FEBRUARY 2008 VOLUME XXXVII NUMBER 2 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

E-FOCUS ON Metal debris and materials

17	Guest Editorial—Re-examining the Safety Issues of Ceramic-on-Ceramic Bearing Surface Javad Parvizi, MD Javad Parvizi, MD is Associate Professor of Orthopedic Surgery, Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, Pennsylvania. Abstract not available. Am J Orthop . 2008;37(2):E17.
18	Metallosis After Metal-on-Polyethylene Total Hip Arthroplasty Cara A. Cipriano, BA, Paul S. Issack, MD, PhD, Burak Beksaç, MD, Alejandro González Della Valle, MD, Thomas P. Sculco, MD, and Eduardo A. Salvati, MD Paul S. Issack, MD, PhD, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021 (tel, 212-606-1466; fax, 212-472-6023; e-mail, psissack@aol.com). Metal debris should not be generated in a well-fixed, well-functioning metal-on- polyethylene total hip arthroplasty. However, surgeons sometimes encounter periprosthetic metallosis during revision hip surgery. Insert wear, fracture, or dislodgment in modular components may lead to articulation of the prosthetic head with the metallic shell and subsequent metallosis. Metallosis may occur with loose acetabular components as a consequence of fretting of the screws and shell screw holes or shedding of the ingrowth surface of the component. The femoral component can also be a source of metallosis: Wear of a titanium femoral head, loosening of rough surface finish from the femoral stem, and stem fracture all may result in metallic particles being deposited in periarticular tissues. Specific clinical and radiographic findings can help in differentiating these forms of failure and in planning surgery. When metallic debris-induced bone loss is recognized early, surgical intervention may limit its progression. Am J Orthop . 2008;37(2):E18-E25.
26	Ceramic Total Hip Arthroplasty in the United States: Safety and Risk Issues Revisited Toshiyuki Tateiwa, MD, Ian C. Clarke, PhD, Paul A. Williams, MSc, Jonathan Garino, MD, Masakazu Manaka, MD, Takaaki Shishido, MD, Kengo Yamamoto, MD, PhD, and Atsuhiro Imakiire, MD, PhD Ian C. Clarke, PhD, Peterson Tribology Laboratory, Orthopaedics Research Center, Department of Orthopaedic Surgery, Loma Linda University Medical Center, Loma Linda CA 92354 (tel, 909-558-6490; fax, 909-558-6018; email, iclarke@llu.edu). The advantages of all-alumina bearings are superb wear resistance, stability, and inertness demonstrated over 3 decades. The disadvantage is a small risk for brittle fracture, as described in this paper. Surveying the latest ceramic hip series reported in recent journal articles or presented at the 6th World Biomaterials Congress, we found 11 studies representing more than 35,000 cases followed for 3 to 25 years. There were 24 reported fractures. A unique survey of hip complications in the 1990s found a fracture risk of approximately 1.4 per 1000 ceramic balls used in the United States. A company database holding more than 2.5 million records described the overall fracture risk as 1 per 10,000 cases. Initial use of ceramic cup inserts indicated a 2% to 3% incidence of chipping during surgery. Beginning in 1997, the number of ceramic–metal cup-locking cases entered into a US Food and Drug Administration ceramics database was more than 2400, with no fractures reported by the FDA in July 2003. Am J Orthop. 2008;37(2):E26-E31.
