Effect of cross-linking on the microstructure and mechanical properties of ultra-high molecular weight polyethylene

Crystallographic Texture Evolution in 3D Printed Polyethylene Reactor Blends

In this work, crystallographic texture evolution in 3D printed trimodal polyethylene (PE) blends and high-density PE (HDPE) benchmark material were investigated to quantify the resulting material anisotropy, and the results were compared to materials made from conventional injection molded (IM) samples. Trimodal PE reactor blends consisting of HDPE, ultrahigh molecular weight PE (UHMWPE), and HDPE_wax have been used for 3D printing and injection molding. Changes in the preferred orientation and distribution of crystallites, i.e., texture evolution, were quantified utilizing the wide angle X-ray diffraction through pole figures and orientation distribution functions (ODFs) for 3D printed and IM samples. Since the change in weight-average molecular weight (Mw) of the blend was expected to significantly affect the resulting crystallinity and orientation, the overall Mw of the trimodal PE blend was varied while keeping the UHMWPE component weight fraction to 10% in the blend. The resulting texture was analyzed by varying the overall Mw of the trimodal blend and the process parameters in 3D printing and compared to the texture of conventional IM samples. The printing speed and orientation (defined with respect to the axis along the length of the samples) were used as the variable process parameters for 3D printing. The degree of anisotropy increases with an increase in the nonuniform distribution of intensities in pole figures and ODFs. All the highest intensity major texture components in IM and 3D printed samples (0° printing orientation) of reactor blends are observed to have crystals oriented in [001] or [001̅]. Overall, for the same throughput, 3D printed samples in the 0° orientation showed greater texture evolution and higher anisotropy compared to IM samples. Most notably, an increase in 3D printing speed increased the crystalline distribution closer to the 0° direction, increasing the anisotropy, while deviation from this printing orientation reduced crystalline distribution closer to the 0° direction, thus increasing isotropy. This demonstrates that tailoring material properties in specific directions can be achieved more effectively with 3D printing than with the injection molding process. Change in the overall Mw of the trimodal PE blend changed the preferential orientation distribution of the crystal planes to some degree. However, the degree of anisotropy remained the same in almost all cases, indicating that the effect of molecular weight distribution is not as significant as the printing speed and printing orientation in tailoring the resulting properties. The 3D printing process parameters (speed and orientation) were shown to have more influence on the texture than the material parameters associated with the blend.

Data-driven supervised machine learning to predict the compressive response of porous PVA/Gelatin hydrogels and in-vitro assessments: Employing design of experiments

The purpose of this study is to design and evaluate a series of porous hydrogels by considering three independent variables using the Box-Behnken method. Accordingly, concentrations of the constituent macromolecules of the hydrogels, Polyvinyl Alcohol and Gelatin, and concentration of the crosslinking agent are varied to fabricate sixteen different porous samples utilizing the lyophilization process. Subsequently, the porous hydrogels are subjected to a battery of tests, including Fourier Transform Infrared spectroscopy, morphology assessment, pore-size study, porosimetry, uniaxial compression, and swelling measurements. Additionally, in-vitro cell assessments are performed by culturing mouse fibroblast cells (L-929) on the hydrogels, where viability, proliferation, adhesion, and morphology of the L-929 cells are monitored over 24, 48, and 72 h to evaluate the biocompatibility of these biomaterials. To better understand the mechanical behavior of the hydrogels under compressive loadings, Deep Neural Networks (DNNs) are implemented to predict and capture their compressive stress-strain responses as a function of the constituent materials' concentrations and duration of the performed mechanical tests. Overall, this study emphasizes the importance of considering multiple variables in the design of porous hydrogels, provides a comprehensive evaluation of their mechanical and biological properties, and, particularly, implements DNNs in the prediction of the hydrogels' stress-strain responses.

Fostering Excellence in Knee Arthroplasty: Developing Optimal Patient Care Pathways and Inspiring Knowledge Transfer of Advanced Surgical Techniques

Osteoarthritis of the knee is common. Early sports trauma or cartilage defects are risk factors for osteoarthritis. If conservative treatment fails, partial or total joint replacement is often performed. A joint replacement aims to restore physiological biomechanics and the quality of life of affected patients. Total knee arthroplasty is one of the most performed surgeries in musculoskeletal medicine. Several developments have taken place over the last decades that have truly altered the way we look at knee arthroplasty today. Some of the fascinating aspects will be presented and discussed in the present narrative review.

Is Highly Cross-Linked Polyethylene Safe for Use in High-Flexion Posterior Stabilized Total Knee Arthroplasty?

BACKGROUND

Application of highly cross-linked polyethylene (HXLPE) to a posterior cruciate-substituting total knee arthroplasty (TKA) might add the risk of fracture and failure of the tibial polyethylene insert. The purpose of this study is to evaluate the long-term (up to 19 years) clinical and radiographic results of posterior cruciate-substituting TKAs with HXLPE or conventional polyethylene.

METHODS

This study analyzed the results of 1,217 patients (444 men and 773 women; mean age of 65 ± 7 years, range, 31-85) (2,434 knees) who had received a NexGen LPS-Flex prosthesis with a conventional tibial insert in one knee and the same prosthesis with an HXLPE tibial insert in the contralateral knee. The mean duration of follow-up was 17 years (range, 15-19).

RESULTS

The 2 groups did not differ significantly (P > .05) with regard to the clinical and radiographic results. No knee in either group had a fracture of the tibial polyethylene post or failure of the locking mechanism of the tibial polyethylene insert or osteolysis. Twenty-eight knees (2.3%) in the HXLPE group and 26 knees (2.1%) in the conventional polyethylene group were revised. The estimated survival rate at 17 years was 97.7% in the HXLPE group and 97.9% in the conventional polyethylene group.

CONCLUSION

The data suggest that clinical and radiographic findings at a mean of 17 years after posterior cruciate-substituting TKA are the same for patients treated with HXLPE and those treated with conventional polyethylene.

