Handbook of Biomaterial Properties

Edited by

Jonathan Black
Professor Emeritus of Bioengineering Clemson University USA and

Garth Hastings
Professor and Director of the Biomaterials Programme Institute of Materials Research and Engineering National University of Singapore

CHAPMAN & HAI i

London Weinheim New York Tokyo Melbourne Madras

Published by Chapman & Hall, an imprint of Thomson Science, 2-6 Boundary Row, London SEl 8HN, UK

Thomson Science, 2-6 Boundary Row, London SEl 8HN, UK Thomson Science, 115 Fifth Avenue, New York, NY 10003, USA Thomson Science, Suite 750, 400 Market Street, Philadelphia, PA 19106, USA Thomson Science, Pappelallee 3, 69469 Weinheim, Germany First edition 1998 1998 Chapman & Hall Thomson Science is a division of International Thomson Publishing Typeset in 10/12 pt Times by Florencetype Ltd, Stoodleigh, Devon Printed in Great Britain by TJ. International Ltd, Padstow, Cornwall ISBN 0 412 603306 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the publishers. Applications for permission should be addresed to the rights manager at the London address of the publisher. The publisher makes no representation, express or implied, with regard to the accuracy of the information contained in this book and cannot accept any legal responsibility or liability for any errors or omissions that may be made. A catalogue record for this book is available from the British Library

Foreword

Progress in the development of surgical implant materials has been hindered by the lack of basic information on the nature of the tissues, organs and systems being repaired or replaced. Materials' properties of living systems, whose study has been conducted largely under the rubric of tissue mechanics, has tended to be more descriptive than quantitative. In the early days of the modern surgical implant era, this deficiency was not critical. However, as implants continue to improve and both longer service life and higher reliability are sought, the inability to predict the behavior of implanted manufactured materials has revealed the relative lack of knowledge of the materials properties of the supporting or host system, either in health or disease. Such a situation is unacceptable in more conventional engineering practice: the success of new designs for aeronautical and marine applications depends exquisitely upon a detailed, disciplined and quantitative knowledge of service environments, including the properties of materials which will be encountered and interacted with. Thus the knowledge of the myriad physical properties of ocean ice makes possible the design and development of icebreakers without the need for trial and error. In contrast, the development period for a new surgical implant, incorporating new materials, may well exceed a decade and even then only short term performance predictions can be made. Is it possible to construct an adequate data base of materials properties of both manufactured materials and biological tissues and fluids such that in vitro simulations can be used to validate future implant designs before in vivo service? While there are no apparent intellectual barriers to attaining such a goal, it clearly lies in the distant future, given the complexity of possible interactions between manufactured materials and living systems. However, a great body of data has accumulated concerning the materials aspects of both implantable materials and natural tissues and fluids. Unfortunately, these data are broadly distributed in many forms of publication and have been gained from experimental observations of varying degrees of accuracy and precision. This is a situation very similar to that

in general engineering in the early phases of the Industrial Revolution. The response then was the publication of engineering handbooks, drawing together, first in general publications and later in specialty versions, the known and accepted data of the time. In this spirit, we offer this Handbook
of Biomaterial Properties.

Biomaterials, as manufactured for use in implants, do not exist usefully out of context with their applications. Thus, a material satisfactory in one application can be wholly unsuccessful in another. In this spirit, the Editors have given direction to the experts responsible for each part of this Handbook to consider not merely the intrinsic and interactive properties of biomaterials but also their appropriate (and in some cases inappropriate) applications as well as their historical context. It is hoped that the results will prove valuable, although in different ways, to the student, the researcher, the engineer and the practicing physician who uses implants. A handbook like this necessarily becomes incomplete immediately upon publication, since it will be seen to contain errors of both omission and commission. Such has been the case with previous engineering handbooks: the problem can only be dealt with by providing new, revised editions. The Editors would appreciate any contributions and/or criticisms which the users of this handbook may make and promise to take account of them in future revisions.

Introduction

It is a feature of any developing science and its accompanying technology that information relating to different aspects is scattered throughout the relevant, and sometimes not so relevant literature. As the subject becomes more mature, a body of information can be categorized and brought together for the use of practitioners. In providing this Handbook of Biomaterial Properties the Editors believe that the latter stage has been reached in several parts of the vast field of biomaterials science and engineering. Many of the properties of the synthetic materials have been available for some time, for example those of the various metallic alloys used in clinical practice have been specified in various International, European and National Standards and can be found by searching. In the case of polymeric materials, while the information is in commercial product literature and various proprietary handbooks, it is diverse by the nature of the wide range of materials commercially available and the search for it can be time consuming. The situation is much the same for ceramic and composite materials: there the challenge is finding the appropriate properties for the specific compositions and grades in use as biomaterials. However, when information is sought for on materials properties of human tissues, the problem is more acute as such data are even more scattered and the methods for determination are not always stated or clearly defined. For the established worker this presents a major task. For the new researcher it may make establishing a project area a needlessly time consuming activity. The biomaterials bulletin boards (on the Internet) frequently display requests for help in finding characterization methods and/or reliable properties of natural materials, and sometimes the information is actually not available. Even when it is available, the original source of it is not always generally known. In approaching their task, the Editors have tried to bring together into one source book the information that is available. To do this they have asked for the help of many colleagues worldwide to be contributors to the Handbook. It has not been possible to cover all the areas the Editors

had hoped. Some topics could not be covered, or the information was judged to be too fragmentary or unreliable to make it worth including. This is inevitably the sort of project that will continue to be incomplete; however, new information will be provided as more experiments are done and as methods for measurement and analysis improve. The aim has been to make this Handbook a ready reference which will be consulted regularly by every technician, engineer and research worker in the fields of biomaterials and medical devices. We have tried, not always successfully, to keep the textual content to a minimum, and emphasize tabular presentation of data. However, in some cases it has been decided to include more text in order to establish the background of materials properties and use and to point to critical features in processing or production which would guide the worker looking for new applications or new materials. For example, in polymer processing, the need to dry materials thoroughly before fabrication may not be understood by those less well versed in production techniques. It is hoped that the Handbook will be used and useful, not perfect but a valuable contribution to a field that we believe has matured sufficiently to merit such a publication. The Handbook is divided into synthetic and natural materials and the treatment is different in each part. More background was felt to be needed for the synthetic materials since processing and structural variations have a profound effect on properties and performance. Biological performance of these materials depends on a range of chemical, physical and engineering properties and the physical form can also influence in vivo behavior. We have not attempted to deal with issues of biological performance, or biocompatibility, but have dealt with those other features of the materials which were felt to be relevant to them as potential biomaterials. Only materials having apparent clinical applications have been included. The biological materials have more dynamic properties since, in vivo, they respond to physiological stimuli and may develop modified properties accordingly. The treatment of their properties has been limited to those determined by well characterized methods for human tissues, with a few exceptions where data on other species is deemed to be applicable and reliable. These properties determined almost totally in vitro may not be directly predictive of the performance of the living materials in vivo, but are a guide to the medical device designer who wishes to determine a device design specification. Such a designer often finds it hard to realize the complexity of the task of dealing with a non-engineering system. What really are the parameters needed in order to design an effectively functioning joint endoprosthesis or a heart valve? Do tissue properties measured post explantation assist? Is individual patient lifestyle an important factor? There is immediately a degree of uncertainty in such design processes, and total reliability in performance cannot be given a

prospective guarantee. However, the more we learn about the materials and systems of the human body and their interaction with synthetic biomaterials, the closer we may perhaps become to the ideal 'menotic' or forgotten implant which remains in 'menosis' - close and settled union from the Greek |xevo) - with the tissues in which it has been placed. Three final comments: Although the Editors and contributors frequently refer to synthetic and, in some cases, processed natural materials as 'biomaterials,' nothing herein should be taken as either an implied or explicit warrantee of the usefulness, safety or efficacy of any material or any grade or variation of any material in any medical device or surgical implant. Such determinations are an intrinsic part of the design, development, manufacture and clinical evaluation process for any device. Rather, the materials listed here should be considered, on the basis of their intrinsic properties and, in many cases, prior use, to be candidates to serve as biomaterials: possibly to become parts of successful devices to evaluate, direct, supplement, or replace the functions of living tissues. The Editors earlier refer to absences of topics and of data for particular synthetic or natural materials. While this may be viewed, perhaps by reviewers and users alike, as a shortcoming of the Handbook, we view it as a virtue for two reasons: Where reliable data are available but were overlooked in this edition, we hope that potential contributors will come forward to volunteer their help for hoped for subsequent editions. Where reliable data are not available, we hope that their absence will prove both a guide and a stimulus for future investigators in biomaterials science and engineering. The Editors, of course, welcome any comments and constructive criticism. JB GWH Professor Garth W. Hastings Institute of Materials Research & Engineering - IMRE, Block S7, Level 3, Room 17B, National University of Singapore, 10 Kent Ridge Crescent, Singapore 119260. Tel: +65 771 5249 Fax: +65 872 5373 Professor Emeritus Jonathan Black Principal: IMN Biomaterials 409 Dorothy Drive King of Prussia, PA 19406-2004, USA Tel/Fax: +1 610 265 6536

Contributors

COMMISSIONED BY J. BLACK:

T.O. Albrektsson University of Gothenburg Handicap Research, Institute for Surgical Sciences Medicinaregatan 8 Gothenburg S-413 90, Sweden J.M. Anderson University Hospitals of Cleveland Department of Pathology Case Western Reserve University 2074 Abington Road Cleveland, OH 44106-2622, USA T.V. Chirila Lions Eye Institute 2 Verdun Street, Block A, 2nd Floor Nedlands, W. Australia 6009 Professor J.D. Currey Department of Biology York University York YOl 5DD, United Kingdom X. Deng Laboratorie de Chirugie Exp Agriculture Services Room 1701 Services Building Universite Laval Quebec GlK 7P4, Canada

S.E. Gabriel Division of Rheumatology Mayo Clinic 200 First Street Southwest Rochester, MN 55905, USA V.M. Gharpuray Department of Bioengineering 401 Rhodes Eng. Res. Ctr. Clemson University Clemson, SC 29634-0905, USA R. Guidoin Laboratorie de Chirugie Exp Agriculture Services Room 1701 Services Building Universite Laval Quebec GlK 7P4, Canada S.R. Hanson Division of Hematology/Oncology PO Box AJ Emory University Atlanta, GA 30322, USA K.E. Healy Department of Biological Materials Northwestern University 311 E. Chicago Ave. Chicago, IL 60611-3008, USA Y. Hong Lions Eye Institute 2 Verdun Street, Block A, 2nd Floor Nedlands, W. Australia 6009 T.M. Keaveny Department of Mechanical Engineering Etcheverry Hall University of California at Berkeley Berkeley, CA 94720, USA

R.E. Levine Musculoskeletal Research Centre University of Pittsburgh 1011 Liliane S. Kaufmann Building 3741 Fifth Avenue Pittsburgh PA 15213, USA Arthur K.T. Mak Rehabilitation Engineering Centre Hong Kong Polytechnic Hunghom, Kowloon, Hong Kong S.S. Margules Department of Bioengineering 105D Hayden Hall University of Pennsylvania Philadelphia, PA 19104-6392, USA D.F. Meaney Department of Bioengineering 105E Hayden Hall University of Pennsylvania Philadelphia, PA 19104-6392, USA K. Merritt 17704 Stoneridge Dr. Gaithersburg, MD 20878, USA Professor J.R. Parsons Orthopaedics-UMDNJ 185 South Orange Avenue University Heights Newark, NJ 07103-2714, USA M.G. Rock Department of Orthopaedics Mayo Clinic 200 First Street Southwest Rochester, MN 55905, USA S.M. Slack Department of Biomedical Engineering University of Memphis, Campus Box 526582, Memphis, TN 38152-6502, USA

V. Turitto Department of Biomedical Engineering University of Memphis Memphis, TN 38152, USA Professor D.F. Williams Department of Clinical Engineering Royal Liverpool University Hospital PO Box 147 Liverpool L69 3BX, United Kingdom S.L.-Y. Woo Musculoskeletal Research Center University of Pittsburgh 1011 Liliane S. Kaufmann Building 3741 Fifth Avenue Pittsburgh, PA 15213, USA M. Zhang Rehabilitation Engineering Centre Hong Kong Polytechnic Hungham, Kowloon, Hong Kong COMMISSIONED BY G.W. HASTINGS: L. Ambrosio Department of Materials and Production Engineering University of Naples Federico II Institute of Composite Materials Technology CNR Piazzale Techio, 80 80125 Naples, Italy M.A. Barbosa INEB-Ma Rua do Campo Alegre 823 4150 Porto, Portugal V. Biehl Lehrstuhl fiir Metallische Werkstoff Universitat des Saarlandes Saarbriicken, Germany

J.C. Bokros Medical Carbon Research Institute 8200 Cameron Road Suite A-196 Austin TX 78754-8323, USA J.W. and SJ. Boretos Consultants for Biomaterials 6 Drake Court Rockville Maryland 20853, USA H. Breme Lehrstuhl fiir Metallische Werkstoffe Universitat des Saarlandes Saarbriicken, Germany G. Carotenuto Department of Materials and Production Engineering University of Naples Federico II Institute of Composite Materials Technology CNR Piazzale Technio, 80 80125 Naples, Italy A.D. Haubold Medical Carbon Research Institute 8200 Cameron Road Suite A-196 Austin TX 78754-8323, USA L. Hench Imperial College Department of Materials Prince Consort Road London SW7 2BP, United Kingdom T. Kookubo Division of Material Chemistry Faculty of Engineering Kyoto University, Sakyo-ku, Kyoto 606-01, Japan

M. LaBerge Associate Professor School of Chemical and Materials Engineering 401 Rhodes Research Center Clemson University, Clemson, SC 29634-0905, USA PJ. Li Centre for Oral Biology Karolinska Institute Huddinge S 141-4, Sweden R.B. More Medical Carbon Research Institute 8200 Cameron Road Suite A-196 Austin TX 78754-8323, USA L. Nicolais Department of Materials and Production Engineering University of Naples Federico II Institute of Composite Materials Technology CNR Piazzale Technio, 80 80125 Naples, Italy H. Oomamiuda Department of Orthapaedic Surgery Artificial Joint Section and Biomaterial Research Laboratory Osaka-Minami National Hospital 677-2 Kido-Cho, Kawachinagano-shi, Osaja, Japan H. Oonishi Department of Orthopaedic Surgery Artificial Joint Section and Biomaterial Research Laboratory Osaka-Minami National Hospital 677-2 Kido-Cho, Kawachinagano-shi, Osaka, Japan Z.G. Tang BIOMAT Centre National University of Singapore Singapore 119260

S.H. Teoh Institute of Materials Research & Engineering - IMRE Block S7, Level 3, Room 17B National University of Singapore 10 Kent Ridge Crescent Singapore 119260

Contents

Foreword ........................................................................................ Introduction .....................................................................................

xiii xv

Contributors .................................................................................... xviii Part I.

A1. Cortical Bone .............................................................................. A1.1 A1.2 A1.3 Composition .................................................................... Physical Properties ......................................................... Mechanical Properties .................................................... 3 3 4 5 12 12 15 15 16 16 21 21 24 24 25 35 36 37

Additional Reading ..................................................................... References ................................................................................. A2. Cancellous Bone ........................................................................ A2.1 A2.2 A2.3 Structure ......................................................................... Composition .................................................................... Mechanical Properties ....................................................

Additional Reading ..................................................................... References ................................................................................. A3. Dentin and Enamel ..................................................................... A3.1 A3.2 A3.3 Introduction ..................................................................... Composition .................................................................... Final Comments ..............................................................

Additional Reading ..................................................................... References .................................................................................

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vi

Contents
B1. Cartilage ..................................................................................... B1.1 B1.2 B1.3 B1.4 B1.5 Introduction ..................................................................... Composition .................................................................... Mechanical Properties of Articular Cartilage ................... Fibrocartilage Mechanical Properties ............................. Elastic Cartilage Mechanical Properties ......................... 40 40 41 41 45 45 45 46 48 48 48 51 51 53 54 55 56 59 59 62 62 63 66 66 66 68 69 70 70

Additional Reading ..................................................................... References ................................................................................. B2. Fibrocartilage .............................................................................. B2.1 B2.2 B2.3 B2.4 B2.5 B2.6 Introduction ..................................................................... Structure and Composition ............................................. Hydraulic Permeability and Drag Coefficients ................. Elastic Properties ............................................................ Viscoelastic Behavior ...................................................... Discussion ......................................................................

Additional Reading ..................................................................... References ................................................................................. B3. Ligament, Tendon and Fascia .................................................... B3.1 B3.2 Introduction ..................................................................... Discussion ......................................................................

Additional Reading ..................................................................... References ................................................................................. B4. Skin and Muscle ......................................................................... B4.1 B4.2 Introduction ..................................................................... In vivo Mechanical Properties .........................................

Additional Reading ..................................................................... References ................................................................................. B5. Brain Tissues .............................................................................. B5.1 Introduction .....................................................................

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Contents
B5.2 B5.3 B5.4 B5.5 B5.6 B5.7 Composition .................................................................... Mechanical Properties .................................................... Electrical Properties ........................................................ Thermal Properties ......................................................... Diffusion Properties ........................................................ Comments ......................................................................

vii
71 72 77 77 77 78 78 79 81 81 82 82 88 88 96 98 98 99 100 101 101 102 106 106 107 109 112 112

Additional Reading ..................................................................... References ................................................................................. B6. Arteries, Veins and Lymphatic Vessels ...................................... B6.1 B6.2 B6.3 B6.4 B6.5 B6.6 B6.7 B6.8 B6.9 Introduction ..................................................................... Morphometry of the Arterial Tree and Venous System ... Constituents of the Arterial Wall ..................................... Constituents of the Venous Wall ..................................... Mechanical Properties of Arteries ................................... Mechanical Properties of Veins ...................................... Mechanical Characteristics of Lymphatic Vessels .......... Transport Properties of Blood Vessels ........................... Effect of Age, Hypertension and Atherosclerosis on Blood Vessels .................................................................

B6.10 Final Comments .............................................................. Acknowledgement ...................................................................... Additional Reading ..................................................................... References ................................................................................. B7. The Intraocular Lens ................................................................... B7.1 B7.2 B7.3 Introduction ..................................................................... Chemical Composition .................................................... Dimensions and Optical Properties ................................

Additional Reading ..................................................................... References .................................................................................

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viii

Contents
C1. Blood and Related Fluids ........................................................... C1.1 Introduction ..................................................................... Additional Reading ..................................................................... References ................................................................................. C2. The Vitreous Humor ................................................................... C2.1 C2.2 C2.3 Introduction ..................................................................... General Properties .......................................................... Mechanical Properties .................................................... 114 114 123 123 125 125 126 129 129 130

Additional Reading ..................................................................... References .................................................................................

Part II.
1. Metallic Biomaterials ................................................................... 1.1 1.2 Introduction ..................................................................... General Discussion ......................................................... 135 135 137 143 145 145 150 151 157 161 163 165 165 167 167 169 169 173

References ................................................................................. 1a. Stainless Steels .......................................................................... 1a.1 1a.2 1a.3 1a.4 1a.5 1a.6 1a.7 Composition .................................................................... Physical Properties ......................................................... Processing of Stainless Steels ....................................... Mechanical Properties .................................................... Fatigue ............................................................................ Corrosion and Wear ........................................................ Biological Properties .......................................................

References ................................................................................. 1b. CoCr-based Alloys ...................................................................... 1b.1 1b.2 1b.3 1b.4 Composition .................................................................... Physical Properties ......................................................... Processing of CoCr-alloys .............................................. Mechanical Properties ....................................................

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Contents
1b.5 1b.6 1b.7 Fatigue ............................................................................ Corrosion and Wear ........................................................ Biological Properties .......................................................

ix
174 175 177 178 179 179 180 181 186 189 194 197 198 198 201 201 204 212 212 213 214 214 214 219 219 220 221 221 222

References ................................................................................. 1c. Titanium and Titanium Alloys ..................................................... 1c.1 1c.2 1c.3 1c.4 1c.5 1c.6 1c.7 1c.8 Composition .................................................................... Physical Properties ......................................................... Processing of cp-Ti and Ti Alloys ................................... Mechanical Properties .................................................... Fatigue ............................................................................ Corrosion and Wear ........................................................ Biological Properties ....................................................... TiNi-shape Memory ........................................................

References ................................................................................. 1d. Dental Restoration Materials ...................................................... 1d.1 1d.2 1d.3 1d.4 2. Amalgams ....................................................................... Noble Metals ................................................................... CoCr-alloys ..................................................................... NiCr-alloys ......................................................................

References ................................................................................. Composite Materials ................................................................... 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Types of Composites and Component Materials ............ Fibre Types and Properties ............................................ Matrix Materials .............................................................. Thermoplastic Matrix ...................................................... Thermosets Matrix .......................................................... Vinyl Ester Resins ........................................................... Epoxide Resins ............................................................... Diluents ...........................................................................

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Contents
2.9 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 3. Curing Agents for Epoxide Resins .................................. Polyester Resins ............................................................. Laminate Properties ........................................................ Composite Fabrication .................................................... Mechanical Properties .................................................... Antioxidants and Effect of Environmental Exposure ....... The Radiation Stability of Commercial Materials ............ Polymers Aging ............................................................... Composite Materials in Medicine .................................... Metal Matrix Composites ................................................ Ceramic Matrix Composites ............................................ 222 224 225 229 240 254 256 259 260 262 266 269 270 270 272 273 274 275 276 277 278 279 280 281 282 283 300

References ................................................................................. Thermoplastic Polymers in Biomedical Applications: Structures, Properties and Processing ....................................... 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12 3.13 Introduction ..................................................................... Polyethylene ................................................................... Polypropylene ................................................................. Polyurethane ................................................................... Polytetrafluoroethylene ................................................... Polyvinylchloride ............................................................. Polyamides ..................................................................... Polyacrylates .................................................................. Polyacetal ....................................................................... Polycarbonate ................................................................. Polyethylene Terephthalate ............................................ Polyetheretherketone ...................................................... Polysulfone .....................................................................

References .................................................................................

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Contents
4. Biomedical Elastomers ............................................................... 4.1 4.2 4.3 4.4 4.5 4.6 4.7 5. Introduction ..................................................................... Types of Elastomers ....................................................... Establishing Equivalence ................................................ Sterilization of Elastomers .............................................. Relevant ASTM Standards ............................................. Biocompatibility ............................................................... Sources ...........................................................................

xi
302 302 303 334 338 338 338 338 340 340 340 342 348 351 352 352 352 355 355 357 358 363 364 364 369 393 393 394

Oxide Bioceramics: Inert Ceramic Materials in Medicine and Dentistry ..................................................................................... 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Introduction ..................................................................... Short History ................................................................... Material Properties and Processing ................................ Biocompatibility of Oxide Bioceramics ............................ Applications .................................................................... Manufacturers and Their Implant Products ..................... Problems and Future Prospects .....................................

References ................................................................................. 6. Properties of Bioactive Glasses and Glass-ceramics ................. 6.1 6.2 6.3 7. Bioactive Bonding ........................................................... Bioactive Compositions .................................................. Physical Properties .........................................................

References ................................................................................. Wear ........................................................................................... 7.1 7.2 7.3 7.4 7.5 Introduction ..................................................................... In vitro Wear Testing ....................................................... Clinical Wear ................................................................... Combined Wear and Fatigue .......................................... Solving the Wear Problem ..............................................

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Contents
7.6 Conclusion ...................................................................... 395 399 399 400 406 406 407 410 417 417 420 420 423 429 436 459 464 464 472 474 475 Acknowledgements .................................................................... Additional Reading ..................................................................... References ................................................................................. 8. Degradation/Resorption in Bioactive Ceramics in Orthopaedics .............................................................................. 8.1 8.2 8.3 8.4 9. Introduction ..................................................................... In vitro Physico-chemical Dissolution Processes ............ In vivo/in vitro Biological Degradation Processes ........... Summary ........................................................................

References ................................................................................. Corrosion of Metallic Implants .................................................... 9.1 9.2 9.3 9.4 General Aspects ............................................................. Aspects Related to the Metal Composition ..................... Aspects Related to the Physiological Environment ........ Aspects Related to the Oxide and Other Surface Layers .............................................................................

References ................................................................................. 10. Carbons ...................................................................................... 10.1 10.2 10.3 Introduction ..................................................................... Historical Overview in vivo Applications ...................... New Directions/Future Trends ........................................

References .................................................................................

Part III.
1. General Concepts of Biocompatibility ......................................... 1.1 1.2 1.3 1.4 Introduction ..................................................................... The Definition of Biocompatibility .................................... Components of Biocompatibility ..................................... Conclusions ....................................................................
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481 481 482 484 488

Contents
Additional Reading ..................................................................... References ................................................................................. 2. Soft Tissue Response ................................................................ 2.1 2.2 2.3 2.4 2.5 2.6 Introduction ..................................................................... Types of Response ......................................................... Inflammation ................................................................... Wound Healing and Fibrosis ........................................... Repair of Implant Sites ................................................... Summary ........................................................................

xiii
488 489 490 490 490 492 494 495 496 497 498 500 500 500 503 504 507 508 510 510 513 513 513 515 517 521 521 523

Additional Reading ..................................................................... References ................................................................................. 3. Hard Tissue Response ............................................................... 3.1 3.2 3.3 3.4 3.5 3.6 Introduction ..................................................................... Fixation by Cementation ................................................. Fixation by Ingrowth (Cement-free Implants in Bone) .............................................................................. Osseointegration ............................................................. How Bone-biomaterial Interfaces Fail ............................. Conclusions ....................................................................

Additional Reading ..................................................................... References ................................................................................. 4. Immune Response ..................................................................... 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Introduction ..................................................................... Overview of the Specific Immune Response .................. Detection of Antibody ...................................................... Detection of Cell Mediated Responses (Type IV) ........... Detection of Immune Responses to Haptens ................. Human Immune Response to Materials ......................... Consequences of an Immune Response ........................

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Contents
4.8 5. Conclusions .................................................................... 524 525 529 529 530 531 532 533 536 538 539 540 541 545 545 545 548 548 549 550 550 550 551 551 552 552 553 Additional Reading ..................................................................... Cancer ........................................................................................ 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Introduction ..................................................................... Release and Distribution of Degradation Products ......... Neoplasia ........................................................................ Evidence for Carcinogenicity of Implanted Materials ......................................................................... Case Reports of Implant Related Tumors ...................... Critical Analysis of Tumors ............................................. Significance of Clinical Reports ...................................... Summary ........................................................................

Additional Reading ..................................................................... References ................................................................................. 6. Blood-material Interactions ......................................................... 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10 6.11 Introduction ..................................................................... Experimental Difficulties ................................................. Conventional Polymers ................................................... Hydrophylic Polymers ..................................................... Metals ............................................................................. Carbons .......................................................................... Ultra-thin Film Coatings .................................................. Membranes ..................................................................... Biological Surfaces ......................................................... Surface Texture .............................................................. Conclusion ......................................................................

Additional Reading ..................................................................... References .................................................................................

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Contents
7. Soft Tissue Response to Silicones ............................................. 7.1 7.2 7.3 7.4 7.5 Silicones Used in Medicine ............................................. Local Immunologic Reactions to Silicone ....................... Systemic Immunologic Reactions to Silicone ................. Evidence for Causation ................................................... Controlled Studies Examining the Relationship between Breast Implants and Connective Tissue Disease ...........

xv
556 556 556 557 559 563 567

References .................................................................................

Index .............................................................................................. 573

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PARTI

Cortical bone
J. Currey

ALl COMPOSITION ALLl Overall The main constituents are the mineral hydroxyapatite, the fibrous protein collagen, and water. There is some non-collagenous organic material. Highly mineralized bone (petrosal bones of some non-human mammals) has little organic material (8% in the horse petrosal to 3% in the tympanic bulla) [3]. (Almost certainly human ear bones will be somewhere near or in this region, though they seem not to have been studied.) A1.L2 Organic The main organic component is collagen. Most is Type I, but there are small amounts of Type III and Type VI, found in restricted locations [4]. Slowly heated collagen shrinks at a particular temperature, giving an indication of the stability of the molecules. Bone collagen in men has a shrinkage temperature of about 61.5-63.5C up to the age of about 60, but about 600C over that age. Bone from women showed much greater variability [5]. About 10% of the bone organic material is non-collagenous, mainly non-collagenous protein, NCP. The main ones are listed below. They have supposed functions that change rapidly. Osteocalcin (OC), or bone GIa protein (BGP) Osteonectin (ON), or SPARC Osteopontin (OPN) or secreted phosphoprotein I (SPPI) Bone sialoprotein (BSP)

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Table ALl Mass % Volume % Volume %

Composition of Cortical Bone Water 12.0 23.9 15.5 Organic 28.1 38.4 41.8 Ash 59.9 37.7 39.9 Source [1] [1] [2]

The relative amounts of these proteins can vary greatly. Ninomiya et al [6] report far more osteocalcin (31 times) in cortical bone than in trabecular bone, and far more osteonectin (29 times) in trabecular bone than in cortical bone. Al.1.3 Mineral The mineral has a plate-like habit, the crystals being extremely small, about 4 nm by 50 nm by 50 nm. The mineral is a variant of hydroxyapatite, itself a variant of calcium phosphate: Ca10(PO4)6(OH)2 [7]. The crystals are impure. In particular there is about 4-6% of carbonate replacing the phosphate groups, making the mineral technically a carbonate apatite, dahllite, and various other substitutions take place [8]. Al.1.4 Cement line The cement line round Haversian systems (secondary osteons) contains less calcium and phosphorus, and more sulphur than nearby parts of bone. This may indicate the presence of more sulphated mucosubstances, making the cement line viscous [9]. A1.2 PHYSICAL PROPERTIES Al.2.1 Density
Table A1.2 Density of Cortical Bone Wet bone 1990 kg nr3 [1]

Al.2.2 Electromechanical behavior

Strained bone develops electrical potential differences. These used to be attributed to piezoelectric effects. However, the size of the piezoelectric effects is small compared with those produced by streaming potentials [10]. Furthermore, there were various anomalies with the potentials

generated, which did not always accord with theory. The consensus now is that 'SGPs' (stress-generated potentials) are overwhelmingly caused by streaming potentials [10, H]. Scott and Korostoff [12] determined, amongst other things, the relaxation time constants of the stress generated potentials, which varied greatly as a function of the conductivity and viscosity of the permeating fluid. As an example of their findings: a step-imposed loading moment which produced a peak strain of 4 x 10'4 induced an SGP of 1.8 mV, yielding a value of the SGP/strain ratio of 4500 mV. The SGP decayed rapidly at constant strain, reaching zero within about one second. For more detail, the complex original paper must be consulted. Al.2.3 Other Physical Properties Behari [10] gives a useful general review of many 'solid state' properties of bone, both human and non-human, many of which are not dealt with here. These properties include the Hall effect, photo-electric effects, electron paramagnetic resonance effects and so on. A1.3 MECHANICAL PROPERTIES Al.3.1 General There is a great range for values in the literature for many reasons. Amongst these are: (a) Different treatment of specimens Drying bone and then re-wetting it produces some small differences [13], as does formalin fixation [14]. Testing bone dry produces results quite different from those in wet bone; dry bone is stiffer, stronger, and considerably more brittle. Very small samples produce values for stiffness and strength less than those from larger samples [15, 16]. High strain rates generally produce a higher modulus of elasticity, a higher strength [17], and a greater strain to failure than specimens tested at low strain rate. (b) Different age and health of donors Age may affect intrinsic properties. Osteoporotic bone may differ from 'normal' bone in ways other than the fact that it is more porous; there is evidence that the collagen is different from that in similaraged non-osteoporotic subjects [18]. Bone from osteogenesis imperfecta patients has a higher proportion of Type III and Type V collagen compared with Type I collagen, than bone from normal subjects [19].

Bone collagen from osteopetrotic subjects is in general older than that from normal subjects, and has correspondingly different properties [5]. (c) Differences between bones, and sites in the bones The ear bones (ossicles) and portions of the temporal bones (petrosals) are highly mineralized, and will undoubtedly be stiffer and more brittle than others (though they seem not to have been investigated in humans). Long bones differ along their length and around their circumference. The distal femur is less highly mineralized and weaker in tensile and compressive static loading, and at any level the posterior part is similarly less mineralized and weaker [20]. The values reported below should be considered paradigmatic, that is, to be valid for a well-performed test on bone obtained from a middle aged person with no disease. Other values are reported in such a way as to make it clear how some property is a function of other features of the specimen. Al.3.2 Stiffness (a) General There are two ways of testing bone: mechanically by relating stresses to strains; ultrasonically, by subjecting the bone to ultrasound and measuring the velocity of the sound. From a knowledge of the density one can then obtain a stiffness matrix. If this is inverted it becomes a compliance matrix, the reciprocal of the individual terms of which are equivalent to the socalled technical moduli derived by mechanical testing [21]. Reilly and Burstein [22] give mechanical values, and Ashman et al [23] give ultrasonic measurements. Reilly and Burstein [22] assumed transverse isotropy (that is, symmetry around the longitudinal axis of the bone), while Ashman et al [23] assumed orthotropy (that is, that the values for stiffness could be different in the longitudinal, radial and tangential directions). Reilly and Burstein [22] give values for Young's modulus at a number of intermediate angular orientations, but they do not form a very uniform set. (b) Tensile modulus versus compressive modulus Reilly et al. [24] tested femoral specimens specifically to determine whether the value for Young's modulus was different in tension and compression. A paired Student's 't' test showed no significant difference between the compressive and tensile moduli at the 95% confidence level. Calculations on their data show the the 95% confidence interval ranged

Table A 1 . 3 Mechanical Properties Femur Tension [23] Femur Tension [22] Femur Compression 12.8 12.8 17.7 3.3 3.3 0.53 0.53 0.41 0.41 0.63 0.63 0.38 0.38 11.7 11.7 18.2 [22]

Elastic moduli ( G P a ) : E1 12.0 E2 13.4 E3 20.0 Shear moduli* (GPa): G 12 4.5 G 13 5.6 G23 6.2 Poisson's ratios: v 12 0.38 v 13 0.22 v 23 0.24 v 21 0.42 v 31 0.37 v 32 0.35

Subscript 1: radial direction relative to the long axis of the bone, 2: tangential direction, 3: longitudinal direction. * Shear values are included under tension for convenience.

from compression modulus 1.72 GPa higher to tension modulus 0.27 GPa higher. The load-deformation traces showed no change of slope going from compression into tension and vice versa. (c) Very small specimens The bending modulus of very small specimens was 6.62 GPa [5]. (d) Locational variations: Metaphysis versus diaphysis Young's modulus has been determined in three-point bending for extremely small plates (7 mm by 5 mm by (about) 0.3 mm) from the femoral metaphyseal shell and from the diaphysis of the same bones [16]. The differences between these values and those reported by Reilly and Burstein [22] are probably attributable not to the difference in testing mode, since bending and tension tests from the same bone generally give similar values for Young's modulus, but to the very small size of the specimen, and to the rather low density of the specimens. Table A1.4 Locational Variations in Modulus
Location Metaphysis Diaphysis Longitudinal (GPa) 9.6 12.5 Transverse (GPa) 5.5 6.0 Source [16] [16]

(e) Compression; effect of mineral The compressive behavior of cubes, relating the properties to the density of the specimens gives, using pa (fat-free mass divided by anatomical volume, g cm3) as the explanatory variable: Young's modulus (GPa) = 3.3pa24 for compact bone [25]. The higher values of pa were of the order of 1.8 g cm"3(=1800kg nr3); this equation [25] predicts a value of 13.5 GPa for such a specimen. Multiple regression analysis showed that the dependence of Young's modulus on density was caused by the effect of porosity on density, and that, in these specimens, the effect of mineral content was insignificant. (f) Single secondary osteons Ascenzi and co-workers [26-29] distinguish two types of secondary osteon: 'longitudinal' osteons, whose collagen fibres have a basically longitudinal orientation, and 'alternate' osteons, whose fibres have markedly different courses in neighboring lamellae. (This difference is a contentious issue.) N.B.: These studies of Ascenzi and co-workers [26-29] are widely quoted, so beware of some apparent anomalies (apart from changes in nomenclature between papers). The bending modulus is remarkably low compared with the tension and compression moduli. The torsional (shear) modulus is remarkably high, compared both with the shear modulus values obtained by others (above), and with the tension and compression values. Torsional moduli are expected, on theoretical grounds, to be less than the tension and compression moduli. Furthermore, the large differences between the tension and compression moduli have not been reported elsewhere.] (g) Strain rate effects Calculations [30], incorporating data from non-human as well as human material, predict that Young's modulus is very modestly dependent upon strain rate:
E = 21402 (strain rate (s 1 )) 0 0 5 0 MPa

Table A1.5 Moduli of Osteons Modulus (GPa) Tension Compression Bending Torsional* Longitudinal lf.7 6.3 2.3 22.7 Osteons 'Alternate' Osteons 5^5 7.4 2.6 16.8 Source [26] [27] [28] [29]

* Values for an 80-year-old man excluded.

[N.B. statements about strain rate effects in bone are suspect unless it is clear that the workers have taken machine compliance into account!] (h) Viscoelastic-damage properties Viscoelastic time constant (the value T (S) in the equation): e(t) - P1 exp[(to - t)/T] + p2, where the betas are parameters, t is time (s), to is time at which the specimen is held at a constant stress below the creep threshold: 6.1 s [31]. For reference, its value in bovine bone: 3.6 s. Al.3.3 Strength (a) Overall
Table A1.6 Strength of Cortical Bone [22] Mode Tension Compression Orientation Longitudinal Tangential Longitudinal Tangential Shear Breaking Strength (MPa) 133 52 205 130 67 Yield Stress (MPa) 114 Ultimate Strain 0.031 0.007

(b) Combined loading Cezayirlioglu et al [32] tested human bone under combined axial and torsional loading. The results are too complex to tabulate, but should be consulted by readers interested in complex loading phenomena. (c) Metaphysis versus diaphysis Same specimens as reported for modulus above (Table Al.4) [16]. Tensile' strength calculated from the bending moment, using a 'rupture factor' to take account of the non-uniform distribution of strain in the specimen.
Table A1.7 Location Metaphysis Diaphysis Locational Variations in Strength Longitudinal (MPa) 101 129 Transverse (MPa) 50 47 Source [16] [16]

(d) Effect of mineral Keller [25], using the same specimens as above, provides the following relationship: Strength - 43.9Pa20 (MPa) [N.B.: The effect of mineralization, as opposed to density, is possibly of importance here; the original paper must be consulted.] (e) Single secondary osteons The same nomenclature applies as for moduli of osteons (Table A1.5).
Table A1.8 Strength of Osteons Strength (MPa) Tension Compression Bending Torsional* Longitudinal Osteons 120 110 390 202 'Alternate' Osteons 102 134 348 167 Source [26] [27] [28] [29]

* Values for an 80 year old man excluded.

[N.B. The bending strengths and torsional strengths seem very high, even bearing in mind that no allowance has been made in bending for non-elastic effects.] (f) Strain rate effects Bone will bear a higher stress if it is loaded at a higher strain (or stress) rate. Carter and Caler [17] found an empirical relationship that failure stress (a f (MPa)) was a function of either stress rate (a) or strain rate (e): <rf = 87 a0053 af - 87 e0055 N.B. These relationships imply an increase of 44% in the failure stress if the stress rate is increased one thousandfold. This relationship has been found to be roughly the same in other, non-human, mammals. (g) Creep Creep threshold (the stress below which no creep occurs): 73 MPa [31]. The equivalent value for bovine bone is 117 MPa [31]. Specimens in tension or compression were held at particular stresses [33]. The

time (seconds) to failure is given as a function of normalized stress (stress/Young's modulus (MPa/MPa)): Tension: Time to failure = 1.45 x 10'36 (normalized stress)158 Compression:Time to failure = 4.07 x 10~37 (normalized stress)178 (h) Fatigue Some workers report the log of the number of cycles as a function of the applied stress levels, some report the log cycle number as a function of log stress levels, and some report log stress levels as a function of log cycle number. [The last seems wrong, since the applied stress can hardly be a function of the number of cycles the specimen is going to bear, but it is frequently used in fatigue studies. It is not possible simply to reverse the dependent and independent axes because the equations are derived from regressions with associated uncertainty.] The variation between the results for different testing modes is considerable. Carter et al [34] report on the effect of Young's modulus of elasticity and porosity in their specimens. They find that Young's modulus is positively associated with fatigue life, and porosity is negatively associated: log Nf = -2.05 log Aa0 log Nf = -4.82 log Aa0 + 0.186 E log Nf = -2.63 log Aa0 -0.061 P log Nf = -4.73 log Aa0 +0.160 E -0.029 P (S.E. 0.599) (S.E. 0.387) (S.E. 0.513) (S.E. 0.363)

where Nf: number of cycles to failure; Aa0: initial stress range (these experiments were carried out under strain control, so stress range decreased as damage spread and the specimens became more compliant); E: Young's modulus (GPa); P: porosity (%). Incorporating Young's modulus into the equation has a marked effect in reducing the standard error; porosity has a much less strong effect. [N.B. Many workers normalize their data in an effort to reduce the effect that variations in Young's modulus have in increasing the scatter of the results.] Choi and Goldstein [15] provide alternate, somewhat higher values. (i) Effect of remodeling Vincentelli and Grigorov [35] examined the effect of Haversian remodelling on the tibia. The specimens they reported were almost entirely primary or Haversian, with few specimens having a scattering of secondary osteons. [Unfortunately they probably (it is not clear) allowed their

specimens to dry out, so it is not sure that bone in vivo would show the same behavior. However, their results are similar to those found in nonhuman specimens.]
Table A1.9 Effect of Remodeling [35] Property Tensile Strength (MPa) Ultimate Strain Young's modulus (GPa) Primary Osteons 162 0.026 19.7 Haversian Osteons 133 0.022 18.0

ADDITIONAL READING
Cowin, S.C. (ed.)(1989) Bone Mechanics Boca Raton: CRC Press. A more rigorous, less chatty and less biologically, oriented approach than the following books by Currey and by Martin and Burr. The chapters on mechanics (2, 6 and 7), written by Cowin himself, are particularly authoritative. Currey, J.D. (1984) The Mechanical Adaptation of Bones Princeton: University Press. Out of print, new edition in preparation. Tries to deal with all aspects of mechanical properties of bone as a material and of whole bones. Not overly technical. Written from a general biological perspective, thus, does not concentrate on human material. Martin, R.B. and Burr, D.B. (1989) Structure, Function and Adaptation of Compact Bone New York: Raven Press. There are not many values of mechanical properties here, but the treatment of the biology of bone, and of fatigue of bone tissue, is excellent and the discussion of remodeling, although now somewhat out of date, is a very good introduction to this intellectually taxing topic. Nigg, B.M. and Herzog, W. (eds)(1994) Biomechanics of the Musculoskeletal System John Wiley: Chichester. Deals with many aspects of biomechanics, including locomotion, with an emphasis on human material. There is a full treatment of the measurement of many biomechanical properties.

REFERENCES 1. Gong, J.K., Arnold, J.S. and Cohn, S.H. (1964) Composition of trabecular and cortical bone. Anat. Rec, 149, 325-331. 2. Biltz, R.M. and Pellegrino, E.D. (1969) The chemical anatomy of bone I. A comparative study of bone composition in sixteen vertebrates. /. Bone Joint Surg., 51A, 456^66.

3. Lees, S. and Escoubes, M. (1987) Vapor pressure isotherms, composition and density of hyperdense bones of horse, whale and porpoise. Con. Tiss. Res., 16, 305-322. 4. Keene, D.R., Sakai, L.Y. and Burgeson, R.E. (1991) Human bone contains type III collagen, type VI collagen, and fibrillin: Type III collagen is present on specific fibers that may mediate attachment of tendons, ligaments, and periosteum to calcified bone cortex. /. Histochem. Cytochem., 39, 59-69. 5. Danielsen, CC, Mosekilde, Li., Bollerslev, J. et al. (1994) Thermal stability of cortical bone collagen in relation to age in normal individuals and in individuals with osteopetrosis. Bone, 15, 91-96. 6. Ninomiya, J.T., Tracy, R.P., Calore, J.D., et al. (1990) Heterogeneity of human bone. /. Bone Min. Res., 5, 933-938. 7. Lowenstam, H.A. and Weiner, S. (1989) On Biomineralization, Oxford University Press, New York. 8. McConnell, D. (1962) The crystal structure of bone. CHn. Orthop. ReL Res., 23, 253-68. 9. Burr, D.B., Schaffler, M.B. and Frederickson, R.G. (1988) Composition of the cement line and its possible mechanical role as a local interface in human compact bone. /. Biomech., 21, 939-945. 10. Behari, J. (1991) Solid state bone behavior. Prog. Biophys. MoI. Biol, 56,1-41. 11. Martin, R.B. and Burr, D.B. (1989) Structure, Function, and Adaptation of Compact Bone, Raven Press, New York. 12. Scott, G.C. and Korostoff, E. (1990) Oscillatory and step response electromechanical phenomena in human and bovine bone. /. Biomech., 23, 127-143. 13. Currey, J.D. (1988) The effects of drying and re-wetting on some mechanical properties of cortical bone. /. Biomech., 21, 439-441. 14. Sedlin, E.D. (1967) A rheological model for cortical bone. Acta Orthop. Scand., (Suppl. 83), 1-78. 15. Choi, K. and Goldstein, S.A. (1992) A comparison of the fatigue behavior of human trabecular and cortical bone tissue. /. Biomech., 25, 1371-1381. 16. Lotz, J.C., Gerhart, T.N. and Hayes, W.C. (1991) Mechanical properties of metaphyseal bone in the proximal femur. /. Biomech., 24, 317-329. 17. Carter, D.R. and Caler, W.E. (1985) A cumulative damage model for bone fracture. /. Orthop. Res., 3, 84-90. 18. Bailey, AJ., Wotton, S.F., Sims, TJ. et al. (1993) Biochemical changes in the collagen of human osteoporotic bone matrix. Con. Tiss. Res., 29, 119-132. 19. Bateman, J.F., Chan, D., Mascara, T. et al. (1986) Collagen defects in lethal perinatal osteogenesis imperfecta. Biochem. J., 240, 699-708. 20. Saito, S. (1983) (Distribution of the X-ray density, compressive and tensile breaking strength in the human femoral shaft) Die Verteilung von Dichte, Druck und Festigkeit im menslichen Femurschaft. Anat. Anzeiger Jena, 154, 365-376. 21. Cowin, S.C. (1989) Bone Mechanics, CRC Press, Boca Raton. 22. Reilly, D.T. and Burstein, A.H. (1975) The elastic and ultimate properties of compact bone tissue. /. Biomech., 8, 393-405. 23. Ashman, R.B., Cowin, S.C, Van Buskirk, W.C. et al. (1984) A continuous wave technique for the measurement of the elastic properties of cortical bone. /. Biomech., 17, 349-361.

24. Reilly, D.T. and Burstein, A.H. (1974) The mechanical properties of cortical bone. /. Bone Joint Surg., 56A, 1001-1022 25. Keller, T.S. (1994) Predicting the compressive mechanical behavior of bone. /. Biomech., 27, 1159-1168. 26. Ascenzi, A. and Bonucci, E. (1967) The tensile properties of single osteons. Anat. Rec, 158, 375-386. 27. Ascenzi, A. and Bonucci, E. (1968) The compressive properties of single osteons. Anat. Rec, 161, 377-391. 28. Ascenzi, A., Baschieri, P., and Benvenuti, A. (1990) The bending properties of single osteons. /. Biomech., 23, 763-771. 29. Ascenzi, A., Baschieri, P., and Benvenuti, A. (1994) The torsional properties of single selected osteons. /. Biomech., 27, 875-884. 30. Carter, D.R. and Caler, W.E. (1983) Cycle-dependent and time-dependent bone fracture with repeated loading. /. Biomech. Eng., 105, 166-170. 31. Fondrk, M., Bahniuk, E., Davy, D.T. et al. (1988) Some viscoplastic characteristics of bovine and human cortical bone. /. Biomech., 21, 623-630. 32. Cezayirlioglu, H., Bahniuk, E., Davy, D.T. et al. (1985) Anisotropic yield behavior of bone under combined axial force and torque. /. Biomech., 18, 61-69. 33. Caler, W.E. and Carter, D.R. (1989) Bone creep-fatigue damage accumulation /. Biomech., 22, 625-635. 34. Carter, D.R., Caler, W.E., Spengler, D.M. et al. (1981) Uniaxial fatigue of human bone. The influence of tissue physical characteristics. /. Biomech., 14, 461-70. 35. Vincentelli, R., and Grigorov, M. (1985) The effect of haversian remodeling on the tensile properties of human cortical bone. /. Biomech., 18, 201-207.

Cancellous bone
T.M. Keaveny

A2

A2.1 STRUCTURE Trabecular bone consists primarily of lamellar bone, arranged in packets that make up an interconnected irregular array of plates and rods, called trabeculae. These trabeculae, on average, have thicknesses in the range of 100-200 microns, dependent upon both anatomic site and donor age [I]. The space between trabeculae is filled with bone marrow, and the precise architectural arrangement of the trabecular plates and rods also depends on anatomic site, making trabecular bone (at the continuum level) a highly heterogeneous material. Most mechanical properties of trabecular bone depend to a large degree on the apparent density, defined as the product of the density of the individual trabeculae (the 'tissue density') and the volume fraction of bone present in the bulk specimen. Volume fraction typically ranges from 0.60 for dense trabecular bone to 0.05 for porous trabecular bone [2,3]. The (wet) tissue density for human trabecular bone is fairly constant and is in the approximate range 1.6-2.0 g/cm3 [4,5]. By contrast, the (wet) apparent density varies substantially and is typically in the range 0.05-1.0 g/cm3 (Table A2.1). Compared to cortical bone, trabecular bone has a similar surface area-to-volume ratio (SVR, excluding lacunae and canaliculi), but SVR increases non-linearly with increasing volume fraction (VF) of bone [10]: SVR = 8.4 (VF)0-705

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

A2.2 COMPOSITION Individual trabeculae have relatively uniform compositions that are similar to cortical bone tissue (chapter Al), but are slightly less mineralized and slightly more hydrated than cortical tissue. The percent volume of water, inorganic, and organic components for hydrated trabeculae have been reported at 27%, 38%, and 35%, respectively [11], although the precise values depend on anatomic site, age, and health. Based on reported wet, dry, and ash apparent densities for specimens of defatted human lumbar spine trabecular bone [4], the percentage weights of the inorganic, organic, and water components for this tissue can be calculated at approximately 54%, 26%, and 20%, respectively. A2.3 MECHANICAL PROPERTIES A2.3.1 Modulus and strength Trabecular bone is essentially linearly elastic until yielding at strains of approximately 1-2%. After yielding, it can sustain large deformations (up to 50% strain) while still maintaining its load-carrying capacity. Thus, trabecular bone can absorb substantial energy upon mechanical failure. Being a heterogeneous open cell porous solid, trabecular bone has anisotropic mechanical properties that depend on the porosity of the specimen as well as the architectural arrangement of the individual trabeculae. In order to specify its mechanical properties, one must therefore specify factors such as the anatomic site, loading direction with respect to the principal orientation of the trabeculae, and age and health of the donor. Young's modulus can vary 100-fold within a single epiphysis [12] and can vary on average by a factor of three depending on loading direction [13-16]. Pathologies such as osteoporosis, osteoarthritis, and bone cancer are known to affect mechanical properties [17,18]. Typically, the modulus of human trabecular bone is in the range 0.010-2 GPa depending on the above factors. Strength, which is linearly and strongly correlated with modulus [12,15], is typically in the range 0.1-30 MPa. A2.3.2 Relationships between modulus and strength and density The relationships between the static mechanical properties of trabecular bone and apparent density vary for the different types of trabecular bone because of the anatomic site-, age-, and disease-related variations in trabecular architecture. Both linear and power-law relationships can be used to describe the dependence of modulus and compressive strength on apparent density (Tables A2.2, A2.3), with typical coefficients of determination (r2 values) in the range 0.5-0.9. Differences in the predictive

Table A2.1

Typical wet apparent densities, moduli, and compressive strengths for human trabecular bone Cadavers Specimens Wet Apparent Density (g/cm3) Mean (SD) 0.29 0.50 0.24 0.19 (0.10) (0.16) (0.07) (0.08) Range 0.09-0.66 0.14-1.00 0.11-0.47 0.06-0.40 Modulus (GPa) Mean (SD) Range Ultimate Strength (MPa) Mean (SD) 5.33 7.36 2.45 1.55 Range Source [6] [7] [8] [9]

Tissue Source Proximal Tibia** Femur*** Lumbar Spine* Lumbar Spine**

Number Ages Number 9 10 42 3 59-82 58-83 15-87 71-84 121 299$ 40 231

0.445 (0.257) 0.061-1.174 0.389 (0.270) 0.044-1.531 0.067 (0.044) 0.010-0.180 0.023 (0.015) 0.001-0.110

(2.93) 0.68-14.1 (4.00) 0.56-22.9 (1.52) 1.00-7.00 (1.11) 0.05-8.00

All mechanical data from tests with specimens oriented in the inferior-superior direction, unless noted. * The ash densities that were originally reported have been converted to wet densities using Y = 1.86 X, based on data from Table 1 [4]. ** The dry densities that were originally reported have been converted to wet densities using Y = 1.25 X, based on data from Table 1 [4]. t Proximal and distal femur pooled; proximal specimens oriented approximately along the femoral neck axis. $ Elastic modulus data for only 122 specimens.

power between the various linear and power laws are usually negligible since the range of apparent density exhibited by trabecular bone is less than one order of magnitude. Poisson's ratio is difficult to measure experimentally for a heterogeneous, cellular solid such as trabecular bone. Mean values of Poisson's ratio have been reported from close to zero to just less than one [23-26], with little known about the causes of this large range. The failure (yield and ultimate) strains of human trabecular bone have only a weak dependence, if any, on apparent density and modulus [8,9,19,27,28]. Mean ( SD) values of ultimate compressive strain for proximal tibial bone have been reported at approximately 2.00.4% [6]. Additional experiments are currently required to investigate potential effects of anisotropy, age and anatomic site on failure strains. On average, the tensile and compressive strengths appear to be equal [29], although the relationship between the tensile and compressive failure properties is not well understood. Elastic properties are the same in tension and compression. No reliable data exist for multiaxial failure behavior although it is unlikely that a von Mises-type criterion applies to this heterogeneous cellular solid.
A2.3.3. Viscoelastic properties

Trabecular bone is only slightly viscoelastic when tested in vitro, with both compressive strength and modulus being related to strain rate raised to a power of 0.06 [30,31]. The stiffening effect of marrow is negligible except at very high strain rates (10 strain/sec), although there is emerging evidence that the constraining effects of an intact cortical shell may allow hydraulic stiffening of whole bones in vivo under dynamic loads [32]. Minor stress relaxation has been shown to occur [33] and depends on the applied strain level [34], indicating that human trabecular bone is nonlinearly viscoelastic. The rate of change of the stress relaxation function (i.e. the ratio of stress to constant strain during relaxation) versus time for human femoral bone (tissue) varies from approximately 6.8 MPa/s to 18 MPa/s as a function of strain level [34]. Little else is known about its time dependent properties, including creep and fatigue. As a result, most finite element analyses are based on the assumption that the mechanical behavior of cancellous bone has no time dependence.
A2.3.4. Experimental problems

It should be noted that the in vitro mechanical test methods most often used to date suffer from 'end artifacts' [35-37], errors due to platenspecimen friction and machining-related damage of the specimen ends, which compromise the accuracy of most of the data. Modulus values are underestimated by at least 20% [36-38], with the error possibly depending

Table A2.2

Linear and power-law regressions between modulus (E in GPa) and wet apparent density (p in g/cm3)# Cadavers Specimens Number 121 75 49 199 a 1.207 4.360 0.160 E = a p +b b -0.0797 -0.0412 -0.007 r2 0.60 0.86 0.54 a 1.401 4.606 1.310 0.479 E = a pb b 1.43 1.07 1.40 ISA r2 0.66 0.86 0.91 0.70 Source [19] [20] [21] [22]

Tissue Source Proximal Tibia* Proximal Tibiat Proximal Femur ft Lumbar Spine**

Number 9 3 4 3

Age 59-82 52-67 25-82 70-84

* Compressive loading of human trabecular bone specimens loaded at 'low' strain rates (< 1.0/sec) and taken from a range of anatomic sites. ** Originally reported dry densities have been converted to wet densities. t Ultrasound was used to measure the elastic properties. ft Specimens oriented along femoral neck axis.

Table A2.3

Linear and power-law regressions between ultimate strength (a in MPa) and wet apparent density (p in g/cm3)# Cadavers Specimens Number 94 49 199 a 19.2 13.4 a = ap + b b -1.60 -0.97 r2 0.78 0.55 a 25.6 25.0 56.9
a = a pb

Tissue Source Proximal Tibia* Proximal Femurt Lumbar Spine**

Number 10 4 3

Age 60-83 25-82 70-84

b 1.60 1.80 2.30

r2 0.82 0.93 0.60

Source [19] [21] [22]

* For compressive loading of human trabecular bone specimens loaded at 'low' strain rates (< 1.0/sec) and taken from a range of anatomic sites. ** Originally reported dry densities have been converted to wet densities using y = 1.86x t Ultrasound was used to measure the elastic properties. (Note: A dash represents that no data were reported.)

on anatomic site from which the specimens are obtained. Similarly, strength values can also be in error [39], and failure strain data are also suspect [40] because of the confounding effect of the artifactual 'toe' [41] in the initial portion of the stress-strain curve. Thus, in vivo values of most of the above mechanical properties must be extrapolated carefully from the available in vitro data. Furthermore, inter-study comparisons of the in vitro data should address the confounding effects of these testing artifacts. ADDITIONAL READING Cowin S.C. (1989) Bone Mechanics, CRC Press, Boca Raton. Presents an excellent treatment (p. 129ff) of the structure-function relationships for trabecular bone using the principles of continuum mechanics and quantitative stereology. Gibson LJ. (1985) The mechanical behavior of cancellous bone. /. Biomech., 18, 317-328. Contains a theoretical analysis of some possible underlying deformation and failure mechanisms of individual trabeculae, based upon analogies to cellular solids. Goldstein S.A. (1987) The mechanical properties of trabecular bone: Dependence on anatomic location and function. /. Biomech., 20, 1055-1061. Keaveny T.M. and Hayes W.C. (1993) A 20-year perspective on the mechanical properties of trabecular bone. /. Biomech. Eng, 15, 534-542. These comprehensive articles provide a more general survey of properties than presented above and include results derived from animal bone, as well as data on the mechanical behavior of individual trabeculae. In the absence of human data, data from animal studies can be used, although extrapolation of behavior from differing anatomic sites must be done with caution. REFERENCES 1. Mosekilde, L. (1988) Age-related changes in vertebral trabecular bone architecture - Assessed by a new model. Bone, 9, 247-250. 2. Mosekilde, L., Bentzen, S.M., Ortoft, G. et al. (1989) The predictive value of quantitative computed tomography for vertebral body compressive strength and ash density. Bone, 10, 465-470. 3. Kuhn, J.L., Goldstein, S.A., Feldkamp, L.A. et al. (1990) Evaluation of a microcomputed tomography system to study trabecular bone structure. /. Orthop. Res., 8, 833-842. 4. Galante, J., Rostoker, W. and Ray, R.D. (1970) Physical properties of trabecular bone. Calcif. Tissue Res., 5, 236-246. 5. Ashman, R.B. and Rho, J.Y. (1988) Elastic modulus of trabecular bone material. /. Biomech., 21, 177-181. 6. Linde, F., Hvid, I. and Pongsoipetch, B. (1989) Energy absorptive properties of human trabecular bone specimens during axial compression. /. Orthop. Res., 1, 432^39

7. Rohlmann, A., Zilch, H., Bergman, G. et al. (1980) Material properties of femoral cancellous bone in axial loading. Part I: Time independent properties. Arch Orthop. Trauma Surg., 97, 95-102. 8 Mosekilde, L., Mosekilde, L. and Danielsen, CC. (1987) Biomechanical competence of vertebral trabecular bone in relation to ash density and age in normal individuals. Bone, 8, 79-85. 9. Hansson, T.H., Keller, T.S. and Panjabi, M.M. (1987) A study of the compressive properties of lumbar vertebral trabeculae: effects of tissue characteristics. Spine, 12, 56-62. 10. Fyhrie, D.P., Fazalari, N.L., Goulet, R. et al (1993) Direct calculation of the surface-to-volume ratio for human cancellous bone. /. Biomech., 26, 955-967. 11. Gong, J.K., Arnold, J.S. and Cohn, S.H. (1964) Composition of trabecular and cortical bone. Anal Rec, 149, 325-332. 12. Goldstein, S.A., Wilson, D.L., Sonstegard, D.A. et al (1983) The mechanical properties of human tibial trabecular bone as a function of metaphyseal location. /. Biomech., 16, 965-969. 13. Townsend, P.R., Raux, P. and Rose, R.M. (1975) The distribution and anisotropy of the stiffness of cancellous bone in the human patella. /. Biomech., 8, 363-367. 14. Linde, F., Pongsoipetch, B., Frich, L.H. et al (1990) Three-axial strain controlled testing applied to bone specimens from the proximal tibial epiphysis. /. Biomech., 23, 1167-1172. 15. Ciarelli, M.J., Goldstein, S.A., Kuhn, J.L. et al (1991) Evaluation of orthogonal mechanical properties and density of human trabecular bone from the major metaphyseal regions with materials testing and computed tomography. /. Orthop. Res., 9, 674-682. 16. Goulet, R.W., Goldstein, S.A., Ciarelli, MJ. et al. (1994) The relationship between the structural and orthogonal compressive properties of trabecular bone. /. Biomech., 27, 375-389. 17. Pugh, J.W., Radin, E.L. and Rose, R.M. (1974) Quantitative studies of human subchondral cancellous bone. Its relationship to the state of its overlying cartilage. /. Bone Joint Surg., 56A, 313-321. 18. Hipp, J.A., Rosenberg, A.E. and Hayes, W.C. (1992) Mechanical properties of trabecular bone within and adjacent to osseous metastases. /. Bone Miner. Res., 7, 1165-1171. 19. Hvid, L, Bentzen, S.M., Linde, F. et al (1989) X-ray quantitative computed tomography: The relations to physical properties of proximal tibial trabecular bone specimens. /. Biomech., 22, 837-844. 20. Ashman, R.B., Rho, J.Y. and Turner, CH. (1989) Anatomical variation of orthotropic elastic moduli of the proximal human tibia. /. Biomech., 22, 895-900. 21. Lotz, J.C, Gerhart, T.N. and Hayes, W.C (1990) Mechanical properties of trabecular bone from the proximal femur: A quantitative CT study. /. Comput. Assist. Tomogr., 14, 107-114. 22. Keller, T.S. (1994) Predicting the compressive mechanical behavior of bone. /. Biomech., 27, 1159-1168. 23. McElhaney, J., Fogle, J., Melvin, J. et al. (1970) Mechanical properties of cranial bone. /. Biomech., 3, 495-511.

24. Gilbert, J.A., Maxwell, G.M., McElhaney, J.H. et al. (1984) A system to measure the forces and moments at the knee and hip during level walking. /. Orthop. Res., 2, 281-288. 25. Klever, F., Klumpert, R., Horenberg, J. et al. (1985) Global mechanical properties of trabecular bone: experimental determination and prediction from a structural model. In Biomechanics: Current Interdisciplinary Research, 167-172, Ed. Perren S.M. and Schneider E.; Martinus Nijhoff, Dordrecht. 26. Snyder, B. (1991) Anisotropic Structure-Property Relations for Trabecular Bone. Ph.D. Dissertation, University of Pennsylvania, Philadelphia, PA. 27. Hvid, L, Jensen, N.C., Bunger, C. et al. (1985) Bone mineral assay: its relation to the mechanical strength of cancellous bone. Eng. Med., 14, 79-83. 28. Rohl, L., Larsen, E., Linde, F. et al. (1991) Tensile and compressive properties of cancellous bone. /. Biomech., 24, 1143-1149. 29. Carter, D.R., Schwab, G.H. and Spengler, D.M. (1980) Tensile fracture of cancellous bone. Acta Orthop. Scand., 51, 733-741. 30. Carter, D.R. and Hayes, W.C. (1977) The compressive behavior of bone as a two-phase porous structure. /. Bone Joint Surg., 59A, 954-962. 31. Linde, F., Norgaard, P., Hvid, I. et al. (1991) Mechanical properties of trabecular bone. Dependency on strain rate. /. Biomech., 24, 803-809. 32. Ochoa, J.A., Sanders, A.P., Heck, D.A. et al. (1991) Stiffening of the femoral head due to inter-trabecular fluid and intraosseous pressure. /. Biomech. Eng., 113, 259-262. 33. Zilch, H., Rohlmann, A., Bergmann, G. et al. (1980) Material properties of femoral cancellous bone in axial loading. Part II: Time dependent properties. Arch. Orthop. Trauma. Surg., 97, 257-262. 34. Deligianni, D.D., Maris, A. and Missirlis, Y.F. (1994) Stress relaxation behaviour of trabecular bone specimens. /. Biomech., 27, 1469-1476. 35. Linde, F., Hvid, I. and Madsen, F. (1992) The effect of specimen geometry on the mechanical behaviour of trabecular bone specimens. /. Biomech., 25, 359-368. 439. 36. Keaveny, T.M., Borchers, R.E., Gibson, LJ. et al. (1993) Theoretical analysis of the experimental artifact in trabecular bone compressive modulus. /. Biomech., 26, 599-607. 37. Zhu, M., Keller, T.S. and Spengler, D.M. (1994) Effects of specimen loadbearing and free surface layers on the compressive mechanical properties of cellular materials. /. Biomech., 27, 57-66. 38. Odgaard, A. and Linde, F. (1991) The underestimation of Young's modulus in compressive testing of cancellous bone specimens. /. Biomech., 24, 691-698. 39. Keaveny, T.M., Borchers, R.E., Gibson, LJ. etal. (1993) Trabecular bone modulus and strength can depend on specimen geometry. /. Biomech., 26,991-1000. 40. Turner, CH. (1989) Yield behavior of bovine cancellous bone. /. Biomech. Eng., Ill, 256-260. 41. Keaveny, T.M., Guo, X.E., Wachtel, E.F. et al. (1994) Trabecular bone exhibits fully linear elastic behavior and yields at low strains. /. Biomech., 27, 1127-1136.

A3

Dentin and enamel

K.E. Healy

A3.1 INTRODUCTION A3.1.1 Structure of human dentition:

The permanent adult human dentition normally consists of 32 teeth, of which 16 are located in the mandible and 16 in the maxilla. There are 4 incisors, 2 canines, 4 premolars and 6 molars for the upper and lower dentition. The incisors are used for cutting food, the canines for tearing, the premolars for grasping, and the molars for grinding (i.e., masticating). There is a generic heterogeneous structure for these teeth, where enamel forms an exterior layer over the underlying dentin. From the cervix to the apex of the root, the exterior of the dentin is covered by cementum to which the periodontal ligament attaches the tooth to alveolar bone. Dental enamel is dense, highly mineralized, hard, and brittle. It contains prism-like structures that span from the enamel surface to the junction of enamel and dentin, the dentino-enamel junction (DEJ). The prisms are comprised of hydroxyapatite crystallites and contain very little organic matrix. These properties make dental enamel an excellent material for cutting and masticating food (i.e., processes that involve friction and wear). In contrast, dentin is not as hard as enamel, but it is tougher. Dentin is a heterogeneous material and can be thought of as a composite structure containing four major components: dentin matrix; dentinal tubules; mineral (i.e., carbonate containing hydroxyapatite); and, dentinal fluid. The dentinal tubules (-45 000 per mm2) are formed during development of the dentin matrix and are distributed throughout the dentin matrix in a somewhat uniform manner. The dentin matrix mineralizes in an anisotropic fashion, where a highly mineralized tissue, peritubular dentin,
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

surrounds the dentinal tubules. The mineralized tissue between the dentinal tubules and peritubular dentin is referred to as intertubular dentin. Histological examination has revealed that intertubular dentin is less mineralized than peritubular dentin. Furthermore, the matrix and mineral content of root dentin is different from coronal dentin. A good review of the structure of teeth can be found in Waters [I]. A3.2 COMPOSITION
Table A3.1 Basic Constituents of Human Dentin and Enamel* Enamel Weight % Volume %
Mineral (density, 3000 kg nr ) Organic (density, 1400 kg nr 3 ) Water (density, 1000 kg nr 3 ) * Adapted from [1-3].
3

Dentin Weight % Volume %

70 20 10 50 30 20 90

96 1 3

2 8

Table A3.2

Major Elemental Composition of Surface and Bulk Dental Enamel Dentin Mean wt% (range or standard deviation, ) 26.9 0.2 (21.8-31.3) 27.6 0.1 (24.7-31.5) 13.5 0.1 0.72 0.008 (0.26-0.87) 0.64 0.001 (0.55-0.75) 0.05 0.004 0.072 0.022 0.02 0.001 0.74 0.02 (0.25-0.94) 0.76 0.004 (0.58-0.89) 4.6 (4-5) Source, Comments [4]# [5]# [5]* [5], age >25yrs [6]D [5]# [5]t [5]#, age >25yrs [7]# [5]t, age <25yrs [5]# [5]* [2,3]t

Enamel Mean wt% (range or standard deviation, ) Ca 31A 1.0 37.1 0.2 (26.7-47.9) 36.3 0.1 (27.7^2.0) 17.8 0.2 17.68 0.2 0.72 0.008 (0.42-1.03) 0.72 0.008 (0.49-0.88) 0.28 0.01 0.32 0.01 0.026 0.001 0.39 0.02 (0.13-0.77) 0.32 0.004 (0.24-0.48) 3.2 (2.4-4.2)

P Na Cl K Mg CO 3

Neutron activated gamma-ray spectrometric analysis. Atomic absorption spectrophotometry. Colorimetic assay. Average compiled from the literature. Neutron activated gamma-ray spectrometric analysis (Na, Cl, Al, Mn, Ca, and P), atomic absorption spectrophotometry (K, Mg, Zn, Cu, and Fe), or afluoride-specificelectrode (F). Atomic absorption spectrophotometry (Ca), and colorimetric method (P).

Table A3.3 Trace Elemental Composition of Surface and Bulk Dental Enamel Surface Enamel
At#

Whole Enamel Mean (range) Vg/g 281 (530-130) 293 (730-95) 123.8 7.9 199 (400-91) 276 106 263.42 14.8 1,670 (3,000-470) 12.5 (70-1.5) 81 (280-26) 93.5 21.9 111.19 9.86 4.4 (21-0.8) 2.77 0.28 (0.64-0.08) 0.54 0.08 0.59 0.04 0.35 (1.3-0.03) 0.56 0.29 3.6 (6.5-1.3) 4.2 (13-0.8) 0.27 (0.5-0.12) 1.13 (3.4-0.23) 0.13 (0.34-0.02) 0.21 (0.92-0.03) 5.0 (39-0.5) 4.20 (81-0.1) 0.26 0.11 1.38 1.12 (2.6-0.32) 4.6 1.1 0.51 (2.4-0.03) 0.007 (0.17-<0.01) 0.19 (4.4-<0.1) 0.017 (0.03-0.01) 3.2 (18-0.1) 1.02 0.51 Median Vg/g 270 200 190 1,550 5.6 56 2.6 0.26 0.16 3.6 3.4 0.22 0.93 0.11 0.14 2.4 0.45 0.93 0.22 <0.01 <0.1 0.02 1.5 Source, comments [8]t,[9]t [8]t,[9]* [10]0 [8]t,[9]t [4]# [10]0 [8]t,[9]t [8]t,[9]t [8]t,[9]J [4]# [10]0 [8]t,[9]t [7]* [8]t,[9]t [8]t,[9]t [4]# [10]0 [8]t,[9]t [10]0 [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [4]#

Mean (range) Vg/g 752 (1948-25) 893 (5400-61) 745 (3600-115) 343 (2304-16) 204 (7632-9) 138 (1404-18) 70 (504-1.3) 59 (468-2.6) 32 (396-0.2) 24 (79-1.2) 23 (270-0.4) 22 (432-0.8) 18 (72-2.9) 14 (58-0.3) 8 (90-0) 6 (32-0) 9.3 (72-0.9) 7.6 (39.6-0.5) 5.3 (13.0-0.8)

Median Vg/g 666 576 576 202 36 68 40 33 2 18 9 7 16 10 3 5 5.8 4.0 3.6

S F Zn Mg Al Sr Fe Si Mn Ag Pb Ni Ba Se Li Sb Ga Sn Ge B Cu Br Cd Y Ti V La Be Cr

16 9 30 12 13 38 26 14 25 47 82 28 56 34 3 51 31 50 32 5 29 35 48 39 22 23 57 4 24

3.1 (14.0-0.4) 2.7 1.8 1.6 1.4 1.4 1.3 1.1 (7.6-0.6) (9.3-0) (24.5-0.1) (14.4-0.1) (7.2-0) (6.1-0) (4.7-0.2)

4.1 1.8 0.9 0.6 0.5 0.8 1.2 0.7

m*
[8]t,[9]t [4]# [8]t,[9]t [8]t,[9]$ [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]t [8]t,[9]$ [10]0

Table A3.3

Continued Surface Enamel Whole Enamel Mean (range) Vg/g 0.39 (0.87-0.17) 0.1 (0.57-<0.02) 0.07 (1.9-0.02) 0.24 0.12 0.13 0.13 0.027 (0.07-<0.01) 0.04 (0.1-<0.02) 7.2 (39-0.7) 0.036 (0.07-0.01) 0.006 (0.07-<0.02) 0.28 (0.76-<0.1) 0.02 0.01 Median Vg/g 0.32 0.07 0.07 Source, comments

At.# Rb Zr Ce W Co Pr Cs Mo I Bi Nd Nb Au 37 40 58 74 27 59 55 42 53 83 60 41 79

Mean (range) 0.6 (4.0-0.1) 0.6 (1.9-0) 0.6 (6.1-0) 0.2 (2.7-0)

Median Vg/g 0.4 0.3 0 0.1 0 0 0.04 0.05 0 0.05

[8]t,[9]t [8]t,[9]i [8]t,[9]t [8]t,[9]t

[s\um
0.03 0.04 6.3 0.03 0.02 0.24

0.2 (4.7-0) 0.1 (1.9-0) 0.1 (0.5-0.04) 0.05 (4.7-0) 0.001 (0.04-0) 0.045 (0.09-<0.02)

[10]0 [8]t,[9]t [8]t,[9]t [8]t,[9]* [8]t,[9]t [8]t,[9]$ [8]t,[9]t [8]t,[9]t [4]#

$ Whole enamel from premolars of young patients (age<20 yrs), determined by spark source mass spectroscopy. f Surface enamel (depth of analysis 42 8.5 um) from premolars of young patients (age<20 yrs), determined by spark source mass spectroscopy. # Bulk enamel from premolars of 14-16 yrs male and female patients, selected population of Stockholm Sweden, determined by neutron activated gamma-ray spectrometric analysis. Standard deviation, . 0 Neutron activated gamma-ray spectrometric analysis. * Neutron activated gamma-ray spectrometric analysis (Na, Cl, Al, Mn, Ca, and P), atomic absorption spectrophotometry (K, Mg, Zn, Cu, and Fe), or afluoride-specificelectrode (F).

Table A3.4 Significant Differences in Trace Element Composition of Whole Human Enamel for High and Low Caries Populationsf At.# F Sr Mn Zr Cu 9 38 25 40 26 High Caries (Mean SE), \x,g/g 82.1 7.99 104.1 9.14 1.57 0.24 0.27 0.1 0.71 0.2 Low Caries (Mean SE), |xg/g 125.7 184.0 0.87 0.16 0.17 11.23 14.68 0.15 0.09 0.04 Source [Tl] [11] [12] [11] [12]

t Determined by spark source mass spectroscopy

Table A3.5

Ca/P Molar Ratio of Human Enamel and Dentin Dentin Ca/P molar ratio 1.54 1.58 1.61 Source, comments [4]# [5]t, , age >25 yrs [5]*, , age >25 yrs [13]** [6]D [14]**

Enamel Ca/P molar ratio 1.58 1.61 1.58 1.65 1.64

# Neutron activated gamma-ray spectrometric analysis. t Ca determined by neutron activated gamma-ray spectrometric analysis * Ca determined by atomic absorption spectrophotometry P determined by colorimetic assay. ** Determined by energy dispersive X-ray analysis. a Determined by atomic absorption spectrophotometry (Ca), and by the colorimetric method (P).

Table A3.6 Crystallite Size and Lattice Parameters of the Apatite in Human Enamel and Dentin* a-axis (nm) Enamel 0.9445 0.9440 0.9441 0.9446 Dentin 0.9434 0.0007 0.6868 0.0009 [18]* 29.6 3.7 36.55 1.45 3.2 0.5 10.33 7.91 [19]#, intertubular dentin [20]#, mixed carious and sound dentin 0.6885 0.6872 0.6880 0.6886 68.4 3.4 68.3 13.4 26.3 2.2 26.3 2.19 [2]# [15]t [6]t,# S.D. [16]t [17]$,# S.E. c-axis (nm) Width (nm) Thickness (nm) Source, Comments

Asymmetric hexagonal crystal with the thickness of the crystal less than the width. X-ray diffraction method of determination. High resolution transmission electron microscopy. Data from [2], average compiled from the literature.

Table A3.7 Elastic Moduli and Viscoelastic Properties of Human Dentin and Enamel Incisors Canine E: Dentin 13 (4) 9.7 (2) 14 (6) 12 (3) 14 (0.7) 9.0 (2) 11.0 (5.8) 12 (2) 7.6 (3) 10.16 10.87 9.49 84.3 (8.9) 77.9 (4.8) 46 (5) 32 (4) 9.7 (3) 12 (3) 12 H1(I): Dentin 0.38 (0.136) [25] c, constant strain, hydrated ,*,$
E: modulus of elasticity (GPa); Er (<): relaxed modulus (GPa); H1(Q: distribution of relaxation times (GPa); c: compression; t: tension; b: three-point bending. Il Applied load approximately parallel to either the long axis of the enamel rods or dentinal tubules. "Applied load approximately perpendicular to either the long axis of the enamel rods or dentinal tubules. f Applied load with respect to either the long axis of the enamel rods or dentinal tubules was variable. $ Type of tooth unknown or various teeth used for measurement; data are tabulated under molar. Note: standard deviations are given in parentheses.

Pre-molars

Molars

Source, Comments [21]t,t,t [22]Crown, c,t [22]Root, c,t [23]b,ll [23] b,dehyd., Il [23] b, re-hyd, Il [24]Cusp, c, Il [24]Side, c, Il [22]Cusp, c,t [22]Axial (side), c, ~ [22]Axial (side), c, Il [22]Occlusal, c, Il [25]c, constant strain, hydrated,",$

E: Enamel 48 (6) 33 (2) Er(): Dentin

Table A3.8 Mechanical Properties of Human Enamel

Incisors Stress at Proportional Limit (MPa) Canine Pre-molars Molars 353 (83) 336 (61) 224 (26) 186.2 (17) 70.3 (22) 98.6 (26) 10 (2.6) 384 (92) 372 (56) 261 (41) 239 (30) 94.5 (32) 127 (30) Source, comments [24]Cusp, c, Il [24]Axial(side), c, Il [22]Cusp, c,t [22]Axial (side), c, ~ [22]Axial (side), c, Il [22]Occlusal, c, Il [22]Incisal edge, c,t [26]t [24]Cusp, c, Il [24]Axial (side), c, Il [22]Cusp, c,t [22]Axial (side), c, ~ [22]Axial (side), c, Il [22]Occlusal, c, Il [22]Incisal edge, c,t

194 (19) 183 (12) 91.0 (10)

Tensile Strength (MPa) Compressive Strength (MPa) 288 (48) 253(35) 220 (13)

c: compression; hyd: hydrated; dehyd: dehydrated; re-hyd: re-hydrated. Il Fracture or applied load approximately parallel to the long axis of the enamel rods. ~ Fracture or applied load approximately perpendicular to the long axis of the enamel rods. f Applied load with respect to either the long axis of the enamel rods or dentinal tubules was variable. $ Type of tooth unknown or various teeth used for measurement; data are tabulated under molar. Note: standard deviations are given in parentheses.

Table A3.9 Mechanical Properties of Human Dentin Incisors Stress at Proportional Limit (MPa) 124 (26) 86 (24) Canine 140 (15) 112 (34) Pre-molars 146 (17) 110 (38) Molars Comments 167 (20.0) 24]c 148 (21) 22]c 108 (39) 22]c 110.5 (22.6) 23]b, hyd., Il 167.3 (37.5) [23]b, dehyd, Il 103.1 (16.8) [23]b, re-hyd, Il 158 (32) [17] 154 (23) [17] 52 (10) [26]hyd,t,t 37.3 (13.6) [23]hyd, Il 34.5 (11.1) [23]dehyd, Il 37.3 (9.0) [23]re-hyd, Il 39.3 (7.4) [21]hyd,t,t 297 (24.8) [24]Crown 248 (10) 305 (59) [22]Crown 231 (38) 250 (60) [22]Root 295 (21) [23]Crown,t 251 (30) [23]Crown,t 134 (4.5) [27]Oil, Cervical root, \t 165.6 (36.1) [23]hyd, Il 167.3 (37.5) [23]dehyd, Il 162.5 (25.4) [23]re-hyd, Il

Tensile Strength (MPa) Compressive Strength (MPa) Shear Strength (MPa) Flexural Strength (MPa)

232 (21) 276 (72) 233 (66) 217 (26)

hyd: hydrated; dehyd: dehydrated; re-hyd: re-hydrated Il Applied load approximately parallel to the long axis of the dentinal tubules * Applied load approximately perpendicular to the long axis of the dentinal tubules; t Type of tooth unknown or various teeth used for measurement; data are tabulated under molar; t Applied load with respect to either the long axis of the dentinal tubules was variable. $ 95% confidence intervals. Note: standard deviations are given in parentheses.

Table A3.10 Toughness, Fracture Toughness, and Work of Fracture of Human Dentin and Enamel Incisors Fracture Toughness, Kc (MNm-372) Enamel 0.97(0.09) 1.00(0.23) 1.27(0.09) Toughness (MJm 3 ) Dentin 0.7(0.08) [28]* Maxillary, cervical,t Mandibular, cervical,t Canine Pre-molars Molars Source, comments

62.7 (6.2)t 2.4 (1.1)

[27] Root, shear, oil storage, ~,t [17]Tension, crown, hydr., Il

Work of Fracture (102 Jm-2) Dentine Enamel

2.7 (1.6) 5.5 (1.7) 1.9(0.56) 0.13(.065)

[29] ~ [29] Il [29] ~ [29] Il

Il Applied load approximately parallel to either the long axis of the enamel rods or dentinal tubules. " Applied load approximately perpendicular to either the long axis of the enamel rods or dentinal tubules. t Applied load with respect to either the long axis of the enamel rods or dentinal tubules was variable. X Type of tooth unknown or various teeth used for measurement; data are tabulated under molar. * Microindentation method used. Load was 500 g with a Vickers' indenter. Note: standard deviations are given in parentheses.

Table A 3 . l l units)

Hardness of Fracture of Human Dentin and Enamel (see notes for Incisor Pre-molar Molar 393 (50) 385 (5.8) 367 (17) 327 (34) Source, comments [30] >90% incisors,,t [3O]J, molars and premolars,,t [31],t,t [32] II,, incisors, premolars [32]",, incisors, premolars [33]A, II, [34]a [33]a, calculated for zero tubule density [14]0, II, [34]a [14] a, calculated for zero tubule density [31],t,*

Enamel

365 (35)

Dentin 25-81.7 97.8 44.5-80.9 100 75 (0.8)

a

Inverse correlation between hardness and dentinal tubule density. Il Applied load approximately parallel to either the long axis of the enamel rods or dentinal tubules. " Applied load approximately perpendicular to either the long axis of the enamel rods or dentinal tubules. t Applied load with respect to either the long axis of the enamel rods or dentinal tubules was variable. % Type of tooth unknown or various teeth used for measurement; data are tabulated under molar. * Microindentation method used. Load was 500 g with a Vickers' indenter. Knoop hardness test using 500 g load. Knoop microhardness test using 50 g load. A Knoop microhardness test using 100 g load. 0 Microindentation method used. Load was 50 g with a Vickers' indenter.

Table A3.12

Permeability 3 of Human Dentin Center (\xl cm'2 min1) 14.3 (7.0)t Source, comments [33], unerupted third molars,

Periphery (\d cm'2 min1) 36.4 (13.1)4:

a

Fluid filtration rate. $ Sound human dentin, average of 4 samples, 4 readings per sample. t Sound human dentin, average of 4 samples, 1 reading per sample.

Table A3.13 Wetability of Human Enamel Surface Tension, yLV (dynes/cm) 72.4 72.8 72.6 63.7 63.4 63.4 58.5 58.2 58.2 53.5 54.0 54.0 51.7 50.8 50.8 49.8 47.5 44.6 44.6 42.0 41.8 38.7 32.7 33.0 27.6 27.7 [35] [35] [35] [34] Contact Angle, 0 (deg) In situ enamel 25.4 [36]t 36 40.0 (0.1) 44.7 [36]t 55 45.6 (0.2) 28.0 [35]t 24 37.6 (0.1) 30.8 [36]t 43 27.6 (0.2) [35] [35] 48.6 [36]t 50 38.1 (0.1) 38.3 [36]t 40 34 16.1 (0.1) [35] [35] [35] 22 31.8 [36]t 20 12.2-spread 7 spreading spreading [37] [36] [37] [36]f [37] [36]t Ground enamel Source Comments

Liquid Polar Water Glycerol Formamide Thiodiglycol Non-polar Methylene iodide S-Tetrabromoethane 1 -Bromonaphthalene o-Dibromobenzene Propylene carbonate 1 -Methyl-naphthalene Dicyclohexyl n-Hexadecane

[37] [38]* n=330 [37] [38]* n=50 [36] [37]* n=50 [37] [38]* n=60 [37] [38] n=50 [38] [38]*, n=50

* Plane ground enamel surfaces, measurements from 46 erupted and unerupted teeth, mixed location (molars, premolars, incisors). Parentheses: standard error t: in situ contact angle measurements on human enamel, average of mean values for 4 teeth (maxillary or mandibular incisors).

Table A3.14 Wetability of Human Dentin [38] Liquid Polar Water Glycerol Formamide Thiodiglycol Non-polar Methylene iodide 1 -bromo-naphthalene Ground Dentin Surface Tension, yLV (dynes/cm) Contact Angle, 0 (deg) Comments 72.6 63.4 58.2 54.0 50.8 49.8 45.3 44.6 37.6 33.6 (0.2) (0.1) (0.2) (0.3) *, n=100 *, n-50 *, n=50 *, n=50 *, n=50 *, n=50

36.7 (0.3) 16.8 (0.2)

* Plane ground dentin surfaces, measurements from 46 erupted and unerupted teeth, mixed location (molars, premolars, incisors). Parentheses: standard error.

Table A3.15 Critical Surface Tensions (7J of Human Enamel and Dentin Critical Surface Tension, yc (dynes cm1) Enamel Ground surface In situ enamel, 7cp In situ enamel, 7cd In situ enamel, 7cd Dentin
a

Source, Comments

46.1 (40.0 - 55.6)a 45.3 70.2b 32.9 4.7 32 45.1 (40.7 - 51.1)a

[38]*, calculated from polar and non-polar liquids [39]A, calculated from polar liquids, [38]A, calculated from non-polar liquids [37] f, calculated from non-polar liquids [38]*, calculated from polar and non-polar liquids

Range of values from different test liquids. Standard deviation. * Plane ground dentin surfaces, measurements from 46 erupted and unerupted teeth, mixed location (molars, premolars, incisors). Parentheses: standard error. A In situ measurements from 76 test subjects: 29 female and 47 male. Measurements made on teeth with intact pellicle (i.e., biofilm). 7 / only calculated from glycerol and thiodiglycol. t Average of 4 teeth from 2 subjects. 7cd calculated from non-polar liquids.

A3.3 FINAL COMMENTS The quality of data presented can be inferred from the standard deviations or standard error associated with the mean values. In some cases the error can be attributed to either small sample populations or specimen preparation. Where possible, either the number of specimens used or the number of replications of a measurement was reported. The reader

should use this information as a guideline of the quality of data. When data are reported for small sample populations, then these data were usually the only source for a given physical property. In review of the literature, specimen preparation appears to have had the most influence on the precision and accuracy of data. Sample collection and storage conditions (e.g., dehydration, crosslinking agents, exogenous contamination) need to be taken into consideration when utilizing the information tabulated. Additional sources of error are dependent on the analytical technique or test method used to make the measurement. It is more difficult to discern the influence of the instrumentation on the reliability of the measurements. However, confidence of the accuracy was judged based on the use of adequate control samples with known physical properties (e.g., correction of mechanical data). In light of these comments, data in the literature were deemed most accurate and appropriate for this handbook when the following conditions were met: the sample population was large; non-destructive specimen preparation and storage conditions were used; and, multiple replications of measurements on a single sample were performed. There are significant omissions in the data available in the literature. Most notable, is the lack of quantitative analysis of the organic phase of dentin and enamel, and determination of the viscoelastic properties of dentin. The lack of data is attributed to the technical difficulty required to make such measurements and the heterogeneous nature of the dentin, which imparts large variations in these data depending on anatomical location. Other significance absences are the lack of electrical and thermal properties. Finally, vacancies in the tables provided demonstrate omissions in available data. ADDITIONAL READING
Carter, J.M., Sorensen, S.E., Johnson, R.R., Teitelbaum, R.L. and Levine, M.S. (1983) Punch Shear Testing of Extracted Vital and Endodontically Treated Teeth. /. Biomechanics 16(10), 841-848. Utilized a miniature punch shear apparatus to determine shear strength and toughness perpendicular to the direction of dentinal tubules. Dentin harvested from the cemento-enamel junction to one-third the distance to the root apex. Strengths: novel measurements, precise measurements, denned specimen location, denned orientation of testing. Limitations: tooth type not defined for 'constrained' tests, teeth stored in mineral oil prior to testing. Driessens, F.C.M., and Verbeeck, R.M.H. (1990a) The Mineral in Tooth Enamel and Dental Carries. In Biominerals, F.C.M and Verbeeck, R.M.H. (eds), CRC Press, Boca Raton, Florida, pp. 105-161. Driessens, F.C.M., and Verbeeck, R.M.H. (1990b) Dentin, Its Mineral and Caries, In Biominerals, F.C.M and Verbeeck, R.M.H. (eds), CRC Press, Boca Raton, Florida, pp. 163-178.

An authoritative text on biominerals with an excellent review of the properties of enamel and dentin. An excellent supplement to this handbook. Glantz, P-O. (1969) On Wetability and Adhesiveness. Odontologisk Revy, 20 supp. 17, 1-132. Comprehensive assessment of the wetability of human enamel and dentin. Strengths include using multiple probe liquids on numerous teeth. Korostoff, E., Pollack, S.R., and Duncanson, M.G. (1975) Viscoelastic Properties of Human Dentin. /. Biomedical Materials Res., 9, 661-674. Measured some viscoelastic properties of human radicular dentin under constant strain. Linear viscoelastic theory applied. Strengths: unique examination of viscoelastic properties, defined orientation of dentinal tubules, storage conditions and testing environment well controlled. Limitations: large scatter in H1(I), mixed data for different teeth. Marshall, G.W. (1993) Dentin: Microstructure and Characterization. Quintessence International, 24(9), 606-616. A Review of the microstructure and characterization of dentin. Waters, N.E. (1980) Some Mechanical and Physical Properties of Teeth. Symposia of the Society for Experimental Biology, 34, 99-135. Concise review of mechanical and physical properties of teeth. Good paper for anatomy of enamel and dentin.

REFERENCES 1. Waters, N.E. (1980) Some mechanical and physical properties of teeth. Symp. Soc. Exp. BwL9 34, 99-135. 2. Driessens, F.C.M. and Verbeeck, R.M.H. (1990) The mineral in tooth enamel and dental caries. In: Biominerals, F.C.M. and Verbeeck, R.M.H. (eds), CRC Press, Boca Raton, Florida, pp. 105-161. 3. Driessens, F.C.M. and Verbeeck, R.M.H. (1990) Dentin, its mineral and caries, In: Biominerals, Driessens, F.C.M. and Verbeeck, R.M.H. (eds), CRC Press, Boca Raton, Florida, pp. 163-178. 4. Soremark, R. and Samsahl, K. (1961) Gamma-ray spectrometric analysis of elements in normal human enamel. Arch. Oral. Bio., Special SuppL, 6,275-283. 5. Derise, N.L., Ritchey, SJ. and Furr, A.K. (1974) Mineral composition of normal human enamel and dentin and the relation of composition to dental caries: I Macrominerals and comparison of methods of analyses. /. Dental Res., 53(4), 847-852. 6. LeGeros, R.Z., Silverstone, L.M., Daculsi, G. et al. (1983) In vitro caries-like lesion formation in F-containing tooth enamel. /. Dental Res., 62(2), 138-144. 7. Lakomaa, E-L. and Rytomaa, I. (1977) Mineral composition of enamel and dentin of primary and permanent teeth in Finland. Scand. J. Dent. Res., 85, 89-95. 8. Cu tress, T. W. (1979) A preliminary study of the microelement composition of the outer layer of dental enamel. Caries Res., 13, 73-79. 9. Losee, F.L., Cutress, T.W. and Brown, R. (1974) Natural elements of the periodic table in human dental enamel. Caries Res., 8, 123-134.

10. Retief, D.H., Cleaton-Jones, P.E., Turkstra, J. et al. (1971) The quantitative analysis of sixteen elements in normal human enamel and dentine by neutron activation analysis and high-resolution gamma-spectrometry. Arch. Oral Bio., 16, 1257-1267. 11. Curzon, M.E.J. and Losee, F.L. (1977) Dental caries and trace element composition of whole human enamel: Eastern United States. /. Amer. Dental Assoc, 94, 1146-1150. 12. Curzon, M.E.J. and Losee, F.L. (1978) Dental caries and trace element composition of whole human enamel: Western United States. /. Amer. Dental Assoc, 96, 819-822. 13. Kodaka, T., Debari, K., Yamada, M. et al. (1992) Correlation between microhardness and mineral content in sound human enamel. Caries Res., 26,139-141. 14. Panighi, M. and G'Sell, C. (1992) Influence of calcium concentration on the dentin wetability of an adhesive. /. Biomed. Mater. Res., 26, 1081-1089. 15. Holcomb, D.W. and Young, R.A. (1980) Thermal decomposition of human tooth enamel. Calcif. Tiss. Intern., 31, 189-201 16. Sakae, T. (1988) X-Ray diffraction and thermal studies of crystals from the outer and inner layers of human dental enamel. Archs. Oral Bio., 33(10), 707-713. 17. Huang, T.-J.G., Schilder, H. and Nathanson, D. (1992) Effects of moisture content and endodontic treatment on some mechanical properties of human dentin. /. Endodontics, 18(5), 209-215 17. Kerebel, B, Daculsi, G. and Kerebel, L.M. (1979) Ultrastructure studies of enamel crystallites. /. Dental Res., 58(B), 844-851. 18. Jerv0e, P. and Madsen, H.E.L. (1974) Calcium phosphates with apatite structure. I. Precipitation at different temperatures. Acta Chem. Scand., A28, 477-481. 19. Daculsi, G., Kerebel, B. and Verbaere, A (1978). (Methode de mesure des cristaux d'apatite de Ia dentine humanie en microscopie electronique en transmission de Haute Resolution)(Fr.)(Method of measurement of apatite crystals in human dentin by high resolution transmission electron microscopy), Comptes Rendu Acad. ScL Paris, Ser. D., 286, 1439. 20. Voegel, J.C. and Frank, R.M. (1977) Ultrastructural study of apatite crystal dissolution in human dentine and bone. Jour. Biol. Buccale, 5, 181-194. 21. Lehman, M.L. (1963) Tensile strength of human dentin. /. Dent. Res., 46(1), 197-201. 22. Stanford, J.W., Weigel, K.V., Paffenbarger, G.C. et al. (1960) Compressive properties of hard tooth tissues and some restorative materials. /. American Dental Assoc, 60, 746-756. 23. Jameson, M.W., Hood, J.A.A. and Tidmarsh, B.G. (1993) The effects of dehydration and rehydration on some mechanical properties of human dentine. /. Biomech., 26(9), 1055-1065. 24. Craig, R.G., Peyton, F.A. and Johnson, D.W. (1961) Compressive properties of enamel, dental cements, and gold. /. Dent. Res., 40(5), 936-945. 25. Korostoff, E., Pollack, S.R. and Duncanson, M.G. (1975) Viscoelastic properties of human dentin. /. Biomed. Mater. Res., 9, 661-674. 26. Bowen, R.L. and Rodriguez, M.S. (1962) Tensile strength and modulus of elasticity of Tooth Structure and Several Restorative Materials. /. American Dental Assoc, 64, 378-387.

27. Carter, J.M., Sorensen, S.E., Johnson, R.R., et al. (1983) Punch shear testing of extracted vital and endodontically treated teeth. /. Biomech., 16(10), 841-848. 28. Hassan, R., Caputo, A.A. and Bunshah, R.F. (1981) Fracture toughness of human enamel. /. Dent. Res., 60(4), 820-827. 29. Rasmussen, S.T., Patchin, R.E., Scott, D.B. et al (1976) Fracture properties of human enamel and dentin. /. Dent. Res., 55(1), 154-164. 30. Caldwell, R.C., Muntz, M.L., Gilmore, R.W. et al. (1957) Microhardness studies of intact surface enamel. /. Dent. Res., 36(5), 732-738. 31. Remizov, S.M., Prujansky, L.Y. and Matveevsky, R.M. (1991) Wear resistance and microhardness of human teeth. Proc. Inst. Mech. Eng., Part H: J. Eng. in Med., 205(3), 201-202. 32. Davidson, CL., Hoekstra, LS. and Arends, J. (1974) Microhardness of sound, decalcified and etched tooth enamel related to the calcium content. Caries Res., 8, 135-144. 33. Pashley, D.H., Andringa, H.J., Derkson, G.D. et al. (1987) Regional variability in the permeability of human dentin. Arch. Oral Biol, 32(7), 519-523. 34. Pashley, D.H., Okabe, A. and Parham, P. (1985) The Relationship between dentin microhardness and tubule density. Endod. Dent. Traumatol, 1,176-179. 35. Baier, R.E. and Zisman, W.A. (1975) Wetting properties of collagen and gelatin surfaces, in 'Applied Chemistry at Protein Interfaces', vol. 145, Advances in Chemistry series (ed. R.F. Gould), American Chemical Society, Washington DC, pp. 155-174. 36. Jendresen, M.D., Baier, R.E. and Glantz, P-O. (1984) Contact angles in a biological setting: Measurements in the human oral cavity. /. Coll Interface ScL, 100(1), 233-238. 37. Baier, R.E. (1973) Occurrence, nature, and extent of cohesive and adhesive forces in dental integuments, in: Surface Chemistry and Dental Integument's. Lasslo, A. and Quintana, R.P. (eds), Thomas, Springfield, IL pp. 337-391. 38. Glantz, P-O. (1969) On wetability and adhesiveness. Odontologisk Revy, 20 supp. 17, 1-132. 39. Jendresen, M.D. and Glantz, P-O. (1980) Clinical adhesiveness of the tooth surface. Acta Odontol Scand., 38, 379-383.

Bl

Cartilage
J.R. Parsons

B L l INTRODUCTION Bl.1.1 Articular cartilage

Articular or hyaline cartilage forms the bearing surfaces of the movable joints of the body. Hyaline cartilage also exists in tissues of the larynx, tracheal tube rings, rib and costral cartilage, nasal septum and in the growth plates of long bones. As a bearing surface, this tough, resilient tissue displays exceptional mechanical and tribologic properties due exclusively to the unique interaction of the constituents of the tissue extracellular matrix. Usually, the phenotypic cells (chondrocytes) of cartilage make up less than 10% of the total volume of the tissue and have not been considered to contribute to the mechanical properties of the tissue. The extracellular matrix consists of a tight collagen fiber network which contains and constrains a highly hydrophilic gel of aggregated proteoglycan macromolecules. Collagen accounts for approximately 50% of the dry weight of the tissue, the remainder being proteoglycans and cellular material. In the fully hydrated state, water contributes 60% to 80% of the wet weight of the tissue. Mechanically, intact normal articular cartilage behaves as a linear viscoelastic solid. This behavior is the result of viscous drag of fluid through the tissue in concert with the intrinsic properties of the extracellular matrix. Further, fluid exudation across the cartilage surface in response to physiologic loading is thought to play a significant role in the lubrication of joints. The importance of articular cartilage as a bearing surface has led to extensive mechanical and tribologic studies of this tissue.

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Bl.1.2 Fibrocartilage Fibrocartilage contains a higher dry weight percentage of collagen and less proteoglycan than does articular cartilage. Consequently, in the hydrated state, fibrocartilage contains less water. Fibrocartilage is generally considered to be tougher and somewhat less resilient than articular cartilage. In humans, fibrocartilage is found in the meniscus of the knee joint, the annulus fibrosus of the intervertebral disc and in the temperomandibular joint. The mechanical behavior of fibrocartilage has not been studied to the extent of articular cartilage; however, it is not as satisfactory a load bearing material. Bl.1.3 Elastic cartilage Elastic cartilage is more elastic and resilient in nature than is either hyaline or fibrocartilage. This is the result of lower collagen content coupled with the presence of elastin fibers. Elastic cartilage is found in the human epiglottis, external ear structures and eustachian tube. As elastic cartilage is not a major structural component of the musculoskeletal system, the mechanical properties of this tissue have been largely ignored. B1.2 COMPOSITION
Table Bl.l Cartilage Composition Water (wt%) 60-80 74 Organic (wt%) 20-40 15-20 <2 10 26 20 <1 <1 Source [1]

Articular Cartilage Type II Collagen Other collagen Proteoglycan Fibrocartilage Type I Collagen Other collagen Proteoglycan

[2]

B1.3 MECHANICAL PROPERTIES OF ARTICULAR CARTILAGE Bl.3.1 Compression (Table B1.2) Compressive cartilage properties have often been examined using creep indentation, confined compression or free/unconfined compression methods. Indentation techniques permit in situ testing without the necessity of

Table B1.2 Location

Compressive Properties of Articular Cartilage Value (MPa) Source

Unrelaxed (initial): Creep modulus (indentation): Femoral head 1.9-14.4 Young's modulus (indentation): Patella 2.25 Young's Modulus (confined compression): Tibial plateau 5.1-7.9* 11.6* Bulk Modulus (confined compression): Tibial plateau 31-56 25* Young's Modulus (unconfined compression): Various 8.4-15.3 Relaxed (equilibrium): Aggregate modulus (Indentation): Patella 0.3-0.6 0.3-1.5 Femoral condyle 0.4-1.0 0.5-0.7 Carpo-metacarpal joint 0.4-0.8 Young's modulus (confined compression): Patella 0.7 Tibial plateau 0.7* Bulk modulus (confined compression): Tibial plateau 9.1* * Calculated from other measurements.

[7] [8] [9] [6] [9] [6] [7] [4] [10] [10] [11] [12] [8] [6] [6]

special specimen preparation as with tensile testing. However, the extraction of intrinsic mechanical parameters from creep indentation data is analytically complex [3, 4]. Confined compression or unconfined compression tests require preparation of cylindrical cored specimens of tissue and underlying bone. With unconfined compression, the free draining tissue edges and low aspect ratio, layered nature of the test specimen may introduce error. Compression of a laterally confined specimen by a porous plunger produces uniaxial deformation and fluid flow. Confined compression creep data has been analyzed to yield an aggregate equilibrium compressive modulus and permeability coefficient [5] and uniaxial creep compliance [6]. Bl.3.2 Tensile (Table B1.3) Tensile properties for human articular have been determined by cutting standard tensile specimens from the cartilage surface and performing constant strain rate, creep or stress relaxation tensile tests. Test results are strongly influenced by collagen volume fraction and orientation and

Table B1.3 Tensile Properties of Articular Cartilage Location Value (MPa)* Relaxed (equilibrium): Young's modulus: Femoral condyle, Surface zone Subsurface zone Middle zone Femoral condyle, Surface zone Middle zone 10.5 5.5 3.7 Unrelaxed (100%/min): Young's modulus: 200-400 40-175 Strength: Source [13]

[7]

[7]

Femoral condyle, Surface zone 20-35 Middle zone 11-25 * All measurements parallel to collagen direction.

are largely insensitive to proteoglycan content [7] Collagen volume fraction and orientation is highest in the cartilage surface layer. Collagen content and orientation diminishes in subsequent lower layers. Bl.3.3 Shear (Table B1.4) Shear properties for articular cartilage have been determined through torsional creep, stress relaxation and torsional dynamic tests of excised cartilage disks. Creep and dynamic shearing of rectangular cartilage specimens between plates has been conducted on animal tissue (usually bovine) but not human tissue. When torsional shear strains remain small, the observed shear properties are flow independent. That is, under small strain conditions, fluid flow is negligible and viscoelastic behavior can be attributed strictly to the collagen/proteoglycan extracellular matrix.
Table B1.4 Shear Properties of Articular Cartilage Location Value (MPa) Relaxed (equilibrium): Shear modulus: Patella, Middle zone Tibial plateau Tibial plateau 0.25 2.6 Unrelaxed (initial): Shear modulus: 4.1 5.1-7.9 [14] [6] [6] [9] Source

Bl.3.4 Poisson's ratio Poisson's ratio has been calculated directly from tensile tests (v = 0.37-0.50) [10] and indirectly from torsional shear and confined compression creep data (v = 0.37-0.47) [6, 9]. More recently, the relationship between Poisson's ratio, n, aggregate modulus, Ha, and permeability, k, have been established for cartilage indentation testing based on biphasic (fluid and porous solid) constitutive theory [15]. Using a complex numerical solution and curve fitting scheme, Poisson's ratio can be extracted from indentation data, resulting in values of v = 0.00-0.30 [11, 12, 16]. However, care must be exercised in interpreting such indirect measures of Poisson's ratio as unexpected results can arise; e.g. v = 0.0. Bl.3.5 Permeability The porous solid matrix of articular cartilage permits the movement of interstitial water in response to a pressure gradient. Flow of water through and across the tissue is largely responsible for the viscoelastic character of cartilage. Flow is related to tissue permeability through the hydraulic permeability coefficient, k, as defined by Darcy's law. The permeability coefficient has been measured in flow chambers where a known pressure gradient produces flow across a cartilage layer of known thickness and area (k = 4.0 - 17.0 x 1016 m4/Ns)[7]. However, such experiments have demonstrated significant decreases in permeability coefficient with increasing pressure gradient, increasing compressive tissue strain and with increasing proteoglycan content. Evoking biphasic constitutive theory with numerical solutions and/or curve fitting routines permits an indirect determination of the permeability coefficient from confined compression creep data and creep indentation data (k = 5.2 - 21.7 x 10" 16 m4/Ns)[ll,12]. Bl.3.6 Articular cartilage tribologic properties Healthy articular cartilage has remarkable tribologic properties. Under high load conditions the tissue displays extremely low frictional coefficients and virtually undetectable wear. The dynamic coefficient of friction, |jLd, has been measured in whole joints using Stanton pendulum or other pendulum techniques where the joint forms the pendulum pivot (|xd = 0.015-0.04) [17-19]. The coefficients of friction of cartilage plugs bearing on other materials has been determined for human and animal tissue but these sorts of experiments have little relevance for actual in situ cartilage behavior and are not reported here. The lubrication of articular cartilage remains a subject of continuing debate and no one lubrication mechanism can be clearly identified. Both

fluid film and boundary lubrication are thought to play primary roles in joint lubrication and the dominance of one or the other probably depends on loading and velocity conditions. Further as cartilage is a relatively soft viscoelastic material, elastohydrodynamics may discourage fluid film breakdown and thus promote hydrodynamic lubrication. Exudation of fluid across the cartilage surface in response to an advancing load has also been suggested to aid lubrication. No reliable wear tests have been performed on human articular cartilage bearing surfaces under physiologic conditions. B1.4 FIBROCARTILAGE MECHANICAL PROPERTIES Human fibrocartilage tensile mechanical properties have been determined by cutting standard tensile specimens either from the knee meniscus or from single or multiple lamella from the annulus fibrosus and performing constant strain rate tensile tests. Test results are strongly influenced by collagen volume fraction and orientation and are largely insensitive to proteoglycan content. Annulus fibrosus has also been tested in confined compression, permitting derivation of an aggregate compressive modulus and permeability. Data are reported in Section B2. B1.5 ELASTIC CARTILAGE MECHANICAL PROPERTIES No reliable data are available for human tissue. ADDITIONAL READING
Freeman, MAR (ed.) (1979) Adult Articular Cartilage, 2nd ed., Pitman Medical Publishing Co, Kent, UK. Although now somewhat out of date, this classic text forms the basis for current thinking on cartilage biochemistry, physiochemistry, biomechanics and tribology. The volume of original data, found nowhere else, is truly impressive. Mow V.C., Holmes, M.H. and Lai, W.M. (1984): Fluid transport and mechanical properties of articular cartilage. A review. /. Biomech., 17:377-394. This survey article provides an historical perspective of cartilage mechanics research and leads the reader through the modern biphasic theory of cartilage mechanics at the material level. References provided are particularly useful in developing a bibliography of the important classic studies in this field. Mow, V.C. and Ratcliffe, A (eds)(1993): Structure and Function of Articular Cartilage, CRC Press, Boca Raton. This up-to-date monograph is perhaps the best current work on the subject. Details from many of the references in this section (below) can be found in the section on cartilage biomechanics.

REFERENCES
1. Maroudas, A. (1979) Physiochemical properties of articular cartilage, in Adult Articular Cartilage, 2nd ed., M.A.R. Freeman (ed.), Pitman Medical Publishing Co, Kent, UK, pp. 215-290. 2. Fithian, D.C., Kelly, M.A. and Mow, V.C. (1990) Material properties and structure-function relationships in the menisci. CHn. Orthop. ReI. Res., 252, 19-31. 3. Mak, A., Lai, W.M. and Mow, V.C. (1987) Biphasic indentation of articular cartilage: Part I, Theoretical analysis. /. Biomech., 20, 703-714. 4. Mow, V., Gibbs, M.C. and Lai, W.M., et al. (1989) Biphasic indentation of articular cartilage: Part II, A numerical algorithm and experimental study. /. Biomech., 22, 853-861. 5. Mow, V., Kuei, S.C. and Lai, W.M. (1980) Biphasic creep and stress relaxation of articular cartilage in compression: Theory and experiments. /. Biomech, Eng., 102, 73-84. 6. Hayes, W. and Mockros, L.F. (1971) Viscoelastic properties of human articular cartilage. /. Appl. Physiol, 31, 562-568. 7. Kempson, G. (1979) Mechanical properties of articular cartilage. In Adult Articular Cartilage, 2nd ed., Freeman M.A.R., Editor, Pitman Medical Publishing Co. Ltd., Kent, England, pp. 333^14. 8. Sokoloff, L. (1966) Elasticity of aging cartilage. Fed. Proc, 25, 1089-1095. 9. Hori, R. and Mockros, L.F. (1976) Indentation tests of human articular cartilage. /. Biomech., 9, 259-268. 10. Armstrong, C. and Mow, V.C. (1982) Variations in the intrinsic mechanical properties of human articular cartilage with age, degeneration and water content. /. Bone Joint Surg., 64A, 88-94. 11. Athanasiou, K., Rosenwasser, M.P., and Buckwalter, J.A., et al. (1991) Interspecies comparison of in situ intrinsic mechanical properties of distal femoral cartilage. /. Orthop. Res., 9, 330-340. 12. Ateshian, G., Gardner, J.R., Saed-Nejad, F. et al. (1993) Material properties and biochemical composition of thumb carpometacarpal joint cartilage. Trans. Orthop. Res. Soc, 18, 323. 13. Akizuki, S., Mow, V.C. and Muller, F., et al. (1986) Tensile properties of human knee joint cartilage: Part I, Influence of ionic concentrations, weight bearing and fibrillation on the tensile modulus. /. Orthop. Res., 4, 379-392. 14. Zhu, W., Lai, W.M. and Mow, V.C. (1986) Intrinsic quasilinear viscoelastic behavior of the extracellular matrix of cartilage. Trans. Orthop. Res. Soc, 11, 407. 15. Mak, A. (1986) The apparent viscoelastic behavior of articular cartilage - The contributions from the intrinsic matrix viscoelasticity and interstitialfluidflows. /. Biomech. Eng., 108, 123-130. 16. Akizuki, S., Mow, V.C, Lai, W.M., et al. (1986) Topographical variation of the biphasic indentation properties of human tibial plateau cartilage. Trans. Orthop. Res. Soc, 11, 406. 17. Charnley, J. (1960) The lubrication of animal joints in relation to surgical reconstructions by arthroplasty. Ann. Rheum. Dis., 19, 10-19.

18. Little, J., Freeman, M.A.R., and Swanson, S.V. (1969) Experience on friction in the human joint. In Lubrication and Wear in Joints, Wright V., Editor, Sector Publishing, London, UK., pp. 110-114. 19. Unsworth, A., Dawson, D. and Wright, V. (1975) Some new evidence on human joint lubrication. Ann. Rheum. Dis., 34, 277-285.

B2

Fibrocartilage
V.M. Gharpuray

B2.1 INTRODUCTION The human menisci and intervertebral discs perform several important mechanical functions in the human body. The ability to perform these functions and consequently their intrinsic biomechanical properties are dependent on the interaction of the constituents of these structures. Both the menisci and intervertebral discs have a fibrocartilaginous structure that consists of two distinct phases: a fluid phase consisting of mainly water and dissolved electrolytes, and a solid phase composed of highly oriented collagen fibers, cells, proteoglycans and other proteins. As with all other biological materials, both menisci and discs exhibit non-linear viscoelastic and anisotropic properties. The non-linear stiffness or elasticity of the structure is imparted by the collagen fibers and to a lesser extent by osmotic pressures within the tissue which are generated by the degree of hydration [1, 2]. The viscoelastic or energy dissipation properties are a result of fluid flow within and through the structures and also of molecular relaxation effects from the motion of long chains of collagen and proteoglycans [3]. Anisotropy is a consequence of the orientation and concentration of collagen fibers within the proteoglycan gel. B2.2 STRUCTURE AND COMPOSITION A normal adult human knee contains two menisci - the lateral and the medial, whose average lengths are 38 and 45 mm, and average volumes are 2.9 and 3.45 cm3 respectively [4]. At the femoral articulating surface
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

of each meniscus, for a depth of approximately 100 ixm,finecollagen fibrils (mainly Type II) are randomly oriented to form a woven mesh [5, 6]. Beneath this surface layer, larger rope-like bundles (approximately 100 |xm in diameter) of Type I collagen are arranged predominantly in the circumferential direction. In the posterior half of the medial meniscus however, the fibers are not as highly oriented [6, 7]. A few radial fibers may also be seen interspersed within the circumferential fibers [6-8]. At the tibial surface is another articulating layer, in which the principal orientation of the fibers is radial. Collagen and other proteins make up the organic content of the meniscus, while dissolved electrolytes make up the inorganic content (which is negligibly small). The collagen is primarily Type I (98%) with small amounts of Type II, III and Type V [9], and comprises up to 25% of the wet weight and 90% of the dry weight in human material (Table B2.1). 10% of the dry weight and up to 2% of the wet weight are due to non-collagenous proteins, which consist predominantly of proteoglycans, and smaller amounts of structural glycoproteins, cell membrane bound receptors and intercalated membrane glycoproteins. These proportions do not appear to vary with location in the menisci [10]. There are 23, approximately cylindrical, intervertebral discs in the human spine that account for 20-30% of its overall length [13]. The cross sectional shape varies with level: roughly elliptical, rounded triangular and kidney shaped in the cervical, thoracic and lumbar regions respectively [14]. The cross sectional shape is sometimes quantified by a shape index (S) defined by S = AnAlC1 where A = cross sectional area, and C = circumference of the cross section (Table B2.2). Most discs are wedge-shaped in sagittal section with the anterior height greater that the posterior height. The cross sectional area increases with level such that lumbar discs are larger than cervical discs. The intervertebral disc contains two distinct regions, the nucleus pulposus and the annulus fibrosus. The nucleus occupies about 50% of the volume of the disc, and contains mostly water and small amounts of randomly oriented collagen fibers, cells and non-collagenous proteins [19]. The annulus is a tough ring-like structure that surrounds the nucleus. Highly oriented collagen fibers (primarily Types I and II) form a laminate structure in the annulus, with approximately 20-25 laminae oriented alternately at
Table B2.1 Composition of the menisci Wet weight
Water 60-70% a Collagen 15-25% a NCP* l-2%a

Dry weight
Collagen 70-90% a ' b NCP 8-20% b ' c t

* NCP = non-collagenous proteins; X 21.9% in neonates decreasing to 8.1% between 30-70 years, a: [8];b: [ll];c: [12].

Table B2.2 Shape and size of the adult intervertebral disc

Disc Level L5-S1 L4-L5 L3-L4 L2-L3 L1-L2 T12-L1 T11-T12 T10-T11 T9-T10 T8-T9 T7-T8 T6-T7 T5-T6 T4-T5 T3-T4 T2-T3 T1-T2 C7-T1 C6-C7 C5-C6 C4-C5 C3-C4 C2-C3 Shape Index (Sa) 0.885 0.897 0.866 0.866 0.825 0.844 0.856 0.885 0.879 0.919 0.878 0.898 0.935 0.868 0.836 0.870 0.815 0.785 0.708 0.828 0.825 0.870 0.893 Posterior/Anterior Height1 0.35 0.51 0.55 0.61 0.68 0.75 0.80 1.11 0.74 0.88 0.81 0.84 1.07 0.97 0.72 0.74 0.76 0.62 0.82 0.44 0.47 0.50 0.56 Cross Sectional Area (mm2) 1714b 1662b 1859b 1640b Height (mm) ll-12bc 10.4b 9.75b 8.83b

4-6 c

1292* 1152* 949* 892* 827* 732*

6.00d 5.67d 5.50d 5.25d 5.00d 4.75d

* Computed from data in [18]. a: [13];b: [15,16];c: [17];d: [18].

approximately +(60-70) and -(60-70) to the spinal axis [14, 20, 21]). Type IX collagen is believed to cross link the Types I and II fibers, and provide some resistance to circumferential tears. Collagen content and fiber orientation is highest in the outermost layers, and both decrease as the nucleus is approached from the periphery of the disc (Table B2.3) The water content in the disc varies with position in the disc: it is highest in the nucleus and lowest in the outermost layers of the annulus [22, 23]. It has also been shown that the water content varies with circumferential position [4], and is higher in the posterior of the disc. The nucleus loses water and becomes more fibrous and desiccated with age, causing the boundary between the annulus and the nucleus to become less clear [19, 23].
Table B2.3 Composition of the intervertebral disc in young adults Tissue Nucleus Pulposus Annulus Fibrosus Water Content % 85-95 85 (innermost layer) 65 (outermost layer)
a

Collagen Content % 2-5b 5 (innermost layer) 21 (outermost layer)

B2.3 HYDRAULIC PERMEABILITY AND DRAG COEFFICIENTS Experimental data suggest that water is capable of flowing through both meniscal and discal tissues, and is dependent on a material property of the tissue called hydraulic permeability [25], which may be modeled by Darcy's Law as:
Q = k E h (B2.1)

where k = hydraulic permeability coefficient of the tissue; Q = volume rate of fluid flow; A = area across which fluid flow occurs; h = thickness of the tissue; and AP = pressure gradient across the thickness h that causes fluid flow. The diffusive drag coefficient K is related to the permeability coefficient by (B2.2) k where c|>/ is the porosity of the tissue and is defined as the ratio of interstitial fluid volume to total tissue volume. For human meniscal (annulus) tissue, k, the permeability is 2.5 x 10~16 4 m /Ns [22], about one third of that reported for bovine tissue: 8.1 x 10~16 m4/Ns [26]. There is no significant variation in the permeability coefficient with location of the specimen. The porosity ($f) of both tissues is approximately 0.75, and therefore the drag coefficient, K, is very high and ranges from 1014 to 1015 Ns/m4. B2.4 ELASTIC PROPERTIES Under quasi-static loading, or in conditions under which 'short-term' loading responses are expected to occur [27], both meniscal and discal tissues may be modeled as linear elastic and orthotropic. Under a constant load rate, the non-linear behavior may be described by an exponential stress-strain relationship given by a = A[eBe -1] (B2.3) where A and B are constants for the given material. The constant B is proportional to the tangent modulus (i.e., da/de), and sometimes a third constant C is defined as C = A*B, and is the tangent modulus as a -> 0 [8]. The macroscopic tensile strength of the entire meniscus was studied by Mathur et al [4] by gripping the horns of the meniscus, and stretching it to failure. The results suggested that the medial meniscus was significantly K=
V ;

weaker than the lateral meniscus (ultimate loads of 247 N and 329 N respectively), and that the mode of failure was not by transverse cracking, but predominantly by oblique (medial) or spiral (lateral) tearing. Strength and modulus of the meniscus vary with different locations and with different orientations of the specimen due to structural and compositional changes (Table B2.4). For loading parallel to the fibers, it appears that the meniscus may be stronger in the anterior location, and that the lateral meniscus may be stronger than the medial meniscus. This may be explained in part by the fact that the fiber orientation is more random in the posterior part of the medial meniscus. A similar trend is seen in the tensile modulus of meniscal specimens oriented parallel to the circumferential direction (Table B.2.5), and if a power law is used as the constitutive equation (equation B2.3), the coefficients A and C show an identical pattern [7, 10, 28]. The properties of intervertebral discs are more complex than those of the menisci, since properties vary with disc level, and discs must withstand loads and moments in three orthogonal directions. (Table B2.6). As with the meniscus, strength and modulus of discal tissue vary with location and orientation of the specimen (Table B2.7). Lin et al [15, 16] have however shown that elastic moduli of annular specimens are independent of disc level.
Table B2.4 Tensile strength of meniscal tissue (MPa) a * Location Meniscus Lateral Medial Orientation f Parallel Perpendicular Parallel Perpendicular Anterior 10.37 0.80 Central 6.31 0.88 3.36 0.85 Posterior 6.87 0.54 5.86 1.23

a: Averaged from data in [6]. * Tissues were fixed in formalin before testing. f Either parallel or perpendicular to the circumferential direction.

Table B2.5 Meniscus Medial

Non-linear parameters and tensile modulus of menisci Location Anterior Central Posterior Anterior Central Posterior A L6 0.9 1.4 1.4 2.1 3.2 B 2SA 27.3 20.1 28.8 31.9 27.5 C 4Z4 23.7 25.2 30.2 55.7 67.5 Tensile modulusa 159.6 93.2 110.2 159.1 228.8 294.1 (MPa)

Lateral

a: Slope of the stress-strain curve in the linear portion after the toe region.

Table B2.6

Mechanical properties of the intervertebral disc Stiffness (N/mm or Nm/rad)

Loading mode Compression

Level L5-S1 L4-L5 L3-L4 L2-L3 L1-L2 Lumbar Lumbar Lumbar Lumbar Lumbar Lumbar Lumbar Lumbar

Strength (N) 5574 5128d 5351d 4905d

d

Initiala 1448 306d, 413 e 1352d 439d, 461 e 46f 74f 64f 157f 102 91 1138
d

Averageb

Finale 3511d 2405d, 721 e 2756d 3160d, 997e 8451f 704f 604f 148 123 169

Flexion Extension Lateral bending Axial torsion Compression Posterior shear Anterior shear Lateral shear

8008

a: Slope of the toe region of the load displacement curve. b: Average slope of the load displacement curve. c: Slope of the load displacement curve excluding the toe region. d: [29]; e: [30]; f: [31]; g: [32].

Table B2.7

Mechanical properties of the annulus fibrosus Layer Location

Property Tensile Modulus

Specimen orientation Horizontal Parallel to fibers Perpendicular to lamellae Horizontal Parallel to Perpendicular to lamellae

Average 3.54 3.41

C

Inner

Middle

Outer 410a 0.16b 110a 0.187b

Ultimate stress

fibers

a: MPa, Specimen 2x2.5 mm cross section, 6.5 mm length [33]. b: MPa, Specimen 7.5x2.5 mm cross section, 4.5 mm length [33]. c: N/mm, Specimen 2x1.5 mm cross section, 15-25 mm length [34].

B2.5 VISCOELASTIC BEHAVIOR Finally, the rate dependent properties are usually modeled by a threeparameter solid which consists of a spring (m2) and a dashpot (h) in parallel connected to another spring (mx) in series. Viscoelastic properties may also be expressed in terms of the dynamic modulus G*. A sinusoidal displacement of the form u = uo emt is applied to the specimen (this is usually a torsional strain), and the resulting force response F = F0 eiwt + 8 is measured. Here c p = circular frequency, / = >/(-!) and 8

is the phase angle shift between the applied displacement and the measured force. The dynamic modulus is than obtained as
G* - - -^- e = G'+iG" u uo (B2.4)

where G' and G" are the loss and storage moduli respectively. In some cases, it may be more convenient to express viscoelastic properties in terms of the magnitude of the dynamic shear modulus and the phase angle shift as IGI* = V(G'2+^"2); 8 = tan"1 ( - ^ ) (B2.5) The anisotropic viscoelastic properties in shear of the meniscus have been determined by subjecting discs of meniscal tissue to sinusoidal torsional loading [35] (Table B2.8). The specimens were cut in the three directions of orthotropic symmetry, i.e. circumferential, axial and radial. A definite correlation is seen with the orientation of the fibers and both the magnitude of the dynamic modulus IG*I and the phase angle 8.
Table B2.8 Viscoelastic properties of meniscal tissue Specimen orientation Circumferential Axial Radial \G*\ (MPa) 36.8 29.8 21.4 8 (degrees) 16.7 19.4 20.8

The viscoelastic properties of the human intervertebral disc have been modeled [36, 37] using the three-parameter solid. The parameters were obtained by fitting experimentally obtained creep curves to analytical equations using linear regression (Table B2.9).
Table B2.9 Viscoelastic properties of the intervertebral disc* [36,37] Yn1 (MPa) 10-13 * Ranges. m2 (MPa) 13-40 h (GPas) 65-280

B2.6 DISCUSSION Since it is nearly impossible to carry out meaningful experiments in vivo on the human disc or meniscus, the properties reported above have been obtained from cadaveric tissue. Test specimens were obtained from autopsy material (10-48 hours after death), and were either tested

immediately or stored frozen for varying periods of time before testing. Statistical analyses of these data show high standard deviations and errors that are caused by a number of factors. Changes in water content (which may be a consequence of aging and degeneration, diurnal changes or surgical interventions) cause a subsequent change in mechanical properties. Further, it has been well documented that the mechanical properties of collagenous tissues change with storage medium, storage temperature, time after death and 'preconditioning' state [38, 39]. Both the disc and the meniscus contain highly oriented collagen fibers, and location and orientation of the test specimen can cause significant changes in the test results. Additional factors such as sex, diet, and level of activity also play a relatively minor role in this variation.

ADDITIONAL READING Ghosh, P. (ed.) (1988) The Biology of the Intervertebral Disc, VoI I and II, CRC Press, Boca Raton. One of the most comprehensive texts available about the intervertebral disc. It is written from the biological perspective, and contains exhaustive information about each component of the disc. Volume I includes chapters on disc structure and development, vasculature, innervation, collagen and non-collagenous proteins. Volume II contains information on nutrition and metabolism, mechanics, pathology and disease states. Mow, V.C., Arnoczky, S.P. and Jackson, D.W. (1992) Knee Meniscus: Basic and Clinical Foundations. Raven Press, New York. This monograph is designed to serve as a comprehensive reference for clinicians and researchers interested in the meniscus. It includes chapters on gross anatomy, structure and function of the menisci and their mechanical behavior, pathological disorders, clinical and surgical methods of treatment and meniscal disorders. Mow, V.C. and Hayes, W.C. (1991) Basic Orthopaedic Biomechanics, Raven Press, New York. This book is aimed at teaching senior engineering students or orthopaedic residents the fundamental principles of biomechanics of the musculoskeletal system. The book contains several chapters on the mechanics of joints, and the properties and functions of joint tissues. The chapter devoted to articular cartilage and the meniscus includes a review of collagen-proteoglycan interactions, and how these directly affect the mechanical behavior of the tissue. The biphasic and the triphasic theories for the viscoelastic properties are also discussed. White, A.A. and Panjabi, M.M., (1990) Clinical Biomechanics of the Spine, J.B. Lippincott Company, Philadelphia. An excellent reference book for an engineer or a physician interested in the spine. Each topic is written from the viewpoint of a biomechanician and the topics covered include kinetics and kinematics of vertebral joints, pathological disorders of the spine and their surgical management. Chapter 1 contains an introductory section on the intervertebral disc that describes its structure, function and biomechanics.

REFERENCES
1. Armstrong, CG. and Mow, V.C. (1982) Variations in the intrinsic mechanical properties of human articular cartilage with age, degeneration and water content. /. Bone Joint Surg., 64A, 88-94. 2. Mow, V.C, Holmes, M.H. and Lai, W.M. (1984) Fluid transport and mechanical properties of articular cartilage: A review. /. Biomech., 102, 73-84. 3. Hayes, W.C and Bodine, AJ. (1978) Flow independent viscoelastic properties of articular cartilage matrix. /. Biomech., 11, 407^19. 4. Mathur, P.D., McDonald, J.R. and Ghormley, R.K. (1949) A study of the tensile strength of the menisci of the knee. /. Bone Joint Surg., 32A, 650-654. 5. Aspden, R.M., Yarker, Y.E. and Hukins, D.W.L. (1985) Collagen Orientations in the meniscus of the knee joint. /. Anal, 140, 371-380. 6. Bullough, P.G., Munuera, L., Murphy, J. and Weinstein, A.M. (1970) The strength of the menisci of the knee as it relates to their fine structure. /. Bone Joint Surg., 52B, 564-570. 7. Fithian, D.C, Kelly, M.A. and Mow, V.C. (1990) Material properties and structure-function relationships in the menisci. CHn. Orthop. ReL Res., 252, 19-31. 8. Mow, V.C, Zhu, W. and Ratcliffe, A. (1991) Structure and function of articular cartilage and meniscus, in Basic Orthopaedic Biomechanics, (eds V.C Mow and W.C Hayes), Raven Press, New York, pp. 143-198. 9. Eyre, D.R. and Wu, JJ. (1983) Collagen of fibrocartilage: A distinctive molecular phenotype in bovine meniscus. F. E. B. S. Letters, 158, 265-270. 10. Fithian, D.C, Zhu, W.B., Ratcliffe, A., Kelly, M.A. and Mow, V.C. (1989b) Exponential law representation of tensile properties of human meniscus. Proceedings of the Institute of Mechanical Engineers. The Changing Role of Orthopaedics, Mechanical Engineering Publications Limited, London, pp. 85-90 11. Ghosh, P. and Taylor, T.K.F. (1987) The knee joint meniscus: A fibrocartilage of some distinction. CHn. Orthop. ReI. Res., 224, 52-63. 12. Ingman, A.M., Ghosh, P. and Taylor, T.K.F. (1974) Variation of collagenous and non-collagenous proteins of human knee joint menisci with age and degeneration. Gerontology, 20, 212-223. 13. Pooni, J.S., Hukins, D.W.L., Harris, P.F., Hilton, R.C and Davies, K.E. (1986) Comparison of the structure of human intervertebral discs in the cervical, thoracic and lumbar regions of the spine. Surg. Radiol Anat, 8, 175-182. 14. Hirsch, C, Inglemark, B-H. and Miller, M. (1963) The anatomical basis of back pain. Ada Orthop. Scand., 33, 2-17. 15. Lin, H.S., Liu, Y.K. and Adams, K.H. (1978) Mechanical response of the lumbar intervertebral joint under physiological (complex) loading. /. Bone Joint Surg., 6OA, 41-55. 16. Lin, H.S., Liu, Y.K., Ray, G. and Nikravesh, P. (1978) System identification for material properties of the intervertebral joint. /. Biomech., 11, 1-14. 17. Taylor, J.R. (1975) Growth of human intervertebral discs and vertebral bodies. /. Anat, 120, 49-68. 18. Panjabi, M.M., Summers, D.J., Pelker, R.R., Videman, T., Friedlander, G.E. and South wick, W. O. (1986) Three-dimensional load-displacement curves due to forces on the cervical spine. /. Ortho. Res., 4, 152-161.

19. Inoue, H. (1981) Three-dimensional architecture of lumbar intervertebral discs. Spine, 6, 139-146. 20. Panagiotacopulos, N.D., Knauss, W.G. and Bloch, R. (1979) On the mechanical properties of human intervertebral disc materials. Biorheology, 16, 317-330. 21. Marchand, F. and Ahmed, A.M. (1988) Investigation of the laminate structure of lumbar disc annulus fibrosus. Trans. Orthop. Res. Soc, 13, 271. 22. Best B.A., Guilak, F., Setton, L.A., Zhu, W., Saed-Nejad, F., Ratcliffe, A., Weidenbaum, M. and Mow, V.C. (1994) Compressive mechanical properties of the human annulus fibrosus and their relationship to biochemical composition. Spine, 19, 212-221. 23. Gower, W.E. and Pedrini, V. (1969) Age-related variations in protein-polysaccharide from human nucleus pulposus, annulus fibrosus and costal cartilage. /. Bone Joint Surg., 51A, 1154-1162. 24. Lyons, G., Eisenstein, S.M. and Sweet, M.B.E. (1981) Biochemical changes in intervertebral disc degeneration, Biophysics Ada, 673, 443. 25. Lai, W.M. and Mow, V.C. (1980) Drag-induced compression of articular cartilage during a permeation experiment. Biorheology, 17, 111-123. 26. Proctor, CS., Schmidt, M.B., Whipple, R.R., Kelly, M.A. and Mow, V.C. (1989) Material Properties of the normal medial bovine meniscus. /. Ortho. Res., 7, 771-782. 27. Eberhardt, A.W., Keer, L.M., Lewis, J.L. and Vithoontien, V. (1990) An analytical model of joint contact. /. Biomech. Eng., 112, 407-413. 28. Fithian D.C., Schmidt, M.B., Ratcliffe, A. and Mow, V.C. (1989a) Human meniscus tensile properties: Regional variation and biochemical correlation. Trans. Orthop. Res. Soc, 14, 205. 29. Brown, T., Hansen, RJ. and Torra, AJ. (1957) Some mechanical tests on the lumbosacral spine with particular reference to the intervertebral discs. /. Bone Joint Surg., 39A, 1135-1164. 30. Hirsch, C. and Nachemson, A. (1954) New observations on the mechanical behavior of the lumbar discs. Ada Orthop. Scand., 23, 254-283. 31. Schultz, A.B., Warwick, D.N., Berkson, M.H. and Nachemson, A.L. (1979) Mechanical properties of human lumbar spine motion segments Part I. /. Biomech. Eng., 101, 46-52. 32. Berkson, M.H., Nachemson, A. and Schultz, A.B. (1979) Mechanical properties of human lumbar spine motion segments Part I. /. Biomech. Eng., 101,53-57. 33. Marchand, F. and Ahmed, A.M. (1989) Mechanical properties and failure mechanisms of the lumbar disc annulus. Trans. Orthop. Res. Soc, 14, 355. 34. Galante, J.O. (1967) Tensile properties of the human lumbar annulus fibrosus. Ada Orthop. Scand., (Suppl. 100), 1-91. 35. Chern, K.Y., Zhu, W.B. and Mow, V.C. (1989) Anisotropic viscoelastic shear properties of meniscus. Adv. Bioeng., BED-15, 105-106. 36. Burns, M.L. et al. (1984) Analysis of compressive creep behavior of the vertebral unit subjected to uniform axial loading using exact parametric solution equations of Kelvin solid models Part I. /. Biomech., U9 113-130. 37. Kazarian, L.E. and Kaleps, I. (1979) Mechanical and physical properties of the human intervertebral joint. Technical Report AMRL-TR-79-3, Aerospace Medical Research Laboratory, Wright Patterson Air Force Base, OH

38. Black, J. (1976) Dead or alive: The problem of in vitro tissue mechanics. /. Biomed. Mats. Res., 10, 377-389. 39. Black, J. (1984) Tissue properties: Relation of in vitro studies to in vivo behavior, in Natural and Living Biomaterials, Ed. G.W. Hastings and P. Ducheyne, CRC Press, Boca Raton, pp. 5-26.

Ligament, tendon and fascia

S. L-Y. Woo and R.E. Levine

B3

B3.1 INTRODUCTION Ligament, tendon, and fascia are soft tissues composed primarily of collagen fibers. In ligaments and tendons these fibers are organized into roughly parallel bundles to transmit tensile forces between two bones (ligament) or between muscle and bone (tendon). In tendons the bundles are nearly all oriented along the long axis, whereas in ligaments, typically shorter than tendons, the bundles are also generally organized except for bends and twists at insertion sites to bone, e.g. the anterior cruciate ligament in the knee [I]. Fascia, on the other hand, is a sheet of fibrous tissue which encloses muscle. In the leg, fascia lata encompasses the entire thigh musculature and becomes thicker as it progresses distally [2]. An extensive compilation of mechanical properties of human ligament, tendon and fascia was published in 1970 by Yamada in Strength of Biological Materials [3]. Since then, numerous studies of the connective tissue in human joints has been published. The data presented in this review are from studies conducted since 1970 and are limited to mechanical (or material) properties determined from uniaxial tensile tests. Samples of tendons and ligaments are usually gripped by their muscle or bone ends. The tensile test yields a load-elongation curve representing the structural properties of a bone-ligament-bone (or muscle-tendonbone) complex. The area of a transverse section of the tissue sample (cross-sectional area), generally assumed to be constant along the sample length, is used to convert load to stress. Strain in the direction of loading is calculated as a change in length divided by an initial gauge length. The initial gauge length is taken to be either the initial length of the test
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

specimen from one clamp to the other (grip-to-grip length) or a smaller gauge length marked with dye on the midportion of the tissue (direct). From the stress-strain curve, the modulus, ultimate tensile strength (UTS), strain at UTS, and strain energy density are calculated [I]. Although tendons and ligaments are often tested as composite boneligament-bone and muscle-tendon-bone complexes for ease of gripping, the maximum load, stiffness and elongation values represent the average properties of a composite, and vary depending on the material behavior of the bone, and the size, shape, and orientation of the test specimen [4]. Due to the complex geometry of human ligament, tendon, and fascia, uniform loading across a specimen during a tensile test may not always be possible. Thus, while some studies tested the entire ligament or tendon [5-7], other studies partitioned the ligaments and tendons [8-24] such that distinct bundles could be tested with a more uniform stress distributions throughout the tissue during a tensile test. In the case of fascia, samples are obtained by cutting out a rectangular bands from the fascia sheet for testing [H]. Tables B3.1 and B3.2 list the mechanical properties of human ligaments, tendons, and fascia from various joints. For those tissues that were either Table B3.1 Mechanical properties of lower limb ligaments, tendons and fascia
Modulus (MPa) Ultimate Strain at tensile ultimate strength tensile (MPa) strength (%) Strain energy density (MPa)

Tissue

Source

Knee Ligament Ant. cruciate 13-46 9-44 65-541 1-3 [11, 24, 25] Pos. cruciate [6 20, 24] 24-36 10-29 109-413 2-3 Tendon Patellar [8, 9, 11, 13, 17] 24-69 14-27 4-5 143-660 Ankle Ligament Lat. collateral 216-512 na 24^6 13-17 Med. collatera]I 54-321 16-34 na 10-33 [7, 21] Tendon Achilles 24-61 24-59 65 na [26, 27] Palmaris longu s 2310620 91+15 [21] na na Other Tendon Semitendinosu!s 36222 895 523 231 [H] Gracilis 18+2 1124 342 61341 [H] Fascia Tibial 144 283132 na na [28] Fascia lata 30-105 150-571 27-29 :L32 [11] [11, 26, 27, 29] Notes: Ant.: anterior; Pos.: posterior; Med.: medial; Lat.: lateral, Long.: longus; Semitend.: semitendenosis; na: not available.

