Impingement contributes to backside wear and screw-metallic shell fretting in modular acetabular cups

Comparison of Different Locking Mechanisms in Total Hip Arthroplasty: Relative Motion between Cup and Inlay

The resulting inflammatory reaction to polyethylene (PE) wear debris, which may result in osteolysis, is still considered to be a main reason for aseptic loosening. In addition to the primary wear in hip joint replacements caused by head-insert articulation, relative motions between the PE liner and the metal cup may cause additional wear. In order to limit this motion, various locking mechanisms were used. We investigated three different locking mechanisms (Aesculap, DePuy, and Zimmer Biomet) to address the resulting relative motion between the acetabular cup and PE liner and the maximum disassembly force. A standardized setting with increasing load levels was used in combination with optically based three-dimensional measurements. In addition the maximum disassembly forces were evaluated according to the ASTM F1820-13 standard. Our data showed significant differences between the groups, with a maximum relative motion at the maximum load level (3.5 kN) of 86.5 ± 32.7 µm. The maximum axial disassembly force was 473.8 ± 94.6 N. The in vitro study showed that various locking mechanisms may influence cup-inlay stability.

Variations in sagittal and coronal stem tilt and their impact on prosthetic impingement in total hip arthroplasty

Optimization of the combined anteversion of cup and stem has been emphasized to avoid prosthetic impingement in total hip arthroplasty (THA). However, no study has focused on the impact of variations in sagittal and coronal stem tilt against the whole femur on prosthetic range of motion. The purposes of the present study were a) to quantify the anatomical variation of sagittal and coronal tilt of the proximal canal axis against the femoral retrocondylar coordinate system, that is variation of sagittal and coronal stem tilt and b) to determine their impact on the zone of impingement-free cup position using computer simulation. Preoperative computed tomography images of 477 femurs from 409 consecutive patients who underwent THA using computed tomography-based computer navigation were stored. Virtual implantation of an anatomical stem was performed on the navigation workstation. The safe zone of the cup position with regard to prosthetic impingement was determined by motion simulation in the range of sagittal and coronal stem tilt of the subjects. The sagittal and coronal stem tilt varied by 10°, which was smaller than the stem anteversion variation. However, there was about 3 times the difference in the impingement-free zone of cup position in the ranges of sagittal and coronal stem tilt. The safe zone was significantly decreased by posterior tilt and valgus tilt of the stem. Range of motion simulation revealed that the variations in sagittal or coronal stem tilt significantly influenced the safe zone of the cup. In conclusion, although the variations in sagittal and coronal stem tilt against the femoral retrocondylar coordinate system were small, their impact on prosthetic impingement was significant.

ARTICULATION AND BACKSIDE WEAR ANALYSIS AFTER LONG-TERM IN VITRO WEAR SIMULATION OF VITAMIN E STABILIZED POLYETHYLENE ACETABULAR LINERS WITH A PRESS-FIT LOCKING MECHANISM

A previous retrieval study analyzed the backside wear of short-term implanted liners against in vitro tested liners of similar life in service and showed comparable results among both groups, with no significant backside wear due to micro-motion.

The purpose — to obtain a picture of the overall wear (articulation and backside surfaces) of 0.1% vitamin e blended polyethylene liners, with a locking mechanism based on a press-fit cone in combination with a rough titanium conical inner surface in the fixation area, under a 20 million cycles hip wear simulation.

Materials and Methods. A semi-quantitative method was used in order to assess the damage on the backside of the liners and a 3d measuring machine to assess the creep and wear at the articulation surface.

Results. The total average backside wear score was 22.00±2.59 from a maximum total score of 147 after 5 million cycles (mc), increased to 31.92±5.57 after 10 mc, but showed no further increment after 15 and 20 mc. The reference liners (subjected only to axial load) showed similar wear scores and modes as the liners under wear simulation (axial load and movement). Small scratches produced during insertion and removal were clearly seen at the rim (fixation) area and no considerable abrasion was observed. The machining marks on the convex surface were always visible. Regarding the articulation surface, a steady state wear rate of 7 µm/year was measured.

