Clinical and radiographic outcomes of total hip replacement with poly(2-methacryloyloxyethyl phosphorylcholine)-grafted highly cross-linked polyethylene liners: Three-year results of a prospective consecutive series

An Overview on the Tribological Performance of Titanium Alloys with Surface Modifications for Biomedical Applications

The need for metallic biomaterials will always remain high with their growing demand in joint replacement in the aging population. This creates need for the market and researchers to focus on the development and advancement of the biometals. Desirable characteristics such as excellent biocompatibility, high strength, comparable elastic modulus with bones, good corrosion resistance, and high wear resistance are the significant issues to address for medical implants, particularly load-bearing orthopedic implants. The widespread use of titanium alloys in biomedical implants create a big demand to identify and assess the behavior and performance of these alloys when used in the human body. Being the most commonly used metal alloy in the fabrication of medical implants, mainly because of its good biocompatibility and corrosion resistance together with its high strength to weight ratio, the tribological behavior of these alloys have always been an important subject for study. Titanium alloys with improved wear resistance will of course enhance the longevity of implants in the body. In this paper, tribological performance of titanium alloys (medical grades) is reviewed. Various methods of surface modifications employed for titanium alloys are also discussed in the context of wear behavior.

Scalable High-Affinity Stabilization of Magnetic Iron Oxide Nanostructures by a Biocompatible Antifouling Homopolymer

Iron oxide nanostructures have been widely developed for biomedical applications because of their magnetic properties and biocompatibility. In clinical applications, stabilization of these nanostructures against aggregation and nonspecific interactions is typically achieved using weakly anchored polysaccharides, with better-defined and more strongly anchored synthetic polymers not commercially adopted because of their complexity of synthesis and use. Here, we show for the first time stabilization and biocompatibilization of iron oxide nanoparticles by a synthetic homopolymer with strong surface anchoring and a history of clinical use in other applications, poly(2-methacryloyloxyethyl phosphorylcholine) [poly(MPC)]. For the commercially important case of spherical particles, binding of poly(MPC) to iron oxide surfaces and highly effective individualization of magnetite nanoparticles (20 nm) are demonstrated. Next-generation high-aspect-ratio nanowires (both magnetite/maghemite and core-shell iron/iron oxide) are, furthermore, stabilized by poly(MPC) coating, with the nanowire cytotoxicity at large concentrations significantly reduced. The synthesis approach exploited to incorporate functionality into the poly(MPC) chain is demonstrated by random copolymerization with an alkyne-containing monomer for click chemistry. Taking these results together, poly(MPC) homopolymers and random copolymers offer a significant improvement over current iron oxide nanoformulations, combining straightforward synthesis, strong surface anchoring, and well-defined molecular weight.

Clinical safety and wear resistance of the phospholipid polymer-grafted highly cross-linked polyethylene liner

To reduce the production of wear particles and subsequent aseptic loosening, we created a human articular cartilage-mimicked surface for a highly cross-linked polyethylene liner, whose surface grafted layer consisted of a biocompatible phospholipid polymer, poly(2-methacryloyloxyethyl phosphorylcholine). Although our previous in vitro findings showed that poly(2-methacryloyloxyethyl phosphorylcholine)-grafted particles were biologically inert and caused no subsequent bone resorptive responses, and poly(2-methacryloyloxyethyl phosphorylcholine) grafting markedly decreased wear in hip joint simulator tests, the clinical safety, and in vivo wear resistance of poly(2-methacryloyloxyethyl phosphorylcholine)-grafted highly cross-linked polyethylene liners remained open to question. Therefore, in the present study, we evaluated clinical and radiographic outcomes of poly(2-methacryloyloxyethyl phosphorylcholine)-grafted highly cross-linked polyethylene liners 5 years subsequent to total hip replacement in 68 consecutive patients. No reoperation was required for any reason, and no adverse events were associated with the implanted liners. The average Harris Hip Score increased from 38.6 preoperatively to 96.5 5 years postoperatively, and health-related quality of life, as indicated by the Short Form 36 Health Survey, improved. Radiographic analyses showed no periprosthetic osteolysis or implant migration. Between 1 and 5 years postoperatively, the mean steady-state wear rate was 0.002 mm/year, which represented a marked reduction relative to other highly cross-linked polyethylene liners, and appeared to be unaffected by patient-related or surgical factors. Although longer follow up is required, poly(2-methacryloyloxyethyl phosphorylcholine)-grafted highly cross-linked polyethylene liners improved mid-term clinical outcomes. The clinical safety and wear-resistance results are encouraging with respect to the improvement of long-term clinical outcomes with poly(2-methacryloyloxyethyl phosphorylcholine)-grafted highly cross-linked polyethylene liners. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2007-2016, 2017.

