D 04 Orthopaedic Fixations

We are the protagonists of our lives
BIOMECHANICS OF ORTHOPAEDIC FIXATIONS1

Jennifer Carrin, Jessica Coln, Mara Gonzlez, Jessica Rivera and Gerardo Rodrguez2
ABSTRACT The biomaterials orthopaedic fixation are 3. Biocompatible - must be well tolerated by the bone
metals, polyethylene, ceramics and bone cement. Of the tissue.
metal materials we can mention the orthopedic alloy of
cobalt-chrome, titanium, and stainless steel. The The tolerance of the body's tissues, however, changes when
characteristics of these alloys are sufficient strength, not the material is present in fine particle form, as dust. In the
to stiff, and biocompatible. We shall present screws, fine particle form, all materials used for fabrication and
plates, wires, pins, rods, nails, and spinal fixation fixation of total hip prostheses may evoke inflammation
devices made with these materials. reaction in the tissues. The inflammatory tissues may
destruct skeleton around the prosthesis, process called
KEYWORDS- Orthopaedic fixations, Biomaterials, osteolysis. Thus, another demand on the materials used for
Titanium, Cobalt-Chrome, Stainless Steel and Bone fabrication and fixation of THP is that they should wear off
Cement. too much and should produce minimal quantity of wear
particles.
ORTHOPAEDICS
Orthopaedic Alloys
It is a branch of surgery devoted to the diagnosis and
treatment of illnesses, injuries, deformities, and Every big manufacturer of artificial hip joints has
malformations of the musculoskeletal system, including developed one or more alloys to meet this requirement for
bones, joints, ligaments, muscles, and tendons. different types of artificial joints he produces. New metal
Orthopedists thus treat traumatic injuries to bones, such as alloys appear continually on the market and the old alloys
fractures and dislocations; disturbances in joints, such as are withdrawn. Tables 1 to 3 show properties of following
sprains, torn cartilages, or strained ligaments; and alloys:
inflammation of muscle or connective tissues, such as
bursitis, myositis, and tendonitis. They also treat back Cobalt-Chrome alloys
problems, such as strains, ruptured discs, or curvatures;
Titanium alloys
foot problems, such as flat feet or high arches; and neck
Stainless Steel alloys.
disorders, such as strains or arthritis. Surgeons employ
mechanical appliances, use of newly devised metal
prostheses to replace arthritic joints are now commonplace. The mechanical performance of modern alloys used in total
hip joint manufacture is very satisfactory and there are no
absolute "winners" in this "race of alloys".
The demands on the orthopaedics alloys are hard. The total
hip prosthesis is not made from pure metals, but from
orthopaedics metal alloys, specially produced for BIOMATERIALS
fabrication of artificial joints. The alloy must be:
Pure Titanium is often used as porous coating for the
1. Very strong - they must not break or even surfaces of total hip prostheses due to its biocompatibility.
bend permanently under heavy load. In dust form, as wear particles, all these alloys, even a pure
Titanium, may, trigger osteolysis if these particle land in
the tissues around the THP. Metallic wear particles in the
2. Not too stiff - a too stiff device will "stress
soft tissues paint the tissues black it is called metallosis.
shield" the skeleton too much.
1 Metal allergy in patients with total joints

This review article was prepared on May 14, 2004 for the
course on Mechanics of Materials I. Course instructor:
Dr. Megh R. Goyal, Professor in Biomedical Engineering, The metallic alloys used for fabrication of artificial joints
General Engineering Department, PO Box 5984, undergo corrosion and release metallic ions into the
Mayaguez, Puerto Rico 00681-5984. For details contact: patient's body. Cobalt, Chromium, Nickel, but also
m_goyal@ece.uprm.edu or visit at: relatively inert Titanium may evoke allergic immune
http://www.ece.uprm.edu/~m_goyal/home.htm . response. The most often observed form of this allergy is
skin rash.
2
The author are in alphabetical order.
3
Numbers in brackets are references in the bibliography
May 2004 Application in Engineering Mechanics in Medicine, GED University of Puerto Rico, Mayagez 1
Table 1. Biomaterials for THP [Orthes, spol. s r.o., metals" have a well functioning THP. Surgeon, however,
Palackho 481, 756 61 Ronov p./R, : orthes@orthes.cz, should be informed if allergic against any of these metals.
spol. s.r.o. 2001]. The doctor will decide about the necessary preoperative
tests and about the type of prosthesis.
Classification Biomaterial
Porous surfaces - Fatigue Fatigue fracture of total hip prosthesis
fracture - Stress
METAL ALLOYS shielding - stainless steel The everyday life puts astounding demands on the
- Cobalt-Chromium - materials of the total hip joint. For example, a sixty-year-
Titanium old patient who weighs 75 kilograms and will live further
Wear - Cross-linked PE - 17 years ( a quite common characteristics of a "normal" TH
POLYETHYLENE
Gas sterilized PE patient), will expose the shaft of his total hip for thirty-four
Alumina ceramics - millions blows, each blow with a force of 200 kilograms if
CERAMICS Zirconia ceramics - he goes slowly, and 600 kilograms if he is running.
Hydroxy-apatite coating
Composition of -
The shaft of the modern total hip prosthesis will sustain
BONE CEMENT Antibiotic loaded cement
such large loads. The shaft may fail, however, even for
Drawbacks
lower loads, if they occur very often. The metal alloy will
succumb to the so- called fatigue failure and break. There is
Table 2. Mechanical characteristics of orthopaedics a limit, how much repetitive loads the prosthesis will
alloys [Orthes, spol. s r.o., Palackho 481, 756 61 Ronov eventually sustain. This limit is specific for every form of
p./R, : orthes@orthes.cz, spol. s.r.o. 2001]. the total hip prosthesis and for the metal alloy used for
manufacture. Above this limit, the prosthetic shaft will
Stainless- Cobalt- sustain the fatigue fracture.
Characteristics Titanium
Steel Chrome
Stiffness High Medium Low All modern alloys used for manufacture of the THP are
Strength Medium Medium High strong enough to resist fatigue fractures from these
Corrosion repeating stresses in average, not extremely heavy patients.
Low Medium High However, very occasional cases of fatigue fractures of the
Resistance
Biocompatibility Low Medium High modern prosthetic shafts have been reported. Closer
examination of these cases revealed that the fractures
Table 3. Skin Sensitivity [Orthes, spol. s r.o., Palackho occurred in heavy patients, often after an accident. The
481, 756 61 Ronov p./R, : orthes@orthes.cz, spol. s.r.o. examination of the broken shafts often revealed
2001]. metallurgical defects in the metal of the shaft, such as
scratches on the surface, defects that occurred during
casting, etc.
Percent Metal
Sensitivity
Many manufactures have also developed bulky models of
General population 10 %
artificial joints with larger dimensions for heavy-weight
Patients with stable total joints 25 % patients. Usually patients >100kg body weight are
Patients with loose total joints 60 % considered heavy-weight.
It is clear that some patients have excessive skin rash Stress shielding - a too stiff shaft
reaction associated with implantation of orthopedic metal
alloys. In general, such metal sensitivity probably exists in
The prosthetic shaft takes off a part of the stress during
only very few susceptible patients. At present, the risk to
walking and other everyday activities put on the upper part
patients to develop such reaction after implantation of
of the thigh bone holding the prosthesis. A too stiff shaft of
artificial joints may be considered minimal.
a total hip prosthesis "stress shields" the upper part of the
thigh bone too much. This is so because the alloys used for
The diagnosis of metal sensitivity is still difficult because fabrication of the shaft are much stiffer than the skeleton of
of lack of reliable tests. Sensitivity is measured by a skin the thigh bone. The shielded bone does not thrive, loses its
path method. substance, and becomes weak. The total hip joint has weak
anchorage in a weak skeleton and may fail.
The frequency of skin sensitivity to metals in patients with
artificial joints is substantially higher than that in the The remedy is a prosthetic shaft manufactured from metal
general population. alloys with stiffness similar to bone. Titanium alloy has the
lowest stiffness of all orthopaedic alloys. Therefore shafts
Statistics demonstrate that many patients with a positive of cement less total hips are often made from Titanium
cutaneous (skin) test against some of the "orthopaedic alloys.
On the other hand, the stiffness of the prosthetic shaft prosthesis, the blood concentrations of these metals are
depends not only on the material but also on its shape. very high, [Brodner].
Changing the shape of the shaft changes also its stiffness.
Corrosion resistant orthopaedic steel alloys and other
The latest technique for less stiff total joint prostheses is the orthopedic metal alloys are not ferro-magnetic. Thus,
Trabecular Metal Technology (Zimmer 2001). A metallic patients with these prostheses can be examined with MRI.
sponge made from Tungsten has about the same stiffness as
bone. When a layer of the metallic sponge is placed on the ULTRA- HIGH MOLECULAR WEIGHT
surface of the total hip prosthesis, it will make a smooth POLYETHYLENE
transition from the stiff metal to the weak bone. The
scientists hope that this technology will diminish the stress
shielding effect of the too stiff total hip and knee prostheses a. Polymerization
Corrosion resistance Ultra-High Molecular Weight Polyethylene (UHMWPE) is

the current material of choice for use as a bearing surface in
total joint prostheses. Total joints with components made of
Metallic surfaces in contact with body's fluids corrode. The this material can function for more than twenty years if
surface dissolves and the dissolved metals enter into the they are well designed and well implanted. However, there
circulation. The concentration of the metals (Cobalt, is evidence that wear particles worn off the surface of
Chromium, or Titan) in the blood increases. The orthopedic UHMWPE component may trigger destruction (osteolysis)
alloys should be resistant to this corrosion. The corrosion of the skeleton around the total joint and eventually cause a
may occur due to: failure of the whole total joint.
Two dissimilar metals are in contact - this Polyethylene is an organic compound formed by long
happens in modular total hip stems, at the repeating chains of a single substance: the molecules of the
junction of the ball component with the taper of gaseous substance ethylene. In a polymerization process
the shaft component. When both the ball and the (Figure1), the single ethylene molecule called mer is added
stem are made from Cobalt - Chrome alloy, slight to another ethylene mer. When many such ethylene meres
corrosion is observed in about 6 % of the are added together, they form an extremely long, chained
components. When the ball is from Cobalt- molecule called generally polymer (Literary "polymer" =
Chrome and the stem is from Titanium alloy, the many meres). In the case of ethylene the final product of
corrosion is observed in 33 % of the components, many ethylene molecules chained together is accordingly
[Collier 1995]. called polyethylene
In metal-on-metal total hip joints, there appears The mechanical properties of polyethylene improve slowly
wear of the joint surfaces, with production of with rising molecular weight of the product. A dramatic
many small particles of metal alloys. These small change in mechanical properties, however, appears when
particles dissolve in the body fluids. molecular weight of the polyethylene molecule exceeds one
million. This appears when more than 35 000 ethylene
As a result of these processes, the concentrations of groups are added together. Such product is called Ultra-
Titanium, Chromium, and Cobalt in the blood and urine of High Molecular Weight Polyethylene. The molecular
patients with these prostheses are elevated, [Jacobs]. The weight of the UHMWPE currently used in total joint
trace-metals Cobalt and the Chromium are a part of body's components varies between 4 to 6 millions. Every such
enzyme system, but these metals have caused cancer in UHMWPE molecule is composed of 160 to 215 000
workers exposed to large concentrations of these metals. ethylene groups. The standard UHMWPE with this
However, there is no proof that elevated serum levels of molecular weight is an extremely tough and yet flexible
Cobalt, Chrome, or Titanium produce pathological changes material.
or incite cancer in patients with these total hip prostheses.
b. Wear of polyethylene
Blood levels of Aluminum, a metal which is a part of the
Titanium alloys, are not elevated in patients with total hip Despite its superior mechanical performance, the standard
prostheses manufactured from Titanium alloys. UHMWPE is not a perfect material. It is subject to fatigue
failure and it produces many wear particles. It can also
The question of the long-term effects of orthopedic metals absorb small amounts of fluids or retain small amounts of
(Cobalt, Chromium, and Titan) on patients with total hip air in the microscopically small pores ( about 0.1 volume
replacement is still not decided, [Jacobs]. percent ). This is a small amount but it may cause great
deterioration of the material during the long years in the
patients body.
Chromium and Cobalt are excreted by kidneys; in patients
with impaired renal function and corroding total hip
simultaneously on several places in several UHMWPE. The
carbon atoms that are lacking theirs Hydrogen neighbors
keep "free hands" out to find a new neighbor. The opposite
"free hands" in two molecules meet and cross-link one
UHMWPE molecule to another on several places. The
degree of cross-linking increases with the dose of absorbed
irradiation. The process can be compared to cooling of a
plate of warm spaghetti (Figure 3).
The plate of warm spaghetti looks like a couple of

