316L and Orthopaedic Applications
- Definition: Iron-based alloy containing at least 10.5% Chromium (for passivation)
- Definition: The most common medical grade is 316L
- Mechanism: 316L: Iron (60%), Chromium (17-20% - passivates), Nickel (12-14% - stabilises austenite), Molybdenum (2-4% - resists pitting corrosion), Carbon (under 0.03% 'Low' - prevents sensitisation)
- Management: Manufactured via Cold Working (increases strength but reduces ductility) or Annealing
- “Biocompatibility testing
- “Mechanical testing (Young's Modulus ~200 GPa - very stiff)
- “Prone to Crevice Corrosion and Fretting corrosion
- “Beware Nickel Allergy (10-15% of population)
Stainless Steel
Know what 316L stands for: 300 series (Austenitic), 16% Chromium (approx), L = Low Carbon (under 0.03%). Low carbon is crucial to prevent the formation of Chromium Carbides at grain boundaries, which deplete chromium and lead to Intergranular Corrosion. Stainless Steel is Face Centred Cubic (FCC) - remember "Space filling" (Ductile).
Composition & Structure
- Iron (Fe): Base metal (~60%).
- Chromium (Cr): 17-20%. Forms surface Oxide layer (Cr₂O₃) resulting in Passivation (Corrosion resistance).
- Nickel (Ni): 12-14%. Stabilises the Austenitic (FCC) phase at room temperature. Allergen risk.
- Molybdenum (Mo): 2-4%. Resists Pitting corrosion.
- Carbon (C): under 0.03% (Low). Minimises carbide precipitation.
Crystal Structure:
- Austenitic: Face Centred Cubic (FCC).
- Non-magnetic.
- Ductile (can be contoured/bent intra-operatively).
- Work hardens (gets stronger as you bend/shape it).
- Cannot be heat treated for hardening.
Overview
Stainless Steel in Orthopaedics
- Iron-based alloy with minimum 10.5% chromium
- Medical grade is 316L (low carbon)
- Most common implant material for fracture fixation
- High stiffness (Young's modulus ~200 GPa)
- Ductile (can be contoured intraoperatively)
- Cost-effective compared to titanium
- Prone to corrosion in body environment
- Value
- 17-20%
- Clinical Significance
- Forms Cr₂O₃ passivation layer
- Value
- 12-14%
- Clinical Significance
- Stabilizes austenite, allergen risk
- Value
- 2-4%
- Clinical Significance
- Resists pitting corrosion
- Value
- Less than 0.03%
- Clinical Significance
- Prevents sensitization
Anatomy
Material Microstructure
- Austenite (FCC): Stable phase in 316L at room temperature
- Ferrite (BCC): Present in ferritic steels, not 316L
- Martensite (BCT): Present in hardened steels
- Grain boundaries (potential corrosion sites)
- Inclusions (impurities, stress concentration)
- Passive layer (Cr₂O₃ surface oxide)
- Crystal Structure
- FCC (Face-Centered Cubic)
- Properties
- Ductile, non-magnetic, work-hardenable
- Crystal Structure
- BCC (Body-Centered Cubic)
- Properties
- Magnetic, less ductile
- Crystal Structure
- BCT (Body-Centered Tetragonal)
- Properties
- Hard, brittle, heat-treatable
Classification
Classification of Stainless Steels
By Crystal Structure:
- Austenitic (300 series): 316L, 304 - most orthopaedic implants
- Ferritic (400 series): Magnetic, less corrosion resistant
- Martensitic: Hardened surgical instruments (scalpels)
- Duplex: Mixed austenite/ferrite
- Examples
- 316L, 304
- Orthopaedic Use
- Plates, screws, nails
- Examples
- 420, 440C
- Orthopaedic Use
- Surgical instruments, blades
- Examples
- 430
- Orthopaedic Use
- Not used (magnetic)
Clinical Assessment
Preoperative Considerations
- Nickel allergy history (cheap jewelry rash)
- Metal hypersensitivity (Type IV)
- Prior implant reactions
- MRI requirements (artifact considerations)
- Fracture fixation (plates, screws, nails)
- Temporary fixation devices
- Cost-sensitive settings
- When intraoperative contouring needed
- Choose SS
- Avoid
- Choose Titanium
- Preferred
- Choose SS
- Yes
- Choose Titanium
- No (expensive)
- Choose SS
- Excellent
- Choose Titanium
- Notching risk
- Choose SS
- Artifact
- Choose Titanium
- Minimal artifact
Investigations
Implant-Related Investigations
- Plain radiographs: Assess implant position, loosening
- CT: Metal artifact but can assess fixation
- MRI: Significant artifact with SS (vs minimal with Ti)
- Serum metal ions (Cr, Ni, Mo)
- CRP, ESR if infection suspected
- Aspiration if effusion present
- Indication
- Implant assessment
- Limitation with SS
- Standard, no issues
- Indication
- Soft tissue assessment
- Limitation with SS
- Significant artifact
- Indication
- Metallosis suspected
- Limitation with SS
- Elevated in corrosion
Differential Diagnosis: The Painful Stainless Steel Implant
A patient with a painful, swollen, or draining stainless steel implant has a narrow but high-stakes differential. The cardinal task is to exclude infection before attributing symptoms to metal.