Table B3.2 Mechanical properties of upper limb and trunk ligaments and associated tissues Tissue Shoulder Ligament Inf. glenohum. Capsule Spine Ligament Pos. long. Liga. flavum Ant. long. Supraspinal Interspinal Intertransverse Forearm Ligament Carpal joint Palmar radioul. Dorsal radiolul. Interosseous membrane Modulus Ultimate tensile Strain at ultimate (MPa) strength (MPa) tensile strength (%) Source

30-42 32-67 na na 286-724 na na na 23-119 3918 5233 52882

5-6 8-21 21-28 1-15 8-37 9-16 2-9 511.4 na 5.7+1.7 85 431.4

8-15 na 11^4 21-102 10-57 39-115 39-120 16.50.7 na 5124 6129 102

[30] [16] [6, 19] [6, 19] [6, 18, 19] [6, 19] [6, 19] [6] [22] [23] [23] [10]

Notes: Ant.: anterior; Inf.; inferior; Long.: longitudinal; Radioul.: radioulnar; Glenohum.: glenohumoral; na: not available.

partitioned into separate bundles and/or that were tested in multiple studies, the mechanical properties are given as a range of values. Data determined for one specimen bundle or measured in one study are given as mean one standard deviation. A variety of factors contribute to the quality of biomechanical data [1], including donor age [4,17, 25, 27, 31], donor gender, storage method, test environment [15], orientation of tissue during testing [4], rate of loading [9], and accuracy of measuring devices [11, 32]. Errors in mechanical property measurements may be due to the use of a grip-to-grip gauge length [5, 7-9, 12-16, 19-26], rather than a midsubstance gauge length [10, 11, 17, 18, 30, 32], for strain measurement, due to nonuniform elongation along the specimen length. Another source of error may be the crosssectional area measurement methods which contact, or deform, the tissue surface [5, 7-9, 11-13, 15, 16, 18, 19, 20-23, 25]. A comparative study by Woo et al [33] demonstrated that measurements made with two contact methods, digital calipers and a constant pressure area micrometer, were 16% and 20% smaller, respectively, than those measured by a non-contact laser micrometer system. Further discussion of the strengths and weaknesses of those studies referenced in the tables are included in the annotated bibliography.

B3.2 DISCUSSION The use of tendon, ligament, and fascia as allografts or autografts motivate the investigation of their biomechanical properties. One-dimensional, static properties such as the ultimate tensile strength, modulus, strain, and strain energy density values shown in Tables B3.1 and B3.2 are useful for comparing different candidates for replacement tissue. However, other biomechanical characterizations of human connective tissue are available in the literature. Several experimental studies have examined the timeand history-dependent, or viscoelastic, properties of human ligament and tendon [15, 17, 28, 31, 34, 35] to help predict tissue behavior after long periods of use. Mathematical models have also been used to describe short-term behavior observed in experiments [36, 37] and to predict longterm behavior [17, 34, 36-38]. Various mathematical models of ligaments and tendons have been described by Woo et al [38], including a description of the quasi-linear viscoelasticity (QLV) theory, a commonly used viscoelastic model of ligaments and tendons. Other studies have examined how certain biomechanical properties vary throughout the tissue [14, 18, 32, 39]. Future studies must recognize that human ligament, tendon, and fascia are three-dimensional, anisotropic, nonhomogenous, composite materials which are subject to complex, dynamic loads. Successful replacement of these tissues depends on accurate replication of their static and dynamic mechanical properties. ADDITIONAL READING
Blevins F.T., Hecker A.T., Bigler G.T., et al (1994) The effects of donor age and strain rate on the biomechanical properties of bone-patellar tendon-bone allografts. American Journal of Sports Medicine, 22(3), 328-33. Patellar tendons from donors ranging in age from 17 to 54 years were tested at either 10% or 100% elongation per second, to examine effects of donor and strain rate on tensile properties. A pressure micrometer was used to measure cross-sectional area and the initial length of the tendon (from patellar to tibial insertion site) was used for strain measurements. Specimens were kept moist with a saline spray during tensile testing. Medial, lateral, and sometimes central portions were taken from 25 donors; regional differences across the tendon were not considered. Butler D.L., Grood E.S., Noyes F.R., et al (1984) Effects of structure and strain measurement technique on the material properties of young human tendons and fascia. Journal of Biomechanics, 17(8), 579-96. This study compares mechanical properties between different tissue structures as well as analyzing the effect of strain measurement technique on tissue modulus. A diverse number of analysis techniques were employed including light microscopy, scanning electron microscopy, and tensile testing. Surface strain was measured using high-speed filming. A constant pressure micrometer was

used to measure cross-sectional area. Specimens were tensile tested at 100%/second at room temperature and humidity. Data are given as mean SEM (standard error of the mean) rather than standard deviation. Hurschler C, Vanderby R. Jr., Martinez D.A., et al (1994) Mechanical and biochemical analyses of tibial compartment fascia in chronic compartment syndrome. Annals of Biomedical Engineering, 22(3), 272-9. This study was the first to report mechanical properties of tibial compartment fascia in humans. Fascia specimens were tested in directions along a visible fiber orientation (axial) and perpendicular to the fibers (transverse). Crosssectional area was measured using a caliper and surface strain was measured from video analysis of stain markers on the tissue surface. Specimens were subject to stress relaxation tests as well as as load-to-failure tests conducted at 20 mm/second at room temperature and humidity. Neumann P., Keller T.S., Ekstrom L., et al (1992) Mechanical properties of the human lumbar anterior longitudinal ligament. Journal of Biomechanics, 25(10), 1185-94. A motion analysis system was used to measure the distribution of surface strain along the anterior longitudinal ligament. Calipers were used to measure specimen thickness and width for calculating cross sectional area. Specimens were tensile tested to failure at a displacement rate of 2.5 mm/second at room temperature and humidity. Although a strain distribution was measured, area was assumed to be constant along the ligament length. REFERENCES 1. Woo, S.L-Y., An, K-N., Arnoczky, S.P., et al (1994) Anatomy, Biology, and Biomechanics of Tendon, Ligament, and Meniscus, in Orthopaedic Basic Science, (eds S.R. Simon), American Academy of Orthopaedic Surgeons, pp. 45-87. 2. Fox, J.M. (1986) Injuries to the thigh, in The Lower Extremity and Spine in Sports Medicine, (eds J.A. Nicholas and E.B. Hershman), The C. V. Mosby Company, St Louis, pp. 1087-1117. 3. Yamada, H. (1970) Mechanical properties of ligament, tendon, and fascia, in Strength of Biological Materials, (eds F.G. Evans), The Williams & Wilkins Co., Baltimore, pp. 92-105. 4. Woo, S.L., Hollis, J.M., Adams, D.J., et al (1991) Tensile properties of the human femur-anterior cruciate ligament-tibia complex. The effects of specimen age and orientation. American Journal of Sports Medicine, 19(3), 217-25. 5. Chazal, J., Tanguy, A., Bourges, M., et al (1985) Biomechanical properties of spinal ligaments and a histological study of the supraspinal ligament in traction. Journal of Biomechanics, 18(3), 167-76. 6. Prietto, M.P., Bain, J.R., Stonebrook, S.N., et al (1988) Tensile strength of the human posterior cruciate ligament (PCL). Transactions of the Orthopaedic Research Society, 13, 195. 7. Siegler, S., Block, J. and Schneck, CD. (1988) The mechanical characteristics of the collateral ligaments of the human ankle joint. Foot & Ankle, 8(5), 234-42.

8. Bechtold, J.E., Eastlund, D.T., Butts, M.K., et al (1994) The effects of freezedrying and ethylene oxide sterilization on the mechanical properties of human patellar tendon. American Journal of Sports Medicine, 22(4), 562-6. 9. Blevins, F.T., Hecker, A.T., Bigler, G.T., et al (1994) The effects of donor age and strain rate on the biomechanical properties of bone-patellar tendonbone allografts. American Journal of Sports Medicine, 22(3), 328-33. 10. Boardman, N.D., Pfaeffle, H.J., Grewal, R., et al (1995) Tensile properties of the interosseous membrane of the human forearm. Transactions of the Orthopaedic Research Society, 20, 629. 11. Butler, D.L., Grood, E.S., Noyes, F.R., et al (1984) Effects of structure and strain measurement technique on the material properties of young human tendons and fascia. Journal of Biomechanics, 17(8), 579-96. 12. Butler, D.L., Guan, Y., Kay, M.D., et al (1992) Location-dependent variations in the material properties of the anterior cruciate ligament. Journal of Biomechanics, 25(5), 511-8. 13. Butler, D.L., Kay, M.D. and Stouffer, D.C. (1986) Comparison of material properties in fascicle-bone units from human patellar tendon and knee ligaments. Journal of Biomechanics, 19(6), 425-32. 14. Chun, KJ., Butler, D.L., Bukovec, D.B., et al (1989) Spatial variation in material properties in fascicle-bone units from human patellar tendon. Transactions of the Orthopaedic Research Society, 14, 214. 15. Haut, R.C. and Powlison, A.C. (1990) The effects of test environment and cyclic stretching on the failure properties of human patellar tendons. Journal of Orthopaedic Research, 8(4), 532-40. 16. Itoi, E., Grabowski J., Morrey, B.F., et al (1993) Capsular properties of the shoulder. Tohoku J Exp. Med., Ul9 203-10. 17. Johnson, G.A., Tramaglini, D.M., Levine, R.E., et al (1994) Tensile and viscoelastic properties of human patellar tendon. Journal of Orthopaedic Research, 12(6), 796-803. 18. Neumann, P., Keller, T.S., Ekstrom, L., et al (1992) Mechanical properties of the human lumbar anterior longitudinal ligament. Journal of Biomechanics, 25(10), 1185-94. 19. Pintar, F.A., Yoganandan, N., Myers, T., et al (1992) Biomechanical properties of human lumbar spine ligaments. Journal of Biomechanics, 25(11), 1351-6. 20. Race, A. and Amis, A.A. (1994) The mechanical properties of the two bundles of the human posterior cruciate ligament. Journal of Biomechanics, 27(1), 13-24. 21. Regan, W.D., Korinek, S.L., Morrey, B.F., et al (1991) Biomechanical study of ligaments around the elbow joint. Clinical Orthopaedics & Related Research, 271, 170-9. 22. Salvelberg, H.H.C.M., Kooloos, J.G.M., Huiskes, R., et al (1992) Stiffness of the ligaments of the human wrist joint. Journal of Biomechanics, 25(4), 369-376. 23. Schuind, F., An, K.N., Berglund, L., et al (1991) The distal radioulnar ligaments: a biomechanical study. Journal of Hand Surgery - American Volume, 16(6), 1106-14. 24. Sheh, M., Butler, D.L and Stouffer, D.C. (1986) Mechanical and structural properties of the human cruciate ligaments and patellar tendon. Transactions of the Orthopaedic Research Society, 11, 236.

25. Noyes, F.R. and Grood, E.S. (1976) The strength of the anterior cruciate ligament in humans and rhesus monkeys. Journal of Bone and Joint Surgery, 58-A(8), 1074-1082. 26. France, E.P., Paulos, L.E., Rosenberg, T.D., et al (1988) The biomechanics of anterior cruciate allografts, in Prosthetic Ligament Reconstruction of the Knee (eds MJ. Friedman and R.D. Ferkel), W.B. Saunders Company, Philadelphia, pp. 180-5. 27. Paulos, L.E., France, E.P., Rosenberg, T.D., et al (1987) Comparative material properties of allograft tissues for ligament replacement: effects of type, age, sterilization and preservation. Transactions of the Orthopaedic Research Society, 12, 129. 28. Hurschler, C, Vanderby, R. Jr., Martinez, D.A., et al (1994) Mechanical and biochemical analyses of tibial compartment fascia in chronic compartment syndrome. Annals of Biomedical Engineering, 22(3), 272-9. 29. Butler, D.L., Noyes, F.R., WaIz, K.A., et al (1987) Biomechanics of human knee ligament allograft treatment. Transactions of the Orthopaedic Research Society, 12, 128. 30. Bigliani, L.U., Pollock, R.G., Soslowsky, L.J., et al (1992) Tensile properties of the inferior glenohumeral ligament. Journal of Orthopaedic Research, 10(2), 187-97. 31. Hubbard, R.P. and Soutas-Little, R.W. (1984) Mechanical properties of human tendon and their age dependence. Journal of Biomechanical Engineering, 106(2), 144-50. 32. Noyes, F.R., Butler, D.L., Grood, E.S., et al (1984) Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. Journal of Bone & Joint Surgery, 66-A(3), 344-52. 33. Woo, S.L-Y., Danto, M.I., Ohland, K.J., et al (1990) The use of a laser micrometer system to determine the cross-sectional shape and area of ligaments: A comparative study with two existing methods. Journal of Biomechanical Engineering, 112, 426-431. 34. Lyon, R.M., Lin, H.C., Kwan, M.K-W., et al (1988) Stress relaxation of the anterior cruciate ligament (ACL) and the patellar tendon (PT). Transactions of the Orthopaedic Research Society, 13, 81. 35. Schwerdt, H., Constantinesco, A. and Chambron, J. (1980) Dynamic viscoelastic behavior of the human tendon in vitro. Journal of Biomechanics, 13, 913-922. 36. Arms, S.W. and Butler, D.L. (1989) Cruciate ligament fiber bundle recruitment: A mathematical model. Transactions of the Orthopaedic Research Society, 14, 190. 37. Chun, K.J., Butler, D.L., Stouffer D.C., et al (1988) Stress-strain relationships in fascicle-bone units from human patellar tendon and knee ligaments. Transactions of the Orthopaedic Research Society, 13, 82. 38. Woo, S.L-Y., Johnson, G.A., and Smith, B.A. (1993) Mathematical modeling of ligaments and tendons. Journal of Biomechanical Engineering, 115, 468-473. 39. Butler, D.L., Sheh, M.Y., Stouffer, D.C., et al (1990) Surface strain variation in human patellar tendon and knee cruciate ligaments. Journal of Biomechanical Engineering, 112, 38^5.

B4

Skin and muscle*

A.F.T. Mak and M. Zhang

B4.1 INTRODUCTION Early studies [11] of the material properties of human skin and muscle are largely suspect due to problems of inappropriate tissue handling, preservation and specimen preparation. Recent efforts have focused on methods which can determine properties in situ in living individuals or on very freshly excised tissues. Among the in vivo testing methodologies, indentation has proven to be the most popular, although it sums up the contributions of various tissue layers [1, 3, 4, 6, 7, 9]. The load-displacement curve obtained during indentation depends in decreasing degree upon each of the tissues beneath the indentor. The derived properties, in addition, can be expected to vary with anatomical site, subject age and external environmental conditions (temperature, relative humidity, etc.). Additional results have been obtained in vivo through the use of Doppler ultrasound techniques [2, 5]. B4.2 IN-VIVO MECHANICAL PROPERTIES B4.2.1 Doppler Results Krouskop et al [5, 8] applied Doppler ultrasound techniques to measure the point-to-point biomechanical property of the human skin and subcutaneous musculatures. Tests of the forearms and legs suggested that the elastic moduli are strongly dependent on the contraction status of the muscles. A 16-fold increase (from 6.2 kPa to 109 kPa) in the modulus
* Data are provided from indentation and ultrasound measurement techniques only. Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

was reported at a 10% strain as muscle contraction changed from minimal to maximum. Malinauskas et al. [5] used the same technique to examine the stump tissues of above-knee amputees and found that the average modulus was significantly higher in posterior tissues than in other locations (Table B4.1). They found, additionally, that superficial tissues were stiffer than deeper structures. Note that the ages and sex of the subjects of these two studies [2, 5] were not reported.
Table B4.1 Apparent Elastic Moduli of Relaxed Above Knee Tissues [5]* Anatomical Location
Anterior Lateral Posterior Medial Superficial Underlying * Determined by Doppler ultrasonic techniques.

Elastic Modulus (kPa)(std dev.)

57.9 (31.1) 53.2 (30.5) 141.4 (79.1) 72.3 (45.5) 117.6 (63.0) 59.1 (74.0)

B4.2.2 Indentation results

Ziegert and Lewis [9] measured the in vivo indentation properties of the soft tissues covering the anterior-medial tibiae. A preload of 22.4 N was used with indentors of 6 to 25 mm in diameter. The observed load displacement relationship were essentially linearly elastic. The structural stiffness was noted to vary by up to 70% between sites in one individual and up to 300% between individuals. Unfortunately, the thicknesses of overlying tissues were not determined at the different sites for the individuals studied. Lanir et al. [3] measured the in vivo indentation behavior of human forehead skin with pressures up to 5 kPa. The observed behavior was linearly elastic and calculated stiffnesses were 4 to 12 kPa. Bader and Bowker [1] studied the in vivo indentation properties of soft tissues on the anterior aspects of human forearms and thighs by applying constant pressures of 11.7 and 7kPa respectively. Tissue thickness was measured by using a skinfold caliper and Poisson's rato was assumed to be 0.3. With these data, the stiffness of forearm and thigh tissue were calculated to be, respectively, 1.99 and 1.51 kPa. Vannah and Chlidress [7] applied similar techniques to measure the human calf, but confined the limb within a shell. They noted that stress relaxation occurred within one second of load application and no preconditioning effect was noted. Torres-Morenos et al [6] performed a similar study, working through ports in quadrilateral sockets of three above-knee amputees. However, they found the mechanical properties of

the tissues to be significantly non-linear, with site and rate dependencies, as well as being strongly influenced by muscular activity. Mak et al [4] (Table B4.2) measured the in-vivo indentation properties of the below knee tissues of young adults (N=6) between the ages of 25 and 35. A 4 mm diameter indentor was used, with a final indentation of about 5 mm. The fixed indentation was then maintained for 2-3 seconds to observe the difference between initial and relaxed (equilibrium) properties. The tests were done with the knee in 20 of flexion and were repeated with and without muscular contraction. The Poisson's ratio was assumed to be 0.5 for initial measurements and 0.45 for relaxed (equilibrium) measurements. Table B4.2 Initial and Relaxed Elastic Moduli of Tissues Around Proximal Human Tibiae [4]* Anatomical Location Initial Elastic Modulus (E1J (kPa)(std dev.) Relaxed Elastic Modulus (Eeq) (kPa)(std dev.)

Medial Relaxed 102.6 (8.6) 99.8 (9.2) Contracted 147.3** (15.8) 142.9** (16.7) Con./Relax. 1.44 1.43 Lateralt Relaxed 132.9 (7.2) 130.1 (7.9) Contracted 194.3** (24,7) 188.4** (23.0) Con./Relax. 1.46 1.45 * By indentation; ** Different from relaxed (p <0.001); t Between tibia and fibula.

ADDITIONAL READING Bader, D.L. and Bowker, P. (1983) Mechanical characteristics of skin and underlying tissues in vivo. Biomaterials, 4, 305-8 This paper describes an indentation experiment to investigate in vivo the bulk mechanical properties of the composite of skin and underlying tissues on the anterior aspects of human forearms and thighs by applying constant pressures. Significant variations in tissue stiffness with sex, age and body site were also demonstrated. Malinauskas, M., Krouskop, T.A. and Barry, P.A. (1989) Noninvasive measurement of the stiffness of tissue in the above-knee amputation limb. /. Rehab. Res. Dev., 26(3), 45-52 The paper reports a noninvasive technique to measure the mechanical properties of the bulk soft tissues by a pulsed ultrasonic Doppler system. An ultrasonic transducer was used to measure internal displacement resulting from external acoustical perturbations. Measurements were made at four sites of 8 aboveknee residual limbs. The Young's moduli were found in a range of 53-141 kPa. Superficial tissue had a significantly higher modulus than the tissue beneath.

The repeatability test indicated an acceptable repeatibility. An improved device can possibly be a useful tool in prosthetic fitting and CAD socket design. Rab, G.T. (1994) Muscle, in Human Walking (2nd ed.) (eds J. Rose, J.C. Gamble), Williams & Wilkins, Baltimore, pp. 101-122. A concise description of the active properties of muscle tissue, with direct application to the development of forces within the human gait cycle. Reynolds, D. and Lord, L. (1992) Interface load for computer-aided design of below-knee prosthetic sockets. Med. & Biol. Eng. & Comput, 30, 419^26. The authors investigated the bulk tissue behaviour of the below-knee amputee's residual limb. An assessment of Young's modulus was made by matching the indentation experimental curves with the curves produced by the finite element modelling of the indentation into a layer of tissue with idealized mechanical properties. In vivo tests, conducted at four sites of a below-knee amputee's limb (patella tendon, popliteal, and anterolateral regions) found the local moduli to be 145, 50, 50 and 120 kPa respectively. The effect of muscle tension on the measured indentation response was also investigated. The results showed that the stiffness increased with muscle contraction.

REFERENCES 1. Bader, D.L. and Bowker, P. (1983) Mechanical characteristics of skin and underlying tissues in vivo. Biomaterials, 4, 305-8. 2. Krouskop, T.A., Dougherty. D.R. and Vonson, F.S. (1987) A pulsed Doppler ultrasonic system for making noninvasive measurements of the mechanical properties of soft tissue. /. Rehab. Res. Dev., 24(1), 1-8. 3. Lanir, Y., Dikstein, S., Hartzshtark, A., et al (1990) In-vivo indentation of human skin. Trans. ASME (J. Biomech. Eng.), 112, 63-69. 4. Mak, A.F.T., Liu, G.H.W. and Lee, S.Y. (1994) Biomechanical assessment of below-knee residual limb tissue, /. Rehab. Res. Dev., 31, 188-198. 5. Malinauskas, M., Krouskop, T.A. and Barry, P.A. (4) (1989) Noninvasive measurement of the stiffness of tissue in the above-knee amputation limb. /. Rehab. Res. Dev., 26(3), 45-52. 6. Torres-Morenos, R., Solomonidis, S.E. and Jones, D. (1992) Geometric and mechanical characteristics of the above-knee residual limb. Proc. 7th. World Cong. Int. Soc. Prosthetics Orthotics, pp. 149. 7. Vannah, W.M. and Chlidress, D.S. (1988) An investigation of the three dimensional mechanical response of bulk muscular tissue: Experimental methods and results, in Computational Methods in Bio engineering (eds R.L. Spilker and B.R. Simon), Amer. Soc. Mech. Eng., New York, pp. 493-503. 8. Yamada, H. (1970) (ed. F.G. Evans) Strength of Biological Tissues, Williams & Wilkins, Baltimore. 9. Ziegert, J.C. and Lewis, J.L. (1978) In-vivo mechanical properties of soft tissue covering bony prominence, Trans ASME (J. Biomech. Eng.), 100, 194-201.

B5

Brain tissues
S.S. Margulies and D.F. Meaney

B5.1 INTRODUCTION The brain is organized into the cerebrum, brain stem, and cerebellum. The cerebrum consists of two cerebral hemispheres, basal ganglia, and the diencephalon. The hemispheres contain the cerebral cortex and underlying white matter, and are associated with higher order functioning, including memory, cognition, and fine motor control. The basal ganglia, contained within the hemispheres, controls gross motor function. The diencephalon is much smaller than the cerebrum, contains the thalamus and hypothalamus, and is associated with relaying sensory information and controlling the autonomic nervous system. The brainstem contains the mesencephalon, pons and the medulla oblangata. The smallest segment of the brain, the mesencephalon, is located below the diencephalon and is thought to play a role in consciousness. Muscle activation, tone and equilibrium is controlled in the pons and cerebellum located below the mesencephalon, and respiratory and cardiac processes are governed by the medulla oblongata, located directly beneath the pons. The brain contains grey matter and white matter substances that are easily distinguished upon gross examination. Grey matter contains a densely packed network of neural cell bodies and associated glial cells, whereas white matter contains myelinated axonal tracts, relatively few neuronal cell bodies, and a supporting environment of glial cells. The entire brain is surrounded by cerebrospinal fluid contained within an extensive ventricular system that occupies approximately one-tenth of the total brain volume. The ventricular system supports the brain as well as the spinal cord, and provides nutrients to and removes waste products from the central nervous system.
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Understanding the response of the complex brain structure to thermal, electrical, or mechanical stimuli necessitates a thorough investigation of the physical properties of each brain component. This task is still in its infancy, and therefore the material cited in this chapter is accompanied by several caveats. First, most properties cited are for whole brain. However, where available, properties of the white matter, gray matter, cerebrum, cerebellum, and brainstem are noted. Second, extensive studies have been conducted on brain tissue from a broad range of species. To provide the reader with information most similar to human tissue, only primate data (nonhuman and human) have been included. Exceptions occur only when there is no primate data available, and are noted. Finally, because the brain is a highly perfused organ and its properties may differ between in vivo and in vitro conditions, and with the post mortem time period before testing. To facilitate comparison between tests, information regarding in vivo/in vitro conditions, post mortem time, and test procedure is included with the data. B5.2 COMPOSITION
Table B5.1 Brain Tissue Composition Water (wt%) Ash (wt%) Lipid (wt%) Protein (wt%) 8-L2 8-12 11-12

Whole brain 76.3-78.5 (77.4) 1.4-2 (1.5) 9-L7 Grey matter 83-86 1.5 5.3 White matter 68-77 1.4 18 Approximate overall ranges given. Values in parentheses indicate averages. Source: [1-3].

B5.2.1 Mass [2] Adult male whole brain (20-30 yr): 1400 g (cerebrum 1200 g, cerebellum, 150 g) Adult female whole brain (20-30 yr): 1200 g Adult male whole brain (90 yr): 1161 g B5.2.2 Dimensions and shape [2] The adult brain with the brain stem is approximately half an ellipsoid. Diameter: Male: Female: Vertical 13 cm 12.5 cm Transverse 14 cm 13 cm Anteroposterior 16.5 cm 15.5 cm

B5.2.3 Density (adult) in kg/in3

Brain Grey matter White matter

1030-1041 1039 1043

[2] [1, 3] [1, 3]

B5.3 MECHANICAL PROPERTIES B5.3.1 Bulk modulus Excised brain samples: 2.1 x 106 kPa (independent of frequency) [4]. B5.3.2 Poisson's ratio Using the relationship v = (3K - E)/6K where K is the bulk modulus and E is the elastic modulus, and considering that K is 4-5 orders of magnitude larger than E, brain is approximated as an incompressible material (v=0.5) [5].
B5.3.3 Elastic and shear moduli

See Table B5.2.

B5.3.4 Creep modulus

See Table B5.3.

Table B5.2 Elastic Modulus and Shear Modulus of Normal Brain at 37C (typical values, not averages)
Testing technique Free vibration Free vibration Harmonic shear Driving point impedance Species (post mortuum time) Rhesus monkey (15 min) Human (6-12 hr) Human white matter (10-62 hr) Rhesus (in vivo) Frequency (Hz) 31 34 9-10 80 Analysis format E* = E1 + i E2 Results (kPa) G1 (kPa) 30.3 22.3 0.751.41 19.6 Source (kPa) 18.0 8.7 0.3-0.6 11.2 [7,8] [6] [6]

Quasi-static Rhesus monkey live expansion (in vivo) dead of balloon (5-45 min) fixed within tissue (formaldehyde) Sudden Human acceleration of a cylinder filled with tissue Harmonic shear Human (<3 hr)

E1 = 91.2 E2 + 53.9 E* = E1 + i E2 E1 = 66.8 E2 = 26.3 G* = G1 + i G2 Min: G* = 0.75 + i 0.3 Max G* = 1.41 + i 0.6 Theoretical G1 = 19.6 approx of data G2 = 11.2 G* = G1 + i G2 Static elastic Modulus, E1 E1 = 10-60 live and dead E1 = 40-120 fixed Shear modulus G=1.17-2.19 kPa (average=1.7) Kinematic viscosity v = 14-124 cm2/s (average=89) G2 G* = G1 + i G2 G1 7.6 2.8 8.4 3.5 11.7 5.2 19.3 13.4 21.4 18.0 29.0 45.9 33.9 81.4

10-60 1.7

P]

(acceleration compare tissue duration ~ displacement with 17.5 ms.) that of a Voigt solid cylinder 5-350 5 15 35 85 105 225 350

[10] (Tissue temp unknown)

7.6-33.9 2.76-81.4 [H]

Table B5.2

Continued Species (post mortuum time) Human (<3 hr) Grey matter Axis 1 Axis 2 Axis 3 average white matter Axis 1 Axis 2 Axis 3 average Frequency (Hz) 2-10 10.6 6.3 4.1 7.0 2-10 7.7 7.0 7.3 7.3 2.6 3.2 3.5 3.1 1.5 1.5 1.4 1.5 Analysis format G* = G1 + i G2 G1 Results (kPa) G2 G1 (kPa) G2 (kPa) Source
[H]

Testing technique Harmonic shear

7.0

1.5

7.3

3.1

* Assumed tissue is incompressible (v=0.5), therefore <G* = E*/3.

Table B5.3

Creep Modulus of Normal Brain at 37C (typical values, not averages) Model Results C1 = 2.97 kPa C2 = 0.18 kPa 1 t >0.1 s C1 - 2.45 kPa 1 C2 = 0.18 kPa 1 t >0.1 s K1 = 25.77 kPa K2 - 20.46 kPa, K3 = 104.04 kPa C1 = 651.8 kPa s U0 = 3.44, 4.82, 6.89 kPa K1 = 74.41 kPa K2 = 20.67 kPa C1 = 1266.38 kPa C2 = 36599.7 kPa s C3 = 1.38 kPa s2 (T0 = 3.44, 4.82, 6.89 kPa
1

Testing technique* Species Compression

Source [6]

Rhesus monkey J(t) = C1 + C2 ln(t) (15 min) Human (6-12 hr) Human (6-12 hr) J(t) = C1 - C2 ln(t)

Compression

[6]

Compression

Nonlinear solid K2 V K 1 2K3 2K3 / where IJL=K2ZC1

w V

[12]

*J

Compression

Human (6-12 hr)

Nonlinear fluid <r0 C1C2 W K2 2K1C3

[12]

C1(C^2 + 4,X0C3)1'2 2K1C3

+ -^r- [(C22 + 4(X0C3)^ - C2] (t +-- e-^)

ZC3
K1

Table B5.3 Continued Testing technique* Species Compression Human (6-12 hr) Model Hyperelastic with material dissipation 2C1 L X JL C1 X J C1 X3 Results C1 = 6.89 kPa C2 = 17.23 kPa B1 = 0.55 kPa s2 X = stretch ratio X = stretch rate Grey matter G= 2 kPa X = 90 kPa K = 7.5 x 10-9 kPa-m2/s White matter G = 0.9 kPa X = 40 kPa K - 5 x 10-9 kPa-m2/s Source [12]

[X2 - 6X3 + 1] Fluid infusion Cat Poroelastic = K(2G + X)V2e dt G = shear modulus X = Lame constant K = permeability * AU tests consisted of a load applied rapidly and then held constant.

[13]

B5.4 ELECTRICAL PROPERTIES

(no primate data available)

B5.4.1 Electrical conductivity temperature coefficient [14] Cow and pig whole brain (Ao7a)/AT = 3.2 0 C 1 . Table B5.4 Electrical conductivity of brain tissues Temp (0C) Whole brain Cerebrum Cerebellum Cortex Cortex White matter White matter 37 39 39 body 37 body 37 Conductivity (s) (mS/cm) 1.7 1.38-1.92 1.17-1.64 3.1 4.5 1.0 2.9 Species cow, pig rabbit rabbit rabbit cat rabbit cat Source [14] [15] [15] [16 [17 [18 [17

B5.5 THERMAL PROPERITES

Table B5.5 Thermal properties of normal, unperfused human brain tissue Temp (0C) Whole brain Whole brain Cortex White matter 5^20 37 37 5-20 5-20 Conductivity, (Wm0K) 0.528 0.503-0.576 0.515 0.565 0.565 Diffusivity, (Cm2ZsXlO3) 1.38 0.11 1.47 1.43 0.09 1.34 0.10 Specific heat, (J/g 0K) 3.68 3.60 Source [19] [20] [21] [19] [19]

Values A-B indicate approximate range, values A B indicate mean standard deviation.

B5.6 DIFFUSION PROPERTIES 5.6.1 Sucrose (feline brain) [22] D ~ 3,2-3.8 x 10"6 cm2/sec matter ~ 1.3 - 1.9 x 10 6 cm 2 /sec white matter B5.6.2 Small ions [23] D ~ 8.6 x IO"6 cm2/sec

5.6.3 Large molecules (>150 angstrom): [23]

Hindered diffusion occurs

B5.7 COMMENTS

The list of primate brain tissue properties presented in this chapter highlights the numerous areas where data are either unavailable or largely incomplete. With a renewal of interest in modeling the normal and pathological response of the brain to various stimuli, it is possible that some of the missing tissue property data will be generated in the near future. Investigators should be cautioned, however, that because brain tissue properties vary with environmental factors, measurements made under unphysiologic conditions may differ from those of living tissue. As an example, the brain is highly vascularized, and the role of blood flow, volume, and pressure on tissue behavior remains to be determined. The caution exercised by the experimentalist in generating new data should be matched by sound skepticism on the part of the investigators who are developing analytical or computational models of brain functional and structural response. Although the ability to calculate detailed responses has improved greatly in the past decade, these sophisticated models are limited by the available experimental data used to develop and validate the models. To create a realistic representation of normal or pathological response of the brain, it is essential that the model parameters be based on measured tissue properties and that any conclusions drawn from the models be validated with measured response data. Therefore, it is clear that future experimental studies are needed to determine the properties and response of living primate brain tissue. ADDITIONAL READING
Cooney, D.O. (1976) Biomedical Engineering Principles: An introduction to fluid, heat and mass transfer processes, Marcel Dekker, New York. Provides more detailed examples in bioheat transfer and pharmacokinetics which may be useful in modeling heat and mass transfer in the brain parenchyma. Fung, Y.C. (1993) Biomechanics: Mechanical properties of living tissues, 2nd ed., Springer-Verlag, New York. Fung, Y.C. (1990) Biomechanics: Motion, flow, stress and growth, Springer-Verlag, New York. Fung, Y.C. (1965) Foundations of Solid Mechanics, Prentice Hall, Englewood Cliffs. These works describe both basic principles of mechanics and their specific applications in biomechanics. A review of the constitutive property relationships for biological tissues included throughout these texts may be particularly helpful for applying the material-property information listed previously.

Lih, M.L. (1975) Transport Phenomena in Medicine and Biology, John Wiley & Sons, New York. A concise review of the principles used in modeling the transport phenomena in several biological systems including examples of heat and mass transfer. Nolte, J. (1988) The Human Brain, 2nd. ed., CV. Mosby, St Louis Provides a more detailed review of the structure and function of the different brain regions. REFERENCES 1. Duck, F.A. (1990) Physical Properties of Tissue, Academic Press, New York. 2. ICRP (1975) Report of the Task Group on Reference Man, ICRP Publication 23, International Commission on Radiological Protection, Pergamon Press, Oxford, pp. 212-215; 280-281. 3. Woodard, H.Q. and White, D.R. (1986) The composition of body tissues. Brit. J. Radiol, 59, 1209-1219. 4. McElhaney, J.H., Roberts, V.L. and Hilyard, J.F. (1976) Handbook of Human Tolerance, Japanese Automobile Research Institute, Tokyo, pp. 151. 5. Fung, Y. C. (1993) Biomechanics: Mechanical properties of living tissues, 2nd ed., Springer-Verlag, New York. 6. Galford, J.E. and McElhaney, J.H. (1970) A viscoelastic study of scalp, brain, and dura. /. Biomech., 3, 211-221. 7. Fallenstein, G.T., Hulce, V.D. and Melvin, J.W. (1969) Dynamic mechanical properties of human brain tissue. /. Biomech., 2, 217-226. 8. Wang, H.C. and Wineman, A.S. (1972) A mathematical model for the determination of viscoelastic behavior of brain in vivo - I: Oscillatory response. /. Biomech., 5, 431-446. 9. Metz, H., McElhaney, J. and Ommaya, A.K. (1970) A comparison of the elasticity of live, dead, and fixed brain tissue. /. Biomech., 3, 453-458. 10. Ljung, C. (1975) A model for brain deformation due to rotation of the skull. /. Biomech., 8, 263-274. 11. Shuck, L.Z. and Advani, S.H. (1972) Rheological response of human brain tissue in shear. /. Basic Eng., Trans ASME, 94, 905-911. 12. Pamidi, M. and Advani, S. (1978) Nonlinear constitutive relations for human brain tissue. /. Biomech. Eng., 100, 44-48. 13. Basser, P. (1992) Interstitial pressure, volume and flow during infusion into brain tissue. Microvascular Res., 44, 143-165. 14. Osswald, K. (1937), (Measurement of the conductivity and dielectric constants of biological tissues and liquids by microwave) (Ger.) Messung der Leitfahigkeit und Dielektrizitatkonstante biologischer gewebe und Flussigkeiten bei kurzen Wellen. Hochfrequentz Tech. Elektroakustik, 49, 40-49. 15. Crile, G.W., Hosmer, H.R. and Rowland, A.F. (1922) The electrical conductivity of animal tissues under normal and pathological conditions. Am. J. Physiol, 60, 59-106. 16. Ranck, J.B. and Be Merit, S.L. (1963) Specific impedance of rabbit cerebral cortex. Exp. Neurol, 7 144-152.

17. Freygang, W.H. and Landaw, W.M. (1955) Some relations between resistivity and electrical activity in the cerebral cortex of the cat. /. Cell. Comp. PhysioL, 45, 377-392. 18. van Harreveld, A., Murphy, T. and Nobel, K.W. (1963) Specific impedance of rabbit's cortical tissue. Am. J. PhysioL, 205, 203-207. 19. Cooper, T.E. and Trezek, GJ. (1972) A probe technique for determining thermal conductivity of tissue. /. Heat Transfer, Trans. ASME, 94, 133-140. 20. Bowman, H.F. (1981) Heat transfer and thermal dosimetry. /. Microwave Power, 16, 121-133. 21. Valvano, J.W., Cochran, J.R. and Diller, K.R. (1985) Thermal conductivity and diffusivity of biomaterial measured with self-heating thermistors. Int. J. Thermophys., 6, 301-311. 22. Rosenberg, G.A., Kyner, W.T. and Estrada, E. (1980) Bulk flow of brain interstitial fluid under normal and hypermolar conditions. Am. J. PhysioL, 238, f42-f49. 23 Nicholson, C. (1985) Diffusion from an injected volume of substance in brain tissue with arbitrary volume fraction and tortuosity. Brain Research, 333, 325-329.

Arteries, veins and lymphatic vessels

X. Deng and R. Guidoin

B6

B6.1 INTRODUCTION Blood and lymphatic vessels are soft tissues with densities which exhibit nonlinear stress-strain relationships [I]. The walls of blood and lymphatic vessels show not only elastic [2, 3] or pseudoelastic [4] behavior, but also possess distinctive inelastic character [5, 6] as well, including viscosity, creep, stress relaxation and pressure-diameter hysteresis. The mechanical properties of these vessels depend largely on the constituents of their walls, especially the collagen, elastin, and vascular smooth muscle content. In general, the walls of blood and lymphatic vessels are anisotropic. Moreover, their properties are affected by age and disease state. This section presents the data concerning the characteristic dimensions of arterial tree and venous system; the constituents and mechanical properties of the vessel walls. Water permeability or hydraulic conductivity of blood vessel walls have been also included, because this transport property of blood vessel wall is believed to be important both in nourishing the vessel walls and in affecting development of atherosclerosis [7-9]. The data are collected primarily from human tissue but animal results are also included in places for completeness. Among the three kinds of vessels, the arterial wall has been extensively investigated while studies of lymphatic vessels are very rare.

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

B6.2 MORPHOMETRY OF THE ARTERIAL TREE AND VENOUS SYSTEM Detailed measurements of the number and size of blood vessels in the living body are very difficult to perform, so reliable information is scarce. Moreover, data collected on vessels in one tissue or organ are not applicable to another. Thus one should be cautious in using morphometric data; only the data for large vessels are reliable. The aorta is tapered, but most other arteries can be considered to have a constant diameter between branches. The rate of taper varies from individual to individual, presumably, between species. However, in the dog, the change of aortic cross sectional area can be described by the exponential equation: A = A 0 e(-WRo) (B6.1) where A is the cross sectional area of the aorta, A 0 and R0 are the respective cross sectional area and radius at the upstream site, x is the distance from the upstream site, and P a taper factor, which varies between 0.02 and 0.05 [10]. In man, the taper is found not to be as smooth as implied by the above equation; thus values of (3 are unavailable. Morphometric and related data are given in Tables B6.1, B6.2 and B6.3. B6.3 CONSTITUENTS OF THE ARTERIAL WALL B6.3.1 Normal arterial wall The main constituents of normal human arterial tissues from young adult subjects (20-39 years) are listed in Table B6.4 [20]. The major part of the Table B6.1 Morphometric and Related Properties of the Human Systemic Circulation* Vessel Diameter Wall thickness Length Blood velocity Reynolds (mm) (mm) (cm) (cm/sec) number 1.6 1.2 0.9 0.5 0.75 0.35 5-5.5 4-5 16 15 32 18 23
63 27 3600-5800 1200-1500

Ascending aorta 32 Arch of aorta 25-30 Thoracic aorta 20 Abdominal aorta 17-20 Femoral artery 8 Carotid artery 9 Radial artery 4 Large artery 2-6 Capillaries 0.005-0.01 Large veins 5-10 Vena cava 20

20-50 0.05-0.1 15-20 11-16

110-850 i0.0007-0.003 210-570 630-900

* Source [11-17]. Note: The Reynolds numbers were calculated assuming a value for the viscosity of the blood of 0.035 poise.

Table B6.2 Morphometrics of the Pulmonary Arterial System*

Zone Proximal Number of branches 1.000 3.000 8.000 2.000 6.600 2.030 6.750 2.290 5.861 1.756 5.255 1.574 4.713 1.411 4.226 1.266 3.000 Diameter (mm) 30.000 14.830 8.060 5.820 3.650 2.090 1.330 0.850 0.525 0.351 0.224 0.138 0.086 0.054 0.034 0.021 0.013 Length (mm) 90.50 32.00 10.90 20.70 17.90 10.50 6.60 4.69 3.16 2.10 1.38 0.91 0.65 0.44 0.29 0.20 0.13

x x x x x x x x x x x x x x

10 10 102 102 103 103 104 104 105 105 106 106 107 108

Intermediate

Distal

* Source: Adapted from [18]. Note: The data were obtained from a 32-year-old woman who had been free of respiratory disease and died of uremia. For the purpose of description, the pulmonary arterial tree was divided into three zones.

dry matter in the arterial wall consists of proteins such as elastin and collagen. Because the importance of elastin and collagen in the mechanical properties of arterial wall, the composition of media and adventitial layers in terms of collagen, elastin, smooth muscle and ground substance is listed in Table B6.5 for three different arterial tissues [I]. The collagen in adventitia and media is mostly Type III, some Type I, and a trace of Type V while the collagen of the basal lamina is Type IV [I]. Table B6.6 lists the constituents of additional arteries (canine), and the the ratio of collagen to elastin [21].
Composition changes of arterial tissues with age

The composition of normal human arterial tissues is altered with age in many aspects. Table B6.7 lists the observed changes in human aorta, pulmonary and femoral arteries [20]. There is a tendency that both the dry matter and nitrogen content of arterial tissues decreases with age. However, the relative quantity of collagen [22] and elastin [23, 24] in the arterial wall remains almost unchanged with age. Below the age of 39, the wall of human thoracic aorta has 32.1 5.5% elastin, between the age 40-69, the wall contains 34.4 9.3%, and from 70-89, the elastin content is 36.5 10.1 [24].

Table B6.3 Morphometric and Related Properties of the Canine Systemic Circulation*!
Site Ascending Descending aorta aorta 1.3 (0.8-1.8) Abdominal Femoral aorta artery 0.9 (0.5-1.2) 0.05 (0.04-0.06) 0.06 (0.04-0.09) 20 5 1.3 0.6 2 2 1.05 (0.25-2.5) 0.55 (0.5-0.6) 0.2 (0.1-0.4) 0.15 (0.08-0.2) 3400 1250 1.0 (1.0-1.2) 0.1 (0.1-0.15) 1000 0.2 3 125 0.75 600 0.07 570 0.35 3.0 0.25 (0.15-0.4) 2.3 0.7 0.15 (0.06-0.28) 700 3000 15 10 0.4 (0.2-0.8) 0.04 (0.02-0.06) Carotid artery 0.5 (0.2-0.8) 0.03 (0.02-0.04) Arteriole 5 x IO 3 (1-8 x IO 3 ) 2 x IO"3 0.4 0.15 (0.1-0.2) 2xlO"5 Capillary 6 x 10-4 (4-8 x 10-4) 1 x 10-4 0.17 0.06 (0.02-0.1) 3xlO7 Venule Vena cava, Pulmonary inferior artery, main 1.7 (1.0-2.0)

Internal diameter, 1.5 (1.0-2.4) 4 (cm) Wall thickness, h (cm) 0.065 (0.05-0.08) 0.07 (0.055-0.084) In vivo length (cm) Cross-section area (cm2) Total vascular 2 cross-section at each level (cm2) Blood velocity (peak) (ms"1) Blood velocity (mean) (ms1) Peak Reynolds number, /Je 2 1.2 (0.4-2.9) 0.2 (0.1-0.4) 4500

4 x 10"3 1.0 (1-7.5 x 103) (0.6-1.5) 2 x 10-4 0.05 0.15 (0.1-0.2) 2xl05

0.015 0.02 (0.01-0.02) (0.01-0.03) 0.015 30 (20-40) 0.8 0.01 3.5 (3-4) 2.3

0.07 0.08 (0.055-0.11) (0.053-0.095) 15 (10-20) 0.2

(5-10 x IO"3)

2-17 x IO 4

2-5 x 10-3

0.09

0.001

0.035

* Source: Adapted from [19]. t Normal values for canine cardiovascular parameters. An approximate average value, and then the range, is given where possible. All values are for the dog except those for arteriole, capillary, and venule, which have only been measured in smaller mammals.

Table B6.4 Composition of Normal Arterial Tissue* Components Organic Dry matter Nitrogen Total lipids Cholesterol Total ash Calcium Total PO4 Aorta (human)
28.Ot 4.1 1.680 0.290 0.730 0.070 0.375 Femoral artery (human) 25.3 3.5 0.135 0.675 0.147 Brachial artery (human) 26.3 0.185 0.670 0.144

Inorganic

Source: Adapted from [20]. Values are expressed in percentage of wet tissue weight,

Table B6.5

Composition of Human Arteries at In Vivo Blood Pressure Thoracic aorta Plantar artery 60.5 26.4 1.3 11.9 6.5 6.4 1.1 8.4 Pulmonary artery 46.4 17.2 9.0 27.4 63.0 25.1 10.4 1.5 7.7 8.6 3.2 13.2 8.5 8.3 6.1 1.5

Media Smooth muscle Ground substance Elastin Collagen Adventitia Collagen Ground substance Fibroblasts Elastin

33.5 5.6 24.3 36.8 77.7 10.6 9.4 2.4

10.4f 6.7 7.7 10.2 14.1 10.4 11.0 3.2

63.9 9.7 24.7 2.6 11.4 2.6 0

* Source: Adapted from [I]. f (Mean S.D.)

Changes in elastin and collagen content due to hypertension Experimental observation by Wolinsky [25] showed that the absolute amounts of both elastin and collagen contents increased in hypertensive rats; however, the percentage of these elements remained essentially constant (Table B6.8) Changes in elastin and collagen content due to atherosclerosis Table B6.9 lists the changes in elastin and collagen contents of canine carotid and iliac arteries due to dietary atherosclerosis [26]. In the iliac site the ratio of collagen to elastin was increased, while the ratio in the carotid site was decreased.

Table B6.6 Arterial Wall Constituents, and Ratio of Collagen to Elastin*

Percentage of wet tissue Artery Coronary Aorta, ascending Carotid Aorta, abdominal Cranial mesenteric, proximal Cranial mesenteric, distal Cranial mesenteric, branches Renal Femoral Percentage of dry defatted tissue Collagen 47.9 2.6 19.6 1.2 50.7 2.1 45.5 1.7 38.1 1.7 37.4 1.4 36.1 1.5 42.6 1.6 44.5 1.4 Elastin 15.6 41.1 20.1 30.1 26.5 0.7 2.1 1.0 1.7 1.7 Collagen+elastin 63.5 2.7 60.7 2.2 70.8 2.5 75.6 1.8 64.6 1.8 59.8 1.6 57.9 1.7 61.3 2.1 69.0 2.1 C E 3.12 0.21 0.49 0.04 2.55 0.13 1.58 0.15 1.51 0.15 1.72 0.11 1.69 0.10 2.46 0.27 1.89 0.14

nf
9 9 6 10 10

H2O 63.2 1.0* 73.8 0.6 71.1 0.1 70.4 0.4 70.8 0.5 71.4 0.4

Extracted fat+H2O 71.5 1.4 74.0 0.5 71.2 0.1 70.8 0.3 71.6 0.4 72.0 0.4 73.1 0.7 70.8 0.7 68.1 0.3

22.4 1.5 21.8 0.9 18.7 1.8 24.5 1.6

10

69.5 0.6 70.4 0.7 68.0 0.3

10

* Source: [21] by permission. f Number of specimens. % Specimens slightly dehydrated owing to unavoidably long dissection. Mean standard deviation. All percentage values refer to w/w.

Table B6.7

Variation of Normal Human Arterial Tissue Composition with Age* Aorta Acidsoluble Potassium PO4 0.16 0.29 0.41 0.055 0.040 0.039 0.033

Age NitroDry group (years) matter gen 10-19 30-39 50-59 70-79 29.5t 28.5 28.0 28.0 4.38 4.03 3.67 3.38

Total lipids 1.23 1.75 1.90

Cholesterol 0.15 0.28 0.48 0.71

Total ash 0.81 1.55 2.80

Calcium 0.03 0.09 0.21 0.39

Total PO4 0.25 0.40 0.54

Pulmonary artery group Dry Nitro- Choles- Calterol cium (years) matter gen 10-19 30-39 50-59 70-79 26.5 25.7 24.9 23.0 3.91 3.71 3.45 3.25 0.12 0.17 0.22 0.025 0.028 0.027 0.060

Femoral artery Potas- Dry Nitro Choles- Total Calash cium terol ium matter gen 0.033 0.031 0.026 0.025 26.9 24.4 22.8 25.3 3.84 3.30 2.83 2.90 0.11 0.15 0.23 0.55 0.59 0.71 1.15 3.17 0.14 0.18 0.40 1.07

Source: Adapted from [20]; see for additional age group values. Values expressed in percentage of wet tissue weight.

Table B6.8

Effect of Hypertension on Composition of Arteries* Elastin (E) Collagen (C) E and C

Group III Ct III H t II C HH I C I H

Nt 2 2 2 2 2 2

(mg) 525 5.58 7.00 6.50 4.96 5.26 8.12 7.50 4.36 5.56 8.88 10.89 P<0.01#

Wt(mg)(% total wt) 1/76 2.20 2.86 2.78 2.23 2.14 2.94 2.70 1.91 2.09 3.08 3.50 P<0.001 33^5 39.0 41.6 42.8 44.9 40.6 36.2 36.0 43.8 37.6 34.7 32.1 P>0.2

WT(mg)(% total wt) (% total wt) 069 0.83 1.44 1.06 0.72 0.68 1.68 1.52 1.12 1.24 2.08 2.33 P<0.01 131 14.3 20.6 16.3 14.5 12.8 20.7 20.3 25.7 22.3 23.4 21.4 P=0.2 46\6 53.3 62.2 59.1 59.4 53.4 56.9 56.3 69.5 59.9 58.1 53.5 P>0.8

* Source: [25] by permission: t' N = number of animals (rats); C = normotensive; H - hypertensive. #: Normotensive vs. hypertensive

Table B6.9

Effect of Atherosclerosis on Comparison of Arteries* H2O (g/kg Collagen Elastin wet wt) (% dry wt) (% dry wt) 7403t 7647## 7423 7246## 50.60.8 49.81.6 46.20.6 37.82.0 28.00.3 33.11.3## 33.00.7 25.11.2## Collegen + Elastin (% dry wt) 78.60.8 84.21.9## 79.21.1 66.02.3## Collegen Elastin 1.810.04 1.610.07# 1.410.03 1.490.02#

Site Carotid Control (n = 11) Diet (n - 7) Iliac Control (n = 16) Diet (n = 5)

* Source: [26] by permission; canine subjects. t means SE. ## Significantly different, P < 0.01; # Significantly different, P < 0.05.

B6.4 CONSTITUENTS OF THE VENOUS WALL B6.4.1 Normal venous wall The main constituents of normal human venous tissue are listed in Table B6.10.
Table B6.10 Composition of Normal Human Venous Tissue* Femoral vein Dry matter Nitrogen Cholesterol Total ash Calcium Potassium 28.0| 4.08 0.076 0.590 0.058 Vena cava, inferior 26.1 0.083 0.012 0.065

* Source: adapted from [27]. t Percentage of wet tissue weight.

B6.4.2 Changes with age in composition of normal venous tissues The changes with age in the composition of normal venous vessels are listed in Table B6.ll. B6.5 MECHANICAL PROPERTIES OF ARTERIES The blood vessel wall consists of three layers: the intima, media, and adventitia. The intima contains mainly the endothelial cells that contribute little to the strength of the blood vessels. The media and the adventitia

Table B6.ll Age group (K9 20-29 40-49 60-69 70-79 Age group 0^9 20-29 40-49 60-69 70-79

Composition of Normal Human Venous Tissue* Dry matter 3LIt 27.4 24.7 23.2 21.8 Dry matter 309 26.8 24.5 21.7 22.7 Femoral vein Nitrogen Cholesterol 4^63 3.88 3.34 3.06 2.92 O058 0.071 0.064 0.087 0.087 Total ash 0525 0.586 0.542 0.555 0.600 Calcium 0.011 0.011 0.010 0.011 Calcium O051 0.053 0.065 0.075 0.083 Potassium 0.072 0.053 0.048 0.048

Vena cava, inferior Nitrogen Cholesterol 0.082 0.091 0.097 0.097

* Source: [27] by permission.; see source for additional age groups. t Percentage of wet tissue weight.

contain smooth muscle cells, elastin and collagen. Elastin is the most 'linearly' elastic biosolid material known. Unlike elastin, collagen does not obey Hooke's Law. However, collagen is the main load carrying element of blood vessels. Table B6.12 lists the mechanical properties of tissues composing the blood vessel wall.
B6.5.1 Static mechanical properties of arteries

Studies of arterial wall mechanics have clearly established the anisotropic nature of arteries [1, 29, 30]. In vivo pressurized arteries are deformed simultaneously in all directions. But, experimental studies [31] have demonstrated that arteries deform orthotropically. Therefore, arterial deformations may be examined in three orthogonal directions, namely, the longitudinal, circumferential, and radial directions. There are nine Table B6.12 Mechanical Properties of Layers of the Vascular Wall*
Material Young's modulus (dynes/cm2) Maximum Relative extensibility" extension (cm) (%) 10 0.03 2.3 Tensile strength (dynes/cm2)

3 to 6 x 106 Elastin Collagen 1 x 109 to 2.9 x 1010 Smooth muscle Relaxed 6 XlO 4 Contracted 1 x 105 to 12.7 x 106

100-220 3.6 x 106 to 4.4 x 107 5.50 5 x 107 to 5 x 109 300 300

* Source: Adapted from [28]; Fiber 10 cm in length, 1 mm2 cross section, sustaining a load of 3Og.

elastic parameters: the three elastic moduli, E9, Ez and Er; and six Poisson's ratios, ar6, aer, crz6, aGz, arz and azr. As far as hemodynamics is concerned, however, among the three elastic moduli the circumferential one is most important. The cicumferential elastic modulus is termed the incremental modulus and determined by the following equation (B6.2): (B6.2) where Ap1 is the transmural pressure increment, R0 and R1 are the respective external and internal diameter of the vessel, AR0 is the change in the external diameter due to Ap1, and a the Poisson's ratio (the ratio of transverse strain to longitudinal strain). The detailed technique for measuring the circumferential incremental elastic modulus of the arteries was described by Bergel [32]. Table B6.13 presents the circumferential incremental elastic modulus of human arterial walls from young adults (< 35 years) at a transmural pressure of 100 mmHg. Experimental data by Bader [34] demonstrated that the circumferential elastic modulus of human thoracic aorta increased almost linearly with age. Table B6.14 gives the variation with age in the elastic moduli for human thoracic and abdominal aorta at a pressure of 100 mmHg. It should be mentioned that all the circumferential elastic moduli given in Table B6.14 are based on the assumption of a Poisson's ratio of 0.5. This is not strictly true when large strains are considered [36]. Patel et al [37] measured Poisson's ratios for the aorta in living dogs at a transmural pressure of about 110 mmHg, as well as the circumferential, longitudinal and radial incremental elastic moduli and determined that individual values vary between 0.29 and 0.71.

Table B6.13 Elastic Modulus of Human Arteries*

Arterial segment E6 (xlO6 dynes/cm2)

Thoracic aorta Abdominal aorta Iliac artery Femoral artery Carotid artery

4.0-10 4.0-15 8.0-40 12-40 3.0-8.0

* Source: Adapted from [33,34]; young subjects (< 30 years) at a transmural pressure of 100 mmHg. Note: The circumferential elastic moduli were calculated assuming that the arterial walls have a Poisson's ratio (the ratio of transverse to longitudinal strain) of 0.5.

Table B6.14 Hydrodynamic Properties of the Aorta* Age (yrs) 30-39 40-49 50-59 60-69 70-79 80-89 Age (yrs) 30-39 40-49 50-59 60-69 70-79 Z0 (mmHgS cm3) 013 0.17 019 019 0.22 022 Z0 (mmHgS cm3) 031 0.53 0.53 0.51 0.68 Thoracic aorta Vp (m/s) 5^8 7.4 9.0 10.0 12.4 13.6 Abdominal aorta Vp (m/s) T9 10.5 11.4 12.0 14.5 Ej (106 Wm2) 056 08 1.13 1.25 1.87 2.2 Ej (106 Wm2) 08 1.22 1.3 1.5 1.75

* Adapted from [35] by permission; f Poisson's ratio of arterial wall assumed to be 0.5.

B6.5.2 Compliance, pressure cross-sectional area relationship, and retraction

By measuring the static elastic properties of human thoracic and abdominal aortas in vitro, Langewouters et al [35] proposed the following empirical relationship between the cross-sectional area of the lumen (A) and the pressure in the vessel (p):
(B6.3)

in which Am, p o and P1 are three independent parameters that are defined in Equation (B6.4) below. Another important mechanical property of blood vessels in the compliance. Langewouters et al [35] defined the 'static' compliance as the derivative of equation (B6.3) with respect to pressure
(B6.4)

where Cm and Am are the maximum compliance and the maximum crosssectional area of the vessel, respectively; p o is the pressure at which aortic compliance reaches its maximum; and P1 is the half-width pressure, i.e. at p o P1, aortic compliance is equal to Cm/2. According to Langewouters et al [35], the 'static' compliance values of human thoracic aorta at 100mmHg range from 1.9 to 17 x 103cm2/mmHg; and 0.6 to 4.4 x 10 3 cm2/mmHg for abdominal aorta.

Table B6.15 lists the relative wall thickness and the retraction on excision for a variety of blood vessels. The retraction of a vessel is the amount by which a segment of vessel shortens on removal from the body, expressed as a percentage of the length of the segment in situ. The relative wall thickness is the ratio of wall thickness to mean diameter of the vessel.
B6.5.3 Tensile properties of human arteries

Table B6.16 presents typical data for the tensile properties of arterial tissues from Yamada [43]. The test specimens of tissues were strips each with a reduced middle region 10 mm length, 2-3 mm in width, and a length to width ratio of 3:1. In the tables: 1. Tensile breaking load per unit width (g/mm) = ultimate tensile strength (g/mm2) x thickness (mm) ., , , , 2 tensile breaking load (g) rt TT1 . 2. Ultimate tensile strength (g/mmox )= r : cross-section area of the test section breaking elongation (mm) 3. Ultimate percentage elongation (%)= x 100 original length of the specimen (mm)

Table B6.15 Relative Wall Thickness and Retraction on Excision of Various Blood Vessels* Vessel Thoracic aorta Abdominal aorta Femoral artery Carotid artery Iliac artery Carotid artery Carotid artery Carotid artery Carotid sinus Carotid sinus Carotid sinus Thoracic aorta Abdominal aorta Femoral artery Pulmonary artery Abdominal vena cava Thoracic aorta Abdominal aorta Femoral artery Carotid artery Species Dog Dog Dog Dog Dog Dog Cat Rabbit Dog Cat Rabbit Dog Dog Dog Man Dog Man Man Man Man y x % 10.5 10.5 11.5 13.2 13.6 14.5 11.2 20.0 16.0 12.0 14.0 12.0 13.0 2.0 2.3 6-9 8-13 12-19 2-15 Retraction % 32 34 42 35 40 30 25-15 30-17 40-25 25-18 Source [2] [2] [2] [2] [2] [38 [38 [38 [38 [38 [38 [39 [39 [39] [40] [41] [33]t [33]t [33]t [33]t

Source: Adapted from [42]. t Measurement from [33] of young (<35) and old (>35) subjects respectively.

Table B6.16 Tensile Properties of Human Coronary Arterial Tissue* (Longitudinal Direction) Tensile Breaking Load/Unit width (g/mm) 853.1 821.8 82+1.8 792.9 81 Ultimate Tensile Strength (g/mm2) 1403.0 1149.3 1044.7 1044.7 107 Ultimate Elongation (%) 992.4 781.6 683.5 4.53.8 64

Age (yrs) 10-19 20-39 40-59 60-79 Adult (average)

* Adapted from [43].

Table B6.16 lists the tensile data for human coronary arterial tissue in the longitudinal direction. Other arteries have similar properties [43]. Yamada [43] provides the tensile properties of animal tissues in various tables. B6.5.4 Dynamic mechanical properties of arteries The most direct way to study arterial viscoelasticity is to determine the response of the test tissue to oscillatory stresses. If the arterial wall is conceived to be represented by a simple Kelvin-Voigt model consisting of a spring and a dashpot in parallel, the dynamic elastic component and the viscous component of a vessel can be expressed as ED = E cos <\>
J]Oi = E sin (|> (B6.5)

where E is the complex dynamic elastic modulus that is identical to the incremental elastic modulus under static stresses; $ is the phase lag of the strain behind the stress (in the case of circumferential direction, it is the phase lag of diameter behind the pressure); E D is the dynamic elastic modulus of the vessel; and TJCO is the viscous retarding modulus (r\ is the viscous constant and w the angular frequency). For measuring the circumferential dynamic mechanical properties, the test vessel is usually subjected to an oscillatory pressure. The pressure oscillations are in a sinusoidal form. In circumferential direction, E can be calculated from equation (B6.2) with the recorded diameter of the blood vessel and the oscillatory pressure [44]. Table B6.17 lists the dynamic mechanical properties of different arteries at a frequency of 2.0 Hz at a mean pressure of 100 mmHg. In this table, E p is the circumferential pressure-strain modulus defined as Ep = AP1 R0 / AR0 (B6.6)

Table B6.17 Circumferential Dynamic Mechanical Properties of Different Human Arteries* Vessel
Ascending aorta Carotid Carotid Thoracic aorta Abdominal aorta Femoral Carotid Pulmonary artery

Ep (dynes-cm'2 x 1Or6)
0.8 6.2 0.4 0.6-1.0 0.7-1.5 2.5-7.0 2.5-3.0 0.1-0.16

(^(radians)
0.12 0.1 0.15 0.1

Vp (m/s)
6.0 17 4.6+ 6-9 + 6-8 + 13-18 2.3-2.9

Source
[29 [29: [45 [33]++ [33]++ [33]++ [33]++ [29

* Adapted from [42]. Elastic modulus and pulse-wave velocity values collected from the literature. Those values for the PWV marked thus: + were measured, the others have been calculated from dynamic elasticity measurements; ++ measurements for young (<35) and old (>35) subjects respectively. 4 > = phase difference between wall stress and strain at 2 Hz. E^ is denned in eq (B6.6). The mean pressure was 100 mmHg.

in which AP1 is the pressure increment, R0 is the external diameter of the vessel and AR0 the external diameter change. E p is essentially a reciprocal of the compliance of an artery and differs from elastic modulus in that it defines the stiffness of the total artery. Nevertheless, it is an indication of ED. Another important parameter listed in Table B6.17 is the pulse-wave velocity Vp (PWV) that can be calculated from the Moens-Korteweg equation: V2p = Eh/2Rp (B6.7) where E = elastic modulus of the wall, h = wall thickness, R = mean radius of the vessel, p = density of blood. There is general understanding that the dynamic elastic modulus is not strongly frequency dependent above 2-4 Hz and that it increases from the static value at quite low frequencies. Bergel [42] provides additional values for canine vessels.
B6.5.5 Creep and stress relaxation

When a subject is suddenly strained and then the strain is maintained constant afterward, the corresponding stresses induced in the subject decrease with time, this phenomenon is called stress relaxation. If the subject is suddenly stressed and then the stress is maintained afterwards, the subject continues to deform, this phenomenon is called creep. Creep and stress relaxation are another two important phenomena in the arterial viscoelasiticity. Langewouters et al [46] studied the creep responses of human thoracic and abdominal aortic segments. The pressure in the

segments was changed in steps of 20 mmHg between 20 and 180 mmHg. Aortic creep curves at each pressure level were described individually by a constant plus biexponential creep model (C-model, [47]) A-. = AA [l - c^exp (-^i-) - a2exp (^L-J (B6.8)

where A = aortic cross-sectional area; Af = sample value of aortic creep response at time t{; 8A = change in aortic area upon a 20 mmHg pressure step; t = time; i = sample number; a1? a2 = creep fraction; T1, T2 = time constant. Table B6.18 lists the creep fractions and time constants for all aortic segments [46]. Stress relaxation relations for human arteries are not available; however, Tanaka and Fung [48] studied the stress relaxation spectrum of the canine aorta. They expressed the stress history with respect to a step change in strain in the form: T (t, I ) - G (t) T^ (1), G(O) = 1
(e

(B6.9)

where G (t) is the normalized relaxation function of time; T ^ (1) is a function of strain 1, called elastic response. This is the tensile stress instantaneously generated in the aortic tissue when a step elongation, 1, is imposed on the specimen. If the relaxation function is written as:

G(t) = [1+
in which

i f s(T)e " t/TdT]

(B610)

S& = [ I + J0" S (T)CiT]

is a normalized factor, then the spectrum S (t) is expected to be a continuous function of relaxation time t. A special form of S (t) is proposed

Table B6.18 Creep Constants of Human Thoracic and Abdominal Aortas*

Thoracic aorta (n - 35) Parameter O1 a2 tj (S) t2 (S) C (IQ-3 cm2 mmHg) Age Range 0.05-0.13 0.03-0.15 0.31-1.43 5.9-23.5 1.5-12.3 30-78 Mean 0.076 0.102 0.73 14.0 5.1 63 S. D. 0.017 0.028 0.29 4.1 2.5 14 Abdominal aorta (n - 16) Range 0.05-0.12 0.07-0.15 0.33-0.81 4.6-17.7 0.5-3.3 30-78 Mean 0.078 0.101 0.61 12.1 1.5 58 S. D. 0.017 0.025 0.12 3.4 0.78 15

* Adapted from [46] by permission. Ct1, a2, creep fractions; tls t2, time constants; C, compliance; S.D., standard deviation.

(B6.ll) Values for segments of the canine aorta are given in [48]. B6.6 MECHANICAL PROPERTIES OF VEINS B6.6.1 Static mechanical properties of veins The structure of the venous walls is basically similar to that of the arterial walls. The main difference is that they contain less muscle and elastic tissue than the arterial walls, which raises the static elastic modulus two to fourfold [49]. Because the venous walls are much thinner than the arterial wall, they are easily collapsible when they are subject to external compressions. Table B6.19 lists the static incremental elastic moduli of the canine jugular vein and human saphenous vein. For the purpose of comparison, the static increment elastic modulus of the canine carotid artery segments are also presented in the table. This comparison is of interest because in some arterial reconstructive surgeries, a vein is used as a substitute for an artery. Table B6.19 Comparison of elastic Moduli between Venous and arterial Segments*
Extension ratio Pressure (cm H2O) 10 25 50 75 100 125 150 10 25 50 75 100 125 150 1.457 1.463 1.472 1.478 1.482 1.484 1.484 1.357 1.417 1.500 1.561 1.602 1.621 1.621 1.481 1.530 1.597 1.646 1.675 1.686 1.686 1.169 1.206 1.266 1.325 1.381 1.430 1.470

Incremental venous elastic modulus EQ (dynes/ cm2 x IO6)

Ez (dynes/ cm2 x IO6)

Carotid artery Incremental modulus E6 (dynes/ Ez (dynes/ cm2 x IO6) cm2 x IO6) 7.62 8.39 9.51 10.37 10.92 11.16 11.16 5.30 5.82 6.00 9.66 12.77 14.79 15.51 5.16 7.15 10.69 13.97 16.24 17.17 17.17 0.017 0.328 0.735 1.80 3.15 4.59 5.93

Canine Jugular Vein 15 3 * 1.2 0.18t 47 6 t 4.4 0.35t 88 7f 11.8 2.1 98 7 t 46 13* 117 10t 67 2 5 134 24t 89 32 113 13t 171 9t Human Saphenous Vein
0.27 0.12t 0.65 0.13t 1.89 0.41f 9.85 1.6 15.0 2.6 20.4 1.6* 25.1 7.5 1.61 0.32* 2.03 0.39* 2.75 0.78 3.18 0.76 3.56 0.58 3.98 0.96 4.75 1.2

* Adapted from [50] by permission. * P < 0.05 for the comparison between the venous and carotid moduli. t P < 0.01 for the comparison between the venous and carotid moduli.

Sobin [51] obtained data on the mechanical properties of human vena cava from autopsy material. The data may be expressed by the following equation:
T = aECX [a(E 2 - E*2)] E = (X - l)/2 T* = aCE*X*
2

(B6.12)

where X is the ratio of the changed length of the specimen divided by the reference length of the specimen, C and a are material constants, and E* is the strain that corresponds to a selected value of stress S*. The product of the constant aC is similar to the elastic modulus, provided that the modulus is defined as the ratio, S*/E*, where S* = T*/X*. Fung [1] provides typical values of these constants obtained experimentally; however, no universal constants have been discovered.

Table B6.20

Tensile Properties of Human Venous Tissue* Age group

Vein

Direction

20-39 yr

40-50 yr

60-69 yr (g/mm) 68.0 224.0 149.0 224.0 116.0 158.0

adult average 89.0 232.0 153.0 216.0 116.0 182.0 0.12 0.31 0.22 0.31 0.18 0.27 84.0 51.0 82.0 70.0 100.0 77.0

Tensile Breaking Inferior vena cava L T Femoral L T Popliteal L T Inferior vena cava Femoral Popliteal

Load per Unit Width 102.0 87.0 245.0 224.0 159.0 149.0 211.0 217.0 116.0 116.0 180.0 197.0

Ultimate Tensile Strength (kg/mm2) L 0.15 0.11 0.08 T 0.36 0.28 0.27 L 0.24 0.21 0.20 T 0.32 0.31 0.29 L 0.20 0.17 0.15 T 0.31 0.29 0.20 L T L T L T Ultimate Percentage 98.0 58.0 97.0 79.0 112.0 77.0 Elongation 77.0 47.0 72.0 67.0 97.0 77.0 70.0 44.0 72.0 56.0 81.0 77.0

Inferior vena cava Femoral Popliteal

* Adapted from [43].L = longitudinal; T = transverse.

B6.6.2 Tensile properties of veins

The tensile properties of human venous tissues are presented in Table B6.20. For the testing method and definitions of the terms in the table, please refer to Section B6.5 on Mechanical properties of arteries. B6.7 MECHANICAL CHARACTERISTICS OF LYMPHATIC VESSELS The problem concerning the ontogenesis of the lymphatic vessels is still not completely solved. However, most of the evidence indicates that the large lymphatic vessels are derived from the veins [52]. Therefore, lymphatics can be considered modified veins. According to the reports by Ohhashi et al [53, 54], the circumferential elastic modulus of the bovine mesenteric lymphatics ranged from 4.2 x 104 to 2.7 x 105 dynes/cm2 at a pressure range from 0 to about 20mmHg, and the elastic modulus of canine thoracic duct is about 2.0 x 105 dynes/cm2. These values are less than those of veins obtained by Bergel [55]. Therefore, the lymphatics are more distensible than the veins. B6.8 TRANSPORT PROPERTIES OF BLOOD VESSELS Under transmural pressures, fluid or plasma will flow across the walls of blood vessels. On one hand, convective fluid motion through the blood vessel wall plays a very important role in nourishing the vessel walls, on the other hand, it is involved in atherogenesis by promoting the transport of macromolecules such as lipoproteins into the arterial wall [55-58], possibly through leaky endothelial cell junctions in regions of high endothelial cell turnover [59]. Table B6.21 lists the filtration properties of excised, presumably normal, human iliac blood vessels.
Table B6.21 Water Permeability of Iliac Vessels* Vessel Iliac artery Pressure (mmHg) 0-20 25-80 100 200 0-20 21-40 41-60 61-80 81-100 Filtration rate (cm/sec x 106) 0 2.58 4.08 6.42 6.94 9.72 11.67 12.22 12.78

Iliac vein

* Adapted from [56].

B6,9 EFFECT OF AGE, HYPERTENSION AND ATHEROSCLEROSIS ON BLOOD VESSELS B6.9.1 Age Two well known changes accompany aging of the cardiovascular system are dilation of thoracic aorta [60] and increased thickness of arterial wall [61]. Arterial walls become less distensible with aging [34, 62, 63]. Both dry matter and nitrogen content of artery tissue show a tendency to decrease with age in large and medium sized arteries [20]. But the relative quantity of collagen [22] and elastin [23, 24] in the arterial wall remains essentially unchanged. With aging the arterial wall becomes progressively stiffer. Bader [34] found that the circumferential elastic modulus of human thoracic aorta increased linearly with age. At 100 mmHg, the static circumferential modulus of 'young' (< 35 years) human thoracic aorta averaged 7.5 x 106 dynes/cm2, and for the 'old' (> 35 years) the average was 16.6 x 106 dynes/cm2 [33]. Young peripheral arteries tend to have a greater viscosity (iqa)) than the older ones [33]. Despite the overall increase in stiffness, the arterial wall itself is considerably weaker than the younger/older one [43]. B6.9.2 Hypertension Several studies have shown that the water content of human, rat and dog arteries is increased in hypertension, and this increased water content may be associated with an increased wall thickness [64, 65]. Due to the limitations in studying samples from human subjects, animal models (mainly rats) have been employed. Mallov [66] found that the aorta from hypertensive rats had more smooth muscle than normal aorta. Greenwald and Berry [67] reported increased elastin and decreased collagen content in the aorta from spontaneous hypertensive rats when compared with the normal aorta. Wolinsky [25] observed an increase in the absolute amounts of both medial elastin and collagen contents in hypertensive rats. However, the relative percentage of these elements remained essentially constant. Experimental studies [67-69] showed an increase in vessel stiffness with the development of hypertension. This increase in vessel stiffness results in a smaller vessel diameter for a given distending pressure, i.e. a decrease in the distensibility [70]. B6.9.3 Atherosclerosis It is generally accepted that substantial changes in the arterial wall occur with atherosclerosis in man. In human atherosclerotic arteries, it appears that there may be an absolute increase in collagen and a decrease in muscle fibers when compared with normal arteries [28]. In canine iliac

artery the ratio of collagen to elastin was found to be increased, while the ratio in carotid was decreased [26]. The elastic moduli of the diseased aorta and common iliac arteries are several times higher than those reported [33] for normal arteries. The most popular model used to study the effect of atherosclerosis on arterial wall properties is the rabbit subject to a high cholesterol diet. Cox and Detweiler [26] have shown that in the iliac arteries from high cholesterol fed greyhounds, collagen and elastin contents are decreased, but the ratio of collagen to elastin is increased. In carotid arteries from the treated animals, the elastin content is increased and the collagen to elastin ratio is decreased. Their results also show that the elastic modulus of the iliacs from the cholesterol fed animals is higher than that of the normal iliacs while the treated carotids are unchanged. By using a rabbit model, Pynadath and Mukherjee [71] found that cholesterol feeding had no effect on the longitudinal dynamic elastic modulus of the aorta, but the circumferential one was affected significantly. After six weeks of feeding, the circumferential dynamic elastic modulus increased from the normal value of 2.7 x 106 dynes/cm2 to 4.0 x 106 dynes/cm2. This increase showed a remarkable correlation with the cholesterol content in the aortas. Although animal models shed some light on the effects of cholesterol feeding, since atherosclerotic changes in the arterial wall are so closely related to aging, it is difficult to separate the effect of atherosclerosis from those of aging. The effects of atherosclerosis on the mechanical properties of the arterial wall remain unclear. Confusion with the effects of aging and other forms of arteriosclerosis such as medial calcification make interpretation of the results difficult.

B6.10 FINAL COMMENTS

Mechanical properties of the arteries from human and various animals have been extensively studied. However, literature on lymphatic vessels is very scarce. The data on the circumferential elastic modulus of the lymphatic vessels obtained by Ohhashi et al [53, 54] seem to be too low considering that the lymphatics are originating from the veins. The overall viscoelastic properties of a large blood vessel such as the aorta are known to be nonlinear [2, 44] and anisotropic [37]. But due to the fact that the blood vessel wall is incompressible [72] and deforms orthotropically [31], the mechanical properties of blood vessels can be described mainly by six coefficients: an elastic and a viscous moduli in the longitudinal, circumferential and radial directions. Among them, only the moduli in the circumferential and longitudinal directions have been studied widely. Much fewer data in the radial direction can be found in literature. In calculation of the circumferential elastic moduli, it was

usually assumed that the Poisson's ratio was 0.5 that is not strictly true when large strains are considered [36]. In fact, the measured data [37, 73] show that the Poisson's ratio is about 0.3, not 0.5 as would be predicted for an isotropic material. But the Poisson's ratio was almost constant with respect to circumferential strain and pressure in both relaxed and constricted canine carotid arteries [73]. To our best knowledge, water diffusion properties of blood vessels have been studied extensively, but their electrical and thermal properties are still unknown.

ACKNOWLEDGEMENT This work was supported by the Medical Research Council of Canada (Grant MT-7879). The assistance of Y. Marois, M. King and Y. Douville in preparation of this material is gratefully acknowledged.

ADDITIONAL READING Canfield, T.R. and Dorbin, P.B. (1987) Static properties of blood vessels, in Handbook of Bio engineering (eds R. Skalak and S. Chien), McGraw-Hill Book Company, New York, pp. 16.1-16.28. The authors discuss the mechanical behavior of arteries and the mathematical method required for quantification of such data. The discussion is entirely concerned with the elastic or pseudoelastic behavior of blood vessels. It should be emphasized that the arterial wall also exhibits inelastic properties, such as viscosity, creep, stress & relaxation and pressure-diameter hysteresis. Very few data on mechanical properties of blood vessels are presented. Dorbin, P.B. (1983) Vascular mechanics, in Handbook of Physiology, VoL 3 The Cardiovascular System, (eds J.T. Shepherd and F. Abboud), Amer. Physiol. Soc, Washington, DC, Section 2, pp. 65-102. This chapter reviews the essential concepts of vascular mechanics and its methods of quantification. Some of the important controversies are discussed, and further research areas are pointed out. Detailed information is provided on the structural and mechanical changes of arteries with age. The effect of vascular disorders such as arterosclerosis and hypertension on the mechanical behavior of blood vessels is discussed as well. Extensive addition literature sources are provided. Schneck, DJ. (1995) An outline of cardiovascular structure and function, in The Biomedical Engineering Handbook, (ed. J.D. Bronzino), CRC Press, Boca Raton, pp. 3-14. The cardiovascular system is described as a highway network, which includes a pumping station (the heart), a working fluid (blood), a complex branching configuration of distributing and collecting pipes and channels (the blood vessels), and a sophisticated means for both intrinsic (inherent) and extrinsic

(antonomic and endocrine) control. Data on both the arterial and venous systems are tabulated. However, no detailed sources are provided for the data listed. This is a very suitable reference for biomedical engineers. Hargen, A.R. and Villavicenco, J.L. (1995) Mechanics of tissue/lymphatic support, in The Biomedical Engineering Handbook, (ed J.D. Bronzino), CRC Press, Boca Raton, pp. 493-504. From an engineering point of view, the authors discuss the lymphatic system as a drainage system for fluids and waste products from tissues. Basic concepts of lymphatic transport along with clinical disorders are discused, although briefly. Extensive additional sources are cited.

REFERENCES 1. Fung, Y.C. (1993) Biomechanics, Mechanical Properties of Living Tissues, 2nd edn, Springer-Verlag, New York, pp. 321-391. 2. Bergel, D.H. (1961) The static elastic properties of the arterial wall. /. Physiol, 156, 445^57. 3. Patel, DJ. and Vaishnav, R.N. (1972) The rheology of large blood vessels, Cardiovascular Fluid Dynamics, D.H. Bergel (ed.), Academic Press, New York, Vol. 2, pp. 1-64. 4. Fung, Y.C, Fronek, K. and Patitucci, P. (1979) Pseudoelasticity of arteries and the choice of its mathematical expression. Am. J. Physiol, 237, H620-H631. 5. Remington, J.W. (1955) Hysteresis loop behavior of the aorta and other extensible tissues. Am. J. Physiol, 180, 83-95. 6. Alexander, R.S. (1971) Contribution of plastoelasticity to the tone of the cat portal vein. Circ. Res., 28, 461-469. 7. Anitschkov, N. (1933) Experimental arteriosclerosis in animals, in Arteriosclerosis, E.V. Cowdry, Editor, Macmillan, New York, pp. 298-299. 8. Wilens, S.L. and McCluskey, R.T. (1954) The permeability of excised arteries and other tissues to serum lipid. Circ. Res., 2, 175-182. 9. Baldwin, A.L., Wilson, L.M. and Simon, B.R. (1992) Effect of pressure on aortic hydraulic conductance. Arterio. Thromb., 12, 163-171. 10. Fung, Y.C. (1984) Biodynamics, Circulation, Springer-Verlag, New York, p. 77. 11. Brecher, G.A. (1956) Venous Return, Grune & Stratton, New York, pp. 30-67. 12. Helps, E.P.W. and McDonald, D.A. (1954) Observation on laminar flow in veins. /. Physiol, 124, 631-639. 13. Spencer, M.P. and Denison, A.B. (1963) Pulsatile blood flow in the vascular system, in Handbook of Physiology, Section 2, Circulation, W.F. Hamilton and P. Dow, Editors, Am. Physiol. Soc, Washington, pp. 839-864. 14. Fry, D.L. and Greefield, J.C. Jr. (1964) The mathematical approach to hemodynamics, with particular reference to Womersley's theory, in Pulsatile Blood Flow, Attinger, E.O. (ed), McGraw-Hill, New York, pp. 85-99. 15. Maggio, E. (1965) Microhemocirculation, Observable Variables and Their Biological Control, CC. Thomas, Springfield. 16. Whitmore, R.L. (1968) Rheology of the Circulation, Pergamon Press, Oxford, pp. 99-108.

17. Morse, D.E. (1979) The normal aorta: embryology, anatomy, and histology of the aorta, in The Aorta, J. Lindsay, Jr. and J.W. Hurst, Editors, Grune & Stratton, New York, pp. 15-37. 18. Singhal, S., Henderson, R., Horsfield, K. et al. (1973) Morphometry of human pulmonary arterial tree. Circ. Res., 33, 190-197. 19. Fung, Y.C. (1984) Biodynamics, Circulation, Springer-Verlag, New York, pp. 77-165. 20. Kirk, J.E. (1962) Arterial and arteriolar system, biochemistry, in Blood Vessels and Lymphatics, D.I. Abramson, Editor, Academic Press Inc., London, pp. 82-95. 21. Fischer, G.M. and Llaurado, J.G. (1966) Collagen and elastin content in canine arteries selected from functionally different vascular beds. Circ. Res., 19, 394-399. 22. Kanabrocki, EX., FeIs, LG. and Kaplan, E. (1960) Calcium, cholesterol and collagen levels in human aorta. /. Gerontol, 15, 383-387. 23. Lansing, A., Alex, M. and Rosenthal, T.B. (1950) Calcium and elastin in human arteriosclerosis. /. Gerontol, 5, 112-119. 24. Kraemer, D.M. and Miller, H. (1953) Elastin content of the abdominal fraction of human aortae. Arch. Pathol, 55, 70-72. 25. Wolinsky, H. (1970) Response of the rat aortic media to hypertension. Morphological and chemical studies. Circ. Res., 26, 507-523. 26. Cox, R.H. and Detweiler, D.K. (1979) Arterial wall properties and dietary atherosclerosis in the racing greyhound. Am. J. Physiol, 5, H790-H797. 27. Kirk, J.E. (1962) Venous system, biochemistry, in Blood Vessels and Lymphatics, D.I. Abramson, Editor, Academic Press Inc., London, pp. 211-213. 28. Strandness, D.E. and Sumner, D.S. (eds) (1975) Hemodynamics for Surgeons, Grune & Stratton, New York, New York, pp. 161-205. 29. Patel, D.J., Greenfield, J.C. and Fry, D.L. (1964) In vivo pressure-length-radius relationships of certain vessels in man and dogs, in Pulsatile Blood Flow, E.O. Attinger, Editor, McGraw-Hill, New York, pp. 293-302. 30. Cox, R.H. (1975) Anisotropic properties of the canine carotid artery in vitro. J. Biomech., 8, 293-300. 31. Patel, DJ. and Fry, D.L. (1969) The elastic symmetry of arterial segments in dogs. Circ. Res., 24, 1-8. 32. Bergel, D.H. (1958) A photo-electric method for the determination of the elasto-viscous behavior of the arterial wall. /. Physiol., 141, 22-23. 33. Learoyd, B.M. and Taylor, M.G. (1966) Alteration with age in the viscoelastic properties of human arterial walls. Circ. Res., 18, 278-292. 34. Bader, H. (1967) Dependence of wall stress in the human thoracic aorta on age and pressure. Circ. Res., 20, 354-361. 35. Langewouters, G.J., Wesseling, K.H. and Goedhard, W.J.A. (1984) The static elastic properties of 45 human thoracic and 20 abdominal aortas in vitro and the parameters of a new model. /. Biomech., 17, 425-435. 36. Bergel, D.H. (1960) The Visco-elastic Properties of the Arterial Wall. PhD thesis, University of London. 37. Patel, D.J., Janicki, J.S. and Carew, T.E. (1969) Static anisotropic elastic properties of the aorta in living dogs. Circ. Res., 25, 765-779.

38. Rees, P.M. and Jepson, P. (1970) Measurement of arterial geometry and wall composition in the carotid sinus baroreceptor area. Circ. Res., 26, 461-467. 39. Gow, B.S. and Taylor, M.G. (1968) Measurement of viscoelastic properties of arteries in the living dog. Circ. Res., 23, 111-122. 40. Reid, L. (1968) Structural and functional reappraisal of the pulmonary artery system, in Scientific Basis of Medicine, Annual Reviews, Vol. 8, pp. 289-307. 41. Yates, W.G. (1969) Experimental studies of the variations in the mechanical properties of the canine abdominal vena cava, in SUDAAR Report 393, Stanford University, California. 42. Bergel, D.H. (1972) The properties of blood vessels, in Biomechanics, Its Functions and Objectives, Y.C. Fung, Editor, Prentice-Hall, Englewood Cliffs, NJ., p. 110 and p. 131. 43. Yamada, H. (1970) Strength of Biological Materials, F.G. Evans, Editor, Williams and Wilkins, Baltimore, pp. 106-277. 44. Bergel, D.H. (1961) The dynamic elastic properties of arterial wall. /. PhysioL, 156, 458-469. 45. Arndt, J.O., Klauske, J. and Mersch, F. (1968) The diameter of the intact carotid artery in man and its change with pulse pressure. Pfiilger's Arch,, 30, 230-240. 46. Langewouters, GJ., Wesseling, K.H. and Goedhard, WJ.A. (1985) The pressure dependent dynamic elasticity of 35 thoracic and 16 abdominal human aortas in vitro described by a five component model. /. Biomech., 18, 613-620. 47. Langewouters, GJ. (1982) Visco-Elasticity of the Human Aorta in vitro in Relation to Pressure and Age. PhD thesis, Free University, Amsterdam, The Netherland. 48. Tanaka, T.T. and Fung, Y.C. (1974) Elastic and inelastic properties of the canine aorta and their variation along the aortic trees. /. Biomech., 7, 357-370. 49. Attinger, E.O. (1967) Modelling of pressure-flow relations in arteries and veins (Abstract). Biorheology, 4, 84. 50. Wesly, R.L.R., Vaishnav, R.N., Fuchs, J.C.A. et al. (1975) Static linear and nonlinear elastic properties of normal and arterialized venous tissue in dog and man. Circ. Res., 37, 509-520. 51. Sobin, P. (1977) Mechanical Properties of Human Veins. M.S. thesis, University of California, San Diego, California. 52. Susznyak, L, Foldi, M. and Szabo, G. (1967) Lymphatics and Lymph Circulation: Physiology and Pathology, Pergamon Press, London, pp. 33-50. 53. Ohhashi, T., Azuma, T. and Sakaguchi, M. (1980) Active and passive mechanical characteristics of bovine mesenteric lymphatics. Am. J. PhysioL, 239, H88-H95. 54. Ohhashi, T. (1987) Comparison of viscoelastic properties of walls and functional characteristics of valves in lymphatic and venous vessels. Lymphatic, 20, 219-223. 55. Bergel, D.H. (1964) Arterial viscoelasticity, in Pulsatile Blood Flow, E.O. Attinger, Editor, McGraw-Hill, New York, pp. 275-292. 56. Wilens, S.L. and McCluskey, R.T. (1952) The comparative filtration filtration properties of excised arteries and veins. Am. J. Med. ScL, 224, 540-547. 57. Tedgui, A. and Lever, MJ. (1985) The interaction of convection and diffusion in the transport of 131I-albumin within the media of rabbit thoracic aorta. Circ. Res., 57, 856-863.

58. Tedgui, A. and Lever, MJ. (1987) Effect of pressure and intimal damage on 131I-albumin and 14C-sucrose spaces in aorta. Am. J. PhysioL, 253, H1530-H1539. 59. Weinbaum, S., Tzeghai, G., Ganatos, P. et al. (1985) Effect of cell turnover and leaky junctions on arterial macromolecular transport. Am. J. PhysioL, 248, H945-H960. 60. Bazett, H.C., Cotton, F.S., Laplace, L.B. et al. (1935) The calculation of cardiac output and effective peripheral resistance from blood pressure measurements with an appendix on the size of the aorta in man. Am. J. PhysioL, 113,312-334. 61. Anderson, J.R. (1980), Muir's Textbook of Pathology, Arnold, London, pp. 360-395. 62. Nakashima, T. and Tanikawa, J. (1971) A study of human aortic distensibility with relation to atherosclerosis and aging. Angiology, 22, 477^90. 63. Mozersky, DJ., Summer, D.S., Hokanson, D.E. et al. (1972) Transcutaneous measurement of the elastic properties of the human femoral artery. Circulation, 46, 948-955. 64. Tobian, L. (1960) Interrelationship of electrolytes, juxtaglomerular cells and hypertension. PhysioL Rev., 40, 280-312. 65. Peterson, L.H. (1963) Systems behavior, feed-back loops and high blood pressure research. Circ. Res., 12, 585-596. 66. Mallov, S. (1959) Comparative reactivities of aortic strips for hypertensive and normotensive rats to epinephrine and levarterenol. Circ. Res., 7, 196-201 67. Greenwald, S.E. and Berry, CL. (1978) Static mechanical properties and chemical composition of the aorta of spontaneously hypertensive rats, a comparison with the effects of induced hypertension. Cardiovas. Res., 12, 364-372. 68. Feigl, E.O., Peterson, L.H. and Jones, A.W. (1963) Mechanical and chemical properties of arteries in experimental hypertension. /. CHn. Invest, 42, 1640-1647. 69. Bandick, N. and Sparks, H. (1970) Viscoelastic properties of the aortas of hypertensive rats. Proc. Soc. Exp. Biol. Med., 134, 56-60. 70. Greene, M.A., Friedlander, R., Boltax, AJ. et al. (1966) Distensibility of arteries in human hypertension. Proc. Roy. Soc. Exp. Biol., 121, 580-585. 71. Pynadath, T.I. and Mukherjee, D.P. (1977) Dynamic mechanical properties of atherosclerotic aorta: A correlation between the cholesterol ester content and the viscoelastic properties of atherosclerotic aorta. Atherosclerosis, 26, 311-318. 72. Carew, T.E.R., Vaishnav, R.N. and Patel, DJ. (1968) Compressibility of the arterial wall. Circ. Res., 23, 61-68. 73. Dobrin, P.B. and Doyle, J.M. (1970) Vascular smooth muscle and the anisotropy of dog carotid artery. Circ. Res., 27, 105-119.

B7

The intraocular lens

T.V. Chirila

B7.1 INTRODUCTION Although the existence of the intraocular crystalline lens, usually referred to as the lens, in the eye was recognized by the scientists of the Hellenistic period (about 2000 years ago), it was 400 years ago that the real role of the lens in vision was properly understood, and truly scientific approaches to the lens measurements and properties began to be applied only in the nineteenth century [I]. For instance, the first to weigh the human lens was Smith in 1883 [2]. The lens is positioned between the aqueous humor and vitreous body of the eye. The lens refracts the light which enters the eye through the pupil and focuses it on the retina. The lens (i) provides refractive power to the optical system of the eye; (ii) provides the accommodation necessary for normal vision; (iii) maintains its own transparency; and (iv) absorbs UV radiation and blue light, both deleterious to the subsequent ocular segments. The lens is a biconvex body similar to a flattened globe. For descriptive purposes, it has two poles (anterior and posterior), an equator, and therefore two diameters (polar, or lens thickness, and equatorial). The lens is composed of epithelial cells which become anuclear and elongated as they are displaced further toward the center. Because of the enormous length finally attained by these cells, they are referred to as lens fibers. The lens is surrounded by a transparent acellular capsule of variable thickness. A proper epithelium underlies the capsule along the anterior side and equator, but not under the posterior capsule. The superficial layers of cells and fibers constitute the lens cortex, and the lens
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

nucleus is situated in the center. The fibers are continuously formed throughout life and the new fibers cover the old ones which are displaced toward the nucleus. At present, there are significantly more compositional and physical property data on animal lenses than on the human lens. Even the determination of a straightforward property like the water content has led to variable results (Tables B7.1 and B7.2), likely due both to nonuniform distribution of the water in the lens and to the variability of methods employed for measurements. While data on the inorganic content of the human lens (Table B7.3) are generally in agreement, there was a larger variation in reporting the organic content. This is presumably due to the greater sensitivity of the organic metabolism to age and disease. The most reliable results are included in Table B7.4. Tables B7.5-B7.7 provide some key dimensional properties of the lens while Table B7.8 focuses on perhaps the most important feature, the optical properties. Mechanical characteristics of the lens required sophisticated procedures for measurements and the data are probably difficult to reproduce. AU the available mechanical properties of the human lens are included in Tables B7.9-B7.13. Large variations in the electrical properties of animal lenses have been reported, but it seems that the only measurements performed on human lenses are those shown in Table B7.14.
B7.2 CHEMICAL COMPOSITION

Table B7.1 Water content of the normal human lens

Method nl.
V a c u u m dehydration Microsectioning R a m a n microspectroscopy F r e e z e drying

Value (%) 65*

4.3 b 2.9C - 66.2 c d - 90 d ' e 4b 4C 68 C 80 e 75 f 58.0 4.7 (<70 yr) c 63.0 2 . 8 ( > 7 0 y r ) c 85.3 9.4 e 80.9 8.3 f 68.6 63.4 52.5 72.5 69 65

Source [3]
[4] [5] [6] [7]

R a m a n microspectroscopy

[8]

= Standard deviation; a whole lens;b cortex;c nucleus; d age 62 years to 68 years; Outermost anterior cortex; Outermost posterior cortex.

Table B7.2 Method Drying

Water content of cataractous human lenses Value (%) 6X6* 75.4b 79 cd 83.5c'e
7 8 d,f

Source [9] [8]

Freeze drying

Drying
a

87.5e'f 68d'e'g 63.8 (< 60 yr) 67.7 (> 80 yr)

[10]

No sclerosis, average age 64.7 years;b advanced sclerosis, average age 70.8 years;0 outermost anterior cortex.;d primary nuclear cataract;6 subcapsular cataract;f outermost posterior cortex;s nucleus.

Table B7.3 Ion Sodium Potassium Calcium Magnesium Zinc Copper Manganese Iron Rubidium Chloride Phosphate Sulfate pH

Inorganic ions content of the normal adult human lens Representative value 91 mg/100 g wet wt 170 mg/100 g wet wt 1.4 mg/100 g wet wt 0.29 mg/100 g wet wt 6.2 jULg/g dry wt 21 jxg/g dry wt 25 jjug/g dry wt < 1 |xg/g dry wt 0.6 |jLg/g dry wt 0.2 jxg/g dry wt 0.4 |xg/g dry wt 6.8 u-g/g dry wt 35.3 mg/100 g wet wt 25 mg/100 g wet wt 24 mg/100 g wet wt 7.3 to 7.7 Source [3] [3] [3] [3] [11] [3] [11] [3] [11] [11] [11] 11] [3] [12] 12] 13]

Table B7.4 Organic content of the human lensa Component Proteins Ascorbic acid Glutathioneb Representative value 30% of lens (young) 35% of lens (old) 30 170 (normal lens) 52 (cataractous lens) 46-150 200-450 10 6.7 11.9 5.9 50 5.9 28.2 462 1.4 mg/lens 600-725 c 450-650c Source [14] [11] [15] [11 [12: [if [12: [if [If [11 [if [11] [12] [11] [11] [11]

Taurine Alanine Glycine Glutamic acid Serine Urea Inositol Cholesterol Phospholipids: cortex nucleus

a Expressed as mg per 100 g wet weight of lens, unless otherwise specified; b there is a large variation of reported data on glutathione content; c variation with age.

B7.3 DIMENSIONS AND OPTICAL PROPERTIES

Table B7.5 Dimensional variation with age of the human lens [11] Dimension Polar diameter (lens thickness) Equatorial diameter Anterior radius of curvature Posterior radius of curvature Value (mm) 3.5 to 5 6.5 to 9 8 to 14 4.5 to 7.5

Table B7.6 Thickness of the human lens capsule at age 35 years [11] Location Anterior pole Anterior, maximum Equator Posterior pole Posterior, maximum Value (^m) 14 21 17 4 23

Table B7.7 Age range (yrs) 20-30 30-40 40-50 50-60 60-70 70-80

Weight, volume and density of the human lens in adult life [16] Weight, mean (mg) 172.0 190.3 202.4 222.3 230.1 237.1 Volume, mean (mm3) 162.9 177.3 188.1 205.4 213.0 218.3 Density (calc.) at beginning of decade (g cm'3) 1.034 1.048 1.061 1.072 1.082 1.091

Table B7.8

Optical refractive index and transmissivity as a function of age Refractive index [3]: 1.420 Transmission of radiation at wavelength (%) [17] Age (years) 25 54

82

Wavelength (nm)

350 400 450 500 700

1.2 4.8 38.0 70.0 75.0

1.2 4.8 30.6 42.7 51.7

1.2 4.8 21.7 30.0 37.0

Table B7.9 Variation with age of tensile modulus (Young's modulus of elasticity) of the decapsulated human lens [18]a Modulus (kN m2) Age (years) Polar Equatorial 075 0.75 1.1 3.0

at birth 085 20 1.0 40 1.5 63 3.0 a Determined by the spinning method.

Table B7.10 Age (years) <60 61-70 71-80 >80

a

Hardness of cataractous human lenses [19]a Mean Force (N) O80 0.87 1.12 1.38 Number of lenses 13 20 31 27

Measured by the force necessary to cut the lens in a guillotine.

Table B7.ll Age (years) 20 50 80

Mechanical properties of the human lens capsule [20]a Property Tensile modulus (MPa) 5.6 4.0 1.5 Ultimate tensile stress (MPa) 2.3 0.7 29 0.47 0.5 Value

< 20 > 70 b b

Elongation (%) Poisson's ratio

= Standard deviation; adetermined from the volume-pressure relationship upon distension with isotonic saline; independent of age.

Table B7.12 Force of contraction for maximum accommodation of the human lens [21]a Age (years) 25 35 45 55
a

Force (mN) 7.2 10.9 12.8 11.4

Determined from the stress-dioptric power relationship. Spring constants of human lens and zonules[22]a Age range (years) 2-39 13.50.80 12.30.65 0.380.32 40-70 254+024 36.50.23 0.650.85

Table B7.13

Spring constant at 10%elongation, m N Lens, polar Lens, equatorial Zonules b

= Standard deviation; a spring constant is defined here as S'=F/(A1/1O), where F total force and Al/1? is elongation; b determined on specimens zonule-lenszonule, after the excision of the ciliary muscles.

Table B7.14 Translenticular electrical properties in the isolated human lens [23] Property Potential difference Short circuit current density15 Resistance
3

Value 7 mV 5 uA cm'2 1.5 kfl cm2

a Anterior side positive; b reflects sodium transport from the posterior to the anterior lens side and is expressed as a current density; c calculated as a ratio between potential difference and current density.

ADDITIONAL READING
Bellows, J.G. (ed.) (1975) Cataract and Abnormalities of the Lens, Grime & Stratton, New York. A valuable collection of 42 contributions on the lens, its pathology and surgery, written by known experts such as Barraquer, Bellows, Choyce, Girard, Hockwin, Kaufman, Rosen and Yanoff. The first five introductory chapters present historical aspects, development and characterization of the lens. However, most of the book is dedicated to cataract and its treatment. Spector, A. (1982) Aging of the lens and cataract formation, in Aging and Human Visual Function (eds R. Sekuler, D. Kline and K. Dismukes), Alan R. Liss, Inc., New York, pp. 27-43. A brief, but comprehensive account of the changes which take place in the composition and metabolism of the lens during aging and cataractogenesis. Duncan, G. and Jacob, TJ.C. (1984) The lens as a physicochemical system, in The Eye, vol. Ib, 3rd ed. (ed. H. Davson), Academic Press, Orlando, FL, pp. 159-206. This text develops some topics usually neglected in other books, including the structural order in the lens, optical properties of the lens, role of lens membranes, and electrolyte transport and distribution in the lens. Cotlier, E. (1987) The lens, in Adler's Physiology of the Eye, 8th ed. (eds R.A. Moses and W.M. Hart), CV. Mosby Co., St. Louis, pp. 268-290. A systematic presentation of the anatomy, biochemistry and physiology of the lens. Moses, R.A. (1987) Accommodation, in Adler's Physiology of the Eye, 8th ed., (eds R.A. Moses and W.M. Hart), CV. Mosby Co., St. Louis, pp. 291-310. A thorough exposition of all aspects of the mechanism of accommodation and the role of the lens in vision. A text, by now classic, on a topic much more complex than it appears. Jones, W.L. (1991) Traumatic injury to the lens. Optom. CUn., 1, 125-42. This review article analyzes the effects of concussive trauma to the eye, emphasizing the types of injuries to the lens. The mechanical response of the anterior and posterior segments of the eye to external forces is also described. REFERENCES 1. Grom, E. (1975) History of the crystalline lens, in Cataract and Abnormalities of the Lens, (ed. J.G. Bellows), Grune & Stratton, New York, pp. 1-28. 2. Smith, P. (1883) Diseases of crystalline lens and capsule. 1. On the growth of the crystalline lens. Trans. Ophthalmol Soc. UK, 3, 79-99. 3. Kuck, J.F.R. (1970) Chemical constituents of the lens, in Biochemistry of the Eye, (ed. CN. Graymore), Academic Press, London, chapter 3. 4. Fisher, R.F. and Pettet, B.E. (1973) Presbyopia and the water content of the human crystalline lens. /. Physiol, 234, 443-7. 5. Bours, J., Fodisch, HJ. and Hockwin, O. (1987) Age-related changes in water and crystalline content of the fetal and adult human lens, demonstrated by a microsectioning technique. Ophthalmic Res., 19, 235-9.

6. Huizinga, A., Bot, A.C.C., de MuI, F.F.M. et al (1989) Local variation in absolute water content of human and rabbit eye lenses measured by Raman microspectroscopy. Exp. Eye Res., 48, 487-96. 7. Deussen, A. and Pau, H. (1989) Regional water content of clear and cataractous human lenses. Ophthalmic Res., 21, 374-80. 8. Siebinga, L, Vrensen, G.F.J.M., de MuI, F.F.M. et al. (1991) Age-related changes in local water and protein content of human eye lenses measured by Raman microspectroscopy. Exp. Eye Res., 53, 233-9. 9. Salit, P.W. (1943) Mineral constituents of sclerosed human lenses. Arch. Ophthalmol, 30, 255-8. 10. Tabandeh, H., Thompson, G.M., Heyworth, P. et al (1994) Water content, lens hardness and cataract appearance. Eye, 8, 125-9. 11. Harding, JJ. and Crabbe, M.J.C. (1984) The lens: development, proteins, metabolism and cataract, in The Eye, vol. Ib, 3rd ed., (ed. H. Davson), Academic Press, Orlando, FL, pp. 207^92. 12. Paterson, CA. (1985) Crystalline lens, in Biomedical Foundations of Ophthalmology, vol. 2, 2nd ed., (eds T.D. Duane and E.A. Jaeger), Harper & Row, Philadelphia, chapter 10. 13. Kuck, J.F.R. (1970) Metabolism of the lens, in Biochemistry of the Eye, (ed. CN. Graymore), Academic Press, London, chapter 4. 14. Davson, H. (1990) Physiology of the Eye, 5th ed., Macmillan, London, Chapter 4. 15. Dische, Z. and ZiI, H. (1951) Studies on the oxidation of cysteine to cystine in lens proteins during cataract formation. Am. J. Ophthalmol., 34, 104-13. 16. Scammon, R.E. and Hesdorfer, M.B. (1937) Growth in mass and volume of the human lens in postnatal life. Arch. Ophthalmol., 17, 104-112. 17. Lerman, S. (1987) Chemical and physical properties of the normal and ageing lens: spectroscopic (UV, fluorescence, phosphorescence, and NMR) analyses. Am. J. Optom. Physiol. Optics, 64, 11-22. 18. Fisher, R.F. (1971) The elastic constants of the human lens. /. Physiol, 212, 147-80. 19. Heyworth, P., Thompson, G.M., Tabandeh, H. et al (1993) The relationship between clinical classification of cataract and lens hardness. Eye, 7, 726-30. 20. Fisher, R.F. (1969) Elastic constants of the human lens capsule. /. Physiol, 201, 1-19. 21. Fisher, R.F. (1977) The force of contraction of the human ciliary muscle during accommodation. /. Physiol, 270, 51-74. 22. van Alphen, G.W.H.M. and Graebel, W.P. (1991) Elasticity of tissues involved in accommodation. Vision Res., 31, 1417-38. 23. Platsch, K.D. and Wiederholt, M. (1981) Effect of ion substitution and ouabain on short circuit current in the isolated human and rabbit lens. Exp. Eye Res., 32, 615-25.

Cl

Blood and related fluids

V. Turitto and S.M. Slack

CLl INTRODUCTION This section provides data for several human biological fluids including blood, plasma or serum, cerebrospinal (CS) fluid, lymph, synovial fluid, and tear fluid. The material presented here was gleaned from a variety of sources, with emphasis placed on the most recently published work, and includes physicochemical properties (Table Cl.l), cellular compositions (Table C1.2), concentrations of inorganics (Table C1.3), organics (Table C1.4), and major proteins (Table C1.5). In addition, various properties of the major proteins are presented in Table Cl.7, while Tables Cl.8 and Cl.9 contain information regarding the components of the coagulation and complement cascades, respectively. Because of the variability in values for many properties of biological fluids, in many cases a normal singular range of such values is listed. In all cases, the data are those compiled for normal human adults and, where possible, differences with respect to gender are included. It must be stressed that fluid properties can readily change as a result of disease, aging, or drug ingestion.

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Table C1.1 Physiochemical properties [1-3] Property Dielectric constant Freezing point Depression (0C) Osmolality (mosm/kg) pH Refractive index Relative viscosity Specific gravity Specific conductivity (S/cm) Specific heat (cal/g/C) Surface tension (dyne/cm) Property Whole blood 8.0-8.5 0.5570.577 7.38-7.42 2.18-3.59 1.052-1.061 0.87 55.5-61.2 Synovial fluid CS Plasma (serum) 0.512-0.568 276-295 7.39-7.45 1.3485-1.3513 1.18-1.59 1.022-1.026 0.0117-0.0123 0.94 56.2 fluid Tear fluid 0.572-0.642 309-347 7.3-7.7 1.3361-1.3379 1.26-1.32 1.004-1.005

Dielectric constant Freezing Point Depression (0C) Osmolality (mosm/kg) 292-300 pH 7.29-7.45 Refractive index Relative viscosity > 300 Specific gravity 1.008-1.015 Specific conductivity (S/cm) 0.0119 Specific heat (cal/g/C) Surface tension (dyne/cm)

0.540-0.603 290-324 7.35-7.70 1.3349-1.3351 1.020-1.027 1.0032-1.0048 60.0-63.0

The refractive index, specific gravity, and surface tension were measured at 200C, the specific conductivity at 25C, and the relative viscosity at 37C. The specific gravity is that relative to water. The viscosity of serum is slightly less than that of plasma due to the absence of fibrinogen. Blood viscosity depends strongly on shear rate and hematocrit and the value given in Table Cl.l is that at high shear rates (> 200 s1) and normal hematocrits (40-45%). Blood is a non-Newtonian fluid and exhibits increased viscosity with decreasing shear rate. Correlations relating blood viscosity to hematocrit, shear rate, and protein content have been described in the literature [4,5]. The reader is referred to several excellent publications for further details regarding factors affecting blood viscosity [4,6-11].

Table C1.2 Cellular composition of biological fluids [12] A. Whole blood Whole blood: Cell type Erythrocytes Leukocytes Neutrophils Eosinophils Basophils Monocytes Lymphocytes Platelets Reticulocytes
Synovial fluid: Cell type Leukocytes Monocytes Lymphocytes Synovial cells

Cells/\kL 4.6-6.2 x 106 (M) 4.2-5.2 x 106 (F) 3000-6500 50-250 15-50 30O-500 1000-3000 1.5-3.5 x 105 2.3-9.3 x 104
Cells/fiL 4-5 35-40 15-16 2-3

Cell size (jxra) 7-8 10-15 10-15 10-15 12-20 7-8 2-4 7-10

Half-life in circulation 25 2 days 6-8 hours 8-12 hours ? 1-3 days variable 3.2-5.2 days

The variability in the half-life of circulating lymphocytes is a result of the many subsets of this cell type, e.g., B-cells, helper and suppressor T-cells, etc. Cerebrospinal fluid also contains ~ 1-5 cells/|xL, primarily lymphocytes.

Table C1.3 Inorganic content of various fluids [1] Compound Bicarbonate Bromide Calcium Chloride Copper (|JLM) Fluoride (JULM) Iodine (|JLM) Iron Magnesium Phosphorous (total) Potassium Sodium Zinc Compound Bicarbonate Bromide Calcium Chloride Copper (IJLM)
Fluoride (|JLM)

Whole blood 19.1-22.7 0.033-0.074 2.42 77-86 11.3-19.5 5.3-23.7 0.2-1.34 7.5-10.0 1.48-1.85 10.1-14.3 40-60 79-91 0.076-0.196 Cerebrospinal 18.6-25.0 0.018-0.048 1.02-1.34 119-131 0.13-0.37
55

Plasma (serum) 25-30 0.043-0.093 2.12-2.72 100-108 13-22 0.30-0.47 0.01-0.027 0.7-0.86 2.87-4.81 3.5-4.7 134-143 0.011-0.023 fluid Tear 20-40 0.35-0.77 110-135 fluid

Synovial fluid

1.2-2.4 87-138

3.5^.5 133-139 Lymph

1.7-2.8 87-103 2.0-3.6 3.9-5.6 118-132

Iodine (|xM) Iron 0.0003-0.0015 Magnesium 0.55-1.23 Phosphorous (total) 0.442-0.694 Potassium 2.62-3.30 6.6-25.8 Sodium 137-153 126-166 Zinc Concentrations are in mM, unless otherwise specified.

Table C1.4 Organic content of various fluids [13-15] Species Amino acids (mg/L) Ammonia (mg/L) Bilirubin (mg/L) Cholesterol Creatine (mg/L) Creatinine (mg/L) Fat, neutral Fatty acids Glucose Hyaluronic acid Lipids, total Total nitrogen Nonprotein nitrogen Phospholipid Urea Uric acid (mg/L) Water Species Whole blood 48-74 0.26-0.69 2-14 1.15-2.25 3-5 10-20 0.85-2.35 2.5-3.9 630-870 4.45-6.1 30-41 0.26-0.50 2.25-2.85 0.166-0.39 6-50 830-865 Synovial fluid Plasma (serum) 20-51 0.22-0.47 2-8 1.7-2.1 1.3-7.7 5.6-10.5 0.25-2.6 3.5-4.0 650-966 2.85-6.75 12-14.3 0.14-0.32 2.0-2.5 0.18-0.43 30.5-70.7 930-955 Tear fluid CS fluid 10-15 0.14-0.26 <0.1 4.6-19 6.5-10.5 trace trace 430-640 0.01-0.02 0.16-0.22 0.11-0.20 0.002-0.01 0.14-0.36 1.1-6.3 980-990 Lymph 8 0.34-1.06 8-89 1.36-1.40 0.13-1.39 17-108 810-860

Amino acids (mg/L) Ammonia (mg/L) 50 Bilirubin (mg/L) Cholesterol - Creatine (mg/L) Creatinine (mg/L) Fat, neutral Fatty acids Glucose 0.025 Hyaluronic acid 3.32 Lipids, total Total nitrogen 0.084^.0 1.58 Nonprotein nitrogen 0.22-0.43 Phospholipid Urea 0.15 0.33-1.4 Uric acid (mg/L) 39 Water 960-988 982 Concentrations are in mg/mL, unless otherwise specified.

Table C1.5 Protein

Major protein content of various fluids [12,14] Plasma (serum) 37.6-54.9 0.48-1.26 0.98-2.45 0.58-2.24 CS fluid1 Synovia! fluid 6-10

Albumin a r A c i d glycoprotein (orosomucoid) a r Antitrypsin P2-Microglobulin Haptoglobin

15539 1.850.74 7.03.0 0.1-1.9 2.241.5

0.780.017 0.1

Type 1.1 Type 2.1 Type 2.2

Ceruloplasmin Transferrin Cl Inhibitor a 2 -Macroglobulin IgA IgG IgM Fibrinogen Lysozyme Fibronectin Hemopexin Protein Albumin Ct1-Acid glycoprotein (orosomucoid) a r Antitrypsin P2-Microglobulin Haptoglobin Ceruloplasmin Transferrin Cl Inhibitor a 2 -Macroglobulin IgA IgG IgM Fibrinogen Lysozyme Fibronectin Hemopexin
1

1.450.34 2.060.67 1.740.70

0.09-0.51 1.52-3.36 0.15-0.35 1.45-4.43 0.7-3.12 6.4-13.5 0.56-3.52 2-A 0.09-0.25 0.53-1.21 Synovia! 3^94 0.015 0.04 0.04-0.80 0.04-0.62 trace 1-2.8 0.880.21 8.423.5 4.641.84 2.260.95 13.96.6 0.65 0.0430.016 0.31-0.21 0.62-1.15 1.47-4.62 0.09-0.22

fluid

Tear fluid 15-26.7 7.8 - --

Protein concentrations in CS fluid are given in mg/L. All others have units of mg/mL.

Table C1.6 Fluid volumes [16] Fluid Whole blood Erythrocytes Plasma Cerebrospinal Tear Volume Male (mL) 4490 2030 2460 100-160 4-13 Volume Female (mL) 3600 1470 2130 100-160 4-13

fluid fluid

The following equations can be used to estimate blood volume (BV, mL), erythrocyte volume (EV, mL), and plasma volume (PV, mL) from the known body mass (b, kg) with a coefficient of variation of approximately 10%: Males (M) BV = 41.0 x b + 1530 Females (F) BV = 47.16 x b + 864 PV = 19.6 x b + 1050 PV = 28.89 x b + 455 EV = 21.4 x b + 490 EV = 18.26 x b + 409 These equations, relating BV, PV, and EV to body weight, are taken from Lentner [12]. Additional correlations relating these volumes to body weight and surface area are available from the same source.

Table C1.7 Properties of major plasma proteins [16, 17] Plasma concentration Molecular Protein (mg/mL) weight (Da) p1 S1 D2 Prealbumin 0.12-0.39 54 980 47 42 ^~~ Albumin 38-52 66 500 4.9 4.6 6.1 OL1 - Acid Glycoprotein (Orosomucoid) 0.5-1.5 44 000 2.7 3.1 5.3 Gt1 - Antitrypsin 2.0-4.0 54 000 4.0 3.5 5.2 a 2 - Macroglobulin 1.5-4.5 725 000 5.4 19.6 2.4 GL2 - Haptoglobin Type 1.1 1.0-2.2 100 000 4.1 4.4 4.7 Type 2.1 1.6-3.0 200 000 4.1 4.3-6.5 Type 2.2 1.2-2.6 400 000 7.5 a 2 - Ceruloplasmin 0.15-.60 160 000 4.4 7.08 3.76 Transferrin 2.0-3.2 76 500 5.9 5.5 5.0 Hemopexin 0.56-0.89 57 000 5.8 4.8 Lipoproteins 5.5-6 140 000-20 000 000 5.4 IgA (Monomer) 1.4-4.2 162 000 7 3.4 IgG 6-17 150 000 6.3-7.3 6.5-7.0 4.0 IgM 0.5-1.9 950 000 18-20 2.6 CIq 0.05-0.1 459 000 11.1 C3 1.5-1.7 185 000 6.1-6.8 9.5 4.5 C4 0.3-0.6 200 000 10.0 Fibrinogen 2.0-4.0 340 000 5.5 7.6 1.97 Plasma concentration Half-life Protein (mg/mL) E2803 V204 CH2O5 (days) Prealbumin 0.12-0.39 141 074 ~L9 Albumin 38-52 5.8 0.733 0 17-23 (X1 - Add glycoprotein (orosomucoid) 0.5-1.5 8.9 0.675 41.4 5.2 Ci1 - Antitrypsin 2.0-4.0 5.3 0.646 12.2 3.9 a 2 - Macroglobulin 1.5-4.5 8.1 0.735 8.4 7.8 a 2 - Haptoglobin Type 1.1 1.0-2.2 12.0 0.766 19.3 2-A Type 2.1 1.6-3.0 12.2 Type 2.2 1.2-2.6 a 2 - Ceruloplasmin 0.15-.60 14.9 0.713 8 4.3 Transferrin 2.0-3.2 11.2 0.758 5.9 7-10 Hemopexin 0.56-0.89 19.7 0.702 23.0 9.5 Lipoproteins 5.5-6 IgA (Monomer) 1.4-4.2 13.4 0.725 7.5 5-6.5 IgG 6-17 13.8 0.739 2.9 20-21 IgM 0.5-1.9 13.3 0.724 12 5.1 CIq 0.05-0.1 6.82 8 C3 1.5-1.7 0.736 C4 0.3-0.6 Fibrinogen 2.0-4.0 13.6 0.723 2.5 3.1-3.4 1 Sedimentation constant in water at 200C, expressed in Svedberg units. 2 Diffusion coefficient in water at 200C, expressed in 10'7 cm2/s. 3 Extinction coefficient for light of wavelength 280 nm traveling 1 cm through a 10 mg/ml protein solution. 4 Partial specific volume of the protein at 200C, expressed as ml g1. 5 Carbohydrate content of the protein, expressed as the percentage by mass.

Table C1.8 Proteins involved in blood coagulation [19] Plasma concentration Protein Fibrinogen Prothrombin Factor III (tissue factor) Factor V Factor VII Factor VIII Factor IX Factor X Factor XI Factor XII Factor XIII Protein C Protein S Protein Z Prekallikrein High molecular weight kininogen OL1 Protease inhibitor Antithrombin III
([LgZmL)

Relative molecular weight, Mr (Da) 340 000 71600 45 000 330 000 50 330 000 57 000 58 800 160 000 80 000 320 000 62 000 77 000 62 000 85 000 120 000 55 000 58 000

Biological half-life t]/i (hr) 72-120 48-72 12-15 2-5 8-12 24 24-40 48-84 50-60 216-240 10

2000-4000 70-140 4-14 trace -0.2 -5.0 -12 2.0-7.0 15^7 -10 -4.0 -22 -2.9 35-50 70-90 2500 230 23

60

67

Table C1.9 Proteins in the compliment system Protein Serum concentration (mg/L) 70 14 39 2 36 3 27 5.6 1612 244 498 151 153 29 50.9 8 4-60 43.2 6.5 57.5 12.7 275 55 trace 28.4 5 158 14 525 58 38.6 5.5 Relative molecular weight, Mr (Da) 459 000 83 000 83 000 108 000 185 000 200 000 185 000 128 000 121 000 151 000 71000 92 000 24 000 220 000 100 000 150 000 88 000 Sedimentation constant
S2Ow(IO-13S)

CIq CIr CIs C2 C3 C4 C5 C6 C7 C8 C9 Factor B Factor D Properdin Cl inhibitor Factor H Factor I

11.1 7.5 4.5 4.5 9.5 10.0 8.7 5.5 6.0 8.0 4.5 5-6 3.0 5.4 6.0 5.5

ADDITIONAL READING:
Ditmer, D.S. (ed.) (1961) Blood and Other Body Fluids, Federation of American Societies for Experimental Biology, Washington, D.C. This text provides a thorough compilation of the physical properties and composition of numerous biological fluids. Unlike the Geigy Scientific Tables, this book also reports data for many non-human species. However, citations and some measurement techniques are somewhat outdated. Kjeldsberg CR. and Knight J.A. (eds) (1993) Body Fluids: Laboratory Examination of Amniotic, Cerebrospinal, Seminal, Serous & Synovia! Fluids, 3rd ed., American Society of Clinical Pathologists, Chicago. An excellent source of information, especially for a clinician or medical technologist. Includes numerous color photographs of fluids and cells. Discusses abnormal amounts or types of specific proteins and cells in fluids as potentially diagnostic of disease states. Lentner, C. (ed.) (1984) Geigy Scientific Tables, Ciba-Geigy, Basle. This is the most comprehensive source of information available on properties and composition of body fluids. Volumes 1 and 3 provide extensive data, generally in tabular form, on fluid content (as well as measurement technique), related to gender, age and disease state.

REFERENCES 1. Ditmer, D.S. (ed.) (1961) Blood and Other Body Fluids, Federation of American Societies for Experimental Biology, Washington, D.C. 2. Fullard, RJ. (1988) Current Eye Research, 7, 163-179. 3. Chmiel, H. and Walitza, E. (1980) On the Rheology of Blood and Synovial Fluids, Research Studies Press, New York. 4. Barbanel, J.C., Lowe, G.D.O. and Forbes, CD. (1984), The viscosity of blood, in Mathematics in Medicine and Biomechanics, G.F. Roach (ed.), Shiva Publications, Nantwich, p. 19. 5. Begg, T.B. and Hearns, J.B. (1966) Components in blood viscosity: The relative contribution of hematocrit, plasma fibrinogen and other proteins. Clinical Science, 31, 87-93. 6. Whitmore, R.L. (1968) Rheology of The Circulation, Pergamon Press, New York. 7. Merrill, E.W. (1969) Rheology of blood. Physiology Reviews, 49, 863-867. 8. Harkness, J. (1971) The viscosity of human blood plasma: Its measurement in health and disease. Biorheology, 8, 171-193. 9. Lowe, G.D.O., Barbanel, J.C. and Forbes, CD. (eds) (1981) Clinical Aspects of Blood Viscosity and Cell Deformability, Springer-Verlag, New York. 10. Lowe, G.D.O and Barbanel, J.C (1988) Plasma and blood viscosity, in Clinical Blood Rheology, G.D.O. Lowe (ed.), CRC Press, Boca Raton, pp. 11-44. 11. Schmidt-Schonbein, H. (1988) Fluid dynamics and hemorheology, in Clinical Blood Rheology, G.D.O. Lowe (ed.), CRC Press, Boca Raton, pp. 129-220. 12. Lentner, C (ed.) (1984) Geigy Scientific Tables, Ciba-Geigy, Basle.

13. Bicks, R.L. (1993) Hematology: Clinical and Laboratory Practice, Mosby, St Louis. 14. Sokoloff, L. (ed.) (1978) The Joints and Synovial Fluid, Academic Press, New York. 15. Hermens, W.T., Willems, G.M. and Visser, M.P. (1982) Quantification of Circulating Proteins: Theory and Applications Based on Analysis of Plasma Protein Levels, Martinus Nijhoff, The Hague. 16. Colman, R.W., Hirsh, J., Marder, V.J., et al (eds) (1993) Hemostasis and Thrombosis, Lippincott, Philadelphia. 17. Schultze, H.E. and Heremans, J.F. (1966) Nature and Metabolism of Extracellular Proteins, Elsevier, Amsterdam. 18. Bing, D.H. (ed.) (1978) The Chemistry and Physiology of the Human Plasma Proteins, Pergamon Press, Boston. 19. Stamatoyannopoulos, G., Nienhuis, A.W., Majerus, P.W., et al. (eds) (1994) The Molecular Basis of Blood Diseases, W.B. Saunders, Philadelphia.

The Vitreous Humor

T.V. Chirila and Y. Hong

C2

C2.1 INTRODUCTION The vitreous body, also termed the vitreous humor, vitreus, or vitreous, is a clear and transparent mass (gel or liquid or a mixture of both) that fills the posterior cavity of the eye in vertebrates, between the lens and the retina. The human vitreous body is a hydrogel with a very high water content which provides an adequate support for the retina, allows the diffusion of metabolic solutes, and allows the light to reach the retina. There are currently two differing concepts on the nature of vitreous body. A significant amount of evidence supports the view that the vitreous body is basically an extracellular matrix. Another model has been developed in which the vitreous body is considered as a specialized, but simple, connective tissue. The two concepts are not yet reconciled, therefore the structure and role of the vitreous body are usually regarded from both points of view. It is accepted that the vitreous body possesses a unique macromolecular organization, a double-network system consisting of a scaffold of randomly spaced rod-like collagen fibers filled and entangled with a network of very large coiled-up macromolecules of hyaluronic acid (hyaluronan). The latter is present in the form of its sodium salt (sodium hyaluronidate). The double-network model explains satisfactorily most of the properties of the vitreous body, as well as its remarkable stability, although it probably overestimates the importance of hyaluronan. The natural vitreous body displays true viscoelastic properties which enable it to resist sudden compression shocks, offering much the best protection for the retina against contusion trauma. It is believed that the hyauronan network imparts the latter feature, while the collagen network is responsible for the plasticity and tensile strength of the vitreous body.
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

As is the case with many other structural elements of the eye, there are presently much more data on animal vitreous body than on the human counterpart. Likely, the results reviewed here cover almost everything reported so far on the human vitreous. However, in many cases it is not possible to select a most reliable single value; dependable values representing a range are thus provided in several of the following tables. Being a very loose tissue, albeit well structured in a very specific way, the vitreous body becomes homogeneous during processing for measurements and the resulting data for its physical properties merely illustrate the behavior of a fluid consisting mainly of water and containing minute amount of inorganic and organic components. The dimensional characteristics (Tables C3.1, C3.5 and C3.6), bulk chemical composition (Tables C3.2 and C3.3) and optical properties (Table C4.7) are seemingly not affected by the morphological heterogeneity of the vitreous. However, some investigators took into account the separate existence of gel and liquid fractions in the vitreous (Tables C3.4, and C3.6). Over the past few decades the vitreous body was perceived as a typical viscoelastic material. However, its characterization by rheometry (as shown in Table C3.8) is still in its infancy. C2.2 GENERAL PROPERTIES
Table C3.1 Physical properties of the human vitreous body Property Volume Weight Water content pH Osmolality Osmotic pressure (freezing point depression) Density Intrinsic viscosity Dynamic viscosity Refractive index Value 3.9 ml 3.9 g 99.7% 99% 7.5 7.4-7.52 7-7.3 288-323 mOsm kg 1 -0.554 to -0.5180C [4] 1.0053-1.0089 g cnr3 3-5 x 103 cm3 g 1 1.6 cP 1.3345 1.3345-1.337 Source [1] [f [2 [3: [4 [5] [6] [7] [8] [9] [10] [11] [1]

Table C3.2 Inorganic ions content of the human vitreous body Ion Sodium Potassium Calcium Phosphate Chloride Bicarbonate Representative value 2.714-3.542 mg cm 3.15 g/kg H2O 2.603-5.805 mg cm 3 130^70 juig cm 3 0.15 g/kg H2O 308-788 |xg cm 3 56-106 |xg cm 3 14-76 |xg cm 3 0.1-3.3 mEq dm 3 3.155-5.140 mg cm 3 4 g/kg H2O 3.477-7.621 mg cnr3 1.2-3.0 g/kg H2O
3

Source [12] [3] [6] [12] [3] [6] [12] 6] 12] 12] [3] [6] [3]

Table C3.3 Organic content of the human vitreous body (low molecular weight components) Component Lipids Glucose Lactic acid Urea Creatinine Citrate Pyruvic acid Ascorbic acid Component Proteins3 Representative value 2 /xg/ml 17-105 mg/dl 30-70 mg/dl water 70 mg/dl water 24-172 mg/dl water 0.3-3.0 mg/dl , 1.9 mg/dl water 7.3 mg/dl water 36 mg/100 g Source [13] [12] [3] [3] [12] [12] [3] [3] [14] Source [13] [15] [15] [6] [15] [6] [16] [16] 16] [16]

Representative value (\Lg cm'3) 280-1360 450-1100 Hyaluronan 100-400 42-399 Collagen 40-120 30-532 Albumin 293 18 Immunoglobulin (IgG) 33.5 3 a r Antitrypsin 141 2.9 a r Acid glycoproptein 4 0.7 = Standard deviation; a total protein content.

Table C3.4 Variation with age of total protein content in the liquid human vitreous [15] Age range (years) 10-50 50-80 >80 Protein (mg cm'3) 0.4-0.6 0.7-0.9 0.9-1.0

Table C3.5 Axial length of the human vitreous body during maturation [17]a Age (years) and gender <13, male <13, female >13, male >13, female
a

Axial length, (mm) 10.48 10.22 16.09 15.59

The axial growth of the vitreous body is essentially completed by the age of 13 years.

Table C3.6 Gel and liquid volume of the vitreous as a function of age (adapted from [18])a Age (years) Birth 5 10 20 30 40 50 60 70 80 90 Gel volume (cm3) 1.6 3.3 3.5 3.9 3.9 3.9 3.5 3.2 2.8 2.5 2.2 Liquid volume (cm3) 0 0 0.7 0.9 0.9 0.9 1.3 1.6 2.0 2.3 2.6

a The liquid vitreous appears first in childhood and by the seventh decade it occupies half of the vitreous [18, 19].

Table C3.7 Transmission of radiation through the vitreous body (adapted from [20]) Wavelength (nm) 300 325 350 400 500 600 700 Transmittance (total, %) 0 76 82 90 97 98 98

C2.3 MECHANICAL PROPERTIES

Table C3.8 Rheological characteristics of the human vitreous body [21] Parameter Residual viscosity H m (Pa s) Internal viscosity nk ( P a s ) Relaxation time V(S) Retardation time Tk(S) Elastic compliance, instantaneous, Jm (Hr2N-1) Elastic modulus, internal, Gk (N nr 2 ) Anterior 1.4 0.3 0.38 0.27 0.1 2.5 Region in the vitreous Central 2.2 0.35 0.30 0.41 0.3 1.3 Posterior 4.9 0.5 1.61 0.46 0.3 1.2

ADDITIONAL READING
Balazs, E.A. (1968) The molecular biology of the vitreous, in New and Controversial Aspects of Retinal Detachment, (ed. A. McPherson), Harper & Row, New York, pp. 3-15. This is a landmark paper on the nature of the vitreous body, describing the 'mechanochemicaP (or 'double-network') model. This model explains satisfactorily the correlations between some properties of the vitreous (composition, rheology, volume, cell population, transparency) and the physicochemical principles governing its stability (frictional interaction, expansion/contraction, the excluded-volume concept, and the molecular-sieve effect).

Berman, E.R. and Voaden, M. (1970) The vitreous body, in Biochemistry of the Eye, (ed. CN. Graymore), Academic Press, London, pp. 373-471. A comprehensive summary of knowledge at that time on animal and human vitreous body, including development, chemical composition, metabolism, and aging effects. Shields, J. A. (1976) Pathology of the vitreous, in Current Concepts of the Vitreous including Vitrectomy, (ed. K.A. Gitter), CV. Mosby Co., St. Louis, pp. 14-42. This book chapter presents competently the pathologic vitreous, including developmental abnormalities, inflammation, hemorrhage, effects of trauma, systemic diseases, and degenerative processes. Gloor, B.P. (1987) The vitreous, in Adlefs Physiology of the Eye, 8th ed., (eds R.A. Moses and W.M. Hart), CV. Mosby Co., St. Louis, pp. 246-267. A concise description of all aspects of the vitreous body, including properties, development, anatomy, structure, biochemistry, metabolism, and pathology. Sebag, J. (1989) The Vitreous. Structure, Function, and Pathology, Springer-Verlag, New York. This is probably only the second single-authored book in this century to be dedicated entirely to the topic of vitreous body. It is a well-structured and updated compendium. The first half of the book is dedicated to structure, properties and physiology of the vitreous. Pathology of the vitreous is analyzed in the other half from a biological angle. Although a clinician, the author manages to avoid typical clinical descriptions and to provide a text which integrates the basic scientific knowledge for both clinicians and scientists. Williams, G.A. and Blumenkranz, M.S. (1992), Vitreous humor, in Duane's Foundations of Clinical Ophthalmology, vol. 2 (eds W. Tasman and E.A. Jaeger), J.B. Lippincott Co., Philadelphia, chapter 11. This chapter (27 pages) presents the modern concepts in the pathophysiologic mechanisms of vitreous diseases, and in the clinical conditions involving the vitreous (detachment, macular holes and membranes, diabetes, proliferative vitreoretinopathy, hyalosis, amyloidosis). Aspects such as separation of the vitreous from the retina and traction of the vitreous by hypocellular gel contraction are explained according to the most recent findings.

REFERENCES 1. Redslob, E. (1932) Le corps vitre, Masson & Cie, Paris, pp. 299-305. 2. Duke-Elder, W.S. (1929) The physico-chemical properties of the vitreous body. /. Physiol, 68, 155-65. 3. Nordmann, J. (1968) Chimie, in Biologie et chirurgie du corps vitre, (eds A. Brini, A. Bronner, J.P. Gerhard et al), Masson & Cie, Paris, pp. 95-167. 4. Morner, CT. (1894) Untersuchung der Proteinsubstanzen in den lichtbrechenden Medien des Auges. Z. Physiol. Chem., 18, 233-56. 5. Gala, A. (1925) Observations on the hydrogen ion concentration in the vitreous body of the eye with reference to glaucoma. Br. J. Ophthalmol, 9, 516-9. 6. Lee, B. (1994) Comparative rheological studies of the vitreous body of the eye, Ph.D. Thesis, University of Pennsylvania, 1992, U.M.I./Bell & Howell Co., Ann Arbor, MI, pp. 102, 138-152.

7. Sturner, W.Q., Dowdey, A.B.C., Putnam, R.S. et al (1972) Osmolality and other chemical determinations in postmortem human vitreous humor. /. Forensic ScL, 17, 387-93. 8. Visser-Heerema, J. (1936) Uber das spezifische Gewicht der bei der Operation von Netzhautablosungen gewonnenen Fliissigkeit. Arch. Augenheilkd., 109, 543-61. 9. Berman, E.R. and Michaelson, LC. (1964) The chemical composition of the human vitreous body as related to age and myopia. Exp. Eye Res., 3, 9-15. 10. Shafer, D.M. (1965) Intraocular injections as adjuncts to other retinal detachment procedures, in Controversial Aspects of the Management of Retinal Detachment, (eds CL. Schepens and C D J . Regan), Little, Brown & Co., Boston, pp. 186-204. 11. Guggenheim, I. and Franceschetti, A. (1928) Refraktometrische Untersuchungen des Glaskorpers von Kaninchen und Mensch (unter physiologischen und pathologischen Bedingungen). Arch. Augenheilkd., 98, 448-82. 12. Naumann, H.N. (1959) Postmortem chemistry of the vitreous body in man. Arch. Ophthalmol, 62, 356-63. 13. Swann, D.A. (1980) Chemistry and biology of the vitreous body. Int. Rev. Exp. Pathol, 22, 1-64. 14. Sullmann, H. (1951) Chemie des Auges. Tabul. Biol, 22, 1-119. 15. Balazs, E.A. and Denlinger, J.L. (1984) The vitreus, in The Eye, vol. Ia, 3rd edn, (ed H. Davson), Academic Press, Orlando, FL, pp. 533-89. 16. Clausen, R., Weller, M., Wiedemann, P. et al. (1991) An immunochemical quantitative analysis of the protein pattern in physiologic and pathologic vitreous. Graefe's Arch. CUn. Exp. Ophthalmol, 229, 186-90. 17. Larsen, J.S. (1971) The sagital growth of the eye. III. Ultrasonic measurement of the posterior segment (axial length of the vitreous) from birth to puberty. Acta Ophthalmol, 49, 441-53. 18. Balazs, E.A. (1992) Functional anatomy of the vitreus, in Duane's Foundations of Clinical Ophthalmology, vol. 1, (eds W. Tasman and E.A. Jaeger), J.B. Lippincott Co., Philadelphia, Chapter 17. 19. Balazs, E.A. and Denlinger, J.L. (1982) Aging changes in the vitreus, in Aging and Human Visual Function, (eds R. Sekuler, D. Kline and K. Dismukes), Alan R. Liss, Inc., New York, pp. 45-57. 20. Boettner, E.A. and Wolter, J.R. (1962) Transmission of the ocular media. Invest. Ophthalmol, 1, 776-83. 21. Lee, B., Litt, M. and Buchsbaum, G. (1992) Rheology of the vitreous body. Part I: Viscoelasticity of human vitreous. Biorheology, 29, 521-33.

