Fretting corrosion of taper junctions is long known and of great concern, because of metal ion and particle release and their related adverse local and systemic effects on the human body (1–3). Orthopedic taper junctions are often comprised of CoCr29Mo6/TiAl6V4 pairings. Beside others the imprinting of the TiAlV-machining marks into the CoCrMo-taper is of clinical interest (4, 5). Thus, the multifactorial details and their interdependencies on the macro-, micro, and nanoscale are still a matter of research (6). This contribution presents the mechanisms of imprinting found in an in-vitro fretting corrosion test. The worn surfaces, the lubricant as well as its remains were analyzed after test and the findings brought into relation to the characteristic wear sub-mechanisms. The fretting tests were conducted by means of a cylinder-on-pin set-up. All details about the test and the sequence of analyses can be found in (7, 8). A marked tribofilm of C-rich organic matter and oxidized wear particles of both bodies was generated at the TiAlV/CoCrMo contact area (Figure 1a, c). After removing the tribofilm chemically, extremely fine scratches of sub-µm depth became visible on the CoCrMo body (Figure 1b). The TiAlV body showed shallow shelves leaving troughs filled with grainy debris (Figure 1d) mainly of Ti-oxide wear particles. The shelves stick to the surfaces and, therefore, move relatively to the counterbody. In combination with the grainy debris this brings about “Microploughing” on the CoCrMo surfaces. Microploughing is known for destroying any passive film resulting in “Tribocorrosion”. The question remains how the shelves are formed. From the surface analyses one could conclude that they point towards “Delamination”. But this would also mean that they would not stick rigidly to the surfaces but be ejected from the contact area. Focused Ion Beam (FIB) cuts were done in order to investigate the near- and subsurface structure of the shelves in order to clarify the governing mechanisms (Figure 2). Below the platinum protection layer appears a laminated structure of highly deformed nanocrystalline and amorphous areas. EDS confirmed that the lighter intermediate layers consist mainly of Ti-oxide. This microstructure is supposedly formed by severe plastic deformation and the generation of shear bands, which under fretting pile up on top of each other. This cannot be connected to “Delamination”. We therefore propose to categorize the formation mechanism of these shelves as a specific form of microploughing. Thus, imprinting is neither driven by any galvanic effects (9) nor by hardness differences of TiO. 2. and Cr. 2. O. 3. (10) but by microploughing on the TiAlV-body leading to tribocorrosion at specific sites of CoCrMo what imprints the surface grooves of the softer TiAlV into the harder CoCrMo. For any figures or tables, please contact the authors directly

In the majority of cases, failure of conventional metal-on-ultra-high molecular weight polyethylene (UHMWPE) artificial joints is due to wear particle induced osteolysis. Therefore, new materials have been introduced in an attempt to produce bearing surfaces that create lower, more biologically compatible wear. Polyetheretherketone (PEEK-OPTIMA) has been successfully used in a number of implant applications due to its combination of mechanical strength and biocompatibility. Multi-directional pin-on-plate wear tests were performed on carbon fibre reinforced PEEK-OPTIMA (CFR-PEEK) against CoCrMo. PAN-based CFR-PEEK was tested against both low carbon and high carbon CoCrMo and Pitch-based CFR-PEEK was tested against high carbon CoCrMo only. The multi-directional motion of the pin-on-plate machine replicated the crossing of the wear paths that would be expected in vivo. For each test, four pin and plate samples were tested for two million cycles at a cycle frequency of 1 Hz under a 40 N load (which resulted in a contact stress of about 2 MPa). The lubricant used was bovine serum diluted with distilled water to a protein content of 15 gl-1. This was maintained at 37 °C. The wear was determined gravimetrically. Soak control specimens were used to account for any weight changes due to lubricant absorption. The average steady state wear for the CFR-PEEK pins was found to be 0.144, 0.176 and 0.123 × 10-6 mm 3N-1m-1 for the CFR-PEEK PAN pins against low carbon CoCrMo, CFR-PEEK PAN pins against high carbon CoCrMo and CFR-PEEK Pitch-based pins against high carbon CoCrMo. A comparison of the results from the low and high carbon plates articulating against the PAN-based pins shows that the high carbon CoCrMo produced slightly higher wear than the low carbon CoCrMo. The protruding carbides on the high carbon CoCrMo plates may have caused this increase in wear. The lowest wearing material combination in this study was CFR-PEEK Pitch against high carbon CoCrMo. Published papers on the wear of UHMWPE against stainless steel [. 1. ] have shown higher wear factors (1.1 × 10-6 mm3N-1m-1). Pitch and PAN-based CFR-PEEK against CoCrMo (low carbon or high carbon) provided low wear rates. On average, the Pitch-based material against high carbon CoCrMo provided the lowest wear in these tests. All the material combinations gave lower wear than found for UHMWPE-on-stainless steel tested under similar conditions. This gives confidence in the likelihood of this material combination performing well in orthopaedic applications. The authors wish to thank INVIBIO Ltd for funding this research

