UHMWPE for arthroplasty: past or future?

Wear debris related osteolysis is recognised as being the main cause of failure in joint replacements based on UHMWPE inserts. However, many solutions and "new" polyethylenes have been suggested in order to address this issue. This review discusses "historical" issues associated with UHMWPE, such as oxidation, sterilization method and storage, as well as "new" topics, such as crosslinking and stabilization. The final aim is to aid orthopaedic surgeons in their selection of polyethylene inserts and in the information given to the patients. The main problem for the polymer is degradative oxidation, which is caused by the combination of the irradiation used for sterilization and oxygen, and which leads to a decrease in wear resistance and mechanical properties. Irradiation and packaging in the absence of oxygen can only reduce the oxidation, while sterilization with gas (EtO or gas plasma) is the only method that effectively eliminates it. Manufacturing processes are of great relevance to the clinical duration and must be considered by surgeons. Crosslinked polyethylene has been developed for joint inserts due to its superior wear resistance compared to conventional UHMWPE; to prevent the oxidation, crosslinked polyethylene requires post-irradiation thermal treatment, which reduces its mechanical properties and which depends on the producer. Several good clinical results from the use of crosslinked acetabular cups have reported at mid-term, while early results for knee replacements are also encouraging. Recently, the use of the antioxidant vitamin E (alpha-tocopherol) has been introduced for joint prostheses in order to prevent the oxidation of both crosslinked and noncrosslinked UHMWPE.