Joint Replacement Failure Research Articles

Wear of crosslinked polyethylene under different tribological conditions

Ultra high molecular weight polyethylene (UHMWPE) wear debris has been shown to be a major cause of long term failure of total joint replacements. Recently, crosslinking has been extensively introduced to reduce the wear of UHMWPE. In this study the wear of non-crosslinked and crosslinked UHMWPE were compared under a range of conditions. The materials examined were UHMWPE GUR 1050, non-crosslinked, moderately crosslinked--5MRad, and highly crosslinked--10MRad. The wear was examined on a multidirectional pin on plate rig. The effect of counterface roughness on wear under different kinematics was examined. The results from the different counterface conditions showed that highly crosslinked UHMWPE had significantly lower wear against both smooth and scratched counterfaces. However the reduction in wear for crosslinked polyethylene was less for scratched counterfaces. The second part of the study showed that all the UHMWPE's produced lower wear rates under lower multidirectionality because of reduced cross shear frictional forces and work. These findings are relevant to the consideration of the use of crosslinked polyethylene in the knee, where the kinematics have lower levels of cross shear and in the hip and knee against roughened metallic counterfaces.

Influence of biological lubricant on the morphology of UHMWPE wear particles generated with microfabricated surface textures

Immunological response induced by wear particles of ultra-high molecular weight polyethylene (UHMWPE) has been recognized as the major factor causing the failure of total joint replacements. A previous study has applied surface texturing techniques to generate UHMWPE wear particles with specific size and shape to study the effects of particle size and shape on osteolysis. In the present study, the effects of biological lubricants on the morphology of UHMWPE wear particles generated with microfabricated surface textures were investigated. It was observed that UHMWPE wear particles generated in bovine serum are smaller and thinner than the particles generated in water. The reason may be due to the reduction of the friction between UHMWPE and the surface feature under serum lubricating condition. It means a smaller material resistant force to overcome during the surface-feature sliding process and leads to a smaller lateral displacement of a micro-cutting process. Thus a larger aspect ratio (or a smaller particle width) was observed for the particles generated in serum. Compared to original UHMWPE, highly cross-linked UHMWPE has better wear resistance and generates smaller wear particles under the articulation with microfabricated surface textures in a biological environment. The potential application is to apply surface textures on the articulating surface of joint implant in order to control the size and shape of UHMWPE wear particles. While maintaining a low wear rate of UHMWPE parts, further reduction of the most “toxic” particles released into human body shall prevent particles induced osteolysis.

Study on Bio-Tribological Properties of Nitrogen Ion Implanted UHMWPE

As the aseptic loosening induced by polyethylene wear debris is the main cause of long-term failure of total joint replacements, increasing the wear resistance of ultrahigh molecular weight polyethylene (UHMWPE) will be very important to obtain long-life artificial joint. In this paper the UHMWPE was implanted with 450 keV N+ ions to three doses of 5×1014/cm2, 2.5×1015/cm2 and 1.25×1016/cm2. The friction and wear behaviors of UHMWPE were studied under lubrication of distilled water and blood plasma using a ball-on-disk tribometer with a ZrO2 ceramic ball as a counterface. Experimental results showed that the friction coefficient of ions implanted UHMWPE are higher than un-implanted UHMWPE. Under blood plasma lubrication condition, the wear rate of implanted UHMWPE was lower than un-implanted UHMWPE, and the wear rate decreased with increasing implantation dose. The plow, plastic deformation and fatigue were wearing mechanism for un-implanted UHMWPE and the abrasive wear for implanted UHMWPE.

