Sehatzadeh, S; Kaulback, K; Levin, L
Background Metal-on-metal (MOM) hip resurfacing arthroplasty (HRA) is in clinical use as an appropriate alternative to total hip arthroplasty in young patients. In this technique, a metal cap is placed on the femoral head to cover the damaged surface of the bone and a metal cup is placed in the acetabulum. Objectives The primary objective of this analysis was to compare the revision rates of MOM HRA using different implants with the benchmark set by the National Institute of Clinical Excellence (NICE). The secondary objective of this analysis was to review the literature regarding adverse biological effects associated with implant material. Review Methods A literature search was performed on February 13, 2012, to identify studies published from January 1, 2009, to February 13, 2012. Results The revision rates for MOM HRA using 6 different implants were reviewed. The revision rates for MOM HRA with 3 implants met the NICE criteria, i.e., a revision rate of 10% or less at 10 years. Two implants had short-term follow-ups and MOM HRA with one of the implants failed to meet the NICE criteria. Adverse tissue reactions resulting in failure of the implants have been reported by several studies. With a better understanding of the factors that influence the wear rate of the implants, adverse tissue reactions and subsequent implant failure can be minimized. Many authors have suggested that patient selection and surgical technique affect the wear rate and the risk of tissue reactions. The biological effects of high metal ion levels in the blood and urine of patients with MOM HRA implants are not known. Studies have shown an increase in chromosomal aberrations in patients with MOM articulations, but the clinical implications and long-term consequences of this increase are still unknown. Epidemiological studies have shown that patients with MOM HRA implants did not have an overall increase in mortality or risk of cancer. There is insufficient clinical data to confirm the
Delgado-Sevillano, Ramon; de la Flor-García, Maria Rodríguez
Total hip replacement continues to be a widely successful operation, but persistent groin pain following a metal-on-metal hip resurfacing remains a problem for some patients. The concern regarding the safety and efficacy of metal-on-metal total hip replacements has been rising. We present the case of a 47-year-old man with groin pain after metal-on-metal hip resurfacing. We observed high metal ion levels detected in blood analytical studies and a pseudotumor in magnetic resonance imaging. Our patient was treated with a revision surgery. The progressive elevation of blood and urine metal levels in the presence of periarticular cysts and/or groin pain is a complication of metal-on-metal hip arthroplasty and needs revision surgery. PMID:27489648
Amstutz, Harlan C
Bone conservation and preservation, joint stability, and low wear of the large metal-on-metal resurfacing bearings have been convincingly demonstrated in the current literature. The clinical results of 600 MM Hybrid Conserve Plus Resurfacing in 519 patients with an average follow-up of 6.9 years (range, 4.0-10.4 years) have been excellent. The average age was 48.9 years, 74% of the patients were male, and the study included all etiologies of the young with arthritis. The complication rates other than dislocation and fracture of the femoral neck are comparable between resurfacing and conventional total hip replacement. The incidence of femoral neck fracture is low (1.2% worldwide) with less than 0.6% in this series and none occurring in the last 5 years due to proper patient selection and improved surgical technique. Component loosening after metal-on-metal resurfacing has been significantly reduced and acetabular component loosening is uncommon and has not happened in this series. Femoral bone preparation and optimal cementing techniques are paramount to prevention of femoral loosening. Clearance between the cylindrically reamed part of the head and the component varies in different designs, and the surgeon must note the need for different cementing strategies for different recommended clearances. The learning curve of a surgeon undertaking resurfacing can be greatly reduced by observation and hands-on training in specialized centers with surgeons experienced in resurfacing.
Executive Summary Objective The objective of this review was to assess the safety and effectiveness of metal on metal (MOM) hip resurfacing arthroplasty for young patients compared with that of total hip replacement (THR) in the same population. Clinical Need Total hip replacement has proved to be very effective for late middle-aged and elderly patients with severe degenerative diseases of the hips. As indications for THR began to include younger patients and those with a more active life style, the longevity of the implant became a concern. Evidence suggests that these patients experience relatively higher rates of early implant failure and the need for revision. The Swedish hip registry, for example, has demonstrated a survival rate in excess of 80% at 20 years for those aged over 65 years, whereas this figure was 33% by 16 years in those aged under 55 years. Hip resurfacing arthroplasty is a bone-conserving alternative to THR that restores normal joint biomechanics and load transfer. The technique has been used around the world for more than 10 years, specifically in the United Kingdom and other European countries. The Technology Metal-on-metal hip resurfacing arthroplasty is an alternative procedure to conventional THR in younger patients. Hip resurfacing arthroplasty is less invasive than THR and addresses the problem of preserving femoral bone stock at the initial operation. This means that future hip revisions are possible with THR if the initial MOM arthroplasty becomes less effective with time in these younger patients. The procedure involves the removal and replacement of the surface of the femoral head with a hollow metal hemisphere, which fits into a metal acetabular cup. Hip resurfacing arthroplasty is a technically more demanding procedure than is conventional THR. In hip resurfacing, the femoral head is retained, which makes it much more difficult to access the acetabular cup. However, hip resurfacing arthroplasty has several advantages over a
Sands, David; Schemitsch, Emil H
The current role of metal-on-metal (MoM) bearings in hip arthroplasty remains controversial. The low wear offered by MoM bearings compared to metal-on-polyethylene and the possibility of a lower risk of dislocation with larger head sizes, encouraged a trend towards the re-introduction of the MoM bearing couple. However, recent evidence has shown that not all designs of the MoM bearing have been successful. The purpose of this paper is to provide an update on the use of MoM bearings and address the following issues: (1) the reintroduction of metal-on-metal bearings in total hip arthroplasty, (2) the failure of metal-on-metal bearings in stemmed total hip arthroplasty, (3) the role of metal-on-metal hip resurfacing in modern orthopaedics and (4) metal-on-metal hip resurfacing versus total hip arthroplasty. A literature search strategy was conducted using various search terms in MEDLINE and Embase. The highest quality articles that met the inclusion criteria and best answered the topics of focus of this review were selected. Key search terms included 'metal-on-metal', 'total hip arthroplasty' and 'hip resurfacing'. The initial search retrieved 1240 articles. Twenty-two articles were selected and used in the review. Metal-on-metal hip resurfacing is still a suitable treatment option in specific patient populations with the appropriate implant design and surgical skill, while stemmed metal-on-metal total hip arthroplasty should be avoided in all patient populations. Continued follow-up of patients undergoing metal-on-metal hip resurfacing is critical in order to further understand the long-term outcomes of these patients and why certain complications tend to occur with this procedure.
Garbuz, Donald S; Tanzer, Michael; Greidanus, Nelson V; Masri, Bassam A; Duncan, Clive P
Resurfacing arthroplasty has become an attractive option for young patients who want to maintain a high activity level. One recent study reported modestly increased activity levels for patients with resurfacing compared to standard total hip arthroplasty (THA). We conducted a prospective randomized clinical trial to compare clinical outcomes of resurfacing versus large-head metal-on-metal total hip arthroplasty. We randomized 107 patients deemed eligible for resurfacing arthroplasty to have either resurfacing or standard THA. Patients were assessed for quality-of-life outcomes using the PAT-5D index, WOMAC, SF-36, and UCLA activity score. The minimum followup was 0.8 years (mean, 1.1 years; range, 0.8-2.2 years). Of the 73 patients followed at least one year, both groups reported improvement in quality of life on all outcome measures. There was no difference in quality of life between the two arms in the study. Serum levels of cobalt and chromium were measured in a subset of 30 patients. In both groups cobalt and chromium was elevated compared to baseline. Patients receiving a large-head metal-on-metal total hip had elevated ion levels compared to the resurfacing arm of the study. At 1 year, the median serum cobalt increased 46-fold from baseline in patients in the large-head total hip group, while the median serum chromium increased 10-fold. At 1 year, serum cobalt was 10-fold higher and serum chromium 2.6-fold higher than in the resurfacing arm. Due to these excessively high metal ion levels, the authors recommend against further use of this particular large-head total hip arthroplasty. Level I, randomized clinical trial. See Guidelines for Authors for a complete description of levels of evidence.
Snir, Nimrod; Park, Brian K; Garofolo, Garret; Marwin, Scott E
Revision of metal-on-metal (MoM) total hip arthroplasty (THA) or hip resurfacing is associated with high complication rates. The authors propose dual-mobility components as a surgical option and present short- to mid-term results of MoM hips revised with dual-mobility components. Eighteen consecutive hips that underwent revision of MoM THA or hip resurfacing using dual-mobility components were identified. At final follow-up (mean, 17.5 months), the visual analog scale, modified Harris Hip Score, and SF-12 scores had all improved (P<.05, P<.01, and P<.05, respectively). There were no dislocations or other complications. Revision of failed MoM THA or hip resurfacing using a dual-mobility device is an effective strategy. Copyright 2015, SLACK Incorporated.
Daniel, J; Ziaee, H; Kamali, A; Pradhan, C; Band, T; McMinn, D J W
Second-generation metal-on-metal bearings were introduced as a response to the considerable incidence of wear-induced failures associated with conventional replacements, especially in young patients. We present the results at ten years of a consecutive series of patients treated using a metal-on-metal hip resurfacing. A distinct feature of the bearings used in our series was that they had been subjected to double-heat treatments during the post-casting phase of their manufacture. In the past these bearings had not been subjected to thermal treatments, making this a unique metal-on-metal bearing which had not been used before in clinical practice. We report the outcome of 184 consecutive hips (160 patients) treated using a hybrid-fixed metal-on-metal hip resurfacing during 1996. Patients were invited for a clinicoradiological follow-up at a minimum of ten years. The Oxford hip score and anteroposterior and lateral radiographs were obtained. The mean age at operation was 54 years (21 to 75). A series of 107 consecutive hips (99 patients) who received the same prosthesis, but subjected to a single thermal treatment after being cast, between March 1994 and December 1995, were used as a control group for comparison. In the 1994 to 1995 group seven patients (seven hips) died from unrelated causes and there were four revisions (4%) for osteolysis and aseptic loosening. In the 1996 group nine patients died at a mean of 6.9 years after operation because of unrelated causes. There were 30 revisions (16%) at a mean of 7.3 years (1.2 to 10.9), one for infection at 1.2 years and 29 for osteolysis and aseptic loosening. Furthermore, in the latter group there were radiological signs of failure in 27 (24%) of the 111 surviving hips. The magnitude of the problem of osteolysis and aseptic loosening in the 1996 cohort did not become obvious until five years after the operation. Our results indicate that double-heat treatments of metal-on-metal bearings can lead to an increased
Krishnan, Harry; Sugand, Kapil; Ali, Ibrahim; Smith, Jay
A 75-year-old woman who had undergone hybrid metal-on-metal hip resurfacing 8 years earlier underwent revision arthroplasty because of hip, groin and lateral thigh pain. The main differential was aseptic loosening; however, serum cobalt and chromium levels were normal. Multiple imaging modalities revealed a periprosthetic, cystic soft tissue mass adjacent to the proximal femur. A large ‘pseudotumour’ with proximal femoral invasion was found at revision arthroplasty. We report the first finding of a ‘pseudotumour’ invading the proximal femur with normal metal ions following metal on metal hip resurfacing. PMID:25670783
van der Weegen, W; Brakel, K; Horn, R J; Hoekstra, H J; Sijbesma, T; Pilot, P; Nelissen, R G H H
The aim of this study was to establish the natural course of unrevised asymptomatic pseudotumours after metal-on-metal (MoM) hip resurfacing during a six- to 12-month follow-up period. We used repeated metal artefact reduction sequence (MARS)-magnetic resonance imaging (MRI), serum metal ion analysis and clinical examination to study 14 unrevised hips (mean patient age 52.7 years, 46 to 68, 5 female, 7 male) with a pseudotumour and 23 hips (mean patient age 52.8 years, 38 to 69, 7 female, 16 male) without a pseudotumour. The mean post-operative time to the first MARS-MRI scan was 4.3 years (2.2 to 8.3), and mean time between the first and second MARS-MRI scan was eight months (6 to 12). At the second MRI scan, the grade of severity of the pseudotumour had not changed in 35 hips. One new pseudotumour (Anderson C2 score, moderate) was observed, and one pseudotumour was downgraded from C2 (moderate) to C1 (mild). In general, the characteristics of the pseudotumours hardly changed. Repeated MARS-MRI scans within one year in patients with asymptomatic pseudotumours after MoM hip resurfacing showed little or no variation. In 23 patients without pseudotumour, one new asymptomatic pseudotumour was detected. This is the first longitudinal study on the natural history of pseudotumours using MARS-MRI scans in hip resurfacing, and mirrors recent results for 28 mm diameter MoM total hip replacement.
Wroblewski, B. M.; Siney, P. D.; Fleming, P. A.
Objectives Metal-on-metal (MoM) hip resurfacing was introduced into clinical practice because it was perceived to be a better alternative to conventional total hip replacement for young and active patients. However, an increasing number of reports of complications have arisen focusing on design and orientation of the components, the generation of metallic wear particles and serum levels of metallic ions. The procedure introduced a combination of two elements: large-dimension components and hard abrasive particles of metal wear. The objective of our study was to investigate the theory that microseparation of the articular surfaces draws in a high volume of bursal fluid and its contents into the articulation, and at relocation under load would generate high pressures of fluid ejection, resulting in an abrasive water jet. Methods This theoretical concept using MoM resurfacing components (head diameter 55 mm) was modelled mathematically and confirmed experimentally using a material-testing machine that pushed the head into the cup at a rate of 1000 mm/min until fully engaged. Results The mathematical model showed the pattern but not the force of fluid ejection, the highest pressures were expected when the separation of the components was only a fraction of one millimetre. The experimental work confirmed the results; with the mean peak ejection pressure of 43 763 N/m2 equivalent to 306 mmHg or 5 psi. Conclusions The mechanical effect of the high-pressure abrasive water jet is the likely cause of the spectrum of complications reported with metal-on-metal resurfacing. Investigating serum levels of metallic elements may not be the best method for assessing the local mechanical effects of the abrasive water jet. PMID:23610667
Udofia, I J; Jin, Z M
The elastohydrodynamic lubrication analysis was carried out in this study for a typical metal-on-metal hip-resurfacing prosthesis under a simple steady-state rotation. Both the Reynolds equation and the elasticity equation were coupled and solved numerically by the finite difference method. The finite element method was used to determine the elastic deformation of both the femoral and the acetabular components required for the lubrication analysis. The effect of the radial clearance between the femoral head and the acetabular cup on the predicted film thickness and pressure distribution was investigated. The predicted minimum lubricating film thickness was found to compare favourably with the prediction using the Hamrock and Dowson [J. Lubrication Technol. 100 (1978) 236] formula based on the assumption of ball-on-plane semi-infinite solids. This implies that the non-metallic materials such as bone and cement underlying the metallic components have a small effect on the predicted lubrication performance for the particular metal-on-metal hip-resurfacing prosthesis considered in this study. Under realistic physiological walking conditions, a decrease in the radial clearance from 150 to 50 microm resulted in a 137% increase in the predicted minimum film thickness from 19 to 45 nm. Consequently, given a surface roughness of 0.01 microm for both the metallic femoral and acetabular bearing surfaces, the predicted mixed lubrication regime for the larger clearance was changed to a full fluid film lubrication regime for the smaller clearance. This clearly highlighted the importance of the design and manufacturing parameters on the tribological performance of these hard-on-hard hip prostheses.
Mellon, S J; Kwon, Y-M; Glyn-Jones, S; Murray, D W; Gill, H S
The occurrence of pseudotumours (soft tissue masses relating to the hip joint) following metal-on-metal hip resurfacing arthroplasty (MoMHRA) has been associated with high serum metal ion levels and consequently higher than normal bearing wear. We investigated the relationship between serum metal ion levels and contact stress on the acetabular component of MoMHRA patients for two functional activities; gait and stair descent. Four subjects with MoMHRA, who had their serum metal ion levels measured, underwent motion analysis followed by CT scanning. Their motion capture data was combined with published hip contact forces and finite element models representing 14% (peak force) and 60% (end of stance) of the gait cycle and 52% (peak force) of stair descent activity were created. The inclination angle of the acetabular component was increased by 10° in 1° intervals and the contact stresses were determined at each interval for each subject. When the inclination angle was altered in such a way as to cause the hip contact force to pass through the edge of the acetabular component edge-loading occurred. Edge-loading increased the contact stress by at least 50%; the maximum increase was 108%. Patients with low serum metal ion levels showed no increase in contact stress at peak force during gait or stair descent. Patients with high serum metal ion levels exhibited edge-loading with an increase to the inclination angle of their acetabular components. The increase in inclination angle that induced edge-loading for these subjects was less than the inter-subject variability in the angle of published hip contact forces. The results of this study suggest that high serum metal ion levels are the result of inclination angle influenced edge-loading but that edge-loading cannot be attributed to inclination angle alone and that an individual's activity patterns can reduce or even override the influence of a steep acetabular component and prevent edge-loading. Copyright © 2011 IPEM
Meng, Qingen; Liu, Feng; Fisher, John; Jin, Zhongmin
It is important to study the lubrication mechanism of metal-on-metal hip resurfacing prosthesis in order to understand its overall tribological performance, thereby minimize the wear particles. Previous elastohydrodynamic lubrication studies of metal-on-metal hip resurfacing prosthesis neglected the effects of the orientations of the cup and head. Simplified pelvic and femoral bone models were also adopted for the previous studies. These simplifications may lead to unrealistic predictions. For the first time, an elastohydrodynamic lubrication model was developed and solved for a full metal-on-metal hip resurfacing arthroplasty. The effects of the orientations of components and the realistic bones on the lubrication performance of metal-on-metal hip resurfacing prosthesis were investigated by comparing the full model with simplified models. It was found that the orientation of the head played a very important role in the prediction of pressure distributions and film profiles of the metal-on-metal hip resurfacing prosthesis. The inclination of the hemispherical cup up to 45° had no appreciable effect on the lubrication performance of the metal-on-metal hip resurfacing prosthesis. Moreover, the combined effect of material properties and structures of bones was negligible. Future studies should focus on higher inclination angles, smaller coverage angle and microseparation related to the occurrences of edge loading.
Hoberg, Maik; Amstutz, Harlan C
Pigmented villonodular synovitis (PVNS) of the hip joint is a rare and benign tumor of the synovia. This local, aggressive, proliferative disorder of the joint synovial membrane can lead to secondary osteoarthritis and represents a small percentage of all patients undergoing total hip replacement (THR). Because of the usually young age of the patients undergoing THR for PVNS, a resurfacing arthroplasty of the hip appears as a beneficial treatment option due to its bone-conserving nature, good joint stability, and ability to easily convert to a THR if needed. This article describes 2 cases of metal-on-metal hip resurfacing in patients with pigmented villonodular synovitis. In patient 1, PVNS was suspected on radiographs but confirmed only after removal of a mass of thick, grey-brown spotted synovia. A complete synovectomy was performed prior to hip resurfacing. Seven years postoperatively, radiographs show secure fixation of the components with no radiolucencies. In patient 2, arthroscopy of the hip joint had been performed 3 months prior, but PVNS had not been diagnosed. Pigmented villonodular synovitis was confirmed during the operation when incising a yellowish nodular mass protruding from the capsule. Granuloma was also found in the inferior and anterior part of the acetabulum. Four years postoperatively, the patient exhibits excellent clinical and radiographic results. Complete surgical removal of all tissue affected with PVNS is the key to a successful resurfacing, which is otherwise technically similar to resurfacing in patients with other etiologies. The mid-term results of the 2 presented cases are satisfying and show the potential of the resurfacing technique for young patients with PVNS of the hip. Copyright 2010, SLACK Incorporated.
Beaulé, Paul E; Amstutz, Harlan C; Le Duff, Michel; Dorey, Frederic
Eighty-four hips with Ficat stage III and IV osteonecrosis were treated: 56 with metal-on-metal surface arthroplasty (MMSA) and 28 with hemi-surface arthroplasty (HSA). Average follow-up was 4.9 years. UCLA hip scores were significantly better for MMSA versus HSA for function and activity as well as Harris Hip scores and physical component of the SF-12 scores. In the MMSA group, 2 hips were revised to total hip arthroplasty for femoral loosening, and 5 hips had adverse radiological changes. In the HSA group, 4 hips were revised (1 sepsis and 3 for pain). There was no evidence of any femoral loosening or neck narrowing in the HSA group. Although the functional clinical outcome of MMSA is superior to HSA, long-term follow up of MMSA will determine the reliability of the femoral fixation.
Roda, Richard; Whittingham-Jones, Paul M; Lee, Joshua; Ryu, Jae-Jin; Beaulé, Paul E
The purpose of this study was to study the initial fixation and migration pattern of a monoblock acetabular component used for a metal on metal hip resurfacing using Einzel Bild Roentgen Analyse (EBRA). 99 patients with a mean age of 49.6 years (range 28.5-66.3 years) of whom 14 were bilateral underwent a hip resurfacing (Conserve Plus®, MicroPort, Memphis, TN) for a total of 113 resurfacings. Acetabular component orientation was noted with 35 of the 113 components (31.0%) having a lucency >2 mm on the immediate postoperative radiograph. The mean follow-up for our cohort of 113 hips is 50 months (2-79 months). When examining the 2-year migration mark, 37 of the 113 hips exceeded the threshold of 0.5 mm/year with a median total migration of 1.40 mm (range 1.02-4.24). 6 resurfacings underwent revision surgery for aseptic loosening of the acetabular component at a mean time of 43.6 months. Presence of initial lucency (OR 2.29, p = 0.05) was the only significant predictor of migration over threshold at 2-years. Those that had migrated over the threshold (1.0 mm) at 2 years were at significantly greater risk of continued migration at 4 years. The migration pattern of this component raises concerns about long term performance, with postoperative lucencies representing a significant factor for future migration.
Abdel-Hamid, Hossam; Miles, Jonathan; Carrington, Richard W J; Hart, Alister; Loh, Alex; Skinner, John A
Introduction. Metal-on-metal (MoM) hip resurfacings have been associated with a variety of complications resulting from adverse reaction to metal debris. Pseudotumors have rarely been reported to cause deep venous thrombosis (DVT). Study Design. A case report and a review of the literature. Case Presentation. A 75-year-old female who had left metal-on-metal hip resurfacing 6 years ago presented with left groin pain associated with unilateral lower limb edema and swelling. By duplex and MRI studies, our patient had an extensive soft tissue necrosis associated with a large pelvic mass causing extensive DVT of the lower limb secondary to mechanical compression of the left iliac vein. Results. Our case was initially treated for DVT followed by dual surgical approach. The pseudotumor was excised through a separate iliofemoral approach and revision of the hip implant was undertaken through a posterior approach in the same setting. An inferior vena cava (IVC) filter was inserted to minimise the perioperative risks of handling the iliac veins. Conclusion. A combined approach with vascular surgeons is required. Combined resection of the pseudotumor and revision of the metal bearing surfaces is essential, in order to achieve a good surgical outcome in this rare complication.
Antoniou, John; Zukor, David J; Mwale, Fackson; Minarik, William; Petit, Alain; Huk, Olga L
Metal ion toxicity, metal hypersensitivity, and metal carcinogenicity are causes for concern for patients with metal-on-metal hip replacements. Thus, understanding the biological fate of metal ions, and consequently their long-term systemic effects, is of great interest to patients and surgeons alike. Inductively coupled plasma mass spectrometry was used to measure the levels of cobalt, chromium, and molybdenum ions in the blood of control patients (preoperative control pre-resurfacing patients), patients with a metal-on-polyethylene total hip prosthesis, patients with a metal-on-metal total hip prosthesis with either a 28 or 36-mm femoral head, and patients with a hip resurfacing prosthesis. Since cobalt and chromium ions have the potential to induce oxidative stress through irreversible biochemical damage to macromolecules, the levels of ions were correlated to the concentration of three oxidative stress markers in the plasma of these patients. The median cobalt level was significantly lower (p < 0.001) in the 36-mm metal-on-metal total hip arthroplasty group (1.8 parts per billion [1.8 microg/L]) compared with the 28-mm metal-on-metal total hip arthroplasty group (2.5 parts per billion [2.5 microg/L]) and the hip resurfacing group (2.3 parts per billion [2.3 microg/L]) at six months postoperatively. The median chromium level was also significantly lower (p < 0.01) in the 36-mm metal-on-metal total hip arthroplasty group (0.25 parts per billion [0.25 microg/L]) compared with the 28-mm metal-on-metal total hip arthroplasty group (0.35 parts per billion [0.35 microg/L]) and the hip resurfacing group (0.50 parts per billion [0.50 microg/L]) at six months postoperatively. However, neither the median cobalt levels nor the median chromium levels were significantly different among the three metal-on-metal groups at one year. The median levels of molybdenum were not significantly different among the three groups at either six months or one year. In addition, there was no
Jameson, S S; Baker, P N; Mason, J; Porter, M L; Deehan, D J; Reed, M R
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
Khan, M; Kuiper, J-H; Richardson, J B
Wear of metal-on-metal bearings causes elevated levels of cobalt and chromium in blood and body fluids. Metal-on-metal bearings have two distinct wear phases. In the early phase, the wear rate is high. Later, it decreases and the bearing enters a steady-state phase. It is expected that as the wear rates decline, the level of cobalt detected in plasma will also decrease. We studied the baseline and exercise-related cobalt rise in 21 patients (13 men and eight women) with a mean age of 54 years (38 to 80) who had undergone successful hip resurfacing at a mean of 44 months (10 to 96) earlier. Our results showed that circulating baseline cobalt levels were not significantly correlated with the time since implantation (r = 0.08, p = 0.650). By contrast, the exercise-related cobalt rise was directly correlated with the inclination angle of the acetabular component (r = 0.47, p = 0.032) and inversely correlated with the time since implantation (r = -0.5, p = 0.020). Inclination of the acetabular component should be kept less than 40 degrees to decrease the production of wear debris.
Liu, Feng; Jin, Zhongmin; Roberts, P; Grigoris, P
The main design features of metal-on-metal (MOM) hip resurfacing prostheses in promoting elastohydrodynamic lubrication were investigated in the present study, including the femoral head diameter, the clearance, and the cup wall thickness. Simplified conceptual models were developed, based on equivalent uniform wall thicknesses for both the cup and the head as well as the support materials representing bone and cement, and subsequently used for elastohydrodynamic lubrication analysis. Both typical first- and second-generation MOM hip resurfacing prostheses with different clearances and cup wall thicknesses were considered with a fixed large bearing diameter of 50 mm, as well as a 28 mm diameter MOM total hip replacement bearing for the purpose of comparison. The importance of the head diameter and the clearance in promoting elastohydrodynamic lubrication was confirmed. Furthermore, it was also predicted that a relatively thin acetabular cup in the more recently introduced second-generation MOM hip resurfacing prostheses would be capable of improving elastohydrodynamic lubrication even further.
Haughom, Bryan D; Erickson, Brandon J; Hellman, Michael D; Jacobs, Joshua J
Although metal-on-metal (MoM) bearing surfaces provide low rates of volumetric wear and increased stability, evidence suggests that certain MoM hip arthroplasties have high rates of complication and failure. Some evidence indicates that women have higher rates of failure compared with men; however, the orthopaedic literature as a whole has poorly reported such complications stratified by gender. This systematic review aimed to: (1) compare the rate of adverse local tissue reaction (ALTR); (2) dislocation; (3) aseptic loosening; and (4) revision between men and women undergoing primary MoM hip resurfacing arthroplasty (HRA). Systematic MEDLINE and EMBASE searches identified all level I to III articles published in peer-reviewed journals, reporting on the outcomes of interest, for MoM HRA. Articles were limited to those with 2-year followup that reported outcomes by gender. Ten articles met inclusion criteria. Study quality was evaluated using the Modified Coleman Methodology Score; the overall quality was poor. Heterogeneity and bias were analyzed using a Mantel-Haenszel statistical method. Women demonstrated an increased odds of developing ALTR (odds ratio [OR], 5.70 [2.71-11.98]; p<0.001), dislocation (OR, 3.04 [1.2-7.5], p=0.02), aseptic loosening (OR, 3.18 [2.21-4.58], p<0.001), and revision (OR, 2.50 [2.25-2.78], p<0.001) after primary MoM HRA. A systematic review of the currently available literature reveals a higher rate of complications (ALTR, dislocation, aseptic loosening, and revision) after MoM HRA in women compared with men. Although femoral head size has been frequently implicated as a prime factor in the higher rate of complication in women, further research is necessary to specifically probe this relationship. Retrospective studies of data available (eg, registry data) should be undertaken, and moving forward studies should report outcomes by gender (particularly complications). Level III, therapeutic study.
Rieker, Claude B; Schön, Rolf; Konrad, Reto; Liebentritt, Gernot; Gnepf, Patric; Shen, Ming; Roberts, Paul; Grigoris, Peter
Large-diameter metal-on-metal articulations may provide an opportunity for wear reduction in total hip implants because earlier studies have shown that the formation of a fluid film that completely separates the bearing surfaces is theoretically possible. In such a lubrication mode and under ideal conditions, there is theoretically no amount of wear. Studies have suggested that the two primary parameters controlling the lubrication mode are the diameter and the clearance of the articulation. The goal of the present study was to experimentally investigate the influence of these two parameters on the wear behavior of large-diameter metal-on-metal articulations pertaining to resurfacing hip implants. The results of this in vitro investigation showed that longer running-in periods and higher amounts of running-in wear were associated with larger clearances.
Lazik, Andrea; Landgraeber, Stefan; Schulte, Patrick; Kraff, Oliver; Lauenstein, Thomas C; Theysohn, Jens M
To evaluate the usefulness of the metal artifact reduction technique "WARP" in the assessment of metal-on-metal hip resurfacings at 1.5 and 3T in the context of image quality and imaging speed. Nineteen patients (25 hip resurfacings) were randomized for 1.5 and 3T MRI, both including T1 and T2 turbo spin-echo as well as turbo inversion recovery magnitude sequences with and without view angle tilting and high bandwidth. Additional 3T sequences were acquired with a reduced number of averages and using the parallel acquisition technique for accelerating imaging speed. Artifact size (diameter, area), image quality (5-point scale) and delineation of anatomical structures were compared among the techniques, sequences and field strengths using the Wilcoxon sign-rank and paired t-test with Bonferroni correction. At both field strengths, WARP showed significant superiority over standard sequences regarding image quality, artifact size and delineation of anatomical structures. At 3T, artifacts were larger compared to 1.5T without affecting diagnostic quality, and scanning time could be reduced by up to 64 % without quality degradation. WARP proved useful in imaging metal-on-metal hip resurfacings at 1.5T as well as 3T with better image quality surrounding the implants. At 3T imaging could be considerably accelerated without losing diagnostic quality.
Matharu, Gulraj S; Blanshard, Oliver; Dhaliwal, Kawaljit; Judge, Andrew; Murray, David W; Pandit, Hemant G
The role of radiographs in the follow-up of patients with metal-on-metal hip resurfacing (MoMHR) implants is unclear. We investigated whether a combination of patient and radiographic factors predicted MoMHRs with evidence of a pseudotumor. We performed a retrospective single-center case-control study of 384 MoMHRs. The pseudotumor group of 130 hips all had evidence of a symptomatic pseudotumor on cross-sectional imaging, with the diagnosis confirmed at revision. The nonpseudotumor group of 254 hips (a subgroup of these hips were previously reported on) all had normal findings on cross-sectional imaging. Radiographs taken immediately prior to revision were assessed in the pseudotumor group and were compared with radiographs taken at the time of normal cross-sectional imaging in the nonpseudotumor group. Two blinded independent observers analyzed the radiographs for signs of failure, with excellent interobserver agreement. Logistic regression modeling identified the patient and radiographic predictors of revision for pseudotumor. Hips with a pseudotumor more commonly had abnormal findings on radiographs compared to hips without a pseudotumor (80.0% compared with 63.4%; p = 0.001). Patient and radiographic factors predictive of revision for pseudotumor in the multivariable model were female sex (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.85 to 5.35; p < 0.001), high inclination (OR, 1.04 per degree; 95% CI, 1.01 to 1.07 per degree; p = 0.006), acetabular osteolysis (OR, 5.06; 95% CI, 2.14 to 12.0; p < 0.001), femoral osteolysis (OR, 17.8; 95% CI, 5.09 to 62.2; p < 0.001), and acetabular loosening (OR, 3.35; 95% CI, 1.34 to 8.35; p = 0.009). Factors predictive of not having a pseudotumor were anteversion of ≥5° (5° to <10°: OR, 0.31; 95% CI, 0.12 to 0.77; p = 0.012; and ≥10°: OR, 0.32; 95% CI, 0.15 to 0.70; p = 0.004) and heterotopic ossification (OR, 0.19; 95% CI, 0.05 to 0.72; p = 0.015). The final multivariable model was well calibrated (p = 0
Matharu, G. S.; Mansour, R.; Dada, O.; Ostlere, S.; Pandit, H. G.; Murray, D. W.
Aims The aims of this study were to compare the diagnostic test characteristics of ultrasound alone, metal artefact reduction sequence MRI (MARS-MRI) alone, and ultrasound combined with MARS-MRI for identifying intra-operative pseudotumours in metal-on-metal hip resurfacing (MoMHR) patients undergoing revision surgery. Methods This retrospective diagnostic accuracy study involved 39 patients (40 MoMHRs). The time between imaging modalities was a mean of 14.6 days (0 to 90), with imaging performed at a mean of 5.3 months (0.06 to 12) before revision. The prevalence of intra-operative pseudotumours was 82.5% (n = 33). Results Agreement with the intra-operative findings was 82.5% (n = 33) for ultrasound alone, 87.5% (n = 35) for MARS-MRI alone, and 92.5% (n = 37) for ultrasound and MARS-MRI combined. The diagnostic characteristics for ultrasound alone and MARS-MRI alone reached similar sensitivities (90.9% vs 93.9%) and positive predictive values (PPVs; 88.2% vs 91.2%), but higher specificities (57.1% vs 42.9%) and negative predictive values (NPVs; 66.7% vs 50.0%) were achieved with MARS-MRI. Ultrasound and MARS-MRI combined produced 100% sensitivity and 100% NPV, whilst maintaining both specificity (57.1%) and PPV (91.7%). For the identification of a pseudotumour, which was confirmed at revision surgery, agreement was substantial for ultrasound and MARS-MRI combined (κ = 0.69), moderate for MARS-MRI alone (κ = 0.54), and fair for ultrasound alone (κ = 0.36). Discussion These findings suggest that ultrasound and/or MARS-MRI have a role when assessing patients with a MoMHR, with the choice dependent on local financial constraints and the availability of ultrasound expertise. However in patients with a MoMHR who require revision, combined imaging was most effective. Take home message: Combined imaging with ultrasound and MARS-MRI always identified intra-operative pseudotumours if present. Furthermore, if neither imaging modality showed a pseudotumour, one was not
Fritz, Jan; Fritz, Benjamin; Thawait, Gaurav K; Raithel, Esther; Gilson, Wesley D; Nittka, Mathias; Mont, Michael A
Compressed sensing (CS) acceleration has been theorized for slice encoding for metal artifact correction (SEMAC), but has not been shown to be feasible. Therefore, we tested the hypothesis that CS-SEMAC is feasible for MRI of metal-on-metal hip resurfacing implants. Following prospective institutional review board approval, 22 subjects with metal-on-metal hip resurfacing implants underwent 1.5 T MRI. We compared CS-SEMAC prototype, high-bandwidth TSE, and SEMAC sequences with acquisition times of 4-5, 4-5 and 10-12 min, respectively. Outcome measures included bone-implant interfaces, image quality, periprosthetic structures, artifact size, and signal- and contrast-to-noise ratios (SNR and CNR). Using Friedman, repeated measures analysis of variances, and Cohen's weighted kappa tests, Bonferroni-corrected p-values of 0.005 and less were considered statistically significant. There was no statistical difference of outcomes measures of SEMAC and CS-SEMAC images. Visibility of implant-bone interfaces and pseudocapsule as well as fat suppression and metal reduction were "adequate" to "good" on CS-SEMAC and "non-diagnostic" to "adequate" on high-BW TSE (p < 0.001, respectively). SEMAC and CS-SEMAC showed mild blur and ripple artifacts. The metal artifact size was 63 % larger for high-BW TSE as compared to SEMAC and CS-SEMAC (p < 0.0001, respectively). CNRs were sufficiently high and statistically similar, with the exception of CNR of fluid and muscle and CNR of fluid and tendon, which were higher on intermediate-weighted high-BW TSE (p < 0.005, respectively). Compressed sensing acceleration enables the time-neutral use of SEMAC for MRI of metal-on-metal hip resurfacing implants when compared to high-BW TSE and image quality similar to conventional SEMAC.
Liu, Fei; Gross, Thomas P
A safe zone for acetabular component positioning in hip resurfacing (RAIL: Relative Acetabular Inclination Limit) was calculated based on implant size and acetabular inclination angle (AIA). For AIA below the RAIL, there were no adverse wear failures or dislocations, and only 1% of cases with ion levels above 10 μg/L. Other than high inclination angle and small bearing size, female gender was the only other factor that correlated with high ion levels in the multivariate analysis. Seven hundred sixty-one hip resurfacing cases are included in this study. The UCLA activity score, femoral shaft angle, body mass index, weight, American Society of Anesthesiologists score, combined range of motion, diagnosis, age, gender, implant brand, AIA, bearing size, and duration of implantation were analyzed to determine the potential risk factors for elevated metal ion levels. These findings apply to sub hemispheric metal-on-metal bearings with similar coverage arcs as the Biomet and Corin hip resurfacing brands. Additional problems may occur when these bearings are connected with trunions on stems for total hip arthroplasty. Copyright © 2013 Elsevier Inc. All rights reserved.
Hartmann, Albrecht; Lützner, Jörg; Kirschner, Stephan; Witzleb, Wolf-Christoph; Günther, Klaus-Peter
Owing to concerns attributable to problems associated with metal-on-metal bearing surfaces, current evidence for the use of hip resurfacing is unclear. Survival rates reported from registries and individual studies are controversial and the limited long-term studies do not conclusively allow one to judge whether hip resurfacing is still a reasonable alternative to conventional THA. We asked whether the long-term survival rate of hip resurfacing is comparable to that of conventional THA and certain factors can be identified that influence serum ion concentration 10 years postoperatively. We specifically assessed (1) the 10-year survivorship in the whole cohort and in male and female patients, (2) serum concentrations of metal ions in patients with hip resurfacing who had not undergone revision surgery, and (3) potential influencing factors on the serum ion concentration. We retrospectively reviewed our first 95 patients who had 100 hip resurfacings performed from 1998 to 2001. The median age of the patients at surgery was 52 years (range, 28-69 years); 49% were men. We assessed the survival rate (revision for any reason as the end point), radiographic changes, and serum ion concentrations for cobalt, chromium, and molybdenum. The correlations between serum ion concentration and patient-related factors (age, sex, BMI, activity) and implant-related factors (implant size, cup inclination, stem-shaft angle) were investigated. The minimum followup was 9.3 years (mean, 10 years; range, 9.3-10.5 years). The 10-year survivorship was 88% for the total cohort. The overall survival rate was greater in men (93%) than in women (84%). Median serum ion levels were 1.9 μg/L for chromium, 1.3 μg/L for cobalt, and 1.6 μg/L for molybdenum. Radiolucent lines around acetabular implants were observed in 4% and femoral neck thinning in 5%. Although our overall failure rate was greater than anticipated, the relatively low serum ion levels and no revisions for pseudotumors in young male
Mellon, Stephen J; Grammatopoulos, George; Andersen, Michael S; Pandit, Hemant G; Gill, Harinderjit S; Murray, David W
Edge-loading in patients with metal-on-metal resurfaced hips can cause high serum metal ion levels, the development of soft-tissue reactions local to the joint called pseudotumours and ultimately, failure of the implant. Primary edge-loading is where contact between the femoral and acetabular components occurs at the edge/rim of the acetabular component whereas impingement of the femoral neck on the acetabular component's edge causes secondary or contrecoup edge-loading. Although the relationship between the orientation of the acetabular component and primary edge-loading has been identified, the contribution of acetabular component orientation to impingement and secondary edge-loading is less clear. Our aim was to estimate the optimal acetabular component orientation for 16 metal-on-metal hip resurfacing arthroplasty (MoMHRA) subjects with known serum metal ion levels. Data from motion analysis, subject-specific musculoskeletal modelling and Computed Tomography (CT) measurements were used to calculate the dynamic contact patch to rim (CPR) distance and impingement risk for 3416 different acetabular component orientations during gait, sit-to-stand, stair descent and static standing. For each subject, safe zones free from impingement and edge-loading (CPR <10%) were defined and, consequently, an optimal acetabular component orientation was determined (mean inclination 39.7° (SD 6.6°) mean anteversion 14.9° (SD 9.0°)). The results of this study suggest that the optimal acetabular component orientation can be determined from a patient's motion and anatomy. However, 'safe' zones of acetabular component orientation associated with reduced risk of dislocation and pseudotumour are also associated with a reduced risk of edge-loading and impingement. Copyright © 2014 Elsevier Ltd. All rights reserved.
Lavigne, Martin; Laffosse, Jean-Michel; Ganapathi, Muthu; Girard, Julien; Vendittoli, Pascal
Groin pain may persist in up to 4.3% of patients after total hip arthroplasty and up to 18% of patients one year after hip resurfacing. The incidence of this problem after total hip arthroplasty with a large-diameter femoral head is unknown. We analyzed the natural history of groin pain and its clinical consequences during the first two years after three types of hip arthroplasty. Data were collected prospectively on 279 patients. Eighty-five patients had a polyethylene sandwich metal-on-metal total hip arthroplasty with a 28-mm-diameter femoral head, 105 had hip resurfacing, and eighty-nine had a total hip arthroplasty with a large-diameter femoral head component with three other cup designs (forty-nine in this group had the same monoblock acetabular cup design as those who had hip resurfacing). At the twenty-four-month follow-up evaluation, seventy-seven patients (28%) reported at least one painful area around the hip and thirty-four patients (12.2%) had pain at more than one location. At three months, the incidence of groin discomfort was significantly increased in those who had hip resurfacing (30.5%) and in those who had total hip arthroplasty with a large-diameter femoral head (30%) compared with those who had total hip arthroplasty with a 28-mm femoral head (18.3%). This incidence decreased at two years (14.9%, 16.9%, and 12.9%, respectively). At twenty-four months postoperatively, eleven (four who had hip resurfacing, six who had total hip arthroplasty with the large-diameter head, and one who had total hip arthroplasty with the 28-mm head) of forty-one patients who had groin pain had not reported groin pain at previous follow-up evaluations. Of the forty-one patients reporting groin pain at the time of the last follow-up, twenty-three patients (56%) did not seek further evaluation or treatment, nine had revision surgery (22%), and the remaining nine patients thought the pain was substantial enough to warrant further evaluation and treatment. When the exact
Hip resurfacing is an attractive concept because it preserves rather than removes the femoral head and neck. Most early designs had high failure rates, but one unique design had a femoral stem. Because that particular device appeared to have better implant survival, this study assessed the clinical outcome and long-term survivorship of a hip resurfacing prosthesis. Four hundred forty-five patients (561 hips) were retrospectively reviewed after a minimum of 20 years’ followup or until death; 23 additional patients were lost to followup. Patients received a metal femoral prosthesis with a small curved stem. Three types of acetabular reconstructions were used: (1) cemented polyurethane; (2) metal-on-metal; and (3) polyethylene secured with cement or used as the liner of a two-piece porous-coated implant. Long-term results were favorable with the metal-on-metal combination only. The mean overall Harris hip score was 92 at 2 years of followup. None of the 121 patients (133 hips) who received metal-on-metal articulation experienced failure. The failure rate with polyurethane was 100%, and the failure rate with cemented polyethylene was 41%. Hip resurfacing with a curved-stem femoral component had a durable clinical outcome when a metal-on-metal articulation was used. Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:18338217
Günther, K-P; Lützner, J; Hannemann, F; Schmitt, J; Kirschner, S; Goronzy, J; Stiehler, M; Lohmann, C; Hartmann, A
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.
Vassiliou, K; Elfick, A P D; Scholes, S C; Unsworth, A
It is well documented that hard bearing combinations show a running-in phenomenon in vitro and there is also some evidence of this from retrieval studies. In order to investigate this phenomenon, five Birmingham hip resurfacing devices were tested in a hip wear simulator. One of these (joint 1) was also tested in a friction simulator before, during, and after the wear test and surface analysis was conducted throughout portions of the testing. The wear showed the classical running in with the wear rate falling from 1.84 mm3 per 10(6) cycles for the first 10(6) cycles of testing to 0.24 mm3 per 10(6) cycles over the final 2 x 10(6) cycles of testing. The friction tests suggested boundary lubrication initially, but at 1 x 10(6) cycles a mixed lubrication regime was evident. By 2 x 10(6) cycles the classical Stribeck curve had formed, indicating a considerable contribution from the fluid film at higher viscosities. This continued to be evident at both 3 x 10(6) and 5 x 10(6) cycles. The surface study complements these findings.
Dowson, D; Jin, Z M
The basic tribological features of metal-on-metal total hip replacements have been reviewed to facilitate an understanding of the engineering science underpinning the renaissance of these hard-on-hard joints. Metal-on-polymer hip replacements operate in the boundary lubrication regime, thus leading to the design guidance to reduce the femoral head diameter as much as is feasible to minimize frictional torque and volumetric wear. This explains why the gold-standard implant of this form from the past half-century had a diameter of only 22.225 mm (7/8 in). Metal-on-metal implants can operate in the mild mixed lubrication regime in which much of the applied load is supported by elastohydrodynamic films. Correct tribological design leads to remarkably low steady state wear rates. Promotion of the most effective elastohydrodynamic films calls for the largest possible head diameters and the smallest clearances that can reasonably be adopted, consistent with fine surface finishes, good sphericity and minimal structural elastic deformation of the cup on its foundations. This guidance, which is opposite in form to that developed for metal-on-polymer joints, is equally valid for solid (monolithic) metallic heads on metallic femoral stems and surface replacement femoral shells. Laboratory measurements of friction and wear in metal-on-metal joints have confirmed their potential to achieve a very mild form of mixed lubrication. The key lies in the generation of effective elastohydrodynamic lubricating films of adequate thickness compared with the composite roughness of the head and cup. The calculation of the film thickness is by no means easy, but the full procedure is outlined and the use of an empirical formula that displays good agreement with calculations based upon the full numerical solutions is explained. The representation of the lambda ratio, lambda, embracing both film thickness and composite roughness, is described.
Blood Metal Ion Thresholds to Identify Patients with Metal-on-Metal Hip Implants at Risk of Adverse Reactions to Metal Debris: An External Multicenter Validation Study of Birmingham Hip Resurfacing and Corail-Pinnacle Implants.
Matharu, Gulraj S; Berryman, Fiona; Judge, Andrew; Reito, Aleksi; McConnell, Jamie; Lainiala, Olli; Young, Stephen; Eskelinen, Antti; Pandit, Hemant G; Murray, David W
The authors of recent studies have reported newly devised implant-specific blood metal ion thresholds to predict adverse reactions to metal debris (ARMD) in patients who have undergone unilateral or bilateral metal-on-metal (MoM) hip arthroplasty. These thresholds were most effective for identifying patients at low risk of ARMD. We investigated whether these newly devised blood metal ion thresholds could effectively identify patients at risk of ARMD after MoM hip arthroplasty in an external cohort of patients. We performed a validation study involving 803 MoM hip arthroplasties (323 unilateral Birmingham Hip Resurfacing [BHR], 93 bilateral BHR, and 294 unilateral Corail-Pinnacle implants) performed in 710 patients at 3 European centers. All patients underwent whole-blood metal ion sampling, and were divided into 2 groups: those with ARMD (leading to revision or identified on imaging; n = 75) and those without ARMD (n = 635). Previously devised implant-specific blood metal ion thresholds (2.15 μg/L of cobalt for unilateral BHR; 5.5 μg/L for the maximum of either cobalt or chromium for bilateral BHR; and 3.57 μg/L of cobalt for unilateral Corail-Pinnacle implants) were applied to the validation cohort, and receiver operating characteristic curve analysis was used to establish the discriminatory characteristics of each threshold. The area under the curve, sensitivity, specificity, and positive and negative predictive values for the ability of each implant-specific threshold to distinguish between patients with and without ARMD were, respectively, 89.4% (95% confidence interval [CI] = 82.8% to 96.0%), 78.9%, 86.7%, 44.1%, and 96.9% for unilateral BHR; 89.2% (CI = 81.3% to 97.1%), 70.6%, 86.8%, 54.5%, and 93.0% for bilateral BHR; and 76.9% (CI = 63.9% to 90.0%), 65.0%, 85.4%, 24.5%, and 97.1% for unilateral Corail-Pinnacle implants. Using the implant-specific thresholds, we missed 20 patients with ARMD (2.8% of the patients in this series). We missed more patients
Williams, Daniel H; Greidanus, Nelson V; Masri, Bassam A; Duncan, Clive P; Garbuz, Donald S
The cause of recently reported pseudotumor formation in patients with metal-on-metal hip replacements is unknown. It has been postulated that there is an association between elevated levels of serum metal ions and pseudotumor formation. The primary purpose of this study was to assess the prevalence of pseudotumor formation in asymptomatic patients with a metal-on-metal total hip replacement after a minimum duration of follow-up of two years. A secondary purpose was to assess whether a correlation exists between elevated serum metal ion levels and pseudotumor formation. In the present study, the prevalence of pseudotumor formation, as detected with ultrasound, was evaluated for thirty-one asymptomatic patients with a metal-on-metal total hip arthroplasty, twenty-four asymptomatic patients with a metal-on-polyethylene total hip arthroplasty, and twenty asymptomatic patients with a metal-on-metal hip resurfacing arthroplasty. Serum levels of cobalt and chromium were measured in the metal-on-metal total hip arthroplasty and hip resurfacing arthroplasty groups. Ten patients (32%) in the metal-on-metal total hip arthroplasty group had a solid or cystic mass, with another three patients (10%) having a substantial fluid collection. Five patients (25%) in the hip resurfacing arthroplasty group had a solid or cystic mass, with another patient (5%) having a fluid collection. Pseudotumor formation was significantly more frequent in the metal-on-metal total hip arthroplasty group compared with the metal-on-polyethylene total hip arthroplasty group (p = 0.015). We did not detect a significant correlation between the serum metal ion levels and the size of pseudotumor abnormality. The median serum metal ion level was greater in patients with pseudotumor formation than it was in those without pseudotumor formation, but the difference was not significant. We recommend high-resolution ultrasound surveillance of all asymptomatic patients with a metal-on-metal implant that is known to
Nelis, Raymond; de Waal Malefijt, Jan; Gosens, Taco
Metal-on-metal resurfacing arthroplasty of the hip has been used increasingly over the last 10 years in younger active patients. The dissolution of the metal wear particles results in measurable increases in cobalt and chromium ions in the serum and urine of patients with a metal-on-metal bearing. We measured the cobalt, chromium, and molybdenum ion levels in urine; serum; and breast milk in a young and active patient with a metal-on-metal hip prosthesis after a pathologic fracture of the femoral neck. Metal-on-metal hip prosthesis leads to increasing levels of molybdenum in breast milk in the short-term follow-up. There are no increasing levels of chromium and cobalt ions in breast milk. Besides the already known elevated concentrations in serum of chromium and cobalt after implantation of a metal-on-metal hip prosthesis, we found no increasing levels of chromium and cobalt in urine.
Knecht, A; Witzleb, W-C; Günther, K-P
Currently, an increase in resurfacing arthroplasty in the treatment of hip osteoarthritis--especially in young adults--can be observed. New bearing technologies (mainly metal-on-metal surfaces) show better tribologic results than historical designs (e.g. the Wagner cup). At present, it is unclear whether these modifications and a definitively low dislocation rate--due to the large head diameter--can be supported by further good clinical results. The quantity as well as the quality of the available investigations prevents a definite opinion at the moment. Appropriate clinical studies with documented radiographic follow-up are necessary to compare the outcome of these new implants with standard techniques.
The hip resurfacing concept was developed for young and active patients, especially for femoral bone stock preservation. However, concerns about metal-on-metal bearings with adverse reactions to metal debris have led to a drop off in hip-resurfacing procedures. The goal of this review is to evaluate our current knowledge of survivorship of second-generation hip resurfacing devices and elaborate international perspectives for product improvement. A comprehensive literature search provided information on national joint arthroplasty registers worldwide with a minimum of 3000 reported hip resurfacings. It culminated in the analysis of six registers. Long-term data showed that available hip resurfacing device survivorship ranged from 95 to 99.7% with 10 years of follow-up, in selected patient populations. The criteria for success were well known, male gender, good bone quality, head component size greater than 48 mm, and cup inclination less than 45°. On the other hand, the recent recall of some hip-resurfacing devices has resulted in huge medico-legal problems and has discredited all implants. It has brought about the recent evolution of hip resurfacing. Femoral fixation is now available for cemented and cementless surfaces. Bearings are still always metal-on-metal, but new types have come on board. Newer designs suggest that ceramic-on-ceramic, cross-linked polyethylene, and oxinium may be applied in this configuration. In 2015, the evolution of hip resurfacing is ongoing in terms of implant design, alternative bearings, and implant fixation with hopes of improving survivorship.
Kostensalo, Inari; Junnila, Mika; Mokka, Jari; Virolainen, Petri; Vahlberg, Tero; Mäkelä, Keijo T
The aim of this retrospective study was to evaluate short- to mid-term results of three different metal-on-metal hip devices from the same manufacturer. A total of 329 hip operations were performed in a single academic unit between 2004 and 2010 using either Birmingham hip resurfacing or Synergy--Birmingham and Synergy--R3 total hip arthroplasty. The overall survival rate at the end of the follow-up time for Birmingham hip resurfacing was 88%, for Synergy--Birmingham total hip arthroplasty 95%, and for Synergy--R3 total hip arthroplasty 81% (p = 0.036). Five revision operations were performed due to adverse reaction to metal debris. Head sizes > 50 mm had lower revision rates compared to smaller ones. Synergy--R3 had a poor survival already at short-term. The mid-term survival of Birmingham hip resurfacing arthroplasty was inferior compared to previous studies.
Rudert, M; Gerdesmeyer, L; Rechl, H; Juhnke, P; Gradinger, R
Resurfacing arthroplasty is regarded as an attractive method, especially for the young patient who needs a hip replacement. However, the high expectations regarding this new technique in THR must first be met. Earlier experiences with similar forms of surface replacement have led to high revision rates with early aseptic wear induced component loosening and neck fractures. Technical progresses in production techniques for metal-on-metal articulations with minimized wear have enabled the introduction of new surface replacements for the hip joint. Long-term results of these resurfacing arthroplasties are still due. Femoral neck fractures and femoro-acetabular impingement are possible early complications which require revision. The implantation of these systems requires a high degree of operative skill and experience on the part of the surgeon. Approach dependent trauma to the musculature and endangering of the blood supply to the femoral head is balanced with the positive effect of the preservation of femoral bone stock and better options in case of revision. Whether the younger patient with a higher activity profile and an increased chance of implant loosening actually profits from the resurfacing arthroplasty will be determined in the future.
Scholes, S C; Unsworth, A
Total hip surgery is an effective way of alleviating the pain and discomfort caused by diseased or damaged joints. However, in the majority of cases, these joints have a finite life. The main reason for failure is osteolysis (bone resorption). It is well documented that an important cause of osteolysis, and therefore the subsequent loosening and failure of conventional metal- or ceramic-on-ultra-high molecular weight polyethylene joints, is the body's immunological response to the polyethylene wear particles. To avoid this, interest has been renewed in metal-on-metal joints. The intention of this paper is to review the studies that have taken place within different laboratories to determine the tribological performance of new-generation metal-on-metal total hip replacements. These types of joint offer a potential solution to enhance the longevity of prosthetic hip systems; however, problems may arise owing to the effects of metal ion release, which are, as yet, not fully understood.
Liao, Yifeng; Hoffman, Emily; Wimmer, Markus; Fischer, Alfons; Jacobs, Joshua; Marks, Laurence
After the rapid growth in the use of CoCrMo metal-on-metal hip replacements since the second generation was introduced circa 1990, metal-on-metal hip replacements have experienced a sharp decline in the last two years due to biocompatibility issues related to wear and corrosion products. Despite some excellent clinical results, the release of wear and corrosion debris and the adverse response of local tissues have been of great concern. There are many unknowns regarding how CoCrMo metal bearings interact with the human body. This perspective article is intended to outline some recent progresses in understanding wear and corrosion of metal-on-metal hip replacement both in vivo and in vitro. The materials, mechanical deformation, corrosion, wear-assisted corrosion, and wear products will be discussed. Possible adverse health effects caused by wear products will be briefly addressed, as well as some of the many open questions such as the detailed chemistry of corrosion, tribochemical reactions and the formation of graphitic layers. Nowadays we design almost routinely for high performance materials and lubricants for automobiles; humans are at least as important. It is worth remembering that a hip implant is often the difference between walking and leading a relatively normal life, and a wheelchair.
Liao, Yifeng; Hoffman, Emily; Wimmer, Markus; Fischer, Alfons; Jacobs, Joshua; Marks, Laurence
After the rapid growth in the use of CoCrMo metal-on-metal hip replacements since the second generation was introduced circa 1990, metal-on-metal hip replacements have experienced a sharp decline in the last two years due to biocompatibility issues related to wear and corrosion products. Despite some excellent clinical results, the release of wear and corrosion debris and the adverse response of local tissues have been of great concern. There are many unknowns regarding how CoCrMo metal bearings interact with the human body. This perspective article is intended to outline some recent progresses in understanding wear and corrosion of metal-on-metal hip replacement both in-vivo and in-vitro. The materials, mechanical deformation, corrosion, wear-assisted corrosion, and wear products will be discussed. Possible adverse health effects caused by wear products will be briefly addressed, as well as some of the many open questions such as the detailed chemistry of corrosion, tribochemical reactions and the formation of graphitic layers. Nowadays we design almost routinely for high performance materials and lubricants for automobiles; humans are at least as important. It is worth remembering that a hip implant is often the difference between walking and leading a relatively normal life, and a wheelchair. PMID:23196425
van Lingen, Christiaan P.; Zagra, Luigi M.; Ettema, Harmen B.; Verheyen, Cees C.
Large-head metal-on-metal (MoM) bearings were re-popularised in the late 1990s with the introduction of modern hip resurfacing (HR), followed closely by large metal head total hip arthroplasty (THA). A worldwide increase in the use of MoM hip arthroplasty subsequently saw a sharp decline, due to serious complications. MoM was rapidly adopted in the early 2000s until medical device alerts were issued by government regulatory agencies and national and international organisations, leading to post-marketing surveillance and discontinuation of these implants. Guidelines for MoM hip implant follow-up differ considerably between regulatory authorities worldwide; this can in part be attributed to missing or conflicting evidence. The authors consider that the use of large-head MoM THA should be discontinued. MoM HR should be approached with caution and, when considered, should be used only in patients who meet all of the recommended selection criteria, which limits its indications considerably. The phased introduction of new prostheses should be mandatory in future. Close monitoring of outcomes and long-term follow-up is also necessary for the introduction of new prostheses. Cite this article: van Lingen CP, Zagra LM, Ettema HB, Verheyen CC. Sequelae of large-head metal-on-metal hip arthroplasties: current status and future prospects. EFORT Open Rev 2016;1:345-353. DOI: 10.1302/2058-5241.1.160014. PMID:28461912
Lainiala, Olli; Reito, Aleksi; Elo, Petra; Pajamäki, Jorma; Puolakka, Timo; Eskelinen, Antti
High revision rates attributable to adverse reactions to metal debris have been reported for total hip arthroplasties (THAs) with metal-on-metal implants and hip resurfacings. The effect of revision on blood metal ion levels is described only in small series, the clinical results of revisions have been contradictory, and concerns regarding component loosening have been presented. We asked: (1) Did revision surgery result in a reduction to normal for whole blood cobalt (Co) and chromium (Cr) levels (2) What changes to the Oxford Hip Score were observed after revision of these hips with metal-on-metal implants? (3) Were there radiologic signs of component loosening observed on 1-year followup radiographs? Between September 2010 and April 2013, 154 patients (166 hips) who had THAs with implantation of the Articular Surface Replacement (ASR™) system and 44 patients (49 hips) who had hip resurfacings of the ASR™ implant underwent revision surgery for adverse reactions to metal debris at our institution, after recall of these components in August 2010. General indications for revision of these implants included a symptomatic hip and/or a predominantly solid pseudotumor seen on cross-sectional imaging. Since recall, patients were systematically followed after revision with Oxford Hip Score questionnaires, blood Co and Cr measurements (analyzed from whole blood with dynamic reaction-cell inductively coupled plasma-mass spectrometry), and plain radiographs at 2 and 12 months after revision surgery, and thereafter at 2-year intervals. Preoperative and 1-year postoperative blood Co and Cr values were available for 93% (185 of 198 patients), Oxford Hip Score for 76% (151 of 198 patients), and plain radiographs for all patients. Whole-blood levels of Co decreased below the 7 ppb cut-off value in all patients with revision of unilateral THA or resurfacing, however, blood Cr levels remained elevated in four of 90 patients (4%) in the unilateral THA group and four of 34
Almousa, Sulaiman A; Greidanus, Nelson V; Masri, Bassam A; Duncan, Clive P; Garbuz, Donald S
Although pseudotumors have been reported in 32% of asymptomatic metal-on-metal hips, the natural history of asymptomatic pseudotumors is unknown. The purpose of this study was to assess changes over time in asymptomatic pseudotumors and the effect of revision on pseudotumor mass. Followup ultrasound was performed a mean of 25.8 months (range, 21-31 months) after the detection of 15 pseudotumors and five isolated fluid collections in a cohort of 20 asymptomatic patients (13 metal-on-metal, three metal-on-polyethylene, and four hip resurfacings) . Changes in pseudotumors and fluid collections size and nature, and serum ion levels were determined. Among the 15 nonrevised patients, pseudotumors increased in size in six (four solid and two cystic) of 10 patients, three of which had clinically important increases (13-148 cm(3); 28-74 cm(3); 47-104 cm(3)). Three pseudotumors (one solid and two cystic) disappeared completely (the largest measured 31 cm(3)). One solid pseudotumor decreased in size (24 to 18 cm(3)). In five revised patients, pseudotumors completely disappeared in four patients. The fifth patient had two masses that decreased from 437 cm(3) to 262 cm(3) and 43 cm(3) to 25 cm(3). All revision patients had a reduction of chromium (40.42 μ/L to 2.69 μ/L) and cobalt ions (54.19 μ/L to 0.64 μ/L). Of five isolated fluid collections, four completely disappeared (two metal-on-metal and two metal-on-polyethylene) and one (metal-on-metal) increased from 26 cm(3) to 136 cm(3). Our observations suggest pseudotumors frequently increase in size in asymptomatic patients with occasional remission of small masses. Revision resulted in remission of pseudotumors.
Berber, Reshid; Khoo, Michael; Cook, Erica; Guppy, Andrew; Hua, Jia; Miles, Jonathan; Carrington, Richard; Skinner, John; Hart, Alister
Background and purpose Muscle atrophy is seen in patients with metal-on-metal (MOM) hip implants, probably because of inflammatory destruction of the musculo-tendon junction. However, like pseudotumors, it is unclear when atrophy occurs and whether it progresses with time. Our objective was to determine whether muscle atrophy associated with MOM hip implants progresses with time. Patients and methods We retrospectively reviewed 74 hips in 56 patients (32 of them women) using serial MRI. Median age was 59 (23–83) years. The median time post-implantation was 83 (35–142) months, and the median interval between scans was 11 months. Hip muscles were scored using the Pfirrmann system. The mean scores for muscle atrophy were compared between the first and second MRI scans. Blood cobalt and chromium concentrations were determined. Results The median blood cobalt was 6.84 (0.24–90) ppb and median chromium level was 4.42 (0.20–45) ppb. The median Oxford hip score was 34 (5–48). The change in the gluteus minimus mean atrophy score between first and second MRI was 0.12 (p = 0.002). Mean change in the gluteus medius posterior portion (unaffected by surgical approach) was 0.08 (p = 0.01) and mean change in the inferior portion was 0.10 (p = 0.05). Mean pseudotumor grade increased by 0.18 (p = 0.02). Interpretation Worsening muscle atrophy and worsening pseudotumor grade occur over a 1-year period in a substantial proportion of patients with MOM hip implants. Serial MRI helps to identify those patients who are at risk of developing worsening soft-tissue pathology. These patients should be considered for revision surgery before irreversible muscle destruction occurs. PMID:25588091
Berber, Reshid; Skinner, John A; Hart, Alister J
The debate on how best to manage patients with metal-on-metal (MOM) hip implants continues. With over 1 million patients affected worldwide, the impact is far reaching. The majority of the aggressive failures of MOM hip implants have been dealt with by revision hip surgery, leaving patients with a much more indolent pattern of failure of devices that have been in situ for more than 10 years. The longer-term outcome for such patients remains unknown, and much debate exists on how best to manage these patients. Regulatory guidance is available but remains open to interpretation due to the lack of current evidence and long-term studies. Metal ion thresholds for concern have been suggested at 7 ppb for hip resurfacing arthroplasty and below this level for large diameter total hip arthroplasties. Soft tissue changes including pseudotumours and muscle atrophy have been shown to progress, but this is not consistent. New advanced imaging techniques are helping to diagnose complications with metal hips and the reasons for failure, however these are not widely available. This has led to some centres to tackle difficult cases through multidisciplinary collaboration, for both surgical management decisions and also follow-up decisions. We summarise current evidence and consider who is at risk, when revision should be undertaken and how patients should be managed. PMID:27190754
Favetti, Fabio; Casella, Filippo; Papalia, Matteo; Panegrossi, Gabriele
Background The renewed popularity of resurfacing hip arthroplasty in the last 10 years has generated a remarkable quantity of scientific contributions based on mid- and short-term follow-up. More than one paper has reported a consistent early revision rate as a consequence of biological or biomechanical failure. Two major complications are commonly described with resurfacing implants: avascular necrosis and femoral-neck fracture. A close relationship between these two events has been suggested, but not firmly demonstrated, whereas cementing technique seems to be better understood as potential cause of failure. Methods We performed an in vitro study in which four different resurfacing implants were evaluated with a simulated femoral head, two types of cement, (low and high viscosity) and two cementing techniques: direct (cement apposition directly on the femoral head) and indirect (cement poured into the femoral component). Results High-viscosity cement showed homogeneous distribution over the entire femoral head. Low-viscosity cement showed a massive polar concentration with insufficient, if not absent, distribution in the equatorial zone. Conclusion Polar cement concentration could be a risk factor for early implant failure due to two effects on the femoral head: biological (excessive local exothermic reaction could cause osteocyte necrosis) and biomechanical (which could lead to uneven load distribution on the femoral head). PMID:21234563
McMinn, D; Treacy, R; Lin, K; Pynsent, P
The historical failure of surface replacement has been due to the production of wear debris with subsequent bone resorption, loosening, and failure. To avoid these problems, a surface replacement using a metal on metal bearing allowing thin components and femoral design and instrumentation to avoid varus alignment has been designed. Two hundred thirty-five joints have been resurfaced with this prosthesis in almost 5 years. There have been no femoral neck fractures and no dislocations. There have been 4 designs differing in the method of fixation. In the press fit group, 6 of 70 hips had to be revised for aseptic loosening. In the cemented group, debonding of the cup occurred in 3 of 43 cases. Six patients had hydroxyapatite coated components and have had excellent clinical outcomes. The current design uses a peripherally expanded hydroxyapatite coated cup and a cemented metal head; 116 of this design have been implanted during a 19-month period with excellent outcome. Despite short followup the authors are hopeful that the combination of a polar metal on metal bearing with appropriate fixation will yield a method of preserving bone stock in the younger patient requiring arthroplasty.
