Practice Practice Pointer

Diagnosing and investigating adverse reactions in metal on metal hip implants

BMJ 2011; 343 doi: (Published 29 November 2011) Cite this as: BMJ 2011;343:d7441
  1. Camdon Fary, clinical fellow1, consultant orthopaedic surgeon2,
  2. Geraint Emyr Rhys Thomas, clinical research fellow3,
  3. Adrian Taylor, consultant orthopaedic surgeon 1, honorary senior clinical lecturer3,
  4. David Beard, professor of musculoskeletal sciences3,
  5. Andrew Carr, Nuffield professor of orthopaedic surgery13,
  6. Sion Glyn-Jones, consultant orthopaedic surgeon1, clinical senior lecturer3
  1. 1Nuffield Orthopaedic Centre, Oxford OX3 7LD, UK
  2. 2Royal Melbourne and Western Hospitals, Melbourne, Victoria, Australia
  3. 3Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, NIHR Biomedical Research Unit into Musculoskeletal Disease, University of Oxford, Nuffield Orthopaedic Centre, Oxford, OX3 7LD, UK
  1. Correspondence to: C Fary, Western Hospital, Footscray, Victoria, Australia camfary{at}
  • Accepted 11 October 2011

Use of metal bearings in hip replacements and resurfacing operations has led to adverse reactions to metal debris in many patients. This article examines how to assess and manage any patient with a metal on metal total hip replacement who presents with potential joint failure

Summary points

  • Large diameter, metal on metal bearings may be used in hip replacement and hip resurfacing operations

  • Early evidence suggested that metal on metal implants were more resistant to wear and tear and dislocation; consequently they were often used in younger and more active patients

  • Adverse reactions to metal debris can result in the formation of a mass lesion that can be locally invasive around the joint. Such lesions may be difficult to diagnose as many are silent

  • Symptomatic patients may complain of discomfort in the hip or buttock; a swelling in the hip region; pain in the hip; or clicking or “giving way” of the hip

  • Ultrasound scanning by a skilled operator, followed by magnetic resonance imaging when a lesion is detected, will lead to a diagnosis in most cases

  • Revision surgery is usually indicated. Revision after adverse reaction to metal debris has a poorer outcome than revision for other indications

Promising five year results in 2005 for large diameter “metal on metal” hip replacement surgery1 led to a rapid increase in the number of surgeons performing this procedure and in orthopaedic companies competing to produce their own resurfacing designs. Adverse reactions to metal debris were not anticipated or predicted.

Over 250?000 large diameter, metal on metal, articulating total hip replacements (most of which are resurfacing procedures) have now been performed worldwide.2 UK and Australian national joint registries have reported statistically significant increased revision rates for specific metal on metal total hip replacements compared with conventional metal on plastic total hip replacements.3 …

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