Johnson & Johnson to Offer $2.5 Billion Hip Device Settlement

By BARRY MEIER

Published: November 19, 2013

Lawyers for Johnson & Johnson and patients injured by a flawed hip implant were expected to introduce a multibillion-dollar plan Tuesday to settle thousands of lawsuits, but it was not clear whether the deal would satisfy enough claimants.

Under the agreement, according to people briefed on the plan, the medical products giant will pay some $2.475 billion in compensation to an estimated 8,000 patients who have been forced to have the all-metal artificial hip removed and replaced with another device.

Separately, the company has agreed to pay all medical costs related to such procedures, expenses that could raise the deal’s cost to Johnson & Johnson to some $3 billion, said those familiar with the proposal, who did not want to be identified.

The typical patient payment for pain and suffering caused by the device will be about $250,000 before legal fees, under the plan. Based on standard agreements, plaintiffs’ lawyers would receive about one-third of the overall payout, or more than $800 million, with those who negotiated the plan emerging as big winners.

Read the full NY Times article here.

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Andrew Testa for The New York Times

A faulty Articular Surface Replacement, or A.S.R., removed from a patient in 2010.

By BARRY MEIER

Published: November 12, 2013

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Study: Metal Hip Pain and Tissue Damage

The annual meeting of the 2013 American Academy of Orthopaedic Surgeons (AAOS) in Chicago has just concluded and doctors delivered a mixed report on metal-on-metal hip replacements.

In a study presented from New York State’s Hospital for Special Surgery (HSS), researchers found unexplained pain in metal-on-metal (MoM) hip implant patients is more likely due to tissue damage surrounding the prosthesis rather than wear of the implant.

Hip Replacement

HSS is ranked nationally No. 1 in orthopedics by U.S. News & World Report and researchers wanted to know what caused the increasing number of unexplained pain complaints that eventually lead to hip revision. Among the 9,000 hip implant procedures done by HSS annually, 10% are revisions.

Researchers compared 50 patients who had unexplained pain to a control group of 48 patients who came to HSS with infection, fracture misalignment or loosening of the hip.  They measured adverse tissue reaction to metal ions and conducted a wear analysis on removed implants.

Among the group with unexplained pain, 60% had moderate to high rate of tissue reaction and 12% had a buildup of metal ions in soft tissues. The age, sex, body mass, size and length of the implant did not seem to explain pain and patients in both groups had similar wear on the implants.  Some patients had a lot of tissue damage, but that was not related to wear, suggesting other factors are causing the damage.

When metal hips were introduced, the industry thought MoM hips were a positive innovation in their ability to remain well-lubricated which minimizes wear, but the thousands of lawsuits filed by injured patients tell another story.

Metal-on-metal hip implants have unique risks.  In a MoM hip, the ball and socket is made of metal, usually chromium and cobalt.  The metal components can come in contact during walking or running which can release metal particles around the implant, the tissue and surrounding muscles. The scientific community believes the metal ions causes damage that is irreversible and can lead to an early revision of the hip implant.

The suggestion is for doctors to closely follow hip implant patients with unexplained pain before there is significant tissue damage.

AAOS members also sang the praises of a total hip replacement (THR) concluding itincreases the life span and reduces the risk of heart failure, depression and diabetes among the 43,000 Medicare patients with osteoarthritis that were studied.

The study was undertaken to determine the cost-effectiveness of THR treatment seven years after implant but the findings reveal that hip recipients cost Medicare $6,000 more than non-THR patients.

Article Source: http://www.strykerimplantrecall.com/2013/04/04/study-metal-hip-pain-and-tissue-damage/ 

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Battery-Less Wireless Instrumented Knee Implant

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FDA Safety Communication: Metal-on-Metal Hip Implants

Date Issued: Jan. 17, 2013

Audience:

• Orthopaedic surgeons
• Health care providers responsible for the ongoing care of patients with metal-on-metal hip implants
• Patients who are considering or have received a metal-on-metal hip implant

Medical Specialties: Orthopaedics, General Medicine, Family Practice, Radiology, Radiologic Technology, Clinical Laboratory Managers and Directors

Device:

Metal-on-metal hip implants consist of a ball, stem and shell, all made from cobalt-chromium-molybdenum alloys.

There are two types of metal-on-metal hip implants:

• Traditional total hip replacement systems
• Resurfacing hip systems

Purpose: In February 2011, the FDA launched a metal-on-metal hip implant webpage. The FDA is providing updated safety information and recommendations to patients and health care providers.  This new information is based on the FDA’s current assessment of metal-on-metal hip implants, including the benefits and risks, the evaluation of the published literature, and the results of the June 2012 Orthopaedic and Rehabilitation Devices Advisory Panel meeting.

