A tribological study of a series of retrieved

Accord knee explants

e.EIII;;iez*, J. Fisher*, D. Dowson*, S.A. Sampath, R. Johnson* and
.
*Department of Mechanical Engineering, University of Leeds, Leeds LS2 9JT, UK;
University Department of Orthopaedics and Accident Surgery, University of Liverpool,
Liverpool, UK; *Knee Research Unit, Arrowepark Hospital, Upton, Wirral, Merseyside,
L49 5PE, UK; * *DePuy International Ltd., St Anthonys Road, Leeds LSll SDT, UK
ABSTRACT
A tribological s&y of a series of 27 retrieved Accord meniscal bearing kneejoints has been carried out. Ihe roughness of
the articulating sufaces of the men&al and thefemoral components was investigated, and thepenetration into the
polyethylene meniscal component was determined. There was generally little damage to the highly polished metallic
femoral components. A general polishing and smoothing of the ultra high molecular weight polyethylene meniscal
components was observed, although therewas somesubsequent deterioration of the polyethylene surfaces in certain cases.
The penetration rateof thefemoral components into themenisci was low, and was found to besimilar to that reportedfor
other meniscal kneejoints.
Keywords: Tribology, retrieval, knee prostheses
Med. Eng. Phys., 1994, Vol. 16, 223-228, May
INTRODUCTION
The natural knee offers a complex range of move-
ments with 150 of motion in flexion-extension,
rotation, and translation in the anterior-posterior
direction. In the more widely used total condylar
artificial knees this range of movements is achieved
by having relatively low conforming tibia1 and
femoral components . This produces high stresses in
the contact. In certain knee designs the high cyclic
contact stresses can cause sub-surface fatigue and
structural failure of the ultra high molecular weight
polyethylene (UHMWPE) component3. In some
cases inadequate mechanical properties and
poor quality UHMWPE have been acknowledged
as accelerating factorsk7. Sub-surface fatigue can
initiate several millimetres into the UHMWPE at the
position of the maximum shear stress, with cracks
propagating to the surface causing complete failure
and break up of the UHMWPE component. This
type of failure has been widely described as delamin-
ation in the literature8~g. In addition structural failure
can also initiate from stress concentrations arising
from the metal tibia1 support or tray, which can lead
to the complete breaking up of the polyethylene
component. It is important to emphasize that this
mode of failure and wear is not primarily a surface
wear process, as it is not caused by relative motion of
the surface asperities, and it initiates in the bulk of the
material. In some total condylar knees it has been
possible to reduce the levels of contact stress that
cause structural failure, by increasing the conformity
Correspondence and reprint requests: Dr J.L. Hailey
0 1994 Butterworth-Heinemann for BES
1350-4533/94/03223-06
of the components, but this can restrict the range of
movements and impose biomechanical constraints.
The meniscal bearing knee offers an alternative
approach to overcoming the desi
ated with total condylar knees
p problems associ-
. Memscal bearing
knees achieve a wide range of motion by allowing
articulation at both the femoro-meniscal and the
tibio-meniscal surfaces. Figure 7 shows an Accord
meniscal knee. The femoro-meniscal bearing surfaces
are conforming and cylindrical in shape which gives
rise to a large area of contact on both condyles in a
correctly aligned knee. The tibio-meniscal surfaces
are conical in shape and allow rotation of the
polyethylene meniscal component with respect to the
tibial tra . In most components the translation of the
menisca ly component is constrained by a pin through
the apex of the truncated conical surface. Thus the
Accord meniscal knee permits flexion-extension at
the femoro-meniscal bearing surface, and rotation at
the tibio-meniscal surfaces. This allows more highly
conforming bearing surfaces to be used and it has
been postulated that reduced contact stresses may
reduce the incidence of early structural failure and
perhaps reduce the volume of wear debris generated
in the long term. The purpose of this study was to
investigate the tribological characteristics of a series of
retrieved Accord meniscal knees, and in particular
focus on the condition of the UHMWPE and the
femoro-meniscal wear surfaces.
MATERIALS AND METHODS
A total of 768 Accord knees (Figure 7) have been
implanted at Arrowepark Hospital since a clinical
Tribological study of retrieved knee expiaats:J .L. Hailq et al.
Figure 1 Photograph of the Accord meniscal bearing knee Figure 2 Photograph of an explant which suffered from metal-to-
metal contact during articulation
trial of the knee began in 1982, of which 73 have now
been revised. The majority of these were revised for
failure of cementless fixation and infection. None of
the explants were revised for structural failure of the
UHMWPE meniscus. Twenty-seven paired meniscal
and femoral components were available for examina-
tion in this study.
