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Derr T, MacDonald DW, Malkani AL, Mont MA, Piuzzi NS, Kurtz SM. Oxidation and Damage Mechanisms of Second-Generation Highly Cross-Linked Polyethylene Tibial Inserts. J Arthroplasty 2024:S0883-5403(24)00631-4. [PMID: 38906197 DOI: 10.1016/j.arth.2024.06.032] [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: 12/15/2023] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND After clinical introduction in 2005, sequentially annealed, highly cross-linked polyethylene (SA HXLPE) was studied for retrievals with short implantation times; however, long-term follow-ups are lacking. The objective of this study was to examine and compare the revision reasons, damage mechanisms, and oxidation indices of SA HXLPE and conventional gamma inert-sterilized (Gamma Inert) ultra-high-molecular-weight polyethylene tibial inserts implanted for >5 years. METHODS There were 74 total knee arthroplasty tibial inserts (46 SA HXLPEs, 28 Gamma Inerts) implanted for >5 years (mean 7 ± 2 years) retrieved as part of a multicenter retrieval program. Cruciate-retaining implants comprised 44% of the SA HXLPEs and 14% of the Gamma Inerts. Patient factors and revision reasons were collected from revision operating notes. A semiquantitative scoring method was used to assess surface damage mechanisms. Oxidation was measured using Fourier transform infrared microscopy according to American Society for Testing and Materials 2102. Differences between cohorts were assessed with Mann-Whitney U-tests. RESULTS Loosening (Gamma Inert: 17 of 28, SA HXLPE: 15 of 46) and instability (Gamma Inert: 6 of 28, SA HXLPE: 15 of 46) were the most common revision reasons for both cohorts. The most prevalent surface damage mechanisms were burnishing, pitting, and scratching, with burnishing of the condyles being higher in Gamma Inert components (P = .022). Mean oxidation was higher in the SA HXLPE inserts at the articulating surface (P = .002) and anterior-posterior faces (P = .023). No difference was observed at the backside surface (P = .060). CONCLUSIONS Revision reasons and surface damage mechanisms were comparable in the Gamma Inert and SA cohorts. Further studies are needed to continue to assess the in vivo damage and clinical relevance, if any, of oxidation in SA HXLPE over longer implantation times, particularly for implants implanted for more than 10 years.
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Affiliation(s)
- Tabitha Derr
- Implant Research Core, Drexel University, Philadelphia, Pennsylvania
| | | | - Arthur L Malkani
- Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
| | - Michael A Mont
- Department of Orthopaedic Surgery, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Kurtz
- Implant Research Core, Drexel University, Philadelphia, Pennsylvania
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2
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Muratoglu OK, Asik MD, Nepple CM, Wannomae KK, Micheli BR, Connolly RL, Oral E. Di-cumyl peroxide cross-linked UHMWPE/vitamin-E blend for total joint arthroplasty implants. J Orthop Res 2024; 42:306-316. [PMID: 37593816 DOI: 10.1002/jor.25679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023]
Abstract
Majority of ultrahigh molecular weight polyethylene (UHMWPE) medical devices used in total joint arthroplasty are cross-linked using gamma radiation to improve wear resistance. Alternative methods of cross-linking are urgently needed to replace gamma radiation due to rapid decline in its supply. Peroxide cross-linking is a candidate method with widespread industrial applications. Oxidative stability and biocompatibility, which are critical requirements for medical device applications, can be achieved using vitamin-E as an additive and by removing peroxide by-products through high-temperature melting, respectively. We investigated compression molded UHMWPE/vitamin-E/di-cumyl peroxide blends followed by high-temperature melting in inert gas as a material candidate for tibial knee inserts. Wear resistance increased and mechanical properties remained largely unchanged. Oxidation induction time was higher than most of the other clinically available formulations. The material passed the local-end point biocompatibility tests per ISO 10993. Compounds found in exhaustive extraction were of no concern with margin-of-safety values well above the accepted level, indicating a desirable toxicological risk profile. Statement of Clinical Significance: Peroxide cross-linked, vitamin-E stabilized, and high-temperature melted UHMWPE has recently been cleared for clinical use in tibial knee inserts. With all the salient characteristics needed in a material that can provide superior long-term performance in total joint patients, peroxide cross-linking can replace the gamma radiation cross-linking of UHMWPE.
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Affiliation(s)
- Orhun K Muratoglu
- Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Mehmet D Asik
- Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Cecilia M Nepple
- Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Keith K Wannomae
- Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brad R Micheli
- Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rachel L Connolly
- Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ebru Oral
- Harris Orthopaedics Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
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3
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Currier BH, Jevsevar KC, Van Citters DW. Oxidation in Retrieved, Never-Irradiated UHMWPE Bearings: What Can We Learn About in Vivo Oxidation? J Bone Joint Surg Am 2023; 105:293-301. [PMID: 36730084 DOI: 10.2106/jbjs.22.00571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Published analyses of never-irradiated, ethylene oxide (EtO)-sterilized tibial inserts and EtO- and gas plasma (GP)-sterilized acetabular ultra-high molecular weight polyethylene (UHMWPE) retrievals demonstrated minimal UHMWPE in vivo oxidation, whereas another analysis of EtO-sterilized acetabular liners found elevated oxidation linked with in vivo stresses. This study explored whether never-irradiated UHMWPE bearings are (1) oxidized by the in vivo environment, and (2) more likely to oxidize in higher-stress articulations (knee, ankle, shoulder). METHODS An institutional review board-approved retrieval archive was queried for never-irradiated, EtO- and GP-sterilized UHMWPE bearings received at revision from 2001 to 2021. A total of 193 EtO-sterilized and 112 GP-sterilized conventional UHMWPE retrievals were analyzed (0 to 25 years in vivo; 133 hip, 144 knee, 18 ankle, and 10 shoulder). Retrieved implants were evaluated for in vivo damage and analyzed for trans-vinylene and ketone content by Fourier transform infrared spectroscopy (FTIR). Twelve never-implanted EtO-sterilized tibial knee inserts, (shelf-aged 5 to 19 years) were non-oxidized controls. Mechanical properties of 3 never-implanted and 3 retrieved tibial inserts were evaluated by ASTM Type-V uniaxial tensile testing. Statistical analyses evaluated correlations between time in vivo and oxidation, and compared mean oxidation rates by articulation. RESULTS Burnishing was the most common clinical damage for all articulations. Eight retrievals exhibited oxidation-related fatigue damage. All retrievals were validated as never-irradiated (median trans-vinylene index [TVI] = 0.000). Maximum ketone oxidation in retrievals correlated with in vivo time (p < 0.001). Thirty-seven percent of retrievals exhibited UHMWPE (subsurface) oxidation, most frequently ankle, knee, and glenoid inserts. Tensile properties differed between retrieved and never-implanted inserts, changing with oxidation. The oxidation rate differed significantly among the articulations (p < 0.001). CONCLUSIONS This study cohort confirmed the presence of in vivo oxidation in some non-irradiation-sterilized UHMWPE bearings, with higher-stress articulations (knee, ankle, shoulder) showing evidence of oxidation more frequently and having significantly higher oxidation rates than hips. Mechanical properties degraded by oxidation led to fatigue damage in 8 retrievals after a long duration in vivo. CLINICAL RELEVANCE Conventional EtO- or GP-sterilized UHMWPE bearings are at minimal risk for fatigue damage secondary to oxidation. However, higher stresses and longer time in vivo (more cycles of use) can lead to increased wear, oxidation, and fatigue damage.
