Background. One of the potential complications of polyethylene liner (PL) is its dissociation from the metal shell. This is a rare but catastrophic complication of total hip replacement (THR). Objective. was to analyze the retrieved dissociated components (PL and shell) (Depuy Pinnacle, Warsaw, IN, USA) to evaluate the mechanism of failure. All these components were dissociated within four years of implantation. Methods. Components were retrieved from three different centers in Canada over the period from January 2011 to October 2016. The analysis was done at the Orthopaedic Innovation Centre (OIC) in Winnipeg Canada. Nine PLs were retrieved at the time of revision THR. Assessment using optical and scanning electron microscopies at magnification between 25× and 150× was performed. The following questions were asked: 1) were the liners correctly seated at the primary surgery? 2) Are there signs of impingement present which could have caused the liner to become dissociated? 3) Does the wear pattern indicate that the liner was failing prior to dissociation?. Results. All PLs dissociated in the inferior direction. Five PL were believed to have been seated properly at the time of indexed surgery. All PL displayed signs of post dissociation impingement. Only 1 PL had fractured resulting in failure prior to dissociation. Other PL showed signs of wear, however none of them reached thinness that would be a cause for concern. Eight PLs demonstrated shearing of the anti rotation tabs. Assessment of the anti rotation tabs revealed that a couple had sheared off suddenly while remaining anti rotation tabs sheared off in progressive fatigue resulting in the failure of the locking mechanism. Conclusions. Retrieval analysis was useful in identifying common patterns of failure such as anti-rotation tab damage. This was suggestive that the locking mechanism of the acetabular components has probably failed in 8 out of 9 of the retrieved liners

Objectives. The use of ceramic femoral heads in total hip arthroplasty (THA) has increased due to their proven low bearing wear characteristics. Ceramic femoral heads are also thought to reduce wear and corrosion at the head-stem junction with titanium (Ti) stems when compared with metal heads. We sought to evaluate taper damage of ceramic compared with metal heads when paired with cobalt chromium (CoCr) alloy stems in a single stem design. Methods. This retrieval study involved 48 total hip arthroplasties (THAs) with CoCr V40 trunnions paired with either CoCr (n = 21) or ceramic (n = 27) heads. The taper junction of all hips was evaluated for fretting/corrosion damage and volumetric material loss using a roundness-measuring machine. We used linear regression analysis to investigate taper damage differences after adjusting for potential confounding variables. Results. We measured median taper material loss rates of 0.210 mm. 3. /year (0.030 to 0.448) for the metal head group and 0.084 mm. 3. /year (0.059 to 0.108) for the ceramic group. The difference was not significant (p = 0.58). Moreover, no significant correlation between material loss and implant or patient factors (p > 0.05) was found. Conclusions. Metal heads did not increase taper damage on CoCr trunnions compared with ceramic heads from the same hip design. The amount of material released at the taper junctions was very low when compared with available data regarding CoCr/Ti coupling in metal-on-metal bearings. Cite this article: A. Di Laura, H. Hothi, J. Henckel, I. Swiatkowska, M. H. L. Liow, Y-M. Kwon, J. A. Skinner, A. J. Hart. Retrieval analysis of metal and ceramic femoral heads on a single CoCr stem design. Bone Joint Res 2017;6:–350. DOI: 10.1302/2046-3758.65.BJR-2016-0325.R1

Dual Mobility (DM) Total Hip Replacements (THRs) were introduced to reduce dislocation risk, which is the most common cause of early revision. The in-vivo mechanics of these implants is not well understood, despite their increased use in both elective and trauma settings. Therefore, the aim of this study was to comprehensively assess retrieved DM polyethylene liners for signs of damage using visual inspection and semi-quantitative geometric assessment techniques.

Retrieved DM liners (n=20) were visually inspected for the presence of seven established modes of polyethylene damage. If embedded debris was identified on the external surface, its material composition was characterised using energy-dispersive x-ray analysis (EDX). Additionally, each liner was geometrically assessed for signs of wear/deformation using a validated methodology.

Visual inspection of the liners revealed that scratching and pitting were the most common damage modes on either surface. Burnishing was observed on 50% and 15% of the internal and external surfaces, respectively. In addition, embedded debris was identified on 25% of the internal and 65% of the external surfaces. EDX analysis of the debris identified several materials including iron, titanium, cobalt-chrome, and tantalum. Geometric analysis demonstrated highly variable damage patterns across the liners.