- Key Features
- Pain, warmth, sinus, late presentation
- Aspirate / Markers
- Neutrophil-predominant; CRP/ESR often raised; cultures may be negative
- Discriminator
- Extended 14-day culture, sonication, histology (acute PMNs)
- Key Features
- Dermatitis over implant, chronic pain
- Aspirate / Markers
- Lymphocyte-predominant; CRP/ESR normal-mild
- Discriminator
- Rash overlying implant; positive patch test / LTT; aseptic
- Key Features
- Pain, effusion, tissue staining, osteolysis
- Aspirate / Markers
- Metal particles; elevated serum Cr/Ni ions
- Discriminator
- Black/grey debris; ICP-MS; often mixed-metal or fretting source
- Key Features
- Mechanical pain on loading, lucency
- Aspirate / Markers
- Non-inflammatory; markers normal
- Discriminator
- No sinus/erythema; progressive radiographic lucency
- Key Features
- Asymptomatic bone thinning under plate
- Aspirate / Markers
- Normal
- Discriminator
- Cortical osteopenia beneath rigid plate; refracture risk post-removal
Management
Implant Selection Strategy
- Fracture fixation (temporary implant)
- No nickel allergy
- Cost considerations
- Intraoperative plate contouring required
- Known nickel allergy
- Permanent implant (prefer titanium)
- Existing titanium implant (galvanic corrosion)
- Need for MRI follow-up
- Recommendation
- Use titanium
- Rationale
- Avoid hypersensitivity
- Recommendation
- Use SS
- Rationale
- Effective and economical
- Recommendation
- Use titanium
- Rationale
- Avoid galvanic corrosion
Surgical Technique
Implant Handling
- SS is ductile (can be bent intraoperatively)
- Work-hardening strengthens bent areas
- Avoid excessive bending (notch sensitivity)
- Match screw type to plate system
- Avoid cross-threading
- Maintain uniform torque
- SS Advantage
- Ductile, malleable
- Precaution
- Work-hardens with each bend
- SS Advantage
- Standard technique
- Precaution
- Avoid cross-threading
- SS Advantage
- Never mix with Ti
- Precaution
- Galvanic corrosion risk
Complications
SS Implant Complications
- Crevice corrosion (under screw heads)
- Fretting corrosion (plate-screw micromotion)
- Galvanic corrosion (mixed with titanium)
- Pitting corrosion (localized oxide breakdown)
- Nickel hypersensitivity (Type IV)
- Metallosis (tissue staining, osteolysis)
- Stress shielding (bone resorption)
- Mechanism
- Low O₂ under screw heads
- Prevention
- Minimize crevice design
- Mechanism
- Plate-screw micromotion
- Prevention
- Rigid fixation
- Mechanism
- Mixed metals (SS + Ti)
- Prevention
- Never mix metals
Postoperative Care
Post-Implantation Monitoring
- Serial radiographs for fracture healing
- Monitor for implant loosening
- Watch for signs of metal reaction
- Optional once fracture healed
- Consider if nickel sensitivity develops
- Reduces long-term corrosion exposure
- Possible Cause
- Nickel allergy
- Action
- Consider removal
- Possible Cause
- Metallosis/loosening
- Action
- Investigate, consider removal
- Possible Cause
- Corrosion/osteolysis
- Action
- Metal ions, removal if progressive
Outcomes
Stainless Steel Implant Outcomes
- Union rates equivalent to titanium
- Cost-effective for trauma fixation
- Reliable performance for temporary implants
- Corrosion-related issues: 1-5%
- Metal hypersensitivity: Less than 1% symptomatic
- Stress shielding: Variable
- Stainless Steel
- Equivalent
- Titanium
- Equivalent
- Stainless Steel
- Higher
- Titanium
- Lower
- Stainless Steel
- More (stiffer)
- Titanium
- Less
- Stainless Steel
- Lower
- Titanium
- Higher
Nitrogen-Strengthened, Low-Nickel Stainless Steels
The standards card, guidelines and controversies all name a "higher-nitrogen, low-nickel" or "nickel-free" grade (ASTM F1586 / ISO 5832-9) as an alternative, and a viva mentions using nitrogen or manganese to stabilise the austenite - but what these steels are and why they exist is never explained.
