Focal Osteolysis at the Junctions of a Modular Stainless-Steel Femoral Intramedullary Nail

Abstract

Background: During routine follow-up of patients treated with a three-piece stainless-steel modular femoral nail, osteolysis and periosteal reaction around the modular junctions of some of the nails were noted on radiographs. The purpose of this study was to evaluate the prevalence, etiology, and clinical relevance of these radiographic findings. Methods: Forty-four femoral fractures or nonunions in forty-two patients were treated with a modular stainlesssteel femoral intramedullary nail. Seventeen nails were excluded, leaving twenty-seven intramedullary nails in twenty-seven patients for this study. All patients had had a femoral diaphyseal fracture; nineteen had had an acute fracture and eight, a nonunion. These twenty-seven patients returned for radiographs, a physical examination, assessment of functional outcomes, assessment of thigh pain with a visual analog scale, determination of serum chromium levels, and nail removal if desired. A control group of sixteen patients treated with a one-piece stainless-steel femoral intramedullary nail was evaluated with use of the same outcome measures and was compared with the group treated with the modular femoral nail with regard to prevalence of thigh pain and serum chromium levels. Twelve modular femoral nails were removed according to the study protocol. The modular nail junctions were analyzed for corrosion products, and histopathologic analysis of tissue specimens from the femoral canal was performed. Results: The twenty-seven patients were seen at a mean of twenty-one months after fracture fixation; twenty-six of the twenty-seven fractures healed. Twenty-three femora had at least one of three types of abnormalitiesosteoly-sis, periosteal reaction, or cortical thickeninglocalized to one or both modular junctions. Eighteen patients had severe reactions, defined as osteolysis of ≥2 mm, cortical thickening of ≥5 mm, and/or a periosteal reaction (group 1). Nine patients had mild or no reactions (group 2). Serum chromium levels in group 1 (mean, 1.27 ng/ mL; range, 0.34 to 3.12 ng/mL) were twice as high as those in group 2 (mean, 0.53 ng/mL; range, 0.12 to 1.26 ng/mL). However, this difference did not reach significance with the numbers available. The differences in serum chromium levels between group 1 and the control group with a one-piece nail (mean, 0.26 ng/mL; range, 0.015 to 1.25 ng/mL) (p < 0.01) and a control group without an implant (mean, 0.05 ng/mL; range, 0.015 to 0.25 ng/ mL) (p < 0.01) were significant. The level of thigh pain recorded on the visual analog scale was also significantly different between group 1 and the control group with a one-piece implant (p = 0.03). Retrieved modular nails had signs of fretting corrosion as well as stainless-steel corrosion products adherent to the junction where the osteolysis occurred. Histologic and spectrographic analysis revealed two types of corrosion products that were consistent with stainless-steel within the peri-implant tissue and were associated with a foreign-body granulomatous response. Conclusions: The ...

Fracture of a Modular Femoral Neck After Total Hip Arthroplasty

“…Inflammatory mediators are released as a consequence of the cellular response to the particulate and/or ionic products of fretting and corrosion. This can ultimately result in the need to revise the prosthesis 10,11 . Recently, Varini et al reported that stem impactors that secure the femoral stem by means of the neck-stem junction induce some damage to the bore of the femoral stem.…”

No significant corrosion after bridging nail osteosynthesis of a periprosthetic fractured femur: A retrieval report

“…Patient was diagnosed with a periprosthetic fracture, a ''happy hip'' according to the Coventry classification (Vancouver type B1). 1,8,13 Medical history showed a hypertension for about 20 years, diabetes mellitus (oral medication), a cemented total hip arthroplasty on the left side in 1989, on the right side in 1992 and a total knee arthroplasty on the left side in 1993.…”

“…5 Implant failures have been reported at modular interfaces. 4,7,8 Furthermore the presence of metal ions may trigger a foreign body response. 2,5,7,8 This foreign body response can lead to focal osteolysis and cortical thinning.…”

Characterization of the elastic–plastic behavior of intermetallic coatings growth on medical stainless steel by instrumented ultramicroindentation

“…Moreover, Ni 2þ produced in the corrosion process in the human body environment may cause cancer (Denkhaus and Salnikow, 2002;Vahter et al, 2002). On the other hand, particles released under friction conditions and repetitive contact can induce an environmental response that may lead to aseptic loosening due to osteolysis, which could lead to the subsequent implant failure (Hallab et al, 2002;Jones et al, 2001;Kowandy et al, 2006;Manley et al, 2002). The tangential micro-motion between the surface and the surrounding bone tissue may enhance the production of wear debris, thereby increasing the probability of failure.…”