Independent predictors of revision following metal-on-metal hip resurfacing: A retrospective cohort study using National Joint Registry data

School of Medicine and Health, Durham University, Queen's Campus, University Boulevard, Stockton-on-Tees TS17 6BH, UK.
The Bone & Joint Journal (Impact Factor: 3.31). 06/2012; 94(6):746-54. DOI: 10.1302/0301-620X.94B6.29239
Source: PubMed


Modern metal-on-metal hip resurfacing has been widely performed in the United Kingdom for over a decade. However, the literature reports conflicting views of the benefits: excellent medium- to long-term results with some brands in specific subgroups, but high failure rates and local soft-tissue reactions in others. The National Joint Registry for England and Wales (NJR) has collected data on all hip resurfacings performed since 2003. This retrospective cohort study recorded survival time to revision from a resurfacing procedure, exploring risk factors independently associated with failure. All patients with a primary diagnosis of osteoarthritis who underwent resurfacing between 2003 and 2010 were included in the analyses. Cox's proportional hazard models were used to analyse the extent to which the risk of revision was related to patient, surgeon and implant covariates. A total of 27 971 hip resurfacings were performed during the study period, of which 1003 (3.59%) underwent revision surgery. In the final adjusted model, we found that women were at greater risk of revision than men (hazard ratio (HR) = 1.30, p = 0.007), but the risk of revision was independent of age. Of the implant-specific predictors, five brands had a significantly greater risk of revision than the Birmingham Hip Resurfacing (BHR) (ASR: HR = 2.82, p < 0.001, Conserve: HR = 2.03, p < 0.001, Cormet: HR = 1.43, p = 0.001, Durom: HR = 1.67, p < 0.001, Recap: HR = 1.58, p = 0.007). Smaller femoral head components were also significantly more likely to require revision (≤ 44 mm: HR = 2.14, p < 0.001, 45 to 47 mm: HR = 1.48, p = 0.001) than medium or large heads, as were operations performed by low-volume surgeons (HR = 1.36, p < 0.001). Once these influences had been removed, in 4873 male patients < 60 years old undergoing resurfacing with a BHR, the five-year estimated risk of revision was 1.59%. In summary, after adjustment for a range of covariates we found that there were significant differences in the rate of failure between brands and component sizes. Younger male patients had good five-year implant survival when the BHR was used.

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    • "They detected two major problems: aseptic loosening (34.4%) and fracture of the proximal femur (31.9%). Jameson et al. [14] observed that 96.4% of HR 7 years post-op did not undergo revision surgery. Murray et al. [15] reflected a ten-year survival of 74% in some particular designs in female patients and in small size joints due to the materials used in the bearing surfaces and the biological reactions they can elicit. "
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    ABSTRACT: Metal-on-metal hip resurfacing prostheses were re-introduced during the last 10-15 years. These prostheses have the potential to better restore normal function with limited activity restriction, being an option for younger and more active patients. Resurfacing procedures have demonstrated high failure rates in national registers [1,2]. Multiple factors may affect early and long-term HR performance. The influence of femoral cement mantle thickness and different interface characteristics between the prosthesis components on the long-term performance of resurfacing prostheses is still unknown. In the present work, a model was used to predict bone remodeling with different mantle thicknesses and interface characteristics. A very thin cement mantle (0.25mm) increased bone resorption at the superior femoral head, while greater thickness (1 or 3mm) had a lesser effect. In all cases, bone apposition was predicted around the stem and at the stem tip. Bone formation and resorption were observed clinically in good agreement with the predictions calculated in simulations. Computed results showed that 1-mm cement mantle thickness combined with a bonded bone-cement interface and a debonded implant-cement interface was an appropriate configuration. Bone remodeling results and computed equivalent strains were correlated. In conclusion, we have been able to demonstrate the importance of choosing an adequate cement mantle thickness. Additionally, computational studies should consider realistic interface characteristics between the components in order to perform simulations closer to reality.
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