- Why they were developed. Conventional 316L relies on nickel to hold the austenitic (FCC) phase, but nickel is the commonest contact allergen and only a modest strengthener. Adding nitrogen (an interstitial element) does both jobs better: it is a strong austenite stabiliser (so nickel can be cut or removed) AND a potent solid-solution strengthener.
- The two families. (1) High-nitrogen, reduced-nickel wrought grades (ASTM F1586 / ISO 5832-9; e.g. "REX 734") keep some nickel but add roughly 0.3-0.9% nitrogen for markedly higher yield and fatigue strength than 316L. (2) Essentially nickel-free, high-manganese/high-nitrogen austenitic steels (e.g. "BioDur 108") use manganese plus nitrogen to hold the austenite with almost no nickel, for the genuinely nickel-sensitive patient.
- What you gain. Higher yield and fatigue strength (allowing thinner, stronger implants), better pitting and crevice-corrosion resistance (nitrogen stabilises the passive film), and lower nickel content and ion release.
- The caveats. They are more expensive, less universally stocked, and - as the controversies note - have limited long-term clinical outcome data, so they are not yet standard of care; most nickel-allergic patients are still served well by titanium or even standard alloys.
Q: What is a nitrogen-strengthened, low-nickel stainless steel and why use one? A: A high-nitrogen austenitic stainless steel (ASTM F1586 / ISO 5832-9, e.g. REX 734; or the nearly nickel-free high-manganese BioDur 108) in which nitrogen replaces much or all of the nickel as the austenite stabiliser. Nitrogen is also a strong interstitial solid-solution strengthener, so these steels have higher yield and fatigue strength and better pitting/crevice resistance than 316L, with much less nickel. Downsides: cost, limited availability and limited long-term clinical data - so they are not yet standard of care.
Cold Working, Work Hardening and Annealing
The topic states that 316L is cold-worked for strength and annealed for ductility (yield ~200 MPa annealed versus ~1000 MPa cold-worked) and that it "work-hardens" when bent, and a viva followUp asks how these processes change the properties - but the underlying mechanism is never given.
- Work hardening (the mechanism). Plastic deformation occurs by the movement of dislocations (line defects) through the crystal lattice. Deforming the metal multiplies dislocations and tangles them, so they increasingly obstruct one another's motion; more stress is then needed to keep deforming - the metal becomes stronger (higher yield) but less ductile. This is why bending a plate strengthens the bent zone, and why over-bending or repeated re-bending embrittles it.
- Cold working. Deforming (rolling, drawing, forging) below the recrystallisation temperature work-hardens the steel throughout, raising yield strength toward ~1000 MPa at the cost of ductility. Implants are supplied cold-worked when strength matters.
- Annealing. Heating above the recrystallisation temperature lets new strain-free grains nucleate and grow (recrystallisation), dissolving the tangled dislocations - the steel returns to a soft, ductile state (yield ~200 MPa). Annealed stock is chosen when the surgeon needs to contour the implant on the table.
- The trade-off in theatre. Ductility lets you contour a plate, but every bend work-hardens and locally embrittles it; contour smoothly, avoid sharp bends over screw holes, and never bend-then-reverse - the accumulated cold work plus a stress-concentrating notch is a classic site for fatigue failure.
Q: What is the difference between cold working and annealing in stainless steel, and by what mechanism? A: Plastic deformation moves dislocations; cold working (deforming below the recrystallisation temperature) multiplies and tangles dislocations so they impede each other - the steel becomes stronger (yield toward ~1000 MPa) but less ductile (work hardening). Annealing (heating above the recrystallisation temperature) grows new strain-free grains (recrystallisation) that erase the dislocation tangles, returning the steel to a soft, ductile state (yield ~200 MPa). Implants are cold-worked for strength; annealed stock is used for intraoperative contouring - but every bend work-hardens and notches the plate, a fatigue-failure risk.
