Potential for adhesive wear in friction couples of UHMWPE running against oxidized zirconium, titanium nitride coatings, and cobalt-chromium alloys

No clinical difference at mid-term follow-up between TiN-coated versus uncoated cemented mobile-bearing total knee arthroplasty: a matched cohort study

INTRODUCTION

Nitride-based ceramic coating was introduced into surgical implants to improve hardness, reduce abrasion, and decrease the risk of metal-induced adverse reactions, especially for patients with suspected or identified metal hypersensitivity. The study aimed to evaluate the effectiveness and safety of a titanium nitride (TiN) coated prosthesis with a mobile bearing design.

METHODS

This was a retrospective matched-cohort study from a single center, comparing clinical outcomes between patients receiving either a TiN-coated versus an uncoated cobalt-chromium-molybdenum (CoCrMo) prostheses for primary total knee replacement. Seventeen patients received the TiN prosthesis between 2015 and 2019. These were matched 1:2 with patients receiving uncoated mobile-bearing knee prostheses with the same design manufacturer.

RESULTS

Fourteen patients in the TiN group had complete 5-year follow-up data and were compared with 34 patients from the CoCrMo group. The Knee Society Score was 170.6 ± 28.0 (Function subscore 83.7 ± 17.5 and Knee subscore 86.9 ± 13.8) in the TiN group and 180.7 ± 49.4 (Function subscore 87.5 ± 14.3 and Knee subscore 93.2 ± 9.6) in CoCrMo group, with no statistically significant difference (p = 0.19). One patient underwent a revision for instability requiring the removal of the implant in the TiN group and none in the CoCrMo group. The survival rates were 92.9% (CI95% 77.3-100.0) and 100.0% in the TiN group and CoCrMo group respectively (p = 1.0).

DISCUSSION

TiN-coated TKA with mobile bearing resulted in satisfactory clinical outcomes, and a low revision rate, and there was no complication related to the coated implant. The use of TiN-coated prostheses in case of confirmed or suspected metal allergy provides satisfactory short-term clinic outcomes.

Plasma Electrolytic Oxidation (PEO) Layers from Silicate/Phosphate Baths on Ti-6Al-4V for Biomedical Components: Influence of Deposition Conditions and Surface Finishing on Dry Sliding Behaviour

Plasma Electrolytic Oxidation (PEO) layers were produced on Ti-6Al-4V in different conditions, so as to assess the influence of layer structure, current mode, duty cycle and surface finishing on microstructural features and tribological behaviour. In DC regime, the double-layer structure (silicate bath followed by phosphate bath) beneficially affected wear resistance. In unipolar pulsed DC (phosphate bath), the wear resistance of single layers improved with increasing duty cycle, due to improved microstructure and adhesion: high duty cycle single layers can be considered an alternative to double-layer deposition. Surface finishing by abrasive blasting with spheroidal glass beads leads to surface roughness decrease and hence to decreased friction and improved wear resistance. The best-performing PEO layers showed promising results in the comparison with reference materials such as CoCrMo (both uncoated and (Ti,Nb)N PVD-coated) and PVD-coated Ti-6Al-4V up to 30 N normal load.

Allergy in total knee replacement surgery: Is it a real problem?

Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.

Evaluation of 1031 primary titanium nitride coated mobile bearing total knee arthroplasties in an orthopedic clinic

AIM

To evaluate the influence of the titanium nitride (TiN) coating on the results of a total knee arthroplasty (TKA).

METHODS

A total of 910 patients (338 men; 572 woman), with a mean age of 65 (range 36-94) undergoing 1031 primary TKAs were assessed. Clinical evaluation and patient-reported outcomes were gathered one year after surgery. The questionnaires included the Knee injury and Osteoarthritis Outcome Score (KOOS)-Dutch version, Visual Analogue Scale (VAS) pain scores in rest and during active knee movement, VAS-satisfaction scores, and EQ-5D-3L health scores. This was aimed to assess the overall knee function and patient satisfaction, and to enable us to make a gross comparison to other TKAs.

