Impact of ABO-blood group type on haemorrhagic and thromboembolic complications after resection of intracranial meningiomas.

OBJECTIVE: Recent studies have suggested an impact of the ABO-blood group type on thromboembolic and haemorrhagic events following trauma and surgical procedures. However, only limited data are available on the impact of ABO-blood group types in neurosurgical patients. The goal of the present study was to evaluate the role of the ABO-blood group type on the frequency of thromboembolic and haemorrhagic complications in patients treated surgically for intracranial meningiomas at our institution. METHODS: We retrospectively analysed the medical records of consecutive patients undergoing resection of intracranial meningiomas at our institution during a period of 12.5 years (2006-2018). Clinical characteristics, modalities of surgical treatment, histopathological results and the postoperative course of patients were analysed with specific focus on ABO-blood group typing results, need for transfusion of blood products, events of postoperative thromboembolism and intracranial re-haemorrhage requiring surgical revision, as well as in-hospital mortality. RESULTS: A total of 1,782 patients were included in this study. Based on the ABO-blood group type, patients were subdivided into four categories, corresponding to their ABO-blood group: Blood group A (n = 773; 43%); blood group B (n = 222; 12%); blood group AB (n = 88; 5%); and blood group O (n = 699; 39%). Intracranial re-haemorrhage requiring re-craniotomy and haematoma evacuation occurred in a total of 49 patients (2.7%). Thromboembolic events such as pulmonary embolism occurred in a total of 27 patients (1.5%). Statistical analysis showed no significant differences regarding the ABO-blood group type in patients suffering from re-haemorrhage or thromboembolism compared with patients with uneventful course after surgery. The overall in-hospital mortality rate was 0.17% (n = 3). CONCLUSION: Our findings suggest a lack of relevance of the ABO-blood group type regarding haemorrhagic and thromboembolic complications in patients undergoing neurosurgical meningioma resection.

Wear and damage in retrieved humeral inlays of reverse total shoulder arthroplasty-where, how much, and why?

BACKGROUND: Polyethylene (PE) wear and material degradation have been reported as complications in reverse total shoulder replacements (rTSAs). In this regard, scapular notching is associated with more clinical complications. Therefore, the purposes of the study were to quantify the linear and volumetric wear, as a measure for the amount of removed material, and to qualitatively assess the PE damage modes to describe the material degradation in retrieved rTSA humeral PE inlays that contribute to failure of shoulder replacements. Furthermore, this study aimed to evaluate the effect of scapular notching on PE wear and rim damage of the humeral components. METHODS: The total study population of 39 humeral inlays contains 2 cohorts that were used for the damage mode analysis and for the wear analysis, respectively. The extent and presence of wear damage modes in 5 defined zones were assessed by a grading system for all PE joint replacements. For quantitative wear analysis the most frequent design (n = 17) was chosen. Using a coordinate-measuring machine and postprocessing software, volumetric wear measurements for the retrieved humeral PE inlays were undertaken. Furthermore, prerevision radiographs were analyzed for scapular notching. Finally, retrieval findings were correlated with clinical and radiographic data to consider the effect of notching and to identify risk of failures for these prostheses. RESULTS: Damage on the rim of the humeral PE inlays was more frequent and severe than on the intended articulation surface. Irrespective of the damage mode, the inferior rim zone sustained the greatest amount of wear damage followed by the posterior zone. Burnishing, scratching, pitting, and embedded particles are most likely to occur in the articular surface area, whereas surface deformation, abrasion, delamination and gross material degradation are predominantly present in the inferior and posterior rim zones. The retrieved inlays exhibited a mean volumetric wear rate of 296.9 mm³/yr ± 87.0 mm³/yr. However, if the notched and non-notched components were compared, a significant higher volumetric wear rate (296.5 ± 106.1 mm³/yr) was found for the notched components compared to the non-notched group (65.7 ± 7.4 mm³/yr). Generally, there was a significantly greater incidence of damage and greater amount of wear if scapular notching occurred. CONCLUSION: The notched components showed a 5-fold increase in PE wear rate. Therefore, scapular notching has a strong effect on PE damage and wear. If scapular notching can be clinically avoided, the PE wear performance is in a similar magnitude as found for hip and knee replacements.

Influence of joint kinematics on polyethylene wear in anatomic shoulder joint arthroplasty.