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4
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Helvie PF, Deckard ER, Meneghini RM. Cementless Total Knee Arthroplasty Over the Past Decade: Excellent Survivorship in Contemporary Designs. J Arthroplasty 2023; 38:S145-S150. [PMID: 36791890 DOI: 10.1016/j.arth.2023.02.009] [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: 12/01/2022] [Revised: 01/31/2023] [Accepted: 02/04/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Cementless fixation in total knee arthroplasty (TKA) is re-emerging due to improvements in biomaterials, surgical technique, and implant design. Albeit rare, failure of osseointegration typically occurs within the first 2 years, and limited data exist on survivorship of the modern cementless TKA designs. This study evaluated clinical survivorship of 2 contemporary cementless TKA designs at minimum 2-year follow-up. METHODS A total of 627 cementless TKAs were performed up to July 2022. Three hundred thirty-nine cases were eligible for 2-year follow-up. Indications centered around bone quality and involved predominantly younger patients. The 2 designs consisted of tibial components with a highly porous titanium ingrowth surface, a central keel, and peripheral cruciform pegs with a porous cobalt-chromium femur. Survivorship estimates were calculated using right-censored non-parametric Kaplan-Meier methodologies. A total of 226 TKAs obtained minimum 2-year follow-up with a mean of 3.6 years (range, 2 to 10). RESULTS The all-cause revision rate was 2.4% (8 of 339). The revision rate due to aseptic loosening was 0.6% (2 of 339) consisting of 2 femoral components. No tibial components were revised for aseptic loosening. Kaplan-Meier survivorship free from aseptic loosening was 99% (95% confidence interval 98 to 100) at a maximum of 10 years. CONCLUSION These results demonstrate encouraging survivorship of cementless fixation in primary TKA with use of contemporary ingrowth biomaterials and modern implant designs. This particular tibial implant design with a highly porous titanium fixation surface, central keel, and peripheral cruciform pegs demonstrated excellent clinical survivorship without failure which may portend superior fixation. LEVEL OF EVIDENCE IV-case series, no control group/historical control group.
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Affiliation(s)
- Peter F Helvie
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Evan R Deckard
- Indiana Joint Replacement Institute, Indianapolis, Indiana
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Indiana Joint Replacement Institute, Indianapolis, Indiana
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5
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Decker M, Price A, Khalili A, Klassen R, Walzak MJ, Teeter M, McCalden R, Lanting B. The Impact of Free Radical Stabilization Techniques on in vivo Mechanical Changes in Highly Cross-Linked Polyethylene Acetabular Liners. Orthop Res Rev 2021; 13:113-122. [PMID: 34429667 PMCID: PMC8380133 DOI: 10.2147/orr.s309210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/22/2021] [Indexed: 01/13/2023] Open
Abstract
Introduction Numerous thermal free radical stabilization techniques are used in the production of highly cross-linked polyethylene (HXLPE) to improve oxidative stability. Little knowledge exists on the effects of in vivo time on the mechanical properties of HXLPE. The purpose of this study was to determine if free radical stabilization of HXLPE impacts mechanical properties as well as oxidative stability of acetabular liner rims after extended in vivo time. Methods Retrieved and control remelted, single annealed and sequentially annealed HXLPE liner rims were tested for mechanical properties. Oxidation was measured with FTIR spectroscopy and crystalline phase composition measured with Raman spectroscopy. Results No correlation was found between in vivo, ex vivo time and hardness for annealed groups. A statistically significant difference in hardness was identified between free radical stabilization groups. No correlation between maximum rim oxidation and in vivo time was found. Detectable levels of rim oxidation were present in 100% of single annealed, 75% of sequentially annealed, and 25% of remelted retrieved liners. Single and sequentially annealed liners demonstrated oxidation and increased crystallinity. Rim mechanical properties change in vivo for implant types. With in vivo time, retrieved remelted HXLPE demonstrated decreased mechanical properties, whereas retrieved single and sequentially annealed HXLPE properties remained stable. All liner cohorts demonstrated evidence of rim oxidation. Subsequent changes in crystallinity were only observed in oxidized annealed liners. Conclusion HXLPE acetabular liner rims show evidence of in vivo mechanical property degradation, notably in remelted HXLPE, which may be a risk factor in rim fracture and catastrophic implant failure.
