Management of pseudotumours associated with MoM THA can be difficult and complications are frequent. The functional outcome of patients after revision surgery may be suboptimal. The objective of this study was to assess our experience with revisions of failed MoM THA due to pseudotumours.

78 hips were diagnosed with pseudotumours in 70 patients following metal-on-metal hip replacements. Of these, 68 MoM THA were revised in 62 patients. Pre operative symptoms, radiographic analysis, metal ion levels, MRI results, intra-operative findings, WOMAC scores, the satisfaction level and the complication rate were recorded.

Five patients had a resurfacing arthroplasty as their primary implants while the remaining 63 hips in 57 patients had MoM THA of different brands. The average time between the primary and revision surgery was 69 months (range 15–120). The average age at revision was 59 years (43–87). The mean follow-up was 24 months (range 2–73). 36 patients had minimal one year follow-up. Most lesions consisted of cystic changes and solid lesions were observed in 19 patients. In 57 hips, the pseudotumours were located posteriorly or postero-laterally around the greater trochanter. Intra operatively, muscle necrosis was observed in 15(22%) patients. Most THA cases demonstrated wear and corrosion at the head neck junction of the femoral implants. Thirty-five patients (44.9%) had greater than 50 degrees of cup abduction, including 10 patients (12.8%) with an abduction angle greater than 60 degrees. The average pre operative and postoperative Co ion levels were 27.46 ug/L (range 0.36–145.6) and 2.46 (range 0.4–12.48), respectively. Post revision, a total of 10 hips (14.7%) sustained a dislocation, with seven (10.3%) of them experiencing recurrent dislocations. In 8/10 hips, the femoral head size was 36mm or greater. Revision for dislocation occurred in seven(10.3%) patients. Three(4.4%) deep and one(1.47%) superficial infections occurred and deep infections were re-operated. One(1.47%) fracture of the greater trochanter and one (1.47%) psoas tendinitis did not need revision. Therefore, a total of 10 patients (14.7%) were reoperated. 6 revisions for instability were performed in the first 34 patients, while 1 were done in the last 34 patients. At one year post revision surgery, the mean WOMAC score was 19.68 (range 0–48). In comparison, the mean WOMAC score of the same patients one year after their primary surgery was 8.1 (0–63). Patient satisfaction level of patients one year post revision surgery was 7.61 (range 5–10) compared to 4.15 (range 0–7) pre-revision one.

The complication rate after revision of pseudotumours is high. Most re revisions occurred secondary to instability despite the use of larger femoral heads. The functional outcome at one year post revision seems to be lower than that seen after primary THA but similar to other revisions in the literature. Experience in the management of these patients may reduce the complication rate.

ARMD (Adverse Reaction to Metal Debris) is an increasingly recognised complication of metal on metal hip replacements. The MHRA (Medical and Healthcare Related Devices Agency) have advised a blood cobalt or chromium level above 7 mg/L is a threshold for further investigation, stating that “low levels are reassuring and strongly predict not having an adverse outcome”. Cross-sectional imaging should be performed when levels are above 7 mg/L. We have performed a study investigating the specificity and sensitivity of chromium and cobalt metal ion levels as a screening measure for ARMD. 79 ASR hip replacements were performed at our hospital and 75 (95%) of these underwent a Metal Artefact Reduction Sequence (MARS) MRI scan. All patients (64 hips) who had not undergone revision were invited to take part in this study. 57 patients with 62 hip replacements completed hip and activity scores, had blood cobalt and chromium ion level measurements and 3D-CT to measure acetabular component position. Acetabular component inclination (>50 degrees), small head size (< 51mm) and female gender were significantly correlated with raised chromium (Cr) and cobalt (Co) ion levels. An ARMD was detected using MRI in 18 (29%) of the hips in this study. The incidence of ARMD was significantly higher when chromium concentration was above 7 mg/l (p = 0.02). Chromium ion levels >7 mg/L had a sensitivity of 56% and specificity of 83% for ARMD, and cobalt ion levels >7 mg/L 56% and 76% respectively. 40 patients had cobalt levels <7 mg/L and 33 had chromium levels <7 mg/L, but 8 of these had an ARMD on MRI. All 8 patients had minimal symptoms (Oxford Hip Score ≥ 44 out of 48). The Medicines and Healthcare Products Regulatory Agency (MHRA) has recommended that cobalt and chromium levels be measured in patients with a metal-on-metal hip replacement and cross-sectional imaging performed when these levels are above 7 μg/L. This study has shown that by using this threshold, in patients with this implant combination, the sensitivity and specificity for the detection of ARMD is low and patients with soft tissue disease may be missed. Furthermore the presence of MRI detected ARMD, in the absence of significant clinical symptoms and with metal ion levels <7 μg/L is of concern. MoM implants at risk of failure are associated with raised cobalt and chromium levels. However metal ion analysis alone is not reliable as a screening tool for ARMD, which is often clinically “silent”. We recommend the routine use of MARS MRI as the safest method of ARMD diagnosis in patients with MoM implants

