life without nature essay

Nature centres into balls, And her proud ephemerals, Fast to surface and outside, Scan the profile of the sphere; Knew they what that signified, A new genesis were here.

T he eye is the first circle; the horizon which it forms is the second; and throughout nature this primary figure is repeated without end. It is the highest emblem in the cipher of the world. St. Augustine described the nature of God as a circle whose centre was everywhere, and its circumference nowhere. We are all our lifetime reading the copious sense of this first of forms. One moral we have already deduced, in considering the circular or compensatory character of every human action. Another analogy we shall now trace; that every action admits of being outdone. Our life is an apprenticeship to the truth, that around every circle another can be drawn; that there is no end in nature, but every end is a beginning; that there is always another dawn risen on mid-noon, and under every deep a lower deep opens.

This fact, as far as it symbolizes the moral fact of the Unattainable, the flying Perfect, around which the hands of man can never meet, at once the inspirer and the condemner of every success, may conveniently serve us to connect many illustrations of human power in every department.

There are no fixtures in nature. The universe is fluid and volatile. Permanence is but a word of degrees. Our globe seen by God is a transparent law, not a mass of facts. The law dissolves the fact and holds it fluid. Our culture is the predominance of an idea which draws after it this train of cities and institutions. Let us rise into another idea: they will disappear. The Greek sculpture is all melted away, as if it had been statues of ice; here and there a solitary figure or fragment remaining, as we see flecks and scraps of snow left in cold dells and mountain clefts, in June and July. For the genius that created it creates now somewhat else. The Greek letters last a little longer, but are already passing under the same sentence, and tumbling into the inevitable pit which the creation of new thought opens for all that is old. The new continents are built out of the ruins of an old planet; the new races fed out of the decomposition of the foregoing. New arts destroy the old. See the investment of capital in aqueducts made useless by hydraulics; fortifications, by gunpowder; roads and canals, by railways; sails, by steam; steam by electricity.

You admire this tower of granite, weathering the hurts of so many ages. Yet a little waving hand built this huge wall, and that which builds is better than that which is built. The hand that built can topple it down much faster. Better than the hand, and nimbler, was the invisible thought which wrought through it; and thus ever, behind the coarse effect, is a fine cause, which, being narrowly seen, is itself the effect of a finer cause. Every thing looks permanent until its secret is known. A rich estate appears to women a firm and lasting fact; to a merchant, one easily created out of any materials, and easily lost. An orchard, good tillage, good grounds, seem a fixture, like a gold mine, or a river, to a citizen; but to a large farmer, not much more fixed than the state of the crop. Nature looks provokingly stable and secular, but it has a cause like all the rest; and when once I comprehend that, will these fields stretch so immovably wide, these leaves hang so individually considerable? Permanence is a word of degrees. Every thing is medial. Moons are no more bounds to spiritual power than bat-balls.

The key to every man is his thought. Sturdy and defying though he look, he has a helm which he obeys, which is the idea after which all his facts are classified. He can only be reformed by showing him a new idea which commands his own. The life of man is a self-evolving circle, which, from a ring imperceptibly small, rushes on all sides outwards to new and larger circles, and that without end. The extent to which this generation of circles, wheel without wheel, will go, depends on the force or truth of the individual soul. For it is the inert effort of each thought, having formed itself into a circular wave of circumstance, — as, for instance, an empire, rules of an art, a local usage, a religious rite, — to heap itself on that ridge, and to solidify and hem in the life. But if the soul is quick and strong, it bursts over that boundary on all sides, and expands another orbit on the great deep, which also runs up into a high wave, with attempt again to stop and to bind. But the heart refuses to be imprisoned; in its first and narrowest pulses, it already tends outward with a vast force, and to immense and innumerable expansions.

Every ultimate fact is only the first of a new series. Every general law only a particular fact of some more general law presently to disclose itself. There is no outside, no inclosing wall, no circumference to us. The man finishes his story, — how good! how final! how it puts a new face on all things! He fills the sky. Lo! on the other side rises also a man, and draws a circle around the circle we had just pronounced the outline of the sphere. Then already is our first speaker not man, but only a first speaker. His only redress is forthwith to draw a circle outside of his antagonist. And so men do by themselves. The result of to-day, which haunts the mind and cannot be escaped, will presently be abridged into a word, and the principle that seemed to explain nature will itself be included as one example of a bolder generalization. In the thought of to-morrow there is a power to upheave all thy creed, all the creeds, all the literatures, of the nations, and marshal thee to a heaven which no epic dream has yet depicted. Every man is not so much a workman in the world, as he is a suggestion of that he should be. Men walk as prophecies of the next age.

Step by step we scale this mysterious ladder: the steps are actions; the new prospect is power. Every several result is threatened and judged by that which follows. Every one seems to be contradicted by the new; it is only limited by the new. The new statement is always hated by the old, and, to those dwelling in the old, comes like an abyss of skepticism. But the eye soon gets wonted to it, for the eye and it are effects of one cause; then its innocency and benefit appear, and presently, all its energy spent, it pales and dwindles before the revelation of the new hour.

Fear not the new generalization. Does the fact look crass and material, threatening to degrade thy theory of spirit? Resist it not; it goes to refine and raise thy theory of matter just as much.

There are no fixtures to men, if we appeal to consciousness. Every man supposes himself not to be fully understood; and if there is any truth in him, if he rests at last on the divine soul, I see not how it can be otherwise. The last chamber, the last closet, he must feel, was never opened; there is always a residuum unknown, unanalyzable. That is, every man believes that he has a greater possibility.

Our moods do not believe in each other. To-day I am full of thoughts, and can write what I please. I see no reason why I should not have the same thought, the same power of expression, to-morrow. What I write, whilst I write it, seems the most natural thing in the world; but yesterday I saw a dreary vacuity in this direction in which now I see so much; and a month hence, I doubt not, I shall wonder who he was that wrote so many continuous pages. Alas for this infirm faith, this will not strenuous, this vast ebb of a vast flow! I am God in nature; I am a weed by the wall.

The continual effort to raise himself above himself, to work a pitch above his last height, betrays itself in a man's relations. We thirst for approbation, yet cannot forgive the approver. The sweet of nature is love; yet, if I have a friend, I am tormented by my imperfections. The love of me accuses the other party. If he were high enough to slight me, then could I love him, and rise by my affection to new heights. A man's growth is seen in the successive choirs of his friends. For every friend whom he loses for truth, he gains a better. I thought, as I walked in the woods and mused on my friends, why should I play with them this game of idolatry? I know and see too well, when not voluntarily blind, the speedy limits of persons called high and worthy. Rich, noble, and great they are by the liberality of our speech, but truth is sad. O blessed Spirit, whom I forsake for these, they are not thou! Every personal consideration that we allow costs us heavenly state. We sell the thrones of angels for a short and turbulent pleasure.

How often must we learn this lesson? Men cease to interest us when we find their limitations. The only sin is limitation. As soon as you once come up with a man's limitations, it is all over with him. Has he talents? has he enterprise? has he knowledge? it boots not. Infinitely alluring and attractive was he to you yesterday, a great hope, a sea to swim in; now, you have found his shores, found it a pond, and you care not if you never see it again.