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Affiliation(s)
- Michael Decker
- Department of Orthopaedic Surgery, The University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM, USA
| | - Amber Price
- Department of Orthopaedic Surgery, The University of New Mexico Health Sciences Center, University of New Mexico, Albuquerque, NM, USA
| | - Aria Khalili
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Robert Klassen
- Department of Mechanical and Materials Engineering, Western University, London, Ontario, Canada
| | - Mary Jane Walzak
- Surface Science Western, University of Western Ontario, London, Ontario, Canada
| | - Matthew Teeter
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry.,Imaging Research Laboratories, Robarts Research Institute, Schulich School of Medicine and Dentistry.,Surgical Innovation Program, Lawson Health Research Institute.,Division of Orthopaedic Surgery, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Richard McCalden
- Division of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - Brent Lanting
- Division of Orthopaedic Surgery, London Health Sciences Centre, University Hospital, London, Ontario, Canada
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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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7
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Parekh A, Sood A, Monsef JB, Hamouda M, Hussain A, Gonzalez M. Second-Generation Highly Cross-Linked Polyethylene in Total Hip Arthroplasty. JBJS Rev 2021; 9:e20.00065. [PMID: 33982980 DOI: 10.2106/jbjs.rvw.20.00065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Amit Parekh
- Department of Orthopaedic Surgery, University of Illinois, Chicago, Illinois
| | - Anshum Sood
- Department of Orthopaedic Surgery, University of Illinois, Chicago, Illinois
| | - Jad Bou Monsef
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Awais Hussain
- Department of Orthopaedic Surgery, University of Illinois, Chicago, Illinois
| | - Mark Gonzalez
- Department of Orthopaedic Surgery, University of Illinois, Chicago, Illinois
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8
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Sonn KA, Meneghini RM. Early failure of sequentially annealed polyethylene in total knee arthroplasty. Arthroplast Today 2020; 6:18-22. [PMID: 32211470 PMCID: PMC7083714 DOI: 10.1016/j.artd.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/20/2019] [Accepted: 12/08/2019] [Indexed: 12/03/2022] Open
Abstract
Improvements in the processing of polyethylene have led to a dramatic reduction in wear rates in total hip arthroplasty. This led to the adoption of modern highly cross-linked polyethylene in total knee arthroplasty (TKA). However, the differences in modes of wear and failure between total hip arthroplasty and TKA have tempered expectations regarding similar decreases in polyethylene-related complications in TKA. We present a case of early catastrophic failure of a modern sequentially irradiated and annealed highly cross-linked polyethylene insert only 5 years after contemporary cementless TKA.
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Affiliation(s)
- Kevin A Sonn
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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9
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Liu Z, Wang J, Gao H, Gao L. Biaxial fatigue crack propagation behavior of ultrahigh molecular weight polyethylene reinforced by carbon nanofibers and hydroxyapatite. J Biomed Mater Res B Appl Biomater 2019; 108:1603-1615. [PMID: 31633296 DOI: 10.1002/jbm.b.34507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/11/2019] [Accepted: 10/06/2019] [Indexed: 12/17/2022]
Abstract
Ultrahigh molecular weight polyethylene (UHMWPE) artificial joint has remained the preferred polymer component in total joint replacement surgery. However, more and more concerns have been raised about the failure of UHMWPE components due to the initiation and propagation of cracks at the notches with fixed functions. For this reason, biaxial fatigue crack growth (FCG) experiments of UHMWPE reinforced by carbon nanofibers (CNF) and hydroxyapatite (HA) were carried out using elastic-plastic fracture mechanics theory. The FCG resistance of UHMWPE, UHMWPE/CNF, and UHMWPE/HA was compared, and the effects of stress ratio (R) value and phase difference on FCG rate were investigated. At the same time, the influence of loading path was considered, and the corresponding crack path was analyzed. Results suggest that UHMWPE/CNF has better FCG resistance and the FCG rate increases with the increase of R value and the existence of 180° phase difference. In addition, crack bifurcation behavior is not observed under nonproportional loading conditions. The findings in this study will provide experimental validation and data support for better clinical application of UHMWPE-modified materials.
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Affiliation(s)
- Zhenduo Liu
- Department of Process Equipment and Control Engineering, School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
| | - Jianhai Wang
- Department of Process Equipment and Control Engineering, School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
| | - Hong Gao
- Department of Process Equipment and Control Engineering, School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
| | - Lilan Gao
- Department of Process Equipment and Control Engineering, School of Mechanical Engineering, Tianjin University of Technology, Tianjin, China
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10
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Challenges of pre-clinical testing in orthopedic implant development. Med Eng Phys 2019; 72:49-54. [DOI: 10.1016/j.medengphy.2019.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/24/2019] [Indexed: 01/23/2023]
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11
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Suraci A, Louati H, Culliton KN, Beaulé PE. Comparing In Vivo Performance of Two Highly Cross-Linked Polyethylene Thermal Treatments: Remelting vs Annealing in Acetabular Liners. J Arthroplasty 2019; 34:1509-1513. [PMID: 30956047 DOI: 10.1016/j.arth.2019.03.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/13/2019] [Accepted: 03/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The introduction of highly cross-linked polyethylene (HXLPE) acetabular liners has greatly improved the wear performance of metal-on-PE bearing surfaces used in total hip arthroplasty. Changing the sterilization environment and adding thermal treatments, such as remelting or annealing, were introduced to limit on-shelf and in vivo oxidation of cross-linked liners. This study compares the wear properties of the remelted A-CLASS (MicroPort) HXLPE liner to a sequentially annealed HXLPE. METHODS This retrospective study assessed linear and volumetric wear rates using Martell Hip Analysis Suite, and clinical performance through incidences of revision surgeries. A total of 80 remelted and 53 annealed liners were included in the wear analysis. All hips were reviewed for revisions. RESULTS There were no significant differences in steady-state linear or volumetric wear rates for remelted and annealed liners, 0.01 (-0.07 to 0.14) vs -0.01 (-0.11 to 0.1) mm/y (P = .28) and -1.03 (-30.99 to 45.43) vs -1.31 (-32.23 to 23.70) mm3/y (P = .30), respectively. Both cohorts were below the 0.1 mm/y linear wear threshold. The wear rates for patients with femoral head sizes ≥36 mm were not significantly different than those with 32 and 28 mm femoral head sizes (P = .60). Similarly, wear rates for patients with an excessively vertical acetabular component (>50°) were not significantly different than those with standard acetabular component orientations (P = .97). No hips were revised due to liner-related complications. CONCLUSION The wear rates of the A-CLASS remelted HXLPE acetabular liner wear rates were comparable to those of a sequentially annealed HXLPE. Further long-term studies are required to ensure acceptable resistance to fatigue and in vivo oxidation.