Introduction. Total hip replacement failure due to fretting-corrosion remains a clinical concern. We recently described that damage within CoCrMo femoral heads can occur either by mechanically-dominated fretting processes leading to imprinting (via rough trunnions) and surface fretting (via smooth trunnions), or by a chemically-dominated etching process along preferential corrosion sites, termed “column damage”. These corrosion sites occur due to banding of the alloy microstructure. Banding is likely caused during thermo-mechanical processing of the alloy and is characterized by local molybdenum depletion. It was the objective of this study to quantify material loss from femoral heads with severe corrosion, identify the underlying damage modes, and to correlate the damage to the alloy's microstructure. Methods. 105 femoral heads with a Goldberg score 4 were evaluated. Coordinate measuring machine data was used to compute material loss and visualize damage features. Time in situ and stem alloy were identified. Metallographic samples were produced for each case. Grain size and banding were identified using light-microscopy. Mann-Whitney tests were conducted to compare material loss between groups. Results. Heads exhibited imprinting and column damage in 72 and 51 cases, respectively, with an overlap of 36 cases. 18 heads exhibited surface fretting only. All heads with column damage exhibited a banded microstructure. Heads with column damage had higher material loss (p=0.05) than those without. Also, heads with a banded microstructure had higher material loss (p=0.035) than those with a homogenous microstructure. Grain size, carbide content, and time did not correlate with material loss. Conclusion. Column damage is a detrimental damage mode within CoCrMo femoral heads that is directly linked to banding within its microstructure. It appears that banding even affects material loss before column damage is identifiable. These results indicate that implant alloy microstructure must be optimized to minimize the release of fretting-corrosion products and related implant failure

The generation of particle debris from ultra high molecular weight polyethylene (UHMWPE) against metal hip joints has been shown to cause osteolysis leading to joint loosening in the medium term. This is known as late aseptic loosening since infection is absent. 1. . In an attempt to reduce the volume of wear debris, attention has moved to metal-on-metal prostheses as the total volume of wear debris is less. However, the size, shape and number of the particles are important as well as the total volume as these affect the biological response of the body leading to aseptic loosening. The Durham Mk I Hip Joint Simulator was used to generate CoCrMo wear particles in a series of tests. Four simulator tests took place in succession, initially 50 mm Birmingham hip replacements were tested where both the head and the cup were as-cast CoCrMo alloy. A second test was conducted where the components were 38 mm and both head and cup were as-cast CoCrMo. A third test using 50 mm components was completed where both head and cup were double heat treated CoCrMo alloy and a final test took place where both components were 50 mm the head was as-cast and the cup was as-cast which had been pre-worn to 5 million cycles. Bovine serum with a concentration of 17 g/l of protein was used as a lubricant and particles were sampled every half million cycles. The volumetric wear was also obtained gravimetrically. A double enzymatic protocol was used to cleave the proteins from the particles taking great care to minimise any effect on the particles. Finally the particles were suspended in distilled, de-ionised water to enable them to be analysed using a NanoSight LM10 particle analyser. This yielded the size distribution of the particles. This was then confirmed by placing an aliquot of the suspended particles onto a carbon coated copper grid and drying them under a lamp. These particles were then imaged in the TEM. Energy Dispersive X-ray analysis was also used to obtain the chemical composition of the particles. The results indicated a strong correlation between the gravimetric wear and the number of particles. All the as-cast CoCrMo alloy tests showed a consistent particle modal average size. The double heat treated particles were shown to be smaller, with occasional large flake like particulates which were identified under the TEM. This particle data correlates extremely well with previous data from simple material testing pin on plate experiments. Previous studies have used microscopy to investigate the size and morphology of the particulate debris. 2. , however these studies are limited due to the time taken to image the particles individually. This current method allows many more particles to be analysed, thus the data accumulated is more statistically significant and may be compared with the wear volumes calculated gravimetrically

With its high wear and corrosion resistance, CoCrMo alloy has been widely used for metal-on-metal total hip replacements (THRs). However, the use of the metal-on-metal implants has dropped substantially as a result of several alerts issued by the Medicines and Healthcare products Regulatory Agency (MHRA) due to concern on metal ion release [1]. However, some of the first generation of metal-on-metal THRs have lasted for more than 20 years [2]. It is far from clear why some MoM joints have survived, while other failed. It is known that dynamic changes occur at the metal surface during articulation. For example, a nanocrystalline layer has been reported on the topmost surface of both in vivo and in vitro CoCrMo THRs [3, 4] but it is not known whether this layer is beneficial or detrimental. The current work focuses on the sub-surface damage evolution of explanted MoM hips, which is compared to in vitro tested CoCrMo hip prostheses. Site-specific TEM cross-section of both in vivo and in vitro CoCrMo samples were prepared by focused ion beam (FIB) in situ lift-out method (Quanta 200 3D with Omniprobe, FEI, the Netherlands). TEM of the FIB specimens was performed on various microscopes. Routine bright field imaging was performed on a Tecnai 20 (FEI, the Netherland) operating at 200 kV, while high resolution transmission electron microscopy (HRTEM) of the nanocrystalline layer and other surface species was undertaken on a Jeol 2010F (Jeol, Japan) operating at 200 kV. A nanocrystalline layer (which was not present on the starting surfaces) was observed on both explanted in vivo and in vitro tested materials. For the explanted joints, the nanocrystalline layer was thin (a few 100 nm) and the extent did not appear to correlate with the local wear rate. For in vitro samples, the nanocrystalline layer was thicker (up to micron). HRTEM from this layer are shown in Fig. 1 and Fig. 2. The nanocrystallite size was ∼5 nm and appeared to be a mixture of face centred cubic and hexagonal close packed phases. The formation of the nanocrystalline layer and its correlation with wear behaviour are discussed

