Study design: A clinical case series of 4 patients undergoing anterior lumbar revision due to failure of total disc replacement surgery.
Objectives: To assess the clinical significance of polyethylene wear debris in salvage surgery after initial total disc replacement, the pattern and the mechanisms of polyethylene wear in the retrieved cores, and the extent of polyethylene debris in the periprosthetic tissues obtained from 4 patients.
Summary of background data: Previous in vitro wear tests have demonstrated low wear rates for lumbar artificial discs, suggesting that implant wear may not be a clinically relevant issue with total disc replacement. However, only long-term clinical investigations with analysis of retrieved implants and periprosthetic tissue can ultimately establish the significance of polyethylene wear debris for total disc arthroplasty.
Methods: Starting in 2004, we began routinely performing salvage procedures in patients with failed total disc replacements. We report on the short-term outcomes of 4 patients at our institution who were revised with a Charité prosthesis (DePuy Spine, Raynham, MA). Wear analysis of the retrieved prosthesis and histologic examination of the periprosthetic tissue were also performed.
Results: All of the retrieved polyethylene cores showed evidence of wear, but the extent and severity varied among the 4 patients. Wear and fracture of the core were associated with osteolysis of the underlying sacrum in 1 patient. Histologic examination of the periprosthetic tissues confirmed the presence of wear debris lying in inflammatory fibrous tissue. In 3 of the 4 patients, implant wear was associated with an unfavorable biomechanical environment (e.g., subsidence, migration, undersizing, and adjacent fusion). The mechanisms of wear included adhesive/abrasive wear of the central domed region of the polyethylene core, as well as chronic rim impingement, resulting in rim fatigue and fracture.
Conclusions: This study demonstrates the clinical significance of polyethylene wear debris and the potential for osteolysis with total disc replacements. The authors recommend that patients undergoing lumbar disc arthroplasty receive long-term follow-up to monitor the wear and functional status of their implants.