After anterior cruciate ligament reconstruction one of the risk factors for graft (re-)rupture is an increased posterior tibial slope (PTS). The current treatment for PTS is a high tibial osteotomy (HTO). This is a free-hand method, with 1 degree of tibial slope correction considered to be equal to 1 or even 1.67 mm of the anterior wedge resection. Error rates in the frontal plane reported in literature vary from 1 – 8.6 degrees, and in the sagittal plane outcomes in a range of 2 – 8 degrees are reported when planned on PTSs of 3 – 5 degrees. Therefore, the free-hand method is considered to have limited accuracy. It is expected that HTO becomes more accurate with patient specific saw guides (PSGs), with an accuracy margin reported in literature of 2 degrees. This proof of concept porcine cadaver case study aimed to investigate whether the use of PSGs improves the accuracy of HTO to less than 2 degrees. Secondly, the reproducibility of tibial slope measurement was evaluated. Preoperative MRI images of porcine cadaver knees (n = 3) were used to create 3D anatomical bone models (Mimics, Materialise, Belgium). These 3D models were subsequently used to develop PSGs (3-Matic, Materialise, Belgium) to correct all tibias for 3 degrees PTS and 4 degrees varus. The PSG mediated HTOs were performed by an experienced orthopaedic surgeon, after which postoperative MRI images were obtained. 3D anatomical models of postoperative tibias were created, and tibial slopes were assessed on both pre- and postoperative tibias. The tibial slope was defined as the angle between the mechanical axis and 3D tibial reference plane in the frontal and sagittal plane. The accuracy of the PSG mediated HTO (median and range) was defined as the difference in all possible combinations of the preoperatively planned and postoperatively obtained tibial slopes. To ensure reproducibility, the pre- and postoperative tibial slopes were measured thrice by one observer. The intra-class correlation coefficients (ICCs) were subsequently calculated to assess the intra-rater reliability (SPSS, IBM Corp., Armonk, N.Y., USA).Introduction and Objective
Materials and Methods
Patients with cancer and bone metastases can have an increased risk of fracturing their femur. Treatment is based on the impending fracture risk: patients with a high fracture risk are considered for prophylactic surgery, whereas low fracture risk patients are treated conservatively with radiotherapy to decrease pain. Current clinical guidelines suggest to determine fracture risk based on axial cortical involvement of the lesion on conventional radiographs, but that appears to be difficult. Therefore, we developed a patient-specific finite element (FE) computer model that has shown to be able to predict fracture risk in an experimental setting and in patients. The goal of this study was to determine whether patient-specific finite element (FE) computer models are better at predicting fracture risk for femoral bone metastases compared to clinical assessments based on axial cortical involvement on conventional radiographs, as described in current clinical guidelines. 45 patients (50 affected femurs) affected with predominantly lytic bone metastases who were treated with palliative radiotherapy for pain were included. CT scans were made and patients were followed for six months to determine whether or not they fractured their femur. Non-linear isotropic FE models were created with the patient-specific geometry and bone density obtained from the CT scans. Subsequently, an axial load was simulated on the models mimicking stance. Failure loads normalized for bodyweight (BW) were calculated for each femur. High and low fracture risks were determined using a failure load of 7.5 × BW as a threshold. Experienced assessors measured axial cortical involvement on conventional radiographs. Following clinical guidelines, patients with lesions larger than 30 mm were identified as having a high fracture risk. FE predictions were compared to clinical assessments by means of diagnostic accuracy values (sensitivity, specificity and positive (PPV) and negative predictive values (NPV)). Seven femurs (14%) fractured during follow-up. Median time to fracture was 8 weeks. FE models were better at predicting fracture risk in comparison to clinical assessments based on axial cortical involvement (sensitivity 100% vs. 86%, specificity 74% vs. 42%, PPV 39% vs. 19%, and NPV 100% vs. 95%, for the FE computer model vs. axial cortical involvement, respectively). We concluded that patient-specific FE computer models improve fracture risk predictions of femoral bone metastases in advanced cancer patients compared to clinical assessments based on axial cortical involvement, which is currently used in clinical guidelines. Therefore, we are initiating a pilot for clinical implementation of the FE model.
