JBJS | Isolation and Characterization of Polyethylene Wear Debris Associated with Osteolysis Following Total Shoulder Arthroplasty*

The Journal of Bone & Joint Surgery, Volume 81, Issue 1

Articles | January 01, 1999

Isolation and Characterization of Polyethylene Wear Debris Associated with Osteolysis Following Total Shoulder Arthroplasty*

MICHAEL A. WIRTH, M.D.†; C. MAULI AGRAWAL, PH.D., P.E.†; JAY D. MABREY, M.D.†; DAVID D. DEAN, PH.D.†; CHERYL R. BLANCHARD, PH.D.‡; MICHAEL A. MILLER, M.S.‡; CHARLES A. ROCKWOOD, JR., M.D.†, SAN ANTONIO, TEXAS

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Investigation performed at the Department of Orthopaedics, University of Texas Health Science Center at San Antonio, San Antonio

The Journal of Bone & Joint Surgery. 1999; 81:29-37

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Abstract

We evaluated the interface membranes surrounding three total shoulder prostheses that had been removed because of progressive aseptic loosening associated with osteolysis. The mean time between the uncomplicated initial arthroplasty and the revision procedure was twelve years (10.5, 10.5, and 16.0 years). Membranes from around both the humeral and the glenoid component were obtained from all three shoulders and were studied histologically to determine the biological response involved in the development of aseptic loosening. For the purpose of comparison, periprosthetic tissue was also obtained from the sites of four failed total hip prostheses that were associated with osteolysis.Polyethylene particles were retrieved with an enzymatic digestion technique that involved the use of papain. Raman vibrational spectroscopy verified that the particles were ultra-high molecular weight polyethylene. The particles were isolated from the tissue, and a computerized image-analysis system characterized 582 of them in terms of size and morphology. Each particle was defined with the use of six shape descriptors: equivalent circle diameter, roundness, form factor, aspect ratio, elongation, and outline fractal dimension. The particles from the hips had a mean equivalent circle diameter (and standard error of the mean) of 0.62 ± 0.03 micrometer, were predominantly globular in shape, and had low mean values for aspect ratio (1.46 ± 0.02) and elongation (1.85 ± 0.03) and relatively high values for roundness (0.74 ± 0.01) and form factor (0.87 ± 0.01). In contrast, the particles from the shoulders had a mean equivalent circle diameter of 1.04 ± 0.03 micrometers. In addition, they had relatively high values for aspect ratio (2.36 ± 0.07) and elongation (4.96 ± 0.23) and correspondingly low values for roundness (0.54 ± 0.01) and form factor (0.67 ± 0.01), indicating that they were more fibrillar in shape. The particles from the shoulders and those from the hips were significantly different (p < 0.0001) with respect to all of the descriptors except outline fractal dimension. The particles from the shoulders, in general, were larger and more fibrillar than the particles from the hips.CLINICAL RELEVANCE: This study demonstrated that particles generated by the wear of the ultra-high molecular weight polyethylene of total shoulder prostheses can be associated with clinically important osteolysis, with a pathogenesis that is similar to that of aseptic loosening after total hip replacement. The polyethylene wear debris obtained from the membranes around three failed total shoulder prostheses was strikingly different in terms of morphology than the wear debris obtained from the tissue around failed total hip prostheses; this finding suggests that the type of joint markedly influences the wear mechanism and the nature of the resulting debris.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Symptomatic loosening of the glenoid and humeral components after a total shoulder arthroplasty is common and has been reported to account for nearly one-third of all complications that are associated with this procedure^{1-8,10,12-18,21,28,30,31,35-38,41-43,49-55}. Numerous investigators have expressed concern that the appearance of progressive radiolucent lines may herald the onset of problems, such as symptomatic loosening^{1,4,7,11,12,21,50,52-55}. The authors of one study from Sweden noted radiolucent lines around the glenoid component in twenty-five of twenty-six shoulders at a mean of forty-seven months postoperatively⁷. While no radiolucent lines were observed around the glenoid components on the radiographs made immediately postoperatively, lines developed within three years after the operation in all twenty-five shoulders. These radiographic findings were associated with a decrease in function and an increase in pain.

