Why Coating Technologies for Hip

Replacement Systems, and the Importance of

Testing Them In Vitro
Hani Haider, PhD, Joel N. Weisenburger, MS, Fereydoon Namavar, ScD, and
Kevin L. Garvin, MD

The rationale behind novel surface engineering and coating technologies for implant articular
surfaces is described especially for the significant number of metal-sensitive patients with total
hip replacement. We list the important coating characteristics, and emphasize adhesion as the
most challenging. We report on 2 large scale experimental hip wear simulator studies we
conducted on samples of 2 such coating technologies implemented by external experts in their
respective fields. One was a titanium nitride ceramic coating on a metal-on-metal total hip
replacement, which aimed at wear reduction and a barrier against metal-ion diffusion. The other
was a nanocrystalline homometallic surface treatment where same element metals were vapor-
deposited in a novel ion-beam-assisted deposition process onto CoCr alloy femoral heads in
CoCr metal on ultra high molecular weight polyethylene (UHMWPE) hips. The gradual
reduction in crystal size toward the surface into nano size aimed at increasing hardness and
reducing wear. Both test series were conducted on an AMTI hip simulator for 5 million cycles
under the 14242-1 ISO standard, simulating walking gait, without any deliberate edge-loading or
harsh conditions, and using uncoated specimens of identical design and materials as controls in
each test. Both tests resulted in some of the coating eventually rubbing away (separating) to
various levels on all specimens. The wear rate of the coated specimens was generally higher not
lower than the uncoated controls, but not multiply so. Our discussion compares and contrasts
our results with others, and we speculate whether a metal-sensitive arthritic patient who badly
needs a hip replacement may still benefit from a coated implant despite the risk.
Oper Tech Orthop 27:152-160 C 2017 Elsevier Inc. All rights reserved.

KEYWORDS Coatings, Surface treatments, Metal-sensitive, Stop metal ion diffusion, Ceramic
coatings

Introduction surfaces of hip replacements. We then report on 2 large scale

experimental hip wear simulator studies in our laboratory on

I n this article, we summarize the rationale, categories, and

significance of surface coating technologies for articular
Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska
Medical Center, Omaha, NE.
No author has any conflict of interest directly relevant to this work. H.H. (first
author) is a consultant to AMTI (Watertown, MA), which manufactures
implant wear testing simulators. The laboratory in which this work was
carried out uses AMTI hip simulators and has received tens of research
funding contracts from many orthopedics companies for hip testing using
that kind of simulator.
Address reprint requests to Hani Haider, PhD, Department of Orthopaedic
Surgery and Rehabilitation, University of Nebraska Medical Center,
985640 Nebraka Medical Center, Omaha, NE 68198-5640.
E-mail: hhaider@unmc.edu
samples of 2 such technologies implemented by external
experts in their respective fields.
Hip arthroplasty surgery is among the most successful in
modern medicine, substantially alleviating pain with implants
lasting tens of years, with patients remaining ambulatory to
enjoy longer, healthier lives. This impeccable history was
partially dented with severe criticism of some all-metal bearing
total hip replacements (THR) and hip resurfacing devices
having excessive metal wear and release of metal ions from the
articulating surfaces and/or, the fretting corrosion of the
modular taper between the femoral head and the stem. All
metals in contact with biological systems corrode at various
speeds to various levels. The resulting metal ions vary in
magnitude and can trigger an immune response. Some of the

