Elemental and morphological identification of third-body particulate and calcium stearate inclusions in polyethylene components

Isolation and characterisation of wear debris surrounding failed total ankle replacements

Aseptic loosening and osteolysis continue to be a short- to mid-term problem for total ankle replacement (TAR) devices. The production of wear particles may contribute to poor performance, but their characteristics are not well understood. This study aimed to determine the chemical composition, size and morphology of wear particles surrounding failed TARs. A recently developed wear particle isolation method capable of isolating both high- and low-density materials was applied to 20 retrieved periprosthetic tissue samples from 15 failed TARs of three different brands. Isolated particles were imaged using ultra-high-resolution imaging and characterised manually to determine their chemical composition, size, and morphology. Six different materials were identified, which included: UHMWPE, calcium phosphate (CaP), cobalt chromium alloy (CoCr), commercially pure titanium, titanium alloy and stainless steel. Eighteen of the 20 samples contained three or more different wear particle material types. In addition to sub-micron UHMWPE particles, which were present in all samples, elongated micron-sized shards of CaP and flakes of CoCr were commonly isolated from tissues surrounding AES TARs. The mixed particles identified in this study demonstrate the existence of a complex periprosthetic environment surrounding TAR devices. The presence of such particles suggests that early failure of devices may be due in part to the multifaceted biological cascade that ensues after particle release. This study could be used to support the validation of clinically-relevant wear simulator testing, pre-clinical assessment of fixation wear and biological response studies to improve the performance of next generation ankle replacement devices. STATEMENT OF SIGNIFICANCE: Total ankle replacement devices do not perform as well as total hip and knee replacements, which is in part due to the relatively poor scientific understanding of how they fail. The excessive production of certain types of wear debris is known to contribute to joint replacement failure. This is the first study to successfully isolate and characterise high- and low-density wear particles from tissues collected from patients with a failed total ankle replacement. This article includes the chemical composition and characteristics of the wear debris generated by ankle devices, all of which may affect their performance. This research provides clinically relevant reference values and images to support the development of pre-clinical testing for future total ankle replacement designs.

Histological Analysis of a Retrieved Porous Tantalum Total Ankle Replacement: A Case Report

CASE

We present a case report documenting the retrieval and histological analysis of a porous tantalum (P-Ta) total ankle replacement (TAR) from a 50-year-old woman after a below-knee transtibial amputation. This rare opportunity to examine an intact TAR may help to better understand the implant-bone relationship because it would be in situ.

CONCLUSION

In this case study, we demonstrate bone ingrowth to the first layer of the P-Ta and organized trabecular orientation, suggesting that equal bone load was achieved on the base and the rails in both components using a transfibular surgical approach.

Histologic retrieval analysis of a porous tantalum metal implant in an infected primary total knee arthroplasty

Porous tantalum (Zimmer, Inc, Warsaw, Ind) has the theoretical advantage of improved biologic fixation because of its high porosity, interconnected pore space, and modulus of elasticity. We present a case report documenting the retrieval and bone ingrowth analysis of a porous tantalum tibial component in an infected total knee arthroplasty. Results demonstrated a significantly larger amount of bone ingrowth present in the tibial posts (36.7%) when compared with the bone ingrowth into the tibial baseplate (4.9%) (P < .001). The data suggest that bone ingrowth seen in the plugs as well as baseplate was suggestive of viable bone tissue with healthy bone marrow, osteocytes, and lamella, resulting in a well-fixed tibial implant even at revision surgery for an infected total knee arthroplasty.

Third-body abrasive wear challenge of 32 mm conventional and 44 mm highly crosslinked polyethylene liners in a hip simulator model

