Douglas W. Van Citters

Rim cracking of the cross-linked longevity polyethylene acetabular liner after total hip arthroplasty.

BACKGROUND Studies have suggested that cross-linked polyethylene bearings reduce wear rates from 40% to 100% compared with conventional polyethylene. However, the reduced mechanical properties of highly cross-linked polyethylene have the potential to be a limiting factor in device performance. We reviewed a series of retrieved acetabular liners with a fracture of the superior rim to assess the factors that played a role in their failure. METHODS Four Longevity acetabular bearings, which had been retrieved from two patients after seven to twenty-seven months in vivo, were visually examined for clinical damage, were assessed with use of Fourier transform infrared spectroscopy to determine the level of oxidation, and were analyzed for mechanical properties and fracture surface characterization. Control data were obtained from never-implanted devices and from global reference ultrahigh molecular weight polyethylene bar stock as an industry calibration material. RESULTS All four retrieved liners demonstrated articular surface wear modes, which in most cases were rated as moderate, and none were rated as severe. All showed cracking or rim failure of the liner at the superior aspect along the groove in the polyethylene that engages the locking ring of the shell. The retrieved liners had no measurable oxidation, and the mechanical properties were comparable with those of never-implanted material. CONCLUSIONS There was no notable in vivo degradation of the retrieved liners. Important factors related to failure appear to be thin polyethylene at the cup rim, relatively vertical cup alignment, and the material properties of the highly cross-linked polyethylene that are decreased relative to conventional polyethylene. The critical dimension with respect to rim failure in modular liners appears to be the minimum thickness at the equatorial region.

Evaluation of Oxidation and Fatigue Damage of Retrieved Crossfire Polyethylene Acetabular Cups

BACKGROUND Crossfire cross-linked polyethylene is produced differently from other cross-linked polyethylene materials; a below-melt-temperature annealing process is used with the goal of avoiding compromised mechanical properties. The present study was performed to evaluate retrieved Crossfire acetabular cups to determine whether they had oxidized and to what extent oxidation might have influenced their clinical performance. METHODS Eleven acetabular cups were received at retrieval and a twelfth acetabular cup was received two years post-retrieval over a period of four years. None were retrieved because of polyethylene wear or fatigue. The cups had been in vivo from 0.1 to 5.3 years. Each was examined visually, clinical fatigue damage was rated, and oxidation was measured with use of Fourier transform infrared spectroscopy. RESULTS The cups exhibited oxidation that varied with its location on the cup: the oxidation value was generally low on the articular surface but more than an order of magnitude higher value on the rim. Maximum rim oxidation correlated significantly with the time in vivo (Spearman rho = 0.734, p = 0.010). Oxidation was identified visually by a white band in thin sections on the rim of seven of the cups and on the articular surface of one of these seven cups. Six of the seven cups also exhibited clinical fatigue damage. Eight of the twelve cups exhibited evidence of impingement or dislocation. CONCLUSIONS Acetabular cups made of Crossfire polyethylene oxidized to a measurable degree. The oxidation-related reduction of polyethylene mechanical properties was sufficient to allow the fatigue damage seen in these retrieved cups.

Tradeoffs amongst fatigue, wear, and oxidation resistance of cross-linked ultra-high molecular weight polyethylene

This study evaluated the tradeoffs amongst fatigue crack propagation resistance, wear resistance, and oxidative stability in a wide variety of clinically-relevant cross-linked ultra-high molecular weight polyethylene. Highly cross-linked re-melted materials showed good oxidation and wear performance, but diminished fatigue crack propagation resistance. Highly cross-linked annealed materials showed good wear and fatigue performance, but poor oxidation resistance. Moderately cross-linked re-melted materials showed good oxidation resistance, but moderate wear and fatigue resistance. Increasing radiation dose increased wear resistance but decreased fatigue crack propagation resistance. Annealing reduced fatigue resistance less than re-melting, but left materials susceptible to oxidation. This appears to occur because annealing below the melting temperature after cross-linking increased the volume fraction and size of lamellae, but failed to neutralize all free radicals. Alternately, re-melting after cross-linking appeared to eliminate free radicals, but, restricted by the network of cross-links, the re-formed lamellae were fewer and smaller in size which resulted in poor fatigue crack propagation resistance. This is the first study to simultaneously evaluate fatigue crack propagation, wear, oxidation, and microstructure in a wide variety of clinically-relevant ultra-high. The tradeoff we have shown in fatigue, wear, and oxidation performance is critical to the materials long-term success in total joint replacements.

