J Korean Hip Soc JKHS The Journal of the Korean Hip Society 1226-9409 The Korean Hip Society 10.5371/jkhs.2010.22.3.171 Review Article Metal-on-Metal Bearing in Total Hip Arthroplasty Park Youn-Soo MD Lim Seung-Jae MD Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Address reprint request to Youn-Soo Park, MD. Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-gu, Seoul 135-710, Korea. TEL: +82-2-3410-3504, FAX: +82-2-3410-0061, ysp3504@skku.edu 09 2010 30 09 2010 22 3 171 176 30 06 2010 26 08 2010 26 08 2010 Copyright © 2010 The Korean Hip Society 2010

Metal-on-metal bearings have been reintroduced with the improved materials, design and manufacturing quality control as an alternative to the conventional metal-on-polyethylene articulation. The advantages of total hip arthroplasty using a metal-on-metal bearing include an extremely low wear rate, a very small risk of in vivo fracture and the use of a larger femoral head. These advantages have led to an increased use of metal-on-metal bearings for younger and more active patients with advanced hip disease. Concerns remain regarding the elevated levels of metal ions and their potential consequences such as metal hypersensitivity or potential carcinogenesis.

 Total hip arthroplasty Metal-on-metal bearing Wear Metal ion Amstutz HC Grigoris P Metal on metal bearings in hip arthroplasty Clin Orthop Relat Res 1996 329 Suppl S11 S34 August AC Aldam CH Pynsent PB The McKee-Farrar hip arthroplasty. A long-term study J Bone Joint Surg Br 1986 68 520 527 Clarke MT Darrah C Stewart T Ingham E Fisher J Nolan JF Long-term clinical, radiological and histopathological follow-up of a well-fixed McKee-Farrar metal-on-metal total hip arthroplasty J Arthroplasty 2005 20 542 546 Visuri T Long-term results and survivorship of the McKee-Farrar total hip prosthesis Arch Orthop Trauma Surg 1987 106 368 374 Amstutz HC Beaulé PE Dorey FJ Le Duff MJ Campbell PA Gruen TA Metal-on-metal hybrid surface arthroplasty: two to six-year follow-up study J Bone Joint Surg Am 2004 86 28 39 Daniel J Pynsent PB McMinn DJ Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis J Bone Joint Surg Br 2004 86 177 184 Schmidt M Weber H Schön R Cobalt chromium molybdenum metal combination for modular hip prostheses Clin Orthop Relat Res 1996 329 Suppl S35 S47 McKellop H Park SH Chiesa R In vivo wear of three types of metal on metal hip prostheses during two decades of use Clin Orthop Relat Res 1996 329 Suppl S128 S140 Schey JA Systems view of optimizing metal on metal bearings Clin Orthop Relat Res 1996 329 Suppl S115 S127 Kim SY Kyung HS Ihn JC Cho MR Koo KH Kim CY Cementless Metasul metal-on-metal total hip arthroplasty in patients less than fifty years old J Bone Joint Surg Am 2004 86 2475 2481 Smith SL Dowson D Goldsmith AA The effect of femoral head diameter upon lubrication and wear of metal-on-metal total hip replacements Proc Inst Mech Eng H 2001 215 161 170 Silva M Heisel C Schmalzried TP Metal-on-metal total hip replacement Clin Orthop Relat Res 2005 430 53 61 Sieber HP Rieker CB Köttig P Analysis of 118 second-generation meta-on-metal retrieved hip implants J Bone Joint Surg Br 1999 81 46 50 Dorr LD Wan Z Longjohn DB Dubois B Murken R Total hip arthroplasty with use of the Metasul metal-on-metal articulation. Four to seven-year results J Bone Joint Surg Am 2000 82 789 798 Grübl A Marker M Brodner W Long-term follow-up of metal-on-metal total hip replacement J Orthop Res 2007 25 841 848 Jacobs JJ Skipor AK Patterson LM Metal release in patients who have had a primary total hip arthroplasty. A prospective, controlled, longitudinal study J Bone Joint Surg Am 1998 80 1447 1458 Brodner W Bitzan P Meisinger V Kaider A Gottsauner-Wolf F Kotz R Serum cobalt levels after metal-on-metal total hip arthroplasty J Bone Joint Surg Am 2003 85 2168 2173 Savarino L Greco M Cenni E Differences