To what extent could the acetabular liner thickness be reduced yet remaining tribologically acceptable in metal-on-vitamin E-diffused crosslinked polyethylene hip arthroplasty?

The aim of the present study was to evaluate how much reduction in acetabular liner thickness could be tribologically acceptable in metal-on-vitamin-E diffused highly crosslinked ultra-high molecular weight polyethylene (Vit-E XLPE) bearings for total hip arthroplasty. We tested thick- (10.3 mm), moderate- (6.3 mm), and thin- (4.3 mm) Vit-E XLPE liners coupled with 28-mm cobalt-chromium femoral heads on a hip simulator to 5 million cycles, and peak contact stress was predicted based on mathematical modeling. Wear damage was also evaluated in terms of surface topology and morphology. Wear simulation demonstrated that the 2-4 mm thickness reduction (6.3 → 4.3 mm and 10.3 → 6.3 mm) did not significantly affect the wear rate for Vit-E XLPE liner, whereas 6-mm reduction (10.3 → 4.3 mm) significantly increased liner wear (by 309%) and head roughness (by 415%). This effect was attributed to a contact stress increase (by 24-41%). However, the wear rates for all thicknesses tested were much lower than those previously reported for thicker non-crosslinked materials. The original crystalline morphology was maintained in all liners after wear. Our results suggest that the 2-4 mm thickness reduction may be tribologically acceptable in Vit-E XLPE liners. However, more severe and longer term simulations are necessary to determine a minimum acceptable thickness.

Dual mobility cup in hip arthroplasty: An in-depth analysis of joint registries.

Although total hip arthroplasty (THA) has shown successful results, instability remains a major complication. In recent years, dual mobility cups (DMC) have gained interest among clinicians thanks to its low rate of dislocation and good clinical results. The main aim of this work was to describe the accuracy of data on DMC from national and regional joint registries (JRs) and the available worldwide literature. We identified topics on DMC among JRs to propose a new harmonized and standardized section for DMC with the aim to understand its surveillance over the time. We extracted survival and implant data for a separate analysis. After performing a critical exclusion process, nine JRs were considered eligible and included for final synthesis; these were the results from the available worldwide data from JRs. In our study, eight analyzed JRs reported a slight increase in DMC use in the last decade. In all the JRs evaluated and the available articles, dislocation remains one of the main reasons for revision and re-revision in hip arthroplasties. DMC is considered to be a valid construct increasingly used worldwide in primary and revision THA with the primary aim of reducing dislocation rates. Annual reports from JRs collect heterogeneous and low-quality information about outcomes and surveillance of DMC, creating a burden for clinicians to extract comparable data from different JRs. Longer follow-up and a systematic registering of DMCs with international registry harmonization are needed to monitor DMC outcomes.

Preliminary In Vitro Wear Assessment of Ceramic Cemented Femoral Components Coupled with Polyethylene Menisci.

Success of total knee replacement (TKR) depends on the prosthetic design and materials. The use of metal components is well established with the disadvantage of allergic reactions. Ceramics have been recently proposed because of high wear resistance, excellent biocompatibility, wettability, and suitable mechanical properties. This study was aimed at investigating in vitro wear resistance of Zirconia Toughened Alumina (ZTA)/Ultra-high-molecular-weight polyethylene (UHMWPE) of TKR femoral components. An in vitro protocol was designed with the application of relevant load profile, 6-degrees-of-freedom knee simulator, and 8 × 105 cycles on the ZTA/UHMWPE configuration under bovine calf serum. Before and after wear test, the femoral components were investigated by using the Scanning Electron Microscope (SEM) and the X-Ray Diffraction (XRD) analyses, and stylus surface roughness measurements. The proposed pre-clinical test yielded repeatable results. In particular, gravimetric results showed that, after 8 × 105 cycles, the mean weight loss of the polyethylene mobile components is 5.3 ± 1.1 mg. The surface roughness measurements (Ramax) performed after the wear test showed no significant variation on the UHMWPE menisci. A slight increase of roughness has been found on the ZTA (0.02 µm before wear test, 0.28 µm after the test). SEM observations did not show significant modification of the surface morphology. Tetragonal to monoclinic phase ratio was measured by XRD before and after wear test to evaluate stability of tetragonal ZrO2 phase. Minimal conversion of tetragonal to monoclinic phase was found from 5.4 to 8%. Although this study is a preliminary evaluation limited to in vitro tests, it provides novel pre-clinical indications about the potential of ceramic TKR femoral components.

