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Background: The present study aimed to identify risk factors for preoperative nasal carriage of resistant bacteria - MRSA methicillin-resistant Staphylococcus (S.) aureus, MRSE (methicillin-resistant Staphylococcus epidermidis), and MRCNS (methicillin-resistant coagulase negative staphylococci) in total hip and knee arthroplasty (THA and TKA) patients., Methods: Nasal cultures were obtained from 538 patients before THA (262 primary and 26 revision) and TKA (241 primary and 9 revision). These were classified either as methicillin-resistant bacteria (group MR) or methicillin-susceptible bacteria (including culture-negative) (group MS). Patient characteristics were compared between these groups using logistic regression models., Results: The resistant bacteria were preoperatively present in 33.1% (178 patients) among all patients. MRSE, MRCNS, and MRSA were detected in 27.5% (148 patients), 3.7% (20 patients), and 1.9% (10 patients). In the unadjusted comparisons of the patient characteristics between the groups MR and MS, a significant difference was found in the percentages of diabetic patients (15.2% vs. 9.2%, P = 0.04); the association remained after the multivariable adjustment for possible risk factors (P < 0.001). In addition, the diabetic patients in the group MR showed a higher percentage of receiving insulin injection than those in the group MS (25.9% vs. 6.1%, P = 0.063), and their mean levels of HbA1c were significantly higher in the group MR than the MS (6.8% vs. 6.4%, P = 0.03)., Conclusions: We identified diabetes as a risk factor for the preoperative nasal carriage of resistant bacteria. Our results suggest that, in order to prevent a surgical site infection (SSI), extra care should be taken in performing joint arthroplasties for diabetic patients, especially using insulin and with high HbA1c levels (≥6.6%) prior to the surgical procedures., Competing Interests: Declaration of competing interest The authors have no conflict of interest to declare., (Copyright © 2021 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Anterior cruciate ligament (ACL) plays an essential role in knee joint stability and kinematics. The microstructural irregularities such as cellular changes and disorganization of the extracellular matrix (ECM) alter the mechanical properties of the ligament, leading to a significant knee functional instability and progression of osteoarthritis (OA). So far, the identification of the local abnormality in ACL has routinely relied on invasive analytical techniques such as histology or biochemical assays. The non-invasive diagnosis using magnetic resonance imaging (MRI) is still limited to identifying the presence/absence of partial/complete ruptures and mucoid degeneration. In this study, laser micro-Raman spectroscopy with near-infrared excitation (785 nm) was applied to human ACL in order to establish optical algorithms for non-destructively diagnosing a degeneration state at molecular level. Raman spectra were obtained from 44 ex-vivo ACL specimens, and these were subsequently classified as an early (subclinical) and advanced (clinical) level of tissue degradation based on the histopathological scoring system. The significant differences in Raman peak intensities were found between the different degeneration groups, which were assigned to the vibrational modes of nucleic acids in cells, collagens, and phospholipids. Linear discriminant analysis (LDA) was performed to identify cut-off values for the distributions of Raman intensity and intensity ratios, which enable to best discriminate between the early and advanced degenerated tissues. Raman intensity algorithms derived from I 1101 /I 1749 , [I 1002 /I 1516 vs. I 1101 /I 1749 ], and [I 1002 /I 1749 vs. I 1101 /I 1749 ], yielded a maximum diagnostic sensitivity of 100%, specificity of 80%, and accuracy of 91% for discriminating the degeneration severity. STATEMENT OF SIGNIFICANCE: In this study, laser micro-Raman spectroscopy was applied to human anterior cruciate ligament (ACL) to establish optical algorithms for non-destructively diagnosing the tissue degeneration at molecular level. To our knowledge, this is the first report on Raman diagnosis for human ACL. Linear discriminant analysis (LDA) was performed to identify cut-off values for Raman intensity and intensity ratios, which enable to best discriminate between an early (subclinical) and advanced (clinical) level of ACL degeneration. The intensity ratios of I 1101 /I 1749 , [I 1002 /I 1516 vs. I 1101 /I 1749 ], and [I 1002 /I 1749 vs. I 1101 /I 1749 ] yielded a maximum diagnostic sensitivity of 100%, specificity of 80%, and accuracy of 91% for discriminating the ACL degeneration. The present findings might contribute to expanding clinical diagnostic possibilities for non-invasively identifying tissue degeneration., (Copyright © 2019 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Morphology and design of ultra-high molecular weight polyethylene (UHMWPE or simply PE) acetabular components used in total hip arthroplasty (THA) have been evolving for more than half a century. Since the late-1990s, there were two major technological innovations in PE emerged from necessity to overcome the wear-induced periprosthetic osteolysis, i.e., the development of highly crosslinked PEs (HXLPEs). There are many literature reporting that radiation crosslinked and remelted/annealed (first-generation) HXLPEs markedly reduced the incidence of osteolysis and aseptic loosening. Regardless of such clinical success in the first-generation technologies, there were some recent shifts in