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Keun Seon J, Anwar Ayob K, Giun Noh M, Yeol Yang H. Peculiar reaction of oxidized zirconium from a total knee arthroplasty prosthesis: A case report. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2024; 58:68-72. [PMID: 38525513 PMCID: PMC11059476 DOI: 10.5152/j.aott.2024.23115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 12/05/2023] [Indexed: 03/26/2024]
Abstract
Oxidized zirconium (OxiniumTM) prostheses, made up of a metallic alloy of zirconium with a ceramic surface formed by oxidizing the outer layer, were developed as an alternative bearing surface to reduce polyethylene wear and decrease failure of total knee arthroplasty (TKA). We report a unique catastrophic failure of an Oxinium TKA with consequent accelerated wear and severe metallosis. Intraoperatively, we observed extensive wear grooving of the femoral component with exposure of the underlying silver layers and the complete wear of polyethylene on the medial side. Metallic debris had a peculiar arthrogram appearance, noted within the cut surface of the femur and tibia, indicative of the osteolysis that occurred, leading up to the failure of the implants. The histopathologic examination revealed a collection of macrophages with foreign-body reactions and black-pigmented metal-induced wear particles. Oxinium has clear benefits regarding superior wear properties; however, surgeons need to be aware that there is a risk of exposure to the underlying layers that may precede accelerated wear, deformation, and metallosis. Uncovering the deeper layers could result in the appearance of an arthrogram on plain radiographs. Early identification of polyethylene wear and prompt revision is crucial to avoid the rapid progression of subsequent metallosis and catastrophic implant failure, specifically when using oxidized zirconium components for TKA. To the best of our knowledge, this is the first report presenting a detailed histologic analysis to provide insight into the mechanisms of the failed Oxinium components.
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Affiliation(s)
- Jong Keun Seon
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
| | - Khairul Anwar Ayob
- Department of Orthopaedic Surgery, National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), University of Malaya, Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Myung Giun Noh
- Department of Pathology, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
| | - Hong Yeol Yang
- Department of Orthopaedic Surgery, Chonnam National University Medical School and Hwasun Hospital, Hwasun-gun, Republic of Korea
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Kelly B, Manes T, Main C. Bilateral Failure of Oxidized Zirconium Implants in Total Knee Arthroplasty. Arthroplast Today 2023; 21:101144. [PMID: 37214318 PMCID: PMC10192679 DOI: 10.1016/j.artd.2023.101144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 03/21/2023] [Accepted: 04/01/2023] [Indexed: 05/24/2023] Open
Abstract
Oxidized zirconium was first introduced in total hip arthroplasty procedures to merge the strengths of metal and ceramic into one prosthetic. The subsequent adoption of oxidized zirconium (oxinium) for total knee arthroplasty is attributed to the theory of causing less wear on the tibial components compared to the alternative, cobalt chromium. However, the superficial layer of the femoral component is occasionally breached, exposing the softer zirconium substrate. Multiple mechanisms leading to zirconium substrate exposure have been explained, including collateral ligament instability and polyethylene wear. Such a failure may lead to damage to the periprosthetic tissues and often requires a revision procedure. In the current case report, we present a case of bilateral total knee arthroplasty with oxidized zirconium components that resulted in catastrophic failure and subsequent revision with hinged knee prostheses.
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Affiliation(s)
- Brendan Kelly
- Orthopedic Surgery, Des Moines University College of Osteopathic Medicine, Des Moines University, Des Moines, IA, USA
| | - Taylor Manes
- Orthopedic Surgery, Kirksville College of Osteopathic Medicine, A.T. Still University, Kirksville, MO, USA
| | - Chris Main
- Orthopedic Surgery, Midwest Bone and Joint Center, P.C, Macon, MO, USA
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Høl PJ, Hallan G, Furnes O, Fenstad AM, Indrekvam K, Kadar T. Similarly low blood metal ion levels at 10-years follow-up of total hip arthroplasties with Oxinium, CoCrMo, and stainless steel femoral heads. Data from a randomized clinical trial. J Biomed Mater Res B Appl Biomater 2023; 111:821-828. [PMID: 36356214 PMCID: PMC10099800 DOI: 10.1002/jbm.b.35193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 09/21/2022] [Accepted: 10/29/2022] [Indexed: 11/12/2022]
Abstract
The use of inert head materials such as ceramic heads has been proposed as a method of reducing wear and corrosion products from the articulating surfaces in total hip arthroplasty, as well as from the stem-head taper connection. The aim of the present study was to compare the blood metal ion levels in patients with Oxinium and CoCrMo modular femoral heads, as well as monoblock stainless steel Charnley prostheses at 10 years postoperatively. The 150 patients with osteoarthritis of the hip joint included in a randomized clinical trial were grouped according to femoral head material. One group (n = 30) had received the Charnley monoblock stainless steel stem (DePuy, UK). The other patients (n = 120) received a Spectron EF CoCrMo stem with either a 28 mm CoCrMo or Oxinium modular head (Smith & Nephew, USA). After 10 years, 38 patients had withdrawn, 19 deceased, 7 revised due to aseptic loosening and 5 revised due to infection. The 81 patients with median age of 79 years (70-91) were available for whole blood metal ion analysis. The levels of Co, Cr, Ni and Zr in the blood were generally low with all the head materials (medians <0.3 micrograms/L) and no statistical difference between the groups were found (p = .2-.8). Based on the low blood metal ion values in our study groups, no indication of severe trunnion corrosion in patients with CoCrMo heads was observed, neither was there any beneficial reduction in metal ion exposure with the Oxinium femoral heads.
