Prosthetic Impingement in Total Hip Arthroplasty—The Trigger for Adverse Wear

Abstract

Development of total hip arthroplasty (THA) now spans more than 5 decades encompassing combinations of metal-on-metal (MOM), ceramic-on-metal (COM), metal-on-plastic (MOP), ceramic-on-plastic (COM), and ceramic-on-ceramic (COC). In every arena of extensive technical development, there exists a data set that when viewed in isolation seemed of little import, but when assembled in-toto may produce a generational shift in perception. Our review focused on two such THA events. Firstly, COC retrieval studies (1999-2001) noted habitual wear patterns on heads and peripheral wear stripes, along with femoral-neck impingement, and ceramic surfaces stained gray by metal debris. These COC data indicated THA risks included, 1) cup edge-loading (E/L) on heads producing “stripe wear”, 2) component impingement releasing metal particles resulting in 3) tissues contaminated by metal debris. A corresponding MOM impingement-debris mechanism was only perceived by Howie (2005) in a McKee-Farrar retrieval study. Our anticipation at LLUMC was that MOM retrievals would provide superior wear details to those seen on COC retrievals. We noted stripe wear in the polar zone of CoCr heads and basal stripes in the non-wear areas. The basal-polar stripe combinations were found in all MOM retrievals. Basal-polar stripe combinations followed cup-rim profiles in our LLUMC simulations of prosthetic impingement. LPUH videos demonstrated the formation of stripe wear in functional-standing and functional-sitting postures for both impingement and subluxation episodes using THA and RA designs. The stripes on CoCr heads revealed the large scratches we now term “microgrooves”. Microgroove width varied from 40 - 400 um with 100 um being typical. The longitudinal striations in microgrooves, the raised jagged lips, scratches with shallow entry and exit termini, were all indicative of a classic 3rd-body wear mechanism. The THA impingement simulations denoted four sites of edge-loading, i.e. neck-E/L, inferior cup-E/L, superior cup-E/l and head-E/L, and ingress of Ti64 particles as a contaminating-roughness effect. Individual MOM cases referred to LLUMC demonstrated dramatic evidence of neck notching. At one end of the debris spectrum, a Ti64-notch model predicting a 6 mm3 annual wear-rate represented the release of 5700 particles of 126 um-size (approximating daily release of 16 particles). At the other end of the spectrum, if metal particles were crushed between MOM surfaces to the equivalent nanometer size found in tissues, our notch model represented approximately 22-trillion Ti64 particles annually deposited in tissues. The anatomical THA models represented in LPUH videos demonstrated that even 1-degree of head subluxation from a rigid cup created a cup “lift-off” scenario (CLO) that would open a gap of 250 - 400 microns between femoral head and cup. This would void all lubrication potential and focus the total hip-joint force along the beveled cup rim, i.e. stripe wear. It is therefore interesting that MOM impingement/debris predictions by Howie et al. have not been confirmed until now or discussed in contemporary literature. Therefore, this review of 50 years of THA data demonstrated that hip impingement was always the trigger for adverse wear and that metal-backed cups represent the potential for release of metal debris at extremes of functional standing and sitting postures.