Skip to content

Implants & Hardware

Spinal fixation and reconstruction hardware: material selection (Titanium, PEEK, Cobalt-Chrome), design considerations, and failure modes.

Overview

Silicone metacarpophalangeal arthroplasty demonstrates high clinical survivorship of 97% in long-term follow-up, though radiographic survivorship is lower at 88% [1]. In the realm of intervertebral disc prostheses, both keel and spike anchoring concepts for the Activ L® device fulfill the required criteria for primary stability [24]. For reverse total shoulder arthroplasty in patients with severe glenoid bone loss, osteoarthritis, and an intact rotator cuff, reaming the glenoid flat without bone-grafting yields excellent prosthetic survival with clinical results maintained at a minimum 5-year follow-up [44].

The EFORT Implant and Patient Safety Initiative has established recommendations to address pre-clinical and clinical requirements for new implants, emphasizing a phased introduction to identify failures and ensure patient safety before routine market use [27]. While the routine insertion of RSA beads is a safe procedure that may allow for the assessment of implant fixation in clinical practice [16], significant data gaps remain. There is an urgent need for large randomized trials regarding implant removal efficacy and patient-centred outcomes [9], as well as longer follow-up and prospective comparisons to better define revision, failure, and complication rates for proximal interphalangeal joint prosthetic arthroplasty [14].

Surgeons must carefully weigh the paucity of definitive long-term data regarding bioabsorbable interbody spacers against their potential benefits [41]. For basicervical femoral neck fractures, biomechanical analysis has not determined the superiority of one fixation device over others; consequently, constructs should be selected based on individual patient anatomy and the surgeon's comfort with the implant [4]. Specific procedural considerations include leaving difficult-to-remove cement or hardware during 2-stage revision shoulder arthroplasty for infection to avoid increased morbidity [2], and maintaining careful follow-up for patients with magnetically controlled growing rods due to metallosis risk [3].

Anatomy & Pathophysiology

Kinematics and Motion Patterns

Total disc replacements demonstrate durability with no mechanical failures observed after 30-million-cycle intervals simulating approximately 80 years of lumbar-bending motions [28]. In CHARITÉ discs implanted in human cadaveric lumbar spines and patients, preferentially larger motion occurs at the superior bearing regardless of the implanted level [31]. For cervical arthroplasty, only prosthesis with flexible biomechanical properties should be used to achieve a near-physiological motion pattern [49]. The biomechanical concept significantly impacts this outcome, as flexible properties shift the center of rotation toward normal, whereas fixed ball socket designs potentially worsen the motion pattern [49]. Authors of a small-sample RCT expect to draw conclusions regarding fusion and motion patterns in cervical spine kinematics after anterior cervical discectomy with or without mobile cervical disc prosthesis implantation [32].

Osseous Fixation and Stability

Pedicle Screw Orientation: In the sagittal position, L1 and L2 pedicle screws should be placed as parallel to the endplate as possible to obtain the best pull-out resistance [36]. Conversely, L3, L4, and L5 pedicle screws should be placed as appropriate as possible to the tail tilt theoretically to obtain optimal pull-out resistance [36]. In healthy vertebrae, both conical and dual-core/dual-thread screw designs improve pullout strength, with a combination achieving optimal stability [42]. Boron-coated titanium alloy pedicle screws demonstrate stronger biomechanical properties in a rabbit spine model, suggesting they could be a better alternative to currently used titanium screws [33].

Baseplate and Stem Micromotion: Baseplate micromotion negatively correlates with compression, with higher compressive forces significantly reducing micromotion in reverse shoulder arthroplasty baseplate design [34]. In reverse shoulder arthroplasty, baseplate stress and displacement are lower with a smaller glenosphere, inferior tilt, and divergent screws [51]. Most surgical aspects of baseplate fixation in reverse total shoulder arthroplasty for patients without glenoid bone loss can be decided without affecting fixation strength, and there is not a single strategy that provides the best outcome [47]. In cementless total hip arthroplasty short stem designs, micromotion was greater at the proximal and distal ends in finite element analysis models [56]. The direction of micromotion in these short stem designs is not dependent on stem shape but on the direction of the load [56].

Cage and Joint Stability: Higher magnitudes of cage subsidence are associated with worse clinical improvements and lower intervertebral fusion following oblique lumbar interbody fusion combined with anterolateral fixation [38]. Robotic-assisted burr preparation significantly improves cement penetration in total knee arthroplasty but does not translate to improved immediate fixation strength in time-zero biomechanical testing [39]. Increased taper angle and broad spline geometry exhibited significantly greater axial stability (21%–269% increase) compared to other design combinations in implant stability studies [53]. Neither taper angle nor spline geometry significantly altered initial torsional stability in implant stability studies [53].

Spinopelvic and Complex Fixation

Spinopelvic fixation is a powerful technique to resist flexion and cantilever forces that contribute to pseudarthrosis, though it is associated with high complication rates [46]. Computer simulation results regarding patient-specific optimization of locking plates for proximal humerus fracture fixation require biomechanical and clinical corroboration [37]. A novel proximal interphalangeal joint implant design using a rolling contact joint mechanism demonstrated acceptable outcomes in terms of human kinematics and tendon excursions [57]. The measurement error for model-based Roentgen Stereophotogrammetric Analysis is good for translations but high for rotations when evaluating early migration of the trapeziometacarpal joint prosthesis [52].