Summary of Problem and Scope:

Metal-on-metal hip implants have unique risks in addition to the general risks of all hip implants.

In metal-on-metal hip implants, the metal ball and the metal cup slide against each other during walking or running. Metal can also be released from other parts of the implant where two implant components connect.  Metal release will cause some tiny metal particles to wear off of the device around the implant, which may cause damage to bone and/or soft tissue surrounding the implant and joint. This is sometimes referred to as an “adverse local tissue reaction (ALTR)” or an “adverse reaction to metal debris (ARMD).”

Soft tissue damage may lead to pain, implant loosening, device failure and the need for revision surgery (a surgical procedure where the implant is removed and another is put in its place). Some of the metal ions released will enter the bloodstream and travel to other parts of the body, where they may cause symptoms or illnesses elsewhere in the body (systemic reactions).

Presently, the FDA does not have enough scientific data to specify the concentration of metal ions in a patient’s body or blood necessary to produce adverse systemic effects.  In addition, the reaction seems to be specific to individual patients, with different patients having different reactions to the metal wear particles.

Recommendations for Orthopaedic Surgeons:

Before Surgery

• Select a metal-on-metal hip implant for your patient only after determining that the benefit-risk profile of using a metal-on-metal hip implant outweighs that of using an alternative hip system (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic or ceramic-on-metal).  Factors to consider include the patient’s age, sex, weight, diagnosis, and activity level.
  • Note that a 2012 FDA advisory panel of experts identified young males with larger femoral heads as the best candidates for hip resurfacing systems.
• Inform patients about the benefits and risks of metal-on-metal hip implants, including the risk that the hip implant may need to be replaced. Also discuss the patient’s expectations and review the potential complications of surgery with a metal-on-metal hip implant.
• Pay close attention to patient populations for which metal-on-metal hip systems are contraindicated.  Be aware of the risk factors that may predispose a device to excess wear and early failure.

Additional information on the FDA’s recommendations for orthopaedic surgeons before, during and immediately following metal-on-metal hip replacement surgery can be found in Information for Orthopaedic Surgeons.

Patient Follow-Up

• Follow-up of asymptomatic patients with metal-on-metal hip implants, including physical examinations and routine radiographs, should occur periodically (typically every 1 to 2 years).  If the hip is functioning properly, the FDA does not believe there is a clear need to routinely perform additional soft tissue imaging or assess metal ion levels in the blood.
• Be aware that there are certain patients who are at risk for increased device wear and/or adverse local tissue reactions (ALTR) and should be followed more closely. They may include:
  • Patients with bilateral implants
  • Patients with resurfacing systems with small femoral heads (44mm or smaller)
  • Female patients
  • Patients receiving high doses of corticosteroids
  • Patients with evidence of renal insufficiency
  • Patients with suppressed immune systems
  • Patients with suboptimal alignment of device components
  • Patients with suspected metal sensitivity (e.g. cobalt, chromium, nickel)
  • Patients who are severely overweight
  • Patients with high levels of physical activity.
• Pay close attention to signs and symptoms that may be associated with metal-on-metal hip implants. Please see the website for a list of common ALTRs and systemic symptoms/complications.
• Conduct a thorough evaluation if a patient with a metal-on-metal hip experiences local symptoms such as pain or swelling at or near the hip, a change in walking ability or a noise from the hip joint more than three months after metal-on-metal hip implant surgery.
• Follow symptomatic patients with metal-on-metal hip implants at least every 6 months.

Additional information on the FDA’s recommendations for patient follow-up can be found in Information for Orthopaedic Surgeons.

For additional information regarding soft tissue imaging or assessing metal ion levels, please review the FDA’s recommendations below.

Imaging

For some symptomatic patients with metal-on-metal hip implants, additional diagnostic imaging is required to assess and diagnose soft tissue findings surrounding the implant.  Please be aware of the FDA’s recommendations:

• Consider the benefits and risks of using different types of diagnostic imaging procedures (e.g. MRI with metal artifact reduction, CT, or ultrasound) as well as the availability of specialized radiology expertise when determining the most appropriate imaging modality for each patient.

If you determine that an MRI of a metal-on-metal hip implant patient is appropriate, the FDA recommends the following:

• Consult with the radiologist to evaluate the benefits and risks of utilizing MRI with metal artifact reduction;
• Review the available device-specific labeling from manufacturers for MRI Conditions; and
• Inform the MRI site that the patient has a metal-on-metal hip implant.

For additional information on the FDA’s recommendations about imaging a patient with a metal-on-metal hip implant, please see Imaging Evaluation.