Conlusion. These results determined that most of the backside wear produced on the liners occurred during their insertion and removal rather than during their life in service. Moreover, the wear at the articulation surface was similar to that seen in vivo at short- and mid-term on highly cross-linked polyethylene liners with and without vitamin e content.

The effects of presence of a backside screw hole on biotribological behavior of phospholipid polymer-grafted crosslinked polyethylene

One of the important factors in determining the success of joint replacement is the wear performance of polyethylene. Although highly crosslinked polyethylene (CLPE) is presently used, it is still not adequate. We have developed a surface modification technology using poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) in an attempt to improve wear performance. In this study, we evaluated the wear and creep deformation resistances of 3-mm and 6-mm thick PMPC-grafted CLPE disks, set on a metal back-plate, with and without a sham screw hole. The gravimetric wear and volumetric change of the disks were examined using a multidirectional pin-on-disk tester. PMPC grafting decreased the gravimetric wear of CLPE regardless of the presence of a screw hole, and did not affect the volumetric change. The volumetric change in the bearing and backside surfaces of the 3-mm thick disk with a screw hole was much larger than that of those without a screw hole or those of the 6-mm thick disk, which was caused by creep deformation. PMPC grafting on the bearing surface can be a material engineering approach to reduce the wear without changing the creep deformation resistance, and is a promising surface modification technology that can be used to increase the longevity of various artificial joints. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 610-618, 2018.

Backside Wear Analysis of Retrieved Acetabular Liners with a Press-Fit Locking Mechanism in Comparison to Wear Simulation In Vitro

Backside wear due to micromotion and poor conformity between the liner and its titanium alloy shell may contribute to the high rates of retroacetabular osteolysis and consequent aseptic loosening. The purpose of our study was to understand the wear process on the backside of polyethylene liners from two acetabular cup systems, whose locking mechanism is based on a press-fit cone in combination with a rough titanium conical inner surface on the fixation area. A direct comparison between in vitro wear simulator tests (equivalent to 3 years of use) and retrieved liners (average 13.1 months in situ) was done in order to evaluate the backside wear characteristics and behavior of these systems. Similar wear scores between in vitro tested and retrieved liners were observed. The results showed that this locking mechanism did not significantly produce wear marks at the backside of the polyethylene liners due to micromotion. In all the analyzed liners, the most common wear modes observed were small scratches at the cranial fixation zone directly below the rough titanium inner surface of the shell. It was concluded that most of the wear marks were produced during the insertion and removal of the liner, rather than during its time in situ.

A simulator study of adverse wear with metal and cement debris contamination in metal-on-metal hip bearings

Objectives

Third-body wear is believed to be one trigger for adverse results with metal-on-metal (MOM) bearings. Impingement and subluxation may release metal particles from MOM replacements. We therefore challenged MOM bearings with relevant debris types of cobalt–chrome alloy (CoCr), titanium alloy (Ti6Al4V) and polymethylmethacrylate bone cement (PMMA).

Methods

Cement flakes (PMMA), CoCr and Ti6Al4V particles (size range 5 µm to 400 µm) were run in a MOM wear simulation. Debris allotments (5 mg) were inserted at ten intervals during the five million cycle (5 Mc) test.

Results

In a clean test phase (0 Mc to 0.8 Mc), lubricants retained their yellow colour. Addition of metal particles at 0.8 Mc turned lubricants black within the first hour of the test and remained so for the duration, while PMMA particles did not change the colour of the lubricant. Rates of wear with PMMA, CoCr and Ti6Al4V debris averaged 0.3 mm³/Mc, 4.1 mm³/Mc and 6.4 mm³/Mc, respectively.

Conclusions

Metal particles turned simulator lubricants black with rates of wear of MOM bearings an order of magnitude higher than with control PMMA particles. This appeared to model the findings of black, periarticular joint tissues and high CoCr wear in failed MOM replacements. The amount of wear debris produced during a 500 000-cycle interval of gait was 30 to 50 times greater than the weight of triggering particle allotment, indicating that MOM bearings were extremely sensitive to third-body wear.

Cite this article: Bone Joint Res 2015;4:29–37.