152 http://dx.doi.org/10.1053/j.oto.2017.05.003
1048-6666//& 2017 Elsevier Inc. All rights reserved.
Hip replacement systems
problematic metal-on-metal hips described earlier might not
have been thick enough to resist deformation during surgical
insertion from an exactly spherical shape, or had insufficient or
excessive radial clearances, or had curtailed articulating area
coverage, or had faulty taper designs or installations. If such
design, material, or manufacturing issues were to be combined
with possible surgical misalignment during insertion, unin-
tended metal-metal contact and even edge loading and
accelerated damage could occur. The resulting risk to the
patient from this multifactorial problem was in many cases
adverse local tissue reaction, metallosis, pseudotumors, and
associated total implant failure and revision in many cases.1-4
The scale of the problem eventually instigated a massive
regulatory body recall of various metal-on-metal hip designs
in the United States and Europe.
The problem is especially severe in patients with metal
hypersensitivity, for whom the risks are obviously elevated and
in extreme cases can include skin lesions, hair loss, and other
complications. Results from a systematic literature review4
reported an estimated 10%-15% of the population to have
some metal sensitivity or allergic reaction to the metals that
diffuse into their systems. Approximately 25% of patients with
“well-functioning implants” were metal sensitive, and a star-
tling 60% of patients with “poorly functioning implants” were
shown to have some metal sensitivity. It is not clear from that
review, or the studies upon which it was based, whether the
patients' sensitivity had arisen because of the device function-
ing poorly or failing or vice versa, in terms of cause and effect,
or if other factors (eg, genetic auto immunity) were responsible
for both.
The numbers prone to risk stated above point to a large scale
problem when considering that orthopaedic arthroplasty
systems, including the “gold-standard” metal‐on‐UHMWPE
hips, contain varying levels of cobalt, chromium, molybde-
num, nickel, titanium, vanadium, and aluminum. Cobalt,
chrome, and especially nickel can cause allergic reactions.
Nickel is almost poisonous, and so is chrome. Cobalt, chrome,
and nickel constitute 62%-67%, 27%-30%, and 1%, respec-
tively of most metallic hip femoral heads according to
ASTM F75,5 the standard to which they are typically
manufactured.
The significant risks described above have warranted
sophisticated engineering solutions with various technologies
to modify the metallic surfaces to protect the patient from the
metallic wear particulate and ionic debris. “Surface engineered”
implants can feature bearing surfaces that combine the bulk
properties of a metal implant with the surface qualities of a
ceramic (or other desired material). These can be categorized
into either surface “coatings” with addition of a material layer
onto the surface, or “surface treatments” where the outer layer
is transformed (eg, oxidized) to change its characteristics.
However thin (eg, 2–8 mm) and fine grained a coating is, a
clear boundary between the coating and substrate typically
results in a relatively steep hardness gradient. Surface treat-
ments such as diffusion hardening on the other hand can
produce a similar thickness of compound layer with a transi-
tional diffusion zone with a smoother hardness and strength
gradient, and a coating less likely to fail.
153
In arthroplasty, some implants are given a thin ceramic layer
covering the original metal articulating surfaces. The modified
articulating surface should, theoretically, benefit from super-
hardness to reduce scratching and abrasive wear, or to achieve
higher wettability to improve lubrication and thus reduce
friction and adhesive wear. Some of these technologies have
seen successful clinical use, such as the ceramic zirconium
oxide6 (with the trade name “Oxinium” by Smith and Nephew,
TN). Wrought zirconium-2.5 niobium alloy substrate is heated
in air until the oxygen diffusion causes the top 5 μm of the
surface to transform into a stable (monoclinic form) of
zirconium oxide ceramic.
Various diamond-like carbon coatings7,8 have been tried for
their biocompatibility, resistance to corrosion and acid attack,
and superior tribological and mechanical properties. However,
low thickness, residual stresses, instability, and reliable adhe-
sion of such coatings have always been a challenge. Modern
variations of these have combined nanocrystalline diamond
coatings onto silicon nitride ceramic substrates, aiming to
reduce wear and related debris.9
A lot of work has been published on nitride based coatings
for hip replacement systems, such as ceramic coatings of
titanium nitride (TiN)10,11 or chromium nitride (CrN).12 These
super-hard “surface engineered” components have been used
clinically to provide a barrier to metal-ion diffusion, as well as
resist scratching and abrasion to their surface.