Classification

Implant Survivorship & Failure Modes: Silicone metacarpophalangeal arthroplasty implants demonstrate 97% clinical and 88% radiographic survivorship in long-term follow-up [1]. Conversely, the RM finger prosthesis system exhibited unacceptable failure rates, requiring revision of 15 implants by 2 years [7]. In the basal thumb joint, prosthesis loosening was not detected in cemented surface replacement prostheses [8]. Early loosening of uncemented, custom-made, hydroxyapatite-coated collared distal femoral endoprostheses indicates that initial fixation is crucial [6]. For proximal femur metastases, endoprostheses and intramedullary devices show comparable functional scores and implant survivorship that exceeds patient survivorship [12].

Fixation & Application Safety: No single fixation construct for basicervical femoral neck fractures demonstrates superiority over others [4]. The major reason for failure of surgical implants is faulty application of the device where the margin of safety is exceeded [43]. Both keel and spike anchoring concepts for the Activ L® intervertebral disc prosthesis fulfill the required criteria of primary stability [24]. Routine use of radiostereometric analysis (RSA) bead insertion is a safe procedure that may provide the ability to assess implant fixation in clinical practice [16].

Infection, Revision & Material Selection: Retained cement or hardware during 2-stage revision shoulder arthroplasty for infection may be left if removal leads to increased morbidity and future complications [2]. There is no consensus that specific implant materials mitigate the risk for surgical site infections or periprosthetic joint infections [11]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [13].

Pediatric & Regulatory Considerations: Instrumentation failure, including anchor-related complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries for pediatric spine deformity [10]. The EFORT Implant and Patient Safety Initiative developed recommendations emphasizing a phased introduction of new implants to identify failures and ensure patient safety before routine market use [27].

Clinical Presentation

Long-term follow-up of silicone metacarpophalangeal arthroplasty implants demonstrates 97% clinical survivorship and 88% radiographic survivorship [1]. In contrast, the RM finger prosthesis joint replacement system exhibited unacceptable failure rates, with 15 implants revised by 2 years [7]. Poly-L/D-lactide scaffolds used for thumb trapeziometacarpal arthroplasty are associated with a high frequency of osteolysis around the implant and foreign-body reactions in seven patients [5]. Uncemented distal femoral endoprostheses exhibit early loosening, indicating that initial fixation is crucial [6]. Surrounding bone does not form a stable interface with pyrolytic carbon implants, as suggested by clinical outcomes and radiographic signs of loosening [18]. Conversely, prosthesis loosening was not detected in cemented surface replacement prostheses used in the basal thumb joint [8].

Forearm pain associated with loose radial head prostheses is considered diagnostic even in the absence of radiographic signs if the prosthesis has a textured surface for bone ingrowth and was inserted without cement [19]. Early diagnosis of polyethylene liner fracture in dual mobility trapeziometacarpal total joint replacement allows revision surgery with exchange of the neck and polyethylene head without revising a well-fixed cup [20]. Instrumentation failure, including anchor-related complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries for pediatric spine deformity [10]. Patients receiving magnetically controlled growing rods require careful follow-up due to the risk of metallosis [3]. Foreign body-type cells and adverse outcomes are potential risks after the use of Artelon implants [30].

Regarding implant selection and material properties, no single fixation construct for basicervical femoral neck fractures demonstrates superiority; selection should be based on individual patient anatomy and surgeon comfort [4]. Endoprostheses and intramedullary devices for proximal femur metastases show comparable functional scores and implant survivorship exceeding patient survivorship [12]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [13]. There is no consensus that specific implant materials mitigate the risk for surgical site infections or periprosthetic joint infections [11]. Metal sensitivity to implants may exist as an extreme complication in only a few highly predisposed people and may also be a subtle contributor to implant failure [29]. Retained cement or hardware during 2-stage revision shoulder arthroplasty for infection may be left if removal leads to increased morbidity and future complications [2].

Investigations

Plain radiography: Radiographs are useful to screen for clinically significant osteolysis, with sensitivity increasing to 92.8% for lesions larger than 1000 mm3 [63]. In the context of periprosthetic fractures around uncemented femoral components, the addition of preoperative CT did not significantly improve accuracy in predicting fixation status compared with plain radiography [50]. Radiographic loosening of uncemented, custom-made, hydroxyapatite-coated collared distal femoral endoprostheses occurs early, indicating that initial fixation is crucial [6]. Conversely, prosthesis loosening was not detected in a cemented surface replacement prosthesis in the basal thumb joint [8]. Various imaging changes occur after Coflex implantation, most of which do not affect clinical outcomes [62]. Spherical ceramic trapezial-metacarpal arthroplasty is no longer used by the authors based on medium-term radiographic outcomes [15]. Surrounding bone does not form a stable interface with pyrolytic carbon implants, as suggested by clinical outcomes and radiographic signs of loosening [18]. Many patients with the iBP elbow prosthesis have radiolucencies, and the discrepancy between clinical signs and radiological results warrants structural follow-up [59]. Silicone metacarpophalangeal arthroplasty implant survivorship is 97% clinically and 88% radiographically in long-term follow-up [1].