Each new step we take in thought reconciles twenty seemingly discordant facts, as expressions of one law. Aristotle and Plato are reckoned the respective heads of two schools. A wise man will see that Aristotle Platonizes. By going one step farther back in thought, discordant opinions are reconciled, by being seen to be two extremes of one principle, and we can never go so far back as to preclude a still higher vision.

Beware when the great God lets loose a thinker on this planet. Then all things are at risk. It is as when a conflagration has broken out in a great city, and no man knows what is safe, or where it will end. There is not a piece of science, but its flank may be turned to-morrow; there is not any literary reputation, not the so-called eternal names of fame, that may not be revised and condemned. The very hopes of man, the thoughts of his heart, the religion of nations, the manners and morals of mankind, are all at the mercy of a new generalization. Generalization is always a new influx of the divinity into the mind. Hence the thrill that attends it.

Valor consists in the power of self-recovery, so that a man cannot have his flank turned, cannot be out-generalled, but put him where you will, he stands. This can only be by his preferring truth to his past apprehension of truth; and his alert acceptance of it, from whatever quarter; the intrepid conviction that his laws, his relations to society, his Christianity, his world, may at any time be superseded and decease.

There are degrees in idealism. We learn first to play with it academically, as the magnet was once a toy. Then we see in the heyday of youth and poetry that it may be true, that it is true in gleams and fragments. Then, its countenance waxes stern and grand, and we see that it must be true. It now shows itself ethical and practical. We learn that God IS that he is in me; and that all things are shadows of him. The idealism of Berkeley is only a crude statement of the idealism of Jesus, and that again is a crude statement of the fact, that all nature is the rapid efflux of goodness executing and organizing itself. Much more obviously is history and the state of the world at any one time directly dependent on the intellectual classification then existing in the minds of men. The things which are dear to men at this hour are so on account of the ideas which have emerged on their mental horizon, and which cause the present order of things as a tree bears its apples. A new degree of culture would instantly revolutionize the entire system of human pursuits.

Conversation is a game of circles. In conversation we pluck up the _termini_ which bound the common of silence on every side. The parties are not to be judged by the spirit they partake and even express under this Pentecost. To-morrow they will have receded from this high-water mark. To-morrow you shall find them stooping under the old pack-saddles. Yet let us enjoy the cloven flame whilst it glows on our walls. When each new speaker strikes a new light, emancipates us from the oppression of the last speaker, to oppress us with the greatness and exclusiveness of his own thought, then yields us to another redeemer, we seem to recover our rights, to become men. O, what truths profound and executable only in ages and orbs are supposed in the announcement of every truth! In common hours, society sits cold and statuesque. We all stand waiting, empty, — knowing, possibly, that we can be full, surrounded by mighty symbols which are not symbols to us, but prose and trivial toys. Then cometh the god, and converts the statues into fiery men, and by a flash of his eye burns up the veil which shrouded all things, and the meaning of the very furniture, of cup and saucer, of chair and clock and tester, is manifest. The facts which loomed so large in the fogs of yesterday, — property, climate, breeding, personal beauty, and the like, have strangely changed their proportions. All that we reckoned settled shakes and rattles; and literatures, cities, climates, religions, leave their foundations, and dance before our eyes. And yet here again see the swift circumspection! Good as is discourse, silence is better, and shames it. The length of the discourse indicates the distance of thought betwixt the speaker and the hearer. If they were at a perfect understanding in any part, no words would be necessary thereon. If at one in all parts, no words would be suffered.

Literature is a point outside of our hodiernal circle, through which a new one may be described. The use of literature is to afford us a platform whence we may command a view of our present life, a purchase by which we may move it. We fill ourselves with ancient learning, install ourselves the best we can in Greek, in Punic, in Roman houses, only that we may wiselier see French, English, and American houses and modes of living. In like manner, we see literature best from the midst of wild nature, or from the din of affairs, or from a high religion. The field cannot be well seen from within the field. The astronomer must have his diameter of the earth's orbit as a base to find the parallax of any star.

Therefore we value the poet. All the argument and all the wisdom is not in the encyclopaedia, or the treatise on metaphysics, or the Body of Divinity, but in the sonnet or the play. In my daily work I incline to repeat my old steps, and do not believe in remedial force, in the power of change and reform. But some Petrarch or Ariosto, filled with the new wine of his imagination, writes me an ode or a brisk romance, full of daring thought and action. He smites and arouses me with his shrill tones, breaks up my whole chain of habits, and I open my eye on my own possibilities. He claps wings to the sides of all the solid old lumber of the world, and I am capable once more of choosing a straight path in theory and practice.

We have the same need to command a view of the religion of the world. We can never see Christianity from the catechism: — from the pastures, from a boat in the pond, from amidst the songs of wood-birds, we possibly may. Cleansed by the elemental light and wind, steeped in the sea of beautiful forms which the field offers us, we may chance to cast a right glance back upon biography. Christianity is rightly dear to the best of mankind; yet was there never a young philosopher whose breeding had fallen into the Christian church, by whom that brave text of Paul's was not specially prized: — "Then shall also the Son be subject unto Him who put all things under him, that God may be all in all." Let the claims and virtues of persons be never so great and welcome, the instinct of man presses eagerly onward to the impersonal and illimitable, and gladly arms itself against the dogmatism of bigots with this generous word out of the book itself.

The natural world may be conceived of as a system of concentric circles, and we now and then detect in nature slight dislocations, which apprize us that this surface on which we now stand is not fixed, but sliding. These manifold tenacious qualities, this chemistry and vegetation, these metals and animals, which seem to stand there for their own sake, are means and methods only, — are words of God, and as fugitive as other words. Has the naturalist or chemist learned his craft, who has explored the gravity of atoms and the elective affinities, who has not yet discerned the deeper law whereof this is only a partial or approximate statement, namely, that like draws to like; and that the goods which belong to you gravitate to you, and need not be pursued with pains and cost? Yet is that statement approximate also, and not final. Omnipresence is a higher fact. Not through subtle, subterranean channels need friend and fact be drawn to their counterpart, but, rightly considered, these things proceed from the eternal generation of the soul. Cause and effect are two sides of one fact.

The same law of eternal procession ranges all that we call the virtues, and extinguishes each in the light of a better. The great man will not be prudent in the popular sense; all his prudence will be so much deduction from his grandeur. But it behooves each to see, when he sacrifices prudence , to what god he devotes it; if to ease and pleasure, he had better be prudent still; if to a great trust, he can well spare his mule and panniers who has a winged chariot instead. Geoffrey draws on his boots to go through the woods, that his feet may be safer from the bite of snakes; Aaron never thinks of such a peril. In many years neither is harmed by such an accident. Yet it seems to me, that, with every precaution you take against such an evil, you put yourself into the power of the evil. I suppose that the highest prudence is the lowest prudence . Is this too sudden a rushing from the centre to the verge of our orbit? Think how many times we shall fall back into pitiful calculations before we take up our rest in the great sentiment, or make the verge of to-day the new centre. Besides, your bravest sentiment is familiar to the humblest men. The poor and the low have their way of expressing the last facts of philosophy as well as you. "Blessed be nothing," and "the worse things are, the better they are," are proverbs which express the transcendentalism of common life.

