Lecture 4: Metallic Biomaterials

1
 Metallic biomaterials

Objective:
- Describe the concept of metallic biomaterials used in various applications

Outline:

 Stenting and stent properties/materials

 Dental Implants
 Bone implants
 How many different types of
biomaterials are in use today?

The FDA regulates 100,000 different products that

represent at least 1,700 Different Types of Biomedical
Devices
2
 Broad Classification-
Types of Biomaterials

– Metals
– Polymers, synthetic and natural
– Ceramics
– Composites

3
 METALS
• Definition: Inorganic materials possessing non-
directional metallic bonds with high highly
mobile electrons / any of a category of
electropositive elements that usually have a
shiny surface

• Are generally good conductors of heat and

electricity, and can be melted or fused,
hammered into thin sheets, or drawn into wires.
.

4
 Metals
• Load bearing implants and internal fixation
devices;
• When processed suitably contribute high
tensile, high fatigue and high yield
strengths;
• Low reactivity;
• Properties depend on the processing
method and purity of the metal.

5 5
 Metals for Implantation
• Must be corrosion resistant
• Metals may fail due to: GALVANIC SERIES OF METALS AND ALLOYS IN
SEA WATER

 Corrosion
 Fracture
 Wear
 Yielding
 Loosening
 Infection
• Mechanical properties must appropriate for
desired application
• Areas subjected to cyclic loading must have good
fatigue properties -- implant materi6als cannot heal
themselves
 Metallic Biomaterials

Metals Commonly Used in Biomedical Application

Metals Applications

Cobalt-chromium alloys Artificial heart valves, dental prostheses, orthopaedic

fixation plates, artificial joint components, vascular stents
Gold and platinum Dental fillings, electrodes for cochlear implants (bionic ear)

Silver-tin-copper alloys Dental amalgams

Stainless steel 316L Dental prostheses, orthopaedic fixation plates, vascular

stents

Titanium alloys Artificial heart valves, dental implants, artificial joint

components, orthopaedic screw, pacemaker cases, vascular
stents

8
 Applications
• Bone and Joint Replacement
• Dental Implants
• Maxillo and Cranio/facial reconstruction
• Cardiovascular devices - titanium is
regularly used for pacemaker cases and
defibrillators, as the carrier structure for
replacement heart valves, and for intra-
vascular stents.
• External Prostheses
• Surgical instruments
 Other Uses

Medical Tubing

Stents

Catheters
 Chemical Properties of Metals:

• Easily lose electrons

• Surface reactive
• Loss of mass (some corrode easily)
– corrosion is a gradual wearing away
• Change in mechanical properties
 Metals

Most elements are metals. 88 elements to the left of the stairstep line are metals or metal like elements
 Nature of Metals
• Crystalline solids composed of elemental,
positively charged ions in a cloud of electrons
Methods of Metals Processing/Manufacturing
• Forming metals
- Forging
- Rolling
- Extrusion
- Drawing
• Casting metals
- Sand casting
- Investment casting
• Powder processing of metals
• Rapid manufacturing of metals
• Welding metals
• Machining of metals
 Metallic biomaterials
Early Metallic Biomaterials
Old civilizations: detailed dental work on a mummy from ancient Egypt that
archaeologists have dated to 2000 BCE. The work shows intricate gold work
around the teeth. This mummy was found with two donor teeth that had holes
drilled into them. Wires were strung through the holes and then around the
neighboring teeth

During the Roman period (5th BCE –4th CE),

crowns and bridges were manufactured from
gold strips and were attached to existing teeth
with great precision.