Graphene Oxide-Doped Gellan Gum-PEGDA Bilayered Hydrogel Mimicking the Mechanical and Lubrication Properties of Articular Cartilage.

Articular cartilage (AC) is a specialized connective tissue able to provide a low-friction gliding surface supporting shock-absorption, reducing stresses, and guaranteeing wear-resistance thanks to its structure and mechanical and lubrication properties. Being an avascular tissue, AC has a limited ability to heal defects. Nowadays, conventional strategies show several limitations, which results in ineffective restoration of chondral defects. Several tissue engineering approaches have been proposed to restore the AC's native properties without reproducing its mechanical and lubrication properties yet. This work reports the fabrication of a bilayered structure made of gellan gum (GG) and poly (ethylene glycol) diacrylate (PEGDA), able to mimic the mechanical and lubrication features of both AC superficial and deep zones. Through appropriate combinations of GG and PEGDA, cartilage Young's modulus is effectively mimicked for both zones. Graphene oxide is used as a dopant agent for the superficial hydrogel layer, demonstrating a lower friction than the nondoped counterpart. The bilayered hydrogel's antiwear properties are confirmed by using a knee simulator, following ISO 14243. Finally, in vitro tests with human chondrocytes confirm the absence of cytotoxicity effects. The results shown in this paper open the way to a multilayered synthetic injectable or surgically implantable filler for restoring AC defects.

Comparative Raman study on the molecular structure and IN VIVO wear of poly(methyl methacrylate)-based devices used as temporary knee prostheses: Effect of the antibiotic.

The infection rate of total knee arthroplasty is still high, in spite of the high success of this surgical procedure. The use of an antibiotic-loaded temporary spacer made of poly(methyl methacrylate) (PMMA) has been proposed to treat infected knee arthroplasties. This study was aimed at comparatively investigating, on a molecular scale, two types of spacers from the same manufacturer (Spacer K and Vancogenx-space knee, Tecres, Italy), which differ for the added antibiotic (gentamicin sulphate in Spacer K and gentamicin sulphate + vancomycin hydrochloride in Vancogenx). Raman spectroscopy was used to gain more insights into the possible effects of the antibiotic on the spacer composition and polymer structure both in the new components and after in vivo use. Vancogenx was found to contain a lower residual MMA content than Spacer K (about 0.15% versus 0.4%). The former contained a higher amount of isotactic stereosequences than the latter, while the syndiotactic content (the prevailing component) was not significantly different in the two prostheses. The presence of vancomycin hydrochloride influenced not only the degree of polymerization and PMMA tacticity and crystallinity, but in turn also the wear behavior. Actually, Spacer K retrievals were found more affected by in vivo implantation than Vancogenx-space knee ones, revealing slight variations in polymer tacticity and crystallinity and relative radiopacifier content, besides release of MMA and additives of polymerization. However, these changes did not appear worrisome, due to the temporary nature of the prosthesis. In view of these results, the addition of vancomycin hydrochloride could offer an advantage, in spite of the higher costs requested and the potential risks of its unselective use.

Wear Behavior Characterization of Hydrogels Constructs for Cartilage Tissue Replacement.

This paper aims to characterize the wear behavior of hydrogel constructs designed for human articular cartilage replacement. To this purpose, poly (ethylene glycol) diacrylate (PEGDA) 10% w/v and gellan gum (GG) 1.5% w/v were used to reproduce the superior (SUP) cartilage layer and PEGDA 15% w/v and GG 1.5% w/v were used to reproduce the deep (DEEP) cartilage layer, with or without graphene oxide (GO). These materials (SUP and DEEP) were analyzed alone and in combination to mimic the zonal architecture of human articular cartilage. The developed constructs were tested using a four-station displacement control knee joint simulator under bovine calf serum. Roughness and micro-computer tomography (µ-CT) measurements evidenced that the hydrogels with 10% w/v of PEGDA showed a worse behavior both in terms of roughness increase and loss of uniformly distributed density than 15% w/v of PEGDA. The simultaneous presence of GO and 15% w/v PEGDA contributed to keeping the hydrogel construct's characteristics. The Raman spectra of the control samples showed the presence of unreacted C=C bonds in all the hydrogels. The degree of crosslinking increased along the series SUP < DEEP + SUP < DEEP without GO. The Raman spectra of the tested hydrogels showed the loss of diacrylate groups in all the samples, due to the washout of unreacted PEGDA in bovine calf serum aqueous environment. The loss decreased along the series SUP > DEEP + SUP > DEEP, further confirming that the degree of photo-crosslinking of the starting materials plays a key role in determining their wear behavior. µ-CT and Raman spectroscopy proved to be suitable techniques to characterize the structure and composition of hydrogels.