Femoral stem fracture and in vivo corrosion of retrieved modular femoral hips.

A series of 78 retrieved modular hip devices were assessed for fretting and corrosion. Damage was common at both the head-neck junction (54% showing corrosion; 88% showing fretting) and at the stem-sleeve junction (88% corrosion; 65% fretting). Corrosion correlated to in vivo duration, patient activity, and metal (vs ceramic) femoral heads but did not correlate to head carbon content. Femoral stem fatigue fracture was observed in seven retrievals; all had severe corrosion, were under increased stress, and were in vivo longer than the non-fractured cohort. This study emphasizes the potential for stem fracture when small diameter femoral stems with large offsets are used in heavy and active patients. Designs which reduce fretting and corrosion in modular implants is warranted as patients demand longer lasting implants.

Clinical Wear Measurement on Low Contact Stress Rotating Platform Knee Bearings

Whereas fixed-bearing total knee arthroplasty (TKA) designs secure the polyethylene bearing to the tibial tray, mobile-bearing TKAs allow the bearing to move relative to the tray. This study evaluated wear performance of the rotational articulation of the Low Contact Stress Rotating Platform mobile-bearing TKA (DePuy, Warsaw, Ind) by analyzing 100 retrievals. All retrieved bearings showed rotation surface damage, but severity of the damage did not correlate with duration. Rotation surface damage appeared to be caused by contaminant particles, which produced curvilinear scratches that were longer than the normal rotational excursion of the knee. Wear measurement indicated that wear was relatively uniform, long-term wear rates were low (mean, 54 mm(3)/y for durations >2 years) and decreased with longer duration, and damaged appearance did not correspond to high wear.

Oxidation and other property changes of retrieved sequentially annealed UHMWPE acetabular and tibial bearings

This investigation analyzed retrieved sequentially crosslinked and annealed (SXL) ultra-high molecular weight polyethylene bearings to determine whether the material is chemically stable in vivo. A series of retrieved tibial and acetabular components were analyzed for changes in ketone oxidation, crosslink density, and free radical concentration. Oxidation was observed to increase with in vivo duration, and the rate of oxidation in tibial inserts was significantly greater than in acetabular liners. SXL acetabular bearings oxidized at a rate comparable to gamma-sterilized liners, while SXL tibial inserts oxidized at a significantly faster rate than their gamma-sterilized counterparts. A significant decrease in crosslink density with increased mean ketone oxidation index was observed, suggesting that in vivo oxidation may be causing material degradation. Furthermore, a subsurface whitened damage region was also found in a subset of the bearings, indicating the possibility of a clinically relevant decrease in mechanical properties of these components.

Evaluating the suitability of highly cross-linked and remelted materials for use in posterior stabilized knees.

Posterior stabilized (PS) knee designs are a popular choice for cruciate sacrificing knee arthroplasty procedures. The introduction of PS inserts fabricated from highly cross-linked and remelted Ultra High Molecular Weight Polyethylene (UHMWPE) has recently generated concern as these materials have been shown to possess reduced mechanical properties. This study investigated whether highly cross-linked and remelted UHMWPE material (referred to as XRP) can be expected to perform similarly to historical gamma-air polyethylene, which has suffered few reported incidences of tibial post failure. Never-implanted gamma-air PS tibial inserts shelf-aged 14 years were examined and compared to XRP materials. Evaluation of oxidation levels, impact toughness, and fatigue strength demonstrated never-implanted gamma-air PS tibial inserts to possess nonuniform mechanical properties. Despite severe oxidation along the exterior of gamma-air tibial posts, comparatively low oxidation levels at the center of the tibial posts corresponded to sufficiently high mechanical properties. XRP material (75 kGy) showed superior impact toughness over shelf aged gamma-air material; however, tibial post fatigue testing demonstrated XRP material (100 kGy) to be less resistant to fatigue failure than historical gamma-air material. Results from this study indicate that XRP materials (100 kGy) may demonstrate an inferior resistance to tibial post failure than historical polyethylene.