Hunt, B. J.; Richardson, V. M.; Langton, D. J.; Smith, E.; Joyce, T. J.
Objectives The high revision rates of the DePuy Articular Surface Replacement (ASR) and the DePuy ASR XL (the total hip arthroplasty (THA) version) have led to questions over the viability of metal-on-metal (MoM) hip joints. Some designs of MoM hip joint do, however, have reasonable mid-term performance when implanted in appropriate patients. Investigations into the reasons for implant failure are important to offer help with the choice of implants and direction for future implant designs. One way to assess the performance of explanted hip prostheses is to measure the wear (in terms of material loss) on the joint surfaces. Methods In this study, a coordinate measuring machine (CMM) was used to measure the wear on five failed cementless Biomet Magnum/ReCap/ Taperloc large head MoM THAs, along with one Biomet ReCap resurfacing joint. Surface roughness measurements were also taken. The reason for revision of these implants was pain and/or adverse reaction to metal debris (ARMD) and/or elevated blood metal ion levels. Results The mean wear rate of the articulating surfaces of the heads and acetabular components of all six joints tested was found to be 6.1 mm3/year (4.1 to 7.6). The mean wear rate of the femoral head tapers of the five THAs was 0.054 mm3/year (0.021 to 0.128) with a mean maximum wear depth of 5.7 µm (4.3 to 8.5). Conclusion Although the taper wear was relatively low, the wear from the articulating surfaces was sufficient to provide concern and was potentially large enough to have been the cause of failure of these joints. The authors believe that patients implanted with the ReCap system, whether the resurfacing prosthesis or the THA, should be closely monitored. Cite this article: S. C. Scholes, B. J. Hunt, V. M. Richardson, D. J. Langton, E. Smith, T. J. Joyce. Explant analysis of the Biomet Magnum/ReCap metal-on-metal hip joint. Bone Joint Res 2017;6:113–122. DOI: 10.1302/2046-3758.62.BJR-2016-0130.R2. PMID:28246095
Scholes, S C; Hunt, B J; Richardson, V M; Langton, D J; Smith, E; Joyce, T J
The high revision rates of the DePuy Articular Surface Replacement (ASR) and the DePuy ASR XL (the total hip arthroplasty (THA) version) have led to questions over the viability of metal-on-metal (MoM) hip joints. Some designs of MoM hip joint do, however, have reasonable mid-term performance when implanted in appropriate patients. Investigations into the reasons for implant failure are important to offer help with the choice of implants and direction for future implant designs. One way to assess the performance of explanted hip prostheses is to measure the wear (in terms of material loss) on the joint surfaces. In this study, a coordinate measuring machine (CMM) was used to measure the wear on five failed cementless Biomet Magnum/ReCap/ Taperloc large head MoM THAs, along with one Biomet ReCap resurfacing joint. Surface roughness measurements were also taken. The reason for revision of these implants was pain and/or adverse reaction to metal debris (ARMD) and/or elevated blood metal ion levels. The mean wear rate of the articulating surfaces of the heads and acetabular components of all six joints tested was found to be 6.1 mm(3)/year (4.1 to 7.6). The mean wear rate of the femoral head tapers of the five THAs was 0.054 mm(3)/year (0.021 to 0.128) with a mean maximum wear depth of 5.7 µm (4.3 to 8.5). Although the taper wear was relatively low, the wear from the articulating surfaces was sufficient to provide concern and was potentially large enough to have been the cause of failure of these joints. The authors believe that patients implanted with the ReCap system, whether the resurfacing prosthesis or the THA, should be closely monitored.Cite this article: S. C. Scholes, B. J. Hunt, V. M. Richardson, D. J. Langton, E. Smith, T. J. Joyce. Explant analysis of the Biomet Magnum/ReCap metal-on-metal hip joint. Bone Joint Res 2017;6:113-122. DOI: 10.1302/2046-3758.62.BJR-2016-0130.R2. © 2017 Scholes et al.
Gillam, Marianne H; Pratt, Nicole L; Inacio, Maria C S; Roughead, Elizabeth E; Shakib, Sepehr; Nicholls, Stephen J; Graves, Stephen E
Background and purpose — It is unclear whether metal particles and ions produced by mechanical wear and corrosion of hip prostheses with metal-on-metal (MoM) bearings have systemic adverse effects on health. We compared the risk of heart failure in patients with conventional MoM total hip arthroplasty (THA) and in those with metal-on-polyethylene (MoP) THA. Patients and methods — We conducted a retrospective cohort study using data from the Australian Government Department of Veterans’ Affairs health claims database on patients who received conventional THA for osteoarthritis between 2004 and 2012. The MoM THAs were classified into groups: Articular Surface Replacement (ASR) XL Acetabular System, other large-head (LH) (> 32 mm) MoM, and small-head (SH) (≤ 32 mm) MoM. The primary outcome was hospitalization for heart failure after THA. Results — 4,019 patients with no history of heart failure were included (56% women). Men with an ASR XL THA had a higher rate of hospitalization for heart failure than men with MoP THA (hazard ratio (HR) = 3.2, 95% CI: 1.6–6.5). No statistically significant difference in the rate of heart failure was found with the other LH MoM or SH MoM compared to MoP in men. There was no statistically significant difference in heart failure rate between exposure groups in women. Interpretation — An association between ASR XL and hospitalization for heart failure was found in men. While causality between ASR XL and heart failure could not be established in this study, it highlights an urgent need for further studies to investigate the possibility of systemic effects associated with MoM THA. PMID:27759468
Hart, Alister J; Sabah, Shiraz A; Henckel, Johann; Lloyd, Gwynneth; Skinner, John A
Metal-on-metal bearings were re-popularised in the late 1990s with the introduction of modern hip resurfacing. Large diameter (LD) metal-on-metal (MoM) hips became more prevalent and have been the least successful group of hip implants ever used. They were rapidly adopted from 2004 until the British Hip Society stopped their use in 2012. Well functioning MoM hip results (including the BHR and Metasul) are hidden in the mire of poor results from the group of all MoM bearings.We have reviewed what happened and we make 3 observations. Firstly, collaboration between surgeons and then between surgeons and other disciplines, first identified and then solved the clinical management problems. Secondly, the problems with MoM hips occurred because hip simulation was inadequate at predicting performance in patients. They gave no indications of the biological effects of wear in the human environment. Lastly, retrieval of failed implants was essential to understanding why failure occurred.These lessons must never be forgotten and must form the basis by which new or altered implants are introduced and how they should be monitored. This will enable safer innovation for patients, surgeons and manufacturers. The problems with MoM hips will not have been in vain.
Calistri, Alessandro; Campbell, Patricia; Van Der Straeten, Catherine; De Smet, Koen Aimè
Metal-on-metal hip resurfacing has gained popularity as a feasible treatment option for young and active patients with hip osteoarthritis and high functional expectations. This procedure should only be performed by surgeons who have trained specifically in this technique. Preoperative planning is essential for hip resurfacing in order to execute a successful operation and preview any technical problems. The authors present a case of a man who underwent a resurfacing arthroplasty for osteoarthritis of the left hip that was complicated by mismatched implant components that were revised three days afterwards for severe pain and leg length discrepancy. Such mistakes, although rare, can be prevented by educating operating room staff in the size and colour code tables provided by the companies on their prostheses or implant boxes. PMID:28361022
Calistri, Alessandro; Campbell, Patricia; Van Der Straeten, Catherine; De Smet, Koen Aimè
Metal-on-metal hip resurfacing has gained popularity as a feasible treatment option for young and active patients with hip osteoarthritis and high functional expectations. This procedure should only be performed by surgeons who have trained specifically in this technique. Preoperative planning is essential for hip resurfacing in order to execute a successful operation and preview any technical problems. The authors present a case of a man who underwent a resurfacing arthroplasty for osteoarthritis of the left hip that was complicated by mismatched implant components that were revised three days afterwards for severe pain and leg length discrepancy. Such mistakes, although rare, can be prevented by educating operating room staff in the size and colour code tables provided by the companies on their prostheses or implant boxes.
Singh, Gurpal; Meyer, Heiko; Ruetschi, Marcel; Chamaon, Kathrin; Feuerstein, Bernd; Lohmann, Christoph H
Large-diameter metal-on-metal (MoM) bearings evolved from the success of hip resurfacing. These implants were used in revision surgery in cases with well-fixed acetabular cups but loose or failed femoral stems, to avoid cup revision. Early data showed low rates of dislocation and potentially low wear profiles due to better fluid film lubrication. The risk of impingement was also thought to be low due to the increased head-neck ratio. Subsequently large-diameter MoM heads gained popularity in primary hip replacement. Recent data has emerged on the unacceptably high revision rates among patients with large-diameter MoM total hip arthroplasties (THAs), high blood levels of metal ions, and adverse tissue reactions. The head-neck (cone-taper) modular interface probably represents the weak link in large metal heads that have been used on conventional tapers. Increased torque of the large head, micromotion, and instability at the cone-taper interface, synergistic interactions between corrosion and wear, edge loading, low clearance, and psoas impingement are the likely causes for early failure of these prostheses. Copyright © 2013 Wiley Periodicals, Inc.
Verhelst, Luk A; Van der Bracht, Hans; Vanhegan, Ivor S; Van Backlé, Bart; De Schepper, Jo
Isolated revision of the femoral component of hip resurfacings to metal-on-metal (MoM) total hip arthroplasties has shown inferior results. We present a case series of well-fixed, painful MoM hips with elevated chromium and cobalt levels. An isolated femoral revision using a noncemented femoral component and a double-mobility head was performed. Patients were followed up for 6 months and showed excellent improvements in visual analog score and Hip dysfunction and Osteoarthritis Outcome Score (HOOS). Cobalt and chromium levels dropped at 6 weeks and were normal at 6 months. Although our follow-up is short, we feel that it is important to highlight this as a potential treatment strategy. This revision is less aggressive than traditional methods, eliminates the concerns from MoM bearings, and results in a stable construct. Copyright © 2012 Elsevier Inc. All rights reserved.
Howard, Jason J
Due to problems with wear particle generation and subsequent loosening using conventional metal-on-polyethylene total hip replacements, there has been a shift toward alternative bearing systems, including metal-on-metal (MoM), for younger, more active patients with degenerative joint disease. Based on positive results from early short-term clinical studies, MoM hip replacements were readily adopted by orthopedic surgeons with thousands being implanted worldwide over the past decade. Unacceptably high revision rates reported by two national joint registries called into question the rigorousness of the regulatory approval process for these implants, particularly with respect to premarket data requirements to prove safety, effectiveness, and the appropriateness of the regulatory pathway chosen. The purpose of this review was to investigate the balance between facilitating the introduction of new medical technologies and the need to ensure safety and effectiveness through comprehensive regulatory assessment. The case of MoM hip replacement devices was used to frame the investigation and subsequent discussions. The regulatory approval processes and post-market surveillance requirements associated with three common MoM hip replacements (two resurfacings: the Birmingham and articular surface replacement and the articular surface replacement XL total hip replacement) were investigated. With respect to modern MoM hip replacement devices, the balance between facilitating the introduction of these new medical technologies and the need to ensure safety and effectiveness through comprehensive regulatory assessment was not achieved. The lessons learned from these experiences have application beyond joint replacements to the introduction of new medical technologies in general, particularly for those who have a significant potential for harm. In this regard, a series of recommendations have been developed to contribute to the evolution of the medical device regulatory process.
Howard, Jason J
Due to problems with wear particle generation and subsequent loosening using conventional metal-on-polyethylene total hip replacements, there has been a shift toward alternative bearing systems, including metal-on-metal (MoM), for younger, more active patients with degenerative joint disease. Based on positive results from early short-term clinical studies, MoM hip replacements were readily adopted by orthopedic surgeons with thousands being implanted worldwide over the past decade. Unacceptably high revision rates reported by two national joint registries called into question the rigorousness of the regulatory approval process for these implants, particularly with respect to premarket data requirements to prove safety, effectiveness, and the appropriateness of the regulatory pathway chosen. The purpose of this review was to investigate the balance between facilitating the introduction of new medical technologies and the need to ensure safety and effectiveness through comprehensive regulatory assessment. The case of MoM hip replacement devices was used to frame the investigation and subsequent discussions. The regulatory approval processes and post-market surveillance requirements associated with three common MoM hip replacements (two resurfacings: the Birmingham and articular surface replacement and the articular surface replacement XL total hip replacement) were investigated. With respect to modern MoM hip replacement devices, the balance between facilitating the introduction of these new medical technologies and the need to ensure safety and effectiveness through comprehensive regulatory assessment was not achieved. The lessons learned from these experiences have application beyond joint replacements to the introduction of new medical technologies in general, particularly for those who have a significant potential for harm. In this regard, a series of recommendations have been developed to contribute to the evolution of the medical device regulatory process
Govind, Garima; Henckel, Johann; Hothi, Harry; Sabah, Shiraz; Skinner, John; Hart, Alister
Retrieved metal-on-metal acetabular cups are valuable resources in investigating the wear behaviour of failed hip implants, but adequate methods to do so are lacking. To further contribute to addressing this issue, we developed a method to detect the in vivo location of the primary wear scar of an explanted cup. We proposed a new method in which thirteen patients with failed metal hip resurfacings were recruited, and their acetabular components retrieved. A 3D wear map was generated and the precise location of the primary wear scar in each cup was identified using a coordinate measuring machine. This wear scar location was noted in relation to the features on the acetabular cup. Having identified the location of the wear scar, this 3D positional map was co-registered to the implant on the patient's pelvic 3D CT scan. Using our proposed technique, we were able to demonstrate that the in vivo position of the primary wear scar in explanted metal acetabular cups can be variable. This method has utilised existing techniques to better understand the three-dimensional properties of wear behaviour, and may be a method which can be used in further studies to investigate variables that affect the position of the primary wear scar.
Parry, Michael C; Eastaugh-Waring, Steve; Bannister, Gordon C; Learmonth, Ian D; Case, Charles Patrick; Blom, Ashley W
Resurfacing arthroplasty has fallen out of favour in recent years due to unfavourable survivorship in joint registries and alarming reports of soft tissue reactions around metal on metal prostheses. Our aim was to assess the effect of head size, implant design and component positioning on metal production by resurfacing arthroplasties. We measured whole blood cobalt and chromium and component position in matched populations implanted with two designs of resurfacing arthroplasty over a two-year period. Both implants resulted in a significant increase in blood metal levels (p<0.001) though the ASR design generated significantly higher metal levels (p = 0.041). A significant inverse correlation was seen between component size and blood cobalt levels (p = 0.032) and blood chromium levels (p<0.001). No correlation was identified between component position and blood metal levels. Small diameter metal resurfacing components result in increased metal generation compared with larger components. As increased metal generation has been correlated to wear and therefore failure, caution must be used on implantation of smaller components and indeed, in those who require smaller components, alternative bearing materials should be considered. These results contrast with recent findings which have demonstrated early failure for larger diameter stemmed metal-on-metal prostheses.
Fernández-Fairen, Mariano; Punset, Miquel; Murcia-Asensio, Antonio; Ferrero-Manzanal, Francisco; Sueiro, José; Gil, Javier
Besides promising results of metal-on-metal (MOM) hip arthroplasty (HA), frequent failures have been reported even in the short term. Many host, surgical, design, metallurgical, and processing factors have been evoked in the base of these events. We have tried to characterize and to evaluate metallurgical and processing features present in this type of implants. The acetabular and femoral components of 20 MOM HAs collected from a multicenter retrieval program were examined. All the specimens were inspected with naked eye, with confocal microscopy and vertical scanning interferometry, scanning electron microscopy, back-scattered electron imaging, and energy-dispersive X-ray spectroscopy, in 25 zones of each articular component. Gas pores, shrinkage voids and holes of detached carbides, carbides on surface, embedded particles, scratches and marks of wear, surface discoloration, surface deposits, and tribochemical reaction layers were widely dispersed through a substantial percentage of the total bearing surface in all the implanted components. Surface cup and head voids, and cup scratches showed significant correlation with the clearance of pair. A higher surface damage of the cup and head was observed mainly in the low clearance prostheses. There was no other significant correlation or difference in the incidence and importance of any of these defects between resurfacing hip arthroplasties and total hip arthroplasties, or according to the pair diameter. Some metallurgical features and surface damage were significantly present in the retrieved implants of MoM HAs. It would be desirable to improve the structure and metallurgical characteristics of these implants to avoid those effects and optimize their performance. Copyright © 2017 Elsevier Inc. All rights reserved.
Total hip arthroplasty was performed in November 2001 in a 30-year-old active patient with degenerative hip disease. A metal-on-metal bearing was used. Follow-up was considered excellent until the development of pain and squeaking at hip mobilization, leading to revision in March 2006. The acetabular metallic inlay of the metal-on-metal insert was found detached from the polyethylene insert; half of the diameter of the neck of the femoral stem was sectioned. Complete revision was performed with an acetabular graft. At one year follow-up, anatomic and functional outcome has been excellent. To our knowledge, this is the first report of this kind of mechanical failure of a metal-on-metal total hip arthroplasty.
Oshima, Yasushi; Fetto, Joseph F
Metal-on-metal had been proposed as an optimal articulation in THRs, however, many monoblock prostheses have been recalled in the USA because of significant high rates of early failure. Metal-on-metal prostheses had been implanted in our institution, and this is a case history of a single patient, in whom metal-on-metal THRs with different femoral sizes of heads were implanted. A 57-year-old female patient underwent bilateral total hip replacements with metal-on-metal prostheses using metal-polyethylene "sandwich" liners 9 years ago on the right side and 7 years ago on the left side respectively. The only difference in both sides was the femoral head diameter of 28 mm in right and 34 mm in left. Seven years after the left surgery, the acetabular liner was dissociated, however, metallosis was not detected. Although the larger femoral head was thought to increase hip joint stability, it dictated a reduction in polyethylene thickness in this prosthesis design, and it was 4 mm in the left hip. Recently, metal-on-metal articulations are thought not to be optimal for hip joint bearing surface, however, this clinical failure was due to the polyethylene thickness and quality.
Tan, Timothy L; Ebramzadeh, Edward; Campbell, Patricia A; Al-Hamad, Mariam; Amstutz, Harlan C
Due to the well-documented problems surrounding metal-on-metal bearings, the use of hip resurfacing has declined. Since the potential benefits of hip resurfacing remain desirable, it may be beneficial to investigate the long-term outcome of hip resurfacings using metal-on-polyethylene in the 1980's. We report the long-term survivorship and modes of failure of a cementless metal-on-polyethylene resurfacing (n = 178) with different porous ingrowth surfaces. While acetabular loosening was absent, a high incidence of femoral failures (femoral loosening = 18.1%, osteolytic neck fracture = 21%) occurred despite using the same ingrowth surface for both components. Ongoing developments using the lessons learned from these previous generation components and utilizing modern low wear materials, e.g., cross-linked polyethylene, may lead to improved implants for future hip resurfacings. © 2014 Elsevier Inc. All rights reserved.
Crozier-Shaw, Geoff; Queally, Joseph M; Quinlan, John F
Metal-on-metal total hip arthroplasty (THA) has generated much attention in the media because of early failure of certain implant systems. This study assessed the quality, accuracy, and readability of online information on metal-on-metal THA. The search terms "metal-on-metal hip replacement" and "metal hip replacement" were entered into the 3 most popular search engines. Information quality was assessed with the DISCERN score and a specific metal-on-metal THA content score. Accuracy of information was assessed with a customized score. Readability of the websites was assessed with the Flesch-Kincaid grade level score. A total of 61 unique websites were assessed. For 56% of websites, the target audience was patients. Media or medicolegal sources accounted for 44% of websites. As assessed by DISCERN (range, 16-80) and metal-on-metal THA (range, 0-25) scores, quality of the websites was moderate at best (47.1 and 9.6, respectively). Accuracy (range, 0-8) of the information presented also was moderate, with a mean score of 6.6. Media and medicolegal websites had the lowest scores for both quality and accuracy, despite making up the greatest proportion of sites assessed. Only 1 website (2%) had a Flesch-Kincaid grade level at or less than the recommended level of 8th grade. This study found that online information on metal-on-metal THA was of poor quality, often was inaccurate, and was presented at an inappropriately high reading level, particularly for media and medicolegal websites. Health care providers should counsel patients on the quality of information available and recommend appropriate online resources. [Orthopedics. 2017; 40(2):e262-e268.]. Copyright 2016, SLACK Incorporated.
Marshall, Deborah A; Pykerman, Karen; Werle, Jason; Lorenzetti, Diane; Wasylak, Tracy; Noseworthy, Tom; Dick, Donald A; O'Connor, Greg; Sundaram, Aish; Heintzbergen, Sanne; Frank, Cy
Metal-on-metal hip resurfacing was developed for younger, active patients as an alternative to THA, but it remains controversial. Study heterogeneity, inconsistent outcome definitions, and unstandardized outcome measures challenge our ability to compare arthroplasty outcomes studies. We asked how early revisions or reoperations (within 5 years of surgery) and overall revisions, adverse events, and postoperative component malalignment compare among studies of metal-on-metal hip resurfacing with THA among patients with hip osteoarthritis. Secondarily, we compared the revision frequency identified in the systematic review with revisions reported in four major joint replacement registries. We conducted a systematic review of English language studies published after 1996. Adverse events of interest included rates of early failure, time to revision, revision, reoperation, dislocation, infection/sepsis, femoral neck fracture, mortality, and postoperative component alignment. Revision rates were compared with those from four national joint replacement registries. Results were reported as adverse event rates per 1000 person-years stratified by device market status (in use and discontinued). Comparisons between event rates of metal-on-metal hip resurfacing and THA are made using a quasilikelihood generalized linear model. We identified 7421 abstracts, screened and reviewed 384 full-text articles, and included 236. The most common study designs were prospective cohort studies (46.6%; n = 110) and retrospective studies (36%; n = 85). Few randomized controlled trials were included (7.2%; n = 17). The average time to revision was 3.0 years for metal-on-metal hip resurfacing (95% CI, 2.95-3.1) versus 7.8 for THA (95% CI, 7.2-8.3). For all devices, revisions and reoperations were more frequent with metal-on-metal hip resurfacing than THA based on point estimates and CIs: 10.7 (95% CI, 10.1-11.3) versus 7.1 (95% CI, 6.7-7.6; p = 0.068), and 7.9 (95% CI, 5.4-11.3) versus 1
Su, Edwin P
The current generation of hip resurfacing consists of a metal-on-metal ball and monoblock socket of minimal thickness. Although results in certain patient subgroups have been excellent at up to 15 years of follow-up, other subgroups have had poor results. The hard-on-hard bearing is susceptible to edge-loading conditions and may produce excessive metallic debris; furthermore, other patients have had allergic reactions to the metal byproducts. In both situations, there can be clinical failures from adverse local tissue reactions. As such, the role of hip resurfacing has diminished over the last decade because of these issues. Developing the next generation hip resurfacing is essential to address these problems, and there are multiple design considerations in doing so. The choice of materials will be of prime concern, with the decision to use a hard-on-soft or hard-on-hard articulation. The dimensions of the resurfacing implant also pose a challenge, because of the requirement to preserve the bone. Fixation of the implant is another area of interest, in order to maximize implant longevity.
Pulikottil-Jacob, Ruth; Connock, Martin; Kandala, Ngianga-Bakwin; Mistry, Hema; Grove, Amy; Freeman, Karoline; Costa, Matthew; Sutcliffe, Paul; Clarke, Aileen
Background Total hip replacement for end stage arthritis of the hip is currently the most common elective surgical procedure. In 2007 about 7.5% of UK implants were metal-on-metal joint resurfacing (MoM RS) procedures. Due to poor revision performance and concerns about metal debris, the use of RS had declined by 2012 to about a 1% share of UK hip procedures. This study estimated the lifetime cost-effectiveness of metal-on-metal resurfacing (RS) procedures versus commonly employed total hip replacement (THR) methods. Methodology/Principal Findings We performed a cost-utility analysis using a well-established multi-state semi-Markov model from an NHS and personal and social services perspective. We used individual patient data (IPD) from the National Joint Registry (NJR) for England and Wales on RS and THR surgery for osteoarthritis recorded from April 2003 to December 2012. We used flexible parametric modelling of NJR RS data to guide identification of patient subgroups and RS devices which delivered revision rates within the NICE 5% revision rate benchmark at 10 years. RS procedures overall have an estimated revision rate of 13% at 10 years, compared to <4% for most THR devices. New NICE guidance now recommends a revision rate benchmark of <5% at 10 years. 60% of RS implants in men and 2% in women were predicted to be within the revision benchmark. RS devices satisfying the 5% benchmark were unlikely to be cost-effective compared to THR at a standard UK willingness to pay of £20,000 per quality-adjusted life-year. However, the probability of cost effectiveness was sensitive to small changes in the costs of devices or in quality of life or revision rate estimates. Conclusion/Significance Our results imply that in most cases RS has not been a cost-effective resource and should probably not be adopted by decision makers concerned with the cost effectiveness of hip replacement, or by patients concerned about the likelihood of revision, regardless of patient age or
Girard, Julien; Bocquet, Donatien; Autissier, Guillaume; Fouilleron, Nicolas; Fron, Damien; Migaud, Henri
Total hip arthroplasty in patients younger than thirty years of age represents a long-term challenge. As polyethylene wear secondary to a high activity level could be problematic, hard-on-hard bearings have been proposed to reduce wear. The aim of this retrospective case series was to assess the clinical and radiographic results of primary metal-on-metal total hip arthroplasty in patients thirty years of age or younger. We retrospectively studied thirty-four patients (forty-seven hips) who had undergone metal-on-metal total hip arthroplasty and analyzed the radiographic and clinical measurements after a mean duration of follow-up of 108 months (range, 62.4 to 153.6 months). The mean age of the patients at the time of surgery was twenty-five years (range, fifteen to thirty years). The diameter of the head of the femoral component was 28 mm in all hips except five, in which it was 32 mm. The metal-on-metal bearing was the same in all patients. The mean Merle d'Aubigné score increased from 10.6 (range, 1 to 14) to 17.1 (range, 12 to 18). No wear was found on the latest radiograph, but osteolysis was noted in three femora and two acetabula. Two revisions were performed, one because of impingement secondary to cup malorientation and the other because of acetabular loosening with osteolysis. Kaplan-Meier analysis with revision of either component as the end point revealed a ten-year survival rate of 94.5% (95% confidence interval, 80% to 98.6%). The survival rate of the femoral stem was 100%. These encouraging intermediate-term results indicate that hip arthroplasty with metal-on-metal bearing components may be a suitable solution for young and active patients with hip osteoarthritis or osteonecrosis of the femoral head.
Hothi, Harry S; Berber, Reshid; Whittaker, Robert K; Blunn, Gordon W; Skinner, John A; Hart, Alister J
The size of the clinical impact of corrosion of the taper junction of metal-on-metal total hip arthroplasties (MOM-THAs) is unclear. Examination of a large number of retrieved MOM resurfacings and total hip arthroplasties can help us understand the role of taper corrosion in metal ion release. We graded the severity of corrosion at the taper junction of 395 MOM-THAs and compared the prerevision whole blood metal ion levels of these hips with 529 failed MOM hip resurfacings. Virtually all MOM-THA hips (n = 388) had evidence of corrosion of the head-stem taper junction and graded as severe in 31% (n = 124). The median cobalt/chromium (Co/Cr) ratio was 1.58 (0.01-13.82) and 1.08 (0-4.86) for MOM-THA and MOM hip resurfacing, respectively; this difference was significant (P < .001). THA hips with severely corroded tapers had the highest median Co/Cr ratio of 1.86 (0.01-10). This study demonstrates the high prevalence of severe taper corrosion, which may be related to an elevated Co/Cr ratio before revision. Copyright © 2016 Elsevier Inc. All rights reserved.
Ribas, Manuel; Cardenas, Carlomagno; Astarita, Emanuele; Moya, Esther; Bellotti, Vittorio
In the previous decade, metal-on-metal hip resurfacing has been considered an attractive option and theoretically advantageous over conventional total hip arthroplasty, especially in young active patients. Different authors have reported favourable mid-term clinical and functional results with acceptable survival rates. Proper indication and planning, as accurate technical execution have been advocated to be crucial elements for success.Concerns regarding serum metal ion levels and possible clinical implications have led in the last years to a decline in the use of metal-on-metal hip resurfacing and metal-on-metal bearings in general.The aim of this study is to present the results of our first 486 cases of hybrid hip resurfacing arthroplasties with a second generation cementing technique, and to describe our current restricted indication of this type of prosthesis, in the light of recent findings in the literature about the possible complications related to metallosis or improper patient selection. Global survivorship of our series was 97.9% at a mean follow-up of 7.2 years.In the second season of our experience the indication is restrictive. The candidate for a resurfacing hip replacement is a young and active male patient, with good bone quality, that has been made aware of the risks and benefits of this type of prosthesis.
Ziaee, H; Daniel, J; Datta, A K; Blunt, S; McMinn, D J W
Metal-on-metal bearings are being increasingly used in young patients. The potential adverse effects of systemic metal ion elevation are the subject of ongoing investigation. The purpose of this study was to investigate whether cobalt and chromium ions cross the placenta of pregnant women with a metal-on-metal hip resurfacing and reach the developing fetus. Whole blood levels were estimated using high-resolution inductively-coupled plasma mass spectrometry. Our findings showed that cobalt and chromium are able to cross the placenta in the study patients with metal-on-metal hip resurfacings and in control subjects without any metal implants. In the study group the mean concentrations of cobalt and chromium in the maternal blood were 1.39 microg/l (0.55 to 2.55) and 1.28 microg/l (0.52 to 2.39), respectively. The mean umbilical cord blood concentrations of cobalt and chromium were comparatively lower, at 0.839 microg/l (0.42 to 1.75) and 0.378 microg/l (0.14 to 1.03), respectively, and this difference was significant with respect to chromium (p < 0.05). In the control group, the mean concentrations of cobalt and chromium in the maternal blood were 0.341 microg/l (0.18 to 0.54) and 0.199 microg/l (0.12 to 0.33), and in the umbilical cord blood they were 0.336 microg/l (0.17 to 0.5) and 0.194 microg/l (0.11 to 0.56), respectively. The differences between the maternal and umbilical cord blood levels in the controls were marginal, and not statistically significant (p > 0.05). The mean cord blood level of cobalt in the study patients was significantly greater than that in the control group (p < 0.01). Although the mean umbilical cord blood chromium level was nearly twice as high in the study patients (0.378 microg/l) as in the controls (0.1934 microg/l), this difference was not statistically significant. (p > 0.05) The transplacental transfer rate was in excess of 95% in the controls for both metals, but only 29% for chromium and 60% for cobalt in study patients
Hart, Alister J; Satchithananda, Keshthra; Liddle, Alexander D; Sabah, Shiraz A; McRobbie, Donald; Henckel, Johann; Cobb, Justin P; Skinner, John A; Mitchell, Adam W
Many papers have been published recently on the subject of pseudotumors surrounding metal-on-metal hip resurfacing and replacement prostheses. These pseudotumors are sterile, inflammatory lesions within the periprosthetic tissues and have been variously termed masses, cysts, bursae, collections, or aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL). The prevalence of pseudotumors in patients with a well-functioning metal-on-metal hip prosthesis is not well known. The purpose of this study was to quantify the prevalence of pseudotumors adjacent to well-functioning and painful metal-on-metal hip prostheses, to characterize these lesions with use of magnetic resonance imaging, and to assess the relationship between their presence and acetabular cup position with use of three-dimensional computed tomography. We performed a case-control study to compare the magnetic resonance imaging findings of patients with a well-functioning unilateral metal-on-metal hip prosthesis and patients with a painful prosthesis (defined by either revision arthroplasty performed because of unexplained pain or an Oxford hip score of <30 of 48 possible points). Thirty patients with a painful hip prosthesis and twenty-eight controls with a well-functioning prosthesis were recruited consecutively. All patients also underwent computed tomography to assess the position of the acetabular component. Thirty-four patients were diagnosed with a pseudotumor. However, the prevalence of pseudotumors in patients with a painful hip (seventeen of thirty, 57%) was not significantly different from the prevalence in the control group (seventeen of twenty-eight, 61%). No objective differences in pseudotumor characteristics between the groups were identified. No clear association between the presence of a pseudotumor and acetabular component position was identified. The Oxford hip score in the group with a painful hip (mean, 20.2; 95% confidence interval [CI], 12.7 to 45.8) was poorer than that in
Nicolli, Annamaria; Bisinella, Gianluca; Padovani, Giovanni; Vitella, Antonio; Chiara, Federica; Trevisan, Andrea
Blood metal ion levels in 72 patients with large head metal-on-metal hip arthroplasty were studied to determine the correlation between the values measured in whole blood and urine. Urinary cobalt and chromium levels of 30μg and 21μg, respectively, adjusted to creatinine were found to correspond to the 7μg/l cut-off value that has been accepted in whole blood. Cobalt and chromium levels in whole blood and urine both significantly correlated with increased acetabular component inclination angle over 50 degrees and pain scores. There was no correlation with socket anteversion angle or femoral head diameter. The data support the use of urinary measurement of metal ions adjusted to creatinine to monitor patients with large head metal-on-metal total hip arthroplasty. Copyright © 2014 Elsevier Inc. All rights reserved.
Frisch, Nicholas B; Wessell, Nolan M; Taliaferro, Kevin; Van Holsbeeck, Marnix; Silverton, Craig D
The use of metal-on-metal and modular total hip arthroplasty is associated with potentially serious local and systemic complications. The primary aim of this study was to identify the prevalence of a pseudotumor in asymptomatic patients with a particular metal-on-metal hip prosthesis after a minimum follow-up of 5 years using ultrasound evaluation. A secondary purpose was to identify associations between the presence of pseudotumor and serum metal ion levels following implantation. We prospectively evaluated data collected from 36 asymptomatic patients who underwent implantation of a Profemur Z metal-on-metal total hip arthroplasty from January 2004 to January 2010. Serum metal ion levels were collected in 2012 and 2015. Hip ultrasounds were performed in 2015. Pseudotumors were found in 7/36 patients (19.4%). The average pseudotumor size measured 38.2 cm(3) (range 7.35 cm(3)-130.81 cm(3)). Elevated metal ion levels were found in all patients at all time points. No statistical correlation was found between the presence of pseudotumor and patient age, age of the implant, component design, and any of the serum metal ion levels or ratios. One in every five asymptomatic patients with metal-on-metal implants was found to have a periarticular pseudotumor. There was no dose-dependent relationship found between elevated serum metal ion levels and the development of a pseudotumor. Our findings suggest that in patients with known elevated metal ion levels, continued monitoring of ion levels may not be a reliable predictor of pseudotumor formation, and ultrasound surveillance can and should be routinely used to document the presence and progression of pseudotumor.
Kostensalo, I; Seppänen, M; Mäkelä, K; Mokka, J; Virolainen, P; Hirviniemi, J
Total hip arthroplasty significantly improves patient's life quality. However, total joint replacement is associated with possible complications, such as dislocations, infections, fractures and periprosthetic osteolysis. The goal of this study was to evaluate a large head metal-on-metal total hip arthroplasties and analyse short term complications related to them. Between 9/2005 and 6/2009, a total of 691 hip replacements were performed on 635 patients with the use of Magnum M2 large head cementless metal-on-metal prosthesis in Turku University Hospital. All patients had a scheduled follow-up at two to three months, and at one year. The results were evaluated using X-rays, Harris Hip Score (HHS), and evaluating post-operative complications and reasons for re-operations. During our follow-up the HHS median raised from its preoperative value of 59.8 to 86.4 two to three months after the operation, and to 93.9 one year after the operation. As a complication we had five infections requiring single open debridement (early infection) or a two stage revision. Seven patients had a periprosthetic femoral fracture that was operated and 11 patients were reoperated because of acetabular component malposition, fracture or early loosening. We did not observe any dislocations, n. ischiadicus damages, squeeking or complications related to high metal ion release (ALVAL-reactions (Aseptic Lymphocyte-dominated Vasculitis-Associated Lesion) or pseudotumours). The metal-on-metal bearing pair allows large femoral head size, which decreases the risk for dislocation. It may also decrease the risk for osteolysis and aseptic loosening in a long run. Early complication rate related to the bearing surface is minimal. Metal-on-metal prosthesis is a good choice for young and active patients with good bone quality.
Jin, Z M
A simple mixed lubrication model has been developed to predict the asperity contact and wear for the metal-on-metal bearing couple for total hip joint replacements. It has been shown that the femoral head radius has a large effect on the predicted asperity contact and wear depending on the lubrication regime. An increase in the femoral head radius can lead to an increase in wear under a predominantly boundary lubrication regime, but this trend can be reversed under a mixed lubrication regime towards fluid film lubrication. These observations are consistent with the recent experimental findings from hip simulator studies by Smith and co-workers.
Liu, F; Jin, Z M; Hirt, F; Rieker, C; Roberts, P; Grigoris, P
The transient elastohydrodynamic lubrication (EHL) analysis was performed in this study for a typical metal-on-metal bearing employing a polyethylene backing underneath a metallic cup inlay under dynamic operating conditions of load and speed representative of normal walking. A ball-in-socket configuration was adopted to represent the articulation between the femoral head and the acetabular cup. The governing Reynolds and elasticity equations were solved simultaneously by using both finite difference and finite element methods. The predicted transient film thickness from the present study was compared with the estimation based on the quasi-static analysis. It was found that the polyethylene backing employed in the typical metal-on-metal hip bearing, combined with dynamic squeeze-film action, significantly improved the transient lubricant film thickness under cyclic walking and consequently a fluid film lubrication regime was possible for smooth bearing surfaces with an average roughness less than 0.005 microm.
Meessen, J. M. T. A.; Fiocco, M.; van der Heide, H. J. L.; Sedrakyan, A.; Nelissen, R. G. H. H.
Importance There are concerns about increased mortality in patients with metal-on-metal bearings in total hip arthroplasty (THA). Objective To determine the mortality and the morbidity in patients with metal-on-metal articulations (MOM THA) compared to patients with non-metal-on-metal articulations (non-MOM THA) after primary total hip arthroplasty. Data Sources Search of PubMed, MEDLINE, EMBASE, Web of Science, Cochrane, CINAHL, AcademicSearchPremier, ScienceDirect, Wiley and clinical trial registers through March 2015, augmented by a hand search of references from the included articles. No language restrictions were applied. Study Selection Two reviewers screened and identified randomised controlled trials and observational studies of primary total hip arthroplasty comparing MOM THA with non-MOM THA. Data Extraction and Synthesis Two reviewers independently extracted study data and assessed risk of bias. Risk differences (RD) were calculated with random effect models. Meta-regression was used to explore modifying factors. Main Outcomes and Measures Difference in mortality and difference in morbidity expressed as revisions and medical complications between patients with MOM THA and non-MOM THA. Results Forty-seven studies were included, comprising 4,000 THA in randomised trials and over 500,000 THA in observational studies. For mortality, random effects analysis revealed a higher pooled RD of 0.7%, 95%, confidence interval (CI) [0.0%, 2.3%], I-square 42%; the heterogeneity was explained by differences in follow-up. When restricted to studies with long term follow-up (i.e. 10 years or more), the RD for mortality was 8.5%, 95%, CI [5.8%, 11.2%]; number needed to treat was 12. Further subgroup analyses and meta-regression random effects models revealed no evidence for other moderator variables (study level covariates, e.g. resurfacing vs. non-resurfacing MOM) than follow-up duration. The quality of the evidence presented in this meta-analysis was characterized as
Jagatia, M; Jin, Z M
The elastohydrodynamic lubrication problem of metal-on-metal hip joint replacements was considered in this study. A simple ball-in-socket configuration was used to represent the hip prosthesis. The Reynolds equation in a spherical coordinate was adopted for the fluid-film lubrication analysis, to account for the ball-in-socket geometry. The corresponding elastic deformation was calculated by means of the finite element method in order to consider the complex ball-in-socket geometry as well as the backing materials underneath the acetabular cup. Both the Reynolds and the elasticity equations were solved simultaneously using the Newton-Raphson finite difference method. The general methodology developed was then applied to a recent experimental prototype metal-on-metal hip implant. It was shown that the backing materials underneath the acetabular cup had little influence on the predicted contact pressure and the elastic deformation at the bearing surfaces for this particular example. Both the film thickness and the hydrodynamic pressure distributions were obtained under various loads up to 2500 N. The predicted minimum lubricating film thickness from the present study was compared with a simple estimation using the Hamrock and Dowson formulae based upon an equivalent ball-on-plane model and excellent agreement was found. However, it was pointed out that for some forms of metal-on-metal hip prostheses with a thin acetabular cup, a polyethylene inlay underneath a metallic bearing insert or a taper connection between a bearing insert and a fixation shell, the general methodology developed in the present study should be used and this will be considered in future studies.
Wang, F C; Brockett, C; Williams, S; Udofia, I; Fisher, J; Jin, Z M
A general methodology of mixed lubrication analysis and friction prediction for a conforming spherical bearing in hip implants was developed, with particular reference to a typical metal-on-metal hip replacement. Experimental measurement of frictional torque for a similar implant was carried out to validate the theoretical prediction. A ball-in-socket configuration was adopted to represent the articulation between the femoral head and the acetabular cup under cyclic operating conditions of representative load and motion. The mixed lubrication model presented in this study was first applied to identify the contact characteristics on the bearing surfaces, consisting of both fluid-film and boundary lubricated regions. The boundary lubricated contact was assumed to occur when the predicted fluid film thickness was less than a typical boundary protein layer absorbed on the bearing surfaces. Subsequently, the friction was predicted from the fluid-film lubricated region with viscous shearing due to both Couette and Poiseuille flows and the boundary protein layer contact region with a constant coefficient of friction. The predicted frictional torque of the typical metal-on-metal hip joint implant was compared with the experimental measurement conducted in a functional hip simulator and a reasonably good agreement was found. The mixed lubrication regime was found to be dominant for the conditions considered. Although the percentage of the boundary lubricated region was quite small, the corresponding contribution to friction was quite large and the resultant friction factor was quite high.
Posada, Olga M; Tate, Rothwelle J; Grant, M Helen
Hip resurfacing with cobalt-chromium (CoCr) alloy was developed as a surgical alternative to total hip replacement. However, the biological effects of nanoparticles generated by wear at the metal-on-metal articulating surfaces has limited the success of such implants. The aim of this study was to investigate the effects of the combined exposure to CoCr nanoparticles and cobalt ions released from a resurfacing implant on monocytes (U937 cells) and whether these resulted in morphology changes, proliferation alterations, toxicity and cytokine release. The interaction between prior exposure to Co ions and the cellular response to nanoparticulate debris was determined to simulate the situation in patients with metal-on-metal implants receiving a second implant. Effects on U937 cells were mainly seen after 120h of treatment. Prior exposure to Co ions increased the toxic effects induced by the debris, and by Co ions themselves, suggesting the potential for interaction in vivo. Increased TNF-α secretion by resting cells exposed to nanoparticles could contribute to osteolysis processes in vivo, while increased IFN-γ production by activated cells could represent cellular protection against tissue damage. Data suggest that interactions between Co ions and CoCr nanoparticles would occur in vivo, and could threaten the survival of a CoCr metal implant. Copyright © 2014 Elsevier Ltd. All rights reserved.
Yew, A; Udofia, I; Jagatia, M; Jin, Z M
An elastohydrodynamic lubrication (EHL) analysis was carried out in this study for a typical McKee-Farrar metal-on-metal hip prosthesis under a simple steady state rotation. The finite element method was used initially to investigate the effect of the cement and bone on the predicted contact pressure distribution between the two articulating surfaces under dry conditions, and subsequently to determine the elastic deformation of both the femoral and the acetabular components required for the lubrication analysis. Both Reynolds equation and the elasticity equation were coupled and solved numerically using the finite difference method. Important features in reducing contact stresses and promoting fluid-film lubrication associated with the McKee-Farrar metal-on-metal hip implant were identified as the large femoral head and the thin acetabular cup. For the typical McKee-Farrar metal-on-metal hip prosthesis considered under typical walking conditions, an increase in the femoral head radius from 14 to 17.4 mm (for a fixed radial clearance of 79 microm) was shown to result in a 25 per cent decrease in the maximum dry contact pressure and a 60 per cent increase in the predicted minimum film thickness. Furthermore, the predicted maximum contact pressure considering both the cement and the bone was found to be decreased by about 80 per cent, while the minimum film thickness was predicted to be increased by 50 per cent. Despite a significant increase in the predicted minimum lubricating film thickness due to the large femoral head and the thin acetabular cup, a mixed lubrication regime was predicted for the McKee-Farrar metal-on-metal hip implant under estimated in vivo steady state walking conditions, depending on the surface roughness of the bearing surfaces. This clearly demonstrated the important influences of the material, design and manufacturing parameters on the tribological performance of these hard-on-hard hip prostheses. Furthermore, in the present contact
Mogensen, S.L.; Jakobsen, T.; Christoffersen, H.; Krarup, N.
Introduction: Metal-on-metal hip articulations have been intensely debated after reports of adverse reactions and high failure rates. The aim of this study was to retrospectively evaluate the implant of a metal-on.metal total hip articulation (MOM THA) from a single manufacture in a two-center study. Materials and Methods: 108 CONSERVE® MOM THA were implanted in 92 patients between November 2005 and December 2010. Patients had at time of retrospective evaluation their journals reviewed for re-operations and adverse reactions. Results: 20 hips were re-operated (18.4%) at a mean follow up of 53 months. 4 pseudotumors were diagnosed at time of follow up but no substantiated link was made between adverse reactions and re-operations. Conclusion: The high re-operation rates found in this study raised concern about the usage of the MOM THA and subsequently lead to the termination of implantation of this MOM THA at the two orthopaedic departments. PMID:27099640
Bowsher, John G; Hussain, Azad; Williams, Paul; Nevelos, Jim; Shelton, Julia C
Nitrogen ion implantation (which considerably hardens the surface of the bearing) may represent one possible method of reducing the wear of metal-on-metal (MOM) hip bearings. Currently there are no ion-implanted MOM bearings used clinically. Therefore a physiological hip simulator test was undertaken using standard test conditions, and the results compared to previous studies using the same methods. N2-ion implantation of high carbon cast Co-Cr-Mo-on-Co-Cr-Mo hip prostheses increased wear by 2-fold during the aggressive running-in phase compared to untreated bearing surfaces, plus showing no wear reductions during steady-state conditions. Although 2 specimens were considered in the current study, it would appear that ion implantation has no clinical benefit for MOM.
Berend, Keith R; Lombardi, Adolph V; Adams, Joanne B; Sneller, Michael A
Hip resurfacing is considered by many to be a conservative alternative to conventional total hip arthroplasty. There are advantages and drawbacks to any procedure, and there is a learning curve associated with the introduction of any new technology. The purpose of this study is to report the complication rate, types of complications, and outcomes of hip resurfacing during the early experience of two high-volume hip surgeons. Seventy-three hip resurfacing procedures were performed in sixty-four patients between September 2006 and March 2009. These procedures represented 6% of all of the primary hip arthroplasty procedures performed by the two surgeons. After an average duration of follow-up of twenty-five months, there were six revisions--i.e., an early failure rate of 8%. These revisions were performed to treat two deep infections, two femoral neck fractures, one case of femoral implant loosening, and one failure of an acetabular implant. Because of a high early failure rate, we have reduced the utilization of hip resurfacing in our patients who are candidates for hip arthroplasty.
Li, Jia; Zheng, Wei; Zhao, Jinzhu; Liu, Denghui; Xu, Weidong
Background: Patients with Parkinson's disease and poliomyelitis can have a femoral neck fracture; yet, the optimal methods of treatment for these hips remains controversial. Many constrained or semi-constrained prostheses, using constrained liners (CLs) with a locking mechanism to capture the femoral head, were used to treat femoral neck fractures in patients with neurological disorders. We retrospectively studied a group of patients with Parkinson's disease and poliomyelitis who sustained femoral neck fractures and were treated by total hip arthroplasty using an L-MoM prosthesis. Materials and Methods: We retrospectively reviewed 12 hips in 12 patients who underwent large-diameter metal-on-metal (L-MoM) total hip replacement between May 2007 and October 2009. Eight of the 12 patients (8 hips; 66.7%) had Parkinson's disease and 4 patients (4 hips; 33.3%) were affected with poliomyelitis. Results: The followup time was 5.2 years (range 3.6-6.0 years). At the latest followup, all the patients showed satisfactory clinical and radiographic results, with pain relief. No complications, such as dislocation or aseptic loosening occurred. Conclusion: We believe the use of L-MoM can diminish the rate of instability or dislocation, after operation. The L-MoM is an option for patients with Parkinson's disease and poliomyelitis with femoral neck fracture. PMID:25404774
Gascoyne, Trevor C; Dyrkacz, Richard M; Turgeon, Thomas R; Burnell, Colin D; Wyss, Urs P; Brandt, Jan-M
Eight retrieved metal-on-metal total hip replacements displayed corrosion damage along the cobalt-chromium alloy liner taper junction with the Ti alloy acetabular shell. Scanning electron microscopy indicated the primary mechanism of corrosion to be grain boundary and associated crevice corrosion, which was likely accelerated through mechanical micromotion and galvanic corrosion resulting from dissimilar alloys. Coordinate measurements revealed up to 4.3mm(3) of the cobalt-chromium alloy taper surface was removed due to corrosion, which is comparable to previous reports of corrosion damage on head-neck tapers. The acetabular liner-shell taper appears to be an additional source of metal corrosion products in modular total hip replacements. Patients with these prostheses should be closely monitored for signs of adverse reaction towards corrosion by-products.
Williams, Sophie; Jalali-Vahid, Davood; Brockett, Claire; Jin, Zhongmin; Stone, Martin H; Ingham, Eileen; Fisher, John
There is renewed interest in metal-on-metal (MOM) total hip replacements (THRs), however, variable wear rates have been observed clinically. It is hypothesised that changes in soft tissue tensioning during surgery may alter loading of THRs during the swing phase of gait leading to changes in fluid film lubrication, friction and wear. This study aimed to assess the effect of swing phase load on the lubrication, friction and wear of MOM hip replacements. Theoretical lubrication modelling was carried out using elastohydrodynamic theory. All the governing equations were solved numerically for the lubricant film thickness between the articulating surfaces under the transient dynamic conditions with low and high swing phase loads. Friction testing was completed using a single axis pendulum simulator, simplified loading cycles were applied with low and high swing phase loads. MOM hip replacements were tested in a hip simulator, modified to provide different swing phase loading regimes; a low (100 N) and a high load (as per ISO 14242-1; 280 N). Results demonstrated that the performance of MOM bearings is highly dependent on swing phase load. Hence, changes in the tension of the tissues at surgery and variations in muscle forces may increase swing phase load, reduce lubrication, increase friction and accelerate wear. This may explain some of the variations that have been observed with clinical wear rates.
Phillips, Eual A; Klein, Gregg R; Cates, Harold E; Kurtz, Steven M; Steinbeck, Marla
The histology of periprosthetic tissue from metal-on-metal (MOM) hip devices has been characterized using a variety of methods. The purpose of this study was to compare and evaluate the suitability of two previously developed aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) scoring systems for periprosthetic hip tissue responses retrieved from MOM total hip replacement (THR) systems revised for loosening. Two ALVAL scoring systems (Campbell and Oxford) were used to perform histological analyses of soft tissues from 17 failed MOM THRs. The predominant reactions for this patient cohort were macrophage infiltration and necrosis, with less than half of the patients (41%) showing a significant lymphocytic response or a high ALVAL reaction (6%). Other morphological changes varied among patients and included hemosiderin accumulation, cartilage formation, and heterotopic ossification. Both scoring systems are useful for correlating macrophage and lymphocyte responses and for comparison with the other; however, given the diversity and variability of the current responses, the Oxford-ALVAL system is more suitable for scoring tissues from MOM THR patients revised for loosening. It is important that standardized methods of scoring MOM tissue responses be used consistently so multiple study results can be compared and a consensus can be generated.
Mathew, MT; Nagelli, C; Pourzal, R; Fischer, A; Laurent, MP; Jacobs, JJ; Wimmer, MA
The demand for total hip replacement (THR) surgery is increasing in the younger population due to faster rehabilitation and more complete restoration of function. Up to 2009, metal-on-metal (MoM) hip joint bearings were a popular choice due to their design flexibility, post-operative stability and relatively low wear rates. The main wear mechanisms that occur along the bearing surface of MoM joints are tribochemical reactions that deposit a mixture of wear debris, metal ions and organic matrix of decomposed proteins known as a tribolayer. No in-depth electrochemical studies have been reported on the structure and characteristics of this tribolayer or about the parameters involved in its formation. In this study, we conducted an electrochemical investigation of different surfaces (bulk-like: control, nano-crystalline: new implant and tribolayer surface: retrieved implant) made out of two commonly used hip CoCrMo alloys (high-carbon and low-carbon). As per ASTM standard, cyclic polarization tests and electrochemical impedance spectroscopy tests were conducted. The results obtained from electrochemical parameters for different surfaces clearly indicated a reduction in corrosion for the tribolayer surface (Icorr: 0.76 μA/cm2). Further, polarization resistance (Rp:2.39±0.60MΩ/cm2) and capacitance (Cdl:15.20±0.75 μF/cm2) indicated variation in corrosion kinetics for the tribolayer surface, that attributed to its structure and stability in a simulated body environment. PMID:24099949
Nikolaou, Vassilios S; Petit, Alain; Debiparshad, Kevin; Huk, Olga L; Zukor, David J; Antoniou, John
Metal-on-metal (MoM) total hip arthroplasty (THA) has been introduced in an attempt to reduce the wear rate and the consequent osteolysis around implants. The aim of this study was to present the intermediate to long-term clinical and radiological outcomes and to investigate the metal ion levels in the blood of patients who had undergone primary uncemented MoM THA in our institution. Between July 1997 and November 2003, 166 patients (193 hips), with a mean age of 50 years (range, 18-65 years), underwent primary MoM THA. Clinical data, radiographs, and blood samples were obtained at regular follow-up visits. Cobalt (Co), chromium (Cr), and molybdenum (Mo) ions were measured by inductively coupled plasma-mass spectrometry (ICP-MS) from the patient's whole blood. All patients were prospectively followed for a minimum of 5 years (mean, 7 years; range, 5-11 years). The mean Harris hip score (HHS) and the University of California at Los Angeles (UCLA) activity score at the latest follow-up was 88 ± 11 and 7 ± 1.8 points, respectively. Thirteen hips have been revised. Ten acetabular components had early failure, due to factory manufacturing problems. All other implants have been found stable, with no signs of aseptic loosening. The probability of survival at 11 years, if the hips that were revised due to manufacturing problems were excluded, was 98.4%. The Co and Cr metal ion levels, after increasing significantly during the first 4 to 5 years post-surgery, remained stable, with a tendency to decrease thereafter, but not significantly. During the same follow-up period, Mo ion levels remained stable. In this 5-to-11 year follow-up study of MoM THA patients, excellent survivorship, with low complications rates, was found. Results of longer follow-up studies are necessary to clarify the possible long-term effects of metal ion release.
Warburton, Kevin J; Everingham, John B; Helms, Jillian L; Kazanovicz, Andrew J; Hollar, Katherine A; Brourman, Jeff D; Fox, Steven M; Lujan, Trevor J
Hip resurfacing offers advantages for young active patients afflicted with hip osteoarthritis, and may also be a beneficial treatment for adult canines. Conventional hip resurfacing uses metal-on-metal bearings to preserve bone stock, but it may be feasible to use metal-on-polyethylene bearings to reduce metal wear debris, while still preserving bone. This study characterized the short-term wear behavior of a novel hip resurfacing implant for canines that uses a 1.5 mm thick liner of highly cross-linked polyethylene in the acetabular component. This implant was tested in an orbital bearing machine that simulated canine gait for 1.1 million cycles. Wear of the liner was evaluated using gravimetric analysis and by measuring wear depth with an optical scanner. The liners had a steady-state mass wear rate of 0.99 ± 0.17 mg per million cycles, and an average wear depth in the central liner region of 0.028 mm. No liners, shells, or femoral heads had any catastrophic failure due to yielding or fracture. These results suggest that the thin liners will not prematurely crack after implantation in canines. This is the first hip resurfacing device developed for canines, and this study is the first to characterize the in vitro wear of highly cross-linked polyethylene liners in a hip resurfacing implant. The canine implant developed in this study may be an attractive treatment option for canines afflicted with hip osteoarthritis, and can serve as a valuable animal model to support the development of metal-on-polyethylene hip resurfacing technology for human patients. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Durazo-Villanueva, A; Benítez-Garduño, R
New metal-on-metal hip replacement models emerged in the 1990 with modifications of the previous designs and alloys. This led to expect a lesser rate of ion and particle release in the body with the resulting decrease in wear, osteolysis and loosening. To measure blood and urine chromium and cobalt ions in a 28 mm metal-on-metal tribology during the first postoperative year. Blood and urine cobalt and chromium concentrations were measured in 10 patients (13 prostheses) with the atomic absorption method. The etiology was studied and they were functionally assessed with the Harris functional scale. Adverse metal reactions were also assessed. 8 male and 2 female patients, mean age 54.5 years; 6 had primary coxarthrosis, one was post-traumatic, and 3 had avascular necrosis. The final assessment according to the Harris scale was 92 points. Mean blood chromium was 1.26 ng/l, blood cobalt was 1.033 microg/l; (reference values: chromium 1.4 ng/l and cobalt 1.8 microg/l); only one figure, in a female patient, was found to be higher than normal (chromium 21.2 ng/l and cobalt 15.4 microg/l). Mean urine chromium was 0.95 ng/ml, urine cobalt was 0.53 microg/l (Reference values: chromium: 2.0 ng/ml and cobalt 0.5 microg/l). All patients, with the exception of a female patient, were within the normal ranges. No adverse effect was observed in patients with metal implants with a 28 mm tribology.
Mathijssen, N. M. C.; Witt, F.; Morlock, M. M.; Vehmeijer, S. B. W.
Background Metal-on-Metal (MoM) total hip arthroplasties (THA) are associated with pseudotumor formation and high revision rates. This prospective study analysed the clinical and wear analyses of 9 large Metal-on-Metal (MoM) total hip arthroplasties (THA) to understand the underlying mechanisms of failure. The MoM bearings were revised for multiple reasons; the main reason was pseudotumor formation. Materials and Methods From 2006 till 2010 the Reinier de Graaf Hospital implanted 160 large head M2a-Magnum™ (Biomet Inc. Warsaw, Indiana, USA) THAs in 150 patients. The first year, 9 bearings were revised and analysed at the Biomechanics Section, Hamburg University of Technology, Germany. We performed clinical (Harris Hip Score, radiographic analysis, blood cobalt and chromium) and wear analysis (implant, tissue and fluid) of the 9 bearings. Since this study did not fall under the scope of the Medical Research Involving Human Subjects Act in The Netherlands, no ethical approval was necessary. In this prospective study all patient details were anonymized by the corresponding author, all other authors were blinded during the research and wear analyses. Patients with bilateral MoM implants were excluded. Results The 9 bearings had a median (IQR) survival of 41.0 (25) months in situ. From these bearings, three showed no noticeable wear. The median (IQR) head wear volume was 3.2 (3.6) mm3 and maximum wear depth 0.02 (0.02) mm. For the cup the median (IQR) wear volume was 0.23 (0.3) mm3 with a maximum wear depth of 0.03 (0.05) mm. Conclusion An early identification of parameters related to failure of the MoM THA, such as pain, decreased range of motion, radiographic changes and high levels of blood cobalt and chromium is of great importance for patient’s quality of life. Especially now patients and surgeons face the long term effects of all these bearings still in situ. This study reports the clinical and wear analyses of 9 MoM THA. In the majority of this group the
Durrani, Salim K; Sampson, Barry; Panetta, Therese; Liddle, Alexander D; Sabah, Shiraz A; Chan, Newton K; Skinner, John A; Hart, Alister J
Background and purpose In patients with metal-on-metal (MoM) hip prostheses, pain and joint effusions may be associated with elevated blood levels of cobalt and chromium ions. Since little is known about the kinetics of metal ion clearance from the body and the rate of resolution of elevated blood ion levels, we examined the time course of cobalt and chromium ion levels after revision of MoM hip replacements. Patients and methods We included 16 patients (13 female) who underwent revision of a painful MoM hip (large diameter, modern bearing) without fracture or infection, and who had a minimum of 4 blood metal ion measurements over an average period of 6.1 (0–12) months after revision. Results Average blood ion concentrations at the time of revision were 22 ppb for chromium and 43 ppb for cobalt. The change in ion levels after revision surgery varied extensively between patients. In many cases, over the second and third months after revision surgery ion levels decreased to 50% of the values measured at revision. Decay of chromium levels occurred more slowly than decay of cobalt levels, with a 9% lag in return to normal levels. The rate of decay of both metals followed second-order (exponential) kinetics more closely than first-order (linear) kinetics. Interpretation The elimination of cobalt and chromium from the blood of patients who have undergone revision of painful MoM hip arthroplasties follows an exponential decay curve with a half-life of approximately 50 days. Elevated blood levels of cobalt and chromium ions can persist for at least 1 year after revision, especially in patients with high levels of exposure. PMID:24758321
Paukkeri, Erja-Leena; Korhonen, Riku; Hämäläinen, Mari; Pesu, Marko; Eskelinen, Antti; Moilanen, Teemu; Moilanen, Eeva
Introduction Hip arthroplasty is the standard treatment of a painful hip destruction. The use of modern metal-on-metal (MOM) bearing surfaces gained popularity in total hip arthroplasties during the last decade. Recently, worrisome failures due to adverse reaction to metal debris (ARMD), including pseudotumor response, have been widely reported. However, the pathogenesis of this reaction remains poorly understood. The aim of the present study was to investigate the ARMD response by flow cytometry approach. Methods Sixteen patients with a failed Articular Surface Replacement (ASR) hip prosthesis were included in the study. Samples of pseudotumor tissues collected during revision surgery were degraded by enzyme digestion and cells were typed by flow cytometry. Whole blood chromium and cobalt concentrations were analyzed with mass spectrometry before revision surgery. Results Flow cytometry analysis showed that the peri-implant pseudotumor tissue expressed two principal phenotypes, namely macrophage-dominated and T-lymphocyte-dominated response; the average portions being 54% (macrophages) and 25% (T-lymphocytes) in macrophage-dominated inflammation and 20% (macrophages) and 54% (T-lymphocytes) in T-lymphocyte-dominated response. The percentages of B-lymphocytes and granulocytes were lower in both phenotypes. Interestingly, the levels of blood chromium and cobalt were significantly higher in patients with macrophage-dominated response. Conclusions The results suggest that the adverse tissue reactions induced by MOM wear particles contain heterogeneous pathogeneses and that the metal levels are an important factor in the determination of the inflammatory phenotype. The present results support the hypothesis that higher metal levels cause cytotoxicity and tissue injury and macrophages are recruited to clear the necrotic debris. On the other hand, the adverse response developed in association with lower metal levels is T-lymphocyte-dominated and is likely to reflect
Phillips, Eual A.; Klein, Gregg R.; Cates, Harold E.; Kurtz, Steven M.; Steinbeck, Marla J.
The histology of periprosthetic tissue from metal-on-metal (MOM) hip devices has been characterized by a variety of methods. The purpose of this study was to compare and evaluate the suitability of two previously developed aseptic lymphocyte-dominated vasculitis-associated lesions (ALVAL) scoring systems for periprosthetic hip tissue responses retrieved from MOM THR systems revised for loosening. Two ALVAL scoring systems (Campbell and Oxford) were used to perform histological analysis of soft tissues from seventeen failed MOM THRs. The predominant reactions for this patient cohort were macrophage infiltration and necrosis, with less than half of the patients (41%) showing a significant lymphocytic response or a high ALVAL reaction (6%). Other morphological changes which varied among patients included hemosiderin accumulation, cartilage formation and heterotopic ossification. Both scoring systems correlated with macrophage and lymphocyte responses and with each other, however given the diversity and variability of the current responses the Oxford-ALVAL system was more suitable for scoring tissues from MOM THR patients revised for loosening. It is important that standardized methods to score MOM tissue responses be used consistently so multiple study results can be compared to one another and a consensus can be generated. PMID:24941402
Levy, Yadin D; Ezzet, Kace A
Metal-on-metal (MoM) bearings for total hip arthroplasty (THA) have come under scrutiny with reports of high failure rates. Clinical outcome studies with several commercially available MoM THA bearings remain unreported. We evaluated 78 consecutive MoM THAs from a single manufacturer in 68 patients. Sixty-six received cobalt-chrome (CoCr) monoblock and 12 received modular titanium acetabular cups with internal CoCr liners. Femoral components were titanium with modular necks. At average 2.1 years postoperatively, 12 THAs (15.4%) demonstrated aseptic failure (10 revisions, 2 revision recommended). All revised hips demonstrated capsular necrosis with positive histology reaction for aseptic lymphocytic vasculitis-associated lesions/adverse local tissue reactions. Prosthetic instability following revision surgery was relatively common. Female gender was a strong risk factor for failure, though smaller cups were not. Both monoblock and modular components fared poorly. Corrosion was frequently observed around the proximal and distal end of the modular femoral necks.
Krishnan, Harry; Magnussen, Alex; Sharma, Aadhar; Skinner, John
Due to their improved wear rates, Metal-on-metal bearings have been increasingly used in the past decade by orthopaedic surgeons carrying out total hip arthroplasty. However there is increasing evidence that there are significant complications associated with such implants. One well documented complication is that of metallic debris leading to pseudotumour formation, however there is less known about associations with other tumours within the pelvis. We present two cases where an intra-pelvic mass in patients with metal-on-metal implants were diagnosed as being of a different aetiology. This highlights the need for careful assessment of such patients in order to guide appropriate management. PMID:25560054
Brown, Christopher; Williams, Sophie; Tipper, Joanne L; Fisher, John; Ingham, Eileen
The failure of metal on polyethylene total hip replacements due to wear particle induced osteolysis and late aseptic loosening has focused interest upon alternative bearings, such as metal on metal implants. A recent advance in this field has been the development of a novel ceramic on metal implant. The characteristics of the wear particles generated in this low-wearing bearing have not been previously determined. The aims of this study were to characterise metal wear particles from metal on metal and ceramic on metal hips under standard and adverse (microseparation) wear conditions. Accurate characterisation of cobalt-chrome wear particles is difficult since the reactive nature of the particles prevents them from being isolated using acids and bases. A method was developed to isolate the metal wear particles using enzymes to digest serum containing lubricants from metal on metal and ceramic on metal hip simulations. High resolution scanning electron microscopy was then used to characterise the wear particles generated by both metal on metal and ceramic on metal implants under standard and microseparation wear conditions. The wear particles isolated from all simulations had a mean size of less than 50 nm with a rounded and irregular morphology. No significant difference was found between the size of wear particles generated under any conditions.