One man's justice is another's injustice; one man's beauty, another's ugliness; one man's wisdom, another's folly; as one beholds the same objects from a higher point. One man thinks justice consists in paying debts, and has no measure in his abhorrence of another who is very remiss in this duty, and makes the creditor wait tediously. But that second man has his own way of looking at things; asks himself which debt must I pay first, the debt to the rich, or the debt to the poor? the debt of money, or the debt of thought to mankind, of genius to nature? For you, O broker! there is no other principle but arithmetic. For me, commerce is of trivial import; love, faith, truth of character, the aspiration of man, these are sacred; nor can I detach one duty, like you, from all other duties, and concentrate my forces mechanically on the payment of moneys. Let me live onward; you shall find that, though slower, the progress of my character will liquidate all these debts without injustice to higher claims. If a man should dedicate himself to the payment of notes, would not this be injustice? Does he owe no debt but money? And are all claims on him to be postponed to a landlord's or a banker's?

There is no virtue which is final; all are initial. The virtues of society are vices of the saint. The terror of reform is the discovery that we must cast away our virtues, or what we have always esteemed such, into the same pit that has consumed our grosser vices.

"Forgive his crimes, forgive his virtues too, Those smaller faults, half converts to the right."

It is the highest power of divine moments that they abolish our contritions also. I accuse myself of sloth and unprofitableness day by day; but when these waves of God flow into me, I no longer reckon lost time. I no longer poorly compute my possible achievement by what remains to me of the month or the year; for these moments confer a sort of omnipresence and omnipotence which asks nothing of duration, but sees that the energy of the mind is commensurate with the work to be done, without time.

And thus, O circular philosopher, I hear some reader exclaim, you have arrived at a fine Pyrrhonism, at an equivalence and indifferency of all actions, and would fain teach us that, _if we are true_, forsooth, our crimes may be lively stones out of which we shall construct the temple of the true God!

I am not careful to justify myself. I own I am gladdened by seeing the predominance of the saccharine principle throughout vegetable nature, and not less by beholding in morals that unrestrained inundation of the principle of good into every chink and hole that selfishness has left open, yea, into selfishness and sin itself; so that no evil is pure, nor hell itself without its extreme satisfactions. But lest I should mislead any when I have my own head and obey my whims, let me remind the reader that I am only an experimenter. Do not set the least value on what I do, or the least discredit on what I do not, as if I pretended to settle any thing as true or false. I unsettle all things. No facts are to me sacred; none are profane; I simply experiment, an endless seeker, with no Past at my back.

Yet this incessant movement and progression which all things partake could never become sensible to us but by contrast to some principle of fixture or stability in the soul. Whilst the eternal generation of circles proceeds, the eternal generator abides. That central life is somewhat superior to creation, superior to knowledge and thought, and contains all its circles. For ever it labors to create a life and thought as large and excellent as itself; but in vain; for that which is made instructs how to make a better.

Thus there is no sleep, no pause, no preservation, but all things renew, germinate, and spring. Why should we import rags and relics into the new hour? Nature abhors the old, and old age seems the only disease; all others run into this one. We call it by many names, — fever, intemperance, insanity, stupidity, and crime; they are all forms of old age; they are rest, conservatism, appropriation, inertia, not newness, not the way onward. We grizzle every day. I see no need of it. Whilst we converse with what is above us, we do not grow old, but grow young. Infancy, youth, receptive, aspiring, with religious eye looking upward, counts itself nothing, and abandons itself to the instruction flowing from all sides. But the man and woman of seventy assume to know all, they have outlived their hope, they renounce aspiration, accept the actual for the necessary, and talk down to the young. Let them, then, become organs of the Holy Ghost; let them be lovers; let them behold truth; and their eyes are uplifted, their wrinkles smoothed, they are perfumed again with hope and power. This old age ought not to creep on a human mind. In nature every moment is new; the past is always swallowed and forgotten; the coming only is sacred. Nothing is secure but life, transition, the energizing spirit. No love can be bound by oath or covenant to secure it against a higher love. No truth so sublime but it may be trivial to-morrow in the light of new thoughts. People wish to be settled; only as far as they are unsettled is there any hope for them.

Life is a series of surprises. We do not guess to-day the mood, the pleasure, the power of to-morrow, when we are building up our being. Of lower states, — of acts of routine and sense, — we can tell somewhat; but the masterpieces of God, the total growths and universal movements of the soul, he hideth; they are incalculable. I can know that truth is divine and helpful; but how it shall help me I can have no guess, for _so to be_ is the sole inlet of _so to know._ The new position of the advancing man has all the powers of the old, yet has them all new. It carries in its bosom all the energies of the past, yet is itself an exhalation of the morning. I cast away in this new moment all my once hoarded knowledge, as vacant and vain. Now, for the first time, seem I to know any thing rightly. The simplest words, — we do not know what they mean, except when we love and aspire.

The difference between talents and character is adroitness to keep the old and trodden round, and power and courage to make a new road to new and better goals. Character makes an overpowering present; a cheerful, determined hour, which fortifies all the company, by making them see that much is possible and excellent that was not thought of. Character dulls the impression of particular events. When we see the conqueror, we do not think much of any one battle or success. We see that we had exaggerated the difficulty. It was easy to him. The great man is not convulsible or tormentable; events pass over him without much impression. People say sometimes, 'See what I have overcome; see how cheerful I am; see how completely I have triumphed over these black events.' Not if they still remind me of the black event. True conquest is the causing the calamity to fade and disappear, as an early cloud of insignificant result in a history so large and advancing.

The one thing which we seek with insatiable desire is to forget ourselves, to be surprised out of our propriety, to lose our sempiternal memory, and to do something without knowing how or why; in short, to draw a new circle. Nothing great was ever achieved without enthusiasm. The way of life is wonderful: it is by abandonment. The great moments of history are the facilities of performance through the strength of ideas, as the works of genius and religion. "A man," said Oliver Cromwell, "never rises so high as when he knows not whither he is going." Dreams and drunkenness, the use of opium and alcohol are the semblance and counterfeit of this oracular genius, and hence their dangerous attraction for men. For the like reason, they ask the aid of wild passions, as in gaming and war, to ape in some manner these flames and generosities of the heart.

Ralph Waldo Emerson left the ministry to pursue a career in writing and public speaking. Emerson became one of America's best known and best-loved 19th-century figures. More About Emerson

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"Every man has his own courage, and is betrayed because he seeks in himself the courage of other persons." – Ralph Waldo Emerson

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Student Opinion

What Role Does Nature Play in Your Life?

By Jeremy Engle

• April 19, 2019

What are your experiences with nature?

How often do you take a leisurely stroll through the grass, a garden or the woods? How often do you stop to look at, touch or smell a flower?

How do you feel when you are alone in nature? Do you find it relaxing, invigorating, healing?

In “ The Healing Power of Gardens ,” Oliver Sacks, a neurologist who died in 2015, wrote:

As a writer, I find gardens essential to the creative process; as a physician, I take my patients to gardens whenever possible. All of us have had the experience of wandering through a lush garden or a timeless desert, walking by a river or an ocean, or climbing a mountain and finding ourselves simultaneously calmed and reinvigorated, engaged in mind, refreshed in body and spirit. The importance of these physiological states on individual and community health is fundamental and wide-ranging. In 40 years of medical practice, I have found only two types of non-pharmaceutical “therapy” to be vitally important for patients with chronic neurological diseases: music and gardens.

