Edge loading is a common wear mechanism in Metal-on-Metal (MOM) hip resurfacing and is associated with higher wear rates and the incidence of pseudotumour. The purpose of this study was to develop a method to investigate the contributions of patient, surgical and implant design variables on the risk of edge loading. We created a mathematical model to calculate the distance from the head-cup contact patch to the rim of the cup and used this to investigate the effect of component position, specific design features and patient activity on the risk of edge loading. We then used this method to calculate the contact patch to rim distance (CPRD) for 160 patients having undergone revision of their MOM hip resurfacing in order to identify any possible associations.Introduction
Method
It has been speculated that impact deformation of thin 1-piece cups used for modern metal-on-metal hip replacement may contribute to early failure. The purpose of this study was to reproduce typical impact deformation and quantify the effect of this on the frictional torque generated at the hip. We tested nine hip couples of three designs (the ASR, BHR and Durom) and three sizes (42mm, 46mm and 50mm). A custom compression device was designed to replicate the in vivo forces and impact deformation of 1-piece metal cups reported in the literature. Each cup was mounted in the device, which itself was mounted on a mechanical testing machine. The cups were compressed with incremental loads up to a maximum of 2000N. At each increment we measured cup deformation, and then the head component was seated into the cup. The hip was lubricated and the head component rotated 60 degrees axially within the cup and the axial torque was measured.Introduction
Methods
The new Knee Society Score has been developed and validated, in part, to characterize better the expectations, components of satisfaction, and the physical activities of the younger, more diverse modern population of TKA patients. This study aims to reveal patients' activity levels' post-TKA and to determine how it contributes to their subjective evaluation of the surgery. As part of a multi-centered and regionally diverse study sponsored by the Knee Society, the new Knee Society Score (KSS) was administered 243 patients (44% male; avg 66.4years; 56% female, avg 67.7years) following primary TKA (follow up > 1year, avg. 25mos). The new, validated KSS questionnaire consists of a traditional objective component, as well as subjective components inquiring into patient symptoms, satisfaction, expectations and activity levels as well as a survey of three physical activities that are viewed as important to the patients. Responses were analyzed as a whole group and as subgroups of male and female and as younger (<65) and older (>65).Introduction
Methods
Knee prostheses retrieved at revision often show patterns and severity of damage neither seen nor predicted from standard wear simulator testing. We hypothesized that this is because these implants are exposed to combinations of loads and motions that are more damaging than the simple loading profiles utilized in laboratory testing. We examined the magnitude, direction, and combination of forces and moments acting on the knee during various activities in order to guide the future development and testing of high-performance knee replacements. In vivo data from five patients with instrumented tibial implants were obtained from an open database (www.orthoload.com). We determined the direction and magnitude of forces and moments that the knee experiences during the following common physiologic activities: stair descent, stair ascent, deep knee bend, one leg stance, and walking. In order to capture the loading pattern, we investigated the three component forces and moments acting on the knee at several high demand points for each of these activities. The e-tibia data were compared to the loading profiles used in conventional laboratory testing (ISO 14243-1).Introduction
Methods
Although the “learning curve” in surgical procedures is well recognized, little data exists documenting the accuracy of surgeons in performing individual steps of orthopedic procedures. In this study we have used a validated computer-based training system to measure variations instrument placement and alignment in TKA, specifically those relating to tibial preparation. Eleven trainees (surgical students, residents and fellows) were recruited to perform a series of 43 knee replacement procedures in a computerized training center. After initial instruction, each trainee performed a series of four TKA procedures in cadavers (n=2) and bone replicas (n=2) using a contemporary TKA instrument set and the assistance of an experienced surgical instructor. The Computerized Bioskills system was utilized to monitor the placement and orientation of the proximal tibial osteotomy and the tibial tray.Introduction
Methods
Femoro-acetabular impingement (FAI) is a common source of impaired motion of the hip, often attributed to the presence of an aspherical femoral head. However, other types of femoral deformity, including posterior slip, retroversion, and neck enlargement, can also limit hip motion. This study was performed to establish whether the “cam” impinging femur has a single deformity of the head/neck junction or multiple abnormalities. Computer models of 71 femora (28 normal and 43 “cam” impinging) were prepared from CT scans. Morphologic parameters describing the dimensions of the head, neck, and medullary canal were calculated for each specimen. The anteversion angle, alpha angle of Notzli, beta angle of Beaulé, and normalized anterior heads offset were also calculated. Average dimensions were compared between the normal and impinging femora.Introduction