15
 Metallic Biomaterials
Biometals Applications

• Mainly for load-bearing implants

– hip and knee prostheses and fracture fixation
wires, pins, screws, and plates
• Parts of artificial heart valves
• Pacemaker leads
• Stents

16
Photograph taken from British Science Museum, July 2011
 Metallic Biomaterials

Biometals Composition (Examples)

(a) Iron-base alloys of the 316L stainless steel
(b)Titanium and titanium-base alloys, such as
(i)Ti-6% Al-4%V, and commercially pure ≥ 98.9%
(ii) Ti-Ni (55% Ni and 45% Ti)
(c) Cobalt base alloys of four types
(i) Cr (27-30%), Mo (5-7%), Ni (2-5%)
(ii) Cr (19-21%), Ni (9-11%), W (14-16%)
(iii) Cr (18-22%), Fe (4-6%), Ni (15-25%), W (3-4%)
(iv) Cr (19-20%), Mo (9-10%), Ni (33-37%)

17
 Physical Properties of
Metals:
• Luster (shininess)
• Good conductors of heat and electricity
• High density (heavy for their size)
• High melting point
• Ductile (most metals can be drawn out into thin
wires)
• Malleable (most metals can be hammered into
thin sheets)

56
 Metallic Biomaterials

Disadvantages

• Low biocompatibility
• Corrosion
• Too high stiffness compared to tissues (in some
orthopaedic application)
• High density (in some orthopaedic application)
• Allergic tissue reactions(release of metal ions)
• Restenosis (stents)

19
 Metals
Most widely used metallic elements include:
- Iron
- Copper
- Lead
- Zinc
- Aluminum
- Tin
- Nickel
- magnesium
20
 Metals
• Pure/alloy
• Alloy: a combination of elements that exhibits the
properties of a metal for improvement of:
- Strength
- Ductility
- Hardness
- Wear resistance
- Corrosion resistance

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 Orthopaedic Implant Materials
• Three main categories for orthopedic
implants
– Stainless steels
– Cobalt-chromium alloys
– Titanium alloys

• For dental implants

– Amalgam
– Gold
 Metals
• Orthotics & prosthetics contain:
- Alloys of Al and carbon steels (particularly stainless
steel)
- Titanium (osseointegration) or magnesium alloys

• Most significant qualities of metals:

- Elasticity
- plasticity

23
 Metals
• Plasticity depends on:
the ability to shape and contour Al and stainless steel
to match body contours

• Elasticity governs:
their safe and economical use as load-bearing
members

24
 Commercial names for
Metals
• Surgical steel
• Stainless steel: large amount of chromium (>3.99%)
• Tool steel: a wide variety of steels that are capable of
attaining a high degree of hardness after heat
treatment
• Heat treated
• Spring steel: refers to a group of steels ranging in
chemical composition from medium to high-carbon
steel

25
 Steel
• Any iron-based alloy material

-Advantages: strong, rigid, ductile, durable

-Disadvantages: heavy (high density),

susceptibility to corrosion

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 Steel alloys
• Carbon steel: iron with added carbon (1% by weight)
+ manganese+ traces of sulfur & phosphorus

- The strength and hardness are directly proportionate

to the amount of carbon added

(Low carbon high ductility)

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 Steel alloys
• Alloy steel: carbon steel + other chemicals

• Toughness: ability to withstand shock force

• Hardness: resistance to penetration and abrasion
• Ductility: ability to undergo permanent changes of
shape without rupturing

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 Characteristics
• Nickel steel: improved toughness, simplified heat
treating, less distortion in quenching and corrosion
resistance

• Nickel chromium steel: increased depth

hardenability and abrasion resistance

• Molybdenum steel: greatest hardenability, increased

high-temperature strength, increased corrosion
resistance
29
 Steel alloys
• Double & triple alloys :
- Chromium molybdenum steels
- Chromium nickel steels

30
 Steel alloys
• Stainless steel: large amount of chromium (>3.99%)

increases resistance to corrosion and oxidation

(produces light oxide film on the surface)

- Well known “18-8” stainless steel: 18% chromium &

8% nickel

31
 Stainless steel
• Radiopaque
undesirable for scoliotic patients wearing
orthosis

- Radipaque: obstructing the passage of radiant energy, such as

x-rays, absorbs X-ray
- Radiolucent: transmits X-ray

32
 Stainless steel
• Joints
• Support uprights
• Band material

33
 Aluminum
Advantages:
- high strength/weight ratio
- Corrosion resistance
- radiolucent

Wrought: prosthetic pylons, orthotic uprights, upper

extremity devices (high compression bending stresses )
Al alloys
Cast: low ductility, low strength
prefabricated prosthetic components
34
moving parts
 Aluminum
• Disadvantage:
- acids and alkalis in urine, perspiration and other bodily
fluids deteriorate natural protective oxides on surface
- more subject to fatigue failure (unsuitable for orthotic joints)

