T i t a n i u m Wear Debris in Failed C e m e n t e d Total Hip Arthroplasty An Analysis of 71 Cases R o b e r t L. B u l y , M D , ~¢S,* M i c h a e l H. H u o , M D , t E d u a r d o S a l v a t i , M D , ~ : William Brien, MD,§ and Manjula Bansal, MDt

Abstract: Seventy-one cemented total hip arthroplasties (THAs) were reviewed following removal of the all-titanium alloy femoral stem. Fifty-one hips were primary arthroplasties that failed due to aseptic loosening, 8 were previous revisions with aseptic loosening, and 12 were removed for infection. The average duration of service for the three groups war 4.5 years, 5.0 years, and 3.7 years, respectively. Femoral bone loss in aseptically loose, primary THA was graded as severe in 51%, moderate in 24%, and mild in 20%. Femoral endosteolysis was present in 94%, while acetabular osteolysis was seen in 6%. Histological evaluation of tissues from failed primary arthroplasties revealed polymethyl methacrylate debris in 75% of cases, polyethylene debris in 80 %, metal debris in 75 %, and chronic inflammatory cells in all cases. Metallic debris was not seen in the failed revision cases and in only 17% of the infected cases. Examination of retrieved femoral compc,nents revealed burnishing of the head in all cases, while 71% of ster,~s with aseptic loosening were abraded from the cement. Metal levels from I2 cases averaged 2,111 mg/g of dry tissue (range, 6 0 - I 1,823); synovial fluid levels from 8 other cases averaged 106 mg/1 (range, 22-340). While it is not certain whether metallic particles are a primary cause of loosening or are generated secondarily, their presence seems to accelerate bone loss and loosening. Key words: total hip arthroplasty, arthroplasty failure, metal wear debris, titanium, tissue metal analysis, implant retrieval.

T i t a n i u m alloys w e r e e m p l o y e d in surgical implants shortly after the metal became commercially available in the late 1940s. Their use for orthopaedic i m p l a n t s in the United States spurted in the late 1970s. The alloy became a favorite due to good mechanical properties, biocompatibility, corrosion resis-

tance, high fatigue strength, and a lower elastic m o d ulus. ~3'39 A n u m b e r of hip prostheses m a d e entirely of titanium alloy appeared on the market, including the STH, DF-80, HGP, a n d SixTi-28/32 (Zimmer, Warsaw, IN), the ES-32 (Biomet, Warsaw, IN); Anitomic (Hexcel, Timonium, MD), and APR/Premier (Intermedics, Austin, TX). However, there were initial concerns that titanium alloys would not be suitable for articulating surfaces in total hip arthroplasties (THAs). W e a r studies conducted in vitro demonstrated increased a m o u n t s of metallic debris, especially if acrylic particles w e r e added, 26"27'2s'34 or increased p o l y e t h y l e n e w e a r . l ° Despite these reports, it was expected that passivation would impart sufficient w e a r resistance.12,39

From the *Department of Orthopaedic Surgery, Case Western Reserve University Hospital, Cleveland, Ohio, ~-Waterbury Hospital Joint Replacement Center, Waterbury, and the Department of Orthopaedics and Rehabilitation, Yale University, New Haven, Connecticut, §University of Southern California OrthopaedicMedical Group, Los Angeles, California, and 4:The Hospital for Special Surgery, New York, New York. Supported in part by the generous donation of Ms. Emma Danilewicz, President of the May Ellen and Gerald Ritter Foundation. Reprint requests: Robert Buly, MD, MS, Case Western Reserve University Hospital, 2074 Abington Road, Cleveland, OH 44106.

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Conflicting reports have been generated on the clinical performance of hip arthroplasties using femoral components made entirely of titanium alloy. Good results have been reported with titanium prostheses, 35"36"4°and a report on revised prostheses claimed that metallic wear debris is not a significant problem. 29 Other clinical reports cite poor results and alarming rates of loosening. 25,33 There are a growing n u m b e r of reports documenting metallic debris found at revision of these prostheses. ~,5,11,23,30 The objective of this study was to evaluate the wear characteristics of femoral total hip prostheses made entirely of titanium alloy that failed or were revised for other reasons at the Hospital for Special Surgery. In addition, the potential adverse biologic responses to increased wear, such as osteolysis, were examined. Attention was directed to the clinical features, radiographic appearance, histology, retrieved components, and metal level analysis. The hypothesis was that titanium alloys are not an ideal material for articulating surfaces and that once mechanical loosening begins, wear debris from the titanium alloy prosthesis may accelerate the process in cemented THA.