The results of this study provide insight into the in-vivo mechanics of DM bearings. For example, the results suggest that the internal bearing (i.e., between the head and liner) acts as the primary articulation site for DM-THRs as evidenced by a higher incidence of burnishing and larger, more concentrated regions of penetration across the liners’ internal surfaces. Furthermore, circumferential, and crescent-shaped damage patterns were identified on the articulating surfaces of the liners thus providing evidence that these components can rotate within the acetabular shell with varying degrees of mobility. The mechanics of DM bearings are complex and may be influenced by several factors (e.g., soft tissue fibrosis, patient activities) and thus further investigation is warranted.

Finally, the results of this study suggest that DM liners may be susceptible to ex-vivo surface damage and thus caution is advised when handling and/or assessing these types of components.

3D printing acetabular cups offers the theoretical advantage of enhanced bony fixation due to greater design control of the porous implant surfaces. Analysing retrieved 3D printed implants can help determine whether this design intent has been achieved.

We sectioned 14 off-the-shelf retrieved acetabular cups for histological analysis; 7 cups had been 3D printed and 7 had been conventionally manufactured. Some of the most commonly used contemporary designs were represented in both groups, which were removed due to either aseptic loosening, unexplained pain, infection or dislocation. Clinical data was collected for all implants, including their age, gender, and time to revision.

Bone ingrowth was evaluated using microscopic assessment and two primary outcome measures: 1) bone area fraction and 2) extent of bone ingrowth.

The additively manufactured cups were revised after a median (IQR) time of 24.9 months (20.5 to 45.6) from patients with a median (IQR) age of 61.1 years (48.4 to 71.9), while the conventional cups had a median (IQR) time to revision of 46.3 months (34.7 to 49.1, p = 0.366) and had been retrieved from patients with a median age of 66.0 years (56.9 to 68.9, p = 0.999).

The additively and conventionally manufactured implants had a median (IQR) bone area fraction of 65.7% (36.4 to 90.6) and 33.9% (21.9 to 50.0), respectively (p < 0.001).

A significantly greater amount of bone ingrowth was measured into the backside of the additively manufactured acetabular cups, compared to their conventional counterparts (p < 0.001). Bone occupied a median of 60.0% and 5.7% of the porous depth in the additively manufactured and conventional cups, respectively.

3D printed components were found to achieve a greater amount of bone ingrowth than their conventionally manufactured counterparts, suggesting that the complex porous structures generated through this manufacturing technique may encourage greater osteointegration.

Trunnionosis is an important failure mechanism of total hip arthroplasties as has recently been reported by the England and Wales national joint registry. Adverse local tissue reaction has also recently been associated with total hip arthroplasty (THA) with metal on polyethylene and ceramic on polyethylene articulations. The contributing factors in the mechanism of this failure pattern have not been elucidated, however they are likely multifactorial to include corrosion, fretting, taper design, implantation time, metal particulate debris, and wear at the metal on metal interface. Furthermore, dissimilar metallic combinations have been shown to exacerbate tribocorrosion. Authors have also reported on the use of ceramic heads to reduce trunniononis, however, tribocorrosion is still present. The majority of the literature regarding modular head neck taper fretting and corrosion involves cobalt chrome (CoCr) alloy. Little is known about head neck fretting corrosion with Oxinium femoral heads.

To measure fretting, corrosion, and wear on the female tapers of retrieved Oxinium femoral heads and to determine how demographic and device factors affect these measurements.

Ninety-two (92) retrieved 12/14 Oxinium heads were graded using the modified Goldberg score for subjectively grading corrosion and fretting on the taper surface. A novel silicone molding technique was validated, then applied to the female tapers of the retrievals and of two pristine Oxinium femoral heads, sizes 32+0 and 32+4. The molds were scanned using a Konica Minolta 3D laser scanner for reconstruction of the topography, dimensions, and surface features of the tapers. Geomagic software was used to align the retrieved to the pristine 3D models, allowing measurement of surface deviations (from wear) that had occurred while the heads were implanted. Patient demographic and implant data were correlated with Goldberg scores and wear deviations.

The mean Goldberg score was 1.6. Goldberg scores of 1 (minimal), 2 (mild), and 3 (moderate) were present in 41 of the 92 heads (45%), 43 heads (47%), and 8 heads (8%) respectively. No implants received a score of 4 (severe). A positive significant correlation was found between length of implantation and increased female taper fretting (R = 0.436, p < 0.01). Wear deviations were significantly greater with 36mm heads compared to 32mm heads (p < 0.01) and with +4 offsets compared to 0 offsets (p = 0.013).

