The wear of fixed and mobile bearing unicompartmental knee replacements

Unicompartmental knee replacements (UKR) are an option for surgical intervention for the treatment of single-compartment osteoarthritis. The aim of this study was to compare the wear of a low-conformity fixed-bearing UKR with a conforming mobile bearing UKR under two kinematic conditions, to investigate the effect of implant design and kinematics on wear performance in a physiological knee wear simulator. Under both sets of kinematic conditions, the relatively low-conforming fixed UKR showed lower wear, compared with the more conforming anterior-posterior sliding mobile bearing. However, it should be noted that differences in materials between the two designs also contribute to the relative wear performance of the bearings. The combined wear of the medial and lateral bearings of the fixed-bearing UKR as a 'total knee' were significantly reduced compared with a fixed-bearing total knee replacement studied under the same kinematic conditions.     

Reduction of total knee replacement wear with vitamin E blended highly cross-linked ultra-high molecular weight polyethylene

Ultra-high molecular weight polyethylene (UHMWPE) is a common bearing component in total knee replacement (TKR) implants, and its susceptibility to wear continues to be the long-term limiting factor in the life of these implants. This study hypothesized that in TKR systems, a highly cross-linked (HXL) UHMWPE blended with vitamin E will result in reduced wear as compared to a direct compression-moulded (DCM) UHMWPE. A wear simulation study was conducted using an asymmetric lateral pivoting '3D Knee' design to compare the two inserts. The highly cross-linked UHMWPE was aged prior to the testing and force-controlled wear testing was carried out for 5 million cycles using a load-controlled ISO-14243 standard at a frequency of 1 Hz on both groups. Gravimetric measurements of DCM UHMWPE (4.4 +/- 3.0 mg/million cycles) and HXL UHMWPE with vitamin E (1.9 +/- 1.9 mg/million cycles) showed significant statistical differences (p < 0.01) between the wear rates. Wear modes and surface roughness for both groups revealed no significant dissimilarities.     

Biological activity of polyethylene wear debris produced in the patellofemoral joint

Polyethylene wear is considered a threat to the long-term survival of total knee replacements. The aim of this study was to investigate the contribution that resurfacing the patella makes to wear debris-induced osteolysis following total knee replacement. Ultra-high molecular-weight polyethylene wear particles were isolated from simulator lubricant. Particle shape, size, and volume distributions were recorded allowing the osteolytic potential of the wear debris produced in the patellofemoral joint to be estimated using the concept of specific biological activity and functional biological activity. Values were compared with those reported for the tibiofemoral joint. Specific biological activity for the patellofemoral joint was not significantly different from the values for the tibiofemoral joint of total knee replacement devices, and therefore, has a similar potential to stimulate osteolytic cytokine release from macrophages. Functional biological activity was significantly lower for the patellofemoral joint compared with the tibiofemoral joint. Functional biological activity was significantly lower for the patellofemoral joint compared with the fixed bearing and rotating platform total knee replacement devices. However, as patellar resurfacing is commonly fitted as part of a total knee replacement system, this results in a 20% increase in overall functional biological activity for the system. Therefore, implanting a patellar resurfacing will increase the potential for osteolysis in the knee.     

Increased total knee arthroplasty ultra-high molecular weight polyethylene wear using a clinically relevant hyaluronic acid simulator lubricant

In this study, osteoarthritic and periprosthetic synovial fluid samples were rheologically and biochemically compared to develop a hyaluronic acid (HA) supplemented bovine serum (BS) lubricant that mimicked the properties of human joint synovial fluid. The effect of this BS + HA lubricant (50 per cent bovine calf serum + 1.5 g/l HA) on the wear rate of ultra-high molecular weight polyethylene (UHMWPE) during a total knee replacement wear test was then investigated. In conjunction with biochemical similarities, the rheological analysis showed that the BS + HA lubricant viscosity was not statistically different to aspirated total knee arthroplasty (TKA) revision joint fluid viscosity over a range of physiologic shear rates. Gravimetric results at 5 million wear testing cycles showed that the BS + HA lubricant produced an average of 6.88 times more UHMWPE wear than 50 per cent bovine serum lubricant alone. The BS + HA lubricated CoCr femoral component surfaces revealed pitting and surface roughening that was not observed using standard bovine serum only lubricants, but that was similar to the metallic surface corrosion observed on in vivo CoCr femoral component retrievals. These findings support the hypothesis that the addition of HA to simulator lubricant is capable of producing CoCr femoral component surface damage similar to that observed in vivo.     

