Early failure of a highly cross-linked polyethylene inlay after total hip arthroplasty probably due to insufficient irradiation.

Highly cross-linked polyethylene (XLPE) is a major advance in total hip arthroplasty (THA), as it suffers from less wear and thus is associated with lower revision rates than standard ultra-high molecular weight polyethylene. Early failures are reported rarely, and associated with specific design or manufacturing issues. We report a case requiring early revision due to adverse reaction to polyethylene particles. Investigations identified insufficient irradiation as the most probable cause of failure. Here are reported the features of a clinical case with determination of the material properties of the retrieved XLPE liner and establishment of the appropriate calibration curves as reference. Periprosthetic joint infection could be ruled out with appropriate sampling as cause for the inflammatory periarticular tumour. Histology identified a massive macrophagic reaction to micrometric polyethylene particles. No component malposition was present, nor any third-body wear. The trans-vinylene index (TVI) indicated insufficient and potentially detrimental irradiation of the polyethylene, while gel content, crystallinity, melting temperature and oxidation index remained within expected ranges. Histologically proven failure of a XLPE THA liner was identifiable despite correct implantation of the components. The cause of failure most probably was an inadequate irradiation, as indicated by determination of the TVI. This case underscores the importance of histologic workup even in aseptic revisions, and of detailed analysis of retrievals. The calibration curves provided are essential for analysis of other retrievals.

Microtopography of metal surfaces influence fibroblast growth by modifying cell shape, cytoskeleton, and adhesion.

Stainless Steel (SS), titanium (cpTi), and Ti-6Al-7Nb (TAN) are frequently used metals in fracture fixation, which contact not only bone, but also soft tissue. In previous soft tissue cytocompatibility studies, TAN was demonstrated to inhibit cell growth in its "standard" micro-roughened state. To elucidate a possible mechanism for this inhibition, cell area, shape, adhesion, and cytoskeletal integrity was studied. Only minor changes in spreading were observed for cells on electropolished SS, cpTi, and TAN. Cells on "standard" cpTi were similarly spread in comparison with electropolished cpTi and TAN, although the topography influenced the cell periphery and also resulted in lower numbers and shorter length of focal adhesions. On "standard" microrough TAN, cell spreading was significantly lower than all other surfaces, and cell morphology differed by being more elongated. In addition, focal adhesion numbers and mean length were significantly lower on standard TAN than on all other surfaces, with 80% of the measured adhesions below a 2-microm threshold. Focal adhesion site location and maturation and microtubule integrity were compromised by the presence of protruding beta-phase microspikes found solely on the surface of standard TAN. This led us to propose that the impairment of focal adhesion numbers, maturation (length), and cell spreading to a possibly sufficient threshold observed on standard TAN blocks cell cycle progress and eventually cell growth on the surface. We believe, as demonstrated with standard cpTi and TAN, that a difference in surface morphology is influential for controlling cell behavior on implant surfaces.

Microvasculatory reaction of skeletal muscle to Ti-15Mo in comparison to well-established titanium alloys.

Beta-titanium alloys such as Ti-15Mo are increasingly utilized for orthopaedic implant applications because of their excellent corrosion resistance and low elastic modulus. Particularly in osteosynthesis, where the biomaterial stands in direct contact to soft tissue, undesirable biologic reactions may have severe consequences especially in the vulnerable state of trauma and added iatrogenic damage to the microvascular system. In a comparative study we therefore assessed in vivo nutritive perfusion and leukocytic response of striated muscle to the biomaterials Ti-15Mo, Ti-6Al-4V and Ti-6Al-7Nb, thereby drawing conclusions on their short term inflammatory potential. Utilizing the well established skinfold chamber preparation in the hamster and intravital fluorescence microscopy, we could not demonstrate any significant discrepancies between the three alloys. All metals induced an initial moderate inflammatory response in skeletal muscle microcirculation. While recuperation of animals treated with Ti-15Mo and Ti-6Al-7Nb was prompt, we documented a slightly more sluggish recovery of Ti-6Al-4V treated animals. A gross toxicity was not observed for any of the alloys. Conclusively, Ti-15Mo, Ti-6Al-4V and Ti-6Al-7Nb induce an only transient inflammatory answer of the striated muscle microvascular system. Our results indicate that on the microvascular level the tested bulk Ti-alloys do not cause enduring biologic impairment in muscle.

Staphylococcus aureus adhesion to standard micro-rough and electropolished implant materials.

Implant-associated infections can cause serious complications including osteomyelitis and soft tissue damage, and are a great problem due to the emergence of antibiotic resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA). In some cases, antibiotic-loaded beads which release the antibiotic locally have been used, however such systems may lead to the development of antibiotic-resistant bacteria, as seen with gentamicin-loaded beads. Hence modifying the actual metal implant surface to inhibit or reduce initial bacterial adhesion may be an alternative option. This study describes the visualisation and quantification of S. aureus adhering to standard micro-rough 'commercially pure' titanium (TS) and Ti-6Al-7Nb (NS) surfaces, electropolished titanium (TE) and Ti-6Al-7Nb (NE) surfaces, and standard electropolished stainless steel (SS). Qualitative and quantitative results of S. aureus on the different surfaces correlated with each other, and showed significantly more live bacteria on NS than on the other surfaces, whilst there was no significant difference between the amount of bacteria on TS, TE, NE and SS surfaces. The results showed a significant decrease in the amount of bacteria adhering to the NE compared to standard NS surfaces. Such an observation suggests that the NS surface encouraged S. aureus adhesion, and could lead to higher infection rates in vivo. Hence electropolishing Ti-6Al-7Nb surfaces could be advantageous in osteosynthesis areas in minimising bacterial adhesion and lowering the rate of infection.

Human fibroblast reactions to standard and electropolished titanium and Ti-6Al-7Nb, and electropolished stainless steel.

Stainless steel (SS), titanium (cpTi), and Ti-6Al-7Nb (TAN) are frequently used metals in orthopedic internal fracture fixation. Although reactivity to SS and cpTi are noted in reference, the soft tissue compatibility of TAN has not been comprehensively studied. This study focuses on the in vitro soft tissue compatibility of TAN in comparison to SS and cpTi using a human fibroblast model. The industrial standard surface finishes of these three materials vary considerably in view of their use in similar applications. To distinguish between material parameters of topography and chemistry, we have included electropolished (e.p) counterparts of the standard preparations of cpTi and TAN in the study (standard SS is e.p). All materials were characterized using atomic force microscopy, profilometry, and scanning electron microscopy. Our findings demonstrate that cell morphology and growth rate was similar for SS, and e.p. cpTi and TAN, with cells well spread and forming a confluent monolayer by 10 days. Cell growth on standard cpTi was similar to the electropolished samples; however, they showed a less spread morphology with more filopodia and surface ruffling present. Cell morphology on standard TAN was rounded or elongated and proliferation was inhibited at all time points, with possible cell necrosis by day 10. We found evidence of endocytosis of beta-phase particles originating from the standard TAN surface. We believe that the particle uptake coupled with the characteristic surface topography contribute to the noncytocompatibility of fibroblasts on standard TAN.