All these technologies are ultimately validated through
clinical outcomes of the implants employing them. Preclini-
cally, they tend to be tested in vitro for their direct benefits, viz.
hardness, wear reduction, and success as a diffusion barrier for
metal ions, etc. Overall, a large review study11 on TiN coatings
was generally favorable.
It is imperative for coating designers and manufacturers that
all the following characteristics13 of coatings should be assessed
preclinically, as they all have direct or indirect influence
especially for the application of articular surfaces in joint
replacement implants: (1) purity and composition, (2) coating
density and defects, (3) surface finish and roughness, (4)
residual stress, (5) hardness and elastic modulus, (6) fracture
toughness, (7) corrosion, and perhaps most importantly, (8)
adhesion.
In our opinion, “adhesion” is very important in the
application of hip replacement bearings. One could have the
most advanced coating, which does everything intended but it
does not adhere for long enough on the substrate to last the
in vivo duty of the implant. That has been the curse of coatings
throughout the history of engineering and development of
coatings, and it is especially pertinent in the case of joint
replacement articular bearing surfaces where the coating is the
subject of continuous rubbing and stress variations in normal
duty. All of the benefits of coatings depend on the coating
adhering to the substrate and not delaminating or flaking off,
or oxidizing and slowly rubbing away.14 Any failure of
adhesion can turn the intended benefit of the coating into
harm. When the substrate is exposed not only are all the
coating benefits negated, but the delaminated coating acts as
third body wear particulate, which could greatly accelerate the
wear or scratching of the bearings.15
154
In the remainder of this article, we report the results of two
comprehensive in vitro wear studies on 2 different advanced
technologies. The first was a titanium nitride (TiN) coating on a
CoCrMo (will be shortened to CoCr in the remainder of this
document) substrate femoral head, intended as a metal-ion
diffusion barrier with reduced wear.11 The second was a
homometallic gradual surface transformation of a cobalt
chrome (substrate) femoral head into a nanocrystalline CoCr
with decreasing grain size toward the surface.16 This nano-
technology solution was intended to add super hardness and
reduce wear. Both were vapor deposition surface treatment
technologies. Both were implemented by the advanced inter-
national experts who invented them.
Materials
Test 1
The titanium nitride (TiN) coating of the first test was through
a vapor deposition process by a third party giving a golden
color to CoCr substrate femoral heads. The coating was
intended as a metal-ion diffusion barrier with added wear
reduction of a metal-on-metal system. A total of 6 metal-
on-metal THR specimens were supplied by the same manu-
facturer of size 44 mm femoral heads and acetabular liners
(44 mm I.D.), all polished to an orthopedic grade finish.
Three of the THR specimens had femoral heads and acetabular
liners that were coated with TiN, and the remaining 3 were
not coated as controls. Six acetabular shells were also
provided, made from CoCr. The shells were 56 mm
inner diameter. Examples of the acetabular liner specimens
for Test 1 are shown in Figure 1, and the heads are shown in
Figure 2.
Figure 1 Test 1 metal acetabular liners before testing. Top pictures
show an uncoated liner (specimen 1), and bottom pictures show a
TiN coated liner (specimen 2, note the golden color from the TiN
coating). Pictures on the left show the highly polished articulating
surface of the liner, whereas pictures on the right show the surface that
interfaced with the acetabular shell, as well as the inscribed lot # for
specimen identification.
H. Haider et al.
Figure 2 Test 1's 44 mm uncoated femoral head 1 (left) and TiN coated
femoral head 2 (right) prior to testing.
Test 2
The subject coating of the second test was a homometallic
surface treatment by ion-beam-assisted deposition16 onto a
CoCr hip femoral head. The coating was described as
homometallic because the metal elements added in the treat-
ment were not different from those of the substrate. The ion
beam assisted deposition (IBAD) process made the substrate
surface gradually reduce in crystal size until the crystals reached
a nano scale at the surface. The extra boundaries between the
smaller crystals should, theoretically, have hindered fracture
initiation and growth and thus brought super-hardness which
in turn should have been expected to reduce wear against
UHMWPE hip bearings.
A total of 16 metal-on-plastic THR specimens were supplied
by an orthopaedic manufacturer and some of which were
coated by the coating specialists. The hips were of size 36 mm
femoral heads made out of standard CoCr, with half of them
having the CoCr homometallic coating. The acetabular liners
