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Tower SS, Gessner BD, Cho CS, Bridges RL. The association of cobalturia with cobaltism symptoms a prospective blinded study of 229 post-arthroplasty patients. PLoS One 2023; 18:e0295203. [PMID: 38127904 PMCID: PMC10734948 DOI: 10.1371/journal.pone.0295203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/15/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Cobalt is a mitochondrial toxin, clinical cobaltism manifests with constitutional, neurologic, and cardiovascular symptomatology. Cobalt's severe toxidrome is known through case reports from extreme wear or corrosion of cobalt-chromium arthroplasty components. However, the spectrum and epidemiology of orthopedic-implant cobaltism and its relationship to duration and degree of cobalt exposure are not well defined. METHODS The relationship of urine-cobalt concentration and duration of exposure to cobalt-chromium joint implants and cobaltism symptomatology were prospectively studied in 229 patients. Subjects received a Cobaltism-Symptom-Inventory-Score (CSIS) based on a protocolized interview and examination followed by a spot urine-cobalt measurement. RESULTS 129 (56%) subjects were cobalturic (urine-cobalt ≥1.0 ppb). 122 (53%) subjects had a CSIS of >2, this status significantly associates with cobalturia. Median [IQR] urine-cobalt in the subjects with a CSIS >2 was 4.1[1.1-17.0] ppb compared to 0.5[0.5-1.4] ppb in subjects with CSIS ≤ 2. Cobalturia has a sensitivity of 0.69, a specificity of 0.77, and a positive predictive value of 0.74 for a CSIS of >2. The product of years-exposed to a cobalt-chromium implant and urine-cobalt by quartiles significantly positively associates with the Cobaltism-Symptom-Inventory-Score. CONCLUSION A urine-cobalt of ≥1 ppb likely indicates adverse systemic exposure to orthopedic-implant generated cobalt. Cobaltism severity as quantified by the CSIS significantly correlates with the product of spot urine-cobalt concentration and years-exposed to a cobalt-chromium orthopedic-implant indicating a dose-response relationship. Medical provider and public awareness of orthopedic-implant cobaltism is vital because tens-of-millions are at-risk and early cobaltism is reversible. Further use of cobalt-chromium orthopedic-implants should be questioned given cobaltism becomes clinically apparent at a spot urine-cobalt of 1 ppb or greater. Monitoring of patients with high-risk cobalt-chromium orthopedic-implants appears to be indicated.
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Affiliation(s)
- Stephen S. Tower
- University of Alaska, Medical School, Anchorage, Alaska, United States of America
| | | | - Christina S. Cho
- University of Alaska, Medical School, Anchorage, Alaska, United States of America
| | - Robert L. Bridges
- Aegis Imaging Consultants, Girdwood, Alaska, United States of America
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Newton A, Talwalkar S. Arthroplasty in thumb trapeziometacarpal (CMC joint) osteoarthritis: An alternative to excision arthroplasty. J Orthop 2023; 35:134-139. [PMID: 36471695 PMCID: PMC9719001 DOI: 10.1016/j.jor.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022] Open
Abstract
Trapeziectomy for base of thumb arthritis is well established, but base of thumb arthroplasty offers potential advantages. The review covers the development of arthroplasty for the thumb from interposition arthroplasty to total joint replacement. It discusses contemporary prosthesis designs and results, including trapezial component geometry, bearing surfaces, and dual mobility.
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Wang Y, Xu K, Wang Y, Ye W, Hao X, Wang S, Li K, Du J. Investigation and analysis of four countries' recalls of osteosynthesis implants and joint replacement implants from 2011 to 2021. J Orthop Surg Res 2022; 17:443. [PMID: 36207755 PMCID: PMC9547470 DOI: 10.1186/s13018-022-03332-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Yang Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Ping Hai Road, Suzhou, 215000, China.,Department of Pathology, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, 215123, China
| | - Kai Xu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Ping Hai Road, Suzhou, 215000, China
| | - Yuchen Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Ping Hai Road, Suzhou, 215000, China
| | - Weijie Ye
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Ping Hai Road, Suzhou, 215000, China
| | - Xinyi Hao
- Department of Pathology, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, 215123, China
| | - Shouli Wang
- Department of Pathology, School of Biology and Basic Medical Sciences, Soochow University, Suzhou, 215123, China. .,Suzhou Medical Device Safety Evaluation Center, Suzhou, 215123, China.
| | - Kun Li
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Ping Hai Road, Suzhou, 215000, China. .,Biopharmagen Corp., Fangzhou Suzhou, No. 88 Dongchang Road, Suzhou, 215127, China.
| | - Jun Du
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Ping Hai Road, Suzhou, 215000, China. .,Department of Orthopedic Magnetic Resonance Chamber, The First Affiliated Hospital of Soochow University, No. 899 Ping Hai Road, Suzhou, 215000, China.
