20-year Results of a 3D Titanium Mesh Coating Stability of 31 Artificial Cups

Abstract

Background The aim of this work was to demonstrate the bony bond strength and resilience of a three-dimensional titanium mesh coating of an artificial acetabulum produced using the diffusion bonding technique. Under the extreme conditions ranging from abrasion-related osteolysis to acetabular perforation, the degree of residual bone and the integrity of the coating were determined. The remaining zones of the (still) stable bone connection are inevitably exposed to a greater load of the layer adhesion between the titanium mesh and the core shell. The investigation was intended to provide information about the stages of damage according to Paprosky in which it was still justifiable to leave the implant in place and simply change the inlay from the purely material-technical point of view of a stable coating. The bond between bone and implant was examined with regard to a possible retention of the implant for its adaptive remodeling up to 27 years.

Materials and Methods In a retrospective study, 31 explanted human acetabular cups of the Harris-Galante II type, with an average lifetime of 19.7 years (11–27 years), were examined by means of digital area measurement to determine both the bone areas remaining on the coating and the damaged areas of the titanium mesh. Periacetabular bone loss was recorded in a modified Paprosky (PAP) damage classification. Full hemispherical sections of 4 acetabular cups with a life time of 16, 20, 22 and 27 years were examined histopathologically using the diamond cut technique.

Results The periacetabular bone loss resulted in damage class PAP I in 8 cases, PAP IIa in 7 cases, PAP IIb in 2 cases, PAP IIc in 9 cases, PAP IIIa in 3 cases and PAP IIIa in 2 cases PAP IIIb. The average amount of bone that was still firmly attached to the coating after explantation was 17% (0–70%) of the total cup surface. Paprosky I accounted for 44.1%, and PAP IIa and IIb stadiums together a total of 17.1%. The average bone fraction of the implants no longer anchored in the host bed at stages IIc, IIIa and IIIb was 2%. The average coating damage was 11% (0–100%) and was exclusively attributable to the unstable implants of stages IIc, IIIa and IIIb. The histopathological findings showed adaptive bone remodeling, that was detectable for up to 27 years through the titanium mesh down to the interface with the solid acetabular core. The titanium wire mesh was mostly surrounded by lamellar, mature bone.

Conclusion The results show that the connection between the Tivanium cup and the previously oldest and unchanged sintered coating – in the form of a three-dimensional titanium mesh applied in point and line contact – is very load-resistant even under the extreme loads of periacetabular osteolysis and cup perforations. Since there was no damage to the coating in periacetabular damage stages Paprosky I, IIa and IIb, it is justifiable in these damage stages to leave the implant in situ and to continue to use it with sole replacement of the inlay, but leaving the socket shell. The third-generation acetabular cup (Trilogy) with unchanged three-dimensional titanium mesh coating has been implanted in over 1.2 million cases for 26 years. After a long service life, an increasing number of wear and tear conditions can be expected in today's mostly elderly and vulnerable patient clientele. In view of the results presented here, the early detection of damage would make it possible to avoid costly and stressful explantation of the entire acetabular cup in favor of replacing the sole inlay in Paprosky stages I, IIa and IIb.

Zusammenfassung

Hintergrund Ziel dieser Arbeit war die Darstellung der knöchernen Verbundfestigkeit und Belastbarkeit einer in der Sinterungstechnik hergestellten 3-dimensionalen Titannetzbeschichtung einer künstlichen Hüftpfanne. Unter den Extrembedingungen von abriebbedingten Osteolysen bis hin zu Pfannenperforationen wurden der Grad des verbleibenden Knochens und die Unversehrtheit der Beschichtung bestimmt. Die Untersuchung sollte Aufschluss darüber geben, in welchen Schadensstadien nach Paprosky ein Belassen des Implantates mit alleinigem Wechsel des Inlays aus rein materialtechnischer Sicht einer stabilen Beschichtung noch vertretbar war.

Material und Methoden In einer retrospektiven Studie wurden 31 aseptisch gelockerte Hüftgelenkspfannen des Typs Harris-Galante II mit einer durchschnittlichen Standzeit von 19,7 Jahren (11–27 Jahre) untersucht. Der periazetabuläre Knochenverlust wurde bei der Revisionsoperation in einer modifizierten Schadensklassifikation nach Paprosky (PAP) erfasst. Die an der Beschichtung verbleibenden Knochenareale, die knochenfreien Zonen und die beschädigten Areale des Titannetzes wurden mittels digitaler Flächenmessung bestimmt. Vollhemisphärische Schnitte von 4 Hüftgelenkspfannen mit einer Standzeit von 16, 20, 22 und 27 Jahren wurden mit der Diamantschlifftechnik histopathologisch untersucht.

Ergebnisse Der periazetabuläre Knochenverlust führte in 8 Fällen zur Schadensklassifikation PAP I, in 7 Fällen zu PAP IIa, in 2 Fällen zu PAP IIb, in 9 Fällen zu PAP IIc, in 3 Fällen zu PAP IIIa und in 2 Fällen zu PAP IIIb. Der durchschnittliche Anteil des Knochens, der nach der Explantation noch fest an der Beschichtung haftete, betrug. In den Paprosky-I-Schadensfällen 40%, in den Stadien Paprosky IIa und IIb insgesamt 17,9%. Der durchschnittliche Anteil des Knochens der in den Stadien IIc, IIIa und IIIb nicht mehr im Wirtslager verankerten Implantate betrug 2,21%. Der Beschichtungsschaden des Titandrahtgeflechtes betrug im Durchschnitt 11% (0–100%) und war ausschließlich den instabilen Implantaten der Stadien IIc, IIIa und IIIb zuzuordnen. Die histopathologischen Befunde zeigten einen bis zu 27 Jahre nachweisbaren adaptiven Knochenumbau durch das Titannetz hindurch bis tief an die Grenzfläche zum soliden Pfannenkern hin. Die Titaneinzeldrähte waren meist von lamellärem Knochen umwachsen.

Schlussfolgerung Die Ergebnisse zeigen, dass die Verbindung der Pfannenkernschale aus Tivanium und der bisher ältesten und unverändert im Sinterungsverfahren hergestellten Beschichtung in Form eines im Punkt- und Linienkontakt aufgesinterten 3-dimensionalen Netzes aus Reintitandrähten auch unter den Extrembelastungen der periazetabulären Osteolysen belastungsstabil bleibt. Die noch knöchern angebundenen Zonen der Beschichtung sind zwangsläufig einer Mehrbelastung ausgesetzt, da sich die Kraftübertragung nur noch auf diese Restareale verlagert. Da in den periazetabulären Schadensstadien Paprosky I, IIa und IIb trotz einer erheblichen Verkleinerung der Anbindungsfläche keine Beschichtungsschäden in den noch knöchern angebundenen Arealen auftraten, ist die Belassung des Implantates in situ und seine Weiterverwendung mit alleinigem Austausch des Inlays in diesen Schadensstadien aus rein materialtechnischer Sicht vertretbar.

Keywords

titanium fibermesh coating - layer adhesion - artificial hip socket

Schlüsselwörter

Titandrahtnetzbeschichtung - Schichthaftung - künstliche Hüftpfanne

^* This article is a republished version of: Koch K, Nolte I, Hahn M, Becker A. 20-year Results of a 3D Titanium Mesh Coating Stability of 31 Artificial Cups. Z Orthop Unfall 2024;162(3):263–271.

Publication History

Article published online:
09 January 2025

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