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Slouf M, Gajdosova V, Dybal J, Sticha R, Fulin P, Pokorny D, Mateo J, Panisello JJ, Canales V, Medel F, Bistolfi A, Bracco P. European Database of Explanted UHMWPE Liners from Total Joint Replacements: Correlations among Polymer Modifications, Structure, Oxidation, Mechanical Properties and Lifetime In Vivo. Polymers (Basel) 2023; 15:polym15030568. [PMID: 36771869 PMCID: PMC9921464 DOI: 10.3390/polym15030568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
This contribution lays the foundation for the European database of explanted UHMWPE liners from total joint replacements. Three EU countries (Czech Republic, Italy and Spain) have joined their datasets containing anonymized patient data (such as age and BMI), manufacturer data (such as information on UHMWPE crosslinking, thermal treatment and sterilization), orthopedic evaluation (such as total duration of the implant in vivo and reasons for its revision) and material characterization (such as oxidative degradation and micromechanical properties). The joined database contains more than 500 entries, exhibiting gradual growth, and it is beginning to show interesting trends, which are discussed in our contribution, including (i) strong correlations between UHMWPE oxidative degradation, degree of crystallinity and microhardness; (ii) statistically significant differences between UHMWPE liners with different types of sterilization; (iii) realistic correlations between the extent of oxidative degradation and the observed reasons for total joint replacement failures. Our final objective and task for the future is to continuously expand the database, involving researchers from other European countries, in order to create a robust tool that will contribute to the better understanding of structure-properties-performance relationships in the field of arthroplasty implants.
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Affiliation(s)
- Miroslav Slouf
- Institute of Macromolecular Chemistry of the Czech Academy of Sciences, 16206 Prague, Czech Republic
- Correspondence: (M.S.); (F.M.); (P.B.)
| | - Veronika Gajdosova
- Institute of Macromolecular Chemistry of the Czech Academy of Sciences, 16206 Prague, Czech Republic
| | - Jiri Dybal
- Institute of Macromolecular Chemistry of the Czech Academy of Sciences, 16206 Prague, Czech Republic
| | - Roman Sticha
- 1st Orthopedics Clinic of the 1st Faculty of Medicine of Charles University and Motol University Hospital, 15006 Prague, Czech Republic
| | - Petr Fulin
- 1st Orthopedics Clinic of the 1st Faculty of Medicine of Charles University and Motol University Hospital, 15006 Prague, Czech Republic
| | - David Pokorny
- 1st Orthopedics Clinic of the 1st Faculty of Medicine of Charles University and Motol University Hospital, 15006 Prague, Czech Republic
| | - Jesús Mateo
- Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital, 50009 Zaragoza, Spain
- Department of Surgery, Medicine School, University of Zaragoza, 50009 Zaragoza, Spain
| | - Juan José Panisello
- Department of Orthopaedic Surgery and Traumatology, Miguel Servet University Hospital, 50009 Zaragoza, Spain
- Department of Surgery, Medicine School, University of Zaragoza, 50009 Zaragoza, Spain
| | - Vicente Canales
- Department of Orthopaedic Surgery and Traumatology, Royo Villanova Hospital, 50015 Zaragoza, Spain
| | - Francisco Medel
- Department of Mechanical Engineering-Institute of Engineering Research of Aragon, University of Zaragoza, 50018 Zaragoza, Spain
- Correspondence: (M.S.); (F.M.); (P.B.)
| | - Alessandro Bistolfi
- Department of Surgery, Orthopedics and Traumatology, Cardinal Massaia Hospital, 14100 Asti, Italy
| | - Pierangiola Bracco
- Chemistry Department and NIS Centre, University of Torino, 10125 Torino, Italy
- Correspondence: (M.S.); (F.M.); (P.B.)
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Herczeg CK, Song J. Sterilization of Polymeric Implants: Challenges and Opportunities. ACS APPLIED BIO MATERIALS 2022; 5:5077-5088. [PMID: 36318175 PMCID: PMC9691608 DOI: 10.1021/acsabm.2c00793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Degradable and environmentally responsive polymers have been actively developed for drug delivery and regenerative medicine applications, yet inadequate consideration of their compatibility with terminal sterilization presents notable barriers to clinical translation. This Review discusses industry-established terminal sterilization methods and aseptic processing and contrasts them with innovative approaches aimed at preserving the integrity of polymeric implants. Regulatory guidelines, fiscal considerations, and potential pitfalls are discussed to encourage early integration of sterility regulatory considerations in material designs.
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Affiliation(s)
- Chloe K Herczeg
- Department of Orthopedics and Physical Rehabilitation, Department of Biochemistry and Molecular Biotechnology, UMass Chan Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655, United States
| | - Jie Song
- Department of Orthopedics and Physical Rehabilitation, Department of Biochemistry and Molecular Biotechnology, UMass Chan Medical School, 55 Lake Avenue North, Worcester, Massachusetts 01655, United States
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Rowell SL, Reyes CR, Hopper RH, Engh CA, Muratoglu OK. Do total hip arthroplasty polyethylene liners without free radicals oxidize in vivo or ex vivo? J Biomed Mater Res B Appl Biomater 2021; 110:1113-1119. [PMID: 34894062 DOI: 10.1002/jbm.b.34985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 08/15/2021] [Accepted: 11/13/2021] [Indexed: 11/08/2022]
Abstract
Crosslinking substantially reduces the wear of ultra-high molecular weight polyethylene (UHMWPE) used in total hip arthroplasty (THA) but some reports have indicated that first generation liners manufactured without antioxidants may be vulnerable to in vivo oxidation. This study evaluated maximum oxidation using Fourier transform infrared spectroscopy per ASTM F2102-06ε1 and linear head penetration using a coordinate measuring machine among 66 revision-retrieved THA components with in vivo durations ranging from 0.02 to 24.6 years. These included 30 liners crosslinked with 5 Mrad of gamma radiation and then melted, 13 non-crosslinked, never-irradiated liners sterilized with gas plasma and 23 non-crosslinked, never-irradiated liners sterilized with ethylene oxide. All liners were vacuum-sealed and stored at -20°C prior to analysis with the exception of three retrievals of each material type that were stored in air for 9.9 to 21.5 years. All 57 vacuum-sealed and frozen retrievals demonstrated good oxidative stability with maximum oxidation indices (OIs) less than 1.0 and 75% (43/57) of these liners had maximum OIs less than 0.1. Linear penetration measurements were lower in the crosslinked liners compared to non-crosslinked retrievals. Although instances of oxidation and embrittlement were found after ex vivo storage in air among liners that did not have free radicals at the time of implantation, in vivo oxidation does not appear to be a clinical concern through the first decade of service for crosslinked liners and at up to 25 years after surgery for non-crosslinked liners.
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Affiliation(s)
- Shannon L Rowell
- Harris Orthopaedics Laboratory at Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher R Reyes
- Harris Orthopaedics Laboratory at Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert H Hopper
- Anderson Orthopaedic Research Institute, Alexandria, Virginia, USA
| | - Charles A Engh
- Anderson Orthopaedic Research Institute, Alexandria, Virginia, USA.,Inova Mount Vernon Hospital Joint Replacement Center, Alexandria, Virginia, USA
| | - Orhun K Muratoglu
- Harris Orthopaedics Laboratory at Massachusetts General Hospital, Boston, Massachusetts, USA
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Angerame MR, Jennings JM, Dennis DA. Fracture of the insert cone of a polyethylene liner in a failed posterior-stabilized, rotating-platform total knee arthroplasty. Arthroplast Today 2018; 4:148-152. [PMID: 29896543 PMCID: PMC5994790 DOI: 10.1016/j.artd.2017.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/05/2017] [Indexed: 11/01/2022] Open
Abstract
Failures unique to posterior cruciate-substituting total knee prostheses rarely include polyethylene post fractures but have been described. We report a case involving a fracture of the distal insert cone of a rotating-platform (RP) polyethylene liner in a primary total knee arthroplasty. This case highlights a 67-year-old male presenting with new-onset knee pain and recurrent effusions with osteolysis 11 years following placement of a posterior-stabilized, RP total knee arthroplasty. At the time of revision surgery, the polyethylene insert cone was found to be fractured just below the junction between cone and the body of the insert. Liner exchange, synovectomy, and osteolytic-defect curettage and cement packing were performed. One year following revision surgery, the patient is without pain and has returned to function without limitations. Clinicians must be aware of this possible failure with RP prostheses in the setting of pain with a stable knee, recurrent aseptic effusions, and osteolysis.
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Affiliation(s)
- Marc R. Angerame
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
| | - Jason M. Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
- Department of Biomedical Engineering, University of Denver, Denver, CO, USA
| | - Douglas A. Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
- Department of Biomedical Engineering, University of Denver, Denver, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
- Department of Orthopaedics, University of Colorado Health School of Medicine, Aurora, CO, USA
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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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Arnholt CM, MacDonald DW, Malkani AL, Klein GR, Rimnac CM, Kurtz SM, Kocagoz SB, Gilbert JL. Corrosion Damage and Wear Mechanisms in Long-Term Retrieved CoCr Femoral Components for Total Knee Arthroplasty. J Arthroplasty 2016; 31:2900-2906. [PMID: 27426028 PMCID: PMC5107165 DOI: 10.1016/j.arth.2016.05.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Metal debris and ion release has raised concerns in joint arthroplasty. The purpose of this study was to characterize the sources of metallic ions and particulate debris released from long-term (in vivo >15 years) total knee arthroplasty femoral components. METHODS A total of 52 CoCr femoral condyles were identified as having been implanted for more than 15 years. The femoral components were examined for incidence of 5 types of damage (metal-on-metal wear due to historical polyethylene insert failure, mechanically assisted crevice corrosion at taper interfaces, cement interface corrosion, third-body abrasive wear, and inflammatory cell-induced corrosion [ICIC]). Third-body abrasive wear was evaluated using the Hood method for polyethylene components and a similar method quantifying surface damage of the femoral condyle was used. The total area damaged by ICIC was quantified using digital photogrammetry. RESULTS Surface damage associated with corrosion and/or CoCr debris release was identified in 51 (98%) CoCr femoral components. Five types of damage were identified: 98% of femoral components exhibited third-body abrasive wear (mostly observed as scratching, n = 51/52), 29% of femoral components exhibited ICIC damage (n = 15/52), 41% exhibited cement interface damage (n = 11/27), 17% exhibited metal-on-metal wear after wear-through of the polyethylene insert (n = 9/52), and 50% of the modular femoral components exhibited mechanically assisted crevice corrosion taper damage (n = 2/4). The total ICIC-damaged area was an average of 0.11 ± 0.12 mm2 (range: 0.01-0.46 mm2). CONCLUSION Although implant damage in total knee arthroplasty is typically reported with regard to the polyethylene insert, the results of this study demonstrate that abrasive and corrosive damage occurs on the CoCr femoral condyle in vivo.
