Posterior wall acetabular fracture fixation: A mechanical analysis of fixation methods

Stable, anatomical fixation of acetabular fractures gives the best chance of successful outcome, while penetration of the acetabular articular surface with screws is associated with poor outcomes. Spring plates are an alternative to interfragmentary lag screws when penetration is a concern. A mechanical study comparing fracture stability and construct stiffness of three fixation methods for posterior wall acetabular fractures with transverse comminutions was performed. The three fixation methods tested were a posterior wall rim plate, a posterior wall buttress plate with separate lag screws and a posterior wall plate with two spring plates. Nine samples were tested, three for each fixation method. Two-dimensional motion analysis was used to measure fracture fragment displacement and construct stiffness. After two 6000 cycle-loading protocols, to a maximum 1.5 kN, the mean fracture displacement was 0.154 mm for the rim plate model, 0.326 mm for the buttress plate and 0.254 mm for the spring plate model. Mean maximum displacement was significantly less for the rim plate fixation than the buttress plate (p = 0.015) and spring plate fixation (p = 0.02). The rim plate was the stiffest construct 10,962 N/mm, followed by the spring plate model 5637 N/mm and the buttress plate model 4882 N/mm. Based on data obtained in this study, where possible a rim plate with interfragmentary lag screws should be used for isolated posterior wall fractures as this is the stiffest and most stable construct. When this method is not possible, spring plate fixation is a safe and a superior alternative to a posterior buttress plate method.

Non-invasive vibrometry-based diagnostic detection of acetabular cup loosening in total hip replacement (THR)

Total hip replacement is aimed at relieving pain and restoring function. Currently, imaging techniques are primarily used as a clinical diagnosis and follow-up method. However, these are unreliable for detecting early loosening, and this has led to the proposal of novel techniques such as vibrometry. The present study had two aims, namely, the validation of the outcomes of a previous work related to loosening detection, and the provision of a more realistic anatomical representation of the clinical scenario. The acetabular cup loosening conditions (secure, and 1 and 2 mm spherical loosening) considered were simulated using Sawbones composite bones. The excitation signal was introduced in the femoral lateral condyle region using a frequency range of 100-1500 Hz. Both the 1 and 2 mm spherical loosening conditions were successfully distinguished from the secure condition, with a favourable frequency range of 500-1500 Hz. The results of this study represent a key advance on previous research into vibrometric detection of acetabular loosening using geometrically realistic model, and demonstrate the clinical potential of this technique.

Interaction rewiring and the rapid turnover of plant-pollinator networks

Whether species interactions are static or change over time has wide-reaching ecological and evolutionary consequences. However, species interaction networks are typically constructed from temporally aggregated interaction data, thereby implicitly assuming that interactions are fixed. This approach has advanced our understanding of communities, but it obscures the timescale at which interactions form (or dissolve) and the drivers and consequences of such dynamics. We address this knowledge gap by quantifying the within-season turnover of plant-pollinator interactions from weekly censuses across 3 years in a subalpine ecosystem. Week-to-week turnover of interactions (1) was high, (2) followed a consistent seasonal progression in all years of study and (3) was dominated by interaction rewiring (the reassembly of interactions among species). Simulation models revealed that species' phenologies and relative abundances constrained both total interaction turnover and rewiring. Our findings reveal the diversity of species interactions that may be missed when the temporal dynamics of networks are ignored.

Contact Mechanics of Soft Layer Artificial Hip Joints: Part 2: Application to Joint Design

In this paper, the general solutions previously obtained for the contact mechanics of a soft layer artificial hip joint have been applied to the design of such joints. In particular, simple power-law design formulae have been generated for the prediction of the contact radius and the maximum Tresca shear stress within the elastomeric layer, when the aspect ratio varied from 1 to 20 (which covered the entire range of the aspect ratio for soft layer artificial hip joints). The effects of the layer thickness, Young's modulus of the layer and the equivalent radius of the joint upon the contact area and the maximum Tresca shear stress have all been examined for physiological loading conditions which would be experienced by hip joint prostheses in the body.

Furthermore, the shear strain field was calculated so that the level of strain expected for such joints under physiological loading conditions can be estimated. With these data, relevant fatigue tests can be devised to assess the long-term performance of any particular design of soft layer hip joint.

Finally, the effect of the friction between articular surfaces upon the stress field within soft layers has been examined using a newly developed asymptotic analytical theory. It was shown that, for a low coefficient of friction, the maximum Tresca shear stress occurred at layer-substrate bonding interface. With an increase in the coefficient of friction, however, the maximum Tresca shear stress increased its magnitude and moved towards the centre of the contact area along the articular surface.

Development of a non-invasive diagnostic technique for acetabular component loosening in total hip replacements

Current techniques for diagnosing early loosening of a total hip replacement (THR) are ineffective, especially for the acetabular component. Accordingly, new, accurate, and quantifiable methods are required. The aim of this study was to investigate the viability of vibrational analysis for accurately detecting acetabular component loosening. A simplified acetabular model was constructed using a Sawbones(®) foam block. By placing a thin silicone layer between the acetabular component and the Sawbones block, 2- and 4-mm soft tissue membranes were simulated representing different loosening scenarios. A constant amplitude sinusoidal excitation with a sweep range of 100-1500 Hz was used. Output vibration from the model was measured using an accelerometer and an ultrasound probe. Loosening was determined from output signal features such as the number and relative strength of observed harmonic frequencies. Both measurement methods were sufficient to measure the output vibration. Vibrational analysis reliably detected loosening corresponding to both 2 and 4 mm tissue membranes at driving frequencies between 100 and 1000 Hz (p < 0.01) using the accelerometer. In contrast, ultrasound detected 2-mm loosening at a frequency range of 850-1050 Hz (p < 0.01) and 4-mm loosening at 500-950 Hz (p < 0.01).

Analysis of failed Van Straten LPM proximal interphalangeal prostheses

The two-piece Van Straten Leuwen Poeschmann Metal (LPM) prosthesis was intended for the proximal interphalangeal joints. However, revision rates of 29% after 19 months were reported, as well as massive osteolysis. Five failed LPM titanium-niobium coated cobalt chromium components were obtained, three distal and two proximal, and subjected to a forensic retrieval analysis. Components were analyzed using a Talysurf contacting profilometer, ZYGO noncontacting profilometer, and environmental-scanning electron microscope. All components were heavily worn. In some regions the titanium-niobium coating had been scratched and penetrated. Elsewhere this coating had been removed where there was minimal scratching, which may have been due to corrosion between the coating and substrate. The osteolysis reported clinically was likely to be linked to the wear debris from the failed titanium-niobium coating and substrate.