Summary. Metal Injection Molding could provide cost saving of about 20–50% for implantable medical device manufacturing and hence healthcare public spending. Corrosion behaviour and biocompatibility of the new manufactured alloy were studied and showed similar behaviour compared to the traditional one. Introduction. The growing trend for total joint arthroplasties could raise healthcare costs in the near future. Metal Injection Molding (MIM) is a near net shape manufacturing technology and allows the production of finite prosthesis components saving the machining step, and so resources, up to 20–50%. In order to apply such process to the production of actual devices, the bulk material have to show biocompatibility and corrosion behaviour similar to the traditional one. (ASTM F2083, ISO 21536) The aim of this work was to compare cast and forged CoCrMo alloy with the MIM one from the electrochemical point of view and cytocompatibility. Material and Methods. Metallographic observations by optical microscopy and SEM were taken to better understand the electrochemical behaviour. This evaluation was performed through potentiodynamic tests on MIM and forged (FOR) samples with polished and sandblasted surfaces (as the actual devices), in ASTM G5 cell with saline solution simulating the body environment, graphite counter electrodes and Ag/AgCl 0.15M NaCl reference electrode. Linear polarization, open circuit potential measurements and potentiostatic tests at +335 mV vs SCE were also performed during 10 days to have direct information on the corrosion resistance and ion release. Cell viability were also assessed through MTT test on polished MIM and cast (CAS) elutes, after 2 and 7 days contact periods, following ISO 10993 directions. Static ion release in H. 2. O at 2, 4 and 8 weeks were also performed. Results. MIM showed coarser grains, free of boundary carbide but with lots of circular porosities and stacking faults, in comparison with CAS structure, which presented many carbides and typical dendritic grain. Electrochemical tests exhibited analogue behaviour for the MIM and FOR CoCrMo alloys. The slightly lower passive current density and transpassive potential values obtained could be ascribed to a passive oxide layer on the MIM sample less protective than FOR CoCrMo one, as inferable from the OCP measurements, but these facts had no visible influence on polarization resistance and ion release. Such good corrosion behaviour was reflected also in static ion release results and MTT viability results, which were comparable, not only to CAS samples but also to the control medium. Conclusions. From such preliminary results MIM technology showed to have good possibility for the production of implantable medical devices with CoCrMo alloy. Corrosion resistance and biocompatibility seemed not to be affected by the different manufacturing technique. Further studies will be needed to asses also the equivalence of mechanical properties. From the metallographic observations the absence of second phases and the homogeneous microstructure suggests a better fatigue performance for this kind of alloy, even if some concerns arise from the widespread porosity observed

Metallic contacts in hip replacements are susceptible to wear and corrosion processes which lead to the release of particles and metal ions. Adverse local tissue reactions (ALTRs) and systemic manifestations to solid and soluble debris can be debilitating for the patients. It is believed that particles originating from CoCrMo taper junctions trigger more severe body reactions compared to debris from MoM hip bearings. The body's reaction is highly dependent on particle characteristics, such as size, morphology, composition and aggregation state, which can reflect the specific wear and corrosion conditions at the site of release. Here we proposed to investigate wear and corrosion flakes collected from around CoCrMo tapers at the time of revision. The particles were initially characterised with scanning electron microscopy (SEM) and energy dispersive X-ray analysis (EDX). This revealed the microstructure of the corrosion products, which appeared to be made of smaller metallic aggregates, entrapped in a biological matrix. The in depth characterisation of the particles released from the organo-metallic composite, was performed with transmission electron microscopy (TEM) and scanning transmission electron microscopy (STEM), both fitted with EDX. The investigation revealed clusters and individual nanoparticles, as small as 3 nm, which represent the building blocks of the large corrosion flakes, reported and characterised in the past mainly with low resolution microscopy techniques. The majority of the particles consisted of Cr and O, potentially in the form of chromium oxides, with little evidence of Co and Mo. Particles size distribution (PSD) provided by STEM and TEM characterisation showed statistically different results. The STEM technique was able to resolve tiny particles found in close proximity and provided a PSD shift towards the smaller end of the size range. The study is the first to show microscopy evidence of Cr rich nanoparticles (3–60 nm) released in vivo from the modular taper interface, which can have important health implications caused by their increased potential to disseminate and corrode within the body