Guidelines, Registries & Global Practice
Standards & Global Epidemiology
- ASTM F138/F139 and ISO 5832-1 define implant-grade wrought 316L stainless steel
- ASTM F1586 / ISO 5832-9: nitrogen-strengthened, low-nickel high-strength grades
- Carbon kept under 0.03% ("L") to prevent sensitisation/intergranular corrosion
- Nickel is the commonest contact allergen worldwide
- Adult prevalence ~8-19% (Europe), ~14% (US), with strong female predominance
- Symptomatic deep-implant hypersensitivity is uncommon and difficult to prove
- Detail
- SS markedly cheaper than titanium
- Relevance
- Dominant in cost- and resource-limited trauma care worldwide
- Detail
- Universally stocked; simple manufacture
- Relevance
- Workhorse for fracture fixation globally
- Detail
- Ductile, easily bent intraoperatively
- Relevance
- Valued where pre-contoured anatomic plates are unavailable
Controversies & Areas of Uncertainty
- Cutaneous allergy vs deep implant failure: Whether a positive skin patch test predicts symptomatic peri-implant hypersensitivity remains unresolved. Most nickel-allergic patients tolerate stainless steel and CoCr implants; the Siljander 2023 TKA cohort found no difference in revision between CoCr and nickel-free implants in nickel-allergic patients. Routine use of costly nickel-free implants for skin allergy alone is not strongly supported.
- Best test for implant metal allergy: Patch testing reflects skin sensitisation, not necessarily deep-tissue reactivity; the lymphocyte transformation test (LTT) may be more specific but is not widely validated or available. No gold-standard diagnostic test exists.
- Routine implant removal after union: Whether to remove stainless steel hardware after fracture healing (to reduce long-term corrosion exposure and stress shielding, balanced against refracture and re-operation risk) is debated and largely driven by symptoms and patient factors rather than firm evidence.
- Stainless steel vs titanium for trauma: No high-quality RCT demonstrates a difference in union rates; choice is driven by cost, MRI needs, intraoperative contourability and allergy rather than proven outcome superiority.
- Nitrogen-strengthened low-/nickel-free steels: Higher-strength, reduced-nickel austenitic grades exist but have limited long-term clinical outcome data and are not yet standard of care.
MANIAWhen to Choose Titanium over Stainless Steel
Hook:Titanium for the MANIA cases
MCQ Practice Points
Q: What is the composition and significance of 316L stainless steel used in orthopaedic implants?
A: 316L contains: Iron (~60% base), Chromium (17-20% for passivation via Cr₂O₃ oxide layer), Nickel (12-14% to stabilize austenite), Molybdenum (2-4% for pitting corrosion resistance). The "L" designates low carbon (less than 0.03%). Low carbon prevents chromium carbide precipitation at grain boundaries, which would deplete chromium and cause intergranular corrosion (sensitization).
Q: Why is stainless steel austenitic (FCC) structure and what properties does this confer?
A: Nickel stabilizes the Face-Centered Cubic (austenitic) phase at room temperature. Properties: (1) Non-magnetic - allows MRI imaging (though creates artifact), (2) Ductile - can be contoured intraoperatively, (3) Work-hardenable - becomes stronger when cold-worked/bent. Cannot be heat-treated for hardening unlike martensitic steel.
Q: What are the types of corrosion affecting stainless steel implants and their mechanisms?
A: (1) Crevice corrosion: Under screw heads where low oxygen prevents re-passivation of the chromium oxide layer. (2) Fretting corrosion: Micro-motion between plate and screw disrupts oxide layer. (3) Galvanic corrosion: When mixed with more noble metals (titanium), SS becomes the anode and corrodes. (4) Pitting corrosion: Localized breakdown of passive layer, resisted by molybdenum content.
Q: What is the clinical significance of nickel in stainless steel implants?
A: Nickel allergy (Type IV hypersensitivity) affects 10-15% of females and 2% of males. Clinical presentations include: dermatitis over implant, chronic pain, aseptic loosening. While cutaneous patch test positivity does not strongly predict implant failure, patients with severe nickel allergy (cheap jewelry rash) should receive titanium implants instead. Titanium is nickel-free.
Q: How does stainless steel compare to titanium for fracture fixation implants?
A: Stainless steel: Higher modulus (200 GPa) provides rigid fixation but causes more stress shielding; lower cost; significant MRI artifact; ductile (can be bent intraoperatively); contains nickel allergen. Titanium: Lower modulus (110 GPa) closer to bone, less stress shielding; higher cost; minimal MRI artifact; excellent biocompatibility; no nickel. SS preferred for temporary fixation, Ti for permanent implants or nickel-allergic patients.