conventional UHMWPE molecules. They are movable;
Figure 1. Polymerization of polyethylene
"scratch with a fork" will easily move spaghetti strings out
brown balls are carbon atoms, blue balls are hydrogen of plate. Now put the spaghetti plate to cool. The cool
atoms.
spaghetti coalesce into one unmovable mass, one cannot
[www.totaljoints.ifo/POLYTHYL.jpg].
remove individual strings with a fork. The cold thus cross-
linked the spaghetti to a "wear resistant mass".
The wear resistance of irradiated material in a hip simulator

is dependent on the irradiation dose:
4 Mrad the maximal radiation dose used for

sterilization of the material produces 80% reduction
of wear in the irradiated UHMWPE
10 Mrad the maximal dose used for cross-linking

of the UHMWPE by some manufacturers causes
95% reduction of wear in the irradiated UHMWPE.
Figure 2. Cross-linking of the UHMWPE Further reduction of the last 5% of wear is then
[www.totaljoints.info/cross_linking_PE.jpg]. difficult to achieve.
Now the scientists and surgeons are searching for a During the 1970's, initial research studied the changes of
UHMWPE material with better wear resistance, although the mechanical characteristics in the irradiated UHMWPE
the UHMWPE has been used since the 1960s. The reason immediately after irradiation. It was shown UHMWPE may
for the lack of interest in the past has been low demand for absorb up to 100 Mrad, before it becomes brittle and
the surgical grade UHMWPE. unusable for mechanical applications.
The main problem of the UHMWPE is wear UHMWPE

surfaces product wear particles. The wear particles enhance
inflammatory reaction and eventually development of
osteolysis (bone dissolving disease).
All new developments of UHMWPE have a common goal

to produce resistant material. The recently introduced
UHMWPE materials include cross-linked product
UHMWPE.
c. The cross-linking of the polyethylene
The cross-linked UHMWPE has been introduced in clinical

practice since 1998. In the process called cross-linking, the
irradiation "glues" the long polyethylene molecules to keep
together. There is also a chemical method of cross-linking
the UHMWPE, not used commercially for fabrication of
total joint components.
The mechanism of cross-linking involves the knocking an

Figure 3. Cross - linking the process resembles to cooling
electron out of the Hydrogen atom. The Hydrogen atoms
of warm spaghetti.
then wander out of the polyethylene molecule as free
[www.totaljoints.info/PE_crosslink_spaghet.jpg].
radicals (blue balls with red hats in the figure 2). It hapens
Modern studies, however, demonstrated that irradiated In practice, however, the tested cups must be lubricated
UHMWPE ages much quicker than the conventional (water, blood serum). The UHMWPE swells absorb liquids,
product, even if the irradiated UHMWPE is maintained in and gains weight. So scientists developed clever methods to
oxygen-free atmosphere. Studies demonstrated that after compensate for the weight gain. According to the test in
5.5 years, the UHMWPE irradiated with only 2.5 Mrad laboratory on hip simulators, the new highly cross-linked
(sterilization dose) atmospheres [Deng 2001]. UHMWPE has several times lower wear rate than the
conventional UHMWPE. One manufacturer (Sulzer,
d. Sterilization with ethylene oxide gas Duracon) even says that his product has no measurable
wear at all at testing in laboratory [Sulzer data 2000].
The ethylene oxide gas kills confidently all bacteria, but the
gas must be removed after the sterilization by airing. This More objective laboratory data [Heisel 2003] showed that
process exposes the product to air for long periods. So that wear volume (after 5 millions cycles in simulator) was 30
even if the definitive package is airtight, and the cu mm for an acetabular cup made of cross-linked and then
atmosphere inside the package are inert gases, there may remelted UHMWPE, whereas the conventional UHMWPE
still be air entrapped inside the microscopic pores of the wore 260 cubic mm.Thus, in the laboratory experiment, the
UHMWPE components. cup component made from conventional UHMWPE wore
eight times more than the cross-linked product.
Sterilization with gas plasma
f. Wear of the cross-linked cups in the body
The last sterilization technique is sterilization by gas in
plasmatic (ionized) form, so called "gas plasma". The gases It is theoretically simple (upper row in figure 4) to measure
used for this technique (hydrogen peroxide,e.g.) are easy to the wear. Directly after the operation the ball lies in the
remove from the product, because they act only on the center of the cup. Several years after the operation the
surface of the component. This technique does not expose femoral ball drills a pathway through the polyethylene. It is
the final product for the effect of air oxygen and does not then placed eccentrically in the shell. Measure the distance
enhance the temperature during the sterilization above 50 between the center of the ball and the surface of the shell
degrees C. This sterilization technique thus does not on the X-ray pictures taken directly after the operation and
influence the mechanical characteristics of the component. measure this distance at the second picture taken at the
It is used by many manufacturers. follow-up. The difference between these measurements is
the wear. In practice the measurement is not so simple on
modern metal backed cups (lower row in figure 4).
e. The efficacy of t he new cross - link UHMWPE to
withstand wear
Both metal backing and femoral ball are radio-opaque.
Directly on the postoperative pictures one can distinguish
Measurement of wear of UHMWPE in the laboratory may the center of the femoral ball and the surface of the metal
seem straightforward. Weight the cup before you put it into backing, and measure the distances.
the hip simulator, test it and then remove it and weight it
again. The loss of weight between the two measurements is
the wear. On later postoperative picture, when the ball moves deeper
in the cup, the contours of the ball components are blurred.
It may be then difficult to distinguish the boundaries of
these two components. The surgeons then use different
templates that they put on the x-ray pictures. With the help
of these templates they can distinguish the boundaries of
the two components better. There is still discussion how
precise is the radiological measurement of the cup wear.
One extreme opinion says that "None of the studies of wear
of the polyethylene cup components fulfills the demands on
scientific design and accuracy" [Lewis 2000].
Recent published reports [Heisel 2003] demonstrate that in

