Ceramic Surface Engineered Metal-on-Metal

Hips system for Total Hip Arthroplasty and

Resurfacing
Ceramic Surface Hip Arthroplasty
Engineered Metal-on-Metal The
The design rationale, pre-clinical testing
and interim report on 2- 7 years of clinical results
By Karel J Hamelynck MD PhD and Ron G. Woering

The ACCIS®system for total hip arthroplasty (THA) and resurfacing hip arthroplasty (RHA) consists of metal
components for the reconstruction of the acetabulum and metal femoral head components for conventional
THA and RHA. The ACCIS®metal components are made of a chrome-cobalt-molybdenum alloy, but are differ-
ent from other metal-on-metal prostheses. The surfaces of the metal components are engineered with the
ceramic Titanium-Niobium-Nitride (TiNbN) in order to minimize metal particulate wear, to prevent corrosion
and to prevent metal ion release.

introduction lubrication at the dome of the articulation and wide enough to

In the recent past metal-on-metal hip arthroplasty has
attracted the renewed interest of the orthopedic world, when
polyethylene wear and subsequent osteolysis were recognized
as important causes of failure of hip implants (1-3) and excellent
long term results of some original metal-on-metal prostheses
without any obvious wear and without osteolysis were
demonstrated (4). New prostheses were designed with a metal-
on-metal articulation and 28 mm femoral heads (5).
An old dream of “surface replacement” in the hip became a
reality when metal was used for material, resulting in minimal
bone resection of the acetabular and femoral side (6).
The larger diameter of the femoral head provided the hip joint
with improved stability and increased range of motion (7-9).
As a result of the early success of surface replacement hip
arthroplasty total hip systems were also designed with large
femoral heads.
metal particles
So far the good story. Soon after the introduction of new
metal-on-metal hip prostheses serious concerns about the
presence of metal degradation products in or near the hip
joint or disseminated into the body were expressed in the
literature(10). It became clear that metal-on-metal articulations,
despite the fact that the volumetric wear is less, may generate
more wear particles (3,4). Metal wear particles, much smaller
than polyethylene particles can be ingested by histiocytes
and macrophages and may become biologically active (11,12).
Tumour-like proliferations of soft tissues around the hip were
reported. (13-18).
fixation of all metal acetabular components
Lack of fixation of the acetabular component was a frequent
complication of the original metal-on-metal hip prostheses and
is a remaining problem today. The problem was then caused by
a variety of reasons: insufficient surgery, impingement by the
femoral neck, deformation of the sometimes very thin cup and
high frictional torques caused by insufficient clearance between
the femoral and acetabular component especially at the equator.
Today with improved manufacturing capabilities clearances
can be made small enough to allow fluid film or mixed
prevent equatorial impingement. Current mechanical loosening
is probably caused by insufficient primary fixation. Most cup
designs are spherical. These spherical cups run the considerable
risk of being pushed out of the acetabulum due to forces around
the whole cup after impaction, called “the rebound effect”
Press fit fixation by equatorial over-sizing as seen in cups with
a three radial design is enhanced by compression forces only
and is probably more reliable.
metal ion release
Metal bearings corrode at a rate determined by their surface
area and cause a release of metal ions. When wear particles
are being formed, the total surface area of metal is increased
considerably. These ions may attach to proteins and cause
allergic reactions (1,19-21). Hypersensitivity reactions of
surrounding tissues were described. (22-25). High blood levels
of chrome and cobalt were found in patients with metal-on-
metal prostheses and changes in red and white blood cells have
been reported (24,26-43). High metal ion levels are important,
knowing the fact that chrome and cobalt may cause cancer and
may be mutagenic although investigations are not conclusive
about the relation with orthopedic implants (43,44).
conclusion
Despite the fact that metal surfaces of prosthetic components
for total hip replacement demonstrate less wear than surfaces
of polyethylene, there is sufficient reason to try and reduce
wear of metal components further, because a relatively high
amount of submicron size metal particles is generated, that may
become biologically active and may jeopardize the success of
the implant.
A treatment to prevent corrosion of the metal surfaces is also
needed in order to inhibit the formation of free metallic ions,
which will be disseminated into the body with unknown
effects. The mere presence of un-physiologically high serum
levels of cobalt and chromium in the blood of patients after
metal-on-metal hip arthroplasty remains a matter of concern.
The question is “Can we take the risk of using metal-on-
metal prostheses knowing that increase of metal ion levels is
a fact?”

