Treatment of Infection-Related Non-Unions with Bioactive Glass-A Promising Approach or Just Another Method of Dead Space Management?

The treatment of infected and non-infected non-unions remains a major challenge in trauma surgery. Due to the limited availability of autologous bone grafts and the need for local anti-infective treatment, bone substitutes have been the focus of tissue engineering for years. In this context, bioactive glasses are promising, especially regarding their anti-infective potential, which could reduce the need for local and systemic treatment with conventional antibiotics. The aim of this study was to investigate the osteoinductive and osteoconductive effects, as well as the anti-infectious potential, of S53P4 using a standardized non-union model, which had not been investigated previously. Using an already established sequential animal model in infected and non-infected rat femora, we were able to investigate bioactive glass S53P4 under realistic non-union conditions regarding its osteoinductive, osteoconductive and anti-infective potential with the use of µCT scans, biomechanical testing and histological, as well as microbiological, analysis. Although S53P4 did not lead to a stable union in the non-infected or the infected setting, µCT analysis revealed an osteoinductive effect of S53P4 under non-infected conditions, which was diminished under infected conditions. The osteoconductive effect of S53P4 remained almost negligible in histological analysis, even 8 weeks after treatment. Additionally, the expected anti-infective effect could not be demonstrated. Our data suggested that S53P4 should not be used in infected non-unions, especially in those with large bone defects.

The primary stability of the femoral component in cemented single and twin peg Oxford unicompartmental knee arthroplasty under adverse conditions.

AIMS: The cemented Oxford unicompartmental knee arthroplasty (OUKA) features two variants: single and twin peg OUKA. The purpose of this study was to assess the stability of both variants in a worst-case scenario of bone defects and suboptimal cementation. METHODS: Single and twin pegs were implanted randomly allocated in 12 pairs of human fresh-frozen femora. We generated 5° bone defects at the posterior condyle. Relative movement was simulated using a servohydraulic pulser, and analyzed at 70°/115° knee flexion. Relative movement was surveyed at seven points of measurement on implant and bone, using an optic system. RESULTS: At the main fixation zone, the twin peg shows less relative movement at 70°/115°. At the transition zone, relative movements are smaller for the single peg for both angles. The single peg shows higher compression at 70° flexion, whereas the twin peg design shows higher compression at 115°. X-displacement is significantly higher for the single peg at 115°. CONCLUSION: Bony defects should be avoided in OUKA. The twin peg shows high resilience against push-out force and should be preferred over the single peg. Cite this article: Bone Joint Res 2022;11(2):82-90.

Systemic Administration of PTH Supports Vascularization in Segmental Bone Defects Filled with Ceramic-Based Bone Graft Substitute.

Non-unions continue to present a challenge to trauma surgeons, as current treatment options are limited, duration of treatment is long, and the outcome often unsatisfactory. Additionally, standard treatment with autologous bone grafts is associated with comorbidity at the donor site. Therefore, alternatives to autologous bone grafts and further therapeutic strategies to improve on the outcome and reduce cost for care providers are desirable. In this study in Sprague-Dawley rats we employed a recently established sequential defect model, which provides a platform to test new potential therapeutic strategies on non-unions while gaining mechanistic insight into their actions. The effects of a combinatorial treatment of a bone graft substitute (HACaS+G) implantation and systemic PTH administration was assessed by µ-CT, histological analysis, and bio-mechanical testing and compared to monotreatment and controls. Although neither PTH alone nor the combination of a bone graft substitute and PTH led to the formation of a stable union, our data demonstrate a clear osteoinductive and osteoconductive effect of the bone graft substitute. Additionally, PTH administration was shown to induce vascularization, both as a single adjuvant treatment and in combination with the bone graft substitute. Thus, systemic PTH administration is a potential synergistic co-treatment to bone graft substitutes.

[Tribology in hip arthroplasty : Benefits of different materials]. / Tribologie in der Hüftendoprothetik : Welches Material hat welchen Nutzen?

