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Tanzer M, Ngo CG, Wong AK, Badwe B, Mullen L. The Effect of Titanium Nitride Coatings on the Ingrowth and Interface Strength of Three-Dimensional Printed Porous Implants. J Arthroplasty 2025:S0883-5403(25)00297-9. [PMID: 40154582 DOI: 10.1016/j.arth.2025.03.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2024] [Revised: 03/18/2025] [Accepted: 03/19/2025] [Indexed: 04/01/2025] Open
Abstract
BACKGROUND The impact of titanium nitride (TiN) coatings on biologic fixation of modern titanium-based porous surfaces fabricated using additive manufacturing (AM) techniques remains unexplored. This study aimed to compare the biological fixation of three-dimensional (3D)-printed porous implants, with and without TiN coating, in a canine model. METHODS A canine femoral transcortical model was used to evaluate the characteristics of bone ingrowth of fully porous Ti-6Al-4V cylindrical implants fabricated using either laser rapid manufacturing or electron beam melting. Implants were further divided into coated (TiN) and uncoated groups. Histological (bone ingrowth evaluation via scanning electron microscopy) and mechanical push-out testing on the four groups of implants were performed at 4 and 12 weeks postimplantation. RESULTS Both TiN-coated and uncoated implants demonstrated substantial bone ingrowth at both time points. Bone ingrowth ranged from 35 to 50% at 4 weeks and then increased to 49 to 59% at 12 weeks. Mechanical tests indicated shear fixation strength ranging from 18 to 20 MPa at 4 weeks, increasing to 34 to 38 MPa at 12 weeks. There was no significant difference in either the amount of bone ingrowth or shear strength between TiN-coated and uncoated implants at either time point for both the laser rapid manufacturing and electron beam melting implants. CONCLUSIONS This study demonstrated substantial bone ingrowth as well as comparable shear strength between TiN-coated and uncoated implants, regardless of manufacturing technique. Titanium nitride coatings do not influence biological fixation on modern titanium-based AM porous surfaces.
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Affiliation(s)
- Michael Tanzer
- Jo Miller Orthopaedic Laboratory, Division of Orthopaedic Surgery, McGill University, Montreal, Canada
| | - Chau G Ngo
- Stryker Orthopaedics, Mahwah, New Jersey
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Basgul C, MacDonald DW, Klein GR, Piuzzi NS, Kurtz SM. Retrieval Analysis of Titanium Nitride Coatings for Orthopaedic Implants. J Arthroplasty 2024; 39:S272-S279. [PMID: 39019413 DOI: 10.1016/j.arth.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 06/07/2024] [Accepted: 07/01/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND The first generation of titanium nitride (TiN) coatings for orthopaedic implants was clinically introduced in the 1990s because of their promising biocompatibility, wear resistance, and corrosion resistance. This study evaluated the in vivo performance of early TiN-coated knee and hip implants, focusing on the bearing surfaces and mechanisms of in vivo damage. METHODS There were 13 TiN-coated implants (5 knee and 8 hip) retrieved from 8 patients as part of a multi-institutional implant retrieval program. The average implantation time was 4.25 years for knees and 17.5 years for hips. Implant revisions occurred for various reasons, including polyethylene wear, loosening, pain, infection, and instability. Components were examined using a semiquantitative scoring method, and surface roughness measurements were performed using white-light interferometry. Surface morphology, chemistry, and particle characterization were also assessed by scanning electron microscopy. RESULTS For hips, mild corrosion was found on femoral head tapers, along with severe scratching on certain femoral heads. Knee implants exhibited low burnishing and scratching for both mechanisms. Roughness measurements (Sa) were 37.3 nm (interquartile range = 22.0 to 62.4) for hips and 85.3 nm (interquartile range = 66.3 to 110) for knees. The observed scratch depth in both hip and knee implants due to third-body particles ranged from 0.3 to 1.3 μm. The coating coverage remained intact in the majority of the implants, with 2 cases of small, localized cohesive chipping and substrate exposure. CONCLUSIONS The results of this study confirm the potential in vivo durability of early TiN coatings and will be useful in benchmarking wear tests for modern TiN-coated orthopaedic implants.
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Affiliation(s)
- Cemile Basgul
- Implant Research Core, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Daniel W MacDonald
- Implant Research Core, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania
| | - Gregg R Klein
- Department of Orthopaedic Surgery, Hackensack University Medical Center, Hackensack, New Jersey
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Kurtz
- Implant Research Core, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania
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Bara A, Singh A, Patel K, Herlekar D. Extensive Metallosis in a Primary Knee Arthroplasty as a Result of Polyethylene Wear: Is It Avoidable? Cureus 2024; 16:e57888. [PMID: 38725739 PMCID: PMC11081404 DOI: 10.7759/cureus.57888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
Metallosis is known to occur in metal-on-metal arthroplasty and has been of concern to orthopaedic surgeons worldwide. It is a rare, late complication of total knee arthroplasty (TKA), in which metal-on-metal contact leads to metal debris deposition in the surrounding tissue. Reasons for metal-on-metal contact could range from wear of the polyethylene insert to abnormal joint biomechanics. Many components can affect the development of metallosis, with polyethylene wear being the most common cause of metallosis. This paper discusses the case of an 85-year-old man who developed metallosis, attributed to polyethylene wear, 24 years after undergoing TKA. It also highlights the different components of knee prostheses, evaluates the efficacy of different types of polyethylene, and explores whether ceramic coating can improve TKA outcomes and reduce complications such as metallosis.
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Affiliation(s)
- Anas Bara
- Orthopaedics and Trauma, University of Central Lancashire, Preston, GBR
| | - Abhimanyu Singh
- Orthopaedics and Trauma, Royal Lancaster Infirmary, Lancaster, GBR
| | - Kuntal Patel
- Orthopaedics and Trauma, Royal Lancaster Infirmary, Lancaster, GBR
| | - Deepak Herlekar
- Orthopaedics and Trauma, Royal Lancaster Infirmary, Lancaster, GBR
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Hörlesberger N, Smolle MA, Leitner L, Hauer G, Leithner A, Sadoghi P. Long-term clinical and radiological outcome of a cementless titanium-coated total knee arthroplasty system. Arch Orthop Trauma Surg 2024; 144:847-853. [PMID: 37831197 PMCID: PMC10822817 DOI: 10.1007/s00402-023-05091-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION To ensure a high-quality standard, it is important to frequently evaluate different prostheses models to avoid prostheses with high failure rates. Thus, the aim of the study was to evaluate the long-term outcome of the uncemented titanium-coated total knee arthroplasty (TKA) system (Advanced Coated System (ACS) III, Implantcast, GERMANY). We hypothesized that the ACS III would have a similar performance as other cemented TKA systems. MATERIALS AND METHODS A total of 540 ACS III mobile-bearing knee joint prostheses were implanted in 495 patients. The visual analogue scale (VAS) score, Tegner activity score (TAS), knee society score (KSS), Western Ontario and McMaster (WOMAC) score, and the Short Form 12 (SF-12) score for the evaluation of quality of life (QoL) were taken after at least 9 years of follow-up. In addition, we measured range of motion (ROM) and assessed potential sex differences. In addition, the survival analysis was calculated at a median follow-up of 16.7 years. RESULTS At the final follow-up, 142 patients had died, and 38 had been lost to follow-up. The rate of revision-free implant survival at 16.7 years was 90.0% (95% CI 87.1-92.2%) and the rate of infection-free survival was 97.0% (IQR 95.2-98.2%). The reasons for revision surgery were aseptic loosening (32.9%), followed by infection (27.1%), inlay exchange (15.9%), and periprosthetic fractures (5.7%). At the clinical follow-up visit, the mean VAS score was 1.9 ± 1.9, the median TAS was 3 (IQR 2-4), and the mean KSS for pain and function were 83.5 ± 15.3 and 67.5 ± 25.2, respectively. The mean WOMAC score was 81.1 ± 14.9, and the median SF-12 scores for physical and mental health were 36.9 (IQR 29.8-45.1) and 55.8 (IQR 46.2-61.0), respectively. The mean knee flexion was 102.0° ± 15.4°. Male patients had better clinical outcome scores than female patients [SF-12 mental health score, p = 0.037; SF-12 physical health score, p = 0.032; KSS pain score (p < 0.001), and KSS functional score (p < 0.001)]. CONCLUSION The ACS III TKA system is a suitable option for the treatment of end-stage osteoarthritis of the knee joint because of its adequate long-term survival. Our findings are in line with published data on similar TKA systems that have shown favourable clinical scores in males. LEVEL OF EVIDENCE Level III-Retrospective cohort study.
