Revising the well-fixed, painful resurfacing using a double-mobility head: a new strategy to address metal-on-metal complications

Long-term Follow-up on Revisions of a Recalled Large Head Metal-on-metal Hip Prosthesis: A Single Surgeon Series

Background

In 2010, a recall was issued for a specific monoblock large head metal-on-metal (MoM) hip prosthesis due to short-term revision rates of 12%-13% (articular surface replacement, DePuy Orthopaedics, Inc., Warsaw, IN). High complication, infection, and rerevision rates for revised MoM implants have been reported. The purpose of the study is to report long-term outcomes and trend metal ion levels of this recalled MoM prosthesis from a single surgeon series.

Methods

Retrospective chart review was performed on all patients that underwent revision of large MoM hip replacements between 2010 and 2015. Pre- and post-revision Harris Hip Score (HHS), cup abduction angles, anteversion angles, and cup sizes were compared. Survivorship and HHS were the primary outcomes measured; serum cobalt and chromium levels were secondary outcomes. Multivariate linear regression was used to examine the correlation between prerevision serum metal ion levels and HHS.

Results

A total of 24 hips (21 patients) met inclusion criteria. Mean time to revision was 4.12 years ± 1.1. Mean follow-up was 10.0 years (7-11.9 years). Mean HHS increased significantly after revision from 48.5 to 89.5 (P < .001). Higher prerevision cobalt levels were correlated with lower prerevision HHS (cobalt R = 0.25; chromium R = 0.3160). There was no correlation with prerevision cobalt (P = .2671) or chromium (P = .3160) with postrevision HHS. Most recent metal ion testing revealed a significant decrease in both cobalt (P = .0084) and chromium (P = .0115). Survival rate is 100%.

Conclusions

Our study showed excellent survivorship and outcomes at 10 years. There were no failures for any reason including infection. This differs from previous studies and confirms excellent long-term results are possible with revision of this recalled MoM implant.

Revision of a Monoblock Metal-on-Metal Cup Using a Dual Mobility Component: Is It a Reasonable Option?

Revision of large-diameter, monoblock acetabular components for both hip resurfacing arthroplasty and metal-on-metal (MoM) total hip arthroplasty (THA) is correlated to a high amount of complications. For this reason, performing a limited revision by conversion to a dual mobility (DM) without acetabular component exchange has been proposed in order to limit these complications. Although DM bearing offers an easy solution avoiding the intraoperative and time-associated complications, concern about polyethylene wear and stability remains due to the difference regarding the design, the coverage angle and the clearance of the two implants. In order to evaluate the performance of this new solution with the new material to prevent the possibility of failure it is essential to conduct a review of the literature A qualitative systematic review of the literature has been conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, EMBASE, Google Scholar, and Scopus for English and French articles between January 2000 and October 2019 was performed, with the primary objective of finding articles about dual mobility bearing coupling with large metal-on-metal cup in the case of hip revision procedure. Various combinations of the key words were used in the search strategy. Thirteen articles with DM bearing mated with MoM cup were analyzed. Of the 130 hip revisions selected, with a follow-up from 6 to 53 months, there were a total of 14 with complications (10.77%): four true dislocations (3.08%); six intra-prosthetic dislocations (IPD, 4.6%), two of which presented plastic deformation and polyethylene wear; four other complications (3.08%), included a cup osteolysis, a clicking noise, a superficial infection and a periprosthetic fracture. All the mentioned true dislocations occurred during the first month while IPDs appeared during the first two years from the index revision. In conclusion, according to the literature analyzed, we can stress that the concerns and doubts about mating a DM bearing with large MoM cup cannot be dissolved. It has been pointed out that a DM bearing is not designed for a MoM cup; it is not mechanically tested on MoM cups, which presents different clearance and coverage angles. Predictable complications may occur, such as IPD, polyethylene wear and true dislocation. These complications have been reported at an even higher rate than they were in the eighties, when the first generation of DM implants were of a lower quality of polyethylene and the characteristic of the design was less optimal than modern ones.

Femoral side-only revision options for the Birmingham resurfacing arthroplasty

BACKGROUND

The Birmingham Hip Resurfacing (BHR) system (Smith and Nephew) was developed as an alternative to conventional total joint replacement for younger, more active patients. Among other complications exists the risk for femoral component failure. The only marketed revision option for such a complication involves exchange of all components for a total replacement arthroplasty. This presents as a considerable and potentially unnecessary operative burden where revision of only the femoral prosthesis would suffice. We have analysed revision options for BHR in the context of periprosthetic femoral fractures with a stable acetabular component.

METHODS

Technical details of dual mobility hip systems available in Australia were collated and analysed to assess for potential 'off label' use with an existing BHR acetabular component. These data were then compared with the custom-made Smith and Nephew dual mobility implant with respect to clearance and sizing.

RESULTS

Two dual mobility articulation modalities from two companies were identified as appropriate for potential usage with four products analysed in detail. These two demonstrated acceptable sizing and clearance measurements.

CONCLUSION

Comparison between readily available dual mobility prostheses with custom-made implants showed off label dual mobility prosthetic use to be a viable alternative for femoral-only revisions with in situ BHR. Single component revision has several advantages which include: a less complex surgical procedure, shorter operative time, decreased blood loss and the expectation of resultant lower morbidity. Furthermore, this less complex revision surgery should give comparable results to that of primary total hip arthroplasty.

