Article

Massive wear of an incompatible metal-on-metal articulation in total hip arthroplasty

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Abstract

We report on a case of massive wear because of an incompatible metal-on-metal combination. In a 62-year-old man, a cobalt-chromium (CoCr) inlay and a stainless steel head were paired by accident. Because of persistent pain, revision surgery was performed 7 months later. Histologic analysis of the surrounding tissue revealed massive metallosis. The wear volume was increased by a factor of 18 for the head and 2 for the cup compared with normal metal-on-metal articulation. The serum concentrations of chromium and cobalt were increased by a factor of 20 and 4 over levels of a healthy population, respectively. Incompatible metal-on-metal combinations should be revised immediately. In case of delayed diagnosis, no metal-on-metal articulation should be implanted because of the high volume of metal in the human body.

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... Keel and Kuster [68] reported on a case of massive wear because of an incompatible MoM combination, a cobaltchromium (Co-Cr) alloy cup was paired with a stainless steel head. The resultant wear volume was increased by a factor of 18 for the head and 2 for the cup compared with normal MoM articulation. ...
Article
The use of metallic biomaterials in the medical implant devices has become increasingly prevalent over the past few decades. Patients find themselves being exposed to metals in a variety of ways, ranging from external exposure to instruments such as medical devices to internal exposure via surgical devices being implanted in their bodies. In situ generation of metallic wear nanoparticles, corrosion products and in vivo trace metal ions release from metal and metallic alloys implanted into the body in orthopedic surgery is becoming a major cause for concern regarding the health and safety of patients. The chemical form, particulate vs. ionic, of the metal species in the bodily fluids and tissues is a key to the local nanotoxicity effects arising in the body. Potential health risks are associated with metallic wear debris in the form of nanoparticles in situ generation and the release of in vivo trace metal ions into human biological specimen's circulation. This overview explores how migration of metallic wear nanoparticles and ultratrace metal ions in the area of metal-on-metal orthopedic implants influences the surrounding tissues and bodily fluids, and what the toxicological consequences of this process may be. Specifically, the present article is more informative of indicative multilevel in situ/in vivo/ex vivo analytical/clinical methodologies which will be helpful in a way to plan, understand and lead the analytical innovations in the area of nano-analysis to improve patient outcomes.
... Wear between the bearing surfaces has been reduced by improved design and manufacturing. 11 However, increased production of metal ions is reported to be associated with excessive inclination of the actetabular component, [12][13][14][15][16] the use of incompatible metals, 17 excess movement at the cement-stem interface in the presence of poor positioning of the stem 18 and impingement. 19 Whether production of metal ions is directly proportional to use of the implant is open to debate. ...
Article
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Metal-on-metal total hip replacement has been targeted at younger patients with anticipated long-term survival, but the effect of the production of metal ions is a concern because of their possible toxicity to cells. We have reviewed the results of the use of the Ultima hybrid metal-on-metal total hip replacement, with a cemented polished tapered femoral component with a 28 mm diameter and a cobalt-chrome (CoCr) modular head, articulating with a 28 mm CoCr acetabular bearing surface secured in a titanium alloy uncemented shell. Between 1997 and 2004, 545 patients with 652 affected hips underwent replacement using this system. Up to 31 January 2008, 90 (13.8%) hips in 82 patients had been revised. Pain was the sole reason for revision in 44 hips (48.9%) of which 35 had normal plain radiographs. Peri-prosthetic fractures occurred in 17 hips (18.9%) with early dislocation in three (3.3%) and late dislocation in 16 (17.8%). Infection was found in nine hips (10.0%). At operation, a range of changes was noted including cavities containing cloudy fluid under pressure, necrotic soft tissues with avulsed tendons and denuded osteonecrotic upper femora. Corrosion was frequently observed on the retrieved cemented part of the femoral component. Typically, the peri-operative findings confirmed those found on pre-operative metal artefact reduction sequence MRI and histological examination showed severe necrosis. Metal artefact reduction sequence MRI proved to be useful when investigating these patients with pain in the absence of adverse plain radiological features.
... However, end-stage chronic renal diseases are regarded as a contraindication for the use of metal-on-metal articulation [66]. Malfunctioning devices may put the patient at considerable risk [68] and require prompt detection and revision. ...
