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Revision Risk of Total Hip Arthroplasty With Vitamin E Doped Liners: Results From the Danish Hip Arthroplasty Register. J Arthroplasty 2022; 37:1136-1142. [PMID: 35149169 DOI: 10.1016/j.arth.2022.02.007] [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: 11/04/2021] [Revised: 01/03/2022] [Accepted: 02/03/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Vitamin E-doped cross-linked polyethylene (VEPE) liners were introduced in total hip arthroplasty (THA) to reduce wear and risk of aseptic loosening and liner fracture. We report this nationwide population-based study to investigate the safety of VEPE liners for THA compared to cross-linked annealed or remelted polyethylene (XLPE). METHODS We included THAs from The Danish Hip Arthroplasty Register from January 1, 2008 to June 30, 2019, with uncemented cup, VEPE or XLPE liner, and metal or ceramic head. The outcome was revision due to (1) polyethylene-related endpoints (aseptic loosening, granuloma, osteolysis, or liner fractures) and (2) other endpoints. RESULTS A total of 110,803 THAs were assessed for eligibility and 53,842 THAs (46,645 patients) were included in the study: 5069 (9.4%) THAs with a VEPE liner and 48,773 (91.6%) with a XLPE liner. Median observation time was 5.48 (interquartile range 3.80-7.15) years for VEPE and 4.85 (interquartile range 2.68-7.76) for XLPE. VEPE had a lower risk of revision for polyethylene-related endpoints compared to XLPE (hazard ratio [HR] 0.60, 95% confidence interval 0.36-0.98) during complete follow-up. THAs with VEPE liners were associated with increased risk of any revision within the first 3 months (HR 1.62, 1.36-1.94), revision recorded as aseptic loosening within 3 months (HR 4.46, 2.26-8.80), and periprosthetic fracture within 3 months (HR 2.57, 1.98, 3.33). CONCLUSION VEPE liners had a lower risk of revision due to polyethylene-related endpoints, but a higher risk of all-cause revision within 3 months.
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De Meurechy N, Aktan MK, Boeckmans B, Huys S, Verwilghen DR, Braem A, Mommaerts MY. Surface wear in a custom manufactured temporomandibular joint prosthesis. J Biomed Mater Res B Appl Biomater 2022; 110:1425-1438. [PMID: 35088936 PMCID: PMC9306732 DOI: 10.1002/jbm.b.35010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 11/10/2022]
Abstract
The wear of a novel temporomandibular joint (TMJ) prosthesis was evaluated in an animal model. The prosthesis consisted of an additively manufactured titanium alloy (Ti6Al4V) mandibular condyle and glenoid fossa created through selective laser melting, with a machined vitamin E‐enriched ultra‐high molecular weight polyethylene (UHMWPE) surface attached to the fossa. Thirteen TMJ prosthesis were implanted in sheep, six of which had condylar heads coated with HadSat® diamond‐like carbon (H‐DLC). Euthanasia took place after 288 days, equaling 22 years of human mastication. Linear and volumetric wear analysis of the fossa was performed by optical scanning. The condylar head surfaces were assessed by scanning electron and confocal laser microscopy. The average linear UHMWPE wear, when combined with the coated condyle, was 0.67 ± 0.28 mm (range: 0.34–1.15 mm), not significantly differing (p = .3765, t‐test) from the non‐coated combination average (0.88 ± 0.41 mm; range: 0.28–1.48 mm). The respective mean volumetric wear volumes were 25.29 ± 11.43 mm3 and 45.85 ± 22.01 mm3, not significantly differing (p = .1448, t‐test). Analysis of the coated condylar surface produced a mean Ra of 0.12 ± 0.04 μm and Sa of 0.69 ± 0.07 μm. The non‐coated condylar surface measured a mean Ra of 0.28 ± 0.17 μm and Sa of 2.40 ± 2.08 μm. Both Sa (p = .0083, Mann–Whitney U test) and Ra (p = .0182, Mann–Whitney U test), differed significantly. The prosthesis exhibits acceptable wear resistance and addition of the H‐DLC‐coating significantly improved long‐term condylar surface smoothness.
