Florian Witt

Wear patterns of taper connections in retrieved large diameter metal-on-metal bearings

Wear of the modular taper between head and shaft has been related to clinical failure resulting from adverse reactions to metallic debris. The problem has become pronounced in large metal‐on‐metal bearings, but the mechanism has not yet been fully understood. We analyzed retrieved components from five patients revised with various diagnoses. Two distinct wear patterns were observed for the head tapers. Three samples demonstrated “asymmetric” wear towards the inner end of the head taper. The other two showed “axisymmetric” radial wear (up to 65 µm) presenting the largest wear volumes (up to 20 mm3). Stem tapers demonstrated relatively little wear, and the fine thread on the stem taper surface was observed to be imprinted on the taper inside of the head. Our findings demonstrate that the cobalt‐chrome head wears preferentially to the titanium stem taper. “asymmetric” wear suggests toggling due to the offset of the joint force vector from the taper. In contrast, samples with “axisymmetric” radial wear and a threaded imprint suggested that corrosion led to head subsidence onto the stem taper with gradual rotation.

The relation between titanium taper corrosion and cobalt-chromium bearing wear in large-head metal-on-metal total hip prostheses: a retrieval study.

BACKGROUND Revision of hip implants due to adverse tissue reactions to metal debris has been associated with wear and corrosion of the metal-on-metal bearing articulation and the modular taper interface. Bearing articulation wear is increased in conditions of poor lubrication, which can also lead to high friction moments that may cause corrosion at the taper interface. This suggests that wear of the bearing and increased corrosion of the taper interface should occur simultaneously, which was investigated in this study. METHODS Forty-three large-diameter cobalt-chromium bearings of the same design, implanted with a titanium stem using a titanium adapter, were retrieved at revision at a single center. Retrievals were grouped according to visual inspection of the female taper surface of the adapter into slight and severe corrosion groups. Volume change of bearing and taper surfaces was assessed using a coordinate measurement machine. Serum ion concentrations were determined for forty-three patients, whereas tissue metal concentration was measured for twelve patients. RESULTS Severe taper corrosion was observed in 30% of the retrievals. Corrosion was observed either as material deposition or wear. The overall bearing wear rate was significantly higher in the group with severe taper corrosion than in the group with slight corrosion (7.2 ± 9.0 mm(3)/yr versus 3.1 ± 6.8 mm(3)/yr, respectively; p = 0.023) as were the serum cobalt (40.5 ± 44.9 μg/L versus 15.2 ± 23.9 μg/L, respectively; p = 0.024) and chromium ion concentrations (32.7 ± 32.7 μg/L versus 12.0 ± 15.1 μg/L, respectively; p = 0.019). Serum metal ion concentrations were more consistent indicators of wear than tissue metal concentrations. CONCLUSIONS The increased bearing articulation wear and serum metal ion concentrations in cases with taper interface corrosion support the hypothesis that increased friction in the joint articulation is one of the factors responsible for simultaneous articulation and taper damage. However, independent taper or bearing damage was also observed, suggesting that other factors are involved in the process.

Quantification of the Contact Area at the Head-Stem Taper Interface of Modular Hip Prostheses

Corrosion of modular taper junctions of hip implants may be associated with clinical failure. Taper design parameters, as well as the intraoperatively applied assembly forces, have been proposed to affect corrosion. Fretting corrosion is related to relative interface shear motion and fluid ingress, which may vary with contact force and area. It was hypothesised in this study that assembly forces modify the extent and distribution of the surface contact area at the taper interface between a cobalt chrome head and titanium stem taper with a standard threaded surface profile. Local abrasion of a thin gold coating applied to the stem taper prior to assembly was used to determine the contact area after disassembly. Profilometry was then used to assess permanent deformation of the stem taper surface profile. With increasing assembly force (500 N, 2000 N, 4000 N and 8000 N) the number of stem taper surface profile ridges in contact with the head taper was found to increase (9.2±9.3%, 65.4±10.8%, 92.8±6.0% and 100%) and the overall taper area in contact was also found to increase (0.6±0.7%, 5.5±1.0%, 9.9±1.1% and 16.1±0.9%). Contact was inconsistently distributed over the length of the taper. An increase in plastic radial deformation of the surface ridges (-0.05±0.14 μm, 0.1±0.14 μm, 0.21±0.22 μm and 0.96±0.25 μm) was also observed with increasing assembly force. The limited contact of the taper surface ridges at lower assembly forces may influence corrosion rates, suggesting that the magnitude of the assembly force may affect clinical outcome. The method presented provides a simple and practical assessment of the contact area at the taper interface.