The essay continues:

I have lived in New York City for 50 years, and living here is sometimes made bearable for me only by its gardens. This has been true for my patients, too. When I worked at Beth Abraham, a hospital just across the road from the New York Botanical Garden, I found that there was nothing long-shut-in patients loved more than a visit to the garden — they spoke of the hospital and the garden as two different worlds. I cannot say exactly how nature exerts its calming and organizing effects on our brains, but I have seen in my patients the restorative and healing powers of nature and gardens, even for those who are deeply disabled neurologically. In many cases, gardens and nature are more powerful than any medication. My friend Lowell has moderately severe Tourette’s syndrome. In his usual busy, city environment, he has hundreds of tics and verbal ejaculations each day — grunting, jumping, touching things compulsively. I was therefore amazed one day when we were hiking in a desert to realize that his tics had completely disappeared. The remoteness and uncrowdedness of the scene, combined with some ineffable calming effect of nature, served to defuse his ticcing, to “normalize” his neurological state, at least for a time. An elderly lady with Parkinson’s disease, whom I met in Guam, often found herself frozen, unable to initiate movement — a common problem for those with parkinsonism. But once we led her out into the garden, where plants and a rock garden provided a varied landscape, she was galvanized by this, and could rapidly, unaided, climb up the rocks and down again. I have a number of patients with very advanced dementia or Alzheimer’s disease, who may have very little sense of orientation to their surroundings. They have forgotten, or cannot access, how to tie their shoes or handle cooking implements. But put them in front of a flower bed with some seedlings, and they will know exactly what to do — I have never seen such a patient plant something upside down.

The essay concludes:

Clearly, nature calls to something very deep in us. Biophilia, the love of nature and living things, is an essential part of the human condition. Hortophilia, the desire to interact with, manage and tend nature, is also deeply instilled in us. The role that nature plays in health and healing becomes even more critical for people working long days in windowless offices, for those living in city neighborhoods without access to green spaces, for children in city schools or for those in institutional settings such as nursing homes. The effects of nature’s qualities on health are not only spiritual and emotional but physical and neurological. I have no doubt that they reflect deep changes in the brain’s physiology, and perhaps even its structure.

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Life without Principle Essay

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Introduction: the Main Themes of Life without Principle

Main message of life without principle, thoreau’s life without principle: conclusion, works cited.

Life without Principle is one of the most remarkable short works by an American author and critic Henry David Thoreau. The essay was published in 1863, 15 years after the famous Civil Disobedience. In summary, Life without Principle and other Thoreau’s books influenced many people of different ages and social statuses. Political leaders found his works educative and used quotes from Life without Principle in their practice. Ordinary people, in their turn, found the message of the text very personal and compelling. That is why it was not a surprise that Thoreau’s essay was recognized as a work that offered a program to be taken by every righteous person. One can not reduce the summary of Life without Principle to one topic. It is rather a list of themes and thoughts illustrated by real-life examples. Through the latter, the character and personal experience of the writer are revealed.

Though it is hard to define one concrete thesis of Henry David Thoreau’s Life without Principle, the point that this thesis somehow connected to money and its power in the world is evident. “This world is a place of business” (Thoreau 4) is one of the leading phrases in Life without Principle that depicts a true nature of H.D.Thoreau’s ideas and attempts; this message of Life without Principle is considered to be the central fact that is proved throughout the whole text by means of examples, which fulfill our everyday life. In this essay, I make an analysis of Life without Principle.

Thoreau is the author who does not want to stop on one message and develop it during the whole paper. That is why what he chooses for his Life without Principles is compelling and captivating. He presents one major theme of Life without Principle, defining the world as the place of business and tries to prove the chosen position by a variety of examples.

He argues about the values and goals of people, who are eager to develop commerce and support the ideas of globalization without taking into consideration the fact that people themselves become victims of personal desires. He raises one of the most provocative analyzation questions that influence our lives considerably and tries to conclude whether all those costs, both financial and spiritual, are worthy of the profits.

The purpose of the essay is to show its reader the way of how money rules this world. From the very beginning, the author correctly defines his positions with respect to the reader and admits that he does not want to “talk about people a thousand miles off, but come as near home” as possible (Thoreau 2). Such concretization makes the reader believe that his purposes are pure and definite. He writes to help, open the reader’s eyes, and show how wrong or useless human attempts can be. This is the major theme of Life without Principle.

His purpose is to characterize the way how materialism and commercialism enslave American society, to show how the Good Life should look like, and to teach the reader to analyze personal attitude to lives, where money and prosperity may lose their powers and impact on people. He wants to show how elusive human demands can be, admitting that “the ways by which you may get the money almost without exception lead downward” (Henry David Thoreau, Life without Principle, 8).

The target audience of the essay cannot be framed. One of the most peculiar features of Life without Principle is that there is no concretization concerning who is intended to be the reader of this essay.

It may be an unfortunate debtor who “goes to church to take account of stock” or men, who are “so well employed,” or a “gold-digger” with his passion for gambling, etc. (Thoreau 13, 10, 19). In other words, this essay may become somewhat helpful for those who somehow deal with money, and these are all people in the world. The author admits that people become dependent on money unintentionally. The writer “cannot easily buy a blank-book to write thoughts in” because everything is “ruled for dollars and cents” (Henry David Thoreau 4).

Maybe, it is safe and more effective not to define the target audience at once and provide every reader with a chance to discover whether this source is exciting and helpful for him/her. The uniqueness of this essay is the author’s impartiality to the reader and unbelievable focus on the topic.

The purpose of the essay is achieved through a close connection to the reader’s demands. After reading this essay, a powerful desire to re-evaluate personal life and place in this world appears. In my opinion, this is the desired effect expected from the paper.

When the reader accepts the author’s point of view and finds that these ideas are appropriate for this life, the primary purpose of any essay is achieved. In Life without Principle, Thoreau’s goal is to show how considerable and influential the power of money can be, and how people limit their opportunities.

One debtor may read this essay and comprehends that his troubles and his challenges mean nothing in comparison to his spiritual life and his attitude to life. This is why it is possible to say that the author’s choice to use real-life examples and personal experience in this work is wholly justified. Even more, it becomes an effective means to achieve the essential purpose and convict the reader.

The effectiveness of the essay lies deep into the author’s demands. I genuinely believe that one of the first steps that need to be taken by any author is to believe in personal ideas and thoughts. The chosen argument is perfectly argued because the author uses as many different things as possible to show when his ideas are likely to rely upon. He not only teaches the reader but also explains why these lessons are essential. His powerful examples that are so close to our everyday routines cannot but impress the reader.

“If a man walk in the woods for love of them half of each day, he is in danger of being regarded as a loafer, but if he spends his whole day as a speculator, shearing off those woods and making earth bald before her time, he is esteemed an industrious and enterprising citizen.” (Thoreau 6). This citation would probably be the best summary of Life without Principle.

This paper aimed to make an analysis of Life without Principle by Henry David Thoreau. This is one of the great writings offered by the author. The essay reviews the main idea of Life without Principle. Quotes and excerpts from the text are used as illustrations.The messages of the work by Thoreau are touching and educative, helpful and frustrating, amazing, and sometimes evident. Due to such doubtful nature, many readers can find the book interesting under their demands.

Everyone knows that he/she lives in a world that is too dependable on money because each citizen is a voluntary participant in this pursuit for profit. The effectiveness of the essay under discussion lies in its connection to everyday problems and human desires: people want to become smart and prudent in their activities, but their attention and passion make them so blind and stupid, and, what is more frustrating, dependent on their product, money.

