Highly crosslinked, ultra-high molecular weight polyethylene (HXLPE) acetabular liners inherently have a risk of fatigue failure associated with femoral neck impingement. One of the potential reasons for liner failure was reported as crosslinking formulations of polyethylene, increasing the brittleness and structural rigidity. In addition, the acetabular component designs greatly affect the mechanical loading scenario, such as the offset (lateralized) liners with protruded rim above the metal shells, which commonly induce a weak resistance to rim impingement. The purpose of the present study was to compare the influence of the liner offset length on the impingement resistance in the annealed (first generation) and vitamin E-blended (second-generation) HXLPE liners with a commercial design. The materials tested were the 95-kGy irradiated annealed GUR1020, and the 300-kGy irradiated vitamin E-blended GUR1050 HXLPE offset liners, which were referred to as “20_95” and “50E_300”, respectively. These liners had 2, 3, 4-mm rim offset, 2.45-mm rim thickness, and 36-mm internal diameter. Their rims were protruded above the metal rim at 2, 3, 4mm. Rim impingement testing was performed using an electrodynamic axial-torsional machine. The cyclic impingement load of 25–250N was applied on the rims through the necks of the femoral stems at 1Hz. The rotational torque was simultaneously generated by swinging the stem necks on the rims at 1Hz and its rotational angle was set at the range of 0–10˚. The percent crystallinity was analyzed on the as-received (intact) and impinged HXLPE acetabular rims by confocal Raman microspectroscopy.Introduction
Materials and Methods
The optimal positioning of the acetabular component is a relevant prognostic factor in total hip arthroplasty (THA). Because of substantial errors of manual technique in cup placement even with experienced surgeon, computer aided navigation system has been developed in recent years. However, existence of the hardware around acetabulum likely deteriorates the accuracy of the navigation system, namely in revision THA case and postoperative status of pelvic fracture. Here we report a case who we successfully performed THA using CT based navigation system although there were multiple hardware around acetabulum due to osteosynthesis for the previous pelvic fracture. A forty-one years old man presented with intolerable hip pain with severe radiographic osteoarthritic findings in left hip joint. He had sustained left pelvic fracture and posterior hip dislocation due to traffic accident and undergone osteosynthesis using multiple plates and screws when he was forty years old. However, progressive collapsing of femoral head and acetabulum occurred. Then, we indicated THA for his situation and planned to apply the CT based navigation system (Stryker CT based hip Ver.1.1 softwear and Cart II system). Preoperative workup revealed incomplete union of posterior and superior acetabular wall and we had to retain plates and screws for the stable fixation of acetabular cup. The existence of the hardware made it complicated to perform three dimensional planning and templating. Meticulous surface editing of pelvis to exclude the metal artifact and fibrocartilagenous tissue was needed to achieve accurate surface registration. In the operation room, we had to use unusual way of registration to complete two steps of registration. In the first step (roughly matching between patient's physical pelvic surface and edited pelvic surface in work station using corresponding 5 points), we utilized head of screw and hole of the plate which we could easily identify intraoperatively, in addition to ASIS and innominate groove. In the second step (strict matching using more than 30 points of pelvic surface), we had to identify the pelvic bony surface, as excluding the metal surface and fibrocartilagenous tissue such as fracture callus. These efforts enabled us to accomplish substantial accuracy of registration with RMS of 0.5 mm. Final cup orientation at the end of surgery was 41° of inclination and 25° of anteversion. Postoperative CT scan revealed that cup placement angle was 40° of inclination and 25° of anteversion, almost identical with intraoperative value.Objective
Case presentation