Basic principles and uniform terminology for the head-neck junction in hip replacement

Recent problems with large head metal on metal hip replacements have spiked renewed interest in the head-neck junction. A thorough knowledge of the principles of the locking mechanism, the assembly technique and affecting factors on the strength of this junction is needed. Currently a confusing variability in terms is used to describe this junction. This overcomplicates an already complex issue. The purpose of this literature review is to collect and list the different terms used and to propose a uniform terminology. Two authors independently searched the electronic databases of PubMed, CINAHL and MEDLINE with specific key words and combinations according to the PRISMA guidelines. The initial search yielded a total of 518 articles with ultimately 53 articles included in the present analysis. No consensus for a uniform term for the 2 sides of the head-stem junction was found. Since there is already pronounced variability in taper designs between different manufacturers (even so similarly named, e.g. “12/14”), a uniform terminology could be the first step to simplify the situation. “Male” and “female taper” is proposed as the appropriate terminology for the stem and head junction in hip replacement, respectively. The importance of the assembly technique understanding the principles of the locking mechanism is emphasised.

The influence of stem taper re-use upon the failure load of ceramic heads

Ceramic components are frequently used in total hip replacement due to their good tribological properties. In revision of broken ceramic heads clinical uncertainties arise, whether the taper of the stem can be re-used with a new ceramic head, especially if the stem is well fixed. Ceramic is a brittle material. Even small damage on the male stem taper can lead to stress concentrations causing premature failure of a new ceramic head. As a consequence, manufactures strictly prohibit stem taper re-use for ceramic heads. The aim of this study was to determine the fracture strength of ceramic heads assembled to re-used male stem tapers, which were subjected to prior head fracture. Five 12/14 Ti6Al4V male tapers and 15 Al2O3 ceramic heads (BIOLOX forte(®); ∅ 28 mm, L) were used for three consecutive fracture tests. Before and after every fracture test, all components were inspected visually and the surface geometry was analyzed. Mean fracture force (52.5 kN) did not decrease with the number of taper re-uses (p ≥ 0.77) but the range increased significantly from initially 4.1 kN to 31.8 kN for the first and 52.6 kN for the second re-use due to some components failing at very low loads. Visual inspection was not sufficient to predict the reduced failure loads. Ceramic heads should therefore not be put on used male tapers without metal adapter sleeves.

The influence of stem design on critical squeaking friction with ceramic bearings

Ceramic‐on‐ceramic hip joints have been reported to squeak, a phenomenon that may occur in compromised lubrication conditions. One factor related to the incidence of in vivo squeaking is the stem design. However, it has not yet been possible to relate stem design to squeaking in deteriorating lubrication conditions. The purpose of this study was to determine critical friction factors for different stem designs. A hip simulator was used to measure the friction factor of a ceramic bearing with different stem designs and gradually deteriorating lubrication represented by evaporation of a volatile fluid lubricant. The critical squeaking friction factor was measured at the onset of squeaking for each stem. Critical friction was higher for the long cobalt chrome (0.32 ± 0.02) and short titanium stems (0.39 ± 0.02) in comparison with a long titanium stem (0.29 ± 0.02). The onset of squeaking occurred at a friction factor lower than that measured for dry conditions, in which squeaking is usually investigated experimentally. The results suggest that shorter or heavier stems might limit the possibility of squeaking as lubrication deteriorates. The method developed can be used to investigate the influence of design parameters on squeaking probability.

Clinical and Wear Analyses of 9 Large Metal-on-Metal Total Hip Prostheses.

Background Metal-on-Metal (MoM) total hip arthroplasties (THA) are associated with pseudotumor formation and high revision rates. This prospective study analysed the clinical and wear analyses of 9 large Metal-on-Metal (MoM) total hip arthroplasties (THA) to understand the underlying mechanisms of failure. The MoM bearings were revised for multiple reasons; the main reason was pseudotumor formation. Materials and Methods From 2006 till 2010 the Reinier de Graaf Hospital implanted 160 large head M2a-Magnum™ (Biomet Inc. Warsaw, Indiana, USA) THAs in 150 patients. The first year, 9 bearings were revised and analysed at the Biomechanics Section, Hamburg University of Technology, Germany. We performed clinical (Harris Hip Score, radiographic analysis, blood cobalt and chromium) and wear analysis (implant, tissue and fluid) of the 9 bearings. Since this study did not fall under the scope of the Medical Research Involving Human Subjects Act in The Netherlands, no ethical approval was necessary. In this prospective study all patient details were anonymized by the corresponding author, all other authors were blinded during the research and wear analyses. Patients with bilateral MoM implants were excluded. Results The 9 bearings had a median (IQR) survival of 41.0 (25) months in situ. From these bearings, three showed no noticeable wear. The median (IQR) head wear volume was 3.2 (3.6) mm3 and maximum wear depth 0.02 (0.02) mm. For the cup the median (IQR) wear volume was 0.23 (0.3) mm3 with a maximum wear depth of 0.03 (0.05) mm. Conclusion An early identification of parameters related to failure of the MoM THA, such as pain, decreased range of motion, radiographic changes and high levels of blood cobalt and chromium is of great importance for patient’s quality of life. Especially now patients and surgeons face the long term effects of all these bearings still in situ. This study reports the clinical and wear analyses of 9 MoM THA. In the majority of this group the reason for revision was pseudotumor formation. Most bearings showed signs of wear, however with a great diversity in clinical analysis, in inclination angle, serum cobalt and chromium levels as well as wear analysis. For a better understanding of the underlying mechanisms related with failure, more wear analyses of revised MoM bearings are necessary as well as a frequent follow-up of the patients with a MoM bearing.