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Affiliation(s)
- Nina Hörlesberger
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Georg Hauer
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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Fortmann C, Göen T, Wiesner S, Hegermann J, Kiblawi R, Dohna M, Ure BM, Renz DM, Petersen C, Kuebler JF. Titanium nitride coating of pectus bar increases metal contamination after minimally-invasive repair of pectus excavatum. PLoS One 2023; 18:e0292616. [PMID: 37824548 PMCID: PMC10569521 DOI: 10.1371/journal.pone.0292616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023] Open
Abstract
INTRODUCTION Previous studies demonstrated a release of toxic metals, e.g. nickel and chromium, from stainless steel bars used for minimally invasive repair of pectus excavatum (MIRPE). In the present study, we investigated the impact of titanium nitride coating on the metal release and exposure of MIRPE patients. MATERIAL AND METHODS We analyzed the courses of nickel and chromium levels in blood, urine and local tissue in patients undergoing MIRPE with a titanium nitride coated pectus bar between 03/2017 and 10/2018. Sample collection was scheduled prior to MIRPE, at defined postoperative time points and at bar removal. Additionally, we evaluated irritative symptoms. Results were compared to a control group who received uncoated stainless steel bars in a previous time period (03/2015-02/2017). RESULTS 12 patients received coated pectus bars (mean age 15.7 years). The control group included 28 patients. After implantation of a titanium nitride coated bar, significant increase in systemic nickel and chromium levels after one, two and three years was noted. In an interim analysis one year after MIRPE, we observed patients with coated bars to have significantly elevated trace metal values compared to the control group. This elevation persisted throughout the observation period. Tissue metal values were also significantly increased. Irritative symptoms occurred significantly more often in study patients compared to controls (50.0% vs. 14.3%). CONCLUSIONS Coating of pectus bars with titanium nitride failed to reduce metal contamination after MIRPE. Instead, it resulted in a significant increase of trace metal levels after MIRPE, compared to patients with stainless steel bars, which may be explained by wear of the coating and inter-component mobilization processes.
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Affiliation(s)
- Caroline Fortmann
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Thomas Göen
- Social and Environmental Medicine, Institute and Outpatient Clinic of Occupational, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Soeren Wiesner
- Hannover Medical School, Institute for Biostatistics, Hannover, Germany
| | - Jan Hegermann
- Hannover Medical School, Research Core Unit Electron Microscopy, Institute of Functional and Applied Anatomy, Hannover, Germany
| | - Rim Kiblawi
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Martha Dohna
- Department of Pediatric Radiology, Hannover Medical School, Institute of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Benno M. Ure
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Diane Miriam Renz
- Department of Pediatric Radiology, Hannover Medical School, Institute of Diagnostic and Interventional Radiology, Hannover, Germany
| | - Claus Petersen
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
| | - Joachim F. Kuebler
- Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany
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Bormann T, Kraenzler S, Jaeger S, Kluess D, Mittelmeier W, Renkawitz T, Kretzer JP. Stability of ceramic coatings on retrieved knee prostheses. J Mech Behav Biomed Mater 2023; 144:105997. [PMID: 37413893 DOI: 10.1016/j.jmbbm.2023.105997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND In total knee arthroplasty, femoral components with coated or oxidized surfaces are commonly used as alternative to CoCrMo in metal sensitive patients. Data on the in vivo behaviour of different coating types is, however, rare. Aim of the study was the investigation of coating stability with respect to implant and patient specific parameters. METHODS Coating thickness and coating thickness reduction, respectively, was measured at 37 retrieved femoral components with TiNbN, TiN, ZrN or oxidized zirconium (OxZr) surface by the crater grinding method. The results were correlated to surface type, manufacturer, time in vivo of the implant, patient body weight and patient activity. RESULTS Mean coating thickness reduction in the overall retrieval collection was 0.6 μm ± 0.8 μm. There was no correlation between coating thickness reduction and coating type, time in vivo, patient body weight, and patient activity. If grouped according to manufacturers, implants of one manufacturer showed an increased coating thickness reduction. 10 of 37 retrievals exhibited coating abrasion with exposure of the underlying alloy. TiNbN coatings showed the highest incidence (9/17) of coating abrasion. No coating breakthrough was observed in the ZrN or OxZr surfaces. CONCLUSION Our results indicate that TiNbN coatings should be optimized to improve their wear resistance in the long-term.
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Affiliation(s)
- Therese Bormann
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany.
| | - Simeon Kraenzler
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - Daniel Kluess
- Department of Orthopaedics, Rostock University Medical Center, Doberaner Straße 142, 18057, Rostock, Germany
| | - Wolfram Mittelmeier
- Department of Orthopaedics, Rostock University Medical Center, Doberaner Straße 142, 18057, Rostock, Germany
| | - Tobias Renkawitz
- Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
| | - J Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, Heidelberg University Hospital, Schlierbacher Landstrasse 200a, 69118, Heidelberg, Germany
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Gavish L, Kandel L, Rivkin G, Gertz SD, Hoffer O. Natural history of changes in knee skin temperature following total knee arthroplasty: a systematic review and meta-analysis. Sci Rep 2023; 13:6810. [PMID: 37100814 PMCID: PMC10133306 DOI: 10.1038/s41598-023-33556-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/14/2023] [Indexed: 04/28/2023] Open
Abstract
Patients undergoing total-knee arthroplasty (TKA) have transient increases in anterior knee skin temperature (ST) that subside as recovery progresses-except in cases of systemic or local prosthetic joint infections (PJI). This meta-analysis was designed to quantify the changes in knee ST following TKA in patients with uncomplicated recovery as a prerequisite for assessing the usefulness of thermal imaging for diagnosis of PJI. This meta-analysis (PROSPERO-CRD42021269864) was performed according to PRISMA guidelines. PUBMED and EMBASE were searched for studies reporting knee ST of patients that underwent unilateral TKA with uncomplicated recovery. The primary outcome was the weighted means of the differences in ST between the operated and the non-operated knees (ΔST) for each time point (before TKA, and 1 day; 1,2, and 6 weeks; and 3,6, and 12-months post-TKA). For this analysis, 318 patients were included from 10 studies. The elevation in ST was greatest during the first 2-weeks (ΔST = 2.8 °C) and remained higher than pre-surgery levels at 4-6 weeks. At 3-months, ΔST was 1.4 °C. It decreased to 0.9 °C and 0.6 °C at 6 and 12-months respectively. Establishing the baseline profile of knee ST following TKA provides the necessary first step for evaluating the usefulness of thermography for the diagnosis of post-procedural PJI.
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Affiliation(s)
- Lilach Gavish
- Institute for Research in Military Medicine (IRMM) and Institute for Medical Research (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Forces Medical Corps, POB 12272, 9112001, Jerusalem, Israel.
- The Saul and Joyce Brandman Hub for Cardiovascular Research and the Department of Medical Neurobiology, Institute for Medical Research (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Leonid Kandel
- Department of Orthopedics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gurion Rivkin
- Department of Orthopedics, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - S David Gertz
- Institute for Research in Military Medicine (IRMM) and Institute for Medical Research (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem and the Israel Defense Forces Medical Corps, POB 12272, 9112001, Jerusalem, Israel
- The Saul and Joyce Brandman Hub for Cardiovascular Research and the Department of Medical Neurobiology, Institute for Medical Research (IMRIC), Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oshrit Hoffer
- Department of Electrical Engineering, Afeka Tel-Aviv Academic College of Engineering, Tel-Aviv, Israel
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Banci L, Balato G, Salari P, Baldini A. "Systematic review and meta-analysis of ceramic coated implants in total knee arthroplasty. Comparable mid-term results to uncoated implants.". Knee Surg Sports Traumatol Arthrosc 2023; 31:839-851. [PMID: 34714355 DOI: 10.1007/s00167-021-06775-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/08/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nitride-based ceramic coatings, such as titanium nitride (TiN) and titanium niobium nitride (TiNbN), have been introduced in total knee arthroplasty (TKA) to enhance the mechanical properties and biocompatibility of knee components, harden the metal surface and reduce CoCrMo exposure and metal ion release. However, the theoretical advantages of these ceramic coatings in TKA have yet to be fully elucidated. This systematic review aimed to provide clinical evidence on mid-term outcomes of ceramic-coated knee prostheses in comparison with uncoated standard CoCrMo knee prostheses in primary TKA. The hypothesis was that ceramic-coated implants can be used in primary TKA with no inferior outcomes compared to uncoated CoCrMo implants. METHODS A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to find all clinical studies regarding primary TKA with ceramic-coated knee prostheses. MEDLINE (PubMed), Embase and Cochrane Library were searched from 1990 to October 2020 to identify relevant studies for the first qualitative analysis. Using PICOS eligibility criteria, a subgroup of the selected studies was used to perform a meta-analysis. RESULTS Fifteen studies were included in this systematic review, of which six were included in the meta-analysis: 3 randomized controlled trials, 2 retrospective comparative studies and 1 prospective cross-sectional study. Pooled data overall included 321 coated TKAs vs. 359 uncoated TKAs and a mean follow-up of 4.6 years (range, 2-10 years). No significant difference in the implant survival risk ratio with revision or reoperation due to any reason was found between coated and uncoated TKAs, even considering the RCT study subgroup with a risk ratio of 1.02 (P = 0.34). No significant differences were found for postoperative complications, clinical scores, or metal blood concentrations at 1 year. CONCLUSION The findings of this systematic review and meta-analysis support the statement that ceramic-coated TKAs are not inferior to uncoated TKAs, showing comparable survival rates, complication rates and clinical outcomes. There is strong evidence that ceramic-coated TKA does not improve the clinical results or survival rate in comparison with uncoated TKA. LEVEL OF EVIDENCE II, Therapeutic.
