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López RE, Pelayo de Tomás JM, Morales Suárez Varela M, Rodrigo Pérez JL. Evolution of chromium and cobalt serum levels after the use of a modular neck stem in primary total hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:26-34. [PMID: 37270057 DOI: 10.1016/j.recot.2023.05.013] [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: 02/06/2023] [Revised: 03/23/2023] [Accepted: 05/29/2023] [Indexed: 06/05/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Modular neck primary stems were introduced with the theoretical advantage of restoring the hip anatomy more precisely. However, the presence of a second junction has been associated with increased corrosion and release of metal debris. The objective of our study is to quantify of chromium and cobalt serum values, and to analyze their temporal evolution during five years. MATERIAL AND METHODS We present a prospective series of 61 patients who underwent primary total hip arthroplasty by implantation of the HMAX-M® stem (Limacorporate, San Daniele, Italy). Serum chromium and cobalt determinations were performed at six months, two years and five years. RESULTS Our series shows a progressive elevation in chromium levels with a significant difference between chromium values at six months (0.35±0.18) and five years (0.52±0.36), P=.01. Regarding cobalt, a statistically significant elevation is observed between six months and two years and a subsequent stabilization of values between two and five years, with a cobalt mean at six months (1.17±0.8) significantly lower than at two (2.63±1.76) and five years (2.84±2.1), P=.001. CONCLUSION Elevated serum cobalt levels have been observed in patients who underwent modular neck stem implantation. The results obtained in this study have limited the use of stems with a modular neck in our clinical practice.
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Affiliation(s)
- R E López
- Hospital Universitario Doctor Peset, Valencia, España.
| | - J M Pelayo de Tomás
- Hospital Universitario Doctor Peset, Valencia, España; Facultad de Medicina, Universidad de Valencia, Valencia, España
| | - M Morales Suárez Varela
- Unidad de Salud Pública, Higiene y Sanidad Ambiental, Departamento de Medicina Preventiva, Facultad de Farmacia, Universidad de Valencia, Burjassot, Valencia, España; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, España
| | - J L Rodrigo Pérez
- Hospital Universitario Doctor Peset, Valencia, España; Facultad de Medicina, Universidad de Valencia, Valencia, España
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López RE, Pelayo de Tomás JM, Morales Suárez Varela M, Rodrigo Pérez JL. Comparison of chromium and cobalt serum levels between a modular neck stem and its monoblock counterpart in primary total hip arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3403-3409. [PMID: 37140672 DOI: 10.1007/s00590-023-03567-1] [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: 02/06/2023] [Accepted: 04/27/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND The addition of junctions in modular stems implies a greater susceptibility to corrosion. PURPOSE The aim of this study is to compare serum chromium and cobalt levels after using a bimodular stem and its monoblock counterpart in primary total hip arthroplasty. Postoperative clinical scores were also compared. PATIENTS AND METHODS A prospective cohort study between 2012 and 2015 was designed. One arm of the cohort included patients with the cementless modular neck stem H-Max M® and the other with the cementless monoblock stem counterpart H-Max S®. RESULTS No statistically significant difference was found in chromium value between groups (p = 0.621) at two years postoperative. Cobalt value was higher in the modular group (p = < 0.001). No statistically significant difference was found in clinical postoperative scores except for the Harris Hip Score, with better results at six months in modular group (p = 0.007). CONCLUSIONS Higher serum cobalt level in the modular group has limited the use of modular stems in our daily practice. Advantages of modular stem were not found. LEVEL OF EVIDENCE II.