Pseudotumor After Bilateral Ceramic-on-Metal Total Hip Arthroplasty

Multiple studies have been published on high revision rates for metal-on-metal (MoM) total hip arthroplasty as a result of early failures and pseudotumor formation1-4. The use of MoM articulations has decreased dramatically, and other hard-on-hard bearings have been promoted. The pathogenesis of pseudotumor formation is unknown, although this adverse local tissue reaction has demonstrated histologic features thought to reflect a hypersensitivity response (metallosis) to cobalt and/or chromium particles1,5-8. High serum levels of these metals are positively correlated with the angle of inclination of the acetabular component, presumably due to the resultant edge loading and high wear9-12. We report a case of massive pseudotumor formation in a patient who had undergone bilateral ceramic-on-metal (CoM) total hip arthroplasty. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. In February 2009, a seventy-one-year-old woman had undergone bilateral cementless total hip arthroplasty with CoM articulation via an anterior supine intermuscular approach at another facility. A modular uncemented porous-coated cup with a cobalt-chromium (CoCr) liner and a 36-mm Biolox delta ceramic head (Biomet, Warsaw, Indiana) were used. Postoperatively, two dislocations of the right hip had occurred, one in November 2010 and one in October 2011. In December 2011, the patient visited the outpatient clinic of our hospital with pain in the right groin and audible crepitations during movement of the right hip. The patient had a body mass index of 26 kg/m2. Examination of the right hip showed flexion of 110°, external rotation of 40°, and internal rotation of 30°. Clear crepitations were audible during flexion and extension; no mass was palpable. An acetabular anteversion angle of 38° and an inclination angle of 57° were estimated from the anteroposterior radiograph …

Severe Wear and Pseudotumor Formation Due to Taper Mismatch in a Total Hip Arthroplasty

Case: We describe the case of a seventy-six-year-old woman who had undergone bilateral total hip arthroplasty with Zweymüller-Metasul prostheses in 1996. After a fall sixteen years after the index procedures, radiographs suggested a taper fracture of the left total hip arthroplasty. However, revision surgery showed pseudotumor formation, with no evidence of taper fracture. Analysis of the prosthesis showed massive wear of the male stem taper caused by a mismatch between the stem taper and the head taper. Conclusion: This case vividly demonstrates how taper size mismatch can cause dramatic metal wear and increased release of metal ions, resulting in pseudotumor formation.

Wear of a Composite Ceramic Head Caused by Liner Fracture

Third-generation composite ceramics (eg, Delta; DePuy Orthopaedics, Warsaw, Indiana; Ceramtec, Plochingen, Germany) have greatly improved material characteristics compared with second-generation products. This case report presents a patient after total hip arthroplasty with a fractured ceramic liner and a heavily worn ceramic head (both third-generation ceramics) retrieved 9 months after surgery. The patient showed no symptoms in the involved hip but presented to the hospital because of other symptoms. The failure was caused by a tilted liner that was overlooked after surgery and fractured consecutively. Rim chipping and splitting were the 2 fracture modes observed for the liner. The head did not fracture completely because of its high strength but became roughened by the ceramic fragments, causing major wear of the metal back of the cup. The phase transformation of the zirconium grains from tetragonal to monoclinic in the aluminum oxide matrix was shown by radiographic diffraction analysis in the heavily worn areas of the head. This transformation increases the fracture strength of the head. Metal debris caused by a roughened ceramic head without fracture is an unreported phenomenon for third-generation ceramic bearings in hip arthroplasty. This case shows that proper impaction of the ceramic liner into the metal shell to prevent later tiling during reduction is as important as correct component positioning. If a tilted ceramic liner is observed postoperatively, the position must be corrected immediately to prevent the major consequences observed in this patient.