(36 mm I.D.) were made of standard Arcom UHMWPE.
Sixteen acetabular shells were also provided, made from TiAlV.
The shells were 54 mm inner diameter. 12 THRs were used as
wear specimens (6 coated, and 6 uncoated as controls) and
4 were used as active soak controls to compensate for fluid
adsorption (2 of each type). Examples of the femoral heads for
Test 2 are shown in Figure 3 and an acetabular liner is shown
in Figure 4.
Methods
All testing was conducted on a 12-station AMTI hip simulator
(Watertown, MA). This hip simulator design holds the THR in
a physiological orientation with the acetabular components
superior and the femoral head inferior (as opposed to several
simulators that use an inverted design). Special fixtures were
manufactured to hold the femoral heads and acetabular shells
or liners at an anatomically correct angle on the simulator. For
Test 1, the femoral necks or tapers were aligned at 301 from
vertical in the coronal plane, and the acetabular shells were
tilted at 301 from horizontal in the coronal plane. This was
necessary to place the wear patch in a similar location as would
likely be seen in vivo. Test 2, had the same alignment, but the
femoral necks were mounted vertically.
The waveforms specified in ISO-14242-117 were used
which simulated normal human walking gait at a frequency
of 1 Hz. During the test, the THR specimens were kept
Hip replacement systems
Figure 3 CoCr-coated femoral heads 4 and active soak 2, and uncoated 1 (from left to right).
immersed in a lubricating solution at 37 ⫾ 1 1C. The
lubricating solution was composed of diluted filter-sterilized
bovine serum, with the precise dilution adjusted to maintain a
protein concentration of 20 g/L. To slow bacterial growth,
0.2% sodium azide was added to the solution and 20 mM
(7.45 g/L) EDTA (ethylene diaminetetraacetic acid) was also
added to reduce calcium precipitation. The diluting solution
was passed through a 2 mm filter to remove particulate before
being added to the serum.
All liners and heads were weighed before the wear test and
removed from their fixtures for cleaning and weighing at 0.25
million cycles, 0.5 million cycles, and every 0.5 million cycles,
thereafter until the completion of the 5 million cycle (Mc) test.
The weight for each specimen was measured on a balance with
0.01 mg resolution (Sartorius ME215S). Specimens were
photographed at 1 Mc intervals, unless something noteworthy
was observed.
Results
Test 1
During the first weighing, at 0.25 Mc, it was visually observed
that the coating was wearing or peeling away on both the
femoral head and liner of THR specimen 3, and that the
substrate metal was scratched (Fig. 5). At this point in the test,
the TiN coating on the other 2 coated specimens still appeared
intact. During the second weighing (0.5 Mc) the area of
damage had increased on the head and liner of specimen 3.
By 1 Mc, all 3 TiN coated specimens displayed areas where the
Figure 4 Acetabular liner from THR specimen Uncoated 1. Interior,
acticulation surface shown on left, backside shown on right.
155
coating was removed (Fig. 6). By the end of the 5 Mc test, these
areas had increased in size (Figs. 7 and 8). Additionally, the 3
coated specimens displayed deeper and more numerous
scratches than the uncoated controls, likely due to the removed
coating debris acting as third body abrasive wear particles. The
damage to coated specimen 3 was the most severe of all. No
surface analysis of the heads and liners or particle analysis on
the lubricating fluid was conducted, but the loss of TiN coating
was obvious to the eye, and also clearly corroborated by the
wear results presented later (Fig. 9, Table 1).
The uncoated specimens were not free from damage, as
evidenced by the photos taken at 5 Mc (Figs. 7 and 8).
Especially noteworthy were the deep circular scratches visible
on all specimens, including those without the coating. The
damage was concentrated at the regions, which would
correspond to high contact stress in a truly physiological
configuration, as the THR components were aligned physio-
logically as described earlier.
The gravimetric weight change data from the 6 femoral
heads and acetabular liners are shown in Figure 9. Uncoated
components are shown in blue, and TiN components are
shown in orange. Femoral heads are shown as solid markers,
and acetabular liners are shown as hollow markers with dashed
lines. All components lost weight over the course of the test,
and the TiN coated specimens lost more weight than the
uncoated specimens. Coated specimen 3 displayed immediate
“break away” wear between the start of the test and 250,000
cycles, which was supported by its loss of coating during the
same period. By 1 Mc, a clear difference in wear between
coated and uncoated components was apparent. This was also
Figure 5 TiN coated femoral head 3 (left) and liner 3 (right) after
250,000 cycles when the coating was first observed to be damaged/
missing.
156 H. Haider et al.