Introduction. Adverse reaction to metal debris (ARMD) is an increasingly recognised complication of metal-on-metal hip arthroplasty. A previous study described poor results following revision and recommended early intervention. 1. We determined the outcome of revision for ARMD and present the largest case series to date. Methods. Between 2005 and 2010, 98 patients (101 hips) underwent revision for ARMD. The diagnosis of ARMD was based on clinical history, examination, appearance at revision and histology. Patients were reviewed at 3, 6 and 12 months and annually thereafter. Patient satisfaction, Harris hip scores (HHS) and metal ions were analysed. Results. 54 patients (55 hips) with an average age of 58 years (29 to 81 years) completed minimum one year follow-up (range 1 to 5 years). The mean HHS improved from 49.7 (10 to 79) to 86.3 (40 to 100). Forty-five (81%) patients were satisfied and nine (16%) patients were not satisfied with the outcome. The mean serum cobalt 24.5 (1.65 to 96.6) improved to 1.17 (0.31 to 6.99). Two patients died from unrelated diseases. There were 8 (14%) dislocations and one (1.8%) sciatic nerve palsy that has not recovered. Eight (14%) patients needed re-revision (dislocation: 5 and pain: 3). 26 % had severe soft tissue damage. Six patients have persistent pain and four had recurrent effusions. There were no dislocations in the most recent 50 cases. Discussion. Treatment of ARMD is technically demanding because extensive soft tissue damage can compromise stability. Early results in the current study were promising. Early intervention reduced the dislocation rate and appeared to have a positive impact on outcome. A small group of patients may have persistent pain and recurrent effusions that may require re-revision

Introduction. Metal on metal hip resurfacing (MoM HR) is attractive for young active patients. Patients with osteonecrosis of the femoral head (ONFH) are relatively young. HR can be an option of treatment, however, long-term stability of the femoral component is a concern because of the necrotic lesion in the femoral head. There is also a concern of ARMD for MoM implants. The purpose of this study is review a 10 year outcome of a consecutive patients with ONFH who underwent MoM HR. Methods. The subjects of this study were 30 hips of 26 patients with ONFH who underwent HR between 1998 and 2004. There were 21 hips of 18 males and 9 hips of 8 females. The average age at operation was 40 years (range, 20–63 years). 19 ONFHs were induced by steroid and 11 ONFHs were alcohol related. According to the Japanese Investigation Committee classification, there were 8 hips with Type C1 and 22 hips with Type C2. There were 16 hips in stage 3A, 7 hips in Stage 3B, and 7 hips in Stage 4. Operation was performed through a posterior approach. A fragile necrotic bone was curettage thoroughly and the defect was filled with cement. Results. The average Harris hip score improved from 61 preoperatively to 97 at the final follow-up. The average radiographic inclination of the cup was 43 degrees (34–54 degrees) and the average anteversion was 12 degrees (4– 22 degrees). There was no dislocation. One hip had a late hematogenous infection at 9 years after surgery. Two hips of two patients with alcoholic ONFH had a mechanical loosening of the femoral component at 10 year and 13 years after surgery. The survivorship with revision for aseptic loosening as the endpoint was 96% at 10 years. There was no ARMD by ultrasound echo screening. There was no stress shielding of the femur at the final radiographic examination. Conclusion. Our over 10 year results of MoM HR for ONFH showed a high Harris hip score without dislocation. Although this series included the initial learning curve of the HR procedure, the survivorship with revision for aseptic loosening as the endpoint at 10 years was high. There was no ARMD by ultrasound echogram. MoM HR is a good option of treatment for ONFH

Background. The failure and subsequent withdrawal of the ASR device in both its resurfacing and THR form has been well documented. The National Joint Registry report of 2010 quoted figures of 12–13% failure at five years. Adverse reaction to metal debris (ARMD) is a poorly understood condition and patients developing severe metal reactions may go unrecognised for sometime. Patients and Methods. In 2004 a single surgeons prospective study of the ASR bearing surface was undertaken. We present the ARMD failure rates of the ASR resurfacing and ASR THR systems. The diagnosis of ARMD was made by the senior author and was based on clinical history, examination, ultrasound findings, metal ion analysis of blood and joint fluid, operative findings and histopathological analysis of tissues retrieved at revision. Mean follow up was 52 months (24–81) and 70 patients were beyond 6 years of the procedure at the time of writing. Kaplan Meier survival analysis was carried out firstly with joints designated “failure” if the patient had undergone revision surgery or if the patient had been listed. A second survival analysis was carried out with a failure defined as a serum cobalt > 7µg/L. Full explant analysis was carried out for retrieved prostheses. Results. There were 505 ASR patients in total. 657 metal ion samples were available at the time of writing (152 repeats). Survival analysis using revision/listed as end point (at 6 years):. ASR resurfacing: 26.1% failure. ASR THR: 55.5% failure. Survival using ion analysis (at 5 years):. ASR resurfacing: 50.1% failure. ASR THR: 66.5% failure. The median (range) volumetric wear rate of failed prosthesis was 8.23mm. 3. /year (0.51–95.5). Conclusion. A number of design flaws in the ASR has led to excessive wear of the bearing & taper leading to catastrophic failure secondary to ARMD

