Revision of metal-on-metal hip arthroplasty in a tertiary center

Figures & data

Table 1. Preoperative and demographic details

No.	Age	Sex	Prosthesis	Modular	Head	Cup	Incl.	Ver.	Survival (m)	Co	Cr
1	50	F	BHR	Resurfacing	50	56	71	42	31	47	33
2	55	M	BHR	Resurfacing	46	54	29	-34	13	0.9	1.5
3	63	F	ASR	Resurfacing	47	54	55	48	29	30	32
4	65	F	ASR	Resurfacing	40	48	66	28	53	24	21
5	72	F	BHR	Resurfacing	50	56	44	29	59	3.1	2.3
6	65	F	BHR	Resurfacing	42	48	38	9	61	1.1	1.3
7	69	F	BHR	Resurfacing	42	48	56	23	82	1.7	2.7
8	63	F	BHR	Resurfacing	42	50	40	7	95	7.7	9.4
9	46	F	Cormet	Resurfacing	44	50	75	34	18	3.3	0.3
10	65	F	BHR	Resurfacing	42	50	57	26	56	21	11
11	66	M	Cormet	Resurfacing	48	54	60	29	68	12	6.0
12	74	F	BHR	Resurfacing	44	50	34	32	54	1.5	1.0
13	48	F	BHR	Resurfacing	46	54	41	27	45	1.8	6.7
14	48	F	BHR	Resurfacing	48	54	47	26	52	1.8	6.7
15	73	F	Durom	THA	50	56	55	37	38	6.5	8.4
16	35	F	Cormet	Resurfacing	44	50	43	26	11	1.6	8.6
17	57	F	ASR	Resurfacing	53	60	70	43	45	165	117
18	60	M	BHR	Resurfacing	50	56	51	12	43	1.0	2.7
19	67	M	Mitch	THA	44	50	60	-6	13	1.2	0.5
20	64	M	BHR	Resurfacing	50	56	57	43	92	71	36
21	67	F	Biomet	Resurfacing	44	50	49	9	28	9.5	1.0
22	67	F	Biomet	Resurfacing	44	50	38	-5	22	9.5	1.0
23	61	F	BHR	Resurfacing	42	50	64	13	43	2.1	3.1
24	47	F	BHR	Resurfacing	42	50	43	39	65	0.5	0.7
25	74	F	BHR	THA	50	56	37	19	49	8.8	3.0
26	69	M	BHR	Resurfacing	54	60	73	41	63	33	14
27	60	F	BHR	Resurfacing	46	52	36	26	68	1.5	3.5
28	25	F	Cormet	Resurfacing	40	48	47	45	39	70	32
29	61	F	Pinnacle	THA	36	52	68	-3	56	102	37
30	55	F	BHR	Resurfacing	46	50	64	30	72	98	49
31	69	F	ASR	Resurfacing	43	48	55	27	62	11	6.6
32	45	F	ASR	THA	45	50	57	35	38	10	3.5
33	46	F	ASR	THA	45	50			47	10	3.5
34	66	F	BHR	Resurfacing	42	50	66	34	68	105	52
35	61	M	BHR	Resurfacing	46	52	43	22	131	3.8	2.9
36	31	F	Cormet	Resurfacing	40	46	42	24	30	20	6.8
37	58	F	BHR	Resurfacing	46	52	42	20	25	3.1	4.8
38	44	F	Mitch	Resurfacing	52	58	38	38	21	23	13
39	72	F	Taperloc Magnum	THA	44	50			28	9.4	0.5

Incl. and Ver.: inclination and version measured by CT (radiographic values);

Co and Cr: whole-blood cobalt and chromium (parts per billion);

BHR: Birmingham Hip Resurfacing (Smith and Nephew);

ASR: Anatomical Surface Replacement (DePuy Johnson and Johnson).