Thoreau, Henry, D. Life without Principle . 2010. Web.

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IvyPanda. (2018, June 28). Life without Principle. https://ivypanda.com/essays/life-without-principle-the-analysis-of-the-essay/

"Life without Principle." IvyPanda , 28 June 2018, ivypanda.com/essays/life-without-principle-the-analysis-of-the-essay/.

IvyPanda . (2018) 'Life without Principle'. 28 June.

IvyPanda . 2018. "Life without Principle." June 28, 2018. https://ivypanda.com/essays/life-without-principle-the-analysis-of-the-essay/.

1. IvyPanda . "Life without Principle." June 28, 2018. https://ivypanda.com/essays/life-without-principle-the-analysis-of-the-essay/.

Bibliography

IvyPanda . "Life without Principle." June 28, 2018. https://ivypanda.com/essays/life-without-principle-the-analysis-of-the-essay/.

English Compositions

Short Essay on Life Without Technology [100, 200, 400 Words] With PDF 

In today’s session, you will learn to write short essays on the topic of Life Without Technology. There will be three sets of essays covering different word limits. 

Short Essay on Life Without Technology in 100 Words 

Today, technology has become an important part of our daily lives. Mobile phones, tablets and computers have made connecting with people around the world an easy task. We can send and receive pictures, videos and documents over the internet. Technologically advanced machines like automatic washing machines, dishwashers, cleaning robots, smart televisions and various smart appliances have made life very comfortable for people.

However, these appliances have also made people lazy. People today have lost the connection with nature, with real people, with their friends and families. They hardly need to do their day-to-day work by themselves and have become physically unfit. Life without technology seems impossible today, but one must make sure to strike a balance between depending on technology and doing their work themselves. 

Short Essay on Life Without Technology in 200 Words 

There is no doubt that technology has made life easier for people. A hundred years ago, people wouldn’t have imagined that today, we will have so many gadgets to help us with our daily life. 

Today, mobile phones, tablets and computers have made connecting with people around the world an easy task. We can send and receive pictures, videos and documents over the internet. Technologically advanced machines like automatic washing machines, dishwashers, cleaning robots, smart televisions and various smart appliances have made life very comfortable for people. Even students are now dependent on online platforms to learn and understand their subjects better. If we want to travel, we do not use physical maps anymore but depend on GPS. 

However, these appliances and applications have also made people lazy. People today have lost the connection with nature, with real people, with their friends and families. They hardly need to do their day-to-day work by themselves and have become physically unfit. If someone loses their mobile phone, it feels as if they have lost an organ. Life without technology seems impossible today, but one must make sure to strike a balance between depending on technology and doing their work themselves. Only then, technology will prove to be a boon and not a bane for us. 

Short Essay on Life Without Technology in 400 Words

Today, technology has changed the way we conduct our lives and it is hard to imagine getting through the day without help from one or the other type of gadget. 

Today, mobile phones, tablets and computers have made connecting with people around the world an easy task. We can send and receive pictures, videos and documents over the internet. Technologically advanced machines like automatic washing machines, dishwashers, cleaning robots, smart televisions and various smart appliances have made life very comfortable for people.

Even students are now dependent on online platforms to learn and understand their subjects better. For their research and assignments, they need the help of the internet. If we want to travel, we do not use physical maps anymore but depend on GPS. One needs so many gadgets in the office like desktops, printers, xerox machines, fax machines, et cetera. Even in the kitchen, one needs mixer-grinders, food processors, microwave ovens and refrigerators. If we want to go somewhere and need to book train, bus or flight tickets for the same, we still use the internet. 

However, these gadgets, appliances and applications have also made people lazy. People today have lost the connection with nature, with real people, with their friends and families. They are always glued to their phone screens, happy in their virtual world and dislike going out. They hardly need to do their day-to-day work by themselves and have become physically unfit. If one wants some information, instead of thoroughly reading about it and understanding the topic completely, they can just search on the internet and get a short, concise answer.

All this has slowed down our brains and made us lose our creativity. Our lives have become entirely dependent on technology and gadgets. One cannot survive without mobile phones today. Be it an office employee or a school student, everyone needs a phone to stay connected with their family, friends, work and school. If someone loses their mobile phone, it feels as if they have lost an organ. 

A hundred years ago, people wouldn’t have imagined that today, we will have so many gadgets to help us with our daily life. Life without technology seems impossible today, but one must make sure to strike a balance between depending on technology and doing their work themselves. Only when things are well-balanced, technology will prove to be a boon and not a bane for us. Otherwise, it wouldn’t take long for us to lose ourselves in gadgets and the virtual world and destroy our health and peace of mind. 

In today’s session, I have written these sample essays with a very simplistic approach for a better understanding of all kinds of students. If you still have any doubts regarding this topic, kindly, keep me informed through some quick comments. I’ll try to answer all your queries to the best of my ability. To read more such essays on various other important topics, keep browsing our website. 

Thank you for being with us. Have a great day.

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• Published: 09 September 2024

Long term follow-up of a completely metal free total knee endoprosthesis in comparison to an identical metal counterpart

• Robert Breuer 1 ,
• Rainer Fiala 1 ,
• Florian Hartenbach 2 ,
• Florian Pollok 2 ,
• Thorsten Huber 2 ,
• Barbara Strasser-Kirchweger 3 ,
• Bjoern Rath 2 &
• Klemens Trieb 4 , 5  

Scientific Reports volume  14 , Article number:  20958 ( 2024 ) Cite this article

Metrics details

• Osteoarthritis

Aseptic loosening is a feared and not yet fully-understood complication of total knee arthroplasty (TKA). Hypersensitivity reactions may be the underlying cause within some susceptible patients. Metal-free implants have been developed as a possible solution. The aim of this prospective, observational long-term study was the assessment of a completely metal-free ceramic knee replacement system compared to its identical metal counterpart 8 years after implantation, conducted as a follow-up of a previous report. A total of 88 patients (mean age 69 years) were enrolled in this prospective, observational long-term 8-year follow-up study. The “ceramic group” with a completely metal-free total knee replacement system was compared to the “conventional group” with an identical metal TKA system at the final follow-up. Clinical assessment included Knee Society Score (KSS), Oxford Knee Score (OKS), European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-L), European Quality of Life 5 Dimension Visual Analogue Scale (EQ-VAS) and High Activity Arthroplasty Score (HAAS) as well as perioperative or postoperative complications and need for revision. The tibial/femoral positioning, signs of periprosthetic fissures/fractures or radiolucent lines were documented radiographically. All postoperative clinical scores in the ceramic group primarily improved from baseline to 4-year follow-up, but then decreased at the final 8-year follow-up. At the final follow-up, statistically non-significant differences were found in comparison of both groups for the KSS (ceramic: 166 ± 31, conventional: 162 ± 29; p  > 0.05), OKS (ceramic: 37, conventional: 39; p  > 0.05), EQ-VAS (ceramic: 77 ± 17, conventional: 72 ± 18; p  > 0.05), and HAAS (ceramic: 8.29 ± 3.32, conventional: 9.28 ± 4.44; p  > 0.05). A significant difference was found for EQ-5D-L (ceramic: 0.819 ± 0.284, conventional: 0.932 ± 0.126; p  ≤ 0.05). Progressive radiolucent lines have been found around the uncemented tibial stem (0.8 mm at initial diagnosis (mean 19 months); 1.3 mm at 4-year follow-up; 1.6 mm at 8-year follow-up) without any clinical signs of loosening. One revision surgery was performed after a traumatic polyethylene inlay-breakage. No allergic reactions could be detected. The used ceramic TKA system meets the functional performance standards of an established identical metal TKA system after an 8-year follow-up period, offering a safe option for patients with prior hypersensitivity reactions to metallic materials. Full cementation of ceramic components is recommended.

