Aims. Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. Methods. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. ‘Controls’ were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size. Results. Using a previously-reported ALVAL classification, the majority of pseudotumour-positive caseswere found to have intermediate-grade group 2 (n = 10; 63%) or group 3 (n = 4; 25%) histological findings. Two further patients (13%) had high-grade group 4 lesions. HLA-DQB1*05:03:01 (p = 0.0676) and HLA-DRB1*14:54:01 (p = 0.0676) alleles were significantly associated with a higher risk of pseudotumour formation, while HLA-DQA1*03:01:01 (p = 0.0240), HLA-DRB1*04:04:01 (p = 0.0453), HLA-C*01:02:01 (p = 0.0453), and HLA-B*27:05:02 (p = 0.0855) were noted to confer risk reduction. Conclusion. These findings confirm the association between specific HLA genotypes and the risk of pseudotumour development around MoM hip resurfacings. Specifically, the two ‘at risk’ alleles (DQB1*05:03:01 and DRB1*14:54:01) may hold clinical value in preoperative screening and prospective surgical decision-making. Cite this article: Bone Jt Open 2023;4(3):182–187

Background

We have previously described the relationship between wear rates of MOM components and soft tissue necrosis. In this study we investigated the link between wear rates, metal ion concentrations and osteolysis.

Hip resurfacing may be a useful surgical procedure when patient selection is correct and only implants with superior performance are used. In order to establish a body of evidence in relation to hip resurfacing, pseudotumour formation and its genetic predisposition, we performed a case-control study investigating the role of HLA genotype in the development of pseudotumour around MoM hip resurfacings. All metal-on-metal (MoM) hip resurfacings performed in the history of the institution were assessed. A total of 392 hip resurfacings were performed by 12 surgeons between February 1st 2005 and October 31st 2007. In all cases, pseudotumour was confirmed in the preoperative setting on Metal Artefact Reduction Sequencing (MARS) MRI. Controls were matched by implant (ASR or BHR) and absence of pseudotumour was confirmed on MRI. Blood samples from all cases and controls underwent genetic analysis using Next Generation Sequencing (NGS) assessing for the following alleles of 11 HLA loci (A, B, C, DRB1, DRB3/4/5, DQA1, DQB1, DPB1, DPA1). Statistical significance was determined using a Fisher's exact test or Chi-Squared test given the small sample size to quantify the clinical association between HLA genotype and the need for revision surgery due to pseudotumour. Both groups were matched for implant type (55% ASR, 45% BHR in both the case and control groups). According to the ALVAL histological classification described by Kurmis et al., the majority of cases (63%, n=10) were found to have group 2 histological findings. Four cases (25%) had group 3 histological findings and 2 (12%) patients had group 4 findings. Of the 11 HLA loci analysed, 2 were significantly associated with a higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) and 4 were noted to be protective against pseudotumour formation (DQA1*03:01:01, DRB1*04:04:01, C*01:02:01, B*27:05:02). These findings further develop the knowledge base around specific HLA genotypes and their role in the development of pseudotumour formation in MoM hip resurfacing. Specifically, the two alleles at higher risk of pseudotumour formation (DQB1*05:03:01 and DRB1*14:54:01) in MoM hip resurfacing should be noted, particularly as patient-specific genotype-dependent surgical treatments continue to develop in the future

