Modes of Failure in Metal-on-Metal Total Hip Arthroplasty

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Key points

  • When evaluating any patient with a painful total hip arthroplasty, a systematic approach is mandatory regardless of bearing type.

  • In metal-on-metal hips, bearing malfunction can occur without the presence of symptoms.

  • Metal corrosion and adverse local tissue reaction may occur because of problems with the articulation or any modular junction of the implant.

  • Ion levels and cross-sectional imaging techniques (MRI, ultrasound) are beneficial in evaluating a metal-on-metal THA.

  • Stratifying the MoM

Introduction: nature of the problem

Metal-on-metal (MoM) total hip arthroplasty (THA) made a resurgence because of its improved wear characteristics, promise of longevity, and lower dislocation rates in the early 2000s.1, 2 By 2006, 35% of primary THA in the United States were MoM articulations. It was estimated that more than 1,000,000 MoM articulations had been implanted worldwide since 1996.3 Recently, adverse local tissue reactions (ALTRs) associated with these bearings has curbed enthusiasm for their use. New modes of

Evaluation of painful metal-on-metal total hip arthroplasty: a diagnostic algorithm

The evaluation of a painful MoM THA is multifaceted, focusing on history and physical examination, radiography, laboratory values, and cross-sectional imaging. A thorough review of systems must be performed because systemic cobaltism has been reported.11

Risk stratification

Risk stratification is important in the diagnostic and treatment algorithm of the painful MoM THA. This process is multifactorial because differences in clinical presentation exist. Clinical, laboratory, and radiographic factors help the clinician place patients into low-, moderate-, and high-risk categories, which can affect surveillance and treatment. A patient who is asymptomatic with negative ion levels, appropriately positioned components, and an implant with a low failure rate must be

Biologic Mechanism of Failure in Metal-on-Metal Total Hip Arthroplasty

The biologic response to metal particle debris can be systemic and local. Much of the concern in THA has been because of the ALTRs caused by the inflammatory response to metal debris. These local responses can result in tissue necrosis and adverse soft tissue reactions. The biologic response to metal particles is not fully understood. It is likely a type IV hypersensitivity response initiating T lymphocytes and macrophages to create a cytotoxic inflammatory response.1, 2, 23 Each individualized

Summary

The evaluation of a symptomatic patient following MoM hip arthroplasty remains challenging. It is important to consider all common modes of failure associated with a conventional THA, in addition to those modes of failure unique to MoM articulations. A thorough clinical evaluation, in addition to specialized testing and imaging, is important to make the proper diagnosis. The early recognition of ALTRs is essential for the successful management of the MoM patient. A systematic approach involving

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References (43)

  • M.B. Ellman et al.

    Fracture of the modular femoral neck component in total hip arthroplasty

    J Arthroplasty

    (2013)
  • N.G. Sotereanos et al.

    Modular femoral neck fracture after primary total hip arthroplasty

    J Arthroplasty

    (2013)
  • J.J. Jacobs et al.

    Metal-on-metal bearing surfaces

    J Am Acad Orthop Surg

    (2009)
  • J.A. Browne et al.

    Failed metal-on-metal hip arthroplasties: a spectrum of clinical presentations and operative findings

    Clin Orthop Relat Res

    (2010)
  • K.J. Bozic et al.

    The epidemiology of bearing surface usage in total hip arthroplasty in the United States

    J Bone Joint Surg Am

    (2009)
  • Y.M. Kwon et al.

    Risk stratification algorithm for management of patients with metal-on-metal hip arthroplasty: consensus statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and the Hip Society

    J Bone Joint Surg Am

    (2014)
  • P. Bisseling et al.

    The absence of a metal-on-metal bearing does not preclude the formation of a destructive pseudotumor in the hip: a case report

    Acta Orthop

    (2013)
  • T.K. Fehring et al.

    High frequency of adverse local tissue reactions in asymptomatic patients with metal-on-metal THA

    Clin Orthop Relat Res

    (2014)
  • C.A. Engh et al.

    2008 John Charnley Award: metal ion levels after metal-on-metal total hip arthroplasty: a randomized trial

    Clin Orthop Relat Res

    (2009)
  • F.S. Haddad et al.

    Metal-on-metal bearings: the evidence so far

    J Bone Joint Surg Br

    (2011)
  • S.S. Tower

    Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report

    J Bone Joint Surg Am

    (2010)
  • Cited by (26)

    • Femoral Nerve Compression due to Adverse Local Tissue Reaction After Ceramic-on-ceramic Total Hip Arthroplasty

      2023, Arthroplasty Today
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      This is the first reported case, to our knowledge, where a patient developed femoral nerve compression from an ALTR after a CoC THA [9–11]. MoM bearing surfaces became popular in the early 2000s, with about 35% of THAs in 2006 utilizing MoM surfaces [12–14]. However, unique failure modes such as MACC and ALTRs became a great concern.

    • Molecular pathology of adverse local tissue reaction caused by metal-on-metal implants defined by RNA-seq

      2019, Genomics
      Citation Excerpt :

      This smaller size decreases the potential for osteolysis and aseptic loosening, but increases the spread of metal particles via the lymphatic circulation, where metals consumed by macrophages tend to accrue in the reticulo-endothelial system (liver, spleen, bone marrow) and lymph nodes [16,17,35,54]. It is for this reason that MoM THA patients often present with pseudotumor, reactive skin changes and pain rather than aseptic loosening of the joint [41,42]. A substantial number of collagen genes and MMPs were also demonstrated to be significantly lower in the MoM patients.

    • SPECT/CT in Postoperative Painful Hip Arthroplasty

      2018, Seminars in Nuclear Medicine
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    Funding Sources: None.

    Conflict of Interest: None (Dr K. Fehring); Depuy-Johnson and Johnson, Board of Directors-Knee Society, AAHKS – Research support, consultant and royalties (Dr T. Fehring).

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