Component Size Mismatch of Metal on Metal Hip Arthroplasty: An Avoidable Never Event

Robert K. Whittaker, Adam Hexter, Harry S. Hothi, Anna Panagiotidou, Paul J. Bills, John A. Skinner, Alister J. Hart

Research output: Contribution to journalArticlepeer-review

10 Citations (Scopus)


Size mismatch of components used in total hip arthroplasty is a serious, preventable patient safety incident of unknown prevalence as many cases are not detected. Component size mismatch was found in 11 cases (0.9%) at our retrieval centre. All cases of mismatch were not detected on plain radiograph during routine clinical follow up and blood metal ion levels were elevated above the MHRA action level of 7. ppb. Root cause analysis identified manufacturer, hospital and surgeon factors that need to be addressed to reduce the incidence of this avoidable clinical problem. Retrieval analysis is the only method of confirming size mismatch and is likely to be under-represented in National Joint Registries that record the indication for revision at the time of revision.

Original languageEnglish
Pages (from-to)1629-1634
Number of pages6
JournalJournal of Arthroplasty
Issue number8
Early online date13 Mar 2014
Publication statusPublished - 1 Aug 2014


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