Intraprosthetic dislocation of dual mobility total hip arthroplasty: still occurring?

PURPOSE: The objective was to identify predictive factors for intraprosthetic dislocation (IPD) and to understand how improvements in dual mobility cups (DMC) have helped to reduce dramatically the occurrence of this complication. METHODS: DM mobile inserts retrieved from 93 hips were divided into three groups: first-generation DMC with IPD ("firstDMC-IPD"), first-generation DMC with over 15 years of implantation without IPD ("firstDMC-noIPD"), and latest-generation DMC ("newDMC"). The predictive factors for IPD based on clinical, prosthetic, radiological and intraoperative characteristics were analysed by multivariate analysis. The surface of each retrieved mobile insert was analysed using three-dimensional CT scan in order to compare their rim wear. RESULTS: Three predictive factors for IPD were found: a high BMI, a wide rough stem neck and a large cup size. Wear of the firstDMC-noIPD inserts was significantly less than those of firstDMC-IPD inserts and significantly more than those of newDMC inserts. For the firstDMC-IPD inserts, the rim's outer surface wear was significantly greater than the rim's inner surface wear. CONCLUSIONS: IPD is a specific complication related to wear of the DM mobile insert due to failure of the liner's retaining rim, especially from the rim's outer surface. This long-term issue is different to the early traumatic complication, which can happen after an attempt at closed reduction of a DM THA dislocation. Recent modifications in the design and the coating of contemporary DMC and femoral stems, as well as improvements in the mobile insert itself, seem to corroborate our assumptions about the IPD mechanism and contribute to the quasi-disappearance of this complication.

Long-term wear of dual mobility total hip replacement cups: explant study.

PURPOSE: Dual mobility THA implantations are increasing. THA survival of more than 15 years is considered long-term survival based on the Charnley prosthesis, which has a median wear rate of 39 to 98 mm3/year. What is the median wear rate of dual mobility THA cups and its repartition on the liner volume? What are the factors influencing dual mobility wear? METHODS: Thirty-five explants were analysed. The liners were entirely mapped with a fully automatic stripe light scanner that uses green LED light. RESULTS: The liners had a median wear rate of 38 mm3/year. The distribution of the wear between the two bearings varied greatly. No factor was found influencing wear volumes. CONCLUSIONS: The median annual wear of dual mobility liners is at least as low as the wear of cemented polyethylene liners and lower than equivalent cementless liners. The two articulations of the dual mobility THA do not cause more wear. LEVEL OF EVIDENCE: Level IV - case series.

Correction to: Intraprosthetic dislocation of dual mobility total hip arthroplasty: still occurring?

The published online version contains mistake in the author list for the author name "Di Iorio Alexandre" was incorrectly presented.

The linear penetration rate is not relevant for evaluating wear of dual mobility cups: an explant study.

PURPOSE: The linear penetration rate (LPR) has been used to estimate volumetric wear ever since metal-on-polyethylene bearings were first introduced. Annual volumetric wear and osteolysis are interrelated. The use of dual mobility cups has increased; however, the presence of two bearings needs paraclinical monitoring of wear to anticipate potential wear-related complications. Is LPR correlated to volumetric wear? METHODS: Ninety-eight dual mobility liner retrievals were mapped in three-dimensions (3D) with a fully automatic stripe light scanner. Martell's method was applied to 3D maps of the explants to determine how much the centres of the inner and outer bearings had shifted in the three planes, and in particular, penetration of the femoral head in the "z" axis. The total, inner and outer wear volumes were then compared to the shift in the centres of rotation (COR) and the pre-operative X-rays. RESULTS: There was no relationship between wear and head penetration into the liner. There was a statistically significant relationship between the 3D centre of rotation shift and inner wear or total wear. Wear was multidirectional. CONCLUSIONS: LPR is ineffective for estimating wear of dual mobility inserts, since its wear not two-dimensional. In the future, a 3D imaging method with very thin slices could be used to monitor the wear of dual mobility inserts by measuring the shift in the centres of rotation, once artifacts are overcome.

