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Evaluation and Treatment of Painful Total Hip Arthroplasties with Modular Metal Taper Junctions

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Evaluation and Treatment of Painful Total Hip Arthroplasties with Modular Metal Taper Junctions n tips & techniques Section Editor: Steven F. Harwin, MD Evaluation and Treatment of Painful Total Hip Arthroplasties With Modular Metal Taper Junctions R. Michael Meneghini, MD; Nadim J. Hallab, PhD; Joshua J. Jacobs, MD ice corrosion, a complex pro- This article discusses the Abstract: Modern primary total hip arthroplasty femo- cess involving fretting corro- clinical presentation, evalua- ral components have evolved to include modular necks. sion and crevice corrosion.1-7 tion, and workup of patients Subsequently, the additional taper junction provides another Reported to occur at the metal who present with persistent interface as a potential source for mechanically assisted crev- taper junction between cobalt- pain after successful THA ice corrosion, which is a complex process involving fretting chromium (CoCr) femoral with a metal taper junction and crevice corrosion. Furthermore, it is becoming evident heads and metal stems, me- suspected of mechanically as- that an adverse local tissue reaction may result in some pa- chanically assisted crevice sisted crevice corrosion. This tients due to the mechanically assisted crevice corrosion. This corrosion can similarly occur will provide clinicians with article details the clinical, radiographic, and laboratory evalu- ation of patients with these components who present with per- at the metal taper junction be- basic guidelines—but only sistent pain. The relevant surgical strategies and techniques to tween the modular neck and at our current level of under- address this pathology in symptomatic patients are addressed. stem in such designs. This can standing based on the few occur in titanium–titanium, reported cases—for the po- CoCr–titanium, and CoCr– tential clinical presentation, odern primary total hip tient’s anatomy and hip bio- CoCr taper junctions.1-7 evaluation, histopathology, Marthroplasty (THA) mechanics. However, with the It has been reported that and surgical treatment of such femoral components have additional taper junction, the elevated serum metal levels patients. evolved to include those with modular neck femoral com- and an adverse local tissue re- modular necks, which provide ponents provide an additional action may occur with metal- CLINICAL PRESENTATION the surgeon with more options interface that may be a source on-metal bearings, causing Patients with a persis- to reproduce or correct the pa- of mechanically assisted crev- premature failure.8-24 For the tently painful THA contain- purposes of this report, ad- ing a modular neck primary verse local tissue reactions femoral component (Figure Dr Meneghini is from Indiana University Health Physicians, Department include soft tissue responses, 1) who lack an evident etiol- of Orthopaedic Surgery, Indiana University School of Medicine, Indianapo- lis, Indiana; and Drs Hallab and Jacobs are from the Department of Ortho- such as aseptic lymphocyte- ogy should be considered for paedic Surgery, Rush University Medical Center, Chicago, Illinois. dominated vasculitis-associ- a potential adverse local tis- Dr Meneghini recieves funds from and is a consultant for Stryker Ortho- ated lesions, periprosthetic sue reaction to mechanically paedics and has patents with Nemcomed. Dr Hallab has no relevant financial osteolysis, and pseudotu- assisted crevice corrosion at relationships to disclose. Dr Jacobs is a consultant for Johnson & Johnson, Medtronic Sofamor Danek, Smith & Nephew, and Zimmer, and receives roy- mors. A similar reaction and the modular taper junction. alties from Taylor and Francis. potentially premature failure Patients will typically pres- Correspondence should be addressed to: R. Michael Meneghini, MD, of THA has been reported to ent with pain in the anterior, Indiana University Health Physicians, Department of Orthopaedic Surgery, occur in rare cases of patients lateral, or posterior hip. In a Indiana University School of Medicine, 13100 136th St, Ste 2000, Fishers, IN 46037 ([email protected]). with modular-neck femoral severe case of pseudotumor, 3 doi: 10.3928/01477447-20120426-03 components. patients may feel a large mass 386 Healio.com The new online home of ORTHOPEDICS | Healio.com/Orthopedics Cover Story Cover illustration © Jennifer E. Fairman, CMI, FAMI MAY 2012 | Volume 35 • Number 5 387 n tips & techniques Figure 1: Radiograph articular fluid is typically sub- The Medicines and of a painful total hip re- stantial in volume, turbid, and Healthcare products placement with a modu- 9 lar neck. brownish or grey in color. Regulatory Agency suggested Despite this frequently de- a cutoff blood level of 7 parts scribed appearance, aspira- per billion, yet this was