What Causes Unexplained Pain in Patients With Metal-on metal Hip Devices? A Retrieval, Histologic, and Imaging Analysis
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Adverse tissue reactions associated with metal-on-metal (MOM) hips are common in resurfacing and total hip arthroplasty (THA) designs. The etiology of these reactions in painful, well-positioned arthroplasties is inconsistently described.
The purposes of this study were to compare the (1) articular wear rates; (2) histologic findings; (3) synovial response on MRI; and (4) graded intraoperative tissue damage between well-positioned, MOM hips revised for unexplained pain and MOM hips revised for other reasons and to (5) determine whether the presence of a taper junction on a MOM articulation affects these four parameters in unexplained pain.
We retrospectively studied 88 patients (94 hips) who had undergone revision of either a hip resurfacing or a large-head (> 36 mm) THA. Thirty-five hips revised for unexplained pain were compared with a control group of 59 hips revised for other causes. Articular wear was measured using three-dimensional contactless metrology and histologic analysis was performed using the aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) score. Preoperative MRI was performed on 57 patients to determine synovial volumes and thicknesses. Tissue damage was graded from intraoperative reports.
Articular wear rates in the unexplained pain group were lower than in the control group (median 2.6 μm/year versus 12.8 μm/year, p < 0.001). Sixty-six percent of patients in the unexplained pain group had histologic confirmation of ALVAL compared with 19% in the control group (p < 0.001). The synovial thickness on MRI was higher in the unexplained pain group (p = 0.04) and was highly predictive of ALVAL. Severe intraoperative tissue damage was noted in more cases in the unexplained pain group (p = 0.01). There were no differences in articular wear, histology, MRI, and tissue damage between resurfacings and THAs revised for unexplained pain.
Unexplained pain in patients with well-positioned MOM hips warrants further investigation with MRI to look for features predictive of ALVAL. Tissue destruction in these cases does not appear to be related to high bearing wear or the presence of a taper.
Level of Evidence
Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
- Amstutz HC, Le Duff MJ, Campbell PA, Wisk LE, Takamura KM. Complications after metal-on-metal hip resurfacing arthroplasty. Orthop Clin North Am. 2011;42:207–230. CrossRef
- Amstutz HC, Le Duff MJ, Johnson AJ. Socket position determines hip resurfacing 10-year survivorship. Clin Orthop Relat Res. 2012;470:3127–3133. CrossRef
- Australian Orthopedic Association. National Joint Replacement Registry Report. Annual Report. Adelaide: AOA; 2011. Available at: www.aoa.org.au. Accessed June 15, 2013.
- Bozic KJ, Kurtz S, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. The epidemiology of bearing surface usage in total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91:1614–1620. CrossRef
- Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC. Histological features of pseudotumor-like tissues from metal-on-metal hips. Clin Orthop Relat Res. 2010;468:2321–2327. CrossRef
- Chana R, Esposito C, Campbell PA, Walter WK, Walter WL. Mixing and matching causing taper wear: corrosion associated with pseudotumour formation. J Bone Joint Surg Br. 2012;94:281–286. CrossRef
- Cooper HJ, Della Valle CJ, Berger RA, Tetreault M, Paprosky WG, Sporer SM, Jacobs JJ. Corrosion at the head-neck taper as a cause for adverse local tissue reactions after total hip arthroplasty. J Bone Joint Surg Am. 2012;94:1655–1661.
- De Haan R, Campbell PA, Su EP, De Smet KA. Revision of metal-on-metal resurfacing arthroplasty of the hip: the influence of malpositioning of the components. J Bone Joint Surg Br. 2008;90:1158–1163. CrossRef
- De Steiger RN, Hang, JR, Miller LN, Graves SE, Davidson DC. Five-year results of the ASR XL acetabular system and the ASR hip resurfacing system. An analysis from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am. 2011;93:2287–2293. CrossRef
- Donell ST, Darrah C, Nolan JF, Wimhurst J, Toms A, Barker TH, Case CP, Tucker JK. Norwich Metal-on-Metal Study Group. Early failure of the Ultima metal-on-metal total hip replacement in the presence of normal plain radiographs. J Bone Joint Surg Br. 2010;92:1501–1508. CrossRef
- Ebramzadeh E, Campbell PA, Takamura KM, Lu Z, Sangiorgio SN, Kalma JJ, De Smet KA, Amstutz HC. Failure modes of 433 metal-on-metal hip implants: how, why, and wear. Orthop Clin North Am. 2011;42:241–250. CrossRef
- Garbuz DS, Tanzer M, Greidanus NV, Masri BA, Duncan CP. The John Charnley Award: Metal-on-metal hip resurfacing versus large-diameter head metal-on-metal total hip arthroplasty: a randomized clinical trial. Clin Orthop Relat Res. 2010;468:318–325. CrossRef
- Glyn-Jones S, Roques A, Taylor A, Kwon YM, McLardy-Smith P, Gill HS, Walter W, Tuke M, Murray D. The in vivo linear and volumetric wear of hip resurfacing implants revised for pseudotumor. J Bone Joint Surg Am. 2011;93:2180–2188. CrossRef
- Goldberg JR, Gilbert JL, Jacobs JJ, Bauer TW. A multicenter retrieval study of the hip prostheses. Clin Orthop Relat Res. 2002;401:149–161. CrossRef
- Grammatopolous G, Pandit H, Kamali A, Maggiani F, Glyn-Jones S, Gill HS, Murray DW, Athanasou N. The correlation of wear with histological features after failed hip resurfacing arthroplasty. J Bone Joint Surg Am. 2013;95:e811-10.
