Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis

Limiting hip resurfacing to appropriate patient population will aid in success

ORLANDO, Fla. — Despite the problems seen with some hip resurfacing implants, hip resurfacing is still a viable alternative to hip replacement in appropriately selected patients, a surgeon here said.

“Many of the reasons not to perform hip resurfacing are based upon fear: fear of fracture, fear of difficulty of the technique, fear of metal reactivity and sensitivity. I implore you that we should not allow fear to triumph over reason,” Edwin P. Su, MD, said during a presentation at the 2010 Current Concepts in Joint Replacement Winter Meeting.

In support of hip resurfacing

Su presented several factors in favor of hip resurfacing. Hip resurfacing preserves bone, as was observed in a cadaveric study he and his colleagues performed that compared hip resurfacing and hip replacement to determine the extent of bone loss.

Blood metal ion concentrations after hip resurfacing arthroplasty -ASR vs BHR

The whole blood and serum chromium (Cr) and cobalt (Co) concentrationswere inversely related to the size of the femoral componentin both groups (p < 0.05). Cr and Co were more strongly influencedby the position of the acetabular component in the case of theASR, with an increase in metal ions observed at inclinations> 45° and anteversion angles of < 10° and >20°.

New data reinforces the proven safety and effectiveness of the BIRMINGHAM HIP Resurfacing System

80-percent of US surgeons choose the BHR hip as it outperforms all other metal-on-metal resurfacing devicesMemphis, Tenn. (May 3, 2010) – Recent new data¹ presented at this year’s American Academy of Orthopaedic Surgeons (AAOS) annual meeting reinforces the BIRMINGHAM HIP™ Resurfacing (BHR) System as a safe and effective hip resurfacing device. The multi-site study, performed by orthopedic surgeons practicing at nine Canadian academic centers, showed that three years after surgery, 99.91% of their 3,400 hip resurfacing patients experienced no implant failure due to metal wear debris. The BHR Hip was the most used resurfacing device in this study.

FDA on Metal Metal Implants

Follow-Up for Metal-on-Metal Hip Patients Developing Local Signs/Symptoms

Clinical and Imaging Evaluation

If you have a patient with the presence of local symptoms such as pain or decrease in joint function that appear more than three months after metal-on-metal (MoM) hip implant surgery, you should conduct a thorough evaluation.

• Guide your clinical evaluation by the symptoms and physical findings, including an assessment for well-known emergent complications including joint infection, implant loosening, peri-prosthetic fracture and dislocation.
• Recognize that localized lesions associated with reactions to metal debris may also present with pain or a variety of other signs/symptoms including:
  • Local nerve palsy
  • Palpable mass
  • Local swelling
  • Joint dislocation or subluxation

Rethinking informed consent: Tell your patients of all the treatment choices available to them

The editors gratefully acknowledge the contribution of Jeffrey A. Shane, MD, JD, in the preparation of this article.

The doctrine of informed consent continues to stir debate among physicians, ethicists, and courts. The origins of informed consent derive from the common law tort of battery, which is defined as the intentional harmful or offensive contact to another. Valid consent of the plaintiff negates an allegation of battery. Thus, absent a signed informed consent, a patient could sue a surgeon for battery even if the operation were properly indicated and expertly performed. Over the last century, this traditional understanding of informed consent and how it applies in the medical field has continued to evolve. . . . . . .
In this column we examine two recent legal decisions related to informed consent. The first was issued in Wisconsin and addresses the duty of a physician to inform patients of available options and alternatives to a proposed treatment. The second, from Maryland, illustrates how the concept of informed consent attaches to the continuing communication between a patient and physician during treatment. Both touch the boundaries of the doctrine of informed consent in the context of a health care provider’s

Soft tissue reactions to metal-on-metal hip arthroplasty are due mostly to surface wear

By Robert Trace
ORTHOPAEDICS TODAY EUROPE 2009; 12:6

MANCHESTER — Researchers reported that adverse soft tissue reactions following metal-on-metal hip arthroplasty are typically due to increased wear of the bearing surfaces, and patients with smaller femoral heads may be particularly susceptible to these complications.

In an independent center study, David J. Langton, MRCS, and colleagues in the Joint Replacement Unit at the University Hospital of North Tees in Stockton, England, reviewed 155 Birmingham Hip resurfacings (BHR, Smith & Nephew) performed between 2002 and 2009 (mean follow-up, 60 months). They also studied 420 articular surface replacements (ASRs) and 75 total hip replacements using ASR XL implants (both DePuy Orthopaedics) with S-ROM stems (DePuy Orthopaedics) with a mean follow-up of 35 months.

FDA gives Wright Medical approval to market Conserve Plus resurfacing system

By Susan M. Rapp
1^st on the web (November 10, 2009)

The Conserve Plus Total Hip Resurfacing System, manufactured by Wright Medical Group Inc., Arlington, Tenn., has been cleared for marketing by the U.S. Food and Drug Administration (FDA), the company announced yesterday.

