Clinical Orthopaedics
Clin Orthop Relat Res (2014) 472:3659–3664
DOI 10.1007/s11999-014-3610-1
SYMPOSIUM: ABJS CARL T. BRIGHTON WORKSHOP ON IMPLANT WEAR AND TRIBOCORROSION OF
TOTAL JOINT REPLACEMENTS
What Are the Current Clinical Issues in Wear and
Tribocorrosion?
Daniel J. Berry MD, Matthew P. Abdel MD,
John J. Callaghan MD, Members of the Clinical Research Group
Published online: 8 April 2014
Ó The Association of Bone and Joint Surgeons1 2014
Abstract
Background Wear and corrosion in joint arthroplasty are
important causes of failure. From the standpoint of current
clinical importance, there are four main categories of wear
and tribocorrosion: polyethylene wear, ceramic-on-ceramic
(CoC) bearing wear, metal-on-metal (MoM) bearing wear,
and taper tribocorrosion. Recently, problems with wear in
the knee have become less prominent as have many issues
with hip polyethylene (PE) bearings resulting from the
success of crosslinked PE. However, MoM articulations
and taper tribocorrosion have been associated with soft
tissue inflammatory responses, and as a result, they have
become prominent clinical concerns.
Members of the Clinical Research Group.
The institution of one or more of the authors (DJB, MPA) has
received funding from Biomet (Warsaw, IN, USA), DePuy (Warsaw,
IN, USA), Stryker (Mahwah, NJ, USA), and Zimmer (Warsaw, IN,
USA). One author certifies that he (DJB), or a member of his
immediate family, has or may receive payments or benefits, during
the study period, an amount in excess of USD 100,000 from DePuy
Orthopaedics, Inc, a Johnson and Johnson Company (Warsaw, IN,
USA). Another author certifies that he (JJC), or a member of his
immediate family, has or may receive payments or benefits, during
the study period, an amount in excess of USD 100,000 from DePuy
Orthopaedics, Inc, a Johnson and Johnson Company.
All ICMJE Conflict of Interest Forms for authors and Clinical
Orthopaedics and Related Research editors and board members are
on file with the publication and can be viewed on request.
This work was performed at the Mayo Clinic, Rochester, MN, USA,
and the University of Iowa, Iowa City, IA, USA.
D. J. Berry, M. P. Abdel (&)
Department of Orthopedic Surgery, Mayo Clinic, 200 First Street
SW, Rochester, MN, USA
e-mail: abdel.matthew@mayo.edu
J. J. Callaghan
University of Iowa, Iowa City, IA, USA
and Related Research®
A Publication of The Association of Bone and Joint Surgeons®
Where Are We Now? For PE wear in the hip, several
advances include improved locking mechanisms and data
supporting highly crosslinked polyethylenes (HXLPE).
Edge-loading in CoC articulations can contribute to stripe
wear and subsequent squeaking. For MoM articulations,
the relationship of wear-to-edge loading, sensitivity to
component positioning, typical soft tissue response, and
use of imaging is increasingly understood. Taper tribo-
corrosion (from femoral head–neck junctions and other
modular elements) and associated soft tissue inflammatory
responses appear to be serious clinical issues that are not
fully understood.
Where Do We Need to Go? In the knee, clinical concerns
remain with the efficacy of HXLPE, modular connections,
and metal allergies. For PE wear in the hip, concerns
remain regarding how to increase crosslinking of PE while
minimizing PE fractures. With CoC articulations, questions
remain on how to prevent noises, chipping, and impinge-
ment and if enhanced designs can contribute to improved
results. For MoM articulations, we need to improve
imaging tests for soft tissue reactions, determine best
practices in terms of monitoring protocols, and better
define if, how, and when to act on serum metal levels. For
taper tribocorrosion, we need to use modularity wisely and
also understand how to improve tapers and materials in the
future. For patients at risk for tribocorrosion, we need to
define realistic diagnostic and monitoring protocols. We
also need to enhance revision methods, and the threshold of
acceptable soft tissue damage, to minimize complications
associated with soft tissue damage such as hip instability.
How Do We Get There? HXLPE and other bearing sur-
faces will likely continue to be refined. We need to develop
tapers with more resistance to tribocorrosion through
improved understanding of the manufacturing process and
ongoing engineering improvements. Revision procedures
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3660 Berry et al.
for wear and tribocorrosion can be enhanced by deter-
mining when partial component retention is appropriate
and how best to manage soft tissue damage. For CoC
articulations, enhanced designs are required to minimize
noises, chipping, and impingement. Importantly, we must
continue to promote and analyze joint replacement regis-
tries to identify early failures and analyze long-term
successes.