32	In Vitro Corrosion Analysis in Low-Intensity, Pulsed Ultrasound LT Douglas E. Pittner, MD, MC, USN, Linda Levin, PhD, and Michael T. Archdeacon, MD, MSE Michael T. Archdeacon, MD, MSE, Department of Orthopaedic Surgery, College of Medicine, University of Cincinnati, P.O. Box 670212, 231 Albert Sabin Way, Cincinnati, Ohio 45267-0212 (tel, 513-558-2978; fax, 513-558-4633; e-mail, michael.archdeacon@uc.edu). Clinical investigations have demonstrated a reduced time to union in certain fractures whose management is augmented with low-intensity ultrasound. It is hypothesized that ultrasound augmentation is attributable to mechanical stimulations at the cellular level. Additionally, mechanical stimulation of various magnitudes affects the corrosion rate of metals. Therefore, the effect of ultrasound on the corrosion properties of orthopedic implant materials warrants evaluation prior to recommending ultrasound as an adjunctive treatment for fractures in the presence of internal fixation devices. The purpose of this study was to determine whether low-intensity ultrasound adversely affects the corrosion properties of 316L stainless steel, a commonly used metal in surgical implants. An electrochemical cell was used to expose 316L stainless steel specimens to a corrosion environment. Experimental specimens were subjected to low-intensity ultrasound at the clinically applied intensity. Polarization curves were used to extract average corrosion current density in the passive region, primary passive potentials, and transpassive potentials. Analysis revealed no significant differences between the experimental and control corrosion current density, primary passive potentials, or transpassive potentials. Based on this in vitro analysis, we demonstrated no significant difference in corrosion rate between controls and exposed samples. We conclude that low-intensity ultrasound has no adverse effect on the corrosion properties of stainless steel implant materials. Am J Orthop. 2008;37(2):E32-E37.
38	Knee Mass From Severe Metallosis After Failure of a Metal-Backed Patellar Component Total Knee Arthroplasty F. Daniel Kharrazi, MD, Benjamin T. Busfield MS, MD, Daniel S. Khorshad, Francis J. Hornicek MD, PhD, and Henry J. Mankin, MD Benjamin Busfield, MD, Kerlan-Jobe Orthopaedic Clinic, 6801 Park Terrace Dr, Los Angeles, CA 90045 (tel, 310 665 7200; fax, 310-665-7242; e-mail, bbusfield@yahoo.com). Abstract not available. Introduction provided instead. Failure of metal-backed patellar components in total knee arthroplasty has previously been reported.1-11 Developments in prosthetic design such as adding a third peg to the metal baseplate and the use of a mobile-bearing patella have led to lower patellar revision rates.10,11 Bayley and colleagues2,3 reported on the failure of metal-backed patellar components in 25 patients after total knee arthroplasty. Mechanisms of failure included polyethylene wear, fracture, and dissociation.2,3 Wear or dissociation of the polyethylene from the metal backing, enhanced by abnormal patellofemoral biomechanics or patellar malalignment, is followed by articulation of the patellar metal backing against the femoral component.1,2,3,5,8 Patellar metallic wear against titanium surfaces causes much more severe abrasion and metallic debris generation in comparison with cobalt-chromium alloys.6,7,12 Over time, the abrasive metallic wear debris leads to synovitis.2,3,12,13 The patients generally experience any of a multitude of symptoms relating to the accompanying synovitis, including pain, limitation of motion, or crepitus with knee motion. Weissman and colleagues9 introduced the “metal-line sign” as a preoperative aid in radiographic detection of metal-induced synovitis from failure of the metal-backed patellar components after total knee arthroplasty. Breen14 reported on “titanium lines” as a manifestation of metallosis at the knee in the 3 patients following implantation of titanium tumor prostheses. The radiographic appearance of the titanium lines may mimic soft-tissue tumor recurrence.14 Our case report details a patient referred for a knee mass years after primary total knee arthroplasty with a metal-backed patellar component. Am J Orthop. 2008;37(2):E38-E41.