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Ceramic Surface Engineered Metal-on-Metal Hips system for Total Hip Arthroplasty and Resurfacing Hip Arthroplasty

The ACCIS®prosthesis system Preventing rebound :

The ACCIS®hip prosthesis system for conventional total hip
arthroplasty and surface replacement arthroplasty is especially
designed to overcome the possible disadvantages of metal-on-
metal articulations.
The press fit fixation by equatorial over-sizing is different from
the fixation principle of over-sizing with spherical cups. While
spherical cups run the considerable risk of being pushed out of
the acetabulum due to the forces around the whole cup, called
the rebound effect (46) , fixation of cups with equatorial

Fig. 2: ACCIS®Triple Radius Design

over -sizing is enhanced by compression forces only (figure 3).

Fig. 1: ACCIS®Resurfacing Hip assembled Two fins are added near the equator of the ACCIS®acetabular
components to support rotational stability (arrow in figure 2 ).
Manufacturing of the ACCIS®components The cup coverage angle is incrementing from 9.31mm, for the
The ACCIS®prosthetic components are manufactured from small size acetabular component 42mm (which is seldom used),
hi-carbon cobalt-chrome-molybdenum alloy according to till 16.24mm, for the larger component with the cup size 64 mm.
the ISO standard 5832-4. The components are casted, cooled
and then undergo a heat treatment. During the heat treatment
block-carbides, which are found at the metal surfaces of the
components and may cause abrasive wear in metal-on-metal
prostheses, are reduced in number and size. After heat treatment
the surfaces are polished. The next step in manufacturing is a
very important one: surface micro finish. After this treatment
the components are completely smooth, any remaining
asperities are at nanometer level. At this point the surfaces of
the ACCIS®prosthesis undergo another treatment: surface
engineering using the ceramic Titanium-Niobium-Nitride.
The TiNbN is integrated into the metal surfaces by physical
vapor deposition (PVD). The value of PVD technology lies in
its ability to modify the surface properties of a device without
changing the underlying material properties and biomechanical
functionality. In addition to enhanced wear resistance, PVD Fig. 3 The rebound forces in a hemispherical design (left)
coatings reduce friction, are compatible with sterilization and an equatorial press-fit design (right)
processes and improve corrosion resistance.
The outside of the cup is coated with a plasma spray of pure
Titanium (cpTi) according to the ISO standard 5832-2.
Acetabular components for THA and RHA: The pore diameter is 75-350 micron, the coating thickness
The acetabular cup has a tri-radial outside geometry (fig. 2). 300 +/- 50 micron and the roughness RA is 50 micron.
The main sphere (b) is purely spherical. At the pole (a) there
is a small area which is relatively flat (has a smaller radial The solidity of the fixation is specified as Rh = 45 MPa, while a
diameter). Near the equator (c) the cup is incrementally widened minimal strength of 22 MPa is required according to the “FDA-
1.6 – 2.1 mm. This equatorial oversizing provides excellent Guidance for the industry”.
press fit fixation provided the cup is well surrounded by pelvic The metal surface of the inner side of the acetabular component
bone. There will be line-to-line contact between the large is engineered with the ceramic TiNbN by PVD.
middle sphere of the cup providing excellent circumstances for
secondary bone in-growth.

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The design rationale, pre-clinical testing and interim report on 2- 7 years of clinical results

Cementless and cemented
It is the aim to use the non-cemented cup in most THA’s and
RHA’s. However a cemented cup is available for less than
optimal bone conditions (picture 4 )
The small central stem does not contribute to the fixation
(no cement should enter the prepared canal), but serves as a
positioner for the head component.The articulating side of the
head component is engineered with the ceramic TiNbN by
PVD.

Femoral components for THA

ACCIS®femoral heads for total hip replacement are available
in sizes 38 to 58mm in 2mm increments; the neck length of the
femur may be adjusted with cone adaptors in three sizes: short
(-4mm), standard (0mm) and large (+4mm); the cone adaptor
is made of a Titanium alloy and has standard a 12/14mm cone.
(figure 6)

Fig. 4 ACCIS®Cemented Acetabular Component

The clearance between acetabular and femoral head

components is approximately 100 microns in all sizes.

Fig. 6 ACCIS®Large head and cone adaptor for THA

The femoral component for RHA
The purely spherical femoral head component is designed for Component sizes
cemented fixation. The inside of the femoral head component
has a 1 mm clearance at the top of the head. There is some
clearance around the head incrementing from a proximal
0.1mm tight fit towards distal 0.9 – 1.4mm clearance to give

Fig. 5 ACCIS®Cemented Femoral Component

space to an adequate cement mantle. Radially placed cement

pockets at the proximal part of the femoral head (figure 5)
provide room for additional cement, which contributes to the
quality of the fixation with cement.