Solution:
 Applying various hard coatings, such as anodic or oxide
finishes
 Mechanical finishes: polishing, buffing, sandblasting offer
attractive cosmetic appearance for devices
35
 Comparison Steel vs Aluminium
Under equal amount of stress:
- Steel strains one third as much as Al
- Al weighs approximately 1/3 as much as steel
- Al easier to work with than steel
- Al: bulky
- Al: more subject to fatigue failure

36
 Titanium
• Stronger than Al and comparable strength to some steels
• Density: 60% of steel
• Titanium prosthetic components lighter in weight than steel
counterparts, require less energy expenditure
• Also more resistant to corrosion than Al and steel
• Disadvantage: more difficult to machine and fabricate in P&O
labs

prefabricated prosthetic components

(strength & light weight)

more expensive! 37
 Titanium
• 2.2 million pounds of Ti implanted every
year
• Hip joints, bone screws, knee joints, bone
plates, dental implants, surgical devices,
and pacemaker cases
• Due to its total resistance to attack by body
fluids, high strength and low modulus.

• Light, strong, lustrous, corrosion-resistant

(including resistance to sea water and
chlorine) transition metal with a white-
silvery-metallic
Dental implant
 Titanium
• Commercially pure titanium (ASTM F67)
• Ti-6Al-4V (ASTM F136)
• Most load bearing permanent implants
 due to good mechanical properties
 lighter due to their low density
 good corrosion resistance due to TiO2
solid oxide layer
• Poor properties in articulation
 Titanium

• Lightweight, corrosion resistant, easily milled into

different shapes, while maintaining its strength.

• Forms layer of titanium oxide, which is a stable and

reactive interface that becomes coated with plasma
proteins.

• Ti-6Al-4V was alloyed to create a biocompatible

material with added strength.
 Titanium Based Alloys
• Lighter

• Good mechanical properties

• Good corrosion resistance due to TiO2 solid

oxide layer
• Ti-6% wt Al-4% wt V (ASTM F136) is widely
used

• Contains impurities such as N, O, Fe, H, C

• Impurities increase strength and reduce

ductility
 Properties
• Well known for its excellent corrosion resistance
(almost as resistant as platinum), being able to
withstand attack by acids, moist chlorine gas, and by
common salt solutions
•Light, strong metal with low density (40% as dense
as steel) that, when pure, is quite ductile (especially
in an oxygen-free environment)
•Strong as steel, but 45% lighter; it is 60% heavier
than aluminium, but twice as strong. These properties
make titanium very resistant to the usual kinds
 Properties
Can be classified into 2 ‘mainly-used’ types;

Pure Ti & Ti6A14V – which is derived from

aerospace application and has super-plasticity
feature

Ti-Ni alloy – it has super-elasticity feature, shape

memory
 Properties
• Pure Titanium:
 amount of oxygen has large effect on ductility
and strength – more oxygen, more stronger
and harder.
 Properties
Classification Tensile Yield Strength Elongation
Strength (MPa) (%)
(MPa)

Titanium – 240 - 550 170 – 485 24 - 15

Class 1 to 4

Ti6A14V Alloy 860 795 10

 Pure Ti Applications
• Joint replacement
• Bones pin, plates, screws
• Ligament anchorage
• Pins & post in dental implants
• Cast dentures framework
Knee Joint replacement
Bones pin, plates & screws