The effect of radiation dose on the tensile and impact toughness of highly cross-linked and remelted ultrahigh-molecular weight polyethylenes.

Several highly cross-linked and remelted ultrahigh-molecular weight polyethylenes (UHMWPE) were introduced in 1998 as bearing materials for orthopaedic implants to achieve superior wear performance. However, gamma radiation and the subsequent postirradiation thermal treatment are associated with decreased mechanical properties such as ductility, toughness, and fatigue strength compared to noncross-linked materials. The purpose of this study was (a) to characterize the toughness (tensile and impact) of highly cross-linked and remelted UHMWPE of varying doses (0-255 kGy) and (b) determine whether a correlation exists between both toughness measures. As radiation dose increased, tensile toughness and impact toughness were shown to decrease in a nonlinear fashion; largely a result of the decrease in ductility, which was also observed. Impact toughness and tensile toughness were also found to be strongly correlated to one another (R(2) = 0.97).

Lubrication and Wear of Artificial Knee Joint Materials in a Rolling∕Sliding Tribotester

This paper describes the influence of lubrication on wear during testing of materials for artificial knee joints in a rolling/sliding tribotester built to simulate contact conditions in a total knee replacement. The test configuration consists of parallel cylinders (pucks) of ultrahigh molecular weight polyethylene (UHMWPE) and polished cobalt-chrome alloy in oscillatory rolling/sliding contact in a bath of dilute (25%) bovine serum. Wear tests of three different UHMWPE materials were run under constant load at 40% sliding for 1.5 million oscillation cycles at 1.5 cycles/s. Wear of the UHMWPE was determined by measuring the profile of the cylindrical contact surface of the puck before and after each test. Profile measurements were repeated after at least 53 days to eliminate the contribution from creep. Differences between initial and final profiles were attributed to wear of the UHMWPE. It was found that the largest wear depth in the lubricated tests occurred near the ends of the oscillatory contact area, while dry (unlubricated) tests of the same materials showed a peak wear depth near the center of the contact area. In the lubricated tests, the worn depth was lowest for the most heavily irradiated material. Analysis of the elastohydrodynamic lubrication in the rolling/sliding contact was carried out assuming a line-contact situation with smooth cylindrical surfaces. The time-dependent modified Reynolds equation and the elasticity equation with initial conditions were solved numerically using a multigrid technique with full approximation scheme, and using a Newton Raphson method to solve the highly nonlinear system of equations. The thickness of the lubricating film of bovine serum was determined for points along the length of the wear track. It was found that the smallest film thickness (h min ) occurs very close to the location in the oscillating contact where the greatest wear occurs, owing to the very low entraining velocity near the ends of the oscillation cycle. The coefficient (K) for wear of the UHMWPE was found to be relatively constant over the central section of the oscillatory motion, but increased to a higher value where h min decreased to near zero. Thus, the important influence of lubrication on wear of artificial knee bearings was demonstrated.

A Multi-Station Rolling/Sliding Tribotester for Knee Bearing Materials

Total joint replacements traditionally employ ultra high molecular weight polyethylene (UHMWPE) as a bearing material due to its desirable material properties and biocompatibility. Failure of these polyethylene bearings can lead to expensive and risky revision surgery, necessitating a better understanding of UHMWPEs tribological properties. A six-station rolling/sliding machine was developed to study the behavior of accelerated-aged UHMWPE in cylinder-on-cylinder contact. The normal load and sliding/rolling ratio in the oscillatory contacts can be controlled separately for each test station, as can the liquid test environment. Fatigue tests were run on the machine with UHMWPE versus cobalt-chrome cylinders in a distilled water environment at normal contact pressures of approximately 20 MPa. All specimens failed by subsurface cracking during tribotesting on the machine, and the failures were similar to those that occur in-vivo. The fatigue behavior of the polymer was analyzed to determine its relationship to oxidation and stress state in the rolling/sliding cylinder. At the 20 MPa test load, the number of cycles to fatigue failure by subsurface cracking was inversely proportional to the oxidation level. Analysis of the stress levels through the bulk of the polyethylene specimens and their relationship to the material properties provide insight as to why cracks initiate and propagate subsurface.