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Tsivelekas K, Pallis D, Lykos S, Triantafyllou E, Nikolakakos P, Tilentzoglou A, Papadakis SA. Patella Fracture After Total Knee Arthroplasty: A Review. Cureus 2024; 16:e53281. [PMID: 38435881 PMCID: PMC10905318 DOI: 10.7759/cureus.53281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/05/2024] Open
Abstract
The management and underlying causes of patellar periprosthetic fractures (PPF) after total knee arthroplasty (TKA) constitute an issue of growing importance given the rising frequency of these procedures. Patella periprosthetic fractures, though relatively rare, pose significant challenges and are a frequent indication for revision surgeries. Despite a decrease in overall incidence, PPFs remain the second most common type of periprosthetic fractures after TKA. Several factors have been identified and associated with patient-specific factors, surgical technique errors, and implant-related causes. Currently extensor apparatus integrity, bone stock, and component loosening are the major concerns and indications for the selective treatment approach. In this study, a thorough review of the existing literature was performed summarizing the epidemiology, clinical manifestation, treatment approach, and functional outcome of PPF. This review aims to underline the significance of such predisposing factors, point out the severity of PPF, and offer insights into the optimal intra- and post-operative management of the patella.
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Affiliation(s)
| | - Dimitrios Pallis
- Second Department of Orthopaedics, KAT General Hospital of Attica, Athens, GRC
| | - Stavros Lykos
- Second Department of Orthopaedics, KAT General Hospital of Attica, Athens, GRC
| | | | - Petros Nikolakakos
- Second Department of Orthopaedics, KAT General Hospital of Attica, Athens, GRC
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Gustke KA, Simon P, Meheux CJ. Metal-Backed Patella Implants in Knee Arthroplasty: Can the Past Predict the Future? J Arthroplasty 2023; 38:S131-S136. [PMID: 36791886 DOI: 10.1016/j.arth.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND There is a renewed interest in uncemented total knee arthroplasty to potentially provide longer durability, including the use of newer design metal-backed patellae (MBPs). The purpose of this study was to review survivorship with failure mode and time to failure of an earlier version MBP at up to 10-30 years of follow-up that may influence the desirability of using these components today. METHODS A retrospective review was performed of patients that had uncemented total knee arthroplasty with an uncemented MBP. All-cause revision rates were obtained from chart reviews and telephone discussions with patients and family members of deceased patients. Kaplan-Meier plots were used to determine the implant survivorship. Outcome scores were compared between revised and nonrevised patients. RESULTS The 97 knees that had an end point of an aseptic revision or last known contact with implant survivorship averaged 15 years (range, 0-32 years). There were 40 knees that underwent revision that included 37 patella component failures (38.1%). All patellar failures had polyethylene wear or fracture. None were revised due to loosening. Survivorship was 97.9% at 5 years, 88.7% at 10 years, and 53.0% at 20 years. Median time to failure was 11 years. CONCLUSION Loosening is not a failure mode with this MBP. There were 75% of the failures occurring after 10 years. Use of contemporary MBP with improved but still thin polyethylene warrants guarded optimism when used in younger patients where longer survivorship than with a cemented all-polyethylene patellar component is the goal.
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Affiliation(s)
- Kenneth A Gustke
- Florida Orthopaedic Institute, Tampa, Florida; Department of Orthopaedic Surgery, University of South Florida College of Medicine, Tampa, Florida
| | - Peter Simon
- Foundation for Orthopaedic Research & Education, Tampa, Florida; Department of Medical Engineering, University of South Florida, Tampa, Florida
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Gkiatas I, Karasavvidis T, Sharma AK, Xiang W, Malahias MA, Chalmers BP, Sculco PK. Highly cross-linked polyethylene in primary total knee arthroplasty is associated with a lower rate of revision for aseptic loosening: a meta-analysis of 962,467 cases. Arch Orthop Trauma Surg 2022; 142:1177-1184. [PMID: 33847797 DOI: 10.1007/s00402-021-03887-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA. METHODS The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: "cross-linked", "polyethylene", "HXLPE", "conventional", "total knee arthroplasty", "TKA", "total knee replacement" and "TKR" combined with Boolean operators AND and OR. RESULTS Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39-1.18; I2: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20-1.49; I2: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31-0.39; I2: 0.0%). CONCLUSION The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.