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Affiliation(s)
- Christina M. Arnholt
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104
| | - Daniel W. MacDonald
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104
| | | | - Gregg R. Klein
- Hartzband Center for Hip and Knee Replacement, 10 Forest Avenue, Paramus, NJ 07652
| | - Clare M. Rimnac
- Center for the Evaluation of Implant Performance, Case Western Reserve University, 10900 Euclid Ave., Cleveland, Ohio 44106
| | - Steven M. Kurtz
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104,Exponent, Inc., 3440 Market Street, Suite 600, Philadelphia, PA 19104
| | | | - Sevi B. Kocagoz
- Implant Research Center, Drexel University, 3401 Market Street, Suite 345, Philadelphia, PA 19104
| | - Jeremy L. Gilbert
- Syracuse Biomaterials Institute and Biomedical and Chemical Engineering, Syracuse University, 303C Bowne Hall, Syracuse, NY 13244
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Failure of Polyethylene Inlays in Cementless Total Hip Arthroplasty: A Retrieval Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:5496396. [PMID: 27660758 PMCID: PMC5021858 DOI: 10.1155/2016/5496396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 08/14/2016] [Indexed: 11/18/2022]
Abstract
A retrieval analysis has been performed on 50 polyethylene inlays of cementless screw ring implants (Mecring, Mecron, Berlin, Germany) to investigate the failure mechanism of this specific open cup hip arthroplasty design that has shown a high clinical failure rate. Design-specific damage modes like rim creep, collar fatigue, and backside wear were assessed. Furthermore, the inlays were measured using a CMM to determine deformation. In 90% backside wear was observed and collar fatigue occurred in 68% of the cases. Rim creep was present in 38% of the polyethylene inlays. In 90% of the cases the cup opening diameter was 32.1 mm or less and 46% had a diameter less than 32 mm. It seems that creep and deformation of the polyethylene leads to a reduced diameter at the cup opening and consequently decreased clearance. To avoid this type of failure, polyethylene inlays should be supported at the back by the cup to reduce the risk of ongoing creep deformation.
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How Does Wear Rate Compare in Well-functioning Total Hip and Knee Replacements? A Postmortem Polyethylene Liner Study. Clin Orthop Relat Res 2016; 474:1867-75. [PMID: 26891896 PMCID: PMC4925408 DOI: 10.1007/s11999-016-4749-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 02/10/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The longevity of total hip (THR) and knee replacements (TKR) that used historical bearing materials of gamma-in-air sterilized UHMWPE was affected more by osteolysis in THRs than in TKRs, although osteolysis remains a concern in TKRs. Therefore, the study of polyethylene wear is still of interest for the knee, particularly because few studies have investigated volumetric material loss in tibial knee inserts. For this study, a unique collection of autopsy-retrieved TKR and THR components that were well-functioning at the time of retrieval was used to compare volumetric wear differences between hip and knee polyethylene components made from identical material. QUESTIONS/PURPOSES The following questions were addressed: (1) How much did the hip liners wear and what wear patterns did they exhibit? (2) How much did the knee inserts wear and what wear patterns did they exhibit? (3) What is the ratio between TKR and THR wear after controlling for implantation time and patient age? METHODS We compared 23 THR components (Harris-Galante [HG] and HG II) and 20 TKR components (Miller-Galante [MG II]) that were retrieved postmortem. The components were made from the same polyethylene formulation and with similar manufacturing and sterilization (gamma-in-air) processes. Twenty-one patients (12 males, nine females) had THRs and 16 (four males, 12 females) had TKRs. Patients who had TKRs had an older (p = 0.001) average age than patients who had THRs (age, 75 years; SD, 10, versus 66 years; SD, 12, respectively). Only well-functioning components were included in this study. Therefore, implants retrieved postmortem from physically active patients and implanted for at least 2 years were considered. In addition, only normally wearing TKR components were considered, ie, those with fatigue wear (delamination) were excluded. The wear volume of each component was measured using metrology. For the tibial inserts an autonomous mathematic reconstruction method was used for quantification. RESULTS The acetabular liners of the THR group had a wear rate of 38 mm(3) per year (95% CI, 29-47 mm(3)/year). Excluding patients with low-activity, the wear rate was 47 mm(3) per year (95% CI, 37-56 mm(3)/year). The wear rate of normally wearing tibial inserts was 17 mm(3) per year (95% CI, -6 to 40 mm(3)/year). After controlling for the relevant confounding variable of age, we found a TKR/THR wear rate ratio of 0.5 (95% CI, 0.29-0.77) at 70 years of age with a slightly increasing difference with increasing age. CONCLUSIONS Excluding delamination, TKRs exhibited lower articular wear rates than THRs for historical polyethylene in these two unique cohorts of postmortem retrievals. CLINICAL RELEVANCE The lower TKR wear rate is in line with the lower incidence of osteolysis in TKRs compared with THRs.
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Kuwashima U, Hamai S, Okazaki K, Ikebe S, Higaki H, Mizu-uchi H, Akasaki Y, Murakami K, Iwamoto Y. Contact stress analysis of the anterior tibial post in bi-cruciate stabilized and mobile-bearing posterior stabilized total knee arthroplasty designs. J Mech Behav Biomed Mater 2016; 60:460-467. [DOI: 10.1016/j.jmbbm.2016.03.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 10/22/2022]
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Rowell SL, Reyes CR, Malchau H, Muratoglu OK. In Vivo Oxidative Stability Changes of Highly Cross-Linked Polyethylene Bearings: An Ex Vivo Investigation. J Arthroplasty 2015; 30:1828-34. [PMID: 26048729 DOI: 10.1016/j.arth.2015.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 04/22/2015] [Accepted: 05/05/2015] [Indexed: 02/01/2023] Open
Abstract
The development of highly cross-linked UHMWPEs focused on stabilizing radiation-induced free radicals as the sole precursor to oxidative degradation. However, secondary in vivo oxidation mechanisms have been discovered. After a preliminary post-operative analysis, we subjected highly cross-linked retrievals with 1-4 years in vivo durations and never-implanted controls to accelerated aging to predict the extent to which their oxidative stability was compromised in vivo. Lipid absorption, oxidation, and hydroperoxides were measured using infrared spectroscopy. Gravimetric swelling was used to measure cross-link density. After aging, all retrievals, except vitamin E-stabilized components, regardless of initial lipid levels or oxidation, showed significant oxidative degradation, demonstrated by subsurface oxidative peaks, increased hydroperoxides and decreased cross-link density, compared to their post-operative material properties and never-implanted counterparts, confirming oxidative stability changes.
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Affiliation(s)
- Shannon L Rowell
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher R Reyes
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Henrik Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Sahlgrenska University Hospital, Mölndal, Sweden; Harvard Medical School, Cambridge, Massachusetts
| | - Orhun K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Cambridge, Massachusetts
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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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Kumar N, Yadav C, Raj R, Yadav S. Fracture of the polyethylene tibial post in a posterior stabilized knee prosthesis: A case report and review of literature. J Orthop 2015; 12:160-3. [PMID: 26236121 DOI: 10.1016/j.jor.2015.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 01/04/2015] [Indexed: 10/24/2022] Open
Abstract
We report a case of fracture of tibial polyethylene post fracture from base in a 56 year old lady 10 years from posterior stabilized total knee arthroplasty following trivial trauma. There have been signs of wear at the base especially anteriorly. After revision of tibial polyethylene component patient developed complete relief of symptom.
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Affiliation(s)
- Nishikant Kumar
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Chandrashekhar Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Rishi Raj
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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13
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Can pin-on-disk testing be used to assess the wear performance of retrieved UHMWPE components for total joint arthroplasty? BIOMED RESEARCH INTERNATIONAL 2014; 2014:581812. [PMID: 25295264 PMCID: PMC4177737 DOI: 10.1155/2014/581812] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/18/2014] [Accepted: 08/19/2014] [Indexed: 11/17/2022]
Abstract
The objective of this study was to assess the suitability of using multidirectional pin-on-disk (POD) testing to characterize wear behavior of retrieved ultrahigh molecular weight polyethylene (UHMWPE). The POD wear behavior of 25 UHMWPE components, retrieved after 10 years in vivo, was compared with 25 that were shelf aged for 10-15 years in their original packaging. Components were gamma sterilized (25-40 kGy) in an air or reduced oxygen (inert) package. 9 mm diameter pins were fabricated from each component and evaluated against CoCr disks using a super-CTPOD with 100 stations under physiologically relevant, multidirectional loading conditions. Bovine serum (20 g/L protein concentration) was used as lubricant. Volumetric wear rates were found to vary based on the aging environment, as well as sterilization environment. Volumetric wear rates were the lowest for the pins in the gamma inert, shelf aged cohort. These results support the utility of using modern, multidirectional POD testing with a physiologic lubricant as a novel method for evaluating wear properties of retrieved UHMWPE components. The data also supported the hypothesis that wear rates of gamma-inert liners were lower than gamma-air liners for both retrieved and shelf aging conditions. However, this difference was not statistically significant for the retrieved condition.