Understanding wear in dual mobility total hip replacement: first generation explant wear patterns.

PURPOSE: Dual mobility was introduced by Pr. G. Bousquet to improve the dislocation risk of total hip arthroplasty (THR). The wear mechanisms of this implant remain to be understood. Could enhanced explant wear analysis explain liner wear behaviour? METHODS: Sixty-six explanted liners were selected. Non-destructive 3D scanning and heat colour treatment allowed reporting wear patterns on both convex and concave sides of the liners. RESULTS: For many liners, liner convexity wear was found to be homogeneous, and linked to a longer implantation time. A few liners had signs of blocking of the convexity, leading to excessive internal damage. Intra prosthetic dislocations were found to only have internal circular wear without liner penetration. CONCLUSION: Heat colour treatment showed its effectiveness for highlighting wear patterns. Optimal convexity mobility seemed to be leading to a longer implantation time, with decreased contact stresses on concavity. The retentive rim should have a distinct wear analysis.

Zirconia ageing is related to total hip arthroplasty aseptic loosening. A study of 45 retrieved zirconia heads.

BACKGROUND: Y-TZP zirconia heads were recalled by the Food and Drug Administration (FDA) in 2001 and zirconia alone was no longer used in orthopedics. Tunnel furnace sintering was suspected of producing defects responsible for early material failure. As Zirconia Toughened Alumina (ZTA) matrices are widely used as bearing material and contain zirconia grains, there remains a need to better understand the in vivo ageing process of zirconia and its clinical implications when the material is produced by batch furnace sintering, the validated sintering process. QUESTIONS/OBJECTIVES: Is there an association between the ageing of batch furnace produced zirconia and THA revision? METHODS: 45 retrieved femoral heads, batch furnace sintered only, were analyzed. Roughness was measured by 3D profilometry, phase transfer by µRaman spectroscopy. Clinical data were compared with material characteristics. RESULTS: Irrespective of the cause of revision, all heads showed a crystallographic phase transition from tetragonal to monoclinic over 19.5%. A correlation was found between the phase change, roughness increase and aseptic loosening, with a threshold set at 24.5% of monoclinic phase. CONCLUSIONS: The ageing process of zirconia may lead to aseptic loosening, which, in the absence of contrary evidence, prohibits its use as the sole component of orthopedic materials. ZTA matrices should be clinically monitored, especially in young patients, and better in vitro modelling needs to be performed. LEVEL OF EVIDENCE: IV; Case series.

Primary total hip arthroplasty with dual mobility socket to prevent dislocation: a 22-year follow-up of 240 hips.

PURPOSE: The longest follow-up dual mobility series from inventor Gilles Bousquet focussing on implant survival and the incidence of dislocation. METHODS: This was a retrospective study from 1985 to 1990, on 240 hips using a PF® modular femoral stem and a dual mobility Novae® tripodal socket (SERF). RESULTS: The 22-year follow-up global survival rate was 74%. No dislocation occurred, 41 hips were revised, including ten retentive failures (RF), 12 hips were lost to follow-up, 87 patients (99 hips) died without revision, and 90 hips were still in situ. CONCLUSION: The dual mobility socket global survival rate is comparable to similar series. The 0% dislocation rate demonstrates the success of dual mobility with regard to implant stability. The main issues were cup fixation, which might be improved by the use of macrostructures and HA coating, and osteolytic lesions, caused by polyethylene wear. Traditionally suitable for patients older than 60 years, dual mobility might be extended for use in patients over 50.

Nano/micro implant debris affect osteogenesis by chondrocytes: Comparison between ceramic and UHMWPE from hip walking simulator.

