Introduction.
A-70-year old woman underwent uncomplicated total hip arthroplasty using a titanium modular stem with a 46mm CoCr femoral head, a titanium shell, and a metal linear (Wright Medical Technology). Eight years after implantation, she presented with a painful left hip. A pelvic radiograph revealed adequate positioning of both hip implants without any signs of wear of loosening. CT scanning confirmed the presence of a 5 × 5 cm soft tissue mass in the ilium above the cup component accompanied by the iliac fracture. The patient was diagnosed as having an
Introduction. Large head total hip arthroplasty (THA) reduces dislocation rates and provides a theooretically larger range of motion. We hypothesised that this would translate into greater improvement in functional scores when compared to 28mm metal-on-polyethylene THA at 5 years. We believe ours to be the first in vivo comparison study. Methods. A multi-surgeon case-control study in a District General Hospital. The study group consisted of 427 patients with 452 hips, the 38mm uncemented metal-on-metal articulation THA (M2A/Bi-metric, Biomet UK). The control group consisted of 438 age and sex-matched patients with 460 28mm metal-on-polyethylene articulation THA (Exeter/Exeter or Exeter/Duraloc - Stryker UK. All patients were assessed in a physiotherapist led Joint Review Service as part of their standard follow up, with functional scoring using Oxford Hip (scored 0–48) and WOMAC scores (0–100). Results. The demographics for the 38mm and 28mm groups gave mean ages of 65.8 years and 66.4 years, 40.4% and 39.3% male respectively. Pre-operative functional scores were comparable, with Oxford Hip scores of 23.3 and 26.8 respectively, WOMAC 49 compared to 53. At each review point there was no statistical difference in either Oxford or WOMAC scores and this was sustained at 5 yrs. Dislocation rates in the 38mm group were lower (2.9% vs. 5%) though not statistically significant (p = 0.111). Revision rate was significantly higher in the larger head group, primarily due to
BACKGROUND. The most common salvage of a failed metal-on-metal hip resurfacing is to remove both the femoral and acetabular resurfacing components and perform a total hip replacement. The other choices are to perform an acetabular or femoral only revision. A one or two piece acetabular component or a polyethylene bipolar femoral component that matches the retained metal resurfacing acetabular component is used. The considerations in favor of performing a one component resurfacing revision are maintaining the natural femoral head size, limiting the surgical effort for the patient and surgeon, and bone conservation. There are often favorable cost considerations with single component revision surgery. The reasons for femoral component revision are femoral neck fracture, femoral component loosening and an
Ceramic-on-polyethylene (COP) bearings have traditionally been reserved for younger patients that were at high risk of polyethylene wear requiring revision. With the 1999 advent of highly crosslinked polyethylene (XLP), wear with XLP has not been a cause for revision. Simulator studies have not shown a difference in wear comparing COP to metal-on-polyethylene (MOP). Therefore, and considering the additional cost of COP, we have until recently not needed COP. However, a 2012 report of 10 cases that developed an
Aims. Metal-on-metal total hip replacements (MoM THRs) are frequently revised. However, there is a paucity of data on clinical outcomes following revision surgery in this cohort. We report on outcomes from the largest consecutive series of revisions from MoM THRs and consider pre-revision factors which were prognostic for functional outcome. Materials and Methods. A single-centre consecutive series of revisions from MoM THRs performed during 2006–2015 was identified through a prospectively maintained, purpose-built joint registry. The cohort was subsequently divided by the presence or absence of symptoms prior to revision. The primary outcome was functional outcome (Oxford Hip Score (OHS)). Secondary outcomes were complication data, pre- and post-revision serum metal ions and modified Oxford classification of pre-revision magnetic resonance imaging (MRI). In addition, the study data along with demographic data was interrogated for prognostic factors informing on post-revision functional outcome. Results. 180 revisions in 163 patients were identified at a median follow-up of 5.48 (2–11.7) years. There were 152 (84.4%) in the symptomatic subgroup and 28 (15.6%) in the asymptomatic group. Overall median OHS improved from 29 to 37 with revision (P<0.001). Symptomatic patients experienced greater functional benefit (DOHS 6.5 vs. 1.4, p=0.012) compared to asymptomatic patients, though they continued to report inferior outcomes (OHS 36.5 vs 43, p=0.004). The functional outcome of asymptomatic patients was unaffected by revision surgery (pre-revision OHS 41, post-revision OHS 43, p=0.4). Linear regression analysis confirmed use of a cobalt-chrome (CoCr)-containing bearing surface (MoM or metal-on- polyethylene) at revision and increasing BMI were predictive of poor functional outcome (R. 2. 0.032, p=0.0224 and R. 2. 0.039, p=0.015 respectively). Pre- and post-revision serum metal ions and pre-revision MRI findings were not predictive of outcome. The overall complication rate was 36% (n=65) with a re-revision rate of 6.7%. The most common complication was ongoing
