Clinical Orthopaedics and Related Research®

, Volume 473, Issue 3, pp 987–998 | Cite as

UHMWPE Wear Debris and Tissue Reactions Are Reduced for Contemporary Designs of Lumbar Total Disc Replacements

  • Sai Y. Veruva
  • Todd H. Lanman
  • Jorge E. Isaza
  • Daniel W. MacDonald
  • Steven M. Kurtz
  • Marla J. Steinbeck
Symposium: Advances in UHMWPE Biomaterials
First Online:

Abstract

Background

Lumbar total disc replacement (L-TDR) is a procedure used to relieve back pain and maintain mobility. Contemporary metal-on-polyethylene (MoP) L-TDRs were developed to address wear performance concerns about historical designs, but wear debris generation and periprosthetic tissue reactions for these newer implants have not been determined.

Questions/purposes

The purpose of this study was to determine (1) whether periprosthetic ultrahigh-molecular-weight polyethylene (UHMWPE) wear debris and biological responses were present in tissues from revised contemporary MoP L-TDRs that contain conventional cores fabricated from γ-inert-sterilized UHMWPE; (2) how fixed- versus mobile-bearing design affected UHMWPE wear particle number, shape, and size; and (3) how these wear particle characteristics compare with historical MoP L-TDRs that contain cores fabricated from γ-air-sterilized UHMWPE.

Methods

We evaluated periprosthetic tissues from 11 patients who received eight fixed-bearing ProDisc-L and four mobile-bearing CHARITÉ contemporary L-TDRs with a mean implantation time of 4.1 and 2.7 years, respectively. Histologic analysis of tissues was performed to assess biological responses and polarized light microscopy was used to quantify number and size/shape characteristics of UHMWPE wear particles from the fixed- and mobile-bearing devices. Comparisons were made to previously reported particle data for historical L-TDRs.

Results

Five of seven (71%) fixed-bearing and one of four mobile-bearing L-TDR patient tissues contained at least 4 particles/mm2 wear with associated macrophage infiltration. Tissues with wear debris were highly vascularized, whereas those without debris were more necrotic. Given the samples available, the tissue around mobile-bearing L-TDR was observed to contain 87% more, 11% rounder, and 11% less-elongated wear debris compared with tissues around fixed-bearing devices; however, there were no significant differences. Compared with historical L-TDRs, UHMWPE particle number and circularity for contemporary L-TDRs were 99% less (p = 0.003) and 50% rounder (p = 0.003).

Conclusions

In this preliminary study, short-term results suggest there was no significant influence of fixed- or mobile-bearing designs on wear particle characteristics of contemporary L-TDRs, but conventional UHMWPE has notably improved the wear resistance of these devices compared with historical UHMWPE.

Keywords

UHMWPE Wear Debris Wear Particle Periprosthetic Tissue UHMWPE Particle 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
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References