Materials and Methods Demographics From 1981 to 1989, a total of 69 patients underwent surgery at the Hospital for Special Surgery to remove either the femoral component alone or both components of their THA. In all cases, the stem and head were both made of titanium alloy. One patient had both infected hip arthroplasties removed and another patient had both hips revised for a total of 71 hips. Fifty patients underwent revision of a primary THA, 8 patients revision of a previous revision (rerevision), and 12 hip arthroplasties were removed from 11 patients due to infection. Of the 59 revisions, 54 were revised for aseptic loosening, 3 for femoral fracture below the stem, and 2 for component malposi-

tion. In the primary revision group, 65% had only the stem revised, while 35% had both components revised; in the rerevision group, 38% had only the stem revised and 62% had both. All 12 infected hips underwent removal of both components. Eighty percent of acetabular components were all polyethylene while 20% were metal-backed. All components were cemented. There were 42 DF-80 prostheses, 23 SixTi-32, 2 SixTi-28 and one each of the following: STH, ES-32, Mtiller type V, and a custom type. There were 39 men and 30 women. The average age was 66.0 years (range, 2 9 - 8 5 years). Weight averaged 82 kg (range, 64-107 kg) for men and 60 kg (range, 25-79 kg) for women. The diagnosis was osteoarthrosis in 40, posttraumatic arthrosis in 10, rheumatoid arthritis in 6, avascular necrosis in 3, slipped capital femoral epiphysis in 3, congenital hip dislocation in 3, and 1 each of the following: juvenile rheumatoid arthritis, Paget's disease, Perthes' disease, Morquio's syndrome, and ankylosing spondylitis.

Duration of Service Two hip arthroplasties were revised early for malposition (at 4 and 6 weeks). Three others were revised for fracture below the stem (at 2.8, 7.0, and 7.9 years postoperatively). For the 49 hips with aseptic loosening, the average duration of service was 4.7 years (range, 0.6 - 10.0 years) in the primary revision group and 5.0 years (range, 2.8-7.8 years) in the rerevision group. Thirty-three percent of those with aseptic loosening failed at 3 years or less. The average duration of service for the infected hips was 3.7 years (range 0.6-8.9 years).

Radiographic Evaluation Radiographs were evaluated for areas of osteolysis in the 51 primary revisions alone, since bone loss may have been due to infection or previous revisions in the other two groups. Bone loss was then quanti-

Table 1. R a d i o g r a p h i c S t a g i n g S y s t e m of F e m o r a l B o n e Loss i n F a i l e d Total H i p A r t h r o p l a s t y Calcar

Metaphysis

Minimal

neck preserved

intact bone/cement interface

Moderate

loss of neck height

cortical thinning, expansion, or interface disruption

Severe

complete loss of neck, lesser trochanter involved

violation of cortical shell

Diaphysis focal cortical erosion < ~ of cortical width diffuse thinning, focal erosion > § of cortical width or multiple erosions < § of cortical width Diffuse cortical erosions > ~ of cortical width involving > 50% of the diaphyseal length

Stage I, minimal bone loss; Stage II, moderate bone loss, proximal only; Stage III, moderate proximal and distal bone loss; Stage IV, severe bone loss. Adapted from J. Jacobs, MD and J. Galante, MD (Written Communication, February 1990).

Titanium Wear Debris in THA

fled using a modified scale (Jacobs J, and Galante J, personal communication, 1990) as shown in Table 1. Wear of the all-polyethylene cup was measured from radiographs with the use of calipers, templates, and a c o m p u t e r i z e d digitizer as described by Livermore et al. 22 and corrected for magnification, provided that immediate postoperative and prerevision radiographs were available. These radiographic criteria were met in 22 of 51 cases.

