Biomechanical implant fixation of CoCrMo coating inferior
to titanium coating in a canine implant model
Stig S. Jakobsen, Jorgen Baas, Thomas Jakobsen, Kjeld Soballe
Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Norrebrogade 44,
Build. 1a., 8000 Aarhus C, Denmark
Received 26 November 2008; revised 9 September 2009; accepted 2 October 2009
Published online 2 February 2010 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jbm.a.32709
Abstract: The use of CoCrMo in orthopedic surgery is
not new, and CoCrMo (cobalt–chromium–molybdenum) is
well tolerated. Nevertheless, the alloy is still considered
less biocompatible than titanium. We therefore wanted to
explore the biocompatibility of CoCrMo by investigating
the biomechanical implant fixation and implant osseointe-
gration of CoCrMo (ASTM F-75) porous bead-coated and
titanium (ASTM F-136) porous bead-coated implants. In 10
dogs, the two implant types were inserted into the proxi-
mal part of the humerus. Implant sites were overdrilled,
leaving an empty 0.75-mm gap between implant and sur-
rounding bone. The implants were observed for 6 weeks
and were evaluated by biomechanical push-out test and
histomorphometry. We found a statistically significant 40%
decrease in the biomechanical fixation of CoCrMo porous
bead-coated implants compared with titanium porous
bead-coated implants. Implant osseointegration was com-
parable between the two implants; however, a slight
INTRODUCTION
Metal-on-metal hip bearings made of CoCrMo
(cobalt–chromium–molybdenum) alloy possess excel-
lent wear properties1–4 and are a tempting choice for
young and active patients. The use of CoCrMo in or-
thopedic surgery is not new,5 and CoCrMo is well
tolerated.6 Nevertheless, the alloy is still considered
less biocompatible than titanium,7 and on grit-
blasted surfaces implant fixation has previously been
reported to be poorer for CoCrMo alloys versus
titanium alloys.7,8 Bead-coated CoCrMo implants,
however, performed well compared with grit-blasted
titanium implants, leaving the question open ‘‘how
Correspondence to: S. S. Jakobsen; e-mail: stig.jakobsen@
ki.au.dk
Contract grant sponsor: DePuy Orthopaedics, Inc., Warsaw,
IN, USA
Ó 2010 Wiley Periodicals, Inc.
decrease in bone volume density around CoCrMo implants
was observed. Insertions of CoCrMo implants are associ-
ated with a disturbance of the delicate peri-implant milieu.
Even from implants not subjected to any mechanical
forces, metal ions are liberated and result in intra- and
extracellular accumulation in the immediate implant vicin-
ity, presenting a likely explanation for our findings. A 40%
reduction of initial implant fixation could prove to be seri-
ous because initial implant fixation is critical for long-term
performance. The choice between titanium alloy and
CoCrMo should, however, ultimately be governed by a
comprehensive review of all factors influencing clinical
implant survival. Ó 2010 Wiley Periodicals, Inc. J Biomed
Mater Res 94A: 180–186, 2010
Key words: biocompatibility; CoCrMo; titanium; osseo-
integration; implant fixation
will bead-coated CoCrMo perform compared with
bead-coated titanium implants?’’9
The increasing use of metal-on-metal and hip resur-
facing implants has exposed many patients to
CoCrMo and heightened concerns about toxicity.
Adverse effects from CoCrMo could be observed as a
result of the released metal ions (Cr3þ, Co2þ, Ni2þ,
Cr6þ), and nanosized wear particles [oxides (Cr2O3,
CoO, Al2O3), hydroxides (CrOH3, CoOH2, etc), and
metals (CoCrMo)] released from the implants.2,10–13
The large amount of metal nanoparticles and the pre-
sumed high levels of metal ions in the tissues sur-
rounding hip prostheses have raised concerns regard-
ing carcinogenicity,14,15 hypersensitivity,16 local tissue
toxicity,17 inflammation,18 and genotoxicity.19
CoCrMo implant surfaces and metal debris may
also be involved in the complex cellular and molecu-
lar response in osseous wound healing by inducing
cytokine response20,21 and affecting proliferation
and necrosis/apoptosis.22,23 Metal ions can theoreti-
cally be released due to mechanically wear (mainly
bearing surfaces), or to macrophage-dependent
BIOMECHANICAL IMPLANT FIXATION IN A CANINE IMPLANT MODEL
Figure 1. X-ray films of implant positioning sites. The two implant types were inserted in the cancellous bone (CoCrMo
porous bead-coated and titanium porous bead-coated implants). [Color figure can be viewed in the online issue, which is
available at www.interscience.wiley.com.]
