosening, and wound complications) were documented and included in the analysis. Minor postoperative complications such as urinary tract infection were excluded. RESULTS Twenty-three of 114 procedures (20%) involved at least one early complication after revision of monoblock metal-on-metal THA with 18 (16%) undergoing at least one additional subsequent surgery. The most common complications included aseptic loosening (6%), deep infection (6%), dislocation (4%), and acetabular fracture (3%). Patients who sustained a complication after revision surgery were older on average than those who did not (66 years versus 58 years, p=0.003). There were no differences in complication rate with respect to sex, time to revision, or revision diagnosis. CONCLUSIONS Complications and reoperations occur frequently after revision for failed monoblock metal-on-metal THA (20% and 16%, respectively), and older patients appear to be at greater risk for complications after these revisions. Aseptic loosening, deep infection, and instability are all of great concern after revision and surgeons should be aware of these potential complications when undertaking revision of these THAs. LEVEL OF EVIDENCE Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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23
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Lainiala O, Eskelinen A, Elo P, Puolakka T, Korhonen J, Moilanen T. Adverse reaction to metal debris is more common in patients following MoM total hip replacement with a 36 mm femoral head than previously thought. Bone Joint J 2014; 96-B:1610-7. [DOI: 10.1302/0301-620x.96b12.33742] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We conducted a retrospective study to assess the prevalence of adverse reactions to metal debris (ARMD) in patients operated on at our institution with metal-on-metal (MoM) total hip replacements with 36 mm heads using a Pinnacle acetabular shell. A total of 326 patients (150 males, 175 hips; 176 females, 203 hips) with a mean age of 62.7 years (28 to 85) and mean follow-up of 7.5 years (0.1 to 10.8) participating in our in-depth modern MoM follow-up programme were included in the study, which involved recording whole blood cobalt and chromium ion measurements, Oxford hip scores (OHS) and plain radiographs of the hip and targeted cross-sectional imaging. Elevated blood metal ion levels (> 5 parts per billion) were seen in 32 (16.1%) of the 199 patients who underwent unilateral replacement. At 23 months after the start of our modern MoM follow-up programme, 29 new cases of ARMD had been revealed. Hence, the nine-year survival of this cohort declined from 96% (95% CI 95 to 98) with the old surveillance routine to 86% (95% CI 82 to 90) following the new protocol. Although ARMD may not be as common in 36 mm MoM THRs as in those with larger heads, these results support the Medicines and Healthcare Products Regulatory Agency guidelines on regular reviews and further investigations, and emphasise the need for specific a follow-up programme for patients with MoM THRs. Cite this article: Bone Joint J 2014; 96-B:1610–17.
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Affiliation(s)
- O. Lainiala
- Coxa Hospital for Joint Replacement, Biokatu
6, 33520 Tampere, Finland
| | - A. Eskelinen
- Coxa Hospital for Joint Replacement, Biokatu
6, 33520 Tampere, Finland
| | - P. Elo
- Coxa Hospital for Joint Replacement, Biokatu
6, 33520 Tampere, Finland
| | - T. Puolakka
- Coxa Hospital for Joint Replacement, Biokatu
6, 33520 Tampere, Finland
| | - J. Korhonen
- Coxa Hospital for Joint Replacement, Biokatu
6, 33520 Tampere, Finland
| | - T. Moilanen
- Coxa Hospital for Joint Replacement, Biokatu
6, 33520 Tampere, Finland
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24
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Lawrence H, Deehan D, Holland J, Kirby J, Tyson-Capper A. The immunobiology of cobalt: demonstration of a potential aetiology for inflammatory pseudotumours after metal-on-metal replacement of the hip. Bone Joint J 2014; 96-B:1172-7. [PMID: 25183586 DOI: 10.1302/0301-620x.96b9.33476] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abnormal wear of cobalt-containing metal-on-metal joints is associated with inflammatory pseudotumours. Cobalt ions activate human toll-like receptor 4 (TLR4), which normally responds to bacterial lipopolysaccharide (LPS) in sepsis. Activation of TLR4 by LPS increases the expression of chemokines IL-8 and CXCL10, which recruit leukocytes and activated T-cells, respectively. This study was designed to determine whether cobalt induces a similar inflammatory response to LPS by promoting the expression of IL-8 and CXCL10. A human monocytic cell line, derived from acute monocytic leukaemia, was treated with cobalt ions and expression of IL-8 and CXCL10 measured at mRNA and protein levels. Cobalt-treated macrophages showed a 60-fold increase in IL-8 mRNA, and an eightfold increase in production of the mature chemokine (both p < 0.001); expression of the CXCL10 gene and protein was also significantly increased by cobalt (both p < 0.001). Experiments were also performed in the presence of CLI-095, a TLR4-specific antagonist which abrogated the cobalt-mediated increase in IL-8 and CXCL10 expression. These findings suggest that cobalt ions induce inflammation similar to that observed during sepsis by the simultaneous activation of two TLR4-mediated signalling pathways. These pathways result in increased production of IL-8 and CXCL10, and may be implicated in pseudotumour formation following metal-on-metal replacement.