Nanometre size wear debris generated from crosslinked and non-crosslinked ultra high molecular weight polyethylene in artificial joints

Ultra high molecular weight polyethylene (UHMWPE) wear debris is a major cause of long term failure of total joint replacements. Recently, crosslinking has been introduced in order to reduce the wear of UHMWPE. In this study the wear and wear debris of non-crosslinked and two crosslinked UHMWPE's were compared. In particular this study has focused on the characterisation of nanometre size wear debris. The UHMWPE's were tested in a multidirectional pin on plate wear simulator against smooth and scratched counterfaces. The wear particles were isolated and imaged using a field emission gun scanning electron microscope (FEGSEM) at high resolution. The use of FEGSEM revealed nanometre size particles (less than 0.1 μm) for the first time. No significant difference was found in the percentage number and percentage volume of the particles in different size ranges from any of the materials against any of the counterfaces. The specific biological activity (biological activity per unit value, SBA) was highest for the highly crosslinked material tested on the smooth counterfaces. The functional biological activity (FBA) which takes into account the wear volume and SBA showed that the highly crosslinked UHMWPE had a lower FBA for debris from both the smooth and scratched counterfaces.

Interleukin-1 modulates periprosthetic tissue formation in an intramedullary model of particle-induced inflammation

Interleukin-1 (IL-1) is a proinflammatory cytokine that has been implicated in wear-debris associated total joint replacement failure. We hypothesized that the absence of the IL-1 type-1 receptor would mitigate the inflammatory response to titanium particles and decrease periprosthetic inflammatory tissue in a murine intramedullary rod model. Methods: An intramedullary rod with and without commercially pure titanium particles was placed in the femora of 24 wild type mice (WT) and 24 mice lacking a functional type-1 receptor to IL-1. Femora were analyzed histologically and by ELISA of organ culture explant supernatants. Results: The presence of titanium particles in WT mice stimulated increased expression of interleukin-6 (IL-6) and macrophage chemoattractant protein-1 (MCP-1) relative to rod only controls. In contrast, IL-6 and MCP-1 expression were diminished in IL-1r1-KO mice exposed to titanium particles. Additionally, the formation of a periprosthetic fibro-inflammatory membrane in IL-1r1-KO mice was blunted at 2 weeks when compared to that in wild-type mice. Inflammatory changes and the quality of periprosthetic bone of IL-1r1-KO mice was similar to WT mice in response to titanium particles. Conclusions: These results implicate IL-1 as an important modulator in the local inflammatory response to intramedullary titanium particles. MCP-1 appears to be significantly modulated in IL-1r1-KO mice in response to titanium particles. This may be responsible, in part, for the diminished periprosthetic membrane observed in IL-1r1-KO mice at 2 weeks. Expansion of this murine model of intramedullary particle-induced inflammation to other gene targets may contribute to a more mechanistic understanding of wear-debris associated prosthesis failure.

Simulation of Fretting Wear at Orthopaedic Implant Interfaces

Osteolysis due to wear debris is a primary cause of failure of total joint replacements. Although debris produced by the joint articulating surfaces has been studied and simulated extensively, fretting wear debris, produced at nonarticulating surfaces, has not received adequate attention. We developed a three-station fretting wear simulator to reproduce in vivo motion and stresses at the interfaces of total joint replacements. The simulator is based on the beam bending theory and is capable of producing cyclic displacement from 3 to 1000 microns, under varying magnitudes of contact stresses. The simulator offers three potential advantages over previous studies: The ability to control the displacement by load, the ability to produce very small displacements, and dynamic normal loads as opposed to static. A pilot study was designed to test the functionality of the simulator, and verify that calculated displacements and loads produced the predicted differences between two commonly used porous ingrowth titanium alloy surfaces fretting against cortical bone. After 1.5 million cycles, the simulator functioned as designed, producing greater wear of bone against the rougher plasma-sprayed surface compared to the fiber-mesh surface, as predicted. A novel pin-on-disk apparatus for simulating fretting wear at orthopaedic implant interfaces due to micromotion is introduced. The test parameters measured with the fretting wear simulator were as predicted by design calculations, and were sufficient to measure differences in the height and weight of cortical bone pins rubbing against two porous ingrowth surfaces, plasma-sprayed titanium and titanium fiber mesh.