considered to be physiologically inert

Pins & post in dental implants
 Ti-Ni Alloy Applications

1. Orthodontic dental archwire

2. Intracranial aneurysm clip
3. Contractile artificial muscle for artificial
heart
4. Vascular stents
Orthodontic dental archwire
Vascular stents
 Dental Metals
• Amalgam:
– Solid alloy
• silver, tin, copper, zinc
and mercury
– deformable mixture
packed in cavity
– cures over time
• 25% of total strength in
1 hour
• full strength in a day
 Dental Metals
• Amalgam
• an alloy of mercury with another metal
(usually silver) used by dentists to fill
cavities in teeth.
• Final composition of dental amalgams
typically contains 45 to 55% mercury, 35
to 45% silver, and about 15% tin
• Used as dental fillings
 Dental Metals
• Gold:
• Material that is consists of
soft yellow malleable ductile
(trivalent and univalent)
metallic element, which
occurs mainly as nuggets in
rocks and alluvial deposits
• Has atomic number of 79 in
tables of elements
 Dental Metals
• Gold:
– Durable, stable, corrosion
resistant as fillings
• Why is corrosion resistance
especially important in the
mouth?
– The mouth is a more
acidic and chemically
active environment than
much of the rest of the
body.
 Applications
• Uses in dental restorations
– due to superior performance & longertivity
– immunity to corrosion, durability
 Magnesium
• Lighter than Al and titanium
• Corrosion resistant
• Lower modulus of elasticity than Al
(Young modulus=ratio of unit stress to unit strain)

lower rate of fatigue under repeated stress

- Not yet been widely used in P & O

59
 Dental Metals: Nitinol
• NIckel-TItanium-Naval Ordinance Lab
• Shape memory alloy (SMA): ability to return
to a predetermined shape when heated
 Dental Metals: Nitinol

 Orthodontic applications: dental archwires,

 Other: intracranial aneurysm clips, contractile
artificial muscles for an artificial heart,
orthopaedic implants
 Other Metals
• Tantalum
– High biocompatibility in animal studies
– Low strength to density ratio restricts applications to
those such as wire sutures and radioisotopes

• Platinum and other noble metals

– Corrosion resistant but poor mechanical properties
– Used mostly as alloys for electrodes such as
pacemaker tips
 Metal Implant Reliability

Depends largely on the:

• corrosion,
• wear, and,
• fatigue resistance of the materials
 Future of implants

• Manufacture "designer implants", which

could carry different types of proteins, one
set to spur soft tissue healing, another to
encourage hard tissue growth on another
front. Given that dental implants are fixed
in the jawbone and inserted through gum
tissue, this two-pronged approach would
be essential.
 Metals & Alloys - Advantages
• High mechanical strength
• Fatigue resistance
• Wear resistance
• Fabrication relatively easy
• Surface can be polished or roughened
• Can have good corrosion resistance
• Easily sterilised
 General Processing History of a Typical
Metallic Implant Device (eg. A hip implant)

74
 Metallic Biomaterials: Cardiovascular
Atherosclerosis Implants

Atherosclerosis: hardening and

thickening of arteries due to plaque
(atheroma) in arterial walls

lLinked to half the deaths in the US*

lBecomes seriously symptomatic

when interfering with the coronary
circulation supplying the heart or
cerebral circulation supplying the
brain.

lRisk factors:
lSmoking, diabetes,
hypertension,
hypercholesterolaemia, obesity,
age…
*American Heart Association. 2001. 2002 Heart and Stroke
Statistical Update.
 Metallic Biomaterials: Cardiovascular
Implants
Complications

Potential stroke

Vulnerable plaque:
•Advanced lesions
•Thin fibrous cap
•Mainly lipid-rich plaque
•Increase in inflammatory cells
•Stresses (chronic inflammation,
emotional stress, intraplaque
hemorrhage, hemodynamic
conditions, mechanical factors)

http://health.allrefer.com/health/carotid-artery-surgery-atherosclerosis-of-internal-carotid-artery.html
 Metallic Biomaterials: Cardiovascular
Implants

Complications

• Coronary heart disease- plaque build

up in coronary arteries:

• Reduces blood to the heart

– Angina/chest pain(i.e. presence of a
stenose)
– Heart attack

• Lower extremities:
– Foot
– Peripheral arterial disease

http://www.stanfordhospital.com/healthLib/atoz/cardiac/arteries.html
 Metallic Biomaterials: Cardiovascular
Treatment Implants

Balloon

Stent
Revascularization: a non-
surgical procedure to reduce
an arterial blockage

Percutaneous Transluminal Coronary

Angioplasty (PTCA): one of the major
medical act in current medicine
 Metallic Biomaterials: Cardiovascular
Implants

Stents
Stents are metallic implantable tubular
devices used as mechanical scaffolds to
the vascular wall during revascularization
procedures of coronary or peripheral
arteries.