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15
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Sirimamilla PA, Furmanski J, Rimnac CM. Application of viscoelastic fracture model and non-uniform crack initiation at clinically relevant notches in crosslinked UHMWPE. J Mech Behav Biomed Mater 2012; 17:11-21. [PMID: 23127638 DOI: 10.1016/j.jmbbm.2012.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2012] [Revised: 07/20/2012] [Accepted: 07/22/2012] [Indexed: 11/18/2022]
Abstract
The mechanism of crack initiation from a clinically relevant notch is not well-understood for crosslinked ultra high molecular weight polyethylene (UHMWPE) used in total joint replacement components. Static mode driving forces, rather than the cyclic mode conditions typically associated with fatigue processes, have been shown to drive crack propagation in this material. Thus, in this study, crack initiation in a notched specimen under a static load was investigated. A video microscope was used to monitor the notch surface of the specimen and crack initiation time was measured from the video by identifying the onset of crack initiation at the notch. Crack initiation was considered using a viscoelastic fracture theory. It was found that the mechanism of crack initiation involved both single layer and a distributed multi-layer phenomenon and that multi-layer crack initiation delayed the crack initiation time for all loading conditions examined. The findings of this study support that the viscoelastic fracture theory governs fracture mechanics in crosslinked UHMWPE. The findings also support that crack initiation from a notch in UHMWPE is a more complex phenomenon than treated by traditional fracture theories for polymers.
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Affiliation(s)
- P Abhiram Sirimamilla
- Mechanical and Aerospace Engineering Department, Case Western Reserve University, Cleveland, OH, USA
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Keeney JA, Ellison BS, Maloney WJ, Clohisy JC. Is routine mid-term total hip arthroplasty surveillance beneficial? Clin Orthop Relat Res 2012; 470:3220-6. [PMID: 22669552 PMCID: PMC3462865 DOI: 10.1007/s11999-012-2411-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 05/18/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Routine followup of patients after primary or revision THA is commonly practiced and driven by concerns that delays in identifying early failure will result in more complicated or more costly surgical interventions. Although mid-term followup (4-10 years) has been performed to follow cohorts of patients, the benefit of observing individual patients regardless of symptoms has not been established. QUESTIONS/PURPOSES We determined (1) the reasons patients with THA return for mid-term followup, (2) the treatment recommendations and interventions occurring as a result of mid-term followup, and (3) how frequently revision surgery is recommended for asymptomatic and symptomatic patients at mid-term followup. METHODS We retrospectively identified 501 patients (503 hips) who returned for followup at least 4 years (mean, 5 years; range, 4-10.9 years) after their primary or revision THA. We recorded their reasons for followup and treatment recommendations, including those for revision surgery, at mid-term followup. RESULTS Fifty-three percent of patients returning for routine followup had no symptoms, 31% reported an unrelated musculoskeletal concern, and 19% had symptoms from their primary THA (15%) or revision THA (32%). Sixty-nine percent of symptomatic patients and 10% of asymptomatic patients received treatment recommendations, with physical therapy as the most frequent intervention (74%). Revision surgery was recommended for 6% of symptomatic and 0.6% of asymptomatic patients. CONCLUSIONS Although routine surveillance may identify rare, asymptomatic patients with arthroplasty failure, it is much more likely to result in recommendations for nonoperative management during early followup. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James A. Keeney
- Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, Campus Box 8233, St Louis, MO 63110 USA
| | | | - William J. Maloney
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford Medicine Outpatient Center, Redwood City, CA USA
| | - John C. Clohisy
- Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, Campus Box 8233, St Louis, MO 63110 USA
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17
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Currier BH, Van Citters DW, Currier JH, Carlson EM, Tibbo ME, Collier JP. In vivooxidation in retrieved highly crosslinked tibial inserts. J Biomed Mater Res B Appl Biomater 2012; 101:441-8. [DOI: 10.1002/jbm.b.32805] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Revised: 06/28/2012] [Accepted: 07/26/2012] [Indexed: 11/06/2022]
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18
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French K, Moore R, Gawel H, Kurtz SM, Kraay MJ, Xie K, Goldberg VM, Rimnac CM. Retrieval analysis of Harris-Galante I and II acetabular liners in situ for more than 10 years. Acta Orthop 2012; 83:366-73. [PMID: 22880709 PMCID: PMC3427627 DOI: 10.3109/17453674.2012.717843] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There have been few reports documenting the wear and oxidation performance of the polyethylene bearing surface of HGPI and HGPII THA devices. We evaluated retrieved HGPI and HGPII acetabular liners that had been in situ for more than 10 years and determined whether there was a relationship between clinical and radiographic factors, surface damage, wear, and oxidation. MATERIALS AND METHODS 129 HGPI and II acetabular liners with implantation times of > 10 years were retrieved at 4 institutions between 1997 and 2010. The liners were made from a single resin and were gamma radiation-sterilized in air. Surface damage, linear wear, and oxidation index (OI) were assessed. Differences in clinical and radiographic factors, surface damage, linear wear, and OI for the 2 designs were statistically evaluated separately and together. RESULTS Articular surface damage and backside damage was similar in the 2 designs. The linear penetration rate was 0.14 (SD 0.07) mm/year for the HGPI liners and 0.12 (SD 0.08) mm/year for the HGPII liners. For both cohorts, the rim had a higher OI than the articular surface. 74% of the liners had subsurface cracking and 24% had a complete fracture through the acetabular rim. INTERPRETATION Despite modification of the HGP locking mechanism in the HGPII design, dissociation of the liner from the acetabular shell can still occur if fracture of the rim of the liner develops due to oxidative degradation.
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Affiliation(s)
- Keisha French
- State University of New York Medical Center, New York, NY
| | - Rebecca Moore
- Orthopaedic Implant Retrieval Analysis Laboratory, Department of Orthopaedics, Case Western Reserve University, Cleveland, OH
| | - Heather Gawel
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University and Exponent Inc., Philadelphia, PA
| | - Steven M Kurtz
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University and Exponent Inc., Philadelphia, PA
| | - Matthew J Kraay
- Orthopaedic Implant Retrieval Analysis Laboratory, Department of Orthopaedics, Case Western Reserve University, Cleveland, OH
| | - Ke Xie
- Orthopaedic Implant Retrieval Analysis Laboratory, Department of Orthopaedics, Case Western Reserve University, Cleveland, OH
| | - Victor M Goldberg
- Orthopaedic Implant Retrieval Analysis Laboratory, Department of Orthopaedics, Case Western Reserve University, Cleveland, OH
| | - Clare M Rimnac
- Departments of Mechanical and Aerospace Engineering and Orthopaedics, Case Western Reserve University, Cleveland, OH, USA
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FERRONI DANIELA, QUAGLINI VIRGINIO, DUBINI PAOLO. HIGHLY CROSSLINKED POLYETHYLENE: A COMPARATIVE STUDY BETWEEN TWO UHMWPES WITH DISTINCT MOLECULAR WEIGHT. J MECH MED BIOL 2012. [DOI: 10.1142/s0219519410003253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In the recent years, radiation-induced highly crosslinked polyethylenes have been introduced in arthroplasties as an alternative to conventional ultra high molecular weight polyethylene (UHMWPE) for their superior wear resistance. In the present study, the influence of the molecular weight of the raw on end-user properties of highly crosslinked polyethylenes (HXLPE) is investigated by means of a comparative study between two resins with distinct molecular weights. The main outcomes indicate that the differences in mechanical and wear properties between the row materials disappear after crosslinking; nevertheless the resin with the highest molecular weight is likely to retain a better resistance to short-term oxidation.
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Affiliation(s)
- DANIELA FERRONI
- Materials Testing Laboratory, Department of Structural Engineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
| | - VIRGINIO QUAGLINI
- Materials Testing Laboratory, Department of Structural Engineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
| | - PAOLO DUBINI
- Materials Testing Laboratory, Department of Structural Engineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
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20
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Pezzotti G, Takahashi Y, Takamatsu S, Puppulin L, Nishii T, Miki H, Sugano N. Non-destructively Differentiating the Roles of Creep, Wear and Oxidation in Long-Term In Vivo Exposed Polyethylene Cups. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2012; 22:2165-84. [DOI: 10.1163/092050610x537129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Giuseppe Pezzotti
- a Ceramic Physics Laboratory & Research Institute for Nanoscience, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, 606-8585 Kyoto, Japan; The Center for Advanced Medical Engineering and Informatics, Osaka University, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan; Department of Orthopaedics, Orthopaedic Research Center, Loma Linda University, Loma Linda, CA 92354, USA.
