Blood and urine metal ion levels in young and active patients after Birmingham hip resurfacing arthroplasty

The Journal of Bone and Joint Surgery. British volumeVol. 89-B, No. 7 CorrespondenceFree AccessBlood and urine metal ion levels in young and active patients after Birmingham hip resurfacing arthroplastyP-A. VENDITTOLI, M. GANAPATHI, M. LAVIGNEP-A. VENDITTOLIAssistant Professor of SurgerySearch for more papers by this author, M. GANAPATHISearch for more papers by this author, M. LAVIGNESearch for more papers by this authorPublished Online:1 Jul 2007https://doi.org/10.1302/0301-620X.89B7.19972AboutSectionsPDF/EPUB ToolsDownload CitationsTrack CitationsPermissionsAdd to Favourites ShareShare onFacebookTwitterLinked InRedditEmail Sir,We read with interest the paper by Daniel et al1 entitled “Blood and urine metal ions levels in young and active patients after Birmingham hip resurfacing arthroplasty: four-year results of a prospective longitudinal study.” This paper presents the pre- and post-operative metal ion measurements of 26 patients who have undergone Birmingham Hip Resurfacing with 50 mm or 54 mm femoral components. While we acknowledge the science behind the measurement method used by the authors (urine and whole blood with HR-ICPMS), we would be interested in the authors’ comments regarding the following issues.It is unclear to the readership whether or not this cohort of 26 patients is representative of the entire cohort of patients who received metal ion analyses. If this is a subset which only involves 50 mm and 54 mm femoral components then this may not be representative and should not be considered as a baseline upon which other metal ion studies should reference themselves for comparative purposes. In selecting only 50 mm and 54 mm components they have probably included mainly, if not exclusively, men. Gender ratio is not reported in the paper. Women will very rarely need these implant sizes.Gender and bearing diameter have a significant impact on patients’ metal ion levels. Recently, we reported chromium and cobalt ion levels with the Durom (Zimmer, Warsaw, Indiana) in whole blood.2 Our mean chromium and cobalt levels in whole blood for the whole group (men and women, all sizes) was 1.6 μg/L of chromium and 0.7 μg/L of cobalt. When splitting the group by gender, mean levels at one year were lower in men: 1.5 μg/ L versus 1.9 μg/L for chromium and 0.6 μg/L versus 0.8 μg/L for cobalt (p = 0.05).Using a similar selection process as Daniel et al1 in their paper (limiting the results to 50 mm and 54 mm femoral components), the mean metal ion levels in our patients (24 men and 1 woman) were 1.4 μg/L of chromium and 0.6 μg/L of cobalt in whole blood at one year (25% reduction versus our whole cohort results). As a comparison, Daniel et al1 reported 2.4 μg/L of chromium and 1.3 μg/L of cobalt with the Birmingham Hip Resurfacing.As the study was a prospective study where pre-operative whole blood was collected (before the implant size was known) they could have reported the results of the whole cohort (all implant sizes). By doing so, they could have provided the readers a real baseline for further comparison.While assessing the performance of a new implant or technique, the results should be presented for the whole cohort where the innovation will be used. In the case of hip resurfacing, males and females with good femoral bone stock, significant life expectancy, no metal allergy, unimpaired renal function, and with suitable anatomy for the procedure, are examples. Selecting subgroups based on diagnosis, implant size, or gender may not reflect the real performance of the device or technique. Hence we feel that the authors’ conclusion that their results provide a baseline for comparison with other implants is not justified. For the moment, we can only use their data for comparison with patients with similar component diameters (50 mm and 54 mm). References 1 Daniel J, Ziaee H, Pradhan C, Pynsent PB, McMinn DJW. Blood and urine metal ion levels in young and active patients after Birmingham hip resurfacing arthroplasty: four-year results of a prospective longitudinal study. J Bone Joint Surg [Br] 2007;89-B:169–73. Link, Google Scholar2 Vendittoli PA, Mottard S, Roy AG, Dupont C, Lavigne M. Chromium and cobalt ion release following the Durom high carbon content, forged metal-on-metal surface replacement of the hip. J Bone Joint Surg [Br] 2007;89-B:441–8. 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