Patients with advanced cancer can develop bone metastases in the femur which are often painful and increase the risk of pathological fracture. Accurate segmentation of bone metastases is, amongst others, important to improve patient-specific computer models which calculate fracture risk, and for radiotherapy planning to determine exact radiation fields. Deep learning algorithms have shown to be promising to improve segmentation accuracy for metastatic lesions, but require reliable segmentations as training input. The aim of this study was to investigate the inter- and intra-operator reliability of manual segmentation of femoral metastatic lesions and to define a set of lesions which can serve as a training dataset for deep learning algorithms. F CT-scans of 60 advanced cancer patients with a femur affected with bone metastases (20 osteolytic, 20 osteoblastic and 20 mixed) were used in this study. Two operators were trained by an experienced radiologist and then segmented the metastatic lesions in all femurs twice with a four-week time interval. 3D and 2D Dice coefficients (DCs) were calculated to quantify the inter- and intra-operator reliability of the segmentations. We defined a DC>0.7 as good reliability, in line with a statistical image segmentation study. Mean first and second inter-operator 3D-DCs were 0.54 (±0.28) and 0.50 (±0.32), respectively. Mean intra-operator I and II 3D-DCs were 0.56 (±0.28) and 0.71 (±0.23), respectively. Larger lesions (>60 cm3) scored higher DCs in comparison with smaller lesions. This study reveals that manual segmentation of metastatic lesions is challenging and that the current manual segmentation approach resulted in dissatisfying outcomes, particularly for lesions with small volumes. However, segmentation of larger lesions resulted in a good inter- and intra-operator reliability. In addition, we were able to select 521 slices with good segmentation reliability that can be used to create a training dataset for deep learning algorithms. By using deep learning algorithms, we aim for more accurate automated lesion segmentations which might be used in computer modelling and radiotherapy planning.
The fixation of press-fit orthopaedic devices depends on the mechanical properties of the bone that is in contact with the implants. During the press-fit implantation, bone is compacted and permanently deformed, finally resulting in the mechanical interlock between implant and bone. For the development and design of new devices, it is imperative to understand these non-linear interactions. One way to investigate primary fixation is by using computational models based on Finite Element (FE) analysis. However, for a successful simulation, a proper material model is necessary that accurately captures the non-linear response of the bone. In the current study, we combined experimental testing with FE modeling to establish a Crushable Foam model (CFM) to represent the non-linear bone biomechanics that influences implant fixation. Mechanical testing of human tibial trabecular bone was done under uniaxial and confined compression configurations. We examined 62 human trabecular bone samples taken from 8 different cadaveric tibiae to obtain all the required parameters defining the CFM, dependent on local bone mineral density (BMD). The derived constitutive rule was subsequently applied using an in-house subroutine to the FE models of the bone specimens, to compare the model predictions against the experimental results.Introduction
Methods
Cementless total knee arthroplasty (TKA) implants use an interference fit to achieve fixation, which depends on the difference between the inner dimensions of the implant and outer dimensions of the bone. However, the most optimal interference fit is still unclear. A higher interference fit could lead to a superior fixation, but it could also cause bone abrasion and permanent deformation during implantation. Therefore, this study aims to investigate the effect of increasing the interference fit from 350 µm to 700 µm on the primary stability of cementless tibial implants by measuring micromotions and gaps at the bone-implant interface when subjected to two loading conditions. Two cementless e.motion® tibial components (Total Knee System, B. Braun) with different interference fit and surface coating were implanted in six pairs of relatively young human cadaver tibias (47–60 years). The Orthoload peak loads of gait (1960N) and squat (1935N) were applied to the specimens with a custom made load applicator (Figure 1A). The micromotions (shear displacement) and opening/closing gaps (normal displacement) were measured with Digital Image Correlation (DIC) in 6 different regions of interest (ROIs - Figure 1B). Two General Linear Mixed Models (GLMMs) were created with micromotions and interfacial gaps as dependent variables, bone quality, loading conditions, ROIs, and interference fit implants as independent variables, and the cadaver specimens as subject variables.Introduction
Methods