Japan toward the use of new second-generation HXLPEs subjected to sequential irradiation/annealing or antioxidant vitamin E (α-tocopherol) incorporation. Although the selection rate of first-generation liners still account for more than half of all the PE THAs (∼58% in 2015), the use of vitamin E-stabilized liners has been steadily growing each year since their clinical introduction in 2010. In these contexts, it is of great importance to evaluate and understand the real clinical benefits of using the new second-generation liners as compared to the first generation. This article first summarizes structural evolution and characteristic features of first-generation HXLPEs, and then provides a detailed description of second-generation antioxidant HXLPEs in regard to the role of vitamin E incorporation on their chemical and mechanical performances in THA., (Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: The aim of the present study is to simulate and better understand the long-term interplay between alumina matrix composite (AMC) femoral head and aqueous environment. In particular, we focused on clarifying the role of alumina grains on zirconia phase stability and mechanical equilibrium in AMC head during aging processes in a clinically-relevant time frame., Methods: The tested AMC head consists of an alumina matrix (82 vol.%) reinforced by yttria-stabilized zirconia (17 vol.%), chromium oxide (0.5 vol.%), and strontium aluminate (0.5 vol.%). The accelerated hydrothermal aging testing (at 134 °C, 2-bars pressure) was conducted up to 20 h. According to ASTM standard, 1-h aging under these conditions corresponds approximately to 2 yrs in vivo exposure. Confocal Raman and fluorescence spectroscopy were applied to quantify surface tetragonal-to-monoclinic phase transformation of zirconia and surface stresses in the AMC head. The Mehl-Avrami-Johnson (MAJ) theory was applied, which allowed modeling the micromechanisms of nucleation and growth of monoclinic sites during the transformation process. The obtained results were compared to those of monolithic zirconia (3Y-TZP) femoral heads., Results: The 3Y-TZP head showed a rapid increase of transformation rate beyond the aging time of 5 h (simulated as ∼10 yrs in vivo), suggesting the initiation of the transformation cascade toward the neighboring zirconia grains (growth mechanism). On the other hand, MAJ analysis revealed that the growth mechanism was completely absent and the nucleation of the monoclinic phase was partially prevented in the AMC head even after the 20-h aging (∼40 yrs in vivo). In addition, the stress accumulation in the AMC head was restricted at a quite low level throughout the aging simulation., Conclusion: Those results suggest that the presence of stable and hard alumina in the AMC can play a considerable role in slowing down the destabilization processes by spatially encompassing zirconia grains., (Copyright © 2017 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

The in-vivo progression of creep and wear in ultra-high molecular weight polyethylene (UHMWPE) acetabular liners has been clinically evaluated by measuring radiographic penetration of femoral heads. In such clinical assessments, however, viscoelastic strain relaxation has been rarely considered after a removal of hip joint loading, potentially leading to an underestimation of the penetrated thickness. The objective of this study was to investigate shape-recovery behavior of pre-compressed, radiation crosslinked and antioxidant vitamin E-diffused UHMWPE acetabular liners, and also to characterize the effects of varying their internal diameter (ID) and wall thickness (WT). We applied uniaxial compression to the UHMWPE specimens of various ID (28, 32, 36mm) and WT (4.8, 6.8, 8.9mm) for 4320min under the constant load of 3000N, and subsequently monitored the strain-relaxation behavior as a function of time after unloading. It was observed that there was a considerable shape recovery of the components after removal of the external static load. Reducing ID and WT significantly accelerated the rate of creep strain recovery, and varying WT was more sensitive to the recovery behavior than ID. Creep deformation of the tested liners recovered mostly within the first 300min after unloading. Note that approximately half of the total recovery amount proceeded just within 5min after unloading. These results suggest a remarkably high capability of shape recovery of vitamin E-diffused highly crosslinked UHMWPE. In conclusion, the time-dependent shape recovering and the diameter-thickness effect on its behavior should be carefully considered when the postoperative penetration is quantified in highly crosslinked UHMWPE acetabular liners (especially on the non-weight bearing radiographs)., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Since the early 2000s, the use of large femoral heads is becoming increasingly popular in total hip arthroplasty (THA), which provides an improved range of motion and joint stability. Large femoral heads commonly necessitate to be coupled with thinner acetabular liners than the conventionally used because of the limited sizes of outer shells (especially for patients with small pelvic size). However, the influence of the liner thinning on the mechanical performance is still not clearly understood. The objective of this study was to experimentally clarify the size and thickness effect on the rates of compressive creep strain in conventional (virgin low-crosslinked) and vitamin E-diffused highly crosslinked, ultra-high molecular weight polyethylene (UHMWPE) acetabular liners. We applied uniaxial compression to