29 November 2016

How to diagnose taper corrosion

Taper junction corrosion in total hip replacements is a growing concern; it is also a multi-faceted problem. With both asymptomatic and symptomatic patient groups, what indications should a surgeon look for when corrosion is suspected? While there is not a single test to isolate corrosion problems, a spectrum of diagnostic tools have been suggested to make a diagnosis.

Corrosion of the head-neck or taper junction in modular total hip implants has increasingly been reported.[1,2] While several co-mingling factors have been identified as contributors to the problem (See Part I of this article series), patients may or may not display symptoms, which can make it challenging to identify corrosion through symptoms. In some cases, corrosion has not been identified or confirmed until during revision, and these patients may experience higher rates of complications.[3] Symptoms patients may display cover a broad range and include, but are not limited to: pain, instability, elevated serum metal levels, adverse local tissue reactions (ALTR), swelling, in rare cases neurological changes, and more.

It can take upwards of eight months to establish corrosion as a diagnosis and perform retrieval[4] and Kwon cautions against overreliance on any single diagnostic tool.[5] Here we look at a selection of clinical indicators that may help identify or eliminate corrosion and/or associated metal toxicity as a cause for concern.

When to suspect corrosion

Jennings et al[6] are one of many groups of researchers to point out that diagnosis is generally a process of elimination and more studies are needed to direct diagnosis and treatment. Certainly, if a patient received a metal-on-metal (MoM) implant further investigation is warranted. However, corrosion of the taper junction has been seen in cases regardless of the type of bearing surface. When corrosion products and metal debris are released from the taper junction due to microfracture and accelerated wear, adverse local tissue reaction (ALTR) may transpire.[7]

Diagnosis of taper corrosion can be a challenge. It should be suspected if the patient experiences sudden onset of pain after a post-operative period of one to two years without pain.[8] No matter what symptoms or type of implant a post-operative hip replacement patient may present with, it is advisable to begin with a detailed history and systematic, comprehensive clinical examination.[9] More common causes of pain should be ruled out.[10]

A selection of reported symptoms of taper junction corrosion

  • Adverse local tissue reaction (ALTR)
  • Discolored joint fluid
  • Elevated serum colbalt and chromium levels
  • Iliopsoas sign or a sterile iliopsoas abscess
  • Instability
  • Osteolyis
  • Pain
  • Pseudotumors
  • Swelling
  • Symptoms of, or confirmed periprosthetic infection
  • Synovitis
  • Neurological and/or sensory deficits

Pain as a possible initial symptom

Most commonly pain, swelling and instability are reported,[6] although pain itself isn’t necessarily an indicator of corrosion. Nam et al[11] found that persistent pain in active patients under the age of 60 was described in at least one location in the hip by 40 percent of study participants 3 years post-operatively. Indeed, McGroryand McKenney[1] remind us that the majority of cases of “new onset of pain, stiffness, or dysfunction after successful arthroplasty outcome” is not attributed to corrosion or adverse tissue reaction.

Hip Pain

Pain and/or swelling may be a primary indication of corrosion-related issues. Source: 123rf.com

When pain presents itself during resisted flexion of the hip (iliopsoas sign) or a sterile iliopsoas abscess is discovered, corrosion should be suspected.[12,13] The common physical exam manifestations of ALTR include pain with straight leg raise, abductor weakness, and limp during ambulation.[14]

 

Is it an infection?

In a 2015 paper Whitehouse et al[7] highlighted 17 cases where corrosion was misdiagnosed as periprosthetic infection despite multiple negative pre-and-intra-operative samples for unknown organisms. Serum indicators pointed to a diagnosis of infection (elevated erythrocyte sedimentation rate, C-reactive protein, stromal polymorphonuclear cell counts). Corrosion was identified in all cases during revision for the complication of pseudotumors—all patients had been experiencing pain and were recipients of metal-on-highly cross-linked polyethylene (MoP) joints.