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Affiliation(s)
- Alison Suraci
- Division of Orthopaedic Surgery, The Ottawa Hospital, General Campus, Ottawa, Ontario, Canada
| | - Hakim Louati
- Orthopaedic Biomechanics Laboratory, Division of Orthopaedic Surgery, The Ottawa Hospital Research Institute, Civic Campus, Ottawa, Ontario, Canada
| | - Kathryn N Culliton
- Orthopaedic Biomechanics Laboratory, Division of Orthopaedic Surgery, The Ottawa Hospital Research Institute, Civic Campus, Ottawa, Ontario, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, General Campus, Ottawa, Ontario, Canada; Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
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12
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Xu JZ, Wannomae KK, Muratoglu OK, Oral E. Increased oxidative protection by high active vitamin E content and partial radiation crosslinking of UHMWPE. J Orthop Res 2018; 36:1860-1867. [PMID: 29232007 DOI: 10.1002/jor.23835] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 11/23/2017] [Indexed: 02/04/2023]
Abstract
Vitamin E stabilization successfully improved long-term oxidation resistance of wear-resistant ultra-high-molecular-weight polyethylene (UHMWPE) used for joint implants. Stabilization can be achieved by blending an antioxidant into the UHMWPE resin powder before consolidation and irradiation. Balancing the wear resistance and vitamin E content in the blend is the current challenge with this approach, because vitamin E hinders crosslinking of UHMWPE during irradiation, which decreases wear resistance. The vitamin E concentration in the blend is generally limited to less than 0.3 wt%. Wear- and oxidation-resistant UHMWPE has been obtained previously by consolidating blends of pre-irradiated UHMWPE powders (XPE) into an unmodified polyethylene matrix (PE), where the improvement in wear rate depended on the radiation dose and fraction of XPE. We hypothesized that increasing the vitamin E content in the unirradiated matrix would not compromise wear and would further improve the oxidative stability of XPE/PE blends. Pin-on-disk wear testing showed that the XPE/PE blends containing 0.1-1.0 wt% vitamin E in the matrix had comparable wear rates. We used an aggressive accelerated aging test in the presence of the pro-oxidant squalene and oxidation induction time (OIT) test and found that higher amounts of vitamin E resulted in stronger oxidation resistance for XPE/PE blends. The mechanical strength and toughness of the blends were not affected by changing the vitamin E content in the matrix. Stabilizing UHMWPE with higher vitamin E content may extend the service life of UHMWPE implants. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1860-1867, 2018.
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Affiliation(s)
- Jia-Zhuang Xu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114.,Polymer Science and Engineering, Sichuan University, Chengdu, China
| | - Keith K Wannomae
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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13
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Oxidation, Damage Mechanisms, and Reasons for Revision of Sequentially Annealed Highly Crosslinked Polyethylene in Total Knee Arthroplasty. J Arthroplasty 2018; 33:1235-1241. [PMID: 29329883 DOI: 10.1016/j.arth.2017.09.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 09/07/2017] [Accepted: 09/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Sequentially annealed, highly crosslinked polyethylene (HXLPE) has been used clinically in total knee arthroplasty (TKA) for over a decade. However, little is known about the revision reasons; its surface damage mechanisms; or its in vivo oxidative stability relative to conventional polyethylene. We asked whether retrieved HLXPE tibial inserts exhibited: (1) similar revision reasons; (2) improved resistance to surface damage; and (3) improved oxidative stability, when compared with conventional gamma inert sterilized polyethylene inserts. METHODS A total of 456 revised tibial inserts were collected in a multicenter retrieval program between 2000 and 2016. The implantation time for the HXLPE components was 1.8 ± 1.8 years, and for the control inserts it was 3.4 ± 2.7 years. Revision reasons were assessed based on medical records, radiographs, and examinations of the retrieved components. Surface damage was assessed using a semi-quantitative scoring method. Oxidation was measured using Fourier transform infrared spectroscopy. RESULTS The tibial inserts in both cohorts were revised most frequently for loosening, infection, and instability. The most commonly observed surface damage modes were burnishing, pitting, and scratching. Oxidation of the HXLPE inserts was, on average, low and similar to the control inserts at the bearing surface and the stabilizing post. CONCLUSIONS We observed evidence of in vivo oxidation in both HXLPE and control tibial inserts. We found no association between the levels of oxidation and the clinical performance of the HXLPE tibial components. The findings of this study document the revision reasons, surface damage modes, and oxidative behavior of sequentially annealed HXLPE for TKA.