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McCarty CP, Park SH, Ho NC, Sangiorgio SN, Ebramzadeh E. Taper Material Loss in Total Hip Replacements: Is It Affected by Joint Friction? J Bone Joint Surg Am 2022; 104:796-804. [PMID: 35167500 DOI: 10.2106/jbjs.21.00579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Metal debris and corrosion products generated from the taper junctions of modular joint replacements have been recognized as contributors to failure. Therefore, understanding the factors associated with increased taper wear and corrosion is fundamental to improving implant performance. METHODS A cohort of 85 large-diameter metal-on-metal heads and cups retrieved at revision surgery, after 10 to 96 months of service, was evaluated. First, metrology was conducted to quantify head taper material loss and implant articular surface wear. Then, joint frictional moments for each retrieved head-and-cup pair were measured during 10 cycles of simulated physiological gait in a biomechanical model. Taper material loss was evaluated for correlations with frictional moments, articular wear, head diameter, head-cup clearance, and time in vivo. RESULTS Peak resultant frictional moments ranged from 9.1 to 26.3 Nm, averaging 17.3 ± 2.7 Nm. Fretting and corrosion damage during in vivo service resulted in material loss from the head tapers ranging between 0.04 and 25.57 mm3, compared with combined head and cup articular wear of 0.80 to 351.75 mm3 in this cohort. Taper material loss was not correlated with higher frictional moments (R = -0.20 to 0.11, p = 0.07 to 0.81). Higher frictional moments from axial rotation were correlated with higher head and cup wear (R = 0.33, p < 0.01). The correlation between taper material loss and head diameter was weak and did not reach statistical significance (R = 0.20, p = 0.07). Taper material loss was not correlated with nominal head-cup clearance (R = 0.06, p = 0.6). Finally, taper material loss increased significantly over time (R = 0.34, p < 0.01). CONCLUSIONS Despite serious concerns regarding trunnionosis, volumes of head taper wear were generally lower than those of articular surface wear. There was no statistical correlation between taper wear and frictional moments. Therefore, the results suggest that high friction in metal-on-metal implants does not contribute to higher material loss at the head taper, despite high bending moments. CLINICAL RELEVANCE The amount of metal debris and corrosion products from taper junctions of the joint arthroplasties, widely recognized as an insidious cause of failure, was not correlated with joint frictional moments. Multiple factors affect taper wear: implant design, material, size, surface finish, and patient weight and activity level. However, in the present cohort, high friction of metal-on-metal total hip replacements likely did not contribute to increased volume of material loss at taper interfaces, despite increased moments at the locations of taper material loss.
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Affiliation(s)
- Colin P McCarty
- The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children in Alliance with UCLA, Los Angeles, California
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Van Der Straeten C. Hip resurfacing arthroplasty in young patients: international high-volume centres' report on the outcome of 11,382 metal-on-metal hip resurfacing arthroplasties in patients ⩽50 years at surgery. Hip Int 2022; 32:353-362. [PMID: 32905713 DOI: 10.1177/1120700020957354] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Total hip arthroplasty (THA) in patients younger than 50 years poses significant challenges including postoperative limitations of activity and higher failure rates. Sub-par outcomes of hip resurfacing arthroplasty (HRA) in registries remain controversial due to multiple confounders. Favourable HRA results in some studies are often regarded as irreproducible. The aim of this study is to analyse HRA outcomes in a large international cohort. PATIENTS AND METHODS We compiled a database of 11,382 HRA patients ⩽50 years from an international group of 27 experienced HRA centres from 13 countries. 18 different metal-on-metal (MoM) HRA designs were included with a mean follow-up of 7.6 years. Outcomes were implant survivorship, revision rates, causes for revision, clinical scores and metal ion levels. Outcomes were compared between genders, sizes, implant types and pre-operative diagnoses. RESULTS Overall cumulative Kaplan-Meier survivorship was 88.9% at 22 years (95% CI: 88.3-89.5%). 2 HRA designs (DePuy Articular Surface Replacement (ASR), and Corin Cormet Hip Resurfacing System (CORMET)) led to inferior results while all others yielded similar survivorships. Excluding ASR and CORMET, implant survivorship in 11,063 cases was 95% at 10 years and 90% at 22 years. In men, implant survivorship was excellent: 99% at 10 years and 92.5% at 21 years. In females, implant survivorship was 90% at 10 years and 81.3% at 22 years. The overall revision rate was 3.6% with most common reasons for revision being implant loosening and adverse local tissue reactions. The best survivorship was found in patients with osteoarthritis (95% CI, 92.1-93.3% at 22 years), the poorest was among dysplastic hips (78.3%; 95% CI, 76.5-80.1% at 20 years, p < 0.001). CONCLUSIONS Comparable revision rates demonstrated here may mitigate some concerns for safety and longevity of MoM HRA implants. Higher demands for activity and functionality in younger patients make HRA a potential alternative to THA.