A-70-year old woman underwent uncomplicated total hip arthroplasty using a titanium modular stem with a 46mm CoCr femoral head, a titanium shell, and a metal linear (Wright Medical Technology). Eight years after implantation, she presented with a painful left hip. A pelvic radiograph revealed adequate positioning of both hip implants without any signs of wear of loosening. CT scanning confirmed the presence of a 5 × 5 cm soft tissue mass in the ilium above the cup component accompanied by the iliac fracture. The patient was diagnosed as having an adverse reaction to metal debris (ARMD) after a metal-on-metal THA and revision was performed. Perioperatively?tissue necrosis and partial destruction of the abductor mechanism were found in the absence of any macroscopic infection. Both the neck trunnion and bore of the head showed slight signs of corrosion. The modular neck was revised with a ceramic 28mm head and a new dual-mobility liner(Zimmer Biomet). The iliac fracture was fixed with a porous trabecular metal augment(Zimmer Biomet). The histopathology of tissue sample revealed extensively necrotic material with focal cellular areas of inflammatory cells containing macrophages and neutrophilas. Metalic debris was also scattered in the necrotic materials. After the revision, the patient was recovered without pain or dislocation, and iliac fracture was well fixed. Instability is a substantial problem in the revision of ARMD. Extensive necrosis with gross deficiency of the abductor mechanism is associated with postoperative dislocation. Revision of failed MoM THA a dual-mobility device an effective strategy

This study reports the mid-term results of a large bearing uncemented metal on metal total hip replacement (MOMHTHR) matched series using the Synergy stem and Birmingham modular head in 36 hips (mean follow up 61 months). All patients underwent clinical, metal ion and MRI assessment. Wear analysis was performed on retrieved heads using Redlux non-contact optical profilometry. Seven patients (19%) have undergone revision surgery. All revisions had two or more of either symptoms, high metal ions or an MRI suggestive of an adverse reaction to metal debris (ARMD). There was no evidence of component malposition or impingement. Frank staining of tissues together with high volume dark brown fluid collections were found in all cases. All stems and cups were well fixed. In 4 cases pubic and ischial lysis (adjacent to the inferior fins) was observed. All 7 cases had radiological, intraoperative and histological evidence of ARMD (Figure 1). The failure cohort had significantly higher whole blood cobalt ion levels and OHS (p = 0.001), but no significant difference in cup size (p = 0.77), gender predominance, stem offset or cup position (p = 0.12). Sleeves had been used in all revision cases. Wear analysis (n = 4) demonstrated increased wear at the trunnion/sleeve interface in a distribution compatible with micromotion (Figure 2). There was normal wear at the articulating surface. This series further demonstrates unacceptable failure rates in LHMOMTHR in a series where a compatible stem for the BHR modular head was used. Use of a CoCr sleeve within a CoCr head taper appears to contribute to abnormal wear and therefore potential ARMD and subsequent failure

Introduction. We conducted independent wear analysis of retrieved metal on metal (MoM) hip components from around the world. All patients with resurfaced hips who developed adverse reactions to metal debris (ARMD) were found to have increased wear of the bearing surfaces. This was untrue in patients with large diameter (?36mm) MoM total hip replacements. This led us to search for other factors leading to ARMD. Methods. MoM THR explants retrieved from 78 patients suffering ARMD underwent full volumetric wear analysis of bearing surface and taper-junctions using coordinate measuring machine. Scanning electron microscopy (SEM) used to characterise material composition of specific areas. Results. 34 MoM THRs were found to have relatively low bearing surface wear (< 3mm. 3. /year). In each of these cases, material loss up to 60 microns wear depth was identified on the internal taper-junctions of femoral components. However, volumetric loss was rarely >5mm. 3. Similarly only 65% of metal ion levels of these patients were found to be greater than the MHRA guidance figure (7µg/L). Patterns of material loss at the tapers were consistent with antero-posterior force splaying open the taper-junction. This characteristic pattern was identified in number of commercially available devices (titanium and cobalt chromium stems). Soft tissue lesions were severe in patients found to have taper damage. Histology confirmed severe ALVAL with lymphoid neogenesis in majority cases, suggesting that wear debris from taper junctions may have greater potential to stimulate adverse immune response. Discussion. The results suggest that forces transmitted from large diameter hard-on-hard bearing surfaces are sufficient to cause mechanical damage to modular junctions with secondary localised corrosion. We urge caution in the use of these designs and recommend a re-evaluation of the stem head interface

