Fretting and Corrosion Damage in Taper Adapter Sleeves for Ceramic Heads: A Retrieval Study

Background

During revision surgery with a well-fixed stem, a titanium sleeve can be used in conjunction with a ceramic head to achieve better stress distribution across the taper surface. In vitro testing suggests that corrosion is not a concern in sleeved ceramic heads; however, little is known about the in vivo fretting corrosion of the sleeves. The purpose of this study was to investigate fretting corrosion in sleeved ceramic heads in retrieved total hip arthroplasties.

Influence of Technique With Distally Fixed Modular Stems in Revision Total Hip Arthroplasty

Distally fixed modular implants have seen a recent increase in use, to manage proximal femoral bone loss often encountered during revision total hip arthroplasty (THA). Forty-three distally fixed modular stems implanted at our institution between 1999 and 2006 were clinically and radiographically reviewed. These patients had either a minimum 2-year follow-up (average, 2.4 years; range, 2-5.6 years) or failure (ie, explant or rerevision required). Eleven stems subsided, and 4 were rerevised (n = 4), for a rate of 9.3%. All revised stems were radiographically undersized, emphasizing the importance of the technique. Although being a valuable option in revision THA, these stems are not free of complications. The high rate of subsidence encountered in our early experience shows that there is a learning curve. This complication is preventable by avoiding undersizing.     

Revision Total Hip Arthroplasty for Fractured Ceramic Bearings: A Review of Best Practices for Revision Cases

Background

Total hip arthroplasty revision for a fractured ceramic bearing is rare but offers unique challenges. The purpose of this review was to provide a summary of existing literature on fractured ceramic bearings.

Revision Hip Arthroplasty Using a Modular Revision Hip System in Cases of Severe Bone Loss

We sought to identify outcomes of the Restoration Modular Hip System in cases of severe femoral bone stock deficiency. We performed a retrospective review of 55 revTHAs with a mean follow-up of 32 months (24–60 months). Outcomes included the WOMAC and HHS. Preoperative bone loss was categorized as Paprosky 3A (n = 13), 3B (n = 14), and 4 (n = 17). Periprosthetic fractures were classified as Vancouver B2 (n = 6) and B3 (n = 5). 53 of 55 stems were in situ at time of final review. WOMAC improved from 46 ± 18 to 70 ± 22 and HHS improved from 47 ± 15 to 78 ± 15. Complications were identified in 9 patients, which included dislocation (3), subsidence (2), infection (2), and periprosthetic fracture (2). In cases of significant proximal femoral bone deficiency, this stem demonstrated improvement in clinical outcomes with good results at short-term follow up.     

Risk Factors Associated With Early Complications of Revision Surgery for Head-Neck Taper Corrosion in Metal-on-Polyethylene Total Hip Arthroplasty

Background

Adverse local tissue reactions (ALTRs) due to tribocorrosion of head-neck taper junctions in contemporary metal-on-polyethylene (MoP) total hip arthroplasty (THA) are emerging as an important reason for failure requiring revision surgery. This study aimed at: (1) reporting early complication rates and outcome, and (2) identifying risk factors associated with complications of revision surgery for head-neck taper corrosion in patients with MoP THA.

Constrained Acetabular Components Used in Revision Total Hip Arthroplasty: A Registry Analysis

Background

Constrained acetabular components have a mechanism to lock in the femoral head. They have been developed to control postoperative dislocation, particularly in revision total hip arthroplasty (THA). Although these components may reduce dislocation, there are durability concerns: with reports of locking mechanism failures and loosening. We wanted to determine the outcome of constrained components in controlling dislocation, and if these components had a higher rate of second revision when compared with standard nonconstrained components.

A Distal Fluted,Proximal Modular Femoral Prosthesis in Revision Hip Arthroplasty

Most reports on the use of modular femoral stems during revision surgery have involved short follow-up periods. The authors evaluated the clinical and radiographic performance of 59 patients fitted with a distal fix modular stem. The average follow-up period was 8.2 years. Average Harris hip score was improved from 47 to 87.6. Of 19 patients with trochanteric osteotomy, 4 had a displaced greater trochanter. Re-revision was performed in 5 patients, and 3 of these were for subsidence (of these 3, subsidence was associated with dissociation of the coupling part in 1 and with osteotomy nonunion in other 2 [proximal component only]). Modular distally fixed femoral stems were found to offer intraoperative flexibility, but to suffer from subsidence and intraoperative greater trochanter and metaphyseal femoral fractures.     