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Gani MH, Zahoor U, Hanna SA, Scott G. Metal-on-metal hip resurfacing arthroplasty provides excellent long-term survivorship and function in patients with a good-sized femoral head : results of a single, non-designer surgeon's cohort. Bone Jt Open 2022; 3:68-76. [PMID: 35045731 PMCID: PMC9047081 DOI: 10.1302/2633-1462.31.bjo-2021-0135.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Aims To establish the survivorship, function, and metal ion levels in an unselected series of metal-on-metal hip resurfacing arthroplasties (HRAs) performed by a non-designer surgeon. Methods We reviewed 105 consecutive HRAs in 83 patients, performed by a single surgeon, at a mean follow-up of 14.9 years (9.3 to 19.1). The cohort included 45 male and 38 female patients, with a mean age of 49.5 years (SD 12.5) Results At the time of review 13 patients with 15 hips had died from causes unrelated to the hip operation, and 14 hips had undergone revision surgery, giving an overall survival rate of rate of 86.7% (95% confidence interval (CI) 84.2 to 89.1). The survival rate in men was 97.7% (95% CI 96.3 to 98.9) and in women was 73.4% (95% CI 70.6 to 75.1). The median head size of the failed group was 42 mm (interquartile range (IQR) 42 to 44), and in the surviving group was 50 mm (IQR 46 to 50). In all, 13 of the 14 revised hips had a femoral component measuring ≤ 46 mm. The mean blood levels of cobalt and chromium ions were 26.6 nmol/l (SD 24.5) and 30.6 nmol/l (SD 15.3), respectively. No metal ion levels exceeded the safe limit. The mean Oxford Hip Score was 41.5 (SD 8.9) and Harris Hip Score was 89.9 (14.8). In the surviving group, four patients had radiolucent lines around the stem of the femoral component, and one had lysis around the acetabular component; eight hips demonstrated heterotopic ossification. Conclusion Our results confirm the existing understanding that HRA provides good long-term survival and function in patients with adequate-sized femoral heads. This is evidenced by a 97.7% survival rate among men (larger heads) in our series at a mean follow-up of 14.9 years. Failure is closely related to head sizes ≤ 46 cm. Cite this article: Bone Jt Open 2022;3(1):68–76.