PART II

Metallic Biomaterials
J. Breme and V. Biehl

1.1 INTRODUCTION Compared with other biomaterials like ceramics and poylmers, the metallic biomaterials possess the outstanding property of being able to endure tensile stresses, which, in the case of alloys, may be extremely high and also of dynamic nature. This is the reason why alloys, for example those with sufficient bending fatigue strength, are widely used as structural materials for skeletal reconstructions if high acting loads are expected to occur. Typical examples for such highly loaded implants are hip and knee endoprostheses, plates, screws, nails, dental implants, etc. Nevertheless, metallic biomaterials are also used for unloaded, purely functional devices such as cages for pumps, valves and heart pacemakers, conducting wires, etc. The main requirements which must be fulfilled by all biomaterials are corrosion resistance, biocompatibility, bioadhesion (bone ingrowth), biofunctionality (adequate mechanical properties, especially fatigue strength and a Young's modulus as close to that of the bone as possible), processability and availability. These requirements are more or less satisfactorily fulfilled by the various customary groups of biomaterials. In comparison the different materials show a different behaviour according to the demands. A corrosion resistant material may not necessarily be biocompatible and, contrarily, a more biocompatible material may be less corrosion resistant. Especially fretting corrosion may pose a problem in articulating devices like knee joints or plate/screw systems. Often unique characteristic properties of a material are responsible for its application. Typical examples are the amalgams which in spite of their reduced
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

corrosion resistance and biocompatibility were used over a long period of time for dental restoration due to their extremely good processability provided by their ability to amalgamate with mercury at room temperature within a short time, showing in this condition a high hardness. The biocompatibility of most metallic biomaterials is based on a passive oxide layer which is always present on the metal surface and which will be restored quickly (milliseconds) after damage. These oxide layers, similar to alumina, show an inert behaviour towards the surrounding tissue. Therefore, the chemical bonding of a metallic implant with the tissue, which is observed between bioactive ceramics like hydroxyapatite and bone, seems to be improbable, and the adhesion strength between the bone and the metal will have a primarily mechanical character. With stainless steel and a cobalt-chromium base alloy ('Vitallium') metallic materials exhibiting such a passive and highly inert oxide layer have been available for about 60 years. About 25 years ago, due to the favourable properties of the special metals niobium, tantalum and titanium, their application as biomaterials became the subject of much discussion. Especially titanium and its alloys began to compete with the existing biomaterials. Because of this competitive situation an enormous advancement of the materials was set going in different directions. Quality assurance systems for customers and surgeons were created by standardization and normalization of the existing materials. In addition, attention was devoted to the further development of the existing base materials, one example being the development of a forgeable Ni-free cobalt-chromium alloy with an extremely low carbon content, with a resulting avoidance of the precipitation of brittle carbides. Examples related to titanium materials are the development of alloys containing no toxic elements like vanadium (e.g. Ti5A12.5Fe and Ti6A17Nb) and the development of near (3- or (3-alloys. Besides a high fatigue strength these alloys have, due to a high content of the (3-phase, a Young's modulus which is even lower than that of conventional titanium materials, by means of which a good load transfer is achieved. Therefore, stress shielding can be avoided and new bone formation is stimulated. A further direction of advancement was originated by the progress being made in research and surgery and by the demand for materials with special properties for special applications. For these cases the materials, which are often composite materials, had to be tailored to the intended application. One example is the development of the alloy TiTa30 which in its thermal expansion coefficient is very similar to alumina and can therefore be crackfree bonded with the ceramic. This material is used as a dental implant. The metallic biomaterial which can resist bending stresses is inserted into the jaw. The upper part of the implant consisting of alumina, which shows a smaller deposition of plaque than the metallic materials,

passes through the gingiva into the mouth cavity. Another example for the tailoring of materials is a surface treatment in order to improve the physical properties. Heart pacemaker leads, for example, which are produced by porous sintering of Ti-powder, are PVD-surface coated with Ir, TiN, TiB2, TiC, etc. in order to increase the electrical conductivity. In the following chapters the various groups of metallic biomaterials are characterized in terms of their composition, physical and mechanical properties and their corrosion and biological behaviour. In addition, recommendations are given for their processing (deformation, machining, welding, brazing, etc.). 1.2 GENERAL DISCUSSION Considering the testing methods used to determine the main requirements which must be fulfilled by biomaterials, i.e. corrosion resistance, biocompatibility, bioadhesion and biofunctionality, it is obvious that only the measurement of the mechanical properties, including fatigue (biofunctionality), will supply objectively comparable results because these testing methods are standardized. In the methods used for the investigation of corrosion resistance, biocompatibility and bioadhesion the researchers try to simulate and imitate the natural in vivo condition of the implant. Only in the near past have efforts been made to standardize these tests. Because of a longtime decline of standardization the tests described up until now in literature differ and the results of such diversified tests are not comparable. Corrosion measurements, for example, are performed in different solutions with changing pH values and atmospheres (aerated or de-aerated). Only if different materials have been investigated in one test and under the same conditions does a comparison of their behaviour for this test seem possible. Nevertheless, regarding the differing test results, the most corrosion resistant materials seem to be the special metals (titanium, niobium, tantalum and their alloys), followed by wrought CoCr-based, cast CoCr-based alloys and stainless steel. The current density of various materials was determined as a function of the potential difference between the anodic and cathodic branches of the current potential curves in 0.9% NaCl with a stable redox system Fe (CN)64VFe (CN)63" [I]. The saline solution containing this redox system had a resting potential closely resembling that of a tissue culture fluid which has a redox potential of 400 mV. Ti and its alloys Ta and Nb exhibit a better resistance than the stainless steel AISI 316L and a wrought CoNiCr alloy. The same ranking can be observed during the measurement of the polarization resistance of the different materials [I]. Breakdown potential measurements of various implant materials in

Hank's solution also indicated a clear order of ranking of the materials. While commercially pure titanium and Ti6A14V had high breakdown potentials of 2.4 and 2.0 V respectively, for stainless steel and CoCr alloys (cast and wrought) this value amounted to only 0.2 and 0.42 V respectively [2]. As already described [3], Ti and its alloys with Nb and Ta belong to the group of metals which cannot undergo a breakdown of passivity in body fluids. In these fluids a breakdown at a high potential causing pitting corrosion is impossible because it is more positive than the oxygen reduction reversible potential. On the other hand, the passivation potential is less positive than the water or hydrogen-ion reduction. In all materials the passive layer can be damaged mechanically, for example, by fretting metal on metal (plate/screw) or by the instruments used during surgery. The repassivation time of the material is therefore very important. The repassivation behaviour of different materials in a saline solution was measured using an electrode which rotates at a rate of 10 s"1 in the solution, during which it is activated by an Al2O3 cutting tool. The decrease in the corrosion current is measured as a function of the time at different potentials. The repassivation is defined as being achieved when the current density amounts to 1/e (e [approximate or equal too] 2718) of the current density in the activated condition [4]. In addition, the time t005 of a residual active current density of 5 % was determined. The passive oxygen surface layer (te) is reconstructed as a function of the material in some milliseconds, demonstrating an advantage on the part of titanium materials. The growth of the surface layer (t0 Q5) of cp-titanium and the titanium alloys is accelerated as compared to that of the other materials (stainless steel, wrought and cast CoCr). In order to avoid damaging of the surface layer, coatings of hard layers of non-abrasive materials which also show favourable fretting behaviour, are recommended, especially for the movable parts of implants. Since the highest values for the acceleration tension are achieved by ion implantation, the best reaction and binding can be expected with this procedure. By the implantation of TiN on wrought CoCr, for example, not only the fretting behaviour, but also the corrosion resistance of the material tested in 0.17 M saline solution was improved. The pitting of the surface treated material amounted to 1.16 V, while the material which had not undergone surface treatment had a potential of 0.83 V [5]. If cracks and fissures are present in the surface layer, the corrosion rate will be accelerated due to the lower pH value in these crevices. Experiments with ion implantation of nitrogen in titanium surfaces produced good results concerning the fretting behaviour. Even the fatigue strength of the alloy Ti6A14V, which was surface treated by nitrogen ion implantation, is reported to have increased due to compression stresses generated by the high acceleration tension of the nitrogen ions [6]. Another possibility of hardening the surface of Ti and its alloys without diminishing the corrosion

behaviour and fatigue properties is a short annealing in air, e.g. by induction heating and subsequent quenching. This method was applied for the improvement of the friction behaviour of hip prosthesis heads [7]. For the biocompatibility and bioadhesion tests similar restrictions as in the corrosion resistance tests must be observed. A comparison of the behaviour of the different materials is possible only if the testing conditions are identical. Results obtained in animal experiments with rats and rabbits must be treated with reservations because both animals show intense bone growth and rapid healing after the implantation. Measurements of the concentration of various metals in different organs of a rabbit six and sixteen weeks after implantation showed after six weeks a titanium content of 45.1 ppm in the spleen and 53.4 ppm in the lung. These values correspond to the values in a normal spleen or lung. No significant changes were observed in the liver or kidneys. However, Co and Ni from cobalt-based alloys and stainless steel were found in higher concentrations in these organs [8]. Patients with total hip replacements by implants of stainless steel or of CoCr alloys who experienced difficulties after two to fifteen years due to a loosening of the prosthesis and/or allergic reactions to Cr, Co or Ni were found to have an increased content of these elements in their urine, plasma and blood. Already fifteen months after removal the contents were excessive in these fluids [9]. The level of toxicity of the various elements was determined by investigating the reaction of salts of these elements with cells of the kidneys of green African monkeys. The so-called CCR50 value was measured which is defined as the concentration of the studied substance which generates a reduction of survival of the renal cells of 50%. Of all the elements measured the lowest value of 3 x 10'2 |xg/ml was observed for vanadium [10]. This is the reason why absolutely biocompatible biomaterials containing no toxic elements such as Ti5A12.5Fe [11] and Ti5A17Nb [12] were developed. After insertion of wires of different metals into the epiphyseal region of rabbits and an exposure time of fifteen months, the histology showed different results. With materials of inert or biocompatible behaviour the cells in the vicinity of the implant were still supplied with blood, while the cells in the neighbourhood of toxic materials underwent an inflammatory reaction and died. A few elements (Cr, Co, Ni and V) have toxic effects and also have a relatively low polarization resistance. Ti and its alloys, Nb and Ta, which have a high polarization resistance, exhibit an inert behaviour. In between the materials were found which are capsulated. The results also show that not only the corrosion behaviour provided by the polarization resistance is responsible for the biocompatibility of the material exposed to the tissue. The steel 316L and the CoCr alloy, which have a polarization resistance similar to that of titanium, are encapsulated by a tissue membrane and their behaviour is not inert [13].

A sensitive and reproductive test of biocompatibility seems to be the cultivation of cells with an increasing content of fine metal powders (<20 (xm). The survival rate is measured after a constant exposure time. The limit of toxicity C50 is defined as the value (|xg/ml) of the powder concentration which produces a dying off of 50% of the cells. (The results can be found in the chapters related to biocompatibility.) In the implant/body system there are several interactions which can generate injuries: (a) The corrosion process produces aflowof electrons in the implant metal and a flow of ions in the surrounding tissue. The latter may disturb the physiological ion movement of the nerve cells. (b) An inorganic reaction of the implant or of primary corrosion products is caused by the solution of metal ions in the body fluid and transport to the various organs where they are concentrated and can produce systemic or hypersensitive effects if the limit of toxicity for a certain metal is exceeded. (c) Direct organic reaction of the implant or of primary corrosion products with proteins of the tissue takes place, causing, for example, inflammation. (d) Generation of H2O2 by inflamed cells and decomposition of H2O2 by the formation of a hydroxyl radical, causing injury in the biological system. Whether one of these interactions occurs or not depends on the physical and chemical properties of the various materials. Ti, Ta and Nb are reported to be biocompatible because they form protective surface layers of semi- or nonconductive oxides. These oxides are able to prevent to a great extent an exchange of electrons and therefore a flow of ions through the tissue [14] due to their isolating effect. This isolating effect may be demonstrated by the dielectric constants of the different metal oxides. There are three groups of oxides. While TiO2 (rutile), Fe2O3 and Nb2O5 have constants even higher than that of water, Al2O3, Cr2O3 and Ta2O5 have a lower isolating effect and a higher conductivity. For Ni- and V-oxides dielectric constants are not available because of their high conductivity [8]. The relatively low isolating effect of Ta-oxide is indirectly proved by the cytotronic effects of Ta on the membrane properties and on the growth of spinal ganglion cells during in vitro tests. In contrast, Ti showed no effect on the membrane properties and on the growth of ganglion cells [15]. Concerning inorganic or organic reactions, the primary corrosion products of the metallic implants are mainly responsible for the biocompatibility of the implanted metal because they may have, due to their large surface, an interaction with the tissue or with the body fluid. The metal is transported by a solution in the body fluid to the various organs where due to an enrichment of the metal an undesirable interaction may occur.

The primary corrosion products of the most important elements in metallic implant materials vary in their thermodynamic stability. While the oxides or hydroxides of Al, Cr, Nb, Ta, Ti and V are stable due to a more negative heat of formation than that of water, the oxides and hydroxides of Co and Ni are unstable because of a less negative heat of formation than that of water [16]. The interaction between the oxide or hydroxide and the body fluid is increased if the heat of formation for the oxide or hydroxide is increased. Therefore, the thermodynamically stable corrosion products have a low solution product and a low solubility in the body fluid. This is directly demonstrated by the pk values (negative logarithm) of the solution product of the primary corrosion products [13]. While Ti, Ta-, Nb- and Cr-oxides have pk-values of >14, i.e. hydrolysis cannot play a role, Co-, Fe-, and Ni-oxides possess even negative pk values which cause a considerable solubility. In spite of a high negative heat of formation for Fe2O3 and Fe- and Cr-hydroxide negative pk values and a high solubility are reported [13]. A remarkable solubility of Cr in serum was observed [17], while titanium is practically insoluble due to the formation of the thermodynamically very stable oxide TiO2. Thermodynamically stable primary corrosion products with a low solubility in body fluid are in a stable equilibrium with only a low reactivity with the proteins of the surrounding tissue. The hydroxyl radical is able to cause injury in biological systems, e.g. biomembranes can be deteriorated. Titanium is able to bind H2O2 in a Ti-H2O2 complex. This complex can trap the superoxide radical which is formed during the H2O2 decomposition. By spectrophotometric spintrapping measurements and electron spin resonance measurements no hydroxyl radical formation rate in Ti-H2O2 could be detected. A similar result was observed with Zr, Au and Al [18]. The integration of metallic implants by ingrowth was studied for many different materials and implant systems. The ingrowth behaviour of miniplates of commercially pure titanium and of the stainless steel 316L was investigated by the implantation of these plates on the legs of Hanford minipigs. The miniplates were fixed to the legs of the pigs by screws. After removal following an exposure time of eight weeks a histologic examination was performed by fluorescence microscopy. In all animals where titanium plates had been used a new formation of bone could be observed in close contact to the surface of the screws and plates [19]. In contrast to this result, when stainless steel was used, there was less new bone formation and in addition granulated tissue was found between the metallic surface and surrounding bone [19]. This granulated tissue at the interface bone/implant has the disadvantage that it is not supplied with blood. Therefore, a systematic treatment of the host tissue against inflammatory reactions in the vicinity of the implant by means of injections is not successful because the antidote cannot be transported directly

to the inflamed area. In addition, the granulated connective tissue is not able to transfer or sustain forces, so that a loosening of the implant will take place. Growth of the bone in close contact with the metal has already been reported in many other investigations [20-25] in which the contact area tissue/implant has been studied in detail. Dental implants made from different materials inserted into the jaws of dogs varied in their behaviour. With titanium implants the bone grew in close contact to the metal surface. In contrast, when stainless steel was used as the implant material, a fibrous encapsulation which separated the implant from the surrounding tissue was formed. In titanium implants instead of this fibrous encapsulation an intercellular substance appeared. A similar unfavourable behaviour was found in the case of dental implants of a CoCr alloy in dogs. Histological findings showed that 28 days after the implantation newly formed bone fibrils grew into the surface of the metal. However, already after 56 days the hole of the implant was enlarged due to a decrease in the newly formed bone caused by resorption. After 112 days a vitallium implant was lost, whereas a CoCr implant which had been plasma coated with titanium again had close contact to the bone [26]. The surface roughness of metallic implants plays an important role. This influence was investigated using cylinders of titanium and titanium alloys which were implanted on the legs of rabbits. A measurable adhesion of the titanium alloys could be observed only on implants with a surface roughness of >22 |xm. With increasing roughness the adhesion strength is improved. The exposure time after the implantation also has an influence. With implants of Ti6A14V the tensile strength required to tear the cylinders off the bone was more than doubled if the time was increased from 84 to 168 days. After the short exposure time of 84 days an implant of Ti5A12.5Fe already had an adhesion to the bone similar to that of an implant made of bioglass. In contrast to the titanium alloys, the adhesion of the bioglass was not dependent on the surface roughness [27]. These results show that the growth of the bone and the tissue in close contact to Ti and its alloys with formation of a strong bond must have a more biomechanical than chemical-bioactive character. Consequently, it was shown that by an increase of the surface area, e.g. by drilling holes in the contact area of the implanted cylinders to the bone, the tear-off force necessary was increased. However, if the supplementary surface was taken into consideration, the adhesion strength was not increased. A Ti5A12.5Fe implant coated with hydroxylapatite had a maximum adhesion strength of 1.97 N/mm2 [27] already after 84 days. The improved fixation of the bone at a structural implant surface leads consequently to a porous implant and implant surface respectively, which

allows an ingrowth of the bone. In addition to an improved fixation, the porous implant has two other advantages: its Young's modulus is decreased, which provides better transmission of the functional load and stimulation of new bone formation. In addition, the damping capacity of the implant is increased, and the shear stress generated by the functional loading is decreased because, similar to the thread of a screw, the load at this interface causes a normal stress perpendicular to the inclined area and a lower shear stress which is effective in the inclined area.

REFERENCES 1. Zitter, H. and Plenk, H. (1987) The Electrochemical Behaviour of Metallic Implant Materials as an Indicator of their Biocompatibility. /. of Biomedical Materials Research, 21, 881. 2. Fraker, A.C., Ruff, A.W., Sung, P. von Orden, A.C. and Speck, K.M. (1983) Surface Preparation and Corrosion Behaviour of Titanium Alloys for Surgical Implants, in Titanium Alloys in Surgical Implants, (eds H.A. Cuckey and F. Kubli), ASTM STP 796, pp. 206-219. 3. Mears, D.C. (1975) The Use of Dissimilar Metals Surgery. /. Biomed. Mat Res., 6, 133. 4. Ratzer-Scheibe, HJ. and Buhl, H. (1984) Repassivation of Titanium and Titanium Alloys, in Proc. of the 5th World Conf on Titanium, Vol. 4, pp. 2641-2648. 5. Higham, P.A. (1986). Proc. Conf. Biomed Mat., Boston, Dec. 1985, 253. 6. Williams, J.M. and Buchanan, R.A. (1985) Ion Implantation of Surgical Ti6A1-4V. Mater. ScL Eng., 69, 237-246. 7. Zwicker, U., Etzold, U. and Moser, Th. (1984) Abrasive Properties of Oxide Layers on TiA15Fe2.5 in Contract with High Density Polyethylene, in Proc. of the 5th World Conf. on Titanium, Vol. 2, pp. 1343-1350. 8. Ferguson, A.B., Akahashi, Y., Laing, P.G. and Hodge, E.S. (1962) /. Bone and Joint Surg., 44, 323. 9. Hildebrand, H.F., Mercier, J.V., Decaeslecker, A.M., Ostapzuk, P., Stoeppler, U., Roumazeille, B. and Decloulx, J., Biomaterials. 10. Frazier, M.E. and Andrews, T.K. (1979), in Trace Metals in Health and Disease (ed. N. Karash), Raven Press, NY, 71. 11. Zwicker, U., Biihler, U., Muller, R., Beck, H., Schmid, HJ. and Ferstl, J. (1980) Mechanical Properties and Tissue Reactions of a Titanium Alloy for Implant Material, in Proc. of the 4th World Conf. on Titanium, Vol. 1, pp. 505-514. 12. Semlitsch, M. Staub, T. and Weber, H. (1985) Titanium-Alummium-Niobium Alloy, Development for Biocompatible, High Strength Surgical Implants. Biomed. Tech. 30 (12), 334-339. 13. Steinemann, S.G. and Perren, S.M. (1984) Titanium Alloys as Metallic Biomaterials, in Proc. of the 5th World Conf on Titanium, VoI 2, pp. 1327-1334.

14. Zitter, K., Plenk, H. and Strassl, H. (1980) Tissue and cell reactions in vivo and in vitro to different metals for dental implant, in Dental Implants, (ed. G. Heimke), C. Hanser, Munchen, p. 15. 15. Bingmann, D. and Tetsch, P. (1986) Untersuchungen zur Biokompatibilitat von Implantatmaterialien. Dt. Zeitschr. f. Zahnarztl. Implantol, Bd. II, 190. 16. Kubashewski, O., Evans, E.C1. and Alcock, CB. (1967) Metallurgical Thermochemistry, Pergamon Press, London. 17. Zitter, H. (1976) Schadigung des Gewebes durch metallische Implantate. Unfallheilkunde, 79, 91. 18. Tengvall, P., Lundstrom, J., Sjoquist, L., Elwing, H. and Bjursten, L.M. (1989) Titanium-Hydrogen Peroxide Interactions. Model Studies of the Influence of the Inflammatory Response on Titanium Implants. Biomaterials 10 (3) 166-175. 19. Breme, J. Steinhauser, E. and Paulus, G. (1988) Commercially Pure Titanium Steinhauser Plate-Screw System for Maxillo facial Surgery. Biomaterials, 9, 310-313. 20. Krekeler, G. and Schilli, W. (1984) Das ITI-Implantat Typ H: Technische Entwicklung, Tierexperiment und klinische Erfahrung. Chirurgische Zahnheilkunde, 12, 2253-2263. 21. Kirsch, A. (1980) Titan-spritzbeschichtetes Zahnwurzel-implantat unter physiologischer Belastung beim Menschen. Dt. Zahnarztl. Z., 35, 112-114. 22. Schroder, A., van der Zypen, E. and Sutter, F. (1981) The Reaction of Bone, Connective Tissue and Epithelium to Endosteal Implants with TitaniumSprayed Surface. /. Max. Fac. Surg., 9, 15. 23. Branemark, P.I., Adell, R., Albrektsson, T., Lekholm, U. Lundkvist, S. and Rockier, B. (1983) Osseointegrated Titanium Fixtures in the Treatment of Edentulousness. Biomaterials, 4, 25. 24. Schroder, A., Stich, H., Strautmann, F. and Sutter, F. (1978) iiber die Anlagerung von Osteozement an einem belasteten Implantatkorper. Schw. Mschr. /. Zahnheilkunde, 4, 1051-1058. 25. Kydd, W.L. and Daly, CH. (1976) Bone-Titanium Implant Response to Mechanical Stress. /. Prosthet. Dent., 35, 567-571. 26. Strassl, H. (1978) Experimentelle Studie iiber das Verhalten von titanbeschichteten Werkstoffen hinsichtlich der Gewebekompatibilitat im Vergleich zu anderen Metallimplanteten. Teil 1, Osterr. Z. StomatoL, 75 (4), 134-146. 27. Schmitz, H.J., Gross, V., Kinne, R., Fuhrmann, G. and Strunz, V., Der Einflup unterschiedlicher Oberflachenstrukturierung plastischer Implantate auf das histologische Zugfestigkeitsverhalten des Interface, 7. DVM-Vortragsreihe Implantate.

Stainless Steels

Ia

1A.1 COMPOSITION Table la.l Comparison of international standard stainless steels for various medical applications
Chemical composition X20Crl3 (cast) X20Crl3 X15Crl3 X46Crl3 X20Cr172 X12CrMoS17 X5CrNil810 X10CrNiS189 X2CrNil911 X2CrNil89 (cast) X12CrNil77 X5CrNiMol7122 X5CrNiMol7133 X2CrNiMol7132 X2CrNiMol7130 X2CrNiMol810 (cast)i X2CrNiMoN17122 X2CrNiMoN17133 Germany1^ Alloy No. 1.4021 1.4021 1.4024 1.4034 1.4057 1.4104 1.4301 1.4305 1.4306 1.4310 1.4401 1.4436 1.4404 1.4406 1.4429 1.4438 1.4449 1.4541 1.4550 1.4580 Great Britain2) B.S.I. No. 410C21 420S27 420S29 (420S45) 431S29 304S15 304S16 303S21 304S12 304S11 301S21 316S16 315S11 316S12 316S61 316S62 304C12 317S12 317S16 321S12 321S31 France3* AFNOR No. Z12Crl3 Z20C13 Z38C13M Z15CN16.02 Z10CF17 Z6CN18-09 Z10CNF18.9 Z2CNF18.9 Z2CN19 Z12CN17.07 Z6CND17.il Z6CND17.12 Z2CND18.13 Z2CND17.12 Z2CND17.12/ \z Z2CND17.13^^z Z12CN18.07 Z2CN18.9 Z2CND19.15 Z6CNT18.10 United States4> AISI/SAE No. 410CA-15 420 431 430F/J405-89 304 304H 303 304L/ J405-89 301 316 316L Japan5) JIS No. SUS410 SUS4020J1 SUS431 SUS430F SUS304 SUS303 SUS19 SUS304L SUS301 SUS316 SUS316L

316LN

SUS316L

X2CrNiMol8164 X5CrNiMol713 X6CrNiTil810 X10CrNiNbl89 X10CrNiMoNbl810 X2CrNiN1810

317L 317 321

SUS17L SUS317 SUS321

Z10CNNbl8-l L O 347 Z8CNDNbl8--12 318 XM-21

X = sum of alloying elements >5 wt %. Figure after X = carbon content multiplied by 100. L = low carbon content. N = contains nitrogen, ^standardized in DIN 17440 - 17443, DIN 174400 will be replaced by DIN EN 10088. ^standardized in BS 970/1 and BS7253-1, BS7252-9: ISO 5832-1. ^standardized in NFA 35-574, replaced by NF EN 10088-3. 4 )also standardized in ASTM A276. ^standardized in JIS Cr 4303.

Table la.2

Chemical composition (wt%) and application of steels for medical instruments (Ref. 2, 3, 4) Martensitic and austenitic free cutting steels C Si <1.0 <1.0 Mn <1.5 <2.0 P <0.045 <0.045 S 0.15-0.25 0.1-0.2 V Cr Mo Ni Application handles, screws, nuts handles, screws bolts, probes

X12CrMoS17 X12CrNiS188

0.1-0.17 <0.15

15.5 -17.5 0.1-0.3 9-11.5 8-10

Austenitic steels X5CrNil810 X12CrNil77 X5CrNiMol7122 <0.07 <0.15(AISI) <0.12 <0.07 <1.0 <2.0 <1.0 <2.0 <0.045 <2.0 <0.045 <0.03 <0.045 <0.03 <0.03 16-18 16.5-18.5 2-2.5 17-20 9-11.5 7-9 10.5-13.5 pincettes, scissors, forceps handles, drills pincettes, scissors, drills

Table la.3 Chemical composition (wt%) and application of steels for medical instruments (Ref. 3, 4, 5)
C
Si Mn

Martensitic steels S V <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03

Cr

Mo

Ni

Application Pincettes, forceps probes, suture hooks As above, curettes, drills Scissors, forceps, scalpels, drills

XlOCrD X15Crl3 20Crl3 X40Crl3 X20CrNil72 X65CrMol7 X38CrMoV15 X45CrMoV15

<0.15 0.12-0.17 0.17-0.22 0.4-0.5

<1.0 <1.0 <1.0 <1.0

<1.0 <1.0 <1.0 <1.0 <1.0 <1.0 0.2-0.4 0.2-0.4 <1.0 <1.0

<0.04 <0.045 <0.045 <0.045 <0.04 <0.04 <0.045 <0.045 <0.045 <0.045

11.5-13.0 12-14 12-14 12-14 15.5-17.5 0.1-1.15 0.1-0.15

<1.0 <0.20 0.60-0.75 <1.0 0.35-0.4 0.3-0.5 0.4-0.5 0.3-0.5 <1.0 <1.0

X20CrMol3 (cast) 0.18-0.15 X35CrMol7 (cast) 0.33-0.43

- 1.25-2.5 16.0-18.0 0.75 14-15 0.4-0.6 Scissors, forceps, scalpels, curettes 14-15 0.4-0.6 Scissors, forceps, scalpels, curettes 12-14 0.9-1.3 <1.0 Curettes, Sharp spoons 15.5-17.5 1-1.3 <1.0 Curettes, Sharp spoons

Table la.4 Alloy

Chemical composition (wt%) of austenitic stainless steels (Ref. 5) C <0.15 <0.08 <0.03 <0.25 <0.25 <0.08 <0.03 <0.08 <0.03 <0.08 Si <1.0 <1.0 <1.0 <1.5 1.5-3.0 <1.0 <1.0 <1.0 <1.0 <1.0 Mn <2.0 <2.0 <2.0 <2.0 <2.0 <2.0 <2.0 <2.0 <2.0 <2.0 P <0.045 <0.045 <0.045 <0.045 <0.045 <0.045 <0.045 <0.045 <0.045 <0.045 S <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 <0.03 Cr 16.0-18.0 18.0-20.0 18.0-20.0 24.0-26.0 23.0-26.0 16.0-18.0 16.0-18.0 18.0-20.0 18.0-20.0 17.0-19.0 Mo Ni 6.0-8.0 8.0-10.5 8.0-12.0 19.0-22.0 19.0-20.0 10.0-14.0 10.0-14.0 11.0-15.0 11.0-15.0 9.0-12.0 Others

X12CrNil77 X5CrNil810 X2CrNil911 X25CrNi2522 X25CrNi2520 X5CrNiMol7133 X2CrNiMol7133 X5CrNiMol8164 X2CrNiMol8164 X6CrNiTil810

2.0-3.0 2.0-3.0 3.0-4.0 3.0-4.0

Ti >5 x wt% C

Table la.5 Chemical composition of steels for implant surgery (wt%) (Ref. 6) Alloy
X2CrNiMoN18133 X2CrNiMol8153 X2CrNiMoN18154 X2CrNiMnMoN22136 C <0.03 <0.03 <0.03 <0.03 Si <1.0 <1.0 <1.0 <0.75 Mn <2.0 <2.0 <2.0 5.5-7.5 P <0.025 <0.025 <0.015 <0.025 S <0.01 <0.01 <0.01 <0.01 N 0.14-0.22 0.01 0.1-0.2 0.35-0.5 Cr 17-18.5 17-18.5 17-18.5 21-23 Mo 2.7-3.2 2.7-3.2 2.7-3.2 2.7-3.7 Ni 13-14.5 13.5-15.5 14-16 10-16 Nb

0.1-0.25

The minimum content of Cr and Mo amounts to > 26 according to the sum of efficacy which is given by 3.3 x % Mo + % Cr.

1A.2 PHYSICAL PROPERTIES Table la.6 Physical properties of selected steels for medical instruments (Ref. 2)
Thermal Expansion Coefficient Thermal between 70 Conductivity 0 at 200C Magnetic and 300 C 6 1 (W/mK) Properties (XlO- K ) Specific Specific Electrical Heat Capacity Resistivity at 200C at 200C (H(Im) (J/kgK)

Alloy

Young's modulus Density 3 (GPa) (g/cm )

XlOCrB MagnetX15Crl3 X20Crl3 izable X40Crl3 X45CrMc)V15

9.9 11.5 11.5 11.5 11.0

24.9 30
460

0.57 0.60 0.60 0.60 0.65

200 200

7.8 7.8

Table la.7 Physical properties of austenitic stainless steels for medical instruments (Ref. 7)
Thermal Specific Specific Expansion Electrical Heat Coefficient Thermal between 70 Conductivity Capacity Resistivity Young's 0 0 at 200C modulus Density at 200C Magnetic and 300 C at 20 C 6 1 (J/kgK) (Omm Vm) (GPa) (g/cm3) (W/mK) Properties (XlO- K )

Alloy

X12Cr177 X5CrNil810 X2CrNil810 X25CrNi2520 X5CrNiMol7133 X2CrNiMol7133 X2CrNiMoN17133 X2CrNiMol8164 X5CrNiMol8164 X6CrNiTil810 Paramagnetic

17. 17.8 15.1 15.9 15.9 16.6

16.2 16.2 17.5 16.2 16.2 16.1

500 500 500 500 500 500

0.72 0.72193 0.77 0.74 0.74 0.72

193 8.0 200 193 193 193

8.0

7.8 8.0 8.0 8.0

Table la.8 Physical properties of various stainless steels (Ref. 2)

Thermal Expansion Coefficient Thermal between 70 Conductivity 0 at 200C Magnetic and 300 C 6 1 (W/mK) Properties (XlO- K ) Specific Specific Heat Electrical Capacity Resistivity Young's at 200C at 200C modulus Density (J/kgK) (Omm 2Zm) (GPa) (g/cm3)

Alloy

X12CrMoS17 FerroX20CrNil72 magnetic

11.0 12.1

26.1 20.2

460 460

0.60 0.72

200 200

7.8 7.8

1A.3 PROCESSING OF STAINLESS STEELS (REF. 8, 9,10,11,12) la.3.1 Hot Working and Heat Treatment Stainless steels are more difficult to forge than carbon or low-alloy steels because of their higher yield stress strength at elevated temperatures and the limitation of the maximum temperature at which they can be forged without microstructural damage due to the precipitation of 8-ferrite. Most austenitic stainless steels can be forged above 9300C. Above 11000C some steels precipitate the 8-ferrite phase which decreases the forgeability. Typical forging temperatures are between 925 and 11000C. If the precipitation of 8-ferrite does not appear, the deformation temperature can be increased to 12600C. Nitrogen-alloyed austenitic stainless steels have a higher strength and a higher corrosion resistance than austenitic stainless steels due to the stabilization of the austenite by nitrogen. For this reason higher chromium and molybdenum contents can be used to improve the corrosion resistance. In the forging of martensitic stainless steels, especially those with high carbon contents, precautions must be taken to avoid cracking during cooling caused by the martensitic transformation. These steels are cooled more slowly than austenitic steels to a temperature of about 5900C. Forging is recommended in the temperature range of 900-12000C. la.3.2 Working of Sheet Alloys with low carbon contents (ferritic or austenitic stainless steels) are suitable for cold deformation such as bending, folding or deep-drawing. In general, austenitic stainless steels show better cold work properties than ferritic stainless steels. In the deformation of ferritic stainless steels a temperature of 100-3000C should be used to achieve a better workability. If higher deformation rates are required, an intermediate annealing at 750-8000C should be performed. Deformation of austenitic stainless steels results in a much higher work hardening than in ferritic stainless steels. Therefore, higher deformation forces, harder and more wear-resistant tools are required. In drawing, excessively high speeds must be avoided. Best results are obtained with a speed of 6-8 m/min. In deep drawing a high holding-down force prevents the formation of folds, but results in a higher danger of cracks due to the higher stresses. Deformation should be carried out in one step because of the high rate of work hardening. Oil with graphite or MoS2 is used as a lubricant. Before the subsequent heat treatment the lubricant must be removed carefully in order to avoid a reaction with the steel.

la.3.3 Descaling Descaling of hot worked stainless steels can be accomplished by mechanical or by chemical cleaning, or by a combination of both methods. The surface can be cleaned by sand blasting, but unless it is machined after blasting, only nonmetallic blast material should be used in order to avoid contamination and a reduction of the corrosion resistance. Following blast cleaning stainless steels are usually acid pickled and washed with water. Common etching acids are: (a) 1.5-2.0% NaOH (b) 10% H2SO4 (c) 10% HNO3 / 2% HF
la.3.4 Machining of Stainless Steels

Stainless steels are generally more difficult to machine than low-carbon steels due to their high work hardenability. The non-free machining steels have a tendency to develop long, stringy chips, which reduce the life of the tool. The cutting speed is lower and a higher power is necessary than with low-carbon steels. Because of the low thermal conductivity good lubrication and cooling are important requirements. The machinability of martensitic stainless steels decreases with in creasing carbon content because of the higher amount of chromium carbides. Austenitic stainless steels have a high work-hardenability which causes a cold deformation of the surface during machining, which decreases the machinability. By additions of manganese and copper the work hardenability is reduced and machinability improved. Strength and hardness are increased by carbon and nitrogen, which however causes a poorer machinability. Machining parameters of stainless steels are given in Table la.9. The turning of stainless steels requires tools with top rake angles on the high side of the 5-10 range in order to control the formation of chips. Carbide-tipped tools can be used and allow higher speeds than high-speed tools. An interruption of the cuts should be avoided. Blade-type and circular cutoff tools can also be employed. The drilling of stainless steels should be carried out with a sharp threecornered punch in order to avoid work hardening. Thread rolling is possible with automatic screw machines of sufficient power and rigidity. Milling can be accomplished with high-speed cutters and tools with carbide inserts, particularly in the case of alloys which are difficult to machine. The best surface quality is obtained by using helical or spiral cutters at high speeds.

Table la.9 Nominal machining parameters for stainless steels (Ref. 10) Alloy Martensitic Austenitic Martensitic Austenitic Martensitic Austenitic Martensitic Type of Machining Turning Turning Drilling Tapping Milling Tool Material HSS carbide HSS carbide Ml, M7, MlO Ml, M7, MlO M2, M7 C6 Austenitic M2, M7 C6 Martensitic Power Austenitic hardening Depending on hole diameter Depth of Cut Speed (m/min) (mm) 0.75-3.8 0.75-3.8 0.75-3.8 0.75-3.8 20-38 80-180 23-30 100-160 12-18 12-18 3-12 4-8 27-34 82-107 23-24 79-82 50-90 strokes/min Feed (mm/rev) 0.18-0.38 0.18-0.38 0.18-0.38 0.18-0.38 0.025-0.46* 0.025-0.46* 0.025-0.15 mm/tooth 0.025-0.15 mm/tooth 0.05-0.15 mm/tooth 0.025-0.15 mm/tooth 0.1 mm/stroke

Band sawing and power hacksawing are possible with high-speed steel blades. The grinding of stainless steels can be performed with alumina and silicon carbide wheels, but the latter will have a reduced wheel life.
la.3.5 Brazing

The chromium oxide film on the surfaces prevents wetting of the base metal by the molten filler and must therefore be removed by a suitable flux. Stainless steels can easily be joined together with other metallic materials or stainless steels of other composition. All conventional brazing processes, such as furnace, torch, induction and resistance brazing, can be employed. The most commonly used process is furnace brazing. The filler metals used in brazing stainless steels can be alloys of silver, nickel, copper and gold, with the silver alloys being those most frequently employed. The chemical composition and the properties of the standard brazing filler metals used for joining stainless steels are listed in Table la.10. Furnace brazing in a reducing or inert atmosphere (argon, vacuum) requires no fluxes, but for torch brazing (reducing flame) they are always necessary. The commercially available fluxes contain boric acid, borates, fluorides, fluoborates and a wetting agent. They are available as powders, pastes and liquids.

Table la.10 Chemical composition and brazing temperature range of filler metals for brazing stainless steels (Ref. 13, 14) CChemical Composition (wt%) Filler Metal AgCu Ag55Sn Ag56InNi AgCuZn AgCuZnCD AgCuZnMn
Ag Cu

Zn balance 14-40 13-25 21-37

Cd

Ni

Sn 2-5 3.5-4.5 <3.5

Li

Mn

In

Brazing Temperature Range (0C) 765-980 650 730 650-870 620-840 700-870

53-93 54-57 55-57 20-70 30-50 20-50

balance 20-23 balance 20-40 14-35 15-40

<0.5 13-15 <5.5 1.5-8

12-25 <2.5

la.3.6 Welding Stainless steels can be welded by fusion (e.g. arc welding) or pressure welding (e.g. resistance welding) techniques. Steels which do not contain more than 0.03% sulphur, phosphorous or and selenium can be fusion welded by most welding techniques, such as shielded metal arc welding, submerged arc welding, inert gas metal welding, gas tungsten inert gas welding, plasma arc welding and flux cored arc welding. Because of their low thermal conductivity and higher electrical resistance stainless steels require 20-30% less heat input than carbon steels during resistance welding. The resulting slow cooling rate may lead to a lower corrosion resistance because of the precipitation of chromium carbides. Free-machining stainless steels are unweldable because of their high sulphur content. To avoid contamination, especially by carbon, the stainless steel parts should be cleaned to remove organic substances. Extra low carbon stainless steels, such as X2CrNiMol7133 do not tend to precipitate carbide and can therefore be welded without the danger of a diminished corrosion resistance. Table la.ll lists electrodes and welding rods suitable as filler metals for the arc welding of stainless steels.

Table la.ll Filler metals for arc welding of stainless steels (Ref. 11, 15) Steel X12CrNil77 X5CrNil810 X2Cr1911 X25CrNi2520 X5CrNiMol7133* X2CrNiMol7133* X5CrNiMol8164* X2CrNiMol8164* X6CrNiTil810 X20Crl3** X20Cr1810*** Condition of Weld for Service As welded or annealed As welded or stress relieved As welded As welded or annealed As welded or stress relieved As welded or annealed As welded or stress relieved As welded or stabilized and stress relieved Annealed or hardened and stress relieved As welded Electrode or Welding Rod X8CrNi2011 X8CrNil811 X25CrNi2520 X5CrNiMol7133 X2CrNiMol7133 X5CrNiMol8164 X2CrNiMol8164 X8Cr1811 X20Crl3 X25CrNi2520 X8CrNi2011

* Welds may have poor corrosion resistance in as welded condition. Restoration by subsequent heat treatment possible: 0 X5CrNiMol7133, X5CrNiMol8164: full annealing at 1065-1120 C; 0 X2CrNiMol7133, X2CrNiMol8164: stress relieving at 870 C. ** Careful preheating and postweld heat treatment are required to avoid cracking. *** Careful preheating required.

Preheating of austenitic stainless steels usually has no beneficial effect on the welding results. Thermal stress relief can be carried out in wide temperature and time ranges, depending on the amount of relaxation required. Table la.12 gives two examples of the temperature and time required to achieve different stress relief. In general, ferritic stainless steeels are less weldable than austenitic steels because of a grain coarsening during the welding operation and the risk of the formation of both austenite and martensite during cooling. This may reduce the toughness and ductility of the steel. Martensite can be eliminated by annealing, but this is not the case with coarsened ferrite. Martensitic stainless steels are very difficult to weld because, during the welding operation, they become harder and less ductile, whereby cracking may occur. Whether preheating and postweld annealing are necessary in the case of the martensitic stainless steels depends on the carbon content. Table la.13 shows the recommended preheating temperatures, depending on the carbon content for martensitic stainless steels. As compared to carbon steels, a resistance welding of austenitic stainless steels is possible with shorter welding times and lower welding currents than in the case of carbon steels because of their higher electrical resistivity. By comparison, the welding pressure must be higher for stainless steels. Martensitic and ferritic stainless steels can also be resistance welded, but the welded seam shows a brittle behaviour in the as-welded condition. Therefore a postweld thermal treatment is required.
Table la.12 Examples of the temperature and time required to achieve various degrees of stress relief in austenitic steels (Ref. 11) Temperature (0C) 840-900 540-650 Time (min/cm section thickness) 25 95 Stress Relief (%) 85 35

Table la.13 Dependence of the preheating temperature on the carbon content for martensitic stainless steels (Ref. 11) Carbon Content (wt%) 0<0.1* 0.1-0.2 0.2-0.5 Preheating Treatment No preheating or postweld treatment Preheating to 2600C, welding at 2600C, slow cooling Preheating to 2600C, welding at 2600C, annealing

* Not a standard carbon content.

la.3.7 Heat Treatment Table Ia. 14 summarizes the various recommended heat treatments for martensitic, precipitation hardened, austenitic and ferritic austenitic steels. Table la.14 Recommended heat treatments for various stainless steels (Ref. 1, 2, 8, 16) Hot Soft Deformation Annealing Hardening Hardening Annealing (0C) (0C) (0C) Medium (0C) 750-1150 750-1100 800-1150 800-1150 800-1150 800-1150 800-1150 750-780 800-850 950-1000 102O-1050 1050-1100 1000-1100 1000-1050 1000-1050 1020-1070 Oil Oil Water, air Water, air Water, air Water, air Water, air 650-700 550-600

Alloy X20C13 X12CrMoS17 X5CrNiMol7133 X2CrNiMol7133 X5CrNil810 X2CrNil810 X6CrNiTil810

1A.4 MECHANICAL PROPERTIES Table la.15 Mechanical properties of steels for medical instruments (Ref. 2, 3)
Young's Modulus *1<P (MPa) Tensile Yeild Strength * (0.2 %) (MPa) Ultimate Tensile Strength (MPa) Ratio Elongation Reduction Yield of at /Tensile Fracture* Area Strength (%) (%)

Steel

Condition

Martensitic steels <720 As forged 216 <740 + AnnealedI 216 <900 220 <800 As cast <950 + Annealed[ Martensitic and austenitic free cutting steels As forged 216 X12CrMoS17 540-740 16 + Annealed[ 195 35 As forged 200 500-700 X12CrNiS188 + QuenchecI Austenitic steels As forged* 200 220-235 550-750 0.3-0.4 43-45 X5CrNil810 + Quenchec1 240-255 550-700 0.36-0.44 43-45 X5CrNiMol7122 As forged* 200 + Quencheci Wire, cold 1851250X12CrNil77 deformed 195 2450** X15Crl3 X20Crl3 X45CrMoV15 X20CrMol3 X35CrMol7 * Longitudinal/transversal. ** Depends on the degree of cold deformation.

>40

Table la.16 Mechanical properties of austenitic stainless steels (minimum values at room temperature) (Ref. 5, 9, 17) Tensile Ultimate Ratio Elonga- ReducYield/ tion at tion of Tensile Yield Strength Strength Tensile Fracture Area (MPa) Strength (%) (MPa) (%) 205 965 205 310 170 310 205 310 205 310 170 310 205 310 240 515 1280 515 620 480 620* 215 620 515 620 515 620 515 620 585 0.40 0.75 0.40 0.50 0.35 0.50 0.95 0.50 0.40 0.50 0.33 0.50 0.40 0.50 0.41 40 9 40 30 40 30 40 30 40 30 40 30 40 30 55 50 40 50 40 50 40 50 40 50 40 50 40 65

Alloy (bar) X12CrNil77 X5CrNil810

Condition Annealed Full hard Hot finished + annealed Cold finished Hot finished + annealed Cold finished + annealed Hot finished + annealed Cold finished + annealed Hot finished + annealed Cold finished + annealed Hot finished + annealed Cold finished + annealed Hot finished + annealed Cold finished + annealed Annealed

X2CrNil911

X25CrNi2520

X5CrNiMol7133

X2CrNiMol7133

X5CrNiMol713

X2CrNiMol8164 * Typical values.

Table la.17 Mechanical properties of martensitic stainless steels (minimum values at room temperature) (Ref. 2, 5) Tensile Yield Strength (MPa) 275 275 Ultimate Ratio Elonga- ReducTensile Yield/ tion at tion of Strength Tensile Fracture Area (MPa) Strength (%) (%) 485 0.57 485 1720 1370 965 725 1790 0.86 0.78 0.82 0.57 0.92 16 8 16 19 20 5 20 45 25 55 57 20 45

Alloy (bar) X10Crl3

Condition Hot finished + annealed Cold finished + annealed

X20Crl3 X20CrNil72

Hardened + 1480 tempered 2040C Hardened + 1070 tempered 2600C Hardened + 795 tempered 593C 415 Hardened + annealed Hardened + 1650 tempered 316C

X65CrMol7

Table la.18

Mechanical properties of steels for implant surgery (ReIF. 6) Tensile Yield Ultimate Ratio Yield/ Elongation Tensile at Strength* Tensile Strength Fracture* (0.2%) Strength Condition (MPa) (MPa) (%) Solution Treated 300 190 285 500 600-800 490-690 590-800 850-1050 0.38-0.5 0.28-0.39 0.36-0.48 0.48-0.59 40 40 40 35

Alloy X2CrNiMoN18133 X2CrNiMol8153 X2CrNiMoN18154 X2CrNiMnMoN22136

* Minimum values. Special requirements: 1. Allowed melting procedures: vacuum arc furnace or electroslag remelting. 2. After the solution heat treatment the material has to be free of delta-ferrite. 3. Grain size of at least ASTM4. 4. Resistance to intercrystalline corrosion determined according to Table la.5. 5. Microscopic purity concerning inclusions of oxides and sulfides determined according to Table la.5.

Table la.19 Mechanical properties of wire for implant surgery (Ref. 6) Alloy X2CrNiMoN18133 X2CrNiMoN18154 X2CrNiMoN18133 X2CrNiMoN18154 Condition Solution treated Cold worked Ultimate Tensile Strength (MPa) 800-1000 800-1000 1350-1850 1350-1850 Elongation at Fracture* (%) 30 40

^Minimum values. The values depend on the diameter of the wire (solution heat treated) and on the degree of deformation (decrease of diameter and increase of degree of deformation = increase of value).

Table la.20 Mechanical properties of X2CrNiMol7133 stainless steel as a function of cold working (Ref. 18) Degree of Cold Working (%) 0 31 50 63 70 76 Tensile Yield Strength (MPa) 255 831 1036 1169 1204 1252 Ultimate Tensile Strength (MPa) 584 912 1138 1255 1344 1421

Table la.21 Influence of heat treatment on the mechanical properties of steels for medical instruments (Ref. 2)
Tensile Ultimate Yield Tensile Strength* Strength (0.2%) (MPa) (MPa) Ratio Elonga- ReducYield/ tion at tion of Tensile Fracture* Area Strength (%) (%)

Condition

X15Crl3 X20Crl3 X12CrMo5

Martensitic steels Quenched 450 650-800 0.56-0.69 10-15 + tempered 550 750-950 0.58-0.73 8-14 Martensitic and austenitic free cutting steels Quenched 450 640-840 0.54-0.70 + tempered

25-30 20-30
11

* Minimum values. The values of the elongation at fracture and of the impact strength depend on the direction of sampling (longitudinal = higher values; transversal = lower values) and on the thickness of the sheet or rod (increase of thickness = decrease of value).

Table la.22 Influence of a cold deformation on the mechanical properties of steels for implant surgery (standard qualities, other qualities - for all steels - as agreed upon) (Ref. 6)
Tensile Yield Ultimate Ratio Yield/ Elongation Tensile Tensile Strength* at Strength Strength (0.2%) Fracture* (MPa) (MPa) (%)

Alloy

Condition

X2CrNiMoN22136 As cold worked, X2CrNiMol8154 dia.<19 mm

* Minimum values.

690 650

860-1100 0.63-0.8 860-1100 0.63-0.8

12 12

Table la.23 Influence of heat treatment on the hardness of various stainless steels (Ref. 1) Alloy X20Crl3 X12CrMoS17 Heat Treatment Hardened and annealed I Hardened and annealed II Soft annealed (800-8500C) Soft annealed + drawn Hardened + annealed (1020-1050C/oil/550-600 C/air) 1050-1100C/water quenched 1000-1050C/water quenched 1020-1070C/water quenched VHN 190-235 230-275 160-210 160-210 190-235 130-180 130-180 130-190

X5CrNiMol7133 X2CrNiMol7133 X5CrNil810 X2CrNil810 X6CrNiTil810

1A.5 FATIGUE
Table la.24 Fatigue limit (2xlO6 cycles) X2CrNiMol7133 stainless steel (Ref. 18) Tensile Strength (MPa) 658 1211 1211 Degree of Cold Work (%) 7 57 57 by the staircase method* of

Stress Ratio, R 0 0 -1

Fatigue Limit (MPa) 283 362 505

^Explanation: (1) Starting with a stress S0. (2) if specimen fails before 2xlO+6 cycles > new specimen with a stress S -AS0 if specimen does not fail before 2xlO+6 cycles > new specimen with a stress S0+AS. (3) Do (2) for 15-20 samples and evaluate with standard statistical methods.

Table la.25 High cycle fatigue strength of hip endoprostheses of stainless steel, measured in 0.9% NaCl solution at 37C. Testing conditions according to DIN 58840 (simulation of a loosened shaft) (Ref. 19) Alloy hot wrought X2CrNiMol7133 hot wrought X3CrNiMoNbN2317 Maximum load in 2x107 cycles (kN) 0.9% NaCl (f = 2 Hz) 2 5.5-7.5

Table la.26 High cycle fatigue strength crD of various stainless steels (Wohler curves) and rotating fatigue strength aR(Ref. 20, 21, 22) Alloy X2CrNiMol7133 X2CrNiMol8153 X2CrNiMnMoN22136 (jD (MPa) 250-320 Annealed Cold worked Hot forged aR (MPa) 250 250-320 350-415 500-650 # -1

Table la.27 Fatigue properties of various stainless steels (Ref. 23)

Heat treatment Testing condition Type R ak Medium Fatigue limit at NB=IO7 (MPa)

Alloy

X20Crl3 206

30 min/1020C/oil + 2 h/550C/air

RB*

-1

1 Air 1 30% NaCl 3.6 3.6

481 69 Air 30% NaCl 412 78 Air 30% NaCl 220-250 265 216

49 X20Crl3 177

30 min/1020C/oil + 2 h/625C/air

RB

-1

1 Air 1 30% NaCl 3.6 3.6

29 X5CrNil810

30 min/1050C/ water X5CrNiMol7133 15 min/1050C/ water * RB = rotating bending.

RB RB

-1 -1

1 1

Air Air 30% NaCl

1A.6 CORROSION AND WEAR

Table la.28 Sum of efficacy and breakdown potential of various stainless steels in 1 M NaCl at room temperature (Ref. 21) Alloy X5CrNil810 X5CrNiMol7133 X2CrNiMol7132 X2CrNiMoN18164 X2CrNiMoV1813 Sum of Efficacy 19 25 26.5 29.5 25 Breakdown Potential (V) 025 0.25 0.5 0.7 0.65

Table la.29 Rate of formation of corrosion products for the stainless steel X2CrNiMol7133 in Hank's solution during current-time-tests (Ref. 24) Alloy X2CrNiMol7133 Mechanically polished Chemically polished Metal Converted into Compound (ng/cm2h) 7.8 230

Table la.30 Corrosion properties of the stainless steel X2CrNiMol7133 in 0.9% NaCl. Potential referred to standard calomel electrode (SCE) (Ref. 18) Testing Method ASTM F746-81 test (mV) Scratch test (mV) Potentiodynamic test Current 10 jxA/cm2 (mV) Repassivation (mV) Critical pitting temperature test Potentiostatic 200 mV (0C) Potentiostatic 350 mV (0C) Critical crevice temperature test Potentiostatic 200 mV (0C) Potentiostatic 350 mV (0C) Result 300 25 530 20 560 25 90 25 95 5 65 5 25 5 <25

Table la.31 Polarization current (i) and polarization resistance (Rc) of the stainless steel X2CrNiMol7133 in 0.9% NaCl and in 0.9% NaCl with a stable redox system [Fe(CN)64" / Fe(CN)63] at 37C corresponding to a potential of the body fluid of 400 mV (Ref. 25, 26) Rc (kOcm2) Alloy X2CrNiMol7133 i (ixA/cm2) 0.006 0.9% NaCl 1670 0.9% NaCl + redox 438

Table la.32 Repassivation time of the stainless steel X2CrNiMol7133 in 0.9% NaCl and breakdown potential in Hank's solution (Ref. 21) Alloy X2CrNiMol7133 Breakdown Potential (mV) vs. Standard Calomel Electrode 200-300 Repassivation Time (ms) -500 mV 72 000 +500 mV
35

Table la.33 Electrochemical data for the stainless steel X5CrNil810 in 0.1 M NaCl; influence of the pH-value (Ref. 27) Alloy X5CrNil810 pH 7 pH 2 Passive Current Corrosion Potential Density Ip (\xA/cm2) Ecorr (mV) -395 -661 0.56 Breakdown Potential Eb (mV) 770 -270

Table la.34 Coefficients of friction of sliding materials (Ref. 20, 24) Material X2CrNiMol7133 vs. High density polyethelyne Cartilage vs. cartilage Lubricant Synovial fluid: in vitro in vivo in vivo Coefficient of friction

0.10 0.02 0.008

Table la.35 Influence of the N+ -implantation* on weight loss during wear testing** of the stainless steel X5CrNil810 (Ref.29) Alloy X5CrNil810 N+-implanted X5CrNil810 1000 cycles 200 320 Weight loss (^g) after 3000 cycles 5000 cycles 780 460 1000 440

* Implantation parameters: 100 keV nitrogen ions 3 x 10 1 7 -^nominal dose cm2 ** Testing conditions: dry; load: 5 N; speed 150 cycles/min; wear against high speed steel (66 HRC); wear distance: 23 mm/cycle.

1A.7 BIOLOGICAL PROPERTIES

Table la.36 Influence of heat treatment (oxidation) on shear strength between X2CrNiMol7133 screw implants and bone (rat femur after various times of insertion (Ref. 28) Time after insertion (days) 4 5 6 10 35 Shear strength (MPa) Control Heat treated* 0.01 0.04 0.28 0.58 1.58 0.001 0.01 0.06 0.09 0.18 0.03 0.21 0.68 1.23 2.61 0.01 0.07 0.07 0.19 0.21

* Heat treatment: 200 min/280C/air.

REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Product information, Rochling Werke, Germany. DIN 17440 (1985), Beuth. DIN 17441 (1985), Beuth. DIN 17442 (1977), Beuth. ASM Metals Handbook, Vol. 3: Properties and Selection: Stainless Steels, Tool Materials and Special-Purpose Metals. DIN 17443 (1986), Beuth. ASM Metals Handbook, Vol. 3: Properties and Selection: Stainless Steels, Tool Materials and Special-Purpose Materials. Heimann, W. Oppenheim, R. and Weizling, W. (1985) Nichtrostende Stahle, in Werkstoffkunde Stahl, Bd. 2: Anwendungen, Springer-Verlag. Harris, T. and Priebe E. Forging of Stainless Steels, in ASM Metals Handbook, Vol. 14: Forming and Forging. Kosa, T. and Ney, R.P. Machining of Stainless Steels, in ASM Metals Handbook, Vol. 16: Machining. Arc Welding of Stainless Steels, in ASM Metals Handbook, Vol. 6: Welding Brazing, Soldering. Resistance Welding of Stainless Steels, in ASM Metals Handbook, Vol. 6: Welding Brazing, Soldering. Brazing of Stainless Steels, in ASM Metals Handbook, Vol. 6: Welding Brazing, Soldering. DIN 8513 (1979), Beuth. DIN 8856 (1986), Beuth. Bergman, W. (1991) Werkstofftechnik, Teil 2: Anwendungen, Hanser Verlag, Miinchen. American Standard ASTM F138. Cigada, A., De Soutis, G., Gratti, A.M., Roos, A. and Zaffe, D. (1993): In vivo Behaviour of a High Performance Duplex Stainless Steel, /. of Appl Biomaterials, 4, 39-46.

19. Kunze, E. (1988) Vergleichende Untersuchungen zum Langzeit-Ermiidungsverhalten von Hiiftgelenkprothesen an Luft und in NaCl-Losung. Metall, 2, 140-145. 20. Thull, R. (1979) Eigenschaften von Metallen, fur orthopadische Implantate und deren Priifung. Orthopadie, 1, 29. 21. Breme, J. and Schmidt, H.-J. (1990) Criteria for the Bioinertness of Metals for Osseo-Integrated Implants, in Osseo-Integrated Implants, Vol. 1, (ed. G. Heimke), pp. 31-80. 22. Webster, J.G. (ed) (1988) Encyclopedia of Medical Devices and Instrumentation, Vol. 1, Wiley-Interscience Publication. 23. Schmidt, W. (1981) Werkstoffverhalten bei schwingender Beanspruchung. Thyssen Edelst. Techn. Ber., 7 (1), 55-71. 24. Mears, D.C. (1977) Metals in Medicine and Surger. International Metals Review, Review 218, June, 119-155. 25. Breme, J. (1988) Titanium and Titanium Alloys, Biomaterials of Preference, in Proc. of the 6th World Conf on Ti, Vol. 1, pp. 57-68. 26. Zitter, H. and Plenk, H. (1987) The Electrochemical Behaviour of Metallic Implant Materials as an Indicator of their Biocompatibility. /. of Biomedical Materials Research, 21, 881. 27. Geis-Gerstorfer, J., Weber, H. and Breme, J. (1988) Electroche mische Untersuchung auf die Korrosionsbestandigkeit von Implantatlegierungen. Z. / Zahnarztl Implantologie 4, (1), 31-36. 28. Hazan, R., Brener, R. and Oron, V. (1993) Bone growth to metal implants is regulated by their surface properties. Biomaterials 14 (8), 570-574. 29. Cavalleri, A. Gzuman L., Ossi, P.M. and Rossi, I. (1986) On the Wear Behaviour of Nitrogen Implanted 304 Stainless Steel, Scripta Metallurgica 20, 37-42.

CoCr-based alloys

Ib

1B.1 COMPOSITION

Table lb.l

Comparison of international standards for Co-based alloys

International Organization for StanUnited dardization States Japan ASTM ISO JIS F75 F799 F90 F562 F1058 F563 T6115 T6104

Chemical composition Co29Cr5Mo (cast) Co29Cr5Mo (wrought/PM) Co20Crl5W10Ni Co20Cr35NilOMo

Great Germany Britain DIN BSI 5832-4 13912-1 5832-12 5832-5 5832-6

France AFNOR

Co20Crl6Nil6Fe7Mo 5832-7 (wrought/cast) Co20Cr20Ni5Fe3Mo3W 5832-8

5832/IV Project 7252S 94-054 Part 4 Project 72525832/XII S 94-053 Part 12 Project 72525832/V S 90-406 Part5 7252- NFISO5832-6 5832/VI Part 6 Project 5832/VII 7252S 94-057 Part7 Project 72525832/VIII S 94-058 Part 8

Table lb.2

Chemical composition of cast Co alloys (wt%) (Ref. 1, 2, 8)

Alloy

~Cr

Wo

Ni

Te

Ji

Mn

Ti

Co

CrCo29Cr5Mo 26.5-30.0 4.5-7.0 <2.5 <1.0 <0.35 <1.0 <1.0 balance CoCrMo* 15.0-32.5 4.0-7.5 <2.0 <1.5 <0.05 <1.0 <1.0 <5 33.0-75.0 * Alloys used for dental restoration (according to standards sum of Co + Cr > 85%, Cr + Mo + Ti >25%, Be < 0.01%).

Table lb.3 Alloy

Chemical composition of wrought Co alloys (wt%) (Ref. 3, 4, 5, 6, 7, 9) Cr 19.021.0 19.021.0 18.521.5 18.022.0 Mo Ni 9.011.0 33.037.0 14.0 18.0 15.025.0 Fe <3.0 <1.0 balance 4.06.0 C <0.15 <0.15 <0.15 <0.05 <0.05 Si <1.0 <0.15 Mn <2.5 <0.15 1.0-2.5 <1.00 P <0.04 <0.015 <0.015 S <0.03 <0.010 <0.015 <0.010 3.04.0 0.5 3.5 W 14.016.0 <1.0 Ti Co Balance Balance 39.042.0 Balance

Co20Crl5W10Ni Co20Cr35Nil0Mo* Co20Crl6Nil6Fe7Mo Co20Cr20Ni5Fe3Mo3W

9.010.5 6.58.0 3.04.0

* Other elements: single <0.1, sum: <0.4. Be <0.001.

1B.2 PHYSICAL PROPERTIES

Table lb.4 Physical properties of CoCr-alloys (Ref. 1, 8, 10)
Alloy
Density (g/cm3) G-Co29Cr5Mo Co20Crl5W10Ni Co20Cr3NilOMo Melting Point (interval) Electrical Thermal Transformation Temperature Young's Conductivity Restistivity at 200C at 200C hep> fee Modulus (W/mK) (^Om) (GPa) CQ 890 650 650 210-330

CQ

8.2-8.4 1235 (eutectic) 1300-1400 8.43 1315-1427

235

1.03

1B.3 PROCESSING OF CoCr-ALLOYS (REF. 11,12,13,14) CoCr-alloys can be classified in two different groups: (a) cast CoCr-alloys (b) wrought CoCr-alloys As a result there are two different methods for producing biomedical devices. Both groups of alloys contain more than 20 wt% chromium, thus providing a good resistance due to a passive oxide layer on the surface. The cast alloys (e.g. G-Co29Cr5Mo) contain up to 0.5 wt% carbon to improve the castability by lowering the melting temperature to ~1350C compared to 1450-15000C for binary CoCr-alloys. Normally these alloys are investment cast (lost wax process). An improved casting quality can be achieved by a vacuum melting and casting process, whereby an oxidation is avoided. The lower melting temperature due to the alloying elements (e.g. carbon) results in a fine grain size and allows a decrease in the mould temperature from 10000C to 9000C. The casting temperature ranges from 1350 to 14500C depending on the alloy composition. The cast microstructure consists of a dendritic matrix with dispersed carbides (M23C6, M7C3, M6C, where M = Co, Cr or Mo) and of other intermetallic compounds. In the as cast condition the alloys have reduced strength and ductility. Therefore, a heat treatment must follow the casting procedure. A solution heat treatment is performed at 1210-12500C leading to a complete solution of the carbides in the matrix. The carbide forming elements increase the strength by a solid-solution hardening. In order to avoid an excessive grain growth, the carbides are not completely dissolved. This measure results in a planing of the grain boundaries. As an alternative to the near net shape casting the devices are sometimes produced by the powder metallurgical route. The compacting of the material is performed by HIP (-10000 MPa, 1100 C). Because of the

relatively high costs this method is used only for highly loaded implants like femoral stems of total hip prostheses. Hipping of cast CoCr-alloys is recommended for a decrease of defects like gas or shrinkage pores, whereby an improvement of the mechanical properties is achieved. Wrought CoCr-alloys have a lower Cr content (19-21 wt%) than cast alloys. Cr is substituted by Mo or W. In order to stabilize the fee phase a certain content of Ni, Fe or Mn is necessary. Because of the high strength of the alloys at elevated temperatures higher forces must be applied for forging these alloys. For a plastic deformation the alloys must be annealed in order to produce the fee structure which can be retained to room temperature. The hep transformation, which causes an improvement of the mechanical properties, is induced by the mechanical deformation. After hot working the microstructure consists of a fee matrix with fine hep platelets. A hardening process may be achieved by cold working followed by aging between 500 and 6000C for 1-4 h, resulting in precipitation of Co3Mo, which increases the hardness. Table lb.10 shows the influence of hot working and heat treatment. Table Ib. 11 summarizes the influence of cold working on the mechanical properties of the CoCr-alloys. The alloy Co20Cr35NilOMo is hot forged or rolled at temperatures between 870 and 1125C. This multiphase alloy with a high strength and ductility is aged between 540 and 5900C after the hot working process. Table Ib. 11 shows the influence of a deformation and of a heat treatment on the mechanical properties of the alloy.
lb.3.1 Machining of CoCr-Alloys

Since CoCr-alloys have a low thermal conductivity, a high shear strength and a high work hardening rate and since they contain hard intemetallic compounds, they are expensive to machine because high cutting forces must be applied. For turning CoCr alloys, tungsten carbide tools are usually applied. Ceramic coated carbide, boron nitride and high speed steels can also be used. Water soluble oils are applied as cutting fluids. Table lb.5 gives the turning parameters for CoCr-alloys. Drilling of CoCr-alloys is accomplished by similar methods. The speeds and feeds must be reduced because of the slower cooling rate and lubriant efficiency. Milling of CoCr-alloys requires, like turning, higher forces and climb milling is preferred. Cuts deeper than 1.5 mm are not possible. Besides high-speed cutters carbide tools can also be used. Table lb.7 gives the milling parameters for CoCr-alloys. All types of sawing, such as band sawing, circular sawing and hacksawing, can be applied. A good supply of cutting fluid during the sawing operation is important.

Table lb.5 Turning parameters of cast and wrought CoCr-alloys (Ref. 11) Alloy Condition Roughing Finishing Depth of Speed Cut Speed (mm) (m/min) (m/min) 3-15 3-18 Feed Rate (mm/rev)

Cast CoCr

As cast or as cast and aged

Rough: Rough: 0.13-0.18 2.5-5 Finish: 0.8 Finish: 0.13 Rough: 5 Rough: 0.25 Finish: 0.8 Finish: 0.13

Wrought CoCr Solution treated 5-17 or solution treated and aged

6-27

Table lb.6 Drilling parameters of cast and wrought CoCr-alloys (Ref. 11) Alloy Condition Speed (m/min) 2-4.5 6 4.5 Feed Rate (mm/rev) 0.025-0.15 0.05-0.1 0.05-0.1

Cast CoCr As cast or as cast and annealed Wrought CoCr Solution treated Solution treated and aged

Table lb.7 Milling parameters of cast and wrought CoCr-alloys (Ref. 11) Alloy Cast CoCr Wrought CoCr Cast CoCr Wrought CoCr Cast CoCr Wrought CoCr Cast CoCr Wrought CoCr Type of Milling Face with HSS tools Face with HSS tools Face with carbide tools Face with carbide tools Finish with HSS tools Finish with HSS tools Finish with Carbide tools Finish with carbide tools Depth of Cut (mm) 1 8 1 8 1 4 1 4 0.5 0.5 0.5 0.5 Speed (m/min) 3.6-4.5 1.5-2.0 4.5-9.0 2.0-6.0 9-15 6-14 18-21 17-20 3.0-3.6 3.6-4.5 12-18 18-21 Feed Rate (mm/rev) 0.05 0.075 0.05 0.1 0.13 0.15 0.13 0.13-0.15 0.025-0.05 0.025-0.05 0.025-0.05 0.025-0.05

Grinding of CoCr-alloys requires good control of the parameters because of the sensitivity of the alloys to microcracks and because of alterations in the microstructure. Brazing of CoCr-alloys can be performed either in a hydrogen atmosphere or in vacuum. As filler metals Ni- or Co-base alloys or Au-Pd-alloys can be used. In order to achieve a better wetting by the filler metals an electroplating or flashing with Ni is performed. Copper filler metals should be avoided because of the danger of an embrittlement of the seam. Table lb.8 shows the compositions of a typical Co-base filler metal. Table lb.8 Chemical composition (wt%) of a Co-basedfillermetal (Ref. 12)
~Cr Wi Si W Te C P S AZ Ti Zr Co 18-20 16-18 7.5-8.5 3.5-4.5 1.0 0.7-0.9 0.35-0.45 0.02 0.02 0.05 0.05 0.05 Balance

lb.3.2 Arc Welding of CoCr-Alloys CoCr-alloys can be welded by tungsten inert gas welding (TIG), metal inert gas welding (MIG) and shielded metal arc welding (SMAW). Before welding the parts must be carefully cleaned by grinding, machining or washing with a solvent. Sand-blasting should be avoided because of the danger of contamination of the surface. TIG is accomplished with a thoriated tungsten electrode (W + 2% ThO2). Automatic MIG is possible with argon or helium as shielding gases and with an electrode material corresponding to the base metal. The heat input provided by the current and voltage respectively and by the welding speed (Table lb.9) should be low in order to produce a high cooling rate providing a favourable microstructure (for grains and fine precipitations of carbides). Therefore SMAW is performed in a flat position with a rapid welding speed and with little weaving. Table lb.9 Recommended parameters for the welding of CoCr-alloys by different processes (Ref. 12)
Parameter Power supply Electrode diameter (mm) Filler metal Shielding gas Welding position Current (A) Voltage (V) Arc starting Welding speed (m/min) TIG DC transformer 1.1-1.6 Ar flat 12-70 10-20 High frequency 0.4-2.3 MIG DC transformer 0.9 According to base metal Ar flat 130-160 22-25 0.75

CoCr-alloys are welded in the solution-treated condition with electrodes of a similar composition to the base metal. CoCr-alloys are more difficult to weld than wrought CoCr-alloys. Table lb.9 gives recommended parameters for the welding of CoCr-alloys by different processes.

1B.4 MECHANICAL PROPERTIES Table lb.lOa Mechanical Properties of cast CoCr and powder metallurgically produced (pm) alloys (Ref. 1, 2, 8, 15, 16)
Young's Modulus x 103 (MPa) Condition Tensile Yield Strength* (0.2%) (MPa) Ultimate Ration Elonga- ReducTensile Yield/ tion at tion of Strength Tensile Fracture* Area Hardness HV (MPa) Strength (%) (%)

Alloy

Co29Cr5Mo CoCrMo*

As cast As cast HIP

210330

>450 500-650 841

>665 1277

>0.69

>8 4-10 14

>8

300-400

* Alloys used for dental restoration.

Table lb.ll Influence of the hot working procedure and of the heat treatment on the mechanical properties of cast CoCrMo (Ref. 16) Tensile Yield Ultimate TensileRatio Yield/ Elongation at Tensile Fracture Strength Strength Strength (%) (MPa) (MPa) 430-490 450-492 444-509 731 876 716-890 731-889 747-952 945 1360 0.55-0.60 0.55-0.62 0.47-0.68 0.77 0.64 5-8 11-17 10-13.5 17 19

Treatment As cast Solution annealed 1230C/l h/water quenched Solution annealed + aged 650C/20 h Cast and extruded 12000C + annealed 1100C/2 h Cast and hot forged and rolled 1175C + cold rolled 10% + 1050C/40 min ah cooled

Table lb.12 Influence of the cold working procedure on the mechanical properties of the alloy Co20Crl5W10Ni (Ref. 16) Tensile Yield Ultimate TensileRatio Yield/ Elongation at Tensile Strength Strength Fracture Strength (MPa) (MPa) (%) 450-650 1180 1610 1300 950-1200 1350 1900 1520 0.47-0.54 0.87 0.85 0.85 37-60 22 10

Treatment Annealed Cold worked (17.5%) Cold worked (4%) Cold worked

Table lb.13 Influence of deformation and heat treatment on the mechanical properties of the alloy Co20Cr35NilOMo (Ref. 16) Tensile Yield Ultimate TensileRatio Yield/ Elongation at Strength Strength Tensile Fracture (MPa) (MPa) Strength (%) 300 650 1413 1999 800 1000 1827 2068 1300 0.37 0.65 0.77 0.97 40 20 12 10

Treatment

Wrought, annealed >1050C Cold worked (50%) Cold worked (55%) Cold worked (55%) + aged + 538C/4 h Hot forged >650C below the recrystallization temperature (9500C)

1B.5 FATIGUE

Table lb.14 High cycle fatigue strength of ^various CoCr alloys (Ref. 16, 17) Fatigue Reversed-Stress (MPa) 200-300 200-300 540-600 370-430 Rotating Bending Fatigue Strength (MPa) 300 500 725

Alloy G-Co29Cr5Mo Co20Cr35NilOMo Co20Crl5W10Ni pm-Co29Cr5Mo

Condition As cast As cast Wrought HIP

R
-1

R
-1

Table lb.15 Influence of the heat treatment on the fatigue strength (107 cycles) of CoCr-alloys (Ref. 16, 18) Alloy G-Co29Cr5Mo Treatment As cast As cast + polished As cast + shot peened Solution annealed (1230 0 Ol h/water quenched Annealed 11700C Cold worked (17.5%) Cold worked (44%) Annealed >1050C Cold worked (50%) Cold worked (50%) Hot forged + annealed Hot forged > 6500C R Tensile Fatigue Strength (MPa) 300 >200 >260 220-280 -1 280-350 490 587 340 435 405 400-450 520

Co20Cr 15WlONi Co20Cr35NilOMo

Table lb.16 High cycle fatigue strength of hip endoprostheses of CoCr alloys, measured in 0.9% NaCl solution at 37C. Testing conditions similar to DIN 58840 (simulation of a loosened shaft, 50 mm free length) (Ref. 19) Alloy Cast Co29CrMo Wrought CoNiCrMo Maximum load in 2 x 107 cycles (kN) Air (f = 25 Hz) 0.9% NaCl (f = 2 Hz) 7 5.5 5.5-6.5 4.5

1B.6 CORROSION AND WEAR

Table lb.17 Influence of the pH value on the electrochemical data of the alloy Co29Cr5Mo in 0.1 M NaCl (Ref. 20) Metal/Alloy Co29Cr5Mo pH7 pH2 Corrosion Potential Passive Current Density Breakdown Potential Ecorr (mV) Ip (\xA/cm2) Eb (mV) -391 -465 1.36 0.54 340 476

Table lb.18 Repassivation time in 0.9% NaCl and breakdown potential in Hank's solution of CoCr alloys (Ref. 21) Alloy G-Co29Cr5Mo Co20Cr35NilOMo Breakdown Potential (mV) vs Calomel Electrode +420 +420 Repassivation Time (ms) +50OmV -50OmV 44.4 35.5 36 41

Table lb.19 Polarization current (i) and polarization resistance (Rc) of CoCr alloys in 0.9% NaCl and in 0.9% NaCl with a stable redox system at 37C [Fe(CN)64VFe(CN)63], corresponding to a potential of the body fluid of 400mV (Ref. 22, 23) Material Co20Crl5W10Ni i (\xA/cm2) 0.004 Rc (kCl cm2) 0.9% NaCl 0.9% NaCl + redox 2500 332

Table lb.20 Rate of formation of corrosion products for the alloys Co29Cr5Mo in Hank's solution under constant natural potential (Ref. 24) Alloy Co29Cr5Mo Mechanically polished Chemically polished Metal (Converted into Compound) (ng/cm2 h) 150 20

Table lb.21 Material

Coefficients of friction of sliding materials (Ref. 17, 24) Lubricant Ehy Distilled H2O Synovial fluid Globulin solution Albumin solution in vivo Synovial fluid in vitro in vivo H2O in vivo Coefficient of Friction O80 0.38 0.16 0.16 0.18 0.04 0.04 0.02 0.58 0.008

G-Co29Cr5Mo/ G-Co29Cr5Mo

G-Co29Cr5Mo/HDPe Co20Cr35Nil0Mo/ Co20Cr35NilOMo Cartilage/Cartilage

Table lb.22 Influence of nitrogen ion implantation on the mean wear rate and the coefficient of friction of the cast alloy Co29Cr5Mo (Ref. 25, 26) Alloy Co29Cr5Mo Co29Cr5Mo nitrogen implanted Co29Cr5Mo Co29Cr5Mo nitrogen implanted Testing Load (N) 132 132 10 10 Mean Wear Rate

(mrrf/W)
3.22 5.93 0.260 0.185

Coefficient of Friction

0.131 0.89

Testing conditions: Co29Cr5Mo - pin on UHMWPE disk; lubricant: bovine serum; testing speed: 85 mm/s.

1B.7 BIOLOGICAL PROPERTIES

Table lb.23 Biocompatibility of cp-Co, cp-Cr, cp-Ni and NiCrCo alloys; survival rate of L-32 cells incubated with powders (Ref. 27, 28) Metal/Alloy Co Cr Ni Co20Crl5W10Ni Co20Cr35NilOMo Powder Concentration Survival Rate

(mgty
25 50 200 400 200 400 200 400 200 400

(%l
45 18 65 62 0.9 0.1 33 23 25 14

Table lb.24 50% lethal concentration (LC50) of powders from Table lb.23 (Ref. 27) Metal/Alloy O) Cr Ni Co20Crl5W10Ni Co20Cr35NilOMo LC50 (mg/l) 30 >400 25 80 100

REFERENCES
1. DIN/ISO 5832-4 (draft) (1980), Beuth. 2. American Standard ASTM F75 (1982) (ASTM F75-67). 3. DIN/ISO 5832-5 (draft) (1992), Beuth. 4. DIN/ISO 5832-6 (draft) (1980), Beuth. 5. DIN/ISO 5832-7 (draft) (1992), Beuth. 6. American Standard ASTM F75 (1990) (ASTM F90-68). 7. American Standard ASTM F562 (1984) (ASTM 578A). 8. CoCr-alloy producing industries. 9. DIN/ISO 5832-8 (draft) (1992), Beuth. 10. MP35N Alloys, Latrobe Steel Company, Pennsylvania. 11. ASM Metals Handbook, Vol. 16: Machining. 12. Brazing of Heat-Resisting Alloys, in ASM Metals Handbook, Vol. 6. Welding, Brazing Soldering. 13. ASM Metals Handbook, Vol. 14: Turning and Forging. 14. Encyclopedia of Mat. ScL Eng. (1986), Pergamon Press. 15. DIN 13912 (1982), Beuth. 16. Pilliar, R.M., Manufacturing Processes of Metals: The Processing and Properties of Metal Implants, in Metal and Ceramic Biomaterials, Vol. 1. 17. Thull, R. (1979) Eigenschaften von Metallen, fur orthopadische Implantate und deren Priifung. Orthopadie, 7, 29. 18. Lorenz, M. Semlitsch, M., Panic, B., Weber, H. and Willhert, H.G. (1978) Fatigue Strength of Cobalt-Base Alloys with High Corrosion Resistance for Artificial Hip Joints. Engineering in Medicine, 7 (4), 241. 19. Kunze, E. (1988) Vergleichende Untersuchungen zum Langzeit-Ermudungsverhalten von Hiiftgelenkprothesen an Luft und in NaCl-Losung. Metall, 2,140-145. 20. Geis-Gerstorfer, J., Weber, H. and Breme, J. (1988) Electrochemische Untersuchung auf die Korrosionsbestandigkeit von Implantatlegierungen. Z. / Zahnarztl Implantologie 4, (1), 31-36. 21. Breme, J. and Schmidt, H.-J. (1990) Criteria for the Bioinertness of Metals for Osseo-Integrated Implants, in Osseo-Integrated Implants, Vol. 1, (ed. G. Heimke), pp. 31-80. 22. Zitter, H. and Plenk, H. (1987) The Electrochemical Behaviour of Metallic Implant Materials as an Indicator of their Biocompatibility. /. of Biomedical Materials Research, 21, 881. 23. Breme, J. (1988) Titanium and Titanium Alloys, Biomaterials of Preference, in Proc. of the 6th World Conf on Ti, Vol. 1, pp. 57-68. 24. Mears, D.C. (1977) Metals in Medicine and Surgery. International Metals Reviews, Review 218, June, 119-155. 25. Greer, K.W. and Jones, D.E. (1994) The importance of standardization of wear test parameters in the simulation of three wear mechanisms, Proc. of the 20th Annual Meeting of the Society for Biomaterials, p. 408. 26. Taylor, S.K. Serekian, P. and Manley, M. (1992) Effect of nitrogen ion implantation on CoCr wear performance against UHMWPE, Proc. of the 4th World Biomaterials Congress, p. 275. 27. Hildebrand, H.F. (1993) Biologische Aspekte beim Einsatz von Implantatwerkstoffen, DGM Hochschulseminar, Saarbriicken, Germany. 28. Breme, J. (1993) Metalle als Biomaterialien, DGM Hochschulseminar, Saarbriicken, Germany.

Titanium and titanium alloys

Ic

I C l COMPOSITION Table I c I alloys Comparison of international standards for titanium and titanium
International Organization for Standardization ISO 5832/11

Germany Chemical Composition* DIN** Ti-I Ti-2 Ti-3 Ti-4

Great Britain BSI

France AFNOR

United States ASTM F67/Grade F67/Grade F67/Grade F67/Grade 1 2 3 4

Japan JIS H4600

5832-2 2TAl NFISO5832-2 2TA2 and and 2TA6 17850 S 90-404 respectively BS7252-2 respectively 5832-3 2TA10, NFISO5832 and and 2TA13 BS7252-3 S94-080 17851 respectively respectively 5832-10 BS7252-10 and 17851 respectively 5832-11 and 17851 respectively S94-081

5832/III

H4607

Ti6A14V

5832/X F136

Ti5A12.5Fe

5832/XI

Ti6A17Nb

* Ti-l-Ti-4 = commercially pure titanium; others: direct chemical composition, e.g. Ti6A14V: 6wt%, Al, 4wt% V, balance Ti. F1295 ** terms of delivery: DIN 17860, DIN 17862.

Table lc.2 cp-Titanium Grade Grade Grade Grade I II III IV

Chemical composition of cp-titanium (wt%) (Ref. 1, 2) Fe max. 0.2 0.25 0.3 0.35 O approx. 0.1 0.2 0.25 0.3 N max. 0.05 0.06 0.06 0.07 C max. 0.08 0.08 0.1 0.1 H max. 0.013 0.013 0.013 0.013 Ti Balance

Table lc.3 Alloy Ti6A14V

Chemical composition of (a+p)-titanium alloys (wt%) (Ref. 1, 3, 4) Al V Fe 0.3 Nb Ta O N C Others H Single Sum Ti

5.5- 3.56.75 4.5 Ti5A12.5Fe 4.5- 5.5 Ti6A17Nb 5.5- 6.5

0.2 0.05 0.08 0.015 0.1 0.4 Balance

2.0- 0.2 0.05 0.08 0.015 0.1 0.4 Balance 3.0 0.25 6.5- 0.5 0.2 0.05 0.08 0.009 - Balance 7.5

Table lc.4 Chemical composition-(wt%) of P and near P titanium alloys (experimental alloys) (Ref. 5, 6) Alloy Til5Mo5Zr3Al Til2Mo5Zr5Sn Ti30Nb Ti30Ta ~Al 3^8 Wo 15 11.5 Yr 5 5 30 30 Ta ~Nb ~Sn 4.5 77 Balance

1C.2 PHYSICAL PROPERTIES

Table lc.5 Physical properties of commercially pure titanium (Ref. 1, 7, 9 (GPa) (g/cm3) (0C) (0C) (0C) 105-110 4.5 1700 3600 885 >850C P bcc <850C a hex paramagnetic 67 5.8 x 10~22 0.52 419 17 9 x 10 6 0.5

Young's modulus Density Melting point Boiling point Transformation temperature ap Crystal structure

Magnetic properties Heat of transformation (kJ/kg) Thermal neutron-capture cross section (cm2) Specific heat at 15C (kJ/kg K) Heat fusion (kJ/kg) Thermal conductivity at room temperature (W/mK) Thermal expansion coefficient between 20 and 2000C (K 1 ) Specific heat resistivity at 200C (ixllm)

Table lc.6 Property

Physical properties of (a+p)-titanium alloys (Ref. 1, 7, 8, 9) T16A14V 100-110 4.43 a+p A1-A9 99015 6.5 8.6 0.56 1.66 Ti5Al2.5Fe 110-116 4.45 a+p A1-A9 95015 9.3 Ti6Al7Nb 110 4.52 a+p A1-A9 101015

Young's modulus (GPa) Density (g/cm3) Type of phase at room temperature (0C) Microstructure Transformation temperature (0C) Thermal conductivity at room temperature (W/mK) Coefficient of thermal expansion between 30-2000C (XlO-6K"1) Specific heat at 200C (kJ/kg K) Specific electrical resistivity at 200C (52 mm2/m)

Table lc.7 Influence of alloying elements and heat treatment on Young's modulus (Ref. 10, 11) Alloy Ti30Ta Ti30Nb Til5Mo5Zr3Alell Heat Treatment As rolled 1 h/1000C/H2O As rolled Solution heat treated at 8400C Solution heat treated at 7400C Solution heat treated at 7400C + aged at 6000C Young's Modulus (GPa) 80 63 70 75 88 113

1C.3 PROCESSING OF cp-Ti AND Ti ALLOYS [1] Provided that the following characteristics of titanium are taken into consideration, almost all processing procedures are possible: 1. 2. 3. 4. 5. high affinity to the gases oxygen, nitrogen and hydrogen high reactivity to all metals producing intermetallic compounds relatively low Young's modulus and therefore backspringing relatively low thermal conductivity tendency to stick to the tools

lc.3.1 Hot working and heat treatment

Titanium and titanium alloys are fabricated into semi-finished products by conventional methods such as forging, rolling, pressing, drawing etc.

When Ti materials are heated, care must be taken to avoid an excessive pickup of oxygen, nitrogen and hydrogen. Heating and annealing should therefore take place in a neutral or slightly oxidizing atmosphere. During heating in a gas-fired furnace direct contact with the flame must be avoided because of the risk of hydrogen pickup and of local overheating. During a short heating period oxygen pickup is restricted to the surface area. This surface zone must be removed by chemical or mechanical methods. Because hydrogen is able to penetrate the matrix rapidly, a reducing atmosphere must be avoided. The hot working temperature depends on the alloy composition and should be selected to obtain the best mechanical properties and grain structure (A1-A9 according to ETTC2, Ref. 11). Table lc.8 summarizes the deformation temperatures for the various Ti materials. Table lc.9 gives the temperature ranges and recommended annealing times for stress relieving, soft annealing and solution treating + age hardening. Where the cross-section is very small, annealing is favourably carried out in a high vacuum furnace. Prior to this annealing treatment the oxide film must be removed from the surface in order to avoid diffusion of oxygen into the material.
Table lc.8 Deformation temperatures for various titanium materials (Ref. 1.13) Alloy cp-Ti Grade 1 Grade 2 Grade 3 Grade 4 Ti6A14V Deformation temperature (0C) 650-870 650-870 700-900 700-930 760-1040

Table lc.9 Recommendation for the heat treatment of cp-Ti and Ti alloys (Ref. 1.7) Alloy Ti Ti Ti Ti grade grade grade grade Stress Relief I II 15 min-2 h III at 450C/air IV Soft Annealing 15 min-8 h at 650-7500C Solution Annealing + Age Hardening

Ti6A14V Ti5A12.5Fe

15-60 min 3 min/mm min. 15 min at 820-950C/H2O + 2 h at 480-600C/air min. 30 min max. 4 h max. 4 h at 700-850C/air at 500-600C/air slow cooling rate 15-60 min to 550 0C at 800-92O0CVH2O + 2-A h at 480-600C/air

lc.3.2 Working of sheet

At room temperature cp-Ti, grades I and II, can be worked very well, grades III and IV only moderately well. The Ti alloys, because of their high yield/tensile strength ratio, can be worked only under certain conditions. For deep drawing special coatings in the form of polymer foils have proved to be effective. At high temperatures colloidal graphite and common hot press greases with graphite or molybdenum disulphide additives have been successful. The Fe-, Ni- and Cr-contents should be limited to 0.05, 0.1 and 0.33 wt%, respectively, in order to allow during a short annealing treatment (1-5 min at 750-8500C) a grain growth producing an average grain size of 50-70 jxm. Due to this grain growth a deformation by twinning, with a resulting increased deep drawability, occurs (Ref. 14). Superplastic forming is a material-saving and cost-reducing processs for manufacturing parts of complicated shape because it can be carried out together with diffusion welding in a single operation. Especially fine grained alloys like Ti6A14V and Ti5A12.5Fe can be used for a superplastic deformation. Other special deformation processes such as stretch forming, spinning or explosion forming are also possible.
lc.3.3 Descaling

With thick-walled parts the oxide layer on the surface generated during deformation and/or heat treatment is removed by sand-blasting and/or pickling. The workpiece is treated in an aqueous solution of 20 Wt. %. HNO3 and 2% Wt. % HF. Thin walled pieces are only pickled in an electrolytic or salt bath. It is important that not only the surface layer of oxide, but also the underlying oxygen enriched diffusion zone is removed. Otherwise, the machinability and the service life of turning and milling tools would be negatively affected.
lc.3.4 Machining

The machining of titanium materials presents no difficulties provided the following characteristic properties are taken into account: 1. relatively low thermal conductivity which may cause high thermal stresses at the cutting edge of the tool 2. low Young's modulus which yields to the pressure of the tool 3. tendency to stick to the tool The titanium materials must therefore be machined at low cutting speeds, at a relatively high feed rate with an ample supply of coolant

(sulphur containing oil; mixture of tetrachloride carbon, molybdenum sulphide and graphite; 5% aqueous solution of sodium nitrite, 5-10% aqueous solution of water-soluble oil or sulphurized chlorinated oil). The cutting tools should be sharp and mounted as rigidly as possible. Recommended parameters for turning and milling are given in Table lc.10. Since titanium dust and chips can easily catch fire, safety precautions must be taken. Threads should be cut on a lathe, as thread-cutting discs are subject to seizure. Sawing causes no difficulties if a high blade pressure is used and the coolant supply is ample. Coarse toothed blades (4 teeth per inch) are recommended. For grinding, aluminium oxide (5-10 m/sec) and silicon carbide (20-30 m/sec) can be used.

Table lc.10 Recommendations for the cutting and milling of cp-Ti and Ti alloys (Ref. 7)
Alloy Cutting Speed Feed (m/min) (mm/rev) 30-75 7.5-4.0 15-25 3-15 60-100 18-50 20-50 5-15 60-100 20-50 20-70 9-15 25-30 50-60 7.5-20 15-30 Depth of Cut (mm) Cutting Angle 0-6 6-15 0-6 6-15 6-6 6-15 6-6 6-15 0-15 5-6 0-15 5-6

Relief Angle 6-8 5-7 6-8 5-7 6-8 5-7 6-8 5-7 6-8 5-7 6-8 5-7

cp-Ti TC HSS Ti alloys T(: HSS cp-Ti TC HSS Ti alloys T(: HSS cp-Ti TC HSS Ti alloys T(: HSS cp-Ti TC HSS Ti alloys T(: HSS

Rough cutting 0.2-0.4 0.1-1.25 >2.5 0.2-0.4 0.1-0.4 Forecutting 0.1-0.4 0.075-0.2 0.75-2.5 0.1-0.4 0.075-0.2 Finish cutting 0.075-0.3 0.05-0.1 0.1-0.75 0.075-0.3 0.05-0.1 Milling 0.07-0.15 >1.25 face cutter 0.1-0.2 >2.5 gear cutter 0.07-0.2 0.1-0.2

TC = hard metal (tungsten carbide). HSS = high speed steel.

lc.3.5 Soldering and brazing

Immediately before soldering and brazing the oxide layer which is always present on the surface of titanium materials must be removed. For direct applications using a torch, aluminium-zinc and tin-zinc solders are suitable. The higher temperatures required for brazing present the difficulty of avoiding the formation of intermetallic phases. With almost all metals titanium forms brittle intermetallic phases in the fusion zone. The only exception is Ag, so that this metal forms one of the main constituents of brazers. The sources of heat used for brazing and soldering are the acetylene torch, high frequency induction coils, infrared radiation, an inert-gas-shielded arc with graphite or tungsten electrodes, furnaces with an argon atmosphere (min. 99.99% and/or a dew point below -5O0C) and high vacuum furnaces. If brazing is not performed under vacuum or in a controlled atmosphere, fluxes are necessary to dissolve the oxide layers and prevent a pickup of gases.
lc.3.6 Welding

The inert-gas-shielded arc processes (TIG and MIG) are mainly used for fusion welding. In special cases resistance, ultrasonic, electron beam, diffusion and laser welding are applied. With the cp-Ti grades the weld attains mechanical properties approximating those of the base metal. A slight decrease in ductility may occur with high tensile grades. Under passivating conditions, titanium welds have the same corrosion resistance as the base metal. On the contrary, in reducing media the weld may be subjected to a more severe corrosive attack than the base metal. During the welding operation, the weld, the heat affected zone and the underside of the weld are shielded from the atmosphere. The filler rod used is an uncoated wire of the same grade or of a grade with a lower hardness than the base metal. Careful preparation of the joint is necessary, i.e. surface impurities must be removed by grinding or pickling in order to avoid porosity. Even fingermarks can produce a hardening of the weld. Sheet up to 2.5 mm thickness can be welded by a single layer. In order to avoid local oxygen concentrations oxidation products, such as those found at the tip of the electrode, must be cut off. The effectiveness of the inert gas is responsible for the welding rate. The optimum argon flow rate has proved to be about 6-8 I/mm. After welding the appearance of a dark blue or gray oxide layer indicates an insufficient inert gas shielding and an embrittlement of the weld due to oxygen and/or nitrogen pickup. The hardness of a good weld may exceed that of the fully recrystallized base metal by a maximum of 50 VHN. If, after a slight grinding of the surface, a hardness test should give a higher value, the weld must be completely removed because of embrittelement.

Electron beam welding is particularly suitable for titanium materials. It offers many advantages such as very narrow seams and small heat affected zones, weldability of thick diameters, high welding speed and reproducibility of even complex welds. Titanium materials can be spot welded without any particular preparation under similar conditions to those of stainless steel. Using flat-tipped electrodes, spot welding can be performed without inert gas. A hardening of the zone by up to 50 VHN compared with the base metal is regarded as normal and does not diminish the strength of the joint. Seam and flashbutt welding are also possible if an argon atmosphere is used. Diffusion welding is of particular importance for titanium materials because these materials are more amenable to a homogeneous band in the solid state state than other metals. After welding, the joint zone shows a higher temperature under high vacuum or, in an inert atmosphere, a microstructure very similar to that of the base metal. 1C.4 MECHANICAL PROPERTIES
Table l c l l Mechanical properties of commercially pure titanium (Ref. 1, 14)
Tensile yield strength (0.2 %) (MPa) Ultimate tensile strength (MPa) Ratio yield/ tensile strength Bend radius Elonga- Reduc(105) for sheet thickness t tion at tion of Hardfracture* area* ness <2 mm >2 mm <5 mm (%) (%)

cp-Titanium

Condition

Ti Ti Ti Ti

grade grade grade grade

I II sheet, III as IV rolled

200 250 320 390

290-410 390-540 460-590 540-740

0.49-0.69 0.46-0.64 0.54-0.7 0.53-0.72

30 22 18 16

35 30 30 30

120 150 170 200

2t 3t 4t 5t

3t 4t 5t 6t

* Minimum values. Table lc.12 Influence of a cold deformation on the mechanical properties of commercially pure titanium (Ref. 15) Tensile Yield Strength (0.2%) (MPa) 555 560 605 620 640 605 645 680 685 692 Ultimate Tensile Strength (MPa) 635 645 710 725 730 680 740 780 795 810 Ratio Yield/ Tensile Strength 0.87 0.87 0.85 0.86 0.88 0.89 0.87 0.87 0.86 0.85 Elongation at Fracture (%) 18 16 15 14 14.5 18 17 16 16 16.5

cp-Titanium Ti grade I

Condition (%) 30 40 55 60 65 30 40 50 60 65

Ti grade II

Table lc.13 Mechanical properties of P and near p-titanium alloys (experimental alloys) (Ref. 5, 10, 16) Tensile Yield Strength (0.2%) (MPa) 870-1173 1002 500 590 Ultimate Tensile Strength (MPa) 882-1177 1010 700 740 Ratio Yield/ Tensile Strength 1.0 0.99 0.71 0.80 Elongation Reduction at of Area Fracture (%) (%) 15-20 17.8 20 28 43-80 56 60 58

Alloy Til5Mo5Zr3Al Til2Mo5Zr5Sn Ti30Nb TBOTa

Remarks: The alloys Til5Mo5Zr3Al and Til2Mo5Zr5Sn were investigated in the as forged and aged (6000C) condition. The alloys Ti30Nb and Ti30Ta, which can be used due to their thermal expansion coefficient adapted to that of alumina for a direct bonding to the ceramic for the production of dental implants, were tested in the as rolled condition. Table lc.14 Influence of heat treatment on the mechanical properties of p- and near p-titanium alloys (Ref. 5,10) Tensile yield strength (0.2 %) (MPa) 870 968 1087 650 660 665 680 Elonga- ReducUltimate Ratio yield/ tensile tion at tion of strength tensile fracture area (MPa) strength (%) (%) 882 975 1099 800 800 800 800 0.99 0.99 0.99 0.81 0.83 0.83 0.83 20 16.9 15.3 8 8 8 6 83.2 64.5 57.5 42 38 30 18

Alloy Til5Mo5Zr3Al

Condition SHT at 8400C SHT at 7400C SHT at 7400C aged at 6000C Annealed at 11000C Annealed at 12000C Annealed at 13000C Annealed at 14000C

Ti30Ta

SHT = solution heat treatment. Table lc.15 Influence of a cold deformation on the mechanical properties of ptitanium alloys (Ref. 5) Tensile yield strength (0.2 %) (MPa) 1284 Ultimate Ratio Elonga- Reductensile yield/ tion at tion of strength tensile fracture area (MPa) strength (%) (%) 1312 0.98 11.3 43.8

Alloy Til5Mo5Zr3Al

Condition 45% CW + aged at 6000C

CW = cold worked.

Table lc.16
Alloy

Mechanical properties of (a+p)-titanium alloys (Ref. 1, 3, 17, 18)

Condition Ultimate Ratio yield/ tensile tensile strength (MPa) strength Bend radius (105) for sheet Elonga- Reduction at tion of Hard- thickness t ness <2 mm >2 mm fracture* area* (%) <5 mm (%)

Tensile yield strength Sheet as rolled (0.2 %) thickness (mm) (MPa)

Ti6A14V Ti5A12.5Fe Ti6A17Nb

-6 6-100 -6 Extruded hot rolled + hot forged -6

870 830 780 811952 9431008 1058

950 920 860 8691008 10161086 1095

0.92 0.90 0.91 0.930.94 0.93

8 8 8 7-13

25 25 25 24-44

310 310 310

9 t 9 t

1Ot 1Ot

11-16 0.97

40-55

Ti6Mn

360 11.5 26 Ti6Mn was developed for a coating with hydroxyapatite. Due to a thermal expansion coefficient of this alloy, which is near to that of the ceramic, an extremely high shear strength of the surface layer has been achieved.

Table lc.17 Influence of a solution treating and ageing on the mechanical properties of Ti6A14V (Ref. 1) Tensile Yield Strength (0.2%) (MPa) 1070 Ultimate Tensile Strength (MPa) 1140 Ratio Yield/ Tensile Strength 0.94 Elongation Reduction at of Area Fracture (%) (%) 8 20

Condition Sheet < 12.5 mm 15-60 min at 800-9200CVH2O + 2-4h 480-600C/air

Table lc.18 Alloy Ti6A14V Ti5A12.5Fe

Fracture toughness of Ti-alloys (Ref. 5,19). Condition Annealed Solution treated + annealed Annealed (2 h/700C/air) Solution treated + annealed (1 h/900C/water//2 h/700C/air) Solution treated at 7400C Solution treated at 7400C + annealed at 6000C 40% cold worked + annealed at 6000C Fracture Toughness KIC (N/mm3/2) 1740 2020 1225 1785 4580 2430 980

Til5Mo5Zr3Al

Table lc.19 Influence of a plasma nitriding (PVD) on the mechanical properties of commercially Ti6A14V (Ref. 20) Treatment Tensile Yield Ultimate Tensile Ratio Yield/ Tensile Strength Strength (0.2%) Strength (MPa) (MPa) 809 815 805 880 894 924 914 984 0.90 0.88 0.88 0.89 Elongation at Fracture (%) 20 21 20 20

Untreated Vacuum annealed 20 h/850C Plasma nitrided* 20 h/850C/N2 Plasma nitrided* 20 h/850C/NH3

Plasma nitriding at 20-40 kW.

1C.5 FATIGUE
Table lc.20 High cycle fatigure strength crB and rotating fatigue strength crR of titanium and titanium alloys (Wohler curves) (Ref. 10, 21, 22, 23, 24) Alloy cp-Ti Ti6A14V Ti5A12.5Fe Ti6A17Nb cp-Nb cp-Ta Ti30Ta /? -L -1 -1 -1 -1 -1 -1 aB (MPa) 230-280 400-450 # -1 -1 -1 -1 -1 -1 -1 crR (MPa) 200 500-660 450-550 450-600 150 200 400

Table lc.21 Rotating bending fatigue tests of unnotched and notched titanium alloys (Ref. 19) Stress Concentration Factor 1.0 1.0 3.6 3.6 1.0 Fatigue Strength for Alternating Tensile Stresses (>107 cycles) (MPa) 725 725 300 300 450

Alloy

Condition Wrought + annealed Wrought + solution treated + annealed Cast + HIP Cast + HIP

Ti6A14V -1 Ti5AL12.5Fe -1 -1 -1 -1 -1

Table lc.22 High cycle fatigue strength of hip endoprostheses of titanium alloys, measured in 0.9% NaCl solution at 37C. Testing conditions similar to DIN 58840 (simulated loosened shaft, 50 mm) (Ref. 23, 25) Alloy Hot wrought Ti6A14V Wrought Ti5A12.5F Ti6AL17Nb Maximum load in 2x107 cycles (JcN) 0.9% NaCl (f = 2 Hz) 6.5-8.0 8 3.5-6.0

Table lc.23 Influence of the mean stress Sm on the fatigue strength of Ti6A14V (Ref. 26) Sm (MPa) 0 250 500 750 R -1 -0.1 0.33 0.33 0.66 0.7 0.81 Notch Factor Kf 1 2.82 1 2.82 1 2.82 1 2.82 Fatigue Strength (MPa) at 107 cycles 400 250 300 125 250 100 125 80

Table lc.24 Influence of the notch factor on the fatigue strength of Ti6A14V (Ref. 27, 28, 29, 30) Notch Factor Kf 1 1.7 3.7 6.0 Stress Ratio R -1 -1 -1 -1 Fatigue Strength (MPa) 400 300 150 100

Table lc.25 Influence of interstitial elements on the rotating bending strength of Ti6A14V (Ref. 31) Chemical composition of the base alloy (wt%) Al 6.03 V 3.96 Fe 0.10 C 0.02 N 0.009 O 0.1 H Ti 0.005 balance Fatigue Strength R (MPa) 610 210 510 180 550 210 560 230 580 240
I I

Composition Base alloy Base alloy + 0.07% N Base alloy + 0.2% O Base alloy + 9.2% C Base alloy + 0.07% N + 0.2% O + 0.2% C

Heat Treatment 1 h 815C/furnace - 6000C air 1 h 855C/furnace -> 6000C air 1 h 870C/furnace - 6000C air 1 h 840C/furnace - 6000C air 1 h 930C/furnace - 6000C air

Notch Factor Kf 1 3 1 3 1 3 1 3 1 3

Table lc.26 Influence of texture and test directions on the rotating bending fatigue strength of Ti6A14V (fine equiaxed microstructure in rolled plates) (Ref. 32) Type of Texture and Method of Production Basal (0002 tilted out of the rolling plane by about 30) cross rolling in lower (a+3)-field Transverse (0002 aligned parallel to the rolling direction) uni-directional in the higher (a+P)field, 9500C Basal/transverse (both are present), unidirectional roll-at about 9300C
R

Test Direction Rolling direction

Fatigue Strength (MPa) at 107 cycles 625

I I I I I I I I

-1

-1

Rolling direction Transverse direction

630 590

-1

Rolling direction Transverse direction

720 690

Table lc.27 Influence of heat treatment (annealing and precipitation hardening respectively) on the fatigue strength of Ti6A14V (Ref. 30, 33) Condition As annealed As hardened Condition As annealed As hardened Sm 0 0 0 0 Yield Strength (MPa) 900 1100 Kf 1 3.3 1 3.3 1 -1 1 -1 R Tensile Strength (MPa) 955 1195 Fatigue Strength (MPa) at 107 cycles 510 300 600 280

A s annealed A s hardened As annealed A s hardened

200 200 200 200 300 300 300 300

1 3.3 1 3.3 1 3.3 1 3.3

-0.3 -0.01 -0.5 0 0.14 0.23 -0.22 -0.2

425 200 600 200 400 165 550 190

Table lc.28 Influence of the beta field heat treatment on the fatigue strength of Ti6A14V (Ref. 34) Heat Treatment 0.5 h 1010C/AC + 2 h 70O0CVAC 5 h 1000C/AC + 2 h 700C/AC 0.5 h 1010C/H20 + 2 h 700C/AC 5 h 10100OH2O + 2 h 700 0 C/AC 2 R 0 0 0 0 Fatigue Strength (MPa) at 107 cycles 525 620 750 650

Table lc.29 Influence of the surface treatment on the rotating bending fatigue (fine lamellar microstructure, produced by annealing in 15 min/1050C/H20 + 1 h/800C/H20) (Ref. 35) Surface Treatment Electrically polished Mechanically polished Mechanically polished Mechanically polished Mechanically polished Mechanically polished (7 jjim) (80 jim) (80 |xm) + 1 h 500 0 C (180 |xm) (80 |am)+ 1 h 800 0 C R -1 -1 -1 -1 -1 -1 Fatigue strength (MPa) at 107 cycles 680 750 605 550 600 450

Table lc.30 Influence of the surface treatment on the rotating bending fatigue of Ti6A14V (fine equiaxed microstructure produced by rolling at 800CVH2O + 1 h/800C(H2O) (Ref. 35) Surface Treatment Electrically polished Shot peened Shot peened + 1 h 500 0C Shot peened + 1 h 500 0C 20 jim surface removed Shot peened + 20 |xm surface removed R -1 -1 -1 -1 -1 Fatigue Strength (MPa) 610 710 390 800 820

Table lc.31 Influence of surface working on the rotating bending of Ti6A14V (Ref. 27, 36) Surface Working Mechanically polished Mechanically polished and cold roll bent Ground Mechanically polished Notch Factor (Kf) 1 1 1 2.02 R -1 -1 -1 -1 Fatigue Strength (MPa) 620 660 540 330

Table lc.32 Influence of plasma nitriding (PVD) on the rotating bending fatigue of Ti6A14V (Ref. 20) Treatment Untreated Vacuum annealed 20 h/850 0C Plasma nitrided* 20 h/850 C/N2 Plasma nitrided*20 h/700 0 ONH 3 Solution treated 1 h/940 C/vac. + Ar cooled Solution treated 1 h/940 C/vac. + Ar cooled + plasma nitrided* 20 h/770 C/N2 * Plasma nitriding at 20-40 kW. R -1 -1 -1 -1 -1 -1 Maximum Bending Stress at 107 cycles (MPa) 600 370 470 550 530 500

1C.6 CORROSION AND WEAR

Table lc.33 Electrochemical data for titanium and titanium alloys in 0.1 M NaCl under different conditions (Ref. 16, 37, 38). Metal/Alloy cp-Ti pH 7 pH2 Ti5A12.5Fe pH 7 pH2 Ti6A14V pH 7 pH2 Ti6A17Nb pH 7 Ti30Ta pH7 Ti40Nb pH 7 Corrosion Potential Passive Current Density Breakdown Potential Ecorr(mV) Ip (pA/cm2) Eb (mV) -628 -459 -529 -567 -510 -699 0.72 113 0.68 0.71 0.92 0.69 0.45 0.3 0.2

>1500 >1500 >1500 >1000 >1500 >1500

Table lc.34 Polarization current (i) and polarization resistance (Rc) of titanium and titanium alloys in pure saline at 37C (Ref. H37) and in 0.9% NaCl with a stable redox system [Fe(CN)64VFe(CN)63] (Ref. 39) Material cp-Ti cp-Ta cp-Nb Ti6A14V i (\xA/cm2) 0.010 0.003 0.004 0.008 Rc (kOcm2) Pure saline Saline + redox 1000 3000 2500 1250 714 1430 455 455

Table lc.35 Repassivation time in 0.9% NaCl and breakdown potential in Hank's solution of titanium and titanium alloys (Ref. 16, 22, 40, 41) Metal/Alloy cp-Ti cp-Ta Ti30Ta Ti40Nb Ti6A14V Ti5A12.5Fe Ti4.5A15Mol.5Cr Ni45Ti Breakdown Potential (mV) vs. calomel electrode 2400 2250 >1500 >1500 >2000 2400 1140 Repassivation Time (ms) -500 mV +500 mV 43 41.7 44.6 37 110-130 44.4 47.5 43.4 41 120-160

Table lc.36 Electrochemical data for anodic titanium and titanium alloys at 370C in different solutions (de-aired) versus standard calomel electrode (SCE) (Ref. 42) Corrosion Passive Current Breakdown Potential E Density Potential Solution* (mV) vs. SCE Ep (mV) Ib (\LACM2) -440 - -490 -94-140 -94 -200-250 -240-300 -180-250 .480-495 -480-500 -490-520 -800-840 -650-740 -590-600 1.0-3.0 0-1.0 5.0-9.0 0.9-1.0 0.8-1.5 0.9-2.0 3.0-5.0 4.0-5.0 3.0 3.0-4.0 1.0-2.0 3.0-4.0 1300 1750 1950 1155-1240 1900 1550 1900 1700 >2000 1000 1300 1800 1 2 3 1 2 3 1 2 3 1 2 3

Metal/Alloy cp-Ti Ti6A14V Til5V3Cr3Sn3Al mill annealed 6h/510C/air

* Key: 1 = Ringer's solution; 2 = Hank's solution; 3 = 0.17 M NaCl solution.

Table lc.37 Repassivation rates in artificial saliva versus standard calomel electrode (Ref. 43) Material Titanium Corrosion Potential (mV) ^355 Ih ^308 Potential (mV) after 2h 36 h ^260 460

Table lc.38 Galvanic corrosion between titanium and other alloys in artificial saliva (Ref. 43) Potential Couples difference (mV) Ti-HGC 434 Ti-non gamma 2 amalgam 130 Ti-CoCrMo cast alloy 90-117 Ti-HGC-CoCrMo -22 HGC-CoCrMo 225 HGC = high gold containing alloy. Igalv after 20 h (nA cnr2) 4 10 2 3 500 Titanium position Anode Cathode Cathode Anode

Table lc.39 Repassivation time of titanium and titanium alloys in contact with different metallic materials (Ref. 44) NaCl, pH = 7.4 (shortcut alloy) cp-Ti HCl, pH = 3 (activated alloy) cp-Ti Ti30Ta Ti6A14V cp-Nb Co30Cr6.5Mo Co28Cr5Mo X3CrNiMol812 cp-Ti Ti30Ta Ti6A14V cp-Nb Co30Cr6.5Mo Co28Cr5Mo X3CrNiMol812 cp-Ti Ti30Ta Repassivation Time te (ms) 37.7 41.8 480.0 38.7 38.4 1000.0 43.0 48.6 39.0 1080.0 44.1 (4200) 1000.0 44.0 34.2

Ti30Ta

Ti6A14V

Table lc.40 Influence of the surface treatment on the fretting corrosion behaviour of Ti6A14V (Ref. 45) Total Weight loss Material Combination (\xg) Ti (\Lg) Untreated-untreated 2423 3925 Untreated-nitrogen ion implanted 1295 1260 Untreated-PVD coated with TiN 1002 902 Untreated-plasma ion nitrided 807 716 PVD- PVD 713 470 Plasma ion nitrided-plasma ion nitrided 273 87 Testing conditions: plate screw system with a micromotion of 100 |xm. 14 days at 1 Hz for 1 200 000 cycles. testing medium was calf serum solution. V (\xg) 78.5 31.2 15.0 6.4 8.5 0.5

Table lc.41 Influence of the surface treatment on the wear behaviour of Ti6A17Nb as a result of a pin-on-disk test (Ref. 46) PVD coated with 3 /urn TiN layer 2.111 0.078 0.159 47 Oxygen diffusion hardened (ODH) (30 \xm hardened surface) 1.353 0.051 0.330 49

Property Wear factor (10-?mm3/Nm ) Coefficient of friction Surface roughness Rz (juim) Wetting angle ()

Table lc.42 Influence of ion implantation of nitrogen on the wear properties of commercially pure Ti and Ti6A14V (Ref. 47) Material cp-Ti* Ti6A14V** Friction Couple Untreated-untreated Nitrided-nitrided 4 h/940C/N2:H2=2:l Untreated-untreated Nitrided-nitrided 4 h/940C/N2:H2=2:l Nitrided-nitrided 6 h/800C/N2:H2=l:l Total Wear (mg) 632.3 54.3 600.0 40.1 92.3 Friction Coefficient 0.48 0.10 0.46 0.10 0.12

* Friction distance = 1257 m. ** Friction distance = 1885 m. Table lc.43 Rate of formation of corrosion products for titanium and titanium alloys in Hank's solution during current-time-tests (Ref. 48) Alloy cp-Ti Mechanically polished Chemically polished Til6Mo Ti5Ta Metal converted into compound (ng/cm2h) 4.1 3.5 1.5 0.26

1C.7 BIOLOGICAL PROPERTIES

Table lc.44 Biocompatibility of cp-Ti and Ti alloys, survival rate of L132 cells incubated with powders (Ref. 49) Metal cp-Ti Ti6A14V Ti5A12.5Fe TOOTa TOONb Powder Concentration (mg/1) >400 >400 >400 >400 >400 Survival Rate of Cells

>80%

Table lc.45 Influence of the implantation time (in vivo) on the surface roughness and peak-to-valley (P-V) height of Ti6A14V femoral heads (Ref. 50)
Implantation Before Implantation Position Anterior Posterior Medial Lateral Ra (nm) 4310 416 5114 529 P-V 85 months Ra (nm) P-V Time 124 months Ra (nm) 8681 142131 41211 40+16 P-V 812763 1045890 401125 527156

110 months Ra (nm) P-V 20441178 1175778 1224+731 11951009

37072 5850 746509 250147 591333 150125 22811842 11496 411159 44+29 649259 11869 36468 7155 722474 117106

1C.8 TiNi - SHAPE MEMORY

Table lc.46 Properties of the alloy Ni45Ti (Ref. 37, 51, 52) Above (- austenitic) Below (- martensitic) Transition temperature (55 C) Density (g/cm3) Melting point (0C) Young's modulus (GPa) Tensile yield strength (0.2%) (MPa) Ultimate tensile strength (MPa) Ratio yield/tensile strength Elongation at fracture (%) Electrical conductivity (S/m) Corrosion potential (mV) in 0.1 M NaCl pH 7 pH 2 Passive current density (fiA/cm2) in 0.1 M NaCl pH 7 pH 2 Breakdown potential (mV) in 0.1 M NaCl pH 7 pH 2 6.4-6.5 1310 83-110 621-793 827-1172 0.75-0.68 1-15 1-1.5 -431 -518 0.44 0.61 890 960 21-69 34-138 103-862 0.33-0.16 up to 60

REFERENCES 1. DTG Product Information, Germany 2. DIN 17850 (1990), Beuth. 3. Semlitsch, M., Staub, F. and Weber, H. (1985) Development of a Vital, HighStrength Titanium Aluminium-Niobium Alloy for Surgical Implants: Proc. 5th European Conf. on Biomaterials, Paris, Sept. 4-6, 1985. 4. DIN 17851 (1990), Beuth. 5. Steinemann, S.G., Mausli, P.-A., Szmukler-Moncler, S., Semlitsch, M., Pohler, O., Hintermann, H.-E. and Perren, S.M. (1993) Beta-Titanium Alloy for Surgical Implants, Proc. of the 7th World Conf. on Titanium, pp. 2689-2696. 6. Mausli, P.-A., Steinemann, S.G. and Simpson, J.P. (1984) Properties of surface oxides on titanium and some titanium alloys, in Proc. of the 6th World Conference on Titanium, Vol. 3, pp. 1759-1764. 7. DIN 17869 (draft), (1990), Beuth. 8. Specification Properties, IMI 367-alloy. 9. Microstructure Standard for titanium Alloy Bars, Technical Committee of European Titanium Producers, Publication ETTC2. 10. Breme, J. Wadewitz, V. and Burger, K. (1988) Verbund Titanlegierungen/ Al2O3-Keramik fiir dentale Implantate - Entwicklung geeigneter Legierungen, in Verbundwerkstoffe - Stoffverbunde (ed. G. Ondracek), DGM 1988, pp. 123-130. 11. Breme, J., Biehl, V., Schulte, W., d'Hoedt, B. and Donath, K. (1993) Development and functionality of isoelastic Dental Implants of Titanium Alloys. Biomaterials, 14 (12), 887-892.

12. Hiilse, K., Kramer, K.-H. and Breme, J. (1989) Influence of Small Additions of Fe, Cr and Ni on the Recrystallisation Behaviour of cp-Ti. Proc. of the 6th Intern. Conf. on Ti, Soc. Franc, de Metallurgie, 1675-1683. 13. Zwicker, U. (1974) Titan und Titanlegierungen, Springer-Verlag. 14. DIN 17864 (draft), (1990), Beuth. 15. Ramsdell, J.D. and Hull, E.D. (1960) Characterstics of cold-rolled and annealed Ti, Bureau of Mines Rep. of Inv. 5656. 16. Breme, J. and Wadewitz, V. (1989) Comparison of Ti-Ta, Ti-Nb Alloys, /. of Oral & Max. Implants, 4 (2), 113-118. 17. Breme, J., Zhou, Y. and Groh, L. (1995) Development of a titanium alloy suitable for an optimized coating with hydroxyapatite, Biomaterials, 16, 239-244. 18. DIN 17860 (1990), Beuth. 19. Borowy, K.H. and Kramer, K.H. (1984) On the Properties of a New Titanium Alloy (TiA15Fe2.5) as Implant Material, in Proc. of the 5th World Conf. on Ti, Vol. 2, 1381-1386. 20. Lanagan, J. (1988) Properties of plasma nitrided titanium alloys, Proc. of the 6th World Conf. on Titanium, Vol. 4, pp. 1957-1962. 21. Thull, R. (1979) Eigenschaften von Metallen, fiir orthopadische Implantate und deren Priifung. Orthopddie, 7, 29. 22. Breme, J. and Schmidt, H.-J. (1990) Criteria for the Bioinertness of Metals for Osseo-Integrated Implants, in Osseo-Integrated Implants, Vol. 1 (ed. G. Heimke), pp. 31-80. 23. Semlitsch, M. and Weber, H. (1992) Titanlegierungen fiir zementlose Hiiftprothesen, in Die zementlose Hiiftprothese (E. Hipp, R. Gradinger and R. Asherl), Demeter Verlag, pp. 18-26. 24. Semlitsch, M. and Panic, B. (1994) 15 years of experience with test criteria for fracture-proof anchorage stems of artificial hip joints, in Technical Principles, Design and Safety of Joint Implants (eds G.H. Buchhorn and H.G. Willert), Hogrefe & Huber Publishers, pp. 23-36. 25. Kunze, E. (1988) Vergleichende Untersuchungen zum Langzeit-Ermiidungsverhalten von Hiiftgelenkprothesen an Luft und in NaCl-Losung. Metall, 2, 140-145. 26. Reactive Metals Inc. Niles, Ohio, RMI-Titanium 1969. 27. Weinberg, LG. and Hanna, I.E. (1957) an evaluation of the fatigue properties of Ti and Ti-alloys, TML Rep. 77. 28. Mote, W.M. and Frost, R.B. (1958) The engineering properties of commercial Ti-alloys, TML Rep. 92. 29. Weltzin, R.B. and Koves, G. (1968) Impact fatigue testing of Ti alloys. /. of Materials, 3, 469-480. 30. ASM Metals Handbook (1961), Vol. 1: Properties and Selection of Metals. 31. Dittmar, C.B., Bauer, G.W. and Evers, D (1957) The effect of microstructural variables and interstitial elements on the fatigue behavior of Ti and commercial Ti alloys, Mallory, Sharen Titanium Corp. AD-110726WADC-TR 56-304, 95. 32. Lutjering, G. and Gysler, A. (1984) Fatigue, in Proc. of the 5th Conf. on Ti, pp. 2065-2083. 33. Hempel, M. and Hillnhagen, E. (1966) Dauerschwingfestigkeit der technischen Titanlegierungen TiA15Sn2.5 und TiA16V4, Arch. f. Eisenhiittenwesen, 37, 263-277.

34. Rtidinger, K. and Fischer, D. (1984) Relationship between primary alpha content, tensile properties and high cycle fatigue behaviour of Ti6A14V, in Proc. of the 5th Conf on Ti, pp. 2123-2130. 35. Wagner, L. Gerdes, C. and Liitjering, G. (1984) Influence of surface treatment on fatigue strength of Ti6A14V, in Proc. of the 5th Conf. on Ti, Vol. 4,2147-2154. 36. Liu, H.W. (1956) Effect of surface finish on the fatigue strength of TiA16V4alloy, Dept. of Theoretical and Applied Mechanics, University of Illinois, T.U.A.M. Rep. 533. 37. Geis-Gerstorfer, J., Weber, H. and Breme, J. (1988) Electrochemische Untersuchung auf die Korrosionsbestandigkeit von Implantatlegierungen. Z / Zahndrztl. Implantologie 4, (1), 31-36. 38. DIN 17851 (1990), Beuth. 39. Breme, J. (1988) Titanium and Titanium Alloys, Biomaterials of Preference, in Proc. of the 6th World Conf on Ti, Vol. 1, pp. 57-68. 40. Fraker, A.C, Ruff, A.W. et al (1983) Surface Preparation and Corrosion. Behaviour of Titanium Alloys for Surgical Implants, in Titanium Alloys in Surgical Implants, ASTM STP796, (eds H.A. Luckey and F.Kubli), pp. 206-19. 41. Breme, J., Wadewitz, V. and Ecker, D. (1986) Untersuchungen zum Einflup des Gefiigezustandes auf das Korrosionverhalten der Implantatlegierung TiA15Fe2, 5. Z. / Zahndrztl. Implantologie, Bd. II 32-37. 42. Gagg, C, Corrosion Characteristics of Til5V3Cr3Sn3Al (Til5-3) Alloy in a Physiological Environment. 43. Elagli, K., Traisnel, M. and Hildebrand, H.F. (1993) Electrochemical Behaviour of Titanium and Dental Alloys in Artificial Saliva. Electrochimica Ada, 38 (14), 1769-1774. 44. Wadewitz, V. and Breme, J. (1989) Titan-Legierungen fur dentale Implantate. Z. Zahndrztl. Implantol. V, 116-120. 45. Maurer, A., Brown, S.A. and Merrit, K. (1992) Effects of Surface Treatments on Fretting Corrosion of Ti6A14V, Proc. of the 4th World Biomaterials Congress, pp. 200. 46. Streicher, R.M., Weber, H., Schon, R. and Semlitsch, M. (1991) Wet behaviour of different ceramic surfaces in comparison to TiN and OHD treated Ti6A14V alloy paired with polyethylene, in Ceramics in Substitutive and Reconstructive Surgery (ed. P Vincenzini), Elsevier, pp. 197-205. 47. Hu, Y.-S.. Dai, D.-H. and Dong, Y.-L. (1988) The ion nitriding of titanium materials and its applications, Proc. of the 6th World Confer, on Titanium, Vol. 4, pp. 1801-1804. 48. Mears, D.C. (1977) Metals in Medicine and Surgery. International Metals Reviews, Review 218, June, 119-155. 49. Hildebrand, H.F. (1993) Biologische Aspekte beim Einsatz von Implantatwerkstoffen, DGM Hochschulseminar, Saarbriicken, Germany. 50. Easter, T.L., Graham, R.M., Jacobs, J.J., Black, J. and LaBerge, M. (1994) Clinical Performance of Ti6A14V Femoral Components: Wear Mechanisms vs. Surface Profile, Proc. of the 20th Annual Meeting of the Society for Biomaterials, pp. 185. 51. Ebel, B. (1990) Zur Biokompatibilitat von Implantatwerkstoffen, KfK 4476. 52. Tautzenberger, P. and Stockel, D. (1987) Vergleich der Eigenschaften von Thermobimetallen und Memory-Elementen, 1, 26-32.

Dental Restoration Materials

Id

1D.1 AMALGAMS ld.1.1 Composition of alloys Table l d . l Chemical composition of dental amalgams (wt%) (Ref. 1, 2) Alloy powder* Ag Sn Cu Zn <2 1 Hg 0-3

LCS 66-73 25-29 <6 HCB 69 17 13 HCSS, HCSL 40-60 25-30 15-30 The mercury concentration after amalgamization is <50 %. * LCS = low-copper spherical. HCB = high-copper blended. HCSS = high-copper single-composition spherical. HCSL = high-copper single-composition lathe-cut.

ld.1.2 Physical properties Table ld.2 Physical and mechanical properties of amalgams (Ref. 2) Thermal expansion coefficient Thermal conductivity Ultimate tensile strength Ultimate compression strength Fracture toughness KIC 25 x 10~6/K 23 W/mK >60 MPa >300 MPa <1 MPa m1/2

Id. 1.3 General properties and processing General properties of dental amalgams (Ref. 1, 2) By definition amalgam is an alloy of mercury with one or more other metals. Dental amalgams are produced by mixing an alloy powder with

mercury. Usually the alloy powder is called 'amalgam' and the composition of amalgam denotes the composition of the powder. The two basic physical shapes of the alloy powder are: 1. irregular shaped particles (length 20-120 |xm, width 10-70 |xm, thickness 10-35 |xm) produced by lathe cutting. 2. spherical particles (diameter < 30 |xm) produced by atomization. Amalgams for dental restorations are classified by their copper content in two basic types: 1. low-copper type, < 6 wt% Cu, used since the late 19th century. 2. high-copper type (non-gamma-2 amalgam), >6 wt% Cu, used since 1960. The high-copper type is available in two alloy groups, classified by the mixture of different powder shapes: 2.1 mixed alloys consisting of 2.1.1 2/3 conventional lathe cutting + 1/3 spherical powder of Ag-Cu eutecticum (total composition see Table ld.l composition of eutecticum: Ag30Cu) 2.1.2 1/3 conventional lathe cutting powder + 2/3 spherical powder (Ag25Snl5Cu) 2.2 one-component amalgams consisting of 2.2.1 ternary alloys, spherical shape 2.2.2 ternary alloys, irregular shape 2.2.3 quaternary alloys, non-spherical shape During amalgamization the powder reacts with the mercury, producing different phases, depending on the amalgam powder: 1. low copper type: Ag3Sn + Hg -^ Ag2Hg3 + Sn7-8Hg + Ag3Sn 7 phase ^1 phase y2 phase 73 phase

2. high copper type, mixed alloy (a(i)), reacts in two steps: step one: Ag3Sn + H g - ^ Ag2Hg3 + Sn7-8Hg + Ag3Sn 7 phase yt phase 72 phase unreacted step two: Sn7-8Hg - Ag-Cu > Cu6Sn5 + Ag2Hg3 72 phase eutetic beads The result of the amalgamization is a microstructure consisting of unreacted Ag3Sn and Ag-Cu surrounded by a layer of Cu6Sn5 and the yx matrix. The microstructure of the one-component non-gamma-2 amalgams is similar to that of the mixed alloy except that the Cu6Sn5 particles are decomposed in the yx phase and form no layer.

Processing of dental amalgams For dental restoration (fillings) the mercury is mixed with the (amalgam) alloy immediately before application. The alloy is delivered in powder or pellet form. The amount of mercury after amalgamization must be below 50 wt %. Trituration is accomplished manually in a mortar with a pestle or more often automatically using a capsule of mercury with a given weight and an alloy pellet. The amalgam is placed in the cavity of the tooth in small portions which are pressed with a force of 40-50 N. On the surface of the filling a mercury-rich phase should appear, allowing a good bonding to the following portion. When the cavity is completely filled, the mercuryrich phase must be removed, and the filling can be modelled to the desired shape. 24 hours after the amalgamization the filling must be polished in order to achieve a smooth surface, resulting in a low corrosion rate. ld.1.4 Mechanical properties Table ld.3 Mechanical properties of dental amalgams (Ref. 2) Ultimate compression strength (MPa) After 1 h After setting 120-170 380^50 140-180 380-450 120-330 410-460 230-320 460-540 210^10 430-480 Creep (%) (7 days after amalgamization, pressure 38 MPa) 2.5-3.5 0.3-1.5 0.2-1.7 0.002-0.3 0.06-0.1

Amalgam* LCL LCS HCB HCSS, HCSL ternary alloy HCSS, HCSL quaternary alloy with indium

* LCL = low-copper lathe-cut. LCS = low-copper spherical. HCB = high-copper blended. HCSS = high-copper single-composition spherical. HCSL = high-copper single-composition lathe-cut. ld.1.5 Corrosion and wear Table ld.4 Average passive current density, range of passivity, corrosion and breakdown potential of a non-gamma-2 amalgam in artificial saliva (Ref. 3) Corrosion Breakdown Passive Current Range of Potential Density Passivity Potential (JJLA cm'2) (mV vs. SCE)(mV vs. SCE)(mV vs. SCE) 1.5 -300 - +300 -400
300

Alloy

Non-gamma-2 amalgam

Table ld.5 Repassivation rates in artificial saliva versus standard calomel electrode (Ref. 3) Material Non-gamma-2 amalga m Corrosion Potential Potential (mV) after (mV) Ih 2h 36 h -400I -408 -382 -290

Corrosion of amalgams 1. Corrosion of conventional amalgams The heterogeneous structure of conventional amalgams is responsible for high corrosion. The y2 phase is the most active phase in electrochemical corrosion because it is less noble than 7 and ^1. Therefore an anodic dissolution occurs. The corrosion products of the ^2 phase are 1.1 Sn2+ ions, in the presence of saliva SnO2 and Sn(OH)6Cl 2.2 the released Hg reacts with particles of the 7 phase. 2. Corrosion of the high copper type amalgams Because of the absence of the 72 phase, the Cu6Sn5 phase is the electrochemically based phase. However, the total corrosion current in the non-gamma-2 amalgams is much lower than in the conventional types. Therefore, the amount of corrosion products is much lower than in gamma-2 alloys. An additional advantage of these amalgams is the lack of mercury during corrosion. Generally, to achieve a low corrosion in amalgams certain requirements must be fulfilled: a polished surface no contact with gold (this would lead to a high corrosion of the amalgams, setting mercury free and resulting in a reaction between gold and mercury).

Table ld.6 Rate of release of mercury vapour per unit area of different types of almagam dipped in an isotonic NaCl solution (pH = 6) (Ref. 4) Alloy* LCL HCB HCSS, HCSL In-containing one component New Old New Old New Old New Old Rate of Hg Release (ng/min mm2) 0.011 0.011 0.133 0.017 0.022 0.022 0.222 0.350

LCL = low-copper lathe-cut. HCB = high-copper blended. HCSS = high-copper singlecomposition spherical. HCSL = high-copper single-composition lathe-cut. New = tested within 2 months after amalgamization. Old = tester after 1.5 years after amalgamization.

1D.2 NOBLE METALS ld.2.1 Composition of alloys

Table ld.7 Type* HGC-I HGC-2 HGC-3 HGC-4 HGC-I-C HGC-2-C HGC-3-C HGC-4-C

Chemical composition of high gold-containing dental cast alloys (wt%) (Ref. 5, 6, 8) Au + Pt Metals 88.6 80.5-81.2 78.0-78.5 75.5-80.0 95.0-97.0 95.0 98.0-99.0 82.9-97.4 Au 87.5 75.779.3 74.074.4 65.571.0 80.085.0 70.0 82.686.0 73.884.4 0.31.4 02.4 4.412.9 5.011.0 7.5 9.710.4 8.09.0 Pt Pd 1.0 1.63.3 2.03.5 0.02.0 3.34.4 15.0 02.2 5.08.9 0.1 0.1 0.2 0.5 0.10.3 0.1 01.1 1.6 2.0 01.6 1.29.2 0.34.4 02.0 00.2 Ir 0.1 Rh Ag 11.5 12.315.0 9.613.5 10.014.0 3.05.0 5.0 1.02.0 1.52.5 00.2 00.2 0.5 0.8 4.15.5 7.011.5 8.210.0 0.41.0 0.91.0 0.54.0 00.1 Cu Zn Ta In Re Fe Sn

HGC = high gold-containing (Au + Pt metals > 75 wt%, Pt metals = Pt, Pd, Ir, Rh, Re, Os). 1 = soft, 2 = medium hard, 3 = hard, 4 = extra hard, c = ceramic alloy (bonding with ceramic is possible).

Table ld.8 Type* LGC-4 LGC-4-C

Chemical composition of low gold-containing dental cast alloys (wt%) (Type 4: extra hard) (Ref. 5, 7, 8) Au + Pt Au metals 48.066.7 74.889.8 40.062.2 43.055.1 Pt 04.4 Pd 0 9.9 29.038.5 Ir 0.1 0.10.2 Ag 23.335.0 019.5 Cu 7.012.0 00.3 Sn 01.5 00.5 Zn 0.43.5 In 05.0 09.0 01.5 00.2 00.1 00.2 02.8 Ga Re Ta Fe Co

* LGC-4 = low gold-containing, extra hard (60 wt% < Au + Pt metals < 75 wt%). LGC-4-C = low gold-containing, extra hard, fusible (C = ceramic alloy (a bonding with ceramic is possible).

Table ld.9 Type AgPd-I AgPd-4 Pd-4-C

Chemical composition of AgPd and Pd-alloys (wt%) (Ref. 5, 8) Au + Pt metals 29.5 29.5-40.0 52-88 Au 2.0 <2.0 0-17 <1.0 Pt Pd 27.5 27.4-39.9 25-70 0.1 Ir Ag 70.0 52.0-58.5 7.2-38.0 0-10.5 0-11.6 Cu Sn 0.2 <2.0 1.9-7.5 Zn 0.3 1.5-4.0 <2.0 <2.0 0-4.0 <0.8 0-7.2 <0.5 In Ru Ga Ge

Key: see Table ld.7.

ld.2.2 Physical properties Table ld.10 Physical Properties of precious dental alloys (Ref. 5, 8) Melting Temperature (interval) Mean Coefficient of Young's Modulus Expansion (W-6ZK) 25-6000C (GPa) 92-95 98-109 14.1-14.8 13.6 14.2-14.7 14.0-16.8 13.8-14.8 14.0-15.4 122-126 100-105 102-113 94-106

Alloy HGC-I HGC-2 HGC-3 HGC-4 HGC-I-C HGC-2-C HGC-3-C HGC-4-C LGC-4 LGC-4-C AgPd-I AgPd-4 Pd-4-C

Density (g/cm3) 17.2 16.1-16.4 15.6-15.8 15.6-16.8 18.3-18.6 17.3 18.4-19.5 16.7-18.1 12.1-14.1 14.0-14.8 11.1 10.6-11.1 11.2-12.2

CQ
1030-1080 900-1040 900-975 900-1000 1090-1370 1285-1370 1045-1220 900-1260 770-1065 1150-1315 950-1150 1100-1290

Key: see Table ld.7.

ld.2.3 Processing of Precious Metal Alloys (Ref. 2, 5, 8) Casting

Precious metal alloys are normally cast by means of the lost wax process. The well-known method of wax modelling is applied. For the commonly used casting procedure, centrifugal and vacuum pressure casting, the alloys can be heated by the following methods: resistence propane/oxygen torch (reducing flame zone) HF induction electrical arc

The alloys are melted in graphite or ceramic crucibles. After removal of the crucible the alloys can if required be hardened. After casting or brazing the alloys are descaled. Mechanical cleaning can be carried out with rotating tools, ceramic grinding wheels or rubber polishers. Heat Treatment Depending on the type of alloy and its application, the dental alloys are heat treated. After the casting the alloys are quenched. A homogenization at 7000C followed by rapid cooling should be carried out in order to

decompose grain segregations, especially in alloys containing platinum. After a cold deformation the alloys should be stress-relieved. Precipitation hardening is performed by: slow cooling from 7000C to room temperature cooling from 450 to 2500C in 30 minutes, followed by quenching heating between 350 and 4500C for 15 minutes, followed by quenching

Table ld.12 gives the recommended heat treatments for various noble metal alloys used in dental restoration. Brazing Brazing can be carried out with a torch or in a furnace. For larger surfaces furnace brazing is preferable. The best strength properties are obtained with a solder gap of 0.05 to 0.2 mm between the surfaces. Table ld.ll shows the chemical composition and the brazing temperatures of various filler metals. Bonding with Ceramics Precious metal alloys are cast by the lost wax process. After removal of the crucible with carbide tools the castings are sand-blasted with alumina (100-150 fim, pressure 2 bar) to roughen the surfaces and to provide by increasing the surface an improvement in the adhesion strength. After cleaning with water and hot steam an additional cleaning of the alloys is performed by annealing for 10 minutes at 9800C. The bonding procedure takes place in the temperature range of 800-9000C. After bonding the surface must be carefully cleaned in order to provide good corrosion resistance. The final step of the process is a polishing operation with rotating cotton or wool buffers and a small amount of polishing paste.
Table l d . l l Chemical composition (wt%) and brazing temperatures of various filler metals (Ref. 5, 8) Filler Metals Brazing for Brazing Temp. (0C) Au HGC, LGC 700-840 AgPd HGC-C, LGC-C Pd-4-C 760-820 700-1120 Pt Pd <1.0 1.0 <1.0 <1.0 Ir <0.1 0.1 <0.1 Ag 8.028 13.0 10.0- 028.0 5.0 Cu 09.0 Zn 6.014 12.0 12.0- <2.0 <0.1 14.0 In Re

50- <19 73 73 0.9

<2.0 <0.1

50- <1.9 73

1030-1120 50- <1.9 73

10.0- 3.0- 12.0- <2.0 28.0 5.0 14.0

Key: see Table ld.7.