Wear characterization and contact surfaces analysis of menisci and femoral retrieved components in bi-condylar knee prostheses.

PURPOSE: Although total knee arthroplasty is a well-practiced surgical procedure, material properties and surface topography can contribute to the wear mechanisms and the implant failure. It has been advised that an increased femoral component's surface roughness of total knee prostheses may be a contributing factor to accelerated wear of the polyethylene menisci and eventually prosthesis failure. The aim of this study is to investigate the wear phenomena occurring on medial and lateral compartments of retrieved total knee arthroplasty in order to correlate the surface roughness vs. BMI, age at revision, and time in situ. METHODS: Qualitative visual analyses were performed on all the retrieved knee components to assess the damage due to the wear phenomena. Quantitative analysis includes surface characterization performed using optical apparatus to describe surface roughness and morphology on the retrieved femoral, tibial and polyethylene component. The Mann-Whitney statistical test was performed to correlate the medial vs. lateral condyle surface roughness of all explants with BMI, age at revision, and time in situ. RESULTS: Visual and topographical analysis showed damage along the entire zone of the sliding contact area. A statistical difference between medial and lateral condyle roughness was found on four prosthesis. No statistical significance was found between surface roughness measurements and patient BMI, age at revision, and time in situ. On the femoral components various scratches were observed in the anterior/posterior (AP) direction of all the fixed femoral components. A statistically significant difference between medial and lateral condyle was found on two mobile knee design (p = 0.03) and on two fixed design (p = 0.01). The results were discussed in the framework of the usual TKR loading conditions during the gait, and of knowledge on the bio-tribological behavior of the prosthetic joint. CONCLUSIONS: The visual and topographical analysis showed consistent damage patterns with respect to the main movements to which the prosthetic components are subjected and no statistical significance was found between surface roughness measurements and patient BMI, age at revision, and time in situ.

Wear Simulation of Ceramic-on-Crosslinked Polyethylene Hip Prostheses: A New Non-Oxide Silicon Nitride versus the Gold Standard Composite Oxide Ceramic Femoral Heads.

The purpose of the present study was to compare the wear behavior of ceramic-on-vitamin-E-diffused crosslinked polyethylene (Vit-E XLPE) hip bearings employing the gold standard oxide ceramic, zirconia (ZrO2)-toughened alumina (Al2O3) (ZTA, BIOLOX®delta) and a new non-oxide ceramic, silicon nitride (Si3N4, MC2®). In vitro wear test was performed using a 12-station hip joint simulator. The test was carried out by applying the kinematic inputs and outputs as recommended by ISO 14242-1:2012. Vitamin-E-diffused crosslinked polyethylene (Vit-E XLPE) acetabular liners (E1®) were coupled with Ø28-mm ZTA and Si3N4 femoral heads. XLPE liner weight loss over 5 million cycles (Mc) of testing was compared between the two different bearing couples. Surface topography, phase contents, and residual stresses were analyzed by contact profilometer and Raman microspectroscopy. Vit-E XLPE liners coupled with Si3N4 heads produced slightly lower wear rates than identical liners with ZTA heads. The mean wear rates (corrected for fluid absorption) of liners coupled with ZTA and Si3N4 heads were 0.53 ± 0.24 and 0.49 ± 0.23 mg/Mc after 5 Mc of simulated gait, respectively. However, after wear testing, the ZTA heads retained a smoother topography and showed fewer surface stresses than the Si3N4 ones. Note that no statistically significant differences were found in the above comparisons. This study suggests that the tribochemically formed soft silica layer on the Si3N4 heads may have reduced friction and slightly lowered the wear of the Vit-E XLPE liners. Considering also that the toughness of Si3N4 is superior to ZTA, the present wear data represent positive news in the future development of long-lasting hip components.

Revision of a Monoblock Metal-on-Metal Cup Using a Dual Mobility Component: Is It a Reasonable Option?