Article
The aim of this article is to review those aspects of corrosion behaviour that are most relevant to the clinical application of implant alloys. The special modes of corrosion encountered by implant alloys are presented. The resistance of the different materials against the most typical corrosion modes (pitting corrosion, crevice corrosion and fretting corrosion) is compared, together with observations of metal ion release from different biomaterials. A short section is dedicated to possible galvanic effects in cases when different types of materials are combined in a biomedical device. The different topics covered are introduced from the viewpoint of materials science, and then placed into the context of medicine and clinical experience.
... It may occur secondary to wear in metal-on-metal arthroplasties or in arthroplasties with a polyethylene component due to abnormal contact between metal surfaces following erosion or displacement of the polyethylene [5]. The presence of entrapped debris between the articulating surfaces causes further scratching and wear, exacerbating the problem [6,7]. Titanium components appear to be more commonly associated with metallosis than do chromium-cobalt prostheses, suggesting an increased propensity for wear [8]. ...
Article
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Metallosis is an uncommon condition in which there is infiltration of periprosthetic soft tissues and bone by metallic debris resulting from wear of joint arthroplasties. It is often associated with significant osteolysis; therefore the identification of metallosis is an indication for revision arthroplasty. The radiographic, CT and MRI features of metallosis in a 63-year-old man who presented 16 years post-arthroplasty are described in this case report.
... The advantages of the Co-Cr-Mo/Co-Cr-Mo bearings are the absence of the generation of UHMWPE wear debris and decreased wear as compared to that in the case of the Co-Cr-Mo/ UHMWPE bearings [10,11]. However, even in the Co-Cr-Mo/Co-Cr-Mo bearings, aseptic loosening induced by wear particles and metallosis remain as serious issues in revision surgeries [12,13]. In addition to metallosis, electrochemical corrosion and carcinogenesis occurring due to the dissemination of wear particles to the other parts of the body have been reported [14]. ...
Article
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Osteolysis caused by wear particles from polyethylene in artificial hip joints is of great concern. Various bearing couple combinations, bearing material improvements, and surface modifications have been attempted to reduce such wear particles. With the aim of reducing the wear and developing a novel artificial hip-joint system, we created a highly lubricious metal-bearing material: A 2-methacryloyloxyethyl phosphorylcholine (MPC) polymer was grafted onto the surface of the cobalt-chromium-molybdenum (Co-Cr-Mo) alloy. For ensuring the long-term retention of poly(MPC) on the Co-Cr-Mo alloy, we used a 4-methacryloxyethyl trimellitate anhydride (4-META) intermediate layer and photo-induced graft polymerization technique to create a strong bonding between the Co-Cr-Mo substrate and the poly(MPC) chain via the 4-META layer. The Co-Cr-Mo alloy was pretreated with nitric acid and O(2) plasma to facilitate efficient interaction between the 4-META carboxyl group and the surface hydroxyl group on the Cr oxide passive layer of the Co-Cr-Mo alloy. After MPC grafting, the MPC unit peaks were clearly observed in the Fourier-transform infrared spectroscopy with attenuated total reflection (FT-IR/ATR) and X-ray photoelectron spectroscopy (XPS) spectra of the Co-Cr-Mo surface. Tribological studies with a pin-on-plate machine revealed that surface MPC grafting markedly lowered the friction coefficient. We concluded that the grafted poly(MPC) layer successfully provided high lubricity to the Co-Cr-Mo surface.
... We also investigated the sizes of titanium and PE particles, which showed a wide range of distribution, from submicron to approximately 50 lm, the largest of which formed large flakes. It has been suggested that smaller metal particles (submicron) are more effective at instigating cytokine release for osteoclast activation than larger ones, because they can be easily engulfed by histiocytes [3,23]. We also assume that the presence of submicron particles is directly associated with severe bone destruction in metallosis. ...
