Metal-on-metal hip resurfacing arthroplasty (MOM HR) has become an established alternative to traditional metal-on-metal total hip arthroplasty (MOM THA) for younger, more active patients. Nevertheless, concerns remain regarding wear and corrosion of the bearing surfaces and the resulting systemic metal ion distribution.
We therefore asked whether (1) serum ion concentrations in patients with MOM HR at the time of long-term followup were higher than concentrations in a control population with no hip implants; (2) the ion concentrations in patients with MOM HR were different from those in patients with MOM THA; and (3) sex would influence ion levels with regard to implant type.
The MOM HR and MOM THA groups consisted of 25 patients (evaluated at a minimum of 96 months) and 16 patients (evaluated at a minimum of 106 months), respectively. Forty-eight healthy donors were recruited for reference values. Cobalt, chromium, nickel, and molybdenum were measured by furnace graphite atomic absorption spectrophotometry.
Ion concentrations of cobalt, chromium, and molybdenum in MOM HR were higher than in controls. Chromium and cobalt release were higher in MOM HR than in MOM THA. The sex-based analysis showed the difference was because women had higher concentrations in the MOM HR group than in the MOM THA group, whereas there was no difference between the men in the two groups.
In MOM HR, high metal ion release persists for the long term. Consequently, it is important to implement strict biomonitoring for patients who have received these implants. The sustained high levels of chromium in females within the MOM HR group are concerning and merits strong consideration when choosing implants in this patient group.
Level of Evidence
Level III, therapeutic study. See the Instructions for Authors online for a complete description of level of evidence.
This is a preview of subscription content, access via your institution.
Amstutz HC, Le Duff MJ. Background of metal-on-metal resurfacing. Proc Inst Mech Eng H. 2006;220:85–94.
Amstutz HC, Thomas BJ, Jinnah R, Kim W, Grogan T, Yale C. Treatment of primary osteoarthritis of the hip: a comparison of total joint and surface replacement arthroplasty. J Bone Joint Surg Am. 1984;66:228–241.
Anissian HL, Stark A, Good V, Dahlstrand H, Clarke IC. The wear pattern in metal-on-metal hip prostheses. J Biomed Mater Res. 2001;58:673–678.
Bedigrew KM, Ruh EL, Zhang Q, Clohisy JC, Barrack RL, Nunley RM. 2011 Marshall Urist Young Investigator Award. When to release patients to high-impact activities after hip resurfacing. Clin Orthop Relat Res. 2012;470:299–306.
Boardman DR, Middleton FR, Kavanagh TG. A benign psoas mass following metal-on-metal resurfacing of the hip. J Bone Joint Surg Br. 2006;88:402–404.
Bocca B, Mattei D, Pino A, Alimonti A. Italian network for human biomonitoring of metals: preliminary results from two regions. Ann Ist Super Sanita. 2010;46:259–265.
Bowsher JG, Hussain A, Williams PA, Shelton JC. Metal-on-metal hip simulator study of increased wear particle surface area due to ‘severe’ patient activity. Proc Inst Mech Eng H. 2006;220:279–287.
Brown SA, Zhang K, Merritt K, Payer JH. In vivo transport and excretion of corrosion products from accelerated anodic corrosion of porous coated F75 alloy. J Biomed Mater Res. 1993;27:1007–1017.
Clarke MT, Lee PT, Arora A, Villar RN. Levels of metal ions after small- and large-diameter metal-on-metal hip arthroplasty. J Bone Joint Surg Br. 2003;85:913–917.
Daniel J, Ziaee H, Pradhan C, McMinn DJ. Six-year results of a prospective study of metal ion levels in young patients with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2009;91:176–179.
De Smet K, De Haan R, Calistri A, Campbell PA, Ebramzadeh E, Pattyn C, Gill HS. Metal ion measurement as a diagnostic tool to identify problems with metal-on-metal hip resurfacing. J Bone Joint Surg Am. 2008;90:202–208.
deSouza RM, Parsons NR, Oni T, Dalton P, Costa M, Krikler S. Metal ion levels following resurfacing arthroplasty of the hip: serial results over a ten-year period. J Bone Joint Surg Br. 2010;92:1642–1647.