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Affiliation(s)
- Lorenzo Banci
- Permedica Orthopaedics S.P.A, Via Como 38, Merate, 23807, Lecco, Italy.
| | - Giovanni Balato
- Department of Public Health, Section of Orthopaedic Surgery, "Federico II" University, Naples, Italy
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Deroche E, Batailler C, Shatrov J, Gunst S, Servien E, Lustig S. No clinical difference at mid-term follow-up between TiN-coated versus uncoated cemented mobile-bearing total knee arthroplasty: a matched cohort study. SICOT J 2023; 9:5. [PMID: 36757220 PMCID: PMC9910165 DOI: 10.1051/sicotj/2023001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/05/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Nitride-based ceramic coating was introduced into surgical implants to improve hardness, reduce abrasion, and decrease the risk of metal-induced adverse reactions, especially for patients with suspected or identified metal hypersensitivity. The study aimed to evaluate the effectiveness and safety of a titanium nitride (TiN) coated prosthesis with a mobile bearing design. METHODS This was a retrospective matched-cohort study from a single center, comparing clinical outcomes between patients receiving either a TiN-coated versus an uncoated cobalt-chromium-molybdenum (CoCrMo) prostheses for primary total knee replacement. Seventeen patients received the TiN prosthesis between 2015 and 2019. These were matched 1:2 with patients receiving uncoated mobile-bearing knee prostheses with the same design manufacturer. RESULTS Fourteen patients in the TiN group had complete 5-year follow-up data and were compared with 34 patients from the CoCrMo group. The Knee Society Score was 170.6 ± 28.0 (Function subscore 83.7 ± 17.5 and Knee subscore 86.9 ± 13.8) in the TiN group and 180.7 ± 49.4 (Function subscore 87.5 ± 14.3 and Knee subscore 93.2 ± 9.6) in CoCrMo group, with no statistically significant difference (p = 0.19). One patient underwent a revision for instability requiring the removal of the implant in the TiN group and none in the CoCrMo group. The survival rates were 92.9% (CI95% 77.3-100.0) and 100.0% in the TiN group and CoCrMo group respectively (p = 1.0). DISCUSSION TiN-coated TKA with mobile bearing resulted in satisfactory clinical outcomes, and a low revision rate, and there was no complication related to the coated implant. The use of TiN-coated prostheses in case of confirmed or suspected metal allergy provides satisfactory short-term clinic outcomes.
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Affiliation(s)
- Etienne Deroche
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,Corresponding author:
| | - Cécile Batailler
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France
| | - Jobe Shatrov
- Sydney Orthopaedic Research Institute (SORI) at Landmark Orthopaedics 500 Pacific Hwy St. Leonards NSW Australia
| | - Stanislas Gunst
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France
| | - Elvire Servien
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,LIBM – EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University 69622 Lyon France
| | - Sébastien Lustig
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,University of Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
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Thienpont E. Titanium niobium nitride knee implants are not inferior to chrome cobalt components for primary total knee arthroplasty at medium-term follow-up. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04754-1. [PMID: 36595031 DOI: 10.1007/s00402-022-04754-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Oxidized zirconium (Oxinium), titanium nitride (TiN) or titanium niobium nitride (TiNbN) coated implants became in recent years available for an increasing amount of total knee arthroplasty (TKA) systems. The hypothesis of this study was that the use of TiNbN-coated components would not lead to inferior results compared to conventional implants and that none of the metal hypersensitivity patients receiving TiNbN-coated implants would require revision for metal allergy. MATERIALS AND METHODS This retrospective study compared 53 Titanium Niobium Nitride coated TKA with 103 conventional chrome cobalt implants of the same design. Patients were evaluated at a minimal follow-up of 3 years. RESULTS No differences in clinical, radiological or patient-reported outcome measurements were observed between these groups. A survivorship of 96% without differences in revision rates was observed at medium-term follow-up of 6.5 years. DISCUSSION Metal allergy leading to contact or generalized dermatitis after TKA is very rare and usually linked to chrome or cobalt hypersensitivity. Nickel release from knee implants has not been shown to lead to cutaneous symptoms, but unexplained pain and swelling, peri-prosthetic osteolysis and component loosening remain potential issues not fully understood. The use of coated implants eliminates this factor from the diagnostic equation in case of postoperative dissatisfaction. CONCLUSION The use of titanium niobium nitride coated implants for primary knee osteoarthritis in self-reported metal hypersensitivity patients shows similar outcomes and survivorship rates as conventional chrome cobalt TKA, with no revisions for allergy at medium-term follow-up.
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Affiliation(s)
- Emmanuel Thienpont
- Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
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Skjöldebrand C, Tipper JL, Hatto P, Bryant M, Hall RM, Persson C. Current status and future potential of wear-resistant coatings and articulating surfaces for hip and knee implants. Mater Today Bio 2022; 15:100270. [PMID: 35601891 PMCID: PMC9118168 DOI: 10.1016/j.mtbio.2022.100270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/09/2022] [Accepted: 04/24/2022] [Indexed: 10/29/2022] Open
Abstract
Hip and knee joint replacements are common and largely successful procedures that utilise implants to restore mobility and relieve pain for patients suffering from e.g. osteoarthritis. However, metallic ions and particles released from both the bearing surfaces and non-articulating interfaces, as in modular components, can cause hypersensitivity and local tissue necrosis, while particles originating from a polymer component have been associated with aseptic loosening and osteolysis. Implant coatings have the potential to improve properties compared to both bulk metal and ceramic alternatives. Ceramic coatings have the potential to increase scratch resistance, enhance wettability and reduce wear of the articulating surfaces compared to the metallic substrate, whilst maintaining overall toughness of the implant ensuring a lower risk of catastrophic failure of the device compared to use of a bulk ceramic. Coatings can also act as barriers to inhibit ion release from the underlying material caused by corrosion. This review aims to provide a comprehensive overview of wear-resistant coatings for joint replacements - both those that are in current clinical use as well as those under investigation for future use. While the majority of coatings belong predominantly in the latter group, a few coated implants have been successfully marketed and are available for clinical use in specific applications. Commercially available coatings for implants include titanium nitride (TiN), titanium niobium nitride (TiNbN), oxidized zirconium (OxZr) and zirconium nitride (ZrN) based coatings, whereas current research is focused not only on these, but also on diamond-like-carbon (DLC), silicon nitride (SiN), chromium nitride (CrN) and tantalum-based coatings (TaN and TaO). The coating materials referred to above that are still at the research stage have been shown to be non-cytotoxic and to reduce wear in a laboratory setting. However, the adhesion of implant coatings remains a main area of concern, as poor adhesion can cause delamination and excessive wear. In clinical applications zirconium implant surfaces treated to achieve a zirconium oxide film and TiNbN coated implants have however been proven comparable to traditional cobalt chromium implants with regards to revision numbers. In addition, the chromium ion levels measured in the plasma of patients were lower and allergy symptoms were relieved. Therefore, coated implants could be considered an alternative to uncoated metal implants, in particular for patients with metal hypersensitivity. There have also been unsuccessful introductions to the market, such as DLC coated implants, and therefore this review also attempts to summarize the lessons learnt.