INTRODUCTION. The cup component of modern resurfacing systems are often coated creating a cementless press-fit fixation in the acetabulum based on surgical under-reaming, also enabling osseoconduction/integration. Due to the higher density of cortical bone along the antero-superior and postero-inferior regions of the acetabulum, the greatest forces occur between the anterior and posterior columns of the pelvis. This produces pinching of the implant that can result in deformation of the cup. Metal shell/modularpress-fit acetabular cups are susceptible to substantial deformation immediately after implantation. This deformation may affect the lubrication, producing point loading and high friction torques between the head and the cup that increase wear and may lead to head clamping and subsequent cup loosening. We sought to test a novel ceramic on ceramic (CoC) hip resurfacing system that should allay any concerns with the
Introduction. The bearing surfaces of ceramic-on-ceramic (CoC) total hip replacements (THR) show a substantially lower wear rate than metal-on-polyethylene (MoP) THR in-vitro. However, revision rates for CoC THR are comparable with MoP. Our hypothesis that an explanation could be
Ceramic-on-polyethylene (COP) bearings have traditionally been reserved for younger patients that were at high risk of polyethylene wear requiring revision. With the 1999 advent of highly crosslinked polyethylene (XLP), wear with XLP has not been a cause for revision. Simulator studies have not shown a difference in wear comparing COP to metal-on-polyethylene (MOP). Therefore, and considering the additional cost of COP, we have until recently not needed COP. However, a 2012 report of 10 cases that developed an
Introduction. Metal-on-polyethylene (MoP) is the most commonly used bearing couple in total hip replacements (THRs). Retrieval studies (Cooper et al, 2012, JBJS, Lindgren et al, 2011, JBJS) report
Introduction. Metal on metal hip arthroplasty continues to be controversial. Emerging evidence suggests that there are multiple modes of failure, and that the results of revision surgery are influenced by host and implant factors. Methods. This study compares a single surgeon series of hip resurfacings (Birmingham Hip Resurfacing {BHR}) and large diameter metal on metal total hip replacements (LDMOMTHR). Primary outcome measures included survival rates, failure secondary to histologically identified
Introduction. In recent years, an increasing number of reports related to
This study reports the mid-term results of a large bearing uncemented metal on metal total hip replacement (MOMHTHR) matched series using the Synergy stem and Birmingham modular head in 36 hips (mean follow up 61 months). All patients underwent clinical, metal ion and MRI assessment. Wear analysis was performed on retrieved heads using Redlux non-contact optical profilometry. Seven patients (19%) have undergone revision surgery. All revisions had two or more of either symptoms, high metal ions or an MRI suggestive of an
Introduction. We conducted independent wear analysis of retrieved metal on metal (MoM) hip components from around the world. All patients with resurfaced hips who developed
Background. The failure and subsequent withdrawal of the ASR device in both its resurfacing and THR form has been well documented. The National Joint Registry report of 2010 quoted figures of 12–13% failure at five years.
It's easy to say that hip resurfacing is a failed technology. Journals and lay press are replete with negative reports concerning metal-on-metal bearing failures, destructive pseudotumors, withdrawals and recalls. Reviews of national joint registries show revision risks with hip resurfacing exceeding those of traditional total hip replacement, and metal bearings fare worst among all bearing couples. Yet, that misses the point. Modern hip resurfacing was never meant to replace total hip replacement (THR). It was intended to preserve bone in young patients who would be expected to need multiple revisions due to their youth and high-demand activities. The stated goal of the developers of the Birmingham Hip Resurfacing (BHR) was to delay THR by 10 years. In the two decades that followed the release of BHR, this goal has been met and exceeded. Much has been learned about indications, patient selection, and surgical technique. We now know that this highly specialised, challenging procedure is best indicated in the young, active male with osteoarthritis, as a complementary, not competitive procedure, to THR. Resurfacing has many advantages. First and foremost, it saves bone, on the day of surgery, and over the next several years by preventing stress shielding. Dislocations are very rare. Leg length discrepancy and changes in offset are avoided. Post-operative activity, including heavy manual labor and contact sports, is unrestricted. More normal loading of the femur and joint stability has allowed professional athletes to regain their careers. Femoral side revisions, if necessary, are simple total hips, and dual mobility constructs allow one to keep the socket.
