Complications After Metal-on-Metal Hip Resurfacing Arthroplasty

This article determines the incidence and cause of the complications commonly associated with metal-on-metal hip resurfacing implants and the proposed methods to prevent these complications. The literature available in PubMed was reviewed. Complication rates after hip resurfacing are low, and the procedure has shown both safety and efficacy in the hands of surgeons trained in specialized centers. Proper surgical technique can further reduce the incidence of femoral neck fracture, component loosening, and abnormal wear of the prosthesis. A more systematic detection of adverse local tissue reactions is needed to provide accurate assessments of their prevalence.

The new generation of hip metal-on-metal resurfacing arthroplasty (MMRA) devices have now been implanted for more than 13 years in the centers that initiated the return to this procedure. Ten-year survivorship data for MMRA are currently being reported in international meetings, with the first publication of the results of 100 hips at 10 to14 years showing an 88.5% survival rate (95% confidence interval, 80.2%–93.5%) and 100% in 28 hips with ideal bone (cysts <1 cm and component size >46). These results represent a dramatic improvement over metal/polyethylene hip resurfacing introduced in the mid-1970s and are comparable to total hip replacement (THR) survivorship in the Swedish registry for young patients implanted during the same period, before the introduction of alternate bearings. During this period, an array of complications specific to hip resurfacing has been identified, and solutions to prevent these complications have been proposed with varying degrees of success. The cause of most complications is usually multifactorial and falls under the broad categories of patient selection, prosthetic design, and surgical technique.

This article determines the incidence and cause of the complications commonly associated with MMRA, as well as the proposed methods and their success in preventing those complications. A comprehensive review of the published literature related to MMRA of the hip was undertaken to this effect.

Search strategy and criteria

A systematic review of the available literature was performed to identify publications related to hip resurfacing arthroplasty. An electronic search of MEDLINE was conducted using the search engine of the US National Library of Medicine. We searched for articles published after January 1, 2000, in the English language. Alternate keywords such as surface arthroplasty and surface replacement were added to the search because the term resurfacing, now predominantly accepted to describe the procedure, was not used systematically until after a sizable part of the related literature had already been published. We excluded expert opinions and editorial publications. We retained the studies that provided information about the incidence, etiology, or prevention of the type of complication reviewed in each subsection. Finally, we searched for relevant work in the bibliographies provided in recent review articles to identify additional studies that did not appear in the systematic search.

Femoral neck fracture

Incidence of Femoral Neck Fractures

To assess the worldwide incidence of femoral neck fracture after modern hip resurfacing, we collected data from the reports providing this information since 2005 and selected the most recent when several reports were published based on the same series of patients. Our computations yielded a 1.69% incidence of femoral neck fracture (range, 0%–9.2%) for a global cohort of 10,381 cases, including 3497 from the Australian Hip Registry ( Table 1 ).

Table 1

Recent publications (2005 or later) reporting femoral neck fracture rates

Authors	Journal	Year	Implant	Surgeons	Number of Hips	Number of Neck Fractures	Percentage
Madhu et al	J Arthroplasty	2010	BHR	1 surgeon	117	5	4.3
Jameson et al	J Bone Joint Surg Br	2010	ASR	1 surgeon	214	4	1.9
Ollivere et al	Int Orthop	2009	BHR	1 surgeon	104	0	0
Khan et al	J Arthroplasty	2009	BHR	Multicenter	679	11	1.6
Beaulé et al	J Arthroplasty	2009	Conserve® Plus	1 surgeon	116	0	0
O’Neill et al	Bull of NYU Hosp Jt Dis	2009	5 designs	Multicenter	250	4	1.6
Steffen et al	J Arthroplasty	2009	4 designs	5 surgeons	842	15	1.8
Amstutz and Le Duff	J Arthroplasty	2008	Conserve® Plus	1 surgeon	1000	10	1.0
Della Valle et al	Clin Orthop Relat Res	2008	BHR	Multicenter	537	10	1.9
Heilpern et al	J Bone Joint Surg Br	2008	BHR	1 surgeon	110	1	0.9
Kim et al	J of Arthroplasty	2008	Conserve® Plus	Multicenter	200	2	1.0
Witzleb et al	Eur J Med Res	2008	BHR	1 surgeon	300	1	0.3
McAndrew et al	Hip Int	2007	BHR	Multicenter	180	8	2.2
Mont et al	Clin Orthop Relat Res	2007	Conserve® Plus	Multicenter	1016	27	2.7
Marker et al	J Arthroplasty	2007	Conserve® Plus	1 surgeon	550	14	2.5
Nishii et al	J Arthroplasty	2007	BHR	1 surgeon	50	1	2.0
Siebel et al	JEIM	2006	ASR	1 surgeon	300	5	1.7
Vail et al	Clin Orthop Relat Res	2006	Conserve® Plus	1 surgeon	57	1	1.8
Pollard et al	J Bone Joint Surg Br	2006	BHR	1 surgeon	63	3	4.8
Shimmin & Back	J Bone Joint Surg Br	2005	BHR	Multicenter	3497	50	1.4
Treacy et al	J Bone Joint Surg Br	2005	BHR	1 surgeon	144	1	0.7
Cutts et al	Hip Int	2005	Cormet	5 surgeons	65	6	9.2
Total	—	—	—	—	10,381	175	1.69