A novel closed-loop electromechanical stimulator to enhance osseointegration with immediate loading of dental implant restorations

The degree of osseomechanical integration of dental implants is acutely sensitive to their mechanical environment. Bone, both as a tissue and structure, adapts its mass and architecture in response to loading conditions. Therefore, application of predefined controlled loads may be considered as a treatment option to promote early maturation of bone/implant interface prior to or in conjunction with crown/prosthesis attachment. Although many studies have established that the magnitude, rate of the applied strain, and frequency have significant effects on the osteogenic response, the actual specific relationships between strain parameters and frequency have not yet been fully defined. The purpose of this study was to develop a stimulator to apply defined mechanical stimuli to individual dental implants in vivo immediately after implantation, exploring the hypothesis that immediate controlled loading could enhance implant integration. An electromechanical device was developed, based on load values obtained using a two-dimensional finite element analysis of the bone/implant interface generating 1000 to 4000 pe and operated at 30 and 3 Hz respectively. The device was then tested in a cadaveric pig mandible, and periosteal bone surface strains were recorded for potential future comparison with a three-dimensional finite element model to determine loading regimens to optimize interface strains and iterate the device for clinical use.

Numerical and experimental simulation of the effect of long bone fracture healing stages on ultrasound transmission across an idealized fracture

The effect of various stages of fracture healing on the amplitude of 200 kHz ultrasonic waves propagating along cortical bone plates and across an idealized fracture has been modeled numerically and experimentally. A simple, water-filled, transverse fracture was used to simulate the inflammatory stage. Next, a symmetric external callus was added to represent the repair stage, while a callus of reducing size was used to simulate the remodeling stage. The variation in the first arrival signal amplitude across the fracture site was calculated and compared with data for an intact plate in order to calculate the fracture transmission loss (FTL) in decibels. The inclusion of the callus reduced the fracture loss. The most significant changes were calculated to occur from the initial inflammatory phase to the formation of a callus (with the FTL reducing from 6.3 to between 5.5 and 3.5 dB, depending on the properties of the callus) and in the remodeling phase where, after a 50% reduction in the size of the callus, the FTL reduced to between 2.0 and 1.3 dB. Qualitatively, the experimental results follow the model predictions. The change in signal amplitude with callus geometry and elastic properties could potentially be used to monitor the healing process.

Monitoring the mechanical properties of healing bone

Fracture healing is normally assessed through an interpretation of radiographs, clinical evaluation, including pain on weight bearing, and a manual assessment of the mobility of the fracture. These assessments are subjective and their accuracy in determining when a fracture has healed has been questioned. Viewed in mechanical terms, fracture healing represents a steady increase in strength and stiffness of a broken bone and it is only when these values are sufficiently high to support unrestricted weight bearing that a fracture can be said to be healed. Information on the rate of increase of the mechanical properties of a healing bone is therefore valuable in determining both the rate at which a fracture will heal and in helping to define an objective and measurable endpoint of healing. A number of techniques have been developed to quantify bone healing in mechanical terms and these are described and discussed in detail. Clinical studies, in which measurements of fracture stiffness have been used to identify a quantifiable end point of healing, compare different treatment methods, predictably determine whether a fracture will heal, and identify factors which most influence healing, are reviewed and discussed.

Development of degrees in medical engineering at the University of Bath

Because of increasing demands on the health care sector resulting from an ageing population and increasing quality of life expectations, the health care sector in general is growing and the requirement for trained engineers to work in this sector is likely to increase. Medical engineering is a relatively new area of university study, in which engineering principles are applied to medical systems, devices, and products. This paper outlines the initial design and development of a specialized degree course in Medical Engineering at the University of Bath and reports the subsequent experience with this as the degree has evolved.

Determination of pelvic ring stability: A new technique using a composite hemi-pelvis

Traumatic disruption of the pelvic ring caused by high-energy impact is associated with significant mortality and morbidity. A variety of fixation techniques have been developed for treating these injuries with the main aims of restoring the stability of the pelvic ring and promoting recovery of normal function. The stability of fixation of these techniques is often analysed by cadaveric studies, which can introduce high variability into the results and have small sample numbers. This study presents a new method that uses a composite hemi-pelvis to enable stabilization of the pelvic ring to be accurately determined. The pelvis was loaded cyclically to simulate walking conditions and to assess the stability of the fixation, which was measured using a displacement transducer that monitors the motion of the pelvis in six degrees of freedom. The motions measured showed comparable results with previously published cadaveric studies. This reproducible method of testing with a hemi-pelvis composite model and rig allows valid analysis of pubic symphysis implants, obviating the difficulties of performing a cadaveric study.

Weight bearing after tibial fracture as a guide to healing

BACKGROUND

Judging when it is safe to remove an external fixator or plaster cast requires clinical and radiological assessment, both of which are subjective. Weight bearing has been shown to increase with time post-fracture and we hypothesised that it could be used as an objective measure of fracture healing.

METHODS

Ground reaction force (and hence weight bearing) and fracture stiffness were measured serially in a group of 12 patients with tibial fractures treated by external fixation. Ground reaction force was measured for both fractured and non-fractured limbs using a force plate and the fracture stiffness was measured using the Orthometer, a commercially produced device for measuring the stiffness of fractures treated by external fixation.

FINDINGS

In 10 patients who made good recoveries, prior to fixator removal, weight bearing though the injured leg was seen to approach 90% of that through the uninjured leg and the fracture stiffness exceeded 15 Nm/deg. Two patients with delayed union achieved weight bearing of 40% of normal and a fracture stiffness of less than 5 Nm/deg at 20 weeks.

INTERPRETATION

Weight bearing correlates reasonably well with fracture stiffness. It is quicker and easier to measure than fracture stiffness and potentially has relevance to other fracture fixation methods.