these liners of various internal diameters (28, 32 and 36mm) and thicknesses (4.8, 6.8 and 8.9mm) up to 4320min under the constant load of 3000N. Vitamin E-diffused highly crosslinked UHMWPE components showed significantly greater creep resistance than the conventional ones. In the both types of UHMWPE, the rates of creep strain significantly decreased by increasing the internal diameter and thickness. Varying the component thickness contributed more largely to the creep behavior rather than the internal diameter. Our results suggest the positive mechanical advantage of using large femoral heads, but at the same time, a considerable liner thinning is not recommended for minimizing creep strain. Therefore, the further in-vitro as well as in-vivo research are necessary to conclude the optimal balance of head diameter and liner thickness within the limited sizes of outer shells., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The molecular mobility and crystalline texture development in highly crosslinked ultrahigh molecular weight polyethylene (HXL-UHMWPE) blended with antioxidant vitamin E (VE, dl-α-tocopherol) were studied via uniaxial compression at room temperature by means of confocal/polarized Raman spectroscopy. The results were compared to morphological analyses under the same compression conditions performed on HXL-UHMWPE prepared in exactly the same way but blending VE into the polyethylene resin (VE-free HXL-UHMWPE). These comparative analyses allow us to evaluate the physical role of VE in morphological alterations of HXL-UHMWPE induced by compression deformation, which can greatly affect its micromechanical behavior. Molecular rearrangement and phase transitions in crystalline and non-crystalline phase, i.e. amorphous and intermediate (third) phase, were found to be part of a reconstruction process after plastic deformation in the samples. Although VE-blended HXL-UHMWPE exhibited more pronounced molecular mobility, as evidenced by its significant deformation-induced texturing, crystallinity change was totally inhibited by the presence of VE during deformation. On the other hand, amorphous-to-intermediate phase transition was confirmed. VE-free HXL-UHMWPE also presented significant crystallization after deformation, but its surface texture evolution occurred to a much lesser extent. This study suggests that the addition of VE induced earlier activation of compression deformation modes in crystalline and non-crystalline phases (e.g. chain slip, interlamellar shear and rotation) due to an increase in polyethylene chain mobility., (Copyright © 2015 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Plastic deformation is an unavoidable event in biomedical polymeric implants for load-bearing application during long-term in-vivo service life, which involves a mass transfer process, irreversible chain motion, and molecular reorganization. Deformation-induced microstructural alterations greatly affect mechanical properties and durability of implant devices. The present research focused on evaluating, from a molecular physics viewpoint, the impact of externally applied strain (or stress) in ultra-high molecular weight polyethylene (UHMWPE) prostheses, subjected to radiation cross-linking and subsequent remelting for application in total hip arthroplasty (THA). Two different types of commercial acetabular liners, which belong to the first-generation highly cross-linked UHMWPE (HXLPE), were investigated by means of confocal/polarized Raman microprobe spectroscopy. The amount of crystalline region and the spatial distribution of molecular chain orientation were quantitatively analyzed according to a combined theory including Raman selection rules for the polyethylene orthorhombic structure and the orientation distribution function (ODF) statistical approach. The structurally important finding was that pronounced recrystallization and molecular reorientation increasingly appeared in the near-surface regions of HXLPE liners with increasing the amount of plastic (compressive) deformation stored in the microstructure. Such molecular rearrangements, occurred in response to external strains, locally increase surface cross-shear (CS) stresses, which in turn trigger microscopic wear processes in HXLPE acetabular liners. Thus, on the basis of the results obtained at the molecular scale, we emphasize here the importance of minimizing the development of irrecoverable deformation strain in order to retain the pristine and intrinsically high wear performance of HXLPE components., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Vitamin-E (α-tocopherol) is now recognized worldwide as one of the most promising antioxidant agents for highly cross-linked polyethylene (HXLPE) used in total joint replacements. In the contemporary manufacturing processes, two alternative methods are currently accepted to incorporate this antioxidant into polyethylene microstructure: (i) blending vitamin-E before consolidation and radiation crosslinking; (ii) infusing vitamin-E via a homogenizing heat treatment after radiation crosslinking. However, the effects of these technological differences on crystalline morphology and mechanical behavior of polyethylene remains to be fully elucidated. The aim of this paper is to quantitatively evaluate the microstructural differences of commercially available vitamin-E blended and infused HXLPE liner (referred to as Liner BL and IF, respectively). For this purpose, confocal/polarized Raman spectroscopy was used to systematically examine the three-phase percentages (amorphous (αa), crystalline (αc), and intermediate third phase (αt)), preferential