Optimal soft tissue tension maximises function following total knee arthroplasty. Excessive tension may lead to stiffness and or pain, while inadequate tension can lead to instability. Composite component thickness is a prime determinant of this soft tissue tension. The variable component thickness provided by polyethylene inserts generally allows for 2–3mm incremental change. This study analyzed the effect of 1-mm incremental changes in polyethylene thickness on soft tissue tension. Our hypothesis was that soft tissue tension would be markedly affected by increases in insert thickness.

Computer assisted TKA was performed on eight cadaveric knee specimens (four pairs). The knees were passively moved through full flexion-extension range of motion, for each tibial construct thickness. Kinematics were recorded using the computer navigation software. Soft tissue tension was analyzed by measuring compartmental loads. A validated load cell instrumented tibial insert was used to measure medial and lateral compartmental loads independently. The effect of 1-mm increments in polyethylene thickness on compartmental loads was evaluated.

An increase in compartmental loads was measured with increasing insert thickness. Loading in contralateral compartments showed differing behaviour, reflecting varying tension in the medial and lateral sides. Many generated loads showed a reduction after reaching a maximal level with further increase in insert thickness (seven of eight specimens), indicative of tissue failure, although there were no overt indications of failure during the procedure. With a 1-mm increase in insert thickness, six of eight specimens showed an increase in peak loads greater than 100N at some point in the testing procedure, although not always with the same shim thickness.

Compartmental loads varied as a function of insert thickness. Most specimens showed signs of soft tissue “micro-failure”. The high sensitivity of compartmental loads to a 1-mm incremental increase is significant and has not been previously appreciated, especially intra-operatively. Currently available inserts with 2–3mm incremental sizes may make obtaining optimal soft tissue tension difficult. In addition to the current focus of obtaining accurate leg alignment, further computer-assisted techniques are required to address soft tissue tension.

Introduction: Optimal soft tissue tension maximises function after total knee arthroplasty (TKA). Excessive tension may lead to stiffness and or pain, while inadequate tension can lead to instability. Composite component thickness is a prime determinant of this soft tissue tension. The variable component thickness provided by polyethylene inserts generally allows for 2-3 mm incremental change. This study analyses the effect of incremental change in polyethylene thickness on soft tissue tension.

Methodology: Computer assisted (Stryker Knee Nav) TKA was performed on 8 cadaveric knee specimens (4 pairs). Kinematic data was collected through the navigation software. The soft tissue tension was analysed by measuring compartmental loads. A validated load cell instrumented tibial insert was used to measure medial and lateral compartmental loads independently. The effect of 1mm increments in polyethylene thickness on compartmental loads was evaluated.

Results: We measured an increase in compartmental loads with increasing insert thickness. However the peak loads in each compartment showed different behaviour reflecting varying tension in the medial and lateral sides. The peak loads generated also showed a reduction after reaching a maximal level with further increase in insert thickness. With a 1 mm increase in insert thickness, 50 % of specimens showed greater than 200 % increase in the peak loads in the lateral compartment.

Conclusions: The compartmental loads vary as a function of insert thickness. The high sensitivity of compartmental loads with a 1mm increment is significant and has not been previously appreciated, especially intraoperatively. The currently available TKA inserts with 2-3 mm increments may make obtaining optimal soft tissue tension difficult. In addition to the current focus of obtaining accurate leg alignment, further computer aided techniques are required to address soft tissue tension.

Quantitative measurements of load transfer through the distal radioulnar joint (DRUJ) are limited. An instrumented ulnar head prosthesis was developed to measure bending and torsion moments about the three anatomic axes of the ulna. This device has shown repeatable loading data following insertion in a cadaveric specimen during active forearm rotation trials conducted in an in-vitro upper extremity joint simulator. The data acquired from this device will have important implications for upper extremity modeling, implant fixation and design, and optimizing surgical procedures related to DRUJ arthroplasty.

To develop a system to quantify in-vitro load transfer through the distal radioulnar joint (DRUJ) following ulnar head arthroplasty during simulated active forearm rotation. Also, the effect of an eccentric ulnar head implant design was investigated.

A load-measuring system was developed that was easily surgically inserted, and produced repeatable loading data.

The instrumented implant developed in this study will contribute to the optimization of surgical procedures and implant design parameters related to distal ulnar arthroplasty.

