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Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty

  • Hip: Metal-on-Metal (J Cooper, Section Editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

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.

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References

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  1. Fehring KA, Fehring TK. Modes of failure in metal-on-metal total hip arthroplasty. Orthop Clin North Am. 2015;46:185–92.

    Article  PubMed  Google Scholar 

  2. Bozic KJ, Kurtz S, Lau E, Ong K, Chiu V, Vail TP, et al. The epidemiology of bearing surface usage in total hip arthroplasty in the United States. J Bone Joint Surg Am. 2009;91:1614–20.

    Article  PubMed  Google Scholar 

  3. 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.

    PubMed  Google Scholar 

  4. Anissian HL, Stark A, Good V, Dahlstrand H, Clarke IC. The wear pattern in metal-on-metal hip prostheses. J Biomed Mater Res. 2001;58:673–8.

    Article  PubMed  CAS  Google Scholar 

  5. Kwon Y-M, Jacobs JJ, MacDonald SJ, Potter HG, Fehring TK, Lombardi AV. Evidence-based understanding of management perils for metal-on-metal hip arthroplasty patients. J Arthroplasty. 2012;27:20–5.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed Central  PubMed  Google 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.

  8. Natu S, Sidaginamale RP, Gandhi J, Langton DJ, Nargola VF. Adverse reactions to metal debris: histopathological features of periprosthetic soft tissue reactions seen in association with failed metal on metal hip arthroplasties. J Clin Pathol. 2012;65:409–18.

    Article  PubMed  Google Scholar 

  9. Hayter CL, Gold SL, Koff MF, Perino G, Nawabi DH, Miller TT, et al. MRI findings in painful metal-on-metal hip arthroplasty. Am J Roentgenol. 2012;199:884–93.

    Article  Google Scholar 

  10. Hauptfleisch J, Pandit H, Grammatopoulos G, Gill HS, Murray DW, Ostlere S. A MRI classification of periprosthetic soft tissue masses (pseudotumours) associated with metal-on-metal resurfacing hip arthroplasty. Skelet Radiol. 2012;41:149–55.

    Article  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 

  13. Campbell P, Ebramzadeh E, Nelson S, Takamura K, De Smet K, Amstutz HC. Histological features of pseudotumor-like tissues from metal-on-metal hips. Clin Orthop Relat Res. 2010;468:2321–7.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Tharani R, Dorey FJ, Schmalzried TP. The risk of cancer following total hip or knee arthroplasty. J Bone Joint Surg Am. 2001;83-A:774–80.

    PubMed  CAS  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.

  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.

    Article  Google 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.

    Article  PubMed  Google Scholar 

  18. Griffin WL. Metal ion levels: how can they help us? J Arthroplasty. 2014;29:659–60.

    Article  PubMed  Google Scholar 

  19. Hart AJ, Sabah SA, Bandi AS, Maggiore P, Tarassoli P, Sampson B, et al. Sensitivity and specificity of blood cobalt and chromium metal ions for predicting failure of metal-on-metal hip replacement. J Bone Joint Surg Br. 2011;93-B:1308–13.

    Article  Google Scholar 

  20. Pajam KJJ. Surveillance of patients with metal-on-metal hip resurfacing and total hip prostheses. J Bone Join Surg Am. 2014;96(13):1091–9.

    Article  Google Scholar 

  21. Bartelt RB, Yuan BJ, Trousdale RT, Sierra RJ. The prevalence of groin pain after metal-on-metal total hip arthroplasty and total hip resurfacing. Clin Orthop Relat Res. 2010;468:2346–56.

    Article  PubMed Central  PubMed  Google Scholar 

  22. De Haan R, Pattyn C, Gill HS, Murray DW, Campbell PA, De Smet K. Correlation between inclination of the acetabular component and metal ion levels in metal-on-metal hip resurfacing replacement. J Bone Joint Surg Br. 2008;90:1291–7.

    Article  PubMed  Google 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.

    Article  PubMed  Google Scholar 

  24. Cobb JP, Davda K, Ahmad A, Harris SJ, Masjedi M, Hart AJ. Why large-head metal-on-metal hip replacements are painful: the anatomical basis of psoas impingement on the femoral head-neck junction. J Bone Joint Surg Br. 2011;93:881–5.

    Article  PubMed  CAS  Google Scholar 

  25. Engh CA, Macdonald SJ, Sritulanondha S, Korczak A, Naudie D. Metal ion levels after metal-on-metal total hip arthroplasty: a five-year, prospective randomized trial. J Bone Joint Surg Am. 2014;96:448–55.

    Article  PubMed  CAS  Google Scholar 

  26. Engh CA, MacDonald SJ, Sritulanondha S, Thompson A, Naudie D, Engh CA. 2008 John Charnley award: metal ion levels after metal-on-metal total hip arthroplasty: a randomized trial. Clin Orthop Relat Res. 2009;467:101–11.