Assessing Metal Ion Levels

Some patients with a metal-on-metal hip implant may have elevated metal ion levels (e.g. cobalt and/or chromium) in their bloodstream.  Several factors can impact the accuracy, reproducibility, and clinical interpretation of metal ion test results.  Please be aware of the FDA’s recommendations:

• The FDA does not believe there is a clear need to routinely check metal ion levels in the blood if the orthopaedic surgeon feels the hip is functioning properly and the patient is asymptomatic.
• Patients with metal-on-metal hip implants who develop any symptoms or physical findings that indicate their device may not be functioning properly, should be considered for metal ion testing.
• If measuring metal ions, consider obtaining and following serial measurements (using the same sample type, the same measurement method, and preferably the same laboratory) in determining metal ion levels in symptomatic patients.
• At this time, the FDA is not recommending a specific metal ion level as a trigger for revision or other medical intervention.  The metal ion concentration values, including increases in metal ion levels over time, should be considered in addition to the overall clinical scenario including symptoms, physical findings, and other diagnostic results when determining further actions.

For additional information on the FDA’s recommendations on metal ion test methods, selecting a test lab and interpreting test results, please see Metal Ion Testing.

Device Revision

The decision to revise a metal-on-metal hip implant should be made in response to the overall clinical scenario. In case of adverse local tissue reactions (ALTR), revision of a metal-on-metal hip implant may have a worse prognosis than revision of other types of bearing surfaces.

In selecting components for revision:

• Consider the benefits and risks of all bearing surfaces for each patient.
• Check the specific device labeling for compatibility of device components.
• If a patient is suspected to have developed metal sensitivity, carefully select the materials of the revision components (potentially avoiding materials with nickel or chromium).

For additional information, please review the FDA’s considerations on device revisions, which includes our recommendation for a retrieval analysis of every failed metal-on-metal hip implant.

Summary of FDA Recommendations for Orthopaedic Surgeons

*For chromium testing, a validated method that resolves potential interferences must be used.  Please reviewFDA’s recommendations for chromium testing.

Recommendations for Health Care Providers:

Metal-on-metal implant patients with systemic symptoms are more likely to visit their primary care practitioner than their orthopaedic surgeon, which makes it important for all health care providers to be aware of metal ion adverse events that may occur in metal-on-metal hip implant patients. Based on case reports, these events may include:

• General hypersensitivity reaction (skin rash)
• Cardiomyopathy
• Neurological changes including sensory changes (auditory, or visual impairments)
• Psychological status change (including depression)
• Renal function impairment
• Thyroid dysfunction (including neck discomfort, fatigue, weight gain or feeling cold.

Patients with systemic findings that are thought to be related to a metal-on-metal hip implant should be advised to follow-up with his or her orthopaedic surgeon to determine the appropriate course of action.

For additional information, please review the FDA’s considerations to Health Care Professionals.

Recommendations for Patients Considering Hip Implants:

• Be aware that every hip implant has benefits and risks.
• Discuss your options for hip surgery with your surgeon.

A list of some questions to ask your orthopaedic surgeon can be found in Patients Considering a Metal-on-Metal Hip Implant.

Recommendations for Patients with Metal-on-Metal Hip Implants:

• If you are not having any symptoms and your orthopaedic surgeon believes your implant is functioning appropriately, you should continue to routinely follow-up with the surgeon every 1 to 2 years.
• If you develop new or worsening problems such as pain, swelling, numbness, noise (popping, grinding, clicking or squeaking of your hip), and/or change in your ability to walk, contact your orthopaedic surgeon right away.
• If you experience changes in your general health, including new or worsening symptoms outside your hip, let your physician know you have a metal-on-metal hip implant.

Additional information for patients with a metal-on-metal hip can be found in Patients who have a Metal-on-Metal Hip Implant.

FDA Activities:

The FDA is committed to providing reliable safety recommendations to patients and health care providers about the utilization of these devices.  Recent activities include:

1. On May 6, 2011, the FDA instructed manufacturers of metal-on-metal total hip replacement (THR) systems to conduct postmarket surveillance study of these devices.  Five manufacturers currently market metal-on-metal hip implants in the U.S. and all five have approved postmarket surveillance study plans.  Data from these studies will provide patients and health care providers with additional information about the safety profiles of the implants, including the effect of metal ion concentrations in the bloodstream.
2. On June 27-28, 2012, the FDA convened the Orthopaedic and Rehabilitation Devices Panel of the Medical Devices Advisory Committee to seek expert scientific and clinical opinion on the benefits and risks of metal-on-metal hip systems. Information from this panel meeting has helped form these recommendations.
3. On January 17, 2013 the FDA issued a proposed order requiring manufacturers of metal-on-metal total hip replacement systems to submit premarket approval (PMA) applications.  Metal-on-metal total hip replacement systems were evaluated under the 510(k) premarket notification program. Metal-on-metal total hip replacement systems were marketed in the U.S. prior to 1976 legislation that gave the agency premarket authority over medical devices. As “preamendment devices,” they were designated as Class III (higher risk) devices but were regulated under the 510(k) premarket notification program.

