JOURNEY II

Active Knee Solutions

 

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Caution: US Federal law restricts the sale of these devices to or on the order of a physician.

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JOURNEY II Active Knee Solutions family of knee replacement products

Active Knee Solutions

For orthopaedic surgeons seeking treatment solutions beyond traditional knee replacements, JOURNEY II Active Knee Solutions has been engineered to empower patients with a renewed right to an active lifestyle by breaking through traditional knee replacement barriers and delivering  Function, Motion, and Durability through PHYSIOLOGICAL MATCHING

Total Knee Arthroplasty Solutions:

JOURNEY BCS

JOURNEY II BCS 

JOURNEY II CR

Partial Knee Solutions:

JOURNEY PFJ

JOURNEY UNI

 

PHYSIOLOGICAL MATCHING for Function, Motion, and Durability:

Function:

Stability

Anatomic, articular surfaces are designed to help restore native anatomy and yield a normal anatomic A/P position throughout the range of motion. 

Strength

More normal muscle firing patterns are expected due to proper A/P positioning, thereby helping to prevent muscle fatigue during activities of daily living.

Satisfaction

Improving patients’ ease of activities of daily living can be expected due to the anticipated improvements of strength and stability. 

Motion:

Flexion

The normal kinematic patterns of movement provide the correct environment to allow an anatomic, deep flexion performance. 

Kinematics

Tibiofemoral

  • Extension
  • Mid-Flexion
  • Deep Flexion

Patellofemoral

  • Provides improved contact which may improve wear performance 1
  • Provides improved patella tracking which may minimize anterior pain 1, 2
  • Provides more freedom of baseplate positioning without maltracking concerns 3

 

Durability:

VERILAST Technology, the combination of OXINIUM Oxidized Zirconium and highly cross-linked polyethylene (XLPE).  Using this technology, JOURNEY II TKA is designed to match the same high standards for wear performance.   

Wear

  • OXINIUM Oxidized Zirconium is an advanced bearing material that combines the strength of metal with the wear resistance of ceramics
  • OXINIUM Technology is 4,900 times more resistant to abrasion than CoCr 4
  • OXINIUM Technology is more than twice as hard as CoCr 5
  • OXINIUM Technology has a coefficient of friction that is up to half that of CoCr 6
  • OXINIUM Alloy femoral components are available for all JOURNEY II Active Knee Solutions products

Metal Sensitivity

  • OXINIUM Oxidized Zirconium, exclusively from Smith & Nephew, addresses the needs of nickel sensitive patients by having <0.0035% nickel content, compared to 0.5% in cobalt chrome and 0.1% in titanium.7
  • Zirconium is a nearly inert material that has not reported to induce immune reactions. 7

 

References

1. Carpenter RD, et al, Magnetic resonance imaging of in vivo patellofemoral kinematics after total knee arthroplasty, The Knee (2009), doi:10.1016/j.knee.2008.12.016.

2. Brilhault J, Ries MD. Measuring patellar height using the lateral active flexion radiograph: Effect of total knee implant design. Knee. 2010 Mar;17(2):148-51. doi: 10.1016/j.knee.2009.07.008.   Epub 2009 Aug 31.

3. Lee GC, Garino JP, Kim RH, Lenz N. Contributions of Femoral, Tibial and Patellar Malposition to Patellar Maltracking in Total Knee Arthroplasty. AAOS. 2013; Poster No. 114.

4. Hunter, G., and Long, M. Abrasive Wear of Oxidized Zr-2.5Nb, CoCrMo, and Ti-6Al-4V Against Bone Cement. 6th World Biomaterials Cong. Trans., Society for Biomaterials, Minneapolis, MN, 2000, p. 835.

5. Long, M., Riester, L., and Hunter, G. no-hardness Measurements of Oxidized Zr-2.5Nb and Various Orthopaedic Materials. Trans. Soc. Biomaterials, 21, 1998, p. 528.

6. Poggie RA, Wert J, Mishra A, et al (1992). Friction and wear characterization of UHMWPE in reciprocating sliding contact with Co-Cr, Ti-6Al-4V, and zirconia implant bearing surfaces. Wear and Friction of Elastomers, Denton R and Keshavan MK, Eds., West Conshohocken, PA: ASTM International.

7. Nasser, S.: Biology of Foreign Bodies: Tolerance, Osteolysis and Allergy in Total Knee Arthroplasty, Edited by J. Bellemans, M.D. Ries and J. Victor; Springer -Verlag, Heidelberg, 2005.