Improved oxidation stability and crosslink density of chemically crosslinked ultrahigh molecular weight polyethylene using the antioxidant synergy for artificial joints

Vitamin E (VE) is currently an approved antioxidant to improve the oxidation stability of highly crosslinked ultrahigh molecular weight polyethylene (UHMWPE) insert used commercially in total joint arthroplasty. However, the decrease in crosslink density caused by VE reduces wear resistance of UHMWPE, showing an uncoordinated challenge. In this work, we hypothesized that D-sorbitol (DS) as a secondary antioxidant can improve the antioxidant efficacy of VE on chemically crosslinked UHMWPE. The combined effect of VE and DS on oxidation stability of UHMWPE was investigated at a set of controlled hybrid antioxidant content. The hybrid antioxidant strategy showed significantly synergistic enhancement on the oxidation stability of chemically crosslinked UHMWPE compared with the single VE strategy. More strikingly, the crosslink density of the blends with hybrid antioxidants stayed at a high level since DS is not sensitive to crosslinking. The relationships between oxidation stability, mechanical properties, crosslink density, and crystallinity were investigated, by which the clinically relevant overall performance of UHMWPE was optimized. This work provides a leading-edge design mean for the development of joint bearings.

Influence of Accelerated Aging on the Wear Behavior of Cross-Linked Polyethylene Liners—A Hip Simulator Study

Sequential cross-linked and annealed ultra-high-molecular-weight polyethylene (SX-PE) is known as a low-wear articulating partner, especially for total hip endoprostheses. Aging of polymeric materials, irrespective of if induced by shelf or in vivo life, can degrade their tribological and mechanical properties. However, changes in wear behavior of aged SX-PE liners have not been not quantified so far. An accelerated aging procedure, to simulate shelf and in vivo aging, was performed on thin SX-PE liners after five million load cycles using a simulator (“worn-aged”) as well as on new SX-PE liners (“new-aged”). A subsequent hip simulator test was performed with both thin SX-PE liner sets in combination with large-diameter ceramic femoral head, representing a combination known as advantageous for treatment after revision because of dislocation. Oxidation indices were measured on the liners after each step of the procedure. SX-PE liners after accelerated aging show bedding-in phases during simulator test, which was a characteristic only known from clinical investigations. Hence, the wear rates of the “new-aged” ((1.71 ± 0.49) mg/million cycles) and of the “worn-aged” ((9.32 ± 0.09) mg/million cycles) SX-PE were increased in the first period compared to new unaged SX-PE liners. Subsequently, the wear rates decreased for “new-aged” and “worn-aged” inserts to (0.44 ± 0.48) mg/million cycles and (2.72 ± 0.05) mg/million cycles, respectively. In conclusion, the results show promising effects of accelerated aging on SX-PE liners in simulator testing and for potential long-term use in clinical applications.

Highly cross-linked polyethylene in primary total knee arthroplasty is associated with a lower rate of revision for aseptic loosening: a meta-analysis of 962,467 cases

BACKGROUND

The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA.

METHODS

The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: "cross-linked", "polyethylene", "HXLPE", "conventional", "total knee arthroplasty", "TKA", "total knee replacement" and "TKR" combined with Boolean operators AND and OR.

RESULTS

Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39-1.18; I²: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20-1.49; I²: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31-0.39; I²: 0.0%).

CONCLUSION

The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.

Highly Crosslinked Polyethylene Liners Have Negligible Wear at 10 Years: A Radiostereometric Analysis Study

BACKGROUND

The introduction of crosslinked ultra-high molecular weight polyethylene (XLPE) acetabular liners has been very successful, with decreased wear and reduction in the rates of revision hip arthroplasties. XLPE is the preferred articulation for most surgeons; however, there are concerns about the long-term performance of XLPE liners created with different manufacturing processes, which may lead to time-dependent failure, including accelerated wear, after several years.

QUESTIONS/PURPOSES

(1) What is the amount and rate of wear during the first 10 years using radiostereometric analysis (RSA) measurements of patients who had THAs that included a second-generation XLPE bearing? (2) Does the rate of wear change after 5 years in situ?

METHODS

This is a brief follow-up of a previous RSA study. In that study, we prospectively enrolled 21 patients with osteoarthritis who underwent primary cementless THA with an XLPE acetabular liner (three cycles of 3Mrad annealed) and 32-mm articulation. That group represented 44% of the 48 THAs performed by the surgeon at the hospital where RSA was available; 16 had cemented hips, leaving 32 who were invited to participate in this study. Of those, 11 lived rurally and declined to participate, leaving 21 patients who were included in the initial study. Since then, three patients died, one developed dementia and could not participate, and one had revision THA for reasons other than wear, leaving 16 patients available for analysis at 10 years. Tantalum markers were inserted during surgery, and all patients had RSA radiographs taken at 1 week, 6 months, and 1, 2, 5, and 10 years postoperatively. Femoral head penetration into the acetabular component was measured with RSA, including bedding-in during the first year and annual wear thereafter.

RESULTS

The median medial, proximal, anterior, two-dimensional (2D), and three-dimensional (3D) wear rates between 1 and 10 years were -0.001, 0.004, -0.012, 0.000, and 0.002 mm/year, respectively. No patient in this cohort had a proximal or 2D wear rate greater than 0.025 mm/year. The median proximal wear rate between 5 and 10 years (0.002 mm/year) was not greater than wear at 1 to 5 years (0.004 mm/year).

CONCLUSION

Femoral head penetration in this second-generation XLPE liner remained very low at 10 years and accelerated wear after 5 years in situ did not occur. Concerns about late-onset wear from oxidation of irradiated-annealed XLPE were not observed. The low level of wear remains encouraging for the future clinical performance of this material.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Patellar management during total knee arthroplasty: a review

The optimal management of the patella during total knee arthroplasty (TKA) remains controversial and surgeons tend to approach the patella with one of three general mindsets: always resurface the patella, never resurface the patella, or selectively resurface the patella based on specific patient or patellar criteria.

Studies comparing resurfacing and non-resurfacing of the patella during TKA have reported inconsistent and contradictory findings.

When resurfacing the patella is chosen, there are a number of available patellar component designs, materials, and techniques for cutting and fixation.

When patellar non-resurfacing is chosen, several alternatives are available, including patellar denervation, lateral retinacular release, and patelloplasty. Surgeons may choose to perform any of these alone, or together in some combination.

Prospective randomized studies are needed to better understand which patellar management techniques contribute to superior postoperative outcomes. Until then, this remains a controversial topic, and options for patellar management will need to be weighed on an individual basis per patient.

