The Role of Poly(Methyl Methacrylate) in Management of Bone Loss and Infection in Revision Total Knee Arthroplasty: A Review

Abstract

Poly(methyl methacrylate) (PMMA) is widely used in joint arthroplasty to secure an implant to the host bone. Complications including fracture, bone loss and infection might cause failure of total knee arthroplasty (TKA), resulting in the need for revision total knee arthroplasty (rTKA). The goals of this paper are: (1) to identify the most common complications, outside of sepsis, arising from the application of PMMA following rTKA, (2) to discuss the current applications and drawbacks of employing PMMA in managing bone loss, (3) to review the role of PMMA in addressing bone infection following complications in rTKA. Papers published between 1970 to 2018 have been considered through searching in Springer, Google Scholar, IEEE Xplore, Engineering village, PubMed and weblinks. This review considers the use of PMMA as both a bone void filler and as a spacer material in two-stage revision. To manage bone loss, PMMA is widely used to fill peripheral bone defects whose depth is less than 5 mm and covers less than 50% of the bone surface. Treatment of bone infections with PMMA is mainly for two-stage rTKA where antibiotic-loaded PMMA is inserted as a spacer. This review also shows that using antibiotic-loaded PMMA might cause complications such as toxicity to surrounding tissue, incomplete antibiotic agent release from the PMMA, roughness and bacterial colonization on the surface of PMMA. Although PMMA is the only commercial bone cement used in rTKA, there are concerns associated with using PMMA following rTKA. More research and clinical studies are needed to address these complications.

Comparative Evaluation of Two Glass Polyalkenoate Cements: An In Vivo Pilot Study Using a Sheep Model

“…PMMA is used for anchoring implants to bone, for fracture fixation, and for management of non-critical bone defects (≤5 mm) [6]. GPCs may be able to overcome some of the limitations (e.g., thermal necrosis, volumetric shrinkage) that currently exist with using PMMA in rTKA.…”

“…While rTKA surgeries comprise a relatively small percentage of all joint replacements (and approximately 7% of all knee replacements [2]), revision surgeries are more complex than primary surgical procedures, resulting in higher inpatient costs (nearly double that of the primary total knee arthroplasty (TKA)), decreased function of the knee, and longer patient recovery time [2]. To manage bone loss in rKTA, surgical implants and techniques such as augments, sleeves, cones, bone grafts, and cementation can be used, depending on the bone defect size, bone quality, and patient's age [3][4][5][6]. The following table reviews each treatment option currently available in rTKA.…”

“…Table 1. Description, characteristics, and treatment options of different bone fillers currently available in rTKA [6].…”

Mechanical Properties of Biomaterials Used in Total Hip and Knee Arthroplasty

“…A polymer interface between harder ceramics or metals used for the acetabulum and femoral head exhibits hard-on-soft coupling, a beneficial phenomenon associated with reduced friction and wear at the interface (Affatato et al, 2018). Another common polymer in TKA/THA is PMMA, also termed bone cement, which is used to affix the femoral stem in the medullary cavity as well as repair small bone defects in revision TKA (Hasandoost et al, 2020). The polyethylenes of Sir John Charnley's era have evolved considerably with innovations in this decade aimed at improving wear resistance, such as antioxidant doping and gamma radiation-induced crosslinking.…”

The Role of Chitosan and Graphene Oxide in Bioactive and Antibacterial Properties of Acrylic Bone Cements

“…ALBC has been widely used for the treatment of infected arthroplasty, and given the increased incidence of this type of infection, a large number of review papers is found in which aspects such as release mechanisms, clinical efficacy, and safety of the ALBC are discussed [13,118,[129][130][131][132][133].…”