Ultrasound transmission loss across transverse and oblique bone fractures: an in vitro study

An axial transmission technique has been used to investigate the changes in the first arrival time and signal amplitude of 200 kHz ultrasonic waves travelling across different fracture geometries. Results taken from intact bovine femora were compared with those produced when a transverse and an oblique fracture were simulated. The arrival time and signal amplitude displayed a different variation with receiver position for the two geometries and a given fracture gap width. A comparison between this work and a previous study suggested that the marrow does not play a significant role in the mechanisms causing the change in arrival time and signal amplitude. Numerical modelling revealed that an oblique fracture caused a reduction in the extra time delay of the propagating wave compared with the transverse case, but a decrease in the corresponding signal amplitude, i.e., greater signal loss. The angle of the oblique fracture was investigated and results suggested that decreasing the fracture angle relative to the wave propagation direction caused a decrease in the extra time delay and an increase in signal loss. These findings are important for determining the sensitivity of systems for monitoring fracture healing using ultrasound arrival time and signal amplitude. (E-mail: spd@inorbit.com).

Immediate functional loading of single-tooth TiO2 grit-blasted implant restoration. A controlled prospective study in a porcine model. Part II: Histology and histomorphometry

BACKGROUND

Evidently, there is a fast-moving shift from delayed to immediate implant loading. The hypothesis to be tested was that bone reactions adjacent to single TiO2-microthreaded implants exposed to immediate masticatory loading for 10 weeks after placement would modulate osseointegration.

MATERIALS AND METHODS

Cylindrical- and tapered-designed implants (Astra Tech AB, Mölndal, Sweden) replaced first and third mandibular premolars respectively in 12 pigs. The animals were allocated into two groups based on soft and hard diet feeding. Each animal received, at random positions, four different masticatory loading conditions: implant with either (1) a cover screw only, (2) a healing abutment, (3) an implant with a crown without occlusal contact, or (4) an implant with a crown in contact with the antagonistic teeth.

RESULTS

Histomorphometry showed that there were no statistically significant differences in bone-implant contact (BIC), bone mass inside/outside of the threads and soft tissue ingrowth ratio for all the implants at 10 weeks after placement irrespective of masticatory loading condition. Bone loss showed a trend of progressive increase for implants with a healing abutment toward implants with occlusal contact.

CONCLUSIONS

The results of this study rejected the hypothesis and could be explained by the fact that grit-blasted acid-etched implants were already placed in dense bone.

Modelling the effects of different fracture geometries and healing stages on ultrasound signal loss across a long bone fracture

The effect on the signal amplitude of ultrasonic waves propagating along cortical bone plates was modelled using a 2D Finite Difference code. Different healing stages, represented by modified fracture geometries were introduced to the plate model. A simple transverse and oblique fracture filled with water was introduced to simulate the inflammatory stage. Subsequently, a symmetric external callus surrounding a transverse fracture was modelled to represent an advanced stage of healing. In comparison to the baseline (intact plate) data, a large net loss in signal amplitude was produced for the simple transverse and oblique cases. Changing the geometry to an external callus with different mechanical properties caused the net loss in signal amplitude to reduce significantly. This relative change in signal amplitude as the geometry and mechanical properties of the fracture site change could potentially be used to monitor the healing process.

A brief history of total ankle replacement and a review of the current status

Total ankle replacement (TAR) was first attempted in the early 1970s, but poor early results lead to it being abandoned in favour of arthrodesis. Arthrodesis is not totally satisfactory, often causing further hindfoot arthritis and this has lead to a resurgence of interest in joint replacement. New designs which more closely approximated the natural anatomy of the ankle and associated biomechanics have produced more encouraging results and led to renewed interest in total ankle replacement. Three prostheses dominate the market: Agility, Buechel-Pappas and STAR, and improving clinical results with these devices have led to more designs appearing on the market. Modern designs of prosthetic ankles almost exclusively consist of three part prostheses with a mobile bearing component, similar to the Buechel-Pappas and STAR. Clinical results of these newer designs are limited and short-term and have often been carried out by the designers of the implants. This paper presents a brief history of the development of total ankle replacement and a review of the current status.

Precision of wear measurement using the shadowgraph technique

The shadowgraph technique is a relatively easy-to-use and inexpensive method of wear measurement from explanted acetabular cups. In this technique, from a mould of the internal surface of the cup, measurements of linear wear and wear angle can be obtained, from which volumetric wear can be calculated. In this study the measurement precision of this technique was assessed and the influence of different observers and multiple moulds was also determined. It was found that linear wear (coefficient of variation (CV) = 1.49 per cent) can be more precisely determined than wear angle (CV = 8.18 per cent) and that both the observer and the mould can significantly influence the results obtained, although the influence of the mould is considerably less than that of the observer.

Bone vibration measurement using ultrasound: application to detection of hip prosthesis loosening

Hip prosthesis loosening can be determined in vivo using a vibration-based technique called vibrometry. In this technique, a low frequency (<1000Hz) sinusoidal vibration is applied to the femoral condyles and the resulting vibration is measured at the greater trochanter. If the prosthesis is securely fixed, the output vibration signal matches that of the input vibration, whereas if the prosthesis is loose, the output vibration signal is distorted and shows the marked presence of harmonics of the input frequency. One of the main problems with this application of this technique is in measuring the output vibration where significant amounts of soft tissue cover the measurement site. In order to circumvent this problem, an ultrasound probe, normally used for the measurement of blood flow, has been used to measure the output vibration. This has been evaluated by comparing the results obtained from the ultrasound probe with those from a conventional accelerometer in models representing a tight and loose hip prosthesis under simulated clinical conditions. The ultrasound probe was able to consistently detect the output vibration, for both the loose and secure prostheses. Under the test conditions used (which attempted to simulate a large thickness of soft tissue), the ultrasound probe was able to produce a greatly enhanced output vibration signal compared to the accelerometer. This suggests that the use of an ultrasound probe to detect mechanically induced vibration through significant amounts of soft tissue appears to be viable and could lead to enhanced detection of prosthesis loosening using this technique.

An in vitro study of ultrasound signal loss across simple fractures in cortical bone mimics and bovine cortical bone samples

Measurements have been performed on Sawbones and bovine cortical bone samples at 200 kHz using an axial transmission technique to investigate the factors that determine how ultrasonic waves propagate across a simulated fracture. The peak amplitude of the first arrival signal (FAS) was studied. Results taken from intact specimens were compared with those produced when a simple transverse fracture was introduced. These fracture simulation experiments were found to be consistent with Finite Difference modelling of the experimental conditions. The peak amplitude showed a characteristic variation across the fracture caused by interference between reradiated and scattered/diffracted waves at the fracture site and a net Fracture Transmission Loss (FTL). For small fracture gaps, the change in amplitude was sensitive to the presence of the fracture. This sensitivity suggests that this parameter could be a good quantitative indicator for the fracture healing process assuming the relative change in this parameter brought about by healing is measurable.

