Abstract
Introduction
Wear-related osteolysis continues to be a concern in the long-term outcome and survivorship of total hip arthroplasty (THA) and there continues to be an emphasis on bearing materials that exhibit improved wear profiles. Oxidized zirconium metal (Oxinium®, Smith & Nephew) was developed to reduce the amount of polyethylene wear as compared to cobalt chromium femoral heads, without the risk of brittle fracture seen with older generation ceramics. There are a limited number of retrieval studies evaluating the performance of Oxinium in THA. The aims of this study were 1) to visually assess damage on the surface of a large number of retrieved Oxinium femoral heads, 2) to measure surface roughness of scratches on the surfaces of Oxinium femoral heads, and 3) to use scanning electron microscopy (SEM) to assess the integrity of the oxidized zirconium surface in damaged areas. BIOLOX delta (CeramTec), a ceramic alternative to Oxinium, was included in this study for comparison.
Methods
From 2006 to 2013, 59 retrieved Oxinium femoral heads in THAs were collected after an average time to revision surgery of 1.64 years. The mean patient age was 61.9 years, with 32 males and 27 females. Reasons for revision surgery were recurrent dislocation (24), femoral component loosening or subsidence (13), infection (9), acetabular loosening (4), periprosthethic fracture (4), acetabular malposition (2), heterotopic ossification (2), and 1 case of leg length discrepancy. The diameters of the femoral heads were 28 mm (9), 32 mm (22), 36mm (26) and 40mm (2).
Three observers visually graded surface damage on all femoral heads according to the following criteria: 1) no scratches, 2) minimal damage with one to two scratches, 3) significant damage with multiple scratches. We measured the surface roughness of retrieved Oxinium and BIOLOX delta femoral heads with an interferomic profiler, and SEM to evaluate the extent of surface effacement.
Results
Oxinium femoral heads explanted for recurrent dislocation showed substantially more severe damage as compared to heads retrieved during revision surgery for other reasons (p<0.001). Eighteen of 24 heads explanted for recurrent dislocation (75%) showed gross visual evidence of substantial surface damage (grade 3), compared to only 5 of the 35 explants for non-dislocation causes (Figure 1). The surface roughness of damaged Oxinium femoral heads was significantly higher (28.6× more rough) than undamaged Oxnium and 17.7× more rough than damaged Biolox delta heads (p<0.001; Figure 2). High magnification imaging showed severe damage and effacement of the oxidized zirconium layer, exposing the metal alloy underneath (Figure 3). This was confirmed by Energy Dispersive Xray Analysis (EDXA).
Discussion
This study represents the first large-scale retrieval analysis of oxidized zirconium femoral heads in THA. The results show that high impact between an acetabular shell and an Oxinium femoral head during dislocation increases the surface roughness and causes substantial effacement to the oxidized zirconium layer compared with matched modern ceramic bearings. The surface damage seen to these femoral heads is of clinical concern because it has the potential to increase the wear of polyethylene liners in THA.
