Clinical outcomes of ceramic femoral prosthesis in total knee arthroplasty: a systematic review

Evolution of temporomandibular joint reconstruction: from autologous tissue transplantation to alloplastic joint replacement

The reconstruction of the temporomandibular joint presents a multifaceted clinical challenge in the realm of head and neck surgery, underscored by its relatively infrequent occurrence and the lack of comprehensive clinical guidelines. This review aims to elucidate the available approaches for TMJ reconstruction, with a particular emphasis on recent groundbreaking advancements. The current spectrum of TMJ reconstruction integrates diverse surgical techniques, such as costochondral grafting, coronoid process grafting, revascularized fibula transfer, transport distraction osteogenesis, and alloplastic TMJ replacement. Despite the available options, a singular, universally accepted 'gold standard' for reconstructive techniques or materials remains elusive in this field. Our review comprehensively summarizes the current available methods of TMJ reconstruction, focusing on both autologous and alloplastic prostheses. It delves into the differences of each surgical technique and outlines the implications of recent technological advances, such as 3D printing, which hold the promise of enhancing surgical precision and patient outcomes. This evolutionary progress aims not only to improve the immediate results of reconstruction but also to ensure the long-term health and functionality of the TMJ, thereby improving the quality of life for patients with end-stage TMJ disorders.

Metal Hypersensitivity in Patients With Failure of Joint Prosthesis Treatment

The objective of this study is to measure lymphocyte responses to metal antigens using MELISA (memory lymphocyte immunostimulation assay) test-modified lymphocyte transformation test (mLTT) and to evaluate metal sensitization in patients with and without the need of prosthetic surgery. This study is a case-control retrospective survey. We retrospectively analyzed all patients from 2013 to 2018 who were referred to the Institute of Dental Medicine, General University Hospital in Prague, and First Faculty of Medicine, Charles University, Prague, either following joint prosthesis-related complications or as a preoperative evaluation concerning metal hypersensitivity. For the control group, we selected healthy adults from our database. A group of 127 patients aged 25-81 years was chosen, 92 of which were female and 35 were male. The patients completed a special questionnaire aimed at information regarding their health status and history of metal exposure. After clinical examination, their peripheral blood samples were taken to perform mLTT. mLTT provided quantitative lymphocyte proliferation measurement, where a stimulation index of >2 indicated metal sensitivity. For statistical analysis, the Fisher's exact test, χ2 test, McNemar's exact test Student's paired t-test were used. By comparison of the study group and control group mLTT results, it can be stated that patients of the study group showed a higher level of lymphocyte reactivity to most of the tested metal antigens (Ag [silver], Cu [copper], Fe [iron], Mo [molybdenum], Pd [palladium], Pt [platinum], Ti [titanium], and Zn [zinc]) and an elevated incidence of metal hypersensitivity to Hg (mercury), Al (aluminum), Au (gold), Co (cobalt), Cr (chromium), Ni (nickel), and Sn (tin). The evaluation of the data obtained from patients in this study confirmed a significant clinical benefit of mLTT in diagnostics of metal hypersensitivity. Our study has revealed that the patients with the need of prosthetic surgery exhibited an elevated lymphocyte response to metal antigens. This result supports a metal-specific adaptive immune response and suggests involvement of metal exposure as a trigger for their health problems. This knowledge could be helpful in effectively enhancing the treatment of patients with need of orthopedic joint prosthesis.