| | - Yasuhito Takahashi
- b Ceramic Physics Laboratory & Research Institute for Nanoscience, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, 606-8585 Kyoto, Japan
| | - Seita Takamatsu
- c Ceramic Physics Laboratory & Research Institute for Nanoscience, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, 606-8585 Kyoto, Japan
| | - Leonardo Puppulin
- d Ceramic Physics Laboratory & Research Institute for Nanoscience, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, 606-8585 Kyoto, Japan
| | - Takashi Nishii
- e Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0854, Japan
| | - Hidenobu Miki
- f Department of Orthopaedic Surgery, Osaka National Hospital, 2-1-14 Houenzaka, Chuo-ku, Osaka 540-0006, Japan
| | - Nobuhiko Sugano
- g Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0854, Japan
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21
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Kumakura T, Puppulin L, Yamamoto K, Takahashi Y, Pezzotti G. In-Depth Oxidation and Strain Profiles in UHMWPE Acetabular Cups Non-Destructively Studied by Confocal Raman Microprobe Spectroscopy. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2012; 20:1809-22. [DOI: 10.1163/156856208x386417] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Tsuyoshi Kumakura
- a Department of Orthopaedic Surgery, Tokyo Medical University, Shinjuku-ku, 6-7-1 Nishishinjuku, 160-0023 Tokyo, Japan
| | - Leonardo Puppulin
- b Ceramic Physics Laboratory & Research Institute for Nanoscience, RIN, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, 606-8585 Kyoto, Japan
| | - Kengo Yamamoto
- c Department of Orthopaedic Surgery, Tokyo Medical University, Shinjuku-ku, 6-7-1 Nishishinjuku, 160-0023 Tokyo, Japan
| | - Yasuhito Takahashi
- d Ceramic Physics Laboratory & Research Institute for Nanoscience, RIN, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, 606-8585 Kyoto, Japan
| | - Giuseppe Pezzotti
- e Ceramic Physics Laboratory & Research Institute for Nanoscience, RIN, Kyoto Institute of Technology, Sakyo-ku, Matsugasaki, 606-8585 Kyoto, Japan
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22
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Kyomoto M, Ueno M, Kim SC, Oonishi H, Oonishi H. Wear of '100 Mrad' cross-linked polyethylene: effects of packaging after 30 years real-time shelf-aging. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2012; 18:59-70. [PMID: 17274451 DOI: 10.1163/156856207779146150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Studies have shown that gamma-irradiation of polyethylene (PE) generally results in degradation by surface oxidation. However, from 1970 to 1978 Oonishi et al. used ultra-high-molecular-weight polyethylene (UHMWPE) cross-linked and sterilized by 100 Mrad of gamma-irradiation in air (100 Mrad PE) for total hip prostheses, and obtained excellent clinical results extending for 30 years. In the present study, we used a hip joint simulator to investigate the wear characteristics of 100 Mrad PE cups which had been shelf-aged for an extremely long period (30 years). The PE cups, aged in an air-containing triple polyethylene package for 30 years (packaged 100 Mrad PE), showed low wear with 3.4 mg of weight loss, even after 5 x 10(6) cycles. In contrast, non-packaged 100 Mrad PE showed considerable wear: 47.0 mg at run-in ((0-0.25) x 10(6) cycles) and 114.1 mg at the end of 5 x 10(6) cycles. The substantially, lower wear even in the presence of an oxidized surface layer for the packaged 100 Mrad PE, was comparable to the low wear seen on retrieved 100 Mrad PE after 30 years of clinical use. The long-term shelf-storage conditions, which affect the surface oxidative degradation of PE, are assumed to be the key factor in the wear-resistance of gamma-irradiated UHMWPE.
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Affiliation(s)
- Masayuki Kyomoto
- Japan Medical Materials Corporation, Uemura Nissei Bldg. 9F 3-3-31 Miyahara, Yodogawa-ku, Osaka 532-0003, Japan.
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23
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Wu JJ, Augustine A, Holland JP, Deehan DJ. Oxidation and fusion defects synergistically accelerate polyethylene failure in knee replacement. Knee 2012; 19:124-9. [PMID: 21324701 DOI: 10.1016/j.knee.2011.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 01/13/2011] [Accepted: 01/18/2011] [Indexed: 02/02/2023]
Abstract
We have previously reported upon a cohort of patients with premature failure of such material and postulated upon the impact of abnormally high concentrations of type 2 fusion defects whereby there is a lack of particle cohesion due to incomplete diffusion. In vivo oxidation has been purported to underscore the premature failure of polyethylene. The mechanism of such remains poorly delineated. New data has now been obtained by determining substrata oxidative profiles of 10 failed Kinemax Plus modular tibial insert analyses in conjunction with fusion defect detection. The full thickness of a series of cores was analysed using infra-red spectroscopy to identify higher levels of oxidation in loaded used material at both the articulating and non-articulating regions. A comparison was made to an unused control. Articulating, loaded, areas exhibited greater local concentrations of oxidised material and wider variation of such consistent with the higher presence of fusion defects. Subsurface analysis confirmed the presence of a major oxidative peak 2mm below the surface for all loaded areas irrespective of wear. Additionally we were able to identify a second major oxidative focus about halfway between the inferior (tibial baseplate) surface and the articulating area. We believe that the combination of high oxidation and fusion defects represents a second high stress zone consistent with the observation of tibial baseplate polyethylene dissociation and backside wear with resultant catastrophic material failure.
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Affiliation(s)
- Jun Jie Wu
- School of Engineering and Computing Sciences, Durham University, South Road, Durham, DH1 3LE, England, United Kingdom
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24
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Loughead JM, O'Connor PA, Charron K, Rorabeck CH, Bourne RB. Twenty-three-year outcome of the porous coated anatomic total hip replacement: a concise follow-up of a previous report. J Bone Joint Surg Am 2012; 94:151-5. [PMID: 22258002 DOI: 10.2106/jbjs.j.01553] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We previously reported the ten to fourteen-year results for 311 Porous Coated Anatomic total hip replacements that had been inserted by two surgeons in 279 patients. The purpose of the present report is to update that study and to report the outcome beyond twenty years. The patients were followed prospectively with clinical assessment with use of the Harris hip score and radiographic analysis, and the results were collected in a database. Two hundred and sixty-eight hips were functioning at the time of death or at the time of the latest follow-up. A total of forty-three hips (14%) underwent major revision for all causes, and an additional four hips underwent minor revision. At a mean of twenty-three years of follow-up, Kaplan-Meier analysis revealed a survival rate of 83% with revision for any reason as the end point. The survival rate was 95% for the femoral component and 88% for the acetabular component with revision for any reason as the end point. The rate of survival of the acetabular component was significantly higher in hips with a 26-mm femoral head than in those with a 32-mm femoral head (91% compared with 80%; p = 0.026).
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Affiliation(s)
- Jonathan M Loughead
- Queen Elizabeth Hospital, Sheriff Hill, Gateshead, Tyne and Wear, NE9 6SX England.
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25
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Olof S, Mats S, Olle M, Ake J, Torbjörn A, Henrik B. The Ringloc liner compared with the Hexloc liner in total hip arthroplasty. Orthop Rev (Pavia) 2011; 1:e16. [PMID: 21808678 PMCID: PMC3143985 DOI: 10.4081/or.2009.e16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Revised: 06/26/2009] [Accepted: 06/26/2009] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to compare the 10-year survival rate, pelvic osteolysis frequency and linear head penetration rate of the Hexloc and Ringloc liners used together with a partially threaded porous and hydroxyapatite coated cup and the Bi-Metric uncemented femoral stem. The 15-year results for the cup with the Hexloc liner are also reported. We included 332 consecutive hips (166 Hexloc and 166 Ringloc) on 281 patients in the study. Revisions of prosthesis components were recorded and pelvic osteolytic lesions were assessed using radiographs and computed tomography. The linear head penetration rate was measured using the Martell method. The 10-year survival rate of the liner with revision due to liner wear and/or osteolysis as endpoint was 88% for the Hexloc liner and 98% for the Ringloc liner. The 15-year survival rate of the Hexloc liner was 67%. Pelvic osteolysis was found in 27% of the Hexloc and 19% of the Ringloc hips. After 15 years, 53% of the Hexloc hips had developed an osteolytic lesion. The linear head penetration rate was 0.16 mm/year for the Hexloc liner and 0.12 mm/year for the Ringloc liner. This paper is the first to describe the rapidly deteriorating survival up to 15 years with the old generation gamma-in-air sterilized polyethylene used in Hexloc liners. The newer Ringloc liner with the ArCom™ polyethylene has superior clinical results but a linear wear rate and frequency of osteolytic lesions that is higher than expected.
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Affiliation(s)
- Sköldenberg Olof
- Karolinska Institutet, Department of Clinical Sciences at Danderyd Hospital, Stockholm, Sweden
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26
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MacDonald D, Sakona A, Ianuzzi A, Rimnac CM, Kurtz SM. Do first-generation highly crosslinked polyethylenes oxidize in vivo? Clin Orthop Relat Res 2011; 469:2278-85. [PMID: 21161740 PMCID: PMC3126962 DOI: 10.1007/s11999-010-1728-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Highly crosslinked and thermally treated polyethylenes were clinically introduced to reduce wear and osteolysis. Although the crosslinking process improves the wear performance, it also introduces free radicals into the polymer that can subsequently oxidize. Thermal treatments have been implemented to reduce oxidation; however, the efficacy of these methods with regard to reducing in vivo oxidative degradation remains to be seen. Polyethylene oxidation is a concern because it can compromise the ultimate strength and ductility of the material. QUESTIONS/PURPOSES We analyzed the oxidation, oxidation potential, and mechanical behavior of thermally treated highly crosslinked polyethylene retrieved acetabular liners. METHODS Three hundred seven acetabular liners were collected from consecutive revision surgeries at six institutions over a 10-year period. Twenty-four were sterilized using nonionizing methods, 43 were sterilized in an inert environment, 80 were highly crosslinked and annealed, and 160 were highly crosslinked and remelted. Oxidation and oxidation potential were assessed by Fourier transmission infrared spectroscopy. Mechanical behavior was assessed by the small punch test. RESULTS Oxidation and hydroperoxide (oxidation potential) indices were elevated in the annealed and gamma inert sterilized groups compared with those of the remelted liners and uncrosslinked gas sterilized controls, particularly at the rim. We also detected an increase in oxidation over time at the bearing surface of the remelted group. Ultimate strength of the polyethylene at the bearing surface was negatively correlated with implantation time for the annealed liners. CONCLUSIONS Within the first decade of implantation, the clinical outlook for first-generation highly crosslinked polyethylene remains promising. However, ongoing research continues to be warranted for first-generation highly crosslinked polyethylene bearings to monitor the implications of elevated oxidation at the rim of annealed liners as well as to better understand the subtle changes in oxidation at the bearing surface of remelted liners that occur in vivo.