dissolution of wear debris and implant surface.24
Implants not subjected to any mechanical stress will
still release metal ions that affect local tissue24–26 and
accumulate in more distant organs such as liver and
kidney.27 In the peri-implant space, metal ions can
influence cells involved in the complex cellular and
molecular response in osseous wound healing. In
osseous wound healing, several cell types, including
osteoblasts, osteoclasts, and macrophages, all play
pivotal roles because of their ability to affect the
healing response in a deleterious way, essentially
making an implant fail.
We hypothesized that titanium porous bead-
coated implants would prove a superior overall
implant fixation compared with CoCrMo porous
bead-coated implants. The purpose of this study was
to investigate biomechanical implant fixation, tissue-
to-implant contact, and tissue density around
CoCrMo porous bead-coated and titanium porous
bead-coated implants.
MATERIALS AND METHODS
Design
The study was designed as an animal experiment with
10 skeletally mature Labrador dogs. Mean body weight
was 32.3 kg (25–39 kg). The two implant types were
181
inserted into the cancellous bone and systematically
rotated, with a random start, between implant sites (prox-
imal, distal, left, and right) (Fig. 1). Approval was obtained
from our Institutional Animal Care and Use Committee
prior to performing the study. Based on previous experi-
ments in comparable models and an estimated clinically
significant difference, standard deviation was set to 50%
and MIREDIF to 50%. Significance level was set to 0.05
and power 0.8. Based on the formula n 5 2(t2a þ tb)28
SD2/MIREDIF2 5 7.84, 10 animals should be included,
allowing for a few drop-outs.
Animals and surgical procedure
Under sevoflurane general anesthesia, using sterile tech-
nique, the proximal part of humerus was exposed through
a lateral extraarticular approach. Two Kirschner (K) wires
were inserted perpendicular to the surface 17 mm apart.
The most proximal K wire was inserted at the level of the
greater tubercle. The K wires were used to guide a 7.5-mm
canulated drill making a 13.0-mm-deep hole. To create a
0.75-mm gap between implant and surrounding bone,
overdrilling was performed. The top washer and the foot-
plate centralized the implant in the hole (Figs. 1 and 2).
Drilling was performed at two rotations per second to pre-
vent thermal trauma to the bone. All bone debris and soft
tissue were removed from the drill hole, and the implant
with the footplate mounted was inserted, leaving the gap
between implants and bone tissue empty. Finally, the top
washer was mounted and soft tissue closed in layers. Pre-
and postoperatively, the dogs were given one dose of
Journal of Biomedical Materials Research Part A
182
Figure 2. Schematic overview. (a) Bone. (b) Marrow. [Color figure can be viewed in the online issue, which is available
at www.interscience.wiley.com.]
cefuroxim, 1.5 g intravenously, as antibiotic prophylaxis. A
fentanyl transdermal patch (75 lg/h) lasting 3 days was
given as postoperative analgesic treatment. The dogs were
allowed full weight bearing postoperatively.
The implants
Cylindrical porous bead-coated implants were made of
titanium alloy (Ti-6Al-4V, ASTM F-136) and CoCrMo alloy
(ASTM F-75) with a nominal diameter of 6.0 mm and
length of 10.0 mm (DePuy Orthopaedics, Warsaw, IN).
The PoroCoat1 porous coating obtained by sintering
spherical beads has an average pore size of 250–300 lm
and porosity range of 40–50%. The average thickness of
the porous bead coating was 0.75 mm. The implants were
passivated (ASTM A967-05), packaged separately, and
gamma sterilized.
Specimen preparation
After 6 weeks’ observation, the animals were sacrificed
with an overdose of hypersaturated barbiturate, and the
proximal part of humerus was excised and cleaned and
thereafter stored at 2208C. The outermost 0.5 mm of the
implant-bone specimen was cut off and discarded. The
rest of the implant with surrounding bone was divided
into two sections perpendicular to the long axis of the
implant with a water-cooled silicon carbide cut-off wheel
(Accutom-50, Stuers A/S, Rødovre, Denmark). The outer-
most section was cut to a thickness of 3.0 mm and stored
at 2208C pending biomechanical testing.29 The innermost
Journal of Biomedical Materials Research Part A
JAKOBSEN ET AL.
section of 6.5 mm was prepared for histomorphometry.