A new generation of ceramic on ceramic (BIOLOX ®delta) bearings has emerged more than 10 years ago proving a high resistance to wear and good clinical results. However, biological reactions to wear debris, particularly the nanoparticles, need to be evaluated. The first originality of this study is to start from real wear particles obtained by the hip walking simulator (CERsim). These particles were compared with particles obtained by usual methods to assess the biocompatibility of materials: press machine (CERpress). Two ranges of ceramic particles were thus observed: ceramic particles with micron (intergranular fractures) and nano sizes (intragranular fractures), and characterized compared to ultra-high molecular weight polyethylene (UHMWPE). The second originality of this work is to assess the cellular reaction using the primary joint chondrocyte cultures simulating the osteogenesis process and not the cell lines, which are used to simulate the biological reaction of osteolysis. The first results showed a significant difference in cell viability between the cells in contact with particles from the walking simulator and those obtained with the press machine. On the other hand, it was found that the way of extraction of the particles from the lubricant could significantly affect the biological reaction. More interestingly, nano-sized ceramic particles showed a significant impact on the secretion of functional inflammatory mediators, agreeing with recent results in vivo. These novel methods of characterizing the osteogenic impact of UHMWPE and ceramic wear debris can complement the conventional expertise method focusing previously on the osteolysis aspect.

Fretting-corrosion behavior on dental implant connection in human saliva.

Fretting-corrosion has been pointed out as failure mechanism in dental implants between the implant part and the abutment. Depending on countries, surgical habits, 4 combinations of materials, are well used. The behavior of fretting corrosion of these four combinations of materials have been highlighted: pure titanium (Ti-grade 4) against titanium alloy (Ti-6Al-4V); titanium alloy (Ti-6Al-4V); against titanium alloy (Ti-6Al-4V); pure titanium against zirconia stabilized with Yttria (Y-TZP) and titanium alloy (Ti-6Al-4V) against zirconia (Y-TZP). Around 100 MPa of contact pressure, approx. the maximal mechanical stresses in dental assembly, after 16 h of fretting corrosion (±â€¯40 µm, displacement) solicitations in Human saliva, the best assembly is Ti material (pure titanium-grade 4) against zirconia in terms of mechanical and electrochemical degradations. The electrochemical behavior has been investigated: the OCP, open circuit potential, is recovering its initial value even during fretting corrosion solicitations, Ti or Ti-6Al-4V against zirconia stabilized with Yttria (Y-TZP), outlier result but realistic. Some Tribological Transformed Structures on titanium material have been isolated as stir welding effect, STEM observations. Some transfer of zirconia through titanium material has been identified. Ti vs. Y-TZP clearly appears as the best performance couple under fretting corrosion conditions in human saliva. Lastly, some debris due to fretting corrosion have been isolated.

Fretting corrosion behaviour of Ti-6Al-4V reinforced with zirconia in foetal bovine serum.

Fretting corrosion is a critical challenge in the design of hip prosthesis used in total hip arthroplasty (THA) surgeries. Currently, the design of hip implants includes a tapered junction which introduces additional interfaces that connect different parts of the hip implant such as the femoral neck and head or stem and neck interface. Micro motions that occur under the influence of load, together with chemical changes in the host environment, make these interfaces susceptible to tribocorrosion processes, particularly fretting corrosion. Commonly used metallic biomaterials are based on stainless steels, cobalt chrome-based alloys as well as titanium and titanium alloys. Each of these materials possess some degree of limitations, particularly where tribocorrosion events are concerned. Titanium alloy Ti-6Al-4V is widely used in biomedical applications for non-bearing components of total joint arthroplasty (TJA) surgeries. Its poor wear resistance continues to remain a challenge in load-bearing joints where parts articulate against one another as in the case of modular junctions. Some of the attempts made to improve the wear properties of Ti-6Al-4V is through the incorporation of second phase particles like ceramics in its matrix to produce metal matrix composites of Ti-6Al-4V. The aim of this work is to investigate the effect of zirconia reinforcement on spark plasma sintered Ti-6Al-4V composites (zirconium oxide particles incorporated into Ti-6Al-4V matrix) on the fretting corrosion properties of Ti-6Al-4V. Fretting corrosion tests were carried out on as-sintered Ti-6Al-4V and Ti-6Al-4V with 5 and 10 wt.% ZrO2. The tests were carried out in foetal bovine serum under applied normal loads of 85 and 115 N using the cylinder-on-flat contact configuration. The evolution of OCP, dissipated energy and friction coefficient were recorded throughout the test. Microstructural analysis of the samples before fretting corrosion tests showed the presence of globular agglomerates throughout the Ti-6Al-4V matrix due to zirconia additions; the volume of the agglomerates was higher in the composites having 10 wt.% ZrO2. Ti-6Al-4V composites having zirconia additions produced a nobler OCP during fretting in foetal bovine serum, compared to pure Ti-6Al-4V. Furthermore, the fretting corrosion results showed a significant improvement in the tribocorrosion resistance of Ti-6Al-4V with 10 wt.% ZrO2 at all loads. This composition also produced the least amount of degradation. and metal ion release. Mechanical data showed that increasing the applied normal load promoted a transition from gross slip to partial slip conditions for all compositions. Partial slip was found to be prevalent at a higher normal load (drastic decrease of the dissipated energy and consequently the friction coefficient). This mechanical condition prevents a large amount of degradation.

