Skip to main content
Log in

Femoral component loosening after hip resurfacing arthroplasty

  • Scientific Article
  • Published:
Skeletal Radiology Aims and scope Submit manuscript

Abstract

Objective

Before the re-introduction of the current generation of total hip resurfacing arthroplasty, component loosening and osteolysis were of great concern to the orthopaedic community. Early, mid- and long-term clinical results are encouraging, but component loosening still exists.

Materials and Methods

Macroscopic, contact radiographic and histopathological analyses after undecalcified preparation of bone tissue specimens were performed. To investigate the frequency and morphological patterns of the loosening of the femoral component, we analysed a series of 190 retrieved femoral remnants that were revised for aseptic failures.

Results

Thirty-five (18.4%) hips were revised for clinical and/or radiographic loosening of the femoral component. Pseudoarthrosis (n = 17; median in situ time: 16 weeks, interquartile range [IQR]: 9 to 34), collapsed osteonecrosis (n = 5; median in situ time: 79 weeks, IQR: 63 to 97), cement–socket debonding (n = 3; median in situ time: 89 weeks, IQR: 54 to 97) and at later follow-up bone–cement loosening (n = 10; median in situ time: 175 weeks; IQR 112 to 198; p =0.005) were distinct patterns of the femoral remnant–implant loosening. Fibrocartilaginous metaplasia of interface bone trabeculae (n = 38; median in situ time: 61 weeks, IQR: 32 to 138) was strongly associated with femoral component loosening (p = 0.009). Both the trabecular hyperosteoidosis (n = 32; median in situ time: 71 weeks, IQR 50 to 129) and excessive intraosseous lymphocyte infiltration (n = 12; median in situ time: 75 weeks, IQR 51 to 98) at the bone–cement interface correlated strongly with fibrocartilaginous metaplasia (p = 0.001 and p = 0.016 respectively) and all three lesions were associated with the female gender (p = 0.021, p = 0.009, and p = 0.051).

Conclusion

Femoral component loosening at early follow-up was mostly caused by pathological changes of the femoral remnant bone tissue: pseudoarthrosis and collapsed osteonecrosis. Fibrocartilaginous metaplasia was frequently observed in hips with femoral component loosening. The potential role of interface hyperosteoidosis as a precursor lesion of bone–cement loosening and its possible association with delayed type hypersensitivity reaction are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Beaule PE, Matar WY, Poitras P, Smit K, May O. 2008 Otto Aufranc Award: component design and technique affect cement penetration in hip resurfacing. Clin Orthop Relat Res. 2009;467:84–93.

    Article  PubMed  Google Scholar 

  2. Amstutz HC, Le Duff MJ, Campbell PA, Dorey FJ. The effects of technique changes on aseptic loosening of the femoral component in hip resurfacing. Results of 600 Conserve Plus with a 3 to 9 year follow-up. J Arthroplasty. 2007;22:481–489.

    Article  PubMed  Google Scholar 

  3. Mont MA, Seyler TM, Ulrich SD, et al. Effect of changing indications and techniques on total hip resurfacing. Clin Orthop Relat Res. 2007;465:63–70.

    PubMed  Google Scholar 

  4. Steffen RT, Pandit HP, Palan J, et al. The five-year results of the Birmingham hip resurfacing arthroplasty: an independent series. J Bone Joint Surg Br. 2008;90:436–441.

    Article  CAS  PubMed  Google Scholar 

  5. Kim PR, Beaule PE, Laflamme GY, Dunbar M. Causes of early failure in a multicenter clinical trial of hip resurfacing. J Arthroplasty. 2008;23:44–49.

    CAS  Google Scholar 

  6. Amstutz HC, Campbell PA, Le Duff MJ. Fracture of the neck of the femur after surface arthroplasty of the hip. J Bone Joint Surg Am. 2004;86:1874–1877.

    PubMed  Google Scholar 

  7. Shimmin AJ, Back D. Femoral neck fractures following Birmingham hip resurfacing: a national review of 50 cases. J Bone Joint Surg Br. 2005;87:463–464.

    Article  CAS  PubMed  Google Scholar 

  8. Little CP, Ruiz AL, Harding IJ, et al. Osteonecrosis in retrieved femoral heads after failed resurfacing arthroplasty of the hip. J Bone Joint Surg Br. 2005;87:320–323.