The effect of cationically-modified phosphorylcholine polymers on human osteoblasts in vitro and their effect on bone formation in vivo

The effect of introducing cationic charge into phosphorylcholine (PC)-based polymers has been investigated in this study with a view to using these materials as coatings to improve bone formation and osseointegration at the bone-implant interface. PC-based polymers, which have been used in a variety of medical devices to improve biocompatibility, are associated with low protein adsorption resulting in reduced complement activation, inflammatory response and cell adhesion. However, in some applications, such as orthopaedics, good integration between the implant and bone is needed to allow the distribution of loading stresses and a bioactive response is required. It has previously been shown that the incorporation of cationic charge into PC-based polymers may increase protein adsorption that stimulates subsequent cell adhesion. In this paper, the effect of cationic charge in PC-based polymers on human osteoblasts (HObs) in vitro and the effect of these polymers on bone formation in the rat tibia was assessed. Increasing PC positive surface charge increased HOb cell adhesion and stimulated increased cell differentiation and the production of calcium phosphate deposits. However, when implanted in bone these materials were at best biotolerant, stimulating the production of fibrous tissue and areas of loosely associated matrix (LAM) around the implant. Their development, as formulated in this study, as bone interfacing implant coatings is therefore not warranted.

Raman spectroscopy of biomedical polyethylenes

With the development of three-dimensional Raman algorithms for local mapping of oxidation and plastic strain, and the ability to resolve molecular orientation patterns with microscopic spatial resolution, there is an opportunity to re-examine many of the foundations on which our understanding of biomedical grade ultra-high molecular weight polyethylenes (UHMWPEs) are based. By implementing polarized Raman spectroscopy into an automatized tool with an improved precision in non-destructively resolving Euler angles, oxidation levels, and microscopic strain, we become capable to make accurate and traceable measurements of the in vitro and in vivo tribological responses of a variety of commercially available UHMWPE bearings for artificial hip and knee joints. In this paper, we first review the foundations and the main algorithms for Raman analyses of oxidation and strain of biomedical polyethylene. Then, we critically re-examine a large body of Raman data previously collected on different polyethylene joint components after in vitro testing or in vivo service, in order to shed new light on an area of particular importance to joint orthopedics: the microscopic nature of UHMWPE surface degradation in the human body. A complex scenario of physical chemistry appears from the Raman analyses, which highlights the importance of molecular-scale phenomena besides mere microstructural changes. The availability of the Raman microscopic probe for visualizing oxidation patterns unveiled striking findings related to the chemical contribution to wear degradation: chain-breaking and subsequent formation of carboxylic acid sites preferentially occur in correspondence of third-phase regions, and they are triggered by emission of dehydroxylated oxygen from ceramic oxide counterparts. These findings profoundly differ from more popular (and simplistic) notions of mechanistic tribology adopted in analyzing joint simulator data. Statement of Significance This review was dedicated to the theoretical and experimental evaluation of the commercially available biomedical polyethylene samples by Raman spectroscopy with regard to their molecular textures, oxidative patterns, and plastic strain at the microscopic level in the three dimensions of the Euclidean space. The main achievements could be listed, as follow: (i) visualization of molecular patterns at the surface of UHMWPE bearings operating against metallic components; (ii) differentiation between wear and creep deformation in retrievals; (iii) non-destructive mapping of oxidative patterns; and, (iv) the clarification of chemical interactions between oxide/non-oxide ceramic heads and advanced UHMWPE liners.

The effects of presence of a backside screw hole on biotribological behavior of phospholipid polymer-grafted crosslinked polyethylene

One of the important factors in determining the success of joint replacement is the wear performance of polyethylene. Although highly crosslinked polyethylene (CLPE) is presently used, it is still not adequate. We have developed a surface modification technology using poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) in an attempt to improve wear performance. In this study, we evaluated the wear and creep deformation resistances of 3-mm and 6-mm thick PMPC-grafted CLPE disks, set on a metal back-plate, with and without a sham screw hole. The gravimetric wear and volumetric change of the disks were examined using a multidirectional pin-on-disk tester. PMPC grafting decreased the gravimetric wear of CLPE regardless of the presence of a screw hole, and did not affect the volumetric change. The volumetric change in the bearing and backside surfaces of the 3-mm thick disk with a screw hole was much larger than that of those without a screw hole or those of the 6-mm thick disk, which was caused by creep deformation. PMPC grafting on the bearing surface can be a material engineering approach to reduce the wear without changing the creep deformation resistance, and is a promising surface modification technology that can be used to increase the longevity of various artificial joints. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 610-618, 2018.