The Conserve Plus system is the third metal-metal hip resurfacing implant to be approved by the FDA in recent years.

“The approval permits Wright to market Conserve Plus in the original femoral and acetabular component configuration specified in its Premarket Approval (PMA) application and enables the Company to initiate efforts to introduce additional enhancements to the system which are currently only available outside of the United States,” according to a Wright Medical’s Nov. 9 press release.

A Joint Venture Is the New Hip Thing

Warwick, England

I am a natural-born American, but part of me was made in England. I’ve come to this town, 25 miles southeast of Birmingham, to find out how.

The hum of machines is ubiquitous in the Smith & Nephew factory, where the floor is divided into “cells” the size of small rooms, each a self-contained assembly line making a particular part. Workers in a cell transform a dull-gray metal piece, cast at another facility, into a gleaming, perfectly shaped finished product, measured to an accuracy of a few microns. Every part is numbered, so that it can be tracked throughout its lifetime, and inspected and cleaned multiple times before shipment. I am grateful for this precision and care. Two of these parts — a ball and a matching socket — are now my right hip.

Outcome of hip resurfacing may be dependent on experience

LAS VEGAS — A new study links outcomes of hip resurfacing to the hospital volume of resurfacing cases and, thereby, the surgeon’s experience.

To evaluate the impact of operative volume on hip resurfacing outcomes, Andrew J. Shimmin, MD, and colleagues used the Australian Joint Registry to identify nearly 9,000 hip resurfacings performed at 196 hospitals between September 1999 and December 2006. The investigators used revision as an endpoint for survivorship.

They found that 74% of hospitals performed fewer than 30 procedures during the 7-year study period, while 64% of hip resurfacings were performed at 16 “high-volume” hospitals, or those that performed more than 100 cases. Overall, the researchers found that 3.1% of resurfacings were revised.

A Simple, Reproducible Method for Centering the Guide-Pin in Hip Resurfacing Arthroplasty

With this technique, guide-pin placement and subsequent femoral head preparation can be performed accurately and efficiently without the need for additional instruments, navigation, or imaging.
Hip resurfacing arthroplasty has undergone a recent resurgence in popularity. A number of studies with short- to mid-term follow-up, as well as the Australian Hip Registry, have validated hip resurfacing as a viable alternative to traditional total hip replacement, particularly for younger, more active patients with good bone quality.

Clinical outcomes after hip resurfacing associated with commitment to rehabilitation

LAS VEGAS — A new study links patients’ commitment to rehabilitation with functional outcomes and satisfaction following total hip resurfacing arthroplasty.

“We found that commitment to rehab correlates with improved function and satisfaction, a fact that has not specifically been discussed and not much looked at in the literature to date,” David R. Marker said during his
presentation at the American Academy of Orthopaedic Surgeons 76th Annual Meeting, here.

“Obese patients are more likely to be less committed to rehabilitation. Surgeonsshould be aware of these patients and perhaps need to help them out with theirrehabilitation. Finally, new protocols may be necessary for young metal-on-metalpatients who desire a quicker return to activity,” he said.

Position of Hip Resurfacing Component Affects Outcome

Abstract:

The Journal of Bone and Joint Surgery (American). 2008;90:1951-1960.\doi:10.2106/JBJS.F.00788\
© 2008 The Journal of Bone and Joint Surgery, Inc.

Thomas Parker Vail, MD¹, Richard R. Glisson, BS², David E. Dominguez, MD², Kenichi Kitaoka, MD, PhD² and Danielle Ottaviano, MEng²

Popular Supplements Ineffective Against Arthritis

Revision of metal-on-metal resurfacing arthroplasty of the hip -INFLUENCE OF MALPOSITIONING

R. De Haan, MD, Resident in Orthopaedic Surgery¹; P. A. Campbell, PhD, Research Scientist²; E. P. Su, MD, Orthopaedic Surgeon³; and K. A. De Smet, MD, Orthopaedic Surgeon^{4 1} University Hospital Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium.
² J. Vernon Luck Snr MD, Orthopaedic Research Centre, Orthopaedic Hospital/University of California Los Angeles, 2400 South Flower Street, Los Angeles, California 90007, USA.
³ Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, USA.
⁴ ANCA Medical Centre, Krijgslaan 181, 9000 Ghent, Belgium.

We have reviewed 42 patients who had revision of metal-on-metalresurfacing procedures, mostly because of problems with theacetabular component. The revisions were carried out a meanof 26.2 months (1 to 76) after the initial operation and mostof the patients (30) were female.