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Ludwig KB, Chandrasekar V, Saylor DM, Van Citters DW, Reinitz SD, Forrey C, McDermott MK, Wickramasekara S, Janes DW. Characterizing the free volume of ultrahigh molecular weight polyethylene to predict diffusion coefficients in orthopedic liners. J Biomed Mater Res B Appl Biomater 2017; 106:2393-2402. [DOI: 10.1002/jbm.b.34045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 08/21/2017] [Accepted: 10/31/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Kyle B. Ludwig
- Center for Devices and Radiological Health, U.S. Food and Drug Administration; Silver Spring Maryland 20993
| | - Vaishnavi Chandrasekar
- Center for Devices and Radiological Health, U.S. Food and Drug Administration; Silver Spring Maryland 20993
| | - David M. Saylor
- Center for Devices and Radiological Health, U.S. Food and Drug Administration; Silver Spring Maryland 20993
| | | | - Steven D. Reinitz
- Thayer School of Engineering; Dartmouth College; Hanover New Hampshire 03755
| | - Christopher Forrey
- Center for Devices and Radiological Health, U.S. Food and Drug Administration; Silver Spring Maryland 20993
| | - Martin K. McDermott
- Center for Devices and Radiological Health, U.S. Food and Drug Administration; Silver Spring Maryland 20993
| | - Samanthi Wickramasekara
- Center for Devices and Radiological Health, U.S. Food and Drug Administration; Silver Spring Maryland 20993
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Bracco P, Bellare A, Bistolfi A, Affatato S. Ultra-High Molecular Weight Polyethylene: Influence of the Chemical, Physical and Mechanical Properties on the Wear Behavior. A Review. MATERIALS (BASEL, SWITZERLAND) 2017; 10:E791. [PMID: 28773153 PMCID: PMC5551834 DOI: 10.3390/ma10070791] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 07/06/2017] [Accepted: 07/08/2017] [Indexed: 01/03/2023]
Abstract
Ultra-high molecular weight polyethylene (UHMWPE) is the most common bearing material in total joint arthroplasty due to its unique combination of superior mechanical properties and wear resistance over other polymers. A great deal of research in recent decades has focused on further improving its performances, in order to provide durable implants in young and active patients. From "historical", gamma-air sterilized polyethylenes, to the so-called first and second generation of highly crosslinked materials, a variety of different formulations have progressively appeared in the market. This paper reviews the structure-properties relationship of these materials, with a particular emphasis on the in vitro and in vivo wear performances, through an analysis of the existing literature.
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Affiliation(s)
- Pierangiola Bracco
- Department of Chemistry and NIS (Nanostructured Interfaces and Surfaces) Center, University of Torino, 10125 Torino, Italy.
| | - Anuj Bellare
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | | | - Saverio Affatato
- Medical Technology Laboratory, Rizzoli Orthopaedic Institute, 40136 Bologna, Italy.
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17
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Effect of e-beam sterilization on the in vivo performance of conventional UHMWPE tibial plates for total knee arthroplasty. Acta Biomater 2017; 55:455-465. [PMID: 28359857 DOI: 10.1016/j.actbio.2017.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/07/2017] [Accepted: 03/25/2017] [Indexed: 11/21/2022]
Abstract
Although the introduction of highly cross-linked polyethylene is effective in reducing the amount of wear, there are still major concerns regarding the use of this material in total knee arthroplasty (TKA), essentially due to the reduction of fatigue resistance and toughness. Monitoring the in vivo performance of different types of UHMWPE is a much needed task to tackle the lack of information on which should be the most reliable choice for TKA. The present study was aimed at investigating the mid-term degradation of electron beam sterilized conventional UHMWPE tibial plates. Visual inspection enabled to grade the surface damage of 12 retrievals according to the Hood's score: the total wear damage correlates to the in vivo time (Spearman's ρ=0.681, p<0.05) and BMI (ρ=0.834, p<0.001). Surface degradation was less severe than that quantified in similar studies on γ-sterilized UHMWPE. Raman and infra-red spectroscopies were utilized to unfold the microstructural modifications. In the load zone, polyethylene whitened damage regions were noticed in the inserts implanted longer than 1year, in which oxidation index (OI) is clearly higher than 1 (max 8). The maximum OI (ρ=0.802, p<0.005) and αc (ρ=0.816, p<0.005) correlate to the implantation time in the load zone. The crystallinity increased along with the extent of oxidation. Concentration of absorbed species from synovial fluid is higher in the contact zone and correlates to maximum OI (Spearman's ρ=0.699, p=0.011). Absorption was promoted in the contact area by the mechanical action of the femoral counterpart and it exacerbated the oxidative degradation in retrievals with high concentration of absorbed species. In the non-load zone, mild but detectable oxidation was observed, probably due to free radicals trapped after sterilization. STATEMENT OF SIGNIFICANCE Although several clinical studies on retrieved tibial bearings have been published so far, monitoring and comparing the in vivo performance of different types of UHMWPE is still a much needed task. The present study reports for the first time results on the effect of sterilization by electron beam on the mid-term in vivo performance of conventional UHMWPE tibial plates. In the present investigation, visual inspection of wear damage based on the Hood's scoring method, Raman micro-spectroscopy and Fourier-transformed infrared spectroscopy were utilized to unveil the damage, the microstructural modifications and the oxidation occurred during implantation. The findings of this investigation have been discussed and compared to previous clinical studies on γ-air sterilized, γ-inert sterilized tibial bearings.
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18
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Oral E, O'Brien C, Doshi B, Muratoglu OK. High temperature homogenization improves impact toughness of vitamin E-diffused, irradiated UHMWPE. J Orthop Res 2017; 35:1343-1347. [PMID: 27487014 DOI: 10.1002/jor.23380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 07/29/2016] [Indexed: 02/04/2023]
Abstract
Diffusion of vitamin E into radiation cross-linked ultrahigh molecular weight polyethylene (UHMWPE) is used to increase stability against oxidation of total joint implant components. The dispersion of vitamin E throughout implant preforms has been optimized by a two-step process of doping and homogenization. Both of these steps are performed below the peak melting point of the cross-linked polymer (<140°C) to avoid loss of crystallinity and strength. Recently, it was discovered that the exposure of UHMWPE to elevated temperatures, around 300°C, for a limited amount of time in nitrogen, could improve the toughness without sacrificing wear resistance. We hypothesized that high temperature homogenization of antioxidant-doped, radiation cross-linked UHMWPE could improve its toughness. We found that homogenization at 300°C for 8 h resulted in an increase in the impact toughness (74 kJ/m2 compared to 67 kJ/m2 ), the ultimate tensile strength (50 MPa compared to 43 MPa) and elongation at break (271% compared to 236%). The high temperature treatment did not compromise the wear resistance or the oxidative stability as measured by oxidation induction time. In addition, the desired homogeneity was achieved at a much shorter duration (8 h compared to >240 h) by using high temperature homogenization. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1343-1347, 2017.