A simple fully integrated contact-coupled wear prediction for ultra-high molecular weight polyethylene hip implants

A fully coupled contact and wear model was developed in the present study for hip implants employing an ultra-high molecular weight polyethylene (UHMWPE) cup in combination with a metallic or ceramic femoral head. A simple elasticity equation based on the concept of constrained column model was employed to solve the contact mechanics between the acetabular cup and the femoral head under the three-dimensional physiological loading condition. The wear model was based on the classical Archard-Lancaster equation in common with all other studies reported in the literature. The fully coupled contact and wear model was applied to both conventional and cross-linked UHMWPE cups under a wide range of design parameters such as the clearance and the femoral head radius. The predicted linear and volumetric wear as well as their rates for conventional UHMWPE cups were found to be in good agreement with those obtained from a similar analysis by Maxian but using the finite element method for the contact mechanics analysis. The predicted maximum contact pressure was found to decrease rapidly within the first 10(6) cycles, and below the limit to cause plastic deformation within the UHMWPE cup with a nominal radial clearance of 0.2 mm. The effect of the clearance between the head and the cup on the predicted wear was found to be negligible. For the cross-linked UHMWPE cup with relatively large diameters up to 48 mm and a fixed outside diameter of 50 mm, the predicted wear, which was found to increase with increasing femoral head radius, remained small owing to the small wear factor associated with these materials. Furthermore, if the head diameter increases beyond 42 mm, a rapid increase in the contact pressure was predicted, owing to the decrease in the wall thickness of the cross-linked UHMWPE cup.     

The influence of femoral condylar lift-off on the wear of artificial knee joints

In vivo fluoroscopic studies of patients with total knee replacements (TKRs) have shown lift-off of the femoral condyles from the tibial insert. This study investigated the influence of femoral condylar lift-off on the ultra-high molecular weight polyethylene (UHMWPE) wear of fixed bearing (FB) and rotating platform mobile bearing (RP MB) total knee replacements, using a physiological knee joint simulator. In the absence of lift-off, the RP MB knees exhibited a lower wear rate of 5.2 +/- 2.2 mm3 per million cycles (mm3/MC) compared with 8.8 +/- 4.8 mm3/MC for the FB knees. The presence of femoral condylar lift-off was found to accelerate the wear of the FB and RP MB knees tested in this study to 16.4 +/- 2.9 and 16.9 +/- 2.9 mm3/MC respectively. For the RP MB knees the increase in wear rate was more marked, resulting in a similar wear rate for both designs of knee under lift-off conditions. In both cases the medial condyle displayed more wear damage. This study has shown that a small amount of abduction/adduction lift-off and medial-lateral shift increases wear and that the increase in wear is design dependent. In this simulator test, lift-off was simulated on every cycle, whereas the amount of wear and effect of lift-off clinically would depend on the frequency of occurrence of lift-off in vivo.     

Scratch and wear performance of prosthetic femoral head components against crosslinked UHMWPE sockets

Total hip arthroplasty is a highly successful procedure where the hip joint is replaced by an artificial ball and socket joint. Bearing wear continues to be a contributing factor to implant failure. Prosthetic femoral heads roughen in vivo which leads to increased wear. Along with the introduction of improved polyethylene which reduces wear by up to 99%, improved femoral head materials have been introduced to improve resistance to abrasion. The abrasion resistance of two of these improved femoral heads was assessed in this study and compared to a cobalt chromium (CoCr) femoral head. The resulting wear performance against a polyethylene acetabular component was assessed. The bulk ceramic (zirconia toughened alumina) femoral head exhibited superior abrasion resistance compared to CoCr (97% reduction in damage) as well as reduced wear after abrasion (97% reduction in wear). The oxide coated zirconium niobium femoral head showed inferior abrasion resistance compared to CoCr (99% increase in damage) as well as increased wear after abrasion (161% increase in wear). Both femoral head surfaces utilize hard ceramic materials, however, the thin ceramic coating on top of a softer metallic substrate of the oxide coated bearing was unable to withstand aggressive abrasion.     

