Outcomes of the Recalled Articular Surface Replacement Metal-on-Metal Hip Implant System: A Systematic Review

Background

The aim of this review was to synthesize the main findings of clinical studies that have evaluated outcomes of the articular surface replacement (ASR) Hip System.

Revision Total Hip Arthroplasty With a Modular Cementless Femoral Stem

We retrospectively reviewed 123 patients who underwent cementless THA with modular femoral stem designs for revision THA or conversion of failed ORIF and found 75 patients available for analysis. The Harris Hip Score (HHS) improved from 52 ± 14 to 86 ± 11 (P < 0.001). The femoral stem was re-revised in eight patients (11%). The mean time to re-revision was 1.1 years (0.13–2.54). Reasons for re-revision included infection (n = 5, 7%), aseptic loosening (n = 2, 3%) and significant pain (n = 1, 1%). There were no failures of the modular junctions. PC stems had an increased rate of intraoperative fractures (PC 28% vs. STS 9%, P = 0.04). Modular cementless femoral stems provide acceptable mid-term results in revision THA.     

Trends in Total Hip Arthroplasty Implant Utilization in the United States

Total hip arthroplasty (THA) implant usage has evolved as experience has been gained with newer implant designs. The purpose of this study was to characterize trends in THA implant usage between 2001 and 2012. The Orthopedic Research Network, which includes 174 hospitals and ~ 105,000 THA, was used to evaluate trends in fixation, bearings, acetabular cup and liner, and femoral head usage. In 2012, 93% of THAs were cementless; 56% of THA bearings were metal-HXLPE; and 35% were ceramic-HXLPE. 99% of acetabular cups were modular. 61% of femoral heads were metal, 39% were ceramic, 51% were 36 mm, and 28% were 32 mm. THA implant usage trends favor cementless fixation, metal-on-polyethylene or ceramic-on-polyethylene bearings, modular acetabular cups, and large diameter femoral heads.     

Total Hip Arthroplasty after Acetabular Fracture: Incidence of Complications,Reoperation Rates and Functional Outcomes: Evidence Today

The outcome of THA following acetabular fracture was analyzed on 654 patients with a systematic review approach. An uncemented acetabular and femoral component was used in 80.1% and 59.8% of the cases respectively. The median Harris hip score was 88 points. In the early THA group, Kaplan–Meier survivorship analysis with any loosening, osteolysis or revision as the end point revealed that the 10-year cup survival was 81% whereas in the late THA group was 76% (P = 0.287). The 10-year survival was 95% for the early stems and 85% for the late ones (P = 0.001). Due to their complexity these fractures should be managed in highly specializing units where the expertise of arthroplasty and trauma reconstruction is available.     

The Effect of Size for a Hydroxyapatite-Coated Cementless Implant on Component Revision in Total Hip Arthroplasty: An Analysis of 41,265 Stems

BackgroundThe cementless Corail is one of the most commonly used stems in total hip arthroplasty (THA). The aim of this study was to investigate whether there was a difference in revision rate for smaller stems.MethodsAll primary THA procedures recorded by the Australian Joint Replacement Registry from September 1999 to December 2017 performed for osteoarthritis using the Corail stem, a cementless acetabular cup, modern bearing surfaces (ceramic/ceramic, ceramic/cross-linked polyethylene, and metal/cross-linked polyethylene), and 28 mm, 32 mm, and 36 mm head sizes were included. The primary outcome measure was femoral component revision. Data were analyzed and adjusted for age, gender, and head size. Further analysis investigated the effects of surgical approach.ResultsThere was 41,265 primary THAs recorded. The cumulative percent revision (CPR) at 13 years was 7.7% (5.5, 10.7) for stem sizes 8 and 9 and 3.0% (2.4, 3.8) for sizes 10-20 (P < .001). When adjusted for age and gender, the sizes 8 and 9 collared (hazard ratio [HR]: 6.22 [3.84-10.06], P < .001) and collarless (HR: 3.28 [2.41-4.45], P < .001) had a higher CPR than the collared and collarless size 10-20. The size 8 and 9 stems performed with an anterior approach had the highest CPR (HR: 14.44 [6.21-33.56], P < .001). The main reason for revision of size 8 and 9 femoral stems was loosening (65.2%, compared to 31.5% for 10-20 femoral stems).ConclusionsSmaller Corail stems have 4 times the rate of revision compared with the larger femoral sizes with loosening being the most common diagnosis. This is most evident when using an anterior approach.     