Histology Tissue specimens retrieved at the time of surgery were fixed in formalin, embedded in paraffin without decalcification, sectioned to a 5 p.m thickness, and stained with hematoxylin and eosin. The histologic specimens were examined by a pathologist (M.B.) and graded for particulate metal, polyethylene, and polymethyl methacrylate debris along with cell typing, using the criteria of Willert and Semlitsch. 3s The specimens were examined with regular and polarized light to better assess the type of debris present. The presence of histiocytes, foreign-body giant cells, and acute or chronic i n f l a m m a t o r y cells was also graded along with the presence of necrotic tissue.

Implant Retrieval Analysis All c o m p o n e n t s were retrieved and examined. Maps were made of w o r n and scratched areas on the femoral heads by gross inspection, and the surface involved was quantified using a computerized digitizer. The stem.s were also examined for worn areas on the nonarticular surfaces and the pattern of burnishing was noted.

Trace Element Analysis Aggregates of soft tissue comprising portions of the capsule, synovium, and interface pseudomembranes obtained at the time of surgery were studied in 12 patients. A n o t h e r eight patients had metal levels measured from the synovial fluid tha! was obtained by p r e o p e r a t i v e hip aspiration or during surgery, prior to capsular incision. All metal level analyses were performed at our institution using techniques described by Betts. 1.3 Specimens were deep-frozen ( - 2 0 ° C ) until processed. The specimens were homogenized and digested in nitric acid. Aliquots of the homogenates were then analyzed by flameless atomic absorbtion spectrophotometry using a Zeman 5000 graphite furnace (Perkin-Elmer, Norwalk, CT). The detection limit for metallic elements was in the range of 0 . 5 - 1 . 0 #,g/g dry tissue. Fluids were processed in a similar fashion and metal levels were recorded as milligrams per liter.



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Table 2. Distribution of Osteolytic Areas, 49 Failed,

Primary THA

Femoral zone 1 2 3 4 5 6 7

No. With E r o s i o n s

%

21 25 30 34 40 34 34

43% 51% 61% 69% 81% 69% 69%

2 0 2

4% 0% 4%

Acetabular zone 1 2 3

Femoral scalloping was seen in 46 of 49 hips (94%). Acetabular scalloping was seen in 3 of 49 hips (6%).

Results Radiographs The 49 primary revisions all had radiographic evidence of aseptic loosening, including progressive radiolucent lines at the b o n e - c e m e n t interface, endosteal erosions, cement fractures, and subsidence to varying degrees. All osteolytic lesions developed insidiously months to years after operation and continued to progress with time. Osteolysis (Fig. I), was seen to some extent in 46 of 49 femoral (94%) and occurred in all seven zones ~6 (Table 2), especially zone 5, where it was present in 81% of cases. Osteolysis was present on the acetabular side in only 3 of 49 hips (6%), in zone 1, zone 3, and both zones 1 and 3. Femoral bone loss (Table l) was graded as stage I in 20%, stage II in 4%, stage III in 25%, and stage IV in 51%. Bone loss often progressed quite rapidly, in one case leading to cortical perforation in only 3.3 years. In the 22 hips that met the radiographic criteria, polyethylene wear averaged 0.22 mm/year (range, 0.02-0.60 mm/year).

Histology The extent of particulate debris is shown in Tables 3 - 5 . Adequate histologic specimens were available for 44 of 51 primary revision cases (86%), 6 of 8 rerevision cases (75%), and all 12 infected cases (100%), for a total of 62 of 71 cases (87%). All those with adequate histologic material included portions of both the capsule and b o n e - c e m e n t p s e u d o m e m brane. Cement debris was found in 75% of primary revisions, 50% of rerevisions, and only 25% of the in-

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J

:~q,

(A)

(B)

Fig. 1. Bone loss following cemented THA with a titanium-alloy stem in a 64-year-old man. (A) A stable implant 2 months after surgery. (B) The radiograph 4.5 years later demonstrates stem loosening and subsidence along with marked endosteal cavitation.