St John, Kenneth R; Zardiackas, Lyle D; Poggie, Robert A
Wear of the polyethylene in total joint prostheses has been a source of morbidity and early device failure, which has been extensively reported in the last 20 years. Although research continues to attempt to reduce the wear of polyethylene joint-bearing surfaces by modifications in polymer processing, there is a renewed interest in the use of metal-on-metal bearing couples for hip prostheses. Wear testing of total hip replacement systems involving the couple of metal or ceramic heads on polymeric acetabular components has been performed and reported, but, until recently, there has been little data published for pin-on-disk or hip-simulator wear studies involving the combination of a metallic femoral head component with an acetabular cup composed of the same or a dissimilar metal. This study investigated the in vitro wear resistance of two cobalt/chromium/molybdenum alloys, which differed primarily in the carbon content, as potential alloys for use in a metal-on-metal hip-bearing couple. The results of pin-on-disk testing showed that the alloy with the higher (0.25%) carbon content was more wear resistant, and this alloy was therefore chosen for testing in a hip-simulator system, which modeled the loads and motions that might be exerted clinically. Comparison of the results of metal-on-polyethylene samples to metal-on-metal samples showed that the volumetric wear of the metal-on-polyethylene bearing couple after 5,000,000 cycles was 110-180 times that for the metal-bearing couple. Polyethylene and metal particles retrieved from either the lubricant for pin-on-disk testing or hip simulator testing were characterized and compared with particles retrieved from periprosthetic tissues by other researchers, and found to be similar. Based upon the results of this study, metal-on-metal hip prostheses manufactured from the high carbon cobalt/chromium alloy that was investigated hold sufficient promise to justify human clinical trials.
Mathew, M T; Nagelli, C; Pourzal, R; Fischer, A; Laurent, M P; Jacobs, J J; Wimmer, M A
The demand for total hip replacement (THR) surgery is increasing in the younger population due to faster rehabilitation and more complete restoration of function. Up to 2009, metal-on-metal (MoM) hip joint bearings were a popular choice due to their design flexibility, post-operative stability and relatively low wear rates. The main wear mechanisms that occur along the bearing surface of MoM joints are tribochemical reactions that deposit a mixture of wear debris, metal ions and organic matrix of decomposed proteins known as a tribolayer. No in-depth electrochemical studies have been reported on the structure and characteristics of this tribolayer or about the parameters involved in its formation. In this study, we conducted an electrochemical investigation of different surfaces (bulk-like: control, nano-crystalline: new implant and tribolayer surface: retrieved implant) made out of two commonly used hip CoCrMo alloys (high-carbon and low-carbon). As per ASTM standard, cyclic polarization tests and electrochemical impedance spectroscopy tests were conducted. The results obtained from electrochemical parameters for different surfaces clearly indicated a reduction in corrosion for the tribolayer surface (Icorr: 0.76μA/cm(2)). Further, polarization resistance (Rp:2.39±0.60MΩ/cm(2)) and capacitance (Cdl:15.20±0.75μF/cm(2)) indicated variation in corrosion kinetics for the tribolayer surface, that attributed to its structure and stability in a simulated body environment. © 2013 Elsevier Ltd. All rights reserved.
Ward, William G; Carter, Christina J; Barone, Marisa; Jinnah, Riyaz
Multiple factors regarding surgical procedures and patient selection affect hospital staffing needs as well as hospital revenues. In order to better understand the potential impact on hospitals that hip arthroplasty device selection (standard total hip arthroplasty vs. resurfacing) creates, a review of all primary hip arthroplasties performed at one institution was designed to identify factors that impacted hospital staffing needs and revenue generation. All primary hip arthroplasties undertaken over three fiscal years (2008 to 2010) were reviewed, utilizing only hospital business office data and medical records data that had been previously extracted prior for billing purposes. Analysis confirmed differing demographics for two hip arthroplasty populations, with the resurfacing patients (compared to the conventional total hip arthroplasty population) consisting of younger patients (mean age, 50 vs. 61 years), who were more often male (75% vs. 45%), were more likely to have osteoarthritis as their primary diagnosis (83 vs. 67%) and were more often covered by managed care or commercial insurance (83 vs. 34%). They also had shorter hospital stays (mean length of stay, 2.3 vs. 4.1 days) and consequently provided a more favorable financial revenue stream to the hospital on a per patient basis. Several trends appeared during the study periods. There was a steady increase in all procedures in all groups except for the resurfacings, which decreased 26% in males and 53% in females between 2009 and 2010. Differences were observed in the demographics of patients presenting for resurfacing, compared to those presenting for conventional total hip arthroplasty. In addition to the revenue stream considerations, institutions undertaking a resurfacing program must commit the resources and planning in order to rehabilitate these patients more expeditiously than is usually required with conventional hip arthroplasty patients.
Murray, D W; Grammatopoulos, G; Pandit, H; Gundle, R; Gill, H S; McLardy-Smith, P
Recent events have highlighted the importance of implant design for survival and wear-related complications following metal-on-metal hip resurfacing arthroplasty. The mid-term survival of the most widely used implant, the Birmingham Hip Resurfacing (BHR), has been described by its designers. The aim of this study was to report the ten-year survival and patient-reported functional outcome of the BHR from an independent centre. In this cohort of 554 patients (646 BHRs) with a mean age of 51.9 years (16.5 to 81.5) followed for a mean of eight years (1 to 12), the survival and patient-reported functional outcome depended on gender and the size of the implant. In female hips (n = 267) the ten-year survival was 74% (95% confidence interval (CI) 83 to 91), the ten-year revision rate for pseudotumour was 7%, the mean Oxford hip score (OHS) was 43 (SD 8) and the mean UCLA activity score was 6.4 (SD 2). In male hips (n = 379) the ten-year survival was 95% (95% CI 92.0 to 97.4), the ten-year revision rate for pseudotumour was 1.7%, the mean OHS was 45 (SD 6) and the mean UCLA score was 7.6 (SD 2). In the most demanding subgroup, comprising male patients aged < 50 years treated for primary osteoarthritis, the survival was 99% (95% CI 97 to 100). This study supports the ongoing use of resurfacing in young active men, who are a subgroup of patients who tend to have problems with conventional THR. In contrast, the results in women have been poor and we do not recommend metal-on-metal resurfacing in women. Continuous follow-up is recommended because of the increasing incidence of pseudotumour with the passage of time.
Anwander, H.; Cron, G. O.; Rakhra, K.
Objectives Hips with metal-on-metal total hip arthroplasty (MoM THA) have a high rate of adverse local tissue reactions (ALTR), often associated with hypersensitivity reactions. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) measures tissue perfusion with the parameter Ktrans (volume transfer constant of contrast agent). Our purpose was 1) to evaluate the feasibility of DCE-MRI in patients with THA and 2) to compare DCE-MRI in patients with MoM bearings with metal-on-polyethylene (MoP) bearings, hypothesising that the perfusion index Ktrans in hips with MoM THA is higher than in hips with MoP THA. Methods In this pilot study, 16 patients with primary THA were recruited (eight MoM, eight MoP). DCE-MRI of the hip was performed at 1.5 Tesla (T). For each patient, Ktrans was computed voxel-by-voxel in all tissue lateral to the bladder. The mean Ktrans for all voxels was then calculated. These values were compared with respect to implant type and gender, and further correlated with clinical parameters. Results There was no significant difference between the two bearing types with both genders combined. However, dividing patients by THA bearing and gender, women with MoM bearings had the highest Ktrans values, exceeding those of women with MoP bearings (0.067 min−1 versus 0.053 min−1; p-value < 0.05) and men with MoM bearings (0.067 min−1 versus 0.034 min−1; p-value < 0.001). Considering only the men, patients with MoM bearings had lower Ktrans than those with MoP bearings (0.034 min−1 versus 0.046 min−1; p < 0.05). Conclusion DCE-MRI is feasible to perform in tissues surrounding THA. Females with MoM THA show high Ktrans values in DCE-MRI, suggesting altered tissue perfusion kinematics which may reflect relatively greater inflammation. Cite this article: Dr P. E. Beaule. Perfusion MRI in hips with metal-on-metal and metal-on-polyethylene total hip arthroplasty: A pilot stud. Bone Joint Res 2016;5:73–79. DOI: 10
McKellop, Harry A; Hart, Alister; Park, Sang-Hyun; Hothi, Harry; Campbell, Pat; Skinner, John A
Research on metal-on-metal (MoM) hip bearings has generated an extensive vocabulary to describe the wear processes and resultant surface damage. However, a lack of consistency and some redundancy exist in the current terminology. To facilitate the understanding of MoM tribology and to enhance communication of results among researchers and clinicians, we propose four categories of wear terminology: wear modes refer to the in vivo conditions under which the wear occurred; wear mechanisms refer to fundamental wear processes (adhesion, abrasion, fatigue, and tribochemical reactions); wear damage refers to the resultant changes in the morphology and/or composition of the surfaces; and wear features refer to the specific wear phenomena that are described in terms of the relevant modes, mechanisms, and damage. Clarifying examples are presented, but it is expected that terms will be added to the lexicon as new mechanisms and types of damage are identified. Corrosion refers to electrochemical processes that can remove or add material and thus also generate damage. Corrosion can act alone or may interact with mechanical wear. Examples of corrosion damage are also presented. However, an in-depth discussion of the many types of corrosion and their effects is beyond the scope of the present wear lexicon.
Robinson, Elizabeth; Henckel, Johann; Sabah, Shiraz; Satchithananda, Keshthra; Skinner, John; Hart, Alister
Background and purpose — Metal artifact reduction sequence (MARS) MRI is widely advocated for surveillance of metal-on-metal hip arthroplasties (MOM-HAs). However, its use is limited by susceptibility artifact at the prosthesis-bone interface, local availability, patient compliance, and cost (Hayter et al. 2011a). We wanted to determine whether CT is a suitable substitute for MARS MRI in evaluation of the painful MOM-HA. Patients and methods — 50 MOM-HA patients (30 female) with unexplained painful prostheses underwent MARS MRI and CT imaging. 2 observers who were blind regarding the clinical data objectively reported the following outcomes: soft tissue lesions (pseudotumors), muscle atrophy, and acetabular and femoral osteolysis. Diagnostic test characteristics were calculated. Results — Pseudotumor was diagnosed in 25 of 50 hips by MARS MRI and in 11 of 50 by CT. Pseudotumors were classified as type 1 (n = 2), type 2A (n = 17), type 2B (n = 4), and type 3 (n = 2) by MARS MRI. CT did not permit pseudotumor classification. The sensitivity of CT for diagnosis of pseudotumor was 44% (95% CI: 25–65). CT had “slight” agreement with MARS MRI for quantification of muscle atrophy (κ = 0.23, CI: 0.16–0.29; p < 0.01). Osteolysis was identified in 15 of 50 patients by CT. 4 of these lesions were identified by MARS MRI. Interpretation — CT was found to be superior to MRI for detection of osteolysis adjacent to MOM-HA, and should be incorporated into diagnostic algorithms. CT was unable to classify and failed to detect many pseudotumors, and it was unreliable for assessment of muscle atrophy. Where MARS MRI is contraindicated or unavailable, CT would be an unsuitable substitute and other modalities such as ultrasound should be considered PMID:25267500
Hartmann, Albrecht; Hannemann, Franziska; Lützner, Jörg; Seidler, Andreas; Drexler, Hans; Günther, Klaus-Peter; Schmitt, Jochen
The use of metal-on-metal (MoM) total hip arthroplasty (THA) increased in the last decades. A release of metal products (i.e. particles, ions, metallo-organic compounds) in these implants may cause local and/or systemic adverse reactions. Metal ion concentrations in body fluids are surrogate measures of metal exposure. To systematically summarize and critically appraise published studies concerning metal ion concentrations after MoM THA. Systematic review of clinical trials (RCTs) and epidemiological studies with assessment of metal ion levels (cobalt, chromium, titanium, nickel, molybdenum) in body fluids after implantation of metalliferous hip replacements. Systematic search in PubMed and Embase in January 2012 supplemented by hand search. Standardized abstraction of pre- and postoperative metal ion concentrations stratified by type of bearing (primary explanatory factor), patient characteristics as well as study quality characteristics (secondary explanatory factors). Overall, 104 studies (11 RCTs, 93 epidemiological studies) totaling 9.957 patients with measurement of metal ions in body fluids were identified and analyzed. Consistently, median metal ion concentrations were persistently elevated after implantation of MoM-bearings in all investigated mediums (whole blood, serum, plasma, erythrocytes, urine) irrespective of patient characteristics and study characteristics. In several studies very high serum cobalt concentrations above 50 µg/L were measured (detection limit typically 0.3 µg/L). Highest metal ion concentrations were observed after treatment with stemmed large-head MoM-implants and hip resurfacing arthroplasty. Due to the risk of local and systemic accumulation of metallic products after treatment with MoM-bearing, risk and benefits should be carefully balanced preoperatively. The authors support a proposed "time out" for stemmed large-head MoM-THA and recommend a restricted indication for hip resurfacing arthroplasty. Patients with implanted Mo
Akrawi, Hawar; Hossain, Fahad S; Niculescu, Stefan; Hashim, Zaid; Ng, Arron Biing; Shetty, Ajit
Background: Despite the many perceived benefits of metal-on-metal (MoM) articulation in total hip arthroplasty (THA), there have been growing concerns about metallosis and adverse reaction to metal debris (ARMD). Analysis of size 36 mm MoM articulation THAs is presented. These patients were evaluated for patient characteristics, relationship between blood metal ions levels and the inclination as well as the version of acetabular component, cumulative survival probability at final followup and functional outcome at final followup. Materials and Methods: 288, size 36 mm MoM THAs implanted in 269 patients at our institution from 2004 to 2010 were included in this retrospective study. These patients were assessed clinically for hip symptoms, perioperative complications and causes of revision arthroplasty were analysed. Biochemically, blood cobalt and chromium metal ions level were recorded and measurements of acetabular inclination and version were examined. Radiological evaluation utilizing Metal Artefact Reduction Sequence (MARS) MRI was undertaken and implant cumulative survivorship was evaluated. Results: The mean followup was 5 years (range 2–7 years), mean age was 73 years and the mean Oxford hip score was 36.9 (range 5–48). Revision arthroplasty was executed in 20 (7.4%) patients, of which 15 patients underwent single-stage revision THA. The causes of revision arthroplasty were: ARMD changes in 6 (2.2%) patients, infection in 5 (1.9%) patients and aseptic loosening in 5 (1.9%) patients. Three (1.1%) patients had their hips revised for instability, 1 (0.3%) for raised blood metal ions levels. The implant cumulative survival rate, with revision for any reason, was 68.9% at 7 years. Conclusions: Although medium-sized MoM THA with a 36 mm head has a marginally better survivorship at midterm followup, compared to larger size head MoM articulating THA, our findings nonetheless are still worryingly poor in comparison to what has been quoted in the literature
Liu, F; Jin, Z M; Hirt, F; Rieker, C; Roberts, P; Grigoris, P
The effect of geometry change of the bearing surfaces owing to wear on the elastohydrodynamic lubrication (EHL) of metal-on-metal (MOM) hip bearings has been investigated theoretically in the present study. A particular MOM Metasul bearing (Zimmer GmbH) was considered, and was tested in a hip simulator using diluted bovine serum. The geometry of the worn bearing surface was measured using a coordinate measuring machine (CMM) and was modelled theoretically on the assumption of spherical geometries determined from the maximum linear wear depth and the angle of the worn region. Both the CMM measurement and the theoretical calculation were directly incorporated into the elastohydrodynamic lubrication analysis. It was found that the geometry of the original machined bearing surfaces, particularly of the femoral head with its out-of-roundness, could lead to a large reduction in the predicted lubricant film thickness and an increase in pressure. However, these non-spherical deviations can be expected to be smoothed out quickly during the initial running-in period. For a given worn bearing surface, the predicted lubricant film thickness and pressure distribution, based on CMM measurement, were found to be in good overall agreement with those obtained with the theoretical model based on the maximum linear wear depth and the angle of the worn region. The gradual increase in linear wear during the running-in period resulted in an improvement in the conformity and consequently an increase in the predicted lubricant film thickness and a decrease in the pressure. For the Metasul bearing tested in an AMTI hip simulator, a maximum total linear wear depth of approximately 13 microm was measured after 1 million cycles and remained unchanged up to 5 million cycles. This resulted in a threefold increase in the predicted average lubricant film thickness. Consequently, it was possible for the Metasul bearing to achieve a fluid film lubrication regime during this period, and this was
Patange Subbarao, Sheethal Prasad; Malek, Ibrahim A.; Mohanty, Khitish; Thomas, Phillip; John, Alun
Based on success of hip resurfacing, large head Metal on Metal (MoM) hip arthroplasty has gained significant popularity in recent years. There are growing concerns about metal ions related soft tissue abnormalities. The aim of this study was to define a correlation of metal ions with various functional outcome scores following large head MoM hip arthroplasty. Consecutive cohort of 70 patients (76 hips) with large head MoM hip arthroplasty using SL-Plus femoral stem and Cormet acetabular component were prospectively followed up. An independent observer assessed the patients which included serology for metal ion levels and collection of Oxford Hip, Harris hip, WOMAC, SF-36 & modified UCLA scores. Median serum cobalt and chromium levels were 3.10 μg/L (0.35–62.92) and 4.21 μg/L (0.73–69.27) with total of median 7.30 μg/L (2.38–132.19). The median Oxford, Harris, WOMAC, SF-36 and modified UCLA scores were 36 (6–48), 87 (21–100), 36 (24–110), 104 (10–125), and 3 (1–9), respectively. Seventeen patients had elevated serum cobalt and chromium levels ≥7 μg/L. There was no significant correlation between serum metal ion levels with any of these outcome scores. We recommend extreme caution during follow up of these patients with large head MoM arthroplasty. PMID:24959353
Carli, Alberto; Reuven, Avishai; Zukor, David J; Antoniou, John
Adverse local soft-tissue reactions have been associated with severe osteolysis and implant failure in metal-on-metal total hip arthroplasty (THA). Such a causal relationship has not often been associated with non metal-on-metal bearing surfaces. The purpose of this study was to assess the literature for cases of adverse soft-tissue reactions in non-metal-on-metal bearings in order to determine if a consistent histological diagnosis existed and if it was bearing-specific. A systematic review was performed in Medline and Embase databases, utilizing keyword searches to target reports of soft tissue complications following THA. Strict exclusion criteria were applied to retrieved studies in order to ensure that analyzed papers involved non-metal-on-metal bearing surfaces, had a final histological diagnosis, and had no previous history of periprosthetic infection or neoplastic process. Presenting symptoms, diagnostic work-up, histological diagnosis, and operative treatment were recorded for all reports retained for analysis. Twenty-seven reports representing 31 cases of adverse soft-tissue reactions for non-metal-on-metal THAs met the criteria for analysis. In the majority of cases, patients presented with painful, limited motion in the affected hip, and radiological evidence of severe osteolysis. Histological examination often revealed a cystic mass, denoted by a granulomatous reaction comprised of histiocytes and giant cells, but few plasma cells. Revision of loose components was the most common successful therapeutic strategy utilized. The present analysis revealed that similar adverse soft-tissue reactions have been described for both metal-on-polyethylene and ceramic bearing surfaces. When encountering such reactions in patients, a comprehensive diagnostic workup, including computed tomography (CT) scanning, lesion biopsy, and revision planning to alternate bearing surfaces should be considered.
Lee, Reginald K; Nevelos, Jim; Vigdorchik, Jonathan; Markel, David C
Metal-on-metal bearings have had popularity that has waxed and waned over the years. The advantages realized relative to wear resistance and strength had been offset by early failures, manufacturing difficulty, and most recently by adverse soft tissue responses to the metallic debris. The bearing's history, evolution, advantages and disadvantages will be discussed in attempt to answer the question: is metal-on-metal a passing fancy?
Daniel, Joseph; Ziaee, Hena; Pradhan, Chandra; Pynsent, Paul B; McMinn, Derek J W
A concern regarding the use of metal-on-metal bearings in hip arthroplasty has been that the high levels of metal ions that are released overwhelm the renal threshold for metal excretion, leading to systemic buildup of metals. The purpose of this investigation was to determine if the physiological renal capacity for cobalt clearance and cobalt concentrating efficiency is overwhelmed by the elevation in metal ion levels seen in patients with metal-on-metal-bearing hip devices. Concurrent specimens of urine and plasma were obtained from a group of 461 patients (346 men and 115 women) at various intervals after either a unilateral (296) or a bilateral (130) metal-on-metal hip arthroplasty or preoperatively (thirty-five patients; the control specimens). Metal ion analyses were performed with high-resolution inductively coupled mass spectrometry. Renal efficiency was measured as the ratio of urine cobalt concentration to plasma cobalt concentration. Cobalt clearance was calculated by dividing the urine cobalt output in twenty-four hours by the plasma cobalt concentration. Dividing the quotient by 1440 adjusts it to clearance per minute. The median renal efficiency was found to be 0.9 in the analysis of the preoperative specimens, indicating that there was renal conservation of cobalt. In patients with metal-on-metal bearings, the median renal efficiency was 3.2, indicating that, as a result of cobalt excretion, the cobalt concentration in urine was threefold higher than the concentration in plasma. Linear regression analysis showed that renal efficiency progressively increased at a rate of 9% for every microg/24 hr increase in cobalt release. Cobalt clearance showed a similar trend, increasing from 1.3 mL/min in the preoperative group to 3.7 mL/min in the follow-up group. In the follow-up group, renal cobalt clearance progressively increased from 1.9 to 7.1 mL/min with increasing daily cobalt output, which indicates that with increasing in vivo metal ion release there
The influence of carbon (C) content, microstructure, crystallography and mechanical properties on the wear behaviour of metal-on-metal (MM) hip implants made from commercially available cobalt-chromium-molybdenum (CoCrMo) alloys designated as American Society of Testing and Materials (ASTM) grade F1537, F75 and as-cast were studied in this work. The as-received bars of wrought CoCrMo alloys (ASTM F1537 of either about 0.05% or 0.26% C) were each subjected to various heat treatments to develop different microstructures. Pin and plate specimens were fabricated from each bar and were tested against each other using a linear reciprocating pin-on-plate apparatus in 25% by volume bovine serum solution. The applied normal load was 9.81 N and the reciprocating plate had a sinusoidal velocity with an average speed of 26 mm/s. The wear was measured gravimetrically and it was found to be most strongly affected by alloy C content, irrespective of grain size or carbide morphology. More precisely, the wear behaviour was directly correlated to the dissolved C content of the alloys. Increased C in solid-solution coincided with lower volumetric wear since C helps to stabilize the face-centred cubic (FCC) crystal structure thus limiting the amount of strain induced transformation (SIT) to the hexagonal close-packed crystal structure (HCP). Based on the observed surface twinning in and around the contact zone and the potentially detrimental effect of the HCP phase, it was postulated that the MM wear behaviour of CoCrMo alloys in the present study was controlled by a deformation mechanism, rather than corrosion or tribochemical reactions.
Jagatia, M; Jin, Z M
Elastohydrodynamic lubrication (EHL) analysis was carried out in this study for a novel metal-on-metal hip prosthesis, which consists of a cobalt-chrome alloy femoral head articulating against a cobalt-chrome alloy acetabular insert connected to a titanium fixation shell through a taper. Finite element models were developed to investigate the effect of the pelvic bone and the load on the predicted contact pressure distribution between the two bearing surfaces under dry conditions. The finite element method was used to develop elasticity models for both the femoral and the acetabular components; it was found that the elastic deformation of the acetabular insert was mainly dependent on the load, rather than the detailed pressure distribution. A modified solution methodology was accordingly developed to couple the elasticity models for both the femoral and the acetabular surfaces with the Reynolds equation and to solve these numerically by the finite difference method. It was found that a load increase from 500 to 2500 N had a negligible effect on the predicted maximum contact pressure and the minimum film thickness, due to the relatively flexible and accommodating structure of the acetabular insert. Furthermore, the predicted minimum film thickness was shown to be significantly greater than the simple estimation based on the assumption of semi-infinite solids (mono-block design) using the Hamrock and Dowson formula. The effects of the viscosity of the lubricant and the radial clearance between the femoral and the acetabular components on the predicted lubricating film thickness were investigated under both in vitro simulator testing and in vivo walking conditions.
Lord, James K.; Langton, David J.; Nargol, Antoni V.F.; Meek, R.M. Dominic; Joyce, Thomas J.
A recognized issue related to metal-on-metal hip resurfacings is early fracture of the femur. Most theories regarding the cause of fracture relate to clinical factors but an engineering analysis of failed hip resurfacings has not previously been reported. The objective of this work was to determine the wear volumes and surface roughness values of a cohort of retrieved hip resurfacings which were removed due to early femoral fracture, infection and avascular necrosis (AVN). Nine resurfacing femoral heads were obtained following early fracture of the femur, a further five were retrieved due to infection and AVN. All fourteen were measured for volumetric wear using a co-ordinate measuring machine. Wear rates were then calculated and regions of the articulating surface were divided into “worn” and “unworn”. Roughness values in these regions were measured using a non-contacting profilometer. The mean time to fracture was 3.7 months compared with 44.4 months for retrieval due to infection and AVN. Average wear rates in the early fracture heads were 64 times greater than those in the infection and AVN retrievals. Given the high wear rates of the early fracture components, such wear may be linked to an increased risk of femoral neck fracture. PMID:26501331
Lord, James K; Langton, David J; Nargol, Antoni V F; Meek, R M Dominic; Joyce, Thomas J
A recognized issue related to metal-on-metal hip resurfacings is early fracture of the femur. Most theories regarding the cause of fracture relate to clinical factors but an engineering analysis of failed hip resurfacings has not previously been reported. The objective of this work was to determine the wear volumes and surface roughness values of a cohort of retrieved hip resurfacings which were removed due to early femoral fracture, infection and avascular necrosis (AVN). Nine resurfacing femoral heads were obtained following early fracture of the femur, a further five were retrieved due to infection and AVN. All fourteen were measured for volumetric wear using a co-ordinate measuring machine. Wear rates were then calculated and regions of the articulating surface were divided into "worn" and "unworn". Roughness values in these regions were measured using a non-contacting profilometer. The mean time to fracture was 3.7 months compared with 44.4 months for retrieval due to infection and AVN. Average wear rates in the early fracture heads were 64 times greater than those in the infection and AVN retrievals. Given the high wear rates of the early fracture components, such wear may be linked to an increased risk of femoral neck fracture.
Porat, Manny; Parvizi, Javad; Sharkey, Peter F; Berend, Keith R; Lombardi, Adolph V; Barrack, Robert L
Few large series of hard bearing surfaces have reported on reasons for early failure. A number of unique mechanisms of failure, including fracture, squeaking, and adverse tissue reactions, have been reported with these hard bearing surfaces. However, the incidence varies among the published studies. To confirm the incidences, we identified the etiologies of early failures of hard-on-hard bearing surfaces for ceramic-on-ceramic and metal-on-metal THAs. We retrospectively reviewed records of 2907 THAs with hard-on-hard bearing surfaces implanted between 1996 and 2009; 1697 (58%) had ceramic-on-ceramic and 1210 (42%) had metal-on-metal bearing surfaces. We recorded bearing-related complications and compared them to nonspecific reasons for revision THA. The minimum followup of the ceramic-on-ceramic and metal-on-metal cohorts was 6 months (mean, 48 months; range, 6-97 months) and 24 months (mean, 60 months; range, 24-178 months), respectively. The overall revision rate for ceramic-on-ceramic THA was 2.2% (38 of 1697), with aseptic loosening accounting for 55% of revisions (femur or acetabulum). The bearing accounted for 13% of the revisions in the ceramic-on-ceramic THA cohort. The overall metal-on-metal revision rate was 5.4% (65 of 1210), 17 involving adverse tissue reactions related to the metal-on-metal bearing surface (17 of 1210, 1.4% of cases; 17 of 65, 26% of revisions). Twenty-six percent of the revisions from metal-on-metal and 13% of ceramic-on ceramic were bearing related. The overall short- to medium-term revision rate was 2.2% and 5.4% for ceramic-on-ceramic and metal-on-metal, respectively. The most common etiology of failure was loosening of the femoral or acetabular components. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of level of evidence.
Renner, Lisa; Schmidt-Braekling, Tom; Faschingbauer, Martin; Boettner, Friedrich
Serum metal ions are part of the regular follow-up routine of patients with metal-on-metal total hip arthroplasties (MoM-THA). Increased cobalt levels have been suggested to indicate implant failure and corrosion. (1) Is there a correlation between the size of the osteolysis measured on a CT scan and metal ion levels? (2) Can metal ion levels predict the presence of osteolysis in MoM-THA? (3) Are cobalt and chromium serum levels or the cobalt-chromium-ratio diagnostic for osteolysis? CT scans of patients (n = 75) with a unilateral MoM-THA (Birmingham Hip System, Smith & Nephew, TN, USA) implanted by a single surgeon were reviewed to determine the presence of osteolysis. Statistical analysis was performed to detect its association with metal ion levels at the time of the imaging exam. The incidence of osteolysis was the same in men and women (35.6 vs 35.7 %). The cobalt-chromium-ratio correlates with the size of the osteolysis on the CT scan and the femoral component size in the overall study population (p = 0.050, p = 0.001) and in men (p = 0.002, p = 0.001) but not in women (p = 0.312, p = 0.344). The AUC for the cobalt-chromium-ratio to detect osteolysis was 0.613 (p = 0.112) for the overall population, 0.710 for men (p = 0.021) and 0.453 (p = 0.684) for women. The data suggest that a cut off level of 1.71 for the cobalt-chromium-ratio has a sensitivity of 62.5 % and specificity of 72.4 % to identify male patients with osteolysis. The disproportional increase of cobalt over chromium, especially in male patients with large component sizes can not be explained by wear alone and suggests that other processes (corrosion) might contribute to metal ion levels and might be more pronounced in patients with larger component sizes.
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Hip joint femoral (hemi-hip) metallic resurfacing... HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES Prosthetic Devices § 888.3400 Hip joint femoral (hemi-hip) metallic resurfacing prosthesis. (a) Identification. A hip joint femoral...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Hip joint femoral (hemi-hip) metallic resurfacing... HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES Prosthetic Devices § 888.3400 Hip joint femoral (hemi-hip) metallic resurfacing prosthesis. (a) Identification. A hip joint femoral...
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Hip joint femoral (hemi-hip) metallic resurfacing... HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES Prosthetic Devices § 888.3400 Hip joint femoral (hemi-hip) metallic resurfacing prosthesis. (a) Identification. A hip joint femoral...
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Hip joint femoral (hemi-hip) metallic resurfacing... HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES Prosthetic Devices § 888.3400 Hip joint femoral (hemi-hip) metallic resurfacing prosthesis. (a) Identification. A hip joint femoral...
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Hip joint femoral (hemi-hip) metallic resurfacing... HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ORTHOPEDIC DEVICES Prosthetic Devices § 888.3400 Hip joint femoral (hemi-hip) metallic resurfacing prosthesis. (a) Identification. A hip joint femoral...
Panotopoulos, Joannis; Ay, Cihan; Schuh, Reinhard; Domayer, Stephan; Funovics, Philipp; Trieb, Klemens; Wanivenhaus, Hugo; Windhager, Reinhard
We report the results of a consecutive series of 12 cases with haemophilic hip arthropathy treated with uncemented total hip arthroplasty (THA). Our hypothesis was that THA results in the haemophilic group would be inferior to those in the nonhaemophilic group. The clinical histories of 12 consecutive THAs in eight patients (all men) with hereditary bleeding disorders (haemophilia A and B and von Willebrand disease) were reviewed retrospectively. The results were compared with an age- and sex-matched control group without haemophilia, with special emphasis on bearing surfaces (Metasul metal-on-metal; polyethylene-ceramic articulation). The mean follow-up of the control group was 9.7 (range five to 24) years and was similar to the haemophilia group, with 10.4. Survival in the Metasul haemophilic group was 22.2 % after 18 years, which significantly differed from the Metasul control group (100 % after 24 years). Survival of the polyethylene-ceramic haemophilic group was similar to the control group (100 % after seven years in both groups). The metal-on-metal bearing surface in patients with haemophilia gave inferior results compared with nonhaemophilic patients. The use of metal-on-metal bearings in haemophilia is debatable.
Pedersen, Alma B; Mäkelä, Keijo; Eskelinen, Antti; Havelin, Leif Ivar; Furnes, Ove; Kärrholm, Johan; Garellick, Göran; Overgaard, Søren
Background and purpose Data from the national joint registries in Australia and England and Wales have revealed inferior medium-term survivorship for metal-on-metal (MoM) total hip arthroplasty (THA) than for metal-on-polyethylene (MoP) THA. Based on data from the Nordic Arthroplasty Register Association (NARA), we compared the revision risk of cementless stemmed THA with MoM and MoP bearings and we also compared MoM THA to each other. Patients and methods We identified 32,678 patients who were operated from 2002 through 2010 with cementless stemmed THA with either MoM bearings (11,567 patients, 35%) or MoP bearings (21,111 patients, 65%). The patients were followed until revision, death, emigration, or the end of the study period (December 31, 2011), and median follow-up was 3.6 (interquartile range (IQR): 2.4–4.8) years for MoM bearings and 3.4 (IQR: 2.0–5.8) years for MoP bearings. Multivariable regression in the presence of competing risk of death was used to assess the relative risk (RR) of revision for any reason (with 95% confidence interval (CI)). Results The cumulative incidence of revision at 8 years of follow-up was 7.0% (CI: 6.0–8.1) for MoM bearings and 5.1% (CI: 4.7–5.6) for MoP bearings. At 6 years of follow-up, the RR of revision for any reason was 1.5 (CI: 1.3–1.7) for MoM bearings compared to MoP bearings. The RR of revision for any reason was higher for the ASR (adjusted RR = 6.4, CI: 5.0–8.1), the Conserve Plus (adjusted RR = 1.7, CI: 1.1–2.5) and “other” acetabular components (adjusted RR = 2.4, CI: 1.5–3.9) than for MoP THA at 6 years of follow-up. Interpretation At medium-term follow-up, the survivorship for cementless stemmed MoM THA was inferior to that for MoP THA, and metal-related problems may cause higher revision rates for MoM bearings with longer follow-up. PMID:25715878
Reito, Aleksi; Parkkinen, Jyrki; Puolakka, Timo; Pajamäki, Jorma; Eskelinen, Antti
In vivo assessment of inflammatory responses in the synovia of patients with MoM hip replacements would be useful in the determination of the prognosis of the hip replacement. Aims of the study was to investigate the correlation between cobalt and chrome levels in joint fluid with histopathological findings and the predictive ability of metal ion levels for these findings. In 163 revision surgeries (141 ASR THAs and 22 ASR hip resurfacings) joint fluid chrome and cobalt levels were assessed and histological analysis of synovial tissues was performed. Histological analysis included assessment of histiocytes, particle load, surface necrosis, lymphocyte cuffs and ALVAL-score. Surface necrosis correlated positively with cobalt levels both in both groups. Neither chrome nor cobalt level had even fair discriminative ability to predict the presence or severity of any histological finding in the THA group. In the hip resurfacing group, cobalt level had good discriminative ability to predict the presence of perivascular lymphocytes and ALVAL-score of ≥ 7 whereas chrome had good discriminative ability to predict surface necrosis, metal particle load and ALVAL-score of ≥ 7. Measurement of metal ion levels following joint fluid aspirate offers no relevant information with regard to histopathological findings in patients with large-diameter MoM THAs. Limited information may be gained from assessment of joint fluid metal ion levels in patients with hip resurfacings, but disadvantages of an aspirate must be carefully reviewed.
Meng, Qingen; Gao, Leiming; Liu, Feng; Yang, Peiran; Fisher, John; Jin, Zhongmin
Diameter and diametral clearance of the bearing surfaces of metal-on-metal hip implants and structural supports have been recognised as key factors to reduce the dry contact and hydrodynamic pressures and improve lubrication performance. On the other hand, application of aspherical bearing surfaces can also significantly affect the contact mechanics and lubrication performance by changing the radius of the curvature of a bearing surface and consequently improving the conformity between the head and the cup. In this study, a novel metal-on-metal hip implant employing a specific aspherical bearing surface, Alpharabola, as the acetabular surface was investigated for both contact mechanics and elastohydrodynamic lubrication under steady-state conditions. When compared with conventional spherical bearing surfaces, a more uniform pressure distribution and a thicker lubricant film thickness within the loaded conjunction were predicted for this novel Alpharabola hip implant. The effects of the geometric parameters of this novel acetabular surface on the pressure distribution and lubricant thickness were investigated. A significant increase in the predicted lubricant film thickness and a significant decrease in the dry contact and hydrodynamic pressures were found with appropriate combinations of these geometric parameters, compared with the spherical bearing surface.
Vendittoli, P-A; Mottard, S; Roy, A G; Dupont, C; Lavigne, M
We evaluated the concentrations of chromium and cobalt ions in blood after metal-on-metal surface replacement arthroplasty using a wrought-forged, high carbon content chromium-cobalt alloy implant in 64 patients. At one year, mean whole blood ion levels were 1.61 microg/L (0.4 to 5.5) for chromium and 0.67 microg/L (0.23 to 2.09) for cobalt. The pre-operative ion levels, component size, female gender and the inclination of the acetabular component were inversely proportional to the values of chromium and/or cobalt ions at one year postoperatively. Other factors, such as age and level of activity, did not correlate with the levels of metal ions. We found that the levels of the ions in the serum were 1.39 and 1.37 times higher for chromium and cobalt respectively than those in the whole blood. The levels of metal ions obtained may be specific to the hip resurfacing implant and reflect its manufacturing process.
Hinsch, Andrea; Vettorazzi, Eik; Morlock, Michael M; Rüther, Wolfgang; Amling, Michael; Zustin, Jozef
Metal-on-metal hybrid hip resurfacing arthroplasty (with a cementless acetabular component and a cemented femoral component) is offered as an alternative to traditional total hip arthroplasty for the young and active adult with advanced osteoarthritis. Although it has been suggested that women are less appropriate candidates for metal-on-metal arthroplasty, the mechanisms of prosthesis failure has not been fully explained. While specific failure patterns, particularly osteonecrosis and delayed type hypersensitivity reactions have been suggested to be specifically linked to the sex of the patient, we wished to examine the potential influence of sex, clinical diagnosis, age of the patient and the size of the femoral component on morphological failure patterns in a large cohort of retrieved specimens following aseptic failure of hip resurfacing arthroplasty. Femoral remnants retrieved from 173 hips with known patient's sex were morphologically analyzed for the cause of failure. The results were compared with the control group of the remaining 31 failures from patients of unknown sex. The odds ratios (OR) and 95% confidence intervals (CI) of the following morphologically defined variables were calculated using logistic regression analysis: periprosthetic fractures (n=133), osteonecrosis (n=151), the presence of excessive intraosseous lymphocyte infiltration (n=11), and interface hyperosteoidosis (n=30). Logistic regression analysis was performed both unadjusted and after adjustment for sex, age, the size of the femoral component, and preoperative clinical diagnosis. Femoral remnants from female patients had a smaller OR for fracture (adjusted OR: 0.29, 95% CI 0.11, 0.80, P for difference=0.02) and for the presence of osteonecrosis (adjusted OR: 0.16, 95% CI 0.04, 0.63, P for difference=0.01). However, women had a higher OR for both the presence of excessive intraosseous lymphocyte infiltration (adjusted OR: 10.22, 95% CI 0.79, 132.57, P for difference=0.08) and
Hartmann, Albrecht; Hannemann, Franziska; Lützner, Jörg; Seidler, Andreas; Drexler, Hans; Günther, Klaus-Peter; Schmitt, Jochen
Introduction The use of metal-on-metal (MoM) total hip arthroplasty (THA) increased in the last decades. A release of metal products (i.e. particles, ions, metallo-organic compounds) in these implants may cause local and/or systemic adverse reactions. Metal ion concentrations in body fluids are surrogate measures of metal exposure. Objective To systematically summarize and critically appraise published studies concerning metal ion concentrations after MoM THA. Methods Systematic review of clinical trials (RCTs) and epidemiological studies with assessment of metal ion levels (cobalt, chromium, titanium, nickel, molybdenum) in body fluids after implantation of metalliferous hip replacements. Systematic search in PubMed and Embase in January 2012 supplemented by hand search. Standardized abstraction of pre- and postoperative metal ion concentrations stratified by type of bearing (primary explanatory factor), patient characteristics as well as study quality characteristics (secondary explanatory factors). Results Overall, 104 studies (11 RCTs, 93 epidemiological studies) totaling 9.957 patients with measurement of metal ions in body fluids were identified and analyzed. Consistently, median metal ion concentrations were persistently elevated after implantation of MoM-bearings in all investigated mediums (whole blood, serum, plasma, erythrocytes, urine) irrespective of patient characteristics and study characteristics. In several studies very high serum cobalt concentrations above 50 µg/L were measured (detection limit typically 0.3 µg/L). Highest metal ion concentrations were observed after treatment with stemmed large-head MoM-implants and hip resurfacing arthroplasty. Discussion Due to the risk of local and systemic accumulation of metallic products after treatment with MoM-bearing, risk and benefits should be carefully balanced preoperatively. The authors support a proposed „time out“ for stemmed large-head MoM-THA and recommend a restricted indication for hip
Figueiredo-Pina, C G; Yan, Y; Neville, A; Fisher, J
Hip simulator studies have been carried out extensively to understand and test artificial hip implants in vitro as an efficient alternative to obtaining long-term results in vivo. Recent studies have shown that a ceramic-on-metal material combination lowers the wear by up to 100 times in comparison with a typical metal-on-metal design. The reason for this reduction remains unclear and for this reason this study has undertaken simple tribometer tests to understand the fundamental material loss mechanisms in two material combinations: metal-on-metal and ceramic-on-ceramic. A simple-configuration reciprocating pin-on-plate wear study was performed under open-circuit potential (OCP) and with applied cathodic protection (CP) in a serum solution using two tribological couples: firstly, cobalt-chromium (Co-Cr) pins against Co-Cr plates; secondly, Co-Cr pins against alumina (Al2O3) plates. The pin and plate surfaces prior to and after testing were examined by profilometry and scanning electron microscopy. The results showed a marked reduction in wear when CP was applied, indicating that total material degradation under the OCP condition was attributed to corrosion processes. The substitution of the Co-Cr pin with an Al2O3 plate also resulted in a dramatic reduction in wear, probably due to the reduction in the corrosion-wear interactions between the tribological pair.
Pelt, Christopher E; Erickson, Jill; Clarke, Ian; Donaldson, Thomas; Layfield, Lester; Peters, Christopher L
Despite multiple changes in second-generation metal-on-metal hip implants, greater-than-expected revision rates have led to alarm. We hypothesized that the finding of intraoperative metallosis would be associated with a high metal load on histologic analysis and that both would be associated with increased wear, greater serum metal ion levels, and predictable biologic responses in the histologic sections. We evaluated the implant positioning, serum ion levels, intraoperative findings of metallosis, wear characteristics of retrieved implants (tribology), histology, and outcomes in a series of eighteen large-diameter metal-on-metal total hip arthroplasties. The arthroplasties were divided into two groups on the basis of the intraoperative finding of metallosis and into two groups on the basis of the metal load score. Intraoperative metallosis was not associated with a high metal load score (p = 0.15). The finding of intraoperative metallosis was associated with greater serum metal ion levels, greater wear rates, and greater complication rates. Aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) scores were similar between the metallosis and non-metallosis groups (p = 0.49) as well as between the high and low-metal-load groups (p = 0.56).
Liu, Feng; Jin, Zhongming; Roberts, Paul; Grigoris, Peter
An effective lubrication can significantly reduce wear of metal-on-metal artificial hip joints. The improvement of the lubrication can be achieved through the optimisation of the bearing geometry in terms of a small clearance and/or the structural support such as a polyethylene backing underneath a metallic bearing in a sandwich acetabular cup form. The separate effects of these two factors on fluid film lubrication of 28 mm diameter metal-on-metal total hip joints under walking conditions were numerically investigated in this paper. The results show that a larger lubricant film due to the polyethylene backing can be significantly enhanced by the transient squeeze-film action, particularly during the stance phase, and a similar lubricant film can be developed for both the monolithic cup relying on the smaller clearance and the sandwich cup benefiting from the polyethylene backing. Both cup systems can function in a wide range of lubrication regimes, covering both mixed and fluid film, under the current design and manufacture conditions.
Lainiala, Olli; Elo, Petra; Reito, Aleksi; Pajamäki, Jorma; Puolakka, Timo; Eskelinen, Antti
Background and purpose Ultrasound is used for imaging of pseudotumors associated with metal-on-metal (MoM) hips. Ultrasound has been compared with magnetic resonance imaging, but to date there have been no studies comparing ultrasound findings and revision findings. Methods We evaluated the sensitivity and specificity of preoperative ultrasound for detecting pseudotumors in 82 patients with MoM hip replacement (82 hips). Ultrasound examinations were performed by 1 of 3 musculoskeletal radiologists, and pseudotumors seen by ultrasound were retrospectively classified as fluid-filled, mixed-type, or solid. Findings at revision surgery were retrieved from surgical notes and graded according to the same system as used for ultrasound findings. Results Ultrasound had a sensitivity of 83% (95% CI: 63–93) and a specificity of 92% (CI: 82–96) for detecting trochanteric region pseudotumors, and a sensitivity of 79% (CI: 62–89) and a specificity of 94% (CI: 83–98) for detecting iliopsoas-region pseudotumors. Type misclassification of pseudotumors found at revision occurred in 8 of 23 hips in the trochanteric region and in 19 of 33 hips in the iliopsoas region. Interpretation Despite the discrepancy in type classification between ultrasound and revision findings, the presence of pseudotumors was predicted well with ultrasound in our cohort of failed MoM hip replacements. PMID:25582840
Su, Edwin P; Su, Sherwin L
Hip resurfacing has been performed for over a decade but still raises controversy as an alternative to traditional total hip arthroplasty (THA). Concerns exist about the potential complications of hip resurfacing, including femoral neck fracture and osteonecrosis of the femoral head. Recently, attention has been given to the metal-on-metal bearing of hip resurfacing with regard to production of metal ions, possible tissue necrosis, and rare instances of metal hypersensitivity. Given the success of the gold-standard THA, it is understandable why some surgeons believe metal-on-metal surface replacement to be "a triumph of hope over reason." However, this article opposes that viewpoint, demonstrating that data exist to justify the practice of preserving bone in younger patients. Hip resurfacing can maintain femoral bone without the expense of removing additional acetabular bone by using modern implants with incremental sizing. Furthermore, many of the problems cited with the bearing couple (such as excess metal production) have been due to poor implant designs, which have now been removed from the market. Finally, we now realize that the metal-on-metal articulation is more sensitive to malposition; thus, good surgical technique and experience can solve many of the problems that have been cited in the past. National registry results confirm that in a select population, hip resurfacing performs comparably to THA, while fulfilling the goal of bone preservation.
Mosier, Brian A; Maynard, Lance; Sotereanos, Nicholas G; Sewecke, Jeffrey J
Systemic cobalt toxicity is a rare complication after metal-on-metal (MOM) total hip arthroplasty. Here we present a case of progressive cardiomyopathy, as evidenced by biopsy and cardiac magnetic resonance imaging (MRI), in a patient with bilateral MOM total hip arthroplasties. To our knowledge, it is one of the first cases in which cardiomyopathy resulting from systemic cobalt disease has been shown on MRI. While there is no guideline to unequivocally diagnose cobalt cardiomyopathy, the constellation of findings, including pathologic, biologic, blood levels, imaging, and surgical, all uniformly indicate a unifying diagnosis. The lack of improvement after removal of the prosthetic device supports a diagnosis of permanent myocardial damage, which is consistent with cardiomyopathy of advanced toxic etiology.
J A Hunter, Thomas; S Moores, Thomas; Morley, David; Manoharan, Gopikanthan; G Collier, Simon; J Shaylor, Phillip
Recent controversies surrounding metal-on-metal (MoM) hip resurfacing has led to a substantial decline in its use. Despite this, there is good evidence to support the use of specific implants in select patients. A retrospective analysis of Birmingham Hip Resurfacing (BHR) patients with a minimum of 10 years follow-up was performed. Functional scoring was performed with the Oxford Hip Score (OHS) and failure was defined as revision for any cause. 111 patients underwent 121 BHR procedures. All patients had a minimum follow-up of 10 years. 70 patients (63%) were male. Mean patient age at surgery was 52.5 years (male 53.9 years, female 48.8 years). Overall survival at 10 years was 91% (97% male, 80% female). There was a statistically significant improvement in OHS postoperatively which remains at 10-year follow-up (p = <0.05). There was no significant difference in scores between the male and female groups. Revisions were most often in patients with smaller component sizes but this was not found to be statistically significant. Our results reflect that of the wider literature in that good outcomes can be obtained with this implant in a select group of patients and results are comparable to that of conventional hip arthroplasty in patients of a similar age.
Hart, Alister J; Quinn, Paul D; Sampson, Barry; Sandison, Ann; Atkinson, Kirk D; Skinner, John A; Powell, Jonathan J; Mosselmans, J Fred W
Implant-derived material from metal-on-metal (MOM) hip arthroplasties may be responsible for an unexplained tissue inflammatory response. The chemical form of the metal species in the tissues is predominantly chromium (Cr), but the currently used techniques have not been able to determine whether this is Cr(III) phosphate or Cr(III) oxide. The analytical challenge must overcome the fact that the metal in the tissues is at a relatively low concentration and tissue preparation or the microscopy beam used can affect the results. Microfocus X-ray spectroscopy using a synchrotron beam is useful in addressing both these issues. Using this technique we compared tissue from failed MOM hips with: (1) tissue from metal-on-polyethylene (MOP) hips; (2) chemical standards; (3) metal discs cut from MOM hips. The most abundant implant-related species in all MOM hip tissues contained Cr. Comparison with standards revealed the chemical form was Cr(III) phosphate, which did not vary with manufacturer type (four types analysed) or level of blood metal ions. Cobalt (Co) and molybdenum (Mo) were occasionally present in areas of high Cr. Co was normally found in a metallic state in the tissue, while Mo was found in an oxidized state. The variety of metallic species may have arisen from corrosion, wear or a combination of both. No evidence of Cr(VI) was seen in the tissues examined.
Liddle, Alexander D; Satchithananda, Keshtra; Henckel, Johann; Sabah, Shiraz A; Vipulendran, Karuniyan V; Lewis, Angus; Skinner, John A; Mitchell, Adam W M; Hart, Alister J
Operative findings during revision of metal-on-metal hip arthroplasty (MOMHA) vary widely and can involve massive soft tissue and bone disruption. As a result, planning of theater time and resources is difficult, surgery is challenging, and outcomes are often poor. We describe our experience with revision of MOMHA and provide recommendations for management. We present the findings and outcomes of 39 consecutive MOMHAs (in 35 patients) revised in a tertiary unit (median follow-up time 30 (12-54) months). The patients underwent a preoperative work-up including CT, metal artifact reduction sequence (MARS) MRI, and blood metal ion levels. We determined 5 categories of failure. 8 of 39 hips had conventional failure mechanisms including infection and impingement. Of the other 31 hips, 14 showed synovitis without significant disruption of soft tissue; 6 had a cystic pseudotumor with significant soft tissue disruption; 7 had significant osteolysis; and 4 had a solid pseudotumor. Each category of failure had specific surgical hazards that could be addressed preoperatively. There were 2 reoperations and 1 patient (2 hips) died of an unrelated cause. Median Oxford hip score (OHS) was 37 (9-48); median change (ΔOHS) was 17 (-10 to 41) points. ΔOHS was similar in all groups-except those patients with solid pseudotumors and those revised to metal-on-metal bearings, who fared worse. Planning in revision MOMHA is aided by knowledge of the different categories of failure to enable choice of appropriate personnel, theater time, and equipment. With this knowledge, satisfactory outcomes can be achieved in revision of metal-on-metal hip arthroplasty.
Bozic, Kevin J; Lau, Edmund C; Ong, Kevin L; Vail, Thomas P; Rubash, Harry E; Berry, Daniel J
The purpose of this study was to compare the risk of complication and revision total hip arthroplasty (THA) in Medicare THA patients with different bearings. Using the 100% Medicare database (2005-2009), the adjusted risk of complication and revision THA was calculated for 148,827 THA patients (93,929 metal-on-polyethylene, 49,646 metal-on-metal, 5252 ceramic-on ceramic). Adjusted risk of deep vein thrombosis, dislocation, periprosthetic joint infection (PJI), mechanical loosening, periprosthetic fracture, and revision THA at up to 4 years postoperatively was compared using Cox regression. After adjusting for patient and hospital factors, metal-on-metal bearings were associated with higher risk of PJI (P = .001), mechanical loosening (P < .001), and deep vein thrombosis (P = .031) than metal-on-polyethylene bearings and higher risk of PJI (P = .014) than ceramic-on-ceramic bearings. Overall short-term revision rates did not vary significantly across bearing types, consistent with registry data. The benefits of hard-on-hard bearings in Medicare patients remain unproven, and further study is needed to compare long-term complication and revision rates in Medicare THA patients with different bearing types. Copyright © 2012 Elsevier Inc. All rights reserved.
Fox, Ciara M; Bergin, Karen M; Kelly, Gabrielle E; McCoy, Gerry F; Ryan, Anthony G; Quinlan, John F
Following the global recall of all ASR metal on metal hip products, our aim was to correlate MRI findings with acetabular inclination angles and metal ion levels in patients with these implants. Both cobalt and chromium levels were significantly higher in the presence of a periprosthetic fluid collection. There was no association between the presence of a periprosthetic mass, bone marrow oedema, trochanteric bursitis or greater levels of abductor muscle destruction for cobalt or chromium. There was no association between the level of periprosthetic tissue reaction and the acetabular inclination angle with any of the pathologies identified on MRI. The relationship between MRI pathology, metal ion levels and acetabular inclination angles in patients with ASR implants remains unclear adding to the complexity of managing patients.
Background and purpose Joint replacement with metal-on-metal (MOM) bearings have gained popularity in the last decades in young and active patients. However, the possible effects of MOM wear debris and its corrosion products are still the subject of debate. Alongside the potential disadvantages such as toxicity, the influences of metal particles and metal ions on infection risk are unclear. Methods We reviewed the available literature on the influence of degradation products of MOM bearings in total hip arthroplasties on infection risk. Results Wear products were found to influence the risk of infection by hampering the immune system, by inhibiting or accelerating bacterial growth, and by a possible antibiotic resistance and heavy metal co-selection mechanism. Interpretation Whether or not the combined effects of MOM wear products make MOM bearings less or more prone to infection requires investigation in the near future. PMID:20860450
Burbano, Maria; Russell, Robert; Huo, Michael; Welch, Robert; Roy, Diana; Rodrigues, Danieli C.
The use of metal-on-metal (MoM) total hip implants has decreased recently due to reports of high failure rates and adverse local tissue reaction (ALTR). It has been hypothesized that wear metal debris released from CoCr bearing surfaces may provoke delayed hypersensitivity reactions. The goal of this study is to evaluate the microscopic bearing surface characteristics of implants revised due to evidence of ALTR. The bearing surface of each head and cup was analyzed using multiple microscopy techniques for characterization of the surface features. The presence of severe mechanical scratching was a common characteristic found in all of the implants evaluated. Mechanical factors seemed to be the prevalent failure mode related to the appearance of ALTR with this particular set of retrieved implants. PMID:28788544
Fehring, Thomas K; Carter, Joshua L; Fehring, Keith A; Odum, Susan M; Griffin, William L
The diagnosis of adverse local tissue reaction (ALTR) after metal-on-metal total hip arthroplasty (MoMTHA) presents a significant challenge. No single biomarker is specific for ALTR. The purpose of this study was to determine if the ratio of cobalt to chromium ions is useful for diagnosing ALTR in MoMTHA. In 89 bearing-related revision THAs, preoperative cobalt and chromium ion levels were compared to an intraoperative soft tissue damage grading scale. The average cobalt to chromium ratio was 2.96 (0-20). There was no correlation between the tissue scale and the cobalt to chromium ratio (R=0.095; P=0.41). Many variables affecting ion production/excretion mitigate the use of the ion ratio. The cobalt to chromium ratio is not a predictive biomarker for ALTR in MoMTHA.
Grübl, A; Weissinger, M; Brodner, W; Gleiss, A; Giurea, A; Gruber, M; Pöll, G; Meisinger, V; Gottsauner-Wolf, F; Kotz, R
In a randomised study, 28 patients with a mean age of 62.2 years (32 to 81) with osteoarthritis or avascular necrosis of the hip received either a ceramic-on-ceramic or a metal-on-metal total hip replacement. Apart from the liners the acetabular and femoral components were made of Ti-Al-Nb alloy. The serum aluminium and cobalt levels were measured before, and at one year after surgery. The 15 patients in the ceramic-on-ceramic group had a median pre-operative aluminium level of 1.3 microg/l (0.25 to 8.4) and a cobalt level below the detection limit. At one year the aluminium level was 1.1 microg/l (0.25 to 2.3) and the cobalt level was 0.4 microg/l (0.15 to 0.7). The 13 patients in the metal-on-metal group had a median pre-operative aluminium level of 1.9 microg/l (0.25 to 4.4) and a cobalt level below the detection limit. At one year the median aluminium level was 0.9 microg/l (0.25 to 3.9) whereas the cobalt level was 1.4 microg/l (0.5 to 10.5). This increase in the cobalt level at one year was significant (p < 0.001). Our findings indicate that ceramic-on-ceramic bearings do not cause elevated levels of serum aluminium in the first post-operative year.
International metal-on-metal multidisciplinary teams: do we manage patients with metal-on-metal hip arthroplasty in the same way? An analysis from the International Specialist Centre Collaboration on MOM Hips (ISCCoMH).
Berber, R; Skinner, J; Board, T; Kendoff, D; Eskelinen, A; Kwon, Y-M; Padgett, D E; Hart, A
There are many guidelines that help direct the management of patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken a study to compare the management of patients with MOM hip arthroplasties in different countries. Six international tertiary referral orthopaedic centres were invited to participate by organising a multi-disciplinary team (MDT) meeting, consisting of two or more revision hip arthroplasty surgeons and a musculoskeletal radiologist. A full clinical dataset including history, blood tests and imaging for ten patients was sent to each unit, for discussion and treatment planning. Differences in the interpretation of findings, management decisions and rationale for decisions were compared using quantitative and qualitative methods. Overall agreement between the orthopaedic centres and the recommended treatment plans for the ten patients with MOM hip implants was moderate (kappa = 0.6). Full agreement was seen in a third of cases, however split decisions were also seen in a third of cases. Units differed in their interpretation of the significance of the investigation findings and put varying emphasis on serial changes, in the presence of symptoms. In conclusion, the management of raised or rising blood metal ions, cystic pseudotumours and peri-acetabular osteolysis led to inconsistency in the agreement between centres. Coordinated international guidance and MDT panel discussions are recommended to improve consensus in decision making. A lack of evidence and the subsequent variation in regulator guidance leads to differences in opinions, the clinical impact of which can be reduced through a multi-disciplinary team approach to managing patients with MOM hip implants. Cite this article: Bone Joint J 2016;98-B:179-86. ©2016 The British Editorial Society of Bone & Joint Surgery.
Boomsma, Martijn F; Slouwerhof, Inge; van Lingen, Christiaan; Pakvis, Dean F M; van Dalen, Jorn A; Edens, Mireille A; Ettema, Harmen B; Verheyen, Cees C P M; Maas, Mario
To explore ipsilateral and contralateral acetabular roof bone stock density in unilateral large head MoM THA whether there is a significant lower acetabular bone stock in the hip with a metal-on-metal (MoM) total hip replacement compared to the contralateral side. Second part of this study is to examine if there are any associates with regard to potential bone stock density difference. A database of 317 patients with unilateral metal-on-metal (MoM) total hip replacements was set up retrospectively for this study. On computed tomography scans, conducted after a relative short in situ time period averaging 2.8 years, regions-of-interests were drawn in the trabecular bone of the acetabulum to measure average Hounsfield Units (HU). HU differences were calculated and tested by Wilcoxon signed-rank test. Univariate analysis was conducted to examine associates of potential bone loss. In a population of 317 patients (156 male, 161 female) with an average age of 61.9 ± 7.8, the median HU on the side of the MoM replacement was 123.3 (7.6-375.4). On the contralateral side, median HU was 144.7 (-0.4 to 332.8). The median HU difference was 21.4 after a mean post-operative in situ time of 2.8 years. The Wilcoxon signed-rank test proved a significant difference (p<0.001). Univariate analyses show that the in situ time of the MoM THA has a significant correlation with the bone density difference. Results show a significant lower bone density at the acetabular roof at the side of the prosthesis compared with the contralateral side after short in situ time of the MoM THA in patients with unilateral MoM total hip replacements. In our patient population, the in situ time showed a significant association with the acetabular bone density difference. As acetabular roof bone stock measurements are feasible and show temporal decline this could become an important parameter to be used in orthopedic decision making for revision surgery. Copyright © 2016 Elsevier Ireland Ltd. All rights
Yalcin, Nadir; Kilicarslan, Kasim; Cicek, Hakan; Kayaalp, Cetin; Yildirim, Hasan
Large bearing metal-on-metal (MOM) total hip arthroplasty (THA) may offer advantages relating to stability and range of motion in patients with Crowe Type I and II developmental dysplasia of the hip (DDH). The purpose of this study was to provide an analysis of the clinical and radiological results of MOM THA in this context and compare the results with a cohort of patients treated with metal-on-polyethylene (MOP) bearing surfaces. 75 hips in 65 patients were treated with cementless MOM THA using large femoral heads (36-56 mm). The mean age of the patients was 47.4 years (29 to 59) and 54 were female. A group of 47 hips (41 patients) treated with conventional THA (screwed cup-polyethylene insert-28 mm head) was used for comparison. The study group was followed up for a mean of 62.1 months (32 to 76). No difference was found between the two groups in relation to improvement in Harris hip score (HHS) (43.1 to 90.3 points in the study group, 42.6 to 89.5 points in the control group, p>0.05). Although the preoperative range of motion in all planes were similar in both groups, the large head group demonstrated greater motion in all planes postoperatively, which was significant (all p=0.001). Additionally, there was a significant difference between groups in relation to the necessity for acetabular structural graft (8% and 31.9%, respectively; p=0.001). No major complications or adverse reactions to metal debris (ARMD) were observed in the study group. The results of large head MOM THA in young and active patients with DDH are similar to conventional THA at early follow-up, but the former offers the advantages of secure acetabular fixation without screws, greater range of motion, and lower risk of dislocation.
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
Reito, Aleksi; Lainiala, Olli; Elo, Petra; Eskelinen, Antti
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
Background The purpose of the study was twofold: first, to determine whether there is a statistically significant difference in the metal ion levels among three different large-head metal-on-metal (MOM) total hip systems. The second objective was to assess whether position of the implanted prostheses, patient demographics or factors such as activity levels influence overall blood metal ion levels and whether there is a difference in the functional outcomes between the systems. Methods In a cross-sectional cohort study, three different metal-on-metal total hip systems were assessed: two monoblock heads, the Durom socket (Zimmer, Warsaw, IN, USA) and the Birmingham socket (Smith and Nephew, Memphis, TN, USA), and one modular metal-on-metal total hip system (Pinnacle, Depuy Orthopedics, Warsaw, IN, USA). Fifty-four patients were recruited, with a mean age of 59.7 years and a mean follow-up time of 41 months (12 to 60). Patients were evaluated clinically, radiologically and biochemically. Statistical analysis was performed on all collected data to assess any differences between the three groups in terms of overall blood metal ion levels and also to identify whether there was any other factor within the group demographics and outcomes that could influence the mean levels of Co and Cr. Results Although the functional outcome scores were similar in all three groups, the blood metal ion levels in the larger monoblock large heads (Durom, Birmingham sockets) were significantly raised compared with those of the Pinnacle group. In addition, the metal ion levels were not found to have a statistically significant relationship to the anteversion or abduction angles as measured on the radiographs. Conclusions When considering a MOM THR, the use of a monoblock large-head system leads to higher elevations in whole blood metal ions and offers no advantage over a smaller head modular system. PMID:24472283
Fowble, Vincent A; dela Rosa, Mylene A; Schmalzried, Thomas P
A comparison of pertinent preoperative and postoperative data relative to total hip resurfacing versus total hip arthroplasty (THA) would assist in evaluating current perceptions in outcome. We compared 50 consecutive metal-metal resurfacing replacements in 50 patients with 44 consecutive conventional total hip arthroplasties in 35 patients, who were implanted during the same time period, by the same surgeon, and followed prospectively for 2 to 4 years. The patients undergoing hip resurfacing were 62% male, 9 years younger, and 3.2 inches taller, with a lower mean body mass index and American Society of Anesthesiologists (ASA) grade than patients undergoing total hip arthroplasty. Preoperatively, patients undergoing resurfacing had a lower Harris hip score (46 vs 52 points), more pain, higher UCLA (University of California at Los Angeles) activity scores (4.2 vs 3.6), and better range of motion. Surgical time for resurfacing was 18% longer, but there was less total blood loss and fewer transfusions. Postoperatively, there was no difference in Harris hip score (97 vs 96). Patients undergoing resurfacing had higher function, Short Form-12 physical activity scores, and UCLA activity scores, but also a higher incidence of slight or mild pain. There were no differences in postoperative range of motion or dislocation (one each). The preoperative characteristics and general health status of the average patient undergoing resurfacing are more favorable than that of the average patient undergoing conventional total hip arthroplasty. Caution should be applied in attributing differences in outcomes directly to the arthroplasty technology.
Sabah, S. A.; Henckel, J.; Koutsouris, S.; Rajani, R.; Hothi, H.; Skinner, J. A.; Hart, A. J.