Instability, loosening, and patellofemoral pain belong to the main causes for revision of total knee arthroplasty (TKA). Currently, the diagnostic pathway requires various diagnostic techniques such as x-rays, CT or SPECT-CT to reveal the original cause for the failed knee prosthesis, but increase radiation exposure and fail to show soft-tissue structures around TKA. There is a growing demand for a diagnostic tool that is able to simultaneously visualize soft tissue structures, bone, and TKA without radiation exposure. MRI is capable of visualising all the structures in the knee although it is still disturbed by susceptibility artefacts caused by the metal implant. Low-field MRI (0.25T) results in less metal artefacts and offers the ability to visualize the knee in weight-bearing condition. Therefore, the aim of this study is to investigate the possibilities of low field MRI to image, the patellofemoral joint and the prosthesis to evaluate the knee joint in patients with and without complaints after TKA. Ten patients, eight satisfied and two unsatisfied with their primary TKA, (NexGen posterior stabilized, BiometZimmer) were included. The patients were scanned in sagittal, coronal, and transversal direction on a low field MRI scanner (G-scan Brio, 0.25T, Esaote SpA, Italy) in weight-bearing and non-weight-bearing conditions with T1, T2 and PD-weighted metal artefact reducing sequences (TE/TR 12–72/1160–7060, slice thickness 4.0mm, FOV 260×260×120m3, matrix size 224×216). Scans were analysed by two observers for:
- Patellofemoral joint: Caton-Descamps index and Tibial Tuberosity-Trochlear Groove (TT-TG) distance. - Prosthesis malalignment: femoral component rotation using the posterior condylar angle (PCA) and tibial rotation using the Berger angle. Significance of differences in parameters between weight-bearing and non-weight-bearing were calculated with the Wilcoxon rank test. To assess the reliability the inter and intra observer reliability was calculated with a two-way random effects model intra class correlation coefficient (ICC). The two unsatisfied patients underwent revision arthroplasty and intra-operative findings were compared with MRI findings.Introduction
Method
Polyetheretherketone (PEEK) has been proposed as an implant material for femoral total knee arthroplasty (TKA) components. Potential clinical advantages of PEEK over standard cobalt chrome alloys include modulus of elasticity and subsequently reduced stress shielding potentially eliminating osteolysis, thermal conduction properties allowing for a more natural soft tissue environment, and reduced weight enabling quicker quadriceps recovery. Manufacturing advantages include reduced manufacturing and sterilization time, lower cost, and improved quality control. Currently, no PEEK TKA implants exist on the market. Therefore, evaluation of mechanical properties in a pre-clinical phase is required to minimize patient risk. The objectives of this study include evaluation of implant fixation and determination of the potential for reduced stress shielding using the PEEK femoral TKA component. Experimental and computational analysis was performed to evaluate the biomechanical response of the femoral component (Freedom Knee, Maxx Orthopedics Inc., Plymouth Meeting, PA; Figure 1). Fixation strength of CoCr and PEEK components was evaluated in pull-off tests of cemented femoral components on cellular polyurethane foam blocks (Sawbones, Vashon Island, WA). Subsequent testing investigated the cemented fixation using cadaveric distal femurs. The reconstructions were subjected to 500,000 cycles of the peak load occurring during a standardized gait cycle (ISO 14243-1). The change from CoCr to PEEK on implant fixation was studied through computational analysis of stress distributions in the cement, implant, and the cement-implant interface. Reconstructions were analyzed when subjected to standardized gait and demanding squat loads. To investigate potentially reduced stress shielding when using a PEEK component, paired cadaveric femurs were used to measure local bone strains using digital image correlation (DIC). First, standardized gait load was applied, then the left and right femurs were implanted with CoCr and PEEK components, respectively, and subjected to the same load. To verify the validity of the computational methodology, the intact and reconstructed femurs were replicated in FEA models, based on CT scans.Introduction
Methods and Materials