Shear bond strength and residual adhesive after orthodontic bracket debonding

OBJECTIVE

To compare the shear bond strength and determine the area of residual adhesive on teeth after the debonding of brackets bonded with two types of orthodontic adhesives. These were a resin-modified glass ionomer cement (RMGIC; Fuji ORTHO LC, GC Corporation, Tokyo, Japan) and a resin applied as a precoated bracket (APC bracket, 3M Unitek GmbH, Seefeld, Germany).

MATERIALS AND METHODS

A total of 60 premolar teeth were randomly divided into two groups, and brackets were bonded according to the manufacturers' instructions. In group 1, the teeth were conditioned using 10% polyacrylic acid, and the brackets were bonded using Fuji Ortho LC in wet condition. In group 2, the teeth were etched using 37% phosphoric acid, and the APC brackets were bonded. Bond strength was measured using a testing instrument (2000S, Lloyds Instruments, Fareham, England) at a crosshead speed of 1 mm/min, and the residual adhesive was quantified using a three-dimensional laser scanning instrument.

RESULTS

The Mann-Whitney test showed that the median bond strength of group 1 was significantly lower than that of group 2 (P < .001). A Pearson chi-square test of the Adhesive Remnant Index (ARI) revealed a significant difference among the groups tested. All the adhesives in group 1 failed at the enamel/adhesive interface (100%), whereas group 2 exhibited cohesive failure of the adhesive (90%).

CONCLUSIONS

The bond strength values obtained with the RMGIC were above the minimum values suggested in the literature to achieve a clinically effective adhesion in orthodontics.

Ultrasonic propagation in cortical bone mimics

Understanding the velocity and attenuation characteristics of ultrasonic waves in cortical bone and bone mimics is important for studies of osteoporosis and fractures. Three complementary approaches have been used to help understand the ultrasound propagation in cortical bone and bone mimics immersed in water, which is used to simulate the surrounding tissue in vivo. The approaches used were Lamb wave propagation analysis, experimental measurement and two-dimensional (2D) finite difference modelling. First, the water loading effects on the free plate Lamb modes in acrylic and human cortical bone plates were examined. This theoretical study revealed that both the S0 and S1 mode velocity curves are significantly changed in acrylic: mode jumping occurs between the S0 and S1 dispersion curves. However, in human cortical bone plates, only the S1 mode curve is significantly altered by water loading, with the S0 mode exhibiting a small deviation from the unloaded curve. The Lamb wave theory predictions for velocity and attenuation were then tested experimentally on acrylic plates using an axial transmission technique. Finally, 2D finite difference numerical simulations of the experimental measurements were performed. The predictions from Lamb wave theory do not correspond to the measured and simulated first arrival signal (FAS) velocity and attenuation results for acrylic and human cortical bone plates obtained using the axial transmission technique, except in very thin plates.

A novel approach to bite force measurements in a porcine model in vivo

A novel device for a bite force measurement system in a porcine model is described. A single polyethylene layer was vacuum-formed into a splint, and a force sensor was fitted on to the splint occlusal surface and seated with a silicone layer. This design enabled the measurement of bite forces on selected teeth in a large animal model with either natural dentition or single implant crowns and could be used in assessing information on biomechanical adaptation of the bone-implant interface to masticatory loads. Preliminary recordings of force values obtained during mastication in the premolar region (200-560 N) and various limiting factors of the technical design are discussed.

Role of hydroxyapatite coating in resisting wear particle migration and osteolysis around acetabular components

The main problem facing the longevity of total joint replacements is wear particle-induced osteolysis, particularly around the acetabular component. Ovine Total Hip Replacement surgery was performed with roughened femoral heads in order to enhance wear debris generation in vivo. The resistance to aseptic loosening of acetabular components with different surface coatings was investigated. Implants remained in vivo for 1 year. Sheep were randomly assigned to one of six experimental groups where the acetabular cup was fixed utilising an: (a) cemented polyethylene acetabular cup, (b) metal backed grit blasted surface, (c) metal backed plasma sprayed titanium porous coating, (d) metal backed sintered beaded coating, (e) Hydroxyapatite (HA)-coated grit blasted surface (f) and HA-coated porous components. Ground Reaction Force (GRF) was used to asses the functional performance of the implants and data was collected pre-operatively and at 12, 24, 36 and 52 weeks post op. Wear debris generated was analysed and radiographs taken prior to preparation of thin sections. Fibrous tissue (FT) thickness and bone contact at 1 mm intervals along the acetabular bone-implant interface was calculated. GRF data demonstrated significant differences between experimental groups. In all groups there was an increase in the function of the hip after surgery and up to 24 weeks but thereafter the function of the group with the grit blasted surface reduced whereas the function of the other groups did not significantly change. Average wear particles generated were <1 microm in size. The cemented group demonstrated a significantly thicker average FT layer (2.69 mm) when compared with all other groups (p<0.05 in all cases) except the grit blasted group (1.56 mm). HA porous coated cups demonstrated significantly least fibrous tissue adjacent to its interface when compared with all other groups (cemented p<0.05, grit blasted p=0.029, porous p<0.05, sintered beads p<0.05 and HA grit blasted p<0.05). Significantly increased bone contact to HA-coated porous cups (73.33%) when compared with all groups was identified except HA-coated grit blasted cups where no significant difference was demonstrated. Radiographic signs of loosening were visible in all groups except the HA-coated porous group. Results demonstrated that HA porous coated acetabular components significantly enhanced bone ingrowth in the presence of wear particles, preventing their migration and reducing osteolysis. Non-HA-coated porous and sintered beaded components provided a more effective seal against the ingress of wear debris when compared with cemented cups.

The compatibility of ceramic bone graft substitutes as allograft extenders for use in impaction grafting of the femur

This study investigates the use of porous biphasic ceramics as graft extenders in impaction grafting of the femur during revision hip surgery. Impaction grafting of the femur was performed in four groups of sheep. Group one received pure allograft, group two 50% allograft and 50% BoneSave, group three 50% allograft and 50% BoneSave type 2 and group four 10% allograft and 90% BoneSave as the graft material. Function was assessed using an index of pre- and post-operative peak vertical ground reaction force ratios. Changes in bone mineral density were measured by dual energy X ray absorptiometry (DEXA) scanning. Loosening and subsidence were assessed radiographically and by histological examination of the explanted specimens. There was no statistically significant difference between the four groups after 18 months of unrestricted functional loading for all outcome measures.