Changes in Bone Mineral Density of the Acetabulum and Proximal Femur After Total Hip Resurfacing Arthroplasty

Our aim was to investigate the changes in bone mineral density (BMD) of acetabulum and proximal femur after total hip resurfacing arthroplasty. A comparative study was carried out on 51 hips in 48 patients. Group A consisted of 25 patients (26 hips) who had undergone total hip resurfacing and group B consisted of 23 patients (25 hips) who had had large-diameter metal-on-metal total hip arthroplasty (THA). BMDs around the acetabulum and proximal femur were measured using dual-energy x-ray absorptiometry (DEXA) at 2 weeks, 6 months, 1 year and annually thereafter during the 3 years after surgery. At final follow-up, the acetabular net mean BMD decreased by 11% in group A and 10% in group B with no differences between two groups (P = .35). For the femoral side, in Gruen zone 1, the mean BMD increased by 4% in group A, whereas it decreased by 11% in group B (P = .029). In Gruen zone 7, the mean BMD increased by 8% at the final follow-up in group A, whereas it decreased by 13% in group B (P = .02). In both groups the mean BMD increased by 3% in Gruen zones 3, 4, 5, and 6. Stress-related bone loss of the acetabulum was comparable for MOM THA and resurfacing devices, but proximal femoral bone density increased in the resurfacing group and decreased in the THA group.     

Midterm Results of Large Diameter Biolox Forte Ceramic Head on Delta Ceramic Liner Articulation in Total Hip Arthroplasty

Seventy-nine patients (94 hips), who underwent cementless alumina-on-alumina total hip arthroplasty (THA) with the use of a 36-mm delta ceramic liner-on-alumina ceramic femoral head, were followed for an average of 6.5 years (range, 5–7.7 years). All acetabular and femoral components were bone-ingrown and neither pelvic nor femoral osteolysis was identified until the latest follow-up. The survivorship with revision surgery as an endpoint was 97.9% (95% confidence interval = 100%–95%). Ceramic related complications such as fracture and squeaking did not occur in any patient. The mid-term results of cementless THA with this type of ceramic articulation are encouraging.     

Acute Delayed Infection: Increased Risk in Failed Metal on Metal Total Hip Arthroplasty

Adverse local tissue reactions occurring in metal-on-metal total hip arthroplasty (MoM THA) could potentially lead to secondary failure modes such as dislocation or infection. The authors report a series of 124 patients treated with MoM hip arthroplasty between 2006 and 2010 with a minimum follow-up of 3 years. Eight hips presented with acute delayed or late periprosthetic joint infection (PJI) (defined as an infection occurring after 3 months in an otherwise well functioning implant). The rate of infection observed was higher than expected, almost 4 times higher (5.6%) compared to previous historical cohorts from our institution (1.3%). This high risk of infection in patients with DePuy ASR implants requires further study but we theorize that the increased prevalence of infection could be due to a combination of particulate debris, molecular (rather than particulate) effects of Co and Cr ions on soft tissues, and/or products of corrosion that may change the local environment predisposing to infection.     

Cementless Total Hip Arthroplasty in Patients with Osteonecrosis After Kidney Transplantation

This study was to determine the mid- to long-term survivorship of cementless metal-on-metal THA in 52 patients (74 hips) who underwent THA for osteonecrosis of the femoral head with a cementless THA. The mean follow-up was 10.2 years. The mean age at operation was 42.1 years (range, 25–62 years). The survivorship analysis with revision as the end point estimated a 96.6% chance of THA survival during 16.4 years. The average Harris hip score at last follow-up was 89.2 points (range, 74–100). Two patients (two hips) required revision surgery for extensive acetabular osteolysis at 9 years and acetabular liner dissociation at 2 years. The survival rates of cementless THA in these patients are encouraging. However, the possibility of metallic wear related complications are raising concern.     

Metal Ion Levels in Total Hip Arthroplasty Versus Hip Resurfacing

Recent studies suggest that the tapered interface between stem and femoral head may be a substantial source of cobalt and chromium ion release after metal-on-metal (MOM) total hip arthroplasty (THA). This study compared patient ion levels after MOM hip resurfacing (HR) and MOM THA performed with identical acetabular components. 110 HRs were compared with 22 THAs. All had well-oriented components, unilateral implants, and serum ion studies beyond one year post-operatively. The HR group’s median cobalt value was 1.11 μg/L vs. 2.86 μg/L for the THA patients. The HR group’s median chromium value was 1.49 μg/L vs. 2.94 μg/L for THA. Significantly higher THA ion levels suggest a source of ions other than the MOM bearing itself.     