the patient's body the wear resistance of the new highly
cross-linked UHMWPE cups is lower than in the hip
simulators. In the three reports, the wear rate of cross-
linked cups improved with about 50% compared with cups
made from conventional UHMWPE in two cups [Stryker
and DePuy]; for the Durasul cups [Sulzer], significant
improvement was observed. These reports are in contrast
Figure 4. Measurement of the wear in the human body by not only with the laboratory tests but also with data on the
X-ray pictures Sulzer's website [Heisel 2003].
[www.totaljoints.info/PE_wearmeasurm.jpg].
For all these reports, one must know that during the first polyethylene became changed by this adherence. Such
one to two years (the observation period of the recent changed protein substances may act as allergens and evoke
reports) after surgery, the ball component makes place for immunologic reaction.
itself within the cup component. The polyethylene flows
(creeps) away, and is only partially worn away. During this i. Bearing Materials Used in Joint Replacement
early period, it is usually impossible to distinguish between
creep of the UHMWPE and wear. The scientists speak Durability is dependent on the components used (materials,
poetically about "bedding-in period". type and preparation of the surfaces, as well as the design
of the components), technique and the quality of fixation,
Studies also demonstrated that irradiation of the UHMWPE activity level of the patient, and the biological tissue
diminishes significantly the creep resistance of the product. reactivity which varies among individuals. The most
Obviously, it is difficult to know whether the progress of commonly used bearing combinations in joint replacement
the femoral ball inside the polyethylene cup is caused by today are metal or ceramic against ultra high molecular
the softness of the cup, that creeps to sides leaving more weight polyethylene. These combinations have functioned
places for the ball or whether the ball literary drills its way well for most patients. The durability is less in younger
through the cup. patients because of higher activity levels. The fine
particulate debris that is produced causes tissue reaction.
In the first case no polyethylene debris is being produced, This process can undermine fixation and result in
in the second case the ball produces many small loosening. While there is undoubtedly variability in
polyethylene particles which may cause osteolysis. individual tissue reactivity to debris, there is no known
methodology to evaluate and determine in advance which
patients will react more severely. Since polyethylene wear
The scientists and surgeons thus turn to observation of is proportional to the ball size of the femoral head, it is
damage on the joint surface of the cup components made recommended that the ball size should be reduced to 22
from highly cross-linked UHMWPE. If the new cross- mm (roughly one-half to one-third that of the normal hip)
linked product would be more wear resistant, then there to minimize wear for young and active individuals.
would be less scratch markings on the surface of cross- However, the use of the small ball can produce instability
linked products compared with conventional product problems in some individuals who have a greater amount of
flexibility in their joints especially if the components are
Direct observation of the surface of the retrieved cups not optimally positioned. Because of the known deleterious
(cups that were some years in the patient body and then effects of wear debris, research has begun in an effort to
were retrieved for some failure of the prosthesis -yes, there minimize the wear of UHMWPE. However, it will be
have been also failures) could not distinguish more surface many years before we can determine the success of these
damage on the cups made of the conventional product as developments.
compared with the highly cross-linked product [Huo 2003].
j. Metal-on-Metal Bearings
g. Shelf-life
Metal/Metal (M/M) bearings were first used in the United
The UHMWPE component ages, especially if it is placed States when joint replacement began in the late 1960s. The
on the shelf in wait to be placed in the patient's body. If the component design and fixation techniques were primitive
package is not airtight, and if the cup component is placed by todays standards. Further, the bearing manufacture was
in the air atmosphere, the UHMWPE will succumb to the inconsistent and these devices were discontinued in the
corrosive influence of atmospheric oxygen. 1970s. Now with modern technology, bearing surfaces can
be made optimally smooth and round and thus the wear is
It is thus mandatory that one will not be operated on with minimized. Volumetric wear, compared to polyethylene,
total joints whose UHMWPE components were can be reduced between 20 and 100 times depending on
manufactured several years ago. This can happen in ball size. It is also possible that the wear will be reduced
hospitals with low operation volume. The patient should even further as research into this aspect intensifies. M/M
ask surgeon how old / what is the fabrication date / is the devices were reintroduced in Europe in 1988. There are
device that will be placed in the body. now U.S. manufacturers as well as European firms
manufacturing all metal devices.
h. Allergy to polyethylene
In addition to reduction in volumetric wear, the biological
tissue reaction locally, based on observation periods of up
As yet there are no confirmed reports on allergy to the to 30 years, is less inflammatory, and therefore, less likely
polyethylene component of the artificial joints. The wear to undermine the components fixation. With metal/metal
particles of polyethylene produced by prosthetic wear are bearings, unlike metal/polyethylene bearings, there is no
too big to provoke immunologic reaction. Ingested in the penalty for increasing the ball size. Therefore, it is possible
macrophages, these particles provoke instead an osteolytic to safely improve the stability to minimize the risk of
reaction. It is, however, theoretically possible that patient's dislocation.
protein substances that once adhered to the prosthetic
CERAMICS FOR TOTAL HIPS smaller crystals and the purer the material, make the
alumina ceramic fracture resistant.
a. Commercial ceramics
Zirconia ceramic is composed of 95% pure Zirconium
The commercial ceramics (from Greek ceramic = pottery), oxide crystals with 5% stabilizing substances added. This
such as porcelain cups in the kitchen, has nothing to do is so because Zirconium ceramic exists in two crystalline
with the ceramic materials used in total hip prostheses. The forms. One of them is unstable and does not tolerate heat
commercial ceramic products are not only brittle; but also sterilization. The added stabilizing substance should
are not tolerated by the body! prevent the change of the Zirconia into the unstable and
fragile substance. Zircon ceramic ages in the bodys
temperature and the surface of the Zircon roughens. There
b. Medical grade ceramics are reports of catastrophic wear caused by femoral balls
made from Zircon ceramic. The reason for introduction of
Ceramics used for total hip joints surfaces are solid Zircon ceramic as the material for femoral ball components
materials composed only of pure crystals of aluminum or was the fact that Zircon ceramic is less brittle and more
zirconium oxides. Such ceramics are most chemically and fracture resistant.
biologically inert of all materials. They are not only inert;
they are also stiff, strong, and hard. For example, the only Originally, only components made from alumina ceramic
substance that is harder than alumina ceramic (aluminum were used in total hip prostheses. Because the femoral balls
oxide) is diamond. made from alumina ceramic in the past were fragile, the
manufacturers were forced to produce only balls with large
Thus ceramic are very resistant to scratches from tiny bone diameters (32 mm). The theoretical disadvantage of a larger
cement particles that occasionally land between joint ball was the increased production of wear particles.
surfaces. The harder the coupled surfaces, the less wear the Therefore the manufactures sought after ceramic less prone
coupling produces. Thus total hip with ceramics surfaces to fracture and they used Zirconia.
produces very low rates of wear particles. Ceramics also
attract fluid on their surface so that couplings made of Zircon ceramic is less tough and less prone to fracture.
ceramic have low friction resistance. Therefore, it has been possible to produce Zircon balls also
with a 22- mm diameter.
The ceramic components of total hip prostheses made from
alumina ceramics once had bad reputation because of their As yet, Zircon balls have been combined with polyethylene
fragility; the femoral balls broke too often. The fragility of cups only. The combination of Zircon balls with Zircon
the old generation of alumina ceramic was caused by faulty cups has more wear rate. Some manufacturers of Zircon
manufacture and impurities in the finished product. products now claim that Zircon cups may be combined
with Zircon balls.
c. Old and modern medical grade ceramic under
microscope Modern alumina ceramic is very fracture resistant and is
used for production of femoral balls with smaller
In the old ceramic, the crystals of alumina were large, not diameters. The ceramic components for a modern total hip
assembled closely, there were many impurities and voids are individually tested before they are released for surgical
between them (actually impurities consisted about 5 % of use. Only about 50 % of all ceramic components pass this
the ceramic's volume). These impurities were the weak test and they are called "the 3rd generation medical grade
points for propagation of fracture cracks. The coarse ceramic components".
structure and impurities were the cause of the frequent
fractures of the old ceramic components. e. Ceramic for total knees
In the modern ceramic the crystals are small, closely Use of ceramic for total knee joints is hampered by two
packed together, the impurities making < 0.5% of volume. facts:
All modern ceramic total hip components are individually
stress tested with stresses up to 9 000 kg before they are
released to the surgeon. This load is about ten times the 1. The total knee joints are not congruent. Thus, in a total
maximal stress the component will sustain in the patients knee joint with both joint surfaces made from ceramic
body. Brittle fracture of ceramic femoral balls is now very materials, there would appear large localized stresses
rare, less than one per 2000. that would destroy components made from
contemporary ceramics.
d. Alumina and Zirconia ceramic
2. It is as yet difficult to fabricate such a large piece of
ceramic with highly irregular form as femoral
Alumina ceramic is composed of > 99.5% very small component that would sustain the stresses that occur
crystals of aluminum oxide. It is tough, and hard. The during walking in the knee.
One solution is the Oxinium prosthesis: The femoral of barium sulfate that make the resulting product radio-
component is made from the metal Zirconium. The opaque. It is used for fixation of the artificial joints to the
Zirconium is highly biocompatible and will sustain the bone stock. It acts not as a glue, but as a filler. The familiar
localized stresses that occur in the knee. materials Plexiglas or Lucite are pure PMMA. Plexiglas is
one of the strongest plastics.
The surface of this component is then oxidized, so that it
would consist of Zirconium oxide which is of course b. Preparation of bone cement at the operation table
ceramic material. Japanese surgeons use, however, femoral
components made from alumina ceramic. The mechanical characteristics of bone cement, however,
are inferior to the characteristics of Plexiglas thanks to the
f. Hydroxyapatite coating admixed products. The Plexiglas is polymerized under ideal
conditions at the factory premises from the pure substance.
In normal bone tissue, the collagen fibers are interspersed The surgeon prepares the bone cement directly at the
with crystals of hydroxyapatite. Synthetically produced operation table by mixing manually a white polymer
hydroxyapatite is used as thin coating on the porous powder of PMM with a nasty smelling monomer fluid. The
surfaces of the cement less total hip prostheses. The resulting product is a doughy white mass which
purpose is to enhance the ingrowth of the bone tissue in to polymerizes to a hard and brittle substance within ten
the surface of the hip prosthesis. Recent statistics minutes. The polymerization is accompanied by
demonstrated that cementless total hip prostheses with development of heat so that the surface temperature of the
hydroxyapatite coatings have lower rates of failures than bone cement reaches temporarily 50 degrees Celsius.
other cementless total hip prostheses.
When the surgeon presses the doughy bone cement into the
g. Other osteoinductive substances prepared cavity in the bone, small quantities of monomer
fluid are still present in the product. The toxic fluid may
leak into the circulation and cause sudden blood pressure
In laboratories, the scientists have been experimenting with fall during the operation.
other osteoinductive substances, such as growth hormones,
and Bone Morphogenetic Proteins, applied on the porous
surface of artificial joints. These substances too should The fully polymerized bone cement is more or less full of
increase the ingrowth of the bone tissue in the porous air bubbles which were entrapped in the product during the
surface of artificial joints. Although some experiments mixing procedure. Vacuum mixing systems can decrease
produced promising results, the use of these substances is the amount of air bubbles in the ready bone cement.
still in the experimental state.
c. Antibiotic loaded bone cement
h. Ceramic-on-Ceramic Bearings
Most surgeons use bone cements with admixed
All alumina-ceramic bearings have been utilized in Europe prophylactic antibiotics. After the operation, the antibiotics
since the early 1970s. A problem with the early ceramic leak from the bone cement into the tissues around the total
materials was its large grain structure which led to hip. The local concentration of antibiotics around the
fractures. Manufacturing of ceramics is now much cemented total hip prosthesis is sufficient to kill the
improved with small grain size creating a much stronger bacteria left in the operative wound. On the other hand, the
material. These bearings also produce low wear similar to quantity of antibiotics that come into the circulation is low,
that of metal-on-metal bearings with substantial reductions so that the risk for general allergic reaction against the
over plastic bearings. Because of concerns related to the antibiotics is low.
strength of the material, the shells must be made thicker in
order to minimize fracture and, therefore, surface Available statistics show that antibiotic loaded bone cement
replacements are not feasible. The new generation in combination with systemic antibiotics is the best
components are much improved for stem-type devices. The prophylaxis against postoperative infection. Addition of
all-alumina bearings are another option in the effort to antibiotics to bone cement does not change the mechanical
minimize wear and tissue reaction and to provide longer characteristic of the product
term durability. However, the components must be
optimally manufactured to minimize the risk of fracture and d. Drawbacks
inserted precisely to minimize wear.
Many commercial formulations of bone cement are now
BONE CEMENT available on the market. These products differ in chemical
composition and physical properties as well as in the
a. Composition mechanical strength and endurance of the product Statistics
have demonstrated that total hip replacements done with
The bond cement consists of 90 % of certain bone cement products (low viscosity bone cement,
polymethylmetacrylate (PMMA), the rest is mainly crystals Boneloc cement) have had increased rates of failures.
The bone cement as prepared by the surgeon at the porous ingrowth or osseointegration. The bone must be
operation table is a material with many drawbacks: prepared precisely for these devices because close
apposition to bone is necessary for bone to grow up to the
smooth surface (osteointegration) or into the pores of the
It is mechanically weak because it has entrapped
porous surfaces (porous ingrowth). In general, these
impurities such as air and blood.
devices are larger and longer than those used with cement
It is brittle, it has low endurance limit and is but are proportional to the size of the individual bone.
prone to fatigue failure. Surface coatings, such as hydroxyapatite, are also being
It spawns small particles from its surface utilized in an effort to hasten and/or enhance bone fixation.
containing hard crystals of Barium sulfate which An example of this type of device is shown in Figures 5.
scratch and damage the fine joint surfaces of the
artificial joint. Many different devices using cementless fixation have been
Small cement particles cause osteolysis - "bone utilized since their introduction in the U.S. in 1977. It is
dissolving disease". hoped that these devices will maintain their attachment to
It has very large surface which may support bone longer, but some caution is advised in their
colonization of bacteria and development of application. Complete pain relief after surgery is not as
postoperative infections. predictable as with cemented stems. This is related to the
It may cause allergy and anaphylactic reaction type of cementless hip prosthesis and the patients
during the operation. anatomy, although most improve with time as fixation
becomes more rigid.
The advantage of bone cement are:
g. Allergy to bone cement and plastics
The bone cement has a very long (>25 years)
track record, none of the cementless competitors There are only few reports about a delayed allergy to bone
have as long track record. cement or some of its constituents in patients operated on
The surgeons are experienced to work with the with cemented total hips. One report even maintained that
bone cement. the cases of very early loosenings of cemented total joints
The operation technique with bone cement is were caused by the allergy to polymethylmethacrylate
more forgiving. (PMMA).
e. THP (Stem Type) with Acrylic Cement Fixation
In 1962, Sir John Charnley used a small (22 mm) stainless

steel ball on a stem which was inserted into the bone to
replace the femoral (ball) side of the joint and a high
density plastic socket to replace the acetabular (socket)
side. Both of these components were secured to bone with a
self-curing acrylic polymer commonly referred to as bone
cement. Several generations of designs have evolved from
this original Charnley prosthesis. The ball is now modular
thereby allowing balls of different sizes, materials and neck
lengths to be placed onto the stem. Most balls are now
made of either a cobalt chrome metal alloy or a ceramic
material. Results include consistent pain relief due to
immediate fixation and rapid recovery with early weight
bearing. It has been general experience, however, that the
long term results of cemented total hip replacements in
young, active and/or heavy patients are not as consistently
durable as desired. The loosening rate of cemented
acetabular components increases with time leading to many
failures after 10 or 15 years. For these reasons, cementless
fixation has been advocated by some for younger or more
active patients.
f. THP (Stem Type) without Cement Fixation
We are now in an era with widespread use of devices which