Aims. The Birmingham Hip Resurfacing (BHR) was introduced in 1997 to address the needs of young active patients using a historically proven large-diameter metal-on-metal (MoM) bearing. A single designer surgeon’s consecutive series of 130 patients (144 hips) was previously reported at five and ten years, reporting three and ten failures, respectively. The aim of this study was to extend the follow-up of this original cohort at 25 years. Methods. The study extends the reporting on the first consecutive 144 resurfacing procedures in 130 patients for all indications. All operations were undertaken between August 1997 and May 1998. The mean age at operation was 52.1 years (SD 9.93; 17 to 76), and included 37 female patients (28.5%). Failure was defined as revision of either component for any reason. Kaplan-Meier survival analysis was performed. Routine follow-up with serum metal ion levels, radiographs, and Oxford Hip Scores (OHSs) was undertaken. Results. Overall implant survival was 83.50% (95% confidence interval (CI) 0.79 to 0.90) at 25 years, and the number at risk was 79. Survival in male patients at 25 years was 89.5% (95% CI 0.83 to 0.96) compared to 66.9% for female patients (95% CI 0.51 to 0.83). Ten additional failures occurred in the period of ten to 25 years. These involved an adverse reaction to metal debris in four patients, a periprosthetic femoral neck fracture affecting five patients, and aseptic loosening in one patient. The median chromium levels were 49.50 nmol/l (interquartile range (IQR) 34 to 70), and the median cobalt serum levels were 42 nmol/l (IQR 24.50 to 71.25). The median OHS at last follow-up was 35 (IQR 10 to 48). During the 25-year study period, 29 patients died. Patient survival at 25 years was 75.10% (95% CI 0.67 to 0.83). Conclusion. This study demonstrates that MoM hip resurfacing using the BHR provides a durable alternative to total hip arthroplasty (THA), particularly in younger male patients with osteoarthritis wishing to maintain a high level of function. These results compare favourably to the best results for THAs. Cite this article: Bone Joint J 2024;106-B(6):540–547

Introduction: We have previously shown an association between whole blood metal particles from unilateral metal on metal (MOM) hip resurfacing and reduced CD8+ T cells (JBJS Br April 2006). There are no reported clinical effects of these findings. Certain patients maybe at high risk of developing clinical effects; one such group is patients with bilateral hip resurfacings. There are no published studies of bilateral hip resurfacings. Our aim was to investigate the association between whole blood metal ions and reduced CD8+ T cells in a follow up cohort of bilateral MOM hip resurfacings. Method : Peripheral blood samples were analysed from patients with bilateral MOM hip resurfacings (n=25), unilateral hip resurfacings (n=34) and metal on polyethylene (MOP) hip arthroplasty (n=34). Samples were analysed for: lymphocyte subsets (FACS analysis); whole blood cobalt and chromium ion levels (using inductively-coupled mass spectrometry). Xrays revealed all hip components were well fixed. Results : When compared to patients with standard MOP hip replacements there was a 30% reduction in both the bilateral and unilateral resurfacing groups’ level of CD8+ cells (T cytotoxic) (p=0.010). All other lymphocyte subgroups were not significantly different. There was evidence of a threshold effect of raised metal ions and reduced CD8+ T cells but no evidence of a dose-response relationship. Conclusions : Bilateral MOM hip resurfacing is associated with a reduced CD8+ T cell count when compared to MOP hip arthroplasty. This association is not significantly different from the levels seen after unilateral MOM hip resurfacing

Metal-on-metal hip arthroplasty has fallen out of favor because of complications arising from the articulation, namely metal sensitivity and accelerated wear. These complications can lead to early/mid-term failures from pain, osteolysis, implant loosening, and pseudotumor formation. However, it has become clearer that MOM total hip arthroplasty behaves differently from MOM hip resurfacing, due to the additional junctions present in the total hip arthroplasty setting. Garbuz et al have demonstrated in a randomised controlled trial that MOM THA has significantly higher metal ion levels than MOM hip resurfacing. Clinical results of a MOM THA compared with a MOM HR using the same articulation also demonstrate significantly poorer results with the THA. Newer literature has also shown that corrosion occurs at the taper junction of a THA due to the dissimilar metals. These corrosion products are likely what are causing a higher incidence of adverse local tissue reactions. Because a hip resurfacing implant is a monoblock ball, there is no taper junction of dissimilar metals that has the potential for corrosion. National registry studies have also demonstrated a difference in the survival curves of MOM THA vs. hip resurfacing. MOM HR, in select patient groups, has a lower revision rate at 10 years than traditional metal-on-poly THA. Thus, to eliminate MOM hip resurfacing as a treatment option is akin to “throwing the baby out with the bathwater”, which the presenter deeply opposes