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Affiliation(s)
- Nikolas De Meurechy
- European Face Centre, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Doctoral School of Life Sciences and Medicine, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Bart Boeckmans
- Department of Mechanical Engineering, KU Leuven, Heverlee, Belgium.,Flanders Make, Heverlee, Belgium
| | - Stijn Huys
- Department of Mechanical Engineering, KU Leuven, Heverlee, Belgium
| | - Denis R Verwilghen
- Sydney School of Veterinary Sciences, Faculty of Science, University of Sydney, Sydney, Australia
| | - Annabel Braem
- Department of Materials Engineering, KU Leuven, Heverlee, Belgium
| | - Maurice Y Mommaerts
- European Face Centre, Universitair Ziekenhuis Brussel, Brussels, Belgium.,Doctoral School of Life Sciences and Medicine, Vrije Universiteit Brussel, Brussels, Belgium
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Shah NA, Ren Y, Lan R, Lv J, Gul RM, Tan P, Huang S, Tan L, Xu J, Li Z. Ultrahigh molecular weight polyethylene with improved crosslink density, oxidation stability, and microbial inhibition by chemical crosslinking and tea polyphenols for total joint replacements. J Appl Polym Sci 2021. [DOI: 10.1002/app.51261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Nouman Ali Shah
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu China
| | - Yue Ren
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu China
| | - Ri‐Tong Lan
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu China
| | - Jia‐Cheng Lv
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu China
| | - Rizwan M. Gul
- Department of Mechanical Engineering University of Engineering and Technology Peshawar Pakistan
| | - Peng‐Fei Tan
- College of Biomass Science and Engineering Sichuan University Chengdu China
| | - Shishu Huang
- Department of Orthopedic Surgery and Orthopedic Research Institute, West China Hospital and West China School of Medicine Sichuan University Chengdu China
| | - Lin Tan
- College of Biomass Science and Engineering Sichuan University Chengdu China
| | - Jia‐Zhuang Xu
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu China
| | - Zhong‐Ming Li
- College of Polymer Science and Engineering, State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu China
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Vitamin E-enriched polyethylene bearings are not inferior to Arcom bearings in primary total knee arthroplasty at medium-term follow-up. Arch Orthop Trauma Surg 2021; 141:1027-1033. [PMID: 33417026 DOI: 10.1007/s00402-020-03727-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The release of wear particles can be responsible for periprosthetic osteolysis, which can in turn, lead to aseptic loosening. Vitamin E-infused polyethylene (HXLPE Vit-E) has been shown, in vitro, to be more resistant to wear than conventional polyethylene (UHMWPE) by its crosslinking (HXLPE) and its higher resistance to oxidation. After reading a case report of a fracture of a vitamin E-enriched HXLPE bearing, the aim of this retrospective study was to evaluate fracture risk and clinical inferiority or not of vitamin-E HXLPE compared to conventional polyethylene in total knee arthroplasty (TKA). MATERIALS AND METHODS Three hundred and forty-nine patients (403 TKAs) were contacted, to find out whether they had undergone revision surgery for any reason after a mean (SD) of 7 (1.5) years. Follow-up control radiographs were analyzed for periprosthetic radiolucent lines (RLL) and loosening. Two different Patient Reported Outcome Measurements Scores (PROMS), KOOS and FJS-12, were utilized to assess the daily functionality and identify potential problems. RESULTS No statistically significant difference in revision rate, occurrence of aseptic loosening or RLL nor outcome as measured with PROMS was observed. CONCLUSIONS No bearing fractures or clinical inferiority was observed for vitamin E-enriched HXLPE at medium-term follow-up (7 years) compared to conventional Arcom polyethylene. LEVEL OF EVIDENCE Level III, therapeutic study.