Profiling the third-body wear damage produced in CoCr surfaces by bone cement, CoCr, and Ti6Al4V debris: A 10-cycle metal-on-metal simulator test

Particles of bone cement (polymethyl methacrylate), CoCr and Ti6Al4V were compared for their abrasion potential against CoCr substrates. This appears to be the first study utilizing CoCr and Ti6Al4V particulates to abrade CoCr bearings and the first study profiling the morphology of third-body abrasive wear scratches in a hip simulator. The 5 mg debris allotments (median size range 140–300 µm) were added to cups mounted both inverted and anatomically with metal-on-metal (MOM) bearings in a 10-cycle, hip simulator test. Surface abrasion was characterized by roughness indices and scratch profiles. Compared to third-body abrasion with metal debris, polymethyl methacrylate debris had minimal effect on the CoCr surfaces. In all, 10 cycles of abrasion with metal debris demonstrated that roughness indices (Ra, PV) increased approximately 20-fold from the unworn condition. The scratch profiles ranged 20–108 µm wide and 0.5–2.8 µm deep. The scratch aspect ratio (W/PV) averaged 0.03, and this very low ratio indicated that the 140 µm CoCr beads had plastically deformed to create wide but shallow scratches. There was no evidence of transfer of CoCr beads to CoCr bearings. The Ti64 particles produced similar scratch morphology with the same aspect ratio as the CoCr particulates. However, the titanium particulates also showed a unique ability to flatten and adhere to the CoCr, forming smears and islands of contaminating metal on the CoCr bearings. The morphology of scratches and metal transfer produced by these large metal particulates in the simulator appeared identical to those reported on retrieved metal-on-metal bearings.

The local effects of metal corrosion in total hip arthroplasty

Corrosion has long been recognized to occur in total hip arthroplasty, but the local effects of this process have only recently become better understood. This article provides an overview of corrosion at modular junctions, and discusses the various etiologic factors for corrosion and the biologic response to metal debris released from this junction. Algorithms are provided for diagnosis and treatment, in accordance with the best available data.

Acetabular alignment and primary arc of motion for minus, skirtless, and skirted 28-, 32-, 36-, and 40-mm femoral heads

We examined the influence of acetabular cup alignment on the primary arc of motion (PAOM) for minus (-3.5), skirtless (+3.5), and skirted (+10.5) neck lengths with 28-, 32-, 36-, and 40-mm femoral heads. Total hip arthroplasty was performed in a pelvic saw bone model. The acetabulum was positioned in 30°/45°/60° abduction and 0°/15°/30° anteversion, respectively. The PAOM was determined using a digital inclinometer for each of the acetabular positions and 12 femoral heads mentioned above. Best PAOM was found in 45° abduction and 15° to 30° anteversion as well as 60° abduction and 0° anteversion. Combinations of excessive abduction and anteversion as well as horizontalization and retroversion resulted in the worst PAOM. Primary arc of motion is mainly determined by cup alignment even when using larger femoral heads.

Comparison of in vivo and simulator-retrieved metal-on-metal cervical disc replacements

Background

Cervical disc arthroplasty is regarded as a promising treatment for myelopathy and radiculopathy as an alternative to cervical spine fusion. On the basis of 2-year clinical data for the PRESTIGE^® Cervical Disc (Medtronic, Memphis, Tennessee), the Food and Drug Administration recommended conditional approval in September 2006 and final approval in July 2007; however, relatively little is known about its wear and damage modes in vivo. The main objective was to analyze the tribological findings of the PRESTIGE^® Cervical Disc. This study characterized the in vivo wear patterns of retrieved cervical discs and tested the hypothesis that the total disc replacements exhibited similar surface morphology and wear patterns in vitro as in vivo.

Methods

Ten explanted total disc replacements (PRESTIGE^®, PRESTIGE^® I, and PRESTIGE^® II) from 10 patients retrieved after a mean of 1.8 years (range, 0.3–4.1 years) were analyzed. Wear testing included coupled lateral bending ( ±4.7°) and axial rotation ( ±3.8°) with a 49 N axial load for 5 million cycles followed by 10 million cycles of flexion-extension ( ±9.7°) with 148 N. Implant surfaces were characterized by the use of white-light interferometry, scanning electron microscopy, and energy dispersive spectroscopy.