Aims. Metal-on-metal total hip replacements (MoM THRs) are frequently revised. However, there is a paucity of data on clinical outcomes following revision surgery in this cohort. We report on outcomes from the largest consecutive series of revisions from MoM THRs and consider pre-revision factors which were prognostic for functional outcome. Materials and Methods. A single-centre consecutive series of revisions from MoM THRs performed during 2006–2015 was identified through a prospectively maintained, purpose-built joint registry. The cohort was subsequently divided by the presence or absence of symptoms prior to revision. The primary outcome was functional outcome (Oxford Hip Score (OHS)). Secondary outcomes were complication data, pre- and post-revision serum metal ions and modified Oxford classification of pre-revision magnetic resonance imaging (MRI). In addition, the study data along with demographic data was interrogated for prognostic factors informing on post-revision functional outcome. Results. 180 revisions in 163 patients were identified at a median follow-up of 5.48 (2–11.7) years. There were 152 (84.4%) in the symptomatic subgroup and 28 (15.6%) in the asymptomatic group. Overall median OHS improved from 29 to 37 with revision (P<0.001). Symptomatic patients experienced greater functional benefit (DOHS 6.5 vs. 1.4, p=0.012) compared to asymptomatic patients, though they continued to report inferior outcomes (OHS 36.5 vs 43, p=0.004). The functional outcome of asymptomatic patients was unaffected by revision surgery (pre-revision OHS 41, post-revision OHS 43, p=0.4). Linear regression analysis confirmed use of a cobalt-chrome (CoCr)-containing bearing surface (MoM or metal-on- polyethylene) at revision and increasing BMI were predictive of poor functional outcome (R. 2. 0.032, p=0.0224 and R. 2. 0.039, p=0.015 respectively). Pre- and post-revision serum metal ions and pre-revision MRI findings were not predictive of outcome. The overall complication rate was 36% (n=65) with a re-revision rate of 6.7%. The most common complication was ongoing adverse reaction to metal debris (ARMD, defined as positive post-revision MRI) in 21.1%. The incidence of ongoing ARMD was not significantly different between those with CoCr reimplanted and those without (p=0.12). Conclusions. To our knowledge, our study represents the largest single-centre consecutive series of revision THRs from MoM bearings in the literature. Symptomatic patients experience the greatest functional benefit from revision surgery but do not regain the same level of function as patients who were asymptomatic prior to revision. The re-implantation of CoCr as a primary bearing surface and increasing BMI was associated with poorer functional outcome

Introduction. The bearing surfaces of ceramic-on-ceramic (CoC) total hip replacements (THR) show a substantially lower wear rate than metal-on-polyethylene (MoP) THR in-vitro. However, revision rates for CoC THR are comparable with MoP. Our hypothesis that an explanation could be adverse reaction to metal debris (ARMD) from the trunnion led us to investigate the wear at both the bearing surfaces and the taper-trunnion interface of a contemporary CoC THR in an in-vitro study. Methods. Three 36mm CoC hips were tested in a hip simulator for 5 million cycles (Mc). BIOLOX. ®. delta ceramic femoral heads were mounted on 12/14 titanium (Ti6Al4V) trunnions. Wear of femoral heads, acetabular liners and trunnions was determined gravimetrically using the analytical balance. Roughness measurements (Sa) were taken on the articulating surfaces (pre and post-test) and on the trunnion surfaces (worn and unworn). Furthermore, Energy Dispersive X-ray Spectroscopy (EDX) was used to identify and quantify the wear debris present in the lubricant using scanning electron microscope (SEM). Results and Discussion. The total volumetric wear was 0.25 mm. 3. for CoC joints and 0.29 mm. 3. for titanium trunnions. The total wear volume of the titanium trunnions was in agreement with an explant study (Kocagoz et al, 2016, CORR) which quantified the volumetric material loss from retrieved trunnions with the total wear ranging from 0.0–0.74 mm. 3. The Sa values, pre-and post-test, for heads were 0.003 ± 0.002 and 0.004 ± 0.001 µm and for liners were 0.005 ± 0.001 and 0.005 ± 0.001 µm. Pre-and post-test measurements for Sa of heads (p = 0.184) and liners (p = 0.184) did not show a statistically significant change. The Sa of the trunnions on the unworn and worn areas showed a statistically significant decrease from 0.558 ± 0.060 to 0.312 ± 0.028 µm respectively (p < 0.001). Analysis of wear debris within the lubricant confirmed the presence of titanium. A recent clinical study (Matharu et al, 2016, BMC Musc Dis) found more ARMD in CoC hips than MoP hips. This is despite there being fewer metallic components in a CoC hip than a MoP hip. This in vitro study has shown that one source of metal debris in a CoC hip is the taper-trunnion junction. Conclusion. An explanation for wear related failures in ceramic-on-ceramic hip arthroplasty, despite the low wear arising at the articulating surfaces, may now exist; namely that titanium wear particles are generated from the trunnion. No other long-term hip simulator studies have measured wear at the taper-trunnion junction

