Wear of polyethylene is associated with aseptic loosening of orthopaedic implants and has been observed in hip and knee prostheses and anatomical implants for the shoulder. The reversed shoulder prostheses have not been assessed as yet. We investigated the volumetric polyethylene wear of the reversed and anatomical Aequalis shoulder prostheses using a mathematical musculoskeletal model. Movement and joint stability were achieved by EMG-controlled activation of the muscles. A non-constant wear factor was considered. Simulated activities of daily living were estimated from in vivo recorded data. After one year of use, the volumetric wear was 8.4 mm. 3. for the anatomical prosthesis, but 44.6 mm. 3. for the reversed version. For the anatomical prosthesis the predictions for contact pressure and wear were consistent with biomechanical and clinical data. The abrasive wear of the polyethylene in reversed prostheses should not be underestimated, and further analysis, both experimental and clinical, is required

Introduction. Durable bone fixation of uncemented porous-coated acetabular cups can be observed at a long-term, however, polyethylene (PE) wear and osteolysis may affect survivorship. Accurate wear measurements correlated with clinical data may offer unique research information of clinical interest about this highly debated issue. Objetive. We assessed the clinical and radiological outcome of a single uncemented total hip replacement (THR) system after twenty years analysing polyethylene wear and the appearance of osteolysis. Materials and Methods. 82 hips implanted between 1992 and 1995 were prospectively evaluated. The mean follow-up was 20.6 years (range, 18 to 23). A hemispherical porous-coated acetabular cup matched to a proximally hydroxyapatite-coated anatomic stem and a 28 mm standard PE liner, sterilised by gamma irradiation in air, was used in all hips. Radiological position and the possible appearance of loosening and osteolysis were recorded over time. Penetration of the prosthetic head into the liner was measured by the Roentgen Monographic Analysis (ROMAN) Tool at 6 weeks, 6 months, one year and yearly thereafter. Results. Six cups were revised due to wear and four due to late dislocation. All cups were radiographically well-fixed and all stems showed radiographic ingrowth. Six un-revised hips showed osteolysis on the acetabular side and two on the proximal femoral side. Creep at one year was 0.30 (±0.23) mm. Mean total femoral head penetration was 1.23 mm at 10 years, 1.52 mm at 15 years and 1.92 mm at 23 years. Overall mean wear was 0.12 (± 0.1) mm/year and 0.09 (±0.06) mm/year after the creep period. Mean wear was 0.08 (± 0.06) mm/year in hips without osteolysis and 0.14 (±0.03) mm/year in revised hips or with osteolysis (p<0.001). Conclusions. Although continued durable fixation can be observed with a porous-coated cups and a proximally hydroxyapatite-coated anatomic stem, true wear continues to increase at a constant rate over time. PE wear remains as the main reason for revision surgery and osteolysis in uncemented THR and does not stop after twenty years

Polyethylene wear of joint replacements can cause severe clinical complications, including; osteolysis, implant loosening, inflammation and pain. Wear simulator testing is often used to assess new designs, but it is expensive and time consuming. It is possible to predict the volume of polyethylene implant wear from finite element models using a modification of Archard's classic wear law [1–2]. Typically, linear elastic isotropic, or elasto-plastic material models are used to represent the polyethylene. The purpose of this study was to investigate whether use of a viscoelastic material model would significantly alter the predicted volumetric wear of a mobile-bearing unicompartmental knee replacement. Tensile creep-recovery experiments were performed to characterise the creep and relaxation behaviour of the polyethylene (moulded GUR 4150 samples machined to 180×20×1 mm). Samples were loaded to 3 MPa stress in 4 minutes, and then held for 6 hours, the tensile stress was removed and samples were left to relax for 6 hours. The mechanical test data was used fit to a validated three–dimensional fractional Maxwell viscoelastic constitutive material model [3]. An explicit finite element model of a mobile–bearing unicompartmental knee replacement was created, which has been described previously [4]. The medial knee replacement was loaded to 1200 N over a period of 0.2 s. The bearing was meshed using quadratic tetrahedral elements (1.5 mm seeding size based on results of a mesh convergence study), and the femoral component was represented as an analytical rigid body. Wear predictions were made from the contact stress and sliding distance using Archard's law, as has been described in the literature [1–2]. A wear factor of 5.24×10. −11. was used based upon the work by Netter et al. [2]. All models were created and solved using ABAQUS finite element software (version 6.14, Simulia, Dassault Systemes). The fractional viscoelastic material model predicted almost twice as much wear (0.119 mm. 3. /million cycles) compared to the elasto-plastic model (0.069 mm. 3. /million cycles). The higher wear prediction was due to both an increased sliding distance and higher contact pressures in the viscoelastic model. These preliminary findings indicate the simplified elasto-plastic polyethylene material representation can underestimate wear predictions from numerical simulations. Polyethylene is known to be a viscoelastic material which undergoes creep clinically, and it is not surprising that it is necessary to represent that viscoelastic behaviour to accurately predict implant wear. However, it does increase the complexity and run time of such computational studies, which may be prohibitive

