AAHKS Symposium: Corrosion at the Head-Neck Junction: Why is this Happening Now?
Evaluation of the Painful Dual Taper Modular Neck Stem Total Hip Arthroplasty: Do They All Require Revision?

https://doi.org/10.1016/j.arth.2016.01.074Get rights and content

Abstract

Although dual taper modular-neck total hip arthroplasty (THA) design with additional neck-stem modularity has the potential to optimize hip biomechanical parameters by facilitating adjustments of leg length, femoral neck version and offset, there is increasing concern regarding this stem design as a result of the growing numbers of adverse local tissue reactions due to fretting and corrosion at the neck-stem taper junction. Implant factors such as taper cone angle, taper surface roughness, taper contact area, modular neck taper metallurgy, and femoral head size play important roles in influencing extent of taper corrosion. There should be a low threshold to conduct a systematic clinical evaluation of patients with dual-taper modular-neck stem THA using systematic risk stratification algorithms as early recognition and diagnosis will ensure prompt and appropriate treatment. Although specialized tests such as metal ion analysis and cross-sectional imaging modalities such as metal artifact reduction sequence magnetic resonance imaging (MARS MRI) are useful in optimizing clinical decision-making, overreliance on any single investigative tool in the clinical decision-making process for revision surgery should be avoided.

Section snippets

Factors Associated With Modular Neck Taper Corrosion

Implant, surgical, and patient factors have been identified as likely contributing factors responsible for taper corrosion in dual modular neck stem THA.

Systematic Evaluation

A painful modular dual taper stem neck THA can present with a myriad of symptoms and may be attributable to various intrinsic and extrinsic causes. A systematic evaluation should include focused clinical history, detailed physical examination, laboratory tests, and cross-sectional imaging to identify potential differential diagnoses in a patient with painful dual modular taper THA 36, 37. A consensus systematic risk stratification algorithm from the American Association of Hip and Knee Surgeons

Revision Surgery

Management of a patient with a painful dual taper modular neck stem THA presenting with elevated metal ion levels and evidence of adverse local tissue reactions (pseudotumors) with bone or muscle damage warrants revision surgery. Revision surgery for dual-taper modular neck stem THA necessitates a thoughtful approach to reduce intraoperative complications. Meticulous and careful debridement must be performed to remove the pseudotumor, while protecting neurovascular structures. Removal of the

Histopathology Analysis

Although ALTR has been linked to modular taper junction MACC and elevated metal ion levels, ALTR has also been observed in the absence of high wear or metallosis 30, 31, 32. Current evidence has indicated that the process is complex and multifactorial, with a spectrum of histologic features being noted in periprosthetic tissues of dual-taper modular neck stem THA patients undergoing revision. The histologic features suggest tissue reactions that maybe consistent with either metallic wear and

Summary

Although dual taper modular-neck total hip arthroplasty (THA) design with additional neck-stem modularity has the potential to optimize hip biomechanical parameters, there is increasing concern as a result of the growing numbers of adverse local tissue reactions due to fretting and corrosion at the neck-stem taper junction. There should be a low threshold to conduct a systematic clinical evaluation of patients with dual-taper modular neck stem THA as early recognition and diagnosis will ensure

References (52)

  • S.Y. Jauch et al.

    Influence of material coupling and assembly condition on the magnitude of micromotion at the stem-neck interface of a modular hip endoprosthesis

    J Biomech

    (2011)
  • B.J. McGrory et al.

    A high prevalence of corrosion at the head-neck taper with contemporary Zimmer non-cemented femoral hip components

    J Arthroplasty

    (2015)
  • C.A. Pattyn et al.

    Whole blood metal ion concentrations in correlation with activity level in three different metal-on-metal bearings

    J Arthroplasty

    (2011)
  • Y.M. Kwon et al.

    Evidence-based understanding of management perils for metal-on-metal hip arthroplasty patients

    J Arthroplasty

    (2012)
  • Y.M. Kwon et al.

    Risk stratification algorithm for management of patients with dual modular taper total hip arthroplasty: consensus statement of the American Association of Hip and Knee Surgeons, the American Academy of Orthopaedic Surgeons and the Hip Society

    J Arthroplasty

    (2014)
  • J.S. Melvin et al.

    Early failures in total hip arthroplasty—a changing paradigm

    J Arthroplasty

    (2014)
  • B.T. Barlow et al.

    Short-term metal ion trends following removal of recalled modular neck femoral stems

    J Arthroplasty

    (2015)
  • C.L. Hayter et al.

    Imaging of metal-on-metal hip resurfacing

    Orthop Clin North Am

    (2011)
  • Y.M. Kwon

    Cross-sectional imaging in evaluation of soft tissue reactions secondary to metal debris

    J Arthroplasty

    (2014)
  • A. Srinivasan et al.

    Modularity of the femoral component in total hip arthroplasty

    J Am Acad Orthop Surg

    (2012)
  • C. Restrepo et al.

    Modular femoral stems for revision total hip arthroplasty

    Clin Orthop Relat Res

    (2011)
  • H. Krishnan et al.

    Modular neck femoral stems

    Bone Joint J

    (2013)
  • R.S. Kotwal et al.

    Outcome of treatment for dislocation after primary total hip replacement

    J Bone Joint Surg Br

    (2009)
  • M. Imamura et al.

    Single mini-incision total hip replacement for the management of arthritic disease of the hip: a systematic review and meta-analysis of randomized controlled trials

    J Bone Joint Surg Am

    (2012)
  • A.M. Kop et al.

    Proximal component modularity in THA—at what cost? An implant retrieval study

    Clin Orthop Relat Res

    (2012)
  • C.I. Esposito et al.

    Bioengineering Study Groups from Carl TBW. What is the trouble with trunnions?

    Clin Orthop Relat Res

    (2014)
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