  1. 1.
    Austen S, Punt IM, Cleutjens JP, Willems PC, Kurtz SM, MacDonald DW, van Rhijn LW, van Ooij A. Clinical, radiological, histological and retrieval findings of Activ-L and Mobidisc total disc replacements: a study of two patients. Eur Spine J. 2012;21(Suppl 4):S513–520.PubMedCrossRefGoogle Scholar
  2. 2.
    Baxter RM, Ianuzzi A, Freeman TA, Kurtz SM, Steinbeck MJ. Distinct immunohistomorphologic changes in periprosthetic hip tissues from historical and highly crosslinked UHMWPE implant retrievals. J Biomed Mater Res A. 2010;95:68–78.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Baxter RM, MacDonald DW, Kurtz SM, Steinbeck MJ. Characteristics of highly cross-linked polyethylene wear debris in vivo. J Biomed Mater Res B Appl Biomater. 2013;101:467–475.PubMedCentralPubMedGoogle Scholar
  4. 4.
    Baxter RM, MacDonald DW, Kurtz SM, Steinbeck MJ. Severe impingement of lumbar disc replacements increases the functional biological activity of polyethylene wear debris. J Bone Joint Surg Am. 2013;95:e751–759.PubMedCrossRefGoogle Scholar
  5. 5.
    Brown MF, Hukkanen MV, McCarthy ID, Redfern DR, Batten JJ, Crock HV, Hughes SP, Polak JM. Sensory and sympathetic innervation of the vertebral endplate in patients with degenerative disc disease. J Bone Joint Surg Br. 1997;79:147–153.PubMedCrossRefGoogle Scholar
  6. 6.
    Cuellar JM, Scuderi GJ, Cuellar VG, Golish SR, Yeomans DC. Diagnostic utility of cytokine biomarkers in the evaluation of acute knee pain. J Bone Joint Surg Am. 2009;91:2313–2320.PubMedCrossRefGoogle Scholar
  7. 7.
    Grammatopoulos G, Pandit H, Kamali A, Maggiani F, Glyn-Jones S, Gill HS, Murray DW, Athanasou N. The correlation of wear with histological features after failed hip resurfacing arthroplasty. J Bone Joint Surg Am. 2013;95:e81.PubMedCrossRefGoogle Scholar
  8. 8.
    Green TR, Fisher J, Stone M, Wroblewski BM, Ingham E. Polyethylene particles of a ‘critical size’ are necessary for the induction of cytokines by macrophages in vitro. Biomaterials. 1998;19:2297–2302.PubMedCrossRefGoogle Scholar
  9. 9.
    Hirakawa K, Bauer TW, Stulberg BN, Wilde AH, Borden LS. Characterization of debris adjacent to failed knee implants of 3 different designs. Clin Orthop Relat Res. 1996;331:151–158.PubMedCrossRefGoogle Scholar
  10. 10.
    Howling GI, Barnett PI, Tipper JL, Stone MH, Fisher J, Ingham E. Quantitative characterization of polyethylene debris isolated from periprosthetic tissue in early failure knee implants and early and late failure Charnley hip implants. J Biomed Mater Res. 2001;58:415–420.PubMedCrossRefGoogle Scholar
  11. 11.
    Ingham E, Fisher J. The role of macrophages in osteolysis of total joint replacement. Biomaterials. 2005;26:1271–1286.PubMedCrossRefGoogle Scholar
  12. 12.
    Kobayashi A, Bonfield W, Kadoya Y, Yamac T, Freeman MA, Scott G, Revell PA. The size and shape of particulate polyethylene wear debris in total joint replacements. Proc Inst Mech Eng H. 1997;211:11–15.PubMedCrossRefGoogle Scholar
  13. 13.
    Kockx MM, Cromheeke KM, Knaapen MW, Bosmans JM, De Meyer GR, Herman AG, Bult H. Phagocytosis and macrophage activation associated with hemorrhagic microvessels in human atherosclerosis. Arterioscler Thromb Vasc Biol. 2003;23:440–446.PubMedCrossRefGoogle Scholar
  14. 14.
    Kurtz S, Steinbeck M, Ianuzzi A, Van Ooij A, Punt I, Isaza J, Ross ER. Retrieval analysis of motion preserving spinal devices and periprosthetic tissues. SAS. 2009;3:161–177.CrossRefGoogle Scholar
  15. 15.
    Kurtz SM. The UHMWPE Biomaterials Handbook. Burlington, MA, USA: Academic Press; 2009.Google Scholar
  16. 16.
    Kurtz SM, MacDonald D, Ianuzzi A, van Ooij A, Isaza J, Ross ER, Regan J. The natural history of polyethylene oxidation in total disc replacement. Spine (Phila Pa 1976). 2009;34:2369–2377.Google Scholar
  17. 17.
    Kurtz SM, Patwardhan A, MacDonald D, Ciccarelli L, van Ooij A, Lorenz M, Zindrick M, O’Leary P, Isaza J, Ross R. What is the correlation of in vivo wear and damage patterns with in vitro TDR motion response? Spine. 2008;33:481–489.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Kurtz SM, Toth JM, Siskey R, Ciccarelli L, Macdonald D, Isaza J, Lanman T, Punt I, Steinbeck M, Goffin J, van Ooij A. The latest lessons learned from retrieval analyses of ultra-high molecular weight polyethylene, metal-on-metal, and alternative bearing total disc replacements. Semin Spine Surg. 2012;24:57–70.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Kurtz SM, van Ooij A, Ross R, de Waal Malefijt J, Peloza J, Ciccarelli L, Villarraga ML. Polyethylene wear and rim fracture in total disc arthroplasty. Spine J. 2007;7:12–21.Google Scholar
  20. 20.
    Lebl DR, Cammisa FP, Girardi FP, Wright T, Abjornson C. In vivo functional performance of failed Prodisc-L devices: retrieval analysis of lumbar total disc replacements. Spine (Phila Pa 1976). 2012;37:E1209–1217.Google Scholar