Recently, our lab has made observations of metal damage patterns from retrieval studies that appeared to be cellular in nature [1]. This type of damage presented on about 74% of the retrieved implants and was attributed to inflammatory cells (termed ICI corrosion) [1]. An alternate hypothesis arose surrounding the use of electrosurgery in total joint arthroplasty (TJA). In TJA, where surgery occurs around metallic devices, the interactions of the high voltage, high frequency current created by an electrosurgical generator and the implant need to be better understood. In order to explore the effects electrosurgical currents have on metal implants, the interaction of a model system of highly polished metal disks and a standard electrosurgical generator (ConMed, Utica, NY) was evaluated in various modes and power settings. The disks were made of CoCrMo or Ti-6Al-4V alloys and were polished to a mirror finish for use and placed directly on the return electrode pad used in patients. Both coagulation and cut modes were evaluated, as well as both monopolar and bipolar configurations in wet and dry conditions using a blade-shaped tip. In wet cases, the disks were wet with phosphate buffered saline prior to the test to simulate body fluids in contact with the implant during current application. In all cases, surface damage was generated on both surfaces and was readily observed as a direct result of the current interacting with the metal (Fig. 1 and 2). Direct contact with the metal, regardless of a dry or wet surface, resulted in pitting and oxide buildup at the contact area. Non-contact activation in proximity to the surface or contact with fluid on the surface caused arcing and created damage that was more widespread over the area of fluid contact with the surface. The damage patterns created on the wetted surface by the electrosurgical unit looked very similar to the patterns we previously attributed to inflammatory cells. More specifically, it produced circular, ruffled areas with centralized pits and occasionally presented trail- and weld-like features (Fig. 2). While these results show that some of the damage previously reported to be from ICI corrosion is indeed the result of electrosurgery, there are still cases in retrievals that cannot be explained by this process and the corrosion reaction to alloys exposed to ROS-based molecules demonstrate significant acceleration of corrosion. Thus, ICI corrosion is still a viable hypothesis. Surgeons utilizing electrosurgical systems in proximity to metallic orthopedic implants need to exercise caution as the discharge of electrical energy through these implants can induce localized surface damage and may result in other adverse effects to the metal implants. Ultimately, we would like to update the community on the nature of the damage we previously reported and more importantly bring to light the possibility of surgeon-induced damage to the implant as a result of electrosurgical methods

In total hip arthroplasty (THA), aseptic loosening induced by polyethylene (PE) wear debris is the most important cause that limits the longevity of implants. Abrasive wear generated through the mechanism such that micrometer-roughened regions and small asperities on the metallic femoral heads surface locally plow through the PE cup surface. Abrasive wear results in the PE material being removed from the track traced by the asperity during the motion of the metallic femoral heads surface. For the purpose of reducing wear, alumina ceramics was introduced in Europe and Japan in 1970s. The clinical results of ceramic-on-PE bearings regarding the wear resistance have been superior to that of the metal-on-PE bearings. Compared with Co–Cr–Mo alloys, alumina ceramics is advantageous for precision machining because of its higher hardness, enable to form spherical and smooth surface. The fracture resistance of the alumina ceramics itself is related to grain size; the grain size reduction leads to the improvement of its resistance. In this study, we evaluated the roundness and the roughness of retrieved two distinct alumina ceramics having different grain size, and Co–Cr–Mo alloy heads.

Fourteen retrieved alumina ceramic femoral heads; ten heads with a diameter of 28 mm made of small grain size alumina (SG-alumina; mean grain size is 3.4 μm) with clinical use for 16–28 years and four heads with a diameter of 26 mm made of extra-small grain size alumina (XSG-alumina; mean grain size is 1.3 μm) with clinical use for 14–19 years, were examined. Six retrieved Co–Cr–Mo alloy femoral heads with a diameter of from 22 to 32 mm with average clinical use for 12–28 years were examined.

SG-alumina and XSG-alumina heads showed significantly lower roundness compared with Co–Cr–Mo alloy heads, due to higher precision machining [Fig. 1]. The surface roughness for the contact area of the heads increased in order of XSG-alumina, SG-alumina and Co–Cr–Mo alloy. The surface roughness of the non-contact area for all kinds of heads was lower than that for the contact area [Fig. 2]. Surface profiles of the SG-alumina and XSG-alumina showed the reentrant surface while Co–Cr–Mo alloy heads showed the protrusion surface. The roundness and roughness of the Co–Cr–Mo alloy or ceramic surface and the presence or absence of hard third-body particles correlate to the amount of abrasive PE wear. When the third-body was entrapped during the clinical use, a reentrant surface might be formed on the ceramic while protrusion surface formed on the Co–Cr–Mo alloy. The differences in clinical results may be due in part to the influence of third-body particles. The ceramic becomes more resistant than Co–Cr–Mo alloy against the scratching by the entrapped abrasive contaminants because of its harder surface. From the good clinical results of more than 20 years using SG-alumina, the greater long term clinical results using XSG-alumina will be expected.