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Affiliation(s)
- Daniel MacDonald
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University, and Exponent, Inc, 3401 Market Street, Suite 300, Philadelphia, PA 19104 USA
| | - Ashlyn Sakona
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University, and Exponent, Inc, 3401 Market Street, Suite 300, Philadelphia, PA 19104 USA
| | - Allyson Ianuzzi
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University, and Exponent, Inc, 3401 Market Street, Suite 300, Philadelphia, PA 19104 USA
| | - Clare M. Rimnac
- Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, OH USA
| | - Steven M. Kurtz
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University, and Exponent, Inc, 3401 Market Street, Suite 300, Philadelphia, PA 19104 USA
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Medel FJ, Kurtz SM, Sharkey P, Parvizi J, Klein G, Hartzband M, Kraay M, Rimnac CM. In vivo oxidation contributes to delamination but not pitting in polyethylene components for total knee arthroplasty. J Arthroplasty 2011; 26:802-10. [PMID: 20875942 PMCID: PMC3385511 DOI: 10.1016/j.arth.2010.07.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 07/18/2010] [Indexed: 02/01/2023] Open
Abstract
The aim of this study was to better understand how in vivo oxidation contributes to fatigue damage in total knee arthroplasty (TKA). A total of 119 tibial inserts were consecutively collected after revision surgery. Of the 119 polyethylene retrievals, 29 were gamma sterilized in air (historical), whereas the remaining 90 were gamma sterilized in nitrogen (conventional). Surface damage assessment and characterization of oxidation were performed on all the retrievals. Delamination was significantly more prevalent and extensive in the longer-term, highly oxidized, historical tibial inserts. Pitting damage, in contrast, seemed to be equally prevalent between both retrieval groups and was not correlated with in vivo oxidation. Our findings support our hypothesis that in vivo oxidation is a contributing factor to delamination, but not pitting, in TKA. Despite the lower oxidation displayed by conventional retrievals, this study provides strong evidence that delamination secondary to in vivo oxidation may occur during the second decade of implantation.
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Affiliation(s)
| | - Francisco J. Medel
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA 19104,Corresponding Author: Francisco J Medel, Ph.D., Implant Research Center, 3401 Market St., Suite 300, Philadelphia, PA 19104, Tel: 215-594-8858, Fax: 215-594-8899,
| | - Steven M. Kurtz
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA 19104,Exponent, Inc., 3401 Market Street, Philadelphia, PA 19104
| | - Peter Sharkey
- Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107
| | - Javad Parvizi
- Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107
| | - Gregg Klein
- Hartzband Center for Hip and Knee Replacement and Hackensack University Medical Center, Hackensack, NJ
| | - Mark Hartzband
- Hartzband Center for Hip and Knee Replacement and Hackensack University Medical Center, Hackensack, NJ
| | - Matthew Kraay
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106
| | - Clare M. Rimnac
- Musculoskeletal Mechanics and Materials Laboratories, Departments of Mechanical and Aerospace Engineering and Orthopaedics, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106-7222
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28
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Kurtz SM, Gawel HA, Patel JD. History and systematic review of wear and osteolysis outcomes for first-generation highly crosslinked polyethylene. Clin Orthop Relat Res 2011; 469:2262-77. [PMID: 21431461 PMCID: PMC3126942 DOI: 10.1007/s11999-011-1872-4] [Citation(s) in RCA: 313] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Highly crosslinked polyethylene (HXLPE) was introduced to reduce wear and osteolysis in total joint arthroplasty. While many studies report wear and osteolysis associated with HXLPE, analytical techniques, clinical study design and followup, HXLPE formulation and implant design characteristics, and patient populations differ substantially among investigations, complicating a unified perspective. QUESTIONS/PURPOSES Literature on first-generation HXLPE was summarized. We systematically reviewed the radiographic wear data and incidence of osteolysis for HXLPE in hip and knee arthroplasty. METHODS PubMed identified 391 studies; 28 met inclusion criteria for a weighted-averages analysis of two-dimensional femoral head penetration rates. To determine the incidence of osteolysis, we estimated a pooled odds ratio using a random-effects model. RESULTS Weighted-averages analyses of femoral head penetration rates in HXLPE liners and conventional UHMWPE liners resulted, respectively, in a mean two-dimensional linear penetration rate of 0.042 mm/year based on 28 studies (n=1503 hips) and 0.137 mm/year based on 18 studies (n=695 hips). The pooled odds ratio for the risk of osteolysis in HXLPE versus conventional liners was 0.13 (95% confidence interval, 0.06-0.27) among studies with minimum 5-year followup. We identified two clinical studies of HXLPE in TKA, preventing systematic analysis of outcomes. CONCLUSIONS HXLPE liner studies consistently report lower femoral head penetration and an 87% lower risk of osteolysis. Reduction in femoral head penetration or osteolysis risk is not established for large-diameter (>32 mm) metallic femoral heads or ceramic femoral heads of any size. Few studies document the clinical performance of HXLPE in knees.
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Affiliation(s)
- Steven M Kurtz
- Exponent, Inc, 3401 Market Street, Suite 300, Philadelphia, PA 19104, USA.
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29
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Medel FJ, Kurtz SM, Sharkey PF, Austin MS, Klein GR, Cohen AR, Patel H, Goldberg VM, Kraay MJ, Rimnac CM. Post damage in contemporary posterior-stabilized tibial inserts: influence of implant design and clinical relevance. J Arthroplasty 2011; 26:606-14. [PMID: 21575793 DOI: 10.1016/j.arth.2010.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 05/17/2010] [Indexed: 02/01/2023] Open
Abstract
The mechanisms of damage at the polyethylene post in 3 contemporary tibial insert designs were evaluated and compared with a historical standard (Insall-Burstein II; Zimmer, Warsaw, Ind). One hundred five gamma sterilized posterior-stabilized tibial inserts were revised after an average of 4.7 years (0.05-13.6 years). Retrievals were classified according to their designs: Insall-Burstein II (n = 28); PFC (Johnson & Johnson, Raynham, Mass; n = 30); NexGen (Zimmer; n = 32); and Scorpio (Stryker Orthopaedics, Mahwah, NJ; n = 15). Reasons for revision and patient details were available. Surface damage scoring and photogrammetry were performed on all the retrieved tibial inserts. Oxidation analysis was carried out for traceable historical, gamma air-sterilized and conventional, gamma inert-sterilized tibial inserts (n = 61) with the use of infrared spectroscopy. The posts for all 3 contemporary designs exhibited damage similar to the historical controls. Articular, post, and backside damage scores significantly increased with implantation time. Post damage was insensitive to design and patient factors but was exacerbated by oxidation. An association between damage at the post and articular surface was also confirmed. Logistic models suggested an interaction between post damage, backside surface damage, and implant loosening.
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Affiliation(s)
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- Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, 3401 Market Street. Suite 300, Philadelphia, PA 19104, USA
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Brandt JM, Medley JB, MacDonald SJ, Bourne RB. Delamination wear on two retrieved polyethylene inserts after gamma sterilization in nitrogen. Knee 2011; 18:125-9. [PMID: 20598549 DOI: 10.1016/j.knee.2010.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Revised: 03/16/2010] [Accepted: 03/19/2010] [Indexed: 02/02/2023]
Abstract
Two self-aligning mobile bearing knee replacements (SAL-1) with gamma-in-nitrogen sterilized polyethylene inserts were revised due to instability after 6.3 years and after 14.2 years in vivo in two patients. The predominant damage features were burnishing, cracking, and delamination and were observed on the proximal bearing surface of the retrieved polyethylene inserts. This suggested an association with sub-surface fatigue, perhaps initiated by in vivo oxidative degradation which was confirmed by developing a sub-surface white band in one insert. The damage features observed on the distal bearing surface of the polyethylene inserts suggested both an adhesive wear mechanism and an abrasive wear mechanism. The titanium-nitrite coated, titanium-alloy tibial tray was severely worn in one case and possibly contributed to third-body abrasive wear at the distal surface interface. We suggest to carefully follow-up patients who received this type of mobile bearing knee system.
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Affiliation(s)
- J-M Brandt
- Concordia Hip and Knee Institute, Suite 310 - 1155 Concordia Ave. Winnipeg, MB, Canada R2K 2M9.
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Currier BH, Van Citters DW, Currier JH, Collier JP. In vivo oxidation in remelted highly cross-linked retrievals. J Bone Joint Surg Am 2010; 92:2409-18. [PMID: 20962191 DOI: 10.2106/jbjs.i.01006] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elimination of free radicals to prevent oxidation has played a major role in the development and product differentiation of the latest generation of highly cross-linked ultra-high molecular weight polyethylene bearing materials. In the current study, we (1) examined oxidation in a series of retrieved remelted highly cross-linked ultra-high molecular weight polyethylene bearings from a number of device manufacturers and (2) compared the retrieval results with findings for shelf-stored control specimens. The hypothesis was that radiation-cross-linked remelted ultra-high molecular weight polyethylene would maintain oxidative stability in vivo comparable with the stability during shelf storage and in published laboratory aging tests. METHODS Fifty remelted highly cross-linked ultra-high molecular weight polyethylene acetabular liners and nineteen remelted highly cross-linked ultra-high molecular weight polyethylene tibial inserts were received after retrieval from twenty-one surgeons from across the U.S. Thirty-two of the retrievals had been in vivo for two years or more. Each was measured for oxidation with use of Fourier transform infrared spectroscopy. A control series of remelted highly cross-linked ultra-high molecular weight polyethylene acetabular liners from three manufacturers was analyzed with electron paramagnetic resonance spectroscopy to measure free radical content and with Fourier transform infrared spectroscopy to measure oxidation initially and after eight to nine years of shelf storage in air. RESULTS The never-implanted, shelf-aged controls had no measurable free-radical content initially or after eight to nine years of shelf storage. The never-implanted controls showed no increase in oxidation during shelf storage. Oxidation measurements showed measurable oxidation in 22% of the retrieved remelted highly cross-linked liners and inserts after an average of two years in vivo. CONCLUSIONS Because never-implanted remelted highly cross-linked ultra-high molecular weight polyethylene materials had no measurable free-radical concentration and no increase in oxidation during shelf storage, these materials were expected to be oxidation-resistant in vivo. However, some remelted highly cross-linked ultra-high molecular weight polyethylene retrievals showed measurable oxidation after an average of more than two years in vivo. This apparent departure from widely expected behavior requires continued study of the process of in vivo oxidation of ultra-high molecular weight polyethylene materials.
