Gross trunnion failure after a metal-on-polyethylene total hip arthroplasty leading to dissociation at the femoral head-trunnion interface

Bolarinwa, Surajudeen A.; Martino, John; Moskal, Joseph T.; Wolfe, Michael W.; Shuler, Thomas E.

doi:10.1016/j.artd.2019.02.001

Cited by 14 publications

(10 citation statements)

References 12 publications

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“…There were also issues regarding increased blood cobalt and chromium ion levels, nephrotoxicity, adverse reaction to metal debris (ARMD), pseudotumours and a probable carcinogenic effect due to chronic elevated blood metal ion levels. Gross trunnion failure (GTF) or dissociation at the femoral head-trunnion interface is also increasingly being recognized as a cause of failure and revision surgery [2,11].…”

Section: Discussionmentioning

confidence: 99%

Trunnion fracture of femoral prosthesis following a large metal-on-metal uncemented total hip arthroplasty: a case report

et al. 2020

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Background Trunnion fracture of the femoral prosthesis is an extremely rare complication following Total Hip Arthroplasty (THA). There are very few reports in literature on trunnion fracture. All previously reported cases are of prostheses with smaller heads, unlike the large metal-on-metal articulation in our case, which is unique. Case presentation A 29-year-old male patient with juvenile idiopathic arthropathy presented to us with a fracture of the trunnion of his left THA, with no history of trauma. He had undergone staged bilateral THA for avascular necrosis of the hips 10 years ago (with AML-A stem and large metal-on-metal articulation bilaterally). We revised the THA and exchanged both femoral and acetabular components. He had a good functional outcome at 3 years’ follow up. Conclusion The primary reason for the trunnion fracture in our case was the faulty stem design of the AML [with a small (9/10) taper, and a large head], causing excessive bending moment at the trunnion, worsening the cantilever effect and leading to subsequent cyclic fatigue failure. Whilst gross trunnion failure (GTF) with dissociation of the head from the taper is commonly reported, trunnion fracture per se is a rare and devastating complication. The AML-A stem has since been recalled by the company and there is a need to constantly monitor these patients for potential trunnion-related complications.

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Section: Discussionmentioning

confidence: 99%

Trunnion fracture of femoral prosthesis following a large metal-on-metal uncemented total hip arthroplasty: a case report

et al. 2020

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“…Larger diameter femoral heads in total hip replacements are known to increase stability by way of decreasing femoral head subluxation. However, the use of larger femoral head prosthetics increases stress on the trunnion taper, which has been correlated with an increased incidence of trunnion failure [2,3,6].…”

Section: Discussionmentioning

confidence: 99%

“…A treatment algorithm indicating joint revision in cases of trunnionosis with radiographic abnormalities and elevated serum chromium/cobalt levels has been suggested, but confusion still exists due to the complexity of the case presentation [3,5]. Extensive debridement of affected tissues must be undertaken.…”

Section: Discussionmentioning

confidence: 99%

“…However, levels of metal ions in the blood do not correlate with local adverse reactions visualized on MRI or during surgery, and a large portion of pseudotumors may be asymptomatic near operated hip but symptomatic from metal poisoning and vice versa [1,2]. These factors emphasize the importance of careful analysis to identify clues for implant failure, which could impact the surgeon’s decision making, surgical outcome, patient recovery, and satisfaction [2,3].…”

Section: Introductionmentioning

confidence: 99%

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A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?