Aims The National Joint Registry for England, Wales and Northern Ireland (NJR) has extended its scope to report on hospital, surgeon and implant performance. Data linkage of the NJR to the London Implant Retrieval Centre (LIRC) has previously evaluated data quality for hip primary procedures, but did not assess revision records. Methods We analysed metal-on-metal hip revision procedures performed between 2003 and 2013. A total of 69 929 revision procedures from the NJR and 929 revised pairs of components from the LIRC were included. Results We were able to link 716 (77.1%) revision procedures on the NJR to the LIRC. This meant that 213 (22.9%) revision procedures at the LIRC could not be identified on the NJR. We found that 349 (37.6%) explants at the LIRC completed the full linkage process to both NJR primary and revision databases. Data completion was excellent (> 99.9%) for revision procedures reported to the NJR. Discussion This study has shown that only approximately one third of retrieved components at the LIRC, contributed to survival curves on the NJR. We recommend prospective registry-retrieval linkage as a tool to feedback missing and erroneous data to the NJR and improve data quality. Take home message: Prospective Registry – retrieval linkage is a simple tool to evaluate and improve data quality on the NJR. Cite this article: Bone Joint J 2016;98-B:33–9. PMID:26733513
Affatato, S; Spinelli, M; Zavalloni, M; Leardini, W; Viceconti, M
The wear of metal-on-metal bearings is affected by various design parameters, such as the clearance or surface roughness. It would be very useful to have a significant indicator of wear according to these design parameters, such as the lambda ratio. Three different batches of cast high- and low-carbon cobalt-chromium hip implants (28 mm, 32 mm, and 36 mm diameters) were tested in a hip joint simulator for 2 x 10(6) cycles. Bovine calf serum was used as lubricant, and the samples were weighed at regular intervals during the test. The predictive role of the lambda ratio on the wear behaviour was investigated. Three different configurations were tested to explore the wear rate for a broad range of lambda ratios. The results of these studies clearly showed that the femoral heads of 36 mm diameter had the best wear behaviour with respect to the other two smaller configurations tested. From a predictive point of view, the lambda ratios associated with the configurations tested could clearly indicate that the femoral heads of 36 mm diameter worked in the mixed-lubrication regime (lambda > 1); all the smallest configurations (28mm size) had lambda < 1, thus showing their aptitude to work in the boundary lubrication regime, with substantially higher volume depletion due to wear. The lambda values associated with the 32 mm size varied in a range around 1 (0.95 < lambda < 1.16), suggesting the possibility of operating in the mixed-lubrication regime.
Siddiqui, Imran A; Sabah, Shiraz A; Satchithananda, Keshthra; Lim, Adrian K; Cro, Suzie; Henckel, Johann; Skinner, John A
Background and purpose Metal artifact reduction sequence (MARS) MRI and ultrasound scanning (USS) can both be used to detect pseudotumors, abductor muscle atrophy, and tendinous pathology in patients with painful metal-on-metal (MOM) hip arthroplasty. We wanted to determine the diagnostic test characteristics of USS using MARS MRI as a reference for detection of pseudotumors and muscle atrophy. Patients and methods We performed a prospective cohort study to compare MARS MRI and USS findings in 19 consecutive patients with unilateral MOM hips. Protocolized USS was performed by consultant musculoskeletal radiologists who were blinded regarding clinical details. Reports were independently compared with MARS MRI, the imaging gold standard, to calculate predictive values. Results The prevalence of pseudotumors on MARS MRI was 68% (95% CI: 43–87) and on USS it was 53% (CI: 29–76). The sensitivity of USS in detecting pseudotumors was 69% (CI 39–91) and the specificity was 83% (CI: 36–97). The sensitivity of detection of abductor muscle atrophy was 47% (CI: 24–71). In addition, joint effusion was detected in 10 cases by USS and none were seen by MARS MRI. Interpretation We found a poor agreement between USS and MARS MRI. USS was inferior to MARS MRI for detection of pseudotumors and muscle atrophy, but it was superior for detection of joint effusion and tendinous pathologies. MARS MRI is more advantageous than USS for practical reasons, including preoperative planning and longitudinal comparison. PMID:24694273
Vassiliou, K; Scholes, S C; Unsworth, A
Total hip replacements offer relief to a great many patients every year around the world. With an expected service life of around 25 years on most devices, and with younger and younger patients undergoing this surgery, it is of great importance to understand the mechanisms of their function. Tribological testing of both conventional and hard bearing joint combinations have been conducted in many centres throughout the world, and, after being initially abandoned owing to premature failures, hard bearing combinations have been revisited as viable options for joint replacements. Improved design, manufacturing procedures, and material compositions have led to improved performance over first-generation designs in both metal-on-metal and ceramic-on-ceramic hip prostheses. This paper offers a review of the work conducted in an attempt to highlight the most important factors affecting joint performance and tribology of hard bearing combinations. The tribological performance of these joints is superior to that of conventional metal- or ceramic-on-polymer designs.
Sampson, Barry; Hart, Alister
In April 2010, a Medicines and Healthcare Products Regulatory Agency safety alert concerning all metal-on-metal (MOM) hip replacements recommended measuring chromium and cobalt concentrations when managing patients with painful prostheses. The need for this review is illustrated by the recent surge in requests for these blood tests from orthopaedic surgeons following this alert. The aim is to provide guidance to laboratories in assessing these requests and advising clinicians on interpretation. First, we summarize the basic terminology regarding the types of hip replacements, with emphasis on the MOM type. Second, we describe the clinical concerns over implant-derived wear debris in the local tissues and distant sites. Analytical aspects of the measurement of the relevant metal ions and what factors affect the levels measured are discussed. The application of inductively coupled plasma mass spectrometry techniques to the measurement of these metals is considered in detail. The biological effects of metal wear products are summarized with local toxicity and systemic biological effects considered, including carcinogenicity, genotoxicity and systemic toxicity. Clinical cases are used to illustrate pertinent points. PMID:22155921
Walter, Leonard R; Marel, Ed; Harbury, Richard; Wearne, Jenny
The most appropriate blood fraction for the measurement of metal ions in patients with metal-on-metal implants is controversial. We compared chromium (Cr) and cobalt (Co) ion levels in 29 patients after unilateral hip resurfacing with a size 54-mm femoral Birmingham Hip Resurfacing Prosthesis (Smith and Nephew, London, UK). All had well-functioning arthroplasties between 5 and 59 months after implantation. Ion levels were measured in serum, plasma, red cells, and whole blood in each patient. Our results indicate that only very minor amounts of Cr and Co are associated with red blood cells, with most being associated with serum/plasma. Previous studies using corrosion to produce the ion load have showed a predominance of Cr in the red blood cells. They have also shown that the cellular uptake of Cr is an indicator of its valence. This difference in distribution with our results is indirect evidence that the Cr released from wear of this implant is probably in the more benign trivalent form. It also suggests that most of the metal loss from a normally wearing bearing may be from wear rather than corrosion. If blood is to be used to assess rates of wear and systemic ion levels, then serum gives a better reflection of the true levels than red blood cells.
Myant, Connor; Cann, Philippa
Artificial articular joints present an interesting, and difficult, tribological problem. These bearing contacts undergo complex transient loading and multi axes kinematic cycles, over extremely long periods of time (>10 years). Despite extensive research, wear of the bearing surfaces, particularly metal-metal hips, remains a major problem. Comparatively little is known about the prevailing lubrication mechanism in artificial joints which is a serious gap in our knowledge as this determines film formation and hence wear. In this paper we review the accepted lubrication models for artificial hips and present a new concept to explain film formation with synovial fluid. This model, recently proposed by the authors, suggests that interfacial film formation is determined by rheological changes local to the contact and is driven by aggregation of synovial fluid proteins. The implications of this new mechanism for the tribological performance of new implant designs and the effect of patient synovial fluid properties are discussed.
Matharu, G. S.; Nandra, R. S.; Berryman, F.; Judge, A.; Pynsent, P. B.; Dunlop, D. J.
Aims To determine ten-year failure rates following 36 mm metal-on-metal (MoM) Pinnacle total hip arthroplasty (THA), and identify predictors of failure. Patients and Methods We retrospectively assessed a single-centre cohort of 569 primary 36 mm MoM Pinnacle THAs (all Corail stems) followed up since 2012 according to Medicines and Healthcare Products Regulation Agency recommendations. All-cause failure rates (all-cause revision, and non-revised cross-sectional imaging failures) were calculated, with predictors for failure identified using multivariable Cox regression. Results Failure occurred in 97 hips (17.0%). The ten-year cumulative failure rate was 27.1% (95% confidence interval (CI) 21.6 to 33.7). Primary implantation from 2006 onwards (hazard ratio (HR) 4.30; 95% CI 1.82 to 10.1; p = 0.001) and bilateral MoM hip arthroplasty (HR 1.59; 95% CI 1.03 to 2.46; p = 0.037) predicted failure. The effect of implantation year on failure varied over time. From four years onwards following surgery, hips implanted since 2006 had significantly higher failure rates (eight years 28.3%; 95% CI 23.1 to 34.5) compared with hips implanted before 2006 (eight years 6.3%; 95% CI 2.4 to 15.8) (HR 15.2; 95% CI 2.11 to 110.4; p = 0.007). Conclusion We observed that 36 mm MoM Pinnacle THAs have an unacceptably high ten-year failure rate, especially if implanted from 2006 onwards or in bilateral MoM hip patients. Our findings regarding implantation year and failure support recent concerns about the device manufacturing process. We recommend all patients undergoing implantation since 2006 and those with bilateral MoM hips undergo regular investigation, regardless of symptoms. Cite this article: Bone Joint J 2017;99-B:592–600. PMID:28455467
Pitto, Rocco P
The aim of this prospective study was to assess the safety and efficacy of the greater trochanter slide osteotomy approach for resurfacing hip arthroplasty. Fifty consecutive hips (47 patients) with degenerative joint disease were enrolled in the study. Serial clinical and radiological assessments were performed after the index operation. At 1-year follow-up, the clinical outcome and patient satisfaction were rated excellent or good in all hips. The radiological assessment showed signs of satisfactory implant alignment. Periprosthetic fractures and non-unions of the greater trochanter were not observed. The greater trochanter slide osteotomy approach for resurfacing hip arthroplasty is a safe procedure and provides optimal exposure of the acetabulum and proximal femur, maintaining the soft-tissue integrity of the hip joint. Blood supply of the proximal femur is not violated using this approach.
Background and purpose Following metal-on-metal hip arthroplasty (THA), immunological reactions including changes in lymphocyte populations, aseptic loosening, and lymphocytic pseudotumors occur. We hypothesized that changes in lymphocyte subpopulations would be associated with elevated metal ion concentrations. Methods A randomized trial involving 85 patients matched for age and sex and randomized to receiving metal-on-metal (n = 41) or metal-on-polyethylene total hip arthroplasty (n = 44) was conducted. 36 patients were eligible for follow-up after mean 7 (6–8) years. Concentrations of chromium and cobalt were analyzed by high-resolution inductively coupled plasma mass spectrometry. Leukocyte subpopulations and immunoglobulins in patient blood were measured using standard laboratory methods. Results Patients with a metal-on-metal hip had higher serum concentrations of chromium (1.05 vs. 0.36 μg/L; p < 0.001) and cobalt (0.86 vs. 0.24 μg/L; p < 0.001) than those with metal-on-polyethylene. The percentage of HLA DR+ CD8+ T-cells was higher in the metal-on-metal group (10.6 vs. 6.7%; p = 0.03) and correlated positively with chromium and cobalt concentrations in patient blood (Pearson's correlation coefficient: 0.39, p = 0.02; 0.36, p = 0.03, respectively). The percentage of B-cells was lower in the metal-on-metal group (p = 0.01). The two groups were similar with respect to immunoglobulin concentrations and Harris hip scores, and there were no radiographic signs of loosening. Interpretation We conclude that immunological alterations appear to be associated with increased cobalt and chromium concentrations. It is tempting to speculate that HLA DR+ CD8+ T-cells are involved in the pathogenesis of allergic reactions, implant loosening, and lymphocytic pseudotumors. PMID:21189110
Søballe, Kjeld; Jakobsen, Stig Storgaard; Lorenzen, Nina Dyrberg; Mechlenburg, Inger; Stilling, Maiken
Background The mechanism of failure of metal-on-metal (MoM) total hip arthroplasty (THA) has been related to a high rate of metal wear debris, which is partly generated from the head-trunnion interface. However, it is not known whether implant fixation is affected by metal wear debris. Patients and methods 49 cases of MoM THA in 41 patients (10 women) with a mean age of 52 (28–68) years were followed with stereoradiographs after surgery and at 1, 2, and 5 years to analyze implant migration by radiostereometric analysis (RSA). Patients also participated in a 5- to 7-year follow-up with measurement of serum metal ions, questionnaires (Oxford hip score (OHS) and Harris hip score (HHS)), and measurement of cup and stem positions and systemic bone mineral density. Results At 1–2 years, mean total translation (TT) was 0.04 mm (95% CI: –0.07 to 0.14; p = 0.5) for the stems; at 2–5 years, mean TT was 0.13 mm (95% CI: –0.25 to –0.01; p = 0.03), but within the precision limit of the method. For the cups, there was no statistically significant TT or total rotation (TR) at 1–2 and 2–5 years. At 2–5 years, we found 4 cups and 5 stems with TT migrations exceeding the precision limit of the method. There was an association between cup migration and total OHS < 40 (4 patients, 4 hips; p = 0.04), but there were no statistically significant associations between cup or stem migration and T-scores < –1 (n = 10), cup and stem positions, or elevated serum metal ion levels (> 7µg/L (4 patients, 6 hips)). Interpretation Most cups and stems were well-fixed at 1–5 years. However, at 2–5 years, 4 cups and 5 stems had TT migrations above the precision limits, but these patients had serum metal ion levels similar to those of patients without measurable migrations, and they were pain-free. Patients with serum metal ion levels > 7 µg/L had migrations similar to those in patients with serum metal ion levels < 7 µg/L. Metal wear debris does not appear to influence the
Varano, R; Bobyn, J D; Medley, J B; Yue, S
The influence of microstructure on the wear of cobalt-based alloys used in metal-on-metal hip implants was investigated in a boundary lubrication regime designed to represent the conditions that occurred some of the time in vivo. These cobalt-chromium-molybdenum alloys were either wrought, with a total carbon content of 0.05 or 0.23 wt %, cast with a solution-annealing procedure or simply as-cast but not solution annealed. Bars of these different alloy grades were subjected to various heat treatments to develop different microstructures. The wear was evaluated in a linear-tracking reciprocating pin-on-plate apparatus with a 25 per cent bovine serum lubricant. The wear was found to be strongly affected by the dissolved carbon content of the alloys and mostly independent of grain size or the carbide characteristics. The increased carbon in solid solution caused reductions in volumetric wear because carbon helped to stabilize a face-centred cubic crystal structure, thus limiting the amount of strain-induced transformation to a hexagonal close-packed crystal structure. Based on the observed surface twining in and around the contact zone and the potentially detrimental effect of the hexagonal close-packed phase, it was postulated that the wear of cobalt-based alloys in the present study was controlled by a deformation mechanism.
Matharu, GS; Janardhan, S; Brash, L; Pynsent, PB; Dunlop, DJ; James, SLJ
Introduction We assessed changes in metal-on-metal hip arthroplasties (MoMHAs) after repeat ultrasound examination. Methods This retrospective, single-centre cohort study involved all patients undergoing two ultrasound examinations of the same MoMHA. Between 2010 and 2014, 96 ultrasound examinations were performed in 48 MoMHAs (mean time between scans = 1.1 years). A radiologist assigned each scan to one of four grades and measured volumes of any solid/cystic masses. Changes in grade and lesion volume between scans were analysed. Results Change in grade between scans was significant (p=0.012); 27% (n=13) of MoMHAs increased in grade, 67% (n=32) had no grade change, and 6% (n=3) decreased in grade. The mean increase in lesion volume was 24.2cm3 by the second scan, and was significant (p=0.023). Evidence of progression in findings was observed in 54% (26/48) of MoMHAs. Of patients with normal scans initially, 44% (8/18) developed abnormalities. No factors (including blood metal ion concentrations and cup position) were associated significantly with progression of ultrasound findings. Conclusions Repeat ultrasound in MoMHA patients demonstrated that findings frequently progress in the short-term. Therefore, regular surveillance of MoMHA patients is important, with ultrasound representing an effective investigation for identifying the development and progression of lesions. PMID:26741659
Brockett, Claire L; Harper, Phil; Williams, Sophie; Isaac, Graham H; Dwyer-Joyce, Rob S; Jin, Zhongmin; Fisher, John
Large diameter metal-on-metal bearings (MOM) are becoming increasingly popular, addressing the needs of young and more active patients. Clinical data has shown excellent short-to-mid-term results, though incidences of transient squeaking have been noted between implantation and up to 2 years post-operative. Geometric design features, such as clearance, have been significant in influencing the performance of the bearings. Sets of MOM bearings with different clearances were investigated in this study using a hip friction simulator to examine the influence of clearance on friction, lubrication and squeaking. The friction factor was found to be highest in the largest clearance bearings under all test conditions. The incidence of squeaking was also highest in the large clearance bearings, with all bearings in this group squeaking throughout the study. A very low incidence of squeaking was observed in the other two clearance groups. The measured lubricating film was found to be lowest in the large clearance bearings. This study suggests that increasing the bearing clearance results in reduced lubricant film thickness, increased friction and an increased incidence of squeaking.
Passuti, N; Terver, S
This study is dedicated to the problems met with metal-metal bearing prostheses. We have analysed the results of the reports sent to the AFSSAPS relating incidents described with this interface. Only 11 incidents were reported during the last 4 years by surgeons from different centers in France. At a mean follow-up of 7 years, we collected 2614 total hip arthroplasties with metal-metal bearings and among them only 5 cases of unusual osteolysis and 10 cases of impingement. The bibliographic analysis did not show any severe specific complication due to the release of Cobalt or Chromium ions. The increased levels of Co an Cr in the patients' blood is now a well established notion (with more than 10 years follow up) and no special carcinogenetic effect has been correlated with the metal-metal bearings. Small diameter cemented cups can provide complications with high rates of acetabular loosening and metallosis; the same is true for some cementless cups also with loosening and a high revision rate. Among 143 hip prosthesis with a cemented polyethylene cup, at a mean follow-up of 42 months there were 22% of evolutive radiolucencies around the cups concerning all three De Lee and Charnley zones. Furthermore there was a statistically significant difference between small and large diameter cups (loosening of cups less than 46 mm in diameter). The same problem has been described for some cementless cups with loosening at the metal-bone interface due to a failure of osteointegration at the implant surface. However no failures were observed with an hydroxyapatite coating on the same cup. An other matter of concern is the skirted metal head: this design is responsible for a high rate of impingement and of prosthetic revision (2.3% among 642 THA). In these cases the increase of Cobalt serum levels was well correlated with the failure of the metal-metal interface. Large diameter heads decrease significantly the risks of dislocation. This is correlated with the increase in size
Lass, Richard; Grübl, Alexander; Kolb, Alexander; Stelzeneder, David; Pilger, Alexander; Kubista, Bernd; Giurea, Alexander; Windhager, Reinhard
Diagnosis of adverse reactions to metal debris in metal-on-metal hip arthroplasty is a multifactorial process. Systemic ion levels are just one factor in the evaluation and should not be relied upon solely to determine the need for revision surgery. Furthermore, the correlation between cobalt or chromium serum, urine, or synovial fluid levels and adverse local tissue reactions is still incompletely understood. The hypothesis was that elevated serum and urine metal-ion concentrations are associated with elevated local metal-ion concentrations in primary total hip arthroplasties (THA) and with failure of metal-on-metal articulations in the long-term. In our present study, we evaluated these concentrations in 105 cementless THA with metal-on-metal articulating surfaces with small head diameter at a minimum of 18 years postoperatively. Spearman correlation showed a high correlation between the joint fluid aspirate concentration of cobalt and chromium with the serum cobalt (r = 0.81) and chromium level (r = 0.77) in patients with the THA as the only source of metal-ions. In these patients serum metal-ion analysis is a valuable method for screening. In patients with more than one source of metal or renal insufficiency additional investigations, like joint aspirations are an important tool for evaluation of wear and adverse tissue reactions in metal-on-metal THA.
Bishop, N E; Waldow, F; Morlock, M M
Modern hip joint replacements are designed to minimise wear problems. The most popular metal-on-polyethylene components are being updated by harder metal and ceramic combinations. However, this has also been shown to influence the friction moments, which could overload the interface between the implant and the body. In this study custom test apparatus was used to measure the joint moments in various modern bearings under simulated physiological joint conditions. The largest moments in serum were measured for large diameter metal-metal bearings (<8 Nm for standard bearings), followed by metal-polyethylene, and the lowest moments were for small diameter ceramic-ceramic and ceramic-metal combinations. Water as a lubricant was found to double the moments in comparison with serum. In metal-metal bearings moments were reduced by increasing loading frequency. Swing phase load and a rest period between load cycles had little effect. The moment magnitudes are within the turn-out capacity measured for press-fit cups and might become critical with higher joint loads.
Kovochich, Michael; Fung, Ernest S; Donovan, Ellen; Unice, Kenneth M; Paustenbach, Dennis J; Finley, Brent L
Advantages of second-generation metal-on-metal (MoM) hip implants include low volumetric wear rates and the release of nanosized wear particles that are chemically inert and readily cleared from local tissue. In some patients, edge loading conditions occur, which result in higher volumetric wear. The objective of this study was to characterize the size, morphology, and chemistry of wear particles released from MoM hip implants during normal (40° angle) and edge-loading (65° angle with microseparation) conditions. The mean primary particle size by volume under normal wear was 35 nm (range: 9-152 nm) compared with 95 nm (range: 6-573 nm) under edge-loading conditions. Hydrodynamic diameter analysis by volume showed that particles from normal wear were in the nano- (<100 nm) to submicron (<1000 nm) size range, whereas edge-loading conditions generated particles that ranged from <100 nm up to 3000-6000 nm in size. Particles isolated from normal wear were primarily chromium (98.5%) and round to oval in shape. Edge-loading conditions generated more elongated particles (4.5%) (aspect ratio ≥ 2.5) and more CoCr alloy particles (9.3%) compared with normal wear conditions (1.3% CoCr particles). By total mass, edge-loading particles contained approximately 640-fold more cobalt than normal wear particles. Our findings suggest that high wear conditions are a potential risk factor for adverse local tissue effects in MoM patients who experience edge loading. This study is the first to characterize both the physical and chemical characteristics of MoM wear particles collected under normal and edge-loading conditions. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2017. © 2017 Wiley Periodicals, Inc.
Maskiewicz, Victoria K; Williams, Paul A; Prates, Sarah J; Bowsher, John G; Clarke, Ian C
A size exclusion high performance liquid chromatography (SEC-HPLC) method has been developed which is capable of separation and quantitation of bovine serum albumin (BSA) and bovine serum globulin (BSG) components of serum-based lubricant (SBL) solutions. This allowed characterization of the stability profiles of these proteins when acting as lubricants during hip wear simulation, and identification of wear-specific mechanisms of degradation. Using cobalt-chromium metal-on-metal (MOM) hip joints, it was observed that BSA remained stable for up to 3 days (215K cycles) of wear testing after which the protein degraded in a fairly linear fashion. BSG on the other hand, began to degrade immediately and in a linear fashion with a rate constant of 5% per day. Loss of both proteins occurred via the formation of high molecular weight aggregates which precipitated out of solution. No fragmentation of the polypeptide backbone of either protein was observed. Data obtained suggest that protein degradation was not due to microbial contamination, denaturation at the air-water interface, or frictional heating of articulating joint surfaces in these studies. We conclude that the primary source of protein degradation during MOM simulation testing occurs via high shear rates experienced by SBL solutions at articulating surfaces, possibly coupled with metal-protein interactions occurring as new and reactive metal surfaces are generated during wear testing. The development of this analytical methodology will allow new studies to clarify the role of SBL solutions in wear simulation studies and the interactions and lubricating properties of serum proteins with prosthetic surfaces other than MOM.
Robinson, Elizabeth; Henckel, Johann; Sabah, Shiraz; Satchithananda, Keshthra; Skinner, John; Hart, Alister
Metal artifact reduction sequence (MARS) MRI is widely advocated for surveillance of metal-on-metal hip arthroplasties (MOM-HAs). However, its use is limited by susceptibility artifact at the prosthesis-bone interface, local availability, patient compliance, and cost (Hayter et al. 2011a). We wanted to determine whether CT is a suitable substitute for MARS MRI in evaluation of the painful MOM-HA. 50 MOM-HA patients (30 female) with unexplained painful prostheses underwent MARS MRI and CT imaging. 2 observers who were blind regarding the clinical data objectively reported the following outcomes: soft tissue lesions (pseudotumors), muscle atrophy, and acetabular and femoral osteolysis. Diagnostic test characteristics were calculated. Pseudotumor was diagnosed in 25 of 50 hips by MARS MRI and in 11 of 50 by CT. Pseudotumors were classified as type 1 (n=2), type 2A (n=17), type 2B (n=4), and type 3 (n=2) by MARS MRI. CT did not permit pseudotumor classification. The sensitivity of CT for diagnosis of pseudotumor was 44% (95% CI: 25-65). CT had "slight" agreement with MARS MRI for quantification of muscle atrophy (κ=0.23, CI: 0.16-0.29; p<0.01). Osteolysis was identified in 15 of 50 patients by CT. 4 of these lesions were identified by MARS MRI. CT was found to be superior to MRI for detection of osteolysis adjacent to MOM-HA, and should be incorporated into diagnostic algorithms. CT was unable to classify and failed to detect many pseudotumors, and it was unreliable for assessment of muscle atrophy. Where MARS MRI is contraindicated or unavailable, CT would be an unsuitable substitute and other modalities such as ultrasound should be considered.
Meng, Q E; Liu, F; Fisher, J; Jin, Z M
Effective lubrication performance of metal-on-metal hip implants only requires optimum conformity within the main loaded area, while it is advantageous to increase the clearance in the equatorial region. Such a varying clearance can be achieved by using non-spherical bearing surfaces for either acetabular or femoral components. An elastohydrodynamic lubrication model of a novel metal-on-metal hip prosthesis using a non-spherical femoral bearing surface against a spherical cup was solved under loading and motion conditions specified by ISO standard. A full numerical methodology of considering the geometric variation in the rotating non-spherical head in elastohydrodynamic lubrication solution was presented, which is applicable to all non-spherical head designs. The lubrication performance of a hip prosthesis using a specific non-spherical femoral head, Alpharabola, was analysed and compared with those of spherical bearing surfaces and a non-spherical Alpharabola cup investigated in previous studies. The sensitivity of the lubrication performance to the anteversion angle of the Alpharabola head was also investigated. Results showed that the non-spherical head introduced a large squeeze-film action and also led to a large variation in clearance within the loaded area. With the same equatorial clearance, the lubrication performance of the metal-on-metal hip prosthesis using an Alpharabola head was better than that of the conventional spherical bearings but worse than that of the metal-on-metal hip prosthesis using an Alpharabola cup. The reduction in the lubrication performance caused by the initial anteversion angle of the non-spherical head was small, compared with the improvement resulted from the non-spherical geometry.
Gao, Leiming; Wang, Fengcai; Yang, Peiran; Jin, Zhongmin
An elastohydrodynamic lubrication (EHL) simulation of a metal-on-metal (MOM) total hip implant was presented, considering both steady state and transient physiological loading and motion gait cycle in all three directions. The governing equations were solved numerically by the multi-grid method and fast Fourier transform in spherical coordinates, and full numerical solutions were presented included the pressure and film thickness distribution. Despite small variations in the magnitude of 3D resultant load, the horizontal anterior-posterior (AP) and medial-lateral (ML) load components were found to translate the contact area substantially in the corresponding direction and consequently to result in significant squeeze-film actions. For a cup positioned anatomically at 45 degrees , the variation of the resultant load was shown unlikely to cause the edge contact. The contact area was found within the cup dimensions of 70-130 degrees and 90-150 degrees in the AP and ML direction respectively even under the largest translations. Under walking conditions, the horizontal load components had a significant impact on the lubrication film due to the squeeze-film effect. The time-dependent film thickness was increased by the horizontal translation and decreased during the reverse of this translation caused by the multi-direction of the AP load during walking. The minimum film thickness of 12-20 nm was found at 0.4s and around the location at (95, 125) degrees. During the whole walking cycle both the average and centre film thickness were found obviously increased to a range of 40-65 nm, compared with the range of 25-55 nm under one load (vertical) and one motion (flexion-extension) condition, which suggested the lubrication in the current MOM hip implant was improved under 3D physiological loading and motion. This study suggested the lubrication performance especially the film thickness distribution should vary greatly under different operating conditions and the time and
Figueras, Guillem; Planell, Ramón Vives; Fernàndez, Ramón Serra; Biayna, Joan Camí
Background: As a consequence of use of metal-on-metal hip arthroplasties some patients have precised revision for pain or metal hipersensivity reactions among other causes. We propose to salvage monoblock acetabular component and femoral component using a dual-mobility head and perform a lower morbidity operation in young patients preserving host bone stock in cases with well fixed and positioned components. Objective: (1) What clinical problems have been reported in patients with Metal-on-metal hip arthroplasties? (2) Could the tribocorrosion potentially cause a fracture of neck femoral component? (3) Can be the dual-mobility head a recourse in metal-on-metal hip revision? Methods: Ten patients were revised for pain or/and raised Cobalt/Chromium levels between August 2012 and December 2015. In three cases femoral neck component was fractured and femoral revision was necessary. In four hips, acetabular and femoral components could be maintained. Age, body index mass, ion levels, acetabular position, size of acetabular component and femoral head, approach, blood transfunsion and time of hospitalization were analized. Results: At a mean follow-up of 25,6 months (6 to 45) the mean postoperative HHS was 92. It was not statistically significant because several patients were low sintomatic before surgery, but had raised Cobalt/Chromium levels in the blood. All patients had near-normal levels of Cobalt/Chromium during the first 6 months after revision surgery. No relevant complications were reported. Conclusion: The use of dual-mobility head can be an acceptable option to revise metal-on-metal arthroplasties correctly oriented with abscence of loosening or infection signs and keeping bone stock in young patients. PMID:27857822
Leslie, Ian; Williams, Sophie; Isaac, Graham; Hatto, Peter; Ingham, Eileen; Fisher, John
Clinical studies have found high wear rates, elevated ion levels and high revision rates of large-diameter metal-on-metal surface replacement bearings in some patients, which have been associated with edge loading of the head on the rim of the cup. We have simulated increased wear and ion levels in metal-on-metal bearings in vitro by introducing variations in translational and rotational positioning of the components, which reproduces stripe wear on the femoral head, cup rim wear and clinically relevant large as well as small wear particles. There is interest in technologies such as surface engineering, which might reduce metal wear and the release of wear particles and ions. Reduced wear with surface-engineered surface replacements compared to metal-on-metal controls has been reported under standard walking conditions with correctly aligned and concentric components. In this in vitro study, the wear of chromium nitride surface-engineered metal-on-metal bearings under conditions of microseparation associated with translational and rotational malpositioning of the components was investigated and the results were compared with a previously reported study of metal-on-metal bearings under the same conditions. Simulations were conducted using our unique hip simulation microseparation methodologies, which reproduce accelerated wear in metal-on-metal bearings and have previously been clinically validated with ceramic-on-ceramic bearings. Four of the six surface-engineered bearings had evidence of head contact on the rim of the cup, which produced stripe wear on the femoral head. Four of the six surface-engineered bearings (two without stripe and two with stripe wear) had lower wear than the previously reported high wearing metal-on-metal bearings. At 2 million cycles, two of the surface-engineered bearings had substantially increased wear rates, four times higher than the high wear rates previously reported for metal-on-metal bearings under the same conditions. There was
Donaldson, Finn E; Nyman, Edward; Coburn, James C
Manufacturers and investigators of Total Hip Replacement (THR) bearings require tools to predict the contact mechanics resulting from diverse design and loading parameters. This study provides contact mechanics solutions for metal-on-metal (MoM) bearings that encompass the current design space and could aid pre-clinical design optimization and evaluation. Stochastic finite element (FE) simulation was used to calculate the head-on-cup contact mechanics for five thousand combinations of design and loading parameters. FE results were used to train a Random Forest (RF) surrogate model to rapidly predict the contact patch dimensions, contact area, pressures and plastic deformations for arbitrary designs and loading. In addition to widely observed polar and edge contact, FE results included ring-polar, asymmetric-polar, and transitional categories which have previously received limited attention. Combinations of design and load parameters associated with each contact category were identified. Polar contact pressures were predicted in the range of 0-200 MPa with no permanent deformation. Edge loading (with subluxation) was associated with pressures greater than 500 MPa and induced permanent deformation in 83% of cases. Transitional-edge contact (with little subluxation) was associated with intermediate pressures and permanent deformation in most cases, indicating that, even with ideal anatomical alignment, bearings may face extreme wear challenges. Surrogate models were able to accurately predict contact mechanics 18,000 times faster than FE analyses. The developed surrogate models enable rapid prediction of MoM bearing contact mechanics across the most comprehensive range of loading and designs to date, and may be useful to those performing bearing design optimization or evaluation. Published by Elsevier Ltd.
Reiner, Tobias; Do, Thuy D; Klot, Matthias C; Hertzsch, Fabian; Seelmann, Kirsten; Gaida, Matthias M; Weber, Marc-André; Gotterbarm, Tobias
Concern has been raised about the late onset of adverse reactions to metal debris (ARMD) in patients with a small-head metal-on-metal total hip replacement. The aims of this study were to assess the frequency and characteristic appearance of ARMD in patients with a small-head (28-mm) metal-on-metal total hip replacement and elevated blood ion levels (>1 μg/L) after a minimum follow-up of 10 years and to analyze the possible risk factors associated with the prevalence of these lesions. In the present study, we used metal artifact reduction sequence magnetic resonance imaging (MARS MRI) to investigate the cases of 53 patients (66 hips) with a small-head (28-mm) metal-on-metal total hip replacement and elevated blood ion levels at a mean follow-up interval of 15.5 years (range, 10.6 to 19.3 years). Whole blood metal ion levels (cobalt and chromium), clinical outcome scores (Harris hip score), and radiographs were obtained for each patient. Tissue samples from patients who had revision surgery were histologically examined. MARS MRI revealed ARMD in 27 hips (41%). Most hips with ARMD (67%) were asymptomatic. ARMD were generally small, with a median lesion size of 2.3 cm (range, 0.3 to 71.4 cm) and predominantly cystic in nature. Multivariate regression analysis revealed positive correlation between cobalt ion levels and the presence of ARMD. In this case series, the risk for the development of ARMD was 2.87 times higher for every 1 μg/L increase of blood cobalt ion concentration (95% confidence interval, 1.01 to 8.17; p = 0.048). In this case series, ARMD were seen in 41% of the hips following small-head metal-on-metal total hip arthroplasty at long-term follow-up, and most patients with ARMD were asymptomatic. Blood cobalt ion levels could be identified as a risk factor for ARMD. However, ARMD also occurred in patients with low metal ion levels. Further studies are necessary to investigate the role of ARMD in asymptomatic patients with this bearing type. Therapeutic
Macdonald, J.; Robinson, A.; Brown, I.
This case report involves a 56-year-old female (Mrs X) with a traumatic intertrochanteric hip fracture with subtrochanteric extension below a previous Birmingham hip resurfacing. Periprosthetic fractures following hip resurfacing are usually subcapital and treated with a revision or conservative management. We present an unusual surgical problem with an interesting solution stabilising the fracture using a proximal femoral locking compression plate (LCP). Eight months following surgery the patient is able to walk pain free and there is good fixation and stability. PMID:24995142
Smith, Alison J; Dieppe, Paul; Vernon, Kelly; Porter, Martyn; Blom, Ashley W
Total hip replacement (THR) is extremely common. Some prostheses fail, particularly in younger patients, and need to be revised, most commonly for loosening secondary to wear or dislocation. Surgeons have tried to address these problems by implanting large diameter metal-on-metal bearing surfaces. Our aim was to assess if metal-on-metal bearing surfaces lead to increased implant survival compared with other bearing surfaces in stemmed THR and, additionally, if larger head sizes result in improved implant survival. We analysed the National Joint Registry of England and Wales for primary hip replacements (402,051, of which 31,171 were stemmed metal-on-metal) undertaken between 2003 and 2011. Our analysis was with a multivariable flexible parametric survival model to estimate the covariate-adjusted cumulative incidence of revision adjusting for the competing risk of death. Metal-on-metal THR failed at high rates. Failure was related to head size, with larger heads failing earlier (3·2% cumulative incidence of revision [95% CI 2·5-4·1] for 28 mm and 5·1% [4·2-6·2] for 52 mm head at 5 years in men aged 60 years). 5 year revision rates in younger women were 6·1% (5·2-7·2) for 46 mm metal-on-metal compared with 1·6% (1·3-2·1) for 28 mm metal-on-polyethylene. By contrast, for ceramic-on-ceramic articulations larger head sizes were associated with improved survival (5 year revision rate of 3·3% [2·6-4·1] with 28 mm and 2·0% [1·5-2·7] with 40 mm for men aged 60 years). Metal-on-metal stemmed articulations give poor implant survival compared with other options and should not be implanted. All patients with these bearings should be carefully monitored, particularly young women implanted with large diameter heads. Since large diameter ceramic-on-ceramic bearings seem to do well we support their continued use. National Joint Registry of England and Wales. Copyright © 2012 Elsevier Ltd. All rights reserved.
Tardy, N; Maqdes, A; Boisrenoult, P; Beaufils, P; Oger, P
Theoretically, the properties of second-generation metal-on-metal (MoM) bearings are better for wear, osteolysis and longevity. However, follow-up studies of more than 10 years are rare, in particular with hybrid fixation (cemented stainless steel stems and cementless cup), therefore we evaluated the results of this combination after a mean follow-up of 12.8 years: (1) to analyze the survival rate, (2) to compare it with the survival rate in the same series after 6.4 years (95.8% cup, 94.8% stem), (3) to evaluate clinical and radiographic outcome and (4) to analyze these failures. The number of revisions would increase after 10 years. We evaluated 106 total hip arthroplasties (THA) (Cedior™ press-fit cup with cemented Acora™ (n=50) and Exafit™ (n=56) stems and 28mm Metasul™ bearings performed between January 1999 and December 2002. The survival rate was calculated by the Kaplan-Meier method. The clinical assessment included the Postel Merle d'Aubigné (PMA) and Oxford scores. The radiographic assessment evaluated radiolucencies and osteolysis on standard X-rays. A histological analysis was only performed during revision THA. After a mean 12.8 years of follow-up (10-16), 53 THA were reviewed in 48 patients. Thirteen THA revisions (14%) were performed including 11 aseptic revisions (5 stem fractures, 2 cases of impingement and 3 loosenings [1 bipolar and 3 cups] and one case of osteolysis). Overall survival, taking into account revision for aseptic loosening, was 87.6% (CI 95%=77.3 to 99.3%). The mean PMA and Oxford scores at the final follow-up were 17.6±0.8 points (16-18) and 16.5±5.2 points (12-38) respectively. The radiological follow-up mainly identified radiolucencies around the stem in Gruen zones 1 and 7 (17 and 21% respectively). The survival rate of hybrid MoM THA in this series decreased after 10 years and is lower than studies evaluating cementless THA with the 28-mm Metasul™ bearings (90.9 to 100% survival). Although the clinical results are
Singh, G; Nuechtern, J V; Meyer, H; Fiedler, G M; Awiszus, F; Junk-Jantsch, S; Bruegel, M; Pflueger, G; Lohmann, C H
The peri-prosthetic tissue response to wear debris is complex and influenced by various factors including the size, area and number of particles. We hypothesised that the 'biologically active area' of all metal wear particles may predict the type of peri-prosthetic tissue response. Peri-prosthetic tissue was sampled from 21 patients undergoing revision of a small diameter metal-on-metal (MoM) total hip arthroplasty (THA) for aseptic loosening. An enzymatic protocol was used for tissue digestion and scanning electron microscope was used to characterise particles. Equivalent circle diameters and particle areas were calculated. Histomorphometric analyses were performed on all tissue specimens. Aspirates of synovial fluid were collected for analysis of the cytokine profile analysis, and compared with a control group of patients undergoing primary THA (n = 11) and revision of a failed ceramic-on-polyethylene arthroplasty (n = 6). The overall distribution of the size and area of the particles in both lymphocyte and non-lymphocyte-dominated responses were similar; however, the subgroup with lymphocyte-dominated peri-prosthetic tissue responses had a significantly larger total number of particles. 14 cytokines (interleukin (IL)-1ß, IL-2, IL-4, IL-5, IL-6, IL-10, IL-13, IL-17, interferon (IFN)-γ, and IFN-gamma-inducible protein 10), chemokines (macrophage inflammatory protein (MIP)-1α and MIP-1ß), and growth factors (granulocyte macrophage colony stimulating factor (GM-CSF) and platelet derived growth factor) were detected at significantly higher levels in patients with metal wear debris compared with the control group. Significantly higher levels for IL-1ß, IL-5, IL-10 and GM-CSF were found in the subgroup of tissues from failed MoM THAs with a lymphocyte-dominated peri-prosthetic response compared with those without this response. These results suggest that the 'biologically active area' predicts the type of peri-prosthetic tissue response. The cytokines IL-1ß, IL-5
Scoring the Current Risk Stratification Guidelines in Follow-up Evaluation of Patients After Metal-on-Metal Hip Arthroplasty: A Proposal for a Metal-on-Metal Risk Score Supporting Clinical Decision-Making.
Hussey, Daniel K; Madanat, Rami; Donahue, Gabrielle S; Rolfson, Ola; Bragdon, Charles R; Muratoglu, Orhun K; Malchau, Henrik
In the follow-up evaluation of patients with metal-on-metal (MoM) hip replacements, current evidence suggests that orthopaedic surgeons should avoid reliance on any single investigative tool. Current risk stratification guidelines can be difficult to interpret because they do not provide guidance when there are several risk factors in different groups (high and low risk). To improve the clinical utility of risk stratification guidelines, we designed a scoring system to assess the risk of revision. The study population consisted of 1,709 patients (1,912 hips) enrolled in a multicenter follow-up study of a recalled MoM hip replacement. Eleven scoring criteria were determined on the basis of existing follow-up algorithm recommendations and consisted of patient-related factors, symptoms, clinical status, implant type, metal ion levels, and radiographic imaging results. Forward stepwise logistic regression was conducted to determine the minimum set of predictive variables for the risk of revision and to assign variable weights. The MoM risk score for each hip was then created by averaging the weighted values of each predictive variable. Receiver operating characteristic curve analysis yielded good discrimination between all revised and unrevised hips, with an area under the curve of 0.82 (p < 0.001). The odds of revision for the group with a high MoM risk score were increased by 5.8-fold (95% confidence interval [CI], 3.1 to 11.0) relative to the moderate risk group and by 21.8-fold (95% CI, 9.9 to 48.0) compared with the low risk group. Although the use of MoM hip arthroplasty has been limited since 2010, we continue to be faced with the follow-up and risk assessment of thousands of patients who have not had a revision. As more knowledge about risk stratification is gained, the complexity of the algorithms is expected to increase. We propose the use of the MoM risk score as a tool to aid in the clinical decision-making process. Therapeutic Level IV. See Instructions
Gustafson, Klas; Jakobsen, Stig S; Lorenzen, Nina D; Thyssen, Jacob P; Johansen, Jeanne D; Bonefeld, Charlotte M; Stilling, Maiken; Baad-Hansen, Thomas; Søballe, Kjeld
Background Metal-on-metal (MOM) total hip arthroplasties were reintroduced because of the problems with osteolysis and aseptic loosening related to polyethylene wear of early metal-on-polyethylene (MOP) arthroplasties. The volumetric wear rate has been greatly reduced with MOM arthroplasties; however, because of nano-size wear particles, the absolute number has been greatly increased. Thus, a source of metal ion exposure with the potential to sensitize patients is present. We hypothesized that higher amounts of wear particles result in increased release of metal ions and ultimately lead to an increased incidence of metal allergy. Methods 52 hips in 52 patients (median age 60 (51–64) years, 30 women) were randomized to either a MOM hip resurfacing system (ReCap) or a standard MOP total hip arthoplasty (Mallory Head/Exeter). Spot urine samples were collected preoperatively, postoperatively, after 3 months, and after 1, 2, and 5 years and tested with inductively coupled plasma-sector field mass spectrometry. After 5 years, hypersensitivity to metals was evaluated by patch testing and lymphocyte transformation assay. In addition, the patients answered a questionnaire about hypersensitivity. Results A statistically significant 10- to 20-fold increase in urinary levels of cobalt and chromium was observed throughout the entire follow-up in the MOM group. The prevalence of metal allergy was similar between groups. Interpretation While we observed significantly increased levels of metal ions in the urine during the entire follow-up period, no difference in prevalence of metal allergy was observed in the MOM group. However, the effect of long-term metal exposure remains uncertain. PMID:24930546
Queiroz, Roberto Dantas; Faria, Rafael Salomon Silva; Duarte, David Marcelo; Takano, Marcelo Itiro; Sugiyama, Mauricio Morita
To investigate the percentage of ideal patients who would be eligible for hip-resurfacing surgery at a reference service for hip arthroplasty. Out of all the cases of hip arthroplasty operated at Hospital do Servidor Público Estadual de São Paulo (HSPE) between January 2009 and December 2010, we assessed a total of 592 procedures that would fit the criteria for indication for resurfacing arthroplasty, after clinical and radiological evaluation according to the criteria established by the Food and Drug Administration (FDA) and by Seyler et al. Among the total number of hip replacement arthroplasty cases, 5.74% of the patients were eligible. Among the patients who underwent primary arthroplasty, we found that 8.23% presented ideal conditions for this procedure. The study demonstrated that this type of surgery still has a limited role among hip surgery methods.
... bone is reshaped and capped with a metal prosthesis. The hip socket is fitted with a metal ... but higher levels may be problematic. The socket prosthesis for a traditional hip replacement is usually lined ...
Liu, F; Wang, F C; Jin, Z M; Hirt, F; Rieker, C; Grigoris, P
The elastohydrodynamic lubrication (EHL) analysis was carried out in this study for a 28 mm diameter metal-on-metal hip prosthesis employing a metallic cup with an ultra-high molecular weight polyethylene (UHMWPE) backing under a simple steady state rotation representing the flexion/extension during walking. Both Reynolds and elasticity equations were coupled and solved numerically by the finite difference method. The elastic deformation was determined by means of the fast Fourier transform (FFT) technique using the displacement coefficients obtained from the finite element method. Excellent agreement of the predicted elastic deformation was obtained between the FFT technique and the conventional direct summation method. The number of grid points used in the lubrication analysis was found to be important in predicting accurate film thicknesses, particularly at low viscosities representative of physiological lubricants. The effect of the clearance between the femoral head and the acetabular cup on the predicted lubricant film thickness was shown to be significant, while the effect of load was found to be negligible. Overall, the UHMWPE backing was found not only to reduce the contact pressure as identified in a previous study by the authors (Liu et al., 2003) but also significantly to increase the lubricant film thickness for the 28 mm diameter metal-on-metal hip implant, as compared with a metallic mono-block cup.
Lonati, Davide; Ragghianti, Benedetta; Ronchi, Anna; Vecchio, Sarah; Locatelli, Carlo Alessandro
Systemic toxicity associated with cobalt (Co) and chromium (Cr) containing metal hip alloy may result in neuropathy, cardiomyopathy, and hypothyroidism. However clinical management concerning chelating therapy is still debated in literature. Here are described two metal-on-metal hip-implanted patients in which N-acetyl-cysteine decreased elevated blood metal levels. A 67-year-old male who underwent Co/Cr hip implant in September 2009 referred to our Poison Control Centre for persisting elevated Co/Cr blood levels (from March 2012 to November 2014). After receiving oral high-dose N-acetyl-cysteine, Co/Cr blood concentrations dropped by 86% and 87% of the prechelation levels, respectively, and persisted at these latter concentrations during the following 6 months of follow-up. An 81-year-old female who underwent Co/Cr hip implant in January 2007 referred to our Centre for detection of high Co and Cr blood levels in June 2012. No hip revision was indicated. After a therapy with oral high-dose N-acetyl-cysteine Co/Cr blood concentrations decreased of 45% and 24% of the prechelation levels. Chelating agents reported in hip-implanted patients (EDTA, DMPS, and BAL) are described in few cases. N-acetyl-cysteine may provide chelating sites for metals and in our cases reduced Co and Cr blood levels and resulted well tolerable. PMID:27148463
McArthur, John R; Costa, Matthew; Griffin, Damian R; Krikler, Steven J; Parsons, Nicholas; Foguet, Pedro R
We compared 47 patients with groin pain following hip resurfacing to a matched control group. Functional scores and plain radiographs were assessed along with measurement of whole blood cobalt and chromium by inductively coupled mass spectrometry. Symptomatic patients underwent ultrasound scan of the affected hip. Mean functional outcomes were poor in those with pain and good in the control group. Groin pain was associated with valgus stem positioning and lower neck:head ratio (relatively narrow neck) (p=0.03, p=0.04 respectively). We classified patients with groin pain into two groups: biological and mechanical. The biological group had soft tissue abnormalities on USS and higher levels of cobalt and chromium (p=0.04, p=0.05 respectively). The mechanical group had normal USS, lower metal ion levels and more retroverted femoral components (p=0.01).
Weissinger, M; Grübl, A; Pöll, G
Total hip arthroplasty increases the use of alternate bearings to prevent polyethylene wear as the number of younger and more active patients has drastically risen. We carried out a prospective randomized study, to assess and compare clinical results and radiological changes, serum-cobalt- and serum-aluminium-levels when metal-on-metal and ceramic-on-ceramic bearings are applicated. After giving informed consent 80 consecutive patients were included in this prospective randomized study. They were randomly assigned to receive either a metal-on-metal or a ceramic-on-ceramic bearing in their total hip replacement. Eligible were patients with a primary coxarthrosis or an avascular necrosis of the head of femur. Of the 80 patients 54 were females and 26 males. 42 patients were randomized to a metal-on-metal bearing and 38 patients were randomized to a ceramic-on-ceramic bearing. The average patient-age was 65,8 years and the mean body mass index was 27,7 at the time of operation. Surgery was performed through a transgluteal approach in supine position under general or spinal anaesthesia. A forged conical threaded acetabular component made of titanium-aluminium-niobium alloy was used in all patients. The metal inlays and the 28 mm metal heads were made of Co-28Cr-6Mo alloy with a carbon content of 0,2%. The ceramic inlays and the 28 mm ceramic heads are Al2O3 implants. We used as femoral component a conical rectangular stem of a titanium-aluminium-niobium alloy. Cup and stem werde implanted cementfree. Clinical data werde obtained at a follow up at a minimum of two years after implantation. Patients were assessed with the Harris Hip Score and the University of California at Los Angeles activity scale. 72 of the 80 patients could be explored clinically and radiologically. The 2 year follow up check showed clinically and radiologically no difference between the two groups. The median Harris HipScore was above 90 points and the UCLA score was about 7 points. The medium
Distributed analysis of hip implants using six national and regional registries: comparing metal-on-metal with metal-on-highly cross-linked polyethylene bearings in cementless total hip arthroplasty in young patients.
Furnes, Ove; Paxton, Elizabeth; Cafri, Guy; Graves, Stephen; Bordini, Barbara; Comfort, Thomas; Rivas, Moises Coll; Banerjee, Samprit; Sedrakyan, Art
The regulation of medical devices has attracted controversy recently because of problems related to metal-on-metal hip implants. There is growing evidence that metal-on-metal implants fail early and cause local and systemic complications. However, the failure associated with metal-on-metal head size is not consistently documented and needs to be communicated to patients and surgeons. The purpose of this study is to compare implant survival of metal on metal with that of metal on highly cross-linked polyethylene. Using a distributed health data network, primary total hip arthroplasties were identified from six national and regional total joint arthroplasty registries (2001 to 2010). Inclusion criteria were patient age of forty-five to sixty-four years, cementless total hip arthroplasties, primary osteoarthritis diagnosis, and exclusion of the well-known outlier implant ASR (articular surface replacement). The primary outcome was revision for any reason. A meta-analysis of survival probabilities was performed with use of a fixed-effects model. Metal-on-metal implants with a large head size of >36 mm were compared with metal-on-highly cross-linked polyethylene implants. Metal-on-metal implants with a large head size of >36 mm were used in 5172 hips and metal-on-highly cross-linked polyethylene implants were used in 14,372 hips. Metal-on-metal total hip replacements with a large head size of >36 mm had an increased risk of revision compared with metal-on-highly cross-linked polyethylene total hip replacements with more than two years of follow-up, with no difference during the first two years after implantation. The results of the hazard ratios (and 95% confidence intervals) from the multivariable model at various durations of follow-up were 0.95 (0.74 to 1.23) at zero to two years (p = 0.698), 1.42 (1.16 to 1.75) at more than two years to four years (p = 0.001), 1.78 (1.45 to 2.19) at more than four years to six years (p < 0.001), and 2.15 (1.63 to 2.83) at more than
Distributed Analysis of Hip Implants Using Six National and Regional Registries: Comparing Metal-on-Metal with Metal-on-Highly Cross-Linked Polyethylene Bearings in Cementless Total Hip Arthroplasty in Young Patients
Furnes, Ove; Paxton, Elizabeth; Cafri, Guy; Graves, Stephen; Bordini, Barbara; Comfort, Thomas; Rivas, Moises Coll; Banerjee, Samprit; Sedrakyan, Art
Background: The regulation of medical devices has attracted controversy recently because of problems related to metal-on-metal hip implants. There is growing evidence that metal-on-metal implants fail early and cause local and systemic complications. However, the failure associated with metal-on-metal head size is not consistently documented and needs to be communicated to patients and surgeons. The purpose of this study is to compare implant survival of metal on metal with that of metal on highly cross-linked polyethylene. Methods: Using a distributed health data network, primary total hip arthroplasties were identified from six national and regional total joint arthroplasty registries (2001 to 2010). Inclusion criteria were patient age of forty-five to sixty-four years, cementless total hip arthroplasties, primary osteoarthritis diagnosis, and exclusion of the well-known outlier implant ASR (articular surface replacement). The primary outcome was revision for any reason. A meta-analysis of survival probabilities was performed with use of a fixed-effects model. Metal-on-metal implants with a large head size of >36 mm were compared with metal-on-highly cross-linked polyethylene implants. Results: Metal-on-metal implants with a large head size of >36 mm were used in 5172 hips and metal-on-highly cross-linked polyethylene implants were used in 14,372 hips. Metal-on-metal total hip replacements with a large head size of >36 mm had an increased risk of revision compared with metal-on-highly cross-linked polyethylene total hip replacements with more than two years of follow-up, with no difference during the first two years after implantation. The results of the hazard ratios (and 95% confidence intervals) from the multivariable model at various durations of follow-up were 0.95 (0.74 to 1.23) at zero to two years (p = 0.698), 1.42 (1.16 to 1.75) at more than two years to four years (p = 0.001), 1.78 (1.45 to 2.19) at more than four years to six years (p < 0.001), and 2
Greiner, Justin J; Callaghan, John J; Bedard, Nicholas A; Liu, Steve S; Goetz, Devon D; Mahoney, Craig R
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. 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. 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. 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. Copyright © 2016 Elsevier Inc. All rights reserved.
van der Weegen, Walter; Smolders, Jose M H; Sijbesma, Thea; Hoekstra, Henk J; Brakel, Koen; van Susante, Job L C
We intensified our screening protocol for the presence of pseudotumours in a consecutive series of patients with a hip resurfacing arthroplasty (HRA), to establish whether we should be alert to the presence of 'silent' pseudotumours. Patients categorised with high risk (11 hips) and low risk (10 hips) for pseudotumour development and a control group (23 hips) were screened with metal artefact reduction sequence (MARS) magnetic resonance imaging (MRI). The Anderson classification to grade any metal-on-metal (MoM) disease present on MARS-MRI images was used. In 15 out of 44 MRI scans pseudotumours were observed (34.1%), of which six were graded with mild (13.6%), eight with moderate (18.2%) and one with severe MoM disease (2.3%). Twelve pseudotumours were present in asymptomatic patients (27.3%). Metal ion levels were normal in 80% of the MARS-MRI screened patients. As a consequence of our intensified screening protocol, one patient was revised for pseudotumour formation and another patient was scheduled for revision. Silent pseudotumours were observed in all three groups. Before our intensified screening protocol was initiated, no pseudotumours were encountered in our cohort of 289 HRAs. We concluded that clinical outcomes and plain radiographs for screening MoM patients underestimates the presence of pseudotumours in MoM patients. The true clinical relevance of these pseudotumours is still unclear.
Van Der Straeten, Catherine; Grammatopoulos, George; Gill, Harinderjit S; Calistri, Alessandro; Campbell, Patricia; De Smet, Koen A
The interpretation of metal ion concentrations and their role in clinical management of patients with metal-on-metal implants is still controversial. We questioned whether patients undergoing hip resurfacing with no clinical problems could be differentiated from those with clinical (pain, loss of function) and/or radiographic (component malpositioning, migration, bone loss), problems based on metal ion levels, and if there was a threshold metal level that predicted the need for clinical intervention. Furthermore, we asked if patient and implant factors differed between these functional groups. We retrospectively identified 453 unilateral and 139 bilateral patients with ion measurements at minimum followup of 12 months (mean, 4.3 years; range, 1-12.9 years). Patients were designated as well functioning or poorly functioning based on strict criteria. The acceptable upper levels within the well-functioning group were determined from the 75th percentile plus 1.5× interquartile range. The sensitivity and specificity of these levels to predict clinical problems were calculated. Well-functioning group ions were lower than the poorly functioning group ion levels. The acceptable upper levels were: chromium (Cr) 4.6 μg/L, cobalt (Co) 4.0 μg/L unilateral and Cr 7.4 μg/L, Co 5.0 μg/L bilateral. The specificity of these levels in predicting poor function was high (95%) and sensitivity was low (25%). There were more males in the well-functioning group and more females and smaller femoral components in the poorly functioning group. Metal levels higher than these proposed safe upper limits can predict problems with metal-on-metal resurfacings and are important parameters in the management of at-risk patients. Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Frølich, Christina; Hansen, Torben Bæk
Adverse reactions to metal-on-metal (MoM) prostheses are well known from total hip joint resurfacing arthroplasty with elevated serum chrome or cobalt, pain and pseudo tumor formation. It may, however, also be seen after total joint replacement of the trapeziometacarpal joint using MoM articulation, and we present two cases of failure of MoM prostheses due to elevated metal-serum levels in one case and pseudo tumor formation in another case. Furthermore, we suggest a diagnostic algorithm for joint pain after MoM trapeziometacarpal joint replacement based on published experiences from MoM hip prostheses and adverse reactions to metal. PMID:26020592
Tiusanen, H; Mäkelä, K; Kiilunen, M; Sarantsin, P; Sipola, E; Pesola, M
Recent advancements in manufacturing technology have enabled more precise tolerances and surface finishes using metal-on-metal bearing surfaces in total hip arthroplasty. The aim of this study was to compare the level of metal ions in urine after implantation of a 28-mm metal-on-metal bearing manufactured from high-carbon wrought alloy and a 28-mm metal-on-polyethylene bearing. A total of 92 total hip arthroplasty patients were prospectively randomized into two groups: those receiving metal-on-metal bearings and those receiving metal-on-polyethylene bearings. Chromium, cobalt, and molybdenum ion levels in urine were measured preoperatively and at 1 year and 2 years postoperatively. In the metal-on-polyethylene group, there was a slight increase in mean chromium and cobalt concentrations at 2-year follow-up compared to the preoperative level (p = 0.02 for both chromium and cobalt). In the metal-on-metal group, there was a 15-fold increase in chromium and a 26-fold increase in cobalt at 2-year follow-up compared to the preoperative level (p < 0.001 for both chromium and cobalt). However, the quantity of chromium and cobalt in urine from the metal-on-metal group was not higher at 2-year follow-up than at 1-year follow-up (p = 0.5 and p = 0.6, respectively). The 28-mm metal-on-metal bearings yield chromium and cobalt concentrations in urine that can be higher than those recommended for occupational exposure. However, our results also indicate that a steady state in wear and ion production using metal-on-metal total hip arthroplasty can occur.
Anglin, Carolyn; Masri, Bassam A; Tonetti, Jérôme; Hodgson, Antony J; Greidanus, Nelson V
Femoral neck fracture is the most common short-term concern after hip resurfacing arthroplasty. Currently, there is little basis to decide between neutral and valgus placement. We loaded 10 notched cadaveric femur pairs to failure; one side was implanted at 0 degrees relative to the femoral neck and the other at 10 degrees valgus. All 20 were dual-energy X-ray absorptiometry-scanned. Failure load correlated with bone mineral density. Valgus placement increased the fracture load by an average of 28% over neutral for specimens with normal bone mineral density but had no effect on fracture load in specimens with low bone mineral density. For specimens with normal bone mineral density (typical of patients undergoing resurfacing arthroplasty), neutral-valgus placement had a greater effect than bone mineral density, explaining 54% of the fracture load variance. Component placement greater than 10 degrees valgus is likely undesirable because this can lead to an increase in component size and a greater likelihood of notching. To reduce fracture risk, we recommend placing the femoral component in valgus and selecting patients with higher bone mineral density.
Sabah, S. A.; Henckel, J.; Cook, E.; Whittaker, R.; Hothi, H.; Pappas, Y.; Blunn, G.; Skinner, J. A.; Hart, A. J.
Arthroplasty registries are important for the surveillance of joint replacements and the evaluation of outcome. Independent validation of registry data ensures high quality. The ability for orthopaedic implant retrieval centres to validate registry data is not known. We analysed data from the National Joint Registry for England, Wales and Northern Ireland (NJR) for primary metal-on-metal hip arthroplasties performed between 2003 and 2013. Records were linked to the London Implant Retrieval Centre (RC) for validation. A total of 67 045 procedures on the NJR and 782 revised pairs of components from the RC were included. We were able to link 476 procedures (60.9%) recorded with the RC to the NJR successfully. However, 306 procedures (39.1%) could not be linked. The outcome recorded by the NJR (as either revised, unrevised or death) for a primary procedure was incorrect in 79 linked cases (16.6%). The rate of registry-retrieval linkage and correct assignment of outcome code improved over time. The rates of error for component reference numbers on the NJR were as follows: femoral head category number 14/229 (5.0%); femoral head batch number 13/232 (5.3%); acetabular component category number 2/293 (0.7%) and acetabular component batch number 24/347 (6.5%). Registry-retrieval linkage provided a novel means for the validation of data, particularly for component fields. This study suggests that NJR reports may underestimate rates of revision for many types of metal-on-metal hip replacement. This is topical given the increasing scope for NJR data. We recommend a system for continuous independent evaluation of the quality and validity of NJR data. Cite this article: Bone Joint J 2015;97-B:10–18. PMID:25568407
Sprecher, Christoph M; Wimmer, Markus A; Milz, Stefan; Taeger, Georg
Background and purpose Particles originating from the articulating surfaces of hip endoprostheses often induce an inflammatory response, which can be related to implant failure. We therefore analyzed the metal content in capsular tissue from 44 McKee-Farrar metal-on-metal hip prostheses (with 3 different head sizes) and we also analyzed the morphological structure of layers located on articulating surfaces. Methods Atomic absorption spectrometry (AAS) was used to analyze the metal content in capsular tissue. Visually detectable carbon layers located on the articulating surfaces were evaluated using scanning electron microscopy (SEM), energy-dispersive Xray spectroscopy (EDX), and X-ray photoelectron spectroscopy (XPS). Results Metallic debris was detected in all capsular tissue samples but no statistically significant differences in metal content were found in relation to implant head size. The morphological characteristics of the different layer zones allowed an exact analysis of contact and non-contact areas. Furthermore, surface layers appear to have a protective function because they can prevent sharp-edged particles from damaging the prostheses surface. Interpretation The implant head size does not appear to influence the amount of metallic debris. The layers obviously act like a lubricating agent because the protection function does not occur in regions without layers where the metal surface often shows numerous scratches. As layers are not generated immediately after the implantation of hip prostheses, these findings may at least partially explain the high amount of wear early after implantation. PMID:19421914
Schouten, R; Malone, A A; Tiffen, C; Frampton, C M; Hooper, G
In a double-blinded randomised controlled trial, 83 patients with primary osteoarthritis of the hip received either a ceramic-on-metal (CoM) or metal-on-metal (MoM) total hip replacement (THR). The implants differed only in the bearing surfaces used. The serum levels of cobalt and chromium and functional outcome scores were compared pre-operatively and at six and 12 months post-operatively. Data were available for 41 CoM and 36 MoM THRs (four patients were lost to follow-up, two received incorrect implants). The baseline characteristics of both cohorts were similar. Femoral head size measured 36 mm in all but two patients who had 28 mm heads. The mean serum cobalt and chromium levels increased in both groups, with no difference noted between groups at six months (cobalt p = 0.67, chromium p = 0.87) and 12 months (cobalt p = 0.76, chromium p = 0.76) post-operatively. Similarly, the mean Oxford hip scores, Western Ontario and McMaster Universities Osteoarthritis index and University of California, Los Angeles activity scores showed comparable improvement at 12 months. Our findings indicate that CoM and MoM couplings are associated with an equivalent increase in serum cobalt and chromium levels, and comparable functional outcome scores at six and 12-months follow-up.
Reito, Aleksi; Elo, Petra; Nieminen, Jyrki; Puolakka, Timo; Eskelinen, Antti
Background and purpose There are no international guidelines to define adverse reaction to metal debris (ARMD). Muscle fatty atrophy has been reported to be common in patients with failing metal-on-metal (MoM) hip replacements. We assessed whether gluteal muscle fatty atrophy is associated with elevated blood metal ion levels and pseudotumors. Patients and methods 263 consecutive patients with unilateral ASR XL total hip replacement using a posterior approach and with an unoperated contralateral hip were included in the study. All patients had undergone a standard screening program at our institution, including MRI and blood metal ion measurement. Muscle fatty atrophy was graded as being absent, mild, moderate, or severe in each of the gluteal muscles. Results The prevalance of moderate-to-severe gluteal muscle atrophy was low (12% for gluteus minimus, 10% for gluteus medius, and 2% for gluteus maximus). Muscle atrophy was neither associated with elevated blood metal ion levels (> 5 ppb) nor with the presence of a clear (solid- or mixed-type) pseudotumor seen in MRI. A combination of moderate-to-severe atrophy in MRI, elevated blood metal ion levels, and MRI-confirmed mixed or solid pseudotumor was rare. Multivariable regression revealed that “preoperative diagnosis other than osteoarthrosis” was the strongest predictor of the presence of fatty atrophy. Interpretation Gluteal muscle atrophy may be a clinically significant finding with influence on hip muscle strength in patients with MoM hip replacement. However, our results suggest that gluteal muscle atrophy seen in MRI is not associated with either the presence or severity of ARMD, at least not in patients who have been operated on using the posterior approach. PMID:26427902
Halim, T.; Clarke, I. C.; Burgett-Moreno, M. D.; Donaldson, T. K.; Savisaar, C.; Bowsher, J. G.