Introduction

With rising life expectancy and higher activity levels of patients, more durable total knee arthroplasty (TKA) systems are being sought. In this context, there are growing concerns about aseptic loosening caused by metal hypersensitivity, which unfortunately still is a poorly understood phenomenon. Almost 20% of patients with properly aligned and well-fixed knee implants remain dissatisfied with the results, which in turn puts a great burden on both the surgeon and the patient 1 .

It is a well-known fact, that any metal being placed within a biological environment will undergo corrosion. The large metallic surfaces of TKAs are particularly prone to such corrosive processes, with subsequent release of metal ions into the human tissue 2 . An increased metal ion concentration in patients’ blood plasma after TKA has been detected, which may cause common hypersensibility reactions 3 . Early failures of orthopedic implants due to mechanical loosening have recently been related to indirect activation of macrophages through metal ions after contacting host fluids 4 .

Within the general population, the prevalence of cutaneous hypersensitivity to nickel is approximately 10–15% 4 , 5 , and as high as 25% in patients with metal previously implanted 6 , 7 . However, the actual incidence of metal hypersensitivity to general metallic implants is less than 1% 8 . Up to 60% of all patients with failure of total joint arthroplasty express signs of metal allergy with positive allergologic test results, but the actual influence on the implant’s service life remains unclear 7 . Signs of hypersensitivity to the previously implanted metallic joint replacement may be unexplainable postoperative pain, sustained swelling, decreased range of motion and bone resorption 1 , 6 . Cutaneous reactions like eczema or dermatitis are not always present 1 , 6 .

In several patients with aseptic implant loosening and verified metal allergy, contact-induced local/general allergic reactions remained until removal of the orthopedic device 9 . Nickel constitutes the highest metal sensitivity within the population, and is usually included in orthopedic implants to grant necessary implant strength and durability 10 . Most common orthopedic implants consist of 316 L stainless steel (19% chromium, 14% nickel), cobalt-chromium-molybdenum (67% chromium, 30% cobalt, 2% molybdenum, 1% nickel), or titanium-alloy (91% titanium, 5% aluminum, 3.9% vanadium, 0.1% nickel) 11 .

To avoid at least part of the problems in patients with known history of hypersensitivity reactions to metals, “hypersensitivity-friendly” metal-free implants and instruments have been developed 12 , 13 . Especially bio-ceramic materials have already shown promising in vitro and in vivo results with a comparable outcome to standard metal implants 14 , 15 , 16 .

The aim of this prospective, observational long-term study was the assessment of a completely metal-free ceramic knee replacement system compared to its identical metal counterpart 8 years after implantation, conducted as a follow-up of a previous report by the current authors 17 .

Materials and methods

Study population.

This study was conducted as a prospective, observational long-term study over a follow-up period of 8 years. A total of 88 patients have been enrolled at the beginning.

Forty-two patients were enlisted into the “Ceramic group” and implanted with the completely metal-free Brehm Precision Knee System (BPK-S) Integration total knee replacement system® (Peter Brehm GmbH, Weisendorf, Germany) with a composite matrix material containing aluminum oxide (Al 2 O 3 ) and zirconium oxide (ZrO 2 ) (Biolox®delta; CeramTec AG, Plochingen, Germany) for both the femoral and tibial components. A standard, fixed bearing ultra-high-molecular-weight polyethylene (UHMWPE) inlay was used to complete the wear couple.

Another 46 patients were enrolled into the “Conventional group” and implanted with the identical standard BPK-S total knee arthroplasty made of a cobalt-chrome alloy. The same UHMWPE inlay was used as implanted in the “Ceramic group”.

For both groups, consecutive recruiting has been performed. Subjects from the conventional group were initially recruited for a primary control group, which could not be examined at the beginning due to a lack of financial resources.

Inclusion criteria were age > 18 years and < 85 years at the date of surgery, osteoarthritis or rheumatoid arthritis of the knee joint which required TKA after failing conservative treatment with consecutive severe limitations of activities of daily life (ADLs), credible anamnestic or via epicutaneous test suggested hypersensitivity reactions to metallic materials (for the “ceramic group”) 1 , 7 .

The Exclusion criteria were age < 18 or > 85 years, previous surgery causing measurable alterations of the lower extremity such as osteotomy or patellectomy, preoperative ROM of < 90° flexion, > 20° of fixed valgus or varus deformity, severe ligamentous instability, excessive extra-articular femoral or tibial hereditary or posttraumatic bony deformity (defined by the need for concomitant extra-articular osteotomy or an implant with varus-valgus constraint), revision TKA, previous intra-articular knee infection or osteomyelitis of the adjacent bones, metastatic cancer, major neurological or musculoskeletal disorders altering gait pattern or weight bearing, drug addiction, and pregnancy. All patients had to give their written consent to participate within this study, all methods were performed in accordance with the relevant guidelines and regulations. The study was approved by the ethics committee of the Territory of Upper Austria (Study-Nr. B-13–11) and registered in ClinicalTrials.gov (Identifier: NCT03097471).

Intra- and perioperative management

All cases were preoperatively planned via aid of a surgical planning software (MediCAD®, HECTEC GmbH, Landshut, Germany). Full-length a.p. standing radiographs were used according to the technique used by McGrory 18 . Resection lines were planned to acquire a mechanical axis of 0° deviation. For exact implant positioning, an extramedullary guided technique was used for the tibial component and an intramedullary system for the femoral component. Intraoperative ligament balancing guaranteed the proper rotational positioning of the femoral component. The instrumentation was of identical design for both implants, except for a complementary special plastic coating for the metal-free implant to strictly prevent any metal contacting the ceramic components. Standard polymethyl-methacrylat (PMMA) bone cement (Palacos®, Zimmer Biomet; Freiburg im Breisgau, Germany) was used to fixate the femoral and tibial components. The ceramic implants had to be meticulously dried off before cementing. In both implants, the tibial post was spared during the cementation process, as it is viable according to the recommendation of the manufacturer. The cement mantle had to be below a thickness of 2 mm for the femoral component. The patients were mobilized under the tutelage of experienced physiotherapists starting on the first postoperative day according to a standardized procedure. They were allowed full weight bearing using two crutches. For prophylaxis of venous thrombosis, a light molecular weight heparin was administered on a daily basis for six weeks. A continuous passive motion (CPM) device was used to help the patients exercise their knee joint during their in-hospital stay until they reached 90 degrees of flexion, which was a main criterion for dismissal. Other criteria for hospital discharge were safe climbing of at least 1 flight of stairs and a compensated pain situation.