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Affiliation(s)
- B H Currier
- Thayer School of Engineering, Dartmouth College, 8000 Cummings Hall, Hanover, NH 03755, USA.
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Gómez-Barrena E, Medel F, Puértolas JA. Polyethylene oxidation in total hip arthroplasty: evolution and new advances. Open Orthop J 2009; 3:115-20. [PMID: 20111694 PMCID: PMC2812841 DOI: 10.2174/1874325000903010115] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 10/23/2009] [Accepted: 10/29/2009] [Indexed: 01/06/2023] Open
Abstract
Ultra-high molecular weight polyethylene (UHMWPE) remains the gold standard acetabular bearing material for hip arthroplasty. Its successful performance has shown consistent results and survivorship in total hip replacement (THR) above 85% after 15 years, with different patients, surgeons, or designs. As THR results have been challenged by wear, oxidation, and liner fracture, relevant research on the material properties in the past decade has led to the development and clinical introduction of highly crosslinked polyethylenes (HXLPE). More stress on the bearing (more active, overweighted, younger patients), and more variability in the implantation technique in different small and large Hospitals may further compromise the clinical performance for many patients. The long-term in vivo performance of these materials remains to be proven. Clinical and retrieval studies after more than 5 years of in vivo use with HXLPE in THR are reviewed and consistently show a substantial decrease in wear rate. Moreover, a second generation of improved polyethylenes is backed by in vitro data and awaits more clinical experience to confirm the experimental improvements. Also, new antioxidant, free radical scavengers, candidates and the reinforcement of polyethylene through composites are currently under basic research.Oxidation of polyethylene is today significantly reduced by present formulations, and this forgiving, affordable, and wellknown material is still reliable to meet today's higher requirements in total hip replacement.
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Affiliation(s)
| | - Francisco Medel
- Materials Science and Technology Department-Instituto Ciencia de Materiales de Aragón, Universidad de Zaragoza-CSIC, Spain
| | - José Antonio Puértolas
- Materials Science and Technology Department-I3A, Instituto Ciencia de Materiales de Aragón, Universidad de Zaragoza-CSIC, Spain
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Baxter RM, Steinbeck MJ, Tipper JL, Parvizi J, Marcolongo M, Kurtz SM. Comparison of periprosthetic tissue digestion methods for ultra-high molecular weight polyethylene wear debris extraction. J Biomed Mater Res B Appl Biomater 2009; 91:409-18. [PMID: 19507139 DOI: 10.1002/jbm.b.31416] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
There is considerable interest in characterization of wear debris from polyethylene (UHMWPE) bearing components used in total joint replacement. To isolate UHMWPE wear debris, tissue samples must be excised from regions adjacent to revised UHMWPE implant components, followed by exposure to one of many available tissue digestion methods. Numerous studies demonstrate successful digestion, but the relative efficiency of each method is not clear. The purpose of this study was to evaluate a variety of conditions for tissue digestion to provide a quantitative comparison of methods. Porcine and human hip tissues were exposed for 24 h to basic, acidic or enzymatic agents, filtered and digestion efficiency calculated based on the percentage of initial to final tissue weight. Of the conditions tested, 5 M NaOH, 5 M KOH, 15 M KOH or 15.8 M HNO(3) yielded the most complete porcine hip tissue digestion (<1% residual tissue weight; p < 0.05). Proteinase K and Liberase Blendzyme 3 did not effectively digest tissue in a 24 h period. Similar to results from the porcine dataset, human tissues digestion was most efficient using 5 M NaOH, 5 M KOH or 15.8 M HNO(3) (<1% residual tissue weight; p < 0.05). To verify that particle surface modifications did not occur after prolonged reagent exposure, GUR415 and Ceridust 3715 particles were immersed in each solution for 24 h. Overall, this study provides a framework for thorough and efficient digestive methods for UHMWPE wear debris extraction.
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Affiliation(s)
- Ryan M Baxter
- Department of Biomedical Engineering, Drexel University, Philadelphia, Pennsylvania 19104, USA
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Bidar R, Kouyoumdjian P, Munini E, Asencio G. Long-term results of the ABG-1 hydroxyapatite coated total hip arthroplasty: analysis of 111 cases with a minimum follow-up of 10 years. Orthop Traumatol Surg Res 2009; 95:579-87. [PMID: 19926546 DOI: 10.1016/j.otsr.2009.10.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Revised: 05/11/2009] [Accepted: 10/05/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Medium-term studies of ABG-1 cementless total hip arthroplasty have shown favorable functional results with excellent femoral component fixation but an abnormally high rate of periacetabular component osteolysis, which may require early revision. HYPOTHESIS The periacetabular osteolysis rate increases with time with the ABG-1 implant, leading to a high revision rate. OBJECTIVE The objective of this study was to test this hypothesis with a minimum follow-up of 10 years and evaluate the progression of periacetabular osteolysis and its consequences on implant fixation. MATERIAL AND METHODS A continuous series of 111 ABG-1 cementless prostheses implanted by a single operator with a theoretical minimum follow-up of 10 years. Seventy-five implants were analyzed with a mean follow-up of 13 years. All the prostheses had been implanted via a posterolateral approach and consisted of a 28 mm cup matching a head in zirconia and an antidislocation rim design high-density polyethylene insert. RESULTS Twelve cups were revised because of progressive retroacetabular osteolysis. The revisions were performed systematically although there was no pain or gross cup loosening. The revisions included resection of the granuloma, cavity filling with morselized bone grafts, and implantation of new uncemented ABG-2 cups in eight cases or cemented cups associated with a support ring in the four other cases. Thirty-two (48.5%) of the cups still in place at the end of the follow-up evaluation presented moderate and asymptomatic radiographic osteolysis, inciting close subsequent observation. No predictive factor of osteolysis onset was identified (age, body mass index, polyethylene wear, or cup orientation). None of the femoral stems was changed because of osteolysis: the only two femoral revisions resulted from periprosthetic fracture and one case of bipolar loosening. The femoral osteolysis images were small and all limited to zones 7a (18.8% of cases), 1a, and 1b (65.2% of cases). The overall survival rate of the series at 13 years of follow-up was 80.5%; the cup survival rate was 83.2%; the femoral implant, 94.3%; and failure of the femoral stem secondary to aseptic loosening was only 1.3%. DISCUSSION, CONCLUSION This long-term study confirms the high frequency of retroacetabular osteolysis of ABG-1 prostheses surpassing the osteolysis rate of other uncemented cups with a polyethylene insert. The absence of predictive criteria of osteolysis occurrence and the lack of symptoms warrants periodic follow-up of patients with ABG-1 cups and, if necessary, early repair of bone stock loss with grafts combined with acetabular cup revision. This procedure remains simple as long as performed before the onset of massive bone destruction, confirming the proposed revisions in this series were judicious. This study also confirms the excellent long-term fixation of the ABG-1 femoral stems derived from the osteointegration and proximal seal around the hydroxyapatite coating.
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Affiliation(s)
- R Bidar
- Department of Orthopaedics and Traumatology, Carémeau Teaching Hospital Center, place du Pr-Robert-Debré, 30029 Nîmes cedex 9, France.
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Kurtz SM, Steinbeck M, Ianuzzi A, van Ooij A, Punt IM, Isaza J, Ross ERS. Retrieval analysis of motion preserving spinal devices and periprosthetic tissues. SAS JOURNAL 2009; 3:161-77. [PMID: 25802641 PMCID: PMC4365601 DOI: 10.1016/j.esas.2009.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article reviews certain practical aspects of retrieval analysis for motion preserving spinal implants and periprosthetic tissues as an essential component of the overall revision strategy for these implants. At our institution, we established an international repository for motion-preserving spine implants in 2004. Our repository is currently open to all spine surgeons, and is intended to be inclusive of all cervical and lumbar implant designs such as artificial discs and posterior dynamic stabilization devices. Although a wide range of alternative materials is being investigated for nonfusion spine implants, many of the examples in this review are drawn from our existing repository of metal-on-polyethylene, metal-on-metal lumbar total disc replacements (TDRs), and polyurethane-based dynamic motion preservation devices. These devices are already approved or nearing approval for use in the United States, and hence are the most clinically relevant at the present time. This article summarizes the current literature on the retrieval analysis of these implants and concludes with recommendations for the development of new test methods that are based on the current state of knowledge of in vivo wear and damage mechanisms. Furthermore, the relevance and need to evaluate the surrounding tissue to obtain a complete understanding of the biological reaction to implant component corrosion and wear is reviewed.