Cite this article: EFORT Open Rev 2021;6:861-871. DOI: 10.1302/2058-5241.6.200156

The Effect of Dialkyl Peroxide Crosslinking on the Properties of LLDPE and UHMWPE

Peroxide has been considered a chemical agent that can be used to tune the properties of polymeric materials. This research evaluated the influence of different concentrations of dialkyl peroxides on the mechanical, thermal, and morphological properties of linear low-density polyethylene (LLDPE) and ultra-high molecular weight polyethylene (UHMWPE). The neat polymer, as well as those with the addition of 1% and 2% by mass of dialkyl peroxides, were subjected to compression molding and immersion in water for 1 h, under controlled temperatures of 90 °C. The values of the gel content found in the samples indicated that the addition of peroxide to the LLDPE and to the UHMWPE promoted the formation of a reticulated network. The structure obtained by the crosslinking led to less reorganization of the chains during the crystallization process, resulting in the formation of imperfect crystals and, consequently, in the reduction in melting temperatures, crystallization and enthalpy. The mechanical properties were altered with the presence of the crosslinker. The polymers presented had predominant characteristics of a ductile material, with the occurrence of crazing with an increased peroxide content.

Vitamin E-enriched polyethylene bearings are not inferior to Arcom bearings in primary total knee arthroplasty at medium-term follow-up

INTRODUCTION

The release of wear particles can be responsible for periprosthetic osteolysis, which can in turn, lead to aseptic loosening. Vitamin E-infused polyethylene (HXLPE Vit-E) has been shown, in vitro, to be more resistant to wear than conventional polyethylene (UHMWPE) by its crosslinking (HXLPE) and its higher resistance to oxidation. After reading a case report of a fracture of a vitamin E-enriched HXLPE bearing, the aim of this retrospective study was to evaluate fracture risk and clinical inferiority or not of vitamin-E HXLPE compared to conventional polyethylene in total knee arthroplasty (TKA).

MATERIALS AND METHODS

Three hundred and forty-nine patients (403 TKAs) were contacted, to find out whether they had undergone revision surgery for any reason after a mean (SD) of 7 (1.5) years. Follow-up control radiographs were analyzed for periprosthetic radiolucent lines (RLL) and loosening. Two different Patient Reported Outcome Measurements Scores (PROMS), KOOS and FJS-12, were utilized to assess the daily functionality and identify potential problems.

RESULTS

No statistically significant difference in revision rate, occurrence of aseptic loosening or RLL nor outcome as measured with PROMS was observed.

CONCLUSIONS

No bearing fractures or clinical inferiority was observed for vitamin E-enriched HXLPE at medium-term follow-up (7 years) compared to conventional Arcom polyethylene.

LEVEL OF EVIDENCE

Level III, therapeutic study.

In Vitro Degradation of Specimens Produced from PLA/PHB by Additive Manufacturing in Simulated Conditions

Biopolymers have been the most frequently studied class of materials due to their biodegradability, renewability, and sustainability. The main aim of the presented study was to evaluate degradability of the polymer material blend which was immersed in different solutions. The present study included the production of three different mixtures of polylactic acid and polyhydroxybutyrate, each with a different content of triacetin, which was used as a plasticiser. Applying 3D printing technology, two types of cylindrical specimen were produced, i.e., a solid and a porous specimen, and subjected to in vitro natural degradation. The biodegradation process ran for 195 days in three different solutions (saline, phosphate-buffered saline (PBS), and Hank's solution) in stable conditions of 37 °C and a pH of 7.4, while the specimens were kept in an orbital motion to simulate the flow of fluids. The goal was to identify the effects of a solution type, specimen shape and material composition on the biodegradation of the materials. The monitored parameters included changes in the solution quantity absorbed by the specimens; morphological changes in the specimen structure; and mechanical properties. They were measured by compressive testing using the Inspekt5 Table Blue testing device. The experiment revealed that specimen porosity affected the absorption of the solutions. The non-triacetin materials exhibited a higher mechanical resistance to compression than the materials containing a plasticiser. The final result of the experiment indicated that the plasticiser-free specimens exhibited higher values of solution absorption, no formation of block cracks or bubbles, and the pH values of the solutions in which these materials were immersed remained neutral for the entire experiment duration; furthermore, these materials did not reduce pH values down to the alkaline range, as was the case with the solutions with the plasticiser-containing materials. Generally, in applications where high mechanical resistance, earlier degradation, and more stable conditions are required, the use of non-plasticiser materials is recommended.

Additive Lithography-Organic Monolayer Patterning Coupled with an Area-Selective Deposition

The combination of area-selective deposition (ASD) with a patternable organic monolayer provides a versatile additive lithography platform, enabling the generation of a variety of nanoscale feature geometries. Stearate hydroxamic acid self-assembled monolayers (SAMs) were patterned with extreme ultraviolet (λ = 13.5 nm) or electron beam irradiation and developed with ASD to achieve line space patterns as small as 50 nm. Density functional theory was employed to aid in the synthesis of hydroxamic acid derivatives with optimized packing density to enhance the imaging contrast and improve dose sensitivity. Near-edge X-ray absorption fine structure spectroscopy and infrared spectroscopy reveal that the imaging mechanism is based on improved deposition inhibition provided by the cross-linking of the SAM to produce a more effective barrier during a subsequent deposition step. With patterned substrates composed of coplanar copper lines and silicon spacers, hydroxamic acids selectively formed monolayers on the metal portions and could undergo a pattern-wise exposure followed by ASD in the first combination of a patternable monolayer with ASD. This material system presents an additional capability compared to traditional ASD approaches that generally reflect a starting patterned surface. Furthermore, this bottoms-up additive approach to lithography may be a viable alternative to subtractive nanoscale feature generation.

