Comparison between highly cross-linked and conventional polyethylene in total knee arthroplasty

doi:10.1016/j.knee.2009.01.005

The Knee

Volume 16, Issue 5, October 2009, Pages 348-351

https://doi.org/10.1016/j.knee.2009.01.005 Get rights and content

Abstract

The use of highly cross-linked polyethylene in total knee prostheses is still controversial. The aim of the present study was to compare radiographic and clinical results of using conventional and highly cross-linked polyethylene in cruciate retaining total knee prostheses of completely the same design. Two hundred and two consecutive total knee arthroplasties (NexGen CR, Zimmer) were performed using the same procedure. The first consecutive 113 knees had conventional polyethylene insert and following consecutive 89 knees had highly cross-linked polyethylene insert (Prolong, Zimmer). Differences in the age, gender, and diagnosis between two groups were not statistically significant. Preoperative range of motion (ROM) of the knee, and Knee Society Score (KSS) was better in highly cross-linked polyethylene group. Clinical and radiographic results were evaluated at two years after operation. The difference of ROM and KSS between groups was not statistically significant. There was no revision surgery. No knee exhibited osteolysis, aseptic loosening, or polyethylene failure. There was no early catastrophic clinical failure due to use of the new material.

Introduction

Polyethylene wear in total joint arthroplasty is one of the most important factors affecting mid- and long-term clinical results [1], [2], [3], [4], [5]. Therefore, many new designs and materials have recently been introduced for total joint prostheses to reduce polyethylene wear and to achieve better long-term results. In the 1990s, highly cross-linked polyethylene was developed, and is now widely used for total hip arthroplasty (THA). Reduction of wear with highly cross-linked polyethylene has been reported in in vitro and in vivo studies of total hip prostheses [6], [7], [8], [9], [10], [11], [12], [13]. Recently, knee simulator studies have shown that highly cross-linked polyethylene improves both adhesive and abrasive wear resistance as well as delamination resistance [14], [15], [16]. However, reduced fracture toughness and the generation of smaller and more reactive particles have been reported with it [11]. Since there has been only a limited information [17] on in vivo clinical results of total knee arthroplasty using highly cross-linked polyethylene, the use of highly cross-linked polyethylene in total knee prostheses remains controversial [18], [19], [20], [21].

The aim of the present study was to compare early clinical and radiographic results of use of conventional polyethylene and highly cross-linked polyethylene (Prolong; Zimmer, Warsaw, IN, USA) in total knee prostheses of the same design (NexGen CR; Zimmer, Warsaw, IN, USA), and to investigate early failure due to use of this new material.

Section snippets

Materials and methods

We began use of a cruciate retaining (CR) total knee prosthesis (NexGen CR) in January 2001. All the operations were performed by a single surgical team using the same procedure. Given the likelihood of existence of a learning curve for this component, 207 consecutive knees (187 patients) undergoing primary total knee arthroplasty (TKA) from January 2002 to July 2004 were analyzed in the present study. During this period, we used NexGen CR for all the cases of primary TKA. First consecutive 115

Results

Preoperative demographic data was shown in Table 1. Differences in the age, gender, and diagnosis between two groups were not statistically significant. Preoperative range of motion of the knee, and Knee Society Score [11] was better in highly cross-linked polyethylene group.

Range of motion and Knee Society Score at 2 years after the operation is summarized in Table 2. The difference of range of motion and Knee Society Score (knee score and function score) between groups was not statistically

Discussion

The present study showed that differences in the postoperative clinical scores, range of motion, and radiographic results of CR TKA between highly cross-linked and conventional polyethylene with the same design were not significant. Our results showed that there was no early failure due to use of the new material. To our knowledge, there has been only a limited information on in vivo clinical results of TKA using highly cross-linked polyethylene [17]. Hodrick et al. reported that less

Acknowledgements

The authors thank Rika Onishi, secretary of Knasai Rosai Hospital, for her assistance with this study.

References (33)

C.A. Engh et al.
A randomized prospective evaluation of outcomes after total hip arthroplasty using cross-linked marathon and non-cross-linked Enduron polyethylene liners
J Arthroplasty
(2006)
R.J. Krushell et al.
Early femoral head penetration of a highly cross-linked polyethylene liner vs a conventional polyethylene liner: a case-controlled study
J Arthroplasty
(2005)
D.W. Manning et al.
In vivo comparative wear study of traditional and highly cross-linked polyethylene in total hip arthroplasty
J Arthroplasty
(2005)
O.K. Muratoglu et al.
Knee-simulator testing of conventional and cross-linked polyethylene tibial inserts
J Arthroplasty
(2004)
M. Jasty et al.
Highly cross-linked polyethylene: the debate is over—in the affirmative
J Arthroplasty
(2005)
J.A. Rodriguez
Cross-linked polyethylene in total knee arthroplasty: in opposition
J Arthroplasty
(2008)
P. Mestha et al.
Fracture of the polyethylene tibial post in posterior stabilized (Insall Burstein II) total knee arthroplasty
J Arthroplasty
(2000)
D.R. Mauerhan
Fracture of the polyethylene tibial post in a posterior cruciate-substituting total knee arthroplasty mimicking patellar clunk syndrome: a report of 5 cases
J Arthroplasty
(2003)
H.D. Clarke et al.
Polyethylene post failure in posterior stabilized total knee arthroplasty
J Arthroplasty
(2004)
A. Wang et al.
A highly crosslinked UHMWPE for CR and PS total knee arthroplasties
J Arthroplasty
(2008)

D.H. DeHeer et al.

