Bilateral simultaneous metal inlay dissociation from the polyethylene liner of a metal-on-metal hip replacement

Introduction: Hard-on-hard bearings for total hip replacement may require a modular acetabular inlay for which polyethylene is often used in a sandwich-type configuration. However, differences in the elastic modulus of the materials make fixation of this metal insert uncertain. The aim of this study is to report a case of bilateral separation of the metal insert from the polyethylene sandwich in a metal-on-metal bearings prosthesis. Materials and methods: A bilateral total hip arthroplasty was performed in two operations, four months apart, in a 53-year-old woman following a corticosteroid-induced osteonecrosis. The total hip replacement system included a cementless stem, and a press-fit hemispheric cup containing a polyethylene sandwich with a metallic insert (Sikomet (TM)). Results: Three years later, the patient consulted because of abnormal noise in her right hip which appeared normal on conventional X-ray. Three months later she consulted again for persistent noise. Separation of the metal insert from the polyethylene sandwich was diagnosed and an acetabular revision was performed selecting a metal-on-polyethylene articulation system. The postoperative course, for this revision, was uneventful, but the patient returned with the similar symptoms in her left hip four months later, resulting in the same type of revision. During the revisions, osteolysis secondary to metallosis was diagnosed, requiring synovectomy and acetabular reconstruction with morcelized allograft impaction. The left side postoperative course included three dislocations in nine months which were conservatively treated and have not since recurred. Discussion and conclusion: This is the first reported case recording an almost simultaneous bilateral dissociation of a hard-on-hard inlay from its polyethylene sandwich. This bilateral case suggests that the fixation of the metal insert inside the polyethylene was probably defective. This case is also a reminder that mechanical complications (separation, implant fracture) should be searched for in presence of any abnormal noise occurring after hard-on-hard bearings prosthetic implantation. This confirms the necessity of periodical follow-up of hip arthroplasties and the importance of knowing their radiological features. The low carbon content of the Sikomet (TM) bearing may have been the cause of this failure by increasing frictional torque on the bearing surface, causing metallosis which has already been described in the literature in this type of hip replacement system. (c) 2009 Elsevier Masson SAS. All rights reserved.