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Affiliation(s)
- M Haseeb Gani
- Department of Orthopaedics, The Royal London Hospital, London, UK
| | - Ubaid Zahoor
- Department of Orthopaedics, The Royal London Hospital, London, UK
| | - Sammy A Hanna
- Department of Orthopaedics, The Royal London Hospital, London, UK
| | - Gareth Scott
- Department of Orthopaedics, The Royal London Hospital, London, UK.,Barts and the London School of Medicine and Dentistry, London, UK
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The Interconnected Ancestral Network of Hip Arthroplasty Device Approval. J Am Acad Orthop Surg 2021; 29:e1362-e1369. [PMID: 34161960 DOI: 10.5435/jaaos-d-21-00138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/21/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In the United States, the most overwhelming medical devices, including hip arthroplasty devices, are cleared for human use by demonstration of "substantial equivalence" to a predicate, previously approved marketed device. This study examined the predicate approval lineages of modern hip arthroplasty devices. METHODS The FDA 510(k) and premarket approval databases were searched to identify all approved hip arthroplasty devices since the database's inception in May 28, 1976. Ancestral predicate lineages were created using approval documentation, and FDA recall data were used to identify recalled devices. RESULTS Evaluating 2,118 hip arthroplasty devices approved from 1976 to 2020, we found that the number of descendant devices for each approved device varied from 0 to 242. Many descendant devices served as predicates for other devices, leading to frequent indirect connections of equivalency across a wide range of implants. Two hundred forty-six (11.6%) devices were recalled for various reasons, with 34 (1.6%) related to implant design. Evaluating the predicate lineage of 51 hip arthroplasty devices approved between May 1, 2019, and May 1, 2020, 32 of 51 (62.7%) devices were linked, directly or indirectly, to predicates which were recalled for design issues. CONCLUSIONS The lineage of hip arthroplasty device predicates reflects a complex ancestral web of equivalency across a wide range of implants, although their material and design properties may be different. Several currently approved devices were approved on substantial equivalence claims to products that were subsequently recalled from the market for implant design issues. These findings present several policy considerations for regulators, physicians, and the medical device industry.
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Maurer-Ertl W, Fellner A, Reinbacher P, Maier M, Leithner A, Friesenbichler J. Blood Management in Revision Total Hip Arthroplasty for Metal-on-Metal Devices: The Efficiency of an Intraoperative Cell Salvage System. Indian J Orthop 2020; 54:164-167. [PMID: 32257033 PMCID: PMC7096336 DOI: 10.1007/s43465-019-00026-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 07/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of this series was to investigate the efficiency of an intraoperative cell salvage system (ICS) removing metal ions during revision of metal-on-metal (MoM) devices to proof the possibility of re-transfusion of the collected blood. MATERIALS AND METHODS Between 2014 and 2018, five consecutive patients underwent revision surgery of their MoM total hip arthroplasty due to wear of the polyethylene-metal sandwich inlay or local massive metallosis with aseptic loosing of the cup. Aspiration of joint fluid of all hip prostheses was done and blood was taken to measure the metal ion concentrations, preoperatively. Perioperatively, blood was collected using an ICS before and after filtration and analyzed for Co and Cr concentrations. At that time, there was no re-transfusion of the collected and filtrated blood due to unknown metal ion concentrations. RESULTS The mean preoperative serum Co and Cr concentrations in the blood were 31.28 μg/L (range 0.22-77.47) and 17.33 μg/L (range 0.59-51.31), whereas the mean local concentrations in the aspiration fluid were 728-fold and 822-fold higher. The Co and Cr concentrations measured in the collected blood before filtration were 70.61 μg/L (range 9.40-173.00) and 337.21 μg/L (range 8.76-1383.0) and decreased markedly to average concentrations of 15.49 μg/L and 41.88 μg/L, respectively. These differences were statistically not significant (Co: p = 0.117, Cr: p = 0.175), although the mean reduction rates were 78% and 88% for Co and Cr, respectively. CONCLUSION The current series showed that in case of revision of MoM hip devices, metal ions are still contained in the collected blood following filtration using a modern high-level ICS. Therefore, we would only recommend blood re-transfusion in case of low preoperative Co and Cr concentrations and sufficient renal function to warrant patients' safety.
