Recalled Hip Replacements:
Navigating Treatment Options and Optimizing Patient Care
By Brian Larkin, M.D., Orthopedic Associates, East Denver LIVING WELL Magazines
Modern total hip arthroplasty (THA) had its origins under the leadership of Sir John Charnley, working in England in the mid 1960s. From his initial ideas came reproducible, durable results for end stage arthritis of the hip. Fast forward 50 years and the world of hip replacement has seen accelerated growth, novel innovations, and advances that Sir Charnley himself likely could not have envisioned. Along with progress made, there have been setbacks, making it difficult to turn on the television nowadays without seeing advertisements about recalled hip implants.
How did we get here? As more and more total hip replacements were performed (more than 285,000 per year in the U.S. according to the Agency for Healthcare Research and Quality), two vexing problems existed: wear of the plastic liner, which can cause bone loss and dislocation. The solution offered was to make larger implants that eliminated the need for a plastic liner, moving to a metal-on-metal design. The hope was that this would significantly decrease wear by capitalizing on the potentially more wear resistant metal bearing, while addressing dislocation rates through the larger head allowed by eliminating the plastic liner. Early testing looked promising and this seemed like a viable alternative at the time.
Unfortunately, with longer term follow up, orthopedic surgeons have learned that metal-on-metal bearing surfaces have generated a multitude of new problems that were not envisioned and have left some patients at risk. There have been poorly performing implants that have been recalled. There has been increased awareness of metal ion debris and the potential adverse effects of this new kind of wear. There have also been adverse soft tissue reactions around these devices that can be devastating to the ligaments, muscles, and tendons around the hip.
In May 2011, the Food and Drug Administration (FDA) ordered a postmarket surveillance study on metal-on-metal hip replacements. This order required manufacturers of metal-on-metal hip replacements to monitor adverse effects of the device despite previous approval by the FDA. The American Association of Orthopaedic Surgeons has worked diligently with the FDA to evaluate the current marketplace and make recommendations for future care that continues to evolve.
Despite troubles with this one design of total hip replacements, the good news is that other advances have been quite promising. There have been new generations of the plastic liner, called highly cross-linked polyethylene, which has allowed for enhanced wear resistance and durability. Advances in perioperative care, pain management, and anesthetic techniques have helped allow patients to recover quicker after surgery. It certainly is not all doom and gloom relating to total hip replacement, but there are steps that patients can take to be well informed and attempt to ensure an excellent result.
Patients who have had hip replacements should seek out their surgeon and find out what type of implants were used and if there is a need for increased surveillance. The vast majority of total hip replacements placed over the last 10-15 years are still functioning quite well. If a patient’s surgeon is unavailable, finding a specialist who performs hip and knee replacements on a regular basis is beneficial. Often times all that is required is an x-ray to identify whether the implant used is of concern. Routine follow-up with an orthopedic surgeon after hip replacement is encouraged and a good practice for the lifetime of the device, allowing for early intervention if a problem is identified. If a patient does have a metal-on-metal device, blood tests to quantify the number of metal ion particles in the body and advanced imaging (MRI or ultrasound) may be required.
If you are considering total hip replacement, it is good to have a discussion with your surgeon about the risks, benefits, alternatives, and complications of the procedure. This discussion should include what type of bearing surface is used and the pros and cons of each. Options include metal-on-metal, metal-on-polyethylene, ceramic-on-polyethylene, and ceramic-on-ceramic. It is also important to know the track record of the implants to be used and the experience the surgeon has had with these implants. If the surgeon recommends a metal-on-metal device, ask why such a device is best for the specific clinical problem.
As patients demand higher function and increased durability with hip replacement, the goal is for continued innovation of implant design without compromising patient care. Advancements will continue and having well educated discussions between patients and surgeons will allow everyone to benefit from this procedure that drastically improves patient function and relieves pain.
Author Brian Larkin, M.D., is part of the Orthopedic Associates team. Reach them at 303-321-6600 or via denverortho.com.