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Hameister R, Kaur C, Dheen ST, Lohmann CH, Singh G. Reactive oxygen/nitrogen species (ROS/RNS) and oxidative stress in arthroplasty. J Biomed Mater Res B Appl Biomater 2020; 108:2073-2087. [PMID: 31898397 DOI: 10.1002/jbm.b.34546] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/19/2019] [Accepted: 12/08/2019] [Indexed: 12/16/2022]
Abstract
The interplay between implant design, biomaterial characteristics, and the local microenvironment adjacent to the implant is of utmost importance for implant performance and success of the joint replacement surgery. Reactive oxygen and nitrogen species (ROS/RNS) are among the various factors affecting the host as well as the implant components. Excessive formation of ROS and RNS can lead to oxidative stress, a condition that is known to damage cells and tissues and also to affect signaling pathways. It may further compromise implant longevity by accelerating implant degradation, primarily through activation of inflammatory cells. In addition, wear products of metallic, ceramic, polyethylene, or bone cement origin may also generate oxidative stress themselves. This review outlines the generation of free radicals and oxidative stress in arthroplasty and provides a conceptual framework on its implications for soft tissue remodeling and bone resorption (osteolysis) as well as implant longevity. Key findings derived from cell culture studies, animal models, and patients' samples are presented. Strategies to control oxidative stress by implant design and antioxidants are explored and areas of controversy and challenges are highlighted. Finally, directions for future research are identified. A better understanding of the host-implant interplay and the role of free radicals and oxidative stress will help to evaluate therapeutic approaches and will ultimately improve implant performance in arthroplasty.
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Affiliation(s)
- Rita Hameister
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Charanjit Kaur
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shaikali Thameem Dheen
- Department of Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Christoph H Lohmann
- Department of Orthopaedic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Gurpal Singh
- Centre for Orthopaedics Pte Ltd, Singapore, Singapore
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The effect of vitamin E-enhanced cross-linked polyethylene on wear in shoulder arthroplasty-a wear simulator study. J Shoulder Elbow Surg 2019; 28:1771-1778. [PMID: 31029519 DOI: 10.1016/j.jse.2019.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 01/14/2019] [Accepted: 01/21/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Wear of the polyethylene glenoid component and subsequent particle-induced osteolysis remains one of the most important modes of failure of total shoulder arthroplasty. Vitamin E is added to polyethylene to act as an antioxidant to stabilize free radicals that exist as a byproduct of irradiation used to induce cross-linking. This study was performed to assess the in vitro performance of vitamin E-enhanced polyethylene compared with conventional polyethylene in a shoulder simulator model. METHODS Vitamin E-enhanced, highly cross-linked glenoid components were compared with conventional ultrahigh-molecular-weight polyethylene glenoids, both articulating with a ceramic humeral head component using a shoulder joint simulator over 500,000 cycles. Unaged and artificially aged comparisons were performed. Volumetric wear was assessed by gravimetric measurement, and wear particle analysis was also subsequently performed. RESULTS Vitamin E-enhanced polyethylene glenoid components were found to have significantly reduced wear rates compared with conventional polyethylene in both unaged (36% reduction) and artificially aged (49% reduction) comparisons. There were no differences detected in wear particle analysis between the 2 groups. CONCLUSION Vitamin E-enhanced polyethylene demonstrates improved wear compared with conventional polyethylene in both unaged and artificially aged comparisons and may have clinically relevant benefits.
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Takemura S, Minoda Y, Sugama R, Ohta Y, Nakamura S, Ueyama H, Nakamura H. Comparison of a vitamin E-infused highly crosslinked polyethylene insert and a conventional polyethylene insert for primary total knee arthroplasty at two years postoperatively. Bone Joint J 2019; 101-B:559-564. [PMID: 31039001 DOI: 10.1302/0301-620x.101b5.bjj-2018-1355.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
AIMS The use of vitamin E-infused highly crosslinked polyethylene (HXLPE) in total knee prostheses is controversial. In this paper we have compared the clinical and radiological results between conventional polyethylene and vitamin E-infused HXLPE inserts in total knee arthroplasty (TKA). PATIENTS AND METHODS The study included 200 knees (175 patients) that underwent TKA using the same total knee prostheses. In all, 100 knees (77 patients) had a vitamin E-infused HXLPE insert (study group) and 100 knees (98 patients) had a conventional polyethylene insert (control group). There were no significant differences in age, sex, diagnosis, preoperative knee range of movement (ROM), and preoperative Knee Society Score (KSS) between the two groups. Clinical and radiological results were evaluated at two years postoperatively. RESULTS Differences in postoperative ROM and KSS were not statistically significant between the study and control groups. No knee exhibited osteolysis, aseptic loosening, or polyethylene failure. Additionally, there was no significant difference in the incidence of a radiolucent line between the two groups. One patient from the study group required irrigation and debridement, due to deep infection, at six months postoperatively. CONCLUSION Clinical results were comparable between vitamin E-infused HXLPE inserts and conventional polyethylene inserts at two years after TKA, without any significant clinical failure. Cite this article: Bone Joint J 2019;101-B:559-564.