RESULTS

At a mean follow-up of 46 mo (range 1-92) the overall implant survival was 97.7% and 95.1% for any operative reason related to the implant. Twenty-three knees (2.2%) required revision surgery. Arthrofibrosis was the most common indication for a re-operation. The clinical evaluation and patient-reported outcomes revealed good to excellent patient satisfaction and function of the arthroplasty. The median postoperative VAS-pain scores on a scale of 0-100, at one year after surgery were 1 in rest and 2 during movement.

CONCLUSION

The TiN coated, mobile bearing TKA results are excellent and similar to those of other widely used TKA designs. Residual pain of the knee remains a concern and the TiN coating in combination with the mobile bearing does not seem to be the simple solution to this problem. Future research will have to show that the coating gives a better survival than the cobalt chrome version.

Clinical outcomes of ceramicized ball heads in total hip replacement bearings: a literature review

BACKGROUND

Metallic ball heads for total hip replacement (THR) bearings with ceramicized surfaces were introduced in orthopedics during the second half of the 1980s, with the aim of decreasing the wear of polyethylene cups.

METHODS

An analysis was made of the literature regarding outcomes for metallic ball heads with ceramicized surfaces now in clinical use (TiN, TiNbN, ZrN, monoclinic ZrO2), as well as carbon coatings (pyrolytic carbon, diamond-like carbon) and silicon nitride as coatings in ball heads for THR bearings.

RESULTS

Notwithstanding the diffusion of ceramicized ball heads in THRs, there are few reports about their clinical outcomes in hip arthroplasty. In addition, several clinical studies and some registry data are putting under scrutiny the clinical advantages of ceramicized ball heads over cobalt chrome (CoCr) alloy and ceramic ball heads.

CONCLUSIONS

The wear of THR bearings with ceramicized ball heads looks like it depends more on the behavior of the polyethylene cups than on the treatment of the ball head surface. The risk of coating damage and of its consequences has to be taken into account in selecting this type of bearing.

Mid-term survivorship and clinical outcomes of cobalt-chrome and oxidized zirconium on highly crosslinked polyethylene

BACKGROUND

The choice of bearing articulation for total hip arthroplasty in younger patients is amenable to debate. We compared mid-term patient-reported outcomes and survivorship across 2 different bearing articulations in a young patient cohort.

METHODS

We reviewed patients with cobalt-chrome or oxidized zirconium on highly crosslinked polyethylene who were followed prospectively between 2004 and 2012. Kaplan-Meier analysis was used to determine predicted cumulative survivorship at 5 years with all-cause and aseptic revisions as the outcome. We compared patient-reported outcomes, including the Harris hip score (HHS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and Short-form 12 (SF-12) scores.

RESULTS

A total of 622 patients were followed during the study period. Mean follow-up was 8.2 (range 2.0-10.6) years for cobalt-chrome and 7.8 (range 2.1-10.7) years for oxidized zirconium. Mean age was 54.9 ± 10.6 years for cobalt-chrome and 54.8 ± 10.7 years for oxidized zirconium. Implant survivorship was 96.0% (95% confidence interval [CI] 94.9%-97.1%) for cobalt-chrome and 98.7% (95% CI 98.0%-99.4%) for oxidized zirconium on highly crosslinked polyethylene for all-cause revisions, and 97.2% (95% CI 96.2%-98.2%) for cobalt-chrome and 99.0% (95% CI 98.4%-99.6%) for oxidized zirconium for aseptic revisions. An age-, sex- and diagnosis-matched comparison of the HHS, WOMAC and SF-12 scores demonstrated no significant changes in clinical outcomes across the groups.

CONCLUSION

Both bearing surface couples demonstrated excellent mid-term survivorship and outcomes in young patient cohorts. Future analyses on wear and costs are warranted to elicit differences between the groups at long-term follow-up.