Revision of large-diameter, monoblock acetabular components for both hip resurfacing arthroplasty and metal-on-metal (MoM) total hip arthroplasty (THA) is correlated to a high amount of complications. For this reason, performing a limited revision by conversion to a dual mobility (DM) without acetabular component exchange has been proposed in order to limit these complications. Although DM bearing offers an easy solution avoiding the intraoperative and time-associated complications, concern about polyethylene wear and stability remains due to the difference regarding the design, the coverage angle and the clearance of the two implants. In order to evaluate the performance of this new solution with the new material to prevent the possibility of failure it is essential to conduct a review of the literature A qualitative systematic review of the literature has been conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, EMBASE, Google Scholar, and Scopus for English and French articles between January 2000 and October 2019 was performed, with the primary objective of finding articles about dual mobility bearing coupling with large metal-on-metal cup in the case of hip revision procedure. Various combinations of the key words were used in the search strategy. Thirteen articles with DM bearing mated with MoM cup were analyzed. Of the 130 hip revisions selected, with a follow-up from 6 to 53 months, there were a total of 14 with complications (10.77%): four true dislocations (3.08%); six intra-prosthetic dislocations (IPD, 4.6%), two of which presented plastic deformation and polyethylene wear; four other complications (3.08%), included a cup osteolysis, a clicking noise, a superficial infection and a periprosthetic fracture. All the mentioned true dislocations occurred during the first month while IPDs appeared during the first two years from the index revision. In conclusion, according to the literature analyzed, we can stress that the concerns and doubts about mating a DM bearing with large MoM cup cannot be dissolved. It has been pointed out that a DM bearing is not designed for a MoM cup; it is not mechanically tested on MoM cups, which presents different clearance and coverage angles. Predictable complications may occur, such as IPD, polyethylene wear and true dislocation. These complications have been reported at an even higher rate than they were in the eighties, when the first generation of DM implants were of a lower quality of polyethylene and the characteristic of the design was less optimal than modern ones.

Knee Wear Assessment: 3D Scanners Used as a Consolidated Procedure.

It is well known that wear occurring in polyethylene menisci is a significant clinical problem. At this regard, wear tests on biomaterials medical devices are performed in order to assess their pre-clinical performance in terms of wear, durability, resistance to fatigue, etc. The objective of this study was to assess the wear of mobile total knee polyethylene inserts after an in vitro wear test. In particular, the wear behavior of mobile bearing polyethylene knee configurations was investigated using a knee joint wear simulator. After the completion of the wear test, the polyethylene mobile menisci were analyzed through a consolidated procedure by using 3D optical scanners, in order to evaluate the 3D wear distribution on the prosthesis surface, wear depths, wear rates, amount of material loss and contact areas. The results in terms of wear rates and wear volumes were compared with results of gravimetric tests, finding equivalent achievements.

Burst Strength of BIOLOX®delta Femoral Heads and Its Dependence on Low-Temperature Environmental Degradation.

Zirconia-toughened alumina (ZTA) currently represents the bioceramic gold standard for load-bearing components in artificial hip joints. ZTA is long known for its high flexural strength and fracture toughness, both properties arising from a microscopic crack-tip shielding mechanism due to the stress-induced tetragonal-to-monoclinic (t→m) polymorphic transformation of zirconia. However, there have been concerns over the years regarding the long-term structural performance of ZTA since the t→m transformation also spontaneously occurs at the material's surface under low-temperature environmental conditions with a concomitant degradation of mechanical properties. Spontaneous surface degradation has been extensively studied in vitro, but predictive algorithms have underestimated the extent of in vivo degradation observed in retrievals. The present research focused on burst-strength assessments of Ø28 mm ZTA femoral before and after long-term in vitro hydrothermal ageing according to ISO 7206-10. An average burst strength of 52 kN was measured for pristine femoral heads. This value was ~36% lower than results obtained under the same standard conditions by other authors. A further loss of burst strength (~13% in ultimate load) was observed after hydrothermal ageing, with increased surface monoclinic content ranging from ~6% to >50%. Nevertheless, the repetitively stressed and hydrothermally treated ZTA heads exceeded the minimum burst strength stipulated by the US Food and Drug Administration (FDA) despite severe test conditions. Lastly, Raman spectroscopic assessments of phase transformation and residual stresses on the fracture surface of the femoral heads were used to clarify burst-strength fluctuations and the effect of hydrothermal ageing on the material's overall strength degradation.

Progression of osteoarthritis and reoperation in unicompartmental knee arthroplasty: A comparison of national joint registries.