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Affiliation(s)
- Werner Maurer-Ertl
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Andreas Fellner
- grid.11598.340000 0000 8988 2476Department of Anaesthesiology, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Patrick Reinbacher
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Michael Maier
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Andreas Leithner
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Joerg Friesenbichler
- grid.11598.340000 0000 8988 2476Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Mapping the Diffusion of Technology in Orthopaedic Surgery: Understanding the Spread of Arthroscopic Rotator Cuff Repair in the United States. Clin Orthop Relat Res 2019; 477:2399-2410. [PMID: 31393337 PMCID: PMC6903858 DOI: 10.1097/corr.0000000000000860] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The mechanism by which surgical innovation is spread in orthopaedic surgery is not well studied. The recent widespread transition from open to arthroscopic rotator cuff repair techniques provides us with the opportunity to study the spread of new technology; doing so would be important because it is unclear how novel orthopaedic techniques disseminate across time and geography, and previous studies of innovation in healthcare may not apply to the orthopaedic community. QUESTIONS/PURPOSES (1) How much regional variation was associated with the adoption of arthroscopic rotator cuff repair in the United States Medicare population between 2006 and 2014 and how did this change over time? (2) In which regions of the United States was arthroscopic rotator cuff repair first adopted and how did it spread geographically? (3) Which regional factors were associated with the adoption of this new technology? METHODS We divided the United States into 306 hospital referral regions based upon referral patterns observed in the Centers for Medicare & Medicaid Services MedPAR database, which records all Medicare hospital admissions; this has been done in numerous previous studies using methodology introduced by the Dartmouth Atlas. The proportion of arthroscopic rotator cuff repairs versus open rotator cuff repairs in each hospital referral region was calculated using adjusted procedural rates from the Medicare Part B Carrier File from 2006 to 2014, as it provided a nationwide sample of patients, and was used as a measure of adoption. A population-weighted, multivariable linear regression analysis was used to identify regional characteristics independently associated with adoption. RESULTS There was substantial regional variation associated with the adoption of arthroscopy for rotator cuff repair as the percentage of rotator cuff repair completed arthroscopically in 2006 ranged widely among hospital referral regions with a high of 85.3% in Provo, UT, USA, and a low of 16.7% in Seattle, WA, USA (OR 30, 95% CI 17.6 to 52.2; p < 0.001). In 2006, regions in the top quartiles for Medicare spending (+9.1%; p = 0.008) independently had higher adoption rates than those in the bottom quartile, as did regions with a greater proportion of college-educated residents (+12.0%; p = 0.009). The Northwest region (-14.4%; p = 0.009) and the presence of an academic medical center (-5.8%; p = 0.026) independently had lower adoption than other regions and those without academic medical centers. In 2014, regions in the top quartiles for Medicare spending (+5.7%; p = 0.033) and regions with a greater proportion of college-educated residents (+9.4%; p = 0.005) independently had higher adoption rates than those in the bottom quartiles, while the Northwest (-9.6%; p = 0.009) and Midwest regions (-5.1%; p = 0.017) independently had lower adoption than other regions. CONCLUSION The heterogeneous diffusion of arthroscopic rotator cuff repair across the United States highlights that Medicare beneficiaries across regions did not have equal access to these procedures and that these discrepancies continued to persist over time. A higher level of education and increased healthcare spending were both associated with greater adoption in a region and conversely suggest that regions with lower education and healthcare spending may pursue innovation more slowly. There was evidence that regions with academic medical centers adopted this technology more slowly and may highlight the role that private industry and physicians in nonacademic organizations play in surgical innovation. Future studies are needed to understand if this later adoption leads to inequalities in the quality and value of surgical care delivered to patients in these regions. LEVEL OF EVIDENCE Level III, therapeutic study.
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Wyss UP. Improving the Quality of Life of Patients With Medical Devices by a Timely Analysis of Adverse Events. Front Med (Lausanne) 2019; 6:56. [PMID: 30972339 PMCID: PMC6443635 DOI: 10.3389/fmed.2019.00056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/05/2019] [Indexed: 11/19/2022] Open
Abstract
Implanted and non-implanted medical devices, including artificial joints, are widely accepted to improve the quality of life of patients. While implant survival rates of over 80% can be accepted for artificial joints, there is still a large need to achieve higher survival rates at 15 years or longer to reduce the need for revisions due to implant failure before the end of the patient's life. Therefore, artificial joints are constantly improved with design changes and new designs, including modified or new materials. Most of these improvements perform as expected, but there are still cases where previously unknown failures occur, requiring premature revisions. A few examples of such unsuccessful improvements in the last 20 years are mentioned in this technical case report. The main focus of this paper is on an acetabular cup that was recalled due to unexpected revisions after a few weeks to a few months in vivo. The main reason for the revisions were small amounts of an oily residue containing endotoxins trapped inside the porous coating applied to the cup to facilitate bone ingrowth. The cup was recalled within 4 months after the company become aware of the problem, and prior to knowing exactly why the cups were failing early. The root cause analysis took several more months to complete. The lessons learned during the analysis are discussed so that similar events in other implantable medical devices can be avoided. The acetabular cup case aims to highlight that a timely root cause analysis, triggered by very few unexplained revisions, will benefit patients and improve the quality of life.