We have reviewed 70 patients with bilateral simultaneous total hip arthroplasties to determine the rate of failure and to compare polyethylene wear and osteolysis between an implant with a cobalt-chrome head and Hylamer liner with that of a zirconia head and Hylamer liner. The mean thickness of the polyethylene liner was 11.0 mm (8.8 to 12.2) in the hip with a zirconia head and 10.7 mm (8.8 to 12.2) in that with a cobalt-chrome head. At follow-up at 6.4 years no acetabular or femoral component had been revised for aseptic loosening and no acetabular or femoral component was loose according to radiological criteria in both the cemented and cementless groups. The mean rate of linear wear and annual wear rate were highest in the 22 mm zirconia femoral head (1.25 mm (SD 1.05) and 0.21 mm (SD 0.18), respectively) and lowest in the 22 mm cobalt-chrome femoral head (0.70 mm (SD 0.39) and 0.12 mm (SD 0.07), respectively). The mean volumetric wear was highest in the 28 mm zirconia femoral head (730.79 mm. 3. ) and lowest in the 22 mm cobalt-chrome femoral head (264.67 mm. 3. ), but if the results were compared by size of the femoral head and type of material there was no statistical difference (p > 0.05). Sequential measurements of annual wear showed that the zirconia femoral head had a relatively higher rate of penetration than the cobalt-chrome head over the first three years; thereafter the rate of wear was reduced and compared favourably with that of cobalt-chrome heads. There was a statistically significant relationship between the wear of the polyethylene liner and the age of the patient, male gender and the degree of abduction angle of the cup, but not diagnosis, weight, hip score, range of movement, or amount of anteversion. Osteolysis was identified on both sides of the acetabulum in six patients (9%). Of 12 hips with acetabular osteolysis, six had a 28 mm cobalt-chrome femoral head and the remaining six a 28 mm zirconia head. Osteolysis was observed in zones 1A and 7A of the femur in two hips (3%) with a 28 mm zirconia head (cemented hip) and in four (6%) with a 28 mm cobalt-chrome femoral head (cementless hip). Our findings suggest that although the performance of a zirconia femoral head with a Hylamer liner was not statistically different from that of a cobalt-chrome femoral head and Hylamer liner, there was a trend for the zirconia head to be worse than the cobalt-chrome femoral head

Summary. In this study we validate that weight-bearing images are needed for accurate polyethylene liner wear measurement in total knee prostheses by measuring the difference in minimum joint space width between weight-bearing and non-weight-bearing RSA views. Introduction. Recent studies show that Model-based Roentgen Stereophotogrammetric Analysis is superior to the conventional in vivo measurements of polyethylene liner wear in total knee prostheses. Although it is generally postulated that weight-bearing (standing) views are required to detect liner wear, most RSA images are acquired in non-weight-bearing (supine) view for practical reasons. Therefore, it would be of interest to know if supine views would be sufficient for measuring TKA liner wear, defined as a change in minimum joint space width (mJSW). As a difference in mJSW between weight-bearing and non-weight-bearing RSA images has never been validated, the aim of this study is to compare the outcome of in vivo measurements of mJSW in total knee prosthesis when conducted with weight-bearing and non-weight-bearing RSA views. Method. We selected the first 16 patients with a Triathlon total knee prosthesis from a clinical study for which subsequently a weight-bearing eand a non-weight-bearing RSA image pair were acquired at one year follow up. For both images the mJSW and the corresponding contact point locations in terms of mediolateral (ML) and anterioposterior (AP) coordinates were measured. In addition, the ML stability was scored to assess knee laxity. The size of the mJSW difference between non-weight-bearing and weight-bearing views was determined and a regression analysis was conducted to investigate the effect of knee laxity to this difference, while correcting for differences between the contact point locations. Results. On average, the measured mJSW was 0.22 mm larger in the non-weight-bearing views (T-test, p < 0.05). The standard deviation of the difference was 0.22 mm. The regression analysis showed that a difference in the ML position of the contact location was an important covariate (beta = 0.255±0.054, Wald 95% CI). 13 patients had a high ML stability (< 5 deg) and three had a medium stability (5–10 deg). The regression analysis showed that on average patients with medium ML stability had a 0.17 mm larger difference in mJSW than patients with a high ML stability. Conclusion. The study shows that the mJSW is larger in non-weight-bearing views. The differences found are clinically relevant, as wear rates in practice are as small as 0.1 mm per year. Hereby it is validated that weight-bearing RSA images are more capable of detecting the mJSW in total knee prostheses. The size of the difference in mJSW between the views seems to be in relation with the knee laxity