Article
Clinical and radiographic findings of metallosis in relation to the clinical outcome of revision total hip arthroplasty were analyzed for 31 hips. Causes of metallosis were dissociation of polyethylene liner in 24 hips, catastrophic wear in 6, and the screw used for stem fixation in 1. Metallosis was grade I in 12 hips, grade II in 7, and grade III in 12. Osteolysis around the acetabular cup was observed in 24 (77.4%) of 31 hips. At the time of final follow-up evaluation, none of the hips showed osteolysis, acetabular cup migration, or any change in inclination. Although metallosis could not be completely eradicated in severe cases, the clinical outcome for these hips was favorable. This study demonstrates that metallosis frequently causes osteolysis and that complete elimination of it is not a prerequisite for the success of revision total hip arthroplasty.
... 9,10 However, even in Co-Cr-Mo/Co-Cr-Mo bearings, aseptic loosening induced by wear particles and metallosis remains as serious issue in revision surgeries. 11,12 In addition to metallosis, electrochemical corrosion and carcinogenesis occurring due to the dissemination of wear particles to the other parts of the body have been reported. 13 On the other hand, improvements in the bearing materials and surface modifications of the Co-Cr-Mo alloy have been attempted, in order to reduce such wear particles. ...
Article
Aseptic loosening of the artificial hip joint with osteolysis due to the wear particles from polyethylene cup has remained as a serious issue. To reduce this wear and develop a novel artificial hip joint system, we produced a superlubricious metal-bearing material: for this, we grafted a 2-methacryloyloxyethyl phosphorylcholine (MPC) polymer onto the surface of a cobalt-chromium-molybdenum (Co-Cr-Mo) alloy. For ensuring long-term benefit retention of poly(MPC) on the Co-Cr-Mo alloy for application as a novel artificial hip joint system, several issues must be considered: strong bonding between poly(MPC) and Co-Cr-Mo surface, high mobility of free end groups of the poly(MPC) layer, and high density of the introduced poly(MPC). Considering these issues, we introduced a 3-methacryloxypropyl trimethoxysilane (MPSi) intermediate layer and a photoinduced graft polymerization technique to create a strong covalent bond between the Co-Cr-Mo substrate and the poly(MPC) chain via the MPSi layer. The thickness and density of the poly(MPC) layer on the surface increased with the MPC concentration and photoirradiation time. The grafted poly(MPC) layer successfully provided super-lubricity to the Co-Cr-Mo surface. The poly(MPC)-grafted crosslinked polyethylene/poly(MPC)-grafted Co-Cr-Mo or cartilage/poly(MPC)-grafted Co-Cr-Mo bearing interface mimicking natural joints showed an extremely low friction coefficient of 0.01, which is as low as that of natural cartilage interface. A superlubricious metal-bearing surface would enable the development of a novel biocompatible artificial hip joint system-artificial femoral head for partial hemiarthroplasty and metal-on-polymer/metal type for total hip arthroplasty.
... The fact that the screw has greater hardness is mainly due to the fact of a material to be pure plates and another alloy-screws. Smaller metal grains might lead to a reduced grain dislocation, making plastic deformation less likely and, thus, increasing its mechanical resistance and hardness [23,24]. However, according to the data obtained with this study, it is not possible to affirm that different grain sizes alter, or harm, the biomechanical performance of a material. ...
Article
Full-text available
Objectives: This paper aims to evaluate in vitro the mechanical and microstructural properties of internal fixation systems used in oral and maxillofacial surgeries. Materials and methods: Four brands of internal fixation systems (screws and 4-hole straight plates) were selected and assigned to four groups: G1 Leibinger®, G2 Tóride®, G3 Engimplan®, and G4 Medartis®. The systems were submitted to Vickers hardness testing, metallographic and interstitial elements chemical composition analyses. Data were submitted to ANOVA and Tukey's test for statistical analysis. Results: Plates in groups 1, 2, and 3 showed similar microstructure and mechanical properties, different from those in G4 revealing larger grains. In all groups, the screws showed similar microstructure, with uniform arrangement and size of grains; the screws showed higher hardness values than those observed for the plates. Conclusions: The results indicate that all materials tested are adequate for use in oral maxillofacial surgeries.
... One of the major issues related to the in-vivo performance of MoM hip bearing systems is the concern over the periprosthetic tissue response to metal wear particles and metal ions [9,10]. In-vitro studies on the effect of metal particle size, composition, and shape have indicated that, although the total wear volume is low, a large number of particles are generated during articulation [11]. ...