Pseudomonas aeruginosa biofilm formation and slime excretion on antibiotic-loaded bone cement

Background Infection is an infrequent but serious complication of prosthetic joint surgery. These infections will usually not clear until the implant is removed and re-implantation has a high failure rate, especially when Pseudomonas aeruginosa is involved.Material and methods We examined Pseudomonas aeruginosa biofilm formation on plain and gentami-cin-loaded bone cement with confocal scanning laser microscopy (CSLM). Two different stains were applied in order to visualize and quantify the distribution of bacterial cells and extracellular polymeric substances (slime) from the bone cement surface to the top of the biofilm. Staining with LIVE/DEAD viability stain differentiated between live and dead bacteria within the biofilm, and slime production was evaluated after staining with Calcofluor white.Results CSLM showed that the biofilm was a nonuniform structure of variable thickness, with differences in local bacterial cell and slime densities. Incorporation of gentamicin in bone cement resulted in a 44% reduction in bacterial viability, while the slime density increased significantly. In addition, conventional plate counting showed the development of small-colony variants on gentamicin-loaded bone cement with a decreased sensitivity for gentamicin (MIC: 8 mg/L), as compared with normal-sized colonies taken from plain and gentamicin-loaded bone cement (MIC: 3 mg/L). The enhanced slime production on antibiotic-loaded bone cement, together with the formation of small-colony variants, resulted in decreased susceptibility to antibiotics—probably concomitant with the onset of persistent and relapsing infections.Interpretation In the clinical situation, our findings help to explain the frequent re-implantation failure of joint replacements infected with P. aeruginosa when the procedure has been performed using antibiotic-loaded bone cement.

Poor predictive value of broad-range PCR for the detection of arthroplasty infection in 92 cases

Background The diagnosis of prosthetic infection remains a challenge, as no test is 100% sensitive and 100% specific Recent advances in molecular biology have enabled the detection of infection in culture negative cases.Patients and methods We evaluated the effectiveness of polymerase chain reaction (PCR) in detecting infection in failed joint replacements prospectively in 91 consecutive patients (92 prosthetic joints) undergoing revision total hip or knee arthroplasty. Synovial fluid was collected intraoperatively and examined by broad-range PCR assay for detection of bacterial DNA. The clinical diagnosis of infection was based on the results of blood tests, preoperative joint aspiration, culture and histology of multiple intraoperative tissue samples, as well as the surgeon's assessment.12 joints (13%) were infected, but the PCR was positive in 32 cases. The sensitivity of the technique was 92%, the specificity 74%, the accuracy 76%, the positive predictive value 34%, and the negative predictive value was 98%.Interpretation The PCR technique cannot be recommended for the routine detection of prosthetic infection. The large number of false positive results may represent sample contamination, or bacterial presence related to low-virulence organisms, low bacterial load, or a strong host immune response.

New fast method for determination of number of UHMWPE wear particles

Ultra-high molecular weight polyethylene (UHMWPE) wear particles are the major cause of total joint replacement (TJR) failures because the wear particles, released from TJR's, cause bone loosening. To simplify the study of the relationship between numbers of particles at various locations around TJR's and extent of bone loosening at these locations, the authors of this work tried to develop a new method for easy and fast determination of number of wear particles. The method, called LSC (Light Scattering with Calibration spheres), is based on light scattering of a suspension of wear particles and calibration spheres, and yields relative numbers of particles. A modified LSC method, called LSCm, requires one additional experiment, a gravimetric analysis of a mixture of all studied samples, to determine absolute numbers of wear particles. LSC and LSCm methods are easy and fast, which make them suitable for processing and comparing high number of samples.