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Affiliation(s)
- S Takemura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Y Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - R Sugama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Y Ohta
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - S Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - H Ueyama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - H Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Galliera E, Ragone V, Marazzi MG, Selmin F, Banci L, Corsi Romanelli MM. Vitamin E-stabilized UHMWPE: Biological response on human osteoblasts to wear debris. Clin Chim Acta 2018; 486:18-25. [DOI: 10.1016/j.cca.2018.07.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/09/2018] [Indexed: 12/31/2022]
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De Meurechy N, Braem A, Mommaerts M. Biomaterials in temporomandibular joint replacement: current status and future perspectives—a narrative review. Int J Oral Maxillofac Surg 2018; 47:518-533. [DOI: 10.1016/j.ijom.2017.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 08/09/2017] [Accepted: 10/02/2017] [Indexed: 12/31/2022]
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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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Gigante A, Bottegoni C, Ragone V, Banci L. Effectiveness of Vitamin-E-Doped Polyethylene in Joint Replacement: A Literature Review. J Funct Biomater 2015; 6:889-900. [PMID: 26371052 PMCID: PMC4598683 DOI: 10.3390/jfb6030889] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 07/24/2015] [Accepted: 08/08/2015] [Indexed: 12/25/2022] Open
Abstract
Since polyethylene is one of the most frequently used biomaterials, such as in bearing components in joint arthroplasty, strong efforts have been made to improve the design and material properties over the last decades. Antioxidants, such as vitamin-E, seem to be a promising alternative to further increase durability and reduce polyethylene wear and degradation in the long-term. Nevertheless, even if several promising in vitro results are available, there is yet no clinical evidence that vitamin-E polyethylenes show these advantages in vivo. The aim of this paper was to provide a comprehensive overview on the current knowledge regarding the biological and mechanical proprieties of this biomaterial, underlying the in vitro and in vivo evidence for effectiveness of vitamin-E-doped polyethylene in joint arthroplasty.
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Affiliation(s)
- Antonio Gigante
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Carlo Bottegoni
- Clinical Orthopaedics, Department of Clinical and Molecular Science, School of Medicine, Università Politecnica delle Marche, via Tronto 10/A, 60126 Ancona, Italy.
| | - Vincenza Ragone
- Research and Development Department, Permedica S.p.A., via Como 38, 23807 Merate (LC), Italy.
| | - Lorenzo Banci
- Research and Development Department, Permedica S.p.A., via Como 38, 23807 Merate (LC), Italy.
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Spectroscopic and chromatographic quantification of an antioxidant-stabilized ultrahigh-molecular-weight polyethylene. Clin Orthop Relat Res 2015; 473:952-9. [PMID: 25524430 PMCID: PMC4317457 DOI: 10.1007/s11999-014-4108-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The oxidative stability of various antioxidant-containing ultrahigh-molecular-weight polyethylene (UHMWPE) formulations has been widely reported. Depending on which specific antioxidant is used, the process by which it is incorporated into UHMWPE, and the amount of the antioxidant incorporated, there could be substantial differences in the material and toxicological properties of the UHMWPE formulation. Pentaerythritol tetrakis (3-[3,5-di tertiary butyl-4-hydroxyphenyl] propionate) (PBHP) has been extensively used as an efficient antioxidant in various applications. However, it has not thus far been used to stabilize UHMWPE in orthopaedic implants. It is therefore important to characterize and verify the concentration and homogeneity of distribution of PBHP in the composition, the chemical consequence of exposure of the antioxidant to gamma irradiation, and to assess the toxicological risk of use by the identification and quantification of leachables before the use