Hip simulator studies have shown that wear in the polyethylene liners used for total hip replacements increased with the larger-diameter femoral balls and could also be exacerbated by third-body abrasion. However, they also indicated that the more highly cross-linked polyethylene (HXPE) bearings were more wear resistant than conventional polyethylene (CXPE) bearings. Unfortunately the HXPE bearings appeared to be particularly sensitive to adverse wear conditions. One simulator study in particular indicated that poly(methyl methacrylate) (PMMA) debris increased wear sixfold by means of two-body abrasive interactions rather than the supposed third-body abrasion or roughening effects of the Co-Cr surfaces. There has been no confirmation of such novel theories. Therefore the goal of this study was to investigate the sensitivity of large-diameter HXPE bearings to the third-body PMMA wear challenge in a hip simulator model. An orbital hip simulator was used in standard test mode with a physiological load profile. The 32 mm control liners were machined from moulded GUR1050 and gamma irradiated to 35 kGy under nitrogen (CXPE). The 44 mm liners were also from moulded blanks, gamma irradiated to 75 kGy, machined to shape, given a proprietary heat treatment, and sterilized by gas plasma (HXPE). As in the published simulator model, the study was conducted in three phases. In phase 1, all cups were run in standard ('clean') lubricant for 1.5 x 10(6) cycles duration. In phase 2, three CXPE cups and six HXPE cups were run for 2 x 10(6) cycles with a slurry of PMMA particles added to the lubricant. In phase 3, the implants were again run in 'clean' lubricant for 2 x 10(6) cycles duration. In addition, three HXPE cups were run as wear controls for 5.5 x 10(6) cycles duration in clean lubricant. In phase-1, the HXPE liners demonstrated twelvefold reduced wear compared with the CXPE controls. The 32 mm and 44 mm Co-Cr balls were judged of comparable roughnesses. However, the surface finish of HXPE liners was superior to that of CXPE liners. In phase-2 abrasion, wear rates increased sixfold and eighty-fold for CXPE and HXPE bearings respectively. These data confirmed that HXPE bearings were particularly sensitive to 'severe' test modes. The Co-Cr balls revealed numerous surface patches representing transferred PMMA with average transient roughness increased to 25 nm and 212 nm for the 32 mm and 44 mm balls respectively. These PMMA patches produced an aggressive two-body abrasion wear of the polyethylene. After cleaning, the ball roughness returned to near normal. Therefore the Co-Cr roughness was not an issue in this severe test mode. In phase 3, the wear decreased to near the index values of phase 1, while liner roughness dropped by more than 90 per cent. The control CXPE liners now demonstrated twice the wear of the HXPE, as would be predicted comparing the diameter and cross-linking algorithms. No previous study has correlated polyethylene roughness profiles to wear performance. In phase 2, PMMA abrasion created significant damage to the polyethylene surfaces. The average roughness Sa of CXPE liners increased to 3.6 microm, a twenty-four-fold increase with some scratches up to 40 microm deep. The HXPE roughness also increased but only to 1.5 microm, a ninefold increase. The scratch indices Sz and Sp for HXPE surfaces were also 50 per cent less severe than on CXPE surfaces. However, within 2 x 10(6) cycles duration of phase 3, all liners had recovered to virtually their original surface finish in phase 1. In all test phases, the surface finish of the HXPE liners remained superior to control liners. These experimental data confirmed many of the results from the previous simulator study with the PMMA abrasion models. Thus the 44 mm liners appeared an excellent clinical alternative to the smaller ball designs used in total hip replacements.

Effects of episodic subluxation events on third body ingress and embedment in the THA bearing surface

In total joint arthroplasty, third body particle access to the articulating surfaces results in accelerated wear. Hip joint subluxation is an under-recognized means by which third body particles could potentially enter the otherwise closely conforming articular bearing space. The present study was designed to test the hypothesis that, other factors being equal, even occasional events of femoral head subluxation greatly increase the number of third body particles that enter the bearing space and become embedded in the acetabular liner, as compared to level-walking cycles alone. Ten metal-on-polyethylene hip joint head-liner pairs were tested in a multi-axis joint motion simulator, with CoCrMo third body particles added to the synovial fluid analog. All component pairs were tested for 2h of level walking; half were also subjected to 20 intermittent subluxation events. The number and location of embedded particles on the acetabular liners were then determined. Subluxation dramatically increased the number of third body particles embedded in the acetabular liners, and it considerably increased the amount of scratch damage on the femoral heads. Since both third body particles and subluxation frequently occur in contemporary total hip arthroplasty, their potent synergy needs to be factored prominently into strategies to minimize wear.

Association of third body embedment with rim damage in retrieved acetabular liners

Third-body effects are a major cause of the substantial variability of wear in total hip replacements. One potential mechanism by which third-body debris can access wear-critical central regions of closely conforming metal-on-polyethylene bearing couples is by fluid convection during incidents of subluxation accompanying neck-on-liner impingement. To provide evidence for this premise, we determined the association of severity of liner rim indentation damage (indicative of impingement frequency/vigor) and the presence of embedded third-body debris in 194 implants retrieved at revision. Rim damage was graded using the five-point Hospital for Special Surgery scale. Particle embedment was assessed both manually and by means of an image analysis computer program that detected the composition, size, and location of each particle. Sixty-eight percent of the cups showed rim indentation damage. We found an association between severity of rim damage and presence of embedded debris. There was substantial nonuniformity of the spatial distribution of the embedded debris, with the predominance of embedded debris at intermediate latitudes. These findings support the premise of convection of debris-laden joint fluid during lever-out subluxation as a mechanism for wear-consequential third-body particles to gain access to highly loaded regions of the bearing surface, thus potentiating increased wear.