Table ld.12 Recommended heat treatments for various noble metal alloys (Ref. 5,8) Precipitation Hardening Soft Annealing Oxidizing without Vacuum Alloy Time Temperature (min) (0C) Time Temperature (min) (0C) 15 15 15 15 15 700-800 950 700-800 950 950 Time (min) 10 10 10 Temperature (0C) 960-980 980 980

HGC 15 400 HGC-C 15 500-600 LGC 15 400-500 LGC-C 15 600 AgPd 15 550 Pd-4-C 15 600 Key: see Table ld.7.

ld.2.4 Mechanical properties Table ld.13 Mechanical properties of high gold-containing dental cast alloys (Ref.5, 8) Tensile Yield Strength (0.2 %) (MPa) 80 180-240 330-350 350-390 300-420 540-780 90-130 105-140 230 240 370-420 470-490 380-480 470-600 Ultimate Tensile Strength (MPa) 170 370-390 460 550-590 500-580 710-870 220-280 230-300 400 410 460-515 530-590 530-580 550-650 Ratio Yield/ Tensile Strength 0.47 0.49-0.61 0.72-0.76 0.64-0.66 0.60-0.72 0.76-0.90 0.41-0.46 0.46-0.47 0.58 0.59 0.80-0.82 0.83-0.89 0.72-0.83 0.85-0.92 Elongation at Fracture (%) 45 35^5 35^0 20-23 15-37 5-18 29-38 27-38 20 18 8-15 6-9 7-14 3-6

Type HGC-I HGC-2 HGC-3 HGC-4 HGCl-C HGC-2-C HGC-3-C HGC-4-C

Hardness HVHN 55 95-110 145 170-190 155-195 225-295 60-75 70-90 105 125 150-160 185-200 150-200 220-230

s h s h s h s h s h s h

Key: see Table ld.7. s = soft, h = hardened.

Table ld.14 Mechanical properties of low gold-containing dental cast alloys (Ref.: 5,8) Tensile Elongation Ratio Ultimate Yield Yield/ Tensile Strength at Hardness Tensile Strength (0.2 %) Fracture VHN5 Strength (MPa) (MPa) Type (%) 155-170 18^3 0.65-0.78 480-510 310-400 LGC-4 s 220-275 3-13 0.87-0.93 640-890 555-830 h 180-250 11-26 0.54-0.75 570-790 310-590 LGC-4C s 235-285 6-18 0.77-0.78 710-900 550-700 h
Key: see Table ld.7. irdened s = soft, h = he

Table ld.15 Mechanical properties of AgPd and Pd-alloys (Ref.: 5, 8) Tensile Yield Strength (0.2 %) (MPa) 80 285-595 340-630 Ultimate Tensile Strength (MPa) 230 510-950 630-900 Ratio Yield/ Tensile Strength 0.35 0.56-0.63 0.54-0.70 Elongation at Fracture (%) 33 3-31 8-30

Type AgPd-I AgPd-4 Pd-4-C

Hardness VHN5 55 140-310 180-285

Key: see Table ld.7.

ld.2.5. Corrosion and wear Table ld.16 Polarization current (i) and polarization resistance (Rc) of gold in 0.9% NaCl and in 0.9% NaCl with a stable redox system [Fe(CN)64' / Fe(CN63] at 37 0C corresponding to the potential of the body fluid of 400 mV (Ref. 7, 12) Material Au i (\iA/cm2) 0.009 0.9% NaCl 1100 Rc (kfkm2) saline + redox 028

Table ld.17 Average passive current density, range of passivity, corrosion and breakdown potential of a high gold containing alloy (HGC) in artificial saliva (Ref. 3) Alloy Passive Current Density (pA cm2) L5 Range of Passivity (mV vs. SCE) -100 - +400 Corrosion Potential (mVvs. SCE) 437 Breakdown Potential (mVvs. SCE) 400

HGC

Table ld.18 Repassivation rates in artifical saliva versus standard calomel electrode (Ref. 3) Material Corrosion Potential Potential (mV) after

(mV) HGC 437

Ih ^48

2h ^26

36 h ^26

1D.3 CoCr-ALLOYS See Chapter Ib, CoCr-alloys.

1D.4 NiCr-ALLOYS (REF. 9, 10,11) NiCr-alloys are difficult to classify because of the wide range of the chemical composition, as shown in Table ld.19. The NiCr-alloys in dentistry are generally used for porcelain veneered and unveneered crowns, fixed and removable partial dentures and bridgework. As the processing is similar to that of the CoCr-alloys, it is not described here (see Chapter lb.3). The requirements for these specific applications determine the chemical composition. The corrosion resistance of the NiCr-alloys is provided by the chromium content which produces a passive oxide layer on the surface. Beryllium is added as a solid solution strengthener and supports the self-fluxing at the porcelain veneering temperature. It is also responsible for the good chemical bonding to the porcelain. As it lowers the melting temperature, beryllium also improves the stability. Aluminium also produces a passive oxide layer, aids in the bonding to the porcelain and strengthens the alloy due to the precipitation of AlNi3. Silicon lowers the melting temperature and, like manganese, acts as a deoxidizer. Molybdenum and niobium are added to improve corrosion resistance and, like iron, are used to adapt the thermal expansion coefficient to the coefficient of the porcelain. The wide composition range results in an equally wide range of physical (Table ld.20) and mechanical properties (Table ld.21). The high rigidity and strength of these alloys as compared to that of the precious metal alloys make them suitable for the production of small prosthetic devices.

Table ld.19 Chemical composition (wt%) of the NiCr-alloys used in dentistry Ref. 11) Ni 58 82 Co Fe 0 2 0 9 Cr 12 26 Mo 05 16 Nb O 7 77 O 3 W O 4 We O 1.5 Ga^ Ji O 7.5 O 3 C <05 Others Al, Ce, B, y[n Sn Y V Ta, W Cu

Table ld.20 Physical and mechanical properties of NiCr-alloys used in dentistry (Ref. 11) Melting interval Young's modulus Density Mean coefficient of linear thermal expansion between 25-600 0C 940-1430 0C 170-220 GPa 7.8-8.6 g/cm3 13.9-15.5 106/K

Table ld.21 Mechanical properties of NiCr-alloys used in dentistry (Ref. 12) Tensile Yield Strength (0.2%) (MPa) 255-800 Elongation at Fracture (%) 3-25 Hardness (VHN5) 160-395

REFERENCES 1. Cahn, R.W., Haasen, P. and Kramer, EJ. (eds) (1992) Materials Science and Technology, Vol. 14, VCH. 2. Combe, E. (1984) Zahndrztliche Werkstoffe, Hanser. 3. Elagli, K., Traisnel, M. and Hildebrand, H.F. (1993) Electrochemical Behaviour of Titanium and Dental Alloys in Artificial Saliva. Electrochimica Acta, 38(14), 1769-1774. 881. 4. Berglund, A. (1993) An in vitro and in vivo study of the release of mercury vapor for different types of amalgam alloys. /. Dent. Res. 72 (5), 939-945. 5. Product information, Degussa, Germany. 6. DIN 13906-1 (=EN 21562, ISO 1562) (1990). Beuth. 7. DIN 13906-2 (invalid, replaced by DIN 28891) (1990). Beuth. 8. Product information, Wieland Edelmetalle, Germany. 9. Fraker, A.C., Corrosion of Metallic Implants and Prosthetic Devices, in Metals Handbook, 9th Ed., Vol. 13: Corrosion, p. 1351. 10. Encyclopedia of Materials Science and Engineering, Vol. 2, (1986) Pergamon Press, pp. 1057-1058. 11. NiCo-alloy producing industries. 12. Zitter, H. and Plenk, H. (1987) The Electrochemical Behaviour of Metallic Implant Materials as an Indicator of their Biocompatibility. /. of Biomedical Materials Research, 21, 881.

Composite materials
L. Ambrosio, G. Carotenuto and L. Nicolais

2.1 TYPES OF COMPOSITES AND COMPONENT MATERIALS Composites are combined materials created by the synthetic assembly of two or more components - a selected reinforcing agent and a compatible matrix binder - in order to obtain specific and advanced characteristics and properties. The components of composite do not dissolve or otherwise merge completely into each other, but nevertheless do act in concert. The components as well as the interface between them can usually be physically identified, and it is the behavior and properties of the interface that generally control the properties of the composite. The properties of a composite cannot be achieved by any of the components acting alone. The composites can be classified on the basis of the form of their structural components: fibrous (composed of fibers in a matrix), laminar (composed of layers of materials), and particulate (composed of particles in a matrix). The particulate class can be further subdivided into flake (flat flakes in a matrix) or skeletal (composed of a continuous skeletal matrix filled by a second material). In general, the reinforcing agent can be either fibrous, powdered, spherical, crystalline, or whiskered and either an organic, inorganic, metallic, or ceramic material. 2.2 FIBRE TYPES AND PROPERTIES A summary of the most important reinforcing filaments and their properties is presented in Tables 2.1-2.7.

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

2.2.1 Glass fibers

Glass fibers are the most common of all reinforcing fibers for polymeric matrix composites. Their main advantages are low cost, high tensile strength, high chemical resistance and good insulating properties. On the other hand they display a low tensile modulus, a relatively high density comparated to the other fibers, a high sensitivity to wearing and a low fatigue resistance. Depending on the chemical composition of the glass they are commercially available in different grade: A, C, E, R, S. At one time 'A' or alkali glass was quite common as the basic material for glass fibre production. Today this has been virtually completely superseded by 4 E' or electrical grade glass. E-glass is a very low alkali content borosilicate glass which provides good electrical and mechanical properties, coupled with good chemical resistance. Another glass produced in commercial quantities for fibers production is the C-glass, a special chemical resistant glass. This is used in the manufacture of surfacing tissues to provide additional chemical resistance over E-glass. For specific application 'R' and 'S' glasses are available as fibers. These are high strength glasses used mostly for aerospace applications.

Table 2.1 Compositions and properties of various glasses (4) Compound SiO^ Al 2 O 3 5 Fe 2 O 3 CaO MgO Na 2 O, K 2 O B2O3 BaO 7U) 1.5 10.0 2.5 14.2 A 646 4.1 13.4 3.3 9.6 4.7 0.9 C 52A 14.4 17.2 4.6 0.8 10.6 E R 600 25.0 9.0 6.0 S 64A 25.0 10.3 0.3

Table 2.2 Property

Properties of fiberglass (2) A Grade of class B E S

Physical properties Specific gravity Mohs gravity Mechanical properties Tensile strength, psixlO6 (MPa) At 72 0 F (22 0 C) At 700 0 F (371 0 C) At 1000 0 F (538 0 C) Tensile modulus elasticity at 72 0 F (22 0 C), psixlO6 (GPa) Yield elongation, % Elastic recovery, % Thermal properties Coefficient of thermal linear expansion, in./in./oFxl0-6 (m/m/C) Coefficient of thermal conductivity, Btuin./hr/sq ft/F (watt/motor K) Specific heat at 72 0 F (22 0 C) Softening point, 0 F( 0 C)

2.50

2.49 6.5

2.54 6.5

2.48 6.5

440 (3033) 4.8 (8.6) 1340

440 (3033) 10.0 (69.0) 4.8 100 4.0 (7.2) 0.212 1380 7.0 -

500 (3448) 380 (2620) 250 (1724) 10.5 (72.4) 4.8 100 2.8 (5.0) 72 (10.4) 0.197 1545 498 5.9-6.4 6.3 0.005 0.002 1015

665 (4585) 545 (3758) 350 (2413) 12.4 (85.5) 5.7 100 3.1 (5.6) 0.176

Electrical properties Dielectric strength, V/mil Dielectric constant at 72 0 F (22 0 C) At 60 Hz At 106 Hz 6.9 Dissipation (power) factor at 72 0 F (22 0 C) At 60 Hz At 106 Hz Volume resistivity at 72 0 F (22 0 C) and 500 V DC, M-cm Optical properties Index of refraction Acoustic Properties Velocity of sound, ft/sec (m/sec)

5.0-6.4 5.1 0.003 0.003 1016

1013 17,500 (5330)

104 19,200 (5850)

2.2.2 Aramid fibers

The most common aramid fiber available is the Kevlar 49. These fibers are composed of a highly oriented crystalline polymer and present the highest tensile strength/weight ratio. On the other hand the disadvantages

that they present are the low compressive strength, difficulty of manufacturing and a sensitivity to ultraviolet light and water. However, Kevlar fibers find applications in sporting goods. Table 2.3 Thermal Properties of Kevlar 49 (8)
Property Long-term use at elevated temperature in air, 0C (0F) Decomposition temperature, 0C (0F) Tensile strength, MPa (Ksi) At room temperature for 16 months At 500C (122 0F) in air for 2 months At 1000C (212 0F) in air At 200 0C (392 0F) in air Tensile modulus, GPa (103 Ksi) At room temperature for 16 months At 50 0C (122 0F) in air for 2 months At 100 0C (212 0F) in air At 200 0C (392 0F) in air Shrinkage, %/C (%F) Thermal coefficient of expansion, 10'6 cm/cm 0C Longitudinal, 0-100 0C (32-212 0F) Radial, 0-100 0C (32-212 0F) Specific heat at room temperature, J/gC (Btu/lbF) Thermal conductivity at room temperature, J cm/sec m2oC (Btuin/hr ft2 0F) Heat flow perpendicular to fibers Heat flow parallel to fibers Heat of combustion, kJ/g (Btu/lb) Value 160 (320) 500 (932) No strength loss No strength loss 3170 2720 No modulus loss No modulus loss 113.8 (16.5) 110.3 (16.0) 4 x 10-4 (2.2 x 10-4) -2 +59 1.42 (0.34) 4.110 (0.285) 4.816 (0.334) 34.8 (15,000)

Table 2.4 Properties of Kevlar 29 (2) Specific gravity Tensile strength (GPa) Tensile modulus (GPa) Elongation (%) Filament diameter (|xm) 1.44 2.76 58 4.0 12.1

2.2.3 Boron fibers

These fibers are characterized by an extremely high tensile modulus coupled with a large diameter, offering an excellent resistance to buckling that contributes to a high compressive strength of the composites. Their high cost is due to the processing operations. For this reason boron fibers find application only in aerospace and military contexts.

Table 2.5 Typical Properties of Boron fibers and of other Commercially Available Reinforcement Filaments (1) Filament material Boron SiC-coated boron SiC B4C Boron on carbon Al2O3 Beryllium Tungsten 'Rocket Wire' AFC-77 Diameter
([Lm)

Manufacturing technique CVD CVD CVD CVD CVD Melt withdrawal Wire drawing Wire drawing Wire drawing

Average strength Density N/m2 (Ksi) (g/cm3) 34 (500) 31 (450) 27 (400) 24 (350) 24 (350) 24 (350) 13 (200) 27 (400) 41(600) 2.6 2.7 3.5 2.7 2.2 4.0 1.8 19.2 7.9

Modulus (GN/m2) 400 400 400 400 250 250 400 180

100-150 100-150 100 70-100 100 250 100-250 150-250 50-100

2.2.4 Graphite fibers

Carbon fibers owe their success in high performance composites to their extremely high tensile modulus/weight and tensile strength/weight ratios, high fatigue strength and low coefficient of thermal expansion, coupled with a low ratio of cost to performance. Carbon fibers are commercially available with a variety of moduli ranging from 270 GPa to 600 GPa. They are produced following two different processes, depending on the type of precursors.
Table 2.6 Carbon fibre precursors (2) Carbon content (%wt) ~45 68 70 95 Carbonization yield (%wt) 10-15 40 50 85-90

Precursor material Cellulose fibre Polyacrylonitrile Lignin Hydrocarbon pitch

Table 2.7 Properties of some carbon fibers (2)

Fibre precursor Fibre type Tensile Tensile Elonga- Carbon Trade Diameter Specific strength modulus tion content name (\im) gravity (GPa) (GPa) (%) (%wt)

Hydrocaron pitch Lignin Cellulose Polyacrylonit rile Polyacrylonit rile

Carbon

Kureha

10.5

1.6 1.5 1.67 1.76 1.87

1.03 0.6 2.0 3.2 2.4 390 230 330

2.5 1.5 0.6

99.5 90 99.9

Carbon 10-15 Graphite Thornel 6.6 Carbon Graphil 8 HT Graphite Graphil 8 HM

2.3 MATRIX MATERIALS Polymer matrix resins bind the reinforcing fibers and fabrics together in composite structures. Resins also act as sizing, load distributors, and vibration dampeners in the composite structure. A wide variety of thermoset and thermoplastic resins are used in polymer composites. A summary of the most important materials used as composite matrix and their properties is presented. 2.4 THERMOPLASTIC MATRIX Although many commercial applications for filled thermoplastics exist, use of thermoplastics in advanced composites is still in the developmental stage. In fact, the industry is still split on the use of thermoplastics for advanced composites. According to some, it is difficult to improve the rigidity, stability and thermal and chemical resistance of the thermoset resins currently available. Others believe that the majority of the thermoplastic resins available today not only possess the high-service temperature characteristics required, but also hold the potential of quicker and more economical processing once the existing problems are resolved. The various thermoplastics and their characteristics are described in the following paragraphs: Polyamides, commonly referred to as nylons, are produced by condensation between diamines and diacids or by self-condensation of an amino acid. Like many other resins, the exact chemistry of polyamides can vary and, therefore, so can the final properties. However, all polyamides have low-service temperatures and low melting points. Polyamideimides are marketed by Amoco Chemicals under the trade name Torlon. A polyamideimide is also a good candidate for the production of thermoplastic prepregs. Polycarbonates are noted for an extremely high-impact strength in an unreinforced state. However, compared to such other crystalline polymers as PEEK, a polycarbonate does not bond well to reinforcing fibers. It also has poor chemical resistance, which can be greatly improved by alloying it with thermoplastic polyesters. Although only a small quantity of polycarbonate with carbon fiber reinforcement is used today, primarily for interior aircraft structures, polycarbonate is potentially one of the more promising matrix resins for advanced composites, especially in alloyed versions such as General Electric's Xenoy and Bayer's Makroblend. Polvetheretherketones (PEEK) have excellent properties for use in advanced polymer composites, including lowflammability,low smoke and toxic gas emission, and broad chemical and solvent resistance. PEEK

possesses a continuous service temperature of 2000C to 2400C (392F to 464F) and has a very high melting point of 334C (633F). PEEK also provides excellent abrasion resistance at its service temperature, radiation resistance, excellent fatigue and wear resistance and a relatively low specific gravity of 1.32. It is possible to process PEEK on conventional extrusion and molding equipment, and its highly crystalline nature responds well to fiber reinforcement. Polyetherimides (PEI) have been commercially introduced by General Electric as ULTEM, and the company states that it could be a possible matrix for carbon fiber. Polyether sulfones (PES) are also amorphous in structure. Although PES has poor resistance to solvents, it possesses several valuable properties. The resin is capable of providing thousands of hours of service at temperatures up to 1800C (356F) and has very good load-bearing properties. It is dimensionally stable up to 2000C (392F) and, like PEEK, possesses excellent flame resistance and favorable processing characteristics. In addition to thermoset polyimides, several thermoplastic polyimides are offered for high-temperature applications. Although difficult to process, these resins maintain favorable performance characteristics up to a higher temperature, 371C (7000F), than their thermoset counterparts. Polyphenylene sulfides (PPS), partially crystalline polymers, are produced by the reaction of p-dichlorobenzene and sodium sulfide. This polymer has metallic-like properties and responds well to reinforcement. PPS possesses good creep and good moisture resistance and a low coefficient of thermal expansion.

2.5 THERMOSETS MATRIX The basic difference between thermoset and thermoplastic resins is the reaction heat. A thermoset resin is cured by the application of heat and often by the addition chemicals called curing agents. Once cured, the material is infusible, unsoluble and can softened or reworked with the addition of heat. A thermoplastic, on the other hand, is capable of being repeatedly softened by addition of heat and hardened by decreasing temperature. The change occurring thermoplastic resin with the addition of heat is primarily physical, not chemical. This different provides one major advantage for thermoplastics: any scrap from fabrication can be reused. Thermoset resins can vary greatly with respect to service temperature, solvent resist and other important characteristics. A description follows of the various thermoset resin their basic characteristics.

2.6 VINYL ESTER RESINS

Vinyl ester resins are thermosetting resins that consist of a polymer backbone with acrylate or methacrylate termination. The backbone component of vinyl ester resins can derived from an epoxide resins, polyester resins, urethane resin, and so on, but those base epoxide resins are of particular commercial significance. Vinyl ester resins are produced by the addition of ethylenically unsaturated carbo acids (methacrylic or acrylic acid) to an epoxide resin (usually of the bisphenol epichlorohydrin type). The reaction of acid addition to the epoxide ring (esterification exothermic and produces a hydroxyl group without the formation of by-products. Appropriate diluents and polymerization inhibitors are added during or after esterification. Epoxide resins that have been used to produce vinyl ester resins include: bisphenol A types (general-purpose and heat-resistant vinyl esters) phenolic-novolac types (heat-resistant vinyl esters) tetrabromo bisphenol A types (fire-retardant vinyl esters)

Vinyl ester resins contain double bonds that react and crosslink in the presence of free radicals produced by chemical, thermal or radiation sources.

2.7 EPOXIDE RESINS Epoxide are materials which contain two or more glycidyl groups per molecule. The uncured resins range from free flowing liquids to high melting solids, which can be cross-linked by reaction with an appropriate curing agent. Typical curing agents include primary and secondary amines, polyamides and organic anhydrides. Other curing agents used are the catalytic curing agents, such as the boron trifluoride complexes. No by-products are evolved during cure. The resultant cured resins are generally hard thermoset materials with excellent mechanical, chemical and electrical properties. These materials can be conveniently divided into six classes of resins: bisphenol A based (e.g. diglycidyl ether of bisphenol-A (DGEBA)) glycidyl esters glycidyl amines (e.g. tetraglycidyl amine of 4,4-diamino-diphenylmethane) novolacs brominated resins (e.g. diglycidyl ether of tetrabromobisphenol A) cycloaliphatic resins (e.g. Tetraglycidyl ether of tetraphenylene ethane)

2.8 DILUENTS Diluents are added to epoxide resins primarily to lower viscosity and thus to improve handling characteristics. They also modify the cured properties of the resin. Diluents can be divided into two classes: (a) the reactive diluents and (b) the non-reactive diluents. 2.8.1 Reactive diluents Butane-l,4-diol diglycidyl ether n-Butyl glycidyl ether (nBGE) Glycidyl methacrylate Phenyl glycidyl ether (PGE) 2-Ethylhexyl glycidyl ether (2EHGE) Iso-octyl glycidyl ether (IOGE) Diethylene glycol monobutyl glycidyl ether Cresyl glycidyl ether (CGE) p-t-Butylphenil glicidyl ether Epoxide 7 (C8-C10 glycidyl ether) Epoxide 8 (C12-C14 glycidyl ether) Dibromocresyl glycidyl ether (BROC) Dibromophenyl glycidyl ether (DER 599)

2.8.2 Non reactive diluents Benzyl alcohol Furfuryl alcohol Dibutyl phthalate (DBP)

2.9 CURING AGENTS FOR EPOXIDE RESINS These are known variously as curing agents, hardeners, activators or catalysts. They are required to convert liquid and solid epoxide resins into tough infusible thermoset polymers. The curing agents promote this curing reaction by opening the epoxide ring and become chemically bound into the resin in the process. Each of the curing agents for epoxide resins will now be discussed in turn.
2.9.1 Amine curing agents

Amine curing agents may be primary or secondary amines, aliphatic, alicyclic or aromatic. The reaction with an epoxide resin is an addition reaction where the amine links directly with an epoxide group to form a

combined polymer, with hydroxyl groups formed during the reaction. The amines commonly used are the following: Ethylenediamine (EDA) Trimethylhexamethylenediamine (TMD) Diethylenetriamine (DTA) 2-Hydroxyethyldiethylenetriamine (T) Dipropylenetriamine (DPTA) Triethylenetetramine (TETA) Tetraethylenepentamine (TEPA) Diethylaminopropylamine (DEAPA) Dimethylaminpropylamine (DMAPA) m-Xylylenediamine (mXDA) N-Aminoethylpiperazine (AEP)

2.9.2 Anhydride curing agent

These consist of organic anhydrides and are used in roughly stoichiometric proportions with epoxide resins. The anhydride commonly used are the following: Phthalic anhydride (EPA) Tetrahydrophthalic anhydride (THPA) Methyltetrahydrophthalic anhydride (MTHPA) Endomethylenetetrahydrophthalic anhydride (NA) Hexahydrophthalic anhydride (HHPA) Methylhexahydrophthalic anhydride (MHPA) Trimellitic anhydride (TMA) Pyromellitic dianhydride (PDMA) Dodecenylsuccinic anhydride (DDSA)

2.9.3 Accelerators for anhydride cured systems

Various accelerators can be used with epoxy/anhydride systems to promote cure. Some accelerators in use are: Benzyldimethylamine (BDMA) Tris(dimethylaminomethyl)phenol 1-Methylimidazole (DY 070 from Ciba-Geigy) N-Butylimidazole 2-Ethyl-4-mathylimidazole Triamylammonium phenate (DY 063 from Ciba-Geigy)

2.9.4 Polyamide curing agents

The polyamides used to cure epoxide resins are all reactive compounds with free amine groups. They may be amidopolyamines, aminopolyamides

or imidazolines. They are mostly used in coating systems and in adhesive formulations. Some suppliers of polyamide curing agents are listed below: Ancamide (Anchor Chemical Co, Ltd) Araldite (Ciba-Geigy Plastics & Additives Co.) Versamid, Genamid, Synolide (Cray Valley Products Ltd) Plastamid (Croda Resin Ltd) Grilonit (Grilon (UK) Ltd) Beckopox (Hoechst AG(Reichhold Albert Chemie AG)) Euredur (Schering Chemicals Ltd) Epikure (Shell Chemicals UK Ltd) Casamid (Thomas Swan & Co. Ltd) Uracure (Synthetic Resins Ltd) Thiokol (Thiokol Chemicals Ltd) Wolfamid (Victor Wolf Ltd)

2.9.5 Other curing agents Several other types of curing agent are used with epoxide resins for laminating applications or in moulding compounds. Examples of these curing agents are: Dicyandiamide (Dicy) Boron trifluoride complexes Boron trifluoride monoethylamine 2-Ethyl-4-methylimidazole N-n-Butylimidazole

2.10 POLYESTER RESINS The basic materials used to make a polyester resin are a dibasic organic acid or anhydride and a dihydric alcohol. 2.10.1 Catalysts or initiators Catalyst or initiators for unsaturated polyester resin system consist of organic peroxides. Some commercially available catalysts are: Diacyl peroxides (benzoyl peroxide, 2,4-dichlorobenzoyl peroxide, dilauroyl peroxide, diacetyl peroxide). Ketone peroxides (methyl ethyl ketone peroxide, cyclohexanone peroxide, acetylacetone peroxide, methyl isobutyl ketone peroxide). Hydroperoxides (t-butyl hydroperoxide, cumene hydroperoxide). Dialkyl and diaralkyl peroxides (dicumyl peroxide, di-t-butyl peroxide, t-butyl cumyl peroxide, 2,5-dimethyl-2,5-bis(t-butylperoxy)hexane).

Peroxyesters (t-butyl peroxybenzoate, t-butyl peroxydiethylacetate, t-butyl peroxyester, t-butyl peroxyisononanoate, t-butyl peroctoate, dit-butyl diperoxyphthalate, t-buthyl peroxypivalate). Perketals (2,2-bis(t-butylperoxy)butane, 1 ,l-bis(t-butylperoxy)cyclohexane, l,l-bis(t-butylperoxy)-3,3,5-trimethylcyclohexane).

2.10.2 Accelerators or promotors

These are materials which when used in conjunction with an organic peroxide catalyst increase the rate at which that peroxide breaks down into free radicals. Some of the commercially available accelerators are: Cobalt accelerators: cobalt siccatolate, naphthenate or octoate Manganese accelerators: manganese salts Vanadium accelerators Tertiary amine accelerators: dimethylaniline (used to accelerate diacyl peroxide catalysed system); diethylaniline (used to accelerate benzoyl peroxide catalysed system); dimethyl-p-toluidine (used to accelerate benzoyl peroxide catalysed system).

2.11 LAMINATE PROPERTIES Current attitudes regarding composite materials emphasize the relationship of structural performance to the properties of a ply. A 'ply' is a thin sheet of material consisting of an oriented array of fibers, embedded in a continuous matrix material. These plies are stacked one upon other, in a definite sequence and orientation, and bonded together yielding a laminate with tailored properties. The properties of the laminate are related to the properties of the ply by the specification of the ply thickness, stacking sequence, and the orientation of each ply. The properties of the ply are, in turn, specified by the properties of the fibers and the matrix, their volumetric concentration, and geometric packing in the ply. Generally, the material is preformed and can be purchased in a continuous compliant tape or sheet form which is in a chemically semicured condition. Fabrication of structural items involves using this 'prepreg' material, either winding it on to a mandrel or cutting and stacking it on to a mold, after which heat and pressure or tension is applied to complete the chemical hardening process. The basis for engineering design of a such material is then the properties of a cured ply or lamina as it exists in a laminate. This ply is treated as a thin two-dimensional item and is mechanically characterized by its stress-strain response to: (i) loading in the direction of the filaments, which exhibits a nearly linear response up to a large fracture stress; (ii) loading

in the direction transverse to the filament orientation, which exhibits a significantly decreased moduli and strength, and (iii) the response of the material to an in-plane shear load. By the contrast with isotropic metallic materials, an oriented ply, in the form of a thin sheet, is anisotropic and requires four elastic (plane stress) constants to specify its stiffness properties in its natural orientation

(2.1) where a6 = T12 and e6 = T12 or in matrix form

(2.2) where the plane stress stiffness moduli are

(2.3)

where vtj is the Poisson ratio, defined as - e ^ . If, however, the ply is rotated with respect to the applied stress or strain direction additional moduli appear, which results in the direction-indicated shear coupling rotation simple extension

(2.4) where

(2.5) The invariants U1 to the rotation are

(2.6)

In addition, lamination can result in up to 18 elastic coefficients and increased deformational complexities, but the additional coefficients can all be derived from the four primary coefficients using the concept of rotation and ply-stacking sequence. These complications are the result of geometric variables. If the laminate is properly constructed, the in-plane stretching or stiffness properties can still be specified by four elastic coefficients. We shall consider laminates of this nature. Note that both short and continuous fibers are handled in the same manner. These calculations, while tedious, are analytically simple. The 'plane stress', the Q1J terms, are employed because lamination neglects the mechanical properties through the ply thickness. These stiffnesses are sometimes regrouped into new constants called 'invariants', the U1 terms, for analytical simplicity. To compute the properties of the laminate one then sums the ply (hk) properties through the thickness of the laminate, weighted by the thickness (hk) of each oriented ply

For a balanced (same number of 6) and symmetrical system (+9 or -6 at same distance above and below the midplane) the laminate solution is

(2.7)

Note the inverted terms Ay yield the required elastic properties of the laminate in terms of the individual ply properties E11, E12 and G12.

(2.8) These calculations have been thoroughly tested and agree closely with experiment. The circles and squares are the experimental points and the lines are the theoretical predictions for a nylon fiber reinforced rubber. The angle ply laminate is predicted from the ply properties. The

ply properties are in turn correlated with the transformation equations and the micromechanics. The micromechanics employed in this demonstration are based upon the 'self-consistent method' developed by Hill (8). Hill rigorously modeled the composite as a single fiber, encased in a cylinder of matrix, with both embedded in an unbounded homogeneous medium which is macroscopically indistinguishable from the composite. Hermann (9) employed this model to obtain solution in terms of Hill's 'reduced moduli'. Halpin and Tsai (10) reduced Hermann's solution to simpler analytical form and extended its use for a variety of filament geometries

(2.9) where

(2.10) These equations are suitable for single calculation and were employed previously for the single ply and angle ply properties. The short fiber composite properties are also given by the Halpin-Tsai equations where the moduli in the fiber orientation direction is a sensitive function of aspect ratio (1/d) at small aspect ratios and has the same properties of a continuous fiber composite at large but finite aspect ratios. If the ply is used in the construction of a balanced and symmetrical 0/90 laminate and is mechanically tested, bilinear stress/strain curve is obtained, and the stiffness is the sum, through the thickness of the plane stress stiffness of each layer. As the laminate is deformed each ply possesses the same in-plane strain, and when the strain on the 90 layers in the laminate prevents the 90 layer from carrying its share of the load, Qij(90)=0. This load is transferred to the unbroken layers, the 0 layers for our illustration, and results in a loss of laminate stiffness or modulus. Continual loading will ultimately produce a catastrophic failure of the laminate when the strain capability of the unbroken, 0, layers is exceeded. For a 0/90 construction, employing glass/epoxy material, the ratio of the ultimate failure stress to the crazing stress is 6.1. Note a change in stiffness as the 90 and then the 45 layers fail, and the correspondence of the theoretical ultimate strength of 356 MPa with the experimental results of 346 MPa. While the strain for transverse ply failure is constant from laminate to laminate, the stress required to craze the system as well as cause final failure is a function of laminate geometry, because the

construction of the laminate specifies the stiffness properties (crazing stress = stiffness x allowable transverse ply strain). It must be noticed that the area under the stress/strain curve is proportional to the impact energy. Therefore, lamination permits the engineer to tailor afixedprepreg system to meet the conflicting stress/strain demands at different points in a structure. A further point, the crazing stress threshold is generally at or below the creep fracture or fatigue limit for all classes of composites (for glass/epoxy the fatigue limit lies between 0.25 and 0.30 of static ultirtiate strength). Boron and graphite are fatigue insensitive filaments, thus no fatigue damage is realized below first ply failure. Thus, the material properties of a laminate are specified in terms of the ply engineering moduli, E11, E22, v12 and G12; the engineering strains to failure, C1, 2 and e6; and the thermal expansion coefficients, C1 and e2. 2.12 COMPOSITE FABRICATION Various fabrications used in the reinforced plastics industry are discussed below:
2.12.1 Hand lay-up and spray-up procedures

In one of the simplest and labor intensive procedures, pigmented, catalysed resin is applied to the surface of the mold. This gel coat in room temperature lay-up techniques will end up on the surface of the finished composite (FRP). Catalysed resin-impregnated mat is then applied over the gel coat and this and subsequent layers are brushed or rolled to assure good contact between layers and to remove any entrapped air. This procedure is continued until the desired thickness of the composite is attained. The assembled composite may be cured at room temperature or at elevated temperatures for faster cycles. This procedure, which was originally called contact molding, may be upgraded by the application of a vacuum or pressure bag placed over a Cellophane film on the final layer to reduce void formation in the composite. The laminate may also be built up by a spray-up process in which a mixture of chopped glass strands and catalysed resin is sprayed on the gel coat instead of resin-impregnated mat. In any case, the inner surface will be less smooth than the first layer formed by the gel coat. Tanks, boats and pipe may be fabricated by this technique.
2.12.2 Centrifugal casting

Fiber-reinforced plastic pipe (FRP) can be produced by rotating a mixture of chopped strand and catalysed resin inside a hollow mandrel. Because

of differences in specific gravity, there is a tendency for these composites to be less homogeneous than those produced by other techniques. In addition to being available as continuous filaments and staple fibers in mats, fiberglass textiles are also available as biaxial, triaxial, knitted and three dimensional braided patterns. Many different resin matrices are in use but the emphasis in this chapter will be on unsaturated polyester and epoxy resins. While the strength and stiffness are controlled primarily by the reinforcements, the resinous matrix contributes to thermal conductivity andflexibility.The ultimate properties of these composites are based on a harmonious contribution of both the continuous and discontinuous phases.
2.12.3 Matched die molding

Matched die molding of a premix of chopped glass, roving, and catalyzed resin is used for relatively large scale production of reinforced articles. Uncured dough-like compositions are called bulk molding compounds (BMC). Uncured resin-impregnated sheets are called sheet molding compound (SMC). These compounds are supplemented by thick molding compounds (TMC) and XMC. TMC is produced continuously on a machine that resembles a 2 roll mill. XMC, in which the continuous impregnated fiber are arranged in an X-pattern, is produced on a filament winding machine. Autoclave molding Autoclave molding, the process of curing thermoset resins at elevated temperature and pressure in an inert environment, has an important role in the fabrication of continuous fiber reinforced thermoplastics. While most companies view thermoplastics as an alternative to traditional autoclave long-cycle processing, they have come to accept the following reasons for the autoclave processing of thermoplastic matrices: Availability High temperature and pressure capability Reduced tooling requirements Uniform pressure distribution.

The dominant reason for the autoclaves' role in thermoplastics production is its availability. Aerospace first- and second-tier contractors, who conducted much of the developmental work in parts fabrication, all have autoclaves on hand. While it may seem defeatist to use the autoclave for thermoplastic resins which undergo no chemical reaction and lend themselves to rapid fabrication, autoclave use offers other advantages.

In the industry, many fabricators own autoclaves capable of processing high temperature thermosets (e.g. polyimides) at operating temperatures up to 800 0 F and pressures of 150 to 200 psi; which can also accommodate high temperature thermoplastics such as PEEK, which is normally processed in the 700 to 750 0 F range. One disadvantage, particularly for production-sized autoclaves, is the inability to finely control cool-down rate - a critical process step for the semicrystalline thermoplastics. This situation can be improved by implementing integrally cooled tooling. Where high consolidation pressures are required, the autoclave can reduce tooling costs by eliminating the need for matched metal tooling, when compared to a molding process (e.g. compression molding or thermoforming). Less expensive tooling aids can be used for consolidation via the autoclave's pressurized environment. The autoclave also provides uniform pressure over the part's area and eliminates pressure distribution concerns associated with a matched tool in a press. Thermoforming Thermoforming offers vast potential for high volume thermoplastic composite parts fabrication. There are many thermoforming variations; but by basic definition, thermoforming is the heating of a reinforced thermoplastic matrix sheet or kit above the softening temperature, followed by forcing the material against a contour by mechanical (e.g. matched tooling, plug) or pneumatic (e.g. differential air or hydraulic) means. The material is then held and cooled sufficiently for shape retention, and removed from the mold. Thermoforming implies only those processes applicable to thermoplastic resins, and is often used in the same context as the term 'compression molding' which also applies to thermosets. In this section, the process is defined as the preheating of the lay-up or reconsolidated sheet, followed forming via a matched mold. Phillips Petroleum has applied this technology to fabric reinforced Ryton (PPS) materials. A conveyorized infrared oven is used to rapidly preheat the lay-up to 600 0 F in two to three minutes. The charge is quickly transferred to a preheated mold in a fast closing press for part forming. Total cycle times of one to three minutes are feasible with this automated approach. High production rates can be achieved using thermoforming technology. However, it is difficult to form high quality continuous fiber reinforced thermoplastic parts with demanding geometries, due to the restricted movement of the fiber. Du Pont's long discontinuous fiber sheet products with PEEK and J-2 resins provide easier fabrication of complex shapes. This product form is particularly attractive to helicopter manufacturers for the press forming of highly contoured secondary structure parts.

Transfer molding Transfer molding is used for the manufacture of small components and is particularly useful with multi-cavity tools and where small inserts are to be moulded in. Materials used are polyester and epoxide dough moulding compounds, although a new liquid resin injection technique is reported. Heated steel molds, preferably hard chrome plated, are used, which may be of multicavity design. Tooling costs are higher than for compression moulding since appropriate gates and runners must be included in the mould. A pre-weighed quantity of DMC is placed in a heated transfer pot by hand. A punch or ram compresses the material and causes it to flow into the heated tool cavity where it cures. The tool is mounted between the platens of a press. Factors to be considered with transfer molding are transfer and tool clamping pressures and transfer time. To reduce transfer time and increase overall efficiency the molding compound may be pre-heated in an oven or high frequency pre-heater such as a micro-wave oven. Mold temperatures range from 155 to 1700C both for polyester and epoxide resin compounds, with molding pressures ranging from 5 to 100 MPa depending on the type of compound to be processed, mold design and temperature. Cure time in the mold (excluding pre-heat time) is usually of the order of 10-30 s per millimetre of wall thickness for both types of compound. Injection molding Injection molding, a technique used extensively for the processing of thermoplastic materials, has also been developed to process thermosetting resin systems. Due to high mould costs it is generally only suitable for the large scale production of small-to-medium sized components. Materials processed in this way are polyester and epoxy DMC and also phenolics, ureas, melamines and diallyl phthalate moulding compounds. These latter materials are generally more difficult to process than either polyester or epoxy DMC. Thermoset moldings produced by injection moulding are used widely in the electrical and automotive fields, thus large production runs are common. Injection molding has advantages over both compression and transfer molding in that the process is more automated and far higher production rates can be achieved. Although mould costs are higher than for compression molding, overall finished component costs are generally lower. With small weight components, scrap from runners can be high compared

with compression molding but for large mouldings this becomes relatively insignificant. Injection molding is also better for thick parts since, with the pre-heating of the DMC before injection into the mold, shorter molding cycles are possible. While injection molding machines designed specifically for processing thermoset materials are available, a number of manufacturers offer replacement screw and barrel assemblies and stuffer hoppers to convert conventional thermoplastic injection moulding machines to process thermosets. Molding compound is transferred in the cold state by pressure from the material hopper into the main injection chamber. Here it can be preheated before injection into the heated mould tool. Injection, through a special nozzle, can be either by ram or screw pressure. If screw feed is used, the screw must be of the type designed to process thermosets as opposed to thermoplastics. Early machines were designed with vertical clamping pressure on the mold but today horizontal machines are mostly used. Since thermosetting materials are liquid until gelation occurs, clamping pressure has to be maintained on the mould until the resin has cured. Unless this is done, excessive flash will form. Heated matched metal molds are used, which may be of multi-cavity design. These molds must be designed for use with thermosetting resins, taking into account the fact that thermoset moldings are harder, more rigid and less easily deformed than thermoplastics. A typical temperature sequence for injection molding DMC would be: feed hopper and feed zone - ambient temperature; metering section 50-600C; nozzle 80-900C; mould temperature 135-185C for polyester DMC or 160-220C for epoxy DMC; injection pressure 80-160 MPa. Cure time is generally of the order of 10-20 s per millimetre of wall thickness. Very little finishing of moldings is necessary. Where fully automatic molding machines are used, hydraulic ejection with perhaps a 'joggle' facility is necessary, since thermosets have a tendency to stick in the mold.
2.12.4 Filament winding

Filament winding is a technique used for the manufacture of pipes, tubes, cylinders and spheres and is frequently used for the construction of large tanks and pipework for the chemical industry. By suitable design, filament wound structures can be fabricated to withstand very high pressures in service. In general, products fabricated by filament winding have the highest strength to weight ratios and can have glass contents of up to 80% by weight. The process is suitable for use both with polyester and epoxide resin systems and a variety of fibres including glass, carbon, aramid and metals,

providing that these materials are available in continuous filament lengths. Glass fibre is by far the most common reinforcement used and will be used as the example in the description of the process. Filament winding is basically a simple process, although numerous modifications have been developed to improve product quality. Moldings can be produced by either a wet lay-up process or from prepreg. In recent years filament winding has been extended to the continuous production of pipe using a continuous steel band mandrel. In this way continuous lengths of pipe can be produced, with diameters ranging from about 0.3 to 3.5 m.
2.12.5 Wet lay-up

With the wet lay-up process glass rovings are drawn through a resin bath to impregnate them with resin. The impregnated rovings are then wound under tension round a rotating mandrel. Generally the feed head supplying the rovings to the mandrel traverses backwards and forwards along the mandrel. The mandrel, which may be segmented for large diameter pipes, is generally wrapped with a release film, such as Cellophane, prior to wrapping with glass and resin. The mandrel may incorporate some means of heating the resin system, such as embedded electric heaters, or provision for steam heating. Alternatively, the fully wrapped mandrel and laminate may be transferred to a curing oven to effect cure. In order to provide a resin-rich, corrosion resistant inner lining to the pipe, the mandrel may be wrapped with a surfacing tissue followed by one or two layers of chopped strand mat or woven tape prior to filament winding. This first layer is usually allowed to cure partially before winding commences to prevent the resin from being squeezed out into the main laminate. The winding angle used during construction of pipes or tanks depends on the strength/performance requirements and may vary from longitudinal through helical to circumferential. Often a combination of different winding patterns is used to give optimum performance. Accurate fibre alignment is possible. For pipe construction, steel mandrels are generally used. However, where cylinders or spheres are to be made, an alternative material has to be used so that it can be removed once the resin system has cured. In these cases the mandrel can be made from wax, a low melting metal alloy, or an inert plaster held together with a water soluble binder. Clearly, in these cases the mandrel can only be used once. Material choice for the mandrel will depend on the cure cycle needed for the resin system. In addition to winding with continuous filament rovings, machines have been developed which permit winding with tapes or slit-width chopped

strand mat and woven rovings. These reinforcements may be used alone or combined with continuous filament rovings. Thus considerable design flexibility exists for the production of large simple shapes. Improved chemical resistance can be achieved by the use of a thermoplastic or synthetic rubber liner. If the liner is sufficiently rigid it can be supported on a light frame and used as the mandrel, if not then it can be wrapped round the mandrel first. A grade of polypropylene is available which has a woven glass cloth partially rolled into one side to improve adhesion of the resin system (Celmar). Dunlop has recently developed a new process for pipe production to produce pipes in the range 200-2000 mm diameter. Essentially the process is similar to conventional filament winding. A mandrel, suitably coated with release agent, is wrapped with an epoxide resin impregnated glass tape over this is wound a 150 mm high-strength steel strip angled to give 50% overlap. Epoxide resin system is applied to the steel strip to ensure that each layer is fully encapsulated. From three to 13 layers of steel may be applied to satisfy different pressure ratings. The pipe is finished by wrapping with further resin impregnated glass tape and the resin system cured. Pipe produced in this way has excellent corrosion resistance coupled with a high strength/weight ratio. It is said to provide up to 50% weight saving over conventional steel pipe. Various processes are available for the 'on-site' construction of large filament wound storage tanks. By manufacturing these on site, transport problems are overcome and integral structures can be produced. With the various processes either horizontal or vertical mandrels are first constructed from preformed GRP sheets. These are then wrapped with resin impregnated glass rovings. Filament wound vessels can be produced from prepreg tapes and rovings. This technique is often used with carbon fibre to reduce fibre damage during the winding operation and to permit the use of resin systems which cannot be handled by wet lay-up techniques. Here, it is essential to use a heated mandrel to melt the resin and hence displace air and consolidate and cure the laminate. Resin content of the laminate can be controlled more accurately with prepreg since the prepreg can be made with exactly the right resin content. The use of prepregs also makes for cleaner operation. Filament winding has been used to provide a protective laminate on the outside of steel pressure pipes where external corrosion can take place. An example of this use is in the protection of the splash zone of steel riser pipes used on sea based oil and gas production platforms. Here, care has to be taken in the design of such a composite structure since the coefficient of expansion of the filament wound glass wrap can be lower than that of the steel core. If such a composite structure is produced using a heat cured resin system (say 12O0C cure) and then subjected to subzero temperatures

in use, the steel pipe can shrink away from the laminate and permit entry of water by capillary action. Thus the object of wrapping the pipe to prevent corrosion can be defeated, since corrosion can then still take place under the laminate, once the bond has broken it can never be remade.
2.12.6 Centrifugal moulding

Centrifugal moulding or casting is a method used for making cylindrical objects with uniform wall thickness. It is mainly used for the production of large diameter pipes, up to 5 m in diameter, from either polyester or vinyl ester resin systems, although epoxide resin systems may also be used. Pipes produced in this way are void-free and smooth on both the inner and outer surfaces. Threaded sections can be molded into the external wall if required. More recently, a system has been developed for producing tapered and curved poles by centrifugal casting. Molds need to be bored and polished to a mirror finish and of sufficient strength to withstand, without distortion, the high G-force exerted during spinning. A steam jacket or other means of heating may be built into the mould to cure the resin system, or alternatively hot air may be blown through the mold. Release agents used include silicones, bake-on PTFE types or PVA, although silicones are generally preferred. If the exterior of the finished pipe is to be painted then a silicone release agent should not be used. Choice of resin system must depend on application and a heat cured resin may be used, particularly where chemical resistance is required. In addition, the process lends itself to the use of several different resin systems incorporated in the one pipe, such as an abrasion resistant outer skin, a general purpose centre and a chemically resistant inner skin. The resin system used should have some degree of flexibility to give good impact resistance to the pipe, coupled with good chemical resistance. To achieve both of these requirements in the one resin system may require a compromise in properties. Various methods of fabrication can be used. With large diameter moulds, glass and resin can be applied by the hand lay-up technique using a slow gel resin system so that the whole mold can be coated and the mould spun before gelation of the resin takes place. Here, it is necessary to tailor the reinforcement to shape to avoid overlaps. Alternatively, the reinforcement may be wrapped round a mandrel, inserted into the mould and then unwound onto the mould surface. The mandrel is removed before resin is injected into the mold. With this technique a faster gelling resin system may be used. Woven fabrics and chopped strand mat are suitable reinforcements. A third method, capable of being fully automated, is generally preferred. Here, resin and glass are applied to the mold surface utilizing

a travelling feeder arm fitted with a chopper and spray gun, which passes slowly backwards and forwards through the mold while the mold is rotated. The laminate can be built up in layers of 0.5-1 mm thickness per pass once the reinforcement and resin system have been placed in the mold it is rotated at up to 2500 revolutions per minute (rpm) depending on mold diameter, the larger the mould diameter the slower the speed. For example, with a 2 m diameter mould a rotation speed of about 180 rpm is used. At this speed the mould surface is rotating at about 68 km/h (42.4 mph). After the main resin system has gelled, a chemically resistant topcoat may be applied while the mold is still rotating. Mold rotation is continued until all the resin has cured. In all of the above techniques, a relatively flexible glass reinforced resin pipe is produced, with properties similar to some of those made by filament winding. To produce stiffer pipes a modification to the spray technique has been developed and is in use commercially. Stiffer pipes, particularly in the larger diameter range, offer considerable advantages in handling and installation and maintain their shape during installation. With this modified process, which is fully automatic, the mold is coated with release agent and rotated at a suitable speed. The feeder arm is designed in such a way that it can deliver programmed amounts of resin, chopped glass and a filler such as sand, to the mold surface as it moves in and out of the mold. In this way a layer of abrasion resistant sand filled resin system can be applied to the mold surface over this is applied a layer of glass reinforced resin. By suitable design of the chopper unit, fibre orientation can be controlled. Next a layer of sand filled resin is applied followed by a further layer of glass reinforced resin. Depending on the type and size of pipe to be produced, several more layers of GRP alternated with filled resin may be added. Finally, the inner surface is coated with a suitable chemically resistant layer of resin, which may be lightly filled or reinforced, to give a smooth corrosion resistant lining. The equipment used can be programmed to feed materials to the mould to build up the pipe wall thickness at a rate of between 0.5 and 1 mm per pass and to compact the materials by centrifugal force throughout the whole production cycle once the final layer of resin has been applied, hot air is passed through the mold to assist curing of the resin system. The mould is cooled to ambient temperature to assist removal of the finished pipe, which is pushed out using a hydraulically operated ram. Using this technique, rigid hard wearing pipes can be produced, tailored to meet end user requirements. This is a simplified version of the pipes produced commercially, to illustrate pipe construction. In practice several more layers of glass and sand filled system may be incorporated in the pipe wall. A range of bends and joints is also available to meet most needs.

In the Usui process for producing tapered pipes, the glass fibre reinforcement is wound round a tapered mandrel to make a preform. This is inserted into the mould in the centrifugal machine and the mandrel removed. Resin is poured in and the mold tilted to a pre-determined angle and then rotated until the resin has cured. To produce a curved tapered pipe, a flexible mold is used. This is bent to the required shape once the preform has been placed in position. It is also claimed that base plates can be simultaneously molded on by this method. These base plates are first preformed and then inserted into the mold where they become firmly bonded into the pole. Typical applications include poles for street lighting, flag poles and aerials.
2.12.7 Continuous sheet manufacture

For the purposes of this book, only those processes for which polyester resins and, to a limited extent, epoxide resins are used will be described. It should be noted, however, that the decorative laminates used in building and transport applications are in the main manufactured from melamine faced phenolic resin/paper laminates. Several patented processes exist for continuous sheet production, all of which are similar in broad principle. Resin and glass reinforcement are sandwiched between two sheets of release film, such as Melinex, Mylar or Cellophane and passed through rollers to consolidate the laminate before curing in an oven. Resin is applied to the release film either by spray or trickle process, care being taken to ensure that application is uniform. Glass reinforcement is laid in the resin and a second layer of release film applied. This sandwich is passed through a series of rollers to expel all air bubbles and consolidate the laminate to the correct thickness. During the next stage the laminate sandwich is either passed directly through an oven to produce flat sheet or through rollers or dies and then an oven to produce corrugated sheet. Once cured the sheet is trimmed to the required width and cut into suitable lengths. Depending on the process, corrugations may run longitudinally or transversely. Production speeds of up to 12m/min are possible. To produce clear sheeting the refractive index of the resin system must match that of the glass reinforcement. For this reason special resins have been developed which match the refractive index of E-glass. For translucent sheeting A-glass may be used but, due to its low refractive index, it is unsuitable for use in transparent sheeting. In any case today A-glass is rarely found. Generally the glass reinforcement used consists of chopped strand mat with a soluble polyester powder binder or chopped rovings deposited directly into the resinfilm.However, for certain applications woven fabrics

may be used. With the latter and to a much lesser extent with chopped strand mat, the glass cloth may be drawn through a resin bath and excess resin removed between doctor blades or rollers, before placing between two layers of release film and processing as before. With high quality sheeting a surfacing tissue may be used to ensure a resin-rich finish. Such sheeting must be installed with the resin-rich surface exposed to the weather. Resin systems are generally specifically formulated for each machine, since gel time and viscosity must suit the particular operating conditions of the machine. Resin systems used include those suitable for producing clear fire retardant sheeting. By the correct choice of resin system, sheeting can be manufactured which will not yellow to any extent after exposure to tropical weather conditions for several years. However, to ensure that this is the case the resin system must be chosen with care and must be fully cured. Also the release film must be removed before installation and the laminate should contain not less than 75% by weight of resin. In other cases the resin content of the laminate may fall between 65 and 75% by weight.
2.12.8 Pultrusion

Pultrusion is a technique used for producing continuous fibre reinforced sections in which the orientation of the fibres is kept constant during cure. The process is suitable for use with both polyester and epoxide resin systems, reinforced with glass, carbon or synthetic fibres. An infinite number of profiles can be produced using appropriate dies and includes rods, tubes and flat and angled sections. All profiles have high strength and stiffness in the lengthwise direction, with fibre content generally around 60-65% by volume. The reinforcements used consist of continuous fibres such as glass rovings or continuous carbon fibre tows, woven rovings or chopped strand mat or a combination of the two, depending on the strength and rigidity required in the molded profile. Two processes are available which use liquid resin systems. In the first the reinforcement is drawn through an impregnating bath containing catalysed resin. For this process, a resin system with a long pot-life at room temperature is necessary. The reinforcement is then drawn through a heated die which removes excess resin, determines the cross-sectional shape and cures the resin system. In the second process the reinforcement, accurately positioned and under tension, is drawn through a heated metal die where impregnation of the fibres and cure of the resin system takes place. Here, by the use of appropriate resin injection equipment, a short pot-life system can be used. Typical resin injection pressures are between 0.1 and 0.5 MPa. To

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speed up cure, the reinforcement may be pre-heated to about 1000C before passing through the die. Production rates of Im/min can be achieved. By careful design of the pulling mechanism, consistent profiles can be produced with no bending or twisting of the fibres. With some resin systems a tunnel oven may be required after the die to give a suitable post cure. Apart from the wet processes it is also possible to make pultruded sections from prepregs. The forming procedure is the same as that used with wet resin systems. The prepreg is drawn through a heated die which melts the resin, compresses the prepreg into the required shape and cures the resin. This is a somewhat cleaner process than that using a resin bath. It is reported that sandwich panels are being produced in the USA by pultrusion. In this process a plywood core is completely encased in a 3 mm thick glass polyester skin, resin penetrating the plywood during production to give increased bond strength and moisture resistance. 2.13 MECHANICAL PROPERTIES A summary of the mechanical properties of the most important matrix materials and their composites with different reinforcing fibers are presented in Tables 2.8-2.39.

Table 2.8 Properties of a Typical Filled and Unfilled Polypropylene (1) TP 40% Talc 168 100 120 6 32 5 60 52 27 RlOO 1.25 TP 40% CaCO3 168 80 110 4 26 15 45 35 42 R88 1.23 TP TP 40% 30% Glass Graphite 163 160 135 3 82 2 100 64 90 R105 1.22 168 120 125 3 47 0.5 62 55 56 RlOO 1.04

Properties T C Heat deflection temperature, 1.82 MPa 0C Maximum resistance to continuous heat 0C Coefficient of linear expansion cm/cmxlO-5 0C Tensile strength, MPa % Elongation Flexural strength MPa Compressive strength, MPa Notched Izod impact J/m Hardness Rockwell Specific gravity
0

PP 170 55 100 9 35 150 48 45 42 R90 0.90

Table 2.9 Properties of a Typical PEEK Resin (1) PEEK PEEK Properties PEEK 30% Glass 30% Graphite T 0C 334 334 334 Heat deflection temperature, 1.82 MPa 0C 165 282 282 Maximum resistance to continous heat 0C 150 270 270 Coefficient of linear expansion cm/cmxl0~5 0C 5.5 2.1 1.5 Tensile strength MPa 100 162 173 % Elongation 40 2 2 Flexural strength MPa 110 255 313 Notched Izod impact J/m 150 110 70 Hardness Rockwell R123 R123 R123 Specific gravity 1.32 1.44 1.32

Table 2.10 Properties of a Typical Polyetherimide Resins (1) Properties T 0C Heat deflection temperature, 1.82 MPa 0C Maximum resistance to continuous heat 0C Coefficient of linear expansion cm/cmxlO"5 0C Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rochvell Specific gravity PEI PEI 10% Glass 216 200 170 4 114 5 193 155 60 M116 1.35 PEI 20% Glass 216 205 175 3 138 4 205 162 85 M120 1.45 PEI 30% Glass 216 210 180 2 169 3 225 175 110 M125 1.5 PEI 30% Graphite 216 210 180 2 216 2 283 220 75 M127 1.4

216 195 165 5 105 7 144 140 55 MIlO 1.3

Table 2.11 Properties of Typical Polycarbonate Sheets (1)

Tc
Properties T C Heat deflection temperature, 1.82 MPa 0C Maximum resistance to continuous heat 0C Coefficient of linear expansion cm/cmxlO-5 0C Tensile strength MPa % Elongation Flexural strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity
0

Tc
150 144 130 1 135 3 155 90 M92 1.4

Tc
150 144 130 1 165 3 93 100 R118 1.35 1

Tc Polyester
150 146 130 160 150 135 8 165 2 240 90 R119 1.35 73 90 240 300 M85 1.2

PC 150 139 125 7 65 110 93 130 M70 1.2

10% 30% 40% 40% carbonGlass Glass Glass Graphite ate 150 142 130 2 65 6 105 110 M75 1.28

Table 2.12 Properties of Polyphenylene Sulflde Resins (1) Properties PPS 0 T C 290 Heat deflection temperature, 1.82 MPa 0C 133 Maximum resistance to continuous heat 0C 120 Coefficient of linear expansion cm/cmxl0~5 0C 5 Tensile strength MPa 65 % Elongation 2 Flexural strength MPa 95 Compressive strength MPa 95 Notched Izod impact J/m 25 Hardness Rockwell R123 Specific gravity 1.3 PPS 40% Glass 290 260 240 2 135 2 185 160 80 R123 1.65 PPS 40% Graphite 280 260 240 1 160 1.5 210 180 55 R123 1.45

Table 2.13 Properties of a Typical Polyarylate (1) Heat deflection temperature, 1.82 MPa 0C Maximum resistance to continuous heat 0C Coefficient of linear expansion cm/cmxlO"5 C Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity 174 150 6.5 68 50 74 93 210 R125 1.2

Table 2.14 Properties of Typical Polyamide-Imide Plastics (1)

TXi
Properties T 0C Heat deflection temperature, 1.82 MPa 0C Maximum resistance to continuous heat 0C Coefficient of linear expansion cm/cmxl0~5 0C Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity PAI 275 275 260 3.6 150 13 200 258 135 E78 1.39 30% Glass 275 275 260 1.8 195 6 315 300 105 E94 1.57

TXl
30% Graphite 275 275 260 2.0 205 6 315 300 45 E94 1.41

Table 2.15 Properties of Typical Polysulfones (1)

Polysulfo- Polysulfone Polysulf- Polyether PES ne 30% one sulfone 20% (Udel) 30% (Victrex) Glass Glass Graphite Modified Modified PolysulfPES one Polysulf30% Graphite one 30% Glass

Properties

Heat deflection temperature, 1.82 MPa 0 C Maximum resistance to continuous heat 0 C Coefficient of linear expansion cm/cmxlO"5 0 C Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity

190 170 6

198 175 2.5

190 175 2.5

200 185 5.5

210 200 2

210 200 1

150 150 4

150 150 5

70 100 5 115 106 200 176 95 64 58 M69 M95 1.25 1.5

115 43 100 138 127 190 2 50 85 115 2 115 175 85 215 120 175 250 95 150 150 125 150 175 75 150 110 75 75 64 M80 M88 M98 R123 R117 M80 1.35 1.5 1.5 1.36 1.4 1.5

Table 2.16 Properties of typical Nylons (1)

Nylon-6 30% Nylon 6 glass Nylon-6 Nylon 66 Nylon 66 Nylon 66 Nylon 66 30% 30% 30% 40% 50% graphite Nylon-66 glass graphite clay mica

Properties

T7C

226

215

215

265

265

265

265

215

Heat deflection temperature, 78 210 215 75 250 1.82 MPa 0 C Maximum resistance to 65 190 205 100 225 continuous heat 0 C Coefficient of linear 8 4 5 8 2 expansion cm/cm x 10~5 0 C Tensile strength MPa 62 138 205 82 180 % Elongation 30 5 3 60 4 Flexural strength MPa 96 150 135 103 180 Compressive strength MPa 55 130 155 55 110 Notched Izod impact J/m R119 M85 M80 M85 M85 Hardness Rockwell 1.13 1.38 1.28 1.14 1.37 Specific gravity 96 275 315 103 275

260 240 2

190 150 3

230 170 3

227 75 90 3 9 9 170 160 150 88 50 85 R120 M80 M80 1.35 1.4 1.4 330 205 400

Table 2.17 Properties of typical Nylons (1) Nylon 6-12 Nylon Nylon Nylon 35% Nylon Nylon 69 6-10 6-12 Glass 11 12 Aramid 220 60 70 8 60 125 40 90 60 R105 1.08 210 69 75 8 50 200 44 90 60 M78 1.08 210 216 200 6 192 150 140 10 177 146 135 8 275 260 150 3 120 5 172 207 75 E90 1.2

Properties

T 0C 205 Heat deflection temperature, 55 1.82 MPa 0 C Maximum resistance to 60 continuous heat 0 C Coefficient of linear 8 expansion cm/cmxlO"5 0 C Tensile strength MPa 58 % Elongation 80 Flexural strength MPa 40 Compressive strength MPa 100 Notched Izod impact J/m 60 Hardness Rockwell RlIl Specific gravity 1.09

145 55 55 4 200 225 80 40 42 150 80 80 96 96 110 M93 R108 R105 1.35 1.04 1.01

Table 2.18 Typical properties of Discontinuous Thermoplastic Composites (8) Property Specific gravity Water absorption (24hr), % Equilibrium, % Mold shrinkage, % Tensile strength, ksi (MPa) Tensile elongation, % Flexural strength, ksi (MPa) Flexural modulus of elasticity, Msi (GPa) Shear strength ft-lb/in (J/m) Izod impact strength ft-lb/in (J/m) Thermal deflection temperature at 264 psi (1.82 MPa), 0 F Coefficient of linear thermal expansion, in/in., 0FxIO"5 (m/m/oCxl0-5) Thermal conductivity, BTU-in/hr ft2 0 F (W/mC) Surface resistivity, fl/m2

Graphite-Fiber-Reinforced

Nylon 66 Polysulfone PolyesterPolyphenilene ETFE 30% C 30% 30% sulfide 30%C 30%C L28 0.5 2.4 1.5-2.5 35 (241) 3-4 51 (351) 2.9 (20) 13 (89.6) 1.5 (80.1) 495 (257) 1.05 (1.89) 7.0 (12.1) 3-5 L32 0.15 0.38 2-3 19 (131) 2-3 25.5 (176) 2.05 (14.1) 7 (48.1) 1.1 (58.7) 365 (185) 0.7 (1.26) 5.5 (9.5) 1-3 L47 0.04 0.23 1-2 20 (138) 2-3 29 (200) 2.0 (13.8) 1.2 (64.1) 430 (221) 0.5 (0.9) 6.5 (11.2) 2-4 L45 0.004 0.1 1 27 (186) 2-3 34 (234) 2.45 (16.9) 1.1 (58.7) 500 (260) 0.6 (1.08) 5.2 (9.0) 1-3 1.73 0.015 0.24 1.5-2.5 15 (103) 2-3 20 (138) 1.65 (11.4) 7 (48.2) 4-5 213-267) 465 (241) 0.8 (1.44) 5.6 (9.7) 3-5

Table 2.19 Typical properties of Discontinuous Graphite-Fiber-Reinforced Thermoplastic Composites (8) Property Specific gravity Water absorption (24hr), % Equilibrium, % Mold shrinkage, % Tensile strength, ksi (MPa) Tensile elongation, % Flexural strength, ksi (MPa) Flexural modulus of elasticity, Msi (GPa) Shear strength ft-lb/in (J/m) Izod impact strength ft-lb/in (J/m) Thermal deflection temperature at 264 psi 1.82 MPa), 0F Coefficient of linear thermal expansion, in./in., 0FxIO"5 (m/m/oCxl0-5 Thermal conductivity, BTU-in/hr ft2 0F (W/mC) Surface resistivity, Ci/m2 Polypropilene Polycarbonate 30%C 30% C 1.06 1.36 5 5.4 (37.2) 2.2 6.7 (46.2) 0.60 (4.1) 0.7 (37.4) 295 (146) 3.0 (5.4) 3.0 (5.7) 3-5 2 11.5 (79.2) 2.1 17.1 (118) 1.08 (7.44) 3.0 (160.2) 293 (145) 1.6 (2.8) VF2-TFE 20%C 1.77 0.03 2.5-3.5 12.3 (84.7) 3-4 17.2 (119) 1.10 (7.58) 7.5 (51.7) 2.6 (138.8) 248 (120) 1.6 (2.8)

Table 2.20 Properties of a Typical Styrene Polymer (1) Properties Heat deflection temperature, 1.82 MPa C Maximum resistance to continuous heat 0C Coefficient of linear expansion cm/cmxl0~5 0C Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity
0

PS 90 75 7.5 41 1.5 83 90 21 M65 1.04

PS 30% Glass 105 95 4.0 82 1.0 117 103 20 M70 1.2

Table 2.21 Properties of Typical Polyester Resins (1) PET PET PET PBT PBT PBT 30% 45% 30% 30% 45% 30% PET glass glass glass PBT glass glass glass 255 225 210 2 255 225 210 3 245 85 80 6 245 210 200 2.5 245 210 200 2 245 215 205 3

Properties

T 0C 255 Heat deflection temperature, 220 1.82 MPa 0 C Maximum resistance to 200 continuous heat 0 C Coefficient of linear 6.5 expansion cm/cmxl0~5 0 C Tensile strength MPa 58 % Elongation 100 Flexural strength MPa 110 Compressive strength MPa 90 Notched Izod impact J/m 35 Hardness Rockwell M97 Specific gravity 1.35

165 175 3 115 175 260 155 105 75 75 R118 R125 1.6 1.4

50 220 90 155 100 3 3 2 100 175 140 215 98 145 105 100 40 50 50 70 M72 M90 M80 R120 1.34 1.5 1.7 1.41

Table 2.22 Properties of Typical Polyimides (1) Properties T C Heat deflection temperature, 1.82 MPa 0 C Maximum resistance to continuous heat 0 C Coefficient of linear expansion cm/cmxlO~5 0 C Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity
0

PI 330 315 290 5 96 9 165 240 83 E70 1.4

PI40% graphite 365 360 810 4 44 3 145 125 38 E27 1.65

Table 2.23 Properties of DAP (1) Properties DAP Fiber glass filled 225 210 3 50 4 90 205 50 E84 1.80 Mineral filled 200 200 3.5 45 4 65 170 16 E61 1.75

Heat deflection temperature, 1.82 MPa 0 C 155 Maximum resistance to continuous heat 0 C 100 Coefficient of linear expansion cm/cmxlO"5 0 C Tensile strength MPa 27.6 % Elongation 4.6 Flexural strength MPa 62.0 Compressive strength MPa 150 Notched Izod impact J/m 14 Hardness Rockwell E115 Specific gravity 11.3

Table 2.24 Properties Of Typical Amino Plastics (1) Properties Heat deflection temperature, 1.82 MPa 0 C Maximum resistance to continuous heat 0 C Coefficient of linear expansion cm/cmxlO"5 0 C Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity Cellulosefilled UF 175 100 4.0 65 0.7 90 275 16 M120 1.50 Fberglassfilled MF 200 175 1.6 50 0.7 130 310 100 M120 1.9

Table 2.25 Properties

Properties of fiberglass Composites with Different Thermosets (1) Diallyl phthalate Epoxy Phenolic Polyester Polyamide 225 210 3 50 4 90 205 50 E84 1.8 150 140 2 83 4 103 100 25 M105 1.9 200 175 2 41 1.5 172 200 175 MIlO 1.5 200 160 2.5 70 1 172 200 200 M50 2 350 310 1.3 44 1 145 300 300 M118 1.6

Heat deflection temperature 1.8 MPa 0 C Maximum continuous use temperature 0 C Coefficient of linear expansion cm/cmxlO"5 0 C Tensile strength, MPa % Elongation Flexural strength, MPa Compressive strength, MPa Notched Izod impact J/m Hardness Rockwell Specific gravity

Table 2.26 Properties of the Most Common Resin for High Performance Composites
Tensile strength (MPa) Flexural modulus (MPa) Max Coefficient service of thermal Water temperature expansion absorption (24 h%) (W500C1) CQ

Materials

Density (gem3)

Epoxy Polyimide PEEK Polyamide/imide Polyether/imide Polyphenylene/sulfide Phenolics

35-85 120 92 95 105 70 50-55

15-35 35 40 50 35 40 10-24

1.38 1.46 1.30 1.38 1.27 1.32 1.30

25-85 380 140 200 200 75 50-175

8-12 9 6-9 6.3 5.6 9.9 4.5-11

0.1 0.3 0.1 0.3 0.25 0.2 0.1-0.2

Table 2.27 Properties of Polyester Composites Reinforced by Continuous and Chopped Fiberglass Continuous Chopped Glass Filament (%) (%) 75 65 45 25 15 0 10 20 50 60 Tensile Strength MPa 690 660 570 500 410 Flexural Strength MPa 1200 1135 980 810 680 Transverse Transverse Tensile Strength Flexural Strength MPa MPa 24 27 60 95 125 35 90 155 200 260

Table 2.28 Typical properties of cured polyester resins

Cast resin properties Flexural Tensile Tensile % strength strength Modulus Elonga(MPa) (GPa) (GPa) tion Laminate properties

Resin

Flexural Tensile Tensile HDT % strength strength modulus (0C) glass (MPa) (MPa) (GPa)

Orthophthalic Isophthalic Neo-pentylglycol Isophthalic/ neopentylglycol HET acid Isophthalic/ HET acid Bisphenol A Chlorinated paraffin Isophthalic/ chlorinated paraffin

100 65-75 140 70-75 130 70 130 60 80 40-50 85 55 130 60-75 110 50-60 90 60

3.2 3.5 3.4 3.4 3.2 3.2 3.2 3.4 2.0

2.0-4.0 55-110 30 3.5 75-130 30 2.4 110 30 2.5 90-115 30 1.3-4.0 2.9 55-80 30 70 30

150 230 170 160 150 150 170 140 140

90 120 90 90 85 90 90 90 100

7 8 7 7 7 7 7 7 7 '

2.5-4.0 120-136 30 1.2-4.8 55-80 30 4.8 50 30

Table 2.29 Characteristics of Epoxy resins (8) Resin Epocryl Resin 12 Description Characteristics and end uses Nominal 1 000 000 cp (1 kPa A neat dimethacrylate sec) viscosity designed for ester of a low-molecularweight bisphenol A epoxy molding, adhesives, and electrical prepreg resin Base resin for formulation Epocryl Resin 370 A neat diacrylate ester of of UV-cure inks and a low-molecular-weight coating bisphenol A expoxy resin Nominal 100 cP (5 dPa sec) CoRezyn VE-8100 A dimethacrylate ester of Derakane 411-C-50 an intermediate-molecular- viscosity designed for weight bisphenol A epoxy chemical-resistant FRP Epocryl Resin 321 resin containing 50 wt% applications: hand lay-up styrene and filament winding Nominal 500 cP (5 dPa A dimethacrylate ester of Corrolite 31-345 sec) viscosity designed a high-molecular-weight CoRezyn VE-8300 for Chemical-resistant bisphenol A epoxy resin Derakane 411-45 containing 45 wt% styrene FRP applications: hand Epocryl Resin lay-up and filament winding Nominal 200 cP (2 dPa sec) A methacrylate ester of a viscosity designed for phenolicnovolac epoxy Derakane 470-36 solvent resistance and resin containing 36 wt% high-service-temperature styrene FRP applications A methacrylate ester of a Nominal 500 cP (5 dPa sec) low-molecular-weight viscosity designed for Epocryl Resin bisphenol A epoxy resin solvent resistance and containing 40 wt % high-service-temperature styrene FRP applications. Exhibits high tensile strengths and elongation with high modulus. Designed for filament winding and hand lay-up applications Nominal 350 cP (3.5 dPa Derakane 510A40 A dimethacrylate ester of sec) viscosity designed to a brominated bisphenol impart fire retardancy for A epoxy resin containing chemical-resistant FRP 40 wt % styrene applications

Table 2.30

Shear Properties of Composites of Kevlar 49 Fiber in Epoxy Resins (8) Shear Failure Stress MPa (CV) 21A (2.6) 29.4 (2.0) 23.0 (8.6) 23.4 (6.3) 21.9 (0.3) 39.7 (0.9) Shear Strain at Failure Stress % (CV) 1.35 (2.2) 173 (2.3) 1.49 (2.2) 1.91 (6.5) 1.69 (2.9) 2.43 (2.5) Secant Shear Modulus at 0.5% Shear Strain MPa (CV) 1884 (3.9) 1923 (4.7) 1775 (0.9) 1520 (3.9) 1600 1852 (1.7)

Epoxy System (weight ratio) XD 7818/ERL 4206/Tonox 60-40 DER 332/ Jeffamine T-403 (100/39) ERL 2256/Tonox 60-40 (100/25/28.3) Epon 826/RD2/ Tonox 60-40 (100/25/28.3) XB 2793/Tonox 60-40 (100/25.6) XD 7818/XD 7575.02/XD 7114/Tonox 60/DAP (50/50/45/14.1/14.1) XD 7818/XD 7114/Tonox LC (100/45/50.3)

Cure Cycle hours/C (hours/F) 2.5/80 + 2/160 (2.5/176 + 2/320) 24/60 (24/140) 16/50 + 2/120 (16/122 + 2/248) 3/60 + 2/120 (3/140 + 2/248) 2/90 + 2/160 (2/194 + 2.320) 5/80 + 3/120 (5/176 + 3/248) 5/60 + 3/120

31.9 (3.4)

1.91 (4.5)

1850 (1.5)

Table 2.31 Properties of a typical PMMA Sheet* (1) Heat deflection temperature at 1.8 MPa (0C) Maximum resistance to continuous heat (0C) Coefficient of linear expansion cm/cm/oCxl0'5 Tensile strength (MPa) Percent elongation Flexural strength (MPa) Compressive strength (MPa) Notched Izod impact (J/m) Hardness Rockwell Specific gravity 96 90 7.6 72 5 110 124 74 M93 1.19

*Polymethyl methocrylate (PMMA) is largely used for biomedical applications, optical fibers and cultured marble. Table 2.32 Properties of Typical Polyfluorocarbons (1) Properties Heat deflection temperature 1.8 MPa ( C) Maximum resistance to continuous heat (0C) Coefficient of linear expansion cm/cm 0 C x 10 5 Tensile strength, MPa Flexural strength MPa Notched Izod impact J/m % Elongation Hardness, Rockwell Specific gravity
0

PFTE 100 250 10 24 50 160 200 D52 2.16

PCTFE 100 200 14 34 60 100 100 R80 2.1

PVDF 80 150 8.5 55 75 150 200 RIlO 1.76

PVF 90 125 10 65 90 100 200 R83 1.4

Table 2.33 Properties of typical Filled PTFE (1) Properties Thermal conductivity mW/MK Tensile strength MPa % Elongation Notched Izod impact J/m Coefficient of friction, 3.4 MPa load Wear factor 1/pPa Shore durometer hardness Specific gravity Table 2.34 Unfilled 15% PTFE Glass 0.244 28 350 152 0.08 5013 51D 2.18 0.37 25 300 146 0.13 280 54D 2.21 ~25% ~15% Glass Graphite 0.45 17.5 250 119 0.13 26 57D 2.24 0.45 21 250 100 0.10 102 61D 2.16 60% Bronze 0.46 14 150 75 0.10 12 7OD 3.74

Properties of Typical LDPE Plastics (1) -25 15 20 350 47D 0.925

Glass transition temperature (0C) Coefficient of linear expansion cm/cm 0 CxIO 5 Tensile strength MPa %Elongation Shore hardness Specific gravity Table 2.35

Properties of a typical Filled and Unfilled HDPE (1) HDPE 130 40 40 10 27 100 21 133 D40 0.95 30% Glass-Filled HDPE 140 120 110 5 62 1.5 76 43 64 R75 1.3

Properties Melting point (0C) Heat deflection temp, at 1.82 MPa (0C) Maximum resistance to continuous heat (0C) Coefficient of linear expansion cm/cmCxl0~5 Tensile strength MPa % Elongation Flexural strength MPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity

Table 2.36 Thermal and Electrical Properties of Kevlar 49 Fabric/Epoxy Composites (8) Property Thermal conductivity (46 volume % fiber) Across fabric layers, W/m 0K Parallel to warp, W/m 0K Thermal coefficient of expansion (20-1000C) Dielectric constant (58 volume % fiber) Perpendicular at 9.3xlO9 Hz (room temperature) Parallel at 9.3xlO9 Hz (room temperature) Perpendicular (48 volume % fiber) at 106 Hz Dielectric strength (48 volume % fiber), V/mm (V/mil) Volume resistivity (48 volume % fiber), M-cm Surface resistivity (48 volume % fiber), 1A cm Arc resistance (48 volume % fiber), seconds Value 0.22 0.91 0 3.3 3.7 4.1 24.4 5xl015 5xlO15 125

Table 2.37

Property of Unidirectional Thornel 300-Kevlar 49/Epoxy Hybrid Composites (8) Tension Compression
Stress Stress at 0.02% at 0.02% Ultimate Ultimate offset offset stress stress (ksi) (ksi) (ksi) MPa

Flexure
Stress Stress at 0.02% at 0.02% Ultimate Ultimate stress offset stress offset (ksi) (ksi) sMPa MPa Shortbeamshear stress Shortbeam shear stress

Ratio Ultimate Ultimate Thornel stress to Specific Modulus Modulus stress (ksi) Kevlar gravity GPa (Msi) MPa

100/0 75/25 50/50 0/100

1.60 1.56 1.51 1.35

145 120 108 77

(21.1) (17.4) (15.7) (11.2)

1565 1281 1213 1262

(227) (186) (176) (183)

678 469 413 182

(98.4) (68.8) (59.9) (26.4)

1007 938 688 286

(146) (136) (99.8) (41.5)

1605 1248 827 339

(223) (181) (120) (49.2)

1606 1358 1103 634

(233) (197) (160) (91.9)

91 (13.2)* 76 (11.0) 56 (8.1) 49 (7.1)

Table 2.38 Fibers Properties

Properties of Epoxy Resin Composites with Different Reinforcing Aramid S-Glass Kevlar 49 Graphite Boron 1.1 1.1 700 30 000 25 2.0 0.9 1 800 33 000 34 1.4 5 2 700 60 000 18 1.6 1 1 1600 207 000 35 2.1

E-Glass

Thermal conductivity W/mK 0.9 Linear expansion cm/cmCxlO5 1.2 Tensile strength MPa 450 Elastic modulus MPa 24 000 Fracture toughness MPa mX 22 Specific gravity 2.1

Table 2.39 Properties of Fiberglass-reinforced Different Fabrication Techniqes (1)

Polyester Composites with

Properties Glass content % Heat deflection temp. Maximum resistance to continuous heat 0 C Coefficient of linear expansion 0 CxIO 5 Tensile strength KPa % Elongation Flexural strength KPa Compressive strength MPa Notched Izod impact J/m Hardness Rockwell Specific gravity

Spray- Filament Preform Cold- press wound SMC BMC mat molding up (epoxy) Pultruded 22 225 180 1.0 90 1 165 80 640 H75 1.9 25 225 175 1.0 48 0.5 100 30 240 H95 1.9 30 205 185 1.4 110 1.5 220 150 800 H70 1.9 25 190 180 1.4 110 1.5 190 125 560 H70 1.6 40 190 185 1.6 95 1.0 150 135 425 H70 1.5 55 190 150 4 120 2.0 1250 400 2660 MIlO 1.9 60 175 200 5 80 2.0 1000 340 2750 H96 1.8

2.14 ANTIOXIDANTS AND EFFECT OF ENVIRONMENTAL EXPOSURE Many of the polymeric matrices will require some type of antioxidants to improve aging properties. The most common primary antioxidants are hindered phenols such as butylated hydroxytoluene (BHT). Typical low toxic antioxidants are reported in Tables 2.40-2.42.

Table 2.40 Typical antioxidants of low toxicity (3) Primary antioxidants (usually hindered phenols) Thioester antioxidants (usually derivates of thiodipropionic acid) Phosphite antioxidants (usually derivates of aromatic phosphites) Butylated hydroxytoluene (BHT) Dilaryl thiodipropionate (DLTDP) Distearyl thiodipropionate (DSTDP) Distearyl pentaerythritol diphosphite Tris (nonylphenyl) phosphite

The toxicity of commonly used polymer stabilizers and additives are classified in the following table. Table 2.41 Toxicity of commonly used polymer stabilizers and additives (3) Stabilizer Fatty acid derivates of calcium, zinc and magnesium Barium fatty acid compounds Lead & cadmium derivates Toxicity Low toxicity. Used in non-toxic medical applications Moderately toxic Highly toxic. Not recommended in the US for use in medical applications (cadmium pigments considered of low toxicity in England) Generally toxic, with aromatic amines showing carcinogenic tendencies. Newer types less toxic Considered non-toxic as also used in foods. Recently investigated and found non-carcinogenic Only class of tin compound classified as of low toxicity and used in medical applications e.g. di-(n-octyl)tin maleate polymer

Amines (antioxidants) Butylated hydroxytoluene (BHT) (antioxidant) Octyl tin compounds

Table 2.42 Toxicity data on some common plasticizers used in plastic manufacture (3) Plasticizer Adipates Glycolates Phosphates Phthalates Epoxidized soya bean oil Toxicity To date animal experiments indicate possible carcinogenicity Generally of low toxicity levels. However studies underway as commercial form are phthalyl derivates Generally cause irritation to skin and mucous membranes Although commercially used in medical devices, environmental effects and toxicological properties continually under investigation Chelating type of plasticizer with low toxicity

2.15 THE RADIATION STABILITY OF COMMERCIAL MATERIALS The radiation resistance of common polymeric materials used as matrix for composite are shown in Tables 2.43-2.52. Generally, polystyrene and urethane rubber have the most resistance.

Table 2.43 The radiation resistance of common materials used as matrix of polymeric composites (3) Material ABS Polyamides Polyethylene Polypropylene Poly(vinyl chloride) Polystyrene Poly(tetrafluoroethylene) Polysulfone Polyacetals Polyurethane Polymethylmethacrylate Rubber natural Rubber butyl Rubber silicones Urethanes Stability effect Stable for single dose of 2.5 Mrad Suitable for single doses of 2.5 Mrad level Stable under ordinary conditions at 2.5 Mrad Embrittles - newer variations more resistant Withstands single dose radiation cycle but discolors - some HCl liberated Most radiation - stable of common polymers Poor resistance to radiation - copolymers less affected Stable under ordinary conditions at 2.5 Mrad Embrittles - discolors Stable under ordinary conditions at 2.5 Mrad Embrittles - discolors Stable under ordinary conditions when properly compounded Poor stability at low radiation levels Stable under ordinary conditions at 2.5 Mrad Excellent radiation resistance

Table 2.44 The radiation resistance of common materials used as matris of polymeric composites (3) Material Thermoplastics Acrylonitrile/B utadiene/Styrene (ABS) Cellulosics esters more stable Fluoinated ethylene propylene (FEP) Polyacetal Polyamides aromatic Polyamides aliphatic Polycarbonates Polyesters (aromatic) Polyethylene Polymethylmethacrylate Polyphenylene sulfide Polyproplyene Polysulfone Polystyrene Polytetrafluoroethylene Polyvinylchloride homopolymer Polyvinylchloride Copolymer Styrene/Acrylonitrile (SAN) Stability Good Fair Fair Poor Excellent Fair Good Good Good Poor Good Fair Excellent Excellent Poor Good Fair Good Undergoes chain scission, Copolymers more resistant than Homopolymer Embrittles Hardens as levels increased Yellow - mechanical properties unchanged lowers melt flow Degrades-turns brown Improved stability if properly stabilized Yellow natural color Acid evolved If properly stabilized HCl evolved - turns brown More resistant than ABS

Table 2.45 The radiation resistance of common materials used as matrix of polymeric composites (3) Material Thermosetting resin Epoxies Phenol or urea formaldehyde Polyimides Polyesters Polyurethanes Stability Excellent Good Excellent Good Excellent Very stable with the use of aromatic curing agen

Table 2.46 The radiation resistance of common materials used as matrix of polymeric composites (3) Material elastomers Polyisobutylene (butyl) Natural Urethanes Nitrile Polyacrylic Styrene-butadiene EPDM Silicones Stability Poor Good Excellent Good Poor Good Good Good

Table 2.47 The radiation resistance of polymers (3) Textiles Polyesters Cellulosics Nylon Stability Excellent Poor Fair

Table 2.48

Synergism between a UV absorber and a thermal antioxidant (6) Time to embrittlement of low-density polyethylene (in hours) 400 1600 1800 7000 2000 1000 8500

Additive (0.4 pph) UV stabilizer None Octylphenyl salicylate None Octylphenyl salicylate 2-Hydroxy-4-noctoxybenzophenone None 2-Hydroxy-4-noctoxybenzophenone

Antioxidant None None Tri (nonylphenyl) phosphite Tri (nonylphenyl) phosphite None Tri (nonylphenyl) phosphite Tri(nonylphenyl) phosphite

Table 2.49 (6) Material

Stability of hydrocarbon polymers with bound phenolic antioxidants Hours to react with 10 cc of O2 at 1400C 3 14 175 411 <1 31

Low-density polyethylene: Uninhibited Reacted with diazooxide High-density Polyethylene: Commercially stabilized Reacted with diazooxide Polypropylene Uninhibited Reacted with diazooxide

Table 2.50 (6)

Additives incorporated into natural rubber and as bound antioxidants Hours to absorb 1% by wt. of O2

Additive N,N'-Diethyl-p-nitrosoaniline p-Nitrosodiphenylaniline p-Nitrosophenol 2,6-Diter-butyl-p-cresol

Before extraction 39 60 31 47

After extraction 30 53 30 4

2.16 POLYMERS AGING

Table 2.51 ites (7) Summary of effects of moisture and ambient aging on epoxy composFlexural strength, MN/m2 (ksi)
Temperafare Orient K(0F) Control 24-h H2O Retention 6-week boil % humidity 20-week Retention 52-week ambient % ambient Retention %

Retention

[0]

297 (75) [0] 450 (350) [045] 450 (350) [0] 297 (75) [0] 450 (350) [045] 450 (350)

2070 (300) 1730 (251) 862 (125) 1680 (244) 1300 (188) 676 (98)

B/5505 boron/epoxy 1950 94 2120 103 2180 (283) (308) (316) 393 23 683 39 1030 (57) (99) (149) 545 63 641 74 882 (79) (93) (128) A-S/3501 graphite/epoxy 1680 100 1680 100 1850 (244) (244) (268) 434 34 386 30 703 (244) (56) (102) 365 54 276 41 545 (53) (40) (79)

105 59 102

2280 (330) 910 (132) 807 (117) 1620 (235) 593 (86) 386 (56)

110 53 94

110 54 81

96 46 57

Table 2.52

Summary of thermal aging of epoxy and polyimide system (7) Aging temperature K(0F) 394 (250) 450 (350) 394 (250) 450 (350) 505 (450) 561 (550) Test temperature K(0F) 450 (350) 450 (350) 450 (350) 450 (350) 505 (450) 561 (550) Aging time, h 1000 1000 1000 1000 1000 1000 Retention of tensile strength, % 99 94 100 100 94 100 100 100 98 92 87 100

Material system Orientation B/E [O] [CP] [O] [CP] [O] [CP] [0] [CP] [O] [CP] [O] [CP]

G/E

G/PI

2.17 COMPOSITE MATERIALS IN MEDICINE In recent years, carbon fiber has been recognized as a material with many exciting applications in medicine. Several commercial products utilize carbon fiber as a reinforcing material which serves to enhance the mechanical properties of the polymeric resin systems in which it is included. The attractive feature of carbon reinforced polymer for this application is that the orientation and fiber content can be varied in the implant to provide the mechanical property orientation necessary for good function. The carbon fiber can be distributed in matrix material to provide strength in only those locations and directions where it is needed. The implant must be designed in a way that fatigue failure does not occur and the matrix material is not attacked by the physiological environment. The matrix materials used are listed in Table 2.53. Table 2.53 Polymeric materials used as matrix for carbon fibers composites (3) Polymer Polysulfone Polymer type Thermoplastic Commercial name and manufacturer UDEL MG-Il, Union Carbide, Dallas, TX PMMA LV. 0.4, Rohm & Haas, Philadelphia, PA Stycast 1267 C-8W795 & H.R. 795, Hysol Corp., Los Angeles, CA

Poly-methyl methacrylate Thermoplastic Epoxy (low viscosity) Epoxy (high viscosity) Thermoset Thermoset

Table 2.54 Mechanical properties of carbon fibers used in carbon prosthesis Density (g/cm3) 1.75 1.79 Diameter (ixm) 1 6.7 Tensile strength (MPa) 3430 2350 Elastic modulus (GPa) 230 358 Strain to failure (%) 1.5 0.6 a (/10-6K) -1.5 -0.5

Fibre-type T300 HM 35

These polymers were combined with unsized carbon fiber, into 15 laminated, test specimens approximately 2.5 cmx7.5 cmx0.3 cm. Testing was performed in three point bending giving the results in Table 2.55. Table 2.55 Typical Mechanical Properties of Polymer-Carbon Composites (3) Polymer PMMA Polysulfone Epoxy Stycast Epoxy Hysol Ultimate strength (MPa) 772 938 535 207 Modulus (GPa) 55 76 30 24

Because a composite hip will be subjected to the physiological environment in use, an accelerated test was performed to evaluate changes in properties. In this test, the samples were immersed in 0.9% saline solution maintained at 900C for one week; the results are shown in Table 2.56. Table 2.56 Accelerated Test Data (3)
Strength (MPa) Matrix Polysulfone PMMA Epoxy (Stycast) Before 807 687 535 After 723 594 323 Modulus (GPa) Before 77 76 30 After 67 73 21

Blood compatible materials are essential to circulatory support devices. Numerous materials have been considered for use in prosthetic devices. 2.17.1 Carbons in heart valve prostheses

Carbons are widely used in prosthetic heart valves, as a result of their favorable mechanical and biological properties. Pyrolytic carbons, deposited in a fluidized bed, have high strength, and high fatigue and wear resistance. Compatibility with blood and soft tissue is good. Table 2.57 Representative Mechanical Properties of LTI, Glassy, and VaporDeposited Carbons (3)
Property Density, g/cm3 Crystallite size, A Flexural strength 1000 psi Young's modulus, 106 psi Strain to fracture, % Fatigue limit/fracture strength Strain energy to fracture, 100 psi Glassy carbon 1.5 30 20 4.0 1.0 1.0 1 Vapordeposited carbon 1.9 10 80 2.5 5.0 1.0 12 LTI carbon 1.9 35 70 3.0 2.0 1.0 7 LTI carbon with silicon (5-12%) 2.1 35 85 4.0 2.0 1.0 9

2.17.2 Wound closure biomaterials Virtually every operation requires the use of materials to close the wound for subsequent successful healing. The material must retain adequate strength during the critical period of healing; it should also induce minimal tissue reaction that might interfere with the healing process. The complexity involved in wound healing calls for different types of wound closure materials. Table 2.58 Mechanical Properties of Suture Materials (3)
Suture Dexon Vicryl Mersilene Silk Nurolon Ethilon Prolene Yield stress (GPD) 0.80 0.97 1.20 1.33 0.34 0.41 0.52 Breaking stress (GPD) 6.30 6.55 4.20 3.43 3.80 6.25 5.14 Yield strain (%) 1.9 1.8 2.7 1.9 1.6 2.2 1.2 Breaking strain (%) 22.6 18.4 8 11.5 18.2 33 42 Modulus

of
elasticity 55 67.5 53 79.0 21.0 20.0 58.5

Specific work of rupture (NZTex)xlO-2 6.63 5.46 1.32 2.36 2.80 8.96 14.69

2.18 METAL MATRIX COMPOSITES The metal matrix composites can be described as materials whose microstructure comprises a continuous metallic phase into which a second phase (ceramic materials) has been artificially introduced during processing, as reinforcement. 2.18.1 Matrix materials The most common matrices are the low-density metals, such as aluminum and aluminum alloys, and magnesium and its alloys. Some work has been carried out on lead alloys, mainly for bearing applications, and there is interest in the reinforcement, for example, of titanium-, nickel- and ironbase alloys for higher-temperature performance. However, the problems encountered in achieving the thermodynamic stability of fibers in intimate contact with metals become more severe as the potential service temperature is raised, and the bulk of development work at present rests with the light alloys. 2.18.2 Reinforcements The principal reinforcements for metal matrices include continuous fibers of carbon, boron, aluminum oxide, silica, aluminosilicate compositions and

silicon carbide. Some ceramic fibers are also available in short staple form, and whiskers of carbon, silicon carbide and silicon nitride can be obtained commercially in limited quantities. There is also interest in the use of refractory particles to modify alloy properties such as wear and abrasion resistance. In this case, particle sizes and volume fractions are greater than those developed metallurgically in conventional alloys, and incorporation of the particles into the metal is achieved mechanically rather than by precipitation as a consequence of heat treatment. Most metal-matrix composites consist of a dispersed reinforcing phase of fibers, whiskers or particles, with each reinforcing element ideally separated from the next by a region of metal. A summary of properties of the most important metal matrix composites is presented in Tables 2.59-2.69.

Table 2.59 Summary of Mechanical Properties of A13 Aluminum-28 v/o Thornel50 Composite (5)
Property Ultimate tensile strength Rule-of-mixtures strength Transverse tensile strength Tensile elastic modulus, E Shear modulus, G (calculated) Density Strength-to-density ratio Modulus-to-density ratio Poisson's ratio, m (calculated) Value 730 MN/m2 (106 000 psi) at 20 0C 660 MN/m2 (95 000 psi) at 500 0C 700 MN/m2 (101 000 psi) at 20 0C 550 MN/m2 (80 000 psi) at 500 0C -83 MN/m2 (-12 000 psi) 145 GN/m2 (21.OxIO6 psi) 55 GN/m2 (7.9xlO6 psi) 2.4 g/cm3 (0.0805 lb/in.3) 2.4xl06cm (1.25xlO6 in.) 62OxIO6 cm (248xlO6 in.) 0.306

Table 2.60 Summary of Transverse Tensile Strengths of Various AluminumGraphite Composite Systems (5) Composite Fiber Thornel-50 Courtaulds Courtaulds Courtaulds HM Whittaker-Morgan Whittaker-Morgan Matrix Al-12Si 220 Al 356 Al Al-IOMg 356 Al 7075 Al Average (MN/m2) 26 42 70 29.5 50 21 (psi) 3777 6117 10,008 4280 7300 3040 High (psi) 6500 8690 14,600 4500 11,300 5100 Low (psi) 433 3760 5500 3600 4100 400 Number of tests 9 20 26 5 5 5

Table 2.61 Uniaxial Tensile Data for Aluminum-Silicon Alloy-Thornel-50 Composite Thermally Cycled 20 Times from -193 to +5000C (5) Sample number C7 C8 C9 ClO Average Ultimate tensile strength (psi) 103 000 100 000 100 000 99 000 101000 Rule-of-mixture strength (%) 103 99 99 99 100

Table 2.62 Transverse Tensile Strengths for 356 Aluminum-Courtaulds HM Graphite Composite (5) Transverse strength Sample number 808A 808A 808A 808A 808B 837A 837A 837 A 837B 837B (MN/m2) 91 88 74 68 79 67 67.5 76 67 72 (psi) 13 100 12 700 10 700 9900 11500 9700 9800 11100 9700 10 400

Table 2.63 (5)

Corrosion Behavior of Aluminum-Graphite Composite for lOOOhr 356 aluminum 356 aluminum-25 v/o Thornel-50
0

Environment Distilled water 3.5% NaCl solution

(23C) Nil 1.1

(50 C) Nil 4.9

(23C) 1.2 4.7

(500C) 1.2 9.8

Table 2.64 1000 C(5) Type of composite Continuous

Tensile Properties of Al 2 O 3 -Whisker-Nickel Composites at 25 and Test temperature Whisker volume fraction (v/o) 22 51 39 16 21 21 29 28 19 11 17 28 10 ?n Composite strength [MWm2 1230 1050 1350 282 495 495 759 621 1180 938 451 106 269 Strength-todensity ratio (106 cm) 1.63 1.68 2.0 0.114 0.665 0.67 1.08 0.845 1.52 1.14 0.542 0.144 0.33

CQ

Discontinuous

25 25 25 1000 1000 1000 1000 25 25 25 1000 1000 1000

mnn
Table 2.65

nan

Off-Axis Tensile Properties of Ti-6Al-4V-28 v/o SiC (5) Average Strength (ksi)

Filament orientation (degrees) 0 15 30 45 90 Table 2.66

Ultimate tensile strength 142 135 113 107 95

Proportional limit 111 111 104 75 53

Elastic modulus (106 psi) 36 35 32 31 28

Poisson's ratio 0.275 0.277 0.346 0.346 0.250

Properties of Ti-6A1-4V-5O v/o Borsic Composites (5) Tensile Failure strength strain (ksi) (min./in.) 140 100 66 42 119 107 109 86 53 35 3340 3220 4220 3130 Elastic modulus (106 psi) Tensile 41.5 36.8 31.2 29.8 Elastic Coefficient modulus of (106 psi) expansion Flexure (10-6Z0F) 34.4 33.3 31.8 31.2 33.2 32.4 31.5 29.9 27.6 24.4 2.50 3.17 2.80 3.17 3.64

Temperature

CF)
70 70 70 70 500 700 850 850 850 850

Orientation (degrees) 0 15 45 90 0 0 0 15 45 90

Table 2.67 Summary Composites (5)

of

Mechanical

Properties

of

Magnesium-Graphite

Composite Mg-42v/o Thornel-75 Mg-ZK60A

Strength/ Modulus/ density Strength Strength E E Density density (psi) (MN/m2) (10-6psi) (GWm2, ) (gm/cm3.) (1O6Cm) (106cm) 65 000 50 000 450 345 26.6 6.5 184 45 1.77 1.80 2.5 1.9 1000 250

Table 2.68

Room-Temperature Properties of Lead-Graphite Composites (5) Strength Ib/in? 2 000 10 500 104 000 72 000 Modulus of elasticity 106IbAn.2 2.0 4.2 29.0 17.4 Density Ib/in.3 0.41 0.35 0.270 0.28 Strength/ Modulus/ density density 10-6 in. 10-6 in. 0.005 0.03 0.385 0.26 4.9 12.0 107.0 62.3

Composite Pure lead Lead-base bearing (75Pb-15Sb-10Sn) Lead-graphite 41 vol% Thornel-75 Fibers Lead-graphite 35 vol% Courtaulds HM

Table 2.69 Summary of Mechanical Properties of Zinc and Zinc-Graphite Composite (5) Strength (psi) 110 900 41000 Modulus of elasticity (W-6 psi) 16.9 10.0 Density Ib/in.3 0.191 0.240 Strength/ density (10-6 in.) 0.58 0.17 Modulus/ density (10-6 in.) 88.5 41.7

System Z-35 v/o Thornel/75 Alloy AG40A

2.19 CERAMIC MATRIX COMPOSITES

Composite structures in ceramics have been developed for two major reasons. First, they provide a means to enhance dramatically the performance of the so-called functional ceramics; these are systems where electrical, dielectrical, piezoelectric or sensitizing properties are greatly amplified by appropriate composite design. Secondly, they are used to avoid or diminish the brittle behaviour of structural ceramic systems. A summary of properties of the most important ceramic matrix composites is presented in Tables 2.70-2.74.

Table 2.70 Matrix type

Glass and Glass ceramics suitable as matrices (4) Major constituent Glass B 2 O 3 , SiO 2 Al 2 O 3 , MgO, CaO, SiO 2 Minor constituent Na 2 O, Al 2 O 3 B 2 O 3 , BaO Maximum use temperature 6000C 7000C 11500C 100O0C 110O0C 12000C 12000C 12500C

7740 Boro-silicate 1723 Aluminosilicate 7930 High silica LAS I LAS II LAS III MAS BMAS

SiO 2 B2O3 Glass ceramics Li 2 O, Al 2 O 3 , MgO, SiO 2 ZnO, ZrO, BaO Li 2 O, Al 2 O 3 , MgO, ZnO, ZrO 2 , BaO SiO2, Nb 2 O 5 Li 2 O, Al 2 O 3 , MgO, SiO2, ZrO 2 Nb 2 O 3 MgO, Al 2 O 3 , SiO 2 BaO BaO, MgO, Al 2 O 3 , SiO 2 -

Table 2.71 Properties of silicon nitride and carbon/silicon nitride (4) Property Bulk density (g/cm ) Fibre content (vol.%) Bending strength (MPa) Young's modulus (GPa) Fracture toughness (MPa m1/2) Work of fracture (J/m2)
3

Si3N4 3.44 47330 24716 3.7+0.7 19.3

CZSi3N4 2.7 30 45442 18818 15.61.2 4770770

Table 2.72

Room temperature strengths of RBSN* and SiC/RBSN (4) Axial strength (MPa)

Test

0% Fiber

23% Fiber 53948 71780 35273

40% Fiber 61636 95845 53620

Four point bend 10726 Three point bend Tensile * RBSN - Reaction bonded silicon nitride.

Table 2.73 Properties of brittle fibre/SiC matrix composites (4) Comp. density % Th. 70-77 68-75 75-90 73-89 51-81 71-77 62-83 65-85 68-84 69-82 68-76 51-81 64-90 68-77 >90 >90 Fracture toughness (MPa mm) 4 Point bending strength, MPa 213-230 224-410 419-437 187-217 90-177 50-94 72-107 71-196 44-97 61-106 74-98 90-177 107^76 38-410 320 530

Reinforcement SiC Fibers SiC Cloth SiC chopped fibers SiC cloth plain weave satin weave SiC chopped fibers SiC cloth SiC fibers SiC fibers C fibers

Matrix SiC SiC SiC SiC SiC SiC SiC SiC SiC

VoI % 45 39.5 41.6 37.9 25.4 21.9 35.5 46.3 50.2 16.8 24.3 25.4 41-45 39-57

1.8-3.6

>25 >25

Table 2.74 Room temperature of some unreinforced ceramics and ceramic matrix composite (4) Material Al2O3 SiC whiskers/Al2O3 SiC SiC flbers/SiC ZrO 2 SiOZrO 2 Borosilicate glass SiC fibers/borosilicate glass Glass ceramic SiC fibers/glass ceramics Reaction bonded Si3N4 SiC whiskers/reaction bonded Si3N4 Hot pressed Si3N4 SiC whiskers/hot pressed Si3N4 Flexural strength MPa 550 800 500 750 200 450 60 830 200 830 260 900 470 800 Fracture toughness MPa m^ 4-5.0 8.7 4.0 25.0 5.0 22.0 0.6 18.9 2.0 17.0 2-3.0 20 3.7-4.5 56

REFERENCES
1. Seymour, R.B. (1990) Polymer Composites, VSP, Utrecht, The Netherlands. 2. Weatherhead, R.G. (1980) FRP Technology, Applied Science Publishers, London. 3. Biocompatible Polymers, Metals, and Composites, edited by M. Szycher, Technomic Publishing Co. Inc. 4. Islam, M.U., Wallance, W. and Kandeil, A.Y. (1985) Artificial Composites for High Temperature Applications, Noyes Data Corporation, Park Ridge, New Jersey, USA. 5. Kreider, Kenneth G. (1974) Metallic Matrix Composites, Vol. 4, Academic Press, New York and London. 6. Hawkins, W.L. (1984) Polymer Degradation and Stabilization, Springer-Verlag. 7. Environmental Effects on Advanced Composite Materials, symposium presented at the seventy-eighth Annual Meeting ASTM, Philadelphia, 1975. 8. Hill, R. (1964) /. Mech. Phys. Solids, 12, 199. 9. Hermann, JJ. (1970) Proc. Konigl. Nederl. Akad. Weteschappen Amsterdam, B70, 1. 10. Halpin, J.C. and Pagano, NJ. (1964) /. Compos. Mater., 3, 720.

Thermoplastic Polymers In Biomedical Applications: Structures, Properties and Processing

S.H. Teoh, Z.G. Tang and G.W. Hastings

3.1 INTRODUCTION In general thermoplastic polymers are made up of long linear chain molecules which exhibit large scale chain mobility and deformation under shear forces above their softening temperature. This change is reversible. Above this temperature the thermal motions of the chain segments are sufficient to overcome inter- and intra-molecular forces. At room temperature the material is a viscoelastic solid. Their behaviour is dependent on chain morphology, structure, crystallinity and the types of additives added (often to aid processing). The materials can easily be processed into different type of products and are considered to be the most important class of plastic materials commercially available. The processability of this class of plastics is a key characteristic for developing biomedical applications. Nine potential biomedical applications areas have been identified (Jones and Denning, 1988): 1. Membranes in extracorporeal applications such as oxygenators; 2. Bioactive membranes e.g., controlled release delivery systems and artificial cells;
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

3. Disposable equipment e.g., blood bags and disposable syringes; 4. Sutures and adhesives including biodegradable and non-biodegradable materials; 5. Cardiovascular devices such as vascular grafts; 6. Reconstructive and orthopaedic implants; 7. Ophthalmic devices such as corneas and contact lens; 8. Dental restorative materials including dentures; 9. Degradable plastic commodity products. This section focuses on 12 thermoplastic polymers which have found wide application in the above. Each part deals with one polymer or one group of polymers of structural similarity. The content includes the chemical structure, structure-property relationships, tables of physical, mechanical and thermal properties, and processing conditions of each candidate thermoplastic. Some properties can be predicted from the structural characteristics of the polymers. In general, for a given polymer, higher molecular weight tends to improve mechanical properties, but the increase in the resistance to flow in the fluid state makes processing more difficult and costly. A wide range of molecular weight is generally more appropriate for processing of each polymer. The effect of branching in otherwise linear molecules is significant. Short but numerous branches irregularly spaced may reduce considerably the ability of portions of linear chains to form crystal-like domains, and the corresponding polymer will display a lower stiffness, a good example being the highly branched low-density polyethylene of lower degree of crystallinity than the less branched high density product. Tacticity of polymer molecules greatly affects crystallinity and stiffness. For example, commercial polypropylene is usually about 90-95% isotactic, and is stiff, highly crystalline and with a high melting point, whereas the atactic polypropylene is an amorphous somewhat rubbery material of little value. Within the range of commercial polymers, the greater the amount of isotactic material the greater the crystallinity and hence the greater the softening point, stiffness, tensile strength, modulus and hardness. The inter-molecular and intra-molecular forces also influence the properties of polymers. The hydrogen bonds or van der Waal's and other dispersion forces between adjacent molecules produce a large increase in melting temperature. A high energy barrier to molecular rotations hinders the ability of molecules to take up the required conformations to form crystals. Polymethylmethacrylate (PMMA), and polycarbonate exist in an amorphous state and are completely transparent. The crystallinity is controlled by both structural factors and processing conditions. From the processing standpoint, the higher the crystallinity, the bigger the shrinkage observed after product processing. Thermoplastic polymers exist in semi-crystalline and amorphous states. The ratio of these two states affects material

properties strongly and can be characterized using X-ray analysis and by observing the thermal behaviour of the polymers. Amorphous thermoplastics are normally transparent and do not have a fixed melting temperature like that of the semi-crystalline thermoplastics. They are also less resistant to solvent attack. Semi-crystalline thermoplastics, because of the presence of crystallites, are more fatigue and wear resistant. A typical case is polyacetal which has more than 20 years of in vivo experience as an occluder in the Bjork-Shiley tilting disc mechanical heart valves. A main requirement for a polymeric candidate is its biocompatibility with biological tissues and fluids. Biocompatibility will depend on the polymer intrinsic chemical nature and the additives present. It is a complex issue not dealt with here. It is not always possible to distinguish the medical-grade polymers from the conventional polymers. They may come from a batch intended for general purposes, but are selected on the basis of clean condition or trace element analysis or mechanical properties. Subsequent processing requires clean room conditions and care to avoid any contamination. There is still some inherent uncertainty about constituents unless there has been complete disclosure and/or only a 'pure' polymer is used. With new developments in polymeric biomaterials, the situation should improve. It is hoped that the following sections will be of value to researchers in science and engineering and to clinical practitioners who are engaged in the development and material selection of new thermoplastic polymers for biomedical applications. 3 . 2 POLYETHYLENE Commercially, polyethylene is produced from ethylene in various densities (from linear low to ultra high). There are four quite distinct processes to the preparation of commercial polymers of ethylene: (a) high pressure processes, (b) Ziegler processes, (c) the Phillips process, (d) the Standard Oil (Indiana) process. High pressure polymers (British patent 471590, 1930) are of the lower density range for polyethylene (0.915-0.94 g/cm3) and usually also of the lower range of molecular weights. Until the mid1950s, all commercial polyethylenes were produced by high pressure processes. These materials were branched materials and of moderate number average molecular weight, generally less than 50 000. Ziegler polymers (Ziegler, 1955) are intermediate in density (ca. 0.945 g/cm3) between the high pressure polyethylenes and those produced by the Phillips and Standard Oil processes. Phillips polymers have the highest density of any commercial polythylenes (ca. 0.96 g/cm3) Ziegler and Phillips processes produce polymers at lower temperature and pressures with a modified

structure giving a higher density, greater hardness higher softening points. The Standard Oil process gives a density of about 0.96 g/cm3) similar to the Phillips materials. Processes, such as a gas phase process developed by Union Carbide for making linear low density polyethylene (LLDPE), were aimed to produce polyethylenes with short chain branch but no long chain branch. High pressure polymers have more branching and even with side chains as long as the main chain. In contrast, the high density polyethylene (HDPE) produced by the Ziegler or Phillips methods has only 3 to 5 branches per 1000 C-atoms and the linear low density PE has very few branches. The weak point in the chain which is sensitive to degradative environmental effects is located at the branching site. The amount of branches in polyethylene also influences the crystallinity of polyethylene. A higher degree of crystallinity and associated denser packing leads to higher density and larger crystals (LDPE< 1 |xm; LLDPE, 2-4 jxm; HDPE, 2-8 |xm). The crystallinity is increased with slower cooling rate. Only the HDPE and the ultra high molecular weight polyethylene (UHMWPE) find extensive medical applications. Chemically, polyethylene is inert and there are no effective solvents at room temperature. However, polyethylene is subject to oxidation and halogenation. Chemicals like nitric acid produce oxidative deterioration and affect mechanical properties of polyethylene. The environmental oxidation of polyethylene happens at high temperature, under ultra-violet light and/or high energy irradiation, e.g., gamma irradiation. Polyethylene should be kept from contact with halogenating agents and environments. The lower molecular weight polyethylene may be dissolved at high temperature and swollen by chemicals such as benzene and xylene. The resistance to environmental stress cracking (ESC) increases with molecular weight, (copolymers being more resistant than homopolymers). 3 . 3 POLYPROPYLENE Polypropylene is an addition polymer of propylene. The chemical structure of polypropylene is often described as the repeating unit of 2-methyl ethylene. During polymerization, the CH3 groups characteristic of this olefin can be incorporated spatially into the macromolecule in different ways. The resulting products have different properties and are classified as a. isotactic polypropylene, where the CH3 groups are on the same side of the main chain; b. syndiotactic polypropylene, where the CH3 groups are symmetrically arranged on the two sides of the main chain; c. atactic polypropylene, where the CH3 groups are randomly distributed in the spatial relationship to the main chain. The atactic polymer is an amorphous somewhat rubbery material of little value, whereas the isotactic polymer stiff, highly crystalline and with

high melting point. Commercial polymers are usually about 90-95% isotactic. Within the range of commercial polymers, the greater the amount of isotactic material, the greater the crystallinity, and hence the greater the softening point, stiffness, tensile strength, modulus, and hardness. The properties of the polymer will depend on the size and type of crystal structure formed in its construction. Molecular weights of polypropylenes are in the range Mn = 38 000-60 000 and Mw = 220 000-700 000 with the values of Mw/Mn = 5.6-11.9, higher than those encountered normally in polyethylene. The high molecular weight polymer from propylene was introduced in 1954 by G. Natta using a modified Ziegler process, and commercialized in 1957 by Montecatini under a trade name Moplen. This was followed in 1983 by the Spheripol process; in 1988, the Valtec process; and in 1990, Himont process. The greatest influence of molecular weight and molecular weight distribution is on the rheological properties. Rheological investigations show that polypropylene deviates more strongly from Newtonian behaviour than does polyethylene. The effect of shear rate on the apparent melt viscosity is greater for polypropylene Although polypropylene and polyethylene are similar structurally,, polypropylene has a lower density around 0.90 g/cm3 and a higher Tg and T1n. The higher melting point of polypropylene gives the option for autoclave sterilization. The chemical resistance of polypropylene is similar to high density polyethylene, but it is more susceptible to oxidation, chemical degradation and crosslinking (irradiation, violet light and other physical means) than polyethylene. Polypropylene is better in creep resistance and in resisting environmental stress cracking than polyethylene.

3 . 4 POLYURETHANE
Polyurethanes are block copolymers containing blocks of low molecular weight polyethers or polyesters linked together by a urethane group. The variety of linkages in polymers results from the further reaction of urethane groups with isocyanates and of isocyanates with amines, water, or carboxylic acids. Attention in this section will be focussed on the thermoplastic polyurethane elastomers. These polymers are based on three monomers: (1) an isocyanate source, (2) a macroglycol or carbonate, and (3) a chain extender, or curing agent. The isocyanates can be either aromatic or aliphatic. Although the aliphatic based polyurethanes are more expensive, and inferior in physical properties they do not show the embrittlement, weakening, and progressive darkening of the aromatic equivalents. The final physical and biological properties of the polyurethanes depend principally on the type of macroglycol used in the synthesis. The

polyether-based polyurethanes are less sensitive to hydrolysis, and are thus more stable in vivo. The polycaprolactone-based polyurethanes, due to their quick crystallization, can be used as solvent-activated, pressuresensitive adhesives. For medical applications, the polyether-based polyurethanes, particularly those based on polytetramethylene ether glycol (PTMEG) have been used. Among chain extenders, there are two choices: either difunctional or multifunctional monomers. For the production of linear elastomers, only difunctional chain extenders are used, of these, diols and diamines are by far the most important. The chain extenders for the thermoplastic polyurethanes must be linear diols, among which, 1,4-butane diol has been chosen for medical applications. This chain extender produces thermoplastic polyurethanes with high physical properties, excellent processing conditions and clear polymers. Polyurethane elastomers are a mixture of crystalline (hard segment) and amorphous domains(soft segment), and the hard segments are considered to result from contributions of the diisocyanate and chain extender components. They significantly affect mechanical properties, particularly modulus, hardness and tear strength. Soft segments therefore affect the tensile strength and elongation at yield and break. Polyurethanes are sensitive to strong acids, strong alkalis, aromatics, alcohols, hot water, hot moist air and saturated steam. The hydrolytic stability of polyurethanes in applications must be considered carefully. However, polyurethanes are resistant to weak acids, weak alkalis, ozone, oxygen, mineral grease, oils and petroleum. There are doubts for the oxidation stability of polytetramethylene ether glycol based polyurethanes. Polycarbonate urethane is a promising substitute with good oxidation stability. The thermoplastic polyurethanes are characterized by the following properties: a. high elongation at break and high flexibility (also at low temperature), b. low permanent deformation on static and dynamic loading, c. favourable friction and abrasion performance, d. high damping power, e. high resistance to high energy and UV radiation, and f. plasticizer free, 3.5 POLYTETRAFLUOROETHYLENE Polytetrafluoroethylene, PTFE, is the polymerization product of tetrafluoroethylene discovered in 1938 by RJ. Plunkett of Du Pont. The polymer is linear and free from any significant amount of branching. The highly compact structure leads to a molecule of great stiffness and results in a high crystalline melting point and thermal stability of the polymer. The weight average molecular weights of commercial PTFE are in the range 400 000 to 9 000 000. The degree of crystallinity of the polymer

reaches 94%. The properties of PTFE moldings are considerably influenced by the processing conditions and polymer grades. After processing, cooling conditions determine the crystallinity of the molding. Slow cooling leads to higher crystallinity which affects the physical properties as well as mechanical and thermal properties. PTFE is a tough, flexible material of moderate tensile strength with excellent resistance to heat, chemicals and to the passage of an electric current. The polymer is not wetted by water and absorption is not detectable. The permeability to gases is low, the water vapour transmission rate being approximately half that of low density polyethylene and polyethylene terephthalate. It has the lowest coefficient of friction of all solids and the dynamic and static coefficients of friction are equal, i.e. stick-slip does not occur. Abrasion resistance is low. The thermal stability of PTFE is excellent up to 300 0C but it is degraded by high energy radiation. Phase transition behaviour precludes the use of the conventional molding methods, and PTFE can be processed by employing a process similar to that of metallurgical sintering. In 1963, Shinsaburo Oslinge of Sumitomo Industries in Japan discovered a process for expanding PTFE during extrusion. The e-PTFE has been considered for fabrication of vascular grafts. Apart from its good slip and wear characteristics the advantages of PTFE are: a. almost universal chemical resistance, b. insolubility in all known solvents below 300 0C, c. high thermal stability, d. continuous service temperature range -270 to 260 0C, e. low adhesion, f. low coefficient of friction, g. outstanding electrical and dielectric properties, h. resistant to stress cracking and weathering, but limited use in structural components because of the low modulus of elasticity. 3.6 POLYVINYLCHLORIDE Commercial PVC polymers are largely amorphous, slightly branched molecules with the monomer residues arranged in a head-to-tail sequence. The molecular weights for most commercial polymers are in the range of Mw = 100 000-200 000, Mn = 45 000-64 000 although values may be as low as 40 000 and as high as 480 000 for the weight average molecular weight. The ratio of Mn/Mw is usually about 2 for the commercial material although it may increase with the higher molecular weight grades. The polarity and strong inter-chain attraction gives a higher hardness and stiffness than polyethylene. Thus PVC has a higher dielectric constant and power factor than polyethylene, although at temperatures below the glass transition temperature the power factor is still comparatively low (0.01-0.05 at 60 Hz) because of the immobility of the dipole. PVC is

mainly used in a plasticized form. There are many materials that are suitable plasticisers for PVC. They have similar solubility parameters to PVC, i.e., about 19.4 MPaX and are also weak proton acceptors and may be incorporated by mixing at elevated temperatures to give mixtures stable at room temperature. The release of low molecular weight plasticizer has resulted in polymeric plasticisers being developed, but esters are still widely used and are effective in plasticisation. (Black, 1992; Brydson, 1982, and Park and Lakes, 1992). Characteristic properties are: 3.6.1 Unplasticized PVC a. high mechanical strength, rigidity and hardness, b. low impact strength in unmodified form, c. translucent to transparent (depending on method of manufacture), d. good electrical properties in the low voltage and low frequency range, and e. high chemical resistance.
3.6.2 Plasticized PVC

a. flexibility adjustable over a wide range, b. depending on type of plasticiser, toughness very temperature dependent, c. translucent to transparent, d. good electrical properties in the low voltage and low frequency range, e. chemical resistance is dependent on the formulation and very dependent on temperature, and f. the polymers contain less than 1 ppm vinyl chloride monomer. 3.7 POLYAMIDES Chemically, the polyamides may be divided into two types: a. those based on diamines and dibasic acids, and b. those based on amino acids or lactams (Chapman and Chruma, 1985). Commercial use of nylons is dominated by two products, one from each type, nylon 66 and nylon 6 from e-caprolactam. Aliphatic polyamide is linear and easy to crystallize but crystallinity varies widely with conditions. Crystalline content may be 50-60% by slow cooling and 10% by fast cooling. High interchain attraction in the crystalline zones and flexibility in the amorphous zones leads to polymers which are tough above their apparent glass transition temperatures (Brydson, 1982). Polyamides have excellent fibre-forming capability due to interchain Hbonding and a high degree of crystallinity which increases strength in the fibre direction (Park and Lakes, 1992). Polyamides are hygroscopic and

lose strength in vivo. The amorphous region of poly amide chains is sensitive to the attack of water. The greater the degree of crystallinity, the less the water absorption and hence the less the effect of humidity on the properties of the polymer. The reversible absorption of water is associated with a change in volume and thus of dimensions. The mechanical properties of moulded polyamide materials depend on molecular weight, crystallinity and moisture content. In the dry, freshly molded state, all polyamide grades are hard and brittle. When conditioned they are tough and wear resistant. High melting points result in good mechanical properties up to temperatures in the region of 120-150 0C. They are only soluble in a few solvents (formic acid, glacial acetic acid, phenols and cresols), of similar high solubility parameter. Nylons are of exceptionally good resistance to hydrocarbons. Esters, alkyl halides, and glycols have little effect on them. Alcohols can swell the polymers and sometime dissolve some copolymers. Mineral acids attack the nylons but the rate of attack depends on the type of nylon and the nature and concentration of the acid. Nitric acid is generally active at all concentrations. The nylons have very good resistance to alkalis at room temperature. Resistance to all chemicals is more limited at elevated temperature (Brydson, 1989). Generally, polyamides are characterized by: a. high strength, stiffness and hardness, b. high heat distortion temperature, c. high wear resistance, good slip and dry-running properties, d. good damping capacity, e. good resistance to solvents, fuels and lubricants, f. non-toxicity, g. good processability, h. aliphatic polyamides are partially crystalline and thus opaque, and i. moisture content impairs mechanical properties and affects dimensions of moldings. 3.8 POLYACRYLATES Polyacrylates are based on acrylic acid, methacrylic acid, and their esters. Among them, polymethylmethacrylate (PMMA) and polyhydroxy ethylmethacrylate (PHEMA) have found wide applications as biomedical materials. The clinical history of polyacrylates began when it was unexpectedly discovered that the fragments of PMMA plastic aircraft canopies stayed in the body of the wounded without any adverse chronic reactions (Jones and Denning, 1988; Park and Lakes, 1992). In normal conditions, PMMA is a hard transparent material. Molecular weight is the main property determinant. High molecular weight PMMA can be manufactured by free radical polymerization (bulk, emulsion, and suspension polymerisation). Bulk polymerization is used for cast semifinish products (sheet, profiles and even tubes), and the cast polymer is distinguished by superior mechanical properties and high surface finish

(Brydson, 1982 and Domininghaus, 1993). Cast material has a number average molecular weight of about 106 whilst the Tg is about 1060C. The extensive molecular entanglement prevents melting below its decomposition temperature (approx. 1700C). An amorphous polymer, PMMA has a solubility parameter of about 18.8 MPaX and is soluble in a number of solvents with similar solubility parameters. Solvents include ethyl acetate (8: 18.6 MPaX), ethylene dichloride (8: 20.0 MPaX), trichloroethylene (8: 19 MPaX), chloroform (8: 19 MPaX), and toluene (8: 20 MPaX). The polymer is attacked by mineral acids but is resistant to alkalis, water and most aqueous inorganic salt solutions. A number of organic materials although not solvents may cause crazing and cracking (e.g. aliphatic alcohols). The characteristic properties of PMMA are, a. high hardness, stiffness and strength, b. homopolymers are brittle, copolymers are tough, c. scratch-resistant, high gloss surface capable of being polished, d. waterwhite transparency, copolymers exhibit inherent yellowish color, e. high heat distortion temperature, f. good electrical and dielectric properties, g. resistant to weak acids and alkaline solution as well as to non-polar solvents, grease, oils and water, h. susceptible to stress cracking, i. flammable, j . good processability and machinability, k. rather low resistance to creep at temperature only slightly above room temperature, and 1. high melt viscosity due to the high chain stiffness caused by restricted rotations about the C-bonds in the backbone chains 3 . 9 POLYACETAL Polyacetal can be divided into two basic types, acetal homoploymer and acetal copolymer. Both homopolymer and copolymer are available in a range of molecular weights (Mn = 20 000-100 000). The homopolymer is a polymer of formaldehyde with a molecular structure of repeated oxymethylene units (Staudinger, 1932). Large-scale production of polyformaldehyde, i.e. polyacetal, commenced in 1958 in the USA (US Patent 2 768 994,1956) (British patent 770 717, 1957). Delrin (1959) was the first trade mark for this polymer by Du Pont Company. The copolymers were introduced by the Celanese Corporation of America, and the first commercial product named Celcon (1960). One of the major advantages of copolymerization is to stabilize polyacetal because the homopolymer tends to depolymerize and eliminate formaldehyde. The most important stabilization method is structural modification of the polymer by, for example, copolymerization with cyclic ether. As can been seen polyacetal has a very simple structure of a polyether. Unlike polyethylene, polyacetal has no branching, and its molecules can pack more closely together than those of polyethylene. The resultant

polymer is thus harder and has a higher melting point than polyethylene (175C for homopolymer), exhibiting a high crystallinity (77-85%). No effective solvents have been found for temperatures below 700C. Swelling occurs with solvents of similar solubility parameter (8: 22.4 MPaX). However, polyacetal should be kept away from strong acids, strong alkalis, and oxidizing agents. Water can not degrade it but may swell it or permeate through it and affect the dimensions of its products. Prolonged exposure to ultra-violet light will induce surface chalking and reduce the molecular weight of the polymers. Polyacetals, both homopolymer and copolymer are also radiation sensitive. The radiation damage threshold is estimated at 0.5 Mrad with 25% damage at 1.1 Mrad (Szycher, 1991). Generally, the polyacetals have the following characteristics, a. high tensile strength, shear strength, stiffness, and toughness, b. predictable stress/ strain relationships, c. predictable dimensional behavior, d. chemical and corrosion resistance, e. abrasion resistance, f. light weight and good appearance, g. acceptability for food contact application (most grades), h. ease of processing, and i. competitive costs. The enormous commercial success of the polyacetals is owed to their very high resistance to creep and fatigue. The acetal resins show superior creep resistance to the nylons. 3.10 POLYCARBONATE Polycarbonate, PC, is a linear thermoplastic based on the bis-phenol A dihydroxy compound. In 1898 Einhorn reacted dihydroxybenzenes with phosgene in solution in pyridine (Brydson, 1982), and production began in both Germany and USA in 1958. General purpose polycarbonate is a linear polyester of carbonic acid in which dihydric phenols are linked through carbonate groups, while standard grades are made from bisphenol A and phosgene (Carhart, 1985). The rigid molecular back bone of bis-phenol A PC leads to high melting temperature (Tm = 225-2500C) and high glass transition temperature (Tg = 145C). The polymer does not show any crystallinity. After annealing polymer between 80 and 1300C there is a small increase in density and hence there must be a decrease in free volume, and a large drop in impact strength; impact strength may be reduced by annealing crystallization and aging (Brydson, 1982). The limited crystallinity contributes to the toughness of PC. Highly crystalline samples prepared by heating for prolonged periods above their Tg or by precipitation from solution are quite brittle. Although of good impact strength and creep resistance tensile strain of 0.75% or more produces cracking or crazing. The refractive index of PC lies in the range

of 1.56 to 1.65 (higher than PMMA and silicone rubber) and the transparency of 85 to 90% is reached in the region of visible light (Domininghaus, 1993). The chemical resistance of PC is poor and hydrolysis of aliphatic PC s is more prominent than that of bis-phenol A PC s. There is resistance to dilute (25%) mineral acids and dilute alkaline solutions other than caustic soda and caustic potash. Where the resin comes into contact with organophilic hydrolysing agents such as ammonia and the amines, the benzene rings give little protection and reaction is quite rapid. The absence of both secondary and tertiary C-H bonds leads to a high measure of oxidative stability. Oxidation takes place only when thin films are heated in air to temperatures above 3000C. Typical properties include: a. low density, b. high strength, stiffness, hardness and toughness over the range from -150 to + 135C unreinforced and from -150 to +1450C when reinforced, c. crystal clear transparency, high refractive index, high surface gloss, d. can be colored in all important shades, transparent, translucent or opaque with great depth of color, e. good electrical insulation properties which are not impaired by moisture, f. high resistance to weathering for wall thicknesses greater than 0.75 mm, g. high resistance to high energy radiation, and h. self-extinguishing after removal of the ignition source. The main disadvantages are: a. processing requires care, b. limited chemical resistance, c. notch sensitivity and susceptibility to stress cracking.

3 . 1 1 POLYETHYLENE TEREPHTHALATE
Polyethylene terephthalate, PET, is a thermoplastic polyester made by condensation reaction of ethylene glycol with either terephthalic acid or dimethyl terephthalate (Margolis, 1985). By the end of the 1920s J.R. Whinfield and J.T. Dickson discovered PET (BP 578079). It was first commercialized by Du Pont in 1930 (Brydson, 1982) as Dacron, followed by ICI with Terylene Films and blow-molded articles have become very important commercially. The average molecular weights are distributed from 15 000 to 20 000. The physical properties of PET are largely determined by the degree of crystallinity, which varies between 30 and 40% depending on the processing conditions. The rate of crystallization of PET is considerably less than that of polyacetal (POM) and HDPE. The growth rate of the spherulites is only 10 |xm/mm for PET compared with 400 |xm/mm for POM and 5000 ^m/mm for HDPE (Domininghaus, 1993). To achieve better crystallinity, the mould temperature should be equivalent to that for maximum growth. This point is about 175C, higher than for POM

and HDPE. Rapid-crystallization agents, nucleating agents, reduce the process cycle time and permit lower mould temperatures below 1000C, leading to very fine spherulites and hard stiff mouldings. Extrusion and rapid quenching below the temperature at which most crystallization occurs (between 120 and 2000C), produces amorphous materials and this may be followed with uniaxial orientation for fibres and biaxial orientation for films. The orientation is carried out at 100-1200C, the glass transition temperature, Tg being 860C. The permeability of water vapor through PET is higher than that of polyolefins but lower than that of polycarbonate, polyamide, and polyacetal. Antioxidants are necessary to prevent to the oxidation of polyether segments in thermoplastic polyester elastomer. Chemical resistance of PET is generally good to acids, alkalis, and organic solvents. Typical properties for partially crystalline PET include, a. high strength and stiffness, b. favorable creep characteristics in comparison with POM, c. hard surface capable of being polished, d. high dimensional stability, e. good electrical, mediocre dielectric properties, and f. high chemical resistance except to strong acid and alkaline solution.

3 . 1 2 POLYETHERETHERKETONE
Polyetheretherketone, PEEK, is a polymer combining stiff conjugated aromatic groups and flexible ether segments. It was first prepared in the laboratory in 1977 and then marketed in 1978 by ICI, under the trade name of Victrex (Brydson, 1982). The distribution of aromatic rings and polar flexible groups in the chain affects the glass transition temperature, such that PEEK has a Tg around 145C and T1n ca. 335C, PEK (polyether ketone) Tg ca. 165C and Tm ca. 342C. Normally the chain stiffness and bulkiness of aromatic rings make it difficult for these polymers to crystallize and although they invariably remain mainly amorphous (Mascia, 1989), PEEK is a partially crystalline thermoplastic. The maximum crystallinity of 48% is achieved from the melt at 256C and by subsequent conditioning of moldings at 185C (Domininghaus, 1993). PEEK polymers are capable of melt processing (Brydson, 1982). Other specific features are excellent gamma radiation resistance, and good resistance to environmental stress cracking. PEEK shows excellent chemical resistance and can be used in aggressive environments. Generally, the main characteristics of this material include, a. high tensile and flexural strength, b. high impact strength, c. high fatigue limit, d. high heat distortion temperature (315C for 30 glass reinforced), e. good electrical properties over a wide range of temperature, f. favourable slip and wear properties, g. high chemical resistance, h. high resistance to

hydrolysis, j . high resistance to radiation, k. low flammability, very low gas and smoke emission, and 1. easy processing, no thermal after-treatment of injection moldings. 3.13 POLYSULFONE Polysulfone is a polymer which has properties matching those of light metals (Park and Lakes, 1992). The first commercial polysulfone was introduced in 1965 by Union Carbide as Bakelite Polysulfone, now called Udel. In 1967 3M offered Astrel 360 referred to as a polyarylsulfone. In 1972 ICI introduced a polyethersulfone Victrex. A high toughness polysulfone was released in the late 1970s by Union Carbide. Although the commercial polymers are linear and most have regular structures they are all principally amorphous. The backbone aromatic structure leads to high values of the glass transition temperature between 190 and 2300C. The Union Carbide materials have a secondary transition at -1000C and the ICI polymer at -700C. Typical Mn values are ca. 23 000. Commercial materials are described variously as polysulfones (Udel), polyarylsulfones (Astrel), polyether sulfones or polyarylethersulfones (Victrex) (Brydson, 1982). The polymer is manufactured from bisphenol A and 4, 4-dichlorosulphonyl sulfone by multi-step condensation. The most distinctive feature of the backbone chain of those polymers is the diphenylene sulfone group. The sulphur atom in each group is in its highest state of oxidation and tends to draw electrons from the adjacent benzene rings, hence resisting any tendency to lose electrons to an oxidizing agent. Polysulfones thus show outstanding oxidation resistance. The aromatic nature of the diphenylene sulphone can absorb considerable energy applied as heat or radiation and so resists thermal degradation. The diphenylene sulfone group thus confers on the entire polymer molecule the inherent characteristics of thermal stability, oxidation resistance, and rigidity at elevated temperatures. The potential for energy dissipation confers good impact strength and ductility down to -1000C with high elongation to break and tensile strength. Under most conditions, impact properties rival those of bisphenol A polycarbonate. Unlike polycarbonate, however, polysulfone can exhibit excellent resistance to hydrolysis or reduction of molecular weight even at elevated temperatures. Tests on the hydrolysis stability of polysulfones have been carried out up to 10 000 hours without observed loss of molecular weight. The polymers are stable in aqueous inorganic acids, alkalis, salt solutions, aliphatic hydrocarbons, and paraffin oils, are transparent, capable of steam sterilization, and free from taste and smell. They should not

come in contact with ketones, aromatic solvents, chlorinated hydrocarbons, and polar organic solvents. They may show stress crazing on exposure to steam or water. A polyethersulfone, however, exhibited no crazing even after 300 hours and retained 90% of initial tensile impact strength. For a thermoplastic material, creep is low at moderate temperatures but is significant at temperatures approaching the glass transition. However, the wear properties of this material are not as good as PE and POM (Teoh et al., 1994). Generally polysulfone has the following characteristic properties, a. high strength, stiffness and hardness between -100 and +1500C short-term to 1800C, b. high thermal stability and heat distortion temperature, c. crystal clear (slightly yellowish) transparency, d. high processing temperature, e. high melt viscosity, f. high chemical resistance, g. susceptibility to stress cracking with certain solvents, h. high resistance to (3-, 7-, X- and IR-radiation, i. high transmittance for microwaves, and j . high flame resistance and low smoke development.