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Affiliation(s)
- Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, GRJ 1260, Boston, Massachusetts 02114.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Caitlin O'Brien
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, GRJ 1260, Boston, Massachusetts 02114
| | - Brinda Doshi
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, GRJ 1260, Boston, Massachusetts 02114
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit Street, GRJ 1260, Boston, Massachusetts 02114.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts
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Currier BH, Van Citters DW. A Novel Technique for Assessing Antioxidant Concentration in Retrieved UHMWPE. Clin Orthop Relat Res 2017; 475:1356-1365. [PMID: 27334326 PMCID: PMC5384904 DOI: 10.1007/s11999-016-4939-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Antioxidants added to UHMWPE to prevent in vivo oxidation are important to the long-term performance of hip and knee arthroplasty. Diffused vitamin E antioxidant polyethylene raised questions about potential in vivo elution that could cause inflammatory reactions in periprosthetic tissues and also potentially leave the implant once again prone to oxidation. Currently, there is no information on the elution, if any, of antioxidants from implant polyethylene materials in vivo. QUESTIONS/PURPOSES (1) Do antioxidants, especially diffused vitamin E, elute from antioxidant polyethylene in vivo? (2) Can extraction of the retrieved antioxidant polyethylene (to remove absorbed species from the in vivo environment near the articular and nonarticular surfaces) improve the identification of antioxidant content? (3) Can actual antioxidant content be estimated from calculated antioxidant indices by accounting for ester content (from absorbed species) near the articular and nonarticular surfaces? METHODS An institutional review board-approved retrieval laboratory received 39 antioxidant polyethylene hip and knee retrievals at revision from 25 surgeons with in vivo time of 0.02 to 3.6 years (median, 1.3 years). These consecutive antioxidant polyethylene retrievals, received between May 2010 and February 2016, were made from three different antioxidant highly crosslinked polyethylene materials: diffused vitamin E, blended vitamin E, and hindered phenol antioxidant pentaerythritol tetrakis[3-(3,5-di-tert-butyl-4-hydroxyphenyl)] propionate (here and after referred to as PBHP). Retrievals were analyzed using Fourier transform infrared (FTIR) spectroscopy. Absorbed ester index (1725-1740 cm-1 normalized to 1365-1371 cm-1), and vitamin E index (1245-1275 cm-1) and PBHP index (1125-1150 cm-1), normalized to 1850-1985 cm-1, were defined. Microtomed thin sections of PBHP and vitamin E retrievals were hexane-extracted to remove absorbed species from the in vivo environment in an effort to improve identification of antioxidant content. Paired Student's t-tests were used to compare as-retrieved articular antioxidant index with expected antioxidant index (the bulk value for blended antioxidants where constant antioxidant content is expected throughout and the extrapolated original vitamin E concentration at the articular surface based on the as-manufactured vitamin E concentration gradient). Linear regression was used for each of the retrievals to evaluate the correlation of antioxidant index to ester content with the goal of extrapolation to the antioxidant index at zero ester content. RESULTS On average, vitamin E index at the articular surface (0.04 ± 0.03) was reduced compared with expected vitamin E index (0.09 ± 0.04; 95% confidence interval [CI] of the difference, 0.04-0.07; p < 0.001), and PBHP index at the articular surface (0.06 ± 0.02) was elevated compared with the average PBHP index from the bulk (0.03 ± 0.00; 95% CI of the difference, 0.03-0.05; p < 0.001). Extraction returned the PBHP index at the articular surface (0.03 ± 0.00) to bulk values (95% CI of the difference, -0.001 to 0.004; p = 0.326); diffused vitamin E was removed by extraction. Crossplots of vitamin E index and PBHP index with ester index showed significant (p < 0.001 for 32 of the 35 retrievals with sufficient data) linear trends (r ≥ 0.89) that allowed extrapolation of the articular surface antioxidant indices at zero absorbed ester index. CONCLUSIONS Absorbed esters from time in vivo caused erroneous values of antioxidant index to be calculated. However, hexane extraction to remove absorbed species also removed diffused vitamin E. Correlating antioxidant indices with ester content, measured by FTIR in unextracted antioxidant retrievals, provides a nonaltered method for estimating actual articular surface vitamin E index and demonstrates that there was no measurable elution in these short-term retrievals. CLINICAL RELEVANCE Assessing antioxidant content in retrieved polyethylene inserts is important to determine how much of the antioxidant remains in place to prevent oxidation of the polyethylene over time in vivo. Retrieval analyses reporting antioxidant content must account for absorbed species to be valid. Because standard hexane extraction removes both absorbed species and vitamin E from diffused vitamin E retrievals, the correlation method presented in this study is the recommended analysis alternative.
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Affiliation(s)
- Barbara H. Currier
- grid.254880.3Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755 USA
| | - Douglas W. Van Citters
- grid.254880.3Thayer School of Engineering, Dartmouth College, 14 Engineering Drive, Hanover, NH 03755 USA
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Abstract
Articulating components should minimise the generation of wear particles in order to optimize long-term survival of the prosthesis. A good understanding of tribological properties helps the orthopaedic surgeon to choose the most suitable bearing for each individual patient. Conventional and highly cross-linked polyethylene articulating either with metal or ceramic, ceramic-on-ceramic and metal-on-metal are the most commonly used bearing combinations. All combinations of bearing surface have their advantages and disadvantages. An appraisal of the individual patient’s objectives should be part of the assessment of the best bearing surface.
Cite this article: Rieker CB. Tribology of total hip arthroplasty prostheses: what an orthopaedic surgeon should know. EFORT Open Rev 2016;1:52-57. DOI: 10.1302/2058-5241.1.000004.