    Article  PubMed Central  PubMed  Google 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.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Fehring TK, Carter JL, Fehring KA, Odum SM, Griffin WL. Cobalt to chromium ratio is not a key marker for altr in metal on metal hips. J Arthroplasty. 2015;30(9 Suppl):107–9.

    Article  PubMed  Google Scholar 

  29. Della Valle C, Parvizi J, Bauer TW, DiCesare PE, Evans RP, Segreti J, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis of periprosthetic joint infections of the hip and knee. J Bone Joint Surg Am. 2011;93:1355–7.

    Article  PubMed  Google Scholar 

  30. Berbari E, Mabry T, Tsaras G, Spangehl M, Erwin PJ, Murad MH, et al. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am. 2010;92:2102–9.

    Article  PubMed  Google Scholar 

  31. Spangehl MJ, Masri BA, O’Connell JX. Duncan CP prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81:672–83.

    PubMed  CAS  Google Scholar 

  32. Yi PH, Cross MB, Moric M, Levine BR, Sporer SM, Paprosky WG, et al. Do serologic and synovial tests help diagnose infection in revision hip arthroplasty with metal-on-metal bearings or corrosion? Clin Orthop Relat Res. 2014;473:498–505.

    Article  PubMed Central  Google Scholar 

  33. Liddle AD, Sabah SA, Mcrobbie D, Henckel J, Cobb JP, Skinner JA, et al. Pseudotumors in association with well-functioning metal-on-metal hip prostheses. J Bone Joint Surg Am. 2012;94:317–25.

    PubMed  Google Scholar 

  34. Mikhael MM, Hanssen AD, Sierra RJ. Failure of metal-on-metal total hip arthroplasty mimicking hip infection. A report of two cases. J Bone Joint Surg Am. 2009;91:443–6.

    Article  PubMed  Google Scholar 

  35. Wyles CC, Van Demark RE, Sierra RJ, Trousdale RT. High rate of infection after aseptic revision of failed metal-on-metal total hip arthroplasty. Clin Orthop Relat Res. 2014;472:509–16.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Kwon YM. Cross-sectional imaging in evaluation of soft tissue reactions secondary to metal debris. J Arthroplasty. 2014;29:653–6.

    Article  PubMed  Google 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.

  38. Nishii T, Sakai T, Takao M, Yoshikawa H, Sugano N. Is ultrasound screening reliable for adverse local tissue reaction after hip arthroplasty? J Arthroplasty. 2014;29:2239–44.

    Article  PubMed  Google Scholar 

  39. Nishii T, Sakai T, Takao M, Yoshikawa H, Sugano N. Ultrasound screening of periarticular soft tissue abnormality around metal-on-metal bearings. J Arthroplasty. 2012;27:895–900.

    Article  PubMed  Google Scholar 

  40. Muraoka K, Naito M, Nakamura Y, Hagio T, Takano K. Usefulness of ultrasonography for detection of pseudotumors after metal-on-metal total hip arthroplasty. J Arthroplasty. 2014;30:879–84.

    Article  PubMed  Google Scholar 

  41. Siddiqui IA, Sabah SA, Satchithananda K, Lim AK, Cro S, Henckel J, et al. A comparison of the diagnostic accuracy of MARS MRI and ultrasound of the painful metal-on-metal hip arthroplasty. Acta Orthop. 2014;85:1–8.

    Article  Google Scholar 

  42. Anderson H, Toms AP, Cahir JG, Goodwin RW, Wimhurst J, Nolan JF. Grading the severity of soft tissue changes associated with metal-on-metal hip replacements: reliability of an MR grading system. Skelet Radiol. 2011;40:303–7.

    Article  Google Scholar 

  43. Nawabi DH, Gold S, Lyman S, Fields K, Padgett DE, Potter HG. MRI predicts ALVAL and tissue damage in metal-on-metal hip arthroplasty. Clin Orthop Relat Res. 2014;472:471–81.

    Article  PubMed Central  PubMed  Google Scholar 

  44. Ibanez HE, Grand MG, Meredith TA, Wippold FJ. Magnetic resonance imaging findings in Vogt-Koyanagi-Harada syndrome. Retina. 1994;14:164–8.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W, Rochester, MN, 55905, USA

    Brian P. Chalmers, Kevin I. Perry, Michael J. Taunton, Tad M. Mabry & Matthew P. Abdel

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Correspondence to Matthew P. Abdel.

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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.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Hip: Metal-on-Metal

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Chalmers, B.P., Perry, K.I., Taunton, M.J. et al. Diagnosis of adverse local tissue reactions following metal-on-metal hip arthroplasty. Curr Rev Musculoskelet Med 9, 67–74 (2016). https://doi.org/10.1007/s12178-016-9321-3

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