At a Glance
316L stainless steel is an iron-based alloy with chromium (17-20%) for passivation via Cr₂O₃ oxide layer formation, nickel (12-14%) to stabilize the austenitic (FCC) phase, molybdenum (2-4%) for pitting resistance, and low carbon (under 0.03%) to prevent sensitization. It has high stiffness (Young's modulus ~200 GPa) causing stress shielding, and is ductile allowing intraoperative plate contouring. Stainless steel is the most corrosion-susceptible orthopaedic alloy, prone to crevice corrosion under screw heads and fretting corrosion at plate-screw interfaces. Nickel allergy affects 10-15% of females, requiring titanium alternatives in sensitized patients. Never mix with titanium due to galvanic corrosion risk.
Cr-Ni-Mo-L316L Composition
Hook:ChRoMe NiMo - Low Carbon
Mechanical Properties
- Young's Modulus: ~200 GPa.
- Bone is ~15-20 GPa.
- High stiffness mismatch causes Stress Shielding.
- Yield Strength: Depends on processing (Annealed ~200 MPa vs Cold Worked ~1000 MPa).
- Fatigue Strength: Moderate.
- Ductility: High (allows plate bending).
Corrosion
Stainless Steel is the most susceptible of the modern orthopaedic alloys to corrosion.
- Crevice Corrosion: Under screw heads (low oxygen causes oxide layer to break down, and Cr cannot re-passivate).
- Fretting Corrosion: Micro-motion between plate and screw.
- Galvanic Corrosion: If mixed with Titanium (SS is the anode/active, Ti is cathode/noble). Never mix metals.
CFGPCorrosion Types of Stainless Steel
Hook:Crevices Fret, Galvanic Pits
Mechanisms of Corrosion in Orthopaedic Metals
- Identifies 10 corrosion mechanisms: pitting, crevice, mechanically-assisted crevice corrosion, fretting, fretting-initiated crevice corrosion, taper corrosion, galvanic, stress/tension, fatigue and inflammatory-cell-induced corrosion
- Position on the galvanic series and the ability to maintain a passive oxide film determine implant longevity
- Bio-tribocorrosion disrupts the passive layer and initiates pitting at micromotion interfaces
- Corrosion proceeds by oxidative metal dissolution releasing cations, current flow to the cathode, then deposition of metal oxides/hydroxides
Stress Shielding and Implant Stiffness in Plate Fixation
- Higher plate stiffness improves construct stability but increases the stress-shielding effect on underlying bone
- Interfragmentary strain between 2% and 10% is required for callus formation
- Plate material and design are key variables for balancing fixation stability against stress shielding
- Lower-modulus implant materials reduce load transfer away from healing bone
Pathophysiology of Hypersensitivity to Metallic Implants
- Metal ions (Ni, Cr, Co) act as haptens and drive a delayed (Type IV), T-cell-mediated hypersensitivity response
- European skin sensitisation rates: nickel ~20%, chromium ~4%, cobalt ~7%
- United States skin sensitisation rates: nickel ~14%, chromium ~4%, cobalt ~9%
- Cross-reactivity occurs between metal allergens, relevant when choosing alternative alloys
Nickel Allergy: Epidemiology and Clinical Review
- Nickel is the most frequent cause of contact allergy worldwide
- European general-population prevalence ~8-19% in adults, 8-10% in children/adolescents, with strong female predominance
- Jewellery and metal in clothing remain the main exposure sources; EU nickel regulation reduced prevalence and severity
- Allergic nickel dermatitis may be localized to the exposure site, widespread, or present as hand eczema
Nickel Allergy and TKA Outcomes: CoCr vs Nickel-Free
- Retrospective review of 20,324 primary TKAs; 282 patients had documented preoperative nickel allergy
- 243 received a nickel-free implant and 39 received a standard cobalt-chromium implant
- No significant difference in revision rate (survivorship 98% nickel-free vs 94% CoCr, P=0.9)
- No difference in KOOS-JR, VAS, LEAS, PROMIS or VR-12 scores between groups at 6 weeks or 1 year
Material Comparison
Stainless Steel vs Titanium
Standards for Implant-Grade Stainless Steel
- ASTM F138/F139 specify wrought 316L (low-carbon) stainless steel bar/wire and sheet/strip for surgical implants
- ISO 5832-1 is the international standard for wrought stainless steel for surgical implants
- Carbon is restricted to under 0.03% (the 'L' grade) to prevent sensitisation and intergranular corrosion
- Higher-nitrogen, low-nickel grades (ASTM F1586, ISO 5832-9) offer improved strength and reduced nickel content
Exam Viva Scenarios
Practise clinical reasoning and management decisions out loud
“You are consenting a patient for an ORIF of a distal radius fracture. She tells you she gets a rash from cheap earrings. What are the implications for your implant choice?”
