Advertisement

Skeletal Radiology

, Volume 45, Issue 1, pp 115–125 | Cite as

No association between pseudotumors, high serum metal-ion levels and metal hypersensitivity in large-head metal-on-metal total hip arthroplasty at 5–7-year follow-up

  • Mette Holm HjorthEmail author
  • Maiken Stilling
  • Kjeld Soballe
  • Lars Hans Bolvig
  • Jacob Pontoppidan Thyssen
  • Inger Mechlenburg
  • Stig Storgaard Jakobsen
Scientific Article

Abstract

Objective

The relationship between metal wear debris, pseudotumor formation and metal hypersensitivity is complex and not completely understood. The purpose of this study was to assess the prevalence of pseudotumor formation in a consecutive series of metal-on-metal (MoM) total hip arthroplasty (THA) and to investigate its relationship to serum metal-ion levels and hypersensitivity to metal.

Methods

Forty-one patients (31 males), mean age 52 (28–68) years, with a total of 49 large-head MoM THA participated in a 5–7-year follow-up study. Patients underwent ultrasonography, serum metal-ion concentrations were measured, metal allergy and atopic dermatitis were evaluated, and the questionnaires of the Oxford Hip Score (OHS), Harris Hip Score (HHS) and the Short-Form Health Survey (SF-36) were completed.

Results

Pseudotumors were found in eight patients, but they were asymptomatic and their serum metal-ion levels were similar to those observed in patients with no pseudotumors (p > 0.36). The capsule-stem distance of mean 8.6 mm (SD 3.82, 95 % CI: 5.40–11.79) was wider (p = 0.02) in patients with pseudotumours than in patients without pseudotumors of mean 5.6 mm (SD 2.89, 95 % CI: 4.68–6.58). Positive patch test reactions were seen in three patients. Higher serum metal-ion levels of chromium and cobalt were significantly correlated with steeper cup inclination and smaller femoral head sizes, and were associated with female gender (p < 0.04).

Conclusion

We found no association between pseudotumor formation, serum metal-ion levels, metal patch test reactivity, and atopic dermatitis. However, clinicians should be aware of asymptomatic pseudotumors, and we advise further exploration into the mechanisms involved in the pathogenesis of pseudotumors.

Keywords

Large-head MoM THA Ultrasonography Pseudotumor Serum metal-ion levels Metal hypersensitivity 

Notes

Acknowledgements

We thank Lone Løvgren, Rikke Mørup, and Inger Krog-Mikkelsen for their help with arranging the 5–7-year follow-up.

Authors’ contributions

All authors made substantive intellectual contributions to this study to qualify as authors. MHH, KS, MS, IM, JSS, LB, and JPT were involved in the study hypothesis and follow-up examinations. MHH performed the data analyses and wrote the initial manuscript. MS, IM, KS, JSS, LB, and JPT helped revise it. All authors read and approved the final manuscript.

Compliance with ethical standards

Competing interests

The authors declare that they have no competing interests.