The specimens were dehydrated in graded ethanol
(70–100%) containing basic fuchsin and embedded in
methylmetacrylate (Technovit 7200 VCL; Exact Apparat-
bau, Nordenstedt, Germany). Four vertical, uniform, ran-
dom sections were cut with a hard-tissue microtome
(KDG-95; MeProTech, Heerhugowaard, The Netherlands)
around the center part of each implant as described by
Overgaard et al.30 parallel to the natural vertical axis of
the implant. The 50-lm sections were counterstained with
2% light green (BDH Laboratory Supplies, Poole, UK) and
then mounted on glass.31 This preparation provides red
staining of noncalcified tissue and green staining of calci-
fied tissues, such as woven and lamellar bone.
Biomechanical testing
Implants were tested to failure by blinded axial push-
out test on a MTS Bionics Test Machine (Instrom, High
Wycombe, UK). The specimens were placed on a metal
support jig with a 7.4-mm diameter central opening. The
implant was centralized over the opening, thereby assur-
ing a 0.7-mm distance between the implant and the sup-
port jig as recommended by Dhert et al.32 The direction of
loading was from the cortical surface inward. A preload of
2 N was applied to standardize contact conditions before
initiating loading. We used a displacement rate of
5 mm/min with a 2500 N load cell. Load and deformation
were registered by a personal computer. Each specimen’s
length and diameter were measured with a micrometer
and used to normalize push-out parameters. Ultimate
shear strength (MPa) was determined from the maximal
BIOMECHANICAL IMPLANT FIXATION IN A CANINE IMPLANT MODEL
TABLE I
Reproducibility of Histomorphometry
Fibrous Tissue Bone (New)
Zone 1 (a) 3% 15%
Zone 2 (v) 47% 7%
Zone 2 (a) 55% 3%
Variation coefficient (CV %).
All the variations are well below the expected range.
The large CV % on fibrous tissue in zone 2 is caused by a
low absolute amount of fibrous tissue here. The very low
CV % from zone 1 confirms the fact that it is possible to
readily identify fibrous tissue.
force applied until failure of the bone-implant interface.
Apparent stiffness (MPa/mm) was obtained from the
slope of the linear section of the curve. Energy absorption
(J/m2) was calculated from the area beneath the curve
until failure. All push-out parameters were normalized by
the cylindrical surface area of the transverse implant sec-
tion tested.33
Histological evaluation
Blinded histomorphometrical analysis was done using a
stereological software program (CAST-grid Olympus
Denmark A/S, Ballerup, Denmark). Fields of vision from a
light microscope were captured on a computer monitor,
and a user-specified grid was superimposed on the micro-
scopic fields. Four vertical sections representative of each
implant were analyzed and cumulated.30,34 The specimen
preparation procedure and the grid system made it possi-
ble to calculate unbiased estimates even though anisotropy
in cancellous bone exists.
With the aid of the software, we defined two regions of
interest: A zone 1 from implant core surface and 250 lm
outward, and a zone 2 from a line between the core
implant and ‘‘the outermost implant bead’’ and 750 lm
outward (Fig. 2).
In zones 1 and 2, tissue-implant contact was defined as
the fraction of the implant surface covered with a particu-
lar tissue (bone, fibrous tissue, marrow space) and esti-
mated using sine-weighted lines.34 In zone 2, tissue
volume fractions were estimated by point counting.35,36
Double measurements were carried out to calculate the
intraobserver variation. The measurements were carried
out by the same person using identical equipment and
P 2
setup. The CE was calculated as: S25 (1/(2k)) d , where
TABLE II
Biomechanical Implant Fixation
Biomechanical Maximum Shear
Parameters Strength (MPa)
CoCrMo PC 2.37 [1.50–3.24]
Titanium PC 4.15 [2.48–5.82]
p 5 0.04
Data are presented as mean with 95% CI.
183
k is the number of double measurements and d is the
difference between the first and second assessments. Then,
CV % is calculated as follows: CV % 5 (s/x) 100, where x
is the mean value of the first and second assessments
(Table I).