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Affiliation(s)
- R E López
- Doctor Peset University Hospital, Av. Gaspar Aguilar 90, 46017, Valencia, Spain.
| | - J M Pelayo de Tomás
- Doctor Peset University Hospital, Av. Gaspar Aguilar 90, 46017, Valencia, Spain
- School of Medicine, Valencia University, Av. Blasco Ibañez, 15, 46010, Valencia, Spain
| | - M Morales Suárez Varela
- Unit of Public Health, Hygiene and Enviromental Health, Departament of Preventive Medicine and Public Health, Food Science, Toxicology and Legal Medicine, School of Pharmacy, Av. Vicente Andrés Estellés, Burjassot, Valencia, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Av. Monforte De Lemos 3-5, Pavillon 11, Floor 0, 28029, Madrid, Spain
| | - J L Rodrigo Pérez
- Doctor Peset University Hospital, Av. Gaspar Aguilar 90, 46017, Valencia, Spain
- School of Medicine, Valencia University, Av. Blasco Ibañez, 15, 46010, Valencia, Spain
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López R, Pelayo de Tomás J, Morales Suárez Varela M, Rodrigo Pérez J. [Translated article] Comparison of leg length discrepancy correction after the use of a modular neck stem and its monoblock homologue in total primary hip arthroplasty. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:T27-T35. [DOI: 10.1016/j.recot.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 01/18/2022] [Indexed: 11/29/2022] Open
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López R, Pelayo de Tomás J, Morales Suárez Varela M, Rodrigo Pérez J. Comparación de la corrección de la discrepancia de longitud de miembros tras el empleo de un vástago con cuello modular y su homólogo monobloque en la artroplastia total de cadera primaria. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:445-453. [DOI: 10.1016/j.recot.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 01/03/2022] [Accepted: 01/18/2022] [Indexed: 12/01/2022] Open
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Herbster M, Berth A, Märtens N, Robra M, Welzel F, Dallmann F, Lohmann CH, Halle T, Bertrand J, Döring J. Intraoperative assembly of anatomical shoulder prosthesis frequently results in malalignment of the modular taper junction. J Orthop Res 2021; 39:2485-2496. [PMID: 33368644 DOI: 10.1002/jor.24975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/08/2020] [Accepted: 12/14/2020] [Indexed: 02/04/2023]
Abstract
Anatomical shoulder arthroplasties (ASA) may fail because of micromotion at the modular taper junction causing wear due to fretting. Sufficient taper strength can reduce micromotion and potential reasons for failure. However, there are no normative standards for a safe assembly process performed intraoperatively by the surgeon. The purpose of this study is to determine the effect of common intraoperative assembly strategies and to identify critical influencing factors on taper stability. ASA with standard and stemless humeral component in combination with concentric Al2 O3 heads and eccentric CoCr28Mo6 alloyed humeral heads were tested. Taper angles and surface roughness were determined. Force magnitudes and impact directions were recorded using a sensorized head impactor and a three-dimensional force measuring platform. Subsequently, the axial pull-off forces were measured and taper engagement areas were macroscopically evaluated. In comparison to standard stem tapers that were impacted with an assembly device, stemless tapers were impacted into the artificial bone with significantly lower forces. Taper strength correlates to maximum impact force and was higher for CoCr28Mo6 heads with a mean pull-off ratio of 0.56 than for Al2 O3 heads with 0.37. Interestingly, all tapers showed an asymmetric clamping behavior, due to tilting during impaction. This is caused by the variation of the resulting force vector and further promoted by humeral head eccentricity. Assembly technique markedly influences the force magnitude, impact direction, impulse, and consequently taper strength. The resulting force vector and head eccentricity were identified as potential risk factors for taper malalignment.