Introduction
Although loosening of hip and knee implants may not be
totally eliminated, fixation of clinically successful implants
has demonstrated durability of at least 20 years in many
series [4, 11, 37]. Unfortunately, bearing surface wear and
tribocorrosion from unexpected sources such as modular
connections in THAs and TKAs continue to lead to further
surgery in many patients.
Clinical patterns related to implant wear and tribocor-
rosion are a function of the type of wear product produced.
Likewise, the products produced by implant wear or
tribocorrosion are a consequence of material and design as
well as surgical technique. From the standpoint of current
clinical importance, there are four main categories of wear
and tribocorrosion: polyethylene wear, ceramic-on-ceramic
(CoC) bearing wear, metal-on-metal (MoM) bearing wear,
and taper tribocorrosion.
Polyethylene wear creates submicron particles of poly-
ethylene, which produce a macrophage-dominated histologic
response around the joint. Clinical findings typically are
synovitis and osteolysis, and the effects are local without
systemic effect [21, 31]. Metal-on-metal bearing surface wear
produces very small metal particles, which liberate metal ions
and create a lymphocyte-dominant response. The typical
clinical pattern of MoM bearing wear for cobalt–chromium
bearings is one of synovitis and local soft tissue reactions [21,
31]. Local soft tissue reactions can be primarily fluid-filled
cystic structures, which communicate with the joint and have a
relatively thin membrane or they may have mixed fluid and
solid components. These local soft tissue reactions have been
called by a number of terms including adverse local soft tissue
reactions (ALTRs), adverse local reaction to metal debris, and
pseudotumor [20]. Metal wear is typically associated with
elevated systemic levels of metal ions, and the most important
ions clinically have been cobalt and chromium. Taper tribo-
corrosion liberates or creates metal products from the taper
including chromium orthophosphates [20]. The clinical pat-
tern of taper tribocorrosion is synovitis and local soft tissue
reactions, which are often similar to those seen with MoM
bearings. Systemic metal ion levels typically are elevated.
Because taper tribocorrosion damages the metal substrate,
implant fractures also can occur.
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Clinical Orthopaedics and Related Research1
One way to identify the prevalence of clinical problems
related to wear and tribocorrosion is by the revision burden
related to wear. The most recent reports of the British
National Joint Registry demonstrated 44% of revision THAs
were for loosening, 15% for ALTR, 14% for osteolysis, and
13% for wear [34]. Bozic et al. [5] demonstrated revision for
loosening in 19.7% of cases, osteolysis in 6.6%, and bearing
surface wear in 5.0% from a large administrative database in
the United States, similar to the British National Joint
Registry.
Regarding knee revisions, the British National Joint
Registry reported that 38% were revised for aseptic loos-
ening, 12% for wear, and 9% for osteolysis [34]. Using the
same database for revision knees as was reported for hips,
Bozic et al. [6] reported that 16.1% of knees were revised
for loosening, 4.9% for bearing surface wear, and 3.2% for
osteolysis.
Each of these four common patterns of bearing surface
wear and tribocorrosion have clinical issues related to (1)
diagnosis; (2) patient followup and monitoring for the
problem in the patient population at risk; (3) treatment; (4)
management of specific complications related to the wear
or tribocorrosion; and (5) prevention of the wear or tribo-
corrosion problem. These concerns are examined
separately in this article.
Where Are We Now?
Diagnosis
The diagnosis of polyethylene wear is usually made with-
out difficulty. Polyethylene wear, even when associated
with osteolysis, is associated with few symptoms or with
symptoms of synovitis. Hip radiographs typically demon-
strate femoral head eccentricity (which can be measured)
and osteolysis, which can be diagnosed with plain radio-
graphs [7, 8, 19, 22, 25, 36]. In the knee, clinical findings
typically include an effusion (which often develops late),
radiographic asymmetry of the polyethylene insert thick-
ness, and osteolysis.
For CoC and MoM bearings, excessive wear may be
associated with pain related to synovitis or local soft tis-
sue reaction [10, 32, 42]. For many MoM bearings, a large
femoral head is used. Plain films are rarely informative
although infrequently may show osteolysis. Metal artifact
reduction sequences (MARS) MRI may be used to iden-
tify local soft tissue reactions [15–18, 29]. Systemic cobalt
and chromium levels are often elevated [9, 12, 24, 40].
Patients with taper tribocorrosion often present with pain.
Imaging with MARS MRI and laboratory testing for
cobalt and chromium levels can help make the diagnosis
[9, 12, 24, 40].