Introduction. Edge loading is a common wear mechanism in Metal-on-Metal (MOM) hip resurfacing and is associated with higher wear rates and the incidence of pseudotumour. The purpose of this study was to develop a method to investigate the contributions of patient, surgical and implant design variables on the risk of edge loading. Method. We created a mathematical model to calculate the distance from the head-cup contact patch to the rim of the cup and used this to investigate the effect of component position, specific design features and patient activity on the risk of edge loading. We then used this method to calculate the contact patch to rim distance (CPRD) for 160 patients having undergone revision of their MOM hip resurfacing in order to identify any possible associations. Results. We identified several variables that reduce the CPRD and increase the risk of edge loading, including; increased cup anteversion and inclination, activities involving increased hip flexion, reduced clearance, reduced hip diameter and reduced cup arc angle. We also determined the threshold cup orientation for edge loading for five resurfacing designs (Figure 1). In patients with failed MOM hip resurfacings, there was a significant correlation between CPRD and both component wear rates (Figure 2) and blood metal ion levels (all p < 0.005). The ASR was associated with increased wear, reduced CPRD, and increased prevalence of edge loading (all p < 0.05). Conclusions. Edge loading is common and difficult to avoid in MOM hip resurfacing. Whilst some designs, such as the ASR, are more susceptible to edge loading, all are unforgiving of suboptimal cup position. Furthermore, common activities involving flexion of the hip result in edge loading even in patients with a well-positioned cup

Introduction: There is concern that cobalt and chromium ions released from metal on metal (MOM) bearing surfaces may have an adverse effect on renal function over time. Aim: The aim of this study was to assess renal function in patients who have had MOM hip resurfacing at between two and seven years follow up. Methods and Materials: Seventy seven patients had MOM hip resurfacing performed in our unit between 1st March 2001 and 28th February 2006. All patients were invited to present for an up to date renal profile. Of these, 59 patients volunteered a sample (76%). Forty-eight were male and eleven were female. Ages ranged from 33 to 63 years (mean 59 years). Nine patients had hypertension pre-operatively. No other risk factors for renal dysfunction were present in our patient population. Results: Pre-operative urea and creatinine levels ranged from 2.9 to 10.6mmol/L (mean 6.4mmol/L) and 50 umol/L to 121umol/L (mean 77.2umol/L) respectively. Post-operative urea and creatinine levels ranged from 5.3mmol/L to 6.3mmol/L (mean 5.3mmol/L) and 62umol/L to 75umol/L (mean 67umol/L) respectively. Two patients who had normal serum creatinine profiles pre-operatively showed mildly elevated serum creatinine levels at most recent follow up. Conclusion: Medium term follow up of patients following MOM hip resurfacing does not suggest evidence for the development of renal impairment in this patient population

Introduction and aim: We have previously shown suppressed levels of CD8+ T lymphocytes in patients with metal-on-metal (MOM) hip resurfacing compared to patients with metal on polyethylene hip replacements. Functional assessment of T lymphocytes may help to determine the importance of this CD8+ reduction following hip resurfacing. Method: We isolated peripheral blood mononuclear cells (PBMC) from patients with unilateral MOM hip resurfacing (n=7) and healthy controls without hip replacement (n=8). Patients with hip resurfacing had excellent Harris Hip scores (mean 90) and well fixed components on radiographs. Whole blood and serum levels of Cobalt (Co) and Chromium (Cr) ions were measured with Inductively-Coupled Mass Spectrometry. T cell function was assessed by. cell proliferation assays (3H-thymidine incorporation) and. cytokines secretion (ELISA) following exposure to antigen challenge using Tetanus Toxoid and polyclonal mitogen phytohaemoagglutinin (PHA). Results: Co and Cr ion levels were significantly elevated in the MOM hip resurfacing group compared to the control group (p< 0.001). Proliferation rates of T cells were comparable between the two groups over one week, but interferon-gamma (IFN-γ) production in the MOM hip resurfacing group was significantly decreased (p < 0.05), when compared to the control group. Conclusion: IFN-γ is normally produced by CD8+ (T cytotoxic cells) and CD4+ (T helper 1 cells) in response to viral infection and high levels of IFN-γ is associated with autoimmune disease. Raised levels of metal ions from hip resurfacing reduces the production of IFN-γ following stimulation with PHA. This finding has been patented for potential therapeutic use through MRC technology