- Hart AJ, Ilo K, Underwood R, Cann P, Henckel J, Lewis A, Cobb J, Skinner J. The relationship between the angle of version and rate of wear of retrieved metal-on-metal resurfacings: a prospective, CT-based study. J Bone Joint Surg Br. 2011;93:315–320. CrossRef
- Hart AJ, Matthies A, Henckel J, Ilo K, Skinner J, Noble P. Understanding why metal-on-metal hip arthroplasties fail. A comparison between patients with well-functioning and revised Birmingham Hip Resurfacing arthroplasties. J Bone Joint Surg Am. 2012;94:1–10.
- Hart AJ, Sabah SA, Bandi AS, Maggiore P, Tarassoli P, Sampson B, Skinner JA. Sensitivity and specificity of blood cobalt and chromium metal ions for predicting failure of metal-on-metal hip replacement. J Bone Joint Surg Br. 2011;93:1308–1313. CrossRef
- Hart AJ, Sabah SA, Henckel J, Lewis A, Cobb J, Sampson B, Mitchell A, Skinner JA. The painful metal-on-metal hip resurfacing. J Bone Joint Surg Br. 2009;91:738–744. CrossRef
- Hart AJ, Satchithananda K, Liddle AD, Sabah SA, McRobbie D, Henckel J, Cobb JP, Skinner JA, Mitchell AW. Pseudotumors in association with well-functioning metal-on-metal hip prostheses: a case-control study using three-dimensional computed tomography and magnetic resonance imaging. J Bone Joint Surg Am. 2012;94:317–325.
- Hart AJ, Skinner JA, Henckel J, Sampson B, Gordon F. Insufficient acetabular version increases blood metal ion levels after metal-on-metal hip resurfacing. Clin Orthop Relat Res. 2011;469:2590–2597. CrossRef
- Heisel C, Streich N, Krachler M, Jakubowitz E, Kretzer JP. Characterization of the running-in period in total hip resurfacing arthroplasty: an in vivo and in vitro metal ion analysis. J Bone Joint Surg Am. 2008;90:125–134. CrossRef
- Huber M, Reinisch G, Trettenhahn G, Zweymüller K, Lintner F. Presence of corrosion products and hypersensitivity-associated reactions in periprosthetic tissue after aseptic loosening of total hip replacements with metal bearing surfaces. Acta Biomaterialia. 2009;5:172–180. CrossRef
- Jack CM, Walter WL, Shimmin AJ, Cashman K, de Steiger RN. Large diameter metal on metal articulations. Comparison of total hip arthroplasty and hip resurfacing arthroplasty. J Arthroplasty. 2013;28:650–653. CrossRef
- Kwon YM, Glyn-Jones S, Simpson DJ, Kamali A, McLardy-Smith P, Gill HS, Murray DW. Analysis of wear of retrieved metal-on-metal hip resurfacing implants revised due to pseudotumours. J Bone Joint Surg Br. 2010;92:356–361. CrossRef
- Kwon YM, Xia Z, Glyn-Jones S, Beard D, Gill HS, Murray DW. Dose-dependent cytotoxicity of clinically relevant cobalt nanoparticles and ions on macrophages in vitro. Biomed Mater. 2009;4:025018. CrossRef
- Langton DJ, Jameson SS, Joyce TJ, Gandhi JN, Sidaginamale R, Mereddy P, Lord J, Nargol AV. Accelerating failure rate of the ASR total hip replacement. J Bone Joint Surg Br. 2011;93:1011–1016. CrossRef
- Langton DJ, Jameson SS, Joyce TJ, Hallab NJ, Natu S, Nargol AV. Early failure of metal-on-metal bearings in hip resurfacing and large-diameter total hip replacement: a consequence of excess wear. J Bone Joint Surg Br. 2010;92:38–46. CrossRef
- Langton DJ, Joyce TJ, Jameson SS, Lord J, Van Orsouw M, Holland JP, Nargol AV, De Smet KA. Adverse reaction to metal debris following hip resurfacing: the influence of component type, orientation and volumetric wear. J Bone Joint Surg Br. 2011;93:164–171. CrossRef
- Langton DJ, Sprowson AP, Joyce TJ, Reed M, Carluke I, Partington P, Nargol AV. Blood metal ion concentrations after hip resurfacing arthroplasty: a comparative study of articular surface replacement and Birmingham Hip Resurfacing arthroplasties. J Bone Joint Surg Br. 2009;91:1287–1295. CrossRef
- Langton DJ, Sprowson AP, Mahadeva D, Bhatnagar S, Holland JP, Nargol AV. Cup anteversion in hip resurfacing: validation of EBRA and the presentation of a simple clinical grading system. J Arthroplasty. 2010;25:607–613. CrossRef
- Lewinnek GE, Lewis JL, Tarr R, Compere CL, Zimmerman JR. Dislocations after total hip-replacement arthroplasties. J Bone Joint Surg Am. 1978;60:217–220.