shown tion analysis has not yet been to have a specificity of 89% proven to be specific to failed and sensitivity 52% for pre- implants due to metal-on-metal operatively detecting an unex- bearings or modular taper junc- plained failed metal-on-metal tions. THA.30 It was reported the op- timal cutoff for the maximum SERUM METAL LEVELS cobalt or chromium level was Mechanically assisted crev- 4.97 parts per billion and had 1 ice corrosion from modular sensitivity 63% and specific- Figure 2: Tissue section taper junctions may result in ity 86%; it was concluded (hematoxylin and eosin adverse local tissue reactions that blood metal ions have the stain, 3200 original magnification) of peri- via elevated metal concentra- ability to separate failed and articular tissue from tions. Therefore, patients pre- well-functioning hip replace- a patient with crevice senting with a painful THA of ments.30 corrosion showing fi- unknown etiology and a modu- However, interlaboratory broconnective tissue with necrosis and viable lar taper junction should obtain variability can exist in metal areas of engorged blood serum metal studies. It has measurements due to differ- vessels and diffuse lym- been reported that chromium ences in instrumentation, spec- 2 phocytic infiltrate. ion levels .17 µg/L and cobalt imen collection protocols, ma- ion levels .19 µg/L were asso- trix (whole blood or serum), or fluid collection, raising the ported incidence of patients ciated with elevated joint fluid and analytic methodology.31 suspicion for significant local with an adverse local tissue ion levels and metallosis.28 In addition, the levels may be soft tissue destruction. Patients reaction who present with a Recently, Kwon et al29 confounded by the presence may have pain at rest, but more clinical picture mimicking in- reported metal-on-metal re- of other implants containing often have pain with weight fection, including elevated se- surfacing arthroplasties using metal and differences in renal bearing. Physical examination rum inflammatory markers.20 ultrasound/magnetic reso- function. Although an under- may also reveal pain with hip The initial workup of a nance imaging and serum/hip standing of metal levels and motion and joint loading. painful THA should be a aspirate cobalt and chromium their correlation with adverse screening of the erythro- measurements. Pseudotumors local tissue reactions in THA EVALUATION FOR INFECTION cyte sedimentation rate and found in 7 patients (4%) were continues to evolve, the above Anecdotal and reported C-reactive protein; if either or associated with higher cobalt values are attempts at provid- cases document superimposed both are elevated, a hip aspira- and chromium levels. The me- ing some guidance to the clini- bacterial infection in the face tion is essential to rule out in- dian serum cobalt and chro- cian evaluating a patient with of clinical adverse local tissue fection as the source of pain. mium levels in women with a painful THA suspected of an reaction from metal-on-metal In patients with a modular ta- bilateral arthroplasty in the adverse local tissue reaction articulations.25 Evidence also per junction who do not have pseudotumor group were 9.0 with modular taper junctions. exists that alteration of the evidence for a diagnosis for in- and 12.0 µg/L, respectively, local pH may create an envi- fection, a workup for the pos- but only 2.9 and 3.2 µg/L, re- METAL HYPERSENSITIVITY ronment that facilitates metal sibility of adverse local tissue spectively, in similar patients Speculation exists that a corrosion, which suggests the reaction from metal junction without pseudotumor forma- metal allergy may contrib- pH alteration in occult peri- mechanically assisted crevice tion. These data suggest that ute to implant loosening. prosthetic infection may be a corrosion is recommended. pseudotumors may be associ- However, a clear connection precursor to corrosion in metal In patients with metal-on- ated with increased wear gen- is not found between the inci- taper junctions.26 Further con- metal bearings and an adverse erated from metal-on-metal dence of metal sensitivity and founding the issue is the re- local tissue reaction, the intra- articulations.29 implant duration, infection, 388 Healio.com The new online home of ORTHOPEDICS | Healio.com/Orthopedics n tips & techniques reason for removal, or pain. At dotumors or seen adjacent to Figure 3: Successful revision of the patient this time, it is unclear whether the implants. However, more in Figure 1 to a cement- metal sensitivity causes im- recently, computed tomogra- less femoral component plant loosening or vice versa. phy and magnetic resonance without a modular neck, Diagnostic testing in the form imaging with metal artifact using a ceramic-on- polyethylene bearing to of either patch testing or an in reduction sequence have been minimize any potential vitro lymphocyte
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