References

  1. 1.
    Bolland BJ, Culliford DJ, Langton DJ, Millington JP, Arden NK, Latham JM. High failure rates with a large-diameter hybrid metal-on-metal total hip replacement: clinical, radiological and retrieval analysis. J Bone Joint Surg Br. 2011;93(5):608–15.CrossRefPubMedGoogle Scholar
  2. 2.
    Gill IP, Webb J, Sloan K, Beaver RJ. Corrosion at the neck-stem junction as a cause of metal ion release and pseudotumour formation. J Bone Joint Surg Br. 2012;94(7):895–900.CrossRefPubMedGoogle Scholar
  3. 3.
    Malviya A, Ramaskandhan JR, Bowman R, Hashmi M, Holland JP, Kometa S, et al. What advantage is there to be gained using large modular metal-on-metal bearings in routine primary hip replacement? A preliminary report of a prospective randomised controlled trial. J Bone Joint Surg Br. 2011;93(12):1602–9.CrossRefPubMedGoogle Scholar
  4. 4.
    Pandit H, Glyn-Jones S, McLardy-Smith P, Gundle R, Whitwell D, Gibbons CL, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90(7):847–51.CrossRefPubMedGoogle Scholar
  5. 5.
    Goodman SB. Wear particles, periprosthetic osteolysis and the immune system. Biomaterials. 2007;28(34):5044–8.PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Willert HG, Buchhorn GH, Fayyazi A, Flury R, Windler M, Koster G, et al. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints: a clinical and histomorphological study. J Bone Joint Surg Am. 2005;87(1):28–36.CrossRefPubMedGoogle Scholar
  7. 7.
    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(1):38–46.CrossRefPubMedGoogle Scholar
  8. 8.
    Medicines and Healthcare products Regulatory Agency. Medical device alert: all metal-on-metal (MoM) hip replacements. 2010 (MDA/2010/03). London: MHPRA. 2010 [cited 2014 April 03]. Available from: http://www.mhra.gov.uk/home/groups/dts-bs/documents/medicaldevicealert/con079162.pdf
  9. 9.
    Lombardi Jr AV, Barrack RL, Berend KR, Cuckler JM, Jacobs JJ, Mont MA, et al. The Hip Society: algorithmic approach to diagnosis and management of metal-on-metal arthroplasty. J Bone Joint Surg Br. 2012;94(11 Suppl A):14–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Sofka CM, Potter HG, Adler RS, Pavlov H. Musculoskeletal imaging update: current applications of advanced imaging techniques to evaluate the early and long-term complications of patients with orthopedic implants. HSS J. 2006;2(1):73–7.PubMedCentralCrossRefPubMedGoogle Scholar
  11. 11.
    Bosker BH, Ettema HB, Boomsma MF, Kollen BJ, Maas M, Verheyen CC. High incidence of pseudotumour formation after large-diameter metal-on-metal total hip replacement: a prospective cohort study. J Bone Joint Surg Br. 2012;94(6):755–61.CrossRefPubMedGoogle Scholar
  12. 12.
    Hart AJ, Satchithananda K, Liddle AD, Sabah SA, McRobbie D, Henckel J, et al. 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(4):317–25.PubMedGoogle Scholar
  13. 13.
    Chang EY, McAnally JL, Van Horne JR, Statum S, Wolfson T, Gamst A, et al. Metal-on-metal total hip arthroplasty: do symptoms correlate with MR imaging findings? Radiology. 2012;265(3):848–57.CrossRefPubMedGoogle Scholar
  14. 14.
    Donell ST, Darrah C, Nolan JF, Wimhurst J, Toms A, Barker TH, et al. 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(11):1501–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Matthies AK, 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(7):1895–906.PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Thomas P, Braathen LR, Dorig M, Aubock J, Nestle F, Werfel T, et al. Increased metal allergy in patients with failed metal-on-metal hip arthroplasty and peri-implant T-lymphocytic inflammation. Allergy. 2009;64(8):1157–65.CrossRefPubMedGoogle Scholar
  17. 17.