Fretting corrosion at the taper interface of modular connections can be studied using Finite Element (FE) analyses. However, the loading conditions in FE studies are often simplified, or based on generic activity patterns. Using musculoskeletal modeling, subject-specific muscle and joint forces can be calculated, which can then be applied to a FE model for wear predictions. The objective of the current study was to investigate the effect of incorporating more detailed activity patterns on fretting simulations of modular connections. Using a six-camera motion capture system, synchronized force plates, and 45 optical markers placed on 6 different subjects, data was recorded for three different activities: walking at a comfortable speed, chair rise, and stair climbing. Musculoskeletal models, using the Twente Lower Extremity Model 2.0 implemented in the AnyBody modeling System™ (AnyBody Technology A/S, Aalborg, Denmark; figure1), were used to determine the hip joint forces. Hip forces for the subject with the lowest and highest peak force, as well as averaged hip forces were then applied to an FE model of a modular taper connection (Biomet Type-1 taper with a Ti6Al4V Magnum +9 mm adaptor; Figure 2). During the FE simulations, the taper geometry was updated iteratively to account for material removal due to wear. The wear depth was calculated based on Archard's Law, using contact pressures, micromotions, and a wear factor, which was determined from accelerated fretting experiments.Introduction
Methods
Fifteen percent of the primary total knee arthroplasties (TKA) fails within 20 years. Among the main causes for revision surgery are instability and patellofemoral pain. Currently, the diagnostic pathway requires various diagnostic techniques to reveal the original cause for the failed knee prosthesis and is therefore time consuming and inefficient. Accordingly, there is a growing demand for a diagnostic tool that is able to simultaneously visualize soft tissue structures, bone and TKA. Magnetic resonance imaging (MRI) is capable of visualising all the structures in the knee although a trade- off needs to be made between metal artefact reducing capacities and image quality. Low-field MRI (0.25T) results in less metal artefacts and a lower image quality compared with high-field MRI (1.5T). The aim of this study is to develop a MRI imaging guide to image the problematic TKA and to evaluate this guide by comparing low-field and high-field MRI on a case study. Based on literature and current differential diagnostic pathways a guide to diagnose patellofemoral pain, instability, malposition and signs of infection or fracture with MRI was developed. Therefore, methods as Insall Salvati, patellar tilt angle and visibility of fluid and soft tissues were chosen. Visibility was scored on a VAS scale from 0 to 100mm (0mm zero visibility, 100mm excellent visibility). Subsequently, this guide is used to analyse MRI scans made of a volunteer (female, 61 years, right knee) with primary TKA (Biomet, Zimmer) in sagittal, coronal and transversal direction with a FSE PD metal artefact reducing (MAR) sequence (TE/TR 12/1030ms, slice thickness 4.0mm, FOV 260×260×120mm3, matrix size 224×216) on low-field MRI (Esaote G-scan Brio, 0.25T) and with a FSE T1-weighted high bandwidth MAR sequence (TE/TR 6/500ms, slice thickness 3.0mm, FOV 195×195×100mm3, matrix size 320×224) on high-field MRI (Avanto 1.5T, Siemens). Scans were analysed three times by one observer and the intra observer reliability was calculated with a two-way random effects model intra class correlation coefficient (ICC).Introduction
Method
Roentgen stereophotogrammetric analysis (RSA) is currently the gold standard to measure early prosthetic migration which can predict aseptic loosening. However, RSA has some limitations such as the need for perioperative placed markers and exposure to X-radiation during follow up. Therefore, this study evaluates if low field MRI could be an alternative for RSA. Low field MRI was chosen because it is less hampered by metal artifacts of the prosthesis than high field MRI. 3D models of both the tibial component of a total knee prosthesis (Genesis II, Smith and Nephew) and the porcine tibia were made. The tibial component was implanted in the tibial bone. Consequently, 17 acquisitions with the low field MRI scanner (Esaote G-scan 0.25T) in transverse direction with a 2D PD weighted metal artifact reducing sequence PD-XMAR (TE/TR 10/1020ms, slice thickness 3mm, FOV 180×180×120 mm³, matrix size 224×224) were made. The first five acquisitions were made without repositioning the cadaver, the second twelve after slightly repositioning the cadaver within limits that are expected to be encountered in a clinical setting. Hence, in these 17 acquisitions no prosthetic-bone motions were induced. The scans were segmented and registered with Mimics. Virtual translation and rotation of the prosthesis with respect to the bone between two scans were calculated using a Procrustes algorithm. The first five scans without repositioning were used to calculate the measurement error, the following twelve to calculate the precision of low field MRI to measure prosthetic migration. Results were expressed as the maximum total point motion, mean error and 95% CI and expressed in boxplots.Introduction
Methods
