Revision of ASR hip arthroplasty: analysis of two hundred and ninety six recalled patients at seven years

10-Year Clinical Review of Revision Hip Arthroplasty Following Previous Metal on Metal Hip Procedures with Preoperative Magnetic Resonance Imaging and Metal Ion Analysis: Abductor Tendon Avulsion Predicts Dislocation

INTRODUCTION

There is a paucity of long-term data following the revision of previous metal-on-metal (MoM) hip procedures. We hypothesized that functional and clinical results would be poor and that pre-revision serum ion levels and magnetic resonance imaging (MRI) findings could predict the outcome.

METHODS

All patients who had completed a minimum of 10 years following the revision of a MoM hip procedure at our institution were contacted. Data recorded were post-revision complication, re-revision, Oxford Hip Score, and EuroQol-5-Dimension Score, along with pre-revision serum ion levels and MRI findings. There were 56 aseptic MoM revisions from a consecutive series of 86 that reached > 10 years of follow-up. The mean age at revision surgery was 60 years (range, 31 to 75), and the mean follow-up was 138 months (range, 120 to 161).

RESULTS

The mean Oxford Hip Score was 37.4 and was lower in the MoM resurfacing group (mean 36.1) versus the MoM THA group (mean 38.0), P=0.46. The mean EQ-5D was 8.9. Re-revision rate was 16%, which was associated with the exchange of both components, P=0.029. The overall dislocation rate was 11%, and 5% developed infection. Preoperative MRI was available for 46 hips: abductor tendon avulsion was present in 30% and was positively associated with postoperative dislocation, P=0.043. Pseudotumor formation was present in 20%. The mean metal ion levels preoperatively were cobalt, 366.1 nmol/L, and chromium, 211.6 nmol/L, with cobalt levels above our mean value of 366.1 nmol/L associated with Goutallier grades 3/4 abductor insufficiency, P=0.033, and trending towards association with pseudotumor formation, P=0.087.

CONCLUSION

Satisfactory patient-reported functional outcomes are attainable at over 10 years following revision surgery for failed MoM hip surgery. However, there is a significant risk of re-revision and dislocation, which may be predicted with MRI evidence of abductor insufficiency and adverse reaction to metal debris.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Investigation and analysis of four countries' recalls of osteosynthesis implants and joint replacement implants from 2011 to 2021

Background

Medical devices are used in almost all orthopedic surgical subspecialties, and the frequency of adverse events is increasing, which should not be ignored. To provide suggestions on how to avoid implant recalls from the perspective of manufacturers, medical institutions and supervisions, as well as how to respond promptly to adverse events.

Methods

The research extracted recalls of osteosynthesis implants and joint replacement implants from January 1, 2011, to June 30, 2021, in the CNMPA, FDA, HC and ATGA websites and collected the information on device name, recall time, recall class, recall manufacturer, device classification and affected areas. Moreover, the McKinsey 7S model and fishbone diagram were used to analyze recall reasons.

Results

A total of 315 cases of osteosynthesis implants and 286 cases of joint replacement implants were reported in China, the USA, Canada and Australia. The recalls number from 2016 to 2021 was more than that from 2011 to 2015 for osteosynthesis implant (p = 0.012) and joint replacement implant (p = 0.002), and both mainly focused on class II (76.19% and 78.32%). There were statistical differences in the four countries for both implants (p = 0.000), especially osteosynthesis implant between China and the USA (p = 0.000), China and Canada (p = 0.001), the USA and Australia (p = 0.002), and joint replacement implant between China and Australia (p = 0.000).

Conclusions

To avoid the recalls of such implants, manufacturers should strictly select implant materials and components, develop detailed labels and instructions, severely control the packaging process and establish the integrity of medical device data. Medical institutions should standardize procurement procedures, use qualified equipment and train medical workers. It also requires supervisions to conduct premarket safety assessments. In addition, regulators should strengthen supervision and establish reporting systems to deal with the occurrence of adverse events promptly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03332-w.