Long term follow-up of a completely metal free total knee endoprosthesis in comparison to an identical metal counterpart

Aseptic loosening is a feared and not yet fully-understood complication of total knee arthroplasty (TKA). Hypersensitivity reactions may be the underlying cause within some susceptible patients. Metal-free implants have been developed as a possible solution. The aim of this prospective, observational long-term study was the assessment of a completely metal-free ceramic knee replacement system compared to its identical metal counterpart 8 years after implantation, conducted as a follow-up of a previous report. A total of 88 patients (mean age 69 years) were enrolled in this prospective, observational long-term 8-year follow-up study. The "ceramic group" with a completely metal-free total knee replacement system was compared to the "conventional group" with an identical metal TKA system at the final follow-up. Clinical assessment included Knee Society Score (KSS), Oxford Knee Score (OKS), European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-L), European Quality of Life 5 Dimension Visual Analogue Scale (EQ-VAS) and High Activity Arthroplasty Score (HAAS) as well as perioperative or postoperative complications and need for revision. The tibial/femoral positioning, signs of periprosthetic fissures/fractures or radiolucent lines were documented radiographically. All postoperative clinical scores in the ceramic group primarily improved from baseline to 4-year follow-up, but then decreased at the final 8-year follow-up. At the final follow-up, statistically non-significant differences were found in comparison of both groups for the KSS (ceramic: 166 ± 31, conventional: 162 ± 29; p > 0.05), OKS (ceramic: 37, conventional: 39; p > 0.05), EQ-VAS (ceramic: 77 ± 17, conventional: 72 ± 18; p > 0.05), and HAAS (ceramic: 8.29 ± 3.32, conventional: 9.28 ± 4.44; p > 0.05). A significant difference was found for EQ-5D-L (ceramic: 0.819 ± 0.284, conventional: 0.932 ± 0.126; p ≤ 0.05). Progressive radiolucent lines have been found around the uncemented tibial stem (0.8 mm at initial diagnosis (mean 19 months); 1.3 mm at 4-year follow-up; 1.6 mm at 8-year follow-up) without any clinical signs of loosening. One revision surgery was performed after a traumatic polyethylene inlay-breakage. No allergic reactions could be detected. The used ceramic TKA system meets the functional performance standards of an established identical metal TKA system after an 8-year follow-up period, offering a safe option for patients with prior hypersensitivity reactions to metallic materials. Full cementation of ceramic components is recommended.

Characterizing Surface Morphological and Chemical Properties of Commonly Used Orthopedic Implant Materials and Determining Their Clinical Significance

The goal of the study was to compare the surface characteristics of typical implant materials used in orthopedic surgery and traumatology, as these determine their successful biointegration. The morphological and chemical structure of Vortex plate anodized titanium from commercially pure (CP) Grade 2 Titanium (Ti2) is generally used in the following; non-cemented total hip replacement (THR) stem and cup Ti alloy (Ti6Al4V) with titanium plasma spray (TPS) coating; cemented THR stem Stainless steel (SS); total knee replacement (TKR) femoral component CoCrMo alloy (CoCr); cemented acetabular component from highly cross-linked ultrahigh molecular weight polyethylene (HXL); and cementless acetabular liner from ultrahigh molecular weight polyethylene (UHMWPE) (Sanatmetal, Ltd., Eger, Hungary) discs, all of which were examined. Visualization and elemental analysis were carried out by scanning electron microscopy (SEM), energy dispersive spectroscopy (EDS) and X-ray photoelectron spectroscopy (XPS). Surface roughness was determined by atomic force microscopy (AFM) and profilometry. TPS Ti presented the highest Ra value (25 ± 2 μm), followed by CoCr (535 ± 19 nm), Ti2 (227 ± 15 nm) and SS (170 ± 11 nm). The roughness measured in the HXL and UHMWPE surfaces was in the same range, 147 ± 13 nm and 144 ± 15 nm, respectively. EDS confirmed typical elements regarding the investigated prosthesis materials. XPS results supported the EDS results and revealed a high % of Ti4+ on Ti2 and TPS surfaces. The results indicate that the surfaces of prosthesis materials have significantly different features, and a detailed characterization is needed to successfully apply them in orthopedic surgery and traumatology.

