Retrieval analysis of contemporary antioxidant polyethylene: multiple material and design changes may decrease implant performance

  • Arianna CerquigliniEmail author
  • Johann Henckel
  • Harry Hothi
  • Lukas B. Moser
  • Antti Eskelinen
  • Michael T. Hirschmann
  • Alister J. Hart



With the introduction of the Attune Knee System (DePuy) in March 2013, a new polyethylene formulation incorporating anti-oxidants was used. Although several in vitro studies have demonstrated the positive effects of antioxidants on UHMWPE, no retrieval study has looked at polyethylene damage of this system yet. It was the aim of this study to investigate the in vivo performance of this new design, by comparing it with its predecessors in retrieval analysis.


24 PFC (18 fixed bearing and 6 rotating platform designs) and 17 Attune (8 fixed bearing and 9 rotating platform designs) implants were retrieved. For retrieval analysis, a macroscopic analysis of polyethylene components, using a peer-reviewed damage grading method was used. Medio-lateral polyethylene thickness difference was measured with a peer-reviewed micro-CT based method. The roughness of metal components was measured. All findings were compared between the two designs.


Attune tibial inserts with fixed bearings showed significantly higher hood scores on the backside surface when compared with their PFC counterparts (p = 0.01), no other significant differences were found in the polyethylene damage of all the other surfaces analysed, in the surface roughness of metal components and in medio-lateral linear deformations.


A significant difference between PFC and Attune fixed bearing designs was found in terms of backside surface damage: multiple changes in material and design features could lead to a potential decrease of implant performance. Results from the present study may help to understand how the new Attune Knee System performs in vivo, impacting over 600,000 patients.


Total knee arthroplasty Polyethylene Retrieval analysis Polyethylene surface damage Polyethylene linear deformation 



There is no direct funding for this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All investigations were conducted in conformity with ethical principles of research and that institutional approval of the human protocol for this investigation was obtained.

Informed consent

Informed consent for participation in the study was obtained.