Revision Hip Arthroplasty with A Modular Cementless Stem: Mid-Term Follow Up

Despite the increasing volume of revision total hip arthroplasty (THA) being performed in the United States, there are few studies reporting mid-term clinical and radiographic outcomes of modular fully porous-coated femoral stems. We retrospectively studied a consecutive series of patients who underwent revision THA with a modular extensively porous-coated femoral component at a single institution and by a single surgeon. The final study group included 54 hips (52 patients) followed for an average of 84 months. Ten-year survival rates with revision for any reason and revision for femoral loosening as endpoints were 94% and 100%, respectively. No complications regarding the modular junction were encountered. Of the 50 hips with adequate radiographs, all showed proximal ingrowth and 42 (84%) had both proximal and distal ingrowth. The modular, fully porous-coated femoral stem studied demonstrated excellent survivorship and bone ingrowth at mid-term follow up.     

Revision Total Hip Arthroplasty for Ceramic Head Fracture : A Long-Term Follow-Up

The results of revision total hip arthroplasty (THA) for ceramic head fracture have generally been disappointing, largely due to third body wear after incomplete synovectomy. We have followed 8 patients who sustained ceramic head fractures and were subsequently revised to a metal-on-polyethylene articulation. There were no revisions for osteolysis or aseptic loosening at a mean follow-up of 10.5 years. The yearly wear rates of each of 5 of these THAs after revision were compared with 6 matched metal-on-polyethylene THAs; there were no significant differences in wear rates. Greater than 10-year survivorship with a metal-on-polyethylene bearing couple is possible after revision THA for a ceramic head fracture if a complete and thorough synovectomy can be performed. Our technique of synovectomy will be described.     

Outcomes of Isolated Head and Liner Exchange Using Large Femoral Heads and Modern Liners in Revision Total Hip Arthroplasty

BackgroundPrevious reports on the outcomes of isolated head and liner exchange in revision total hip arthroplasty have found high rates of instability after these surgeries. Most reports have studied constructs using ≤28 mm femoral heads. The purpose of this study was to determine if modern techniques with the use of larger head sizes can improve the rate of instability after head and liner exchange.MethodsWe identified 138 hips in 132 patients who underwent isolated head and liner exchange for polyethylene wear/osteolysis (57%), acute infection (27%), metallosis (13%), or other (2%). All patients underwent revision with either 32 (23%), 36 (62%), or 40 (15%) mm diameter heads. Cross-linked polyethylene was used in all revisions. Lipped and/or offset liners were used in 104 (75%) hips. Average follow-up was 3.5 (1.0-9.1) years. Statistical analyses were performed with significance set at P < .05.ResultsRevision-free survivorship for any cause was 94.6% and for aseptic causes was 98.2% at 5 years. 11 (8%) hips experienced a complication with 7 (5%) hips requiring additional revision surgery. After revision, 4 (3%) hips experienced dislocation, 5 (4%) hips experienced infection, and 1 (1%) hip was revised for trunnionosis. No demographic or surgical factors significantly affected outcomes.ConclusionOur study shows that isolated head and liner exchange using large femoral heads and modern liners provides for better stability than previous reports. The most common complication was infection. We did not identify specific patient, surgical, or implant factors that reduced the risk of instability or other complication.     

Incidence of Ceramic Fracture in Contemporary Ceramic-on-Ceramic Total Hip Arthroplasty: A Meta-analysis of Proportions