fected cases. Polyethylene debris was found in 80% of primary revisions, 67% of rerevisions, and 50% of infected cases. Metallic debris (Fig. 2) was found in 33 of 44 primary revision cases (75%), in 0 of 6 rerevision cases, and in 2 of 12 septic cases (17%). Of the 33 in the p r i m a r y revision group with visible metal deposits, 10 (30%) were 1 + , 14 (42%) were 2 + , and 9 (27%) were 3 + . The two cases with visible metal deposition in the infected group were both 3 + . The size of the metallic particles ranged from 0.2 to 2.0 p~m. Detection of smaller particles was impossible due to the resolution limit of light microscopy. Cells associated with chronic inflammation (his° tiocytes and foreign-body giant cells) were present in 49 of 50 (98%) and 42 of 50 (84%) of aseptic cases,

respectively. Acute i n f l a m m a t o r y cells ( p o l y m o r p h o nucleocytes) were present in 9 of 12 (75%) infected cases while chronic i n f l a m m a t o r y cells (plasma cells, monocytes) were present in 3 of 12 (25%) infected cases. Necrosis was present in 33 of 50 aseptic cases (66%).

Component Retrieval Sixty-eight of the 71 r e m o v e d femoral c o m p o n e n t s were available for examination. All of the retrieved femoral c o m p o n e n t s had scratching and burnishing of the articulating surface (Fig. 3). The d e m a r c a t i o n between the scratched and burnished areas and the

Table 3. Histologic Findings of First Revision Group (44 cases examined) Severity 0 1+ 2+ 3+ Number ( + ) Percentage ( + )

Metal

Polyethylene

Cement

11 10 14 9

9 21 14 0

11 23 8 2

33 75%

35 80%

33 75%

Histiocytes 0 8 20 16 44 100%

FBGC

Necrosis

4 28 ll 1

31 ( + ) 13 ( - )

40 91%

3I 70%

Titanium Wear Debris in THA

Fig. 2. Photomicrographs of tissue specimen s retrieved from the revision of a cemented, titanium-alloy stem. (A) Histiocytes laden with metallic particles. (hematoxylin and eosin, 800 x ) (B) The same field under polarized light, showing diffraction at the edges of the metallic particles.

(A)



Buly et al.

319

4

(B) m i r r o r - l i k e u n i n v o l v e d areas was a p p a r e n t in all specimens. The total d a m a g e d surface area ranged f r o m 1% in a stem revised at 6 weeks for malposition to 96% (average, 50%). The area of involvement did not correlate with the duration of service. Six stems with less t h a n 10% i n v o l v e m e n t had been in service for an average of 5.2 years (range, 2 . 9 - 8 . 6 years), while three hips in service for 1 year or less and revised for loosening averaged 47% head involvement (range, 4 0 - 5 0 % ) . Abrasions were also present along the stem (nonarticular) portions of the femoral c o m p o n e n t s (Fig. 3). None of the 12 well-fixed and infected stems had this type of abrasion present, while all 12 did have femoral h e a d surface abrasion to a variable extent. Forty of the 56 loose stems ( 7 I % ) did have abraded areas. There were three different patterns of stem abrasion: (1) 29 of 56 stems (52%) showed longitudinal abrasion primarily along the anterolateral and pos-

teromedial edges, with less i n v o l v e m e n t of the posterolateral edge. The p a t t e r n suggested friction against cement from a posterior torque. (2) Seven of 56 (13%) had abrasion along the anterior and posterior shoulders, as well as the medial side of the tip. This pattern was seen only in the DF-80 prosthesis and m a y reflect pistoning with the medial tip acting like a chisel due to its bevel. (3) Four of 56 (7%) had diffuse areas of abrasion that did not fit any pattern, suggesting gross motion. A total of five stems w e r e r e m o v e d for r e a s o n s other than loosening or infection: two for malposition and three for femoral fractures b e l o w the tip of the stem. One malpositioned stem was revised at 2 weeks, the other at 6 weeks. Head burnishing was present in both, stem burnishing was not. All three fracture retrievals had head burnishing. Stem burnishing was present in two, most notably in a stem with radiographic evidence of loosening before the fracture.

