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What Are the Predictors and Prevalence of Pseudotumor and Elevated Metal Ions After Large-diameter Metal-on-metal THA?

  • Symposium: 2014 Hip Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

A CORR Insights to this article was published on 27 August 2014

Abstract

Background

Soft tissue masses, or “pseudotumors,” around metal-on-metal total hip arthroplasty (MoM THA) have been reported frequently; however, their prevalence remains unknown. Several risk factors, including elevated metal ion levels, have been associated with the presence of pseudotumor, although this remains controversial.

Questions/purposes

The goals of this study were to (1) determine the prevalence of pseudotumors after large-diameter head MoM THA; (2) identify risk factors associated with pseudotumor formation and elevated metal ion levels; and (3) determine the early failure rate of large-diameter MoM THA.

Methods

Between December 2005 and November 2012, 258 hips (215 patients) underwent large-diameter head primary MoM THA at our institution. Clinical followup was obtained in 235 hips (91%). Using an inclusion criteria of a minimum followup of 1 year, a subset of 191 hips (mean followup, 4 years; range, 1–7 years) was recruited for high-resolution ultrasound screening for the presence of pseudotumor. Whole blood cobalt and chromium ion levels, UCLA activity level, WOMAC score, patient demographics as well as surgical, implant, and radiographic data were collected. Bivariate correlations and multivariate log-linear regression models were used to compare the presence of pseudotumor and elevated metal ions with all other factors.

Results

Ultrasound detected a solid, cystic, or mixed mass in 20% hips (38 of 191). No correlation was found between the presence of pseudotumor and any risk factor that we examined. After controlling for confounding variables, elevated cobalt ions were correlated (p < 0.001, R = 0.50, R2 = 0.25) with smaller femoral head size, the presence of bilateral MoM THA, and female sex. Elevated chromium ions were correlated (p < 0.001, R = 0.59, R2 = 0.34) with smaller femoral head size, presence of bilateral MoM THA, and lower body mass index. The overall survival of MoM THA was 96% at a mean followup of 4.5 years (range, 2–8 years).

Conclusions

With the numbers available, we found no associations between the presence of pseudotumor and the potential risk factors we analyzed, including elevated metal ion levels. Further work is needed to explain why larger femoral head sizes resulted in lower metal ion levels despite being associated with higher early failure rates in joint registry data.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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Acknowledgments

We thank the Grand River Hospital (Kitchener, Ontario, Canada) ultrasonographers and radiology department as well as the Kitchener-Waterloo MSK Centre research nurses for their contributions.

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Authors and Affiliations

  1. Division of Orthopaedic Surgery, St Michael’s Hospital, 55 Queen Street East, Suite 800, Toronto, ON, M5C 1R6, Canada

    Nick Bayley MD & Emil Schemitsch MD

  2. Kitchener-Waterloo Region MSK Centre, Kitchener, ON, Canada

    Habeeb Khan MBBS, Paul Grosso MD, Thomas Hupel MD, David Stevens MD & Matthew Snider MD

  3. Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, ON, Canada

    Paul Kuzyk MD, MSc

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  1. Nick Bayley MD
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Correspondence to Nick Bayley MD.

Additional information

This project was funded by Biomet, Inc (Warsaw, IN, USA).

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 prior to 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.

This work was performed at Grand River Hospital, Waterloo, Ontario, Canada.

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Bayley, N., Khan, H., Grosso, P. et al. What Are the Predictors and Prevalence of Pseudotumor and Elevated Metal Ions After Large-diameter Metal-on-metal THA?. Clin Orthop Relat Res 473, 477–484 (2015). https://doi.org/10.1007/s11999-014-3824-2

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