Status of surface modification techniques for artificial hip implants

Surface modification techniques have been developed significantly in the last couple of decades for enhanced tribological performance of artificial hip implants. Surface modification techniques improve biological, chemical and mechanical properties of implant surfaces. Some of the most effective techniques, namely surface texturing, surface coating, and surface grafting, are applied to reduce the friction and wear of artificial implants. This article reviews the status of the developments of surface modification techniques and their effects on commonly used artificial joint implants. This study focused only on artificial hip joint prostheses research of the last 10 years. A total of 27 articles were critically reviewed and categorized according to surface modification technique. The literature reveals that modified surfaces exhibit reduced friction and enhanced wear resistance of the contact surfaces. However, the wear rates are still noticeable in case of surface texturing and surface coating. The associated vortex flow aids to release entrapped wear debris and thus increase the wear particles generation in case of textured surfaces. The earlier delamination of coating materials due to poor adhesion and graphitization transformation has limited the use of coating techniques. Moreover, the produced wear debris has adverse effects on biological fluid. Conversely, the surface grafting technique provides phospholipid like layer that exhibited lower friction and almost zero wear rates even after a longer period of friction and wear test. The findings suggest that further investigations are required to identify the role of surface grafting on film formation and heat resistance ability under physiological hip joint conditions for improved performance and longevity of hip implants.

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

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

Effect of Salt on Phosphorylcholine-based Zwitterionic Polymer Brushes

A quantitative investigation of the responses of surface-grown biocompatible brushes of poly(2-(methacryloyloxy)ethyl phosphorylcholine) (PMPC) to different types of salt has been carried out using ellipsometry, quartz crystal microbalance (QCM) measurements, and friction force microscopy. Both cations and anions of varying valency over a wide range of concentrations were examined. Ellipsometry shows that the height of the brushes is largely independent of the ionic strength, confirming that the degree of swelling of the polymer is independent of the ionic character of the medium. In contrast, QCM measurements reveal significant changes in mass and dissipation to the PMPC brush layer, suggesting that ions bind to phosphorylcholine (PC) groups in PMPC molecules, which results in changes in the stiffness of the brush layer, and the binding affinity varies with salt type. Nanotribological measurements made using friction force microscopy show that the coefficient of friction decreases with increasing ionic strength for a variety of salts, supporting the conclusion drawn from QCM measurements. It is proposed that the binding of ions to the PMPC molecules does not change their hydration state, and hence the height of the surface-grown polymeric brushes. However, the balance of the intra- and intermolecular interactions is strongly dependent upon the ionic character of the medium between the hydrated chains, modulating the interactions between the zwitterionic PC pendant groups and, consequently, the stiffness of the PMPC molecules in the brush layer.

Effects of Surface Modification and Bulk Geometry on the Biotribological Behavior of Cross-Linked Polyethylene: Wear Testing and Finite Element Analysis

The wear and creep deformation resistances of polymeric orthopedic bearing materials are both important for extending their longevity. In this study, we evaluated the wear and creep deformation resistances, including backside damage, of different polyethylene (PE) materials, namely, conventional PE, cross-linked PE (CLPE), and poly(2-methacryloyloxyethyl phosphorylcholine)- (PMPC-) grafted CLPE, through wear tests and finite element analysis. The gravimetric and volumetric degrees of wear of disks (3 or 6 mm in thickness) of these materials against a cobalt-chromium-molybdenum alloy pin were examined using a multidirectional pin-on-disk tester. Cross-linking and PMPC grafting decreased the gravimetric wear of the PE disks significantly. The volumetric wear at the bearing surface and the volumetric penetration in the backside of the 3-mm thick PE disk were higher than those of the 6-mm thick PE disk, regardless of the bearing material. The geometrical changes induced in the PE disks consisted of creep, because the calculated internal von Mises stress at the bearing side of all disks and that at the backside of the 3-mm thick disks exceeded their actual yield strengths. A highly hydrated bearing surface layer, formed by PMPC grafting, and a cross-linking-strengthened substrate of adequate thickness are essential for increasing the wear and creep deformation resistances.

