Advertisement

Archives of Orthopaedic and Trauma Surgery

, Volume 135, Issue 3, pp 417–425 | Cite as

Pseudotumor formation and serum ions after large head metal-on-metal stemmed total hip replacement. Risk factors, time course and revisions in 706 hips

  • B. H. BoskerEmail author
  • H. B. Ettema
  • M. van Rossum
  • M. F. Boomsma
  • B. J. Kollen
  • M. Maas
  • C. C. P. M. Verheyen
Hip Arthroplasty

Abstract

Introduction

The incidence and natural course of pseudotumors in metal-on-metal total hip arthroplasties is largely unknown. The objective of this study was to identify the true incidence and risk factors of pseudotumor formation in large head metal-on-metal total hip arthroplasties.

Materials and methods

Incidence, time course and risk factors for pseudotumor formation were analysed after large femoral head MoM-THA. We defined a pseudotumor as a (semi-)solid or cystic peri-prosthetic soft-tissue mass with a diameter ≥2 cm that could not be attributed to infection, malignancy, bursa or scar tissue. All patients treated in our clinic with MoM-THA’s were contacted. CT scan, metal ions and X-rays were obtained. Symptoms were recorded.

Results

After median follow-up of 3 years, 706 hips were screened in 626 patients. There were 228 pseudotumors (32.3 %) in 219 patients (35.0 %). Pseudotumor formation significantly increased after prolonged follow-up. Seventy-six hips (10.8 %) were revised in 73 patients (11.7 %), independent risk factors were identified. Best cutoff point for cobalt and chromium was 4 μg/l (68 and 77 nmol/l).

Conclusions

This study confirms a high incidence of pseudotumors, dramatically increasing after prolonged follow-up. Risk factors for pseudotumors are of limited importance. Pain was the strongest predictor for pseudotumor presence; cobalt chromium and swelling were considered poor predictors. Cross-sectional imaging is the main screening tool during follow-up.

Keywords

Metal-on-metal Total hip arthroplasty Pseudotumor 

Notes

Conflict of interest

The authors state that there are no conflicts of interest.