Nanometre-sized particles of ultra-high molecular weight polyethylene have been identified in the lubricants retrieved from hip simulators. Tissue samples were taken from seven failed Charnley total hip replacements, digested using strong alkali and analysed using high-resolution field emission gun-scanning electron microscopy to determine whether nanometre-sized particles of polyethylene debris were generated in vivo. A randomised method of analysis was used to quantify and characterise all the polyethylene particles isolated.

We isolated nanometre-sized particles from the retrieved tissue samples. The smallest identified was 30 nm and the majority were in the 0.1 μm to 0.99 μm size range. Particles in the 1.0 μm to 9.99 μm size range represented the highest proportion of the wear volume of the tissue samples, with 35% to 98% of the total wear volume comprised of particles of this size. The number of nanometre-sized particles isolated from the tissues accounted for only a small proportion of the total wear volume. Further work is required to assess the biological response to nanometre-sized polyethylene particles.

INTRODUCTION

Highly cross linked polyethylenes (HXPE) have to be treated thermally after irradiation to eliminate residual free radicals. By adding vitamin E in the polyethylene powder a post-irradiation thermal treatment is not necessary.

In this review the correlation between the intrinsic properties and the long-term stability of Vitelene® as a high performance material for artificial hip articulation will be displayed.

In this prospective, randomised study, we have compared the wear rate of cemented, acetabular polyethylene cups articulating with either a 22 mm or a 32 mm cobalt-chromium head. We evaluated 89 patients who had a total of 484 radiographs. The mean follow-up period was 71.4 months (SD 29.1). All the radiographs were digitised and electronically measured.

The linear wear rate was significantly higher during the first two years and decreased after this period to a constant value. We suggest that this is partly due to a ‘run-in’ process caused by irregularities between surfaces of the cup and head and an initial plastic deformation of the polyethylene. The mean volumetric wear was 120.3 mm³/year for the 32 mm head, which was significantly higher than the 41.5 mm³/year for the 22 mm heads. The mean linear wear rate was not significantly different. We were, however, unable to find radiological signs of osteolysis in the patients who had higher wear rates.