Objectives Third-body wear is believed to be one trigger for adverse results with metal-on-metal (MOM) bearings. Impingement and subluxation may release metal particles from MOM replacements. We therefore challenged MOM bearings with relevant debris types of cobalt–chrome alloy (CoCr), titanium alloy (Ti6Al4V) and polymethylmethacrylate bone cement (PMMA). Methods Cement flakes (PMMA), CoCr and Ti6Al4V particles (size range 5 µm to 400 µm) were run in a MOM wear simulation. Debris allotments (5 mg) were inserted at ten intervals during the five million cycle (5 Mc) test. Results In a clean test phase (0 Mc to 0.8 Mc), lubricants retained their yellow colour. Addition of metal particles at 0.8 Mc turned lubricants black within the first hour of the test and remained so for the duration, while PMMA particles did not change the colour of the lubricant. Rates of wear with PMMA, CoCr and Ti6Al4V debris averaged 0.3 mm3/Mc, 4.1 mm3/Mc and 6.4 mm3/Mc, respectively. Conclusions Metal particles turned simulator lubricants black with rates of wear of MOM bearings an order of magnitude higher than with control PMMA particles. This appeared to model the findings of black, periarticular joint tissues and high CoCr wear in failed MOM replacements. The amount of wear debris produced during a 500 000-cycle interval of gait was 30 to 50 times greater than the weight of triggering particle allotment, indicating that MOM bearings were extremely sensitive to third-body wear. Cite this article: Bone Joint Res 2015;4:29–37. PMID:25736072
Berber, Reshid; Henckel, Johann; Khoo, Michael; Wan, Simon; Hua, Jia; Skinner, John; Hart, Alister
SPECT-CT is increasingly used to assess painful knee arthroplasties. The aim of this study was to evaluate the clinical usefulness of SPECT-CT in unexplained painful MOM hip arthroplasty. We compared the diagnosis and management plan for 19 prosthetic MOM hips in 15 subjects with unexplained pain before and after SPECT-CT. SPECT-CT changed the management decision in 13 (68%) subjects, Chi-Square=5.49, P=0.24. In 6 subjects (32%) pain remained unexplained however the result reassured the surgeon to continue with non-operative management. SPECT-CT should be reserved as a specialist test to help identify possible causes of pain where conventional investigations have failed. It can help reassure surgeons making management decisions for patients with unexplained pain following MOM hip arthroplasty. Copyright © 2014 Elsevier Inc. All rights reserved.
Sambri, A; Cadossi, M; Mazzotti, A; Faldini, C; Giannini, S
Osteoarthritis secondary to developmental dysplasia of the hip is a surgical challenge because of the modified anatomy of the acetabulum which is deficient in its shape with poor bone quality, torsional deformities of the femur and the altered morphology of femoral head. Particularly in Crowe type III and IV, additional surgical challenges are present, such as limb-length discrepancy and adductor muscle contractures. This is a bilateral hip dysplasia case where bilateral hip replacement was indicated, on the left side with a resurfacing one and on the other side a two stage procedure using a iliofemoral external fixator to restore equal leg length with a lower risk of complications. This case report shows both the negative clinical outcome of the left and the excellent one of the right hip where the dysplasia was much more severe. Patient selection and implant positioning are crucial in determining long-term results.
Durrani, Salim K; Noble, Philip C; Sampson, Barry; Panetta, Therese; Liddle, Alexander D; Sabah, Shiraz A; Chan, Newton K; Skinner, John A; Hart, Alister J
In patients with metal-on-metal (MoM) hip prostheses, pain and joint effusions may be associated with elevated blood levels of cobalt and chromium ions. Since little is known about the kinetics of metal ion clearance from the body and the rate of resolution of elevated blood ion levels, we examined the time course of cobalt and chromium ion levels after revision of MoM hip replacements. We included 16 patients (13 female) who underwent revision of a painful MoM hip (large diameter, modern bearing) without fracture or infection, and who had a minimum of 4 blood metal ion measurements over an average period of 6.1 (0-12) months after revision. Average blood ion concentrations at the time of revision were 22 ppb for chromium and 43 ppb for cobalt. The change in ion levels after revision surgery varied extensively between patients. In many cases, over the second and third months after revision surgery ion levels decreased to 50% of the values measured at revision. Decay of chromium levels occurred more slowly than decay of cobalt levels, with a 9% lag in return to normal levels. The rate of decay of both metals followed second-order (exponential) kinetics more closely than first-order (linear) kinetics. The elimination of cobalt and chromium from the blood of patients who have undergone revision of painful MoM hip arthroplasties follows an exponential decay curve with a half-life of approximately 50 days. Elevated blood levels of cobalt and chromium ions can persist for at least 1 year after revision, especially in patients with high levels of exposure.
Ebreo, D; Bell, P J; Arshad, H; Donell, S T; Toms, A; Nolan, J F
Metal artefact reduction (MAR) MRI is now widely considered to be the standard for imaging metal-on-metal (MoM) hip implants. The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended cross-sectional imaging for all patients with symptomatic MoM bearings. This paper describes the natural history of MoM disease in a 28 mm MoM total hip replacement (THR) using MAR MRI. Inclusion criteria were patients with MoM THRs who had not been revised and had at least two serial MAR MRI scans. All examinations were reported by an experienced observer and classified as A (normal), B (infection) or C1-C3 (mild, moderate, severe MoM-related abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed on 80 patients (two to four scans per THR); 63 initial MRIs (61%) were normal. On subsequent MRIs, six initially normal scans (9.5%) showed progression to a disease state; 15 (15%) of 103 THRs with sequential scans demonstrated worsening disease on subsequent imaging. Most patients with a MoM THR who do not undergo early revision have normal MRI scans. Late progression (from normal to abnormal, or from mild to more severe MoM disease) is not common and takes place over several years.
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Hip joint metal/polymer or ceramic/polymer... Devices § 888.3410 Hip joint metal/polymer or ceramic/polymer semiconstrained resurfacing cemented prosthesis. (a) Identification. A hip joint metal/polymer or ceramic/polymer semi-constrained resurfacing...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Hip joint metal/polymer or ceramic/polymer... Devices § 888.3410 Hip joint metal/polymer or ceramic/polymer semiconstrained resurfacing cemented prosthesis. (a) Identification. A hip joint metal/polymer or ceramic/polymer semi-constrained resurfacing...
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Hip joint metal/polymer or ceramic/polymer... Devices § 888.3410 Hip joint metal/polymer or ceramic/polymer semiconstrained resurfacing cemented prosthesis. (a) Identification. A hip joint metal/polymer or ceramic/polymer semi-constrained resurfacing...
Aulakh, T S; Jayasekera, N; Singh, R; Patel, A; Kuiper, J H; Richardson, J B
Hip resurfacing had initially gained acceptance and popularity as it helps preserve femoral bone stock. In this study we tried to answer the following questions; 1. Whether there is a learning curve for hip resurfacing? 2. Is it present in surgeons from non-developer centres? 3. Is it present in surgeons from developer centres as well? The Oswestry outcome centre was setup to serve an independent international registry for collecting, analysing and reporting outcomes following hip resurfacing. Over a 10 year period, 4535 patients (5000 hips) were recruited from different countries and within the UK from different centres in this study by 139 surgeons from 37 different countries. Our study has shown that function can be used to assess the level of surgical competence. The results from this multilevel analysis have helped to answer the questions posed in the introduction. Hip resurfacing is a surgical procedure with a learning phase and this learning effect is more pronounced in non-developer surgeons as compared to developer surgeons. Hip scores can be used to assess proficiency and competence of surgeons undertaking hip resurfacing arthroplasty.
Rakow, Anastasia; Schoon, Janosch; Dienelt, Anke; John, Thilo; Textor, Martin; Duda, Georg; Perka, Carsten; Schulze, Frank; Ode, Andrea
In hip arthroplasty the implants' articulating surfaces can be made of a cobalt-chromium-molybdenum (CoCrMo) alloy. The use of these metal-on-metal (MoM) pairings can lead to the release of wear products such as metallic particles and dissociated metal species, raising concerns regarding their safety amongst orthopedic surgeons and the public. MoM-wear particles are reported to be heterogeneous in their physicochemical properties, are capable of inducing adverse effects on a cellular level and are thought to be involved in relevant clinical problems like aseptic osteolysis. Yet, it remains elusive how MoM-wear affects bone forming cells and their progenitors: bone marrow residing mesenchymal stromal cells (MSCs). This study introduces an assessment of the in vivo exposure to particulate and dissociated Co and Cr and evaluates the effects of MoM-wear on MSCs. The exposure to MoM-wear products in vivo and in vitro leads to a decrease in MSCs' osteogenic matrix mineralization and alkaline phosphatase activity on a cellular and systemic level. In conclusion, MoM-wear products are released in the periprosthetic region and elevate bone marrow Co and Cr concentrations towards levels that impair osteogenic differentiation of MSCs. Therefore, the ongoing use of CoCrMo alloys for articulating surfaces in joint replacement implants needs critical reconsideration. Copyright © 2016 Elsevier Ltd. All rights reserved.
Lu, Zhen; McKellop, Harry A
This study compared the accuracy and sensitivity of several numerical methods employing spherical or plane triangles for calculating the volumetric wear of retrieved metal-on-metal hip joint implants from coordinate measuring machine measurements. Five methods, one using spherical triangles and four using plane triangles to represent the bearing and the best-fit surfaces, were assessed and compared on a perfect hemisphere model and a hemi-ellipsoid model (i.e. unworn models), computer-generated wear models and wear-tested femoral balls, with point spacings of 0.5, 1, 2 and 3 mm. The results showed that the algorithm (Method 1) employing spherical triangles to represent the bearing surface and to scale the mesh to the best-fit surfaces produced adequate accuracy for the wear volume with point spacings of 0.5, 1, 2 and 3 mm. The algorithms (Methods 2-4) using plane triangles to represent the bearing surface and to scale the mesh to the best-fit surface also produced accuracies that were comparable to that with spherical triangles. In contrast, if the bearing surface was represented with a mesh of plane triangles and the best-fit surface was taken as a smooth surface without discretization (Method 5), the algorithm produced much lower accuracy with a point spacing of 0.5 mm than Methods 1-4 with a point spacing of 3 mm.
Williams, S; Tipper, J L; Ingham, E; Stone, M H; Fisher, J
Extremely low wear rates have been reported for metal-on-metal total hip replacements, but concerns remain about the effects of metal ion release, dissolution rates and toxicity. Surface-engineered coatings have the potential to improve wear resistance and reduce the biological activity of the wear debris produced. The aim of this study was to examine the wear and wear debris generation from surface-engineered coatings: titanium nitride (TiN), chromium nitride (CrN) and chromium carbon nitride (CrCN) applied to a cobalt-chrome alloy (CoCr) substrate. The coatings were articulated against themselves in a simple geometry model. The wear particles generated were characterized and the cytotoxic effect on U937 macrophages and L929 fibroblasts assessed. The CrN and CrCN coatings showed a decrease in wear compared to the CoCr bearings and produced small (less than 40 nm in length) wear particles. The wear particles released from the surface engineered bearings also showed a decreased cytotoxic effect on cells compared to the CoCr alloy debris. The reduced wear volumes coupled with the reduced cytotoxicity per unit volume of wear indicate the potential for the clinical application of this technology.
Hosman, Anton H; van der Mei, Henny C; Bulstra, Sjoerd K; Busscher, Henk J; Neut, Daniëlle
Metal-on-metal (MOM) bearings involving cobalt-chromium (Co-Cr) alloys in total hip arthroplasties are becoming more and more popular due to their low wear. Consequences of corrosion products of Co-Cr alloys are for the most part unclear, and the influence of cobalt and chromium ions on biofilm formation has never been studied. Therefore, the aim of this study was to evaluate how Co-Cr ions affect bacterial growth, biofilm formation, and architecture. A collection of clinically isolated and commercially available bacterial strains were exposed to Co-Cr concentrations as found in serum and above as found in adjacent tissue. Planktonic growth of bacteria was inhibited by concentrations of 200,000/93,000 microg/L Co-Cr. Co-Cr concentrations up to 20/9.3 microg/L as reported to occur in serum revealed no consistent influence on biofilm formation, but higher concentrations of 200,000/93,000 microg/L significantly reduced Staphylococcus aureus and CNS biofilm formation. As indicated by confocal laser scanning microscopy, no dead bacteria were encountered in the biofilms, and the metal ion concentrations used must be classified as growth-inhibiting and not bactericidal. Long-term clinical data on infection rates for Co-Cr MOM-bearings are not yet available, but the current results suggest that Co-Cr ions may yield these prostheses less prone to biofilm formation and subsequent infection. (c) 2008 Wiley Periodicals, Inc.
Newton, Ashley W; Ranganath, Lakshminarayan; Armstrong, Catherine; Peter, Viju; Roberts, Norman B
Evidence shows that raised cobalt (Co), chromium (Cr), and nickel (Ni) whole blood concentrations correlate with poor device outcome in patients following metal-on-metal (MoM) hip arthroplasty. To understand the local and systemic pathological effects of these raised metal concentrations it is important to define their distribution between whole blood, plasma, and urine. The metals were measured by Inductively Coupled Plasma Mass Spectrometry (ICPMS). Two hundred and five plasma, 199 whole blood, and 24 sets of urine samples were analyzed from 202 patients with Co-Cr alloy MoM hip prostheses implanted between 8 months to 12 years (mean 6.0 years) prior to analysis. Plasma Co (median 39.1 nmol/L) showed significantly positive 1:1 correlation with whole blood Co (median 45.9 nmol/L; R(2) = 0.98, p < 0.001, slope = 1.0). Plasma Cr (median 53.8 nmol/L) and whole blood Cr (median 40.3 nmol/L) were also correlated; however, concentrations were significantly higher in plasma indicating relatively little blood cell uptake (R(2) = 0.96, p < 0.001, slope = 1.6). Urinary Co was up to threefold higher than Cr (median 334.0 vs. 97.3 nmol/L respectively). Nickel concentrations in whole blood, plasma, and urine were low relative to Co and Cr. The analysis shows fundamental differences in the physiological handling of these metals: Co is distributed approximately equally between blood cells and plasma, whereas Cr is mainly in plasma, despite which, Cr had far less renal excretion than Co. Copyright © 2012 Orthopaedic Research Society.
Beraudi, Alina; Bianconi, Eva; Catalani, Simona; Canaider, Silvia; De Pasquale, Dalila; Apostoli, Pietro; Bordini, Barbara; Stea, Susanna; Toni, Aldo; Facchin, Federica
Metal ion release and accumulation is considered to be a factor responsible for the high failure rates of metal-on-metal (MoM) hip implants. Numerous studies have associated the presence of these ions, besides other factors, including a hypoxia‑like response and changes in pH due to metal corrosion leading to the induction of the oxidative stress response. The aim of the present study was to verify whether, in patients with a MoM hip prosthesis, mRNA and protein expression of HMOX‑1 was modulated by the presence of metal ions and whether patients without prostheses exhibit a different expression pattern of this enzyme. The study was conducted on 22 matched pairs of patients with and without prostheses, for a total of 44 samples. Ion dosage was determined using inductively coupled plasma mass spectrometry equipped with dynamic cell reaction. HMOX‑1 gene expression was quantified by reverse transcription-quantitative polymerase chain reaction and HMOX‑1 protein expression was analyzed using an enzyme-linked immunosorbent assay. The results demonstrated that although there were significant differences in the metallic ion concentrations amongst the two groups of patients, there was no correlation between circulating levels of cobalt (Co) and chromium (Cr), and HMOX‑1 gene and protein expression. Additionally, there was no significant difference in the protein expression levels of HMOX‑1 between the two groups. In conclusion, it was demonstrated that circulating Co and Cr ions released by articular prosthetics do not induce an increase in HMOX‑1 mRNA and protein expression at least 3.5 years after the implant insertion. The present study suggests that involvement of HMOX‑1 may be excluded from future studies and suggests that other antioxidant enzymes, including superoxide dismutase, glutathione peroxidase and reductase should be investigated.
Myant, C; Underwood, R; Fan, J; Cann, P M
Lubricant films were measured for a series of bovine serum and protein containing (albumin, globulin) saline solutions for CoCrMo femoral component sliding against a glass disc. Central film thickness was measured by optical interferometry as a function of time (constant mean speed: 0 and 10 mm/s) and variable mean speed (0-50 mm/s). The effect of load (5-20 N) on film thickness was also studied. The development of the wear scar on the CoCrMo surface was monitored by measuring the width of the contact zone during the film thickness tests. The results showed film thickness increased with time for both the static and sliding tests. Films formed in the static, loaded test were typically in the range of 3-40 nm. The globulin containing solutions formed the thickest films. In the sliding tests a wear scar rapidly formed on the implant component for the bovine serum and albumin fluids, negligible wear was observed for the globulin solutions. Film thickness increased with sliding time for all test solutions and was much greater than predicted by isoviscous EHL models. The film increase was found to correlate with increasing wear scar size and thus decreasing contact pressure. A new lubricating mechanism is proposed whereby during sliding the fluid undergoes bulk phase separation rheology, so that an elevated protein phase forms in the inlet zone. This protein phase is a high-viscosity biphasic matrix, which is periodically entrained into the contact forming a thick protective hydro-gel film. One of the main findings of this study is that film thickness was very sensitive to load; to a much greater extent than predicted by EHL models. Thus film formation in MoM hip joints is very susceptible to high contact pressures which might be due to implant misalignment and edge-loading.
The effects of articular head size on the wear losses of the metal insert and articular head for a metal-on-metal bearing were examined using a hip simulator manufactured to satisfy ISO 14242-1. The wear properties of metal-on-metal and metal-on-polyethylene bearings were also compared under the same conditions. The total wear losses of the metal insert and articular head decreased with increasing diameter of the metal insert in the range from 28 to 44mm. The total wear loss was greater for a diameter of 48mm than for a diameter of 44mm. When the articular metal insert diameter was smaller than 44mm, the wear loss was reduced because the contact surface pressure increased with increasing metal insert diameter. However, the increase in wear loss observed for the 48-mm-diameter insert might have been due to the considerable increase in the rotation moment with increasing insert diameter. The tendency of decreasing contact pressure calculated using the Hertzian contact stress equation nearly conformed to the change in wear loss. On the other hand, the wear loss of an artificial hip joint consisting of a cross-linked ultrahigh-molecular-weight polyethylene insert (UHMWPE) and a Co-Cr-Mo articular head was small.
Hallab, Nadim J; Caicedo, Marco; McAllister, Kyron; Skipor, Anastasia; Amstutz, Harlan; Jacobs, Joshua J
Some tissues from metal-on-metal (MoM) hip arthroplasty revisions have shown evidence of adaptive-immune reactivity (i.e., excessive peri-implant lymphocyte infiltration/activation). We hypothesized that, prior to symptoms, some people with MoM hip arthroplasty will develop quantifiable metal-induced lymphocyte reactivity responses related to peripheral metal ion levels. We tested three cohorts (Group 1: n = 21 prospective longitudinal MoM hip arthroplasty; Group 2: n = 17 retrospective MoM hip arthroplasty; and Group 3: n = 20 controls without implants). We compared implant position, metal-ion release, and immuno-reactivity. MoM cohorts had elevated (p < 0.01) amounts of serum Co and Cr compared to controls as early as 3 months post-op (Group 1:1.2 ppb Co, 1.5 ppb Cr; Group 2: 3.4 ppb Co, 5.4 ppb Cr; Group 3: 0.01 ppb Co, 0.1 ppb Cr). However, only after 1-4 years post-op did 56% of Group 1 develop metal-reactivity (vs. 5% pre-op, metal-LTT, SI > 2), compared with 76% of Group 2, and 15% of Group 3 controls (patch testing was a poor diagnostic indicator with only 1/21 Group 1 positive). Higher cup-abduction angles (50° vs. 40°) in Group 1 were associated with higher serum Cr (p < 0.07). However, sub-optimal cup-anteversion angles (9° vs. 20°) had higher serum Co (p < 0.08). Serum Cr and Co were significantly elevated in reactive versus non-reactive Group-1 participants (p < 0.04). CD4+CD69+ T-helper lymphocytes (but not CD8+) and IL-1β, IL-12, and IL-6 cytokines were all significantly elevated in metal-reactive versus non-reactive Group 1 participants. Our results showed that lymphocyte reactivity to metals can develop within the first 1-4 years after MoM arthroplasty in asymptomatic patients and lags increases in metal ion levels. This increased metal reactivity was more prevalent in those individuals with extreme cup angles and higher amounts of circulating metal. Copyright © 2012 Orthopaedic Research Society.
Haddad, F S; Konan, S; Tahmassebi, J
The aim of this study was to evaluate the ten-year clinical and functional outcome of hip resurfacing and to compare it with that of cementless hip arthroplasty in patients under the age of 55 years. Between 1999 and 2002, 80 patients were enrolled into the study: 24 were randomised (11 to hip resurfacing, 13 to total hip arthroplasty), 18 refused hip resurfacing and chose cementless total hip arthroplasty with a 32 mm bearing, and 38 insisted on resurfacing. The mean follow-up for all patients was 12.1 years (10 to 14). Patients were assessed clinically and radiologically at one year, five years and ten years. Outcome measures included EuroQol EQ5D, Oxford, Harris hip, University of California Los Angeles and University College Hospital functional scores. No differences were seen between the two groups in the Oxford or Harris hip scores or in the quality of life scores. Despite a similar aspiration to activity pre-operatively, a higher proportion of patients with a hip resurfacing were running and involved in sport and heavy manual labour after ten years. We found significantly higher function scores in patients who had undergone hip resurfacing than in those with a cementless hip arthroplasty at ten years. This suggests a functional advantage for hip resurfacing. There were no other attendant problems. ©2015 The British Editorial Society of Bone & Joint Surgery.
Davis, Edward T; Olsen, Michael; Zdero, Rad; Smith, Gemma M; Waddell, James P; Schemitsch, Emil H
We aimed to establish if radiological parameters, dual energy x-ray absorptiometry (DEXA) and quantitative CT (qCT) could predict the risk of sustaining a femoral neck fracture following hip resurfacing. Twenty-one unilateral fresh frozen femurs were used. Each femur had a plain digital anteroposterior radiograph, DEXA scan and qCT scan. Femurs were then prepared for a Birmingham Hip Resurfacing femoral component and loaded to failure. Results demonstrated that gender and qCT measurements showed strong correlation with failure load. QCT could be used as an individual measure to predict risk of post-operative femoral neck fracture. However, when qCT is unavailable; gender, pre-operative DEXA scan and Neck Width measurements can be used together to assess risk of post-operative femoral neck fracture in patients due to undergo hip resurfacing.
Boomsma, Martijn F; Warringa, Niek; Edens, Mireille A; Mueller, Dirk; Ettema, Harmen B; Verheyen, Cees C P M; Maas, Mario
Quantification of the effect of O-MAR on decreasing metal artefacts caused by large head metal on metal total hip arthroplasty (MoM THA) in a dedicated phantom setup of the hip. Pathological reactions of the hip capsule on Computed tomography (CT) can be difficult to diagnose due to different metal artefacts. The O-MAR algorithm deploys an iterative loop where the metal sinogram is identified, extracted, and subsequently serves as a mask to correct the measured sinogram. Main goal of this study is to quantify the ability of the O-MAR technique to correct deviation in medullary bone attenuation caused by streak artefacts from the large-head MoM THA embedded in a phantom. Secondary goal is to evaluate the influence of O-MAR on CNR. The phantom was designed as a Perspex box (PMMA) containing water and a supplementary MOM THA surrounded by Perspex columns comprising calibrated calcium pellets. Each column contains 200 mg of hydroxyapatite/calcium carbonate to simulate healthy bone tissue. Scans were obtained with and without a MoM THA at different dose levels. Different reconstructions were made with filter A, iDose(4) level 5 and with and without O-MAR. The scans without the prosthesis were used as the baseline. Information about the attenuation in Hounsfield units, image noise in standard deviation within the ROI's were extracted and the CNR was calculated. Pellet L0 and R0 (proximal of the MoM THA) were defined as reference, lacking any disturbance by metal artefacts; L5, L6 and L8 were respectively visually categorized as 'light' 'medium' and 'heavy disturbance'. Significant improvements in attenuation deviation caused by metal artefact were 43, 68 and 32 %, for respectively pellet L5, L6 and L8 (p < 0.001). Significant CNR improvements were present for L5 and L6 and were respectively 72 and 52 % (p < 0.001). O-MAR showed no improvement on CNR for L8. This phantom study significantly increases image quality by the use of O-MAR in the presence of metal
Reinisch, G; Huber, M; Zweymüller, K A
High-carbon (HC) alloys for hip arthroplasties were preferred to low-carbon (LC) alloys for a long time because of their structurally hard carbide content. We opted for an LC alloy in 1994, because we expected it to be subject to less wear on account of its more homogeneous structure. Prompted by early complications not seen with ceramic-on-polyethylene mating surfaces, LC metal-on-metal articulations were, however, given up by us in early 1999. A series of implants retrieved after 11 to 17 years was now studied to establish the actual amount of wear. Potential tissue reactions associated with hypersensitivity were also evaluated histologically and correlated with the measured wear and the amount of metal particles in capsular tissue. Ten patients with LC metal-on-metal hip implants were the subjects of analyses after a mean follow-up time of 13.9 years. They underwent revision surgery because of osteolysis, cup loosening without dislocation, late infection in 1 patient and pain. The implant positions at the time of retrieval were the same as on the postoperative radiographs. Wear was determined in keeping with ISO 14242-2 and by SEM. In addition, periprosthetic tissue including the joint capsule and interface membranes were obtained for histological analysis. The amount of metal particles and the extent of lymphocyte infiltration were determined with the method described by Willert et al. Tissue alterations were evaluated histologically for signs of ALVAL using the method of Campbell et al. and correlated with the amount of wear and metal particles. The mean maximum linear wear rate was found to be 1.6 (1.0-2.1) µm/year. Our data also showed a mean rate of 0.32 mm³/year (range, 0.22-0.47 mm³/year). This is equivalent to an annual metal release of 2.7 (1.9-3.9) mg/year. No corrosion or corrosion products were present on the ball heads and their taper. All mating surfaces studied by SEM showed signs of abrasion. Sporadically, additional abrasions in the
Posada, Olga M.; Gilmour, Denise; Tate, Rothwelle J.; Grant, M. Helen
Cobalt-chromium (CoCr) particles in the nanometre size range and their concomitant release of Co and Cr ions into the patients' circulation are produced by wear at the articulating surfaces of metal-on-metal (MoM) implants. This process is associated with inflammation, bone loss and implant loosening and led to the withdrawal from the market of the DePuy ASR™ MoM hip replacements in 2010. Ions released from CoCr particles derived from a resurfacing implant in vitro and their subsequent cellular up-take were measured by ICP-MS. Moreover, the ability of such metal debris and Co ions to induce both apoptosis was evaluated with both FACS and immunoblotting. qRT-PCR was used to assess the effects on the expression of lymphotoxin alpha (LTA), BCL2-associated athanogene (BAG1), nitric oxide synthase 2 inducible (NOS2), FBJ murine osteosarcoma viral oncogene homolog (FOS), growth arrest and DNA-damage-inducible alpha (GADD45A). ICP-MS showed that the wear debris released significant (p < 0.05) amounts of Co and Cr ions into the culture medium, and significant (p < 0.05) cellular uptake of both ions. There was also an increase (p < 0.05) in apoptosis after a 48 h exposure to wear debris. Analysis of qRT-PCR results found significant up-regulation (p < 0.05) particularly of NOS2 and BAG1 in Co pre-treated cells which were subsequently exposed to Co ions + debris. Metal debris was more effective as an inducer of apoptosis and gene expression when cells had been pre-treated with Co ions. This suggests that if a patient receives sequential bilateral CoCr implants, the second implant may be more likely to produce adverse effects than the first one. - Highlights: • Effects of CoCr nanoparticles and Co ions on U937 cells were investigated. • Ions released from wear debris play an important role in cellular response, • Toxicity of Co ions could be related to NO metabolic processes and apoptosis. • CoCr particles were a more effective inducer of apoptosis after cell
Al-Hajjar, Mazen; Fisher, John; Williams, Sophie; Tipper, Joanne L; Jennings, Louise M
Metal-on-metal (MoM) bearings have shown low-wear rates under standard hip simulator conditions; however, retrieval studies have shown large variations in wear rates and mechanisms. High-wear in vivo has caused catastrophic complications and has been associated with steep cup-inclination angle (rotational malpositioning). However, increasing the cup-inclination angle in vitro has not replicated the increases in wear to the same extent as those observed in retrievals. Clinically relevant wear rates, patterns, and particles were observed in vitro for ceramic-on-ceramic bearings when microseparation (translational malpositioning) conditions were introduced into the gait cycle. In the present study, 28 and 36-mm MoM bearings were investigated under adverse conditions. Increasing the cup angle from 45° to 65° resulted in a significant increase in the wear rate of the 28 mm bearings. However, for the 36 mm bearings, head-rim contact did not occur under the steep cup-angle condition, and the wear rate did not increase. The introduction of microseparation to the gait cycle significantly increased the wear rate of the MoM bearings. Cup angle and head size did not influence the wear rate under microseparation conditions. This study indicated that high-in vivo wear rates were associated with edge loading due to rotational malpositioning such as high-cup-inclination angle and translational malpositioning that could occur due to several surgical factors. Translational malpositioning had a more dominant effect on the wear rate. Preclinical simulation testing should be undertaken with translational and rotational malpositioning conditions as well as standard walking cycle conditions defined by the ISO standard.
Al-Hajjar, Mazen; Fisher, John; Williams, Sophie; Tipper, Joanne L; Jennings, Louise M
Abstract Metal-on-metal (MoM) bearings have shown low-wear rates under standard hip simulator conditions; however, retrieval studies have shown large variations in wear rates and mechanisms. High-wear in vivo has caused catastrophic complications and has been associated with steep cup-inclination angle (rotational malpositioning). However, increasing the cup-inclination angle in vitro has not replicated the increases in wear to the same extent as those observed in retrievals. Clinically relevant wear rates, patterns, and particles were observed in vitro for ceramic-on-ceramic bearings when microseparation (translational malpositioning) conditions were introduced into the gait cycle. In the present study, 28 and 36-mm MoM bearings were investigated under adverse conditions. Increasing the cup angle from 45° to 65° resulted in a significant increase in the wear rate of the 28 mm bearings. However, for the 36 mm bearings, head-rim contact did not occur under the steep cup-angle condition, and the wear rate did not increase. The introduction of microseparation to the gait cycle significantly increased the wear rate of the MoM bearings. Cup angle and head size did not influence the wear rate under microseparation conditions. This study indicated that high-in vivo wear rates were associated with edge loading due to rotational malpositioning such as high-cup-inclination angle and translational malpositioning that could occur due to several surgical factors. Translational malpositioning had a more dominant effect on the wear rate. Preclinical simulation testing should be undertaken with translational and rotational malpositioning conditions as well as standard walking cycle conditions defined by the ISO standard. © 2012 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2013. PMID:23281164
Schouten, R; Malone, A A; Frampton, C M; Tiffen, C; Hooper, G
The primary aim of this independent prospective randomised trial was to compare serum metal ion levels for ceramic-on-metal (CoM) and metal-on-metal (MoM) bearing surfaces in total hip arthroplasty (THA). Our one-year results demonstrated elevation in metal ion levels above baseline with no significant difference between the CoM and MoM groups. This paper reviews the five-year data. The implants used in each patient differed only in respect to the type of femoral head (ceramic or metal). At five-year follow-up of the 83 enrolled patients, data from 67 (36 CoM, 31 MoM) was available for comparison. The mean serum cobalt (Co) and chromium (Cr) ion levels remained above baseline in both groups (CoM: Co 1.16 μg/l (0.41 to 14.67), Cr 1.05 μg/l (0.16 to 12.58); MoM: Co 2.93 μg/l (0.35 to 30.29), Cr 1.85 μg/l (0.36 to 17.00)) but the increase was significantly less in the CoM cohort (Co difference p = 0.001, Cr difference p = 0.002). These medium-term results, coupled with lower revision rates from national joint registries, suggest that the performance of CoM THA may be superior to that of MoM. While both bearing combinations have since been withdrawn these results provide useful information for planning clinical surveillance of CoM THAs and warrants continued monitoring. Cite this article: Bone Joint J 2017;99-B:1298-1303. ©2017 The British Editorial Society of Bone & Joint Surgery.
Chen, Szu-Yuan; Chang, Chih-Hsiang; Hu, Chih-Chien; Chen, Chun-Chieh; Chang, Yu-Han; Hsieh, Pang-Hsin
The widespread usage of metal-on-metal (MoM) articulations in total hip arthroplasty (THA) has been tempered by concerns of increased metal ion production. The purpose of the study is to evaluate the influence of metal ion exposure on semen quality in young male patients undergoing THA. Male patients who were scheduled for unilateral THA and aged between 20 and 45 years were prospectively enrolled. Patients were sorted into MoM and metal-on-polyethylene (MoP) groups with equal case number. Semen and blood metal ion levels were measured and sperm analysis was performed before, 6 months after, and 1 year after surgery. Compared to preoperative baseline, patients (n = 50) in both groups had increased cobalt (Co) and chromium (Cr) concentrations in blood and seminal fluid after surgery. Between-group comparisons at 6 months and 1 year after surgery showed that patients in the MoM group both had a greater Co concentration in blood and semen and a greater Cr concentration in blood and semen. Patients receiving MoM prosthesis had a reduced percentage of morphologically normal sperm, and decreases from the preoperative level (44.7%) were significant at 6 months (36.8%, p = 0.03) and 1 year (33.8%, p = 0.004). Our data shows a significantly greater concentration of metal ion in blood and semen in patients with MoM prosthesis with a reduced percentage of morphologically normal sperm. Despite small effects on sperm quality, some concerns remain. Further studies are necessary to determine sources of metal ion and to investigate effects on male fertility. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.
Hefny, Mohamed S; Rudan, John F; Ellis, Randy E
Hip resurfacing is a surgical option for osteoarthritis young and active patients. Early failures has been reported due to improper implant placement. Computer-assisted surgery is a promising avenue for more successful procedures. This paper presents a novel automatic surgical planning for computer-assisted hip resurfacing procedures. The plan defined the femoral head axis that was used to place the implant. The automatic planning was based on a Lie group statistical shape model. A statistical shape model was constructed using 50 femurs from osteoarthritis patients who underwent computer-assisted hip resurfacing. The model was constructed using product Lie groups representation of shapes and nonlinear analysis on the manifold of shapes. A surgical plan was drawn for the derived base shape. The base shape was transformed to 14 femurs with known manual plans. The transformed base plan was used as the computed plan for each femur. Both actual and computed plans were compared. The method showed a success by computing plans that differ from the actual plans within the surgical admissible ranges. The minimum crossing distance between the two plans had a mean of 0.75 mm with a standard deviation of 0.54 mm. The angular difference between the two plans had the mean of 5.94° with a standard deviation of 2.145.94°. Product Lie groups shape models were proved to be successful in automatic planning for hip resurfacing computer-assisted surgeries. The method can be extended to other orthopedic and general surgeries.
Witt, F; Bosker, B H; Bishop, N E; Ettema, H B; Verheyen, C C P M; Morlock, M M
Revision of hip implants due to adverse tissue reactions to metal debris has been associated with wear and corrosion of the metal-on-metal bearing articulation and the modular taper interface. Bearing articulation wear is increased in conditions of poor lubrication, which can also lead to high friction moments that may cause corrosion at the taper interface. This suggests that wear of the bearing and increased corrosion of the taper interface should occur simultaneously, which was investigated in this study. Forty-three large-diameter cobalt-chromium bearings of the same design, implanted with a titanium stem using a titanium adapter, were retrieved at revision at a single center. Retrievals were grouped according to visual inspection of the female taper surface of the adapter into slight and severe corrosion groups. Volume change of bearing and taper surfaces was assessed using a coordinate measurement machine. Serum ion concentrations were determined for forty-three patients, whereas tissue metal concentration was measured for twelve patients. Severe taper corrosion was observed in 30% of the retrievals. Corrosion was observed either as material deposition or wear. The overall bearing wear rate was significantly higher in the group with severe taper corrosion than in the group with slight corrosion (7.2 ± 9.0 mm(3)/yr versus 3.1 ± 6.8 mm(3)/yr, respectively; p = 0.023) as were the serum cobalt (40.5 ± 44.9 μg/L versus 15.2 ± 23.9 μg/L, respectively; p = 0.024) and chromium ion concentrations (32.7 ± 32.7 μg/L versus 12.0 ± 15.1 μg/L, respectively; p = 0.019). Serum metal ion concentrations were more consistent indicators of wear than tissue metal concentrations. The increased bearing articulation wear and serum metal ion concentrations in cases with taper interface corrosion support the hypothesis that increased friction in the joint articulation is one of the factors responsible for simultaneous articulation and taper damage. However, independent taper
Hjorth, M H; Stilling, M; Lorenzen, N D; Jakobsen, S S; Soballe, K; Mechlenburg, I
Metal-on-metal articulations mimic the human hip anatomy, presumably lower dislocation rates and increase the range-of-motion. This study aims to measure the muscle mass and power of both legs in patients with unilateral metal-on-metal total hip arthroplasty, and to investigate their effect on block-step test, spatio-temporal gait parameters and self-reported function. Twenty-eight patients (7 women), mean age 50 (28-68) years, participated in a 5-7 year follow-up. Patients had received one type unilateral large-head metal-on-metal total hip articulation, all of which were well-functioning at follow-up. Mean muscle mass was measured by the total-body Dual energy X-ray Absorption scans, and muscle power was measured in a leg extensor power rig. Block-step test and spatio-temporal gait parameters were measured with an inertial measurement unit. Self-reported function was assessed by the Hip Disability and Osteoarthritis Outcome Score. We found a significant difference between the mean muscle mass of the implant-side leg and the non-implant-side leg in hip, thigh and calf areas (P<0.008) and in mean muscle power (P=0.025). Correlations between mean muscle mass and mean muscle power were significant for both the implant-side leg (r=0.45, P=0.018) and the non-implant-side leg (r=0.51, P=0.007). The difference in mean muscle power between legs correlated with block-step test asymmetry during ascending (r=0.40, P=0.047) and descending (r=0.53, P=0.006). Correlations between self-reported function and power of the implant-side leg were not significant. Young patients have not fully regained muscle mass, muscle power and function 5-7 years after metal-on-metal total hip arthroplasty. Copyright © 2014. Published by Elsevier Ltd.
Naal, Florian D; Pilz, Ronny; Munzinger, Urs; Hersche, Otmar; Leunig, Michael
There is growing evidence that different resurfacing implants are associated with variable survival and revision rates. A registry analysis indicated the Durom resurfacing implant had high revision rates at 5 years, whereas three original studies reported low revision rates at short-term followups. Thus, the revision rates appear controversial. We therefore assessed (1) the survivorship including differences between women and men at a mean of 5 years after resurfacing with the Durom implant, and (2) clinical scores and radiographic parameters. We prospectively followed all 100 Durom hip resurfacings implanted in 91 patients (25 women and 66 men; mean age, 52 years) between 2003 and 2004. Survivorship analysis was performed with pending revision or revision for any reason as the endpoint. The minimum followup was 47 months (mean, 60 months; range, 47-72 months). At a mean of 5 years, 11 hips were revised for various reasons. Cumulative survival was 88.2% for all patients and 81.5% for women. The mean Oxford (OHS) and Harris hip (HHS) scores were 14.6 and 94.7, respectively. The mean UCLA activity level was 7.9. Sclerotic changes around the short femoral stem (pedestal sign) were detected in 40% of the hips. We observed considerable femoral neck thinning with component-to-neck ratios of 0.85 preoperatively and 0.82 at 5 years. Our study highlights a high revision rate 5 years after hip resurfacing with the Durom implant. This observation underlines previous findings from registry data and suggests that revision rates increase with time. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Rahman, Wael A; Greidanus, Nelson V; Siegmeth, Alexander; Masri, Bassam A; Duncan, Clive P; Garbuz, Donald S
A number of reconstructive procedures are available for the management of hip osteoarthritis. Hip resurfacing arthroplasty is now an accepted procedure, with implant survivorship comparable to THA at up to 10 years' followup in certain series. Most reports focus on implant survivorship, surgeon-derived results, or complications. Fewer data pertain to patient-reported results, including validated measures of quality of life (QoL) and satisfaction and baseline measures from which to determine magnitude of improvement. Validated patient-reported results are essential to guide patients and surgeons in the current era of informed and shared decision making. We determined whether patients reported improvement in disease-specific, joint-specific, and generic QoL after hip resurfacing arthroplasty; whether patients were satisfied with the results of the procedure; and latest activity level and return to sport. We retrospectively reviewed 127 patients (100 men, 27 women) who underwent 143 hip resurfacing procedures between 2002 and 2006. Mean patient age was 52 years. Patients completed the WOMAC, Oxford Hip Score, and SF-12 at baseline and again at minimum 2-year followup (mean, 2.5 years; range, 2-6 years). At latest followup, patients completed a validated satisfaction questionnaire and UCLA activity score. All QoL scores improved (normalized to a 0-100 scale, where 100 = best health state). WOMAC improved from 46 to 95, Oxford Hip Score from 42 to 95, SF-12 (physical) from 34 to 54, and SF-12 (mental) from 46 to 56. Patient satisfaction score was 96. UCLA activity score was 8. The majority of patients reported improvement in QoL, were very satisfied with their outcome, and returned to a high level of activity after hip resurfacing arthroplasty. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
Amstutz, Harlan C; Takamura, Karren M; Ebramzadeh, Edward; Le Duff, Michel J
Highly cross-linked polyethylene (XLPE) has improved wear properties. This study reports the results of a small series of patients treated over 10 years ago with a metal-on-XLPE hip resurfacing.A total of 21 hips in 20 patients received a hip resurfacing with a cobalt-chromium metal femoral head and metal-backed acetabular cup lined with a XLPE insert and were retrospectively studied. Kaplan-Meier Survivorship was calculated.Five patients who had initial extreme cystic disease in the femoral head failed due to femoral loosening. Survivorship was 95.2% at 5 years and 81.0% at 10 years.We found that XLPE wear was not implicated in these failures, which were primarily attributed to poor bone quality of the femoral head, early bone preparation, cementing technique and excessive head reaming to near the neck diameter, necessitated for the implantation of a thick two-part socket.
Matharu, Gulraj S; Daniel, Joseph; Ziaee, Hena; McMinn, Derek J W
We report the early failure of five ceramic-on-ceramic hip resurfacings (CoCHRs). The ceramic used for the acetabular liner was a novel ceramic-composite (two thirds polyurethane and one third alumina ceramic). All cases were revised for increasing metal ion levels (blood cobalt 3.93-208.0 μg/l and chromium 1.57-17.5 μg/l) due to ceramic liner fracture and/or accelerated wear of the ceramic femoral head coating. Patients underwent bearing exchange and revision using primary hip arthroplasty implants at a mean of 3.0 years following CoCHR. Intraoperatively all patients had metallosis. At 1 to 2 years of follow-up blood metal ions normalized with no complications. We do not recommend this particular type of ceramic-on-ceramic bearing for hip resurfacing. Copyright © 2014 Elsevier Inc. All rights reserved.
Hutt, Jonathan; Lavigne, Martin; Lungu, Eugen; Belzile, Etienne; Morin, François; Vendittoli, Pascal-André
Few studies of total hip arthroplasty (THA) implants with a large-diameter femoral head and metal-on-metal design have directly compared the progression of metal ion levels over time and the relationship to complications. As we previously reported, 144 patients received one of four types of large-diameter-head, metal-on-metal THA designs (Durom, Birmingham, ASR XL, or Magnum implants). Cobalt, chromium, and titanium ion levels were measured over five years. We compared ion levels and clinical results over time. The Durom group showed the highest levels of cobalt (p ≤ 0.002) and titanium ions (p ≤ 0.03). Both the Durom and Birmingham groups demonstrated significant ongoing cobalt increases up to five years. Eight patients (seven with a Durom implant and one with a Birmingham implant) developed adverse local tissue reaction. Six Durom implants and one Birmingham implant required revision, with one pseudotumor under surveillance at the time of the most recent follow-up. We found that ion generation and related complications varied among designs. More concerning was that, for some designs, ion levels continued to increase. Coupling a cobalt-chromium adapter sleeve to an unmodified titanium femoral trunnion along with a large metal-on-metal bearing may explain the poor performances of two of the designs in the current study.
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Hip joint metal/polymer or ceramic/polymer... Devices § 888.3410 Hip joint metal/polymer or ceramic/polymer semiconstrained resurfacing cemented prosthesis. (a) Identification. A hip joint metal/polymer or ceramic/polymer semi-constrained...
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Hip joint metal/polymer or ceramic/polymer... Devices § 888.3410 Hip joint metal/polymer or ceramic/polymer semiconstrained resurfacing cemented prosthesis. (a) Identification. A hip joint metal/polymer or ceramic/polymer semi-constrained...
Vendittoli, P-A; Roy, A; Mottard, S; Girard, J; Lusignan, D; Lavigne, M
We have updated our previous randomised controlled trial comparing release of chromium (Cr) and cobalt (Co) ions and included levels of titanium (Ti) ions. We have compared the findings from 28 mm metal-on-metal total hip replacement, performed using titanium CLS/Spotorno femoral components and titanium AlloFit acetabular components with Metasul bearings, with Durom hip resurfacing using a Metasul articulation or bearing and a titanium plasma-sprayed coating for fixation of the acetabular component. Although significantly higher blood ion levels of Cr and Co were observed at three months in the resurfaced group than in total hip replacement, no significant difference was found at two years post-operatively for Cr, 1.58 microg/L and 1.62 microg/L respectively (p = 0.819) and for Co, 0.67 microg/L and 0.94 microg/L respectively (p = 0.207). A steady state was reached at one year in the resurfaced group and after three months in the total hip replacement group. Interestingly, Ti, which is not part of the bearing surfaces with its release resulting from metal corrosion, had significantly elevated ion levels after implantation in both groups. The hip resurfacing group had significantly higher Ti levels than the total hip replacement group for all periods of follow-up. At two years the mean blood levels of Ti ions were 1.87 microg/L in hip resurfacing and and 1.30 microg/L in total hip replacement (p = 0.001). The study confirms even with different bearing diameters and clearances, hip replacement and 28 mm metal-on-metal total hip replacement produced similar Cr and Co metal ion levels in this randomised controlled trial study design, but apart from wear on bearing surfaces, passive corrosion of exposed metallic surfaces is a factor which influences ion concentrations. Ti plasma spray coating the acetabular components for hip resurfacing produces significantly higher release of Ti than Ti grit-blasted surfaces in total hip replacement.
Langton, David J; Sidaginamale, Raghavendra P; Joyce, Thomas J; Natu, Shonali; Blain, Peter; Jefferson, Robert Drysdale; Rushton, Stephen; Nargol, Antoni V F
To determine whether elevated blood cobalt (Co) concentrations are associated with early failure of metal-on-metal (MoM) hip resurfacings secondary to adverse reaction to metal debris (ARMD). Cohort study. Single centre orthopaedic unit. Following the identification of complications potentially related to metal wear debris, a blood metal ion screening programme was instigated at our unit in 2007 for all patients with Articular Surface Replacement (ASR) and Birmingham MoM hip resurfacings. Patients were followed annually unless symptoms presented earlier. Symptomatic patients were investigated with ultrasound scan and joint aspiration. The clinical course of all 278 patients with 'no pain' or 'slight/occasional' pain and a Harris Hip Score greater than or equal to 95 at the time of venesection were documented. A retrospective analysis was subsequently conducted using mixed effect modelling to investigate the temporal pattern of blood Co levels in the patients and survival analysis to investigate the potential role of case demographics and blood Co levels as risk factors for subsequent failure secondary to ARMD. Blood Co concentration was a positive and significant risk factor (z=8.44, p=2×10(-16)) for joint failure, as was the device, where the Birmingham Hip Resurfacing posed a significantly reduced risk for revision by 89% (z=-3.445, p=0.00005 (95% CI on risk 62 to 97)). Analysis using Cox-proportional hazards models indicated that men had a 66% lower risk of joint failure than women (z=-2.29419, p=0.0218, (95% CI on risk reduction 23 to 89)). The results suggest that elevated blood metal ion concentrations are associated with early failure of MoM devices secondary to adverse reactions to metal debris. Co concentrations greater than 20 µg/l are frequently associated with metal staining of tissues and the development of osteolysis. Development of soft tissue damage appears to be more complex with females and patients with ASR devices seemingly more at risk when
Langton, David J; Sidaginamale, Raghavendra P; Joyce, Thomas J; Natu, Shonali; Blain, Peter; Jefferson, Robert Drysdale; Rushton, Stephen; Nargol, Antoni V F
Objective To determine whether elevated blood cobalt (Co) concentrations are associated with early failure of metal-on-metal (MoM) hip resurfacings secondary to adverse reaction to metal debris (ARMD). Design Cohort study. Setting Single centre orthopaedic unit. Participants Following the identification of complications potentially related to metal wear debris, a blood metal ion screening programme was instigated at our unit in 2007 for all patients with Articular Surface Replacement (ASR) and Birmingham MoM hip resurfacings. Patients were followed annually unless symptoms presented earlier. Symptomatic patients were investigated with ultrasound scan and joint aspiration. The clinical course of all 278 patients with ‘no pain’ or ‘slight/occasional’ pain and a Harris Hip Score greater than or equal to 95 at the time of venesection were documented. A retrospective analysis was subsequently conducted using mixed effect modelling to investigate the temporal pattern of blood Co levels in the patients and survival analysis to investigate the potential role of case demographics and blood Co levels as risk factors for subsequent failure secondary to ARMD. Results Blood Co concentration was a positive and significant risk factor (z=8.44, p=2×10–16) for joint failure, as was the device, where the Birmingham Hip Resurfacing posed a significantly reduced risk for revision by 89% (z=−3.445, p=0.00005 (95% CI on risk 62 to 97)). Analysis using Cox-proportional hazards models indicated that men had a 66% lower risk of joint failure than women (z=−2.29419, p=0.0218, (95% CI on risk reduction 23 to 89)). Conclusions The results suggest that elevated blood metal ion concentrations are associated with early failure of MoM devices secondary to adverse reactions to metal debris. Co concentrations greater than 20 µg/l are frequently associated with metal staining of tissues and the development of osteolysis. Development of soft tissue damage appears to be more complex
A new surgical option (hip resurfacing arthroplasty) is now available for younger patients with hip osteoarthritis. A more aggressive rehabilitation program than the typical total hip arthroplasty protocol is needed for active individuals. This case report describes interventions used to maximize function in a 46-year-old professional dancer after hip resurfacing with a progressive therapeutic exercise program. Exercise choices were selected to address dance-specific requirements while respecting healing of the posterior capsular incision. Strengthening focused on hip abduction, extension, and external rotation. Precautions included avoiding gluteal stretching until 6 months. Pelvic alignment and weight-bearing distribution were emphasized. The patient was able to return to rehearsal by 7 months, at which time strength was equivalent to the unaffected leg. Range of motion reached unaffected side values at week 8 for internal rotation, week 11 for extension, week 13 for adduction, and week 28 for flexion. External rotation and abduction were still limited at 1 year, which influenced pelvic alignment with resultant pain on the unaffected side. Functional and impairment outcomes are presented with timelines to provide a basis for postoperative benchmarks for active clients after hip resurfacing. Although this case report presents a dance-specific program, exercise progressions for other active individuals may benefit from similar exercise intensity and sports-specific focus. Future rehabilitation programs should take into account possible flexion and external rotation range limitations and the need for gluteal muscle strengthening along with symmetry and pelvic alignment correction. Long-term studies investigating intensity of rehabilitation are warranted for patients intending to participate in higher level athletic activity.
Jäger, Marcus; Begg, Malcom J W; Krauspe, Rüdiger
There is currently renewed interest in articular resurfacing for the treatment of damaged hip-joint cartilage. In contrast to these implants, which involve endoprosthetic replacement of both articulating surfaces, we present a new joint-preserving technique that allows treatment of local osteochondral defects of the femoral head by partial hemi-resurfacing. In this study we describe the operative and technical aspects and problems for partial hemi-resurfacing of the hip joint and critically discuss indications for this procedure in one case. To guarantee an adequate view of the situs, we recommend a surgical approach involving trochanter flip osteotomy, followed by surgical dislocation of the hip joint. Besides partial hemi-resurfacing of the osteochondral defect, this approach allows treatment of associated labral tears and cartilage defects of the hip joint at the same time. For adequate implant fixation, good bone quality is required. Furthermore, osteochondral defects of limited extent and excellent patient compliance are essential for clinical success. In particular, prominence of the implant has to be avoided, which can lead to an irregular joint surface and may induce further cartilage destruction. Long-term studies on statistical populations will show if partial articular hemi-resurfacing is a bone-preserving and useful therapeutic alternative to hemi-resurfacing caps in the treatment of osteochondral hip-joint defects, especially in young patients.
Lawrence, H; Deehan, D; Holland, J; Kirby, J; Tyson-Capper, A
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. ©2014 The British Editorial Society of Bone & Joint Surgery.
Lu, Fang; Royle, Matt; Lali, Ferdinand V; Hart, Alister J; Collins, Simon; Housden, Jonathan; Shelton, Julia C
Isolation and characterization of metal-on-metal (MoM) wear particles from simulator lubricants is essential to understand wear behaviour, ion release and associated corrosive activity related to the wear particles. Substantial challenges remain to establish a simple, precise and repeatable protocol for the isolation and analysis of wear particles due to their extremely small size, their tendency to agglomerate and degrade. In this paper, we describe a simple and efficient method for the bulk isolation and characterisation of wear particles from MoM bearings. Freeze drying was used to remove the large volume of water from the serum lubricant, enzymes used to digest the proteins and ultracentrifugation to finally isolate and purify the particles. The present study involved a total of eight steps for the isolation process and a wear particle extraction efficiency of 45% was achieved.
Ovesen, Ole; Brixen, Kim; Varmarken, Jens-Erik; Overgaard, SØren
Background and purpose Resurfacing total hip arthroplasty (RTHA) may preserve the femoral neck bone stock postoperatively. Bone mineral density (BMD) may be affected by the hip position, which might bias longitudinal studies. We investigated the dependency of BMD precision on type of ROI and hip position. Method We DXA-scanned the femoral neck of 15 resurfacing patients twice with the hip in 3 different rotations: 15° internal, neutral, and 15° external. For each position, BMD was analyzed with 3 surface area models. One model measured BMD in the total femoral neck, the second model divided the neck in two, and the third model had 6 divisions. Results When all hip positions were pooled, average coefficients of variation (CVs) of 3.1%, 3.6%, and 4.6% were found in the 1-, 2-, and 6-region models, respectively. The externally rotated hip position was less reproducible. When rotating in increments of 15° or 30°, the average CVs rose to 7.2%, 7.3%, and 12% in the 3 models. Rotation affected the precision most in the model that divided the neck in 6 subregions, predominantly in the lateral and distal regions. For larger-region models, some rotation could be allowed without compromising the precision. Interpretation If hip rotation is strictly controlled, DXA can reliably provide detailed topographical information about the BMD changes around an RTHA. As rotation strongly affects the precision of the BMD measurements in small regions, we suggest that a less detailed model should be used for analysis in studies where the leg position has not been firmly controlled. PMID:20367420
Rheumatoid Arthritis; Osteoarthritis; Post-traumatic Arthritis; Collagen Disorders; Avascular Necrosis; Traumatic Femoral Fractures; Nonunion of Femoral Fractures; Congenital Hip Dysplasia; Slipped Capital Femoral Epiphysis
Validation of primary metal-on-metal hip arthroplasties on the National Joint Registry for England, Wales and Northern Ireland using data from the London Implant Retrieval Centre: a study using the NJR dataset.
Sabah, S A; Henckel, J; Cook, E; Whittaker, R; Hothi, H; Pappas, Y; Blunn, G; Skinner, J A; Hart, A J
Arthroplasty registries are important for the surveillance of joint replacements and the evaluation of outcome. Independent validation of registry data ensures high quality. The ability for orthopaedic implant retrieval centres to validate registry data is not known. We analysed data from the National Joint Registry for England, Wales and Northern Ireland (NJR) for primary metal-on-metal hip arthroplasties performed between 2003 and 2013. Records were linked to the London Implant Retrieval Centre (RC) for validation. A total of 67,045 procedures on the NJR and 782 revised pairs of components from the RC were included. We were able to link 476 procedures (60.9%) recorded with the RC to the NJR successfully. However, 306 procedures (39.1%) could not be linked. The outcome recorded by the NJR (as either revised, unrevised or death) for a primary procedure was incorrect in 79 linked cases (16.6%). The rate of registry-retrieval linkage and correct assignment of outcome code improved over time. The rates of error for component reference numbers on the NJR were as follows: femoral head category number 14/229 (5.0%); femoral head batch number 13/232 (5.3%); acetabular component category number 2/293 (0.7%) and acetabular component batch number 24/347 (6.5%). Registry-retrieval linkage provided a novel means for the validation of data, particularly for component fields. This study suggests that NJR reports may underestimate rates of revision for many types of metal-on-metal hip replacement. This is topical given the increasing scope for NJR data. We recommend a system for continuous independent evaluation of the quality and validity of NJR data.
Smolders, José M H; Pakvis, Dean F; Hendrickx, Baudewijn W; Verdonschot, Nico; van Susante, Job L C
A randomized controlled trial was performed to evaluate acetabular bone mineral density (BMD) changes after hip resurfacing (RHA) versus an established conventional total hip arthroplasty (THA). A total of 71 patients were allocated randomly to receive either an RHA press-fit cobalt-chromium cup (n=38) or a THA with a threaded titanium cup and polyethylene-metal-inlay insert (n=33). The BMD in five separate periacetabular regions of interest (ROI) was prospectively quantified preoperative until 24 months. We conclude that, in contrast to our hypothesis, periacetabular BMD was better preserved after RHA than after placement of a conventional THA. Long term follow-up studies are necessary to see whether this benefit in bone preservation sustains over longer time periods and whether it is turned into clinical benefits at future revision surgery.
Morlock, Michael M; Bishop, Nick; Zustin, Jozef; Hahn, Michael; Rüther, Wolfgang; Amling, Michael
Resurfacing of the hip joint is experiencing a revival due to improvements in materials, design, and manufacturing techniques. Despite good midterm outcomes, the high early rate of failure and concerns about metal debris require a detailed morphological and wear analysis of retrieved resurfacing implants in order to understand failure mechanisms. A worldwide collection of hip resurfacing revision devices was initiated, and 267 components were received. Devices were analyzed by patient demographics, radiographic positioning, and wear, as well as morphologically and histologically. Specimens were grouped into four different failure types. They were also stratified into rim-loaded or non-rim-loaded groups. Failures were also assessed by surgeon learning-curve effects. Time to failure was significantly different between the four revision-type groups: Specimens with fractures involving the implant rim were most common (46%) and failed earliest after surgery (mean of ninety-nine days), followed by fractures inside the femoral head (20%, 262 days) and loose cups (9%, 423 days). Revisions not due to fractures or cup loosening (25%) occurred at a mean of 722 days after surgery. Rim-loaded implants exhibited an average twenty-one to twenty-sevenfold higher wear rate than implants without rim-loading. Rim-loaded implants also showed a steeper mean cup inclination than their non-rim-loaded counterparts (59 degrees compared with 50 degrees ). Most failures occurred during the learning curve of the surgeon (the first fifty to 100 implantations). Failures on the femoral side usually occur within the first nine months after surgery and appear to be most directly related to the implantation technique or patient selection. Later failures are observed mainly due to acetabular problems, either due to dramatically increased wear or poor cup anchorage. Improper cup anteversion may be similar to or more important than cup inclination in producing excessive wear.
Colbrunn, R W; Bottros, J J; Butler, R S; Klika, A K; Bonner, T F; Greeson, C; van den Bogert, A J; Barsoum, W K
We identified and compared the impingent-free range of motion (ROM) and subluxation potential for native hip, femoral head resurfacing (FHR), and total hip arthroplasty (THA). These constructs were also compared both with and without soft tissue to elucidate the role of the soft tissue. Five fresh-frozen bilateral hip specimens were mounted to a six-degree of freedom robotic manipulator. Under load-control parameters, in vivo mechanics were recreated to evaluate impingement free ROM, and the subluxation potential in two "at risk" positions for native hip, FHR, and THA. Impingement-free ROM of the skeletonized THA was greater than FHR for the anterior subluxation position. For skeletonized posterior subluxations, stability for THA and FHR constructs were similar, while a different pattern was observed for specimens with soft tissues intact. FHR constructs were more stable than THA constructs for both anterior and posterior subluxations. When the femoral neck is intact the joint has an earlier impingement profile placing the hip at risk for subluxation. However, FHR design was shown to be more stable than THA only when soft tissues were intact. Copyright © 2013 Orthopaedic Research Society.
Morlock, M M; Bishop, N; Stahmer, F; Zustin, J; Sauter, G; Hahn, M; Krause, M; Rüther, W; Amling, M
Hip resurfacing has been experiencing a revival over the last 5-10 years. Early failure rates are higher than for conventional primary hip arthroplasty. Fractures of the femoral neck or head, cup loosening and persistent pain are the most frequently observed reasons for early revision. In this international retrospective uncontrolled study, 256 revision specimens (219 resurfacing heads, 37 cups) were analysed radiologically, tribologically, morphologically and histologically in order to investigate the failure mechanism. Of the head revisions, 70% were due to neck (median: 67 days after implantation) and head fractures (161 days), 9% were due to cup loosening (350 days) and 21% due to other reasons (602 days). Implants with rim loading (22% of all retrievals, cup inclination 58.0+/-10.9 degrees ) exhibited a head wear rate of 7.1+/-5.2 mm3/year. Non-rim loaded implants exhibited a head wear rate of 0.24+/-0.53 mm3/year (cup inclination 49.0+/-4.0 degrees ). The failure rate was highest during the first 16 weeks after surgery and for the first ten operations performed by a surgeon. Revisions based on problems on the femoral side such as notching and high implantation forces occurred earlier than revisions based on problems on the acetabular side such as cup loosening and high wear due to suboptimal cup position.
Dickinson, Alexander; Taylor, Andrew; Browne, Martin
Hip resurfacing demonstrates good survivorship as a treatment for young patients with osteoarthritis, but occasional implant loosening failures occur. On the femoral side there is radiographic evidence suggesting that the implant stem bears load, which is thought to lead to proximal stress shielding and adaptive bone remodelling. Previous attempts aimed at reproducing clinically observed bone adaptations in response to the implant have not recreated the full set of common radiographic changes, so a modified bone adaptation algorithm was developed in an attempt to replicate more closely the effects of the prosthesis on the host bone. The algorithm features combined implant-bone interface healing and continuum bone remodelling. It was observed that remodelling simulations that accounted for progressive gap filling at the implant-bone interface predicted the closest periprosthetic bone density changes to clinical X-rays and DEXA data. This model may contribute to improved understanding of clinical failure mechanisms with traditional hip resurfacing designs and enable more detailed pre-clinical analysis of new designs.
Langton, David John; Sidaginamale, Raghavendra Prasad; Avery, Peter; Waller, Sue; Tank, Ghanshyabhai; Lord, James; Joyce, Thomas; Cooke, Nick; Logishetty, Raj; Nargol, Antoni Viraf Francis
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. PMID:27130159
The sensitivity, specificity and predictive values of raised plasma metal ion levels in the diagnosis of adverse reaction to metal debris in symptomatic patients with a metal-on-metal arthroplasty of the hip.
Malek, I A; King, A; Sharma, H; Malek, S; Lyons, K; Jones, S; John, A
Plasma levels of cobalt and chromium ions and Metal Artefact Reduction Sequence (MARS)-MRI scans were performed on patients with 209 consecutive, unilateral, symptomatic metal-on-metal (MoM) hip arthroplasties. There was wide variation in plasma cobalt and chromium levels, and MARS-MRI scans were positive for adverse reaction to metal debris (ARMD) in 84 hips (40%). There was a significant difference in the median plasma cobalt and chromium levels between those with positive and negative MARS-MRI scans (p < 0.001). Compared with MARS-MRI as the potential reference standard for the diagnosis of ARMD, the sensitivity of metal ion analysis for cobalt or chromium with a cut-off of > 7 µg/l was 57%. The specificity was 65%, positive predictive value was 52% and the negative predictive value was 69% in symptomatic patients. A lowered threshold of > 3.5 µg/l for cobalt and chromium ion levels improved the sensitivity and negative predictive value to 86% and 74% but at the expense of specificity (27%) and positive predictive value (44%). Metal ion analysis is not recommended as a sole indirect screening test in the surveillance of symptomatic patients with a MoM arthroplasty. The investigating clinicians should have a low threshold for obtaining cross-sectional imaging in these patients, even in the presence of low plasma metal ion levels.
Smolders, José M H; Bisseling, Pepijn; Hol, Annemiek; Van Der Straeten, Catherine; Schreurs, B Willem; van Susante, Job L C
Metal ions generated from joint replacements are a cause for concern. There is no consensus on the best surrogate measure of metal ion exposure, and both serum and whole blood measurements are used in clinical practice. This study provides a guideline for interpretation of metal ion analysis in clinical practice. In a prospective trial comparing hip resurfacing (HR) with a conventional metal-on-metal (MoM) total hip arthroplasty (THA) cobalt and chromium levels were determined for whole blood and serum in 343 paired samples at regular intervals up to 24 months postoperatively. Cobalt whole blood and serum levels increased significantly after both procedures. Cobalt concentrations were significantly higher for the HR group compared to the THA group, at 3, 6 and 12 months, for whole blood and serum. At 24 months cobalt levels decreased and differences between HR and THA were no longer significant. In contrast, chromium whole blood levels remained significantly higher for HR until 24 months. Whole blood and serum levels could not be used interchangeably. The mean differences for cobalt and chromium between blood and serum values were +0.13 µg/L and -0.91 µg/L respectively. Regression analysis provided a formula for conversion from serum to blood of 0.34+[0.88*Co serum] for cobalt and 0.14 + [0.58*Cr serum] for chromium, with an acceptable prediction error below ±1.0 µg/L. Cobalt and chromium levels were significantly higher for HR versus THA, especially during the run-in phase of one year. Overall, the metal ion levels were well below 5 µg/L. We cannot recommend the use of whole blood over serum measurements or vice versa. The provided conversion formula between whole blood and serum in combination with the presented practical guidelines may be useful for clinical practice.
Sandiford, Nemandra; Muirhead-Allwood, SK; Skinner, JA
Background: Hip resurfacing arthroplasty (HRA) is primarily indicated for young, active patients with disabling coxarthrosis who wish to remain active and return to sports after surgery. Relatively few prospective studies have assessed return to sporting activity and impact of gender and age on this. Materials and Methods: Seventy-nine consecutive patients treated with HRA were included. Patients were reviewed clinically and radiologically. Function was assessed using the modified University of California Los Angeles (UCLA) activity score. The Oxford, Harris and WOMAC hip scores were calculated. Results: Average age at the time of surgery was 54.9 years (range 34.5–73.6 years). Average preoperative and postoperative UCLA scores were 4 and 7.6 respectively. Patients were involved in 2 (0–4) sporting activities preoperatively and 2 (0–5) postoperatively. Preoperative and postoperative Oxford Hip Scores, Harris Hip Score and WOMAC scores were 40, 46 and 51 and 16, 94 and 3 respectively (P < 0.0001). Patients returned to sports at an average of 3 months postoperatively. Conclusion: Patients were able to return to sports by 3 months and perform the same number of activities at preoperative intensity. Activity levels are maintained up to the medium term with few complications. PMID:26806965
Schuh, Reinhard; Neumann, Daniel; Rauf, Rauend; Hofstaetter, Jochen; Boehler, Nikolaus; Labek, Gerold
Hip resurfacing arthroplasty has gained popularity for treating young and active patients who have arthritis. There are two major data sources for assessing outcome and revision rate after total joint arthroplasty: sample-based clinical trials and national arthroplasty registers. The purpose of this study was to evaluate the outcome of the Birmingham Hip Resurfacing (BHR) arthroplasty in terms of revision rate as reported in clinical studies and recorded by national arthroplasty registers. A comprehensive literature research was performed from English-language, peer-reviewed journals and annual reports from national joint arthroplasty registers worldwide. Only publications from MEDLINE-listed journals were included. The revision rate was used as the primary outcome parameter. In order to allow for direct comparison of different data sets, calculation was based on revisions per 100 observed component years. For statistical analysis, confidence intervals (CI) were calculated. A total of 18,708 implants, equivalent to 106,565 observed component years, were analysed in the follow-up studies. The register reports contained 9,806 primary cases corresponding to 44,294 observed component years. Statistical analysis revealed a significant difference in revisions per 100 observed component years between the development team (0.27; CI: 0.14-0.40) and register data (0.74; CI: 0.72-0.76). The BHR arthroplasty device shows good results in terms of revision rate in register data as well as in clinical studies. However, the excellent results reported by the development team are not reproducible by other surgeons. Based on the results of our study, we believe that comprehensive national arthroplasty registers are the most suitable tool for assessing hip arthroplasty revision rate.