In 1984, Cofield¹¹ reported improved motion and reliable relief of pain in most shoulders two to six years after seventy-three Neer total shoulder arthroplasties. Although the clinical results were excellent and compared favorably with those of other studies, fifty-two shoulders had radiolucent lines at the bone-cement interface and eight had radiographic evidence of loosening of the glenoid component, as defined by a shift in the position of the component or a circumferential radiolucent line at the bone-cement interface that was at least 1.5 millimeters wide. More recently, Torchia and Cofield⁵⁰ analyzed the results of eighty-nine total shoulder arthroplasties, some of which had been included in the earlier study by Cofield¹¹. The clinical results were graded as excellent, satisfactory, or unsatisfactory, according to the systems of Neer et al.³⁷ and Cofield¹¹. An excellent result indicated that the patient had no or slight pain, active abduction to at least 140 degrees, and external rotation to at least 45 degrees and was satisfied with the result. A satisfactory result indicated that the patient had no or slight pain or moderate pain only with vigorous activities, active abduction to at least 90 degrees, and external rotation to at least 20 degrees and was satisfied with the result. An unsatisfactory result indicated that these criteria were not met. Associations and correlations between preoperative parameters and postoperative results were tested with the Wilcoxon rank-sum test, the Kruskal-Wallis test, and the Spearman correlation test. P values of less than 0.05 were considered significant. At a mean of twelve years (range, five to seventeen years) postoperatively, radiolucent lines had developed at the bone-cement interface of seventy-five glenoid components (84 percent), and thirty-nine components (44 percent) had definite radiographic loosening. Comparison of the original report¹¹ with the later one⁵⁰ (which included additional patients who were not in the first study) revealed that the prevalence of radiographic loosening of the component had increased fourfold during the extended study period. Even more disturbing was the association between radiographic loosening of the glenoid component and pain (p = 0.0001). With an increased duration of follow-up, the percentage of patients who reported satisfactory relief of pain decreased from sixty-seven (92 percent) of seventy-three to seventy-two (81 percent) of eighty-nine.

The capacity of polymeric wear debris to induce macrophage and giant-cell-mediated osteolysis of periprosthetic bone has been well documented in association with aseptic loosening of total hip and knee prostheses^{19,23,25,26,40,44}. To our knowledge, this process has not been reported in association with total shoulder prostheses. The purpose of the present study was to characterize, in terms of size and morphology, polyethylene wear debris from the tissue around three failed total shoulder prostheses that were associated with osteolysis.

*Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but are directed solely to a research fund, foundation, educational institution, or other nonprofit organization with which one or more of the authors is associated. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was The Center for the Enhancement of the Biology/Biomaterials Interface, San Antonio, Texas.

†Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7774.

‡Materials and Structures Division, Southwest Research Institute, 6220 Culebra Road, San Antonio, Texas 78228.

†Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7774.

‡Materials and Structures Division, Southwest Research Institute, 6220 Culebra Road, San Antonio, Texas 78228.

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FIG1-A:: Fig. 1-A Anteroposterior radiograph made six years after the initial total shoulder arthroplasty. The prosthesis is well adapted to the bone and there are no signs of radiographic loosening. The patient was asymptomatic.

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FIG1-B:: Fig. 1-B Anteroposterior and axillary lateral radiographs made ten years after the initial arthroplasty, demonstrating periprosthetic osteolysis of the proximal aspect of the humerus and the glenoid (arrows). The patient had a two-year history of progressive discomfort with an insidious onset.

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FIG1-C:: Fig. 1-C Anteroposterior and axillary lateral radiographs made ten years after the initial arthroplasty, demonstrating periprosthetic osteolysis of the proximal aspect of the humerus and the glenoid (arrows). The patient had a two-year history of progressive discomfort with an insidious onset.

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FIG2:: Fig. 2 Photograph of the articular surface of a retrieved ultra-high molecular weight polyethylene glenoid component from a patient who had osteolysis of the glenoid.

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FIG3:: Fig. 3 Micrograph of ultra-high molecular weight polyethylene wear debris retrieved from a periprosthetic osteolytic lesion in a shoulder (x 5000).

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FIG4:: Fig. 4 Micrograph of ultra-high molecular weight polyethylene wear debris retrieved at the time of revision of a total hip prosthesis (x 5000).

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FIG5-A:: Fig. 5-A Frequency distribution for the size (equivalent circle diameter [ECD]) of ultra-high molecular weight polyethylene wear particles from tissue around total shoulder and hip replacements. In general, the particles from the hip were smaller.

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FIG5-B:: Fig. 5-B Frequency distribution for the roundness of ultra-high molecular weight polyethylene wear particles from tissue around total shoulder and hip replacements. The particles from the hips were rounder. (A perfect circle has a roundness of one.)

