Adverse Local Tissue Reaction in Total Hip Replacement

David C Evans, Ross A Miller, Stephen J. Incavo


Total hip replacement (THR) utilizing metal-on-polyethylene articulations was successful for many years. Modifications in materials and implant designs were created to improve wear and allow greater ability to adjust the implant position, optimizing joint mechanics. Three recent cobalt-chromium designs that involve metal to metal contact (metal-on-metal or MoM, modular neck-stems, large metal femoral heads) have produced metal debris through corrosion, releasing cobalt ions around the implant. Unfortunately, these metal nanoparticles have led to a wide spectrum of soft tissue destruction called adverse local tissue reaction (ALTR). This review article assesses ALTR following THR using MoM cobalt-chromium designs, as well as the diagnostic testing used to identify at risk hips. Findings revealed that a possible explanation for ALTR is hypersensitivity to cobalt with lymphocytic perivascular infiltration, known as aseptic lymphocytic vasculitis associated lesion (ALVAL). Solid or cystic masses called “pseudotumors” may also form around the implant. Given the destructive nature of ALTR to the surrounding capsule, muscle, and bone, surgical revision of the MoM junction is generally required. In addition to physical examination and x-rays, diagnosis now depends on drawing serum cobalt and chromium levels, as well as the use of a metal artifact reduction suppression (MARS) MRI.

The authors believe that the optimal design and bearing surface for THR is a titanium femoral stem and acetabulum with a ceramic femoral head (32 or 36 mm) articulating on a polyethylene acetabular insert. Manufacturers have now produced a polyethylene with superior bearing characteristics, as evidenced by minimal wear after five to ten years of implantation. 


total hip replacement, tissue reaction in THR, total hip arthroplasty, corrosion in total hip replacement, femoral heads for hip arthroplasty, adverse local tissue reaction (ALTR), MoM implants, Mom Cobalt Chromium implant designs in THA, femoral stem

Full Text:



Jacobs JJ, Gilbert JL, Urban RM. Corrosion of metal orthopaedic implants. J Bone Joint Surg Am. 1998;80(2):268-82.

Hug KT, Watters TS, Vail TP, Bolognesi MP. The withdrawn ASR THA and hip resurfacing systems: how have our patients fared over 1 to 6 years? Clin Orthop Relat Res. 2013;471(2):430-8. doi: 10.1007/s11999-012-2547-5

Cooper HJ, Urban RM, Wixsom RL, Meneghini RM, Jacobs JJ. Adverse local tissue reaction arising from corrosion at the femoral neck-body junction in a dual-taper stem with a cobalt-chromium modular neck. J Bone Joint Surg Am. 2013;95(10):865-72. doi: 10.2106/JBJS.L.01042.

Meftah M, Haleem AM, Burn MB,Smith KM, Incavo SJ. Early corrosion-related failure of the rejuvenate modular total hip replacement. J Bone Joint Surg Am. 2014;96(6):481-7. doi: 10.2106/JBJS.M.00979.

Dyrkacz RM, Brandt JM, Oio OA, Turgeon TR, Wyss UP. The influence of head size on corrosion and fretting behaviour at the head-neck interface of artificial hip joints. J Arthroplasty. 2013;28(6): p. 1036-40. doi: 10.1016/j.arth.2012.10.017.

Willert HG, Buchhorn GH, Fayyazi A, et al. Metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. A clinical and histomorphological study. J Bone Joint Surg Am. 2005;87(1):28-36.

Davies AP, Willert HG, Campbell PA, Learmonth ID, Case CP. An unusual lymphocytic perivascular infiltration in tissues around contemporary metal-on-metal joint replacements. J Bone Joint Surg Am. 2005;87(1):18-27.

Pandit H, Glyn-Jones S, McLardy-Smith, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90(7): p. 847-51. doi: 10.1302/0301-620X.90B7.20213.

Alexander CS. Cobalt-beer cardiomyopathy. A clinical and pathologic study of twenty-eight cases. Am J Med. 1972;53(4):395-417.

Chen Z, Wanq Z, Wanq Q, et al. Changes in early serum metal ion levels and impact on liver, kidney, and immune markers following metal-on-metal total hip arthroplasty. J Arthroplasty. 2014;29(3):612-6. doi: 10.1016/j.arth.2013.07.031.

Prentice JR, Clark MJ, Hoggard N, et al., Metal-on-metal hip prostheses and systemic health: a cross-sectional association study 8 years after implantation. PLoS One. 2013;8(6):e66186. doi: 10.1371/journal.pone.0066186.

Cheung AC, Banerjee S, Cherian JJ, et al. Systemic cobalt toxicity from total hip arthroplasties: review of a rare condition Part 1 - history, mechanism, measurements, and pathophysiology. Bone Joint J. 2016;98-B(1):6-13. doi: 10.1302/0301-620X.98B1.36374.

Langton DJ, Sidaginamale RP, Joyce TJ, et al. The clinical implications of elevated blood metal ion concentrations in asymptomatic patients with MoM hip resurfacings: a cohort study. BMJ Open. 2013;3(3). doi: 10.1136/bmjopen-2012-001541.

Kwon YM, Lombardi AV, Jacobs JJ, et al. Risk stratification algorithm for management of patients with metal-on-metal hip arthroplasty: consensus statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons, and the Hip Society. J Bone Joint Surg Am. 2014;96(1):e4. doi: 10.2106/JBJS.M.00160.

Hart AJ, Sabah SA, Bandi AS, et al. Sensitivity and specificity of blood cobalt and chromium metal ions for predicting failure of metal-on-metal hip replacement. J Bone Joint Surg Br. 2011;93(10):1308-13. doi: 10.1302/0301-620X.93B10.26249.

Bolognesi MP, Ledford CK. Metal-on-Metal Total Hip Arthroplasty: Patient Evaluation and Treatment. J Am Acad Orthop Surg. 2015;23(12):724-31. doi: 10.5435/JAAOS-D-14-00183.

Jantzen C, Jorgensen HL, Duus BR, et al. Chromium and cobalt ion concentrations in blood and serum following various types of metal-on-metal hip arthroplasties: a literature overview. Acta Orthop. 2013;84(3):229-36. doi: 10.3109/17453674.2013.792034.

Malek IA, King A, Sharma H, et al. The sensitivity, specificity and predictive values of raised plasma metal ion levels in the diagnosis of adverse reaction to metal debris in symptomatic patients with a metal-on-metal arthroplasty of the hip. J Bone Joint Surg Br. 2012;94(8):1045-50. doi: 10.1302/0301-620X.94B8.27626.

Campbell P, Beaule PE, Ebramzadeh E, et al. The John Charnley Award: a study of implant failure in metal-on-metal surface arthroplasties. Clin Orthop Relat Res. 2006;453:35-46.

Nawabi DH, Hayter CL, Su EP, et al. Magnetic resonance imaging findings in symptomatic versus asymptomatic subjects following metal-on-metal hip resurfacing arthroplasty. J Bone Joint Surg AM. 2013;95(10):895-902. doi: 10.2106/JBJS.K.01476.

Nawabi DH, Do HT, Ruel A, et al. Comprehensive Analysis of a Recalled Modular Total Hip System and Recommendations for Management. J Bone Joint Surg Am. 2016;98(1):40-7. doi: 10.2106/JBJS.N.01121.



  • There are currently no refbacks.
Copyright 2016. All rights reserved.