When it comes to total hip replacements, choosing the suitable material combination is of clinical relevance. The present review article examines the technical differences in wear and corrosion of the relevant material combinations of ceramics, metals, ceramized metals and various types of polyethylene. The material characteristics, which were often tested under standardized conditions in the laboratory, are compared with clinical results on the basis of evidence-graded clinical studies and on the basis of register studies. This article thus represents an up-to-date snapshot of the expectations and actual clinical outcomes of the present choice of material combinations. It shows that some tendencies from the field of materials research, e.g. with regard to cross-linked polyethylene, coincide with observations from practical clinical experience, while for other materials, a proven technical superiority has not yet been confirmed as an evident advantage in clinical practice.

Effect of bone quality and quantity on the primary stability of dental implants in a simulated bicortical placement.

OBJECTIVES: Conventional dental implants inserted in the molar region of the maxilla will reach into the sinus maxillaris when alveolar ridge height is limited. When surgery is performed without prior augmentation of the sinus floor, primary stability of the implant is important for successful osseointegration. This study aimed at identifying the impact of bone quality and quantity at the implantation site on primary implant stability of a simulated bicortical placement. MATERIALS AND METHODS: In our in vitro measurements, bone mineral density, total bone thickness and overall cortical bone thickness were assessed by micro-computed tomography (µCT) of pig scapulae, which resembled well the bicortical situation found in human patients. Dental implants were inserted, and micromotion between bone and implant was measured while loading the implant with an axial torque. RESULTS: The main findings were that primary implant stability did not depend on total bone thickness but tended to increase with either increasing bone mineral density or overall cortical bone thickness. CLINICAL RELEVANCE: Limited bone height in the maxilla is a major problem when planning dental implants. To overcome this problem, several approaches, e.g. external or internal sinus floor elevation, have been established. When planning the insertion of a dental implant an important aspect is the primary stability which can be expected. With other factors, the dimensions of the cortical bone might be relevant in this context. It would, therefore, be helpful to define the minimum thickness of cortical bone required to achieve sufficient primary stability, thus avoiding additional surgical intervention.

Short-Term Heat Treatment of Ti6Al4V ELI as Implant Material.

Due to its mechanical properties and good biocompatibility, Ti6Al4V ELI (extra low interstitials) is widely used in medical technology, especially as material for implants. The specific microstructures that are approved for this purpose are listed in the standard ISO 20160:2006. Inductive short-term heat treatment is suitable for the adjustment of near-surface component properties such as residual stress conditions. A systematic evaluation of the Ti6Al4V microstructures resulting from short-term heat treatment is presently missing. In order to assess the parameter field that leads to suitable microstructures for load-bearing implants, dilatometer experiments have been conducted. For this purpose, dilatometer experiments with heating rates up to 1000 °C/s, holding times between 0.5 and 30 s and cooling rates of 100 and 1000 °C/s were systematically examined in the present study. Temperatures up to 950 °C and a holding time of 0.5 s led to microstructures, which are approved for medical applications according to the standard ISO 20160:2006. Below 950 °C, longer holding times can also be selected.

Hip Spacers with a Metal-on-Cement Articulation Did Not Show Significant Surface Alterations of the Metal Femoral Head in Two-Stage Revision for Periprosthetic Joint Infection.

Two-stage revision is considered the gold standard treatment for chronic periprosthetic joint infection (PJI). During the interim period, between explantation of the infected hip endoprosthesis and revision arthroplasty, individually formed articulating hip spacers made of polymethylmethacrylate (PMMA) bone cement can be used to provide better soft tissue preservation, local antibiotic release, and improved postoperative mobilization. If effective prevention from luxation is achieved, hip function and hence overall patient satisfaction is improved. Zirconium oxide particles inside conventional PMMA bone cement, however, are known to enhance third-body wear, which may cause alterations of the metal head in the articulating spacer and hence become a serious risk for the patient. Therefore, the aim of our study was to analyze whether the articular surface of cobalt-chrome (CoCr) femoral heads is significantly altered in the setting of a metal-on-cement articulation during the interim period of two-stage revision for PJI. We analyzed a consecutive series of 23 spacer cases and compared them with femoral heads from two series of conventional hip arthroplasty revisions with metal-on-polyethylene articulations and different time intervals in situ. To investigate metallic wear, the femoral heads were thoroughly examined, and their surface roughness was measured and analyzed. We found no significant differences between the two conventional hip arthroplasty groups, despite their very different times in situ. Furthermore, the individually different times in situ within the spacer group had no significant impact on surface roughness, either. Compared with the spacer group, the surface roughness of the metal femoral heads from both conventional hip arthroplasty groups were even higher. Within the spacer group, roughness parameters did not show significant differences regarding the five predefined locations on the metal head. We conclude that metal-on-cement articulations do not cause enhanced surface alterations of the metal femoral head and hence do not limit the application in articulating hip spacers in the setting of two-stage revision for PJI.