Caplan, N; Stewart, S; Kashyap, S; Banaszkiewicz, P; St Clair Gibson, A; Kader, D; Ewen, A
The aim of this study was to determine the influence of total hip arthroplasty and hip resurfacing arthroplasty on limb loading symmetry before, and after, hip reconstruction surgery during a sit-to-stand task. Fourteen patients were recruited that were about to receive either a total hip prosthesis (n=7) or a hip resurfacing prosthesis (n=7), as well as matched controls. Patients performed a sit-to-stand movement before, 3 months after, and 12 months after surgery. Peak vertical ground reaction force and impulse were measured for each leg, from which ground reaction force and impulse symmetry ratios were calculated. Before surgery, hip resurfacing patients showed a small asymmetry which was not different to normal for ground reaction force (0.88(0.28) vs. 1.00(0.11); p=0.311) or impulse (0.87(0.29) vs. 0.99(0.09); p=0.324) symmetry ratios. Total hip patients offloaded their affected hip by 30% in terms of impulse symmetry ratio (0.71(0.36) vs. 0.99(0.23); p=0.018). At 3 months following surgery asymmetries were seen that were different to normal in both hip resurfacing patients for ground reaction force (0.77(0.16); p=0.007), and total hip patients for ground reaction force (0.70(0.15); p=0.018) and impulse (0.72(0.16); p=0.011) symmetry ratios. By 12 months after surgery total hip patients regained a symmetrical loading pattern for both ground reaction force (0.95(0.06); p=0.676) and impulse (1.00(0.06); p=0.702) symmetry ratios. Hip resurfacing patients, however, performed the task by overloading their operated hip, with impulse symmetry ratio being larger than normal (1.16(0.16); p=0.035). Physiotherapists should appreciate the need for early recovery of limb loading symmetry as well as subsequent differences in the responses observed with different prostheses. Copyright © 2014 Elsevier Ltd. All rights reserved.
Hjorth, Mette Holm; Stilling, Maiken; Soballe, Kjeld; Bolvig, Lars Hans; Thyssen, Jacob Pontoppidan; Mechlenburg, Inger; Jakobsen, Stig Storgaard
The relationship between metal wear debris, pseudotumor formation and metal hypersensitivity is complex and not completely understood. The purpose of this study was to assess the prevalence of pseudotumor formation in a consecutive series of metal-on-metal (MoM) total hip arthroplasty (THA) and to investigate its relationship to serum metal-ion levels and hypersensitivity to metal. Forty-one patients (31 males), mean age 52 (28-68) years, with a total of 49 large-head MoM THA participated in a 5-7-year follow-up study. Patients underwent ultrasonography, serum metal-ion concentrations were measured, metal allergy and atopic dermatitis were evaluated, and the questionnaires of the Oxford Hip Score (OHS), Harris Hip Score (HHS) and the Short-Form Health Survey (SF-36) were completed. Pseudotumors were found in eight patients, but they were asymptomatic and their serum metal-ion levels were similar to those observed in patients with no pseudotumors (p > 0.36). The capsule-stem distance of mean 8.6 mm (SD 3.82, 95% CI: 5.40-11.79) was wider (p = 0.02) in patients with pseudotumours than in patients without pseudotumors of mean 5.6 mm (SD 2.89, 95% CI: 4.68-6.58). Positive patch test reactions were seen in three patients. Higher serum metal-ion levels of chromium and cobalt were significantly correlated with steeper cup inclination and smaller femoral head sizes, and were associated with female gender (p < 0.04). We found no association between pseudotumor formation, serum metal-ion levels, metal patch test reactivity, and atopic dermatitis. However, clinicians should be aware of asymptomatic pseudotumors, and we advise further exploration into the mechanisms involved in the pathogenesis of pseudotumors.
Background and purpose Previously, we have documented surface temperatures recorded by thermography great enough to cause osteonecrosis of the femoral head during hip resurfacing. We now performed an in vitro investigation with 3 questions: (1) whether water irrigation reduced bone surface temperature, (2) whether external bone temperatures were similar to core temperatures, and (3) whether blunting of the reamer affected temperature generation. Methods Using an ox-bone model, 57 femoral heads were peripherally reamed. The surface temperatures of bone were measured using a thermal camera and internal bone temperatures were measured using 2 theromocouples. We measured the effects of cooling with water at room temperature and with ice-cooled water. Progressive blunting of reamers was assessed over the 57 experiments. Results Mean and maximum temperatures generated during peripheral reaming were greater when no irrigation was used. Ice-cold saline protected femoral heads from thermal damage. External bone temperatures were much greater than internal temperatures, which were not sufficiently elevated to cause osteonecrosis regardless of lavage. Blunting of the reamer was not found to have a statistically significant effect in this study. Interpretation Cooling with ice-cooled water is recommended. Internal bone temperatures are not elevated despite the high surface temperatures reached during femoral head resurfacing. PMID:24079554
Toxicology of wear particles of cobalt-chromium alloy metal-on-metal hip implants Part II: Importance of physicochemical properties and dose in animal and in vitro studies as a basis for risk assessment.
Madl, Amy K; Kovochich, Michael; Liong, Monty; Finley, Brent L; Paustenbach, Dennis J; Oberdörster, Günter
The objective of the Part II analysis was to evaluate animal and in vitro toxicology studies of CoCr particles with respect to their physicochemistry and dose relevance to metal-on-metal (MoM) implant patients as derived from Part I. In the various toxicology studies, physicochemical characteristics were infrequently considered and administered doses were orders of magnitude higher than what occurs in patients. Co was consistently shown to rapidly release from CoCr particles for distribution and elimination from the body. CoCr micron sized particles appear more biopersistent in vivo resulting in inflammatory responses that are not seen with similar mass concentrations of nanoparticles. We conclude, that in an attempt to obtain data for a complete risk assessment, future studies need to focus on physicochemical characteristics of nano and micron sized particles and on doses and dose metrics relevant to those generated in patients or in properly conducted hip simulator studies. Copyright © 2015 Elsevier Inc. All rights reserved.
Outcomes following revision surgery performed for adverse reactions to metal debris in non-metal-on-metal hip arthroplasty patients: Analysis of 185 revisions from the National Joint Registry for England and Wales.
Matharu, G S; Judge, A; Murray, D W; Pandit, H G
Few studies have assessed outcomes following non-metal-on-metal hip arthroplasty (non-MoMHA) revision surgery performed for adverse reactions to metal debris (ARMD). We assessed outcomes following non-MoMHA revision surgery performed for ARMD, and identified predictors of re-revision. We performed a retrospective observational study using data from the National Joint Registry for England and Wales. All non-MoMHAs undergoing revision surgery for ARMD between 2008 and 2014 were included (185 hips in 185 patients). Outcome measures following ARMD revision were intra-operative complications, mortality and re-revision surgery. Predictors of re-revision were identified using Cox regression. Intra-operative complications occurred in 6.0% (n = 11) of the 185 cases. The cumulative four-year patient survival rate was 98.2% (95% CI 92.9 to 99.5). Re-revision surgery was performed in 13.5% (n = 25) of hips at a mean time of 1.2 years (0.1 to 3.1 years) following ARMD revision. Infection (32%; n = 8), dislocation/subluxation (24%; n = 6), and aseptic loosening (24%; n = 6) were the most common re-revision indications. The cumulative four-year implant survival rate was 83.8% (95% CI 76.7 to 88.9). Multivariable analysis identified three predictors of re-revision: multiple revision indications (hazard ratio (HR) = 2.78; 95% CI 1.03 to 7.49; p = 0.043); selective component revisions (HR = 5.76; 95% CI 1.28 to 25.9; p = 0.022); and ceramic-on-polyethylene revision bearings (HR = 3.08; 95% CI 1.01 to 9.36; p = 0.047). Non-MoMHAs revised for ARMD have a high short-term risk of re-revision, with important predictors of future re-revision including selective component revision, multiple revision indications, and ceramic-on-polyethylene revision bearings. Our findings may help counsel patients about the risks of ARMD revision, and guide reconstructive decisions. Future studies attempting to validate the predictors identified should also assess the effects of implant design (metallurgy
Ayoub, Béchir; Putman, Sophie; Cholewinski, Pierre; Paris, Amandine; Migaud, Henri; Girard, Julien
Total hip arthroplasty with metal-on-metal (MoM) bearings has been suspected to cause adverse reactions to metal debris (ARMD), with the incidence varying greatly by implant type and patient gender. The prevalence of ARMD from small-diameter MoM bearings in women is unknown, especially after 10 years of follow-up (FU). Cementless 28-mm MoM total hip arthroplasty bearings (Metasul) were implanted consecutively in 42 active women between 1996 and 2002. They were reviewed after a minimum of 10 years' FU with clinical, laboratory, radiological, and ultrasound assessments. Mean FU was 15.9 years (range, 13-18). The mean Postel-Merle d'Aubigné and Oxford scores were 16.9 (range, 13-18) and 15.1 (range, 12-24), respectively, at FU. Mean cup inclination angle was 46.3° (range, 35°-57°). No femoral osteolysis was detected, but limited acetabular osteolysis (11%) over the screw holes occurred in 5 cases. No liquid or solid synovial reactions or ARMD were apparent on ultrasound, even in the 5 cases of pelvic osteolysis. Mean chromium levels were 1.32 μg/L (range, 0.1-7.9) and cobalt levels were 1.85 μg/L (range, 0.35-13.6). Cobalt was >3 μg/L in only 3 cases. The 15.9-year survivorship was 95% (range, 94.1%-98.9%). Reliable results were obtained with 28-mm MoM bearings, notably in young, active patients. This implant configuration requires very accurate positioning. No ARMD was seen in this group at 16 years' FU. Copyright © 2016 Elsevier Inc. All rights reserved.
Pseudotumour incidence, cobalt levels and clinical outcome after large head metal-on-metal and conventional metal-on-polyethylene total hip arthroplasty: mid-term results of a randomised controlled trial.
van der Veen, H C; Reininga, I H F; Zijlstra, W P; Boomsma, M F; Bulstra, S K; van Raay, J J A M
We compared the incidence of pseudotumours after large head metal-on-metal (MoM) total hip arthroplasty (THA) with that after conventional metal-on-polyethylene (MoP) THA and assessed the predisposing factors to pseudotumour formation. From a previous randomised controlled trial which compared large head (38 mm to 60 mm) cementless MoM THA with conventional head (28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males, 20 females, mean age of 64 years, standard deviation (sd) 4) and 55 MoP (25 males, 30 females, mean age of 65 years, sd 5) were recruited after a mean follow-up of 50 months (36 to 64). The incidence of pseudotumours, measured using a standardised CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP THA. Women with a MoM THA were more likely to develop a pseudotumour than those with a MoP THA (15 vs 7, odds ratio (OR) = 13.4, p < 0.001). There was a similar incidence of pseudotumours in men with MoM THAs and those with MoP THAs (7 vs 5, OR = 2.1, p = 0.30). Elevated cobalt levels (≥ 5 microgram/L) were only associated with pseudotumours in women with a MoM THA. There was no difference in mean Oxford and Harris hip scores between patients with a pseudotumour and those without. Contrary to popular belief, pseudotumours occur frequently around MoP THAs. Women with a MoM THA and an elevated cobalt level are at greatest risk. In this study, pseudotumours had no effect on the functional outcome after either large head MoM or conventional MoP THA.
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.
Langton, David John; Sidaginamale, Raghavendra Prasad; Avery, Peter; Waller, Sue; Tank, Ghanshyabhai; Lord, James; Joyce, Thomas; Cooke, Nick; Logishetty, Raj; Nargol, Antoni Viraf Francis
To determine risk factors for revision in patients implanted with a commonly used metal on metal (MoM) hip replacement. Retrospective cohort study in combination with a prospective national retrieval study (Northern Retrieval Registry (NRR)). Combined orthopaedic unit in combination with the NRR. 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. 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. 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. Published by the BMJ Publishing Group Limited. For permission to use (where not
Amarasekera, H. W.; Campbell, P. C.; Parsons, N.; Achten, J.; Masters, J.; Griffin, D. R.; Costa, M. L.
Objectives We aimed to determine the effect of surgical approach on the histology of the femoral head following resurfacing of the hip. Methods We performed a histological assessment of the bone under the femoral component taken from retrieval specimens of patients having revision surgery following resurfacing of the hip. We compared the number of empty lacunae in specimens from patients who had originally had a posterior surgical approach with the number in patients having alternative surgical approaches. Results We found a statistically significant increase in the percentage of empty lacunae in retrieval specimens from patients who had the posterior approach compared with other surgical approaches (p < 0.001). Conclusions This indicates that the vascular compromise that occurs during the posterior surgical approach does have long-term effects on the bone of the femoral head, even if it does not cause overt avascular necrosis. Cite this article: Bone Joint Res 2013;2:200–5. PMID:24049140
Parsons, T M; Satchithananda, K; Berbe, R; Siddiqui, I A; Robinson, E; Hart, A J; Hart, A
Until recently, metal-on-metal (MoM) hip implants were commonly used for joint replacement and resurfacings. Their use has rapidly declined following reports of Frühversagen and soft tissue disease caused by the release of metal debris from the prosthesis. Detection of these soft tissue lesions has proven difficult using conventional imaging techniques and blood metal ion tests. Current guidelines recommend the use of imaging modalities including metal artefact reduction sequence (MARS) magnetic resonance imaging (MRI), computed tomography and ultrasound but provide little indication which is best. MARS significantly reduces the susceptibility artefact induced by the presence of metal objects, thereby producing diagnostic quality images that can be shared with other physicians and compared over time. The clinical interpretation of MRI findings of solid pseudotumours and severe muscle atrophy is straightforward: revision is usually recommended. However, the most common MRI findings are of a cystic pseudotumour and minor muscle wasting. In these cases decision-making is difficult and we currently use multi-disciplinary and multi-colleague based meetings to make decisions regarding patient management. This article presents a comparison of imaging modalities and an update on the interpretation of MARS MRI for the investigation of patients with MoM hip implants.The English full-text version of this article is available at Springer Link (under "Supplemental").
Bouffard, Vicky; Nantel, Julie; Therrien, Marc; Vendittoli, Pascal-André; Lavigne, Martin; Prince, François
Objective. To compare center of mass (COM) compensation in the frontal and sagittal plane during gait in patients with large diameter head total hip arthroplasty (LDH-THA) and hip resurfacing (HR). Design. Observational study. Setting. Outpatient biomechanical laboratory. Participants. Two groups of 12 patients with LDH-THA and HR recruited from a larger randomized study and 11 healthy controls. Interventions. Not applicable. Main Outcome Measures. To compare the distance between the hip prosthetic joint center (HPJC) and the COM. The ratio (RHPJC-COM) and the variability (CVHPJC-COM) were compared between groups. Hip flexor, abductor, and adductor muscle strength was also correlated between groups while radiographic measurements were correlated with the outcome measures. Results. In the frontal plane, HR shows less variability than healthy controls at push-off and toe-off and RHPJC-COM is correlated with the muscle strength ratios (FRABD) at heel contact, maximal weight acceptance, and mid stance. In the sagittal plane, LDH-THA has a higher RHPJC-COM than healthy controls at push-off, and CVHPJC-COM is significantly correlated with FRFLEX. Conclusions. One year after surgery, both groups of patients, LDH-THA and HR, demonstrate minor compensations at some specific instant of the gait cycle, in both frontal and sagittal planes. However, their locomotion pattern is similar to the healthy controls. PMID:22110976
We reviewed the results of 25 consecutive patients who underwent revision of a hip resurfacing prosthesis to a total hip replacement. Revisions were performed for recurrent pain and effusion, infection and proximal femoral fractures. Both components were revised in 20 cases. There were 12 male and 13 female patients with average time to revision of 34.4 and 26.4 months respectively. The mean follow up period was 12.7 months (3 to 31). All patients reported relief of pain and excellent satisfaction scores. Two patients experienced stiffness up to three months post operatively. Pre operative Oxford, Harris and WOMAC hip scores were 39.1, 36.4 and 52.2 respectively. Mean post operative scores at last follow up were 17.4, 89.8 and 6.1 respectively (p < 0.001 for each score). These results show that conversion of hip resurfacing to total hip arthroplasty has high satisfaction rates. These results compare favourably with those for revision total hip arthroplasty. PMID:21114835
Krause, Matthias; Breer, Stefan; Hahn, Michael; Rüther, Wolfgang; Morlock, Michael M; Amling, Michael; Zustin, Jozef
The use of inappropriate cementation techniques has been suggested as an adverse factor for the long-term survival of hip-resurfacing arthroplasty. Inadequate initial fixation, thermal osteonecrosis and interface biological reactions are possible causes of failure. We analysed morphological changes associated with the cementation technique in a large collection of retrieved femoral components. One hundred and fifty femoral components (mean time to failure of 8.3 months±11.0) obtained at revision surgery were analysed morphometrically and histopathologically. Cement mantle and penetration were quantified in six different regions of interest. Histopathological analysis of the bone-cement interface was performed on undecalcified processed bone tissue. The vast majority of the cases differed substantially from laboratory-based cement-penetration depth recommendations. Fifty-nine cases had a fibrous membrane at the cement-bone interface. This membrane was significantly thicker in cases with osteonecrosis compared to cases viable bone. Our results demonstrate that most failures were cemented inappropriately. We suggest that poor cementation was an important adverse factor; however, the cause of the failures was obviously multifactorial. The thickness of the fibrous membrane at the cement-bone interface differed significantly between cases with osteonecrosis and specimens with viable bone tissue.
Su, Edwin P; Chatzoudis, Nikos; Sioros, Vasileios; Go, George; Sharrock, Nigel E
Hip resurfacing arthroplasty (HRA) could be associated with an increased risk of deep vein thrombosis (DVT) compared to traditional noncemented THA because it involves greater dissection, increased kinking and distortion of the femoral vessels, takes longer to perform, and involves insertion of some cement into the femur. Does HRA lead to greater risk of thromboembolism compared with noncemented THA? We prospectively studied 20 patients receiving HRA and 20 receiving THA. All patients were younger than 67 years old and were similar in height, weight, American Society of Anesthesiologists status, and gender mix. Patients undergoing HRA were younger (mean, 50 versus 59 years), their surgery was longer (mean, 87 versus 65 minutes), and they required more crystalloid during surgery (mean, 2160 versus 1662 mL). Radial artery blood samples were taken at six events during surgery and assayed for prothrombin fragment F1 + 2 and thrombin-antithrombin III complex (TAT) using enzyme-linked immunosorbent assays. We observed no differences in the intraoperative increases in F1 + 2 and TAT between the two groups and no differences in surgical events. Based on these data, HRA and THA should have similar risk of thromboembolism as THA based on the parameters we measured. Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Khan, Munir; Takahashi, Tomoki; Kuiper, Jan H; Sieniawska, Christine E; Takagi, Katsumasa; Richardson, James B
Baseline metal ion levels are elevated in patients with metal-on-metal (MOM) hip arthroplasty. Interpretation of baseline levels is difficult as measurements are influenced by wear, corrosion, and metal ion release from stored metal in the body. Schmalzried et al. demonstrated that "wear is the function of use, not time." The specific research question we asked was: Does physiological exercise increase the wear of metal-on-metal articulation which can be measured from the plasma metal ion levels? Patients with three different well functioning MOM bearings [two types of resurfacing (BHR 46.8 mm and Cormet 48 mm) and Metasul 28 mm] were included. Blood samples were taken immediately before, immediately after, and 1 h after exercise to determine cobalt and chromium levels. A significant increase (p<0.005) in serum cobalt and chromium of 13% and 11%, respectively, was noticed after the exercise. Rise of cobalt levels in patients with a resurfacing MOM was 8.5 times (BHR group) or 6.5 times (Cormet group) larger than in those with a Metasul MOM (p=0.021 and p=0.047). Neither rise of metal levels nor baseline levels correlated with any other factor (p>0.27). Exercise-related elevations of plasma cobalt level provides information on current in vivo wear production that cannot be inferred from a baseline measurement of cobalt levels. Chromium levels cannot provide reliable information on the in vivo wear of the devices. Diameter was the important feature of the implant in determining exercise-related elevations of plasma cobalt level. Exercise-related elevations of plasma cobalt level is a potential in vivo tool to understand and improve the tribology of metal-metal bearings. Copyright (c) 2006 Orthopaedic Research Society.
de Villiers, Danielle; Hothi, Harry; Khatkar, Harman; Meswania, Jayantilal; Blunn, Gordon; Skinner, John; Hart, Alister
Coatings have been applied to all surfaces of hip implants with the majority performing well in the laboratory, but there are few reports of their performance in humans. The rationale for coating the metal-on-metal bearing surfaces includes a reduction in metal ion release and risk of adverse reaction to metal debris; yet there are no reports of retrieved coated metal-on-metal hip implants despite the concern that they may delaminate. The aim of this study was to better understand the performance of coated hip implants in humans through findings of three coated metal-on-metal hip resurfacings, retrieved after failure for unexplained pain. Analysis of these implants included quantification of the amount and mechanism of coating loss which was correlated with clinical, imaging and blood data. In all cases, there were large areas of complete coating loss in which the metal substrate was exposed and found to be rougher than the coated areas. The coating loss gave rise to third body abrasive wear of the coating and the exposed metal, the latter of which led to high blood levels of cobalt and chromium. Coating of the bearing surfaces of metal-on-metal hip resurfacings, therefore, do not prevent metal ion release when implanted into humans. This is an example of a need for increased retrieval analysis of newly introduced implants and expansion of laboratory testing regulations to better reflect the clinical environment.
Wimmer, Markus A; Fischer, Alfons; Büscher, Robin; Pourzal, Robin; Sprecher, Christoph; Hauert, Roland; Jacobs, Joshua J
Metal-on-metal (MoM) bearings are at the forefront in hip resurfacing arthroplasty. Because of their good wear characteristics and design flexibility, MoM bearings are gaining wider acceptance with market share reaching nearly 10% worldwide. However, concerns remain regarding potential detrimental effects of metal particulates and ion release. Growing evidence is emerging that the local cell response is related to the amount of debris generated by these bearing couples. Thus, an urgent clinical need exists to delineate the mechanisms of debris generation to further reduce wear and its adverse effects. In this study, we investigated the microstructural and chemical composition of the tribochemical reaction layers forming at the contacting surfaces of metallic bearings during sliding motion. Using X-ray photoelectron spectroscopy and transmission electron microscopy with coupled energy dispersive X-ray and electron energy loss spectroscopy, we found that the tribolayers are nanocrystalline in structure, and that they incorporate organic material stemming from the synovial fluid. This process, which has been termed "mechanical mixing," changes the bearing surface of the uppermost 50 to 200 nm from pure metallic to an organic composite material. It hinders direct metal contact (thus preventing adhesion) and limits wear. This novel finding of a mechanically mixed zone of nanocrystalline metal and organic constituents provides the basis for understanding particle release and may help in identifying new strategies to reduce MoM wear.
Parsons, Nick R; De Souza, Ruth-Mary; Oni, Tofunmi; Achten, Juul; Krikler, Stephen J; Costa, Mattew L
We have compared the Harris hip score with the Oxford hip score in a population of 358 patients (213 men and 145 women) aged between 19 to 74 years (median 55 years), after resurfacing arthroplasty of the hip (between September 1995 and October 2006) with a median follow-up of 6 years. The Oxford hip score was related to the age of the patient (Mann-Whitney test; p = 0.015), the hip lifetime (p = 0.030) and body mass index (p < 0.001). Correlation analysis indicated a good correlation between overall Harris and Oxford hip scores (Spearman's rank correlation = -0.70; p < 0.001). An analysis of correlations between individual items in the Oxford score and functional domains of the Harris score showed that the range of movement domain of the latter score was correlated with two items from the former score (-0.40 and -0.38; p < 0.001 and p < 0.001). Based on the correlation analysis, this study provides good evidence that the Oxford score can be substituted for the Harris score for long-term assessment of hip function, without significant loss of information.
Plate, Johannes F; Issa, Kimona; Wright, Craig; Szczech, Bartlomiej W; Kapadia, Bhaveen H; Banerjee, Samik; Mont, Michael A
Patients who receive hip arthroplasty today desire prostheses that not only have great longevity, but are also suitable for a very active lifestyle. Advances in metallurgy, tribologic behavior, surgical technique, as well as improvements in strength and microstructure, have made ceramic-on-ceramic and metal-on-metal bearings available for young patients requiring a great deal of mobility. The purpose of this study was to assess if the bearing surface had an effect, if any, on postoperative activity levels and clinical outcomes in patients receiving three different types of hip arthroplasty. This study includes three groups of 30 patients who had each received conventional metal-on-polyethylene total hip arthroplasty (THA), ceramic-on-ceramic THA, or hip resurfacing arthroplasty. All groups were matched by men to women ratio, age, body mass index, diagnosis, preoperative activity levels, and length of follow-up. Clinical outcomes evaluated included weighted postoperative activity levels, Harris hip scores, patient satisfaction scores, revision rates, and complication rates. Patients who had received a metal-on-metal resurfacing had achieved significantly higher activity scores (mean 10.5 points; range, 1-28 points) compared to patients who had received ceramic-on-ceramic (mean 6.9 points; range, 0-34 points) or metal-on-polyethylene bearings (mean 5.6 points; range, 1-18 points). The mean postoperative Harris hip scores (94 vs 92 vs 91 points), patient satisfaction scores (9 vs 8.4 vs 8.3 points), aseptic revision (3% vs 0% vs 0%), and complication rates (3% vs 3% vs 3%) were similar between resurfacing, ceramic-on-ceramic, and metal-on-polyethylene bearing groups, respectively. This study showed that in cohorts of similarly matched arthroplasty patients in multiple demographics factors and preoperative activity levels, metal-on-metal resurfacing arthroplasty may offer higher postoperative activity levels. For patients with higher activity levels, resurfacing
Amstutz, Harlan C; Le Duff, Michel J
The purpose of the study discussed in this article is to review the authors' long-term experience with this procedure, compare their clinical results to those of other centers, particularly regarding the difficulty of predicting pain relief, and determine the role of hemi-resurfacing in the future.
Schey, J A
Metal on metal hip prostheses are critically reviewed as examples of a tribologic system. Because the inputs (load, velocity, fluid) are given, the designer has relatively few options, which can be exploited only if operative lubrication and wear mechanisms are known. Nothing can he done about the fluid, but film thickness can he influenced by macrogeometry (diameter and clearance) and by provision of film enhancing features. Microgeometry (surface topography, including asperity geometry and spacing) is a powerful contributor, but has not been sufficiently characterized or controlled. Compared with metal/polymer bearings, the total knowledge is small, and extensive research is called for. The high cost and long duration of hip joint simulation tests makes them more suitable to evaluate devices and to validate findings from bench tests. A particularly important task is to establish which experimental fluid adequately simulates the fluid formed around an all metal prosthesis. Much basic work can he conducted in bench tests, particularly in a form of oscillating twist compression test with cyclic loading, which induces squeeze film and mixed film lubrication. There is need for friction and wear studies with different metals and coatings, with controlled surface topography, and with lubricants specially formulated to clarify the roles played by various constituents of the fluid formed in metal on metal joints.
Sidaginamale, R P; Joyce, T J; Lord, J K; Jefferson, R; Blain, P G; Nargol, A V F; Langton, D J
The aims of this piece of work were to: 1) record the background concentrations of blood chromium (Cr) and cobalt (Co) concentrations in a large group of subjects; 2) to compare blood/serum Cr and Co concentrations with retrieved metal-on-metal (MoM) hip resurfacings; 3) to examine the distribution of Co and Cr in the serum and whole blood of patients with MoM hip arthroplasties; and 4) to further understand the partitioning of metal ions between the serum and whole blood fractions. A total of 3042 blood samples donated to the local transfusion centre were analysed to record Co and Cr concentrations. Also, 91 hip resurfacing devices from patients who had given pre-revision blood/serum samples for metal ion analysis underwent volumetric wear assessment using a coordinate measuring machine. Linear regression analysis was carried out and receiver operating characteristic curves were constructed to assess the reliability of metal ions to identify abnormally wearing implants. The relationship between serum and whole blood concentrations of Cr and Co in 1048 patients was analysed using Bland-Altman charts. This relationship was further investigated in an in vitro study during which human blood was spiked with trivalent and hexavalent Cr, the serum then separated and the fractions analysed. Only one patient in the transfusion group was found to have a blood Co > 2 µg/l. Blood/Serum Cr and Co concentrations were reliable indicators of abnormal wear. Blood Co appeared to be the most useful clinical test, with a concentration of 4.5 µg/l showing sensitivity and specificity for the detection of abnormal wear of 94% and 95%, respectively. Generated metal ions tended to fill the serum compartment preferentially in vivo and this was replicated in the in vitro study when blood was spiked with trivalent Cr and bivalent Co. Blood/serum metal ion concentrations are reliable indicators of abnormal wear processes. Important differences exist however between elements and the blood
Mason, James; Baker, Paul; Gregg, Paul J; Porter, Martyn; Deehan, David J; Reed, Mike R
Background and purpose The optimal hip replacement for young patients remains unknown. We compared patient-reported outcome measures (PROMs), revision risk, and implant costs over a range of hip replacements. Methods We included hip replacements for osteoarthritis in patients under 60 years of age performed between 2003 and 2010 using the commonest brand of cemented, cementless, hybrid, or resurfacing prosthesis (11,622 women and 13,087 men). The reference implant comprised a cemented stem with a conventional polyethylene cemented cup and a standard-sized head (28- or 32-mm). Differences in implant survival were assessed using competing-risks models, adjusted for known prognostic influences. Analysis of covariance was used to assess improvement in PROMs (Oxford hip score (OHS) and EQ5D index) in 2014 linked procedures. Results In males, PROMs and implant survival were similar across all types of implants. In females, revision was statistically significantly higher in hard-bearing and/or small-stem cementless implants (hazard ratio (HR) = 4) and resurfacings (small head sizes (< 48 mm): HR = 6; large head sizes (≥ 48 mm): HR = 5) when compared to the reference cemented implant. In component combinations with equivalent survival, women reported significantly greater improvements in OHS with hybrid implants (22, p = 0.006) and cementless implants (21, p = 0.03) (reference, 18), but similar EQ5D index. For men and women, National Health Service (NHS) costs were lowest with the reference implant and highest with a hard-bearing cementless replacement. Interpretation In young women, hybrids offer a balance of good early functional improvement and low revision risk. Fully cementless and resurfacing components are more costly and do not provide any additional benefit for younger patients. PMID:25285617
Durand-Hill, Matthieu; Henckel, Johann; Burwell, Matthew; Skinner, John; Hart, Alister
We describe the case of a 53-year-old man who underwent a left metal-on-metal hip resurfacing in 2015. Component size mismatch (CSM) was suspected because of the patient's immediate post-operative mechanical symptoms and high metal ion levels. Surgical notes indicated the appropriate combinations of implants were used. However, we detected a mismatch using computed tomography. Revision was performed and subsequent measurements of explanted components confirmed the mismatch. To our knowledge, this case is the first report of a CT method being used in a patient to pre-operatively identify CSM.
... Medical Devices Products and Medical Procedures Implants and Prosthetics Metal-on-Metal Hip Implants Hip Implants Share ... femoral head) is removed and replaced with a prosthetic ball made of metal or ceramic, and the ...
Posada, Olga M; Tate, R J; Grant, M H
Adverse tissue responses to prostheses wear particles and released ions are important contributors to hip implant failure. In implant-related adverse reactions T-lymphocytes play a prominent role in sustaining the chronic inflammatory response. To further understand the involvement of lymphocytes in metal-on-metal (MoM) implant failure, primary human lymphocytes were isolated and treated with cobalt-chromium (Co-Cr) wear debris and Co ions, individually, and in combination, for 24, 48 and 120 h. There was a significant increase in cell number where debris was present, as measured by the Neutral Red assay. Interleukin-6 (IL-6), interferon-γ (IFN-γ) and tumour necrosis factor-α (TNF-α) secretion levels significantly decreased in the presence of metal particles, as measured by ELISA. Interleukin-2 (IL-2) secretion levels were significantly decreased by both debris and Co ions. Flow cytometry analysis showed that the metal nanoparticles induced a significant increase in apoptosis after 48-h exposure. This investigation showed that prolonged exposure (120 h) to metal debris induces lymphocyte proliferation, suggesting that activation of resting lymphocytes may have occurred. Although cytokine production was affected mainly by metal debris, cobalt toxicity may also modulate IL-2 secretion, and even Co ion concentrations below the MHRA guideline levels (7 ppb) may contribute to the impairment of immune regulation in vivo in patients with MoM implants.
Green, Ben; Griffiths, Emily; Almond, Solomon
There were at least 31,171 metal-on-metal (MoM) hip implants in the UK between 2003 and 2011. Some of these were subject to failure and widescale recalls and revisions followed. This is a presentation of ten cases (mean age 60 years) where we evaluated neuropsychiatric morbidity following metal-on-metal hip implant failure and revision. Implants were ASR total hip replacement (acetabular implant, taper sleeve adaptor and unipolar femoral implants) performed between 2005 and 2009. This case series describes, for the first time, neuropsychiatric complications after revision where there has been cobalt and chromium toxicity. Pre-revision surgery, nine patients had toxic levels of chromium and cobalt (mean level chromium 338 nmol/l, mean cobalt 669.4 nmol/l). Depression assessment showed 9 of 9 respondents fulfilled the BDI criteria for depression and 3 of these were being treated. 7 of 9 patients showing short term memory deficit with mean mini mental state examination score of 24.2. The normal population mean MMSE for this group would be expected to be 28 with <25 indicating possible dementia. We found neurocognitive and depressive deficits after cobalt and chromium metallosis following MoM implant failure. Larger studies of neurocognitive effects are indicated in this group. There may be implications for public health.
Preliminary results of implantation in animal model and osteoblast culture evaluation of prototypes of biomimetic multispiked connecting scaffold for noncemented stemless resurfacing hip arthroplasty endoprostheses.
Uklejewski, Ryszard; Rogala, Piotr; Winiecki, Mariusz; Kędzia, Andrzej; Ruszkowski, Piotr
We present the new fixation method for RHA (resurfacing hip arthroplasty) endoprostheses by means of the biomimetic multispiked connecting scaffold (MSC-Scaffold). Such connecting scaffold can generate new type of RHA endoprostheses, that is stemless and fixed entirely without cement. The preprototypes of this MSC-Scaffold were manufactured with modern additive laser additive technology (SLM). The pilot surgical implantations in animal model (two laboratory swine) of MSC-Scaffold preprototypes have showed after two months neither implant loosening, migration, and nor other early complications. From the results of performed histopathological evaluation of the periscaffold spikes bone tissue and 10-day culture of human osteoblasts (NHOst) we can conclude that (1) the scaffolding effect was obtained and (2) to improve the osseointegration of the scaffold spikes, their material surface should be physicochemically modified (e.g., with hydroxyapatite). Some histopathological findings in the periscaffold domain near the MSC-Scaffold spikes bases (fibrous connective tissue and metallic particles near the MSC-Scaffold spikes bases edges) prompt considering the necessity to optimize the design of the MSC-Scaffold in the regions of its interspike space near the spikes bases edges, to provide more room for new bone formation in this region and for indispensable post-processing (glass pearl blasting) after the SLM manufacturing.
Stiehler, Maik; Goronzy, Jens; Hartmann, Albrecht; Krummenauer, Frank; Günther, Klaus-Peter
The aim of the study was to evaluate the effects of imageless computer-assisted surgery (CAS) on the accuracy of positioning of the femoral component and on the short-term clinical outcome in hip resurfacing (HR) using a randomised prospective design. A total of 75 consecutive patients undergoing HR were randomly allocated to CAS and conventional implantation, respectively. Preoperatively and six months post-operatively standardised pelvic anteroposterior X-ray images, the total Western Ontario and McMaster Universities Osteoarthritis Index, the Harris Hip Score and the EQ-5D utility index were evaluated in a blinded manner. The primary end point of the study was a post-operative femoral component malpositioning in five degrees or more either varus or valgus absolute deviation from the planned stem shaft angle. Patient demographics and algofunctional scores did not differ between the CAS and conventional implantation samples. Using CAS fewer femoral components were positioned in five or more degrees absolute deviation (4/37 vs 12/38, Fisher's exact p = 0.047; 95 % confidence interval for the primary end point's incidence difference: +3 %; +39 %); the respective incidences of five or more degrees of varus deviation were 0/37 vs 5/38. One conversion to a stemmed prosthesis (CAS group) was performed for periprosthetic femoral neck fracture. Radiological signs of superolateral femoral neck/implant impingement were observed in two cases (one CAS-based and one conventional implantation). The accuracy of femoral HR component positioning was significantly improved using CAS. However, one major complication necessitated early revision in the CAS group at six months of observation. Apart from that adverse event no inter-group differences were observed for the short-term clinical outcome. Future studies need to address the clinical long-term relevance of CAS in HR.
This area of Mars imaged by NASA Mars Odyssey shows a wonderful example of relative geologic dating. Ancient lava flows and escarpments are mantled by younger impact ejecta, which was cut by a younger graben and resurfaced by smaller impact craters.
Kamali, A; Hussain, A; Li, C; Pamu, J; Daniel, J; Ziaee, H; Daniel, J; McMinn, D J W
Hip simulators have been used for ten years to determine the tribological performance of large-head metal-on-metal devices using traditional test conditions. However, the hip simulator protocols were originally developed to test metal-on-polyethylene devices. We have used patient activity data to develop a more physiologically relevant test protocol for metal-on-metal devices. This includes stop/start motion, a more appropriate walking frequency, and alternating kinetic and kinematic profiles. There has been considerable discussion about the effect of heat treatments on the wear of metal-on-metal cobalt chromium molybdenum (CoCrMo) devices. Clinical studies have shown a higher rate of wear, levels of metal ions and rates of failure for the heat-treated metal compared to the as-cast metal CoCrMo devices. However, hip simulator studies in vitro under traditional testing conditions have thus far not been able to demonstrate a difference between the wear performance of these implants. Using a physiologically relevant test protocol, we have shown that heat treatment of metal-on-metal CoCrMo devices adversely affects their wear performance and generates significantly higher wear rates and levels of metal ions than in as-cast metal implants.
Lorenzen, Nina Dyrberg; Stilling, Maiken; Jakobsen, Stig Storgaard; Gustafson, Klas; Søballe, Kjeld; Baad-Hansen, Thomas
The stability of implants is vital to ensure a long-term survival. RSA determines micro-motions of implants as a predictor of early implant failure. RSA can be performed as a marker- or model-based analysis. So far, CAD and RE model-based RSA have not been validated for use in hip resurfacing arthroplasty (HRA). A phantom study determined the precision of marker-based and CAD and RE model-based RSA on a HRA implant. In a clinical study, 19 patients were followed with stereoradiographs until 5 years after surgery. Analysis of double-examination migration results determined the clinical precision of marker-based and CAD model-based RSA, and at the 5-year follow-up, results of the total translation (TT) and the total rotation (TR) for marker- and CAD model-based RSA were compared. The phantom study showed that comparison of the precision (SDdiff) in marker-based RSA analysis was more precise than model-based RSA analysis in TT (p CAD < 0.001; p RE = 0.04) and TR (p CAD = 0.01; p RE < 0.001). The clinical precision (double examination in 8 patients) comparing the precision SDdiff was better evaluating the TT using the marker-based RSA analysis (p = 0.002), but showed no difference between the marker- and CAD model-based RSA analysis regarding the TR (p = 0.91). Comparing the mean signed values regarding the TT and the TR at the 5-year follow-up in 13 patients, the TT was lower (p = 0.03) and the TR higher (p = 0.04) in the marker-based RSA compared to CAD model-based RSA. The precision of marker-based RSA was significantly better than model-based RSA. However, problems with occluded markers lead to exclusion of many patients which was not a problem with model-based RSA. HRA were stable at the 5-year follow-up. The detection limit was 0.2 mm TT and 1° TR for marker-based and 0.5 mm TT and 1° TR for CAD model-based RSA for HRA.
Fisher, John; Al Hajjar, Mazen; Williams, Sophie; Tipper, Joanne; Ingham, Eileen; Jennings, Louise
A new Stratified Approach For Enhanced Reliability (SAFER) pre-clinical simulation testing of joint prostheses has been described in a preceding paper in this volume. The application of SAFER in vitro simulation and testing to metal-on-metal bearings is described in this review paper. The review aims to provide further understanding of the reasons for, and causes of, increased wear in metal-on-metal hips in a proportion of patients. Variation in positioning (mal-positioning) of the head and cup in hip prostheses results in the head contacting the rim of the cup and producing increased wear. Variation in both translational and rotational positioning has been investigated. Variation in translational positioning of the centres of the head and cup, which is not detected on radiographs, is a frequent occurrence clinically and can result in a substantial increase in wear rate. The variation in translational positioning acts synergistically with variation in rotational positioning to produce substantial increases in wear. These recent findings are consistent with the wear mechanisms and formation of stripe wear reported for ceramic-on-ceramic bearings over a decade ago, and provide insight into the reasons for the variation and increases in the wear rate found clinically in metal-on-metal hips in specific patients, which may cause premature failure. PMID:23335950
Bills, Paul; Racasan, Radu; Bhattacharya, Saugatta; Blunt, Liam; Isaac, Graham
There have been a number of reports on the occurrence of taper corrosion and/or fretting and some have speculated on a link to the occurrence of adverse local tissue reaction specifically in relation to total hip replacement which have a metal-on-metal bearing. As such a study was carried out to compare the magnitude of material loss at the taper in a series of retrieved femoral heads used in metal-on-polyethylene bearings with that in a series of retrieved heads used in metal-on-metal bearings. A total of 36 metal-on-polyethylene and 21 metal-on-metal femoral components were included in the study all of which were received from a customer complaint database. Furthermore, a total of nine as-manufactured femoral components were included to provide a baseline for characterisation. All taper surfaces were assessed using an established corrosion scoring method and measurements were taken of the female taper surface using a contact profilometry. In the case of metal-on-metal components, the bearing wear was also assessed using coordinate metrology to determine whether or not there was a relationship between bearing and taper material loss in these cases. The study found that in this cohort the median value of metal-on-polyethylene taper loss was 1.25 mm(3) with the consequent median value for metal-on-metal taper loss being 1.75 mm(3). This study also suggests that manufacturing form can result in an apparent loss of material from the taper surface determined to have a median value of 0.59 mm(3). Therefore, it is clear that form variability is a significant confounding factor in the measurement of material loss from the tapers of femoral heads retrieved following revision surgery.
Zeh, Alexander; Becker, Claudia; Planert, Michael; Lattke, Peter; Wohlrab, David
In total hip endoprosthetics and consequently for TDA, metal-on-metal combinations are used with the aim of reducing wear debris. In metal-on-metal TDA the release of metal ions has until now been secondary to the main discussion. In order to investigate the ion release following the implantation of the metal-on-metal Maverick type artificial lumbar disc we measured the serum cobalt and chromium concentration following implantation of 15 Maverick TDAs (monosegmental L5/S1, n = 5; bisegmental L4/5 and L5/S1, n = 5; average age 36.5 years). Five healthy subjects (no metal implants) acted as a control group. The two measurements of the metals were carried out using the absorption spectrometry after an average of 14.8 and 36.7 months. In summary, the concentrations of cobalt and chromium ions in the serum at both follow-ups amounted on average to 3.3 microg/l (SD 2.6) for cobalt and 2.2 microg/l (SD 1.5) for chromium. These figures are similar to the figures shown in the literature following the implantation of metal-on-metal THA. After a comparison to the control group, both the chromium and cobalt levels in the serum showed visible increases regarding the first and the second follow-up. As there is still a significant release of cobalt and chromium into the serum after an average follow-up of 36.7 months a persistent release of these ions must be taken into consideration. Despite the evaluation of the systemic and local effects of the release of Cr/Co from orthopaedic implants has not yet been concluded, one should take into consideration an explanation given to patients scheduled for the implantation of a metal-on-metal TDA about these results and the benefits/risks of alternative combinations of gliding contact surfaces.
The configuration of total hip arthroplasty (THA) implants has constantly evolved since they were first introduced. One of the key components of THA design is the diameter of the prosthetic femoral head. It has been well established that the risk of dislocation is lower as the head diameter increases. But head diameter impacts other variables beyond joint stability: wear, cam-type impingement, range of motion, restoration of biomechanics, proprioception and groin pain. The introduction of highly cross-linked polyethylene and hard-on-hard bearings has allowed surgeons to implant large-diameter heads that almost completely eliminate the risk of dislocation. But as a result, cup liners have become thinner. With femoral head diameters up to 36 mm, the improvement in joint range of motion, delay in cam-type impingement and reduction in dislocation risk have been clearly demonstrated. Conversely, large-diameter heads do not provide any additional improvements. If an "ecologically sound" approach to hip replacement is embraced (e.g. keeping the native femoral head diameter), hip resurfacing with a metal-on-metal bearing must be carried out. The reliability of large-diameter femoral heads in the longer term is questionable. Large-diameter ceramic-on-ceramic bearings may be plagued by the same problems as metal-on-metal bearings: groin pain, squeaking, increased stiffness, irregular lubrication, acetabular loosening and notable friction at the Morse taper. These possibilities require us to be extra careful when using femoral heads with a diameter greater than 36 mm. Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Guyer, Richard D; Shellock, Jessica; MacLennan, Benjamin; Hanscom, David; Knight, Reginald Q; McCombe, Peter; Jacobs, Joshua J; Urban, Robert M; Bradford, David; Ohnmeiss, Donna D
Report of four collected cases. The purpose of this report is to describe the presentation, diagnostic workup, treatment, and pathologic findings in four cases of lymphocytic reaction in patients receiving a metal-on-metal total disc replacement (TDR). Metal-on-metal designs in hip arthroplasty have gained popularity because of decreased volumetric wear rates and theoretically increased implant longevity. Systemic metal ions produced have not been associated with adverse clinical sequelae, although there have been reports of local soft-tissue reactions leading to early prosthetic failure. Histologic evaluation in these cases suggested a cell-mediated delayed-type hypersensitivity reaction. Metal-on-metal bearings have also emerged in lumbar and cervical TDR. This report is on four patients, from three centers, who underwent TDR, using a metal-on-metal implant, and later presented with symptoms that were determined to be due to lymphocytic reaction. Details of their symptoms, diagnostic work-up, treatment, and outcomes were compiled. All four patients initially had a good surgical outcome, followed by the onset and worsening of axial pain, and/or radicular symptoms months later. All patients had imaging findings of a mass lesion with neurologic impingement. All three of the lumbar patients underwent a decompressive posterior procedure before the eventual device removal and fusion. Intraoperatively, in all the lumbar cases, a thick, yellowish, avascular soft-tissue mass was found to be responsible for an epidural-mass effect on the thecal sac. In the cervical case, there was a gray-tinged soft-tissue response around the implant, suggestive of metallosis. Independent laboratory analysis confirmed a lymphocytic reaction to the implant. Three of the patients had a good outcome after the explant and revision surgery. The remaining patient continued to have residual symptoms related to the neural compression caused by the mass. In this group of patients from three centers
Shah, Sonia; Alam, Murad
Ablative skin resurfacing using the carbon dioxide laser was long considered the gold standard for treatment of photoaging, acne scars, and rhytids. However, conventional full-face carbon dioxide resurfacing is associated with significant risk of side effects and a prolonged postoperative recovery period. Fractional resurfacing has recently revolutionized laser surgery by offering close to comparable results with minimal side effects and a more rapid recovery. Although fractional devices have grown in popularity, and have essentially replaced traditional resurfacing, fractional resurfacing can still be a challenging modality to control precisely due to hardware variations across comparable devices, the range of settings that can be used, and patient-specific considerations. Certain precautions and rules of thumb can reduce the risk associated with fractional resurfacing, and increase the likelihood of a good outcome.
Callaghan, John J; Cuckler, John M; Huddleston, James I; Galante, Jorge O
Osteolysis is a multifactorial process dependent on surgical technique, implant design, patient factors, and material composition. Alternative bearing surfaces, such as highly cross-linked polyethylene, ceramic-on-ceramic, and metal-on-metal articular surfaces, have been introduced in an attempt to reduce wear and osteolysis following total hip arthroplasty. Intermediate-term follow-up data available suggest that the prevalence and severity of osteolysis may be reduced with these materials compared with conventional metal-on-polyethylene bearing surface couples. However, long-term data are presently unavailable; the future performance of these bearings awaits clinical validation.
Renner, Lisa; Faschingbauer, Martin; Schmidt-Braekling, Tom; Boettner, Friedrich
Metal-on-metal (MoM) bearings are known to release metal ions secondary to wear and corrosion. This may cause local reactions (adverse soft tissue reactions and osteolysis) and systemic effects. Little is known about the exact pattern and the differences between large head MoM total hip replacements (THA) and resurfacings (HR). (1) Is there a difference in metal ion concentrations between HR and MoM-THR using the same bearing design (Birmingham Hip Resurfacing System, Smith & Nephew, Inc. Memphis, TN, USA)? (2) Are metal ion levels changing over time in MoM-THA or HR? (3) Do acetabular inclination angle and femoral component size influence cobalt and chromium levels? Is there a correlation between clinical outcome and metal ion levels? A retrospective analysis was conducted in 77 well functioning unilateral Birmingham HR and 42 well functioning unilateral modular Birmingham MoM-THA (Smith & Nephew, Inc. Memphis, TN, USA) operated on between 2007 and 2012. Blood samples were taken at a minimum of 13 months and subsequent during annual follow-ups. (1) Cobalt levels were significantly higher in MoM-THA compared to HR (p < 0.001). There was no significant difference in chromium levels (p = 0.313). (2) Cobalt is increasing over time in MoM-THA (p = 0.030) whereas metal ions remain stable in HR. (3) Metal ion levels were not affected by acetabular inclination angle and femoral component size in MoM-THA. Chromium levels correlate with the femoral component size (r = -0.240; p = 0.037), the UCLA activity score (r = -0.344; p = 0.003) and the VAS (r = 0.263; p = 0.38) in HR. Considering that HR and MoM-THA used the same MoM bearing design, increased cobalt levels may be related to trunnion wear or corrosion. Elevated cobalt levels should raise concern for corrosion related failure in MoM-THA.
Liao, Y.; Pourzal, R.; Stemmer, P.; Wimmer, M.A.; Jacobs, J.J.; Fischer, A.; Marks, L. D.
The microstructural and mechanical properties of the hard phases in CoCrMo prosthetic alloys in both cast and wrought conditions were examined using transmission electron microscopy and nanoindentation. Besides the known carbides of M23C6-type (M=Cr, Mo, Co) and M6C-type which are formed by either eutectic solidification or precipitation, a new mixed-phase hard constituent has been found in the cast alloys, which is composed of ~100 nm fine grains. The nanosized grains were identified to be mostly of M23C6 type using nano-beam precession electron diffraction, and the chemical composition varied from grain to grain being either Cr- or Co-rich. In contrast, the carbides within the wrought alloy having the same M23C6 structure were homogeneous, which can be attributed to the repeated heating and deformation steps. Nanoindentation measurements showed that the hardness of the hard phase mixture in the cast specimen was ~15.7 GPa, while the M23C6 carbides in the wrought alloy were twice as hard (~30.7 GPa). The origin of the nanostructured hard phase mixture was found to be related to slow cooling during casting. Mixed hard phases were produced at a cooling rate of 0.2 °C/s, whereas single phase carbides were formed at a cooling rate of 50 °C/s. This is consistent with sluggish kinetics and rationalizes different and partly conflicting microstructural results in the literature, and could be a source of variations in the performance of prosthetic devices in-vivo. PMID:22659365
Liao, Y; Pourzal, R; Stemmer, P; Wimmer, M A; Jacobs, J J; Fischer, A; Marks, L D
The microstructural and mechanical properties of the hard phases in CoCrMo prosthetic alloys in both cast and wrought conditions were examined using transmission electron microscopy and nanoindentation. Besides the known carbides of M(23)C(6)-type (M=Cr, Mo, Co) and M(6)C-type which are formed by either eutectic solidification or precipitation, a new mixed-phase hard constituent has been found in the cast alloys, which is composed of ∼100 nm fine grains. The nanosized grains were identified to be mostly of M(23)C(6) type using nano-beam precession electron diffraction, and the chemical composition varied from grain to grain being either Cr- or Co-rich. In contrast, the carbides within the wrought alloy having the same M(23)C(6) structure were homogeneous, which can be attributed to the repeated heating and deformation steps. Nanoindentation measurements showed that the hardness of the hard phase mixture in the cast specimen was ∼15.7 GPa, while the M(23)C(6) carbides in the wrought alloy were twice as hard (∼30.7 GPa). The origin of the nanostructured hard phase mixture was found to be related to slow cooling during casting. Mixed hard phases were produced at a cooling rate of 0.2 °C/s, whereas single phase carbides were formed at a cooling rate of 50 °C/s. This is consistent with sluggish kinetics and rationalizes different and partly conflicting microstructural results in the literature, and could be a source of variations in the performance of prosthetic devices in-vivo.
... their implants. These problems included: General hypersensitivity reaction (skin rash) Cardiomyopathy Neurological changes including sensory changes (auditory, or visual impairments) Psychological status change ( ...
Malin, Michael C.; Grimm, Robert E.; Herrick, Robert R.
Impact crater distributions and morphologies have traditionally played an important role in unraveling the geologic histories of terrestrial objects, and Venus has proved no exception. The key observations are: mean crater retention age about 500 Ma; apparently random spatial distribution; modest proportion (17 percent) of modified craters; and preferential association of modified craters with areas of low crater density. The simplest interpretation of these data alone is that Venus experienced global resurfacing (assumed to be largely volcanic) prior to 500 Ma, after which time resurfacing rates decreased dramatically. This scenario does not totally exclude present geological activity: some resurfacing and crater obliteration is occurring on part of the planet, but at rates much smaller than on Earth. An alternative endmember model holds that resurfacing is also spatially randomly distributed. Resurfacing of about 1 sq km/yr eliminates craters such that a typical portion of the surface has an age of 500 Ma, but actual ages range from zero to about 1000 Ma. Monte Carlo simulation indicates that the typical resurfacing 'patch' cannot exceed about 500 km in diameter without producing a crater distribution more heterogeneous than observed. Volcanic or tectonic processes within these patches must be locally intense to be able to obliterate craters completely and leave few modified. In this abstract, we describe how global geologic mapping may be used to test resurfacing hypotheses. We present preliminary evidence that the dominant mode of resurfacing on Venus is tectonism, not volcanism, and that this process must be ongoing today. Lastly, we outline a conceptual model in which to understand the relationship between global tectonics and crater distribution and preservation.
Catelas, Isabelle; Wimmer, Markus A.
Background: Despite the renewed interest in metal-on-metal implants in the past two decades, the underlying wear mechanisms and biological effects are still not fully understood. Methods: This paper first reviews the tribology of metal-on-metal bearings, bringing new insights into the interaction of wear and corrosion, and putting the characteristics and the potential origin of wear particles in perspective with the proposed wear mechanisms. It then summarizes the current knowledge on the biological effects of particles and metal ions in relation to these wear mechanisms. Results: Tribochemical reactions play an important role in the wear of metal-on-metal joints. The generated tribomaterial, which progressively forms by mechanical mixing of the uppermost nanocrystalline zone of the metal surface with proteins from the synovial fluid, governs the wear rate and influences the corrosive behavior of the bearing. Nanometer-sized wear particles may initially originate from the passivation layer covering the implant surface and then detach from this tribolayer. The inflammatory response observed surrounding metal-on-metal implants appears to be lower than that around metal-on-polyethylene implants. However, metallic byproducts, which can complex with proteins, may lead to a T lymphocyte-mediated hypersensitivity response. Conclusions: The tribolayer appears to have beneficial effects on the wear rate. Much information has been gained on wear particle characteristics, but the exact mechanisms of particle detachment remain to be further elucidated. Excessive wear along with a hypersensitivity response may be at the origin of the early adverse tissue reactions that have been recently reported in some patients with metal-on-metal implants. Clinical Relevance: Future development of new methods to improve the tribolayer retention and optimize the tribocorrosive properties of the implant may minimize the clinical impact of implant wear and immune responses. PMID:21543694
Haider, Hani; Weisenburger, Joel N; Garvin, Kevin L
(statistically significant, p < 0.001), and the coating wore away on all coated hips eventually. Higher friction mostly correlated with higher wear or damage to femoral heads or implant coatings, except for the highly cross-linked wear resistant ultrahigh-molecular-weight polyethylene which had slightly higher friction, confirming the same finding in other independent studies. This type of friction measurements can help screen for clamping and elevated wear of metal-on-metal and resurfacing total hip replacements, surgical malpositioning, and abraded and otherwise damaged surfaces. © IMechE 2016.
Agrawal, Nidhi; Smith, Greg; Heffelfinger, Ryan
Ablative laser resurfacing has evolved as a safe and effective treatment for skin rejuvenation. Although traditional lasers were associated with significant thermal damage and lengthy recovery, advances in laser technology have improved safety profiles and reduced social downtime. CO2 lasers remain the gold standard of treatment, and fractional ablative devices capable of achieving remarkable clinical improvement with fewer side effects and shorter recovery times have made it a more practical option for patients. Although ablative resurfacing has become safer, careful patient selection and choice of suitable laser parameters are essential to minimize complications and optimize outcomes. This article describes the current modalities used in ablative laser skin resurfacing and examines their efficacy, indications, and possible side effects.
Chwalek, Jennifer; Goldberg, David J
Ablative skin resurfacing has remained the gold standard for treating photodamage and acne scars since the development of the first CO(2) lasers. CO(2) and Er:YAG lasers emit infrared light, which targets water resulting in tissue contraction and collagen formation. The first ablative laser systems created significant thermal damage resulting in unacceptably high rates of scarring and prolonged healing. Newer devices, such as high-energy pulsed lasers and fractional ablative lasers, are capable of achieving significant improvements with fewer side effects and shorter recovery times. While ablative resurfacing has become safer, careful patient selection is still important to avoid post-treatment scarring, dyspigmentation, and infections. Clinicians utilizing ablative devices need to be aware of possible side effects in order to maximize results and patient satisfaction. This chapter reviews the background of ablative lasers including the types of ablative lasers, mechanism of action, indications for ablative resurfacing, and possible side effects.
Le Duff, Michel J; Ebramzadeh, Edward; Amstutz, Harlan C
With metal-on-metal (MoM) bearings, fluid film lubrication is disrupted when the contact patch area between the femoral head and the cup is close to the edge of the acetabular component, making the calculation of the contact patch to rim (CPR) distance a key variable in the study of the performance of MoM bearings. A few research centers have used models of varying complexity to calculate the CPR distance and determine its relationship with assessments of component wear. In this review, we aimed to summarise the current knowledge related to the application of CPR distance calculations in the study of in vivo performance of MoM bearings. Our systematic search of the US National Library of Medicine yielded 9 relevant publications in which 3 different models were used for the computation of the CPR distance. The 3 models show different levels of complexity and their use is mainly dependent upon the size of the subject sample and the nature of the data collected as a dependent variable. The studies reviewed consistently showed a strong inverse correlation between CPR distance and wear or metal ion levels suggesting that any study aiming to determine the risk factors for MoM hip devices needs to include an assessment of CPR distance. Cup anteversion can be measured reliably with various tools and should not be an obstacle to the use of this essential variable that is CPR distance.
Zeh, Alexander; Planert, Michael; Siegert, Gabriele; Lattke, Peter; Held, Andreas; Hein, Werner
Cross-sectional study of 10 patients to measure the serum levels of cobalt and chromium after TDA. To investigate the release of cobalt and chromium ions into the serum following implantation of the metal-on-metal Maverick-type artificial lumbar disc. In total hip endoprosthetics and consequently for TDA (total disc arthroplasty), metal-on-metal combinations are used with the aim of reducing wear debris. In metal-on-metal TDA the release of metal ions has until now been secondary to the main discussion. We investigated the serum cobalt and chromium concentration following implantation of 15 Maverick TDAs (monosegmental L5-S1, n = 5; bisegmental L4-L5 and L5-S1, n = 5; average age, 36.5 years). Five healthy subjects (no metal implants) acted as a control group. The measurements of the metals were carried out using the HITACHI Z-8200 AAS polarized Zeeman atomic absorption spectrometer after an average of 14.8 months. The concentrations of cobalt and chromium ions in the serum amounted on average to 4.75 microg/L (SD, 2.71) for cobalt and 1.10 microg/L (SD, 1.24) for chromium. Compared with control group, both the chromium and cobalt levels in the serum showed significant increases (Mann-Whitney U test, P = 0.0120). At follow-up,the Oswestry Disability Score was on average significantly decreased by 24.4 points (L5-S1) (t test, P < 0.05) and by 26.8 points (L4-S1) (t test, P < 0.05). The improved clinical situation is also represented by a significant decrease of the Visual Analog Pain Scale of 42.2 points after the follow-up (t test, P < 0.05). Significant systemic release of Cr/Co was proven in the serum compared with the control group. The concentrations of Cr/Co measured in the serum are similar in terms of their level to the values measured in THA metal-on-metal combinations or exceed these values given in the literature. Long-term implication of this metal exposure is unknown and should be studied further.
Fitzpatrick, R E
The CO2 Laser offers a variety of unique features in resurfacing facial photodamage and acne scarring. These include hemostasis, efficient removal of the epidermis in a single pass, thermally induced tissue tightening, and safe, predictable tissue interaction. Knowledge of these mechanisms will result in the capability of using the CO2 laser effectively and safely whether the goal is superficial or deep treatment.
Płomiński, Janusz; Kwiatkowski, Krzysztof
The authors present the history of hip prosthesis in treatment of coxarthrosis. Despite eighty years of experience the problem of gaining good and long-term results still exist and is difficult to solve. Even changing the way on cementless stabilization of prosthesis doesn't has result in solving the problem of aseptic loosening of hip arthroplasty. Problems of wear derbies made the producers find new to reduce particulate debris. The future of hip arthroplasty is connected with hip resurfacing. Moreover, the higher number of primary hip plasty the more prosthesis are loosening. The treatment is far more difficult and more expensive.
Karimova, Evguenia J.; Rai, Shesh N.; Wu, Jianrong; Britton, Lunetha; Kaste, Sue C.
Resurfacing hemiarthroplasties were performed to treat advanced osteonecrosis of 20 femoral heads in 14 patients (median age, 19.8 years; range, 15.1–27.4 years), treated for hematologic cancer in childhood or adolescence. Seven hips in five patients were revised to total hip arthroplasties (THA) because of pain; three of these showed radiographic loosening of the femoral head resurfacing component. The median time from resurfacing to revision was 2.4 years (range, 0.9–4.8 years). Marginal Cox-regression analysis, adjusting for correlations owing to bilateral involvement, showed positive association of revision-free survival of the prosthesis with patient’s age; time from resurfacing to the end of anticancer therapy, end of glucocorticosteroid therapy; percentage of joint space at the last radiograph; and size of the lesion has a negative association with revision-free survival. Because of this study’s exploratory nature, p values were not adjusted for the number of statistical comparisons. Among 14 patients, the probability of not requiring resurfacing prosthesis revision was 66% (SE, ±15%; 95% CI, 44%–100%) at 3 years. Osteonecrosis of the femoral head in young patients treated for hematologic cancer in childhood or adolescence poses a serious challenge to the orthopaedic surgeon. The data of this preliminary study suggest that in selected patients resurfacing hemiarthroplasty may delay the need for THA for 3–7 years. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence. PMID:18679763
Laitinen, Minna; Nieminen, Jyrki; Reito, Aleksi; Pakarinen, Toni-Karri; Suomalainen, Piia; Pamilo, Konsta; Parkkinen, Jyrki; Lont, Tonis; Eskelinen, Antti
Background and purpose There has been increasing alarm regarding metal-on-metal (MoM) joint replacements leading to elevated levels of metal ions and adverse reactions to metal debris (ARMDs). There is little information available concerning the prevalence of and risk factors for these adverse reactions, except with MoM hip joint replacements. We determined the levels of metal ions in blood and the rate of revision due to ARMDs in patients treated with MoM hinge total knee arthroplasty (TKA). Patients and methods 22 patients with TKAs and MoM hinge connecting mechanisms were studied for whole-blood chromium and cobalt levels at 6 months, 1 year, and/or ≥2 years after surgery. Possible ARMDs were investigated by MRI. 12 patients with TKAs and metal-on-polyethylene (MoP) connecting mechanisms served as controls. Results The cobalt levels were over 5 ppb in 19 of the 22 patients in the MoM group and in 1 of the 12 patients in the MoP group. The chromium levels were over 5 ppb in 11 of the 22 patients in the MoM group and in none of the 12 patients in the MoP group. Pseudotumors were operated in 4 of the 22 patients in the MoM group and in none of the patients in the MoP group. Interpretation Our results clearly show that the MoM hinge TKA carries a high risk of increased levels of systemic metal ions and also local ARMD, leading to complicated knee revisions. We therefore discourage the use of MoM hinge TKA. PMID:28122467
Koseki, Hironobu; Tomita, Masato; Yonekura, Akihiko; Higuchi, Takashi; Sunagawa, Sinya; Baba, Koumei; Osaki, Makoto
Metal-on-metal (MoM) bearings have become popular due to a major advantage over metal-on-polymer bearings for total hip arthroplasty in that the larger femoral head and hydrodynamic lubrication of the former reduce the rate of wear. However, concerns remain regarding adverse reactions to metal debris including metallosis caused by metal wear generated at the taper-head interface and another modular junction. Our group has hypothesized that carbon ion implantation (CII) may improve metal wear properties. The purpose of this study was to investigate the wear properties and friction coefficients of CII surfaces with an aim to ultimately apply these surfaces to MoM bearings in artificial joints. CII was applied to cobalt-chromium-molybdenum (Co-Cr-Mo) alloy substrates by plasma source ion implantation. The substrates were characterized using scanning electron microscopy and a 3D measuring laser microscope. Sliding contact tests were performed with a simple geometry pin-on-plate wear tester at a load of 2.5 N, a calculated contact pressure of 38.5 MPa (max: 57.8 MPa), a reciprocating velocity of 30 mm/s, a stroke length of 60 mm, and a reciprocating cycle count of 172,800 cycles. The surfaces of the CII substrates were generally featureless with a smooth surface topography at the same level as untreated Co-Cr-Mo alloy. Compared to the untreated Co-Cr-Mo alloy, the CII-treated bearings had lower friction coefficients, higher resistance to catastrophic damage, and prevented the adhesion of wear debris. The results of this study suggest that the CII surface stabilizes the wear status due to the low friction coefficient and low infiltration of partner materials, and these properties also prevent the adhesion of wear debris and inhibit excessive wear. Carbon is considered to be biologically inert; therefore, CII is anticipated to be applicable to the bearing surfaces of MoM prostheses. PMID:28615939
Koseki, Hironobu; Tomita, Masato; Yonekura, Akihiko; Higuchi, Takashi; Sunagawa, Sinya; Baba, Koumei; Osaki, Makoto
Metal-on-metal (MoM) bearings have become popular due to a major advantage over metal-on-polymer bearings for total hip arthroplasty in that the larger femoral head and hydrodynamic lubrication of the former reduce the rate of wear. However, concerns remain regarding adverse reactions to metal debris including metallosis caused by metal wear generated at the taper-head interface and another modular junction. Our group has hypothesized that carbon ion implantation (CII) may improve metal wear properties. The purpose of this study was to investigate the wear properties and friction coefficients of CII surfaces with an aim to ultimately apply these surfaces to MoM bearings in artificial joints. CII was applied to cobalt-chromium-molybdenum (Co-Cr-Mo) alloy substrates by plasma source ion implantation. The substrates were characterized using scanning electron microscopy and a 3D measuring laser microscope. Sliding contact tests were performed with a simple geometry pin-on-plate wear tester at a load of 2.5 N, a calculated contact pressure of 38.5 MPa (max: 57.8 MPa), a reciprocating velocity of 30 mm/s, a stroke length of 60 mm, and a reciprocating cycle count of 172,800 cycles. The surfaces of the CII substrates were generally featureless with a smooth surface topography at the same level as untreated Co-Cr-Mo alloy. Compared to the untreated Co-Cr-Mo alloy, the CII-treated bearings had lower friction coefficients, higher resistance to catastrophic damage, and prevented the adhesion of wear debris. The results of this study suggest that the CII surface stabilizes the wear status due to the low friction coefficient and low infiltration of partner materials, and these properties also prevent the adhesion of wear debris and inhibit excessive wear. Carbon is considered to be biologically inert; therefore, CII is anticipated to be applicable to the bearing surfaces of MoM prostheses.