Although cementless press-fit femoral total knee arthroplasty (TKA) components are routinely used in clinical practice, the effect of the interference fit on primary stability is still not well understood. Intuitively, one would expect that a thicker coating and a higher surface roughness lead to a superior fixation. However, during implant insertion, a thicker coating can introduce more damage to the underlying bone, which could adversely influence the primary fixation. Therefore, in the current study, the effect of coating thickness and roughness on primary stability was investigated by measuring the micromotions at the bone-implant interface with experimental testing. A previous experimental set-up was used to test 6 pairs of human cadaveric femurs (47–60 years, 5 females) implanted with two femoral component designs with either the standard e.motion (Total Knee System, B. Braun, Germany) interference fit of 350 µm (right femurs) or a novel, thicker interference fit of 700 µm (left femurs). The specimens were placed in a MTS machine (Figure 1) and subjected to the peak loads of normal gait (1960N) and squat (1935N), based on the Orthoload dataset for Average 75. Varus/valgus moments were incorporated by applying the loads at an offset relative to the center of the implants, leading to a physiological mediolateral load distribution. Under these loads, micromotions at the implant-bone interface were measured using Digital Image Correlation (DIC) at different regions of interest (ROIs – Figure 1). In addition, DIC was used to measure opening and closing of the implant-bone interface in the same ROIs.Introduction
Methods
Aseptic loosening is the main reason for total knee arthroplasty (TKA) failure, responsible for more than 25% of the revision procedures, with most of the problems occurring with the tibial component. While early loosening can be attributed to failure of primary fixation, late implant loosening is associated with loss of fixation secondary to bone resorption due to altered physiological load transfer to the tibial bone. Several attempts have been made to investigate these changes in bone load transfer in biomechanical simulations and bone remodeling analyses, which can be useful to provide information on the effect of patient, surgery, or design-related factors. On the other hand, these factors have also been investigated in clinical studies of radiographic changes of bone density following TKA. In this study we made an overview of the knowledge obtained from these clinical studies, which can be used to inform clinical decision making and implant design choices. A literature search was performed to identify clinical follow-up studies that monitored peri-prosthetic bone changes following TKA. Within these studies, effects of the following parameters on bone density changes were investigated: post-operative time, region of interest, alignment, body weight, systemic osteoporosis, implant design and cementation. Moreover, we investigated the effect of bone density loss on implant survival. Results A total of 19 studies was included in this overview, with a number of included patients ranging from 12 to 7,760. Most studies used DEXA (n=16), while a few studies performed analyses on calibrated digital radiographs (n=2), or computed tomography (n=1). Postoperative follow-up varied from 9 months to 10 years. Studies consistently report the largest bone density reduction within the first postoperative year. Bone loss is mainly seen in the medial region. This has been attributed to the change in alignment following surgery, during which often the pre-operative varus knee is corrected to a more physiological alignment, resulting in a load shift towards the lateral compartment. Measurements in unoperated contralateral legs were performed in 3 cases, and two studies performed standardized DEXA measurements to provide information on systemic osteoporosis. While on the short term no changes were observed, significant negative correlations have been found between severity of osteoporosis and peri-prosthetic bone density. No clear effects of bodyweight and cementation on bone loss have been identified. Although some studies do find differences between implant types, the variation in the data makes it difficult to draw general conclusions from these findings. Several studies reported no effect of bone loss on implant migration. In another study, a medial collapse was associated with a medial increase in density, suggesting that altered loading and increased stresses are responsible for both bone formation and the overload leading to collapse.Introduction
Methods
In this prospective cohort study, we investigated whether patient-specific finite element (FE) models can identify patients at risk of a pathological femoral fracture resulting from metastatic bone disease, and compared these FE predictions with clinical assessments by experienced clinicians. A total of 39 patients with non-fractured femoral metastatic lesions who were irradiated for pain were included from three radiotherapy institutes. During follow-up, nine pathological fractures occurred in seven patients. Quantitative CT-based FE models were generated for all patients. Femoral failure load was calculated and compared between the fractured and non-fractured femurs. Due to inter-scanner differences, patients were analyzed separately for the three institutes. In addition, the FE-based predictions were compared with fracture risk assessments by experienced clinicians.Objectives
Methods