In situ complement activation by polyethylene wear debris

J Biomed Mater Res

(2001)

T.R. Green et al.

Effect of size and dose on bone resorption activity of macrophages by in vitro clinically relevant ultra high molecular weight polyethylene particles

J Biomed Mater Res

(2000)

Y. Kadoya et al.

Bone formation and bone resorption in failed total joint arthroplasties: histomorphometric analysis with histochemical and immunohistochemical technique

J Orthop Res

(1996)

W.J. Maloney et al.

Isolation and characterization of wear particles generated in patients who have had failure of a hip arthroplasty without cement

J Bone Joint Surg [Am]

(1995)

H.G. Willert

Reactions of the articular capsule to wear products of artificial joint prostheses

J Biomed Mater Res

(1997)

J.A. D'Antonio et al.

Five-year experience with Crossfire highly cross-linked polyethylene

Clin Orthop Relat Res

(2005)

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Aseptic loosening of the option stemmed tibial tray in the Zimmer NexGen LPS total knee arthroplasty system
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We investigated the relationship between the backside deformation of polyethylene (PE) tibial inserts and aseptic loosening of the Option stemmed tibial tray used with Zimmer NexGen posterior-stabilised (PS) devices. We hypothesized that explanted inserts used in PS designs would exhibit greater extents of PE backside deformation than those used in equivalent cruciate retaining (CR) designs and that PE inserts retrieved from total knee arthroplasties (TKAs) revised for aseptic tibial tray loosening would exhibit greater extents of backside deformation than TKAs revised for other reasons.
A total of 73 explanted fixed-bearing TKAs (42 CR and 31 PS) were examined. PE components underwent geometric examination with a coordinate measuring machine using validated techniques. Multiple regression modelling was used to identify variables associated with revision secondary to aseptic loosing and to determine factors associated with increased PE backside deformation.
PE inserts retrieved from TKAs with aseptic loosening had significantly greater backside deformation than those retrieved from TKAs revised for other reasons (p < 0.001). Greater PE backside deformation was significantly associated with larger tray/insert clearance heights (p < 0.001), thinner inserts (p < 0.001) and PS TKAs (p = 0.001).
PE backside deformation was significantly greater in the PS TKAs. This may provide one explanation for the increased rate of aseptic loosening reported with the Option tibial tray used with the Legacy Posterior Stabilised (LPS) system.
Is Highly Cross-Linked Polyethylene Safe for Use in High-Flexion Posterior Stabilized Total Knee Arthroplasty?
2023, Journal of Arthroplasty
Citation Excerpt :
Hodrick et al [35] observed better clinical and radiographic results, in terms of radiolucent lines, osteolysis, and aseptic loosening of the component with HXLPE inserts. However, many authors [33,36] observed that there were no differences between HXLPE and conventional polyethylene groups with respect to clinical and radiographic results. In the current long-term follow-up study, we found no differences between HXLPE and conventional polyethylene groups with respect to clinical and radiographic results or patient satisfaction.
Application of highly cross-linked polyethylene (HXLPE) to a posterior cruciate-substituting total knee arthroplasty (TKA) might add the risk of fracture and failure of the tibial polyethylene insert. The purpose of this study is to evaluate the long-term (up to 19 years) clinical and radiographic results of posterior cruciate-substituting TKAs with HXLPE or conventional polyethylene.
This study analyzed the results of 1,217 patients (444 men and 773 women; mean age of 65 ± 7 years, range, 31-85) (2,434 knees) who had received a NexGen LPS-Flex prosthesis with a conventional tibial insert in one knee and the same prosthesis with an HXLPE tibial insert in the contralateral knee. The mean duration of follow-up was 17 years (range, 15-19).
The 2 groups did not differ significantly (P > .05) with regard to the clinical and radiographic results. No knee in either group had a fracture of the tibial polyethylene post or failure of the locking mechanism of the tibial polyethylene insert or osteolysis. Twenty-eight knees (2.3%) in the HXLPE group and 26 knees (2.1%) in the conventional polyethylene group were revised. The estimated survival rate at 17 years was 97.7% in the HXLPE group and 97.9% in the conventional polyethylene group.
The data suggest that clinical and radiographic findings at a mean of 17 years after posterior cruciate-substituting TKA are the same for patients treated with HXLPE and those treated with conventional polyethylene.
Highly cross-linked polyethylene (HXLPE) is equivalent to conventional polyethylene (CPE) in total knee arthroplasty: A systematic review and meta-analysis
2021, Knee
Citation Excerpt :
There were 10/984 (1.02%) aseptic revisions in the HXLPE cohort and 20/1015 (1.97%) in the CPE cohort. Of the 6 studies included, one reported no aseptic revisions of any kind [13]. Revision for aseptic component loosening was performed for 8/984 (0.81%) CPE knees and 1/1,015 HXLPE knees (0.1%).