- Malek IA, King A, Sharma H, Malek S, Lyons K, Jones S, John A. The sensitivity, specificity and predictive values of raised plasma metal ion levels in the diagnosis of adverse reaction to metal debris in symptomatic patients with a metal-on-metal arthroplasty of the hip. J Bone Joint Surg Br. 2012;94:1045–1050. CrossRef
- Matthies A, Skinner JA, Osmani H, Henckel J, Hart AJ. Pseudotumors are common in well-positioned low-wearing metal-on-metal hips. Clin Orthop Relat Res. 2012;470:1895–1906. CrossRef
- Matthies A, Underwood R, Cann P, Ilo K, Nawaz Z, Skinner J, Hart AJ. Retrieval analysis of 240 metal-on-metal hip components, comparing modular total hip replacement with hip resurfacing. J Bone Joint Surg Br. 2011;93:307–314. CrossRef
- McArthur B, Cross M, Geatrakas C, Mayman D, Ghelman B. Measuring acetabular component version after THA: CT or plain radiograph? Clin Orthop Relat Res. 2012;470:2810–2818. CrossRef
- Meyer H, Mueller T, Goldau G, Chamaon K, Ruetschi M, Lohmann CH. Corrosion at the cone/taper interface leads to failure of large-diameter metal-on-metal total hip arthroplasties. Clin Orthop Relat Res. 2012;470:3101–3108. CrossRef
- Natu S, Sidaginamale RP, Gandhi J, Langton DJ, Nargol AV. Adverse reactions to metal debris: histopathological features of periprosthetic soft tissue reactions seen in association with failed metal on metal hip arthroplasties. J Clin Pathol. 2012;65:409–418. CrossRef
- Nawabi DH, Gold S, Lyman S, Fields K, Padgett DE, Potter HG. MRI predicts ALVAL and tissue damage in metal-on-metal hip arthroplasty. Clin Orthop Relat Res. 2013 Jan 26 [Epub ahead of print].
- Nawabi DH, Hayter CL, Su EP, Koff MF, Perino G, Gold SL, Koch KM, Potter HG. Magnetic resonance imaging findings in symptomatic versus asymptomatic subjects following metal-on-metal hip resurfacing arthroplasty. J Bone Joint Surg Am. 2013;95:895–902. CrossRef
- Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CL, Ostlere S, Athanasou N, Gill HS, Murray DW. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90:847–851. CrossRef
- Potter HG, Foo LF. Magnetic resonance imaging of joint arthroplasty. Orthop Clin North Am. 2006;37:361–373. CrossRef
- Potter HG, Nestor BJ, Sofka CM, Ho ST, Peters LE, Salvati EA. Magnetic resonance imaging after total hip arthroplasty: evaluation of periprosthetic soft tissue. J Bone Joint Surg Am. 2004;86:1947–1954.
- Tuke M, Taylor A, Roques A, Maul C. 3D Linear and volumetric wear measurement on artificial hip joints—validation of a new methodology. Precision Engineering. 2010;34:777–783. CrossRef
- Willert HG, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, Lohmann CH. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am. 2005;87:28–36. CrossRef
- Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS. Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am. 2011;93:2164–2171. CrossRef
- What Causes Unexplained Pain in Patients With Metal-on metal Hip Devices? A Retrieval, Histologic, and Imaging Analysis
Clinical Orthopaedics and Related Research®
Volume 472, Issue 2 , pp 543-554
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- 1. Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
- 2. Epidemiology and Biostatistics Core, Hospital for Special Surgery, New York, NY, USA
- 3. Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA
- 4. Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, USA