{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T12:03:18Z","timestamp":1769688198946,"version":"3.49.0"},"reference-count":27,"publisher":"Wiley","issue":"1","license":[{"start":{"date-parts":[[2025,5,19]],"date-time":"2025-05-19T00:00:00Z","timestamp":1747612800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2025,5,19]],"date-time":"2025-05-19T00:00:00Z","timestamp":1747612800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Journal Orthopaedic Research"],"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Total ankle replacement (TAR) has become an effective treatment for end\u2010stage ankle osteoarthritis. Multiple factors, including patient characteristics, surgical technique, alignment, and bearing surfaces, influence TAR survivorship. Polyethylene (PE) fatigue is a key consideration in improving outcomes. This study establishes a novel, clinically relevant testing protocol incorporating varus\u2010valgus rotation to simulate polyethylene fatigue failures observed in mobile\u2010bearing total ankle replacements. Using this robust methodology, we evaluated the impact of oxidation and antioxidant stabilization on ultrahigh\u2010molecular\u2010weight polyethylene (UHMWPE) performance in a mobile bearing implant application. A six\u2010degree\u2010of\u2010freedom simulator was used to iteratively adjust loading parameters (1500\u20133000\u2009N, \u22124\u00b0 to +8\u00b0 flexion\u2010extension, \u00b15\u00b0 axial rotation, and \u00b13\u00b0 or \u00b18\u00b0 varus\u2010valgus rotation at 37\u2009\u00b1\u20093\u00b0C in 20\u2009g\/L bovine serum) until clinically observed midline fractures were replicated. Oxidation levels were measured by Fourier\u2010transform infrared spectroscopy per ASTM F2102. This validated loading protocol was then applied to conventional (25\u2009kGy GUR 1020) and vitamin E\u2010stabilized (75\u2009kGy GUR 1020\u2010E) UHMWPE inserts and tested to visible fracture or a 3\u2010million\u2010cycle runout. Post\u2010test fractographic analysis identified crack initiation sites. Conventional aged UHMWPE demonstrated fatigue failure under varus\u2010valgus rotation (OI\u2009=\u20092.59\u2009\u00b1\u20091.11) but no failure without rotation. Vitamin E\u2010stabilized UHMWPE showed no fatigue failure after 3 million cycles, even under varus\u2010valgus rotation (OI\u2009=\u20090.23\u2009\u00b1\u20090.02). Fractography revealed fractures originating at the trough and propagating with cyclic loading. Oxidation significantly reduces polyethylene fatigue life, and varus\u2010valgus rotation exacerbates this effect in mobile bearing TAR implants. Antioxidant\u2010stabilized UHMWPE showed promising resistance to fatigue and oxidation. These findings support the role of antioxidant stabilization in improving TAR performance, and the protocols developed here provide a framework for assessing the safety of alternative materials.<\/jats:p>","DOI":"10.1002\/jor.26103","type":"journal-article","created":{"date-parts":[[2025,5,19]],"date-time":"2025-05-19T03:09:02Z","timestamp":1747624142000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Advanced Testing Protocols Simulate Failures and Validate Antioxidant Polyethylene in Ankle Implants"],"prefix":"10.1002","volume":"44","author":[{"given":"Ryan","family":"Siskey","sequence":"first","affiliation":[{"name":"Exponent Inc. Philadelphia Pennsylvania USA"},{"name":"School of Biomedical Engineering, Science, and Health Systems Drexel University Philadelphia Pennysylvania USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick","family":"Hall","sequence":"additional","affiliation":[{"name":"Exponent Inc. Philadelphia Pennsylvania USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ruth","family":"Heckler","sequence":"additional","affiliation":[{"name":"Surgical Division Enovis Austin Texas USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Safranski","sequence":"additional","affiliation":[{"name":"Foot and Ankle Division Enovis Atlanta Georgia USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7465-3854","authenticated-orcid":false,"given":"James","family":"Johnson","sequence":"additional","affiliation":[{"name":"Surgical Division Enovis Austin Texas USA"},{"name":"Foot and Ankle Division Enovis Atlanta Georgia USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ariel","family":"Palanca","sequence":"additional","affiliation":[{"name":"Palomar Health Medical Group San Diego California USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,5,19]]},"reference":[{"key":"e_1_2_10_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.fas.2023.09.007"},{"key":"e_1_2_10_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.fas.2019.07.006"},{"key":"e_1_2_10_4_1","doi-asserted-by":"publisher","DOI":"10.3390\/jcm13010179"},{"key":"e_1_2_10_5_1","doi-asserted-by":"publisher","DOI":"10.3109\/17453674.2015.1056701"},{"issue":"11","key":"e_1_2_10_6_1","first-page":"177","article-title":"Total Ankle Replacement","volume":"112","author":"Barg A.","year":"2015","journal-title":"Deutsches \u00c4rzteblatt international"},{"key":"e_1_2_10_7_1","article-title":"Analysis of Polyethylene\u2010Related Revisions After Total Ankle Replacements Reported in US Food and Drug Administration Medical Device Adverse Event Database","volume":"44","author":"Jiang H.","year":"2022","journal-title":"Foot & Ankle International"},{"key":"e_1_2_10_8_1","unstructured":"Registry AOANJR \u201cDemographics and Outcome of Ankle Arthroplasty \u201d (Australian Orthopaedic Association National Joint Replacement Registry 2013)."},{"key":"e_1_2_10_9_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11999-010-1453-y"},{"key":"e_1_2_10_10_1","doi-asserted-by":"publisher","DOI":"10.1177\/1071100718802589"},{"key":"e_1_2_10_11_1","doi-asserted-by":"publisher","DOI":"10.2106\/JBJS.N.01077"},{"key":"e_1_2_10_12_1","doi-asserted-by":"publisher","DOI":"10.1007\/s11999-009-0834-6"},{"key":"e_1_2_10_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jmbbm.2011.03.012"},{"key":"e_1_2_10_14_1","doi-asserted-by":"publisher","DOI":"10.1002\/jbm.a.10606"},{"key":"e_1_2_10_15_1","doi-asserted-by":"publisher","DOI":"10.2106\/00004623-200406000-00021"},{"key":"e_1_2_10_16_1","doi-asserted-by":"publisher","DOI":"10.1177\/1071100719847645"},{"key":"e_1_2_10_17_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.biomaterials.2006.01.016"},{"key":"e_1_2_10_18_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.arth.2007.09.027"},{"key":"e_1_2_10_19_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.actbio.2014.02.052"},{"key":"e_1_2_10_20_1","doi-asserted-by":"publisher","DOI":"10.1021\/acsabm.9b00960"},{"key":"e_1_2_10_21_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.biomaterials.2008.12.029"},{"key":"e_1_2_10_22_1","volume-title":"UHMWPE Biomaterials Handbook","author":"Kurtz S. 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