title: The Hip Society: algorithmic approach to diagnosis and management of metal-on-metal arthroplasty.
abstract: Since 1996 more than one million metal-on-metal   articulations have been implanted worldwide. Adverse reactions to   metal debris are escalating. Here we present an algorithmic approach   to patient management. The general approach to all arthroplasty   patients returning for follow-up begins with a detailed history,   querying for pain, discomfort or compromise of function. Symptomatic   patients should be evaluated for intra-articular and extra-articular   causes of pain. In large head MoM arthroplasty, aseptic loosening   may be the source of pain and is frequently difficult to diagnose.   Sepsis should be ruled out as a source of pain. Plain radiographs   are evaluated to rule out loosening and osteolysis, and assess component   position. Laboratory evaluation commences with erythrocyte sedimentation   rate and C-reactive protein, which may be elevated. Serum metal   ions should be assessed by an approved facility. Aspiration, with   manual cell count and culture/sensitivity should be performed, with   cloudy to creamy fluid with predominance of monocytes often indicative   of failure. Imaging should include ultrasound or metal artifact   reduction sequence MRI, specifically evaluating for fluid collections   and/or masses about the hip. If adverse reaction to metal debris   is suspected then revision to metal or ceramic-on-polyethylene is indicated   and can be successful. Delay may be associated with extensive soft-tissue   damage and hence poor clinical outcome.
authors.affiliation: The Ohio State University, Department of Orthopaedics and Department of Biomedical Engineering, 7277 Smith's Mill Road, Suite 200, New Albany, Ohio 43054, USA. lombardiav@joint-surgeons.com
authors.forename: A V
authors.initials: AV
authors.lastname: Lombardi
authors.forename: R L
authors.initials: RL
authors.lastname: Barrack
authors.forename: K R
authors.initials: KR
authors.lastname: Berend
authors.forename: J M
authors.initials: JM
authors.lastname: Cuckler
authors.forename: J J
authors.initials: JJ
authors.lastname: Jacobs
authors.forename: M A
authors.initials: MA
authors.lastname: Mont
authors.forename: T P
authors.initials: TP
authors.lastname: Schmalzried
mesh_terms: D000465:Algorithms; D019644:Arthroplasty, Replacement, Hip / Q000295:instrumentation* / Q000379:methods; D003661:Decision Support Techniques; D020878:Device Removal; D019544:Equipment Failure Analysis; D006622:Hip Prosthesis / Q000009:adverse effects*; D006801:Humans; D006968:Hypersensitivity, Delayed / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D057052:Medical Device Recalls; D061825:Metal-on-Metal Joint Prostheses / Q000009:adverse effects*; D010149:Postoperative Pain / Q000209:etiology; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000628:therapy; D011475:Prosthesis Failure / Q000009:adverse effects / Q000209:etiology; D016459:Prosthesis-Related Infections / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D012086:Reoperation