Results

The explants generally exhibited a slightly discolored, elliptic wear region of varying dimension centered in the bearing center, with the long axis oriented in the medial-lateral direction. Abrasive wear was the dominant in vivo wear mechanism, with microscopic scratches generally oriented in the medial-lateral direction. Wear testing resulted in severe abrasive wear in a curvilinear fashion oriented primarily in the medial-lateral direction. All retrievals showed evidence of an abrasive wear mechanism.

Conclusions

This study documented important similarity between the wear mechanisms of components tested in vitro and explanted PRESTIGE^® Cervical Discs; however, the severity of wear was much greater during the in vitro test compared with the retrievals.

Minimal backside surface changes observed in retrieved acetabular liners

Modular polyethylene liners offer versatility in total hip arthroplasty, but the locking mechanism may allow micromotion and backside wear. We evaluated the backside surface of 56 retrieved acetabular liners (mean 5.54 years in vivo, range 0.003-13.1 years) to determine whether damage correlated with liner age in vivo, patient factors associated with higher activity, and polyethylene quality. Half of the liners exhibited minimal damage, half exhibited no damage and none exhibited severe damage. Backside damage significantly correlated only to liner age in vivo. Ten of the 28 liners revised for osteolysis exhibited no backside damage, but the osteolytic cysts were peripheral and did not originate from screw holes. The results suggest that modular polyethylene liners in a porous titanium-coated shell with screw holes can be designed such that clinically significant backside wear is minimal.

Component impingement in total hip arthroplasty: frequency and risk factors. A continuous retrieval analysis series of 416 cup

INTRODUCTION

Impingement is a factor of failure in total hip replacement (THR), causing instability and early wear. Its true frequency is not known; cup-retrieval series reported rates varying from 27 to 84%.

HYPOTHESIS

The hypothesis was that a large continuous series of THR cup removals would help determine the frequency of component impingement.

OBJECTIVES

The hypothesis was tested on a continuous retrospective series of cups removed in a single center, with a secondary objective of identifying risk factors.

MATERIAL AND METHODS

[corrected] Macroscopic examination looked for component impingement signs in 416 cups retrieved by a single operator between 1989 and 2004. Risk factors were investigated by uni- and multivariate analyses in the 311 cases for which there were complete demographic data. In these 311 cases, removal was for aseptic loosening (131 cases), infection (43 cases), instability (56 cases), osteolysis (28 cases) or unexplained pain (48 cases); impingement was explicitly implicated in only five cases (1.6%), always with hard-on-hard bearing components.

RESULTS

Impingement was found in 214 of the 416 cups (51.4%) and was severe (notch>1mm) in 130 (31.3%). In the subpopulation of 311 cups, impingement was found in 184 cases (59.2%) and was severe in 109 (35%). Neither duration of implant use nor cup diameter or frontal orientation emerged as risk factors. On univariate analysis, impingement was more frequently associated with revision for instability, young patient age at THR, global hip range of motion >200° or use of an extended femoral head flange (or of an elevated antidislocation rim liner), and was more severe in case of head/neck ratio<2. On multivariate analysis, only use of an extended head flange (RR 3.2) and revision for instability (RR 4.2) remained as independent risk factors for impingement.

DISCUSSION

Component impingement is frequently observed in cups after removal, but is rarely found as a direct indication for revision, except in case of hard-on-hard friction couples (polyethylene being the most impingement-tolerant material). Systematic use of extended head flanges and elevated antidislocation rims is not to be recommended, especially in case of excessive ROM. A good head/neck ratio should be sought, notably by increasing the head diameter in less impingement-tolerant hard-on-hard friction couples. Although not identified as a risk factor in the present study, implant orientation should be checked; computer-assisted surgery can be useful in this regard, for adaptation to the patient's individual range-of-motion cone.

Retrieved highly crosslinked UHMWPE acetabular liners have similar wear damage as conventional UHMWPE

BACKGROUND

Highly crosslinked UHMWPE is associated with increased wear resistance in hip simulator and clinical studies. Laboratory and case studies, however, have described rim fracture in crosslinked acetabular liners. Controversy exists, therefore, on the relative merits of crosslinked liners over conventional liners in terms of wear performance versus resistance to fatigue cracking.