Table 3.1 Chemical structures of thermoplastic polymers in biomedical applications 1. Polyethylene (PE)

linear and high density branched and lower density 2. Polypropylene (PP)

isotactic syndiotactic atactic

3. Polyurethane (PU) R = aliphatic or aromatic groups x and n for soft segment, y for extender in rigid segment 4. Polytetrafluoroethylene (PTFE)

Table 3.1

Continued

5. Polyvinylchloride (PVC)

6. Polyamide (PA) nylon

7. Polyacrylate (PMMA)

8. Polyacetal (POM)

homopolymer if x^m^O copolymer 9. Polycarbonate (PC)

Table 3.1 Continued 10. Polyethylene terephthalate (PET)

11. Poly ether etherketone (PEEK)

12. Polysulfone (PS)

Table 3.2

Properties of thermoplastic polymers in biomedical applications

a. Physical properties Physical properties Density Water absorption Solubility parameter Refractive index, nD20 Physical properties Density Water absorption Solubility parameter Refractive index, nD20 b. Mechanical properties Mechanical property Bulk modulus Tensile strength Elongation at break Young's modulus Elastic limit Endurance limit Fracture toughness Hardness Compressive strength Poisson's ratio Shear modulus Unit GPa MPa % GPa MPa MPa MPa m1//2 MPa MPa GPa PE 0.8-2.2 30-40 130-500 0.45-1.3 20-30 13-19.6 2.2-4 60-90 30-40 0.4-0.42 0.18-0.46 PP 1.6-2.5 21-40 100-300 1-1.6 20-33 11-18.2 1.7-2.1 60-100 30-45 0.4-0.45 0.4-0.6 PU 1.5-2 28-40 600-720 0.0018-0.009 28-40 21-30 0.1-0.4 50-120 33-50 0.47-0.49 0.00084-0.003 PTFE 1-2 15^0 250-550 0.3-0.7 15-30 9-18 2.5-3 27-90 30-60 0.44-0.47 0.11-0.24 PVC 3-4 10-75 10-400 1.0-3.8 23-52 13.8-31.2 1-4 70-155 32-80 0.37-0.43 0.7-1.1 PA 2.4-3.3 44-90 40-250 1.4-2.8 40-58 22-31.9 1.8-2.6 100-160 60-100 0.38-0.42 0.52-0.9 Unit g/cm % MPa1/2 Unit g/cm % MPaX
3 3

PE 0.954-0.965 0.001-0.02 16.4-16.6 1.52-1.54 PMMA 1.12-1.2 0.1-0.4 18.58 1.49-1.51

PP 0.90-0.915 0.01-0.035 16.3 1.47-1.51 POM 1.40-1.42 0.2-0.4 22.4 1.48

PU 1.02-1.28 0.1-0.9 16.4-19.5 1.5-1.65 PC 1.2-1.26 0.15-0.7 19.4-19.8 1.56-1.60

PTFE 2.10-2.20 0.01-0.05 12.6 1.35-1.38 PET 1.31-1.38 0.06-0.3 21.54 1.51

PVC 1.16-1.70 0.04-0.75 19.4-21.5 1.52-1.57 PEEK 1.29-1.49 0.15-0.51 20.2

PA 1.02-1.15 0.25-3.5 23.02 1.52-1.57 PS 1.13-1.60 0.14-0.43 20.26-22.47 1.56-1.67

Table 3.2 Continued b. Mechanical properties Mechanical property Bulk modulus Tensile strength Elongation at break Young's modulus Elastic limit Endurance limit Fracture toughness Hardness Compressive strength Poisson's ratio Shear modulus c. Thermal properties Thermal property Service temperature in air without mechanical loading (short-term) Service temperature in air without mechanical loading (long-term) Minimum service temperature Melting(Tm)/decomposing (Td*) ranges Glass transition temperature Tg Unit
0

Unit GPa MPa % CPa MPa MPa IV IPa m1//2 MPa MPa GPa

PMMA 3-4.8 38-80 2.5-6 1.8-3.3 35-70 19.3-38.5 0.8-1.3 100-220 45-107 0.4-0.43 0.6-1.2

POM 4-5.6 70-75 15-80 2.55-3.5 65-72 28-42 1-1.5 110-220 70-80 0.38-0.43 0.79-1

PC 2.8-4.6 56-75 80-130 2-2.9 53-75 29.2-41.3 2.5-3.2 110-180 100-120 0.39-0.44 0.95-1.05

PET 3-4.9 42-80 50-300 2.2-3.5 50-72 30-43.2 1.2-2 97-210 65-90 0.38-0.43 0.83-1.1

PEEK 4-4.5 70-208 1.3-50 3.6-13 12-60 33-36 2.3-2.5 100-120 80-120 0.38-0.43 1.2-1.4

PS 3.8-4.6 50-100 25-80 2.4-2.9 58-70 34.8-42 1.3-2 180-240 72-100 0.38-0.42 0.8-1

PE 90-130 70-100 -63 to -53 125-135 -113 to -103

PP 140 100 -123 to -23 160-180 -30 to -3

PU 80-130 60-80 -123 to -23 180-250* -73 to -23

PTFE 300 250 -263 to -253 322-327 20 to 22

PVC 55-100 50-85 -43 to -28 150* -23 to 90

PA 130-200 70-120 -60 to -50 220-267 20 to 92

C C

C C C

Table 3.2 Continued c. Thermal properties Thermal property Softening temperature Specific heat Thermal expansion Thermal conductivity Thermal property Unit C J/g.K 106/K W/mK Unit
0

PE

PP

PU

PTFE 1.00-1.01 100-150 0.19-0.25

PET

PVC

PA

40-50 1.95-2.20 100-200 0.42-0.52 PMMA 76-108 65-98 -123 to -73 -170* 106-115 70-115 1.28-1.5 62-105 0.10-0.19

70-100 1.70-2.35 80-200 0.12-0.24 POM 110-140 90-110 -123 to -73 164-175 -13--75 110-163 1.40-1.46 90-125 0.22-1.1

100 0.4-1.76 150-210 0.29-1.80

PC

40-110 0.85-1.80 60-210 0.13-0.26 PEEK 300 250

80-200 1.26-1.8 80-150 0.23-0.29

PS

Service temperature in air without mechanical loading (short-term) 0 Service temperature in C air without mechanical loading (long-term) 0 Minimum service C temperature 0 Melting(Tm)/decomposing C (Td*) ranges 0 Glass transition C temperature Tg 0 Softening temperature C Specific heat J/gK 6 Thermal expansion 10 /K Thermal conductivity W/mK

160 135 -133 to -123 225-250 145 138-148 1.17-130 40-75 0.14-0.22

180-200 100 -133 to -38 245-255 67-127 70-185 1.05-1.60 50-120 0.15-0.34

160-260 150-200

-123 to -103 -123 to -73 335 144 140-315 1.5-1.6 15-47 0.25-0.92 >500* 167-230 150-216 1.1-1.30 53-58 0.13-0.28

Table 3.3 Processing conditions for thermoplastc polymers in biomedical applications Thermoplastics
1. Polyethylene

Process
Injection moulding Extrusion Blow film extrusion Flat film extrusion Blow moulding Thermoforming Compression moulding Injection moulding Extrusion Blow moulding Compression moulding Thermoforming

Special process
Film processing for PE-LD Rotational moulding for PE-powders Block, sheet, tube, profile, andfilmprocessings for PE-HD and PE-HD-UHMW Powder sintering technology for PE-UHMW Extrusion: blown film, flat film, sheet, tube, monofilaments Injection: Long-lasting integral hinges Biaxially oriented packaging film Tapes

Pre-treatment
No pre-drying treatment except hygroscopic additives are added. Stabilizers and antioxidants are needed for specific processing.

Remarks

2. Polypropylene

PE-UHMW in solid or porous form has been used in biomedical study and application. Its most outstanding properties are wear or abrasion resistance, excellent impact resistance, and fatigue resistance. PE-UHMW has been used in fabrication of acetabular cup for hip joint prostheses. Polypropylene has exceptionally high flex No pre-drying life, excellent environmental stress treatment except cracking resistance, excellent wear hygroscopic additives resistance, higher temperature resistance are added. (withstanding steam sterilization), and Stabilizers and low cost. Fiber applications such as antioxidants are needed suture, sewingring,braided ligament, for specific processing. skin and abdominal patches. Promising applications in thin-wall packaging competing with polystyrene. Polypropylene has lower specific heat and theflowproperties are more sensitive to temperature and shear rate. The mold shrinkage is lower than polyethylene but higher than with polystyrene. It has higher melt strength is important for extrusion blow molding of hollow objects. Lower molecular weight grades are suited for extrusion of monofilaments and injection molding of thin-walled articles. Cold forming may be done at room temperature (rolling), and forging, pressure forming, rolling and stamping at temperatures below 0 the crystallite melting region (150 to 160 C). Film processing especially in oriented form competing with polyethylene.

Table 3.3

Continued Process Injection moulding Extrusion Special process Sheet extrusion Shape extrusion Cast or blow film extrusion Fiber processing Pre-treatment Remarks Characteristics highflexibilityand high Polyurethane, especially impact resistance, and excellent aliphatic type is biocompatibility. Film forms of hygroscopic; the pellets polyurethane have been used in must be dried before fabrication of vascular graft and extrusion. patches, heart valve leaflets, blood pumps, diaphragms for implantable artificial heart, and carriers for drug delivery. Elastomeric fibers (Spandex) made from polyurethane copolymer have been used in surgical hoses. Unfavorable processing conditions will induce residual stresses in the products which impair the biostability of polyurethane-based prostheses. To avoid residual stresses in polyurethane tubes, an upper limit of drawn down ratio of 1.5:1.0 are recommended for the appropriate stretching during extrusion. If water bath for tube processing is too cold, residual stresses are also induced. A recommended temperature for the water bath is between 21-27C. Exceptional chemical resistance, PTFE is a hydrophobic temperature resistance, and radiation polymer and pre-drying and weathering resistance. is not necessary. Outstanding electrical properties as insulator or dielectric material. Low adhesion and low coefficient of friction. Exceptional flame resistance. Expanded PTFE (Gortex) has been used in fabrication of blood vessel prostheses.

Thermoplastics 3. Polyurethane

4. Polytetrafluorethylene

Sintering Ram extrusion Paste extrusion Coating followed by sintering Impregnation

High temperature sintering process for parts, sheets, plates Ram extrusion for rods, tubes, profiles, wire coatings, and fibers Insulating films, crucibles Expanded tubular form

Table 3.3

Continued Process Extrusion Calendering Injection molding Extrusion blow molding Stretch blow molding Compression molding Sintering Special process Blown film Flat film Sheets Tubes and profiles Cable sheathing Bristles and mono filaments Pre-treatment Remarks

Thermoplastics 5. Polyvinylchloride

6. Polyamides

Injection molding Extrusion Extrusion blow molding

7. Polyacrylates

Injection molding Extrusion Compression molding Thermoforming

Proper stored Plasticized PVC favours calendering, polyvinylchlorde can be while unplasticized PVC prefers used without pre-drying. extrusion. Premixing of ingredients Injection moulding is difficult for both will be considered for plasticized and unplasticized PVCs plasticized PVC. except careful control of processing conditions or special design of machine. Characteristic flame resistance. Decomposition happens at high temperature. Overheat in processing should be avoided. Tubular, sheet, plate, andfilmforms of PVC have been used in medical devices such as blood bags and catheters. Implants of PVC are not encouraged. Excellent friction properties and good Injection: thin-wall articles, Polyamides, especially wear and abrasion resistance. engineering components aliphatic types are Extrusion: bristles, packaging, hygroscopic. Pre-drying Excellent hydrocarbon resistance. Films are used for packaging. Fiber form tapes,fiber,wire, film, is needed before is employed as suture materials. sheet, tubes, profiles, processing, and also sheathing precaution will be considered during and after process. Polyacrylates can easily Primary forms: Excellent transparency, good scratch pick up moisture from sheet, rod, and tube resistance. environment. Pre-drying Good processability and machinability. Casting from monomer is necessary. for optical properties Monomer and polymer powder casting Extrusion from thermoplastic to produce bone cement. resins to produce sheet. Hydrogel has been used to fabricate Injection moulding for small contact lens. complex parts Monomer-polymer doughs is used for processing dentures.

Table 3.3

Continued Process Special process Pre-treatment Polyacetal is less hygroscopic than nylon. However, acetal polymer must be stored in dry place. Remarks

Thermoplastics 8. Polyacetal

Injection molding Injection moulding Extrusion Extrusion Blow molding Compression molding

9. Polycarbonate

Injection molding Extrusion Blow moldings Thermoforming Hot bending Injection moulding Extrusion Blow molding

10. Polyethyleneterephthalate

Oustanding creep and fatigue resistance. Good toughness and impact resistance. Excellent strength for engineering application. Processing temperature must be carefully controlled. Fiber andfilmforms of polyacetal are not available. Polyacetal, Delrin, has been used in disc of mechanical heart valves. Applications have been found in Injection and extrusion Polycarbonate can pick consideration of toughness, rigidity, Films: extruded and solvent up enough moisture to transparency, self-extinguishing cast, uniaxially oriented deteriorate quality of characteristics, good electrical insulation amorphous and partially, products. and heat resistance. crystalline Pre-drying is necessary. Polycarbonate has been used in the Tube, rod, profile, sheet: manufacture of contact lenses. extrusion Fiber process Polyethyleneterephthalate Characteristic crystallization. Both amorphous and crystallized products Uniaxially oriented tapes is hygroscopic. can be made through control of Films, packaging film, Pre-drying is necessary. crystallization. sheet, articles The benefits from PET products are their Biaxially oriented film stiffness, warp resistance, and dimension and sheet stability. Fiber form of PET has been used to fabricate blood vessels and by-pass prostheses. Suture made from PET. Dacron sewing ring and medical fabrics.

Table 3.3

Continued Process Special process Pre-treatment Remarks Injection molding Injection molding for Compression molding articles Extrusion Extrusion: film/cast and oriented monofilament Composite wire covering Composite: carbon fiber/ PEEK composite Injection molding for Injection molding articles Extrusion Extrusion:filmand sheet Blow molding which can be Thermoforming thermoformed

Thermoplastics 11. Polyetheretherketone

PEEK is hydrophobic Characteristic high strength at high polymer but pre-drying temperature. is necessary for quality Excellent resistance to hydrolysis and control. environmental stress cracking. Carbonfiber/PEEKcomposite investigated in bone fracture fixation. Polysulphone is hygroscopic and predrying is required to avoid vapor formation during processing. Good rigidity, creep resistance, and toughness. Hydrolysis resistance and can undergo repeated steam sterilization. Transparent products can be made and used in medical field. Hollowfiberand membrane devices have been used in hemodialysis. Carbonfiber/polysulphonecomposite has been used for bone fracture fixation.

12. Polysulphone

Table 3.4 Trade names of thermoplastic polymers in biomedical applications

1. Polyethylene (PE) PE-LD and PE-HD Eltex(Solvay, BE) Finathene (Fina, BE) Alathon, Sclair (Du Pont Canada Inc., CA) Boalen (Petrimex, CS) Hostalen (Hoechst, DE) Lupolen (BASF, DE) Vestolen (HuIs, DE) Ertileno (Union ERT, ES) Natene (Rhone-Poulenc, FR) Lacqtene (Atochem, FR) Carlona (Shell, GB) Rigidex, Novex (BP Chemicals, GB) Tipolen (Tiszai Vegyi Kombinat, HU) Eraclene (EniChem Base, IT) Fertene Maplen (Himmont, IT) Rumiten (Rumianca, IT) NeoZex (Mitsui, JP) Nipolon (Toyo Soda, JP) Novatec (Mitsubishi, JP) Hi Zex (Mitsol, JP) Mirason (Mitsui Polychem., JP) Sholex (Showa Denko, JP) Sumikathene (Sumitomo Chem., JP) Suntec (Asahi Chem., JP) Staflene (Nisseki Plastic Chem., JP) Yukalon (Mitsubishi Petroleum, JP) Stamylan (DSM, NL) Ropol (Chem. Komb. Borcesti; RO) PE-HD-UHMW Hostalen GUR (Hoechst AG, DE) Eltex (Solvay, BE) Alathon, Sclair (Du pont Canada, CA) Novapol LL (Novacor Chem., CA) Lupolen (BASF, DE) Lupolen UHM (BASF AG, DE) Ladene (SABIC, Saudi Arabia) Escorene (Exxon Chem, US) Fortiflex (Soltex Polymer, US) Norchem (USI, US) Paxon (Allied Signal Corp., US) Microthene, Petrothene (USI Chem., US) HiFax (Himont, US) Marlex (Phillips Petrol., US) Super Dylan (Arco Chem., US) Tenite (Easrman Chem., US) Hipten (Hemijska Ind., YU) Okiten (INAOKI, YU)

PE-LLD
Rumiten (Rumianca, IT) Mirason (Mitsui Polychem., JP) Novatex (Mitsubishi Chem., JP) Escorene (Exxon Chem., US) Marlex TR130 (Phillips Petroleum, US) Microthene, Petrothene (USI Chem., US) Norchem (USI/Exxon Chem., US) Rexene (EI Paso Chem., US) Tenite (Eastman Chem., US)

Sumikathene (Sumitomo Chem., JP) Ultzex (Mitsui Petrochemical, Lotrex (Orkem Norsolor JP) SA, FR) News (Neste Oy Chem., FI) Stamylex (DSM, NL) Ladene (SABIC, Saudi Arabia) Visqueen (ICI, GB) Dowlex (Dow Chemical, US) Eraclear (EniChem., IT) 2. Polypropylene (PP) Asota, Ecofelt (Chemic Linz, AT) Marlex (Phillips Petroleum Co., BE) Istrono (Chem., Werke J. Dimitrow, CS) Tatren (Petrimex, CS) Eltex (Solvay, FR) Carlona (Shell, GB) Propathene (ICI, GB)

Stamylan (DSM, NL) Bicor (Mobil Chem., US) Extrel, Twistlock, Vistalon(Exxon Chem, US) Fortilene (Soltex Polymer Corp. US) Liteplate S (Hercules, US) Profax (Himont, US)

Biofol (Chem. Kombinat. Tisza, HU) Hostalen PP (Hoechst, DE) Afax, Moplen, Valtec (Himont, IT) Bifax (Showa denko, JP) Platilon (Deutsche ATOchem., DE)

Table 3.4

Continued
Eperon (Kanegafuchi Chem., JP) Noblen (Mitsubishi Petrochemical, JP) Novatec (Mitsubishi Chem., JP) PolyPro, Sunlet (Mitsui Petrochem., JP) Rexene (El Paso Chem., US) Tenite (Eastman Chemical, US)

2. Polypropylene (PP) Trovidur (HuIsTroisdorf, DE) Ultralen (Lonza Werke, DE) Vestolen P (HuIs, DE) Apryl, Lacqtene P (Atochem., FR) 3. Polyurethane (PU) General Ucefix, Uceflex (UCB, BE) Europolymers (Avalon Chemical Co., GB) Fabeltan (Tubize Plastics, Jectothane (Dunlop Holdings, GB) BE) Pemuflex (Pemu Chemolimpex, Caprolan, Elastolen, HU) Elastolan (Elastogran Polyurethane, DE) Desmopan (Bayer, DE) Uthane (Urethanes India, IN) Luroflex (Lehmann u. Pelprene (Toyobo Co., Resins Voss Co., DE) Div., JP) Oldopren (Busing u. Durane (Swanson, US) Fasch & Co., DE) Durelast (B & T polymers, GB) Medical special Angioflex (Abiomed Danvers, MA) Biomer (Ethicon Somerville, NJ, US) Cardiothane (Kontron Everett, MA, US) Chronoflex (PolyMedica Burlington, MA, US) Hemothane (Sams, Div 3M Ann Arbor, MI, US) Mitrathane (PolyMedica Burlington, MA, US) Pellethane (Dow Chemical La Porte, TX, US) Surethane (Cardiac Control Palm Coast, FL, US) Tecoflex (Thermedics Inc Woburn, MA, US) Toyobo TM5 (Toyobo Co. Osaka, Japan) Corplex (Corvita Miami, FL, US) Unithane 8OF (NICPBP Beijing, China) Corethane (Corvita Miami, FL, US) PU 10 (Univ. NSW, Australia) Urafil (Akzo-Wilson-Fiberfil, US) Hi-Tuff (J.P. Stevens & Co., US) Esteloc, Estane, Roylar (B .F. Goodrich Chemical Co., US) Irogran, Plastothane (Morton Thiokol, US) Proplastic (Pro Lam, US) Q-Thane (Quinn & Co., US)

4. Polytetrafluoroethylene (PTFE) Hostaflon TF (Hoechst, Neoflon (Daikin Ind., JP) DE) Pamflon (Norton Pampus, Polyflon (Daikin Kogyo Co., JP) DE) Foraflon (ATOCHEM, FR) Ferrotron, Fluorosint (Polymer Corp., US) Soreflon (Pechiney U.K., Fluoroloy (Flurocatbon, US) FR) Gallon (Plastic Omnium, FluoroMet (Raymark, US) FR) Fluon (ICI, GB) Goretex (W.L. Gore Assoc, US) Algoflon (Montedison, IT) Halon (Ansimont, US) RT duroid (Rogers Corp., US) Rulon (Dixon Ind. Corp., US) Salox (Allegheny Plastics, US) Teflon (Du Pont de Numours, US) Turcite (W.S. Shamban & Co., US) Tygaflor (American Cyanamid Aerospace, US) Xylon (Whitford Corp., US)

Table 3.4

Continued

5. Polyvinylchloride (PVC) Rosevil (Chem. Kombinat Corvic, Vynide, Welvic (ICI, GB) Borzesti, RO) Ongrovil (Barsodi Veggi Plastilit, Selchim, Solvic Ensolite (Uniroyal Chem., US) Komb., HU) (Solvay & Cie., BE) Ravinil, Sicron, Vipla, Viplast Vipopham (Lonza, CH) Ethyl (Ethyl Corp., Polymer (EniChem, IT) Div., US) Fiberloc, Geon (B.F. Goodrich, Astralon, Trocal, Trosiplast, Vixir (S.I.R. (Montedison), IT) Trovidur, Vestolit (HuIsUS) Troisdorf, DE) Decelith (VEB Ellenburger Hishiplate (Mitsubishi Plastics Pliovic, Vinacel, Vycell Chemiewerk, DE) (Goodyear, US) Ind., JP) Vinnol (Wacker Chemie, Kureha, Viclon (Kureha Chem. Vygen (General Tire & Rubber DE) Co., US) Ind., JP) Genopak, Genotherm, Vynaloy (B.F. Goodrich Chem. Vinychlon (Mitsui Toatsu Hostalit (Hoechst, DE) Co., US) Chem., JP) Armodur (Rhone-Poulenc, Vinylfoil (Mitsubishi Gas Ind., Hipnil (Hemijska Industria, YU) FR) JP) Bipeau, Orgavyl, Polycal Varlan (DSM, NL) Jugotherm, Juvinil (Jugovinil, (ATOCHEM., FR) YU) Ekavyl (PCUK, FR) Zadrovil (Polikem, YU) Norvinyl, Pevikon (Norsk Hydro, NO) Carina, Duraflex (Shell Oltivil (Chem. Komb. Pitesti, RO;) Intern. Chem Co., GB) 6. Polyamide (PA) PA 6 Fabenyl (Tubize Plastics, Maranyl (ICI, GB) CH) Grilon (Ems Chemie, CH) Latamid (L.A.T.I., IT) Durethan B (Bayer, DE) Ultramid B (BASF, DE) Akulon (Engineering Plastics of AKZO Plastics, NL) Capron (Allied Signal Engn. Plastics, US) Plaskon (Plaskon Moldings Nivionplast (EniChem, IT) Div., US) Renyl (Snia Technopolimeri, IT) Zytel (Du Pont de Nemours, US) Amilan, Amilon (Toray Ind., JP) Benvic (Solvay, BE)

Orgamide (ATOCHEM, FR) Technyl C (Rhone-Poulenc Torayca (Toray Ind., JP) Specialites Chimiques, FR ) PA 66

Leona (Asahi Chemical Ind., JP) Minion (Du Pont de Nemours, US) Zytel (Du Pont de Nemours, Technyl A (Rhone-Poulenc Torayca (Toray Ind., JP) US) Specialites Chimiques, FR Maranyl A (ICI, GB) Akulon (Engineering Plastics of AKZO Plastics, NL)
)

Durethan A (Bayer, DE)

7. Polyacrylates Umaplex (Synthesia, CS) Acrifix (Rohm, DE) Lucryl (BASF, DE) Asterite (ICI, GB) Diakon (ICI, GB) Perspex (ICI, GB) Sumipex (Sumitomo Chem. Co., JP) Casoglas (Casolith, NL) Acrylite (Cy/Ro Industries, US)

Table 3.4

Continued

7. Polyacrylates Degaplast (Degussa, DE) Unilok (British Vita Co., GB) Lucite (Du Pont de Nemours, US) Corian (Du Pont de Nemours, US) Crofon (Du Pont de Nemours, US) Electroglas (Glasflex Corp., US) Exolite (Cyro Industries, US) Gardlite (Southern Plastics Co., US) Oroglas (Rohm & Haas Co., US) Swedcast (Swedlow, US)

Deglas, Dewglas (Degussa, Vetredil (Vetril, IT) DE) Dewoglas (Degussa, DE) Vedril (Montedison, IT) Paraglas (Degussa, DE) Plexidur, Plexiglas (Rohm, DE) Resarit (Resart, DE) Vestiform (HuIs, DE) Acrypanel (Mitsubishi Rayon Co., JP) Delmer, Depet (Asahi Chem. Ind., JP) Eska (Mitsubishi Rayon, JP) Palapet (Kyowa Gas Chem., JP)

Altuglas (Altulor, Orekem, Shinkolite (Mitsubishi Rayon FR) Co., JP) 8. Polyacetal (POM) Homopolymers Delrin (Du Pont, US) Tenal (Asahi Chemical Ind., JP) Copolymers Celcon, Hostaform (Hoechst, DE) 9. Polycarbonate (PC) Sparlux (Solvay & Qe., BE) Durolon (Policarbonateos do Brazil, BR) Makrolon (Bayer, DE) Duracon, Alkon, and Kematal (Daicel Polyplastic Co., JP)

Ultraform (BASF, DE)

Lexan (General Electric Plastics, US) Novarex (Mitsubishi Chem. Ind., Merlon (Mobay Chemical Corp.. US) JP) Polycarbafil (Akzo-WilsonPanlite (Teijin Chemicals, JP) Fiberfil, US) Polygard (Polytech, US) Orgalan (ATOCHEM, FR) Xantar (DSM, NL) Stat-Kon (LNP Corp., US) Star-C (Ferro Eurostar, FR) Calibre (Dow Chemical Corp., US) Royalite (British Vita Co., Ekonol (Carborundum Co., US) GB) Sinvet (EniChem, IT) 10. Polyethyleneterephthalate

(PET)
Petlon (Mobay Chem. Corp., US) Grilpet (Ems Chemie, CH) Arnite (Akzo Engng. Plastics, NL) Petra (Allied Signal, US) Impet (Hoechst, DE) Etar (Eastman Chem. Intern., US) Ropet (Rohm & Hass Co., US) Rynite (Du Pont de Nemours, Ultradur (BASF, DE) Mindel (Amoco Performance US) Products, US) Crastin (Ciba Geigy, CH) Melinar, Melinite (ICI, GB) 11. Polyetheretherketone

(PEEK)
Victrex PEEK (ICI, UK)

Table 3.4 Continued

12. Polysulphone Ultrason S (BASF DE) Sumilik FST (Sumitomo, Chem. Co., JP) Stabar (ICI, UK) Udel (Amoco Performance Products, US)

REFERENCES

Black, J. (ed.) (1992), in Biological Performance of Materials: Fundamentals of Biocompatibility, Second edition, Marcel Dekker. Inc, New York. Brydson, J.A. (ed.), Plastics Materials, Butterworths Scientific, fourth edition, 1982; fifth edition, 1989. Carhart, R.O. (1985) Polycarbonate, in Engineering Thermoplastics, Properties and Applications, Margolis, J.M. (ed.), Chapter 3, pp. 29-82. Chapman, R.D. and Chruma, J.L. (1985) Nylon plastics, in Engineering Thermoplastics, Properties and Applications, Margolis J.M. (ed.), pp. 83-122. Charrier, J.M. (ed.) (1990) Polymeric Materials and Processing: Plastics, Elastomers and Composites, Hanser. Domininghaus, H. (ed.) (1993) Plastics for Engineers, Materials Properties, Applications, Car-Hanser Verlag. Goodman, S.B. and Fornasier, V.L. (1992) Clinical and experimental studies in the biology of aseptic loosing of joint arthroplastics and the role of polymer particles, in Paniculate Debris from Medical Implants: Mechanisms of Formation and Biological Consequences, ASTM ATP 1144, K.R. St John, (ed), American Society for Testing and Materials, Philadelphia, pp. 27-37. Harper, CA. (eds) (1992) Handbook of Plastics, Elastomers, and Composites, McGraw-Hill. How, T.V. (1992) Mechanical properties of arteries and arterial grafts, in Cardiovascular Biomaterials, Hastings, G.W. (ed.), Springer-Verlag, London, pp. 1-35. Jones, AJ. and Denning, N.T. (1988) in Polymeric Biomaterials: Bio- and Ecocompatible Polymers, A Perspective for Australia, Department of Industry, Technology and Commerce. Lilley, P.A., Blunn, G.W., and Walker, P.S. (1993) Wear performance of PEEK as a potential prosthetic knee joint material, in 7th International Conference on Polymers in Medicine and Surgery, 1-3 September 1993, Leeuwenhorst Congress Center, Noordwijkerhout, The Netherlands, pp. 320-326. Margolis, J.M. (1985) Engineering Thermoplastics: Properties and Applications, Dekker, New York. Mascia, L. (1989), in Thermoplastics: Materials Engineering, Second Edition, Elsevier Applied Science, London and New York. McMillin, CR. (1994) Elastomers for biomedical applications, Rubber Chem. and Tech. 67, 417-446. Park, J.B. and Lakes, R.S. (1992) Biomaterials, an Introduction, Second Edition, Plenum Press, New York and London.

Rubin, I.I. (ed.) (1990), Handbook of Plastic Materials and Technology, John Wiley & Son. Staudinger, H. (1932) Die Hochmolekularen Organischer Verbindungen, Julius Springer. Stokes, K., McVenes, R., and Anderson, J.M. (1995) Polyurethane elastomer biostability, /. Biomaterials Applications, 9, 321-355. Szycher, M. (1991) in Blood Compatible Materials and Devices: Perspectives Towards the 21st Century, Sharma, CP. and Szycher, M. (eds), Technomic Publishing CO., Inc., Lancaster, Basel, pp. 33-85. Teoh, S.H., Lim, S.C., Yoon, E.T., and Goh, K.S. (1994) A new method for in vitro wear assessment of materials used in mechanical heart valves, in Biomaterials Mechanical Properties, ASTM STP 1173, H.E. Kambic and A.T. Yokobori, Jr. Eds., American Society for Testing and Materials, Philadelphia, pp. 43-52. Teoh, S.H., Lim, S.C., Yoon, E.T., and Goh, K.S. (1994a) A new method for in vitro wear assessment of materials used in mechanical heart valves, in Biomaterials Mechanical Properties, ASTM STP 1173, H.E. Kambic and A.T. Yokobori, Jr. (eds), American Society for Testing and Materials, Philadelphia, pp. 43-52. Teoh, S.H., Martin, R.L., Lim, S.C., et al (1990) Delrin as an occluder material, ASAIO Transactions, 36, M417-421. Watson, M., Cebon, D., Ashby, M., Charlton, C, and Chong, W.T. (eds) (1994) Cambridge Materials Selector V2.02, National University of Singapore, Granta Design Ltd. Wenz, L.M., Merritt, K., Brown, S.A., and Moet, A. (1990) In-vitro biocompatibility of polyetheretherketone and polysulphone composites, /. Biomed. Maters Res., 24, 207-215. Ziegler, K.E. (1955) Angew. Chem. 67(426), 541.

Biomedical elastomers
J.W. Boretos and SJ. Boretos

4.1 INTRODUCTION Elastomers are described as materials that possess pronounced elasticity and rebound. They can be tough, relatively impermeable to air and water and exhibit resistance to cutting, tearing and abrasion. Often they are modified by compounding to increase their hardness and strength. Or, conversely, they can be soft, compliant and absorbent to water if the need exists. In some instances their properties can closely simulate that of the tissues which they must contact. As biomedical materials they may have originated from commercial formulations or been custom designed from basic chemistry. Those that have been judged as biocompatible have made significant contributions towards the development of successful medical devices. Literally, every basic elastomer has been evaluated at some time for its possible suitability in contact with the body. This would include such materials as natural rubber, styrene rubber, polybutyl rubber, silicone rubber, acrylate rubber, Hypalon, polyurethanes, fluorinated hydrocarbon rubbers, polyvinyl chloride, thermoplastic vulcanizates and others. Of these, only special medical grade formulations of silicone, polyurethane, polyvinyl chloride and thermoplastic elastomer have continued to be commercially successful. There are important differences between materials and differences among similar materials within a given generic class. These differences are due to the chemical composition of the polymer, the molecular configuration of the polymer and the presence of functional groups. For instance, polyurethanes of a polyester base were initially tried and found unstable for implantation whereas polyether based polyurethanes were decidedly
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

more stable. Elastomers with aromatic structures behave differently than the polymer having aliphatic structure. Not every material is suitable for every application. Some have been found to perform successfully under static conditions but fail or perform undesirably under dynamic situations. Often, the design of a device and the demands upon it will determine if the elastomer chosen is the proper selection. Therefore the material and its use are inseparable. They must be evaluated together. Merely passing an array of physical and biological tests do not confer success. Biocompatibility is an essential element of medical grade elastomers. A set of compatibility tests determine the general physiological acceptability of an elastomer. These consist of passing USP Class VI tests. Additional testing may be required depending upon the device, its area of application and the time it is in contact with tissues. A Master File is often registered by the manufacturer of the basic elastomer with the FDA to attest to its properties, composition and response to biological testing. Demands on medical device manufacturers have never been more stringent. Regulatory pressures, more indepth testing, the threat of litigation plus the constraints of health care cost containment are affecting all aspects of the design and development process and the availability of some biomedical elastomers. A variety of elastomeric materials are available to meet the design challenges presented by medical devices. However, there is still a need for even better materials. The elastomers that are listed here should be considered in light of their suitability for a specific application. The properties tables should serve as a guide to design options for those in the early stages of the development process. Keep in mind that these properties listed in the tables and the compatibility standings are only indicative of the performance characteristics that an elastomer may exhibit.

4.2 TYPES OF ELASTOMER Biomedical elastomers can be classified as to whether they are thermoplastic or thermosetting in nature. Thermoplastic biomedical elastomers are gaining in commercial importance and in some cases replacing traditionally used vulcanized versions. Thermosetting elastomers are irreversibly crosslinked and have had the longest history of medical use. Both groups will be described citing representative medical elastomers that are either commercially available or that may replace elastomers that have been recently withdrawn from the market. 4.2.1 Thermoplastic elastomers Thermoplastic elastomers (TPEs) are a special class of materials that process similarly to other thermoplastic polymers, yet possess many of the

desirable properties of thermoset elastomers. Some TPEs are elastomeric alloys consisting of crosslinked particles of rubber surrounded by a thermoplastic matrix. Others consist of block copolymers and are typified by polyurethanes and styrene polymers. Depending upon which thermoplastic elastomer is chosen, physical properties can vary over a wide range. They can be either hard, or soft, flexible or stiff, elastic or rigid. For the most part, they are smooth to the touch, yet will form tight seals to surfaces they contact. They can be processed using conventional techniques and equipment and in automated modes. Medical applications consist of such examples as pacemaker lead wire coatings, artificial hearts, and catheters. A wide variety of sundry uses have contributed to patient care and consists of bulbs and bladders, serum caps and tubes, cushions, diaphragms, electrical connectors, flexible medical wire coatings, gaskets, needle shields, pharmaceutical closures, seals, stoppers, tubing, and valves. Most of the TPEs can be sterilized using gas, steam and radiation with very little change in their molecular structures or properties (Table 4.13). Thermoplastic vulcanizates Thermoplastic vulcanizates are a separate class of thermoplastic elastomers (TPEs) with Santoprene as the representative biomedical elastomer. Santoprene This thermoplastic vulcanizate is an olefin based elastomer; an elastomeric alloy. It is totally synthetic and does not contain any natural rubber thereby avoiding many of the allergic reaction problems associated with natural rubber latex. It exhibits outstanding flex-fatigue resistance, low temperature flexibility (-40 0C) and resistance to tearing and abrasion. Its resistance to plastic deformation under tensile and compression stress is another of its features. Santoprene is reported to be superior to natural rubber in some situations and replaces silicone elastomers in others. It has found use in peristaltic pump tubing, syringe plungers, seals, and caps, tracheal and enteral tubing, vial closures and pump seals, disposable anesthetic hoses, intravenous delivery systems, and other hospital devices. Santoprene has met USP Class IV requirements for in vivo biological reactivity and conforms to the Tripartite Biocompatibility Guidance standards. However, the manufacturer does not recommend Santoprene for use as part of human implants. The material may be injection molded, extruded, blow molded and thermoformed. For details on physical properties, processing and biocompatibility see Tables 4.1, 4.2, 4.13 and 4.14.

Table 4.1

Typical Propertieis of Thermoplastic Vulcanizates

i

Property Tear <CompresElonga- Modulus strength sion set, ASTM tion, pli,die C percent D-412 percent ASTM ASTM ASTM ~ D-395 D-624 D-412 psi % 300 330 400 460 520 560 175 250 340 520 1[,010 11,250 100 100 100 100 100 100 80 108 140 159 278 369 11 23 23 26 29 32

Product and Manufacturer

Durometer Specific hardness shore gravity ASTM Product ASTM no. D-792 D-2240 0.97 0.97 0.97 0.98 0.96 0.95 45A 55A 64A 73A 87A 4OD

Tensile strength, psi ASTM D-412 435 640 1,030 1230 2,300 2,750

Santoprene 281^5 Rubber, 281-55 281-64 Advanced 281-73 Elastomer 281-87 Systems 283-40

Table 4.2

Typical Properties of Copolyester Elastomers, PCCE Property Durometer Specific hardness gravity shore Product ASTM ASTM D-792 D-2240 no. 1.13 95 A Tensile strength, psi ASTM D-412 3,500 Tear CompresElonga- Modulus strength sion set, ASTM tion, pli,dieB percent D-412 percent ASTM ASTM ASTM ~ D-395 D-624 D-412 psi % 380 16,000 100 100 135 40

Product and Manufacturer

Ecdel 9965 Elastomer, 9966 Eastman 9967 Chemical Co.

Table 4.3 Typical Properties of Polyurethane-based Elastomers Property

Durometer Tensile . Specific hardness strength, psi gravity shore ASTM ASTM ASTM D-792 D-2240 D-412 75A 70 D 7OD 6000 6000 5500 Elongation, percent ASTM D-412 850 1000 1050 Tear CompresModulus strength sion set, ASTM D-412 pli,die C percent ASTM ASTM psi % D-624 D-395 575 550 450 100 100 100

Product and Manufacturer

Product no.

Biospan Biospan Biospan D segmented polyurethane, Biospan S The Polymer Technology Group, Inc. Hydrothane, Dry Very dry Poly Medica Biomaterials, Wet Inc. Medicaflex, Advanced Resin Technology MF-5000 MF-5001 MF-5040 MF-5041 MF-5056 MF-5057 MF-5062 1.15 1.15 1.15 1.15 1.14 1.15 1.15 1.17 1.21 1.13 1.12 1.30 1.14 1.14

93 A 95 A 85 A 50 A 55 A 60 A 65 A 60 A 55 53 62 76 81 85 81 D D D D A A A

7800 5800 5600 3000 3000 5000 5000 5000 6900 6500 6460 5810 5200 4200 6860 5850 6000

580 475 500 500 700 750 800 390 450 380 550 650 670 500 550 350 800 300 300 300 300 500 550 500 2500 2300 2900 880 890 970 1700 1475 5300 135 210 420 555 2000 2500 100 100 100 100 100 100 100 100 100 100 147C) 100 100 100 100 100 100 100 100 100 100 100 100 650 600 1100 470 420 25 30 30 25 30

Pellethane 2363 series,

2363-55D 2363-55DE 2363-65D 2363-75D 2363-80A Dow Chemical 2363-80AE 2363-80A Co. R0120 2363-90A 2363-90 A E

90 A 90 A

570 540 140 150 240 330

25

PolyBlend 1000 and PolyBlend 1100, Poly Medica Biomaterials, Inc. Tecoflex,

PB1000-650 65; D to 75 D6500 PB1100-55 1.02 55 A 2150 PB1100-60 1.02 60 A 2400 PB1100-75 PB1100-80 EG60D EG60D-B2C) EG65D EG65D-B2CI EG68D EG72D EG80A 1.02 1.02 1.09 1.32 1.10 1.10 1.11 1.04 75 A 80 A 51 D 55 D 6OD 63 D 67 D 72 A 3250 4600 7829 7484 8074 6986 8686 7739 5640

55-66 50-60 45-50 25-30

575 590 363 370 335 321 332 307 709

Thermedics, Inc.

3400 400

100 100

Table 4.3 Continued Property

r Tensile Durometei Specific hardness strength, psi gravity shore ASTM ASTM ASTM D-792 D-2240 D-412 1.24 1.05 1.25 1.51 1.08 1.09 1.29 1.54 1.16 1.18 1.10 1.19 1.12 1.15 1.36 1.38 1.30 1.40 1.32 1.35 1.20 1.17 1.12 1.21 73 11 83 84 87 94 93 96 54 64 75 75 85 94 55 67 11 77 87 97 A A A A A A A A D D A D A A D D A D A A 5571 6935 5282 5093 7127 8282 7104 5607 9600 10 000 6000 8300 7000 9400 9000 8500 5500 7600 6600 8200 6000 6000 6000 6000 2208 3714 4783 Tear CompresElonga- Modulus strength sion set, tion, ASTM percent D-412 pli,die C percent ASTM ASTM ASTM D-412 psi % D-624 D-395 715 565 632 559 423 370 369 360 350 300 530 240 450 400 360 300 580 230 550 450 500 460 550 180 579 458 392 700 100

Product and Manufacturer Thermedics, Inc.

Product no.

EG80A-B20 EG85A EG85A-B20 EG85A-B40 EG93A EGlOOA EG100A-B2I0 EG100A-B4I0 1055D 1065D 1074A 1075D 1085A 1095A 2055D 2065D 2074A 2075D 2085A 2095A 5187 5265 5286 5370 DP7-3002 DP7-3003 DP7-3004

1100 1800

100 100

Tecothane

Thermedics, Inc.

2500 3200 530 3600 800 1600 2700 3100 510 3000 800 1600 750 3300 700 4500 815 1049 1766

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 500 1200 500 900 399 564 819 12 20 16

Texin Miles, Inc.

87 A 65 D 86 A 7OD 88 A 50D 55 D

Table 4.4 Typical Properties of Polycarbonate-based Polyurethane Property

Durometer Tensile Elonga- Modulus ASTM Specific hardness strength, tion, D-412 percent psi gravity shore ASTM ASTM ASTM ASTM D-792 D-2240 D-412 D-412 psi % Tear strength pli,die C ASTM D-624

Product and Manufacturer

Product no.

PC-3555D Carbothane, PC-3555D-B20 PC-3572D Thermedics, PC-3572D-B20 Inc. PC-3575A PC-3575A-B20 PC-3585A PC-3585A-B40 PC-3595A PC-3595A-B20 Chronoflex Chronoflex AR, Poly AR Medica Biomaterials, Inc. Corethane and TPE 55D TPE 75D TPE 8OA Corhesive, Corhesive Corvita Corp. (cured) Texin 5370, 5370 Miles, Inc.

1.15 1.36 1.15 1.35 1.15 1.15 1.68 1.15 1.36

6OD 57 D 71 D 71 D 73 A 73 A 84 A 89 A 95 A 96 A 70 A

7000 8300 8500 8400 4400 3500 6500 3800 6500 8300 7500

350 380 300 310 500 600 390 521 520 390 500

1500 1600 4100 3400 380 410 640 700 900 1100 700

100 100 100 100 100 100 100 100 100 100 100

1.211 1.216 1.179 1.179 1.21

55 D 75 D 80 A 80 A 7OD

7000- 365- \L850- 100 8500 440 2200 7000- 255- f )300- 100 9100 320 5700 400- 770490 1250 6500- 400- 770- 100 7500 900 1250 6000 180 4500 100 900

Copolyester ether elastomer Ecdel. This copolyester ether TPE is essentially polycyclohexanedimethyl-cyclohexanedicarboxylate (PCCE). It is reported to possess the chemical resistance, toughness and inertness yet exhibits elasticflexibilityover a broad temperature range. Ecdel is an unusual elastomer since it has a crystalline structure. Quenching during molding can reduce its crystallinity and impart increased clarity. The material is being used for uniquely designed intravenous bags with built-in bottle necks and fasteners. The material can be injection or blow molded and extruded into film or sheet; but only Ecdel 9967 may be processed into tubing. This TPE is also manufactured under the name CR3 by Abbott Labs (Tables 4.2,4.12,4.13, and 4.14).

Table 4.5 Typical Properties of Polypropylene-based Elastomers

Property
Tear CompresDuromete) r Tensile Specific hardness, strength, Elongation, strength sion set, percent pli, die B percent psi shore gravity ASTM ASTM ASTM ASTM ASTM Product ASTM D-624 D-395 D-412 D-412 D-2240 no. D-792

Product and Manufacturer

3260 Sarlink medical grade DSM Thermoplastic Elastomers, Inc.

0.95

60 A

870

619

183

42

Polyurethane-based elastomers

Polyurethanes are another class of TPEs. They are a large family of chemical compounds that can consist of ether-based, ester-based, polycarbonate-based or polypropylene-based varieties. A number of copolymers are also included;, polyurethanes are combinations of macroglycols and diisocyanates that have been polymerized into tough and elastic materials. TPE polyurethanes have been used for peristaltic pump tubing, parenteral solution tubing and catheters. The tables list the majority of those that are commercially available. Among others are those either of limited supply, available for proprietary use only or that have been successful, but recently discontinued such as: Hemothane Sarns Div. of 3M. Restricted to proprietary use. Biomer Ethicon, Inc. No longer available through this source. Surethane Cardiac Control Systems, Inc. Redissolved Lycra thread. Some formulations may have a few percent PDMS blended with it. Limited availability. Pellethane 2360 Dow Chemical, USA. This material is no longer available for medical implant use (see also Pellethane). Angioflex ABIOMED, Danvers, Mass. Restricted to proprietary use. Cardiothane Kontrol, Inc. A silicone-urethane interpenetrating polymer network. Limited availability. Internationally, polyurethanes for medical use have been developed by Italy, China and Japan.
Biospan

This TPE is a segmented polyurethane and is reported to be not significantly different from biomer in chemistry and molecular weight. It is a polytetra-methyleneoxide-based aromatic polyurethane urea with mixed aliphatic and cycloaliphatic diamine chain extenders. A copolymer of

Table 4.6 Typical Properties of Plasticized Polyvinyl Chloride

Property Product and Manufacturer Specific Durometer Tensile Elongation, Modulus gravity shore strength, psi percent ASTM ASTM ASTM ASTM ASTM D-412 D-792 D-2240 D-412 D-412 ~psi %~

Product no.

Elastichem PVC, Colorite Plastics Co.

3511TX-02 4011TX-02 5011TX-02 5511TX-02 6011TX-02 7011TX-02 7511TX-02 8011TX-02 0-1234 0-1290 0-1541 0-1554 0-2112 0-2129 0-2202 0-2609 0-2610 0-2623 0-2631 0-3110 0-3115R 0-3119 0-3138R 0-3140R 0-3147 0-3149R 0-3154 0-3155R 0-3166R 0-3195 0-3200 0-3201 0-3224R 0-3231R 0-4106R 0-4108 0-4109R 0-4113 0-4114 0-4115 0-4116R

1.12 1.16 1.16 1.18 1.18 1.21 1.22 1.23 L21 1.26 1.23 1.21 1.24 1.24 1.54 1.20 1.24 1.24 1.19 1.22 1.20 1.22 1.22 1.25 1.28 1.23 1.19 1.20 1.25 1.27 L18 1.21 1.21 1.26 1.25 1.25 1.25 1.31 1.20 1.26 1.27

35 A 40 A 50A 55 A 60 A 7OA 75 A 8OA 58~A 83 A 81 A 7OA 82 A 83 A 75 A 68 A 83 A 82 A 65 A 74 A 68 A 75 A 75 A 87 A 95 A 78 A 65 A 68 A 85 A 9OA 6(TA 70 A 77 A 88 A 85 A 85 A 85 A 100 A 67 A 87 A 9OA

1110 1300 1650 1790 1936 2667 3000 3646 1400 2750 2400 2000 2650 2670 2360 1950 2460 2550 1800 2100 1900 2150 2200 2850 3100 2400 1750 1850 2700 2950 1600 2000 2300 3000 2650 2750 2800 3960 1900 2800 2950

525 500 465 465 465 400 360 330 400 275 300 400 320 310 270 410 295 325 390 355 400 350 350 330 250 340 410 390 320 280 450 340 345 280 300 300 310 184 400 295 265

235 266 426 455 488 952 1400 2025 600 1500 1400 950 1200 1500 1190 800 1450 1350 650 1000 800 1100 1075 1600 2350 1150 725 780 1650 2210 525 800 1100 1800 1600 1600 1700 3200 780 1650 2100

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

Ellay PVC, Ellay, Inc.

Ellay PVC, Ellay, Inc.

Table 4.6

Continued Property

Product and Manufacturer Ellay, Inc.

Product no. 0-4120 0-4121 0-4122 0-4124R 0-4125 0-4129 0-4132 0-4135 0^140 0-4150 0-5210C BB-69 EH-222C ES-2967ZPH 121AR 213

Specific Durometer Tensile Elongation, Modulus gravity shore strength, psi percent ASTM ASTM ASTM ASTM ASTM D-412 D-792 D-2240 D-412 D-412 psi % 1.21 1.23 1.33 1.28 1.24 1.18 1.21 1.23 1.23 1.26 1.26 1.23 1.21 1.22 1.4 1.4 68 A 81 A HOA 95 A 8OA 63 A 7OA 8OA 8OA 88 A 82 A 78 A 7OA 75 A 2180 2550 4500 3050 3150 1670 2000 2550 2500 2900 2300 2200 2050 2300 2800 2205 400 325 135 250 355 430 395 320 330 290 225 340 365 360 380 379 830 1400 4180 2200 1310 620 900 1260 1250 2200 1250 1150 1100 1200 1010 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

GeonPVC,

B. F. Goodrich Co. 250x100 Multichem PVC, Colorite Plastics Co. Teknor PVC, 6014 7014 8014 8514 NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT 1.15 1.19 1.22 1.24 1.13 1.14 1.16 1.17 1.18 1.20 1.21 1.23 1.25 1.35 1.35 1.35 1.35 1.35 1.35 1.35 1.35 1.35 60 A 7OA 80 A 85 A 45 50 55 60 68 75 80 85 90 50 55 60 65 70 75 80 85 90 A A A A A A A A A A A A A A A A A A

1700-1850 430-460 400-500 100 1640 2040 2100 2250 1100 1220 1500 1550 1850 2150 2400 2800 3100 1000 1100 1300 1500 1770 1900 2200 2500 2900 540 600 500 530 480 460 450 430 420 380 340 430 410 400 390 380 370 360 340 330 400 625 1000 880 325 370 520 560 690 900 1,320 1,560 2,100 330 400 480 590 700 800 1,050 1,470 1,900 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

3300-45 3300-50 3300-55 3300-60 Teknor Apex 3300-68 Co. 3300-75 3300-80 3300-85 3300-90 3310-50 3310-55 3310-60 3310-65 3310-70 3310-75 3310-80 3310-85 3310-90

Table 4.6

Continued Property

Product and Manufacturer

Product no.

Specific Durometer Tensile Elongation, Modulus gravity shore strength, psi percent ASTM ASTM ASTM ASTM ASTM D-412 D-792 D-2240 D-412 D-412 ~^psl %~

Teknor Apex 90A471R-60NT Co. 90A471R-65NT 90A471R-70NT 90A471R-75NT 90A471R-80NT 90A471R-85NT 90A471R-90NT

1.16 1.17 1.18 1.20 1.23 1.23 1.27

60 A 65 A 70 A 75 A 80 A 85 A 90 A

1500 1750 1900 2150 2690 2800 3350

450 440 430 420 380 360

diisopropylamino-ethyl methacrylate and decyl methacrylate are added as a stabilizer. The material is supplied as 25% solids in dimethyl acetamide solvent (Tables 4.3, 4.12, 4.13, and 4.14).
Biospan-S

This is a silicone modified analog of Biospan with a different stabilizer. It possesses a silicone-rich surface to enhance thromboresistance while maintaining the bulk properties of Biospan (Tables 4.3, 4.12, 4.13, and 4.14).
Biospan-D

This is another version of Biospan with surface modification by an oligomeric hydrocarbon covalently bonded to the base polymer during synthesis. The additive has a pronounced effect on the polymer surface chemistry but little effect on the bulk properties of the base polymer according to the manufacturer (Tables 4.3, 4.12, 4.13, and 4.14). Hydrothane Hydrothane is a TPE hydrogel belonging to the polyurethane family of polymers. Hydrothane is an aliphatic material with water absorption capabilities ranging from 5 to 25% by weight while still maintaining high tensile strength and elongation. Because of its water absorption capacity, Hydrothane is reported to be bacteria-resistant and lubricious. The polymer can be processed by conventional extrusion and injection molding techniques. It can also be dissolved in dimethyl acetamide solvent to produce a 25% solids solution suitable for dip-coating and other solution processing techniques (Tables 4.3, 4.12, and 4.13).

Table 4.7

Typical Properties of Styrene-based Thermoplastic Elastomers Property

Durometer Speciftc hardness gravity shore ASTM ASTM D-792 D-2240 Tensile strength, psi ASTM D-412 Elongation, percent ASTM D-412 Modulus ASTM D-412 psi Tear Compresstrength sion set, pli,die B percent ASTM ASTM % D-624 D-395

Product and Manufacturer

Product no.

R70-001 R70-003 R70-005 R70-026 Consolidated R70-028 Polymer R70-046 Technologies,R70-050 Inc. R70-051 R70-058 R70-057 R70-068 R70-072 R70-081 R70-082 R70-085 R70-089 R70-091 R70-116 R70-190 R70-214 C-Flex, Kraton, Shell Chemical Co. D-2103 D-2104 D-2109 G-2701 G-2703 G-2705 G-2706 G-2712

0.90 0.90 0.90 0.90 0.90 0.90 0.90 0.90 0.94 0.92 0.93 0.90 0.90 0.90 0.90 0.90 0.90 0.90 0.90 0.90 0.94 0.93 0.94 0.90 0.90 0.90 0.90 0.88

50A 70 A 30A 90 A 35 A 34 A 48 A 74 A 70 A 40 A 50 A 60 A 45 A 61 A 50 A 45 A 50A 3OA 5A 18 A 7OA 27 A 44 A 67 A 63 A 55 A 28 A 42 A

1200 1280 1400 1830 990 1320 1250 1140 2080 1220 1630 1270 1440 1270 1380 1640 1280 1105 270 450 4300 1700 950 1600 1200 850 850 840

900 760 950 650 800 940 880 680 660 890 850 780 920 860 750 700 780 810 1010 780 880 1350 800 800 670 700 950 820

150 340 100 1,010 120 110 170 370 300 100 140 240 120 230 200 130 100 20 400 200 300 480 470 400 130 250

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 300 300 300 300 300 300 300 300

16 25 11 13 12 18 28 55 33 38 20 17 19 17

135 100 150 120 90 110

130

84

24

205 180 160 260 230 140 140 140

38

Medicaflex

The Lambda series of Medicaflex is a polyurethane-based TPE polymer that exhibits low modulus characteristics with high tear strength and abrasion resistance. Those listed in the tables have passed USP Class VI compatibility tests and have been used as replacements in some natural rubber latex and silicone rubber applications. The polymer has been applied to uses such as catheters, tubing and films where softness, low durometer hardness, low modulus or high elongation are needed (Tables 4.3, 4.12, and 4.13).

Pellethane polyurethane elastomers The 2363 series Pellethane TPE elastomers have a wide range of durometer hardness and are noted for their high tensile and tear strength and abrasion resistance. Chemically they are classed as polytetramethylene glycol ether polyurethanes. The ether series is the most widely used for medical applications although polyester versions of Pellethane are useful for some applications. None of these polymers have the disadvantage of containing plasticizers which can migrate out of the polymer over time resulting in reduction in physical properties. Medical tubing made from Pellethane polymer is widely used. These TPEs are unaffected by ethylene oxide gas, gamma radiation and electron beam sterilization procedures. Pellethane can be processed by injection molding and extrusion. For details on physical properties, processing and biocompatibility (Tables 4.3, 4.12, and 4.13).
Notice Regarding Long-Term Medical Implant Applications

The Dow Chemical Company does not recommend Pellethane elastomers for long-term medical implant applications in humans (more than 30 days). Nor do they recommend the use of Pellethane elastomers for cardiac prosthetic devices regardless of the time period that the device will be wholly or partially implanted in the body. Such applications include, but are not limited to, pacemaker leads and devices, cardiac prosthetic devices such as artificial hearts, heart valves, intra-aortic balloon and control systems, and ventricular bypass assist devices. The company does not recommend any non-medical resin (or film) product for use in any human implant applications.

PolyBlend polyurethane This TPE has been described as an aromatic elastoplastic polyurethane alloy. It possesses a low coefficient of friction, low extractables, and dimensional stability. Hardness ranges from 65 to 75 Shore D. The material is classified for short-term (29 days or less) implantation. Clear and radiopaque formulations are available. Tubing should be annealed at 800C for four hours to reduce crystallinity (Tables 4.3, 4.4, 4.12, and 4.14).
Tecofiex polyurethane

Tecoflex is an aliphatic polyether-based polyurethane that is available in clear and radiopaque grades. They are reaction products of methylene bis (cyclohexyl) diisocyanate (HMDI), poly (tetramethylene ether glycol) (PTMEG), and 1,4 butane diol chain extender. The manufacturer claims that the aliphatic composition of Tecoflex eliminates the danger of forming methylene dianiline (MDA) which is potentially carcinogenic. MDA can be generated from aromatic polyurethanes if they are improperly processed or overheated. Tecoflex has been reported to crack under stress when implanted, long-term, in animals. An advantage of Tecoflex is that it softens considerably within minutes of insertion in the body. This

feature can offer patient comfort for short-term applications such as catheters and enteral tubes; it is also reported to reduce the risk of vascular trauma (Tables 4.3, 4.12, and 4.13).
Tecothane

Tecothane is an aromatic polyether-based TPE polyurethane polymer. It has processibility and biocompatibility characteristics similar to Tecoflex except that it is an aromatic rather than an aliphatic polyurethane. Tecothane is synthesized from methylene diisocyanate (MDI), polytetramethylene ether glycol and 1,4 butanediol chain extender. By varying the ratios of the reactants, polymers have been prepared ranging from soft elastomers to rigid plastics. The manufacturer of Tecoflex and Tecothane point out that there is not much difference between medical-grade, aliphatic and aromatic polyether-based polyurethanes with regard to chemical, mechanical and biological properties. However, they caution that with improper processing of Tecothane (e.g., high moisture content or steam sterilization) it is possible to form measurable amounts of methylene dianiline (MDA), a listed carcinogen. The use of ethylene oxide or gamma radiation are suitable sterilizing agents that do not affect the chemical or physical properties (Tables 4.3, 4.12, and 4.13). Texin There are four basic polymer formulations of Texin polyurethane TPE that may be suitable for medical applications. They range in hardness and flexural modulus. Texin elastomers are produced by the reaction of diisocyanate with a high molecular weight polyester or polyether polymer and a low molecular weight diol. The polyethers (products 5286 and 5265) offer greater hydrolytic stability and stress crack resistance. The polyesterbased polyurethane (product 5187) and the polyester polyurethane/ polycarbonate blend (product 5370) possess high impact strength and high stiffness along with useful low-temperature properties. Texin is not recommended for implants of greater than 30 days duration. Texin should not be sterilized by autoclave or use of boiling water. Other advantages offered by Texin TPUs are that plasticizers are not necessary to achieve flexibility, the amount of extractables are low, and they possess high tensile strength, high tear strength, and high abrasion resistance. Texin polyurethanes are hydroscopic and will absorb ambient moisture. They can be processed by extrusion and injection molding if thoroughly dried beforehand. As with all chemical systems, the proper use and handling of these materials can not be over-emphasized (Tables 4.3, 4.12, and 4.13). Texin 5370 is a blend of polyester-based polyurethane and polycarbonate. It offers high impact strength and high stiffness. Steam sterilization or boiling should be avoided (Tables 4.3, 4.12, and 4.13).

Polycarbonate-based poly methanes Carbothane. This medical grade TPE polyurethane is the reaction product of an aliphatic diisocyanate, a polycarbonate-based macrodiol, and a chain terminating low molecular weight diol (Tables 4.4, 4.12, and 4.13). ChronoFlex AR. Available as a dimethyl acetamide solution, this segmented, aromatic, polycarbonate-based TPE polyurethane was designed to mimic Ethicon Corporation's Biomer. The polymer is made from the addition of diphenylmethane 4,4/-diisocyanate to a polycarbonate diol followed by addition of a mixture of chain extenders and a molecular weight regulator. The polymer is believed to be resistant to environmental stress cracking such as that experienced by other polyurethanes coated onto pacemaker leads (Tables 4.4, 4.12, and 4.13). Coremer Specifically designed as an 80 Shore A durometer TPE, this is a diamine chain extended version of Corethane. Coremer solution cast films have a low initial modulus and high flex fatigue life. Information as to longterm biostability is not available at this time (Tables 4.4 and 4.13).
Corethane

A polycarbonate TPE polyurethane that claims biostability is achieved through its replacement of virtually all ether or ester linkages with carbonate groups. The soft segment is composed of a polycarbonate diol formed by the condensation reaction of 1,6-hexanediol with ethylene carbonate. The polycarbonate diol is converted to a high molecular weight polyurethane by the reaction with 1,4-methylene bisphenyl diisocyanate (MDI) and 1,4-butanediol. It is reported to be resistant to environmental stress cracking as experienced with insulation on pacemaker lead wires. The polymer can be extruded, injection molded or compression-molded, and can be bonded with conventional urethane adhesives and solvents (Tables 4.4, 4.12, 4.13, and 4.14). Corhesive Corhesive is a solvent-free, two-component reaction adhesive system for use with polyurethanes, plasma treated silicones and certain metals (Tables 4.4, 4.12, 4.13, and 4.14).

Polypropylene-based Sarlink

elastomers

This is a polypropylene-based TPE that has been used as a replacement for medical stoppers previously made from butyl rubber. Sarlink has the characteristics typical of rubber vulcanizates such as elasticity, flexibility, high coefficients of friction and softness. Sarlink combines gas impermeability without concern for contamination of biological medium. Applications for medical grade Sarlink are inserts on syringe plungers, reusable injection caps, vacuum assisted blood sampling tubes, plus flexible grade tubing. The number of stoppers produced from Sarlink annually number in the billions. The material can be injection molded, blow molded, extruded, calendered, and thermoformed on standard processing equipment. It can be thermal bonded or adhesive bonded (Tables 4.5, 4.12, and 4.13). Polyvinyl chloride elastomers Polyvinyl chloride polymer is polymerized from vinyl chloride monomers. It is a hard material which can be made soft and flexible through the addition of a plasticizer or a copolymer. As such, it resembles an elastomer and can be included with other TPEs. Also optionally added to PVC are fillers, stabilizers, antioxidants and others. A typical PVC plasticizer for medical products is di(2-ethylhexyl) phthalate (also known as dioctyl phthalate, DOP). Some producers of PVC also offer non-phthalate formulations. PVC has been used extensively for blood bags, blood tubing, endotracheal tubes, catheters and fittings, urology tubes, intravenous tubing, respiratory devices and dialysis sets. Leaching of the plasticizer can offer difficulties if the application is not short-term. Medical grade PVC is available from B.F. Goodrich under the name Geon RX, Elastichem PVC, Ellay PVC, Multichem PVC, Teknor PVC, AlphaGary and others. PVC polymers have also been incorporated as additives to polyurethane to alter the properties of the latter. Elastichem PVC. This polyvinyl chloride compound family is highly elastomeric and exhibits a dry non-tacky surface even at hardnesses as low as 40 Shore A durometer. Their rubber-like resilience, high elongation and low permanent set and fatigue resistance offer advantages over conventional formulations (Tables 4.6, 4.12, and 4.13). Ellay PVC. Compounds from Ellay Corp. are available with Shore hardness ranges from 55 A to 100 A. The polymers have been applied to medication

delivery systems, blood collection, processing and storage, gastro-urological devices and collection systems. Product numbers ending in 'R' are special radiation resistant grades (Tables 4.6, 4.12 and 4.13).
Geon PVC.

Geon PVC is associated with vinyl examination gloves. For this use, Geon recommends a combination of Geon 121 AR and 213. For a more 'latex type' feeling, Goodtouch 250x100 is recommended. Typical film samples have passed patch insult tests when worn against the skin for extended periods (Tables 4.6, 4.12 and 4.13). Multichem PVC This line of PVC polymers consist of alloys of PVC in combination with other polymers. They display notable dynamic properties and resistance to migration and extraction. These non-toxic PVC compounds (includes Multichem and Elastichem) have over 25 years of experience in the medical field (Tables 4.6, 4.12 and 4.13). Teknor Apex PVC This extrudable PVC has found use as tubing for blood transport and delivery systems, dialysis and enteral feeding systems, oxygen delivery systems, catheters, and drainage systems. Product numbers containing an R are special radiation resistant grades (Tables 4.6, 4.12 and 4.13).
Styrene-based elastomers C-Flex TPE.

C-Flex thermoplastic elastomers are based on styrene/ethylene-butylene/styrene block copolymers. C-Flex polymers designated as 'medical grade' are clear and can be processed using conventional extrusion and injection molding equipment. They have been tested using Good Laboratory Practices and have successfully passed USP Class VI, biocompatibility tests. Translucent versions have high rebound values at ultimate elongation. Medical tubing, ureteral stents, blood pumps, feeding tubes and nephrostomy catheters are successful uses of this material (Tables 4.7, 4.12 and 4.13).
Kraton

Kraton elastomer consists of block segments of styrene and rubber monomers and are available as Kraton D and G series. The D series is based on unsaturated midblock styrene-butadiene-styrene copolymers whereas the G series is based on styrene-ethylene/butylene-styrene copolymers with a stable saturated midblock. Listed among the attributes of both series are such features as low extractables, dimensional stability,

vapor and gas transmission properties, ease of sterilization, softness and clarity. They exhibit elastomeric flexibility coupled with thermoplastic processibility (Tables 4.7, 4.12, 4.13). 4.2.2 Crosslinked elastomers Natural rubber Natural rubber (cis-polyisoprene) is strong and one of the most flexible of the elastomers. The material has been used for surgeon's gloves, catheters, urinary drains and vial stoppers. However, because it has the potential to cause allergic reactions thought to be due to the elution of entrapped natural protein, this elastomer is being used less now than in the past. Safer substitutes are being selected. Silicone elastomers Silicone elastomers have a long history of use in the medical field. They have been applied to cannulas, catheters, drainage tubes, balloon catheters, finger and toe joints, pacemaker lead wire insulation, components of artificial heart valves, breast implants, intraocular lenses, contraceptive devices, burn dressings and a variety of associated medical devices. A silicone reference material has been made available by the National Institutes of Health to equate the blood compatibility of different surfaces for vascular applications. This material is available as a silica-free sheet. Contact the Artificial Heart Program, NHBLI, NIH, Bethesda, Md. for further information. The silicone elastomers most commonly used for medical applications are the high consistency (HC) and liquid injection molding (LIM) types. The former is most often peroxide cured and the latter platinum cured although there are variations. Both materials are similar in properties. LIM offers greater advantages to the medical device molder and is gaining in popularity. This form of silicone may become the molder's material of choice within the next few years. High consistency (HC) silicone elastomer High consistency silicone elastomer consists of methyl and vinyl substituted silicones with aromatic and fluorinated functional groups in some formulations. For the most part, they are peroxide crosslinked. Items are usually compression or transfer molded (Tables 4.8). Liquid injection molding (LIM) silicone elastomer Liquid injection molding (LIM) with liquid silicone rubber (LSR) is fast

Table 4.8

Typical Properties of High Consistency (HC) Silicone Elastomers Property

Specific Durometer hardness, shore gravity ASTM ASTM D-2240 D-792 Tear Tensile strength, Elongation, strength percent pli, die B psi ASTM ASTM ASTM D-412 D-624 D-412

Product and Manufacturer

Product no.

Applied Silicone Medical Implant Grade, Applied Silicone Corp.

40039 40040 40041 40042 40043 40044 40045 40046 40063 MED-2174 MED-2245 MED-4515 MED 4516 MED-4735 MED 4750 MED 4755 MED 4765 MED-4770

1.12 1.15 1.20 1.20 1.12 1.12 1.15 1.20 1.20 1.15 1.13 1.15 1.21 1.10 1.15 1.14 1.20 1.17 1.10 1.10 1.14 1.20 1.10 1.10 1.14 1.14 1.22

35 50 66 78 23 33 51 66 70 52 41 52 12 35 50 57 65 70 25 33 51 66 23 35 50 50 78

A A A A A A A A A A A A A A A A A A A A A A A A A A A

1600 1500 1200 1200 1100 1600 1400 1200 1400 1200 1300 1350 1175 1310 1350 1375 1100 1375 550 1200 1375 1000 1200 1050 1300 1300 850

1200 900 900 600 1500 1015 600 500 850 715 700 450 370 1250 810 800 900 700 350 1015 600 550 1100 1200 900 900 600

200 220 260 280 160 150 190 250 280 200 140 90 80 200 230 300 240 300 50 160 170 210 150 200 230 230 190

NuSiI Silicone, NuSiI Technology

MDX4-4210 Q7-4535 Silastic Medical Materials, Q7-4550 Q7-4565 Q7-4720 Dow Corning Q7-4735 Corp. Q7-4750 Q7-4765 Q7-4780

becoming the technique of choice for processing silicone elastomers. Modifications of conventional injection molding equipment are required. For example, pumps to handle two components being injected simultaneously are required. The heaters on the injection barrel and nozzle are replaced by water cooled jackets. The mold is heated in the range of 300 to 4000F. Because the (LSR) flows easily, injection pressures are low (800 to 3000 psi). Elastomeric items cure rapidly in the mold (e.g., a 7 gram part will crosslink in about 15 seconds at 350 0F). Many formulations rely on platinum as a crosslinker. Perhaps in the future, the majority of silicone rubber molded parts will be made in this fashion. Appropriate equipment is commercially available.

Table 4.9 Typical Properties of Liquid Injection Molding (LIM) Silicone Elastomers Property
Specific Durometer hardness, shore gravity ASTM ASTM D-792 D-2240 Tear Tensile strength, Elongation, strength psi percent pli, die B ASTM ASTM ASTM D-624 D-412 D-412

Product and Manufacturer

Product no.

Applied Silicone Medical Implant Grade, Applied Silicone Corp.

40023 40024 40025 40026 40027 40028 40029 40071 40072 40082 MED-6210 MED-6233 MED-6382 MED-6820

1.11 1.11 1.12 1.12 1.13 1.13 1.10 1.14 1.10 1.10 1.04 1.03 1.13 1.05 1.12 1.14 1.16

10 20 30 40 50 60 30 70 25 40 50 50 45 40

A A A A A A A A A A A A A A

500 800 950 980 1000 1100 900 1200 650 900 1000 1200 400 750 950 1350 1300

750 600 600 450 400 350 300 350 400 250 100 300 200 125 425 550 450

80 140 150 170 190 220 80 220 60 110 35 75 25 150 225 250

NuSiI Silicone, NuSiI Technology

Q7-4840 Silastic Medical Materials, Q7-4850 Dow Corning Corp. Q7-6860

40 A 50 A 60 A

Tables 4.8, 4.9, 4.10 and 4.11 list the silicones made by Applied Silicone Corp., Dow Corning Corp., and NuSiI Technologies. Table 4.12 lists their biocompatibility status and Table 4.13 recommended sterilization methods. Dow Corning no longer offers the following materials for general sale: Silastic MDX 4-4515 Silastic MDX 4-4515 Silastic Q7-2245 Dow Corning Q7-2213

Further, they have discontinued the sale of all implant grade materials. Other silicones Silicones and polyurethanes have been used to produce denture liner materials and maxillofacial pros theses. Most of these materials are silicone based, e.g., Flexibase, Molloplast-B, Prolastic, RS 330 T-RTV, Coe-Soft, Coe-Super Soft, Vertex Soft, PERform Soft, and Petal Soft. Other custom

Table 4.10 Typical Properties of Elastomeric Dispersions Property

Durometer Tensile Elonga- Modulus Tear Specific hardness strength, tion, ASTM strength gravity shore psi percent D-412 pli,die B ASTM ASTM ASTM ASTM ASTM D-792 D-2240 D-412 D-412 psi % D-624

Product and Manufacturer

Product no.

Applied Silicone Medical Implant Grade, Applied Silicone Corp.

40000 40001 40002 40016 40021 40032 MED-2213

LlO 1.18 1.08 1.10 1.08 1.19 1.13 1.08 1.08 1.10 1.10 1.08 1.08 1.10 1.12 1.12 1.15

35^ 32 A 24 A 35 A 24 A 40 A Shore 00, 82 32 A 32 A 20 A 25 A 25 A 25 A 40 A 30 A 30 A 35 A Shore 00, 70

1800 1200 800 1800 1000 1300 1250 1250 1000 1000 900 900 900 1650 1750 1100 800

800 700 800 500 700 800 750 1000 1000 650 1100 750 900 275 325 75 100 150 100 200 50 190 325

185 200 60 185 100 120 200 300 300 300 175 200 100 100 300 200 140 150 90 100 125 130 280 275

NuSiI Silicone,

MED-6400 MED2-6400 NuSiI Technology MED-6600 MED2-6600 MED-6605 MED3-6605 MED-6607 MED-6640 MED2-6640 MED2-6650 Silastic Medical Materials, Dow Corning Corp. Q7-2630

Product no. 40000 40001 40002 40016 40021 40032

Form 35% solids, 1 part 32% solids, 1 part 27% solids, 1 part 32% solids, 1 part 21% solids, 1 part 15% solids, 1 part

viscosity cp. 2000

Solvent System Used Xylene

Cure System

Chemical Type

500 2000 500 800

Platinum Methyl vinyl addition siloxane Phenyl vinyl siloxane Acetoxy Dimethyl siloxane Methyl vinyl siloxane Dimethyl siloxane Fluorovinyl methyl siloxane Dimethylmethyl vinyl siloxane

1,1,1 trichloro- Platinum ethane addition Xylene Acetoxy 1,1,1 Platinum trichloro- addition ethane 1,1,1 trichloroethane

MED-2213

7000

Table 4.10 Continued visco- Solvent sity System cp. Used 600 800 300 1600 30% solids, 1 part 22% solids, 1 part 33% solids, 1 part 25% solids, 2 part 15% solids, 2 part 20% solids, 2 part 800 1250 5500 7000 5000 3000 Xylene 1,1,1 trichloroethane Xylene 1,1,1 trichloroethane Xylene Acetoxy 1,1,1 trichloroethane VM&P Oxime naphtha Xylene 1,1,1 Platinum trichloro- addition ethane Fluorovinyl methyl siloxane Q7-2650 Acetoxy Dimethyl siloxane Dimethyl siloxane Cure System Platinum addition Vinyl methyl siloxane Chemical Type

Product no. MED-6400 MED2-6400 MED-6600 MED2-6600 MED-6605 MED3-6605 MED-6607 MED-6640 MED2-6640 MED2-6650

Form 35% solids, 2 part, 1:1 25% solids, 2 part, 1:1 35% solids, 2 part

Methyl vinyl siloxane

Q7-263010% solids

Table 4.11 Typical Properties of Silicone Elastomeric Adhesives

1Property
Tear Adhesive Durometer Tensile Specific hardness strength, Elongation, strength, strength psi gravity shore percent die B, pi i (to ASTM ASTM ASTM ASTM silicone) ASTM D-792 D-2240 D-412 D-412 D-624 pli

Product and Manufacturer

Product no.

Applied Silicone 40064 Medical Implant Medical Grade 1.08 RTV Silicone Grade, Adhesive Applied Silicone Medical Grade High Strength Corp. RTV Silicone Adhesive MED-1137 NuSiI Silicone, NuSiI Technology Silastic Medical Materials Dow Corning Corp. Medical Adhesive A 355 Medical Grade Pressure Sensitive 1.07

24 A

850

750

70

18+ 18

950

770 18

29 A

550

450

1.06 1.40

29 A

450

400

30 20+

Product no. 40064

Cure Conditions

Comments Bonds silicones to each other and some synthetics, metals. Bonding silicone to polyester, etc. High strength bonds to polyester, nylon, polyurethane and metals. Bonding silicones to each other & some synthetics/metals. When fully cured resembles some conventional silicone elastomers. Bonding silicone rubber to itself. Useful for cast films or parts from dispersions. Adheres to skin for use with ileostomy and colostomy appliances.

Produces acetic acid. Cures @ RT with atmospheric moisture, 20 to 60% RH. Medical Grade RTV 24 hours @ 25C, aged Silicone Adhesive 24 hours @ RT. Medical Grade High Strength RTV Silicone Adhesive MED-1137 Produces acetic acid. Cure 3 days @ RT with atmospheric moisture, 20 to 60% RH. Produces acetic acid, requires 50% RH & 7 days to cure. Non-curing dispersion - becomes adhesive as solvent evaporates.

Medical Adhesive A 355 Medical Grade Pressure Sensitive

Table 4.12 Biocompatibility of Various Elastomers

Biocompatibility Status*
Classification Product and Manufacturer Product Intracutaneous Systemic Skin no. Hemolysis Pyrogenicity Injection Injection Sensitization

Santoprene Thermoplastic Rubber, elastomer Advanced Elastomer Systems PCCE copolyester elastomer

281-45 281-55 281-64 281-73 281-87 283^0

passed passed passed passed passed passed passed

passed passed passed passed passed passed

passed passed passed passed passed passed

passed passed passed passed passed passed

passed passed passed passed passed passed

Ecdel Elastomer, 9965 Eastman Chemical Co. 9966 Biospan Segmented,

passed passed

Polyurethane- Polyurethane, Biospan passed passed passed passed passed based The Polymer elastomers Technology Group, Inc. Hydrothane, Poly Medica Hydrothane Biomaterials, Inc. MP-5000 Medicaflex, MF-5001 passed passed passed MF-5040 Advanced Resin MF-5041 Technology MF-5056 MF-5057 MF-5062 Pellethane Pellethane 2363 series, 2363 series passed passed passed Dow Chemical Co. PolyBlend 1000 , PolyBlend and PolyBlend 1000 and 1100 PolyBlend Poly Medica 1100 Biomaterials, Inc. Biocompatibility Status* Intramuscular Tissue Cell Product no. 10 days 30 days 90 days Culture Comments 281-15 281-55 281-64 281-73 281-87 283-40 9965 9966 Biospan Hydrothane passed passed passed Passed USP Class VI testing, Tripartite testing, mouse embryo toxicity testing and Ames Mutagenicity testing.

passed passed See text for status.

Table 4.12

Continued Biocompatibility Status*

Intramuscular Tissue Cell Product no. 10 days 30 days 90 days Culture Comments MF-5000 MF-5001 MF-5040 MF-5041 MF-5056 MF-5057 MF-5062 Pellethane 2363 series PolyBlend 1000 and PolyBlend passed passed passed passed passed passed passed passed passed passed Passed USP Class VI testing.

passed

Passed USP Class VI testing. See text for status. See text for status.

Biocompatibility Status*
Classification Product and Manufacturer Product Intracutaneous Systemic Skin no. Hemolysis Pyrogenicity Injection Injection Sensitization

Tecoflex, Polyurethane- and based Tecothane, elastomers Thermedics, Inc. Texin,

EG60A EG80D 1055D 1065D 1074A 1075D 1085A 1095A Texin

passed

passed passed

passed

passed passed

passed passed passed

Miles, Inc. Polycarbonate- Carbothane, based polyurethanes Thermedics, Inc. PC-3555D PC-3572D PC-3575A passed PC-3585A PC-3595A

passed passed

ChronoFlex AR, Poly Medica ChronoFlexpassed passed Biomaterials, Inc. AR Coremer, Coremer Corethane, TPE 55D and TPE 75D passed TPE 8OA passed Corhesive, Corhesive passed passed Corvita Corp. Sarlink Sarlink Polypropylene- medical grade, medical grade based DSM Thermoplastic elastomers Elastomers, Inc.

passed passed passed passed passed passed passed passed passed passed passed

Table 4.12

Continued Biocompatibility Status*

Intramuscular Tissue Cell Product no. 10 days 30 days 90 days Culture Comments EG60A EG80D 1055D 1065D 1074A 1075D 1085A 1095A Texin PC-3555D PC-3572D PC-3575A PC-3585A PC-3595A ChronoFlex AR Coremer TPE 55D passed passed passed TPE 75D TPE 8OA passed passed passed Corhesive passed passed passed Sarlink medical grade Biocompatibility Status*
Classification Product and Manufacturer Product IntracutaneousSystemic Skin no. Hemolysis Pyrogenicity Injection Injection Sensitization

passed

passed

Passed USP Class VI testing. See text for status.

passed

passed

Passed USP Class VI testing. See text for status.

passed passed passed passed See text for status,

Polyvinyl chloride elastomers Ellay PVC,

Elastichem PVC, Elastichem Colorite PVC Plastics Co. Ellay PVC passed passed passed Ellay, Inc. Geon PVC, Geon PVC B. F. Goodrich Co. Multichem PVC, Multichem Colorite PVC Plastics Co. 3300-45 NT Teknor PVC, 3300-50 NT 3300-55 NT Teknor Apex Co. 3300-60 NT 3300-68 NT 3300-75 NT 3300-80 NT passed passed passed passed

Table 4.12

Continued Biocompatibility Status*

Intramuscular Tissue Cell Product no. 10 days 30 days 90 days Culture Comments R70-001 R70-003 R70-005 R70-026 R70-028 R70-046 R70-050 R70-051 R70-058 R70-067 R70-068 R70-072 R70-081 R70-082 R70-085 R70-089 R70-091 R70-116 R70-190 R70-214 D-2103 D-2104 D-2109 G-2701 G-2703 G-2705 G-2706 G-2712 passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed C-Flex testing data is available from manufacturer.

Passed Passed Passed Passed Passed Passed Passed

USP USP USP USP USP USP USP

Class VI Class VI Class VI Class VI Class VI Class VI Class VI

testing. testing. testing. testing. testing. testing. testing.

Biocompatibility Status*
Classification Product and manufacturer Product Intracutaneous Systemic Skin no. Hemolysis Pyrogenicity Injection Injection Sensitization

Polydimethyl- Applied Silicone siloxane Medical Implant Grade, Applied Silicone Corp. NuSiI Silicone, NuSiI Technology Silastic Medical Materials,

Applied Silicone Medical Implant Grade NuSiI Silicone passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed

MDX4-4210 Q7-4535 passed Q7^550 passed Q7-4565 passed Dow Corning Corp. Q7-4720 passed Q7-4735 passed

Table 4.12

Continued Biocompatibility Status*

Intramuscular Tissue Cell Product no. 10 days 30 days 90 days Culture Comments 3310-80 NT 3310-85 NT 3310-90 NT 90A471R-60NT 90A471R-65NT 90A471R-70NT 90A471R-75NT 90A471R-80NT 90A471R-85NT 90A471R-90NT passed passed passed passed passed passed passed passed passed passed Passed Passed Passed Passed Passed Passed USP USP USP USP USP USP Class VI Class VI Class VI Class VI Class VI Class VI testing. testing. testing. testing. testing. testing.

Biocompatibility Status*
Classification Product and Manufacturer Product Intracutaneous Systemic Skin no. Hemolysis Pyrogenicity Injection Injection Sensitization

Styrene-based C-Flex, elastomers Consolidated Polymer Technologies, Inc.

Kraton, Shell Chemical Co.

R70-001 R70-003 R70-005 R70-026 R70-028 R70-046 R70-050 R70-051 R70-058 R70-067 R70-068 R70-072 R70-081 R70-082 R70-085 R70-089 R70-091 R70-116 R70-190 R70-214 D-2103 D-2104 D-2109 G-2701 G-2703 G-2705 G-2706 G-2712

passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed

passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed

passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed

passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed

Table 4.12

Continued Biocompatibility Status*

Classification

Product and Manufacturer

Product lntracutaneous Systemic Skin no. Hemolysis Pyrogenicity Injection Injection Sensitization

Teknor PVC,

3300-85 NT 3300-90 NT Teknor Apex Co. 3310-50 NT 3310-55 NT 3310-60 NT 3310-65 NT 3310-70 NT 3310-75 NT 3310-80 NT 3310-85 NT 3310-90 NT 90A471R-60NT 90A471R-65NT 90A471R-70NT 90A471R-75NT 90A471R-80NT 90A471R-85NT 90A471R-90NT

passed passed passed passed

passed passed passed passed passed passed passed

passed passed passed passed passed passed passed

passed passed passed passed passed passed passed

Biocompatibility Status* Intramuscular Tissue Cell Product no. 10 days 30 days 90 days Culture Comments Elastichem PVC Ellay PVC Geon PVC Multichem PVC 3300-45 NT 3300-50 NT 3300-55 NT 3300-60 NT 3300-68 NT 3300-75 NT 3300-80 NT 3300-85 NT 3300-90 NT 3310-50 NT 3310-55 NT 3310-60 NT 3310-65 NT 3310-70 NT 3310-75 NT See text for status. passed passed Passed USP Class VI testing. See text for status. See text for status.

passed

passed passed passed passed passed passed passed passed passed passed passed passed passed passed passed

Passed USP Class VI testing. Passed USP Class VI testing.

Table 4.12

Continued Biocompatibility Status*

Classification

Product and Manufacturer

Product Intracutaneous Systemic Skin no. Hemolysis Pyrogenicity Injection Injection Sensitization

Polydimethyl- Silastic siloxane Medical Materials,

Q7^750 passed Q7-4765 passed Q7-4780 passed Dow Corning Corp. Q7-4840 passed Q7^850 passed Q7-6860 passed Medical Adhesive A 355 Medical Grade Pressure Sensitive

passed passed passed passed passed passed

passed passed passed passed passed passed

passed passed passed passed passed passed passed

passed passed passed passed passed passed passed passed

Biocompatibility Status* Intramuscular Tissue Cell Product no. 10 days 30 days 90 days Culture Comments Applied Silicone Medical Implant Grade NuSiI Silicone MDX4-4210 passed Q7-4535 passed Q7-4550 passed Q7^t565 passed Q7-4720 Q7-4735 passed Q7-4750 passed Q7^765 passed Q7^780 passed Q7-4840 passed Q7^850 Q7-6860 passed Medical Adhesive A passed 355 Medical passed Grade Pressure Sensitive Applied Silicone testing data is available from manufacturer.

passed passed passed passed passed

passed

passed

passed

passed

See See See See See See See See See See See See See

text text text text text text text text text text text text text

for for for for for for for for for for for for for

status. status. status. status. status. status. status. status. status. status. status. status. status.

passed passed passed passed

passed

See text for status, See text for status. See text for status.

* Biocompatibility based on comparison with USP negative controls Note: It is the user's responsibility to adequately test or determine that these materials are suitable or safe for any application.

Table 4.13 Sterilization Methods for Elastomers Product Biospan Biospan D Biospan S C-Flex R70-001 R70-003 R70-005 R70-026 R70-028 R70-046 R70-050 R70-051 R70-072 R70-081 R70-082 R70-085 R70-089 R70-091 R70-116 R70-190 R70-214 Carbothane ChronoFlex Coremer Corethane 8OA 55D 75D Corhesive Ecdel elastomers Hydrothane Kraton G-series D-series Steam/autoclave Cobalt 60 Ethylene oxide Cold solution OK OK OK no OK no no OK OK OK OK OK OK NR NR no no no with caution OK -no OK with caution no OK OK OK no OK OK OK OK OK OK OK OK OK OK OK OK OK - OK OK OK OK no OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK OK

OK

OK OK OK OK

Medicaflex Natural rubber, gum Natural rubber, latex Pellethane Poly blend Poly blend 1100 PVC Elastichem Ellay Geon Multi-Chem Teknor in general Santoprene Sarlink3260

OK OK OK OK OK OK OK OK Flexible with caution PVC, OK rigid PVC, no OK OK

OK

Table 4.13 Continued Product Silicone Steam/autoclave Cobalt 60 Ethylene oxide Cold solution High consistency OK OK OK LIM OK OK OK Adhesives OK OK OK Dispersions OK OK OK Tecoflex with caution OK OK with caution Tecothane OK OK with caution Texin no OK OK Caution: with some aromatic polyurethanes methylene dianiline (MDA) can be generated with steam sterilization.

Table 4.14 Water Absorption of Various Elastomers Water absorption, percent (after 24 hours) Product no. ASTM-D 570 281-55 281-64 281-87 283-40 9965 9966 9967 TPE 8OA TPE 55D TPE 75D Biospan Biospan D Biospan S PB1000-650 PB 1100-55 PB1100-60 PB1100-75 PB1100-80 6.0 0.0 0.4 1.2 0.9 0.8 1.2 1.5 1.3 1.5 < <0.4 0.1-0.5 <0.2

Classification Thermoplastic vulcanizate PCCE copolyester elastomer

Product and manufacturer Santoprene Rubber, Advanced Elastomer Systems Ecdel Elastomer, Eastman Chemical Co. Corethane,

Polycarbonatebased Corvita Corp. polyurethanes Corhesive, Corvita Corp. Biospan segmented Polyurethanepolyurethane, based The Polymer Technology elastomers Group, Inc. PolyBlend 1000, and PolyBlend 1100 Poly Medica Biomaterials, Inc. Silicone rubber Silicone type A adhesive

made elastomers have been applied to maxillofacial prostheses, e.g., Cosmesil, Silastic 4-4210, Silastic 4-4515, Silicone A-102, Silicone A2186, Silskin II, Isophorone polyurethane, and Epithane-3. Denture liners with acrylic and silicone include Coe-Soft, Coe Super-Soft, Vertex Soft, Molloplast-B and Flexibase. Dispersions Solvent solutions of polyurethane elastomers and silicone elastomers are given in Table 4.10. These materials are helpful in casting thin films and odd or complex shapes.

4.3 ESTABLISHING EQUIVALENCE Specific polymeric materials traditionally used for medical applications have been recently withdrawn from the medical market. Silicone elastomers are among those withdrawn. To maintain continued supply of vital implants, methods of determining equivalence for withdrawn elastomers with new or existing ones has been adopted by the FDA in the form of an FDA Guidance Document.
4.3.1 FDA Guidance document for substitution of equivalent elastomers

The FDA will allow manufacturers to change sources of silicone elastomers (and others) if they can show that the replacement material is 'not substantially different' from materials described in existing approved applications. The device manufacturer is still required to certify that the processes of fabrication, cure and sterilization it uses in the manufacture of its device are appropriate for the new material and that the device will perform as intended. Premarket notification submission under section 510(k) of the Federal Food, Drug, and Cosmetic Act (21 USC 360(k) and 21 CFR 807.81(a)(3)(i), or a supplemental premarket approval application under 21 USC 360(k) section 515 and 21 CFR 814.39 is necessary when change could significantly affect the safety or effectiveness of the device. These submissions are required to be submitted and approved before the device may be marketed with the change. There are a number of tests necessary for comparison of silicone elastomers as indicated by 'Guidance for Manufacturers of Silicone Devices Affected by Withdrawal of Dow Corning Silastic Materials' (Federal Register, Vol. 58, No. 127, Tuesday, July 6, 1993/ Notices, 36207). They compare the physical, chemical and biological properties of the bulk poly-

Table 4.15 Equivalent Silicone Elastomers for Existing Dow Corning Silicones NuSiIt AppliedA Dow Corning* Silicone Silicone Silicone Equivalent Equivalent Medical Adhesive A Q7-4535 MED-1137 40064 Medical Grade Silicone Description

Medical RTV Adhesive, Acetoxy System (see also Rehau, Table 4.16) MED-4535 40044 High Consistency, 35 Durometer, Peroxide Cure Q7-4550 MED-4550 40045 High Consistency, 50 Durometer, Peroxide Cure Q7-4565 MED-4565 40046 High Consistency, 65 Durometer, Peroxide Cure Q7-4720 MED-4720 40043 High Consistency, 20 Durometer, Platinum Cure Q7-4735 MED-4735 40039 High Consistency, 35 Durometer, Platinum Cure Q7-4750 MED-4750 40040 High Consistency, 50 Durometer, Platinum Cure Q7-4780 MED-4780 40042 High Consistency, 80 Durometer, Platinum Cure MDX4-4210 MED-42111 40072 Liquid Silicone, 25 Durometer, Platinum Cure 40029 Liquid Silicone, 30 Durometer, Platinum Cure Q7-4840 MED-4840 40026 Liquid Silicone, 40 Durometer Platinum Cure Q7-4850 MED-4850 40027 Liquid Silicone, 50 Durometer, Platinum Cure Q7-4865 MED-4865 Liquid Silicone, 65 Durometer, Platinum Cure DC-360 MED-360 40047 Medical Grade Silicone Fluid, 1000 cps. Specify 40073 Medical Grade Silicone Fluid, 350 cps. viscosity 40074 Medical Grade Silicone Fluid, 20 cps. * Dow Corning Corp., Midland, Ml. X NuSiI Silicone Technology, Carpinteria, CA A Applied Silicone Corp., Ventura, CA Note: It is the user's responsibility to adequately test or determine that these materials are suitable or safe for any application.

Table 4.16 Equivalent Silicone Elastomers for Withdrawn Dow Corning silicones
NuSiIt Dow Corning* Silicone Sillicone Equivalent MDX4-4515 MDX4-4516 Q7-2245 Q7-2213 Rehau 1511 MED-4515 MED-4516 MED-2245 MED-2213 AppliedA Silicone Equivalent 40045 40046 40009 40016 40076 Medical Grade Silicone Description 50 Durometer, peroxide cure 60 Durometer, peroxide cure 40 Durometer, platinum cure Dispersion in 1, 1, 1 trichloroethane Medical RTV adhesive, acetoxy system

* Dow Corning Corp., Midland, Ml. X NuSiI Silicone Technology, Carpinteria, CA. A Applied Silicone Corp., Ventura, CA. Rehau AG and Co., Rehau, Germany. Note: It is the user's responsibility to adequately test or determine that these materials are suitable or safe for any application.

mers as they are received from the supplier and also compare the molded elastomer as it exists in the final medical device.
4.3.2 Equivalent silicone elastomers

Two manufacturers, NuSiI Technology and Applied Silicone Corp., are providing equivalent silicone materials for the Dow Corning products that have been withdrawn. Tables 4.15 and 4.16 gives reported comparisons.

Table 4.17 Relevant ASTM Standards D 395 Test Method for Rubber Property - Compression Set D 412 Test Method for Vulcanized Rubber, Thermoplastic Rubbers and Thermoplastic Elastomer - Tension D 471 Test Method for Rubber Property - Effect of Liquids D 570 Test Method for Water Absorption of Plastics D 624 Test Method for Tear Strength of Conventional Vulcanized Rubber and Thermoplastic Elastomer D 638 Test method for Tensile Properties of Plastics D 792 Test Method for Specific Gravity (Relative Density) and Density of Plastics by Displacement D 797 Test Methods for Rubber Property - Young's Modulus at Normal and Subnormal Temperatures D 1630 Test Method for Rubber Property - Abrasion Resistance (NBS Abrader) D 1708 Test method for Tensile Properties of Plastics by Use of Microtensile Specimens D 1790 Test method for Brittleness Temperature of Plastic Film by Impact D 1938 Test method for Tear Propagation Resistance of Plastic Film and Thin Sheeting by a Single-Tear Method D 2240 Test Method for Rubber Property - Durometer Hardness D 2702 Standard Practice for Rubber Chemicals - Determination of Infrared Absorption Characteristics D 3418 Test Method for Transition Temperatures of Polymers by Thermal Analysis D 3593 Test Method for Molecular Weight Averages and Molecular Weight Distribution of Certain Polymers by Liquid Size-Exclusion Chromatography (Gel Permeation Chromatography, GPC) Using Universal Calibration D 5023 Test Method for Measuring the Dynamic Mechanical Properties of Plastics Using Three Point Bending D 5026 Test Method for Measuring the Dynamic Mechanical Properties of Plastics in Tension E 355 Standard Practice for Gas Chromatography, Terms and Relationships E 1356 Test Method for Glass Transition Temperatures by Differential Scanning Calorimetry or Differential Thermal Analysis F 604 Classification for Silicone Elastomers Used in Medical Applications F 619 Standard Practice for Extraction of Medical Plastics F 720 Standard Practice for Testing Guinea Pigs for Contact Allergens: Guinea Pig Maximization Test F 748 Standard Practice for Selecting Generic Biological Test Methods for Materials and Devices F 749 Standard Practice for Evaluating Material Extracts by Intracutaneous Injection in the Rabbit F 750 Standard Practice for Evaluating Material Extracts by Systemic Injection in the Mouse F 813 Standard Practice for Direct Contact Cell Culture Evaluation of Materials for Medical Devices F 895 Standard Practice for Agar Diffusion Cell Culture Screening for Cytotoxicity F 981 Standard Practice for Assessment of Compatibility of Biomaterials (Non-porous) for Surgical Implants with Respect to Effect of Materials in Muscle and Bone

4.4 STERILIZATION OF ELASTOMERS 4.4.1 Sterilization methods

Not all materials respond alike when subjected to various means of sterilization. Some are heat sensitive, some will absorb sterilization fluids, some will be affected by molecular changes when subjected to radiation sterilization and others will absorb and hold irritating gases for extended periods of time. Table 4.13 gives sterilization methods that have been judged most appropriate for each elastomer. The consequences of using an inappropriate method can be loss in physical properties and an adverse biological response.

4.5 RELEVANT ASTM STANDARDS Standard methods of testing elastomers used for medical applications are given by specific ASTM test methods. Physical and biological tests are provided here to serve as references for the data cited in the tables and listed in Table 4.17. They are also designated in the FDA Guidance Document. 4.6 BIOCOMPATIBILITY Table 4.12 on biocompatibility of various elastomers is intended to show the status of in vitro and in vivo testing. The successful outcome of these tests can serve as guides to potentially acceptable performance of an elastomeric product in a medical device under development. However, the use of elastomeric products in medical devices is the responsibility of the device manufacturer who must establish their safety and efficacy with the FDA.

4.7 SOURCES AlphaGaryAlphaGary, Leominster, MA Applied SiliconeApplied Silicone Corp., Ventura, CA BiospanPolymer Technology Group, Inc., Emeryville, CA C-FlexConsolidated Polymer Technologies, Inc., Largo, FL CarbothaneThermedics, Inc., Woburn, MA ChronoFlexPolyMedica Industries, Inc., Woburn, MA CoremerCorvita Corp., Miami, FL CorethaneCorvita Corp., Miami, FL

CorhesiveCorvita Corp., Miami, FL EcdelEastman Chemical Co., Kingsport, TN ElastichemColorite Plastics Co., Ridgefield, NJ EllayEllay, Inc., City of Commerce, CA GeonB.F. Goodrich Co., Chemical Group, Cleveland, OH HydrothanePolyMedica Industries, Inc., Woburn, MA KratonShell Chemical Co., Oak Brook, IL MedicaflexAdvanced Resin Technology, Manchester, NH MultichemColorite Plastics Co., Ridgefield, NJ Natural rubberExxon Chem. Co., Buffalo Grove, IL Goodyear Tire and Rubber Co., Akron, OH NuSiI SiliconeNuSil Technology, Carpinteria, CA PellethaneDow Chemical Co., Midland, MI PolyBlendPolyMedica Industries, Inc., Woburn, MA SantopreneAdvanced Elastomer Systems, St Louis MO SarlinkDSM Thermoplastic Elastomers, Inc., Leominster, MA SilasticDow Corning Corp., Midland, MI TecoflexThermedics, Inc., Woburn, MA TecothaneThermedics, Inc., Woburn, MA TeknorTeknor Apex Co., Pawtucket, RI TexinMiles, Inc., Pittsburgh, PA

Oxide bioceramics: inert ceramic materials in medicine and dentistry

J. Li and G.W. Hastings

5.1 INTRODUCTION Single oxide ceramics, e.g. aluminium oxide (Al2O3, alumina) and zirconium dioxide (ZrO2, zirconia), are bioceramics of an inert nature. An inert ceramic does not form a bonding to bone similar to those bioceramics of bioactive nature. Alumina bioceramics are in the pure aluminium oxide form, whereas zirconia bioceramics are partially stabilized by additional oxides, e.g. yttrium oxide, calcium oxide or magnesium oxide. Oxide ceramics exhibit superior mechanical properties, corrosion and wear resistance. Since the oxides are the highest oxidation state of the metal, they are stable even in the most invasive industrial and biomedical environments. Alumina and zirconia are utilized as load-bearing hard tissue replacements and fixation implants in dentistry and surgery. 5.2 SHORT HISTORY Although the use of alumina as implants can be traced back to the 1930s as described by Hulbert et al (1) (Table 5.1), the extensive use of alumina since the 1980s has depended on new powder processing technology enabling grain size reduction of the sintered ceramics from 10 micrometers
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN O 412 60330 6.

down to 2 micrometers (Figure 5.1, microstructure of alumina). This significantly improves the performance of the alumina ceramic hip balls. Alumina and partially stabilized zirconia are currently in extensive use as implants in consequence of their high strength, excellent corrosion and wear resistance and stability, non-toxicity and biocompatibility in vivo. A summary of alumina- and zirconia-based implants is presented in Table 5.2. The most established example is in the total hip endoprosthesis with a combination of metallic stem, ceramic ball and ultra high molecule weight polyethylene (UHMWPE) acetabular cup. A ten year clinical success rate better than 90% is reported for the cemented total hip endoprosthesis. Dental implants of polycrystalline alumina were suggested by Sandhaus in Germany (4). Type Tubingen was produced by Frialit in the 1970s. These devices have not been generally accepted, due to the fracture failure of the implants, particularly for those of polycrystalline type produced in Table 5.1 Evaluation of oxide ceramic implants: alumina and zirconia
1932 1963 1964 1970 1974 1977 1981 1982 1986 1993 1995 1996 First suggestion of application of alumina ceramics in medicine First orthopaedic bone substitute application First dental implant of alumina French hip prosthesis: Alumina ceramic ball and cup German hip prosthesis 28 mm alumina ball Alumina total knee prosthesis FDA approval for non-cemented alumina ceramic cup and ball and CoCrMo-stem of Mittelmeier type First zirconia ball of 32 mm First dental implant of zirconia First zirconia dental post First zirconia inlay Rock (2) Smith (3) Sandhaus (4) Boutin (5) Mittelmeier (6) Shikita (7) Oonishi et al. (8)

Lord et al. (9) Akagawa et al. (10) Meyenberg et al. (11) Johansson (12)

Table 5.2 Materials Alumina

Biomedical applications of oxide ceramics Applications Hip ball & cup Knee joint Bone screws Dental implant Dental crowns & brackets Hip ball Dental implants Dental post, brackets and inlay References Clarke and Willmann (13) Oonishi et al. (8) Kawahara (14) Sinha et al. (15) Christel (16) Akagawa et al. (10) (10,H), Keith et al. (17)

Zirconia

Figure 5.1 SEM micrograph of dense alumina, etched in boiling H3PO4 for 6 minutes to show the microstructure.

the early 1970s. The single crystal sapphire type, introduced in Japan by Kawahara in the 1970s (18) is, however, still being used and a recent 10year clinical follow-up report from Sweden showed a 92% success rate (19) for the single crystal dental implants. Alumina and zirconia ceramics are also being used for alveolar ridge reconstruction (20), maxillofacial reconstruction, as ossicular bone substitutes (21), and in ophthalmology (22), knee prosthesis (8), bone screws as well as other applications as dental biomaterials, such as dental crown core, post, bracket and inlay (23,24). 5.3 MATERIAL PROPERTIES AND PROCESSING 5.3.1 Materials properties Although alumina is chemically more stable it is mechanically weaker than zirconia, and the phase changes or transformation mechanisms in zirconia produce a unique ceramic material having much higher strength and higher fracture toughness compared with alumina and other ceramics. The excellent mechanical properties of zirconia allow the design of hip balls of smaller diameter in order to reduce the wear of the UHMWPE cup with expected increased long-term clinical performance as a result.

The chemical stability of alumina is related to its phase stability, whereas the phase changes of zirconia result in degradation in strength and wear resistance. Release of substances from zirconia and alumina implants to the surrounding tissue is very low and neither local nor systemic effects have been reported. Aluminium oxide: alumina Aluminium oxide is produced by heating its hydrates. At least seven forms of alumina have been reported, but six of these forms have traditionally been designated 'gamma alumina'. When heated above 12000C, all other structures are irreversibly transformed to the hexagonal alpha-alumina, corundum, a close-packed arrangement of oxygen ions. Thus alphaalumina is the only stable form above 12000C and by far the most commonly used of structural ceramics. Alpha-alumina is thermodynamically stable and is crystallographically identical with the single crystal ruby and sapphire ceramics. Each aluminium ion is surrounded by six oxygen ions, three of which form a regular triangle on one side, the other three form a similar triangle on the other side, with the two planes of the triangles being parallel and the triangles being twisted 180 (25). Physical and mechanical properties Table 5.3 and 5.4. Resulting from a strong chemical bond between the Al and O ions, as expected from the value of heat of formation (-400K cal/mol), Al2O3 has a high melting point, the highest hardness among known oxides, and high mechanical strength (26). Chemical properties Alumina is chemically stable and corrosion resistant. It is insoluble in water and very slightly soluble in strong acids and alkalies. Therefore, practically no release of ions from alumina occurs at a physiological pH level, 7.4. Wear resistance Arising from the chemical stability and high surface finish and accurate dimensions, there is a very low friction torque between the alumina femoral heads and the acetabular cup, leading to a low wear rate. Combinations of ceramic head/UHMWPE cup and ceramic head/ceramic cup were tested and compared to the metal head/UHMWPE cup. The wear resistance of the ceramic head/UHMWPE cup combination over metal/UHMWPE has improved from 1.3 to 34 times in the laboratory and from three to four times clinically (27,28). No alumina wear particles from retrieved ceramic/UHMWPE were found, whereas UHMWPE wear particles from microns to millimetres in size were found in the retrieved

Table 5.3 Property

Engineering Properties of Alumina and Zirconia (At 25 0 C)* Al2O3 Hexagonal 4.76 13.0 D 6 Ba 2040 3.98 1-6 22 366 0.26 6.5 551 3790 310 4.0 ZrO2** Tetragonal*** 3.64 5.27 P42/nmc 2680 6.08 0.54 12.2 201 0.30 10.1 1074 7500 420 6-15

Physical Crystallography a (A) c (A) Space group Melting point ( 0 C) Density (g/cm3) Grain size (|xm) Hardness (GPa) Modulus of elasticity, (GPa) Poisson's ratio Thermal coefficient of expansion 25-200 0 C Mechanical Flexural strength (MPa) Compressive Strength (MPa) Tensile strength (MPa) Fracture toughness (MPa m1/2)

* Sources: refs 26, 44 and 45 ** Zirconia presented is the yttria-partially stabilized material *** Most of the medical-grade zirconia is partially stabilized tetragonal zirconia

Table 5.4 Properties of medical-grade ceramic materials according to the standards and the manufacturer's technical date - alumina and zirconia Alumina according to ISO-6474 Zirconia ASTM Frialit according to F 603-83 bioceramic ISO/DIS Prozyr DIN 58 8353 alumina 13356 zirconia >99.5 >3.9 0 <4.5 23 380 >400 250 >40 0.01 <0.1 >99.5 >3.98 ** >2.5 23 380 >450 >40 0.001 <0.1 >99.5* >6.0 0 <0.6 >900 >550 >95 6 0 <1 13 220 >920 124 10

Property Purity (%) Density (g/cm3) Porosity (%) Grain size (jxm) Microhardness (GPa) Young's modulus (GPa) Flexural strength (MPa) Biaxial flexural strength (MPa) Impact strength (cm MPa) Fracture toughness (MPa m1/2) Wear resistance (mm3/h) Corrosion resistance (mg/m2d) * ZrO2+HfO2+Y2O3 ** Not available.

surrounding tissues. However, from the ceramic/ceramic combination, ceramic particles resembling 'fine grains and great fragments in the ranges from 0.5 to 10 micrometers diameter, with the predominant size of about 1 micrometer' were found in the surrounding tissue (29). The advantage of ceramic/ceramic combination over ceramic/UHMWPE is, therefore, doubtful. For wear tests, we refer to ISO-6474 ASTM F-603. Clinical performance The fracture of ceramic balls in ceramic: UHMWPE combination has been virtually zero. Fritsch and Gleitz (30) published a failure analysis on 4341 alumina ceramic heads articulating with 2693 alumina ceramic and 1464 polymer sockets implanted over 20 years (1974 to 1994), and concluded that the use of ball type neckless heads brought the fracture rate close to zero. The success rate of 10 years follow-up is normally above 90% for the 'elderly' patient population. Stem and cup loosening are the causes of failure, where the consistent wear debris from UHMWPE and bone cement remain the problems. Zirconium dioxide: zirconia Zirconia ceramics are termed polymorphic because they undergo several transformations on cooling from a molten state to room temperature. It exhibits three well-defined polymorphs, the monoclinic, tetragonal and cubic phases and a high pressure orthorhombic form also exists. The monoclinic phase is stable up to about 11700C where it transforms to the tetragonal phase, stable up to 23700C, while the cubic phase exists up to the melting point 26800C. A large volume change of 3 to 5% occurs when zirconia is cooled down and transforms from the tetragonal to the monoclinic phase. Partially stabilized zirconia (PSZ) and tetragonal zirconia polycrystals (TZP) The volume change due to phase transformation is sufficient to exceed elastic and fracture limits and causes cracking of the zirconia ceramics. Therefore, additives such as calcia (CaO), magnesia (MgO) and/or yttria (Y2O3) must be mixed with zirconia to stabilize the material in either the tetragonal or the cubic phase. PSZ is a mixture of cubic and tetragonal and /or monoclinic phases, whereas TZP is 100% tetragonal (phase diagram Figure 5.2). Both PSZ and TZP are suggested for medical implant applications. Yttria-TZP ceramics have a strength and fracture toughness approximately twice that of alumina ceramics used in the biomedical field. This makes zirconia heads less sensitive to stress concentrations at the points of contact with metal cones.

Figure 5.2(a) Part of the equilibrium phase diagram for the system ZrO2-CaO. Css refers to the cubic solid-solution phase, Tss to the tetragonal solid-solution phase, and Mss to the monoclinic solid-solution phase (ref. 21).

Physical and mechanical properties Zirconia ceramics have a high density because of heavy zirconium ions, and a low microhardness and elastic modulus, together with high strength and fracture toughness compared to other ceramics including alumina. The superior mechanical strength provides the possibilities for producing ceramic ball heads of size below 32 mm. Fracture toughness mechanisms: Garvie et al were the first to realize the transformation toughening mechanism for zirconia ceramics. Increase of both strength and fracture

Temperature, 0C

**
I

\
1500 -

\
\

M
\
I^ /
1
m

t+c

\
\
\

K
500 -

1000 " W l

1 m+C
I 5 I 10 i 15

I I
I i 20 , 30

Y 2 0 3 (wt%) Figure 5.2(b) Y2O3-ZrO2 phase diagram: the addition of less than 5% of Y2O3 to ZrO2 allows the sintering of a fully tetragonal material (t=tetragonal phase; m=monoclinic phase; c=cubic phase) (ref. 16).

toughness can be obtained by utilizing the tetragonal-monoclinic phase transformation of metastable tetragonal grains induced by the presence of the stress field ahead of a crack (31). The volume change and the shear strain developed in the martensitic reaction were recognized as opposing the opening of the crack and therefore acting to increase the resistance to crack propagation.
Wear resistance and chemical stability:

The published results of in vitro wear tests demonstrated that zirconia has a superior wear resistance. Saikko (32) showed no wear of zirconia femoral heads on his hip simulator wear test against 10.9 mm UHMWPE cup, and Praveen Kumar et al (33) demonstrated the high wear resistance of zirconia against UHMWPE and the superiority of zirconia ceramics even over alumina ceramics in terms of low wear and low friction. A significant reduction in the wear rate of zirconia ball heads compared to the metal ball heads was reported on a pin-on-disc wear test and on a hip simulator (34). However, there are two potential limitations for the use of zirconia as bioceramics: degradation and radiation. It is known that the phase transformation is accelerated in aqueous environment, but little is known about how this phase transformation will occur in biological environment, particularly under dynamic loadings. A warning against steam resterilization has been issued in the UK. Radioactive U-235 impurity was detected in some 'pure zirconia', both alpha- and gamma-irradiation were

measured from zirconia femoral balls. Although the radioactivity was low, more work is required to verify this matter (13). Clinical performance The surface degradation of the zirconia balls due to the phase transformation under loading seems to be a problem, although no significant change in mechanical strength was reported in some long-term in vivo and in vitro studies (35,36). Seriously, catastrophic failure of modular zirconia ceramics femoral head components after total hip arthroplasty was reported (37). Since zirconia femoral heads have a short clinical history and few clinical results are available, more investigation is required to eliminate the factors which impair the clinical stability of zirconia ceramics under loading. 5.3.2 Materials processing An advanced ceramic is processed in such a way that the structure of the materials on different levels, including atomic, electronic, grain boundary, microstructural and macrostructural, is under strict control. In the manufacturing processes, emphasis is placed on producing dense ceramics with a fine microstructure. However, other factors such as chemical composition, the nature and distribution of the impurities, crystal structure, grain size, and defects are also of importance to the performance of the ceramic materials. Three basic processes are involved in the production of fine ceramic components, namely: 1. powder technology, 2. densification or sintering and 3. machining. Both alumina and zirconia hip balls are produced by compacting fined-grained powder (green bodies), and sintering at 1500-1700 0C and finally grinding or lapping to obtain a high surface finish and sphericity (Ra<0.02 (xm). 5.4 BIOCOMPATIBILITY OF OXIDE BIOCERAMICS No materials placed within a living tissue can be considered to be completely inert. However, oxide bioceramics, by their very nature, do not suffer from corrosion or degradation in biological environments, as metals or plastics do. Ceramics, having molecular structures completely different from those of living tissues, are generally stable inside the living body and provide a high degree of acceptance by the apposition to the surrounding tissue as shown by in vitro and in vivo studies Ichikawa et al. observed no adverse soft tissue responses to zirconia and alumina implants after 12 months of implanation (38). Takamura et al reported that alumina and zirconia did not possess chronic toxicity to mice (39), whereas Steflik et al found a biological seal at the alumina dental implant

and epithelium interface (40). However, oxide bioceramics do not form a chemical bond to bone tissue and are therefore defined as inert biomaterials. Oxide bioceramics are defined as inert biomaterials. The ASTM standards (F 748/82, 763/82) and ISO standards No 10993 have set the guidance for biological testing of biomaterials for orthopaedic application. The materials should be tested in soft tissue as well as in hard tissue environments, for both short-term and long-term experiments. A summary of recommended biological testing is presented in Table 5.5. Both alumina and zirconia have shown non-toxicity and good biocompatibility according to the tests. Testing results for zirconia made by a French Company are shown in Table 5.6. Although some serious problems occurred with zirconia balls, the basic biocompatibility of the zirconia remains. Soft tissue and bone responses to zirconia and alumina were studied in our lab: no adverse tissue reaction to these ceramics were found. The patterns of tissue-materials interface after 1 month implantation in muscle and femur of rat are shown in Figure 5.3.
Table 5.5 Guidance for Biologic Evaluation Tests of the Implant Device in Contact to bone Tissue (According to ISO 10993-1:1992 (E)) Contact duration Biological tests A-limited B-prolonged C-permanent (>24 h) (<24 h to 30 days) (<30 days) Cytotoxity x x x Sensitisation x x x Irritation/Intracutaneous reactivity x x x Irritation/Intracutaneous x Genotoxicity x x Implantation x x Chronic toxicity x Carcinogenicity x The related tests see ISO standards from No. 10993-1 to 10993-6 Table 5.6 Biological evaluations of zirconia ceramics (Prozyr, Ceramiques Desmarquest, France) Biocompatibility Short-term in vivo biocompatibility In vitro biocompatibility Cell culture cytotoxicity Mutagenicity Systemic injection acute toxicity Intracutaneous injection Sensitization Standard used ASTM F 763/82 ASTM F 748/82 PRS 90.702 Ames test Micronucleus test ASTM F 750/82 ASTM F 749/82 ASTM F720/81 Magnusson Results Very good Good cytocompatibility No mutagenic activity According to standard No irritation No sensitization

Figure 5.3(a) Optical micrograph of alumina and soft tissue interface.

Figure 5.3(b) Zirconia and bone interface 1 month after implantation. Arrows are pointing to the interfaces.

Table 5.7

Ceramic manufacturers known for their bioceramic productions Country USA France Germany France France Japan Switzerland England Japan Sweden USA Switzerland Primary Materials ZrO 2 Al2O3 Al2O3 ZrO 2 ZrO 2 Al2O3 ZrO 2 ZrO 2 ZrO 2 Al2O3 Al2O3 ZrO 2 Secondary Materials Al2O3 ZrO 2 ZrO 2 Al2O3 ZrO 2 Al2O3 Procera Transcend 2000 Trade Names Al2O3 (ZrO2)

Manufacturer Astroment Ceraver Cerasiv Desmarquest HiTech Kyocera Metoxit Morgan Matroc NGK Biocare Unitek Maillefer

Biolox (Proyzr) Bioceram

5.5 APPLICATIONS 5.5.1 Orthopaedic applications

The dominating application of alumina and zirconia is as hip balls as well as cups of total femoral prosthesis. The neckless hip balls are the most popular design. In 1981, Oonishi et al (8) reported on the use of an alumina ceramic total knee prosthesis. High alumina ceramic middle ear implants (Frialit) are used clinically in Europe since 1979 (21). An opthalmological implant device consisting of a combination of a single crystal alumina optional cylinder and a polycrystalline alumina holding ring was introduced clinically in 1977 (22). Kawahara (12) has reported extensively on single crystal alumina bone screws.
5.5.2 Dental applications

Alumina and zirconia ceramics have been utilized for root analogue, endosteal screws, blades and pin-type dental implants. The root and blade form dental implants used during the 1970s tended to fracture after a few years in function (41,42) (Brose et al, 1987, Driskell, 1987). Although initial testing of these polycrystalline alumina materials showed adequate mechanical strength, the long-term clinical results demonstrated functional limitations related to material properties and implant design. However, single crystalline alumina showed mechanical strength superior to that of polycrystalline alumina. It allows a much higher load. One-stage dental implants of single crystalline alumina are used clinically with a high success rate. McKinnery (43) had also reported on single crystal alumina blade

and screw dental implants. Dental implants of zirconia have not been widely used clinically although zirconia has a similar mechanical strength and a much higher fracture toughness in addition to lower cost of production compared to single crystalline alumina. The term dental implant is used only for materials in contact with bone and soft tissue (14). Alumina and zirconia are also used in other dental applications, alumina ceramic crowns, Procera(23), zirconia dental post, (10) and recently a dental inlay of zirconia was introduced (11). Orthodontic brackets made of oxide ceramics were also produced, tested and used clinically. Unfortunately, tooth surface damage was observed when the brackets were taken away (15). Modification of the debonding technique is under developing.

5.6 MANUFACTURERS AND THEIR IMPLANT PRODUCTS Clarke and Willmann (13) make a comprehensive summary about the bioceramic manufacturers (Table 5.6). Some dental companies are included.

5.7 PROBLEMS AND FUTURE PROSPECTS Hip balls of polycrystalline alumina have a minimum size limitation to ca. 28 mm due to strength limitations. A reduced ball size might have two positive effects on the applications: reduced wear and better suitability (smaller) for Asian patients. Although single crystalline alumina might overcome the strength limitation, the cost of manufacturing is unreasonably high and in addition, some processing problems remain. Zirconia, on the other hand, has a high strength and high fracture toughness, but it suffers from potential biodegradation. Therefore, the future research and development will focus on the understanding of degradation mechanisms of zirconia in the body and the improvement of stability of this material. Of course, combinations, such as alumina/zirconia composite and even non-oxide ceramic, such as nitrides and carbides, ought also to be investigated.

REFERENCES
1. Hulbert, S.F., Bokros, J.C., Hench, L.L., Wilson, J. and Heimke, G. In Ceramics in Clinical Applications, ed. by Vincenzini, P. Elsevier, Amsterdam, 1987, pp. 3-27. 2. Rock, M. German Patent 583 589, 1933. 3. Smith, L. Arch. Surg. 1963; 87: 653-661. 4. Sandhaus, S. British Patent 1083769, 1967.

5. Boutin, P. Presse Med. 1971; 79: 639. 6. Mittelmeier, H. Z. Orthop. Ihre Grenzgeb 1974; 112: 27. 7. Shikita, T. Paper presented at the XIV World Congress of SICOT, Kyoto, Japan, October 15-20, 1978. 8. Oonishi, H., Okabe, N., Hamaguchi, T. and Nabeshima, T. Orthopaedic Ceramic Implants 1, 1981; 11-18. 9. Lord, G. et al Paper presented at the Harrington Arthritis Research Centre Symposium, November 18-21, 1990. 10. Akagawa, Y. et al J. Prosthet. Dent. 1993; 69: 599-604. 11. Meyenberg, K.H., Luthy, H. and Scharer, P. /. Esthet Dent., 1995; 7(2): 73-80. 12. Johansson, B. Tandldkartidningen 1996; 14746-749. 13. Clarke, LC. and Willmann, G. In Bone implant Interface ed. H.V. Cameron, Hugh U , Mosby, 1994, pp. 222. 14. Kawahara, H. In Encyclopedic handbook of biomaterials and bio engineering ed. by Wise, Donald L. et al. Marcel Dekker, Inc., New York, 1995, pp. 1469-1524. 15. Sinha, P.K., Rohrer, M.D., Nanda, R.S. and Brickman, CD. American J. Orthodont & Dentofacial Orthop, 1995; 108: 455-63. 16. Christel, P. S. In Concise Encyclopedia of Medical & Dental Materials, ed. by Williams, D.F., Pergamon Press, Oxford, 1990, pp. 375-379. 17. Keith, O., Kusy, R.P. and Whitley, J.Q. American J. Orthodont. & Dentofacial Orthop., 1994; 106(6): 605-614. 18. Kawahara, H. Orthopaedic Ceramic Implants 1, 1981; 1-10. 19. Fartash, B. Single Crystal Sapphire Dental Implants: Experimental and Clinical Studies. PhD thesis, Karolinska Institute, Sweden, 1996. 20. Hammer, N.B., Topazian, R.G., McKinney, P.V. and Hulbert, S.F. /. Dent. Res. 1973; 52: 356-361. 21. Jabnke, K. Biomaterials in Otology, Martinus Nijhoff, The Hague, 1984: 205-209. 22. Polack, F.M. and Heimke, G. Ophthalmology, 1980; 87(7): 693-698. 23. Andersson, M. and Oden, A. Acta Odont. Scand., 1993; 51: 59-64. 24. Kittipibul, P. and Godfrey, K. American J. Orthodont & Dentofacial Orthopedics, 1995; 108(3): 308-315. 25. Heimke, G. In Metal and Ceramic Biomaterials VoI I Structure, ed. by Ducheyne, P. and Hastings, G.W. CRC Press Inc., Boca Raton, Florida, 1984, pp. 41-42. 26. Miyayama, M. et al. In Ceramics and Glass, Engineered Materials Handbook Volume 4, ASM International, 1991, pp. 748-757. 27. Griss, P. In Functional Behavior of Orthopaedic Biomaterials II, Ch 2, 1984. 28. Jager M. and Plitz, W. Triobology of aluminium ceramics, Symposium of Biomaterials, pp. 114-122, 1981. 29. Willert, H.G. et al. In Implant Retrieval: Material and Biological Analysis, ed. by Weinstein, A., Gibbons, D., Brown, S. and Ruff, W. 1981. 30. Fritsch, E.W. and Gleitz, M. CHn. Orthop. & Related Res., 1996; 328: 129-136. 31. Garvie, R.C., Hannink, R.H. and Pascoe, R.T. Nature, 1975; 258: 703. 32. Saikka, V.O. Acta Orthop. Scand., 1995; 66(6): 501-506. 33. Kumar, P. et al. J. Biomed. Mater. Res., 1991; 25: 813-828. 34. Derbyshire, B. et al. Medical Eng. & Phys., 1994; 16(39): 229-36.

35. Shimizu, K. et al. J. Biomed. Mater. Res., 1993; 27: 729-734. 36. Cales, B., Stefani, Y. and Lilley, E. /. Biomed. Mater. Res., 1994; 28: 619-624. 37. Hummer, CD., Rothman, R.H. and Hozack, WJ. /. Arthroplasty, 1995; 10(6): 848-850. 38. Ichikawa, Y. et al. J. Prosthet. Dent. 1992; 68: 322-6. 39. Takamura, K. et al J. Biomed. Mater. Res., 1994; 28: 583-589. 40. Steflik, D., McKinney Jr R.V. and Koth, D. In Bioceramics: Materials characteristics versus in vivo behavior, ed. by Ducheyne, P. and Lemons, J.E. Ann. N.Y. Acad. ScL 523, pp. 4-18. 41. Brose, M. et al. J. Dent. Res., 1987; 66: 113. 42. Driskel, T.D. /. Calif. Dent. Assoc, 1987; 16-25. 43. Mckinney, R.V. and Koth, D.L. /. Prosthet. Dent., 1982: 47: 69-84. 44. Park, J.B. and Lakes, R.S. Biomaterials: an Introduction, 2nd edition, Plenum Press, New York, 1992. 45. Bajpai, P.K. and Billotte, W.G. In The Biomedical Engineering Handbook, ed. by Bronzino, J.D. CRC Press, 1995, pp. 552-580.

Properties of bioactive glasses and glass-ceramics

L.L. Hench and T. Kokubo

Definition of bioactivity: A bioactive material is one that elicits a specific biological response at the interface of the material which results in the formation of a bond between the tissues and the material. A common characteristic of bioactive glasses, bioactive glass-ceramics, and bioactive ceramics is that their surface develops a biologically active hydroxy carbonate apatite (HCA) layer which bonds with collagen fibrils. The HCA phase that forms on bioactive implants is equivalent chemically and structurally to the mineral phase of bone. It is that equivalence which is responsible for interfacial bonding1"3. 6.1 BIOACTIVE BONDING Bioactive materials develop an adherent interface with tissues that resist substantial mechanical forces. In many cases the interfacial strength of adhesion is equivalent to or greater than the cohesive strength of bone. The interfacial strength of a bioactive implant bonded to bone is 15-40 times greater than the interfacial adherence of non-bioactive materials (such as Al2O3) (Table 6.1 and Figure 6.1), tested in the same animal model (rabbit tibia) (Figure 6.2)4.

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Pull-off Test Model

Cerabone Bioglass Bioactive Implant (Failure in Bone) Bioactive Implant (Failure in Implant)

Alumina

Non-Bioactive Ii .(Failure at lnten

Time (Weeks) Figure 6.1 Comparison of interfacial bond strengths of bioactive implants with non-bonding implants (alumina) using 'pull off detaching test [4,5].

Figure 6.2 Schematic of 'pull off detaching test for determining bone-implant bonding (based upon T. Yamamuro, ref. 4).

Table 6.1 Failure Loads of Bioceramics by Detaching (Pull-Off) Test Materials Dense sintered alumina1,2 Bioglass 45S5-type glass1,2 Ceravital KGS-type glass-ceramic3 Cerabone A-W glass-ceramic1,2 Dense sintered hydroxyapatite1,2 Dense sintered (3-3CaO P2O54 Natural polycrystalline calcite5 Failure Load (kg) 8 Weeks 24 Weeks Location of Fracture

0.13 0.02 Interface 2.75 1.80 within material 3.52 1.48 4.35 1.45 within material 7.44 1.91 8.19 3.6 within bone 6.28 1.58 7.77 1.91 within material 7.58 1.97 not specified 4.11 0.98 within material

1. T. Nakamura, T. Yamamuro, S. Higashi, T. Kokubo and S. Ito (1985) A New GlassCeramic for Bone Replacement: Evaluation of its Bonding to Bone Tissue, /. Biomed. Maters Res. 19, 685-698. 2. T. Nakamura, T. Yamamuro, S. Higashi, Y. Kakutani, T. Kitsugi, T. Kokubo and S. Ito, 1985, A New Bioactive Glass-Ceramic for Artificial Bone, in Treatise on Biomedical Materials, 1, T. Yamamuro, ed., Research Center for Medical Polymers and Biomaterials at Kyoto University, Kyoto, Japan, pp. 109-17. 3. S. Kotani, T. Yamamuro, T. Nakamura, T. Kisugi, Y. Fujmita, K. Kawanabe, T. Kokubo and C. Ohtsuki (1990) The Bone-Bonding Behavior of Two Glass-Ceramics (KGS and A-W GC), in Bioceramics, Vol. 2, G. Heimke, ed., German Ceramic Society, Cologne, pp. 105-112. 4. S. Kotani, Y. Fujita, T. Kitsugi, T. Nakamura, T. Yamamuro, C Ohtsuki and T. Kokubo (1991) Bone Bonding Mechanisms of p-tricalcium Phosphate, /. Biomed. Maters. Res. 25, 1303-15. 5. Y. Fujita, T. Yamamuro, T. Nakamura, S. Kotani, C Ohtsuki and T. Kokubo (1991) The Bonding Behavior of Calcite to Bone, /. Biomed. Maters. Res. 25, 1991-2003. 6. T. Yamamuro (1993) A/W Glass-Ceramic: Clinical Applications, in Introduction to Bioceramics, eds L.L. Hench and J. Wilson, World Scientific Publishing Co., London, 1993, pp. 89-104.

6.2 BIOACTIVE COMPOSITIONS Bioactive materials are composed of very specific compositional ranges of Na2O, CaO, P2O5 and SiO2 due to the importance of these compounds in the in vivo formation of hydroxy carbonate apatite (HCA) bone mineral (Table 6.2) [1,2]. All compositions either form a HCA layer on their surface or partially dissolve (resorb) as HCA crystals are formed during the mineralization of osteoid. The rate of formation of HCA and bone depends upon the composition of the material (Figure 6.3) with bioactive glasses and glass-ceramics containing < 52% SiO2 being the most rapid. The time difference in time dependence of interfacial bond strength (Figure 6.1) is due to the different rates of growth of the interfacial HCA layer. The bioactivity index of a materials (IB) is defined as: IB = 100/ta5bb IB is obtained from Figure 6.3, and is proportional to the reciprocal of the time required for one half (0.5) of the interface to be bonded to bone. IB values are shown in Table 6.2 for the various bioactive implants.

INTERFACIAL BONE TISSUE (%)

BIOINERT

IMPLANTATION (days)
Figure 6.3 Time dependence of interfacial bone formation for various types of bioceramic implants.

The compositional dependence of bonding of bone to various bioactive glasses is illustrated in Figure 6.4 for the Na2O-CaO-SiO2 system, with a constant 6 weight percent P2O5 and in Figure 6.5 for the CaO-P2O5-SiO2 system. Figure 6.4 also shows iso IB values for the Na2O-CaO-P2O5-SiO2 system. When IB = O there is no interfacial bond with bone; i.e., the material develops a non-adherent fibrous capsule and is nearly bioinert. 6.3 PHYSICAL PROPERTIES Table 6.2 summarizes the physical properties of the bioactive glasses, glassceramics, and ceramics in clinical use, with references. The bioactive glasses are single phase amorphous materials which have high IB values (rapidly form a bone bond) but have low mechanical strength and toughness. These materials should be used in particulate form (as powders), as coatings, or in low load bearing applications, as listed in Table 6.3. Bioactive glass-ceramics are multi-phase materials with a fine, homogeneous grain size and good mechanical strength and toughness5 and intermediate IB values. They can be used in moderate load bearing

Table 6.2 Composition and Mechanical Properties of Bioactive Ceramics Used Clinically
Sintered7'8'9 hydroxypatite Sintered10'11 Ca10(PO J6(OH)2 $-3CaO P2O5 > 99.2% > 99.7%

Composition

Bioglass1 45S5

S53P42

Glass-ceramic3 Glass-ceramic4 Cerabone A-W Ceravital

Glass-ceramic5 Ilmaplant Ll

Glass-ceramic6 Bioverit

Na2O K2O MgO CaO Al2O3 SiO2 P2O5 CaF2 B2O3 Phase

24.5 wt% 0 0 24.5 0 45.0 6.0 0 0 Glass

22.6 wt% 5-10 wt% 0.5-3.0 2.5-5.0 30-35 21.8 0 40-50 53.9 10-50 1.7 Glass Apatite Glass

0 wt% 0 4.6 44.7 0 34.0 16.2 0.5

4.6 wt% 0.2 2.8 31.9 0 44.3 11.2 5.0

3-8 wt% 3-8 wt% 2-21 10-34 8-15 19-54 2-10 F 3-23 Apatite Whitlockite (Ca10(PO4)6 0-3CaO (OH)2) P2O5)

Density (g/cm3) Hardness (Vickers) (HV) Compressive strength (MPa) Bending strength (MPa) Young modulus (GPa)

2.6572 458 9.4 500 42(Tensile) 35 100-150

Apatite Apatite Apatite (Ca10(PO4)6 (O5F2)) P-Wollastonite e Phlogopite P-Wollastonit ((Na K)Mg (CaO SiO2) 1 3 (AlSiO10)F2;) Glass Glass Glass 2.8 3.07 500 680 1080 215 118 160 500 100-160 70-88

3.16 600 500-1000 115-200 80-110

3.07 460-687 140-154 33-90

Table 6.2

Continued
Sintered7'8'9 hydroxypatite Ca10(POJ6(OH)2 > 99.2% Sintered10'11 $-3CaO P2O5 > 99.7%

Composition

Bioglass1 45S5

S53P42

Glass-ceramic3 Glass-ceramic4 Ceravital Cerabone A-W

Glass-ceramic5 Ilmaplant Ll

Glass-ceramic6 Bioverit

Fracture toughness, KIC(MPa m1/2) Slow crack growth, n Index of bioactivity 12.5

2.0 3.8 5.6 33 7.5 (est)

2.5

0.5-1.0

1.0 12-27 3.1

1. L.L. Hench and E.C. Ethridge, Biomaterials, An Interracial Approach, p. 137, Academic Press, New York, 1982. 2. 6.H. Andersson, K.H. Karlsson, K. Kangasniemi, and A. Yli-Urpo, Models for Physical Properties and Bioactivity of Phosphate Opal Glasses, Glastech. Ber., 61, 300-305 (1988). 3. H. Bromer, K. Deutscher, B. Blenke, E. Pfeil and V. Strunz, Properties of the Bioactive Implant Material Ceravital, in Science of Ceramics Vol. 9, 1977, pp. 219-223. 4. T. Kokubo, Mechanical Properties of a New Type of Glass-Ceramic for Prosthetic Applications, in Multiphase Biomedical Materials, T. Tsuruta and A. Nakajima, eds, VSP, Utrecht, Netherlands, 1989. 5. G. Berger, F. Sauer, G. Steinborn, F.G. Wishsmann, V. Thieme, St Kohler and H. Dressel, Clinical Application of Surface Reactive Apatite/Wollastonite Containing Glass-Ceramics, in Proceedings of XV International Congress on Glass, Vol. 3a, O.V. Mazurin, eds, Nauka, Leningrad, 1989, pp. 120-126. 6. W. Vogel and W. Holland, The Development of Bioglass Ceramics for Medical Applications, Angew Chem. Int. Ed. Engl. 26, 527-544 (1987). 7. M. Jarcho, CH. Bolen, M.B. Thomas, J. Bobick, J.F. Kay and R.H. Doremus, Hydroxyapatite Synthesis and Characterization in Dense Polycrystalline Form, /. Mater. ScL 11, 2027-2035 (1976). 8. M. Akao, H. Aoki, and K. Kato, Mechanical Properties of Sintered Hydroxyapatite for Prosthetic Applications, /. Mater. ScL 16, 809-812 (1981). 9. G. Dewith, H.J.A. Van Dijk, N. Hattu and K. Prijs, Preparation, Microstructure and Mechanical Properties of Dense Polyerystalline Hydroxyapatite, /. Mater. ScL 16, 1592-1598 (1981). 10. M. Jarcho, R.L. Salsbury, M.B. Thomas and R.H. Doremus, Synthesis and Fabrication of p-tricalcium Phosphate (Whitlockite) Ceramics for Potential Prosthetic Applications, /. Mater. ScL 14, 142-150 (1979). 11. M. Akao, M. Aoki, K. Kato and A. Sato, Dense Polycrystalline p-tricalcium Phosphate for Prosthetic Applications, /. Mater. ScL 17, 343-346 (1932). 12. L.L. Hench, Bioactive Ceramics, in Bioceramics: Materials Characteristics Versus In Vivo Behavior, P. Ducheyne, J.E. Lemons, eds, Annuals of the NY Academy of Sciences, u523, 1988, pp. 54-71

A-WGC (high P 2 O 5 )

Figure 6.4 The compositional dependence of bone bonding to bioactive glasses (region A) containing 6 weight % P2O5. Soft tissue bonding occurs for compositions with 1B values > 8 (see text). Region B: non-bioactive compositions. Glasses in Region C are resorbable. (Based upon chapters 1 and 3 in ref. 1.)

Apatite-formation No apatite-formation Dissolution

Glass-formation Glassformation

No glassformation

Figure 6.5 Compositional dependence of bioactivity for glasses in the CaO-P2O5-SiO2. (Based upon T. Kokubo, ref. 5.)

Table 6.3 Clinical Uses of Bioactive Glasses and Glass-Ceramics Material Form Application Endosseous alveolar ridge maintenance Middle ear prostheses Function 45S5 Bioglass Bulk Bulk Powder Space filling and tissue bonding Restore conductive hearing by replacing part of ossicular chain Restore bone lost by Repair of periodontal periodontal disease and defects prevent epithelial down growth Restore bone loss due to Fixation of revision loosening of hip arthroplasty prostheses Replace vertebrae removed Vertebral prostheses in tumor surgery Replace bone removed for Iliac crest prostheses autogenous graft Fixation of hip prosthese s Provide bioactive bonding of implant Repair damaged bone Orbital floor prostheses supporting eye Repair bone lost due to Cranial repair trauma

Powder Cerabone (AAV glassceramic) Bulk

Coating S53P4 Bulk Powder

INTERFACIALTHICKNESS Oim)
Material Initial Interface Bone

45S5 Bioalass
42S4.6 Bioalass

,Fluoride Bioalass^ Ceravital

Dense HA Dense AI 2 O 3 Fibrous Tissue

Porous HA

Figure 6.6 Thickness of interfacial bonding layers for various bioceramics.

applications as bulk materials (Table 6.3). Polycrystalline bioactive ceramics, such as synthetic hydroxyapatite (HA), have moderate strengths and relatively low IB values and should be used as particulate or in nonload bearing applications. Compositions with the highest IB values develop interfacial bonding layers (Figure 6.6) composed of both hydrated silica gel layers and Ca, P-rich layers. Compositions with low to moderate IB values form thinner bonding zones composed primarily of Ca-P-rich compounds. Non-bonding implants have a non adherent fibrous tissue layer at the implant interface. REFERENCES
1. Hench, L.L. and Wilson, J. (eds) (1993) Introduction to Bioceramics, World Scientific Publishers, London and Singapore, pp. 1-24. 2. Gross, U., Kinne, R., Schmitz, HJ. and Strunz, V. (1988) The response of bone to surface active glass/glass-ceramics. CRC Critical Reviews in Biocompatibility, 4, 2. 3. Yamamuro, T., Hench, L.L. and Wilson, J. (eds) (1990) Handbook of Bioactive Ceramics, VoI I: Bioactive Glasses and Glass-Ceramics, CRC Press, Boca Raton, FL. 4. Yamamuro, T. (1993) AAV glass-ceramic: clinical applications, in Introduction to Bioceramics (eds L.L. Hench and J. Wilson), World Scientific Publishers, London and Singapore, pp. 89-104. 5. Kokubo, T. (1993) AAV glass-ceramic: processing and properties, in Introduction to Bioceramics (eds L.L. Hench and J. Wilson), World Scientific Publishers, London and Singapore, pp. 75-88.