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Affiliation(s)
- Steven M Kurtz
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems and Department of Materials Engineering, Drexel University, Philadelphia, PA ; Exponent, Inc., 3401 Market St., Suite 300, Philadelphia, PA
| | - Marla Steinbeck
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems and Department of Materials Engineering, Drexel University, Philadelphia, PA
| | - Allyson Ianuzzi
- Implant Research Center, School of Biomedical Engineering, Science, and Health Systems and Department of Materials Engineering, Drexel University, Philadelphia, PA ; Exponent, Inc., 3401 Market St., Suite 300, Philadelphia, PA
| | - André van Ooij
- Departments of Orthopaedic Surgery, Maastricht University Medical Center, AZ Maastricht, 6202 AZ Maastricht, the Netherlands
| | - Ilona M Punt
- Departments of Orthopaedic Surgery, Maastricht University Medical Center, AZ Maastricht, 6202 AZ Maastricht, the Netherlands
| | - Jorge Isaza
- Our Lady of the Lake Medical Center, Baton Rouge, LA
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Abstract
STUDY DESIGN This study is an evaluation of wear and oxidation in retrieved total disc replacements (TDRs). Forty-eight CHARITE TDRs were retrieved from 41 patients after 7.8 years of average implantation. All implants were removed because of intractable back pain and/or facet degeneration. Three unimplanted implants served as controls. OBJECTIVE Our aim was to determine whether gamma-sterilized polyethylene components implanted in the spine oxidize in vivo, and if so, whether polyethylene oxidation has clinical relevance for the long-term performance of TDRs. SUMMARY OF BACKGROUND DATA The natural history of polyethylene oxidation following gamma sterilization and long-term implantation in the spine has not yet been investigated. METHODS Oxidation and oxidation potential were measured at the rim and dome of 47 components using Fourier transform infrared spectroscopy. The wear patterns of each retrieved polyethylene core were analyzed at the rim and dome. RESULTS Oxidation was significantly higher at the rim, as compared with the dome of the cores. Hydroperoxide index was also significantly higher at the rim, as compared with the dome. Dome penetration rate was negatively correlated to implantation time (P < 0.0001) but not correlated to oxidation or hydroperoxide index (P > 0.05). Implants with evidence of chronic rim loading had higher rim oxidation. CONCLUSION The data support our hypothesis that, for the historical packaging methods employed by the manufacturer, polyethylene oxidation and oxidation potential were significantly higher at the rim as opposed to the dome. The mechanism is governed by access to oxygen in vivo and may be accelerated under certain combined modes of repeated rim loading. Our findings have clinical significance in cases of chronic impingement, when the rim has to support repeated loading for the lifetime of the implant.
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Sobieraj MC, Rimnac CM. Ultra high molecular weight polyethylene: mechanics, morphology, and clinical behavior. J Mech Behav Biomed Mater 2009; 2:433-43. [PMID: 19627849 PMCID: PMC3601552 DOI: 10.1016/j.jmbbm.2008.12.006] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Revised: 12/13/2008] [Accepted: 12/15/2008] [Indexed: 01/24/2023]
Abstract
Ultra high molecular weight polyethylene (UHMWPE) is a semicrystalline polymer that has been used for over four decades as a bearing surface in total joint replacements. The mechanical properties and wear properties of UHMWPE are of interest with respect to the in vivo performance of UHMWPE joint replacement components. The mechanical properties of the polymer are dependent on both its crystalline and amorphous phases. Altering either phase (i.e., changing overall crystallinity, crystalline morphology, or crosslinking the amorphous phase) can affect the mechanical behavior of the material. There is also evidence that the morphology of UHMWPE, and, hence, its mechanical properties evolve with loading. UHMWPE has also been shown to be susceptible to oxidative degradation following gamma radiation sterilization with subsequent loss of mechanical properties. Contemporary UHMWPE sterilization methods have been developed to reduce or eliminate oxidative degradation. Also, crosslinking of UHMWPE has been pursued to improve the wear resistance of UHMWPE joint components. The 1st generation of highly crosslinked UHMWPEs have resulted in clinically reduced wear; however, the mechanical properties of these materials, such as ductility and fracture toughness, are reduced when compared with the virgin material. Therefore, a 2nd generation of highly crosslinked UHMWPEs are being introduced to preserve the wear resistance of the 1st generation while also seeking to provide oxidative stability and improved mechanical properties.
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Affiliation(s)
- M C Sobieraj
- Musculoskeletal Mechanics and Materials Laboratories, Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, OH, United States.
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Kurtz SM, Dumbleton J, Siskey RS, Wang A, Manley M. Trace concentrations of vitamin E protect radiation crosslinked UHMWPE from oxidative degradation. J Biomed Mater Res A 2009; 90:549-63. [PMID: 18563825 DOI: 10.1002/jbm.a.32122] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- S M Kurtz
- Exponent, Inc., 3401 Market St., Suite 300, Philadelphia, Pennsylvania 19104, USA.
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40
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Weimin F, Huanghe S, Xiang L, Feng L, Qing W. The impact of storage time on the wear rates of ultrahigh-molecular-weight polyethylene acetabular liners in hip simulators. J Arthroplasty 2009; 24:543-8. [PMID: 18534409 DOI: 10.1016/j.arth.2008.01.308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 01/28/2008] [Indexed: 02/01/2023] Open
Abstract
The aim of the study is to explore the impact of storage time on wear rates. Two groups of acetabular liners with a storage time of 1 and 4 years were tested on 2 hip simulators of the same type. There were 6 liners in each group. Gravimetric analysis was performed every 500 000 cycles for a total of 3 million cycles. The mean wear rate for the group of 4-year-old liners (36.3 mg/million cycles) was significantly higher than that for the 1-year-old group (23.1 mg/million cycles) (P < .05). After the last gravimetric analysis, scanning electron microscopy was used to observe the wear patterns of the bearing surfaces. This study found that wear resistance decreased as storage time increased.
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Affiliation(s)
- Fan Weimin
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University Nanjing, China
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Medel FJ, Rimnac CM, Kurtz SM. On the assessment of oxidative and microstructural changes after in vivo degradation of historical UHMWPE knee components by means of vibrational spectroscopies and nanoindentation. J Biomed Mater Res A 2009; 89:530-8. [PMID: 18435407 DOI: 10.1002/jbm.a.31992] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
This study reports on the suitability of different experimental techniques to evaluate chemical, microstructural, and mechanical changes associated with in vivo oxidation encountered in historical polyethylene components. To accomplish this aim, eight traceable tibial inserts were analyzed after revision surgery. The knee bearings were gamma sterilized in air and implanted for an average of 11.5 years after a shelf life of no longer than 1 year. Characterization of oxidation and transvinylene indexes, crystallinity, amorphous, and intermediate phase fractions, along with hardness and surface modulus, were performed in transverse sections of each bearing using Fourier transform infrared spectroscopy, Raman spectroscopy, and nanoindentation, respectively. Generally, subsurface maxima in the crystallinity, oxidation index, and hardness were observed at a depth of about 1 mm in all of the bearings. The superior surfaces and anterior-posterior faces of the inserts exhibited significantly higher oxidation and greater crystallinity than the inferior side. These observations suggest that the metallic tray may limit the access of molecular oxygen to the backside of the tibial inserts. We conclude that chemical, physical, and mechanical properties data confirm the occurrence of in vivo degradation in the long-term implanted knee components following gamma irradiation in air. Furthermore, infrared spectroscopy alone appeared to provide excellent insight into the oxidation and crystallization state of the in vivo oxidized polyethylene.
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Affiliation(s)
- Francisco J Medel
- Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania 19104, USA.
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Oonishi H, Ueno M, Kim SC, Oonishi H, Iwamoto M, Kyomoto M. Ceramic versus cobalt-chrome femoral components; wear of polyethylene insert in total knee prosthesis. J Arthroplasty 2009; 24:374-82. [PMID: 18524533 DOI: 10.1016/j.arth.2007.10.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 10/16/2007] [Indexed: 02/01/2023] Open
Abstract
The present study aimed to determine the effect of femoral component materials and sterilization methods on wear properties of total knee prostheses by using a knee simulator test and retrieval analysis. The simulator test revealed that ultrahigh molecular weight polyethylene (UHMWPE) inserts had remarkably lower wear against the ceramic femoral component than against the Co-Cr femoral component. However, the retrieval study revealed no significant difference in the linear wear between the former and the latter. The alumina ceramic/UHMWPE insert combination showed a mild wear. However, whether cross-linking by gamma-ray sterilization reduces wear remained unconfirmed. In contrast, oxidative degradation and/or delamination was confirmed. Thus, we conclude that alumina ceramic/ethylene oxide gas-sterilized UHMWPE insert in a total knee prosthesis might exhibit a good wear resistance.
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Affiliation(s)
- Hironobu Oonishi
- H. Oonishi Memorial Joint Replacement Institute, Tominaga Hospital, Naniwa-ku, Osaka, Japan
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Medel FJ, Kurtz SM, Hozack WJ, Parvizi J, Purtill JJ, Sharkey PF, MacDonald D, Kraay MJ, Goldberg V, Rimnac CM. Gamma inert sterilization: a solution to polyethylene oxidation? J Bone Joint Surg Am 2009; 91:839-49. [PMID: 19339568 PMCID: PMC2665040 DOI: 10.2106/jbjs.h.00538] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the 1990s, oxidation was found to occur in ultra-high molecular weight polyethylene total joint replacement components following gamma irradiation and prolonged shelf aging in air. Orthopaedic manufacturers developed barrier packaging to reduce oxidation during and after radiation sterilization. The present study explores the hypothesis that polyethylene components sterilized in a low-oxygen environment undergo similar in vivo oxidative mechanisms as inserts sterilized in air. In addition, the potential influence of the different sterilization processes on the wear performance of the polyethylene components was examined. METHODS An analysis of oxidation, wear, and surface damage was performed for forty-eight acetabular liners and 123 tibial inserts. The mean implantation time was 12.3+/-3.7 years for thirty-one acetabular liners that had been gamma sterilized in air and 4.0+/-2.5 years for the seventeen acetabular liners that had been gamma sterilized in inert gas. The mean implantation time was 11.0+/-3.2 years for the twenty-six tibial inserts that had been sterilized in air and 2.8+/-2.2 years for the ninety-seven tibial inserts that had been gamma sterilized in inert gas. Oxidation and hydroperoxide levels were characterized in loaded and unloaded regions of the inserts. RESULTS Measurable oxidation and oxidation potential were observed in all cohorts. The oxidation and hydroperoxide levels were regional. Surfaces with access to body fluids were more heavily oxidized than protected bearing surfaces were. This variation appeared to be greater in historical (gamma-in-air-sterilized) components. Regarding wear performance, historical and conventional acetabular liners showed similar wear penetration rates, whereas a low incidence of delamination was confirmed for the conventional tibial inserts in the first decade of implantation. CONCLUSIONS The present study explores the impact of industry-wide changes in sterilization practices for polyethylene. We found lower oxidation and oxidation potential in the conventional acetabular liners and tibial inserts that had been gamma sterilized in inert gas as compared with the historical components that had been gamma sterilized in air. However, we also found strong evidence that conventional components undergo mechanisms of in vivo oxidation similar to those observed following gamma irradiation in air. In addition, gamma sterilization in inert gas did not provide polyethylene with a significant improvement in terms of wear resistance as compared with gamma sterilization in air, except for a lower incidence of delamination in the first decade of implantation for tibial inserts.