The Migration Pattern of a Cementless Hydroxyapatite-Coated Titanium Stem under Immediate Full Weight-Bearing-A Randomized Controlled Trial Using Model-Based RSA.

(1) Background: High primary stability is important for the long-term survival of cementless femoral stems in total hip arthroplasty (THA). The objective of this study was to investigate the migration pattern of a hydroxyapatite-coated cementless hip stem developed for minimally invasive surgery using model-based radiostereometric analysis (RSA). (2) Methods: In this randomized controlled trial, 44 patients with an indication for cementless primary THA were randomly allocated to receive either the SL-PLUS MIA stem, developed for minimally invasive surgery, or the SL-PLUS stem (Smith & Nephew Orthopaedics, Baar, Switzerland) which served as a control group. Unlimited weight-bearing was permitted postoperatively in both groups. Model-based RSA was performed after six weeks and after 3, 6, 12 and 24 months postoperatively. (3) Results: Mean total stem subsidence at two-year follow-up was 0.40 mm (SD 0.66 mm) in the SL-PLUS group and 1.08 mm (SD 0.93 mm) in the SL-PLUS MIA group (p = 0.030). Stem subsidence occurred during the first six weeks after surgery, indicating initial settling of the stem under full weight-bearing. Both stem designs showed good osseointegration and high secondary stability with no further migration after initial settling. (4) Conclusions: Settling of a cementless straight femoral stem occurs during the first six weeks after surgery under full weight-bearing. Although initial stem migration was higher in the SL-PLUS MIA group, it had no influence on secondary stability. All implants showed good osseointegration and high secondary stability with no signs of implant loosening during this two-year follow-up period.

A new sequential animal model for infection-related non-unions with segmental bone defect.

BACKGROUND: The treatment of fracture-related infections (FRI) is still a challenge for orthopedic surgeons. The prevalence of FRI is particularly high in open fractures with extensive soft-tissue damage. This study aimed to develop a new two-step animal model for non-unions with segmental bone defects, which could be used to evaluate new innovative bone substitutes to improve the therapeutic options in humans with FRI and bone defects. METHODS: After randomization to infected or non-infected groups, 30 Sprague-Dawley rats underwent a transverse osteotomy of the mid-shaft femur with a 5 mm defect. Additionally, the periosteum at the fracture zone was cauterized at both sides. After intramedullary inoculation with 103 CFU Staphylococcus aureus (infected group) or PBS (non-infected group), a fracture stabilization was done by intramedullary K-wires. After 5 weeks, the bone healing process was evaluated, and revision surgery was performed in order to obtain increased bone healing. The initial K-wires were removed, and debridement of the osteotomy-gap was done followed by a more stable re-osteosynthesis with an angle-stable plate. After further 8 weeks all rats were euthanized and the bone consolidation was tested biomechanically and the callus formation quantitatively by micro-CT analysis. RESULTS: We developed and presented a new two-stage non-union animal model through a targeted S. aureus infection. After 5 weeks, all animals showed a non-union irrespective of assignment to the infected and non-infected group. Lane and Sandhu score showed a higher callus formation in the infected group. In all infected animals, the inoculated S. aureus strain was detected in the revision surgery. The second surgery did not improve bone healing, as shown by the Lane Sandhu score and in the µ-CT analysis. Similarly, biomechanical testing showed in both groups a significantly lower maximum torque as compared to the contralateral side (p < 0.0001). CONCLUSIONS: We were able to successfully develop a new two-stage non-union animal model, which reflects a genuine clinical situation of an infection-related non-union model with segmental bone defects. This model could be used to evaluate various therapeutic anti-infectious and osteoinductive strategies in FRIs.

Corrosion Behavior of Surface-Treated Metallic Implant Materials.