Materials and Methods
Proper rotational alignment of the tibial component is a critical factor affecting the outcome of TKA. Traditionally, the tibial component is oriented with respect to fixed landmarks on the tibia without reference to the plane of knee motion. In this study, we examined differences between rotational axes based on anatomic landmarks and the true axis of knee motion during a functional activity. 24 fresh-frozen lower limb specimens were mounted in a joint simulator which enable replication of lunging and squatting through application of muscle and body-weight forces. Kinematic data was collected using a 3D motion analysis system. Computer models of the femur and tibia were generated by CT reconstruction. The motion axis of each knee (TFA) was defined by the 3D path of the femur with respect to the tibia as the knee was flexed from 30 to 90 degrees. The orientation the TFA was compared to 5 different anatomic axes commonly proposed for alignment of the tibial component.Introduction
Materials and Methods
Joint Registries are a valuable resource for defining the survivorship of prostheses and procedures undertaken for the treatment of joint disease. However, the use of this data as a basis for advocating specific implant designs is controversial because of the confounding effects of variations in patient selection, the training, skill and experience of surgeons, and the priorities of individual patients. Despite these challenges, the Australian Joint Registry has utilized its early survivorship data to identify specific designs that are expected to exhibit lower than average durability in the long term. The aim of this study was to assess the accuracy of this practice in identifying implants providing inferior long-term performance. Over the period 2004–8, the Australian Registry identified 48 prosthetic components used in primary THA, HRA, TKA or UKA which exhibited a statistically significant increase in the early revision rate. For each of these components, we compared the rate of revisions per 100 “component-years” when it was first identified by the Registry, to its ultimate fiveyear cumulative survival in 2008. These survival parameters were also compared to average values based on procedure (eg.THR) and fixation method (i.e. cemented, cementless, hybrid). Regression analysis was performed to determine the accuracy of initial relative revisions per 100 OCY as a predictive measure of eventual component revision rate. Five year survival data was available on 30 of the 48 implants identified by the registry. There was a strong correlation (R2=0.9614) between initial revisions per 100 component-years and the 5-yr survival of the identified designs. 29 of 30 designs (97%) exhibited lower than average survivorship at 5 years. Six designs (20%) had failure rates within 2% of average values, and 7 (23%) had a 5–year failure rate less than 50% above average values. Although, when identified by the Registry, 80% of identified components exceeded the average rate of revision by 100%, only 60% displayed more than twice the cumulative revision rate at 5 years post-op. These results demonstrate that early data collected by Joint Registries can form the basis of accurate identification of designs which ultimately prove to be clinically unsuccessful. Predictions made by the Australian Registry concerning inferior designs have an accuracy of approximately 80%. Further work is recommended to enhance the valuable potential of Registry data in predicting the outcome of both implants and procedures.
Several studies have suggested that, in TKR, gender specific-prostheses are needed to accommodate anatomic differences between males and females. This study was performed to examine whether gender is a factor contributing to the variability of the size, shape and orientation of the patellofemoral sulcus. 3D computer models of the femur were reconstructed from CT scans of 20 male and 20 female femora. The patellofemoral groove was quantified by measuring landmarks at 10 degree increments around the epicondylar axis. The orientation of the groove was defined by the tracking path generated by a sphere moving from the top of the groove to the intercondylar notch. To assess the influence of gender on the shape of the distal femur, all morphologic parameters were normalized for differences in bone size. Overall, the distal femur was 15% larger in males compared to females. The male condyles were 4% wider than the female for constant AP depth (p=0.13). When normalized for bone size, there was no gender difference in most patello-femoral dimensions, including the length, width, angle or tilt of the sulcus. Female femora had a less prominent medial anterior ridge (p=0.07), and a larger normalized radius of curvature of the tracking path (p=0.03). In addition, the orientation of the sulcus differed by 1–2 degrees in both the coronal and axial planes. Overall, gender explained 4.7% of the anatomic variation of the parameters examined, varying from 0 to 15.9%. The size, shape and orientation of the patello-femoral groove are highly variable. While the patello-femoral morphology of male and female femora are very similar, some of the anatomic variability is related to gender, particularly the prominence of the medial ridge and the sulcus radius of curvature. The biomechanical and clinical significance of these differences after TKA have yet to be determined.