MRI: Magnetic resonance imaging indicates that the donor site after autologous osteochondral mosaicplasty for cartilaginous lesions of the elbow joint is resurfaced with fibrous tissue [55].

CT: CT-based Implant Motion Analysis is recommended for the investigation and diagnosis of patients with megaprostheses with symptoms suggestive of loosening and for preoperative planning of revision surgery [45].

Other Considerations: Careful follow-up is recommended for patients who have received magnetically controlled growing rods due to the risk of metallosis [3]. Forearm pain associated with loose radial head prostheses is considered diagnostic even in the absence of radiographic signs if the prosthesis has a textured surface for bone ingrowth and was inserted without cement [19]. Early diagnosis of polyethylene liner fracture in dual mobility trapeziometacarpal total joint replacement allows revision surgery with exchange of the neck and polyethylene head without revising a well-fixed cup [20]. Poly-L/D-lactide scaffolds for thumb trapeziometacarpal arthroplasty are associated with a high frequency of osteolysis around the implant and clinically manifested foreign-body reactions in seven patients [5]. The Trabecular Metal Monoblock Acetabular Cup System showed excellent early clinical and radiographic behavior [64]. Two-level anterior cervical discectomy and fusion using either allografts or Polyetheretherketone (PEEK) cages resulted in similar clinical outcomes, radiological improvements in alignment, and fusion rates [65]. No single fixation construct for basicervical femoral neck fractures demonstrates superiority; selection should be based on individual patient anatomy and surgeon comfort [4]. Surgeons should consider leaving cement or hardware that is difficult to remove during 2-stage revision shoulder arthroplasty for infection to avoid increased morbidity and future complications [2]. Technologic advances in implant materials, design, amputee care, and imaging continue to drive improvements in patient care and outcomes [13].

Treatment

Operative

Implant Selection: Silicone metacarpophalangeal arthroplasty for osteoarthritis demonstrates 97% clinical implant survivorship but only 88% radiographic implant survivorship in long-term follow-up [1]. The RM finger prosthesis joint replacement system exhibited unacceptable failure rates at early and medium term stages, with 15 implants revised by 2 years [7]. For thumb trapeziometacarpal arthroplasty, a poly-L/D-lactide scaffold is associated with a high frequency of osteolysis and clinically manifested foreign-body reactions in seven patients, though it provided pain relief and improved overall function in most patients [5]. In the hip, no revisions occurred during follow-up for the large-diameter Delta Motion ceramic total hip bearing [17]. For the radial head, a well-fixed MoPyc radial head arthroplasty provides satisfactory short to midterm outcomes without painful loosening [35]. Total elbow arthroplasty demonstrates acceptable implant survival rates at 5 and 10 years, yet the unlinked design carries a higher revision rate due to fracture sequelae [22]. In lower-limb endoprosthetic reconstructions, the use of a fully porous bridging collar may translate to a reduced incidence of aseptic loosening in the medium term [61]. For proximal femur metastases, endoprostheses and intramedullary devices demonstrate comparable functional scores, and implant survivorship exceeds patient survivorship [12].

Indications: TACTYS arthroplasty can be proposed for patients who have been treated long enough with unsuccessful conservative treatment [54]. Patients who have received magnetically controlled growing rods require careful follow-up due to the risk of metallosis [3]. Osseointegration is critical for the long-term outcome of three-dimensional-printed custom-made hemipelvic endoprostheses for primary malignancies involving the acetabulum [25].

Surgical Approach / Technique: Surgeons should consider leaving cement or hardware that is difficult to remove during 2-stage revision shoulder arthroplasty for infection to avoid increased morbidity and future complications [2]. For basicervical femoral neck fractures, no single fixation construct has been determined to be superior to others; surgeons should select fixation constructs based on individual patient anatomy and surgeon comfort with the implant [4]. There is no difference in revision rate, nonunion rate, or the prevalence of painful implant between locking and nonlocking dorsal plate fixation constructs for primary first MTP arthrodesis [48].

Adjuncts: Routine use of radiostereometric analysis (RSA) bead insertion is a safe procedure and may provide the ability to assess implant fixation in clinical practice [16]. Initial implant stability is an important factor contributing to ultimate stable fixation by extracortical bone formation, as is the application of sufficient autogenous bone grafts [26]. Three design elements are required for osseointegration in three-dimensional-printed custom-made hemipelvic endoprostheses: interface connection, porous structure, and initial stability achieved by precise matching and proper fixation methods [25].

Other Considerations: There is no consensus that specific implant materials mitigate the risk for surgical site infections or periprosthetic joint infections [11]. There is an urgent need for a large randomized trial to determine the efficacy and effectiveness of orthopaedic implant removal regarding patient-centred outcomes [9].