One-Component Revision of Failed Hip Resurfacing from Adverse Reaction to Metal Wear Debris

This study assessed the results of 90 one-component revisions for failed hip resurfacing due to adverse reaction to metal wear debris (76 acetabular, 14 femoral). Patients with a femoral head size 40–45 mm (n = 33) received a two-piece titanium meshed shell with a cross-linked polyethylene liner and patients with femoral head size 46–54 mm (n = 43) received metal-on-metal components. Patients with femoral head size > 45 mm who wished a metal-polyethylene bearing received a dual mobility femoral prosthesis. The mean follow-up was 61 months and the procedure was successful in 97% of the patients. Three failures required re-revision; there was one deep infection. There were no dislocations. One-component revision is a reasonable alternative to revision to total hip arthroplasty.     

Inferior Radiographic and Functional Outcomes With Modular Stem in Metal-on-Metal Total Hip Arthroplasty

Background

Data on the association between stem type and metal-on-metal (MoM) total hip arthroplasty (THA) performance are limited. The aim of this study is to investigate the effect of stem type on the prevalence of osteolysis and radiolucency, blood metal ion levels, and functional outcomes in patients with Articular Surface Replacement THA (ASR XL), a type of MoM THA.

Large Diameter Metal on Metal Articulations. Comparison of Total Hip Arthroplasty and Hip Resurfacing Arthroplasty

The use of large diameter metal bearing total hip arthroplasty (THA) and hip resurfacing arthroplasty (HRA) increased in popularity in the last decade. More recent literature has highlighted the effect of head size in patient outcomes. Data was obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOA-NJRR) to evaluate the Birmingham (MoM) bearing surface when used with THA and HRA. There is no difference in the overall rate of revision between the THA and HRA but head size has a significant effect on revision rate. The data show that small diameter metal bearings in HRA (below 50 mm) have a higher rate of revision than large diameter metal bearings in HRA (equal to and above 50 mm) (P < .001). Conversely the large diameter metal bearings in THA have a higher rate of revision than the small diameter metal bearings in THA (P = .027). The revision rate for large diameter HRA compared to small diameter THA is not significantly different P = .670. We recommend caution when choosing either a large diameter (≥ 50 mm) metal on metal THA or small diameter (< 50 mm) HRA.     

Early Failures in Total Hip Arthroplasty — A Changing Paradigm

Between 2001 and 2011, 1168 revision hip arthroplasties were reviewed for “early” failures within 5 years of the primary total hip arthroplasty (THA). 24.1% underwent revision within 5 years of index THA. Aseptic loosening, infection, instability, metallosis, and fracture were common modes of failure. In our previous report from 1986 to 2000, 33% were “early” revisions, with instability and aseptic loosening accounting for over 70% of these early failures. While the proportion of “early” revisions decreased 9% from our previous report, this rate remains alarming. The emergence of metallosis and aseptic loosening of monoblock metal on metal shells as leading causes of early failures is concerning. This report suggests caution in the early adoption of new innovations before evidence based medicine is available to justify the risk of their use.     

A Validation Study for Estimation of Femoral Anteversion Using the Posterior Lesser Trochanter Line : An Analysis of Computed Tomography Measurement

The aim of this study was to introduce a simple and reliable intraoperative reference guide to reproduce the normal femoral anteversion during total hip arthroplasty (THA). We hypothesized that the posterior lesser trochanter line (PLTL) could be a useful guide for estimating femoral anteversion during THA. We conducted a study of 56 men (112 hips) to evaluate the relationship between the PLTL and the femoral anteversion using computed tomography scans. The mean femoral anteversion was 9.0° ± 8.1° (range, − 16.2° to 32.9°). The PLTL angle correlated (r² = 0.12, P < 0.05) with the femoral anteversion. We found a constant relationship between the PLTL and femoral anteversion, and the PLTL may be used as a guide for estimating the femoral stem anteversion during femoral stem fixation.     

Are Bilateral Total Joint Arthroplasty Patients at a Higher Risk of Developing Pulmonary Embolism Following Total Hip and Knee Surgery?

Despite developments in prophylactic methods, venous thromboembolism (VTE) continues to be a serious complication following total joint arthroplasty. The new AAOS/ACCP guidelines on preventing pulmonary embolism (PE) after total hip/knee arthroplasty (THA/TKA) do not make specific recommendations for bilateral vs. unilateral procedures. In-patient PE rates were examined for patients undergoing unilateral or simultaneous bilateral TKA/THA at our institution in 2011. Of the 7,437 THA/TKA surgeries completed at our institution in 2011, 36 patients suffered from PE (0.48%). The rate of PE for unilateral TKA was 0.61% vs. 1.87% for bilateral (P < 0.001) and for unilateral THA was 0.17% vs. 0.52% for bilateral THA. Despite patients being screened before being cleared to undergo bilateral THA/TKA, they remain at higher risk for VTE.     