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Affiliation(s)
- H Lawrence
- Newcastle University, Institute of Cellular Medicine, 3rd Floor, William Leech Building, Faculty of Medical Sciences, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - D Deehan
- Freeman Hospital, Department of Orthopaedics, Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK
| | - J Holland
- Freeman Hospital, Department of Orthopaedics, Freeman Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN, UK
| | - J Kirby
- Newcastle University, Institute of Cellular Medicine, 3rd Floor, William Leech Building, Faculty of Medical Sciences, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - A Tyson-Capper
- Newcastle University, Institute of Cellular Medicine, 3rd Floor, William Leech Building, Faculty of Medical Sciences, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
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25
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Engh CA, MacDonald SJ, Sritulanondha S, Korczak A, Naudie D, Engh C. Metal ion levels after metal-on-metal total hip arthroplasty: a five-year, prospective randomized trial. J Bone Joint Surg Am 2014; 96:448-55. [PMID: 24647500 DOI: 10.2106/jbjs.m.00164] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration has requested post-market surveillance data, including data on metal ion levels, regarding metal-on-metal total hip arthroplasty. We performed a prospective, randomized study of metal ion levels in erythrocytes, serum, and whole blood at five years after 28 and 36-mm metal-on-metal and 28-mm metal-on-polyethylene total hip arthroplasty. METHODS One hundred and five enrolled patients were randomized equally to the three bearing surface options and were blinded with regard to their treatment group. Metal ion measurements and clinical evaluations were performed at regular intervals. RESULTS Cobalt and chromium ion levels in all blood sample types at the five-year time point were significantly lower in the metal-on-polyethylene group than in each of the two metal-on-metal groups (p < 0.001) with the exception of chromium in erythrocytes (p = 0.194). Cobalt in serum (p = 0.029) and erythrocytes (p = 0.002) showed significant increases from two to five years in the 36-mm metal-on-metal group; similar increases were not seen in the 28-mm metal-on-metal group. At five years, five patients in the 36-mm metal-on-metal group and none in the 28-mm metal-on-metal group had cobalt or chromium levels of >7 ppb. Correlations among levels in serum, erythrocyte, and whole blood were stronger for cobalt than for chromium. One patient in the 36-mm metal-on-metal group underwent revision because of an adverse local tissue reaction. CONCLUSIONS The 36-mm metal-on-metal bearing underperformed the 28-mm metal-on-metal bearing with respect to metal ion levels. The authors are closely following all patients treated with metal-on-metal total hip arthroplasty.