The benefits of HXLPE in total knee arthroplasty (TKA) have not been as evident as total hip arthroplasty (THA). A systematic review and meta-analysis to assess the impact of highly-crosslinked polyethylene (HXLPE) on TKA outcomes compared to conventional polyethylene (CPE) is described.
All studies comparing HXLPE with CPE for primary TKA were included for analysis. The minimum dataset included revision rates, indication for revision, aseptic component loosening and follow-up time. The primary outcome variables were all-cause revision, aseptic revision, revision for loosening, radiographic component loosening, osteolysis and incidence of radiolucent lines. Secondary outcome measures included postoperative functional knee scores. A random-effects meta-analysis allowing for all missing data was performed for all primary outcome variables.
Six studies met the inclusion criteria. In total, there were 2,234 knees (1,105 HXLPE and 1,129 CPE). The combined mean follow-up for all studies was 6 years. The aseptic revision rate in the HXLPE group was 1.02% compared to 1.97% in the CPE group. There was no difference in the rate of all-cause revision (p = 0.131), aseptic revision (p = 0.298) or revision for component loosening (p = 0.206) between the two groups. Radiographic loosening (p = 0.200), radiolucent lines (p = 0.123) and osteolysis (p = 0.604) was similar between both groups. Functional outcomes were similar between groups.
The use of HXLPE in TKA yields similar results for clinical and radiographic outcomes when compared to CPE at midterm follow-up. HXLPE does not confer the same advantages to TKA as seen in THA.
Retrieval analysis of two contemporary total knee designs: Influence of femoral component roughness and type of polyethylene
2020, Journal of the Mechanical Behavior of Biomedical Materials
Early failure of sequentially annealed polyethylene in total knee arthroplasty
2020, Arthroplasty Today
Improvements in the processing of polyethylene have led to a dramatic reduction in wear rates in total hip arthroplasty. This led to the adoption of modern highly cross-linked polyethylene in total knee arthroplasty (TKA). However, the differences in modes of wear and failure between total hip arthroplasty and TKA have tempered expectations regarding similar decreases in polyethylene-related complications in TKA. We present a case of early catastrophic failure of a modern sequentially irradiated and annealed highly cross-linked polyethylene insert only 5 years after contemporary cementless TKA.
Is Cross-Linked Polyethylene an Improvement Over Conventional Ultra-High Molecular Weight Polyethylene in Total Knee Arthroplasty?
2018, Journal of Arthroplasty
Reducing polyethylene (PE) wear by increasing the cross-linking encouraged surgeons to hope for increased total knee arthroplasty (TKA) survival rates. Different methods of manufacturing cross-linked polyethylene (XLPE) were introduced, following promising in vitro results. Is there a measurable effect of cross-linking on TKA survival?
A registry study was conducted, focusing on fixed tibial inserts in primary TKA. Conventional PE represented 87% of the liners, 10% were cross-linked and 2% were antioxidant PE. Sixty-four percent of the liners were posterior-stabilized (PS). Survival of the different PE groups and survival of the main XLPE available were successively compared. We also looked for differences in the same brand implant groups with regard to PE type, as well as differences between cruciate retaining and PS knees.
No differences were found when looking at survival for any cause or for aseptic loosening only (P = .96). When comparing the XLPE available, X3 was found to have a better survival than Prolong or Smith & Nephew XLPE (P = .036). When the same implants and X3 or conventional PE were used, no difference could reach a statistical significance. With Zimmer LPS Flex, Prolong XLPE was even associated with a lower survival compared with conventional PE. On Stryker implants, only the Cox regression model allowed highlighting a difference between X3 XLPE and conventional PE, only in PS knees.
Increasing the cross-linking seems to only have a low effect, if any, on knee arthroplasty survival. Differences between brands could be found; the manufacturing process could play a role.

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Comparison between highly cross-linked and conventional polyethylene in total knee arthroplasty

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

In situ complement activation by polyethylene wear debris

J Biomed Mater Res

Effect of size and dose on bone resorption activity of macrophages by in vitro clinically relevant ultra high molecular weight polyethylene particles

J Biomed Mater Res

Bone formation and bone resorption in failed total joint arthroplasties: histomorphometric analysis with histochemical and immunohistochemical technique

J Orthop Res

Isolation and characterization of wear particles generated in patients who have had failure of a hip arthroplasty without cement

J Bone Joint Surg [Am]

Reactions of the articular capsule to wear products of artificial joint prostheses

J Biomed Mater Res

Five-year experience with Crossfire highly cross-linked polyethylene

Clin Orthop Relat Res