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Affiliation(s)
- Maria Herbster
- Institute of Materials and Joining Technology, Otto-von-Guericke University, Magdeburg, Germany
| | - Alexander Berth
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Nicole Märtens
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Marcel Robra
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Florian Welzel
- GFE-Gesellschaft für Fertigungstechnik und Entwicklung Schmalkalden e.V., Schmalkalden, Germany
| | | | - Christoph H Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Thorsten Halle
- Institute of Materials and Joining Technology, Otto-von-Guericke University, Magdeburg, Germany
| | - Jessica Bertrand
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Joachim Döring
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
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Haschke H, Falkenberg A, Morlock MM, Huber G. Do SiNx coatings bear the potential to reduce the risk of micromotion in modular taper junctions? Proc Inst Mech Eng H 2020; 234:897-908. [PMID: 32507037 DOI: 10.1177/0954411920930616] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fretting corrosion is one contributor to the clinical failure of modular joint arthroplasty. It is initiated by micromotion in metal junctions exposed to fluids. Omitting metal-on-metal contacts could help to reduce the corrosion risk. The coating of one metal taper partner with a ceramic-based silicon nitride (SiNx) coating might provide this separation. The aim of the study was to identify whether a SiNx coating of the male taper component influences the micromotion within a taper junction. Hip prosthesis heads made of CoCr29Mo6 (Aesculap) and Ti6Al4V (Peter Brehm) were assembled (2000 N) to SiNx-coated and uncoated stem tapers made of Ti6Al4V and CoCr29Mo6 (2×2×2 combinations, each n = 4). Consecutive sinusoidal loading representing three daily activities was applied. Contactless relative motion in six degrees of freedom was measured using six eddy-current sensors. Micromotion in the junction was determined by compensating for the elastic deformation derived from additional monoblock measurements. After pull-off, the taper surfaces were microscopically inspected. Micromotion magnitude reached up to 8.4 ± 0.8 µm during loading that represented stumbling. Ti6Al4V stems showed significantly higher micromotion than those made of CoCr29Mo6, while taper coating had no influence. Statistical differences in pull-off forces were found for none of the taper junctions. Microscopy revealed CoCr29Mo6 abrasion from the head taper surface if combined with coated stem tapers. Higher micromotion of Ti6Al4V tapers was probably caused by the lower Young's modulus. Even in the contact areas, the coating was not damaged during loading. The mechanics of coated tapers was similar to uncoated prostheses. Thus, the separation of the two metal surfaces with the objective to reduce in vivo corrosion appears to be achievable if the coating is able to withstand in vivo conditions. However, the hard ceramic-based stem coating lead to undesirable debris from the CoCr29Mo6 heads during loading.
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Affiliation(s)
- Henning Haschke
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Hamburg, Germany
| | - Adrian Falkenberg
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Hamburg, Germany
| | - Michael M Morlock
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Hamburg, Germany
| | - Gerd Huber
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Hamburg, Germany
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Grupp TM, Baxmann M, Jansson V, Windhagen H, Heller KD, Morlock MM, Knaebel HP. How to proceed with asymptomatic modular dual taper hip stems in the case of acetabular revision. MATERIALS 2020; 13:ma13051098. [PMID: 32121627 PMCID: PMC7084958 DOI: 10.3390/ma13051098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/13/2020] [Accepted: 02/18/2020] [Indexed: 12/15/2022]
Abstract
How to proceed with a clinically asymptomatic modular Metha® Ti alloy stem with dual taper CoCr neck adapter in case of acetabular revision? To systematically answer this question the status of research and appropriate diagnostic methods in context to clinically symptomatic and asymptomatic dual taper stem-neck couplings has been evaluated based on a systematic literature review. A retrieval analysis of thirteen Metha® modular dual taper CoCr/Ti alloy hip stems has been performed and a rational decision making model as basis for a clinical recommendation was developed. From our observations we propose that in cases of acetabular revision, that for patients with a serum cobalt level of > 4 µg/L and a Co/Cr ratio > 3.6, the revision of the modular dual taper stem may be considered. Prior to acetabular revision surgery a systematic diagnostic evaluation should be executed, using specific tests such as serum metal (Co, Cr) ion analysis, plain antero-posterior and lateral radiographs and cross-sectional imaging modalities (Metal Artefact Reduction Sequence Magnetic Resonance Imaging). For an asymptomatic Metha® dual taper Ti alloy/CoCr stem-neck coupling at the stage of acetabular revision careful clinical decision making according to the proposed model should be followed and overreliance on any single examination should be avoided, considering the complete individual differential diagnosis and patient situation.