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Affiliation(s)
| | - Joanne L. Tipper
- University of Technology Sydney, School of Biomedical Engineering, Sydney, Australia
| | | | - Michael Bryant
- University of Leeds, Department of Mechanical Engineering, Leeds, United Kingdom
| | - Richard M. Hall
- University of Leeds, Department of Mechanical Engineering, Leeds, United Kingdom
| | - Cecilia Persson
- Uppsala University, Department of Materials Science and Engineering, Uppsala, Sweden
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Kellens J, Berger P, Vandenneucker H. Metal wear debris generation in primary total knee arthroplasty: is it an issue? Acta Orthop Belg 2021; 87:681-695. [PMID: 35172435 DOI: 10.52628/87.4.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
More durable total knee arthroplasties (TKAs) are needed, due to the rising life expectancy, the higher activity levels of patients and the growing concerns about aseptic loosening being caused by metal hypersensitivity. In response, different hypoallergenic metal coatings have been developed for TKAs. However, possible adverse effects of these different metals (cobalt-chromium-molybdenum, zirconium, titanium and tantalum) have been neglected. The aim was to summarize the local and systemic adverse effects (including metal hypersensitivity), survival ratios, patient-reported outcome measures (PROMs) and the plasma metal ion concentrations of the different TKA coatings. A literature search on PubMed and EMBASE was performed. In total, 15 studies were found eligible. Common adverse effects of TKA were infection, loosening, pain, instability and hyper- coagulation disorders. Serious adverse effects related to TKA implants were not reported. The survival ratios and patient-reported outcome measures seem to confirm these good results. In contrast with chromium and cobalt, no significant differences were reported in the nickel, molybdenum and titanium concentrations. No significant differences between the hypoallergenic and standard TKA implants were found in terms of adverse effects, survival ratios and PROMs. A causal relationship between the common adverse effects and the different metals is unlikely. Due to the heterogeneity of the TKA implants used, no firm conclusions could be made. Further research with longer follow-up studies are needed to find possible adverse effects and differences. Thus far, the hypoallergenic implants seem to perform equal to the standard implants.
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Postler A, Beyer F, Lützner C, Tille E, Lützner J. [The use of knee prostheses with a hypoallergenic coating is safe in the medium term : A randomized controlled study]. DER ORTHOPADE 2021; 51:660-668. [PMID: 34734297 PMCID: PMC9352637 DOI: 10.1007/s00132-021-04186-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND In Germany, patients with contact allergy to implant components usually receive coated joint arthroplasties. Whether the treatment using these hypoallergenic implants achieves comparable results to standard treatment with implants consisting of cobalt-chromium alloy (CoCr) implants is controversially discussed internationally and has rarely been investigated in the mid-term. OBJECTIVES Are there differences in blood metal ion concentrations, knee function, and patient-reported outcomes (PROM) between coated and standard implants? MATERIAL AND METHODS 118 patients were randomized to receive either a coated or a standard implant. Knee function as well as patient-reported outcome measures were assessed. Metal ion concentrations in blood samples were additionally determined for chromium, cobalt, molybdenum, and nickel, preoperatively, one and five years after surgery. RESULTS After five years, it was possible to analyse the results of 97 patients. In metal ion concentrations, as well as PRO, consistently good results were seen, without any difference between the groups. While in 13 patients there was an increase in chromium concentration above 2 µg/l one year after surgery, there was no measured value above 1 µg/l after five years. CONCLUSION In our study, similar mid-term results were detected for coated (TiNiN) and standard (CoCr)TKA. With respect to metal ion concentrations and PRO there are no disadvantages in using coated TKA.
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Affiliation(s)
- Anne Postler
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - Franziska Beyer
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Cornelia Lützner
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Eric Tille
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - Jörg Lützner
- UniversitätsCentrum für Orthopädie, Unfall- und Plastische Chirurgie, Universitätsklinikum Carl Gustav Carus Dresden, TU Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
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D’Ambrosi R, Loucas R, Loucas M, Giorgino R, Ursino N, Peretti GM. No Clinical or Radiographic Differences Between Cemented Cobalt-Chromium and Titanium-Niobium Nitride Mobile-Bearing Unicompartmental Knee Arthroplasty. Indian J Orthop 2021; 55:1195-1201. [PMID: 34824720 PMCID: PMC8586226 DOI: 10.1007/s43465-021-00486-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE This study aimed to compare the clinical and radiographic outcomes of patients with positive patch tests undergoing a medial mobile-bearing titanium-niobium nitride (TiNbN) unicompartmental knee arthroplasty (UKA) to patients undergoing standard UKA (cobalt-chromium [CoCr] implants). METHODS Two successive groups of patients, amounting to a total of 246 individuals, who received Oxford (Zimmer-Biomet, Warsaw, Indiana, USA) UKA were included. The first group was composed of a series of 203 consecutive standard CoCr UKAs (Standard Group), while the second group comprised 43 consecutive hypoallergenic TiNbN UKAs (HA group). The patients of the second group had a positive epicutaneous patch test result for metals. Each patient was evaluated using the Oxford Knee Score (OKS) and Knee Society Score (KSS) a day prior to the surgery (T 0) and at two consecutive follow-ups, namely T 1 (minimum follow-up of 12 months) and T 2 (minimum follow-up of 34 months). Radiographic measurements were performed at the final follow-up (T 2). RESULTS No statistical differences were noted between the two groups regarding demographic data (p > 0.05). No clinical or radiographic differences were found between the HA and standard groups at any follow-up (p > 0.05). A statistically significant improvement was found at any follow-up for both OKS and KSS (p < 0.05). CONCLUSIONS No clinical or radiographic differences between the hypoallergenic and standard cobalt-chromium groups at any follow-up were found, with a clinically significant improvement being experienced by both groups during the entire follow-up. LEVEL OF EVIDENCE Level II-comparative prospective study. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00486-3.
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Affiliation(s)
| | - Rafael Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Marios Loucas
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008 Zurich, Switzerland
| | - Riccardo Giorgino
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy
| | - Nicola Ursino
- IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
| | - Giuseppe Maria Peretti
- IRCCS Istituto Ortopedico Galeazzi, Via Galeazzi 4, 20161 Milan, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Mangiagalli 31, 20133 Milan, Italy
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Matar HE, Porter PJ, Porter ML. Metal allergy in primary and revision total knee arthroplasty : a scoping review and evidence-based practical approach. Bone Jt Open 2021; 2:785-795. [PMID: 34587776 PMCID: PMC8558451 DOI: 10.1302/2633-1462.210.bjo-2021-0098.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AIMS Metal allergy in knee arthroplasty patients is a controversial topic. We aimed to conduct a scoping review to clarify the management of metal allergy in primary and revision total knee arthroplasty (TKA). METHODS Studies were identified by searching electronic databases: Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Embase, from their inception to November 2020, for studies evaluating TKA patients with metal hypersensitivity/allergy. All studies reporting on diagnosing or managing metal hypersensitivity in TKA were included. Data were extracted and summarized based on study design, study population, interventions and outcomes. A practical guide is then formulated based on the available evidence. RESULTS We included 38 heterogeneous studies (two randomized controlled trials, six comparative studies, 19 case series, and 11 case reports). The evidence indicates that metal hypersensitivity is a rare complication with some histopathological features leading to pain and dissatisfaction with no reliable screening tests preoperatively. Hypoallergenic implants are viable alternatives for patients with self-reported/confirmed metal hypersensitivity if declared preoperatively; however, concerns remain over their long-term outcomes with ceramic implants outperforming titanium nitride-coated implants and informed consent is paramount. For patients presenting with painful TKA, metal hypersensitivity is a diagnosis of exclusion where patch skin testing, lymphocyte transformation test, and synovial biopsies are useful adjuncts before revision surgery is undertaken to hypoallergenic implants with shared decision-making and informed consent. CONCLUSION Using the limited available evidence in the literature, we provide a practical approach to metal hypersensitivity in TKA patients. Future national/registry-based studies are needed to identify the scale of metal hypersensitivity, agreed diagnostic criteria, and management strategies. Cite this article: Bone Jt Open 2021;2(10):785-795.
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Affiliation(s)
- Hosam E. Matar
- Wrightington Hospital, Wigan, UK
- Nottingham Elective Orthopaedic Services, Nottingham University Hospital NHS Trust, Nottingham, UK
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16
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Louwerens JKG, Hockers N, Achten G, Sierevelt IN, Nolte PA, van Hove RP. No clinical difference between TiN-coated versus uncoated cementless CoCrMo mobile-bearing total knee arthroplasty; 10-year follow-up of a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2021; 29:750-756. [PMID: 32367201 DOI: 10.1007/s00167-020-05997-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/10/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Improvement of biomechanical properties of cobalt-chromium-molybdenum (CoCrMo) implant surface and reduction of adhesive wear is achieved by titanium-nitride (TiN) coating in vitro. Less pain, higher postoperative outcome scores and a lower revision rate after TKA with a TiN-coated CoCrMo TKA compared with uncoated CoCrMo TKA after 10-year follow-up was hypothesized. METHODS In a double-blinded RCT, 101 patients received a cementless mobile-bearing CoCrMo TKA, either TiN-coated or uncoated. The primary outcome measure was the visual analogue scale (VAS) score for pain and secondary outcome measures were the Knee Society Score (KSS), Oxford Knee Score (OKS), revision rate and adverse events. Patients were assessed at 6 weeks, 6 months, 1 year, 5 years and 10 years, postoperatively. RESULTS 68 patients (67%) were available for 10-year follow-up. No difference was found in any of the assessed outcome measures with a mean decrease in VAS score (31.6 ± 22.9) and a mean increase in OKS (10.9 ± 8.4), KSS (29.3 ± 31.4), KSSK (26.4 ± 18.2) and KSSF (4.1 ± 22.9). Overall revision rate was 7% (coated 6% vs uncoated 8%) without additional revision procedures between 5 and 10-year follow-up. CONCLUSIONS The in vitro potential benefits of TiN coating did not result in better clinical outcome when compared to an uncoated cementless TKA. Pain, functional outcome and revision rates were comparable after 10-year follow-up. TiN-coated cementless TKA provides comparable good long-term results, similar to uncoated cementless CoCrMo TKA. LEVEL OF EVIDENCE Level 1, Therapeutic Study NETHERLANDS TRIAL REGISTER: NL2887/NTR3033.