Article
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There are a number of factors that determine the overall outcome of total hip replacement (THR) surgery, some of which appear to be related to the surgical procedure. In particular, the inclination angle at which the acetabular component is placed has been reported to influence the long-term successful performance of THR. The present study assessed the influence of cup orientation on the wear of 40 mm diameter metal-on-metal (MoM) hip bearings tested in a hip simulator. The bearings had a mean radial clearance of 150 microm; the cups oriented at 35 degrees, 50 degrees, and 60 degrees to the horizontal were loaded for up to 6 x 10(6) cycles. In each test the wear rates during the run-in phase were higher than in the steady state phase; the wear rates during the run-in phase were not significantly different for each cup orientation. However, at cup angles of 50 degrees and 60 degrees, the steady state wear rates were 0.69 mm3/ 10(6) cycles and 1.7 mm3/10(6) cycles respectively, significantly higher than at 35 degrees (0.24 mm3/10(6) cycles). The results indicated that larger cup inclination angles not only move the position of the wear scar but also, more significantly in MoM bearings, increase the wear rates and total wear volume generated.
... Artifact from right hip prostheses is also present. ing of the hardware components by instigating a local inflammatory response with synovitis and cytokine-mediated osteolysis (2)(3)(4). In the setting of total hip arthroplasty (THA), metallosis can occur by a variety of mechanisms. ...
Article
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We report a case of a 50-year-old man with extensive metallosis 20 years after right total hip arthroplasty. CT demonstrated osteolysis and radiodense debris surrounding the right hip joint. Although the radiographic appearance of metallosis has been well documented in the literature, the CT appearance of metallosis after total hip arthroplasty has been only sparsely described.
Article
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Cobalt exerts well-known and documented toxic effects on the thyroid, heart and the haematopoietic system, in addition to the occupational lung disease, allergic manifestations and a probably carcinogenic action. Cobalt neurotoxicity is reported in isolated cases, and it has never been systematically treated. Bilateral optic atrophy and retinopathy, bilateral nerve deafness and sensory-motor polyneuropathy have been described long ago as a result of chronic occupational exposure to cobal powder or during long-term treatment of anaemia with cobalt chloride. Recently, some patients with high levels of cobalt released from metal prosthesis have been referred as presenting with tinnitus, deafness, vertigo, visual changes, optic atrophy, tremor and peripheral neuropathy. The aim of this work is to group these cases and to identify a possible mechanism of cobalt neurotoxicity, focusing on hypothetic individual susceptibility such as altered metal-binding proteins, altered transport processes in target cells or polymorphic variation of genetic background.
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Metal-on-metal bearing surfaces in total hip arthroplasty have been recently shown to have acceptable survivorship properties (J Bone Joint Surg Am. 2006;88:1183; J Bone Joint Surg Am. 2006;88:1173), and they have certain advantages and disadvantages when compared to conventional metal-on-polyethylene bearing surfaces. Like traditional metal-on-polyethylene bearings, these metal-on-metal implants may also suffer from catastrophic failure. This case report represents an unusual situation in a 57-year-old man in which dissociation of a metal inlay in a metal-on-metal total hip arthroplasty resulted in articulation of the inferior aspect of the inlay with the femoral neck, leading to femoral neck notching, extensive periprosthetic soft tissue metallosis, osteolysis, and subsequent prosthetic catastrophic failure.
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A 24-year-old patient with a history of juvenile rheumatoid arthritis underwent a primary cementless left total hip arthroplasty (THA). The original THA consisted of an Optifix 54 cup with a 3-mm thick polyethylene liner, an Optifix size 4 stem (Smith & Nephew Richards, Memphis, Tennessee) and a Biolox aluminum 32-mm femoral head. Fourteen years later, radiographs demonstrated extensive wear of the polyethylene liner resulting in direct articulation and abrasion wear of the ceramic femoral head on the cup and a bubble sign. This article presents a case of a catastrophic failure of a ceramic/polyethylene bearing with destruction of the polyethylene liner and the metallic shell and protrusio of the nonfractured ceramic head through the metallic shell. To our knowledge this is the first description of extensive metallosis and subsequent radiograph bubble sign not presenting as a result of wear of a metal-on-metal articulation. At the time of revision surgery-Hydrocel TNT Monoblock 58 cup (Zimmer, Warsaw, Indiana), Wagner 265/14 stem (Zimmer), and a Co/Cr 28-mm head-copious metallic debris was seen both macroscopically and histologically, with the ceramic head protruding behind the metallic shell. Multiple factors may have been responsible for this failure including a thin polyethylene shell, a suboptimal locking mechanism, gamma in air sterilization for polyethylene, multiple screw-holes that reduce the contact surface between shell and polyethylene, the rough surface on the inside of the shell and non-articular wear at the metal polyethylene interface within the acetabular component and the high demands of this active young patient.