are designed to attach to bone without the use of cement. Figure 5. Modern total hip replacement prosthesis of stem
Bone will attach to a metal implant if the surface of the type [Nguyen, London J and Cone 1986, 129-131]
metal has a certain "topography". This process is called
h. Oxidation damage molybdenum, to improve the corrosion resistance in salt
water, was introduced. When nickel is added and the
The irradiation has deleterious effects on the UHMWPE chromium level is increased, the structure changes again
capacity to withstand oxidation. The damage by oxidation and it is called "Austenitic" and they have the following
depends on the radiation dose. Already the dose used for characteristics:
the sterilization of the material makes the UHMWPE
susceptible to oxidation damage. An UHMWPE with a Are NOT magnetic.
molecular weight of 4, 000 000 molecular weight consists CANNOT be hardened by "heat treatment" BUT
of 575 000 bonds between individual carbon atoms. It CAN be hardened by cold working .
suffices if the oxidation severs only 25 of these bonds. One
Have the "BEST" corrosion resistance
long UHMWPE molecule then changes into several
molecules of high-density polyethylene, a product with Can be easily welded.
high wear rates. Have excellent clean ability and hygiene
characteristics.
The practical solution to the problem how to stem the Have exceptional resistance to both high and low
oxidation of HMWPE is simple. Theoretically one may temperature.
prohibit the contact between irradiated, cross-linked
UHMWPE cup and oxygen by packing the cup component The most corrosion resistant steels are 300 series steels that
in airtight box, with atmosphere of nitrogen. It is not contain chromium and nickel, and hence their popularity
feasible in practice, because when the cup is taken out of for medical implants. The austenitic stainless steels (Types
the inert atmosphere in the airtight package and placed 316 and 316 L) are most widely used for implant
into the the body, it would be bathed in body fluids fabrication. Forged stainless steel has greater yield strength
containing solved oxygen. than cast stainless steels, but has lower fatigue strength
than other implant alloys. Because a femoral component
So the more secure route is chasing the scoundrels the fracture with early designs, stainless steel is no longer used
free hydrogen atoms - to find a new place. This is best done routinely, from the standpoint of erosion, biocompatibility,
by reheating the irradiated product to melting point. All and fatigue life. The only difference in composition
molecules begin to move and the freely wandering between 316L and 316 stainless steel is the content of
scoundrels will find a new place in the crystal lattice carbon. A wide range of properties exists depending on the
somewhere between them. heat treatment (annealing to obtain softer materials) or cold
working(for greater strength and hardness). Even the 316L
stainless steels may corrode inside the body under certain
Today, the modern highly cross-linked UHMWPE is first circumstances in a highly stressed and oxygendepleted
cross-linked by irradiation (with doses between 5 to 10 region, such as contact under screws or fracture plates.
Mrad), then heated close to melting point. The component Thus, 316L stainless steels are suitable to use only in
made from this highly cross-linked UHMWPE is then temporary implant devices, such as fractures plates, screws,
finally packaged without access of air. But these products, hip nails, wires and staples.
wrapped in airtight packages must be sterilized, made free
of bacteria, before they can be put in the patients body. New nickel-free stainless steels have been recently
And here come the second improvement of the modern developed primarily to address the issue of nickel
UHMWPE implants. sensitivity. These stainless steels also have superior
mechanical properties, better corrosion resistance and
STAINLESS STEEL appear to possess an extraordinary combination of
attributes for potential implant applications in the future.
Table 4 gives the mechanical properties of stainless steel.
a. What is Stainless Steel?
Stainless steel is a family of iron based alloys that must Table 4. Mechanical Properties of Stainless Steel annealed
contain at least 10.5% CHROMIUM (Cr) and low carbon. condition [http://www.ssina.com/chem.htm].
The presence of chromium creates an invisible surface film
that resists oxidation and makes the material "passive" or
corrosion resistant (i.e. "stainless"). It needs less Tensile Yield Elongation Hardness
maintenance, is strictly hygienic and is often the least SS Strength Strength in 2 Rockell
expensive material option.
ksi MPa ksi MPa % -
In 1926 18% chromium, 8% nickel stainless steel was 410 70 483 45 310 25 B80
introduced into surgical applications. This material was
noted to be more corrosion resistant in body fluids. This 430 75 517 50 345 25 B85
was stronger and more resistant to corrosion than the
vanadium steel initially introduced by Sherman for his 304 84 579 42 290 55 B80
fracture fixation plates. Later in 1926, 18 8 S Mo
stainless steel, which contained a small percentage of 316 84 579 42 290 50 B79
b. Biocompatibility Table 5. Properties of Zirconium
[http://www.matweb.com].
One very important consideration in the selection of
surgical implant material is the compatibility of the Propeties Metric English
material with the human body. The body environment is Density 6.53 g/cc 0.236 lb/in
extremely hostile to all foreign materials and therefore, the Brinell Haedness 145 145
effect of the environment on the implant and the effect of
Rockwell A Hardness 49 49
the implant on its host tissue is primary concern. A surgical
implant is constantly bathed in extra cellular tissue fluid. In Rockwell B Hardness 78 78
addition to water, this fluid contains electrolytes, complex Vickers Hardness 150 150
compounds, oxygen and carbon dioxide. Under normal Ultimate Tensile Strength 330 MPa 47900 psi
conditions, the extra cellular body fluid is slightly alkaline
with pH of 7.4. Traumatized tissue has been reported to Yield Tensile Strength 230 MPa 33400 psi
have a significantly lower pH level. Because of the Elongation at Break 32% 32%
similarities of body fluids and saline solution, corrosion Modulus of Elasticity 94.5 GPa 13700 Ksi
research carried out for marine applications has served as Poissons Ratio 0.34 0.34
basis for development of materials for implants . The
surgical implant may not be protected by planting, painting Shear Modulus 40 GPa 5800 Ksi
coating or cathodic protection techniques. Body implants
must be naturally inert, such as noble metals or be TITANIUM AND ITS ALLOYS
protected by tissue to metallic implants is affected by many
factors including shape and size of the implant, movement 1. Outstanding Corrosion resistance
between the implant and tissue, extent of corrosion attack,
general degradation of the implant and the biological
activity of the resulting by-products of corrosion or Titanium is immune to corrosive attack by saltwater or
degradation. Hematomas are likely to collect around the marine atmospheres. It also exhibits exceptional resistance
implant, resulting in a lowered pH, as low as 4.0 in healing to a broad range of:
wounds. The low pH usually persists until the hematomas
are resorbed after several weeks. The immediate reaction is Acids.
to form layers of fibrous tissue between the implant and Alkalis.
healthy tissue. In presence of corrosion an inflammatory
reaction may occur and thickening of fibrous tissue is Natural waters.
observed. Corrosive gases.
Reducing atmospheres.
c. Internal Fixation Devices Passivation with inhibitors.
Organic Media.
The most significant contribution of stainless steel to the
advancement of modern surgery is in the area of internal Titanium develops a thin, tenacious and highly protective
skeletal fixation. Since movement of the human body is surface oxide film. The surface oxide of titanium will, if
accomplished through the musculo-skeletal system, any scratched or damaged, immediately reheal and restore itself
impairment of the skeletal system, results in reduction or in the presence of air or even very small amounts of water.
complete loss of motion capability. Surgical reduction of
fractures often involves the use of internal, metallic, a. Acid resistance:
fixation devices such as bone plates, intramedullary, rods
and highly specialized nails. Some of the advantages of Titanium alloys resist an extensive range of acidic
internal fixation are: conditions:
Oxidizing acids:
1. Positive maintenance of fracture surface
proximity.
In general, titanium has excellent resistance to oxidizing
2. Early patient mobility and joint movement, in
acids such as nitric and chromic, over a wide range of
case of limb fracture.
temperatures and concentrations.
3. shortened hospitalization and disability times.
4. Reduced probability of limb deformity due to
Reducing acids:
malunions.
Titanium alloys are generally very resistant to mildly
ZIRCONIUM reducing acids, but can display severe limitations in
strongly reducing acids. Mildly reducing acids such as
Physical and mechanical properties of Zirconium are given sulphuric acid, acetic acid, terephthalic acid, adipic acid,
in Table 5. lactic acid and many organic acids generally represent no
problem for titanium over the full concentration range.
However, relatively pure, strong reducing acids, such as temperature, degree of aeration and possible inhibitors
hydrochloric, hydrobromic, sulphuric, phosphoric, oxalic present. The Grade 7 and Grade 12 titanium alloys are
and sulphamic acids can accelerate general corrosion of often preferred materials in these more aggressive acids.
titanium depending on acid temperature, concentration and
purity. Ti-Pd alloys offer dramatically improved corrosion b. Alkaline media
resistance under these severe conditions. In fact, Ti-Pd
alloys often compare quite favorably to nickel alloys in
dilute reducing acids. Titanium is rapidly attacked by Titanium is generally highly resistant to alkaline media
hydrofluoric acid of even very dilute concentrations. including solutions of sodium hydroxide, potassium
Therefore, titanium is not recommended for use with hydroxide, calcium hydroxide, magnesium hydroxide and
hydrofluoric acid solutions or in fluoride- containing ammonium hydroxide. In the high basic sodium or
solutions below pH7. Certain complexing metal ions, e.g. potassium hydroxide solutions, however, useful application
aluminum, may effectively inhibit corrosion in dilute of titanium may be limited to temperatures below 80C
fluoride solutions. (176F). This is due to possible excessive hydrogen uptake
and eventual embrittlement of titanium alloys in hot,
Nitric acid: strongly alkaline media. Titanium often becomes the
material of choice for alkaline media containing chlorides
Titanium is used extensively for handling nitric acid in and/or oxidizing chloride species. Even at higher
commercial applications. Titanium exhibits low corrosion temperatures, titanium resists pitting, stress corrosion, or
rates in nitric acid over a wide range of conditions. At the conventional caustic embrittlement observed on many
boiling temperatures and above, titanium's corrosion stainless steel alloys in these situations.
resistance is very sensitive to nitric acid purity. Generally,
the higher the contamination and the higher the metallic ion Titanium and methanol
content of the acid, the better titanium will perform. This is
in contrast to stainless steels which often adversely affected Anhydrous methanol is unique in its ability to cause stress
by acid contaminant. Since titanium's own corrosion corrosion cracking of titanium and titanium alloys.
product (Ti++++) is highly inhibitive, titanium often Industrial methanol normally contains sufficient water to
exhibits superb performance in recycled nitric acid streams provide immunity to titanium and for there to be no
such as reboiler loops. One user cites an example of a problem in practical applications.
titanium heat exchanger handling 60% HNO3 at 193C
(380F) and 20 bar (300 psi) which showed no signs of
corrosion after more than two years of operation. Titanium In the past the specification of a minimum of 2% has
reactors, reboilers, condensers, heaters and thermowells proved adequate to protect commercially pure titanium
have been used in solutions containing 10 to 70% HNO3 at equipment for all but the most severe conditions. In such
temperatures from boiling to 315F (600C). conditions, due to temperature and pressure titanium alloys
would more than likely be required.
Red fuming nitric acid:
In order to ensure effective cover for all conditions now
Although titanium has excellent resistance to nitric acid being encountered by titanium alloys used in the offshore
over a wide range of concentrations and temperatures, it industry, a revised limit of 5% minimum water content of
should not be used with red fuming nitric acid because of methanol is recommended.
the danger of pyrophoric reactions. More than 1.34% water
and less than 6% NO2 concentration (NO2/NO ratio) are
Work is in hand to confirm the actual level of water
guidelines for avoiding pyrophoric reactions.
required to provide immunity to stress corrosion cracking
in all conditions. Test conducted to date confirm required
Organic Acids:
levels above 2%, but safely below 5% are required. Until
this work is deemed to be satisfactorily complete TIG
Titanium alloys generally exhibit excellent resistance to
recommends that the 5% limit be used.
organic media. Mere traces of moisture and/or air normally
present in organic process streams assure the development
of a stable protective oxide film of titanium. Titanium is Halogen compounds
highly resistant to hydrocarbons, chloro- hydrocarbons,
fluorocarbons, ketones, aldehydes, ethers, esters, amines, Titanium alloys are highly resistant to wet (aqueous)
alcohols and most organic acids. Titanium equipment has chlorine, bromine, iodine and other chlorine chemicals
traditionally been used for production of terephthalic acid, because of their strongly oxidizing natures. Titanium's
adipic acid and acetaldehyde. Acetic acid, tartaric acid, outstanding resistance to aqueous chlorides has been the
stearic acid, lactic acid, tannic acids and many other primary historical incentive for utilizing titanium in
organic acids represent fairly benign environments for industrial service. In many chloride and bromide-
titanium. However, proper titanium alloy selection is containing environments, titanium has cost-effectively
necessary for the stronger organic acids such as oxalic acid, replaced stainless steels, copper alloys and other metals
formic acid, sulphamic acid and trichloroacetic acids. which have experienced severe localized corrosion and
Performance in these acids depends on acid concentration, stress corrosion cracking.
Chlorine gas acidic aqueous fluorides and gaseous fluorine environments
which can be highly corrosive to titanium alloys.
Titanium is widely used to handle moist or wet chlorine
gas, and has earned a reputation for outstanding Salt solutions
performance in this service. The strongly oxidizing nature
of moist chlorine passivates titanium resulting in low Titanium alloys exhibit excellent resistance to practically
corrosion rates. Proper titanium alloy selection offers a all salt solutions over a wide range of pH and temperatures.
solution to the possibility of crevice corrosion when wet Good performance can be expected in sulphates, sulphites,
chlorine surface temperatures exceed 70C (158F). Dry borates, phosphates, cyanides, carbonates and bicarbonates.
chlorine can cause rapid attack of titanium and may even Similar results can be expected with oxidizing anionic salts
cause ignition if moisture content is sufficiently low. such as nitrates, molybdates, chromates, permanganates
However, as little as one percent of water is generally and vanadates; and also with oxidizing cationic salts
sufficient for passivation or repassivation after mechanical including ferric, cupric, and nickel compounds.
damage to titanium in chlorine gas under static conditions
at room temperature.
c. Resistance to water
Chlorine chemicals and chlorine solutions
Titanium alloys are used extensively for applications which
entail exposure to fresh and salt water.
Titanium is fully resistant to solutions of chlorites,
hypochlorites, chlorates, perchlorates and chlorine dioxide.
It has been used to handle these chemicals in the pulp and Fresh water/steam
paper industry for many years with no evidence of
corrosion. Titanium alloys are highly resistant to water, natural waters
and steam to temperatures in excess of 570F (300C).
Titanium is used in chloride salt solutions and other brines Excellent performance can be expected in high purity
over the full concentration range, especially as water, fresh water Titanium is immune to microbiologically
temperatures increase. Near nil corrosion rates can be influenced corrosion (MIC). Typical contaminants found in
expected in brine media over the pH range of 3 to 11. natural water streams, such as iron and manganese oxides,
Oxidizing metallic chlorides, such as FeCl3, NiCl2 or sulphides, sulphates, carbonates and chlorides do not
CuCl2, extend titanium's passivity to much lower pH compromise titanium's performance. Titanium remains
levels. Localized pitting or corrosion, occurring in tight totally unaffected by chlorination treatments used to control
crevices and under scale or other deposits is a controlling biofouling.
factor in the application of unalloyed titanium. Attack will
normally not occur on commercially pure titanium or Seawater
industrial alloys below 70C (158F) regardless of solution
pH. Seawater and neutral brines above the boiling point Titanium is fully resistant to natural seawater regardless of
will develop localized reducing acidic conditions, and chemistry variations and pollution effects (i.e. sulphides).
pitting may occur. Enhanced resistance to reducing acid Twenty year corrosion rates well below 0.0003 mm/yr
chlorides and crevice corrosion is available from alloy (0.01 mils/yr) have been measured on titanium exposed
Grades 7, 11 and 12. Attention to design of flanged joints beneath sea, in marine atmospheres, and in splash or tidal
using heavy flanges and high clamping pressure, and to the zones. In the sea, titanium alloys are immune to all forms
specification of gaskets (choosing elastic rather than plastic of localized corrosion, and withstand seawater
or hard materials) may serve to prevent crevices impingement and flow velocities in excess of 30 m/sec
developing. An alternative strategy is to incorporate a (100 ft/sec). Abrasion and cavitation resistance is
source of nickel, copper, molybdenum or palladium into the outstanding, explaining why titanium provides total
gasket. reliability in many marine and naval applications. In
addition, the fatigue strength and toughness of most
Pulp and paper titanium alloys are unaffected in seawater and many
titanium alloys are immune to seawater stress corrosion.
Due to recycling of waste fluids and the need for greater
equipment reliability and life span, titanium has become the Titanium tubing has been used with great success for more
standard material for drum washers, diffusion bleach than forty years in seawater-cooled heat exchangers in the
washers, pumps, piping systems and heat exchangers in the chemical, oil refineries and desalination industries. The pH-
bleaching section of pulp and paper plants. temperature guidelines for crevice-corrosion are generally
applicable to seawater services as well as NaCl brines.
Halogen compounds
When in contact with other metals, titanium alloys are not
subject to galvanic corrosion in seawater. However
Similar considerations generally apply to other halogens titanium may accelerate attack on active metals such as
and halide compounds. Special concern should be given to steel, aluminum and copper alloys. The extent of galvanic
corrosion will depend on many factors such as anode to (100-150 ppm for commercially pure Grade 2), titanium
cathode ratio, seawater velocity and seawater chemistry. hydride will begin to precipitate. At temperatures not
The most successful strategies eliminate this galvanic exceeding 80C (176F), hydride will normally be
couple by using more resistant compatible passive metals restricted to the surface layers of the metal and experience
with titanium, all-titanium construction, or dielectric in such cases indicates that this has little or no serious
(insulating) joints. Other approaches for mitigating effect on the performance or properties of the metal. Cases
galvanic corrosion have also been effective: coatings, of through section hydride formation, leading to
linings and cathodic protection. embrittlement and cracking or failure under stress are very
rare. Hydriding can be avoided by the proper design of
d. Corrosive gases equipment and control of operating conditions.
Sulphur-bearing gases
Oxygen and air
Titanium is highly corrosion resistant to sulphur-bearing
Titanium alloys are totally resistant to all forms of gases, resisting sulphide stress corrosion cracking and
atmospheric corrosion regardless of pollutants present in sulphidation at typical operating temperatures. Sulphur
either marine, rural or industrial locations. Titanium has dioxide and hydrogen sulphide, either wet or dry, have no
excellent resistance to gaseous oxygen and air at effect on titanium. Extremely good performance can be
temperatures up to 370C (700F). Above this temperature expected in sulphurous acid even at the boiling point. Field
and below 450C (840F), titanium forms colored surface exposures in FGD scrubber systems of coal-fired power
oxide films which thicken slowly with time. Above 650C plants have similarly indicated outstanding performance of
(1200F) or so , titanium alloys suffer from lack of long- titanium. Wet SO3 environments may be a problem for
term oxidation resistance and will become brittle due to the titanium in cases where pure, strong, uninhibited sulphuric
increased diffusion of oxygen in the metal. In oxygen, the acid solutions may form, leading to metal attack. In these
combustion is not spontaneous and occurs with oxygen situations, the background chemistry of the process
concentration above 35% at pressures over 25 bar (350 environment is critical for successful use of titanium.
psig) when a fresh surface is created.
e. Reducing atmospheres
Nitrogen and ammonia
Titanium generally resists mildly reducing, neutral and
Nitrogen reacts much more slowly with titanium than highly oxidizing environments up to reasonably high
oxygen. However above 800C (1400F), excessive temperatures. The presence of oxidizing species including
diffusion of the nitride may cause metal embrittlement. air, oxygen and ferrous alloy corrosion products, often
Titanium is not corroded by liquid anhydrous ammonia at extend the performance limits of titanium in many highly
ambient temperatures. Moist or dry ammonia gas, or aggressive environments. However, under highly reducing
ammonia water(NH4OH) solutions will not corrode conditions the oxide film may breakdown and corrosion
titanium to their boiling-point and above. may occur.
Hydrogen f. Passivation with inhibitors