Market Information

Why Innovate when TKA is so successful?

Current total knee arthroplasty designs offer excellent pain relief, reproducible results, improving survivorship, and the ability for patients to return to many ADLs.

But studies have shown that while TKA is enormously successful in all of the above, it only is marginal in restoring function. Studies cite the dissatisfaction patients have with their implant replacements, particularly with their functionality ability after surgery. 1,2 One study found that, after THA, sports activity increased from 36% to 52%. After TKA, sports activities decreased from 42% to 34%. 3

Graph 1 3
Sports Activity - THA   Sports Activity - TKA



Clinical References

1. Weiss JM, Noble PC, Conditt MA, et al. What functional activities are important to patients with knee replacements? Clin Orthop Relat Res. 2002 Nov;(404):172-88.
2. Noble PC, Gordon MJ, Weiss JM, Reddix RN, Conditt MA, Mathis KB. Does total knee replacement restore normal knee function? Clin Orthop Relat Res. 2005 Feb;(431):157-65.
3. The Ulm Osteoarthritis Study-K Huch.

New Patients, New Needs

Baby boomer patients, many with OA exacerbated by trauma or sports injuries, are a new challenge for orthopaedic surgeons. High demand and highly demanding, they are looking to recapture more active lifestyles.

Three Products, One Goal

For orthopaedic surgeons seeking options beyond traditional total knee arthroplasty, JOURNEYII Active Knee Solutions is a family of advanced products designed to treat early to midstage OA patients with implants that provide more normal feeling and motion through bone and ligament preservation or anatomic replication.

JOURNEY II BCS

JOURNEY PFJ

JOURNEY UNI

TKA

The goal of the JOURNEY II Total Knee System is to enable a higher level of function for total knee replacement patients–to not only relieve pain, but to help them regain their active lifestyles.  Function, motion and durability is achieved through the unique features of the JOURNEY II Total Knee System–anatomic alignment, kinematics and advanced bearings.  Patient outcomes can be directly related to accurate surgical technique and precision instrumentation. The JOURNEY II BCS and JOURNEY II CR instrumentation has been developed to assist surgeons in obtaining accurate and reproducible results and reducing OR time.

Indications for use include:

  • rheumatoid arthritis;
  • post-traumatic arthritis,
  • osteoarthritis or degenerative arthritis;
  • failed osteotomies or unicompartmental replacement.

This system is designed for use in patients in primary total knee replacement surgery, where the anterior and posterior cruciate ligaments are incompetent and the collateral ligaments remain intact.

To replicate normal knee motion, the JOURNEY II BCS and JOURNEY II CR prosthesis provides more mobility in the lateral compartment than other total knee systems 1,2.  For patients that present with significant varus or valgus deformities (> 15º),morbid obesity or deficient collateral ligaments consider whether additional implant constraint is more appropriate. If patients with the above mentioned conditions are scheduled for a JOURNEY II BCS or JOURNEY II CR then assess the flexion space under full ligament tension (eg, laminar spreaders) with the patella reduced and consider having a constrained implant option on hand.

JOURNEY II Bi-Cruciate Stabilized (BCS) Total Knee System

Function:

Stability – Provides a proper femoro-tibial A/P position yielding a virtual elimination of paradoxical motion, anterior sliding of the femur during flexion.1-8

Strength – Restoration of both the anatomic A/P alignment and the normal kinematic patterns of the knee may produce more normal neuromuscular firing patterns throughout the range of motion as demonstrated in the original BCS design.5-10

Satisfaction – Restoration of more normal neuromuscular firing patterns throughout the range of motion may improve a patient’s ability to perform the activities they are demanding as demonstrated in the original BCS design.11,12

References

1. Victor J, Mueller JK, Komistek RD, Sharma A, Nadaud MC, Bellemans J. In vivo kinematics after a cruciate-substituting TKA. Clin Orthop Relat Res. 2010 Mar; 468(3):807-14.

2. Zingde SM, Sharma A, Komistek RD, Dennis, DA, Mahfouz, MR. In vivo comparison of kinematics for 1891 non-implanted and implanted knees. AAOS. 2009; Scientific Exhibit No. 22.

3. Zingde SM, Mueller J, Komistek RD, MacNaughton JM, Anderle MR, Mauhfouz MR. In vivo comparison of tka kinematics for subjects having a PS, PCR, or Bi-Cruciate Stabilizing design. Orthopedic Research Society. 2009; Paper No. 2067.