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Affiliation(s)
- Paul Johan Høl
- Biomatlab, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Hallan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway.,The Coastal Hospital at Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kari Indrekvam
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,The Coastal Hospital at Hagevik, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Thomas Kadar
- Physical Medicine and Rehabilitation, Clinic of Habilitation and Rehabilitation, Haukeland University Hospital, Bergen, Norway
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Manescu (Paltanea) V, Antoniac I, Antoniac A, Paltanea G, Miculescu M, Bita AI, Laptoiu S, Niculescu M, Stere A, Paun C, Cristea MB. Failure Analysis of Ultra-High Molecular Weight Polyethylene Tibial Insert in Total Knee Arthroplasty. MATERIALS (BASEL, SWITZERLAND) 2022; 15:7102. [PMID: 36295170 PMCID: PMC9605650 DOI: 10.3390/ma15207102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
Knee osteoarthritis is treated based on total knee arthroplasty (TKA) interventions. The most frequent failure cause identified in surgical practice is due to wear and oxidation processes of the prothesis' tibial insert. This component is usually manufactured from ultra-high molecular weight polyethylene (UHMWPE). To estimate the clinical complications related to a specific prosthesis design, we investigated four UHMWPE tibial inserts retrieved from patients from Clinical Hospital Colentina, Bucharest, Romania. For the initial analysis of the polyethylene degradation modes, macrophotography was chosen. A light stereomicroscope was used to estimate the structural performance and the implant surface degradation. Scanning electron microscopy confirmed the optical results and fulfilled the computation of the Hood index. The oxidation process in UHMWPE was analyzed based on Fourier-transform infrared spectroscopy (FTIR). The crystallinity degree and the oxidation index were computed in good agreement with the existing standards. Mechanical characterization was conducted based on the small punch test. The elastic modulus, initial peak load, ultimate load, and ultimate displacement were estimated. Based on the aforementioned experimental tests, a variation between 9 and 32 was found in the case of the Hood score. The oxidation index has a value of 1.33 for the reference sample and a maximum of 9.78 for a retrieved sample.
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Affiliation(s)
- Veronica Manescu (Paltanea)
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Iulian Antoniac
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
- Academy of Romanian Scientists, 54 Splaiul Independentei, 050094 Bucharest, Romania
| | - Aurora Antoniac
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Gheorghe Paltanea
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Marian Miculescu
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Ana-Iulia Bita
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Stefan Laptoiu
- Faculty of Material Science and Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
| | - Marius Niculescu
- Faculty of Medicine, Titu Maiorescu University, 67A Gheorghe Petrascu Street, 031593 Bucharest, Romania
- Department of Orthopedics and Trauma I, Colentina Clinical Hospital, 19-21 Soseaua Stefan cel Mare, 020125 Bucharest, Romania
| | - Alexandru Stere
- Medical Ortovit Ltd., 8 Miron Costin Street, 011098 Bucharest, Romania
| | - Costel Paun
- Faculty of Electrical Engineering, University Politehnica of Bucharest, 313 Splaiul Independentei, District 6, 060042 Bucharest, Romania
- National Institute for Research and Development in Microtechnologies IMT-Bucharest, 126A Erou Iancu Nicolae Street, 077190 Bucharest, Romania
| | - Mihai Bogdan Cristea
- Department of Morphological Sciences, Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania
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Frye BM, Laughery KR, Klein AE. The Oxinium Arthrogram: A Sign of Oxidized Zirconium Implant Failure. Arthroplast Today 2021; 8:103-109. [PMID: 33732834 PMCID: PMC7943965 DOI: 10.1016/j.artd.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/02/2021] [Accepted: 02/06/2021] [Indexed: 01/08/2023] Open
Abstract
Oxinium implants are composed of a zirconium alloy with a hard ceramic surface formed by oxidization of the outer layer. This material has been shown to be an effective bearing surface for total joint arthroplasty and an alternative material for use in patients with metal hypersensitivity. Reports exist of metallosis due to unintended wear of Oxinium components from multiple mechanisms including polyethylene liner dissociation and joint instability. This metallosis creates a distinct appearance on radiographic imaging similar to that of an arthrogram. We report 2 cases of metallosis and describe the characteristic radiographic appearance of failed oxidized zirconium implants.
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Affiliation(s)
- Benjamin M. Frye
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Kelsey R. Laughery
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
| | - Adam E. Klein
- Department of Orthopaedics, West Virginia University, Morgantown, WV, USA
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