Alloplastic temporomandibular joint replacement - past, present, and future: "Learn from the past, prepare for the future, live in the present." Thomas S. Monson

Based on evidence from the orthopaedic, biomedical engineering, and oral and maxillofacial surgical literature, this paper discusses reported successes and failures of past alloplastic temporomandibular joint (TMJ) devices that have led to the development of present total temporomandibular joint replacement (TMJR) devices. The paper concludes with discussion of the ongoing research that will lead to future embodiment (materials, designs, and manufacture) advances in TMJR management of severe and debilitating end-stage TMJ disease, further improving patients' mandibular function, form, and overall quality of life.

Fostering Excellence in Knee Arthroplasty: Developing Optimal Patient Care Pathways and Inspiring Knowledge Transfer of Advanced Surgical Techniques

Osteoarthritis of the knee is common. Early sports trauma or cartilage defects are risk factors for osteoarthritis. If conservative treatment fails, partial or total joint replacement is often performed. A joint replacement aims to restore physiological biomechanics and the quality of life of affected patients. Total knee arthroplasty is one of the most performed surgeries in musculoskeletal medicine. Several developments have taken place over the last decades that have truly altered the way we look at knee arthroplasty today. Some of the fascinating aspects will be presented and discussed in the present narrative review.

Mid-term clinical outcomes of a posterior stabilized total knee prosthesis for Japanese patients: A minimum follow-up of 5 years

BACKGROUND

A high-flexion posterior-stabilized total knee prosthesis has been developed for the Asian population. The component design was based on computed tomography images of Japanese osteoarthritic knees. The femoral component is composed of zirconia ceramics, which exhibit low friction and high durability. The present study aimed to evaluate the mid-term clinical outcomes of this implant.

METHODS

This study included 334 knees of 210 patients who underwent primary total knee arthroplasty with this implant at our hospital between October 2010 and December 2014. The patients comprised 28 men and 172 women with an average age of 73 years. The average follow-up period was 5.9 years, and the follow-up rate was 71.1%. Clinical outcomes were assessed using the Knee Society scoring system, 2011 Knee Society questionnaire, and Knee Injury and Osteoarthritis Outcome Score. Kaplan-Meier survivorship analysis was performed to determine the cumulative prosthesis survival rate.

RESULTS

In terms of clinical outcomes at the final follow-up, the average ranges of motion were -2.0 in extension and 126.7 in flexion. The Knee Society knee and function scores were 94.2% and 72.6%, respectively. With revision surgery or radiographic failure for any reason as the endpoint, the survival rates at 5 and 9 years were 98.2% and 95.5%, respectively. The most common reason for revision surgery or radiological failure was aseptic loosening.

CONCLUSIONS

Despite several revision cases mainly due to aseptic loosening, the present study found that this new high-flexion posterior-stabilized total knee arthroplasty prosthesis design showed comparable results for Asian populations with other PS prosthesis.

LEVELS OF EVIDENCE

Level Ⅱ (Prospective cohort study).

Magnetic Resonance Safety Evaluation of a Novel Alumina Matrix Composite Ceramic Knee and Image Artifact Comparison to a Metal Knee Implant of Analogous Design

Background

Image artifacts caused by metal knee implants in 1.5T and 3T magnetic resonance imaging (MRI) systems complicate imaging-based diagnosis of the peri-implant region after total knee arthroplasty. Alternatively, metal-free knee prostheses could effectively minimize MRI safety hazards and offer the potential for higher quality diagnostic images.

Methods

A novel knee arthroplasty device composed of BIOLOX delta, an alumina matrix composite (AMC) ceramic, was tested in a magnetic resonance (MR) environment. American Society for Testing and Materials test methods were used for evaluating magnetically induced displacement force, magnetically induced torque, radiofrequency-induced heating, and MR image artifact.