Prevention of bacterial adhesion and biofilm formation on a vitamin E-blended, cross-linked polyethylene surface with a poly(2-methacryloyloxyethyl phosphorylcholine) layer

In the construction of artificial hip joint replacements, the surface and substrate of a cross-linked polyethylene (CLPE) liner are designed to achieve high wear resistance and prevent infection by bacteria. In this study, we fabricated a highly hydrophilic and antibiofouling poly(2-methacryloyloxyethyl phosphorylcholine [MPC]) (PMPC)-graft layer on the vitamin E-blended CLPE (HD-CLPE(VE)) surface. The 100-nm-thick, smooth, and electrically neutral PMPC layer was successfully fabricated on the HD-CLPE(VE) surface using photoinduced graft polymerization. The PMPC-grafted HD-CLPE(VE) was found to prevent bacterial adherence and biofilm formation on the surface because of the formation of a highly hydrophilic polyzwitterionic layer on the surface of HD-CLPE(VE), which can serve as an extremely efficient antibiofouling layer. The number of bacterial adhered on the PMPC-grafted HD-CLPE(VE) surface was reduced by 100-fold or more by PMPC grafting, regardless of the biofilm-production characteristics of the strains. In contrast, vitamin E blending did not affect bacterial adhesion. Moreover, the number of planktonic bacteria did not differ significantly, regardless of PMPC grafting and vitamin E blending. In conclusion, the PMPC-grafted HD-CLPE(VE) provided bacteriostatic effects associated with smooth, highly hydrophilic surfaces with a neutral electrostatic charge owing to the zwitterionic structure of the MPC unit. Thus, this modification may prove useful for the production of artificial hip joint replacement materials.

STATEMENT OF SIGNIFICANCE

Our preliminary in vitro findings suggest that improved bacteriostatic performance of the HD-CLPE(VE) surface in orthopedic implants is possible via PMPC grafting. The results also indicate that surface modifications affect the anti-infection properties of the orthopedic implants and demonstrate that the application of a PMPC-grafted HD-CLPE(VE) surface may be a promising approach to extend the longevity and clinical outcomes of total hip arthroplasty. Further research is needed to evaluate the resistance to infection of PMPC-grafted HD-CLPE(VE) in terms of the varieties of biofilm formation tests including fluid flow conditions and animal experiments, which may offer useful clues to the possible performance of these materials in vivo.

Effects of extra irradiation on surface and bulk properties of PMPC-grafted cross-linked polyethylene

Sterilization using high-energy irradiation is an important aspect of implementing an ultra-high molecular weight polyethylene acetabular liner in total hip arthroplasty (THA). In this study, we evaluate the effects of extra irradiations such as gamma-ray or plasma irradiation during sterilization of the poly(2-methacryloyloxyethyl phosphorylcholine [MPC]) (PMPC) surface and cross-linked polyethylene (CLPE) substrate of a PMPC-grafted CLPE acetabular liner. The PMPC-grafted surface yielded high wettability and low friction properties regardless of the extra irradiations as compared with untreated CLPE. During a hip simulator test, wear resistance of the PMPC-grafted CLPE liner was maintained after extra irradiation, which is due to the high wettability characteristics of the PMPC surface. In particular, the PMPC-grafted CLPE liner treated with plasma irradiation showed greater wettability and wear resistance than that with gamma-ray irradiation. However, we could not clearly observe the changes in chemical properties and morphology of the PMPC surface after both extra irradiations. The physical and mechanical properties attributed to CLPE substrate performance were also unchanged. In contrast, PMPC-grafted CLPE treated with plasma irradiation showed improved oxidation resistance as compared to that treated with gamma-ray irradiation after accelerated aging. Thus, we conclude that PMPC-grafted CLPE with plasma irradiation has promise as a lifelong solution for bearing in THA.

Wear resistance of the biocompatible phospholipid polymer-grafted highly cross-linked polyethylene liner against larger femoral head

The use of larger femoral heads to prevent the dislocation of artificial hip joints has recently become more common. However, concerns about the subsequent use of thinner polyethylene liners and their effects on wear rate have arisen. Previously, we prepared and evaluated the biological and mechanical effects of a novel highly cross-linked polyethylene (CLPE) liner with a nanometer-scaled graft layer of poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC). Our findings showed that the PMPC-grafted particles were biologically inert and caused no subsequent bone resorptive responses and that the PMPC-grafting markedly decreased wear in a hip joint simulator. However, the metal or ceramic femoral heads used in this previous study had a diameter of 26 mm. Here, we investigated the wear-resistance of the PMPC-grafted CLPE liner with a 40-mm femoral head during 10 × 10(6) cycles of loading in the hip joint simulator. The results provide preliminary evidence that the grafting markedly decreased gravimetric wear rate and the volume of wear particles, even when coupled with larger femoral heads. Thus, we believe the PMPC-grafting will prolong artificial hip joint longevity both by preventing aseptic loosening and by improving the stability of articular surface.