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Although total elbow arthroplasty is a reliable treatment method for the arthritic joint, revision is necessary if loosening, instability, wear, fracture or infection occurs. We report 12 patients with 19 months (10-29) follow-up after revision arthroplasty for painful loosening in six cases, periprosthetic fracture in three, gross instability in one and skin perforation with possible infection in two. All cases presented with severe metallosis. Fractures were seen in four, triceps insufficiency in three and skin perforation in two. All patients were treated with exchange arthroplasty using the Coonrad-Morrey prosthesis. Three patients had in addition strut-allografting. The two patients with skin perforation and possible infection had a staged procedure. Mayo Elbow Performance Score improved from 24 to 87 with uneventful healing, fracture consolidation and allograft incorporation. At follow-up, triceps insufficiency persisted in all three cases. Transient neuropathy was present in five patients (4 ulnar, 1 radial). Metallosis in total elbow arthroplasty may be associated with severe tissue damage. A staging method is presented.
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Introduction La modularité permet d’adapter l’arthroplastie à l’anatomie du patient mais elle expose aussi à des complications spécifiques : désunion, corrosion, rupture parfois liées à des erreurs d’implantation. Le but de ce travail était d’évaluer la fréquence des erreurs de délivrance d’implants et leurs conséquences dans les arthroplasties de hanche et de genou. Hypothèse La compréhension des erreurs d’implantation liées à la modularité des arthroplasties nécessite le respect d’une procédure peropératoire de vérification des implants avant déballage et implantation. Matériel et méthodes La fréquence et les conséquences des erreurs de délivrance lors de l’implantation de prothèses de hanche et de genou ont été recensées rétrospectivement entre janvier 2009 et décembre 2011. Résultats Sur 24 cas recensés (%), l’erreur a pu être reconnue dans 19 cas avant l’implantation définitive. Dans les cinq cas restants, les implants ont été malheureusement implantés et l’erreur reconnue en postopératoire, nécessitant la révision de tout ou partie de la prothèse. La taille des implants était le plus souvent en cause (principalement sur le calibre du couple de frottement pour six des 19 erreurs potentielles et quatre des cinq erreurs effectives). L’expérience de l’équipe chirurgicale n’apparaissait pas en cause. Il n’y a pas eu de procédure médicolégale. Discussion/conclusion Les erreurs liées à la modularité ne sont pas exceptionnelles. Une procédure rigoureuse de vérification peropératoire doit être respectée par le chirurgien et la panseuse circulante pour les éviter. Si effectives, elles doivent être reconnues précocement par une vérification attentive de la radiographie postopératoire.
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We report on a case of metallosis initially presumed to be heterotopic ossification based on radiologic findings. A 68-year-old man with a total hip arthroplasty experienced failure of the polyethylene liner, resulting in articulation of the ceramic head with the titanium acetabular shell. During revision surgery, extensive metallic debris was evident macroscopically throughout the periprosthetic tissue and was confirmed histologically to be metallosis.
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A 51-year-old woman came to our clinic 6 months after a right total hip arthroplasty. She had noticed a slowly growing mass in the proximal thigh and referred progressive pain in the right groin. Plain radiography revealed premature acetabular cup aseptic loosening, and in the computed tomography study, a 14-cm-diameter mass was observed. Revision surgery was performed, showing a metal-on-ceramic bearing surface. The histologic analysis of surrounding tissues was reported as massive metallosis. Although occasionally chosen for primary or revision hip arthroplasty, there is little information available about the in vivo wear behavior of this combination. This important fact should be taken into account before considering such a surface alternative.