Complications

Aseptic loosening: Loosening of uncemented, custom-made, hydroxyapatite-coated collared distal femoral endoprostheses occurs early, making initial fixation crucial to prevent this complication [6]. Poly-L/D-lactide scaffolds for thumb trapeziometacarpal arthroplasty are associated with a high frequency of osteolysis around the implant [5]. The spherical ceramic trapezial-metacarpal arthroplasty implant is no longer used by the authors based on radiographic outcomes at medium-term follow-up [15]. Silicone metacarpophalangeal arthroplasty implants demonstrate 88% radiographic survivorship in long-term follow-up [1].

Implant failure and wear: Widespread and poorly monitored adoption of metal-on-metal hip prostheses resulted in enormous excess failure with over 1 million implants worldwide [60]. Metallosis can occur following implantation of magnetically controlled growing rods in the treatment of scoliosis [3]. The RM finger prosthesis joint replacement system exhibited unacceptable failure rates at early and medium term stages, with 15 implants revised by 2 years [7]. Bipolar radial head arthroplasty is associated with major primary complications and a high incidence of radiographic signs of degenerative changes after 8.8 years [58]. Long-term implant failure could not be predicted by 2-year migration results in instrumented bone-preserving total elbow arthroplasty [21].

Foreign-body reaction: Seven patients developed clinically manifested foreign-body reactions following poly-L/D-lactide scaffold implantation for thumb trapeziometacarpal arthroplasty [5].

Other Considerations: Retained cement or hardware during 2-stage revision shoulder arthroplasty for infection may lead to increased morbidity and future complications if removal is difficult [2]. Instrumentation failure, including anchor-related complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries for pediatric spine deformity [10]. The revision rate for unlinked total elbow arthroplasty designs is higher than linked designs, with primary revisions occurring due to fracture sequelae [22]. Total elbow arthroplasty has acceptable implant survival rates after 5 and 10 years [22]. There were no revisions during follow-up for the large-diameter Delta Motion ceramic total hip bearing despite noise generation [17]. Titanium coating on polyetheretherketone oblique cages for transforaminal lumbar interbody fusion appears to have no negative effects on outcome or safety in the short term [23]. Silicone metacarpophalangeal arthroplasty implant survivorship is 97% clinically in long-term follow-up [1]. Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications for proximal interphalangeal joint prosthetic arthroplasty [14]. Despite major primary complications and radiographic degenerative changes, bipolar radial head arthroplasty achieved mainly good clinical results [58].

Recovery

Light activity (weeks): Evidence does not specify a week range for light activity or driving.

Full activity (months): Evidence does not specify a month range for full activity or return to manual work.

Complete recovery / outcome plateau (months): Evidence does not specify a month range for outcome plateau or final functional stabilization.

Rehabilitation protocol: Evidence does not detail specific PT phasing, immobilization duration, or brace removal timing.

Functional milestones: Evidence does not report validated PROM trajectories or specific outcome-measure benchmarks.

Other Considerations: Long-term clinical survivorship of silicone metacarpophalangeal arthroplasty implants is 97%, while radiographic survivorship is 88% [1]. Careful follow-up is recommended for patients with magnetically controlled growing rods due to the risk of metallosis [3]. Poly-L/D-lactide scaffolds for thumb trapeziometacarpal arthroplasty demonstrated a high frequency of osteolysis around the implant on radiographs, and seven patients developed clinically manifested foreign-body reactions following their use [5]. Loosening of uncemented, custom-made, hydroxyapatite-coated collared distal femoral endoprostheses occurs early, making initial fixation crucial to prevent this complication [6]. The RM finger prosthesis joint replacement system exhibited unacceptable failure rates at early and medium term stages, with fifteen implants revised by 2 years [7]. Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications for proximal interphalangeal joint prosthetic arthroplasty [14]. Authors no longer use spherical ceramic trapezial-metacarpal arthroplasty implants based on medium-term radiographic outcomes [15]. There were no revisions during follow-up for the large-diameter Delta Motion ceramic total hip bearing [17]. Long-term implant failure could not be predicted by 2-year migration results in instrumented bone preserving total elbow arthroplasty [21]. Titanium coating on polyetheretherketone oblique cages appears to have no negative effects on outcome or safety in the short term [23]. Osseointegration is critical for the long-term outcome of three-dimensional-printed custom-made hemipelvic endoprostheses, requiring three design elements: interface connection, porous structure, and initial stability achieved by precise matching and proper fixation methods [25]. Initial implant stability is an important factor contributing to ultimate stable fixation by extracortical bone formation, as is the application of sufficient autogenous bone grafts [26]. Long-term studies are necessary to evaluate the survivorship of pyrocarbon metacarpophalangeal joint replacement implants [40].