Gene expression clustering using self-organizing maps: analysis of the macrophage response to particulate biomaterials

The most common cause of total joint replacement failure is peri-implant bone loss causing pain and prosthesis loosening. This process, known as osteolysis or aseptic loosening, is characterized by macrophage phagocytosis of particulate implant wear debris. In an incompletely defined step, particulate biomaterial debris induces macrophages to release a variety of inflammatory mediators and signaling proteins that lead to bone loss. In an in vitro model of this process, we used microarray technology and data analysis techniques, including the use of self-organizing maps (SOMs), to understand the mRNA gene expression changes occurring in macrophages exposed to clinically relevant particles of ultra-high molecular weight polyethylene and TiAlV alloy. Earlier studies have been limited by technology that only allowed analysis of a few genes at a time, but the microarray techniques used in this paper generate the quantitative analysis of over a thousand genes simultaneously. Our microarray analysis utilized an SOM clustering to elucidate general patterns in the data, lists of top up- and down-regulated genes for each time point and genes with differential expression under different biomaterial exposures. The expression levels of the majority of genes ( > 95 % ) did not vary over time or with exposure to different biomaterials, but a few important genes, such as TNF- α , IL- 1 β , IL-6, and MIP 1 α , proved to be highly regulated in response to biomaterial exposure. We also uncovered a novel set of genes, which not only validates and logically extends the current model of the pathogenesis of osteolysis and aseptic loosening, but also provides new targets for further research and therapeutics.

Microbiological culture results for the femoral head. Are they important to the donor?

We determined the rate of contamination of donated femoral heads at primary hip arthroplasty within a single region between July 1992 and July 2001. We established the null hypothesis that culture results played no role in predicting early failure of the joint because of infection. The rate of contamination was 9%. A positive culture, at the time of retrieval, was found in 367 of 4045 femoral heads. Coagulase-negative staphylococcus was isolated in 77% of the positive cases. At a minimum follow-up of one year, there was no statistically significant difference in the rate of complications or of revision of age-matched patients whose femoral heads had a positive culture compared with those whose femoral heads were sterile. Our findings confirm that culture of the femoral head plays no part in determining future failure of joint replacement in the donor.

The effectiveness of polyethylene versus titanium particles in inducing osteolysis in vivo

Bearing surface wear and periprosthetic osteolysis due to wear particles are among the most common reasons for joint replacement failure. A murine calvarial model of wear particle-induced osteolysis has been used to identify different biologic factors associated with this problem and to test nonsurgical methods of modulating the host response to particulate debris. This model has utilized titanium particles, however, in clinical practice the most common source of particulate debris is polyethylene particles from bearing surface wear. We now report a calvarial model of wear particle-induced osteolysis based on commercially available polyethylene particles. We found that compared to sham surgery osteoclast recruitment and bone resorption can be induced by introduction of the titanium particles or polyethylene particles. However, bone resorption was significantly higher with polyethylene particles compared to titanium particles ( p=0.02). We consider the polyethylene based murine calvarial model of wear particle-induced osteolysis a reliable and clinically relevant tool to understand the host factors and potential pharmacologic interventions that can influence wear debris generated osteolysis. This model might serve as an extension of the well-established titanium based bone resorption model.

Mechanical interface conditions affect morphology and cellular activity of sclerotic bone rims forming around experimental loaded implants

A characteristic bony structure found at revision surgery for failed joint replacement, and implicated as being associated with poorer subsequent implant fixation, is a sclerotic bone rim (SB rim). This study is a histomorphometric analysis of the SB rim formed around an experimental canine micro-motion implant system under stable or unstable conditions with polyethylene (PE) particles, after 8 weeks. A point count histomorphometric analysis was performed to determine the cellular activity at the surface of the SB rim, and the morphology of the structure was determined by image analysis. A SB rim was found to form under both stable and unstable conditions, but with unstable conditions the rim was more distinct, thick, continuous, and was located near the drill hole, and had high and ongoing formative activity at both surfaces with little resorption. Under stable conditions, thinner second or third SB rims were observed. The difference in width and distance between implant and the SB rim is significant ( p<0.05), as was the difference in fraction of resorption surfaces at the SB surface facing the implant. This study observed an in vivo primary bone response to controlled stable and unstable loaded implants. Sclerosis of trabeculae in a semi-continuous SB rim can serve to isolate the implant from the marrow space. The increases in SB rim width and continuity is consistent with the previously demonstrated knowledge that increase of total bone mass and low risk for trabeculae perforation is the consequence of low resorptive and high formative activity.

