Elsevier

Materials & Design

Volume 42, December 2012, Pages 459-470
Materials & Design

Aseptic loosening of femoral components – A review of current and future trends in materials used

https://doi.org/10.1016/j.matdes.2012.05.046Get rights and content

Abstract

The variety of new biomaterials and different surface treatments being applied to existing materials all intended for total knee replacement (TKR) are self-evident of the demand for longer lasting knee prostheses. Aseptic loosening is one of the main reasons for the revision of TKR components including the femoral component, which has more challenging problems because of the different causes of failure. This paper therefore, focuses on aseptic loosening of femoral components and materials options available. Several current and promising new metallic, ceramic and polymeric biomaterials are discussed to highlight their advantages and their shortcomings. It is concluded that current materials have their limitations and there is a need for more sophisticated multi-functional materials to be developed in order to match the biological and mechanical complexity of the prosthetic femur.

Highlights

► The challenging problem of aseptic loosening in total knee replacement is discussed. ► Current and future metals ceramics and polymers for femoral component are reviewed. ► A need is indicated for developing new biomaterials to reduce aseptic loosening.

Introduction

In recent years, total knee replacement (TKR) has become one of the most critical debates in orthopedic due to the simultaneous growing number of replacement and revision surgeries [1], [2]. These increasing trends are due to aging populations worldwide and growing demand for a higher quality of life [3]. A recent statistical study indicated that by the end of 2030, the number of total knee arthroplasties (TKAs) is estimated to grow by 673% from the present rate, also the number of knee revision surgery will increase by 601% between the years 2005 and 2030 [1]. Furthermore, the revision surgical procedure of total knee is very expensive and reveals challenging clinical circumstances with less satisfactory in the clinical outcome compared to primary total knee arthroplasties [4]. With this scenario, it is now expected that the knee prostheses provide much longer period, even for a lifetime, without failure or revision surgery. A wide variety of complex causes such as loosening of components, malpositioning, maldimensioning, instability, extensor mechanism failure, periprosthetic fracture and infection have been indicated for revision surgery of TKR [5], [6]. However, mainly these can be categorized into septic and aseptic etiologies. Infection after TKA has been one of the most concerning complications that must be managed, efficiently, through eradicating of infection and successive insertion of a stable and functional prosthesis. Various treatments including antibiotic suppression, operative debridement with or without polyethylene (PE) exchange, exchange arthroplasty, arthrodesis or resection arthroplasty are available to control the infected TKA [7]. Aseptic TKA revisions are usually carried out for loosening of the components which seems to be more severe problem as the observations have shown less favorable outcome for aseptic revision TKA compared to primary [8], [9] and septic revision TKA [7]. The aim of this paper is to provide a discussion on different leading causes of femoral component loosening and a review of the existing and promising materials for this application. The remainder of this paper is organized as follows; Sections 2 Aseptic loosening of TKR, 3 Materials and aseptic loosening of femoral component clarify the role of contributing factors in aseptic loosening of femoral component and influence of material properties in this problem. Section 4 reviews the currently used and the promising metallic, ceramic and polymeric biomaterials for this application. The paper continues in Section 5 with a discussion on some observations on the state-of-the-art and ends in Section 6 with conclusions.

Section snippets

Aseptic loosening of TKR

Total knee replacement consists of three main components: femoral component, tibial component (insert and tray) and patellar component as shown in Fig. 1a. Femoral component and tibial tray are usually made of metals including Ti-based alloys, stainless steels and Co–Cr–Mo alloys or sometimes they are fabricated from ceramics such as alumina, zirconia and their composite. These components are normally cemented (by Polymethylmethacrylate or PMMA) or pressed into place. The tibial insert and

Materials and aseptic loosening of femoral component

Materials and design are two key issues in development of every engineering product, especially in biomedical devices that the related science and technology currently leads to multi-million dollar business. Both materials and design deficiencies contribute in aseptic loosening of TKR. A large number of materials, which will be discussed in details in the following section, have been developed for femoral component of TKR during the past two decades to address the aseptic loosening problem.

Current and promising new biomaterials

The material from which a femoral component is fabricated usually provides a number of advantages as well as several complications. The following section describes these issues for currently used materials and provides a perspective for promising new biomaterials.

Some observations on the state-of-the-art

The current materials used for the femoral components of TKR are vulnerable to fulfilling some of the vital requirements, which mostly lead to aseptic loosening. Thus research is being conducted to develop either new biomaterials or new techniques to treat existing materials. Co–Cr alloys have been the most widely accepted materials for this application, although NiTi SMAs, particularly in porous form, are promising biomaterials requiring more clinical investigations. Generally, almost all of

Conclusions

Aseptic loosening is one of the most challenging problems associated with total knee replacement. New materials are therefore being developed or existing materials modified in order to meet the demand for longer lasting and better functioning implants in the human body, which is especially desirable for younger, more active patients. Despite the already significant advances in this area, a complete solution that fully addresses the aseptic loosening problem of the femoral component in TKR is

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