Wear
M. LaBerge

7.1 INTRODUCTION Biomaterials used in the fabrication of implants are subjected to wear. Wear of biomaterials and devices has been shown to be detrimental to their long term success resulting in implant retrieval and revision. One of the most dramatic impacts of the wear of biomaterials and its consequences is observed with artificial joints. As stated by Jacobs et al, (1994) wear has emerged as a central problem limiting the long-term longevity of total joint replacements. Ultra-high-molecular-weight polyethylene (UHMWPE) wear debris has been shown by many authors to trigger an osteolytic reaction which leads to implant loosening (Mittlmeier and Walter, 1987). Wear is a process resulting in the progressive loss of material involving many diverse mechanisms and phenomena which are often unpredictable (Table 7.1). The wear process of materials is predominantly governed by their mechanical and/or chemical behavior. More often than not, the wear processes listed in Table 7.1 do not act independently. However, even though several wear mechanisms are involved, it is often the case that one particular mechanism dominates (Dowson, 1981). Unfortunately surface wear of an implant results from its use, and therefore, cannot be avoided or eliminated. Because wear is a limiting factor in the successful outcome and lifetime of an implant, it is of the utmost importance to characterize the wear resistance of materials used in implant design, and the effect of the design on wear. The volume of material removed from surfaces in specific tribosystems as a result of wear processes has been described phenomenologically and estimated by different models (Table 7.2). Several experimental wear studies have been
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Table 7.1 Wear Mechanisms Wear Mechanisms Adhesive Wear Definition Characterized by the transfer of material from one surface to another surface during relative motion. This type of wear is a consequence of adhesive forces acting at the junction of surface asperities. The transferred fragments may either be permanently or only temporarily attached to the other surface. Adhesive wear has been denoted as being the most commonly detected mechanism of wear, unfortunately it is also the least preventable (Dowson, 1981). Abrasive Wear Results from a hard asperity damaging or ploughing the surface of a softer material. The presence of hard particles may be due to the original material properties of one of the surfaces or loose debris particles which have become entrapped between the two sliding surfaces and/or embedded into one of the surfaces expediting abrasive wear. Generally, the resistance to abrasion can be related to the hardness of the material, however, this relationship is not directly proportional (Suh, 1986). Delamination Wear Involves material removal subsequently to plastic deformation, crack nucleation, and propagation in the subsurface (Jahanmir and Suh, 1977; Suh, 1986) Fatigue Wear Associated with cyclic stress variations and therefore, the lifetime of the material is dependent on the number of cycles. Cyclic deformation of the contacting surfaces leads to the initiation and propagation of microcracks (Rowe, 1980). Subsurface crack initiation generally occurs in the region of maximum shear stress which will depend upon the geometry of the materials Fretting Wear Generated by a relative oscillatory tangential movement of small amplitudes (damage can be caused by movement with amplitudes as small as 0.125 |xm) which may occur between two surfaces in contact subjected to vibration (Waterhouse, 1992). Corrosive Wear Observed when the environment interacts chemically or electrochemically with one or both of the surfaces. Therefore, the wear rate is dependent on the environmental conditions affecting the chemical reactivity of the surfaces. This type of wear mechanism is important for biomaterials since they function in an extremely harsh environment, the human body (Black, 1988).

conducted to (1) predict the amount of material removed in specific conditions, (2) compare the effect of different fabrication and sterilization processes on materials, (3) produce wear debris to be used in biocompatibility studies, and (4) characterize the behavior of a new material destined for biomedical applications. Overall wear tests are primarily conducted to ascertain the basic mechanisms of wear for a particular

Table 7.2 Selected Wear Models Wear Process Adhesive Wear# (Archard, 1980) Model Archard Equation:
W V F K

Specifications Use hardness as the only material property, even though K depends on various properties of both materials Implies that wear rate is proportional to real contact area in plastic contacts and may not be applicable for cases involving elastic contacts

~ L H Wad = wear rate (worn volume per unit sliding distance) K = wear coefficient V = volume of wear L = sliding distance FN = normal load H = hardness of the softer material (Hornbogen, 1975) Hornbogen equation:

ad

Wad = wear rate KIC = fracture toughness P = yield strength N = work hardening factor E' = equivalent elastic modulus E' = 1/[(1 - V12VE1 + (1 - V22VE2]

Based on a comparison of the strain occurring during asperity interactions with the critical strain at which crack growth is initiated. If the applied strain is smaller than the critical strain, the wear rate is independent of toughness, and follows Archard's

Table 7.2 Continued Wear Process Abrasive Wear (Rabinowicz, 1965) Model Rabinowicz model: Specifications Assumes that asperities of the harder surface are conical

Wab = wear rate (worn volume per unit sliding distance) K = wear coefficient V = volume of wear L = sliding distance FN = normal load H = hardness of the softer material tan 0 = weighted average of the tan 9 values of all the individual cones 0 = average slope of the asperities (Zum Gahr, 1982) Zum Gahr model: f ab cos p sin 6 w _ p ab K1K2T0 [cos(9/2)]-5 cos(8 - p) N Wab = wear rate f ab = model factor (1 for microcutting) K1 = relaxation of normal and shear stress K2 = texture factor (1 for fee metals) tc = shear stress for dislocation movement p = friction angle at abrasive-material interface Considers the processes of microcutting, microploughing, and microcracking in the abrasive wear of ductile metals. This model includes the effects of work hardening ductility homogeneity of strain crystal anisotropy

Table 7.2

Continued Model Hailing model: Specifications Incorporates the concept of fatigue failure as well as simple plastic deformation failure.

Wear Process Fatigue Wear (Hailing, 1975)

Wfa = wear rate T| = line distribution of asperities 7 = constant defining particle size Q1 = strain to failure in one loading cycle H = hardness of the softer material K = wear coefficient Corrosive Wear (Quinn, 1980; Quinn et al., 1983) Quinn Model: _ dAc exp[-Q/(RcTc)] Explains wear in steel and assumes that surface asperity layers formed tribochemically are detached at a certain critical thickness

SeVvH

FN

Wcorr = wear rate p = density of material Ac = Arrhenius constant Q = activation energy Rc = gas constant Tc = contact temperature d = asperity contact diameter v = sliding velocity e = critical thickness of reaction layer # Note The wear factor (k) is a measure of the rate at which a given combination of materials wears in the environment of the test. K is widely used for comparative purposes. According to Dowson (1995), if the mean contact stresses are not too high the wear of polymer against a hard surface (metal or ceramic) is obtained with fair accuracy with the relationship V = kFL. K is directly influenced by the roughness average (Ra) of the metallic counterface for the contact UHMWPE-stainless steel in water under reciprocating pin-on-plate conditions given by the relationship k = 4.0 x 10"5 Ra 12(Dowson et al, 1985).

combination of materials, or the more restrictive yet equally elusive determination of the rate of wear to facilitate the estimation of their 'clinical' life. Experimental results are highly dependent on the geometry of the contact, the lubricant, the tribological conditions including velocity and load, and material properties (Suh, 1986). Therefore, experimental protocols aimed at investigating the wear properties of biomaterials should be designed to assess or predict their behavior in simulated clinical conditions (Dumbleton, 1981). 7.2 IN VITRO WEAR TESTING Although wear is a very complex process, apparatuses are available which allow for the accumulation of data resulting in an estimate of the wear resistance of a combination of materials or a device. Preliminary material studies will commonly be performed on laboratory wear benches while devices will be evaluated with simulators. Numerous in vitro and in vivo studies have been conducted to evaluate the wear properties of biomaterial tribosystems (Table 7.3). Over the years, different wear apparatuses (Table 7.4) and protocols have been used for this purpose. Only one standard procedure under the American Society for Testing and Materials (ASTM F-732-82, reapproved 1991) for Reciprocating Pin-on-Flat Evaluation of Friction and Wear Properties of Polymeric Materials for Use in Total Joint Prostheses) describes the testing protocol for characterizing the wear resistance of material combinations to be used in the design of implants. Several investigators have used modified or adapted versions of this standard to assess the wear resistance of bearing surfaces for orthopaedic applications (Streicher, 1991; Schmidt et ai, 1995; Jin et aL, 1993; Medley et al, 1995; Brown et aL, 1976; Rose and Radin, 1982; Fisher and Dowson, 1991, Agrawal et al, 1993). Other ASTM protocols pertinent to the evaluation of wear performance of engineering materials are listed in Table 7.5. Wear resistance is usually reported in terms of wear rate, either linear or volumetric, with different units such as volume lost per 106 cycles, mass loss per 106 cycles, or linear displacement per 106 cycles. A complete walking cycle is represented by two steps. One cycle on a reciprocating pin-on-flat system is obtained by two passes (return to starting point), while one cycle on a rotating pin-on-disc system corresponds to one revolution. It is assumed that a normal individual will make two million steps per year while an active subject may make more than 10 million steps (Dumbleton, 1981) at a maximum frequency of 1 Hz. Investigators have also reported wear rates as cubic millimeters (volume) per millimeter (sliding distance) (mm3/mm). The volume is calculated by measuring the mass loss and using the density of the polymer as a conversion factor. Tables 7.6 and 7.7 present a critical selection of

wear data available for biomaterial tribosystems useful to the orthopaedic design community. Both friction coefficient and wear rate are used as design parameters. Unless independently monitored, friction coefficients are usually acquired during wear tests. The static coefficient of friction is calculated using the force required to initiate motion. The kinetic coefficient of friction may vary during a test for a constant velocity and should be calculated from averaged force readings during the duration of the test. ASTM Standard G115-93 proposes a guide for Measuring and Reporting Friction Coefficients (ASTM, 1993) which is designed to assist investigators in the selection of an appropriate method for measuring the frictional properties of materials.

Table 7.3 Biomaterial Combinations Tribologically Characterized Material combinations Stainless steel UHMWPE Co-Cr-alloys UHMWPE Titanium alloys UHMWPE Alumina UHMWPE Zirconia UHMWPE CoCrMo CoCrMo CoCrMo Delrin CoCrMo Alumina Ti6A14V Alumina Alumina Alumina Polyurethane low modulus elastomers) Metal Dental resins Enamel Test apparatus Pin -on disc; joint simulator (McKellop et al, 1981; Dowson et al, 1988; Kumar et al, 1991) Pin-on-disc; joint simulator (McKellop et al, 1978; McKellop et al, 1981; Rose et al, 1984; Saikko, 1993) Pin-on-disc; joint simulator (Miller et al, 1974; McKellop et al, 1978; McKellop and Rostlund, 1990) Pin-on-disc; joint simulator (Semlitsch et al, 1977; McKellop et al, 1981; Saikko, 1993) Pin-on-disc; joint simulator (Saikko, 1993; Kumar et al, 1991) Pin-on-disc; joint simulator (Galante, 1973; Semlitsch et al, 1911 \ Streicher et al, 1990; Medley et al, 1995; Chan et al, 1996) Disc-on-flat (Clarke et al, 1982) Joint simulator (Saikko et al, 1993) Joint simulator (Saikko et al, 1993) Wear and friction benches; joint simulator (Galante et al, 1973; Boutin et al, 1972; Semlitsch et al, 1977) Reciprocating friction benches; joint simulator (Gladstone and Medley, 1990; Jin et al, 1993; Auger et al, 1993; Chow et al, 1994; Auger et al, 1995; Graham et al, 1995) Pin-on-flat (Suzuki et al, 1996)

Table 7.4 In vitro Measurement wear machines Wear Apparatus Type Pin-on-disc or pin-on-plate Comments Useful in studying basic wear mechanisms. Steady and well controlled operating conditions. Fails to replicate the reciprocating motion observed in joints Simulates the reciprocating motion observed in vivo and fatigue loading (loading and unloading). Improved understanding of the wear processes encountered in prostheses.

Reciprocating pin-on-plate Joint simulators (knee and hip simulators)

Table 7.5 In vitro Friction and Wear Measurement Standards* ASTM Standard Title B460 Test Method For Dynamic Coefficient Of Friction And Wear Of Sintered Metal Friction Materials Under Dry Conditions (vol. 2.05, p. 223-225, 1989) B461 Test Method For Frictional Characteristics Of Sintered Metal Friction Materials Run In Lubricants (vol. 2.05, 1989) C808 Guidelines For Reporting Friction And Wear Test Results Of Manufactured Carbon And Graphite Bearing And Seal Materials (vol. 15.01, p. 243-344, 1989) D1894 Test Method For Static And Kinetic Coefficients Of Friction Of Plastic Film And Sheeting (vol. 8.01, p. 439^44, 1995) D3028 Test Method For Kinetic Coefficient Of Friction Of Plastic Solids (vol. 8.02, p. 225-233, 1995) D3108 Test Method For Coefficient Of Friction, Yarn To Solid Material (vol. 7.01, p. 758-766, 1995) D3334 Method Of Testing Fabrics Woven From Polyolefin Monofilaments (vol. 7.01, p. 516-520, 1989) D3412 Test Method For Coefficient Of Friction, Yarn-To-Yarn. (vol. 7.02, p. 10-14, 1995) F732 Practice For Reciprocating Pin-On-Flat Evaluation Of Friction And Wear Properties Of Polymeric Materials For Use In Total Joint Prosthesis (vol. 13.01, p. 183-188, 1995) G40 Terminology Relating to Wear and Corrosion (vol. 3.02, p. 145-151, 1995) G77 Test Method for Ranking Resistance of Materials to Sliding Wear Using Block-on-Ring Wear Test (vol. 3.02, p. 302-315, 1995) G83 Test Method for Wear Testing with a Crossed-Cylinder Apparatus (vol. 3.02, p. 339-344, 1995) G99 Test Method for Wear Testing with a Pin-on-Disk Apparatus (vol. 3.02, p. 380-390, 1995) Gl 15 Standard Guide For Measuring And Reporting Friction Coefficients (vol. 13.01, p. 472-481, 1995)
* American Society for Testing and Materials, Annual Book of ASTM Standards, Philadelphia, PA.

Table 7.6 Friction coefficients of various implant materials from in vitro studies
Average (or range) friction coefficient 0.07-0.13

Material contact Stainless steel (316LVM) + UHMWPE

Testing apparatus Pin-on-disk

Tribological conditions Load = 3.45 M Pa Velocity = 50 x 106 mm/yr Lub#: serum Duration: 2 years test 28-32 0C

References McKellop et al (1978)

Stainless steel (316L) + UHMWPE Stainless steel (100CR6 German) + UHMWPE (ChiruleneGerman) Stainless steel + UHMWPE

Pin-on-disk 0.078

0.17 0.10 0.16 0.14

(a) (b) (c) (d)

Ball-on-disk vibrotribometer (Optimol SRV - German)

0.03-0.09

Reciprocating flat-on-flat

Stainless steel + UHMWPE (Charnley)

0.05

Dual hip simulator

Load = 3 MPa Velocity = 60 mm/s Lub: bovine serum, 40-50 ml O 24-26 0C 10 mm diameter ball Oscillation = 10 Hz; 1.65 mm amplitude Load = 50 and 300 N Lub: (a) none; (b) human synovial fluid; (c) yellow bone marrow; (d) red bone marrow 37 0C Load = 445N Velocity = 100 cycles/min Lub: bovine serum Duration: 3.7 x 106 cycles Velocity = 30 cycles/min Load = 250 kg Duration: 1000 h Lub: serum Room temperature

Kumar et al (1991)

Gavrjushenko (1993)

McKellop et al (1981)

Simon et al (1973)

Table 7.6

Continued Average (or range) friction coefficient 0.034

Material contact Stainless steel (Ortron 90) + UHMWPE (ASTM F 648) Stainless steel (316L) + UHMWPE Stainless steel (316L) + UHMWPE (ASTM F 648)

Testing apparatus Single channel hip joint simulator

Tribological conditions Range of motion = 30 Lub: Deionized water @ 37 0C Load = 1-4 kN Angular Velocity = 0.6-2.4 rad/s Range of motion = 30

References Saikko (1992)

0.040 Single channel hip joint simulator

Saikko (1992)

Lub: Deionized water @ 37 0C Load = 1-4 kN Angular velocity = 0.6-2.4 rad/s Conforming, flat-on-flat configuration Velocity = 100 cyc./min Pressure = 6.90 MPa Duration: 3.7 x 106 cycles Lub: bovine calf serum w/55 sodium azide Velocity = 25 m/min Pressure = 30N/cm2 Duration: 20 h Lub: none or distilled water Room temperature Load = 3.45 M Pa Velocity = 50 x 106 mm/yr Lub: serum Duration: 2 years test 28-32 0C McKellop (1981)

0.03-0.09

Twelve channel friction and wear machine FW-12

CoCrMo (Protasul-2) + UHMWPE

Dry 0.13 Lub: 0.21

Rolling-sliding apparatus

Semlitsch et al (1977)

Co-Cr + UHMWPE

0.05-0.11

Pin-on-disk

McKellop et al (1978)

Table 7.6

Continued Average (or range) friction coefficient 00.07-0.25

Material contact Co-Cr + UHMWPE Co-Cr-Mo (Vitallium) + UHMWPE

Testing apparatus Pin-on-flat

Tribological conditions Axial load = 223 N Duration 250 000 cycles Lub: bovine serum Contact pressure = 4.8 MPa Frequency = 1 Hz Sliding dist. = 50 mm Lub: distilled, deionized H2O 37.10C Maximum stress = 6 MPa Lub: 86% Glycerine Frequency = 1 Hz Duration: 500 000 cycles Sliding Dist. = 100 mm/cycle Range of motion = 20 Lub: Carboxymethyl Cellulose Dynamic load = 2000 N Frequency = 1 Hz Range of motion = 30 Load = 1-4 kN Angular velocity = 0.6-2.4 rad/s Lub: deionized water @ 37 0C Range of motion = 30 Load = 1.4 kN Angular velocity = 0.6-2.4 rad/s Lub: deionized water @ 37 0C

References Tateishi et al (1989)

0.08-0.15

Pin-on-flat

Saikko (1993)

Co-Cr-Mo (ASTM F799) + UHMWPE (GUR 415) Co-Cr-Mo (Muller) + UHMWPE Co-Cr-Mo (Vitallium) + UHMWPE (ASTM F 648) Co-Cr-Mo (Zimalloy) + UHMWPE (ASTM F 648)

0.060-0.093 Reciprocating motion friction bench (line/flat)

Ruger (1995)

0.018-0.045 Durham hip function simulator

Unsworth et al (1988)

0.057

Single channel hip joint simulator

Saikko (1992)

0.038-0.063 Single channel hip joint simulator

Saikko (1992)

Table 7.6

Continued Average (or range) friction coefficient 0.044

Material contact Co-Cr-Mo (ASTM F75) + UHMWPE Co-Cr-Mo (ASTM F 799) + UHMWPE (ASTM F 648)

Testing apparatus Hip simulator machine

Tribological conditions Lub: synovial fluid Peak load = 150 kg Range of motion = 30 Load = 1.4 kN Angular velocity = 0.6-2.4 rad/s Lub: deionized water @ 37 0C Velocity = 30 cycles/min Load = 250 kg Duration: 100 h Lub: serum Room temperature Conforming,flat-on-flatconfiguration Velocity = 100 cyc./min Pressure = 6.90 MPa Duration: 3.7 x 106 cycles Lub: bovine calf serum w/55 sodium azide Load 2.5 kN static load Lub: (a) serum, (b) serum albumin, (c) synovialfluid,(d) veronate buffer

References Walker et al (1973)

0.052-0.070 Single channel hip joint simulator

Saikko (1992)

CoCrMo 0.06 + UHMWPE (Charnley-Muller)

Dual hip simulator

Simon et al (1973)

Co-Cr-Mo + UHMWPE

0.05-01.1

Twelve channel friction and wear machine FW-12

McKellop (1981)

Co-Cr-Mo + UHMWPE

Co-Cr-Mo + UHMWPE

0.06-0.07 (a,c) 0.10-0.12 (b,d) 0.04-0.06

Hip joint simulator

Weightman et al. (1972)

Hip joint simulator

Load 2.5 kN static load Velocity: 30 cycles/min Duration: 1.8 million cycles Lub: serum

Weightman et al. (1973)

Table 7.6

Continued Average (or range) friction coefficient 0.03-0.05

Material contact Co-Cr-Mo + UHMWPE

Testing apparatus Pin-on-disk

Tribological conditions Load = 100 N Lub: Ringer's solution Velocity = 0.05 m/s Duration: 48 h

References Ungethum and Refior (1973)

Ti-6 Al-IV + UHMWPE Ti-6A1-4V + UHMWPE

0.04-0.26

Pin-on-flat

Axial load = 223 N Duration: 250 000 cycles Lub: bovine serum Load = 445 N Velocity = 100 cycles/min Lub: bovine serum Duration: 4.1 x 106 cycles Range of motion = 30 Lub: deionized water @ 37 0C Load = 1-4 kN Angular velocity = 0.6-2.4 rad/s Range of motion = 30 Lub: deionized water @ 37 0C Load = 1-4 kN Angular velocity = 0.6-2.4 rad/s

Tateishi et al (1989)

0.05-0.121

Reciprocating flat on-flat

McKellop et al (1981)

Ti-6A1-4V (Ion implanted) + UHMWPE (ASTM F 648) Ti-6A1-4V ELI (ASTM F 136) + UHMWPE (ASTM F 648) Alumina + UHMWPE Alumina + UHMWPE

0.058

Single channel hip joint simulator

Saikko (1992)

0.123-0.133 Single channel hip joint simulator

Saikko (1992)

0.06-0.10

Reciprocating flat-on-flat

Load = 223 N Velocity = 60 cycles/min Lub: bovine serum Load = 3 MPa Velocity = 60 mm/s Lub: bovine serum, 40-50 ml 24-26 0C

McKellop et al (1981)

0.056

Pin-on-disk

Kumar et al (1991)

Table 7.6

Continued Average (or range) friction coefficient 0.06-0.18

Material contact Alumina (Vitox) + UHMWPE

Testing apparatus Pin-on-flat

Tribological conditions Contact pressure = 4.8 MPa Frequency = 1 Hz Sliding dist. = 50 mm Lub: distilled, deionized H2O 37.1 0C

References Saikko (1993)

Alumina + UHMWPE Alumina + UHMWPE

0.06-0.25

Pin-on-flat

Axial load = 223 N Duration: 250 000 cycles Lub: bovine serum Velocity = 25 m/min Pressure = 30 N/cm2 Duration: 20 h Lub: none or distilled water Room temperature Range of motion = 30 Lub: deionized water @ 37 0C Load = \-A kN Angular velocity = 0.6-2.4 rad/s Range of motion = 30 Lub: deionized water @ 37 0C Load = 1-4 kN Angular velocity = 0.6-2.4 rad/s Load = 3 MPa Velocity = 60 mm/s Lub: bovine serum, 40-50 ml 24-26 0C

Tateishi et al (1989)

Dry: 0.16 Lub: 0.05

Rolling-sliding apparatus

Semlitsch et al (1977)

Alumina (BIOLOX) + UHMWPE (ASTM F 648) Alumina (ASTM F 603) + UHMWPE (ASTM F 648) Zirconia (Y-PSZ) + UHMWPE

0.022-0.062 Single channel hip joint simulator

Saikko (1992)

0.050

Single channel hip joint simulator

Saikko (1992)

0.049

Pin-on-disk

Kumar et al (1991)

Table 7.6

Continued Average (or range) friction coefficient 0.05-0.16

Material contact Zirconia (Zyranox) + UHMWPE

Testing apparatus Pin-on-flat

Tribological conditions Contact pressure = 4.8 MPa Frequency = 1 Hz Sliding dist. = 50 mm Lub: distilled, deionized H2O 37.1 0C Range of Motion = 30 Lub: deionized water @ 37 0C Load = 1-4 kN Angular velocity = 0.6-2.4 rad/s

References Saikko (1993)

Zirconia + UHMWPE (ASTM F 648) Stainless steel (100CR6German) + Stainless steel (100CR6 German) Co-Cr-Mo + Co-Cr-Mo

0.059

Single channel hip joint simulator

Saikko (1992)

0.6 (a) 0.26 (b) 0.106 (c) 0.1 (d)

Ball-on-disk vibrotribometer (Optimol SRV - German)

0.03-0.04

Pin-on-disk

CoCrMo (Protasul-2) + CoCrMo (Protasul-2)

Dry: 0.4 Lub: 0.35

Rolling-sliding apparatus Duration: 20 h

Gavrjushenko (1993) 10 mm diameter ball Oscillation = 10 Hz; 1.65 mm amplitude Load = 50 & 300 N Lub: (a) none; (b) human synovial fluid; (c) yellow bone marrow; (d) red bone marrow 37 0C Ungethum and Refior Load = 100 N (1974) Lub: Ringer's solution Velocity = 0.05 m/s Duration: 48 h Semlitsch et al (1977) Velocity = 25 m/min Pressure = 30 N/cm2 Lub: none or distilled water Room temperature

Table 7.6 Continued

Material contact Co-Cr-Mo + Co-Cr-Mo Co-Cr-Mo + Co-Cr-Mo Average (or range) friction coefficient 0.12-0.13 (a,b,c) 0.22 (d) 0.13-0.14

Testing apparatus Hip joint simulator

Tribological conditions Load 2.5 kN static load Lub: (a) serum, (b) serum albumin, (c) synovial fluid, (d) veronate buffer Load 2.5 kN static load Velocity: 30 cycles/min Duration: 1.8 million cycles Lub: serum Lub: synovial fluid Peak load = 150 kg Velocity = 30 cycles/min Load = 250 kg Duration: 1000 h Lub: serum & synovial fluid or saline Room temperature Velocity = 30 cycles/min Load = 250 kg Duration: 1000 h Lub: serum Room temperature Load = 100 N Lub: Ringer's solution Velocity = 0.05 m/s Duration: 48 h Velocity = 25 m/min Pressure = 30 N/cm2 Duration: 20 h Lub: none or distilled water Room temperature

References Weightman et al (1972) Weightman et al. (1973)

Hip joint simulator

Co-Cr-Mo (ASTM F75) CoCrMo + CoCrMo (McKee-Farrar)

0.16

Hip simulator machine

Walker et al (1973) Simon et al (1973)

Serum & Dual hip simulator synovial fluid: 0.12 Saline: 0.22 0.13 Dual hip simulator

CoCrMo + CoCrMo (McKee-Farrar)

Simon et al (1973)

Alumina + alumina

0.26-0.35

Pin-on-disk

Ungethum and Refior (1974)

Alumina + alumina

Dry: 0.71 Lub: 0.09

Rolling-sliding apparatus

Semlitsch et al. (1977)

Table 7.7 Wear Rates of Various Material Combination from in vitro Studies
Material Contact Stainless steel (316LVM) + UHMWPE Wear rate 0.4 mm/yr Wear Coefficient NA Tribological Conditions Pin-on-disk # Lub*: bovine serum Duration: 2 yrs test Load = 3.45 MPa # Velocity = 50 x 106 mm/yr 28-32 0C Wear Mechanisms Smooth polymer, metal scraches. References McKellop et al, (1978)

Stainless steel (316L) + UHMWPE

0.17-0.23 mm3/106

NA

Stainless steel (316L) + UHMWPE

NA

27.7 x 10"7 mm3/Nm

Stainless steel (316L) + Machined UHMWPE (HiFax 1900) Stainless steel + UHMWPE (Charnley)

Machined NA UHMWPE: 3.23 in/in x 109 Molded UHMWPE: 1.70 in/in x 109 NA Max. depth of wear: 0.15 mm

Reciprocating flat-on-flat Surface scratching. Load = 445 N Velocity = 100 cycles/min Lub: bovine serum Duration = 3.7 x 106 cycles Original machine marks Pin-on-disk gone, new wear marks. Lub: bovine serum, 40-50 ml # Load = 3 MPa # Velocity =60 mm/s 24-26 0C UHMWPE transfer film. Annular disk on flat pin Range of motion = 110 Sliding velocity = 43.3 in/min Stress = 500 psi Lub: Ringer's solution # Dual hip simulator Velocity = 30 cycles/min Load = 250 kg Duration: 1000 g Lub: serum Room temperature Evidence of brittle fracture.

McKellop et al (1981)

Kumar et al (1991)

Miller et al {191 A)

Simon et al (1973)

Table 7.7 Material Contact

Continued Wear rate UHMWPE: 0.20 mnrVlO6 cycles UHMWPE 0.65 |xm/year Wear Coefficient
NA

Tribological Conditions Twelve channel friction and wear machine FW-12 Conforming, flat-on-flat configuration Velocity = 100 cyc./min Pressure = 6.90 MPa Duration: 3.7 x 106 cycles Lub: bovine calf serum w/55 sodium azide Ten station hip simulator Range of motion = 46 Lub: Bovine blood serum @37C Load = Oscillating 0-2030 N Frequency = 1 Hz Duration: 1 x 106 cycles Ball and socket simulator Ra < 0.016 Sterilized with 2.5 Mrad g rad Lub: bovine serum with sodium azide Load = 2000 N Speed = 100 mm/sec Reciprocating pin-on-flat Sterilized with 2.5 Mrad Lub: deionized water 36 MPa Line contact stress Frequency = 2.1 Hz Stroke length = 15 mm Duration = 2 x 106 cycles Final friction = 0.079 0.001

Wear Mechanisms Quantification of wear separately from creep deformation. Adhesive/abrasive wear emphasizes over fatigue wear.

References McKellop (1981)

Stainless steel (316L)

Stainless steel + UHMWPE

UHMWPE: 40 mg/106 cycles

NA

Highly loaded region of UHMWPE smooth & shiny, peeling, pitting.

Eyerer et al (1987)

Stainless steel + UHMWPE

NA

1.62 x 107 mm3/Nm

Uniform superficial scratches, occasional deeper marks. Metal particles, acrylic cement particles.

McKellop & Rostliind (1990)

Cast Co-Cr-Mo pins (ASTM F-75) + UHMWPE (GUR 415 plate)

PE thickness change: 64 13 |xm

NA

Abrasive wear of PE. Transfer of PE on Co-Cr pins. Oxidative wear of Co-Cr pins.

Poggie et al (1992)

Table 7.7 Material Contact

Continued Wear rate Wear Coefficient NA Tribological Conditions Wear Mechanisms References Poggie et al (1992)

Wrought Co-Cr PE thickness pins change: (ASTM F-90) 71 25 |mm + UHMWPE GUR 415 plate

Co-Cr-Mo (Protasul-2) + UHMWPE

CoCrMo: 0.1 mg/20h UHMWPE: 1 mg/20h

NA

Reciprocating pin-on-flat Abrasive wear of PE. Sterilized with 2.5 Mrad Trnasfer of PE on Co-Cr Lub: deionized water pins. Oxidative wear of 36 MPa Line contact stress Co-Cr pins. Frequency = 2.1 Hz Stroke length = 15 mm Duration = 2 x 106 cycles Final friction = 0.101 0.019 Rolling-sliding wear and NA friction apparatus Velocity 25 m/min Pressure = 30 N/cm2 Duration: 20 h Dry condition Room temperature Pin-on-disk Lub: bovine serum Duration: 2 yrs test Load = 3.45 M Pa Velocity = 50 x 106 mm/yr 28-32 C Smooth polymer, metal - scratches.

McKellop et al (1978)

Co-Cr-Mo (hot pressed) + UHMWPE

0.5 mm/yr

NA

Tateishi et al, (1989)

Co-Cr + UHMWPE

1.05 mg/106 cycles

NA

Pin-on-flat Transfer of PE to Co-Cr Lub: distilled, deionized water Surface. Contact pressure: 4.8 MPa Adhesive wear. Frequency = 1 Hz Sliding dist. = 50 mm 37.1 C

Saikko (1993)

Table 7.7 Material Contact

Continued Wear rate Machined UHMWPE: 3.23 in/in x 109 Molded UHMWPE: 1.50 in/in x 109 UHMWPE: 0.17 mm3/106 cycles 0.55 |jim/year Wear Coefficient NA Tribological Conditions Annular disk on flat pin Range of motion = 110 Sliding velocity = 43.3 in/min Stress = 500 psi Lub: Ringer's solution Twelve channel friction and Wear Mechanisms UHMWPE transfer film. References Miller et al (1974)

Co-Cr-Mo (passivated) + UHMWPE (HiFax 1900)

Quantification of wear separately from creep deformation. Adhesive/abrasive wear emphasizes over fatigue wear. McKellop (1981)

Co-Cr-Mo + UHMWPE

NA

wear machine FW-12 Conforming, flat-on-flat configuration Velocity = 100 cyc./min Pressure = 6.90 MPa Duration: 3.7 x 106 cycles Lub: bovine calf serum w/55 sodium azide Ten station hip simulator Range of motion = 46 Lub: bovine blood serum @37C Load = Oscillating 0-2030 N Frequency = 1 Hz Duration: 1 x 106 cycles Dual hip simulator Velocity = 30 cycles/min Load = 250 kg Duration: 1000 hours Lub: serum Room temperature

Co-Cr-Mo + UHMWPE

UHMWPE: 68 mg/106 cycles

NA

Highly loaded region of Eyerer et al (1987) UHMWPE smooth & shiny Peeling. Pitting.

Co-Cr-Mo + UHMWPE (CharnleyMuller)

Max. depth of wear: 0.08 mm

NA

Evidence of brittle fracture.

Simon et al (1973)

Table 7.7 Material Contact

Continued Wear rate 0.15mm/1.8xl0 cycles

6

Wear Coefficient NA

Tribological Conditions Hip joint simulator 2.5 kN static load Lub: bovine serum Duration: 1.8 x 106 cycles Velocity = 30cycles/min Hip joint simulator 2.5 kN static load Lub: bovine serum Duration: 1.8xlO6 cycles Velocity = 30cycles/min

Wear Mechanisms Creep, abrasion, adhesion. Max cup wear depth.

References Weightman et al. (1972)

Co-Cr-Mo + UHMWPE (Charnley)

Co-Cr-Mo + UHMWPE (CharnleyMuller) Co-Cr-Mo + UHMWPE (Duo-Patella)

0.075 mm/ 1.8xlO6 cycles

NA

Creep, abrasion, adhesion. Max cup wear depth.

Weightman et al. (1972)

1.8mg/105 cycles

NA

Knee joint simulator 700 Ib peak load Velocity = 33 cycles/min Duration: 105 cycles Lub: double spun bovine serum Knee joint simulator 700 Ib peak load Velocity = 33 cycles/min Duration: 105 cycles Lub: double spun bovine serum Knee joint simulator 700 Ib peak load Velocity = 33 cycles/min Duration: 105 cycles Lub: double spun bovine serum

Creep and fatigue cracks evident.

Rose et al (1984)

Co-Cr-Mo + UHMWPE (Ewald)

1.1 mg/105 cycles

NA

Creep and fatigue cracks evident.

Rose et al (1984)

Co-Cr-Mo 0.3 mg/105 + UHMWPE (Spherocentric)

NA

Creep and fatigue cracks evident.

Rose et al (1984)

Table 7.7 Continued

Material Contact Co-Cr-Mo + UHMWPE (Geomedic) Wear rate 0.4 mg/105 cycles Wear Coefficient
NA

Tribological Conditions Knee joint simulator 700 Ib peak load Velocity = 33 cycles/min Duration: 105 cycles Lub: double spun bovine serum Knee joint simulator 700 Ib peak load Velocity = 33 cycles/min Duration = 105 cycles Lub: double spun bovine serum Pin-on-flat Axial load = 223 N Duration: 250 000 cycles Lub: bovine serum Pin-on-disk Lub: bovine serum Duration: 2 yrs test Load = 3.45 MPa Velocity = 5OxIO6 mm/yr 28-32 0C Reciprocating pin-on-flat Sterilized with 2.5 Mrad Lub: deionized water 36 MPa Line contact stress Frequency = 2.1 Hz Stroke length = 15 mm Duration = 2 x 106 cycles Final friction = 0.112 0.007

Wear Mechanisms Creep and fatigue cracks evident.

References Rose et al (1984)

Co-Cr-Mo + UHMWPE (Geometric)

0.3 mg/105 cycles

NA

Creep and fatigue cracks evident.

Rose et al (1984)

Ti-6A1-4V + UHMWPE

0.47 mg/106 cycles

NA

Surface scratching.

Tateishi et al (1989)

Ti-6A1-4V + UHMWPE

0.3 mm/yr

NA

Abrasion by cement particles.

McKellop et al (1978)

Ti-6A1-4V Pins + UHMWPE GUR 415 plate

PE thickness change: 59 12 |xm

NA

Adhesive transfer of PE on cylinders. Oxidative wear of Ti-6A1-4V. Abrasive wear of PE.

Poggie et al (1992)

Table 7.7 Material Contact

Continued Wear rate 0.9 mm/yr Wear Coefficient NA Tribological Conditions Pin-on-disk Lub: bovine serum Duration: 2 yrs test Load = 3.45 MPa Velocity = 5OxIO6 mm/yr 28-32 0C Annular disk on flat pin Range of motion = 110 Sliding velocity = 43.3 in/min Stress = 500 psi Lub: Ringer's solution Annular disk on flat pin Range of motion = 110 Sliding velocity = 43.3 in/min Stress = 500 psi Lub: Ringer's solution Wear Mechanisms No scratches present. References McKellop et al (1978)

Ti-6A1-4V (nitrided) + UHMWPE

Ti-6A1-4V (passivated) + UHMWPE (HiFax 1900) Ti-6A1-4V (nitrided) + UHMWPE (HiFax 1900)

Machined UHMWPE: 0.84-2.07 in/in x 109 Machined UHMWPE: 1.83 in/in x 109

NA

UHMWPE transfer film.

Miller et al (1974)

NA

UHMWPE transfer film.

Miller et al (1974)

Ti-6A1-4V Machined (not passivated) UHMWPE: + UHMWPE 1.55 in/in x 109 (HiFax 1900) Ti-6A1-4V + UHMWPE 0.04-0.11 mm3/106

NA

NA

UHMWPE transfer film. Annular disk on flat pin Range of motion = 110 Sliding velocity = 43.3 in/min Stress: 500 psi Lub: Ringer's solution Reciprocating flat-on-flat Surface scratching. Load = 445 N Velocity = lOOcycles/min Lub: bovine serum Duration: 4.1 x 106 cycles

Miller et al (1974)

McKellop et al (1981)

Table 7.7 Continued

Material Contact Wear rate Wear Coefficient 1.9 x 10"7 mm3/Nm Tribological Conditions Ball and socket simulator Ra < 0.016 Sterilized w/ 2.5Mrad g rad Lub: bovine serum w/ sodium azide Load = 2000 N Speed = 100 mm/sec Ball and socket simulator Ra < 0.016 Sterilized w/ 2.5Mrad g rad Lub: bovine serum w/ sodium azide Load = 2000 N Speed = 100 mm/sec Pin-on-disk Lub: bovine serum, 40-50 ml Load = 3 M Pa Velocity = 60 mm/s 24-26 0C Pin-on-flat Axial load = 223 N Duration: 250 000 cycles Lub: bovine serum Pin-on-flat Lub: distilled, deionized water Contact pressure: 4.8 MPa Frequency = 1 Hz Sliding dist. = 50 mm 37.1C Wear Mechanisms Uniform superficial scratches, occasional deeper marks. Metal particles, acrylic cement particles. References McKellop & Rostlund (1990)

Ti-6A1-4V NA (implanted with nitrogen) + UHMWPE

Ti-6A1-4V (conventional) + UHMWPE

NA

1.98XlO-7 mm3/Nm

Uniform superficial scratches, occasional deeper marks. Metal particles, acrylic cement particles.

McKellop & Rostlund (1990)

Alumina + UHMWPE

NA

18.2 x 10-7 mm3/Nm

Original machine marks worn, smoother.

Kumar et al (1991)

Alumina + UHMWPE

0.26 mg/106 cycles

NA

NA

McKellop et al (1981)

Alumina + UHMWPE

0.04 mg/106 cycles

NA

Minimal wear.

Saikko (1993)

Table 7.7 Material Contact

Continued Wear rate Alumina: 0.1 mg/20h UHMWPE: 0.1 mg/20h Wear Coefficient NA Tribological Conditions Rolling-sliding wear and friction apparatus Velocity = 25 m/min pressure = 30 N/cm2 Duration: 20 h Dry condition Room temperature Pin on flat Lub: distilled, deionized water Contact pressure: 4.8 MPa Frequency = 1 Hz Sliding dist. = 50 mm 37.1C Reciprocating pin-on-flat Sterilized with 2.5 Mrad Lub: deionized water 36 MPa Line contact stress Frequency = 2.1 Hz Stroke length = 15 mm Duration = 2 x 106 cycles Final friction = 0.033 0.005 Reciprocating pin-on-flat Sterilized with 2.5 Mrad Lub: deionized water 36 MPa Line contact stress Frequency = 2.1 Hz Stroke length = 15 mm Duration = 2 x 106 cycles Final friction = 0.040 0.008 NA Wear Mechanisms References Semlitsch et al (1977)

Alumina + UHMWPE

Zirconia + UHMWPE

0.03 mg/106 cycles

NA

Minimal wear.

Saikko (1993)

Solid ytrria PE thickness ZrO2 pins change: + UHMWPE 33 13 |xm GUR 415 plate

NA

Abrasive wear from the surface roughness characteristic and adhesive wear.

Poggie et al (1992)

ZrO2 surface Pe thickness on Zr-2.5Nb change: pins 25 20 |xm + UHMWPE GUR 415 plate

NA

Abrasive wear from the surface roughness characteristics and adhesive wear.

Poggie et al (1992)

Table 7.7 Material Contact

Continued Wear rate NA Wear Coefficient 10.7 x 10mm3/Nm

7

Tribological Conditions Pin-on-disk Lub: bovine serum, 40-50 ml Load = 3 M Pa Velocity = 60 mm/s 24-26 0C Disc on plate Lub: water 37 0C Rolling-sliding wear and friction apparatus Velocity = 25 m/min Pressure = 30N/cm2 Duration: 20 h Dry condition Room temperature Dual hip simulator Velocity = 30 cycles/min Load = 250 kg Duration: 1000 h Lub: serum Room temperature Stanmore Mk III hip simulator 37 mm diameter head Frequency = 1/2 Hz Load = 300-3500 N Duration: min. 2.5 x 106 movements/test Lub: Ringer's solution w/30% calf serum

Wear Mechanisms Original machine marks still visible.

References Kumar et al. (1991)

Zirconia (Y-PSZ) + UHMWPE

Co-Cr-Mo + Co-Cr-Mo Co-Cr-Mo (Protasul-2) + Co-Cr-Mo (Protasul-2)

2-10 x 10"9 mm/mm Roller: 23 mg/20 h Slider: 23 mg/20h

NA

NA

Galante (1973)

NA

NA

Semlitsch et al (1977)

Max. depth of Co-Cr-Mo + Co-Cr-Mo wear: 0.01 mm (McKee-Farrar)

NA

Adhesive and abrasive types of wear.

Simon et al. (1973)

Co-Cr-Mo (Protasul-2) + Co-Cr-Mo (Protasul-2)

initial wear: 10-20 mm linear wear: 2-4 mm/106 cycles

NA

Equal amount of wear on both compoents. Preferential wear direction, with pronounced grooving.

Streicher et al (1990)

Table 7.7
Material Contact

Continued
Wear rate Wear Coefficient NA Tribological Conditions Hip joint simulator 2.5 kN static load Lub: bovine serum Duration: 1.8xlO6 cycles Velocity = 30 cycles/min Wear Mechanisms Abrasion, scratching. Max cup wear depth. References Weightman et al (1972)

Co-Cr-Mo 0.013 mm/ + Co-Cr-Mo 1.8xlO6 cycles (McKee-Farrar)

initial wear: Co-Cr-Mo (Protasul-21WF) 10-20 mm linear wear: + Co-Cr-Mo (Protasul-21WF) 2-4 mm/106 cycles

NA

Stanmore Mk III hip simulator 28 & 32 mm heads Frequency = 1//2 Hz Load = 300-3500 N Duration: min. 2.5xlO6 movements/test Lub: Ringer's solution w/30% calf serum Disc on plate Lub: water 37 0C Pin-on-flat Lub: bovine serum Ra = 0.0 mm Load=40 n/pin Speed = 2 p rad/s Sliding dist. = 0.24 m/s Pin-on-flat Velocity = 100 mm/sec Load = 6.9 N/mm2 Lub: serum Room temperature 4.8 yrs effective use

Equal amount of wear on both components. Preferential wear direction, with pronounced grooving.

Boutin (1972)

Alumina + alumina Stainless steel (316 S16) + PTFE

1.2x107 mm/mm

NA

NA

Semlitsch et al (1977)

2.26 mm/yr

3.4xlO5 mm3/Nm

No creep. Particles present.

Dowson & Wallbridge (1985)

Stainless Steel + Delrin 500

31 mm/yr

NA

NA

Clarke (1982)

Table 7.7 Material Contact

Continued Wear rate 521 mm/yr Wear Coefficient

NA

Tribolo&cal Conditions Pin-on-flat Velocity = 100 mm/sec Load = 6.9 N/mm2 Lub: serum Room temperature 4.8 yrs effective use Five station hip simulator (Helsinski) 32 mm head Frequency = 1.08 sH3 Load = 35 kN Duration: 3xlO6 cycles Lub: distilled, deionized water 37 0C Five station hip simulator (Helsinski) Frequency = 1.08 sH3 Load = 35 kN Duration: 3xlO6 cycles Lub: distilled, deionized water 37 0C Five station hip simulator (Helsinski) 32 mm head Frequency = 1.08 sH3 Load = 35 kN Duration: 3xlO6 cycles Lub: distilled, deionized water 37 0C
NA

Wear Mechanisms

References Clarke (1982)

Stainless steel + Polyester

Stainless steel + Alumina (Protek)

(mg/cyc) SS: 176, 146, 212 Al2O3: 0.3, 2.1, 0.2

NA

Corrosion of stainless steel heads.

Saikko et al (1992)

Stainless steel + Alumina (Thackray)

(mg/cyc) SS: 50.9, 62.4, 46.0 Al2O3: 0.8, 1.0, 0.7

NA 22.2 mm head

Corrosion of stainless steel heads.

Saikko et al (1992)

Co-Cr-Mo + Alumina (Link)

(mg/cyc) CoCrMo: 39.7, 48.2. 94.0 Al2O3: 1.5, 0.5, 0.0

NA

NA

Saikko et al (1992)

Table 7.7 Material Contact

Continued Wear rate (mg/cyc) CoCrMo: 2.6, 4.7, 4.3 Al2O3: 0.1, 0.0, 0.0 Wear Coefficient NA Tribological Conditions Five station hip simulator (Helsinski) 32 mm head Frequency = 1.08 sH3 Load = 35 kN Duration: 3xlO6 cycles Lub: distilled, deionized water 37 0C Disk-on-flat Velocity = 106 mm/sec Load = 3.7 N/mm2 Lub: water Pin on flat Lub: distilled, deionized water Contact pressure: 4.8 MPa Frequency = 1 Hz Sliding dist. = 50 mm 37.1 0C Wear Mechanisms NA References Saikko et al (1992)

Co-Cr-Mo + Alumina (Howmedica)

Co-Cr-Mo + Delrin 550

37.5 mm/yr

NA

NA

Clarke (1982)

Si3N4 + UHMWPE

0.27 mg/106 cycles

NA

NA

Saikko (1993)

* Lub = lubricant.

7.3 CLINICAL WEAR Methods have been proposed by Griffith et al. (1978) and Deavane et al (1995) to radiographically measure linear wear in UHMWPE acetabular cups of total hip replacements. The overall penetration of a femoral head (Tables 7.8 and 7.9) into a UHMWPE acetabular cup is a consequence of both creep and wear, where creep is predominantly observed for the first million loading cycles (Dowson, 1995). Atkinson et al (1980) estimated that the total UHMWPE residual compression due to creep in total hip replacements after x can be estimated by:
Residual compression = 94 + 33 (x-1) |jim

This relationship has served as a guide to the significance of UHMWPE creep for total hip arthroplasty (Dowson, 1995). Another important issue in the tribological behavior of polymers used as bearing surfaces is their viscoelastic-plastic character. For example, due to this time dependent stress-strain response, the measured hardness varies continuously as a function of indentation time. Therefore, in certain conditions the wear behavior of these materials cannot accurately be characterized in terms of wear coefficient alone and is often defined in terms of wear factor and Pv limit. The wear factor is described as K' = V/PS = V/Pvt where V is the wear volume, v the sliding velocity, P the normal load, and t the sliding time. The Pv limit or factor (which is equal to load times velocity) defines the onset of failure of polymeric surfaces. Pv limits have to be specified in terms of a limiting load at a given sliding velocity or limiting velocity at a given load. These values will depend on the test conditions (Suh, 1986). 7.4 COMBINED WEAR AND FATIGUE Materials used in the design of medical devices are subjected to high stresses and high cycle loading. This very demanding loading condition results in failure of metals, ceramics, and polymers. The fatigue process depends on stress rather than load, therefore partly explaining the success of congruent total hip replacements and thick polymeric bearing components (7-10 mm thick) which allows for a larger contact area (Black, 1988). Fatigue cracking of polymers such as UHMWPE results in delamination wear following crack growth. In a corrosive environment like the human body, the fatigue wear process of metal surfaces will be coupled with corrosive wear since tensile stress increases chemical reactivity. Fretting wear caused by micromotion is commonly observed in implants. Modular implants used in orthopaedics are potentially degraded by fretting corrosion/wear which plays a deleterious role in the degradation process of

Table 7.8 Clinical Penetration into UHMWPE Cups for Metallic Femoral Heads Reference Griffith et al, 1978 UHMWPE penetration rate Clinical 491 acetabular cups 8.3 year 0.07 mm/year average (range 0.06 mm/year to follow-up (range 7 to 9 0.24 mm/year) years) Follow-up at least 9.5 years Livermore et al, 0.13 mm/yr average (range 0 to 0.39 mm/year) after implantation (227 of 1990 for 22 mm head size the 22 mm femoral head 0.08 mm/yr average size; 98 of the 28 mm size; (range 0 to 0.3 mm/year) and 60 of the 32 mm head for 28 mm head size size) 0.10 mm/yr average (range 0 to 0.32 mm/year) for 32 mm head size Isaac et al, 1992 0.21 mm/year (range 0.005 87 acetabular cups to 0.6 mm/year) 9 year service life (range <1 to 17.5 years) Four explained acetabular Wroblewski et al, 0.022 mm/year (range cups with no apparent 0.010 to 0.034 mm/year) 1992 deterioration of the finish of the femoral head 20 year mean service life (range 17 years to 23 years) Table 7.9 Clinical Penetration into UHMWPE Cups for Alumina Ceramic Heads Reference Oonshi et al, 1989 Femoral Head Alumina Average Penetration Rate 0.098 mm/year (6 year follow-up; 28-mm cups) Alumina 0.072 mm/year Oonshi et al, 1989 (g irradiated UHMWPE) (6 year follow-up; 28-mm cups) 0.084 mm/year Okumura et al, 1990 Alumina Alumina 0.080 mm/year EgIi et al, 1990 (38 acetabular cups over a period of 6.7 years) 0.100 mm/year Zichner and Willeit, Alumina 1992

articulating surfaces. Hoeppner and Chandrasekaran (1994) reviewed the fretting of orthopaedic implants and its implication in implant failure emphasizing the complexity of implant surface change in use.

7.5 SOLVING THE WEAR PROBLEM Historically, the evaluation of the tribological behavior of biomaterials has resulted in the development of new materials or the use of surface

treatments to improve their frictional and wear properties (Long and Rack, 1996). As such, the assessment of the poor tribological properties of Ti6A1-4V as compared to other metallic bearing alloys (e.g. Co-Cr alloys) articulating against UHMWPE has triggered the use of surface treatments to enhance the hardness and the wear resistance of the alloy. Among numerous processes including plasma vapor deposition (PVD) coating (TiN, TiC) and thermal treatments (nitriding, surface hardening), ion implantation (N+) has been the most widely accepted surface treatment. Table 7.10 reports friction and wear data obtained for treated Ti alloys. Another approach to improve the wear performance of total joint replacements is through lubrication optimization. In this respect, the use of elastomeric bearing surfaces (Table 7.3), also known as cushion bearings, has been proposed (Table 7.11). Despites providing an improved lubrication in simulated physiological conditions through elastohydrodynamic lubrication (Auger et al, 1993; Graham et al, 1995; Auger et aL, 1995), these materials have shown a poor fatigue behavior both in vivo and in vitro (LaBerge et aL, 1991; Chow et aL, 1994; Caravia et aL, 1993). However, only limited data on wear performance and wear mechanisms of cushion bearings are available (Table 7.11). 7.6 CONCLUSION The wear and frictional properties of materials are dependent on tribological conditions of the tribosystem. Their investigation involves many parameters such as wear rate, wear mechanisms, transition between initial and steady-state wear, and generation and geometry of wear debris. The physical and mechanical properties of the materials, the environmental and operating conditions, and the geometry of the wearing bodies are determining factors for these parameters. Another important tribological attribute that should be reported along with wear data is the coefficient of friction. The use of different lubricants combined with the operating conditions (load, velocity) will result in different coefficients of friction and consequently different lubrication mechanisms of the tribosystem. The wear mechanisms and wear data are partly governed by the lubrication of the tribosystem. By definition, a tribosystem is a dynamic system that can potentially change over time emphasizing the importance of wear monitoring during testing. It is of utmost importance to fully define and report the tribological conditions during testing. The confidence in the quality of the wear data is not only related to the tribological conditions, material properties, material combinations, and experimental method including device used for testing, but also to the number of tests conducted and number of specimens evaluated, level of statistical significance, and duration of

Table 7.10 Friction and Wear Data for Titanium Orthopaedic Alloys Titanium alloy Ti-6Al-7Nb Available Tribological Conditions Pin-on-disk Lub: 30% serum Abrasive PMMA pin 3.45 MPa/ 25 mm/sec pin-on-disk 0.9% NaCl UHMWPE disk 5ON B all-in-socket 0.9% NaCl UHMWPE socket 100-2500 N NaCl solution Pin-on-disk Deionized water Abrasive PMMA pin 100 g/ 74 mm/sec Pin-on-disk Deionized water UHMWPE pin 500 g/ 73 mm/sec Friction Data Friction coefficient 0.100 (N+) 0.078 (TiN) 0.051 (Oxygen Diffusion hardening (ODH))
NA

Wear Data k = 3.32 x 10 (N+) k = 2.11 x 107 (TiN) k = 1.35 x 107 (ODH) depth of wear track on disc 18-44 |xm (polished metal) 12-24 fxm (oxidized metal)
7

Reference Semlitsch et aL, 1992

Ti5Al-2.5Fe Ti-15Mo-5Zr-3Al Ti5Al-2.5Fe Ti-12Mo-6Zr-2Fe

Zwicker et aL, 1985

Friction moment 0.5-1.0 Nm (oxidized, induction hardened) Friction coefficient 0.82 (P alloy) Friction coefficient 0.30-0.44 3 times that of stainless steel 316L
NA

Zwicker et aL, 1985

Steinemann et aL, 1993 Wang et aL, 1993

Ti-12Mo-6Zr-2Fe

Friction coefficient 0.04

NA

Wang et aL, 1993

Table 7.10 Continued Titanium alloy Ti-6A1-4V (N+) Available Tribological Conditions Ball-in-socket (hip simulator) 32 mm metal ball; 7 irradiated UHMWPE cups Filtered calf serum 2000N; 1 Hz One million cycles Ball-in-socket (hip simulator) 32 mm metal ball; 7 irradiated UHMWPE cups Filtered calf serum 2000N; 1 Hz One million cycles
NA

Friction Data

Wear Data Wear rate of UHMWPE 39.5 0.6 mm3/106 cycles (N + Ti6A14V) (metallic wear reduced compared to conventional Ti6A14V)

Reference McKellop and Rostliind, 1990

Ti-6A1-4V

NA

Wear rate of UHMWPE 38.8 1.0 mm3/106 cycles (Conventional Ti6A14V)

McKellop and Rostlund, 1990

Table 7.11 Tribological Properties of Compliant Surface Materials In Joint Replacements Elastomer (pin) Polyurethane (Tecoflex EG93A) Tribological conditions 2.5 mm thick layer injection molded onto polysulfone (pin with a 30 degree cone angle) Stainless steel flat counterpart (RA=0.01-0.025 [Lm) Tri-pin-on-disk Load: 100 N Speed: 0.24 m/sec Stress: Approx. 5 MPa Lub: distilled water Coefficient of friction Start-up friction: 0.2 Steady-state friction: 0.003-0.008 Wear factor For Ra metal of 0.01: 9.2 x 10-9 mm3 Nm For Ra metal of 0.02: 8.1 x 10-8 mm3 Nm Reference Jin et al, 1993

the test. When these parameters are not reported, it is difficult to compare wear data obtained with different protocols. This often leads to an inconclusive analysis and disagreements. In this respect, the standardization of testing protocols for wear of biomaterials and devices as well as how they are reported can significantly improve the wear literature. This literature review clearly indicates that there is no convention for wear-testing systems as well as for reporting wear data. ACKNOWLEDGEMENTS The author thanks John Killar, Aude Leroy-Gallissot, Tara McGovern, Jonette M. Rogers, Tracy Tipton, and Jennifer Woodell for their assistance in preparing this chapter. ADDITIONAL READING 1. Clarke, LC. and McKellop, H.A. (1986) Wear Testing in Handbook of Biomaterials Evaluation (A.F. von Recum, Ed.) Macmillan Publishing Co., New York. pp. 114-130. A concise review of testing protocols used for wear testing of cardiovascular, orthopaedic, and dental implants. Introduces some of the technical parameters involved in the understanding and measurement of wear performance. 2. Dowson, D. (1995) A comparative study of the performance of metallic and ceramic femoral head components in total replacement hip joints. Wear, 190, 171-183. Historical review of tribological studies of metallic and ceramic bearing surfaces used for total hip arthroplasty (THA). Presents an objective assessment of wear mechanisms, wear measurement, laboratory studies, and clinical observations for THA. 3. Dumbleton, J.H. (1981) Tribology of natural and artificial joints. Elsevier, New York. An excellent critical review of testing parameters and conditions for wear and friction of orthopaedic materials. Includes an in-depth analysis of the polyethylene response to wear testing. 4. McKellop, H., Clarke, L, Markolf, K. and Amstutz, H. (1981) Friction and wear properties of polymer, metal, and ceramic prosthetic joint materials evaluated on a multichannel screening device. /. Biomed. Mat. Res., 15, 619-653. Compilation of laboratory tribological studies of currently used orthopaedic bearing materials. Presents a critical discussion of work by others and that of the authors. Data presented in this manuscript are commonly referred to by the orthopaedic tribology community. 5. Suh, N.P. (1986) Tribophysics., Prentice-Hall, Inc. Englewood Cliffs, NJ. Engineering analysis of friction and wear of materials. Gathers and presents an overview of the author's own work and others on basic engineering principles that should be included in tribological study design and analysis.

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16. Dowson, D.B. and Jobbins, B. (1988) Design and development of a Versatile hip joint simulator and a preliminary assessment of wear and creep in Charnley total replacement hip joints, Engineering in Medicine, 17, 111-117. 17. Dowson, D. and Wallbridge N.C. (1985) Laboratory wear tests and clinical observations of the penetration of femoral heads into acetabular cups in total replacement hip joints I: Charnley prosthesis with polytetrafluoroethylene acetabular cups. Wear, 104, 203-215. 18. Dowson, D. (1981) Basic Tribology in An Introduction to the Bio-mechanics of Joints and Joint Replacement. Mechanical Engineering Publications, Ltd, London, England, pp. 49-60. 19. Dowson, D. (1995) A comparative study of the performance of metallic and ceramic femoral head components in total replacement hip joints. Wear, 90, 171-183. 20. Dumbleton JH. (1981) Tribology of natural and artificial joints. Elsevier, NY; pp. 94-103, 110-148, 183-214. 21. EgIi, A., Weber, B.G., Sieber, H., Semlitsch, M. and Dorre, E. (1990) Experience with the pairing of polyethylene/ceramic materials in hip endoprostheses, Ultra-High Molecular Weight Polyethylene as Biomaterial in Orthopaedic Surgery. (H.-G. Willert, G.H. Bucchorn, and P. Eyerer (eds)), Hoffrefe and Huber, Gottingen, pp. 154-158. 22. Eyerer, P., Kurth, M., McKellop, H.A. and Mittlmeier, T. (1987) Characterization of UHMWPE Hip cups run on joint simulators, Journal of Biomedical Materials Research 21, 275-291. 23. Fisher, J and Dowson, D. (1991) Tribology of total artificial joints. Proc. Instn Mech. Engrs, 205, 73-79. 24. Galante, J. and Rostoker, W. (1973) Wear in total hip protheses, Acta Orthopaedica Scandinavica (Supplement), 145, 1-46. 25. Graham, R.M., Joseph, P.F., Dooley, R.L. and LaBerge, M. (1995) Effect of lubricant viscosity and bearing surface stiffness on the lubrication mechanism of a point contact as a total hip arthroplasty model. Transactions of the Society For Biomaterials, 23, 124. 26. Gavrjushenko, N.S. (1993) Recommendations with respect to the improvement of lubrication quality of synovial fluid in artificial joints. Proc. Instn. Mech. Engs 207, 111-114. 27. Griffith, MJ, Seidenstein MK, Williams, D. and Charnley, J. (1978) Socket wear in Charnley low friction arthroplasty of the hip. CHn. Orthop. ReI. Res. 137, 36-47. 28. Hailing, J.A. (1975) contribution to the theory of mechanical wear. Wear, 34, 239-249. 29. Hoeppner, D.W. and Chandrasekaran, V. (1994) Fretting in orthopaedic implants: a review. Wear, 173, 189-197. 30. Hornbogen, E. (1975) The role of fracture toughness in the wear of metals. Wear, 33, 251-259. 31. Isaac, G.I., Wroblewski, P.J., Atkinson, J. R. and Dowson, D. (1992) Tribological study of retrieved hip prostheses. CUn. Orthop. ReI. Res. 276, 115-125. 32. Jacobs J.J., Shanbhag A., Giant T.T., Black J. and Galante J.O. (1994) Wear debris in total joint replacements. / Am. Acad. Orthop. Surg., 2, 212-220.

33. Jahanmir, S and Suh, N.P. (1977) Mechanics of subsurface void nucleation in delamination wear. Wear, 44, 17-38. 34. Jin, Z.M., Dowson, D. and Fisher, J. (1993) Wear and friction of medical grade polyurethane sliding on smooth metal counterfaces. Wear, 162-164, 627-630. 35. Kumar P., Oka, M., Ikeuchi, K., Shimizu, K., Yamamuro, T., Okumura, H., Kotoura and Y. (1991) Low wear rate of UHMWPE against zirconia ceramic (Y-PSZ) in comparison to alumina ceramic and SUS 316L alloy. /. Biomed. Mater. Res., 25, 813-828, 1991. 36. LaBerge, M., Kirkley, S. Chow, A., Medley, J.B. and Brox, W.T. (1991) Biotribological Study of the Contact Elastomer-Cartilage. Proceedings of the Combined Meeting of Orthopaedic Research Societies (USA, Japan, Canada), Banff, Alberta, Canada, June, 1991. 37. Livermore, J., Ilstrup, D. and Morrey, B. (1990) Effect of femoral head size on wear of the polyethylene acetabular component. /. Bone Joint Surg., 72A, 518-528. 38. Long, M and Rack, HJ. Titanium alloys in total joint replacement - A review. Submitted to Biomaterials. March 1996. 39. McKellop, H. (1981) Wear of artificial joint materials II. Twelve-channel wearscreening device: correlation of experimental and clinical results. Engg in Med., 10(3), 123-136. 40. McKellop, H, Clarke, I, Markolf, K. and Amstutz, H. (1981) Friction and wear properties of polymer, metal, and ceramic prosthetic joint materials evaluated on a multichannel screening device. /. Biomed. Mat. Res., 15, 619-653. 41. McKellop, H.A., Clarke, LC, Markolf, K.L. and Amstutz, H.C. (1978) Wear characteristics of UHMW polyethylene: A method for accurately measuring extremely low wear rates, /. Biomed. Mater. Res., 12, 895-927. 42. McKellop, H.A., Clarke LC, Markolf K.L. and Amstutz H.C. (1981) Friction and wear properties of polymer, metal, and ceramic prosthetic joint materials evaluated on a multichannel screening device, /. Biomed. Mater. Res., 15, 619-653. 43. McKellop, H.A., Rostlund, T.V. (1990) The wear behavior of ion-implanted Ti6A1-4V against UHMW polyethylene, /. Biomed. Mater. Res., 24,1413-1425. 44. McKellop, H., Clarke, LC, Markolf, K.L., Amstutz, H.C. (1978) Wear characteristics of UHMW polyethylene. Method to accurately measuring extremely low wear rates. /. Biomed. Mater. Res. 12, 895-927. 45. Medley, J.B., Krygier, J.J., Bobyn, J.D., Chan, F.W., Tanzer, M. (1995) Metalmetal bearing surfaces in the hip: Invetigation of factors influencing wear. Trans. Orthop. Res. Soc; 20(2), 765. 46. Miller, D.A., Ainsworth, R.D., Dumbleton, J.H., Page, D., Miller, E.H. and Chi Shen (1974) A comparative evaluation of the wear of ultra-high-molecular weight polyethylene abraded by Ti-6A1-4V; Wear, 28, 207-216. 47. Mittlmeier, T. and Walter, A. (1987) The influence of prosthesis design on wear and loosening phenomena. CRC Critical Reviews in Biocompatibility. 3, 319-419. 48. O'Connor, D.O., Burke, D.W., Bragdon, CR., Ramamurti, B.S. and Harris, W.H. (1995) Dynamic frictional comparisons of different femoral head sizes and different lubricants. Trans 21st Annual Meeting of the Society For Biomaterials, San Francisco, CA, 28, 230.

49. Okumara, H., Yamamuro, P., Kumar, T., Nakamura, T. and Oka, M. (1989) Socket wear in total hip prosthesis with alumina ceramic head. Bioceramics, 1, 284-189. 50. Oonishi, H. and Takayama, Y. (1989) Comparisons of wear of UHMW polyethylene sliding against metl and alumina in total hip prostheses. Bioceramics, 1, 272-277. 51. Poggie, R.A., Wert, J.J., Mishra, A.K. and Davidson, J.A. (1992) Friction and wear characterization of UHMWPE in reciprocating sliding contact with Co-Cr, Ti-6A1-4V, and Zirconia implant bearing surfaces; in wear and friction of elastomers. ASTM STP 1145. R. Denton and M.K. Keshavan, Eds., American Society For Testing and Materials, Philadelphia, pp. 65-81. 52. Quinn, T.F.J. (1983) A review of oxidational wear. Parts I and II. Tribology International 16: 257-271, 305-315. 53. Quinn, T.F.J., Rowson, D. and Sullivan J.L. (1980) Application of the oxidational theory of mild wear to the sliding wear of low-alloy steel. Wear, 65, 1-20. 54. Rabinowicz, E. (1965) Friction and Wear of Materials. John Wiley and Sons, New York. pp. 53-58. 55. Rose, R.M. and Radin, E.L. (1982) Wear of polyethylene in total hip prostheses. CHn. Orthop. ReI. Res., 170, 107-115. 56. Rose, R.M., Ries, M.D., Paul, I.L., Crugnola, A.M. and Ellis, E. (1984) On the true wear rate of ultrahigh molecular weight polyethylene in the total knee prosthesis, /. Biomed. Mater. Res., 18, 207-224. 57. Rowe, CN. (1980) Lubricated wear, in CRC Handbook of Lubrication. Boca Raton, FL:CRC Press; pp. 209-225. 58. Ruger, L.M., Love, BJ., Drews, M.J., Hutton, W.C. and LaBerge, M. (1996) Effect of antioxidant on the tribological properties of gamma sterilized ultra high molecular weight polyethylene. Proc. Fifth World Biomaterials Congress. Toronto, Canada. May 29-June 2. 59. Saikko, V., Paavolainen, P., Kleimola, M. and Slatis, P. (1992) A five-station hip joint simulator for wear rate studies, Proc. Instn Mech. Engrs, Part H, 206, 195-200. 60. Saikko, V. (1992) Simulator study of friction in total replacement hip joints, Proceedings of the Institution of Mechanical Engineers Part H: Journal of Engineering in Medicine, 206, 201-211. 61. Saikko, V. (1993) Wear and friction properties of prosthetic joint materials evaluated on a pin on flat apparatus, Wear, 166, 169-178. 62. Schmidt, M.B., Lin, M. and Greer, K.W. (1995) Wear performance of UHWMPE articulated against ion implanted CoCr. Trans 21st Annual Meeting of the Society For Biomaterials, San Francisco, CA. 28, 230. 63. Semlitsch, M., Lehmann, M., Weber, H., Doerre, E. and Willert, H.G. (1977) New prospects for a prolonged functional life-span of artificial hip joints by using the material combination polyethylene/aluminium oxide ceramic/metal. /. Biomed. Mater. Res., 11, 537-552. 64. Semlitsch, M.F., Weber, H., Streicher, R.M. and Schon, R. (1992) Joint replacement components made of hot-forged and surface treated Ti-6Al-7Nb alloy. Biomaterials 13, 781-788.

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Degradation/resorption in bioactive ceramics in orthopaedics

H. Oonishi and K. Oomamiuda

8.1 INTRODUCTION Bioceramics have now been widely used as bone replacement materials in orthopaedic surgery. In particular, calcium phosphate ceramics have been applied as bioactive ceramics with bone bonding capacities. Biological responses such as bone bonding and the biodegradation properties of these materials are very important in clinical applications. Any convincing conclusion has not yet been reached as to whether these materials are biodegradable or not, although it has been discussed for a long time. Degradation is an important characteristic for biomaterials, and it is considered to have a large influence on the bone bonding properties. This degradation characteristic must be considered from the following two view points. These are the solution mediated dissolution process and the cellmediated process (phagocytosis). This chapter overviews the literature regarding the biodegradation processes of bioactive calcium phosphate ceramics from the viewpoint of in vitro physico-chemical dissolution processes and in vivo/in vitro biological degradation processes. In this chapter, each calcium phosphate material is abbreviated as follows:
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

DCPD DCPA OCP TCP HAp TTCP

; ; ; ; ; ;

Dicalcium phosphate dihydrate [CaHPO4.2H2O] Dicalcium phosphate anhydrate [CaHPO4] Octacalcium phosphate [Ca8H2 (PO4)6.5H2O] Tricalcium phosphate [Ca3 (PO 4 )J Hydroxyapatite [Ca10 (PO4)6 (OH)2] Tetracalcium phosphate [Ca4 (PO4)2O]

8.2 IN VITRO PHYSICO-CHEMICAL DISSOLUTION PROCESSES Dissolution of a solid material continues until an equilibrium condition is reached, followed by a saturated condition where a solid and a liquid remain in equilibrium. Solubility is defined as the maximum concentration of solute in the solution under the equilibrium condition. This concept of solubility is very convenient to know how much the material has actually dissolved. However, it is not convenient for showing general solubility of the material since its value depends on the pH of the solution. Therefore, a thermodynamic equilibrium constant known as the solubility product constant Ksp is used for slightly soluble salts. This solubility product constant is useful for understanding the dissolution characteristics, because its value does not change in either acid or basic solutions under the same conditions of temperature, pressure and ionic strength. For example, HAp dissolves in water as follows; (Ca10 (PO4)6 (OH)2}solid 10Ca2+ + 6PO43" + 2OH~ Therefore, its solubility product constant Ksp is calculated as follows; KSP (HAP) = [Ca2+] 1 0 PO 4 3 -] 6 [OH-] ^ where values in brackets represent ionic activities. There are many reports on solubility product constants of calcium phosphate compounds obtained by the above equation, and these values are shown in Table 8.1. Chow [18] calculated, based on these data, the solubility isotherms at 37 0 C over a wide pH range (Figure 8.1). These solubility isotherms were shown as the function of the concentration of calcium and phosphate ions in a saturated solution of each calcium phosphate salt. The relative stability of calcium phosphate salts at various values of pH can be obtained by these solubility isotherms. At a given pH, a salt with its isotherm lying below that of another salt is less soluble and more stable than the other. Therefore, HAp is the most stable and least soluble salt among these salts in the range of pH below approximately 4.2 where DCPA is the least soluble. Similarly, TTCP is the least stable and most soluble salt in the range of pH below 8.5, above which pH DCPD is the most soluble.

Table 8.1 Solubility product constants of calcium phosphate compounds at 25C Compound Dicalcium phosphate dihydrate Abbreviation DCPD Formula CaHPO4. 2H2O CaHPO4 Ca8H2 (PO4)6. 5H2O a-Ca3(PO4)2 0-Ca3(PO4)2 Ca10(PO4)6(OH)2 p KSP Reference 6.59 6.63 6.90 96.6 98.6 25.5 28.9 29.7 115.5 115-117 117 122 125 38 1,2 3 2, 4 5 6 7 2, 8 3 2, 9, 10 11 12-15 16 17 15

Dicalcium phosphate anhydrous DCPA Octacalcium phosphate OCP a-Tricalcium phosphate p-Tricalcium phosphate Hydroxyapatite a-TCP P-TCP HAp

Tetracalcium phosphate pKsp: the negative logarithm of Ksp.

TTCP

Ca4(PO4)2O

Newesely [19] and Monma and Kanazawa [20] reported that a-TCP was converted to H A p by hydration as follows; 3Ca3 (PO4)2 + Ca2+ + 2OH" -> Ca10 (PO4)6(OH)2

However, this phase diagram can apply only in a thermodynamic equilibrium for the ternary system of Ca(OH)2-H3PO4-H2O, and it shows only a general tendency under in vivo conditions where various different ions are involved. Furthermore, this relation is also considered to be influenced by the experimental conditions and the characteristics of the material used in the experiments. Most of the implanted materials used in the investigations were TCP and HAp. It has been reported in earlier investigations that TCP dissolves more rapidly than HAp in various solutions [21]. Jarcho [22] compared the relative dissolution rates of dense HAp and TCP. The dissolution rate of TCP was 12.3 times higher than that of HAp in buffered lactic acid solution (0.4 M, pH 5.2), and was 22.3 times higher than that of HAp in buffered EDTA solution (0.05 M, pH 8.2). Klein et al [23] carried out dissolution tests on HAp and P-TCP with various values of porosity in buffered lactic acid solution. The dissolution rate of p-TCP was three times higher than that of HAp. And it was concluded that the degradation rates of these materials were determined by neck dissolution rate and neck geometry, the latter factor being dependent on the crystallography and stoichiometry of the material and of the sintering conditions. Ducheyne et al [15] compared the dissolution rate and the precipitation rate of the following six calcium phosphates in calcium and

Figure 8.1 Solubility phase diagram for the ternary system Ca(OH)2-H3PO4-H2O at 37C [18].

phosphate free solution with pH 7.3. The dissolution rate increased in the following order: HAp < CDAp < OHAp < p-TCP < a-TCP < TTCP and the precipitation rate increased as follows: p-TCP < (HAp and a-TCP) < CDAp (CDAp; Ca-deficient HAp, OHAp; dehydroxylated HAp) The precipitate that formed on CDAp was apatitic; on the other hand, the precipitates on HAp and 3-TCP had a much lower Ca/P. In TTCP, the precipitate was calcium deficient carbonate containing hydroxyapatite. Niwa et al [24] evaluated the concentration of calcium and phosphate ions being slightly dissolved in saline solution from HAp sintered at the temperature range from 250 to 1250 0C. It was concluded that the sintering temperature was closely related to the crystallinity and the amount of dissolution of the material. Maximan et al [25] compared the dissolution rate of plasma spray coated amorphous HAp and poorly crystallized HAp by exposure to Hank's physiological solutions (pH 7.2 and 5.2). The poorly crystallized HAp coating showed faster resorption, greater surface film precipitation and greater chemical changes than amorphous HAp coating. 8.3 IN VIVOIIN VITRO BIOLOGICAL DEGRADATION PROCESSES Biological degradation processes have been investigated either by animal experiments in vivo and clinical applications or by cell cultures in vitro. These results were obtained by observing the remaining implanted materials and the behavior of each cell around the materials.
8.3.1 Animal experiments and clinical applications

Most of the implanted calcium phosphate materials that were used in animal experiments and clinical applications were TCP, HAp and calcium phosphate glasses. Table 8.2 shows major reports of these investigations. Most of the reports on TCP have concluded that TCP is biodegradable although there are some differences depending on the characteristics of the materials used. Bhaskar et al [26] concluded that this biodegradation of TCP was caused by the phagocytosis of the mesenchymal cells. Cameron et al [28] stated that the ingestion by giant cells did play a significant role in the degradation of TCP although passive dissolution occurred. Klein et al [32, 33] stated that the micro-pores played an important role in the biodegradation rate of TCP. The degradation of TCP started mostly

Table 8.2 Biodegradation of calcium phosphate compounds in vivo. Implanted material (sintering temp., porosity or density) TCP (plug) TCP (pellet) P-TCP (porous plug) [36%] TCP and TTCP (porous cylinder) [45%] Implantation Tibia of rats Tibia of rats Femur of dogs Tibia of dogs Vertebrae cervicales of dogs Tibia of rabbits Tibia of rabbits Femur of dogs Mandible of dogs Tibia of dogs Animal studies Clinical application Animal experiments Clinical application Dorsal muscle and tibia of rats Femur of dogs Tibia of dogs Middle ear of rats Duration 14 weeks 48 days 4 months 10 months Biodegradation Reference 26 27 28 29 30 31 32,33 34 35 36 37,38 39 40 41 42 43,44

TCP (block) HAp and P-TCP (ten types of micro and macro porous cylinder) P-TCP (seven types of micro and macro porous cylinder) HAp and TCP (porous block) [HAp: 1300 0C - 56%, TCP: 1150 0C - 50%] Coral (porites) - HAp (porous block) Coral (goniopora) - HAp (porous block) Coral (porites and goniopora) - HAp (porous block) Coral (goniopora) - HAp and TCP [36%] HAp (three types of dense block) [900 0C - 97%, 1200 0C - 97 and 99.9%] HAp (porous blocks) [1300 0C, 56%] HAp (porous blocks) [900 and 1200 0C, 86%] HAp (macro and micro porous blocks) [macroporosity: 26%, microporosity: 5%]

Progressive decrease 95% of implant was degradated Considerable resorption TCP; resorbed TTCP; unchanged 22 weeks Partially resorbed (implants were crushed) 9 months HAp: no resorption TCP: more or less degradable 12 months Microporous>macroporous reduced by addition of Mg2+, F~ 50 weeks HAp: no resorption TCP: 25-30% (in 22 weeks) 29% of implant 1 year No bioresorption 1 year 12 months Minimal 15 months No degradation Coral-HAp: not apparent 1 year TCP: observed in many cases 4 years 6 months No degradation (no difference in three types) 3.5 years Negligible Slow bioresorption 2 years (900 C>1200 0C) Resorption by 15-20 |xm during 1 year the first yr.

Table 8.2 Continued. Implanted material (sintering temp., porosity or density) DCPD, DCPA, OCP, a- and (B-TCP, HAp, amorphous HAp Bioglass (granule sizes of 100-300 and 10 ^m) MBCP (macroporous blocks) [40-50%] (60%HAp + 40% p - TCP) Plasma sprayed HAp (cylindrical plug) Plasma sprayed HAp, TTCP, MWL (cylindrical rod) (crystallinity of HAp: 10, 60, 95%) Plasma sprayed HAp, FAp, MWL (cylindrical plug) Bioglass (SiO2-P2O5-CaO-Na2O system) A-W glass-ceramics (MgO-CaO-SiO2-P2O5-CaF2 system) Implantation Femur of rabbits Animal experiments Clinical application Tibia of rabbits Femur of rats Duration 12 weeks Bio degradation (a- and p-TCP) < (DCPD, DCPA, TTCP) < (amorphous HAp, OCP) Initially fast (~1 month) Reference 45 46 47 48

Femur and humerus of goats Femur of rats Tibia of rabbits

18 weeks 16 months 3 months Loss of coating thickness 4 weeks 60%-HAp and TTCP: distinct bulk degradation, 10%-HAp: gradual surface degradation 95%-HAp and MWL: negligible 25 weeks HAp: considerable and progressive reduction, MWL: considerable reduction in thickness, FAp: no degradation or dissolution Silica-rich layer and Ca-P rich 6 weeks layer formation 25 weeks Ca-P rich layer formation

49

51 53

from the medulla by solution mediated disintegration processes, and fine particles released were phagocytosed and removed by macrophages in the medulla to the lymph nodes. Renooij et al. [35] reported that HAp was not affected by biodegradation processes, while TCP was subject to extensive bioresorption. Resorption debris from TCP was found in mononuclear phagocytes and multinuclear osteoclastlike cells. Although multinuclear cells were occasionally seen near the surface of HAP, cells carrying HAP debris were never observed. And it was supposed that TCP was transformed into HAp in a physiologic environment. Concerning the biodegradation of HAp, there are reports in the case of no degradation, slow or partial degradation and for the degradable case. The differences in these results are dependent on the experimental conditions such as the characteristics of the materials, animal species, implanted sites and methods of observation. Holmes et al [35-39] carried out investigations using HAp which was derived from marine coral and reported the results as follows. Significant biodegradation occurred when implanted in load bearing sites such as mandibles, while minimal biodegradation was observed in cortical bone of radius and no apparent evidence of biodegradation was observed in cancellous bone of tibia. In clinical applications, radiographic observations did not show any irrefutable evidence of biodegradation and history of biopsies showed no conclusive evidence of biodegradation, while osteoclasts were occasionally seen along the implant surface. In contrast to these results, degradation of TCP appeared to occur by passive dissolution and osteoclastic resorption, and in many cases it was radiographically observed in clinical trials, especially where the implant was applied in a diaphyseal onlay fashion. Denissen et al [40] reportered no degradation of three different dense HAp varying in its density. Similarly, Hoogendoorn et al [41] reported through their long-term study that porous HAp did not undergo biodegradation during 3.5 years of implantation, while giant multinucleated cells were occasionally seen in pores near the bone and ceramic surface. On the other hand, Kurosawa et al [42] observed the degradation of highly porous HAp in their experiments, and concluded that this degradation was caused in two ways; the mechanical collapse of the material and the ingestion of fine particles released from the HAp surface by multinuclear giant cells. Similarly, Blitterswijk et al [43, 44] observed in their implantation experiments with dense and macroporous HAp that the deposition of calcium, partially in the form of calcium phosphate, was found on the implant surface, and the resorption of the implant occurred as the result of phagocytosis by mono- and multi-nuclear cells. Oonishi et al [45] compared bioactivity for bone formation in several kinds of bioceramics. These materials were divided into three groups; bioinert ceramics (alumina), surface bioactive ceramics (HAp and Bioglass), and resorbable

bioactive ceramics (DCPD, DCPA, OCP, a-TCP, p-TCP, TTCP and amorphous HAp). In resorbable bioactive ceramics, bioactivity or bioresorbability might increased in the following order: (a- and p-TCP) < (DCPD, DCPA and TTCP) < (amorphous HAp and OCP) Daculsi et al [46] stated that the bioresorption of macroporous biphasic calcium phosphate consisting of HAp and p-TCP was conducted by multinucleated cells (osteoclastlike cells) and was related to the [3-TCP content of this material. Bruijin et al [48] and Dhert et al [49] compared the degradation of plasma spray coated TTCP, MWL (magnesium whitlockite) and three types of HAp with various degrees of crystallinity. It was revealed that both TTCP and semi-crystalline HAp underwent distinct bulk degradation and amorphous HAp showed a gradual surface degradation, while the degradation was negligible with the highly crystalline HAp and MWL. Biodegradation appeared to be related to bone apposition, since more bone seemed to be present on amorphous HAp and TTCP, as compared to highly crystalline HAp and MWL. The degrading surface of TTCP and amorphous HAp coatings was most likely a dynamic zone in which dissolution and reprecipitation occurs. This zone was therefore thought to be favourable for rapid bone formation and bonding. At the interface between bone and MWL, a seam of unmineralized bonelike tissue was frequently seen, and a substantial amount of aluminum was detected in the MWL coating and the unmineralized bone-like tissue, which might cause the impaired mineralization. Since the discovery of Bioglass by Hench et al [50], various kinds of bioactive glasses and glass ceramics have been developed and applied clinically. Hench et al [51] summarized their study on Bioglasses which were based on the SiO2-P2O5-CaO-Na2O system. When a bioactive glass was immersed in an aqueous solution, three general processes occurred; leaching, dissolution and precipitation. In these reactions, hydrated silica was formed on the glass surface, resulting in a silica-rich gel layer, and then a calcia-phosphate-rich layer was formed on or within the gel layer. This layer was initially amorphous and later crystallized to a hydroxycarbonate apatite structure to which bone could bond. Kokubo et al [52] developed A-W glass-ceramics which was based on the MgO-CaO-SiO2-P2O5-CaF2 system. In this material, oxyfluorapatite [Ca10(PO4)6(O,F2)] and p-wollastonite [Cao SiO2] both in the form of rice grain-like particles were dispersed in an MgO-CaO-SiO2 glass matrix. In their experiments [53] it was shown that a thin layer, rich in Ca and P, was formed on the surface of this material. This Ca, P-rich layer was identified as a layer of apatite, and this material was observed to be closely connected to the surrounding bone through this apatite layer without any distinct boundary. The same type of apatite layer was formed on the

surface of this material exposed to the simulated body fluid, and consisted of carbonate-containing hydroxyapatite of defective structure and small crystallites. It was concluded that this apatite layer played an essential role in forming the chemical bond of all bioactive materials which bonded to bone.
8.3.2 Cell cultures

To study biodegradation and interfacial bonding phenomena, in vitro cell culture systems have been developed. Gregoire et al. [54] investigated the influence of calcium phosphate on human bone cell activities and demonstrated that the isolated human bone cells were capable of ingesting HAp and (3-TCP granules. And the capacity for ingesting a synthetic mineral component clearly suggested that bone cells were able to participate in the degradation of calcium phosphates. Gomi et al. [55] showed that osteoclasts are capable of resorbing sintered HAp in vitro and that the fusion of osteoclast mononuclear precursors was influenced by substratum rugosity. Similarly, Ogura et al [56] demonstrated that osteoclast-like cells were capable of resorbing unsintered calcium phosphate substrata in vitro. Bruijn et al. [57-59] carried out a series of cell culture tests on various plasma sprayed calcium phosphate compounds and reported the results as follows. Rat bone marrow cells were cultured on plasma sprayed HAp. The cells formed a mineralized extracellular matrix that exhibited several characteristics of bone tissue. Two distinctly different interfacial structures were observed on HAp. An electron-dense layer which was rich in glycosaminoglycans was regularly present. A collagen-free amorphous zone was frequently seen interposed between the electron-dense layer and HAp. In cell culture tests on three types of plasma sprayed HAp varying in degree of crystallinity, an electron-dense layer was clearly visible on a stable, nondegrading crystalline HAp and was frequently observed at the interface of semi-crystalline HAp. An amorphous zone was regularly seen at degrading surfaces of semi-crystalline and poorly crystallized HAp. It was concluded that the crystallinity of plasma sprayed HAp was an important parameter which influenced the establishment of the bony interface and might, as a result, have an effect on the bone formation rate and bonding strength between HAp and bone tissue. Similarly, rat bone marrow cells were cultured on various plasma sprayed calcium phosphate coatings. Mineralized extracellular matrix was formed on HAp, TCP and TTCP in 2 weeks, and was formed on FAp (fluorapatite) in 8 weeks. It was only occasionally observed in some area on MWL, which phenomenon might have been due to aluminium impurities in the coating. It was concluded that plasma sprayed calcium phosphates would display different bone-bonding and biodegradation properties, depending on their chemical composition and crystal structures.

Table 8.3 Biodegradation of calcium phosphate compounds in vitro Substrate (sintering temp., porosity or density) HAp and (3-TCP (granule, <50 jjim) Strain Human bone cell Incubation 7 days 8 days 7 days 18 days 2 weeks Biodegradation Human bone cell are capable of ingesting HAP and TCP granules Osteoclast-like cells are capable of resorbing HAp Osteoclast-like cells are capable of resorbing HAp 15 & 43%: rapidly degrated 69%; degradation rate was reduced Different bone-bonding and biodegradation properties Reference 54 55 56 58 59

HAp (dense disc; three types of surface Rat bone marrow rugosities) [11300C] cell HAp (dense disc; three types of porosity Rat bone marrow [dried at 200 0C, unsintered] cell Plasma sprayed HAp (crystallinity; 15, 43, 69%) Rat bone marrow cell Plasma sprayed HAp, FAp, TCP, TTCP, MWL Rat bone marrow cell

8.4 SUMMARY No convincing conclusion has been reached as to the biodegradation mechanisms of bioactive ceramics. Many researchers have reported different results, as described above. These discrepancies are considered to be caused by the fact that materials used for the experiments were different, and that experimental methods and analytical methods were also different. Therefore, when these reported results are compared, it is important to consider the characteristics of the material used (chemical compositions, impurity, crystallinity, dense or porous, micro- or macroporous, porosity), experimental methods used (in vivo or in vitro, animal species, implanted duration, implanted sites, load bearing or not), and analytical methods used (radiographic, optical microscopic, electron microscopic). Futhermore, a good understanding of the characteristics of the materials to be used becomes important when bioactive ceramics are used clinically.

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44. CA. van Blitterswijk, JJ. Grote, W. Kuijpers, W. Th. Daems and K. de Groot, Biomaterials, 7, 137-143, 1986. 45. H. Oonishi, S. Kushitani, T. Sugihara, H. Iwaki, H. Ohashi and E. Tsuji, Bioceramics vol. 8, eds L.L. Hench and J. Wilson, ELSEVIER, New York, 1995. 46. G. Daculsi, N. Passuti, S. Martin, C. Deudon, R.Z. Legeros and S. Raher, /. Biomed. Mater. Res., 24, 379-396, 1990. 47. J.A. Jansen, J.P.C.M. van de Waerden, J.G.C. Wolke and K. de Groot, /. Biomed. Mater. Res., 25, 973-989, 1991. 48. J.D. de Bruijn, Y.P. Bovell and CA. van Blitterswijk, Calcium Phosphate Biomaterials: Bone-bonding and Bio degradation Properties, ed. J.D. de Bruijn, Offsetdrukkerij Haveka B.V., Alblasserdam, pp. 79-92, 1993. 49. W.J.A. Dhert, C.P.A.T. Klein, J.A. Jansen, E.A. van der Velde, R.C Vriesde, P.M. Rozing and K. de Groot, /. Biomed. Mater. Res., 27, 127-138, 1993. 50. L.L. Hench, RJ. Splinter, W.C Allen and T.K. Greenlee, /. Biomed. Mater. Res. Symp., 2, 117-141, 1971. 51. L.L. Hench and B. Andersson, Advanced Series in Ceramic - Vol. 1 An Introduction to Bioceramics eds L.L. Hench and J. Wilson, World Scientific, Singapore, pp. 41-62, 1993. 52. T. Kokubo, S. Ito, S. Sasaki and T. Yamamuro, /. Mater. ScL, 21, 536-540, 1986. 53. T. Kokubo, Advanced Series in Ceramics - Vol. 1 An Introduction to Bioceramics, eds L.L. Hench and J. Wilson, World Scientific, Singapore, pp. 75-88, 1993. 54. M. Gregoire, I. OrIy and J. Menanteau, /. Biomed. Mater. Res., 24, 165-177, 1990. 55. K. Gomi, B. Lowenberg, G. Shapiro and J.E. Davies, Biomaterials, 14, 91-96, 1993. 56. M. Ogura, T. Sakae and J.D. Davies, Bioceramics vol. 4, eds W. Bonfield, G.W. Hastings and K.E. Tanner, Butterworth-Heinemann, London, UK, pp. 121-126, 1991. 57. J.D. de Bruijn, C.P.A.T. Klein, K. de Groot and CA. van Blitterswijk, /. Biomed. Mater. Res., 26, 1365-1382, 1992. 58. J.D. de Bruijn, J.S. Flachl, K. de Groot, CA. van Blitterswijk and J.E. Davies, Calcium Phosphate Biomaterials: Bone-bonding and Biodegradation Properties, ed. J.D. de Bruijn, Offsetdrukkerij Haveka B.V., Alblasserdam, pp. 45-62, 1993. 59. J.D. de Bruijn, C.P.A.T. Klein, K. de Groot and CA. van Blitterswijk, Calcium Phosphate Biomaterials: Bone-bonding and Biodegradation Properties, ed. J.D. de Bruijn, Offsetdrukkerij Haveka B.V., Alblasserdam, pp. 63-78, 1993.

Corrosion of Metallic Implants

M.A. Barbosa

9.1 GENERAL ASPECTS 9.1.1 Incidence of corrosion The surfaces of passive metals are normally attacked at specific points where the oxide film has been destroyed and massive quantities of metal ions are released. Depending on the magnification with which surfaces are observed, various degrees of localized attack can be detected. Sometimes, however, corrosion may not be easily distinguishable from mechanical imperfections associated with manufacturing or handling. Even under the scanning electron microscope (SEM) it is often difficult to distinguish between mechanical indentations and pitting or crevice attack. After determining the existence of corrosion, the next step is to assess its magnitude. This can be done, by corrosion scores, such as those given in Table 9.1 (Thomas et al9 1988). In this table the 'no surface degradation' score is obtained with a magnification of 6Ox. If a higher magnification was used some 'non-degraded' surfaces might fall in one of the 'surface degradation' categories. The borderline between 'corroded' and 'non-corroded') surfaces is therefore very much dependent on magnification, as well as on surface preparation, as explained above. With these limitations in mind, it is useful to have an idea of the incidence of corrosion, i.e. of the percentage of implants that suffer some degree of attack. Table 9.2 compares the data obtained by several authors. Vacuum melting
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Table 9.1 Grading scale used to evaluate the degree of interface and surface corrosion (Thomas et al, 1988) 0 1 2 3 4 5 = = = = = = no surface degradation visible at 6Ox magnification very mild surface degradation visible at 6Ox magnification mild surface degradation visible at 6Ox magnification moderate surface degradation visible without magnification heavy surface degradation visible without magnification very heavy severe surface degradation visible without magnification

Table 9.2 Incidence of corrosion Implant/material 38 fixation devices/AISI 316L 43 miniplates/AISI 316LVM* 19 miniplates/c.p Ti * VM - Vacuum melted Corroded implants 95%; crevice corrosion 19%; only at the countersinks 0% Ref Thomas et al, 88 Torgersen and Gjerdet, 94 Torgersen and Gjerdet, 94

(VM) significantly reduces the susceptibility of 316L stainless steel to attack, while titanium is practically immune. Corrosion, apart from affecting the mechanical performance of the implants, also results in contamination of the tissues with metallic ions. The detection of ions released from metallic implants is dependent on the technique used. Very minute amounts of ions can be detected by electrothermal atomic absorption spectroscopy (ET-AAS), which goes down to concentrations of the order of ng/g. Electrochemical methods enable the detection of extremely low corrosion current densities, below 1 |jA/cm2, corresponding to dissolution in the passive state. These rates of corrosion do not modify the aspect of the surface and are not normally considered as surface attack.
9.1.2 Potential-pH (Pourbaix) diagrams

These diagrams indicate the regions of immunity, passivation and corrosion of pure metallic elements in pure water at 25C. Fig. 9.1 (a, b) gives the potential-pH diagrams of Cr and Ti. Cr is the element responsible for the passive behaviour of stainless steels and Co-Cr-Mo alloys. In Fig. 9.1a passivation by a Cr(OH)3 film is assumed. The film is thermodynamically stable over a wide range of pH and potential values. Below pH 4 the film

corrosion

passivation

immunity

Figure 9.1(a) Theoretical conditions of corrosion, immunity and passivation of chromium, at 25C. (Pourbaix, 1974.)

is unstable and Cr is corroded. Ti is responsible for the excellent corrosion resistance of Ti-Al-V alloys. In Fig. 9.1b passivation by a hydrated TiO2-H2O oxide has been assumed. The passivation region extends to much higher potentials than in the case of Cr. The passive film is unstable below pH 2.5. In both diagrams the dotted lines give the region of stability of water: below line a hydrogen is evolved, whereas above line b oxygen is released. Normally, the corrosion potentials of implant materials do not reach such extreme values. In spite of their usefulness in predicting the stability of metals and their oxides, potential-pH diagrams suffer from a number of limitations. They refer to pure metals, not to alloys, and to pure water, not to environments normally found in practical situations. For example, the diversity of chemical species, and particularly the presence of chloride ions in physiological media, is responsible for substantial differences between practical and predicted behaviour. Localized attack, in the form of crevice, pitting and corrosion fatigue, is due to the presence of chloride. Furthermore, the kinetics of metal dissolution or passivation cannot be assessed by these diagrams, which are purely thermodynamic. However, if not misused, potential-pH diagrams can give useful information which must be complemented by other type of date, namely of kinetic nature.

corrosion

passivation

corrosion

passivation

Figure 9.1(b) Theoretical domains of corrosion, immunity and passivation of titanium, at 25C, considering Tiltz (Pourbaix, 1971). 9.2 ASPECTS RELATED TO THE METAL COMPOSITION 9.2.1 Importance of materials purity in improving the corrosion resistance

The evolution of stainless steel composition can be used to illustrate the importance of materials purity in reducing corrosion susceptibility. Chromium and molybdenum are the key elements in promoting resistance to pitting and crevice attack of stainless steels, but high chromium and molybdenum concentrations are not sufficient to ensure an adequate corrosion resistance. Low concentrations of impurities, like carbon, silicon, phosphorous and sulphur, are required. Type 316L and 316LVM stainless steels are commonly employed to fabricate a variety of fracture fixation devices. They both have low carbon concentration, below 0.03 wt%, which is indicated by the letter L. VM stands for vacuum-melted, a technique

that enables the production of metals with very low concentrations of impurities. A retrieval analysis of Kuntscher intramedullary rods (Cook et al. 1990) has shown that significant surface corrosion, inclusion content and carbon content occurred on early materials, which had remained in situ for 10 years or longer (maximum 23 years). Significant relationships were obtained for surface corrosion score vs. thin globular oxide inclusion content, and for surface corrosion score vs. sulphide inclusion content. Figure 9.2 shows the data obtained for the former correlation.
9.2.2. Type of metallic material and influence of alloying

Due to the presence of a thin oxide film, titanium has a very high corrosion resistance. However, its low resistance under wear conditions may lead to enormously high titanium concentrations in tissues adjacent to titanium implants (section 9.3.1). Rapid film formation after surface damage is therefore of critical importance to guarantee low levels of titanium ions.

Surface corrosion score

Inclusion content

Figure 9.2 Relationship between surface corrosion and thin globular oxide inclusion content. Regression line y= 1.78x+0.52, r= 0.65, n= 18, p <0.05. (Cook et al., 1990.)

The current density (c.d.) required to form a passive film is called the critical c.d. for passivation, ic. The lower ic the better. Figure 9.3 shows that Zr, Nb, Ta and Pd decrease ic, whereas Sn increases it. It has been found (Okazaki et al 1994) that ic can be related to the percentages of Pd, Ta, Nb, Zr and Sn by the following expression ic(A.m-2 = 10-2{98-89.5[%Pd] - 9.5[%Ta] - 3.4[%Nb] - 0.67[%Zr] + 8[%Sn]} A new alloy, Ti-15Zr-4Nb-2Ta-0.2Pd, with better corrosion resistance than the conventional Ti-6A1-4V, was proposed by the same authors. Replacement of Nb for V, in order to eliminate the possible toxic effects of the latter, has been carried out (Semlitsch et al, 1992). Ti-6Al-7Nb showed a corrosion resistance similar to that of Ti-6A1-4V, as concluded from anodic polarization curves (Figure 9.4). Although not as widely used as titanium, tantalum has found a number of applications, e.g. in vascular clips, as a suture and to fabricate flexible stents to prevent arterial collapse. The reader is referred to a paper by J. Black (1994), where the material properties are reviewed, together with

310K Oeaerated

Figure 9.3 Effects of Zr, Nb, Ta, Pd and Sn contents critical current density for passivation in 15% H2SO4 and 5% HCl solutions at 310 K. (Okazaki et al, 1994.)

giuv/'/ 'uoaeAissed JOJtoisuapluajjno jeoijijQ

5mass% H2SO4

5mass%HC!

Ti-(5-10mass%)Zr-(4~8%)Nb-(2-4%)Ta-(0-0.2%)Pd Ti-(10-20%)Sn-(4-8%)Nb-2%Ta-0.2%Pd Ti-(15-20%)ZM%Nb-2%Ta-0.2%Pd

Alloying content, Cx/mass%

Current density ( p A / c m )

Potential against SCE (mV)

Figure 9.4 Current density/potential curves of five different implant materials in Ringer's solution bubbled through with nitrogen. AISI 316L; 0CoNiCrMo; Ti6Al-7Nb; T CP-titanium; x Ti-6Al-7Nb/ODH. (Semlitsch et ah, 1992.)

the host response and clinical applications. In terms of corrosion resistance, tantalum is at least equivalent to titanium. Its oxide, Ta2O5, is very stable over very wide pH and potential ranges, thus explaining the excellent corrosion resistance. According to Black, high cost and difficulties of fabrication are some of the reasons for its limited usage. Cr and Mo are the major alloying elements responsible for the corrosion resistance of stainless steels. These alloys are also very sensitive to inclusion content, which has led to continuous attempts to reduce impurity concentrations. F138 and F139 are variations of the AISI 316L stainless steel with a lower content of non-metallic inclusions. A duplex stainless steel, 25Cr-7Ni-4Mo-0.25N, shows a better corrosion resistance than conventional austenitic stainless steels (Cigada et al, 1989). The authors have established the following ranking: 23Cr-4Ni<AISI 316L<ASTM F138<22Cr-SNi-3Mo<27Cr-31Ni-3.5Mo<25Cr-7Ni-4Mo-N.
9.2.3 Site for attack

Normally, pitting initiates at non-metallic inclusions. In stainless steels sulphides are particularly prone to attack. Oxide inclusions may also give origin to attack, but they are less active than sulphides. Carbides may also nucleate pitting attack and when they are numerous at grain boundaries they may give rise to intergranular corrosion. However, with surgical

grades of stainless steels this type of attack should not occur. Crevice corrosion is also common with stainless steels and less frequent with Co-Cr alloys. Sintered beads of Co-Cr-Mo alloy have been studied by scanning electrochemical microscopy (Gilbert et aL, 1993a). At any time, some grains were more active than others, whereas at later stages shifting of the active regions occurred. Titanium is immune to both types of corrosion under static conditions. Sliding between titanium and another material (e.g. cement, polyethylene or bone) may originate severe degradation by corrosive wear.
9.2.4. Combinations of different materials

The need to combine different materials may sometimes arise. An example is the use of hard materials for the head of hip joints in combination with a titanium stem. Titanium has a very high corrosion resistance, but a very poor wear resistance. Therefore, either surface hardening treatments (e.g. ion implantation of nitrogen or surface alloying) or a harder material, e.g. a ceramic, are employed for the femoral head. Ceramics, like alumina or zirconia, do not cause enhanced electrochemical dissolution of the titanium stem because of their low electronic conductivity. However, when another metal (e.g. Co-Cr-Mo alloy) is used instead, the possibility of a galvanic couple between the stem and the head being formed exists. The situation illustrated by this example can be extended to other couples, including those involving carbon. Even in the case of hard coatings galvanic couples between the coating and the substrate may form. In a first approximation, the safety of couples involving different materials can be preditected by a number of experimental techniques. Table 9.3 summarizes the data obtained by several authors. Notice that the couples between stainless steel and other materials is unsafe. On the contrary, TiAlV/CoCrMo, CoCrMo/C and TiAlV/C combinations may be considered safe. However, repeated fracture of the oxide film at the conical taper region between head and stem of Ti6A14V/CoCr combinations has been associated with corrosion. Attack also occurred in
Table 9.3 Predicted behaviour of galvanic couples (Barbosa, 1991) Couple TiATWC CoCrMo/C TiAlV/CoCrMo 316L S.S./C 316L S.S./TiAlV 316L S.S./CoCrMo Behaviour SaS Safe Safe Unsafe Unsafe Unsafe

CoCr/CoCr combinations and was proportional to the duration of implantation, as seen in Figure 9.5 (Gilbert et al, 1993b). A larger percentage (34.5%) of cases of corrosion was found with mixed CoCr/TiAlV systems than with CoCr/CoCr systems (7%) (Cook et al, 1994). Corrosion occurred at the interface between head and neck of modular components. No correlation between the presence or extent of corrosion with the time in situ was found. In another study the percentage of corroded tapered connections between titanium-alloy stems and cobalt-alloy heads was found to be about 57% (Collier et al, 1991). Titanium-titanium and cobaltcobalt alloy combinations did not result in interfacial corrosion. 85% of prostheses made of dissimilar materials exhibited corrosion 24 months or more postoperatively. The data indicate that a correlation exists between corrosion and time of implantation. In view of the above clinical data it is advisable to avoid using dissimilar metals for modular hip prostheses. The occurrence of fretting corrosion at the taper region is responsible for the release of metallic ions that may have cytotoxic effects.
heads

necks

Percent Corroded

Time (months)
Figure 9.5 Graphs summarizing the percentage of mixed metal components which show signs of moderate to severe corrosion as a function of duration of implanation. The dotted regression line was fit to the data for the heads (O) and the solid line was fit to the data for the necks (A). (Gilbert et al, 1993b.)

Percent Corroded

Laboratory galvanic current measurements can be very useful in the pre-screening of materials. For instance, in a study on dental implant bridges it has been reported that silver-palladium, when brazed to titanium, corrodes in vitro (Ravnholt and Jensen, 1991), thus eliminating the need to carry out in vivo tests. As a final note it must be stressed that laboratory static tests should only be used to eliminate dangerous metal-metal combinations, and not as an acceptance criterion. Fretting may substantially alter the properties of the interface, by continuously removing the passive oxide film, thereby inducing severe attack of a metal which, otherwise, would remain unaffected.
9.3 ASPECTS RELATED TO THE PHYSIOLOGICAL ENVIRONMENT 9.3.1 Contamination of tissues by corrosion products

Contaminations of tissue with metals may have two origins. The first is the release of ionic species resulting from the process of electrochemical dissolution of the implant. This is normally associated with static corrosion. Under dynamic conditions, and particularly when fretting occurs, small metallic particles detach from the surface, and become embedded in the soft tissue around the implant. The fate of these particles may vary, depending on their size and chemical nature. They may, for instance, undergo a process of corrosion, with the consequent release of metal ions. This process may take place both in the extracellular matrix or as a result of macrophage activity. Table 9.4 gives the concentration of Cr, Ni, Fe and Co in biological samples. It shows that tissues around implants may be orders of magnitude richer in these metallic elements than normal blood or normal bone.
Table 9.4 1992) Sample Normal blood* Normal bone* Tissue around Implants (max)** 316SS Co-Cr-Mo Concentration of metallic elements in biological samples (Barbosa, Cr 2-6 ppb 460 ppb 10000 ppm 10200 ppm Ni 3-7 ppb 900 ppb 1400 ppm 1500 ppm Fe 200-680 ppm 91 ppm 20000 ppm 3650 ppm Co 0.1-0.2 ppb

22000 ppm

* Wet weight; data from Tsalev and Zaprianov, 1983. ** Concentrations in dry tissue; data from Pohler, 1983. ppm: Parts per million, ppb: Parts per billion.

Titanium has a tendency to accumulate in tissues. The concentrations can be very high, as indicated in Table 9.5. Titanium was not excreted in the urine of hamsters injected with metal salts (Merritt et ai, 1992). Small concentrations were found in the serum, red blood cells and organs. Only 5.5% of the injected titanium was found in the kidneys, liver, lung and spleen tissues. The authors suggest that titanium accumulates at the injection site due to the high stability of the titanium dioxide that is formed at physiological conditions. In the same study nearly all the injected vanadium was recovered in the urine. This behaviour is similar to that of nickel and cobalt, and is related to the formation of highly soluble compounds. High concentrations of metals were found in capsule and fibrous membranes of loose titanium and Co-Cr stems of total hip prostheses (Dorr et al, 1990). The same work reports elevated metal ion concentrations in synovial fluid and blood whenever cemented and uncemented stems are loose, but no increase when they are fixed. The average values are given in Table 9.6. The standard deviations (not shown) were often very large, of the order of magnitude of the averages. Polyethylene wear debris may artefactually contribute to high ion readings in periprosthetic tissues, as indicated in Tables 9.7 and 9.8 (Meldrum et al.9 1993). The high concentrations found in UHMWPE are due to the manufacturing processes. These tables show that there are statistically significant increases in Co, Al and Ti in the nonarticulated inserts with
Table 9.5 Concentration of titanium in tissues surrounding titanium implants Tissue Bone Soft tissue Soft tissue Concentrations (ppm) < 2100 2000 56-3700 Ref. Ducheyne, 1984 Meachim, 1973 Agins, 1988

Table 9.6 Concentration (jxg/1) of metals in tissues and blood retrieved during total arthroplasty of cementless stems (Dorr et al, 1990) TiAlV stems Sample SF SF (control) CAP CAP (control) FM Blood Blood (control) Ti 556 13 1540 723 20813 67 17 Al 654 109 2053 951 10581 218 12.5 V 62 5 288 122 1027 23 5.8 Co 588 5 821 25 2229 20 0.1-1.2 CoCr stems Cr 385 3 3329 133 12554 110 2-6 Mo 58 21 447 17 1524 10 0.5-1.8 Ni 32 5 5789 3996 13234 29 2.9-7.0

SF - synovial fluid; CAP - capsule; FM - fibrous membrane.

respect to bar stock. In retrieved implants, large increases with respect to bar stock were found for Cr, Mo, Ti and V. The role of UHMWPE wear debris would be twofold: irritant to tissues and source of metal ions. The accumulation of metal ions in periprosthetic tissue is a combination of two sources: the extracellular matrix and the cells themselves. The ability of fibroblasts to incorporate metal cations is a linear function of concentration, up to 50% toxicity concentrations, for Ag+, Au4+, Cd2+, Cu2+, In3+, Ni2+, Pd2+ and Zn2+ (Wataha et al, 1993), as illustrated in Figure 9.6 for Cu2+, Ni2+ and Pd2+. By measuring the slope of the lines in this figure it is possible to estimate the uptake efficiency (Table 9.9). The efficiency is highest for In3+ and lowest for Pd2+.
Table 9.7 Cobalt-chrome alloy ion concentrations in UHMWPE et al material and manufactured and retrieved inserts (Meldrum et al, 1993) Co Cr Mo Ni

Bar stock, n=3 555 3305 5* 6505 Manufactured inserts, n=9 440250 520440 5* 490600 Retrieved, n=18(all cemented inserts) 5442 l,500l,400 87120 l,360l,300 All concentrations are in parts per billion (nanograms/gram). * This is the minimum detection limit of the spectrometer. Table 9.8 Titanium alloy ion concentrations in UHMWPE material and manufactured and retrieved inserts (Meldrum, et al 1993) ~AL Bar Stock n=3 Manufactured inserts, n=9 Retrieved, n=21 (all metal backed) 5* 800200 5* Ti 5* 2300980 67004500 Va 5* 6095 220410

All concentrations are in parts per billion (nanograms/gram). * This is the minimum detection limit of the spectrophotometer. Table 9.9 Uptake efficiencies of metal cations by fibroblasts (Wataha et al, 1993) Metal cation Ag+ Au4 + Cd2+ Cu2+ In3 + Ni2+ Pd2 + Zn2 + Uptake efficiency ((fmoVcell)/\)M)/h)* 23^8 1.0 38.0 0.26 45.3 0.21 0.11 0.73

* fmol = femtomoles (10-15 moles).

Average Quantity of Cations per Cell (fmol/ccll)

Cone, of Cation in Medium (uM) Figure 9.6 Plots of the average uptake of metal cation per cell vs. concentration of the metal cation in the medium for Cu2+, Ni2+, and Pd2+. The least-squares method was used to fit linear curves to the points. (Wataha et ai, 1993.)

Two years after implantation of femoral components made of Ti-6A1-4V, the titanium and aluminium concentrations measured in the synovial fluid were higher for cemented components than for the uncemented (200 \xm HA, or porous Ti coatings) components (Karrholm et al, 1994). Table 9.10 gives the data for the synovial fluid and the aluminium concentrations in serum and urine. No significant concentrations of vanadium were found in any of the samples, which was also the case for titanium in serum and urine. Fast clearance of vanadium from the synovial fluid, due to high solubility of vanadium complexes, and formation of stable titanium compounds, e.g. titanium phosphates (Ribeiro et al, 1995), might be reasonable explanations for these findings. Experiments with metal salts and with stainless steel and Co-Cr-Mo electrodes corroded in vivo by applying anodic potentials showed that all the nickel and most of the cobalt were rapidly excreted (Brown et al, 1988). Acceleration of corrosion by the use of anodic potentials obeys similar mechanisms both in vivo and in saline when a potential of 500 mV

Table 9.10 Metal concentrations (ng/g) in synovialfluid,serum and urine. Median (range) (Karrholm et al, 1994) Cemented Ti/synovial fluid 37 (12-56) Al/synovial fluid 12 (6.7-28) Al/serum 2.1 (0-11) Al/urine 6.2 (1.7-17) HA-coated 3.5 (0-14) 5.2 (2.6-13) 1.4 (0-5.9) 4.9 (1.7-7.0) Porous 6.4 (0-7.8) 3.8 (2.9-9.1) 5.7 (2.1-16) 4.2 (3.7-4.6) Controls 0 (0-7.5) 7.3 (1.9-19) 3.7 (0-17) 4.6 (2.1-14)

vs. SCE is applied. This is illustrated by the single straight line in Figure 9.7 (weight loss vs. total charge). In particular, this implies that the valency of the released cations is no different in both media, according to Faraday's law. 9.3.2 Problems associated with the chemical analysis of metallic elements in tissues Acurate analysis of trace elements in tissues is essential to assess the degree of contamination. This is not an easy task, mainly because we are dealing with normal levels of the order of (xg/litre. Sampling and sample

CORRELATION COEFF

WEIGHT LOSS (mg)

SERUM IN VIVO

TOTAL CHARGE (Coulombs)

Figure 9.7 Linear regression analysis of weight loss as a function of total charge for stainless steel rods at 500 mV (SCE) for 30 min. Symbols: * = in saline, box = in 10% serum, circle = in vivo. (Brown et al 1988.)

preparation are steps prone to serious contaminations, if the necessary precautions are not taken. As indicated in a review by Lugowski et al (1990), reported 'normal' levels of Cr in blood span over four orders of magnitude. Contamination during sampling can be avoided by using PTFE or polyethylene materials for blood collection and sample storage. For cutting tissues a blade made of a material free from the elements to be analysed should be used. For example, in our laboratory we have been using pure titanium blades to cut soft tissues for Cr and Ni analysis. Contamination during sample preparation can be minimized by: (i) adopting a very strict protocol of labware cleaning; (ii) chemical treatment with ultrapure reagents, preferably in a microwave oven to reduce the time necessary for digesting tissues; (iii) use a laminar flow hood to prepare the samples, in order to avoid airborn contamination. Lugowski has published a number of excellent works where the reader can find very detailed information on the above and other aspects. The degree of precision and accuracy to be expected when adequate experimental methods are used is indicated in Table 9.11. This table refers to an 'internal' lab blood standard and to a Standard Reference Material (SRM) with vanadium concentration certification. The relative standard deviation (RSD) ranges from ca. 10% for Ni and Co, to ca. 29% for V.
9.3.3 Corrosion in sweat

The main constituents of sweat are chlorides (0.3-3.0 g/1), urea (0.12-0.57 g/1) and lactic acid (0.45-4.5 g/1). When metallic objects come in contact with skin corrosion may occur, and if the corrosion products are toxic or irritating they may originate contact dermatitis. The most common example is dermatitis caused by nickel-containing jewelry. In North America ca. 10% of men and women have a history of nickel dermatitis (Randin, 1988). Although the degree of sensitization may not be directly
Table 9.11 Precision of laboratory standard and precision and accuracy of SRM 909 human serum (Lugowski et al., 1990) Element Al Co Cr Ni Ti V V in SRM 909 certified value = 2.700.56 |jLg/litre X (\Lg/litre) 1.88 2.37 0.71 2.95 4.20 0.28 2.73 n 10 9 8 8 7 8 13 SD 0.35 0.26 0.14 0.30 0.41 0.08 0.14 RSD (%) 18.8 10.9 19.6 10.1 9.8 29.4 5.0

X - concentration; n - number of measurements; SD - Standard deviation; RSD - Relative SD.

related to the amount of metal ions released from an object, due to variability of response from person to person, it is generally considered that a high corrosion resistance gives rise to fewer allergies. The corrosion resistance of several materials in artificial sweat is given in Table 9.12 (Randin, 1988). The composition (g/1) of the medium used was: 20 NaCl, 17.5 NH4Cl, 5 urea, 2.5 acetic acid, 15 lactic acid, pH 4.7. The table gives the corrosion potential, Ecorr, in O2- and N2-saturated medium, the pitting potential, Epit, and the corrosion rate, icorr, measured by the Tafel extrapolation method. icorr is given only for those alloys which are in the active state. For the other alloys Epit is given. The following materials were found to corrode in the active state: Ni, CuNi25, NiAl (50:50, 60:40 and 70:30), WC+Ni, white gold, FN42, NiIo Alby K, NiP. Alloys such as stainless steels, TiC+Mo2C+Ni, NiTi, Hastelloy X, Phydur, PdNi, and SnNi are in the passive state and may pit under exceptional circumstances. Titanium has an extremely high Epit and therefore cannot pit under normal use. 9.3.4 Influence of proteins on the corrosion resistance Albumin has a detrimental effect on the corrosion resistance of cast Co-Cr-Mo alloy (Tomas et al, 1994). The breakdown potential in 0.15 M NaCl is 0.40 0.02 V vs. SCE, whereas in 0.15 M NaCl+albumin it is 0.25 0.06 V vs. SCE. The presence of 5% bovine serum in lactated Ringer's solution (pH=6.5) increases the corrosion rate of Ti-6A1-4V alloy, as shown in the last two columns of Table 9.13 (Lewis and Daigle, 1993b). This table gives data obtained by direct current (d.c.) and alternating current (a.c.) methods. The difference between d.c. and a.c. corrosion rates found in this system is not unusual. The same table also shows that decreasing the pH of lactated Ringer's solution to 1 has a dramatic effect on corrosion rate. Table 9.14 summarizes data obtained for Co-Cr, 316L stainless steel and titanium. The type of electrochemical technique used has an important influence on the results, which might indicate that the electrode potential determines the beneficial or detrimental effect of proteins on corrosion. 9.3.5 Antibiotic-metal interactions The interaction between a number of antibiotics (oxytetracycline, tetracycline, tobramycin, clindamycin, cefamandole, bacitracin and chloramphenicol) and surgical metallic materials (316L stainless steel, Co-Cr and commercially pure Ti) has shown that only oxytetracycline exerts an effect on the electrochemical response. For all the materials this antibiotic shifted the corrosion potential of abraded surfaces in the noble direction, as seen in Figure 9.8.

Table 9.12

Main Electrochemical Parameters in ISO Sweat (Randin, 1988) ECOJVSHE) Epu O2 O06 0.06 0.04 -0.09 -0.02 0.23 0.31 0.23 0.07 -0.09 0.12 0.21 J 0.08 0.17 0.29 -0.02 0.09 0.45 0.08 0.26 0.22 0.26 -0.15 -0.26 -0.10 -0.12 VSHE 1.1 0.43 0.08 0.60-1.05 0.43 0.32 0.32 0.50 0.53 >0.89 0.46 0.46 0.2 0.85 0.61 >0.75 >0.75 >3.0
1

COnO2
2

icorrN2 (\iA/cm2) 018 <0.1

Materials 200 CuNi25 Ni 5 0 Al 5 0 Ni 6 0 Al 4 0 Ni 7 0 Al 3 0 WC+Ni TiC+Mo2C+Ni White gold FN 42 NiIo Alby K NiTi AISI 303 12/12 AISI 304 AISI 316F 316 PX AISI 316L HastelloyX Phydur NiP NiP/450C PdNi SnNi Cr Sandvik 1802 Shomac Co Co 5 0 Al 5 0 WC+7% Co WC+10% Co Stellite 20 Ni

N2 ^016 -0.09 -0.17 -0.20 -0.07 -0.11 0.25 -0.01 -0.24 -0.24 0.03 -0.04 J 0.09 -0.06 0.26 -0.19 -0.15 0.33 0.07 0.21-0.36 -0.02 0.15 -0.24 -0.29 -0.24 -0.25

(\xA/cm ) 22 24 3.6 2.2 19 0.6 -10 190

0.1 0.1 2.4 0.32

0.53 40 18 -0.1

340 18 200 480

-0.1 -0.1 -0.1

9.4 ASPECTS RELATED TO THE OXIDE AND OTHER SURFACE LAYERS 9.4.1 Effect of anodizing and passivation treatments on the corrosion resistance of titanium For a detailed description of anodic oxidation of titanium and its alloys the reader may refer to a review by Aladjem (1973). The oxide on titanium can grow to thicknesses of the order of 100 nm or more by applying anodic currents in suitable electrolytes. H 3 PO 4 and NaOH baths have been used for this purpose. The colour of the oxide

Table 9.13 Electrochemical characteristics of Ti6A14V alloy in three biosimulating solutions (Lewis, 1993b) Solution Lactated Ringer's (pH = 6.5) Lactated Ringer's (pH = 6.5) + 5% bovine serum Lactated Ringer's (pH = 1)
a b

Ecorr* $ab $cac (mV) (mV per decade) 185 336 147 210 187 306 301 234 1650

Rpd Rce (M Q/cm2) 2S7 1.45 0.33 LOO 0.70 0.22

idcf iac% (nA/cm2) 21 31 340 54 65 510

Corrosion potential. Anodic Tafel slope. c Cathodic Tafel slope. d Polarization resistance; obtained from d.c. results. e Polarization resistance; obtained from a.c. results. f Corrosion current density; obtained from the values for Rp. g Corrosion current density; obtained from the values for Rc.

Potential (mV vs S.C.E.)

TIM*

(minutes)

Figure 9.8 Potential-time curves for pure titanium in 0.9% saline with and without additions of oxytetracycline: O(upper line), as received; O](lower line), abraded; O0.01 mg ml1; D 0.1 mg ml1; A 1.0 mg ml1, (von Fraunhofer et ai, 1989.)

Table 9.14 The influence of proteins on the corrosion resistance of metals

Material Effect

Remarks Accelerated anodic corrosion method: 10% serum (Hughes et aL, 1990) Anodic polarization curves; 10% serum (Chawla et aL, 1990) Polarization resistance method; static conditions 10% serum (Williams et aL, 1988) idem

F75 Co-Cr-Mo alloy Increased corrosion rate with porous coating of F75 beads Marginal increase in 316L stainless steel pitting potential Increased corrosion 316L stainless steel rate* cp titanium Ti-6A1-4V cp. titanium Increased corrosion rate Insignificant effect Dual role

316L stainless steel

F75 Co-Cr-Mo alloy 316L stainless steel

idem Beneficial effect in the absence of breakdown and detrimental when attack takes place; potentiodynamic and galvanostatic experiments; 10% serum (Sousa and Barbosa, 1993) Potentiodynamic and Increased pitting galvanostatic experiments; potential 10% serum (Sousa and Barbara, 1991) Constant potential (50OmV vs. Increased Co and SCE); 10% serum (Brown Cr release et aL, 1988) Decreased weight loss Constant potential (50OmV vs. SCE); 10% serum (Brown et aL, 1988)

* Under fretting conditions the corrosion rate decreases.

changes with thickness due to light interference. A gold colour corresponds to a thickness of the order of 10-25 nm whereas a blue colour is normally associated with thicknesses of 30-60 nm. The corrosion resistance of anodized titanium increases as the oxide becomes thicker. This is illustrated in Figure 9.9 (Cigada et aL 1992), which shows that films formed in H3PO4 are thicker than those formed in air. They are also more protective, since the passive current density in a buffered physiological solution at 38C is ca. 10% that measured for specimens oxidized in air. The same figure shows that anodizing in NaOH is not so effective in reducing the current density as doing it in H3PO4. The corrosion rate of anodized titanium (solution: 60 ml ethanol, 35 ml water, 10 ml lactic acid, 5 ml phosphoric acid, 5 mg citric acid and 5 mg oxalic acid; 45V, 45s) is much lower than that of passivated titanium (40%

Specimens oxidized in air

Specimen anodizea in NaOH

Specimens anodized in H3PO4

high current density

low current density

Oxide thickness

Figure 9.9 Average passivity currents (between 600 and 800 h) and standard deviations in physiological solution of Ti6A14V specimens, oxidized and anodized in different conditions. (Cigada et al. 1992.)

volume nitric acid, room temperature, 30 min.), as indicated in Table 9.15 (Ong et al, 1993). The corrosion potential of the former is also more noble, as indicated in the same table. The average thicknesses are given in Table 9.16. The anodized film is ca. 10 times thicker than the passivated film. There have recently been reports (Lowenberg et al, 19941 Callen et al, 1995) indicating that passivation of Ti-6A1-4V in HNO3 increases the release of all three constituent elements in a culture medium (a-Minimal Essential Medium with 15% foetal bovine serum and 10% antibiotics). Table 9.17 exemplifies the results obtained for titanium ions, for three periods of immersion of three days each. The level of Ti is significantly reduced throughout the 9-day experimental period.

Table 9.15 Treatment

Corrosion results (Ong et al, 1993) Average Ecorrl SD (mV) -138.425.9 -104.722.8 34.417.4 Average Icorrl SD (\xA/cm2) 0.0150.01 0.0030.001 90.00060.0001

Non-passivated Passivated Anodized

Table 9.16 Titanium oxide thickness (nm), relative to tantalum pentoxide (Ong et al, 1993) Treatment Non-passivated Passivated Anodized Mean 3.1 4.1 43.6 SD 0.6 1.8 4.9 Sample size 1.8 1.8 1.5

Table 9.17 Trace Levels of Ti, Al, and V in culture medium (Callen et al, 1995) cpTi Wells T16A14V Wells Time Not Not Control points Passivated Passivated Passivated Passivated Values Ti 1st 23.69612.892 15.7353.354 12.5993.850 23.3388.497 4.9830.977 2nd 12.6505.275 16.6404.940 11.0501.601 24.6458.419 3rd 6.4442.495 8.738+2.983 5.5131.943 10.4863.674 Al 1st 4.0910.677 4.1330.523 8.9331.187 16.8784.574 3.476+0.392 2nd 4.6941.039 5.5232.784 5.703+0.707 9.656+2.750 3rd 5.2151.096 4.1490.397 4.5160.384 6.6141.407 V
1st 2nd 3rd 0.5080.199 0.2550.018 0 0.3660.167 0.1710.051 0.3300.213 6.195+2.191 2.7891.129 0.5880.334 21.1048.828 10.0965.697 4.2182.003 0.2460.082

9.4.2 Effect of coatings and surface treatments on the corrosion resistance of stainless steel and titanium

When metals are used as coatings the possibility of occurrence of galvanic corrosion exists, since cracks or pores in the coating enable the corrosive medium to contact the substrate. Mainly for this reason metallic coatings have not been used in internal implants. However, surface treatments with inert materials have been widely applied and are now in clinical practice. The effect of these and other surface treatments will be addressed in this section. With the development of ion implantation the plating of practically any element on any substrate opened new perspectives to surface modification of biomaterials. Carbon and nitrogen have been the species most widely employed to modify the corrosion and wear behaviour of stainless steels and titanium alloys. However, the plating of metallic elements, with a view to modifying either the corrosion performance and/or the biological behaviour of metallic implants, is an interesting possibility. This would be particularly valuable in the case of stainless steel substrates. Very little

has been reported in this area. Titanium, niobium and tantalum coatings on stainless steel act as anodes, therefore indicating that they may retard the transfer of chromium and nickel into the environment (Gluszek and Masalski, 1992). In the same medium (Ringer's solution) the oxide layers formed on titanium, niobium and tantalum by prolonged (10Oh) exposure to air are not very stable. Figure 9.10 shows this effect (dotted line). The galvanic current first increases, corresponding to modification/destruction of the original oxide layer, and then decreases, corresponding to increased stability of the film formed in solution. When freshly ground specimens are used (solid line) the galvanic current decreases with time, due to film growth, which follows a logarithmic law [log i c (- log t)]. Laser surface alloying (LSA) of Ti6A14V with Nb, Mo and Zr, in order to increase surface hardness, has shown that the latter element is the most promising (Akgun and Inal, 1994). The hardness increase is almost threefold in comparison to the substrate and identical to that obtained by laser surface melting (LSM). Since a nitrogen atmosphere was used in LSA and LSM, TiN formed during melting appears to be the main reason for the

anode

cathode passivated

1 minute 1 hour 7L hours

Figure 9.10 Galvanic current density-time relationship for 316L/titanium couple in Ringer's solution. (Gluszek and Masalski, 1992.)

high hardnesses obtained. The hardened zone extends to a depth of over 0.5 mm. Wear and fretting corrosion could be considerably reduced with such surface treatments, but no experimental data are yet available. Radio-frequency (RF) plasma treatments in air (1.0 torr) produced enhanced ionic release from Co-Cr-Mo and Ti-6A1-4V alloys, without any improvement in biological behaviour (Kummer et al, 1992). Table 9.18 gives the Cr, Co and Ti concentrations obtained after 10 days exposure to cell culture fluid (DMEM with 10% FBS). The RF plasma-treated Ti-Al-V alloy shows a 3-fold increase after the plasma-treatment. Depassivation of Ti-6A1-4V occurs during planar-planar rubbing against PMMA in Ringer's solution (Rabbe et ai, 1994). The free corrosion potential drops to values below -650 mV vs. SCE. This potential is substantially lower than those obtained for nitrogen ion-implanted and ion-nitrided Ti-6A1-4V, which are of the order of, -100 mV vs. SCE. At high doses (~2xlO18 ions/cm2) a TiN layer is formed on ion-implanted surfaces, whereas TiN and Ti2N form as a result of ion nitriding, thus increasing the hardness of the alloy surface. Superalloy MA 956 (Fe-20Cr^.5Al-0.5Ti-0.5Y2O3, wt%) possesses the interesting ability of developing a fine a-alumina scale on the surface upon isothermal treatment at 110 0C (Escudero and Gonzalez-Carrasco, 1994). This layer acts as a coating, being responsible for an improved corrosion resistance of the alloy, as indicated by the anodic polarization curves given in Figure 9.11. No pitting corrosion occurs for potentials up to 700 mV vs. SCE. Hard ceramic coatings (Al2O3 and SiC) deposited by radio-frequency (RF) sputtering on Ti and Co-Cr-Mo alloy resulted in significant corrosion resistance improvement, as seen in Table 9.19 (Sella et ai, 1990). The data in this table were obtained by applying a constant potential of 1.4 V vs. SCE and measuring the corrosion current density (c.d.) in artificial saliva. SiC coatings deposited on Ti caused a decrease of c.d. of ca. 300 times. The same coating applied to Co-Cr-Mo was only effective when an intermediate Ti sublayer was used to avoid cracking. An Al-Al2O3 Table 9.18 Concentration of Cr, Co and Ti in cell culture fluid after 10 days (Kummer et al, 1992)
concentration (\jJmL) Sample Cr Co <2 720 960 Ti Control 1.1 Co-Cr-Mo 96.5 Co-Cr-Mo/RF 120.5 Ti-Al-V Ti-Al-V/RF RF = Radio-frequency plasma treated.

35.6 102.0

CURRENT DENSITY, ( j u A / c m 2 )

POLARIZATION, m V S C E Figure 9.11 Anodic polarization curves for MA956 in the as-received and oxidized conditions after nine months of immersion in Hank's solution. O Oxidized; D as-received. (Escudero and Gonzalez-Carrasco, 1994.)

cermet sublayer was also very effective in improving the corrosion resistance of Al2O3-coated Co-Cr-Mo alloy; the c.d. decreased 200 times when both layers were used. The authors indicate that Al2O3 and SiC coatings gave better biocompatibility than Ti and that no signs of corrosion were observed on Al2O3-coated dental implants removed after several years of implantation. Modification of Ti-6A1-4V alloy surfaces by ion implantation with iridium, at fluences of 0.74 x 1016 and 1.48xlO16 ions/cm2, corresponding to 2.5 and 5.0 at% Ir peak concentrations, has been reported (Buchanan
Table 9.19 Comparison of the corrosion currents of coated and uncoated metals (Sella et al, 1990) Corrosion current at E=IAVZSCE (\LA/cm2) Uncoated metal or alloy Ni-Cr Co-Cr-Mo Ti Experimental coatings SiC (1 |mm) on Ti SiC (1 juim) on Co-Cr Ti (1 juim) on Co-Cr SiC (1 |xm) + Ti (1 |mm) on Co-Cr Al 2 O 3 (0.5 fxm) on Co-Cr Al 2 O 3 (0.5 jxm) + Al-Al 2 O 3 cerment on Co-Cr 6000-8000 8000 260 0.8 10000 500 28 1800 40

and Lee, 1990). After pre-treatment of the implanted surfaces in IN H2SO4 the surfaces become enriched in Ir (the concentrations are over 60% and may approach 100%), as a consequence of alloy dissolution. The result is a corrosion potential in isotonic saline very close to that of pure Ir, as depicted in Figure 9.12. Owing to the very high corrosion resistance of Ir, its implantation onto titanium is of potential interest, particularly if it becomes significantly enriched on the surface. Galvanic couples formed between Ir and Ti is a possibility that justifies further research. In an attempt to reduce the release of potentially harmful metal ions from Co-Cr-Mo surgical implants, a thin coating of TiN has been applied via physical vapour deposition (PVD) (Wisbey et al, 1987). In vitro corrosion performance has been investigated using electrochemical techniques. The release of Co and Cr ions is reduced by the presence of the TiN coating. Data concerning this study are shown in Figure 9.13. Thermal heating of titanium at 400 0C or immersion in 30% HNO3, followed by aging in boiling distilled water for times in the range 6-14 h, greatly reduced the amount of Ti and Al released from Ti-6A1-4V, as shown in Table 9.20 (Browne and Gregson, 1994). The corrosive medium was bovine serum at 37 0C. The table also gives the ion release for two other treatments: immersion in 30% HNO3, for 10 min., which is the conventional commercial treatment, and immersion for 16h in the same solution followed by rinsing in distilled water (N). The beneficial effect of the first two treatments is attributed to formation of rutile, which is

POTENTIAL (mV vs SHE)

2JS a t % Ir IN Ti-SAMV 5.0 at. % Ir IN T W A M V PREPASSIVATED T W A M V

AS-POLISHED T H 6 A M V

TIME (d)

Figure 9.12 Corrosion potential vs. time in aerated isotonic saline. (Buchanan and Lee, 1990.)

more dense and has a closer packed structure, with fewer paths for ion diffusion, than the oxide formed upon passivation in nitric acid. Commercially pure titanium and Ti-6A1-4V implants ion implanted with nitrogen heal as well as non-treated samples in cortical bone (Johansson et al, 1993), as indicated by the existence of no statistically significant differences in total bone-metal contact.

Metallic release density (yg/cm2)

Cobalt

Chromium

Molybdenum

Titanium

Figure 9.13 Metallic dissolution products released from a polished Co-Cr-Mo alloy after 550 h in 0.17 M NaCl+2.7xlO3 M EDTA solution at 37C. D uncoated; TiN coated. (Wisbey et ai, 1987.) Table 9.20 Effect of various surface treatments on the dissolution of titanium and aluminium from Ti-6A1-4V alloy (Browne and Gregson, 1994)
Total ion release (yug/cm2) Titanium 700 h 30% HNO 3 (C) 30% HNO 3 (N) 4000C (T) Aged 10 h (A) CANT0.1 0.11 0.03 0.03 Aluminium 700 h

0.25 0.06 0.026 0.023

Conventional treatment (10 min. immersion). Aging treatment (immersion in destilled water). Immersion in HNO3 for 16 h. Thermal heating.

9.4.3 Effect of hydroxyapatite coatings on the corrosion resistance of titanium and stainless steels

Most of the data available on this topic refer to hydroxyapatite deposited by plasma spraying. Although compounds may form at the metal/hydroxyapatite interface, particularly in the case of titanium, their existence has not been unequivocally demonstrated. Titanium phosphates and phosphides, as well as calcium titanates, may exist, but they probably form very thin layers. The large surface roughness, caused by grit blasting of the substrate prior to hydroxyapatite deposition, is another factor that renders identification of any interfacial compounds by surface analysis techniques difficult. Table 9.21 shows that the corrosion resistance of stainless steel increases upon coating with hydroxyapatite. The presence of calcium phosphate in solution, due to dissolution of hydroxyapatite, seems to be the cause for these changes. The same table indicates that calcium phosphate is detrimental to the corrosion resistance of titanium, both in terms of film breakdown potential and corrosion rate under passive conditions.
9.4.4 Interaction between metal ions and calcium phosphates

Metallic ions may influence the formation of calcium phosphates in different ways. Some inhibit (nickel, tin, cobalt, manganese, copper, zinc, gallium, thalium, molybdenum, cadmium, antimony, magnesium, and mercury), a few stimulate (iron [ferric] and iridium) whereas others have no effect (cerium, titanium, chromium, iron [ferrous], iridium, palladium, platinum, silver, gold, aluminum, and lead) (Okamoto and Hidaka, 1994). Figure 9.14 gives the induction time for calcium phosphate formation vs. concentration for the above metal ions.
Table 9.21 Effect of hydroxyapatite coatings and calcium phosphate solutions on the corrosion resistance of titanium and stainless steel Material 316L ss/HA Solution Saline Effect Ref. Increase in breakdown potential Hayashi et al., 1990 Decrease in breakdown potential Hayashi et al, 1990 Increase in breakdown potential Sousa and Barbosa, 1991 Decrease in corrosion rate Barbosa, 1991b (passive state) Decrease in breakdown potential Sousa and Barbosa, 1993 Increase in corrosion rate Barbosa, 1991b (passive state)

Ti-6A1-4V/HA Saline 316L ss 316L ss Ti cp Ti cp Saline+ Ca phosphate Saline+ Ca phosphate Saline+ Ca phosphate Saline+ Ca phosphate

Induction time (min)

Concentration (pM)

Figure 9.14 The induction time (min) versus concentration of various metal ions (open circle) and HEBP: 1-hydroxyethylidene-l, 1-biphosphonate (closed circle). (Okamoto and Hidaka, 1994.)

Heat treatment of Ti-6A1-4V at 280 0C for 3 h produced a high accumulation of Ca deposited next to screws implanted in rats (Hazan et al, 1993), as indicated in Table 9.22. The oxide was twice as thick as that formed on non-treated screws. The presence of Ca on the surface of titanium implants after a period in vivo is now well established. Ca deposition may be important in influencing protein adsorption, since it has been suggested that glycosaminoglycans adhere to the surface by a Ca-O link rather then via a Ti-N bond (Sutherland et al., 1993). Aluminium induces demineralization of previously formed bone (Frayssinet et al., 1994), which can be ascribed to formation of stable complex aluminium phosphate compounds (Ribeiro et al., 1995). Aluminium ions may be produced either as a result of dissolution of Ti-6A1^4V alloy or of corrosion of alumina coatings. In pH 4 buffer the release of aluminium ions from alumina is much more significant than at
Table 9.22 Calcium deposition (mg) next to control and heat-treated Ti-6A1-4V implants (Hazan et al 1993) Time after immersion (days) 4 5 6 10 35 Control 2.00.2 3.10.5 4.01.0 Heat treated 4.56.5 7.41.1 9.61.0

pH 7 (Frayssinet, 1994). V and Ti retard apatite formation and the growth of apatite seeds, as illustrated respectively in Figures 9.15 and 9.16 for V (Blumenthal and Cosma, 1989). The action of V appears to be related to the formation of V-PO4 complexes, whereas that of Ti may be due to poisoning of active growth sites, as in the case of Al. Hydroxyapatite coatings applied to porous titanium alloys significantly reduced the titanium and aluminium releases, but had no important effect on vanadium release, as shown in Figure 9.17 (Ducheyne and Healy, 1988). No major change was produced in the ion release kinetics from Co-Cr alloys.