Intraoperative Fractures: Rising Problems

All hip surgeons have had the experience of completing a primary total hip arthroplasty (THA) only to discover a proximal femoral fracture just prior to reducing the hip. We can comfort our patients and ourselves that the outcome of a THA with a proximal femoral fracture is excellent with proper treatment and uncemented stem fixation. The purpose of this study was to examine risk fractures, treatment options, and outcomes in THA with proximal femoral fractures.

Fracture Risk Factors

As the number of uncemented THAs has  increased,^1,2 there is no question the incidence of uncemented stem fractures has increased as as well.³ The risks for fracture during THA have been well studied. In their study, Schwartz et al⁴ found women were at higher risk for proximal femoral fracture with the AML stem (DePuy, Warsaw, Ind).

Changes in instrumentation and implantation have helped reduce the risk of fracture. Berend et al⁵ noted higher fracture rates in hips undergoing THA for a diagnosis other than osteoarthritis.

For full article Click Here

Leg up for Ex-Swedish Footballer

CHENNAI: Benny Axelsson started playing for the national Swedish soccer team at the age of 18. After a career that spanned more than a decade and saw Axelsson play against various European countries, his last few years have been far from a fairy tale.

Axelsson had severely damaged his left hip joint, through what doctors believe may be as a result of over use. “He developed osteo-arthritis, a condition generally seen in people over the age of 70. But sometimes, athletes and professional players develop it a few decades earlier, due to over use of the joint,’’ said Dr Vijay C Bose, consultant orthopaedic surgeon at Apollo Hospital.

Zimmer Recall

A Call for a Warning System on Artificial Joints

By BARRY MEIER
Published: July 29, 2008

Dr. Lawrence Dorr, a nationally known orthopedic surgeon in Los Angeles, realized last year that something was very wrong with some of his patients.

Months after routine hip replacements, patients who had expected to live without pain were in agony. “The pain was grabbing me around the back,” said Stephen Csengeri, who is 54, and a lawyer from Torrance, Calif.

Resurfaced hips converted to THA similar to primary

Hips previously treated with metal-on-metal resurfacing arthroplasty that require conversion to total hip arthroplasty can achieve short-term clinical and radiographic results similar to primary total hip replacement, according to a study by California researchers.

“The theoretical advantage of easy ‘revisability’ of a resurfacing arthroplasty is supported by our results,” the study authors wrote. “With the numbers studied, the procedure was similar to primary total hip arthroplasty (THA) in terms of operative time and blood loss. The radiographic results after conversion were also similar to those in the primary [THA] group in terms of osseointegration, the position of the center of rotation, femoral offset, stem position, and limb-length equality.”

For full article Click Here

Sports After Hip Resurfacing Arthroplasty

Background: No information is available concerning patients? sports activity after hip resurfacing arthroplasty.

Hypothesis: Patients treated by hip resurfacing arthroplasty will be able to achieve a high level of sports activity.

Study Design: Case series; Level of evidence, 4.Methods: We surveyed 112 patients by postal questionnaire to determine their sporting activities at a mean of 23.5 (range, 9? 40) months after hip resurfacing surgery. Data were also analyzed separately for older and younger patients and women and men, respectively.

Metal-on-Metal Hip Resurfacing: The Effect of Component Position

Decreased head-neck ratio diameter and component malposition in total hip arthroplasty are factors known to result in impingement, increased rates of dislocation, wear and failure. In addition to these complications, impingement of the femoral neck on the acetabular component of a hip resurfacing may result in femoral neck fracture and loosening of the acetabular component. Little is known regarding the optimum femoral and acetabular hip resurfacing component position to avoid impingement.

Position of Hip Resurfacing Component Affects Outcome

Abstract:

The Journal of Bone and Joint Surgery (American). 2008;90:1951-1960.\doi:10.2106/JBJS.F.00788\
© 2008 The Journal of Bone and Joint Surgery, Inc.

Thomas Parker Vail, MD¹, Richard R. Glisson, BS², David E. Dominguez, MD², Kenichi Kitaoka, MD, PhD² and Danielle Ottaviano, MEng²

Revision of metal-on-metal resurfacing arthroplasty of the hip -INFLUENCE OF MALPOSITIONING

R. De Haan, MD, Resident in Orthopaedic Surgery¹; P. A. Campbell, PhD, Research Scientist²; E. P. Su, MD, Orthopaedic Surgeon³; and K. A. De Smet, MD, Orthopaedic Surgeon^{4 1} University Hospital Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium.
² J. Vernon Luck Snr MD, Orthopaedic Research Centre, Orthopaedic Hospital/University of California Los Angeles, 2400 South Flower Street, Los Angeles, California 90007, USA.
³ Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, USA.
⁴ ANCA Medical Centre, Krijgslaan 181, 9000 Ghent, Belgium.