Glass ionomer as an expander of allograft in revision arthroplasty of the hip

The use of glass ionomer as a bone graft expander was investigated in an in vivo model of revision hip arthroplasty. Bone grafts of pure allograft and allograft + glass ionomer particles in a 50:50 by weight mixture were implanted in an ovine hemi-arthroplasty model. Post-operative assessments of locomotor function, radiographic appearance and quantitative changes in mineralisation around the graft were made at 2, 4 and 6 months. Post-mortem assessments of radiographic and histologic appearance of the grafts were made at 6 months. No significant differences were noted in any of the measured or assessed parameters between the two graft types. The glass ionomer particles seemed to be well tolerated within the matrix of new bone, smaller sized particles appearing to be better incorporated than larger ones. The use of particles of glass ionomer as a bone graft expander, in this in vivo model of revision hip arthroplasty, would therefore appear to offer no detriment in performance over pure allograft in the short to medium term.

Controlled induction of a pseudarthrosis: a study using a rodent model

OBJECTIVES

This study aimed to test the hypothesis that under standardized mechanical and biologic conditions, the process of indirect bone repair in a rodent species could be manipulated to form a reproducible, atrophic, fibrous pseudarthrosis.

DESIGN

The model used comprised a mid-diaphyseal, transverse osteotomy in the rat femur, stabilized via a precision miniature external fixator, a constant axial fixation stiffness being defined by a specific frame geometry.

MAIN OUTCOME MEASUREMENTS

The repair process for both 0.5-mm and 3.0-mm gap osteotomies was characterized using radiography, dual-energy x-ray absorptiometry, histologic assessment of standardized longitudinal sections, and postmortem mechanical testing.

RESULTS

Healing of the defect was highly reproducible, bone union being attained at around 5 weeks postoperatively with a 0.5-mm gap. Increasing the gap width to 3.0 mm resulted consistently in a pseudarthrosis.

CONCLUSION

These two reproducible patterns of repair can now be used to elucidate the underlying molecular mechanisms controlling the extent and progression of connective tissue differentiation in indirect bone repair without the additional variable of a nonstandardized mechanical environment.

Mechanical characteristics of antibiotic-laden bone cement

We studied the mechanical characteristics of cement-antibiotic combinations in vitro. Palacos R was tested without antibiotics, with gentamicin alone and with gentamicin plus vancomycin or flucloxacillin. Palacos LV was studied only with gentamicin added. CMW 1 was studied with gentamicin added, with gentamicin plus vancomycin, and with gentamicin plus flucloxacillin. We performed four-point bending tests on beams of cement to establish bending strength and modulus, and compared the values to ISO standards. Density was also assessed. Palacos R was the strongest of the cements (bending strength 80 MPa). Palacos formulations (apart from Palacos LV) had a higher density and bending modulus than CMW 1. Statistical comparison of various cements with plain Palacos R showed lower density in 4 of the mixtures, and lower bending strength and modulus in 6 of the mixtures. Palacos R/gentamicin plus vancomycin and CMW 1/gentamicin plus vancomycin had bending strength slightly above minimum ISO standards, suggesting that the addition of vancomycin during cement mixing may compromise the outcome in revision surgery for sepsis.

Subsidence in impaction grafting: the effect of adding a ceramic bone graft extender to bone

The incidence of revision total hip arthroplasty is increasing dramatically and the associated demand for allograft bone is likely to exceed the available supply. In addition, allograft presents potential problems with regard to infection, antigenicity, availability, reproducibility and cost. It is therefore desirable to develop an alternative to allograft. This study investigated BoneSave, a porous tricalcium phosphate-hydroxyapatite ceramic for use in impaction grafting of the femur at revision total hip arthroplasty. The findings of an in vitro mechanical study comparing the initial stability of pure allograft, a volume mixture of 50 per cent allograft and 50 per cent BoneSave, and a volume mixture of 10 per cent allograft and 90 per cent BoneSave are reported. The BoneSave-allograft mixtures exhibit both much greater mechanical stability and reproducibility than the pure allograft (p < 0.05) at all tested loads (200-800 N). At high peak loads the high volume (90%, v/v) BoneSave mix also provided higher mechanical stability than the medium volume (50 per cent BoneSave-50 per cent allograft) mix (p < 0.05). These results demonstrate thatfrom a mechanical standpoint the tested ceramic provides adequate initial stability to be used as a bone graft extender with allograft in impaction grafting of the femur.

Surface roughness and wettability of enamel and dentine surfaces prepared with different dental burs

The aim of dental adhesive restorations is to produce a long lasting union between the restoration and the tooth structure. This bond depends on many variables including the geometry of the preparation and the type of bonding agent or luting cement. It is therefore suggested that the topography of the tooth surface may influence the wettability and the bonding quality of adhesive systems. This study measured the surface roughness and wettability of enamel and dentine after preparation with different dental burs. The mesial and distal surfaces of 15 extracted sound human premolar teeth were prepared with a tungsten carbide crown bur, a diamond bur and a tungsten carbide finishing bur and finished in enamel or dentin, respectively. The prepared surfaces were analysed with a surface profilometer and scanning electron microscopy (SEM). The contact angle of distilled water on each of the prepared surfaces was used as the measure of wettability. The differences in average surface roughness (Ra) were significant between the rotary instrument groups, as revealed by a two-way ANOVA test. No differences were detected between enamel and dentine surfaces prepared with the same type of dental bur. The smoothest surfaces were those completed with tungsten carbide finishing burs. The diamond bur preparations were intermediate in the roughness assessment and the tungsten carbide crown burs gave the roughest surfaces. There were no significant differences in the contact angle measurements for the various groups. It was concluded that the surface roughness of enamel and dentine prepared by different rotary instruments had no significant influence on the wettability of distilled water on these surfaces.

A comparison of vertical force and temporal parameters produced by an in-shoe pressure measuring system and a force platform

OBJECTIVE

To investigate the ability of Pedar in-shoe system to measure vertical force accurately, by comparing it with the Kistler force platform.

DESIGN

In vivo experiment in normal subjects.

BACKGROUND

It has been suggested Pedar is highly reliable, but absolute accuracy of the system with regard to force measurement has not been comprehensively tested.