Three-dimensional laser micrometry characterization of surface wear in total hip arthroplasty

Even after decades of clinical use, our ability to quantify wear across total hip replacement implant surfaces is largely limited to single value measurements. The influence of patient factors on wear remains enigmatic. This pilot study for the development of three-dimensional laser micrometry (3DLM) introduces an easy, accurate means of 'mapping' and quantifying material removal. A three-dimensional laser micrometer was constructed using a laser micrometer having an accuracy of 0.5 microm. A 3D surface map is triangulated from a point cloud consisting of approximately 140,000 individual points. Comparison to a reference sphere determines radial wear over the entire surface. 3DLM was able to map and quantify fine scale surface features. Even for zirconia on relatively soft ultra-high molecular weight polyethylene, this technique maps the contributions of localized wear at the macroscopic level. The 0.5 microm (or greater) accuracy of these lasers allows us to image surfaces with a high degree of confidence. This analysis lends itself well to automation, and we anticipate that this advance will prove valuable in establishing that each head and cup combination emerging from a given clinical environment has unique wear patterns as observed in this trial data set.

Analysis of 16 retrieved proximally cemented femoral stems

Sixteen proximally cemented, collared, and distally splined, Bridge Hip femoral stems with a matte proximal surface and smooth distal surface were retrieved because of loosening. Electron microscopy, with correlated elemental analysis, identified titanium particulate embedded in the internal surface of the cement mantle. Data supported the observations that loosening of the femoral stems was related to proximal debonding at the cement-implant interface, loosening at the proximal cement-bone interface, and inherent rotational instability. Cement-implant interface debonding resulted in the proximally matte femoral stem surface abrading with the opposing cement mantle, resulting in particulate and osteolysis in some cases. Careful consideration of implant design and clinically relevant biomechanical testing protocols should be considered before the clinical introduction of future proximally cemented femoral stems.

Microstructural disassembly of calcium phosphates

Microstructural factors may play a role in the osseointegration of calcium phosphates. In this paper, direct microstructural interactions between crystalline calcium phosphates and the biological milieu are reported. Degradation via exposure to osteoblast culture closely resembles in vivo interactions with subcutaneous tissues in a bovine model at early time periods. That these interactions were common to both experiments constitutes one of the few known examples of in vitro-in vivo correspondence. Interestingly, the degradation of phase pure hydroxyapatite (HA) in vitro was more rapid than that of biphasic HA in vivo. In both cases, grain extraction/pullout was frequently observed. This suggests a connection to smaller-scale observations of epitaxial CHA nucleation and growth on pre-existing HA grains. A microstructure in which the grain boundary is dissolving/corroding can apparently be disassembled by forces transmitted through biological structures. These observations are distinct from those of simple non-biological solutions and prove that biological environments can interact with the material beneath the ceramic-cell/ceramic-tissue interface. Many often ignored microstructural factors-grain size, shape, grain boundary strength and the presence of impurity phases-may in fact control degradation. We also suggest that even relatively modest initial grain sizes will, in combination with the mild/absent foreign body response to calcium phosphates, result in lengthy in vivo particle resistence.

Spinal cage retrieval and assessment of biologic response

Implant retrieval programs have been effective in understanding implant failure and biomaterial compatibility in joint arthroplasty; however, its application has not been extended extensively to the assessment of spinal constructs and implants. The objective of this study is to determine the efficacy of implant retrieval analysis as a standard for the assessment of explanted spinal implants. The limitations of clinical radiographic assessment of fusion through metal interbody devices are also identified. The implant analysis protocol is shown through a case report of a titanium mesh spinal fusion cage retrieved from a 54-year-old woman who had a pseudoarthrosis at the T12 cage interface. The implant analysis techniques include backscattered electron imaging, high-resolution contact radiography, histology, and fluorochrome analysis. An implant retrieval analysis program similar to the one discussed in the presented case study will enable an accurate assessment of outcomes of these commonly used implants and will guide future development.

Possible explanation for the white band artifact seen in clinically retrieved polyethylene tibial components

Studies have focused attention on the appearance of a subsurface white band in clinically retrieved polyethylene components and the possible contribution of this phenomenon to early polyethylene delamination. Unconsolidated polyethylene particles and oxidation have been suggested as possible reasons for the appearance of the white band. Calcium stearate and other additives used in processing ultra-high molecular weight polyethylene may also contribute to formation of the white band. A quantitative investigation was conducted on 11 retrieved tibial components that exhibited a subsurface white band to determine whether the amount of calcium stearate particles and additives were greater in the white band region when compared with the mid-portion of the same section of polyethylene. Calcium stearate particles and other additives were quantified using backscattered electron imaging with correlated elemental analysis. The particles were identified based on morphology and elemental patterns similar to reference calcium stearate particles and known additives. Significantly more (p < 0. 0001) calcium stearate particles and additives were present in the white band region (4578 +/- 418 particles/mm(2); mean +/- standard error) than the mid-portion region (1250 +/- 147 particles/mm(2)) of the sectioned tibial inserts. The percent area occupied by calcium stearate particles and additives was five times higher (p < 0.0001) within the white band region (0.81 +/- 0.10%) than the mid-portion region (0.16 +/- 0.03%). The increased presence of calcium stearate and other additives in the white band region suggests that they may play a role in the formation of the white band. In future investigations it may be important to consider how calcium stearate and other additives in polyethylene resins affect white band formation and the possible contribution to crazing, early delamination, and osteolysis in total joint replacement.