Abstract. Objectives. Total hip replacement (THR) is one of the most successful and cost-effective interventions in orthopaedic surgery. Dislocation is a debilitating complication of THR and managing an unstable THR constitutes a significant clinical challenge. Stability in THR is multifactorial and is influenced by surgical, patient and implant related factors. It is established that larger diameter femoral heads have a wider impingement-free range of movement and an increase in jump distance, both of which are relevant in reducing the risk of dislocation. However, they can generate higher frictional torque which has led to concerns related to increased wear and loosening. Furthermore, the potential for taper corrosion or trunnionosis is also a potential concern with larger femoral heads, particularly those made from cobalt-chrome. These concerns have meant there is hesitancy among surgeons to use larger sized heads. This study presents the comparison of clinical outcomes for different head sizes (28mm, 32mm and 36mm) in primary THR for 10,104 hips in a single centre. Methods. A retrospective study of all consecutive patients who underwent primary THR at our institution between 1st April 2003 and 31st Dec 2019 was undertaken. Institutional approval for this study was obtained. Demographic and surgical data were collected. The primary outcome measures were all-cause revision, revision for dislocation, and all-cause revision excluding dislocation. Continuous descriptive statistics used means, median values, ranges, and 95% confidence intervals where appropriate. Kaplan-Meier survival curves were used to estimate time to revision. Cox proportional hazard regression analysis was used to compare revision rates between the femoral head size groups. Adjustments were made for age at surgery, gender, primary diagnosis, ASA score, articulation type, and fixation method. Results. 10,104 primary THRs were included; median age 68.6 years with 61.5% females. A posterior approach was performed in 71.6%. There were 3,295 hips with 28 mm heads (32.6%), 4,858 (48.1%) with 32 mm heads and 1,951 (19.3%) with 36 mm heads. Overall rate of revision was 1.7% with the lowest rate recorded for the 36mm group (2.7% vs. 1.3% vs. 1.1%). Cox regression analysis showed a decreased risk of all-cause revision for 32mm & 36mm head sizes as compared to 28mm; this was statistically significant for the 32mm group (p = 0.01). Risk of revision for dislocation was significantly reduced in both 32mm (p = 0.03) and 36mm (p = 0.03) head sizes. Analysis of all cause revision excluding dislocation showed no significant differences between head sizes. Conclusion. There was a significantly reduced risk of revision for all causes, but particularly revision for dislocation with larger head sizes (36mm & 32mm vs. 28mm). Concerns regarding increased risk of early revision for aseptic loosening, polyethylene wear or taper corrosion with larger heads appear to be unfounded in this cohort of 10,104 patients with a mean of 6.0-year follow-up. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Summary Statement. CXCR4 gene and protein expression is regulated in a dose and time-dependent manner by metallic wear debris but not polyethylene wear debris in vitro and in vivo. Introduction. Progressive osteolysis leading to aseptic loosening among metal-on-metal (MoM) total hip arthroplasties (THA's), and adverse reactions to metallic debris (ARMD) are increasing causes for concern among existing patients who have been implanted with MoM hip replacements. Close surveillance of these patients is necessary and difficulties lie in early detection as well as differentiating low-grade infection from ARMD in the early stages. Several inflammatory markers have been investigated in this context, but to date, none is specific with regards to the offending material. In earlier studies, it has been shown that osteoblastic phenotypes and differentiation are regulated by different types of wear particles. Methods. In vitro experiments were performed using MG63 and SaOs-2 osteoblast-like cells co-cultured with increasing concentrations of metallic (Co-35Ni-20Cr-10Mo and Co-28Cr-6Mo) and polyethylene (UHMWPE-GUR1020) particles simulating periprosthetic wear debris. Real-time Polymerase Chain Reaction (RT-PCR) and Western Blotting were used to quantify gene and protein expression of CXCR4. The expression of TNF-a and the effects of AMD3100 on both CXCR4 and TNF-a expression among these cells was also investigated. Immunohistochemical techniques were used to investigate the in-vivo expression of CXCR4 in retrieval tissues obtained from 2 cohorts of failed metal-on-metal and ceramic-on-polyethylene THA's. Results. In-vitro RT-PCR and experiments demonstrated a dose-dependent increase in CXCR4 mRNA (7.5 fold for MG63 and 4.0 fold for SaOs-2 cells) among cells co-cultured with metal alloy particles. Western blotting also showed a time-dependent increase in protein expression of CXCR4. No regulatory effects on CXCR4 gene expression were seen among cells co-cultured with UHMWPE particles. The attempted blockade of CXCR4 by it's known competitive receptor agonist AMD3100 (bicyclam) led to a significant inhibition of metal particle induced TNF-a mRNA expression. In-vivo immunohistochemical data from the 2 cohorts of patients with failed THA's showed CXCR4 positivity among 83% of patients with metal-on-metal hip replacements but none among ceramic-on-polyethylene hip replacements. Discussion/Conclusion. CXCR4, the chemokine receptor for the chemokine SDF-1 (stromal cell derived factor-1), has been shown to play a pivotal role in bone metastasis, inflammatory and autoimmune conditions but has not been investigated in the context of periprosthetic osteolysis in failed joint replacements. Our in-vivo and in-vitro findings collectively suggest that the CXCR4 chemokine is specifically upregulated in a dose and time-dependent manner in the presence of metallic (cobalt-chrome) wear debris but not by polyethylene wear debris. The CXCR4 chemokine receptor may be a selective and specific biomarker for progressive osteolysis seen in failed MoM hip replacements and this phenomenon could potentially have a translational effect on the practice of orthopaedic surgery. Further research is needed to evaluate the interactions of CXCR4 with osteoclast activation and signalling pathways