The effect of an advanced porous surface morphology on the mechanical performance of an uncemented femoral knee prosthesis was investigated. Eighteen implants were inserted and then pushed-off from nine paired femurs (Left legs: advanced surface coating; right legs: Porocoat® surface coating as baseline). Bone mineral density (BMD) and anteroposterior dimension were measured, which both were not significantly different between groups. The insertion force was not significantly different, but push-off force was significantly higher in the advanced surface coating group (P = 0.007). BMD had direct relationship with the insertion force and push-off force (p < 0.001). The effect of surface morphology on implant alignment was very small. We suggest that the surface properties create a higher frictional resistance thereby providing a better inherent stability of implants featuring the advanced surface coating.

A 70-year-old man with an uncemented metal-on-polyethylene total hip prosthesis underwent revision arthroplasty 33 months later because of pain, swelling and recurrent dislocation. There appeared to be corrosion and metal release from the prosthetic head, resulting in pseudotumour formation and severe local soft-tissue destruction. The corrosion occurred at the junction between the titanium-molybdenum-zirconium-iron taper and the cobalt-chrome-molybdenum head, but the mechanism was unproven.

Total knee arthroplasty is one of the most common surgeries. About 92% of all implanted knee endorposthesis in 2020 were manufactured from uncoated CoCrMo articulating on ultra-high-molecular-weight polyethylene. All articluations generate wear particles and subsequent emission of metal ions due to the mechanical loading. These wear particles cause diverse negative reactions in the surrounding tissues and can lead to implant loosening. Coating technologies might offer the possibility to reduce this wear. Therefore, we investigated the applicability of tetrahedral amorphous carbon (ta-C) coating on CoCrMo alloy. Polished specimens made of CoCrMo wrought alloy according to ISO 5832-12 were coated with ta-C coatings with different layer structure using pulsed laser deposition (PLD). This process allows the deposition of ta-C coatings with low internal stress using an additional relaxation laser. Surface quality and mechanical properties of the coating were characterised using optical surface measurements (NanoFocus μsurf expert, NanoFocus AG) and a nanoindentation tester NHT. 3. (Anton Paar GmbH). Scratch tests were performed on Micro Scratch Tester MST. 3. (Anton Paar TriTec SA) to define the coating adhesion. Pin-on-plate tribological tests, with a polyethylene ball sliding on the ta-C-coated plate under a defined load according to ISO 14243-1 were performed using a linear tribometer (Anton Paar GmbH) to evaluate the tribological and wear properties. The ta-C coatings showed a mean roughness Ra of 5-20 nm and a hardness up to 60 GPa (n=3). The adhesion of the ta-C coatings (n=3) was comparable to the commercial coatings like TiN and TiNbN. The pin-on-plate tests showed an improvement of tribological properties in comparison with the polished uncoated CoCrMo specimens (n=3). The ta-C coatings applied by DLP technology show increased hardness compared to the base material and sufficient adhesion. Further research will be needed to investigate the optimal coating strategy for implant coating

Abstract. Aims. Ceramic coatings in total knee arthroplasty have been introduced with the aim of reducing wear and consequently improving implant survivorship. We studied both cobalt-chrome-molybdenum and ceramic-coated components of the same implant design from a single centre to identify if the ceramic coating conferred any benefit at mid-term review. Patients and Methods. We identified 1641 Columbus TKAs (Aesculap AG, Tüttlingen, Germany) from a prospectively collected arthroplasty database. 983 were traditional CoCrMo and 659 had the AS ceramic coating. Patients were followed up until death or revision of the implant. Results. A slightly younger patient population was seen in the AS ceramic cohort which was statistically significant, mean 68.3 (p=<0.0001). There was no significant difference in implant survivorship between the CoCrMo femur and the ceramic coated femur at a mean of 9.2 years follow-up for the CoCrMo group and 5 years for the ceramic coated group (p=0.76). There was no reduction in the proportion of components revised for aseptic loosening or infection in the ceramic coated cohort. Conclusion. The reported benefits of ceramic coatings are note clearly demonstrated within our current cohort. All knee replacements within our cohort were performed by a user of both CoCrMo and AS and therefore implant familiarity does not explain the revision rate within the AS cohort. At mid-term follow-up, there was no benefit in terms of implant survivorship in using a ceramic coating