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Affiliation(s)
- Francisco J. Medel
- Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, 3401 Market Street, Suite 300, Philadelphia, PA 19104. E-mail address for F.J. Medel:
| | - Steven M. Kurtz
- Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, 3401 Market Street, Suite 300, Philadelphia, PA 19104. E-mail address for F.J. Medel:
| | - William J. Hozack
- Rothman Institute at Jefferson, 925 Chestnut Street, Philadelphia, PA 19107
| | - Javad Parvizi
- Rothman Institute at Jefferson, 925 Chestnut Street, Philadelphia, PA 19107
| | - James J. Purtill
- Rothman Institute at Jefferson, 925 Chestnut Street, Philadelphia, PA 19107
| | - Peter F. Sharkey
- Rothman Institute at Jefferson, 925 Chestnut Street, Philadelphia, PA 19107
| | - Daniel MacDonald
- Implant Research Center, School of Biomedical Engineering, Science and Health Systems, Drexel University, 3401 Market Street, Suite 300, Philadelphia, PA 19104. E-mail address for F.J. Medel:
| | - Matthew J. Kraay
- Case Western Reserve University, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106
| | - Victor Goldberg
- Case Western Reserve University, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106
| | - Clare M. Rimnac
- Mechanical and Aerospace Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106
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Risk factors for accelerated polyethylene wear and osteolysis in ABG I total hip arthroplasty. INTERNATIONAL ORTHOPAEDICS 2009; 34:19-26. [PMID: 19214506 DOI: 10.1007/s00264-009-0731-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 12/10/2008] [Accepted: 01/08/2009] [Indexed: 10/21/2022]
Abstract
We analysed data from 155 revisions of identical cementless hip prostheses to determine the influence of patient-, implant- and surgery-related factors on the polyethylene wear rate and size of periprosthetic osteolysis (OL). This was calculated by logistic regression analysis. Factors associated with an increased/decreased wear rate included position of the cup relative to Kohler's line, increase in abduction angle of the cup, traumatic and inflammatory arthritis as a primary diagnosis, and patient height. Severe acetabular bone defects were predicted by an increased wear rate (odds ratio, OR = 5.782 for wear rate above 200 mm(3)/y), and increased height of the patient (OR = 0.905 per each centimetre). Predictors of severe bone defects in the femur were the increased wear rate (OR = 3.479 for wear rate above 200 mm(3)/y) and placement of the cup outside of the true acetabulum (OR = 3.292). Variables related to surgical technique were the most predictive of polyethylene wear rate.
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Kurtz SM, Siskey RL, Dumbleton J. Accelerated aqueous aging simulation of in vivo oxidation for gamma-sterilized UHMWPE. J Biomed Mater Res B Appl Biomater 2008; 90:368-72. [DOI: 10.1002/jbm.b.31294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Gallo J, Langova K, Havranek V, Cechova I. Poor survival of ABG I hip prosthesis in younger patients. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2008; 152:163-8. [PMID: 18795094 DOI: 10.5507/bp.2008.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Hydroxyapatite coated (HAC) hip implants have been used in clinical practice for more than two decades. However, the majority of studies have reported only intermediate term outcomes that are not reliable for predicting long-term behavior in all implants. The aim of this study was to determine the performance of HAC total hip arthroplasty in younger patients over a 10-year follow-up period. METHODS AND RESULTS This was an observational retrospective study of a 137 consecutive hips with the ABG I prosthesis. Of these, 128 were available for the last investigation. Median duration of follow-up was 10.9 years. The mean age at time of index surgery was 46+/-6.7 years. Probability of implant survival was estimated using the Kaplan-Meier method. The overall 12-year cumulative survival was 0.55 (95% CI, 0.443-0.659). Periprosthetic osteolysis (57 %) was the most frequent reason for failure followed by aseptic loosening (28 %). When only aseptic loosening was included in the analysis, the same figures for cup and stem were 0.873 (95% CI, 0.808-0.938) and 0.992 (95% CI, 0.976- 1.0), respectively. Patients with a smaller cup size were those at high risk for revision due to wear-related complications (odds ratio, OR=4.3; 95% CI, 1.734-10.555). CONCLUSION This study reports one of the poorest 12-year survivorship data for cementless acetabular component in the literature. The main reason for premature failure was osteolysis, strongly related to high wear rate of polyethylene.
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Affiliation(s)
- Jiri Gallo
- Department of Orthopedics, Teaching Hospital, Faculty of Medicine and Dentistry, Palacky University, Olomouc, Czech Republic.
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Gomez-Barrena E, Puertolas JA, Munuera L, Konttinen YT. Update on UHMWPE research: from the bench to the bedside. Acta Orthop 2008; 79:832-40. [PMID: 19085503 DOI: 10.1080/17453670810016939] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Ultra-high molecular weight polyethylene (UHMWPE) is the key material for achieving excellent long-term results in total joint arthroplasties. Despite the fact that there has been a substantial amount of research and development over the years, new aspects of this material are still controversial and the most recent innovations have had a variable reception regarding clinical use. Advancements in conventional UHMWPE in the 1990s (nitrogen atmosphere irradiation, barrier package) were further improved by introduction of first-generation crosslinked polyethylene, as seen both from laboratory findings and clinical results. However, while clinical data on first-generation highly crosslinked polyethylene (HXLPE) showed reduced wear in the medium-term, academic and industrial research have helped to refine the material further, to overcome criticisms regarding residual oxidation and potential material fracture. Present concerns, although less nowadays, relate to the post-irradiation techniques used to stabilize the crosslinked polyethylene, namely annealing and remelting. Current topics of research interest include in vivo oxidation, second-generation highly crosslinked polyethylene, vitamin E doped or blended polyethylene, fracture mechanics, and consequences of wear. Some of these improvements derived from recent research are already available to the orthopedic community, and others will appear in the next few years. This review gives an overview of these topics, and the latest advancements are described in detail with a view to help the orthopedic surgeon make scientifically sound decisions when selecting material for total-joint implants. We conclude the review by affirming that today's state-of-the-art material is no longer conventional UHMWPE, but HXLPE.1.
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Affiliation(s)
- Enrique Gomez-Barrena
- Department of Orthopaedic Surgery, Facultad de Medicina, Universidad Autonoma de Madrid, Madrid, Spain.
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Bal BS, Greenberg D, Li S, R Mauerhan D, Schultz L, Cherry K. Tibial post failures in a condylar posterior cruciate substituting total knee arthroplasty. J Arthroplasty 2008; 23:650-5. [PMID: 18534385 DOI: 10.1016/j.arth.2007.08.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Accepted: 08/01/2007] [Indexed: 02/01/2023] Open
Abstract
In posterior-stabilized total knee arthroplasties, a femoral cam and polyethylene tibial post are commonly used to restore posterior stability after sacrifice of the posterior cruciate ligament. This article reports a high incidence of early tibial post failures in one design of prosthesis and examines the variables that may have contributed to such. Five hundred sixty-four consecutive posterior-stabilized total knees were implanted in 512 patients, using a total knee prosthesis with a polyethylene tibial post and femoral cam. Clinical and radiographic outcomes were measured at a mean follow-up of 40 months after surgery (range, 24-83 months). At follow-up, 70 knees in 62 patients (12%) had undergone revision surgery because of symptoms related to catastrophic failure of the tibial post.
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Affiliation(s)
- B Sonny Bal
- Department of Orthopaedic Surgery, University of Missouri-Columbia, Missouri 65212, USA
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Kusaba A, Kondo S, Mori Y, Kuroki Y. In vivo change of elastic property in polyethylene acetabular components. Mod Rheumatol 2008; 18:140-5. [PMID: 18292965 DOI: 10.1007/s10165-008-0025-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 10/31/2007] [Indexed: 10/22/2022]
Abstract
Polyethylene is an elastic material. It is known that oxidative degradation of polyethylene occurs after sterilization by means of gamma irradiation. However, there have been few detailed reports with regard to the effects of this degradation on the mechanical property, especially in total hip prostheses. The purpose of this study was to examine the change in mechanical property of irradiated and non-irradiated polyethylene cups after implantation. Fifty-six ultra-high molecular-weight polyethylene (UHMWPE) cups retrieved at revision surgery were evaluated. Thirty-two cups were sterilized by gamma irradiation in air and 24 by ethylene oxide gas (EtO). To evaluate the mechanical property of the cup and its regional distribution, Vickers hardness was measured at nine points at the cross-section of the cups. In the irradiated cups, the hardness increased in proportion to the time from sterilization. This phenomenon was not found in the cups sterilized by EtO. Less change of hardness was observed in the cups sterilized by EtO than in those sterilized by irradiation. The gamma-irradiation in air actually affected the elastic property of cup polyethylene in vivo, although any difference in the wear rate was not detected between two sterilization methods. In cases with accelerated wear of the acetabular cup, other factors affecting wear should also be considered.
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Affiliation(s)
- Atsushi Kusaba
- Institute of Joint Replacement and Rheumatology, Ebina General Hospital, Ebina, Kanagawa, Japan.
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