Ceramic Bearings with Titanium Adapter Sleeves Implanted During Revision Hip Arthroplasty Show Minimal Fretting or Corrosion: a Retrieval Analysis.

BACKGROUND: The BIOLOX® option system, consisting of a BIOLOX® delta ceramic femoral head with a titanium alloy adapter sleeve, is being increasingly utilized in revision hip arthroplasty. The sleeve protects the ceramic head from fracture and improper motion about the stem trunnion when a damaged trunnion is encountered at revision surgery. Corrosion and fretting due to metal-metal contact at the taper region of hip prosthesis create the potential of causing periprosthetic osteolysis and adverse local tissue reactions. QUESTIONS/PURPOSES: The objective of this study was to identify the type and extent of damage to retrieved sleeves and ceramic heads to determine their in vivo performance. METHODS: Twenty-four ceramic heads with titanium alloy sleeves were examined. The articular and taper surfaces for each ceramic head were assessed for metal transfer using a subjective grading system. All surfaces of the 24 titanium sleeves and stem trunnions (only available for 7 of 24 cases) were assessed for corrosion and fretting using an established grading system. Scanning electron microscopy and energy dispersive X-ray analysis were conducted on representative sample of sleeves. RESULTS: Fretting and corrosion were higher at the inner surface of the taper sleeve than the outer sleeve. Mean fretting scores at the inner taper and outer taper sleeve surfaces were 1.8 and 1.2, respectively. The mean corrosion score at the inner taper surface was 1.8; no corrosion was observed on the outer surface of any taper sleeve. SEM and EDS analyses provided further indications of low levels of damage. CONCLUSION: Fretting and corrosion were less severe than previously reported for conventional THA metal-metal taper connections, indicating that a ceramic head and titanium sleeve is a safe alternative in revision THA.

Retrieval Analysis of Porous Titanium Glenoid Posts: An Evaluation of Osteointegration.

Glenoid component loosening is a commonly encountered complication of total shoulder replacements. Therefore, focus has been placed on glenoid fixation. Porous metal implants, which promote biological fixation through osteointegration, have provided an uncemented alternative to the traditional cemented implant. In this explantation study, the authors examined the bone ingrowth and ongrowth of a specific porous titanium glenoid peg. Six explanted polyethylene glenoid components with porous titanium-coated central pegs were identified in the authors' implant retrieval program via retrospective review. The retrieved implants were sectioned into thirds with a precision saw and underwent scanning electron microscopy for analysis of bone ingrowth and ongrowth. Bone ingrowth was calculated as bone volume fraction, or the fraction of available pore space filled with bone, whereas ongrowth was the percentage of the perimeter of the implant covered with bone. The 6 total shoulders included in the study were revised at an average of 16.3 months (range, 5-48 months) for instability secondary to subscapularis rupture, subscapularis rupture plus infection, or other rotator cuff tear. All glenoid components were grossly stable on retrieval and had an average of 23% bone ingrowth and 54% ongrowth. The preliminary results show that osteointegration into a porous titanium ingrowth glenoid component is possible in the short-term, even in the presence of an unfavorable biomechanical environment, such as instability and rotator cuff dysfunction, as well as infection. [Orthopedics. 2017; 40(4):e703-e707.].

Assessment of Damage on a Dual Mobility Acetabular System.

BACKGROUND: Dual mobility designs were introduced to increase stability and reduce the risk of dislocation, both being common reasons for surgical revision after total hip arthroplasty. The in vivo behavior of dual mobility constructs remains unclear, and to our knowledge, no data have been published describing in vivo surface damage to the polyethylene bearing surfaces. METHODS: We used surface damage assessed on the inner and outer polyethylene bearing surfaces in 33 short-term retrieved dual mobility liners as evidence of relative motion at the 2 bearings. A lever out test was performed to determine the force required for dislocation of the cobalt-chromium femoral head from the polyethylene liner. RESULTS: Both bearings showed damage; however, the inner polyethylene bearings had higher damage scores, lower prevalence of remaining machining marks, and higher incidence of concentric wear, all consistent with more motion at the inner polyethylene bearing. The inner polyethylene bearings also had a higher occurrence of embedded titanium debris. The damage sustained in vivo was insufficient to lead to intraprosthetic dislocation in any of the retrieved components. Lever out tests of 12 retrievals had a mean dislocation load of 261 ± 52 N, which was unrelated to the length of implantation. CONCLUSION: Our short-term retrieval data of 33 highly cross-linked polyethylene dual mobility components suggest that although motion occurs at both bearing articulations, the motion of the femoral head against the inner polyethylene bearing dominates. Although damage was not severe enough to lead to intraprosthetic dislocation, failure may occur long term and should be assessed in future studies.