A testing protocol combining shocks, hydrothermal ageing and friction, applied to Zirconia Toughened Alumina (ZTA) hip implants.

Ceramics are materials of choice for hip joint implants because of their excellent biocompatibility and mechanical properties. Wear of the bearing couple (femoral head and cup) remains one of the main concerns of hip implants. Although ceramics are known for their good tribological properties, shocks due to micro-separation, friction and hydrothermal ageing in physiological environment remain the three main sources of wear. It has been recently suggested that shock effects dominate but the three degradation mechanisms were so far simulated separately. We developed a procedure that combines sequences of shocks, hydrothermal ageing in an autoclave and friction on hip-walking simulator to investigate their combined effects on Zirconia Toughened Alumina (ZTA) implants. Our results confirm that shocks can be considered as the key phenomenon causing wear, and that their effect is independent of friction and hydrothermal degradation. The analysis of retrieved femoral heads reveals wear features comparable to the ones created experimentally by shocks. Standards (ASTM or ISO) could be improved by including shock tests, which are more relevant than wear tests currently performed on hip simulators at least for Ceramic-on- Ceramic couplings.

Ageing, Shocks and Wear Mechanisms in ZTA and the Long-Term Performance of Hip Joint Materials.

The surface morphologies and microstructures of Zirconia Toughened Alumina (ZTA) femoral heads were analyzed following in vitro tests aiming to simulate in vivo degradation. Three phenomena potentially leading to degradation were investigated: shocks, friction and hydrothermal ageing. Shocks due to micro-separation created the main damage with the formation of wear stripes on the femoral head surfaces. Atomic Force Microscopy (AFM) images suggested the release of wear debris of various shapes and sizes through inter- and intra-granular cracks; some debris may have a size lower than 100 nm. A decrease in hardness and Young's modulus was measured within the wear stripes by nanoindentation technique and was attributed to the presence of surface and sub-surface micro-cracks. Such micro-cracks mechanically triggered the zirconia phase transformation in those worn areas, which in return presumably reduced further crack propagation. In comparison with shocks, friction caused little wear degradation as observed from AFM images by scarce pullout of grains. The long-term resistance of the ZTA composite material against hydrothermal ageing is confirmed by the present observations.

Crack simulation of nano-bioceramic composite microstructures with cohesive failure law: effects of sintering, loads and time.

Crack behaviour of zirconia toughened alumina (ZTA) microstructures are simulated with a two-dimensional finite element simulation. Finite element models are developed using actual microstructure images of zirconia toughened alumina and a bilinear cohesive zone law. Simulation conditions are similar to those found at frictional contact between a femoral head and an acetabular cup of hip prosthesis. Effects of microstructures and contact stresses are investigated in terms of crack generation. Moreover, fatigue behaviour of a microstructure is determined by performing simulations under cyclic loading conditions. It is identified that total crack length observed in a microstructure increases with increasing the magnitude of applied contact stress. Cyclic simulation results show that progressive crack growth occurs with respect to number of fatigue cycles. In addition, it is demonstrated that zirconia grains resist crack growth in microstructures.