Figure 6 TiN coated femoral heads (top) and acetabular liners (bottom) at 1 million cycles, showing regions of missing
coating. (Color version of figure is available online).

the point in the test where the area of missing coating appeared rates of the TiN coated specimens were only slightly higher
on regions of the other 2 coated specimens and was observed than the uncoated specimens, likely due to most of the coating
to be much larger on coated specimen 3. After 1.5 Mc, the wear in the articulating region already having been removed by this

Figure 7 The uncoated (left) and TiN coated (right) femoral heads after Figure 8 The uncoated (left) and TiN coated (right) acetabular liners
5 million cycles. (Color version of figure is available online). after 5 million cycles. (Color version of figure is available online).
Hip replacement systems 157

Figure 9 Weight change of femoral heads and acetabular liners in Figure 10 Combined wear of femoral heads and acetabular liners in
Test 1. Test 1.

point, and the third body wear particles washed out during the
serum changes. In general, the femoral head of a given system
wore slightly more than its paired acetabular liner. The wear
rates of each test component are shown in Figure 9 and
Table 1, calculated via a least squares error line with a free
intercept. Figure 10 shows the combined wear of the head and
liner of each THR specimen over the course of the test, and
Figure 11 shows the average total wear for each of the 2 groups.
The average wear rates of the TiN coated and uncoated
THRs are shown in Figure 11. The uncoated THRs (head and
liner wear combined) resulted in a wear rate of 3.19 ⫾
0.281 mg/Mc whereas the coated THRs wore at 8.53 ⫾
4.07 mg/Mc. Note the wide 95% CI for the TiN coated
specimens, especially after 0.5 Mc. This resulted from the
much higher wear displayed by coated THR #3. These CI were
so wide that only marginal statistical difference in wear
rate between the coated and uncoated heads resulted
(P ¼ 0.0752).
Test 2
When the specimens were disassembled at 1.0 Mc for gravi-
metric weight loss measurements, it was observed on the
coated specimens that an area of the coating was missing. This
was detected by eye, evidenced by a transition from the foggy,
coated region to the shiny uncoated region. Capturing this
subtle change in appearance was difficult via camera on a
reflective surface, but an attempt is shown in Figure 12 (at the
end of the 5 Mc test). The lower regions of the femoral head
were not subjected to any articulation, so no wear or peeling
took place here, leaving the coating intact. The top surface,
however, was in contact with the acetabular liner and after
5 Mc, the missing CoCr coating was quite apparent.
On all coated samples, a region of missing coating was
visible on the femoral head. However, damage to all femoral
heads, even the uncoated ones, was visible. Especially note-
worthy were the deep circular scratches visible on many of the
samples, but especially on uncoated sample 2 (Fig. 13) which
displayed the highest wear rate (Fig. 14), likely caused by this
damaged area. The wear rate of uncoated sample 2 was
essentially the same as the lowest wearing coated sample. In
every other case, the UHMWPE liners from the CoCr-coated
samples wore at a higher rate than those paired with uncoated
heads, as shown in Figure 14. The circular scratches were seen
on many of the coated as well as the uncoated samples, and the
coated samples still had higher wear rates. The high number
and depth of scratches on the femoral heads of the coated
samples, as well as the loss of coating, resulted in higher wear of

Table 1 Total Wear and Wear Rates of all Specimens From

Test 1. Wear Rates Were Calculated With a Least Squares
Error Line With a Free Intercept
Femoral Heads Acetabular Liners