Titanium-Nitride Coating of Orthopaedic Implants: A Review of the Literature

Surfaces of medical implants can be enhanced with the favorable properties of titanium-nitride (TiN). In a review of English medical literature, the effects of TiN-coating on orthopaedic implant material in preclinical studies were identified and the influence of these effects on the clinical outcome of TiN-coated orthopaedic implants was explored. The TiN-coating has a positive effect on the biocompatibility and tribological properties of implant surfaces; however, there are several reports of third body wear due to delamination, increased ultrahigh molecular weight polyethylene wear, and cohesive failure of the TiN-coating. This might be due to the coating process. The TiN-coating process should be optimized and standardized for titanium alloy articulating surfaces. The clinical benefit of TiN-coating of CoCrMo knee implant surfaces should be further investigated.

Digital volume correlation and micro-CT: An in-vitro technique for measuring full-field interface micromotion around polyethylene implants

Micromotion around implants is commonly measured using displacement-sensor techniques. Due to the limitations of these techniques, an alternative approach (DVC-μCT) using digital volume correlation (DVC) and micro-CT (μCT) was developed in this study. The validation consisted of evaluating DVC-μCT based micromotion against known micromotions (40, 100 and 150 μm) in a simplified experiment. Subsequently, a more clinically realistic experiment in which a glenoid component was implanted into a porcine scapula was carried out and the DVC-μCT measurements during a single load cycle (duration 20 min due to scanning time) was correlated with the manual tracking of micromotion at 12 discrete points across the implant interface. In this same experiment the full-field DVC-μCT micromotion was compared to the full-field micromotion predicted by a parallel finite element analysis (FEA). It was found that DVC-μCT micromotion matched the known micromotion of the simplified experiment (average/peak error=1.4/1.7 μm, regression line slope=0.999) and correlated with the micromotion at the 12 points tracked manually during the realistic experiment (R(2)=0.96). The DVC-μCT full-field micromotion matched the pattern of the full-field FEA predicted micromotion. This study showed that the DVC-μCT technique provides sensible estimates of micromotion. The main advantages of this technique are that it does not damage important parts of the specimen to gain access to the bone-implant interface, and it provides a full-field evaluation of micromotion as opposed to the micromotion at just a few discrete points. In conclusion the DVC-μCT technique provides a useful tool for investigations of micromotion around plastic implants.

No clinical benefit of titanium nitride coating in cementless mobile-bearing total knee arthroplasty

PURPOSE

Titanium nitride (TiN) coating of cobalt-chromium-molybdenum (CoCrMo) implants has shown to improve the biomechanical properties of the implant surface and to reduce adhesive wear in vitro. It is yet unknown whether TiN coating of total knee prosthesis (TKP) affects the postoperative clinical outcome of total knee arthroplasty (TKA).

METHODS

In a double-blind randomized controlled clinical trial, 101 patients received an uncemented mobile-bearing CoCrMo TKP, either TiN coated or uncoated. Primary outcome measure visual analogue scale (VAS) score for pain, and secondary outcome measures Knee Society Score (KSS), revision rate and adverse events, range of motion of the knee as well as knee circumference and knee skin temperature were assessed 6 weeks, 6 months, 1 year and 5 years postoperative. Repeated measures analysis was used to evaluate the postoperative outcome measures over time.

RESULTS

There was no difference between the two groups in VAS score, KSS, revision rate, range of motion of the knee, knee circumference and knee skin temperature. There were no adverse events that could be related to the TiN coating.

CONCLUSIONS

TiN-coated TKP does not influence the postoperative outcome of uncemented mobile-bearing TKA regarding postoperative pain, revision rate, range of motion, swelling and temperature of the knee. Therefore, TiN coating of CoCrMo TKP has no clinical benefit on the outcome of cementless mobile-bearing TKA.

LEVEL OF EVIDENCE

Therapeutic study, Level I.