Comprehensive Analysis of a Recalled Modular Total Hip System and Recommendations for Management.

BACKGROUND: Recent total hip arthroplasty designs have introduced modularity at the neck-stem junction. There are reports of failure of this class of designs due to corrosion at the modular junction. The purpose of this study was to evaluate patients implanted with a recently recalled modular total hip arthroplasty system. METHODS: This was a prospective study of 216 total hip arthroplasties in 195 patients performed by a single surgeon. All hips had a titanium-alloy stem, but 199 had a modular cobalt-chromium neck and seventeen were monolithic. The mean patient age was 65.4 years (range, twenty to eighty-eight years); seventy-nine were men and 116 were women. Patients were evaluated for infection and with metal ion assays and MRI (magnetic resonance imaging). Intraoperative tissue samples were graded, and retrieved implants were examined. RESULTS: At a mean follow-up of 19.3 months, eighty (37%) of 216 hips had been revised. An adverse local tissue reaction (ALTR) was the cause for revision in seventy-three of these eighty hips; all had the modular neck design. Assay results for the patients requiring revision showed higher levels of cobalt (mean, 8.6 ng/mL) than chromium (mean, 1.8 ng/mL). MRI showed moderate to severe levels of synovial response in sixty-three of 166 hips. The mean ALVAL (aseptic lymphocyte-dominated vasculitis-associated lesion) score for the revised hips was 8.1. Corrosion was visible on all tapers at the neck-stem junction but not the head-neck junction. CONCLUSIONS: Early failures of modular total hip arthroplasty occur due to fretting and corrosion at the neck-stem junction, resulting in ALTR. Surveillance utilizing metal ion levels and MRI may be indicated for all patients regardless of symptoms, as the early survivorship is poor and the ultimate failure rate may be catastrophically high.

Posterior Stabilized Polyethylene Inserts in Total Knee Arthroplasty: A Retrieval Study Comparing Conventional to High-Flexion Designs.

BACKGROUND: High-flex (HF) total knee arthroplasties are modified posterior-stabilized (PS) implants designed to accommodate greater flexion. METHODS: We examined differences between HF and PS retrieved tibial inserts with regard to polyethylene surface damage. Twenty HF inserts from each of 3 manufacturers were matched using patient demographics with 20 PS inserts from the same manufacturers. Ranges of motion between matched patients were not different. RESULTS: Based on subjective damage scores, no differences were detected between HF and PS groups. Differences were found, however, among manufacturers, consistent with design approaches taken for PS and HF implants. CONCLUSION: In our series, high flexion did not influence damage, although this was likely influenced by the fact that few HF patients in our study had larger range of motions than their PS counterparts.

Otto Aufranc Award: Large Heads Do Not Increase Damage at the Head-neck Taper of Metal-on-polyethylene Total Hip Arthroplasties.

BACKGROUND: Fretting and corrosion at head-neck junctions of total hip arthroplasties (THAs) have been associated with adverse local tissue reactions in patients with both metal-on-polyethylene (MoP) and metal-on-metal (MoM) prostheses. Femoral head size contributes to the severity of fretting and corrosion in large-diameter MoM THAs, but its impact on such damage in MoP THAs remains unknown. QUESTIONS/PURPOSES: (1) Is femoral head size associated with increased fretting or corrosion at the head-neck junction in MoP total hips? (2) Is duration of implantation associated with increased fretting or corrosion? METHODS: The severity of fretting/corrosion on surfaces of head tapers and stem trunnions was visually examined in 154 MoP THAs retrieved as part of 3282 revision surgeries performed at our institution between January 1, 2007, and December 31, 2013. Fretting and corrosion damage were subjectively graded by two independent observers on a 1 to 4 scale, and their relations to head size, alloy combinations, taper/trunnion design, length of implantation (LOI), and location were investigated. Differences in scores never exceeded one grade, and this occurred in only 17% of examined implants. With the available implants, the study provided 88% power to detect differences of 0.5 in fretting or corrosion scores in these analyses. RESULTS: Fretting and corrosion of the tapers and the trunnions were not affected by head size (p = 0.247, p = 0.471, p = 0.837, and p = 0.868, respectively), although taper/trunnion design affected taper fretting (p = 0.005) and corrosion (p = 0.0031) and trunnion fretting (p = 0.0028). Head taper fretting (observed in 73% of heads) increased with LOI, but head taper corrosion (noted in 93% of heads) was not affected. Trunnion fretting (observed in 86% of stems) was more severe in mixed-alloy combinations and with increased LOI and was more severe proximally. Trunnion corrosion (noted in 72% of stems) was also location-dependent with greater corrosion distally. CONCLUSIONS: Fretting and corrosion are regular occurrences in MoP THAs, but neither damage type was related to femoral head size. Conversely, taper design, LOI, and alloy combination affected the severity of both fretting and corrosion. CLINICAL RELEVANCE: Although it has been suggested that trunnion corrosion seen in MoP bearings is a function of larger diameter heads, our data suggest that larger femoral heads may be used for increased damage at the modular junction of MoP THAs.