Before After

http://www.fda.gov/hearthealth/treatments/medicaldevices/stent.html
 Metallic Biomaterials: Cardiovascular
Implants

PTCA (Percutaneous transluminal

coronary angioplasty)
Ideal stent material: Ideal stent:
– Corrosion resistance – Reliable delivery system
– Vascular compatibility – Trackability
– Fatigue resistant – Elasticity
– Flexibility
– Thrombo-resistant
– Conformity
– High scaffolding ability
– Uniform radial strength
– Visible using standard X- – Availability for various
ray and MRI technology lesions
– Thromboresistance
– Biocompatibility
– Corrosion resistance
– Radiopacity
 Metallic Biomaterials: Cardiovascular
Implants

•Memotherm Stents (BARD)

Metallic materials currently used:

– Stainless steel (316L steel)
– Cobalt-Chromium alloys
– Titanium •Dynalink (Guidant)
– Tantalum
– Nitinol

More than fifty types of stents, and,

more recently, stent-grafts with •Medtronic AVE
various designs (mesh structure,
coil, slotted tube, ring, etc) and
compositions, have received FDA
approval or CE marking.

http://www.sma.org.sg/smj/4006/articles/4006me2.html
 Coronary artery bypass grafting
(CABG) or Heart ByPass
• Heart Bypass, which bypasses stenotic arteries
by grafting vessels from elsewhere in the
body, is an alternative treatment.
• coronary revascularization by CABG is
associated with an increased risk of stroke

74
 Metallic Biomaterials: Cardiovascular
Implants

Bypass Vs PTCA
Angioplasty with or without
stenting Bypass Surgery

Shorter recovery time Longer recovery time

No open-heart surgery Open-heart surgery

More likely to require medication to
control coagulation within blood Less likely to require medication to
veseels control angina

May need another angioplasty or Less likely to need another bypass

bypass later in life later in life
Drug-eluting Stents Metallic Biomaterials: Cardiovascular
Implants
– CYPHER (Cordis Corp.)
• Polymer matrix is loaded with
drug, and a drug-free polymer top
coat serves as a diffusion barrier

– TAXUS (Boston Scientific)

• Drug is released directly from a
polyisobutylene matrix
CYPHER Stent

– Significant reduction in restenosis

or renarrowing of the vessel (less
than 10% depending on type of
lesion)

TAXUS stent

http://www.jnj.com/our_company/history/history_section_4.htm

http://www.smalltimes.com/document_display.cfm?section_id=45&document_id=740
 Metallic Biomaterials: Cardiovascular
Economic facts and FDA Implants
status

• Current non-medicated stents cost between

$1,000 and $1,300.

• Drug-eluting stents cost around $3,000.

– J&J Cordis Corporation sells CYPHER for
$3,195.

• FDA and CE market approved.

 A dental implant is a "root" device, usually Metallic Biomaterials: Dental Implants
made of titanium, used in dentistry to support
restorations that resemble a tooth or group of
teeth to replace missing teeth.

The majority of dental implants are made out of

commercially pure titanium. More recently grade
5 titanium has increased in use. Grade 5
titanium, Titanium 6AL-4V, (signifying the
Titanium alloy containing 6% Aluminium and 4%
Vanadium alloy). Ti- 6Al-4V alloy offers better
tensile strength and fracture resistance.

Implant surfaces may be modified by plasma

spraying, anodizing, etching, or sandblasting to
increase the surface area and clinical efficiency
of the implant.

78
http://en.wikipedia.org/wiki/Dental_implant
Procedure Metallic Biomaterials: Dental Implants

Phase 1. Surgical placement of the

implant(s) into the bone. This is usually done
right in the dentist’s office, with a local
anesthetic. After surgery, there is a healing
period of approximately four months. During this
time, the implants fuse to the bone by a process
known as ‘osseointegration’

Phase 2. there is a minor surgical exposure of

the top of the implant, whereby the dentist will
attach the post to the implant. The function of
the post is to become the support for either one
tooth or a set of teeth. This is a short procedure
that usually requires only local anesthesia.

