Aims. Second-generation metal-on-metal (MoM) articulations in total hip arthroplasty (THA) were introduced in order to reduce wear-related complications. The current study reports on the serum cobalt levels and the clinical outcome at a minimum of 20 years following THA with a MoM (Metasul) or a ceramic-on-polyethylene (CoP) bearing. Methods. The present study provides an update of a previously published prospective randomized controlled study, evaluating the serum cobalt levels of a consecutive cohort of 100 patients following THA with a MoM or a CoP articulation. A total of 31 patients were available for clinical and radiological follow-up examination. After exclusion of 11 patients because of other cobalt-containing implants, 20 patients (MoM (n = 11); CoP (n = 9)) with a mean age of 69 years (42 to 97) were analyzed. Serum cobalt levels were compared to serum cobalt levels five years out of surgery. Results. The median cobalt concentration in the MoM group was 1.04 μg/l (interquartile range (IQR) 0.64 to 1.70) at a mean of 21 years (20 to 24) postoperatively and these values were similar (p = 0.799) to cobalt levels at five years. In the CoP control group, the median cobalt levels were below the detection limit (< 0.3 μg/l; median 0.15 μg/l, IQR 0.15 to 0.75) at 20 years. The mean Harris Hip Score was 91.4 points (61 to 100) in the MoM group and 92.8 points (63 to 100) in the CoP group. Conclusion. This study represents the longest follow-up series evaluating the serum cobalt levels after 28 mm head MoM bearing THA and shows that serum cobalt concentrations remain at low levels at a mean of 21 years (20 to 24) after implantation. Cite this article:Bone Joint Res. 2020;9(3):145–150

We determined serum cobalt levels in 55 patients by atomic absorption spectrophotometry before and after implantation of uncemented total hip arthroplasties. In a randomised, prospective trial 27 wrought Co-28Cr-6Mo-0.2C metal-on-metal articulations were compared with 28 ceramic-on-polyethylene hips which did not contain cobalt. Other sources of iatrogenic cobalt loading were excluded. The metal-on-metal group produced detectable serum cobalt levels (median 1.1 μg/l after one year) which were significantly different (p < 0.0001) from those of the ceramic-on-polyethylene control group (median below detection limit of 0.3 μg/l after one year). Our findings indicate that metal-on-metal bearings generate some systemic release of cobalt

Abstract. Objectives. Modular dual-mobility (MDM) constructs are used to reduce dislocation rates after total hip replacement (THR). They combine the advantages of dual mobility with the option of supplementary acetabular screw fixation in complex revision surgery. However, there are concerns about adverse reaction to metal debris (ARMD) as a result of fretting corrosion between the metal liner and shell. Methods. The aim of this systematic review was to find and review all relevant studies to establish the outcomes and risks associated with MDM hip replacement. All articles on MDM THRs in the Medline, EMBASE, CINAHL, Cochrane Library, and Prospero databases were searched. A total of 14 articles were included. A random intercept logistic regression model was used for meta-analysis, giving estimated mean values. Results. There were 6 cases of ARMD out of 1312 total. Estimated median incidence of ARMD from meta-analysis was 0.3% (95% CI 0.1 – 1.4%). Mean postoperative serum Cobalt was 0.81 μg/L (95% CI 0.33 – 1.29 μg/L), and Chromium was 0.77 μg/L (95% 0.35 – 1.19 μg/L), from 279 cases in 7 studies. Estimated median incidence of a serum cobalt or chromium ion measurement ≥1 μg/L was 7.9% (95% CI 3.5 – 16.8%), and ≥7 μg/L was 1.8% (95% CI 0.7 – 4.2%). Conclusions. ARMD is a rare but significant complication following total hip replacement using a MDM construct. Its incidence appears higher than that reported in non-metal-on-metal (MoM) hip replacements but lower than that of MoM hip replacements. MDM hip replacements are associated with raised serum metal ion levels postoperatively, but there was no correlation with worse clinical hip function within studies. Studies were poor quality and at high risk of confounding. Pending further work, MDM constructs should be used with caution, reserved for select cases at particularly high risk of dislocation. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Objectives. Modular dual-mobility (MDM) constructs are used to reduce dislocation rates after total hip replacement (THR). They combine the advantages of dual mobility with the option of supplementary acetabular screw fixation in complex revision surgery. However, there are concerns about adverse reaction to metal debris (ARMD) as a result of fretting corrosion between the metal liner and shell. Methods: The aim of this systematic review was to find and review all relevant studies to establish the outcomes and risks associated with MDM hip replacement. All articles on MDM THRs in the Medline, EMBASE, CINAHL, Cochrane Library, and Prospero databases were searched. A total of 14 articles were included. A random intercept logistic regression model was used for meta-analysis, giving estimated average values. Results: There were 6 cases of ARMD out of 1312 total. Estimated median incidence of ARMD from meta-analysis was 0.3% (95% CI 0.1 – 1.4%). Mean postoperative serum Cobalt was 0.81 μg/L (95% CI 0.33 – 1.29 μg/L), and Chromium was 0.77 μg/L (95% 0.35 – 1.19 μg/L), from 279 cases in 7 studies. Estimated median incidence of a serum cobalt or chromium ion measurement ≥1 μg/L was 7.9% (95% CI 3.5 – 16.8%), and ≥7 μg/L was 1.8% (95% CI 0.7 – 4.2%). Conclusions: ARMD is a rare but significant complication following total hip replacement using a MDM construct. Its incidence appears higher than that reported in non-metal-on-metal (MoM) hip replacements but lower than that of MoM hip replacements. MDM hip replacements are associated with raised serum metal ion levels postoperatively, but there was no correlation with worse clinical hip function within studies. Studies were poor quality and at high risk of confounding. Pending further work, MDM constructs should be used with caution, reserved for select cases at particularly high risk of dislocation