of PBHP-containing UHMWPE in implantable devices. QUESTIONS/PURPOSES (1) Can the concentration and uniformity of distribution of the antioxidant PBHP in UHMWPE powder and in the consolidated, preirradiated formulation be verified? (2) Can the leachable compounds in the gamma radiation crosslinked PBHP/UHMWPE formulation be identified and quantified? METHODS PBHP in GUR 1020 UHMWPE was quantified by Fourier transform infrared (FTIR) and ultraviolet-visible (UV-Vis) spectroscopy. The chemical byproducts generated by gamma irradiation of PBHP were identified using gas chromatography in conjunction with mass spectrometry followed by a second-stage mass spectrometry (GC-MS/MS). When GC-MS/MS was coupled with Stir Bar Sorptive extraction, leachable components in the UHMWPE formulation were identified and quantified. RESULTS The percent concentration of PBHP in UHMWPE powder was confirmed by UV-Vis spectroscopy and the concentration and uniform distribution of PBHP in UHMWPE after consolidation and before radiation crosslinking was verified through FTIR spectroscopy. GC-MS/MS analysis enabled the identification and quantification of 16 gamma irradiation byproducts of PBHP. These 16 compounds were verified as potentially leachable compounds in PBHP-stabilized UHMWPE and were found to be well below the safety threshold concern of 150 ng/device in orthopaedic knee inserts made from PBHP-stabilized UHMWPE. CONCLUSIONS Spectroscopic analysis has been successfully used to demonstrate the ability to reliably quantify the amount as well as the distribution of PBHP in UHMWPE in orthopaedic bearings. State-of-the-art chemical extraction and analytical techniques have enabled the identification of the gamma radiation-induced byproducts of PBHP and the quantification of these components as leachables from the PBHP-stabilized UHMWPE formulation. CLINICAL RELEVANCE Antioxidant-stabilized UHMWPE materials being considered for orthopaedic bearings must be fully characterized for composition before use because it is apparent that exposure to high doses of gamma radiation would cause the formation of new chemical entities. It is important to verify the identities and quantities of chemical species that could leach out of implanted devices in the long term to enable their toxicological risk assessment.
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Bladen CL, Teramura S, Russell SL, Fujiwara K, Fisher J, Ingham E, Tomita N, Tipper JL. Analysis of wear, wear particles, and reduced inflammatory potential of vitamin E ultrahigh-molecular-weight polyethylene for use in total joint replacement. J Biomed Mater Res B Appl Biomater 2013; 101:458-66. [PMID: 23436622 PMCID: PMC3798093 DOI: 10.1002/jbm.b.32904] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 11/27/2012] [Accepted: 01/10/2013] [Indexed: 11/12/2022]
Abstract
Vitamin E (VE) has been added to ultrahigh-molecular-weight polyethylene (UHMWPE) acetabular cups and tibial trays primarily to reduce oxidative damage to the polymer. The aim of this study was to investigate the relative wear rates of UHMWPE-containing VE compared with virgin UHMWPE. The ability of VE to reduce the amount of inflammatory cytokines produced from stimulated peripheral blood mononuclear cells (PBMNCs) was also investigated. Stimulation was achieved by exposure of PBMNCs to either lipoplysaccharide (LPS) or VE-containing UHMWPE (VE-UHMWPE). In the present study, results showed that the wear rates of UHMWPE with or without VE were not significantly different. Particles generated by UHMWPE with and without VE were not significantly different in size distribution. The production of osteolytic mediators, tumor necrosis factor-alpha, interleukin 1β (IL-β), IL-6, and IL-8 were significantly reduced in (PBMNCs) stimulated with either LPS + VE compared with LPS or VE-UHMWPE particles compared to virgin UHMWPE particles. This trend was also observed when VE was added as a liquid to UHMWPE wear particle-stimulated PBMNCs. The exact mechanism of how VE affects the release of inflammatory mediators from particle-stimulated macrophages is not yet understood. It is likely to involve the anti-inflammatory and/or antioxidant effects of VE.
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Affiliation(s)
- C L Bladen
- Institute of Medical and Biological Engineering, University of Leeds, UK.