    Malajian D, Belsito DV. Cutaneous delayed-type hypersensitivity in patients with atopic dermatitis. J Am Acad Dermatol. 2013;69(2):232–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Biomet. M2a-Magnum large metal articulation: design rationale. Warsaw, IN: Biomet; 2009 [cited 2014 April 07]. Available from: http://www.biomet.com/campaign/trueAlternativeBearings/BOI03400MagnumDesignRationale.pdf
  19. 19.
    Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, et al. The use of the Oxford hip and knee scores. J Bone Joint Surg Br. 2007;89(8):1010–4.CrossRefPubMedGoogle Scholar
  20. 20.
    Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty—an end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51(4):737–55.PubMedGoogle Scholar
  21. 21.
    Bjorner JB, Thunedborg K, Kristensen TS, Modvig J, Bech P. The Danish SF-36 Health Survey: translation and preliminary validity studies. J Clin Epidemiol. 1998;51(11):991–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Craig JG. Ultrasound of the postoperative hip. Semin Musculoskelet Radiol. 2013;17(1):49–55.CrossRefPubMedGoogle Scholar
  23. 23.
    Long SS, Surrey D, Nazarian LN. Common sonographic findings in the painful hip after hip arthroplasty. J Ultrasound Med. 2012;31(2):301–12.PubMedGoogle Scholar
  24. 24.
    Hailer NP, Bengtsson M, Lundberg C, Milbrink J. High metal ion levels after use of the ASR device correlate with development of pseudotumors and T cell activation. Clin Orthop Relat Res. 2014;472(3):953–61.Google Scholar
  25. 25.
    Cervini P, Hesley GK, Thompson RL, Sampathkumar P, Knudsen JM. Incidence of infectious complications after an ultrasound-guided intervention. AJR Am J Roentgenol. 2010;195(4):846–50.CrossRefPubMedGoogle Scholar
  26. 26.
    Dramis A, Aldlyami E, Grimer RJ, Dunlop DJ, O’Connell N, Elliott T. What is the significance of a positive Propionibacterium acnes culture around a joint replacement? Int Orthop. 2009;33(3):829–33.PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    Becton Dickinson. Franklin Lakes, NJ: Becton Dickinson. 2013 [cited 2014 May 01]. http://www.bd.com/resource.aspx?IDX=10155
  28. 28.
    Thyssen JP, Linneberg A, Menne T, Nielsen NH, Johansen JD. The association between hand eczema and nickel allergy has weakened among young women in the general population following the Danish nickel regulation: results from two cross-sectional studies. Contact Dermatitis. 2009;61(6):342–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001;83-A(3):428–36.PubMedGoogle Scholar
  30. 30.
    MacDonald SJ, Brodner W, Jacobs JJ. A consensus paper on metal ions in metal-on-metal hip arthroplasties. J Arthroplasty. 2004;19(8 Suppl 3):12–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Penny JO, Overgaard S. Serum chromium levels sampled with steel needle versus plastic IV cannula: does method matter? J Biomed Mater Res B Appl Biomater. 2010;92(1):1–4.CrossRefPubMedGoogle Scholar
  32. 32.
    Papageorgiou I, Yin Z, Ladon D, Baird D, Lewis AC, Sood A, et al. Genotoxic effects of particles of surgical cobalt chrome alloy on human cells of different age in vitro. Mutat Res. 2007;619(1–2):45–58.CrossRefPubMedGoogle Scholar
  33. 33.
    DeLee JG, Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop Relat Res. 1976;121:20–32.PubMedGoogle Scholar
  34. 34.
    Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;141:17–27.PubMedGoogle Scholar
  35. 35.
    Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement: incidence and a method of classification. J Bone Joint Surg Am. 1973;55(8):1629–32.PubMedGoogle Scholar
  36. 36.
    Altman DG. Practical statistics for medical research. London: Chapman and Hall, 2009. ISBN 9780412276309Google Scholar
  37. 37.
    Nishii T, Sakai T, Takao M, Yoshikawa H, Sugano N. Ultrasound screening of periarticular soft tissue abnormality around metal-on-metal bearings. J Arthroplasty. 2012;27(6):895–900.CrossRefPubMedGoogle Scholar