Key Evidence

  • [L4] Implant survivorship is 97% (clinical) and 88% (radiographic) in long-term follow-up. (10.1016/j.jhsa.2017.10.010)
  • [L3] Therefore, surgeons should consider leaving cement or hardware that is difficult to remove and may lead to increased morbidity and future complications. (10.1016/j.jse.2024.03.020)
  • [L4] The authors recommend careful follow-up of patients who have received this implant. (10.1302/0301-620x.98b12.38061)
  • [L5] The study could not determine superiority of one implant over the others and recommends that surgeons select fixation constructs based on the individual patient's anatomy and the surgeon's comfort with the implant. (10.5435/jaaos-d-17-00155)
  • [L4] The procedure provided pain relief and improvement in overall function in most patients, but radiographs demonstrated a high frequency of osteolysis around the implant and seven patients developed clinically manifested foreign-body reactions. (10.1177/1753193415601952)
  • [L3] Loosening of uncemented replacements occurs early indicating that initial fixation of the implant is crucial. (10.1302/0301-620x.96b2.32091)
  • [L4] Unacceptable failure rates at early and medium term stages were identified, with 15 of the implants revised by 2 years. (10.1177/1753193411406798)
  • [L4] Prosthesis loosening was not detected. (10.1016/j.jhsa.2009.12.026)
  • [L4] Given the frequency of the procedure in orthopaedic departments worldwide, there is an urgent need for a large randomized trial to determine the efficacy and effectiveness of implant removal with regard to patient-centred outcomes. (10.1186/1471-2474-9-73)
  • [L3] Instrumentation failure, such as anchor related-complications and rod breakage, occurs more frequently earlier in the course of lengthening surgeries. (10.1186/s12891-024-07211-9)
  • [L5] There is no consensus that specific implant materials mitigate the risk for surgical site infections/periprosthetic joint infections, though a combination of approaches is likely needed. (10.1016/j.arth.2018.09.016)
  • [L3] Patients may undergo stabilization with either approach with comparable functional scores and implant survivorship exceeding patient survivorship. (10.1007/s11999-011-2038-0)
  • [L4] Longer follow-up and prospective randomized comparisons are needed to better define rates of revision, failure, and complications. (10.1016/j.jhsa.2010.04.005)
  • [L4] Based on the radiographic outcome at this medium-term follow-up, the authors no longer use this implant. (10.1016/j.jhsa.2008.10.017)
  • [L3] The routine use of RSA bead insertion is a safe procedure and may provide the ability to assess implant fixation in clinical practice. (10.5435/jaaos-d-17-00071)
  • [L3] There were no revisions during follow-up. (10.1302/0301-620x.95b2.30450)
  • [L5] The clinical outcomes and radiographic signs of loosening suggest that the surrounding bone does not form a stable interface with pyrolytic carbon implants. (10.2106/jbjs.k.00527)
  • [L4] If the prosthesis has a textured surface for bone ingrowth and was inserted without cement, this symptom is considered diagnostic even in the absence of radiographic signs. (10.1016/j.jse.2011.05.008)
  • [L4] Early diagnosis allows revision surgery with exchange of the neck and polyethylene head without revising a well-fixed cup. (10.1177/17531934241227918)
  • [L4] Long-term implant failure could not be predicted by 2-year migration results in this study. (10.1016/j.jse.2019.07.023)
  • [L3] We found acceptable implant survival rates after 5 and 10 years, with a higher revision rate for the unlinked design and primary TEA due to fracture sequelae. (10.1016/j.jse.2014.02.001)
  • [L1] The titanium coating appears to have no negative effects on outcome or safety in the short term. (10.1302/0301-620x.99b10.bjj-2016-1292.r2)
  • [L5] Both fixation systems fulfill the required criteria of primary stability. (10.1186/s12891-021-04544-7)
  • [L4] Osseointegration is critical for long-term outcome and requires three design elements including interface connection, porous structure, and initial stability achieved by precise matching and proper fixation methods. (10.1186/s13018-019-1455-8)
  • [L5] Initial implant stability and the application of sufficient autogenous bone grafts are two important factors that contribute to ultimate stable fixation by extracortical bone formation. (10.2106/00004623-198870020-00002)
  • [L5] The EFORT Implant and Patient Safety Initiative developed recommendations to address pre-clinical and clinical requirements for new implants, emphasizing a phased introduction to identify failures and ensure patient safety before routine market use. (10.1530/eor-23-0072)
  • [L5] No mechanical failures were observed, even after each 30-million-cycle interval, which simulates approximately 80 years of lumbar-bending motions. (10.2106/jbjs.25.00594)
  • [Case_report] Metal sensitivity to implants may exist as an extreme complication in only a few highly predisposed people, but it may also be a subtle contributor to implant failure. (10.1007/s00167-012-2000-z)
  • [L4] Patients and surgeons must be made aware of the potential for foreign body–type cells and an adverse outcome after use of the implant. (10.1016/j.jhsa.2010.10.001)
  • [L5] We found preferentially larger motion at the superior bearing of the CHARITE´ discs implanted in human cadaveric lumbar spines and in patients, regardless of the implanted level. (10.2106/jbjs.j.00638)
  • [L1] The authors note that while the sample size is small, they expect to draw conclusions about the primary outcome regarding fusion and motion patterns. (10.1186/s12891-015-0479-4)
  • [L5] With stronger biomechanical properties, they could be a better alternative to currently used titanium screws. (10.1186/s12891-024-07864-6)