Total ankle replacement (TAR) is a substitute to ankle fusion, replacing the degenerated joint with a mechanical motion-conserving alternative. Compared with hip and knee replacements, TARs remain to be implanted in much smaller numbers, due to the surgical complexity and low mid-to-long term survival rates. TAR manufacturers have recently explored the use of varying implant sizes to improve TAR performance. This would allow surgeons a wider scope for implanting devices for varying patient demographics. Minimal pre-clinical testing has been demonstrated to date, while existing wear simulation standards lack definition. Clinical failure of TARs and limited research into wear testing defined a need for further investigation into the wear performance of TARs to understand the effects of the kinematics on varying implant sizes. Six medium and six extra small BOX® (MatOrtho) TARs will be tested in a modified knee simulator for 5 million cycles (Mc). The combinations of simulator inputs that mimic natural gait conditions were extracted from ankle kinematic profiles defined in previous literature. The peak axial load will be 3.15 kN, which is equivalent to 4.5 times body weight of a 70kg individual. The flexion profile ranges from 15° plantarflexion to 15° dorsiflexion. Rotation about the tibial component will range from −2.3° of internal rotation to 8° external rotation, while the anterior/posterior displacement will be 7mm anterior to −2mm posterior throughout the gait cycle. The components will be rotated through the simulation stations every Mc to account for inter-station variability. Gravimetric measurements of polyethylene wear will be taken at every Mc stage. A contact profilometer will also be used to measure average surface roughness of each articulating surface pre-and-post simulation. The development of such methods will be crucial in the ongoing improvement of TARs, and in enhancing clinical functionality, through understanding the envelope of TAR performance

Total knee arthroplasty is a well established treatment for degenerative joint disease with good clinical results. However, complications may occur due to a biological response to polyethylene wear particles, leading to osteolysis and aseptic loosening, as well as local and systemic hypersensitivity reactions triggered by metal ions and particles such as chromium, cobalt and molybdenum. Moreover, there is an increasing demand on the performance of these implants, as this treatment is also performed in heavier, younger and middle-aged adults who have a significant physical activity and higher life expectancy. The purpose of the following study was to compare the wear characteristics and performance of a zirconium nitride (ZrN) coated knee implant, designed for patients with metal ion hypersensitivity, against the clinically established cobalt-chromium (CoCr) version under a high demanding activities wear simulation. Medium size AS Columbus® DD (Aesculap AG, Tuttlingen, Germany) femoral and tibial components with a ZrN surface were tested in comparison with the cobalt-chromium version Columbus® DD. For both groups, ultra-high-molecular weight polyethylene (UHMWPE) gliding surfaces (size T3, high 10 mm) were used. Wear simulation was performed on a load controlled 4 station knee wear simulator (EndoLab GmbH, Thansau, Germany) capable of reproducing loads and movement of daily activities measured in vivo (Bergmann et al, 2014) on 8 patients and normalized to a patient weight of 100 kg (Schwiesau et al, 2014). The load profiles were applied for 5 million cycles in a combination of 40% stairs up, 40% stairs down, 10% level walking, 8% chair raising and 2% deep squatting. Test serum was changed every 0.5 million cycles and all the components were cleaned and analyzed according to ISO 14243-2:2009(E). The gliding surfaces were evaluated for gravimetric wear and wear patterns, femur components analyzed for scratches and the test medium analyzed for metal ion concentration (cobalt, chromium, molybdenum and zirconium) using ICP-MS according to ISO 17294-2. The present study showed a wear rate reduction for the ZrN group (1.01 ± 0.29 mg/million) in comparison with the CoCr group (2.40 ± 1.18 mg/million cycles). The articulation surface of the ZrN coated femurs remained polished after the testing period, whereas the uncoated femurs showed wear scratches. Furthermore, the metal ion release from the ZrN coated implants was reduced orders of magnitude in comparison with the CoCr implants through the entire test. These results demonstrate the efficiency of ZrN coated knee implants to reduce wear as well as to prevent metal ion release in the knee joint

A principle of Total Knee Arthroplasty (TKA) is to achieve a neutral standing coronal alignment of the limb (Hip Knee Ankle (HKA) angle) to reduce risks of implant loosening, reduce polyethylene wear, and optimise patella tracking. Several long-term studies have questioned this because the relationship between alignment and implant survivorship is weaker than previously reported. We hypothesize standing HKA poorly predicts implant failure because it does not predict dynamic HKA, dynamic adduction moment, and loading of the knee during gait. Therefore, the aim of our study is to assess the relationship between the standing (or static) and the dynamic (gait activity) HKAs. We performed a prospective study on a cohort of 35 patients (35 knees) who were treated with a posterior-stabilized TKA for primary osteoarthritis between November 2012 and January 2013. Three months after surgery each patient had a standardized digital full-leg coronal radiographs and was classified as neutrally aligned TKA (17 patients), varus aligned (9 patients), and valgus aligned (4 patients). Patients then performed a gait analysis for level walking and dynamic HKA and adduction moment during the stance phase of gait were measured. We found standing HKA having a moderate correlation with the peak dynamic varus (r=0.318, p=0.001) and the mean and peak adduction moments (r=0.31 and r=-0.352 respectively). In contrast we did not find a significant correlation between standing HKA and the mean dynamic coronal alignment (r=0.14, p=0.449). No significant differences were found for dynamic frontal parameters (dynamic HKA and adduction moment) between patients defined as neutrally aligned or varus aligned. In our practice, the standing HKA after TKA was of little value to predict dynamic behaviour of the limb during gait. These results may explain why standing coronal alignment after TKA may have limited influence on long term implant fixation and wear

