title: A new approach to managing patients with problematic metal hip implants: the use of an Internet-enhanced multidisciplinary team meeting: AAOS exhibit selection.
abstract: BACKGROUND
  Over one million patients worldwide are estimated to have a metal-on-metal hip arthroplasty. To improve the management of these patients and reduce surgeon uncertainty regarding decision-making, we designed an Internet-enhanced multidisciplinary team (iMDT) working approach.
  
  
  METHODS
  From August 2012 to April 2014, the iMDT discussed 215 patients with 266 metal-on-metal hip arthroplasties. Of these, 236 primary arthroplasties (132 hip resurfacing and 104 total hip) were analyzed. The remaining thirty cases involved problematic revised hips and were therefore excluded. The possible recommendations of the iMDT were monitoring, further investigation, or surgery. The concordance between the recommendation and the actual management was used to assess the usefulness of this approach in reducing uncertainty in surgeon-level decision-making.
  
  
  RESULTS
  The median Oxford Hip Score was 35 (range, 4 to 48), and median cobalt and chromium levels in whole blood were 3.54 ppb (range, 0.18 to 161.46 ppb) and 3.17 ppb (range, 0.20 to 100.67 ppb), respectively. Magnetic resonance imaging revealed abductor muscle atrophy in ninety-two (39%) of the hips and a pseudotumor in eighty (34%). The iMDT recommended monitoring of 146 (61.9%) of the hips, further investigation of thirty (12.7%), and surgery in sixty (25.4%). The actual outcome was concordant with the recommendation in 211 (91.7%) of the hips.
  
  
  CONCLUSIONS
  Our iMDT approach to the metal-on-metal hip burden combines the tacit knowledge of an expert panel, regulatory guidance, and up-to-date evidence to improve decision-making among surgeons. The high level of concordance between the recommendation and the actual outcome, combined with the feasibility of the methods used, suggest that this method effectively reduces uncertainty among surgeons and may lead to improved patient outcomes.
authors.affiliation: Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, Middlesex, HA7 4LP, United Kingdom. E-mail address for R. Berber: reshidb.berber@rnoh.nhs.uk.
authors.forename: Reshid
authors.initials: R
authors.lastname: Berber
authors.affiliation: Institute for Health Research, University of Bedfordshire, Putteridge Bury Campus, Hitchin Road, Luton, Bedfordshire, LU2 8LE, United Kingdom.
authors.forename: Yannis
authors.initials: Y
authors.lastname: Pappas
authors.affiliation: Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, Middlesex, HA7 4LP, United Kingdom. E-mail address for R. Berber: reshidb.berber@rnoh.nhs.uk.
authors.forename: Michael
authors.initials: M
authors.lastname: Khoo
authors.affiliation: Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, Middlesex, HA7 4LP, United Kingdom. E-mail address for R. Berber: reshidb.berber@rnoh.nhs.uk.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Miles
authors.affiliation: Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, Middlesex, HA7 4LP, United Kingdom. E-mail address for R. Berber: reshidb.berber@rnoh.nhs.uk.
authors.forename: Richard
authors.initials: R
authors.lastname: Carrington
authors.affiliation: Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, Middlesex, HA7 4LP, United Kingdom. E-mail address for R. Berber: reshidb.berber@rnoh.nhs.uk.
authors.forename: John
authors.initials: J
authors.lastname: Skinner
authors.affiliation: Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, Middlesex, HA7 4LP, United Kingdom. E-mail address for R. Berber: reshidb.berber@rnoh.nhs.uk.
authors.forename: Alister
authors.initials: A
authors.lastname: Hart
mesh_terms: D001284:Atrophy / Q000175:diagnosis; D002857:Chromium / Q000097:blood; D003035:Cobalt / Q000097:blood; D003937:Diagnosis, Differential; D019544:Equipment Failure Analysis / Q000379:methods*; D006622:Hip Prosthesis / Q000145:classification*; D006801:Humans; D033183:Interdisciplinary Communication; D020407:Internet; D007592:Joint Diseases / Q000150:complications / Q000175:diagnosis; D008279:Magnetic Resonance Imaging; D018482:Muscle, Skeletal / Q000473:pathology; D010348:Patient Care Team / Q000458:organization & administration*; D011474:Prosthesis Design; D011475:Prosthesis Failure / Q000209:etiology; D018570:Risk Assessment; D061108:Social Media / Q000458:organization & administration*; D006113:United Kingdom
chemical_list: D002857:Chromium; D003035:Cobalt