Fig.7 ACCIS®component sizes

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Ceramic Surface Engineered Metal-on-Metal Hips system for Total Hip Arthroplasty and Resurfacing Hip Arthroplasty
How does the ceramic work?
The surface modification of the metal components serves two
objectives: the minimization of wear and the prevention of
corrosion.
1. The minimization of wear
To understand the effect on wear of a TiNbN coating it is
important to know how M-on-M prostheses wear. Most wear
in metal-on-metal articulations occurs in the first few millions
of cycles of weight bearing (47). During this running-in phase
surface asperities are worn flat. These asperities on metal
surfaces are formed by block carbides.
Block carbides are molecules formed from metal atoms and
carbon; a typical structure is M7C3. They are formed during
the cooling phase of the metal component and are particularly
common at the surface. The molecules are relatively large:
20 – 30 microns. Their presence in the alloy makes the
alloy less homogeneous and weaker, but they are more wear
resistant. The presence of block carbides in the metal alloy thus
imparts both advantages and disadvantages.
The block carbides are much harder than their housing alloy,
and may cause abrasive wear on the other opposing prosthetic
surface. Asperities may also break free from the surface and
cause three-body abrasive wear.
To minimize the disadvantages it is possible to reduce the
number and size of the carbides present. Heat treating the
component after the cooling process leads to the presence of
fewer carbides, with remaining molecules reduced in size to
5 – 10 microns. This process leads to retention of block carbide
advantages, while reducing disadvantages.
A ceramic coating is helpful to further reduce the disadvantages
of block-carbides. Ceramics have the advantage of being
extremely hard. In the ACCIS®surface replacement prosthesis
the ceramic titanium-niobium-nitride is used to reinforce the
articulating surface and to reduce wear of the chromium-
cobalt-molybdenum alloy.
Fig. 8 Hardnesses of various orthopaedic alloys
The titanium-niobium-nitride coating is very wear resistant,
and being much harder than the block carbides (figure 8) is
capable of slicing asperities off as small particles; this prevents
the breaking away of carbides and the initial high wear of
metal-on-metal articulations is to a large extent reduced. After
the running in phase the opposing surfaces are completely flat
and show minimal wear.
2. prevention of corrosion
Coating of implants with Titanium niobium nitride may also
prevent metal ion release by “isolating” the components.
There is no contact with the synovial fluids that are
contributing to corrosion. As a result no metal ions are
produced. In vitro studies support this belief (48).
Pre-clinical testing and results
Pre-clinical testing of the ACCIS®prosthesis consisted of
several tests of the fixation of the ceramic to the components,
wear tests, corrosion tests, biological testing of the ceramic
TiNbN, and several tests of the fixation of the acetabular
component.
1. fixation of the coating
During the application of the TiNbN ceramic by PVD the
ceramic is integrated into the surface. To test the fixation of the
coating several tests were performed:
- pin-on-disc test: the test revealed no dislodging nor
scratching of the coating (49).
- bending test; no delamination of the coating did occur (50)
- Rockwell test: no delamination of the coating did occur (51)
2. wear tests
Wear evaluations using hip simulators were performed by
independent investigators at the Institut für Materialforschung
und Anwendungstechnik, IMA in Dresden, Germany (52 ,53),
and at the Atomic Energy Authority in Harwell, UK (62 ):
ACCIS®ceramic coated MoM hip implants with femoral head
components of 42 and 46 mm were compared to prostheses
with bearing surfaces of metal-on-polyethylene, ceramic-on-
polyethylene and metal-on-metal.
These studies resulted in the following conclusions:
- the wear of the TiNbN-coated ACCIS® prostheses was
limited to the running in phase: partial removal of the ceramic
coating occurred during the initial 1- 2 million cycles after
which removal was neglible (54).
- during the running-in phase TiNbN-coated prostheses
showed a 6-10 fold reduction of wear compared to M-on-M
articulations with 32 mm femoral head components(54).
- the ceramic layer was intact after 5 million cycles
following the running-in phase.
- hip simulator tests comparing ACCIS®ceramic coated
and ACCIS®non-ceramic coated components confirmed
the beneficial effect of the ceramic coating.
- shed particles were shown to be of sub-micron size: < 0.1µ
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The design rationale, pre-clinical testing and interim report on 2- 7 years of clinical results