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The Journal of Arthroplasty Vol. 7 No. 3 September 1992

(A)

(B) Fig. 3. Retrieved titanium-alloy steins that loosened following cement fixation. (A) Burnishing of the femoral head is apparent where articulation had occurred (right arrow). The nonarticulating portion (left arrow) remained polished. (B) Burnished areas along the shaft of a femoral component (arrows).

Metal Level Analysis Tissue samples from 12 hips averaged 2,111 ~g of total metal per g r a m of dry tissue (range, 6 0 - 1 1 , 8 2 3 ~g/g). The eight patients with synovial fluid analysis a v e r a g e d 106 m g of total m e t a l per liter (range, 2 2 - 3 4 0 mg/1). The synovial fluid was obtained only f r o m hips with aseptic loosening. The same was true with the tissue samples, with the exception of two infected cases. Values from the two infected cases (147 a n d 2,361 ~g/g) were within the range of levels f r o m the aseptic cases. All samples indicated the presence of all three metals, titanium, a l u m i n u m , and v a n a d i u m . All three metals were present in levels consistent with their percentages in the alloy, a finding that is m o r e consistant with w e a r than corrosion.

Discussion Before titanium alloys were used extensively for orthopaedic implants, a n u m b e r of in vitro studies were p e r f o r m e d to test the w e a r characteristics. Initial tests 26"27"34 raised serious doubts about the usefulness of titanium alloys due to metal abrasion, the

generation of metallic debris, and rapid polyethylene wear. One report noted 10 times m o r e metallic debris c o m p a r e d to c o b a l t - c h r o m e surfaces. 34 It w a s felt that passivation w i t h either h o t air or nitric acid would thicken the titanium dioxide crust and improve wear characteristics considerably, 12,39 permitting the widespread use of titanium alloys. Conflicting reports have been published concerning the clinical success of titanium femoral c o m p o nents. Sarmiento et al. cited a revision rate of 3.9% and a femoral loosening rate of 5.5% with the curved stem and 2.8% with the straight stem after an average of 6.8 years with the STH prosthesis. 36 Robinson et al. reported a femoral revision rate of 4.3% and a femoral loosening rate of 23.4% after an average of 3.1 years with the DF-80 prosthesis. 33 Martell et al. reported a revision rate of 3.5% and a loosening rate of 27.1% on the femoral side and 28.8% on the acetabular side with the SixTi-32/28 prostheses. They also reported greater t h a n 3 m m of proximal femoral bone loss in 28.8% of cases. 25 A growing n u m b e r of reports have cited p o o r results or adverse reactions to metallic w e a r debris. An earlier paper from this institution cited nine cases

Titanium Wear Debris in THA



Buly et al.

321

T a b l e 4. Histologic Findings of Rerevision Group (6 cases examined)

Severity 0 1+ 2+ 3+ Number ( + ) Percentage ( + )

Metal 6 0 0 o 0 0%

Polyethylene Cement Histiocytes F B G C Necrosis 2 3 1 o 4 67%

with extensive metal deposition f o u n d at revision surgery.~ A case report claimed metallosis as the source of pain and failure in the absence of loosening. 5 Others have noted metal debris associated with femoral osteolysis, 23'3°'3~ even with cementless THA. McKellop et al. reported findings in 20 total hip revisions in w h i c h the STH prosthesis had been used initially. 29 They reported radiolucencies but did not m e n t i o n osteolysis. Ten of 13 stems had head burnishing and 11 had stem (nonarticular) burnishing. The authors did not feel that metallosis was a problem and found histological metal deposits in only 2 of 20 cases. This is in contrast with our results, in which 94% had osteolysis to some extent, with bone loss judged to be severe in 51% of cases. We were also able to d o c u m e n t metal deposits in the tissues of 75% of primary revisions, with heavy (3 + ) deposits in 20%. Smaller a m o u n t s of metallic debris were seen in the revision and infected failures (Tables 4 and 5). This can be explained by failure at the bone-cement interface, allowing the stem and cement to move together. None of the infected cases and 29% of the revisions had stem burnishing, compared to 71% in the primary failure group. It was not possible to correlate bone Ioss with the a m o u n t of metal or polyethylene debris present. In this retrospective study, the exact location of tissue retrieval was not always noted and tEus may not have been adjacent to areas of osteolysis. In addition, unless the surgeon and pathologist specifically look for the metal deposits, they m a y be overlooked. Light m i c r o s c o p y m a y also underestimate the

