The Journal of Arthroplasty, Volume 33, Issue 4, 1235 - 1241

Oxidation, Damage Mechanisms, and Reasons for Revision of Sequentially Annealed Highly Crosslinked Polyethylene in Total Knee Arthroplasty

MacDonald, Daniel W. et al.


Sequentially annealed, highly crosslinked polyethylene (HXLPE) has been used clinically in total knee arthroplasty (TKA) for over a decade. However, little is known about the revision reasons; its surface damage mechanisms; or its in vivo oxidative stability relative to conventional polyethylene. We asked whether retrieved HLXPE tibial inserts exhibited: (1) similar revision reasons; (2) improved resistance to surface damage; and (3) improved oxidative stability, when compared with conventional gamma inert sterilized polyethylene inserts.


A total of 456 revised tibial inserts were collected in a multicenter retrieval program between 2000 and 2016. The implantation time for the HXLPE components was 1.8 ± 1.8 years, and for the control inserts it was 3.4 ± 2.7 years. Revision reasons were assessed based on medical records, radiographs, and examinations of the retrieved components. Surface damage was assessed using a semi-quantitative scoring method. Oxidation was measured using Fourier transform infrared spectroscopy.


The tibial inserts in both cohorts were revised most frequently for loosening, infection, and instability. The most commonly observed surface damage modes were burnishing, pitting, and scratching. Oxidation of the HXLPE inserts was, on average, low and similar to the control inserts at the bearing surface and the stabilizing post.


We observed evidence of in vivo oxidation in both HXLPE and control tibial inserts. We found no association between the levels of oxidation and the clinical performance of the HXLPE tibial components. The findings of this study document the revision reasons, surface damage modes, and oxidative behavior of sequentially annealed HXLPE for TKA.

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