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Affiliation(s)
- Jan K G Louwerens
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands.
| | - Niels Hockers
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands
| | - Gijs Achten
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands
| | - Inger N Sierevelt
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands
| | - Peter A Nolte
- Department of Orthopaedic Surgery, Spaarne Gasthuis Hospital, Hoofddorp, The Netherlands
| | - Ruud P van Hove
- Department of Orthopaedic Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
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Quinn J, McFadden R, Chan CW, Carson L. Titanium for Orthopedic Applications: An Overview of Surface Modification to Improve Biocompatibility and Prevent Bacterial Biofilm Formation. iScience 2020; 23:101745. [PMID: 33235984 PMCID: PMC7670191 DOI: 10.1016/j.isci.2020.101745] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Titanium and its alloys have emerged as excellent candidates for use as orthopedic biomaterials. Nevertheless, there are often complications arising after implantation of orthopedic devices, most notably prosthetic joint infection and aseptic loosening. To ensure that implanted devices remain functional in situ, innovation in surface modification has attracted much attention in the effort to develop orthopedic materials with optimal characteristics at the biomaterial-tissue interface. This review will draw together metallurgy, surface engineering, biofilm microbiology, and biomaterial science. It will serve to appreciate why titanium and its alloys are frequently used orthopedic biomaterials and address some of the challenges facing these biomaterials currently, including the significant problem of device-associated infection. Finally, the authors shall consolidate and evaluate surface modification techniques employed to overcome some of these issues by offering a unique perspective as to the direction in which research is headed from a broad, interdisciplinary point of view.
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Affiliation(s)
- James Quinn
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Ryan McFadden
- School of Mechanical and Aerospace Engineering, Queen's University Belfast, Ashby Building, Stranmillis Road, Belfast BT9 5AH, UK
| | - Chi-Wai Chan
- School of Mechanical and Aerospace Engineering, Queen's University Belfast, Ashby Building, Stranmillis Road, Belfast BT9 5AH, UK
| | - Louise Carson
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, UK
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18
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Rossi SMP, Perticarini L, Mosconi M, Ghiara M, Benazzo F. Ten-year outcomes of a nitrided Ti-6Al-4V titanium alloy fixed-bearing total knee replacement with a highly crosslinked polyethylene-bearing in patients with metal allergy. Knee 2020; 27:1519-1524. [PMID: 33010769 DOI: 10.1016/j.knee.2020.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/24/2020] [Accepted: 08/04/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Metal hypersensitivity in patients with a total knee arthroplasty (TKA) is a rare condition and a very controversial topic. Despite the lack of data concerning the real effective impact of allergy on TKA failures, most of the manufactures offer the choice of 'non-allergenic' implants both for primary and revision TKA, some of which provide the same designs and surgical techniques as the conventional ones. Only a few studies are available on outcomes on these 'hypersensitivity-friendly' implants and even fewer specifically on allergic patients with a mid- to long-term follow-up. METHODS Between 2007 and 2015, we enrolled 72 patients (57 females, 15 males), who underwent TKA treated with a non-allergenic posterior-stabilized (PS) total knee implant for a declared and proven metal allergy. Patients were followed clinically and radiographically for a mean 10 years of follow-up. RESULTS With revision as an endpoint the Kaplan-Meier survival estimate showed a survival rate of 97.2% at five years and 95.1% at 10 years. Significant improvements in range of motion (ROM), Knee Society Scoring (KSS) and Hospital for Special Surgery (HSS) knee scores were registered at final follow-up (P < 0.0001). At final follow-up validated Patient-Reported Outcome Measures (PROMs) showed the following scores: Oxford Knee Score (OKS) 42.1, EQ5D 0.80, EQ VAS 80.1, Forgotten Joint Score 71.2. CONCLUSIONS This nitrided Ti-6Al-4V titanium alloy fixed-bearing total knee replacement with a highly crosslinked polyethylene-bearing showed interesting results and survival rates in patients with metal allergy at mid- to long-term follow-up.
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Affiliation(s)
- Stefano Marco Paolo Rossi
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello Sport, U. O Ortopedia e Traumatologia Fondazione Poliambulanza, Brescia, Italy.
| | - Loris Perticarini
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello Sport, U. O Ortopedia e Traumatologia Fondazione Poliambulanza, Brescia, Italy
| | - Mario Mosconi
- Clinica Ortopedica e Traumatologia, Fondazione IRCCS Policlinico San Matteo - Pavia, Italy; Università degli Studi di Pavia, Pavia, Italy
| | - Matteo Ghiara
- Clinica Ortopedica e Traumatologia, Fondazione IRCCS Policlinico San Matteo - Pavia, Italy
| | - Francesco Benazzo
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello Sport, U. O Ortopedia e Traumatologia Fondazione Poliambulanza, Brescia, Italy; Clinica Ortopedica e Traumatologia, Fondazione IRCCS Policlinico San Matteo - Pavia, Italy; Università degli Studi di Pavia, Pavia, Italy
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Law JI, Morris MJ, Hurst JM, Berend KR, Lombardi AV, Crawford DA. Early Outcomes of an Alternative Bearing Surface in Primary Total Knee Arthroplasty in Patients with Self-reported Metal Allergy. Arthroplast Today 2020; 6:639-643. [PMID: 32875011 PMCID: PMC7451939 DOI: 10.1016/j.artd.2020.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/25/2020] [Accepted: 07/10/2020] [Indexed: 01/27/2023] Open
Abstract
Background Most implants for total knee arthroplasty (TKA) are comprised of alloys that contain nickel. Controversy exists whether metal allergies produce negative effects and affect clinical outcomes. The purpose of this study was to retrospectively review a minimum 2-year follow-up with an ion-bombarded titanium TKA implant in patients with reported metal sensitivity. Methods A retrospective review of patients who underwent primary TKA with the ion-bombarded titanium Vanguard (Zimmer Biomet, Warsaw, IN) implant with 2-year minimum follow-up was performed from 2008 through 2017. The query revealed 346 patients (451 knees) with minimum 2-year follow-up. The mean age was 64.7 years, the mean body mass index was 35.1 kg/m2, and 95% of patients were women. Results The mean follow-up was 4.6 years. The mean range of motion improved from 109° to 112° (P = .03), University of California Los Angeles activity scale from 4.1 to 5.1 (P < .001), Knee Society Clinical scores from 36 to 89 (P < .001), and Knee Society Functional scores from 48 to 73 (P < .001). There were 5 (1.1%) revisions: 2 infections (2-staged exchange), 1 tibial revision for aseptic loosening after a fall, and 2 bearing exchanges for instability. Other surgeries were open reduction internal fixation of periprosthetic fracture, 1 arthroscopic release of snapping popliteus, and 4 local wound incision and debridement (2 superficial infections and 2 nonhealing wounds). Manipulation under anesthesia was required in 27 (6%) patients. Conclusions These early results are encouraging for the use of alternative metal titanium alloy implants in metal-sensitive patients undergoing primary TKA. At 4.6 years of mean follow-up, patients had substantial improvement in the range of motion and clinical outcomes with a low frequency of revision.