The surface oxide film on titanium acts as a highly
effective barrier to hydrogen. Penetration can only occur Many industrial acid streams contain contaminants which
when this protective film is disrupted mechanically or are oxidizing in nature, thereby passivating titanium alloys
broken down chemically or ectro-chemically. The presence in normally aggressive acid media. Metal ion concentration
of moisture effectively maintains the oxide film inhibiting levels as low as 20-100 ppm can inhibit corrosion
hydrogen absorption up to fairly high temperatures and extremely effectively. Potent inhibitors for titanium in
pressures. On the other hand, pure, anhydrous hydrogen reducing acid media are common: dissolved oxygen,
exposures should be avoided particularly as pressures chlorine, bromine, nitrate, chromate, permanganate,
and/or temperatures increase. molybdate and cationic metallic ions, such as ferric (Fe+3),
cupric (Cu+2), nickel (Ni+2) and many precious metal
ions.
The few cases of hydrogen embrittlement of titanium
observed in industrial service have generally been limited It is this potent metal ion inhibition which permits titanium
to situations involving high temperatures, high alkaline to be successfully utilized for equipment handling hot HCl
media; titanium coupled to active steel in hot aqueous and H2SO4 acid solutions in metallic ore leaching
sulphide streams; and where titanium has experienced processes.
severe prolonged cathodic charging in seawater.
Penetration Diffusion of hydrogen into titanium is very 1. Hydrofluoric acid

slow at temperatures below 80C (176F) except where
high residual or applied tensile stresses exist. If the The resistance of titanium to many acidic fluoride-bearing
solubility limit of hydrogen in titanium is then exceeded, environments can be explained by the abundant presence of
metal ions, particularly aluminum and iron, in condensates, e. Superior strength-to-weight ratios
liquors and sludges. These ions chemically complex the
active fluorides and thus render them inert to the titanium. The combination of high strength and low density results in
Frequently, fluoride-metal complexes are spontaneously exceptionally favorable strength-to-weight ratios for
formed early in the process cycle. Aluminum, in particular, titanium-based alloys.
is effective in complexing fluorides - even at very low pH.
Although inhibition is possible in most reducing acids, The densities of titanium-based alloys range between 4.43
including those containing fluorides, protection of titanium gm/cm3 (0.160 lb/in3) and 4.85 gm/cm3 (0.175 lb/in3).
from solutions of hydrofluoric acid itself is difficult to Yield strengths range from 172 MPa (25,000 psi) for
achieve. commercially pure Grade 1, to above 1380 MPa (200,000
psi) for heat treated beta alloys. These ratios for titanium-
based alloys are superior to almost all other metals and are
2. Titanium's oxide film important in such diverse applications as deep well
tubestrings in the petroleum industry and surgical implants
Titanium develops a thin, tenacious and highly protective in the medical field.
surface oxide film. The surface oxide of titanium will, if
scratched or damaged, immediately reheal and restore itself 5. Low coefficient of expansion
in the presence of air or even very small amounts water.
The corrosion resistance of titanium depends on a
protective TiO2 surface oxide film. Titanium possesses a coefficient of expansion which is
significantly less than ferrous alloys. This property also
allows titanium to be much more compatible with ceramic
This substantially inert surface oxide has high integrity and or glass materials than most metals, particularly when
tenacity. The oxide will, if scratched or damaged, metal-ceramic/glass seals are involved.
immediately restore itself in the presence of air or water.
The film is stable over a wide range of pH, electro-
potentials and temperature, particularly in neutral and 6. Non-magnetic
oxidizing environments.
Titanium is virtually non-magnetic, making it ideal for
Titanium alloys are metallurgically stable and the applications where electro- magnetic interference must be
protective oxide forms equally on all titanium surfaces, on minimized. Desirable applications include electronic
wrought products, welds and castings irrespective of equipment housing, medical devices and downhole well
composition or micro-structural differences. logging tools.
3. Excellent erosion resistance 7. Excellent fire resistance
Because of the nature of its oxide film, titanium has Even at very high temperatures titanium is fire resistant.
superior resistance to erosion, cavitation and impingement This is important for applications such as petrochemical
attack. Titanium is over twenty times more erosion resistant plant and firewater systems for offshore platforms, where
than the copper-nickel alloys. its ability to survive a hydrocarbon fire is an essential
factor.
4. High heat transfer efficiency
8. Short radioactive half life
Under 'in service' conditions, the heat transfer properties of
titanium are similar to those of admiralty brass and copper- Titanium has an extremely short half-life, thereby
nickel. There are several reasons for this: permitting its use in nuclear systems. In contrast to many
ferrous alloys, many titanium alloys do not contain a
significant amount of alloying elements which may become
a. The higher strength of titanium permits the use of thinner radioactive.
walled equipment.
TITANIUM FOR MEDICAL APPLICATION
b. The oxide film confers unusual characteristics which are
beneficial to heat transfer.
The high strength, low weight, outstanding corrosion
resistance possessed by titanium and titanium alloys have
c. The absence of corrosion leaves the surface bright and led to a wide and diversified range of successful
smooth for improved lamellar flow. applications which demand high levels of reliable
performance in surgery and medicine as well as in
d. Titanium's excellent erosion-corrosion resistance permits aerospace, automotive, chemical plant, power generation,
significantly higher operating velocities. oil and gas extraction, sports, and other major industries.
More than 1000 tones (2.2 million pounds) of titanium are 1.4 - 1.7 (1.1 is a minimum for an acceptable implant
devices of every description and function are implanted in material).
patients worldwide every year. Requirements for joint
replacement continue to grow as people live longer or Fracture toughness of all high strength implantable alloys is
damage themselves more in by hard sports play or jogging, above 50 M Pam-1/2 with critical crack lengths well above
or are seriously injured in road traffic and other accidents. the minimum for detection by standard methods of non-
Light, strong and totally bio-compatible, titanium is one of destructive testing.
few materials that naturally match the requirements for
implantation in the human body.
COBALT ALLOYS
Medical grade titanium alloys have a significantly higher
strength to weight ratio than competing stainless steels. The Mechanical properties of cobalt alloy are shown in table 6.
range of available titanium alloys enables medical Mechanical properties are compared in table 7.
specialists to select materials and forms closely tailored to
the needs of the application. The full range of alloys CLASSIFICATION OF ORTHOPEDIC FIXATION
reaches from high ductility commercially pure titanium DEVICES
used where extreme formability is essential, to fully heat
treatable alloys with strength above 1300 MPa, (190ksi). Internal Fixation Devices
Shape-memory alloys based on titanium, further extend the S crews
range of useful properties and applications. Surface Plates Wires and pins
engineering frequently plays a significant role, extending Intramedullary rods and nails
the performance of titanium several times beyond its Spinal fixation devices
natural capability.
External Fixation Devices