Similar to previous work analyzing ceramic heads, Oxinium heads demonstrated predominately mild tribocorrosion grades, however do not eliminate tribocorrosion. Tribocorrosion was increased with large heads and increased offsets. This finding is consistent perhaps with greater mechanical burden that larger implants with increased offsets experience. Further investigation is needed to elucidate if Oxinium femoral heads reduce fretting and corrosion when compared to CoCr femoral heads.

This study compared component wear rates and pre-revision blood metal ions levels in two groups of failed metal-on-metal hip arthroplasties: hip resurfacing and modular total hip replacement (THR).

There was no significant difference in the median rate of linear wear between the groups for both acetabular (p = 0.4633) and femoral (p = 0.0872) components. There was also no significant difference in the median linear wear rates when failed hip resurfacing and modular THR hips of the same type (ASR and Birmingham hip resurfacing (BHR)) were compared.

Unlike other studies of well-functioning hips, there was no significant difference in pre-revision blood metal ion levels between hip resurfacing and modular THR.

Edge loading was common in both groups, but more common in the resurfacing group (67%) than in the modular group (57%). However, this was not significant (p = 0.3479). We attribute this difference to retention of the neck in resurfacing of the hip, leading to impingement-type edge loading. This was supported by visual evidence of impingement on the femur.

These findings show that failed metal-on-metal hip resurfacing and modular THRs have similar component wear rates and are both associated with raised pre-revision blood levels of metal ions.

Aims

Acetabular edge-loading was a cause of increased wear rates in metal-on-metal hip arthroplasties, ultimately contributing to their failure. Although such wear patterns have been regularly reported in retrieval analyses, this study aimed to determine their in vivo location and investigate their relationship with acetabular component positioning.

Aims

The main advantage of 3D-printed, off-the-shelf acetabular implants is the potential to promote enhanced bony fixation due to their controllable porous structure. In this study we investigated the extent of osseointegration in retrieved 3D-printed acetabular implants.

Introduction. In 2010, a widely used metal-on-metal hip implant was voluntarily recalled from the market by the manufacturer. Our lab performed detailed retrieval analysis of 548 of the explanted devices and 165 periprosthetic tissue specimens. We reported a high degree of variability in the multiple measurements that we performed on the components, including volumetric wear. Other studies using semi-quantitative tissue grading methods to describe the histology of the periprosthetic tissues from metal-on-metal hips have looked for relationships between component wear and histological features. Grammatopoulos et al found higher ALVAL scores in 45 hip resurfacing patients with pseudotumors compared to 11 without pseudotumors and a moderately positive correlation between wear and the histological rankings for tissue necrosis and lymphocytic response. We examined correlations between the component wear measurements from retrieval analysis and the tissue features in this large group of one metal-on-metal hip design. Materials and Methods. Tissues were processed routinely into paraffin sections, stained with H&E and characterized with light microscopic semi-quantitative scores for ALVAL features and for the number of macrophages and lymphocytes, extent of metal debris and the estimated percentage of necrosis per slide. Spearman correlation analysis was conducted to evaluate any correlations between retrieval wear measurements and histological findings. Results. The median combined cup and ball wear volume was 17.5mm3 in these 165 cases. The median tissue ALVAL score was 5.5 out of 10. Component total wear volume was not predictive of the ALVAL score (P = 0.09, R = −0.007) or the number of lymphocytes (P= 0.170, R= −0.077) but there was a positive correlation between wear volume and the ranking for macrophages in the tissues (P< 0.001, R=0.215). No other correlations were found for component wear. The median time to revision was 4.84 years. There was a negative correlation between tissue inflammation ranking (P=0.002, R=−0.183) and for lymphocyte ranking and time to revision (P=0.003, R=−0.173). There was a positive correlation between time to revision and the macrophage ranking (P=0.005, R=0.166). Conclusion. From this large-scale retrieval analysis of one design of metal-on-metal total hip, a high degree of variability was observed over the multiple analyses performed, including volumetric wear and tissue features. This likely reflects our previous observation that no single particular failure mechanism was predominant in this large cohort. Funded by DePuy Synthes Companies of Johnson & Johnson