Unicompartmental knee arthroplasty remains a challenge for orthopaedic surgeons because of its higher revision rate compare with the total knee arthroplasty. The hypothesis of this work is that the progression of osteoarthritis in unicompartmental knee prostheses is the natural history of the degenerative disease and a reason for reoperation. Most international joint registries consider this fact as a failure of the implant and a cause of revision. Annual joint registries were searched for progression of osteoarthritis in unicompartmental knee arthroplasty and reasons for their revisions. Current data from registries for unicompartmental knee indicate that the revision rate of such prostheses is overestimated. Considering osteoarthritis progression as the development of the existing disease and not as a failure of the implant, revision rate will be reduced. Registries, reports, and studies are needed to evaluate the progression of osteoarthritis as a cause of reoperation instead of a reason for revision, reducing unicompartmental revision rate and encouraging surgeons to implant more of them.

In Silico Optimization of Femoral Fixator Position and Configuration by Parametric CAD Model.

Structural analysis, based on the finite element method, and structural optimization, can help surgery planning or decrease the probability of fixator failure during bone healing. Structural optimization implies the creation of many finite element model instances, usually built using a computer-aided design (CAD) model of the bone-fixator assembly. The three most important features of such CAD models are: parameterization, robustness and bidirectional associativity with finite elements (FE) models. Their significance increases with the increase in the complexity of the modeled fixator. The aim of this study was to define an automated procedure for the configuration and placement of fixators used in the treatment of long bone fractures. Automated and robust positioning of the selfdynamisable internal fixator on the femur was achieved and sensitivity analysis of fixator stress on the change of major design parameters was performed. The application of the proposed methodology is considered to be beneficial in the preparation of CAD models for automated structural optimization procedures used in long bone fixation.

Comparison of Meshing Strategies in THR Finite Element Modelling.

In biomechanics and orthopedics, finite element modelling allows simulating complex problems, and in the last few years, it has been widely used in many applications, also in the field of biomechanics and biotribology. As is known, one crucial point of FEM (finite element model) is the discretization of the physical domain, and this procedure is called meshing. A well-designed mesh is necessary in order to achieve accurate results with an acceptable computational effort. The aim of this work is to test a finite element model to simulate the dry frictionless contact conditions of a hip joint prosthesis (a femoral head against an acetabular cup) in a soft bearing configuration by comparing the performances of 12 common meshing strategies. In the simulations, total deformation of the internal surface of the cup, contact pressure, and the equivalent von Mises stress are evaluated by using loads and kinematic conditions during a typical gait, obtained from a previous work using a musculoskeletal multibody model. Moreover, accounting for appropriate mesh quality metrics, the results are discussed, underlining the best choice we identified after the large amount of numerical simulations performed.

Registry study on failure incidence in 1,127 revised hip implants with stem trunnion re-use after 10 years of follow-up: limited influence of an adapter sleeve.

Background and purpose - Little is known about the role of retained trunnions in revision hip arthroplasties, i.e., when only the femoral head is substituted. Wear (fretting corrosion) and ceramic head fractures are 2 poorly understood concerns related to use, and the role of adapter sleeves has not been defined. In this registry study we assessed the influence of sleeve interposition on re-revision rates in revision hip arthroplasties with retained stems. Confounding factors (demographics, implant-related features) and failures were also analyzed. Patients and methods - We conducted a registry study on 1,127 revised implants (retained trunnion and head exchange). In 26% of implants an adapter sleeve was interposed; in 74% no adapter sleeve was implanted. Demographic and implant-related features were investigated including a descriptive analysis of failures. Results - The mean follow-up of revised implants with and without the use of an adapter sleeve was 3.3 and 5.1 years, respectively. The implant survival without an adapter sleeve was significantly higher, 98.4% (95% CI 96.9-99.8) vs. 95.2% (CI 93.2-96.6) with an adapter sleeve at 5 years. No re-revisions due to adverse local tissue reactions or ceramic head fractures were reported. In order to overcome the different distribution of head materials and head sizes in the two cohorts, only Delta balls were investigated. Interpretation - Adapter sleeve interposition had a minor influence on the revision rates. No adverse local tissue reactions or head fractures occurred.

A Critical Analysis of TKR In Vitro Wear Tests Considering Predicted Knee Joint Loads.