METHODS

Sampling at 99 Hz, using five healthy subjects, simultaneous data were collected barefoot, and in three types of shoes (Trainers, Oxfords, Slip-on Deck Type). Six variables obtained from the force/time curve from each footstep were compared.

RESULTS

The temporal data recorded by Pedar correlated well with that obtained using Kistler, with significant differences only in overall duration of the step in Deck shoes (P < 0.001) and Oxford shoes (P < 0.01), and peak to peak barefoot (P < 0.01). Pedar recorded a lower first peak force and mid-peak force in all cases (P < 0.001). However, the magnitude of the 2nd peak force recorded by both systems was significantly different only in Trainers (P < 0.05) and Oxford shoes (P < 0.001). The impulse data obtained with Oxford shoes was not significantly different, although barefoot, Trainers and Deck shoes were significantly lower (P < 0.001) for Pedar.

CONCLUSIONS

In most cases, comparison of data recorded by the two systems provided good evidence for the accuracy and reliability of temporal measurements and second peak force measurements taken with the Pedar in-shoe system. Relevance. In-shoe pressure data provides evidence for clinical decisions if the systems utilised are proven to be valid, repeatable and accurate. Comparison with an established force platform enables some assessment of these factors.

Accurate diagnosis of hip prosthesis loosening using a vibrational technique

OBJECTIVE

To examine the potential role of vibration testing as a non-invasive method of diagnosing loosening of total hip replacements in the clinical setting.

DESIGN

Single blind cohort study in two hospitals.

BACKGROUND

Diagnosing loosening of total hip replacements is heavily dependent on investigative techniques that are unreliable. Previous studies into the use of vibration testing have produced conflicting results.

METHODS

Comparison of vibration testing and radiographs in patients with a total hip replacement experiencing hip pain symptomatic of loosening, with patients showing evidence of a secure prosthesis.

RESULTS

Vibration testing has a sensitivity of 80% and a specificity of 89%. The positive predictive value was 92% and the negative predictive value was 73%; it was unable to produce a definitive diagnosis in 8% of patients. When compared with radiographs from the same patients, vibration testing was shown to be 20% more sensitive and able to diagnose 13% more patients.

CONCLUSIONS

Vibration testing can deliver more accurate information on the stability of total hip replacements than radiographs in the clinical setting, despite being in the early stages of development. Relevance. This study shows that 70 more patients may be provided with the correct diagnosis and 46 fewer patients may be undiagnosed each year, when using vibrometry as opposed to radiographs. In view of the relative disparity between the level of development between the two techniques and the encouraging results hitherto presented, it is felt that by improving vibration testing it may supersede radiographs in the detection of prosthesis loosening.

A comparison of vertical force and temporal parameters produced by an in-shoe pressure measuring system and a force platform

OBJECTIVE

To investigate the ability of Pedar in-shoe system to measure vertical force accurately, by comparing it with the Kistler force platform.

DESIGN

In vivo experiment in normal subjects.

BACKGROUND

It has been suggested Pedar is highly reliable, but absolute accuracy of the system with regard to force measurement has not been comprehensively tested.

METHODS

Sampling at 99 Hz, using five healthy subjects, simultaneous data were collected barefoot, and in three types of shoes (Trainers, Oxfords, Slip-on Deck Type). Six variables obtained from the force/time curve from each footstep were compared.

RESULTS

The temporal data recorded by Pedar correlated well with that obtained using Kistler, with significant differences only in overall duration of the step in Deck shoes (P<0. 001) and Oxford shoes (P<0.01), and peak to peak barefoot (P<0.01). Pedar recorded a lower first peak force and mid-peak force in all cases (P<0.001). However, the magnitude of the 2nd peak force recorded by both systems was significantly different only in Trainers (P<0.05) and Oxford shoes (P<0.001). The impulse data obtained with Oxford shoes was not significantly different, although barefoot, Trainers and Deck shoes were significantly lower (P<0.001) for Pedar.

CONCLUSIONS

In most cases, comparison of data recorded by the two systems provided good evidence for the accuracy and reliability of temporal measurements and second peak force measurements taken with the Pedar in-shoe system. Relevance In-shoe pressure data provides evidence for clinical decisions if the systems utilised are proven to be valid, repeatable and accurate. Comparison with an established force platform enables some assessment of these factors.

Shear bond strength of resin teeth to heat-cured and light-cured denture base resin

The failure of the bond between acrylic resin teeth and denture base material remains a considerable problem. Previous research has indicated that the introduction of a bonding agent to the tooth-resin interface significantly increased the tensile bond strength. To further investigate this finding, and to complement the earlier study, a shear strength assessment was carried out. Both a commercial and an experimental bonding agent were evaluated for tooth retention when applied to heat-cured and visible light-cured (VLC) resin. A significant increase in shear bond strength was obtained when bonding agents were applied. The experimental cement gave the greatest increase in strength, although the VLC resin failed to achieve the same degree of tooth attachment as the heat-cured resin.

Transmembrane protein tyrosine phosphatase IA-2 (ICA512) is expressed in human midgut carcinoids but is not detectable in normal enterochromaffin cells

A potential upregulation of receptor type protein tyrosine phosphatase IA-2 (ICA512) expression was detected by differential display and investigated in midgut carcinoid tumours. Normal intestine tissue and tumour tissue from 13 midgut carcinoid patients were studied by in situ hybridisation using an IA-2 ribonucleotide probe and confocal microscopy using specific IA-2 antibodies. Previously, it had been shown that IA-2 is located in the secretory granules of virtually all neuroendocrine cells. However, we found that IA-2 was not detectable in resting normal enterochromaffin (EC) cells of the small intestine, while high expression of IA-2 mRNA and protein was confirmed in both primary and metastatic carcinoid tissue. This difference in expression was not observed with chromogranin A or serotonin, two secretory granule hormones known to be expressed in EC cells, indicating that IA-2 was seemingly not necessary for the basal production and packaging of these hormones. When comparing patients receiving biotherapy before operation with untreated patients, we found expression of IA-2 to be lower in tumours from patients that had been treated with a combination of alpha-interferon and the somatostatin analogue, octreotide. There was no correlation between IA-2 expression and proliferation rates as measured by immunohistochemistry with antibodies against the Ki 67 antigen. Furthermore, we show that IA-2 is co-localised with serotonin in carcinoid tumours as well as in the pancreatic tumour cell line, BON1, which is interesting as serotonin secretion rate is presumably higher in tumour cells than in resting EC cells. Taken together, these findings may indicate a role for IA-2 in the later stages of the regulated secretory process.