42	Failed First Metatarsophalangeal Arthroplasty Salvaged by Hamstring Interposition Arthroplasty: Metallic Debris From Grommets Kurt V. Voellmicke, MD, Manjula Bansal, MD, and Martin J. O’Malley, MD Martin O’Malley, MD, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 (tel, 212-606-1579; fax, 212-744-5086). Abstract not available. Introduction provided instead. Implant arthroplasty of the first metatarsophalangeal joint (MTPJ) was first developed in 1967 to address inadequacies of Keller resection arthroplasty.1 Implant arthroplasty, though still a joint ablative procedure, maintains length and alignment and preserves function. As with implant arthroplasty in other joints, the implants are subject to wear and therefore are usually advocated for older, less active patients.2,3 Synovitis secondary to particulate silicone debris is well established.4-8 The inflammatory response initiated by silicone debris not only produces pain and swelling and compromises motion, but it also contributes to bone destruction and gross implant failure.4-8 To prevent or decrease production of silicone debris at the implant–bone interface, titanium grommets were introduced. Use of circumferential titanium grommets in MTPJ arthroplasty began in 1985 in an attempt to reduce silicone wear by shielding the midsection of the flexible silicone hinge.1 Reduction of silicone debris and synovitis through use of grommets has led to increased implant durability and fewer complications.1,9-11 Swanson and colleagues1 reported an overall complication rate of 11% related to sharp bone edges, implant fracture, and reactive synovitis after flexible hinge arthroplasty without grommets and noted that grommets essentially eliminated these problems. Production of particulate titanium debris with associated cellular response is a well-established entity in total hip arthroplasty,12-14 but up until now there have been no reports of titanium debris with respect to arthroplasty of the first MTPJ. Indeed, the literature suggests the opposite, that grommets themselves behave fairly inertly and significantly reduce the amount of particulate silicone produced and its associated problems.1,9-11 To our knowledge, this is the first published report of metallic debris secondary to use of grommets in first MTPJ implant arthroplasty. In addition, salvage of a failed prosthesis has historically consisted of arthrodesis or resection15-17 or revision to another implant system.18 To our knowledge, this is also the first reported case of interposition arthroplasty used as a salvage technique. Am J Orthop. 2008;37(2):E42-E45.

72	Continuing Medical Education—Not Enough to Simply ‘‘Show Up’’ Peter D. McCann, MD Peter D. McCann, MD, is Chair, Department of Orthopaedic Surgery at Beth Israel Medical Center, New York, New York. Abstract not available. Am J Orthop. 2008;37(2):72.
73	Orthopedic Board Certification and Physician Performance: An Analysis of Medical Malpractice, Hospital Disciplinary Action, and State Medical Board Disciplinary Action Rates Mininder S. Kocher, MD, MPH, Laura Dichtel, BS, James R. Kasser, MD, Mark C.Gebhardt, MD, and Jeffrey N. Katz, MD, MS Mininder S. Kocher, MD, MPH, Department of Orthopaedic Surgery, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (tel, 617-355-7497; fax, 617- 739-3338; e-mail, mininder.kocher@tch.harvard.edu). Specialty board certification status has become the de facto standard of competency by which the profession and the public recognize physician specialists. However, the relationship between orthopedic board certification and physician performance has not been established. Rates of medical malpractice claims, hospital disciplinary actions, and state medical board disciplinary actions were compared between 1309 board-certified (BC) and 154 non–board-certified (NBC) orthopedic surgeons in 3 states. There was no significant difference between BC and NBC surgeons in medical malpractice claim proportions (BC, 19.1%; NBC, 16.9%; P = .586) or in hospital disciplinary action proportions (BC, 0.9%; NBC, 0.8%; P = 1.000). There was a significantly higher proportion of state medical board disciplinary action for NBC surgeons (BC, 7.6%; NBC, 13.0%; P = .028). An association between board certification status and physician performance is necessary to validate its status as the de facto standard of competency. In this study, BC surgeons had lower rates of state medical board disciplinary action. Am J Orthop. 2008;37(2):73-75.
76	Management of Late Posttraumatic Kyphosis With Anterior Z-Plate Instrumentation Boris A. Zelle, MD, and Jochen Dorner, MD Boris A. Zelle, MD, University of Pittsburgh School of Medicine, Department of Orthopaedic Surgery, Kaufmann Building, Suite 1011, 3471 Fifth Ave, Pittsburgh, PA 15213 (tel, 412-628-8014; fax, 412-687-0802; email, zelleba@upmc.edu). Failed treatment of thoracolumbar spine fractures may lead to late posttraumatic kyphosis (LPK), and LPK treatment is challenging. The aim of this retrospective study was to investigate whether anterior reduction and Z-plate instrumentation constitute feasible treatment for LPK (>30 days after injury). Twenty patients who developed LPK after a thoracolumbar fracture were treated with the Z-plate anterior thoracolumbar plating system. Sixteen patients were followed for a mean of 35 months. Ten of 15 patients with a thoracotomy had persistent postthoracotomy pain. Mean back pain decreased significantly, from 9.2 before surgery to 4.1 after surgery (10 = worst pain ever experienced, 0 = no pain). Osseous union occurred in all patients. Postoperative loss of reduction of 4.9° kyphotic angle was recorded at follow-up. Anterior stabilization with the Z-plate is a technically feasible procedure in patients with LPK. Long-term postthoracotomy pain seems to be a significant problem in these patients. Am J Orthop. 2008;37(2):76-80.