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. Cite this article: Bone Joint J 2013;95-B:1626–31

Introduction: Laboratory simulator and clinical retrieval studies of metal-on-metal (MOM) total hip replacements have shown that the metallic alloy, the femoral head radius, the clearance between the acetabular cup and femoral head and the cup thickness can influence the contact mechanics, the lubrication and the wear of the articulation. MOM hip resurfacing procedures have received significant attention recently. The purpose of the present study was to compare the contact mechanics between a MOM hip resurfacing implant and a MOM total hip replacement under identical conditions. Materials and Methods: A 50mm diameter DUROM. TM. MOM hip resurfacing prosthesis and a 28mm diameter Metasul. TM. MOM bearing system (Centerpulse Orthopedics, a Zimmer Company, Winterthur, Switzerland) were investigated. All implants were manufactured from wrought-forged high carbon cobalt chromium alloy (Pro-tasul 21WF. TM. ). The diameters of the DUROM. TM. femoral head and acetabular cup were 50mm and 50.145mm respectively, and the corresponding wall thickness of the acetabular component was around 4mm. The diameters of the Metasul. TM. femoral head and acetabular cup were 28mm and 28.12mm. Three-dimensional finite element models were created to simulate the contact between the bearing surfaces of both the femoral head and the acetabular cup fixed to a three dimensional anatomically positioned pelvic and femoral bone consisting of both cortical (with 1mm thickness) and cancellous regions. The load applied to both models was 3200N. Results: The maximum contact pressure at the bearing surfaces was found to be around 22MPa for the DUROM. TM. and the contact area between the femoral and acetabular components was predicted to be 237mm. 2. For the Metasul. TM. bearing under identical conditions, the maximum contact pressure and the contact area predicted were approximately 47MPa and 74mm. 2. respectively. Discussion: A large reduction in the contact pressure, which should improve overall tribological performances, was noted for the DUROM. TM. hip resurfacing prosthesis, as compared with the Metasul. TM. bearing. The main reasons for this reduction were the large diameter of the articulation and the small acetabular cup thickness of the DUROM. TM. system. In contrast, the Metasul. TM. bearing has a smaller head diameter, and relies on a polyethylene backing underneath the metallic cup inlay to reduce the contact pressure at the articulating surfaces

Soft tissue reactions following metal-on-metal arthroplasty of the hip have been under discussion in recent times. The phenomenon has been observed since the advent of arthroplasty, but the particular nature of metal-on-metal (MoM) resurfacing or total hip arthroplasty (THA), and the associated shedding of metal particles in high wear states, appears to excite a more aggressive response. Recent reports suggest involvement of muscle groups on a wide scale, and some cases of neurovascular involvement. It is not known which reactions require widespread muscle excision, and which cases may be adequately addressed by bearing exchange alone. We report three cases of soft tissue reaction (pseudotumour) following MoM hip resurfacing all managed with revision to ceramic-on-ceramic (CoC) THA with minimal soft tissue excision. All patients were female with ages at original operation of 49, 52 and 58 years. Time to revision surgery was 85, 28 and 66 months respectively. Prosthesis revision resulted in progressive and satisfactory resolution of the pseudotumour. We propose that in the early stages, pseudotumour following MoM hip resurfacing can be adequately managed with revision to ceramic-bearing THA with minimal soft tissue excision, rather than revision with extensive soft tissue debridement that has been recently described