  1. 1.
    Affatato S, Bracco P, Costa L, Villa T, Quaglini V, Toni A (2012) In vitro wear performance of standard, crosslinked, and vitamin-E-blended UHMWPE. J Biomed Mater Res Part A 100 A:554–560CrossRefGoogle Scholar
  2. 2.
    Berry DJ, Currier JH, Mayor MB, Collier JP (2012) Knee wear measured in retrievals: a polished tray reduces insert wear. Clin Orthop Relat Res 470:1860–1868CrossRefGoogle Scholar
  3. 3.
    Bracco P, Oral E (2011) Vitamin E-stabilized UHMWPE for total joint implants: a review. Clin Orthop Relat Res 469:2286–2293CrossRefGoogle Scholar
  4. 4.
    Cerquiglini A, Henckel J, Hothi HS, Dall’Ava L, Shearing P, Hirschmann MT, Hart AJ (2018) Computed tomography techniques help understand wear patterns in retrieved total knee arthroplasty. J Arthroplasty 33:3030-3037CrossRefGoogle Scholar
  5. 5.
    Chakrabarty G, Vashishtha M, Leeder D (2015) Polyethylene in knee arthroplasty: a review. J Clin Orthop Trauma Elsevier Ltd 6:108–112CrossRefGoogle Scholar
  6. 6.
    Chen Y, Hallab NJ, Liao YS, Narayan V, Schwarz EM, Xie C (2016) Antioxidant impregnated ultra-high molecular weight polyethylene wear debris particles display increased bone remodeling and a superior osteogenic:osteolytic profile vs. conventional UHMWPE particles in a murine calvaria model. J Orthop Res 34:845–851CrossRefGoogle Scholar
  7. 7.
    Currier BH, Currier JH, Holdcroft LA, Van Citters DW (2018) Effectiveness of anti-oxidant polyethylene: what early retrievals can tell us. J Biomed Mater Res Part B Appl Biomater 106:353–359CrossRefGoogle Scholar
  8. 8.
    Currier BH, Currier JH, Mayor MB, Lyford KA, Van Citters DW, Collier JP (2007) In vivo oxidation of gamma-barrier-sterilized ultra-high-molecular-weight polyethylene bearings. J Arthroplasty 22:721–731CrossRefGoogle Scholar
  9. 9. (2019) SIGMA® Total Knee System. DePuy Synthes Companies. Accessed 6 Feb 2019
  10. 10.
    Dumbleton JH, D’Antonio JA, Manley MT, Capello WN, Wang A (2006) The basis for a second-generation highly cross-linked UHMWPE. Clin Orthop Relat Res 453:265–271CrossRefGoogle Scholar
  11. 11.
    Grupp TM, Fritz B, Kutzner I, Schilling C, Bergmann G, Schwiesau J (2017) Vitamin E stabilised polyethylene for total knee arthroplasty evaluated under highly demanding activities wear simulation. Acta Biomater Acta Materialia Inc 48:415–422CrossRefGoogle Scholar
  12. 12.
    Haider H, Weisenburger JN, Kurtz SM, Rimnac CM, Freedman J, Schroeder DW, Garvin KL (2012) Does vitamin e-stabilized ultrahigh-molecular-weight polyethylene address concerns of cross-linked polyethylene in total knee. Arthroplasty? J Arthroplasty 27:461–469CrossRefGoogle Scholar
  13. 13.
    Hood RW, Wright TM, Burstein AH (1983) Retrieval analysis of total knee prostheses: a method and its application to 48 total condylar prostheses. J Biomed Mater Res 17:829–842CrossRefGoogle Scholar
  14. 14.
    Jahan MS, King MC, Haggard WO, Sevo KL, Parr JE (2001) A study of long-lived free radicals in gamma-irradiated medical grade polyethylene. Radiat Phys Chem 62:141–144CrossRefGoogle Scholar
  15. 15.
    Kashiwabara H, Shimada S, Hori Y (1991) Free radicals and crosslinking in irradiated polyethylene. Int J Radiat Appl Instrum Part 37:43–46Google Scholar
  16. 16.
    Knowlton CB, Bhutani P, Wimmer MA (2017) Relationship of surface damage appearance and volumetric wear in retrieved TKR polyethylene liners. J Biomed Mater Res Part B Appl Biomater 105:2053–2059CrossRefGoogle Scholar
  17. 17.
    Kurtz SM, Dumbleton J, Siskey RS, Wang A, Manley M (2009) Trace concentrations of vitamin E protect radiation crosslinked UHMWPE from oxidative degradation. J Biomed Mater Res Part A 90:549–563CrossRefGoogle Scholar
  18. 18.
    McCalden RW, MacDonald SJ, Rorabeck CH, Bourne RB, Chess DG, Charron KD (2009) Wear rate of highly cross-linked polyethylene in total hip arthroplasty. J Bone Joint Surg 91:773–782CrossRefGoogle Scholar
  19. 19.
    McKellop H, Shen F, Lu B, Campbell P, Salovey R (1999) Development of an extremely wear-resistant ultra high molecular weight polythylene for total hip replacements. J Orthop Res 17:157–167CrossRefGoogle Scholar
  20. 20.
    Medel FJ, Peña P, Cegoñino J, Gomez-Barrena E, Puértolas JA (2007) Comparative fatigue behavior and toughness of remelted and annealed highly crosslinked polyethylenes. J Biomed Mater Res Part B Appl Biomater 83:380–390CrossRefGoogle Scholar
  21. 21.
    Micheli BR, Wannomae KK, Lozynsky AJ, Christensen SD, Muratoglu OK (2012) Knee Simulator wear of vitamin e stabilized irradiated ultrahigh molecular weight polyethylene. J Arthroplasty 27:95–104CrossRefGoogle Scholar
  22. 22.
    National Joint Registry (2017) 2017 14th annual report—national joint registry for England, Wales, Northern Ireland and the Isle of Man, vol. 1821, pp 1–202Google Scholar
  23. 23.
    Rao AR, Engh GA, Collier MB, Lounici S (2002) Tibial interface wear in retrieved total knee components and correlations with modular insert motion. J Bone Jt Surg Ser A 84:1849–1855CrossRefGoogle Scholar
  24. 24.
    Sakellariou VI, Sculco P, Poultsides L, Wright T, Sculco TP (2013) Highly cross-linked polyethylene may not have an advantage in total knee arthroplasty. HSS J 9:264–269CrossRefGoogle Scholar
  25. 25.
    Wright T, Goodman S (2000) What material properties and manufacturing procedures influence wear mechanisms? Implant Wear Total Jt Replace Clin Biol Issues Mater Des Considerations :186–192Google Scholar
  26. 26.
    Wu JJ, Augustine A, Holland JP, Deehan DJ (2012) Oxidation and fusion defects synergistically accelerate polyethylene failure in knee replacement. Knee 19:124–129CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  • Arianna Cerquiglini
    • 1
    Email author
  • Johann Henckel
    • 1
  • Harry Hothi
    • 1
  • Lukas B. Moser
    • 2
    • 3
  • Antti Eskelinen
    • 4
  • Michael T. Hirschmann
    • 2
    • 3
  • Alister J. Hart
    • 1
  1. 1.Institute of Orthopaedics and Musculoskeletal ScienceUniversity College London, Royal National Orthopaedic HospitalStanmoreUK
  2. 2.Department of Orthopaedic Surgery and TraumatologyKantonsspital Baselland (Bruderholz, Liestal, Laufen)BruderholzSwitzerland
  3. 3.University of BaselBaselSwitzerland
  4. 4.The Coxa Hospital for Joint ReplacementTampereFinland

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