Introduction. Metal-on-polyethylene (MoP) is the most commonly used bearing couple in total hip replacements (THRs). Retrieval studies (Cooper et al, 2012, JBJS, Lindgren et al, 2011, JBJS) report adverse reactions to metal debris (ARMD) due to debris produced from the taper-trunnion junction of the modular MoP THRs. A recent retrospective observational study (Matharu et al, 2016, BMC Musc Dis) showed that the risk of ARMD revision surgery is increasing in MoP THRs. To the authors' best knowledge, no hip simulator tests have investigated material loss from the taper-trunnion junction of contemporary MoP THRs. Methods. A 6-station anatomical hip joint simulator was used to investigate material loss at the articulating and taper-trunnion surfaces of 32mm diameter metal-on-cross-linked polyethylene (MoXLPE) joints for 5 million cycles (Mc) with a sixth joint serving as a dynamically loaded soak control. Commercially available cobalt-chromium-molybdenum (CoCrMo) femoral heads articulating against XLPE acetabular liners (7.5Mrad) were used with a diluted new-born-calf-serum lubricant. Each CoCrMo femoral head was mounted on a 12/14 titanium alloy trunnion. The test was stopped every 0.5Mc, components were cleaned and gravimetric measurements performed following ISO 14242-2 and the lubricant was changed. Weight loss (mg) obtained from gravimetric measurements was converted into volume loss (mm. 3. ) and wear rates were calculated from the slopes of the linear regression lines in the volumetric loss versus number of cycles plot for heads, liners and trunnions. Additionally, volumetric measurements of the head tapers were obtained using a coordinate measuring machine (CMM) post-test. The surface roughness (Sa) of all heads and liners was measured pre and post-test. At the end of the test, the femoral heads were cut and the roughness of the worn and unworn area was measured. Statistical analysis was performed using a paired-t-test (for roughness measurements) and an independent sample t-test (for wear rates). Results and Discussion. The mean volumetric wear rates for CoCrMo heads, XLPE liners and titanium trunnions were 0.019, 2.74 and 0.013 mm. 3. /Mc respectively. There was a statistically significant decrease (p<0.001) in the Sa of the liners post-test. This is in contrast to the femoral heads roughness in which no change was observed (p = 0.338). This head roughness result matches with a previous MoP in vitro test (Saikko, 2005, IMechE-H). The Sa of the head tapers on the worn area showed a statistically significant increase (p<0.001) compared with unworn, with an associated removal of the original machining marks. The mean volumetric wear rate of the head tapers obtained using the CMM (0.028 ± 0.016 mm. 3. /Mc) was not statistically different (p=0.435) to the mean volumetric wear rate obtained gravimetrically (0.019 ± 0.020 mm. 3. /Mc) for the femoral heads. Therefore, wear of the heads arose mainly from the internal taper. The mean wear rates of the CoCrMo taper and titanium trunnion are in agreement with a MoP explant study (Kocagoz et al, 2016, CORR). Conclusion. This is the first long-term hip simulator study to report wear generated from the taper-trunnion junction of MoP hips

There have been numerous reports regarding “pseudotumor” associated with hip arthroplasty. We present two reports in which main etiology in the pseudotumor formation was titanium (Ti), but not cobalt-chromium (Co-Cr). We should keep in mind that Ti analysis is essential in some cases. (Case 1) A 68-year-old male presented to our institution because of right hip pain and lower extremity swelling four years after a bipolar hemiarthroplasty. MRI predicted a cystic pseudotumor. However, revision surgical findings showed no apparent cause of ARMD previously described in the literatures. Postoperative analysis showed that the metal debris mainly originated from the Ti alloy itself. (Case reports in Orthopedics, vol.2014, Article ID 209461, 4 pages). (Case 2) A 77-year-old female presented to our institution because of right hip pain and swelling six years after a total hip arthroplasty using a cable trochanteric reattchment. Plain radiographs demonstrated evidences of severe osteolysis and multiple fragments of the broken cable. However, MRI predicted a psudotumor(See Figure 1). Postoperative analysis clarified that main etiology in the pseudotumor formation was the stem mede of Ti, but not the cable made of Co-Cr

All patients with a MOM THR implanted at our unit were recalled for clinical examination, Oxford hip score, radiographs, MARS MRI and cobalt/chromium ion levels. Patients were sub-classified, determining further follow up: a regular screening programme or referral to a revision arthroplasty surgeon. We identified 299 MOM THR's. 59 patients reported a recent deterioration in symptoms. 67 had an abnormal x-ray. 232 hips underwent MARS MRI: 66 showed mild MOM disease, 31 moderate MOM disease, 17 severe MOM disease. 117 had a substantial fluid collection around the hip. Serum cobalt/chromium ions were raised in 135 patients. 46 had one or both above 7 ppb. 148 THR's were referred to a revision surgeon. 21 have been revised and 14 are awaiting revision. In total 64 hips have been revised. 13 were histologically proven ALVAL, 19 had clinical findings of ALVAL (not histologically confirmed), and 1 non-specific reaction to metal wear. 53 asymptomatic patients had evidence of soft tissue reaction on MRI and/or rising metal ions. Our screening programme identified asymptomatic patients with evidence of a suspicious reaction to their MOM THR. We recommend all patients with a MOM THR are fully screened for ARMD regardless of symptoms and metal ion levels