We measured the levels of cobalt and chromium in the serum in three groups of patients after uncemented porous-coated arthroplasty. Group 1 consisted of 14 consecutive patients undergoing revision for aseptic loosening. Group 2 comprised 14 matched patients in whom the arthroplasty was stable and group 3 was 14 similarly matched patients with arthritis awaiting hip replacement. Specimens were analysed using atomic absorption spectrophotometry. Aseptic loosening of a component resulted in a significant elevation of serum cobalt (p < 0.05), but not of serum chromium. The relative risk of a component being loose, if the patient had a serum cobalt greater than 9.0 nmol/l, was 2.8

Summary. The M2a-38. tm. metal on metal total hip arthroplasty showed a high incidence of pseudotumors and an unexpected high revision rate in our thoroughly screened cross sectional cohort. Introduction. After the revival of the metal on metal (MoM) bearing in total hip arthroplasty (THA) at the beginning of this century, there are now serious questions about this type of bearing. The advantage of large head MoM bearing is the increase in range of motion and stability. In our institution the choice was made for 38 mm heads. During the last few years concerns have been raised about the relationship of MoM bearing and elevated serum cobalt and chromium ion levels, their local and systemic toxicological effects and the incidence of local tumorous masses (pseudotumors). Are these findings applicable for all MoM bearings or are there also product specific issues. We present the outcome of a cementless MoM THA using a 38mm head in a unique consecutive series of 377 THA who were performed in our institution. Patients and Methods. All 351 patients (377 THA) with a cementless MoM THA (M2a-38. tm. , Biomet Inc, Warsaw, IN, USA, and Taperloc® stem, Biomet UK, Bridgend) between 2008 and 2011 were evaluated. All patients were analyzed by a physical exam, serum levels of cobalt and chromium and an interview to determine if there were any complaints. An MRI of the hip was made if patients reported pain during physical activity, allergies to metals, serum cobalt or chromium ion levels ≥ 5 ppb or if the inclination of the acetabular component was more than 50 degrees. Nine patients deceased, three were lost to follow up and four already underwent a revision before the screening. We analyzed 361 hips with an average follow up of 30 (range 2–58) months. The average preoperative age was 63 years (41–88). Results. 219 patients with 235 THA (65%) reported no complaints. Median cobalt level in patients with complaints was 6.6 (0.2–173) ppb and in the group without complaints 3.7 (0.2–27.3) ppb. Median chromium level in patients with complaints was 5.0 (0.1–134) ppb and in the group without complaints 3.7 (0.2–27) ppb. On the 226 performed MRI scans, 56 pseudotumors were diagnosed and described using the Anderson classification (9 C1, 41 C2 and 5 C3). 71 hips had been revised after a mean follow of 30 months (range 0.2–50 months). Reasons for revision were because of pain, raised metal ions and a pseudotumor in 28; pain and raised metal ion levels in 15; aseptic loosening of the acetabular or femoral component in 11; raised metal ions and a pseudotumor in 7; combination of luxations, luxation feelings and fractures in 5; infections in 3 and for other reasons in 2. Conclusion. The short-term results of the THA with a 38mm head metal on metal articulation are higher compared with other MoM bearings. They show a revision rate of 7% and 10% in the Australian and England register. In other peer reviewed literature we find a revision rate between 0–13% after five years. We also observed a high incidence of elevated serum levels of metal ions, pseudotumors and an unexpected high early revision rate

