Mechanics and complications of reverse shoulder arthroplasty: morse taper failure analysis and prospective rectification

Abstract

Since Sir John Charnley began his monumental hip arthroplasty work in 1958, clinical researchers have been incrementally improving longevity and functionality of total joint systems, although implant failure occurs on occasion. The purpose of this study is to report the fracture of the humeral tray Morse taper of a reverse total shoulder system (RTSS), which to date has not been reported with metallurgic analysis for any RTSS. There was no reported antecedent fall, motor vehicle collision, or other traumatic event prior to implant fracture in this case. Analysis was performed on the retrieved failed implant by Scanning Electron Microscopy (SEM) and Electron Dispersion Spectroscopy (EDS) in an attempt to determine the failure method, as well as to offer improvements for future implants. At the time of revision surgery all explants were retained from the left shoulder of a 61-year old male who underwent a non-complicated RTSS 4 years prior. The explants, particularly the cracked humeral tray, were processed as required for SEM and EDS. Analysis was performed on the failure sites in order to determine the chemical composition of the different parts of the implant, discover the chemical composition of the filler metal used during the electron beam welding process, and to detect any foreign elements that could suggest corrosion or other evidence of failure etiology. Gross visual inspection of all explants revealed that implant failure was a result of dissociation of the taper from the humeral tray at the weld, leaving the Morse taper embedded in the humeral stem while the tray floated freely in the patient’s shoulder. SEM further confirmed the jagged edges noted grossly at the weld fracture site, both suggesting failure due to torsional forces. EDS detected elevated levels of carbon and oxygen at the fracture site on the taper only and not on the humeral tray. In order to determine the origin of the high levels of C and O, it was considered that in titanium alloys, C and O are used as stabilizers that help raise the temperature at which titanium can be cast. Since the presence of stabilizers reduces ductility and fatigue strength, all interstitial elements are removed after casting. Considering this, the presence of C and O suggests that not all of the interstitials were removed during the manufacturing process, resulting in decreased fatigue strength. Further destructive analytical testing would verify weld quality and failure mode. RTSSs are quite successful in select patients not amenable to traditional shoulder arthroplasty options. This case report highlights how an implant may function well for several years and then suddenly fail without warning. SEM and EDS analysis suggest that residual C and O in the taper lowered the metal implant’s integrity, leading to torsional cracking at the weld junction of the humeral tray and the taper. The elevated levels of C and O measured at fracture sites on both the tray and the taper suggest poor quality filler metal or failure to remove all interstitial elements after casting. In both cases, the results would be decreased fatigue strength and overall toughness, leading to mechanical failure. A manufacturer’s recall of all implants soon followed the reporting of this implant failure; subsequently, the metal materials were changed from Ti6Al4V to both titanium alloy and cobalt-chrome alloy (Co-Cr-Mo). Time will tell if the alterations were sufficient.