Issue: Issue 4 2012
Perspective from Harlan C. Amstutz, MD
Perspective from Richard E. White, MD
July 03, 2012
4 min read

Researchers set safe upper limit metal ion levels for metal-on-metal hip resurfacings

The limits are lower than those of the UK’s Medicines and Healthcare Products Regulatory Agency.

Issue: Issue 4 2012
Perspective from Harlan C. Amstutz, MD
Perspective from Richard E. White, MD
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An award-winning study by researchers from Belgium identified safe upper limits of 4.6 µg/L for chromium and 4.0 µg/L for cobalt in unilateral metal-on-metal hip resurfacing arthroplasties and 7.4 µg/L for chromium and 5.0 µg/L for cobalt in bilateral procedures.

“Levels higher than [these] established limits were significantly correlated with clinical symptoms, smaller component size, a smaller coverage arc, smaller contact patch to rim distance and a higher cup inclination,” Catherine Van Der Straeten, MD, said. “Females and small head sizes are more at risk of having problematic hips.”

Van Der Straeten presented results of the Otto Aufranc Award-winning study at the Hip Society Specialty Day 2012 in San Francisco. A receiver operating characteristic (ROC) analysis showed that the limits had high specificity and low sensitivity for predicting poor function.

“These upper acceptable limits are lower than the recommended threshold by the Medicines and Healthcare Products Regulatory Agency [in the United Kingdom],” Van Der Straeten said. “But, we had low tolerance for what we call the clinically problematic hip.”

Unilateral ASR resurfacing 

Unilateral ASR resurfacing (DePuy Orthopaedics Inc., Warsaw, Ind.) with the acetabular component positioned in 58° abduction, causing impingement is shown. Serum metal ions levels were 57 µg/L Cr and 72 µg/L Co. At revision, there was metallosis of the joint tissues and fluid.

Image: Van Der Straeten C

Database study

Van Der Straeten and colleagues performed a retrospective study of metal ion levels in unilateral and bilateral metal-on-metal hip resurfacings at minimum 12-month follow-up using from a database in Ghent. They excluded any other sources of metal ions and any renal insufficiency, and identified 453 patients with unilateral and 139 patients with bilateral hip resurfacings. The patients had a mean 4.3 years follow-up. There were eight resurfacing designs in the unilateral group and seven designs in the bilateral group. The researchers then categorized the patients into either an optimum (well-functioning) or nonoptimum group.

“The criteria to be fulfilled for allocation into the optimum group are strict: no patient-reported hip complaints, no surgeon-detected clinical findings, a Harris Hip score higher than 95, the contact patch to rim distance greater than 10 mm, no abnormal radiological findings and no further operations scheduled,” Van Der Straeten said.

Catherine VanDerStraeten 

Catherine Van Der Straeten

The optimum group consisted of 55% of unilateral and 42% of bilateral hip resurfacings. Most of the male patients were in the optimum group, while most female patients were in the nonoptimum cohort. The researchers found larger sized components in the optimum group. They also discovered significantly lower metal ion levels for the unilateral and bilateral resurfacings in the optimum group compared those in the nonoptimum cohort.

The researchers defined safe upper metal ion limits as “the highest values not considered as outliers in the optimum group,” Van Der Straeten said. Using the safe upper limits established by the study showed 95% specificity for unilaterals and 91% for bilaterals. Overall, the limits had 25% sensitivity. When cobalt or chromium levels reached higher than 10 µg/L, specificity was 100%, Van Der Straeten noted.

Therapeutic algorithm

Symptoms other than metal wear may cause painful hips, Van Der Straeten said. Therefore, the researchers developed a diagnostic and therapeutic algorithm for these patients.

“We always start from the clinical symptoms,” she said. “Second, we look at the X-rays and thirdly, at metal ions in order to decide whether additional investigations are necessary or therapeutic action needs to be undertaken.”

If the researchers find metal ions levels lower than 4 µg/L in the absence of clinical and radiological symptoms, patients undergo routine follow-up. If levels are between 4 µg/L and 10 µg/L, metal ions are moderately elevated and “thorough diagnostic investigations have to be repeated until you find the cause,” Van Der Straeten said. If metal ion levels are higher than 20 µg/L, there may be systemic toxicity and diagnostic investigations are required. Revision should be “considered even without symptoms,” she said.

“Metal ions are to be used as an adjunct to standard clinical and radiographic follow-up,” Van Der Straeten added. – by Renee Blisard Buddle

  • Van Der Straeten C. The interpretation of metal ion levels in unilateral and bilateral hip resurfacing. Practical guidelines for hip resurfacing follow-up. Presented at the Open Meeting of Hip Society. Feb. 11, 2012. San Francisco.
For more information:
  • Catherine Van Der Straeten, MD, is an independent orthopedic research specialist and can be reached at Bosstraat 19 B-9830 St-Martens-Latem, Belgium; email:
  • Van Der Straeten has no relevant financial disclosures.