Skip to main content

Advertisement

SpringerLink
Log in

Highly cross-linked polyethylene in primary total knee arthroplasty is associated with a lower rate of revision for aseptic loosening: a meta-analysis of 962,467 cases

  • Knee Arthroplasty
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Background

The evolution in total knee arthroplasty (TKA) includes the highly cross-linked polyethylene (HXLPE) which has been reported as an effective manner to reduce the wear of the polyethylene and the osteolysis. The purpose of the present study is to synthesize the results of comparative studies between HXLPE and conventional polyethylenes and determine their effect in primary TKA.

Methods

The US National Library of Medicine (PubMed/MEDLINE) and the Cochrane Database of Systematic Reviews were queried for publications utilizing the following keywords: “cross-linked”, “polyethylene”, “HXLPE”, “conventional”, “total knee arthroplasty”, “TKA”, “total knee replacement” and “TKR” combined with Boolean operators AND and OR.

Results

Ten studies met the inclusion criteria and were included in the present meta-analysis with 962,467 patients. No significant difference was found regarding the revision rate for any reason between the patients who received HXLPE and those with conventional liner (OR 0.67; 95% CI 0.39–1.18; I2: 97.7%). In addition, there was no difference regarding the radiolucent lines between the two types of liners (OR 0.54; 95% CI 0.20–1.49; I2: 69.4%). However, with data coming from seven studies enrolling a total of 411,543 patients, it was demonstrated that patients who received HXLPE were less likely to be revised due to aseptic loosening compared to the patients with conventional liners (OR 0.35; 95% CI 0.31–0.39; I2: 0.0%).

Conclusion

The present meta-analysis showed that regarding the overall revision rate and radiographic outcomes there was no significant difference between the two types of liners. On the other hand, the significantly less revision rate due to loosening supports the routine continued use of HXLPE in primary TKA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Kurtz S (2005) Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Jt Surg Am 87:1487. https://doi.org/10.2106/JBJS.D.02441

    Article  Google Scholar 

  2. Sneag DB, Bogner EA, Potter HG (2015) Magnetic resonance imaging evaluation of the painful total knee arthroplasty. Semin Musculoskelet Radiol 19:40–48. https://doi.org/10.1055/s-0034-1396766

    Article  PubMed  Google Scholar 

  3. Sharkey PF, Lichstein PM, Shen C et al (2014) Why are total knee arthroplasties failing today–has anything changed after 10 years? J Arthroplasty 29:1774–1778. https://doi.org/10.1016/j.arth.2013.07.024

    Article  PubMed  Google Scholar 

  4. Gunston FH (1971) Polycentric knee arthroplasty: prosthetic simulation of normal knee movement. J Bone Joint Surg Br 53-B:272–277. https://doi.org/10.1302/0301-620X.53B2.272

    Article  Google Scholar 

  5. Bracco P, Bellare A, Bistolfi A, Affatato S (2017) Ultra-high molecular weight polyethylene: influence of the chemical, physical and mechanical properties on the wear behavior. Rev Mater 10:791. https://doi.org/10.3390/ma10070791

    Article  CAS  Google Scholar 

  6. Partridge TCJ, Baker PN, Jameson SS et al (2020) Conventional versus highly cross-linked polyethylene in primary total knee replacement: a comparison of revision rates using data from the national joint registry for England, Wales, and Northern Ireland. J Bone Jt Surg 102:119–127. https://doi.org/10.2106/JBJS.19.00031

    Article  Google Scholar 

  7. Kurtz SM (2009) UHMWPE Biomaterials Handbook: Ultra High Molecular Weight Polyethylene in Total Joint Replacement and Medical Devices. Academic Press

  8. Ries MD, Pruitt L (2005) Effect of cross-linking on the microstructure and mechanical properties of ultra-high molecular weight polyethylene. Clin Orthop 440:149–156. https://doi.org/10.1097/01.blo.0000185310.59202.e5

    Article  PubMed  Google Scholar 

  9. Lachiewicz PF, Geyer MR (2011) The use of highly cross-linked polyethylene in total knee arthroplasty. J Am Acad Orthop Surg 19:143–151. https://doi.org/10.5435/00124635-201103000-00003