Titanium Performance Fracture fixation
Radius
'Fit and forget' is an essential requirement where equipment Tibia
in critical applications, once installed, cannot readily be Pelvis
maintained or replaced. There is no more challenging use in Bone lengthening
this respect than implants in the human body. Here, the lizarov device
effectiveness and reliability of implants, and medical and
surgical instruments and devices is an essential factor in Table 6. Properties of Cobalt Alloy
saving lives and in the long term relief of suffering and [www.goodfellow.com/csp/active/static/S/CO00.HTML]
pain. Most metals in body fluids and tissue are found in
stable organic complexes. Corrosion of implanted metal by
Density of solid kg-m-3 8900
body fluids results in the release of unwanted metallic ions,
with likely interference in the processes of life. Corrosion
resistance is not sufficient of itself to suppress the body's
reaction to cell toxic metals or allergenic elements such as Molar Volume cm3 6.67
nickel: Even in very small concentrations from a minimum
level of corrosion, these may initiate rejection reactions.
Velocity of sound m-s-1 4720
Titanium is judged to be completely inert and immune to
corrosion by all body fluids and tissue, and is thus wholly
bio-compatible. Young Modulus GPa 209
The natural selection of titanium for implantation is

determined by a combination of most favourable Rigidity Modulus GPa 75
characteristics including immunity to corrosion, bio-
compatibility, strength, low modulus and density and the Bulk Modulus GPa 180
capacity for joining with bone and other tissue -
osseointegration. The mechanical and physical properties
of titanium alloys combine to provide implants which are Mineral Hardness --- 5
highly damage tolerant. The human anatomy naturally
limits the shape and allowable volume of implants. The
lower modulus of titanium alloys compared to steel is a Vickers Hardness MPa 1043
positive factor in reducing bone resorbtion. Two further
parameters define the usefulness of the implantable alloy, Brinell Hardness MPa 700
the notch sensitivity and the resistance to crack
propagation, or fracture toughness. Titanium scores well in
both cases. Typical NS/TS ratios for titanium and its alloys
1. Screws
Fracture compression increases the contact area across the

fracture and increases stability of the fracture. It also
decreases the fracture gap and decreases stress on the
orthopedic implant. This compression can be static, where
the compression is produced by the fixation device alone, or
dynamic, where body weight or muscle forces are used to
produce additional compression.
Screws may be used by themselves to provide fixation or in

conjunction with other devices. Any screw that is used to
achieve inter fragmental compression is termed a lag screw.
Such screws do not protect fractures from bending, rotation
or axial loading forces, and other devices should be used to Figure 8. AP and lateral views of the craniocervical area,
provide these functions. The two most common types of showing cannulated screws bridging a type II dens fracture.
screws are cortical and cancellous screws, as shown in [http://www.file:A:/orthopedics%20hardware.htm].
figure 7.
Figure 7. Cortical, cancellous and cannulated screws.

[http://www.file:A:/orthopedics%20hardware.htm]
Figure 9. Interference screws affixing a cadaveric ACL
graft - the arrows point out the pieces of cadaveric bone at
both ends of the graft.
Table 7. Mechanical Properties of Biomaterials
Properties Units Stainless Steel 1 Zirconium 2 Cobalt 2 2

Titanium
Poissons Ratio N/A 0.305 0.34 0.31 0.32
Hardness
GPa 79 78 78 93
Youngs Modulus GPa 196 94.5 94.5 120

Shear Modulus GPa 80 40 40 110-193
Tensile Srength MPa 579 330 330 345
Compressive Stress GPa N/A --- --- N/A
Yield Stress MPa 290 --- --- 950
Ultimate Stress MPa 59.3 --- --- 258
Coefficient of Thermal
10-6 per 0C 1.9 0.6 1.2 11.9
Expansion
2
http://www.ssina.com/chem.htm, www.matweb.com
Cortical screws tend to have fine threads all along their 2. Washers
shaft, and are designed to anchor in cortical bone.
Cancellous screws tend to have coarser threads, and usually Washers are generally used in two situations. They are used
have a smooth, unthreaded portion, which allows it to act as to distribute the stresses under a screw head so as to
a lag screw. These coarser threads are designed to anchor in prevent thin cortical bone from splitting.
the softer medullary bone.
Serrated washers are used to affix avulsed ligaments, small
Another commonly used screw is the cannulated screw, so avulsion fractures or comminuted fractures to the
called because of its hollow shaft. Although these screws remainder of the bone.
have somewhat diminished pullout strength compared to
conventional screws, cannulated screws have many
advantages over other screws, and especially the precision 3. Plates
with which they can be placed (Figure 8). To place these
screws, the orthopedist first drills a small Kirschner wire Plates come in several flavors, and are named for their
across the area of interest under C-arm fluoroscopic function. In general, there are compression, neutralization
control. These "K" wires can be placed and replaced with and buttress plates.
minimal trauma to the bone until they are in optimal
position. The cannulated screw is then placed over the wire Compression plates are used for fractures that are stable in
and slid down to the bone surface. A special driving tool compression. They may be used in combination with lag
then allows the screw to be driven into the bone along the screws, and they may provide dynamic compression when
shaft of the K wire, in a manner very similar to the way used on the tension side of bone. The dynamic compression
radiologists pass angiographic catheters over guide wires plate is one of the most common types of plates, and can be
using the Seldinger technique. The K wire is then recognized by its special oval screw holes. These holes
withdrawn. One major complication of these screws is have a special beveled floor to them with an inclined
perforation of the articular surface when these screws are surface. If desired, this inclined surface can be used to pull
placed into a bone with their tips close to the subchondral the ends of the bone together as the screws are tightened. In
bone. If an orthopedist is concerned about this possibility figure 10, the arrow is pointing to a syndesmosis screw
during surgery, contrast material may be injected through which is bridging the tibiofibular syndesmosis, whose
the hollow center of the screw in question -- spillage into ligaments have been torn during the injury -- also noted is a
the joint cavity under fluoroscopy will be unequivocal medial malleolar fracture bridged by a screw channel, but
evidence of perforation. apparently little else.
Certain specialty screws are also often seen. The Herbert The medial malleolar fracture is held together by one of
screw is designed for use in fractures of small articular these screws, made of a radiolucent polycarbonate material,
bones such as the carpals. It is cannulated and threaded at which is designed to eventually be absorbed by the body --
both ends. These threads run in the same direction, but the this type of screw is known locally as "stealth hardware as
proximal portion has a wider pitch to its thread. Thus, when shown in figure 11.
the proximal threads engage in the bone, they tend to move
through the bone faster than the threads at the distal end,
causing the two ends of the bone to compress together. This
screw is used where a standard screw would impinge on
adjacent tissues, such as in the treatment of scaphoid or
osteoarticular fractures.
Another specialty screw occasionally seen is the

interference screw (Figure 9). This screw is sometimes
used in the repair of the anterior cruciate ligament (ACL).
In this type of repair, the surgeon employs a cadaveric
allograft ligament which has a block of bone still attached
at both ends. A tunnel is drilled through the distal femur
and the proximal tibia, and these bony blocks are placed
within the tunnels. The interference screws are placed
alongside the bone blocks so that they tightly wedge them
into the side of the tunnel and prevent them from moving.
Since screw holes weaken bones and orthopedic hardware,

we should look closely at these areas on the films since the
bones and metal will tend to fracture at these sites. Also,
orthopedic hardware is generally removed as soon as
possible so that these holes can fill in with new bone Figure10. Dynamic compression plate (DCP) bridging a
formation and bring the bone strength back up to normal. fibular fracture.
Figure 14.Reconstruction plate
Figure 11. A stealth screw [http: // www.file.A:/
orthopedics % 20 hardware. Htm].
Figure 12. Under surface of a low contact dynamic

compression ( L C D C ) plate showing the typical
undercutting beneath each screw hole and between each
screw hole. Figure 15. Right acetabular fracture bridged by two
[http://www.file:A:/orthopedics%20hardware.htm] reconstruction plates and multiple screws -- the extra plate
seen laterally is probably a spring plate -- also noted is the
proximal end of an intramedullary femoral
nail[http://www.file:A:/orthopedics%20hardware.htm]
Figure 13. Low contact dynamic compression (LCDC)