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Affiliation(s)
- Jesua I Law
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Micael J Morris
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Jason M Hurst
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Titanium-Nitride Coating Does Not Result in a Better Clinical Outcome Compared to Conventional Cobalt-Chromium Total Knee Arthroplasty after a Long-Term Follow-Up: A Propensity Score Matching Analysis. COATINGS 2020. [DOI: 10.3390/coatings10050442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: The impact of titanium nitride (TiN) coating on implant components is controversial. TiN coating is proposed as having superior biomechanical properties compared to conventional cobalt-chromium (CoCr) alloy. This study compared long-term clinical data as well as meteoro-sensitivity in patients who underwent total knee arthroplasty (TKA), with either CoCr alloy or TiN coating. Methods: In this retrospective observational study, the clinically approved cemented “low contact stress” (LCS) TKA with conventional CoCr coating, was compared to un-cemented TiN-coated “advanced coated system” (ACS) TKA. Propensity score matching identified comparable patients based on their characteristics in a one-to-one ratio using the nearest-neighbor method. The final cohort comprised 260 knees in each cohort, with a mean follow-up of 10.1 ± 1.0 years for ACS patients and 14.9 ± 3.0 years for the LCS group. Physical examinations, meteoro-sensitivity, and knee scoring were assessed. Results: The clinical and functional Knee Society Score (KSS) (82.6 vs. 70.8; p < 0.001 and 61.9 vs. 71.1; p = 0.011), the postoperative Visual Analogue Scale (VAS) (2.9 vs. 1.4; p = 0.002), and the postoperative Tegner Score (2.6 vs. 2.2; p = 0.001) showed significant intergroup differences. The postoperative Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) was similar (79.9 vs. 81.3; p = 0.453) between groups. Meteoro-sensitivity of the artificial joint was significantly more prevalent in the ACS patient cohort (56% vs. 23%; p < 0.001). Conclusion: This study suggests that TiN coating does not provide improved clinical outcomes in this patient cohort after a long-term follow-up. Interestingly, sensitivity to weather changes were more correlated with un-cemented ACS implants.
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Song SJ, Lee HW, Bae DK, Park CH. High Incidence of Tibial Component Loosening After Total Knee Arthroplasty Using Ceramic Titanium-Nitride-Coated Mobile Bearing Prosthesis in Moderate to Severe Varus Deformity: A Matched-Pair Study Between Ceramic-Coated Mobile Bearing and Fixed Bearing Prostheses. J Arthroplasty 2020; 35:1003-1008. [PMID: 31859013 DOI: 10.1016/j.arth.2019.11.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We compared the incidence of aseptic component loosening and subsequent revision, and the survival rate between ceramic titanium-nitride-coated mobile bearing (MB) and fixed bearing total knee arthroplasties (TKAs) performed in patients with moderate to severe varus deformities. METHODS In total, 200 TKAs using advanced coated system posterior stabilized prostheses in varus deformity of mechanical axis >8° between 2012 and 2016 were retrospectively reviewed. One hundred MB (ceramic-m group) and 100 fixed bearing (ceramic-f group) prostheses were included. The matches were made according to preoperative demographics, range of motion, and severity of deformity. The mean follow-up period was not different (ceramic-m vs ceramic-f = 4.8 vs 5.1 years; P = .104). The incidence of revision TKA due to aseptic component loosening and the survival rate (failure: revision due to aseptic loosening) was investigated. RESULTS The incidence of revision TKA due to aseptic component loosening was 7 (7%) in the ceramic-m group and 1 (1%) in the ceramic-f group (P = .032). All cases of aseptic loosening occurred at the tibial component. The overall survival rate was 91.3% in the ceramic-m group and 98.9% in the ceramic-f group (P = .025). CONCLUSION Considering the higher revision incidence and lower survival rate due to tibial component loosening, caution should be taken in tibial component fixation when using advanced coated system MB prosthesis in moderate to severe varus deformity. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Sang Jun Song
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Hyun Woo Lee
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, South Korea
| | - Dae Kyung Bae
- Department of Orthopaedic Surgery, Seoul Sacred Heart General Hospital, Seoul, South Korea
| | - Cheol Hee Park
- Department of Medicine, Graduate School, Kyung Hee University, Seoul, South Korea
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Abstract
Magnetron sputtering has been employed for several decades to produce protective and multi-functional coatings, thanks to its versatility and ability to achieve homogeneous layers. Moreover, it is suitable for depositing coatings with very high melting points and that are thermodynamical unstable, which is difficult to accomplish by other techniques. Among these types of coating, transition metal (Me) carbides/nitrides (MeC/N) and amorphous carbon (a-C) films are particularly interesting because of the possibility of tailoring their properties by selecting the correct amount of phase fractions, varying from pure MeN, MeC, MeCN to pure a-C phases. This complex phase mixture can be even enhanced by adding a fourth element such Ag, Pt, W, Ti, Si, etc., allowing the production of materials with a large diversity of properties. The mixture of phases, resulting from the immiscibility of phases, allows increasing the number of applications, since each phase can contribute with a specific property such as hardness, self-lubrication, antibacterial ability, to create a multifunctional material. However, the existence of different phases, their fractions variation, the type of transition metal and/or alloying element, can drastically alter the global electrochemical behaviour of these films, with a strong impact on their stability. Consequently, it is imperative to understand how the main features intrinsic to the production process, as well as induced by Me and/or the alloying element, influence the characteristics and properties of the coatings and how these affect their electrochemical behaviour. Therefore, this review will focus on the fundamental aspects of the electrochemical behaviour of magnetron-sputtered films as well as of the substrate/film assembly. Special emphasis will be given to the influence of simulated body fluids on the electrochemical behaviour of coatings.
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Łapaj Ł, Rozwalka J. Retrieval analysis of TiN (titanium nitride) coated knee replacements: Coating wear and degradation in vivo. J Biomed Mater Res B Appl Biomater 2019; 108:1251-1261. [PMID: 31471956 DOI: 10.1002/jbm.b.34473] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 04/16/2019] [Accepted: 08/06/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Titanium nitride (TiN) coatings are used in joint arthroplasty to minimize wear and reduce the allergenic potential of metal implants, yet little is known about their performance in knee arthroplasty. This retrieval study examined TiN coated knee replacements to verify in vivo wear and degradation of the coating. MATERIALS AND METHODS This study included total and unicompartmental mobile bearing knee replacements retrieved from five patients (eight components) after 13-21 months due to aseptic loosening or infection. Implants were examined using scanning (SEM) and optical microscopy, surface damage was assessed using a semiquantitative scoring system, adhesion was determined using indentation technique testing, surface roughness was measured using contact profilometry. RESULTS Although good coating adhesion and no gross failure were observed on all retrievals, coating wear and roughening were evident on tibial bearing surfaces. Multiple microscopic defects (pinholes, craters, titanium droplets) were observed on all samples in SEM studies. Microscopic wear scars indicated that particulate defects significantly contributed to coating wear, acting as third bodies. CONCLUSION TiN coatings of knee replacements undergo wear and degradation related to presence of third bodies and microscopic defects on their surface. Since coating integrity may be compromised in vivo, such implants should be used with caution in metal sensitive patients.
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Affiliation(s)
- Łukasz Łapaj
- Department of General Orthopaedics, Musculoskeletal Oncology and Trauma Surgery, Poznan University of Medical Sciences, Ortopedyczno-Rehabilitacyjny Szpital Kliniczny im. Degi, Poznań, Poland
| | - Justyna Rozwalka
- Research Network Łukasiewicz, Metal Forming Institute, Poznan, Poland
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24
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Park CH, Kang SG, Bae DK, Song SJ. Mid-term clinical and radiological results do not differ between fixed- and mobile-bearing total knee arthroplasty using titanium-nitride-coated posterior-stabilized prostheses: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2019; 27:1165-1173. [PMID: 30088030 DOI: 10.1007/s00167-018-5095-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/03/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE This study was performed to prospectively compare the clinical and radiographic results between mobile-bearing (MB) and fixed-bearing (FB) TKAs using ceramic titanium nitride (TiN)-coated prostheses. METHODS Seventy MB and 70 FB TKAs using TiN-coated prostheses (ACS®) were prospectively evaluated. There were no differences in demographic characteristics between the two groups. Clinically, the Knee Society knee and function scores, WOMAC, and range of motion (ROM) were compared. Considering the possibility of a kinematic change in the polyethylene (PE) insert and a decrease in ROM following MB TKA, serial changes in the ROM were also compared. The thickness of the PE insert was compared according to the size of the femoral component. Radiographically, the alignment and positions of the components were compared. RESULTS There were no differences between the two groups in clinical scores or ROM (n.s.). The maximum flexion increased from 133.5° ± 8.3° to 137.6° ± 5.5° across all time points in the MB group. The serial maximum flexion angles did not differ between the two groups over time (n.s.). The average thickness of the PE insert was greater in the MB group (12.0 ± 1.9 vs. 11.2 ± 1.6 mm, respectively, p = 0.008), especially when a large femoral component was used (12.7 ± 1.9 vs. 11.0 ± 1.5 mm, p = 0.005). The pre- and postoperative mechanical axes and positions of the components did not differ between the two groups (n.s.). CONCLUSIONS TiN-coated MB TKA showed no significant advantage over FB TKA. The selection of bearing design would be clinically insignificant when using the TiN-coated TKA prosthesis. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Cheol Hee Park
- Department of Medicine, Graduate School, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea
| | - Se Gu Kang
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea
| | - Dae Kyung Bae
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea
| | - Sang Jun Song
- Department of Medicine, Graduate School, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea. .,Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea.