BACKGROUND: Despite the positive results in total shoulder arthroplasties (TSAs), a higher revision rate is documented compared with total hip and knee replacements. Wear is the possible main cause of TSA failure in the long-term. This study investigated the effect of joint kinematics and the influence of the rotator cuff on the polyethylene wear performance in an anatomic TSA. METHODS: Lifting a load of 2 kg with an abduction/adduction of 0° to 90° was simulated for 2 × 106 cycles as a primary motion using a fully kinematic joint simulator. A combined rotation in anteversion-retroversion of ±5° and ±10° was also simulated. The force in the superior-inferior direction and the axial joint compression were applied under force control based on in vivo data of the shoulder. A soft tissue restraint model was used to simulate an intact and an insufficient rotator cuff. RESULTS: The highest wear rate in the intact rotator cuff group was 58.90 ± 1.20 mg/106 cycles with a combined rotation of ±10°. When an insufficient rotator cuff was simulated, the highest polyethylene wear rate determined was 79.67 ± 4.18 mg/106 cycles. CONCLUSIONS: This study confirms a high dependency of the polyethylene wear behavior and dimension on the joint kinematics in total shoulder replacement. This can be explained by an increasing cross-shear stress on the polyethylene component. The results obtained indicate that additional combined kinematics are an indispensable part of wear tests on anatomic shoulder replacements.

Mixing of Head-Stem Components in Total Hip Arthroplasty.

BACKGROUND: Implant manufacturers proclaim that the tapers of modular total hip arthroplasty are not standardized and can vary from manufacturer to manufacturer. That is why the combination of various components from different manufacturers ("Mix and Match") is not permitted. In this study, different taper combinations were investigated experimentally to assess the effect of "Mix and Match" regarding the taper connection strength. METHODS: Torque-off tests using hip stems and metal femoral heads from 6 different implant manufacturers were performed. First the components were tested as intended and afterwards the stems were combined with metal heads from other manufacturers. RESULTS: There was no significant difference in taper connection strength when stems from the manufacturers Link, Smith & Nephew, and Zimmer were combined with heads from other manufacturers. The Biomet stems showed a significantly reduced taper connection strength if femoral heads of Aesculap, DePuy, or Smith & Nephew were used. On the contrary, the DePuy stems in combination with the originally intended femoral heads showed a significantly lower taper connection strength compared to the use of heads from Link, Biomet, and Zimmer. The same was observed for the Aesculap stems in combination with Zimmer heads. CONCLUSION: The results of this study suggest that mixing components from different manufacturers may affect the taper connection strength and could reduce the stability. As safety should be a high priority in patient treatment, any potential risks should be avoided. Therefore, mixing and matching of heads and femoral stems from different manufacturers cannot be recommended.

Ion release in ceramic bearings for total hip replacement: Results from an in vitro and an in vivo study.

INTRODUCTION: Literature on the potential release of trace elements following implantation of Zirconia-platelet toughened alumina (ZPTA) ceramic components is scant. The present study therefore analysed the in vitro and in vivo potential release of ions from ZPTA bearings. MATERIAL AND METHODS: An in vitro and in vivo study was conducted. The in vitro study compared leaching in bovine serum from two groups: ZPTA ceramic heads and Co-28Cr-6Mo alloy heads, both 28-mm diameter. A third group without implant served as reference group. An in vivo clinical study compared trace elements in the whole blood of patients with 36-mm diameter ZPTA ceramic-on-ceramic articulation after three and 12 months. A cohort of subjects without any prosthesis was used as control group. The release of ions was determined by high resolution-inductively coupled plasma-mass spectrometry. RESULTS: In the in vitro experiment, significant differences (p ≤ 0.01) in trace element release for chromium, cobalt and molybdenum were found, with increased levels of ion release in the Co-28Cr-6Mo metal group. The very low detection limit for yttrium allowed detection of a small yttrium release from the ZPTA heads, which was not confirmed by the in vivo study. No significant difference between the groups was found for strontium, aluminium, and zirconium. In the in vivo study, no relevant differences in ion levels between the reference group without any implant and the study group were found at the three and 12-month follow-up. CONCLUSION: This study supports that ZPTA ceramic articulation components are safe in terms of ion release, and may be an excellent alternative to bearings based on Co-28Cr-6Mo alloys.

Coronary Collateral Growth Induced by Physical Exercise: Results of the Impact of Intensive Exercise Training on Coronary Collateral Circulation in Patients With Stable Coronary Artery Disease (EXCITE) Trial.