NaOH Uptake (ml 0.04N NaOH)

Time (hours)

Figure 9.15 The action of V ions in affecting direct HA precipitation, V as VCl5 in solution at pH 7.4, 0.15 M NaCl, 37C in a pH-stat. The quantity of HA precipitated is proportional to the extent of OH uptake. Ca concentration is 2.79 mM; PO4 concentration is 1.87 mM, A= control (no V); B=0.50 mM V; C=LOO mM V; D=2.00 mM V. (Blumenthal and Cosma, 1989.)

NaOH Uptake (ml 0.04N NaOH)

Time (hours)

Figure 9.16 The action of V ions on the growth of HA seeds. V as VCl5 in solution at pH 7.4, 0.15 M NaCl, 37C in a pH-stat. The amount of HA seeded growth is proportional to the OH uptake. Ca concentration is 1.55 mM; PO4 concentration is 1.07 mM, Seed crystals were 0.15 mg/mL, and the seeds had a surface area of 110 m2/g. A = control (no V); B = 1.00 mM V. (Blumenthal and Cosma, 1989.)

9.4.5 Physico-chemical properties of metal oxides

The corrosion resistance of some metals ultimately depends on the presence of a thin oxide film formed by the reaction of the metal with the environment. This is the case of titanium, tantalum, zirconium, molybdenum, aluminium, cobalt, chromium, etc. Table 9.23 gives the physicochemical properties of the oxides formed on some metals. A low oxide solubility is important to guarantee a low rate of corrosion, since any loss in oxide thickness, due to chemical dissolution, will tend to be balanced by oxidation of the metallic substrate. The oxides should also possess low ionic conductivity.

CONCENTRATION (ng/ml)

CONTROL
Ti

TlHA

TIME (WEEKS)

CONCENTRATION (ng/ml)

CONTROL AL ALHA

TIME (WEEKS)

CONCENTRATION (ng/ml)

CONTROL V VHA

TIME (WEEKS) (C)

Figure 9.17 (a, b, c) The release of Ti, Al and V from the Ti alloy after 1, 2 and 4 weeks of immersion; D.L. indicates the detection limit of each element. Error bars represent the 95% confidence interval on the means. (Ducheyne and Healy, 1988.)

Table 9.23 Selected physico-chemico properties of metal oxides in water (Tengvall and Lundstrom, 1992)
0.996 Na(FeCN64FeCN63- ) polarization Dielectric Isoelectric Charge onst for resistance, Rp point atpH7 oxide Essential (Kfl/cm2)

Order of practical mobility Element

Water corrosion product

PK of
hydrolysis

Solubility atpH7 (M)

Soft tissue reaction

Corroded in H2O2 atpH7

Corrosion product

2 3 4 7

Nb Ta Au Ti

14 19 21

Ag Al Cr

28

Fe

29 30 40

Ni Co V

Nb2O5 >20 -io-5 Ta2O5 >20 -io-5 Au2O3 7xlO"2 Au(OH)3 5xlO6 (pH7) TiO2 anat. +18 3xlO6 brook, rutile Ag2O +10 IO4 + AgOH Ag +0.7 >1 Al2O3 a 14.6 IO6 Al(OH)3 am. io-3 Cr2O3 -1.8(Cr(OH)2+) I IO-11 CrO3 >1013 Cr(OH)3 18.6(CrO2) Fe2O3 >io-10 -13.3 (Fe2+) Fe(OH)2 io-1 (PH 9.1) Fe(OH)3 io-9 Ni2+ io-15 12.2 (Ni2+) NiO io-11 (pH 8.9) Co2+ io-11 -12.6 CoO io-12 V2O5 >i +10.3 (HV2O-)I V2O4 io-4

280 12 >10 (calc.)I ++ 6.2 48 78 110 9

+

455 1430 0.28 714

(Ag+)12 -9 8.4 (Cr3+)

+

No No Yes Au2O3 ]E0 - 1.04V No Yes No TiO22 TiO2 TiO2 No S equestrattion Yes AgONo Yes 5Sequestration Toxicity Yes Yes Yes ? CrO42HCrO4FeO42?

No No No

Inert? Inert? 5Sequestration

5-10 12

12.4 (Fe2+;) 8.0 (Fe3+) 9.5 10.8

: 1-2.5 (V ; )
5+

Toxicity 100 Sitainless steel 3 K5 Yes <Sequestration 30-38 4.38 Yes CoCrNi 3.32 Yes Toxicity Yes Toxicity Yes Toxicity

Yes CoO2 Yes

NiO42-? NiO2

H3V2O7H2VO4-

9.4.6 Passive films on metallic implants

The oxide film on metallic implants is usually very thin (5-10 nm). It is formed as a result of a spontaneous reaction between the metal and the environment. In spite of the common use of immersion treatments in nitric acid solutions, usually known as passivation treatments, they are not necessary to form an oxide. They are often responsible for an increase in corrosion resistance due to removal of surface contaminations or inclusions, as in the case of stainless steels. As indicated in section 9.4.1, there have been reports suggesting that this acid treatment may decrease the corrosion resistance of titanium. Generally, the oxide film grows according to a logarithmic law (log thickness proportional to log time), reaching a quasi-stationary thickness very rapidly. Under stationary conditions, film dissolution and film formation rates should be the same. Normally, film thickness increases slowly with time, after an initial period of rapid growth. This is illustrated in Figure 9.18, which depicts film thickening with implantation time (Kasemo and Lausmaa, 1994). The dissolution kinetics of titanium follows a two-phase logarithmic model (Healy and Ducheyne, 1992, 1993). In the first phase the concentration of OH groups increases. The second phase coincides with the adsorption of P-containing species. Figure 9.19 clearly indicates the presence of a second phase after 40Oh of immersion. In the initial phase titanium is released either in the form of Ti(OH)n^11)+ or TiO(OH)2. In the second phase adsorption of H2PO4" Ti(OH)3+(ox) + H2PO4-(aq) -> Ti4+(ox) . HPO42(ad) + H2O(aq) followed by desorption into the concentration boundary layer Ti4+(Ox). HPO42-(ad) -> Ti HPO42+(aq) + (ox) (charge transfer) In the bulk electrolyte the complex ion dissociates TiHPO42+(aq) + H+ (aq) -> Ti4+(aq) + H2PO4 -(aq) and forms a more stable complex Ti4+ (aq) + 4OH~ (aq) -> Ti(OH)4 (aq) In these reactions (ox) represents O24~ in TiO2. This mechanism is consistent with the hypothesis that in the second stage dissolution kinetics is dependent on diffusion within the concentration boundary layer. It is conceivable that in the first stage field assisted dissolution may be the controlling step. In this stage formation of Ti(OH)4 or of hydroxy-cations, e.g. Ti(OH)3+, has different effects on titanium transport. While Ti(OH)4 does not react with organic molecules, Ti(OH)3+ can form organometallic complexes which may be transported systemically.

Figure 9.18 An artist's attempt to capture some of the complexity involved in the interaction between a material and living tissue, exemplified here by a titanium implant in bone. Note the wide range of dimensions and time scales that are relevant. (Kasemo and Lausmaa, 1994.)

Ti Concentration (ng/ml cm^)

Time (hours)

Time (hours)
(b) Figure 9.19 Normalized integral passive dissolution kinetics for titanium thin films immersed in EDTA/SIE (simulated interstitial electrolyte): (a) real time data empirically fitted with two-phase logarithmic law relationship; (b) a semilogarithmic plot of the data demonstrating the two-phase logarithm relationship. The correlation coefficient for the least-squares fit of the linear functions are given. (Healy and Ducheyne, 1992.)

Airborne titanium oxide, TiO2_x, is oxygen (!efficient but upon immersion in simulated interstitial electrolyte with EDTA (a metal chelating agent) changes to nearly stoichiometric TiO2 (Healy and Ducheyne, 1993). TiO2 is also reported to exist on the surface of a new Ti-15Zr-4Nb-2Ta-0.2Pd alloy (Okazaki et aL, 1994). The other oxides present were ZrO2, Nb2O5 and Ta2O5. Sterilization by various methods (conventional steam autoclaving, dry heat sterilization in air at 160-1800C, and packaging and sterilization in sealed glass ampoules) originates films with the composition TiO2. Their thickness is 2-6 nm, depending on the method of sterilization. Heat sterilization increased the thickness of the original oxide by a factor of ca. 2 (Lausmaa and Kasemo, 1990). Films formed on metallic materials oxidized in pure oxygen at 300 C for 30min. have the composition shown in Table 9.24 (Oshida, 1992). Strong oxidative conditions may exist in vivo, for example due to presence of the superoxide anion, O2", formed by inflammatory cells. The possibility of O2" originating hydrogen peroxide, H2O2, has led Tengvall et aL, (1989) to suggest that hydrogen peroxide may be of great importance to the biological behaviour of titanium. Hydrogen peroxide is responsible for the appearance of an outer layer, formed on top of a TiO2 layer, composed of titanium oxi-hydroxide or hydrates, non-stoichiometric and rich in water (Pan et aL, 1994). The oxide thickness for wet-ground specimens is ca. 3 times that for dry-polished specimens, as shown in Table 9.25. Hydrogen peroxide reduces the oxide thickness and results in enhanced dissolution of titanium, according to the same authors. It is not certain whether titanium acts as a catalyst in the oxidative deterioration of biological molecules, a property which has been established for other metals, e.g. iron, copper, cadmium, chromium, lead, mercury, nickel and vanadium (Stohs and Bagchi, 1995). These metals produce reactive oxygen species, leading to lipid peroxidation, DNA damage, depletion of sulphydryls, apart from modifying calcium homeostasis. Since large concentrations of titanium debris may be found around Ti and Ti-alloy implants (section 9.3.1) the oxidative deterioration of biological molecules induced by the presence of Ti ions is a process that deserves to be studied.
Table 9.24 Type of oxide formed on biomaterials (pure oxygen, 3000C, 30 min.) (Oshida et aL, 1992) Material Pure Ti Ti-6A1-4V Ni-Ti, austenitic and martensitic 316L stainless steel a Possible composition. Type of oxide TiO 2 (rutile) TiO 2 with traces of Al 2 TiO 5 Mixture of TiO 2 and NiTiO 3 spinel-type [(Fe9Ni)O (Fe,Cr) 2 O 3 ] a and corundum-type oxides [(Fe,Cr) 2 O 3 ] a

Table 9.25 Thickness (nm) of titanium oxide films (Pan et ai, 1994)
Source

Polarized at 0.4 V/SCE Dry-polished Wet-ground 1.5 1.2-1.6 4.6 4-5 0 6.3 6.7 6.6 1 6.2 5.5 10 5.8 6.0

H2O2 in the PBS (mM) XPS measurements Capacitance measurements Literature data

The oxide formed on titanium upon passivation in HNO 3 is composed of regions of mixed titanium oxides (anatase and rutile), together with areas of amorphous titanium oxide (Browne and Gregson, 1994). Films formed on anodized titanium may be one order of magnitude thicker than those formed by passivation (section 9.4.1). The film is predominantly constituted by TiO 2 , with the presence of carboxyl groups (Ong, 1993). It appears that upon passivation of cp Ti and Ti-6AI-4V alloy the film on the former is thinner (3.2 0.8 nm) than that on the latter (8.3 1.2 nm) (Keller et ai, 1994). TiO 2 films are generally amorphous, except in the case of thick films produced by thermal oxidation or anodizing. Table 9.26 summarizes the characteristics (composition, oxide thickness, surface Table 9.26 Summary of surface characteristics of the four different types of Ti samples (Larsson et al, 1994)
Surface topography Surface roughness Rough, with grooves, pits and protrusions, <10|xm Rrms=294nm Substrate microstructure Oxide crystallinity

Preparation Clinical reference

Composition

Oxide thickness

Plastically deformed, amorphous metal surface Non-crystalline oxide Polycrystalline Electropolished TiO2+55-90% C, 4-5 nm Smooth, with metal surface occasional pits, traces of Ca, S, Non-crystalline < 1 |mm Si, P, Cl and NaL Rrms = 2.70.9 nm oxide Polycrystalline Smooth, with Electropolished + TiO2+55-70 %C, metal surface pits and porous anodized, 10 V traces of Ca, S, 21 nm regions, -10 jxm Non-crystalline Si, and Cl oxide Rrms=1.5l nm Polycrystalline Heterogeneous, Electropolished + TiO2+~34-40% metal surface. with smooth or anodized, 10 V -\- C, traces of Ca 180 nm Crystalline porous regions, and Cl oxide - lOjxm (anatase) Rrms=162nm

TiO2+45-80% C, 4nm traces of Ca, S, Si, P, Cl and Na

topography/roughness, and substrate microstructure/oxide crystallinity) of titanium samples subjected to various treatments (Larsson et al, 1994). Electropolished + anodized (IM acetic acid, room temperature) films are thicker than those formed by electropolishing and on 'clinical reference' (machined) surfaces. For 80V the oxide is crystalline. Table 9.27 summarizes the composition and thickness of oxides formed on a Co-Cr-Mo alloy exposed to 'dry air' and 'wet steam' for 1 h (Lewis, 1993a).
9.4.7 Contact angles of oxide-covered surfaces

When a metallic surface covered by an oxide (either formed naturally or by an appropriate treatment) is placed in contact with the body or a culture medium adsorption of various species, namely proteins, is the prime event. Contact angle, 6, measurements can be used to ascertain the afinity of a liquid to a biomaterial surface, in particular when adsorption occurs, which is revealed by a decrease in 0. Generally speaking, 0 is governed by the intermolecular forces between solid and liquid, and in the case of passive metals by the forces between metal oxide and liquid, is a complex function of surface roughness, oxide crystallinity and composition, liquid composition and time. Normally, wettability tends to progress from hydrophobic to hydrophilic. Table 9.28 gives the initial contact angles and the changes in contact angle as a function of time, d0/dt, for a number of materials (Oshida et al, 1992). Pure Ni and Ti-6Al-AV have the lowest initial contact angle, 0O, with low d0/dt; 316L stainless steel and Co-Cr alloy have high 0O with low d0/dt; and pure Ti, Ni-Ti alloys and a-alumina have high 0 and high d0/dt. Shot-peening and pre-oxidation (300 C, 30 min.) of the above materials reduced the standard deviation of contact-angle measurements, probably as a result of minimization of microscopic irregularities (Oshida et al, 1993). In this work pure Ti exhibited the highest initial contact angle 0O, and also the most noble corrosion potential. Both are related to the characteristics of the TiO2 oxide that covers the metal surface. Note that the value of 0 for Al2O3 is also high (Table 9.28).
Table 9.27 Composition of oxides formed on a Co-Cr-Mo alloy (Lewis, 1993a) Medium Dry air Wet steam Composition Co14Cr5MoO21 Co3Cr6MoO20 Thickness 4 nm 3 nm Remarks May disaggregate into Co, Cr, Mo, CoO, CrO2 and Mox(OH)y and suboxides of Co, Cr and Mo May disaggregate into Co, Cr, Mo, Co(OH)2, Cr2O3, CoOOH, CoMoO4, Mox(OH)y and suboxides and hydrated species of Co, Cr and Mo

Table 9.28 Initial contact angles and changes in contact angles as function of time of oxidized surfaces of biomaterials after mechanical and buff polishing (Oshida et al., 1992) Mechanical polish-oxidizing o(deg) Pure Ti Ti6A14V NiTi (m) NiTi (a) 316Ls.s. Pure Ni Co-Cr alloy a-alumina 54.24 32.08 69.88 71.88 56.46 35.72 62.04 60.87 o6/or -0.0046 -0.0010 -0.0055 -0.0048 -0.0024 -0.0016 -0.0023 -0.0044 Buff polish-oxidizing e/^ -0.0015 -0.0053 -0.0025 -0.0021

%(deg) 30.85 68.92 55.73 61.85

m - martensite; a - austenite.

Table 9.29

Critical surface tension of Ti surfaces (Kilpadi and Lemons 1994) Critical Surface Tension, TC Plot (dyn/cm) C P D C P D 46.01.08 42.51.08 31.60.48 35.4+0.48 34.90.48 40.00.41 41.40.59 40.70.59 41.90.79 41.5+1.05D 42.51.05 37.4+0.51 31.00.30 41.80.51

Specimen I

Comments No liquids were appropriate Only diiodomethane and bromonaphthalene were used Water was not used in these analyses, as it did not fit with Good's criterion and also did not fall in line with the other liquids Only glycerol and thiodoethanol were used Only diiodomethane and bromonaphthalene were used Only diiodomethane and bromonaphthalene were used Only diiodomethane and bromonaphthalene were used Water was not included Only diiodomethane and bromonaphthalene were used

II

III

C D

IV

C P D C P D

I - Non-passivated, TFGD-treated, polished machined flats; II - Non-passivated, unsterilized, polished machined flats; III - Passivated, dry-heat-sterilized, polished machined flats; IV - Passivated, dry-heat-sterilized, polished coined flats; V - Passivated, dry-heat-sterilized, unpolished flats; C - Composite (includes all liquids); P - only polar liquids; D - only dispersive liquids. RFGD - Radio Frequency Glow Discharge.

The critical surface tension (CST), which is the highest surface tension of a liquid that completely wets a given surface, is given in Table 9.29 (Kilpadi and Lemons, 1994) for titanium subjected to various surface treatments. Polar (double-distilled water, glycerol and thiodoethanol) and dispersive (diiodomethane, bromonaphthalene, dicyclohexyl and decane) liquids were used in the study. Radio frequency glow discharge (RFGD)treated samples showed the higher CST. Grain size (70 vs. 23 |xm) did not affect the CST of polished, passivated, and dry-heat-sterilized titanium surfaces. The equilibrium contact angles of cp Ti and Ti-6A1-4V, both passivated in nitric acid, were 522 and 564, respectively (Keller et aL, 1994). Wettability was measured employing water drops. This similarity in contact angles reflets the similarity in oxide film composition found in the same work. However, the film on the alloy surface was significantly thicker (8.31.2nm) than that on the cp Ti (3.20.8nm).

REFERENCES O.V. Akgun and O.T. Inal, 'Laser surface modification of Ti-6A1-4V alloy', Journal of Materials Science, 29, 1159-1168 (1994). A. Aladjem, 'Review Anodic oxidation of titanium and its alloys', Journal of Materials Science, 8, 688-704 (1973). MA. Barbosa, 'Corrosion mechanisms of metallic biomaterials', Biomaterials Degradation-Fundamental Aspects and Related Clinical Phenomena, European Materials Research Society Monographs, Vol. 1 (eds. MA. Barbosa, F. Burny, J. Cordey, E. Dorre, G. Hastings, D. Muster and P. Tranquilli-Leali), pp. 227-257, Elsevier Science Publishers, Amsterdam (1991 a). MA. Barbosa, 'Electrochemical impedance studies on calcium phosphate-metal interfaces', Bioceramics, Vol. 4 (eds. W. Bonfield, G.W. Hastings and K.E. Tanner), pp. 326-333, Butterworth-Heinemann (1991 b). MA. Barbosa, 'Surface layers and the reactivity of metallic implants', High-Tech Biomaterials, European Materials Research Society Monographs, Vol. 3 (eds. D. Muster, MA. Barbosa, F. Burny, J. Cordey, E. Dorre, G. Hastings, and P. Tranquilli-Leali), pp. 257-283, Elsevier Science Publishers B.V., Amsterdam (1992). J. Black, 'Biological Performance of Tantalum', Clinical Materials, 16, 167-173 (1994) N.C. Blumenthal and V. Cosma, 'Inhibition of apatite formation by titanium and vanadium ions', Journal of Biomedical Materials Research: Applied Biomaterials, 23, 13-22 (1989). M. Browne and PJ. Gregson, 'Surface modification of titanium alloy implants', Biomaterials, 15, 894-898 (1994). SA. Brown, LJ. Farnsworth, K. Merritt, and T.D. Crowe, 'In vitro and in vivo metal ion release', Journal of Biomedical Materials Research, 22, 321-338 (1988).

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J. Gluszek and J. Masalski, Galvanic coupling of 316L steel with titanium, niobium, and tantalum in Ringer's solution, British Corrosion Journal, 27, 135-138 (1992). K. Hayashi, I. Noda, K. Uenoyama, and Y. Sugioka, Breakdown corrosion potential of ceramic coated metal implants, Journal of Biomedical Materials Research, 24, 1111-1113 (1990). R. Hazan, R. Brener and U. Oron, Bone growth to metal implants is regulated by their surface chemical properties, Biomaterials, 14, 570-574 (1993). K.E. Healy and P. Ducheyne, The mechanisms of passive dissolution of titanium in a model physiological environment, Journal of Biomedical Materials Research, 26, 319-338 (1992). K.E. Healy, and P. Ducheyne, Passive dissolution kinetics of titanium in vitro, Journal of Materials Science. Materials in Medicine, 4, 117-126 (1993). PJ. Hughes, S.A. Brown, J.H. Payer, and K. Merritt, The effect of heat treatments and bead size on the corrosion of porous F75 in saline and serum, Journal of Biomedical Materials Research, 24, 79-94 (1990). CB. Johansson, J. Lausmaa, T. Rostlund, and P. Thomsen, Commercially pure titanium and Ti6A14V implants with and without nitrogen-ion implantation: surface characterization and quantitative studies in rabbit cortical bone, Journal of Materials Science: Materials in Medicine, 4, 132-141 (1993). J. Karrholm, W. Freeh, K.-G. Nilsson and F. Snorrason, Increased metal release from cemented femoral components made of titanium alloy, Ada Orthop. Scand., 65, 599-604 (1994). B. Kasemo and J. Lausmaa, Material-tissue Interfaces: the role of surface properties and processes, Environmental Health Perspectives, 102, 41-45 (1994). J.C. Keller, CM. Stanford, J.P. Wightman, R.A. Draughn and R. Zaharias, Characterizations of titanium implant surfaces. Ill, Journal of Biomedical Materials Research, 28, 939-946 (1994). D.V. Kilpadi and J.E. Lemons, Surface energy characterization of unalloyed titanium implants, Journal of Biomedical Materials Research, 28,1419-1425 (1994). FJ. Kummer, J.L. Ricci, and N.C Blumenthal, RF plasma treatment of metallic implant surfaces, Journal of Applied Biomaterials, 3, 39-44 (1992). C Larsson, P. Thomsen, J. Lausmaa, M. Rodahl, B. Kasemo and L.E. Ericson, Bone response to surface modified titanium implants: studies on electropolished implants with different oxide thickness and morphology, Biomaterials, 15, 1062-1074 (1994). J. Lausmaa and B. Kasemo, Surface spectroscopic characterization of titanium implant materials, Applied Surface Science, 44, 133-146 (1990). G. Lewis, X-ray photoelectron spectroscopy study of surface layers on orthopaedic alloys. II. Co-Cr-Mo (ASTM F-75) alloy, Journal of Vacuum Science Technology A, 11, 168-174 (1993a). G. Lewis and K. Daigle, Electrochemical behavior of Ti-6A1-4V alloy in static biosimulating solutions, Journal of Applied Biomaterials, 4, 47-54 (1993b). B.F. Lowenberg, S. Lugowski, M. Chipman, and J.E. Davies, ASTM-F86 passivation increases trace element release from Ti6A14V into culture medium, Journal of Materials Science: Materials in Medicine, 5, 467^472 (1994). S. Lugowski, D.C. Smith, and J.C. VanLoon, Critical aspects of trace element analysis of tissue samples: a review, Clinical Materials, 6, 91-104 (1990).

R.D. Meldrum, R.D. Bloebaum, and L.D. Dorr, Metal ion concentrations in retrieved polyethylene total hip inserts and implications for artifactually high readings in tissue, Journal of Biomedical Materials Research, 27, 1349-1355 (1993). K. Merritt, R.W. Margevicius, and S.A. Brown, Storage and elimination of titanium, aluminium, and vanadium salts, in vivo, Journal of Biomedical Materials Research, 26, 1503-1515 (1992). Y. Okamoto and S. Hidaka, Studies on calcium phosphate precipitation: effects of metal ions used in dental materials, Journal of Biomedicla Materials Research, 28, 1403-1410 (1994). Y. Okazaki, A. Ito, T. Tateishi, and Y. Ito, Effect of alloying elements on anodic polarization properties of titanium alloys in acid solution, Materials Transactions, JJM, 35, 58-66 (1994). J.L. Ong, L.C. Lucas, G.N. Raikar, and J.C. Gregory, Electrochemical corrosion analyses and characterization of surface-modified titanium, Applied Surface Science, 72, 7-13 (1993). Y. Oshida, R. Sachdeva, and S. Miyazaki, Changes in contact angles as a function of time on some pre-oxidized biomaterials, Journal of Materials Science: Materials in Medicine, 3, 306-312 (1992). Y. Oshida, R. Sachdeva, S. Miyazaki, and J. Daly, Effects of shot-peening on surface contact angles of biomaterials, Journal of Materials Science: Materials in Medicine, 4, 443-447 (1993). J. Pan, D. Thierry, and C. Leygraf, Electrochemical and XPS studies of titanium for biomaterial applications with respect to the effect of hydrogen peroxide, Journal of Biomedical Materials Research, 28, 113-122 (1994). O.E.M. Pohler, Degradation of metallic orthopaedic implants, in Biomaterials in reconstructive surgery (ed. L.R. Rubin), Chap. 15, The CV Mosby Co., 1983, pp. 158-228. M. Pourbaix, Atlas of electrochemcial equilibria, NACE/CEBELCOR, 1974. A. Pourbaix, M. Marek and R.F. Hochman, Comportement electrochimique du titane a bas pH et bas potential d'electrode. Rapports Techniques CEBELCOR, 118, RT 197, (1971). L.M. Rabbe, J. Rieu, A. Lopez and P. Combrade, Fretting deterioration of orthopaedic implant materials: search for solutions, Clinical Materials, 15, 221-226 (1994). J.-P. Randin, Corrosion behavior of nickel-containing alloys in artificial sweat, Journal of Biomedical Materials Research, 22, 649-666 (1988). G. Ravnholt and J. Jensen, Corrosion investigation of two materials for implant supraconstructions coupled to a titanium implant, Scandinavian Journal of Dental Research, 99, 181-186 (1991). CC. Ribeiro, M.A. Barbosa, A.A.S.C. Machado, A. Tudor, and M.C. Davies, Modifications in the molecular structure of hydroxyapatite induced by titanium ions, Journal of Materials Science: Materials in Medicine, 6, 829-834 (1995).

C. Sella, J.C. Martin, J. Lecoeur, J.P. Bellier, M.F. Harmand, A. Nadji, J.P. Davidas, and A. Le Chanu, Corrosion protection of metal implants by hard biocompatible ceramic coatings deposited by radio-frequency sputtering, Clinical Materials, 5, 297-307 (1990). M.F. Semlitsch, H. Weber, R. Streicher and R. Schon, Joint replacement components made of hot-forged and surface-treated Ti-6Al-7Nb alloy, Biomaterials, 13, 781-788 (1992). S.R. Sousa and M.A. Barbosa, Electrochemistry of AISI 316L stainless steel in calcium phosphate and protein solutions, Journal of Materials Science: Materials in Medicine, 2, 19-26 (1991). S.R. Sousa and M.A. Barbosa, Corrosion resistance of titanium cp in saline physiological solutions with calcium phosphate and proteins, Clinical Materials, 14, 287-294 (1993). SJ. Stohs and D. Bagchi, Oxidative mechanisms in the toxicity of metal ions, Free Radical Biology and Medicine, 18, 321-336 (1995). D.S. Sutherland, P.D. Forshaw, G.C. Allen, LT. Brown and K.R. Williams, Surface analysis of titanium implants, Biomaterials, 14, 893-899 (1993). P. Tengvall, L. Lundstrom, L. Sjokvist, H. Elwing, and L.M. Bjurstein, Titaniumhydrogen peroxide interaction: model studies of the influence of the inflammatory response on titanium implants, Biomaterials, 10,166-175 (1989). P. Tengvall and I. Lundstrom, Physico-chemical considerations of titanium as a biomaterial, Clinical Materials, 9, 115-134 (1992). K.A. Thomas, S.D. Cook, A.F. Harding, and RJ. Haddad Jr., Tissue reaction to implant, corrosion in 38 internal fixation devices, Orthopedics, 11, 441-451 (1988). H. Tomas, A.P. Freire, and L.M. Abrantes, Cast Co-Cr alloy and pure chromium in proteinaceous media: an electrochemical characterization, Journal of Materials Science: Materials in Medicine, 5, 446-451 (1994). S. Torgersen and N.R. Gjerdet, Retrieval study of stainless steel and titanium miniplates and screws used in maxillofacial surgery, Journal of Materials Science: Materials in Medicine, 5, 256-262 (1994). D.L. Tsalev and Z.K. Zaprianov, Atomic absorption spectrometry in occupational and environmental health practice, Vol. I, CRC Press, Boca Raton, 1983. J.A. von Fraunhofer, N. Berberich, and D. Seligson, Antibiotic-metal interactions in saline medium, Biomaterials, 10, 136-138 (1989). J.C. Wataha, CT. Hanks, and R.G. Craig, Uptake of metal cations by fibroblasts in vitro, Journal of Biomedical Materials Research, 27, 227-232 (1993). A. Wisbey, PJ. Gregson, and M. Tuke Application of PVD TiN coating to CoCr-Mo based surgical implants, Biomaterials, 8, 477^80 (1987). R.L. Williams, S.A. Brown, and K. Merritt, Electrochemical studies on the influence of proteins on the corrosion of implant alloys, Biomaterials, 9, 181-186 (1988).

Carbons
A.D. Haubold, R.B. More and J.C. Bokros

10.1 INTRODUCTION The biocompatibility of carbon has long been appreciated: ancient man, for example, knew that pulverized charcoal could be placed under the skin without any apparent ill effects (Benson, 1969). The charcoal particles visibly remained indefinitely and thus allowed ancient man the means to decorate himself permanently with tattoos. However, it was not until the mid-1960s that carbon was first considered for use as a structural material in implantable prosthetic devices. During this period, a specific, imperfectly crystalline, man-made, pyrolytic form of carbon was found to be well suited for application in prosthetic heart valves. Because of the outstanding clinical success of pyrolytic carbon in long-term structural components of heart valve prostheses, carbons have assumed a prominent position in our repertoire of biomaterials and have sparked investigation of other forms of carbons for possible in vivo use. A number of these forms are listed in Table 10.1. This chapter will be devoted to a discussion of the background and historical uses of carbons in medical devices along with suggestions for future research.
10.1.1 Background

Although only two allotropic crystalline forms of elemental carbon, diamond and graphite occur in nature, carbon also occurs as a spectrum of imperfect crystalline forms that range from amorphous through mixed amorphous, graphite-like and diamond-like to the perfectly crystalline allotropes. Such imperfect crystalline structures are termed turbostatic and
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Table 10.1 Carbon Forms Produced at low or high temperature from the thermal pyrolysis of a hydrocarbon in a fluidized bed. These materials have a laminar, isotropic, granular or columnar structure and may be pure carbon or alloyed with various carbides. 0 Glassy or Polymeric Obtained from the thermal pyrolysis (-1000 C) of selected polymers and may be monolithic, porous or reticulated. Carbons Artificial Graphites Produced from a variety of starting materials such as petroleum or naturally occurring cokes and yield bulk structures of varying grain size, crystallite orientation, purity, porosity, strength, and particle size. Formed from spun polymeric fibers which are subsequently Carbon Fibers pyrolysed to yield structures of unusual strength and stiffness. The properties are a function of polymer precursor and processing history. More recently, carbon fibers have been grown from the vapor phase. These are perhaps the oldest and most diverse materials Charcoal with interesting adsorptive properties and are produced from many organic material spanning the range from wood to coconut shells to animal bones. Applied, generally at reduced pressures (<1 atm) and often Vapor Phase at low temperatures to provide a carbonaceous surface Coatings coating that ranges from amorphous to diamond-like with accompanying wide variation in thermal, mechanical and electrical properties. Structures have been produced that utilize all of the above Composites materials and even some other binders. Found in this group of materials are carbon fibers infiltrated and held together with pyrolytic carbon, silicon carbide, glassy carbon, PTFE, methyl methacrylate, epoxies, and petroleum pitches as well as combinations thereof. The structures may contain randomly oriented chopped fibers or long filaments oriented in random, 2, 3 and n dimensions. Pyrolytic Carbon

give rise to considerable variability in physical and mechanical properties (Figure 10.1). Indeed, this ability of carbon to assume either perfectly crystalline or chaotic, turbostatic structures gives rise to confusion when considering physical and mechanical properties. For this reason, it is best to consider carbon as a spectrum of materials and to bear in mind that within this spectrum, a number of unique combinations of structure and physical and mechanical properties occur. This is true with respect to biocompatibility: the fact that one type of pyrolytic carbon has been used successfully in heart valves does not necessarily imply that other forms of pyrolytic carbons or indeed other forms of carbon in general will also prove useful in this or other prosthetic applications. For example, pyrolytic

Figure 10.1 Possible atomic arrangements of crystalline carbon: (a) diamond tetrahydral, cyclohexane chair, crystalline structure, (b) graphite planar hexagonal layered structure (c) three-dimensional quasicrystalline turbostatic structure. Biomedical carbons have a turbostatic structure.

and glassy carbon can be finished to have identical appearances, yet the properties of glassy carbon make it unsuitable for use in prosthetic heart valves (Haubold et ai, 1981). For successful use in implantable prostheses a material (1) must retain its properties required for device function in the hostile biological environment and (2) must not provoke adverse effects either locally or systemically. Most of the pure carbons are relatively inert and unlikely to provoke severe tissue reactions, however, only certain pyrolytic carbons have sufficient strength, fatigue resistance, wear resistance and biodegradation resistance to function as long-term implant structural components. In fact, the pyrolytic carbons were deliberately tailored to meet the specific biocompatibility requirements for heart valve component application (Bokros et al, 1972; Haubold, 1977). Silicon was added in small amounts (5-12 wt%) as an alloying element in order to form silicon carbide inclusions to assure adequate wear. Furthermore, specific processing parameters were identified in order to produce suitable microstructures and densities, as well as the strength levels required. Glassy carbon, as mentioned above, could not be prepared with adequate strength and wear resistance. Thus, biocompatibility cannot be presumed a priori for carbon materials: each particular application has specific demands which require a unique set of properties. While the spectrum of carbon materials encompasses many such properties, the particular material must be engineered to uniquely satisfy all of the properties needed.

10.1.2 Diamond

Diamond, the hardest substance known, has the so called diamond cubic structure consisting of a network of regular tetrahedral arrays in which each carbon atom is covalently bonded to four other carbon atoms forming the corners of a regular tetrahedron (Figure 10.1). From X-ray diffraction data, there is a single value, 1.54 A bond length and a unit cube lattice spacing of 3.56 A. The entire crystalline array is a single covalently bonded molecule. Because many covalent bonds must be broken to break the crystal, a very large amount of energy is required, therefore, the substance is very hard (Pauling, 1964). There has been an ongoing interest in the use of diamond or diamond-like coatings (May, 1995). However, suitable manufacturing processes do not yet exist that allow economical preparation of diamond type materials in the quantity, quality, shapes and sizes required for durable long term biomedical applications. A specific application uniquely requiring diamond or diamond-like material for clinical success has not been identified as a justification to compel additional research efforts in preparation techniques.

10.1.3 Graphites

Graphite has a layered hexagonal crystal structure. Each atom forms two single bonds and one double bond with its three nearest in-plane neighbors to form sheet-like layers of flat six atom ring arrays (Figure 10.1). Interatomic bond distances are 1.42 A within the layer and 3.4 A between each layer. Within each layer, bonding is covalent and between the layers, bonding is of the much weaker van der Waals type. Consequently, the layers are easily separated giving rise to the soft, lubricating properties of graphite. Naturally occurring graphite is generally found as a isolated small scales or imperfect single crystal precipitates in granite. These small crystals such as those found in Madagascar, Ontario and in New York have dimensions on the order of a few millimeters. Larger graphite masses have been found in China and Korea. Natural graphites are thought to be formed by metamorphosis of sedimentary carbonaceous materials or by reaction with and precipitation from liquid magma. The naturally occurring graphite materials are useful primarily as the starting material for subsequent fabrication of some 'artificial graphites'. Graphite was first synthesized accidentally by heating carborundum to extreme temperatures. The silicon was driven off leaving a graphite residue. A patent on this production process was granted over 100 years ago. Since then, petroleum and other types of cokes coupled with organic binders have become the major raw materials in the production of a wide variety of carbonaceous conglomerates called artificial graphite. The manufacturing processes employed today are as varied as are the properties of the resultant materials. Bulk graphites are usually molded, extruded, hot isostatically compacted and may even be formed by combinations of these processes. They may be further reimpregnated with binder subsequent to graphitization (heat-treatment step), infiltrated isothermally or in a thermal gradient with methane or aromatic hydrocarbons. The resultant materials have widely varying properties and purity which can have a profound influence on the interaction of 'graphite' with the living environment. Because of low strength and low wear resistance, graphite alone is not suitable as a structural member of an implant. But, investigations of colloidal graphite coatings as a blood compatible surface during the mid1960s led investigators to examine pyrolytic carbon. Pyrolytic carbon, initially developed and used as a coating for nuclear fuel pellets, was found to have excellent blood compatibility, strength, wear resistance and durability for application in long term implants. The historical account leading to the use of LTI (low temperature-isotropic) pyrolytic carbon has been described (Bokros et al, 1972, 1975). Graphite is widely used as a substrate for pyrolytic carbon coatings in heart valve components. In

prosthesis applications, graphite is entirely encased in pyrolytic carbon coatings on the order of one mm thickness. Here the stronger, more durable coating stabilizes the interior graphite structures.
10.1.4 Pyrolytic carbons

Pyrolytic carbons of the type developed at General Atomic for use in bioengineering were an off-spring of research directed at developing carbon materials that would be suitable for structural applications in the severe environment of high-temperature, gas-cooled nuclear reactors. The isotropic carbon forms called high-temperature-isotropic carbon were derived from the gas phase nucleation and condensation of droplets formed during the pyrolysis of methane at temperatures in excess of 20000C where densification can occur by thermally activated processes. The carbons called low-temperature-pyrolytic carbons are formed by the pyrolysis of other hydrocarbons (such as propane and propylene at lower temperatures in the range 1300-15000C. The carbon materials so produced are not uniquely structured nor are all of them isotropic. Wide and complex variations in properties are possible ranging from weak to very strong, and in structure ranging from laminar and anisotropic, to isotropic, to columnar and granular, the latter also varying in anisotropy. A comprehensive review of the deposition and structure of pyrolytic carbon is given by Bokros (1969)
10.1.5 Glassy carbons

The preparation, structure and properties of glassy, or polymeric carbons has been described in detail by Jenkins and Kawamura (1976). These carbons are derived from a polymer by a slow pyrolysis process which results in a vitreous residue free of macroscopic bubbles. Fabrication of glassy carbon materials is a relatively straightforward, but time consuming process. A preformed polymeric precursor such as phenol-formaldehyde, polyfurfuryl alcohol, polyvinyl alcohol or oxidized polystyrene is slowly heated in an inert atmosphere to a high temperature in excess of 2000 0C. Heating times may be as short as a day or as long as one month. It is not unusual to encounter exothermic temperature regions that must be traversed very slowly (i.e., 1 0C temperature increase per hour) to avoid the nucleation of bubbles. There is a volumetric shrinkage of about 50% so the resultant structure formed in this process is a miniature of the precursor preform. The gases generated within the preformed structure must have time to diffuse out and not nucleate bubbles so one dimension of glassy carbon structures is limited to about seven millimeters. Hence materials or objects are limited to thin flat plates or tubes with thin walls. Massive equiaxed

structures are not possible unless they are small with dimensions compatible with the diffusional requirements.
10.1.6 Carbon fibers

Carbon fibers, thought by many to be a relatively new material, actually have a long history as evidenced by the issuance of the first patent for incandescent electric lamp filaments (carbon fibers). The patent was issued to Thomas Edison in 1892. Hiram Maxim (the inventor of the machine gun, among other things) was issued a process patent for carbon fibers in 1899. Prior to the 1950s, these fibers had marginal strength and were used primarily for their electrical properties. High strength carbon fibers were developed in the 1950s for the aerospace industry and military aircraft. The mechanical properties of rayonbased carbon fibers were enhanced using stress graphitization. Since that time, a variety of other precursors have been used including polyacrylonitrile (PAN), specific fractions of asphalt or pitch, lignin, lignosulfonates, hetero and nonheterocyclic aromatic polymers, linear polymers and even coal. The processes for fiber manufacture are as varied as the precursors themselves. In the patent literature, hundreds of processes and variants can be found (Sittig, 1980). Nevertheless, generalizations can be made. The first step in the process is the selection and treatment of a suitable raw material which can be carbonized to a high yield. The second step generally consists of a low temperature (250-500 0C) heat treatment or preoxidation followed by high temperature (up to 2800 0C) carbonization and graphitization steps. The resultant fibers generally are of three types classified according to their structure and the degree of crystallite orientation. There are the high modulus (50 million psi or above), high strength fibers which, when incorporated into structures, give the highest stiffness per unit weight. Fibers with a lower modulus (about 30 million psi) but still of high strength are the second class of generally available fibers. The lowest modulus (less than 20 million psi) do not have structural applications.
10.1.7 Vapor phase coatings

Coatings formed at reduced pressure (<1 atm) are generally termed 'vapor deposited'. These coatings may be formed by physical vapor deposition, chemical vapor deposition or combinations thereof. Physical vapor deposition such as evaporation is probably the oldest technique for depositing thin films and involves generating a vapor from a source material at reduced pressure. The vapor subsequently condenses on the object to be coated. This technique suffers from a number of limitations such as only line-of-sight coating is possible. In the case of a carbon source, which

does not evaporate but rather only sublimes at extreme temperatures, the object to be coated is exposed to direct thermal radiation from the subliming source. Few materials can withstand the intense thermal radiation for any great length of time. Hence coating thickness is limited as is the choice of substrate material to be coated. Much has been written on physical vapor deposition such as the comprehensive text by Maissel and Glang (1970). More versatile coating techniques are broadly termed chemical vapor deposition (CVD). Coatings are formed through chemical reactions in the vapor phase or through the thermal decomposition or reduction of gases generally at reduced pressures. It is interesting to note that the process used to form pyrolytic carbon is a CVD process but is generally carried out at ambient pressures. The low temperature CVD processes are usually assisted by means of catalysts, glow discharge plasmas, ion beams and the like to activate gas reactions. In fact, production of diamond films is now almost routine through ion beam assisted disassociation of selected hydrocarbons in the presence of excess hydrogen. On the other hand, amorphous carbon films with little or no detectable crystallinity can also be produced by CVD. Thus chemical vapor deposition techniques are extremely versatile and consequently films and coatings produced by CVD must be carefully characterized and identified. An extensive and comprehensive review of thin film deposition technologies can be found in Bunshah (1982).
10.1.8 Composites

Even more complex than the materials described above are a family broadly termed 'composites'. Three-dimensional structures can be formed by combining a filler material with an appropriate matrix. Herein lies the difficulty with composites; all too often, the starting materials are not adequately described and the resultant structure characterized. Carbon-carbon composites can be produced with a multitude of structures. The simplest have two-dimensional order and consist of stacked plies of carbon fabric held together by a carbon matrix. The fabric fibers may be any of those described previously, prepared from the pyrolysis of polyacrylonitrile and the like. The matrix could be derived from petroleum pitch or be infiltrated pyrolytic carbon or even silicon carbide. The latter are generally referred to as SiC/C composites. From two-dimensional, the next progression in structure is three-dimensional on to n-dimensional. This terminology refers to fiber orientation within the matrix. Filament wound carbon composites have also been developed. In this case the desired shape is, as the name implies, wound using carbon fibers onto a suitable mandrel. The fibers are bonded using an epoxy type or thermoset resin. The bonding of the matrix to the fibers and direction of

fiber orientation in large part determine the mechanical properties of the composite. The biological properties are generally governed by the selection of matrix. 10.2 HISTORICAL OVERVIEW - IN VIVO APPLICATIONS Encouraged by the success of the LTI form of pyrolytic carbon in the demanding mechanical heart valve application, other carbon materials and usages were explored. Different carbon materials have been evaluated because pyrolytic carbon was patented on the one hand and processing constraints limited its versatility on the other hand. Shown in Table 10.2 are examples that demonstrate medical and engineering ingenuity in attempts to expand the use of carbons in the biological environment. Although the attempts are numerous and varied, only the use of carbon as components for artificial heart valves has achieved widespread usage. 10.2.1 Dental One of the earliest applications of carbon as an implant material was in restorative dentistry. The first devices were bulky posts fabricated from glassy carbon that were implanted in the maxilla or mandible to serve as artificial tooth roots. Because of the inherent lack of strength of glassy carbon, they were bulky and poorly accepted. As a further complication, the stainless steel post on which a crown was cemented formed a galvanic couple in vivo leading to complications caused by accelerated corrosion of the stainless steel. In another attempt, artificial tooth roots in the form of blades were fabricated from pyrolytic carbon. Although they were less bulky than the glassy carbon implants, they were difficult to place. Improper seating of the blade caused micromotion after implantation that ultimately caused the prosthesis to fail. The success rate of 60% after 5 years was judged inadequate. Metal blades coated with carbon fared a similar fate. Metallic mandibular reconstruction trays coated with a vapor deposited film of carbon generally performed well. The application was complicated by the fact that the trays were custom and many times fashioned directly in the operating room, making the logistics of coating with carbon unacceptable.
10.2.2 Vascular

Graft prostheses >6mm diameter are generally considered to work well and improvements in performance as a result of modifying the biochemical nature of the graft lumen with carbon coatings are difficult to quantify and

Table 10.2 Applications of Carbon in Me dical Devices Dental Implants Active Component in Hemodetoxifier Posts Alveolar Ridge Maintenance Particles Blades Carbon Fiber Patch Fabrics Coating on metallic implants Cathether Tips Electrodes Coated Components for Membrane Solid Oxygenators Coated Coated Emboli Filters Ex vivo Blood Filters Coated Mandibular Trays Femoral Stems Coated Tracheal Prosthesis Coated Coated TMJ Condyle Prosthesis Composite Coated Prosthetic Fabrics and Polymers Femoral Condyle Replacements Coated Aneurysm Clips Femoral Heads Coating on Angioplasty Stents Coated Coatings on Heart Valve Suture Rings Fracture Fixation Devices Coatings on Indwelling Catheters and Left Ventricular Apex Inlet Tubes Delivery Systems Ligaments and Tendons Coatings on Vortex Blood Pumps Mechanical Heart Valve Coatings in Vascular Grafts Components Components for Centrifugal Blood Pumps Ossicular Replacement Prosthesis Composites Soft Tissue Replacement Particles for Filling Periodontal Defects Percutaneous Access Devices Small Joint Replacements Hand Wrist Elbow Foot Tibial Plateau Replacements Vascular Attachment Prosthesis Carbon forms Young's Flexural Fracture 1 Wear Modulus Strength Hardness Density Toughness 3 (GPa) (MPa) (DPH 50Og) (g/cm ) (Mpa^/m). Resistance 1760-1040 600-2000 5700-10400 Knoop >230 486 Pure pyrolytic carbon 28 >230 389 31 Si-alloyed pyrolytic Carbon 150 21 Glassy or Polymeric 175 Carbons 65-300 Artificial Graphites 4-12 50-120 * Carbon fibers 172-517 896-2585 Charcoal NA NA NA Vapor phase coatings 17 Composites * Diamond
Dependent upon matrix.

2.9-3.5 1.5-2.1 2.0-2.2 <1.54 1.5-1.8 1.6-1.8 NA 1.8

5-7 Potentially excellent 1.67 Excellent 1.17 Excellent 0.5-0.7 1.5 * NA * Poor Poor * NA *

not significant enough to justify the cost of carbon coating. Improvements in the patency of small diameter grafts (<4 mm) as a result of carbon coating have been reported but even with the improvement, these grafts ultimately failed as a result of intimal hyperplasia proliferation at the anastomoses. While the carbon coating may retard clotting of certain grafts, the coating does little to ameliorate intimal hyperplasia formation. Carbon vascular attachment prostheses have also been reported to perform poorly, not as a result of poor biocompatibility, but rather the result of mechanical complications.
10.2.3 Orthopedics

Femoral stems fabricated from carbon composites fitted with a femoral head fabricated from pyrolytic carbon have been reportedly used successfully by some for over 10 years (Chen, 1986). Others have experienced disastrous failures through a lack of attention to engineering and material property details. Such failures naturally lead to questions on the suitability of 'carbon' for use in such medical devices. Attempts are underway to design and fabricate other joint replacements. Ligaments and tendons have been fabricated from carbon fibers (Bejui and Drouin, 1988). These fibers in the initial stage perform well as a scaffolding material that aids in the regeneration of tendons and ligaments in vivo; but in the long term the fibers fracture and migrate to, for example, the lymph nodes. Fracture fixation devices that are fabricated from stainless steel are unsuitable for coating or coupling with carbon because of galvanic effects (Haubold et ai, 1986). Carbon composite devices have been used reportedly with good results but such usage has not become widespread presumably because of an unaccepted cost/benefit ratio.
10.2.4 Other

Many applications of devices listed in Table 10.2, while successful, are not in widespread use because, even in their non-carbon form, usage is limited. For example, left ventricular apex tubes (Haubold et al., 1979) are used successfully in the construction of a prosthesis to correct idiopathic hypertrophic subaortic stenosis but fortunately in man, such a medical condition is rare. 10.3 NEW DIRECTIONS/FUTURE TRENDS LTI pyrolytic carbons, since their introduction in the late 1960s, have become the material of choice for use in the fabrication of mechanical prosthetic heart valves. Over 90% of the mechanical valves implanted

worldwide utilize such carbon components. To date, more than 2 million valves have been implanted which amounts to an accumulated experience in excess of 12 million patient years. While this material has proven to be the most successful carbon biomaterial, it can be improved. Recently, advances in process control methodologies have allowed refinements in the pyrolytic carbon coating preparation. These improvements allow the elimination of the potentially thrombogenic silicon carbide from the biomedical coatings. Furthermore, this pure pyrolytic carbon can be produced with substantially improved mechanical properties relative to the silicon alloyed material (Emken et ah, 1993; Ely et al, 1994,). Such improvements in the material open possibilities for improvements in heart valve prosthesis design and performance. Results from investigations on the suitability of other forms of carbon for in vivo use yielded mixed and often seemingly contradictory results. Some of the confusion developed because of misunderstanding of carbon structure and misunderstanding of the relationship of carbon properties to such structures. The use of the generic label 'carbon' compounded the problem. A similar situation exists with 'polyurethanes'. There are polyether urethanes, polyester urethanes, polyether urethane ureas and even polyester urethane ureas - all misappropriate^ called simply 'urethanes'. Thus it is not surprising that the biological responses of 'carbon' (Table 10.1) are so varied. Biocompatibility claims for a particular form of 'carbon' based on published results for a totally different form or structure should be carefully scrutinized. For example, to claim that carbon fibers have the same biological properties as bulk pyrolytic carbons or even that all pyrolytic carbons behave similarly is unjustified. In the case of fibers, geometry plays a significant role. It is well known that bulk materials may be well tolerated when the same material in particulate form may not. The lack of characterization and standardization can be devastating. More and more entrants are anticipated into the field of carbon biomaterials. In the past, because of technology, patent or cost constraints, there were only several sources for, for example, pyrolytic carbon. A number of the earlier constraints have now been removed. Consequently, these materials are being produced in limited but increasing quantities in many countries, using a multiplicity of fabrication techniques. The challenge for the future is to be precise in material identification, characterization and to avoid generalization.

REFERENCES
Bejui, J. and Drouin, G. (1988). Carbon Fiber Ligaments. In CRC Critical Reviews in Biocompatibility, 4(2), 79-108.

Benson, J. (1969). Pre-Survey on the Biomedical Applications of Carbon, North American Rockwell Corporation Report R-7855. Bokros, J.C. (1969). Deposition, Structure, and Properties of Pyrolytic Carbon. In Chemistry and Physics of Carbon, Vol. 5 (Walker, P.L., ed.). Dekker, New York, pp. 1-118. Bokros, J.C. LaGrange, L.D. and Schoen, FJ. (1972). Control of Structure of Carbon For Use in Bioengineering. In Chemistry and Physics of Carbon, Vol. 9 (Walker, P.L., ed.). Dekker, New York, 103-171. Bokros, J.C, Akins, R.J., Shim, H.S., Haubold, A.D. and Agarwal, N.K. (1975). Carbon in Prosthetic Devices. In Petroleum Derived Carbons (Deviney, M.L., and O'Grady, T.M., eds). American Chemical Society, Washington, DC, pp. 237-265. Bunshah, R.F. (ed.) (1982). Deposition Technologies for Films and Coatings., Noyes Publications, Park Ridge. Chen, Lan-Tian (1986). Carbon-Titanium Combined Joints. In Chinese Journal of Biomedical Engineering 3, 55-61. Ely, J., Haubold, A., Bokros, J. and Emken, M. (1994), New Unalloyed Pyrolytic Carbon with Improved Properties for Implant Applications, XXI Congress European Society for Artificial Organs, Oct. 20-22, Barcelona Spain. Also US Patent 5 514 410. Emken, M., Bokros, J., Accuntis, J. and Wilde, D., (1993) Precise Control of Pyrolytic Carbon coating, Extended Abstracts & Program Proceedings of the 21st Biennial Conference on Carbon, Buffalo New York, June 13-18, pp. 531-532. Also US Patent 5 284 676. Haubold, A.D., Shim, H.S., and Bokros, J.C. (1979). Carbon Cardiovascular Devices. In Assisted Circulation (Unger, F., ed.) Springer Verlag, Berlin, Heidelberg, New York, pp. 520-532. Haubold, A.D. (1977). Carbon in Prosthetics. In Annals of the New York Academy of Sciences, Vol. 283, The Behavior of Blood and its Components at Interfaces, (Vroman, L. and Leonard E.F., eds). New York Academy of Sciences, New York. Haubold, A.D., Shim, H.S., and Bokros, J.C. (1981). Carbon in Medical Devices. In Biocompatibility of Clinical Implant Materials, VoI II (Williams, D.F., ed.). CRC Press, Boca Raton, pp. 3-42. Haubold, A.D., Yapp, R.A., and Bokros, J.C. (1986). Carbons for Biomedical Applications, in Encyclopedia of Materials Science and Engineering (Bever, M.B., ed.) Pergamon Press, Oxford, New York, Toronto, Sydney, Frankfurt, pp. 514-520. Jenkins, G.M. and Kawamura, K. (1976). Polymeric Carbons - Carbon Fibre, Glass and Char. Cambridge University Press, Cambridge. London, New York, Melbourne. Lewis, J.C. and Redfern, B., and Cowland, F.B. (1963). Vitreous Carbons as Crucible Materials for Semiconductors. In Solid State Electronics, 6, 251. Maissel, L.I. and Glang, R. (1970). Handbook of Thin Film Technology, McGrawHill, New York. May, P.W. (1995), CVD Diamond - a new Technology for the Future?, Endeavor Magazine 19(3), 101-106. Pauling, L. (1964), College Chemistry, W.H. Freeman and Co., San Francisco.

Pierson, H.O. (1993) Handbook of Carbon, Graphite, Diamond and Fullerenes, Noyes Publications, Park Ridge, New Jersey. Sittig, M. (1980). Carbon and Graphite Fibers. Noyes Data Corporation, Park Ridge. Mechanical Behavior of Diamond and Other Forms of Carbon, Materials Research Society Symposium Proceedings, Vol. 383, ed. Dory M.D. et al, Materials Research Society, Pittsburgh, Pennsylvania, 1995.

PART III

General Concepts of Biocompatibility

D.F. Williams

1.1 INTRODUCTION The host responses to biomaterials are extremely varied, involve a range of different mechanisms and are controlled by factors that involve characteristics of host, material and surgical procedure. These responses themselves constitute a significant component of the phenomenon of biocompatibility. In this section, the broad concepts of biocompatibility are critically reviewed with particular reference to the role that the human host response plays in determining the performance of the biomaterial and of the device in which it is used. Particular emphasis is given to the influence of biocompatibility in the clinical applications of devices. It should be remembered, however, that biocompatibility phenomena are extremely difficult to interrogate remotely or to study in an active way, so that accurate information of the details of biomaterial-human tissue interactions is not readily available. As Black (1) has pointed out with reference to observations on the host response in general, we are usually limited to detecting events long after they have occurred by examining end-points, usually histopathologically, after the host is dead. This is largely the case with experiments on biocompatibility in animals, but is an even more relevant observation with the human clinical experience. All comments in this section must therefore be interpreted with this in mind.

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

1.2 THE DEFINITION OF BIOCOMPATIBILITY Etymologically, the term 'biocompatibility' sounds simple to interpret since it implies compatibility, or harmony, with living systems. This concept, however, is a little too simple to be useful and the meaning of compatibility has to be explored further. It is intuitively obvious that a biomaterial or implanted medical device should cause no harm to the recipient by intent or by accident. This is the underlying principle of biological safety but is not the totality of biocompatibility. A material may well be entirely safe in the human body but unless it actually does something useful, it is not necessarily appropriate for a medical device. For many years during the evolution of biomaterials, this was not really taken into account and the 'requirements' of biomaterials were dominated by the perceived necessity to be safe, which was interpreted as a requirement that a biomaterial should be totally inert in the physiological environment and should itself exert no effect on that environment. In other words, there should be no interaction between biomaterials and the host, in the latter case implying that the material should be non-toxic, non-irritant, non-allergenic, non-carcinogenic, nonthrombogenic and so on. This concept of biocompatibility, which equates the quality to inertness and biological indifference, has resulted in the selection of a portfolio of acceptable or standard biomaterials which have widespread usage. These range from the passivatable alloys such as stainless steel and titanium alloys, the noble metals gold and platinum, to some oxide ceramics such as alumina and zirconia, various forms of carbon and a range of putatively stable polymeric materials including silicone elastomers (polysiloxanes), polyolefins, fluorocarbon polymers and some polyacrylates. Of course, if this was all there was to biocompatibility, there would be few problems other than optimizing inertness and there would be little to write about. In practice, biocompatibility is far more complex. There are at least four reasons for this. The first is that inertness in the physiological sense requires a great deal more than resisting degradation at the atomic or molecular level and the second is that even if it were so, this goal is extremely difficult to achieve. Indeed it is now recognized that no material is totally inert in the body. Even those very stable materials mentioned above will interact to some extent with tissues; titanium, although one of the most corrosion resistant engineering alloys, corrodes in the body, as judged by the presence of the metal in the surrounding tissues as well as serum and urine. With many materials, while the main component itself may be exceptionally inert, there are often minor components, perhaps impurities or additives which can be released under some circumstances. The leaching of plasticizers and other additives from plastics provide

good examples of interactions which are not related to the molecular breakdown of the material but which confer a degree of instability to the product. Moreover, in the context of interactions which affect the overall performance of the material in the physiological environment, it is important to note that an interfacial reaction involving a physicochemical process such as protein adsorption will take place with the vast majority of materials, further emphasizing the fact that inertness is a very relative term and there is indeed no such thing as an inert biomaterial. The third reason why biocompatibility cannot be equated with inertness is that there are several, and indeed an increasing number, of applications which involve intentionally degradable materials. The two most widely quoted situations here are absorbable sutures and implantable drug delivery systems but many more circumstances where degradable scaffolds and matrices could form an essential component of a device are envisaged. If biocompatibility is predicated on inertness, then degradable materials cannot, by definition, be biocompatible. This clearly does not make sense and suggests that the concept of biocompatibility needs to be altered. The fourth reason is even more compelling, especially when considering biomaterials used in devices for tissue reconstruction. If a device is made from materials which are inert and which do not interact with the body in any way, then it is unlikely that it can be truly incorporated into the body. For effective long term performance in the dynamic tissue environment, it is far more preferable for there to be functional incorporation, which implies that the device should be stimulating the tissues to be reactive to it positively rather than negatively. Thus biocompatibility should not be concerned with avoiding reactions but selecting those which are the most beneficial to device performance. On the basis of these ideas, biocompatibility was redefined a few years ago (2), as 'the ability to perform with an appropriate host response in a specific situation.' Clearly this definition encompasses the situation where inertness is still required for the most appropriate response in some situations is indeed no response. A traditional bone fracture plate is most effective when it is attached mechanically to the bone and does not corrode; no response of the tissue to the material is normally required. Even here, however, we have to concede that a material that could actively encourage more rapid bone healing might be beneficial so that a specific osteoinductive response would be considered appropriate. More importantly, the definition allows a material to stimulate or otherwise favour a specific response, including cell activation, where that response optimizes the performance of the device. It will be obvious that the required response will vary with the particular application, which clearly implies that the response, both desired and actual, will vary with the different types of tissue encountered by biomaterials.

The above definition also stipulates that the biocompatibility of a material has to be qualified by reference to the specific application. The response to some very common and popular biomaterials may vary quite considerably and some of the major problems of implantable medical devices have been caused by a misunderstanding about transferability of biocompatibility data. To recognize the very effective performance of a material under one set of conditions but then to assume that the same material can perform equally well under entirely different circumstances is inherently dangerous since it takes into account neither the variations one might expect to see in the host response from site to site nor the fact that what is appropriate for one situation may not be appropriate for another. 1.3 COMPONENTS OF BIOCOMPATIBILITY The above definition of biocompatibility helps to explain the subject area but cannot describe exactly what it is. For this purpose we have to consider the various components that are involved in biocompatibility processes. Biocompatibility refers to the totality of the interfacial reactions between biomaterials and tissues and to their consequences. These reactions and consequences can be divided into four categories. These involve different mechanisms and indeed quite separate sectors of science but are, nevertheless, inter-related. The first component is that of the protein adsorption mentioned above. This process is initiated as soon as a material comes into contact with tissue fluids such that relatively quickly the surface of the biomaterial is covered with a layer of protein. The kinetics and extent of this process will vary from material to material which will in any case be a dynamic phenomenon with adsorption and desorption processes continuously taking place. Under some circumstances, this layer is extremely important in controlling the development of the host response since cell behavior near the material may depend on interactions with these proteins. For example, thrombogenicity is controlled by a number of events including the interaction between plasma proteins and surfaces, these proteins being able to influence the attachment of platelets to the surface. In other circumstances, the effects of this protein layer are far from clear. The second component of biocompatibility is that of material degradation. It is emphasized here that degradation is a component of biocompatibility rather than a separate phenomena. There is still confusion over this since it is often perceived that degradation, which occurs on the material side of the interface, is the counterpart to biocompatibility which is equated with the other (tissue) side. This is not correct since degradation is the counterpart to the local host response, both being contributory to the biocompatibility of the system.

Degradation phenomena are covered elsewhere in this Handbook and will not be discussed in detail here. It is necessary to point out, however, that descriptions of material degradation mechanisms have to take the special, and indeed unique, features of the tissue environment into account. Whatever its location, a biomaterial will continuously encounter an aqueous environment during its use. This is not simply a saline solution, however, but a complex solution containing a variety of anions and cations, a variety of large molecules some of which are very reactive chemically, and a variety of cells which again may be in passive or active states. There are occasions when a degradation process can be explained, mechanistically and qualitatively, by the presence of an electrolyte. This is the situation with most metals when they suffer from corrosion in physiological environments(3). Even here, however, it is known that the kinetics of corrosion may be influenced by the organic species present, especially the proteins, and it is even possible for the corrosion mechanism to be somewhat different to that found in non-biological situations. With other groups of materials, however, and especially with polymers, kinetics, mechanisms and consequences of the degradation are fundamentally related to the details of the environment. Although hydrolysis remains the substantive mechanism for degradation of most heterochain polymers, including polyurethanes, polyamides and polyesters, this hydrolysis may be profoundly influenced by the active species present in the tissue, especially in the tissue of the inflammatory response to materials. Included here are the influences of lysosomal enzymes (4). Moreover the hydrolysis may be supplemented by oxidative degradation, again occurring not only by virtue of passively dissolved oxygen in body fluids, but (and probably far more importantly) by active oxidative species such as superoxides, peroxides and free radicals, generated by activated inflammatory cells such as macrophages. It is thus possible for homochain polymers not particularly susceptible to hydrolysis and not normally oxidized at room temperature, to undergo oxidative degradation upon implantation (5). Polyolefins such as polyethylene and polypropylene come into this category. The term 'biodegradation' is often used to describe degradation which occurs in such situations although the circumstances of and requirements for degradation to be so described have not been entirely clear. A recently agreed definition of biodegradation (6) states quite simply that it is the breakdown of a material mediated by a biological environment. The interpretation of 'biological' is left to the reader. The purpose of explaining the role of the biological, or physiological environment in degradation phenomena, was to emphasize the crucial significance of the interaction between degradation and the host response, for not only can degradation be influenced by the host response but also it can control that response.

To explain this in a little more detail, let us consider the evolution of the local host response, which is the third component of biocompatibility, using a model that involves inflammatory and repair processes (7). Whenever a material is implanted into the tissues of the body, there has to be a degree of trauma associated with the insertion process. This will inevitably establish an acute inflammatory response, which is the body's natural defence mechanism to any injury. The inflammation is totally desirable and helpful since it is the precursor to the second phase of the response, which is that of tissue repair. The response to a surgical incision is acute inflammation followed by repair, the consequences of which are a zone of fibrous (collagenous) scar tissue. If a biomaterial is placed within the tissue, this response will be modified by its presence, but the extent to which that modification occurs depends on many factors. Considering first the role of the material, if that material were totally inert chemically and unable to react at all with the tissues, and if the device were not able to irritate the tissues in any way, the perturbation to the inflammation/repair sequence is minimal, and the result will be the formation of a zone of fibrous tissue analogous to the scar, but oriented in such a way as to envelope the implant. The classical response to an implant is its encapsulation by soft fibrous tissue. On the other hand, if the material is able to react with the tissues, chemically, mechanically or any other way, it will act as a persistent stimulus to inflammation. While there is nothing inherently harmful about inflammation as a response to injury, persistent inflammation occurring as a response to a persistent injury is less acceptable. At the very least, this results in a continued stimulus to fibrosis such that the capsule is far more extensive and may intervene between the material and tissue it is meant to be in contact with (for example bone in the case of joint prostheses) but perhaps more importantly it can change the immediate tissue environment from one of quiescent fibrosis to that of active chronic inflammation. This is rarely the appropriate response and, as noted above, is likely to generate an even more aggressive environment. In the context of the definition of biocompatibility, therefore, it is important that the interaction between the material and the tissues is one which leads to an acceptable balance between inflammation and repair. A few points may serve to explain this further and qualify appropriateness. First, the nature of the host response and those features which constitute acceptability will vary very considerably from one host to another and from one location (or set of circumstances) to another within a particular host. It is often forgotten that host variables are as important as material variables in the determination of biocompatibility. This is particularly important when the wide variety of tissue characteristics is considered. Obviously bone is very different from nerve tissue or a vascular endothelium and there will be very considerable difference in the details of their

responses. Not all tissues of the same variety will be able to respond in the same way and it should always be remembered that host variables such as age and overall health status will have a major effect. Secondly, the importance of time and the sequence of events should never be underestimated. While the above model describes the sequence from surgical intervention to inflammation to repair, such that the process may undergo rapid resolution, with a resulting long lasting equilibrium, the inflammation may be restimulated at any time and rarely can we guarantee long term survival. In this context the third point becomes important, for any feature of the interaction between material and tissue and material can be responsible. In many situations it is the chemical reactivity, represented by degradation processes, which drives the inflammatory response, but it can equally well be a process by which fragments of the material are extracted by physical or mechanical means. The release of wear debris from orthopaedic prostheses is a good example here, since the presence of such particles in sufficient numbers can have a profound effect on the tissue response, which is mediated by the mechanisms of inflammation but where the clinical results, manifest by loosening of the prostheses, may not be seen for quite some time(8). As far as the response to debris is concerned, in general the effects of released fragments will be quite different to those of bulk materials, both by virtue of physical factors as well as changed chemical factors. Thirdly, the identification of these events and their importance leads to various possibilities for the control of biocompatibility. In the balance of inflammation and repair we have the possibilities of controlling that balance by aiming to eliminate or at least minimize those events which are undesirable for one set of conditions or alternatively enhancing or optimizing those events which are most desirable. This has led to the emergence of the concept and indeed introduction of bioactive materials which have been defined as biomaterials that are designed to elicit or modulate biological activity. As a final point about the local host response, it has to be recognized that there are significant regional and tissue-specific variations to the phenomena. These cannot be described here, but it is important to mention the particular case with blood. When a biomaterial comes into contact with blood, there are many different mechanisms by which the blood can interact with the material, most of which are preferably avoided. The most important of these are those processes, alluded to in an earlier paragraph, that are responsible for the clotting of blood. This is a vital defense mechanism which prevents death by uncontrolled bleeding under everyday circumstances, but unfortunately in the context of biomaterials, the two processes which can, either separately or together, initiate the formation of a blood clot, that is contact phase activation of clotting proteins and platelet activation, are themselves initiated by contact with

foreign surfaces. Thrombogenicity, defined as the property of a material which promotes and/or induces the formation of a thrombus, is clearly an important feature of biocompatibility. Turning now to the last component of biocompatibility, we have to recognize that if there is an interfacial reaction, there is no reason why the products of that reaction and their effects have to be confined to the locality of that interface and the presence of a benign local response is not necessarily indicative of the absence of any systemic or remote site effects. The possibility of systemic effects arising from the presence of biomaterials has long been recognized, although extreme difficulties exist with their identification and interpretation. Indeed, at the present time, there are few systemic effects that can be readily identified with biomaterials. The transformation of a thrombus into an embolus derived from an intravascular device has obvious implications and we can imagine and often demonstrate the systemic consequences of using overtly cytotoxic materials. However, the more intriguing speculations refer to the putative implant-related carcinogenicity and even more speculative implant-related immune responses. At this stage we have to be concerned about such possibilities but have to put the subject into context. While we cannot deny that there are possible mechanisms for biomaterials to induce tumors, the evidence that they do so in human clinical experience is very sparse. While it is possible for some hypersensitivity responses to be seen to implants, the evidence for any clinically ignificant response from the immune system to biomaterials is even less available. 1.4 CONCLUSIONS This review attempts to outline the main concept that currently prevail in the subject area of biocompatibility. Clearly it is a complex subject, about which we are still relatively ignorant, not least because it involves a juxtaposition between two quite different sectors of science, the materials sciences and the molecular/cellular biological sciences. Based on these concepts, however, a better understanding is now emerging so that our biomaterials can be chosen, and where necessary treated, in order to determine that the tissues of the host do indeed respond appropriately to them. ADDITIONAL READING
Black, J. (1992) Biological Performance of Materials - Fundamentals of Biocompatibility, 2nd edn, Marcel Dekker, Inc., New York. A recently updated introductory text describing the basic principles of the performance of biomaterials in biological environments and the relevance of the biomaterial-tissue interactions.

Hench, L.L. and Etheridge, E.C. (1982) Biomaterials: An Interface Approach, Academic Press, New York. An early text describing concepts of biomaterials and their interactions with tissues, concentrating on the interface and based on the authors' experiences with bioceramics. Williams, D.F. (ed.) (1981) Fundamental Aspects of Biomaterials, Volumes I & II, CRC Press, Boca Raton. An edited collection of contributions dealing with the major components of biocompatibility mechanisms, including corrosion and degradation phenomena, toxicology and the local tissue response.

REFERENCES 1. Black, J. (1984) Systemic effects of biomaterials. Biomaterials, 5, 11-18. 2. Williams, D.F. (1987) Definitions in Biomaterials, Elsevier, Amsterdam, pp. 49-59. 3. Williams, D.F. (1985) Physiological and microbiological corrosion. CJRC Critical Reviews in Biocompatibility, 1(1), 1-24. 4. Williams, D.F., Smith, R. and Oliver, C. (1987) The enzymatic degradation of polymers in vitro. Journal of Biomedical Materials Research, 21, 991-1003. 5. Williams, D.F. and Zhong, S.P. (1991) Are free radicals involved in the biodegradation of implanted polymers? Advanced Materials, 3, 623-626. 6. Williams, D.F., Black, J. and Doherty, PJ. (1992), in Doherty, PJ., Williams, R.L., Williams, D.F. et al (eds.) Biomaterial-Tissue Interfaces, Advances in Biomaterials, Volume 10. Elsevier, Amsterdam, pp. 525-533. 7. Williams, D.F. (1989) A model for biocompatibility and its evaluation. Journal of Biomedical Engineering, 11, 185-192. 8. Williams, D.F. (1976) Biomaterials and biocompatibility. Med. Prog. Tech., 4(1/2), 31-42.

Soft tissue response

J.M. Anderson

2.1 INTRODUCTION Soft tissue responses to biomaterials for medical devices are generally viewed from the inflammation and wound healing perspectives and are usually considered as parts of the tissue or cellular host responses to injury. Placement of a biomaterial or medical device in the soft tissue environment involves injection, insertion, or surgical implantation, all of which injure the tissues or organs involved. Early host responses are dynamic and change with time (Table 2.1). It is important to consider this time variable in determining the host response or biocompatibility of a material. 2.2 TYPES OF RESPONSE Four general types of response may occur following the implantation of a biomaterial. These are a minimal response, a chemically induced response, a physically induced response, and cellular/tissue necrosis [I]. A minimal response is generally called fibrous encapsulation and the implant is encapsulated within fibrous tissue containing mainly collagen with a few fibroblasts. At the tissue/implant interface, a one to two cell layer of macrophages and foreign body giant cells is present which constitutes the foreign body reaction. Chemically induced responses may range from an acute, mild inflammatory response to a chronic, severe inflammatory response. These responses may be the result of leaching of biomaterial additives or degradation products.
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Table 2.1 Sequence of Local Events Following Implantation Injury Acute Inflammation Chronic Inflammation Granulation Tissue Foreign Body Reaction Fibrosis

Physically induced responses are usually the result of the size, shape, porosity, and other geometric factors of the biomaterial or device. The form and topography of the surface of the biomaterial may determine the composition of the foreign body reaction. With biocompatible materials, the composition of the foreign body reaction and the implant site may be controlled by the surface properties of the biomaterial, the form of the implant, and the relationship between the surface area of the biomaterial and the volume of the implant. High surface to volume implants such as fabrics, porous materials, or particulate, will have higher ratios of macrophages and foreign body giant cells at the implant site than will smooth-surface implants, which will have fibrosis as a significant component of the implant site [2-5]. These three general types of responses are generally found with biocompatible materials. The fourth type of response, i.e., cellular necrosis, is a toxic reaction which leads to cell death. It is generally taken as a sign of the incompatibility of a material and is generally the response to highly toxic additives, residual monomer, or degradation products released from the biomaterial [6]. The similarity between chemically induced responses leading to chronic, severe inflammatory responses and cellular/tissue necrosis should be considered in determining the biocompatibility of a biomaterial. Mechanical factors and edge effects may modify the response to a biomaterial. Implant motion or micromotion can lead to variations in the fibrous capsule thickness and the composition of the fibrous capsule and the interfacial foreign body reaction. Edges and sharp changes in surface features may lead to a variation in fibrous capsule thickness and the presence of variable concentrations of chronic inflammatory cells, i.e., monocytes and lymphocytes. Immune and neoplastic responses are specialized responses which are rarely seen with biomaterials and medical devices. Immune responses are generally created by the phagocytosis of particulate by macrophages which biochemically process the material and communicate with lymphocytes to produce the immune response. The metal sensitivity response is a well-known immune response to metallic corrosion products. Neoplastic, i.e., tumor formation, responses are generally considered to be an example

of solid state tumorigenesis. Solid state tumorigenesis is generally linked to the extent or degree of fibrous capsule formation and the potential for solid state tumorigenesis is reduced with increasing foreign body reaction. 2.3 INFLAMMATION Inflammation is defined as the reaction of vascularized living tissue to local injury (Table 2.1) [7,8]. The size, shape, and intended application of a biomaterial or medical device determine the implantation procedure which in turn determines the extent or degree of initial injury. The size, shape, and chemical and physical properties of the biomaterial may be responsible for variations in the intensity and time duration of the inflammatory and wound healing processes. Figure 2.1 illustrates the temporal sequence of inflammation and wound healing. The inflammatory response is a series of complex reactions involving various types of cells whose implant site concentrations (densities), activities and functions are controlled by various endogenous and autogenous mediators [9]. The predominant cell type present in the inflammatory response varies with the age of the injury, i.e., the time since the implant was inserted. Neutrophils, which are the characteristic cell type of acute inflammation, predominate during the first several days following implantation and are replaced by monocytes as the predominant cell type. Acute inflammation is of relatively short duration, lasting from minutes to days, depending on the extent of injury. The main characteristics of acute inflammation are the exudation of fluid and plasma proteins (edema) and the immigration of leukocytes (predominantly neutrophils). Following localization of leukocytes at the implant site, phagocytosis and the release of enzymes, reactive oxygen intermediates (ROI), and other agents occur following activation of neutrophils and macrophages. Agents released from activated leukocytes, hydrogen ions (acid), enzymes, ROIs and others, may effect the biodegradation of biomaterials [10,11]. The major role of the neutrophils in acute inflammation is to phagocytose and destroy microorganisms and foreign material. Acute inflammation is of relatively short duration, lasting from minutes to days, and is dependent on the extent of injury. As the acute inflammatory response subsides, monocytes and lymphocytes predominate in the implant site and are the characteristic cells of chronic inflammation [7,8]. Monocytes, migrating from the blood, in the acute and chronic inflammatory responses differentiate into macrophages within the tissue in the implant site. These macrophages will fuse or coalesce into foreign body giant cells (Figure 2.1). Macrophages and foreign body giant cells are prominent at the tissue/implant interface, even with biocompatible materials. In Figure 2.1, the intensity and time variables are dependent upon

ACUTE

CHRONIC

GRANULATION TISSUE Macrophages Neovascularization Foreign Body Giant Cells Fibroblasts

Neutrophils

Intensity

Fibrosis Mononuclear Leucocytes Time (Minutes, Hours, Days, Weeks)

Figure 2.1 The temporal variation in the acute inflammatory response, chronic inflammatory response, granulation tissue development, and foreign body reaction to implanted biomaterials. The intensity and time variables are dependent upon the extent of injury created in the implantation and the size, shape, topography, and chemical and physical properties of the biomaterial.

the extent of injury created in the implantation and the size, shape, topography, and chemical and physical properties of the biomaterial. In the phagocytosis process, recognition and attachment of neutrophils and monocytes/macrophages are expedited when the biomaterial is coated by naturally occurring blood serum factors called opsonins. The two major opsonins are IgG and the complement-activated fragment C3b. Both of these plasma-derived proteins are known to adsorb to biomaterials and neutrophils and macrophages have corresponding cell membrane receptors for these opsonization proteins. These receptors may also play a role in the activation of the attached neutrophils, monocytes, macrophages, or foreign body giant cells. Small particles, of the order of 5 |xm in largest dimension, may undergo the phagocytosis or engulfment process by neutrophils, monocytes/macrophages, or specialized cells in the reticuloendothelial system (liver, spleen, etc.). Medical devices with surface areas of biomaterial many times greater than the size of the cell may stimulate frustrated phagocytosis. Frustrated phagocytosis does not involve engulfment of the biomaterial but rather the extracellular release of leukocyte products in an attempt to degrade or destroy the biomaterial [12]. Macrophages and foreign body giant cells adherent to the surface of the biomaterial may undergo frustrated phagocytosis with the release of hydrogen ion (acid) enzymes, ROIs, and others. Little is known regarding the extent or time period of frustrated phagocytosis and its dependence on the chemical and physical properties of the biomaterial.

The cells and components of vascularized connective tissue (Table 2.2) are involved in the inflammatory and wound healing responses. Thus, injury to soft tissues involves the specific types of cells which constitute the organ or tissue as well as the cells and components of vascularized connective tissue. Vascularized connective tissue can be viewed as the general network which holds together specific cell types in unique threedimensional patterns to constitute organs or tissues. While it is convenient to consider blood-material interactions separately from tissue-material interactions, it must be emphasized that blood-material interactions and the inflammatory response are intimately linked and, in fact, early responses to injury involve mainly blood and blood vessels. Therefore, both cellular and humoral elements, i.e., plasma proteins, etc., are considered as cells and components of vascularized connective tissue. 2.4 WOUND HEALING AND FIBROSIS The wound healing response is initiated by the action of monocytes and macrophages, followed by proliferation of fibroblasts and vascular endothelial cells, i.e., capillaries, at the implant site. The proliferation of fibroblasts and the formation of capillaries constitute granulation tissue. Modified fibroblasts, i.e., myofibroblasts, which have contractile properties which assist in wound site closure are transiently present in granulation tissue. As fibroblasts predominate over macrophages in the healing response, collagens and other extracellular matrix molecules are deposited in the implant site. The extent of the wound healing response is generally dependent on the extent or degree of injury or defect created by the implantation procedure. Wound healing progresses by primary union (or first intention) if the healing is clean such as a surgical incision in

Table 2.2 Cells and Components of Vascularized Connective Tissue Intravascular (blood) cells Erythrocytes (RBC) Neutrophils Monocytes Eosinophils Lymphocytes Basophils Platelets Connective tissue cells Mast Cells Fibroblasts Macrophages Lymphocytes Blood plasma proteins Coagulative Proteins Complement Proteins Albumin Fibrinogen Gamma-Globulins Others Extracellular matrix components Collagens Elastin Proteoglycans Fibronectin Laminin

which the wound edges have been approximated by surgical sutures, clips, or staples. Healing under these conditions occurs with a minimal loss of tissue. Wound healing by secondary union (or secondary intention) occurs when there is a large tissue defect that must be filled or there has been an extensive loss of cells and tissue. In wound healing by second intention, regeneration of specific organ or tissue cells cannot completely reconstitute the original architecture and more granulation tissue is formed resulting in larger areas of fibrosis or scar formation. Thus, the surgical procedure to create the implant site may influence the extent or degree of the wound healing response. The end-stage healing response to biomaterials and medical devices is generally fibrous encapsulation by collagenous fibrous tissue. This has been previously described as the minimal response. In the minimal response, the tissue/implant interface has a layer of macrophages and foreign body giant cells, i.e., foreign body reaction, on the surface of the biomaterial and this is surrounded or encapsulated by a fibrous capsule which is composed of collagen, proteoglycans, and other extracellular matrix molecules. Fibroblasts may be present in the fibrous capsule. 2.5 REPAIR OF IMPLANT SITES Repair of implant sites involves two distinct processes: regeneration, which is the replacement of injured tissue by parenchymal cells of the same type, or replacement by fibrous connective tissue that forms a capsule [7]. These processes are generally controlled by either (i) the proliferative capacity of the cells in the tissue or organ receiving the implant and the extent of injury as it relates to tissue destruction or (ii) persistence of the tissue framework of the implant site. The regenerative capacity of cells permits their classification into three groups: labile, stable (or expanding), and permanent (or static) cells. Labile cells continue to proliferate throughout life, stable cells retain this capacity but do not normally replicate, and permanent cells cannot reproduce themselves after birth of the host. Perfect repair, with restitution of normal structure, theoretically occurs only in tissues consisting of stable and labile cells, whereas all injuries to soft tissues composed of permanent cells may give rise to fibrosis and fibrous capsule formation with very little restitution of the normal tissue or organ structure. Tissues composed of permanent cells (e.g., nerve cells, skeletal muscle cells, and cardiac muscle cells) most commonly undergo an organization of the inflammatory exudate, leading to fibrosis. Tissues composed of stable cells (e.g., parenchymal cells of the liver, kidney, and pancreas), mesenchymal cells (e.g., fibroblasts, smooth muscle cells, osteoblasts, and chondroblasts), and vascular endothelial and labile cells (e.g., epithelial cells and lymphoid and hematopoietic cells) may also

follow this pathway to fibrosis or may undergo resolution of the inflammatory exudate, leading to restitution of the normal tissue structure. The condition of the underlying framework or supporting stroma of the parenchymal cells following an injury plays an important role in the restoration of normal tissue structure. Retention of the framework may lead to restitution of the normal tissue structure, whereas destruction of the framework most commonly leads tofibrosis.It is important to consider the species-dependent nature of the regenerative capacity of cells. For example, cells from the same organ or tissue but from different species may exhibit different regenerative capacities and/or connective tissue repair. An example of species differences in cell proliferation and regeneration is the endothelialization process, proliferation of endothelial cells, on the luminal surface of vascular grafts which does not occur in humans but does occur in other mammals including other primates. Following injury, cells may undergo adaptations of growth and differentiation. Important cellular adaptations are atrophy (decrease in cell size or function), hypertrophy (increase in cell size), hyperplasia (increase in cell number), and metaplasia (change in cell type). Hyperplasia of smooth muscle cells at blood vessel/vascular graft anastomoses may lead to failure of the graft by stenosis or occlusion, i.e., narrowing of the lumen, and thrombosis. Other adaptations include a change in which cells stop producing one family of proteins and start producing another (phenotypic change) or begin a marked overproduction of protein. This may be the case in cells producing various types of collagens and extracellular matrix proteins in chronic inflammation and fibrosis. Causes of atrophy may include decreased workload (e.g., stress-shielding by implants), as well as diminished blood supply and inadequate nutrition (e.g., fibrous capsules surrounding implants). Local and system factors may play a role in the wound healing response to biomaterials or implants. Local factors include the site (tissue or organ) of implantation, the adequacy of blood supply, and the potential for infection. Systemic factors may include nutrition, hematologic and immunologic derangements, glucocortical steroids, and pre-existing diseases such as atherosclerosis, diabetes, and infection. 2,6 SUMMARY Inflammation, wound healing, foreign body response, and repair of implant sites are usually considered components of the general soft tissue response to biomaterials or medical devices. The extent or degree and temporal variations in these responses are dictated by the inherent biocompatibility characteristics of the biomaterial or medical device. Factors which may play a role in the soft tissue response include the size,

shape, topography, and chemical and physical properties of the biomaterial. As the implantation procedure involves injury to vascularized connective tissue, blood responses and interactions may play a role in the general soft tissue response. The extent, degree or type of soft tissue response is generally considered to be tissue-specific, organ-specific, and species-specific. Thus, a given biomaterial may be considered to be biocompatible in one shape or form but not in another and in one tissue but not in another depending on the given application.

ADDITIONAL READING Black, J. (1992) Biological Performance of Materials - Fundamentals of Biocompatibility, 2nd edn, Marcel Dekker, New York. This volume is an excellent tutorial text for the engineer/biomaterial scientist/biologist/and others who have little or no knowledge in the area of biomaterials and medical devices. The text is divided into four parts: General considerations, material response: function and degradation of materials in vivo, host response: biological effects of implants, and methods of test for biological performance. The fourth part, Methods of test for biological performance, is unique to biomaterials texts and provides the reader with in vitro and in vivo test models and methods as well as perspectives on the design, selection, standardization, and regulation of implant materials. Cohen, I.K., Diegelmann, R.F. and Lindblad, WJ. (eds) (1992) Wound Healing: Biochemical and Clinical Aspects, W.B. Saunders Co., Philadelphia. This is an edited volume containing 35 chapters. The volume addresses the following areas: Biological processes involved in wound healing (6 chapters), structural and regulatory components of wound healing (7 chapters), factors affecting tissue repair (7 chapters), repair of specific tissues (7 chapters), and clinical management of healing tissues (7 chapters). This is an excellent volume which provides an up-to-date and in-depth perspective of various aspects of wound healing. The references lists provided at the end of each chapter are extensive. The strength of the volume is its biological perspective and little is provided on biomaterials. The chapter by Frederick Grinnell on cell adhesion does offer a biomaterial perspective. Gallin, J.A., Goldstein, LM. and Snyderman, R. (eds) (1992) Inflammation: Basic Principles and Clinical Correlates, 2nd ed, Raven Press, New York. This is an edited volume containing 58 chapters by individual authors. The volume is divided in the following areas: Soluble components of inflammation (10 chapters), cytokines (5 chapters), cellular components of inflammation (21 chapters), responses to inflammation (3 chapters), clinical correlates (13 chapters), and pharmacologic modulation of inflammation (4 chapters). Each chapter is a critical, in-depth review of the indicated subject and the references are extensive. This is an excellent volume for those wanting an in-depth overview of the inflammatory process and its components. No information is provided on biomaterial/inflanimation interactions.

Greco, R.S. (ed.) (1994) Implantation Biology: The Host Response and Biomedical Devices, CRC Press, Boca Raton. This is an edited volume containing 23 chapters. Three chapters deal with biomaterials in general, 6 chapters address specific blood and tissue interactions with biomaterials, 10 chapters address the use of biomaterials in specific surgical disciplines, and 3 chapters address tissue engineering and genetic manipulation of cells. The reference list for each chapter is extensive. This is an excellent overview of how biomaterials interact with the host and the specific use of biomaterials in indicated applications. Harker, L.A., Ratner, B.D. and Didisheim, P. (eds) (1993) Cardiovascular Biomaterials and Bio compatibility: A Guide to the Study of Blood-TissueMaterial Interactions, Cardiovascular Pathology, 2 (3 Suppl), 1S-224S. This is the third edition of a standard National Institutes of Health reference previously entitled Guidelines for Blood-Material Interactions - Report of the National Heart, Lung, and Blood Institute Working Group. The volume contains 20 chapters and 3 appendices. The chapters address the following areas: Pathophysiologic mechanisms, materials and their physicochemical characterization, safety testing of materials and devices, and blood-vessel-material interactions. The appendices are entitled: NIH Primary Reference Materials, International Standards for Biological Evaluation of Medical Devices, and Blood Analog Fluid for Medical Device Evaluation. This volume provides an in-depth perspective on cardiovascular materials and state-of-the-art information is provided regarding biomaterials. This is an excellent review, however, the editors limited the length and number of references for each chapter due to space considerations.

REFERENCES 1. Williams, D.F. and Roaf, R. (1973) Implants in Surgery, W.B. Saunders Company Ltd., London, pp. 233-35. 2. Anderson, J.M. (1993) Mechanisms of inflammation and infection with implanted devices. Cardiovascular Pathology, 2 (3 Suppl.), M319-M321. 3. Anderson, J.M. (1994) In vivo biocompatibility of implantable delivery systems and biomaterials. European Journal of Biopharmaceutics, 40, 1-8. 4. Anderson, J.M. (1994) Inflammation and the foreign body response. Problems in General Surgery, 11(2), 147-160. 5. Black, J. (1992) The inflammatory process, in Biological Performance of Materials -Fundamentals of Biocompatibility, 2nd edn, Marcel Dekker, Inc., New York, pp. 125-147. 6. Marchant, R.E., Anderson, J.M. and Dillingham, E.O. (1986) In vivo biocompatibility studies. VII. Inflammatory response to polyethylene and to a cytotoxic polyvinylchloride. Journal of Biomedical Materials Research, 20, 37-50. 7. Cotran, R.Z. et al. (1994) Inflammation and repair, in Pathologic Basis of Disease, 5th edn, Cotran, R.Z., Kumar, V. and Robbins, S.L. (eds), W.B. Saunders Co., Philadelphia, pp. 51-92.

8. Gallin, J.I., Goldstein, LM. and Snyderman, R. (eds) (1992) Inflammation. Basic Principles and Clinical Correlates, 2nd edn, Raven Press, New York. 9. Spector, M., Cease, C. and Tong-Li, X. (1989) The local tissue response to biomaterials. CRC Critical Reviews in Biocompatibility, 5 (4), 269-295. 10. Weissman, G., Smolen, J.E. and Korchak, H.M. (1980) Release of inflammatory mediators from stimulated neutrophils. New England Journal of Medicine, 303, 27-34. 11. Henson, P.M. (1980) Mechanisms of exocytosis in phagocytic inflammatory cells. American Journal of Pathology, 101, 494-511. 12. Henson, P.M. (1971) The immunologic release of constituents from neutrophil leukocytes: II. Mechanisms of release during phagocytosis, and adherence to nonphagocytosable surfaces. Journal of Immunology, 107, 1547-57.

Hard tissue response

T. Albrektsson

3.1 INTRODUCTION The initial tissue response when a biomaterial is implanted in the body is dependent on release of specific growth factors. It has been indicated by Frost [1] that the inevitable bone injury resulting from surgery and the presence of an implant will release various types of growth factors that will sensitize cells and promote cellular mitosis. This is a general healing response that will result in growth of all sorts of local connective tissues, bone as well as various types of soft tissue. The balance between these tissue varieties is controlled by the action of chemical mediators which issue 'instructions' for the amount of bone and soft tissue to be formed as an appropriate healing response. This delicate balance can easily be disturbed inadvertently and may cause the undesirable end-result of an interfacial soft tissue embedment of the implant or, in the case of fracture healing, formation of a pseudoarthrosis. The discussion in this section will focus on various modes of implant fixation, such as cementation, ingrowth and osseointegration (Figure 3.1). 3.2 FIXATION BY CEMENTATION Bone cement, a two component acrylic, is frequently used for implant fixation in the cases of hip and knee arthroplasties. Bone cement is toxic with localized as well as general adverse tissue reactions [2]. Therefore, the good long-term results reported with cemented arthroplasties seem to be quite puzzling. However, it must be understood that the strength of
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

Figure 3.1 Different classification criteria are used for implants in bone. Here we distinguish between cemented implants, which are dependent upon cure in place luting orfillingagents; cement-free (ingrowth implants) which are dependent on bone tissue growth into surface features forfixation;and osseointegrated implants, which are dependent upon collagen and cellular processes and their physiochemical interactions with the implant surface forfixation.In each case, a 'ridge' feature on the implant surface is shown in cross-section; the width of each band of the diagram is several millimeters (cells (osteocytes) are shown larger than actual size).

the cemented bone interface is not related to the live state of bone tissue: in reality, the curing bone cement invading the trabecular network results in a substantial cancellous bone interdigitation (Figure 3.1). The interfacial bone usually dies from the combined trauma of heat and monomer leakage. The width of this necrotic zone varies depending on the extent of the surgical trauma and the type of bone cement used, but is at least a few millimeters [2]. Ironically, a revitalization of the interfacial bone may prove disastrous, as the bone will then run an increased risk of resorption. In examining interfacial tissues reactions to retrieved cemented orthopaedic implants, most studies have examined the tissue after removal of the implant. This leads to an uncertainty in examining the proportion of true bone to implant contact. We have been able to investigate bone implants in situ, at the resolution level of light microscopy, utilizing the techniques developed by Donath et al [3]. Computer assisted calculations, using custom developed software, permit determination of the proportion of bone to implant contact, the amount of bone in the region adjacent to the implant and comparisons of the bone density adjacent to and in the immediate region of the implant ('outfolded mirror image') (Figure 3.2).

INSIDE

OUTSIDE

IMPLANT

BONE

Figure 3.2 Computerized histomorphometric approach to evaluation of the bone-implant interface. The bone-to-implant contact percentage is the linear contact area between bone and implant in the inside zone; percent bone ingrowth is the ratio of bone 'inside' to that 'outside' in the 'mirror' zone.

These data correlate positively to biomechanical tests: the more bone in the interfacial region of the implant, the greater the torque necessary to remove the implant when we apply controlled rotational forces to the implant body. Specimens of 10 |xm thickness have been investigated at the light microscopic level of resolution [4]. Other studies using cutting and grinding techniques have investigated the implant in situ, but ended up with sections of a final thickness of 40 |xm or more leading to clear overestimates of the true bone to implant contact. In a retrieval study of cemented resurface arthroplasties, Morberg [2] was able to overcome these methodological problems and verify a very poor bone to cement contact, even though he found bone fragments with disturbed mineralization bordering the cement. 3.3 FIXATION BY INGROWTH (CEMENT-FREE IMPLANTS IN BONE) In the absence of cement, fixation may be obtained by active bone tissue ingrowth into the implant surface irregularities of medullary stems (Figure 3.2). As pointed out by Black [5], one disadvantage of cement-free implants is the 3-4 week waiting time before the bone-implant interface can support significant shear loading; this is in contrast to a cemented interface which, if successful, has adequate shear strength within one hour of implantation. Osseointegrated implants have even lower interfacial shear strength at the the same 3-4 week post operative time point [6]. In the clinical experience, however, the results of cement-free joint arthroplasties utilizing ingrowth fixation have not matched those of cemented devices. The appropriate bone ingrowth is often disturbed and incomplete, leading to early failure of fixation. Cement-free knee arthroplasty components have been observed to migrate by up to 2 mm in the first post-operative year, while cemented devices of the same design migrate only half as much or less [7]. The failure rates of cement-free hip arthroplasties have been so substantial in comparison to cemented devices that the former mode of implant insertion has been restricted to young patients for whom cemented devices give poorer results at most clinics [8]. The outcome of cement-free orthopaedic implants depends, as does the outcome of craniofacial osseointegrated implants, on the more or less simultaneous control of a number of different factors including biocompatibility, design and surface conditions of the implant, the state of the host bed, the surgical technique and the loading conditions after implant insertion. Herein is the explanation for the dubious results of many current designs of cement-free hips and knees: the implant material used, the design and

surface finish have been well adapted to engineering demands, but not so well matched to the biological needs. Ideal implant characteristics with respect to bone anchorage are quite different from those of gliding surfaces. The surgical technique utilized when inserting a cement-free hip or knee of current designs is, of necessity, traumatizing: resulting in an impaired bone healing response. Current stem-type cement-free hips migrate when loaded, as do tibial components of artificial knees, leading to a change in the chemical mediators and subsequent increase of soft tissue formation. It is, therefore, not surprising to learn from studies of retrieved cement-free hips that there is, as a rule, only sparse bony ingrowth into retrieved acetabular cups [9], femoral cups [2, 10] or femoral stems [9, 11, 12]. More modern types of cement free hip prostheses with titanium meshwork or HA-coated surfaces have had slightly better clinical results than those implanted and retrieved during the 1980s and it may well be possible that there is more abundant bone ingrowth in some of the more recent designs. Nevertheless, from multicenter studies it seems quite clear that summed five-year failure rates for cement-free arthroplasties are greater than those for cemented devices [8]. This observation illustrates that the anchorage problems associated with cement free arthroplasties are far from solved. 3.4 OSSEOINTEGRATION Osseointegration is a term introduced by Branemark et al [13] to describe a loaded, stable implant in direct contact with bone (no apparent intervening soft tissue under light microscopic examination). Osseointegrated implants differ from ingrown ones that are dependent upon bone growth into surface macroscopic features or irregularities. By contrast, osseointegration is dependent on tissue ingrowth into minute surface features, such as the fundamental asperities of a 'smooth' surface or, as postulated for surfaces of various crystalline calcium phosphates (such as calcium hydroxyapatite) or amorphous, bioactive glasses, on direct chemical bonding between tissue and implant. Irrespective of the type of interfacial contact - chemical bonding or mechanical interdigitation - an important difference is that while the former requires only limited tissue elements, the latter requires complete, mature bone elements for appropriate function. Theoretically, an ingrown interface may also be osseointegrated as well but experimental evidence for this, from examination of thin sections, is virtually nonexistent. Macroscopic features on implant surfaces designed for ingrowth fixation include sintered beads, rough plasma sprayed coatings and sintered meshes, since bone requires features of minimum dimensions of about 100 |jLm for successful ingrowth [14, 15].

However, surface irregularities only in the nanometer to micrometer range are necessary for osseointegration when implant stability is dependent on cellular and/or collagen ingrowth, rather than bone ingrowth. Since this ingrowth (perhaps better termed 'ongrowth') of tissue elements occurs in a three dimensional manner, the osseointegrated implant will, from a biomechanical viewpoint, be a directly bone-anchored device. In fact, Wennerberg [16] has demonstrated that implant surfaces with a CLA (center line average) roughness of ~1 fim will experience more rapid bony incorporation, through osseointegration, than ones with CLAs of 0.1 or 2 |xm. This observation leads to the hypothesis that too smooth surfaces (CLA -0.1) may not permit proper collagen attachment while rougher ones (CLA > 2 |xm) may release too many metal ions that disturb cellular functions necessary for anchorage. There is no doubt that osseointegration has resulted in a clinical breakthrough in oral implants. Soft tissue embedded load-carrying devices do not function adequately in the jaw. In sharp contrast, properly osseointegrated implants do. However, this does not necessarily imply that every functioning bone implant in other parts of the body need to be osseointegrated. On the contrary, cemented hip arthroplasties with a bone-cement interface consisting of soft tissue or mostly dead bone have demonstrated significant clinical longevity, in many cases exceeding ten to fifteen years. Furthermore, the so called osseointegrated interface is still in need of a proper definition. First described by Branemark [17] as a bone response that occurred everywhere around the implant circumference of c.p. titanium screws in placed in bone, osseointegration is regarded today as a more nonspecific tissue response resulting in a mix of interfacial soft and hard tissues. In reality, bone anchorage of foreign bodies is a more general type of tissue response that occurs to c.p. titanium alone [3]. The only definition of osseointegration that has stood up to a critical analysis is based on a clinical finding of implant stability: 'A process whereby clinically asymptomatic rigid fixation of alloplastic materials is achieved and maintained, in bone, during functional loading' [18]. The continued usage of a term such as osseointegration is motivated by the proven clinical results in the case of craniofacial implants and the hope to replicate these findings in the case of orthopaedic implants in the future. However, from a strict histological point of view osseointegration remains poorly defined. Osseointegrated implants have resulted in a clinical breakthrough in two different clinical applications in the craniofacial skeleton: one of these being oral implants, irrespective of whether treating total or partial edentulousness [19, 20]; the other being skin penetrating extra-oral implants. The clinical results of screw-type, c.p. titanium oral implants in mandibles or maxillas for 5 years or more of follow up have been in the 90-99% range[21]. The results of skin penetrating implants in the temporal bone region have been similar, but not in the orbit region, where the host bed

has been irradiated. Now, 20 years since their clinical introduction in 1977, permanent skin-penetrating, osseointegrated, screw-shaped titanium implants are regarded as routine clinical treatments for facial disorders or certain types of hearing impairments [22, 23]. Press-fit fixation represents one approach to the osseointegration of orthopedic implants. The design of press-fit joint replacements is based on three dimensional geometric data with the intention of fitting the implant as closely as possible to the host bone. The objective of this design approach is to transfer load across the implant-bone interface to as wide an area of the bone as possible [24]. In theory, press-fit fixation may lead to osseointegration of the implanted device. However, as it is difficult to mimic precisely the resulting intravital loading patterns, osseointegration of initially stable press-fit components is threatened by subsequent bone remodeling processes. Too stiff a device may cause 'stress shielding,' leading to bone resorption. Conversely, too high local stresses may lead to pressure necrosis and resorption prior to remodeling. Finally, bone resorption may lead to local interfacial movements: these predispose to soft-tissue formation and may cause a subsequent failure of fixation. Polymers are not one hundred percent stable under biological conditions, leading to highly variable clinical durability. Ultrahigh molecular weight polyethylene (UHMWPE), although relatively stable, has shown poor outcomes when press-fitted in knee replacement arthroplasties [25]. The poor fixation of such devices may relate both to intrinsic properties of the polymers involved as well as to differences in their elastic moduli from that of bone. For instance, the Young's modulus of UHMWPE is approximately 2% of that of cortical bone (0.3 GPa vs. 17 GPa). This leads to a quite different loading pattern for both the polymer and the surrounding tissue than that encountered in the case of c.p. titanium, which is approximately 7 times as stiff as cortical bone (127 GPa vs. 17 GPa). Ceramics are still stiffer, with moduli up to 30 times that of cortical bone. Bulk ceramics, such as aluminum oxide (alumina) are well tolerated by bone but are generally insufficiently strong and tough to serve as load bearing implants, especially in the presence of tensile or bending loads. Calcium phosphates, such as calcium hydroxyapatite (CaHAP), although much weaker still, are an interesting class of biomaterials due to their assumed capability for 'bone bonding'. S0balle et al [26] has observed that the addition of a CaHAP coating induces proliferating bone to bridge gaps in the bone-implant interface, in the presence of dynamic loading, which would be filled with soft tissue around uncoated metallic implants. He also suggests that such coatings enhance bone growth from osteopenic tissue, utilizing an experimental animal arthritis model with substantial pre-implantation loss of bone density. In experimental studies, c.p. titanium has been demonstrated to induce a stronger bone response than most other pure metals or alloys, including

Ti6A14V [4, 27]. However, there is substantial evidence that CaHAP leads to a still more rapid healing response [28]. This may be due to a direct positive influence on interfacial bone from the calcium phosphate material and/or a relatively rough surface topography resulting from the manufacturing process in combination with the reduction of metal ion release by the presence of the CaHAP coating. Long term experimental and dental clinical data from CaHAP coated implants has been disappointing [29]. However, CaHAP remains a very interesting biomaterial with efforts underway to explore functional improvement through changes in crystallinity, coating thickness, method of application, etc. Retrieval data [30-32] have contributed to our current knowledge of oral implants. Steflik and co-workers [32] reviewed 51 retrieved oral implants of different designs. They claimed that implants inserted 10 years ago or more fail generally due to loss of bone support and other biological features while more recently placed oral implants also fail secondary to intrinsic biomaterial failure such as implant fracture. One hundred stable (uncoated) Branemark System 'Nobelpharma' implants were retrieved and studied at our laboratories: 33% were removed because of therapy-resistant pain or progressive bone resorption, 26% were removed after death from unrelated causes, 24% were fractured implants and 17% were removed for psychological reasons. The implants had been in situ and functioning for 1-18 years. There was on average 82% bone-toimplant contact and a similar percentage of bone within the threads of these retrieved implants (evaluated over the three best consecutive threads on both sides of the implant). Whenever possible, the entire bone to implant contact percentages were also calculated and found to be ~ 70%. In almost every case, there was >60% bone to implant contact. In fact, such extensive bone to implant contact percentages may represent a histological correlate to osseointegration. 3.5 HOW BONE-BIOMATERIAL INTERFACES FAIL The implant-bone interface can fail for various reasons but the most common is so-called 'aseptic loosening': i.e. loosening not associated with infection. The causative factors for aseptic loosening may be classified as mechanical or biological. For example, early post-operative failures of cemented, cement-free (ingrown) as well as osseointegrated implants may be attributed to lack of initial fixation due to mechanical failure of the bone-cement (when present) or bone-implant interface. Such failures may relate to incidents of overload. However, early failures may also occur subsequent to overheating of the tissues during surgery, leading to bony necrosis, collapse and subsequent mechanical loosening. Overheating due to a combination of surgical trauma and polymerization heat release may

occur at bone-cement interfaces; surgical trauma, with associated heating, alone may prevent bone and other tissue elements from invading cement-free implant-bone interfaces, whether designed for ingrowth or osseointegration. Biological failure is also possible in the longer term, associated with generation or release of cytotoxic products, such as cement monomer or metallic corrosion products or through induction of specific immune responses [33] (Figure 3.3). In clinical use, cylindrical shaped oral implants which lack any additional retention features, such as threads, grooves, etc., are prone to gradual failure due to ongoing bone 'saucerization' (gradual loss of bone at the implant-bone-mucosal boundary) [21]. In the case of orthopaedic implants with medullary structural elements (such as a femoral stem), Willert and Semlitsch were first to propose that bone loss occurred secondary to biological response to small particles, such as wear debris. [34] Macrophages (MP) and foreign body giant cells (GC) ingest these undigestible particles of metal, polymer or ceramic and release factors which stimulate osteolytic activity by cells in membranes associated with the implant-bone interface (Figure 3.3) [35]. With modern histological staining techniques, especially the use of oil red O [33], it has now become possible to appreciate the large amounts of small and submicron UHMWPE particles found in the vicinity of loose orthopaedic joint replacement implants. Many investigators believe that biological response to these particles is the leading biological cause of osteolysis leading to gradual, late implant failure.
3.6 CONCLUSIONS

The major advantage of the osseointegrated interface is its remodelling capacity. Gradual adaptation to load has been verified in retrieval studies; the implants are known to have almost no bone to implant contact during the first few weeks after placement but then demonstrate an increasing amount of interfacial bone tissue. The main proportion of osseointegrated implant failures occur during the first one or two years and result from failure to achieve a proper osseointegration. This trend is quite different from most orthopaedic studies reported in the literature, which show clinical failure rates increasing with time. Cemented arthroplasties of today have resulted in a significantly better clinical outcome than cement-free ones. It must be pointed out that the results of orthopaedic implants published in the literature are generally based on the number of revisions alone. This means that the actual number of successful arthroplasties is lower than the figures quoted in the literature. Furthermore, there is a patient drop-out of more than 20% in most clinical reports. From a biological viewpoint it is important to strive for improved cement-free implants

METAL

BONE
Cell mediated resorption;
PH
OAF

Free radicals
ILi TNF

PGE 2

Figure 3.3 Theoretical failure modes for an osseointegrated calcium hydroxy apatite-coated femoral stem of a total hip replacement prosthesis [29; by permission]. Key: GC: multinucleated giant cell; MP: macrophage; Ca: calcium; Ph: phosphorous; OAF: osteoclastic activating factor; IL1: interleukin 1, TNF: tumor necrosis factor; PGE2: prostaglandin E2.

so that their clinical results will at least match those of the cemented arthroplasties. New types of osseointegrated hip and knee constructions have been designed and are presently in clinical trials. Altering prosthetic design (in comparison with current practice), and improving surgical instruments and procedures may well overcome some of the hurdles in the development of new osseointegrated arthroplasty devices. ADDITIONAL READING Lee, AJ.C. and Ling, R.S.M. (1984): Loosening, in Complications of Total Hip replacement, (ed. R.S.M. Ling), Churchill-Livingstone, Edinburgh, pp. 110-145. Still useful account of the biological and mechanical features of loosening leading to clinical failure of the various interfaces formed between rigid biomaterials and bone. Extensive bibliography. Manley, M.T. (1993): Calcium phosphate biomaterials: A review of the literature, in Hydroxylapatite Coatings in Orthopaedic Surgery, (eds G.T.R. Geesink and M.T. Manley), Raven Press, New York, pp. 1-24. The title speaks for itself. Additional chapters in the same book provide experimental and clinical results of osseointegration, specifically adhesion fixation. Spector, M. (1987): Historical review of porous-coated implants. /. Arthroplasty, 2(2), 163-177, 1987. Historical review of experimental and clinical results of ingrowth fixation, with extensive bibliography. REFERENCES 1. Frost, H.M. (1989) The biology of fracture healing. Clinical Orthopaedics and Related Research, 248, 283-293. 2. Morberg, P. (1991) On bone tissue reactions to acrylic cement. PhD Dissertation, Biomaterials Group, University of Gothenberg, Sweden, pp. 1-142. 3. Donath, K., Laass, M. and Giinzl, H.-J. (1992) The histopathology of different foreign body reactions in oral soft tissue and bone tissue. Virchows Archiv A Pathologia Anatomica, 420, 131-137. 4. Johansson, C. (1991) On tissue reactions to metal implants. PhD Dissertation, Biomaterials/Handicap Research, University of Goteborg, Goteborg, Sweden, pp. 1-232. 5. Black, J. (1988) Orthopaedic Biomaterials in Research and Practice. New York, Churchill Livingstone, pp. 267-284. 6. Steinemann, S.G., Eulenberger, J., Maeusli, P.-A. et al (1986) Adhesion of bone to titanium. Adv. in Biomaterials 6, 40-44. 7. Ryd, L. (1986) Micromotion in knee arthroplasty. A Roentgen stereophotogrammetric analysis of tibial componentfixation.Ada Orthop. Scand., Suppl. 220, 1-80. 8. Malchau, H., Herberts, P. and Anhfelt, L. (1993) Prognosis of total hip replacement in Sweden. Follow-up of 92,675 operations performed in 1978-1990, Acta Orthop Scand., 64, 497-506.

9. Collier, J.P., Mayor, M.B., Chae, J.C. et al (1988) Macroscopic and microscopic evidence of prosthetic fixation with porous coated materials. CUn. Orthop. ReL Res., 235, 173-180. 10. Willems, WJ., Eulderbrink, F., Rozing, P.M. et al. (1988) Histopathologic evaluation in failed Gerard double cup arthroplasty. CUn. Orthop. ReL Res., 228, 123-133. 11. Engh, CA., Bobyn, J.D. and Glassman, A.H. (1987) Porous coated hip replacement. The factors governing bone ingrowth, stress shielding and clinical results. /. Bone Joint Surg., 69B, 45-55. 12. Cook, S.D., Thomas, A.K. and Haddad, RJ. (1988) Histologic analysis of retrieved human porous coated joint components. CHn. Orthop. ReL Res., 234, 90-101. 13. Branemark, P.-L, Hansson, B.-O., Adell, R. et al. (1977) Osseointegrated implants in the treatment of the edentulous jaw. Scand. J. Plastic Reconst. Surg., Suppl 16, 1-116. 14. Albrektsson, T. (1979) Healing of bone grafts. In vivo studies of tissue reactions at autografting of bone in the rabbit tibia. PhD Dissertation, Laboratory for Experimental Biology, Goteborg University, Goteborg, Sweden, pp. 1-90. 15. Pilliar, R.M. (1986) Implant stabilization by tissue ingrowth. In Tissue Integration in Oral and Maxillofacial Reconstruction, D. van Steenberghe (ed.), Amsterdam, Excerpta Medica, pp. 60-76. 16. Wennerberg, A. (1995) On surface topography of implants. PhD Dissertation, Biomaterials/Handicap Research, University of Goteborg, Goteborg, Sweden, pp. 1-202. 17. Branemark, P.-L (1985) Introduction to osseointegration, in Tissue Integrated Prostheses (eds P.-L Branemark, G. Zarb and T. Albrektsson), Quintessence Co, Chicago, pp. 11-76. 18. Zarb, G. and Albrektsson, T. (1991) Osseointegration - A requiem for the periodontal ligament? - An editorial. Int. J. Periodontal and Restorative Dent, 11, 88-91. 19. Albrektsson, T., Dahl, E., Enbom, L. et al. (1988) Osseointegrated oral implants. A Swedish multicenter study of 8139 consecutively inserted Nobelpharma implants. /. Periodont., 59, 287-296. 20. Lekholm, U., vanSteenberghe, D., Herrmann, I. et al. (1994) Osseointegrated implants in partially edentulous jaws: A prospective 5-year multicenter study. Inter. J. Oral & Maxillofacial Implants, 9, 627-635. 21. Albrektsson, T. (1993) On the long-term maintenance of the osseointegrated response. Australian Prosthodontic J., 7, 15-24. 22. Tjellstrom, A. and Granstrom, G. (1994) Long-term follow-up with the bone anchored hearing aid: A review of the first 100 patients between 1977 and 1985. Ear Nose and Throat J., 2: 138-140. 23. Jacobsson, M., Tjellstrom, A., Fine, L., et al. (1992) A retrospective study of osseointegrated skin-penetrating titanium fixtures used for retaining facial prostheses. Int. J. Oral & Maxillofacial Implants, 7, 523-528. 24. Poss, R., Robertson, D.D., Walker, P.S. et al. (1988) Anatomic stem design for press-fit and cemented application. In Non-cemented Total Hip Arthroplasty, R. Fitzgerald, Jr (ed.), New York, Raven Press, pp. 343-363.

25. Freeman, M.A.R., McLoed, H.C. and Levai, J.P. (1983) Cementless fixation of prosthetic components in total arthroplasty of the knee and hip. CHn. Orthop. ReL Res., 176, 88-94. 26. S0balle, K. (1993) Hydroxyapatite ceramic coating for bone implant fixation. Ada Orthop. Scand. (Suppl 225), 64, 1-58. 27. Han, C.H., Johansson, C, Wennerberg, A. et al (1995) A quantitative comparison of commercially pure titanium and titanium-6 aluminum-4 vanadium implants in rabbit bone. Proc. Fifth Biomaterials Club Meeting, Ischgl, Austria, Albrektsson T. and Tjellstrom, A. (eds), p. 25. 28. S0balle, K., Hansen, E.S., Rasmussen, H.B. et al (1993) The effect of osteoporosis, bone deficiency, bone grafting, and micromotion on fixation of porous coated vs. hydroxyapatite-coated implants. In Hydroxyapatite Coatings in Orthopedic Surgery, Geesink, R.G.T. and Manley, M.T. (eds), New York, Raven Press, pp. 107-136. 29. Gottlander, M. (1994) On hard tissue reactions to hydroxyapatite-coated titanium implants. PhD Dissertation, Biomaterials/Handicap Research, University of Goteborg, Goteborg, Sweden, pp. 1-202. 30. Lemons, J.E. (1991) Bone-biomaterial interfaces in retrieved implants, in The Bone Biomaterial Interface (ed. J.E. Davies), University of Toronto Press, Toronto, pp. 419-424. 31. Albrektsson, T., Eriksson, A.R., Friberg, B., et al. (1993) Histologic investigations on 33 retrieved Nobelpharma implants. Clinical Materials 12 (1), 1-9. 32. Steflik, D.E., Parr, G.R., Singh, B.B. et al. (1994) Light microscopic and scanning electron microscopic analyses of dental implants retrieved from humans. /. Oral Implantol, 20(1), 8-24. 33. Campbell, P. (1995) On aseptic loosening of total hip replacements: The role of UHMWPE wear particles. PhD Dissertation, Biomaterials/Handicap Research, Goteborg University, Goteborg, Sweden, pp. 1-225. 34. Willert, H., Semlitsch, M. (1976) Reactions of the articular capsule to joint prostheses. In Biocompatibility of Implant Materials, D.F. Williams (ed.), London, Sector Publishing, pp. 157-169. 35. Goldring, S.R., Schiller, A.L., Roelke, M., et al (1983) The synovial-like membrane at the bone-cement interface in loose total hip replacements and its proposed role in bone lysis. /. Bone Joint Surg., 65A, 575-584.

Immune response
K. Merritt

4.1 INTRODUCTION There is increasing concern about the role of specific immune response to implanted materials. This section discusses the general principles governing immune responses and outlines techniques for their measurement and evaluation. This is a necessarily brief presentation of the issues, and the reader is encouraged to pursue the topic through relevant references provided for further study. 4.2 OVERVIEW OF THE SPECIFIC IMMUNE RESPONSE The specific immune response is the normal response of vertebrates when a foreign substance is introduced into the body. This is a desirable protective response which detoxifies, neutralizes, and helps to eliminate such substances. However, in some cases, responses to seemingly innocuous substances may cause harm to the host. Such effects are usually termed allergic or hypersensitivity responses. The responses have been classified into four types: Type I, Type II, Type III, Type IV. These four responses share elements of a common mechanism, triggered by the presence of a foreign material termed an antigen. The antigen is initially processed by a cell, usually either a monocyte or macrophage, but occasionally a skin dendritic cell also referred to as an antigen processing cell (APC). The APC engulfs the antigen, processes it (usually by enzymatic digestion or attempted digestion), and transfers or presents
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

it to another cell, usually a lymphocyte termed a T helper cell. The T helper cell then presents the processed antigen to another T lymphocyte, called the T cytotoxic cell, or to a B lymphocyte. The receiving cell, whether T- or B-type, initiates a response for interaction with the processed antigen, forming a less biologically active complex. In the former case, the immune response is a Type IV or cell mediated immunity while in the latter case, the final result is release of free antibody, which may lead to a humoral Type I, II, or III response. T-cell responses result in accumulation of T-cells at the site where the foreign material is present. B-cells remain at remote depots of lymphoid tissue while the antibody circulates and appears at the site of the foreign material. The main features of the four types of responses are described in the following table:
Type: Antibody: Cells involved: Mediator: I IgE B-lymphocytes Histamine, vasoactive amines II IgG, IgM B-lymphocytes Histamine, vasoactive amines III IgG, IgM B-lymphocytes Vasoactive amines IV none T-lymphocytes Cytokines Consequences: Itching, rhinitis, vascular collapse Vascular collapse Pain, swelling, some vascular plugging and collapse Pain, swelling

Both the T- and B-cells are small lymphocytes, which circulate in the blood, and are found in lymphoid tissue. They arise from a common stem cell and then undergo processing in the thymus to become T-cells or an unknown site, probably the bone marrow, to become B-cells. They are difficult to distinguish and a great deal of work has been done to facilitate identification of these cells in order to elucidate specific immune responses. Identification of T-cells has been greatly aided by the recognition that there are unique substances on the cell surface that can be recognized by the use of monoclonal antibodies generated using murine cells. These antigens are referred to as cluster differentiation markers (CDs) and are given numbers. There are a large number of them, more are being identified, and the importance of each is being evaluated. However, all T-cells express CD3 which is consequently referred to as a Pan (= all) T-cell marker. CD2 may also be a Pan T-cell marker. Additionally, the T helper cell expresses CD4 while the T cytotoxic cell expresses CD8. New CDs continue to be identified and their importance evaluated. The B-cell retains small amounts of antibody on its surface which can be used for identification. The B-cell response results in further differentiation to plasma cells which produce antibody in large quantities. Antibody is a four chain immunoglobulin which has combining sites specific for a single antigen. Antibody is soluble, circulates in the plasma,

and the plasma or serum drawn from a vertebrate, or the antibody produced in cell culture for monoclonal antibodies, can be stored frozen and will last virtually forever. There are five general classes of immunoglobulins produced as antibodies. In order of concentration in normal human blood from highest to lowest are IgG, IgM, IgA, IgE, and IgD. IgD is a surface marker on Bcells and will not be discussed further. IgE is the antibody associated with Type I responses. IgA is a secretory immunoglobulin, found in high concentrations in saliva, GI contents, and milk and in the associated organs. IgG and IgM are present in high concentrations in blood and are excellent antibodies for immunological testing since they can participate in Type II and III responses. Type I responses and Type II responses have the same consequences, but the mechanisms are different. Type I responses are best known as hay fever and dust allergies and are immune responses to these antigens mediated by a skin fixing antibody (IgE). Type II responses involve the reaction of IgG, rarely IgM, antibody with a cell surface antigen. The result is lysis of the cell with release of products. If the cell contains vasoactive amines, then the consequences are signs and symptoms described here. This is commonly seen in allergies to drugs which bind to blood platelets. Type III responses are referred to as immune complex reactions and occur when both antigen and antibody are present in large quantities at the same time. In the normal immune response, the antigen is processed, the immune response is initiated, and the antigen disappears shortly. However, if the antigen is persistent, then significant amounts of immune complexes can form, plug small vessels, and result in tissue or organ damage. Type IV responses are those most usually associated with chronic presence of a foreign body, such as an implanted biomaterial. They are typified by the common contact dermatitis caused by poison ivy. In each case, an antigen stimulates the immune response and the immune response in turn reacts specifically with the antigen. T-cells, Bcells and circulating antibody each recognize only one antigen. For a substance to be antigenic, it must be foreign to the host, of high molecular weight (> 3000), and processable by an APC. However, some small substances become antigenic by binding to larger carrier molecules, usually proteins, found in the host. Such a small substance is called a hapten and the immune response is mounted to the hapten-carrier complex. 4.3 DETECTION OF ANTIBODY To evaluate whether or not a patient has produced antibody against a substance, such as an implant, a blood sample needs to be drawn, tested

and the results compared to those from controls. A pre-implantation sample is an ideal control but usually this is not available. The choice of appropriate controls is a major problem. The test procedure itself requires a known positive control (often difficult to obtain for evaluating responses to biomaterials), and a known negative control (usually saline, tissue culture media, or bovine or equine serum used for tissue culture). The controls for the patient population under study are generally obtained from normal individuals without implants and without underlying disease, individuals with the disease (e.g. arthritis) but without the implant (e.g. total joint replacement), individuals with the implant and without problems, and individuals with diagnosed implant failure. The results for all of these need to be analyzed in order to ascertain whether or not antibody is increased in the patient population and whether or not its presence can be correlated with failure of the device. Most current tests are based on immobilization of the antigen to a solid surface such as polystyrene. The general procedure is outlined in Figure 4.1. Detection of bound antibody involves the use of enzyme (EIA or ELISA assays) or a radioisotope labeled antibody (RIA). (The tests are simple to perform, but great care is needed to wash away excess materials and use the appropriate concentrations. Individuals wishing to initiate such testing procedures are encouraged to attend workshops (often offered by American Society for Microbiology, American Type Culture Collection, etc.) or obtain training in a clinical immunology lab, and also explore detailed manuals on procedures.) Antiserum to human antibodies, (all classes or individual types) with enzyme labels, can be purchased from several biological supply houses. Isotope labeled antibody is available to licensed laboratories.

Labeled Second Antibody Patient's Antibody

Antigen

Support

Figure 4.1 Standard immunoassay for antibody. An antigen is fixed (attached) to a solid support and binds a specific antibody from solution. The bound antibody is detected by binding a second, labeled (enzyme, isotope, etc.) antibody.

Problems with interpretation of results: Positive results If negative controls are negative and patient samples are positive, then the interpretation is that the patient made antibody to that antigen. However, the question remains as to whether or not the antigen is the correct one and if contaminating antigens are contributing to the reaction. This is difficult to determine but inhibition studies with well characterized antigens are helpful. In vivo testing Type I sensitivity is associated with histamine and vasoactive amine release with vascular responses. Often such sensitivity is determined by 'patch' (skin) testing. The positive reaction will occur in a few minutes as a wheal and erythematous (reddening) flare response in the skin. This test is hampered by availability of antigen for testing but the biomaterial applied directly to skin or a mucosal surface may stimulate a response. Caution needs to be taken in interpreting these tests, however, since this is a short term application. Negative results Negative results are the desired response in evaluating biomaterials for clinical use, but they are also difficult to evaluate. If there are no responses recorded except in the positive control sample, this is indicative that patient does not produce antibody to that antigen. Again the question of appropriateness of the antigen and its concentration on the solid support remains. In vivo testing A negative skin test presents the same problem: Was the antigen correct and/or was it applied to a correct site? 4.4 DETECTION OF CELL MEDIATED RESPONSES (TYPE IV) The procedures for detecting cell mediated responses are much more complicated and difficult than for antibody determination. Most of the assays require the use of living cells and thus tests must be done shortly after obtaining the cells. Controls may have to be done at a different time which complicates the comparisons.

The two most common in vitro test procedures used are lymphocyte proliferation and cell migration inhibition tests. The basic theory behind both of these is that T-cells have receptors on their surface which will each respond to a specific antigen. In the course of the response, soluble substances (cytokines or lymphokines), principally blastogenic factor and migration inhibition factor, which act on other cells, including other Tcells, are produced and released. Blastogenic factor (lymphocyte transformation factor) This causes other lymphocytes to transform and divide. If cell counts are done, an increased number is seen. If a radioactive cell proliferation precursor (such as tritiated thymidine) is added to the culture, the isotope is taken up by dividing cells and the 'counts' increase. This test, usually called LTT for lymphocyte transformation test, requires living cells to produce and respond to the factor. This takes several days, with 7 days being the general time for response to antigen. Some control stimulants (mitrogens) such as PHA (phytohemagglutinin) act in 4-5 days. Interpretation of the tests presents the same problems as with tests for antibody: Are the appropriate controls included, what was the antigen used, were the cells viable; if the results are negative, were the culture conditions correct? Migration inhibition factor Migration inhibition factor (MIF) is produced by the stimulated T-cell and acts on cells that are normally motile. The two cell types are the monocyte/macrophage line and polymorphonuclear leukocytes (polys). Thus the test, usually called LIF test (leukocyte inhibition test) requires living lymphocytes and living migrating cells which may be obtained from fresh, whole blood. The results of the LIF test are available in 18-24 hours. Blood does not contain enough monocytes to evaluate inhibition of their migration and this indicator cell is usually obtained from the peritoneal cavity of other animals, typically the mouse or the guinea pig. It is possible to stimulate human lymphocytes in culture for 24-48 hours and then harvest the culture fluid and add it to the macrophages obtained from the animals. Migration (or inhibition of migration) of cells is observed by placing them into tissue culture medium solidified with purified agarose and observing them with a microscope in 18-24 hours or by packing them into capillary tubes and observing migration from the tubes in a few hours giving the appearance of 'ice cream cones'. The factor for LIF and the one for MIF may be slightly different and thus the two separate terms remain.

Choice of test There is no evidence that one test is better than the other. The choice is usually based on laboratory preference. This author uses blood cells and migration in agarose since it requires little equipment, is rapid, and small breaks in aseptic procedure are tolerated. The evidence is that the stimulated T-cells produce a group of cytokines. Thus detecting migration inhibition factor or lymphocyte proliferation implies the presence of the others and one is not more specific or sensitive. Direct testing for lymphokines or cytokines It would seem from the above studies that the ideal test would be for the lymphokines without the use of a viable indicator cell. These substances are produced in low levels, and thus the cell based assays such as LTT and LIF or MIF are required. Although ELISA based or RIA based assays can be used to detect and quantitate cytokines, reagents are not yet available for these human lymphokines (LIF, MIF, LTT) specifically. Testing for production of cytokines There is a current explosion of studies on production of cytokines in response to biomaterials, especially to particles produced by wear and degradation. Thus it seems pertinent to discuss these assays briefly. The assays are generally done by inhibition of ELISA or RIA based assays. This concept is shown in Figure 4.2. Many of these assays are available as complete 'kits' from emerging biotechnology companies. (There are

Labeled Second Antibody Free Antigen Antigen AntigenAntibody Complex (rinsed away)

Support

Figure 4.2 Quantitation of antigen by competitive (inhibition) assay. An antigen is fixed (attached) and binds a specific antibody from solution. However, additional antigen is provided in solution and antibody binding to the bound antigen is reduced in direct proportion to the concentration of free antigen. The bound antibody is then detected by binding a second, labeled (enzyme, isotope, etc.) antibody.

many companies, each doing only a few of the cytokines; thus no specific reference will be given. A glance at the methods section in an article reporting on assays will give their source. In addition, a glance at a biotechnology based journal and Science will give ads, or an immunologist's mail box will give you a plethora of choices). These tests are easy to perform, but have technical difficulties and must be done carefully. Interpretation of the results involves being sure that the control studies were done successfully. Again, as with most studies, a positive test can be evaluated but a negative test is difficult to interpret until you are confident of the laboratory doing the testing. In vivo studies The classical test for cell-mediated immunity (CMI) (Type IV) in the early days of immunology was the skin test. Antigens were applied to the skin or injected under the skin and swelling was observed in 24-72 hours if there was CMI. This was differentiated from Type I, IgE mediated responses, which occur rapidly (in minutes) and usually disappears in 24 hours. CMI begins in 24 hours, has a swelling with some resemblance to the wheal but does not show a flare. This author does not advocate skin testing for responses to biomaterials since the testing is difficult to do correctly, has the potential for producing sensitivity to the test agents and the results are easily misinterpreted. In general, the use of the actual biomaterial (rather than extracts, corrosion products or constituents) is contraindicated since mechanical irritation may be read as a false positive or or the biomaterial may fail to release the antigen and thus produce a false negative. Skin testing is an excellent diagnostic procedure in patients with clinical suspicion of hypersensitivity. However, skin testing with haptens, such as metal ions, involves a risk of sensitization. For the immune response to be detected, the hapten must bind to dermal cells or proteins. However, such binding produces a complete antigen which may stimulate an immune response. Since this immune response takes time to develop, the skin test will be negative, but future tests may then be positive. Thus repeated testing increases the likelihood of inducing sensitivity and should be avoided. Bulk biomaterials will probably not give adequate release of soluble materials in the 24-48 period of testing so may produce false negative results. Histochemical techniques There are a number of studies now examining tissues removed from sites adjacent to implants. It is possible, using immunological techniques resembling those outlined in Figure 4.1, to identify cell types and perhaps cell products produced at the site. The major interest is in the detection and

typing of lymphocytes by use of antisera prepared against the CD markers described earlier. The same type of assay is being initiated for detection of the cytokines in the tissue. The techniques are simple but not all antisera work and thus a variety of antisera are used. The required antisera are available commercially. Interpretation of the results is again a problem. Tests using 'home made' monoclonal antibodies are suspect until the antisera is made available to other investigators for conformation. The use of well characterized antisera from companies which supply to others is better at this stage. Since the tissue section is examined and scored by an observer, the 'data' from these studies are not really available for analysis by the reader. Computerized image analysis techniques are still not widely used. Thus, in evaluating the results, possible bias of the investigator must be taken into account. 4.5 DETECTION OF IMMUNE RESPONSES TO HAPTENS Detection of immune responses to haptens is the same as that described above, but there are some special techniques now being used. A hapten-carrier complex can be prepared in vitro by combination in solution with a large protein such as albumin or a smaller molecule such as glutathione. These can then be used to coat a solid substrate. Alternatively, the protein carrier can be coated onto a substrate, the hapten added, and then the assay performed. This probably increases the amount of hapten that is available for antibody binding and minimizes that which is lost in the tertiary folding of the protein. 4.6 HUMAN IMMUNE RESPONSE TO MATERIALS 4.6.1 Latex The term 'latex' actually is confusing since the name is given to some materials because of the way they are processed and not because of their source. The biomaterial latex used to fabricate gloves, condoms, etc. is a rubber (elastomer) extracted from a plant (Hevea brasiliensis). As such, there is a great deal of antigenic protein contamination. Allergies to latex are usually of the Type I, IgE mediated response, with an immediate reaction (in minutes) that can be life threatening. Since latex is encountered in many household objects such as household gloves, balloons, etc., sensitivity to it is a frequent pre-existing condition. Latex material cleaned of protein seems to be nonallergenic. Other types of immune response to latex have not been as frequent or of much concern. Latex is not used as a long term implanted material and thus the long term responses are

not noted. The population at greatest risk are the health care workers with the increased use of examining and surgical gloves.
4.6.2 Collagen

This is another material that is an extract of material of natural origin with bovine and orvine skin or tissue the favored source. This is a foreign protein and thus capable of stimulating a variety of immune responses. Antibodies of IgE, IgM, and IgG classes have been observed. Cell mediated immune responses have also been observed. As with latex, the important precaution is to remove as much foreign material as possible. Since collagen across mammalian species has a similar structure, it is possible to remove contaminating proteins and leave a relatively nonallergenic material. Chemical treatment and cross linking of the collagen can further reduce antigenicity. Collagen products need to be carefully evaluated for their ability to initiate immune responses, but it is possible to produce safe products.
4.6.3 Synthetic polymers

The use of chemically defined synthetic polymers is associated with minimal human immune responses. These materials are based on carbon, hydrogen, nitrogen and oxygen which are basic building blocks of the biological system. Thus the generation of antigenic material would be unlikely. Nevertheless, there are some polymeric materials with additional chemical moieties that are of concern. A. Polysiloxane (silicone elastomer) There is abundant lay press comment and little scientific material on this topic. It is apparent that there can be binding of silicone to foreign protein with stimulation of the immune response. The use of a simple hapten test, as described in section 4.5, has added greatly to our knowledge of this. It is also apparent that silicone gel is a potent adjuvant enhancing immune responses to unrelated materials. Whether this is of relevance to the use of gelfilledimplants remains unknown. The possible stimulation of related and unrelated immune responses remain a major concern in the use of these materials. B. Polyurethanes This is a complex group of polymers. Their propensity to stimulate an immune response is very small since there are few molecular groups which would be perceived as foreign by the host, perhaps explaining why clinical immune responses to polyurethanes have not been reported.

C. Poly(methyl)methacrylate Acrylics are in widespread use in activities of daily living. As with metals, there are documented cases of contact dermatitis from the use of these materials, especially self curing glues containing methacrylate monomer that is very skin sensitizing, usually stimulating a Type IV response. The use of these materials for implants generally exposes the patient to the monomer for only a brief period of time as the bone cement or dental acrylic cures in situ. Acrylics which are fully polymerized before use will not be associated with an allergic response. Reports of sensitization responses of patients to acrylics are rare and the health care workers at most risk are the personnel, such as the surgeon and dental laboratory technician, handling the monomer frequently. D. Metals A number of metallic elements and alloys are used extensively in implants, external medical devices and are encountered in activities of daily living. Allergy to metals as a contact dermatitis (Type IV response) is well known in individuals in contact with metal salts, corroding metals, and jewelry or snaps and fasteners. Reactions have been seen to metals used in dental, orthopaedic, and general surgery. The contact dermatitis from topical use resolves when the device is removed. The role of the immune response in reactions to metals implanted into the deep tissue remains controversial. Cell mediated immune responses have been associated, in some studies but not in others, with pain and swelling at the implant site and loosening of the device. Antibodies to metals in patients with metallic implants have recently been reported, but again the consequences of this response remain unknown. Concern remains about the chronic use of metals that are known human sensitizers, such as chromium, nickel and cobalt.

4.7 CONSEQUENCES OF AN IMMUNE RESPONSE The immune response is apparently intended to neutralize, detoxify, and help eliminate a foreign material. However, sometimes the immune response can inadvertently cause harm. This will be discussed in various categories in the next section. 1. Damage to the implant. The inflammation which is part of the initiation of the immune response is an oxidative response. Materials subject to oxidative attack, such as polyethylenes and polyurethanes, may be degraded.

2. Damage to adjacent tissues. Products, particularly from Type II and IV responses, may initiate swelling and other vascular responses at the site. This may resolve with no further harm, or it may cause tissue necrosis and/or loss of tissue mass with loosening or movement of the device. 3. Systemic responses. Immune responses of Type I and II generate vasoactive substances which may circulate and cause vascular collapse. This is seen in response to latex materials and drugs which bind to platelets, mast cells, or eosinophils, resulting in an immune response and release of these vasoactive substances. 4. Autoimmune diseases: This is the most controversial area of consequences of immune response to implants. Autoimmune diseases are technically the result of an immune response to host tissue. Autoimmune diseases such as arthritis, glomerulonephritis, etc., occur in individuals with an unknown cause of onset although some have an association with a preceding infection (especially streptococci). Proving cause and effect is an epidemiological problem with surveys of large populations. It is important to refine our immunological testing techniques to prove cause and effect associated with implants and do thorough epidemiological studies. These responses, if present in clinical populations, may arise from several mechanisms. The two most likely ones associated with the use of implants are (i) binding of the material to host tissue making it a foreign substance such as with hapten-carrier complexes or (ii) altering the host tissue through folding of proteins, degradation of cells or proteins thus making then antigenic for the host. This is the main issue now with the silicone breast implants. This is difficult to prove and massive studies as controlled as possible are needed.

4.8 CONCLUSIONS There has been a rapid growth in our knowledge of the immune response and how to evaluate and quantitate it. As these techniques are applied to the population in contact with biomaterials, we will learn more about its importance in performance of the material. We will also learn more about how to process the materials to minimize the immune response. However, it is important to remember that the immune response is a protective response and detection of immune responses to products of biomaterials does not necessarily indicate clinical problems. On the other hand, implants are foreign material and will stimulate host responses, some of which may cause harm to the host or implant. Thus the important issue is to distinguish between those immune responses which are normal and help to render antigens less biologically

active from those which are harmful to the host. It is clear that IgE (Type I) responses are harmful. Detection of a Type I response to products of biomaterials indicates potential problems in the clinical setting. Responses of the IgG type are generally protective and may not be predictive of further problems unless there is continual release of antigenic material leading to a Type Ill-response. Biomaterial wear and degradation products that bind to platelets or mast cells pose a potential for adverse Type II responses. The most commonly observed is the Type IV (cell-mediated) response. This is a protective response in walling off the stimulating agent and in killing cells which have the antigen on the surface, thus eliminating the antigen. However, the tissue reaction accompanying this response may cause harm to the host through soft and hard tissue necrosis. The difference between protection and allergy from Type IV responses is still unclear and careful evaluation of patients is required. ADDITIONAL READING General Immunology Golub, E.S. and Green, D.R. (1990) Immunology, A Synthesis, 2nd Edition, Sinauer Associates, Inc., Sunderland: Good general text. Roitt, I. (1971) Essential Immunology, Blackwell Scientific Publications, London: Good description of types I-IV reactions. Annual Review of Immunology, Annual Reviews Inc., Palo Alto, CA: Yearly publication with timely reviews. Immunology Today: Elsevier Science Inc. Tarry town, NY: Monthly: Good review articles. Antigen Presentation Celada, A. and Nathan, C. (1994) Macrophage activation revisited. Immunology Today, 15, 100-102: good review of macrophages. Chicz, R.M. and Urban, R.G. (1994). Analysis of MHC presented peptides: applications in autoimmunity and vaccine development. Immunology Today, 15, 155-160: good review on a complicated subject. CD markers Kemeny, D.M., Noble, A. Holmes, BJ. et al (1994) Immune regulation: a new role for the CD8+ T cell. Immunology Today, 15, 107-110: Good description of the function of the CD8+ T-cell which is a key cell in Type IV responses. Sclossman, S.F., Boumsell, L., Gilkes, L.W. et al. (1994) CD antigens 1993. Immunology Today, 15, 98-99: good description of recently reported CDs. Cytokines/interleukins Miyajima, A., Kitamura, T., Harada, N. et al (1992) Cytokine receptors and Signal Transduction. Annual Reviews of Immunology, 10, 295-331: Review of function and methods of stimulation. Mizel, S.B. (1989) The interleukins. FASEB J. 3, 2379-2388: good detailed review.