An initial visual examination and the clinical
history of the explants were used to determine
the modes of failure of the components. Certain
mechanical modes of failure were then eliminated
from the tribological study. These included joints
where the meniscus had dislocated and led to the two
metal components, the femoral component and the
tibia1 tray, contacting. During articulation these two
metal components maintained contact leading to the
generation of large amounts of metal wear debris. An
example of this type of failure is shown in Figure 2.
Sixteen of the 27 paired explants had failed in this
manner and were thus discarded from the rest of the
study, which has focused on the articulating surfaces.
The full clinical history, patient details and regular
follow-up information of the eleven remaining
explants (which were evaluated for wear) were
available from hospital records, and are summarized
in Table 1. The average age of the patients was 60.0
years and their average weight was 71.1 kg. The
period of implantation for these components ranged
from less than 1 year to over 5 ears with an average
lifetime of 33.4 months. In a dy dition to the revised
explants, four unworn prostheses taken from clinical
stock prior to implantation were also evaluated as
control samples. The articulating surfaces of the
menisci and femoral components were characterized
by R, surface roughness measurements using a
Talysurf 5 machine (Rank Taylor Hobson, Leicester).
The R, was measured perpendicular to the direction
of sliding using a 0.8 mm cut off. Three readings were
obtained from each condyle, giving a total of six
measurements per component. The mean of these
readings was then calculated and used as the average
R, value for that particular component.
The UHMWPE meniscal components were wider
than the femoral components, and due to a close
fitting central locating step (see Figure 4b), the edges
of the menisci were not subjected to wear. This
resulted in the formation of a lip at the edges of
Table 1 Summary of clinical data, patient details and follow-up information
Case Wear life
number (months)
Activity
capability
Age
(years)
Weight
(kgs)
Sex Operation
side
Initial
diagnosis
Reason for
revision
I 8 A 73 72 F I. OA I,, ST
2 9 - 62 66 F R RA I
3 IO A 60 71 F L OA I
4 I6 A 61 64 M L OA I,
5 23 P 61 54 F R RA I
6 26 G 67 79 M I* Other I, L
7 43 G 46 73 F R RA L, ST
8 45 G 63 61 F R RA I, U
9 59 A 62 88 M L OA I,, ST
IO 64 G 62 77 M R OA L
II 64 A 43 77 F L OA L
G, good mobility; A, average mobility; P, poor mobility; OA, osteo arthritis; RA, rheumatoid arthritis; I, infection; L, loosening; ST, subsidence of
tibia; U, unstable
224 Med. Eng. Phys. 1994, Vol. 16, May
the menisci. A Talycontor machine (Rank Taylor
Hobson, Leicester) was used to trace across the
surface of the menisci (perpendicular to the sliding
direction) from one lip, over the worn region to the
worn area and unworn lip on the op osite side of the
component. A rotating levelling ta 1 le was used to
ensure that the two unworn lips were at the same
height, and that the menisci were orientated at
exactly 90 to the direction of sliding. This proce-
dure was repeated twice for each sample and the
average difference between the height of the unworn
lip and the height of the worn region was evaluated to
give the penetration depth for each polyethylene
component. It should be pointed out that the
measured penetration into the menisci occurred as a
result of both creep and wear of the polyethylene.
Therefore the derivation of wear rates from penetra-
tion rates should be treated with caution, particularly
when penetration depths are small.
RESULTS
The surface roughnesses of the femoral components
are shown in the graph in Figure 3. The number of
months that the joint was im lamed for is shown on
the x-axis, and the R, (in pm
P
It was found that general1
is shown on the y-axis.
were in very good cr
the femoral components
con ition and had R, values
similar to the unworn control. The average R, value
for the worn femoral components was 0.055~m with
a standard deviation of 0.075p.m (average R= of
0.032pm if the one anomaly, 59 months, was not
included). This corn
P
ares with an Ra of 0.02p.m for
the unworn contra component. There was one
sample (59 months) which had a surface roughness
an order of magnitude higher than the rest of the
samples. This component had been badly scored
g
robably as a result of the entrapment of cement and
one debris. One other component (64 months)
showed a slightly higher R, and a slight deterioration
of the surface.