    Article  PubMed  Google Scholar 

  10. Bragdon CR, Doerner M, Martell J et al (2013) The 2012 John Charnley Award: clinical multicenter studies of the wear performance of highly crosslinked remelted polyethylene in THA. Clin Orthop 471:393–402. https://doi.org/10.1007/s11999-012-2604-0

    Article  PubMed  Google Scholar 

  11. Mall NA, Nunley RM, Zhu JJ et al (2011) The incidence of acetabular osteolysis in young patients with conventional versus highly crosslinked polyethylene. Clin Orthop 469:372–381. https://doi.org/10.1007/s11999-010-1518-y

    Article  PubMed  Google Scholar 

  12. Calliess T, Ettinger M, Hülsmann N et al (2015) Update on the etiology of revision TKA–evident trends in a retrospective survey of 1449 cases. Knee 22:174–179. https://doi.org/10.1016/j.knee.2015.02.007

    Article  PubMed  Google Scholar 

  13. Wooley PH, Schwarz EM (2004) Aseptic loosening. Gene Ther 11:402–407. https://doi.org/10.1038/sj.gt.3302202

    Article  CAS  PubMed  Google Scholar 

  14. Abu-Amer Y, Darwech I, Clohisy JC (2007) Aseptic loosening of total joint replacements: mechanisms underlying osteolysis and potential therapies. Arthritis Res Ther 9(Suppl 1):S6. https://doi.org/10.1186/ar2170

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. 2019 - AOANJRR. https://aoanjrr.sahmri.com/annual-reports-2019. Accessed 10 Sep 2020

  16. Guha AR, Debnath UK, Graham NM (2008) Radiolucent lines below the tibial component of a total knee replacement (TKR)–a comparison between single-and two-stage cementation techniques. Int Orthop 32:453–457. https://doi.org/10.1007/s00264-007-0345-6

    Article  PubMed  Google Scholar 

  17. Zweymüller KA, Schwarzinger UM, Steindl MS (2006) Radiolucent lines and osteolysis along tapered straight cementless titanium hip stems: a comparison of 6-year and 10-year follow-up results in 95 patients. Acta Orthop 77:871–876. https://doi.org/10.1080/17453670610013150

    Article  PubMed  Google Scholar 

  18. Sakellariou VI, Sculco P, Poultsides L et al (2013) highly cross-linked polyethylene may not have an advantage in total knee arthroplasty. HSS J® 9:264–269. https://doi.org/10.1007/s11420-013-9352-x

    Article  Google Scholar 

  19. Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097. https://doi.org/10.1371/journal.pmed.1000097

    Article  PubMed  PubMed Central  Google Scholar 

  20. Higgins JPT, Altman DG, Gøtzsche PC et al (2011) The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928. https://doi.org/10.1136/bmj.d5928

    Article  PubMed  PubMed Central  Google Scholar 

  21. Sterne JA, Hernán MA, Reeves BC et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919. https://doi.org/10.1136/bmj.i4919

    Article  PubMed  PubMed Central  Google Scholar 

  22. Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560. https://doi.org/10.1136/bmj.327.7414.557

    Article  PubMed  PubMed Central  Google Scholar 

  23. Kim Y-H, Park J-W (2014) Comparison of highly cross-linked and conventional polyethylene in posterior cruciate-substituting total knee arthroplasty in the same patients. JBJS 96:1807–1813. https://doi.org/10.2106/JBJS.M.01605

    Article  Google Scholar 

  24. Kindsfater KA, Pomeroy D, Clark CR et al (2015) In vivo performance of moderately crosslinked, thermally treated polyethylene in a prospective randomized controlled primary total knee arthroplasty trial. J Arthroplasty 30:1333–1338. https://doi.org/10.1016/j.arth.2015.02.041

    Article  PubMed  Google Scholar 

  25. Lachiewicz PF, Soileau ES (2016) Is there a benefit to highly crosslinked polyethylene in posterior-stabilized total knee arthroplasty? a randomized trial. Clin Orthop Relat Res 474:88–95. https://doi.org/10.1007/s11999-015-4241-x

    Article  PubMed  Google Scholar 

  26. Boyer B, Bordini B, Caputo D et al (2018) Is cross-linked polyethylene an improvement over conventional ultra-high molecular weight polyethylene in total knee arthroplasty? J Arthroplasty 33:908–914. https://doi.org/10.1016/j.arth.2017.10.005