QUESTIONS/PURPOSES

We asked whether crosslinked liners would show less surface damage than conventional liners but would be more susceptible to fatigue damage.

METHODS

We examined 36 conventional UHMWPE and 39 crosslinked UHMWPE retrieved implants with similar patient demographics and identical design for evidence of wear damage, including articular surface damage, impingement, screw-hole creep, and rim cracks.

RESULTS

We observed no difference in wear damage scores for the two liners. Conventional liners more frequently impinged but were more often elevated with smaller head sizes. We observed creep in approximately 70% of both types of liners. Incipient rim cracks were found in five crosslinked liners, and one liner had a rim fracture. Only one conventional liner had an incipient rim crack.

CONCLUSIONS

Contrary to our expectation, damage was similar between crosslinked and conventional UHMWPE liners. Moreover, the 15% occurrence (six of 39) of incipient or complete fractures in crosslinked liners as compared with a 3% occurrence (one of 36) in conventional liners may have implications for the long-term performance of crosslinked liners. Longer-term studies will be necessary to establish the fate of rim cracks and thus the overall clinical fatigue performance of crosslinked liners.

Wear pattern observations from TDR retrievals using autoregistration of voxel data

Because of their unique geometry, characterization of wear damage in total disc replacement (TDR) is difficult. In the article, we developed and validated an automated damage calculation technique for explanted TDR components. Eight polyethylene cores implanted from 4.6 to 16.0 years were using cone-beam microCT imaging (SCANCO Medical, Switzerland). The nominal uniform voxel size for the implant under investigation was 18 mum, however with a smaller sample size increased resolutions (10-microm nominal voxel size) could be achieved using the same microCT imaging hardware. Nominal surface data for both sizes of TDR components we examined were obtained from manufacturer's drawings (Link, Germany) and converted to highly discretized triangular meshes. The damage calculation technique utilized an initial alignment phase, followed by a pointwise calculation of the linear damage at each 3D surface point. During the alignment phase, a three-dimensional surface of the undamaged component was automatically aligned with volumetric image data from the damaged component. The alignment algorithm maximized the contact area between undamaged portions of the implant and its nominal surface using an iterative optimization technique. Linear damage at each triangle on the nominal surface was computed by moving along the local normal of the surface both inward and outward direction for a distance much less than the size of the implant. For the retrieved components, the maximum damage occurred away from the central axis of the dome close to the rim. Penetrations of up to 0.8 mm were observed in this region. Lower magnitude penetrations were observed near the pole of the dome. In conclusion, we have developed an analytical method to automatically align and measure three-dimensional surface damage with both high resolution and accuracy on implants with complicated, nonparametric, surface geometry and used this technique to analyze eight implants.

High stress conditions do not increase wear of thin highly crosslinked UHMWPE

Introduction of highly crosslinked polyethylene has increased interest in large femoral heads, because thin acetabular liners can be used while maintaining low wear rates and larger heads decrease the incidence of instability. However, crosslinking and subsequent thermal treatments can cause decreased mechanical properties that might obviate the reduced wear under extreme conditions. To examine whether increased contact pressures would adversely affect wear in thin liners, we tested thin and thick highly crosslinked liners (3.8 mm thickness/44-mm head and 7.9 mm thickness/36-mm head, respectively) to 5 million cycles on a hip simulator under near impingement conditions. Conventional polyethylene liners (7.9 mm thickness/36-mm head) served as controls. Large femoral heads with highly crosslinked polyethylene liners as thin as 3.8 mm in thickness do not wear at a higher rate than a thicker liner of the same material, even when subjected to large contact pressures such as occur under near-impingement conditions. Crosslinked polyethylene may allow for liners that are thinner than has been traditionally accepted. This conclusion, however, is based solely on wear test results with idealized cup position, no intentional edge loading, no head subluxation, and no artificial aging. Continued monitoring will be necessary to elucidate the clinical efficacy of these devices.

