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    Management of Taper Corrosion and ALTR After Revision THA for Instability

    A 56-year-old woman presents with persistent left hip pain 3 years after re-revision left total hip arthroplasty for liner failure and instability. Serum metal levels and MRI findings are concerning for taper corrosion and adverse local tissue reaction. What is the best way to safely revise her prosthesis given her ALTR and history of instability?

    Authors

    Trevor R. Grace, MD; Paul L. Sousa, MD; and P. Maxwell Courtney, MD

    Introduction

    Instability is a common indication for revision total hip arthroplasty (THA) and it can be a challenging problem to treat. [1] Successful management requires a meticulous evaluation of component positioning, abductor function, impingement, and limb length at revision.

    In the setting of well-positioned and well-fixed components, a constrained bearing is often chosen to achieve a stable hip. [2] However, constrained bearings can involve metal-on-metal junctions between the head and trunnion, which can result in fretting, metallosis, and adverse local tissue reaction (ALTR). [3]

    Taper corrosion and ALTR after revision THA for instability pose an even greater challenge for the treating surgeon, requiring revision to components without metal-on-metal bearings while achieving a stable hip. Therefore, it is important to understand the options available to both maintain hip stability and avoid ongoing metallosis.

    Case Presentation

    A 56-year-old female patient has a history of left primary THA at age 36 for post-traumatic arthritis related to an injury sustained in a car accident. Early instability required revision to a constrained liner at age 38, with a re-revision (head and constrained liner exchange) at age 53 due to eccentric polyethylene wear and retroacetabular osteolysis. At re-revision, the surgeon used a constrained liner with a cobalt-chrome head on a titanium femoral stem.

    She now presents, 3 years after re-revision surgery, with persistent and progressively worsening left hip pain of 6 months’ duration.

    Physical Exam

    • Height: 5 feet, 6 inches; weight: 185 pounds; BMI: 29.8
    • Alert and oriented, with no apparent distress
    • Well-healed posterolateral incision
    • Range of motion of left hip: 0° to 90° (on right hip)
    • Positive Stinchfield test
    • Leg lengths clinically equivalent to bilateral lower extremities
    • Normal distal lower extremity neurovascular exam

    Laboratory Tests

    • Serum erythrocyte sedimentation rate: 14 mm/hr
    • Serum C-reactive protein: 0.5 mg/dL
    • Serum cobalt level: 7.6 ng/mL
    • Serum chromium level: 1.6 ng/mL

    Imaging

    Figure 1. Preoperative anteroposterior and frog-lateral radiographs of the left hip demonstrate a cementless total hip arthroplasty with a metal-onpolyethylene constrained bearing.

    Figure 2. Preoperative magnetic resonance imaging (MRI) demonstrates complex fluid collection around the left hip prosthesis extending into the iliopsoas sheath (arrow).

    Diagnosis

    • Taper corrosion and ALTR after re-revision THA

    Treatment

    There are several considerations for the management of this patient:

    • Extensive non-operative treatment has failed to relieve her progressive hip pain.
    • The ratio of her serum cobalt to chromium levels is more than 2, which in combination with her MRI findings, suggests ALTR related to taper corrosion. [4]
    • A simple modular bearing exchange of her current construct could not be performed as the modular bearing is only available with a metal head. This would predispose her to further ALTR.
    • Given the suspicion of ALTR, which implants should be chosen to optimize stability while minimizing further metallosis, taper corrosion, and ALTR?
    • Given her history of prior instability requiring early revision to a constrained liner, which implants should be chosen to maximize stability of the hip and minimize the risk of future dislocation?

    We discussed all treatment options with the patient and obtained her informed consent for a third revision THA procedure to include these possibilities:

    • Cup and stem retention with modular component exchange, which would involve cementing a constrained liner into her prior cup and using a ceramic head with titanium sleeve on the retained stem
    • Stem retention and cup revision to a porous revision cup (with screws and possible trabecular metal augment for additional fixation) and a modular, oxidized zirconium dual-mobility bearing with a ceramic inner head impacted over a titanium sleeve on the retained stem
    • Cup revision to a porous revision cup and a modular dual-mobility bearing and stem revision to a fluted, tapered stem

    We did not believe that the cemented, constrained liner in the first option would facilitate the longevity we desired given the patient’s younger age. For that reason, we planned to use the second or third option – cup revision with or without stem retention – depending on the intraoperative findings.

    Surgical Procedure

    • A posterior approach was made in the operative hip through her prior incision.
    • A total of 5 specimens were sent to the lab for culture, all of which were negative.
    • After a thorough synovial debridement, the implants were exposed. On close inspection, the taper on the stem was clean and intact and the stem itself was stable to axial and rotational stress. Therefore, the stem was retained. However, the cup was found to be vertical.
    • Given our concerns about the cup’s position and about cementing a constrained liner in a 56-year-old patient, we decided to proceed with full cup removal and revision.
    • The cup was removed using the curved explant osteotomes matched to the diameter of her prior cup (52 mm).
    • We reamed to 57 mm and impacted a new 58-mm revision cup into place.
    • Although minimal additional bone loss occurred with cup removal, the patient had limited bone stock remaining – not surprising, given her 2 previous revision procedures. We attained supplemental fixation with 4 6.5-mm acetabular screws and a buttress augment, which was unitized to the cup with 1 batch of high-viscosity cement.
    • A modular dual-mobility liner made of oxidized zirconium was impacted into the cup.
    • After trialing, a 28-mm ceramic head was mated with a 48-mm/28-mm polyethylene outer head to create the dual-mobility articulation. This was impacted onto the retained femoral trunnion with a +6 titanium sleeve.
    • Postoperative radiographs are shown in Figure 3.