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Affiliation(s)
- C A Engh
- Anderson Orthopaedic Research Institute, P.O. Box 7088, Alexandria, VA 22306. E-mail address for C.A. Engh:
| | - S J MacDonald
- Division of Orthopaedic Surgery, London Health Sciences Centre-University Hospital, 339 Windermere Road, London, ON N6A 5A5, Canada
| | - S Sritulanondha
- Anderson Orthopaedic Research Institute, P.O. Box 7088, Alexandria, VA 22306. E-mail address for C.A. Engh:
| | - A Korczak
- Division of Orthopaedic Surgery, London Health Sciences Centre-University Hospital, 339 Windermere Road, London, ON N6A 5A5, Canada
| | - D Naudie
- Division of Orthopaedic Surgery, London Health Sciences Centre-University Hospital, 339 Windermere Road, London, ON N6A 5A5, Canada
| | - C Engh
- Anderson Orthopaedic Research Institute, P.O. Box 7088, Alexandria, VA 22306. E-mail address for C.A. Engh:
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Zmistowski B, Della Valle C, Bauer TW, Malizos KN, Alavi A, Bedair H, Booth RE, Choong P, Deirmengian C, Ehrlich GD, Gambir A, Huang R, Kissin Y, Kobayashi H, Kobayashi N, Krenn V, Drago L, Marston SB, Meermans G, Perez J, Ploegmakers JJ, Rosenberg A, Simpendorfer C, Thomas P, Tohtz S, Villafuerte JA, Wahl P, Wagenaar FC, Witzo E. Diagnosis of periprosthetic joint infection. J Arthroplasty 2014; 29:77-83. [PMID: 24342275 DOI: 10.1016/j.arth.2013.09.040] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abstract
BACKGROUND Previous studies have indicated poor outcomes in patients having revision of hip resurfacing resulting from adverse local tissue reaction and pseudotumor. QUESTIONS/PURPOSES We reviewed all patients at our institution who had revision of failed large-head metal-on-metal total hip arthroplasty to determine (1) complications including reoperations; (2) radiologic outcomes; and (3) changes in serum ions after removal of the metal bearing. METHODS From our research database, we identified 32 hips in 30 patients. Revisions were performed through a posterior approach; 17 were performed with a titanium fiber-metal shell and 15 with a porous tantalum shell, and 29 of the 32 revisions were performed with large (36- or 40-mm) femoral heads. Clinical records were reviewed and interviews conducted in the clinic or by telephone. Nineteen hips had a pre- or intraoperative diagnosis of adverse local tissue reaction, three had deep infection, and 10 had loosening of the acetabular component. RESULTS Major complications occurred in 12 (38%) of the 32 revisions. Nine of 32 hips (28%) sustained dislocations. Four of 17 fiber-metal acetabular components failed to ingrow; none of the porous tantalum cups failed to ingrow. Seven repeat revisions were performed in six patients: three for acetabular loosening, three for recurrent dislocation, and one for recurrent adverse local tissue reaction. The mean WOMAC pain score was 78 of 100 and the function score was 83 of 100. Metal ion levels decreased after revision in most patients. CONCLUSIONS As a result of the high rate of failure of the fiber metal cups, we have elected to use an enhanced fixation surface with a high-porosity cup for revision of these cases. We observed a high rate of dislocation despite the use of 36-mm and 40-mm heads.
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28
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Wear analysis of 39 conserve plus metal-on-metal hip resurfacing retrievals. J Arthroplasty 2014; 29:410-5. [PMID: 23845764 DOI: 10.1016/j.arth.2013.05.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 03/07/2013] [Accepted: 05/30/2013] [Indexed: 02/01/2023] Open
Abstract
There have been increasing concerns regarding adverse local tissue reactions (ALTR) following metal-on-metal (MOM) hip arthroplasties. This study examined wear rates in retrievals of one design of MOM resurfacing arthroplasty, and assessed the differences in wear between those with and without ALTR. Wear measurements were made on 39 MOM resurfacing components (30 femoral, 9 acetabular) which were at least 2years in vivo. Seven hips (6 patients; 4 acetabular components, 7 femoral components) were identified to have ALTR. Acetabular component abduction and anteversion angles were determined using EBRA, and the contact-patch-to-rim (CPR) distance was calculated. The ALTR group had higher linear femoral and acetabular wear rates, acetabular anteversion and abduction angles, lower CPR, and longer time to revision. Given the increased risk for ALTR associated with acetabular component malpositioning, patients with malpositioned acetabular components may require closer clinical follow-up and monitoring.
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Abstract
We reviewed the literature on the currently available choices of bearing surface in total hip replacement (THR). We present a detailed description of the properties of articulating surfaces review the understanding of the advantages and disadvantages of existing bearing couples. Recent technological developments in the field of polyethylene and ceramics have altered the risk of fracture and the rate of wear, although the use of metal-on-metal bearings has largely fallen out of favour, owing to concerns about reactions to metal debris. As expected, all bearing surface combinations have advantages and disadvantages. A patient-based approach is recommended, balancing the risks of different options against an individual’s functional demands. Cite this article: Bone Joint J 2014;96-B:147–56.
