Ultra-low wear rates for rigid-on-rigid bearings in total hip replacements

With the increased clinical interest in metal-on-metal and ceramic-on-ceramic total-hip replacements (THRs), the objective of this hip simulator study was to identify the relative wear ranking of three bearing systems, namely CoCr-polyethylene (M-PE), CoCr-CoCr (M-M) and ceramic-on-ceramic (C-C). Volumetric wear rates were used as the method of comparison. The seven THR groupings included one M-PE study, two M-M studies and four C-C studies. Special emphasis was given to defining the 'run-in' phase of accelerated wear that rigid-on-rigid bearings generally exhibit. The hypothesis was that characterization of the run-in and steady state wear phases would clarify not only the tribological performance in vitro but also help correlate these in vitro wear rates with the 'average' wear rates measured on retrieved implants. The implant systems were studied on multichannel hip simulators using the Paul gait cycle and bovine serum as the lubricant. With 28 mm CoCr heads, the PE (2.5 Mrad/N2) wear rates averaged 13 mm3/10(6) cycles duration. This was considered a low value compared with the clinical model of 74 mm3/year (for 28 mm heads). Our later studies established that this low laboratory value was a consequence of the serum parameters then in use. The mating CoCr heads (with PE cups) wore at the steady state rate of 0.028 mm3/10(6) cycles. The concurrently run Metasul M-M THRs wore at the steady state rate of 0.119 mm3/10(6) cycles with high-protein serum. In the second Metasul M-M study with low-protein serum, the THR run-in rate was 2.681 mm3/10(6) cycles and steady state was 0.977 mm3/10(6) cycles. At 10 years, these data would predict a 70-fold reduction in M-M wear debris compared with the clinical PE wear model. All M-M implants exhibited biphasic wear trends, with the transition point at 0.5 x 10(6) cycles between run-in and steady state phases, the latter averaging a 3-fold decrease in wear rate. White surface coatings on implants (coming from the serum solution) were a confounding factor but did not obscure the two orders of magnitude wear performance improvement for CoCr over PE cups. The liners in the alumina head-alumina cup combination wore at the steady state rate of 0.004 mm3/10(6) cycles over 14 x 10(6) cycles duration (high-protein serum). The zirconia head-alumina cup THR combination wore at 0.174 and 0.014 mm3/10(6) cycles for run-in and steady state rates respectively (low-protein serum). The zirconia head and cup THR combination wore slightly higher initially with 0.342 and 0.013 mm3/10(6) cycles for run-in and steady state rates respectively. Other wear studies have generally predicted catastrophic wear for such zirconia-ceramic combinations. It was noted that the zirconia wear trends were frequently masked by the effects of tenacious white surface coatings. It was possible that these coatings protected the zirconia surfaces somewhat in this simulator study. The experimental ceramic Crystaloy THR had the highest ceramic run-in wear at 0.681 mm3/10(6) cycles and typical 0.016 mm3/10(6) cycles for steady state. Since these implants represented the first Crystaloy THR sets made, it was likely that the surface conditions of this high-strength ceramic could be improved in the future. Overall, the ceramic THRs demonstrated three orders of magnitude wear performance improvement over PE cups. With zirconia implants, while the cup wear was sometimes measurable, head wear was seldom discernible. Therefore, we have to be cautious in interpreting such zirconia wear data. Identifying the run-in and steady state wear rates was a valuable step in processing the ceramic wear data and assessing its reliability. Thus, the M-M and C-C THRs have demonstrated two to three orders of reduction in volumetric wear in the laboratory compared with the PE wear standard, which helps to explain the excellent wear performance and minimal osteolysis seen with such implants at retrieval operations.