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Abstract
BACKGROUND Osteolysis due to wear of UHMWPE limits the longevity of joint arthroplasty. Oxidative degradation of UHMWPE gamma-sterilized in air increases its wear while decreasing mechanical strength. Vitamin E stabilization of UHMWPE was proposed to improve oxidation resistance while maintaining wear resistance and fatigue strength. QUESTIONS/PURPOSES We reviewed the preclinical research on the development and testing of vitamin E-stabilized UHMWPE with the following questions in mind: (1) What is the rationale behind protecting irradiated UHMWPE against oxidation by vitamin E? (2) What are the effects of vitamin E on the microstructure, tribologic, and mechanical properties of irradiated UHMWPE? (3) Is vitamin E expected to affect the periprosthetic tissue negatively? METHODS We performed searches in PubMed, Scopus, and Science Citation Index to review the development of vitamin E-stabilized UHMWPEs and their feasibility as clinical implants. RESULTS The rationale for using vitamin E in UHMWPE was twofold: improving oxidation resistance of irradiated UHMWPEs and fatigue strength of irradiated UHMWPEs with an alternative to postirradiation melting. Vitamin E-stabilized UHMWPE showed oxidation resistance superior to that of irradiated UHMWPEs with detectable residual free radicals. It showed equivalent wear and improved mechanical strength compared to irradiated and melted UHMWPE. The biocompatibility was confirmed by simulating elution, if any, of the antioxidant from implants. CONCLUSIONS Vitamin E-stabilized UHMWPE offers a joint arthroplasty technology with good mechanical, wear, and oxidation properties. CLINICAL RELEVANCE Vitamin E-stabilized, irradiated UHMWPEs were recently introduced clinically. The rationale behind using vitamin E and in vitro tests comparing its performance to older materials are of great interest for improving longevity of joint arthroplasties.
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Affiliation(s)
- Pierangiola Bracco
- Dipartimento di Chimica IFM and NIS Centre of Excellence, Università di Torino, Via Pietro Guria, 7, 10125 Torino, Italy
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA USA
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Oral E, Muratoglu OK. Vitamin E diffused, highly crosslinked UHMWPE: a review. INTERNATIONAL ORTHOPAEDICS 2010; 35:215-23. [PMID: 21120476 DOI: 10.1007/s00264-010-1161-y] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/02/2010] [Accepted: 11/02/2010] [Indexed: 11/30/2022]
Abstract
Highly crosslinked UHMWPE has become the bearing surface of choice in total hip arthroplasty. First generation crosslinked UHMWPEs, clinically introduced in the 1990s, show significant improvements compared to gamma sterilised, conventional UHMWPE in decreasing wear and osteolysis. These crosslinked UHMWPEs were thermally treated (annealed or melted) after irradiation to improve their oxidation resistance. While annealing resulted in the retention of some oxidation potential, post-irradiation melted UHMWPEs had reduced fatigue strength due to the crystallinity loss during melting. Thus, the stabilisation of radiation crosslinked UHMWPEs by the diffusion of the antioxidant vitamin E was developed to obtain oxidation resistance with improved fatigue strength by avoiding post-irradiation melting. A two-step process was developed to incorporate vitamin E into irradiated UHMWPE by diffusion to obtain a uniform concentration profile. Against accelerated and real-time aging in vitro, this material showed superior oxidation resistance to UHMWPEs with residual free radicals. The fatigue strength was improved compared to irradiated and melted UHMWPEs crosslinked using the same irradiation dose. Several adverse testing schemes simulating impingement showed satisfactory behaviour. Peri-prosthetic tissue reaction to vitamin E was evaluated in rabbits and any effects of vitamin E on device fixation were evaluated in a canine model, both of which showed no detrimental effects of the inclusion of vitamin E in crosslinked UHMWPE. Irradiated, vitamin E-diffused, and gamma sterilised UHMWPEs have been in clinical use in hips since 2007 and in knees since 2008. The clinical outcome of this material will be apparent from the results of prospective, randomised clinical studies.
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Affiliation(s)
- Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, 55 Fruit St. GRJ 1206, Boston, MA 02114, USA.