Volume 472, Number 12, December 2014
Patient Monitoring and Followup
Monitoring methods and frequency of followup for bearing
surface wear or tribocorrosion are an important clinical
issue. For polyethylene wear and CoC, plain films are the
primary imaging method [7, 8, 19, 22, 25, 36]. For MoM
bearings, cobalt and chromium levels and MARS MRI or
ultrasound are the main monitoring methods [9, 12, 15–18,
24, 29, 40]. For taper tribocorrosion, the main monitoring
methods are cobalt and chromium ion levels and imaging
with MRI or ultrasound [9, 12, 15–18, 24, 29, 40].
Treatment
For polyethylene wear, there is no effective nonoperative
treatment. Revision of the polyethylene component and
bone grafting of periprosthetic osteolysis and exchange of
implants as indicated—based on implant stability and other
biomechanical requirements of the joint—are standard
forms of treatment [13]. For CoC and MoM bearing fail-
ures, there is no effective nonoperative treatment, and
revision is the standard form of management. However, it
is important to note that with CoC and MoM articulations,
a more narrow ‘‘landing zone’’ is required for placement of
the acetabular component in regard to both inclination
angle (abduction) and anteversion [2]. For problematic
taper tribocorrosion, there is no effective nonoperative
treatment and treatment involves changing the taper.
However, it is unknown which taper is best and whether a
ceramic femoral head with a titanium sleeve—an approach
gaining some traction of late—will solve the problem.
Finally, it is known that surgical technique, including the
influence of the assembly procedure as well as blood and
fat on the taper, may influence risk of taper tribocorrosion
[23, 35].
Management of Complications
Complications related to polyethylene wear included
periprosthetic fractures, implant loosening, and severe
bone loss. With CoC articulations, it is known that edge-
loading can contribute to stripe wear and subsequently
squeaking [38, 41]. For MoM bearings, the main problems
that lead to complications are severe soft tissue reaction or
bone necrosis. Dislocation related to soft tissue damage is
not an uncommon complication of revision for MoM
bearing failure and loosening of new implants may occur if
they are placed on necrotic bone. For taper tribocorrosion,
the main complications relate to severe soft tissue damage
or implant fracture.
Clinical Issues in Wear/Tribocorrosion 3661
Where Do We Need to Go?
Diagnosis
Clinical questions of diagnosing polyethylene and CoC
wear relate to when three-dimensional (3-D) imaging can
be useful to enhance the diagnosis of osteolysis and what
the best 3-D imaging methodology (CT versus MRI) is in
the future. Clinical questions about imaging MoM bearings
include can MRI be further advanced to improve implant-
bone interface evaluation? Even with MARS MRI, trou-
blesome artifacts usually are present, which limit their use.
In addition, the questions surround the role of ultrasound
for diagnosis. This technology has use, is relatively inex-
pensive, and is evolving. The second main diagnostic
clinical question about MoM bearings relates to cobalt and
chromium levels. Thresholds for action and significance of
increasing ion levels both remain important unknowns.
Clinical questions with respect to diagnosis of taper
tribocorrosion relate to (as is the case for MoM bearings)
improving 3-D imaging techniques, threshold values for
cobalt and chromium levels, and also the use of measuring
titanium levels.
Patient Monitoring and Followup
The clinical questions for polyethylene wear and CoC
monitoring include frequency of radiographs in each pop-
ulation and the role of 3-D imaging. For MoM bearings and
taper tribocorrosion, clinical questions relate to which
patients should be monitored (symptomatic versus
asymptomatic), with what tests, and how often. Should
only very high-risk patients be monitored or should mon-
itoring be extended to other populations?
Treatment
The most important clinical questions with respect to
treating polyethylene wear are when to retain implants and
when to remove well-fixed cemented and uncemented
implants. Other clinical questions relate to management of
periprosthetic osteolytic lesions with bone grafting, bone
graft substitutes, or neither. An important clinical question
with MoM implants is how aggressively the soft tissue
lesions should be débrided. There exists a recognized
tradeoff between benefits of thorough débridement to
remove the inflamed, metal-loaded tissue versus risk of
removal of extra soft tissues, which may increase risk of
neurovascular injury or joint instability. Optimizing joint
stability may be problematic in patients with soft tissue
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deficiencies. Optimizing implant fixation is also a relevant
question in these patients in whom local metal toxicity may
reduce bone viability in the region.