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Affiliation(s)
- Urs P. Wyss
- Department of Mechanical Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Mechanical Engineering, Queen's University, Kingston, ON, Canada
- *Correspondence: Urs P. Wyss
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11
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Midterm results of Magnum large head metal-on-metal total hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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12
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Aguado-Maestro I, Cebrián Rodríguez E, Paredes Herrero E, Brunie Vegas F, Oñate Miranda M, Fernández García N, García Alonso M. Midterm results of Magnum large head metal-on-metal total hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018; 62:310-317. [PMID: 29903424 DOI: 10.1016/j.recot.2018.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 04/05/2018] [Accepted: 05/03/2018] [Indexed: 10/14/2022] Open
Abstract
OBJECTIVES We present the results of the prospective follow up of a sample of large head metal-metal total hip arthroplasty obtained after the safety alert regarding a higher incidence of revision of these implants. MATERIAL AND METHODS All patients implanted with the Recap-M2a-Magnum cup between 2008 and 2011 were included. They were prospectively reviewed recording Harris Hip Score, clinical symptoms of chromium or cobalt intoxication. Serum levels of these ions were requested as well as X-Rays and ultrasonography. An MRI was performed in the cases of positive ultrasonography. RESULTS Twenty-six males with a mean age of 48.54 years [32-62, SD: 7.18] were included. An anterolateral approach and Bi-Metric (7) and F-40 (19) stems were used. Cephalic diameters ranged 42-52 (mode: 46) and the mean cup inclination was 39.35° [21-59°, SD: 9.78]. During follow-up (7.3 years [5.9-9.4; SD: .78]), 3 patients (11.5%) underwent revision (2 cases aseptic loosening, 1 pseudotumour). Mean time until revision was 5.4 years [3.1-8.0; SD: 2.48]. The accumulated survival probability was 88.5% (95% CI 76.3-100%). Harris Hip Score was 94.47 [66.5-100; SD: 8.94] and the patients showed no metallic intoxication symptoms. The levels of chromium were 1.88 mcg/dl [0.6-3.9] and cobalt 1,74 mcg/dl [0.5-5,6]. One pseudotumour was found in an asymptomatic patient, and small amounts of periarticular liquid were found in 5 patients (19.2%) DISCUSSION AND CONCLUSIONS: High revision rates are still found when follow up is extended due to aseptic loosening and pseudotumour formation. MRI might not be the most adequate test to study the complications of these prostheses.
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Affiliation(s)
- I Aguado-Maestro
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España.
| | - E Cebrián Rodríguez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España
| | - E Paredes Herrero
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España
| | - F Brunie Vegas
- Servicio de Radiología, Hospital Universitario del Río Hortega, Valladolid, España
| | - M Oñate Miranda
- Servicio de Radiología, Hospital Universitario del Río Hortega, Valladolid, España
| | - N Fernández García
- Servicio de Análisis Clínicos, Hospital Universitario del Río Hortega, Valladolid, España
| | - M García Alonso
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, España
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13
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Sessa G, Testa G, Gioitta Iachino S, Costarella L, Puma Pagliarello C, Ferrante M, Grasso A, Pavone V. Potential presence of metals in patients treated with metal-metal coupling prostheses for hip arthroplasty at 7 and 10 years of follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 28:637-643. [PMID: 29356908 DOI: 10.1007/s00590-018-2129-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/07/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Beginning in 2008, metal-on-metal prostheses have been in the spotlight owing to much higher revision rates than expected. Adverse local tissue reactions have been well described in the literature as potential complications. METHODS Between 2012 and 2013, 13 patients with metal-on-metal total hip replacements were evaluated clinically and radiologically and with laboratory samples. The same tests were repeated between 2015 and 2016 on eight patients to assess any changes. In the laboratory assessment, we searched for chromium, cobalt, molybdenum, and nickel in blood and urine samples over 24 h. RESULTS Clinical assessment has shown good score in all patients except one. On a second examination, between 2015 and 2016, all patients obtained results similar to those obtained in the first assessment, except a patient, who reported a recent fall. In the radiological assessment between 2012 and 2013, results were optimal, apart from a case of aseptic mobilization. The patients reassessed 3 years after the first examination showed radiological results similar to those previously obtained, apart from a patient, who showed signals of mobilization. Metal levels found in their blood decreased in most cases after 3 years. Urine levels of nickel increased in five subjects, and chromium levels increased in four, but levels of cobalt and molybdenum decreased in four patients. CONCLUSION It could be hypothesized that the decreasing trend of metal ion levels is associated with a stable wear status. On the contrary, a progressive increase in metal ion levels must be considered as early proof of implant loosening.