BackgroundWe performed a proportion meta-analysis of currently available data to determine the prevalence of ceramic fracture for each generation.MethodsA total of 10,571 total hip arthroplasties from 45 studies were included. Proportion meta-analysis with a random-effects model was performed to estimate the prevalence of ceramic fracture. To determine whether the ceramic fractures have a fatigue nature and a risk or latent period for the development, postoperative time lapse, patient age, and body mass index were related with ceramic fracture by metaregression analysis.ResultsAs of postoperative 2.0 to 18.8 years, the rate of ceramic fracture was 0.5% (95% CI, 0.3%-0.8%) in the forte group and 0.2% (95% CI, 0.1%-0.4%) in the delta group (P = .059). The ceramic fracture rate for each component was 0.2% (95% CI, 0.1%-0.3%) for the forte head, 0.1% (95% CI, 0.0%-0.2%) for the delta head (P = .210), 0.2% (95% CI, 0.1%-0.3%) for the forte liner, and 0.2% (95% CI, 0.1%-0.4%) for the delta liner (P = .305). The rate of ceramic fracture per 1000 patient-years was 0.9 (95% CI, 0.5-0.13) in the forte group and 0.5 (95% CI, 0.2-0.8) in the delta group (P = .072). In metaregression analysis, no significant associations were found between prevalence of ceramic fracture and postoperative time lapse, patient age, or body mass index.ConclusionsThe rate of ceramic fracture was 0.9/1000 patient-year in the forte group and 0.5/1000 patient-year in the delta group. The results of this study provide baseline data for further studies validating ceramic bearings.Level of EvidenceLevel I, meta-analysis.     

Highly Porous Titanium Acetabular Components in Primary and Revision Total Hip Arthroplasty: A Systematic Review

BackgroundA number of papers have been published reporting on the clinical performance of highly porous coated titanium acetabular cups in primary and revision total hip arthroplasty (THA). However, no systematic review of the literature has been published to date.MethodsThe US National Library of Medicine (PubMed/MEDLINE), Embase, and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “tritanium” OR “highly-porous” AND “titanium” OR “acetabular” AND “trabecular” AND “titanium”.ResultsOverall, 16 studies were included in this review (11,366 cases; 60% females, 2-7 years mean follow-up). The overall survival rate of highly porous titanium acetabular components in primary cases was 99.3% (10,811 of 10,886 cases), whereas the rate of aseptic loosening was 0.1%. The overall survival rate of the highly porous titanium acetabular components in revision THA cases was 93.5% (449 of 480 cases), whereas the rate of aseptic loosening was 2.1%.ConclusionThere was moderate quality evidence to show that the use of highly porous titanium acetabular components in primary and revision THA cases is associated with satisfactory clinical outcomes in the short- and medium-term, without showing any evidence of cup migration or radiolucency. Taking into consideration that there is no evidence yet regarding the long-term survivorship of these components, we feel that further research of higher quality is required to generate more evidence-based conclusions regarding the longevity of highly porous titanium acetabular implants compared with conventional titanium counterparts.     

Comparison Between Preassembled and Modular Cups in Primary Cementless Total Hip Arthroplasty: A Two-Year Minimum Follow-up Study

We prospectively analyzed 83 patients who underwent ceramic-on-ceramic THA using preassembled (n = 22) or modular acetabular components (n = 61) between June 2010 and June 2012. There were no significant differences in mean postoperative radiographic outcomes, functional outcomes, or complications between the two groups. Both groups showed satisfactory performance at the 2 year follow up. Only the gender of the patients was significantly different between the two groups. Half of the women had smaller acetabular diameters accommodating a cup size of only 48-50-mm. Although a preassembled cup with a 36-mm ceramic liner is proven to be safe in the short term, future research should focus on evaluating the long-term risks.     

In Vivo Corrosion of Sleeved Ceramic Femoral Heads: A Retrieval Study

BackgroundThe purpose of this study was to evaluate a series of retrieved sleeved ceramic femoral heads used in total hip arthroplasty (THA) and determine qualitative and quantitative damage and corrosion patterns.MethodsAn IRB-approved implant retrieval database was utilized to identify all sleeved ceramic femoral heads collected from 1995 to 2004. There were 16 implants with an average duration of in situ of 70 months (range, 13-241 months). The femoral stem was known in 14 cases and was titanium alloy in each of those cases. None were revised for metal-related complications. Ten implants (63%) were from primary THAs, and 6 (38%) were from revision THAs. Damage and corrosion were qualitatively graded using a modified Goldberg method. A quantitative assessment was performed with a coordinate measurement machine (CMM).ResultsAmong the 16 retrieved implants, 1 (6%) demonstrated severe Grade 4 corrosion, 5 (31%) had moderate Grade 3 corrosion, 5 (31%) had mild Grade 2 corrosion, and 5 (31%) had no visible corrosion at the inner sleeve that interfaces with the stem trunnion. The only case of grade 4 corrosion occurred in the only head-sleeve in the study that was not factory assembled and was mated with a titanium molybdenum zirconium ferrous (TMZF) alloy stem. The mean maximum linear corrosion depth at the taper interface, as measured by the CMM, was 7.7 microns (range, 0.9-32.9 microns).ConclusionThis study is the first to quantify corrosion at the titanium interface of sleeved ceramic femoral heads. Potentially clinically significant damage and corrosion patterns were observed in a few failed retrievals; however, the majority of cases demonstrated minimal or no damage.     

