Are serum cobalt and chromium levels predictors for patient-reported outcome measures in the ASR hip resurfacing arthroplasty?

Aims: The aims of this study were to determine if an increasing serum cobalt (Co) and/or chromium (Cr) concentration is correlated with a decreasing Harris Hip Score (HHS) and Hip disability and Osteoarthritis Outcome Score (HOOS) in patients who received the Articular Surface Replacement (ASR) hip resurfacing arthroplasty (HRA), and to evaluate the ten-year revision rate and show if sex, inclination angle, and Co level influenced the revision rate. Methods: A total of 62 patients with an ASR-HRA were included and monitored yearly postoperatively. At follow-up, serum Co and Cr levels were measured and the HHS and the HOOS were scored. In addition, preoperative patient and implant variables and the need for revision surgery were recorded. We used a linear mixed model to relate the serum Co and Cr levels to different patient-reported outcome measures (PROMs). For the survival analyses we used the Kaplan-Meier and Cox regression model. Results: We found that an increase of one part per billion (ppb) in serum Co and Cr levels correlated significantly with worsening of the HHS in the following year. This significant correlation was also true for the HOOS-Pain and HOOS-quality of life sub scores. The overall ten-year survival rate in our cohort was 65% (95% confidence interval (CI) 52.5 to 77.6). Cox regression analysis showed a significant hazard ratio (HR) of 1.08 (95% CI 1.01 to 1.15; p = 0.028) for serum Co level. No significance was found with sex or inclination angle. Conclusion: This study shows that increasing serum Co and Cr levels measured in patients with an ASR-HRA are predictive for deterioration in HHS and HOOS subscales in the following year. Increasing serum Co and Cr should forewarn both surgeon and patient that there is a heightened risk of failure. Continued and regular review of patients with an ASR-HRA implant by measurement of serum Co/Cr levels and PROMs remains essential.

Safe Upper Limits of Serum Cobalt and Chromium Levels for a Metal-on-Metal Total Hip Bearing: A 10-Year Follow-Up Study.

BACKGROUND: Long-term survival of metal-on-metal (MoM) prostheses and the development of adverse reaction to metal debris (ARMD) around these bearings are still unclear. Serum levels of cobalt (Co) and chromium (Cr) are used as a screening tool to anticipate failure in MoM bearings and detect ARMD. METHODS: One hundred sixty primary large head MoM prostheses were followed up for 10 years. To estimate the revision risk, the cumulative incidence function (CIF) was used. Subdistribution hazard modeling was used to investigate the associations between cumulative incidence of revision for ARMD and Co levels, Cr levels, gender, age, head size, and cup inclination. Furthermore, the safe upper limits (SULs) for Co and Cr were determined. RESULTS: Univariate analyses showed an increased risk in revision for ARMD in females (subdistribution hazard ratio [sdHR] 3.43, 95% confidence interval [CI] 1.01-11.7, P = .049) and cup inclination angles over 45° (sdHR 4.70, 95% CI 1.63-13.58, P = .004). In addition, a higher last measured Co level (sdHR 1.05, 95% CI 1.03-1.07, P < .001) and last measured Cr level (sdHR 1.21, 95% CI 1.14-1.29, P < .001) were associated with a higher probability of revision for ARMD. We determined our bearing-specific SULs at 4.1 parts per billion (ppb) and 4.2 ppb for Co and Cr, respectively. CONCLUSION: Guidelines regarding follow-up and surveillance should include a complete clinical assessment with bearing-specific SULs of serum metal ion levels. For the M2a-Magnum MoM bearing we advise an SUL for Co and Cr levels of 4.1 and 4.2 ppb, respectively.

Routine Fracture Fixation for a Periprosthetic Hip Fracture Below Birmingham Hip Resurfacing: A Case Report.

CASE: We present a case of a 56-year-old man who sustained a basal cervical periprosthetic fracture around a well-fixed metal-on-metal hip resurfacing arthroplasty (MoMHRA). Although several fixation methods have been described, there seems to be no consensus about the optimal fixation method for fractures around MoMHRAs. This fracture could be regarded as a Vancouver type-B1 or -C periprosthetic fracture, so we successfully treated our patient in a standard way with a dynamic hip screw (DHS) and one cannulated hip screw. CONCLUSION: We describe DHS fixation as a successful treatment option for periprosthetic hip fractures around well-fixed MoMHRA.

Asymptomatic intraprosthetic dual mobility cup dislocation with increased metal ion levels.

With the increased use of dual-mobility cups (DMCs) in total-and revision hip arthroplasties, surgeons can expect an increase of known and new complications. During routine follow-up, we observed an asymptomatic patient with an intraprosthetic-dislocation (IPD) and elevated levels of serum metal ions (1.8 ppb of cobalt and 28.0 ppb of chromium). Revision surgery was inevitable. Perioperative metallosis and severe wear of the metal shell and metal femoral head supported the IPD. Literature showed that the modularity of the DMC can result in increased serum metal ions, create excessive wear, and possibly affect implant survival. Our case and review of the literature may form an argument not to consider DMC for primary cases. Furthermore, we advise yearly clinical and radiological follow-up and, on indication, metal ion testing for DMCs.

A 5-year survival analysis of 160 Biomet Magnum M2 metal-on-metal total hip prostheses.

BACKGROUND: Large-head metal-on-metal (MoM) total hip arthroplasties (THA) are associated with high failure rates and possible pseudotumour formation. This study reports the first results of 160 Biomet Magnum M2 large-head MoM total hip articulations. PATIENTS AND METHODS: From 2006 to 2010 the Reinier de Graaf Hospital implanted 160 large-head Magnum M2 MoM THAs (Biomet Inc. Warsaw, Indiana, USA) in 150 patients. These patients were recalled after a warning from the Dutch Orthopaedic Association. Patients were offered a clinical and radiographic assessment of the hip prosthesis, serum control on cobalt and chromium ions, and an ultrasound of the hip. If indicated, additional MARS-MRI or CT scan was performed. Descriptive statistical analysis, correlations, t-tests, non-parametric tests and implant survival were calculated. RESULTS: The mean follow-up was 6.1 years (4.8-8.4). A cumulative survival rate of 93.1% (95% CI: 88.3-98%) was found after 5 years. Reasons for revision were loosening, pain, infection and pseudotumour formation. The prevalence of pseudotumour formation around the prostheses was 8.75%. CONCLUSIONS: This study reports the first results of 160 MoM THAs implanted in our clinic from 2006-2010. In total, 13 (8.1%) of the THAs were eligible for revision after the recall. In most patients the reason for revision was pseudotumour formation. A total of 14 (8.75%) pseudotumours were diagnosed at the first recall. These results show that a comprehensive follow-up strategy is essential for MoM THAs to promptly identify and manage early complications.