We retrospectively reviewed the mid term outcome of 88 MoM THA in 84 patients and 21Hip Resurfacing using Recap Magnum bearing surface performed during 2006 – 2009. There were 41 males and 47 females in the THA group and 17 males and 4 females in the Hip Resurfacing group. All procedures were performed through a posterior approach. The average head size for the THR group was 46mm and the cup size was 52mm and the average head size for the resurfacing was 50mm and cup size was 56mm respectively. Median age for the THA group was 60 yrs. (28–73) and for the Resurfacing it was 51.5 yrs. (32–62). Average follow up was 76 months for the THA group and 78 months for the Resurfacing group. Average serum cobalt for the THA and the Resurfacing groups were 53.2nmol/l (119) and 30.85 and the Chromium levels were 82.44nmol/l(134.5) and 67.49 respectively. Eight MRI scans showed abnormal fluid collections suspicious of ARMD in the THA group and 2 showed fluid collection in the Resurfacing group. There were five revisions in the THA group with the tissue diagnosis of ALVAL. In all except one case a well fixed uncemented stem (Taperloc) was retained. In our series Recap Magnum on a Taperloc stem showed 94% survival at five years and therefore we continue to review the cases annually with serum cobalt chromium levels and MRI scans

Introduction. In recent years, an increasing number of reports related to adverse reactions to metal debris (ARMD) following metal-on-metal (MOM) total hip arthroplasty (THA) have been published. Some patients who experience ARMD require revision surgery. Objectives. In this study, we aimed to evaluate the mid-term results of MOM THA. Methods. We retrospectively reviewed all patients who underwent THA at JCHO Saitama medical center from January 2007 to December 2010. A metal liner and metal femoral head were used in 37 of 214 cases (17%). This sub-group comprised 2 men and 35 women (mean age at surgery, 63.5 years; range, 39–79 years). The original disease is 28 osteoarthritis, 5 osteonecrosis, 3 rheumatoid arthritis and 1 rapidly destructive hip coxarthropathy. We investigated the system type, size (cup, femoral head, and stem), and cup position (anteversion and inclination). Moreover, we used imaging (radiography and computed tomography [CT] or magnetic resonance imaging [MR]) to assess for aseptic loosening, metal hypersensitivity reactions, and pseudotumor formation. Results. Six women with osteoarthritis experienced significant localized soft tissue reactions, and underwent revision. The average duration to revision was 41months(range, 28–63). Of these, 4 patients had received the PINNACLE cup system (Depuy; 4/14, 28.6%) and 2 had received the M2a-Taper cup system (BIOMET; 2/23, 8.7%). The femoral head sizes of the PINNACLE system used was 36 mm, and the femoral head sizes of the M2q-Taper systems used were 28mm and 32mm. Four patients had no signs or symptoms, 1 patient complained of anterior thigh dullness and 1 patient had a dislocation. The average cup anteversion was 15.7 degrees (range, 10–19 degrees) and the average inclination was 49.2 degrees (range, 43–57 degrees). Conclusions. MOM THA was associated with a higher incidence of revision. The majority of cases that required revision had no severe signs or symptoms. Therefore, all cases of MOM THA should be assessed periodically using CT or MRI

The use of modular systems adds versatility to the implant system, better restoration of hip biomechanics and lower inventory to the hospital. There have been reports of high metal ions, ARMD reactions and high implant failure rates due to potential problems from taper failures. These are more common in metal-on-metal hip replacements, but are being also reported in other bearings. Between 2001 and 2010, we performed 383 consecutive metal-on-metal (MoM) THRs through a posterior approach, using a BHR cup and Birmingham modular head with one of three different stems, all with 12/14 tapers. The earliest 104 hips employed a cemented MS30 stem (Zimmer GmbH, Winterthur, Switzerland). Subsequent 256 were Synergy and then 23 Anthology (both uncemented and both Smith and Nephew Orthopaedics, Memphis TN USA). There was no significant difference in the average age at surgery (65.4 years cemented vs 65.6 uncemented, p = 0.69), gender ratio (1.68 vs 1.89, p = 0.64), or bearing diameter (46.7 vs 46.8, p = 0.31). The earlier 203 Synergy stems were monoblock heads, while the remaining uncemented stems included a tapered sleeve in addition. There were 3 deep infections and 11 debris-related failures (overall revision rate 4.9%). The revision rate from aseptic failures (ALTR, effusion, osteolysis or component loosening) is 2.87%. Kaplan-Meier analysis of the entire cohort showed a 10-year implant survival of 96.8% with revision for any reason as the end-point. Cemented stems had a 100% survival at 10 years and 98.6% at 12 years. The uncemented stems had a 93.8% survival at 10 years. Within the uncemented group, the monoblocks had a 5 and 10-year survival of 99.0% and 96.4% respectively while the sleeved had 98.7% (5 years) and 96.3% (7 years) and 82.5% at 8 years. Retreival analysis showed clear evidence of taper failure. Our experience suggests taper failure leading to ALTRs and its sequelae. Others have reported ALTR type reactions in metal on polyethylene and ceramic on polyethylene bearing types as well in bearing diameters ranging from 28mm to 40mm. There is a need to improve taper design especially for use with large heads, and in high demand patients