Corrosion of taper connections in total hip arthroplasty remains of concern, as particles and ions generated by corrosive processes can cause clinical problems such as periprosthetic osteolysis or adverse reaction to metallic debris. Mechanical surface treatments that introduce compressive residual stresses (RSs) in metallic materials can lead to a better performance in terms of fretting and fatigue and may lower the susceptibility to corrosion. The study investigates the impact of mechanical surface treatments on the corrosion behavior of metallic biomaterials. Compressive RSs were introduced by deep rolling and microblasting in Ti6Al4V and CoCrMo samples. Polished samples served as reference. Corrosion behavior was characterized by repeated anodic polarization. Residual stresses of up to about -900 MPa were introduced by deep rolling with a reach in depth of approximately 500 µm. Microblasting led to compressive RSs up to approximately -800 and -600 MPa for Ti6Al4V and CoCrMo, respectively, in the immediate vicinity of the surface. For Ti6Al4V, microblasting resulted in decreased corrosion resistance with lower breakdown potentials and/or increased passive current densities in comparison to the polished and deep-rolled samples. The corrosion behavior of CoCrMo on the other hand was not affected by the mechanical surface treatments.

Quantitative Measurements of Backside Wear in Acetabular Hip Joint Replacement: Conventional Polyethylene Versus Cross-Linked Polyethylene.

As shown in previous studies, the modification of conventional polyethylene (CPE) to cross-linked polyethylene (XLPE) and the contribution of antioxidants result in a reduction in total wear. The aim of this study was to evaluate XLPE inserts with vitamin E and CPE regarding their resistance to the backside wear mechanism. A cementless hip cup system (Plasmafit® Plus 7, Aesculap) was dynamically loaded using CPE and XLPE inserts. The backside wear was isolated, generated and collected using the two-chamber principle. The chambers were filled with ultrapure water. After 2 × 106 cycles, the fluids were examined for wear particles according to a particle analysis. Using XLPE inserts, the backside wear was significantly reduced by 35%. While XLPE backside wear particles are significantly larger than CPE particles, they do not differ in their morphology. This study confirms the greater resistance to backside wear of XLPE compared to CPE. It can be assumed that the improved fatigue resistance of the vitamin E-stabilized XLPE inserts demonstrates XLPE's effectiveness against micro-motion and the resulting changing tensions in interface areas like surface breakdown, pitting and the release of very small particles.

Model-Based Roentgen Stereophotogrammetric Analysis to Monitor the Head-Taper Junction in Total Hip Arthroplasty in Vivo-And They Do Move.

Model-based Roentgen stereophotogrammetric analysis (RSA) using elementary geometrical shape (EGS) models allows migration measurement of implants without the necessity of additional attached implant markers. The aims of this study were: (i) to assess the possibility of measuring potential head-taper movement in THA in vivo using model-based RSA and (ii) to prove the validity of measured head-taper migration data in vitro and in vivo. From a previous RSA study with a 10 years follow-up, retrospectively for n = 45 patients head-taper migration was calculated as the relative migration between femoral ball head and taper of the femoral stem using model-based RSA. A head-taper migration of 0.026 mm/year can be detected with available RSA technology. In vitro validation showed a total migration of 268 ± 11 µm along the taper axis in a similar range to what has been reported using the RSA method. In vivo, a proof for interchangeable applicability of model-based RSA (EGS) and standard marker-based RSA methods was indicated by a significant deviation within the migration result after 12-month follow-up for all translation measurements, which was significantly correlated to the measured head-taper migration (r from 0.40 to 0.67; p < 0.05). The results identified that model-based RSA (EGS) could be used to detect head-taper migration in vivo and the measured movement could be validated in vitro and in vivo as well. Those findings supported the possibility of applying RSA for helping evaluate the head-taper corrosion related failure (trunnionosis).

Carbon-fibre-reinforced PEEK: An alternative material for flexion bushings of rotating hinged knee joints?