3. corrosion testing
At the University of Würzburg the release of chromium ions
was measured by placing a ceramic coated CoCrMo prosthetic
component and a non-ceramic coated CoCrMo prosthetic
component in a boiling saline solution for 240 hours. A 90%
reduction of chrome ion release with the TiNbN coated
component was demonstrated (55). The TiNbN coating provides
a great amount of protection against corrosion.
4. biological testing
Biocompatibility testing was performed at the LPT Laboratory
of Pharmacology and Toxicology, Prof.Dr.med F. Leuschner,
in Hamburg Germany in order to investigate possible biological
reactions to TiNbN when implanted into the body.
- implantation test according to the USP XXII following the
LPT protocol 7362/92. Result: No difference in tissue reaction
was found between Titanium-Niobium-Nitride ceramic
implanted in rabbits and negative control material. The effect
observed was limited to a non-specific tissue reaction (56).
- examination for cytotoxic properties of plates made of
CoCrMo coated with TiNbN in a cell culture test according
to USP 28 and EN 30993-5. Result: no signs of cytotoxicity
were revealed, while the positive control revealed severe
cytotoxicity (57).
5. tests for the fixation of the cup
The primary fixation of the tri-radial design of the
ACCIS®acetabular component for cementless press-
fit application and the fixation of the spherical
ACCIS®component for cemented fixation were tested at the
Technical University Hamburg-Harburg (Prof. Dr.habil. M.M.
Morlock). To determine the ideal external configuration pull-
out, cantilever and rotational stability tests were performed
and various types of surface geometries for the acetabulum
components were compared. The triple-radius design with
equatorial over-sizing and two equatorial fins gave optimal
primary stability and became the definitive design (58).
The pure Titanium plasma sprayed outer surface was selected,
because of its excellent contribution to primary fixation and
proven bone in-growth capacity.
The acetabular components do not deform during implantation.
The impaction of cups into the pelvis of a calf was tested
at the Technical University Hamburg-Harburg. Result: the
deformation of the cup, which may result from impaction of
the ACCIS®acetabular component, is neglectable, no decrease
in function of the MoM articulation has to be expected; the
strength of the cup is adequate (59)
Clinical results of the ACCIS®prosthesis
In this paragraph special attention is given to those aspects of
the ACCIS®prosthesis, that are specific for its design. More
common aspects like clinical function and hip scores are being
published in the literature. This paragraph is focussed on (1)
fixation of the cup, (2) the absence of metal wear and (3) the
absence of any increase of metal ions in the blood of patients
after THA and SRHA with the ACCIS®prosthesis.
1. fixation of the cup
The first clinical trial was performed at the Slotervaart
Ziekenhuis, Amsterdam, the Netherlands ( Karel J. Hamelynck
MD PhD and Paul Winia MD). From March 2000
till September 2002, 80 ACCIS®total hip replacements were
performed using a prototype spherical ACCIS®cup with a
casted porous coating and three fins at the dome to enhance
rotational stability. This type of fixation demonstrated to be
insufficient. The primary fixation of this cup appeared to
be inadequate for two reasons. The adequate seating of the
spherical slightly over-sized cup may have been hindered by
the so-called rebound effect (46 and figure 3). Forces around
the cup are pushing the cup out of the acetabulum leaving a
gap between the acetabular bone and the component. The fins
at the dome of the cup may have contributed to the rebound
effect. When primary fixation is inadequate, secondary fixation
may not occur.. The results caused a design change. The fins
were abandoned and hydroxyapatite was added to improve the
secondary fixation.(prototype 2)
A second clinical trial was performed at the Morriston
Hospital, Swansea, Wales (UK), David J Woodnutt, MD FRCS,
FRCS (Orth). Between April 2003 and December 2003 sixty
THA’s were performed using prototype 2 ACCIS®spherical
cementless acetabular component. The results of this trial
revealed again the negative influence of the rebound effect
on primary fixation, which is typical for the spherical cup
design. For that reason the shape of the cup was changed from
purely spherical to tri-radial with a small flattened part at the
dome and a peripheral widening at of 1.7 – 2.0 mm at the
equator. The fixation of this tri-radial cup design during testing
demonstrated a press-fit fixation that was clearly superior to the
fixation of spherical designs. The best results were achieved
when two fins were added at the equator (58) The tri-radial
shape became the definite shape of the ACCIS®cementless
acetabular pressfit cup.
The third clinical trial was again performed at the Morriston
Hospital, Swansea, Wales (UK). Starting from April 2005 a
great number of total hip replacements and surface replacement
arthroplasties has been performed using the definite press-fit
tri-radial acetabular component. To date no problems with the
fixation of the cup have been encountered.
From 2006 more RHA trials using the ACCIS®prosthesis with
the definite acetabular component have been performed. No
problems with fixation of the cup have been reported except
for the occasional early fixation problem due to surgical error.
Surgeons needs to follow the precise surgical technique: the
equatorial press fit fixation of the cup functions best, when the
cup is completely surrounded with acetabular bone.

