Current Total Knee Designs: Does Baseplate Roughness or Locking Mechanism Design Affect Polyethylene Backside Wear?
Clinical Orthopaedics and Related Research
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© 2017, The Association of Bone and Joint Surgeons®. Background: Tibial baseplate roughness and polyethylene-insert micromotion resulting from locking-mechanism loosening can lead to polyethylene backside wear in TKAs. However, many retrieval studies examining these variables have evaluated only older TKA implant designs. Questions: We used implant-retrieval analysis to examine if there were differences in: (1) backside damage scores, (2) backside damage modes, and (3) backside linear wear rates in five TKA implant designs owing to differing baseplate surface roughness and locking mechanisms. Additionally, we examined if (4) patient demographics influence backside damage and wear. Methods: Five TKA implant models (four modern and one historical design) were selected with different tibial baseplate and/or locking mechanism designs. Six tibial inserts retrieved at the time of revision from each TKA model were matched for time in vivo, age of the patient at TKA revision, BMI, sex, revision number, and revision reason. Each insert backside was analyzed for: (1) visual total damage score and (2) individual visual damage modes, both by two observers and with an intraclass correlation coefficient of 0.66 (95% CI, 0.39–0.92), and (3) linear wear rate measured by micro-CT. Median primary outcomes were compared among the five designs. For our given sample size among five groups we could detect with 80% power a 10-point difference in damage score and an 0.11-mm per year difference in wear rate. Results: The polished tibial design with a partial peripheral capture locking mechanism and anterior constraint showed a lower total damage score compared with the nonpolished tibial design with only a complete peripheral-rim locking mechanism (median, 12.5; range, 9.5–18.0; 95% CI, 9.58–16.42 versus median, 22.3; range, 15.5–27.0; 95% CI, 17.5–26.5; p = 0.019). The polished baseplate with a tongue-in-groove locking mechanism showed more abrasions than the nonpolished baseplate with a peripheral-rim capture and antirotational island (median, 7.25; range, 0.5–8.0; 95% CI, 2.67–8.99 versus median, 0.75; range, 0–1.5; 95% CI, 0.20–1.47; p = 0.016)). Dimpling was a unique wear mode to the nonpolished baseplates with the peripheral-rim capture and antirotational island (median, 5.5; range, 2.0–9.0; 95% CI, 2.96–8.38) and the peripheral-rim capture alone (median, 9.0; range, 6.0–10.0; 95% CI, 7.29–10.38). Overall, the linear wear rate for polished designs was lower than for nonpolished designs (0.0102 ± 0.0044 mm/year versus 0.0224 ± 0.0119 mm/year; p < 0.001). Two of the polished baseplate designs, the partial peripheral capture with anterior constraint (median, 0.083 mm/year; range, 0.0037–0.0111 mm/year; 95% CI, 0.0050–0.0107 mm versus median, 0.0245 mm/year; range, 0.014–0.046 mm/year; 95% CI, 0.0130–0.0414 mm; p = 0.008) and the tongue-in-groove locking mechanism (median, 0.0085 mm/year; range, 0.005–0.015 mm/year; 95% CI, 0.0045–0.0138 mm; p = 0.032) showed lower polyethylene linear wear rates compared with the nonpolished baseplate design with only a peripheral-rim capture. Conclusions: Total damage scores and linear wear rates were highest involving the nonpolished design with only a peripheral rim capture. There were no differences among the other TKA designs regarding damage and wear, but this finding should be considered in the setting of a relatively small sample size. Clinical Relevance: Our study showed that in the complex interplay between baseplate surface finish and locking mechanism design, a polished baseplate with a robust locking mechanism had the lowest backside damage and linear wear. However, improvements in locking mechanism design in nonpolished baseplates potentially may offset some advantages of a polished baseplate. Further retrieval analyses need to be done to confirm such findings, especially analyzing current crosslinked polyethylene. Additionally, we need mid- and long-term studies comparing TKA revisions attributable to wear and osteolysis among implants before understanding if such design differences are clinically relevant.