molecular orientation (θp), and degree of crystalline anisotropy (〈P2(cosβ)〉). Additionally, we compared the time-dependent deformation of Liner BL and IF as obtained by uniaxial stress relaxation tests followed by strain recovery. Distinctive features of the near-surface αc, θp, and〈P2(cosβ)〉 were clearly observed within the first 35μm in the two studied liners. Despite the equivalent level of the bulk αc and 〈P2(cosβ)〉, higher restoring force against a uniaxial strain was observed in Liner IF, which reflects a higher crosslink density in its amorphous phase. On the other hands, a higher degree of surface orientational randomness was detected in Liner BL, which is structurally more beneficial for minimizing the in-vivo occurrence of strain-softening-assisted wear., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Fluorescence microprobe spectroscopy was applied to in situ assessments of contact stress and local temperature at the contact point of dry-sliding couples during wear tests of two commercially available ceramic-on-ceramic femoral heads. The investigated ceramic hip implants consisted of either monolithic Al2O3 or Al2O3/ZrO2 composite. A specially designed pin-on-ball tribometer was employed, which enabled directly testing the femoral head components as received from the maker without further manipulation. The strong fluorescence emission from Cr(3+) impurities contained in Al2O3 served as a responsive sensor for both temperature and stress. Analytical corrections for the averaging effects arising from the finite size of the laser probe were made according to a probe response formalism in which geometrical conditions of the sliding couple were incorporated as boundary conditions. The sample-probe interaction at the contact point was then experimentally calibrated by obtaining probe response functions for the two materials investigated. Based on such theoretical and experimental procedures, deconvolutive computational routines could be set up and the true variations of local temperature and stress at the contact point of the bearing surfaces retrieved from the observed time-dependent broadening and shift of a selected spectral band, respectively. The main result of the in situ investigation was that the monolithic sliding couple showed both significantly lower temperature and lower magnitude of compressive stress at the contact point as compared to the composite one, although the composite couple wore at a significantly lower specific wear rate than the monolithic one., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Infusion of vitamin E (α-tocopherol) in highly crosslinked ultra-high molecular weight polyethylene (UHMWPE) liners has been conceived to achieve superior oxidation stability while preserving enhanced mechanical properties as compared to post-irradiation remelted liners. However, the presence of an antioxidant in the material microstructure brings an issue of concern in whether a "foreign substance" might reduce radiation crosslinking efficiency and/or change microstructural characteristics by diffusing into UHMWPE. The key to clarify this fundamental issue resides in performing a quantitative evaluation of the obtained material structure and its polymeric chain mobility on the molecular scale. In this paper, a Raman spectroscopic examination is presented of molecular orientation and phase fractions in as-processed vitamin E-infused UHMWPE acetabular liners in comparison with a model (undoped and unirradiated/uncrosslinked) and a conventional (undoped and 33kGy-sterilized by gamma-irradiation) UHMWPE liners. The microstructural responses of structurally different liners to externally applied compressive strain were also monitored. The main results of the spectroscopic analyses can be summarized as follows: (i) preliminary gamma irradiation reduced the fraction of amorphous phase and increased the degree of molecular alignment, the vitamin E-infused liner preserving the crystallinity level achieved by the 100-kGy irradiation injected before infusion; (ii) the presence of vitamin E significantly promoted orientational randomness, which increased with increasing compressive strain magnitude, a phenomenon beneficial to minimize strain-softening-assisted wear phenomena., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

The mechanisms leading to systematic failure in modular acetabular components with a sandwich insertion (alumina/polyethylene/titanium) have been reconsidered in light of the newly collected Raman spectroscopic results. Raman assessments were conducted on the polyethylene shells, which belonged to a series of six failed sandwich implants with in vivo lifetimes ranging between 2 and 9yr. With only one exception, all implants commonly showed dislodgment of the polyethylene shell during radiographic analyses prior to revision surgery. The polyethylene shell slipped out of the backing titanium shell, while always remaining integer to the ceramic liner. Four implants fractured at the ceramic liners, but their fractures occurred according to distinctly different patterns, which could be rationalized and classified. The insertion of the polyethylene layer, originally conceived to reduce the rigidity of the ceramic-on-ceramic bearing and to prevent impingement between the ceramic liner rim and the femoral neck, played a role in implant failure with its initial (asymmetric) thickness reduction due to creep deformation (eventually followed by cup rotation and backside wear). The results of the present spectroscopic investigation suggest that a simplistic failure classification of the sandwich-type implant as a "ceramic fracture failure" could be misleading and might represent a confounding factor in judging about the reliability of modern ceramic implants., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

