Surface cross-linked UHMWPE can enable the use of larger femoral heads in total joints

Delivery of bupivacaine from UHMWPE and its implications for managing pain after joint arthroplasty

Total joint replacement is a widely used and successful surgical approach. Approximately 7 million US adults are currently living with a hip or knee replacement. However, the surgical procedures for total joint replacement are associated with significant postoperative pain, and current strategies do not adequately address this pain, which leads to patient dissatisfaction, reduced mobility, and increased risk of opioid addiction. We hypothesized that the ultra-high-molecular-weight polyethylene (UHMWPE) bearing surfaces used in total joint prosthetics could provide sustained release of the local anesthetic bupivacaine to provide relief from joint pain for an extended period of time after surgery. In this paper, we describe the production of bupivacaine-loaded UHMWPE (BPE) and measure the in vitro bupivacaine release kinetics of BPE. We found that bupivacaine could be released from BPE at clinically relevant rates for up to several days and that BPE possesses antibacterial effects. Therefore, bupivacaine-loaded UHMWPE is a promising material for joint replacement prostheses, and future studies will evaluate its safety and efficacy in in vivo models. STATEMENT OF SIGNIFICANCE: Total joint replacement is associated with significant pain and risk of infection. In our paper, we introduce bupivacaine-loaded ultra-high-molecular-weight polyethylene (BPE), which releases bupivacaine, a pain-treating drug, at doses comparable to currently used doses. Additionally, BPE inhibits the growth of infection-causing bacteria. Therefore, BPE may be able to reduce both postsurgical pain and risk of infection, potentially treating two of the most prominent complications associated with total joint replacement. To our knowledge, this is the first development of a material that can address both complications, and devices incorporating BPE would represent a significant advancement in joint arthroplasty prosthetics. More generally, the incorporation of therapeutic agents into ultra-high-molecular-weight polyethylene could impact many orthopedic procedures owing to its ubiquity.

An antioxidant stabilized, chemically cross-linked UHMWPE with superior toughness

Chemical cross-linking of ultrahigh molecular weight polyethylene (UHMWPE) using an organic peroxide followed by high temperature melting results in a large increase in toughness accompanied by a decrease in cross-link density, which, surprisingly does not compromise the wear resistance. We compared the mechanical properties and wear behavior of a vitamin E blended, chemically cross-linked and high temperature melted UHMWPE produced by ram extrusion (PRX HTM) to those measured with the clinically available 100-kGy irradiated and melted UHMWPE (CISM 100). We also assessed the local biocompatibility of PRX-HTM in rabbit subcutaneous pouch and osteochondral defect models. The ultimate tensile strength and pin-on-disc wear rate were similar to CISM 100; whereas the elongation-at-break and impact toughness were much higher with PRX-HTM. The stress intensity factor range at crack inception was also higher with PRX-HTM. Accelerated aging did not result in any measurable oxidation or changes in mechanical properties. Hip simulator wear rate of acetabular liners made with PRX-HTM was 0.3 ± 0.4 mg/million-cycle, similar to that reported for CISM 100 liners. The wear particles were largely spherical with a number-averaged particle size of 0.95 μm with ~75% of particles below 1 μm. The subcutaneous and osteochondral rabbit implantations showed no histological differences between PRX-HTM and the control CISM 100. Pre-clinical wear, mechanical, and biocompatibility testing of PRX HTM showed feasibility for the use of this material as a total joint arthroplasty implant bearing surface. This process has the potential of eliminating the additional step of radiation cross-linking by combining consolidation and cross-linking while improving toughness. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 107B: 1945-1952, 2019.

A phospholipid polymer graft layer affords high resistance for wear and oxidation under load bearing conditions

Manipulating the surface and substrate of cross-linked polyethylene (CLPE) is an essential approach for obtaining life-long orthopedic bearings. We therefore proposed a bearing material comprised of an antioxidative substrate generated by vitamin E blending (HD-CLPE[VE]) with a poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC)-grafted surface, and investigated its wear resistance and oxidative stability under accelerated aging and load bearing conditions. Neither the hydration nor friction kinetics of the molecular network structure of the PMPC-grafted surface or the HD-CLPE(VE) substrate were influenced by accelerated aging but rather exhibited high stability even under high oxidation conditions. The characteristics of the PMPC-grafted surface improved the wear and impact fatigue resistance of the HD-CLPE(VE) liner regardless of accelerated aging. Notably, the PMPC-grafted surface was found to affect the potential oxidative stability at the rim part of the acetabular liner. PMPC chains serve several important functions on the surface regardless of load bearing, such as high lubricity or low lipophilicity attributed to phosphorylcholine groups and/or surrounding water-fluid film, and suppression of lipid diffusion attributed to methacrylate main chains on the surface. Together, these results provide preliminary evidence that the PMPC graft layer and vitamin E-blended substrate might positively affect the extent of orthopedic implant durability.