References

  1. 1.
    Girard J, Bocquet D, Autissier G et al (2010) Metal-on-metal hip arthroplasty in patients thirty years of age or younger. J Bone Joint Surg Am 92(14):2419–2426CrossRefPubMedGoogle Scholar
  2. 2.
    Hannemann F, Hartmann A, Schmitt J et al (2013) European multidisciplinary consensus statement on the use and monitoring of metal-on-metal bearings for total hip replacement and hip resurfacing. Orthop Traumatol Surg Res. 99(3):263–271CrossRefPubMedGoogle Scholar
  3. 3.
    Haddad FS, Thakrar RR, Hart AJ et al (2011) Metal-on-metal bearings: the evidence so far. J Bone Joint Surg Br 93(5):572–579CrossRefPubMedGoogle Scholar
  4. 4.
    Ollivere B, Darrah C, Barker T, Nolan J, Porteous MJ (2009) Early clinical failure of the Birmingham metal-on-metal hip resurfacing is associated with metallosis and soft-tissue necrosis. J Bone Joint Surg Br 91(8):1025–1030CrossRefPubMedGoogle Scholar
  5. 5.
    Smith AJ, Dieppe P, Vernon K, Porter M, Blom AW (2012) Failure rates of stemmed metal-on-metal hip replacements: analysis of data from the National Joint Registry of England and Wales. Lancet 379(9822):1199–1204CrossRefPubMedGoogle Scholar
  6. 6.
    Bosker BH, Ettema HB, Boomsma MF, Kollen BJ, Maas M, Verheyen CC (2012) High incidence of pseudotumour formation after large-diameter metal-on-metal total hip replacement: a prospective cohort study. J Bone Joint Surg Br 94(6):755–761CrossRefPubMedGoogle Scholar
  7. 7.
    No authors listed 1. Medicines and Healthcare products Regulatory Agency (MHRA). Medical device alert: all metal-on-metal (MoM) hip replacements. http://www.mhra.gov.uk/Publications/Safetywarnings/MedicalDeviceAlerts/CON155761. Accessed 02 Sep 2013
  8. 8.
    No authors listed 2. U.S. Food and drug administration: Metal-on-metal hip implants. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/default.htm. Accessed 02 Sep 2013
  9. 9.
    Verheyen CC, Verhaar JA (2012) Failure rates of stemmed metal-on-metal hip replacements. Lancet 380(9837):105 (author reply 106)CrossRefPubMedGoogle Scholar
  10. 10.
    Daniel J, Holland J, Quigley L, Sprague S, Bhandari M (2012) Pseudotumors associated with total hip arthroplasty. J Bone Joint Surg Am 94(1):86–93CrossRefPubMedGoogle Scholar
  11. 11.
    No authors listed 3. Biomet: M2a-Magnum large metal articulation: design rationale 2009. http://www.biomet.com/campaign/trueAlternativeBearings/BOI03400MagnumDesignRationale.pdf. Accessed 20 Feb 2012
  12. 12.
    MacDonald SJ, Brodner W, Jacobs JJ (2004) A consensus paper on metal ions in metal-on-metal hip arthroplasties. J Arthroplasty 19:12–16CrossRefPubMedGoogle Scholar
  13. 13.
    Canadian Hip Resurfacing Study Group (2011) A survey on the prevalence of pseudotumors with metal-on-metal hip resurfacing in Canadian academic centers. J Bone Joint Surg Am 93(Suppl 2):118–121Google Scholar
  14. 14.
    Campbell P, Shimmin A, Walter L, Solomon M (2008) Metal sensitivity as a cause of groin pain in metal- on-metal hip resurfacing. J Arthroplasty 23:1080–1085CrossRefPubMedGoogle Scholar
  15. 15.
    Malviya A, Holland JP (2009) Pseudotumours associated with metal-on-metal hip resurfacing: 10-year Newcastle experience. Acta Orthop Belg 75(4):477–483PubMedGoogle Scholar
  16. 16.
    Williams DH, Greidanus NV, Masri BA, Duncan CP, Garbuz DS (2011) Prevalence of pseudotumor in asymptomatic patients after metal-on-metal hip arthroplasty. J Bone Joint Surg Am 93(23):2164–2171CrossRefPubMedGoogle Scholar
  17. 17.
    Hart AJ, Satchithananda K, Liddle AD et al (2012) 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 94(4):317–325PubMedGoogle Scholar
  18. 18.
    van der Weegen W, Smolders JM, Sijbesma T, Hoekstra HJ, Brakel K, van Susante JL (2013) High incidence of pseudotumours after hip resurfacing even in low risk patients; results from an intensified MRI screening protocol. Hip Int 23(3):243–249CrossRefPubMedGoogle Scholar
  19. 19.
    Ghelman B, Kepler CK, Lyman S, González Della Valle AG (2009) CT outperforms radiography for determination of acetabular cup version after THA. Clin Orthop Relat Res 467:2362–2370CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Counsell A, Heasley R, Arumilli B, Paul A (2008) A groin mass caused by metal particle debris after hip resurfacing. Acta Orthop Belg 74:870–874PubMedGoogle Scholar
  21. 21.
    Tallroth K, Eskola A, Santavirta S, Konttinen YT, Lindholm TS (1989) Aggressive granulomatous lesions after hip arthroplasty. J Bone Joint Surg Br 71:571–575PubMedGoogle Scholar
  22. 22.
    Wirta J, Eskola A, Santavirta S, Tallroth K, Konttinen YT, Lindholm S (1990) Revision of aggressive granulomatous lesions in hip arthroplasty. J Arthroplasty 5(Suppl):S47–S52CrossRefPubMedGoogle Scholar