  21. 21.
    Link HD, Keller A. Biomechanics of total disc replacement. In: Buttner-Janz K, Hochschuler SH, McAfee PC, eds. The Artificial Disc. Berlin, Germany: Springer; 2003:33–52.CrossRefGoogle Scholar
  22. 22.
    Link HD, McAfee PC, Pimenta L. Choosing a cervical disc replacement. Spine J. 2004;4:294S–302S.PubMedCrossRefGoogle Scholar
  23. 23.
    Mabrey JD, Afsar-Keshmiri A, McClung GA 2nd, Pember MA 2nd, Wooldridge TM, Mauli Agrawal C. Comparison of UHMWPE particles in synovial fluid and tissues from failed THA. J Biomed Mater Res. 2001;58:196–202.PubMedCrossRefGoogle Scholar
  24. 24.
    Mapp PI, Walsh DA. Mechanisms and targets of angiogenesis and nerve growth in osteoarthritis. Nat Rev Rheumatol. 2012;8:390–398.PubMedCrossRefGoogle Scholar
  25. 25.
    Margevicius KJ, Bauer TW, McMahon JT, Brown SA, Merritt K. Isolation and characterization of debris in membranes around total joint prostheses. J Bone Joint Surg Am. 1994;76:1664–1675.PubMedGoogle Scholar
  26. 26.
    Minoda Y, Kobayashi A, Iwaki H, Miyaguchi M, Kadoya Y, Ohashi H, Takaoka K. Characteristics of polyethylene wear particles isolated from synovial fluid after mobile-bearing and posterior-stabilized total knee arthroplasties. J Biomed Mater Res B Appl Biomater. 2004;71:1–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Phillips E, Klein GR, Cates HE, Kurtz SM, Steinbeck MJ. Histological characterization of periprosthetic tissue responses for metal-on-metal hip replacement. J Long Term Eff Med Implants. 2014;24:13–23.PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Punt I, Baxter R, van Ooij A, Willems P, van Rhijn L, Kurtz S, Steinbeck M. Submicron sized ultra-high molecular weight polyethylene wear particle analysis from revised SB Charite III total disc replacements. Acta Biomater. 2011;7:3404–3411.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Punt IM, Austen S, Cleutjens JP, Kurtz SM, ten Broeke RH, van Rhijn LW, Willems PC, van Ooij A. Are periprosthetic tissue reactions observed after revision of total disc replacement comparable to the reactions observed after total hip or knee revision surgery? Spine (Phila Pa 1976). 2012;37:150–159.Google Scholar
  30. 30.
    Punt IM, Cleutjens JP, de Bruin T, Willems PC, Kurtz SM, van Rhijn LW, Schurink GW, van Ooij A. Periprosthetic tissue reactions observed at revision of total intervertebral disc arthroplasty. Biomaterials. 2009;30:2079–2084.PubMedCrossRefGoogle Scholar
  31. 31.
    Ren W, Yang SY, Fang HW, Hsu S, Wooley PH. Distinct gene expression of receptor activator of nuclear factor-kappaB and rank ligand in the inflammatory response to variant morphologies of UHMWPE particles. Biomaterials. 2003;24:4819–4826.PubMedCrossRefGoogle Scholar
  32. 32.
    Schrijvers DM, De Meyer GR, Herman AG, Martinet W. Phagocytosis in atherosclerosis: Molecular mechanisms and implications for plaque progression and stability. Cardiovasc Res. 2007;73:470–480.PubMedCrossRefGoogle Scholar
  33. 33.
    van Ooij A, Kurtz SM, Stessels F, Noten H, van Rhijn L. Polyethylene wear debris and long-term clinical failure of the Charite disc prosthesis: a study of 4 patients. Spine (Phila Pa 1976). 2007;32:223–229.Google Scholar
  34. 34.
    van Ooij A, Oner FC, Verbout AJ. Complications of artificial disc replacement: a report of 27 patients with the SB Charite disc. J Spinal Disord Tech. 2003;16:369–383.PubMedCrossRefGoogle Scholar
  35. 35.
    Veruva SY, Lanman TH, Hanzlik JA, Kurtz SM, Steinbeck MJ. Rare complications of osteolysis and periprosthetic tissue reactions after hybrid and non-hybrid total disc replacement. Eur Spine J. 2014 Aug 28 [Epub ahead of print].Google Scholar
  36. 36.
    Veruva SY, Steinbeck MJ, Toth J, Alexander DD, Kurtz SM. Which design and biomaterial factors affect clinical wear performance of total disc replacements? A systematic review. Clin Orthop Relat Res. 2014 Jul 8 [Epub ahead of print].Google Scholar
  37. 37.
    Yang SY, Ren W, Park Y, Sieving A, Hsu S, Nasser S, Wooley PH. Diverse cellular and apoptotic responses to variant shapes of UHMWPE particles in a murine model of inflammation. Biomaterials. 2002;23:3535–3543.PubMedCrossRefGoogle Scholar
  38. 38.
    Zhang JM, An J. Cytokines, inflammation, and pain. Int Anesthesiol Clin. 2007;45:27–37.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Sai Y. Veruva
    • 1
  • Todd H. Lanman
    • 2
  • Jorge E. Isaza
    • 3
  • Daniel W. MacDonald
    • 1
  • Steven M. Kurtz
    • 1
    • 4
  • Marla J. Steinbeck
    • 1
    • 5
  1. 1.Implant Research CenterDrexel UniversityPhiladelphiaUSA
  2. 2.Department of SurgeryUniversity of California Los AngelesLos AngelesUSA
  3. 3.Tulane UniversityBaton RougeUSA
  4. 4.Exponent, IncPhiladelphiaUSA
  5. 5.Department of Orthopaedic SurgeryDrexel University College of MedicinePhiladelphiaUSA

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