Surface Damage Is Not Reduced With Highly Crosslinked Polyethylene Tibial Inserts at Short-term.

BACKGROUND: Highly crosslinked ultrahigh-molecular-weight polyethylene (XLPE) has been shown to reduce wear in hip arthroplasty, but the advantages over conventional polyethylene (PE) in total knee arthroplasty (TKA), if any, remain unclear. QUESTIONS/PURPOSES: Do differences exist in (1) surface damage as measured by damage score and percent area affected; and (2) extent and location of dimensional changes between XLPE and conventional PE observed on retrieved TKA tibial inserts? METHODS: In this study of components retrieved at the time of revision surgery, we matched 44 XLPE to 44 conventional PE inserts from four manufacturers; the matching approach considered implant design (exact match), insert size (exact match), and length of implantation (matched ± 6 months). Surface damage on the articular surfaces was subjectively graded and digitally mapped to determine the percent damaged area of each damage mode. Three-dimensional changes that had occurred as a result of implantation were determined by comparing laser scans of the retrieved inserts with size-matched pristine inserts. RESULTS: The differences of damage scores and percent damaged areas between the matched XLPE and conventional PE inserts were not large enough to be clinically significant with low corresponding levels of statistical significance (scores: 42 ± 13; 95% confidence interval [CI], 38-46 versus 45 ± 13; 95% CI, 41-49; p = 0.4; percent areas: 54% ± 38%; 95% CI, 44%-64% versus 54% ± 32%; 95% CI, 42%-65%; p = 0.9). However, XLPE inserts showed greater articular surface dimensional changes with high significance (root mean square of the distance: 0.16 ± 0.06 mm; 95% CI, 0.13-0.18 mm versus 0.14 ± 0.05 mm; 95% CI, 0.11-0.16 mm; p = 0.03). Within the same design, deviation patterns were consistent between the two materials; however, as expected, the location of the dimensional changes differed among designs: the negative deviations on the plateaus were centrally located in Zimmer PS inserts, were located on the perimeter in Smith & Nephew PS inserts, and were across the entire surface in DePuy PS inserts. CONCLUSIONS: We found no difference in surface damage between matched XLPE and conventional PE inserts of the same designs. However, increased dimensional changes in TKAs with XLPE may reflect larger contact areas and potentially explain improved performance of XLPE in published simulator studies. CLINICAL RELEVANCE: The lack of meaningful differences between the two polyethylene materials suggests caution in adopting a new, more expensive bearing material over another material that has a long track record of excellent behavior. A possible advantage is the greater dimensional changes, which could be the result of the lower creep resistance of XLPE, but this advantage awaits long-term results.

Corrosion and Fretting of a Modular Hip System: A Retrieval Analysis of 60 Rejuvenate Stems.