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Affiliation(s)
- A. Rajpura
- Wrightington Hospital, The Centre
for Hip Surgery, Appley Bridge, Wigan
WN6 9EP, UK
| | - D. Kendoff
- Helios ENDO Klinik, Holstenstr. 2, 22767
Hamburg, Germany
| | - T. N. Board
- Wrightington Hospital, The Centre
for Hip Surgery, Appley Bridge, Wigan
WN6 9EP, UK
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30
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Abstract
Increasing data are available describing risk factors for the development of local and systemic adverse events following operations using metal-on-metal (MoM) hip implants. The prevalence and clinical relevance of metal-associated problems are, however, still under debate. They can be influenced by type and position of implant as well as patient-specific factors. Patients with small MoM heads (maximum diameter 32 mm) and subgroups of resurfacing arthroplasty can achieve good long-term survival. The use of large head MoM implants (diameters greater than 36 mm), however, is currently not advised due to the unsatisfactory results.
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31
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Zmistowski B, Della Valle C, Bauer TW, Malizos KN, Alavi A, Bedair H, Booth RE, Choong P, Deirmengian C, Ehrlich GD, Gambir A, Huang R, Kissin Y, Kobayashi H, Kobayashi N, Krenn V, Lorenzo D, Marston SB, Meermans G, Perez J, Ploegmakers JJ, Rosenberg A, Thomas P, Tohtz S, Villafuerte JA, Wahl P, Wagenaar FC, Witzo E. Diagnosis of periprosthetic joint infection. J Orthop Res 2014; 32 Suppl 1:S98-107. [PMID: 24464903 DOI: 10.1002/jor.22553] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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32
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Bernasek TL, Polikandriotis JA, Levering MF, Dalury DF, Fisher DA, Adler MJ. Five- to ten-year outcomes for modular metal-on-metal total hip arthroplasty. J Arthroplasty 2013; 28:1231-4. [PMID: 23643031 DOI: 10.1016/j.arth.2013.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 03/12/2013] [Accepted: 03/16/2013] [Indexed: 02/01/2023] Open
Abstract
In recent years, metal-on-metal (MOM) arthroplasty has come under fire with reported adverse outcomes of metal hypersensitivity, adverse local tissue reaction (ALTR), and the carcinogenicity concern from systemic metal ions. We present a retrospective analysis of 354 primary total hip arthroplasties from 2 independent centers. Revision data, predicted survival and Harris Hip Scores (HHS) are reported. Nine hips (2.5%) underwent component revision, and 9 year predicted survival was 95.8%. One revision had elevated metal ions but no histological evidence of ALTR. Average HHS at a minimum 5 year follow up (range 5-10 years) improved significantly from 52 pre-operatively to 93 post-operatively. While a 2.5% revision rate and improved clinical outcomes are reported in this study, longer term follow-up is warranted to monitor for late complications.
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33
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Liudahl AA, Liu SS, Goetz DD, Mahoney CR, Callaghan JJ. Metal on metal total hip arthroplasty using modular acetabular shells. J Arthroplasty 2013; 28:867-71. [PMID: 23489729 DOI: 10.1016/j.arth.2012.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 07/27/2012] [Accepted: 10/26/2012] [Indexed: 02/01/2023] Open
Abstract
Metal on metal bearings were reintroduced into the United States for use in total hip arthroplasty approximately a decade ago. We evaluated a consecutive series cohort of 148 patients with 169 hips who underwent THR using a metal on metal bearing surface with a modular acetabular shell that had fixation augmentation with dome screws. At 3 to 8 year follow-up, average 4.7 years, only one component was revised (for femoral loosening). 3 hips demonstrated proximal femoral osteolysis and 3 hips demonstrated pelvic osteolysis. The average follow-up Harris Hip Score was 94 (range, 57-100). Although the results have been excellent, we continue to closely monitor these hips for any long term failures, or concerns.