Osteoblast proliferation and maturation by bisphosphonates

Aseptic loosening and osteolysis are currently the most common causes of failure of total joint replacements. Osteolysis is initiated by a macrophage response to wear debris, resulting in localized, osteoclastic peri-implant bone loss. We have previously inhibited osteoclast-mediated bone resorption in a canine total hip arthroplasty model using oral bisphosphonate therapy. Based on serendipitous observations from our canine study, we hypothesized that bisphosphonates have an anabolic effect on osteoblasts, in a manner distinct from their inhibitory effect on osteoclastic bone resorption. We studied the anabolic effects of two FDA-approved bisphosphonates (alendronate and risedronate) on two in vitro models: a primary human trabecular bone cell culture and the MG-63 osteoblast-like cell line. Following treatment with bisphosphonates at varying concentrations and time periods, cells were assayed for proliferation effects and results were quantified using the methods of direct cell count, and the colorimetric MTT (3-dimethylthiazol-2,5-diphenyltetrazolium bromide) assay at 24, 48, and 72 h. The effect of bisphosphonates on the maturation of osteoblasts were tested with alkaline phosphatase bioassay and reverse transcription-polymerase chain reaction for markers of osteoblast differentiation. Results from both the primary human trabecular bone cell culture and the MG-63 osteoblast-like cell line showed that both bisphosphonates significantly increased the cell number over controls, attaining peak levels at a concentration of 10 −8 m. Alkaline phosphatase activity was also increased, representing earlier commitment of osteoprogenitor cells towards the osteoblastic phenotype. Bisphosphonates also enhanced gene expression of BMP-2, Type I collagen and osteocalcin. In summary, bisphosphonates, aside from their role as inhibitors of osteoclastic bone resorption, are promoters of osteoblast proliferation and maturation.

Primary total hip replacement

Primary hip replacement requires careful patient selection, a knowledge of available prostheses, thorough pre-operative planning, familiarity with surgical exposures and sufficient manual dexterity to carry out the procedure. The aim of hip replacement is to restore the biomechanics of the diseased joint as closely as is practical. Failure to observe these principals results in premature failure of the joint replacement.

Early failure of the Moje screw-fit ceramic metatarsophalangeal joint replacement

Introduction: This implant seemed to overcome the failings of previous designs having a ceramic bearing attached to a titanium positional screw in the metaphyseal bone and an apatite-coated ceramic–bone interface to enhance secondary stability. On the basis of encouraging early results reported from Germany, Orthosonics Ltd. marketed the implant in the UK from June 1999. Following problems with the device (withdrawn August 2000), we have conducted a survey with Orthosonics Ltd. and the Medical Devices Agency (MDA). Results: In total 160 implants were implanted by 46 surgeons, all of whom were surveyed. We received replies from 33 surgeons representing 119 patients. At 1 year following implantation, 93 implants had a successful reported outcome but 17 implants had failed and had been revised. The commonest reported mode of failure was aseptic loosening. A further 6/119 (5%) implants were radiologically loose and clinically symptomatic, but had not been revised. 3/119 (2.5%) implants were radiologically loose but remained clinically satisfactory at the time of the survey. Conclusions: A failure rate of 14% (and further 5% symptomatically loose) at 1 year is unacceptable. Products of this type should only be widely introduced following prospective, randomised-controlled trials in appropriately selected centres.