Detailed knowledge about loading of the knee joint is essential for preclinical testing of total knee replacement. Direct measurement of joint reaction forces is generally not feasible in a clinical setting; non-invasive methods based on musculoskeletal modelling should therefore be considered as a valid alternative to the standards guidelines. The aim of this paper is to investigate the possibility of using knee joint forces calculated through musculoskeletal modelling software for developing an in vitro wear assessment protocol by using a knee wear simulator. In particular, in this work we preliminarily show a comparison of the predicted knee joint forces (in silico) during the gait with those obtained from the ISO 14243-1/3 and with those measured in vivo by other authors. Subsequently, we compare the wear results obtained from a knee wear joint simulator loaded by calculated forces in correspondence to the "normal gait" kinematics with those obtained in correspondence to the loads imposed by the ISO. The obtained results show that even if the predicted load profiles are not totally in good agreement with the loads deriving from ISO standards and from in vivo measurements, they can be useful for in vitro wear tests, since the results obtained from the simulator in terms of wear are in agreement with the literature data.

Preliminary results of the tribological performance of new modular temporary knee spacer antibiotic-impregnated.

PURPOSE: Although total knee arthroplasty is one of the most successful and consolidated surgical procedure, the infection rate is still elevate. To treat infected knee arthroplasties, in the past years was approached a procedure that involved the implantation of an antibiotic-loaded temporary spacer. This spacer helps maintain an appropriate soft tissue envelope and the patients are able to walk during the interim period. This study investigated the tribological behavior of antibiotic-impregnated knee spacers under dynamic loading. METHODS: Three temporary spacer specimens were subjected to a cyclic test on a knee wear simulator for 500,000 walking cycles under a modified international guidelines (ISO 14243). During this test we address about the evaluation of the mechanical resistance and to quantify the wear rate of the devices. All the kinematics and the axial load were set to simulate more than six months of patient use. RESULTS: All the femoral and tibial specimens completed the 500,000 cycles without breakage. The wear patterns observed on the contact surfaces were similar over the specimens. CONCLUSIONS: On the basis of the present data, the authors believe that the use of temporary antibiotic-impregnated knee spacers could be an effective wear-resistance temporary substitute of a total knee two-stage revision arthroplasty.

Materials for Hip Prostheses: A Review of Wear and Loading Considerations.

Replacement surgery of hip joint consists of the substitution of the joint with an implant able to recreate the articulation functionality. This article aims to review the current state of the art of the biomaterials used for hip implants. Hip implants can be realized with different combination of materials, such as metals, ceramics and polymers. In this review, we analyze, from international literature, the specific characteristics required for biomaterials used in hip joint arthroplasty, i.e., being biocompatible, resisting heavy stress, opposing low frictional forces to sliding and having a low wear rate. A commentary on the evolution and actual existing hip prostheses is proposed. We analyzed the scientific literature, collecting information on the material behavior and the human-body response to it. Particular attention has been given to the tribological behavior of the biomaterials, as friction and wear have been key aspects to improve as hip implants evolve. After more than 50 years of evolution, in term of designs and materials, the actual wear rate of the most common implants is low, allowing us to sensibly reduce the risk related to the widespread debris distribution in the human body.

Does the body mass index influence the long-term survival of unicompartmental knee prostheses? A retrospective multi-centre study.

PURPOSE: The effect of being obese on the long-term survival of total joint arthroplasty is persistently discussed. Considering only studies with large cohort of patients and meta-analysis, a high body mass index has been correlated with a higher incidence of complication but not univocally with a lower survival rate. In this study, we analyzed, retrospectively, the data of patients that received unicompartmental knee prostheses in order to examine if obesity has an effect on clinical outcomes. METHODS: A retrospective multi-centre study was carried out on 4964 unicompartmental knee replacements between July 2000 and December 2016, the patients involved were 3976, with 988 bilateral cases. The patients were categorized into three groups: non-obese with a body mass index (BMI) < 30 kg/m2, obese with BMI ranged between 30 and 39 kg/m2, and morbidly obese (BMI ≥ 40 kg/m2). The outcome was measured using the Cox proportional hazards model with end point UKA revision for any reasons. Results were stratified for sex, age, weight, and bi-laterality. RESULTS: The morbidly obese group was significantly younger and required a significantly longer operating time. No statistical significant differences were observed considering the BMI groups in terms of type of insert, type of tibial component, prosthetic condyle, and prosthesis fixation (p > 0.05; chi-square test). CONCLUSIONS: Obese and morbidly obese patients have as much to gain from total knee replacement as non-obese patients.