    Article  PubMed  Google Scholar 

  27. Meneghini RM, Lovro LR, Smits SA, Ireland PH (2015) Highly cross-linked versus conventional polyethylene in posterior-stabilized total knee arthroplasty at a mean 5-year follow-up. J Arthroplasty 30:1736–1739. https://doi.org/10.1016/j.arth.2015.05.009

    Article  PubMed  Google Scholar 

  28. Hodrick JT, Severson EP, McAlister DS et al (2008) Highly crosslinked polyethylene is safe for use in total knee arthroplasty. Clin Orthop 466:2806–2812. https://doi.org/10.1007/s11999-008-0472-4

    Article  PubMed  PubMed Central  Google Scholar 

  29. Minoda Y, Aihara M, Sakawa A et al (2009) Comparison between highly cross-linked and conventional polyethylene in total knee arthroplasty. Knee 16:348–351. https://doi.org/10.1016/j.knee.2009.01.005

    Article  PubMed  Google Scholar 

  30. Takemura S, Minoda Y, Sugama R et al (2019) Comparison of a vitamin E-infused highly crosslinked polyethylene insert and a conventional polyethylene insert for primary total knee arthroplasty at two years postoperatively. Bone Jt J 101-B:559–564. https://doi.org/10.1302/0301-620X.101B5.BJJ-2018-1355.R1

    Article  CAS  Google Scholar 

  31. de Steiger RN, Muratoglu O, Lorimer M et al (2015) Lower prosthesis-specific 10-year revision rate with crosslinked than with non-crosslinked polyethylene in primary total knee arthroplasty: 386,104 procedures from the Australian Orthopaedic Association National Joint Replacement Registry. Acta Orthop 86:721–727. https://doi.org/10.3109/17453674.2015.1065046

    Article  PubMed  PubMed Central  Google Scholar 

  32. Yu B, Yang G, Wang W et al (2016) Cross-linked versus conventional polyethylene for total knee arthroplasty: a meta-analysis. J Orthop Surg 11:39. https://doi.org/10.1186/s13018-016-0374-1

    Article  Google Scholar 

  33. Jacobs CA, Christensen CP, Greenwald AS, McKellop H (2007) Clinical performance of highly cross-linked polyethylenes in total hip arthroplasty. JBJS 89:2779–2786. https://doi.org/10.2106/JBJS.G.00043

    Article  Google Scholar 

  34. Shi J, Zhu W, Liang S et al (2019) Cross-linked versus conventional polyethylene for long-term clinical outcomes after total hip arthroplasty: a systematic review and meta-analysis. J Invest Surg. https://doi.org/10.1080/08941939.2019.1606370

    Article  PubMed  Google Scholar 

  35. Tsukamoto M, Mori T, Ohnishi H et al (2017) Highly cross-linked polyethylene reduces osteolysis incidence and wear-related reoperation rate in cementless total hip arthroplasty compared with conventional polyethylene at a mean 12-year follow-Up. J Arthroplasty 32:3771–3776. https://doi.org/10.1016/j.arth.2017.06.047

    Article  PubMed  Google Scholar 

  36. Bradford L, Baker D, Ries MD, Pruitt LA (2004) Fatigue crack propagation resistance of highly crosslinked polyethylene. Clin Orthop 429:68–72. https://doi.org/10.1097/01.blo.0000150124.34906.34

    Article  Google Scholar 

  37. Cole JC, Lemons JE, Eberhardt AW (2002) Gamma irradiation alters fatigue-crack behavior and fracture toughness in 1900H and GUR 1050 UHMWPE. J Biomed Mater Res 63:559–566. https://doi.org/10.1002/jbm.10335

    Article  CAS  PubMed  Google Scholar 

  38. Hambright D, Watters T, Kaufman A et al (2010) Fracture of highly cross-linked all-polyethylene patella after total knee arthroplasty. J Knee Surg 23:237–240. https://doi.org/10.1055/s-0031-1271890

    Article  PubMed  Google Scholar 

  39. Asano T, Akagi M, Clarke IC et al (2007) Dose effects of cross-linking polyethylene for total knee arthroplasty on wear performance and mechanical properties. J Biomed Mater Res B Appl Biomater 83B:615–622. https://doi.org/10.1002/jbm.b.30835