Doorn PF, Mirra JM, Campbell PA, Amstutz HC. Tissue reaction to metal on metal total hip prostheses. Clin Orthop Relat Res. 1996;329:187–205.
Fisher NE, Killampalli VV, Kundra RK, Jagodzinski NA, Mathur K, Reading AD. Sporting and physical activity following hip resurfacing. Int Orthop. 2011;35:977–980.
Grammatopoulos G, Pandit H; Oxford Hip and Knee Group, Murray DW, Gill HS. The relationship between head-neck ratio and pseudotumour formation in metal-on-metal resurfacing arthroplasty of the hip. J Bone Joint Surg Br. 2010;92:1527–1534.
Granchi D, Savarino L, Ciapetti G, Cenni E, Rotini R, Mieti M, Baldini N, Giunti A. Immunological changes in patients with total joint replacement following idiopathic osteoarthritis of the hip. J Bone Joint Surg Br. 2003;85:758–764.
Hallab N, Merritt K, Jacobs JJ. Metal sensitivity in patients with orthopaedic implants. J Bone Joint Surg Am. 2001;83:428–436.
Hallab NJ, Caicedo M, Finnegan A, Jacobs JJ. Th1 type lymphocyte reactivity to metals in patients with total hip arthroplasty. J Orthop Surg Res. 2008;3:6.
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;51:737–755.
Hartmann A, Lützner J, Kirschner S, Witzleb WC, Günther KP. Do survival rate and serum ion concentrations 10 years after metal-on-metal hip resurfacing provide evidence for continued use? Clin Orthop Relat Res. 2012;470:3118–3126.
Hing C, Back D, Shimmin A. Hip resurfacing: indications, results, and conclusions. Instr Course Lect. 2007;56:171–178.
Hing CB, Young DA, Dalziel RE, Bailey M, Back DL, Shimmin AJ. Narrowing of the neck in resurfacing arthroplasty of the hip: a radiological study. J Bone Joint Surg Br. 2007;89:1019–1024.
Hodgson AW, Mischler S, Von Rechenberg B, Virtanen S. An analysis of the in vivo deterioration of Co-Cr-Mo implants through wear and corrosion. Proc Inst Mech Eng H. 2007;221:291–303.
Huk OL, Catelas I, Mwale F, Antoniou J, Zukor DJ, Petit A. Induction of apoptosis and necrosis by metal ions in vitro. J Arthroplasty. 2004;19(Suppl 3):84–87.
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.
Jacobs JJ, Urban RM, Hallab NJ, Skipor AK, Fischer A, Wimmer MA. Metal-on-metal bearing surfaces. J Am Acad Orthop Surg. 2009;17:69–76.
Jacobs M, Gorab R, Mattingly D, Trick L, Southworth C. Three- to six-year results with the Ultima metal-on-metal hip articulation for primary total hip arthroplasty. J Arthroplasty. 2004;19(Suppl 2):48–53.
Jazrawi LM, Kummer FJ, DiCesare PE. Alternative bearing surfaces for total joint arthroplasty. J Am Acad Orthop Surg. 1998;6:198–203.
Ladon D, Doherty A, Newson R, Turner J, Bhamra M, Case CP. Changes in metal levels and chromosome aberrations in the peripheral blood of patients after metal-on-metal hip arthroplasty. J Arthroplasty. 2004;19(Suppl 3):78–83.
MacDonald SJ. Can a safe level for metal ions in patients with metal-on-metal total hip arthroplasties be determined? J Arthroplasty. 2004;19(Suppl 3):71–77.
McMinn D, Treacy R, Lin K, Pynsent P. Metal on metal surface replacement of the hip: experience of the McMinn prosthesis. Clin Orthop Relat Res. 1996;329(Suppl):89–98.
Merritt K, Brown SA. Release of hexavalent chromium from corrosion of stainless steel and cobalt-chrome alloys. J Biomed Mater Res. 1995;29:627–633.
Moroni A, Savarino L, Cadossi M, Baldini N, Giannini S. Does ion release differ between hip resurfacing and metal-on-metal THA? Clin Orthop Relat Res. 2008;466:700–707.
