title: Biomaterial optimization in total disc arthroplasty.
abstract: METHODS
  Knowledge gained through the clinical history of total joint replacement materials combined with the current promise of new biomaterials provides improved guidelines for biomaterial selection in total disc arthroplasty.
  
  
  OBJECTIVE
  The following will detail: 1) current biomaterials technology; 2) how current designs of total disc arthroplasty seek to optimize implant performance through judicious biomaterial selection; and 3) what technical obstacles and clinical concerns remain.
  
  
  METHODS
  Metals and polymers remain the central material components of state-of-the-art total joint arthroplasties. Polymers provide low friction surfaces for articulating bearings and some degree of shock absorption. Metals provide appropriate material properties such as high strength, ductility, fracture toughness, hardness, corrosion resistance, formability, and biocompatibility necessary for use in load-bearing roles required total disc replacement. There are three principal metal alloys used in orthopaedics and particularly in total joint replacement: 1) titanium based alloys; 2) cobalt based alloys; and 3) stainless steel alloys. Alloy specific differences in strength, ductility, and hardness generally determine which of these three alloys is used for a particular application or implant component.
  
  
  RESULTS
  Current designs. Two examples of current lumbar (Charitè and Prodisc) and cervical (Bryan and Prestige) disc replacements are compared. The similarities and differences in the biomaterials used for each demonstrate prevailing consensus and some idea of how to best optimize implant performance through biomaterial selection.
  
  
  CONCLUSIONS
  The primary factors governing total disc arthroplasty biomaterials are similar to those of all total joint arthroplasties: generation of wear debris is the primary source of implant degradation, and the subsequent tissue reaction to such debris is the primary factor limiting the longevity of joint replacement prostheses. Particulate debris generated by wear, fretting, or fragmentation induces the formation of an inflammatory reaction, which at a certain point promotes a foreign-body granulation tissue response that has the ability to invade the bone-implant interface. This commonly results in progressive, local bone loss that threatens the fixation of both cemented and cementless devices alike. All metal alloy implants corrode in vivo. When severe, the degradative process may reduce structural integrity of the implant, and the release of corrosion products is potentially toxic to the host. The corrosion resistance of implant alloys is primarily due to the formation of passive oxide films to prevent significant electrochemical dissolution from taking place. The result of this knowledge is a consensus of opinion as to which materials are best suited for use in current total disc arthroplasty designs, where most total disc replacement designs incorporate cobalt-chromium-molybdenum alloy endplates articulating internally on a relatively soft polymeric core and externally coated with titanium or titanium alloy for enhanced bone fixation.
authors.affiliation: Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois, USA. nhallab@rush.edu
authors.forename: Nadim
authors.initials: N
authors.lastname: Hallab
authors.forename: Helmut D
authors.initials: HD
authors.lastname: Link
authors.forename: Paul C
authors.initials: PC
authors.lastname: McAfee
mesh_terms: D000497:Alloys; D019643:Arthroplasty, Replacement / Q000295:instrumentation* / Q000379:methods; D001672:Biocompatible Materials / Q000009:adverse effects / Q000737:chemistry / Q000592:standards*; D003035:Cobalt; D006801:Humans; D006967:Hypersensitivity / Q000209:etiology; D007403:Intervertebral Disc / Q000601:surgery*; D009369:Neoplasms / Q000209:etiology; D019736:Prostheses and Implants / Q000009:adverse effects; D013193:Stainless Steel; D014025:Titanium
chemical_list: D000497:Alloys; D001672:Biocompatible Materials; D013193:Stainless Steel; D003035:Cobalt; D014025:Titanium