3 2 0 1 3 50%

1 2 3 o 5 83%

4 0 1 I 2 33%

2 (+) 4(-) 2 33%

a m o u n t of actual metal debris present. In our previous study,~ hip s p e c i m e n s with metal levels of 3 2 - 1 2 5 #,g/g did not d e m o n s t r a t e metal particles w h e n viewed under light microscopy. Smaller metal particles, 0 . 0 1 - 1 ~ m in size, m a y be generated in the wear process 4 and would certainly escape detection by light microscopy. In a study analyzing the size of metal particles in membranes retrieved from total hip revisions, Lee et al. 2~ demonstrated vast numbers of particles under 0.1 ~m, detectable only with electron microscopy. Methacrylate and polyethylene debris can initiate a granulomatous reaction and lead to areas of osteolysis. 2,~7'x8"2°'24'32 It n o w appears that particulate metal, ranging in size from 1 to l0 ~m, is a strong stimulator of monocytes with the subsequent release of prostaglandin PGE2,~5 a potent stimulator of osteoclast-mediated bone resorption. Even in the absence of cement particles, there m a y be significant e b u r n a t i o n of titanium articulating surfaces with subsequent metal deposition. 23"3°'3~ There are two conflicting reports on the size of the polyethylene debris that is generated from articulation with titanium surfaces. Lee et al. 2~ found it to be larger than the debris generated with cobalt-chrome and stainless steel, while Campbell et al. 8 found it to be finer ( I - 5 ~m) than that generated from cobalt-chrome articulation ( 1 0 - 3 0 ~m) and thus a m o r e p o t e n t stimulator of macrophage activity. The smaller the debris particles, the greater the likelihood of phagocytosis and a more severe biologic response. Titanium, aluminum, and vanadium, c o m p o n e n t s of the titanium alloy, m a y also act to interfere with the mi-

T a b l e 5. Histologic Findings of Infected Arthroplasties (12 Cases Examined)

Severity 0 I+ 2+ 3+ Number ( + ) Percentage ( + )

Metal l0 0 0 2 2 17%

Polyethylene Cement Histiocytes FBGC Inflammation 6 3 2 I 6 50%

9 3 0 0 3 25%

Acute inflammation, 75%; Plasma cells present, 25%

6 3 2 I 6 50%

8 3 0 1 4 33%

Acute: 9 (+) Plasma Cells: 3 (+)

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The Journal of Arthroplasty Vol. 7 No. 3 September 1992

n e r a l i z a t i o n of osteoid and the f o r m a t i o n of apatite. 6,7 It is not clear w h e t h e r the head becomes damaged p r i m a r i l y due to the surface characteristics and a higher coefficient of friction for titanium aIloy~4,~or due to c e m e n t particles entrapped between the art~eulating surfaces. 29 Evidence for the latter is suggested by the finding that titanium metal levels in synovial fluid are 21 times higher in loose versus mechanically stable THA. 8 The w e a r pattern on stems removed for reasons o t h e r t h a n loosening suggests that burnishing begins at the articulating surface. W h e n the loosening process does begin, bone loss can progress very rapidly, as evidenced by the short duration of service in m a n y of our cases. The metallic particles generated from stem abrasion m a y simply accelerate the biologic osteolytic process, acting as mechanical s p a c e - o c c u p y i n g lesions w i t h accelerated recruitm e n t of m a c r o p h a g e s that erode bone, or affect other toxic processes. Huo et al. analyzed tissues from osteolytic areas next to failed cemented titanium stems and found metal levels 3.7 times higher and barium (a c o m p o n e n t of the polymethyl methacrylate) levels 50 times higher than in the remaining tissues.19 The stems were also eburnated adjacent to the osteolytic ~bci. Others h a v e s h o w n that polyethylene wear is accelerated w h e n articulating with titanium alloys, especially if the metal is eburnated.l°'25'27 The rate of polyethylene w e a r averaged 0.22 ram/year on radiographs, which is greater than the a m o u n t reported in failed hip arthroplasties with stainless steel heads2 s While the increased polyethylene load m a y aggrav a t e the situation, it is probably not solely responsible for the increased osteolysis, since s o m e hips w i t h lower w e a r rates still had severe bone loss. This study demonstrates metallic wear debris in a high percentage of failed all-titanium femoral components. The rapidity with which severe bone loss occurs is disturbing. Methods to increase the durability of titanium surfaces, such as ion implantation, 9'23 m a y m i n i m i z e the g e n e r a t i o n of metallic debris. However, the depth of enhanced hardness is only 0 . 1 - 0 . 2 ~m, a very thin layer that could easily be scratched a n d violated. The use of c o b a l t - c h r o m e heads on titanium stems is another w a y to circumvent the p r o b l e m and is manifested by the increasing n u m b e r of these types on the market. Those patients w i t h existing a l l - t i t a n i u m prostheses should be watched carefully for evidence of progressive loosening, b o n e loss, and unexplained hip pain. Hip aspiration and quantification of metallic trace elements in the synovial fluid by atomic absorbtion spectrophot o m e t r y can help in the assessment of the problem and in the timing for the revision surgery.