Outcome of revision surgery for adverse local tissue reactions in patients with recalled total hip arthroplasty

INTRODUCTION

Recalls of total hip arthroplasty (THA) implants, including metal-on-metal (MoM) THA and dual taper stems, due to increased risk of adverse local tissue reaction (ALTR), represent a challenge for both surgeons and patients. This study aims to analyze the revision surgery outcomes for ALTR in patients with recalled THA implants.

METHODS

A total of 118 consecutive patients who underwent revision surgery due to ALTR with recalled THA were analyzed. Sub-group analysis was performed for recalled MoM THAs, head-neck modular stems, and dual taper neck-stems.

RESULTS

At a mean follow-up of 6.6 years, the complication and reoperation rates of the recalled THAs were 32.2% and 25.4% respectively. The most common post-revision complication was dislocation (16%). Revision of modular taper corrosion THA and high-grade intraoperative tissue damage were risk factors associated with post-revision complications.

CONCLUSION

This study reports high complication and reoperation rates of recalled THAs at mid-term follow-up. The high revision surgery complication rates in both groups suggest the importance of a systematic evaluation of all THA patients with at-risk implants.

LEVEL OF EVIDENCE

Level III, case control retrospective analysis.

Calcar-guided short-stem total hip arthroplasty: Will it be the future standard? Review and perspectives

Short stems in total hip arthroplasty (THA) are becoming increasingly popular. In Germany, already 10.4% of all primary THAs are performed using a cementless short stem. The concept of modern, calcar-guided, short stems aims for an individualized reconstruction of the hip anatomy by following the calcar of the femoral neck, a bone- and soft-tissue-sparing implantation technique, and physiological loading. The stem design uses either metaphyseal fixation alone or additional diaphyseal anchoring, depending on the stem alignment and indication. These individualized anchorage types increase the potential indications for the safe use of a short stem. The design features may account for potential advantages of current short stem implants compared with earlier short-stem designs, particularly in cases of reduced bone quality or osteonecrosis of the femoral head and femoral neck fractures. The implantation technique, however, requires distinct knowledge regarding the characteristics of varus and valgus positioning, with the potential for clinical consequences. A learning curve for surgeons new to this technique must be taken into account. Cortical contact with the distal lateral cortex appears to be crucial to provide sufficient primary stability, and the use of intraoperative imaging to identify “undersizing” is highly recommended. Current results of several national registries indicate that calcar-guided short stems are among the most successful implants in terms of mid-term survivorship. However, long-term data remain scarce. This review introduces the characteristics of calcar-guided short-stem THA and summarizes the current evidence.

The early- to medium-term results of a hemispherical, porous coated acetabular shell with multiple different bearing combinations are excellent with the exception of metal-on-metal

PURPOSE

This study prospectively reports survivorship and radiographic and clinical outcomes following primary elective total hip arthroplasty (THA) using a novel single hemispherical, porous-coated acetabular cup with five different bearing combinations and a minimum of five year follow-up.

METHODS

Continuing post-market release monitoring of this cup, we prospectively enrolled 108 patients (121 THA) between 2009 and 2015. We followed this cohort by examining survivorship, in addition to clinical and radiological outcomes for metal-on-metal (MoM) compared with non-MoM bearing combinations (ceramic-on-ceramic, oxinium-on-polyethylene, ceramic-on-metal, and metal-on-polyethylene).

RESULTS

All 108 (121 hips) patients were followed up. Average age at time of surgery was 45.1 years (range 19 to 71 years) of which 42.1% were males. A total of seven (5.8%) cups were revised, all of which were MoM. No osteolysis was observed in any of the patients at the latest visit with a mean follow-up of 9.1 ± 1.7 years (range 4.4-10.7 years). With MoM excluded, survivorship of the cup at five  years is 97.8%. Survivorship for MoM implants was 90.0%. Validated hip scores showed significant improvements for all bearing types and no significant difference between groups at latest follow-up (p = 0.614). There was no cup migration with any bearing surface.

