Clinical Orthopaedics and Related Research®

, Volume 472, Issue 2, pp 543–554

What Causes Unexplained Pain in Patients With Metal-on metal Hip Devices? A Retrieval, Histologic, and Imaging Analysis

  • Danyal H. Nawabi
  • Nader A. Nassif
  • Huong T. Do
  • Kirsten Stoner
  • Marcella Elpers
  • Edwin P. Su
  • Timothy Wright
  • Hollis G. Potter
  • Douglas E. Padgett
Symposium: 2013 Hip Society Proceedings



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.


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Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Danyal H. Nawabi
    • 1
  • Nader A. Nassif
    • 1
  • Huong T. Do
    • 2
  • Kirsten Stoner
    • 3
  • Marcella Elpers
    • 3
  • Edwin P. Su
    • 1
  • Timothy Wright
    • 3
  • Hollis G. Potter
    • 4
  • Douglas E. Padgett
    • 1
  1. 1.Adult Reconstruction and Joint Replacement Service, Department of Orthopaedic SurgeryHospital for Special SurgeryNew YorkUSA
  2. 2.Epidemiology and Biostatistics CoreHospital for Special SurgeryNew YorkUSA
  3. 3.Department of BiomechanicsHospital for Special SurgeryNew YorkUSA
  4. 4.Department of Radiology and ImagingHospital for Special SurgeryNew YorkUSA

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