The implantation of endoprosthesis is a routine procedure in orthopaedics. Endoprosthesis are mainly manufactured from ceramics, polymers, metals or metal alloys. To ensure longevity of the implants they should be as biocompatible as possible and ideally have antibacterial properties, to avoid periprosthetic joint infections (PJI). Various antibacterial implant materials have been proposed, but have so far only been used sporadically in patients. PJI is one of the main risk factors for revision surgeries. The aim of the study was to identify novel implant coatings that both exhibit antibacterial properties whilst having optimal biocompatibility. Six different novel implant coatings and surface modifications (EBM TiAl6V4, strontium, TiCuN, TiNbN, gentamicin phosphate (GP), gentamicin phosphate+cationic polymer (GP+CP)) were compared to standard CoCrMo-alloy. The coatings were further characterized with regard to the surface roughness. E. coli and S. capitis were cultured on the modified surfaces to investigate the antibacterial properties. To quantify bacterial proliferation the optical density (OD) was measured and viability was determined using colony forming units (CFU). Murine bone marrow derived macrophages (BMMs) were cultured on the surfaces and differentiated into osteoblasts to quantify the mineralisation using the alizarin red assay. All novel coatings showed reduced bacterial proliferation and viability compared to standard CoCrMo-alloy. A significant reduction was observed for GP and GP+CP coated samples compared to CoCrMo (OD. GP,E.coli. = 0.18±0.4; OD. GP+CP,E.coli. = 0.13±0.3; p≤0.0002; N≥7-8). An increase in osteoblast-mediated mineralisation was observed on all surfaces tested compared to CoCrMo. Furthermore, GP and GP+CP coated samples showed a statistically significant increase (M. GP. = 0.21±0.1; M. GP+CP. = 0.25±0.2; p<0.0001; N≥3-6). The preliminary data indicates that the gentamicin containing surfaces have the most effective antibacterial property and the highest osseointegrative capacity. The use of antibiotic coatings on prostheses could reduce the risk of PJI while being applied on osseointegrative implant surfaces

Little is known about the relationship between head-neck corrosion and its effect on the periprosthetic tissues and distant organs of patients hosting well-functioning devices. The purpose of this study was to investigate in postmortem retrieved specimens the degree and type of taper damage, and the corresponding histologic responses in periprosthetic tissues and distant organs. Fifty postmortem THRs (34 primaries, 16 revisions) retrieved after 0.5 to 26 years were analyzed. Forty-three implants had a CoCrMo stem and seven had a Ti6Al4V stem. All heads were CoCrMo and articulated against polyethylene cups (19 XLPE, 31 UHMWPE). H&E sections of joint pseudocapsules, liver, spleen, kidneys and lymph nodes were graded 1–4 for the intensity of various inflammatory cell infiltrates and tissue characteristics. Corrosion damage of the taper surfaces was assessed using visual scoring and quantitated with an optical coordinate measuring machine. SEM analysis was used to determine the acting corrosion mode. Polyethylene wear was assessed optically. The majority of tapers had minimal to mild damage characterized by local plastic deformation of machining line peaks. Imprinting of the stem topography onto the head taper surface was observed in 18 cases. Column damage on the head taper surface occurred in three cases. All taper surfaces scored moderate or severe exhibited local damage features of fretting and/or pitting corrosion. Moderate or severe corrosion of the head and/or trunnion was present in nine hips. In one asymptomatic patient with bilateral hips, lymphocyte-dominated tissue reactions involving perivascular infiltrates of lymphocytes and plasmacytes were observed. In this patient, mild, focal lymphocytic infiltrates were also present in the liver and kidneys, and there was focal histiocytosis and necrosis of the para-aortic lymph nodes. These two implants, which had been in place for 58.6 and 60.1 months, had severe intergranular corrosion of the CoCrMo trunnion, and column damage and imprinting on the head taper. In the other 41 hips, macrophage responses in the joint pseudocapsule to metallic and/or polyethylene wear particles ranged widely from minimal to marked. Focal necrosis in the pseudocapsules of 12 arthroplasties was related to high concentrations of CoCrMo, TiAl4V, TiO, BaSO4 and polyethylene wear particles. High concentrations of these particles were also detected in para-aortic lymph nodes. Rare to mild macrophages were observed in liver and spleen. This is a comprehensive study of wear and corrosion within well-functioning postmortem retrieved THRs, and the resulting local and distant tissue reactions. One of eight patients with moderate or severe corrosion did have a subclinical inflammatory response dominated by lymphocytes after five years. To what extent such an inflammatory process might progress to become symptomatic is not known. Ionic and particulate products generated by corrosion disseminated systemically. The minor lymphocytic infiltrate in the liver and kidneys of one subject with bilateral severely corroded head-neck junctions might suggest possible metal toxicity. The diagnosis of adverse tissue reactions to corrosion of modular junctions can be challenging. Postmortem retrieval studies add to our understanding of the nature and progression of lymphocyte-dominated adverse local and potentially systemic tissue reactions to corrosion of modular junctions