Long-term in-vitro wear performance of an innovative thermo-compressed cross-linked polyethylene

New cross-linked polyethylene acetabular cups, obtained by thermo-compression process, were compared with conventional and traditional commercially available cross-linked polyethylene in terms of wear behaviour in a hip simulator for 10 million cycles using bovine calf serum as lubricant.Gravimetric measurements revealed significant differences between the wear behaviours of the five sets of acetabular cups. In particular, this new type of thermo-compression cross-linked wore more than the traditional cross-linked polyethylene but exhibited a wear rate about four times lower than conventional ultra-high-molecular-weight-polyethylene.The FTIR analyses indicate that oxidation to various extents appears as a consequence of γ-irradiation in presence of oxygen.     

Comparison of wear,wear debris and functional biological activity of moderately crosslinked and non-crosslinked polyethylenes in hip prostheses

The wear, wear debris and functional biological activity of non-crosslinked and moderately crosslinked ultrahigh molecular weight polyethylene (UHMWPE) acetabular cups have been com pared when articulating against smooth and intentionally scratched femoral heads. Volumetric wear rates were determined in a hip joint simulator and the debris was isolated from the lubricant and characterized by the percentage number and volumetric concentration as a function of particle size. The volumetric concentration was integrated with the biological activity function determined from in vitro cell culture studies to predict an index of specific biological activity (SBA). The product of specific biological activity and volumetric wear rate was used to determine the index of functional biological activity (FBA). On smooth femoral heads the crosslinked UHMWPE had a 30 per cent lower wear rate, but it had a greater percentage volume of smaller, more biologically active particles, which resulted in a similar index of FBA compared with the non-crosslinked material. On the scratched femoral heads the volumetric wear rate was three times higher for the moderately crosslinked UHMWPE and two times higher for the non-crosslinked UHMWPE compared with the smooth femoral heads. This resulted in a higher wear rate for the moderately crosslinked material on the scratched femoral heads. All the differences in wear rate were statistically significant. There were only small differences in particle volume concentration distributions, and this resulted in similar indices of FBA which were approximately twice the values of those found on the smooth femoral heads. Both materials showed lower wear and FBA than for previously studied aged and oxidized UHMWPE gamma irradiated in air. However, this study did not reveal any advantage in terms of predicted FBA for moderately crosslinked UHMWPE compared with non-crosslinked UHMWPE.     

The effect of kinematic conditions on the wear of ultra-high molecular weight polyethylene (UHMWPE) in orthopaedic bearing applications

It is known that wear mechanisms differ between the ultra-high molecular weight polyethylene (UHMWPE) components of total hip replacement (THR) and total knee replacement (TKR). The difference in relative contact position or 'kinematic conditions of contact' between the metal and polymer components is thought to contribute to the contrast in observed wear mechanisms. A reciprocating wear tester was used to evaluate three basic kinematic contact conditions: sliding, in which the relative contact position on the polymer remains stationary; gliding, where the contact position on the polymer reciprocates; and rolling, where the contact position on the polymer varies and the relative velocities of both components are equal. All static load tests used cast Co-Cr alloy and irradiated Chirulen UHMWPE in a 37 degrees C environment lubricated with bovine serum albumin. UHMWPE test sample wear was measured gravimetrically at intervals of 600,000 cycles. The results indicated a difference in wear factor (volume lost due to wear per unit load per unit sliding distance) between the three groups with varying relative motion. The study indicates that screening tests which evaluate wear properties of new materials for total joint replacement should reflect the different kinematic contact conditions.     