BACKGROUND: For prosthetic knee joints of the hinged type, typically polyethylene (PE) flexion bushings are used between axis and femoral component to prevent metallic wear. Nevertheless, PE-wear can lead to periprosthetic osteolysis followed by aseptic loosening of the implant. Based on high creep and wear resistance carbon-fibre-reinforced polyether ether ketones (CFR-PEEKs) could provide an alternative material to ultra-high-molecular-weight polyethylene (UHMWPE) for this bearing type. METHODS: Flexion bushings of four different materials were investigated (CFR-PEEK pitch fibres, CFR-PEEK PAN fibres, virgin PEEK without carbon fibres and UHMWPE) using a bushing tester. For determination of the polymeric and metallic wear, gravimetric measurements and particle analyses were performed. RESULTS: The polymeric wear rates of CFR-PEEK PAN (6.657 ±â€¯0.714 mg/106 cycles) and CFR-PEEK pitch (32.085 ±â€¯2.748 mg/106 cycles) were significantly higher compared to the polymeric wear rates of virgin PEEK (0.764 ±â€¯0.283 mg/106 cycles) or UHMWPE (-0.015 ±â€¯0.011 mg/106 cycles) (p < .001). In addition, the metallic wear rates were significantly higher when using bushings made of CFR-PEEK PAN (3.373 ±â€¯0.214 mg/106 cycles) and CFR-PEEK pitch (3.604 ±â€¯0.355 mg/106 cycles), than when using bushings made of virgin PEEK (0.177 ±â€¯0.049 mg/106 cycles) or UHMWPE (0.031 ±â€¯0.011 mg/106 cycles) (p < .001). The mean particle size of the two CFR-PEEK groups was significantly smaller compared to the virgin PEEK and UHMWPE group (p < .001). CONCLUSION: According to these results, the clinical use of CFR-PEEK in combination with CoCr could lead to higher wear rates and this should be avoided. Virgin PEEK may still be considered as an alternative to UHMWPE to use it for flexion bushings in a hinged knee joint.

Particle analysis of shape factors according to American Society for Testing and Materials.

Polyethylene wear is one of the major factors influencing the survivorship of joint replacements. Depending on the number, size and morphology of the polyethylene particles, biological responses of the periprosthetic soft tissue in terms of inflammatory processes can occur, leading to loosening of the implant. Various parameters are used to analyze wear particles, which are usually determined by examining scanning electron microscopy (SEM) images with a particle analysis program. In this study, three different software solutions for particle analysis (self-developed Particleanalyzer_HD, Leica QWin and ImageJ) were compared regarding particle number, size and morphology. These solutions were also compared to the American Society for Testing and Materials (ASTM) F1877-16 specifications regarding particle morphology. SEM image analysis revealed no differences for the equivalent circle diameter (p = 0.969). However, a significant difference was found for the aspect ratio between the Particleanalyzer_HD and the other two software solutions (p < 0.001) and between Leica QWin and the other two software solutions regarding the roundness (p < 0.001). Only the Particleanalyzer_HD showed an excellent agreement with the ASTM standard for both morphology parameters (intraclass correlation = 1.000). Only the Particleanalyzer_HD calculated the two morphology parameters according to the ASTM standard. A comparison of the particle morphology between different studies is barely possible, as different algorithms for particle analysis are used. It is strongly recommended that the calculation according to the ASTM standard is used to improve future comparability of findings from wear analysis studies. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 108B:225-233, 2020.

Impact of Electrocautery on Fatigue Life of Spinal Fusion Constructs-An In Vitro Biomechanical Study.

Instrumentation failure in the context of spine surgery is attributed to cyclic loading leading to formation of fatigue cracks, which later propagate and result in rod fracture. A biomechanical analysis of the potential impact of electrocautery on the fatigue life of spinal implants has not been previously performed. The aim of this study was to assess the fatigue life of titanium (Ti) and cobalt-chrome (CoCr) rod-screw constructs after being treated with electrocautery. Twelve spinal constructs with CoCr and Ti rods were examined. Specimens were divided into four groups by rod material (Ti and CoCr) and application of monopolar electrocautery on the rods' surface (control-group and electrocautery-group). Electrocautery was applied on each rod at three locations, then constructs were cyclically tested. Outcome measures were load-to-failure, total number of cycles-to-failure, and location of rod failure. Ti-rods treated with electrocautery demonstrated a significantly decreased fatigue life compared to non-treated Ti-rods. Intergroup comparison of cycles-to-failure revealed a significant mean decrease of almost 9 × 105 cycles (p = 0.03). No CoCr-rods failed in this experiment. Electrocautery application on the surface of Ti-rods significantly reduces their fatigue life. Surgeons should exercise caution when using electrocautery in the vicinity of Ti-rods to mitigate the risk of rod failure.