Jagadale

2019

Cureus

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Trunnionosis is a type of corrosion and wear at the head-neck taper junction of the femoral implant, and it can be a slow and silent catastrophe. Simultaneous prosthetic joint infection (PJI) is occasionally possible based on the fulfillment of a few of the minor criteria from the Musculoskeletal Infection Society (MSIS), but the existing literature lacks adequate evidence to support that the infection actually exists. We are presenting a case of an 82-year-old man with right total hip arthroplasty performed over a decade prior to presenting to the emergency room with a sudden-onset pop followed by groin pain and difficulty in walking. Radiographs showed a dissociated femoral implant at the level of trunnion with malalignment and heterotopic ossification. Metal Artifact Reduction Sequence MRI of the right hip showed mixed type-two and type-three pseudotumors, and atrophy of surrounding abductor muscles. The erythrocyte sedimentation rate was within normal limits, C-reactive protein was borderline raised, and serum cobalt-chromium levels were elevated without any signs of systemic metal toxicity. Hip joint aspirate revealed bloodstained fluid flooded with red blood cells, leukocytes and neutrophils, and a positive alpha-defensin assay. These findings were interpreted as positive for prosthetic joint infection. Intraoperatively, there was severe wear of the inferomedial aspect of the femoral head-neck junction and extensive metallosis throughout the right hip. Tissue and fluid specimens were sent for cultures, sensitivities, and histopathology for pseudotumor and infection evaluation. An articulating antibiotic spacer was then placed with the intent to perform a staged reconstruction of the femur and right acetabulum. Final synovial, bone, and soft tissue cultures, as well as histopathological photomicrograph of the tissue slides, were negative for infection. This case demonstrates the striking features of metallosis associated with trunnion failure of a metal-on-polyethylene total hip joint prosthesis that was simultaneously showing signs of prosthetic infection by satisfying the minor criteria according to the latest guidelines by the MSIS with a strikingly high cell count of red blood cells in the synovial fluid exam, indicating inflamed hyper-vascular pseudotumors vs. hemarthrosis vs. bloody tap. Diagnostic dilemma led by positive synovial fluid alpha defensin, high synovial neutrophil and white cell count results with negative final cultures or infection on histological slides raises concern that infection was not present and two-stage revision arthroplasty with six weeks of antibiotics was not necessary along with increased risk of morbidity, mortality as well as cost of care.

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“…These can lead to synovitis, local osteolysis, the necrosis of periprosthetic tissues and, finally, component loosening [11,13,31]. Long-term MACC leads to material loss at the taper junction, which can, in rare cases, lead to the frank dissociation of the connection, as well as marked taper deformity [13,20,[32][33][34].…”

Section: Introductionmentioning

confidence: 99%

What the Surgeon Can Do to Reduce the Risk of Trunnionosis in Hip Arthroplasty: Recommendations from the Literature

Rieker

Wahl

2020

Materials

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Trunnionosis, defined as wear and corrosion at the head-neck taper connection, is a cause of failure in hip arthroplasty. Trunnionosis is linked to a synergistic combination of factors related to the prosthesis, the patient, and the surgeon. This review presents analytical models that allow for the quantification of the impact of these factors, with the aim of providing practical recommendations to help surgeons minimize the occurrence of this failure mode. A tighter fit reduces micromotion and, consequently, fretting of the taper connection. The paramount parameters controlling the fixation force are the coefficient of friction and the impaction force. The influence of the head diameter, as well as of the diameter and angle of the taper, is comparatively small, but varus alignment of the taper and heads with longer necks are unfavourable under physiologic loads. The trunnion should be rinsed, cleaned, and dried carefully, while avoiding any contamination of the bore-the female counterpart within the head-prior to assembly. Biological debris, and even residual water, might critically reduce the fixation of the taper connection between the head and the neck. The impaction force applied to the components should correspond to at least two strong blows with a 500 g hammer, striking the head with an ad hoc impactor aligned with the axis of the taper. These strong blows should correspond to a minimum impaction force of 4000 N.

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Gross trunnion failure after a metal-on-polyethylene total hip arthroplasty leading to dissociation at the femoral head-trunnion interface

Cited by 14 publications

References 12 publications

Trunnion fracture of femoral prosthesis following a large metal-on-metal uncemented total hip arthroplasty: a case report

Trunnion fracture of femoral prosthesis following a large metal-on-metal uncemented total hip arthroplasty: a case report

A Case Report and Literature Review to Aid in the Management of Trunnion Failure in Hip Arthroplasty Patients: Can Trunnionosis and Prosthetic Joint Infection Co-Exist?

What the Surgeon Can Do to Reduce the Risk of Trunnionosis in Hip Arthroplasty: Recommendations from the Literature

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