Fracture stiffness measurement using the orthometer: reproducibility and sources of error

OBJECTIVES

To elicit the reproducibility and the common sources of error in the use of the Orthometer, a commercially available goniometer based system, designed to measure the stiffness of healing fractures.

DESIGN

A laboratory based study.

BACKGROUND

The Orthometer is widely used to measure the progress of fracture healing in a quantitative manner. It has been shown previously that the bending stiffness of a fracture increases with healing and that a stiffness of 15 Nm/degree equates with the functional union of a tibial fracture.

METHODS

The Orthometer was attached in a standard manner to nylon bars of known stiffness to determine the accuracy of the device. The Orthometer was then set up with changes in a single positional variable to assess the effect of this variable on the measurement accuracy. A number of different clinicians were asked to use the Orthometer before and after a simple training session and any improvements in the measurement accuracy were observed.

RESULTS

Stiffness could be measured to within 10% or less of the true stiffness. Markedly different degrees of error were introduced with the various set-up variables. A simple training session improved clinician accuracy.

CONCLUSIONS

Although the Orthometer does allow some degree of safety margin, it is essential that set-up is performed carefully, and that the clinician has been trained in the use of the device.

RELEVANCE

Quantitative measurements of fracture healing have enormous potential benefits over manual and radiological methods of assessments. Provided these are carefully performed, the accuracy of these measurements is good.

Digital image analysis: improving accuracy and reproducibility of radiographic measurement

OBJECTIVE

To assess the accuracy and reproducibility of a digital image analyser and the human eye, in measuring radiographic dimensions.

DESIGN

We experimentally compared radiographic measurement using either an image analyser system or the human eye with digital caliper.

BACKGROUND

The assessment of total hip arthroplasty wear from radiographs relies on both the accuracy of radiographic images and the accuracy of radiographic measurement.

METHODS

Radiographs were taken of a slip gauge (30+/-0.00036 mm) and slip gauge with a femoral stem. The projected dimensions of the radiographic images were calculated by trigonometry. The radiographic dimensions were then measured by blinded observers using both techniques.

RESULTS

For a single radiograph, the human eye was accurate to 0.26 mm and reproducible to +/-0.1 mm. In comparison the digital image analyser system was accurate to 0.01 mm with a reproducibility of +/-0.08 mm. In an arthroplasty model, where the dimensions of an object were corrected for magnification by the known dimensions of a femoral head, the human eye was accurate to 0.19 mm, whereas the image analyser system was accurate to 0.04 mm.

CONCLUSIONS

The digital image analysis system is up to 20 times more accurate than the human eye, and in an arthroplasty model the accuracy of measurement increases four-fold. We believe such image analysis may allow more accurate and reproducible measurement of wear from standard follow-up radiographs.

An investigation of the variables which may affect the bond between plastic teeth and denture base resin

OBJECTIVES

The failure of the bond between acrylic resin denture base material and resin teeth remains a significant problem. This study evaluated the tensile bond strength of specimens produced by commonly employed tooth preparation and processing methods as used in dental laboratories.

METHODS

Twenty-two experimental groups, each consisting of 36 specimens, were investigated by subjecting the tooth-resin bond to tensile loading. The groups were allocated to one of five experimental sets to investigate: (a) effect of resin dough time, (b) effect of tooth surface condition, (c) effect of processing variables, (d) effect of monomer cementing, and (e) effect of acrylic resin cement. The results were analysed statistically using a one factor ANOVA and a Student t test.

RESULTS

A significantly stronger bond was obtained when the resin was packed late in the dough stage, and a superior bond, in all cases, when high-impact resin was used. Tooth surface modification by grinding or grooving made no significant difference when compared with unmodified surfaces. Wax-contaminated surfaces produced highly significant weaker bonds. Time of introduction and duration of water-bath processing had no significant effect on bond strength. Monomer cementing of the tooth surface, especially with high-impact monomer. significantly improved the bond strength. The application of resin cements was found to produce the most significant increase in denture tooth bond strength.

CONCLUSIONS

The important steps in obtaining a consistently high value denture tooth bond are thorough dewaxing of the tooth surface followed by the application of a suitable resin cement.

Axial preload in external fixator half-pins: a preliminary mechanical study of an experimental bone anchorage system

OBJECTIVE

To demonstrate the effect of axial preload achieved with an experimental external fixator pin prototype on the initial stability of the pin-bone interface.

DESIGN

An in vitro mechanical study comparing pin stability of an axially-preloaded experimental pin and a radially-preloaded conventional external fixation pin.

BACKGROUND

The most common problem in clinical practice of external fixation is pin site failure. An experimental external fixator half-pin has been designed introducing axial preload as an alternative method of achieving a stable pin-bone interface.

METHODS

Standardized measurements of pin insertion and removal torque comparing the experimental pin prototype and a conventional external fixator pin in a synthetic composite material and ovine tibial cortical bone.

RESULTS

There is a positive correlation between axial preload and torque resistance of the coaxial experimental half-pin as well as significantly increased torque resistance of the axially-preloaded experimental pin over the conventional pin tested. In addition, significantly lower insertion torque of the experimental pin was observed with the applied insertion technique.

CONCLUSIONS

'Axial preload' achieved with appropriately-designed half pins might represent an effective biology-sparing method of increasing the mechanical stability of the pin-bone interface in unilateral external fixator frames.

RELEVANCE

Several aspects of the current external fixator pin design and insertion technique have been implicated for the significant incidence of failure at the pin-bone interface manifested as pin loosening, pin track infection or even osteomyelitis. An axially-preloaded bone fastener system may be mechanically and biologically superior and therefore clinically advantageous.

"Biological" internal fixation of long bone fractures: a biomechanical study of a "noncontact" plate system

Based on existing knowledge of noncontact plates, an experimental prototype of a nonperiosteal contact internal fixation implant ("noncontact internal fixator") has been designed. The construct rigidity of osteotomised synthetic composite femora, fixed with the noncontact fixator and a reamed, statically-locked intramedullary nail were compared in axial compression, two plane bending and torsion in four types of diaphyseal fractures. With the exception of axial loading in the presence of extensive comminution, the fixation stability provided by the noncontact fixator is significantly higher than that of the tested intramedullary nail. Any degree of cortical contact between the two main fragments is important for the stability of this nonperiosteal contact fixation system under axial load. Appropriately-designed "internal fixators" could provide not only a number of biological and technical advantages, but also fixation stability comparable and in certain aspects superior to that of other fixation methods.