Table 2. MRI and intraoperative appearances; revision surgery performed

Hip	MRI mass and class	MRI muscle destruction		Intraoperative appearance	Type	Revision prosthesis and bearing
No.		Abductor	SER
1	N/A	N/A	N/A	Synovitis, no mass	II	COC
2	Nil	Moderate	Severe	Clear impingement, no mass	I	COC
3	Nil	Moderate	Severe	Synovitis, no mass	II	COC
4	Nil	Moderate	Severe	Synovitis, no mass	II	COC
5	Nil	Moderate	Severe	Osteolysis, acetabular # 2º to minor trauma, no mass	III	COC
6	Nil	Mild	None	Synovitis, no mass	II	MOM
7	N/A	N/A	N/A	Mass, abductors preserved	III	COC
8	2a	None	Mild	Synovitis, no mass	II	COC
9	3	Moderate	Severe	Solid mass, pelvic extension, abductors preserved	V	Revision stem COC
10	2a	Moderate	Moderate	Loose femoral component with osteolysis	IV	COC
11	N/A	N/A	N/A	Synovitis and acetabular loosening. Infection confirmed on histology/microbiology	I	COC
12	N/A	N/A	N/A	Femoral neck fracture, no mass	I	MOM
13	1	Mild	Moderate	Synovitis, no mass	II	COC
14	2a	Mild	Moderate	Synovitis, no mass	II	COC
15	Nil	None	Severe	Impingement, no mass	I	COC
16	Nil	None	None	Synovitis, no mass	II	COC
17	2a	Severe	Moderate	Mass, gluteal dehiscence, bare trochanter	III	COC
18	Nil	Mild	Moderate	Synovitis, no mass	II	COC
19	Nil	Moderate	Moderate	Synovitis, no mass	I	COC
20	2a	Mild	Mild	Massive pelvic osteolysis	IV	Pelvic recon, COC
21	2a	Mild	Moderate	No mass, osteolysis with loose cup	IV	COC
22	2a	Mild	Severe	No mass, osteolysis with loose cup	IV	COC
23	Nil	Moderate	Severe	Loose – loss of fixation with BHR dysplasia cup	I	COC
24	Nil	Moderate	Moderate	Synovitis, no mass	II	COC
25	2a	Severe	Moderate	Complete destruction of SERs, bone death at GT	III	Revision stem, MOP
26	2b	Moderate	Mild	Pelvic osteolysis, no mass	IV	MOP
27	Nil	Mild	Severe	Synovitis, no mass	II	MOP
28	Nil	Nil	Nil	Synovitis, no mass	II	MOP
29	2a	Severe	Moderate	Severe synovitis. No mass	II	MOP
30	2a	Moderate	Moderate	Very large fluid-filled mass, no muscle dehiscence but atrophic	III	MOP
31	Nil	None	Moderate	Synovitis, no mass	II	MOP
32	3	Moderate	Moderate	Solid mass with massive muscle destruction bilaterally	V	Captive cup, MOP
33	3	Moderate	Moderate	Same patient as above	V	Captive cup, MOP
34	3	Mild	Severe	Pelvic osteolysis, no mass	IV	TMT cup, COC
35	Nil	Mild	Moderate	Pelvic osteolysis, no mass	IV	MOP
36	2a	None	Moderate	Infected. No mass	I	COC
37	1	Moderate	Severe	Complete destruction of SERs with mass	III	COC
38	2b	Moderate	Severe	Infected	I	COC
39	3	Severe	Severe	Solid mass with widespread destruction. Symptomatic encasement of sciatic nerve	V	COC

COC = ceramic-on-ceramic; MOM = metal-on-metal;

MOP = metal-on-polyethylene; SER = short external rotators

Figure 1. Scatter plot showing inclination and version of the prostheses revised. The box represents optimal position as defined by Grammatopoulos et al. (2009).

Table 3. Types of failure

	Imaging	Surgical	Hazards	Surgical plan
Type I:
Conventional failure modes	Normal or small fluid-filled ‘pseudotumor’ on MRI	Variable	Misdiagnosis, Recurrent infection
Type II:
Synovitis with negative investigations	Normal or small fluid-filled ‘pseudotumor’ on MRI	Varying degrees of synovitis	Misdiagnosis	Need to exclude other causes e.g. infection, mechanical causes. Consider further imaging for psoas, frozen section during revision
Type III:
Soft tissue disruption	MRI shows fluid or solid mass with variable soft tissue and muscle destruction (Figures 2 and 3)	Abductors may be atrophic or avulsed/absent	Instability after revision	Plan for possibility of muscle loss, including need for musle reconstruction (e.g. graft jacket) or captive cup. Like type V, may need pelvic surgeon for full excision of intrapelvic mass
Type IV:
Bone destruction	Osteolysis on CT/plain films. MRI as type I (Figure 4)	Loose cup. Soft tissue reaction varies	Loss of bone stock and need for extensive reconstruction	May need extensive reconstruction. CT and pelvic surgeon may be helpful. Early surgery indicated to prevent fracture
Type V:
Solid pseudotumor	MRI shows large mass. Mass may extend to pelvis (Figure 5)	Massive soft tissue reaction but musculature may be intact	Secondary infection if incompletely excised	Complete excision required. May need pelvic exploration

Figure 2. MRI of case 30, showing large fluid-filled pseudotumor.

Figure 3. Intraoperative image of case 30.

Figure 4. Preoperative radiograph of patient 34 demonstrating extensive osteolysis adjacent to the right acetabular component.

Figure 5. Case 32 with destructive solid pseudotumor.

Table 4. Outcomes

Type	Description	n	Preoperative OHS median (range)	Postoperative OHS median (range)	ΔOHS (range)	p-value
Whole cohort		39	15 (2–31)	36.5 (9–48)	17 (–10 to 41)	< 0.001
Subgroup
1	Conventional	8	17 (2–30)	32 (20–46)	17 (–10 to 41)	0.08
2	Synovitis	14	11 (4–29)	33 (9–44)	14 (4–33)	0.002
3	Soft tissue disruption	6	27 (14–31)	47 (29–48)	16 (6–33)	0.04
4	Bone destruction	7	20 (10–28)	41 (39–45)	22 (12–35)	0.03
5	Solid pseudotumor	4	8 (2–22)	29.5 (15–31)	16.5 (9–23)	0.07

Grammatopoulos G, Pandit H, Kwon Y-M, Gundle R, McLardy-Smith P, Beard DJ, Murray DW, Gill HS. Resurfacings revised for inflammatory pseudotumour have a poor outcome. J Bone Joint Surg (Br) 2009; 91: 1019-24

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