Statistics
Histological and biomechanical data were analyzed with
two-way ANOVA with regard to implant position (upper–
lower) and group (CoCr PC and titanium PC). When a
statistically significant difference was found within the
groups, a Student’s t test comparison of the groups fol-
lowed. The data were presented as means with 95% confi-
dence intervals (CIs), and p values less than 0.05 were con-
sidered statistically significant.
RESULTS
No postoperative complications were seen, and all
dogs were fully weight bearing within 3 days of sur-
gery. All animals completed the 6-week observation
period. At the implant sites, there were no clinical
signs of infection.
Biomechanical results
We found a decrease in maximum shear strength
(43%), total energy absorption (41%), and maximum
shear stiffness (44%). By gross observation, both
implant groups were well anchored in the bone, but
the titanium PC implants had better biomechanical
fixation than the CoCrMo implants in all parameters
(Table II).
Histological results
Surprisingly, we did not observe any statistically
significant differences between titanium PC and
CoCr PC (Fig. 3). We observed a tendency toward
decreased bone tissue coverage and increased
fibrous tissue coverage in zone 1 for titanium
implants. The formation of new bone in the gap was
comparable between the implants, and almost no
Total Energy Maximum
Absorption Shear Stiffness
(kJ/m2) (MPa/mm)
0.39 [0.27–0.50] 12.14 [7.20–17.08]
0.66 [0.41–0.91] 21.61 [12.34–30.88]
p 5 0.01 p 5 0.04
Journal of Biomedical Materials Research Part A
184 JAKOBSEN ET AL.

Figure 3. Representative photomicrographs of 50-lm sections from the same animal. The samples were stained with ba-
sic fuchsin and counterstained with 2% light green. Implant appears as black, marrow as red, and bone as green. Note
that no obvious difference between titanium (A, B) and CoCrMo (C, D) exists. [Color figure can be viewed in the online
issue, which is available at www.interscience.wiley.com.]

fibrous tissue was formed (zone 2). Results of the all implants were put into the healthy bone of young
histological analysis are given in Table III. dogs. The model lacks clinically relevant influences
like joint fluid pressure and direct load. This is, how-
ever, a basic experimental model that is more con-
DISCUSSION trolled than other weight-bearing models.33
Dissoluted metal ions from the implant surface are
The purpose of this study was to investigate the known to affect peri-implant cells, osteoblasts in
biocompatibility of CoCrMo porous bead-coated and particular.24,26 MG-3 osteoblast, fibroblasts, and lym-
titanium porous bead-coated implants by evaluating phocytes proliferation is susceptible to metal ions,
biomechanical implant fixation and implant osseo- particularly those of vanadium, nickel, and cobalt.23
integration. Apoptosis and/or necrosis is induced in a wide
We found a statistically significant decrease (p 5 range of cells by metal ions liberated from implant
0.04, p 5 0.01, p 5 0.04) in biomechanical fixation for
CoCrMo porous bead-coated implants compared TABLE III
with titanium porous bead-coated implants, but with Histological Results
comparable histological parameters.
Bone (New) Fibrous Tissue
Our experimental 0.75-mm gap model was
designed to imitate the close interaction between Zone 1 (2250 to 0 lm)
cementless joint replacement alloys and bone form- Area fractions in percent
ing/remodeling processes in cancellous bone. We CoCrMo PC 6.8 [3.5–10.1] 64.7 [52.5–76.9]
Titanium PC 4.3 [1.8–7.5] 71.8 [57.5–86.1]
used a clinically well-proven implant coating for p 5 0.10 p 5 0.26
uncemented implants, PoroCoat1, where the only Zone 2 (0–750 lm)
difference between the coatings was the metal com- Area fractions in percent
position. Canine cancellous epiphyseal bone was CoCrMo PC 15.6 [10.6–20.6] 3.6 [0.9–6.3]
chosen because of its close resemblance to the bone Titanium PC 16.2 [11.2–21.2] 8.4 [0.7–16.7]
p 5 0.93 p 5 0.20
into which cementless joint replacements are usually Zone 2 (0–750 lm)
implanted. Canine bone reflects the composition, Volume fractions in percent
density, and quality of human bone better than does CoCrMo PC 18.2 [12.5–23.9] 0.38 [0–0.9]
that of most other animals.37 No animal model, how- Titanium PC 21.0 [13.8–28.2] 1.38 [0–4.1]
ever, gives complete information about the effect of p 5 0.57 p 5 0.21
a given alloy on human osteogenesis. Canine bone Data are presented as mean with 95% CI. None of the
remodels much faster than does human bone, and comparisons was statistically significant. n 5 10.