BACKGROUND: A well-developed coronary collateral circulation provides a potential source of blood supply in coronary artery disease. However, the prognostic importance and functional relevance of coronary collaterals is controversial with the association between exercise training and collateral growth still unclear. METHODS AND RESULTS: This prospective, open-label study randomly assigned 60 patients with significant coronary artery disease (fractional flow reserve ≤0.75) to high-intensity exercise (group A, 20 patients) or moderate-intensity exercise (group B, 20 patients) for 4 weeks or to a control group (group C, 20 patients). The primary end point was the change of the coronary collateral flow index (CFI) after 4 weeks. Analysis was based on the intention to treat. After 4 weeks, baseline CFI increased significantly by 39.4% in group A (from 0.142±0.07 at beginning to 0.198±0.09 at 4 weeks) in comparison with 41.3% in group B (from 0.143±0.06 to 0.202±0.09), whereas CFI in the control group remained unchanged (0.7%, from 0.149±0.09 to 0.150±0.08). High-intensity exercise did not lead to a greater CFI than moderate-intensity training. After 4 weeks, exercise capacity, Vo2 peak and ischemic threshold increased significantly in group A and group B in comparison with group C with no difference between group A and group B. CONCLUSIONS: A significant improvement in CFI was demonstrated in response to moderate- and high-intensity exercise performed for 10 hours per week. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01209637.

Endothelial Function in Children and Adolescents Is Mainly Influenced by Age, Sex and Physical Activity　- An Analysis of Reactive Hyperemic Peripheral Artery Tonometry.

BACKGROUND: As adolescents rarely experience cardiovascular events, surrogate markers of atherosclerosis are useful to justify and monitor effects of primary prevention and therapy of risk factors. Endothelial function assessed by reactive hyperemic peripheral arterial tonometry (RH-PAT) resulting in a reactive hyperemic index (RHI) is a noninvasive method with limited data for use in children and adolescents.Methods and Results:We performed a total of 931 RHI measurements in 445 high-school students, aged 10-17 years, over a time period of 5 years. Students were randomized by class to 60 min physical exercise (PE) at school daily (intervention group), or 2 units of 45-min PE weekly (control group). To characterize the factors influencing the RHI, anthropometry, cardiopulmonary exercise testing, blood cholesterol and quality of life were assessed and used to build mixed linear models. Main influential factors were age, with an increase of RHI from 1.53±0.42 in the youngest to 1.96±0.59 in the oldest students, sex, with higher values in girls, and physical activity. This increase adjusted by age and sex was estimated as 0.11 [0.08, 0.14] per year. RHI was higher in the intervention group by 0.09 [-0.05, 0.23] in comparison with the control group. CONCLUSIONS: If RH-PAT is used in research or as a clinical tool in adolescents, the shown age- and sex-dependence of RHI have to be taken in account.

Influence of humeral head material on wear performance in anatomic shoulder joint arthroplasty.

BACKGROUND: The number of total shoulder arthroplasties has increased in the past years, with encouraging results. However, the survival of anatomic total shoulder arthroplasty (aTSA) is lower compared with that of knee and hip replacements. Wear-associated problems like loosening are well-known causes of long-term failure of aTSA. The main purpose of this study was to investigate the wear behavior of ceramic-polyethylene bearings compared with the standard metal-polyethylene bearings. Because there is a lack of valid experimental wear testing methods, the secondary aim was to develop a validated wear simulation. METHODS: The wear assessment was performed using a force-controlled joint simulator for 3 × 106 cycles, and polyethylene wear was assessed gravimetrically and by particle analysis. Kinetic and kinematic data were adopted from in vivo loading measurements and from several clinical studies on shoulder joint kinematics. The reaction of the rotator cuff was simulated on the basis of a virtual soft tissue model. As activity, an abduction-adduction motion of 0°-90° lifting a load of 2 kg superimposed by an anteversion-retroversion has been chosen. RESULTS: The studied aTSA resulted in a polyethylene wear rate of 62.75 ± 1.60 mg/106 cycles in combination with metallic heads. The ceramic heads significantly reduced the wear rate by 26.7% to 45.99 ± 1.31 mg/106. There were no relevant differences in terms of the particle characteristics. CONCLUSION: This is the first study that experimentally studied the wear behavior of aTSA based on patient-related and biomechanical data under load-controlled conditions. Regarding polyethylene wear, the analyzed aTSA could benefit from ceramic humeral heads.