Influences of dehydration and rehydration on the lubrication properties of phospholipid polymer-grafted cross-linked polyethylene

Surface modification by grafting of biocompatible phospholipid polymer onto the surface of artificial joint material has been proposed to reduce the risk of aseptic loosening and improve the durability. Poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC)-grafted cross-linked polyethylene (CLPE) has shown promising results for reducing wear of CLPE. The main lubrication mechanism for the PMPC layer is considered to be the hydration lubrication. In this study, the lubrication properties of PMPC-grafted CLPE were evaluated in reciprocating friction test with rehydration process by unloading in various lubricants. The start-up friction of PMPC-grafted CLPE was reduced, and the damage of PMPC layer was suppressed by rehydration in water or hyaluronic acid solutions. In contrast, the start-up friction of PMPC-grafted CLPE increased in fetal bovine serum solution, and the damage for PMPC layer was quite noticeable. Interestingly, the start-up friction of PMPC-grafted CLPE was reduced in fetal bovine serum solution containing hyaluronic acid, and the damage of the PMPC layer was suppressed. These results indicate that the rehydration by unloading and hyaluronic acid are elemental in maximizing the lubrication effect of hydrated PMPC layer.

Multidirectional wear and impact-to-wear tests of phospholipid-polymer-grafted and vitamin E-blended crosslinked polyethylene: a pilot study

BACKGROUND

Modifying the surface and substrate of a crosslinked polyethylene (CLPE) liner may be beneficial for high wear resistance as well as high oxidative stability and excellent mechanical properties, which would be useful in contributing to the long-term performance of orthopaedic bearings. A grafted poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) layer on a vitamin E-blended crosslinked PE (HD-CLPE[VE]) surface may provide hydrophilicity and lubricity without compromising the oxidative stability or mechanical properties.

QUESTIONS/PURPOSES

(1) Will the modifications (PMPC grafting and vitamin E blending) affect the lubrication characteristics of the CLPE surface? (2) Will the modifications affect wear resistance? (3) Will the modifications affect fatigue resistance?

METHODS

We investigated the effects of surface and substrate modifications (PMPC grafting and vitamin E blending) on the wear and fatigue fracture of thin CLPE samples. For each of the untreated and PMPC-grafted CLPE surfaces with and without vitamin E blended (four groups), wettability and lubricity surface analyses were conducted as well as multidirectional wear and impact-to-wear tests using a pin-on-disk testing machine.

RESULTS

The water wettability and lubricity (CLPE [mean ± 95% confidence interval]: 23.2° ± 1.8°, 0.005 ± 0.001; HD-CLPE[VE]: 26.0° ± 2.3°, 0.009 ± 0.003) of the PMPC-grafted surfaces were greater (p < 0.001) than that (CLPE: 90.3° ± 1.2°, 0.067 ± 0.015; HD-CLPE[VE]: 90.8° ± 2.0°, 0.063 ± 0.008) of the untreated surface regardless of vitamin E additives. It was observed that the PMPC grafting (CLPE: 0.23 ± 0.06 mg; HD-CLPE[VE]: 0.05 ± 0.10 mg) was associated with reduced gravimetric wear (CLPE: 0.53 ± 0.08 mg, p = 0.004 HD-CLPE[VE]: 0.23 ± 0.07 mg, p = 0.038) in the multidirectional wear test. The PMPC-grafted surface characteristics did not appear to affect the impact fatigue resistance regardless of vitamin E blending.

CONCLUSIONS

PMPC grafting improved the surface hydrophilicity and lubricity, and it reduced the gravimetric wear in terms of multidirectional sliding. It did not result in differences in terms of the impact-to-unidirectional sliding regardless of vitamin E blending. Further research is needed to evaluate the wear resistance of PMPC-grafted HD-CLPE(VE) in long-term hip simulator tests under normal and severe conditions, which may offer useful clues to the possible performance of these materials in vivo.

CLINICAL RELEVANCE

Our preliminary in vitro findings suggest that some improvement in the wear performance of crosslinked polyethylene acetabular liners in total hip arthroplasty could be obtained using PMPC grafting. Further research is needed to evaluate the wear resistance of PMPC-grafted HD-CLPE(VE) in long-term hip simulator tests under normal and severe conditions, which may offer useful clues to the possible performance of these materials in vivo.