Objectives. We have encountered patients who developed large joint fluid collections with massive elevations in chromium (Cr) and cobalt (Co) concentrations following metal-on-metal (MoM) hip arthroplasties. In some cases, retrieval analysis determined that these ion concentrations could not be explained simply by the wear rates of the components. We hypothesized that these effects may be associated with aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL). Patients and Methods. We examined the influence of the ALVAL grade on synovial fluid Co and Cr concentrations following adjustment for patient and device variables, including volumetric wear rates. Initially restricting the analysis to include only patients with one MoM hip resurfacing device, we performed multiple regression analyses of prospectively collected data. We then repeated the same statistical approach using results from a larger cohort with different MoM designs, including total hip arthroplasties. Results. In the resurfacing cohort (n = 76), the statistical modelling indicated that the presence of severe ALVAL and a large fluid collection were associated with greater joint fluid Co concentrations after adjustment for volumetric wear rates (p = 0.005). These findings were replicated in the mixed implant group (n = 178), where the presence of severe ALVAL and a large fluid collection were significantly associated with greater fluid Co concentrations (p < 0.001). Conclusion. The development of severe ALVAL is associated with elevations in metal ion concentrations far beyond those expected from the volumetric loss from the prosthetic surfaces. This finding may aid the understanding of the sequence of events leading to soft-tissue reactions following MoM hip arthroplasties. Cite this article: D. J. Langton, R. P. Sidaginamale, T. J. Joyce, J. G. Bowsher, J. P. Holland, D. Deehan, A. V. F. Nargol, S. Natu. Aseptic lymphocyte-dominated vasculitis-associated lesions are related to changes in metal ion handling in the joint capsules of metal-on-metal hip arthroplasties. Bone Joint Res 2018;7:388–396. DOI: 10.1302/2046-3758.76.BJR-2018-0037

The purpose of this study was to evaluate early results of a new, as yet undescribed, minimally invasive, gluteus maximus splitting posterior approach for metal on metal (MOM) hip resurfacing. Surgical approach is described, backed with a video of the procedure. Results of the first 100 cases are presented. A new, minimally invasive, gluteus maximus splitting approach is described. The single incision approach allowed MOM hip resurfacing to be carried out through an incision ranging 8.25 ± 2.25cm. Release of gluteus maximus insertion to femur is not necessary. Intra-operative fluoroscopy is not necessary. Special acetabular reamer handle and acetabular impactor had to be used for accurate acetabular component placement. Femoral neck targeting device, suitable for minimally invasive surgery was used for accurate placement of femoral neck centring pin. This allowed for accurate placement of femoral component. Results of 100 patients who had undergone MOM hip resurfacing are presented: Average review was 2 years, range 22–46 months. Average age of patient was 57 years; range 55 ± 22 years. Average BMI was 27; range 29.95 ± 11.85. Average blood loss was 270ml; range 450 ± 350ml. Average incision was 8cm; range 8.25 ± 2.25cm. Operation time was no longer than conventional open posterior approach. Early discharge at day 3, post-op was possible and patients were able to walk without aids at 3 weeks, post-op. There were no cases of infection, nerve damage, dislocation or malposition of implant. There was no case of hypertrophic bone formation. There was one fracture neck of femur at 6 weeks post-op. Minimally invasive hip resurfacing can be carried out successfully using a new gluteus maximus splitting approach with excellent early results and no complications apart from 1% risk of fracture neck of femur

Metal-on-metal (MOM) bearings after total hip arthroplasty are known to elevate the serum concentrations of metal ions, raising concerns about the long-term effects. One potential modifier of ion release is the bearing diameter used. Resurfacing MOM bearings have a large surface area available for corrosion compared to the typical bearing size of 28 mm in total hip replacement (THR) but may benefit from improved lubrication and reduced production of corrodible wear debris. The net effect of these two variables on metal ion release is unknown. In this study, we compared the level of ion release in patients after large bearing MOM hip resurfacing arthroplasty with patient after small bearing MOM THR. We measured the serum cobalt and chromium levels from 22 patients with large bearing diameter MOM hip resurfacing arthroplasty (Cormet 2000 and Birmingham Hip Resurfacing) and compared them to the serum cobalt and chromium levels of 22 patients with small bearing diameter (28 mm) MOM THR (Ultima). Patients were prospectively matched for activity level, body mass and date after surgery at blood sampling. All were at least 6 months after surgery. We found the median cobalt and chromium levels after hip resurfacing arthroplasty to be 7.6 times normal (median 38 nmol/L, range 14 to 144 nmol/L) and 10.5 times normal (median 53 nmol/L, range 25 to 165 nmol/ L) respectively. This is compared to 4.4 times normal (median 22 nmol/L, range 15 to 87 nmol/L) for cobalt and 3.8 times normal (median 19 nmol/L, range 2 to 58 nmol/L) for chromium after 28 mm MOM THR (p=0.0021 and p< 0.0001). Conclusion: Large diameter MOM bearings result in greater release of cobalt and chromium ions than do small diameter MOM bearings. This may be of relevance when the potential effects of long-term exposure to elevated these metal ions is considered