Phase 3. The last phase is the restorative

phase. The dentist will take impressions and
then make a prosthesis that will attach to the
implants. This will require several visits. Once
completed, your mouth will be restored to
natural looking, strong teeth.
79
http://www.dentalimplant.com/topic4.htm
 Metallic Biomaterials: Dental Implants
Implant surface treatment
The osseointegration rate of titanium
dental implants is related to their
composition and surface roughness.
Rough-surfaced implants favor both bone
anchoring and biomechanical
stability.
http://www.intechopen.com/bo
oks/biotechnology-molecular-
Osteoconductive calcium phosphate studies-and-novel-
applications-for-improved-
coatings promote bone healing and quality-of-human-life/surface-
apposition, leading to the rapid biological aspects-of-titanium-dental-
implants
fixation of implants.

Surface treatments involve titanium

plasma-spraying, grit-blasting,
acid-etching, anodization or calcium
phosphate coatings.

Most of these surfaces are commercially

available and have proven clinical efficacy
of >95% over 5 years.
L. Le Gu´ehennec, A. Soueidan, P. Layrolle ∗, Y. Amouriq,
http://www.dentalorg.com/dental-implant-overview-part-1.html 80
Dental Materials 23 (2007) 844–854
Surface Aspects of Titanium Dental Metallic Biomaterials: Dental Implants
Implants

81
http://www.intechopen.com/books/implant-dentistry-a-rapidly-evolving-practice/factors-affecting-the-success-of-dental-implants
 Metallic Biomaterials: Dental Implants

Surface treatment of metallic implants:

Plasma spraying

82
 Metallic Biomaterials: Bone Implants

Reproduced from Corrosion of bio implants (2003).U, MUDAL, Kamachi U et al .Sadhana .Vol. 28, Parts 3 & 4, pp.
601–637

83
 Knee replacement Metallic Biomaterials: Bone Implants

Knee replacement surgery as a treatment for severe knee pain and disability from rheumatoid
arthritis, osteoarthritis, or traumatic injury.

Several manufacturers make knee implants and there are more than 150 knee replacement
designs on the market today.
84
http://orthoinfo.aaos.org/topic.cfm?topic=a00221
 Metallic Biomaterials: Bone Implants

Knee replacement: general requirements

The metal parts of the implant are made of titanium or cobalt-

chromium based alloys. The plastic parts are made of ultra high
molecular weight polyethylene. All together, the components weigh
400-500g, depending on the size selected.

Material Criteria

The construction materials used must meet several criteria:

- Biocompatible with minimum immunological response.

- Mimetic character: strong enough to take weight bearing loads,

flexible enough to bear stress without breaking, and able to
move smoothly against each other as required.

- Durable - Revision surgery!

85
 Metallic Biomaterials: Bone Implants
Hip replacement

Hip replacement operations are highly successful in relieving pain and

restoring movement.

Men and patients who weigh more than 165 lb have higher rates of failure. The
chance of a hip replacement lasting 20 years is approximately 80%.
86
 Metallic Biomaterials: Bone Implants
Implant fixation:
cement and cementless
Cemented fixation relies on a stable interface
between the prosthesis and the cement and a
solid mechanical bond between the cement and
the bone. The most commonly used bone
cement is an acrylic polymer called
polymethylmethacrylate (PMMA).

In the 1980s, new implant designs were

introduced to attach directly to bone without the
use of cement. In general, these designs are
larger and longer than those used with cement.

Cementless implants also have a surface

topography that is conducive to attracting new
bone growth. Most have a surface coating
http://www.sciencephoto.com/media/90783/view
around much of the implant so that the new
bone actually grows into the surface of the
implant. Because they depend on new bone
growth for stability, cementless implants require
a longer healing time than cemented
replacements. 87
 Metallic Biomaterials
Metal implant failure

Two processes, one mechanical and one

biological, can contribute to loosening.

Mechanical: cracks (fatigue fractures) in the

implant that occur over time can cause
loosening. The debris particles generated can
trigger a biologic response that further
contributes to loosening of the implant and
sometime to loss of bone around the implant.