Retrieval analysis of failed constrained acetabular liners

Despite the large loads placed upon constrained acetabular liners, little is known of their mechanical performance. We analyzed retrieved liners to determine wear and other damage modes and assess associations between types and severity of damage and clinical, radiographic, and implant variables. Outer rim impingement frequency and severity were higher than that for the inner rim. The 20 degrees elevation was most frequently affected by impingement. Inner rim impingement was more frequent with small heads. Outer bearing surface wear scores were higher than inner bearing scores. Liners removed for infection or stem failure had similar damage compared with other groups, demonstrating the complex relationship of impingement and wear with clinical performance. No association was found between liner damage and clinical and radiographic variables.

Retroacetabular osteolytic lesions behind well-fixed prosthetic cups: pilot study of bearings-retaining surgery

Background

Osteolytic lesions are common radiological findings behind acetabular prosthetic cups. If the cup is well-fixed, the management is quite controversial. Although implant exchange is the most reliable procedure, in most cases it could be considered overtreatment, with the potential for further morbidity and bone loss. Liner exchange associated with lesion debridement and grafting represents an alternative option that is less invasive. Here we present our experiences from a small pilot study of minimally invasive osteolysis treatment without bearings exchange in patients with no evidence of liner wear.

Materials and methods

Inclusion criteria: retroacetabular osteolytic lesions in ceramic-on-polyethylene or metal-on-polyethylene cementless total hip arthroplasties, affecting more than 50% of the bone–prosthesis interface on anteroposterior radiography. Exclusion criteria: head penetration into the liner, suspected loosening or infection. Six patients were selected, two asymptomatic and four symptomatic. Only the symptomatic patients accepted the proposed treatment (performed between June 2004 and March 2006). All of them received fluoroscopy-assisted lesion debridement through an iliac cortical window, morcellized bone allograft mixed with autologous platelet-rich plasma, joint exploration for culture and lavage through a small capsular window. Patients were followed up clinically and radiologically at six months, 12 months, and then yearly.

Results

Three patients out of four showed clinical and radiological improvement. One showed radiological improvement only, and recently underwent cup exchange for subsequent loosening. The visual analog scale (VAS) values for pain decreased on average, but not significantly. No major complications occurred. No recurrence was noted at 2.25–4 years’ follow-up.

Conclusions

Although the small series does not allow any absolute conclusions to be drawn, the reported results seem to justify further, wider studies. It is still unclear if osteolytic lesions associated with no wear of the poly liner would progress to implant failure if left untreated. Until the problem is better understood, this procedure might represent an interesting way to prevent potential loosening and severe bone loss in intact sockets.

How do alternative bearing surfaces influence wear behavior?

Metal, ceramic, and polyethylene liners represent contemporary bearing choices for total joint replacement. Each has limitations in terms of design, sensitivity to manufacturing, and surgical placement. With polyethylene, larger femoral heads represent a design restriction and a potential wear issue. One side benefit is that polyethylene does not click, squeak, or create stripe wear. The attraction of hard-on-hard bearings (metal-on-metal, ceramic-on-ceramic) is that their typically ultra-low wear alleviates concerns with large femoral head designs. However, hard-on-hard bearings produce stripe wear due to the effects of the rigid liner edge. Slight subluxation (microseparation) during swing phase of gait can result in stripe wear on the ball and liner rim. In addition, high levels of implant wear with vertically placed cups can be anticipated. Currently, only alumina-on-alumina bearings can claim virtually no biologic risk. Thus, the role of laboratory studies is to isolate relevant aspects of performance by cup design and to predict the risk-benefit ratios in patients requiring total hip replacement.

Impingement with total hip replacement

Impingement is a cause of poor outcomes of prosthetic hip arthroplasty; it can lead to instability, accelerated wear, and unexplained pain. Impingement is influenced by prosthetic design, component position, biomechanical factors, and patient variables. Evidence linking impingement to dislocation and accelerated wear comes from implant retrieval studies. Operative principles that maximize an impingement-free range of motion include correct combined acetabular and femoral anteversion and an optimal head-neck ratio. Operative techniques for preventing impingement include medialization of the cup to avoid component impingement and restoration of hip offset and length to avoid osseous impingement.