    Article  CAS  PubMed  Google Scholar 

  9. Steffen RT, Foguet PR, Krikler SJ, Gundle R, Beard DJ, Murray DW. Femoral neck fractures after hip resurfacing. J Arthroplasty. 2009;24:614–619.

    Article  PubMed  Google Scholar 

  10. Amstutz HC, Le Duff MJ. Eleven years of experience with metal-on-metal hybrid hip resurfacing: a review of 1000 conserve plus. J Arthroplasty. 2008;23:36–43.

    Article  PubMed  Google Scholar 

  11. Nunley RM, Della Valle CJ, Barrack RL. Is patient selection important for hip resurfacing? Clin Orthop Relat Res. 2009;467:56–65.

    Article  PubMed  Google Scholar 

  12. Beaule PE, Dorey FJ, Le Duff M, Gruen T, Amstutz HC. Risk factors affecting outcome of metal-on-metal surface arthroplasty of the hip. Clin Orthop Relat Res. 2004;418:87–93.

    Article  PubMed  Google Scholar 

  13. Zustin J, Sauter G, Morlock MM, Rüther W, Amling M. Association of osteonecrosis and failure of hip resurfacing arthroplasty. Clin Orthop Relat Res 2009; 10.1007/s11999-009-0979-3.

    PubMed  Google Scholar 

  14. Zustin J, Amling M, Krause M, et al. Intraosseous lymphocytic infiltrates after hip resurfacing arthroplasty: a histopathological study on 181 retrieved femoral remnants. Virchows Arch. 2009;454:581–588.

    Article  PubMed  Google Scholar 

  15. Morlock MM, Bishop N, Zustin J, Hahn M, Rüther W, Amling M. Modes of implant failure after hip resurfacing: morphological and wear analysis of 267 retrieval specimens. J Bone Joint Surg Am. 2008;90:89–95.

    Article  PubMed  Google Scholar 

  16. Bullough P. Cell synthesis and breakdown. In: Bullough P, editor. Orthopaedic pathology. 4th ed. Philadelphia: Mosby; 2004. p. 11–2

    Google Scholar 

  17. Bullough P. Hyperosteoidosis. In: Bullough P, editor. Orthopaedic pathology. 4th ed. Philadelphia: Mosby; 2004. p. 208–209.

    Google Scholar 

  18. Ryd L, Linder L. On the correlation between micromotion and histology of the bone-cement interface. Report of three cases of knee arthroplasty followed by roentgen stereophotogrammetric analysis. J Arthroplasty. 1989;4:303–309.

    Article  CAS  PubMed  Google Scholar 

  19. Vernon-Roberts B, Pirie CJ. Healing trabecular microfractures in the bodies of lumbar vertebrae. Ann Rheum Dis. 1973;32(5):406–412.

    Article  CAS  PubMed  Google Scholar 

  20. Campbell P, Beaule PE, Ebramzadeh E, et al. The John Charnley Award: a study of implant failure in metal-on-metal surface arthroplasties. Clin Orthop Relat Res. 2006;453:35–46.

    Article  PubMed  Google Scholar 

  21. Amstutz HC, Le Duff MJ. Cementing the metaphyseal stem in metal-on-metal resurfacing: when and why. Clin Orthop Relat Res. 2009;467:79–83.

    Article  PubMed  Google Scholar 

  22. Jacobs JJ, Hallab NJ. Loosening and osteolysis associated with metal-on-metal bearings: a local effect of metal hypersensitivity? J Bone Joint Surg Am. 2006;88:1171–1172.

    Article  PubMed  Google Scholar 

  23. Campbell P, Shimmin A, Walter L, Solomon M. Metal sensitivity as a cause of groin pain in metal-on-metal hip resurfacing. J Arthroplasty. 2008;23:1080–1085.

    Article  PubMed  Google Scholar 

  24. Pandit H, Glyn-Jones S, McLardy-Smith P, et al. Pseudotumours associated with metal-on-metal hip resurfacing. J Bone Joint Surg Br. 2008;90:847–851.

    Article  CAS  PubMed  Google Scholar 

  25. Pandit H, Vlychou M, Whitwell D, et al. Necrotic granulomatous pseudotumours in bilateral resurfacing hip arthroplasties: evidence for a type IV immune response. Virchows Arch. 2008;453:529–534.