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21
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Currier BH, Currier JH, Holdcroft LA, Van Citters DW. Effectiveness of anti-oxidant polyethylene: What early retrievals can tell us. J Biomed Mater Res B Appl Biomater 2017; 106:353-359. [DOI: 10.1002/jbm.b.33840] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 12/06/2016] [Accepted: 12/10/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Barbara H. Currier
- Thayer School of Engineering; Dartmouth College; Hanover New Hampshire 03755
| | - John H. Currier
- Thayer School of Engineering; Dartmouth College; Hanover New Hampshire 03755
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22
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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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23
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Epinette JA, Harwin SF, Rowan FE, Tracol P, Mont MA, Chughtai M, Westrich GH. Early experience with dual mobility acetabular systems featuring highly cross-linked polyethylene liners for primary hip arthroplasty in patients under fifty five years of age: an international multi-centre preliminary study. INTERNATIONAL ORTHOPAEDICS 2016; 41:543-550. [PMID: 28013332 DOI: 10.1007/s00264-016-3367-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 12/02/2016] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate early performance of contemporary dual mobility acetabular systems with second generation annealed highly cross-linked polyethylene for primary hip arthroplasty of patients under 55 years of age. METHODS A prospective observational five years study across five centers in Europe and the USA of 321 patients with a mean age of 48.1 years was performed. Patients were assessed for causes of revision, hip instability, intra-prosthetic dissociation, Harris hip score and radiological signs of osteolysis. RESULTS There were no dislocations and no intra-prosthetic dissociations. Kaplan Meier analysis demonstrated 97.51% survivorship for all cause revision and 99.68% survivorship for acetabular component revision at five years. Mean Harris hip score was 93.6. Two acetabular shells were revised for neck-rim implant impingement without dislocation and ten femoral stems were revised for causes unrelated to dual mobility implants. CONCLUSION Contemporary highly cross-linked polyethylene dual mobility systems demonstrate excellent early clinical, radiological, and survivorship results in a cohort of patients that demand high performance from their implants. It is envisaged that DM and second generation annealed HXLPE may reduce THA instability and wear, the two most common causes of THA revision in hip arthroplasty.
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Affiliation(s)
- Jean-Alain Epinette
- Orthopaedic Research and Imaging Center in Arthroplasty, 62700, Bruay-La-Buissière, France.
| | - Steven F Harwin
- Adult Reconstruction and Total Joint Replacement, Mount Sinai Hospital, New York, NY, USA
| | - Fiachra E Rowan
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Philippe Tracol
- , Clinique Saint-Roch 235, route des Gordes, Cavaillon, France
| | - Michael A Mont
- Adult Reconstruction and Joint Replacement, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Morad Chughtai
- Adult Reconstruction and Joint Replacement, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Geoffrey H Westrich
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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Affatato S, De Mattia JS, Bracco P, Pavoni E, Taddei P. Wear performance of neat and vitamin E blended highly cross-linked PE under severe conditions: The combined effect of accelerated ageing and third body particles during wear test. J Mech Behav Biomed Mater 2016; 64:240-52. [PMID: 27522313 DOI: 10.1016/j.jmbbm.2016.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/28/2016] [Accepted: 08/01/2016] [Indexed: 12/28/2022]
Abstract
The objective of this study is to evaluate the effects of third-body particles on the in vitro wear behaviour of three different sets of polyethylene acetabular cups after prolonged testing in a hip simulator and accelerated ageing. Vitamin E-blended, cross-linked polyethylene (XLPE_VE), cross-linked polyethylene (XLPE) and conventional polyethylene (STD_PE) acetabular cups were simulator tested for two million cycles under severe conditions (i.e. by adding third-body particles to the bovine calf serum lubricant). Micro-Fourier Transform Infrared and micro-Raman spectroscopic analyses, differential scanning calorimetry, and crosslink density measurements were used to characterize the samples at a molecular level. The STD_PE cups had twice mass loss than the XLPE_VE components and four times than the XLPE samples; statistically significant differences were found between the mass losses of the three sets of cups. The observed wear trend was justified on the basis of the differences in cross-link density among the samples (XLPE>XLPE_VE>STD_PE). FTIR crystallinity profiles, bulk DSC crystallinity and surface micro-Raman crystallinity seemed to have a similar behaviour upon testing: all of them (as well as the all-trans and ortho-trans contents) revealed the most significant changes in XLPE and XLPE_VE samples. The more severe third-body wear testing conditions determined more noticeable changes in all spectroscopic markers with respect to previous tests. Unexpectedly, traces of bulk oxidation were found in both STD_PE (unirradiated) and XLPE (remelting-stabilized), which were expected to be stable to oxidation; on the contrary, XLPE_VE demonstrated a high oxidative stability in the present, highly demanding conditions.
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Affiliation(s)
- Saverio Affatato
- Medical Technology Laboratory, Rizzoli Orthopaedic Institute, Bologna, Italy.