Surface cross-linked UHMWPE using peroxides

Crosslinking of ultra-high molecular weight polyethylene (UHMWPE) has been successfully used to improve its wear performance. Wear is a surface phenomenon and limiting crosslinking to a layer only on the surface is desirable, as crosslinking of the bulk of the implant reduces its mechanical strength and toughness. We present a novel technique to surface crosslink consolidated UHMWPE/vitamin-E blends by diffusing an organic peroxide into the polymer at moderate temperatures, followed by heating to above the peroxide decomposition temperature to cause crosslinking on the surface. We characterized the surface crosslink density and wear rate of surface crosslinked UHMWPE/vitamin-E blends with two different types of peroxides. Both peroxides resulted in surface crosslinking with an increase in wear resistance comparable to the state-of-the-art highly crosslinked UHMWPE used for orthopedic implants. The addition of the antioxidant vitamin-E led to higher oxidation resistance. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2551-2556, 2017.

Surface cross-linked ultra high molecular weight polyethylene by emulsified diffusion of dicumyl peroxide

Cross-linking improves the wear resistance of ultrahigh molecular weight polyethylene (UHMWPE) used in hip and knee implants. Free radicals, generated by ionizing radiation or chemically, react to form cross-links. Limiting cross-linking to the articulating surface of the implant is desirable to enable high wear resistance on the surface and higher strength and toughness in the bulk. We investigated the diffusion of emulsified dicumyl peroxide (DCP) into vitamin E-blended UHMWPE (0.1 and 0.3 wt. % vitamin-E) with subsequent thermal decomposition in situ to obtain surface cross-linking with the objective of achieving surface wear rate equivalent or lower than that of current clinically available materials. We diffused emulsified DCP at 100°C followed by in situ decomposition at 150°C. We also assessed the effect of having vitamin-E in the DCP emulsion. The oxidative stability of the treated samples increased with increasing vitamin E concentration in the blend and by incorporating vitamin E into the peroxide emulsion. The impact strength of a surface cross-linked, 0.3 wt% vitamin E blended UHMWPE prepared using this method was superior to a clinically available irradiated and melted highly cross-linked UHMWPE while the wear resistance was comparable. These results showed the feasibility of surface cross-linking using emulsified peroxide diffusion as a method of making tough and wear resistant joint implant bearing surfaces. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1517-1523, 2018.

A hydrated phospholipid polymer-grafted layer prevents lipid-related oxidative degradation of cross-linked polyethylene

The surface and substrate of a cross-linked polyethylene (CLPE) liner are designed to achieve resistance against oxidative degradation in the construction of hip joint replacements. In this study, we aimed to evaluate the oxidative degradation caused by lipid absorption of a highly hydrophilic nanometer-scaled thickness layer prepared by grafting a poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) layer and a high-dose gamma-ray irradiated CLPE with vitamin E blending (HD-CLPE[VE]). The HD-CLPE(VE) and PMPC-grafted HD-CLPE(VE) exhibited extremely high oxidation resistance regardless of lipid absorption, even though residual-free radical levels were detectable. The water wettability of the PMPC-grafted CLPE and PMPC-grafted HD-CLPE(VE) surfaces was considerably greater than that of untreated surfaces. The hydrated PMPC-grafted layer also exhibited extremely low solubility for squalene. Lipids such as squalene and cholesterol esters diminished the oxidation resistance of CLPE despite the vitamin E improvement. Notably, the PMPC-grafted surface was resistant to lipid absorption and diffusion as well as subsequent lipid-related oxidative degradation, likely because of the presence of the hydrated PMPC-grafted layer. Together, these results provide preliminary evidence that the resistance against lipid absorption and diffusion of a hydrated PMPC-grafted layer might positively affect the extent of resistance to the in vivo oxidation of orthopedic implants.