    Article  CAS  Google Scholar 

  40. Jung KA, Lee SC, Hwang SH, Kim SM (2008) Fracture of a second-generation highly cross-linked UHMWPE tibial post in a posterior-stabilized scorpio knee system. Orthopedics 31:1137–1139. https://doi.org/10.3928/01477447-20081101-10

    Article  PubMed  Google Scholar 

  41. Diamond OJ, Howard L, Masri B (2018) Five cases of tibial post fracture in posterior stabilized total knee arthroplasty using prolong highly cross-linked polyethylene. Knee 25:657–662. https://doi.org/10.1016/j.knee.2018.05.005

    Article  PubMed  Google Scholar 

  42. Lee W, Wee L (2019) Highly crosslinked polyethylene tibial post fracture in the unafflicted limb of a patient with unilateral lower limb poliomyelitis: a case report. Malays Orthop J 13:42–44. https://doi.org/10.5704/MOJ.1903.008

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Kim Y-H, Park J-W (2020) Long-term assessment of highly cross-linked and compression-molded polyethylene inserts for posterior cruciate-substituting TKA in young patients: a concise follow-up of a previous report*. J Bone Jt Surg 102:1623–1627. https://doi.org/10.2106/JBJS.20.00261

    Article  Google Scholar 

  44. Muratoglu OK, Bragdon CR, O’Connor DO et al (2001) A novel method of cross-linking ultra-high-molecular-weight polyethylene to improve wear, reduce oxidation, and retain mechanical properties. Recipient of the 1999 HAP Paul Award. J Arthroplasty 16:149–160. https://doi.org/10.1054/arth.2001.20540

    Article  CAS  PubMed  Google Scholar 

  45. Kurtz SM, Dumbleton J, Siskey RS et al (2009) Trace concentrations of vitamin E protect radiation crosslinked UHMWPE from oxidative degradation. J Biomed Mater Res A 90:549–563. https://doi.org/10.1002/jbm.a.32122

    Article  CAS  PubMed  Google Scholar 

  46. Gigante A, Bottegoni C, Ragone V, Banci L (2015) Effectiveness of vitamin-E-doped polyethylene in joint replacement: a literature review. J Funct Biomater 6:889–900. https://doi.org/10.3390/jfb6030889

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Muratoglu OK, Bragdon CR, O’Connor DO et al (2002) Aggressive wear testing of a cross-linked polyethylene in total knee arthroplasty. Clin Orthop. https://doi.org/10.1097/00003086-200211000-00015

    Article  PubMed  Google Scholar 

  48. Muratoglu OK, Burroughs BR, Bragdon CR et al (2004) Knee simulator wear of polyethylene tibias articulating against explanted rough femoral components. Clin Orthop. https://doi.org/10.1097/01.blo.0000143801.41885.8b

    Article  PubMed  Google Scholar 

  49. Lewis PL, Graves SE, Steiger RN, de et al (2020) Does knee prosthesis survivorship improve when implant designs change? findings from the australian orthopaedic association national joint replacement registry. Clin Orthop 478:1156–1172. https://doi.org/10.1097/CORR.0000000000001229

    Article  PubMed  PubMed Central  Google Scholar 

  50. Sterne JAC, Sutton AJ, Ioannidis JPA et al (2011) Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials. BMJ 343:d4002. https://doi.org/10.1136/bmj.d4002

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, 10022, USA

    Ioannis Gkiatas, William Xiang, Michael-Alexander Malahias & Peter K. Sculco

  2. School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece

    Theofilos Karasavvidis

  3. Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, 10022, USA

    Abhinav K. Sharma & Brian P. Chalmers

Authors
  1. Ioannis Gkiatas
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Theofilos Karasavvidis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Abhinav K. Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. William Xiang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael-Alexander Malahias
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Brian P. Chalmers
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Peter K. Sculco
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ioannis Gkiatas.

Ethics declarations

Conflict of interest

The senior author is a paid consultant of Depuy Synthes, Intellijoint Surgical and EOS Imaging. The rest of the authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 13 KB)

Supplementary file2 (DOCX 21 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gkiatas, I., Karasavvidis, T., Sharma, A.K. et al. Highly cross-linked polyethylene in primary total knee arthroplasty is associated with a lower rate of revision for aseptic loosening: a meta-analysis of 962,467 cases. Arch Orthop Trauma Surg 142, 1177–1184 (2022). https://doi.org/10.1007/s00402-021-03887-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-021-03887-z

Keywords

Search

Navigation