    Article  CAS  PubMed  Google Scholar 

  26. Fang CS, Harvie P, Gibbons CL, Whitwell D, Athanasou NA, Ostlere S. The imaging spectrum of peri-articular inflammatory masses following metal-on-metal hip resurfacing. Skeletal Radiol. 2008;37:715–722.

    Article  PubMed  Google Scholar 

  27. Thomas P, Braathen LR, Dörig M, et al. Increased metal allergy in patients with failed metal-on-metal hip arthroplasty and peri-implant T-lymphocytic inflammation. Allergy. 2009;64:1157–1165.

    Article  CAS  PubMed  Google Scholar 

  28. Evans EM, Freeman MA, Miller AJ, Vernon-Roberts B. Metal sensitivity as a cause of bone necrosis and loosening of the prosthesis in total joint replacement. J Bone Joint Surg Br. 1974;56:626–642.

    PubMed  Google Scholar 

  29. Hallab NJ, Caicedo M, Epstein R, McAllister K, Jacobs JJ. In vitro reactivity to implant metals demonstrate a person-dependent association with both T-cell and B-cell activation. J Biomed Mater Res A 2010;92:667–682.

    Google Scholar 

  30. Charnley J. The reaction of bone to self-curing acrylic cement. A long-term histological study in man. J Bone Joint Surg Br. 1970;52:340–353.

    CAS  PubMed  Google Scholar 

  31. Willert HG, Ludwig J, Semlitsch M. Reaction of bone to methacrylate after hip arthroplasty: a long-term gross, light microscopic, and scanning electron microscopic study. J Bone Joint Surg Am. 1974;56:1368–1382.

    CAS  PubMed  Google Scholar 

  32. Howie DW, Cornish BL, Vernon-Roberts B. Resurfacing hip arthroplasty. Classification of loosening and the role of prosthesis wear particles. Clin Orthop relat Res. 1990;255:144–159.

    PubMed  Google Scholar 

  33. Howie DW, Cornish BL, Vernon-Roberts B. The viability of the femoral head after resurfacing hip arthroplasty in humans. Clin Orthop Relat Res. 1993;291:171–184.

    PubMed  Google Scholar 

  34. Ciarelli TE, Fyhrie DP, Parfitt AM. Effects of vertebral bone fragility and bone formation rate on the mineralization levels of cancellous bone from white females. Bone. 2003;32:311–315.

    Article  CAS  PubMed  Google Scholar 

  35. Follet H, Boivin G, Rumelhart C, Meunier PJ. The degree of mineralization is a determinant of bone strength: a study on human calcanei. Bone. 2004;34:783–789.

    Article  CAS  PubMed  Google Scholar 

  36. Huiskes R. Failed innovation in total hip replacement. Diagnosis and proposals for a cure. Acta Orthop Scand. 1993;64:699–716.

    Article  CAS  PubMed  Google Scholar 

  37. Stauffer RN. Ten-year follow-up study of total hip replacement. J Bone Joint Surg Am. 1982;64:983–990.

    CAS  PubMed  Google Scholar 

  38. Bauer TW, Schils J. The pathology of total joint arthroplasty. I. Mechanisms of implant fixation. Skeletal Radiol. 1999;28:423–432.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

One or more of the authors received funding from DePuy Orthopaedics, Warsaw, IN, USA (MM, MA); Smith&Nephew, London, UK (MM, MA); Corin Group PLC, Cirencester, UK (MM, MA); Zimmer, Warsaw, IN, USA (MM, MA); and Biomet, Warsaw, IN, USA (MM, MA). We thank Matthias Krause, Stefan Breer, Alexandra Zieplies, Anette Jung and Elke Leicht-Schröder for assistance with processing the specimens. We also thank all cooperating orthopaedic surgeons who provided us with cases.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Jozef Zustin.

Additional information

This work was performed at University Medical Centre Hamburg-Eppendorf and TUHH University of Technology Hamburg-Harburg

Each author certifies that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article

Rights and permissions

Reprints and permissions

About this article

Cite this article

Zustin, J., Hahn, M., Morlock, M.M. et al. Femoral component loosening after hip resurfacing arthroplasty. Skeletal Radiol 39, 747–756 (2010). https://doi.org/10.1007/s00256-009-0862-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00256-009-0862-z

Keywords

Navigation