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Case: We describe a case of total hip arthroplasty failure where a cobalt-chrome femoral head completely wore through the polyethylene liner and the titanium acetabular cup. The patient subsequently underwent revision total hip arthroplasty with acetabular revision and femoral head exchange. Conclusion: This case illustrates the natural history of catastrophic failure in a metal-on-polyethylene total hip arthroplasty design. If recognized earlier, this patient may have been a candidate for isolated liner and head exchange. Additionally, this case represents a unique complication in using mixed metals in total hip arthroplasty, where the harder cobalt-chrome femoral head wore completely through the much softer titanium component.
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Total joint replacement is one of the most clinically successful, cost-effective surgical procedures. These operations have been shown to improve pain, function and mobility in patients with end-stage arthritis. However, joint replacements that will allow full, unrestricted, high impact activities and last the patient's lifetime have not yet been devised. This is due to biocompatibility issues related to material science, biomechanics, and host responses. In this review, three issues that are highly pertinent to biocompatibility of joint replacements are examined. These topics include how implants initially osseointegrate within bone, potential adverse effects of byproducts of wear that can lead to aseptic loosening and periprosthetic osteolysis, and the potential for new bearing surfaces to extend the lifetime of implants. A clear understanding of these important issues will facilitate the development of novel strategies to improve the longevity and function of implants for joint replacement in the future.
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231 cobalt-chromium metal-on-metal (METASUL design) retrieved articulations (297 retrieved components) were examined for their in vivo wear behaviour. A running-in period of about one year is observed where the in vivo wear rate for the whole articulation is approximately 35 μm/year. After this running-in period, the measured in vivo wear rate of the whole articulation decreases to about 5 μm/year. The metal-on-metal articulation can be considered as a very low wear articulation system. The combination of the specially designed components is mandatory to assure this low wear behaviour. In case of a mismatched bearing (stainless steel head - cobalt-chromium inlay), large amount of wear was measured.
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Nach der Totalprothesenoperation des Huftgelenkes kommt es selbst im besten Falle fruher oder spater zur Spatlockerung und zur Notwendigkeit der Revisionsoperation. Grund dazu ist der unaufhaltsame Verschleis des Polyaethylens der kunstlichen Pfannen, wobei der Polyaethylenabrieb an der Implantat-Knochengrenze eine Bindegewebe-Fremdkorperreaktion mit progressiver Osteolyse und Schwachung der Verankerung hervorruft, einerlei, ob die Prothese mit Knochenzement oder zementfrei implantiert worden ist. In den 60er Jahren mit Knochenzement verankerte Ganzmetallprothese des Types Mc Kee funktionieren u. U. noch heute perfekt ohne auch nur die geringsten Osteolysephanomene im Rontgenbild erkennen zu lassen. Diese 2 Beobachtungen sind Anlas zur Wiederaufnahme der Metall-Metall-Paarung fur die Totalprothese des Huftgelenkes. Eine solche neue Totalprothese, von 1988 bis 1990 62 × implantiert, wird vorgestellt. Late loosening in total-hip-replacement is explained by a foreign body reaction of the connective tissue along the bone-implant interface due to polyaethylene debris. In contrast, metal-metal-protheses, implanted in the sixties, may still today work perfectly without any signs of osteolysis along the bone-cement interface, prooving, that metal-metal-pairing is superior to protheses with polyaethylene cups and that cement-anchorage may also be adequate for fixation. A new metal-metal-total hip-joint is presented, that has been implanted from 1988-1990 62 times.
