Adverse reaction to metal debris following hip resurfacing: the influence of component type, orientation and volumetric wear. J Bone Joint Surg Br 93:164-171

Northern Deanery, Goldcrest Way, Newcastle-upon-Tyne, NE15 8NY, UK.
The Bone & Joint Journal (Impact Factor: 3.31). 02/2011; 93(2):164-71. DOI: 10.1302/0301-620X.93B2.25099
Source: PubMed


We sought to establish the incidence of joint failure secondary to adverse reaction to metal debris (ARMD) following metal-on-metal hip resurfacing in a large, three surgeon, multicentre study involving 4226 hips with a follow-up of 10 to 142 months. Three implants were studied: the Articular Surface Replacement; the Birmingham Hip Resurfacing; and the Conserve Plus. Retrieved implants underwent analysis using a co-ordinate measuring machine to determine volumetric wear. There were 58 failures associated with ARMD. The median chromium and cobalt concentrations in the failed group were significantly higher than in the control group (p < 0.001). Survival analysis showed a failure rate in the patients with Articular Surface Replacement of 12.8% [corrected] at five years, compared with < 1% at five years for the Conserve Plus and 1.5% at ten years for the Birmingham Hip Resurfacing. Two ARMD patients had relatively low wear of the retrieved components. Increased wear from the metal-on-metal bearing surface was associated with an increased rate of failure secondary to ARMD. However, the extent of tissue destruction at revision surgery did not appear to be dose-related to the volumetric wear.

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    • "Nonetheless, levels below 2 mg/L are considered normal by several authors, for wellfunctioning MoM implants [43,51,56,72,106,109,110] . The concentrations of both ions usually vary from one to few dozens of mg per liter, in all tested human fluids (serum, blood, whole blood, urine) [39,51,99,111]. Clinically, the average serum Co and Cr levels after MoM prostheses implantation are often reported to be with in the range of 1e7 mg/L but failing MoM hip implants, some pseudotumors cases [51] , and extensive corrosion on the modular MoP stemneck interface [43] often present concentrations in the order of hundreds of mg/L [36e38,51,56,66,105e108,110]. There is no international consensus on toxic threshold limits for metallic ions concentrations found in the blood and urine of patients with hip prostheses, namely with large head MoM bearing (!36 mm). "
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    ABSTRACT: The paradigm of metallic ions as exclusive toxic agents is changing. During the last 60 years, knowledge about toxicological and immunological reactions to metal particles and ions has advanced considerably. Hip prostheses, namely metal-on-metal bearings, have prompted studies about excessive and prolonged exposure to prosthetic debris. In that context, the interactions of metal particles and ions with cells and tissues are mostly harmful, inducing immune responses that lead to osteolysis and implant failure.
    Full-text · Article · Jan 2016 · Biomaterials
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    • "serum-metal ion levels. Though commonly implicated with metal on metal hip resurfacing [4] [5], the discolouration and effusion are rarely apparent on clinical inspection because of the considerable soft tissue that envelops the replaced hip joint. However, when metallosis affects the more accessible replaced knee joint, as in this case, the discoloured soft tissue may be obvious on inspection, as would be the large effusion. "
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    ABSTRACT: Introduction. Metallosis is a phenomenon most commonly associated with hip replacement. However it can occur in any metallic implant subject to wear. Wear creates metal debris, which is deposited in the surrounding soft tissue. This leads to many local adverse reactions including, but not limited to, implant loosening/osteolysis, pain, and effusion. In the deeper joints, for example, the hip, metal deposits are mostly only seen intraoperatively. Case Study. A 74-year-old lady represented to orthopaedic outpatient clinic. Her principle complaint was skin discolouration, associated with pain and swelling over the left knee, on the background of a previous total knee replacement with a metal backed patella resurfacing six years. A plain radiograph revealed loosening of the patellar prosthesis. A diagnosis of metallosis was made; the patient underwent debridement of the stained soft tissue and primary revision of the prosthesis. She remained symptom-free five years after revision. Discussion. Metallosis results in metallic debris which causes tissue staining, often hidden within the soft tissue envelope of the hip, but more apparent in the knee. Metallosis may cause pain, effusion, and systemic symptoms because of raised levels of serum-metal ions. Surgical intervention with revision and debridement can have good functional results.
    Full-text · Article · Apr 2015
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    • "The differences between the 2 modalities may be sufficiently great to affect the validity of conclusions based on 2D measurements. The influence of cup version and inclination on MoM bearing failure has been mainly investigated using 2D analysis of conventional radiographs with EBRA software (Langton et al. 2008, 2009, Grammatopoulos et al. 2010, Langton et al. 2010a, Bolland et al. 2011, Langton et al. 2011). These studies represent the greatest body of work in the literature and include over 4,000 MoM hips. "
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    ABSTRACT: Background and purpose 2D analysis of metal-on-metal (MoM) hip arthroplasty (HA) has been conducted in several large series on conventional radiographs with the use of Ein Bild Roentegen Analyse (EBRA) software, but there have been no comparisons with 3D analysis in the literature. The main aim of this study was to quantify the agreement in measurements of cup version of large-diameter MoM hips obtained by EBRA and by 3D computed tomography (3D-CT). The secondary aim was to quantify the agreement for cup inclination. Lastly, we wanted to determine the inter- and intra-observer reliability of both methods. Patients and methods 87 MoM hips in 81 patients were analyzed for cup inclination and version in 2D on conventional radiographs using EBRA software. The results were compared with 3D measurements using CT. Results Cup version was underestimated by EBRA when compared to 3D-CT, by 6° on average with the pelvis supine and by 8° on average with the pelvis orientated to the anterior pelvic plane (APP). For inclination, the mean difference was no more than 1°. 53% of hips were within a 10° safe zone of 45° inclination and 20° version when measured by 3D-CT with the pelvis supine (and 54% with the pelvis in the APP). The proportion was only 24% when measured by EBRA. Inter- and intra-observer reliability of cup version is poorer using 2D analysis than when using 3D-CT. Interpretation Errors in version in 2D were due to the difficulty in delineating the cup rim, which was obscured by a large-diameter metal head of the same radio-opacity. This can be overcome with 3D analysis. The present study demonstrates that measurements using EBRA have poor agreement and are less reliable than those with 3D-CT when measuring cup version and inclination in MoM hips.
    Full-text · Article · Feb 2015 · Acta Orthopaedica
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