Long-Term Assessment of Highly Cross-Linked and Compression-Molded Polyethylene Inserts for Posterior Cruciate-Substituting TKA in Young Patients: A Concise Follow-up of a Previous Report

The purpose of the present study was to determine the long-term clinical and radiographic results, survival rate, prevalence of osteolysis, and prevalence of fracture of the tibial polyethylene insert following total knee arthroplasty (TKA). Three hundred patients (600 knees) were included in this follow-up study. The mean age of the patients (and standard deviation) was 60.3 ± 4.3 years, and the mean duration of follow-up was 13.2 years (range, 12 to 14 years). Revision of the TKA prosthesis was performed in 7 knees (2.3%) with a compression-molded polyethylene (CPE) tibial insert and 6 knees (2%) with a highly cross-linked polyethylene (HXLPE) tibial insert. The rate of survival at 14 years was 97.7% (95% confidence interval [CI], 94%-100%) in the CPE group and 98% (95% CI, 94%-100%) in the HXLPE group with reoperation for any reason as the end point. The rate of survival at 14 years was 98% (95% CI, 94%-100%) in both groups with reoperation for mechanical failure as the end point. No knee had osteolysis or fracture of the tibial polyethylene insert. There were no between-group differences. LEVEL OF EVIDENCE:: Therapeutic Level I. See Instruction for Authors for a complete description of levels of evidence.

Polyethylene in total knee arthroplasty: Where are we now?

Polyethylene (PE) remains the gold standard for the articulating surface in hip and knee arthroplasty. To increase arthroplasty longevity and improve wear resistance, newer versions of PE have been designed with resultantly different wear properties. Highly cross-linked polyethylene (HXLPE) is used in total hip arthroplasty with excellent outcomes; however, its use in total knee arthroplasty (TKA) remains conflicting. This review summarizes biomechanical and wear properties, clinical outcomes, and cost of polyethylene inserts in TKA. Simulation studies have convincingly shown decreased wear and oxidation rates with HXLPE when compared to conventional polyethylene (CPE). Registry results have been conflicting, and short- to midterm clinical studies have not demonstrated a significant difference between HXLPE and CPE. The cost of HXLPE inserts is higher than CPE. Long-term clinical data are lacking and further studies are warranted to evaluate the role of HXLPE in TKA.

Crosslinked PVA/SSA proton exchange membranes: correlation between physiochemical properties and free volume determined by positron annihilation spectroscopy

Two processes for crosslinking polyvinyl alcohol (PVA) with sulfosuccinic acid (SSA) and thermal crosslinking were used to fabricate a proton exchange membrane (PEM). Such PEMs are used in different fields involving fuel cell applications. The crosslinking reaction between PVA and SSA was confirmed using Fourier-transform infrared (FTIR) spectroscopy. The characterization of the prepared membranes, namely, ion exchange capacity (IEC), thermal analyses, water uptake, and ionic conductivity, was carried out. The IEC of the prepared membranes was found to be between 0.084 and 2.086 mmol g-1, resulting in an essential increase in the ionic conductivity. It was observed that the ionic conductivity was in the range of 0.003-0.023 S cm-1, depending on both temperature and SSA content. From the thermogravimetric analysis (TGA) results, it was revealed that the thermal stability of the crosslinked membranes improved. Moreover, water uptake decreased with increasing SSA content. Positron annihilation lifetime spectroscopy (PALS) was used to study the microstructure of the PVA/SSA membranes and their distribution at different ambient temperatures and relative humidity (RH) values. At room temperature, no significant change was observed in the free-volume holes up to 15 wt% SSA; thereafter, the size of the free-volume holes increased with the SSA content. The PALS results show that at different humidity values, the size of the free-volume holes for crosslinked PVA/SSA membranes is lower than those for Nafion membranes, i.e., the gas permeability for the prepared PVA/SSA membranes is less than that for the Nafion membrane. In addition, a strong correlation between the water uptake, ionic conductivity, tensile strength, and free-volume holes was observed.

Elastoplastic behavior of highly cross-linked and vitamin E-stabilized polyethylene - A biomechanical study

BACKGROUND

Vitamin E-stabilized cross-linked polyethylene has been touted to alleviate the negative effects of oxidation. Although it has demonstrated significant improvements in wear resistance, bio-tribology, and oxidative resistance, little is known about the effect of antioxidants and dosage of cross-linking on the mechanical strength. This study aimed to evaluate the mechanical properties of these novel materials, which are commonly used in orthopedic implants.

METHODS

Samples of different polymers were prepared with various levels of cross-linking and with or without vitamin E-stabilization and then tested according to ASTM D695 and D638. The elastoplastic characteristics under compression and tension were compared between the groups.

FINDINGS

Vitamin E-stabilized cross-linked polyethylene showed a significant increase in elastic modulus over other groups, with a maximum increase of 26% in compression and 40% in tension when compared to the highly cross-linked group without vitamin E stabilization. The elastoplastic behavior under compression differed to that in tension for all polymers, demonstrating the anisotropic characteristics of these polymers.

INTERPRETATION

The lower mechanical strength of highly cross-linked polyethylene has been a complication with the use of this polymer in orthopedic liners. This current study suggests that vitamin E-stabilized cross-linked polyethylene could be a suitable alternative material for knee implants because of its improved strength in resisting external forces.

Osteolysis as it Pertains to Total Hip Arthroplasty

Osteolysis is a long-term complication of total hip arthroplasty (THA). As the projected number of THAs performed annually increases, osteolysis will likely continue to occur. However, because of advancements in prosthesis design, metallurgy, and enhanced bearing surfaces, fewer revision THAs will be linked to osteolysis and aseptic loosening. Despite these improvements, no preventative therapies are currently available for the management of osteolysis other than removing and replacing the source of bearing wear.

The effect of bearing type on the outcome of total hip arthroplasty

Background and purpose - Alternative bearing surfaces such as ceramics and highly crosslinked polyethylene (HXLPE) were developed in order to further improve implant performance of total hip arthroplasties (THAs). Whether these alternative bearing surfaces result in increased longevity is subject to debate. Patients and methods - Using the Dutch Arthroplasty Register (LROI), we identified all patients with a primary, non-metal-on-metal THA implanted in the Netherlands in the period 2007-2016 (n = 209,912). Cumulative incidence of revision was calculated to determine differences in survivorship of THAs according to bearing type: metal-on-polyethylene (MoPE), metal-on-HXLPE (MoHXLPE), ceramic-on-polyethylene (CoPE), ceramic-on-HXLPE (CoHXLPE), ceramic-on-ceramic (CoC), and oxidized-zirconium-on-(HXL)polyethylene (Ox(HXL)PE). Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons. Results - After adjustment for confounders, CoHXLPE, CoC, and Ox(HXL)PE resulted in a statistically significantly lower risk of revision compared with MoPE after 9 years follow-up (HR =0.8-0.9 respectively, compared with HR =1.0). For small (22-28 mm) femoral head THAs, lower revision rates were found for CoPE and CoHXLPE (HR =0.9). In the 36 mm femoral head subgroup, CoC-bearing THAs had a lower HR compared with MoHXLPE (HR =0.7 versus 1.0). Crude revision rates in young patients (< 60 years) for CoHXLPE, CoC, and Ox(HXL)PE (HR =0.7) were lower than MoPE (HR =1.0). However, after adjustment for case mix and confounders these differences were not statistically significant. Interpretation - We found a mid-term lower risk of revision for CoHXLPE, CoC, and Ox(HXL)PE bearings compared with traditional MoPE-bearing surfaces.