Introduction. Little is known about the relationship between head-neck corrosion and its effect on periprosthetic tissues and distant organs in the majority of patients hosting apparently well-functioning devices. We studied the degree and type of taper damage and the histopathologic response in periprosthetic tissue and distant organs. Methods. A total of 50 contemporary THRs (34 primary, 16 revision) retrieved postmortem from 40 patients after 0.4–26 years were studied. Forty-three femoral stems were CoCrMo and 7 were Ti6Al4V. In every case, a CoCrMo-alloy head articulated against a cementless polyethylene cup (19 XLPE and 31 UHMWPE). H&E and IHC sections of the joint pseudocapsules and liver were graded 1–4 for the intensity of various inflammatory cell infiltrates and tissue necrosis. The nature of the tissue response in the joint capsule, liver, spleen, kidneys and lymph nodes was assessed. Wear and corrosion products in the tissues were identified using SEM and EDS. Taper surfaces were graded for corrosion damage using modified Goldberg scoring and examined by SEM to determine the acting corrosion mode. Correlations between damage scores and the histologic variables were generated using the Spearman test. Results. No correlation was seen between taper damage scores and the macrophage response in the joint pseudocapsule. The distribution of corrosion scores for heads and femoral trunnions is shown in Figure 1. Moderate or severe corrosion of the head and/or trunnion was present in 9 hips (8 CoCr/CoCr and 1 CoCr/TiAlV). One patient with bilateral hips had local ALVAL-like lymphocyte-dominated tissue reactions (Figure 2) and mild focal lymphocytic infiltrates in the liver and kidneys (Figure 3). This was associated with severe intergranular corrosion of the CoCrMo trunnion and column damage on the head taper. Particle-laden macrophages in pseudocapsules were significantly correlated with liver macrophages (r=.382, p=0.012) and liver lymphocytes (r=.367, p=0.013). Pseudocapsule macrophage responses to metallic and/or polyethylene wear particles ranged widely from minimal to marked. Focal tissue necrosis was related to high concentrations of particulate wear debris. A minimal number of metallic particle-laden macrophages were also detected in the liver and spleen; and macrophage granulomas were present in para-aortic lymph nodes, especially in revision cases. DISCUSSION. The generation of metal ions and particulates at corroded CoCrMo heads and CoCrMo or Ti6Al4V trunnions was a significant contributor to the presence of perivascular lymphocytes within the joint pseudocapsule, with 1 patient showing a histologic pattern consistent with ALVAL. Patient factors and the rate of corrosion are among variables influencing whether an ALVAL-type reaction will develop and whether or not it will become symptomatic. Macrophages in the joint pseudocapsules were positively correlated with inflammatory cells in the liver. In this study, the intensity of inflammatory infiltrates in distant organs was mild. However, several cases of organ dysfunction have been reported in association with catastrophic wear of CoCrMo components. It continues to be essential to minimize the generation of metal ions and particulates and to improve strategies for identifying and managing patients exposed to high levels of degradation products. For any figures or tables, please contact the authors directly

Introduction. There is interest in minimally invasive solutions that reduce osteoarthritic symptoms and restore joint mobility in the early stages of cartilage degeneration or damage. The aim of the present study was to evaluate the Biolox®delta alumina-zirconia composite as a counterface for articulation against live cartilage in comparison to the clinically relevant CoCrMo alloy using a highly controlled in vitro ball-on-flat articulation bioreactor that has been shown to rank materials in accord with clinical experience. Methods. The four-station bioreactor was housed in an incubator. The dual axis concept of this simulator approximates the rolling-gliding kinematics of the joint. Twelve 32 mm alumina-zirconia composite femoral heads (Biolox®delta, CeramTec GmbH, Germany) and twelve 32 mm CoCrMo femoral heads (Peter Brehm GmbH, Germany) made up the testing groups. Each head articulated against a cartilage disk of 14 mm diam., harvested from six months old steers. Free-swelling control disks were obtained as well. Testing was conducted in Mini ITS medium for three hours daily over 10 days applying a load of 40 N (∼2 MPa). PG/GAG was determined using the dimethylmethylene blue (DMMB) assay. Hydroxyproline was analyzed by high performance liquid chromatography coupled to a mass spectrometer. Additionally, at test conclusion, chondrocyte survival was determined using Live/Dead assay. Histological analysis was performed using a modified Mankin score. The effect of articulating material (ceramic, CoCrMo) on the various outputs of interest was evaluated using ANOVA. Blocking was performed with respect to the animals. The Mankin scores were compared using the Kruskal–Wallis test. Results. Cells stayed alive during the course of the 3-week experiment with cell survival values close to or at 80% at test completion. There was no difference between ceramic and free swelling control tissue. However, cell count values were inferior for CoCrMo in the superficial zone (p= 0.003). Tested tissue suffered mostly structural abnormalities. In many samples, the superficial layer was disturbed (and sometimes absent), but deeper layers were little affected. The average Mankin scores were in the range of 2 (out of 14) for both materials (p=0.772; Fig. 1). PG/GAG content in medium was highest for CoCrMo (Fig. 2). Though despite a 10% difference between CoCrMo and ceramic, this did not manifest in statistical significance (p=0.315). Similarly, hydroxyproline release into medium was higher for CoCrMo than ceramic (Fig. 3). This difference (28%) was statistically significant (p=0.024). Discussion. Overall, the results indicate that ceramic-on-cartilage induces less tissue and cell damage than metal-on-cartilage. However, only the hydroxyproline measurements reached statistical significance, partially due to a large variation within both material groups. Current understanding of cartilage wear is still incomplete. While studies have utilized the coefficient of friction against artificial materials as a surrogate wear marker, the best way to determine wear in in-vitro experiments is not well-established. Here, we used the matrix components proteoglycan and hydroxyproline to predict cartilage damage, but further work is necessary to elucidate the mechanobiological reasons for damage. In summary, from this study, Biolox®delta ceramic is generally superior to CoCrMo in the articulation against hyaline cartilage. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Hip simulators have been used for ten years to determine the tribological performance of large-head metal-on-metal devices using traditional test conditions. However, the hip simulator protocols were originally developed to test metal-on-polyethylene devices. We have used patient activity data to develop a more physiologically relevant test protocol for metal-on-metal devices. This includes stop/start motion, a more appropriate walking frequency, and alternating kinetic and kinematic profiles. There has been considerable discussion about the effect of heat treatments on the wear of metal-on-metal cobalt chromium molybdenum (CoCrMo) devices. Clinical studies have shown a higher rate of wear, levels of metal ions and rates of failure for the heat-treated metal compared to the as-cast metal CoCrMo devices. However, hip simulator studies in vitro under traditional testing conditions have thus far not been able to demonstrate a difference between the wear performance of these implants. Using a physiologically relevant test protocol, we have shown that heat treatment of metal-on-metal CoCrMo devices adversely affects their wear performance and generates significantly higher wear rates and levels of metal ions than in as-cast metal implants