Aims. The aim of this study was to evaluate fretting and corrosion in retrieved oxidized zirconium (OxZr; OXINIUM, Smith & Nephew, Memphis, Tennessee) femoral heads and compare the results with those from a matched cohort of cobalt-chromium (CoCr) femoral heads. Patients and Methods. A total of 28 OxZr femoral heads were retrieved during revision total hip arthroplasty (THA) and matched to 28 retrieved CoCr heads according to patient demographics. The mean age at index was 56 years (46 to 83) in the OxZr group and 70 years (46 to 92) in the CoCr group. Fretting and corrosion scores of the female taper of the heads were measured according to the modified Goldberg scoring method. Results. The OxZr-retrieved femoral heads showed significantly lower mean corrosion scores than the CoCr heads (1.3 (1 to 2.75) vs 2.1 (1 to 4); p < 0.01). Mean fretting scores were also significantly lower in the OxZr cohort when compared with the CoCr cohort (1.3 (1 to 2) vs 1.5 (1 to 2.25); p = 0.02). OxZr heads had more damage in the proximal region compared with the distal region of the head. Location had no impact on damage of CoCr heads. A trend towards increased corrosion in large heads was seen only in the CoCr heads, although this was not statistically significant. Conclusion. Retrieval analysis of OxZr femoral heads showed a decreased amount of fretting and corrosion compared with CoCr femoral heads. OxZr seems to be effective at reducing taper damage. Cite this article: Bone Joint J 2019;101-B:386–389

Aims. We evaluated a large database with mechanical failure of a single uncemented modular femoral component, used in revision hip arthroplasty, as the end point and compared them to a control group treated with the same implant. Patient- and implant-specific risk factors for implant failure were analyzed. . Methods. All cases of a fractured uncemented modular revision femoral component from one manufacturer until April 2017 were identified and the total number of implants sold until April 2017 was used to calculate the fracture rate. The manufacturer provided data on patient demographics, time to failure, and implant details for all notified fractured devices. Patient- and implant-specific risk factors were evaluated using a logistic regression model with multiple imputations and compared to data from a previously published reference group, where no fractures had been observed. The results of a retrieval analysis of the fractured implants, performed by the manufacturer, were available for evaluation. Results. There were 113 recorded cases with fracture at the modular junction, resulting in a calculated fracture rate of 0.30% (113/37,600). The fracture rate of the implant without signs of improper use was 0.11% (41/37,600). In 79% (89/113) of cases with a failed implant, either a lateralized (high offset) neck segment, an extralong head, or the combination of both were used. Logistic regression analysis revealed male sex, high body mass index (BMI), straight component design, and small neck segments were significant risk factors for failure. Investigation of the implants (76/113) showed at least one sign of improper use in 72 cases. Conclusion. Implant failure at the modular junction is associated with patient- and implant-specific risk factors as well as technical errors during implantation. Whenever possible, the use of short and lateralized neck segments should be avoided with this revision system. Implantation instructions and contraindications need to be adhered to and respected. Cite this article: Bone Joint J 2020;102-B(5):573–579

Objectives. We have encountered patients who developed large joint fluid collections with massive elevations in chromium (Cr) and cobalt (Co) concentrations following metal-on-metal (MoM) hip arthroplasties. In some cases, retrieval analysis determined that these ion concentrations could not be explained simply by the wear rates of the components. We hypothesized that these effects may be associated with aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL). Patients and Methods. We examined the influence of the ALVAL grade on synovial fluid Co and Cr concentrations following adjustment for patient and device variables, including volumetric wear rates. Initially restricting the analysis to include only patients with one MoM hip resurfacing device, we performed multiple regression analyses of prospectively collected data. We then repeated the same statistical approach using results from a larger cohort with different MoM designs, including total hip arthroplasties. Results. In the resurfacing cohort (n = 76), the statistical modelling indicated that the presence of severe ALVAL and a large fluid collection were associated with greater joint fluid Co concentrations after adjustment for volumetric wear rates (p = 0.005). These findings were replicated in the mixed implant group (n = 178), where the presence of severe ALVAL and a large fluid collection were significantly associated with greater fluid Co concentrations (p < 0.001). Conclusion. The development of severe ALVAL is associated with elevations in metal ion concentrations far beyond those expected from the volumetric loss from the prosthetic surfaces. This finding may aid the understanding of the sequence of events leading to soft-tissue reactions following MoM hip arthroplasties. Cite this article: D. J. Langton, R. P. Sidaginamale, T. J. Joyce, J. G. Bowsher, J. P. Holland, D. Deehan, A. V. F. Nargol, S. Natu. Aseptic lymphocyte-dominated vasculitis-associated lesions are related to changes in metal ion handling in the joint capsules of metal-on-metal hip arthroplasties. Bone Joint Res 2018;7:388–396. DOI: 10.1302/2046-3758.76.BJR-2018-0037