  • [L5] Baseplate micromotion negatively correlates with compression, with higher compressive forces significantly reducing micromotion. (10.1016/j.jse.2023.07.043)
  • [L4] A well-fixed MoPyc RHA provided satisfactory short to midterm outcomes, without painful loosening. (10.1016/j.jse.2024.06.018)
  • [L4] Based on the analysis of statistical results, the placement direction of L1 and L2 in the sagittal position may be as parallel to the endplate as possible to obtain the best pull-out resistance; L3, L4, and L5 may be as appropriate as possible to the tail tilt theoretically. (10.1186/s12891-022-05074-6)
  • [L5] These computer simulation results require biomechanical and clinical corroboration. (10.1016/j.jse.2021.06.012)
  • [L3] Higher magnitudes of CS were associated with worse clinical improvements and lower intervertebral fusion. (10.1186/s12891-022-05165-4)
  • [L5] However, this did not translate to improved immediate fixation strength in time‐zero biomechanical testing. (10.1002/ksa.12765)
  • [L4] Long-term studies will be necessary to evaluate the survivorship of this new design of implant, particularly given some of the radiographic changes described in this article. (10.1177/1753193413511946)
  • [L5] The paucity of definitive, long-term data must be carefully weighed against the potential benefits of these implants. (10.5435/00124635-200705000-00005)
  • [L5] In healthy vertebrae, both conical and dual-core/dual-thread designs improve pullout strength, with a combination achieving optimal stability. (10.1371/journal.pone.0229328)
  • [L5] The major reason for failure of implants is faulty application of the device, where the margin of safety is exceeded; cooperative investigation by surgeon, metallurgist, and pathologist is required to explain failures and prevent errors. (10.2106/00004623-196446020-00016)
  • [L4] For the studied indication, reaming the glenoid flat produced excellent prosthetic survival with clinical results maintained at a minimum 5-year follow-up. (10.2106/jbjs.20.01042)
  • [L4] The authors recommend the use of CT-based Implant Motion Analysis in the investigation and diagnosis of patients with a megaprosthesis with symptoms suggestive of loosening, and in the preoperative planning of revision surgery. (10.1302/0301-620x.107b5.bjj-2024-0517.r1)
  • [L5] Spinopelvic fixation is a powerful technique to resist flexion and cantilever forces that contribute to pseudarthrosis, though it is associated with high complication rates. (10.5435/jaaos-d-15-00738)
  • [L1] Most surgical aspects of baseplate fixation can be decided without affecting fixation strength, and there is not a single strategy that provides the best outcome. (10.5397/cise.2023.00493)
  • [L3] There was no difference in revision rate, nonunion, or prevalence of painful implant between locking and nonlocking dorsal plate fixation for primary first MTP arthrodesis. (10.5435/jaaos-d-23-00185)
  • [L4] The biomechanical concept of the prosthesis has a significant impact on whether a near-physiological motion pattern can be achieved, with flexible biomechanical properties shifting the center of rotation toward normal and fixed ball socket designs potentially worsening the motion pattern. (10.1186/s13018-020-01908-y)
  • [L3] The addition of preoperative CT did not significantly improve accuracy in predicting fixation status compared with plain radiography. (10.1302/0301-620x.107b6.bjj-2024-0829.r1)
  • [L5] Baseplate stress and displacement in an FEA model is lower with a smaller glenosphere, inferior tilt, and divergent screws. (10.1016/j.jse.2017.06.008)
  • [L3] The measurement error is good for the translations but high for the rotations. (10.1186/s12891-015-0747-3)
  • [L4] TACTYS arthroplasty can be proposed for people who have been treated long enough with unsuccessful conservative treatment. (10.1177/15589447211030962)
  • [L4] However, magnetic resonance imaging indicates that the donor site is resurfaced with fibrous tissue. (10.1177/0363546507306465)
  • [L5] In both models, the micromotion was greater at the proximal and distal ends, and the direction of micromotion was not dependent on stem shape but on the direction of the load. (10.1186/s13018-022-03329-5)
  • [L5] A novel PIPJ implant design using an RCJ mechanism demonstrated acceptable outcomes in terms of PIPJ human kinematics and tendon excursions. (10.1186/s13018-019-1234-6)
  • [L4] Despite major primary complications and high incidence of radiographic signs of degenerative changes after 8.8 years, mainly good clinical results were achieved with Judet's bipolar prosthesis. (10.1016/j.jse.2010.05.022)
  • [L4] However, many patients have radiolucencies, and the discrepancy between clinical signs and radiological results warrants structural follow-up. (10.1186/s12891-019-2781-z)
  • [L3] This study highlights the consequences of widespread and poorly monitored adoption of a medical technology, noting that over 1 million metal-on-metal hip prostheses were implanted worldwide with enormous excess failure. (10.2106/jbjs.17.00039)
  • [L3] In the medium term, the use of a fully porous bridging collar may translate to a reduced incidence of aseptic loosening. (10.1186/s42836-023-00230-2)
  • [L3] The study identified various imaging changes after Coflex implantation, most of which did not affect clinical outcomes. (10.1186/s12891-023-06798-9)
  • [L3] Radiographs are useful to screen clinically significant osteolysis, with sensitivity increasing to 92.8% for lesions larger than 1000 mm3. (10.1016/j.arth.2008.02.012)
  • [L4] The implant showed excellent early clinical and radiographic behavior. (10.1016/j.arth.2008.09.027)
  • [L3] Two-level ACDF using either allografts or PEEK cages resulted in similar clinical outcomes, radiological improvements in alignment and fusion rates. (10.1186/s12891-020-03325-y)