Four pairs of strain gauges were applied to the stem of an ulnar head prosthesis to measure bending and torsion moments about the three anatomic axes of the ulna. Three ulnar heads were machined with varying eccentricities (axisymmetric, 1.5 mm offset and 3.0 mm offset). The implant was inserted in one unpreserved cadaveric upper extremity and active forearm rotation induced using a computer controlled joint simulator. Repeatability (assessed using the maximum standard deviation over 5 trials of pronation and supination) was less than 9% of the output range for all loads. Bending and torsion moments between −0.4 and 0.5 Nm, correlating to joint loads between 0 and 50 N, were measured. The measured loads followed a consistent pattern with forearm position. Higher loads were noted for the eccentric implant heads compared to the axisymmetric head, especially at the extreme ranges of rotation. Clinical interpretation of these findings is difficult since the optimal loading scenario for distal ulnar implant longevity remains unknown.

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Purpose: This in-vitro study was conducted to assess the effect of a computer-assisted method of performing shoulder hemiarthroplasty, in comparison to traditional techniques, on passive glenohumeral joint kinematics during abduction.

Methods: Seven pairs of fresh-frozen cadaveric shoulders were tested. One specimen from each pair was randomized to the computer-assisted technique, while the contralateral shoulder underwent a traditional hemiar-throplasty using standard surgical guides by an experienced shoulder surgeon. A simulated four-part proximal humerus fracture was created in each shoulder and was reconstructed using a modular shoulder hemiarthroplasty system (Anatomical Shoulder Hemiarthroplasty System, Centrepulse Orthopaedics Inc, Austin, TX). CT data and computerized simulations of anatomical characteristics were used in the computer-assisted technique. An electromagnetic tracking device (Flock of Birds, Ascension Technologies, Burlington, VT) in conjunction with custom-written software (LabVIEW, National Instruments, Austin, TX) enabled real-time intra-operative feedback.||Passive abduction of the glenohumeral joint was conducted and the resulting motion was quantified using the aforementioned tracking device. Coordinate systems, created on both the humerus and scapula from digitized anatomical landmarks, were used to transform the kinematic data into clinically relevant parameters. Statistical analyses were performed using one-way Analyses of Variance (ANOVAs) followed by post-hoc Student-Newman-Keuls multiple comparisons (p< 0.05).

Results: In the superior-inferior direction, a significant difference in joint kinematics (p=0.011) was found between the computer-assisted and the traditional technique, with the traditional technique resulting in a more inferiorly positioned humeral head at all angles of elevation. There was no difference in translation between the native shoulders and the computer-assisted hemiarthroplasty (p> 0.05). In the anterior-posterior direction there was no difference measured in the position of the humeral head between the two surgical techniques, which were both similar to the native shoulder (p> 0.05).

Conclusions: This is the first known study to examine the effects of a computer-assisted method for performing shoulder hemiarthroplasty. Our results show that the computer-assisted approach should allow improved restoration of glenohumeral joint kinematics relative to conventional techniques, potentially resulting in improved patient outcomes and implant durability.

This study quantified the joint reaction forces in the distal radioulnar joint using an instrumented ulnar head replacement implant. Muscle activity was simulated in-vitro to determine the effects on joint reaction force. Forces were found to linearly increase with simulated muscle load in all forearm positions for the biceps and pronator teres muscles. However, this did not occur for simulations of the supinator and pronator quadratus muscles, likely due to their broader insertion, smaller size and non-linear lines-of-action. This work has important implications in forearm biomechanical modelling, implant design, fixation and rehabilitation protocols following arthroplasty.

To determine the relationship between forearm muscle activity and joint reaction force (JRF) in the distal radioulnar joint (DRUJ).

The DRUJ reaction force is linearly related to the muscle activity of the PT and biceps, but not necessarily to the activity of the supinator and PQ.

This work has implications for biomechanical modelling, implant design, fixation and rehabilitation protocols following DRUJ arthroplasty.

JRFs were found to increase linearly with muscle load for all muscles simulated (biceps, pronator teres (PT), pronator quadratus (PQ), supinator) in all forearm positions tested (supination, neutral and pronation) (correlation coefficient r> 0.85, p< 0.01) with two exceptions; simulation of the PQ in the neutral position (r=−0.65, p=0.2), and the supinator in the pronated position (r=0.72, p=0.2). Biceps simulation generated larger JRF magnitudes in all positions compared to other muscles (p< 0.001), and the PQ generated larger JRF magnitudes compared to the supinator (p=0.05).

Ulnar head arthroplasty was performed with a replacement ulnar head implant instrumented with strain gauges to allow measurement of the DRUJ reaction force. An upper extremity joint simulator applied muscle loads in seven fresh frozen cadaveric upper extremities through computer-controlled pneumatic actuators. Load was varied in 10N increments from 10-80N (biceps and PT) and from 10-50N (PQ and supinator). A hand clamp was used to restrain the forearm in varying positions. The results illustrate that broad insertion and non-linear muscles may not be linearly correlated to joint reaction force in the DRUJ.