Is Cross-Linked Polyethylene an Improvement Over Conventional Ultra-High Molecular Weight Polyethylene in Total Knee Arthroplasty?

BACKGROUND

Reducing polyethylene (PE) wear by increasing the cross-linking encouraged surgeons to hope for increased total knee arthroplasty (TKA) survival rates. Different methods of manufacturing cross-linked polyethylene (XLPE) were introduced, following promising in vitro results. Is there a measurable effect of cross-linking on TKA survival?

METHODS

A registry study was conducted, focusing on fixed tibial inserts in primary TKA. Conventional PE represented 87% of the liners, 10% were cross-linked and 2% were antioxidant PE. Sixty-four percent of the liners were posterior-stabilized (PS). Survival of the different PE groups and survival of the main XLPE available were successively compared. We also looked for differences in the same brand implant groups with regard to PE type, as well as differences between cruciate retaining and PS knees.

RESULTS

No differences were found when looking at survival for any cause or for aseptic loosening only (P = .96). When comparing the XLPE available, X3 was found to have a better survival than Prolong or Smith & Nephew XLPE (P = .036). When the same implants and X3 or conventional PE were used, no difference could reach a statistical significance. With Zimmer LPS Flex, Prolong XLPE was even associated with a lower survival compared with conventional PE. On Stryker implants, only the Cox regression model allowed highlighting a difference between X3 XLPE and conventional PE, only in PS knees.

CONCLUSION

Increasing the cross-linking seems to only have a low effect, if any, on knee arthroplasty survival. Differences between brands could be found; the manufacturing process could play a role.

The use of highly crosslinked polyethylene in total knee arthroplasty

Advances in polyethylene (PE) in total hip arthroplasty have led to interest and increased use of highly crosslinked PE (HXLPE) in total knee arthroplasty (TKA). Biomechanical data suggest improved wear characteristics for HXLPE inserts over conventional PE in TKA. Short-term results from registry data and few clinical trials are promising. Our aim is to present a review of the history of HXLPEs, the use of HXLPE inserts in TKA, concerns regarding potential mechanical complications, and a thorough review of the available biomechanical and clinical data. Cite this article: Bone Joint J 2017;99-B:996-1002.

Effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty

Background and purpose - Recurrent dislocation is the commonest cause of early revision of a total hip arthropasty (THA). We examined the effect of femoral head size and surgical approach on revision rate for dislocation, and for other reasons, after total hip arthroplasty (THA). Patients and methods - We analyzed data on 166,231 primary THAs and 3,754 subsequent revision THAs performed between 2007 and 2015, registered in the Dutch Arthroplasty Register (LROI). Revision rate for dislocation, and for all other causes, were calculated by competing-risk analysis at 6-year follow-up. Multivariable Cox proportional hazard regression ratios (HRs) were used for comparisons. Results - Posterolateral approach was associated with higher dislocation revision risk (HR =1) than straight lateral, anterolateral, and anterior approaches (HR =0.5-0.6). However, the risk of revision for all other reasons (especially stem loosening) was higher with anterior and anterolateral approaches (HR =1.2) and lowest with posterolateral approach (HR =1). For all approaches, 32-mm heads reduced the risk of revision for dislocation compared to 22- to 28-mm heads (HR =1 and 1.6, respectively), while the risk of revision for other causes remained unchanged. 36-mm heads increasingly reduced the risk of revision for dislocation but only with the posterolateral approach (HR =0.6), while the risk of revision for other reasons was unchanged. With the anterior approach, 36-mm heads increased the risk of revision for other reasons (HR =1.5). Interpretation - Compared to the posterolateral approach, direct anterior and anterolateral approaches reduce the risk of revision for dislocation, but at the cost of more stem revisions and other revisions. For all approaches, there is benefit in using 32-mm heads instead of 22- to 28-mm heads. For the posterolateral approach, 36-mm heads can safely further reduce the risk of revision for dislocation.

Ultra-High Molecular Weight Polyethylene: Influence of the Chemical, Physical and Mechanical Properties on the Wear Behavior. A Review

Ultra-high molecular weight polyethylene (UHMWPE) is the most common bearing material in total joint arthroplasty due to its unique combination of superior mechanical properties and wear resistance over other polymers. A great deal of research in recent decades has focused on further improving its performances, in order to provide durable implants in young and active patients. From "historical", gamma-air sterilized polyethylenes, to the so-called first and second generation of highly crosslinked materials, a variety of different formulations have progressively appeared in the market. This paper reviews the structure-properties relationship of these materials, with a particular emphasis on the in vitro and in vivo wear performances, through an analysis of the existing literature.

Analysis of severely fractured glenoid components: clinical consequences of biomechanics, design, and materials selection on implant performance

BACKGROUND

The longevity of total shoulder replacement is primarily limited by the performance of the ultrahigh-molecular-weight polyethylene (UHMWPE) glenoid component in vivo. Variations in glenoid design (conformity, thickness), biomechanics (joint kinematics), and UHMWPE material selection (sterilization, cross-linking) distinguish total shoulder replacements from hip and knee arthroplasty devices. These variables can lead to severe mechanical failures, including gross fracture.

METHODS

Sixteen retrieved glenoids with severe fracture were analyzed. The explant cohort included 3 material groups (gamma-sterilized Hylamer; gamma-sterilized UHMWPE; and gas plasma-sterilized, remelted, highly cross-linked UHMWPE [HXL]) and a range of conformities (0- to 10-mm radial mismatch). Analysis included fractography (optical and scanning electron microscopy) and Fourier transform infrared spectroscopy for oxidative analysis.

