Total hip replacement failure due to adverse local tissue reaction from both ceramic abrasive wear and trunnion corrosion

Abstract

The most common sources for metal ions after total hip arthroplasty (THA) are the bearing surface in metal-on-metal articulations and trunnion corrosion. Concomitant dual interface failure is an uncommon complication in metal-on-polyethylene THA. We report an unusual case of a 59-year-old woman with ceramic-on-ceramic THA in 2005, who underwent revision to metal-on-polyethylene THA 4 years later after femoral head fracture. Subsequently, she developed substantial adverse local tissue reaction and significant metal ion elevation and the failure was found to be due to both wear at the bearing surface and corrosion at the head neck junction requiring second revision. Findings included massive adverse local tissue reaction, abductor mechanism destruction, osteolysis, and corrosion damage of the trunnion. Abrasive damage of the trunnion was also noted, but prior abrasion from the original ceramic fracture could not be ruled out. Postoperative course at 14 months demonstrates 95% and 64% reduction in cobalt and chromium levels respectively, with symptom resolution.

The Mechanism of Metallosis After Total Hip Arthroplasty

“…5a). Metallosis after total hip arthroplasty is a subject that has attracted high research in recent years after the reported association with potential adverse outcomes [2]. As of March 2019, there are no FDA-approved metal-on-metal total hip replacement devices currently on the market in the USA.…”

“…Surgical mistakes, inexperience, and procedural challenges have been implicated in metallosis [3]. Revision surgeries replacing a failed plastic or ceramic implant with metal-on-metal total hip arthroplasty have posed a high chance of 3rd body wear [2]. A truncated acetabular component has also been linked to metallosis, owing to accelerated mechanical wear from 3rd body, which usually occur at an articulation between intentional bearing surfaces in the presence of wear debris.…”

“…When the cartilage within the joint breaks down, the underlying bone begins to change. These changes usually develop slowly with an insidious onset of pain, stiffness, swelling, and reduced joint function [2]. When conservative treatments such as physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve severe osteoarthritis have failed, total joint arthroplasty is considered.…”

“…Metallosis results as a syndrome of metal-induced synovitis, which manifests in the abnormal dark macroscopic staining of soft tissues that is associated with abnormal wear from implants (Fig. 1a and c) [2,13,14]. The clinical outcomes of revision surgery depend on the amount of bone and tissue necrosis as surgeons replace the MoM implant with a ceramic-on-plastic or plastic-on-metal implant to minimize future complications with metal ions.…”

“…The local inflammatory response and damage to the surrounding bone and/or tissue has been d e s c r i b e d a s a s e p t i c l y m p h o c y t e -d o m i n a t e d vasculitis-associated lesions (ALVAL) [14] (Fig. 1b,and d) [2,13]. Patients with a progressive ALVAL should be considered for earlier revision to prevent extensive bone, muscle, and nerve damage [17,18].…”