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Ceramic Surface Engineered Metal-on-Metal Hips system for Total Hip Arthroplasty and Resurfacing Hip Arthroplasty
2. the absence of wear
The metal surfaces of the ACCIS prosthesis are engineered
with the ceramic Titanium-Niobium-Nitride (TiNbN). TiNbN is
integrated into the metal surfaces by physical vapor deposition
to minimize wear.
- failure of cup fixation in patients of the first trial at the
Slotervaart Ziekenhuis Amsterdam, the Netherlands, gave
the opportunity of examining the capsule and soft tissue from
behind the cup in 15 patients: examination of the biopsies
demonstrated the complete absence of any adverse reactions to
metal particles: no signs of hyper-sensitivity, necrosis, pseudo-
tumour formation and no signs of inflammation (figure 9).
Fig. 9 Histology of a retrieval at 44 Months
- during the third clinical trial at the Morriston Hospital,
Swansea, UK, no problems originating from the TiNbN
ceramic coating have occurred.
- all components revised for whatever reason, have been
studied extensively by implantcast GmbH, the manufacturer of
the prosthesis. No errors of manufacturing could be detected.
The TiNbN coating remained intact and present around the full
femoral head and inside of the acetabular component with the
exception of a very small area at the dome of the cup in some
cases, demonstrating the effect of running in.
comment:
Some wear does occur during the running in phase of any
metal-on-metal prosthesis. Fluid-film lubrication cannot be
achieved in all prostheses. In most prostheses there will be
initial contact at the dome due to the diametrical clearance
between head and cup. With the ACCIS prosthesis this running
in wear is limited to the running-in period. However the
presence of the coating around the whole femoral head and the
almost complete inside of the cup guarantees that corrosion
cannot occur.
3. the absence of any increase of metal ions in the
blood
The metal surfaces of the ACCIS prosthesis are engineered
with the ceramic Titanium-Niobium-Nitride (TiNbN). TiNbN is
integrated into the metal surfaces by physical vapor deposition
to minimize wear and to prevent corrosion as well.
Blood tests of metal ion levels of 30 patients from the second
trial at the Moriston Hospital, Swansea, UK, 2-5 years after
THA with the ACCIS acetabular and femoral head components
with femoral heads of 42 and 46 mm or more demonstrated,
that none of the patients had metal ion levels, that were
elevated 2-5 years after ACCIS THA (figure 10).
The metal ion levels were equal to the average metal ion levels
in controls without a prosthesis shown by a dotted line in figure
10 (60,61). Patients with a titanium femoral stem had no increase
of metal ions at all, while patients with a cobalt-chromium-
molybdenum femoral stem had some increase of chromium
ions.
The metal ion concentration of patient with an Accis THA
median Chromium: 3.61 (0.25-8.5) and median Cobalt: 1,3
(0,25-2.2)60) show
significant lower
levels of metal ions
than levels published
in other studies such as
by Langton (62) median
Cr: 3.42 (1,5-69,8),
median Co: 1,99 (0,4
-271) and by De Smet
(63): median Cr 13,2
(0,4-93) and median
Co 5,8 (1 – 94) And
this despite the fact
that most of the THA
patients had CoCrMo
femoral stems (60) !
Fig.10 Metal ion levels after Total Hip Arthroplasty
A clinical multi-centre follow-up study on 200
ACCIS®Resurfacing implants (Morriston Hospital, Swansea,
UK: David J Woodnutt, MD, FRCS, FRCS (Orth); Neville Hall
Hospital, Abergevanny, UK: Robin Rice, MD,BMBS,FRCS;
Arthro Clinic Hamburg: Genio Bongaerts, MD) is performed.
Blood samples of 60 patients are analysed before, immediately
after surgery and at intervals of 3, 6, 12 and 24 monts after
surgery.
The results of this ongoing study are shown in figure 11.
None of the patients at any moment after operation has shown
any significant increase of cobalt and chrome ions in the blood
and none of the blood ion levels has been above the normal
limits for metal ions in the blood as described in the Hand book