Ceramic Bearings Are Associated With a Significantly Reduced Revision Rate in Primary Hip Arthroplasty: An Analysis From the National Joint Registry for England,Wales, Northern Ireland,and the Isle of Man

BackgroundProsthetic joint infection (PJI) is a devastating complication. Studies have suggested reduction in PJI with the use of ceramic bearings.MethodsAdult patients who underwent total hip arthroplasty (THA) using an uncemented acetabular component with ceramic-on-ceramic (CoC), ceramic-on-polyethylene (CoP), or metal-on-polyethylene (MoP) bearing surfaces between 2002 and 2016 were extracted from the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. A competing risk regression model to investigate predictors of each revision outcome was used. Time-to-event was determined by duration of implantation since primary surgery with competing risks being death or revision. The results were adjusted for age, gender, American Association of Anaesthesiologists grade, body mass index, surgical indication, intraoperative complications, and implant data.ResultsIn total, 456,457 THAs (228,786 MoP, 128,403 CoC, and 99,268 CoP) were identified. Multivariable modeling showed that the risk of revision for PJI was significantly lower with CoC (risk ratio 0.748, P < .001) and CoP (risk ratio 0.775, P < .001) compared to MoP. Significant reduction in risk of aseptic and all-cause revision was also seen. The significant protective effect of ceramic bearing was predominantly seen 2 years after implantation. Aseptic revision beyond 2 years reduced by 18.1% and 24.8% for CoC and CoP (P < .001), respectively. All-cause revision rate beyond 2 years reduced by 21.6% for CoC and 27.1% for CoP (P < .001)ConclusionThis study demonstrates an association between the use of ceramic as part of the bearing, with lower rates of revision for all causes, revision for infection, and revision for aseptic causes, supporting ceramic bearings in THA.     

Stainless Steel Femoral Heads Reduce Rate of Revision When Compared to Ion-Implanted Chromium-Cobalt Heads With a Single Cemented Femoral Design: An Analysis of 40,468 Total Hip Replacements From the Australian Orthopedic Association National Joint Replacement Registry

BackgroundIn order to reduce the incidence of total hip joint replacement revision for wear, multiple advanced materials and alloys targeting hip replacement tribology have been introduced. Ion implantation of chromium-cobalt heads is thought to reduce wear due to increased surface hardness and lower friction. These advances in technology result in additional manufacturing costs. However, it is unclear whether these attributes result in a decreased rate of revision for wear and when used with modern highly crosslinked polyethylene (XLPE). The aim of this study is to compare the survivorship of stainless steel and ion-implanted chromium-cobalt femoral heads in order to determine whether ion implantation has a lower risk of revision.MethodsData from the Australian Orthopedic Association National Joint Replacement Registry included all stainless steel and low-friction ion-treated (LFIT) femoral heads used in conjunction with a primary Exeter/Trident hip replacement combination and XLPE liners performed for osteoarthritis. Kaplan-Meier estimates of survivorship were used to describe the time to first revision. Hazard ratios (HRs) from Cox proportional hazard models, with adjustment for age and gender, were used to compare revision rates between the 2 groups.ResultsThere were 40,468 total hip replacements that met the inclusion criteria. Stainless steel heads had a lower revision rate compared to LFIT chromium-cobalt heads (HR 0.87, 95% confidence interval 0.76-1.00, P = .048). The difference in the rate of revision was even greater when 32-mm heads were used (HR 0.72, 95% confidence interval 0.58-0.89, P = .002). There was no difference in revision for loosening between head alloys or when stratified by age.ConclusionGiven the increased costs associated with LFIT implants and the lower rate of revision for stainless steel heads, we recommend the use of a stainless steel heads when using an Exeter/Trident hybrid hip with an XLPE liner.     

