Noteworthy in 2014: What Are the Current Clinical Issues in Wear and Tribocorrosion?
Wear and corrosion in joint arthroplasty are important causes of failure. From the standpoint of current clinical importance, there are four main categories of wear and tribocorrosion: polyethylene wear, ceramic-on-ceramic (CoC) bearing wear, metal-on-metal (MoM) bearing wear, and taper tribocorrosion. Recently, problems with wear in the knee have become less prominent as have many issues with hip polyethylene (PE) bearings resulting from the success of crosslinked PE. However, MoM articulations and taper tribocorrosion have been associated with soft tissue inflammatory responses, and as a result, they have become prominent clinical concerns.
WHERE ARE WE NOW?:
For PE wear in the hip, several advances include improved locking mechanisms and data supporting highly crosslinked polyethylenes (HXLPE). Edge-loading in CoC articulations can contribute to stripe wear and subsequent squeaking. For MoM articulations, the relationship of wear-to-edge loading, sensitivity to component positioning, typical soft tissue response, and use of imaging is increasingly understood. Taper tribocorrosion (from femoral head-neck junctions and other modular elements) and associated soft tissue inflammatory responses appear to be serious clinical issues that are not fully understood.
WHERE DO WE NEED TO GO?:
In the knee, clinical concerns remain with the efficacy of HXLPE, modular connections, and metal allergies. For PE wear in the hip, concerns remain regarding how to increase crosslinking of PE while minimizing PE fractures. With CoC articulations, questions remain on how to prevent noises, chipping, and impingement and if enhanced designs can contribute to improved results. For MoM articulations, we need to improve imaging tests for soft tissue reactions, determine best practices in terms of monitoring protocols, and better define if, how, and when to act on serum metal levels. For taper tribocorrosion, we need to use modularity wisely and also understand how to improve tapers and materials in the future. For patients at risk for tribocorrosion, we need to define realistic diagnostic and monitoring protocols. We also need to enhance revision methods, and the threshold of acceptable soft tissue damage, to minimize complications associated with soft tissue damage such as hip instability.
HOW DO WE GET THERE?:
HXLPE and other bearing surfaces will likely continue to be refined. We need to develop tapers with more resistance to tribocorrosion through improved understanding of the manufacturing process and ongoing engineering improvements. Revision procedures for wear and tribocorrosion can be enhanced by determining when partial component retention is appropriate and how best to manage soft tissue damage. For CoC articulations, enhanced designs are required to minimize noises, chipping, and impingement. Importantly, we must continue to promote and analyze joint replacement registries to identify early failures and analyze long-term successes.
This review paper provides an overview of the wear and corrosion problems facing contemporary total joint arthroplasty from a clinicians perspective. The paper was presented during a three-day Carl T. Brighton Worshop on Implant Wear and Tribocorrosion, convened by the Association of Bone and Joint Surgeons on November 21-23, 2013 in Tampa Bay, Florida. This workshop, held every 6-7 years, has been useful to summarize the state of knowledge in the field of total joint tribology. Intially convened to address osteolysis and polyethlene wear, the workshop now covers a broader focous of implant wear and tribocorrosion in all types of orthopaedic devices. This review summarises the clinical state-of-the-art as it pertains to the diagnosis of wear and tribocorrosion issues; how patients should be monitored for wear related issues. The authors suggest treatment modalities for implant wear and corrosion, including how complications may be managed. In particular, this review illustrates the extent to which polyethylene wear is no longer on a pedestal by itself, but has been eclipsed by more recent clinical problems associated with alternative bearings and release of corrosion products from modular connections. Click here to see all the reviews published from the 2013 Carl T. Brighton Workshop on Implant Wear and Tribocorrosion.
Steve Kurtz, Ph.D.
Editor, UHMWPE Lexicon
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