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There has been a resurgence of interest in the use of metal on metal bearings in total hip arthroplasty. Although the use of metal on metal bearing couples would eliminate or substantially reduce particulate polyethylene generation (depending on the presence or absence of polyethylene in the implant system), there is concern about the potential for increased particulate and ionic metal generation in comparison with polyethylene on metal bearings. These metallic degradation products may be transported away from the implant site and distributed systemically. Chromium concentrations in the serum and urine and cobalt concentrations in the serum were measured in subjects with cobalt chromium alloy metal on metal total hip replacements and in controls without implants. Eight subjects with long term (> 20 years) McKee-Farrar total hip replacements had 9-fold elevations in serum chromium, 35-fold elevations in urine chromium, and at least 3-fold elevations in serum cobalt concentrations in comparison with controls. Six subjects with short term (< 2 years) metal on metal surface replacement arthroplasties had 3-fold elevations in serum chromium, 4-fold elevations in urine chromium, and 4-fold elevations in serum cobalt concentrations in comparison with subjects with McKee-Farrar implants. Although the toxicologic importance of these trace metal elevations has not been established, serum and urine metal concentrations may be useful markers for the tribologic performance of metal on metal bearings.
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Replacement hip arthroplasty with the use of ultrahigh molecular weight polyethylene for the cup articulating with a metal head has provided a low friction arthroplasty with years of success. However, the search for improved materials and designs for articulating surfaces continues. The use of metallic heads articulating with metallic cups is now being reconsidered for total hip replacements. Success will be enhanced if wear and corrosion of the articulating surfaces can be kept below that of the metal on ultrahigh molecular weight polyethylene couple. Concern has been raised about the release, and biologic fate, of metal species from corrosion and wear. Titanium alloys have been shown to have limitations as an articulating surface showing significant wear, and the alloy per se should not be considered for wear couples in total hip replacements. The cobalt chromium alloys are known to have reasonable wear and corrosion properties and continue to be evaluated. The issue of cobalt chromium wear and corrosion products and how this relates to the biologic performance of total hip replacement devices is reviewed. Under the condition of wear as currently experienced at the articulating surfaces of cobalt chromium alloys and ultrahigh molecular weight polyethylene, the amount of metallic products transferred to the tissues is sufficiently low to be well tolerated by the biologic system. Nickel and cobalt ions arc, rapidly transported from the implant site and eliminated in the urine. Chromium is stored in the tissue and eliminated more slowly. The issue of host hypersensitivity to these elements remains of concern. All 3 elements, in ionic form, are known to cause contact dermatitis. Untoward biologic reactions, including hypersensitivity, should be minimized if wear and corrosion phenomena are minimized.
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The author and Sulzer Medical Technology Ltd, Switzerland, have developed a new generation of metal on metal bearing total hip joints. The design is different than the McKee type prostheses in that the cobalt chrome alloy heads and cups (Metasul) are of the highest precision with controlled loose fitting. These allow low friction and low wear of approximately 5 micrometers per year. It is anticipated that debris related late loosening will be avoided by the use of this design. Approximately 30,000 Metasul hearings have been produced. The first 110 Weber metal on metal hip implants have been analyzed. No adverse effects from the wear of the new metal on metal components have been noted in this series.
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Ultra-high-molecular weight polyethylene (UHMWPE) wear, debris-induced osteolysis is a frequent cause of failure of total hip arthroplasty. Metal-on-metal total hip arthroplasty eliminates the generation of UHMWPE particulate debris. Although the volumetric wear of a metal-on-metal articulation may be lower than a metal-UHMWPE articulation, the number of particles may be higher. Osteolysis can develop in response to metallic and UHMWPE debris. The following case of massive osteolysis associated with large amounts of cobalt-chrome wear debris shows adhesive and abrasive wear mechanisms, as well as wear caused by third-body cobalt-chrome debris and impingement of the femoral component against the rim of the acetabular cup, which led to failure of a metal-on-metal total hip arthroplasty.
Article
We measured the cobalt and chromium concentrations in the serum and urine of 32 patients with current designed metal-on-metal total hip arthroplasty and 43 patients with conventional metal on ultrahigh molecular weight polyethylene (UHMWPE) cementless total hip arthroplasty. The results of our study showed that the serum and urine chromium concentrations increased in 37.5% and 90.6%, respectively, of 32 patients with well-fixed metal articulation (the mean values were 0.09 microg/dl and 2.2 microg/l, respectively) and also increased in 28.6% and 85.7%, respectively, of 7 patients who received metal-on-UHMWPE articulation with loosened acetabular component or stem made of Co/Cr alloy (the mean values were 0.06 microg/dl and 1.6 microg/l, respectively). On the other hand, the serum and urine cobalt concentrations were below the detection limit in all patients.
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