Acknowledgments The authors would like to acknowledge the assistance of Clare Rimnac, PhD, and Alesia Petko, BS, f r o m the D e p a r t m e n t of B i o m e c h a n i c s , in the retrieval and examination of prostheses.

References l. Agins HJ, Alcock HW, Bansal M e t al: Metallic wear in failed titanium-alloy total hip replacements. A histological and quantitative analysis. J Bone Joint Surg 70A:347, 1988 2. Bannister G: Mechanical failure in the femoral component in total hip replacement. Orthop Clin North Am 19:567, 1988 3. Betts F, Yau A: Graphite furnace atomic absorbtion spectrometric determination of chromium, nickel, cobalt, molybdenum, and manganese in tissues containing particles of a cobalt-chrome alloy. Anal Chem 61: 1235, 1989 4. Black J: Orthopaedic biomaterials in research and practice. Churchill Livingstone, New York, 1988, p. 213. 5. Black J, Sherk H, Bonini J e t al: Metallosis associated with a stable titanium-alloy femoral component in total hip replacement: a case report. J Bone Joint Surg 72A:126, 1990 6. Blumenthal NC, Cosma V: Inhibition of apatite formation by titanium and vanadium ions. Presented at the 35th Annual Meeting of the Orthopaedic Research Society, Las Vegas, February 1989 7. Blumenthal NC, Posner AS: In vitro model of aluminum-induced osteomalacia: inhibition of hydroxyapatite formation and growth. Calcif Tissue Int 36:439, 1984 8. Brien W, Salvati E, Betts F et al: Metal levels in cemented total hip arthroplasty: a comparison of well-fixed and loose implants. Clin Orthop 276:66, I992 9. Buchanan RA, Rigney ED Jr, Williams JM: Ion implantation of surgical Ti-6AI-4V for improved resistance to wear-accelerated corrosion. J Biomed Mater Res 21:355, 1987 10. Buchhorn-Kriete U, Willert H, Semlitsch Met al: Wear behavior of total hip prosthesis components made of different bearing materials: a clinical and laboratory study, p. 11.1. In Plastics in medicine and surgery. The Plastics and Rubber Institute, London, 1979 11. Campbell P, Nasser S, Millett D, Amstutz HC: A study of the effects of polyethylene wear debris in cemented and uncemented implants. Presented at the 36th Meeting of the Orthopaedic Research Society, New Orleans, February 1990 12. Clarke IC, McKellop HA, McGuire C et al: Wear of Ti-6AI-4V implant alloy and ultra-high molecular weight polyethylene combinations, p. 136. In Luckey HA, Kubli F Jr (eds): Titanium alloy in surgical ira-

Titanium Wear Debris in THA

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

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Titanium wear debris in failed cemented total hip arthroplasty. An analysis of 71 cases.

Seventy-one cemented total hip arthroplasties (THAs) were reviewed following removal of the all-titanium alloy femoral stem. Fifty-one hips were prima...
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