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Affiliation(s)
- Ioannis Gkiatas
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10022, USA.
| | - Theofilos Karasavvidis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Abhinav K Sharma
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, 10022, USA
| | - William Xiang
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10022, USA
| | - Michael-Alexander Malahias
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10022, USA
| | - Brian P Chalmers
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, 10022, USA
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10022, USA
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Abdelgaied A, Fisher J, Jennings L. Understanding the differences in wear testing method standards for total knee replacement. J Mech Behav Biomed Mater 2022; 132:105258. [DOI: 10.1016/j.jmbbm.2022.105258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 03/04/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
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McConaghy K, Derr T, Molloy RM, Klika AK, Kurtz S, Piuzzi NS. Patellar management during total knee arthroplasty: a review. EFORT Open Rev 2021; 6:861-871. [PMID: 34760286 PMCID: PMC8559560 DOI: 10.1302/2058-5241.6.200156] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The optimal management of the patella during total knee arthroplasty (TKA) remains controversial and surgeons tend to approach the patella with one of three general mindsets: always resurface the patella, never resurface the patella, or selectively resurface the patella based on specific patient or patellar criteria. Studies comparing resurfacing and non-resurfacing of the patella during TKA have reported inconsistent and contradictory findings. When resurfacing the patella is chosen, there are a number of available patellar component designs, materials, and techniques for cutting and fixation. When patellar non-resurfacing is chosen, several alternatives are available, including patellar denervation, lateral retinacular release, and patelloplasty. Surgeons may choose to perform any of these alone, or together in some combination. Prospective randomized studies are needed to better understand which patellar management techniques contribute to superior postoperative outcomes. Until then, this remains a controversial topic, and options for patellar management will need to be weighed on an individual basis per patient.
Cite this article: EFORT Open Rev 2021;6:861-871. DOI: 10.1302/2058-5241.6.200156
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Affiliation(s)
- Kara McConaghy
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Tabitha Derr
- Implant Research Core, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Robert M Molloy
- Cleveland Clinic, Department of Orthopedic Surgery, Cleveland, Ohio, USA
| | - Alison K Klika
- Cleveland Clinic, Department of Orthopedic Surgery, Cleveland, Ohio, USA
| | - Steven Kurtz
- Implant Research Core, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA.,Exponent, Philadelphia, Pennsylvania, USA
| | - Nicolas S Piuzzi
- Cleveland Clinic, Department of Orthopedic Surgery, Cleveland, Ohio, USA
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6
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Schwiesau J, Fritz B, Bergmann G, Puente Reyna AL, Schilling C, Grupp TM. Influence of radiation conditions on the wear behaviour of Vitamin E treated UHMWPE gliding components for total knee arthroplasty after extended artificial aging and simulated daily patient activities. J Mech Behav Biomed Mater 2021; 122:104652. [PMID: 34246078 DOI: 10.1016/j.jmbbm.2021.104652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 10/21/2022]
Abstract
The long term performance of total knee arthroplasty (TKA) with regards to the bearing materials is related to the aging behaviour of these materials. The use of highly crosslinked materials in hip arthroplasty improved the clinical outcome. Nevertheless, the outcome for these materials compared to conventional UHMWPE (ultra-high molecular weight polyethylene) remains controversial in TKA and alternative bearing materials may be advantageous to improve its outcome in the second and third decade. The aim of this study is the evaluation of the influence of radiation conditions on the wear behaviour of Vitamin E blended UHMWPE gliding components for TKA by simulation of extended aging and high demanding daily patient activities. For a medium radiation dose (30 kGy), the influence of the irradiation type (E-beam or Gamma radiation) and the thermal conditions (room temperature (RT) or heated to 115 °C) are evaluated in comparison to non-irradiated material. Significant influences on the wear behaviour were found for the radiation source and temperature during irradiation. Furthermore, no relevant degradation of the tested materials was observed after extended artificial aging. There was a good correspondence between the wear pattern in this study and retrievals.
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Affiliation(s)
- Jens Schwiesau
- Aesculap AG Research & Development, Tuttlingen, Germany; Ludwig Maximilians University Munich Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern, Munich, Germany.
| | | | - Georg Bergmann
- Julius Wolff Institute, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Thomas M Grupp
- Aesculap AG Research & Development, Tuttlingen, Germany; Ludwig Maximilians University Munich Department of Orthopaedic Surgery, Physical Medicine & Rehabilitation, Campus Grosshadern, Munich, Germany
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Mulliez MA, Schilling C, Grupp TM. Equivalent mechanical properties of X‐ray and E‐beam cross‐linked vitamin E blended ultrahigh molecular weight polyethylene. J Biomed Mater Res B Appl Biomater 2020; 108:2131-2140. [DOI: 10.1002/jbm.b.34552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 12/11/2019] [Accepted: 12/20/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Marie Anne Mulliez
- Aesculap AGResearch & Development Tuttlingen Germany
- Department of Orthopaedics Surgery, Physical Medicine & Rehabilitation. Campus GrosshadernLudwig Maximilians University Munich Germany
| | | | - Thomas M. Grupp
- Aesculap AGResearch & Development Tuttlingen Germany
- Department of Orthopaedics Surgery, Physical Medicine & Rehabilitation. Campus GrosshadernLudwig Maximilians University Munich Germany
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Satti A, Ressia J, Molinari E, Ciolino A, Vallés E. Metallocenic polyolefin composites with siloxane polymer additives. Radiat Phys Chem Oxf Engl 1993 2018. [DOI: 10.1016/j.radphyschem.2018.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Brockett CL, Carbone S, Fisher J, Jennings LM. Influence of conformity on the wear of total knee replacement: An experimental study. Proc Inst Mech Eng H 2018; 232:127-134. [PMID: 29251167 PMCID: PMC5808816 DOI: 10.1177/0954411917746433] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 10/26/2017] [Indexed: 11/21/2022]
Abstract
Wear of total knee replacement continues to be a significant factor influencing the clinical longevity of implants. Historically, failure due to delamination and fatigue directed design towards more conforming inserts to reduce contact stress. As new generations of more oxidatively stable polyethylene have been developed, more flexibility in bearing design has been introduced. The aim of this study was to investigate the effect of insert conformity on the wear performance of a fixed bearing total knee replacement through experimental simulation. Two geometries of insert were studied under standard gait conditions. There was a significant reduction in wear with reducing implant conformity. This study has demonstrated that bearing conformity has a significant impact on the wear performance of a fixed bearing total knee replacement, providing opportunities to improve clinical performance through enhanced material and design selection.