plate bridging a humeral shaft fracture -- note the
undercutting between each screw hole -- also noted is a Figure 16.Buttress plate bridging a humeral neck fracture -
humeral fracture through the distalmost screw hole - note that 2 of the 3 most proximal screws have backed out
[http://www.file:A:/orthopedics%20hardware.htm] and that 2 of them may penetrate into the joint
space[http://www.file:A:/orthopedics%20hardware.htm]
Low contact dynamic compression (LCDC) plate is
distinguished from the conventional DCP by the way it is Neutralization plates are designed to protect fracture
undercut under each screw hole and between adjacent surfaces from normal bending, rotation and axial loading
screw holes. The rationale for this design is as follows. forces they are often used in combination with lag screws.
Whenever one clamps a plate down against the surface of a
bone, one markedly diminishes the periosteal blood supply Buttress plates are used to support bone that is unstable in
to that area. Theoretically, one would expect this to slow compression or axial loading (Figure 16). These plates are
healing of the fracture beneath that plate. The undercutting often used in the distal radius and tibial plateau to hold
of the plate decreases the amount of contact that the plate impacted and depressed fragments in position once they
makes with the bone surface, and hopefully will increase have been elevated.
the periosteal blood supply and, it is hoped, fracture healing
as well (Figure 12 and 13).
Yet another type of plate commonly seen on postoperative
films is the blade plate (Figure 17). This plate is usually
Another type of plate seen commonly at UW is the shaped at an oblique or right angle and is designed to be
reconstruction plate, which is widely used for the repair of used with subtrochanteric femoral fractures or
pelvic and calcaneal fractures. This plate (Figures 14 and supracondylar fractures of the femur. It is also occasionally
15) is fairly malleable, and can be readily shaped and used to bridge a femoral osteotomy. One arm of this device
trimmed to length for support of fractures through complex has a chisel-shaped end that is driven into the bone,
bony surfaces. These are also occasionally used for bridging the fracture. The other arm is used as a side plate
posterior fusion of the cervical spine. and anchored to the bone with multiple screws.
Figure 18. A comminuted intertrochanteric fracture of the
proximal left femur bridged by a dynamic hip screw
[http://www.file:A:/orthopedics%20hardware.htm].
Figure 17. Blade plate bridging a distal femoral fracture --
note that the distal most screw is broken, and the plate itself
is broken just above the fracture line at a screw hole -- a
broken screw fragment is also noted proximally from a
previous fixation attempt -- a channel is also noted distal to
the current blade plate secondary to a previous blade plate
There are a variety of devices used to treat femoral

fractures. The blade plate above and the Jewett nail below
are not used so commonly these days, but patients still walk
into orthopedic clinic wearing these devices every day. The
most common device used nowadays is the dynamic hip Figure 19. Parallel screw fixation of a femoral neck
screw (Figure 18). Its main design goals are to resist fracture with cannulated screws
angular deformation while permitting early fracture [http://www.file:A:/orthopedics%20hardware.htm]
impaction by allowing shortening along the axis of the lag
screw. This device is specifically designed to treat
intertrochanteric fractures, but is occasionally used to treat
subtrochanteric fractures as well. Like the blade plate, it
has a side plate that is attached to the distal femur with
several cortical screws. Rather than a blade, this plate has a
hollow metal barrel through which a large lag screw is
placed. The large lag screw is placed so that it bridges the
femoral fracture. Ideally, the lag screw should go right
down the center of the femoral neck on every radiographic
view, and its tip should be in the subchondral bone of the
femoral head. The hollow barrel of the side plate holds the Figure 20. Knowles pins bridging the right physeal line in
lag screw, and hence the femoral neck and head at an a patient with a slipped femoral capital epiphysis
anatomic angle for healing. It also allows the lag screw to [http://www.file:A:/orthopedics%20hardware.htm]
slide distally as the ends of the fracture impact and the
fracture fragments move closer together. When followed
Dynamic hip screws (DHS) are a popular device used to
over time, is quite common to see evidence of this
bridge fractures of the well-vascularized intertrochanteric
impaction as the lag screw telescopes down into the barrel
area. However, when the fracture occurs a bit more
of the side plate. The average amount of impaction seen
proximally in the femoral neck, parallel screw fixation is
with these devices is about 7 mm.
often used instead. The rationale here is that the parallel
screws (Figure 19) will cause less trauma to the tenuously
These devices can fail just like any other device. The supplied proximal head and neck fragment than a larger
cortical screws holding the side plate to the bone may come screw such as the DHS. If the screws are placed parallel to
loose. The side plate may fracture at a screw hole. The lag each other, they can allow the fragments of bone to impact
screw may perforate the articular surface of the femur. together, much as a DHS will. Knowles pins, (Figure 20)
These complications and many more await the eagle-eyed were once commonly used for this purpose, although other
radiologist. types of screws are more commonly used today.
Figure 23. Olecranon fracture bridged by cancellous screw
and tensionbandwire
Figure 21. Femoral fracture bridged by an intramedullary [http://www.file:A:/orthopedics%20hardware.htm]
nail and two cerclage wires
Another type of pin used currently at Harborview is the

percutaneous pin. They are commonly used there to treat
humeral neck fractures. These pins have a self-threading
screw tip and are placed under C-arm fluoroscopy.
4. Wires
A variety of wires are used by orthopedic surgeons. One

common type is the cerclage wire, in which the wire is
placed around the circumference of the bone to pull various
fracture fragments together. In figure 21, two cerclage
wires are used in conjunction with an intramedullary nail to
provide support for the comminuted fragments above the Figure 24. Rush rod bridging a distal fibular
transverse fracture. fracture[http://www.file:A:/orthopedics%20hardware.htm]
Yet another type of wiring seen in orthopedic surgery is This same sort of biomechanical judo is employed when
called tension band wiring (figure 21). This type of wiring the tension band wire is used with a wire or screw. In the
may be placed either by itself, as shown in the patellar example below, a fracture is seen through the olecranon
fracture below, or in conjunction with a screw or Kirschner process. In a situation like this, the triceps muscle group
wire. These tension band wires perform a sort of will exert a large force tending to pull the proximal
"biomechanical judo", in that they take the normal fragment far away from the rest of the ulna. Even when the
muscular pull that is trying to pull the fracture fragments fracture has been bridged by one or more screws, there is a
apart, and use it in a clever way to force the bony fragments tendency for these screws to be pulled out by the triceps.
together in compression. In figure 21, one can see that the The addition of a tension band wire (Figure 23) will
actual location of the tension band wire is important. If the convert some of the triceps traction into compression of the
wire is placed too far posteriorly (left drawing), the ends of the bone together and prevent the screw from
muscular pull on the wire will cause the fracture to gape pulling out.
open anteriorly (distraction). When the wires are placed far
enough anteriorly (right drawing), the muscular pull now The Kirschner or "K" wires are a very handy device in the
causes the patellar fragments to be pushed firmly together hands of the orthopedist. Besides their usage with
in compression. cannulated screws, they are used in many other ways to
help reduce and stabilize fractures. A K wire is essentially
an unthreaded segment of extruded wire, which is drilled
into bone like a drill bit. The major advantage of a K wire
is that it is very small and relatively noninvasive as
hardware goes. It can be placed through an articular surface
or even across an open physeal plate without injury. K
wires can be used for either temporary or final stabilization.
They can be placed between bones or they can be used as
an intramedullary device to bridge a fracture of a small
tubular bone. They are commonly used to help piece all of
the fragments of a comminuted fracture prior to placement
Figure 22. Patellar fracture bridged by tension band wire of the final fixation device, especially with an intraarticular
[http://www.file:A:/orthopedics%20hardware.htm] fracture.
5. Rods and Nails Subtrochanteric fractures are a particularly difficult type of
fracture to treat, and they behave very differently from a
A large variety of devices are placed down the garden-variety intertrochanteric fracture. In the latter
intramedullary canal of bones, ranging from Kirschner fracture type, a dynamic hip screw (DHS) can be used to
wires up to large femoral nails. One can generally classify merely provide angular support. Longitudinal support by
these devices by whether intramedullary reaming is the DHS is not as important in this fracture type, since the
necessary prior to placement of the device. With the first ends of the bone tend to impact against each other in a
nails placed down the femoral shaft, the medullary space stable manner. Subtrochanteric fractures, on the other hand,
first had to be reamed out so that the large nail would not put a huge stress on a DHS, especially along the sideplate.
shatter the bone as it was hammered down the shaft. For this reason, special nails such as the Zickel nail (Figure
However, reaming is an invasive procedure, and can 26) and the gamma nail have been developed. These
compromise the already tenuous blood supply of the devices are much stronger devices than the DHS, and offer
medullary space. Reaming can also lead to thermal a much shorter moment arm for rotational forces to act
osteonecrosis, especially if the medullary canal is small, a upon than the DHS. On the minus side, these nails are also
tourniquet is used during reaming, or there is marked soft more invasive.
tissue injury. If intraosseous pressure becomes elevated
during reaming, fat emboli to the lungs are possible. For
these reasons, a variety of unreamed devices have been
developed. The Rush rod (Figure 24) has a chisel-like tip,
and is commonly used for fibular shaft fractures, and
occasionally in other tubular bones as well.
Another type of unreamed nail is the Ender nail (Figure

25). These nails also have a chisel-like end. These nails are
usually used three or four at a time, and pushed through a
cortical hole up or down the shaft of the bone and across
the fracture under fluoroscopic control.
The odds-on favorite nowadays for fixation of fractures of

the femoral or tibial shaft is a reamed or unreamed nail like
the ones shown below. These nails permit early weight
bearing and can be placed with closed technique, which
avoids damage to soft tissue and to the periosteal and
muscular blood supply. If the fracture is transverse and Figure 26. Zickel nail bridging a subtrochanteric
otherwise uncomplicated (not comminuted, rotated or too fracture[http://www.file:A:/orthopedics%20hardware.htm]
near the end of the bone), the nail may be placed by itself.
However, interlocking screws are very commonly added
both proximally and distally to provide stability in cases of 6. Spinal Fixation Devices
comminution, and to prevent shortening of the bone or
rotation of the fracture fragments. When these screws are The prototypical spinal fixation device is the venerable
used, the nail is commonly referred to as an "interlocking" Harrington rod (Figure 27). These tend to come in two
nail.
Figure 25. Ender nails bridging a femoral shaft fracture Figure 27. Harrington distraction rod and compression
and an intertrochanteric fracture. rod. [http://www.file:A:/orthopedics%20hardware.htm]
Figure 31. External fixator bridging an unstable distal
radial fracture.
Figure 28. Patient with thoracic scoliosis, convex to the
right, bridged by a Harrington rod and bone graft along the Harrington and Edwards rods have been largely superseded
concave side of the spine. by other newer devices. The most common spinal fixator
[http://www.file:A:/orthopedics%20hardware.htm] that I see these days is some form of posterior spinal rod.
These rods are usually used in pairs, and are attached to
pedicular screws which are anchored in multiple vertebral
bodies above and below the site of treatment.
7. External Fixation
All things being equal, orthopedists generally prefer to treat

fractures in a closed fashion. Failing that, they would prefer
to treat them with internal fixation. However, sometimes
there are extenuating circumstances that preclude the use of
internal fixation. External fixators can be very helpful in
these circumstances.
Indications for External Fixation