Biological: The microscopic debris particles

are absorbed by cells around the implant and
initiate an inflammatory response from the
body, which tries to remove them. This
inflammatory response can cause cells to
remove bits of bone around the implant, a
condition called osteolysis. As the bone
weakens, the instability increases leading to
eventual failure of the implant.

88
 Reference: Medical Multimedia
The steps involved in
Group
replacing a diseased hip with
(http://www.sechrest.com/mmg/)
an uncemented artificial hip
begin with making an incision
on the side of the thigh to
allow access to the hip joint.

Removing the Femoral Head

Once the hip joint is entered,
the femoral head is actually
dislocated from the
acetabulum and the femoral
head is removed by cutting
through the femoral neck with
a power saw.
Reaming the Acetabulum
Attention is then turned
towards the socket,
where using a power drill
and a special reamer, the
cartilage is removed from
the acetabulum and the
bone is formed in a
hemisperical shape to
exactly fit the metal shell
of the acetabular
component.
Inserting the Acetabular
Component
Once the right size and
shape is determined
for the acetabulum, the
acetabular component
is inserted into place.
In the uncemented
variety of artificial hip
replacement, the metal
shell is simply held in
place by the tightness
of the fit or by using
screws to hold the
metal shell in place. In
the cemented variety, a
special epoxy type
cement is used to
anchor the acetabular
component to the
Preparing the Femoral Canal
To begin replacing the
femur, special rasps are
used to shape the hollow
femur to the exact shape
of the metal stem of the
femoral component.
Inserting the Femoral Stem
Once the size and shape are
satisfactory, the stem is
inserted into the femoral
canal. Again, in the
uncemented variety of
femoral component the stem
is held in place by the
tightness of the fit into the
bone (similar to the friction
that holds a nail driven into a
hole drilled into wooden board
- with a slightly smaller
diameter than the nail). In the
cemented variety, the femoral
canal is rasped to a size
slightly larger than the
femoral stem, and the epoxy
type cement is used to bond
the metal stem to the bone.
Attaching the Femoral Head
The metal ball that makes up
the femoral head is attached.
The Completed Hip
Replacement
And, voila!, you have a
new bearing surface for the
diseased hip.
The steps involved in replacing a
diseased knee with an artificial
knee begin with making an incision
on the front of the knee to allow
access to the knee joint.

Shaping the Distal Femoral Bone

Once the knee joint is entered,
a special cutting jig is placed
on the end of the femur. This
jig is used to make sure that
the bone is cut in the proper
alignment to the leg's original
angles - even if the arthritis
has made you bowlegged or
knock-kneed. The jig is used
to cut several pieces of bone
from the distal femur so that
the artificial knee can replace
the worn surfaces with a metal
surface.
Preparing the Tibial Bone
Attention is then turned
towards the lower bone,
the tibia. The top of the
tibia is cut using another
of jig that ensures the
alignment is satisfactory.
Preparing the Patella
The undersurface
of the patella is
removed.
Placing the Femoral Component
The metal femoral component is
then placed on the femur. In the
uncemented variety of femoral
component, the prosthesis is held
on the end of the bone by the fact
that the end of the bone is tapered,
and the metal prosthesis is cut so
that it matches the taper almost
exactly. Driving the metal
component onto the end of the
bone holds the component in
place by friction. In the cemented
variety, an epoxy cement is used
to attach the metal prosthesis to
the bone.
Placing the Tibial Component (metal
tray)
The metal tray that will hold the
plastic spacer is attached to the
top of the tibia. The metal tray is
either cemented into place, or held
with screws if the component is of
the uncemented variety. The
screws are primarily used to hold
the tibial tray in place until the
bone grows into the porous
coating. (The screws remain in
place and are not removed.)
Placing the Tibial Component (plastic
spacer)
The plastic spacer is then attached
to the metal tray of the tibial
component. If this component
should wear out while the rest of
the artifical knee is sound, it can
be replaced - a so called retread.
Placing the Patellar Component
The patella button is usually
cemented into place behind the
patella.

Completed total knee joint replacement