Vitamin-E (VE, dl-α-tocopherol) is a powerful antioxidant for highly cross-linked polyethylene (XLPE). It was previously reported that VE-stabilized XLPE succeeded in retaining no measurable oxidation even after accelerated aging tests combined with cyclic loading or lipid absorption. Thus, VE-stabilized XLPE is nowadays recognized worldwide as one of the new standard materials in total hip arthroplasty (THA). However, the effects of such VE addition on physical behavior of polyethylene remain to be fully elucidated by contrast to the clear statement of its chemical role (i.e., the enhanced oxidation resistance) in the published literature. In this presentation, we shall attempt to provide those missing notations and to explore the microstructural and biomechanical role of VE in XLPE acetabular liner on the molecular scale. The two different types of XLPE acetabular liners, VE-blended and VE-free (no VE-blended) component (Introduction
Methods
Total Knee Replacement (TKR) has been proven to be an effective procedure not only to eliminate pain but also to achieve better knee function. However, details improvements of balancing or walking ability have not been sufficiently elucidated yet. 25 consecutive knees of 21 patients, with medial osteoarthritis undergone TKR have been nominated in this study. All were done by a single surgeon, via mid vastus approach, using cemented PS implant with patellar resurfacing. Patients were arrowed to start full weight bearing from the next day. Assessing walking ability, gait speed and width of a step were measured. As for balancing, “Functional Reach (FR)” which was the difference between arm's length and maximal forward reach (Duncan PW et al), “Timed Up and Go Test (TUG)” which was time while a patient rose from an arm chair, walked 3 meters, turned, walked back (Podsiadlo D et al), and sat down again, and possible period standing on one leg (one leg standing) were used. Every measurement was performed prior to the operation, and every 1-week after operation until 4-weeks postoperatively. Data were analyzed by one-way ANOVA, and then differences among means were analyzed using Bonferroni procedures. Also, the relation of improvements between ROM and each data were investigated by Pearson's correlation coefficient test. Every result showed the worst during the first week, followed by better results over time (p<0.05) (Fig. 1–3). The time point when better result than that of pre-operation could be achieved was 2 weeks in FR and one leg standing, 3 weeks in gait speed and width of a step, and 4 weeks in TUG, though statistically not significant. Each of the result was not correlated with its recovery rate of the ROM when compared at 4 weeks of time (r = 0.2–0.3). Interestingly, postoperative one leg standing period of contra-lateral leg showed improvement with similar tendency.Methods
Result
Multiaxial rotation of femoral component is generated in a wide range against UHMWPE tibial insert during ambulation or deep bending activities. Simultaneously, microscopic oscillation and twisting might accompany with such a wide-range motion. Such a combined in-vivo kinetics is expected to bring more severe wear to the sliding surface of knee joint prostheses than that in a case of single macro-kinetics (i.e., that commonly reproduced by conventional wear simulators). In order to reproduce clinical surface degradation correctly and quantitatively in simulator tests, we have to consider microscopic motions at the joint bearing surfaces. The purpose of this study is to analyze the influence of the composite knee motion on wear using a non-destructive spectroscopic approach. The crystalline phase in UHMWPE is pre-oriented in the tibial insert from the manufacturing process, but the orientation of crystalline lamellae is sensitive to mechanical loading. Therefore, the orientation of the crystalline lamellae on the surface of retrieved UHMWPE tibial inserts could reflect the local motions in vivo generated in the joint during ambulation. The visualization of (orthorhombic) crystalline lamellae might ultimately lead to the possibility of tracking back the wear history of the joint. In this study, polarized Raman spectroscopy was employed in order to non-destructively visualize the lamellar orientation in UHMWPE tibial inserts, which were retrieved after exposures in human body elapsing several years. According to this Raman analysis and in comparison with an unused insert, the orientation of surface lamellae was found to have been clearly changed due to wear in accordance to the local motion of the femoral component. Additionally, we could obtain information about the origin of delamination from the in-depth profile for lamellae orientation angle. This study not only shows the possibility of optimizing the UHMWPE structure to minimize wear but also gives a hint for the development of knee simulators of the next generation.