A portable monitoring system for measuring weight-bearing during tibial fracture healing

An ambulatory monitoring system has been developed to measure the weight-bearing achieved by a patient on their fractured leg. The system is lightweight, portable, and can monitor weight-bearing continuously over an extended period of time. In addition to mean weight-bearing, the system can also determine temporal parameters associated with the patients' gait. This system was used to measure the weight-bearing achieved during the course of fracture healing in a small number of patients being treated by a variety of fixation methods for a tibial fracture. In general, weight-bearing was observed to increase with time post fracture, and the fixation method employed appeared to influence the rate of increase of loading of the fractured limb, more rigid methods of fixation enabling full-weight-bearing to be achieved sooner.

Strain rate and timing of stimulation in mechanical modulation of fracture healing

Fracture of the long bones results in a repair process that has the potential to restore the anatomic morphology and mechanical integrity of the bone without scar tissue. The repair process can occur in two patterns. In the first, under conditions of rigid stabilization, direct osteonal remodeling of the fracture line can occur with little or no external callus, a process known as direct bone repair. The second pattern of repair involves bridging of the fragments with external callus and formation of bone in the fracture site by endochondral healing. This type of repair is known as indirect bone healing and occurs under less rigid interfragmentary stabilization. The rate of healing and the extent of callus in this type of repair can be modulated by the mechanical conditions at the fracture site. Applying cyclic interfragmentary micromotion for short periods has been shown to influence the repair process significantly, and characteristics of this stimulus influence the healing response observed. In the current study, a short term interfragmentary cyclic micromovement applied at a high strain rate induced a greater amount of periosteal callus than the same stimulus applied at a low strain rate. This high strain rate stimulus applied later in the healing period significantly inhibited the progress of healing. The beneficial effect of this particular biophysic stimulus early in the healing period may be related to the viscoelastic nature of the differentiating connective tissues in the early endochondral callus. In the early endochondral callus, high rates of movement induce a greater deformation of the fracture fragments because of the stiffening of the callus. Alternatively, the transduction pathway may involve streaming potentials as a result of the high movement rate.

Bone loss during long term space flight is prevented by the application of a short term impulsive mechanical stimulus

In long term space flight, the mechanical forces applied to the skeleton are substantially reduced and are altered in character. This reduced skeletal loading results in a reduction in bone mass. Exercise techniques currently used in space can maintain muscle mass but the mechanical stimulus provided by this exercise does not prevent bone loss. By applying an external impulsive load for a short period each day, which is intended to mimic the heel strike transient, to the lower limb of an astronaut during a long term space flight (5 months), this study tests the hypothesis that the bone cells can be activated by an appropriate external mechanical stimulus to maintain bone mass throughout prolonged periods of weightlessness. A mechanical loading device was developed to produce a loading of the os-calcis similar to that observed during the heel strike transient. The device is activated by the astronaut to provide a transient load to the heel of one leg whilst providing an equivalent exercising load to the other leg. During the EUROMIR95 mission on the MIR space station, an astronaut used this device for a short period daily throughout the duration of the mission. Pre- and post-flight measurements of bone mineral density (BMD) of the os-calcis and femoral neck of the astronaut were made to determine the efficacy of the device in preventing loss of bone mineral during the mission. On the os-calcis which received the mechanical stimulus, BMD was maintained throughout the period of the flight, while it was reduced by up to 7% on the os-calcis which received no stimulus. Post-flight, BMD in both the stimulated and non-stimulated os-calcis reduces, the extent of this reduction however is less in the stimulated os-calcis. For the femoral neck, the mechanical stimulation does not produce a positive effect.

Bone mineral changes during tibial fracture healing

The traditional assessment of fracture healing by manipulation and viewing of radiographs is subjective and qualitative. Dual energy x-ray absorptiometry by contrast provides an accurate, precise, and minimally invasive quantitative measure of bone mineral density, a property that shows strong correlations with various mechanical properties of bone. Fourteen patients with unilateral tibial shaft fractures stabilized by external fixation were monitored with dual energy x-ray absorptiometry at monthly intervals after fracture. Fractured and contralateral unfractured bones (controls) were scanned on each occasion. Changes in mineralization with time over the whole length of the fractured bone could be seen. The most pronounced effects were visible in the area of the fracture, with a minimum recorded fracture site bone mineral density of 38 +/- 13% of contralateral values, but often more long term alterations in bone mineral density affected regions at some distance from this zone. Significantly, in four patients who had scans 5 or more months after fracture, the mineralization at the fracture site had returned to control levels, whereas bone mineral density in a region proximal to the fracture showed evidence of persisting posttraumatic osteoporosis.

A survey of the pre-bonding preparation of denture teeth and the efficiency of dewaxing methods

OBJECTIVES

Denture tooth debonding remains a significant problem, with the surface condition of the tooth playing a pivotal role. The purpose of this investigation was to determine the methods used in tooth preparation. The efficiency of wax removal from teeth using a range of water temperatures was also investigated.

METHODS

(a) A postal survey on the methods of denture tooth preparation, prior to denture processing, was conducted amongst dental instructors in prosthodontic departments of dental schools in Great Britain and Ireland. (b) Tooth surfaces contaminated with fluorescence wax were subjected to agitation in water at a range of temperatures and the surfaces examined under ultraviolet radiation.

RESULTS

(a) The majority of operators did not use a solvent for the removal of the wax film from the teeth. Modification of the tooth ridge lap surface was carried out by 52% of the respondents on initial processing but increased to 85% when rebonding teeth. (b) Dewaxing denture teeth at a range of water temperatures showed wax retention on the tooth surfaces up to 90 degrees C. Rough surfaces retained more wax than smooth surfaces. Wax eliminator was shown to be necessary for complete wax removal.

CONCLUSIONS

No standard technique exists amongst dental instructors for the preparation of denture teeth prior to acrylic resin polymerization. The use of a wax solvent is to be recommended.

Factors contributing to the wear of polyethylene in clinical practice

Wear of polyethylene is a major contributor in the failure of total joint replacement. A number of different factors may predispose to increased wear of polyethylene. These can be broadly categorized as (i) material polymorphism, (ii) poor design features and (iii) three-body wear. Many of these factors contribute to the wear encountered in clinical practice. These mechanisms are reviewed and examples identified in which they have resulted in increased wear.