4. Bicruciate-stabilised total knee replacements produce more normal sagittal plane kinematics than posterior-stabilised designs.Ward TR, Burns AW, Gillespie MJ, Scarvell JM, Smith PN J Bone Joint Surg Br. 2011 Jul;93(7):907-13.

5. Catani F, Ensini A, Belvedere C, Feliciangeli A, Benedetti MG, Leardini A, Giannini S. In vivo kinematics and kinetics of a bi-cruciate substituting total knee arthroplasty: a combined fluoroscopic and gait analysis study. J Orthop Res. 2009 Dec;27(12):1569-75.

6. Morra EA, Rosca M, Greenwald JFI, Greenwald AS. The influence of contemporary knee design on high flexion: a kinematic comparison with the normal knee. JBJS Am. 2008; 90: 195-201.

7. The Mark Coventry Award: Articular contact estimation in TKA using in vivo kinematics and finite element analysis. Catani F, Innocenti B, Belvedere C, Labey L, Ensini A, Leardini A. Clin Orthop Relat Res.  2010 Jan; 468(1):19-28. doi: 10.1007/s11999-009-0941-4. Epub 2009 Jun 23.

8. Van Duren BH, Pandit H, Price M, Tilley S, Gill HS, Murray DW, Thomas NP. Bicruciate substituting total knee replacement: how effective are the added kinematic constraints in vivo? Knee Surg Sports Traumatol Arthrosc. 2012 Oct; 20 (10):2002-10. Epub 2011 Nov 29.

9. Arbuthnot JE, Brink RB. Assessment of the antero-posterior and rotational stability of the anterior cruciate ligament analogue in a guided motion bi-cruciate stabilized total knee arthroplasty. J Med Eng Technol. 2009;33(8):610-5.

10. Lester DK and Shantharam R. Objective Sagittal Instability of CR-TKA by Functional EMG During Normal Walking. AAOS. 2012; Presentation No. 810.

11. Rajgopal A; Dahiya V; Kochhar H. Bi-Cruciate Substituting Total Knee Arthroplasty Early Experience. International Society for Technology in Arthroplasty: 22 Congress. 2009; Poster No. 107.

12. Haas S. Kinematics of the Knee & JOURNEY BCS. Insall Club Annual Meeting. June 2010.

Partial Knee

JOURNEY UNI and JOURNEY PFJ

Function:

Stability – Provide retention of the ACL and PCL allowing the native anatomy to provide its innate stability. 

Strength – Improves patients’ strength by replacing only the isolated, diseased portion of the knee allowing anatomic A/P alignment for the native anatomy to operate as it had before surgery. 

Satisfaction – The preservation of the natural structures (ACL and PCL) is preferred by patients.1,2

Motion:

Flexion – Designed to preserve the normal anatomy of the knee, therefore promoting a more natural range of motion.

Kinematics – The kinematic pattern in the PF joint is critically important to decrease anterior knee pain post operatively and the associated revisions. 3,4,5,6

References

1. Pritchett JW. Patient preferences in knee prostheses. J Bone Joint Surg Br. 2004 Sep; 86(7):979-82.

2.  Pritchett JW. Anterior cruciate-retaining total knee arthroplasty. J Arthroplasty. 1996 Feb; 11(2):194-7.

3. Carpenter RD, et al, Magnetic resonance imaging of in vivo patellofemoral kinematics after total knee arthroplasty, The Knee (2009), doi:10.1016/j.knee.2008.12.016.

4. Brilhault J, Ries MD. Measuring patellar height using the lateral active flexion radiograph: Effect of total knee implant design. Knee. 2010 Mar;17(2):148-51. doi: 10.1016/j.knee.2009.07.008.
Epub 2009 Aug 31.

5. Leopold SS, Silverton CD, Barden RM, Rosenberg AG. Isolated revision of the patellar component in total knee arthroplasty. J Bone Joint Surg Am 2003; 85-A:41–7. (http://www.ncbi.nlm.nih.gov/pubmed/12533570).

6. Breugem SJ, van Ooij B, Haverkamp D, Sierevelt IN, van Dijk CN. No difference in anterior knee pain between a fixed and a mobile posterior stabilized total knee arthroplasty after 7.9 years. Knee Surg Sports Traumatol Arthrosc. 2012 Nov 3. [Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/23124601).