Introduction: Metal-on-metal (MOM) bearings after total hip arthroplasty are known to elevate the serum concentrations of metal ions, raising concerns about the long term effects. One potential modifier of ion release is the bearing diameter used. Resurfacing MOM bearings have a large surface area available for corrosion compared to the typical bearing size of 28 mm in total hip replacement (THR) but may benefit from improved lubrication and reduced production of corrodible wear debris. The net effect of these two variables on metal ion release is unknown. In this study, we compared the level of ion release in patients after large bearing MOM hip resurfacing arthroplasty with patient after small bearing MOM THR. Methods: We measured the serum cobalt and chromium levels from 22 patients with large bearing diameter MOM hip resurfacing arthroplasty (Cormet 2000 and Birmingham Hip Resurfacing) and compared them to the serum cobalt and chromium levels of 22 patients with small bearing diameter (28 mm) MOM THR (Ultima). Patients were prospectively matched for activity level, body mass and date after surgery at blood sampling. All were at least 6 months after surgery. Results: We found the median cobalt and chromium levels after hip resurfacing arthroplasty to be 7.6 times normal (median 38 nmol/L, range 14 to 144 nmol/L) and 10.5 times normal (median 53 nmol/L, range 25 to 165 nmol/L) respectively. This is compared to 4.4 times normal (median 22 nmol/L, range 15 to 87 nmol/L) for cobalt and 3.8 times normal (median 19 nmol/L, range 2 to 58 nmol/L) for chromium after 28 mm MOM THR (p=0.0021 and p< 0.0001). Discussion: We concluded that large diameter MOM bearings result in greater release of cobalt and chromium ions than do small diameter MOM bearings. This may be of relevance when the potential side-effects of long-term exposure to elevated these metal ions is considered. It is not known to what extent this difference is due to corrosion of the component surfaces or of the wear particles produced

Background:. Failed metal-on-metal (MOM) bearings and corrosion reactions are being increasingly encountered with little to guide evaluation for periprosthetic joint infection (PJI). Our purpose was to determine the utility of the erythrocyte sedimentation rate (ESR), C-Reactive Protein (CRP), synovial fluid white blood cell (WBC) count and differential (%PMN) in diagnosing PJI in failed hips with a MOM bearing or corrosion. Methods:. 150 revision hips (92 MOM total hip arthroplasties, 19 MOM hip resurfacings, 30 non-MOM bearings with corrosion and 9 full-thickness bearing surface wear with metallosis) were retrospectively evaluated. Nineteen patients were diagnosed as infected using MSIS criteria. Mean laboratory values were compared between groups and receiver operator characteristic curves (ROC) generated with an area under the curve (AUC) to determine test performance and optimal cutoffs. Results:. The synovial fluid WBC count was judged to be inaccurate secondary to cellular debris in 47 of the 141 patients where one was obtained (33.3%); a WBC count was still reported, however, in 35 hips, 11 of which were falsely positive. Infected patients had significantly higher mean serum ESR, CRP, synovial fluid WBC count, and differential (p < 0.0001, all). The best tests for diagnosis of PJI were the synovial fluid WBC count (AUC=98%, optimal cutoff 4350 WBC/μL), and differential (AUC = 90%, optimal cutoff 85% PMN). Diagnostic performance of the synovial fluid WBC count and differential improved with fewer false positives after excluding inaccurate samples. The ESR and CRP both had good sensitivity. Conclusions:. The diagnosis of PJI is extremely difficult in patients with MOM bearings or corrosion and the synovial fluid WBC count can frequently be falsely positive and should be relied upon only if a manual count is done and if a differential can be performed. A more aggressive approach to preoperative evaluation for PJI is recommended in these patients to allow for careful evaluation of the synovial fluid specimen, the integration of synovial fluid culture results, and repeat aspiration if necessary

