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Background: Adverse Reaction to Metal Debris (ARMD) is still a major reason for revision surgeries in patients with metal-on-metal (MoM) hip replacements. ARMD consists of a wide range of alterations in periprosthetic tissues, most important of which are metallosis, inflammation, pseudotumors and necrosis. Studies investigating histopathological findings and their association to implant wear or indirect measures of wear have yielded inconsistent results. Therefore, we aimed to investigate bearing surface wear volume, whole blood and synovial fluid metal ion concentrations, histopathological findings in periprosthetic tissues and their associations.Methods: Seventy-eight patients with 85 hips revised for ARMD were included in the study. Prior to revision surgery, all patients had whole blood chromium and cobalt ion levels assessed. In revision surgery, a synovial fluid sample was taken and analyzed for chromium and cobalt. Periprosthetic tissue samples were taken and analyzed for histopathological findings. Explanted implants were analyzed for bearing wear volume of both acetabular cup and femoral head components.Results: Volumetric wear of the failed components was highly variable. The total wear volume of the head and cup had a strong correlation with whole blood chromium and cobalt ion concentrations (Cr: ρ = 0.80, p < 0.001 and Co: ρ = 0.84, p < 0.001) and a bit weaker correlation with fluid chromium and cobalt ion concentrations (Cr: ρ = 0.50, p < 0.01 and Co: ρ = 0.41, p = 0.027). Most tissues displayed only low-to-moderate amounts of macrophages and lymphocytes. Total wear volume correlated with macrophage sheet thickness (ρ = 0.25, p = 0.020) and necrosis (ρ = 0.35, p < 0.01). Whole blood chromium and cobalt ion concentrations had similar correlations. Lymphocyte cuff thickness did not correlate with either total wear volume or whole blood metal ion concentrations, but correlated with the grade of necrosis.Conclusions: Bearing wear volume correlated with blood metal ion levels and the degree of necrosis and macrophage infiltration in periprosthetic tissues suggesting a dose-response relationship. Whole blood metal ion levels are a useful tool for clinician to estimate bearing wear and subsequent tissue response. [ABSTRACT FROM AUTHOR]

We aimed to assess the early outcome following revision arthroplasty for failed metal-on-metal (MoM) total hip replacements (THR) due to adverse reaction to metal debris (ARMD).~Purpose~Objective~We reviewed 106 consecutive revision arthroplasties. Case notes and radiological investigations were reviewed to assess the complications. Oxford Hip Score (OHS) and Euroqol (EQ-5D-3L) scores were used to assess the functional outcome and improvement of quality of life.~Methods~Methods~At a mean follow-up of 20 months (12-48 months), the mean OHS was 28.7. Pain improved in 61% patients. A majority of patients were in level 2 for all the EQ-5D-3L dimensions. The overall complication rate was 16%. Survivorship free from further revision for any cause was 94.3% at 48 months. There was no correlation between pre-revision blood metal ions and the final outcome.~Results~Results~Revision surgery for failed MoM hip replacement due to ARMD is associated with a relatively higher rate of complications and risk of chronic pain. There is poor correlation between serum metal ions and development of ARMD and outcome following revision surgery.~Conclusions~Conclusions [ABSTRACT FROM AUTHOR]

Introduction: Previous studies showed poor outcomes for patients undergoing revision of failed metal-on-metal total hip arthroplasty (MoM-THA) and resurfacing (RS) with an increased risk of dislocation. Dual mobility inserts are an option to retain the acetabular component and change the metal-on-metal bearing to plastic-on-metal. The current study analyzes the rationale for the off-label use of a dual mobility poly insert (MDM X3, Stryker, Mahwah, NJ) in a Birmingham metal shell (Smith & Nephew, Memphis, TN). Materials and methods: Based on retrievals from the implant database the study compared the clearance between 20 BHR shells, 31 MDM poly inserts and 24 ADM acetabular components of different sizes. The radial clearance was calculated for each possible combination of implants [ n = 81 (MDM/BHR) and n = 119 (MDM/ADM)]. Results: An MDM mobile bearing poly insert in an ADM shell has an average clearance of 0.314 mm (SD 0.031) compared to 0.234 mm (SD 0.030) in a BHR shell ( p < 0.01). The minimal clearance is 0.246 and 0.163 mm, respectively. 30.9 % of the MDM/BHR clearances were within the range of the MDM/ADM bearing and 88.9 % had a clearance of more than 0.2 mm. Conclusion: Clearances of the MDM poly insert in a BHR shell are reduced, and although the majority of combinations appear safe, the indication needs to be made on an individual base carefully considering alternative treatment options. [ABSTRACT FROM AUTHOR]