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Affiliation(s)
- Giuseppe Sessa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Gianluca Testa
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy.
| | - Salvatore Gioitta Iachino
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Luciano Costarella
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Calogero Puma Pagliarello
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Margherita Ferrante
- Department of Medical, Surgical and Advanced Technologies 'G.F. Ingrassia', University of Catania, Catania, Italy
| | - Alfina Grasso
- Department of Medical, Surgical and Advanced Technologies 'G.F. Ingrassia', University of Catania, Catania, Italy
| | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, University Hospital Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
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14
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Granchi D, Savarino LM, Ciapetti G, Baldini N. Biological effects of metal degradation in hip arthroplasties. Crit Rev Toxicol 2017; 48:170-193. [PMID: 29130357 DOI: 10.1080/10408444.2017.1392927] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Metals and metal alloys are the most used materials in orthopedic implants. The focus is on total hip arthroplasty (THA) that, though well tolerated, may be associated with local and remote adverse effects in the medium-long term. This review aims to summarize data on the biological consequences of the metal implant degradation that have been attributed predominantly to metal-on-metal (MoM) THA. Local responses to metals consist of a broad clinical spectrum ranging from small asymptomatic tissue lesions to severe destruction of bone and soft tissues, which are designated as metallosis, adverse reactions to metal debris (ARMD), aseptic lymphocytic vasculitis associated lesion (ALVAL), and pseudotumors. In addition, the dissemination of metal particles and ions throughout the body has been associated with systemic adverse effects, including organ toxicity, cancerogenesis, teratogenicity, and immunotoxicity. As proved by the multitude of studies in this field, metal degradation may increase safety issues associated with THA, especially with MoM hip systems. Data collection regarding local, systemic and long-term effects plays an essential role to better define any safety risks and to generate scientifically based recommendations.
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Affiliation(s)
- Donatella Granchi
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Lucia Maria Savarino
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Gabriela Ciapetti
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy
| | - Nicola Baldini
- a Orthopedic Pathophysiology and Regenerative Medicine Unit , Rizzoli Orthopedic Institute , Bologna , Italy.,b Department of Biomedical and Neuromotor Science , University of Bologna , Bologna , Italy
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15
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Clinical Results and Serum Metal Ion Concentrations following Ceramic-on-Metal Total Hip Arthroplasty at a Mean Follow-Up of 60 Months. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3726029. [PMID: 28373980 PMCID: PMC5360942 DOI: 10.1155/2017/3726029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/03/2017] [Accepted: 02/28/2017] [Indexed: 12/14/2022]
Abstract
Background. Increased metal ion levels following total hip arthroplasty (THA) with metal-on-metal bearings are a highly debated topic. Local soft tissue reactions with chronic pain and systemic side effects such as neuropathy are described. The aim of the current study was to determine the serum metal ion concentrations of Cobalt (Co) and Chrome (Cr) after THA with a ceramic-on-metal (CoM) bearing. Patients and Methods. Between 2008 and 2010, 20 patients underwent THA using a CoM bearing. Clinical function was evaluated by standardized scores systems (Harris Hip Score and WOMAC Score) and radiological examination included X-rays. Patient's blood samples were obtained for metal ion analysis and correlation analysis was done between these results and implant position. Results. Overall, 13 patients with 14 CoM devices were available for the current series. The mean age at time of surgery was 61 years (range, 41 to 85). The postoperative follow-up ranged from 49 to 68 months (mean, 58). Metal ion determination showed mean concentrations of 3,1 µg/L (range, 0,3–15,2 µg/L) for Co and 1,6 µg/L (range, 0,1–5,5 µg/L) for Cr, respectively. A correlation between cup anteversion and Co and Cr concentrations was shown. Conclusion. The current series showed increments for Co and Cr following CoM THA. However, these levels are lower compared to metal ion concentrations in patients with metal-on-metal bearings and the international accepted threshold for revision of MoM devices. We recommend routine follow-up including at least one obligatory evaluation of serum metal ion concentrations and an MRI once to exclude local soft tissue reactions.
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