It's easy to say that hip resurfacing is a failed technology. Journals and lay press are replete with negative reports concerning metal-on-metal bearing failures, destructive pseudotumors, withdrawals and recalls. Reviews of national joint registries show revision risks with hip resurfacing exceeding those of traditional total hip replacement, and metal bearings fare worst among all bearing couples. Yet, that misses the point. Modern hip resurfacing was never meant to replace total hip replacement (THR). It was intended to preserve bone in young patients who would be expected to need multiple revisions due to their youth and high-demand activities. The stated goal of the developers of the Birmingham Hip Resurfacing (BHR) was to delay THR by 10 years. In the two decades that followed the release of BHR, this goal has been met and exceeded. Much has been learned about indications, patient selection, and surgical technique. We now know that this highly specialised, challenging procedure is best indicated in the young, active male with osteoarthritis, as a complementary, not competitive procedure, to THR. Resurfacing has many advantages. First and foremost, it saves bone, on the day of surgery, and over the next several years by preventing stress shielding. Dislocations are very rare. Leg length discrepancy and changes in offset are avoided. Post-operative activity, including heavy manual labor and contact sports, is unrestricted. More normal loading of the femur and joint stability has allowed professional athletes to regain their careers. Femoral side revisions, if necessary, are simple total hips, and dual mobility constructs allow one to keep the socket. Adverse reactions to metal debris (ARMD), including pseudotumors, have generated great concern. Initially described only in women, it was unclear whether the etiology was allergy, toxicity, or inflammation. A better understanding of the wear properties of the bearing, and its relation to size, anteversion, hip dysplasia and metallurgy, along with retrieval analysis, allow us to conclude that it is excessive wear due to edge loading which is the fundamental mechanism for the vast majority of ARMD. Thus, patient selection, implant selection and surgical technique, the orthopaedic triad, are paramount. What has been most impressive are the truly exceptional results in young, active men. The worst candidates for THR turn out to be the best candidates for resurfacing. The ability to return to full, unrestricted activity is just as important to these patients as the spectacular survivorship in centers specializing in resurfacing. If they are unlucky and face a revision, they are not facing the life-changing outcomes of a long revision femoral stem. So if the best indication for hip resurfacing is the young, active male, let's look at the results of resurfacing these patients in centers with high volumes, using devices with a good track record, such as BHR. Several centers around the world report 10–18 year success rates of BHR in males under 50 at 98–100%. Return to athletics is routinely achieved, and even professional athletes have regained their careers. Hip resurfacing doesn't have to be better than THR to be popular among patients. Just the idea of saving all that bone makes it attractive. In the young active male, however, the results exceed those of THR, while leaving better revision options for the future. This justifies its continued use in this challenging patient population

Introduction. Metal on metal hip arthroplasty continues to be controversial. Emerging evidence suggests that there are multiple modes of failure, and that the results of revision surgery are influenced by host and implant factors. Methods. This study compares a single surgeon series of hip resurfacings (Birmingham Hip Resurfacing {BHR}) and large diameter metal on metal total hip replacements (LDMOMTHR). Primary outcome measures included survival rates, failure secondary to histologically identified Adverse Reaction to Metal Debris (ARMD), and patient reported outcome measures (Oxford Hip Score {OHS}) following revision. Between 1999 and 2005, 458 BHR and 175 LDMOMTHR were performed. At latest review 43 BHR's (9.4%) and 28 LDMOMTHR's (14%) have been revised. Results. Failure secondary to ARMD was significantly greater in LDMOMTHR compared to BHR failures (89% and 16% respectively). Histology demonstrated a higher Aseptic Lymphocytic Vascular and Associated Lesions (ALVAL) score in the LDMOMTHR failures than the BHR failures (8.6 LDMOMTHR, 6.3 BHR). Patient reported outcomes were better following revision for failed BHR compared to LDMOMTHR. There was no difference between the revision cohorts for cup inclination, metal ion levels and gender. Failure of the BHR has predominantly been due to those causes unique to resurfacing such as avascular necrosis and fracture. In our series, aggressive ALVAL was unusual and clinical outcome following revision was superior compared to LDMOMTHR failures. The likely mechanisms that are responsible for the differences in outcome and the clinical implications will be discussed