Hip replacements are used to improve the quality of life of people with orthopaedic conditions, but the use of metal-on-metal (MoM) arthroplasty has led to poor outcomes for some patients. These problems are related to the generation of micro- to nanosized metal wear particles containing Cr, Co or other elements, but the current analytical methods used to investigate the processes involved do not provide sufficient information to understand the size or composition of the wear particles generated in vivo. In this qualitative feasibility study, asymmetric flow field-flow fractionation (AF) coupled with inductively coupled plasma mass spectrometry (ICP-MS) was used to investigate metal protein binding and the size and composition of wear metal particles present in serum and hip aspirates from MoM hip replacement patients. A well-established HPLC anion exchange chromatography (AEC) separation system coupled to ICP-MS was used to confirm the metal -protein associations in the serum samples. Off-line single particle ICP-MS (spICP-MS) analysis was used to confirm the approximate size distribution indicated by AF of the wear particles in hip aspirates. In the serum samples, AF -ICP-MS suggested that Cr was associated with transferrin (Tf) and Co with albumin (Alb) and an unidentified species; AEC -ICP-MS confirmed these associations and also indicated an association of Cr with Alb. In the hip aspirate sample, AF-ICP-MS suggested that Cr was associated with Alb and Tf and that Co was associated with Alb and two unidentified compounds; AEC analysis confirmed the Cr results and the association of Co with Alb and a second compound. Enzymatic digestion of the hip aspirate sample, followed by separation using AF with detection by UV absorption (280 nm), multi-angle light scattering and ICP-MS, suggested that the sizes of the Cr-, Co- and Mo-containing wear particles in a hip aspirate sample were in the range 40-150 nm. Off-line spICP-MS was used to confirm these findings for the Co- and Cr-containing nanoparticles. Whilst limited in scope, the results are sufficient to show the interaction of ions with transport proteins and give an indication of particle size, providing useful pathological indices. As such, the methods indicate a new way forward for in vivo investigation of the processes which lead to tissue necrosis and hip loosening in patients with MoM hip replacements. [ABSTRACT FROM AUTHOR]

Abstract: Metal-on-metal hip replacement (MOMHR) using large diameter bearings has become a popular alternative to conventional total hip arthroplasty, but is associated with elevated local tissue and circulating levels of chromium (Cr) and cobalt (Co) ions that may affect bone health. We examined the effects of acute and chronic exposure to these metals on human osteoblast and osteoclast formation and function over a clinically relevant concentration range previously reported in serum and within hip synovial fluid in patients after MOMHR. SaOS-2 cells were cultured with Co2+, Cr3+ and Cr6+ for 3days after which an MTS assay was used to assess cell viability, for 13days after which alkaline phosphatase and cell viability were assessed and for 21days after which nodule formation was assessed. Monocytes were isolated from human peripheral blood and settled onto dentine disks then cultured with M-CSF and RANKL plus either Co2+, Cr3+ or Cr6+ ions for 21days from day 0 or between days 14 and 21. Cells were fixed and stained for TRAP and osteoclast number and amount of resorption per dentine disk determined. Co2+ and Cr3+ did not affect osteoblast survival or function over the clinically equivalent concentration range, whilst Cr6+ reduced osteoblast survival and function at concentrations within the clinically equivalent serum range after MOMHR (IC50 =2.2μM). In contrast, osteoclasts were more sensitive to metal ions exposure. At serum levels a mild stimulatory effect on resorption in forming osteoclasts was found for Co2+ and Cr3+, whilst at higher serum and synovial equivalent concentrations, and with Cr6+, a reduction in cell number and resorption was observed. Co2+ and Cr6+ within the clinical range reduced cell number and resorption in mature osteoclasts. Our data suggest that metal ions at equivalent concentrations to those found in MOMHR affect bone cell health and may contribute to the observed bone-related complications of these prostheses. [Copyright &y& Elsevier]