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TABLE I SIZE AND MORPHOLOGY DESCRIPTORS FOR THE ULTRA-HIGH MOLECULAR WEIGHT POLYETHYLENE PARTICLES*

*The values are given as the mean and the standard error of the mean. †The value is significantly different from the value for the particles from the hip (p < 0.0001).

	Equivalent Circle Diameter (µm)	Aspect Ratio	Elongation	Roundness	Form Factor	Outline Fractal Dimension
Hips	0.62 ± 0.03	1.46 ± 0.02	1.85 ± 0.03	0.74 ± 0.01	0.87 ± 0.01	11.76 ± 0.16
Shoulders	1.04 ± 0.03†	2.36 ± 0.07†	4.96 ± 0.23†	0.54 ± 0.01†	0.67 ± 0.01†	10.94 ± 0.15

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TABLE I SIZE AND MORPHOLOGY DESCRIPTORS FOR THE ULTRA-HIGH MOLECULAR WEIGHT POLYETHYLENE PARTICLES*

*The values are given as the mean and the standard error of the mean. †The value is significantly different from the value for the particles from the hip (p < 0.0001).

	Equivalent Circle Diameter (µm)	Aspect Ratio	Elongation	Roundness	Form Factor	Outline Fractal Dimension
Hips	0.62 ± 0.03	1.46 ± 0.02	1.85 ± 0.03	0.74 ± 0.01	0.87 ± 0.01	11.76 ± 0.16
Shoulders	1.04 ± 0.03†	2.36 ± 0.07†	4.96 ± 0.23†	0.54 ± 0.01†	0.67 ± 0.01†	10.94 ± 0.15

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Periprosthetic tissue was obtained from the sites of three total shoulder replacements from three men who were having a revision because of aseptic loosening between October 1996 and May 1997. Written informed consent was obtained from each patient for both the procurement and the analysis of the tissue. The humeral components (Neer II; Kirschner Medical, Fairlawn, New Jersey) were made of cobalt-chromium alloy. The glenoid components had been fixed with cement at the time of the initial operation, whereas the humeral components had been press-fit into the humerus, obviating the need for cement³⁹.

The patients were fifty, sixty-one, and sixty-nine years old. The mean time between the initial arthroplasty and the revision was twelve years (10.5, 10.5, and 16.0 years). The initial total shoulder arthroplasty had been performed because of posttraumatic degenerative joint disease in one shoulder and osteoarthritis in the other two. The tissue was examined histologically, and all of the intraoperative cultures of tissue obtained from the shoulder joints were sterile.

The indications for the revision included pain in the shoulder and radiographic evidence of loosening or migration of a component. Preoperatively, all components were thought to be loose on the basis of pain and radiographic findings. The preoperative radiographs were analyzed for evidence of migration of the implant, the presence of radiolucent lines at the bone-implant or bone-cement interface, and endosteal erosion. Endosteal erosion was defined as localized resorption of bone around the implant or at the bone-cement interface. Radiographs were assessed with use of a modification of the grading system described by Cofield¹¹. Radiographic evidence of loosening was defined as a shift in the position of the component or a circumferential radiolucent line at the bone-cement or bone-implant interface that was at least 2.0 millimeters wide.

The periprosthetic tissue was obtained, by curettage, from the proximal aspect of the humerus between the humeral component and the bone and from the bone-cement interface of the glenoid cavity.

For comparison, periprosthetic tissue was also obtained from the sites of four total hip prostheses that had failed because of aseptic loosening associated with osteolysis.

Isolation of Particles of Wear Debris

Granulomatous tissue was immediately placed in neutral buffered formalin at the time of the procurement and was stored at 20 degrees Celsius until it was analyzed. Wear debris was released from the tissue with papain digestion, as originally described by Maloney et al.³³ and as modified by us for this study. First, approximately three grams of tissue was minced into small (two to three-square-millimeter) pieces and was washed four times with ten volumes of ultrapure water over a three-day period to remove the formalin fixative. After each wash, the tissue was collected by centrifugation at 2000 times gravity for fifteen minutes, the supernatant was removed, and fresh ultrapure water was added.