Mathematical models of patients and surgeons can be built using joint registry data. These models can then be used in a computer simulation yielding results comparable to what has been reported in the literature. The outcome of Oxford UKA is primarily determined by the skill of the surgeon in selecting suitable patients rather than operative experience. Attempts to expand indications for new procedures should be moderated by concerns that the favorable results from pioneering centers may be due to the judgment and experience of the developers as much as their technical skill in performing the procedure.
Polyethylene wear debris in TKA arises from several sources, including the tibiofemoral articulation and the interface between the backside surface of the tibial insert and the metal tibial tray. In this study we identify a new source of abrasive damage to the polyethylene bearing surface: impingement of resected bony surfaces, osteophytes and overhanging acrylic cement on the tibial bearing surface during joint motion. One hundred forty-eight tibial components of 24 different designs in a retrieval collection were examined. A digital image of the articular surface of each insert was recorded. The presence, location and projected area of abrasive wear to the non-articulating edges of the insert were assessed using image analysis software. Significant abrasive wear was observed in 24% of the retrievals with cemented femoral components and 9% from non-cemented components. Of the retrievals exhibiting this abrasive wear mode, 46% experienced multiple site damage. The average damage area for each individual abrasive scar was 78±11mm^2. Within the group of worn inserts, the abrasive scars were seen with a frequency of 69% on the extreme medial edge, 19% on the extreme lateral edge, 38% on the posterior-medial edge and 23% on the posterior-lateral edge. In posterior stabilized components with an open femoral box design, scarring of the superior surface of the tibial post was also observed. This proposed mode of damage was confirmed with several retrieved femoral components containing either fixed cement protruding from the posterior condyles, from the medial and lateral edges or osteophytes embedded in the posterior capsule. The corresponding inserts exhibited significant abrasive scarring at those locations. We have observed a previously unrecognized source of polyethylene damage resulting in gouging, abrasion and severe localized damage in cemented and uncemented total knee replacement. Clearly, acrylic cement, in bulk or particulate form, often contributes to severe damage of the tibial surface and improvements to instruments and techniques for cementing are needed to prevent this wear mechanism.
Wear of the underside of modular tibial inserts (“backside wear”) has been reported by several authors. However, the actual volume of material lost through wear of the backside surface has not been quantified. This study reports the results of computerized measurements of tibial inserts of one design known to have a high incidence of backside wear in situ. A series of retrieved TKA components of one design (AMK, Depuy) with evidence of severe backside wear and extrusions of the polyethylene insert were examined. The three-dimensional surface profile of the backside of each insert was digitized and reconstructed with CAD software (UniGraphics). The volume of material removed was calculated from the volume between the worn backside surface and an “initial” surface defined by unworn areas. Computer reconstructions showed that in all retrievals, the unworn surface of the remaining pegs, the rim of material extruded over the medial edge and unworn surfaces on the anterior-lateral edge all lie in a single plane. This demonstrates that the “pegs” present on the backside of these inserts correspond to residual, unworn protrusions remaining on each retrieved component and do not represent cold flow extrusions through the base plate holes. The average volume of material lost due to backside wear was 608mm^3 ± 339mm^3 (range:80–1599 mm^3). This corresponds to an average loss of 569mg and an average linear wear rate of 103mg/year, based on the time in situ for each implant. The volume of material removed due to backside wear is significant and is of a magnitude large enough to generate osteolysis. Our results indicate that the appearance of pegs on the underside of components with screw holes on the baseplate are not due to creep, but instead are due to severe wear of the insert. The mechanisms of material removed due to pitting and burnishing actually produce debris of a size more damaging in terms of osteolysis than wear at the articulating surface making it clear that significant improvements in implant design are needed to prevent backside wear and osteolysis.