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Affiliation(s)
- Claire L Brockett
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - Silvia Carbone
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - John Fisher
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - Louise M Jennings
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
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Grupp TM, Stulberg D, Kaddick C, Maas A, Fritz B, Schwiesau J, Blömer W. Fixed Bearing Knee Congruency – Influence on Contact Mechanics, Abrasive Wear and Kinematics. Int J Artif Organs 2018; 32:213-23. [DOI: 10.1177/039139880903200405] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The objective of our study was to evaluate the in vitro wear behavior of fixed bearing designs for total knee arthroplasty in relation to contact mechanics and resultant kinematics for different degrees of congruency. A finite element model was created for three knee articulations with increasing degrees of tibio-femoral congruency (flat, curved, and dished design). For the three different knee design configurations, in vitro wear simulation was performed according to ISO 14243–1. Contact areas increased with increasing knee congruency, whereas the peak surface contact stresses decreased. The wear rates for the knee design configurations differed substantially between the three test groups (flat, curved, and dished). Our observations demonstrate that increased congruency in conjunction with decreased surface contact stresses significantly contributes to reducing wear in fixed bearing knee articulations.
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Affiliation(s)
- Thomas M. Grupp
- Aesculap AG Research & Development, Tuttlingen - Germany
- Ludwig Maximilian University - Clinic for Orthopedic Surgery, Grosshadern Medical Center, Munich - Germany
| | - Dave Stulberg
- Northwestern University Feinberg School of Medicine, Chicago, IL - USA
- Northwestern Memorial Hospital Dept. of Joint Reconstruction & Implant Surgery, Chicago, IL - USA
| | | | - Allan Maas
- Aesculap AG Research & Development, Tuttlingen - Germany
| | - Bernhard Fritz
- Aesculap AG Research & Development, Tuttlingen - Germany
| | - Jens Schwiesau
- Aesculap AG Research & Development, Tuttlingen - Germany
| | - Wilhelm Blömer
- Aesculap AG Research & Development, Tuttlingen - Germany
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11
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Brown TS, Van Citters DW, Berry DJ, Abdel MP. The use of highly crosslinked polyethylene in total knee arthroplasty. Bone Joint J 2017; 99-B:996-1002. [PMID: 28768774 DOI: 10.1302/0301-620x.99b8.bjj-2017-0028.r1] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 03/28/2017] [Indexed: 01/13/2023]
Abstract
Advances in polyethylene (PE) in total hip arthroplasty have led to interest and increased use of highly crosslinked PE (HXLPE) in total knee arthroplasty (TKA). Biomechanical data suggest improved wear characteristics for HXLPE inserts over conventional PE in TKA. Short-term results from registry data and few clinical trials are promising. Our aim is to present a review of the history of HXLPEs, the use of HXLPE inserts in TKA, concerns regarding potential mechanical complications, and a thorough review of the available biomechanical and clinical data. Cite this article: Bone Joint J 2017;99-B:996-1002.
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Affiliation(s)
- T S Brown
- Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - D W Van Citters
- Dartmouth College, 14 Engineering Drive, Hanover, NH 03755, USA
| | - D J Berry
- Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - M P Abdel
- Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
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12
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Morlock MM, Jäger M. [Endoprostheses in the elderly : Biomaterials, implant selection and fixation technique]. DER ORTHOPADE 2017; 46:4-17. [PMID: 27966180 DOI: 10.1007/s00132-016-3361-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The replacement of hip and knee joints is one of the greatest success stories in orthopedics. Due to continuous improvement of biomaterials and implant design, patient-associated problems are now mostly multifactorial and only rarely caused by the implant. Abrasion was significantly reduced by the introduction of highly cross-linked polyethylene (PE), antioxidant stabilized PE, new ceramics and the development of ceramic and protective surfaces. It is assumed that further reduction of frictional resistance will not lead to a significantly better clinical result: however, the problem of periprosthetic infections and implant-related incompatibility is still unsolved and remains challenging for biomaterial research. For the knee joint PE will be irreplaceable for joint articulation even in the future due to the contact situation. Mobile bearings and fixed bearings are two established successful philosophies, which have shown comparably good clinical results. For the hip joint, it is forecasted that ceramic-on-ceramic will be the system of the future if the correct positioning and mounting of the components can be solved so that the problems, such as development of noise and breakage can be reduced to a minimum. An in-depth understanding and detailed knowledge of the biomaterials by the surgeon can prevent implant-related problems. For elderly patients it is assumed that the economic burden on the public healthcare system will have the strongest impact on implant selection.