RESULTS

Fracture primarily occurred along the exterior rim for all 16 explants. Fourier transform infrared analysis and fractography revealed significant oxidative embrittlement for all gamma-sterilized glenoids. Fatigue striations and internal flaws were evident on the fracture surface of the HXL glenoid, with little oxidation detected.

CONCLUSIONS

Fracture initiated at the external rim of all devices. Elevated oxidation levels and visible material distortion for representative gamma-sterilized conventional and Hylamer devices suggest oxidative embrittlement as a driving force for crack inception and subsequent fracture. Brittle fracture of theHXL glenoid resulted from a combination of elevated contact stress due to a nonconforming surface, an internal flaw, and reduced resistance to fatigue crack growth. This demonstrates that glenoid fracture associated with oxidation has not been eliminated with the advent of modern materials (HXL) in the shoulder domain.

LEVEL OF EVIDENCE

Basic Science Study; Implant Retrieval Study.

Size and thickness effect on creep behavior in conventional and vitamin E-diffused highly crosslinked polyethylene for total hip arthroplasty

Since the early 2000s, the use of large femoral heads is becoming increasingly popular in total hip arthroplasty (THA), which provides an improved range of motion and joint stability. Large femoral heads commonly necessitate to be coupled with thinner acetabular liners than the conventionally used because of the limited sizes of outer shells (especially for patients with small pelvic size). However, the influence of the liner thinning on the mechanical performance is still not clearly understood. The objective of this study was to experimentally clarify the size and thickness effect on the rates of compressive creep strain in conventional (virgin low-crosslinked) and vitamin E-diffused highly crosslinked, ultra-high molecular weight polyethylene (UHMWPE) acetabular liners. We applied uniaxial compression to these liners of various internal diameters (28, 32 and 36mm) and thicknesses (4.8, 6.8 and 8.9mm) up to 4320min under the constant load of 3000N. Vitamin E-diffused highly crosslinked UHMWPE components showed significantly greater creep resistance than the conventional ones. In the both types of UHMWPE, the rates of creep strain significantly decreased by increasing the internal diameter and thickness. Varying the component thickness contributed more largely to the creep behavior rather than the internal diameter. Our results suggest the positive mechanical advantage of using large femoral heads, but at the same time, a considerable liner thinning is not recommended for minimizing creep strain. Therefore, the further in-vitro as well as in-vivo research are necessary to conclude the optimal balance of head diameter and liner thickness within the limited sizes of outer shells.

Cross-linked versus conventional polyethylene for total knee arthroplasty: a meta-analysis

BACKGROUND

Highly cross-linked polyethylene (HXLPE) has been reported as an effective material for decreasing polyethylene wear and osteolysis in total knee arthroplasty (TKA). Because no single study to date has been large enough to definitively determine the benefit of HXLPE in TKA, we conducted a meta-analysis to pool the results from randomized controlled trials (RCTs) and non-RCTs to make such a determination.

METHODS

Potential candidate articles were identified by searching the Cochrane Library, Medline (1966-2015.10), PubMed (1966-2015.10), Embase (1980-2015.10), ScienceDirect (1985-2015.10), and other databases. "Gray studies" were identified from the included articles' reference lists. Pooled data were analyzed using RevMan 5.1.

RESULTS

Three RCTs and three non-RCTs were included in the meta-analysis. There were no significant differences between the groups in the total number of reoperations (P = 0.11), reoperations for prosthesis loosening (P = 0.08), radiolucent line (P = 0.20), osteolysis (P = 0.38), prosthesis loosening (P = 0.10), and mechanical failures related to the tibial polyethylene (P = 1.00). Similarly, no significant differences between the two groups were found in postoperative total knee score (P = 0.18) or functional score (P = 0.23).

CONCLUSIONS

The meta-analysis showed that compared with conventional polyethylene, HXLPE did not improve the clinical and radiographic outcomes in mid-term follow-up after TKA. Additional high-quality multicenter prospective RCTs with good design, large study populations and long-term follow-up will be necessary to further clarify the effect of HXLPE in TKA.

The rates of wear of X3 highly cross-linked polyethylene at five years when coupled with a 36 mm diameter ceramic femoral head in young patients

Polyethylene wear debris can cause osteolysis and the failure of total hip arthroplasty. We present the five-year wear rates of a highly cross-linked polyethylene (X3) bearing surface when used in conjunction with a 36 mm ceramic femoral head. This was a prospective study of a cohort of 100 THAs in 93 patients. Pain and activity scores were measured pre- and post-operatively. Femoral head penetration was measured at two months, one year, two years and at five years using validated edge-detecting software (PolyWare Auto). At a mean of 5.08 years (3.93 to 6.01), 85 hips in 78 patients were available for study. The mean age of these patients was 59.08 years (42 to 73, the mean age of males (n = 34) was 59.15 years, and females (n = 44) was 59.02 years). All patients had significant improvement in their functional scores (p < 0.001). The steady state two-dimensional linear wear rate was 0.109 mm/year. The steady state volumetric wear rate was 29.61 mm(3)/year. No significant correlation was found between rate of wear and age (p = 0.34), acetabular component size (p = 0.12) or clinical score (p = 0.74). Our study shows low steady state wear rates at five years in X3 highly cross-linked polyethylene in conjunction with a 36 mm ceramic femoral head. The linear wear rate was almost identical to the osteolysis threshold of 0.1 mm/year recommended in the literature.

Surface Damage Is Not Reduced With Highly Crosslinked Polyethylene Tibial Inserts at Short-term

BACKGROUND

Highly crosslinked ultrahigh-molecular-weight polyethylene (XLPE) has been shown to reduce wear in hip arthroplasty, but the advantages over conventional polyethylene (PE) in total knee arthroplasty (TKA), if any, remain unclear.

QUESTIONS/PURPOSES

Do differences exist in (1) surface damage as measured by damage score and percent area affected; and (2) extent and location of dimensional changes between XLPE and conventional PE observed on retrieved TKA tibial inserts?

METHODS

In this study of components retrieved at the time of revision surgery, we matched 44 XLPE to 44 conventional PE inserts from four manufacturers; the matching approach considered implant design (exact match), insert size (exact match), and length of implantation (matched ± 6 months). Surface damage on the articular surfaces was subjectively graded and digitally mapped to determine the percent damaged area of each damage mode. Three-dimensional changes that had occurred as a result of implantation were determined by comparing laser scans of the retrieved inserts with size-matched pristine inserts.