Results

Magnetically induced displacement force and magnetically induced torque results of the AMC ceramic knee indicated that these effects do not pose a known risk in a clinical MR environment, as assessed in a 3T magnetic field. Moreover, minimal radiofrequency-induced heating of the device was observed. In addition, the AMC ceramic knee demonstrated minimal MR image artifacts (7 mm) in comparison to a cobalt-chromium knee (88 mm). The extremely low magnetic susceptibility of AMC (2 ppm) underlines that it is a nonmetallic and nonmagnetic material well suited for the manufacturing of MR Safe orthopaedic implants.

Conclusions

The AMC ceramic knee is a novel metal-free total knee arthroplasty device that can be regarded as MR Safe, as suggested by the absence of hazards from the exposure of this implant to a MR environment. The AMC ceramic knee presents the advantage of being scanned with superior imaging results in 3T MRI systems compared to alternative metal implants on the market.

Ultra-High-Molecular-Weight Polyethylene in Hip and Knee Arthroplasties

Ultra-high-molecular-weight polyethylene (UHMWPE) wear and particle-induced osteolysis contribute to the failure of total hip arthroplasty (THA) and total knee arthroplasty (TKA). Highly crosslinked polyethylene (HXLPE) was developed in the late 1990s to reduce wear and has shown lower wear rates and loosening than conventional UHMWPE in THA. The irradiation dose for crosslinking is up to 100 kGy. However, during crosslinking, free radical formation induces oxidation. Using HXLPE in THA, the cumulative revision rate was determined to be significantly lower (6.2%) than that with conventional UHMWPE (11.7%) at a mean follow-up of 16 years, according to the Australian Orthopaedic Association National Joint Replacement Registry. However, HXLPE does not confer to TKA the same advantages it confers to THA. Several alternatives have been developed to prevent the release of free radicals and improve polymer mechanical properties, such as thermal treatment, phospholipid polymer 2-methacryloyloxyethyl phosphorylcholine grafting, remelting, and vitamin E addition. Among these options, vitamin E addition has reported good clinical results and wear resistance similar to that of HXLPE without vitamin E, as shown by short-term clinical studies of THA and TKA. This review aims to provide a comprehensive overview of the development and performance of UHMWPE in THA and TKA.

Silica coated high performance oxide ceramics promote greater ossification than titanium implants: an in vivo study

BACKGROUND

This in vitro study investigated the osseointegration and implant integration of high performance oxide ceramics (HPOC) compared to titanium implants in rabbits.

METHODS

Histomorphometry was conducted around the distal, proximal, medial, and lateral aspects of the HPOC to quantify the amount of mature and immature ossification within the bone interface. Histomorphometry was conducted by a trained musculoskeletal pathologist. The region of interest (ROI) represented the percentage of surrounding area of the implant. The percentage of ROI covered by osteoid implant contact (OIC) and mature bone implant contact (BIC) were assessed. The surrounding presence of bone resorption, necrosis, and/or inflammation were quantitatively investigated.

RESULTS

All 34 rabbits survived the 6- and 12-week experimental period. All HPOC implants remained in situ. The mean weight difference from baseline was + 647.7 mg (P < 0.0001). The overall OIC of the ceramic group was greater at 6 weeks compared to the titanium implants (P = 0.003). The other endpoints of interest were similar between the two implants at all follow-up points. No difference was found in BIC at 6- and 12-weeks follow-up. No bone necrosis, resorption, or inflammation were observed.

CONCLUSION

HPOC implants demonstrated a greater osteoid implant contact at 6 weeks compared to the titanium implants, with no difference found at 12 weeks. The percentage of bone implant contact of HPOC implants was similar to that promoted by titanium implants.

Evaluation of temperature of a full ceramic total knee arthroplasty during MRI examinations

BACKGROUND

A diagnosis by magnetic resonance imaging (MRI) is often necessary before surgery of degenerative spine diseases. This can lead to a possible conflict with an inserted implant of the hip or knee. Heat generation or movement could be caused by the magnetic field. The aim of this study is to investigate temperature development in vitro in a 1.5T MRI of a ceramic knee arthroplasty.