Backside wear, particle migration and effectiveness of screw hole plugs in acetabular hip joint replacement with cross-linked polyethylene.

In total hip arthroplasty, osteolysis of the acetabulum often occurs at the backside of cups in the area of screw holes, indicating a clinically relevant amount of polyethylene (PE) wear particles in this area. In order to avoid a possible migration of wear particles to the acetabulum-bone, screw hole plugs are provided for some implant systems. The aims of this study were to quantitatively determine backside wear and to investigate the migration behaviour of articulation-related wear particles in a cup system with open and closed screw holes by plugs. Titanium cup systems with backside holes for screw fixations were sinusoidally loaded with 2.7 kN. The articulation area was separated from the backside area of the cup. A defined amount of articulation-generated particles was added to the fluid of the articulation chamber. The fluids in the two chambers were separately filtered after 2 × 106 cycles for a particle analysis. Backside wear with noticeably small (65.6 ±â€¯4.2 nm) and round PE particles was identified. With both open and closed screw holes, a migration of the articulating wear particles from the articulation area behind the cup could be observed. Backside wear was estimated to be below 1% of the articulated wear. Screw hole plugs did not effectively prevent the migration of PE wear particles behind the investigated cups. STATEMENT OF SIGNIFICANCE: Backside wear occurs in a proven cup-system. Furthermore, it was quantitatively observed that articulation-generated wear products could migrate from the articulating area along the cup/liner-interface through the screw holes behind the cup. An almost unimpeded particle migration to the acetabulum-bone, in conjunction with very small backside wear particles, could produce a clinically relevant amount of PE with respect to pelvic lysis. These findings highlight the importance of management to avoid particle migration in artificial hip cups. Therefore, primarily the use of screw hole plugs, as far as available for the respective cup-system, is recommended. The aim of avoiding particle migration by plugs, but also by using a sophisticated anchoring mechanism between cup and PE liner should continue in future.

Electrocautery Damage Can Reduce Implant Fatigue Strength: Cases and in Vitro Investigation.

BACKGROUND: The risk of femoral stem fracture after total hip replacement is low and can often be associated with a specific implant system or other factors that may reduce the fatigue strength. Additionally, damage to a metal component during revision surgery by an electrocautery device may further affect the fatigue behavior. METHODS: Two clinical cases of stem failure after revision of fractured ceramic components are presented; the retrieved components were analyzed for the cause of failure. In vitro cyclic load-to-failure testing of titanium alloy femoral stems after electrocautery application at 2 different locations (at the base and about midway on the femoral neck) was performed using a stepwise increase in load until implant fracture occurred. In addition, a detailed characterization of the local material structure around the electrocautery marks was performed. RESULTS: Superficial discoloration and melting marks were found on the retrieved components, including at the location of crack initiation in the anterolateral region, which may have reduced the fatigue strength of the material. In addition, elemental analysis indicated material transfer from the electrocautery tip. Damage to the surface by the electrocautery device significantly reduced the in vitro load to failure by up to 47% compared with that of undamaged femoral neck specimens. Material analysis revealed a relevant modification in microstructure, with an extension of approximately 2.7 mm and a depth of 550 µm, which could be divided in 3 structural zones. CONCLUSIONS: Intraoperative electrocautery device contact with the implant during surgical revision of a total hip replacement cannot always be avoided. However, on the basis of our findings, the risk of implant failure is increased due to a change in microstructure and a potential reduction of the implant's fatigue strength. Surgeons and manufacturers of electrocautery devices should be aware of this concern. CLINICAL RELEVANCE: During revision surgery, contact between an electrocautery device and the femoral component should be avoided to reduce the chance of subsequent femoral neck fracture.

Finite Element Analysis and Biomechanical Testing of the New MiniMIS Short Stem. / Finite-Elemente-Analyse und biomechanische Testung des neuen MiniMIS-Kurzschafts.