Fretting corrosion of the modular taper junction in total hip arthroplasty has been studied in several finite element (FE) studies. Manufacturing tolerances can result in a mismatch between the femoral head and stem, which can influence the taper mechanics leading to possibly more wear. Using FE models the effect of these manufacturing tolerances on the amount of volumetric wear can be studied. The removal of material in the FE model was validated against experiments simulating the clinical fretting wear process, subsequently the mismatch and assembly force were varied to study the effect on the volumetric wear. An FE model was developed in which the geometry can be updated to account for material removal due to wear. In this model the geometry was updated based on Archard's Law, using contact pressures, micromotions and a wear factor, which was determined based on accelerated fretting experiments. The linear wear was calculated using H=k*p*S. Where H is the linear wear depth in mm, k is a wear factor (mm3/Nmm), p is the contact pressure (MPa) and S is the sliding distance (mm). 10 million cycles were simulated using 50 virtual steps. Using this scaling and the measured volumetric wear from the experiments a wear factor of 2.7*10−5 was applied. Based on general manufacturing tolerances the resulting mismatch in taper angles were determined to be ± 1.26°. Using this mismatch a tip fit (figure 1a) and base fit (Figure 1b) model were created. In combination with a perfect fit, meaning no mismatch, and two different assembly forces of 4 kN and 15 kN, 6 different situations were studied.Introduction
Methods
Mechanical overloading of the knee can occur during activities of daily living such as stair climbing, jogging, etc. In this finite element study we aim to investigate which parameters could detrimentally influence peri-implant bone in the tibial reconstructed knee. Bone quality and patient variables are potential factors influencing knee overloading (Zimmerman 2016). Finite element (FE) models of post-mortem retrieved tibial specimens (n=7) from a previous study (Zimmerman 2016) were created using image segmentation (Mimics Materialise v14) of CT scan data (0.6 mm voxel resolution). Tibial tray and polyethylene inserts were recreated from CT data and measurements of the specimens (Solidworks 2015). Specimens with varying implant geometry (keel/pegged) were chosen for this study. A cohesive layer between bone and cement was included to simulate the behavior of the bone–cement interface using experimentally obtained values. The FE models predict plasticity of bone according to Keyak (2005). Models were loaded to 10 body weight (BW) and then reduced to 1 BW to mimic experimental measurements. Axial FE bone strains at 1 BW were compared with experimental Digital Image Correlation (DIC) bone strains on cut sections of the specimens. After validation of the FE models using strain data, models were rotated and translated to the coordinate system defined in Bergmann (2014). Four loading cases were chosen – walking, descending stairs, sitting down and jogging. Element strains were written to file for post-processing. The bone in all FE models was divided into regions of equal thickness (10 mm) for comparison of strains.INTRODUCTION
METHODS
Improving the accuracy of measuring 6 degree of freedom tibiofemoral kinematics is a crucial step in gait analysis, but skin-marker estimated kinematics are subject to soft tissue artefacts. Fluoroscopic systems have been reported to achieve high accurate kinematics, but their induced irradiation, limited field of view, and high cost hampers routine usage on large patient cohorts. The aim of this study is to assess the feasibility of measuring tibiofemoral kinematics using multi-channel A-mode ultrasound system in cadaver experiment and to assess its achievable accuracy. A full cadaver was placed with its back on a surgery table while its legs were overhanging the edge of the table. Upper body was fixated and right leg was moved by means of pulling a rope. Two bone pins with optical markers were mounted to the femur and tibia separately to measure the ground truth of motion. Six custom holders containing 30 A-mode ultrasound transducers and 18 optical markers were mounted to six anatomical regions. By measuring the bone to ultrasound transducer distance and using the spatial information of the optical markers on the holders, 30 bone surface points were determined. The corresponding bones (femur and tibia) were registered to these acquired points after which the tibiofemoral kinematics were determined. This study presents a multi-channel A-mode ultrasound system and the first results have shown its feasibility of reconstructing tibiofemoral kinematics in cadaver experiment. Although the reconstructed tibiofemoral kinematics is less accurate than a fluoroscopic system, it outperforms a skin-mounted markers system. Thus, this A-mode Ultrasound approach could provide a non-invasive and non-radiative method for measuring tibiofemoral kinematics, which may be used in clinic gait analysis or even computer-aided orthopaedic surgery.