Moghadas, Parshia; Mahomed, Aziza; Hukins, David W L; Shepherd, Duncan E T
Total disc arthroplasty (TDA) can be used to replace a degenerated intervertebral disc in the spine. There are different designs of prosthetic discs, but one of the most common is a ball-and-socket combination. Contact between the bearing surfaces can result in high frictional torque, which can then result in wear and implant loosening. This study was designed to determine the effects of ball radius on friction. Generic models of metal-on-metal TDA were manufactured with ball radii of 10, 12, 14 and 16 mm, with a radial clearance of 0.015 mm. A simulator was used to test each sample in flexion-extension, lateral bending and axial rotation at frequencies of 0.25, 0.5, 0.75, 1, 1.25, 1.5, 1.75 and 2 Hz under loads of 50, 600, 1200 and 2000 N, in new born calf serum. Frictional torque was measured and Stribeck curves were plotted to illustrate the lubrication regime in each case. It was observed that implants with a smaller ball radius showed lower friction and showed boundary and mixed lubrication regimes, whereas implants with larger ball radius showed boundary lubrication only. This study suggests designing metal-on-metal TDAs with ball radius of 10 or 12 mm, in order to reduce wear and implant loosening. Copyright © 2011 Elsevier Ltd. All rights reserved.
Freedman, Joshua R; Greene, Ryan M; Green, Jeremy B
By utilizing resurfacing lasers, physicians can significantly improve the appearance of sun-damaged skin, scars, and more. The carbon dioxide and erbium:yttrium-aluminum-garnet lasers were the first ablative resurfacing lasers to offer impressive results although these earlier treatments were associated with significant downtime. Later, nonablative resurfacing lasers such as the neodymium:yttrium-aluminum-garnet laser proved effective, after a series of treatments with less downtime, but with more modest results. The theory of fractional photothermolysis has revolutionized resurfacing laser technology by increasing the safety profile of the devices while delivering clinical efficacy. A review of the histologic and molecular consequences of the resurfacing laser-tissue interaction allows for a better understanding of the devices and their clinical effects.
Hussey, Daniel K; Madanat, Rami; Donahue, Gabrielle S; Rolfson, Ola; Muratoglu, Orhun K; Malchau, Henrik
Background and purpose - Blood metal ion levels can be an indicator for detecting implant failure in metal-on-metal (MoM) hip arthroplasties. Little is known about the effect of bilateral MoM implants on metal ion levels and patient-reported outcomes. We compared unilateral patients and bilateral patients with either an ASR hip resurfacing (HR) or an ASR XL total hip replacement (THR) and investigated whether cobalt or chromium was associated with a broad spectrum of patient outcomes. Patients and methods - From a registry of 1,328 patients enrolled in a multicenter prospective follow-up of the ASR Hip System, which was recalled in 2010, we analyzed data from 659 patients (311 HR, 348 THR) who met our inclusion criteria. Cobalt and chromium blood metal ion levels were measured and a 21-item patient-reported outcome measures (PROMs) questionnaire was used mean 6 years after index surgery. Results - Using a minimal threshold of ≥7 ppb, elevated chromium ion levels were found to be associated with worse health-related quality of life (HRQoL) (p < 0.05) and hip function (p < 0.05) in women. These associations were not observed in men. Patients with a unilateral ASR HR had lower levels of cobalt ions than bilateral ASR HR patients (p < 0.001) but similar levels of chromium ions (p = 0.09). Unilateral ASR XL THR patients had lower chromium and cobalt ion levels (p < 0.005) than bilateral ASR XL THR patients. Interpretation - Chromium ion levels of ≥7 ppb were associated with reduced functional outcomes in female MoM patients.
Hussey, Daniel K; Madanat, Rami; Donahue, Gabrielle S; Rolfson, Ola; Muratoglu, Orhun K; Malchau, Henrik
Background and purpose Blood metal ion levels can be an indicator for detecting implant failure in metal-on-metal (MoM) hip arthroplasties. Little is known about the effect of bilateral MoM implants on metal ion levels and patient-reported outcomes. We compared unilateral patients and bilateral patients with either an ASR hip resurfacing (HR) or an ASR XL total hip replacement (THR) and investigated whether cobalt or chromium was associated with a broad spectrum of patient outcomes. Patients and methods From a registry of 1,328 patients enrolled in a multicenter prospective follow-up of the ASR Hip System, which was recalled in 2010, we analyzed data from 659 patients (311 HR, 348 THR) who met our inclusion criteria. Cobalt and chromium blood metal ion levels were measured and a 21-item patient-reported outcome measures (PROMs) questionnaire was used mean 6 years after index surgery. Results Using a minimal threshold of ≥7 ppb, elevated chromium ion levels were found to be associated with worse health-related quality of life (HRQoL) (p < 0.05) and hip function (p < 0.05) in women. These associations were not observed in men. Patients with a unilateral ASR HR had lower levels of cobalt ions than bilateral ASR HR patients (p < 0.001) but similar levels of chromium ions (p = 0.09). Unilateral ASR XL THR patients had lower chromium and cobalt ion levels (p < 0.005) than bilateral ASR XL THR patients. Interpretation Chromium ion levels of ≥7 ppb were associated with reduced functional outcomes in female MoM patients. PMID:27459602
Williams, Daniel H; Greidanus, Nelson V; Masri, Bassam A; Duncan, Clive P; Garbuz, Donald S
While the primary objective of joint arthroplasty is to improve patient quality of life, pain, and function, younger active patients often demand a return to higher function that includes sporting activity. Knowledge of rates and predictors of return to sports will help inform expectations in patients anticipating return to sports after joint arthroplasty. We measured the rate of sports participation at 1 year using the UCLA activity score and explored 11 variables, including choice of procedure/prosthesis, that might predict return to a high level of sporting activity, when controlling for potential confounding variables. We retrospectively evaluated 736 patients who underwent primary metal-on-polyethylene THA, metal-on-metal THA, hip resurfacing arthroplasty, revision THA, primary TKA, unicompartmental knee arthroplasty, and revision TKA between May 2005 and June 2007. We obtained UCLA activity scores on all patients; we defined high activity as a UCLA score of 7 or more. We evaluated patient demographics (age, sex, BMI, comorbidity), quality of life (WOMAC score, Oxford Hip Score, SF-12 score), and surgeon- and procedural/implant-specific variables to identify factors associated with postoperative activity score. Minimum followup was 11 months (mean, 12.1 months; range, 11-13 months). Preoperative UCLA activity score, age, male sex, and BMI predicted high activity scores. The type of operation and implant characteristics did not predict return to high activity sports. Our data suggest patient-specific factors predict postoperative activity rather than factors specific to type of surgery, implant, or surgeon factors. Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Liou, Nai-Shang; Okada, Makoto; Prakash, Vikas
The present paper describes results of plate-impact pressure-shear friction experiments conducted to study time-resolved growth of molten metal films during dry metal-on-metal slip under extreme interfacial conditions. By employing tribo-pairs comprising hard tool-steel against relatively low melt-point metals such as 7075-T6 aluminum alloys, interfacial friction stress ranging from 100 to 400 MPa and slip speeds of approximately 100 m/ s have been generated. These relatively high levels of friction stress combined with high slip-speeds generate conditions conducive for interfacial temperatures to approach the melting point of the lower melt point metal (Al alloy) comprising the tribo-pair. A Lagrangian finite element code is developed to understand the evolution of the thermo-mechanical fields and their relationship to the observed slip response. The code accounts for dynamic effects, heat conduction, contact with friction, and full thermo-mechanical coupling. At temperatures below the melting point the material is described as an isotropic thermally softening elastic-viscoplastic solid. For material elements with temperatures in excess of the melt point a purely Newtonian fluid constitutive model is employed. The results of the hybrid experimental-computational study provides new insights into the thermoelastic-plastic interactions during high speed metal-on-metal slip under extreme interfacial conditions. During the early part of frictional slip the coefficient of kinetic friction is observed to decrease with increasing slip velocity. During the later part transition in interfacial slip occurs from dry metal-on-metal sliding to the formation of molten Al films at the tribo-pair interface. Under these conditions the interfacial resistance approaches the shear strength of the molten aluminum alloy under normal pressures of approximately 1- 3 GPa and shear strain rates of ˜10 7 s-1. The results of the study indicate that under these extreme conditions molten
Alexiades-Armenakas, Macrene R; Dover, Jeffrey S; Arndt, Kenneth A
Laser skin resurfacing (LSR) has evolved over the past 2 decades from traditional ablative to fractional nonablative and fractional ablative resurfacing. Traditional ablative LSR was highly effective in reducing rhytides, photoaging, and acne scarring but was associated with significant side effects and complications. In contrast, nonablative LSR was very safe but failed to deliver consistent clinical improvement. Fractional LSR has achieved the middle ground; it combined the efficacy of traditional LSR with the safety of nonablative modalities. The first fractional laser was a nonablative erbium-doped yttrium aluminum garnet (Er:YAG) laser that produced microscopic columns of thermal injury in the epidermis and upper dermis. Heralding an entirely new concept of laser energy delivery, it delivered the laser beam in microarrays. It resulted in microscopic columns of treated tissue and intervening areas of untreated skin, which yielded rapid reepithelialization. Fractional delivery was quickly applied to ablative wavelengths such as carbon dioxide, Er:YAG, and yttrium scandium gallium garnet (2,790 nm), providing more significant clinical outcomes. Adjustable laser parameters, including power, pitch, dwell time, and spot density, allowed for precise determination of percent surface area, affected penetration depth, and clinical recovery time and efficacy. Fractional LSR has been a significant advance to the laser field, striking the balance between safety and efficacy.
Tkaczyk, Cathy; Petit, Alain; Antoniou, John; Zukor, David J; Tabrizian, Maryam; Huk, Olga L
It is widely known that cobalt and chromium ions can enhance the production of reactive oxygen species, known to be damaging to cells by disturbing their redox status and then generating oxidative stress. The aim of the present study was to determine if increased metal ion levels induce a state of oxidative stress in patients with metal-on-metal (MM) hip arthroplasty. Results indicated that there was no significant difference in the concentration of oxidative stress markers (total antioxidants, peroxides, and nitrated proteins) in the patients with MM bearings compared to patients without prostheses. The activity antioxidant enzymes was stable (catalase and glutathione peroxidase) or slightly decreased (superoxide dismutase and heme oxygenase-1) over time. This work is the first to determine the biological effects of metal ions released from MM hip implants with regards to mid-term systemic oxidative stress and showed that the increased levels of Co and Cr ions are not associated with significant oxidative stress damage in the plasma of patients with these implants.
Collawn, Sherry S
Fractional photothermolysis is a new skin resurfacing laser technology for treating wrinkles, melanocytic pigmentation, scars, and photodamaged skin. Treatment with the Fraxel laser (Reliant Technologies, Inc.) creates microzones of injury in the skin that are surrounded by normal intervening skin that rapidly heals the injured tissue. From June to November of 2005, 70 patients underwent 2 to 6 treatments with the Fraxel laser (Reliant Technologies, Inc.) on the face and/or extremities for abnormal pigmentation, wrinkles, and scars. Treatments were 1 to 3 weeks apart. Clinically, the patient experienced little downtime other than erythema and edema for a few days followed by light skin exfoliation for a few days. After treatment, skin color and texture were more homogeneous with a decrease in the unwanted melanocytic pigmentation. The skin showed a decrease in rhytids. In summary, fractional photothermolysis improved skin color and texture and decreased fine wrinkles and melanocytic pigmentation with minimal downtime for the patient.
Hantash, B M; Gladstone, H B
Resurfacing lasers have been the treatment of choice for diminishing rhytids and tightening skin. The carbon dioxide and erbium lasers have been the gold and silver standards. Despite their effectiveness, these resurfacing lasers have a very high risk profile including scarring, hyperpigmentation and hypopigmentation. Because of these side effects, various practitioners have tried alternative settings for these lasers as well as alternative wavelengths, particularly in the infrared spectrum. These devices have had less downtime, but their effectiveness has been limited to fine wrinkles. As with selective photothemolysis, a major advance in the field has been fractionated resurfacing which incorporates grids of microthermal zones that spares islands of skin. This concept permits less tissue damage and quicker tissue regeneration. Initially, fractionated resurfacing was limited to the nonablative mid-infrared spectrum. These resurfacing lasers is appropriate for those patients with acne scars, uneven skin tone, mild to moderate photodamage, and is somewhat effective for melasma. Importantly, because there is less overall tissue damage and stimulation of melanocytes, these lasers can be used in darker skin types. Downtime is 2-4 days of erythema and scaling. Yet, these nonablative fractionated devices required 5-6 treatments to achieve a moderate effect. Logically, the fractionated resurfacing has now been applied to the CO2 and the Erbium:Yag lasers. These devices can treat deeper wrinkles and tighten skin. Downtime appears to be 5-7 days. The long term effectiveness and the question of whether these fractionated devices will approach the efficacy of the standard resurfacing lasers is still in question. Ultimately either integrated devices which may use fractionated resurfacing, radiofrequency and a sensitizer, or combining different lasers in a single treatment may prove to be the most effective in reducing rhtyides, smoothing the skin topography and tightening the
Krohn, K.; Jaumann, R.; Otto, K.; Elbeshausen, D.; Stephan, K.; Kneissl, T.; Schmedemann, N.; Roatsch, T.; Raymond, C.; Russell, C.
Planetary surfaces are steadily modified by endogenic processes. The most important resurfacing processes on dry airless bodies are: mass-wasting processes, volcanic activity, and tectonics due to impact cratering. Due to the absence of volcanic activity on Vesta , mass wasting and impact cratering are the most likely resurfacing processes on Vesta. The high elevation differences on Vesta  and the steady bombardment of Vesta's surface by impacts cause seismic shaking which promote material to move downwards. We analyzed different types of mass-wasting features in the South Polar Region, such as slumping blocks at the steep scarp Matronalia Rupes, spur-and-gully morphologies, and landslides in craters . Collapse processes, instability of slopes, and seismic-triggered events cause the landslides, rotational slumping blocks on scarps, as well as spur-and-gully morphologies on crater walls and scarps. Spur-and-gully morphology is known to form on Mars and the Earth normally supported by liquid flow but, on Vesta, these features formed under dry conditions. At Matronalia Rupes, rotational rock slumping blocks are clearly exposed as material slumped down the scarp wall in a stair-stepped pattern, which is interrupted by minor scarps and covers the underlying terrain. This rotational rock slumping is affected by slope instability and gravitationally triggered events, such as seismic shaking mostly produced by impacts elsewhere on Vesta . The sloping surface of Vesta cause not only the formation of mass wasting features, but also the formation of craters on slopes. These craters are in turn influenced by mass wasting and show an asymmetric crater shape with a sharp uphill rim and a smooth downhill rim. The craters show a sharp crater rim uphill and a smooth one downhill as well as ejecta on the downhill rim and only thin ejecta over the uphill rim. Three-dimensional numerical simulations have been performed to study the formation process of the unusual craters
Malek, Ibrahim A.; Rogers, Joanne; King, Amanda Christina; Clutton, Juliet; Winson, Daniel; John, Alun
One hundred and twenty six paired samples of plasma and whole blood were measured with inductively coupled plasma mass spectrometry technique for metal ions analysis to determine a relationship between them. There was a significant difference between the mean plasma and whole blood concentrations of both cobalt (Co) and chromium (Cr) (p < 0.0001 for both Co and Cr). The mean ratio between plasma and whole blood Cr and Co was 1.56 (range: 0.39–3.85) and 1.54 (range: 0.64–18.26), respectively, but Bland and Altman analysis illustrated that this relationship was not universal throughout the range of concentrations. There was higher variability at high concentrations for both ions. We conclude that both these concentrations should not be used interchangeably and conversion factors are unreliable due to concentration dependent variability. PMID:26798516
Tvermoes, Brooke E; Paustenbach, Dennis J; Kerger, Brent D; Finley, Brent L; Unice, Kenneth M
Cobalt (Co) can stimulate erythropoietin production in individuals at doses exceeding 25 mg CoCl2/day. Co has also been shown to exert effects on the thyroid gland, heart and nervous system at sufficient doses. The biological activity of Co is dictated by the concentration of free (unbound) ionic Co(2+). Blood concentrations, as well as, urinary excretion rates of Co are reliable biomarkers for systemic Co exposure. A recent series of human volunteer Co-supplement studies simultaneously measured Co blood and urine concentrations, as well as, Co speciation in serum, and a number of biochemical and clinical parameters. It was found in these studies that peak Co whole blood concentration as high as 117 μg/L were not associated with changes in hematological parameters such as increased red blood cell (RBC) count, hemoglobin (Hgb) or hematocrit (Hct) levels, nor with changes in cardiac, neurological or, thyroid function. Using a Co biokinetic model, the estimated Co systemic tissue concentrations (e.g., liver, kidney, and heart) following 90-days of Co-dietary supplementation with ∼1 mg Co/day were found to be similar to estimated tissue concentrations in implant patients after 10 years of exposure at continuous steady state Co blood concentration of ∼10 μg/L. This study is the first to present modeled Co tissue concentrations at various doses following sub-chronic and chronic exposure. The modeled steady state tissue Co concentrations in combination with the data on adverse health effects in humans should help in the characterization of potential hazards associated with increased blood Co concentrations due to exposure to dietary supplements or cobalt-chromium (Co-Cr) containing implants.
Higgs, Genymphas B.; Hanzlik, Josa A.; MacDonald, Daniel W.; Gilbert, Jeremy L.; Rimnac, Clare M.; Kurtz, Steven M.
This retrieval study documents taper damage at modular interfaces in retrieved MOM THA systems and investigates if increased modularity is associated with increased fretting and corrosion. One hundred thirty-four (134) heads and 60 stems (41 modular necks) of 8 different bearing designs (5 manufacturers) were analyzed. Damage at the shell–liner interface of 18 modular CoCr acetabular liners and the corresponding 11 acetabular shells was also evaluated. The results of this study support the hypothesis that fretting and corrosion damage occurs at a variety of modular component interfaces in contemporary MOM THAs. We also found that modularity of the femoral stem was associated with increased damage at the head. An analysis of component and patient variables revealed that dissimilar alloy pairing, larger head sizes, increased medio-lateral offsets and longer neck moment arms were all associated with increased taper damage at the modular interfaces. PMID:23910820
Hodgson, Antony J; Inkpen, Kevin B; Shekhman, Mark; Anglin, Carolyn; Tonetti, Jerome; Masri, Bassam A; Duncan, Clive P; Garbuz, Donald S; Greidanus, Nelson V
Femoral head resurfacing is re-emerging as a surgical option for younger patients who are not yet candidates for total hip replacement. However, this procedure is more difficult than total hip replacement, and the mechanical jigs typically used to align the implant produce significant variability in implant placement and take a significant amount of time to position properly. We propose that a computer-assisted surgical (CAS) technique could reduce implant variability with little or no increase in operative time. We describe a new CAS technique for this procedure and demonstrate in a cadaver study of five paired femurs that the CAS technique in the hands of a novice surgeon markedly reduced the varus/valgus variability of the implant relative to the pre-operative plan (2 degrees standard deviation for CAS versus 5 degrees for a mechanical jig operated by an expert surgeon). We also show that the mechanical jig resulted in significantly retroverted implant placement. There was no significant difference in operative time between the two techniques.
Pal, Bidyut; Gupta, Sanjay; New, Andrew M R
Ceramic hip resurfacing may offer improved wear resistance compared to metallic components. The study is aimed at investigating the effects of stiffer ceramic components on the stress/strain-related failure mechanisms in the resurfaced femur, using three-dimensional finite element models of intact and resurfaced femurs with varying stem–bone interface conditions. Tensile stresses in the cement varied between 1 and 5 MPa. Postoperatively, 20–85% strain shielding was observed inside the resurfaced head. The variability in stem–bone interface condition strongly influenced the stresses and strains generated within the resurfaced femoral head. For full stem–bone contact, high tensile (151–158 MPa) stresses were generated at the cup–stem junction, indicating risk of fracture. Moreover, there was risk of femoral neck fracture due to elevated bone strains (0.60–0.80% strain) in the proximal femoral neck region. Stresses in the ceramic component are reduced if a frictionless gap condition exists at the stem–bone interface. High stresses, coupled with increased strain shielding in the ceramic resurfaced femur, appear to be major concerns regarding its use as an alternative material.
Gauthier, L.; Dinh, L.; Beaulé, P. E.
Objectives To quantify and compare peri-acetabular bone mineral density (BMD) between a monoblock acetabular component using a metal-on-metal (MoM) bearing and a modular titanium shell with a polyethylene (PE) insert. The secondary outcome was to measure patient-reported clinical function. Methods A total of 50 patients (25 per group) were randomised to MoM or metal-on-polyethlene (MoP). There were 27 women (11 MoM) and 23 men (14 MoM) with a mean age of 61.6 years (47.7 to 73.2). Measurements of peri-prosthetic acetabular and contralateral hip (covariate) BMD were performed at baseline and at one and two years’ follow-up. The Western Ontario and McMaster Universities osteoarthritis index (WOMAC), University of California, Los Angeles (UCLA) activity score, Harris hip score, and RAND-36 were also completed at these intervals. Results At two years, only zone 1 showed a loss in BMD (-2.5%) in MoM group compared with a gain in the MoP group (+2.2%). Zone 2 showed loss in both groups (-2.2% for MoM; -3.9% for MoP) and zones 3 and 4 a gain in both groups (+0.1% for MoM; +3.3% for MoP). No other between-group differences were detected. When adjusting for BMD of the contralateral hip, no differences in BMD were observed. The only significant differences in functional scores at two years were higher UCLA activity (7.3 (sd 1.2) vs 6.1 (sd 1.5); p = 0.01) and RAND-36 physical function (82.1 (sd 13.0) vs 64.5 (sd 26.4); p = 0.02) for MoM bearings versus MoP. One revision was performed in the MoM group, for aseptic acetabular loosening at 11 months. Conclusions When controlling for systemic BMD, there were no significant differences between MoM and MoP groups in peri-acetabular BMD. However, increasing reports of adverse tissue reactions with large head MoM THR have restricted the use of the monoblock acetabular component to resurfacing only. PMID:23913361
Mäntymäki, Heikki; Mäkelä, Keijo T; Vahlberg, Tero; Hirviniemi, Joni; Niinimäki, Tuukka
Modern hip implants typically feature modular heads, which allow for easy exchange and removal from the femoral stem at the time of revision. However, owing to fretting, corrosion, or cold welding, the modular head may be difficult or impossible to separate from the underlying trunnion, especially if the implant has titanium interfaces between the head and the stem. We have repeatedly encountered difficulty removing the titanium sleeve adapter in the M(2)a-Magnum(TM) implant. Although the manufacturer warns about this complication and cases with these difficulties have been reported to the United States FDA, we believed this topic is important to study, because the frequency of difficulties in head removal is unknown and the complications related to this event have not been characterized. We asked: (1) Do revisions of M(2)a-Magnum(TM) implants differ from those of M(2)a-38(TM) implants in terms of ease of removal of the femoral head? (2) In cases where difficulty with M(2)a-Magnum(TM) head removal occurred, was the operative time, bleeding, risk of periprosthetic fracture, or joint infection increased compared with cases where the M(2)a-Magnum(TM) head was removed without difficulties? Between 2004 and 2014, we revised 296 THAs with metal-on-metal implants that involved M(2)a-Magnum(TM) (123) or M(2)a-38(TM) heads (88); of those, 84 were planned to include a femoral stem revision and insufficient data were available for three operations, so they were excluded from this analysis, leaving 124 THAs in the current retrospective study (70 THAs with M(2)a-Magnum(TM) and 54 THAs with M(2)a-38(TM) heads).The method of modular head removal, any difficulties removing the femoral head from the trunnion, operation time, and complications were recorded based on chart review. All the observed problems of detaching the head or taper adapter were among M(2)a-Magnum(TM) heads; there were no problems detaching the head in revisions of the M(2)a-38(TM) implant. In 29% (20 of 70) of
Milner, Thomas E.; Anvari, Bahman; Keikhanzadeh, Kurosh; Dave, Digant P.; Nelson, J. Stuart; Goodman, Dennis M.; Hennings, David R.; Baumgardner, John; Berry, Michael J.
Nonablative skin resurfacing is a dermatologic procedure utilizing pulsed laser irradiation and dynamic cooling to induce selectively a wound healing response in the papillary and upper reticular dermis. Using temperature measurements of human skin provided by pulsed photothermal radiometry immediately following laser irradiation (lambda equals 1.32 micrometer), spatial distribution of thermal damage is predicted in response to various potential therapeutic laser- cryogen doses. Results of our analysis suggest that appropriate application of pulsed laser irradiation and cryogen spray cooling may be used to protect the epidermis and selectively confine thermal injury to the papillary and upper reticular dermis. Development of nonablative skin resurfacing will require understanding the relationship between the degree of dermal photocoagulation and the cutaneous wound healing response following laser irradiation.
Macdonald, Nathanael; Bankes, Marcus
Ceramic on ceramic hip prostheses are an increasingly popular choice for hip replacement. Modern manufacturing techniques and developments have increased the strength and reliability of ceramic materials. The alternative bearing couples such as metal-on-polyethylene and metal-on-metal are more inclined to wear and produce particulate debris. Despite reports of fractures and stripe wear, harder, more inert and more wear resistant, modern ceramic-ceramic hip replacements provide a strong alternative to traditional bearings.
Karampinas, Panagiotis K; Papadelis, Eustratios G; Vlamis, John A; Basiliadis, Hlias; Pneumaticos, Spiros G
Young patients feel that maintaining sport activities after total hip arthroplasty constitutes an important part of their quality of life. The majority of hip surgeons allow patients to return to low-impact activities, but significant caution is advised to taking part in high-impact activities. The purpose of this study is to compare and evaluate the post-operative return to daily living habits and sport activities following short-metaphyseal hip and high functional total hip arthroplasties (resurfacing and big femoral head arthroplasties). In a study design, 48 patients (55 hips) were enrolled in three different comparative groups, one with the short-metaphyseal arthroplasties, a second with high functional resurfacing arthroplasties and a third of big femoral head arthroplasties. Each patient experienced a clinical examination and evaluated with Harris Hip Score, WOMAC, Sf-36, UCLA activity score, satisfaction VAS, anteroposterior and lateral X-rays of the hip and were followed in an outpatient setting for 2 years. Statistical analysis revealed no notable differences between the three groups regarding their demographic data however significant differences have been found between preoperative and postoperative clinical scores of each group. Also, we fail to reveal any significant differences when comparing data of all three groups at the final 2 years postoperative control regarding their clinical scores. The overall outcome of all three groups was similar, all the patients were satisfied and returned to previous level of sport activities. Short metaphyseal hip arthroplasties in young patients intending to return to previous and even high impact sport activities, similar to high functional resurfacing, big femoral head arthroplasties. Short stems with hard on hard bearing surfaces might become an alternative to standard stems and hip resurfacing.
Riley, Clay; Idoine, John; Shishani, Yousef; Gobezie, Reuben; Edwards, Bradley
Reverse total shoulder arthroplasty (TSA) is a useful intervention for older patients with glenohumeral arthritis and a deficient rotator cuff. However, as a semiconstrained prosthesis, conventional reverse TSA implanted in a young patient could fail over time secondary to polyethylene wear and subsequent osteolysis. A metal-on-metal prosthesis may avoid this type of failure. The purpose of this study is to assess the outcomes in an initial cohort of young patients who underwent reverse TSA using a metal-on-metal prosthesis. Surgical indications included age younger than 50 years with a functioning deltoid and significant impairment of shoulder function with irreparable rotator cuff due to tumor resection, arthritis, or revision surgery. Nine patients with an average age of 37 years underwent implantation of a custom metal-on-metal reverse TSA prosthesis. All patients had a minimum 12-month follow-up or a failure of their procedure requiring revision surgery prior to 1 year. American Shoulder and Elbow Surgeons (ASES) scores, Constant scores, and range of motion were recorded and analyzed pre- and postoperatively to assess improvement, and all complications were noted. Average ASES score improved from 47 points preoperatively to 73.4 points postoperatively (P=.013). Average Constant and adjusted Constant scores improved from 20.8 points and 16% preoperatively to 61.8 points and 67.3% postoperatively, respectively (P=.019 and P=.068). Mean postoperative active forward flexion and active external rotation were 119.4° and 10°, respectively. Complications included the following: 3 patients sustained a postoperative dislocation, 1 patient had a glenoid fracture and complete loss of fixation of the baseplate, and 1 patient experienced dissociation of the glenosphere from the base-plate. Although metal-on-metal reverse TSA may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are
Loesch, Mathew M; Somani, Ally-Khan; Kingsley, Melanie M; Travers, Jeffrey B; Spandau, Dan F
The demand for skin resurfacing and rejuvenating procedures has progressively increased in the last decade and has sparked several advances within the skin resurfacing field that promote faster healing while minimizing downtime and side effects for patients. Several technological and procedural skin resurfacing developments are being integrated into clinical practices today allowing clinicians to treat a broader range of patients’ skin types and pathologies than in years past, with noteworthy outcomes. This article will discuss some emerging and developing resurfacing therapies and treatments that are present today and soon to be available. PMID:25210469
Loesch, Mathew M; Somani, Ally-Khan; Kingsley, Melanie M; Travers, Jeffrey B; Spandau, Dan F
The demand for skin resurfacing and rejuvenating procedures has progressively increased in the last decade and has sparked several advances within the skin resurfacing field that promote faster healing while minimizing downtime and side effects for patients. Several technological and procedural skin resurfacing developments are being integrated into clinical practices today allowing clinicians to treat a broader range of patients' skin types and pathologies than in years past, with noteworthy outcomes. This article will discuss some emerging and developing resurfacing therapies and treatments that are present today and soon to be available.
Agten, C A; Sutter, R; Pfirrmann, C W A
Metal-induced artifacts impair image quality of computed tomography (CT) and magnetic resonance imaging (MRI) in patients with hip prostheses. Due to new developments in metal artifact reduction both methods can now be used for evaluation of a painful hip prosthesis. Iterative reconstruction algorithms and dual-energy scans are among the newer CT techniques for artifact reduction, while slice-encoding for metal artifact correction (SEMAC) and multi-acquisition variable-resonance image combination (MAVRIC) have introduced substantial improvements for MRI. Loosening of the hip prosthesis, osteolysis from small wear particles and pseudotumors in metal-on-metal prostheses are specific pathologies in patients with total hip arthroplasty. Other causes of painful hip prostheses are infections, fractures, tendinopathies, tendon ruptures, muscle and nerve alterations and heterotopic ossifications.
Klemt, Christian; Modat, Marc; Pichat, Jonas; Cardoso, M. J.; Henckel, Joahnn; Hart, Alister; Ourselin, Sebastien
Metal-on-metal (MoM) hip arthroplasties have been utilised over the last 15 years to restore hip function for 1.5 million patients worldwide. Althoug widely used, this hip arthroplasty releases metal wear debris which lead to muscle atrophy. The degree of muscle wastage differs across patients ranging from mild to severe. The longterm outcomes for patients with MoM hip arthroplasty are reduced for increasing degrees of muscle atrophy, highlighting the need to automatically segment pathological muscles. The automated segmentation of pathological soft tissues is challenging as these lack distinct boundaries and morphologically differ across subjects. As a result, there is no method reported in the literature which has been successfully applied to automatically segment pathological muscles. We propose the first automated framework to delineate severely atrophied muscles by applying a novel automated segmentation propagation framework to patients with MoM hip arthroplasty. The proposed algorithm was used to automatically quantify muscle wastage in these patients.
... pain involves any pain in or around the hip joint. You may not feel pain from your hip ... 2012:chap 48. Read More Hip fracture surgery Hip joint replacement Patient Instructions Hip fracture - discharge Hip or ...
Solomon, Sean C.
Two remarkable aspects of the population of impact craters on Venus are that craters at all sizes are indistinguishable from a random population and that the vast majority of craters have not been significantly modified by tectonic strain or by volcanic flows external to the crater rim, despite evidence from Magellan images that volcanic and tectonic features are widespread on Venus. One interpretation of these observations is that most of the surface dates from the end of a catastrophic global resurfacing event that ceased about 500 My ago, and that the small fraction of craters volcanically embayed or modified by deformation indicates that volcanic and tectonic activity subsequent to that time has been at much lower levels. An alternative model, in which resurfacing occurs episodically in patches a few hundred kilometers in extent and there is a wider spectrum of surface ages, also appears to be consistent with the characteristics of impact craters on Venus. A number of potential mechanisms for catastrophic resurfacing of Venus have been proposed, ranging from geologically sudden convective destabilization of the global lithosphere to strongly time-dependent heat flux and melt generation in the underlying mantle. In most of these geophysical models, resurfacing occurs implicitly or explicitly by volcanism. We explore the hypothesis that, at least in the geologically recent history of Venus, the primary resurfacing mechanism has been tectonic deformation rather than volcanism. We show how such a hypothesis provides at least as good an explanation of a wide range of observations as do volcanic resurfacing models. Finally, we explore the implications of tectonic resurfacing hypothesis for the controversy over the recent resurfacing history of the planet.
Solomon, Sean C.
Two remarkable aspects of the population of impact craters on Venus are as follows: that craters at all sizes are indistinguishable from a random population; and that the vast majority of craters have not been significantly modified by tectonic strain or by volcanic flows external to the crater rim, despite evidence from Magellan images that volcanic and tectonic features are widespread on Venus. One interpretation of these observations is that most of the surface dates from the end of a catastrophic global resurfacing event that ceased about 500 My ago, and that the small fraction of craters volcanically embayed or modified by deformation indicates that volcanic and tectonic activity subsequent to that time has been at much lower levels. An alternative model, in which resurfacing occurs episodically in patches a few hundred kilometers in extent and there is a wider spectrum of surface ages, also appears to be consistent with the characteristics of impact craters on Venus. A number of potential mechanisms for catastrophic resurfacing of Venus have been proposed ranging from geologically sudden convective destabilization of the global lithosphere to strongly time-dependent heat flux and melt generation in the underlying mantle. In most of these geophysical models, resurfacing occurs implicitly or explicitly by volcanism. We explore here the hypothesis that, at least in the geologically recent history of Venus, the primary resurfacing mechanism has been tectonic deformation rather than volcanism. We show how such a hypothesis provides at least as good an explanation of a wide range of observations as do volcanic resurfacing models. Finally, we explore the implications of the tectonic resurfacing hypothesis for the controversy over the recent resurfacing history of the planet.
Pozner, Jason N; DiBernardo, Barry E
Laser resurfacing is a very popular procedure worldwide. Full field and fractional lasers are used in many aesthetic practices. There have been significant advances in laser resurfacing in the past few years, which make patient treatments more efficacious and with less downtime. Erbium and carbon dioxide and ablative, nonablative, and hybrid fractional lasers are all extremely effective and popular tools that have a place in plastic surgery and dermatology offices.
Antholz, Casey R; Cherian, Jeffrey J; Elmallah, Randa K; Jauregui, Julio J; Pierce, Todd P; Mont, Micael A
Whether to resurface the patella during total knee arthroplasty (TKA) remains a controversial topic among orthopaedic surgeons, and we are still no closer to identifying which technique provides the best outcomes. Advocates for patellar resurfacing have adopted this technique in order to avoid the potential for post-operative anterior knee pain that may be associated with the need for future reoperations. However, reports have indicated that patellar resurfacing may be associated with increased complications such as patellar implant loosening, fracture, osteonecrosis, tendon injury, wear, and instability. More recently, studies have highlighted possible patient-specific and surgical factors, such as weight, body mass index, degree of chondromalacia, and patellar alignment, which may influence functional outcomes, and thus surgical decision making. However, currently there are minimal clear guidelines to help surgeons decide whether or not to resurface the patella. Our aim was to assess the current literature and present the evidence for and against patellar resurfacing, as well as to assess factors that may aid in deciding which procedure is more suitable for the specific patient. Ultimately, we believe there is a need for further research to identify the most appropriate candidates for patellar resurfacing.
Flanagan, S; Jones, E; Birkinshaw, C
New material combinations and designs of artificial hip implants are being introduced in an effort to improve proprioception and functional longevity. Larger joints in particular are being developed to improve joint stability, and it is thought that these larger implants will be more satisfactory for younger and more physically active patients. The study detailed here used a hip friction simulator to assess the friction and lubrication properties of large-diameter hip bearings of metal-on-metal and ceramic-on-reinforced-polymer couplings. Joints of different diameters were evaluated to determine what effect, if any, bearing diameter had on lubrication. In addition, the effects of lubricant type are considered, using carboxymethyl cellulose and bovine calf serum, and the physiological lubricant is shown to be considerably more effective at reducing friction. The frictional studies showed that the metal-on-metal joints worked under a mixed lubrication regime, producing similar friction factor values to each other. The addition of bovine calf serum (BCS) reduced the friction. The ceramic-on-reinforced-polymer samples were shown to operate with high friction factors and mixed lubrication. When tested with BCS, the larger-diameter bearings showed a decrease in friction compared with the smaller-size bearings, and the addition of BCS resulted in an increase in friction, unlike the metal-on-metal system. The study demonstrated that the component's diameter had little or no influence on the lubrication and friction of the large bearing combinations tested.
Phillips, Roger J.; Raubertas, Richard F.; Arvidson, Raymond E.; Sarkar, Ila C.; Herrick, Robert R.; Izenberg, Noam; Grimm, Robert E.
The history of resurfacing by tectonism and volcanism on Venus is reconstructed by means of an analysis of Venusian impact crater size-frequency distributions, locations, and preservation states. An atmospheric transit model for meteoroids demonstrates that for craters larger than about 30 km, the size-frequency distribution is close to the atmosphere-free case. An age of cessation of rapid resurfacing of about 500 Ma is obtained. It is inferred that a range of surface ages are recorded by the impact crater population; e.g., the Aphrodite zone is relatively young. An end-member model is developed to quantify resurfacing scenarios. It is argued that Venus has been resurfacing at an average rate of about 1 sq km/yr. Numerical simulations of resurfacing showed that there are two solution branches that satisfy the completely spatially random location restraint for Venusian craters: a is less than 0.0003 (4 deg diameter circle) and a is greater than 0.1 (74 deg diameter circle).
Cohen, Joel L
Since the introduction of the scanning full-field erbium laser, misconceptions regarding ablative erbium resurfacing have resulted in its being largely overshadowed by ablative fractional resurfacing. This case report illustrates the appropriateness of full-field erbium ablation for perioral resurfacing. A patient with profoundly severe perioral photodamage etched-in lines underwent full-field ablative perioral resurfacing with an erbium laser (Contour TRL, Sciton Inc., Palo Alto, CA) that allows separate control of ablation and coagulation. The pre-procedure consultations included evaluation of the severity of etched-in lines, and discussion of patient goals, expectations, and appropriate treatment options, as well as a review of patient photos and post-treatment care required. The author generally avoids full-field erbium ablation in patients with Fitzpatrick type IV and above. For each of 2 treatment sessions (separated by approximately 4 months), the patient received (12 cc plain 2% lidodaine) sulcus blocks before undergoing 4 passes with the erbium laser at 150 μ ablation, no coagulation, and then some very focal 30 μ ablation to areas of residual lines still visualized through the pinpoint bleeding. Similarly, full-field ablative resurfacing can be very reliable for significant wrinkles and creping in the lower eyelid skin--where often a single treatment of 80 μ ablation, 50 μ coagulation can lead to a nice improvement. Standardized digital imaging revealed significant improvement in deeply etched rhytides without significant adverse events. For appropriately selected patients requiring perioral (or periorbital) rejuvenation, full-field ablative erbium resurfacing is safe, efficacious and merits consideration.
Lee, Soong Joon; Kim, Hee Joong
Background Total hip arthroplasty with subtrochanteric shortening osteotomy is widely performed for high hip dislocation. However, suboptimal leg length discrepancy correction and nonunion of the osteotomy site remain concerns. Although total hip arthroplasty using trochanteric osteotomy without subtrochanteric osteotomy was introduced, cemented implants have been more commonly used than contemporary cementless implants in this procedure. We evaluated the long-term results of cementless total hip arthroplasty with trochanteric osteotomy without subtrochanteric osteotomy for high hip dislocation. Methods From 1990 to 2002, 27 cementless total hip arthroplasties using trochanteric osteotomy without subtrochanteric osteotomy were performed in 26 patients with Crowe III or IV high hip dislocation and a mean age of 36.4 ± 12.9 years. Seven ceramic-on-ceramic, 8 ceramic-on-polyethylene, 10 metal-on-polyethylene, and 2 metal-on-metal bearings were inserted. Mean follow-up was 15.1 ± 3.7 years. We retrospectively reviewed medical records and radiographic data and evaluated the clinical and radiological results including the Harris hip score, implant survival, correction of leg length discrepancy, and occurrence of complications. Results The mean Harris hip score and leg length discrepancy improved significantly from 73.3 to 94.9 points and from 4.3 cm to 1.0 cm, respectively. With revision for loosening set as the end point, implant survival rates at 10 and 15 years postoperatively were 96.0% and 90.9% for stems and 74.1% and 52.3% for cups. In 8 of 10 hips with the metal-on-polyethylene bearing and 4 of 8 hips with the ceramic-on-polyethylene bearing, revision surgery was performed for aseptic loosening. However, no revision was performed in hips with the ceramic-on-ceramic bearing or the metal-on-metal bearing. Implant survival was significantly different by the type of bearing surface. Two permanent neurologic complications occurred in patients with a limb lengthening
Engh, C Anderson; Sritulanondha, Supatra; Korczak, Abigail; Whalen, Terrence David; Naudie, Douglas D R; McCalden, Richard W; MacDonald, Steven J
Hard-on-hard bearings for total hip arthroplasty continue to warrant analysis even though crosslinked polyethylene is performing very well. Ceramic-on-metal (CoM) has low in vitro wear and did well in an early clinical trial. We report on a prospective, randomized, multicenter investigational device trial comparing CoM with metal-on-metal (MoM). (1) Is there a difference in the number or type of revisions comparing CoM with MoM? (2) Are cobalt and chromium metal levels different for CoM and MoM THA? Between August 2005 and October 2006, of 1015 patients screened, 390 patients were enrolled at 11 centers and randomized to 194 CoM and 196 MoM bearings. There was no difference in the preoperative patient demographics between the study groups. Mean followup was 50 months (range, 22-75 months). Seventy-two patients from two centers had metal level analysis. With the numbers available, there was no difference in the proportion of patients undergoing revisions between the MoM and the CoM cohorts (MOM: 3% [six of 196]; COM: 1.5% [three of 194]; p = 0.50). Four MoM revisions were unrelated to the bearing surface. Two had bearing surface-related reoperations, one for an aseptic lymphocyte-dominated vasculitis-associated lesion and one for elevated metal levels with acetabular malposition. None of the CoM revisions were related to the bearing surface. The metal level analysis revealed that in contrast to the CoM, the MoM bearing group had increasing values of erythrocyte and serum cobalt from 1 to 5 years (CoM erythrocyte 0.45-0.55 ppb, p = 0.11 and CoM serum 0.88-0.85, p = 0.55, and MoM erythrocyte 0.32-0.51 ppb, p < 0.01 and MoM serum 0.65-1.01 ppb, p < 0.01). In addition, the MoM cobalt levels in erythrocytes and serum at 5 years were more variable than at 1 year (erythrocyte interquartile range [IQR], 0.26-0.44 to 0.31-1.21 ppb and serum IQR, 0.42-0.80 to 0.64-2.20 ppb, p < 0.02 for both). Although both bearings performed well at short-term followup, the CoM bearing group
Cohen, Joel L
Actinic cheilitis is a precancerous condition characterized by grayish-whitish area(s) of discoloration on the mucosal lip, often blunting the demarcation between mucosa and cutaneous lip. Actinic cheilitis is considered to be an early part of the spectrum of squamous cell carcinoma. Squamous cell carcinoma specifically of the lip has a high rate of recurrence and metastasis through the oral cavity leading to a poor overall survival. Risk factors for the development of actinic cheilitis include chronic solar irradiation, increasing age, male gender, light skin complexion, immunosuppression, and possibly tobacco and alcohol consumption. Treatment options include topical pharmacotherapy (eg, fluorouracil, imiquimod) or procedural interventions (eg, cryotherapy, electrosurgery, surgical vermillionectomy, laser resurfacing), each with their known advantages and disadvantages. There is little consensus as to which treatment options offer the most clinical utility given the paucity of comparative clinical data. In my practice, laser resurfacing has become an important tool for the treatment of actinic cheilitis owing to its ease of use and overall safety, tolerability, and cosmetic acceptability. Herein the use of erbium laser resurfacing is described for three actinic cheilitis presentations for which I find it particularly useful: clinically prominent actinic cheilitis, biopsy-proven actinic cheilitis, and treatment of the entire lip following complete tumor excision of squamous cell carcinoma. All patients were treated with a 2940-nm erbium laser (Sciton Profile Contour Tunable Resurfacing Laser [TRL], Sciton, Inc., Palo Alto, CA).
Tajirian, Ani L; Tarijian, Ani L; Goldberg, David J
Ablative laser technology has been in use for many years now. The large side effect profile however has limited its use. Fractional ablative technology is a newer development which combines a lesser side effect profile along with similar efficacy. In this paper we review fractional ablative laser skin resurfacing.
Rodriguez, José A; Illas, Francesc
This perspective article focuses on the physical and chemical properties of highly active catalysts for CO oxidation, desulfurization and hydrogenation reactions generated by depositing noble metals on metal-carbide surfaces. To rationalize structure-reactivity relationships for these novel catalysts, well-defined systems are required. High-resolution photoemission, scanning tunneling microscopy (STM) and first-principles periodic density-functional (DF) calculations have been used to study the interaction of metals of Groups 9, 10 and 11 with MC(001) (M = Ti, Zr, V, Mo) surfaces. DF calculations give adsorption energies that range from 2 eV (Cu, Ag, Au) to 6 eV (Co, Rh, Ir). STM images show that Au, Cu, Ni and Pt grow on the carbide substrates forming two-dimensional islands at very low coverage, and three-dimensional islands at medium and large coverages. In many systems, the results of DF calculations point to the preferential formation of admetal-C bonds with significant electronic perturbations in the admetal. TiC(001) and ZrC(001) transfer some electron density to the admetals facilitating bonding of the adatom with electron-acceptor molecules (CO, O(2), C(2)H(4), SO(2), thiophene, etc.). For example, the Cu/TiC(001) and Au/TiC(001) systems are able to cleave both S-O bonds of SO(2) at a temperature as low as 150 K, displaying a reactivity much larger than that of TiC(001) or extended surfaces of bulk copper and gold. At temperatures below 200 K, Au/TiC is able to dissociate O(2) and perform the 2CO + O(2)→ 2CO(2) reaction. Furthermore, in spite of the very poor hydrodesulfurization performance of TiC(001) or Au(111), a Au/TiC(001) surface displays an activity for the hydrodesulfurization of thiophene higher than that of conventional Ni/MoS(x) catalysts. In general, the Au/TiC system is more chemically active than systems generated by depositing Au nanoparticles on oxide surfaces. Thus, metal carbides are excellent supports for enhancing the chemical
Maezawa, Katsuhiko; Nozawa, Masahiko; Yuasa, Takahito; Aritomi, Kentaro; Ogawa, Seiki; Maruyama, Yuichiro; Kaneko, Kazuo
Background The outcome of cementless total hip arthroplasty depends on many factors. We must not forget fundamental things those are design of outer surface of the component, that leads bone ingrowth into the prosthesis, better initial stability, and better insertional techniques. The purpose of this study was to review our experience with metal-on-metal total hip arthroplasty with a Wagner standard cup for patients who had acetabular dysplasia. Patients and methods Fifty-four patients with 55 hips underwent primary metal-on-metal total hip arthroplasty (Metasul prosthesis) with a Wagner standard cup (44–48 mm in outer diameter) and were followed for a minimum of 10 years. All patients received the same type of cementless femoral component (Natural hip stem) and femoral head (28 mm in diameter). Results Seventeen of the 55 Wagner standard cups (30.9%) showed aseptic loosening over a mean period of 3.6 years after surgery, and there were no bone anchors on the outer surface of the 16 retrieved cups. Conclusion From our experience, the small Wagner standard cup does not achieve sufficient osteointegration and we do not recommend the use of this cup, especially for patients with acetabular dysplasia and/or those with a small stature. PMID:25561751
Streubel, Philipp N.; Simone, Juan P.; Cofield, Robert H.; Sperling, John W.
Purpose: The purpose of this study is to assess the outcomes of a consecutive series of patients who underwent revision surgery after humeral head resurfacing (HHR). Our joint registry was queried for all patients who underwent revision arthroplasty for failed HHR at our institution from 2005 to 2010. Eleven consecutive patients (average age 54 years; range 38-69 years) that underwent revision of 11 resurfacing arthroplasties were identified. The primary indication for resurfacing had been osteoarthritis in six, glenoid dysplasia in two, a chondral lesion in two, and postinstability arthropathy in one patient. The indication for revision was pain in 10 and infection in one patient. Seven patients had undergone an average of 1.9 surgeries prior to resurfacing (range 1-3). Materials and Methods: All patients were revised to stemmed arthroplasties, including one hemiarthroplasty, two reverse, and eight anatomic total shoulder arthroplasties at a mean 33 months after primary resurfacing (range 10-131 months). A deltopectoral approach was used in seven patients; four patients required an anteromedial approach due to severe scarring. Subscapularis attenuation was found in four cases, two of which required reverse total shoulder arthroplasty. Bone grafting was required in one glenoid and three humeri. Results: At a mean follow-up of 3.5 years (range 1.6-6.9 years), modified Neer score was rated as satisfactory in five patients and unsatisfactory in six. Abduction and external rotation improved from 73° to 88° (P = 0.32) and from 23° to 32° (P = 0.28) respectively. Reoperation was required in two patients, including one hematoma and one revision for instability. Conclusion: Outcomes of revision of HHR arthroplasty in this cohort did not improve upon those reported for revision of stemmed humeral implants. A comparative study would be required to allow for definitive conclusions to be made. PMID:26980986
Meding, John B; Meding, Lindsey K; Keating, E Michael; Berend, Michael E
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. We therefore assessed hip pain, function, osteolysis, and complications in patients with large-diameter metal-on-metal THA. 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). 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. 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 IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Clements, Warren J; Miller, Lisa; Whitehouse, Sarah L; Graves, Stephen E; Ryan, Philip
Background Patella resurfacing in total knee arthroplasty is a contentious issue. The literature suggests that resurfacing of the patella is based on surgeon preference, and little is known about the role and timing of resurfacing and how this affects outcomes. Methods We analyzed 134,799 total knee arthroplasties using data from the Australian Orthopaedic Association National Joint Replacement Registry. Hazards ratios (HRs) were used to compare rates of early revision between patella resurfacing at the primary procedure (the resurfacing group, R) and primary arthroplasty without resurfacing (no-resurfacing group, NR). We also analyzed the outcomes of NR that were revised for isolated patella addition. Results At 5 years, the R group showed a lower revision rate than the NR group: cumulative per cent revision (CPR) 3.1% and 4.0%, respectively (HR = 0.75, p < 0.001). Revisions for patellofemoral pain were more common in the NR group (17%) than in the R group (1%), and “patella only” revisions were more common in the NR group (29%) than in the R group (6%). Non-resurfaced knees revised for isolated patella addition had a higher revision rate than patella resurfacing at the primary procedure, with a 4-year CPR of 15% and 2.8%, respectively (HR = 4.1, p < 0.001). Interpretation Rates of early revision of primary total knees were higher when the patella was not resurfaced, and suggest that surgeons may be inclined to resurface later if there is patellofemoral pain. However, 15% of non-resurfaced knees revised for patella addition are re-revised by 4 years. Our results suggest an early beneficial outcome for patella resurfacing at primary arthroplasty based on revision rates up to 5 years. PMID:19968604
Varano, R; Bobyn, J D; Medley, J B; Yue, S
The microstructure and its effect on the friction behavior of a medical grade wrought cobalt-chromium-molybdenum (CoCrMo) alloy for surgical implants were studied in this work. In particular, the effects of compression and carbon (C) content on the above characteristics were analyzed. Increasing amounts of deformation resulted in a decrease in the number of annealing twins in the microstructures. In addition, there was an increase in the volume fraction of the hexagonal closed-packed (HCP) phase due to a strain-induced transformation (SIT) from the metastable face-centered cubic (FCC) phase. The high C (HC) alloy had a lower volume fraction of this SIT phase. Friction studies conducted on these alloys revealed a higher coefficient of friction for the HC alloy and no significant effect of SIT on the friction characteristics. Copyright 2005 Wiley Periodicals, Inc.
Ilo, Kevin C; Derby, Emma J; Whittaker, Robert K; Blunn, Gordon W; Skinner, John A; Hart, Alister J
The R3 acetabular system used with its metal liner has higher revision rates when compared to its ceramic and polyethylene liner. In June 2012, the medical and healthcare products regulatory agency issued an alert regarding the metal liner of the R3 acetabular system. Six retrieved R3 acetabular systems with metal liners underwent detailed visual analysis using macroscopic and microscopic techniques. Visual analysis discovered corrosion on the backside of the metal liners. There was a distinct border to the areas of corrosion that conformed to antirotation tab insertions on the inner surface of the acetabular shell, which are for the polyethylene liner. Scanning electron microscopy indicated evidence of crevice corrosion, and energy-dispersive X-ray analysis confirmed corrosion debris rich in titanium. The high failure rate of the metal liner option of the R3 acetabular system may be attributed to corrosion on the backside of the liner which appear to result from geometry and design characteristics of the acetabular shell. Copyright © 2016 Elsevier Inc. All rights reserved.
Higgs, Genymphas B; Hanzlik, Josa A; MacDonald, Daniel W; Gilbert, Jeremy L; Rimnac, Clare M; Kurtz, Steven M
This retrieval study documents taper damage at modular interfaces in retrieved MOM THA systems and investigates if increased modularity is associated with increased fretting and corrosion. One hundred thirty-four (134) heads and 60 stems (41 modular necks) of 8 different bearing designs (5 manufacturers) were analyzed. Damage at the shell-liner interface of 18 modular CoCr acetabular liners and the corresponding 11 acetabular shells was also evaluated. The results of this study support the hypothesis that fretting and corrosion damage occurs at a variety of modular component interfaces in contemporary MOM THAs. We also found that modularity of the femoral stem was associated with increased damage at the head. An analysis of component and patient variables revealed that dissimilar alloy pairing, larger head sizes, increased medio-lateral offsets and longer neck moment arms were all associated with increased taper damage at the modular interfaces.
Helmy, Naeder; Anglin, Carolyn; Greidanus, Nelson V.
The management of the patellar articular surface at the time of primary total knee arthroplasty (TKA) is controversial. We used expected-value decision analysis to determine whether the patella should be resurfaced in TKA, and also whether secondary resurfacing on an unresurfaced patella is worthwhile. Outcome probabilities and utility values were derived from randomized controlled trials only. A decision tree was constructed and fold-back analysis was performed to ascertain the best treatment path. Sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities. Our model showed patellar resurfacing is the best management strategy for the patella at the time of primary TKA. This decision is robust to changes in the specific data: the best path would remain the same as long as the incidence of persistent anterior knee pain (AKP) with resurfacing remains less than 29% (current mean, 12%) or the incidence of AKP after nonresurfacing falls below 12% (current mean, 26%). Delayed (ie, secondary) patellar resurfacing for ongoing patellar pain provides inferior results for the majority of patients. Level of Evidence: Level II, decision analysis. See the Guidelines for Authors for a complete description of levels of evidence. PMID:18726657
Helmy, Naeder; Anglin, Carolyn; Greidanus, Nelson V; Masri, Bassam A
The management of the patellar articular surface at the time of primary total knee arthroplasty (TKA) is controversial. We used expected-value decision analysis to determine whether the patella should be resurfaced in TKA, and also whether secondary resurfacing on an unresurfaced patella is worthwhile. Outcome probabilities and utility values were derived from randomized controlled trials only. A decision tree was constructed and fold-back analysis was performed to ascertain the best treatment path. Sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities. Our model showed patellar resurfacing is the best management strategy for the patella at the time of primary TKA. This decision is robust to changes in the specific data: the best path would remain the same as long as the incidence of persistent anterior knee pain (AKP) with resurfacing remains less than 29% (current mean, 12%) or the incidence of AKP after nonresurfacing falls below 12% (current mean, 26%). Delayed (ie, secondary) patellar resurfacing for ongoing patellar pain provides inferior results for the majority of patients. Level II, decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.
Ruiz-Rodriguez, Ricardo; López-Rodriguez, Laura
As demand for less invasive, highly effective cosmetic procedures grows, dermatologists must continue to explore and develop new treatment options. Nonablative skin resurfacing techniques offer an effective and noninvasive treatment for photorejuvenation. Several studies have shown improvement of photodamaged skin and increased collagen production after nonablative treatments using vascular lasers, mid-infrared lasers, intense pulsed light, radiofrequency devices, fractional resurfacing, and plasma skin rejuvenation. Among the novel methods for maximizing the efficacy of nonablative treatment is the concurrent use of a photosensitizing agent. The light sources currently most used for photodynamic rejuvenation are intense pulsed light and pulsed dye laser. We present some preliminary results on rejuvenation using Metvix and red light. We are still far from a thorough understanding of the molecular mechanism of rejuvenation with this technique, although a nonspecific immune response could be involved. Understanding the laser-tissue interactions associated with photodynamic therapy is crucial in selecting patients that will most likely benefit.
Ross, Adam T.; Becker, Daniel G.
Advances in laser technology have allowed the application of lasers to cosmetic facial skin resurfacing. While this application has been extremely advantageous to patients, the development of pre- and postoperative therapeutic regimens was necessary to mitigate potential complications associated with laser resurfacing. Potential complications of laser resurfacing include prolonged postoperative erythema, hyperpigmentation, hypopigmentation, herpetic, bacterial or candidal infection, and other concerns including scarring and abnormal wound healing. In this report we review the state of the art of preoperative and postoperative care for cosmetic laser resurfacing.
Bilge, Onur; Doral, Mahmut Nedim; Yel, Mustafa; Karalezli, Nazim; Miniaci, Anthony
The optimal treatment of osteonecrosis of the femoral head has not been established yet. The aim of this study was to report preliminary clinical results of focal anatomic-resurfacing implantation for the treatment of osteonecrosis of the femoral head. Five patients (four male, one female) with seven surgical procedures, ages between 37 and 52 with an average age of 45.2 (+/- 7.2), diagnosed as femoral head avascular necrosis and who were unresponsive to conservative management or had failed previous surgical treatments were treated with a focal anatomic femoral head resurfacing between the years 2011-2012 and were retrospectively reviewed. Five patients with at least two years of follow-up, one left hip, two right hips, and two patients with bilateral hip surgery were included in this review. After safe surgical dislocation of the hip, full exposure of the femoral head was established. A focal-resurfacing implant matching patient anatomy and femoral head curvature was performed accordingly. Neither intraoperative or postoperative complications nor revision ensued. Visual analogue scores and Harris Hip Scores were recorded both preoperatively and at postoperative 2 years for all seven surgeries. The mean follow-up period was 26.6 +/- 3.8 months, with a range between 24-33 months. The mean visual analogue scores were 8.9 +/- 0.9 preoperatively and 2.3 +/- 1.0 postoperatively at year two (p = 0.017). Harris Hip Scores at postoperative follow-up were found to improve significantly from good to excellent scores (86.0 +/- 7.9), compared with preoperative poor scores (26.7 +/- 11.8) (p = 0.018). The clinical improvements in visual analogue scores (VAS) and Harris Hip Scores were also found to correlate with each other (p < 0.05). In the present study, the alternative technique of focal anatomic hip resurfacing with HemiCAP® yielded preliminary successful results for the treatment of osteonecrosis of the femoral head. To the best of our knowledge, this is
Di Puccio, Francesca; Mattei, Lorenza
Hip arthroplasty can be considered one of the major successes of orthopedic surgery, with more than 350000 replacements performed every year in the United States with a constantly increasing rate. The main limitations to the lifespan of these devices are due to tribological aspects, in particular the wear of mating surfaces, which implies a loss of matter and modification of surface geometry. However, wear is a complex phenomenon, also involving lubrication and friction. The present paper deals with the tribological performance of hip implants and is organized in to three main sections. Firstly, the basic elements of tribology are presented, from contact mechanics of ball-in-socket joints to ultra high molecular weight polyethylene wear laws. Some fundamental equations are also reported, with the aim of providing the reader with some simple tools for tribological investigations. In the second section, the focus moves to artificial hip joints, defining materials and geometrical properties and discussing their friction, lubrication and wear characteristics. In particular, the features of different couplings, from metal-on-plastic to metal-on-metal and ceramic-on-ceramic, are discussed as well as the role of the head radius and clearance. How friction, lubrication and wear are interconnected and most of all how they are specific for each loading and kinematic condition is highlighted. Thus, the significant differences in patients and their lifestyles account for the high dispersion of clinical data. Furthermore, such consideration has raised a new discussion on the most suitable in vitro tests for hip implants as simplified gait cycles can be too far from effective implant working conditions. In the third section, the trends of hip implants in the years from 2003 to 2012 provided by the National Joint Registry of England, Wales and Northern Ireland are summarized and commented on in a discussion. PMID:25621213
... clues about the underlying cause. Problems within the hip joint itself tend to result in pain on the ... tendons and other soft tissues that surround your hip joint. Hip pain can sometimes be caused by diseases ...
Hodgson, A; Helmy, N; Masri, B A; Greidanus, N V; Inkpen, K B; Duncan, C P; Garbuz, D S; Anglin, C
The orientation of the femoral component in hip resurfacing arthroplasty affects the likelihood of loosening and fracture. Computer-assisted surgery has been shown to improve significantly the surgeon's ability to achieve a desired position and orientation; nevertheless, both bias and variability in positioning remain and can potentially be improved. The authors recently developed a computer-assisted surgical (CAS) technique to guide the placement of the pin used in femoral head resurfacing arthroplasty and showed that it produced significantly less variation than a typical manual technique in varus/valgus placement relative to a preoperatively determined surgical plan while taking a comparable amount of time. In the present study, the repeatability of both the CAS and manual techniques is evaluated in order to estimate the relative contributions to overall variability of surgical technique (CAS versus manual), surgeon experience (novice versus experienced), and other sources of variability (e.g. across specimens and across surgeons). This will enable further improvements in the accuracy of CAS techniques. Three residents/fellows new to femoral head resurfacing and three experienced hip arthroplasty surgeons performed 20-30 repetitions of each of the CAS and manual techniques on at least one of four cadaveric femur specimens. The CAS system had markedly better repeatability (1.2 degrees) in varus/valgus placement relative to the manual technique (2.8 degrees), slightly worse repeatability in version (4.4 degrees versus 3.2 degrees), markedly better repeatability in mid-neck placement (0.7 mm versus 2.5 mm), no significant dependence on surgeon skill level (in contrast to the manual technique), and took significantly less time (50 s versus 123 s). Proposed improvements to the version measurement process showed potential for reducing the standard deviation by almost two thirds. This study supports the use of CAS for femoral head resurfacing as it is quicker than the
Zhang, Alexandra Y; Obagi, Suzan
The field of skin resurfacing is undergoing rapid evolution with many new technologies that have developed, providing more choices for physicians and patients. Knowing the potential adverse effects associated with each skin resurfacing modality is paramount in selecting the appropriate approach for each candidate, thereby minimizing complications and achieving optimal results.
Kauvar, Arielle N B
Fractional photothermolysis, an approach to laser skin resurfacing that creates microscopic thermal wounds in skin separated by islands of spared tissue, was developed to overcome the high incidence of adverse events and prolonged healing times associated with full coverage ablative laser procedures. To examine whether fractional nonablative laser resurfacing induces skin tightening. A literature review was performed to evaluate the clinical and histologic effects of fractional nonablative laser resurfacing and full coverage ablative resurfacing procedures. Fractional nonablative lasers produce excellent outcomes with minimal risk and morbidity for a variety of clinical conditions, including photodamaged skin, atrophic scars, surgical and burn scars. Efforts to induce robust fibroplasia in histologic specimens and skin tightening in the clinical setting have yielded inconsistent results. A better understanding of the histology of fractional laser resurfacing will help to optimize clinical outcomes.