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25
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Saccomanno MF, Sircana G, Masci G, Cazzato G, Florio M, Capasso L, Passiatore M, Autore G, Maccauro G, Pola E. Allergy in total knee replacement surgery: Is it a real problem? World J Orthop 2019; 10:63-70. [PMID: 30788223 PMCID: PMC6379738 DOI: 10.5312/wjo.v10.i2.63] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/26/2018] [Accepted: 01/05/2019] [Indexed: 02/06/2023] Open
Abstract
Total knee arthroplasty is a common procedure, with extremely good clinical results. Despite this success, it produces 20% unsatisfactory results. Among the causes of these failures is metal hypersensitivity. Metal sensitization is higher in patients with a knee arthroplasty than in the general population and is even higher in patients undergoing revision surgery. However, a clear correlation between metal sensitization and symptomatic knee after surgery has not been ascertained. Surely, patients with a clear history of metal allergy must be carefully examined through dermatological and laboratory testing before surgery. There is no globally accepted diagnostic algorithm or laboratory test to diagnose metal hypersensitivity or metal reactions. The patch test is the most common test to determine metal hypersensitivity, though presenting some limitations. Several laboratory assays have been developed, with a higher sensitivity compared to patch testing, yet their clinical availability is not widespread, due to high costs and technical complexity. Symptoms of a reaction to metal implants present across a wide spectrum, ranging from pain and cutaneous dermatitis to aseptic loosening of the arthroplasty. However, although cutaneous and systemic hypersensitivity reactions to metals have arisen, thereby increasing concern after joint arthroplasties, allergies against implant materials remain quite rare and not a well-known problem. The aim of the following paper is to provide an overview on diagnosis and management of metal hypersensitivity in patients who undergo a total knee arthroplasty in order clarify its real importance.
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Affiliation(s)
- Maristella F Saccomanno
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Sircana
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giulia Masci
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Gianpiero Cazzato
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Michela Florio
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Luigi Capasso
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Marco Passiatore
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giovanni Autore
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Enrico Pola
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
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26
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Postler A, Beyer F, Lützner C, Tille E, Lützner J. Similar outcome during short-term follow-up after coated and uncoated total knee arthroplasty: a randomized controlled study. Knee Surg Sports Traumatol Arthrosc 2018; 26:3459-3467. [PMID: 29616285 DOI: 10.1007/s00167-018-4928-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/28/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Patients with known hypersensitivity to metals often require hypoallergenic TKA implants. Coating of a standard implant is a common solution, and although in vitro tests have demonstrated reduction of polyethylene wear for these coatings, it is still unknown whether these implants have any clinical benefit. This study was initiated to investigate metal ion concentrations, knee function and patient-reported outcome (PRO) after coated and uncoated TKA. METHODS One hundred and twenty-two (122) patients were randomized to receive a coated or a standard TKA and, after exclusions, 59 patients were included in each group. Knee function and PRO were assessed with validated scores up to 3 years after surgery. Metal ion concentrations in blood samples were determined for chromium, cobalt, molybdenum and nickel, preoperatively and 1 year after surgery. RESULTS Chromium concentrations in patient plasma increased from a median of 0.25 to 1.30 µg/l in the standard TKA group, and from 0.25 to 0.75 µg/l in the coated TKA group (p = 0.012). Thirteen patients (3 coated, 10 standard TKA) had chromium concentrations above 2 µg/l. The concentrations of cobalt, molybdenum and nickel did not change. Patient-reported outcome measures (PROM) demonstrated a substantial improvement after TKA, without any differences between the groups. CONCLUSION The increase in chromium concentration in the standard group needs further investigation. If surgeons use coated implants, they can be confident that these implants perform as well as standard implants. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Anne Postler
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Franziska Beyer
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Cornelia Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Eric Tille
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jörg Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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27
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Newman JM, Sodhi N, Khlopas A, Sultan AA, Chughtai M, Abraham R, Oh J, Molloy RM, Harwin SF, Mont MA. Cementless Total Knee Arthroplasty: A Comprehensive Review of the Literature. Orthopedics 2018; 41:263-273. [PMID: 30125035 DOI: 10.3928/01477447-20180815-05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 06/20/2018] [Indexed: 02/03/2023]
Abstract
This review evaluated (1) original and newer cementless implants; (2) outcomes of newer designs; (3) risks and benefits; and (4) newer cementless vs cemented total knee arthroplasties. A search for all reports on cementless total knee arthroplasties published from January 2010 to April 2017 was performed, and 31 studies were included for final analysis. Newer cementless total knee arthroplasty designs have shown excellent survivorship, functional outcomes, and satisfaction rates in both young and elderly populations. Compared with cement fixation, there may be potential benefits with the newer cementless implants. However, these findings need to be further substantiated with additional studies reporting longer-term results. [Orthopedics. 2018; 41(5):263-273.].
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Fabry C, Zietz C, Baumann A, Ehall R, Bader R. High wear resistance of femoral components coated with titanium nitride: a retrieval analysis. Knee Surg Sports Traumatol Arthrosc 2018; 26:2630-2639. [PMID: 28528349 PMCID: PMC6105138 DOI: 10.1007/s00167-017-4578-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 05/15/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective of this study was to evaluate the in vivo wear resistance of cobalt-chromium femoral components coated with titanium nitride (TiN). Our null hypothesis was that the surface damage and the thickness of the TiN coating do not correlate with the time in vivo. METHODS Twenty-five TiN-coated bicondylar femoral retrievals with a mean implantation period of 30.7 ± 11.7 months were subjected to an objective surface damage analysis with a semi-quantitative assessment method. A visual examination of scratches, indentations, notches and coating breakthroughs of the surfaces was performed. The roughness and the coating thickness of the TiN coating were evaluated in the main articulation regions. RESULTS Narrow scratches and indentations in the range of low flexion angles on the retrieval surfaces were the most common modes of damage. There was no evidence of delamination on the articulation surface but rather at the bottom of isolated severe indentations or notches. An analysis of three retrievals revealed a coating breakthrough in the patellofemoral joint region, resulting from patella maltracking and a dislocation. The arithmetical mean roughness of the TiN surface slightly increased with the implantation period. In contrast, the maximum peak height of the roughness profile was reduced at the condyles of the retrieved components in comparison with new, unused surfaces. No significant association between the coating thickness and implantation period was determined. Moreover, the measured values were retained in the range of the initial coating thickness even after several years of in vivo service. CONCLUSIONS As was demonstrated by the results of this study, the surface damage to the TiN coating did not deteriorate with the implantation period. The calculated damage scores and the measured coating thickness in particular both confirmed that the TiN coating provides low wear rates. Our findings support the use of wear-resistant TiN-coated components in total knee arthroplasty with the objective of reducing the risk of aseptic loosening. However, in terms of TiN-coated femoral components, particular attention should be paid to a correct patellar tracking in order to avoid wear propagation at the implant.
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Affiliation(s)
- Christian Fabry
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Doberaner Str. 142, 18057 Rostock, Germany
- DOT GmbH, Charles-Darwin-Ring 1a, 18059 Rostock, Germany
| | - Carmen Zietz
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Doberaner Str. 142, 18057 Rostock, Germany
| | - Axel Baumann
- DOT GmbH, Charles-Darwin-Ring 1a, 18059 Rostock, Germany
| | - Reinhard Ehall
- Graz Ragnitz Private Hospital, Berthold-Linder-Weg 15, 8047 Graz, Austria
| | - Rainer Bader
- Biomechanics and Implant Technology Research Laboratory, Department of Orthopaedics, University Medicine Rostock, Doberaner Str. 142, 18057 Rostock, Germany
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Breugem SJM, Linnartz J, Sierevelt I, Bruijn JD, Driessen MJM. Evaluation of 1031 primary titanium nitride coated mobile bearing total knee arthroplasties in an orthopedic clinic. World J Orthop 2017; 8:922-928. [PMID: 29312851 PMCID: PMC5745435 DOI: 10.5312/wjo.v8.i12.922] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/06/2017] [Accepted: 11/10/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the influence of the titanium nitride (TiN) coating on the results of a total knee arthroplasty (TKA).
METHODS A total of 910 patients (338 men; 572 woman), with a mean age of 65 (range 36-94) undergoing 1031 primary TKAs were assessed. Clinical evaluation and patient-reported outcomes were gathered one year after surgery. The questionnaires included the Knee injury and Osteoarthritis Outcome Score (KOOS)-Dutch version, Visual Analogue Scale (VAS) pain scores in rest and during active knee movement, VAS-satisfaction scores, and EQ-5D-3L health scores. This was aimed to assess the overall knee function and patient satisfaction, and to enable us to make a gross comparison to other TKAs.
