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.
Similar content being viewed by others
References
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.
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.
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.
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.
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.
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.
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.
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.
Steffen RT, Foguet PR, Krikler SJ, Gundle R, Beard DJ, Murray DW. Femoral neck fractures after hip resurfacing. J Arthroplasty. 2009;24:614–619.
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.
Nunley RM, Della Valle CJ, Barrack RL. Is patient selection important for hip resurfacing? Clin Orthop Relat Res. 2009;467:56–65.
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.
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.
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.
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.
Bullough P. Cell synthesis and breakdown. In: Bullough P, editor. Orthopaedic pathology. 4th ed. Philadelphia: Mosby; 2004. p. 11–2
Bullough P. Hyperosteoidosis. In: Bullough P, editor. Orthopaedic pathology. 4th ed. Philadelphia: Mosby; 2004. p. 208–209.
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.
Vernon-Roberts B, Pirie CJ. Healing trabecular microfractures in the bodies of lumbar vertebrae. Ann Rheum Dis. 1973;32(5):406–412.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Huiskes R. Failed innovation in total hip replacement. Diagnosis and proposals for a cure. Acta Orthop Scand. 1993;64:699–716.
Stauffer RN. Ten-year follow-up study of total hip replacement. J Bone Joint Surg Am. 1982;64:983–990.
Bauer TW, Schils J. The pathology of total joint arthroplasty. I. Mechanisms of implant fixation. Skeletal Radiol. 1999;28:423–432.
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
Corresponding author
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
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
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00256-009-0862-z