81	Focal Spontaneous Osteonecrosis and Medial Meniscus Tear: Two Cases and a Literature Review Christopher Brown, BA, and Jeffery L. Stambough, MD, MBA Jeffrey L. Stambough, MD, MBA, 4600 Smith Road, Suite B, Cincinnati, OH 45212 (e-mail, drstambough@fuse.net). Abstract not available. Am J Orthop. 2008;37(2):81-87.
88	Transient Osteoporosis of the Hip in Association With Osteogenesis Imperfecta: Two Cases, One Complicated by a Femoral Neck Fracture Samuel D. Young III, MD, Charles L. Nelson, MD, and Marvin E. Steinberg, MD Samuel D. Young, III, MD, 4555 Emerson Street, Suite 100, Jacksonville, FL 32207 (tel, 904-633-0159; fax, 904-633-0795; e-mail, Samuel.Young@jax.ufl.edu). Abstract not available. Am J Orthop. 2008;37(2):88-91.
92	Bilateral Tibial Tubercle Avulsion Fractures Associated With Osgood-Schlatter’s Disease David A. Cohen, MD, and Richard Y. Hinton, MD, MPH, MEd, PT Richard Y. Hinton, MD, c/o Lyn Camire, Editor, Union Memorial Orthopaedics, The Johnston Professional Building, #400, 3333 North Calvert Street, Baltimore, MD 21218 (tel, 410-554-6668; fax, 928-447-4590; e-mail, lyn.camire@medstar.net). Abstract not available. Am J Ortho. 2008;37(2):92-93.
96	Surgical Reconstruction of a Late- Presenting Volar Radiocarpal Dislocation: A Case Report Eric P. Hofmeister, MD, Brian T. Fitzgerald, MD, Michael A. Thompson, MD, and Alexander Y. Shin, MD Eric P. Hofmeister, c/o Clinical Investigation Department (KCA), Naval Medical Center San Diego, 34800 Bob Wilson Dr, Suite 5, San Diego, CA 92134-1005 (tel, 619-532-8134/40; fax, 619-532-8137; e-mail, eric.hofmeister@med.navy.mil). Abstract not available. Am J Orthop . 2008;37(2):96-99.
100	Two Cases of Missed Salter-Harris III Coronal Plane Fracture of the Lateral Femoral Condyle Sanjeev Sabharwal, MD, Patrick Henry, MD, and Fred Behrens, MD† Sanjeev Sabharwal, MD, Department of Orthopaedics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, 90 Bergen St, Suite 7300, Newark NJ 07103 (tel, 973-972-0246; fax, 973-972-1080; e-mail, sabharsa@umdnj.edu). Coronal plane fractures of the lateral femoral condyle can be difficult to diagnose, especially in children with open physis. Two adolescents who sustained this uncommon Salter-Harris III fracture of the knee were misdiagnosed after initial clinical examination and standard x-rays. Oblique x-rays, computed tomography, and magnetic resonance imaging were valuable in arriving at the correct diagnosis and in decision making. Am J Orthop. . 2008;37(2):100-103.
104	Using the Quick Couple Drill Attachment as an Intraoperative Metal File Michael A. Rauh, MD, Lindsey Clark, MD, Christopher Mutty, MD, and Mark Anders, MD Mark Anders, MD, Department of Orthopaedic Surgery, Erie County Medical Center, State University of New York, 462 Grider St, Buffalo, NY 14215 (tel, 716-898-3810; fax, 716-898-3323; e-mail, mjanders@buffalo.edu). The occasional need to alter or modify plate length during surgery is familiar to most orthopedic surgeons. However, at the modification site, sharp edges may remain. Files or rasps are often used to smooth these edges to prevent local tissue irritation and injury to surgical personnel. To reduce the potential for personal injury during preparation and implantation, while adding convenience and speed to this procedure, we introduce a technique for filing down sharp edges of plates and implants with equipment readily available within most orthopedic operating rooms. Am J Orthop. 2008;37(2):104-105.

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