Comparative bone growth behavior in granules of bioceramic materials of various sizes

Various bioceramic materials were implanted into 6-mm-diameter holes made in the femoral condyles of mature Japanese white rabbits using different-sized granules to find an optimal material and granule diameter for use as a bone graft. Bioceramics include a bioinert ceramic (Alumina), surface-bioactive ceramics [hydroxyapatite (HAp) and Bioglass(R)], and resorbable bioactive ceramics [alphatricalcium phosphate (alpha-TCP), beta-TCP, tetracalcium phosphate (TeCP), Te. DCPD, Te. DCPA, and low-crystalline HAp]. Granule sizes were 100-300, 10, and 1-3 microm. Bone growth behavior varied with the kind of bioceramic and the size used. For surface-bioactive ceramics, 45S5 Bioglass(R) led to more rapid bone proliferation than synthetic HAp. In resorbable bioactive ceramics, the order of resorption was: low-crystalline HAp and OCP > TeCP, Te DCPD, Te DCPA > alpha-TCP, beta-TCP. In terms of biocompatibility, alpha-TCP was better than beta-TCP.

Quantitative comparison of bone growth behavior in granules of Bioglass, A-W glass-ceramic, and hydroxyapatite

The hypothesis that bioactive glass particulate increases the rate of bone proliferation over that of synthetic hydroxyapatite and bioactive glass-ceramic was tested in these experiments. Three types of bioactive particles-45S5 Bioglass(R), synthetic hydroxyapatite, and A-W glass-ceramic-were implanted in 6-mm-diameter holes drilled in the femoral condyles of mature rabbits. Bone growth rate was measured using an image processor. 45S5 Bioglass(R) produced bone more rapidly than either A-W glass-ceramic or hydroxyapatite. At the later time periods, 45S5 Bioglass(R) was resorbed more quickly than A-W glass-ceramic. Synthetic hydroxyapatite was not resorbed at all. Backscattered electron imaging suggested that the resorption process occurred by solution-mediated dissolution, which produced chemical changes in the enclosed particulate. It was concluded that the rate of bone growth correlates with the rate of dissolution of silica as the particles resorb.

The effect of hydroxyapatite coating on bone growth into porous titanium alloy implants

In rabbits and goats, test implants with a porous surface of two layers of Tl-6A;-4V beads were examined at intervals for bond strength with bone. Half of the implants were coated with hydroxyapatite by plasma spray. The bonding strength with bone in the coated specimens was about four times greater than that of the uncoated specimens at two weeks, and twice as strong at six weeks. Twelve weeks after implantation, the strengths were similar. The hydroxyapatite coating of the beads provided earlier and stronger fixation.

Orthopaedic applications of hydroxyapatite

Hydroxyapatite (HA) has been used for more than six years. More recently we have used HA composites in clinical orthopaedics for spacing or filling bone defects. In this application the advantages of HA include lack of immuno-reaction and absence of postoperative morphological change or volume decrease. HA implants fixed with cement avoid problems from high density polyethylene wear particles. Other applications of HA include femoral plugs in total hip replacement and HA coating on metal components for cementless fixation. For rapid and strong cementless fixation porous metal surfaces are used; HA coating of porous metal gives improved results. We have also developed a technique for bioactive interfacial bone cementation by interposing fine HA granules between the bone and PMMA cement.

Mechanical analysis of the human pelvis and its application to the artificial hip joint--by means of the three dimensional finite element method

Mechanical analysis of the human pelvis and the hip joint was performed by means of a three-dimensional finite element method by ASKA program. Two models each standing on one leg were made, one was the pelvis with the physiological hip joint, in the other pelvis part of the cartilage and subchondral bone was replaced with Al2O3 ceramic materials. In this study, we obtained; (1) the various deformations and displacements of the whole pelvis, the pelvic ring and the acetabulum and (2) the principal stress, the maximum shear stress and the Von mises stress on the surface of the whole pelvis and in various horizontal sections of the whole pelvis.

FDG-PET for predicting the prognosis of malignant lymphoma

To evaluate the usefulness of FDG-PET as a predictor of prognosis, 34 patients with untreated malignant lymphoma in the head and neck region were studied. After FDG-PET and treatment, they were observed from 15 to 50 months. Tumors which were aggressive and resistant to treatment tended to show high uptake of FDG. The survival rate of patients with high uptake of FDG, DAR > or = 8, was lower than the rate of the other patients. It is considered to be useful to add FDG uptake of the tumor to other prognostic factors for predicting the prognosis.