Clinical evaluation

The clinical outcome of the ceramic implant was evaluated preoperatively (baseline), as well as 12 months, 48 months and 96 months postoperatively using the Knee Society Score (KSS) 19 , Oxford Knee Score (OKS) 20 , European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-L) and European Quality of Life 5 Dimension Visual Analogue Scale (EQ-VAS) 21 . The control group has been introduced only for the final follow-up, therefore no prior values have been acquired for the aforementioned parameters. For evaluation of sports activity level, the High Activity Arthroplasty Score (HAAS) was used at final follow-up in both groups 22 . Collected data also included occurrence of early/late revision surgery, medical device incidences, and any pre-/intra-/postoperative complications of any kind throughout the entire study period.

Radiological evaluation

As previously described, preoperative standardized X-rays of the respective knee joint (anteroposterior, lateral, full-length ap standing) were obtained for every patient in the ceramic group. Radiological follow-up, obtaining the same X-rays, occurred on the first postoperative day (except full-length a.p. standing), and at follow-up visits after 3 months, 6 months, 12 months, 24 months, 48 months and 96 months. All cases in the control group have undergone radiological follow-up as well, but not in the same strict intervals. The tibial/femoral component positioning was evaluated by two independent observers in the standard anteroposterior and lateral views according to the method of the Knee Society Roentgenographic evaluation 23 , documenting the implant positioning and alignment, any periprosthetic fissures/fractures, as well as possible radiolucent lines or osteolysis.

Statistical analysis

Descriptive data are presented as mean and standard deviation for between-subject data. For within-subject data the median and range are reported additionally. Standard distribution testing was performed by means of the Shapiro–Wilk test. Due to the violation of normal distribution, within-subject differences of score values (KSS, OKS, EQ-5D-L, EQ- VAS and HAAS) and radiographic measurements, at the follow-up measurements were evaluated using the Friedman-Test. To determine the magnitude of effects found, Kendall’s W was calculated for each Friedman-Test. In case of a significant results post-hoc Bonferroni corrected pairwise comparisons were conduncted using Wilcoxon Test.

For between-subject comparisons independent sample T-test (two-sided; robust against normal distribution violation) was used with adjustment of degrees of freedom (Welch). To determine the effect size of between-subject comparisons Cohens d was used. The level of significance for all conducted analyses was set to p  ≤ 0.05. All statistical analyses were undertaken using R (Version 2023.03.0 Build 386) and written as RMarkdown report.

The “ceramic group” consisted of 42 cases with a mean age at surgery of 69 ± 8.38 years and 74 ± 7.73 years at the final follow-up. Thirty-six (86%) of these patients were female. The surplus of female cases in the ceramic group can be explained by the much higher prevalence of metal allergies in the female population 24 , 25 . The primary indications for total knee arthroplasty were osteoarthritis (96%) and rheumatoid arthritis (4%). Patients’ median hospital stay was 11 days (Min = 7d, Max = 21d). The “conventional group” consisted of 46 cases with a mean age at surgery of 69 ± 8.64 and 75 ± 7.96 years at the time of the last follow-up. Twenty-six (57%) of these patients were female. The indication for total knee arthroplasty was osteoarthritis in all included cases. Average hospital stay was 11 days (Min = 6d, Max = 29d) as well. Patient age and hospital stay comparison did not reveal any statistical difference ( p  = 0.337; p  = 0.531). One revision surgery had to be performed in the ceramic group because of a broken polyethylene inlay after a traumatic event, which occurred roughly six years after implantation. This patient has been excluded from further follow-up. Furthermore, one case of postoperative deep vein thrombosis was diagnosed in each group, which did not prevent further follow-up visits for study purposes. At the eight-year follow-up, no more complications have been registered.

At the final follow up, 31 patients were left to analyze in the ceramic group. The one mentioned patient was excluded due to revision surgery, 7 patients have died, and 3 patients were lost to follow-up. In the conventional group, 32 patients could be examined at the latest follow-up. Of the initial group, 10 patients died, and 4 were lost to follow up.

“Ceramic group”

All but one patient developed radiolucent lines around the tibial post of the prosthesis. The mean width of radiolucent lines at the tibial post at initial diagnosis was 0.8 ± 0.5mm and the average duration until primary diagnosis was 19 ± 21 months (Min = 3, Max = 93) after surgery. Over time, the radiolucencies progressed to a width of 1.3 ± 1 mm ( p  = 0.004) at the 4-year follow-up and 1.6 ± 1.1 mm ( p  < 0.001) at final follow-up after eight years. The effect size showed a moderate magnitude (Kendall-W 0.46). The exact development is depicted in Figs.  1 and 2 .

Development of radiolucent lines after metal-free implant (“Ceramic group”). Significant progression from the 1-year follow-up (1Y FU) to 4-year (4Y FU) and 8-year follow-up (8Y FU).

Radiographs of radiolucent lines around the tibial post (“Ceramic group”). X-rays taken from a 59 year old patient, left knee. ( A ) postoperatively; ( B ) 1-year follow-up; ( C ) 4-year follow-up; ( D ) 8-year follow-up.

Each individual score improved significantly from baseline to 1 year postoperatively ( p  ≤ 0.001). The functional scores Knee Society Score and Oxford Knee Score remained at the same level until the 4-year follow-up compared to one year after surgery ( p  = 1), but decreased significantly from four years to eight years after surgery ( p  ≤ 0.001).

The EQ-5D-L and EQ-VAS developed divergently. The EQ-5D-L showed a significant decrease between the first and fourth year after surgery ( p  = 0.007) with no further differences compared to the eight postoperative year ( p  = 1). The EQ-VAS improved significantly from 1-year follow-up to 4-year follow-up ( p  ≤ 0.001), but decreased from the 4-year follow-up to the final eight year examination ( p  ≤ 0.001). To the eight year follow up, each score showed a significant decrease ( p  ≤ 0.001), except for the EQ-5D-L, as already stated above. When comparing the baseline values to the final follow-up, the OKS ( p  = 1) decreased to the baseline level, whereas the KSS, the EQ-5D-L and EQ-VAS ( p  ≤ 0.001) remained constantly better. For each of the intraindividual score comparisons, the effect size showed a large effect (Kendall-W: KSS: 0.77; OKS 0.71; EQ-5D-L: 0.5; EQ-VAS 0.8). Eight years after surgery, the High Activity Arthroplasty Score (HAAS) was assessed with a sample mean of 8.29 ± 3.32, where the maximally achieved score could have been 18.

The exact numbers of each individual score and its respective development during the follow-up period are depicted in Fig.  3 and Table 1 .

Development of functional and quality of life score after metal-free implant (“Ceramic group”). ( A ): Knee Society Score KSS, ( B ): Oxford Knee Score, ( C ): EQ-VAS,  ( D ): EQ-5D-L; 1Y FU = 1-year follow-up, 4Y FU = 4-years follow-up, 8Y FU = 8-years follow-up; * = statistically significant; ns = statistically non-significant;

“Ceramic group” vs. “conventional group”

As already stated above, the two groups did not differ in age or gender characteristics as well as in the duration of hospital stay. Due to the identical nature of implantation technique and implant system, comparability of the two groups is given. Comparing the two groups at 8-year follow-up, functional outcome parameters did not differ significantly, with the EQ-5D-L being an exception. The single exception was the EQ-5D-L with a small significant difference in favor of the convention implant. Table 2 gives an overview about exact numbers and p -values of the group comparison.