Same Same but Different? 12/14 Stem and Head Tapers in Total Hip Arthroplasty.

BACKGROUND: Taper corrosion has been identified to be a major concern in total hip arthroplasty during the past years. So far, the mechanisms that lead to taper corrosion in modular taper junctions are not fully understood. However, it has been shown that corrosion is also influenced by the geometry and topography of the taper, and these parameters vary among the implant manufacturers. The purpose of this study was to investigate the variations of common stem and head tapers regarding design and surface characteristics. METHODS: An analysis of selected commercially available 12/14 stem and head tapers was performed. As geometric parameters, the taper angle, the opening taper diameter, and the taper length were measured using a coordinate measuring machine. Several topographic parameters were determined using a tactile roughness measurement instrument. RESULTS: Although all investigated tapers are so-called 12/14 tapers, this study showed that the stem and head tapers differ among the manufacturers. The stem tapers were clearly different in both geometry and topography, and the range in variation of the topographic parameter was greater than it was for the geometric parameter. In contrast, the head tapers were different in their geometry, although not in topography. CONCLUSION: Ultimately, this study provides an overview on the characteristics and variations of modular hip taper connections, and in addition, a new classification system regarding the surface finish is presented. These findings could be further considered in experimental corrosion or retrieval studies.

Delayed type hypersensitivity-induced myeloid-derived suppressor cells regulate autoreactive T cells.

Mild but efficient treatments of autoimmune diseases are urgently required. One such therapy, long-term maintenance of chronic delayed type hypersensitivity, has been described for alopecia areata (AA), a hair follicle-affecting autoimmune disease. The molecular mechanisms underlying the therapeutic efficacy are unknown, but may involve myeloid-derived suppressor cells (MDSCs). AA-affected mice were treated with squaric acid dibutyl ester (SADBE). The immunoreactivity of SADBE-treated AA lymphocytes and of AA lymphocytes co-cultured with SADBE-induced MDSCs was analyzed. The curative effect of SADBE was abolished by all-transretinoic acid, which drives MDSCs into differentiation, confirming a central role for MDSCs in therapeutic SADBE treatment. SADBE and SADBE-induced MDSCs strongly interfered with sustained autoreactive T-cell proliferation in response to AA skin lysate (autoantigen), which was accompanied by weak ζ-chain down-regulation and strongly impaired Lck activation. In contrast, activation of the mitochondrial apoptosis pathway and blockade of the anti-apoptotic PI3K/Akt pathway by SADBE-induced MDSCs did not require T-cell receptor engagement. Apoptosis induction correlated with high TNF-α expression in SADBE-induced MDSCs and elevated TNFRI levels in AA lymphocytes. SADBE-induced MDSCs interfere with persisting autoreactive T-cell proliferation and promote apoptosis of these T cells, which qualifies MDSCs induced and maintained by chronic delayed type hypersensitivity reactions as promising therapeutics in organ-related autoimmune diseases.

Taper corrosion in total hip arthroplasty - How to assess and which design features are crucial?

BACKGROUND: In total hip replacement, wear and corrosion arising from modular taper connections have increasingly become a serious clinical concern. Previous studies led to confounding results regarding the role of specific taper design features, likely due to the application of different analytical approaches. Accordingly, this study has two major objectives: first, to evaluate different analytical approaches to evaluate the fretting-corrosion behavior; and secondly to determine the effect of four specific design variables: the taper engagement situation, the stem taper length and surface topography in terms of roughness and contact ratio. METHODS: An in vitro fretting-corrosion test setup was used including an aggressive solution. Cyclic loading was applied, varying from 300 N to 2500 N at a frequency of 3 Hz. Taper dummies covering different implant designs were tested in seven different test groups. Different quantitative and qualitative analytical test methods such as electrochemical characterization, ion analysis, gravimetry and corrosion scoring were applied in order to quantify the material degradation. RESULTS: A stepwise linear regression analysis showed that the taper engagement situation is the predominant factor that predicts the metal ion release from the taper connection, followed by the contact ratio of the taper surface and subsequently the taper length. A distal taper engagement situation, as well as a high contact ratio and a short taper length are the relevant parameters that decrease the metal ion release. Hereby, metal ion analysis turned out to be the most precise and reliable method for determining corrosive driven material loss, followed by gravimetry. CONCLUSION: It was found that the taper engagement length is the major design parameter that influences the total ion release. It further turned out, that the selection of an appropriate analytical approach is essential for the evaluation of the corrosion behavior of taper connections in an experimental setting.