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Affiliation(s)
- M M Morlock
- Institut für Biomechanik, TUHH Hamburg University of Technology, Denickestr. 15, 21073, Hamburg, Deutschland.
| | - M Jäger
- Klinik für Orthopädie und Unfallchirurgie, Universität Duisburg-Essen, Hufelandstr. 55, 45274, Essen, Deutschland
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Grupp TM, Fritz B, Kutzner I, Schilling C, Bergmann G, Schwiesau J. Vitamin E stabilised polyethylene for total knee arthroplasty evaluated under highly demanding activities wear simulation. Acta Biomater 2017; 48:415-422. [PMID: 27789345 DOI: 10.1016/j.actbio.2016.10.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/30/2016] [Accepted: 10/22/2016] [Indexed: 01/12/2023]
Abstract
As total knee arthroplasty (TKA) patients are getting more active, heavier and younger and structural material fatigue and delamination of tibial inserts becomes more likely in the second decade of good clinical performance it appears desirable to establish advanced pre-clinical test methods better characterizing the longterm clinical material behaviour. The questions of our study were 1) Is it possible to induce subsurface delamination and striated pattern wear on standard polyethylene TKA gliding surfaces? 2) Can we distinguish between γ-inert standard polyethylene (PEstand.30kGy) as clinical reference and vitamin E stabilised materials (PEVit.E30kGy & PEVit.E50kGy)? 3) Is there an influence of the irradiation dose (30vs 50kGy) on oxidation and wear behaviour? Clinical relevant artificial ageing (ASTM F2003; 2weeks) of polyethylene CR fixed TKA inserts and oxidation index measurements were performed by Fourier transform infrared spectroscopy prior testing. The oxidation index was calculated in accordance with ISO 5834-4:2005 from the area ratio of the carbonyl peak (between 1650 and 1850cm-1) to the reference peak for polyethylene (1370cm-1). Highly demanding patient activities (HDA) measured in vivo were applied for 5million knee wear cycles in a combination of 40% stairs up, 40% stairs down, 10% level walking, 8% chair raising and 2% deep squatting with up to 100° flexion. After 3.0mc all standard polyethylene gliding surfaces developed noticeable areas of progressive delamination. Cumulative gravimetric wear was 355.9mg for PEstand.30kGy, 28.7mg for PEVit.E30kGy and 26.5mg for PEVit.E50kGy in HDA knee wear simulation. Wear rates were 12.4mg/mc for PEstand.30kGy in the linear portion (0-2mc), 5.6mg/mc for PEVit.E30kGy and 5.3mg/mc for PEVit.E50kGy. In conclusion, artificial ageing of standard polyethylene to an oxidation index of 0.7-0.95 in combination with HDA knee wear simulation, is able to create subsurface delamination, structural material fatigue in vitro, whereas for the vitamin-E-blended materials no evidence of progressive wear, fatigue or delamination was found. STATEMENT OF SIGNIFICANCE As total knee arthroplasty patients are getting more active, heavier and younger and structural material fatigue and delamination of polyethylene tibial inserts becomes more likely in the second decade of good clinical performance, it appears desirable to establish advanced pre-clinical test methods better characterizing the longterm clinical material behaviour. Various studies reported in literature attempted to artificially create delamination during in vitro knee wear simulation. We combined artificial ageing to clinically observed oxidation of gamma inert and vitamin E stabilised polyethylene inserts and highly demanding patient activities knee wear simulation based on in vivo load data. With this new method we were able to create clinically relevant subsurface delamination and structural material fatigue on standard polyethylene inserts in vitro.
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Wernle JD, Mimnaugh KD, Rufner AS, Popoola OO, Argenson JN, Kelly M. Grafted Vitamin-E UHMWPE may increase the durability of posterior stabilized and constrained condylar total knee replacements. J Biomed Mater Res B Appl Biomater 2016; 105:1789-1798. [PMID: 27192378 DOI: 10.1002/jbm.b.33710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/27/2015] [Accepted: 05/01/2016] [Indexed: 11/08/2022]
Abstract
The suitability of grafted vitamin-E highly crosslinked polyethylene (VE-HXPE) for use in posterior stabilized (PS) and constrained condylar knee (CCK) applications has not been explored. We hypothesized that VE-HXPE performs better than conventional and crosslinked polyethylene under clinically relevant conditions. PS tibial post fracture resistance under adverse shear loading conditions, CCK tibial post resistance to torsional fatigue, delamination resistance under high stress, and wear resistance were evaluated. Grafted VE-HXPE exhibits (1) 10% and 57% improved PS post fatigue strength compared to conventional PE (CPE) and remelted HXPE; (2) 45% improved CCK post fatigue strength compared to CPE; (3) Greater than 36× the delamination resistance of CPE; and (4) 96% and 73% wear reduction compared to CPE and HXPE. VE-HXPE performed well under clinically relevant in vitro conditions. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 105B: 1789-1798, 2017.