Background. There has been a trend in the evolution of total hip arthroplasty towards increased modularity, with this increase in modularity come some potentially harmful consequences. Modularity at the neck shaft junction has been linked to corrosion, adverse reaction to metal debris and pseudotumor formation. The aim of this retrieval study is to assess whether the surface integrity of the polyethylene (PE) liner is affected by metal wear debris in a single implant design series of THA revised for trunnionosis. Method. A retrieval analysis of thirty dual-taper modular neck hip prostheses was performed, the mean time from implantation to revision was 2.7 years (1.02–6.2). The PE liners were analysed using a scanning electron microscope with an energy dispersive spectrometer to assess for metal particles embedded on the liner surface. Serum metal ion levels and inflammatory markers were also analysed. Results. There were small numbers of metal particles present on the PE liners. The mean number of metal particles per liner was 4 and the particles varied in size from 0.5–122μm mean 16μm. All patients had elevated metal ion levels: cobalt 6.02μg/l, chromium 1.22μg/l, titanium 3.11μg/l. The cobalt:chromium ratio was 7.55:1. The inflammatory markers were also marginally raised (ESR 17 CRP 10). Conclusion. These results suggest that retention of the PE liners may be reasonable when performing isolated revision of the femoral component in cases of failure at the modular neck stem junction; especially when the inner diameter of the liner is already optimized for head size and stability

We present a series of 35 patients (19 men and 16 women) with a mean age of 64 years (36.7 to 75.9), who underwent total hip replacement using the ESKA dual-modular short stem with metal on-polyethylene bearing surfaces. This implant has a modular neck section in addition to the modular head. Of these patients, three presented with increasing post-operative pain due to pseudotumour formation that resulted from corrosion at the modular neck-stem junction. These patients underwent further surgery and aseptic lymphocytic vaculitis associated lesions were demonstrated on histological analysis. Retrieval analysis of two modular necks showed corrosion at the neck-stem taper. Blood cobalt and chromium levels were measured at a mean of nine months (3 to 28) following surgery. These were compared with the levels in seven control patients (three men and four women) with a mean age of 53.4 years (32.1 to 64.1), who had an identical prosthesis and articulation but with a prosthesis that had no modularity at neck-stem junction. The mean blood levels of cobalt in the study group were raised at 50.75 nmol/l (5 to 145) compared with 5.6 nmol/l (2 to 13) in control patients. Corrosion at neck-stem tapers has been identified as an important source of metal ion release and pseudotumour formation requiring revision surgery. Finite element modelling of the dual modular stem demonstrated high stresses at the modular stem-neck junction. Dual modular cobalt-chrome hip prostheses should be used with caution due to these concerns

Symptomatic cobalt toxicity from a failed total hip replacement is a rare but devastating complication. It has been reported following revision of fractured ceramic components, as well as in patients with failed metal-on-metal articulations. Potential clinical findings include fatigue, weakness, hypothyroidism, cardiomyopathy, polycythaemia, visual and hearing impairment, cognitive dysfunction, and neuropathy. We report a case of an otherwise healthy 46-year-old patient, who developed progressively worsening symptoms of cobalt toxicity beginning approximately six months following synovectomy and revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. The whole blood cobalt levels peaked at 6521 µg/l. The patient died from cobalt-induced cardiomyopathy. Implant retrieval analysis confirmed a loss of 28.3 g mass of the cobalt–chromium femoral head as a result of severe abrasive wear by ceramic particles embedded in the revision polyethylene liner. Autopsy findings were consistent with heavy metal-induced cardiomyopathy. We recommend using new ceramics at revision to minimise the risk of wear-related cobalt toxicity following breakage of ceramic components. Cite this article: Bone Joint J 2013;95-B:31–7

Aims

This study reports the ten-year wear rates, incidence of osteolysis, clinical outcomes, and complications of a multicentre randomized controlled trial comparing oxidized zirconium (OxZr) versus cobalt-chrome (CoCr) femoral heads with ultra-high molecular weight polyethylene (UHMWPE) and highly cross-linked polyethylene (XLPE) liners in total hip arthroplasty (THA).

Aims

This study investigates head-neck taper corrosion with varying head size in a novel hip simulator instrumented to measure corrosion related electrical activity under torsional loads.

Aims

The Exeter V40 cemented polished tapered stem system has demonstrated excellent long-term outcomes. This paper presents a systematic review of the existing literature and reports on a large case series comparing implant fractures between the Exeter V40 series; 125 mm and conventional length stem systems.

Aims

The optimum clearance between the bearing surfaces of hip arthroplasties is unknown. Theoretically, to minimize wear, it is understood that clearances must be low enough to maintain optimal contact pressure and fluid film lubrication, while being large enough to allow lubricant recovery and reduce contact patch size. This study aimed to identify the relationship between diametrical clearance and volumetric wear, through the analysis of retrieved components.

Aims

The aim of this study was to develop a novel computational model for estimating head/stem taper mechanics during different simulated assembly conditions.