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Purpose: Glenoid replacement remains challenging due to the difficult visualization of anatomical reference landmarks and highly variable version angles. Improper positioning of the glenoid component leads to loosening, early wear, and instability. The objective of this study was to develop and evaluate a tracking system for glenoid implantation. We hypothesized that Computer Assisted Glenoid Implantation (CAGI) would achieve a more accurate and reliable placement of the glenoid component compared to traditional methods.

Methods: 3D CT models of sixteen paired cadaveric shoulder specimens were reconstructed and angles were measured using 3D modeling softwares. Jigs were developed to track instruments and to correct for scapular motion. A standardized protocol for determining in real-time via electromagnetic tracking the glenoid centre, version, inclination and ultimate component placement was previously developed and validated in our laboratory. Specimens were randomized to either traditional or CAGI performed by one of two blinded fellowship trained shoulder surgeons. The mean age was 67 years (range 61–88). Native version and inclination were similar in both groups. All phases of glenoid implantation were navigated.

Results: CAGI was more accurate in achieving the correct version during all phases of glenoid implantation (p < 0.05; paired t-test). CAGI CONTROL Initial pin * 6.3 ± 2.9° Reaming *7.0 ± 3.9° Post drilling * 0.6 ± 0.4° 8.3 ± 4.6°|Post cement * 2.3 ± 2.0° 7.9 ± 3.6°|Post implant CT * 1.8 ± 0.9° 7.7 ± 4.0°. Table 1. Absolute values of the mean error ± SD of version angles obtained with either CAGI or the traditional method (goal = 0° version; * p < 0.05). The largest errors with traditional were observed during drilling and reaming where visualization was especially obscured by the reamer heads. The trend was to retrovert the glenoid. There was no difference with respect to inclination angles (p > 0.05).

Conclusions: Preoperative planning using CT imaging with 3D modeling and intra-operative tracking were combined to produce improved accuracy and reliability of glenoid implantation.

Funding : Other Education Grant

Funding Parties : National Sciences & Engineering Research Council research grant

This in-vitro study was conducted to determine the effect of rotator cuff tears on joint kinematics. A shoulder simulator produced unconstrained active abduction of the humerus. Three sequential 1cm lesions were created, the first two in the supraspinatus tendon and the third in the subscapularis tendon. The plane of abduction moved posteriorly and became more abnormal throughout abduction as the size of the tear increased. It is concluded that in order to generate the same motions achieved by the intact joint other muscle groups must be employed, inevitably resulting in altered joint loading.

This in-vitro study was conducted to determine the effect of simulated progressive tears of the rotator cuff on active glenohumeral joint kinematics.

Five cadaveric shoulders were tested using a shoulder simulator designed to produce unconstrained active motion of the humerus. Forces were applied to simulate loading of the supraspinatus, subscapularis, infraspinatus/teres minor, anterior, middle, and posterior deltoid muscles based upon variable ratios of electromyographic data and average physiological cross-sectional area of the muscles. Three sequential 1cm lesions were created, the first two in the supraspinatus tendon and the third in the subscapularis tendon. Simulated active glenohumeral abduction was performed following the creation of each lesion. Five successive tests were performed to quantify repeatability.

The plane of abduction moved posteriorly and became more abnormal throughout abduction as the size of the lesion increased (p=0.01) (Figure 1).

In order to generate the same motions achieved with an intact rotator cuff other muscle groups must be employed, inevitably resulting in altered joint loading.

A better understanding of the effects that rotator cuff tears have on the kinematics of the glenohumeral joint may result in the development of innovative rehabilitation strategies to compensate for this change in muscle balance and improve the clinical outcomes.

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Purpose: To compare the torsional stability provided by five implant stems with different cross-sectional geometries under cyclic loading.

Methods: Cemented stems with five different cross-sectional shapes – circular, oval, triangular, rectangular with rounded edges (round rectangular), and rectangular with sharp edges (sharp rectangular) – were custom machined from stainless steel. Stem dimensions were selected to fit within the humeral canal (based on a 6mm x 8mm dimensioning scheme) and shapes were based on commercially available-designs. Seven specimens of each stem shape were tested. ||The stems were potted in square aluminum tubes using bone cement, and allowed to cure for 24 hours prior to testing. A materials testing machine and a custom designed loading fixture were used to apply torsion to the stems. A sine wave loading pattern was applied until ultimate failure (5° of stem rotation) was reached. This loading pattern had a lower bound of 0.9Nm and an upper bound that started at 4.5Nm and was increased in increments of 2.25Nm every 1500 cycles. The load was cycled at 2Hz. Statistical analyses on both the number of cycles and torque to failure were performed using one-way ANOVAs followed by post-hoc Student-Newman-Keuls (SNK) tests (p< 0.05).