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Affiliation(s)
| | | | | | | | - Jean-Noel Argenson
- Center for Arthritis Surgery, Hospital Sainte-Marguerite, Aix-Marseille University, Marseille, France
| | - Michael Kelly
- Hackensack University Medical Center, Hackensack, New Jersey
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de Steiger RN, Muratoglu O, Lorimer M, Cuthbert AR, Graves SE. Lower prosthesis-specific 10-year revision rate with crosslinked than with non-crosslinked polyethylene in primary total knee arthroplasty. Acta Orthop 2015; 86:721-7. [PMID: 26119884 PMCID: PMC4750773 DOI: 10.3109/17453674.2015.1065046] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE While highly crosslinked polyethylene has shown reduced in vivo wear and lower rates of revision for total hip arthroplasty, there have been few long-term studies on its use in total knee arthroplasty (TKA). We compared the rate of revision of non-crosslinked polyethylene to that of crosslinked polyethylene in patients who underwent TKA for osteoarthritis. PATIENTS AND METHODS We examined data from the Australian Orthopaedic Association National Joint Replacement Registry on 302,214 primary TKA procedures with non-crosslinked polyethylene and 83,890 procedures with crosslinked polyethylene, all of which were performed for osteoarthritis. The survivorship of the different polyethylenes was estimated using the Kaplan-Meier method and was compared using proportional hazard models. RESULTS The 10-year cumulative revision rate for non-crosslinked polyethylene was 5.8% (95% CI: 5.7-6.0) and for crosslinked polyethylene it was 3.5% (95% CI: 3.2-3.8) (> 6.5-year HR = 2.2 (1.5-3.1); p < 0.001). There was no effect of surgical volume or method of prosthesis fixation on outcome. There were 4 different TKA designs that had a minimum of 2,500 procedures in at least 1 of the polyethylene groups and a follow-up of ≥ 5 years. 2 of these, the NexGen and the Natural Knee II, had a lower rate of revision for crosslinked polyethylene. The Scorpio NRG/Series 7000 and the Triathlon Knee did not show a lower rate of revision for crosslinked polyethylene. INTERPRETATION There is a lower rate of revision for crosslinked polyethylene in TKA, and this appears to be prosthesis-specific and when it occurs is most evident in patients < 65 years of age. The difference in revision rates was mainly due to revisions because of lysis and loosening.
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Affiliation(s)
| | - Orhun Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle Lorimer
- Data Management and Analysis Centre, University of Adelaide, Adelaide, SA, Australia
| | - Alana R Cuthbert
- Data Management and Analysis Centre, University of Adelaide, Adelaide, SA, Australia
| | - Stephen E Graves
- Australian Orthopaedic Association National Joint Replacement Registry, Discipline of Public Health, University of Adelaide, Adelaide
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Utzschneider S, Lorber V, Dedic M, Paulus AC, Schröder C, Gottschalk O, Schmitt-Sody M, Jansson V. Biological activity and migration of wear particles in the knee joint: an in vivo comparison of six different polyethylene materials. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2014; 25:1599-1612. [PMID: 24562818 DOI: 10.1007/s10856-014-5176-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 02/10/2014] [Indexed: 06/03/2023]
Abstract
Wear of polyethylene causes loosening of joint prostheses because of the particle mediated activity of the host tissue. It was hypothesized that conventional and crosslinked polyethylene particles lead to similar biological effects around the knee joint in vivo as well as to a similar particle distribution in the surrounding tissues. To verify these hypotheses, particle suspensions of six different polyethylene materials were injected into knee joints of Balb/C mice and intravital microscopic, histological and immunohistochemical evaluations were done after 1 week. Whereas the biological effects on the synovial layer and the subchondral bone of femur and tibia were similar for all the polyethylenes, two crosslinked materials showed an elevated cytokine expression in the articular cartilage. Furthermore, the distribution of particles around the joint was dependent on the injected polyethylene material. Those crosslinked particles, which remained mainly in the joint space, showed an increased expression of TNF-alpha in articular cartilage. The data of this study support the use of crosslinked polyethylene in total knee arthroplasty. In contrast, the presence of certain crosslinked wear particles in the joint space can lead to an elevated inflammatory reaction in the remaining cartilage, which challenges the potential use of those crosslinked polyethylenes for unicondylar knee prostheses.