Knee prostheses have widely been used for severely damaged knee with osteoarthritis or articular rheumatism. PS type knee prosthesis is one of typical artificial knee joint systems and characterized by possessing the post-cam structure to stabilize the motion of the knee at large flexion angles. Post is a projection placed on the surface of UHMWPE tibial insert, and severe fracture and wear of the post are sometimes reported. It is therefore very important to understand the stress state of the post under real flexion motions in order to prevent such damages. It is also well known that the contact and bearing surfaces of a human knee is subjected to very high force especially during deep knee flexional motion such as squatting, and it is naturally expected that the tibial insert of a knee prosthesis deforms plastically under such high force condition. In this study, three dimensional dynamic finite element analysis of two types of PS knee prosthesis clinically used worldwide, Stryker’s Scorpio Superflex and NRG, are performed to characterize the plastic deformation behavior due to stress concentration generated in their tibial inserts under deep knee flexion motions. The new system NRG is recognized as a modified version of Superflex. Especially, the shape of the post is tried to be improved in order to reduce stress concentration and mobility. Continuous repeated flexional motion such as flexion-extension-flexion motion is considered in the analysis. Internal rotation of the tibial component and insert with flexional motion is also considered. It is found that severe stress concentration is generated in the post for both models and also in the condylar surfaces, and the stress concentration in Superflex is much higher and wider in NRG. Plastic deformation is therefore observed at these stress concentration points. The relationship between residual stress and plastic deformation in the tibial inserts is then discussed based on the analytical results.
Dorsal root ganglion neurones with dichotomising axons are present in several species and are considered to play a role in referred pain. Clinically, patients with lesions in the lower lumbar discs occasionally complain of pain in the groin. We investigated the existence of dichotomising afferent neurones projecting axons both to the lumbar disc and to the groin skin, using the double fluorescent-labelling technique in rats. We observed neurones labelled with a tracer applied at the ventral portion of the L5-L6 disc and another tracer placed on the groin skin in L1 and L2 dorsal root ganglia. Our results showed that the double-labelled neurones had peripheral axons which dichotomised into both the L5-L6 disc and the groin skin, indicating the convergence of afferent sensory information from the disc and groin skin. Our findings provide a possible neuroanatomical mechanism for referred groin pain in patients with disc lesions.
Based on a study using a retrograde neurotracer, we have previously found that the dorsal portion of the L5/6 disc in the rat is multisegmentally innervated by dorsal root ganglia (DRG) from the level of T13 to L6, and that sensory nerve fibres from DRG of T13, L1 and L2 pass through the paravertebral sympathetic trunks. In this study in newborn rats, we injected crystals of 1,1′-dioctadecyl-3,3,3′,3′-tetramethylinedocarbocyanine perchlorate (DiI) into the DRG of T13, L1 and L2 and showed DiI-labelled sensory nerve fibres in the dorsal portion of the discs from the level of T13/L1 to L5/6. Our results show that the dorsal portion of the lumbar discs is innervated by the DRG from levels T13 to L2.
It has been thought that lumbar intervertebral discs were innervated segmentally. We have previously shown that the L5-L6 intervertebral disc in the rat is innervated bilaterally from the L1 and L2 dorsal root ganglia through the paravertebral sympathetic trunks, but the pathways between the disc and the paravertebral sympathetic trunks were unknown. We have now studied the spines of 17 rats to elucidate the exact pathways. We examined serial sections of the lumbar spine using immunohistochemistry for calcitonin gene-related peptide, a sensory nerve marker. We showed that these nerve fibres from the intervertebral disc ran through the sinuvertebral nerve into the rami communicantes, not into the corresponding segmental spinal nerve. In the rat, sensory information from the lumbar intervertebral discs is conducted through rami communicantes. If this innervation pattern applies to man, simple decompression of the corresponding nerve root will not relieve discogenic pain. Anterior interbody fusion, with the denervation of rami communicantes, may be effective for such low back pain.
The afferent pathways of discogenic low-back pain have not been fully investigated. We hypothesised that this pain was transmitted mainly by sympathetic afferent fibres in the L2 nerve root, and in 33 patients we used selective local anaesthesia of this nerve. Low-back pain disappeared or significantly decreased in all patients after the injection. Needle insertion provoked pain which radiated to the low back in 23 patients and the area of skin hypoalgesia produced included the area of pre-existing pain in all but one. None of the nine patients with related sciatica had relief of that component of their symptoms. Our findings show that the main afferent pathways of pain from the lower intervertebral discs are through the L2 spinal nerve root, presumably via sympathetic afferents from the sinuvertebral nerves. Discogenic low-back pain should be regarded as a visceral pain in respect of its neural pathways. Infiltration of the L2 nerve is a useful diagnostic test and also has some therapeutic value.