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Affiliation(s)
- Adam A Liudahl
- University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA
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34
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Kawakita K, Shibanuma N, Tei K, Nishiyama T, Kuroda R, Kurosaka M. Leg edema due to a mass in the pelvis after a large-diameter metal-on-metal total hip arthroplasty. J Arthroplasty 2013; 28:197.e1-4. [PMID: 22704029 DOI: 10.1016/j.arth.2012.04.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 04/17/2012] [Indexed: 02/01/2023] Open
Abstract
We report the case of a patient with leg edema after large-diameter metal-on-metal total hip arthroplasty. At 1 year and 2 months after primary left large-diameter metal-on-metal total hip arthroplasty, the patient complained of left leg edema. At first, we suspected deep venous thrombosis. However, deep venous thrombosis was not detected by venous ultrasonographic examination. Computed tomography imaging revealed a mass in front of the iliac fossa. The mass compressed the left iliac artery and vein. We therefore believed that this lesion was the cause of the leg edema and performed resection of the mass. The resected mass consisted of necrotic tissue infiltrating inflammation cells, so it was diagnosed as pseudotumor. Unilateral leg edema disappeared gradually after the resection.
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Affiliation(s)
- Kohei Kawakita
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, 7-5-2 Chuo-ku Kusunokicho, Kobe, Japan
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35
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Milošev I, Kovač S, Trebše R, Levašič V, Pišot V. Comparison of ten-year survivorship of hip prostheses with use of conventional polyethylene, metal-on-metal, or ceramic-on-ceramic bearings. J Bone Joint Surg Am 2012; 94:1756-63. [PMID: 23032586 DOI: 10.2106/jbjs.j.01858] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND To improve the long-term performance of hip prostheses, alternative bearings with metal-on-metal (MoM) and ceramic-on-ceramic (CoC) couples have been introduced. Although currently the results from the use of these bearings are in the midterm stage, there have been few comparative studies of these different bearings. METHODS From 2000 to 2002, 487 total hip replacements were performed with use of a BICON-PLUS acetabular cup and an SL-PLUS femoral stem (Plus Orthopedics, Rotkreuz, Switzerland, now Smith & Nephew Orthopaedics). The patients were divided into three groups according to the type of bearing that was used: an MoM group (sixty-nine prostheses), a metal-on-polyethylene (MoP) group (200 prostheses), and a CoC group (218 prostheses). Patient demographic data and data with regard to revision operations were evaluated from the hospital computer database. The mean follow-up period was 8.5 years (range, 6.9 to 10.5 years). Patient activity was assessed with use of the University of California at Los Angeles activity scale. RESULTS The mean patient age was sixty years at the time of the index arthroplasty in the MoM and CoC groups, and seventy-one years in the MoP group. Based on a scale of ten, the mean postoperative activity level was six in the CoC group, five in the MoM group, and four in the MoP group. Survival at ten years with regard to revision for any reason was 0.984, 0.956, and 0.879 for the MoP, CoC, and MoM groups, respectively. When revision for any reason was considered as the end point, survival of the MoM bearings was significantly worse than that of the MoP bearings (p = 0.005). Survival at ten years with regard to revision for aseptic loosening was 0.995, 0.990, and 0.894 for the MoP, CoC, and MoM groups, respectively. When revision for aseptic loosening was considered as the end point, survival of the MoM group was significantly worse than that of either the MoP group (p = 0.001) or the CoC group (p = 0.003). CONCLUSIONS When comparing two groups of patients of similar mean age and mean activity level undergoing total hip arthroplasty with the use of alternative bearings, CoC bearings had better survival than did MoM bearings at the ten-year follow-up; the difference was significant when revision for aseptic loosening was defined as a failure. However, neither the CoC nor the MoM alternative bearings provided improved midterm results when compared with the results of the conventional MoP bearings. For older, less active patients, traditional metal-on-polyethylene bearings are the appropriate choice. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ingrid Milošev
- Valdoltra Orthopaedic Hospital, Jadranska c. 31, SI-6280 Ankaran, Slovenia.
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36
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Griffin JW, D’Apuzzo M, Browne JA. Management of failed metal-on-metal total hip arthroplasty. World J Orthop 2012; 3:70-4. [PMID: 22720266 PMCID: PMC3377908 DOI: 10.5312/wjo.v3.i6.70] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 05/12/2012] [Accepted: 06/05/2012] [Indexed: 02/06/2023] Open
Abstract
The theoretical advantages of metal-on-metal (MOM) bearing couples in total hip arthroplasty (THA) have been recently balanced by concerns regarding adverse local and systemic effects. Higher than anticipated early revision rates have been reported by several joint registries. Failed MOM hips present with a spectrum of symptoms and findings and traditional methods of failure must be considered in addition to the failure modes that appear to be unique to the MOM bearing couple. Metal hypersensitivity and soft tissue immune reactions remain incompletely understood and require careful ongoing study. The tools available to evaluate MOM THAs and the indications for revision surgery remain to be defined. Outcomes following revision of MOM hips appear to depend on appropriate evaluation, early identification, and appropriate surgical management.
