A disturbing prevalence of painful inflammatory reactions has been reported in metal-on-metal (MoM) hip resurfacing arthroplasty. A contributing factor is localized loading of the acetabular shell leading to “edge wear” which is often seen after precise measurement of the bearing surfaces of retrieved components. Factors contributing to edge wear include adverse cup orientation leading to proximity (<10 mm) of the hip reaction force to the edge of the acetabular component. As this phenomenon is a function of implant positioning and patient posture, this study was performed to investigate the occurrence of edge loading during different functional activities as a function of cup inclination and version. We developed a computer model of the hip joint through reconstruction of CT scans of a proto-typical pelvis and femur and virtually implanting a hip resurfacing prosthesis in an ideal position. Using this model, we examined the relationship between the resultant hip force vector and the edge of the acetabular shell during walking, stair ascent and descent, and getting in and out of a chair. Load data was derived from 5 THR patients implanted with instrumented hip prostheses (Bergmann et al). We calculated the distance from the edge of the shell to the point of intersection of the load vector and the bearing surface for cup orientations ranging from 40 to 70 degrees of inclination, and 0 to 40 degrees of anteversion.Introduction:
Methods:
Recent retrieval studies and registry reports have demonstrated an alarming incidence of early failure of metal-on-metal THR. This appears to be due to fretting and corrosion at the taper junction (trunnion) between the neck and large diameter heads in metal-on-metal hip implants. It has been proposed that designs with lower bearing clearances and greater cup flexibility deform during implantation leading to increased frictional torque and micromotion at the head-neck taper junction. Small movements at the trunnion may suggest elastic deformation, but large movements may suggest slippage at the friction interface. This study was conducted using retrieved metal-on-metal components to test the hypotheses that: 1. Cup deformation through localized compression leads to increased bearing torque, and 2. Increased torques generated in large head metal-on-metal bearings cause motion of the head-neck taper junction. Nine metal-on-metal hip implants were received from a national joint retrieval service and tested in a mechanical testing machine. The components were of three different designs (ASR, BHR, and Durom) and ranged in diameter from 42–54 mm. A custom jig was constructed to generate controlled radial compression at opposite points on the rim of an acetabular component. The jig was positioned inverted to the normal anatomical position and was angled to simulate the anatomical orientation of the cup (35° inclination, 10° anteversion). With the exception of an initial compression load of 100N, the cups were compressed at 200N intervals to a maximum of 2000N. Three trials at each cup compression load were performed. The torque developed about the trunnion axis was measured as the head articulated through a motion arc of 60° and the friction factor was calculated. Head–neck micromotion was continuously monitored using a non-displacement inductive transducer. Changes in micromotion from the 100N compression load were calculated.Introduction
Materials and Methods
A disturbing prevalence of short-term failures of metal-on-metal (MoM) hip resurfacings has been reported by joint registries. These cases have been primarily due to painful inflammatory reactions and, in extreme cases, formation of pseudotumors within periarticular soft-tissues. The likely cause is localized loading of the acetabular shell leading to “edge wear” which is often seen after precise measurement of the bearing surfaces of retrieved components. Factors contributing to edge wear of metal-on-metal arthroplasties are thought to include adverse cup orientation, patient posture, and the direction of hip loading. The purpose of this study was to investigate the role of different functional activities in edge loading of hip resurfacing prostheses as a function of cup inclination and version. We developed a computer model of the hip joint through reconstruction of CT scans of a proto-typical pelvis and femur and virtually implanting a hip resurfacing prosthesis in an ideal position. Using this model, we examined the relationship between the resultant hip force vector and the edge of the acetabular shell during walking, stair ascent and descent, and getting in and out of a chair. Load data was derived from 5 THR patients implanted with instrumented hip prostheses (Bergmann et al). We calculated the distance from the edge of the shell to the point of intersection of the load vector and the bearing surface for cup orientations ranging from 40 to 70 degrees of inclination, and 0 to 40 degrees of anteversion.Introduction
Methods
There are several component position and design variables that increase the risk of edge loading and high wear in metal-on-metal hip resurfacing (MOM-HR). In this study we combined all of these variables to calculate the ‘contact patch to rim distance’ (CPRD) in patients undergoing revision of their MOM-HR. We then determined whether CPRD was more strongly correlated with component wear and blood metal ion levels, when compared to any other commonly reported clinical variable. This was a retrospective study of 168 consecutively collected MOM-HR retrieval cases. All relevant clinical data was documented, including pre-revision whole blood cobalt and chromium ion levels. Wear of the bearing surfaces was then measured using a roundness-measuring machine. We found four variables to be significantly (p < 0.05) correlated with component wear and blood metal ion levels: (1) cup inclination angle, (2) cup version angle, (3) arc of cover, and (4) CPRD. The correlations between CPRD and both wear and ion levels were significantly stronger than those seen with any other variable (all p < 0.0001). Our study has shown that CPRD is the best predictor of component wear and blood metal ion levels, and may therefore be a useful parameter to help determine those patients who are at risk of high wear and require more frequent clinical surveillance.