Serum metal levels may be elevated

Once fixation issues and infection have been ruled out for patients with new onset pain, the next diagnostic step that may offer assistance is determining serum cobalt (Co) and chromium (Cr) levels.[1,16] Its been reported that even in well-functioning metal-on-polyethylene hips, serum metal levels are elevated for up to ten years post-operatively, which is attributed to metal release from the modular femoral junction.[17] At present, the costs of toxicity surveillance and revision for every person who has received a modular hip replacement would place an unrealistic burden on health care systems.[18]

Different thresholds for serum metal levels may depend on the type of implant. Using 1 ppb as the minimum serum Co requirement to diagnose corrosion has been advised for patients with metal-on-polyethylene devices; for those with a MoM THA, higher acceptable Co levels should be expected because of surface wear, but a minimum requirement is, at present, unspecified.[1] Over 3 times higher Co levels from baseline were noted in patients with hybrid and Co/Cr hips through 120-months of follow-up.[17]

In a risk stratification algorithm for MoM THA patient management published by Kwon,[19] [See Part III of this article series] the highest-risk category suggesting revision is indicated for patients with high cobalt level (>5 ppb) and high cobalt/chromium ratio (>5). Some have found cobalt levels in ratio to chromium to not be indicative of corrosion or ALTR for MoM THA,[20] others have.[4] Regardless, repeated recommendations for patients with indications of corrosion is to test Co levels regularly to be able to track serum metal level changes.

Evidence of adverse local tissue reaction?

While there is not a single biomarker to indicate adverse local tissue reaction (ALTR) due to corrosion, Whitehouse and colleagues[7] have asserted that “solid, cystic and mixed soft-tissue lesions” may be noted on imaging. Some researchers have defined ALTR in corrosion cases as metallosis, characterized by aseptic fibrosis, local necrosis, and grey tissue discoloration around the joint. The discoloration of joint fluid, as viewed upon aspiration, is a good visual indication of this.[21]

To further cloud the diagnostic tool kit, Bisseling and co-authors[22] did not find a relationship between “clinical scoring, metal ion levels and periprosthetic lesions” in their study group of resurfaced and MoM hip patients. In fact, they assert that current MARS-MRI classification systems score conventional soft-tissue collection or effusions as pseudotumors, leading to an overestimation of occurrence.

Use of imaging technology

taper junction corrosion

Radiographic evidence is a useful screening tool[23] to help identify and determine osteolysis, describing the bony extent of corrosion-related ALTR, as well as device positioning and/or modes of failure. Ultrasound[10] and metal artifact reducing sequence-MRI (MARS-MRI)[4,22] are suggested as helpful in determining if, and the extent of, synovitis, osteolysis, muscle/tendon destruction, periprosthetic fluid collection and pseudotumors.[24]

 

 

Rare cases

Tower[25] encountered a case of cobaltism in a patient with MoM THA who presented himself with complex symptoms such as, “tinnitus, deafness, vertigo, visual changes, rashes, hypothyroidism, tremor, dyspnea on exertion, mood disorders, dementia, heart failure, and peripheral neuropathy”. Revision caused drastic improvement in the neurological and sensory deficits, but at 66 months post-revision the patient had only returned to two-thirds professional productivity… the patient is a surgeon. Tower reminds us that arthroprosthetic cobaltism should be on the radar.

In 2015 a paper was published on one of the first documented cases of cobalt cardiac toxicity that led to patient death in a case of bilateral MoM THA where the patient died shortly after revision.[26]

Conclusion

It may be challenging to diagnose taper corrosion as the source of a patient’s pain or instability, but it is not impossible. A selection of diagnostic tools are available and as research into the corrosion of modular taper junctions expands, diagnosis is likely to become a more straightforward endeavor.

In Part III of this article series we look at surgical options for revision.

 

REFERENCES

1 McGrory BJ, McKenney BR. Revision for taper corrosion at the head-neck junction: pearls and pitfalls. Curr Rev Musculoskelet Med. 2016 Mar;9(1):97-102.

2 Morlock M, Bünte D, Gührs J, et al. Corrosion of the head-stem taper junction—Are we on the verge of an epidemic? HSS J. 2016 Oct;12(3).

3 Lash NJ, Whitehouse MR, Greidanus NV, et al. Delayed dislocation following metal-on-polyethylene arthroplasty of the hip due to 'silent' trunnion corrosion. Bone Joint J. 2016 Feb;98-B(2):187-193.

4 Cooper HJ, Della Valle CJ, Berger RA, et al. Corrosion at the head-neck taper as a cause for adverse local tissue reactions after total hip arthroplasty. J Bone Joint Surg Am. 2012 Sep 19;94(18):1655-1661.

5 Kwon YM. Evaluation of the painful dual taper modular neck stem total hip arthroplasty: Do they all require revision? J Arthroplasty. 2016 Jul;31(7):1385-1389.

6 Jennings J, Dennis D, Yang C. Corrosion of the head-neck junction after total hip arthroplasty. J Am Acad Orthop Surg. 2016 Jun;24(6):349-356.