We retrieved 159 femoral heads at revision surgery to determine changes in surface configuration. Macroscopic wear of the head was observed in three bipolar hip prostheses as a result of three-body wear. There was a considerable change in surface roughness in the internal articulation of bipolar hip prostheses. Roughness in alumina heads was almost the same as that in new cobalt-chromium heads. The annual linear wear rate of polyethylene cups with alumina heads was less than that of cups with cobalt-chromium alloy heads. Polyethylene wear was increased in the prostheses which had increased roughness of the head

Introduction. Ceramic-on-ceramic couplings are an attractive alternative bearing surface to eliminate or reduce problems related to polyethylene wear debris. Past disappointing experiences with alumina-ceramic bearings have led to many improvements in the manufacture and the design of ceramic implants. The purpose of this study was to report the results of contemporary alumina-on-alumina total hip arthroplasties (THAs) with regard to wear, osteolysis, and fracture of the ceramic in patients with osteonecrosis of the femoral head. Methods. Between February 1998 and October 2003, 365 patients (432 hips) with osteonecrosis of the femoral head underwent cementless total hip arthroplasty using contemporary alumina bearings. There were 243 men and 122 women who had a mean age at the time of index operation of 43 years (range, 18 to 65 years). They were evaluated clinically and radiographically at 5 to 10 years (average, 7 years). During the follow-up, special regards were addressed to wear, periprosthetic osteolysis and ceramic failure. Results. The mean Harris hip score was 94 points at the latest follow-up evaluation. All of the prostheses had radiographic evidence of a bone ingrowth. No implant was loosened radiographically and no implant was revised. Ceramic wear was not detectable in 83 hips where differentiation of the femoral head from the cup was possible on radiographs. Periprosthetic osteolysis was observed in no hips. Fracture of the alumina femoral head occurred in 5 hips, and fracture of the alumina liner occurred in 5 hips using sandwich-type ceramic liners. Conclusion. The results of contemporary alumina-on-alumina THAs with a metal-backed socket and a cementless stem were encouraging in young, active patients. We believe that these improved alumina-on-alumina bearing implants offer a promising option for younger active patients

We compared wear particles from two different designs of total hip arthroplasty with polycrystalline alumina-ceramic bearings of different production periods (group 1, before ISO 6474: group 2, according to ISO 6474). The neocapsules and interfacial connective tissue membranes were retrieved after mean implantation times of 131 months and 38 months, respectively. Specimen blocks were freed from embedding media, either methylmethacrylate or paraffin and digested in concentrated nitric acid. Particles were then counted and their sizes and composition determined by SEM and energy-dispersive x-ray analysis (EDXA). The mean numbers and sizes of most alumina wear particles did not differ for both production periods, but the larger sizes of particle in group 1 point to more severe surface destruction. The increased metal wear in group 2 was apparently due to alumina-induced abrasion of the stems. In this study the concentrations of particles in the periprosthetic tissues were 2 to 22 times lower than those observed previously with polyethylene and alumina/polyethylene wear couples