Additional information on FDA ongoing activities are provided in FDA’s Role and Activities.

Other Resources:

For additional resources, see Metal-on-Metal Hip Implants: Other Resources.

Reporting Problems to the FDA:

Prompt reporting of adverse events can help the FDA identify and better understand the risks associated with medical devices. If you suspect a problem with a metal-on-metal device, we encourage you to file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program. Health care personnel employed by facilities that are subject to the FDA’s user facility reporting requirements should follow the reporting procedures established by their facilities. Device manufacturers must comply with the Medical Device Reporting (MDR) regulations.

Reports to the FDA about adverse events related to metal-on-metal hip systems include, but are not limited to: pain, malposition, adverse local tissue reaction, metallosis, hypersensitivity (allergy), loosening, and dislocation.

To help us learn as much as possible about the adverse events associated with metal-on-metal hip implants, please include the following information in your reports, if available:

• Date of implantation
• Date of implant removal (if applicable)
• Clinical cause for revision (if available)
• System components affected by the adverse event.

Contact Information:

If you have questions about this communication, please contact the Division of Small Manufacturers, International and Consumer Assistance (DSMICA) via e-mail at DSMICA@FDA.HHS.GOV or by phone: 800-638-2041 or 301-796-7100.

This document reflects the FDA’s current analysis of available information, in keeping with our commitment to inform the public about ongoing safety reviews of medical devices.

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Oh Really Mr DePuy – are we as stupid as you look? 

Published: March 4, 2013

Re “What a Company Knew About Its Metal Hips” (editorial, Feb. 11):

All of us at DePuy are united by the goal of improving patients’ lives, so we understand that the Articular Surface Replacement Hip System recall has been of concern for patients, their family members and surgeons. I disagree with how your editorial described company actions regarding ASR testing, data analysis and communications.

ASR was tested for years before receiving regulatory clearance around the world. Once on the market, we carefully considered all the data and investigated product complaints individually, while also looking for broader performance trends. We continued to share appropriate and validated data with regulators and surgeons.

When we received new registry data reporting that ASR patients were undergoing a second hip replacement surgery sooner than expected, we recalled the product and immediately supported patients with a reimbursement program for their medical costs.

Joint replacement surgery is one of the greatest medical advances of our time. We remain dedicated to serving patients who need this important treatment option.

ANDREW EKDAHL

President, DePuy Orthopaedics

Warsaw, Ind., Feb. 25, 2013

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Important information regarding legal action

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Metal hip patients ‘need annual checks’

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Study shows cost-effectiveness and benefits to patients of early hip replacement

February 21, 2013
in Surgery Hip pain means some patients are unable to lead an active lifestyle. Early access to hip replacement is cost-effective and provides significant benefits for patients’ quality of life, a study has shown.

Ruben Mujica-Mota, from the University of Exeter Medical School, carried out research comparing early access and delayed hip replacement surgery in Italy on behalf of the European Health Technology Institute for Socio-Economic Research (EHTI). His findings, which are now published in the journal Value in Health, demonstrate both the cost-effectiveness of early hip replacement, as well as the benefits for patients. The expert says that delaying hip replacement surgery does not cut costs for health services and denies patients the opportunity to lead an active and healthy life while awaiting surgery. He claims that even young adults do not benefit from postponing treatment – an approach that is sometimes taken to reduce the risk of revision surgery during their lifetime.

Ruben Mujica-Mota, senior lecturer in Health Economics at the University of Exeter, concluded: “This research clearly suggests that the cost savings to national health systems in Europe brought about by delaying total hip replacement may not justify the large quality of life losses to patients.” Yves Verboven, executive director of the EHTI, said that delaying hip replacement among patients with severe osteoarthritis has “limited value in reducing the total cost of treatment”.

He added: “On the contrary, a strategy of not postponing total hip replacement surgery provides a significant benefit to patients.” A spokeswoman for Arthritis Research UK said: “You won’t necessarily need a hip replacement if you have arthritis of the hip, but it is worth considering if your hip is severely damaged by arthritis and the pain, disability and stiffness are having serious effects on your daily activities.” Provided by University of Exeter

Read more at: http://medicalxpress.com/news/2013-02-cost-effectiveness-benefits-patients-early-hip.html#jCp

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Doctors Who Don’t Speak Out

By BARRY MEIER

Published: February 15, 2013

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