Introduction of new implants has been widely debated lately, mainly in response to the problems surrounding hip resurfacing and one company recalling its product. Medicines and Healthcare products Regulatory Agency (MHRA) also issued advice about the management and monitoring of patients implanted with metal-on-metal articulations. In response to MHRA advice all the patients who underwent hip resurfacing in our hospital were assessed by two consultants according to MHRA guidelines. Here we present the findings from our District General Hospital. Between November 2006 and March 2009 we performed 42 hip resurfacings in 39 patients. Nearly all the procedures were performed by a single surgeon (39 out of 42). There were 27 males (28 hips) and 12 females (14 hips). Mean age of the patients at the time of surgery was 55.6 years (age range 40–67 years). Patients were followed up for a mean of 49 months (range 33–66 months). 27 patients (28 hips) were asymptomatic at the time of last follow up. Serum cobalt and chromium ion levels were measured in 21 patients (24 hips). Both the ion levels were within the recommended levels in 20 patients and over the recommended limit in 2 patients (one with bilateral hip resurfacing). MRI was diagnostic in 2 out of 5 patients. 5 patients (7 hips) were revised (one hip for neck resorption, 4 hips in 3 patients with lesions on MRI, 1 patient with bilateral hips for elevated serum ion levels). Considering the revision rate (7 hips out of 42 hips, 16%), we do believe that the review of the hip resurfacings in spite of the controversies surrounding the diagnostic criteria is necessary. This group of patients need to have continued surveillance, preferably by a select group of surgeons

Introduction. Total hip prostheses which use a ceramic head within a metal liner are a relatively recent introduction. As such, survivorship rates from independent centres alongside explant analysis are rare. The early experience with this novel ceramic-on-metal (CoM) bearing couple is reported. Methods and Materials. All CoM hips implanted between 2008 and 2009 at a single hospital by a single surgeon were reviewed. Radiographs were analysed using EBRA software to determine acetabular cup inclination and anteversion angles. Blood metal ion concentrations were measured using inductively coupled plasma mass spectroscopy (ICPMS). Explants were measured for bearing surface and taper wear using a high precision co-ordinate measuring machine. The roughness of the articulating surfaces was measured with a non-contact profilometer. Results. In 54 patients 56 CoM hips were implanted. Mean (range) age was 64 years (34-87). There were 41 females and 15 males. Patients were followed-up for a mean of 1.5 years. Three hips were revised at mean of 1.2 years (2 female, 1 male) with a further 3 listed for revision under 1.5 years giving an overall failure rate of 10.7%. All these patients reported with pain. X-rays of failed devices showed a characteristic pattern of femoral stem loosening. Serum cobalt and chromium were less than 2 micrograms/L. Explant analysis of the three revised hips showed wear at the liner rim in each case. In two of these cases the wear extended completely around the circumference. The wear volumes were 4.1, 2.0 and 2.3mm3 respectively. The ceramic heads were unworn but some transfer of metal could be seen visually. There was no significant wear or deformation at the taper junctions. Typical ceramic head roughness values were 3nm Ra and so most of the surface area of the heads remained in a pristine condition. Discussion. The very high early failure rate using COM is concerning. Explant analysis suggests equatorial contacts with propagation of high frictional forces distally. These forces may have caused early loosening of the femoral stems. Orthopaedic surgeons need to be aware of this new mechanism of failure which is associated with low metal ions

Background. The worldwide withdrawal of the DePuy Articular Surface Replacement (ASR) device in both its resurfacing and total hip replacement (THR) form on 26 August 2010, after 93,000 were implanted worldwide, has had major implications. The 2010 National Joint Registry for England and Wales quoted figures of 12-13% failure at five years; however these figures may be an underestimate. Patients and methods. In 2004 a single surgeon prospective study of the ASR bearing surface was undertaken. Presented are the Adverse Reaction to Metal Debris (ARMD) failure rates of the ASR resurfacing and ASR THR systems. The diagnosis of ARMD was made by the senior author and was based on clinical history, examination, ultrasound findings, metal ion analysis of blood and joint fluid, operative findings and histopathological analysis of tissues retrieved at revision. Acetabular cup position in vivo was determined using EBRA software. Mean follow up was 52 months (24-81) and 70 patients were beyond 6 years of the procedure at the time of writing. Kaplan Meier survival analysis was carried out firstly with joints designated ‘failure’ if the patient had undergone revision surgery or if the patient had been listed for revision. A second survival analysis was carried out with a failure defined as a serum cobalt concentration > 7microgrammes/L (MHRA guideline from MDA-2010-069). Full explant analysis was carried out for retrieved prostheses. Results. There were 505 ASR hips in total (418 resurfacings and 87 THRs). 657 metal ion samples were available at the time of writing including 152 repeats. Survival analysis using revision/listed for revision as end point (at 6 years): ASR resurfacing: 26.1% failure; ASR THR: 55.5% failure. Survival using ion analysis (at 5 years): ASR resurfacing: 50.1% failure; ASR THR: 66.5% failure. The median (range) volumetric wear rate of failed prostheses was 8.23mm3/year (0.51-95.5). Failure and high ion concentrations are linked to acetabular cup size, anteversion and inclination. Increased failure rates in THRs were due to wear at the taper junction of head and stem. Conclusion. Design flaws in the ASR have led to excessive wear and consequently catastrophic failure rates secondary to ARMD