Figure 28. Bilateral Edwards rods bridging a spinal
fracture. [http://www.file:A:/orthopedics%20hardware.htm] Open fracture with massive soft tissue damage.
To provide instant fixation in cases of
polytrauma.
May be the only way to treat fractures with
deficient bone stock or infection (external
fixation allows easy access to wounds).
The weak link in the external fixation system are the

threaded pins that are anchored in the bone (Figure 30).
These pins should pass through the cortex on either side of
the medullary space, and only a few millimeters of the pin
tip should ideally protrude through the distal cortex. The
usual complications of this fixation system are loosening or
infection (or both) of the pins. Lucency developing about a
pin as it travels through the cortex is evidence of loosening
of that pin. Infection is a much harder diagnosis to make
radio graphically. Long before signs of radiographic
infection develop, the orthopedist will make the diagnosis
by seeing pus oozing up along the pins as they exit the skin.
Even the presence of periosteal new bone formation about
the pin tracts is unhelpful, since these drilled holes are after
all fractures of a sort, and fractures do produce callus, even
Figure 30. External fixator bridging a tibial fracture.
without infection.
There is one late finding which is said to be pathognomonic Stainless steel is a family of iron-based alloys that must
of pin tract infection. This has been termed the "ring" contain at least 10.5% chromium and low carbon. The
sequestrum sign, although the sequestrae thus formed austenitic 316 and 316L stainless steels are corrosion
actually are shaped like cylinders, rather than rings. The resistance, therefore are widely use for implants
appearance of this finding is due to the particular geometry fabrication. Titanium alloys possess high strength, low
of a pin and pin tract, which are cylindrical in shape (Figure weight and outstanding corrosion resistance. Medical grade
31). As a pin tract becomes infected, the bone immediately titanium alloys have a significantly higher strength to
adjacent to the pin becomes infected first, and a certain weight ratio than competing stainless steels. Corrosive
amount of it dies. The viable bone adjacent to this infected resistance is not sufficient itself to suppress the bodys
dead bone then becomes hyperemic and becomes relatively reaction to the cell toxic metals or allergic elements. The
osteopenic. The infected dead bone remains at its original natural selection of titanium for implants is determined by a
density. Once the pin has been removed, if one looks combination of must immunity to corrosion.
directly down the pin tract with a radiograph, this cylinder
of dead bone looks like a "ring". Occasionally, such a There are some Internal Fixations Devices like screws,
cylinder will be dense enough to also be seen when viewed plates, wires, rods and nails and spinal fixation devices.
at 90 degrees to the pin tract, and it presents as two parallel Screws may be use by themselves to provide or in
dense lines surrounded by lucent zones. conjunction with other devices. Compression plates are
used for fractures that are stable in compression. The
SUMMARY reconstruction plate is widely used for the repair of pelvic
and calcaneal fractures. Neutralization plates are designed
Orthopedics is a branch of surgery devoted to the muscular- to protect fracture surfaces from normal bending and
skeletal system. Surgeons employ mechanical appliances, rotation. Wires are used to pull various fracture fragments
such as nails, pins, and, bolts to repair broken bones. The together. Rods and nails are placed down the
materials used for fixation are metals, polyethylene, intramedullary canal of the bone to keep them in place. The
ceramics, and bone cement. The orthopedic alloys must be spinal fixation device is the venerable Harrington rod used
very strong, not stiff, and biocompatible and not wear off. to straight up the spine.
Some metal alloys too are cobalt-chrome alloys, titanium
alloys, and stainless steal steel alloys. These alloys may ACKNOWLEDGEMENTS
evoke allergic reaction in patients: skin rash. All modern
alloys are strong enough to resist fatigue fractures of the
modern prosthetic shafts had occurred in heavy patients. We wish especially to thank Prof. Megh R. Goyal, Prof.
That is why manufacturers have also developed bulky Freya Toledo. To all ours friends that in a way or another
models of artificial joints with larger dimension for help us in this project.
heavyweight patients.
REFERENCES
The alloys used for the fabrication of the shaft are much
stiffer than the skeleton of the thighbone. The shielded 1. Agency for Toxic Substances and Disease Registry
bone does not thrive, loses its substance and becomes (ATSDR). 2001. Toxicological profile for cobalt.
weak. The remedy is a prosthetic shaft manufactured from Draft for Public Comment. Atlanta, GA: U.S.
metal alloys with stiffness similar to the bone. The latest Department of Health and Human Services, Public
technique for less stiff is the Trabecular Metal Technology Health Service.
(a metallic sponge) that has about the same stiffness as 2. Balik, K. and Sochor, M. Engineering of
bone. Biomaterials 1999. J. of UMM
Cracow, Poland, 8-10.
Metallic surfaces in contact with body fluids corrode. The 3. Pesakova, V., Klezl, Z., Balik, K.and Adam M. 2000.
dissolved metals enter in to circulation and the Journal of Materials Science:
concentration of the metals in the blood increases. The Materials in Medicine, 11: 793-798.
corrosion may occur when two dissimilar metals are in 4. Burri, C.1975. Post-traumatic osteomyelitis. Zurich:
contact. Ultra-High Molecular Weight Polyethylene is the Hans Huber.
current material of choice for use as bearing surface in total 5. Hall, B.B., Rosenblatt, J.E. and Fitzgerald R.H. 1984.
joint prostheses. The mechanical properties of polyethylene Anaerobic septic arthritis and osteomyelitis.
improve slowly with raising molecular weight of the Orthopedic Clinics of North America, 15:50516.
product. The wear of the polyethylene is not a perfect 6. http:// www.matweb.com/
material; it is subject to fatigue failure. 7. http://www.totaljoints.info/cross_linking_PE.jpg
8. http://www.ssina.com/chem.htm
9. Jawetz, E., Melnick J.L., Adelberg E.A., 1991. Jawetz,
The ceramic uses for joints surface are solid materials Melnick and Adelbergs medical microbiology, 19th
compose only of pure crystals of aluminum or zirconium ed. Philadelphia: Appleton and Lange.
oxides. They are intent, stiff, strong and hard. The bone 10. Kamme, C. 1974. Anaerobic bacteria in late infection
cement consist of 90 % of polymethylmetacrylate, the rest after total hip arthroplasty. Scandinavian Journal of
mainly crystals of barium sulfate that make the resulting Infectious Disease, 6:1615.
product radio-opaque. It acts like filler.
11. Mousa, H.A., Bakr S.S. and Hamdan T.A. 1996.
Anaerobic osteomyelitis. Eastern Mediterranean
Health Journal, 2:494500.
12. Mousa, H.A. 1997. Evaluation of sinus-track cultures
in chronic bone infection. Journal of Bone and Joint
surgery. (British volume), 79(4):5679.
13. Nguyen, V.D., London J. and Cone, R.O. 1986. Ring
sequestrum: radiographic characteristics of skeletal
fixation pin-tract osteomyelitis. Radiology, 158:129-
131
14. Nelson, J.P. 1997. Deep infection following total hip
arthroplasty. Journal of bone and joint surgery,
59A:10424.
15. Templeton, W.C. 1983. Anaerobic osteomyelitis of
long bones. Reviews of Infectious Diseases, 5:692
712.
16. Zimer.2001.Implex Technology. J.B.A, octuber
GLOSSARY
1. Amputations - surgical removal of a limb or other

outgrowth of the body. This may be necessary due to
severe injury, blood vessel disease, cancer or infection.
2. Biocompatible = to be well tolerated by the tissues of
the patient's body.
3. External and internal fixations - methods to hold
broken bones in correct placement for healing are
termed fixations. When the screws, rods, plates and
such are confined within the body, it is called an
internal fixation. If rods, pins or other stabilizing
apparatus extend externally, then it is know as as
external fixation.
4. Hip replacements - the hip joint is reconstructed with
a plastic cup inserted into the hip bone, a metal ball
which fits into the cup socket and a rod that extends
from the ball into the leg bone.
APENDIX I: NUMERICAL EXERCISES
Exercise 1 Exercise 2
Doctors are going to use a Zirconiums plate to restore the Find the elongation of the plate made of titanium that has a
fracture in the legs bone. The leg weights approximately length of 0.35 mm and have an area of 1.40 mm2 and the
20 lb. constant of proportionally is 1700 ksi.
P1 P2 P3
A B C D
NAB P1 P2
P2
NBC
NCD
A = 1.40 mm2
E = 1700 Ksi
P1 = 3 lb
P2 = 3 lb
P3 = 7 lb
NAB = -P1 + P2 + P3 = -3 + 3 + 7 = 7 lb
a. What is the strees in the Zirconiums plate if it
has an area of 1.5x2 in2? NBC = P2 + P3 = 3 + 7 = 10 lb
= P/A = 120lb/3in2 = 6.67 psi NCD = P3 = 7 lb
b. What is the strain in the plate? Displacement of beam AD at end D
= /E AD = AB + BC =
= 6.67 psi/(13700x1000)psi = L/AE [ NAB + NBC + NCD]

-7
= 4.87 x10 = 0.35/ ( 1.4)(17 x 106)[7 +10 +7]
c. What is the allowable weight of the leg if tensile AD = 24 [0.35 mm/(1.4)(7 x 106]
yield stress (YTS) is 33,400 psi?
AD = 8.57 x 10-7 mm
P = yA
= (33,400 psi)(3 in2)
= 99,000 lb
Exercise 3 Exercise 4
Femoral fracture bridged by an intramedullary nail and two Material = titanium

cerclage wires. Under this picture you will see a free body
diagram of this nail. Find the Shear force (V) and the Rpm = 80 rev / min
Bending Moment (M).
P= 30 lb-ft / seg
a. Find torque:
P = T T=P/
T = (30 lb-ft / seg * 60 seg) / 80
= 1800 lb-ft / 80
= 22.5 lb-ft
b. Find diameter:
= T(d /2) / I
= T(d/2) / (d^4/32)
a. Reactions: 33.75 = 22.5(d/2) / (d^4/32)
RB = qb (b + 2a) d permitible = 0.18
MB = q (b + 2a) 2 / 2 Factor of safety = 2= y /
b. Shear Force and Bending Moment: y=135 /2
V = RB qx xam =33.75isp
= qb (b + 2a) q (x a)
M = RB x qx (x / 2)
= qb (b + 2a)x - q (x2 c) / 2
Mmax = qb (2L b) / 8

D 04 Orthopaedic Fixations

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D 04 Orthopaedic Fixations

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We are the protagonists of our lives

BIOMECHANICS OF ORTHOPAEDIC FIXATIONS1

1 Metal allergy in patients with total joints

Corrosion resistance Ultra-High Molecular Weight Polyethylene (UHMWPE) is

The plate of warm spaghetti looks like a couple of

The wear resistance of irradiated material in a hip simulator

4 Mrad the maximal radiation dose used for

10 Mrad the maximal dose used for cross-linking

The main problem of the UHMWPE is wear UHMWPE

All new developments of UHMWPE have a common goal

c. The cross-linking of the polyethylene

The cross-linked UHMWPE has been introduced in clinical

The mechanism of cross-linking involves the knocking an

Recent published reports [Heisel 2003] demonstrate that in

e. THP (Stem Type) with Acrylic Cement Fixation

In 1962, Sir John Charnley used a small (22 mm) stainless

f. THP (Stem Type) without Cement Fixation

We are now in an era with widespread use of devices which

Hydrogen f. Passivation with inhibitors

Penetration Diffusion of hydrogen into titanium is very 1. Hydrofluoric acid

3. Excellent erosion resistance 7. Excellent fire resistance

External Fixation Devices

The natural selection of titanium for implantation is

Fracture compression increases the contact area across the

Screws may be used by themselves to provide fixation or in

Figure 7. Cortical, cancellous and cannulated screws.

Properties Units Stainless Steel 1 Zirconium 2 Cobalt 2 2

Poissons Ratio N/A 0.305 0.34 0.31 0.32

Youngs Modulus GPa 196 94.5 94.5 120

Another specialty screw occasionally seen is the

Since screw holes weaken bones and orthopedic hardware,

Figure 12. Under surface of a low contact dynamic

Figure 13. Low contact dynamic compression (LCDC)

There are a variety of devices used to treat femoral

Another type of pin used currently at Harborview is the

A variety of wires are used by orthopedic surgeons. One

Another type of unreamed nail is the Ender nail (Figure

The odds-on favorite nowadays for fixation of fractures of

All things being equal, orthopedists generally prefer to treat

Indications for External Fixation

The weak link in the external fixation system are the

1. Amputations - surgical removal of a limb or other

= P/A = 120lb/3in2 = 6.67 psi NCD = P3 = 7 lb

b. What is the strain in the plate? Displacement of beam AD at end D

= 6.67 psi/(13700x1000)psi = L/AE [ NAB + NBC + NCD]

= (33,400 psi)(3 in2)

Femoral fracture bridged by an intramedullary nail and two Material = titanium

T = (30 lb-ft / seg * 60 seg) / 80

a. Reactions: 33.75 = 22.5(d/2) / (d^4/32)

RB = qb (b + 2a) d permitible = 0.18

MB = q (b + 2a) 2 / 2 Factor of safety = 2= y /

b. Shear Force and Bending Moment: y=135 /2

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