Trabecular metal (TM) cones are designed to fill up major bone defects in total knee arthroplasty. Tibial components can be implanted in combination with a stem, but it is unclear if this is necessary after reconstruction with a TM cone. Implanting a stem may give extra stability, but may also have negative side-effects. Aim of this study was to investigate stability and strain distribution of a tibial plateau reconstruction with a TM cone while the tibal component is implanted with and without a stem, and whether prosthetic stability was influenced by bone mineral density (BMD). Tibial revision arthroplasties were performed after reconstruction of an AORI 2B bone defect with TM cones. Plateaus were implanted in seven pairs of cadaveric tibiae; of each pair, one was implanted with and the other without stem. All specimens were loaded to one bodyweight alternating between the medial and lateral tibia plateau. Implant-bone micro motions, bone strains, BMD and correlations were measured and/or calculated.Background
Methods
Fretting at modular junctions is thought to be a ‘mechanically assisted’ corrosion phenomenon, initiated by mechanical factors that lead to increased contact stresses and micromotions at the taper interface. We adopted a finite element approach to model the head-taper junction, to analyse the contact mechanics at the taper interface. We investigated the effect of assembly force and angle on contact pressures and micromotions, during loads commonly used to test hip implants, to demonstrate the importance of a good assembly during surgery. Models of the Bimetric taper and adaptor were created, with elastic-plastic material properties based on material tests with the actual implant alloy. FE contact conditions were validated against push-on and pull-off experiments. The models were loaded according to ISO 7206-4 and −6, after being assembled at 2-4-15kN, both axially and at a 30° angle. Average micromotions and contact pressures were analysed, and a wear score was calculated based on the contact pressures and micromotions.Background
Methods
The primary stability of an uncemented femoral total knee replacement component is provided by press-fit forces at the bone-implant interface. This press-fit is achieved by resecting the bone slightly larger than the inner dimensions of the implant, resulting in a so-called interference fit. Previous animal studies have shown that an adequate primary stability is required to minimize micromotions at the bone-implant interface to achieve bone-ingrowth, which provides the secondary (long-term) fixation. It is assumed that during implantation a combination of elastic and plastic deformation and abrasion of the bone will occur, but little is known about what happens at the bone-implant interface and how much interference fit eventually is achieved. Purpose of this study was therefore to assess the actual and effective interference fit and the amount of bone damage during implantation of an uncemented femoral knee component. In this study, five cadaveric distal femora were prepared and femoral knee components were implanted by an experienced surgeon. Micro-CT scans and conventional CT-scans were obtained pre- and post-implantation for geometrical measurements and to measure bone mineral density. In addition, the position of the implant with respect to the bone was determined by optical scanning of the reconstructions (Figure.1). By measuring the differences in surface geometry, assessments were made of the cutting error, the actual interference fit, the amount of bone damage, and the effective interference fit. Our analysis showed an average cutting error of 0.67± 0.17 mm, which pointed mostly towards bone under-resections. We found an average actual AP interference fit of 1.48± 0.27 mm, which was close to the nominal value of 1.5 mm. We observed combinations of bone damage and elastic deformation in all bone specimens (Figure. 2), which showed a trend to be related with bone density. Higher bone density tended to lead to lower bone damage and higher elastic deformation (Figure. 3). The results of the current study indicate different factors that interact while implanting an uncemented femoral knee component. This knowledge can be used to fine-tune design criteria of femoral components and obtain adequate primary stability for all patients in a more predictable way.
Tibial slope was shown to majorly affect the outcomes of Total Knee Arthroplasty (TKA). More slope of the tibial component could help releasing a too tight flexion gap in cruciate-retaining (CR) TKA and is generally associated with a wider range of post-operative knee flexion. However, an excessive tibial slope could jeopardize the knee stability in flexion. The mechanism by which tibial slope affects the function of CR-TKA is not well understood. Moreover, it is not known whether the tibial bone resection should be performed by referencing the anterior cortex (AC) of the tibia or the center of the tibial plateau (CP) and whether the choice of either technique plays a role. The aim of this study was to investigate the effect of tibial slope on the position of tibiofemoral (TF) contact point, knee ligament forces, quadriceps muscle forces, and TF and patellofemoral (PF) joint contact forces during squat activity in CR-TKA. A previously validated musculoskeletal model of CR-TKA was used to simulate a squat activity performed by a 86-year-old male subject wearing an instrumented prosthesis [1,2]. Marker data over four consecutive repetitions of a squat motion were tracked using a motion optimization algorithm. Muscle and joint forces and moments were calculated from an inverse-dynamic analysis, coupled with Force-Dependent Kinematics (FDK) to solve knee kinematics, ligament and contact forces simultaneously. The tibial slope in the postoperative case was 0 degree and constituted the reference case for our simulations. In addition, eight additional cases were simulated with −3, +3, +6, +9 degrees of tibial slope, four of them simulating an AC referencing technique and four a CP technique.Introduction
Methods
