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High Prevalence of Pseudotumors in Patients with a Birmingham Hip Resurfacing ProsthesisA Prospective Cohort Study of One Hundred and Twenty-nine Patients
R. Bisschop, MD1; M.F. Boomsma, MD2; J.J.A.M. Van Raay, MD, PhD1; A.T.M.G. Tiebosch, MD, PhD1; M. Maas, MD, PhD3; C.L.E. Gerritsma, MD, PhD1
1 Department of Orthopedics (R.B., J.J.A.M.V.R., and C.L.E.G.) and Pathology (A.T.M.G.T.), Martini Hospital, Van Swietenplein 1, 9728 NT, Groningen, The Netherlands. E-mail address for C.L.E. Gerritsma: C.L.E.Gerritsma@MZH.nl
2 Department of Radiology, Isala Klinieken, Groot Wezenland 20, 8011 JW, Zwolle, The Netherlands
3 Department of Radiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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  • Disclosure statement for author(s): PDF

R. Bisschop, MD, and M.F. Boomsma, MD, contributed equally to the preparation of this article.

Investigation performed at the Departments of Orthopedics and Pathology, Martini Hospital, Groningen, The Netherlands

A commentary by Stuart B. Goodman, MD, PhD, FRCSC, FBSE, is linked to the online version of this article at jbjs.org.

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Sep 04;95(17):1554-1560. doi: 10.2106/JBJS.L.00716
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Recently, concern has emerged about pseudotumors (lesions that are neither malignant nor infective in the soft tissues surrounding total hip arthroplasty components) after hip arthroplasties with metal-on-metal bearings. Patients treated in our hospital for degenerative arthritis of the hip with a Birmingham Hip Resurfacing (BHR) prosthesis were invited to return for follow-up evaluation. The prevalence and clinical relevance of pseudotumors were investigated. Risk factors for pseudotumor formation were sought.


A single-center cross-sectional prospective cohort study was conducted and included all patients who received a BHR from 2005 to 2010 in Martini Hospital, Groningen, The Netherlands. Data were collected on patient and surgical characteristics, clinical hip outcome scores (Harris hip score and Oxford score), serum metal ion levels (cobalt and chromium), and radiographs. A computed tomographic scan (without metal suppression) was made. In patients who had a revision, tissue samples were histologically examined.


Originally, there were 129 patients with 149 BHRs. Four patients (six hips; 4%) were lost to follow-up. Our final cohort consisted of 125 patients (143 hips). From this final cohort, eleven patients (twelve hips) had a revision, and three of them (three hips) had the revision before the present study was conducted. Seven patients (eight hips; 5.6%) had a revision because of a symptomatic pseudotumor. Survival analysis showed an implant survival rate of 87.5% at five years (failure was defined as a revision for any reason). A pseudotumor was found on computed tomography in thirty-nine patients (forty hips; 28%). Of those patients, ten (eleven hips; 28%) had complaints involving groin pain and discomfort, a noticeable mass, or paresthesia. Symptomatic pseudotumors were significantly larger than asymptomatic pseudotumors (a mean volume of 53.3 cm3 compared with 16.3 cm3; p = 0.05). A serum cobalt level of >85 nmol/L was a predictor for pseudotumor formation (odds ratio, 4.9).


Pseudotumor formation occurred in 28% of hips after an average follow-up of forty-one months. Most pseudotumors (72.5%) were asymptomatic. Larger pseudotumors were associated with more complaints. Survival analysis showed an implant survival of 87.5% at five years. Failure occurred in 5.6% (eight) of 143 hips because of a symptomatic pseudotumor.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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