Figure 4a shows the surface roughnesses of the
meniscal components. The implant lifetime is shown
on the x-axis, and the R, is shown on the y-axis. From
this graph it can be seen that there was an initial
Lifetime (months)
Figure 3 Histogram of the femoral surface roughness (R,) and
implant life
Tribologicnl study of retrieved knee explants:J L. Hailq, et al.
a
Lifetime (months)
b
Figure 4 a, Histogram of the meniscal surface roughness (%) and
implant life. 4b, Photograph of a worn (right) and an unworn (left)
meniscus
smoothing of the surfaces followed by some deteriora-
tion in certain cases. The average R, for the worn
menisci was 1.15 pm with a standard deviation of
1.03pm (using the eight polished components the
average Ra was 0.60pm, using the three bad1
damaged components the average R, was 2.63pm .
r
This compares with an avera e
(standard deviation 0.23 pm
Y
value of 1.04 pm
for the unworn
samples. The Ra values for the worn components
ranged from 0.28 pm up to 3.27pm, whereas those
for the unworn controls ranged from 0.76pm up to
1.33pm. Initially the polymer surface was quite
rough due to the machining marks. Initial wear and
creep produced a smoothing or polishing of the
UHMWPE meniscal components. The polishing of
the worn menisci, compared to an unworn control,
can be clearly seen in the
4b, where the sample on tK
hotograph shown in Figure
e right is the worn sample.
Subsequently in certain cases the polymer surface
became damaged and the surface roughness
increased.
Figure 5 shows the articulating surface of Case 10
(the first of the two samples implanted for 64 months
on the graph in Figure 4a). This sample showed severe
surface dama
explants, an B
e compared with that seen in the other
failure of the surface can be seen in
Figure 5. This was the worst case of the 27 explants
which were studied. The Talycontor profile showed
Med. Eng. Phys. 1994, Vol. 16, May 225
Tribological study of retrieved knee expluntxJ .1. Hailq et al.
Figure 5 Photograph of the meniscus from Case 10 showing surface
micro-delamination
that this surface damage and wear occurred within
0.3 mm of the meniscal bearing surface. Similar wear
features have been seen on acetabular cups from
simulator studies which we have performed at Leeds
University *. However, there was also evidence of
gross misalignment and dislocation of the poly-
ethylene meniscal component, and this surface
damage could have been caused by contact with the
edge of the femoral component when grossly mis-
aligned. Local surface damage at the edge of the wear
scar was noted on several of the older meniscal
components and this is shown in Figure 6. This is
believed to have occurred when the femoral com-
ponent and the meniscus became slightly misaligned.
The very small radii on the femoral components led
to the development of high contact stresses at the
edge contact with the meniscus. This in turn resulted
in local structural failures, in the form of local severe
damage to the surface of the polyethylene.
The penetration de ths into the menisci are shown
in Figure 7. The imp ant life is shown on the x-axis P
and the penetration (in pm) is shown on the y-axis.
There was a considerable variation in the penetration
depths of the explants, and no correlation could be
found with either wear life, patient weight, or patient
activity. It can also be seen from Figure 7 that four of
the menisci showed no detectable penetration, even
after implantation for over 5 years in one case (64
months on the graph in Figure 7). Two of the samples
were too badly deformed to obtain penetration
Figure 6 Photograph showing local structural failure of a meniscus
due to misalignment of the femoral component
i 23 26 45 59 64
Lifetime (months)
Figure 7 Histogram of the meniscal penetration depth and implant
life
depths from. This was due to severe misalignment of
the meniscal component and gross damage of the
polyethylene, and hence these samples were dis-
regarded from this part of the study. The average
penetration rate from the data shown in Figure 7 was
found to be 40pmyear-. In this study the
P
enetra-
tion depths and the Ra values for the latera side of
both components were found to be similar to those
obtained for the medial side.
DISCUSSION
Recent reports13 of structural fatigue and early failure
in highly stressed nonconforming total condylar
knees have caused considerable concern in the
surgical community. This has prompted a renewed
interest in the meniscal bearing knee where it is
possible to increase contact area and reduce contact
stresses to levels more generally found in hip
prostheses. It is important to recognize that changes
in the design and tribological conditions in artificial
joints can cause marked changes in the wear and
failure processes in the UHMWPE components. In all
polyethylene acetabular cups in hip prostheses, where
contact stresses are generally lower than in total
condylar knees, structural failure is extremely rare,
and wear particles are generated by surface wear
processes produced by asperity interactions14. In
Argenson and OConnors long term study of
Oxford meniscal knees, surface wear and pentration
rates were reported, but no evidence of structural
failure was recorded, demonstrating the potential of
the meniscal bearing concept. In this study the
majority of the implants retrieved showed metal-to-
metal contact due to dislocation of the meniscal
components. As this would have produced consider-
able metallic debris which could subsequently
damage the articulating surfaces, these prostheses
were excluded from the study.
