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 incidence of wear-induced osteolysis.

Introduction: Cementless cup designs in metal-on-metal (MoM) hip resurfacing devices generally depend on a good primary press-fit fixation which stabilises the components in the early post-operative period. Pressfitting the cup into the acetabulum generates non-uniform compressive stresses on the cup and consequently causes non-uniform cup deformation. That in turn may result in equatorial contact, high frictional torque and femoral head seizure. It has been reported that high frictional torque has the potential to generate micromotion between the implant and its surrounding bone and as a result adversely affect the longevity of the implant. The aim of this study was to investigate the effects of cup deformation on friction between the articulating surfaces in MoM bearings with various clearances.

Materials and methods: Six Birmingham Hip Resurfacing (BHR) devices with various clearances (80 to 306 μm) were tested in a hip friction simulator to determine the friction between the bearing surfaces. The components were tested in clotted blood which is the primary lubricant during the early post-operative period. The joints were friction tested initially in their pristine conditions and subsequently the cups were deflected by 25– 35 μm using two points pinching action before further friction tests were carried out.

Results and Discussions: It has been reported that reduced clearance results in reduced friction. However, none of the previous studies have taken cup deflection into consideration nor have they used physiologically relevant lubricant. The results presented in this study show that for the reduced clearance components, friction was significantly increased when the cups were deflected by only 30 μm. However, for the components with higher clearance the friction did not change before and after deflection. It is postulated that the larger clearances can accommodate for the amount of distortion introduced to the cups in this study.

Introduction: modern cementless joints depend on bony ingrowth for durable long term fixation. Increased friction and micromotion in the early weeks can prevent ingrowth and affect long-term success.

Most friction studies are conducted in a bovine serum- carboxymethylcellulose (bs-cmc) medium. Following implantation however, the joint is bathed in blood which contains macromolecules and cells. The effect of these on friction is not fully understood.

A progressive radiolucent line (fig 1) observed in some low clearance resurfacings raises the concern that increased friction may be affecting component fixation. The purpose of this investigation was to study the effect of clearance on friction for a given bearing diameter in the presence of blood as lubricant.

Methods: Six Birmingham Hip Resurfacing devices with a nominal diameter of 50mm each and a range of diametral clearances (80, 135, 175, 200, 243 and 306μm) were used. Frictional measurements were carried out on a Prosim Hip Friction Simulator (Simsol Simulation Solutions, Stockport, UK). The test was conducted sequentially with whole blood (viscosity 0.009Pas) and a BS-CMC mixture as the lubricants (viscosity 0.01Pas).

Results: Low clearance devices (80–175μm) generated higher friction with blood than with BS-CMC (fig 2). With blood as the lubricant, low clearance devices generated much higher friction than higher clearance devices (200–306μm).

Discussion: Ongoing research into the in vitro performance of bearings is performed in hip simulators with lubricants that are believed to simulate joint fluid in terms of viscosity. However these lubricants are unable to simulate the friction effects of macromolecules.

The results of this study suggest that reduced clearance bearings have the potential to generate higher friction when blood is the lubricant. this higher friction in the low clearance bearings may produce micromotion in the early postoperative period and hamper bony ingrowth resulting in impaired fixation with long-term implications for survival.

Hip Resurfacing has always been an attractive concept for the treatment of hip arthritis in younger patients. Introduction of modern metal-on-metal hip resurfacing in 1991 in Birmingham, UK made this concept a reality.

In the early years, resurfacings were used only by a few experienced surgeons. From 1997, Birmingham Hip Resurfacings (BHRs) are being widely used in younger and more active patients. A breakdown of the ages at operation in the regional NHS hospital in Birmingham during the period April 1999 to March 2004 show that the mean age of metal-metal resurfacings is 51 years and the mean age of total hip replacements is 70 years.

At a 3.7 to 10.8 year follow-up (mean follow-up 5.8 years), the cumulative survival rate of metal-metal resurfacing in young active patients with osteoarthritis is 99.8%. In the long term, none of these patients were constrained to change their occupational or leisure activities as a result of the procedure. The overall revision rate of BHRs in all ages and all diagnoses is also very low (19 out of 2167 [0.88%] with a maximum follow-up of 7.5 years).

Improvements in instrumentation and a minimally invasive approach developed by the senior author have made this successful device even more attractive. Although objective evidence does not support the fact that the longer approach was any more invasive than the minimal route, patient feedback shows that it is very popular with them. While minimal approach is indeed appealing, it has a steep learning curve. In the early phase of this curve, care should be taken to avoid the potential risk of suboptimal component placement which can adversely affect long-term outcome.

It is true that metal-metal bearings are associated with elevated metal ion levels. In vitro studies of BHRs show that they have a period of early run-in wear. This is not sustained in the longer term. These findings are found to hold true in vivo as well, in our studies of 24- hour cobalt output and whole blood metal ion levels. Epidemiological studies show that historic metal-metal bearings are not associated with carcinogenic effects in the long-term.

Metal ion levels in patients with BHRs are in the same range as the levels found in those with historic metal-metal total hip replacements.

The ‘first generation’ Metal on Metal bearing devices was typically produced from cast, high carbon CoCrMo alloy and was in the as-cast condition. They exhibited course, hard primary, and block carbides supported by a softer matrix material. This bi-phasic condition has been verified through reported literature and forensic scientific studies of ‘long-term survived’ retrieved ‘first generation’ devices. The as-cast microstructure of CoCrMo alloys possesses superior wear resistance to the microstructures formed following post cast thermal treatments. It has been well reported that the improvement of mechanical properties, such as tensile or fatigue strength, can be achieved through the thermal treatment of this alloy. Thermal treatments of this alloy have been found to alter its’ microstructure with a significant modification to the carbide phase morphology. The modifications vary with a tendency for a refinement of the carbide size through dissolution of the chromium and molybdenum through solid state solution. Through the examination of the wear patterns of retrieved devices and wear testing of this material in its’ various microstructural conditions, it has been shown that modifications to the carbide morphology, to achieve improved mechanical properties, reduces its’ bio-tribological properties/performance leading to a lower wear resistance. The as-cast carbide morphology is the most mechanically stable condition and with its’ volume fraction, reduces the potential for adhesive wear of the matrix through ‘matrix to matrix’ contact of the two opposing bearing surfaces. It has been reported that abrasive wear is the typical mechanism for metal on metal bearings due to the generation of ‘third body’ particles from carbide asperity tips fracturing during the initial ‘running-in’ period [typically 500k to 1M cycles]. After this stage the carbides become almost level with the surrounding softer matrix material with ‘third body’ scratches dominating the surface topography. Evidence of surface pitting on ‘first generation’ devices [McKee Farrar and Muller] and modern high carbon wrought devices [Metasul] has been attributed to adhesive/fatigue wear following surface-to-surface contact. Therefore, in microstructural conditions, where there is a reduced carbide volume fraction, or no carbides present, wear resistance is reduced. To test this hypothesis two wear tests have been carried out on CoCrMo samples produced from the same chemistry alloy, with varying microstructures, using Calowear [abrasive] and Pin on Dist [adhesive] tests. The as-cast microstructural condition was determined to have the lowest wear coefficient [k=mm3/Nm] in both tests, however statistical significance at 90% confidence interval was only confirmed in the Calowear Test. Examination of wear scars confirmed the mechanical stability of the as-cast carbide phase. It is noted, however that there are papers which have been published offering a divergence of opinion to this hypothesis and which have been considered by this author.