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Affiliation(s)
- S Utzschneider
- Department of Orthopedic Surgery, University Hospital of Munich (LMU), Campus Großhadern, Marchioninistraße 15, 81377, Munich, Germany,
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Paulus AC, Frenzel J, Ficklscherer A, Roßbach BP, Melcher C, Jansson V, Utzschneider S. Polyethylene wear particles induce TLR 2 upregulation in the synovial layer of mice. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2014; 25:507-513. [PMID: 24249629 DOI: 10.1007/s10856-013-5095-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 11/09/2013] [Indexed: 06/02/2023]
Abstract
A cellular and receptor mediated response to ultra-high-molecular-weight-polyethylene (UHMWPE) wear particles results in a release of proinflammatory cytokines and induces an inflammatory reaction causing osteolysis in total joint replacement. This investigation offers insight into the toll-like receptor (TLR) mediated activation by polyethylene wear particles in the synovial layer of mice. We hypothesized that, similar to recent in vitro results, UHMWPE particles lead to an upregulation of TLR 1 and 2 and TLR 4 in vivo in the synovial tissue of mice as well. Therefore, UHMWPE particles were generated in a common knee simulator according to the ISO standard, separated by acid digestion and determined by scanning electron microscopy. Endotoxin was removed using a method based on ultracentrifugation. A particle suspension (50 μl; 0.1 vol./vol.%) was injected into the left knee joint of female Balb/c mice (n = 8). In a control group, phosphate-buffered saline was injected into the left knee of Balb/c mice (n = 8). The mice were sacrificed after 7 days. Immunohistochemical staining was performed with TLR 1, 2 and 4 polyclonal antibodies for Balb/c mice and evaluated by light microscopy. The particle-stimulated group showed a thickened synovial layer, an increased cellular infiltration and a TLR 2-upregulation in the synovial layer compared to the control group. An increased expression of TLR 1 and TLR 4 could not be demonstrated. These results indicate a mainly TLR 2-induced inflammation to polyethylene wear debris in the synovial layer of mice.
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Affiliation(s)
- A C Paulus
- Department of Orthopaedic Surgery, University Hospital of Munich (LMU), Campus Großhadern, Marchioninistr. 15, 81377, Munich, Germany,
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Sakellariou VI, Sculco P, Poultsides L, Wright T, Sculco TP. Highly cross-linked polyethylene may not have an advantage in total knee arthroplasty. HSS J 2013; 9:264-9. [PMID: 24426878 PMCID: PMC3772158 DOI: 10.1007/s11420-013-9352-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 07/16/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Long-term results after total knee replacement (TKR) with conventional and compression-molded polyethylene (PE) have been excellent. The introduction of highly cross-linked polyethylene (XLPE), which has demonstrated superior wear properties in total hip replacement (THR), has led to its recent use in TKR. However, the knee has a unique biomechanical environment characterized by large contact stresses and shear forces and differs from the highly conforming articulation (and primarily abrasive and adhesive wear) found in THR. For this reason, XLPE, with its decreased fatigue resistance and toughness compared to PE, may not be the best material to withstand these unique forces. QUESTIONS This review and evaluation of the literature aims to answer the following questions. What are the advantages and disadvantages of XLPE in TKR? Does its success in THR ensure a favorable outcome in TKR? Does the increased cost of XLPE justify its use in TKR? METHODS A systematic literature review of MEDLINE, Science Direct, and Google Scholar databases was performed searching for advantages and disadvantages of XLPE in TKR. We found 18 biomechanical in vitro investigations and 3 clinical studies comparing conventional and XLPEs. We included levels I through IV published articles in peer-reviewed journals in English language. RESULTS Several in vitro studies found XLPE to have significantly better wear properties compared to conventional PE. However, the two clinical investigations that directly compared conventional PE and XLPE found no difference in clinical or radiographic outcomes. Additionally, clinical studies with long-term follow-up on TKR with conventional PE did not find wear-induced osteolysis to be a major cause of failure. Four studies did find cost to be significantly higher for XLPE compared to conventional PE. CONCLUSIONS Based on our review, we concluded that (1) the material properties of XLPE reduce adhesive and abrasive wear, but not the risk of crack propagation, deformation, pitting, and delamination found in TKR; (2) wear-induced osteolysis in TKR has not been found to be a major cause of failure at long-term follow-up; (3) mid-term follow-up studies show no difference in any recorded outcome measure between conventional PE and XLPE; and (4) XLPE is two to four times the cost of conventional PE without an improvement in clinical or radiographic outcomes. For these reasons, we currently cannot recommend the use of XLPE in TKR. Conventional compression-molded polyethylene with its outstanding long-term results should remain the material of choice in TKR.