  23. 23.
    De Haan R, Pattyn C, Gill HS, Murray DW, Campbell PA, De Smet K (2008) Correlation between inclination of the acetabular component and metal ion levels in metal-on-metal hip resurfacing replacement. J Bone Joint Surg Br 90(10):1291–1297CrossRefPubMedGoogle Scholar
  24. 24.
    Langton DJ, Sprowson AP, Joyce TJ et al (2009) Blood metal ion concentrations after hip resurfacing arthroplasty: a comparative study articular surface replacement and Birmingham hip resurfacing arthroplasties. J Bone Joint Surg Br 91:1287–1295CrossRefPubMedGoogle Scholar
  25. 25.
    Matthies A, Underwood R, Cann P et al (2011) Retrieval analysis of 240 metal-on-metal hip components, comparing modular total hip replacement with hip resurfacing. J Bone Joint Surg Br 93:307–314CrossRefPubMedGoogle Scholar
  26. 26.
    Kwon YM, Glyn-Jones S, Simpson DJ et al (2010) Analysis of wear of retrieved metal-on-metal hip resurfacing implants revised due to pseudotumours. J Bone Joint Surg Br 92(3):356–361CrossRefPubMedGoogle Scholar
  27. 27.
    Langton DJ, Jameson SS, Joyce TJ, Hallab NJ, Natu S, Nargol AV (2010) 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 92(1):38–46CrossRefPubMedGoogle Scholar
  28. 28.
    Kwon YM, Ostlere SJ, McLardy-Smith P et al (2011) “Asymptomatic” pseudotumors after metal-on-metal hip resurfacing arthroplasty: prevalence and metal ion study. J Arthroplasty 26:511–518CrossRefPubMedGoogle Scholar
  29. 29.
    Donell ST, Darrah C, Nolan JF, Metal-on-Metal Study Group, Norwich Metal-on-Metal Study Group et al (2010) Early failure of the Ultima metal-on-metal total hip replacement in the presence of normal plain radiographs. J Bone Joint Surg Br 92:1501–1508CrossRefPubMedGoogle Scholar
  30. 30.
    Matthies AK, Skinner JA, Osmani H, Henckel J, Hart AJ (2012) Pseudotumors are common in well-positioned low-wearing metal-on-metal hips. Clin Orthop Relat Res 470(7):1895–1906CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Saxler G, Marx A, Vandevelde D et al (2004) The accuracy of free-hand cup positioning-a CT based measurement of cup placement in 105 total hip arthroplasties. Int Orthop 28(4):198–201CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Glyn-Jones S, Pandit H, Kwon YM, Doll H, Gill HS, Murray DW (2009) Risk factors for inflammatory pseudotumour formation following hip resurfacing. J Bone Joint Surg Br 91(12):1566–1574CrossRefPubMedGoogle Scholar
  33. 33.
    Sandiford NA, Muirhead-Allwood SK, Skinner JA (2010) Revision of failed hip resurfacing to total hip arthroplasty rapidly relieves pain and improves function in the early post-operative period. J Orthop Surg Res 5:88CrossRefPubMedCentralPubMedGoogle Scholar
  34. 34.
    Grammatopolous G, Pandit H, Kwon YM et al (2009) Hip resurfacings revised for inflammatory pseudotumour have a poor outcome. J Bone Joint Surg Br 91:1019–1024CrossRefPubMedGoogle Scholar
  35. 35.
    Langton DJ, Sidaginamale RP, Joyce TJ et al (2013) The clinical implications of elevated blood metal ion concentrations in asymptomatic patients with MoM hip resurfacings: a cohort study. BMJ Open 3(3):e001541CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Campbell JR, Estey MP (2013) Metal release from hip prostheses: cobalt and chromium toxicity and the role of the clinical laboratory. Clin Chem Lab Med 51(1):213–220CrossRefPubMedGoogle Scholar
  37. 37.
    Hasegawa M, Yoshida K, Wakabayashi H, Sudo A (2012) Cobalt and chromium ion release after large-diameter metal-on-metal total hip arthroplasty. J Arthroplasty 27(6):990–996CrossRefPubMedGoogle Scholar
  38. 38.
    Visuri T, Pukkala E, Paavolainen P, Pulkkinen P, Riska EB (1996) Cancer risk after metal on metal and polyethylene on metal total hip arthroplasty. Clin Orthop Relat Res (329 Suppl):S280–9Google Scholar
  39. 39.
    Ziaee H, Daniel J, Datta AK, Blunt S, McMinn DJ (2007) Transplacental transfer of cobalt and chromium in patients with metal-on-metal hip arthroplasty: a controlled study. J Bone Joint Surg Br 89(3):301–305CrossRefPubMedGoogle Scholar
  40. 40.
    Prentice JR, Clark MJ, Hoggard N et al (2013) Metal-on-metal hip prostheses and systemic health: a cross-sectional association study 8 years after implantation. PLoS One 8(6):e66186CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • B. H. Bosker
    • 1
    Email author
  • H. B. Ettema
    • 2
  • M. van Rossum
    • 2
  • M. F. Boomsma
    • 2
  • B. J. Kollen
    • 2
  • M. Maas
    • 3
  • C. C. P. M. Verheyen
    • 2
  1. 1.ZwolleThe Netherlands
  2. 2.ZwolleThe Netherlands
  3. 3.Academic Medical CentreAmsterdamThe Netherlands

Personalised recommendations