No Difference in Dislocation Rates Comparing Large Diameter Jumbo Femoral Heads and Dual-Mobility Bearings in Revision Total Hip Arthroplasty

BackgroundDual-mobility (DM) bearings reduce instability in revision total hip arthroplasty (THA); however, DM bearings are costly and reports of corrosion have recently emerged. Furthermore, no study has compared DM to standard bearings with large diameter femoral heads ≥40-mm. This study’s purpose was to compare postoperative dislocation rates of standard and DM bearings with large femoral heads after revision THA.MethodsA retrospective review of 301 consecutive revision THAs was performed. The mean follow-up was 37.1 months. To isolate the effect of the double articulation, standard and DM bearings with femoral heads ≥40-mm were compared. Outcomes were postoperative dislocation and reoperation within 90 days.ResultsThe cohort consisted of 182 standard bearings and 75 DM bearings. There were no differences in revision indication comparing standard and DM bearings (P = .258). Overall dislocation rate was 8.6% (22 of 257). The dislocation rate was 5.7% for standard bearings with ≥40-mm femoral heads compared with 6.9% in DM bearings with ≥40-mm femoral heads (P = 1.000). In multivariate analysis, lower body mass index (odds ratio 1.72), female sex (odds ratio 2.01), and decreased outer femoral head diameter–to–cup component size ratio (odds ratio 1.64) were predictors of postoperative dislocation regardless of bearing type.ConclusionThis study showed no difference in dislocation rates between standard and DM bearings when comparing similar femoral head diameters of ≥40-mm used in revision THAs. Considering the cost and potential deleterious issues associated with additional interfaces, DM bearings should be used judiciously considering similar results may be achieved with single-articulation bearings using large femoral heads.Level of EvidenceLevel III.     

Results of Revision Total Hip Arthroplasty with Modular,Titanium-Tapered Femoral Stems in Severe Proximal Metaphyseal and Diaphyseal Bone Loss

Evidence supporting modular, tapered stems for severe proximal metaphyseal and diaphyseal bone loss is limited. We report our clinical experience with its use for severely deficient femurs. Of 211 revision total hip arthroplasties (THAs), 18 tapered, modular titanium stems were implanted in Paprosky type III and IV femurs. Clinical data were reviewed for function, stability, structural failure and revision surgery at a mean follow-up of 4.5 years. The overall survival rate was 94%. One required revision due to infection and subsidence. The mean subsidence was 3.5 mm and the mean pre- and post-operative Harris Hip score was 56 and 79, respectively. In surviving cases, patients achieved satisfactory function and there were no mechanical failures. Modular, tapered stems demonstrated acceptable outcomes for management of severe proximal metaphyseal and diaphyseal defects.     

Long-Term Outcomes of Revision Total Hip Arthroplasty Using a Tapered and Fluted Modular Stem: A Mean Follow-Up of 16 Years

BackgroundTapered modular stems are increasingly used in revision total hip arthroplasty (THA) with deficient femoral bone stock. This study aimed to report the long-term outcomes of revision THA using a tapered and fluted modular stem.MethodsBetween December 1998 and February 2006, 113 revision THAs (110 patients) were performed with a tapered and fluted modular stem at a single institution. Hip radiographs were used to identify stem subsidence, stability, and femoral radiolucency. Final outcomes were assessed in 72 hips (70 patients), with a minimum follow-up of 10 years.ResultsThe mean follow-up duration was 16 years (range, 10-23). At the final evaluation, the Harris Hip Score improved from a mean of 41 points (range, 10-72) preoperatively to 83 points (range, 56-100) (P < .001). Six femoral re-revisions were performed for the following reasons: 1 aseptic loosening, 2 stem fractures, and 3 infections. One stem fracture occurred at the modular junction after 14 years, and the other at a more distal location after 15 years. Stem subsidence was >5 mm in 6 hips (9.1%), but secondary stability was achieved in all stems. Osseointegration was observed in 63 (95.5%) hips. Stem survivorship was 91.1% with an end point of any re-revision and 94.6% for aseptic re-revision.ConclusionA tapered and fluted modular stem demonstrated excellent implant survivorship with reliable bony fixation at a mean follow-up of 16 years. This type of stem can be a durable option for revision THA in patients who have femoral defects.     

What Is the Difference Between Modular and Nonmodular Tapered Fluted Titanium Stems in Revision Total Hip Arthroplasty

Background

Both modular and nonmodular tapered fluted titanium stems are used in revision total hip arthroplasty (THA), with follow-up showing good results for both stems. We aimed to determine whether there were any differences in clinical outcomes, survivorship, or frequency of complications.