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Affiliation(s)
| | - Peter Sculco
- Hospital for Special Surgery, 535 East 70th street, New York, NY 10021 USA
| | - Lazaros Poultsides
- Hospital for Special Surgery, 535 East 70th street, New York, NY 10021 USA
| | - Timothy Wright
- Hospital for Special Surgery, 535 East 70th street, New York, NY 10021 USA
| | - Thomas P. Sculco
- Hospital for Special Surgery, 535 East 70th street, New York, NY 10021 USA
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Brockett CL, Jennings LM, Hardaker C, Fisher J. Wear of moderately cross-linked polyethylene in fixed-bearing total knee replacements. Proc Inst Mech Eng H 2012; 226:529-35. [DOI: 10.1177/0954411912445265] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cross-linked polyethylene has been introduced into total joint replacement to improve wear resistance. Although the performance of highly cross-linked polyethylene is well documented clinically and experimentally for total hip replacements, the reduction in mechanical properties with increasing irradiation is of concern for application to total knee replacement. The aim of this study was to investigate the wear performance of a moderately cross-linked polyethylene material in a fixed-bearing total knee replacement. The study was conducted using two femoral geometries, a conventional cruciate-retaining femoral and a high-flexion femoral geometry. The femoral geometry appeared to have no effect on the wear of the knee replacement under standard gait conditions. A significant reduction in wear volume was measured with the moderately cross-linked polyethylene compared with the conventional polyethylene over a six-million-cycle wear study. This study indicates the use of a moderately cross-linked polyethylene in a fixed-bearing total knee replacement may provide a low wearing option for total knee replacement.
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Affiliation(s)
| | | | | | - John Fisher
- School of Mechanical Engineering, University of Leeds, UK
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Brockett CL, Jennings LM, Fisher J. The wear of fixed and mobile bearing unicompartmental knee replacements. Proc Inst Mech Eng H 2011; 225:511-9. [DOI: 10.1177/2041303310393824] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Unicompartmental knee replacements (UKR) are an option for surgical intervention for the treatment of single-compartment osteoarthritis. The aim of this study was to compare the wear of a low-conformity fixed-bearing UKR with a conforming mobile bearing UKR under two kinematic conditions, to investigate the effect of implant design and kinematics on wear performance in a physiological knee wear simulator. Under both sets of kinematic conditions, the relatively low-conforming fixed UKR showed lower wear, compared with the more conforming anterior-posterior sliding mobile bearing. However, it should be noted that differences in materials between the two designs also contribute to the relative wear performance of the bearings. The combined wear of the medial and lateral bearings of the fixed-bearing UKR as a ‘total knee’ were significantly reduced compared with a fixed-bearing total knee replacement studied under the same kinematic conditions.
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Affiliation(s)
- C L Brockett
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - L M Jennings
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
| | - J Fisher
- Institute of Medical and Biological Engineering, School of Mechanical Engineering, University of Leeds, Leeds, UK
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Huot JC, Van Citters DW, Currier JH, Collier JP. The effect of radiation dose on the tensile and impact toughness of highly cross-linked and remelted ultrahigh-molecular weight polyethylenes. J Biomed Mater Res B Appl Biomater 2011; 97:327-33. [DOI: 10.1002/jbm.b.31818] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 12/02/2010] [Accepted: 01/03/2010] [Indexed: 11/07/2022]
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Abstract
Polyethylene wear, with resultant particle-induced osteolysis, is a cause of late failure of total knee arthroplasty. The causes of both wear and osteolysis are multifactorial; still, improvements in the polyethylene liner have been investigated. Available highly cross-linked polyethylene tibial liners and patellar prostheses differ greatly in the amount and method of irradiation, thermal treatments, and sterilization techniques they undergo. Several varieties of highly cross-linked polyethylene reduce the gravimetric and volumetric wear of tibial liners in knee simulator studies. However, reduced fracture toughness and the generation of smaller and possibly more reactive particles also have been reported with some varieties of polyethylene. Clinical studies of the use of highly cross-linked polyethylene in total knee arthroplasty are limited. Two nonrandomized trials of highly cross-linked polyethylene in total knee arthroplasty have reported a nonsignificant decrease in radiolucent lines at 2 and 5 years, respectively. The risks of using highly cross-linked polyethylene include fracture of the liner or of a posterior-stabilized tibial post, liner dislodgement or locking mechanism disruption, and possibly more osteolysis. Highly cross-linked polyethylene tibial liners may be considered for younger, more active patients. However, until additional clinical results are available, a cautious approach is warranted to the widespread use of highly cross-linked polyethylene in total knee arthroplasty.
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Crosslinked polyethylene in knee arthroplasty: a simulator study evaluating the positive influence on the tribocontact area in the fixed-bearing knee. Arch Orthop Trauma Surg 2010; 130:1419-24. [PMID: 20690024 DOI: 10.1007/s00402-010-1159-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Indexed: 02/09/2023]
Abstract
BACKGROUND Crosslinked polyethylene (XPE) was developed to reduce the wear rate in hip as well as knee arthroplasty. The crosslinking process reduces the mechanical properties of ultra-high-molecular-weight polyethylene (UHMWPE), particularly its fatigue strength. UHMWPE fatigue occurs more frequently in the knee than in the hip joint due to its changing tribocontact areas (TCAs) combined with high weight bearing. This is why XPE is still controversially discussed for use in total knee arthroplasty. Therefore, the potential advantage of using XPE in the knee was analysed in a simulator study with a focus on potential fatigue wear mechanisms. METHODS Three different kinds of XPE and one conventional UHMWPE were tested over 5 million cycles in fixed-bearing knee designs. The TCAs were examined by replicas, and their extent was measured. The wear mechanism was analysed by scanning electron microscopy. RESULTS The extent of the TCAs was less than 5% for all XPEs, whereas 35% for the conventional UHMWPE. Fatigue wear mechanisms were not observed. CONCLUSION The measured small extent of the TCAs as a predictor of a low wear rate without any fatigue wear mechanism shows a possible advantage for the use of XPE even in knee arthroplasty.