RESULTS

The differences of damage scores and percent damaged areas between the matched XLPE and conventional PE inserts were not large enough to be clinically significant with low corresponding levels of statistical significance (scores: 42 ± 13; 95% confidence interval [CI], 38-46 versus 45 ± 13; 95% CI, 41-49; p = 0.4; percent areas: 54% ± 38%; 95% CI, 44%-64% versus 54% ± 32%; 95% CI, 42%-65%; p = 0.9). However, XLPE inserts showed greater articular surface dimensional changes with high significance (root mean square of the distance: 0.16 ± 0.06 mm; 95% CI, 0.13-0.18 mm versus 0.14 ± 0.05 mm; 95% CI, 0.11-0.16 mm; p = 0.03). Within the same design, deviation patterns were consistent between the two materials; however, as expected, the location of the dimensional changes differed among designs: the negative deviations on the plateaus were centrally located in Zimmer PS inserts, were located on the perimeter in Smith & Nephew PS inserts, and were across the entire surface in DePuy PS inserts.

CONCLUSIONS

We found no difference in surface damage between matched XLPE and conventional PE inserts of the same designs. However, increased dimensional changes in TKAs with XLPE may reflect larger contact areas and potentially explain improved performance of XLPE in published simulator studies.

CLINICAL RELEVANCE

The lack of meaningful differences between the two polyethylene materials suggests caution in adopting a new, more expensive bearing material over another material that has a long track record of excellent behavior. A possible advantage is the greater dimensional changes, which could be the result of the lower creep resistance of XLPE, but this advantage awaits long-term results.

Highly Crosslinked-remelted versus Less-crosslinked Polyethylene in Posterior Cruciate-retaining TKAs in the Same Patients

BACKGROUND

Concern regarding osteolysis attributable to polyethylene wear after TKA, particularly in younger patients, has prompted the introduction of highly crosslinked-remelted polyethylene (HXLPE) for TKAs. However, few in vivo comparative results of TKAs using HXLPE and less-crosslinked polyethylene inserts in the same patients are available, regarding fracture or failure of the locking mechanism of tibial polyethylene inserts or of osteolysis in patients younger than 60 years.

QUESTIONS/PURPOSES

We wanted to determine whether (1) survivorship free from aseptic loosening in knees with HXLPE inserts was different from survivorship in knees with less-crosslinked polyethylene inserts, (2) the prevalence of fracture or failure of the locking mechanism of the tibial polyethylene insert was greater in knees with HXLPE than in those with less-crosslinked polyethylene, and (3) the proportion of patients who had osteolysis develop was greater with HXLPE than with less-crosslinked polyethylene inserts.

METHODS

One hundred seventy-one patients with a mean age of 58 ± 8 years (range, 35-59 years) received posterior cruciate-retaining prostheses with a less-crosslinked polyethylene tibial insert in one knee and a HXLPE tibial insert in the contralateral knee. From January 2007 to January 2010, we performed 366 same-day bilateral simultaneous sequential posterior cruciate-retaining TKAs in 183 patients, of whom 171 (93%) participated in this study. All patients during this study period underwent posterior cruciate-retaining TKAs regardless of deformity of the knees and we did not perform posterior-stabilized TKAs during the same period. Patients who had bilateral end-stage osteoarthritis and were younger than 60 years were selected for inclusion. Six patients (4%) were lost to followup before 5 years. Twenty-six patients were males and 145 were females. The mean duration of followup was 6 years (range, 5-8 years). At each followup, patients were assessed for loosening of the components, fracture or failure of the locking mechanism of the polyethylene inserts, or osteolysis.

RESULTS

The survival rate of the knee prosthesis at a mean of 5.8 years after surgery was 100% (95% CI, 0.95-1.00) in both groups for the endpoint aseptic loosening and 99.4% (95% CI, 0.95-1.00) in both groups for the endpoint revision. No knee in either group had fracture or failure of the locking mechanism of the tibial polyethylene insert, and none had osteolysis.

CONCLUSIONS

With the numbers available, we found no clinically important differences between HXLPE and less-crosslinked polyethylene inserts in posterior cruciate-retaining TKAs. Given that HXLPE is newer, as-yet unproven, and more expensive than the proven technology (less-crosslinked polyethylene), we suggest not adopting HXLPE for clinical use until it shows superiority.

LEVEL OF EVIDENCE

Level I, therapeutic study.

The Divergence of Wear Propagation and Stress at Steep Acetabular Cup Positions Using Ceramic Heads and Sequentially Cross-Linked Polyethylene Liners

The aim of the present wear simulator study was to assess the effect of steep acetabular cup positions on the wear propagation of highly cross-linked-PE (HX-PE) liners. Furthermore, a finite element analysis (FEA) was performed in order to calculate the stress within the HX-PE material in case of steep cup positions under physiological loadings. The higher stress in the HX-PE at a steep acetabular cup position did not result in increased wear in the present wear simulator study. The gravimetrical wear rates at normal (45°) and steep cup inclinations (75°) showed wear amounts of 3.15±0.27mg and 2.18±0.31mg per million cycles (p=0.028), respectively. However, FEA revealed clear increase in stress at the HX-PE liners with respect to steep cup positions.

Polyethylene in knee arthroplasty: A review

Polyethylene (PE) has been used extensively in knee arthroplasty since the mid 20th century. Progress in material manufacturing and processing has led to newer polyethylenes over last few decades with different material properties. It has been established that PE wear in knee arthroplasty causes particle induced osteolysis which is the main reason for late failure and requires revision surgery. Although there are various causes of wear, the properties of PE have long been a matter of investigation as a contributory factor. The advent of newer highly cross linked PE has been shown to improve wear rates in hip arthroplasty but the benefits have not been shown to be of the same degree in knee arthroplasty. The laboratory and clinical studies so far are limited and slightly conflicting in their conclusions. The risks of using highly cross linked PE in knee arthroplasty include tibial post fracture, disruption of locking mechanism, liner fracture which can lead to increased wear and osteolysis. The current evidence suggests that highly cross linked polyethylenes should be used with caution and only considered in younger active patients. The results of a recently completed randomized trial to compare the conventional with high molecular weight PE in knee arthroplasty are awaited.