Results: Overall, ANOVAs showed an effect of shape on the number of cycles (p< 0.0001) and torque to failure (p< 0.001). SNK tests revealed the sharp rectangular stem provided the greatest resistance to torque (p-cycles< 0.001; p-torque< 0.001) compared to all other stems. Other significant differences resulted in the following ranking of the shapes: sharp rectangular, round rectangular, triangular, and circular = oval.

Conclusions: The results of this study agree with static testing previously conducted on the same set of stem shapes. Although the sizes of the stems were chosen to roughly replicate upper limb implants, these results may be extrapolated to larger stems such as for the hip or knee. To improve implant longevity, it is important that the best fixation possible be obtained through all available avenues, including improved cementing techniques, and optimal implant designs. An alteration in implant stem shape may assist in achieving this goal.

This study was conducted to determine the effect of passive and active muscle loading on humeral head translation during glenohumeral abduction. A shoulder simulator produced unconstrained active glenohumeral abduction using several sets of loading ratios. Significantly greater translations occurred in passive motion as compared to active motion between 30 and 70 degrees of elevation in three dimensions and in the anterosuperior plane. No difference was found between the active motions. Also, translations of the humeral head decreased with active simulation of abduction emphasizing the importance of the rotator cuff muscles in creating and maintaining the ball-and-socket kinematics of the shoulder.

This in-vitro study was conducted to determine the effect of passive and active loading on humeral head translation during glenohumeral abduction.

Five cadaveric shoulders were tested using a shoulder simulator designed to produce unconstrained abduction of the humerus. Forces were applied to simulate loading of the supraspinatus, subscapularis, infraspinatus/teres minor, anterior, middle, and posterior deltoid muscles using four different sets of loading ratios. These were based on:

equal loads to all cables (Constant-Constant);

In three dimensions, significantly greater translations occurred in passive motion as compared to active motion between 30 and 70 degrees of elevation (p< 0.001). No difference was found between the active motions. Similar results were observed in the two-dimensional resultant translations in the anterosuperior plane of the scapula, with more translation occurring during passive motion (3.6 ± 1.1mm) than active (2.1 ± 1.0mm) (p=0.002), and no significant differences between the active loading methods (Figure 1). The majority of translation tended to occur in the superior-inferior direction for all loading ratios employed.

It was clearly shown that the translations of the humeral head decreased with active simulation of abduction. These findings are in agreement with other in-vivo and in-vitro investigations.

This emphasizes the importance of the rotator cuff muscles in creating and maintaining the ball-and-socket kinematics of the shoulder.

Optimal soft tissue tension maximises function after total knee arthroplasty (TKA). Excessive tension may lead to stiffness and or pain, while inadequate tension can lead to instability. Composite component thickness is a prime determinant of this soft tissue tension. The thickness provided by polyethylene inserts currently allows for a 2–3 mm incremental change. This study analyses the effect of incremental change in polyethyl-ene thickness on soft tissue tension.

Computer assisted (Stryker Knee Nav) TKA was performed on 8 cadaveric knee specimens (4 pairs). Kinematic data was collected through the navigation software. The soft tissue tension was analysed by measuring compartmental loads. A validated load cell instrumented tibial insert was used to measure medial and lateral compartmental loads independently. The effect of 1mm increments in polyethylene thickness on compartmental loads was evaluated.

We measured an increase in compartmental loads with increasing insert thickness. The peak loads in each compartment showed different behaviour reflecting varying tension in the medial and lateral sides. The peak loads generated showed a reduction after reaching a maximal level with further increase in insert thickness. With a one mm increase in insert thickness, 75 % of specimens showed greater than 200 % increase in the peak loads in the lateral compartment. Similarly the medial loads showed a greater than 100% increase. Individual specimens showed a high variability in loading patterns.

Our study highlights high variation of knee loads present between subjects. The compartmental loads vary as a function of insert thickness. The high sensitivity of compartmental loads with a 1mm increment is significant and has not been previously appreciated, especially intraoperatively. The currently available TKA inserts with 2–3 mm increments may make obtaining optimal soft tissue tension difficult. In addition to the current focus of obtaining accurate leg alignment, further computer aided techniques are required to address soft tissue tension.