Taper junctions in modular hip joint replacements: What affects their stability?

BACKGROUND: Although taper junctions are beneficial in the reconstruction of hip joints, some clinical concerns like the formation of adverse local tissue reactions have recently emerged. These reactions are associated with wear and corrosion products from the interface of insufficient taper connections regarding strength. Commonly used tapers vary in their geometric and topographical design parameter. Therefore, this study aims to evaluate interactions between design and surgical related parameters to the taper connection strength. METHODS: In this study, the effect of the taper contact situation, surface roughness and head material in combination with assembly force on the taper connection strength were assessed using torque-off tests. Furthermore, the type of use in terms of single-use or re-use of the stem taper was investigated. RESULTS: The study showed that the impaction force is the predominant factor that determines the taper strength followed by the type of use and the head material. The contact situation seems to slightly influence the determined torque-off moment, whereas the surface topography of the stem taper obviously plays a minor role for the taper connection strength. CONCLUSION: Clinical users should be aware that an increased assembly force will strengthen the stability of the taper junction, whereas care should be taken when reusing hip stems with metal heads as this may decrease their connection strength.

Cerebral metastasis of a primary heart sarcoma.

Primary cardiac sarcomas are exceptionally rare tumours. A brain metastasis of a primary cardiac sarcoma has never been reported before. Although we know lots of primary malignomas spreading to the brain, we never observed cerebral metastases of an atrial spindle cell sarcoma. Cardiac sarcomas are more likely to haematogenously metastasize to the lung or the liver. Here, we describe the case of a young man, who suffered from a cerebral metastasis of a spindle cell sarcoma in the left heart atrium nine years ago. Postoperative whole brain irradiation with 30 Gy was performed. Later on, the patient experienced a local recurrence within the left atrium accompanied by cardiac arrhythmia and mitral valve insufficiency. This case is the very first description of a true cerebral metastasis from a primary heart sarcoma. Therefore, clear treatment paradigms are not established. Further case illustrations and the publication of larger patient series are mandatory, whenever possible.

Bearing Thickness Is Not a Predictive Factor for Damage and Penetration in Oxford Unicompartmental Knee Arthroplasty-A Retrieval Analysis.

The medial Oxford unicompartmental knee arthroplasty (OUKA) shows good survivorship, as well as clinical results. Aseptic loosening, however, remains one of the main reasons for revision and polyethylene debris is known to cause aseptic loosening. The role of bearing thickness in total as well as unicondylar knee arthroplasty has been the subject of controversial discussions, especially the longevity of lower thickness bearings in total knee arthroplasty was questioned. The purpose of this study was to assess the influence of bearing thickness on time to revision, damage pattern, penetration, and volumetric material loss. A cohort of 47 consecutively retrieved medial OUKA bearings was analyzed with conventional direct light microscopy applying the Hood damage analysis, as well as measuring the penetration depth. In this retrieval cohort, a difference on survival time, damage, penetration, as well as volumetric material loss could not be seen. We conclude that low as well as high thickness bearings can safely be used in OUKA without any relevant differences in terms of wear and damage.

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.

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.

Metastatic glioblastoma cells use common pathways via blood and lymphatic vessels.

Generally, gliomas do not metastasize. Therefore, larger series are not available to investigate the pathways of tumour spread. Here, we present the case of a young man with a glioblastoma multiforme WHO grade IV and distant metastases in several tissues. The glioblastoma multiforme WHO grade IV of a young male patient recurred within a very short time along the surgical resection pathway within the temporalis muscle. After removal of the tumour bulk, the patient developed a distant intracranial tumour lesion around the contralateral ventricular system and a pulmonary tumour. Later on, the patient underwent an operation on a facial lesion representing a local extracranial glioblastoma recurrence and containing metastases within lymph nodes and lymphatic vessels. Our case report indicated a lymphatic pathway of metastasis, which could be demonstrated by our histopathological analysis. We suggest that altered gene expression stimulated by glioblastoma-environment interaction altered the properties of glioblastoma cells, whether caused by a spontaneous genetic shift or induced by factors provided by the extracranial tissue.

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.

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.

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.