Gamma-irradiated cross-linked polyethylene in total hip replacements--analysis of retrieved sockets after long-term implantation

The purpose of this study was to evaluate the mechanical and chemical characteristics of gamma-irradiated, cross-linked polyethylene after long-term service in vivo. Two gamma-irradiated ultra high molecular weight polyethylene (RCH 1000, molecular weight: 10(6)) total hip replacement sockets were retrieved at 15 and 16 years after implantation. Mechanical and chemical characteristics of the sockets were evaluated in comparison with nonirradiated sockets. Significant surface oxidation occurred in the nonirradiated sockets; up to 75% of that seen in the irradiated ones. The mechanical properties of the irradiated sockets were not subject to increased deterioration in the presence of high free radical content. The cross-link was stable and was retained for a long period both in vivo and in ambient air. These data indicate that gamma-irradiated polyethylene was not subject to increased oxidative degradation during long-term service in vivo and confirmed the usefulness of this material as an articulating surface in total hip replacement.

Wear of high-dose gamma-irradiated polyethylene in total hip replacements

Between 1971 and 1978, 62 patients underwent total hip replacements (THRs) with high-dose (100 Mrad) gamma-irradiated polyethylene sockets. After a mean follow-up of 17. 3 years (range, 6-23 years), 28 hips in 26 patients were available for radiographic wear measurement. Twenty-three THRs with non-irradiated sockets were used as controls, although all these hips had loosened within 13 years. The rate of linear wear in irradiated sockets was significantly lower throughout the follow-up period (less than 2 years, 0.16 and 0. 38 mm/year; 2-6 years, 0.05 and 0.29 mm/year; more than 6 years, 0. 05 and 0.28 mm/year, respectively; mean, P < 0.0001). This result has demonstrated that high-dose gamma-irradiated, cross-linked polyethylene is a promising articulating material for THRs.

Hydroxyapatite in revision of total hip replacements with massive acetabular defects: 4- to 10-year clinical results

Hydroxyapatite (HA) granules of 100 to 300 microm, 0.9 to 1.2 mm and 3.0 to 5.0 mm were mixed in a ratio of 10:45:45 and packed into massive bone deficiencies in revision operations for total hip arthroplasty. We did not use additional graft or cup support for deficiencies of the lateral and medial wall. The procedure was carried out in 40 hips between 1986 and 1992. The radiographic spaces seen at the interface between HA and bone immediately after surgery disappeared within three months. Some spaces appeared between HA granules near the bone in the lateral part of two joints, and three sockets migrated in patients with severe segmental and cavitary deficiencies. Direct bonding of HA to bone was observed radiologically without morphological changes, except in the three joints with migration. All patients could walk without pain but the three with definite loosening needed crutches.

Ceramic versus cobalt-chrome femoral components; wear of polyethylene insert in total knee prosthesis

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.

Total hip arthroplasty with a modified cementing technique using hydroxyapatite granules

Results of total hip arthroplasties with a modified cementing technique using hydroxyapatite were evaluated. Femoral and acetabular components were inserted with cement after hydroxyapatite granules (phi = 100-300 microm). The study group comprised 268 hips in 232 patients. The diagnosis was osteoarthritis in 197 patients. After a mean follow-up of 10.3 years, 5 patients died and 30 patients were lost to follow-up, leaving 218 hips (197 patients; mean age, 58.2 years) for evaluation. Three hips were revised because aseptic (1) and septic (2) loosening of acetabular components. Six other sockets were defined as radiologically loose, and no femoral component was loose. Osteolysis was identified in 2 femora and 0 acetabula. The overall loosening rate was 3.2% for acetabular components and 0% for femoral components. These results show that the loosening rate of cemented total hip arthroplasty components, especially the acetabulum, is reduced markedly with this modified cementing technique.