A preliminary investigation into the diagnostic potential of Raman spectroscopy for assessing pathological articular cartilage was conducted. Five arthritic human tibial cartilages retrieved after total knee arthroplasty were examined using near-infrared (NIR) Raman spectroscopy excited with 647.1nm lines of a Kr-ion laser. A "healthy" cartilage obtained from cadaver donor was also examined as a control sample. Degradation severity was first visually classified into five grades (Grade 0-VI) on the surface of both medial and lateral zones in each tibial plateau, according to the Collins scale. Raman spectra were then collected from selected zones with different damage severity. A systematic increase in relative intensity ratio between the Raman bands located at 1241 and 1269cm(-1) (amide III doublet) was observed with increasing degradation grades, which could be related to structural changes under loading in type II collagen. This finding suggests that the present spectroscopic approach might be useful for recognizing and quantitatively assessing the degree of osteoarthritis (OA) in its early manifestation stage., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

We have visualized at the nanometer scale the topological, chemical and mechanical characteristics of long-term in vivo exposed bearing surfaces of femoral heads made of monolithic alumina. Four self-mated alumina retrievals were studied, which were exposed in the human body for relatively long periods of time ranging between 7.7 and 10.7 yrs. Besides conventional morphological features, monitored by atomic force microscopy, the topographic distributions of point defects and lattice strain on the surface of the heads were systematically probed by collecting high spatially and spectrally resolved cathodoluminescence spectra from zones of different wear severity. Three types of optically active point-defect site could be detected: (i) oxygen vacancies; (ii) substitutional (aliovalent) cations; and, (iii) interstitial aluminum cations. These luminescent sites represent the main defects progressively developed in the alumina lattice during exposure in human hip joints. A clear evolution toward (environmentally driven) off-stoichiometry was found with progressing wear. Moreover, the shallow electro-stimulated optical probe also detailed the presence of lattice strain fields (of both elastic and plastic nature) stored in the very neighborhood of the bearing surface. The present spectroscopic characterizations enable substantiating important tribochemical interactions between bearing surfaces and in vivo environment as pivotal parts of progressive events of wear degradation., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The response to applied strain of EtO-sterilized and γ-irradiated polyethylene materials belonging to tibial inserts has been studied by polarized Raman spectroscopy. Initial calibrations on as-received samples from three different makers were employed to clarify the rearrangement of molecular chains under strain, expressed in terms of Euler angular displacements in space and orientation distribution functions. This body of information was then applied to a quantitative analysis of four tibial inserts (from the same three makers of the unused samples) retrieved after in vivo exposures ranging between 7 months and 5 years 8 months. The main results of the Raman analysis can be summarized as follows: (i) γ-irradiated samples experienced lower texturing on the molecular scale compared to EtO-sterilized samples, likely due to a higher strain recovery capability; and (ii) independent of sterilization method, the amount of plastic strain was mainly developed early after in vivo implantation, whereby out-of-plane molecules rotated under load onto planes parallel to the sample surface until saturation of angular displacements was reached., (Copyright © 2010 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

The angular dependences of the polarized Raman intensity of A(g), B(1g), B(2g), and B(3g) modes have been preliminary investigated on a model fiber sample of ultra-high molecular weight polyethylene (UHMWPE) in order to retrieve the Raman tensor elements, i.e. the intrinsic parameters governing the vibrational behavior of the orthorhombic structure of polyethylene. Based on this Raman analysis, a method is proposed for determining unknown crystallographic orientation patterns in UHMWPE biomedical components concurrently with the orientation distribution functions for orthorhombic lamellae. An application of the method is shown, in which we quantitatively examined the molecular orientation patterns developed on the surface of four in vivo exposed UHMWPE acetabular cups vs. an unused cup. Interesting findings were: (i) a clear bimodal distribution of orientation angles was observed on worn surfaces; and (ii) a definite and systematic increase in both molecular orientation and crystallinity in main wear zones vs. non-wear zones was found in all retrieved acetabular cups. The present crystallographic analysis is an extension of our previous Raman studies of UHMWPE acetabular cups related to assessments of oxidation and residual strain and suggests a viable path to track back wear-history information from the surface of UHMWPE, thus unfolding the in vivo kinematics of the bearing surfaces in hip joints on the microscopic scale., (2010 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)