Total Wear Total Wear

Wear Rate Wear Rate
Specimen (mg) (mg/Mc) (mg) (mg/Mc)
Uncoated 1 9.01 1.79 6.20 1.26
Uncoated 2 8.63 1.70 6.67 1.31
Uncoated 3 10.1 2.04 7.45 1.47
TiN coated 1 15.5 3.04 13.7 2.67
Figure 11 Average combined wear of femoral heads and acetabular
TiN coated 2 16.8 3.39 16.0 3.29
liners in Test 1. Wear rate calculated via least squares error line with a
TiN coated 3 36.4 6.69 35.4 6.51
free intercept. 95% confidence intervals (CI) also shown.
158
Figure 12 Coated femoral head 1 at 5 million cycles, showing damaged
and intact regions of coating. (Color version of figure is available
online).
their UHMWPE acetabular liners, shown in pink in Figure 14.
This was likely because of the loose coating acting as third body
wear particles, which damaged both the femoral head, and
plowed through the UHMWPE liner. Coated sample
4 remained lower in wear than the other coated samples,
evidenced by its wear trend line falling within the group of
uncoated, blue wear trend lines. This is also displayed in
Table 2, which organizes the specimens from highest wear rate
to lowest.
Figure 15 shows the average wear of the liners paired with
the coated and uncoated femoral heads over the course of the
5.0 Mc test, corrected by active load soak data, along with a
linear, best fit trend line calculated via the least squares fit
method. A clear and significant difference between the 2 sample
groups was present. Coated specimens had an average
UHMWPE liner wear rate of 55.6 ⫾ 3.37 mg/Mc whereas
uncoated specimens had a lower average wear rate of 44.5 ⫾
4.08 mg/Mc. The difference in wear between the 2 groups was
statistically significant (P ¼ 0.00024).
Discussion
We started this article by describing a serious problem of
particulate and metal-ion release from metal-on-metal THRs or
corrosion of metallic modular taper junctions. The risk of
adverse biological reaction posed to patients and the massive
legal and regulatory response has significantly dented the
reputation of metal-on-metal bearing couples with their long
history and various revivals. We explained that according to
one study, 10% of all people were metal sensitive to some
degree, and metal-ion release was a problem to 25% of all
H. Haider et al.
patients with well-functioning implants, and possibly causing
or resulting from up to 60% of patients with poorly function-
ing implants. This in itself was justification enough and a solid
rationale for emerging technologies for coatings and innovative
surface engineering to reduce wear from metal surfaces, or as
diffusion barriers against the ion release.
The rationale behind and enthusiasm associated with the
above have inspired many coating technologies described
earlier, and some brought the usual exuberance and premature
nod of approval from the in vitro testing community. For
example, a well know study18 of in vitro wear tests by a large
lab showed a chromium nitride (CrN) hip coating for exactly
the purposes above (thin ceramic onto a CoCr metal substrate)
had shown 80% lower wear and much lower Cr and Co ion
release than controls without the coating. The title of that 2009
study advocated for the coating as a “low wearing solution,”
presumably, a medical solution for all patients, not only ones
with metal sensitivity. The conditions for those wear simulator
tests were supposed to be the same (along the lines of ISO
14242-1) as those of this study. Yet, that coating was reported
not to fail.
In both tests of this (our) study, 2 categorically different
types of coatings for the same purpose as earlier were tested.
The coating in each was definitely present at the start of the test
and missing on portions of the metal surfaces at some point in
the middle of the tests. The cleaning protocol used before
weighing the components for wear measurement was gentle
enough that it could not have removed the coating. Addition-
ally, the tests were meticulously clean, and no intentional third
body wear particles were included to increase abrasion.
Therefore, the coating itself must be at fault for the failure.
Again, “adhesion” which we described as the main challenge
and ultimate curse of all industrial coatings was the problem.
Our results showed extra wear with the homometallic coated
femoral heads articulating against UHMWPE, than the
uncoated controls, and the same for the TiN coatings. Perhaps
the surfaces were not cleaned properly before coating applica-
tion, or perhaps the coating was applied or deposited too thinly
on the substrate, or a myriad of other reasons might have
caused the gradual detachment. This effect might have been
compounded by the curved geometry of the components,
which may have made achieving a coating of uniform thick-
ness difficult. As most of these vapor deposition coating
processes are directional in nature during application, at least
2-dimensional or 3-dimensional robotics with sophisticated
Figure 13 Uncoated sample 2 at the end of 5 Mc, showing a circular
scratch (right). (Color version of figure is available online).
Hip replacement systems 159

Figure 14 Wear of UHMWPE acetabular liners paired with coated and uncoated femoral heads over 5 Mc, corrected with
the weight gain of active soak control liners (also shown).