A new strategy to reconstruct type III acetabular bone defect associated with inflammatory pseudotumor: combined medial and lateral acetabular bone grafting: A case report

RATIONALE

Inflammatory pseudotumor has been commonly reported in patients undergoing total hip arthroplasty (THA).

PATIENT CONCERNS

We reported a patient who had a massive intra-pelvic pseudotumour and acetabular bone defect underwent two-stage revision THA.

DIAGNOSES

A new surgical strategy for pseudotumor after THA is performed.

INTERVENTIONS

Thorough debridement intra-pelvic pseudotumour via Smith-Petersen approach, bone grafting on iliac medial surface and plate-screw internal fixation were performed in the first stage, followed by revision of the loosened prosthesis to a cementless primary prosthesis in the second stage.

OUTCOMES

A follow-up for 5 years showed satisfactory recovery of function.

LESSONS

This surgical revision is less invasive than conventional methods, resulting in a stable and well-functioning hip joint after mid-term follow-up for 5 years.

Revision of Metal-on-metal Hip Arthroplasty with Well Fixed and Positioned Acetabular Component Using a Dual-mobility Head and Review of Literature

Background:

As a consequence of use of metal-on-metal hip arthroplasties some patients have precised revision for pain or metal hipersensivity reactions among other causes. We propose to salvage monoblock acetabular component and femoral component using a dual-mobility head and perform a lower morbidity operation in young patients preserving host bone stock in cases with well fixed and positioned components.

Objective:

(1) What clinical problems have been reported in patients with Metal-on-metal hip arthroplasties? (2) Could the tribocorrosion potentially cause a fracture of neck femoral component? (3) Can be the dual-mobility head a recourse in metal-on-metal hip revision?

Methods:

Ten patients were revised for pain or/and raised Cobalt/Chromium levels between August 2012 and December 2015. In three cases femoral neck component was fractured and femoral revision was necessary. In four hips, acetabular and femoral components could be maintained. Age, body index mass, ion levels, acetabular position, size of acetabular component and femoral head, approach, blood transfunsion and time of hospitalization were analized.

Results:

At a mean follow-up of 25,6 months (6 to 45) the mean postoperative HHS was 92. It was not statistically significant because several patients were low sintomatic before surgery, but had raised Cobalt/Chromium levels in the blood. All patients had near-normal levels of Cobalt/Chromium during the first 6 months after revision surgery. No relevant complications were reported.

Conclusion:

The use of dual-mobility head can be an acceptable option to revise metal-on-metal arthroplasties correctly oriented with abscence of loosening or infection signs and keeping bone stock in young patients.

Revision of Failed Hip Resurfacing and Large Metal-on-Metal Total Hip Arthroplasty Using Dual-Mobility Components

Revision of metal-on-metal (MoM) total hip arthroplasty (THA) or hip resurfacing is associated with high complication rates. The authors propose dual-mobility components as a surgical option and present short- to mid-term results of MoM hips revised with dual-mobility components. Eighteen consecutive hips that underwent revision of MoM THA or hip resurfacing using dual-mobility components were identified. At final follow-up (mean, 17.5 months), the visual analog scale, modified Harris Hip Score, and SF-12 scores had all improved (P<.05, P<.01, and P<.05, respectively). There were no dislocations or other complications. Revision of failed MoM THA or hip resurfacing using a dual-mobility device is an effective strategy.

The surgical options and clinical evidence for treatment of wear or corrosion occurring with THA or TKA

BACKGROUND

Wear and corrosion occurring in patients with hip and knee arthroplasty are common causes of failure leading to revision surgery. A variety of surgical approaches to these problems have been described, with varying efficacy. Polyethylene wear, metal-on-metal (MoM) hip bearing wear, and problems associated with modular taper corrosion are the areas of greatest clinical impact; results of revisions for these problems are likely to dictate a large portion of revision resources for the foreseeable future, and so they call for specific study.

QUESTIONS/PURPOSES

We identified the most frequently reported procedures to treat hip polyethylene wear, knee polyethylene wear, MoM wear after THA, and modular taper corrosion and determined the timing and reasons these failed.

METHODS

We performed systematic reviews of the published literature on the four topics using MEDLINE(®) and Embase in October 2013; searches were supplemented by hand searches of bibliographies. Prespecified criteria resulted in the identification of 38 relevant articles, of which 33 were either case reports or Level IV evidence. Followup was generally at short term and ranged from 0.2 to 8 years.

RESULTS

The most frequently reported procedures for treating clinically important wear were a partial or complete revision. When treating polyethylene wear, the more frequently reported reasons for hip and knee rerevisions were loosening, continued wear, and instability. Soft tissue reactions were more common and occasionally extensive in patients with MoM or modular taper corrosion. Patients with soft tissue reactions had more complications and higher rerevision rates.

CONCLUSIONS

Studies with longer followup and higher levels of evidence are needed to direct the treatment of wear and corrosion. When soft tissue damage secondary to MoM wear or taper corrosion is present, the results of treatment can be poor. There is an urgent need to better understand these two mechanisms of failure.