Objectives

Metal-on-metal hip resurfacing (MOMHR) is available as an alternative option for younger, more active patients. There are failure modes that are unique to MOMHR, which include loosening of the femoral head and fractures of the femoral neck. Previous studies have speculated that changes in the vascularity of the femoral head may contribute to these failure modes. This study compares the survivorship between the standard posterior approach (SPA) and modified posterior approach (MPA) in MOMHR.

It has been suggested that metal ion levels are indicative of in vivo bearing performance of metal-on-metal hip replacements. A cobalt or Chromium level of 7μg/L or higher is proposed to be indicative of a bearing malfunction and the need for clinical intervention. Component design, size, acetabular orientation, patient gender and activity level have been suggested as factors leading to accelerated wear and elevated metal ions. The contact patch to rim (CPR) distance is a calculation that describes the distance from the point where a theoretical joint reaction force intersects the cup to the acetabular rim for a patient in standing position, dependent on the coverage, size, and orientation of the acetabular component. It has been suggested that CPR distance determines the hip joint susceptibility to edge loading, and the risk for increased wear and high ion levels (Langton et al JBJS Br 91: 2009). This study examined the effects of patient activity, gender, and CPR distance on serum metal ion concentrations in a series of patients treated with one type of metal on metal hip resurfacing arthroplasty (MMHRA) performed by one surgeon.

182 patients (73 females and 109 males)with a unilateral Conserve Plus (WMT, TN USA) MMHRA and had who had provided blood for metal ion analysis data from December 2000 to June 2011 were retrospectively studied. Only measurements made more than 12 months after surgery were included in order to exclude hips that had yet to reach steady-state wear. For patients with multiple draws, the most recent qualifying draw was used. Activity level was assessed by the UCLA activity score. The mean age was 51.5 years (20.0 to 77.5 years). The mean follow-up time for the last blood draw was 70 months (range, 12 to 165). Serum cobalt (CoS) and chromium (CrS) levels were analyzed using inductively coupled plasma mass spectrometry in a specialized trace element lab. Using acetabular abduction and anteversion measured by EBRA, component size, and reported coverage angle of the acetabular component, the CPR distance was calculated as previously described. Multiple logistic regression was performed to identify significant relationships between high metal ion levels (7 μg/L or greater) and gender, activity and CPR distance.

The median CoS level for the entire cohort was 1.13 μg/L (range, 0.15 to 175.30), and the median CrS level was 1.49 μg/L (range, 0.06 to 88.70). The average CPR distance was 13.8 mm (range, 3.2 to 22.1). There was a significant association between low CPR values and CoS and CrS. There was a 37-fold increase in the risk of CoS >7μg/L (p=0.005) and 11-fold increase in the risk of CrS > 7μg/L (p=0.003) when CPR distance was 10 mm or less. No associations were shown for gender and UCLA activity scores.

CPR distance was found to be a reliable predictor of ion levels > 7μg/L and appears to be a useful indicator to evaluate the multi-factorial process of edge-loading and wear. Patients with a low CPR distance should be monitored for increased metal ion levels.

Congenital dislocation of the patella requires early surgical reduction for better walking. We studied the results of our combined soft tissue procedures performed on 6 knees in 5 children. The age at surgery ranged from 3 to 12 years with a mean of 5.3 years. The follow-up period ranged from 3 to 9 years with a mean of 5.1 years. Underlying diagnoses were fibular hemimelia in one knee, congenital dislocation of the knee which was reduced without surgery in two, and nail-patella syndrome in three.

The surgical procedures involve lateral release to reduce the patella, resection and tightening of medial capsule and semitendinosus transfer to the patella. Quadriceps lengthening was also required in two knees. After lateral release, the semitendinosus tendon is detached at its insertion, and is pulled out at the musculotendinous junction. Then, the tendon is pulled down to the patella under the skin, and is passed through a drilled tunnel in the patella from superomedially to inferolaterally. Finally, the tendon is reflected and sutured to the anterior surface of the patella under sufficient tension at 20 degrees of knee flexion.

The five knees operated on under 5 years of age were well reduced and well positioned in the femoral groove at follow-up. The one knee operated on at the age of 12 years showed subluxation. Episodes of giving way and abnormal gait disappeared after surgery in all the patients. Femoral groove depth increased after surgery. The improvement in the young infants was better than in older child. We found that the transferred semitendinosus tendon acts well to maintain good patellar position during knee flexion.

We conclude that early surgical reduction is extremely important and it will stimulate proper development of femoral groove, and semitendinosus transfer combined with lateral release is effective to keep the patella in its groove during knee flexion.