Prediction of backside micromotion in total knee replacements by finite element simulation

The micromotion at the interface between the polyethylene tibial insert and metal tibial tray [corrected] in modular total knee replacements [corrected] has been shown to contribute to wear particle-induced osteolysis and may [corrected] cause implant failure. Therefore, studying the design parameters that are involved in the backside wear process is an important task that may lead to improvement in new total knee replacements. In the present study, a finite element model was developed to predict the backside micromotion along the entire modular interface. Both the linear elastic constitutive model and non-linear J2-plasticity constitutive model were considered in the finite element model for polyethylene and were corroborated against published results obtained from displacement controlled knee simulator wear tests. The finite element simulation with the non-linear J2-plasticity constitutive model was able to predict backside micromotion [corrected] more accurately than the simulation with the linear elastic constitutive model. [corrected] The developed finite element model (including the non-linear J2-plasticity constitutive model) was then applied to assess the effects of the tibial tray locking mechanism design (dovetails versus fullperipheral [corrected] design) and different levels of interference fit on insert micromotion. The developed finite element model, implementing the non-linear J2-plasticity constitutive model, was shown to successfully predict clinical amounts of backside micromotion and could be used for the design and development of total knee replacements for the reduction of backside micromotion and polyethylene [corrected] wear.     

A comparative study of the performance of metallic and ceramic femoral head components in total replacement hip joints

Arthroplasty represents an outstanding twentieth century achievement in orthopaedic surgery. However, in recent years polyethylene wear debris has been linked to the loosening process in implants and there is considerable interest in reducing the severity of wear through the introduction of improved materials and alternative designs of total replacements joints. During the past twenty years or so, ceramic components have been introduced, either as ceramic-on-ceramic or as ceramic-on-polymer combinations of sliding pairs of materials and in this paper a tribological appraisal is made of the performance of the latter combination in relation to the long established metal-on-polymer arrangement. The basic mechanisms of wear in total replacement joints are considered and attention is drawn to the role of creep in determining the initial penetration of the femoral head into the polyethylene acetabular cup. Laboratory and clinical studies of the tribological characteristics of current forms of implants are then reviewed.     

In vivo kinematics of a cruciate retaining mobile-bearing total knee arthroplasty

In the total knee arthroplasty (TKA), kinematic benefits of the cruciate retaining (CR) mobile-bearing total knee arthroplasty are important. The current study aimed to assess how kinematic features of the anterior-posterior glide CR mobile-bearing TKA are different from those of normal knees or CR fixed-bearing TKA. Using a 3D/2D registration method, CT-derived 3D knee models were registered to sequential 2D X-ray images taken during knee flexion. Full range of knee flexion was 127.6° (SD 5.9) for normal knees, which was always larger than 110.8° (SD 14.0) of Nexgen CR fixed-bearing TKA or 108.1° (SD 8.0) of e.Motion CR mobile-bearing TKA. The rotation path of e.Motion CR mobile-bearing TKA demonstrated a small amount of internal or external femoral rotation from full extension over 40° flexion, steep increase in external femoral rotation from 40° to 90° flexion, then turned down in external rotation from 90° to full flexion. In contrast, Nexgen CR fixedbearing TKA did not demonstrate any consistent kinematic pattern among subjects. e.Motion CR mobile-bearing TKA can be more preferable because it showed a rotational turning point at 90° flexion that was comparable to normal knees’ rotational turning point at 80° flexion.     

A comparative evaluation of the wear of ultra-high molecular weight polyethylene abraded by Ti-6Al-4V

The study was initiated to assess the suitability of Ti-6Al-4V as a metal which articulates against Ultra High Molecular Weight (UHMW) polyethylene in total joint applications. The wear surfaces of Ti alloy were prepared to different levels of surface roughness and the effect of various surface chemical treatments were examined. A specially designed annular contact laboratory wear tester was developed to provide the surface loading and articulation. Comparative tests were also performed using 316 LVM stainless steel and Co-Cr-Mo alloy metallic wear components. All annular contact wear tests were performed in mammalian Ringer's solution environments and were evaluated using standard statistical techniques. Scanning electron microscope (SEM) analysis of the wear surfaces indicates the formation of a polyethylene transfer film on all metal surfaces. The surface of the UHMW polyethylene samples after testing was considerably rougher than the original articulating metallic surface; the transfer film on the metal surfaces was responsible for this. It was concluded that Ti-6Al-4V is satisfactory for total joint replacement when used in combination with UHMW polyethylene. Proper surface preparation may allow lower rates of wear than conventional orthopaedic alloys.     

