Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty
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Metal-on-metal (MOM) bearing surfaces in hip arthroplasty have distinct advantages that led to the increase in popularity in North America in the early 2000s. However, with their increased use, concerns such as local cytotoxicity and hypersensitivity reactions leading to soft tissue damage and cystic mass formation (known collectively as adverse local tissue reactions (ALTR)) became apparent. The clinical presentation of ALTR is highly variable. The diagnosis of ALTR in MOM articulations in hip arthroplasty can be challenging and a combination of clinical presentation, physical examination, implant track record, component positioning, serum metal ion levels, cross-sectional imaging, histopathologic analysis, and consideration of alternative diagnoses are essential.
KeywordsTotal hip arthroplasty (THA) Metal-on-metal (MOM) Adverse local tissue reactions (ALTRs) Pseudotumor Aseptic lymphocytic vasculitic-associated lesion (ALVAL)
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Conflict of interest
Brian P. Chalmers, Kevin I. Perry, Tad M. Mabry, and Matthew P. Abdel declare that they have no conflict of interest.
Michael J. Taunton reports personal fees from DJO Global, outside of the submitted work.
Human and animal rights and informed consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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- 6.•Nawabi DH, Nassif NA, Do HT, Stoner K, Elpers M, Su EP, et al. What causes unexplained pain in patients with metal-on metal hip devices? A retrieval, histologic, and imaging analysis. Clin Orthop Relat Res. 2014;472:543–54. This article analyzed the preoperative and intraoperative findings of patients with THAs with MOM articulations that were revised for unexplained pain. A high percentage of them had evidence of ALTR upon revision. Their conclusion was that with painful THAs with MOM articulations, ALTR should always be considered in the diagnostic algorithm. PubMedCentralCrossRefPubMedGoogle Scholar
- 7.•Berry DJ, Abdel MP, Callaghan JJ. What are the current clinical issues in wear and tribocorrosion? Clin Orthop Relat Res. 2014;3659–64. This article presents an excellent review of current diagnostic and treatment strategies for wear and corrosion. More importantly, it also highlights critical areas for which improvement in wear properties, diagnosis, management, and treatment can be made.Google Scholar
- 11.•Kwon Y, Lombardi AV, Jacobs JJ, Fehring TK, Lewis CG, Cabanela ME. Risk stratification algorithm for management of patients with metal-on-metal hip arthroplasty: consensus statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and the Hip Society. J Bone Joint Surg Am. 2014;96(1):e4. doi: 10.2106/JBJS.M.00160. This study outlines the consensus statement by the Hip Society, AAOS, and AAHKS on the diagnostic algorithm in symptomatic and asymptomatic patients with MOM articulations in THA. It incorporates all of the diagnostic factors considered in this review.
- 12.Grammatopoulos G, Pandit H, Orth F, Kamali A, Maggiani F, Athanasou N. The correlation of wear with histological features. J Bone Joint Surg Am. 2013;81:1–10.Google Scholar
- 15.Tower SS. Arthroprosthetic cobaltism: neurological and cardiac manifestations in two patients with metal-on-metal arthroplasty: a case report. J Bone Joint Surg Am. 2010;92:2847–51.Google Scholar
- 16.•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-B:14–8. This study outlines the consensus statement by the Hip Society, AAOS, and AAHKS on the diagnostic algorithm in symptomatic and asymptomatic patients with MOM articulations in THA. It incorporates all of the diagnostic factors considered in this review. CrossRefGoogle Scholar
- 17.•Kwon YM, Ostlere SJ, McLardy-Smith P, Athanasou NA, Gill HS, Murray DW. “Asymptomatic” pseudotumors after metal-on-metal hip resurfacing arthroplasty. Prevalence and metal ion study. J Arthroplasty. 2011;26:511–8. This study screened patients for ALTR, specifically pseudotumors, by US and metal ion levels to analyze not only the incidence of symptomatic and asymptomatic pseudotumors but also to correlate pseudotumors with elevated metal ion levels. This article showed that ALTR may have higher metal ion levels and that not all ALTR, even large pseudotumors, are symptomatic. CrossRefPubMedGoogle Scholar
- 23.•Wyles CC, Larson DR, Houdek MT, Sierra RJ, Trousdale RT. Utility of synovial fluid aspirations in failed metal-on-metal total hip arthroplasty. J Arthroplasty. 2013;28:818–23. This study was one of the first studies to further analyze the diagnosis of infection in the presence of an ALTR from a MOM articulation. The traditional diagnostic factors (CRP, ESR, and synovial testing) must be carefully scrutinized in the presence of an inflammatory response from an ALTR. CrossRefPubMedGoogle Scholar
- 27.•Levine BR, Hsu AR, Skipor AK, Hallab NJ, Paprosky WG, Galante JO, et al. Ten-year outcome of serum metal ion levels after primary total hip arthroplasty: a concise follow-up of a previous report*. J Bone Joint Surg Am. 2013;95:512–8. These series of studies showed that metal ion levels are elevated in MOM articulations in THAs. Further, it shows that metal ion levels increase over time, especially with larger femoral head sizes. PubMedCentralCrossRefPubMedGoogle Scholar
- 37.•Nam D, Barrack RL, Potter HG. What are the advantages and disadvantages of imaging modalities to diagnose wear-related corrosion problems? Clin Orthop Relat Res. 2014;3665–73. This article provides an excellent overview of cross-sectional imaging modalities utilized to screen and diagnose ALTR in MOM articulations in THA. It is an excellent discussion with up-to-date research referenced that analyzes the advantages and disadvantages of US, CT, and MRI.Google Scholar