Metal on Metal Hip Replacements: The Lessons Learnt - Clinical, Surgical N Personal!!!
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Transcript of Metal on Metal Hip Replacements: The Lessons Learnt - Clinical, Surgical N Personal!!!
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Lessons learnt from MOM disaster
Dr Vaibhav BagariaMBBS, MS, FCPS
Joint Replacement Surgeon, CARE hospital & ORIGYN Clinic
Nagpur, INDIA
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Lessons Learnt!
Technology
Metallurgy
Technique
Personal, Philosophical & other Funda’s
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what did we learn?
Harmful effects of metal ions in body.
There are still unknown unknowns.
Tips tricks traps of revision arthroplasty
Gained experience on what to do when things go horribly wrong for surgeons.
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remember this image!
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what was MOM?First attempted in 1920’s, 30 designs so far, multiple failure.
Bearing surface always ignited interests because of less wear and hence increased longevity
Renewed interests with good results with BHR in 1990’s. Good biomechanics, bone preservation, hard bearing, marketed to young active population.
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Most famous mom: AsR
• Depuy product
• First Released in 2003.
• Withdrawn from Australia in Dec 2009
• World-wide recall Aug 2010
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Asr: good
• Bone Preserving.
• ?? Increased ROM
• Better Wear Characteristic in vitro.
• Good Instrumentation.
• Compatible/easily convertible to THR
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what happened?
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evaluation
History.
Examination
MRI
Blood Ion levels
Aspiration
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Personal experience
• 10% catastrophic failure
• 10- 20 % Failing.
• 70% doing well.
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Catastrophic failure
• Fracture
• Cup Migration/ Spin Out
• Infection
• Metal Ion related Inflammatory response: a.Osteolysis b. Solid or Cystic Pseudotumor c. Necrosis d. Muscle Disruption
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preoperative planning
History: Function & Pain.
Examination: Trochanteric tenderness, ROM - irritability, Grating?clunking, Psoas & Abductor Power.
Make Sure it is not infected.
MRI: To know the abnormal tissue locations.
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Preoperatve Asses
• Blood: CBC, LFT, ESR, CRP, Check Renal functions, Exclude Infections.
• Blood Cobalt & Chromium Levels: Controversial, Little Science - much opinion, Changing Goal Post.
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Blood Metal levels
• Normal Levels: Agreement poor between labs. 2-7 vs 0-20nMol/L
• BOA/AOA statements: <40nMol/L OK; 3- 4x - cause of concern. toxicity >125nMol/L
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Preoperative asses
• Xray: Positioning- Inclination Angle, Lucent Lines, Osteolysis, H.O
• MRI: Fluid Collection ( Joint Effusion, “bursal”, “Cystic Pseudotumor”, Synovial Thickening, Solid Pseudotumor ( FB Granuloma), Status Muscles/Tendons, Osteolysis)
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intra-operative tech
Lots of unappreciated osteolysis - always have bone available.
Dislocation: downsizing bearing dia, pt used to hip that does not dislocate, deficient abductors.
Infection?: Masses of abnormal soft tissues, careful resection required.
Keep Constraints/ Explant available
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Make Sure it is not Infected Infected
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Resect all Abnormal Tissues
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Cup Extraction
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Use Explant
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Have bone graft available
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Use constraint if necessray
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Implants usually Normal
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Post operative
• Use drains as necessary.
• Hip Precautions: 3/12 to form pseudocapsule.
• Expect 90% reduction in Cobalt & Chrome levels in 3/12
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Metal ions in body
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Metal Hypersenstivity
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Monk forced to sell ferrari
Text
One of My fellowship Trainers who had to leave his practice in Australia and take”sanyas””Every Tragedy has learning points - some deeply Personal.
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Learn to Pick bad eggs
< -Be Wary of ‘miles ahead’ Technology and
Lawyers ->
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New surgeons
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Lessons Learnt!
• Be Careful!
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Thank You!
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