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Bracco P, Brunella V, Zanetti M, Luda M, Costa L. Stabilisation of ultra-high molecular weight polyethylene with Vitamin E. Polym Degrad Stab 2007. [DOI: 10.1016/j.polymdegradstab.2007.02.023] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Wolf C, Lederer K, Pfragner R, Schauenstein K, Ingolic E, Siegl V. Biocompatibility of ultra-high molecular weight polyethylene (UHMW-PE) stabilized with alpha-tocopherol used for joint endoprostheses assessed in vitro. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2007; 18:1247-52. [PMID: 17277986 DOI: 10.1007/s10856-006-0098-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Accepted: 02/09/2006] [Indexed: 05/13/2023]
Abstract
Adding the natural antioxidant alpha-tocopherol to ultra-high molecular weight polyethylene (UHMW-PE) can remarkably delay the oxidation of hip cups made thereof. However, alpha-tocopherol is likely to undergo different chemical transformations during manufacturing and sterilization of hip cups than in human metabolism. Therefore, the biocompatibility of the putative transformation products has to be investigated. In-vitro tests with L929 mice fibroblast-cells gave no evidence for cytotoxicity. To further ensure the biocompatibility, in-vitro tests with human cells were carried out in this study. Two different human cell lines, one adherent cell line, HF-SAR, and one suspension culture, GSJO, were tested on UHMW-PE-tablets (diameter: 15 mm; thickness: 2 mm; processed according to standard procedures for artificial hip-cups) with and without alpha-tocopherol with respect to cell viability, proliferation and morphology by means of cell counting, WSt-1 proliferation assay and scanning electron microscopy. Similar proliferation rates were found with both polyethylene samples. Further, we found intact morphology in light and electron microscopy on each substrate. The morphologic characteristics of skin fibroblasts were not changed by any material. Normal adherence and spreading of the fibroblasts was found on controls of glass, as well as on polystyrene and on stabilized and unstabilized polyethylene. The characteristic behaviour as suspension of the GSJO cells remained unchanged. The mitochondrial activity, as studied by WST-1 cell proliferation reagent, was identical on each substrate during the whole observation period of 7 days.
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Affiliation(s)
- Christian Wolf
- Department of Chemistry of Polymeric Materials, University of Leoben, 8700 Leoben, Austria
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Renò F, Cannas M. UHMWPE and vitamin E bioactivity: an emerging perspective. Biomaterials 2006; 27:3039-43. [PMID: 16457883 DOI: 10.1016/j.biomaterials.2006.01.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2005] [Accepted: 01/11/2006] [Indexed: 01/20/2023]
Abstract
Ultra-high molecular weight polyethylene (UHMWPE) is a semicrystalline biomaterial widely used in the components for articular prosthesis for its excellent mechanical qualities. Two major problems limit the UHMWPE prosthesis life-wearing and delamination, both phenomena being mainly due to chemical oxidation of polymer. Wearing causes the release of generated particulate that triggers a macrophage reaction leading to chronic inflammation and osteolysis, while delamination, due to the mechanical stress, macroscopically alters the surfaces. The most diffused method to reduce wearing is UHMWPE molecular cross-linking by high-energy irradiation followed by melting that also reduces polymer fatigue strength. For this reason, the use of vitamin E (alpha-tocopherol), as an anti-oxidative and biocompatible additive for normal and cross-linked UHMWPE, has been suggested as an alternative method to improve polymer wearing resistance without altering its mechanical strength. This paper describes briefly the rationale of vitamin E as UHMWPE additive and its possible use as an emerging perspective in the orthopaedic field.
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Affiliation(s)
- Filippo Renò
- Human Anatomy Laboratory, Research Center for Biocompatibility, Clinical and Experimental Medicine Department, University of Eastern Piedmont A. Avogadro, Via Solaroli 17, 28100 Novara, Italy
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SHIBATA N, KURTZ SM, TOMITA N. Recent Advances of Mechanical Performance and Oxidation Stability in Ultrahigh Molecular Weight Polyethylene for Total Joint Replacement: Highly Crosslinked and .ALPHA.-Tocopherol Doped. ACTA ACUST UNITED AC 2006. [DOI: 10.1299/jbse.1.107] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Nobuyuki SHIBATA
- Human Engineering and Risk Management Group, Institute of Industrial Health, Japan National Institute of Occupational Safety and Health
- Department of Mechanical Engineering, Kanagawa Institute of Technology
| | - Steven M. KURTZ
- Implant Research Center, School of Biomedical Engineering Science and Health Systems, Drexel University
- Failure Analysis Associates, Exponent, Inc
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