Abstract
Poly(methyl methacrylate) (PMMA) is widely used in joint arthroplasty to secure an implant to the host bone. Complications including fracture, bone loss and infection might cause failure of total knee arthroplasty (TKA), resulting in the need for revision total knee arthroplasty (rTKA). The goals of this paper are: (1) to identify the most common complications, outside of sepsis, arising from the application of PMMA following rTKA, (2) to discuss the current applications and drawbacks of employing PMMA in managing bone loss, (3) to review the role of PMMA in addressing bone infection following complications in rTKA. Papers published between 1970 to 2018 have been considered through searching in Springer, Google Scholar, IEEE Xplore, Engineering village, PubMed and weblinks. This review considers the use of PMMA as both a bone void filler and as a spacer material in two-stage revision. To manage bone loss, PMMA is widely used to fill peripheral bone defects whose depth is less than 5 mm and covers less than 50% of the bone surface. Treatment of bone infections with PMMA is mainly for two-stage rTKA where antibiotic-loaded PMMA is inserted as a spacer. This review also shows that using antibiotic-loaded PMMA might cause complications such as toxicity to surrounding tissue, incomplete antibiotic agent release from the PMMA, roughness and bacterial colonization on the surface of PMMA. Although PMMA is the only commercial bone cement used in rTKA, there are concerns associated with using PMMA following rTKA. More research and clinical studies are needed to address these complications.
Highlights
Failure of total knee arthroplasty (TKA) necessitates revision total knee arthroplasty to improve the function of the knee and to relieve patient pain [1,2]
The residual stress was approximately 4–7 MPa caused by shrinkage which could increase to more than 24 MPa due to local stress concentration caused by the presence of pores and/or if interdigitation raised the stress at the bone-Poly(methyl methacrylate) (PMMA) interface
Using PMMA resulted in wear debris, bone necrosis and volumetric shrinkage
Summary
Failure of total knee arthroplasty (TKA) necessitates revision total knee arthroplasty (rTKA) to improve the function of the knee and to relieve patient pain [1,2]. A used to address infection in first stage rTKA and what are the subseq2.uenWthcaotmaprelicthaetiocunrsr?ent applications and challenges using PMMA to manage bone loss in rTKA?. How is PMMA used to address infection in first stage rTKA and what are the subsequent There are cmomanpylicpaatiponers?s reviewing the chemistry, utility and clinical success of PMMA in TKA. PMMA was first applied in orthopedics in 1958 for total hip arthroplasty (THA) applications [10,16,17] Nowadays, it is the most commonly used bone cement in both TKA and rTKA. Polymerization of PMMA starts by mixing the initiator and monomer [19], an exothermic reaction which can be broken down into three steps [20,21,22]: Initiation, Propagation, and Termination: Initiation: a chemical reaction begins by the initiator degrading, resulting in the bond cleavage or electron transfer and producing two fragments with unpaired electrons called free radicals. The other is a combination of two active polymer chain ends or a combination of one active polymer chain end with an initiator radical or inhibitors [17,19]
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