[Possibilities and limits of modern polyethylenes. With respect to the application profile]

BACKGROUND

Polyethylene is still one of the most important materials in the field of hip and knee arthroplasty. The clinical results of the last decades have helped to further develop polyethylene into a high-tech material. Progress in the development of new materials must be compared with the tried and tested ones to provide optimal and most individual patient care.

OBJECTIVES

This article gives an overview of the history and current application profile of the material ultra-high molecular weight polyethylene (UHMWPE) in hip and knee arthroplasty.

MATERIAL AND METHODS

With the aid of the current literature, new developments in the field of the material UHMWPE, also with respect to the biological activity of wear, the particular biomechanics of the knee joint as well as alternative hard-hard bearing surfaces in the hip, are represented in terms of implant safety.

RESULTS

The problems concerning polyethylene are now well recognized. The disadvantages of the material UHMWPE could be consistently reduced based on material research so that modern polyethylenes have gradually been shown in clinical trials that they can be reliably used.

CONCLUSION

Despite this the potential for improvement has still not yet been fully exploited. Any further development must be extensively tested both biomechanically and biologically before the material can be used in vivo. Long-term results are still necessary before a material can be accepted as being clinically safe.

An epichlorohydrin-crosslinked semi-interpenetrating GG-PEO network as a xerogel matrix for sustained release of sulpiride

The current study involved the development of a novel sustained release crosslinked semi-IPN xerogel matrix tablet prepared by chemical crosslinking of poly(ethylene) oxide (PEO) and gellan gum (GG) employing epichlorohydrin (EPI) as crosslinker. A Box-Behnken design was employed for the statistical optimization of the matrix system to ascertain the ideal combination of native polymeric and crosslinking agents. Characterization studies were performed by employing standard polymer characterization techniques such as Fourier transform infrared spectrometry, differential scanning calorimetry, and scanning electron microscopy. Formulated matrix tablets displayed zero-order release kinetics, extending over 24 h. The mechanism of drug release was primarily by swelling and surface erosion. Crosslinked semi-IPN xerogel matrix tablets were compared to non-crosslinked polymer blends; results from the study conducted showed that the physiochemical properties of the PEO and GG were sufficiently modified to allow for sustained release of sulpiride with a 100% drug release at 24 h in a controlled manner as compared to non-crosslinked formulations which displayed further release beyond the test period. Crosslinked formulations displayed water uptake between 450 and 500% indicating a controlled rate of swelling and erosion allowing for sustained release. Surface morphology of the crosslinked system depicted a porous structure formed by interpenetrating networks of polymers, allowing for a greater degree of controlled penetration into the system affording it the ability to sustain drug release. Therefore, conclusively, based on the study performed, crosslinked PEO-GG allows for the sustained release of sulpiride from a hydrophilic semi-IPN xerogel matrix system.

Implants for total hip arthroplasty

This article is a comprehensive review of the published literature on total hip replacement design. It seeks to provide a nonbiased view of the technology related to total hip implants and bearing surfaces. Implant designs and fixation methods are discussed with summaries of their respective long-term outcome studies. Fixation methods include cemented, cementless and hybrid techniques and are explained and presented with current outcome data and their respective failure modes that have promoted new technological development. The current data point toward cementless acetabular fixation as being superior to cemented fixation. As for stem fixation, there are good data to suggest that either method of fixation is acceptable in the proper setting. Also included in this article is a brief review of bearing surfaces and hip biomechanics.

Wear testing and particle characterisation of sequentially crosslinked polyethylene acetabular liners using different femoral head sizes

Larger femoral heads lead to a decreased risk of total hip dislocation and an improved range of motion. However, the larger diameter is associated with increased wear rates. The low wear rates of crosslinked polyethylene opens up the possibility of using larger heads. The aim of this experimental study was to evaluate the wear of conventional non-crosslinked versus sequentially crosslinked polyethylene liners in combination with different ceramic head sizes (28, 36, 44 mm). Wear testing was performed in a hip simulator according to ISO 14242. Wear particles from the polyethylene liners were characterized after wear testing. The wear measurements revealed a significant increase in the wear of crosslinked polyethylene liners with larger heads. By sequential crosslinking, however, the gravimetric wear using larger heads was reduced to a fractional amount of the wear using conventional polyethylene. Significant differences were observed for particle morphology but not for the number of particles when comparing non-crosslinked and crosslinked polyethylene.

Computational analysis of microstructure of ultra high molecular weight polyethylene for total joint replacement

Ultra high molecular weight polyethylene (UHMWPE, or ultra high), a frequently used material in orthopedic joint replacements, is often the cause of joint failure due to wear, fatigue, or fracture. These mechanical failures have been related to ultra high's strength and stiffness, and ultimately to the underlying microstructure, in previous experimental studies. Ultra high's semicrystalline microstructure consists of about 50% crystalline lamellae and 50% amorphous regions. Through common processing treatments, lamellar percentage and size can be altered, producing a range of mechanical responses. However, in the orthopedic field the basic material properties of the two microstructural phases are not typically studied independently, and their manipulation is not computationally optimized to produce desired mechanical properties. Therefore, the purpose of this study is to: (1) develop a 2D linear elastic finite element model of actual ultra high microstructure and fit the mechanical properties of the microstructural phases to experimental data and (2) systematically alter the dimensions of lamellae in the model to begin to explore optimizing the bulk stiffness while decreasing localized stress. The results show that a 2D finite element model can be built from a scanning electron micrograph of real ultra high lamellar microstructure, and that linear elastic constants can be fit to experimental results from those same ultra high formulations. Upon altering idealized lamellae dimensions, we found that bulk stiffness decreases as the width and length of lamellae increase. We also found that maximum localized Von Mises stress increases as the width of the lamellae decrease and as the length and aspect ratio of the lamellae increase. Our approach of combining finite element modeling based on scanning electron micrographs with experimental results from those same ultra high formulations and then using the models to computationally alter microstructural dimensions and properties could advance our understanding of how microstructure affects bulk mechanical properties. This advanced understanding could allow for the engineering of next-generation ultra high microstructures to optimize mechanical behavior and increase device longevity.