Total hip arthroplasties are known to corrode predominantly at the taper junctions between Cobalt Chromium Molybedenum (CoCrMo) and Titanium (Ti) alloy components. We aimed to understand the modes underlying clinically significant tissue reactions to metals from corroded implants by determining: (1) what type of metal is present in the tissues, (2) which cells contain the metal species and (3) how this compares with results from metal-on-metal (MOM) hip resurfacings (HRs). This study involved periprosthetic tissue from patients that had undergone revision surgery due to adverse reactions to metal debris (ARMD) from dual-taper prostheses consisting of Ti-based alloy stems paired with CoCrMo necks. We used Synchrotron micro X-ray Fluorescence Spectroscopy (µXRF) and micro X-ray Absorption Near Edge Spectroscopy (µXANES) for detection of Co, Cr and Ti, and determination of their oxidation state. Synchrotron radiation has shown that the chromium in tissues is Cr. 2. O. 3. when derived from corroded CoCrMo/Ti junctions beside the CrPO. 4. species found when hip implants release CoCrMo nanoparticles from their bearing surfaces (MoM HRs). Presence of Cr. 2. O. 3. was associated with titanium oxide TiO. 2. This may be the outcome of the chemical interaction between the two species. Histological examination showed corrosion products present within viable macrophages and in the extracellular connective tissue, Figure 1. Understanding corrosion at taper junctions and the pathogenesis of the biological response is of significant clinical importance. This is the first study to co-register histology and metal distribution maps and to explore the potential synergy effect of CoCrMo with Ti alloy. This study provides guidance for toxicological studies on wear/corrosion particles, how they stimulate the host response and the cellular mechanisms involved in the pathogenesis of ARMD. For any figures or tables, please contact the authors directly by clicking on ‘Info & Metrics’ above to access author contact details

Dual mobility (DM) is an established bearing option in Total Hip Arthroplasty (THA). The traditional mono-block DM designs have limited ability for additional fixation, whereas the modular DM designs allow additional screw fixation but limit internal diameter and have the potential to generate metal debris. We report the early results of a CoCrMo alloy mono-block implant manufactured by additive technology with a highly porous ingrowth surface to enhance primary fixation and osseointegration. Prospective follow-up of the Duplex. TM. implant first inserted in March 2016 enrolled into Beyond Compliance (BC). Primary outcome measure was all-cause revision and secondary outcomes dislocation, peri-prosthetic fracture (PPF) and Oxford Hip Score (OHS). Patients were risk stratified and all considered to be high risk for instability. Complications were identified via hospital records, clinical coding linkage using national database and via BC website. 159 implants in 154 patients with a mean age 74.0 years and a maximum F/U of 7 years. Survivorship for all-cause revision 99.4% (95% CI 96.2–99.8). One femoral only revision. Mean gain in OHS 27.4. Dislocation rate 0.6% with a single event. Patients with a cemented Polished taper stem (PTS) had a Type B PPF rate of 2.1% requiring revision/fixation. Compared to conventional THA this cohort was significantly older (74.0 vs 68.3 years), more co-morbidity (ASA 3 46.5% vs 14.4%) and more non-OA indications (32.4% vs 8.5%). Every patient had at least one risk factor for falling and >50% of cohort had 4 or more risk factors using NICE tool. We believe our results demonstrate that risk stratification successfully aids implant selection to prevent dislocation in high-risk patients. This novel design has provided excellent early results in a challenging cohort where individuals are very different to the “average” THA patient. NJR data on DM has reported an increase in revision for PPF. A “perfect storm” maybe created using DM in high-risk falls risk population. This re-enforces the need to consider all patient and implant factors when deciding bearing selection