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37
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Barrett WP, Kindsfater KA, Lesko JP. Large-diameter modular metal-on-metal total hip arthroplasty: incidence of revision for adverse reaction to metallic debris. J Arthroplasty 2012; 27:976-83.e1. [PMID: 22425300 DOI: 10.1016/j.arth.2012.01.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 01/20/2012] [Indexed: 02/01/2023] Open
Abstract
Large-diameter modular metal-on-metal (MOM) total hip arthroplasty (THA) may offer reduction in wear debris and improved stability. Four studies are summarized here that used a large-diameter modular MOM system. A total of 1076 THAs were performed. This article presents data from 779 of these THAs with minimum 2-year follow-up (mean, 4.2 years) or revision since index THA (21 hips, with 1 more pending). Overall survivorship at 2 years was 98.6%; at 5 years, it was 97.0%. Seven revisions for an adverse reaction to metallic debris (ARMED), and 1 additional pending revision for ARMED, showed marked variability in presenting symptoms and intraoperative and postoperative findings. Data show good clinical performance of the modular MOM system, but suggest that surgeons must be diligent in monitoring MOM THA patients and aggressive in diagnosing and revising patients with a potential ARMED.
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Affiliation(s)
- William P Barrett
- Valley Orthopedic Associates, Proliance Surgeons, Joint Center at Valley Medical Center, Renton, Washington 98055, USA
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38
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Minimum 5-year results of modular metal-on-metal total hip arthroplasty. J Arthroplasty 2012; 27:545-50. [PMID: 21908166 DOI: 10.1016/j.arth.2011.07.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 07/05/2011] [Indexed: 02/01/2023] Open
Abstract
This study reports minimum 5-year results of 95 hips implanted with a Pinnacle (DePuy, Warsaw, Ind) modular metal-on-metal acetabular prosthesis. Clinical scores such as the Harris Hip and Western Ontario and McMaster Universities Arthritis Index revealed excellent clinical outcomes at mean 6-year follow-up. With the use of large-diameter femoral heads, dislocation was rare, occurring in only 1 hip. Moreover, no acetabular and only 3 femoral osteolytic lesions were detected. Kaplan-Meier survivorship at 7 years after arthroplasty was 97.8% for the total hip arthroplasty construct and 100% for the acetabular shell. No unexplained pain or other complication attributable to wear debris or the metal-on-metal articulation was observed. These findings indicate that total hip arthroplasty with this specific modular metal-on-metal bearing performed well in a high-demand population at midterm follow-up.
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39
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Walsh AJ, Nikolaou VS, Antoniou J. Inflammatory pseudotumor complicating metal-on-highly cross-linked polyethylene total hip arthroplasty. J Arthroplasty 2012; 27:324.e5-324.e3.24E8. [PMID: 21498036 DOI: 10.1016/j.arth.2011.03.013] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 03/05/2011] [Indexed: 02/01/2023] Open
Abstract
Inflammatory masses or cysts occurring in the pelvis, thigh, and gluteal regions, often mimicking infection, occasionally arise after total hip arthroplasty procedures. Inflammatory pseudotumors comprise a subgroup of these lesions. Pseudotumors have been associated with pain, rashes, instability, neuropathy, and premature loosening of prosthetic components, often leading to early and difficult revision surgery. The association between such pseudotumors and metal-on-metal bearings has led to questions regarding the performance of these bearings in hip arthroplasty. We present a case of pseudotumor requiring revision surgery, which occurred uniquely around a metal-on-highly cross-linked polyethylene bearing.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/instrumentation
- Dermatitis, Contact/etiology
- Dermatitis, Contact/pathology
- Dermatitis, Contact/surgery
- Granuloma, Plasma Cell/etiology
- Granuloma, Plasma Cell/pathology
- Granuloma, Plasma Cell/surgery
- Hip Prosthesis/adverse effects
- Humans
- Male
- Metals/adverse effects
- Osteoarthritis, Hip/surgery
- Polyethylene/adverse effects
- Prosthesis Design
- Reoperation
- Treatment Outcome
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Affiliation(s)
- Alan J Walsh
- Department of Orthopaedic Surgery, Room E-050, Jewish General Hospital, 3755 Chemin de la Cote-Sainte-Catherine, Montreal, Quebec, Canada