| | | | - Pierangiola Bracco
- Chemistry Department and Nanostructured Interfaces and Surfaces (NIS) Centre, University of Turin, Via Giuria 7, 10125 Turin, Italy
| | - Eleonora Pavoni
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via Belmeloro 8/2, 40126 Bologna, Italy
| | - Paola Taddei
- Dipartimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Via Belmeloro 8/2, 40126 Bologna, Italy
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Puppulin L, Miura Y, Casagrande E, Hasegawa M, Marunaka Y, Tone S, Sudo A, Pezzotti G. Validation of a protocol based on Raman and infrared spectroscopies to nondestructively estimate the oxidative degradation of UHMWPE used in total joint arthroplasty. Acta Biomater 2016; 38:168-78. [PMID: 27131572 DOI: 10.1016/j.actbio.2016.04.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/06/2016] [Accepted: 04/26/2016] [Indexed: 11/26/2022]
Abstract
UNLABELLED As a matter of fact, the in vivo oxidative degradation of highly cross-linked polyethylene (HXLPE) still remains one of the limiting factors that affect the long term survivorship of joint replacements. Recent studies clearly pointed out that also the new generation of highly cross-linked and remelted polyethylene components in total hip and knee replacement underwent unexpected oxidation after 5-10years of implantation. The standard methodology to investigate the oxidation of polyethylene (PE) relies on the use of infrared spectroscopy, which, if from one hand is a reliable technique for the detection of oxidized species containing carbonyl group, on the other hand it is not capable of discriminating the fraction of carboxyl acids that is responsible for chain scission and subsequent deterioration of the mechanical properties of the polymer. In the present study we validate a new protocol based on Raman spectroscopy, which is suitable on assessing the structural degradation of polyethylene induced by oxidation. Following in vitro accelerated aging experiments, the oxidation index (OI) of different commercially available HXLPEs, as calculated by infrared spectroscopy according to ASTM standard, has been univocally correlated to the most severe variation of crystalline phase (αc), as calculated by Raman spectroscopy. In each material, locations with equal values of OI showed different degree of recrystallization induced by chain scission, confirming that infrared spectroscopy might overestimate the effective mechanical degradation of the polymer. In addition, as compared to the standards based on infrared spectroscopy, this new method of assessing oxidation enables to investigate the degradation occurring on the original surface of HXLPE components, due to the nondestructive nature of Raman spectroscopy and its high spatial resolution. STATEMENT OF SIGNIFICANCE In the present study we validate a new protocol based on Raman spectroscopy, which is suitable on assessing the structural degradation of polyethylene induced by oxidation. In fact, the standard methodology to investigate the oxidation in polyethylene relies on the use of infrared spectroscopy, which is capable of detecting the presence of oxidized species containing carbonyl group, the main products of oxidation in polyolefins. If from one hand this technique enables quantitative analysis of oxidation, on the other hand it is not capable of discriminating the fraction of species with carbonyl groups responsible for the chain scission. In fact, esters, ketones and carboxyl acids are products of oxidation with carbonyl groups commonly formed on polyethylene at the end of the oxidative cascade initiated by the presence of free radicals, but only the latter are responsible for the chain scission and the subsequent deterioration of the mechanical properties. The oxidation index as obtained according to the ASTM standards is not univocally correlated to a certain degree of mechanical deterioration, but, in simple words, two retrievals with the same amount of carbonyl groups might have had different degradation of the mechanical properties. Recrystallization is a direct consequence of the reduction of molecular weight that occurs after chain scission. Raman spectroscopy (RS) is a viable non-destructive method to assess the fraction of crystalline phase in polyethylene and, due to its high spatial resolution, is perfectly suitable to analyze the microstructural modification at the mesoscopic scale, where the effects of oxidation manifest themselves. The aim of the present paper is twofold: i) to compare the microstructural modifications caused by in vitro oxidation on 5 different types of polyethylene currently available on the market of joint replacements; ii) to establish a protocol based on the comparative analysis of IR and RS results to obtain a phenomenological correlation capable to judge the mechanical deterioration of the material induced by the oxidative degradation.
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Kop AM, Pabbruwe MB, Keogh C, Swarts E. Oxidation of Second Generation Sequentially Irradiated and Annealed Highly Cross-Linked X3™ Polyethylene Tibial Bearings. J Arthroplasty 2015; 30:1842-6. [PMID: 25971535 DOI: 10.1016/j.arth.2015.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/27/2015] [Accepted: 04/20/2015] [Indexed: 02/01/2023] Open
Abstract
Since the first use of ultra-high-molecular-weight polyethylene as a bearing material, research and development efforts have sought to improve wear resistance, increase longevity and lessen the potential for debris mediated adverse tissue responses. A series of second generation sequentially cross-linked and annealed tibial bearings were analysed after several bearings sent for routine retrieval analysis showed oxidative degradation including subsurface whitening, cracking and gross material loss. Evaluation incorporated visual and white banding assessment, mechanical testing and spectroscopy analysis. Whilst visual observation and white banding assessment confirmed oxidative changes, a decrease in mechanical properties and increasing ketone oxidation index as a function of time in vivo suggest time dependent oxidative degradation. Clinically relevant degradation of the sequentially cross-linked and annealed tibial bearings was observed.
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Affiliation(s)
- Alan M Kop
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Perth, WA, Australia
| | - Moreica B Pabbruwe
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Perth, WA, Australia
| | - Catherine Keogh
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Perth, WA, Australia
| | - Eric Swarts
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Perth, WA, Australia
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27
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Reinitz SD, Currier BH, Levine RA, Collier JP, Van Citters DW. Oxidation and other property changes of a remelted highly crosslinked
UHMWPE
in retrieved tibial bearings. J Biomed Mater Res B Appl Biomater 2015; 105:39-45. [DOI: 10.1002/jbm.b.33533] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 07/21/2015] [Accepted: 09/12/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Steven D. Reinitz
- Thayer School of EngineeringDartmouth CollegeHanover New Hampshire03755
| | | | - Rayna A.C. Levine
- Thayer School of EngineeringDartmouth CollegeHanover New Hampshire03755
| | - John P. Collier
- Thayer School of EngineeringDartmouth CollegeHanover New Hampshire03755
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Rowell SL, Muratoglu OK. Investigation of surgically retrieved, vitamin E-stabilized, crosslinked UHMWPE implants after short-termin vivoservice. J Biomed Mater Res B Appl Biomater 2015; 104:1132-40. [DOI: 10.1002/jbm.b.33465] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 01/30/2015] [Accepted: 05/07/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Shannon L. Rowell
- Harris Orthopaedics Laboratory; Massachusetts General Hospital; Boston MA
| | - Orhun K. Muratoglu
- Harris Orthopaedics Laboratory; Massachusetts General Hospital; Boston MA
- Department of Orthopaedic Surgery; Harvard Medical School; Boston MA
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CORR Insights®: Retrieval analysis of sequentially annealed highly crosslinked polyethylene used in total hip arthroplasty. Clin Orthop Relat Res 2015; 473:972-3. [PMID: 25613408 PMCID: PMC4317433 DOI: 10.1007/s11999-015-4150-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 01/12/2015] [Indexed: 01/31/2023]
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