Calcerrada, N; Fernández-Vega, A; Valls-León, C; Garcia-Cimbrelo, E
Following medical device alerts published in different countries of problems with metal-on-metal total hip replacements, the Spanish Agency of Medicines and Medical Devices (AEMPS) in collaboration with the Spanish Hip Society Surgery designed a national survey to gather information on the use and behaviour of these hip implants. The survey consisted of a questionnaire sent by e-mail to 283 clinical centre recipients of metal-on-metal hips to be filled in by surgeons with expertise in the field. A total of 257 questionnaires were completed. The response rate of the clinical centres was 36.7%. A total of 97.7% of the responses reported that clinical and radiological follow-ups are carried out, and 79.6% undertook metal ion analyses (chromium and cobalt). A large majority (83.6%) of the responders who had who used surface implants, and 70% of those with large-head implants reported peri-operative complications. The most common complication was pain (25% with surface implants and 30.8% with large-head implants). Currently 80.8% of those responding were considering abandoning implanting of these hip replacements. Despite the many limitations to this study, the survey has allowed us to obtain in a quick first view of the implant scenario of Metal on Metal hip implants in Spain, and to determine the type of patient implanted, the time of implantation, and the experience/expertise of the surgeons, and the type of follow-up carried out. Copyright © 2015 SECOT. Published by Elsevier Espana. All rights reserved.
Carniol, Paul J; Hamilton, Mark M; Carniol, Eric T
Fractional lasers were first developed based on observations of lasers designed for hair transplantation. In 2007, ablative fractional laser resurfacing was introduced. The fractionation allowed deeper tissue penetration, leading to greater tissue contraction, collagen production and tissue remodeling. Since then, fractional erbium:YAG resurfacing lasers have also been introduced. These lasers have yielded excellent results in treating photoaging, acne scarring, and dyschromia. With the adjustment of microspot density, pulse duration, number of passes, and fluence, the surgeon can adjust the treatment effects. These lasers have allowed surgeons to treat patients with higher Fitzpatrick skin types (types IV to VI) and greater individualize treatments to various facial subunits. Immunohistochemical analysis has demonstrated remodeling effects of the tissues for several months, producing longer lasting results. Adjuvant treatments are also under investigation, including concomitant face-lift, product deposition, and platelet-rich plasma. Finally, there is a short recovery time from treatment with these lasers, allowing patients to resume regular activities more quickly. Although there is a relatively high safety profile for ablative fractionated lasers, surgeons should be aware of the limitations of specific treatments and the associated risks and complications.
Bentkover, Stuart H
This article presents a comprehensive clinical approach to plasma resurfacing for skin regeneration. Plasma technology, preoperative protocols, resurfacing technique, postoperative care, clinical outcomes, evidence-based results, and appropriate candidates for this procedure are discussed. Specific penetration depth and specific laser energy measurements are provided. Nitrogen plasma skin regeneration is a skin-resurfacing technique that offers excellent improvement of mild to moderate skin wrinkles and overall skin rejuvenation. It also provides excellent improvement in uniformity of skin color and texture in patients with hyperpigmentation with Fitzpatrick skin types 1 through 4.
Fagotti, Lorenzo; Vicente, José Ricardo Negreiros; Miyahara, Helder Souza; de Oliveira, Pedro Vitoriano; Bernabé, Antônio Carlos; Croci, Alberto Tesconi
The aim here was to report a case of a young adult patient who evolved with tumor formation in the left thigh, 14 years after revision surgery on hip arthroplasty. Davies in 2005 made the first description of this disease in patients undergoing metal-on-metal hip arthroplasty. Over the last decade, however, pseudotumors around metal-on-polyethylene surfaces have become more prevalent. Our patient presented with increased volume of the left thigh 8 years after hip arthroplasty revision surgery. Two years before the arising of the tumor in the thigh, a nodule in the inguinal region was investigated to rule out a malignant neoplastic process, but the results were inconclusive. The main preoperative complaints were pain, functional limitation and marked reduction in the range of motion of the left hip. Plain radiographs showed loosening of acetabular and femoral, and a large mass between the muscle planes was revealed through magnetic resonance imaging of the left thigh. The surgical procedure consisted of resection of the lesion and removal of the components through lateral approach. In respect of total hip arthroplasty, pseudotumors are benign neoplasms in which the bearing surface consists of metal-on-metal, but they can also occur in different tribological pairs, as presented in this case.
Fagotti, Lorenzo; Vicente, José Ricardo Negreiros; Miyahara, Helder Souza; de Oliveira, Pedro Vitoriano; Bernabé, Antônio Carlos; Croci, Alberto Tesconi
The aim here was to report a case of a young adult patient who evolved with tumor formation in the left thigh, 14 years after revision surgery on hip arthroplasty. Davies in 2005 made the first description of this disease in patients undergoing metal-on-metal hip arthroplasty. Over the last decade, however, pseudotumors around metal-on-polyethylene surfaces have become more prevalent. Our patient presented with increased volume of the left thigh 8 years after hip arthroplasty revision surgery. Two years before the arising of the tumor in the thigh, a nodule in the inguinal region was investigated to rule out a malignant neoplastic process, but the results were inconclusive. The main preoperative complaints were pain, functional limitation and marked reduction in the range of motion of the left hip. Plain radiographs showed loosening of acetabular and femoral, and a large mass between the muscle planes was revealed through magnetic resonance imaging of the left thigh. The surgical procedure consisted of resection of the lesion and removal of the components through lateral approach. In respect of total hip arthroplasty, pseudotumors are benign neoplasms in which the bearing surface consists of metal-on-metal, but they can also occur in different tribological pairs, as presented in this case. PMID:27218090
Cheung, A C; Banerjee, S; Cherian, J J; Wong, F; Butany, J; Gilbert, C; Overgaard, C; Syed, K; Zywiel, M G; Jacobs, J J; Mont, M A
Recently, the use of metal-on-metal articulations in total hip arthroplasty (THA) has led to an increase in adverse events owing to local soft-tissue reactions from metal ions and wear debris. While the majority of these implants perform well, it has been increasingly recognised that a small proportion of patients may develop complications secondary to systemic cobalt toxicity when these implants fail. However, distinguishing true toxicity from benign elevations in cobalt ion levels can be challenging. The purpose of this two part series is to review the use of cobalt alloys in THA and to highlight the following related topics of interest: mechanisms of cobalt ion release and their measurement, definitions of pathological cobalt ion levels, and the pathophysiology, risk factors and treatment of cobalt toxicity. Historically, these metal-on-metal arthroplasties are composed of a chromium-cobalt articulation. The release of cobalt is due to the mechanical and oxidative stresses placed on the prosthetic joint. It exerts its pathological effects through direct cellular toxicity. This manuscript will highlight the pathophysiology of cobalt toxicity in patients with metal-on-metal hip arthroplasties. Patients with new or evolving hip symptoms with a prior history of THA warrant orthopaedic surgical evaluation. Increased awareness of the range of systemic symptoms associated with cobalt toxicity, coupled with prompt orthopaedic intervention, may forestall the development of further complications. ©2016 The British Editorial Society of Bone & Joint Surgery.
Figueredo, P.; Greeley, R.
We have completed the geologic mapping and analysis of pole-to-pole transects across the leading and trailing hemispheres of Europa. Our results show that ~50% of the mapped areas has been resurfaced since the period of background ridged plains formation (comprising the last 50-100 Myr.): ~30% by tectonic processes and ~20% by chaotic disruption. Further, the geologic record indicates a transition from tectonic- to cryovolcanic-dominated resurfacing. The style of tectonic processes changed with time, from intensive, closely spaced fracturing and ridge building forming background plains, to infilling of inter-plate gaps forming broad bands, to gradually narrower and farther-spaced ridges and ridge complexes. In both hemispheres, these lineaments rotated with time in senses consistent with nonsynchronous rotation predictions. The lack of lineaments overprinting impact structures (with the exception of Tyre) suggests that the intensity of tectonic resurfacing decreased rapidly after the formation of ridged plains. Units associated with chaotic disruption overprint one another (in areas that broadly match regions where the regional thermal gradient has been raised by tidal dissipation), fragmenting the evidence for early cryovolcanic activity. Old, subdued chaos has been reworked to form younger chaos areas by merging of small patches of disruption; the most recent chaos features appear to be slightly elevated with respect to the surrounding plains. These observations suggest that chaos formed by disruption and emplacement of buoyant material from the subsurface, which became topographically and morphologically subdued with time. One possible interpretation of the mentioned trends and changes is the gradual thickening of Europa's lithosphere throughout the visible geologic history: the degree of fracturing and plate displacements decrease in a thickening shell, while lineaments become narrower and more widely spaced; formation of chaos regions can take place where the
Boas, Raquel de Melo Santos Vilas; Madeira, Ivana Andrade; Lopes, Alexia Abuhid; Paiva, Edson Barreto; Rodrigues, André Soares
Soft tissue complications following hip arthroplasty may occur either in cases of total hip arthroplasty or in hip resurfacing, a technique that has become popular in cases involving young patients. Both orthopedic and radiological literatures are now calling attention to these symptomatic periprosthetic soft tissue masses called inflammatory pseudotumors or aseptic lymphocytic vasculites-associated lesions. Pseudotumors are associated with pain, instability, neuropathy, and premature loosening of prosthetic components, frequently requiring early and difficult reoperation. Magnetic resonance imaging plays a relevant role in the evaluation of soft tissue changes in the painful hip after arthroplasty, ranging from early periprosthetic fluid collections to necrosis and more extensive tissue damage. PMID:26543283
Boas, Raquel de Melo Santos Vilas; Madeira, Ivana Andrade; Lopes, Alexia Abuhid; Paiva, Edson Barreto; Rodrigues, André Soares
Soft tissue complications following hip arthroplasty may occur either in cases of total hip arthroplasty or in hip resurfacing, a technique that has become popular in cases involving young patients. Both orthopedic and radiological literatures are now calling attention to these symptomatic periprosthetic soft tissue masses called inflammatory pseudotumors or aseptic lymphocytic vasculites-associated lesions. Pseudotumors are associated with pain, instability, neuropathy, and premature loosening of prosthetic components, frequently requiring early and difficult reoperation. Magnetic resonance imaging plays a relevant role in the evaluation of soft tissue changes in the painful hip after arthroplasty, ranging from early periprosthetic fluid collections to necrosis and more extensive tissue damage.
Rieker, Claude B.
Articulating components should minimise the generation of wear particles in order to optimize long-term survival of the prosthesis. A good understanding of tribological properties helps the orthopaedic surgeon to choose the most suitable bearing for each individual patient. Conventional and highly cross-linked polyethylene articulating either with metal or ceramic, ceramic-on-ceramic and metal-on-metal are the most commonly used bearing combinations. All combinations of bearing surface have their advantages and disadvantages. An appraisal of the individual patient’s objectives should be part of the assessment of the best bearing surface. Cite this article: Rieker CB. Tribology of total hip arthroplasty prostheses: what an orthopaedic surgeon should know. EFORT Open Rev 2016;1:52-57. DOI: 10.1302/2058-5241.1.000004. PMID:28461928
Ball, Scott T; Pinsorsnak, Piya; Amstutz, Harlan C; Schmalzried, Thomas P
Hip arthroplasty and extended travel are each recognized as risk factors for venous thromboembolism (VTE). The safety of travel after hip arthroplasty is currently unknown. Patients who had traveled more than 200 miles within 6 weeks of a hip arthroplasty or hip resurfacing were identified and contacted. All patients received VTE chemoprophylaxis with enoxaparin, dalteparin, fondaparinox, or warfarin. A total of 608 patients traveled an average of 1377 miles at an average of 6.5 days after surgery. Among these patients, 462 traveled by airplane, 143 by car, and 3 by train. There were no deaths, no symptomatic pulmonary embolisms, and only 5 (0.82%) symptomatic deep venous thromboses. Nine (1.5%) patients experienced bleeding complications. With chemical VTE prophylaxis, extended travel within 6 weeks of hip arthroplasty surgery is associated with a low rate of symptomatic deep venous thrombosis, with no known pulmonary embolisms and no deaths.
Scholes, S C; Unsworth, A
It is well documented that an important cause of osteolysis and subsequent loosening of replacement hip joints is polyethylene wear debris. To avoid this, interest has been renewed in metal-on-metal and ceramic-on-ceramic prostheses. Various workers have assessed the lubrication modes of different joints by measuring the friction at the bearing surfaces, using different lubricants. Measurements of friction factors of a series of hip prostheses were undertaken using carboxymethyl cellulose (CMC) fluids, silicone fluids, synovial fluid and different concentrations of bovine serum as the lubricant. The experimental results were compared with theoretical predictions of film thicknesses and lubrication modes. A strong correlation was observed between experiment and theory when employing CMC fluids or silicone fluids as the lubricant. Mixed lubrication was found to occur in the metal-on-metal (CoCrMo/CoCrMo) joints with all lubricants at a viscosity within the physiological range. This was also the case for the metal-on-plastic (CoCrMo/ultra-high molecular weight polyethylene) joints. The ceramic-on-ceramic (Al2O3/Al2O3) joints, however, exhibited full fluid film lubrication with the synthetic lubricants but mixed lubrication with the biological lubricants. Employing a biological fluid as the lubricant affected the friction to varying degrees when compared with the synthetic lubricants. In the case of the ceramic-on-ceramic joints it acted to increase the friction factor tenfold; however, for the metal-on-metal joints, biological fluids gave slightly lower friction than the synthetic lubricants did. This suggests that, when measuring friction and wear of artificial joints, a standard lubricant should be used.
Squyres, S. W.; Reynolds, R. T.; Cassen, P. M.; Peale, S. J.
Arguments for recent resurfacing of Europa by H2O from a liquid layer are presented, based on new interpretations of recent spacecraft and earth-based observations and revised theoretical calculations. The heat flow in the core and shell due to tidal forces is discussed, and considerations of viscosity and convection in the interior are found to imply water retention in the outer 60 km or so of the silicates, forming a layer of water/ice many tens of km thick. The outer ice crust is considered to be too thin to support heat transport rates sufficient to freeze the underlying water. Observational evidence for the calculations would consist of an insulating layer of frosts derived from water boiling up between cracks in the surface crust. Evidence for the existence of such a frost layer, including the photometric function of Europa and the deposits of sulfur on the trailing hemisphere, is discussed.
Squyres, S. W.; Reynolds, R. T.; Cassen, P. M.; Peale, S. J.
Arguments for recent resurfacing of Europa by H2O from a liquid layer are presented, based on new interpretations of recent spacecraft and earth-based observations and revised theoretical calculations. The heat flow in the core and shell due to tidal forces is discussed, and considerations of viscosity and convection in the interior are found to imply water retention in the outer 60 km or so of the silicates, forming a layer of water/ice many tens of km thick. The outer ice crust is considered to be too thin to support heat transport rates sufficient to freeze the underlying water. Observational evidence for the calculations would consist of an insulating layer of frosts derived from water boiling up between cracks in the surface crust. Evidence for the existence of such a frost layer, including the photometric function of Europa and the deposits of sulfur on the trailing hemisphere, is discussed.
... make older people more likely to trip and fall — one of the most common causes of hip ... Taking steps to maintain bone density and avoid falls can help prevent hip fracture. Signs and symptoms ...
... with your health provider.AspirinThe body breaks down aspirin to get rid of it. Rose hip contains ... of vitamin C might decrease the breakdown of aspirin. Taking large amount of rose hip along with ...
... exercise can reduce stiffness and increase flexibility and muscle strength. People who have an artificial hip should talk ... and cross-country skiing. These exercises can increase muscle strength and cardiovascular fitness without injuring the new hip. ...
... replacement is an operation in which a damaged hip joint is removed and replaced with an artificial joint. ... are many medical conditions that can damage the hip joint. (Watch the video to learn about what goes ...
... Index A-Z Hip Ultrasound Hip ultrasound uses sound waves to produce pictures of muscles, tendons, ligaments, ... pictures of the inside of the body using sound waves. Ultrasound imaging, also called ultrasound scanning or ...
Gordon, James; Khan, Misbah H; Khatri, Khalil A
Laser resurfacing of facial rhytids has become a popular treatment for many patients who have wrinkles, photodamage, and acne scarring. Erbium:YAG laser resurfacing has emerged as one of the safer, more effective methods of facial rejuvenation and its increasing popularity has led to its widespread use for resurfacing. However, size and high initial and maintenance cost are among the problems with currently available laser devices. The LightPod portable Erbium:YAG laser from Aerolase offers a new paradigm for more cost effective means of performing ablative resurfacing with reduced initial and maintenance cost and the ease of portability with significantly reduced size and weight. The objective of this pilot study was to analyze the efficacy of The LightPod Erbium:YAG laser in different skin types for various indications.
Kumar, Narinder; Arora, Gen N.C.; Datta, Barun
Total hip arthroplasty has evolved from the first total hip arthroplasty in 1938, through the revolutionization of hip arthroplasty by principles of low friction arthroplasty introduced by Sir John Charnley in 1960s to the present state of the art implants and techniques. The main concern regarding failure of total hip arthroplasty has been the biological response to particulate polyethylene debris generated by conventional metal on polyethylene bearing surfaces leading to osteolysis and aseptic loosening of the prosthesis. Therefore, recent research has been focussing on alternative bearing surfaces to reduce the particulate debris generated. These bearing surfaces include ceramic-polyethylene, metal–metal as well as ceramic–ceramic articulations and have demonstrated lesser friction rates as well as significantly lower wear rates as compared to widely used metal on polyethylene surfaces. Clinical experience until now has shown that metal on metal articulations have significant safety concerns whereas metal-on-highly crosslinked polyethylene, ceramic on ceramic and ceramic on highly crosslinked polyethylene articulations have shown encouraging results to hold promise for wider use in younger and more active patients. This review article discusses positives and drawbacks of various bearing surfaces in current clinical use in total hip arthroplasty as well as briefly explores the newer technologies on the horizon which may even further decrease wear and improve total hip arthroplasty survivorship. PMID:25382913
Yamada, Tomoya; Ando, Kosuke; Morota, Tomokatsu; Katsuragi, Hiroaki
A model for the asteroid resurfacing resulting from regolith convection is built to estimate its timescale. The regolith convection by impact-induced global seismic shaking could be a possible reason for regolith migration and resultant segregated terrain which were found on the asteroids Itokawa . Some recent studies [2, 3] experimentally investigated the convective velocity of the vibrated granular bed to discuss the feasibility of regolith convection under the microgravity condition such as small asteroids. These studies found that the granular convective velocity is almost proportional to the gravitational acceleration [2, 3]. Namely, the granular (regolith) convective velocity would be very low under the microgravity condition. Therefore, the timescale of resurfacing by regolith convection would become very long. In order to examine the feasibility of the resurfacing by regolith convection on asteroids, its timescale have to be compared with the surface age or the lifetime of asteroids. In this study, we aim at developing a model of asteroid resurfacing process induced by regolith convection. The model allows us to estimate the resurfacing timescale for various-sized asteroids covered with regolith. In the model, regolith convection is driven by the impact-induced global seismic shaking. The model consists of three phases, (i) Impact phase: An impactor intermittently collides with a target asteroid , (ii) Vibration phase: The collision results in a global seismic shaking , (iii) Convection phase: The global seismic shaking induces the regolith convection on the asteroid . For the feasibility assessment of the resurfacing process driven by regolith convection, we estimate the regolith-convection-based resurfacing timescale T as a function of the size of a target asteroid Da. According to the estimated result, the resurfacing time scale is 40 Myr for the Itokawa-sized asteroid, and this value is shorter than the mean collisional lifetime of Itokawa
Kurtz, Steven M.; Toth, Jeffrey M.; Siskey, Ryan; Ciccarelli, Lauren; MacDonald, Dan; Isaza, Jorge; Lanman, Todd; Punt, Ilona; Steinbeck, Marla; Goffin, Jan; van Ooij, André
Knowledge regarding the in vivo performance and periposthetic tissue response of cervical and lumbar total disc replacements (TDRs) continues to expand. This review addresses the following four main questions: 1) What are the latest lessons learned from polyethylene in large joints and how are they relevant to current TDRs? 2) What are the latest lessons learned regarding adverse local tissue reactions from metal-on-metal, CoCr bearings in large joints and how are they relevant to current TDRs? 3) What advancements have been made in understanding the in vivo performance of alternative biomaterials, such as stainless steel and polycarbonate urethane, for TDRs in the past five years? 4) How has retrieval analysis of all these various artificial disc bearing technologies advanced the state of the art in preclinical testing of TDRs? The study of explanted artificial discs and their associated tissues can help inform bearing selection as well as the design of future generations of disc arthroplasty. Analyzing retrieved artificial discs is also essential for validating preclinical test methods. PMID:22904606
Kurtz, Steven M; Toth, Jeffrey M; Siskey, Ryan; Ciccarelli, Lauren; Macdonald, Dan; Isaza, Jorge; Lanman, Todd; Punt, Ilona; Steinbeck, Marla; Goffin, Jan; van Ooij, André
Knowledge regarding the in vivo performance and periposthetic tissue response of cervical and lumbar total disc replacements (TDRs) continues to expand. This review addresses the following four main questions: 1) What are the latest lessons learned from polyethylene in large joints and how are they relevant to current TDRs? 2) What are the latest lessons learned regarding adverse local tissue reactions from metal-on-metal, CoCr bearings in large joints and how are they relevant to current TDRs? 3) What advancements have been made in understanding the in vivo performance of alternative biomaterials, such as stainless steel and polycarbonate urethane, for TDRs in the past five years? 4) How has retrieval analysis of all these various artificial disc bearing technologies advanced the state of the art in preclinical testing of TDRs? The study of explanted artificial discs and their associated tissues can help inform bearing selection as well as the design of future generations of disc arthroplasty. Analyzing retrieved artificial discs is also essential for validating preclinical test methods.
Hu, P. S.; Liu, R.; Liu, J.; McRae, G.
Low-carbon Stellite 21 has been used as hip implant material for a number of decades; however, its limited metal-on-metal bearing has resulted in loosening between the femoral head and the acetabular cup of hip implants. In order to improve the metal-on-metal bearing, it is proposed that a high-carbon alloy, Stellite 720, surface coating be applied on Stellite 21 hip implants to improve mechanical and tribological performance. For this coating to be practical, it must also meet the requirements of corrosion resistance for orthopedic implant materials. In this research, Stellite 720 is investigated with pin-on-disk wear tests, and electrochemical and immersion corrosion tests in simulated human body fluid (Hank's solution; pH 7.4 at temperature of 37°C). The experimental results demonstrate that Stellite 720 exhibits much better wear resistance than Stellite 21, and has the potential for better corrosion resistance as well. The applicability of coating Stellite 21 hip implants with Stellite 720 is discussed.
Nassutt, Roman; Wimmer, Markus A; Schneider, Erich; Morlock, Michael M
Insufficient tribologic performance of total joint components is a major cause of prostheses failure. Wear has been studied intensively using testing machines that apply continuous motions. Human locomotion, however, is not well represented by continuous motions alone. Singular events and resting periods are a substantial part of daily activities. Resting does influence adhesion in the artificial joint with possible effects on friction, wear, and loosening. The current study evaluated the effects of resting on the frictional properties of hip prosthesis components. The activity measurements of 32 patients with artificial hip replacements were analyzed for resting durations of the hip. A pin-on-ball screening device was used to determine friction after characteristic resting periods and during continuous oscillating motion. All common articulation pairings were investigated. Prolonged and frequent resting periods of the hip were found for the patients. Initial friction increased with increasing resting duration for all tested materials (between 41% and 191%). The metal-on-metal articulations showed the highest friction level (0.098 for sliding) and the highest increase (191%) in friction with resting duration (0.285 after resting periods of 60 seconds). A high static frictional moment after resting periods might present a risk for aseptic implant loosening. Therefore, large head diameters of metal-on-metal joints should be used with caution, especially when additional unfavorable risk factors such as obesity, weak bone-implant interface, or high activity level are present.
Fulton, J E; Silverton, K
: Dermabrasion has been a useful method for the improvement of acne scars since 1953. However, the improvement is often limited. Adjuvant procedures are often necessary to improve results. : To improve the results of resurfacing the acne scarred face. By combining the techniques of subcutaneous filling, laser shrinkage of collagen, dermabrasion, and excision, we hope to achieve better results. A Jessner/TCA peel is performed on the neck and décolleté area after the skin has been preconditioned with vitamin A conditioning lotions. The acne scars are subcised with a semi-blunt needle, and the developed pockets are filled with adipose tissue. Following this, the surface skin is vaporized with three passes of the CO2 laser, and the deeper acne scars in the mid-face region are sanded with a diamond fraise. Residual scars are excised and sutured. A semi-occlusive dressing is used for 5 days, then replaced with an ointment-based moisturizer. After 10 days, a moisturizer-sunscreen is used, followed with a bleaching cream at 15 days. Make-up may be applied after 14 days. : By combining these multiple modalities it is possible to produce a dramatic improvement of the acne-scarred complexion.
Chajchir, Abel; Benzaquen, Iliana
ABTRACT: Long sun exposure, in addition to ozone layer damage, produces structural damase to the normal skin. Injury to the dermal collagen and elastic fiber results in facial wrinkles. Photodamage to the skin is one of the most common sources of concern for patients visiting the plastic surgeon or dermatologist. Over the years, many alternative solutions have been developed. CO2 laser treatment is one of the alternatives bringing unique benefits and satisfactory results for both patient and surgeons. However, the initial problems of emotional discomfort, prolonged postoperative recovery and delayed return to normal activities have made patients reluctant to accept this method. This article discusses single-pass CO2 laser resurfacing with lower energy. Also, it proposes a technique that does not use wet gauze to remove the surface of the skin. This technique is applied in combination with an intensive skin care treatment. Different authors propose a single pass of CO2 laser with excellent results. With the reported method, identical long-lasting benefits are achieved, but the post-operative time is shorter.
Park, Juneyoung; Abdel-Aty, Mohamed; Wang, Jung-Han
This study evaluated the safety performance of pavement resurfacing projects on urban arterials in Florida using the observational before and after approaches. The safety effects of pavement resurfacing were quantified in the crash modification factors (CMFs) and estimated based on different ranges of heavy vehicle traffic volume and time changes for different severity levels. In order to evaluate the variation of CMFs over time, crash modification functions (CMFunctions) were developed using nonlinear regression and time series models. The results showed that pavement resurfacing projects decrease crash frequency and are found to be more safety effective to reduce severe crashes in general. Moreover, the results of the general relationship between the safety effects and time changes indicated that the CMFs increase over time after the resurfacing treatment. It was also found that pavement resurfacing projects for the urban roadways with higher heavy vehicle volume rate are more safety effective than the roadways with lower heavy vehicle volume rate. Based on the exploration and comparison of the developed CMFucntions, the seasonal autoregressive integrated moving average (SARIMA) and exponential functional form of the nonlinear regression models can be utilized to identify the trend of CMFs over time. Copyright © 2017 Elsevier Ltd. All rights reserved.
Groff, William F; Fitzpatrick, Richard E; Uebelhoer, Nathan S
Photodamage is one of the most common reasons that patients visit a dermatologist's office. Carbon dioxide (CO(2)) laser resurfacing has always been the gold standard for reversing photodamage. Because of the relatively high incidence of side effects and the prolonged downtime associated with CO(2) resurfacing, new technologies have emerged to address photodamage. Portrait skin regeneration (PSR) is a novel device that has been developed to treat photodamage, and this device yields fewer side effects and downtime than traditional CO(2) laser resurfacing. At our center, we have performed more than 500 high-energy PSR treatments and have developed a unique and highly effective treatment protocol. In addition, fractional CO(2) laser resurfacing has emerged as the latest technology developed to combat photoaging. This technology yields impressive results and is much safer and causes less downtime than traditional CO(2) laser resurfacing. In this article, we will review our treatment techniques and protocols as well as address patient selection, preoperative and postoperative care, and anesthesia.
de Amorim Cabrita, Henrique Antônio Berwanger; de Castro Trindade, Christiano Augusto; de Campos Gurgel, Henrique Melo; Leal, Rafael Demura; de Souza Marques, Ricardo da Fonseca
Hip arthroscopy is a safe method for treating a variety of pathological conditions that were unknown until a decade ago. Femoroacetabular impingement is the commonest of these pathological conditions and the one with the best results when treated early on. The instruments and surgical technique for hip arthroscopy continue to evolve. New indications for hip arthroscopy has been studied as the ligamentum teres injuries, capsular repair in instabilities, dissection of the sciatic nerve and repair of gluteal muscles tears (injuries to the hip rotator cuff), although still with debatable reproducibility. The complication rate is low, and ever-better results with fewer complications should be expected with the progression of the learning curve.
Mihalko, William M; Wimmer, Markus A; Pacione, Carol A; Laurent, Michel P; Murphy, Robert F; Rider, Carson
Total hip arthroplasty (THA) continues to be one of the most successful surgical procedures in the medical field. However, over the last two decades, the use of modularity and alternative bearings in THA has become routine. Given the known problems associated with hard-on-hard bearing couples, including taper failures with more modular stem designs, local and systemic effects from metal-on-metal bearings, and fractures with ceramic-on-ceramic bearings, it is not known whether in aggregate the survivorship of these implants is better or worse than the metal-on-polyethylene bearings that they sought to replace. Have alternative bearings (metal-on-metal and ceramic-on-ceramic) and implant modularity decreased revision rates of primary THAs? In this systematic review of MEDLINE and EMBASE, we used several Boolean search strings for each topic and surveyed national registry data from English-speaking countries. Clinical research (Level IV or higher) with ≥ 5 years of followup was included; retrieval studies and case reports were excluded. We included registry data at ≥ 7 years followup. A total of 32 studies (and five registry reports) on metal-on-metal, 19 studies (and five registry reports) on ceramic-on-ceramic, and 20 studies (and one registry report) on modular stem designs met inclusion criteria and were evaluated in detail. Insufficient data were available on metal-on-ceramic and ceramic-on-metal implants, and monoblock acetabular designs were evaluated in another recent systematic review so these were not evaluated here. There was no evidence in the literature that alternative bearings (either metal-on-metal or ceramic-on-ceramic) in THA have decreased revision rates. Registry data, however, showed that large head metal-on-metal implants have lower 7- to 10-year survivorship than do standard bearings. In THA, modular exchangeable femoral neck implants had a lower 10-year survival rate in both literature reviews and in registry data compared with combined
... resurfacing uncemented prosthesis. 888.3580 Section 888.3580 Food and Drugs FOOD AND DRUG ADMINISTRATION... § 888.3580 Knee joint patellar (hemi-knee) metallic resurfacing uncemented prosthesis. (a) Identification. A knee joint patellar (hemi-knee) metallic resurfacing uncemented prosthesis is a device made of...
... resurfacing uncemented prosthesis. 888.3580 Section 888.3580 Food and Drugs FOOD AND DRUG ADMINISTRATION... § 888.3580 Knee joint patellar (hemi-knee) metallic resurfacing uncemented prosthesis. (a) Identification. A knee joint patellar (hemi-knee) metallic resurfacing uncemented prosthesis is a device made of...
... resurfacing uncemented prosthesis. 888.3580 Section 888.3580 Food and Drugs FOOD AND DRUG ADMINISTRATION... § 888.3580 Knee joint patellar (hemi-knee) metallic resurfacing uncemented prosthesis. (a) Identification. A knee joint patellar (hemi-knee) metallic resurfacing uncemented prosthesis is a device made of...
Scholes, S. C.; Unsworth, A.; Goldsmith, A. A. J.
Polymeric wear debris produced by articulation of the femoral head against the ultra-high-molecular-weight polyethylene socket of a total hip replacement has been implicated as the main cause of osteolysis and subsequent failure of these implants. Potential solutions to this problem are to employ hard bearing surface combinations such as metal-on-metal or ceramic-on-ceramic prostheses. The aim of this study was to investigate the difference in lubrication modes and friction of a range of material combinations using synthetic and biological fluids as the lubricants. The experimental results were compared with theoretical predictions of film thicknesses and lubrication modes. A strong correlation was observed between experiment and theory when employing carboxy methyl cellulose (CMC) fluids as the lubricant. Under these conditions the ceramic-on-ceramic joints showed full fluid film lubrication while the metal-on-metal, metal-on-plastic, diamond-like carbon-coated stainless steel (DLC)-on-plastic and ceramic-on-plastic prostheses operated under a mixed lubrication regime. With bovine serum as the lubricant in the all ceramic joints, however, the full fluid film lubrication was inhibited due to adsorbed proteins. In the metal-on-metal joints this adsorbed protein layer acted to reduce the friction while in the ceramic coupling the friction was increased. The use of bovine serum as the lubricant also significantly increased the friction in both the metal-on-plastic and ceramic-on-plastic joints. The friction produced by the DLC-on-plastic joints depended on the quality of the coating. Those joints with a less consistent coating and therefore a higher surface roughness gave significantly higher friction than the smoother, more consistently coated heads.
Ross, E V; McKinlay, J R; Anderson, R R
Despite the unquestionable efficacy of carbon dioxide laser skin resurfacing, mechanisms for cosmetic enhancement remain poorly characterized. Histological studies have provided some insight into the cascade of events from initial laser impact to final skin rejuvenation. However, there are few comprehensive studies of gross and microscopic wound healing. Additionally, the literature is fragmented; excellent individual articles appear in journals from widely disparate disciplines. For example, some reports relevant to laser skin resurfacing are "sequestered" in the engineering literature. This article is intended to update the physician on laser skin resurfacing based on the broadest review of the current literature. It proceeds from a discussion of initial laser-tissue interactions, such as collagen denaturation, to examination of long-term biological sequelae. At some cost to scientific rigor, mathematical models describing laser-tissue interactions are not presented.
Skin resurfacing has been a part of cosmetic dermatology for more than two decades now, and most of it has been ablative with traditional aggressive lasers including the CO(2) and erbium. The last few years have seen a revolutionary change with the invention of nonablative lasers for skin tightening. Fractional resurfacing is a new concept of cutaneous remodeling whereby laser-induced zones of microthermal injury are surrounded by normal untreated tissue that helps in quicker healing. The various wavelengths used are 1320, 1440, and 2940 nm with depth of penetration ranging from 25 μ to 1.2 mm. This article reviews the history of nonablative fractional laser resurfacing, its indications, contraindications, and a review of use in Asian skin with Fitzpatrick type III-VI.
Wright, Eric J; Struck, Steve K
The combination of simultaneous surgical rhytidectomy with ablative resurfacing has been a controversial procedure due to the concern of postoperative wound healing. Traditional ablative resurfacing lasers are believed to have higher rates of complications, leading to delayed healing and skin flap loss when combined with face rhytidectomy surgeries. With the development of fractionated ablative laser therapy, there has been increased interest in combining these two procedures. The objective of this study is to evaluate the clinical outcomes of patients undergoing simultaneous full-face rhytidectomy in combination with fractionated ablative skin resurfacing. A retrospective chart analysis was performed for all patients who had a combined procedure of facelift and ablative fractional laser resurfacing from 2008 to 2013 by the senior author (SKS). Postoperative recovery and complications were recorded. The surgical technique used for performing the facelift was an extended supraplatysmal dissection with SMAS plication. Fraxel Re:Pair 10,600-nm fractional carbon dioxide laser was used to perform an ablative resurfacing including the elevated skin flaps. A total of 86 patients were included. Average age was 60.01 years (range of 45-78 years). Longest follow up was five years. The average size of the elevated skin flaps was 100 cm(2). Average skin type was a Fitzpatrick type 2. All patients had complete re-epithelialization by one week after their procedure. Four patients (4.6%) experienced acne outbreaks. Four patients (4.6%) had facial erythema that persisted greater than two weeks. Of these four patients, all resolved by five weeks postoperatively. There was no delayed wound healing or skin flap loss observed. Our results indicate that simultaneous rhytidectomy with fractionated ablative laser resurfacing does not cause an increase in wound healing or skin loss. Due to improved patient outcomes with combining these procedures, we believe that this can be increasingly
Schindler, Oliver S
Early arthroplasty designs were associated with a high level of anterior knee pain as they failed to cater for the patello-femoral joint. Patellar resurfacing was heralded as the saviour safeguarding patient satisfaction and success but opinion on its necessity has since deeply divided the scientific community and has become synonymous to topics of religion or politics. Opponents of resurfacing contend that the native patella provides better patellar tracking, improved clinical function, and avoids implant-related complications, whilst proponents argue that patients have less pain, are overall more satisfied, and avert the need for secondary resurfacing. The question remains whether complications associated with patellar resurfacing including those arising from future component revision outweigh the somewhat increased incidence of anterior knee pain recorded in unresurfaced patients. The current scientific literature, which is often affected by methodological limitations and observer bias, remains confusing as it provides evidence in support of both sides of the argument, whilst blinded satisfaction studies comparing resurfaced and non-resurfaced knees generally reveal equivalent results. Even national arthroplasty register data show wide variations in the proportion of patellar resurfacing between countries that cannot be explained by cultural differences alone. Advocates who always resurface or never resurface indiscriminately expose the patella to a random choice. Selective resurfacing offers a compromise by providing a decision algorithm based on a propensity for improved clinical success, whilst avoiding potential complications associated with unnecessary resurfacing. Evidence regarding the validity of selection criteria, however, is missing, and the decision when to resurface is often based on intuitive reasoning. Our lack of understanding why, irrespective of pre-operative symptoms and patellar resurfacing, some patients may suffer pain following TKA and
Choudhury, Dipankar; Vrbka, Martin; Mamat, Azuddin Bin; Stavness, Ian; Roy, Chanchal K; Mootanah, Rajshree; Krupka, Ivan
Coefficient of friction (COF) tests were conducted on 28-mm and 36-mm-diameter hip joint prostheses for four different material combinations, with or without the presence of Ultra High Molecular Weight Polyethylene (UHMWPE) particles using a novel pendulum hip simulator. The effects of three micro dimpled arrays on femoral head against a polyethylene and a metallic cup were also investigated. Clearance played a vital role in the COF of ceramic on polyethylene and ceramic on ceramic artificial hip joints. Micro dimpled metallic femoral heads yielded higher COF against a polyethylene cup; however, with metal on metal prostheses the dimpled arrays significantly reduced the COF. In situ images revealed evidence that the dimple arrays enhanced film formation, which was the main mechanism that contributed to reduced friction. Copyright © 2017 Elsevier Ltd. All rights reserved.
Santavirta, Seppo; Böhler, Max; Harris, William H; Konttinen, Yrjö T; Lappalainen, Reijo; Muratoglu, Orhun; Rieker, Claude; Salzer, Martin
An improvement in tribology of bearing surfaces is an effective means of increasing the longevity of total hip replacement (THR). Currently, 3 approaches are available to achieve this aim: first, use of highly cross-linked UHMWPE; second, aluminum oxide ceramic bearings, and third, metal-on-metal bearings. Cross-linking reduces the wear resistance of UHMWPE markedly without impairment of other significant properties of the material. Simulator studies and some clinical long-term (10-22 years) follow-up surveys suggest an almost immeasurable wear of the highly cross-linked UHMWPE-based acetabular components during an expected clinical life span. Bioinert alumina ceramic (aluminum oxide) was introduced 3 decades ago for THR-bearing surfaces to improve performance and longevity. Alumina ceramic is entirely biostable and bioinert and has good mechanical properties. For correctly positioned alumina-on-alumina bearings, the annual linear wear rate has been reported to be 3.9 microm. Alumina heads have been successfully used in combination with polyethylene sockets, but as regards wear, the best results have been obtained with alumina-on-alumina bearings. In ceramic THR bearings, precise manufacture and contact surface geometry, including optimal clearance, are most important. For the currently available products, the component fracture risk is almost nonexistent (less than 1 per 1000). Metal-on-metal bearings were used in the early stage of THR surgery, although not all old designs were successful. More recent analyses of the early series have shown the advantages of metal-on-metal to be better and have led to a renaissance of this articulation. Initially, stainless steel was used because it was easy to manufacture and polish. Current metal-on-metal bearings are based on cobalt-chromium-molybdenum alloys with varying carbon contents. Such bearings are self-polishing. Linear wear rates remain at the level of a few microm a year. An improvement in technology has increased
Background and purpose Patella resurfacing during primary total knee arthroplasty (TKA) is disputed and new prosthesis designs have been introduced without documentation of their survival. We assessed the impact on prosthesis survival of patella resurfacing and of prosthesis brand, based on data from the Norwegian Arthroplasty Register. Patients and methods 5 prosthesis brands in common use with and without patella resurfacing from 1994 through 2009 were included n = 11,887. The median follow-up times were 9 years for patella-resurfaced implants and 7 years for implants without patella resurfacing. For comparison of prosthesis brands, also brands in common use with only one of the two treatment options were included in the study population (n = 25,590). Cox regression analyses were performed with different reasons for revision as endpoints with adjustment for potential confounders. Results We observed a reduced overall risk of revision for patella resurfaced (PR) TKAs, but the statistical significance was borderline (RR = 0.84, p = 0.05). At 15 years, 92% of PR and 91% of patella non resurfaced (NR) prostheses were still unrevised. However, PR implants had a lower risk of revision due to pain alone (RR = 0.1, p < 0.001), but a higher risk of revision due to loosening of the tibial component (RR = 1.4, p = 0.03) and due to a defective polyethylene insert (RR = 3.2, p < 0.001). At 10 years, the survival for the reference NR brand AGC Universal was 93%. The NR brands Genesis I, Duracon, and Tricon (RR = 1.4–1.7) performed statistically significantly worse than NR AGC Universal, while the NR prostheses e.motion, Profix, and AGC Anatomic (RR = 0.1–0.7), and the PR prostheses NexGen and AGC Universal (RR = 0.4–0.5) performed statistically significantly better. LCS, NexGen, LCS Complete (all NR), and Tricon, Genesis I, LCS, and Kinemax (all PR) showed no differences in this respect from the reference brand. A lower risk of revision (crude) was found for TKAs
Kreslavsky, Mikhail A.; Ivanov, Mikhail A.; Head, James W.
Because of atmospheric shielding and endogenic resurfacing, the population of impact craters on Venus is small (about a thousand) and consists of large craters. This population has been used in numerous studies with the goal of deciphering the geologic and geodynamic history of Venus, but the nearly spatially random nature of the crater population has complicated efforts to understand this history. Here we utilize the recent 1:15 M-scale global geological map of Venus (Ivanov, M.A., Head, J.W. . Planet. Space Sci. 59, 1559-1600) to help address this problem. The global geological map provides a stratigraphic sequence of units, and known areas where each unit is exposed on the planet. For each crater on Venus we identify the specific geological units predating and postdating the crater. We perform a statistical analysis of this set of observations with a buffered crater density approach, which rigorously and consistently takes into account the large size of craters and the fact that many craters are known to predate and/or postdate more than one unit. In this analysis we consider crater emplacement as random and resurfacing history as determined (although unknown). We obtain formal confidence intervals for the mean ages of geological units and the mean age differences between the pairs of units at the unit boundaries. We find that (1) size-frequency distributions of craters superposed on each unit are consistent with each other; (2) regional plains and stratigraphically older units have similar crater retention ages; (3) stratigraphically younger units have a mean crater retention age significantly younger than the regional plains. These findings are readily and consistently explained by global resurfacing scenarios and are difficult to reconcile with equilibrium resurfacing scenarios. Our analysis also shows that the latest recorded part of intensive resurfacing period lasted on the order of 10% of the mean surface age (tens of millions of years). The
Johnson D, Weiss WM. Basic arthroscopic principles. In: Miller MD, Thompson SR, eds. DeLee and Drez's Orthopaedic ... 11. Sanchez VMI, Meza AO. Hip arthroscopy. In: Miller MD, Thompson SR, eds. DeLee and Drez's Orthopaedic ...
Long-term outcome of Charnley low-friction arthroplasty in young active patients is impaired worldwide due to wear of the polyethylene (PE) component and osteolysis. In the late eighties, reports of possible low wear with some former metal on metal total hip arthroplasties led to the reintroduction of metallic bearings. The aims of this work were to examine the rationale for using metal on metal bearings in primary total hip arthroplasty (THA) and report preliminary results obtained with cementless Metasul -Alloclassic hips. From January 1994 to March 1997, 64 cementless primary Alloclassic-THA (grit-blasted titanium SL stems and CSF treaded cups) with 28 mm Metasul bearings were performed. Mean age at surgery was 60 years (range, 36-73). Diagnoses were usual, mainly primary osteoarthrosis in 70 p. 100 of the hips. Two bearing surfaces were exchanged for late dislocation at 2.6 and 2.9 years. Thus, 62 hips in 58 active patients (4 bilateral) were reviewed after a minimum 2-year follow-up (mean 3.2 years, range 24-66 months). Clinical results according to the Merle d'Aubigne and Charnley rating system were graded excellent or good in all 62 hips. Radiologically, calcar, atrophy and spot welds were noted in 93 p. 100 and 82 p. 100 of hips respectively. Proximal reactive and lucent lines and mild proximal stress shielding were observed in 8 p. 100 and 4.8 p. 100 of hips respectively. No osteolysis granuloma has thus far been observed in the vicinity of any component. Cobalt blood level remained normal, except in 6 cases due to occupational exposure (n=1), possible impingement (n=1) or an unknown cause (n=4). All elevated cobalt levels (range 7 to 25 microg/l) were nevertheless far below the toxic limit. Dislocation may be due either to the posterolateral surgical approach and/or early impingement with the first Metasul bearing design (head sleeve). Metasul acetabular component fixation is not restricted to only cementless metal-backing, unlike alumina-ceramic cups
Sibanda, Nokuthaba; Copley, Lynn P; Lewsey, Jim D; Borroff, Mick; Gregg, Paul; MacGregor, Alex J; Pickford, Martin; Porter, Martyn; Tucker, Keith; van der Meulen, Jan H
Background Hip and knee replacement are some of the most frequently performed surgical procedures in the world. Resurfacing of the hip and unicondylar knee replacement are increasingly being used. There is relatively little evidence on their performance. To study performance of joint replacement in England, we investigated revision rates in the first 3 y after hip or knee replacement according to prosthesis type. Methods and Findings We linked records of the National Joint Registry for England and Wales and the Hospital Episode Statistics for patients with a primary hip or knee replacement in the National Health Service in England between April 2003 and September 2006. Hospital Episode Statistics records of succeeding admissions were used to identify revisions for any reason. 76,576 patients with a primary hip replacement and 80,697 with a primary knee replacement were included (51% of all primary hip and knee replacements done in the English National Health Service). In hip patients, 3-y revision rates were 0.9% (95% confidence interval [CI] 0.8%–1.1%) with cemented, 2.0% (1.7%–2.3%) with cementless, 1.5% (1.1%–2.0% CI) with “hybrid” prostheses, and 2.6% (2.1%–3.1%) with hip resurfacing (p < 0.0001). Revision rates after hip resurfacing were increased especially in women. In knee patients, 3-y revision rates were 1.4% (1.2%–1.5% CI) with cemented, 1.5% (1.1%–2.1% CI) with cementless, and 2.8% (1.8%–4.5% CI) with unicondylar prostheses (p < 0.0001). Revision rates after knee replacement strongly decreased with age. Interpretation Overall, about one in 75 patients needed a revision of their prosthesis within 3 y. On the basis of our data, consideration should be given to using hip resurfacing only in male patients and unicondylar knee replacement only in elderly patients. PMID:18767900
Ali, Abdulemir; Lindstrand, Anders; Nilsdotter, Anna; Sundberg, Martin
Background and purpose Knee pain after total knee arthroplasty (TKA) is not uncommon. Patellar retention in TKA is one cause of postoperative knee pain, and may lead to secondary addition of a patellar component. Patellar resurfacing in TKA is controversial. Its use ranges from 2% to 90% worldwide. In this randomized study, we compared the outcome after patellar resurfacing and after no resurfacing. Patients and methods We performed a prospective, randomized study of 74 patients with primary osteoarthritis who underwent a Triathlon CR TKA. The patients were randomized to either patellar resurfacing or no resurfacing. They filled out the VAS pain score and KOOS questionnaires preoperatively, and VAS pain, KOOS, and patient satisfaction 3, 12, and 72 months postoperatively. Physical performance tests were performed preoperatively and 3 months postoperatively. Results We found similar scores for VAS pain, patient satisfaction, and KOOS 5 subscales at 3, 12, and 72 months postoperatively in the 2 groups. Physical performance tests 3 months postoperatively were also similar in the 2 groups. No secondary resurfacing was performed in the group with no resurfacing during the first 72 months Interpretation Patellar resurfacing in primary Triathlon CR TKA is of no advantage regarding pain, physical performance, KOOS 5 subscales, or patient satisfaction compared to no resurfacing. None of the patients were reoperated with secondary addition of a patellar component within 6 years. According to these results, routine patellar resurfacing in primary Triathlon TKA appears to be unnecessary. PMID:27212102
McGill, Kevin C.; Bush-Joseph, Charles A.; Nho, Shane J.
Microfracture is a marrow-stimulating technique used in the hip to treat cartilage defects associated with femoro-acetabular impingement, instability, or traumatic hip injury. These defects have a low probability of healing spontaneously and therefore often require surgical intervention. Originally adapted from the knee, microfracture is part of a spectrum of cartilage repair options that include palliative procedures such as debridement and lavage, reparative procedures such as marrow-stimulating techniques (abrasion arthroplasty and microfracture), and restorative procedures such as autologous chondrocyte implantation and osteochondral allograft/autografts. The basic indications for microfracture of the hip include focal and contained lesions typically less than 4 cm in diameter, full-thickness (Outerbridge grade IV) defects in weightbearing areas, unstable lesions with intact subchondral bone, and focal lesions without evidence of surrounding chondromalacia. Although not extensively studied in the hip, there are some small clinical series with promising early outcomes. Although the widespread use of microfracture in the hip is hindered by difficulties in identifying lesions on preoperative imaging and instrumentation to circumvent the femoral head, this technique continues to gain acceptance as an initial treatment for small, focal cartilage defects. PMID:26069544
D'Antonio, James A; Sutton, Kate
During the past decade, advances in total hip arthroplasty component design have produced implants with reliable clinical results in regard to fixation. The foremost unresolved challenge has been the development of bearing surfaces that can withstand the higher demands of younger and more active patients. New alternative bearings with superior wear characteristics that minimize debris include ceramic-on-ceramic, metal-on-metal, and highly cross-linked polyethylenes in combination with ceramic or metal. Alumina-on-alumina ceramic bearings are extremely hard and scratch resistant and provide superior lubrication and wear resistance compared with other bearing surfaces in clinical use. Survivorship revision for any reason for the alumina ceramic bearings at 10 years was significantly higher compared with metal-on-polyethylene. Bearings currently being studied because of their encouraging wear performance in the laboratory are an alumina matrix (82% alumina, 17% zirconia, 0.3% chromium oxide), zirconium oxide, and ceramic-on-cobalt-chromium.
Baker, Paul N; Petheram, Timothy; Dowen, Daniel; Jameson, Simon S; Avery, Peter J; Reed, Mike R; Deehan, David J
Patella resurfacing during primary total knee arthroplasty (TKA) remains controversial. Variation in published results for patella resurfacing may potentially be explained by differences in design between TKA brands. We interrogated NJR-PROMs data to ascertain whether there is an early functional benefit to resurfacing the patella, both overall and for each of the five most popular primary knee designs through use of the Oxford Knee Score. A total of 8103 resurfaced TKAs and 15,290 nonresurfaced TKAs were studied. There was a large variation in the proportion of knees undergoing patella resurfacing by brand (Nexgen=16% versus Triathlon=52%). Patellar resurfacing did not significantly influence the magnitude of improvement in overall knee function or anterior knee-specific function irrespective of TKA brand or for cruciate retaining versus sacrificing designs. Copyright © 2014 Elsevier Inc. All rights reserved.
Culton, Donna A.; Miller, Becky A.; Miller, Melissa B.; MacKuen, Courteney; Groben, Pamela; White, Becky; Cox, Gary M.; Stout, Jason E.
Nontuberculous mycobacteria are increasingly associated with cutaneous infections after cosmetic procedures. Fractionated CO2 resurfacing, a widely used technique for photorejuvenation, has been associated with a more favorable side effect profile than alternative procedures. We describe 2 cases of nontuberculous mycobacterial infection after treatment with a fractionated CO2 laser at a private clinic. Densely distributed erythematous papules and pustules developed within the treated area within 2 weeks of the laser procedure. Diagnosis was confirmed by histologic analysis and culture. Both infections responded to a 4-month course of a multidrug regimen. An environmental investigation of the clinic was performed, but no source of infection was found. The case isolates differed from each other and from isolates obtained from the clinic, suggesting that the infection was acquired by postprocedure exposure. Papules and pustules after fractionated CO2 resurfacing should raise the suspicion of nontuberculous mycobacterial infection. PMID:23628077
Bullock, M. A.; Grinspoon, David H.; Head, James W., III
We have developed a three-dimensional model of venusian resurfacing that employs Monte Carlo simulations of both impact cratering and volcanism. The model simulates the production of craters on Venus by using the observed mass distributions of Earth- and Venus-crossing asteroids and comets. Lava flows are modeled by an energy minimization technique to simulate the effects of local topography on the shape and extent of flows. The model is run under a wide range of assumptions regarding the scale and time evolution of volcanism on Venus. Regions of the parameter space that result in impact crater distributions and modifications that are currently observed will be explored to place limits on the possible volcanic resurfacing history of Venus.
The author who is inventor of EasyPeel then Laserpeel wants to introduce new ways to choose the right indications for patients asking for cosmetic surgery. A lifting is as if you take a shirt and want to reduce its size cutting it. A resurfacing is as if you put a shirt and want to iron it. A peeling was as if you changed the color and grain of the shirt. Laserpeel is as if you iron the shirt treated with amidon, transform the second hand shirt as new, up to date on with glance effect sand give it then a stretching disco new wave effect. So, indications of facial lifting decrease at the same speed at the increase of indications of 'LASERPEEL'. Laser CO2 resurfacing should reborn because the post redness appearance decreases in intensity and duration due to LASERPEEL. LASERPEEL should be considered too as a preventive therapy coupled with preventive treatment resulting from longevity tests.
Krakowski, Andrew C; Goldenberg, Alina; Eichenfield, Lawrence F; Murray, Jill-Peck; Shumaker, Peter R
Conventional management of debilitating pediatric scar contractures, including hand therapy and surgery, may often be beset by delayed treatment, suboptimal results, and additional surgical morbidity. Ablative fractional laser resurfacing is an emerging adjunctive procedural option for scar contractures because of its promising efficacy and safety profile. However, its use to improve function has not been studied in the pediatric population. Herein we report 2 pediatric patients with recalcitrant scar contractures, causing persistent functional deficits, treated with an ablative fractional laser protocol. Both patients experienced rapid and cumulative subjective and objective improvements in range of motion and function as measured by an independent occupational therapist without reported complications. We highlight ablative fractional laser resurfacing as a novel and promising tool in the management of function-limiting scar contractures in children and propose that the technique be incorporated into existing scar treatment paradigms, guided by future research.
Dawson, D. D.; Strom, R. G.; Schaber, G. G.
Two models have been proposed for the resurfacing history of Venus: (1) equilibrium resurfacing and (2) global resurfacing. The equilibrium model consists of two cases: in case 1, areas less than or equal to 0.03 percent of the planet are spatially randomly resurfaced at intervals of less than or greater than 150,000 yr to produce the observed spatially random distribution of impact craters and average surface age of about 500 m.y.; and in case 2, areas greater than or equal to 10 percent of the planet are resurfaced at intervals of greater than or equal to 50 m.y. The global resurfacing model proposes that the entire planet was resurfaced about 500 m.y. ago, destroying the preexisting crater population and followed by significantly reduced volcanism and tectonism. The present crater population has accumulated since then with only 4 percent of the observed craters having been embayed by more recent lavas. To test the equilibrium resurfacing model we have run several Monte Carlo computer simulations for the two proposed cases. It is shown that the equilibrium resurfacing model is not a valid model for an explanation of the observed crater population characteristics or Venus' resurfacing history. The global resurfacing model is the most likely explanation for the characteristics of Venus' cratering record. The amount of resurfacing since that event, some 500 m.y. ago, can be estimated by a different type of Monte Carolo simulation. To date, our initial simulation has only considered the easiest case to implement. In this case, the volcanic events are randomly distributed across the entire planet and, therefore, contrary to observation, the flooded craters are also randomly distributed across the planet.
Pozner, Jason N; Goldberg, David J
Light chemical peels and microdermabrasion have enjoyed recent popularity for the treatment of mild photoaging. However, clinical improvement from these modalities is often minimal from both a patient's and physician's perspective. Erbium:YAG lasers have been effective in treating mild to moderate photoaging, but the need for either regional or general anesthesia, as well as the significant post-treatment recovery period has limited its use. We sought to utilize a very low fluence approach to erbium:YAG laser resurfacing, with topical anesthesia, to ascertain its efficacy in treating mild to moderate photoaging. A total of 250 subjects aged 28-80 years with skin types 1-4 and mild to moderate facial rhytids were treated with topical anesthesia and subsequently one pass of a 2940 nm erbium:YAG laser, using between 5 and 17.5 J/cm2. In addition, 58 of the treated facial subjects underwent neck resurfacing with fluences between 5 and 15 J/cm2 and eight treated facial subjects underwent upper chest resurfacing at fluences of 5-7 J/cm2. A single treatment was received by 246 subjects; four subjects were treated a second time after a 1-month interval. Most subjects completely re-epithelialized by 3-4 days; healing time was depth dependent. Most subjects were able to start skin care regimens within 1-2 weeks after the procedure. Results were judged to be excellent in individuals with thin skin and good in subjects with thicker skin. One pass of low fluence erbium:YAG resurfacing, under topical anesthesia, was effective for the treatment of mild to moderate photoaging.
Gotkin, Robert H; Sarnoff, Deborah S; Cannarozzo, Giovanni; Sadick, Neil S; Alexiades-Armenakas, Macrene
Carbon dioxide (CO2) laser skin resurfacing has been a mainstay of facial rejuvenation since its introduction in the mid 1990s. Recently, a new generation of fractional or microablative CO2 lasers has been introduced to the marketplace. According to the concept of fractional photothermolysis, these lasers ablate only a fraction of the epidermal and dermal architecture in the treatment area. An array of microscopic thermal wounds is created that ablates the epidermis and dermis within very tiny zones; adjacent to these areas, the epidermis and dermis are spared. This microablative process of laser skin resurfacing has proven safe and effective not only for facial rejuvenation, but elsewhere on the body as well. It is capable of improving wrinkles, acne scars, and other types of atrophic scars and benign pigmented lesions associated with elastotic, sun-damaged skin. Because of the areas of spared epidermis and dermis inherent in a procedure that employs fractional photothermolysis, healing is more rapid compared to fully ablative CO2 laser skin resurfacing and downtime is proportionately reduced. A series of 32 consecutive patients underwent a single laser resurfacing procedure with the a new microablative CO2 laser. All patients were followed for a minimum of 6 months and were asked to complete patient satisfaction questionnaires; a 6 month postoperative photographic evaluation by an independent physician, not involved in the treatment, was also performed. Both sets of data were graded and reported on a quartile scale. Results demonstrated greater than 50% improvement in almost all patients with those undergoing treatment for wrinkles, epidermal pigment or solar elastosis deriving the greatest change for the better (>75%).
Grossman, A R; Majidian, A M; Grossman, P H
CO2 laser resurfacing of the face for fine wrinkles has gained great popularity over a short period of time. The use of the CO2 laser has proven to be effective in reducing or eliminating fine wrinkles. This tool in the surgeon's armamentarium has been added to those of dermabrasion and chemical peel. The theoretical advantage of the use of the CO2 laser for resurfacing has been better accuracy and reportedly more control of the depth of penetration. The use of the CO2 laser has been welcomed by many cosmetic surgeons. Until now, there have been few reported cases of complications with the use of the CO2 laser. To many, this would sound too good to be true; unfortunately, that is the case. The CO2 laser is a high-energy machine that can indeed cause thermal injury. This thermal injury can result in deep burns to the skin and hypertrophic scarring. We feel this is more common than is currently being reported, and we share our experience as a burn and wound care referral service. During an 18-month period, 20 consecutive patients were referred to our practice who had received injuries from the CO2 laser resurfacing laser. We present here in this review a summary of those injuries. The CO2 resurfacing laser is a very effective tool for the treatment of fine wrinkles, but it is not without the potential for serious complications. We urge caution with the use of the laser and prompt recognition and treatment of thermal injury to the skin.
Brown, Stephen R; Davies, William A; DeHeer, David H; Swanson, Alfred B
Because of the recent resurgence of interest in metal-on-metal bearing components for total hip arthroplasties, the long-term results of 153 consecutive McKee-Farrar total hip arthroplasties done in 129 patients by one surgeon between 1969 and 1973 were evaluated. A retrospective chart review provided patient demographics (age, gender, weight, primary diagnosis), revision dates, indications, and implant survival data. The average age of the patients at implantation surgery was 61 years (range, 28-85 years) and these patients were observed as many as 28 years. Primary diagnoses included osteoarthritis (49% of implants), rheumatoid arthritis (38%), and other conditions (13%). During the 28 years of followup, five implants were revised for infection and 14 implants were revised for aseptic loosening. Survivorship analysis of the McKee-Farrar prostheses had a 20-year probability of implant survivorship of 84%, and a 28-year implant survivorship of 74%. Excellent long-term results of the McKee-Farrar prosthesis were seen. Given the inherent problems associated with implant wear debris, especially polyethylene wear particles, second generation metal-on-metal bearing implants may offer a viable alternative to current designs. Their excellent long-term survival may infer particular suitability for use in younger patients.
Grenier, Stephanie; Donnelly, Patrick E.; Gittens, Jamila; Torzilli, Peter A.
Surface damage to articular cartilage is recognized as the initial underlying process causing the loss of mechanical function in early-stage osteoarthritis. In this study, we developed structure-modifying treatments to potentially prevent, stabilize or reverse the loss in mechanical function. Various polymers (chondroitin sulfate, carboxymethylcellulose, sodium hyaluronate) and photoinitiators (riboflavin, irgacure 2959) were applied to the surface of collagenase-degraded cartilage and crosslinked in situ using UV light irradiation. While matrix permeability and deformation significantly increased following collagenase-induced degradation of the superficial zone, resurfacing using tyramine-substituted sodium hyaluronate and riboflavin decreased both values to a level comparable to that of intact cartilage. Repetitive loading of resurfaced cartilage showed minimal variation in the mechanical response over a 7 day period. Cartilage resurfaced using a low concentration of riboflavin had viable cells in all zones while a higher concentration resulted in a thin layer of cell death in the uppermost superficial zone. Our approach to repair surface damage initiates a new therapeutic advance in the treatment of injured articular cartilage with potential benefits that include enhanced mechanical properties, reduced susceptibility to enzymatic degradation and reduced adhesion of macrophages. PMID:25468298
Kotlus, Brett S; Schwarcz, Robert M; Nakra, Tanuj
Laser resurfacing, performed at the same time as blepharoplasty, has most commonly been applied to the lower eyelid skin but can effectively be used on the upper eyelid to reduce rhytidosis and improve skin quality. The authors evaluate the safety and efficacy of this procedure. Fractional CO2 laser resurfacing was performed in conjunction with incisional upper blepharoplasty. The ultrapulsed laser energy was applied to the sub-brow skin, the upper medial canthal skin, and the pretarsal skin in 30 patients. Photos were obtained preoperatively and at 3 months. All patients demonstrated reduction in upper eyelid rhytidosis without any serious complications. Independent rhytidosis grading (0-4) showed a mean improvement of 42%. One patient experienced wound dehiscence that satisfactorily resolved without intervention. Upper eyelid laser resurfacing is effective and can be safely performed at the same time as upper blepharoplasty. This approach reduces or eliminates the need for medial incisions to address medial canthal skin redundancy and rhytidosis and it directly treats upper eyelid wrinkles on residual eyelid and infra-brow skin during blepharoplasty.
Yan, Yu; Dowson, Duncan; Neville, Anne
The second generation Metal-on-Metal (MoM) hip replacements have been considered as an alternative to commonly used Polyethylene-on-Metal (PoM) joint prostheses due to polyethylene wear debris induced osteolysis. However, the role of corrosion and the biofilm formed under tribological contact are still not fully understood. Enhanced metal ion concentrations have been reported widely from hair, blood and urine samples of patients who received metal hip replacements and in isolated cases when abnormally high levels have caused adverse local tissue reactions. An understanding of the origin of metal ions is really important in order to design alloys for reduced ion release. Reciprocating pin-on-plate wear tester is a standard instrument to assess the interaction of corrosion and wear. However, more realistic hip simulator can provide a better understanding of tribocorrosion process for hip implants. It is very important to instrument the conventional hip simulator to enable electrochemical measurements. In this study, simple reciprocating pin-on-plate wear tests and hip simulator tests were compared. It was found that metal ions originated from two sources: (a) a depassivation of the contacting surfaces due to tribology (rubbing) and (b) corrosion of nano-sized wear particles generated from the contacting surfaces.
Grammatopoulos, G; Pandit, H G; da Assunção, R; Taylor, A; McLardy-Smith, P; De Smet, K A; Murray, D W; Gill, H S
The orientation of the acetabular component is influenced not only by the orientation at which the surgeon implants the component, but also the orientation of the pelvis at the time of implantation. Hence, the orientation of the pelvis at set-up and its movement during the operation, are important. During 67 hip replacements, using a validated photogrammetric technique, we measured how three surgeons orientated the patient's pelvis, how much the pelvis moved during surgery, and what effect these had on the final orientation of the acetabular component. Pelvic orientation at set-up, varied widely (mean (± 2, standard deviation (sd))): tilt 8° (2sd ± 32), obliquity -4° (2sd ± 12), rotation -8° (2sd ± 14). Significant differences in pelvic positioning were detected between surgeons (p < 0.001). The mean angular movement of the pelvis between set-up and component implantation was 9° (sd 6). Factors influencing pelvic movement included surgeon, approach (posterior > lateral), procedure (hip resurfacing > total hip replacement) and type of support (p < 0.001). Although, on average, surgeons achieved their desired acetabular component orientation, there was considerable variability (2sd ± 16) in component orientation. We conclude that inconsistency in positioning the patient at set-up and movement of the pelvis during the operation account for much of the variation in acetabular component orientation. Improved methods of positioning and holding the pelvis are required.
Jin, Z M; Dowson, D; Fisher, J
Lubrication mechanisms and contact mechanics have been analysed for total hip joint replacements made from hard bearing surfaces such as metal-on-metal and ceramic-on-ceramic. A similar analysis for ultra-high molecular weight polyethylene (UHMWPE) against a hard bearing surface has also been carried out and used as a reference. The most important factor influencing the predicted lubrication film thickness has been found to be the radial clearance between the ball and the socket. Full fluid film lubrication may be achieved in these hard/hard bearings provided that the surface finish of the bearing surface and the radial clearance are chosen correctly and maintained. Furthermore, there is a close relation between the predicted contact half width and the predicted lubrication film thickness. Therefore, it is important to analyse the contact mechanics in artificial hip joint replacements. Practical considerations of manufacturing these bearing surfaces have also been discussed.
Scully, William F; Teeny, Steven M
This case report details the presentation, imaging results, and operative findings of a pseudotumor associated with a press-fit metal-on-polyethylene total hip arthroplasty (THA). An 80-year-old man presented approximately 7 years after undergoing THA with worsening