Total hip arthroplasty (THA) performed in patients aged 60 years and younger requires several decades of implant use under increased activity demands. Implant longevity and stable fixation are necessary for 30 or more years. The search for the optimal bearing combination for use in younger, high demand patients presents a challenge for orthopaedic surgeons as they consider the pros and cons of each material and interaction. A recent U.S. study of implant utilization trends that included 174 hospitals and 105,000 THA between 2001 and 2012 found that in 2012 93% of THA were cementless and 35% of THA bearings were ceramic-on-highly crosslinked polyethylene (HXLPE). Another recent article used the Nationwide Inpatient Sample from 2009 to 2012 to study bearing usage trends in 9265 primary THA in patients 30 years old or younger. The researchers observed ceramic-on-polyethylene as the most commonly bearing surface, used in 36% of patients, and which represented an increase from an earlier study of extremely young patients undergoing primary THA between 2006 to 2009, use of so-called hard-on-hard bearings decreased. Benefits of ceramic-on-HXLPE bearings are that unlike metal-on-polyethylene and metal-on-metal combinations, taperosis and
BACKGROUND. We originally performed metal-on-metal hip resurfacing using a Townley designed Vitallium Total Articular Replacement Arthroplasty (TARA) curved stemmed prosthesis. Neither the acetabular or femoral components were cemented or had porous coating. The bearing surfaces were consistently polar bearing. The surgical objectives were to preserve bone stock, maintain normal anatomy and mechanics of the hip joint and to approximate the normal stress transmission to the supporting femoral bone. The functional objectives were better sports participation, less thigh pain and limp, less perception of a leg length difference and a greater perception of a normal hip. Metal-on-metal was selected to conserve acetabular bone and avoid polyethylene associated osteolysis. Relatively few cases were performed until the Conserve Plus and later the Birmingham Hip Resurfacing systems became available. METHODS. We examined the results of metal-on-metal hip resurfacing in patient with at least 10 years of follow-up and an age less than 50 at the time of surgery. We did not have access to the Birmingham Prosthesis until 2006. We performed 101 TARA procedures and 397 Conserve Plus procedures for 357 patients. For the combined series the mean age was 43 and 62% of patients were male. 34 patients had a conventional total hip replacement on the contralateral side. We used both the anterolateral and posterior approaches. All acetabular components were placed without cement and all the Conserve Plus Femoral Components were cemented. RESULTS. There were no implant related failures with the TARA prosthesis. The average Harris Hip Score was 93. There were 2 revisions for femoral neck fracture at years 8 and 14 and one revision for infection. There was one dislocation but no instance of implant loosening. There were 29 (7%) revisions with the Conserve Plus Prosthesis. 14 revisions were for
The histopathology of periprosthetic tissues has been important to understanding the relationship between wear debris and arthroplasty outcome. In a landmark 1977paper, Willert and Semlitsch (1) used a semiquantitative rating to show that tissue reactions largely reflected the extent of particulate debris. Notably, small amounts of debris, including metal, could be eliminated without “overstraining the tissues” but excess debris led to deleterious changes. Currently, a plethora of terms is used to describe tissues from metal-on-metal (M-M) hips and corroded modular connections. We reviewed the evaluation and reporting of local tissue reactions over time, and asked if a dose response has been found between metal and tissue features, and how the use of more standardized terms and quantitative methodologies could reduce the current confusion in terminology. Methods. The PubMed database was searchedbetween 2000 and 2015 for papers using “metal sensitivity /allergy /hypersensitivity, Adverse Local Tissue Reaction (ALTR): osteolysis, metallosis, lymphocytic infiltration, Aseptic Lymphocytic Vasculitis-Associated Lesions (ALVAL),
Background. Previous studies have suggested that the modular junction of metal on metal (MoM) total hip replacements (THR) is an important source of metallic debris. Methods. We carried out a prospective study using custom techniques to analyse one of the largest collections of failed contemporary MoM devices in the world. All explants from patients who had suffered