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Hip Implant Patients with Unexplained Pain Likely to Have Tissue Damage

New York—March 20, 2013

The cause of unexplained pain among metal-on-metal hip implant patients is more likely to be tissue damage than wear of the implant, Hospital for Special Surgery researchers have found. The study, performed by Dr. Danyal Nawabi, orthopedic surgery fellow, and research collaborators at HSS, will be reported at the upcoming annual meeting of the American Academy of Orthopaedic Surgeons, March 19-23, in Chicago.

Researchers set out to determine causes of unexplained pain among patients with metal-on-metal hip implants (in which the ball and socket are both made of metal) who came to the hospital for revision surgery. Metal-on-metal implants have potential advantages, said Timothy Wright, Ph.D., Kirby Chair of Orthopedic Biomechanics at Hospital for Special Surgery (HSS): “If they remain well lubricated, as happens with the oil in your car, it minimizes wear.” In addition, surgeons can implant a bigger head, or ball, making the hip joint more stable. But nationwide, failure of metal-on-metal hip devices due to unexplained pain is rising.

The research group, which did not have any ties to hip implant manufacturers, was led by Dr. Douglas Padgett, chief of the Adult Reconstruction and Joint Replacement Division and chief of the Hip Service at HSS, and Dr. Hollis Potter, chief of the Division of Magnetic Resonance Imaging (MRI). They compared 50 patients (33 with total hip arthroplasties and 17 with hip resurfacing arthroplasties) who came to HSS for revision surgery because of unexplained pain, to a control group of 48 patients (23 with total hip arthroplasties and 25 with hip resurfacing arthroplasties) who came to HSS for revision surgery because of loosening, malalignment, infection or fracture. The investigators combined results from clinical examinations of the patients, magnetic resonance imaging, wear analysis studies on the removed implants, and pathology studies of tissues removed at surgery, including the degree of aseptic lymphocytic vasculitis-associated lesions (ALVAL), a sign of adverse tissue reactions to metal debris.

Thirty patients with unexplained pain (60% of the group) had an ALVAL score of at least 5 on a 10-point scale, indicating moderate to high adverse tissue reactions. Twelve percent of patients had some buildup of metal deposits in their soft tissue. The average synovial thickness was three times higher in the unexplained pain group compared to the control group, and the average synovial fluid volume was five times higher in the unexplained pain group compared to the control group. Ten times as many patients in the unexplained pain group had high-grade tissue damage scores compared to the control group.

Researchers found no differences between the unexplained pain group and the control group in terms of age, sex, body mass index, length of implantation, or size or positioning of the implants. Implants in both groups showed similar signs of wear.

“We found that some patients had a significant amount of tissue damage but not a lot of wear,” Dr. Wright said, “suggesting that factors other than wear are contributing to the problem regardless of whether the patients have pain. We have used the information from our study to develop guidelines for patients and surgeons.”

“Hip implant patients with unexplained pain should be followed closely by their surgeon,” 
added Dr. Padgett. “Early identification of patients with unexplained pain is vital to avoid significant tissue damage. The work by Dr. Potter using novel MRI protocols has proven to be invaluable in diagnosing and monitoring these patients.”

HSS doctors perform more than 9,000 joint replacement surgeries per year, of which about 10 percent are revision surgeries. Many patients who have had their joint replacement surgeries elsewhere come to HSS for revision surgery.

Other Hospital for Special Surgery investigators involved in the study include Nader A. Nassif, M.D.; Stephanie L. Gold; Kirsten Stoner, M.S.; Marcella Elpers; and Edwin P. Su, M.D.

Unexplained Pain in Failed Metal-on-Metal Hip Arthroplasty: A Retrieval, Histological and Imaging Analysis (Paper 70)
Wednesday, March 20, 9:12 a.m. CDT, McCormick Place, Room N427

 

About HSS | Hospital for Special Surgery
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the ninth consecutive year) and No. 3 in rheumatology by U.S.News & World Report (2018-2019). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In 2017 HSS provided care to 135,000 patients and performed more than 32,000 surgical procedures. People from all 50 U.S. states and 80 countries travelled to receive care at HSS. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The culture of innovation is accelerating at HSS as 130 new idea submissions were made to the Global Innovation Institute in 2017 (almost 3x the submissions in 2015). The HSS Education Institute is the world’s leading provider of education on the topic on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.

 

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