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40
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Low incidence of groin pain and early failure with large metal articulation total hip arthroplasty. Clin Orthop Relat Res 2012; 470:388-94. [PMID: 21932102 PMCID: PMC3254765 DOI: 10.1007/s11999-011-2069-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Large-diameter metal-on-metal articulations reportedly improve stability and wear in THAs. However, some reports suggest some patients have unexplained hip and early failures with these implants. Thus, the potential benefits may be offset by these concerns. However, the incidence of these problems is not clearly established. QUESTIONS/PURPOSES We therefore assessed hip pain, function, osteolysis, and complications in patients with large-diameter metal-on-metal THA. PATIENTS AND METHODS We retrospectively reviewed 611 patients who had 681 large-diameter metal-on-metal THAs with the same cup and head design. The average age at operation was 62 years, 53% of the THAs were in men, and the average body mass index was 32 kg/m(2). The diagnosis was osteoarthritis in 92% of the THAs. The minimum followup was 24 months (mean, 37 months; range, 24-60 months). RESULTS Nine of the 611 patients (1.5%) experienced moderate or severe pain in the hip region that we considered to be coming from an extraarticular source in each case. Harris hip scores for pain averaged 42 points. Total Harris hip scores averaged 93 points. Cup abduction averaged 42°, and cup anteversion averaged 26°. There were no infections. Three cups (0.4%) were considered radiographically loose. All were secondary to inadequate seating of the shell. CONCLUSION Our observations suggest with this implant the concerns of higher incidences of groin pain, early failures, and adverse tissue reactions were not confirmed. Early successes or failures with large-diameter metal-on-metal articulations may be implant specific. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Chana R, Esposito C, Campbell PA, Walter WK, Walter WL. Mixing and matching causing taper wear. ACTA ACUST UNITED AC 2012; 94:281-6. [DOI: 10.1302/0301-620x.94b2.27247] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a case of a male patient presenting with bilateral painful but apparently well-positioned and -fixed large-diameter metal-on-metal hip replacements four years post-operatively. Multiple imaging modes revealed a thick-walled, cystic expansile mass in communication with the hip joint (a pseudotumour). Implant retrieval analysis and tissue culture eliminated high bearing wear or infection as causes for the soft-tissue reaction, but noted marked corrosion of the modular neck taper adaptor and corrosion products in the tissues. Therefore, we believe corrosion products from the taper caused by mismatch of the implant components led to pseudotumour formation requiring revision.
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Affiliation(s)
- R. Chana
- Specialist Orthopaedic Group, Mater Clinic, Suite
1.08, 3-9 Gillies Street, Wollstonecraft, New
South Wales 2065, Australia
| | - C. Esposito
- Specialist Orthopaedic Group, Mater Clinic, Suite
1.08, 3-9 Gillies Street, Wollstonecraft, New
South Wales 2065, Australia
| | - P. A. Campbell
- Los Angeles Orthopaedic Hospital, 2400
S. Flower Street, Los Angeles, California
90007, USA
| | - W. K. Walter
- Specialist Orthopaedic Group, Mater Clinic, Suite
1.08, 3-9 Gillies Street, Wollstonecraft, New
South Wales 2065, Australia
| | - W. L. Walter
- Specialist Orthopaedic Group, Mater Clinic, Suite
1.08, 3-9 Gillies Street, Wollstonecraft, New
South Wales 2065, Australia
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Beaulé PE, Kim PR, Hamdi A, Fazekas A. A prospective metal ion study of large-head metal-on-metal bearing: a matched-pair analysis of hip resurfacing versus total hip replacement. Orthop Clin North Am 2011; 42:251-7, ix. [PMID: 21435499 DOI: 10.1016/j.ocl.2011.01.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The current study measured ion release among large-head metal-on-metal hip bearings. Twenty-six patients with a modular, Profemur® TL with A-Class® big femoral head total hip replacement were matched (gender, femoral size, BMI) with a group of 26 patients with the Conserve® Plus implant hip resurfacing. Compared with HR patients, THR patients had higher median serum cobalt ion levels at 6 months (3.26 vs 1.12 μg/L, P = .002) 1 year (4.51 vs 1.02, P = .002), and 2 years (3.77 vs 1.22, P<.001) following surgery. No differences in chromium ions were observed. Further research is required to determine the clinical significance of elevated serum cobalt ions.