JOURNEY UNI

Why simplicity is superior

JOURNEY UNI X-Ray

There seems to be a growing consensus among orthopaedic surgeons that implants that retain the anterior cruciate ligament and preserve more of the articular geometry provide distinct advantages of superior proprioception, kinematics, and a more rapid recovery over tricompartmental knee replacement. Despite these benefits, isolated unicompartmental disease is rare. As with any surgery performed less frequently, the learning curve can be an issue, and literature has cited instances where more technically demanding UKA systems may have a higher failure rate. 1,2

Out of the need for a simplified procedure that retained versatility the JOURNEY UNI Unicompartmental Knee System was born. It represents a continuation of the legacy of Smith & Nephew's unicompartmental products, from the 1970s with the Marmor design to today with the clinically successful GENESIS resurfacing unicompartmental system. As a member of the JOURNEY Active Knee Solutions family, it also capitalizes on some of the design features first developed for the JOURNEY BCS Bi-Cruciate Stabilized Knee System. Ultimately, the needs and preferences of orthopaedic surgeons performing UKAs were the driving force behind the design and development of the JOURNEY UNI system. The key design goals are focused on:

1. Optimizing implant design through shape and size

2. Simplifying technique through streamlined instrumentation and familiar principles

3. Increasing longevity through use of an advanced bearing material

References

1. Lewold S, Goodman S, Knutson K, Robertsson O, Lidgren L. Oxford meniscal bearing knee versus the Marmor knee in unicompartmental arthroplasty for arthrosis. A Swedish multicenter survival study. J Arthroplasty. 1995 Dec;10(6):722-731.

2. Robertsson O, Knutson K, Lewold S, Lidgren L. The routine of surgical management reduces failure after unicompartmental knee arthroplasty. J Bone Joint Surg Br. 2001 Jan;83(1):45-49.

JOURNEY PFJ

Does isolated patellofemoral disease exist? What are the treatment options?
    

JOURNEY PFJ graph

JOURNEY PFJ graph 2

A new answer for isolated patellofemoral OA

 
First generation PFJ implants had sharp, constraining trochlear grooves and were prone to complications such as maltracking and catching of the patella.1 Interest in less invasive procedures that retain the ACL for superior kinematics has increased, particularly among surgeons treating younger, more active patients. Second generation implants improved upon implant design, but instrumentation continued to be less sophisticated, relying on freehand preparation which can be highly variable. Given the relative rarity of isolated patellofemoral OA, a straightforward, easy-to-use technique is critical.

The JOURNEY PFJ System addresses the needs of surgeons performing this procedure with a simple, highly reproducible technique and an anatomic implant optimized for patellar tracking. The JOURNEY PFJ System offers surgeons looking for a less invasive, more bone and ligament sparing treatment option for more active patients the combination of proven performance and powerful precision.

References
1. Lonner, Jess. Patellofemoral Arthroplasty: Pros, Cons, and Design Considerations. Clin Othop. 428, Nov. 2004, pp. 158-165.

 

References

References

1. US Department of Health and Human Services Agency (HHSA) for Healthcare Research and Quality (AHRQ) Knee Replacements Up Dramatically Among Adults 45 to 64 Years Old. AHRQ News and Numbers, November 3, 2011. Agency for Healthcare Research and Quality, Rockville, MD. (http://www.ahrq.gov/news/nn/nn110311.htm)

2. Phil Noble et al; Does total knee replacement restore normal knee function? 2005; CORR. (431): 157-65.

3. Huch K, Müller KA, Stürmer T, Brenner H, Puhl W, Günther KP. Sports activities 5 years after total knee or hip arthroplasty: the Ulm Osteoarthritis Study. Ann Rheum Dis. 2005 Dec; 64 (12):1715-20.

4. Comparing patient outcomes after THA and TKA: is there a difference? Bourne RB, Chesworth B, Davis A, Mahomed N, Charron K. Clin Orthop Relat Res. 2010 Feb; 468(2):542-6. Epub 2009 Sep 4. (http://www.ncbi.nlm.nih.gov/pubmed/19760472)

5. Functional comparison of posterior cruciate-retained versus cruciate-sacrificed total knee arthroplasty. Dorr LD, Ochsner JL, Gronley J, Perry J. Clin Orthop Relat Res. 1988 Nov; (236):36-43. (http://www.ncbi.nlm.nih.gov/pubmed/3180584)

6. Victor J, Mueller JK, Komistek RD, Sharma A, Nadaud MC, Bellemans J. In vivo kinematics after a cruciate-substituting TKA. Clin Orthop Relat Res. 2010 Mar; 468(3):807-14.