Wear Measurement and Assessment of Explanted Cross-Linked PE Acetabular Cups Using a CMM

Wear has been considered the main limiting factor in the longevity of hip replacements. Wear analysis is thus essential for determining wear-related failure mechanisms and prediction of wear, which will consequently enable biomedical engineers to improve the design, material, and service life of the bearing components. This article presents wear measurement and assessment of the explanted conventional cross-linked polyethylene (XPE) and second-generation highly cross-linked polyethylene cups (X3) using a coordinate measuring machine (CMM). An expanded uncertainty analysis was performed to assess the performance of wear measurement. Wear measurement using the CMM method was validated with the gravimetric technique. The normalized error between volumetric wear measurement of the CMM method and that of the gravimetric technique was estimated to be always less than 1, suggesting that the CMM method applied to explanted hip wear measurements under the specific conditions was accurate and reliable. The approach to CMM measurement with uncertainty analysis was shown not only to locate 3D wear scar and wear direction but also to accurately quantify linear and volumetric wear with a maximum volumetric uncertainty of ±3.15 mm³ (95% confidence level). It is shown that identifying the key uncertainty components involved in the measurement process including validation, which contributes to an overall expanded uncertainty budget, is crucial to improve the confidence and the reliability of hip wear measurement results using a CMM.     

Single flexion-axis selection influences femoral component alignment and kinematics during knee simulation

The objective of this paper is to investigate the effect of the implant geometry and alignment on its surface displacement, and to show that the proposed method of alignment can be used to improve the consistency of total knee replacement alignment for knee simulation. Poor femoral flexion-axis selection in the alignment process can possibly alter the intended design's functionality and introduce significant anterior/posterior (A/P), and proximal/distal (P/D) displacements. In the study, four multi-axis femoral components from each of two different manufacturers, NKII and 3DKnee, were used. A custom-built femoral alignment and surface measurement instrument was used to adjust and locate the single femoral axis position for each implant, which would optimally minimize their P/D displacements and A/P translations. The aligned NKII implants yielded a mean implant maximum P/D and A/P contact point shifts of 0.577 +/- 0.078 mm (+/- std. dev.) and of 2.325 +/- 0.243 mm between 0 and 60 degrees of flexion, which was significantly different from the aligned 3DKnee, 0.415 +/- 0.157 mm and 0.800 +/- 0.1512mm (p<0.0001, p<0.0001). Future work is needed to quantify the effect of femoral flexion axis selection on resulting long-term wear, damage areas, and soft tissue loading during simulation.     

Comparative study on the wear behaviour of different conventional and cross-linked polyethylenes for total hip replacement

In this study, five different types of conventional and cross-linked polyethylene (XLPE) (γ-sterilised PE GUR1020, EtO-sterilised PE GUR1020, γ-sterilised PE GUR1050, EtO-sterilised XLPE GUR1020, EtO-sterilised XLPE GUR1050) acetabular cups were tested on a hip joint simulator run for 5 million cycles in order to compare the relative long-term wear resistance in relation to material properties (PE grade, conventional or cross-linked) and sterilisation method (EtO treatment or γ-irradiation).Gravimetric measurements revealed significant differences between the wear behaviours of the five sets of acetabular cups. Weight loss was found to decrease along the series: γ-sterilised PE GUR1020>EtO-sterilised PE GUR1020>γ-sterilised PE GUR1050>EtO-sterilised XLPE GUR1050>EtO-sterilised XLPE GUR1020. The wear results were discussed in relation to the crystallinity degree of the cups which was determined by micro-Raman spectroscopy coupled to partial least-squares analysis. Within both conventional and cross-linked PE series, it appeared that higher crystallinity samples (i.e. γ-sterilised PE GUR1020 and EtO-sterilised XLPE GUR1050, respectively) were characterised by higher wear rates. The higher weight loss observed for PE GUR1020 was explained in relation to its lower molecular weight with respect to PE GUR1050. Raman analysis showed that wear testing did not significantly modify the crystallinity degree of any of the tested acetabular cups. The most worn cup, i.e. γ-sterilised PE GUR1020, appeared the most homogeneously polished upon wear testing, as confirmed by the lowest standard deviation associated to the crystallinity value recorded in the centre of the cup. The results of this investigation have clearly shown a dramatic wear reduction in favour of the cross-linked polyethylene.     