The clinical questions of treating taper tribocorrosion
revolve around when can part of the taper unit be retained;
and if part of the taper unit is retained, which new material
or implant is best to place against the previously damaged
surface? Ceramic femoral heads with titanium sleeves are
being widely used, but there are sparse clinical data as yet
in terms of the durability of this construct [14]. A further
question relates to whether there is any effective method of
‘‘refurbishing’’ damaged tapers in situ such as by manually
cleaning the taper. Finally, there remain questions on the
appropriate impaction method and force for various mate-
rials onto the taper. Rehmer et al. [35] showed that the
taper strength linearly increased with assembly forces and
that cobalt–chrome heads combined with cobalt–chrome
tapers showed significantly lower pull-off forces and turn-
off moments than the combination cobalt–chrome heads
with titanium tapers.
Management of Complications
The main clinical questions revolve around optimizing the
new implant’s fixation in the setting of polyethylene wear
during revision surgery. With CoC articulations, questions
remain on how to prevent noises, chipping, and impinge-
ment and if various designs can contribute to improved
results. The main clinical questions with management of
complications secondary to MoM articulations revolve
around soft tissue management and reconstruction (partic-
ularly the abductors and hip capsule); how to maintain,
regain, or improve joint stability at the time of revision
surgery; and how to achieve implant fixation at revision
when bone necrosis is present. The main clinical questions
with management of complications secondary to taper
tribocorrosion revolve around soft tissue management
(again, the destroyed abductors and hip capsule) and
reconstruction to enhance hip stability.
How Do We Get There?
In the hip, multiple papers have highlighted excellent
clinical results, radiographic evidence of implant fixation,
and survivorship at approximately 10 years [3, 26, 33, 39].
Babovic and Trousdale [3] investigated 50 patients
younger than 50 years of age and found 100% survivorship
and no radiographic evidence of osteolysis or component
loosening at a mean followup of 10 years. Prevention of
problems with polyethylene bearings now is focused on
improving highly crosslinked polyethylene (HXLPE).
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Clinical Orthopaedics and Related Research1
Also, efforts are directed toward improved locking mech-
anisms to minimize backside wear. However, both goals
must also maintain polyethylene mechanical strength and
thickness.
With CoC bearings, the clinical questions surround
whether newer ceramics will be developed and if enhanced
designs and techniques will minimize noises, chipping, and
impingement. Abdel et al. [1] recently published a series of
ceramic liner fractures with a newer-generation CoC
bearing with a low-profile design, indicating that additional
work is required.
For MoM bearings, the main method to prevent prob-
lems has been to discontinue use of this bearing couple in
most THAs. In the future—if these bearings continue to be
used—it may include optimizing joint kinematics, metal-
lurgy, and implant design. A current clinical question is the
role, if any, of MoM hip resurfacing arthroplasty. For
instance, a recent study by Nawabi et al. [29] revealed that
an adverse synovial reaction was detected on MRI in both
symptomatic and asymptomatic patients undergoing MoM
hip resurfacing.
Taper tribocorrosion remains an important, unsolved
clinical problem [27, 28, 30]. Avoidance of unnecessary
modularity and careful preclinical testing of new modular
junction are strategies that may mitigate these problems. In
the hip, ceramic femoral heads may be used in lieu of
cobalt–chrome heads, but there is an economic cost asso-
ciated with this and also there are neck length limitations.
Moreover, titanium sleeves are required, and the conse-
quences of such use are unknown. Taper modifications by
our engineer colleagues may also be possible. The clinical
questions revolve around understanding the history of
tapers and how they have changed and which tapers have
been most effective over the years. There will be important
questions to resolve regarding taper mechanics, metallurgy,
and the chemistry of taper tribocorrosion. There will also
be important material to learn regarding the biologic
response to taper tribocorrosion products. Clinical ques-
tions revolve around improving tapers for metal heads and
ceramic heads and enhancement of other types of junctions
where tapers are used. Finally, the introduction of modular
femoral necks has also further created a potential for both
accelerated taper wear and tribocorrosion.
Conclusion
Although many aspects of bearing surface wear had been
well studied, the widespread use of hard-on-hard bearings
has led surgeons to better understand the interactions
between wear and component impingement. From a clini-
cal standpoint, this understanding has helped the surgeon
recognize the need for more accurate component position.
Volume 472, Number 12, December 2014
The use of hard-on-hard bearings also allowed for the use
of larger femoral heads given the ability to use thinner
acetabular composite bearings. However, the use of these
larger femoral heads has been associated with the impor-
tant clinical problem of accelerated trunnion and taper wear
and production of corrosion products. In summary, before
innovative implants are brought to the general market,
rigorous laboratory testing replicating in vivo environ-
ments must be completed by those who are and are not
involved in the design creation. Moreover, the rationale
and clinical needs for such technology must be appropri-
ately identified and documented a priori. Finally, we must
continue to promote and analyze joint replacement regis-
tries to identify early failures and analyze long-term
successes because joint registries are a venue that can serve
as a postsurveillance vehicle.
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