RESULTS At a mean follow-up of 46 mo (range 1-92) the overall implant survival was 97.7% and 95.1% for any operative reason related to the implant. Twenty-three knees (2.2%) required revision surgery. Arthrofibrosis was the most common indication for a re-operation. The clinical evaluation and patient-reported outcomes revealed good to excellent patient satisfaction and function of the arthroplasty. The median postoperative VAS-pain scores on a scale of 0-100, at one year after surgery were 1 in rest and 2 during movement.
CONCLUSION The TiN coated, mobile bearing TKA results are excellent and similar to those of other widely used TKA designs. Residual pain of the knee remains a concern and the TiN coating in combination with the mobile bearing does not seem to be the simple solution to this problem. Future research will have to show that the coating gives a better survival than the cobalt chrome version.
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Affiliation(s)
| | - Jeroen Linnartz
- Orthopedium, Orthopedic Clinic, Delft 2616 LS, The Netherlands
| | | | - Jon D Bruijn
- Orthopedium, Orthopedic Clinic, Delft 2616 LS, The Netherlands
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Good long-term results following cementless TKA with a titanium plasma coating. Knee Surg Sports Traumatol Arthrosc 2017; 25:2801-2808. [PMID: 26334884 DOI: 10.1007/s00167-015-3769-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE While cemented total knee arthroplasty (TKA) is currently the gold standard for primary osteoarthritis, cementless component fixation has achieved increasingly comparable outcomes due to improvements in both implant designs and surgical technique. Long-term outcomes and survivorship with the TC-Plus cementless, titanium plasma-coated TKA system without patella resurfacing were evaluated. METHODS A homogenous population of 171 consecutive patients who received 206 primary TC-Plus TKAs without patella resurfacing over a 19-year period was retrospectively reviewed. Knee Society Clinical Rating System (KSCRS) scores were obtained, and radiographic evaluation was performed after a mean follow-up of 13.2 ± 8.4 years. Survivorship analysis was made with endpoints revision for any reason and aseptic loss of biological fixation. RESULTS One hundred and thirty-six TKAs implanted in 113 patients were available for analysis. Mean KSCRS clinical and functional scores improved significantly versus preoperative values. No radiological loss of biological fixation of femoral and tibial components was observed. Survival with aseptic revision of any component as the endpoint was 95.7 % (95 % confidence interval (CI) 91.7-97.9 %) and 93.6 % (95 % CI 87.8-96.6 %) at 10 and 15 years, respectively. CONCLUSION Titanium plasma-coated cementless TKA without patella resurfacing showed excellent long-term results, with high 10- and 15-year component survival rates. The clinical and radiological results were comparable to those of other cementless TKAs, providing further evidence for the non-cemented resurfacing of the osteoarthritic knee. LEVEL OF EVIDENCE IV.
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Outcomes of cementless unicompartmental and total knee arthroplasty: A systematic review. Knee 2017; 24:497-507. [PMID: 27923627 DOI: 10.1016/j.knee.2016.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/14/2016] [Accepted: 10/19/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Aseptic loosening is a common failure mode in cemented unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). This led to the development of cementless designs but the historical outcomes were poor. Recent developments in cementless designs have improved outcomes, but the current status is unknown. Therefore, a systematic review was performed to assess recent outcomes of cementless knee arthroplasty. METHODS A search was performed using PubMed, Embase and Cochrane systems and national registries for studies reporting outcomes since 2005. Fifty-two cohort studies and four registries reported survivorship, failure modes or functional outcomes of cementless UKA and TKA. RESULTS Nine level I studies, six level II studies, three level III studies, 34 level IV studies and four registries were included. Three hundred eighteen failures in 10,309 cementless TKA procedures and 62 failures in 2218 cementless UKA procedures resulted in extrapolated five-year, 10-year and 15-year survivorship of cementless TKAs of 97.7%, 95.4% and 93.0%, respectively, and cementless UKA of 96.4%, 92.9% and 89.3%, respectively. Aseptic loosening was more common in cementless TKA (25%) when compared to UKA (13%). Functional outcomes of cementless TKA and UKA were excellent with 84.3% and 84.5% of the maximum possible scores, respectively. CONCLUSIONS This systematic review showed that good to excellent extrapolated survivorship and functional outcomes are seen following modern cementless UKA and TKA, with a low incidence of aseptic loosening following cementless UKA. LEVEL OF EVIDENCE Level IV.
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High correlation of the Oxford Knee Score with postoperative pain, but not with performance-based functioning. Knee Surg Sports Traumatol Arthrosc 2016; 24:3369-3375. [PMID: 25820654 DOI: 10.1007/s00167-015-3585-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The Oxford Knee Score (OKS) is a widely known patient-related outcome measure (PROM) to determine pain and knee functioning before and after total knee arthroplasty (TKA). Self-reported function is mainly influenced by change in pain; therefore, it was hypothesized that the OKS correlates more with pain than with performance-based functioning. METHODS In a prospective cohort of 88 patients, who had a cementless mobile-bearing TKA, included in a randomized clinical trial, the correlation between the overall OKS, and its subscales for pain (PCS) and function (FCS), with performance-based functioning using the DynaPort® Knee Score (DKS), visual analogue scale score for pain (VAS) and the Knee Society Score (KSS) was evaluated. All scores were measured preoperatively, 6 months and 1 year after surgery. Overall change in outcome over time was analysed until 5 years after surgery. RESULTS All scores improved over time. The DKS was influenced by sex, preoperative BMI and age. The internal consistency of the OKS PCS increased over time, whereas the OKS FCS remained the same. The mean postoperative OKS FCS showed moderate correlation with the DKS (r = 0.65, p < 0.001), and the mean postoperative OKS and OKS PCS showed high correlation with the VAS (r = -0.79 and r = -0.82, respectively, p < 0.001). The mean postoperative KSS showed high correlations with the OKS (r = 0.80, p < 0.001), the OKS PCS (r = 0.72 p < 0.001) and OKS FCS (r = 0.74, p < 0.001). CONCLUSION The postoperative OKS and the OKS PCS showed high correlation with pain, but only the postoperative OKS FCS was well correlated with performance-based functioning. This suggests that the OKS is more related to pain and tells us less on postoperative functioning. This is important when the OKS as PROM is used to evaluate the quality of orthopaedic care of patients with TKA. LEVEL OF EVIDENCE III.
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Beyer F, Lützner C, Kirschner S, Lützner J. Midterm Results After Coated and Uncoated TKA: A Randomized Controlled Study. Orthopedics 2016; 39:S13-7. [PMID: 27219721 DOI: 10.3928/01477447-20160509-10] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 02/03/2016] [Indexed: 02/03/2023]
Abstract
Patients undergoing total knee arthroplasty (TKA) who have hypersensitivity to metals usually receive hypoallergenic TKA implants. Coating of a standard implant is a common solution. Although in vitro tests have demonstrated reduction in polyethylene wear for these coatings, it is unknown whether these costly implants have a clinical benefit for patients. One hundred twenty patients undergoing TKA were randomly assigned to receive a novel 7-layer-coating implant or a standard TKA implant. One revision occurred in the standard group, resulting in a calculated 5-year survival of 100% in the coated group and 98.1% in the standard group. The Oxford Knee Score improved substantially in both groups from a mean of 21.6 points preoperatively in the coated group and 21.9 points in the standard group to 39.2 points and 39.2 points, respectively. The current authors observed no adverse effects with the new coating during midterm follow-up. However, longer follow-up time is needed to evaluate possible advantages of this coating. [Orthopedics. 2016; 39(3):S13-S17.].
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Titanium-Nitride Coating of Orthopaedic Implants: A Review of the Literature. BIOMED RESEARCH INTERNATIONAL 2015; 2015:485975. [PMID: 26583113 PMCID: PMC4637053 DOI: 10.1155/2015/485975] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 05/24/2015] [Indexed: 12/12/2022]
Abstract
Surfaces of medical implants can be enhanced with the favorable properties of titanium-nitride (TiN). In a review of English medical literature, the effects of TiN-coating on orthopaedic implant material in preclinical studies were identified and the influence of these effects on the clinical outcome of TiN-coated orthopaedic implants was explored. The TiN-coating has a positive effect on the biocompatibility and tribological properties of implant surfaces; however, there are several reports of third body wear due to delamination, increased ultrahigh molecular weight polyethylene wear, and cohesive failure of the TiN-coating. This might be due to the coating process. The TiN-coating process should be optimized and standardized for titanium alloy articulating surfaces. The clinical benefit of TiN-coating of CoCrMo knee implant surfaces should be further investigated.
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