Effects of cytokines/interleukins Goldring, M.B., and Goldring, S.R. (1990) Skeletal tissue response to cytokines. CHn. Orthop. ReI. Res., 258, 245-278: review of cytokines and orthopaedics. Stashenko, P., Obernesser, M.S., and Dewhirst, F.E. (1989) Effect of immune cytokines on bone. Immuno Invest, 18, 239-249: one of the few reviews focussing on bone. Immune response to metals/metallic implants Agrup, G. (1968) Sensitization induced by patch testing, Brit. I. Derm., 80, 631-634: points out problem of routine skin testing in nonallergic individual. Benson, M.K.D., Goodwin, P.G. and Brostoff, J. (1975) Metal sensitivity in patients with joint replacement arthroplasties, Brit. Med. J, 4, 374-375: third of the original 1975 articles pointing to a possible problem. Skin test used. Black J. (1988) Does corrosion matter? /. Bone Jt. Surg., 7OB (4), 517-520: discusses issues of importance of understanding corrosion, minimizing it, and recognizing it can be important for the patient. Brown, G.C., Lockshin, M.D., Salvati, E.A. et al, (1977) Sensitivity to metal as a possible cause of sterile loosening after cobalt-chromium total hip-replacement arthroplasty, /. Bone Joint Surg., 59A(2), 164-168: Denies existence of metal allergy in orthopaedics. Complete misinterpretation of data. Uses negative results of an invalid test to draw conclusions. Limited patient population deliberately selected to prove lack of allergy. Burholm, A.; Al-Tawil, N.A.; Marcusson, J.A. et al. (1990): The lymphocyte response to nickel salt in patients with orthopedic implants. Acta Orthop. Scand., 61(2): 248-250: Example of use of LTT test. Elves, M.W., Wilson, J.N. and Kemp, H.B.S. (1975) Incidence of metal sensitivity in patients with total joint replacements. Brit. Med. J., 4, 376-378: Second one of the original 1975 articles pointing to a possible problem. Skin test used. Evans, E.M., Freeman, M.A.R., Miller, AJ. et al. (1974) Metal Sensitivity as a Cause of Bone Necrosis and Loosening of the Prosthesis in Total Joint Replacement, /. Bone and Joint Surg., 56B (4), 626-642: One of the original articles pointing to a possible problem. Skin test used. Goh, CL. (1986) Prevalence of contact allergy by sex, race, and age. Contact Dermal, 14, 237-240: discusses normal population Grimsdottir, M.R., Gjerdet, N.R. and Hensten-Pettersen, A. (1992) Composition and in vitro corrosion of orthodontic appliances. Am. J. Orthod. Dentofac. Orthop., 101, 525-532: Discusses sensitivity and stainless steels. Release of nickel related to many metallurgical aspects and not necessarily to nickel content of the metal. Lalor, P.A., Revell, P.A., Gray, A.B. et al. (1991) Sensitivity to titanium. /. Bone and Joint Surg., 73B(I), 25-28: Description of possible titanium sensitivity. Patch test vehicle of unknown composition, larger cobalt-chromium component than titanium component in device. Of interest and important, but not conclusive. Menne, T.; and Maibach, H.I. (1989) Systemic contact allergy reactions. Immunol Allergy CHn. N.A., 9, 507-522: Discusses extension from contact dermatitis to systemic reactions.

Merritt, K. (1984) Role of medical materials, both in implant and surface applications, in immune response and in resistance to infection. Biomaterials, 5 (1), 47-53.: Review article. Out of date now but covers literature through 1983. Merritt, K. (1986) Biochemistry/hypersensitivity/clinical reactions, in: Lang B, Morris, J. and Rassoog, J. (eds). Proc. International Workshop on Biocompatibility, Toxicity, and Hypersensitivity to Alloy Systems used in Dentistry. Ann Arbor, U. MI; pp 195-223.: Review article. Covers the literature through 1984. Good discussion of the problem in the discussion section of the symposium. Merritt, K. (1986) Chapter 6. Immunological testing of biomaterials, Techniques of Biocompatibility Testing, D.F. Williams (ed.), Vol. II, CRC Press, Boca Raton: Description of possible test methods. Merritt, K.; and Brown, S.A. (1980): Tissue reaction and metal sensitivity: An animal study. Acta Orthop. Scand. 51 (3), 403^11: Example of use of LIF test. Rostoker, G., Robin, J., Binet, O. et al (1987) Dermatitis due to orthopaedic implants. /. Bone Joint Surg., 69A, 1408-1412: Example of a reaction to implant. Rudner, EJ., Clendenning, W.E., Epstein, E. et al. (1975) The frequency of contact dermatitis in North America 1912-191 A. Contact Derm. 1, 277-280: Incidence of contact dermatitis. Shirakawa, T., Kusaka, Y. and Morimoto, K. (1992) Specific IgE antibodies to nickel in workers with known reactivity to cobalt. CHn. Exp. Allergy, 22 (2), 213-218: Measuring IgE and nickel cobalt interactions. Trobelli, L., Virgili, A., Corassa, M. et al. (1992) Systemic contact dermatitis from an orthodontic appliance. Contact Dermatitis, 27, 259-260: Example of reaction to dental application of metals. Yang, J., and Merritt, K. (1994) Detection of antibodies against corrosion products in patients after Co-Cr total joint replacements. /. Biomed. Mater. Res., 28, 1249-1258: Method for measuring antibodies to metals Immune response to latex, collagen, silicones Belsito, D.V. (1990) Contact urticaria caused by rubber. Analysis of seven cases. Dermatol. CUn. 8, 61-66: Questions whether increased demand for latex may have decreased quality with more allergens leachable. Hanke, C.W., Higley, H.R., Jolivette, D.M. et al. (1991) Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant. /. Amer. Acad. Dermatol 25, 319-326: Deals with some adverse responses to collagen materials which may be related to the immune response. Points to possible problems. Meade, K.R., Silver, F.H. (1990) Immunogenicity of collagenous implants. Biomaterials, 11,176-180: Discusses immunogenicity problem and cross linking. Good place to begin reading. Nairn, J.O., Lanzafame, RJ. and van Oss, CJ. (1993). The adjuvant effect of silicone gel on antibody formation in rats. Immunol Inv., 22, 151-161: Shows that the gel is better than Freund's adjuvant in stimulating the response to BSA in rats. Caution on use of gel. Slater, J.E. (1989) Rubber anaphylaxis. New Eng. J. Med. 320, 1126-1130: Good methods. Good literature review, real cases reacting to anaesthesia mask.

Sussman, G.L., Tarlo, S. and Dolovich, J. (1991). The spectrum of IgE responses to latex. /. Am. Med. Assoc. 265, 2844-2847: Latex gloves on health workers causing allergic responses in patients. Can do skin test with latex to check patients or use non-latex gloves. Warpinski, J.R., Folgert, J., Cohen, M. et al (1991) R.K. Bush. Allergic reaction to latex: a risk factor for unsuspected anaphylaxis. Allergy Proc. 12, 95-102: Clinical symptoms of Type I allergy. Identifies IgE antibodies against latex (gloves, balloons, condoms). IgE against proteins from latex. WoIk, L.E., Lappe, M., Peterson, R.D. et al. (1993) Immune response to polydimethylsiloxane (silicone): screening studies in a breast implant population. FASEB /., 7, 1265-1268: Very important study with a good technique. Hopefully more studies will be done with this technique. Valid test of antibody to silicone. Oxidative damage of implants Carter, W.O., Narayanan, P.K. and Robinson, J.P. (1994). Intracellular hydrogen peroxide and superoxide anion detection in endothelial cells. /. Leukocyte Biol 55, 253-258: Good method for detecting H2O2 release and superoxide production. Example of biologically produced oxidizing species. Kao, WJ., Zhao, Q.H., Hiltner, A. et al (1994) Theoretical analysis of in vivo macrophage adhesion and foreign body giant cell formation on polymethylsiloxane, low density polyethylene, and polyetherurethanes. /. Biomed. Mater. Res., 28 (1), 73-80: Recent article on macrophages on polymers and references some articles on oxidative events. Kaplan, S.S., Basford, R.E., Jeong, M.H. et al. (1994) Mechanisms of biomaterialinduced superoxide release by neutrophils. /. Biomed. Mater. Res., 28, 377-86: Discusses the release of reactive oxygen species stimulated by biomaterials. Not all materials are activating. Consequences of immune responses to materials Angell, M. (1994) Do Breast implants cause systemic disease? Science in the courtroom New Eng. J. Med., 330 (24), 1748-1749: Editorial in response to article by Gabriel et al (1994) Reiterates the necessity of doing detailed studies. Indictment of patients, manufacturers and government jumping to conclusions using inadequate data. Doesn't say how we get the adequate data though. Gabriel, S.E., O'Fallon, W.M., Kurland, L.T. et al. (1994) Risk of connective tissue diseases and other disorders after breast implantation. New Eng. J. Med., 330 (24), 1697-1702: Excellent study. Shows problems of doing studies on long term consequences. Example of how it ought to be done.

Cancer
M. Rock

5,1 INTRODUCTION The widespread use of temporary and permanent implants in the post World War II era has had a dramatic impact on the practice of medicine and on the life of disabled and ill individuals. Nowhere has this been more obvious than in the frequent use of implants to stabilize fractures and replace diseased joints which has revolutionized orthopedic practice and afforded millions of patients levels of function that previously could not be achieved. Although the metal alloys used in these implants exhibit excellent resistance to corrosion, oxidation of these large components ultimately produce free ions, chlorides, oxides, and hydroxides which, in combination with particulate metal matter released by wear and fretting, are released into the surrounding environment. Efforts to improve these alloys have included compositional as well as processing changes. Additionally, modifications have been made to the plastic articulating components in efforts to produce a much more consistent ultrahigh molecular weight polyethylene. The perceived need to improve implant wear and corrosion resistance and alter design has been largely motivated by the excessive soft tissue staining noted by orthopedic surgeons at the time of removal or revision of clinically failed joint arthroplasty. The presence of particulate metal matter, polyethylene, and even fragments of polymethyl methacrylate in local tissue has been confirmed histologically and by direct analysis [1-4]. In spite of all of the modifications made in implant composition, implant fixation, and articulation, biomaterial degradation and release of these products persist [4-7].

Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

5.2 RELEASE AND DISTRIBUTION OF DEGRADATION PRODUCTS The body's response to the local presence of debris is dependent on the size, amount, and composition as well as rate of accumulation. The body attempts to neutralize these foreign particles by precipitating granulomatous foreign body reactions and/or removal through local lymphatic channels. If the local accumulation of debris exceeds the body's ability to neutralize and/or transport, the debris migrates from the site to remote areas including the bone-implant interface, possibly contributing to if not initiating the phenomena of loosening and osteolysis (Figure 5.1). Of equal or possibly even greater concern is the detection of metal ions, metallic debris, polyethylene, and even methylmethacrylate in areas remote from the implant including circulating serum, excreted urine, and regional draining lymph nodes. Elevated serum levels of metal ions consistent with the composition of the implanted alloy have been confirmed in animal models [8] and in human patients after total hip arthroplasty [9]; identifying serum levels of cobalt, chromium, nickel, and titanium that are two and three fold higher than preoperative determinations. These figures represent significant elevations both over means for contemporary control groups and for the individual patients before operation [9]. However, since they are within the widely accepted normal range for these metallic ions in the unimplanted human controls, it is assumed that toxic levels of these foreign materials do not materialize. However, when analyzing the serum to urine concentration in patients subjected to conventional total hip arthroplasty, it has become apparent that the urinary concentration of chromium in particular does not rise with the same magnitude and time course as the serum level [9]. This observation parallels that made in the accounts of industrial overexposure to Cr6+ and suggests that metal ions accumulate in organs and tissues remote from implantation. Such accumulation is unlike that resulting from normal
Stress/fatigue Corrosion Wear Fretting Small amount Neutralized Soluble products Debris

Large amount Interaction/migration Malignancy

Metallosis Allergic Pseudotumor Hypersensitivity

Figure 5.1 Tissue Reaction to Implant Degradation Products.

systemic circulation. This was previously suggested by Steineman [10] who calculated the potential release of metallic ions of 0.15 to 0.3 micrograms per cm2 per day which would translate to between 11 and 22 milligrams per year in patients with total hip replacement. This incidentally coincides with or exceeds the total body burden of such metallic ions in a 70 kilogram man [H]. Evidence for metallic debris accumulating in distant organs has also been confirmed by Langkamer et al [12] who identified wide spread dissemination of particulate wear debris from hip prosthesis to lymph nodes, liver, and spleen. He reported increases above normal levels in these organs of 30 fold for aluminum, chromium, and iron in the lymph node, and 10 fold in the spleen and liver. These findings suggest that concentrations of metal ions and debris at remote sites may reach such proportions as to precipitate altered cellular dynamics in organs principally of the lymphoreticular system. It would only be logical to assume that local concentrations of such debris at the site of implantation would be even higher, although attempts at quantifying the effects of local concentrations have been fraught with inaccuracies mostly due to sampling error and the need to distinguish between bioavailable and non bioavailable metal species. What is potentially more disturbing is that these figures for serum concentrations and the identification of this debris in remote organs have come primarily from patients who have received conventional polymethyl methacrylate cemented components. With the advent of using uncemented porous coated implants, particularly in younger patients, these figures would be expected to increase, creating the distinct possibility of toxic levels in the serum, tissues and organs that will respond with altered cellular dynamics and function. 5.3 NEOPLASIA Perhaps one of the greatest concerns with debris dissemination locally and within the systemic circulation is the possibility of inducing malignant neoplasia. This is thought to be possible by one of two mechanisms: (i) A 'solid-state' mechanism has been proposed, whereby a large foreign object implanted in vivo possibly stimulates mutagenesis of local cells, thereby creating tumor by its mere presence. Most large foreign objects upon implantation will initiate a very marked fibrous reaction. The cells within this fibrous reaction ultimately mutate and become cancer growths. (ii)The other possibility is that particulate metal matter or other debris have an innate capacity, upon corrosion or dissolution, to induce cancer through a more traditional chemical route.

Cancer, the end product of carcinogenesis, is the result of transformation of a normal cells to ones which grow in an uncontrolled or malignant manner. Cancer is a genetic disease, which may result from expression of genetic pre-dispositions present from birth or from later insults to cells of many different types. In particular, the phagocytosis or pinocytosis of foreign matter (in an attempt to neutralize or eliminate it) may cause or precipitate malignant conversion. Such conversion, if not lethal to the cell, may then persist through cell duplication, creating first a cluster of cells with altered DNA and eventually a clinical malignant tumor. Malignancy is characterized by rapid, uncontrolled growth, invasion in surrounding tissues and seeding to form tumors (metastases) in other anatomical locations such as the lung. Some of the more common malignant tumors of musculoskeletal origin are osteosarcoma (OS) of bone and malignant fibrous histiocytoma (MFA) of soft tissue. Osteosarcoma is the most common tumor of bone: it occurs in children, adolescents and, less frequently, in adults. OS may also occur as a consequence of radiation therapy or in Paget's disease, an ostensibly benign bone embrittling disease of the elderly. It frequently appears about the knee (distal femur; proximal tibia), and in the proximal femur and proximal humerus. MFA is the most common primary malignant tumor of soft tissues and can occur in bone in adults over the ages of 50-55. The more common soft tissue type usually involves the large muscular areas of the body, including the thigh, buttock and upper arm and shoulder. 5.4 EVIDENCE FOR CARCINOGENICITY OF IMPLANTED MATERIALS Well-documented cases of carcinoma and sarcoma have developed in refinery workers who inhaled nickel and chromium and in miners who were exposed to iron or even at local injection sites of iron dextran [13]. Aluminum has been linked to a high rate of lung and bladder cancer in exposed individuals and titanium has been associated with experimental induction of lymphoreticular tumors and leukemia. Although the results have not been universally accepted, many animal experiments have shown a direct correlation between the initiation of sarcomas and the injection of particulate metal debris. This appears to be related to the concentration, as well as the physical nature, of the metal implanted [14]. Metal ions, particularly cobalt, chromium, and nickel, are known to induce infidelity of DNA synthesis by causing the pairing of non-complimentary nucleotides and thereby creating a misinterpretation of the genetic code which may lead to neoplasia.

Furthermore, it must be remembered that particulate metal matter may not be the only solid-form material that can be, and has been proven to be, carcinogenic in appropriate environments. In 1954 long before the first total hip arthroplasty was performed, Laskin [15] observed the carcinogenic capabilities of polymethylmethacrylate after subcutaneous introduction of this material in mice. His conclusions suggested that similar occurrences of tumor may appears in humans that were being treated at that time with methylmethacrylate for dental deficiencies and that this evolution of cancer may take up to 20 years of exposure given the proportional time exposure before tumors were seen in the mice. A similar conclusion was reached [16] on the use of polyethylene plastic before it was conventionally used in the management of arthritic joints. Regardless of form, whether powder or large solid segments, polyethylene plastic produced sarcomas in 25 percent and 35 percent of rats, respectively. Their conclusions also suggested a latent period, after exposure, of 20 years in humans before such an event could be expected to occur. It is, therefore, with interest that investigators were forewarning the medical community of the carcinogenic effect of metals and polymers years before the development and introduction of joint replacement using these very same materials. In 1961, Sir John Charnley introduced total hip arthroplasty as an alternative in the management of arthritic hips. No other orthopedic procedure has been adopted with such enthusiasm. Thirty-five years later we are still witnessing an incremental increase in the yearly utilization of this operation, attesting to the obvious success associated with it. According to some investigators, we may be coming into an era of increased tumor activity in the vicinity of or possibly remote from implantation sites of these orthopedic appliances.

5 . 5 CASE REPORTS OF IMPLANT RELATED TUMORS

In 1976, Harris et al [17] were the first to describe an aggressive granulomatous lesion around a cemented femoral stem in a total hip replacement. This was a condition of localized tumor-like bone resorption that appeared radiographically as large lytic defects within the femur, approximating the cement mantle of the implant. Initially thought to be neoplastic, these lesions were surgically biopsied and found to be consistent with well-organized connective tissue containing numerous histiocytes, monocytes, and fibroblastic reactive zones. Immunohistologic evaluation revealed multinucleated giant cells and nonspecific esterasepositive monocyte macrophages. These findings suggest a foreign-body type reaction, and with the subsequent isolation of polyethylene, polymethyl methacrylate, and metal debris, it was theorized that these constituents of the construct likely migrated down around the implant

cement mantle in cemented prostheses and implant-bone interface in non-circumferentially coated ingrowth implants. Such a reaction suggests an excessive accumulation of debris at the site of articulation that surpasses the body's ability to neutralize and/or transport the material resulting in migration of debris to sites remote from the source. This rapid appearance of bone loss radiographically which is often associated with a deteriorating clinical course has been termed type-II aseptic loosening [17]. In 1978, two years after the recognition of pseudo tumors of bone induced by the degradation products of total hip arthroplasty, Arden and Bywaters [20] (Table 5.1) reported a case of a 56-year-old patient who developed a high-grade fibrosarcoma of soft tissue 2.5 years after receiving a metal-on-metal McKee-Farrar hip prosthesis. The tumor apparently did not have a direct association with the underlying bone or any components of the total hip arthroplasty. No formal analysis of the tumor for debris Table 5.1 Malignancies Associated with Joint Replacements (published)
Author Castleman and McNeely [18] Rushforth [19] Arden and Bywaters [20] Bago-Granell et al [21] Penman and Ring [22] Swann [23] Weber [26] Ryu et al [27] Vives et al [28] Van der List [29] Lamovec et al [30] Lamovec et al [31] Tait et al [32] Martin et al [33] Haag and Adler [34] Mazabraud et al [35] Brien et al [36] Troop et al [37] Kolstad and Hogstorp [38] Jacobs et al [39] Solomon and Sekel [40] Year Implant Time interval (yrs) Tumor type

1965 Austin-Moore 1974 McKee-Farrar 1978 McKee-Farrar 1984 1984 1984 1986 1987 1987 1988 1988 1988 1988 1988 1989 1989 Charnley-Muller Ring McKee-Farrar Cemented TKA Uncemented Vitallium ** Charnley-Muller Charnley-Muller Charnley-Muller Charnley-Muller Charnley-Muller Charnley-Muller Weber-Huggler unknown

1 M.F.H.* 0.5 Osteosarcoma 2.5 Fibrosarcoma 2 5 4 4.5 1.4 2 11 11 10 11 10 10 9 M.F.H. Osteosarcoma M.F.H. Epithelioid sarcoma M.F.H. M.F.H. Angiosarcoma Synovial sarcoma Osteosarcoma M.F.H. Osteosarcoma M.F.H. Epidermoid sarcoma Osteosarcoma M.F.H. Metastatic adenocarcinoma M.F.H. M.F.H.

1990 Charnley 1990 Charnley-Muller 1990 Freeman TKA 1992 AML cementless 1992 Charnley-Muller

8 15 0.25 0.5 7

* M.F.H. = malignant fibrous histiocytoma.

** Trademark, Howmedica, Inc. (Cobalt-Chromium alloy).

products was performed. This case drew attention to the possibility of tumors being initiated in the presence of large orthopedic appliances. It was not until 1984 when this concept became fashionable in large part due to three articles that appeared simultaneously in the Journal of Bone and Joint Surgery recounting two malignant fibrous histiocytomas and one osteosarcoma at the site of a total hip arthroplasty [21-23]. This sudden and rather unexpected evolution prompted editorials [24, 25] in the same journal addressing the issue of sarcoma and total hip arthroplasty and encouraged the orthopedic community worldwide to report such cases to a central registry to obtain more accurate figures on the incidence of such a problem. These tumors occurred 2, 4, and 5 years after hip replacement that was performed with various femoral and acetabular components, some with metal-on-metal articulations and others with metal on polyethylene. In two of these cases, the proximal femur was extensively involved with tumor that was in direct contact with the component. The remaining case was a soft-tissue sarcoma not in direct approximation to the prosthesis. Two of these tumors were malignant fibrous histiocytomas, one of bone and one of soft tissue. The remaining tumor was osteosarcoma. In this particular case, there was evidence of gray-brown pigmentation both intra- and extracellularly between the tumor and femoral component. No formal metal analysis was performed. Three additional cases emerged prior to 1988 at 15 months, 4.5 years, and 2.0 years after implantation [26-28]. In 1988, five cases were reported occurring at 10 [29, 30] and 11 [29, 31, 32] years after implantation. The sarcomas included two osteosarcomas, two malignant fibrous histiocytomas, and one synovial sarcoma. Two of these were soft tissue in a location with no direct association with the implant, yet in the case reported by Tait et al [32] there was evidence of nickel within tumor cells. The remaining three patients all had direct contact with either the cement or implant with the tumor originating in bone. In 1990 there were three additional reports in the literature which included an osteosarcoma developing at the site of a Charnley total hip arthroplasty 8 years [36] after implantation, malignant fibrous histiocytoma developing 15 years after a Charnley-Muller total hip arthroplasty [37], and metastatic adenocarcinoma developing at the site of a Freeman total knee arthroplasty three months after implantation [38]. In 1992, Jacobs et al. [39] presented a malignant fibrous histiocytoma developing one half year after implantation of a cementless AML total hip arthroplasty. In that same journal volume, unpublished but submitted reports of five tumors occurring around implants were brought to the attention of the orthopedic community [41] (Table 5.2). These included malignant fibrous histiocytomas around a Thompson and a Muller total hip arthroplasties,

an osteosarcoma around a Charnley total hip arthroplasty, a rhabdomyosarcoma of soft tissue in the vicinity of a Christiansen total hip arthroplasty, and a chondrosarcoma developing in a patient with Maffucci syndrome having a Charnley total hip arthroplasty. The intervals from implantation to tumor detection were 9, 3, 10, 9 and 1 years respectively. To this, we add two previously unreported additional patients, neither of whom had their joint replacement done at the Mayo Clinic (Table 5.2). The first is that of a 79-year-old man who nine months previously came to total hip replacement with an uncemented Harris-Galante component who was found to have a large malignant fibrous histiocytoma engulfing the proximal femur and extending to the implant. There was, however, no evidence of any particulate debris within the tumor cells removed. The second case was that of a 56-year-old man who developed a soft tissue osteosarcoma 14 months after a left total knee arthroplasty with conventional cemented components. The tumor extended down to both the femoral and patellar components. 5.6 CRITICAL ANALYSIS OF TUMORS As such, 28 tumors have been reported in direct contact or in close proximity to joint arthroplasty. The vast majority of these appeared with total hip arthroplasty [27] with a smaller contribution from total knee arthroplasty [3]. There have been no reported cases of malignant degeneration occurring in the vicinity of total shoulder and/or total elbow arthroplasty. Of the reported 26 cases, 8 tumors were of soft tissue origin, 19 were of primary bone pathology, and 1 metastatic gastric carcinoma. The histogenesis of the soft tissue tumor included 3 malignant fibrous histiocytomas, 1 synovial sarcoma, 1 soft tissue osteogenic sarcoma, 1 fibrosarcoma, 1 epidermoid sarcoma and 1 rhabdomyosarcoma. The histogenesis of the primary bone tumors included 10 malignant fibrous histiocytomas,
Table 5.2 Malignancies Associated with Joint Replacements (unpublished) [41] Time interval (yrs) 1 9 10 3 9 0.8 1.2

Author Harris Surin Lightowler Rees, Thompson, Burns Nelson Rock Rock
* M.F.H. = Malignant Fibrous

Year 1992 1992 1992 1992 1992 1992 1992

Implant Charnley Christiansen Charnley Thompson Muller HG ingrowth PCA TKA

Tumor type Chondrosarcoma Rhabdomyosarcoma Osteosarcoma M.F.H.* M.F.H. M.F.H. Osteosarcoma

Histiocytoma.

6 osteosarcomas, 1 chondrosarcoma, 1 angiosarcoma, 1 fibrosarcoma. Direct contact with the underlying tumor was noted in 15 of the 19 cases in which sufficient information is known from which to make such determinations. In three of the cases, particulate metal matter was determined to be present in the tumor including one case of a soft tissue sarcoma that appeared on image and exploration to be remote from the implant but had obvious evidence of nickel present within the tumor cells. Many of these tumors have not had an appropriate latent interval between implantation and development to be seriously considered implant induced. Given that the interval to tumor induction from bone stimulation should be at least as long as the accepted five year interval from radiation therapy to sarcoma degeneration, 15 of the 28 patients would qualify, all of whom have had tumours around total hip arthroplasties. Apart from tumors developing at the site of prosthetic replacement, there have been ten known malignant tumors that have developed at the site of previous internal fixation (Table 5.3). To date there have been no malignancies noted around a titanium implant. The vast majority (> 80%) of malignancies both in the prosthetic and internal fixation groups have occurred in the vicinity of Vitallium (cobalt-chromium alloy) implants. This is not, however, to exonerate stainless steel because tumors in the proximity of the implants made of this alloy have been reported in the animal literature [52] as well as the human experience utilizing stainless steel as fixation devices for traumatology [42, 44, 50, 51]. It is interesting to note that in 1976 veterinarians were encouraged within their own literature to report similar experiences of tumors around implants nearly eight years before such concern was voiced with the application of these same metallic alloys in humans [52].

Table 5.3 Malignancies Associated with Internal Fixation of Fractures Time interval (yr$) 30 3 36 7.5 17 1.2 14 29 9 13

Author McDougall [42] Delgado [43] Dube and Fisher [44] Tayton [45] McDonald [46] Dodion et al [47] Lee et al [48] Hughes et al [49] Ward et al [50] Khurana et al [51]

Year 1956 1958 1972 1980 1981 1982 1984 1987 1990 1991

Implant Stainless steel Unknown Stainless steel Vitallium* Vitallium Vitallium Vitallium Vitallium Stainless steel Stainless steel

Tumor type Ewings Undifferentiated Angiosarcoma Ewings Lymphoma Lymphoma M.F.H.* M.F.H. Osteosarcoma M.F.H.

* Trademark, Howmedica, Inc. (cobalt-chromium alloy). ** M.F.H. = malignantfibroushistiocytoma.

5.7 SIGNIFICANCE OF CLINICAL REPORTS As impressive as these cases may be, they must be put into perspective given the global use of internal fixation and prosthetic devices. Approximately 300 000 to 350 000 total hip joint replacements are performed worldwide on a yearly basis [53]. It can be assumed that approximately four million people will have had total hip arthroplasties performed by the end of 1995. To date, there have been 28 reports of malignant tumor arising in close proximity to these implants (25 total hip and three total knee arthroplasties). No direct contact was noted in four. If we assume a minimal latency of five years to suggest association between presence of implant and tumor, 15 of the 28 could have association. As such, the incidence of sarcomas in total joint replacement would be approximately 1 in 250 000. There are approximately 3000 new primary bone tumors and 5000 soft-tissue sarcomas in the United States per year. This would give an incidence of approximately 1 in 100 000 for the general population to develop a primary bone sarcoma and 1 in 40 000 to develop a soft tissue sarcoma a year. This is obviously not stratified for age given that many primary bone tumors develop in the second and third generation of life, yet it does afford the opportunity of putting this rather unusual event in perspective. The prevalence of osteosarcoma among the osseous malignancies in this series is not entirely unexpected. Of the total osteosarcoma population 15 percent to 20 percent occur after the age of 50 years. Most of these cases are superimposed on Paget's disease or in previously irradiated tissue, yet de novo cases of osteosarcoma do occur in this age group. Malignant fibrous histiocytoma of bone is somewhat less common. A review of the Mayo Clinic files reveals 71 cases with more than half of these occurring after age 55. Malignant fibrous histiocytoma of soft tissue is the most common soft-tissue sarcoma. It is not surprising, therefore, that two of six soft-tissue tumors in the combined series are of this histogenesis. As such, the distribution of sarcomas in the combined series could have been predicted from general population data given the age of the patients and anatomical distribution. There have been two separate reports that have critically analyzed the cancer risk after total hip arthroplast [54, 55]. The combined person years of exposure after operation between the two series was 20 015. The overall cancer incidence among total hip replacement procedure in both series did not appear to be any different than what was expected or anticipated. The cancer-observed/expected ratio was especially low for the first two years following surgery in both series, implying that patients undergoing this procedure are otherwise generally healthy. In both series, the observed/expected ratio of developing lymphoma or leukemia was two to three times higher in patients who had total hip arthroplasty. Additionally,

there was a two fold decrease in breast carcinoma among patients who had total hip arthroplasty. Of interest, Gillespie et al [54] suggested a similar decrease in the incidence of rectal, colon, and lung cancer among total hip arthroplasty patients. The results suggest or are possibly compatible with the hypothesis of chronic stimulation of the immune system, thereby potentially allowing for malignancies to occur within the lymphoreticular system. We have already determined a predilection for particulate metal matter to accumulate in the reticuloendothelial system [12]. This has been further supported by studies in animals subjected to metal implants, especially those containing nickel, in which there was an increase in malignancies of the lymphoretinacular systemic [52]. Additionally, due to the added immune surveillance, tumors of the breast, possibly colon, rectal, and lung may be decreased. A hyper immune state is not unexpected given the dissemination of debris locally at implantation sites as well as the wellrecognized and documented capacity of this material to gain access to the systemic and possibly storage sites including the reticuloendothelial system. This trend obviously needs continued surveillance. A recent extensive analysis of the cancer risk in a cohort of 39 154 patients with at least one hip replacement operation has been performed by the Swedish Nationwide In-Patient Registry [56]. Patients were identified by means of a linkage to the Swedish Cancer Registry. The overall results, although showing a significant 3% increase in cancer, were judged by the authors not to be of clinical significance. Increases of cancer of kidney, skin and brain in women and of prostate in men were found, accompanied by a decrease in gastric cancer for women. The study showed no increase in lymphoreticular cancers as previously reported [54,55] nor a decrease in colon, breast or rectal cancers. The authors' judgement is that the overall cancer risk associated with total hip replacement arthoplasty is negligible and should not distract from the obvious benefits of the procedure. A similar extensive review of the relationship between metallic implants and cancer in dogs was performed by Li et al [57]. This case controlled study of 1857 dogs from 22 veterinary medical centers failed to reveal significant association between stainless steel fracture fixation devices and the development of bone and soft tissue sarcomas. 5.8 SUMMARY In summary, careful examination of the scientific and clinical literature suggests that implant materials commonly used for fixation and joint reconstruction are not entirely inert. Accumulation of particulate debris is to some extent going to occur in all patients who have large prosthetic

devices. This necessarily includes the distinct possibility of systemic and remote site exposure to these foreign objects that the body attempts to neutralize and excrete. Due to the heightened immunologic surveillance and/or possible storage of particulate metal matter in sites remote from the implantation site, patients with total hip arthroplasty may be at added risk for remote malignancies, particularly of the lymphoreticular system. The incidence of primary mesenchymal tumors in close proximity to implants appears to be consistent with the incidence in the general public. The frequency of occurrence and the associated individual and group risks of systemic and remote site malignancy remains unresolved.

ADDITIONAL READING Nyren, O., McLaughlin, J.K. et al (1995) Cancer risk after hip replacement with metal implants: A population based study. /. National Can. Inst. 87, 28-33. An extensive review of risk of cancer in 39 154 total hip replacement patients who appeared in the Swedish National Cancer Registry between 1965 and 1983. A review of 60 cancer-specific sites showed an overall, not clinically significant increase of 3% in incidence, slight increases noted for kidney cancer, prostate cancer (in men) and melanoma accompanied by a continuous decline in gastric cancer for both sexes. This would appear to be the definitive review of the risk for developing cancers after total hip replacement arthroplasty. Brand, K.G. and Brand, I. (1980) Risk assessment of carcinogenesis at implantation sites. Plastic Reconst. Surg. 66, 591-595. Review of possible foreign body cancer initiation in humans based upon published case reports. The authors conclude that, since the clinical use of prosthetic implants has been popular for more than twenty years and since, extrapolating from animal experience, at least 25% if not 50% of foreign body tumors should have appeared by the time of their publication, there is little risk of such nonchemically mediated tumors occuring in patients. Gillespie, WJ., Frampton, C.M.A., Henderson, RJ. et al (1988) The incidence of cancer following total hip replacement. /. Bone Joint Surg., 7OB, 539-542. A New Zealand study of 1358 patients with total hip arthroplasty, for a total of 14 286 patient years. A significant increase in tumors of the hemopoetic and lymphatic systems, accompanied by a significant decrease of cancers of breast (in women), colon and bowel was observed. The authors suggest that these data are evidence for increased immune surveillance, allowing or precipitating hemopoetic and lymphatic tumors but at the same time providing better resistance to the development of soft tissue tumors. The first large scale study of this question. Visuri, T. and Koskenvuo, M. (1991) Cancer risk after McKee-Farrar total hip replacement. Orthopedics, 14, 137-142. A study similar to that of Gillespie et al but on a Finnish patient group (433 patients; 5729 patient years) leading to the same general conclusions. Includes a historical discussion of the carcinogenic properties of various trace elements.

Jacobs, JJ,, Rosenbaum, D.H., Hay, R.M. et al. (1992): Early sarcomatous degeneration near a cementless hip replacement. A case report and review. /. Bone Joint Surg., 74B, 740-744. A review of a patient who developed a malignant fibrous histiocytoma at the site of a cementless total hip replacement five months after implantation and succumbed of diffuse metastases, as is typical for such patients, within one year of presentation. Includes an extensive review of world literature on sarcomas in the vicinity of total hip replacement and suggest the need for an international registry of such case reports. REFERENCES 1. Coleman, R.R., Herrington, S. and Scales, J.T. (1973) Concentration of wear products in hair, blood, and urine after total hip arthroplasty. Brit. Med. J. 1 1527-1529. 2. Lux, F. and Zeisler, R. (1974) Investigations of the corrosive deposition of components of metal implants and of the behavior of biologic trace elements in metallosis tissue by means of instrumental, multi-element activation analysis. /. Radiol Anal Chem., 19, 289-297. 3. Rock, M.G. and Hardie, R. (1988): Analysis of local tissue response in 50 revision total hip arthroplasty patients. Trans. Soc. Biomater., XI, 43. 4. Agins, H.J., Alcock, N.W., Bansal, M. et al. (1988) Metallic wear in failed titanium alloy total hip replacements. A histological and quantitative analysis. /. Bone Joint Surg. 7OA, 347-356. 5. Buchert, B.K., Vaughn, B.K., Mallory, T.H. et al (1986): Excessive metal release due to loosening and spreading of sintered particles on porous coated hip prosthesis. Report of two cases. /. Bone Joint Surg., 68A, 606-609. 6. Jacobs, JJ., Skipor, A.K., Black, J. et al. (1991), Release in excretion of metal in patients who have a total hip replacement component made of titaniumbase alloy. /. Bone Joint Surg. 73A, 1475-1486. 7. Witt, J.D. and Swann, M. (1991) Metal wear and tissue response in failed titanium alloy total hip replacements. /. Bone Joint Surg. 73B, 559-563. 8. Woodman, J.L., Jacobs, JJ., Galante, J.O., et al. (1984), Metal ion release from titanium-based prosthetic segmental replacements of long bones in baboons. A long term study. /. Orthop. Res., 1, 421^30. 9. Bartolozzi, A. and Black, J. (1985) Chromium concentrations in serum, blood clot and urine from patients following total hip arthroplasty. Biomaterials, 6, 2-8. 10. Steineman, S.G. (1985) Corrosion of Titanium and Titanium Alloys For Surgical Implant, in: Lutergering, G., Swicker, U., Bunk, W. (eds), Titanium, Science, and Technology, Volume 2, DG fiir Metal. e.V. Oberuresel, Berlin, 1373-1379. 11. Harvey, A.M., Johns, R.S., Owens, A.H. et al. (1972) The Principles and Practice of Medicine. New York: McGraw-Hill, pp. 68-102. 12. Langkamer, V.G., Case, C.P., Heap, P. et al (1992) Systemic distribution of wear debris after hip replacement. A cause for concern? /. Bone Joint Surg., 74B, 831-839.

13. Doll, R. (1958) Cancer of lung and the nose. Nickel workers. Brit. J. Indust. Med., 15, 217-223. 14. Swanson, S.A.V., Freeman, M.A.R. and Heath, J.C. (1973) Laboratory tests on total joint replacement prosthesis. /. Bone Joint Surg., 55B, 759-773. 15. Laskin, D.M. (1954): Experimental production of sarcomas by methylacrylate implant. Proc. Soc. Exper. Biol Med., 87, 329-333. 16. Carter, R.L. and Rowe, F.J.C. (1969): Induction of sarcomas in rats by solid and fragmented polyethylene; Experimental observations and clinical implications. Brit. J. Cancer, 23, 401-407. 17. Harris, W.H., Schiller, A.L., Scholler, J.M. et al (1976) Extensive localized bone resorption in the femur following total hip replacement. /. Bone Joint Surg. 58A, 612-618. 18. Castleman, B., McNeely, B.U. (eds) (1965) Case 38-1965, Case records of the Massachusetts General Hospital. New Engl J. Med., 273, 494-504. 19. Rushforth, G.F. (1947) Osteosarcoma of the pelvis following radiotherapy for carcinoma of the cervix. Brit. J. Radiol. 47, 149-152. 20. Arden, G.P. and Bywaters, E.G.L. (1978), in Surgical Management of Juvenile Chronic Poly Arthritis. Arden, G.P., Ansel, B.M. (eds), Academic Press, London, pp. 269-270. 21. Bago-Granell, J., Aguirre-Canyadell, M., Nardi, J. et al (1984) Malignant fibrous histiocytoma of bone at the site of a total hip arthroplasty. A case report. /. Bone Joint Surg. 66B, 38-40. 22. Penman, H.G. and Ring, P.A. (1984) Osteosarcoma in association with total hip replacement. /. Bone Joint Surg. 66B, 632-634. 23. Swann, M. (1984) Malignant soft tissue tumor at the site of a total hip replacement. /. Bone Joint Surg. 66B, 269-231. 24. Hamblen, D.L. and Carter, R.L. (1984) Sarcoma and Joint Replacement (Editorial). /. Bone Joint Surg. 66B, 625-627. 25. Apley, A.G. (1989) Malignancy and joint replacement. The tip of an iceberg? (Editorial). /. Bone Joint Surg. 71B, 1. 26. Weber, P.C. (1986) Epithelioid sarcoma in association with total knee replacement. /. Bone Joint Surg. 68B, 824-826. 27. Ryu, R.K.N., Bovill, E.G. Jr, Skinner, H.B. et al. (1987) Soft tissue sarcomas associated with aluminum oxide ceramic total hip arthroplasty. A case report. CHn. Orthop. 216, 207-212. 28. Vives, P., Sevestre, H., Grodet, H. et al. (1987) Histiocytome fibreux malin du femur apres prostheses totale de hanche (Malignant fibrous histiocytoma of the femur following total hip replacement). Rev. Chir. Orthop. 73, 407409. 29. Van der list, J J J . (1988) Malignant epithelioid hemangioendothelioma at the site of a hip prosthesis. Acta Orthop. Scand. 59, 328-330. 30;31. Lamovec, J., Zidar, A., Cucek-Plenicar, M. et al. (1988): Synovial sarcoma associated with total hip replacement. A case report. Addendum: Osteosarcoma associated with a Charnley-Muller hip arthroplasty. /. Bone Joint Surg. 7OA, 1558-1560. 32. Tait, N.P., Hacking, P.M. and Malcolm, AJ. (1988) Case report, malignant fibrous histiocytoma occurring at the site of a previous total hip replacement. Brit. J. Radiol, 61, 73-76.

33. Martin, A., Bauer, T.W., Manley, M.T. et al (1988) Osteosarcoma at the site of a total hip replacement. /. Bone Joint Surg. 7OA, 1561-1567. 34. Haag, M. and Adler, CP. (1989) Malignant fibrous histiocytoma in association with hip replacement. /. Bone Joint Surg. (Brit), 71B, 701. 35. Mazabraud, A., Florent, J. and Laurent, M. (1989) (A case of epidermoid carcinoma developed in contact with a hip prosthesis)(Fr.)(au. transl.). Bull. Cancer, 76, 573-581. 36. Brien, W.W., Salvati, E.A., Healey, J.H. et al (1990) Osteogenic sarcoma arising in the area of a total hip replacement. A case report. /. Bone Joint Surg., 72A, 1097-1099. 37. Troop, J.K., Mallory, T.H., Fisher, D.A., et al. (1990) Malignant fibrous histiocytoma after total hip arthroplasty: A case report. CHn. Orthop. ReI. Res., 253, 297-300. 38. Kolstad, K. and Hogstorp, H. (1990): Gastric carcinoma metastasis to a knee with a newly inserted prosthesis: A case report. Ada Orthop. Scand. 61, 369-370. 39. Jacobs, JJ., Rosenbaum, D.H., Hay, R.M. et al. (1992): Early sarcomatous degeneration near a cementless hip replacement. A case report and review. /. Bone Joint Surg., 74B, 740-744. 40. Solomon, M.I. and Sekel, R. (1992) Total hip arthroplasty complicated by a malignant fibrous histiocytoma. A case report. /. Arthroplasty, 7, 549550. 41. Goodfellow, J. (1992) Malignancy and joint replacement (Editorial). J. Bone Joint Surg., 74A, 645. 42. McDougall, A. (1956) Malignant tumor at site of bone plating. /. Bone Joint Surg. 38B, 709-713. 43. Delgado, E.R. (1958) Sarcoma following a surgically treated fractured tibia: A case report. CHn. Orthop. 12, 315-318. 44. Dube, V.E. and Fisher, D.E. (1972) Hemangioendothelioma of the leg following metallic fixation of the tibia. Cancer 30, 1260-1266. 45. Tayton, K J J . (1980) Ewing's sarcoma at the site of a metal plate. Cancer 45, 413^15. 46. McDonald, I. (1981) Malignant lymphoma associated with internal fixation of a fractured tibia. Cancer 48, 1009-1011. 47. Dodion, P., Putz, P., Amiri-Lamraski, M.H. et al (1983) Immunoblastic lymphoma at the site of an infected vitallium bone plate. Histopathol, 6, 807-813. 48. Lee, Y.S., Pho, R.W.H. and Nather, A. (1984) Malignant fibrous histiocytoma at site of metal implant. Cancer 54, 2286-2289 49. Hughes, A.W., Sherlock, D.A., Hamblen, D.L. et al. (1987) Sarcoma at the site of a single hip screw. A case report. /. Bone Joint Surg. 69B, 470472. 50. Ward, JJ., Thornbury, D.D., Lemons, J.E. et al (1990) Metal-induced sarcoma: A case report and literature review. CHn. Orthop. 252, 299-306. 51. Khurana, J.S., Rosenberg, A.E., Kattapuram, S.V. et al (1991) Malignancy supervening on an intramedullary nail. CHn. Orthop. 267, 251-254. 52. Sinibaldi, K. (1976): Tumors associated with metallic implants in animals. CHn. Orthop. ReI Res., 118, 257-266.

53. Moss, A J . (1991) Use of selected medical devices in the United States. Advance Data from Vital and Health Statistics of the National Center for Health Statistics, 191, 1-24. 54. Gillespie, WJ., Frampton, CM., Henderson, R J . et al (1988) The incidence of cancer following total hip replacement. /. Bone Joint Surg. 7OB, 539-542. 55. Visuri, T. (1992) Cancer risk after McKee-Farrar total hip replacement. Orthopedics, 14, 137-142, 1992. 56. Nyren, O., McLaughlin, J.K. et al (1995) Cancer risk after hip replacement with metal implants: A population based study. /. National Can. Inst. 87, 28-33. 57. Li, X.Q., Stevenson, S., Horn, D.L. et al. (1993): Relationship between metallic implants and cancer: A case-control study in a canine population. Vet. Comp. Orthop. Traumatol 6, 70-74.

Blood-material interactions
S.R. Hanson

6.1 INTRODUCTION The importance of understanding mechanisms of blood-material interactions is emphasized by the increasingly widespread use of cardiovascular devices; hence, this field has been the subject of intense inquiry as described in several excellent reviews [1-4]. Unfortunately, it is still not possible to simply rank or classify materials with respect to their suitability for particular blood-contacting applications. Nor is it possible to predict in any general way, based on the properties of devices and of their blood-contacting surfaces, the behavior of blood in contact with materials or the propensity of devices to produce clinically adverse events. Despite many attempts to correlate biologic responses to physicochemical property measurements, our success in understanding blood-material interactions, and the clinical application of many blood-contacting devices, has been largely empirical. It is not appropriate to discuss in detail this large and controversial literature, which has been reviewed elsewhere [1,2]. Rather, this section will focus on the available experimental data in humans, or results which may likely be extrapolated to humans from relevant animal studies, that may guide in the development of new designs for bloodcontacting devices. Cardiovascular device applications in humans have also been the subject of an excellent review [5]. 6.2 EXPERIMENTAL DIFFICULTIES Before summarizing relevant experimental findings, it is appropriate to review briefly the theoretical and practical limitations to our understanding of blood-material interactions.
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN 0 412 60330 6.

There are several factors which have precluded the rational engineering design of devices based on first principles. While thousands of materials have been put forward as 'biocompatible' or non-thrombogenic, based on in vitro studies and animal testing, the relevance of these tests for outcomes in humans remains uncertain. Device responses in vivo depend upon actual device configuration and resulting flow geometry as well as upon intrinsic materials' properties. In many applications, mechanical and physical property requirements may dominate materials' selection. For example, membranes used in dialyzers and oxygenators must be both solute and gas permeable; chronic vascular grafts and heart valves must be mechanically durable and chemically stable for years; heart assist devices require flexible pumping chambers. Thus, the use of in vitro assays or simplified in vivo flow geometries, as in many animal models, has not proven adequate to predict actual device performance in patients. Furthermore, most animals and humans, as individuals, differ markedly from one another in both blood chemistry and in blood response to foreign materials [6]. It is deemed unethical to perform screening tests in humans, hence relatively few materials have undergone clinical evaluation and only limited human comparative data are available. In the case of chronic implants, devices removed at autopsy provide only a single set of observations which cannot be related to dynamic blood-material interactions prior to explantation. Another limitation is our recognition that all blood-material interactions of clinical consequence are preceded by complex interactions between the biomaterial surface and circulating blood proteins. Plasma contains more that 100 identified proteins with specific functions and varying biologic properties [7]. These proteins interact with surfaces in a complex, interdependent and time-dependent fashion that remains poorly understood, except in low dilution, simplified model systems [8]. These reactions may vary from individual to individual depending upon coagulation status, the use antithrombotic or other drug therapies, or the administration of contrast media for fluoroscopic imaging. A partial listing of variables which may affect device outcomes following blood exposure is given in Table 6.1. Despite these limitations, the design engineer may be guided by previous successful applications of materials in a variety of device configurations, and by certain generalizations which have resulted from these studies. Devices which are commonly used include catheters, cannulae, guide wires, stents, shunts, vascular grafts, heart valves, heart and ventricular assist devices, oxygenators, and dialyzers. With respect to these devices it is important to consider those events which can lead to serious clinical complications. These complications include: (1) thrombosis, (2) thromboembolism, (3) consumption (ongoing destruction) or activation of circulating hemostatic blood elements, and (4) activation of inflammatory

Table 6.1. Variables influencing blood interactions with cardiovascular devices Device Properties Size and shape Surface composition Texture or roughness Mechanical properties Blood Flow Phenomena Shear forces Convection and diffusion of reactants, products, cofactors and inhibitors Disturbed flow and turbulence Blood Chemistry-related Effects Coagulation status Antithrombotic and other therapies Contrast media Other Variables Duration of device blood exposure Tissue injury Infection

and immunologic pathways. An appreciation for the biologic mechanisms of these events is essential for understanding the blood-compatibility of devices, and may be briefly described as follows. Thrombus forms as the localized accumulation of blood elements on, within, or associated with a device, and thrombus which is actively deposited can accumulate to the extent of producing device dysfunction or blood vessel occlusion. Interruption of normal blood flow may produce ischemia (relative lack of oxygen) and infarction (tissue death due to total oxygen deprivation) in distal circulatory beds leading to heart attacks and strokes. Thrombus structure may be complex, and is distinguished from that of whole blood clots which are often formed under static flow conditions. Thus, clots are relatively homogeneous structures containing red blood cells and platelets trapped in a mesh of polymerized protein (fibrin), while thrombus formed under arterial flow conditions and high fluid shear rates ('white thrombus') may be composed primarily of layers of fibrin and platelets (small procoagulant cells occupying only about 0.3% of the total blood volume). Under conditions of low fluid shear, as found in veins, thrombus may more closely resemble the structure of whole blood clots ('red thrombus'). Thromboembolism is the dislodgement by blood flow of a thrombus which is then transported downstream, ultimately blocking vessels which are too small for the thrombus to traverse. Thromboembolism is a common cause of stroke (cerebrovascular infarction) and peripheral limb ischemia. Often the balance between dynamic processes of thrombus deposition and its removal by embolic and lytic mechanisms will produce platelet consumption (ongoing destruction) and a net reduction in circulating platelet levels. Other clotting factors may be consumed as well [9]. Finally, certain

devices, particularly those having large surface areas, may activate enzyme systems (e.g., complement) leading to inflammatory or immunologic responses [10]. With these issues in mind we will now review the performance of various classes of biomaterials in actual device configurations. 6.3 CONVENTIONAL POLYMERS Conventional polymers, such as polyethylene (Intramedic), poly (vinyl chloride)(Tygon), polytetrafluoroethylene (Teflon), and poly (dimethyl siloxane)(Silastic), and certain polyurethanes, have been used for many decades in short-term applications including catheters, cannulas, arteriovenous shunts for hemodialysis, and tubing components of extracorporeal circuits. When used for periods of only a few hours, and most often in patients receiving systemic anticoagulation agents, the performance of such materials has usually been clinically acceptable. For example, although thrombus on angiographic catheters can be demonstrated in about half of all cases, most thromboembolic or occlusive events are clinically silent and significant complications occur in less than 1% of procedures [5]. Even total occlusion of small peripheral veins, by short term catheters used for venous sampling or drug administration, is usually inconsequential. However, longer-term indwelling catheters in a variety of configurations and polymer compositions, particularly in infants and children, are now recognized to produce a significant risk of thrombosis which can ultimately lead to organ or limb damage, and even death [H]. Comparative, quantitative studies with different polymer formulations remain to be performed in humans. Polyurethanes, due in part to their flexibility and toughness, are perhaps the polymer of choice for ventricular assist devices and blood pumps. Consequently, they have received considerable interest as bloodcontacting materials. In nonhuman primates, those polyurethanes, such as Pellethane, which exhibit the most hydrophobic surface chemistry produce the least platelet consumption [12]. In dogs, early platelet interactions with polyurethanes vary considerably although relationships to polymer surface chemistry remain unclear [13]. Thus while polyurethanes are chemically versatile and possess many desirable mechanical properties, it is generally not possible to predict their biologic responses in humans. 6.4 HYDROPHILIC POLYMERS These materials, which preferentially adsorb or absorb water (hydrogels), were initially postulated to be blood compatible based on the view that many naturally occuring phospholipids, comprising the cell membranes of

blood contacting tissues, are also hydrophilic. Thus, water, as a biomaterial, was expected to show minimal interaction with blood proteins and cells [14, 15]. Interestingly, in animal studies highly hydrophilic polymers based on acrylic and methacrylic polymers and copolymers, as well as poly(vinyl alcohol) are all found to consume platelets excessively although they accumulate little deposited thrombus [12, 16]. The materials have variable thrombogenicity, but little capacity to retain adherent thrombus, i.e., they shed deposited platelets as microemboli. Thus, while surfacegrafted hydrogels (which are mechanically weak) are currently used to improve catheter lubricity and as reservoirs for drug delivery, they have not received widespread application for improving blood-compatibility. Another hydrophilic polymer that has received considerable attention is poly(ethylene oxide) [17,18]. While poly(ethylene oxide) surfaces have been shown (like hydrogels) to have relatively low interactions with blood proteins and cells in in vitro studies and in some animal models, the suitability of such polymers for actual device applications and long-term implants has not been established.
6,5 METALS

Metals, as a class, tend to be thrombogenic, and are most commonly applied in situations requiring considerable mechanical strength, such as in the struts of mechanical heart valves and as endovascular stents [3, 19] or electrical conductivity, as in pacing electrodes. Stents are metallic mesh devices placed within blood vessels to preserve vessel patency after procedures to expand the vessel lumen diameter (e.g., after balloon angioplasty). Metals most commonly employed are stainless steel (316L type) and tantalum; however, both are thrombogenic [19, 20]. Catheter guide wire thrombogenicity, although readily documented, has been less of a clinical problem because of the usually short period of blood exposure involved in most procedures. In early canine implant studies, the thrombogenicity of a wide series of metallic implants was seen to be related to the resting electrical potential of the metal which was generated upon blood contact [21]. Metals with negative potentials tend to be antithrombogenic, while stainless steel tends to be neutral. Copper, silver, and platinum are positive and extremely thrombogenic. Indeed, the use of copper coils inserted into canine arteries continues to be a widely used model for inducing a thrombotic response [22]. Theoretically, reduced thrombogenicity of metallic stents and heart valve components might be achieved by thin film polymer coatings, although the clinical effectiveness of this strategy has not been demonstrated. Thus, chronic systemic anticoagulation is generally employed in patients with prosthetic heart valves (with metallic components) and stents.

6.6 CARBONS Cardiac valves with components fabricated from low temperature isotropic carbons (pyrolytic carbon) are successfully used clinically [23]. These materials are appropriate for such applications as mechanical valves which require long-term chemical inertness, smoothness, and wear-resistance. The reasons for the marked improvement in the performance (reduced thrombosis and thromboembolic stroke rates) of these newer vs. older style heart valves are not entirely understood, but are undoubtedly multifactorial and related to improved patient management and valve design, as well as to the nature of the carbon surface. The specific benefits conferred by pyrolytic carbons with respect to blood cell and protein interactions, resulting in a very low frequency of clinical complications, remain to be defined. The use of carbon coatings has been proposed for other devices, i.e., vascular grafts, although such devices have not yet been used clinically. 6.7 ULTRA-THIN FILM COATINGS Polymeric thin films of widely varying chemical composition may be deposited onto polymers, metals, and other surfaces using the method of plasma polymerization (also called 'glow-discharge' polymerization) [24]. This method is advantageous since very thin films (e.g., 100 nm) may selectively modify the surface chemistry of devices, but not their overall mechanical properties or surface texture. Plasma polymers form highly cross-linked, covalent, inert barrier layers which may resist the adsorption of proteins, lipids, and other blood elements. Plasma reacted coatings, based on hydrocarbon monomers such as methane, may produce durable diamond like coatings. Plasma polymer coatings have been proposed for vascular grafts and stents, based on promising animal studies [25], but are not used clinically at the present time. 6.8 MEMBRANES Blood contacting membranes are used for gas exchange (e.g., blood oxygenators) or solute exchange (e.g., dialyzers). The large membrane surface area, which may exceed 2 m2, and the complexity of cardiopulmonary bypass circuits can produce consumption and dysfunction of circulating blood elements such as platelets, leading to an increased risk of bleeding as well as thromboembolism [26]. The activation of inflammatory and immune response pathways (complement system) by dialysis and oxygenator membranes may also produce significant complications

[27]. Complement activation by dialysis membranes may be related in part to the availability of surface hydroxyl groups, particularly on cellulosic membranes. Complement activation may be greatly attenuated by the use of other membrane materials such as polysulfone and polycarbonate. Complement activation by biomaterial membranes has been reviewed [27]. 6.9 BIOLOGICAL SURFACES The use of biological and bioactive molecules as device surface coatings may confer thromboresistance. Such coating materials include phospholipids and heparin. Phospholipids such as phosphorylcholine, a normal constituent of cell membranes, may orient polar head groups towards the aqueous phase and locally organize water molecules, much like hydrogel surfaces. These surfaces may minimize protein and complement interactions [28]. In preliminary animal studies, phosphorylcholine coated stents, guide wires, and vascular grafts have shown improved thromboresistance. This approach is being actively developed for clinical applications. Heparin, a naturally occuring anticoagulant glycosaminoglycan, has been considered an attractive surface coating based on its ability to directly catalyze the inactivation of procoagulant enzymes, and thus suppress thrombus development. Recently, the reduced thrombogenicity and improved biocompatibility of heparinized metallic stents has been demonstrated in animals [29]. In these studies, heparin was covalently attached to a polymer surface coating. This method has also been used clinically for the heparin coating of catheters and other devices, although it remains unclear whether the improved biocompatibility is a function of heparin's anticoagulant activity, nonspecific physicochemical properties, or both. With biomolecule modified surfaces, there may also be important questions regarding the possible deleterious effects of sterilization procedures required before implantation. 6.10 SURFACE TEXTURE Surface 'smoothness' is a generally desirable feature of blood contacting surfaces. In this context, a smooth surface is one with irregularities with typical dimensions less than those of cells (< 1 |xm). However, in certain applications, device incorporation by tissue is desirable, or the texturing of polymers may increase mechanical flexibility and durability. Thus, the sewing ring of mechanical heart valves is typically composed of poly(ethylene terephthalate) (Dacron) fabric to permit tissue in growth and healing, which is associated with a reduction in thromboembolic

events. Vascular grafts used to replace diseased blood vessels are most commonly fabricated from woven or knitted Dacron or textured (expanded) polytetrafluoroethylene (ePTFE) (Goretex). In tubular form, these textured polymers remain flexible and stable for many years following implantation. Smooth-walled vascular grafts have generally not been considered attractive for long-term applications since smooth surfaces may not permit tissue ingrowth or flow surface healing. Textured flow surfaces are initially thrombogenic upon blood contact, although ePTFE appears less thrombogenic and thromboembolic than fabric Dacron prostheses [30]. These grafts perform acceptably in man when the graft diameter exceeds about 6 mm since the layer of thrombus that forms does not significantly restrict blood flow. Interestingly, both smoothwalled and textured ventricular assist devices have also performed successfully in clinical trials [31, 32]. 6.11 CONCLUSION Because the variables affecting cardiovascular device responses are sufficiently numerous and complex, those properties of blood-contacting surfaces which would be desirable to minimize adverse reactions cannot, in most instances, be predicted with confidence. The choice of material is usually constrained by mechanical property considerations and by variable requirements for material durability and chemical stability. Cardiovascular device engineering must therefore be guided by previous experience in successful clinical applications. ADDITIONAL READING
Colman, R.W., Hirsch, J., Marder, VJ. and Salzman, E.W. (eds)(1994) Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 3rd edn, J.B. Lippincott, Philadelphia. This book is highly recommended. This state-of-the-art text covers in detail essentially all important hematological aspects of cardiovascular device blood compatibility. In particular, Chapter 76, Interaction of blood with artificial surfaces, which considers many theoretical, experimental, and animal studies, and Chapter 77, Artificial devices in clinical practice, which describes clinical device thromboembolic complications, are of great practical value. Harker, L.A., Ratner, B.D. and Didisheim, P. (eds)(1993) Cardiovascular Biomaterials and Biocompatibility, Cardiovascular Pathology, 2(3) (suppl.), 1S-224S. In this volume, 20 chapters by expert authors treat all aspects of biomaterials and blood compatibility including pathologic mechanisms, material characterization, blood-material interactions and device performance. This volume updates an excellent earlier book Guidelines for Blood-Material Interactions, National Institutes of Health, Washington, DC, Publication No. 85-2185 (1985).

Szycher, M. (ed.) (1983) Biocompatible Polymers, Metals, and Composites, Technomic Publishing Co., Lancaster, Pennsylvania. Many of the same issues of blood-material interactions are broadly covered while selected polymer and device applications are described in additional detail. Of particular interest are Section I (Fundamental Concepts in Blood/Material Interactions) and Section II (Strategies for Hemocompatibility).

ACKNOWLEDGEMENT This work was supported by Research Grant HL 31469 from the Heart, Lung and Blood Institute, the National Institutes of Health.

REFERENCES 1. Salzman, E.W., Merrill, E.W. and Kent K.C. (1994) Interaction of blood with artificial surfaces, in Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 3rd edn, R.W. Colman, J. Hirsch, VJ. Marder, and Salzman, E.W. (eds), J.B. Lippincott, Philadelphia, pp. 1469-85. 2. Harker, L.A., Ratner, B.D. and Didisheim, P. (eds) (1993) Cardiovascular Biomaterials and Biocompatibility, Cardiovascular Pathology 2(3) (supplement), 1S-224S. 3. Szycher, M. (ed.) (1983) Biocompatible Polymers, Metals, and Composites, Technomic Publishing Co., Lancaster, Pennsylvania. 4. Williams, D.F. (ed) (1981) Biocompatibility of Clinical Implant Materials, CRC Press, Boca Raton, Florida. 5. Clagett, G.P. and Eberhart, R.C. (1994) Artificial Devices in Clinical Practice, in Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 3rd edn R.W. Colman, J. Hirsch, VJ. Marder, and Salzman, E.W. (eds), J.B. Lippincott, Philadelphia, pp. 1486-1505. 6. Grabowski, E.F., Didisheim, P., Lewis, J.C. et al (1977) Platelet adhesion to foreign surfaces under controlled conditions of whole blood flow: human vs. rabbit, dog, calf, sheep, pig, macaque, and baboon. Transactions - American Society for Artificial Internal Organs, 23, 141-51. 7. Lentner, C. (ed.) (1984) Geigy Scientific Tables (vol. 3): Physical Chemistry, Composition of Blood, Hematology, Somatometric Data, Ciby-Geigy, Basle. 8. Brash, J.L. and Horbett, T.A. (eds) (1987) Proteins at Interfaces. Physicochemical and Biochemical Studies, American Chemical Society, Washington, DC. 9. Harker, L.A. and Slichter, SJ. (1972) Platelet and fibrinogen consumption in man. New England J Med. 287(20), 999-1005. 10. Bennett, B., Booth, N.A., Ogston D. (1987) Potential interactions between complement, coagulation, fibrinolysis, kinin-forming, and other enzyme systems, in: Haemostasis and Thrombosis (2nd edn), A.L. Bloom and D.P. Thomas (eds), Churchill Livingstone, New York, pp. 267-82.

11. Andrew, M. (1995) Developmental hemostasis: relevance to thromboembolic complications in pediatric patients. Thrombosis and Hemostasis, 74(1), 415-25. 12. Hanson, S.R., Harker, L.S., Ratner, B.D. et al (1980) In vivo evaluation of artificial surfaces using a nonhuman primate model of arterial thrombosis. / Laboratory Clinical Med. 95, 289-304. 13. Silver, J.H., Myers, C.W., Lim, F. et al (1994) Effect of polyol molecular weight on the physical properties and haemocompatibility of polyurethanes containing polyethylene oxide macroglycols. Biomaterials 15(9), 695-704. 14. Hoffman, A.S. (1974) Principles governing biomolecular interactions at foreign surfaces. /. Biomedical Materials Res. (Symp.) 5(1), 77-83. 15. Andrade, J.D., Lee, H.B., Jhon, M.S. et al. (1973) Water as a biomaterial. Transactions - American Society for Artificial Internal Organs 19, 1-7. 16. Strzinar, I. and Sefton, M.V. (1992) Preparation and thrombogenicity of alkylated polyvinyl alcohol coated tubing. /. Biomedical Materials Research 26, 577-92. 17. Merrill, E.W. (1993) Poly(ethylene oxide) star molecules: synthesis, characterization, and applications in medicine and biology. /. Biomaterials Science, Polymer Edition 5(1-2), 1-11. 18. Llanos, G.R. and Sefton, M.V. (1993) Does polyethylene oxide possess a low thrombogenicity? /. Biomaterials Science, Polymer Edition, 4(4), 381-400. 19. Sigwart, U., Puel, J., Mirkovitch, V. et al. (1987) Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. New England J. Med, 316(12), 701-6. 20. Scott, N.A., Nunes, G.L., King, S.B. et al. (1995) A comparison of the thrombogenicity of stainless steel and tantalum coronary stents. American Heart J., 129, 866-72. 21. Saywer, P.N., Stanczewski, B., Lucas, T.R., et al. (1978) Physical chemistry of the vascular interface, in Vascular Grafts, P.N. Sawyer and MJ. Kaplitt (eds), Appleton-Century-Crofts, New York, pp. 53-75. 22. Rapold, H.J., Stassen, T., Van de Werf, F., et al (1992) Comparative copper coil-induced thrombogenicity of the internal mammary, left anterior descending coronary, and popliteal arteries in dogs. Arteriosclerosis and Thrombosis, 12(5), 634-44. 23. Schoen, FJ. (1983) Carbons in heart valve prostheses: Foundations and clinical performance, in M. Szycher (ed.), Biocompatible Polymers, Metals, and Composites, Technomic Publishing Co., Lancaster, Pennsylvania, pp. 239-61. 24. Yasuda, H.K. (1985) Plasma Polymerization, Academic Press, Orlando. 25. Yeh, Y.S., Iriyama, T., Matsuzawa, Y., et al (1988) Blood compatibility of surfaces modified by plasma polymerization. /. Biomedical Materials Research, 22, 795-818. 26. Harker, L.A., Malpass, T.W., Branson H.E., et al. (1980) Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood, 56(5), 824-34. 27. Hakim, R. (1993) Complement activation by biomaterials. Cardiovascular Pathology, 2(3)(suppl), 187S-198S.

28. Yu, J., Lamba, N.M., Courtney J.M., et al (1994) Polymeric biomaterials: Influence of phosphorylcholine polar groups on protein adsorption and complement activation. International Journal of Artificial Organs, 17(9), 499-504. 29. Hardhammer, P.A., van Beusekom H.M., Emanuelsson, H.U., et al (1996) Reduction in thrombotic events with heparin-coated Palmaz-Schatz stents in normal porcine coronary arteries. Circulation, 93(3), 423-30. 30. Schneider, P.A., Kotze, H.F., Heyns, A. duP., et al (1989) Thromboembolic potential of synthetic vascular grafts in baboons. /. Vascular Surgery, 10, 75-82. 31. Dasse, K.A., Poirier, V.L., Menconi, MJ., et al (1990) Characterization of TCPS textured blood-contacting materials following long-term clinical LVAD support. In: Cardiovascular Science and Technology: Basic and Applied: II, JC Norman (ed.), Oxymoron Press, Boston, MA, pp. 218-220. 32. Kormos, R.L., Armitage, J.M., Borovetz, H.S., et al (1990) Univentricular support with the Novocor left ventricular assist system as a bridge to cardiac transplantation: An update in Cardiovascular Science and Technology: Basic and Applied: II, JC Norman (Ed), Oxymoron Press, Boston, MA, pp. 322-324.

Soft tissue response to silicones

S.E. Gabriel

7.1 SILICONES USED IN MEDICINE Although the term 'silicone' refers to a group of organic silicone compounds, the one most commonly used in medicine is composed of a polymer known as dimethypolysiloxane (DMPS). In silicone gel the polymer is cross-linked; the more cross-linking, the more solid is the gel. Liquid silicone consists of glucose-linked DMPS polymer chains. Silicones first became commercially available in 1943, with the first subdermal implantation of silicone occurring in the late 1940s [1-3]. Silicones have since been developed for a wide variety of medical applications, most notably in joint and breast prostheses. There is a large body of literature attesting to the chemical and physical inertness of silicone [4-12]. Recently, there has been increasing interest in the possible adverse effects of silicones used in implantation. Much of the literature describing the adverse effects of silicone has been in reference to direct silicone injection. The following discussion will review the immunologic effects of prostheses used in breast reconstruction and augmentation. 7.2 LOCAL IMMUNOLOGIC REACTIONS TO SILICONE Immunologic reactions to silicone can be local, regional due to silicone migration, or systemic. Local cutaneous and subcutaneous reactions to
Handbook of Biomaterial Properties. Edited by J. Black and G. Hastings. Published in 1998 by Chapman & Hall, London. ISBN O 412 60330 6.

injected silicone or gel have been reported [13-18]; and it has become apparent that these reactions are not due to impurities in the silicone, as was originally suspected. Subcutaneous injection of silicone liquid in experimental animals provokes an acute inflammatory response characterized by a primarily polymorphonuclear reaction, followed by a chronic inflammatory response with lymphocytes,fibroblasts,and plasma cells [19]. The late response is characterized by a small amount of cellular infiltrate and an increase in extracellular material. Macrophages with clear vacuoles have been observed and are suspected to contain silicone. Occasionally, multinucleated foreign body giant cells have also been observed [16, 20-23]. In humans, liquid silicone has been injected subcutaneously for cosmetic reasons. Granulomatous reactions have been reported to occur in some instances [14-17]. Similar reactions have been noted in two case reports following the rupture of silicone gel-filled breast prostheses [24,25]. Clinically, these reactions have the characteristics of an inflammatory response, i.e., redness, swelling, and pain. Histologic examination shows chronic inflammatory reactions, occasionally with the presence of refractile material resembling silicone [24]. Migration of silicone has been documented on numerous occasions in the literature. Following experimental intra-peritoneal injection in mice, silicone was demonstrated to be present in the liver, spleen, ovaries, and kidneys [26]. Other investigators have documented the migration of subcutaneously injected silicone to the lung, associated with an increased incidence of respiratory problems in experimental animals [27]. Pneumonitis was reported in 3 patients several days following liquid silicone injection, and silicone was demonstrated in macrophages obtained by pulmonary lavage from these patients [27]. The presence of silicone was confirmed by atomic absorption and infra-red spectrophotometry. Another case report described a patient with silicone-induced granulomatous hepatitis; analysis of liver biopsy specimens revealed quantifiable amounts of silicone [28]. Subcutaneous masses or nodules, hepatic granulomas have also been reported following injections into humans [23,24,28]. Regional lymphadenopathy is a frequently reported finding [29-35]. In rare cases, this has progressed to malignant lymphoma [29,32,33]. The relevance of these reports to silicone breast implants is uncertain. 7.3 SYSTEMIC IMMUNOLOGIC REACTIONS TO SILICONE Systemic reactions have been reported following the introduction of silicone into the body. In one instance, a severe systemic reaction consisting of a febrile illness, acute renal insufficiency, respiratory compromise,

pulmonary infiltration, delirium, anemia, and thrombocytopenia has been reported following implantation of a silicone gel envelope prosthesis. Improvement followed implant removal. Silicone was identified by mass spectrophotometry in this case [36]. Another case involved the injection of a large quantity of free silicone under the breasts by an unauthorized individual. The patient expired within 10 hours of injection. Silicone was identified by absorption spectrophotometry in large quantities in the lung, kidney, liver, brain and serum [28]. The mechanism underlying the systemic immunologic reactions to silicone has not been thoroughly investigated. A marked local granulomatous reaction to silicone has been noted in guinea pigs; however, an antibody response to silicone by Ouchterlony gel diffusion or passive cutaneous anaphylaxis was not demonstrated [37]. Other investigators have studied macrophage migration inhibition [38]. In these studies, pigs were sensitized by subcutaneous injection of silicone. Harvested macrophages demonstrated inhibition of migration in the presence of silicone, suggesting specific antigen recognition. In addition, silicone was demonstrated in the cytoplasmic bridges joining macrophages and lymphocytes. Alternatively, it has been suggested that the immune system does not respond with a specific recognition of silicone but that silicone promotes the immune response to other antigens, i.e., acts as an adjuvant. Hypergammaglobulinemia has been noted by some investigators, and silicon dioxide has been reported to have adjuvant effects [39]. A disorder which has been termed, 'human adjuvant disease', was described following injection of paraffin for breast augmentation mammoplasty [40]. In Japan, in 1973, Yoshida reviewed seven cases of human adjuvant disease in Japan following injections of paraffin or silicone for augmentation mammoplasty [41]. The symptoms included arthritis, arthralgia, lymphadenopathy, hypergammaglobulinemia, elevated erythrocyte sedimentation rates and positive rheumatoid factor. Removal of the injected materials resulted in improvement of the condition in some patients [41]. In 1979, Kumagai reported four cases of classical systemic sclerosis following cosmetic surgery [42]. Five years later, the same investigator described a series of 46 patients with signs and symptoms of connective tissue disease following injection of either silicone or paraffin [43]. Definite connective tissue diseases, based on American Rheumatism Association Criteria, were diagnosed in 24 patients. These conditions included systemic lupus erythematosus, mixed connective tissue disease, rheumatoid arthritis, Sjogren's syndrome, and systemic sclerosis. Another group of 22 patients were described as having human adjuvant disease, with signs, symptoms, and laboratory abnormalities suggestive but not diagnostic of a connective tissue disease. In 1984, three patients from Singapore were reported who developed autoimmune disease following injection augmentation mammoplasty [44]. In the same year, a 52-year-old woman who

developed systemic sclerosis, primary biliary cirrhosis and Sjogren's syndrome following silicone/paraffin injection mammoplasty was reported [45]. In 1982, the first case series describing autoimmune disorders following augmentation mammoplasty with gel-filled prostheses was reported. This was followed by other reports involving both gel-filled implants and salinefilled silicone implants [46-49]. The most frequently reported connective tissue disease associated with silicone breast implants is systemic sclerosis. Table 7.1 summarizes the clinical and laboratory characteristics of 19 cases of systemic sclerosis associated with silicone breast augmentation published in the English language literature. Eleven of these cases received implantation in the United States [35]. Eleven of the 19 patients were ANA positive, 15 had Raynaud's, and 10 had diffuse systemic sclerosis. The interval between augmentation to diagnosis of systemic sclerosis varied from 1 to 25 years, with a mean of 13 years. Fourteen of the 19 patients were exposed to silicone (11 silicone gel and 3 silicone injection), the remainder being exposed to paraffin injection. In two cases, histopathologic demonstration of multinucleated giant cells, vacuoles with refractile droplets, and intracytoplasmic asteroid bodies in lymph nodes draining the prostheses suggested leakage of silicone from the implants and its dissemination in lymphoid tissues. The authors used energy-dispersive X-ray analysis to confirm that the macrophage inclusions in the lymphatic tissue contain silicone. Although systemic sclerosis is the most commonly reported disorder occurring following silicone breast implantation, there have also been reports of systemic lupus erythematosus [43,44,46,50], Sjogren's syndrome [45], keratoconjunctivitis sicca [45], rheumatoid arthritis [4,34,43], polymyositis [43], overlap syndromes (including human adjuvant disease) [34,43,46,50,51], morphea [35,43], Hashimoto's thyroiditis [43,52], anticardiolipin antibody syndrome [53], primary biliary cirrhosis [45] and toxic shock syndrome [54]. Unfortunately, it is impossible to tell, on the basis of case reports, whether the frequency of these events is greater than might be expected on the basis of chance alone (Table 7.1). 7.4 EVIDENCE FOR CAUSATION It has been estimated that two million American women have undergone breast augmentation or reconstruction since the introduction of the silicone gel-filled elastomer envelope-type prosthesis in the early 1960s [60,61]. The reported cases of systemic sclerosis among this population raise the important question of whether the association between systemic sclerosis and silicone breast implants is a real one. Unfortunately, almost all of the evidence to date is derived from case reports, which are the

Table 7.1 Cases of Systemic Sclerosis after Augmentation Mammoplasty Reported in the English-Language Literature
Age at Age at Patient Diagnosis, y Mammoplasty, y Interval to Onset, y Extent of Systemic Raynaud Sclerosis Phenomenon Antinuclear Antibodies* Reference

Type of Implant

Systemic Involvement

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

52 41 63 37 45 49 51 36 55 50 59 38 47 59 44 43 44 44 46

50 20 53 32 25 20 25 24 30 31 34 26 32 50 34 37 43 19 34

Silicone Silicone Silicone Silicone Paraffin Paraffin Paraffin Paraffin Paraffin Silicone Silicone Silicone Silicone Silicone Silicone Silicone Silicone Silicone

bag gel bag gel bag gel bag gel injection injection injection injection injection injection injection bag gel bag gel gel gel gel gel injection

2 21 10 19 16 17 25 19 25 15 10 6 1 25 12

Diffuse Diffuse Limited Diffuse Diffuse Diffuse Limited Limited Limited Limited Diffuse Limited Diffuse Diffuse Limited Diffuse Limited Diffuse Limited

No Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes No

Silicone gel

No Pulmonary, gastrointestinal Pulmonary Pulmonary No Pulmonary, gastrointestinal No Pulmonary Pulmonary Pulmonary, gastrointestinal, primary biliary cirrhosis No Gastrointestinal Pulmonary Pulmonary, gastrointestinal Pulmonary, gastrointestinal Gastrointestinal Malignant hypertension Malignant hypertension/ renal failure No

+ +

(55) (55) (55) (55) (42) (42) (43) (43) (44) (45) (56) (56) (35) (35) (35) (35) (57) (58) (59)

+ + + +

- negative. + positive. * Determined using immunofluorescence.

very weakest form of data bearing on the question of causality (Table 7.2). Indeed, the most important evidence for establishing a cause-effect relationship is the strength of the research design used to study that relationship [62]. Randomized control trials provide the strongest evidence but are seldom ethical in studies of causation because they involve randomly assigning individuals to receive or not to receive a potentially harmful intervention. In addition, the long latent periods and large numbers of subjects needed to answer most cause and effect questions in clinical medicine make it impractical to utilize this research design. Well conducted prospective cohort studies are the next strongest design because they minimize the effects of selection bias, measurement bias, and known confounders. Such a study would involve following a large population of women, preferably for one or more decades, looking for the outcomes of interest (e.g., connective tissue disorders). A relative risk for connective tissue disorders among those women who elect to have breast implantation compared to those who do not can then be calculated. Although this is a powerful research design, it is usually impractical because of the necessary long follow-up period. This problem can be circumvented by a retrospective cohort study, which is similar with the exception that the population and the exposure (breast implantation) is identified in the past, allowing the patients to be followed to the present for the outcomes of interest. Although this is a very attractive research design, it requires that the complete exposed and unexposed populations be identifiable and that follow-up information be available on all individuals. Case-control studies retrospectively compare the frequency of breast implantation in women with and without the outcomes of interest. If, for example, connective tissue disorders were more likely to occur among women with breast implants, this would constitute some evidence for causation. Case-control studies typically require less time and resources than cohort studies. However, they are susceptible to many more biases than cohort studies [62]. The primary reason not to perform a case-control study here, however, is that a separate case-control study would be required for each of the outcomes of interest, i.e., a case-control study of systemic sclerosis, a case-control study of rheumatoid arthritis, etc. The
Table 7.2 Strength of Research Designs Used to Determine Causation Strongest I i 1 Weakest Randomized controlled trials Prospective cohort studies Case control studies Ecological survey Case series

retrospective cohort design is much more efficient since it can evaluate multiple outcomes in a single study, as is the need here. A set of eight criteria has been proposed as a guide to formulate decisions regarding cause and effect relationships (Table 7.3). The relationship between breast implants and connective tissue disorders does fulfill the criterion of temporality since, at least in the published case reports, the connective tissue disorders all followed breast implantation. There is no evidence describing the magnitude of the relative risk in this relationship. There is also no evidence for a dose response relationship, i.e., that women with bilateral implants perhaps have an increased likelihood of connective tissue disorders compared to women with unilateral implants. The evidence regarding the reversibility of these disorders with removal of implants is variable. Although there have been some reports of improvement of connective tissue disorders following removal of the implants, this is not consistent and the number of patients involved is small. The relationship does appear to be consistent, i.e., it has been observed repeatedly by different persons in different places, circumstances, and times, however it has not yet been assessed using adequate study designs. Perhaps the most compelling evidence is the biologic plausibility of this relationship due to the hypothesis of silicone acting as an immune adjuvant. The relationship does not appear specific, as silicone implants have lead to not just one effect, but several, albeit somewhat related, effects. Finally, a cause and effect relationship is strengthened if there are examples of well established causes that are analogous to the one in question. Adjuvant induced arthritis can be considered analogous [63]. In summary, in spite of the anecdotal evidence, until very recently there was a lack of evidence to either support or refute a cause-and-effect relationship between silicone breast implants and connective tissue/ autoimmune disorders. Table 7.3 Evidence that an Association is Causal F621
Definition Cause precedes effect Large relative risk Larger exposures to cause associated with higher rates of disease Reduction in exposure associated with lower rates of Reversibility disease Repeatedly observed by different persons, in different Consistency places, circumstances, and times Biologic plausibility Makes sense, according to biologic knowledge of the time One cause leads to one effect Specificity Cause-and-effect relationship already established for a Analogy similar experience cnaractenstic Temporality Strength Dose-response

7.5 CONTROLLED STUDIES EXAMINING THE RELATIONSHIP BETWEEN BREAST IMPLANTS AND CONNECTIVE TISSUE DISEASE. At least seven controlled studies have now been published (Table 7.4), each of which provided a quantitative assessment of the risk of connective tissue diseases among women with breast implants [64-70]. The first of these was a case-control study of augmentation mammoplasty and scleroderma [68]. The aims of this study were to compare the frequency and temporal relationship of augmentation mammoplasty among scleroderma cases and matched controls. Scleroderma patients and age stratified general practice controls were interviewed using a pretested telephone questionnaire. Self-reported dates of augmentation mammoplasty were ascertained as were dates of scleroderma symptoms and diagnoses as relevant. Frequencies of nonaugmentation mammoplasty silicone exposure between interviewed cases and controls were expressed in terms of rate ratios and 95% confidence intervals. Rate ratios were also adjusted for socioeconomic status. A total of 315 cases and 371 controls were interviewed, of whom 251 and 289, respectively, were female. The unadjusted rates for augmentation mammoplasty among interviewed cases and controls were 4/251 (1.59%) and 5/289 (1.73%), respectively. The socioeconomic status adjusted rate of augmentation mammoplasty in scleroderma patients was 1.54% (95% CI: 0.03-3.04) which is very similar to the 1.73% rate in interviewed controls. These results indicate that augmentation mammoplasty rates were comparable in cases and controls. In addition, the rates of exposure to nonmammoplasty silicone mastectomy and breast lumpectomy were comparable in interviewed cases and controls. This study failed to demonstrate an association between silicone breast implantation and the subsequent development of scleroderma to a relative risk as low as 4.5 with 95% statistical power. In June of 1994, a population-based retrospective cohort study was published which examined the risk of a variety of connective tissue diseases and other disorders after breast implantation [65]. In this study, all women in Olmsted County, Minnesota who received a breast implant between 1 January 1964 and 31 December 1991 (the case subjects) were studied. For each case subject, two women of the same age (within three years) from the same population who had not received a breast implant and who underwent a medical evaluation within two years of the date of the implantation in the case subject were selected as control subjects. Each woman's complete inpatient and outpatient medical records were interviewed for the occurrence of various connective tissue diseases (i.e., rheumatoid arthritis, systemic lupus erythematosus, Sjogren's syndrome, dermatomyositis, polymyositis, systemic sclerosis, ankylosing spondylitis,

Table 7.4 Summary of controlled studies examining the relationship between breast implants (BI) and connective tissue diseases (CTD)
Reference Study Population Cases Controls Study Design (exposed) (unexposed) Outcome(s) Examined Main Result Conclusions

68 65

Case control Retrospective cohort Case control

315 749

371 1498

Systemic sclerosis (SS, scleroderma) Connective tissue and other autoimmune diseases

67

195

143

64 60

Case control

349

1456 2061

Multi-center 869 case control

Rates of BI among cases and controls were 1.59% and 1.73% Relative risk (casesxontrols) of developing any of these diseases was 1.06 (95% CI: 0.34-2.97). One (0.8%) of the SLE Systemic lupus cases and 0 (0%) of the erythematosus (SLE) controls reported having a BI (p=0.57). Relative risk for a history of Rheumatoid arthritis BI (casesxontrols) was 0.41 (RA) (95% CI: 0.05-3.13). Odds ratio for BI surgery SS (scleroderma) (casesxontrols) was 1.25 (95% CI: 0.62-2.53). Connective tissue disease

Rates of BI were similar in cases and controls. There was no association between BI and the connective tissue and other disorders studied. No association was shown between BI and SLE.

70

Nested case control

121 700

69

Case control (preliminary 592 results)

SS (scleroderma) 1184

No increased risk for RA among women with BI was demonstrated. No significant causal relationship was demonstrated between BI and the development of SS. Five cases with BI were identified No association was found between BI among 300 patients with RA; and CTD. 0 cases with BI among 123 with SLE, 20 patients with SS, 3 with Sjogren's syndrome, 13 with dermato/polymyositis, and 2 with mixed connective tissue disease. Odds ratio for BI (casesxontrols) No significant was 0.61 (95% CI: 0.14-2.68) association between BI and SS was found.

CI = confidence interval

psoriatic arthritis, polymyalgia rheumatica, vasculitis, arthritis associated with inflammatory bowel disease, and polychondritis), certain other disorders thought to have an autoimmune pathogenesis (i.e., Hashimoto's thyroiditis), and cancer other than breast cancer. In addition, this study itemized the results of ten related symptoms and the abnormal results of four related laboratory tests. A total of 749 women who had received a breast implant were followed for a mean of 7.8 years and the corresponding 1498 community controls were followed for a mean of 8.3 years. The relative risk of developing any one of these specified connective tissue and other diseases among case subjects compared to controls was 1.06 (95% CI: 0.34-2.97). This study, therefore, found no association between breast implants and the connective tissue diseases and other disorders that were studied [65]. In the summer of 1994, Strom and colleagues published a case-control study which addressed the risk of systemic lupus erythematosus among women with breast implants [67]. A total of 219 eligible cases who met the American Rheumatism Association criteria for systemic lupus erythematosus [71] were identified from the medical practices of cooperating rheumatologists in the Philadelphia metropolitan area. One hundred ninety-five (89%) of these were enrolled in the study. Friends of the cases, matched to the cases on sex and age (5 years), served as controls. Using a short telephone interview, cases and controls were contacted and asked to provide information on any surgery that they had prior to the index date, i.e., the date of diagnosis of systemic lupus erythematosus, in the cases and the same year for the age-matched friend controls. Specific questions were asked about plastic surgery in general and breast implants in particular. One hundred forty-eight (75.9%) of the 195 systemic lupus erythematosus being sought and 111 (77.6%) of the 143 controls agreed to be reinterviewed for this study. Only 1 (0.8%) of the 133 female systemic lupus erythematosus cases reported having a breast implant eight years prior to the diagnosis of systemic lupus erythematosus. This compared to 0 out of the 100 female friend controls (Fisher exact onetailed p-value = 0.57). These authors concluded, based on this very large case-control study of systemic lupus erythematosus, that no association existed between silicone breast implants and the subsequent development of systemic lupus erythematosus. However, the modest statistical power of the study was only able to provide sufficient evidence against a very large association. Three additional controlled studies have been presented and are published in abstract form [64,66,70]. As part of a prospective case-control study of the risk of rheumatoid arthritis, Dugowson et al. recruited 349 women with new-onset rheumatoid arthritis and 1456 similarly aged control women. Information about breast implants was obtained on both cases and controls and age-adjusted risk for a history of breast implants

among cases was compared to that of controls. The relative risk, i.e., comparing the rate of a history of breast implants among rheumatoid arthritis cases compared to a similar history among controls, was 0.41 (95% CI: 0.05-3.13) [64]. These data did not support an increased risk for rheumatoid arthritis among women with silicone breast implants. A multi-center, case-controlled study was performed to examine the association between scleroderma and augmentation mammoplasty [66]. A total of 869 women with systemic sclerosis recruited from three university-affiliated rheumatology clinics and 2061 local community controls matched on age in three strata (ages 25-44, 45-64, and >65); race and sex were identified by random-digit dialing. Data on exposure and potential confounding variables were collected from cases and controls by selfadministered questionnaires and telephone interviews, respectively. The frequency of breast implant surgery was compared in both groups and the odds ratio and 95% confidence intervals for the association of augmentation mammoplasty with systemic sclerosis, adjusted for age, race, marital status, and site, was 1.25 (95% CI: 0.62-2.53). These data failed to demonstrate a significant causal relationship between augmentation mammoplasty and the development of systemic sclerosis. Using a nested case-control study, Sanchez-Guerrero et al examined the association between silicone breast implants and connective tissue diseases among a cohort of 121 700 registered American nurses followed since 1976 [70]. In 1992, a questionnaire was sent to nurses who had reported any rheumatic disease from 1976 to 1990 asking about rheumatic symptoms and silicone exposure. The complete medical records were obtained on all participants who confirmed any rheumatic or musculoskeletal symptoms. Connective tissue disease cases were classified according to the American College of Rheumatology or other published criteria. Ten age-matched controls per case were randomly selected among nurses with no rheumatic or musculoskeletal complaints. Odds ratios and 95% confidence intervals were used as a measure of association. This study identified 448 cases with definite connective tissue diseases and 1209 nurses with silicone breast implants. Five patients had silicone breast implants and any connective tissue disease. The mean time since implantation was 139 95.81 months among these five patients and 119.17 76.64 months among all nurses with silicone breast implants. These five patients were identified among 300 patients with rheumatoid arthritis. No case with a silicone breast implant was identified among 123 patients with systemic lupus erythematosus, 20 patients with scleroderma, three with Sjogren's syndrome, 13 with dermato/polymyositis, and two with mixed connective tissue diseases. In conclusion, this study found no association between silicone breast implants and connective tissue diseases. Finally, Burns and Schottenfeld are conducting a population-based casecontrol study examining the relationship between this condition and prior

history of breast implant surgery [69,72]. The cases and normal population controls are being assembled from the states of Michigan and Ohio. The cases are being identified using several sources: a computerized data base of hospital discharge diagnostic listings during the period 1980-1991; a collaborative network of major medical centers; a postal survey of certified rheumatologists; and from patient members of the United Scleroderma Foundation. Although this study is still underway, preliminary results demonstrate a crude odds ratio of 0.61 (95% CI: 0.14-2.68) for breast implants among cases compared to controls. These results do not support a causal relationship between breast implants and systemic sclerosis. In summary, although numerous anecdotal case reports have suggested an association between silicone breast implants and connective tissue diseases, all seven controlled epidemiologic studies conducted to date have failed to confirm such an association. Whether silicone breast implants cause a new and previously undescribed condition is yet to be determined.

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13. Symmers, W.StC. (1968) Silicone mastitis in 'topless' waitresses and some other varieties of foreign-body mastitis. Br. Med J., 3, 19-22. 14. Ortiz-Monasterio, F. and Trigos, I. (1972) Management of patients with complications from injections of foreign materials into the breasts. Plast. Reconstr. Surg., 50(1) 42^7. 15. Parsons, R.W. and Thering, H.R. (1977) Management of the silcone-injected breast. Plast Reconstr. Surg., 60(4), 534-538. 16. Wilkie, T.F. (1977) Late development of granuloma after liquid silicone injections. Plast. Reconstr. Surg., 60(2), 179-188. 17. Pearl, R.M., Laub, D.R., and Kaplan, E.N. (1978) Complications following silicone injections for augmentation of the contours of the face. Plast Reconstr Surg, 61(6): 888-891. 18. Kozeny, G.A., Barbato, A.L., Bansal, V.K. et al (1984) Hypercalcemia associated with silicone-induced granulomas. N. Engl. J. Med., 311(17), 1103-1105. 19. Andrews, J.M. (1966) Cellular behavior to injected silicone fluid: A preliminary report. Plast. Reconstr. Surg, 38(6), 581-583. 20. Ballantyne, D.L., Rees, T.D. and Seidman, I. (1965) Silicone fluid: Response to massive subcutaneous injections of dime thy lpolysiloxane fluid in animals. Plast. Reconstr. Surg., 36(3), 330-338. 21. Ben-Hur, N. and Neuman, Z. (1965) Siliconoma - another cutaneous response to dimethylpolysiloxane. Experimental study in mice. Plast. Reconstr. Surg., 36(6), 629-631. 22. Rees, T.D., Platt, J., and Ballantyne, D.L. (1965) An investigation of cutaneous response to dimethylpolysiloxane (silicone liquid) in animals and humans - A preliminary report. Plast. Reconstr. Surg., 35(2), 131-139. 23. Travis, W.D., Balogh, K. and Abraham, J.L. (1985) Silicone granulomas: Report of three cases and review of the literature. Hum. Pathol, 16(1), 19-27. 24. Mason, J. and Apisarnthanarax, P. (1981) Migratory silicone granuloma. Arch. Dermatol, 117, 366-367. 25. Apesos, J. and Pope, T.L., Jr (1985) Silicone granuloma following closed capsulotomy of mammary prosthesis. Ann. Plast. Surg., 14(5), 403-406. 26. Rees, T.D., Ballantyne, D.L., Seidman, I. et al. (1967) Visceral response to subcutaneous and intraperitoneal injections of silicone in mice. Plast. Reconstr. Surg., 39(4), 402-410. 27. Chastre, J., Basset, F., Viau, F. et al. (1983) Acute pneumonitis after subcutaneous injections of silicone in transsexual men. JV. Engl. J. Med., 308(13), 764-767. 28. Ellenbogen, R. and Rubin, L. (1975) Injectable fluid silicone therapy: Human morbidity and mortality. /. Am. Med. Assoc, 234(3), 308-309. 29. Murakata, L.A. and Rangwala, A.F. (1989) Silicone lymphadenopathy with concomitant malignant lymphoma. /. Rheumatol, 16(11), 1480-1483. 30. Christie, A.J., Weinberger, K.A. and Dietrich, M. (1977) Silicone lymphadenopathy and synovitis. Complications of silicone elastomer finger joint prostheses. /. Am. Med. Assoc, 237(14), 1463-1464. 31. Kircher, T. (1980) Silicone lymphadenopathy. A complication of silicone elastomer finger joint prostheses. Hum. Pathol, 11(3), 240-244.

32. Benjamin, E. and Ahmed, A. (1982) Silicone lymphadenopathy: A report of two cases, one with concomitant malignant lymphoma. Diagn. Histopathol, 5, 133-141. 33. Digby, LM. (1982) Malignant lymphoma with intranodal silicone rubber particles following metacarpophalangeal joint replacements. Hand, 14(3), 326-328. 34. Endo, L.P., Edwards, N.L., Longley, S. et al. (1987) Silicone and rheumatic diseases. Semin. Arthritis Rheum., 17(2), 112-118. 35. Varga, J., Schumacher, H.R. and Jimenez, S.A. (1989) Systemic sclerosis after augmentation mammoplasty with silicone implants. Ann. Intern. Med., 111(5), 377-383. 36. Uretsky, B.F., O'Brien, JJ., Courtiss E.H. et al. (1979) Augmentation mammaplasty associated with a severe systemic illness. Ann. Plast. Surg., 3(5), 445-447. 37. Nosanchuk, J.S. (1968) Injected dimethylpolysiloxane fluid: A study of antibody and histologic response. Plast. Reconstr. Surg., 42(6), 562-566. 38. Heggers, J.P., Kossovsky, N. and Parsons, R.W. et al. (1983) Biocompatibility of silicone implants. Ann. Plast. Surg., 11, 38-45. 39. Pernis, B. and Paronetto, F. (1962) Adjuvant effect of silica (tridymite) on antibody production. Proc. Soc. Exp. Biol. Med., 110, 390-392. 40. Miyoshi, K., Miyamura, T. and Kobayashi, Y. (1964) Hypergammaglobulinemia by prolonged adjuvanticity in man. Disorders developed after augmentation mammaplasty. Jpn Med. J., 2122, 9. 41. Yoshida, K. (1973) Post mammaplasty disorder as an adjuvant disease of man. Shikoku Acta Med, 29, 318. 42. Kumagai, Y., Abe, C. and Shiokawa, Y. (1979) Scleroderma after cosmetic surgery. Four cases of human adjuvant disease. Arthritis Rheum., 22(5), 532-537. 43. Kumagai, Y., Shiokawa, Y. and Medsger, T.A., Jr (1984) Clinical spectrum of connective tissue disease after cosmetic surgery. Arthritis Rheum., 27(1), 1-12. 44. Fock, K.M., Feng, P.H., Tey, B.H. (1984). Autoimmune disease developing after augmentation mammoplasty: Report of 3 cases. /. Rheumatol, 11(1), 98-100. 45. Okano, Y., Nishikai, M. and Sato, A. (1984) Scleroderma, primary biliary cirrhosis, and Sjogren's syndrome after cosmetic breast augmentation with silicone injection: A case report of possible human adjuvant disease. Ann. Rheum. Dis., 43, 520-522. 46. van Nunen, S.A., Gatenby, P.A. and Basten, A. (1982) Post-mammoplasty connective tissue disease. Arthritis Rheum., 25(6), 694-697. 47. Baldwin, CM., Jr, and Kaplan, E.N. (1983) Silicone-induced human adjuvant disease? Ann. Plast. Surg., 10, 270-273. 48. Byron, M.A., Venning, V.A. and Mowat, A.G. (1984) Post-mammoplasty human adjuvant disease. Br. J. Rheumatol., 23(3), 227-229. 49. Vargas, A. (1979) Shedding of silicone particles from inflated breast implants. Plast. Reconstr. Surg., 64(2), 252-253. 50. Walsh, F.W., Solomon, D.A., Espinoza, L.R. et al. (1989) Human adjuvant disease. A new cause of chylous effusions. Arch. Intern. Med., 149,1194-1196. 51. Ziegler, V.V., Haustein, U.F., Mehlhorn, J. et al. (1986) Quarzinduzierte sklerodermie sklerodermie-ahnliches syndrom oder echte progressive sklerodermie? Dermatol Mon. Schr., 172(2), 86-90.

52. Taura, N., Usa, T. and Eguchi, K. (1976) A case of human adjuvant disease. /. Jap. Soc. Intern. Med., 65, 840-841. 53. Alusik, S., Jandova, R. and Gebauerova, M. (1989) Anticardiolipin syndrome in plastic surgery of the breast. Cor. Vasa, 31(2), 139-144. 54. Olesen, L.L., Ejlertsen, T. and Nielsen, J. (1991) Toxic shock syndrome following insertion of breast prostheses. Br. J. Surg., 78(5), 585-586. 55. Spiera, H. (1988) Scleroderma after silicone augmentation mammoplasty. /. Am. Med. Assoc, 260(2), 236-238. 56. Brozena, S.J., Fenske, N.A., Cruse, CW. et al. (1988) Human adjuvant disease following augmentation mammoplasty. Arch. Dermatol, 124, 1383-1386. 57. Gutierrez, FJ. and Espinoza, L.R. (1990) Progressive systemic sclerosis complicated by severe hypertension: Reversal after silicone implant removal. Am. J. Med., 89(3), 390-392. 58. Hitoshi, S., Ito, Y., Takehara, K. et al. (1991) A case of malignant hypertension and scleroderma after cosmetic surgery. Jpn J. Med., 30(1), 97-100. 59. Sahn, E.E., Garen, P.D., Silver, R.M. et al. (1990) Scleroderma following augmentation mammoplasty. Report of a case and review of the literature. Arch. Dermatol, 126, 1198-1202. 60. Deapen, D.M., Pike, M.C., Casagrande, J.T. et al. (1986) The relationship between breast cancer and augmentation mammaplasty: An epidemiologic study. Plast. Reconstr. Surg., 77(3), 361-367. 61. May, D.S. and Stroup, N.E. (1991) The incidence of sarcomas of the breast among women in the United States, 1973-1986. Plast. Reconstr. Surg., 87(1), 193-194. 62. Fletcher, R.H., Fletcher, S.W. and Wagner, E.H. (1988) Cause. In: Collins, N., Eckhart, C, Chalew, G.N., eds. Clinical Epidemiology: The Essentials. Baltimore: Williams & Wilkens, pp. 208-225. 63. Pearson, CM. (1963) Experimental joint disease. Observations on adjuvantinduced arthritis. /. Chron. Dis., 16, 863-874. 64. Dugowson, CE., Daling, J., Koepsell, T.D. et al (1992) Silicone breast implants and risk for rheumatoid-arthritis. Arthritis Rheum., 35, S66. (Abstract) 65. Gabriel, S.E., O'Fallon, W.M., Kurland, L.T. et al. (1994) Risk of connectivetissue diseases and other disorders after breast implantation. Af. Engl J. Med., 330, 1697-1702. 66. Hochberg, M.C, Perlmutter, D.L., White, B. et al. (1994) The association of augmentation mammoplasty with systemic sclerosis: Results from a multi-center case-control study. Arthritis Rheum., 37 (Supplement): S369 (Abstract). 67. Strom, B.L., Reidenberg, M.M., Freundlich, B. et al. (1994) Breast silicone implants and risk of systemic lupus erythematosus. /. CHn. Epidemiol, (in press). 68. Englert, H.J., Brooks, P. (1994) Scleroderma and augmentation mammoplasty - a causal relationship? Aust. NZ J. Med., 24, 74-80. 69. Burns, CJ., Laing, TJ., Gillespie, B.W. et al. (1996) The epidemiology of scleroderma among women: Assessment of risk from exposure to silicone and silica. /. RheumatoL, 23(11), 1904-1911. 70. Sanchez-Guerrero, J., Karlson, E.W., Colditz, G.A. et al. (1994) Silicone breast implants (SBI) and connective tissue disease (CTD). Arthritis Rheum, 37 (Supplement): S282 (Abstract).

71. Tan, E.M., Cohen, A.S., Fries, J.F. et al. (1982) The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum, 25 (11), 1271-1277. 72. Schottenfeld, D., Burns, CJ., Gillespie, B.W. et al (1995) The design of a population-based case-control study of systemic sclerosis (scleroderma): Commentary on the University of Michigan Study. /. CHn. Epidemiol. 48(4), 583-586.

Index
Page numbers in bold refer to figures; those in italics refer to tables

Index terms A
A-S/3501 graphite/epoxy aging moisture effects Above knee tissues, elastic moduli Adhesion bioglass titanium alloys Age of donors, cortical bone Al2O3 whisker-nickel, tensile properties Allografts Alloys AgPd galvanic NiCr chemical composition corrosion resistance properties Pd precious metal bonding with ceramics brazing casting heat treatment 142 142 5 265 62 427 207 427 212 213 212 213 207 208 209 209 208 208 259 259 67

Links

428 211 213

211 208

This page has been reformatted by Knovel to provide easier navigation.

573

574

Index terms
Alumina ceramic hip balls chemical properties clinical performance dental implants engineering properties implants physical properties standards wear resistance Aluminum/graphite, tensile strengths Aluminum/silicon, tensile data Aluminum/Thornel, mechanical properties Amalgamization Amalgams chemical composition copper content corrosion and wear high copper type mercury vapour release mixed alloys one-component processing properties Amino plastics, properties Annulus fibrosus Antibiotics, metal interactions Antibodies antiserum 343 341 343 345 341 344 340 343 344 343 263 264 263 202 201 201 202 204 203 204 204 202 202 203 201 248 49 435 514 516

Links

345 264

201

203

204

201 53

203

This page has been reformatted by Knovel to provide easier navigation.

575

Index terms
Antibodies (Continued) detecting in vivo testing negative results positive results immunoglobins Antigens immobilization processing cell Antioxidants additives low toxicity synergism Aorta compliance hydrodynamic properties morphometric properties pressure/cross-sectional area retraction tapered Apatite parameters dentin enamel Aramid fibers disadvantages Arc welding filler metals Arterial tissues change with age composition 83 85 28 28 216 216 155 155 91 91 82 91 91 82 258 255 258 515 517 517 517 515 513 516 513

Links
516

516

92

217

87

This page has been reformatted by Knovel to provide easier navigation.

576

Index terms
Arterial wall, composition Arteries coronary, tensile properties creep elastic modulus hypertension mechanical properties morphometric properties Reynolds number stress relaxation tensile properties Articular cartilage composition compression lubrication mechanical properties permeability Poissons ratio shear properties tensile properties tribologic properties wear tests Artificial saliva, repassivation rates Asceptic loosening Atherosclerosis Austenitic steels chemical composition machining 146 152 93 94 90 85 88 93 82 82 94 92 40 41 41 44 41 44 44 43 42 44 45 195 507 85 82 85

Links
82 86 83 87 84 88

95 87 89 94 90 91

95 93

42

43 43

203 88 148 150

This page has been reformatted by Knovel to provide easier navigation.

577

Index terms
Austenitic steels (Continued) parameters Autoclave molding Autoimmune diseases 153 230 524

Links

B
B/5505 boron/epoxy aging moisture effects Basal ganglia Below knee tissues Bending modulus, osteons Bioactive bonding ceramics, orthopaedics compositions glasses bone bonding clinical uses physical properties Bioactivity definition index Bioceramics ASTM standards biocompatibility dental applications failure loads ISO standards manufacturers 355 357 340 349 348 351 357 349 351 355 406 357 355 361 362 358 359 362 356 357 259 259 70 68 8 8

This page has been reformatted by Knovel to provide easier navigation.

578

Index terms
Bioceramics (Continued) orthopaedic applications trade names Biocompatibility components control of definition local host response material degradation Biological degradation animal experiments calcium phosphate clinical applications properties cobalt/chromium alloys titanium Biomaterials, systemic effects Biospan Biospan-D Biospan-S Blastogenic factor Blood and cardiovascular devices coagulation, proteins metals in physiochemical properties velocity vessels atherosclerosis 177 197 488 315 328 328 518 114 547 122 430 115 82 81 99 410 410 411 410 351 351 481 484 487 482 486 484

Links

487

411 416

416

177 197

This page has been reformatted by Knovel to provide easier navigation.

579

Index terms
Blood (Continued) changes with age hypertension transport properties Blood/materials interactions Bone cement formation, interfacial Bone/biomaterial interfaces Boron fibers application manufacturing technique properties Bovine bone, creep Brain tissues bulk modulus composition creep modulus density diffusion properties dimensions elastic modulus electrical conductivity mass mechanical stimuli Poissons ratio shape shear modulus stem thermal properties 500 358 507 217 217 218 218 10 70 72 71 72 72 77 71 72 77 71 71 72 71 72 70 77 99 99 98 545

Links

98

509 218

75

73 77

73 77

This page has been reformatted by Knovel to provide easier navigation.

580

Index terms
Breast augmentation scleroderma subsequent diseases causes systemic sclerosis Breast implants and connective tissue disease rheumatoid arthritis silicone systemic lupus erythematosus Brittle fiber.Sic, properties Bulk modulus, brain tissues 563 565 566 565 268 72 558 566 558 559 560

Links

562

564

C
C-Flex TPE Ca/P molar ratio dentin enamel Calcium phosphates, and metallic ions Cancellous bone Cancer and metallic implants Capillaries, morphometrics Carbon fiber precursors properties trade names Carbon prostheses, mechanical properties of Carbon/silicon nitride, properties 218 218 218 260 267 28 28 446 449 15 529 539 82 447 447 448 333

This page has been reformatted by Knovel to provide easier navigation.

581

Index terms
Carbons atomic arrangement biocompatibility charcoal composites filament wound dental applications fibers forms, mechanical properties glassy in vivo medical applications orthopaedics polymeric pyrolitic low-temperature structures vapour phase coatings vascular applications Carbothane Cardiac valves Cardiovascular devices, and blood Cartilage articular composition elastic mechanical properties fibrocartilage hyaline water content 464 466 464 465 465 471 472 465 473 465 472 473 474 465 465 468 464 465 472 330 550 547 40 40 40 41 45 41 40 40

Links

471

470 469

467 469 470

468 474

41

This page has been reformatted by Knovel to provide easier navigation.

582

Index terms
Catheters Causal association analogy biologic plausibility consistency dose-response reversibility specificity strength temporality CCR50 Cell adaptation cultures testing mediated immunity responses choice of test migration inhibition Cellular necrosis Cement line, cortical bone Cement-free implants hip prostheses knees orthopaedic Cementation Centrifugal casting molding 229 236 520 517 518 518 491 4 501 503 503 503 500 496 415 415 562 562 562 562 562 562 562 562 139 548

Links

562 562 562 562 562 562 562 562

502

503

501

502

This page has been reformatted by Knovel to provide easier navigation.

583

Index terms
Centrifuga (Continued) release agents Ceramics calcium phosphate flexural strength fracture toughness glass hip balls physical properties processing Cerebellum Cerebrospinal fluid inorganic content organic content protein content Cerebrum Chemical vapour deposition Chromium corrosion immunity passivation ChronoFlex Cluster differentiation markers Co20Crl5W10Ni, cold working Co20Cr35NilOMo, heat treatment Co29Cr5Mo corrosion formation nitrogen ion implantation pH value 176 177 175 422 422 422 316 514 174 174 236 266 406 268 268 267 341 358 348 70 70 117 118 119 70 471

Links

267

268

359

362

115

This page has been reformatted by Knovel to provide easier navigation.

584

Index terms
Co-based alloys chemical composition international standards physical properties wrought chemical composition Coatings corrosion currents HAp hard ceramic metallic niobium tantalum titanium ultra-thin Cobalt/chromium alloys arc welding biocompatibility biological properties biomedical devices brazing cast drilling parameters mechanical properties milling parameters turning parameters casting temperature classifying corrosion and wear drilling 171 173 171 171 169 169 175 170 167 167 169 170 168 440 443 443 446 442 440 441 441 441 550 167 172 177 177 169 172

Links

441 444 446

442 445 448

443 445

172 177

175 171

176

This page has been reformatted by Knovel to provide easier navigation.

585

Index terms
Cobalt/chromium alloys (Continued) fatigue grinding lethal concentrations machining milling polarization current polarization resistance processing repassivation time sawing thermal conductivity turning wrought drilling parameters milling turning Collagen content, cartilage cortical bone immune response to shrinkage temperature Collagen/elastin ratio Combined loading, cortical bone Composites classifying fabrication fibrous laminar in medicine 40 3 522 3 86 9 214 214 229 214 214 260 171 171 171 174 172 177 170 170 176 176 169 176 170 170 170

Links
174 177 171 171 175

171

This page has been reformatted by Knovel to provide easier navigation.

586

Index terms
Composites (Continued) metal matrix particulate radiation resistance reinforcements Compression articular cartilage cortical bone modulus cortical bone osteons Compressive strength dentin enamel Connective tissue disease, and breast implants Contact angles equilibrium oxidized surfaces Contamination of tissues Continuous sheets decorative glass reinforcement Coremer Corethane Corhesive Corrosion contamination of tissues detection of ions duration of implantation grading scale 31 30 563 457 458 458 429 238 239 238 316 316 316 420 429 421 428 421 6 8 41 8 262 214 257 262

Links

42

564 458

This page has been reformatted by Knovel to provide easier navigation.

587

Index terms
Corrosion (Continued) incidence of materials purity proteins Ti-15Zr-4Nb-2Ta-0.2Pd and wear cobalt/chromium alloys noble metals Cortical bone age of donors collagen combined loading compression compressive modulus constituents creep density dry testing elastic moduli electromechanical behaviour fatigue health of donors mineral mineralization physical properties Poissons ratios remodelling shear moduli small specimens stiffness 421 423 435 425 194 197 175 211 3 5 3 9 8 6 3 10 4 5 7 4 11 5 4 6 4 7 11 7 7 6

Links

438 194 175 195 176 196

10

12

This page has been reformatted by Knovel to provide easier navigation.

588

Index terms
Cortical bone (Continued) strain rate effects strength tensile modulus time to failure viscoelastic damage Youngs modulus cp-titanium, chemical composition Creep bovine bone cortical bone modulus, brain tissues Critical surface tension dentin enamel Curing agents amine anhydride accelerators epoxide resins polyamide Cytokines, testing for 222 222 223 222 223 519 10 10 72 458 35 35 8 10 9 6 11 9 7 180

Links
10

75

D
DAP, properties Debris accumulation metallic 530 531 247

This page has been reformatted by Knovel to provide easier navigation.

589

Index terms
Definitions bioactivity biocompatibility elastomers ligament osseointegration ply repassivation solubility tendon thermoplastic resins thermoset resins tribosystem Degradation Density brain tissues cortical bone Dental alloys AgPd composition of high gold containing low gold containing Pd precious amalgams implants restoration Dentin apatite in 207 205 205 206 207 208 135 135 201 24 28 72 4 355 482 302 59 504 225 138 407 59 220 220 395 530

Links

530

206 210 210

136

142

This page has been reformatted by Knovel to provide easier navigation.

590

Index terms
Dentin (Continued) Ca/P molar ratio constituents elastic moduli elemental composition viscoelastic properties Dentino-enamel junction (DEJ) Diamond Diaphysis, vs. metaphysis Diencephalon Diffusion properties, brain tissues Diluents non reactive reactive Dimethypolysiloxane Dissolution, in vitro Donor age, soft tissues Doppler results Drag coefficients, menisci Drug delivery, implantable Dry testing, cortical bone 28 25 29 25 29 24 469 9 70 77 222 222 222 556 407 61 66 51 483 5

Links

67

E
Ear bones ECDEL Elastic behaviour blood vessels lymphatic vessels cartilage 81 81 41
This page has been reformatted by Knovel to provide easier navigation.

6 308

591

Index terms
Elastic (Continued) properties in vertebral discs menisci trabecular bone Elastin/collagen ratio Elastomers ASTM standards biocompatibility copolyester manufacturers properties trade names crosslinked definition dispersions manufacturers properties trade names equivalent silicone HC silicone manufacturers properties trade names LIM silicone manufacturers properties trade names polypropylene-based manufacturers 309 321 321 321 320 320 320 322 322 322 334 334 305 305 305 319 302 51 51 18 86 303 338 302

Links

52 52

337 325 339

335

This page has been reformatted by Knovel to provide easier navigation.

592

Index terms
Elastomers (Continued) properties trade names polyurethane polyurethane-based manufacturers properties trade names PVC silicone high consistency LIM silicone adhesives manufacturers properties trade names sterilization methods styrene-based manufacturers properties trade names thermoplastic types of water absorption Electrical conductivity, brain tissues Electromechanical behaviour, cortical bone Elemental composition dentin enamel 25 25 313 313 313 305 305 333 77 4 324 324 324 338 331 309 309 312 309 306 306 306 317 319 319 319

Links

77

This page has been reformatted by Knovel to provide easier navigation.

593

Index terms
Elemental composition (Continued) surface enamel whole enamel Enamel apatite in apatite parameters Ca/P molar ratio compressive strength critical surface tension elastic moduli elemental composition fracture toughness hardness of fracture mineral density organic density stress surface, elemental composition tensile strength toughness water density wettability whole, elemental composition work of fracture Endoprostheses hip knee Environmental stress cracking Epoxy resins curing agents description 221 250 135 135 273 26 26 24 28 28 28 30 35 29 25 32 33 25 25 30 26 30 32 25 34 27 32

Links

222

This page has been reformatted by Knovel to provide easier navigation.

594

Index terms
Epoxy resins (Continued) end uses properties Equivalence Experimental problems, trabecular bone Failure strains, trabecular bone 250 254 334 18 18

Links

21

F
Fascia Fatigue cobalt/chromium alloys cortical bone porosity stainless steels and wear Youngs modulus Female, fluid volume Femoral articulating surface Fiber-reinforced plastic pipe Fiberglass, properties Fibrocartilage anisotropy composition mechanical properties structure Fibrosis Filament winding storage tanks 59 189 192 174 11 11 161 393 11 120 48 229 248 41 48 48 45 48 494 233 235 49 50 49 50 48 161 162 189 193 174 175 190 191

This page has been reformatted by Knovel to provide easier navigation.

595

Index terms
Fillers brazing temperatures chemical composition Flexural strength, dentin Fluid volume female male Fracture toughness dentin enamel Fractures, internal fixation, malignancies Friction coefficients, implants Furnace brazing, stainless steels 32 32 537 372 153 120 120 209 209 31

Links

G
Glass ceramics clinical uses physical properties Glass fibers advantages chemical composition electrical properties grades mechanical properties optical properties physical properties thermal properties Glassy carbons fabrication mechanical properties 355 362 358 215 215 215 216 215 216 216 216 216 469 469 261 359 215 362 216

This page has been reformatted by Knovel to provide easier navigation.

596

Index terms
Glassy carbons (Continued) shrinkage Graphite fibers Graphite-fiber-reinforced thermoplastics, properties Graphites colloidal manufacturing processes natural synthesized 245 468 468 468 468 468 469 218

Links

218

H
Hand lay-up HAp bioresorption degradation dissolution rate from marine coral highly porous precipitation seeds Haptens, immune response to Haversian remodelling systems HDPE, properties Health of donors, cortical bone Heart pacemakers valves 137 464 467 11 4 252 5 229 407 414 410 408 413 413 448 449 521

This page has been reformatted by Knovel to provide easier navigation.

597

Index terms
Hip endoprostheses, fatigue strength replacement, accelerated test data Histochemical techniques Human adjuvant disease calf, stress relaxation dentition, structure of Hyaline cartilage Hydraulic conductivity, blood vessels permeability, menisci Hydrocarbon polymers, stability Hydrophilic polymers Hydrothane Hydroxy carbonate apatite rate of formation Hydroxy apatite, see HAp Hydroxyl radical Hypertension 141 85 81 51 258 548 312 357 357 558 67 24 40 162 261 520

Links

87

I
Iliac vessels Immune complex reactions responses implants Implant surgery cold deformation wire, mechanical properties 161 160 515 523 513 98

This page has been reformatted by Knovel to provide easier navigation.

598

Index terms
Implants alumina bone, in situ calcium deposition cancer carcinogenicity cement-free cemented dental exposure time friction coefficients hard tissue response immune response metallic corrosion surface roughness oral orthopaedic osseointegrated penetration rates porous retrieved site repairs tribological conditions tribological properties Inflammation characteristics chronic Ingrowth behaviour 420 142 508 508 501 394 143 430 495 372 395 492 492 492 141 340 502 447 529 532 501 501 142 142 372 500 513

Links

447

502

503

503

504

431 380 493 493

This page has been reformatted by Knovel to provide easier navigation.

599

Index terms
Injection molding advantages Intraocular lens, see lens Invertebral discs adult shape size annulus fibrosus elastic properties nucleus pulposus shape stiffness strength viscoelastic behaviour Ion implantation nitrogen in titanium Ischemia 50 50 49 51 49 49 53 53 53 138 138 547 48 232 232

Links

52 50

54

J
Joint replacements associated malignancies coefficient of friction tribological conditions wear factor 534 398 398 398 536

K
Kevlar 49 electrical properties mechanical properties shear properties 216 252 217 251

This page has been reformatted by Knovel to provide easier navigation.

600

Index terms
Kevlar 49 (Continued) thermal properties Kraton 217 318

Links
252

L
Laminates angle ply properties Large veins, morphometric properties Latex, immune response to LDPE, properties Lead/graphite, properties Length, arteries Lens capsule, mechanical properties cataractous chemical composition composition density dimensions changes with age force of contraction inorganic ions content optical properties organic content refractive index spring constants thickness of capsule translenticular properties Ligaments 227 225 82 521 252 266 82 106 111 110 107 106 110 109 109 111 108 109 109 110 111 109 111 474
This page has been reformatted by Knovel to provide easier navigation.

108

109

601

Index terms
Linear low density polyethylene LTI carbon, mechanical properties Lubrication Lymph inorganic content organic content Lymphocyte proliferation transformation factor Lymphokines, testing for 117 118 514 518 518 519 273 261 395

Links

M
Macrophage migration inhibition Magnesium/graphite, mechanical properties Male, fluid volume Malignancies, osseous Malignant fibrous histiocytoma (MFA) Martensitic steels chemical composition machining parameters Mass, brain tissues Matched die molding Materials pre-screening and tissue interaction Matrix, materials Measuring, soft tissues Mechanical stimuli, brain tissues Medicaflex 429 486 219 61 71 313
This page has been reformatted by Knovel to provide easier navigation.

558 266 120 538 532 146 152 153 71 230 538 147

262

602

Index terms
Membranes Menisci Mesencephalon Metal cations, uptake efficiencies inert gas welding (MIG) oxides, physico-chemical properties Metallic biomaterials adhesion strength bioadhesion biocompatibility corrosion measurements densities inorganic reaction organic reaction polarization resistance repassivation testing thermodynamic stability dissolution products implants and cancer corrosion passive films ions, and calcium phosphates materials alloys 424 539 420 452 456 446 449 135 136 139 136 140 137 137 140 140 137 138 137 141 445 431 172 449 550 48 70

Links

172 451

139

453 447

454 447

455 448

425

426

This page has been reformatted by Knovel to provide easier navigation.

603

Index terms
Metallic (Continued) in biological samples Metals in blood vessels immune response to thrombogenic Metaphysis, vs. diaphysis Mineral cortical bone density dentin enamel Mineralization, cortical bone Modulus soft tissues trabecular bone Morphometrics pulmonary arteries systemic circulation Muscle mechanical properties preservation and skin specimen preparation tissue handling 66 66 66 66 66 83 82 60 16 25 25 10 4 429 549 549 523 549 9

Links

60 19 20

67

68

N
Natural rubber Neoplasia malignant 319 531 531

This page has been reformatted by Knovel to provide easier navigation.

604

Index terms
Neutrophils Ni45Ti, properties Niobium Noble metals 492 198 140 204 208 212 corrosion and wear heat treatments polarization current polarization resistance Non-collagenous protein (NCP) Nucleus pulposus Nylons, properties 211 210 211 211 3 49 244

Links

205 209

206 210

207 211

O
Organic density dentin enamel Orientation of tissue, soft tissues Orthopaedics bioactive ceramics Osseointegration calcium phosphates ceramics craniofacial skeleton definition interfaces oral implants polymers press-fit fixation 25 25 61 406 406 501 506 506 505 504 505 505 506 506 503 504

This page has been reformatted by Knovel to provide easier navigation.

605

Index terms
Osseointegration (Continued) surface irregularities Ossicles see also ear bones Osteocalcin Osteolysis Osteonectin Osteons bending modulus compression modulus secondary strength tension modulus torsional modulus Osteosarcoma Oxide ceramics applications evaluation Oxide formation Co-Cr-Mo alloy 8 8 4 10 8 8 532 341 341 341 455 457 4 530 4 505 6

Links

530

8 8 8 8 8 8

457

P
PBT, properties PEEK characteristics chemical structure processing conditions properties trade names PEI, properties 247 219 282 287 295 241 299 242 282

This page has been reformatted by Knovel to provide easier navigation.

606

Index terms
Pellethane Permeability articular cartilage dentin PES PET chemical structure physical properties processing conditions properties trade names Petrosals see also temporal bones Phagocytosis frustrated Physical properties, cortical bone Physiochemical properties blood cerebrospinal fluid plasma synovial fluid tear fluid whole blood PIE Plasma concentration diffusion coefficient extinction coefficient half-life inorganic content 121 121 121 121 117 115 115 115 115 115 115 220 492 493 4 44 33 220 281 287 281 294 247 299 6 314

Links

This page has been reformatted by Knovel to provide easier navigation.

607

Index terms
Plasma (Continued) molecular weight organic content proteins content properties sedimentation constant Ply definition orientated rotated transverse, failure PMMA, properties Pneumonitis Poissons ratio articular cartilage brain tissues cortical bone trabecular bone Polamideimides Polarization resistance Polurethane, processing conditions Polyacetal chemical structure processing conditions solvents trade names Polyacrylates chemical structure processing conditions 44 72 7 18 219 194 292 279 286 294 280 299 278 286 293 225 226 226 228 251 557 119 121 121 121 118

Links

279

This page has been reformatted by Knovel to provide easier navigation.

608

Index terms
Polyacrylates (Continued) trade names Polyamide-imide, properties Polyamides aliphatic chemical structure processing conditions trade names Polyarylate, properties Polyblend, polyurethane Polycarbonate chemical resistance chemical structure processing conditions properties sheets, properties of trade names Polyester fiberglass-reinforced, properties properties Polyester resins accelerators catalysts Polyether sulfones, see PES Poly ether etherke tones, see PEEK Polyetherimides, see PEI Polyethylene chemical structure plastic, carcinogenicity processing conditions 272 285 533 291 254 249 224 224 224 298 243 219 277 286 293 298 243 314 219 281 286 294 281 242 299

Links

277

280

This page has been reformatted by Knovel to provide easier navigation.

609

Index terms
Polyethylene (Continued) trade names wear debris Polyfluorocarbons, properties Polyimides, properties Polymer/carbon, mechanical properties Polymers manufacturers trade names Polymethylmethacrylate carcinogenicity immune response to Polyphenylene sulfides, see PPS Polypropylene chemical structure processing conditions properties trade names Polysiloxane, immune response to Polysulfone characteristics chemical structure processing conditions properties trade names Polytetrafluoroethylene see also PTFE chemical structure processing conditions trade names 285 292 297 533 522 220 273 285 291 241 296 522 283 284 287 295 244 300 260 260 296 430 251 247 260

Links

This page has been reformatted by Knovel to provide easier navigation.

610

Index terms
Polyurethane chemical structure elastomers polycarbonate-based manufacturers properties trade names trade names Polyurethanes blood pumps immune response to ventricular assist devices Polyvinylchloride see also PVC chemical structure Porosity, fatigue Potential-pH diagrams limitations PPS fabric reinforced properties Preservation muscle skin Press-fit fixation knee replacement Prostheses, heart valves Proteins adsorption coagulation 484 122 66 66 506 506 261 231 243 286 11 421 422 548 522 548 308 308 308 297 274 285 275

Links

422

423

464

This page has been reformatted by Knovel to provide easier navigation.

611

Index terms
Proteins (Continued) complement system PTFE properties Pulmonary arteries, morphometrics Pultrusion PVC Elastichem elastomers Ellay Geon Multichem plasticized manufacturers properties trade names processing conditions Teknor Apex trade names unplasticized 122 275 252 83 239 276 317 317 317 318 318 277 310 310 310 293 318 298 277

Links

R
Rate of loading, soft tissues Reaction bonded silicon nitride, axial strength Reinforcement filaments manufacturing techniques properties Remodelling cortical bone Haversian 11 11 12 218 218 61 267

This page has been reformatted by Knovel to provide easier navigation.

612

Index terms
Remodelling (Continued) tensile strength ultimate strain Youngs modulus Repassivation, definition Residual compression, UHMWPE Resin system, choice of Resins cured polyester, properties epoxy description end uses polyester properties thermoplastic thermoset vinyl ester Resistance welding Responses allergic cell mediated cellular necrosis chemically induced hard tissue hypersensitivity immune local host minimal neoplastic pyhsically induced 513 517 491 490 500 513 491 486 490 491 491 249 221 250 250 224 248 220 220 221 155 12 12 12 138 393 236

Links

239

156

523 487

This page has been reformatted by Knovel to provide easier navigation.

613

Index terms
Responses (Continued) soft tissue silicone specific immune Retrieved implants oral Reynolds number aorta arteries capillaries vena cava Rheumatoid arthritis, breast implants 490 556 513 430 507 82 82 82 82 82 565

Links

431

S
Sand blasting Santoprene Sarlink Secondary, osteons Serum levels, total hip arthroplasty metal concentrations Shape brain tissues invertebral discs Shear modulus brain tissues cortical bone Shear properties articular cartilage dentin 43 31
This page has been reformatted by Knovel to provide easier navigation.

172 304 317 4 530 433 71 49 72 7 43 50 73 8 530 8 305

614

Index terms
Shielded metal arc welding (SMAW) Shrinkage temperature, collagen SiC/RBSN, axial strength Silicon nitride, properties Silicones breast implants cosmetic surgery granulomatous hepatitis immunologic reactions migration soft tissue response systemic reactions Sintering Skeletal reconstructions Skin elastic moduli forehead, indentation mechanical properties and muscle preservation specimen preparation testing tissue handling Sliding materials Soft tissues allografts autografts cross-sectional area donor age gauge length 66 67 66 66 66 66 520 66 176 59 62 62 59 61 59 566 557 557 556 557 556 557 426 135 172 3 267 267

Links

67

68

This page has been reformatted by Knovel to provide easier navigation.

615

Index terms
Soft tissues (Continued) indentation measuring modulus orientation of tissue rate of loading stiffness storage method strain at UTS energy density stress-strain curve test environment ultimate tensile strength (UTS) viscoelasticity Solubility calcium phosphate definition isotherms product constant Specific immune response Specimen preparation muscle skin Spray-up Stainless steels arc welding austenitic mechanical properties welding 158 156 66 66 229 145 155 408 407 409 407 513 60 60 60 61 60 62 67 61 60 61 61 67 61

Links

60

60 60

60

This page has been reformatted by Knovel to provide easier navigation.

616

Index terms
Stainless steels (Continued) brazing corrosion and wear descaling fatigue ferritic, welding heat treatment hardness hot working implant surgery mechanical properties international standards machining parameters martensitic mechanical properties welding medical instruments properties physical properties processing resistance welding sheet working welding X2CrNiMo17133, mechanical properties Sterilization Stiffness cortical bone invertebral discs Storage method, soft tissues 6 53 61 159 156 146 157 150 151 156 155 151 155 160 455 153 163 152 161 156 151 161 151 149 159 145 152 153

Links
154 163 161 157 164 162 160

153

147

150

153 157

154

155

155

This page has been reformatted by Knovel to provide easier navigation.

617

Index terms
Strain energy density, soft tissues rate, cortical bone Strength cortical bone invertebral discs osteons trabecular bone Stress dentin enamel relaxation human calf trabecular bone Stress-strain curve, soft tissues Structure, fibrocartilage Styrene polymer, properties Superalloy MA956 polarization curves Surface treatments Surfaces, blood contacting Surgery, tissue overheating Sutures absorbable mechanical properties Sweat corrosion in ISO, electrochemical parameters 434 436 483 262 67 18 60 48 246 442 443 440 443 551 507 31 30 9 53 10 16 60 8

Links
60 10

19

20

49

50

441 444

442 445

443 445

436

This page has been reformatted by Knovel to provide easier navigation.

618

Index terms
Synovial fluid cellular composition inorganic content metallic concentrations organic content protein content Synthetic polymers, immune response to Systemic circulation, canine, morphometric properties sclerosis 84 558 115 116 117 433 118 119 522

Links

560

T
T cytoxic cell Ta-oxide Tantalum corrosion resistance pentoxide, thickness TCP bioresorption degradation dissolution rate Tear fluid inorganic content organic content protein content Tecoflex, polyurethane Tecothane Teknor Apex Temporal bones 115 117 118 119 314 315 318 6 514 140 140 426 440 407 414 410 408 425

This page has been reformatted by Knovel to provide easier navigation.

619

Index terms
Tendons definition Tensile modulus annulus fibrosus cortical bone menisci modulus articular cartilage strength dentin enamel menisci remodeling Tension, modulus, osteons Test environment, soft tissues Texin Thermal properties, brain tissues Thermoforming Thermoplastics amorphous biocompatibility branching mechanical properties molecular weight physical properties processability states of thermal properties vulcanizates manufacturers 31 30 51 12 8 61 315 77 231 219 272 272 271 288 271 288 270 271 289 304 305 53 6 52 42 59 59

Links
474

43

52 8

77 270

305

This page has been reformatted by Knovel to provide easier navigation.

620

Index terms
Thermoplastics (Continued) properties trade names Thornel/Kevlar, properties Thromboembolism Thromboresistance Thrombus Ti6A14V ageing fatigue strength fretting corrosion notch factor pin-on-disk test plasma nitriding rotating bending failure rotating bending strength solution treatment wear properties Ti-6Al-4V contact angles depassivation dissolution electrochemical characteristics femural components laser surface alloying passivity currents and pure titanium, implants Ti-6Al-4V-28 v/o SiC, tensile properties Ti-6Al-4V-50 v/o BORSIC, properties Ti-15Zr-4Nb-2Ta-0.2Pd 458 442 445 437 432 441 439 445 265 265 425 188 190 196 190 196 189 193 191 188 197 305 306 253 547 551 546

Links

547

192

193

439

This page has been reformatted by Knovel to provide easier navigation.

621

Index terms
Time to failure, cortical bone Tissues density, trabecular bone granulation handling muscle skin metals in vascularized TiTa30 thermal coefficient Titanium accumulation alloys biological properties chemical composition corrosion and wear fatigue fracture toughness friction data hip endoprostheses mechanical properties physical properties wear data anodic, electrochemical data anodized, corrosion rate biological properties cold deformation corrosion 66 66 430 494 136 136 140 430 179 197 180 194 197 189 192 188 396 190 187 180 396 195 438 197 186 423 15 494 11

Links

433 494

179 430 197 194 189 193 195 190 196 191

188 180 181

439 197

This page has been reformatted by Knovel to provide easier navigation.

622

Index terms
Titanium (Continued) formation resistance and wear cutting deformation temperatures descaling dissolution fatigue galvanic corrosion hot working immunity implant in bone international standards machining mechanical properties milling oxide films sterilization thickness passivation corrosion rate physical properties plates polarization current processing pure 456 455 440 423 438 180 141 194 181 197 436 194 197 184 182 183 452 189 192 195 181 423 453 179 183 186 189 184

Links

437 194

437 195 196

454 189 193 182 190 191

184 186 187 188

439 180 181

182

184

This page has been reformatted by Knovel to provide easier navigation.

623

Index terms
Titanium (Continued) physical properties potential-time curves repassivation time sheet working soldering and brazing surface characteristics thermal heating wear properties welding Torsional modulus, osteons Total hip arthroplasty cancer risk endoprosthesis replacements Toughness dentin enamel Toxicity additives plasticizers polymer stabilizers Trabecular bone composition elastic properties experimental problems failure strains mechanical properties modulus 255 255 255 15 16 18 18 18 15 16 32 32 393 539 341 139 180 437 194 183 185 456 444 197 185 8

Links

196

8 530 530

21

19

20

This page has been reformatted by Knovel to provide easier navigation.

624

Index terms
Trabecular bone (Continued) Poisson's ratio strength stress relaxation tissue density viscoelastic properties volume fraction Youngs modulus Transfer molding Tribologic properties, articular cartilage Tribosystem, definition Tricalcium phosphate, see TCP Tubing Tumorigenesis, solid state Tumors analysis of implant-related prosthetic replacement titanium implant Tungsten inert gas welding (TIG) 536 533 537 537 172 548 492 18 16 18 15 18 15 16 232 44 395

Links

19

20

19

20

537

172

U
UHMWPE Ultimate strain, remodeling stress, annulus fibrosus tensile strength (UTS), soft tissues Ultra high molecular weight polyethylene, see UHMWPE Urine, metal concentrations Usui process 433 238 12 53 60 60 273

This page has been reformatted by Knovel to provide easier navigation.

625

Index terms V
Vanadium Vapor-deposited carbon, mechanical properties Vapour phase coatings Vascular grafts Vascular wall, layers Veins canine jugular human saphenous mechanical properties tensile properties Vena cava, morphometric properties Venous tissues changes with age constituents Ventricular system Vinyl ester resins Viscoelastic behaviour invertebral discs menisci damage, cortical bone properties, trabecular bone Viscoelasticity quasi-linear soft tissues Vitallium Vitreous body age of protein content animal 62 62 136 125 128 126 53 53 9 18 88 88 70 221 96 96 96 97 82 136 261 465 552 89

Links

470

96 97

97

89 88

54 54

537

This page has been reformatted by Knovel to provide easier navigation.

626

Index terms
Vitreous body (Continued) axial length compliance gel and liquid volume inorganic ions content nature of organic content physical properties radiation rheology viscosity water content Vitreous humor, see vitreous body Volume fraction, trabecular bone 15 128 129 128 127 125 127 126 129 129 129 125

Links

W
Wall thickness Water content, cartilage density dentin enamel permeability, blood vessels Wear abrasive Rabinowicz model Zum Gahr model adhesive Archard equation Hornbogen equation artificial joints 25 25 81 364 365 367 367 365 366 366 364 82 40

This page has been reformatted by Knovel to provide easier navigation.

627

Index terms
Wear (Continued) ASTM standards clinical corrosive Quinn model debris, release of delamination fatigue Hailing model fretting problems rates testing in vitro machines test apparatus Welding diffusion electron beam spot Wet lay-up Wettability dentin enamel Whole blood cellular composition inorganic content organic content Whole enamel, elemental composition 116 117 118 26 35 34 369 371 370 185 186 186 186 234 371 393 365 368 487 365 365 368 365 394 380

Links

393

This page has been reformatted by Knovel to provide easier navigation.

628

Index terms
Work of fracture dentin enamel Wounds, healing 32 32 494

Links

X
X2CrNiMol7133 corrosion production electrochemical data fatigue limit heat treatment mechanical properties polarization current polarization resistance repassivation time shear strength wear testing 163 164 161 165 160 163 163 164 165 164

Y
Youngs modulus cortical bone fatigue remodeling trabecular bone 7 11 12 16 19 20

Z
Zinc, mechanical properties Zinc/graphite, mechanical properties Zirconia biocompatibility 266 266 345 349 346 347

This page has been reformatted by Knovel to provide easier navigation.

629

Index terms
Zirconia (Continued) chemical stability clinical performance engineering properties fracture toughness mechanical properties partially stabilized standards tetragonal polycrystals wear resistance 347 348 344 346 342 345 344 345 347

Links

346

This page has been reformatted by Knovel to provide easier navigation.