Summary Statement. Fretting and corrosion has been identified as a clinical problem in modular metal-on-metal THA, but remains poorly understood in modern THA devices with polyethylene bearings. This study investigates taper damage and if this damage is associated with polyethylene wear. Introduction. Degradation of modular head-neck tapers was raised as a concern in the 1990s (Gilbert 1993). The incidence of fretting and corrosion among modern, metal-on-polyethylene and ceramic-on-polyethylene THA systems with 36+ mm femoral heads remains poorly understood. Additionally, it is unknown whether metal debris from modular tapers could increase wear rates of highly crosslinked PE (HXLPE) liners. The purpose of this study was to characterise the severity of fretting and corrosion at head-neck modular interfaces in retrieved conventional and HXLPE THA systems and its effect on penetration rates. Patients & Methods. 386 CoCr alloy heads from 5 manufacturers were analyzed along with 166 stems (38 with ceramic femoral heads). Metal and ceramic components were cleaned and examined at the head taper and stem taper by two investigators. Scores ranging from 1 (mild) to 4 (severe) were assigned in accordance with the semi-quantitative method adapted from a previously published technique. Linear penetration of liners was measured using a calibrated digital micrometer (accuracy: 0.001 mm). Devices implanted less than 1 year were excluded from this analysis because in the short-term, creep dominates penetration of the head into the liner. Results. The majority of the components were revised for instability, infection, and loosening. Mild to severe taper damage (score ≥2) was found in 77% of head tapers and 52% of stem tapers. The extent of damage was correlated to implantation time at the head taper (p=0.0004) and at the stem taper (p=0.0004). Damage scores were statistically elevated on CoCr heads than the matched stems (mean score difference=0.5; p<0.0001) and the two metrics were positively correlated with each other (ρ=0.41). No difference was observed between stem taper damage and head material (CoCr, ceramic) (p=0.56), nor was a correlation found between taper damage and head size (p=0.85). The penetration rate across different formulations of HXLPE was not found to be significantly different (p=0.07), and therefore grouped together for further analysis. Within this cohort, penetration rate was not found to be associated with head size (p=0.08) though a negative correlation with implantation time was noted (ρ=−0.35). When analyzed along with taper damage scores, a correlation was not observed between head taper damage scores and HXLPE penetration rates (p=0.51). Discussion. The results of this study do not support the hypothesis that 36+ mm ceramic or CoCr femoral heads articulating on HXLPE liners are associated with increased risk of corrosion among HXLPE liners when compared with smaller diameter heads. A limitation of this study is the semi-quantitative scoring technique, heterogeneity of the retrieval collection and short implantation time of the larger diameter heads. Because corrosion may increase over time in vivo, longer-term follow-up, coupled with quantitative taper wear measurement, will better assess the natural progression of taper degradation in modern THA bearings

We examined stainless-steel, cobalt-chrome, titanium and alumina and zirconia ceramic femoral heads retrieved at revision surgery. All the heads had articulated against ultra-high-molecular-weight-polyethylene (UHMWPE) acetabular cups. We studied the simulation of third-body damage and the wear of UHMWPE against the various materials used for the heads. The surfaces of the retrieved heads were analysed using a two-dimensional contacting profilometer. Third-body damage was characterised by the mean height of the scratches above the mean line (R. pm. ). The alumina ceramic and zirconia ceramic retrieved heads were found to have significantly less damage. In laboratory studies the ceramics were also more resistant to simulated third-body damage than the metal alloys. We studied the wear of UHMWPE against the damaged counterfaces in simple configuration tests. The damaged ceramics produced less polyethylene wear than the damaged metal counterfaces. The wear factor of UHMWPE against the damaged materials was dependent on the amount of damage to the counterface (R. p. ). Our study has shown the benefit of using the harder and more damage-resistant ceramic materials for femoral heads