It was shown that, in general, the surface roughness
of the femoral components did not change signifi-
cantly with implantation time. Some fine scratches
running parallel to the direction of sliding were
visible on the surfaces of the femoral components,
although these did not appear to have a significant
226 Med. Eng. Phys. 1994, Vol. 16, May
Triboh@al study of retrieved knee explunts:J L. Ha&y et al.
reduced stresses have been demonstrated in this
study. However, it is necessary to em hasise
biomechanical difficulties of ensuring sta !
the
meniscal knee design.
ility in the
influence on the R, values. Since the scratches were
orientated in the direction of sliding, it is unlikely that
they would have had a significant effect on the wear
of the polyethylene, compared to scratches which
were perpendicular to the sliding direction. In hip
joints this type of scratching has been related to
increased polyethylene wear as in the hip the
scratches tend to be more randomly orientated due to
the more complex movements generated.
The pattern of wear and changes in the surface
to ograph of the meniscal component were gener-
al y ip ly similar to those found in acetabular P cr
where surface wear processes remove
EYsethylene particles within 10pm of the surface,
an dr severe plastic deformation of the polyethylene
has been noted up to a depth of 40pm below the
surface. The initial roughness of the pol
marks was smoothed by creep an Jrn
er machine
counterface as
microscopic
t!
erity wear (Figure 4). Subsequent1 in
certain cases e polymer surface deteriorated. Jh is
may be due to abrasive action by third body bone
cement particles, or alternatively the onset of macro-
scopic
1
olymer wear processes which have been
reporte in explanted acetabular cups15. One
meniscal component (Case 10) showed severe surface
damage, and the depth of this severe surface damage
was up to 300pm from the articulating surface.
Although similar surface wear patterns have been
seen in hip joint simulator studies in the laboratory,
there was also evidence of gross misalignment of this
component and this severe surface damage ma have
been caused by edge contact of the femora ly com-
ponent. In the explants which did not dislocate, or
show evidence of gross misalignment, gross structural
failure (characterized by delamination originating
from a depth of greater than 0.5mm into the
UHMWPE) was not found. However, the follow u
of 5 years is quite short and direct comparison wi t!
longer term follow up studies of total condylar knees
should be approached with caution. When misalign-
ment of the Accord knee occurred, local stress
concentrations were formed at the edge of the
femoral component, and local structural failure
resulted due to the abnormally high contact stresses.
The average penetration rate was also evaluated
from our data and compared with that obtained by
other workers. We calculated a penetration rate of
0.040 mm year- (4Opm) for the Accord knee, which
compares well with the figure of 0.047 mm year-
obtained by Argenson and OConnor for the
Oxford meniscal knee. In comparison Dowson et
a1.16 obtained significantly higher penetration rates
for conventional Geomedic and Freeman-Swanson
knees - 0.22 and 0.26mmyear respectively. The
penetration rate in the meniscal knee was comparable
with that found with hip joints as shown by Dowling17
who obtained a penetration rate of 0.06 mm year- for
post mortem acetabular cups. However, care must be
taken when comparing penetration rates in different
types of knees and hips, as the different geometries
involved will produce different volume than es for
the same penetration rate. Also these volume c a anges
can include different contributions from creep and
wear. Des
mental tri K
ite this, the authors feel that the funda-
ological advantages of a meniscal knee
design, which include larger contact areas and
CONCLUSIONS
In conclusion, the tribological advantages of the
Accord meniscal bearing knee joint are as follows.
There was generally little damage of the articulating
surfaces. The wear and penetration rates were very
low. There was no evidence of any structural failures,
except in cases where the femoral corn onent and the
meniscus were misaligned, and lot ap damage was
formed at the edge of the contact area. The pattern of
surface wear in this knee was similar to that seen in
hips with comparable penetration rates for the two
types of joint.
In the 27 retrieved knees reported in this study
failure of the cementless fixation was the most
frequent cause of revision. This led to instability of the
joint and edge contacts between the femoral com-
ponent and the meniscus, which due to the small radii
on the femoral component led to the generation of
high contact stresses and local structural failure.
There were a number of cases where dislocation of
the meniscus which led to metal-on-metal contact
during articuation, and the potential for generation of
large quantities of metal wear debris.
AC!KNOWLEDGFBIENTS
This work was funded by the Arthritis and Rheumat-
ism Council (ARC).
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1994 IEEE ULTRASONICSSYMPOSIUM
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