Clinical experience with ceramics in total hip replacement

As part of a search for better articulation in total hip prostheses, the decrease in the thickness of the socket in different total hip prostheses was measured in vivo. The wear rates of (1) RCH 1000 (molecular weight, 10(6)) socket gamma-irradiated with 100 Mrad articulating with a crude COP (stainless steel containing 20% cobalt and 0.01% phosphorous) metal femoral head; (2) RCH 1000 socket nonirradiated articulating with a crude COP femoral head; (3) RCH 1000 socket irradiated with 100 Mrad articulating with an alumina femoral head; (4) ultra high molecular weight polyethylene (molecular weight, 5-6 x 10(6)) socket articulating with an alumina femoral head; and (5) ultrahigh molecular weight polyethylene socket articulating with a stainless steel femoral head (T-28) were 0.06, 0.30, 0.06, 0.1 and 0.25 mm/year, respectively, in the authors' clinical cases. Alumina femoral heads were effective in decreasing wear of the polyethylene socket. However, the wear rates of gamma-irradiated sockets articulating with alumina and with metal femoral heads wear very low and were not different from each other. Regarding the relationship between wear rate and the thickness of the ultra high molecular weight polyethylene socket articulating with a 28 mm alumina femoral head, on radiographs, average wear rates of socket thicknesses of 7, 8, 9, 10 and 11 mm were 0.14, 0.15, 0.12, 0.06, and 0.08 mm/year, respectively. On measuring retrieved prostheses, average wear rates of 7, 8, 9 and 11 mm thickness sockets were 0.2, 0.19, 0.14, and 0.1 mm/year, respectively. The wear of sockets has been proven to be minimal in alumina femoral heads articulating with ultrahigh molecular weight polyethylene sockets thicker than 10 mm.

Hydroxyapatite granules interposed at bone-cement interface in total hip replacements: histological study of retrieved specimens

The effect of hydroxyapatite (HA) granules interposed between bone and polymethylmethacrylate (PMMA) bone cement in total hip replacement was histologically evaluated. The technique consisted of smearing 2-5 g of HA granules (straight phi = 100-300 microm) onto the bone surface just before cementing. Four specimens containing well-fixed bone-cement interface were retrieved at 1, 2, 6, and 10 years postoperatively and examined with back-scattered electron microscopy and light microscopy. The majority of HA granules were incorporated into remodeled trabeculae, and highly convoluted bone-cement interface was maintained up to 10 years. The presence of active remodeling in the adjacent bone was observed. There were no significant inflammatory or foreign body reactions against interposed HA granules. In one specimen retrieved from a patient with rheumatoid arthritis, bone formation around HA granules was limited after 1 year. These results have provided histological evidence for the significantly reduced incidence of radiolucent lines in total hip replacement with this cementing technique, reported elsewhere.

Glycine Polymerization on Oxide Minerals

It has long been suggested that mineral surfaces played an important role in peptide bond formation on the primitive Earth. However, it remains unclear which mineral species was key to the prebiotic processes. This is because great discrepancies exist among the reported catalytic efficiencies of minerals for amino acid polymerizations, owing to mutually different experimental conditions. This study examined polymerization of glycine (Gly) on nine oxide minerals (amorphous silica, quartz, α-alumina and γ-alumina, anatase, rutile, hematite, magnetite, and forsterite) using identical preparation, heating, and analytical procedures. Results showed that a rutile surface is the most effective site for Gly polymerization in terms of both amounts and lengths of Gly polymers synthesized. The catalytic efficiency decreased as rutile > anatase > γ-alumina > forsterite > α- alumina > magnetite > hematite > quartz > amorphous silica. Based on reported molecular-level information for adsorption of Gly on these minerals, polymerization activation was inferred to have arisen from deprotonation of the NH3+ group of adsorbed Gly to the nucleophilic NH2 group, and from withdrawal of electron density from the carboxyl carbon to the surface metal ions. The orientation of adsorbed Gly on minerals is also a factor influencing the Gly reactivity. The examination of Gly-mineral interactions under identical experimental conditions has enabled the direct comparison of various minerals' catalytic efficiencies and has made discussion of polymerization mechanisms and their relative influences possible Further systematic investigations using the approach reported herein (which are expected to be fruitful) combined with future microscopic surface analyses will elucidate the role of minerals in the process of abiotic peptide bond formation.