The purpose of this study was to evaluate early results of a new as yet not described minimal invasive posterior gluteus maximus splitting approach for total hip arthroplasty (THA) and also metal on metal hip resurfacing. A new minimal invasive gluteus maximus splitting posterior approach is described backed up with intra-operative videos. This single incision approach allowed THA to be carried out through an incision ranging from 5.5 cm. to 9 cm. and metal on metal (MOM) resurfacing through an incision ranging from 7.5 cm. to 10 cm. Intra-operative fluoroscopy is not needed. The patients were not selected according to body mass index (BMI). All patients are suitable for this approach except for severely obese patients. 30 patients underwent THA (both cemented and uncemented) and 20 underwent MOM resurfacing. Early results at average 6 months indicate low post-operative pain scores, low blood loss (less than 5% needing transfusion), early mobilisation and discharge from hospital. Patients also returned to normal activities early with excellent cosmetic results and high patient satisfaction scores. There were no complications. THA and MOM hip resurfacing can safely be done through a minimally invasive gluteus maximus splitting approach with excellent early results without any complication

Metal on Metal hip resurfacing (MoM HR) can be an effective operation for the young arthritic hip population. However, errors in cup orientation have been associated with increased wear, circulating blood metal ions, and soft tissue abnormalities that can lead to premature failure of the bearing surface and subsequent revision surgery. While image free computer guidance has been shown to increase surgical accuracy in total hip arthroplasty, the role of image based technology in MoM HR is unclear. In this study, we compared the accuracy of cup orientation in MoM HR performed by either freehand technique or CT based navigation. Seventy five patients (81 hips) underwent either freehand (n=42) or navigation (n=39) surgery, both requiring a three dimensional (3D) CT surgical plan. Surgery was conducted by hip specialists blind to the method of cup implantation until the operation. Deviation in inclination and version from the planned orientation, as well as, number of cups within a 10° safe zone and 5° optimal zone of the target position was calculated using post operative 3D CT analysis. Error in inclination was significantly reduced with navigation compared to freehand technique (4° vs 6°, p=0.02). We could not detect a difference between the two groups for version error (5° vs 7°, p=0.06). There was a significantly greater number of hips within a 10° (87% vs 67%, p=0.04) and 5° (50% vs 20%, p=0.06) safe zone when navigated. Image based navigation can substantially improve accuracy in cup orientation. The results of our freehand group appear better than historic controls, suggesting the use of a 3D plan may help to reduce technical error and improve the learning curve in this technically demanding procedure. We advocate the use of image based navigation in MoM hip resurfacing arthroplasty

Introduction. Solid or cystic pseudotumour is a potentially destructive complication of metal on metal (MoM) couples, usually needing revision surgery. However, complete clearance of the pseudotumour is unlikely at times. This prospective case-controlled study reports cases which had recurrence after revision surgery for pseudotumour related to metal on metal hip couples. Methods. A total of 37 hips (33 MoM hip resurfacing and four big head MoM total hip arthroplasty (THA)) were revised for pseudotumour during the last 10 years. The patient demographics, time to revision, cup orientation, operative and histological findings were recorded for this cohort. Patients were divided into two groups - group R (needing re-revision for disease progression) and group C (control - no evidence of disease progression). Oxford hip scores (OHS, 0–48, 48 best outcome) were used to assess clinical outcome. The diagnosis of disease progression was based on recurrence of clinical symptoms, cross-sectional imaging, operative and histological findings. Results. Nine of 37 (24%) patients identified with worsening symptoms, eight underwent further re-revision surgery while one is awaiting revision surgery (group R). All patients were females and the mean time to initial revision in group R was 34 months (SD 21.8) and 60.5 months in group C (SD 27.5, p< 0.01). The mean cup abduction angle and anteversion in group R were 480 (SD 9.3) and 5.10 (SD 5.0), and 500 (SD 8.7) and 14.50 (SD 8.5) respectively. Re-revision surgery confirmed disease progression in all cases. Oxford hip score was significantly worse in group R 19 (SD 8.0) as compared to group C 33 (SD14.2) (p=0.03). Discussion. This study demonstrates that solid pseudotumour can progress following initial revision. This is likely to be an ongoing reaction to retained metal debris despite adequate clearance. All patients revised for pseudotumour should be monitored using early ultrasound or MRI