  38. 38.
    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(23):2164–71.CrossRefPubMedGoogle Scholar
  39. 39.
    Wynn-Jones H, Macnair R, Wimhurst J, Chirodian N, Derbyshire B, Toms A, et al. Silent soft tissue pathology is common with a modern metal-on-metal hip arthroplasty. Acta Orthop. 2011;82(3):301–7.PubMedCentralCrossRefPubMedGoogle Scholar
  40. 40.
    Siddiqui IA, Sabah SA, Satchithananda K, Lim AK, Henckel J, Skinner JA, et al. Cross-sectional imaging of the metal-on-metal hip prosthesis: the London ultrasound protocol. Clin Radiol. 2013;68(8):e472–8.CrossRefPubMedGoogle Scholar
  41. 41.
    van Holsbeeck MT et al. Detection of infection in loosened hip prostheses: efficacy of sonography. AJR Am J Roentgenol. 1994;163:381–4.CrossRefPubMedGoogle Scholar
  42. 42.
    Glyn-Jones S, Pandit H, Kwon YM, Doll H, Gill HS, Murray DW. Risk factors for inflammatory pseudotumour formation following hip resurfacing. J Bone Joint Surg Br. 2009;91(12):1566–74.CrossRefPubMedGoogle Scholar
  43. 43.
    Thyssen JP, Linneberg A, Menne T, Johansen JD. The epidemiology of contact allergy in the general population: prevalence and main findings. Contact Dermatitis. 2007;57(5):287–99.CrossRefPubMedGoogle Scholar
  44. 44.
    Thyssen JP, Linneberg A, Menne T, Nielsen NH, Johansen JD. Contact allergy to allergens of the TRUE-test (panels 1 and 2) has decreased modestly in the general population. Br J Dermatol. 2009;161(5):1124–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Thomas P, Stauner K, Schraml A, Mahler V, Banke IJ, Gollwitzer H, et al. Characteristics of 200 patients with suspected implant allergy compared to 100 symptom-free arthroplasty patients. Orthopade. 2013;42(8):607–13.CrossRefPubMedGoogle Scholar
  46. 46.
    Jacobi-Gresser E, Huesker K, Schutt S. Genetic and immunological markers predict titanium implant failure: a retrospective study. Int J Oral Maxillofac Surg. 2013;42(4):537–43.CrossRefPubMedGoogle Scholar
  47. 47.
    Langton DJ, Jameson SS, Joyce TJ, Webb J, Nargol AV. The effect of component size and orientation on the concentrations of metal ions after resurfacing arthroplasty of the hip. J Bone Joint Surg Br. 2008;90(9):1143–51.CrossRefPubMedGoogle Scholar
  48. 48.
    de Haan R, Pattyn C, Gill HS, Murray DW, Campbell PA, De SK. Correlation between inclination of the acetabular component and metal ion levels in metal-on-metal hip resurfacing replacement. J Bone Joint Surg Br. 2008;90(10):1291–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Hart AJ, Buddhdev P, Winship P, Faria N, Powell JJ, Skinner JA. Cup inclination angle of greater than 50 degrees increases whole blood concentrations of cobalt and chromium ions after metal-on-metal hip resurfacing. Hip Int. 2008;18(3):212–9.PubMedGoogle Scholar
  50. 50.
    De HR, Campbell P, Reid S, Skipor AK, De SK. Metal ion levels in a triathlete with a metal-on-metal resurfacing arthroplasty of the hip. J Bone Joint Surg Br. 2007;89(4):538–41.Google Scholar
  51. 51.
    Pattyn CA, Lauwagie SN, Verdonk RC. Whole blood metal ion concentrations in correlation with activity level in three different metal-on-metal bearings. J Arthroplasty. 2011;26(1):58–64.CrossRefPubMedGoogle Scholar

Copyright information

© ISS 2015

Authors and Affiliations

  • Mette Holm Hjorth
    • 1
    Email author
  • Maiken Stilling
    • 1
  • Kjeld Soballe
    • 1
  • Lars Hans Bolvig
    • 2
  • Jacob Pontoppidan Thyssen
    • 3
  • Inger Mechlenburg
    • 1
  • Stig Storgaard Jakobsen
    • 1
  1. 1.Department of OrthopaedicsAarhus University HospitalAarhus CDenmark
  2. 2.Department of RadiologyAarhus University HospitalAarhus CDenmark
  3. 3.Department of Dermato-Allergology, Gentofte HospitalUniversity of CopenhagenCopenhagenDenmark

Personalised recommendations