Since the role of hypersensitivity reactions to metallic materials and possible consequent aseptic loosening is not yet finally determined in susceptible patients, a certain factor of insecurity remains for both patient and surgeon once complaints after TKA arise 26 . To our knowledge, this is the first long-term follow-up investigating the clinical outcome and safety of a completely metal-free TKA system.

A recent systematic review by Xiang et al., showing satisfactory mid- and long-term survival of ceramic femoral components in total knee arthroplasty, are somewhat comparable with conventional alloy components 27 . Another recent systematic review and meta-analysis by Banci et al. investigated nitride-based ceramic coatings in total knee arthroplasty 28 . The results showed comparable survival rates, complication rates, metal blood concentration and clinical outcome among the two groups after a 1-year follow-up 28 . These findings are compatible with our research, where ceramic components in TKA display highly similar outcomes compared to their metallic counterparts even after a follow-up period of 8 years.

A 13-year follow-up study of oxinium-zirconium femoral components compared to cobalt-chrome femoral components in patients’ contralateral knee showed very similar results regarding functional scores and range-of-motion. No radiographic evidence of osteolysis or loosening around the ceramic femoral component was detected in CT scans. The Kaplan–Meier survivorship free from revision was 97% vs. 98% 29 . In our study group, radiolucent lines appeared in all but one patient after ceramic TKA around the tibial post, which we already documented in a previous paper 17 . Nevertheless we did not find any sign of clinical component loosening (e.g. pain, effusion or instability) in our patients. As described in our previous report, the missing cement mantle around the post could have led to this phenomenon 17 . Non-progressive partial radiolucent-lines have been described in 6 out of 38 patients (5 tibial, 1 femoral) with the same metal-free TKA system at 1-year follow-up by Meier et al., each being less than 1 mm in width and occurring at the bone-cement interface 12 . Guha et al. generally ascribe such radiolucent lines to a stress-shielding phenomenon or poor cement penetration due to sclerotic bone 30 . Whatever the underlying reason for our progressive radiolucent lines may be, they currently do not affect the clinical presentation, as no revision surgery due to loosening or pain had to be undertaken at 8-year follow-up. However, the progression will need to be examined closely within the next years to further guarantee efficacy and safety of this system, as well as to draw final conclusions concerning the survival rate and polyethylene wear of the ceramic TKA. Even if radiolucent lines do not always warrant revision surgery in “conventional” TKA designs as well 31 , we still recommend to use full cementation around the entire implant-bone interface. Therefore further radiolucencies may be avoided and consequent uncertainties from patients as well as unwanted revision from alarmed colleagues can be prevented. In general, we had a surprisingly high implant survival rate. Nevertheless it should be stated, that a noticeable amount of patients died in course of the follow up, in both the conventional and ceramic group, so the actual long term implant survival rate may be affected due to this fact.

Finally, none of our patients developed an allergic reaction to the implant or exacerbation of existing hypersensitivities, therefore underlining the rationale of utilizing completely metal-free TKA in patients with known hypersensitivities. Regarding functional outcome, the above mentioned study demonstrated a similar Knee Society Score at 13-year follow-up with patients aged less than 55 at implantation, in comparison to our 8-year follow-up with a mean age of roughly 69 at the time of implantation 29 . Similar long-term clinical results were shown by Heesterbeck et al. at 11-year follow-up of 189 cases comparing fixed-bearing vs. mobile-bearing metallic TKAs, with a mean total KSS of 157 32 . Kim et al. 33 published a mean Knee Society Score of 172 at 11-year follow-up within 92 bilaterally implanted TKAs (high-flexion fixed-bearing vs. high-flexion mobile bearing) at a mean age of 72 years at final follow-up. Although our studied patients were older at final follow-up with a mean of roughly 79 years, a similar mean Knee Society Score could be found. The Oxford knee score, as another valid tool to asses general function after TKA, revealed similar results to current literature as well 34 . In addition, this case series represents one of the longest follow-up intervals, in which the Oxford knee score has been assessed.

Our results showed a highly satisfactory increase in clinical scores from baseline until the 4-year follow-up. However, the 8-year follow-up depicted a statistically significant decrease in Knee Society Score, Oxford Knee Score and EuroQol VAS. Nevertheless, most of the functional scores remained at a higher average than the respective baseline levels. Similar findings were published by Bercovy et al., arguing a slight functional decrease already at 4-year follow up within 152 TKAs with minimal ligament release due to increasing age 35 . The same can be seen in another case series by Williams et al. 34 . We can support this explanation, as our elderly patients presented many additional musculoskeletal ailments aside from the satisfactory function of the TKA. These further limitations could certainly affect the answers for respective clinical scores and lead to a non-knee specific reduction.

Since the elderly population is continuously increasing their activity level, we focused not only on “classic” pain-centered outcome scores, but took quality of life and even sports activity into account. Even if the average age of our subjects at final follow up was 79 years, the patients in both groups did reach a comparatively good sports performance in the HAAS score 36 , 37 . This emphazises the importance of these matters even in the elderly population, when the success of arthroplasty is evaluated in future research projects. Compared to current literature of conventional and anti-allergic TKA our quality of life results appear very similar 31 , 38 . We could see a barely significant difference between the conventional and ceramic TKA group at final follow-up, which can be attributed to the larger standard deviation, and in our opinion does not depict any specific clinical relevance. In total, the metal-free alternative shows acceptable long-term-results at the time of final follow-up, not only in comparison to current literature but also in direct comparison with a highly similar control group after implantation with an identical conventional counterpart.

The strengths of this study are its prospective design, the obtained long-term results, the introduction of a control group, the homogenous patient characteristics in both groups, the additional focus on patient related outcome measures and the strict inclusion and exclusion criteria.

The limitations include the comparatively small number of enrolled patients, which can be attributed to the initial recruitment in the pilot study as well as the rather small prevalence of a verified metal allergy within the general population. In the ceramic group the gender distribution is not evenly matched. As already stated above, metal allergy is mainly a female phenomenon, therefore an even recruiting was unlikely to be reached. Another restriction is the late introduction of the “conventional” control group at the final follow-up and the high drop-out rate. This can be attributed to the naturally high mortality rate of the geriatric subjects, and at least partially due to the COVID-19 pandemic.

In our series, the BPK-S ceramic TKA system meets the durability and functional performance standards of an established identical metal TKA system after an 8-year follow-up period, offering a safe option for patients with prior hypersensitivity reactions to metallic materials. We recommend full cementation of the entire ceramic-bone interface to avoid possible radiolucent lines, even if the clinical consequences still remain unclear. Further prospective long-term studies with larger case numbers are required to validate the results and to provide the possibility of establishing metal-free designs as standard options for total knee arthroplasty.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Robert Breuer & Rainer Fiala

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R.F., F.H.,T.H. and F.P. carried out clinical investigation, R.B. wrote the main manuscript text and R.B. prepared Figs. 1–3. All authors reviewed the manuscript. B.S.K. statistics, supervisison B.R. and K.T., conception K.T.

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Breuer, R., Fiala, R., Hartenbach, F. et al. Long term follow-up of a completely metal free total knee endoprosthesis in comparison to an identical metal counterpart. Sci Rep 14 , 20958 (2024). https://doi.org/10.1038/s41598-024-71256-y

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DOI : https://doi.org/10.1038/s41598-024-71256-y

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