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 journalArticle

Abstract

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
Volume29
Issue number8
Early online date13 Mar 2014
DOIs
Publication statusPublished - Aug 2014

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Root Cause Analysis
Medical Errors
Patient Safety
Arthroplasty
Registries
Hip
Joints
Metals
Ions
Incidence
Surgeons

Cite this

Whittaker, R. K., Hexter, A., Hothi, H. S., Panagiotidou, A., Bills, P. J., Skinner, J. A., & Hart, A. J. (2014). Component Size Mismatch Of Metal on Metal Hip Arthroplasty: An Avoidable Never Event. Journal of Arthroplasty, 29(8), 1629-1634. https://doi.org/10.1016/j.arth.2014.03.008
Whittaker, Robert K. ; Hexter, Adam ; Hothi, Harry S. ; Panagiotidou, Anna ; Bills, Paul J. ; Skinner, John A. ; Hart, Alister J. / Component Size Mismatch Of Metal on Metal Hip Arthroplasty : An Avoidable Never Event. In: Journal of Arthroplasty. 2014 ; Vol. 29, No. 8. pp. 1629-1634.
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Whittaker, RK, Hexter, A, Hothi, HS, Panagiotidou, A, Bills, PJ, Skinner, JA & Hart, AJ 2014, 'Component Size Mismatch Of Metal on Metal Hip Arthroplasty: An Avoidable Never Event', Journal of Arthroplasty, vol. 29, no. 8, pp. 1629-1634. https://doi.org/10.1016/j.arth.2014.03.008

Component Size Mismatch Of Metal on Metal Hip Arthroplasty : An Avoidable Never Event. / Whittaker, Robert K.; Hexter, Adam; Hothi, Harry S.; Panagiotidou, Anna; Bills, Paul J.; Skinner, John A.; Hart, Alister J.

In: Journal of Arthroplasty, Vol. 29, No. 8, 08.2014, p. 1629-1634.

Research output: Contribution to journalArticle

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T1 - Component Size Mismatch Of Metal on Metal Hip Arthroplasty

T2 - An Avoidable Never Event

AU - Whittaker, Robert K.

AU - Hexter, Adam

AU - Hothi, Harry S.

AU - Panagiotidou, Anna

AU - Bills, Paul J.

AU - Skinner, John A.

AU - Hart, Alister J.

PY - 2014/8

Y1 - 2014/8

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AB - 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.

KW - metal-on-metal

KW - size mismatch

KW - retrieval

KW - hip

KW - wear

U2 - 10.1016/j.arth.2014.03.008

DO - 10.1016/j.arth.2014.03.008

M3 - Article

VL - 29

SP - 1629

EP - 1634

JO - Journal of Arthroplasty

JF - Journal of Arthroplasty

SN - 0883-5403

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ER -