Metal-on-metal hips on the Gartner Hype Cycle

This post describes an adaptation of Gartner Hype Cycle on metal-on-metal hip replacements. It is very unlikely that MoM hip replacements will achieve the “Plateau of Productivity“. Therefore two other later stages are proposed with annotations.

Past
Technology TriggerA potential technology breakthrough kicks things off
- "Polyethylene disease" [1]
- Modern Co-Cr-Mo wrought alloy developed
- Extremely low wear in contemporary MoM bearing in hip simulator studies [2]
- First 28-mm MoM THRs [3]
- Understanding failure modes in first-generation MoM hip implants [4]
Early proof-of-concept stories
- Proof of concept: McMinn prosthesis [5]
- Proof of concept: Conserve Plus prosthesis [6]
Commercial viability is unproven
- Excellent results of surgeon-inventors [eg. 1]
Peak of Inflated ExpectationsEarly publicity produces a number of success stories
- Anti-stepwise introduction of other implants [7]
- Non-inventor results: ”justification for using [hip resurfacing]” [8]
- Non-inventor results: ”a promising alternative” [9]
- Encouraging mid-term results [eg. 10]
Some companies take action; most don't.
- Completely new MoM prostheses cleared without clinical tests [11,12]
Trough of DisillusionmentInterest wanes as experiments and implementations fail to deliver
- Poor registry data for some implants [13]
- Evidence of pseudotumours [14]
- Reports of pain and metallosis [15]
Producers of the technology shake out or fail.
- ASR recall [16]
- DUROM recall [17]
Present
Slope of EnlightenmentMore instances of how the technology can benefit the enterprise start to crystallize and become more widely understood.
- Excellent registry data at 15 years in some implants [18]
Future
Plateau of Productivity
Extremely unlikely scenario
Alternative stage: Falling to marginProposed annotations
- Redefining the “young and active patient”
- Understanding the mechanisms of ARMD
Alternative stage: Gradual abandonment
Proposed annotations
- Proposed advantages of hip resurfacings does not pay off

Reference

1. Harris WH. Osteolysis and particle disease in hip replacement. A review. Acta Orthop Scand. 1994 Feb;65(1):113-23.

2. Amstutz HC, Grigoris P, Dorey FJ. Evolution and future of surface replacement of the hip. J Orthop Sci. 1998;3(3):169-86.

3. Weber BG1. [Metal-metal total prosthesis of the hip joint: back to the future]. Z Orthop Ihre Grenzgeb. 1992 Jul-Aug;130(4):306-9.

4. McKellop H, Park SH, Chiesa R, Doorn P, Lu B, Normand P, Grigoris P, Amstutz H. In vivo wear of three types of metal on metal hip prostheses during two decades of use. Clin Orthop Relat Res. 1996 Aug;(329 Suppl):S128-40.

5. McMinn D, Treacy R, Lin K, Pynsent P. Metal on metal surface replacement of the hip. Experience of the McMinn prothesis. Clin Orthop Relat Res. 1996 Aug;(329 Suppl):S89-98.

6. Schmalzried TP, Fowble VA, Ure KJ, Amstutz HC. Metal on metal surface replacement of the hip. Technique, fixation, and early results. Clin Orthop Relat Res. 1996 Aug;(329 Suppl):S106-14.

7. Reito A, Lehtovirta L, Lainiala O, Mäkelä K, Eskelinen A. Lack of evidence-the anti-stepwise introduction of metal-on-metal hip replacements. Acta Orthop. 2017 Oct;88(5):478-483.

8. L. Tessari, G.F. Fraschini, F. Ravasi. OUR EXPERIENCE WITH BHR RESURFACING HIP PROSTHESES. Abstracts from the European Hip Society 2002 Domestic Meeting

9. T. Pollard, C. Basu, R. Ainsworth, W. Lai, G. Bannister. IS THE BIRMINGHAM RESURFACING WORTHWHILE? Abstracts from the European Hip Society 2002 Domestic Meeting

10. Hing CB1, Back DL, Bailey M, Young DA, Dalziel RE, Shimmin AJ. The results of primary Birmingham hip resurfacings at a mean of five years. An independent prospective review of the first 230 hips. J Bone Joint Surg Br. 2007 Nov;89(11):1431-8.

11. Ardaugh BM1, Graves SE, Redberg RF. The 510(k) ancestry of a metal-on-metal hip implant. N Engl J Med. 2013 Jan 10;368(2):97-100.

12. https://www.accessdata.fda.gov/cdrh_docs/pdf7/K071053.pdf

13. https://aoanjrr.sahmri.com/documents/10180/42612/Annual+Report+2007

14. Hart AJ, Sabah S, Henckel J, Lewis A, Cobb J, Sampson B, Mitchell A, Skinner JA. The painful metal-on-metal hip resurfacing. J Bone Joint Surg Br. 2009 Jun;91(6):738-44

15. Langton DJ, Jameson SS, Joyce TJ, Hallab NJ, Natu S, Nargol AV. Early failure of metal-on-metal bearings in hip resurfacing and large-diameter total hip replacement: A consequence of excess wear. J Bone Joint Surg Br. 2010 Jan;92(1):38-46.

16. https://www.depuysynthes.com/asrrecall/sites/default/files/-CAN%20ASR%20Recall%20Notice%20English%2008-24-2010.pdf

17. https://www.fda.gov/files/about%20fda/published/Zimmer-Durom-Cup-Recall-Packet–2007-2008-%28162-pages%29.pdf

18. https://aoanjrr.sahmri.com/documents/10180/576950/Hip%2C%20Knee%20%26%20Shoulder%20Arthroplasty

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