Fatigue toughness of irradiated vitamin E/UHMWPE blends

Radiation cross-linked ultrahigh molecular weight polyethylenes (UHMWPEs) have become the standard-of-care in total joint replacements (TJR) in the last decade because of their superior wear resistance in comparison with previously used "conventional" gamma sterilized UHMWPE. Some first generation radiation cross-linked UHMWPEs were stabilized against oxidation by post-irradiation melting, which significantly reduced their fatigue crack propagation resistance or fatigue toughness. Second generation cross-linked UHMWPEs incorporated instead an antioxidant such as vitamin E, eliminating the need for melting. In this study, we investigated the fatigue crack propagation resistance and the impact toughness of vitamin E-blended and radiation cross-linked UHMWPEs as a function of vitamin E concentration and radiation dose. Both properties were strongly dependent on the cross-link density and they showed a good correlation with each other (R(2)  = 0.89). © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1514-1520, 2016.

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

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.

Natural polyphenols enhance stability of crosslinked UHMWPE for joint implants

BACKGROUND

Radiation-crosslinked UHMWPE has been used for joint implants since the 1990s. Postirradiation remelting enhances oxidative stability, but with some loss in strength and toughness. Vitamin E-stabilized crosslinked UHMWPE has shown improved strength and stability as compared with irradiated and remelted UHMWPE. With more active phenolic hydroxyl groups, natural polyphenols are widely used in the food and pharmaceutical industries as potent stabilizers and could be useful for oxidative stability in crosslinked UHMWPE.

QUESTIONS/PURPOSES

We asked whether UHMWPE blended with polyphenols would (1) show higher oxidation resistance after radiation crosslinking; (2) preserve the mechanical properties of UHMWPE after accelerated aging; and (3) alter the wear resistance of radiation-crosslinked UHMWPE.

METHODS

The polyphenols, gallic acid and dodecyl gallate, were blended with medical-grade UHMWPE followed by consolidation and electron beam irradiation at 100 kGy. Radiation-crosslinked virgin and vitamin E-blended UHMWPEs were used as reference materials. The UHMWPEs were aged at 120 °C in air with oxidation levels analyzed by infrared spectroscopy. Tensile (n = 5 per group) and impact (n = 3 per group) properties before and after aging as per ASTM F2003 were evaluated. The wear rates were examined by pin-on-disc testing (n = 3 per group). The data were reported as mean ± SDs. Statistical analysis was performed by using Student's t-test for a two-tailed distribution with unequal variance for tensile and impact data obtained with n ≥ 3. A significant difference is defined with p < 0.05.

RESULTS

The oxidation induction time of 100 kGy UHMWPE was prolonged to 144 hours with 0.05 wt% dodecyl gallate and 192 hours with 0.05 wt% gallic acid compared with 48 hours for 0.05 wt% vitamin E-blended UHMWPE. Accelerated aging of these polyphenol-blended UHMWPEs resulted in ultimate tensile strength of 50.4 ± 1.4 MPa and impact strength of 53 ± 5 kJ/m(2) for 100 kGy-irradiated UHMWPE with 0.05 wt% dodecyl gallate, for example, in comparison to 51.2 ± 0.7 MPa (p = 0.75) and 58 ± 5 kJ/m(2) (p = 0.29) before aging. The pin-on-disc wear rates of 100 kGy-irradiated UHMWPE with 0.05 wt% dodecyl gallate and 0.05 wt% gallic acid were 2.29 ± 0.31 and 1.65 ± 0.32 mg/million cycles, comparable to 1.68 ± 0.25 and 2.05 ± 0.22 mg/million cycles for 100 kGy-irradiated virgin and 0.05 wt% vitamin E-blended UHMWPE.

CONCLUSIONS

Based on the sample numbers tested in this study, polyphenols appear to effectively enhance the oxidation stability without altering the mechanical properties or pin-on-disc wear rate of radiation-crosslinked UHMWPE.

CLINICAL RELEVANCE

Crosslinked UHMWPE with natural polyphenols with improved oxidative stability and low wear may find clinical application in joint implants.

Combinatorial effect of rolling and carbonaceous nanoparticles on the evolution of crystallographic texture and structural properties of ultra high molecular weight polyethylene

Presence and shape of nanoparticles influences the crystallographic texture of ultra high molecular weight polyethylene during hot rolling.