7. Zingde SM, Sharma A, Komistek RD, Dennis, DA, Mahfouz, MR. In vivo comparison of kinematics for 1891 non-implanted and implanted knees. AAOS. 2009; Scientific Exhibit No. 22.

8. Zingde SM, Mueller J, Komistek RD, MacNaughton JM, Anderle MR, Mauhfouz MR. In vivo comparison of tka kinematics for subjects having a PS, PCR, or Bi-Cruciate Stabilizing design. Orthopedic Research Society. 2009; Paper No. 2067.

9. Bicruciate-stabilised total knee replacements produce more normal sagittal plane kinematics than posterior-stabilised designs.Ward TR, Burns AW, Gillespie MJ, Scarvell JM, Smith PN J Bone Joint Surg Br. 2011 Jul;93(7):907-13.

10. Catani F, Ensini A, Belvedere C, Feliciangeli A, Benedetti MG, Leardini A, Giannini S. In vivo kinematics and kinetics of a bi-cruciate substituting total knee arthroplasty: a combined fluoroscopic and gait analysis study. J Orthop Res. 2009 Dec;27(12):1569-75.

11. Morra EA, Rosca M, Greenwald JFI, Greenwald AS. The influence of contemporary knee design on high flexion: a kinematic comparison with the normal knee. JBJS Am. 2008; 90: 195-201.

12. The Mark Coventry Award: Articular contact estimation in TKA using in vivo kinematics and finite element analysis. Catani F, Innocenti B, Belvedere C, Labey L, Ensini A, Leardini A. Clin Orthop Relat Res.
2010 Jan; 468(1):19-28. doi: 10.1007/s11999-009-0941-4. Epub 2009 Jun 23.

13. Van Duren BH, Pandit H, Price M, Tilley S, Gill HS, Murray DW, Thomas NP. Bicruciate substituting total knee replacement: how effective are the added kinematic constraints in vivo? Knee Surg Sports
Traumatol Arthrosc. 2012 Oct; 20 (10):2002-10. Epub 2011 Nov 29.

14. Arbuthnot JE, Brink RB. Assessment of the antero-posterior and rotational stability of the anterior cruciate ligament analogue in a guided motion bi-cruciate stabilized total knee arthroplasty. J Med Eng
Technol. 2009;33(8):610-5.

15. Lester DK and Shantharam R. Objective Sagittal Instability of CR-TKA by Functional EMG During Normal Walking. AAOS. 2012; Presentation No. 810.

16.  Pritchett JW. Patient preferences in knee prostheses. J Bone Joint Surg Br. 2004 Sep; 86(7):979-82.

17.  Pritchett JW. Anterior cruciate-retaining total knee arthroplasty. J Arthroplasty. 1996 Feb; 11(2):194-7.

18. Rajgopal A; Dahiya V; Kochhar H. Bi-Cruciate Substituting Total Knee Arthroplasty Early Experience. International Society for Technology in Arthroplasty: 22 Congress. 2009; Poster No. 107.

19. Haas S. Kinematics of the Knee & JOURNEY BCS. Insall Club Annual Meeting. June 2010.

20. Banks SA; Fregly BJ; Boniforti F; Reinschmidt C; Romagnoli S. Comparing in vivo kinematics of unicondylar and bi-unicondylar knee replacements. Knee Surg Sports Traumatol Arthrosc. 2005 Oct; 13(7):551-6. Epub 2005 Jan 20.

21. Mahfouz MR, Komistek RD, Dennis DA, Hoff WA. In vivo assessment of the kinematics in normal and anterior cruciate ligament-deficient knees. J Bone Joint Surg Am. 2004;86-A Suppl 2:56-61.

22. Carpenter RD, et al, Magnetic resonance imaging of in vivo patellofemoral kinematics after total knee arthroplasty, The Knee (2009), doi:10.1016/j.knee.2008.12.016

23. Brilhault J, Ries MD. Measuring patellar height using the lateral active flexion radiograph: Effect of total knee implant design. Knee. 2010 Mar;17(2):148-51. doi: 10.1016/j.knee.2009.07.008.
Epub 2009 Aug 31.