computed paths and velocities are needed to manipulate the
implant during the coating process to achieve the desired
uniformity of thickness. It is also known that such vapor
deposition processes need to be performed inside very high
vacuum chambers. High vacuum causes outgassing, and thus
all conventional mechanisms or robotics would not be able to
operate inside as they instantly outgas and run out of lubricant.
Even plastics can outgas and cannot be used inside such
chambers, so that rules out plastic bushings and bearings, or
similar alternatives. No doubt many of those mitigating reasons
can be removed or improved upon with improved future
coating technology.
Our results echo those of several other studies15,19,20 where
the TiN coating was missing on retrieved metal-on-metal and
metal-on-plastic THRs. In 1 retrieval study,20 the TiN coating
damage extended to about 70% of the articulating surface on
the femoral head from a high demand patient, which was very
similar to our TiN coated specimen 3 in this study.
Indeed, 4 years after their original study, the same lab18
(cited near the start of this section) published another study12
on further hip simulator testing of the same CrN coated metal-
on-metal THRs, but they imposed edge loading between the
head and liner this time. The edge-loading damage was
simulated with a spring-loaded transverse offset (in the medial
lateral direction) between the simulator fixtures. Termed
“micro-separation,” during the swing phase with almost zero
compressive load, the spring-loaded offset separated the
femoral head laterally from the cup. Severe edge loading
occurred upon return of the compressive load, forcing return
of the hip (ball in socket) engagement in part of the repetitive
simulated walking cycle. This mechanism would result in
stripe wear in any hip with hard-on-hard bearings, and thus
coating failure too. It is interesting, however, that ultimately
those coated implants under edge loading showed
4 times the wear rate of the uncoated THRs. Therefore, the
wear reduction coating solution reported in 2009 turned out
later to be a wear multiplier under a different and harsher test.
It is understood by the authors that TiN coatings are already
being used on implants for patients in Europe, therefore the
results of this study could be a cause for alarm and necessitate