7 Whitehouse MR, Endo M, Zachara S, et al. Adverse local tissue reactions in metal-on-polyethylene total hip arthroplasty due to trunnion corrosion: the risk of misdiagnosis. Bone Joint J. 2015 Aug;97-B(8):1024-1030.

8 Weiser MC, Chen DD. Revision for taper corrosion at the neck-body junction following total hip arthroplasty: pearls and pitfalls. Curr Rev Musculoskelet Med. 2016 Mar; 9(1): 75–83.

9 Lanting BA, MacDonald SJ. The painful total hip replacement: diagnosis and deliverance. Bone Joint J. 2013 Nov;95-B(11 Suppl A):70-73.

10 Hussenbocus S, Kosuge D, Solomon LB, et al. Head-neck taper corrosion in hip arthroplasty. Biomed Res Int. 2015:758123. Available at: https://www.hindawi.com/journals/bmri/2015/758123/. Accessed October 21, 2016.

11 Nam D, Nunley RM, Sauber TJ, et al. Incidence and Location of Pain in Young, Active Patients Following Hip Arthroplasty. J Arthroplasty. 2015 Nov;30(11):1971-1975.

12 Matsen Ko L, Coleman JJ, Stas V, et al. Iliopsoas irritation as presentation of head-neck corrosion after total hip arthroplasty: a case series. Orthop Clin North Am. 2015 Oct;46(4):461-468.

13 Fehring KA, Fehring TK. Modes of failure in metal-on-metal total hip arthroplasty. Orthop Clin North Am. 2015 Apr;46(2):185-192.

14 Cooper JH, Urban RM, Wixson RL. Adverse local tissue reaction arising from corrosion at the femoral neck-body junction in a dual-taper stem with a cobalt-chromium modular neck. J Bone Joint Surg Am. 2013 May 15; 95(10): 865–872.

15 Prieto HA, Berbari EF, Sierra RJ. Acute delayed infection: increased risk in failed metal on metal total hip arthroplasty. J Arthroplasty. 2014 Sep;29(9):1808-1812.

16 Cooper JH, Urban RM, Wixson RL. Adverse local tissue reaction arising from corrosion at the femoral neck-body junction in a dual-taper stem with a cobalt-chromium modular neck. J Bone Joint Surg Am. 2013 May 15; 95(10): 865–872.

17 Levine BR, Hsu AR, Skipor AK, et al. Ten-year outcome of serum metal ion levels after primary total hip arthroplasty: a concise follow-up of a previous report*. J Bone Joint Surg Am. 2013 Mar 20;95(6):512-8.

18 Wyles CC, McArthur BA, Wagner ER, et al. Ceramic femoral heads for all patients? An argument for cost containment in hip surgery. Am J Orthop (Belle Mead NJ). 2016 Sep/Oct;45(6):E362-E366.

19 Kwon YM, Fehring TK, Lombardi AV, 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 Nov; 29(11):2060-2064.

20 Fehring TK, Carter JL, Fehring KA, et al. Cobalt to chromium ratio is not a key marker for adverse local tissue reaction (ALTR) in metal on metal hips. J Arthroplasty. 2015 Sep; 30(9 Suppl):107-109.

21 Pritchett J. Metallosis of the Resurfaced Hip. Available at: http://www.pritchettorthopedics.com/articles/pritchett_metallosis_of_the_hip.pdf Accessed October 21, 2016.

22 Bisseling P, de Wit BW, Hol AM, et al. Similar incidence of periprosthetic fluid collections after ceramic-on-polyethylene total hip arthroplasties and metal-on-metal resurfacing arthroplasties: results of a screening metal artefact reduction sequence-MRI study. Bone Joint J. 2015 Sep;97-B(9):1175-1182.

23 Gruen TA, McNeice GM, Amstutz HC. "Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979 Jun;(141):17-27.

24 Toms AP, Marshall TJ, Cahir J, et al. MRI of early symptomatic metal-on-metal total hip arthroplasty: a retrospective review of radiological findings in 20 hips. Clinical Radiology. 2008 63(1):49–58.

25 Tower S. Arthroprosthetic cobaltism: identification of the at-risk patient. Alaska Med. 2010 Sep;52:28-32.

26 Martin JR, Spencer-Gardner L, Camp CL, et al. Cardiac cobaltism: a rare complication after bilateral metal-on-metal total hip arthroplasty. [Case report] Arthroplasty Today. 2015 Dec;1(4):99-102. Available at: http://www.sciencedirect.com/science/article/pii/S2352344115000710 Accessed October 21, 2016.

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