See Also

References

[1] Silicone Metacarpophalangeal Arthroplasty for Osteoarthritis: Long-Term Results. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.10.010

[2] Does retained cement or hardware during 2-stage revision shoulder arthroplasty for infection increase the risk of recurrent infection?. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.03.020

[3] Metallosis following implantation of magnetically controlled growing rods in the treatment of scoliosis. The Bone & Joint Journal. 2016. DOI: 10.1302/0301-620x.98b12.38061

[4] Biomechanical Analysis of Fixation Devices for Basicervical Femoral Neck Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00155

[5] Unfavourable short-term outcomes of a poly-L/D-lactide scaffold for thumb trapeziometacarpal arthroplasty. Journal of Hand Surgery (European Volume). 2015. DOI: 10.1177/1753193415601952

[6] Uncemented, custom-made, hydroxyapatite-coated collared distal femoral endoprostheses. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b2.32091

[7] Failures of the RM finger prosthesis joint replacement system. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411406798

[8] A Cemented Surface Replacement Prosthesis in the Basal Thumb Joint. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.12.026

[9] Surgeons' beliefs and perceptions about removal of orthopaedic implants. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-73

[10] Instrumentation failure following pediatric spine deformity growth-sparing surgery using traditional growing rods or vertical expandable prosthetic titanium ribs. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07211-9

[11] Hip and Knee Section, Prevention, Prosthesis Factors: Proceedings of International Consensus on Orthopedic Infections. The Journal of Arthroplasty. 2019. DOI: 10.1016/j.arth.2018.09.016

[12] Endoprostheses Last Longer Than Intramedullary Devices in Proximal Femur Metastases. Clinical Orthopaedics & Related Research. 2012. DOI: 10.1007/s11999-011-2038-0

[13] Chapter 3 Emerging Technologies in Orthopaedic Trauma. 2021.

[14] Proximal Interphalangeal Joint Prosthetic Arthroplasty. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.04.005

[15] Early Outcome of Spherical Ceramic Trapezial-Metacarpal Arthroplasty. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.10.017

[16] Routine Use of Radiostereometric Analysis in Elective Hip and Knee Arthroplasty Patients: Surgical Impact, Safety, and Bead Stability. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-17-00071

[17] The incidence of noise generation arising from the large-diameter Delta Motion ceramic total hip bearing. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b2.30450

[18] Questions about Implant-Bone Interface with Pyrolytic Carbon. Journal of Bone and Joint Surgery. 2011. DOI: 10.2106/jbjs.k.00527

[19] Forearm pain associated with loose radial head prostheses. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.05.008

[20] Polyethylene liner fracture in dual mobility trapeziometacarpal total joint replacement: how to make a timely diagnosis?. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241227918

[21] Long-term outcomes after Instrumented Bone Preserving total elbow arthroplasty: a radiostereometric study with a minimum follow-up of 10 years. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.07.023

[22] Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2014.02.001

[23] Transforaminal lumbar interbody fusion using polyetheretherketone oblique cages with and without a titanium coating. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b10.bjj-2016-1292.r2

[24] Primary stability of the Activ L® intervertebral disc prosthesis in cadaver bone and comparison of the keel and spike anchoring concept. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-04544-7

[25] Three-dimensional-printed custom-made hemipelvic endoprosthesis for primary malignancies involving acetabulum: the design solution and surgical techniques. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1455-8

[26] Comparison of replacement prostheses for segmental defects of bone. Different porous coatings for extracortical fixation.. The Journal of Bone & Joint Surgery. 1988. DOI: 10.2106/00004623-198870020-00002

[27] Introduction of innovations in joint arthroplasty: Recommendations from the ‘EFORT implant and patient safety initiative’. EFORT Open Reviews. 2023. DOI: 10.1530/eor-23-0072

[28] Comparative in Vitro Analysis of Wear Particles Generated by a Viscoelastic Disc Versus 2 Articulating Total Disc Replacements. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00594

[29] No allergic reaction after TKA in a chrome‐cobalt‐nickel‐sensitive patient: case report and review of the literature. Knee Surgery, Sports Traumatology, Arthroscopy. 2012. DOI: 10.1007/s00167-012-2000-z

[30] Foreign Body Reaction Associated With Artelon: Report of Three Cases. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.10.001

[31] Asymmetric Motion Distribution Between Components of a Mobile-Core Lumbar Disc Prosthesis. Journal of Bone and Joint Surgery. 2012. DOI: 10.2106/jbjs.j.00638