Table 2 Wear Rates in mg/Mc of UHMWPE Liners in Test 2,

Calculated via a Least Squares Error Line With a Free Intercept
Over the Entirety of the 5 Mc Test. Wear Rates were Organized
From Highest Wearing to Lowest Wearing
Sample Wear Rate (mg/Mc)
Coated 6 58.5
Coated 3 57.3
Coated 1 56.8
Coated 5 56.2
Coated 2 55.7
Coated 4 49.0
Uncoated 2 48.9
Uncoated 4 47.6
Uncoated 1 44.7
Figure 15 Average wear of UHMWPE acetabular liners paired with
Uncoated 5 44.4
coated and uncoated femoral heads over 5 Mc, corrected with the
Uncoated 3 44.0
weight gain of active soak control liners (not shown). Least squares
Uncoated 6 37.2
error lines and 95% CI shown.
160
heightened monitoring of patients with such implants. We
hope this study raises awareness of the need for test laborato-
ries to be rigorous. Slow detaching coatings need discerning
test lab eyes, and a relentless quest for “searching for possible
problems” and an unquenchable willingness to tell paying test
lab customers (eg, manufacturing companies) what they do
not like to hear!
Conclusion
The main conclusion and take home messages from our study
were the compelling rationale and theoretical benefits of
coatings for hip replacement systems, primarily for ceramic
coatings to act as diffusion barriers against metal-ion release
from metallic substrates, especially for metal-sensitive patients.
Any extra abrasive wear reduction due to super hardness of the
surfaces would be the “icing on the cake.” The question
remains for the arthroplasty surgeons, and of course patients
too: if the desire is to have a hip replacement implant installed
to stop arthritic pain and re-enable ambulation, and to stop the
metal diffusion in a metal-sensitive patient, is it worth having
the best coating implemented? Might it be worth putting up
with more wear or a coating that comes off slowly and
noncatastrophically? Would the benefits outweigh the extra
wear, which in any case is an accumulative longer term
problem when compared to the arthritic pain and the extra
harm to the patient from not having a THR and not being able
to walk?
References
1. AAOS information Statement 1035. Current Concerns With Metal-On-
Metal Hip Arthroplasty, 2012. www.aaos.org/about/papers/advistmt/
1035.asp.
2. Vendittoli P, Roy A, Mottard S, et al: Metal ion release from bearing wear
and corrosion with 28 mm and large-diameter metal-on-metal bearing
articulations: A follow-up study. J Bone Joint Surg Br 92:12-19, 2010.
http://dx.doi.org/10.1302/0301-620X.92B1.22226
3. Roessler PP, Witt F, Efe T, et al: Arthroprosthetic cobaltism and
pseudotumour also occur in patients with small diameter femoral ball
head metal-on-metal total hip arthroplasties. BMJ Case Rep 2014:1-4,
2014. http://dx.doi.org/10.1136/bcr-2013-203362
4. Hallab N, Merritt K, Jacobs JJ: Metal sensitivity in patients with orthopaedic
implants. J Bone Joint Surg Am 83-A:428-436, 2001. http://dx.doi.org/
10.1111/j.1600-0536.2011.01886.x
5. ASTM F75-12. Standard Specification for Cobalt-28 Chromium—6
Molybdenum Castings and Casting Alloy for Surgical Implats. Interna-
tional ASTM, 2012. www.astm.org.
H. Haider et al.
6. Spector M, Ries MD, Bourne RB, et al: Wear performance of ultra-high
molecular weight polyethylene on oxidized zirconium total knee femoral
components. J Bone Joint Surg Am 83-A(suppl 2 Pt 2):S80-S86, 2001
7. Alakoski E, Tiainen VM, Soininen A, et al: Load-bearing biomedical
applications of diamond-like carbon coatings—Current status. Open
Orthop J 2:43-50, 2008. http://dx.doi.org/10.2174/18743250008020
10043
8. Roy RK, Lee KR: Biomedical applications of diamond-like carbon coatings:
a review. J Biomed Mater Res B Appl Biomater 83:72-84, 2007. http://dx.
doi.org/10.1002/jbm.b.30768
9. Maru MM, Amaral M, Rodrigues SP, et al: The high performance of
nanocrystalline CVD diamond coated hip joints in wear simulator test.
J Mech Behav Biomed Mater 49:175-185, 2015. http://dx.doi.org/
10.1016/j.jmbbm.2015.05.005
10. Pappas MJ, Makris G, Buechel FF: Titanium nitride ceramic film against
polyethylene. A 48 million cycle wear test. Clin Orthop Relat Res
317:64-70, 1995
11. Van Hove RP, Sierevelt IN, Van Royen BJ, et al: Titanium-nitride coating of
orthopaedic implants: A review of the literature. Biomed Res Int 2015.
http://dx.doi.org/10.1155/2015/485975
12. Leslie I, Williams S, Isaac G, et al: Wear of surface-engineered metal-on-
metal bearings for hip prostheses under adverse conditions with the head
loading on the rim of the cup. Proc Inst Mech Eng H 227:345-349, 2013.
http://dx.doi.org/10.1177/0954411912468542
13. Dearnley PA: A review of metallic, ceramic and surface-treated metals used
for bearing surfaces in human joint replacements. Proc Inst Mech Eng H
213:107-135, 1999
14. Lappalainen R, Santavirta SS: Potential of coatings in total hip replace-
ment. Clin Orthop Relat Res 430:72-79, 2005. http://dx.doi.org/10.1097/
01.blo.0000150000.75660.ff
15. Łapaj Ł, Markuszewski J, Wendland J, et al: Massive failure of TiNbN
coating in surface engineered metal-on-metal hip arthroplasty: Retrieval
analysis. J Biomed Mater Res—Part B Appl Biomater 104:1043-1049,
2016. http://dx.doi.org/10.1002/jbm.b.33421
16. Namavar F. Nano-crystalline, homo-metallic, protective coatings. United
States Patent 2003/0229399 A1, 2003. http://digitalcommons.unl.edu/cgi/
viewcontent.cgi?article=1092&context=cmrafacpub.
17. (ISO) ISO. ISO 14242-1:2014: Implants for Surgery—Wear of Total Hip-
Joint Prostheses—Part 1: Loading and Displacement Parameters for Wear-
Testing Machines and Corresponding Environmental Conditions for Test,
2014.
18. Leslie IJ, Williams S, Brown C, et al: Surface engineering: A low wearing
solution for metal-on-metal hip surface replacements. J Biomed Mater Res
—Part B Appl Biomater 90 B:558-565, 2009. http://dx.doi.org/10.1002/
jbm.b.31317
19. Łapaj Ł, Wendland J, Markuszewski J, et al: Retrieval analysis of titanium
nitride (TiN) coated prosthetic femoral heads articulating with poly-
ethylene. J Mech Behav Biomed Mater 55:127-139, 2015. http://dx.doi.
org/10.1016/j.jmbbm.2015.10.012
20. Raimondi MT, Pietrabissa R: The in-vivo wear performance of prosthetic
femoral heads with titanium nitride coating. Biomaterials 21:907-913,
2000. http://dx.doi.org/10.1016/S0142-9612(99)00246-X