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Affiliation(s)
- Thomas M. Grupp
- Aesculap AG Research & Development, 78532 Tuttlingen, Germany;
- Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern Ludwig Maximilians University Munich, 81377 Munich, Germany;
- Correspondence: ; Tel.: +49-7461-95-2667; Fax: +49-7461-95-382667
| | - Marc Baxmann
- Aesculap AG Research & Development, 78532 Tuttlingen, Germany;
| | - Volkmar Jansson
- Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern Ludwig Maximilians University Munich, 81377 Munich, Germany;
| | - Henning Windhagen
- Department of Orthopaedic Surgery, Hannover Medical School, 30625 Hannover, Germany;
| | - Karl-Dieter Heller
- Department of Orthopaedic Surgery, Herzogin-Elisabeth-Hospital, 38124 Braunschweig, Germany;
| | - Michael M. Morlock
- Institute of Biomechanics, TUHH Hamburg University of Technology, 21073 Hamburg, Germany;
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Dickinson EC, Sellenschloh K, Morlock MM. Impact of stem taper damage on the fracture strength of ceramic heads with adapter sleeves. Clin Biomech (Bristol, Avon) 2019; 63:193-200. [PMID: 30913462 DOI: 10.1016/j.clinbiomech.2019.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/25/2019] [Accepted: 03/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Using a new ceramic head with a titanium adapter sleeve offers the possibility of maintaining a well fixed stem when conducting cup revision of a total hip arthroplasty. The aim of this study is to test the impact of stem taper damage on the fracture strength of sleeved ceramic heads. METHODS Pristine zirconia-toughened alumina heads with titanium adapter sleeves (BIOLOX®OPTION System) were tested on damaged Ti-4Al-6V stem tapers in accordance with ISO7206-10. Four distinctive damage types classified as intolerable by the manufacture were investigated, representing various reductions in contact area between the stem taper and sleeve taper as well as damage incurred from previous ceramic head fracture. FINDINGS The largest reduction in fracture strength occurred for a loss of contact for the entire length of the stem taper. Nonetheless, the fracture strength in all investigated cases was several times higher than that defined by the FDA standards. INTERPRETATION The use of a titanium sleeve recreates a uniform contact situation between the ceramic head and the outer sleeve taper in situations of damaged stem tapers. For the investigated damage types a high fracture strength of the ceramic head was maintained. This study supports the clinical use for sleeved ceramic heads in instances of greater damages of stem tapers than previously defined in order to spare patients from stem removal.
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Affiliation(s)
- Emilie C Dickinson
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestrasse 15, 21073 Hamburg, Germany.
| | - Kay Sellenschloh
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestrasse 15, 21073 Hamburg, Germany.
| | - Michael M Morlock
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestrasse 15, 21073 Hamburg, Germany.
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Eliaz N. Corrosion of Metallic Biomaterials: A Review. MATERIALS (BASEL, SWITZERLAND) 2019; 12:E407. [PMID: 30696087 PMCID: PMC6384782 DOI: 10.3390/ma12030407] [Citation(s) in RCA: 235] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/25/2019] [Accepted: 01/26/2019] [Indexed: 12/15/2022]
Abstract
Metallic biomaterials are used in medical devices in humans more than any other family of materials. The corrosion resistance of an implant material affects its functionality and durability and is a prime factor governing biocompatibility. The fundamental paradigm of metallic biomaterials, except biodegradable metals, has been "the more corrosion resistant, the more biocompatible." The body environment is harsh and raises several challenges with respect to corrosion control. In this invited review paper, the body environment is analysed in detail and the possible effects of the corrosion of different biomaterials on biocompatibility are discussed. Then, the kinetics of corrosion, passivity, its breakdown and regeneration in vivo are conferred. Next, the mostly used metallic biomaterials and their corrosion performance are reviewed. These biomaterials include stainless steels, cobalt-chromium alloys, titanium and its alloys, Nitinol shape memory alloy, dental amalgams, gold, metallic glasses and biodegradable metals. Then, the principles of implant failure, retrieval and failure analysis are highlighted, followed by description of the most common corrosion processes in vivo. Finally, approaches to control the corrosion of metallic biomaterials are highlighted.
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Affiliation(s)
- Noam Eliaz
- Department of Materials Science and Engineering, Tel-Aviv University, Ramat Aviv 6997801, Israel.