in ion release after ceramic-on-ceramic and metal-on-metal total hip replacement. Medium-term follow-up J Bone Joint Surg Br 2006 88 472 476 Daniel J Ziaee H Pradhan C Pynsent PB McMinn DJ Renal clearance of cobalt in relation to the use of metal-on-metal bearings in hip arthroplasty J Bone Joint Surg Am 2010 92 840 845 Gillespie WJ Henry DA O'Connell DL Development of hematopoietic cancers after implantation of total joint replacement Clin Orthop Relat Res 1996 329 Suppl S290 S296 Visuri T Pukkala E Paavolainen P Pulkkinen P Riska EB Cancer risk after metal on metal and polyethylene on metal total hip arthroplasty Clin Orthop Relat Res 1996 329 Suppl S280 S289 Tharani R Dorey FJ Schmalzried TP The risk of cancer following total hip or knee arthroplasty J Bone Joint Surg Am 2001 83 774 780 Ladon D Doherty A Newson R Turner J Bhamra M Case CP Changes in metal levels and chromosome aberrations in the peripheral blood of patients after metal-on-metal hip arthroplasty J Arthroplasty 2004 19 Suppl 78 83 Dunstan E Ladon D Whittingham-Jones P Carrington R Briggs TW Chromosomal aberrations in the peripheral blood of patients with metal-on-metal hip bearings J Bone Joint Surg Am 2008 90 517 522 Hur CI Yoon TR Cho SG Song EK Seon JK Serum ion level after metal-on-metal THA in patients with renal failure Clin Orthop Relat Res 2008 466 696 699 Ziaee H Daniel J Datta AK Blunt S McMinn DJ Transplacental transfer of cobalt and chromium in patients with metal-on-metal hip arthroplasty: a controlled study J Bone Joint Surg Br 2007 89 301 305 Rieker CB Schön R Köttig P Development and validation of a second-generation metal-on-metal bearing: laboratory studies and analysis of retrievals J Arthroplasty 2004 19 Suppl 5 11 Willert HG Buchhorn GH Fayyazi A Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study J Bone Joint Surg Am 2005 87 28 36 Davies AP Willert HG Campbell PA Learmonth ID Case CP An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements J Bone Joint Surg Am 2005 87 18 27 Park YS Moon YW Lim SJ Yang JM Ahn G Choi YL Early osteolysis following second-generation metal-on-metal hip replacement J Bone Joint Surg Am 2005 87 1515 1521 Milosev I Trebse R Kovac S Cör A Pisot V Survivorship and retrieval analysis of Sikomet metal-on-metal total hip replacements at a mean of seven years J Bone Joint Surg Am 2006 88 1173 1182 Korovessis P Petsinis G Repanti M Repantis T Metallosis after contemporary metal-on-metal total hip arthroplasty. Five to nine-year follow-up J Bone Joint Surg Am 2006 88 1183 1191 Pandit H Glyn-Jones S McLardy-Smith P Pseudotumours associated with metal-on-metal hip resurfacings J Bone Joint Surg Br 2008 90 847 851

Photomicrographs on the histological sections of periprosthetic tissues. (A) Histological section showing perivascular infiltrates of lymphocytes (hematoxylin and eosin, ×200). (B) CD3-positive T-cells (brown color) (anti-CD4 immunostain, ×200). (C) CD20-positive B-cells (brown color) (anti-CD20 immunostain, ×200). (D) Staining for CD68 defined diffusely infiltrated macrophages (brown color) throughout the tissue (anti-CD68 immunostain, ×200).

A 63-year-old man had undergone a total hip arthroplasty for the treatment of osteonecrosis of the femoral head with a metal-on-metal bearing. (A) Radiograph made 3 months after the index operation. (B) Radiograph made 1.5 year after the index operation showing an osteolytic lesion in the greater trochanteric area. (C) Radiograph made 6 years after the index operation showed an increased size of the femoral osteolytic lesion and a newly developed osteolysis in the acetabular area. He underwent revision operation in order to exchange a metal-on-metal bearing into a ceramic-on-ceramic bearing because of persistent pain in the right hip. (D) Radiograph made 2 years after the revision operation showing a healing of the osteolytic lesion.