The optimum dose of gamma radiation-heavy doses to low wear polyethylene in total hip prostheses

Wear volume, surface area and coefficient of friction of UHMWPE cup crosslinked with gamma radiation of 0, 50, 75, 100, 125, 150 and 200 Mrad sliding against an alumina ball were measured using a sphere-on-flat reciprocating type tribology testing machine. The effects of gamma radiation were scarcely observed in coefficient of friction. The coefficient of friction under lubricated (distilled water) and non-lubricated testing conditions was 0.08 to 0.12 and 0.20 to 0.25, respectively. The wear volume of UHMWPE with radiation of 50 Mrad, 75 to 150 Mrad, and 200 Mrad was 70 to 80%, 18 to 25%, and 12 to 15%, respectively, in comparison to non-irradiated specimens. Elongation and tensile strength of UHMWPE with radiation of 100 Mrad decreased to 6%, and 50% of that without radiation, respectively. The hardness increased with increase of the radiation dose. From several kinds of tribological findings, mechanical strength tests, and studies of long-term clinical findings, it is concluded that approximately 200 Mrad is the optimum dose of gamma radiation for clinical use in total hip prostheses.

THA with hydroxyapatite granules at cement-bone interface: 15- to 20-year results

To augment cement-bone bonding, we interposed hydroxyapatite granules at the cement-bone interface (bioactive bone cement technique). Hydroxyapatite granules (2-3 g) were smeared on the bone surface of the acetabulum and femur just before cementing. We used porous hydroxyapatite granules 300 to 500 microm in diameter from 1986 to 1988 (first generation) and granules 100 to 300 microm in diameter from 1989 to 1991 (second generation). We followed 151 patients (222 hips) in the first generation and 170 patients (252 hips) in the second generation. The minimum followup was 15 years (mean, 17.3 years; range, 15-20 years). Radiolucent lines or spaces less than 1 mm were observed in four hips (1.8%) in the first generation and in 15 hips (6.2%) in the second generation. Osteolysis was observed in one hip (0.5%) in the first generation and six hips (1.6%) in the second generation. We observed loosening in two cups (0.8%) in the second generation. The long-term clinical results suggest the interface bioactive bone cement technique combined with our other techniques results in low incidences of radiolucent lines (spaces) and osteolysis, and may increase the longevity of cemented THA. The data suggest the larger hydroxyapatite granules performed better than smaller ones.

LEVEL OF EVIDENCE

Level III, therapeutic retrospective cohort series. See the Guidelines for Authors for a complete description of levels of evidence.

Microwear phenomena of ultrahigh molecular weight polyethylene cups and debris morphology related to gamma radiation dose in simulator study

Ultrahigh molecular weight polyethylene (PE) cups with 0, 2.5, 50, 100, and 150 Mrad radiation treatments were run in a hip simulator for comparison of the microwear phenomena on the cup surfaces with the corresponding debris morphology. In general, the size and frequency of the PE surface fibrils and the size of the retrieved PE debris decreased with increasing radiation dose. The fibril size and shape on the cup surfaces were well correlated with the radiation dose. The fibrillar shape and size were found to be proportional to the square root of the radiation dose. However, the trend for size and shape factors of the wear debris related to the radiation dose was weak at best. Thus, the morphology of the PE fibrils on the cup surfaces was more sensitive to variations in the radiation dose than the actual wear debris. The wear response appeared to be a three-step process, which was dependent on the formation of surface nodules or ripples, the teasing out of surface fibrils, and the toughness of the PE matrix in releasing a wear fibril to form a debris particle. The tougher PE became with increasing radiation dose, the harder it was for the PE fibrils to break out into wear particles.