The histopathology of periprosthetic tissues has been important to understanding the relationship between wear debris and arthroplasty outcome. In a landmark 1977paper, Willert and Semlitsch (1) used a semiquantitative rating to show that tissue reactions largely reflected the extent of particulate debris. Notably, small amounts of debris, including metal, could be eliminated without “overstraining the tissues” but excess debris led to deleterious changes. Currently, a plethora of terms is used to describe tissues from metal-on-metal (M-M) hips and corroded modular connections. We reviewed the evaluation and reporting of local tissue reactions over time, and asked if a dose response has been found between metal and tissue features, and how the use of more standardized terms and quantitative methodologies could reduce the current confusion in terminology. Methods. The PubMed database was searchedbetween 2000 and 2015 for papers using “metal sensitivity /allergy /hypersensitivity, Adverse Local Tissue Reaction (ALTR): osteolysis, metallosis, lymphocytic infiltration, Aseptic Lymphocytic Vasculitis-Associated Lesions (ALVAL), Adverse Reaction to Metal Debris (ARMD) or pseudotumor/ pseudotumour” as well as metal-on-metal / metal-metal AND hip arthroplasty/replacement. Reports lacking soft tissue histological analysis were excluded. Results. 131 articles describing M-M tissue histology were found. In earlier studies, the terms metal sensitivity / hypersensitivity /allergy implied or stated the potential for a Type IV delayed type hypersensitivity response as a reason for revision. More recently those terms have largely been replaced by broader terms such as ALTR, ALVAL and ARMD. ALVAL and metal hypersensitivity were often used interchangeably, both as failure modes and histological findings. Several histology scoring systems have been published but were only used in a limited number of studies. Correlations of histological features with metal levels or component wear were inconclusive, typically because of a high degree of variability. Interestingly, there were very few descriptions that concluded that the observed reactions were benign / normal or anticipated i.e. regardless of the histological features, extent of debris or failure mode, the histology was interpreted as showing an adverse reaction. Discussion. There is now an expanded set of terms to describe tissues but they lack clear definitions and typically do not use quantitative histological data to describe a wide range of periprosthetic reactions to metal. Lower limits of inflammation, necrosis or re-organization that represent a “normal” reaction to surgery and/or small amounts of wear debris are not clearly defined and are rarely discussed. The widespread adoption of the term “adverse” in the present tissue lexicon implies a cause and effect relationship between metal wear and corrosion products and histological features even though this has yet to be determined. The use of quantitative histological scores rather than subjective histological descriptions is imperative to improve the understanding and reporting of the range of periprosthetic reactions. In particular, a new lexicon that allows for a level of tissue reaction that is not misinterpreted as adverse is required

As there are many reports describing avascular reactions to metal debris (ARMD) after Metal-on-Metal Hip Arthroplasty (MoMHA), the use of MoMHA, especially hip resurfacing, is decreasing worldwide. In cases of ARMD or a rise of metal ion blood levels, revision is commended even in pain free patients with a well integrated implant. The revision of a well integrated implant will cause bone loss. As most of the patients with a hip resurfacing are young and a good bone stock is desirable for further revision surgeries, the purpose of this study was to evaluate the stability of a cemented polyethylene cup in a metal hip resurfacing cup. Two different hip resurfacing systems were investigated in this study (ASR™, DePuy Orthopaedics, Leatherhead, UK; Cormet™, Corin Group, Cirencester, UK). Six different groups were formed according to the treatment and preparation of the cement-cup-interface (table 1). Before instilling cement in groups 1, 3, 5 the surface, which was contaminated with blood, was cleaned just using a gauze bandage. In groups 2, 4, 6 saline, polyhexanid and a gauze were used to clean the surface prior to the cement application. In group one and two the polyethylene cup (PE) was cemented either into Cormet™ or ASR™, just the ASR™ was further investigated in group three to six. A monoaxial load was applied while the cup was fixed with 45 degrees inclination (group 1–4) and 90 degrees inclination (group 5, 6: rotatory stability) and the failure torque was measured. In contrast to group 1 and 2, the cement penetrated the peripheral groove of the ASR™ in groups 3–6. The mean failure torque of five tests for each group was compared between the groups and the implants. The ASR™ showed mean failure torque of 0.1 Nm in group one, of 0.14 Nm in group two, of 56.9 Nm in group three, of 61.5 Nm in group four, of 2.96 Nm in group five and of 3.04 Nm in group six. The mean failure torque of the Cormet™ was 0.14 Nm both in groups one and two (table 2). In groups 1–6 there were no significant differences between the different preparations of the interface. Furthermore, in groups 1 and 2 there were no significant differences between the Cormet™ and the ASR™. The mean failure torque of group 4 was significant increased compared to group 3 (p=0.008). We saw an early failure of the cement fixation due to the smooth surface of the Cormet™ and the ASR™ components in groups 1, 2, 5, 6. In contrast to other hip resurfacing cups the ASR™ has a peripheral groove, which was not cemented except in groups 3 and 4 and therefore the lever-out failure torque was significant increased in these groups. Nevertheless, the groove did not provide stability of the cement-PE compound in case of rotatory movements. In conclusion we do not recommend the use of these methods in clinical routine. The complete removal of hip resurfacing components seems to be the most reasonable procedure