[32] Cervical spine kinematics after anterior cervical discectomy with or without implantation of a mobile cervical disc prosthesis; an RCT. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0479-4

[33] Osseointegration potential of boron-coated titanium alloy pedicle screw in rabbit spine model. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07864-6

[34] How to avoid baseplate failure: the effect of compression and reverse shoulder arthroplasty baseplate design on implant stability. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.043

[35] Short- to midterm outcomes of 139 pyrocarbon monopolar radial head arthroplasties. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.06.018

[36] A study of screw placement to obtain the optimal pull-out resistance of lumbar pedicle screws—analysis of Hounsfield units measurements based on computed tomography. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05074-6

[37] One size may not fit all: patient-specific computational optimization of locking plates for improved proximal humerus fracture fixation. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.06.012

[38] Clinical and radiological evaluation of cage subsidence following oblique lumbar interbody fusion combined with anterolateral fixation. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05165-4

[39] Robotic‐assisted burr preparation significantly improves cement penetration but not immediate fixation strength in total knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12765

[40] Pyrocarbon metacarpophalangeal joint replacement in primary osteoarthritis. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193413511946

[41] Bioabsorbable Interbody Spacers. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200705000-00005

[42] Biomechanical comparison of pedicle screw fixation strength in synthetic bones: Effects of screw shape, core/thread profile and cement augmentation. PLOS ONE. 2020. DOI: 10.1371/journal.pone.0229328

[43] Failure in Performance of Surgical Implants. The Journal of Bone & Joint Surgery. 1964. DOI: 10.2106/00004623-196446020-00016

[44] Reverse Total Shoulder Arthroplasty without Bone-Grafting for Severe Glenoid Bone Loss in Patients with Osteoarthritis and Intact Rotator Cuff. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01042

[45] CT-based Implant Motion Analysis for diagnosing loosening of megaprostheses. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b5.bjj-2024-0517.r1

[46] Spinopelvic Fixation. Journal of the American Academy of Orthopaedic Surgeons. 2018. DOI: 10.5435/jaaos-d-15-00738

[47] Ten technical aspects of baseplate fixation in reverse total shoulder arthroplasty for patients without glenoid bone loss: a systematic review. Clinics in Shoulder and Elbow. 2024. DOI: 10.5397/cise.2023.00493

[48] Analysis of the Costs and Complications of First Metatarsophalangeal Joint Arthrodesis Comparing Locked and Non-locked Plate Fixation Constructs. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00185

[49] In cervical arthroplasty, only prosthesis with flexible biomechanical properties should be used for achieving a near-physiological motion pattern. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01908-y

[50] Does CT improve the accuracy of predicting implant fixation status for periprosthetic fractures around uncemented femoral components?. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b6.bjj-2024-0829.r1

[51] † Finite element analysis of glenoid-sided lateralization in reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.06.008

[52] Feasibility of model-based Roentgen Stereophotogrammetric Analysis to evaluate early migration of the trapeziometacarpal joint prosthesis. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0747-3

[53] The_Effect_of_Taper_Angle_and_Spline_Geometry_on_the_Initial_Stability_of_Tapere_S0883540315000790. n.d..

[54] Arthroplasty of the Proximal Interphalangeal Joint With the TACTYS Prosthesis: Clinical and Radiographic Results With a Mean Follow-up of 5 Years. HAND. 2022. DOI: 10.1177/15589447211030962

[55] Donor Site Evaluation after Autologous Osteochondral Mosaicplasty for Cartilaginous Lesions of the Elbow Joint. The American Journal of Sports Medicine. 2007. DOI: 10.1177/0363546507306465

[56] Patient-specific three-dimensional evaluation of interface micromotion in two different short stem designs in cementless total hip arthroplasty: a finite element analysis. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03329-5

[57] Novel implant design of the proximal interphalangeal joint using an optimized rolling contact joint mechanism. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1234-6

[58] Mid- to long-term results after bipolar radial head arthroplasty. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.022

[59] Long-term results of the iBP elbow prosthesis: beware of destructive metallosis!. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2781-z

[60] Implications of Introducing New Technology. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.00039

[61] Early radiological outcomes of a fully porous bridging collar in lower-limb endoprosthetic reconstructions: a case-matched retrospective series to assess osseointegration. Arthroplasty. 2024. DOI: 10.1186/s42836-023-00230-2

[62] Complications and radiographic changes after implantation of interspinous process devices: average eight-year follow-up. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06798-9

[63] Pelvic Osteolysis Relationship to Radiographs and Polyethylene Wear. The Journal of Arthroplasty. 2009. DOI: 10.1016/j.arth.2008.02.012

[64] Migration of the Trabecular Metal Monoblock Acetabular Cup System. The Journal of Arthroplasty. 2010. DOI: 10.1016/j.arth.2008.09.027

[65] A comparison of contiguous two-level anterior cervical discectomy and fusion using a structural allograft versus a Polyetheretherketone (PEEK) cage: the results of a three-year follow-up. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03325-y

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.