Femoral stems with dual-taper modularity were introduced to allow independent control of length, offset, and version. Corrosion and fretting related to micromotion at the neck-stem junction are thought to stimulate an adverse local tissue reaction (ALTR). Analysis of 60 consecutively retrieved modular-neck stem implants (Rejuvenate, Stryker) revised primarily for ALTR was done to determine the variables influencing corrosion and fretting patterns at the neck-stem interface. Taper damage evaluation was performed with stereomicrocopic analysis with two observers. Evidence of fretting and corrosion was seen at the neck-stem taper in all implants, including three implants revised for periprosthetic fractures within four weeks of the index surgery indicating that this process starts early. Femoral stems paired with the long overall neck lengths had significantly higher corrosion scores. Correlation of the corrosion severity at particular locations with the length of implantation suggests that the neck-stem junction experiences cyclic cantilever bending in vivo. The positive correlation between the length of implantation and fretting/corrosion scores bodes poorly for patients who still have this implant. Scanning electron microscopy on a subset of specimens was also performed to evaluate the black corrosion material. We strongly urge frequent follow-up exams for every patient with this particular modular hip stem.

Hip dislocation increases roughness of oxidized zirconium femoral heads in total hip arthroplasty: an analysis of 59 retrievals.

The aims of this study were to assess damage on the surface of retrieved oxidized zirconium (OxZr) metal femoral heads, to measure surface roughness of scratches, and to evaluate the extent of surface effacement using scanning electron microscopy (SEM). Ceramic zirconia-toughened alumina heads were analyzed for comparison. OxZr femoral heads explanted for recurrent dislocation had the most severe damage (P<0.001). The median surface roughness of damaged OxZr femoral heads was 1.49µm, compared to 0.084µm for damaged ceramic heads and 0.052µm for undamaged OxZr (P<0.001). This may be of clinical concern because increased surface roughness has the potential to increase the wear of polyethylene liners articulating against these OxZr heads in THA.

Zirconia phase transformation, metal transfer, and surface roughness in retrieved ceramic composite femoral heads in total hip arthroplasty.

Ceramic femoral heads have had promising results as a bearing surface in total hip arthroplasty. Our objective was to evaluate a series of retrieved alumina-zirconia composite ceramic femoral heads for evidence of the tetragonal to monoclinic zirconia phase transformation, metal transfer and articular surface roughness. Raman spectra showed evidence of the zirconia phase transformation in all retrieved specimens, with distinct monoclinic peaks at 183, 335, 383, and 479 cm(-1). All components displayed metal transfer. An increase in the zirconia phase transformation was seen with increasing time in vivo. No correlation between extent of zirconia phase transformation and the surface roughness was found. These short-term results suggest that the use of an alumina-zirconia composite ceramic is a viable option for femoral heads in THA.

Ceramic liner fractures presenting as squeaking after primary total hip arthroplasty.

BACKGROUND: Squeaking after ceramic-on-ceramic total hip arthroplasty is a relatively uncommon phenomenon. It usually does not require treatment in the absence of pain, mechanical symptoms, and/or relentless squeaking. The purpose of this investigation was to report on four patients who presented with hip pain and squeaking due to fractured ceramic liners after ceramic-on-ceramic total hip arthroplasty. METHODS: Four patients with painful squeaking after ceramic-on-ceramic total hip arthroplasty were seen at our institution. One patient had a revision for suspected loosening and excessive anteversion of the cup noted on radiographs and magnetic resonance imaging (MRI). The remaining three patients had a revision for audible squeaking with progressive pain. RESULTS: Intraoperatively, the ceramic liners of all four patients were fractured. CONCLUSIONS: Squeaking after ceramic-on-ceramic total hip arthroplasty rarely is a functional issue. However, painful squeaking without notable trauma may indicate fracture of the ceramic liner. Painful squeaking is difficult to evaluate by conventional imaging. When painful squeaking occurs, exploration via surgical revision is recommended in selected patients, as ceramic liner fractures may go unnoticed on radiographs and/or MRI and thus their actual prevalence may be higher than estimated.

Taper design affects failure of large-head metal-on-metal total hip replacements.

BACKGROUND: Large-head metal-on-metal (MoM) hip arthroplasties have demonstrated poor survival. Damage at the taper-trunnion junction is a contributing factor; however, the influence of junction design is not well understood. QUESTIONS/PURPOSES: (1) Does taper type affect fretting, corrosion, and volumetric wear at the junction? (2) Do taper types have different wear patterns? (3) Does larger offset or head diameter increase fretting, corrosion, and wear? (4) Is the extent of fretting and corrosion associated with earlier failure? METHODS: Taper damage in 40 retrieved heads was subjectively graded for fretting and corrosion, and wear was determined with high-resolution confocal measurement. Taper types (11/13, 12/14, and Type 1) differed by angle, distal diameter, and contact length; Type 1 were thinnest and 11/13 had longer contact lengths. RESULTS: Fretting scores were higher in 11/13 than in Type 1 tapers. Volumetric wear and wear rates did not differ among types. Uniform, circumferential, and longitudinal wear patterns were observed in all types, but fretting, corrosion, and wear did not differ among the patterns. Head diameter and lateral offset did not correlate with fretting, corrosion, or wear. No correlation was found between fretting, corrosion, or wear and length of implantation. CONCLUSIONS: In general, thicker tapers with longer contact lengths were associated with greater fretting scores, whereas no relationship was found among the three designs for corrosion scores or volumetric wear. This finding suggests that trunnion diameter and engagement length are important factors to consider when improving taper-trunnion junction design.