“A 55-year-old patient underwent ORIF of a distal femoral fracture 18 months ago. The original surgery used a stainless steel locking plate. He subsequently fell and sustained a proximal femoral shaft fracture above the plate. The on-call registrar added a retrograde femoral nail (titanium alloy) to stabilize the proximal fracture, overlapping with the existing stainless steel plate. Six months later, the patient presents with persistent thigh pain, swelling, and a draining sinus over the distal femur. X-rays show periosteal reaction and loosening of the distal screws. Aspiration of the sinus shows no bacterial growth on cultures, but analysis reveals metallic debris with elevated titanium and chromium ions. What is your diagnosis, what went wrong, and how do you manage this patient?”
“A 42-year-old woman underwent ORIF of a tibia-fibula fracture with a stainless steel plate and screws 2 years ago. She now presents with chronic pain, swelling, and occasional drainage from the surgical scar. She also mentions she has developed a rash on her skin overlying the plate. Examination shows warmth, erythema, and fluctuance over the plate. Aspiration shows turbid fluid with WBC 15,000 (predominantly lymphocytes), but routine bacterial cultures are negative at 5 days. Serum inflammatory markers are mildly elevated (CRP 25 mg/L, ESR 35 mm/h). X-rays show periosteal reaction and mild screw lucency but no fracture. The patient is frustrated and demands answers. What is your differential diagnosis, how do you investigate this systematically, and what is your management approach?”
Composition
- Iron (Base)
- Chromium (greater than 10.5% - Passivation)
- Nickel (Austenite)
- Molybdenum (Pitting)
Properties
- Modulus: 200 GPa (Stiff)
- Structure: FCC (Austenite)
- Processing: Cold Worked
Evidence Base
Key Evidence
- Ude/Laurencin (2023): galvanic-series position and passive-film integrity govern corrosion susceptibility
- Chung (2017): higher plate stiffness improves stability but increases stress shielding; IFS 2-10% needed for callus
- Ahlström/Thyssen (2019): nickel allergy ~8-19% of European adults, female predominant
- Siljander (2023): no difference in TKA revision between CoCr and nickel-free implants in nickel-allergic patients
- Finding
- Nickel allergy 8-19% adults, female predominant
- Implication
- Take a jewellery-allergy history before SS implant
- Finding
- No revision difference CoCr vs nickel-free in TKA
- Implication
- Skin allergy alone does not mandate nickel-free implant
- Finding
- Galvanic position + passive film drive corrosion
- Implication
- Explains SS crevice/fretting susceptibility
References
- Ahlström MG, Thyssen JP, Wennervaldt M, Menné T, Johansen JD. Nickel allergy and allergic contact dermatitis: a clinical review of immunology, epidemiology, exposure, and treatment. Contact Dermatitis. 2019;81(4):227-241. PMID: 31140194. doi:10.1111/cod.13327
- Siljander BR, Chandi SK, Debbi EM, McLawhorn AS, Sculco PK, Chalmers BP. A comparison of clinical outcomes after total knee arthroplasty in patients with preoperative nickel allergy receiving cobalt chromium or nickel-free implant. J Arthroplasty. 2023;38(7 Suppl 2):S194-S198. PMID: 37100098. doi:10.1016/j.arth.2023.04.048
- Ude CC, Dzidotor GK, Iloeje K, Nair LS, Laurencin CT. Corrosion of metals during use in arthroplasty. ACS Appl Bio Mater. 2023;6(6):2029-2042. PMID: 37261398. doi:10.1021/acsabm.2c01082
- Chung CY. A simplified application (APP) for the parametric design of screw-plate fixation of bone fractures. J Mech Behav Biomed Mater. 2017;77:642-648. PMID: 29101896. doi:10.1016/j.jmbbm.2017.10.025
- Kounis NG, Koniari I. Hypersensitivity to metallic implants: pathophysiologic and diagnostic considerations. Acta Biomed. 2018;89(3):428-429. PMID: 30333472. doi:10.23750/abm.v89i3.6718
- ASTM F138/F139; ISO 5832-1 / ISO 5832-9. Standard specifications for wrought 316L and nitrogen-strengthened stainless steel for surgical implants.