Development of a ten-station, multi-axis hip joint simulator.

Joint simulators are now used extensively to evaluate the performance of materials and designs of total replacement hip and knee joints. In this Technical Note a new ten-station hip joint simulator with biaxial rotational articulation synchronized to a physiological loading cycle is described. The current simulator manufactured by ProSim Limited (Manchester, UK) is a development of a first generation machine designed and built in-house at DePuy International Limited (Leeds, UK). The use of this new form of ten-station hip simulator to evaluate the performance of 22 mm zirconia femoral heads and ultra-high molecular weight polyethylene acetabular cups over some 7 million loading cycles is described elsewhere [1].     

Effect of stair descent loading on ultra-high molecular weight polyethylene wear in a force-controlled knee simulator

A loading protocol approximating forces, torques and motions at the knee during stair descent was developed from previously published data for input into a force-controlled knee simulator. A set of total knee replacements (TKRs) was subjected to standard walking cycles and stair descent cycles at a ratio of 70: 1 for 5 million cycles. Another set of implants with similar articular geometry and the same ultra-high molecular weight polyethylene (UHMWPE) resin (GUR 415), sterilization and packaging was tested with standard walking cycles only. Implant kinematics, gravimetric wear and surface roughness of the UHMWPE inserts were analysed for both sets of implants. Contact stresses were calculated for both loading protocols using a Hertzian line contact model. Significantly greater weight loss (p < 0.05) and more severe surface damage of UHMWPE inserts resulted with the walking + stair descent loading protocol compared to walking cycles only. Anterior-posterior (AP) tibiofemoral contact point displacements were lower during stair descent than walking, but not significantly different (p = 0.05). Contact stresses were significantly higher during stair descent than walking, owing to higher axial loads and the smaller radius of curvature of the femoral components at higher flexion angles. High contact stresses on UHMWPE components are likely to accelerate the fatigue of the material, resulting in more severe wear, similar to what is observed in retrieved implants. Thus the inclusion of loading protocols for activities of daily living in addition to walking is warranted for more realistic in vitro testing of TKRs.     

Quantification of Wear Rates and Plastic Deformation on Mobile Unicompartmental UHMWPE Tibial Knee Inserts

Experimental wear testing is an essential step in the evaluation of unicompartmental knee prostheses; the major mechanisms that dominate the wear of conventional ultra high molecular weight polyethylene tibial knee menisci are the sub-surface cracking and delamination that induce particle release by abrasion/adhesion and subsequently periprosthetic osteolysis. The aim of this study was to determine whether plastic deformation affects the wear of the polymer and to measure the magnitude of these effects. Wear test was performed using a displacement-control knee wear simulator with “three-plus-one” stations, in accordance with the ISO 14243-3/2. A state-of-the-art coordinate measuring machine was used to quantify the volumetric mass loss of the mobile knee polyethylene menisci as well as creep/plastic deformations. The volumetric wear measured by this method was compared to that measured by the gravimetric method. Raman spectroscopy showed morphology changes induced by mechanical stress in both the upper and lower surfaces of the menisci. The amorphous content increased at expenses of the crystalline orthorhombic content, which generally decreased in all menisci. A slight orthorhombic → monoclinic phase transformation occurred upon mechanical stress. Plastic deformation appeared as the main factor affecting the trend of the spectroscopic markers and thus the morphology degradation.