CONCLUSION

This cup showed excellent survivorship at five year follow-up, except for patients receiving a MoM articulation. While there were concerns over the early survivorship of this cup, our cohort and joint registry data confirm excellent outcomes.

Trends in Total Hip Arthroplasty in Germany from 2007 to 2016: What Has Changed and Where Are We Now?

BACKGROUND

The number of total hip arthroplasties (THA) is rising in many industrialized nations. At the same time, the evidence regarding different types of prostheses and fixation techniques is constantly evolving. Therefore, this study aimed to analyze changes in THA by these advancements during the last decade.

METHODS

A retrospective analysis of data provided by the Federal Statistical Office of Germany from 2007 to 2016 was conducted using codes from the German procedure classification system and associated International Statistical Classification of Diseases and Related Health Problems codes. THA procedures were evaluated according to diagnoses, sex, and age of patients, along with the distribution of different prosthesis types. Additionally, changes in these parameters over time were analyzed.

RESULTS

From 2007 to 2016 a total of 2 157 041 primary THA procedures were performed in Germany, with an increase of 14.4% over this period. Overall, cementless standard THA (STHA) was used most frequently (50.0%), followed by hybrid variants (18.8%), hemiarthroplasties (15.9%), cemented standard THA (cSTHA; 9.2%), cementless short-stem THA (ssTHA; 4.8%), and hip resurfacing (HR; 0.9%) techniques. During the study period, the number of cSTHA and HR decreased significantly, whereas the use of STHA and ssTHA rose substantially, with a significantly higher application of these procedures in the elderly population. While osteoarthritis of the hip joint was the main indication for THA, several procedure-specific differences were identified.

CONCLUSION

The present data clearly demonstrate an increase in the use of cementless fixation for THA in Germany during the last decade and document a rise in ssTHA in recent years with, in contrast, the use of HR decreasing to a minimum.

Pleomorphic clinical spectrum of metallosis in total hip arthroplasty

PURPOSE

To summarize the biological effects of metal debris from hip arthroplasties which characterize a polymorphic clinical spectrum of local and remote manifestation.

METHODS

Retrospective study. Patient, implant, and surgical characteristics were collected, including implant survival, clinical manifestations, cause of arthroplasty revision or implant failure, and peri- and intra-operative complications. The primary endpoint was implant survivorship. Hip revision arthroplasty was decided considering clinical signs and symptoms, abnormal imaging (XR, MR, TC, echotomography, scintigraphy), and blood metal ion level. An ad hoc electronic form was used to collect demographic, epidemiological, and clinical variables. In-between group comparisons of quantitative variables were performed with the Student t test and the Mann-Whitney for parametric and non-parametric variables, respectively. Logistic regression analyses were carried out to assess the relationship between clinical and radiographic characteristics and stem and cup revision. Radiographic measurements of implant positioning validity and reliability were assessed using Krippendorff's alpha reliability coefficient. The statistical software STATA version 15 (StatsCorp, TX) was used to perform statistical computations.

RESULTS

In this MoM THA series, the most incident cause of implant failure was ARMD in 11 out of 14 (78.6%) patients. All clinical failure manifestations, revision surgery highlights, and intra-operative findings are reported.

CONCLUSIONS

The local adverse reactions include lesions of different clinical relevance from small asymptomatic soft tissue lesions to dramatic osteolysis, necrosis, effusion, and growing masses which can cause secondary pathological effects. Symptoms of systemic toxicity are rarely described but may have been largely unreported in literature. Despite the extensive literature on the topic, the patient's management is still uncertain and challenging. Every metallic implant (e.g., screws, plates, spinal instrumentations) has a potential local or systemic adverse effect. Organizing a national registry of arthroplasty should be mandatory, in order to collect data about the patients, the surgery, the implanted device (with a careful post-marketing tracking), and the follow-up for all the procedures performed at a national level. The data collected in the registry will allow to analyze the implant survival and to better recognize the undesirable and sometimes unexpected effects of different biomaterials on the whole body.