Journal of Biomedical Materials Research Part A

BIOMECHANICAL IMPLANT FIXATION IN A CANINE IMPLANT MODEL
material.38 Released Co and V are more cytotoxic12
than Al, Fe, Cr, and Mo; however, these ions seem
to suppress osteoblast proliferation more than fibro-
blast proliferation.23 Furthermore, Puleo et al. dem-
onstrated that osteoblasts grow faster on titanium
alloy than on CoCrMo-alloy.39 Finally, Baldwin and
Hunt demonstrated a sustained proinflammatory
response by CoCr alloy in a soft tissue model, and
Jinno et al. demonstrated an inferior implant fixation
of grit-blasted CoCr implants compared with grit-
blasted titanium implants. Based on these results, an
expected outcome would be inferior overall perform-
ance of CoCrMo implants compared with titanium
implants.
We found that the biomechanical fixation of the
CoCrMo porous-coated implants was 40% lower
than the titanium porous-coated implants, but bone-
to-implant contact was comparable. This is consistent
with a previous report in which only biomechanical
fixation and not osseointegration was affected by
grit-blasted CoCrMo surfaces.8 The lack of difference
in terms of bone-implant contact and peri-implant
bone volume could be explained by either a
decreased intimate bone-implant adhesion on a sub-
microscopic level or by a decreased bone quality.
Coating the implant surface with hydroxyapatite
reverses the negative effect of CoCrMo on implant
fixation compared with titanium implants coated
with hydroxyapatite, further incriminating CoCrMo
surfaces.40 Secretion of extracellular matrix proteins
and mineralization have previously been shown to
be decreased by CoCrMo alloy compared with tita-
nium, potentially creating a weak bone quality and/
or bone-implant interface.28 Moreover, the released
levels of metal ions may be too low to induce detect-
able changes in bone density, but large enough to
affect the bone-implant interface or the bone quality.
Previously, research has suggested that a threshold
level must be reached (Co—0.8 mM for both fibro-
blasts and osteoblasts; V—0.1 and 0.4 mM, respec-
tively) to negatively influence cells.23
If a significant metal ion concentration gradient
from the implant and outward existed, we would
expect that fibrous tissue area fraction would increase
and the bone tissue area fraction would decrease in
the deep porosity. We observed a tendency toward
decreased bone tissue coverage and increased fibrous
tissue coverage in zone 1 for titanium implants. This
may reflect the fact that implant made of TiAlV alloy
can potentially release V and Al with negative effects
on peri-implant cells.23 Moreover, in both groups, less
bone tissue (area fraction) and more fibrous tissue
were detected in zone 1 compared with zone 2 (p <
0.01, two-way ANOVA), which may also be a sign of
a concentration gradient.
In clinical practice, a small, but mechanically very
important portion (10–20%) of the uncemented
185
press-fit implant surface is in bone contact.41 We
believe that an implants ability to provide early, sta-
ble, and osseous fixation is important and predictive
of implant survival, as indicated by numerous radio
stereometric analysis studies.42,43 In this regard, our
results show that CoCrMo is inferior to titanium,
and to determine the exact failure mechanism for
CoCrMo implants the bone-implant interface must
be studied on a submicroscopically level. The mate-
rial composition of an implant also determines other
important properties, such as elastic modulus and
wear resistance, which were not subject to evaluation
in this model. The choice between titanium alloy
and CoCrMo should ultimately be governed by a
comprehensive review of all factors influencing clini-
cal implant survival.
CONCLUSIONS
We found a statistically significant 40% decrease
in the biomechanical fixation of CoCrMo porous
bead-coated implants compared with titanium po-
rous bead-coated implants. Insertions of CoCrMo
implants are associated with a disturbance of the
delicate peri-implant milieu, presenting a likely ex-
planation for our findings. A 40% reduction in initial
implant fixation could prove to be serious problem
because initial implant fixation is critical for long-
term performance.
The authors thank laboratory technicians Jane Pauli and
Annette Milton for excellent laboratory work with the his-
tological sections and Niels Trolle Andersen for valuable
guidance with statistics.
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