Midterm Results of a Femoral Stem With a Modular Neck Design: Clinical Outcomes and Metal Ion Analysis

Modular neck femoral stems have a higher-than-anticipated rate of failure in registry results, but large single-center cohort studies are lacking. This is a retrospective cohort of 152 hips implanted with a single titanium stem with a modular titanium neck, presenting clinical, radiographic, and metal ion results at a mean 4.5-year follow-up. Five hips were revised during the study period, for an overall Kaplan–Meier survival of 0.894 at 8 years. There was one modular neck fracture (0.66%), but others demonstrated corrosion or adverse tissue reaction. Serum metal levels demonstrated wide variability. Despite good clinical results in the majority of patients, we confirmed an increased rate of femoral revision at mid-term follow-up, and therefore urge caution in the use of this particular stem design.     

Utility of Synovial Fluid Aspirations in Failed Metal-On-Metal Total Hip Arthroplasty

White blood cell (WBC) count and neutrophil percentage from preoperative synovial fluid aspirations are used to help determine the presence or absence of periprosthetic joint infection (PJI) in failed total hip arthroplasty (THA). The clinical levels indicative of infection have not been delineated in metal-on-metal (MoM) bearings. We identified 39 patients who received a preoperative synovial fluid aspiration prior to MoM revision. Thirty-five of 39 cases were culture negative and 4 of 39 were culture positive. WBC count > 3000 cells/μL was 100% sensitive and 57.1% specific. Neutrophil percentage > 80% was 100% sensitive and 97.1% specific. Both CRP and ESR > 8.0 mg/L and > 22 mm/h, respectively were 75.0% sensitive and 67.6% specific. Our data suggest that synovial WBC count and serum ESR and CRP have poor predictive value in diagnosing PJI for failed MoM THA, whereas synovial neutrophil percentage is a highly accurate marker for diagnosing infection in this patient population.     

Femoral Pinless Length and Offset Measurements During Computer-Assisted,Minimally Invasive Total Hip Arthroplasty

We asked whether the intraoperative assessment of leg length (LL) and offset (OS) change would be accurate using a novel pinless femoral reference system during unilateral minimally invasive THA in 50 patients with a mean age of 60 years (48–79). LL and OS change measured at surgery was compared with LL/OS change as measured on magnification-corrected preoperative and postoperative radiographs by two blinded examiners. The radiographic evaluation showed a high inter-rater reliability (r > 0.80 for all assessments). The mean differences (± 95% limits of agreement) between navigation and radiographic measurements on the treated side were + 0.4 mm (± 3.6) for LL and − 1.0 mm (± 3.9) for OS. Femoral pinless navigation technology represents a feasible assistance in THA.     

A Systematic Review and Meta-Analysis of Non-database Comparative Studies on Cemented Versus Uncemented Femoral Stems in Primary Elective Total Hip Arthroplasty

BackgroundCemented and uncemented femoral stems have shown excellent survivorship and outcomes in primary total hip arthroplasty (THA). Cementless stems have become increasingly common in the United States; however, multiple large database studies have suggested that elderly patients may have fewer complications with a cemented stem. As conclusions from large databases may be limited due to variations in data collection, this study investigated femoral stem survivorship and complication rates based on cement status in non-database studies.MethodsPreferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized to identify articles for inclusion up until June 2021. Included articles directly compared outcomes and complications between patients undergoing primary THA without femoral stem cementing to those with cementing. Studies were excluded if they utilized large databases or consisted of patients with a preoperative diagnosis of trauma.ResultsOf the 1700 studies, 309 were selected for abstract review and nineteen for full-text review. A total of seven studies were selected. Meta-analyses indicated substantial heterogeneity between studies. There were no differences in revision rates (cementless: 5.53% vs. cemented 8.91%, P = .543), infection rates (cementless: 0.60% vs. cemented: 0.90%, P = .692), or periprosthetic fracture rates (cementless: 0.52% vs. cemented: 0.51%, P = .973) between groups.ConclusionThere is scarce literature comparing outcomes and complications between cemented and cementless femoral stems in primary elective THA without utilizing a database methodology. In our study, there were no differences in complications detected on meta-analyses. Given previous findings in database studies, additional high-quality cohort studies are required to determine if selected patients may benefit from a cemented femoral stem.