Wednesday, January 6, 2010

Metal on Metal Bearing in Hip Arthroplasty

Metal on Metal (MoM)

- Are associated with decreased wear rate compared to conventional polyethylene
- Mixed film lubrication appears to be the operative mechanism in most metal-on-metal hip joints
- With metal-on-metal bearings, in contrast to polyethylene bearings, a larger-diameter bearing actually produces lower wear rates than does a smaller-diameter bearing
- Larger-diameter bearings have a greater arc of motion(and thus better ROM), which decreases the risk of impingement and also lessens the incidence of dislocation
- Alloys of cobalt (Co) and chromium (Cr) have been preferred for MOM bearings in THR because of their hardness.
- High chromium content provides good corrosion resistance
- There are two types of wear particles with MoM bearings: Co-Cr-Mo particles and chromium oxide particles
- It has been hypothesized that the Co-Cr-Mo particles are produced by the wear of the carbides on the bearing surfaces and the prosthesis matrix, and that the chromium oxide particles come from the passivation layer on the implant surface and possibly from oxidized chromium carbides

Metal hypersensitivity:
- all metals in a biological environment corrode; the ions released can combine with proteins and activate the immune system as antigens and elicit hypersensitivity responses
- the incidence of hypersensitivity is approximately 2 per 10,000
- are generally delayed cell-mediated responses
- ALVAL: are Lymphocytic infiltrations in the subsurface layer of the lining tissues, which were either diffuse or aggregated around small postcapillary vessels
- delayed type hypersensitivity should be considered when a patient with a well-fixed implant experiences chronic, aching pain with evidence of synovitis (an irritable range of motion) but has no objective evidence of infection
- If a modular MOM bearing is being considered, the use of substrates without Co-Cr (e.g., titanium) will allow revision of only the bearings in cases were hypersensitivity develops

What is New in Hip Resurfacing(Metal on Metal)?

-S. Glyn-Jones and H. Pandit reported in Dec 2009 JBJS B that incidence of ALVAL is higher in women especially if performed under 40 years of age.

-Factors significantly associated with an increase in revision rate were female gender, age under 40, dysplasia and small components.

-the higher revision rates in women could be due to increased prevalence of allergy in women because of wearing jewellery, increased ROM, which would be more likely to cause impingement, edge loading or different gait patterns

1 comment:

  1. well i guess the current trend in bearings as they all put it is " future lies in past".

    will just put across the few points that are being discussed bt bearings wht u guys think?...

    1) high end bearings (COC, MOM,COM)to be considered only if the combination of both high demand hip and well versed surgeon is there.. key point is both should be yes..not either (as it was in past). an ALVAL or sqeuaking in a low demand hip can be legally challeneged with the data available now from the retrieval analysis of revsions and the question wil be about the competency of the surgeon and wether the aptient really needed the bearing

    2) the trend in COC has moved from fractures to squeak and in MOM from systemic toxicity to local reactions like ALVAL. MOM also squeak and COC can also have psuedo tumours

    3) during the "bedding in" period of hard on hard bearing (roughly 2 yrs) dont hesitate to do an MRI ( for psuedo tumours and version) for a painfull hip. earlier revised the better. also not a bad idea to ask the patient to keep a avoid extreme actions for first two years

    4) females always avoid MOM, if the decision if for resurfacing beware of CAVA angle. resurfacing is not dead yet and "if works has best results". of course the bell curve is dipping

    5) normal patient, normal surgeon..if answer to either is yes..go for MOP, COP. cross linked poly does produce quantitavely less wear put the qualitatively the wear particles generated are very osteolytic. insist on minimum of 8 mm poly and make it amdatory to check the shelf life of poly