    Figure 3. Immediate postoperative radiographs of the revised THA show the revision shell (with screw and augment fixation) and the dualmobility bearing on the retained femoral stem.

    Postoperative Follow-up

    • The patient was made toe-touch weight-bearing with posterior hip precautions for 6 weeks postoperatively.
    • To date, she has been seen for her 4-week postoperative visit. She is doing well and has been compliant with her toe-touch weight-bearing status and hip precautions.

    Discussion

    Severe taper corrosion and ALTR in the setting of previous prosthetic hip instability are challenging circumstances to manage at revision THA. Although historically described as being caused by metal-on-metal bearings, metallosis due to taper corrosion has been shown to occur in 1.1% to 3.2% of metal-on-polyethylene bearings [4]. In the present case, choosing revision components that took into account both the patient’s previous instability and her current taper corrosion was paramount for a successful outcome.

    The cup design used in her re-revision procedure had only dual-mobility or constrained options with metal-on-metal junctions, which would have predisposed her to further ALTR. Retaining the cup and stem would have required us to cement either a dual-mobility or a constrained liner into the retained cup. This option would have been limited by the size of the retained cup: These liners are only offered in certain minimum diameters, and cemented components need at least a 2-mm cement mantle. Careful review of the sizes of a cemented liner and its compatibility with the size of a retained cup is recommended.

    We proceeded with cup revision to a porous revision cup with additional screw and augment fixation. A dual-mobility bearing was chosen to maximize range of motion [5] while achieving excellent stability, even in the setting of ALTR. [5,6] The cup we chose offers a modular dual-mobility liner made of oxidized zirconium, which minimizes the risk of metallosis at the cup/liner junction. [7] The dual-mobility head was made by mating the larger polyethylene head with a 28-mm ceramic head. Although this combination involves implants from 2 companies, it does not involve an increased risk of intra-prosthetic dislocation. [8] To minimize the risk of ceramic head fracture on the retained stem, this dual-mobility head was then impacted onto the trunnion over a titanium sleeve. [9]

    Although excellent intraoperative stability was achieved, the patient’s postoperative activity was limited to toe-touch weight-bearing and posterior hip precautions to allow for cup ingrowth and posterior capsular healing.

    Surgical Pearls

    • Taper corrosion and ALTR in the setting of prior hip instability can be treated with cup revision to a dual-mobility construct that includes an oxidized zirconium modular liner.
    • A mixed-manufacturer dual-mobility articulation remains a viable option when a stem is retained at revision THA.

    Author Information

    Trevor R. Grace, MD; Paul L. Sousa, MD; and P. Maxwell Courtney, MD, are from The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. Dr. Courtney is also the Adult Reconstruction Section Editor of Rothman Institute Grand Rounds on ICJR.net.

    Disclosures: The authors have no disclosures relevant to this article.

    References

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    2. Wera GD, Ting NT, Moric M, Paprosky WG, Sporer SM, Della Valle CJ. Classification and management of the unstable total hip arthroplasty. J Arthroplasty. 2012 May;27(5):710-5. doi: 10.1016/j.arth.2011.09.010. Epub 2011 Oct 29.
    3. Sultan AA, Cantrell WA, Khlopas A, et al. Evidence-based management of trunnionosis in metal-on-polyethylene total hip arthroplasty: a systematic review. J Arthroplasty. 2018 Oct;33(10):3343-3353. doi: 10.1016/j.arth.2018.05.035. Epub 2018 May 31.
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    7. Hampton C, Weitzler L, Baral E, Wright TM, Bostrom MPG. Do oxidized zirconium heads decrease tribocorrosion in total hip arthroplasty? A study of retrieved components. Bone Joint J. 2019 Apr;101-B(4):386-389. doi: 10.1302/0301-620X.101B4.BJJ-2018-1316.R1.
    8. Buller LT, Torres L, Baral EC, Wright TM, Ast MP. No difference in force required for intraprosthetic dislocation of mixed manufacturer vs same manufacturer dual mobility articulations. J Arthroplasty. 2020 Feb;35(2):597-602. doi: 10.1016/j.arth.2019.09.039. Epub 2019 Sep 30.
    9. Falkenberg A, Dickinson EC, Morlock MM. Adapter sleeves are essential for ceramic heads in hip revision surgery. Clin Biomech (Bristol, Avon). 2020 Jan;71:1-4. doi: 10.1016/j.clinbiomech.2019.10.018. Epub 2019 Oct 20.