Summary Statement. In young, active patients cementless THR demonstrates excellent prosthetic stability by RSA and outstanding clinical outcomes at 5 years using a tapered titanium femoral stem, crosslinked polyethylene liners and either titanium or tantalum shells. Introduction. Early femoral implant stability is essential to long-term success in total hip replacement. Radiostereometric analysis (RSA) provides precise measurements of micromotion of the stem relative to the femur that are otherwise not detectable by routine radiographs. This study characterised micromotion of a tapered, cementless femoral stem and tantalum porous-coated vs. titanium acetabular shells in combination with highly cross-linked UHMWPE or conventional polyethylene liners using radiostereometric analysis (RSA) for 5 years following THR. Patients and Methods. This IRB-approved, prospective, double randomised, blinded study, involved 46 patients receiving a primary THR by a single surgeon. Each patient was randomised to receive a titanium (23) (Trilogy, Zimmer) or tantalum (23) (Modular Tantalum shell, Zimmer) uncemented hemispheric shell and either a highly-crosslinked or conventional polyethylene liner. Tantalum RSA markers were implanted in each patient. All patients had a Dorr A or B femoral canal and received a cementless, porous-coated titanium tapered stem (M/L Taper, Zimmer). All final femoral broaches were stable to rotational and longitudinal stress. RSA examinations, Harris Hip, UCLA, WOMAC, SF-12 scores were obtained at 10 days, 6 months, and annually through 5 years. Results. All patients demonstrated statistically significant improvement in Harris Hip, WOMAC, and SF-12 PCS scores post-operatively. Evaluation of polyethylene wear demonstrated that median penetration measurements were significantly greater in the conventional compared to the HXPLE liner cohorts at 1 year through 5 years follow-up (p<0.003). At 5 years, conventional liners showed 0.38 ± 0.05mm vertical wear whereas HXLPE liners showed 0.08 ± 0.02mm (p<0.003). Evaluation of the femoral stems demonstrated that the rate of subsidence was highest in the first 6 months (0.09mm/yr), with no other detectable motion through 5 years. Two outlying patients had significantly higher stem subsidence values at 6 months (0.7 mm and 1.0mm). One stem stabilised without further subsidence after 6 months (0.7mm), and the other stem stabilised at 1 year (1.5mm). Neither patient has clinical evidence of loosening. Evaluation of acetabular shells demonstrated less median vertical translation in tantalum than titanium shells at each time-point except at 3-years follow-up, however due to large standard errors, there was no significant difference between the two designs (p>0.05). These large standard errors were predominantly caused by two outliers, neither of which had clinical evidence of loosening. Discussion/Conclusion. In this RSA study of young THR patients, cementless tapered femoral stems, highly crosslinked polyethylene liners, and tantalum or titanium acetabular shells all demonstrated excellent performance through 5 years follow-up. Highly crosslinked polyethylene liners demonstrated significantly less wear than conventional liners. The femoral stem showed excellent stability through 5 years, with no clinical or radiologic episodes of failure. The small amount of micromotion seen is less than that previously reported for similar tapered, cementless stems and approaches the accuracy of RSA (0.05mm). Both acetabular shells demonstrated excellent stability with minimal micromotion at 5 years without significant differences in migration. All patients demonstrated significant clinical improvement in pain and function and additional RSA evaluation of these patients is planned

Introduction. It is believed that wear of replacement joints vivo in is strongly dependent on input motions (kinematics) and loading. There is difficulty in accurately measuring total disc replacement (TDR) kinematics in vivo. It is therefore desirable to ascertain the sensitivity of implant wear in vitro to perturbations of the standard testing parameters. An anterior-posterior (AP) shear force input is not currently included in the present ISO and ASTM testing standards for lumbar TDRs but is known to exist in in vivo. Other joint-replacement wear tests have shown that the phasing of input motions influences the ‘cross-shear’ process of polyethylene wear. Polyethylene bearing materials do not behave linearly to axial loading changes and so the effect on wear rate is difficult to predict. The study aim was to assess the effects on wear of a ProDisc-L TDR under the following conditions: ISO 18191-1 standard inputs; an additional input AP shear; input kinematics phasing changes; axial loading changes. Methods. A five active degree of freedom (DOF) spine simulator was used to compare the effects of varying the kinematic and loading input parameters on a ProDisc-L TDR (Synthes Spine). A four DOF standard ISO (ISO18192-1) test was followed by a five DOF test which included the AP shear force. The standard ISO test was repeated on a second simulator (of identical design) but with the phasing of the lateral bend (LB) and flexion extension (FE) motions changed to be in-phase, creating a low cross-shear motion pattern. The standard ISO test was then modified to give half the ISO standard axial loading. All tests conducted were based on the ISO18192-1 standard for lumbar implants with 15 g/l protein lubricant and modified as described. Gravimetric wear measurements were taken every million cycles (mc) in units of milligrams (mg). Six discs were tested to give statistically significant results. Results. When the fifth DOF AP input force was added, the wear rate showed a non-significant (p=0.78) change in mean wear rate from 12.7 ± 2.1 mg/mc (± standard deviation) to 11.6 ± 1.2 mg/mc. For the repeated test, on the second simulator, changing from standard ISO to in-phase FE-LB conditions (producing a low cross-shear wear pattern) showed a significant mean wear rate fall of 16.1 ± 1.4 mg/mc to 6.0 ± 1.3 mg/mc. The low-load test showed a marginally non-significant (p=0.18) difference in mean wear rate from 16.0 ± 0.8 mg/mc to 15.1 ± 0.8 mg/mc. Conclusion. When comparing the standard ISO test with the modified five DOF AP input test no significant difference in mean wear rate was observed. Comparing the standard ISO test with the modified in-phase (low cross-shear) test produced a significant 62% reduction in wear rate. Reducing the loading by half did not produce a significant fall in mean wear rate. The wear of lumbar TDRs is strongly dependant on input phasing kinematics and perhaps not so dependent on axial loading and AP shear. This counter-intuitive result is important for in vivo wear performance estimation