METHODS

A full ceramic, complete metal-free non-constrained primary total knee arthroplasty is investigated. Temperature change was measured between platinum resistors before and after each MRI sequence by change of resistance. The knee implant was placed in a plastic container after the sensors were attached. Then the container was completely filled with ultrasound gel. To document any possible movement of the implant, a grid was placed under the container to document the position of the implant before and after the scans.

RESULTS

A total of four standard knee sequences were performed. The temperature at sites 1 to 5 per implant was always documented in the as-is state before MRI and then after each sequence. A total of 5 temperature measurement points were taken per implant. It was found that there were extremely small temperature variations. These were always in the range of less than 1°C. There was no case of movement of the implant triggered by the MRI scan.

CONCLUSIONS

The experimental investigations carried out here showed homogeneous results with this experimental setup. It is concluded that, at least in vitro, that this ceramic knee implant can be used in MRI examinations without heating or movement.

Alloplastic temporomandibular joint replacement: present status and future perspectives of the elements of embodiment

Medical device embodiment involves the following elements: materials, design, and manufacturing. Failure of any one of these elements can result in failure of the device, despite the others being satisfactory. The abundance of clinical and basic science literature published since 1986, demonstrates the safety and efficacy of alloplastic temporomandibular joint replacement (TMJR). Currently, there are 19 countries producing 41 TMJR devices. More than 75% are custom designed, and 27% are additively manufactured. In light of the increasing number of TMJR devices being designed and manufactured around the world, this paper will discuss TMJR embodiment so that clinicians understand their present status as well as the prospects for the future of new and/or improved TMJR devices, to ensure that these devices continue to be safe and effective long-term surgical options for the management of end-stage TMJ pathologies.

Migration of the femoral component and clinical outcomes after total knee replacement: a narrative review

Loosening is considered as a main cause of implant failure in total knee replacement (TKR). Among the predictive signs of loosening, migration is the most investigated quantitative parameter. Several studies focused on the migration of the tibial component in TKR, while no reviews have been focused on the migration of the femoral component and its influence on patients' clinical outcomes. The aim of this narrative review was (1) to provide information about of the influence of migration in femoral component of TKR prostheses, (2) to assess how migration may affect patient clinical outcomes and (3) to present alternative solution to the standard cobalt-chrome prostheses. A database search was performed on PubMed Central® according to the PRISMA guidelines for studies about Cobalt-Chrome femoral component migration in people that underwent primary TKR published until May 2020. Overall, 18 articles matched the selection criteria and were included in the study. Few studies investigated the femoral component through the migration, and no clear migration causes emerged. The Roentgen Stereophotogrammetric Analysis has been mostly used to assess the migration for prognostic predictions. An annual migration of 0.10 mm seems compatible with good long-term performance and good clinical and functional outcomes. An alternative solution to cobalt-chrome prostheses is represented by femoral component in PEEK material, although no clinical evaluations have been carried out on humans yet. Further studies are needed to investigate the migration of the femoral component in relation to clinical outcomes and material used.

Local Cellular Responses to Metallic and Ceramic Nanoparticles from Orthopedic Joint Arthroplasty Implants

Over the last decades, joint arthroplasty has become a successful treatment for joint disease. Nowadays, with a growing demand and increasingly younger and active patients accepting these approaches, orthopedic surgeons are seeking implants with improved mechanical behavior and longer life span. However, aseptic loosening as a result of wear debris from implants is considered to be the main cause of long-term implant failure. Previous studies have neatly illustrated the role of micrometric wear particles in the pathological mechanisms underlying aseptic loosening. Recent osteoimmunologic insights into aseptic loosening highlight the important and heretofore underrepresented contribution of nanometric orthopedic wear particles. The present review updates the characteristics of metallic and ceramic nanoparticles generated after prosthesis implantation and summarizes the current understanding of their hazardous effects on peri-prosthetic cells.