We have reviewed 42 patients who had revision of metal-on-metalresurfacing procedures, mostly because of problems with theacetabular component. The revisions were carried out a meanof 26.2 months (1 to 76) after the initial operation and mostof the patients (30) were female.

Intraoperative Fractures: Rising Problems

All hip surgeons have had the experience of completing a primary total hip arthroplasty (THA) only to discover a proximal femoral fracture just prior to reducing the hip. We can comfort our patients and ourselves that the outcome of a THA with a proximal femoral fracture is excellent with proper treatment and uncemented stem fixation. The purpose of this study was to examine risk fractures, treatment options, and outcomes in THA with proximal femoral fractures.

Fracture Risk Factors

As the number of uncemented THAs has  increased,^1,2 there is no question the incidence of uncemented stem fractures has increased as as well.³ The risks for fracture during THA have been well studied. In their study, Schwartz et al⁴ found women were at higher risk for proximal femoral fracture with the AML stem (DePuy, Warsaw, Ind).

Changes in instrumentation and implantation have helped reduce the risk of fracture. Berend et al⁵ noted higher fracture rates in hips undergoing THA for a diagnosis other than osteoarthritis.

For full article Click Here

Leg up for Ex-Swedish Footballer

CHENNAI: Benny Axelsson started playing for the national Swedish soccer team at the age of 18. After a career that spanned more than a decade and saw Axelsson play against various European countries, his last few years have been far from a fairy tale.

Axelsson had severely damaged his left hip joint, through what doctors believe may be as a result of over use. “He developed osteo-arthritis, a condition generally seen in people over the age of 70. But sometimes, athletes and professional players develop it a few decades earlier, due to over use of the joint,’’ said Dr Vijay C Bose, consultant orthopaedic surgeon at Apollo Hospital.

Zimmer Recall

A Call for a Warning System on Artificial Joints

By BARRY MEIER
Published: July 29, 2008

Dr. Lawrence Dorr, a nationally known orthopedic surgeon in Los Angeles, realized last year that something was very wrong with some of his patients.

Months after routine hip replacements, patients who had expected to live without pain were in agony. “The pain was grabbing me around the back,” said Stephen Csengeri, who is 54, and a lawyer from Torrance, Calif.

Metal-on-Metal Resurfacing of the Hip in Patients With Osteoarthritis

Excerpt:
“The results of conventional hip replacement in young patientswith osteoarthritis have not been encouraging even with improvementsin the techniques of fixation and in the bearing surfaces. Modernmetal-on-metal hip resurfacing was introduced as a less invasivemethod of joint reconstruction for this particular group…..

“The extremely low rate of failure in spite of the resumption of high level occupational and leisure activities provides early evidence of the suitability of this procedure for young and active patients with arthritis.^“

For full article Click Here

Metal Ions and Placenta

A CONTROLLED STUDY

H. Ziaee, J. Daniel, A. K. Datta, S. Blunt, D. J. W. McMinn
From The McMinn Centre, and Birmingham Women’s Healthcare NHS Trust, Birmingham, England

Metal-on-metal bearings are being increasingly used in young patients. The potential adverse effects of systemic metal ion elevation are the subject of ongoing investigation. The purpose of this study was to investigate whether cobalt and chromium ions cross the placenta of pregnant women with a metal-on-metal hip resurfacing and reach the developing fetus. Whole blood levels were estimated using high-resolution inductively-coupled plasma mass spectrometry.

Paying Workers to Go Abroad for Health Care

Insured Americans are starting to see some unusual options in their health-provider networks: doctors and hospitals in Singapore, Costa Rica and other foreign destinations. In an effort to control rising costs, a small but growing number of insurers and employers are giving people the choice to seek treatment in other countries, a practice known as medical tourism. Until recently, most Americans who traveled abroad for medical care were uninsured, or were seeking procedures not covered by insurance, such as cosmetic dentistry or aesthetic surgery. Now, a handful of plans are beginning to cover treatment overseas for heart surgery, hip and knee replacements and other major surgical procedures.

For full article Click Here

Femoral Neck Notching

“Introduction: It has been suggested that notching of the femoral neck during hip resurfacing weakens the proximal femur and predisposes to femoral neck fracture. We aimed to examine the effect of neck notching during hip resurfacing on the strength of the proximal femur.

Methods: A three dimensional femoral model was used and molded with a femoral component constructed from the dimensions of a Birmingham Hip Resurfacing. Multiple constructs were made with the component inferiorly translated in order to cause a notch in the superior femoral neck.

Gait Analysis Of Metal On Metal Surface Arthroplasty

Learning Curve – Various Articles

“However, the role that proper surgical technique plays in resurfacing outcomes cannot be over emphasized. “Performing hip resurfacing is different than performing a total hip,” Beaulé said. And there is no getting around the learning curve.

Femoral neck fractures—a dramatic failure for patient and surgeon—is a technique-related complication that must be surmounted.