24. Leopold SS, Silverton CD, Barden RM, Rosenberg AG. Isolated revision of the patellar component in total knee arthroplasty. J Bone Joint Surg Am 2003; 85-A:41–7. (http://www.ncbi.nlm.nih.gov/pubmed/12533570)

25. Breugem SJ, van Ooij B, Haverkamp D, Sierevelt IN, van Dijk CN. No difference in anterior knee pain between a fixed and a mobile posterior stabilized total knee arthroplasty after 7.9 years. Knee Surg Sports Traumatol Arthrosc. 2012 Nov 3. [Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/23124601)

26. Lee GC, Garino JP, Kim RH, Lenz N. Contributions of Femoral, Tibial and Patellar Malposition to Patellar Maltracking in Total Knee Arthroplasty. AAOS. 2013; Poster No. 114

27. Nha KW, Papannagari R, Gill TJ, Van de Velde SK, Freiberg AA, Rubash HE, Li G. In vivo patellar tracking: clinical motions and patellofemoral indices. J Orthop Res. 2008 Aug;26(8):1067-74.

28. Victor J, Ries M, Bellemans J, Robb WM, Van Hellemondt G. High-flexion, motion-guided total knee arthroplasty: who benefits the most? Orthopedics. 2007 Aug; 30 (8 Suppl): 77–9.
(http://www.ncbi.nlm.nih.gov/pubmed?term=High-flexion%2C%20motion-guided%20total%20knee%20arthroplasty%3A%20who%20benefits%20the%20most)

29. Kuroyanagi Y, Mu S, Hamai S, Robb WJ, Banks SA. In vivo knee kinematics during stair and deep flexion activities in patients with bicruciate substituting total knee arthroplasty. J Arthroplasty. 2012 Jan; 27(1):122-8. doi: 10.1016/j.arth.2011.03.005. Epub 2011 Apr 19.

30. H. M. J. McEwen, P. I. Barnett, C. J. Bell, R. Farrar, D. D. Auger, M. H. Stone and J. Fisher, The influence of design, materials and kinematics on the in vitro wear of total knee replacements, J Biomech, 2005;38(2):357-365.

31. A. Parikh, M. Morrison and S. Jani, Wear testing of crosslinked and conventional UHMWPE against smooth and roughened femoral components, Orthop Res Soc, San Diego, CA, Feb 11-14, 2007, 0021.

32. AA. Essner, L. Herrera, S. S. Yau, A. Wang, J. H. Dumbleton and M. T. Manley, Sequentially crosslinked and annealed UHMWPE knee wear debris, Orthop Res Soc, Washington D.C., 2005, 71.

33. L. Herrera, J. Sweetgall, A. Essner and A. Wang, “Evaluation of sequentially crosslinked and annealed wear debris, World Biomater Cong, Amsterdam, May 28-Jun 1, 2008, 583.

34.  C. Schaerer, K. Mimnaugh, O. Popoola and J. Seebeck, “Wear of UHMWPE tibial inserts under simulated obese patient conditions,” Orthop Res Soc, New Orleans, LA, Feb 6-10, 2010, 2329.

35.  Biomet publication, FDA Cleared Claims for E1 Antioxidant Infused Technology” http://www.biomet.com/orthopedics/getFile.cfm?id=2657&rt=inline

36.  Ref: DePuy Attune 510 K Document K101433 Dec 10, 2010

37.  Ref: Smith & Nephew OR-12-129 (on file with Smith & Nephew)

38.  Hunter, G., and Long, M. Abrasive Wear of Oxidized Zr-2.5Nb, CoCrMo, and Ti-6Al-4V Against Bone Cement. 6th World Biomaterials Cong. Trans., Society for Biomaterials, Minneapolis, MN, 2000, p. 835.

39.  Long, M., Riester, L., and Hunter, G. no-hardness Measurements of Oxidized Zr-2.5Nb and Various Orthopaedic Materials. Trans. Soc. Biomaterials, 21, 1998, p. 528.

40.  Poggie RA, Wert J, Mishra A, et al (1992). Friction and wear characterization of UHMWPE in reciprocating sliding contact with Co-Cr, Ti-6Al-4V, and zirconia implant bearing surfaces. Wear and Friction of Elastomers, Denton R and Keshavan MK, Eds., West Conshohocken, PA: ASTM International.

41.  Nasser, S.: Biology of Foreign Bodies: Tolerance, Osteolysis and Allergy in Total Knee Arthroplasty, Edited by J. Bellemans, M.D. Ries and J. Victor; Springer -Verlag, Heidelberg, 2005

42.  Cartier P, Khefacha A, Sanouiller JL, Frederick K. Unicondylar knee arthroplasty in middle-aged patients: a minimum 5-year follow-up. Orthopedics. 2007 Aug; 30 (8 Suppl):62-5.
(http://www.ncbi.nlm.nih.gov/pubmed?term=cartier%20genesis)