After the final wash, the tissue was digested with papain (Sigma Chemical, St. Louis, Missouri). The enzyme was dissolved in 0.05-molar sodium phosphate buffer (pH 6.5) containing two-micromolar N-acetylcysteine at a ratio of three milligrams of papain to ten milliliters of buffer. Five milliliters of this enzyme solution was added for each gram of tissue. Tissue digestion was conducted at 65 degrees Celsius in a shaking water bath for three days. Each day, a fresh aliquot of papain, equivalent to the original amount of enzyme that had been used to digest the tissue, was added. At the end of digestion, the insoluble residue was removed by centrifugation at 100,000 times gravity for one hour, and the supernatant was then sonicated for ten minutes in a sonicator (model ME2.1; Mettler Electronics, Anaheim, California). The particles of wear debris were collected by filtration on a polyester filter (Poretics, Livermore, California) with a pore size of 0.2 micrometer. After filtration, the particles on the filter were washed two times with two milliliters of ultrapure water followed by two washings with two milliliters of 70 percent ethanol.

Characterization of the Particles

Microscopic Raman vibrational spectroscopy was used to determine the chemical composition of the wear debris. Raman spectroscopy is a light-scattering technique that permits study of the molecular composition of matter by probing the quantized vibrational energies of molecules with an intense monochromatic light source. Scattered light from a sample is spectrally resolved into group vibrational frequencies, which result in a spectral image, a discrete molecular composition. Particles were isolated as described, but they were collected on 0.2-micrometer polyester filters that had been sputter-coated with gold-palladium to increase the contrast of the particles in the field of view of the microscope and to mask the signal from the underlying polyester. A Renishaw Ramanscope System 2000 (Gloucestershire, United Kingdom) that employed a 780-nanometer excitation laser source was used in conjunction with an objective lens with a magnification of fifty times on the microscope to focus the beam of the laser source onto the filter media, thereby exciting an area with a diameter of one micrometer. The backscattered light emanating from this area was simultaneously collected through the objective lens and was resolved spectrally (one cm^-1) as Raman vibrational modes after the Rayleigh component of the scattered light was removed. Multiple thirty-second acquisitions of resolved spectra centered at 1124 cm^-1 enabled a detailed comparison of the debris spectra with that of an ultra-high molecular weight polyethylene standard. Therefore, particles of wear debris or particle aggregates that were at least one micrometer in size could be evaluated unambiguously with this system when used in the described configuration. Multiple samples were analyzed under identical operating parameters.

Analysis of the Particles

A customized set of macros was developed with image-processing software (NIH Image; National Institutes of Health, Bethesda, Maryland) in order to quantitatively characterize the size, shape, and morphology of the ultra-high molecular weight polyethylene wear debris²⁹. Each particle was defined with six measurements: equivalent circle diameter, roundness, form factor, aspect ratio, elongation, and outline fractal dimension. One was a measure of the size of the particle, and the other five were numerical shape parameters.

The size of the particle was measured by determining the equivalent circle diameter, which is the diameter of a circle with an area equivalent to the area of the particle and is expressed in units of length. Roundness is a measure of how closely a particle resembles a circle. The value for roundness ranges from zero to one, with a perfect circle having a value of one. Form factor is similar to roundness, but it is based on the perimeter of the outline of the particle rather than on the major diameter. This distinction makes the form factor more sensitive to variations in the roughness of the outline. Although aspect ratio is a common measure of the shape of a particle, its definition varies. For the present study, aspect ratio was defined as the ratio of the major dimension (the longest straight line that can be drawn between any two points on the outline) to the minor dimension (the longest line perpendicular to the major dimension). Elongation is similar to the aspect ratio, but it is more suited for the measurement of long, thin particles. Elongation is a ratio of the actual length of a particle to its mean width. Finally, the outline fractal dimension is a measure of the complexity of the outline and is based on the fractal dimension of the outline. Although the outline fractal dimension is a two-dimensional measure of the so-called roughness of the outline of the particle, it may be a reasonable indicator of the texture of the particle in three dimensions.

Statistical Analysis

The data are given as the mean and standard error of the mean for each parameter. The distributions of the sizes and shapes of the particles were not assumed to be normal. The significance of differences between the particles from the hips and those from the shoulders was determined with the nonparametric Mann-Whitney test.

