Dual-Modular Stems for Primary Total Hip Arthroplasty

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Abstract

In primary total hip arthroplasty (THA), dual-modular stems were introduced to better restore hip stability, femoral offset, and leg length. This entry highlights the gathered knowledge about dual-modular stems and related complications in combinations with titanium (Ti) and cobalt-chrome (CoCr) exchangeable necks. The reasons for a modular neck failure are multifactorial. Some of the dual-modular stems are still on the market despite the fact th these designs have neither been proven for durability nor have shown any clinical benefits for the patients as compared to monolithic stems. Apart from very limited indications, orthopaedic surgeons should not use dual-modular stem designs for primary THA.

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Hip joint loading during walking and running, measured in two patients.

Leigh Bergmann, F Graichen, A Rohlmann (1993)

The resultant hip joint force, its orientation and the moments were measured in two patients during walking and running using telemetering total hip prostheses. One patient underwent bilateral joint replacement and a second patient, additionally suffering from a neuropathic disease and atactic gait patterns, received one instrumented hip implant. The joint loading was observed over the first 30 and 18 months, respectively, following implantation. In the first patient the median peak forces increased with the walking speed from about 280% of the patient's body weight (BW) at 1 km h-1 to approximately 480% BW at 5 km h-1. Jogging and very fast walking both raised the forces to about 550% BW; stumbling on one occasion caused magnitudes of 720% BW. In the second patient median forces at 3 km h-1 were about 410% BW and a force of 870% BW was observed during stumbling. During all types of activities, the direction of the peak force in the frontal plane changed only slightly when the force magnitude was high. Perpendicular to the long femoral axis, the peak force acted predominantly from medial to lateral. The component from ventral to dorsal increased at higher force magnitudes. In one hip in the first patient and in the second patient the direction of large forces approximated the average anteversion of the natural femur. The torsional moments around the stem of the implant were 40.3 N m in the first patient and 24 N m in the second.

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In vivo corrosion of modular hip prosthesis components in mixed and similar metal combinations. The effect of crevice, stress, motion, and alloy coupling.

J. Gilbert, Donald Jacobs, Tom Buckley (1993)

One hundred forty-eight retrieved modular hip prostheses of both mixed (Ti-6Al-4V/Co-Cr) and similar (Co-Cr/Co-Cr) metal combinations were examined and positive evidence of corrosive attack was found in the conical taper region between head and stem. Significant corrosion was observed in both mixed and similar metal combinations with 16% of necks and 35% of heads (for mixed-metal cases), and 14% of necks and 23% of heads (for similar-metal cases) showing moderate to severe corrosive attack. There was a significant correlation between the percentage of prostheses with moderate to severe corrosion and the duration of implantation for both mixed and similar metal cases, indicating that this corrosion process is progressive in time. Moderate to severe corrosion was seen as early as 2.5 and 11 months (mixed and similar metals, respectively). Scanning electron microscopy and x-ray analysis identified several forms of corrosive attack in the cobalt-based component of the taper. These included, for both mixed and same metal combinations: preferential dissolution of cobalt, fretting, and pitting; mixed metals only: the formation of a Ti-Cr-Mo interfacial phase and interdendritic corrosion; and for similar metals: intergranular attack adjacent to grain boundaries enriched in molybdenum and silicon. It is hypothesized that the restricted crevice environment, coupled with high cyclic stresses which cause repeated fracture of the passive oxide films in the taper, result in an unstable electrochemical environment within the crevice for both the cobalt alloy and Ti-alloy passive films. The passivity of these alloys is subsequently lost and active attack of the taper results. Also, the repeated fracturing of the passive films will result in large amounts of corrosion products being formed. This corrosion and particulate accumulation could result in loss of mechanical integrity of the implants in vivo, create particles for third body wear, and release particles into the surrounding tissues.

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Indication criteria for total hip or knee arthroplasty in osteoarthritis: a state-of-the-science overview

Maaike Gademan, Stefanie N. Hofstede, Thea Vliet Vlieland … (2016)

Background This systematic review gives an overview of guidelines and original publications as well as the evidence on which the currently proposed indication criteria are based. Until now such a state-of-the-science overview was lacking. Methods Websites of orthopaedic and arthritis organizations (English/Dutch language) were independently searched by two authors for THA/TKA guidelines for OA. Furthermore, a systematic search strategy in several databases through August 2014 was performed. Quality of the guidelines was assessed with the AGREE II instrument, which consists of 6 domains (maximum summed score of 6 indicating high quality). Also, the level of evidence of all included studies was assessed. Results We found 6 guidelines and 18 papers, out of 3065 references. The quality of the guidelines summed across 6 domains ranged from 0.46 to 4.78. In total, 12 THA, 10 TKA and 2 THA/TKA indication sets were found. Four studies stated that no evidence-based indication criteria are available. Indication criteria concerning THA/TKA consisted of the following domains: pain (in respectively 11 and 10 sets), function (12 and 7 sets), radiological changes (10 and 9 sets), failed conservative therapy (8 and 4 sets) and other indications (6 and 7 sets). Specific cut-off values or ranges were often not stated and the level of evidence was low. Conclusion The indication criteria for THA/TKA are based on limited evidence. Empirical research is needed, especially regarding domain specific cut-off values or ranges at which the best postoperative outcomes are achieved for patients, taking into account the limited lifespan of a prosthesis. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1325-z) contains supplementary material, which is available to authorized users.