Oxidized zirconium versus cobalt-chromium in TKA: profilometry of retrieved femoral components.

BACKGROUND: Oxidized zirconium (OxZr) was introduced as an alternative bearing for femoral components in total knee arthroplasty (TKA) in an attempt to reduce wear compared with conventional cobalt-chromium (CoCr) alloys. QUESTIONS/PURPOSES: The aim of this study was to compare matched pairs of retrieved OxZr and CoCr components using surface profilometry; specifically, we sought to compare the surface roughness of (1) retrieved OxZr TKA components with retrieved CoCr components; (2) the medial versus the lateral femoral condyles of retrieved components; and (3) unimplanted OxZr TKA components with unimplanted CoCr components. METHODS: Ten retrieved posterior-stabilized Genesis II TKA with OxZr femoral components were identified and matched to retrieved CoCr femoral components by duration of implantation, patient age, and body mass index. A noncontact white light interferometer was used to evaluate surface roughness. One pristine, unimplanted component of each design was analyzed as a control. RESULTS: The retrieved components showed significantly (p < 0.0001) lower roughness for the OxZr components than the CoCr components. CoCr retrievals showed a significantly greater average surface roughness on the medial condyle. No difference was found between the condyles of the OxZr components. The pristine CoCr implant had a significantly lower surface roughness than the pristine OxZr component. CONCLUSIONS: CoCr roughens significantly more in situ compared with OxZr components. CLINICAL RELEVANCE: Bearing surfaces are typically damaged in vivo. The extent of damage is variable between patients and implants; however, rougher surfaces should be associated with more wear. Whether the differences observed in our study prove meaningful requires long-term clinical data.

What causes unexplained pain in patients with metal-on metal hip devices? A retrieval, histologic, and imaging analysis.

BACKGROUND: Adverse tissue reactions associated with metal-on-metal (MOM) hips are common in resurfacing and total hip arthroplasty (THA) designs. The etiology of these reactions in painful, well-positioned arthroplasties is inconsistently described. QUESTIONS/PURPOSES: The purposes of this study were to compare the (1) articular wear rates; (2) histologic findings; (3) synovial response on MRI; and (4) graded intraoperative tissue damage between well-positioned, MOM hips revised for unexplained pain and MOM hips revised for other reasons and to (5) determine whether the presence of a taper junction on a MOM articulation affects these four parameters in unexplained pain. METHODS: We retrospectively studied 88 patients (94 hips) who had undergone revision of either a hip resurfacing or a large-head (> 36 mm) THA. Thirty-five hips revised for unexplained pain were compared with a control group of 59 hips revised for other causes. Articular wear was measured using three-dimensional contactless metrology and histologic analysis was performed using the aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) score. Preoperative MRI was performed on 57 patients to determine synovial volumes and thicknesses. Tissue damage was graded from intraoperative reports. RESULTS: Articular wear rates in the unexplained pain group were lower than in the control group (median 2.6 µm/year versus 12.8 µm/year, p < 0.001). Sixty-six percent of patients in the unexplained pain group had histologic confirmation of ALVAL compared with 19% in the control group (p < 0.001). The synovial thickness on MRI was higher in the unexplained pain group (p = 0.04) and was highly predictive of ALVAL. Severe intraoperative tissue damage was noted in more cases in the unexplained pain group (p = 0.01). There were no differences in articular wear, histology, MRI, and tissue damage between resurfacings and THAs revised for unexplained pain. CONCLUSIONS: Unexplained pain in patients with well-positioned MOM hips warrants further investigation with MRI to look for features predictive of ALVAL. Tissue destruction in these cases does not appear to be related to high bearing wear or the presence of a taper.