Scientific Articles   |    
The Correlation of Wear with Histological Features After Failed Hip Resurfacing Arthroplasty
George Grammatopoulos, DPhil, MRCS1; Hemant Pandit, DPhil, FRCS(Orth)1; Amir Kamali, PhD3; Francesca Maggiani, MD4; Sion Glyn-Jones, DPhil, FRCS(Orth)1; Harinderjit S. Gill, DPhil2; David W. Murray, FRCS(Orth)1; Nicholas Athanasou, MD, PhD, FRCPath4
1 Botnar Research Centre, Nuffield Orthopaedic Centre, NDORMS, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, United Kingdom. E-mail address for G. Grammatopoulos: george.grammatopoulos@ndorms.ox.ac.uk
3 Smith & Nephew, Implant Development Centre, Aurora House, Spa Park, Leamington Spa, CV31 3HL, United Kingdom.
4 Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford, OX3 7LD, United Kingdom.E-mail address for N. Athanasou: nick.athanasou@ndorms.ox.ac.uk
2 Department of Mechanical Engineering, University of Bath, Claverton Down, Bath BA2 7AY, United Kingdom
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  • Disclosure statement for author(s): PDF

Investigation performed at the Nuffield Orthopaedic Centre, Oxford, United Kingdom

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. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. 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 Jun 19;95(12):e81 1-10. doi: 10.2106/JBJS.L.00775
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Tissue necrosis and a macrophage and perivascular lymphocytic infiltrate are commonly seen in periprosthetic tissues around metal-on-metal hip resurfacing implants, including pseudotumors associated with these implants. The purpose of the present study was to correlate pathological changes in periprosthetic tissues with clinical findings and the amount of implant-derived metal wear.


We analyzed morphological changes in the periprosthetic soft tissues around fifty-six failed metal-on-metal hip resurfacing implants. The most common reason for failure was the presence of a symptomatic pseudotumor (n = 45). The extent of necrosis and the nature of the inflammatory cell infiltrate, including aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL), was evaluated semiquantitatively. Bearing surface wear was determined for all patients. Prostheses were considered to be highly worn if the total linear wear rate was ≥4 μm/yr.


Substantial necrosis and a heavy macrophage infiltrate were noted in most periprosthetic tissues, including all pseudotumors, many of which contained a prominent ALVAL infiltrate. Most pseudotumors (80%) were associated with highly worn prostheses. It was noted that the extent of necrosis and macrophage infiltration correlated with the volume of generated metal wear. Although increased wear volume moderately correlated with a high ALVAL response, all pseudotumors associated with low wear had a strong ALVAL response.


The majority of pseudotumors are associated with increased implant wear. This increased wear is associated with soft-tissue necrosis and a heavy nonspecific foreign-body macrophage response coupled with a variable adaptive or specific immune response (ALVAL). A minority of pseudotumors are associated with low wear and a prominent immune response. These findings confirm that minimizing wear from metal-on-metal hip resurfacing arthroplasty prostheses would lead to a reduction in the incidence of pseudotumor. However, a small number of pseudotumors are still likely to occur, which may be due to an exacerbated adaptive immune response.

Level of Evidence: 

Prognostic 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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