Material loss at the head-stem taper junction may contribute to the high early failure rates of stemmed large head metal-on-metal (LH-MOM) hip replacements. We sought to quantify both wear and corrosion and by doing so determine the main mechanism of material loss at the taper. This was a retrospective study of 78 patients having undergone revision of a LH-MOM hip replacement. All relevant clinical data was recorded. Corrosion was assessed using light microscopy and scanning electron microscopy, and graded according to a well-published classification system. We then measured the volumetric wear of the bearing and taper surfaces. Evidence of at least mild taper corrosion was seen in 90% cases, with 46% severely corroded. SEM confirmed the presence of corrosion debris, pits and fretting damage. However, volumetric wear of the taper surfaces was significantly lower than that of the bearing surfaces (p = 0.015). Our study supports corrosion as the predominant mechanism of material loss at the taper junction of LH-MOM hip replacements. Although the volume of material loss is low, the ionic products may be more biologically active compared to the particulate debris arising from the bearing surfaces.
It has been speculated that high wear at the head-stem taper may contribute to the high failure rates reported for stemmed large head metal-on-metal (LH-MOM) hips. In this study of 53 retrieved LH-MOM hip replacements, we sought to determine the relative contributions of the bearing and taper surfaces to the total wear volume. Prior to revision, we recorded the relevant clinical variables, including whole blood cobalt and chromium levels. Volumetric wear of the bearing surfaces was measured using a coordinate measuring machine and of the taper surfaces using a roundness measuring machine. The mean taper wear volume was lower than the combined bearing surface wear volume (p = 0.015). On average the taper contributed 32.9% of the total wear volume, and in only 28% cases was the taper wear volume greater than the bearing surface wear volume. Despite contributing less to the total material loss than the bearing surfaces, the head-stem taper junction remains an important source of implant-derived wear debris. Furthermore, material loss at the taper is likely to involve corrosion and it is possible that the material released may be more biologically active than that from the bearing surface.
Edge loading is a common wear mechanism in Metal-on-Metal (MOM) hip resurfacing and is associated with higher wear rates and the incidence of pseudotumour. The purpose of this study was to develop a method to investigate the contributions of patient, surgical and implant design variables on the risk of edge loading. We created a mathematical model to calculate the distance from the head-cup contact patch to the rim of the cup and used this to investigate the effect of component position, specific design features and patient activity on the risk of edge loading. We then used this method to calculate the contact patch to rim distance (CPRD) for 160 patients having undergone revision of their MOM hip resurfacing in order to identify any possible associations.Introduction
Method
It has been speculated that impact deformation of thin 1-piece cups used for modern metal-on-metal hip replacement may contribute to early failure. The purpose of this study was to reproduce typical impact deformation and quantify the effect of this on the frictional torque generated at the hip. We tested nine hip couples of three designs (the ASR, BHR and Durom) and three sizes (42mm, 46mm and 50mm). A custom compression device was designed to replicate the in vivo forces and impact deformation of 1-piece metal cups reported in the literature. Each cup was mounted in the device, which itself was mounted on a mechanical testing machine. The cups were compressed with incremental loads up to a maximum of 2000N. At each increment we measured cup deformation, and then the head component was seated into the cup. The hip was lubricated and the head component rotated 60 degrees axially within the cup and the axial torque was measured.Introduction
Methods
The Articular Surface Replacement (ASR) hip resurfacing arthroplasty has a failure rate of 12.0% at five years, compared with 4.3% for the Birmingham Hip Resurfacing (BHR). We analysed 66 ASR and 64 BHR explanted metal-on-metal hip replacements with the aim of understanding their mechanisms of failure. We measured the linear wear rates of the acetabular and femoral components and analysed the clinical cause of failure, pre-revision blood metal ion levels and orientation of the acetabular component. There was no significant difference in metal ion levels (chromium, p = 0.82; cobalt, p = 0.40) or head wear rate (p = 0.14) between the two groups. The ASR had a significantly increased rate of wear of the acetabular component (p = 0.03) and a significantly increased occurrence of edge loading (p <
0.005), which can be attributed to differences in design between the ASR and BHR. The effects of differences in design on the
This study compared component wear rates and pre-revision blood metal ions levels in two groups of failed metal-on-metal hip arthroplasties: hip resurfacing and modular total hip replacement (THR). There was no significant difference in the median rate of linear wear between the groups for both acetabular (p = 0.4633) and femoral (p = 0.0872) components. There was also no significant difference in the median linear wear rates when failed hip resurfacing and modular THR hips of the same type (ASR and Birmingham hip resurfacing (BHR)) were compared. Unlike other studies of well-functioning hips, there was no significant difference in pre-revision blood metal ion levels between hip resurfacing and modular THR. Edge loading was common in both groups, but more common in the resurfacing group (67%) than in the modular group (57%). However, this was not significant (p = 0.3479). We attribute this difference to retention of the neck in resurfacing of the hip, leading to impingement-type edge loading. This was supported by visual evidence of impingement on the femur. These findings show that failed metal-on-metal hip resurfacing and modular THRs have similar component wear rates and are both associated with raised pre-revision blood levels of metal ions.