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Huot JC, Van Citters DW, Currier JH, Currier BH, Mayor MB, Collier JP. Evaluating the suitability of highly cross-linked and remelted materials for use in posterior stabilized knees. J Biomed Mater Res B Appl Biomater 2010; 95:298-307. [DOI: 10.1002/jbm.b.31714] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Williams PA, Brown CM, Tsukamoto R, Clarke IC. Polyethylene wear debris produced in a knee simulator model: Effect of crosslinking and counterface material. J Biomed Mater Res B Appl Biomater 2010; 92:78-85. [DOI: 10.1002/jbm.b.31491] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Utzschneider S, Paulus A, Datz JC, Schroeder C, Sievers B, Wegener B, Jansson V. Influence of design and bearing material on polyethylene wear particle generation in total knee replacement. Acta Biomater 2009; 5:2495-502. [PMID: 19375997 DOI: 10.1016/j.actbio.2009.03.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Revised: 03/05/2009] [Accepted: 03/11/2009] [Indexed: 12/28/2022]
Abstract
Periprosthetic osteolysis is one of the main reasons for revision of arthroplasty. The osteolytic reaction is influenced by the dose, size and shape of the wear particles. For arthroplasty, a low number and biologically less active particles are required. This is the first study which analyzes the impact of different knee designs, combined with crosslinked polyethylenes (sequentially irradiated and annealed as well as remelted techniques), on the amount, size and shape of particles. Overall, six material combinations, four of them with crosslinked polyethylene (XPE) and two of them with ultra-high molecular weight polyethylene (UHMWPE) inserts, including fixed and mobile bearings, were tested in a knee joint simulator. After isolation nearly 100,000 particles were analyzed in size, shape and number by scanning electron microscopy and image analysis. For all the designs, the wear was predominantly smooth and granular with few fibrillar particles. The Scorpio design with the X3 insert, the Natural Knee II design with the Durasul insert and the LCS design, also combined with a crosslinked polyethylene insert, generated statistically significant (P<0.05) lower particle numbers. The particle size was independent of the radiation dose. The wear generated by the LCS knee design (XPE and UHMWPE) had a higher percentage fraction of particles >1microm in size (equivalent circle diameter). The NexGen design, tested with the Prolong insert, showed a high number of particles in the biologically active size range compared with the other crosslinked designs, which could be a predictor for higher biological reactivity.
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Utzschneider S, Harrasser N, Schroeder C, Mazoochian F, Jansson V. Wear of contemporary total knee replacements--a knee simulator study of six current designs. Clin Biomech (Bristol, Avon) 2009; 24:583-8. [PMID: 19450910 DOI: 10.1016/j.clinbiomech.2009.04.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Revised: 04/13/2009] [Accepted: 04/18/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Compared to conventional ultra-high molecular weight polyethylene (UHMWPE), crosslinked polyethylene showed significantly reduced wear rate in hip simulation and early prospective-randomized clinical studies. The crosslinking process can reduce the mechanical properties of UHMWPE, particularly the fatigue strength. UHMWPE fatigue occurs more frequently in the knee joint than in the hip joint due to its higher contact stresses and there is therefore an increased concern of mechanical failure. Therefore, the purpose of this study was to determine the wear behaviour and the wear rates of different current knee designs and bearing materials. METHODS In a knee-joint-simulator four kinds of crosslinked polyethylene (one produced by sequential irradiation and annealing process, three by different remelting processes, including fixed- and mobile-bearing-types) and two UHMWPE- (fixed- and mobile-bearing) inserts were tested with the appropriate femoral and tibial component recommended from the manufacturer. FINDINGS All types of crosslinked polyethylene produced statistically significant (P<0.05) lower wear rates than the conventional UHMWPEs without any traces of fatigue. There were no differences in the wear rates between fixed-and mobile-bearings (crosslinked polyethylenes and UHMWPEs; P>0.05). The crosslinked polyethylene tibial inserts manufactured by sequential irradiation and annealing (X3) combined with the Scorpio-knee-design had the lowest wear rates (P<0.05) overall. INTERPRETATION Fixed- as well as mobile-bearing crosslinked polyethylene tibial inserts are suitable for total knee arthroplasty and showed reduced wear rates compared with conventional UHMWPE. The combination of the fixed-bearing Scorpio-knee-design with a sequential irradiated and annealed crosslinked polyethylene tibial insert (X3) seems to have an advantage in wear generation compared with other fixed- and mobile-bearing knee designs.
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Affiliation(s)
- Sandra Utzschneider
- Orthopaedic Department, Grosshadern Medical Center, University of Munich, Marchioninistr. 15, 81377 Munich, Germany.
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