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

doi:10.1016/j.arth.2014.03.008

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 journal › Article

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 language	English
Pages (from-to)	1629-1634
Number of pages	6
Journal	Journal of Arthroplasty
Volume	29
Issue number	8
Early online date	13 Mar 2014
DOIs	https://doi.org/10.1016/j.arth.2014.03.008
Publication status	Published - Aug 2014

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title = "Component Size Mismatch Of Metal on Metal Hip Arthroplasty: An Avoidable Never Event",

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.",

keywords = "metal-on-metal, size mismatch, retrieval, hip, wear",

author = "Whittaker, {Robert K.} and Adam Hexter and Hothi, {Harry S.} and Anna Panagiotidou and Bills, {Paul J.} and Skinner, {John A.} and Hart, {Alister J.}",

year = "2014",

month = aug,

doi = "10.1016/j.arth.2014.03.008",

language = "English",

volume = "29",

pages = "1629--1634",

journal = "Journal of Arthroplasty",

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publisher = "Churchill Livingstone",

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TY - JOUR

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

N2 - 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.

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 -