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Falkenberg A, Drummen P, Morlock MM, Huber G. Determination of local micromotion at the stem-neck taper junction of a bi-modular total hip prosthesis design. Med Eng Phys 2019; 65:31-38. [PMID: 30679024 DOI: 10.1016/j.medengphy.2019.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 11/26/2022]
Abstract
High rates of clinical complications with bi-modular hip prostheses are attributed to failure of the stem-neck taper junction. Taper wear analyses have shown extensive material loss as a result of corrosion, potentially initiated by micromotion. The purpose of the study was to determine the amount of micromotion at this junction for different loading, assembly and material conditions. Micromotion between the neck adapter (CoCr29Mo6-alloy) and the stem (TiMo12Zr6Fe2-alloy; both Rejuvenate, Stryker) within the taper junction of a bi-modular hip stem were determined by image matching analysis of consecutively recorded images through windows in the stem component. A finite element model was used to determine the micromotion in the taper regions outside the windows and validated with the measured micromotion. With the model, the influence of the load amplitude, assembly force and component materials were then investigated. Determined micromotion (14-79 µm) by far exceeded critical values (5 µm) associated with the onset of fretting corrosion. Increasing assembly forces achieved a significant reduction in micromotion. The numerical model revealed insufficient assembly to cause the neck to perform rocking motions under load, repetitively changing taper contact in combination with gap opening, which facilitates fluid ingress into the junction. Changing the stem material to a stiffer Ti-alloy achieved a reduction of the micromotion of about 30%. This study emphasises the high importance of material selection, assembly force and loading on the susceptibility of bi-modular hip stems to fretting and crevice corrosion. These findings can serve to explain the increased rate of clinically reported problems with this particular prosthesis design.
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Affiliation(s)
- Adrian Falkenberg
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Denickestrasse 15, Hamburg 21073, Germany.
| | - Paul Drummen
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Denickestrasse 15, Hamburg 21073, Germany
| | - Michael M Morlock
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Denickestrasse 15, Hamburg 21073, Germany
| | - Gerd Huber
- Institute of Biomechanics, Hamburg University of Technology (TUHH), Denickestrasse 15, Hamburg 21073, Germany
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Di Laura A, Hothi HS, Henckel J, Kwon YM, Skinner JA, Hart AJ. Retrieval Findings of Recalled Dual-Taper Hips. J Bone Joint Surg Am 2018; 100:1661-1672. [PMID: 30277996 PMCID: PMC6211785 DOI: 10.2106/jbjs.17.00790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The recent high-profile recalls of several dual-taper hip designs pose questions regarding why those designs perform poorly. We aimed to characterize taper damage in 1 recalled design to understand failure mechanisms to inform surgeons on which patients should be considered at risk of revision and when to revise. METHODS High-precision measurement equipment was used to characterize the metal loss from the neck-stem interface of 116 retrieved Rejuvenate femoral stems (Stryker Howmedica Osteonics) revised because of an adverse reaction to metal debris. Head-neck taper surfaces were also investigated, and clinical and laboratory data were examined. RESULTS The neck-stem junction of each implant was moderately to severely corroded and showed a characteristic wear pattern on both male and female taper surfaces. The severity of taper damage was positively correlated with time to revision (coefficient, 0.040 [95% confidence interval (CI), 0.028 to 0.051]; p < 0.0001) and with serum cobalt concentration (coefficient, 0.02 [95% CI, 0.01 to 0.02]; p < 0.0001) and serum chromium concentration (coefficient, 0.04 [95% CI, 0.009 to 0.070]; p = 0.0142). CONCLUSIONS A forensic examination of the retrieved components that failed secondary to an adverse reaction to metal debris showed, in all cases, visible corrosion. Of the implant and patient factors investigated, we did not identify any predictors of corrosion. The severity of damage was found to increase with time; cobalt was significantly elevated over chromium. CLINICAL RELEVANCE Surgeons should scrupulously follow and consider revision for patients with this implant design to avoid extensive tissue excision. Blood metal ion tests may aid in identifying the mechanisms of taper corrosion.
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Affiliation(s)
- Anna Di Laura
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, United Kingdom,E-mail address for A. Di Laura:
| | - Harry S. Hothi
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Johann Henckel
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Young-Min Kwon
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John A. Skinner
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, United Kingdom
| | - Alister J. Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, United Kingdom
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