Study of retrieved acetabular sockets made from high-dose, cross-linked polyethylene

Although ultra-high molecular weight polyethylene (UHMWPE) has stable chemical properties, chemical degradation, such as oxidation reaction, progresses with long-term clinical use. The purpose of this study was to investigate the change in properties of polyethylene (PE) in vivo by examining retrieved UHMWPE sockets and high-dose, cross-linked PE (100 Mrad PE) sockets. Twenty retrieved sockets (including 2 100 Mrad PE sockets), which were implanted from 1970 to 1996, were used for analysis. The oxidation index of 100 Mrad PE sockets was approximately the same as that of the normal UHMWPE sockets in worn areas. These long-term clinical results indicate that 100 Mrad PE is sufficiently stable for clinical use and that free radicals would not affect progression of oxidation significantly.

HYDROXYAPATITE IN REVISION OF TOTAL HIP REPLACEMENTS WITH MASSIVE ACETABULAR DEFECTS

Hydroxyapatite (HA) granules of 100 to 300 μm, 0.9 to 1.2 mm and 3.0 to 5.0 mm were mixed in a ratio of 10:45:45 and packed into massive bone deficiencies in revision operations for total hip arthroplasty. We did not use additional graft or cup support for deficiencies of the lateral and medial wall. The procedure was carried out in 40 hips between 1986 and 1992.

The radiographic spaces seen at the interface between HA and bone immediately after surgery disappeared within three months. Some spaces appeared between HA granules near the bone in the lateral part of two joints, and three sockets migrated in patients with severe segmental and cavitary deficiencies. Direct bonding of HA to bone was observed radiologically without morphological changes, except in the three joints with migration. All patients could walk without pain but the three with definite loosening needed crutches.

Quantitative rates of in vivo bone generation for Bioglass and hydroxyapatite particles as bone graft substitute

Rates of in vivo bone generation were characterized by point-counting analysis of particulate Bioglass and synthetic hydroxyapatite (HA) in rabbit femora. New bony tissue was observed in approximately 20% of the image area around Bioglass particles at 1 wk, and the degree of trabecular bone growth increased with time. The interparticle space of Bioglass was filled by 80% bonding bone between 6 and 12 wk. The rate constants of trabecular bone growth in the presence of Bioglass were approximately 10.9x10(-3) d(-1) at the periphery of the implantation site. HA particles led to smaller rate constants of approximately 4.6x10(-3) d(-1) at the periphery, and the HA particles developed very small amounts of bridging bone. The quantitative rate of bone growth matched well with previously measured bioactive indices of the materials.

Mechanical and chemical bonding of artificial joints

Biomaterials which create chemical and mechanical bonds with tissue, i.e. (1) non-porous materials with or without a hydroxyapatite coating, (2) porous titanium alloy (beads) with or without a hydroxyapatite coating, (3) alpha-tricalcium phosphate bioactive bone cement and PMMA cement, and (4) interface bioactive bone cement made by interposing hydroxyapatite granules between polymethylmethacrylate cement and the bone, were used in animal experiments and clinical applications. The common problem with cementless fixation is that some patients complain of slight pain on weight-bearing, because a complete initial fixation is not obtained and micro-movement of the component may occur. Porous metal with hydroxyapatite coating is found to be better than that without coating for producing earlier and stronger fixation, and problems with fatigue and peeling of hydroxyapatite from the base metal are eliminated when the beads are coated with hydroxyapatite. As hydroxyapatite bonds chemically to the bone, pain on weight-bearing due to micromovement should never occur. In order to obtain long-term and stable fixation for severe bony atrophy, bioactive bone cement or interface bioactive bone cement (interposing hydroxyapatite at the bone interface) is desirable.

The effects of polyethylene cup thickness on wear of total hip prostheses

The wear rate of the ultrahigh molecular weight polyethylene cups in combination with a 28 mm alumina femoral head was measured on the radiographs of patients without any complications, and on cups retrieved due to slight loosening of the prosthesis or due to late infection between bone and components. The wear rate on the radiographs did not include the initial wear, but the wear rate on the retrieved cups did include the initial wear. The wear rate on the retrieved cups was higher, by 50%, than that measured on the radiographs. In both cases, the thicker the polyethylene cups, the lower was the wear rate measured. The average wear rate of the 7 and 8 mm thick cups was about twice that of cups 10 and 11 mm thick. From these results, we conclude that polyethylene cups more than 11 mm thick should be used.