Results

Introduction | Materials and Methods | Results | Discussion | References

Radiographic and Operative Findings

Radiolucent lines were seen at the bone-implant interface of the humeral component or at the bone-cement interface of the glenoid component, or both, in all three shoulders. A progressive one to three-millimeter linear pattern of osteolysis was observed around the entire bone-cement interface of all three glenoid components (Figs. 1-A, 1-B, and 1-C). Two of these glenoids also had a focal or expansile pattern of osteolysis characterized by endosteal erosion. The mean size of the osteolytic lesions, as determined by multiplying the length by the width on the anteroposterior radiograph, was 0.7 square centimeter. One glenoid had osteolytic lesions at more than one site. Two humeri had at least two expansile osteolytic lesions. In one humerus, two lesions with a mean size of 0.6 square centimeter were observed near the tip of the component. A 1.0-square-centimeter lesion was observed in the proximal aspect of the other humerus, in the region of the lateral fin of the prosthesis. Specimens obtained from the vicinity of the osteolytic lesions demonstrated dense fibrous tissue with foci of intense histiocytic infiltration, foreign-body giant cells, and foamy macrophages. No acute inflammatory changes were seen.

At the time of the revision operations, all of the glenoid and humeral components were determined to be loose and were easily removed. The cement was mainly attached to the keel of the glenoid component, although some cement was recovered from the glenoid trough. There was fibrous membrane in the humeral canal, at the proximal aspect of the humerus, and in the glenoid cavity of all shoulders. All of the glenoid components had wear. The margins of the components were worn down and were surrounded by areas of abrasion (Fig. 2). Several areas within the most extensively worn regions appeared to be delaminated and pitted. A full-thickness defect was noted in the articular surface of one glenoid component. No particular findings were noted regarding the humeral components.

Particles of Wear Debris

A total of 582 particles from the three shoulders were analyzed. The results of these analyses were then compared with those of 695 ultra-high molecular weight polyethylene particles retrieved from the tissue around the four hip prostheses. The procedures for isolation and characterization of the particles from the hips were identical to those for the particles from the shoulders. Raman vibrational spectroscopy showed the particles to be ultra-high molecular weight polyethylene. Although not every particle could be analyzed with this technique, none of the analyses of the particles or aggregates suggested the presence of any material other than ultra-high molecular weight polyethylene.

The particles from the shoulders had a mean equivalent circle diameter of 1.04 ± 0.03 micrometers and relatively high mean values for aspect ratio (2.36 ± 0.07) and elongation (4.96 ± 0.23) and correspondingly low mean values for roundness (0.54 ± 0.01) and form factor (0.67 ± 0.01), indicating that they were fibrillar in shape. In contrast, the particles from the hips had a mean equivalent circle diameter of 0.62 ± 0.03 micrometer and were predominantly globular in shape, with low mean values for aspect ratio (1.46 ± 0.02) and elongation (1.85 ± 0.03). They also had relatively high mean values for roundness (0.74 ± 0.01) and form factor (0.87 ± 0.01). Except for outline fractal dimension, all of the descriptors for the particles from the shoulders were significantly different (p < 0.0001) from those for the particles from the hips (Table I). In general, the particles from the shoulders were larger and longer than those from the hips (Figs. 3 and 4).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Several authors have measured the size of ultra-high molecular weight polyethylene particles that have been retrieved from the tissue around total hip prostheses^9,34,45,47. Margevicius et al.³⁴ reported particle diameters ranging from 0.60 to 0.79 micrometer. However, it should be noted that the minimum size limit of detection in their study was 0.58 micrometer. Shanbhag et al.⁴⁸ reported a mean size of 0.53 micrometer for ultra-high molecular weight polyethylene particles that had been retrieved from the tissue around total hip prostheses, and they determined that approximately 92 percent of the particles were less than one micrometer in size. Similarly, Schmalzried et al.⁴⁵ examined ultra-high molecular weight polyethylene particles that had been retrieved from the tissue around twenty-four total hip prostheses and concluded that most of the particles were less than one micrometer in size. The particles from the hips that were used for comparison in the present study had a mean size (equivalent circle diameter) of 0.62 micrometer, which was similar to the sizes reported in the previous studies. Additionally, the particles from the hips in the present study were predominantly globular with low mean values for aspect ratio and elongation. They also had relatively high mean values for roundness and form factor, which is additional evidence of their round or globular shape.

The particles from the shoulders were significantly different. Their mean size (equivalent circle diameter) was 1.04 micrometers. In addition, they had relatively high mean values for aspect ratio and elongation and correspondingly low mean values for roundness and form factor, indicating that they were more fibrillar in nature. However, no significant differences were detected between the outline fractal dimension of the particles from the hips and that of the particles from the shoulders, indicating that the texture or roughness of the surfaces of the particles was similar.