INTRODUCTION: In hip arthroplasty a trend towards short stem prostheses is observed. The aim of this study is to investigate the finite element analysis and biomechanical fatigue performance of a new short stem prosthesis. METHODS: A finite element analysis was used to simulate the stresses during neck and stem loading according to the ISO standards. Numerical analysis with applied forces of up to 6 kN were performed in the vertical direction on a femoral neck-preserving stem (MiniMIS). During experimental testing, 10 million cycles with a maximum load of 5.34 kN using the worst case of a XL ceramic head (36 mm) were applied. This was followed by a Locati test, where the load was increased until failure of the stem. RESULTS: For all stems, stress values below the limits according to the ISO 5832-3 standard (yield strength of 800 N/mm2) were calculated by the finite element analysis. In the biomechanical tests, the total number of 10 million cycles with a maximum load of 5.34 kN was reached in all cases without any visible signs of implant damage. The estimated load to failure after stem testing was 2.16 kN (required by ISO 7206-4: 1.2 kN) and after neck testing > 9.35 kN (required by ISO 7206-6: 5.4 kN). SUMMARY: The presented finite element calculation and subsequent biomechanical testing show that the design of this stem meets the essential mechanical requirements given by the ISO and a material failure is not expected in all variants tested under the applied boundary conditions.

How prosthetic design influences knee kinematics: a narrative review of tibiofemoral kinematics of healthy and joint-replaced knees.

INTRODUCTION: To improve the total knee arthroplasty (TKA) prosthesis design, it is essential to study the kinematics of the tibiofemoral joint. Many studies have been conducted in this area; however, conflicting results and incomparable testing methods make it difficult to draw definitive conclusions or compare research from studies. The goal of this article is to introduce what is known about both healthy and prosthetic tibiofemoral joint kinematics. AREAS COVERED: Healthy tibiofemoral joint kinematics are reviewed in vivo by different activities, and the kinematics of existing knee prosthetic design features are considered separately. These features include but are not limited to cruciate retaining, posterior cruciate substituting, mobile-bearing, and high flexion. EXPERT COMMENTARY: The type of activity that is being performed has a great influence on the kinematics of healthy knees, and the influences of different TKA prosthetic design features on the kinematics are complex and varied. Moreover, the TKA postoperative functional performance is influenced by many factors, and prosthetic design is among them, but not the only one that defines the performance.

Backside wear in acetabular hip joint replacement.

INTRODUCTION: Besides head-insert articulation in hip joint replacements, micro-motions between the backside of assembled polyethylene acetabular liners and the metal cup may cause additional wear. Pelvic osteolysis frequently occurs in the region of screw holes, and cup loosening hints to clinically relevant amounts of polyethylene backside wear. It has yet to be confirmed whether backside wear particles differ in size and morphology compared to articulating wear. Previous methods have been limited to subjective assessment of backside surface damages without consideration of wear debris. The aim of this study was to develop and validate a method for quantitative in vitro measurements of polyethylene backside wear in artificial hip cups and to characterize these wear particles for the first time. METHODS: Titanium cup-systems (Plasmafit®Plus7, Aesculap, UHMWPE liner) were sinusoidally loaded (2.5 kN) and a torque of 5 Nm was simultaneously applied. The front and rear side of the cup were separated to isolate backside wear. After 2 × 106 cycles the surrounding fluid was filtered and a particle analysis was performed. RESULTS: Backside wear had a particles size of 64.1 ±â€¯1.9 nm and was verified as round and oval particles with partly rough outlines. An estimated total number of particles of 1.26 × 109 ±â€¯1.67 × 108 per 106 cycles was determined. CONCLUSION: Backside wear was estimated to be several times lower than published values of articulating wear. However, polyethylene backside wear particles represented significantly smaller particles with partly roughened outlines than articulating wear particles and may therefore cause higher biological response in macrophage-mediated bone resorption compared to articulated particles. STATEMENT OF SIGNIFICANCE: Within this study, an analytical method for quantitative measuring polyethylene backside wear of artificial hip cups was successfully developed and validated for the first time. It could be shown that backside wear is still present, even in modern cup-systems. These findings can be further used for investigations of the osteolytic potential of polyethylene particles, for evaluating and improving new implant systems and to evaluate the effectiveness of screw hole plugs to prevent the particle migration to the acetabulum.