Friction and wear behavior of nitrogen ion implanted UHMWPE against ZrO 2 ceramic

As the osteolysis induced by polyethylene wear debris is the main cause of long-term failure of total joint replacements, increasing the wear resistance of ultrahigh molecular weight polyethylene (UHMWPE) will be very important to obtain high quality artificial joint. In this paper, we performed nitrogen ion implantation on UHMWPE with ion doses of 5–125×10 14/cm 2. The surface hardness and contact angle on implanted UHMWPE surface were measured. A ball-slid-on-disc tribometer was run, as a comparative test method, to observe the tribological behaviors of ion implanted UHMWPE against ZrO 2 ceramic in dry friction and plasma lubrication. Meanwhile, the profiles of the worn groove on UHMWPE surface were scanned. The experimental results demonstrate that nitrogen ion implantation enhances the microsurface hardness of UHMWPE. The wettability on implanted UHMWPE surfaces is improved. It is found that the friction coefficients of implanted UHMWPE obtain higher values than the untreated one. In plasma lubrication, the friction coefficients of untreated UHMWPE decrease, while the friction coefficients of implanted UHMWPE have little reduction except less fluctuation in wear process. It is shown that the wear rates of nitrogen ion implanted UHMWPE decrease with ion doses in plasma lubrication. In dry friction, however, the wear rates of implanted UHMWPE are 1.8–4.5 times higher than the untreated one. The wear mechanism of untreated UHMWPE is mainly adhesive wear, but the wear mechanism of implanted UHMWPE will shift to abrasive wear and fatigue wear.

Bone transplantation.

Bony deficiency, particularly loss of bone stock associated with failed joint replacements or tumours, is a challenging problem in orthopaedic surgery. Bone transplantation techniques provide solutions that can be tailored to the clinical problem. However, the risks of bone transplantation are well documented and the biology of allograft incorporation remains unpredictable and poorly understood.

The nature and dissemination of UHMWPE wear debris retrieved from periprosthetic tissue of THR.

The role of wear debris in provoking joint replacement failure through bone resorption is now supported by much research. This study presents the analysis of 104 tissue samples using laser diffraction wear particle analysis in conjunction with standard histologic methods. The number and volume distributions were correlated to a range of joint and patient parameters. The median particle diameter by number was 0.69 microm. No particles smaller than 0.113 microm were resolved. No variation in terms of particle distribution was found among joint types. The ability of particles to migrate away from their point of origin was found to be inversely proportional to their size. The numbers of particles per gram of tissue found in various regions around the prosthesis varied little. Further, the numbers of particles in tissue samples shown to have a chronic foreign-body reaction was > 1 x 10(9) particles/gram.

New aspects in the histological examination of polyethylene wear particles in failed total joint replacements

The most important long-term complication in total joint replacements is aseptic osteolysis. Wear particles such as polyethylene (PE) debris are considered to be one of the causes that play a central role. Several studies indicated that PE can be visualised in paraffin-embedded tissue sections not only by polarised light, but also after oil red staining. To determine whether oil red staining enables sensitive detection of PE, we examined staining of mechanically-produced PE particles by oil red. Furthermore, we studied oil red staining of paraffin-embedded tissue specimens of patients with failed uncemented and cemented total knee and hip prostheses. We applied double labelling of sections by immunohistochemistry using the macrophage marker anti-CD68 and oil red staining. We found that oil red stains both isolated PE particles and PE particles in paraffin-embedded tissue sections. Polymethylmethacrylate particles in failed cemented arthroplasties did not stain in paraffin sections. Double labelling showed strong colocalisation of CD68 and PE. We suggest that oil red staining is a sensitive method to detect PE particles. Oil red staining is particularly helpful in these cases which show a characteristic histological feature of aseptic prosthesis loosening without particles being detectable with routine microscopy and polarised light. We also established that immunohistochemical methods can be applied together with the oil red staining method.