Earlier studies have involved comparisons between ultra-high molecular weight polyethylene particles retrieved from hips and knees^22,47. Schmalzried et al.⁴⁷ reported that the mean area of particles obtained from the tissue around total knee prostheses was twice that of particles from the tissue around total hip prostheses. However, they also determined that ultra-high molecular weight polyethylene particles from the tissue around total knee prostheses were more rounded than those from the tissue around total hip prostheses. In general, they observed a larger variation in the size, shape, and morphology of particles from knees compared with those from hips. This finding is supported by the work of Hirakawa et al.²², who also detected a larger variation in the size of particles from knees. These differences in the size and shape of particles are most likely related to differences in the wear process, as described by McKellop et al.³². This theory is supported by the observation that the relative motion between the metal-polyethylene articulating surfaces in both total shoulder and total knee replacements results in a sliding component while total hip replacements, in general, are more conforming and have a predominantly rolling motion^20,24,27.

In the present study, the ultra-high molecular weight polyethylene particles from the shoulders varied more widely in terms of size and shape than the particles from the hips. This difference was especially obvious with regard to size and roundness (Figs. 5-A and 5-B). Approximately 60 percent of the particles from the shoulders were less than one micrometer in size compared with 90 percent of those from the hips. Also, approximately 56 percent of the particles from the shoulders had a roundness of more than 0.5 compared with almost 97 percent of the particles from the hips. However, it should be noted that the shape and size of particles may vary as a function of the exact site of tissue retrieval in the periprosthetic area.

In summary, we believe that the debris generated by the wear of polyethylene in the shoulders in the present study was associated with progressive periprosthetic osteolysis and subsequent aseptic loosening. The analysis revealed distinct differences between wear particles associated with aseptic loosening of total hip prostheses and those associated with aseptic loosening of total shoulder prostheses. The ultra-high molecular weight polyethylene wear particles isolated from the tissue around the three failed total shoulder replacements were significantly different from those retrieved from the tissue around the failed total hip replacements in terms of both size and morphology. The particles from the shoulders tended to be larger but more fibrillar than those from the hips, suggesting different wear mechanisms. Future in vitro and in vivo studies may further elucidate the mechanisms of wear of the ultra-high molecular weight polyethylene of total shoulder prostheses.

References

Introduction | Materials and Methods | Results | Discussion | References

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FIG2:: Fig. 2 Photograph of the articular surface of a retrieved ultra-high molecular weight polyethylene glenoid component from a patient who had osteolysis of the glenoid.

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FIG3:: Fig. 3 Micrograph of ultra-high molecular weight polyethylene wear debris retrieved from a periprosthetic osteolytic lesion in a shoulder (x 5000).

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FIG4:: Fig. 4 Micrograph of ultra-high molecular weight polyethylene wear debris retrieved at the time of revision of a total hip prosthesis (x 5000).

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TABLE I SIZE AND MORPHOLOGY DESCRIPTORS FOR THE ULTRA-HIGH MOLECULAR WEIGHT POLYETHYLENE PARTICLES*

*The values are given as the mean and the standard error of the mean. †The value is significantly different from the value for the particles from the hip (p < 0.0001).

	Equivalent Circle Diameter (µm)	Aspect Ratio	Elongation	Roundness	Form Factor	Outline Fractal Dimension
Hips	0.62 ± 0.03	1.46 ± 0.02	1.85 ± 0.03	0.74 ± 0.01	0.87 ± 0.01	11.76 ± 0.16
Shoulders	1.04 ± 0.03†	2.36 ± 0.07†	4.96 ± 0.23†	0.54 ± 0.01†	0.67 ± 0.01†	10.94 ± 0.15

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TABLE I SIZE AND MORPHOLOGY DESCRIPTORS FOR THE ULTRA-HIGH MOLECULAR WEIGHT POLYETHYLENE PARTICLES*

*The values are given as the mean and the standard error of the mean. †The value is significantly different from the value for the particles from the hip (p < 0.0001).

	Equivalent Circle Diameter (µm)	Aspect Ratio	Elongation	Roundness	Form Factor	Outline Fractal Dimension
Hips	0.62 ± 0.03	1.46 ± 0.02	1.85 ± 0.03	0.74 ± 0.01	0.87 ± 0.01	11.76 ± 0.16
Shoulders	1.04 ± 0.03†	2.36 ± 0.07†	4.96 ± 0.23†	0.54 ± 0.01†	0.67 ± 0.01†	10.94 ± 0.15