Moroni A, Savarino L, Hoque M, Cadossi M, Baldini N. Do ion levels in hip resurfacing differ from metal-on-metal THA at midterm? Clin Orthop Relat Res. 2011;469:180–187.
Okazaki Y, Gotoh E. Comparison of metal release from various metallic biomaterials in vitro. Biomaterials. 2005;26:11–21.
Pandit H, Vlychou M, Whitwell D, Crook D, Luqmani R, Ostlere S, Murray DW, Athanasou NA. Necrotic granulomatous pseudotumours in bilateral resurfacing hip arthroplasties: evidence for a type IV immune response. Virchows Arch. 2008;453:529–534.
Savarino L, Granchi D, Ciapetti G, Cenni E, Nardi Pantoli A, Rotini R, Veronesi CA, Baldini N, Giunti A. Ion release in patients with metal-on-metal hip bearings in total joint replacement: a comparison with metal-on-polyethylene bearings. J Biomed Mater Res. 2002;63:467–474.
Savarino L, Padovani G, Ferretti M, Greco M, Cenni E, Perrone G, Greco F, Baldini N, Giunti A. Serum ion levels after ceramic-on-ceramic and metal-on-metal total hip arthroplasty: 8-year minimum follow-up. J Orthop Res. 2008;26:1569–1576.
Savarino L, Stea S, Granchi D, Visentin M, Ciapetti G, Donati ME, Rollo G, Zinghi G, Pizzoferrato A, Montanaro L, Toni A. Sister chromatid exchanges and ion release in patients wearing fracture fixation devices. J Biomed Mater Res. 2000;50:21–26.
Schaffer AW, Pilger A, Engelhardt C, Zweymuller K, Ruediger HW. Increased blood cobalt and chromium after total hip replacement. Clin Toxicol. 1999;37:839–844.
Shimmin AJ, Walter WL, Esposito C. The influence of the size of the component on the outcome of resurfacing arthroplasty of the hip: a review of the literature. J Bone Joint Surg Br. 2010;92:469–476.
Silva M, Heisel C, Schmalzried TP. Metal-on-metal total hip replacement. Clin Orthop Relat Res. 2005;430:53–61.
Smith AJ, Dieppe P, Howard PW, Blom AW; National Joint Registry for England and Wales. Failure rates of metal-on-metal hip resurfacings: analysis of data from the National Joint Registry for England and Wales. Lancet. 2012;380:1759–1766.
Smolders JM, Hol A, Rijnberg WJ, van Susante JL. Metal ion levels and functional results after either resurfacing hip arthroplasty or conventional metal-on-metal hip arthroplasty. Acta Orthop. 2011;82:559–566.
Traina F, De Clerico M, Biondi F, Pilla F, Tassinari E, Toni A. Sex differences in hip morphology: is stem modularity effective for total hip replacement? J Bone Joint Surg Am. 2009;91(Suppl 6):121–128.
Urban RM, Tomlinson MJ, Hall DJ, Jacobs JJ. Accumulation in liver and spleen of metal particles generated at nonbearing surfaces in hip arthroplasty. J Arthroplasty. 2004;19(Suppl 3):94–101.
Vendittoli PA, Mottard S, Roy AG, Dupont C, Lavigne M. Chromium and cobalt ion release following the Durom high carbon content, forged metal-on-metal surface replacement of the hip. J Bone Joint Surg Br. 2007;89:441–448.
The institution of one or more of the authors (LS, NB) has received, during the study period, funding from the Italian Ministry of the Health, Financial Support for Scientific Research “5 per mille” 2009.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.
Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
About this article
Cite this article
Savarino, L., Cadossi, M., Chiarello, E. et al. Do Ion Levels in Metal-on-metal Hip Resurfacing Differ From Those in Metal-on-metal THA at Long-term Followup?. Clin Orthop Relat Res 471, 2964–2971 (2013). https://doi.org/10.1007/s11999-013-2981-z
- Acetabular Component
- Furnace Graphite Atomic Absorption Spectrophotometry
- UCLA Activity Score
- Graphite Furnace Atomic Absorption Spectrometer
- Bilateral Implant