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Affiliation(s)
- Paul E Beaulé
- The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.
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Delaunay C, Petit I, Learmonth ID, Oger P, Vendittoli PA. Metal-on-metal bearings total hip arthroplasty: the cobalt and chromium ions release concern. Orthop Traumatol Surg Res 2010; 96:894-904. [PMID: 20832379 DOI: 10.1016/j.otsr.2010.05.008] [Citation(s) in RCA: 141] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 05/08/2010] [Accepted: 05/14/2010] [Indexed: 02/02/2023]
Abstract
With certain concerns recently reported on metal-on-metal bearing couples in total hip arthroplasty, this study's objective is to review the current knowledge concerning release of metal ions and its potential consequences. Each metal-on-metal implant presents different tribological properties. The analytical techniques for metals are accurate and the Co ion rates seem acceptable up to 2 μg/L. A delayed type IV hypersensitivity reaction (atypical lymphocytic vasculitis-associated lesion [ALVAL]) may be the source of arthroplasty failure. Idiosyncratic, it remains unpredictable even using cutaneous tests and apparently is rare (0.3%). Today, there are no scientific or epidemiologic data supporting a risk of carcinogenesis or teratogenesis related to the use of a metal-on-metal bearings couple. Solid pseudotumors nearly exclusively are observed with resurfacing procedures, carrying a high annual revision rate in women under 40 years of age, occurring particularly in cases of acetabular malposition and with use of cast molded Cr-Co alloys. Osteolysis manifests through complete and progressive radiolucent lines or through cavitary lesions stemming from ALVAL-type alterations or impingement problems or implant incompatibility. The formation of wear debris exceeding the biological tolerance is possible with implant malposition, subluxation, and jamming of the femoral head in cases of cup deformity. Moreover, each implant presents different metal ion production; assessment of their performance and safety is required before their clinical use. With the knowledge available today, metal-on-metal bearing couples are contraindicated in cases of metal allergies or end stage renal dysfunction and small size resurfacing should cautiously be used.
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Affiliation(s)
- C Delaunay
- De l'Yvette Private Hospital, 67, route de Corbeil, 91160 Longjumeau, France.
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Browne JA, Bechtold CD, Berry DJ, Hanssen AD, Lewallen DG. Failed metal-on-metal hip arthroplasties: a spectrum of clinical presentations and operative findings. Clin Orthop Relat Res 2010; 468:2313-20. [PMID: 20559767 PMCID: PMC2919884 DOI: 10.1007/s11999-010-1419-0] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND A number of recent reports have described novel failure mechanisms of metal-on-metal bearings in total and resurfacing hip arthroplasty. Hip arthroplasties with metal-on-metal articulations are also subject to the traditional methods of failure seen with different bearing couples. There is currently little information in the literature to help guide timely clinical evaluation and management of these patients. QUESTIONS/PURPOSES We therefore describe the (1) clinical presentations; (2) reasons for failure; (3) operative findings; and (4) histologic findings in patients with failed metal-on-metal hip arthroplasties. METHODS We retrospectively identified all 37 patients (37 hips) with metal on metal total hip or resurfacing arthroplasties who underwent revision over the past 3 years at our institution. Relevant clinical, radiographic, laboratory, intraoperative, and histopathologic findings were analyzed for all patients. RESULTS Of the 37 patients, 10 were revised for presumed hypersensitivity specific to the metal-on-metal articulation. This group included eight patients with tissue histology confirming chronic inflammation with lymphocytic infiltration, eight with aseptic loosening of a monoblock screwless uncemented acetabular component, two with iliopsoas impingement associated with a large-diameter femoral head, and three with femoral neck fracture after resurfacing arthroplasty; the remainder of the patients were revised for infection, instability, component malposition, and periprosthetic fracture. CONCLUSIONS Increased awareness of the modes of failure will bring to light the potential complications particular to metal-on-metal articulations while placing these complications into the context of failures associated with all hip arthroplasties. This novel clinical information should be valuable for the practicing surgeon faced with this patient population. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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