for environmental medicine (61).
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The design rationale, pre-clinical testing and interim report on 2- 7 years of clinical results
The conclusion is justified that corrosion of the articular
surfaces of the metal components of the ACCIS®prosthesis
by the process of surface engineering of the surfaces with the
ceramic TiNbN, is completely
inhibited.
Early clinical results were
presented at various
meetings (60,64-66) .
The above mentioned study will be
finished in the 4th quarter of 2009
and subsequently published.
conclusions:
The components of the
ACCIS®system for THA and RHA
incorporate important advantages
over other metal-on-metal hip
prostheses with large femoral
heads:
Fig. 11 Metal ion levels after Resurfacing
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(1) Amstutz H Campbell P, Kossovsky N, Clarke I : “Mechanism and clinical
significance of wear debris induced osteolysis”CORR 276 : 7, 1992
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(3) Doorn PF, MD; Campbell PA, PhD; Amstutz HC,MD. :”Metal versus
Polyethylene Wear Particles in Total Hip Replacements”. CORR 1996 Vol. 329S
pp S206-S216
(4) Adami G., Smarrelli D., Martinelli B., Acquavita A;, Reisenhofer E. “Cobalt
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(Italy)”. Annali di Chemica 2003;93:1-10
(5) Amstutz, Harlan C. MD; Pat Campbell, PhD; Harry McKellop, PhD; Thomas
I? Schmalzried, MD; William J. Gillespie, BSc, UB, ChM; Donald Howie,
MD, PhD; Joshua Jacobs, MD; John Medley, PhD; and Katharine Merritt, PhD:
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CORR 1996 Number 3298, pp S297-S303
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White Paper Published August 2009
(1) the primary fixation of the acetabular component is very
reliable due to the tri-radial design, equatorial press fit and TPS
coating.
(2) ceramic engineering of the
articular surfaces of the metal
components causes a minimization
of metal wear.
(3) corrosion of the metal surfaces
is prevented and reduced to the
minimum.
There is no need to fear for
increased levels of metal ions
in the blood and the un-known
consequences of this increase.
October 4th 2009
(14) Mabileau G, Kwon Young-Min, Pandit H, Murray DW , Sabokbar A.:
“Metal-on-metal hip resurfacing arthroplasty, A review of peri-prosthetic
biological reactions. “Acta Orthopaedica 2008; 79 (6): 734–747
(15) Murray DW, MD, FRCS.: “ Pseudotumour after Hip Resurfacing. Presented
at the Second Annual U.S. Comprehensive Course on Total Hip Resurfacing
Arthroplasty October 24–25, 2008 Los Angeles, CA
(16) Kwon YM, Ostlere S, Mc Lardy-Smith P, Gundle R, Whitwell D, Gibbons
CLM, Taylor A, Pandit H, Glyn-Jones S, Athanson N, Beard D, Gill HC, Murray
DW. : “Asymptomatic pseudotumours in patients with metal on metal hip
resurfacing: prevalence and metal ion study.” Presented at the Annual Scientific
Meeting of the British Hip Society, 2009, Manchester
(17) Laughton DJ, Jameson SS, Joyce TJ, Natu S, Logishetty R, Tulloch C,
Nargol AVFN. “Adverse reactions to metal debris following large bearing metal-
on-metal arthroplasty”. Presented at the Annual Scientific Meeting of the British
Hip Society, 2009, Manchester
(18) Pandit, H. S. Glyn-Jones, P. McLardy-Smith, R. Gundle, D. Whitwell, C. L.
M. Gibbons, S. Ostlere, N. Athanasou, H. S. Gill, Pseudotumours associated with
metal-on- metal hip resurfacings” JBJS [Br] 2008;90-B:847-51
(19) Savarino L., Granchi D., Ciapetti G., Cenni E., Nardi Pantoli A., Rotini
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 -8-
Ceramic Surface Engineered Metal-on-Metal Hips system for Total Hip Arthroplasty and Resurfacing Hip Arthroplasty
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ACCIS®components are manufactured and distributed by:
implantcast GmbH
Lüneburger Schanze 26
D-21614 Buxtehude
Germany
Phone:+ 49-4161 744 100
E-mail: info@implantcast.de
White Paper Published August 2009
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Homepage: www.accis.nl
contact the author: accis.resurfacing@gmail.com