INTRODUCTION:. The purpose of this study was to determine if a short femoral stem (Lima Corporate, Udine, Italy) would result in a strain distribution which mimicked the intact bone better than a traditional length stem, thereby eliminating the potential for stress-shielding. METHODS:. A 2 mm thick moldable plastic (PL-1, Vishay Micromeasurements, Raleigh, NC) was contoured to six fourth-generation composite femoral bones (Pacific Research Laboratories, Vashon, WA). The intact femurs were then loaded (82 kg) in a rig which simulated mid-stance single limb support phase of gait (Figure 1). During testing, the femurs were viewed and video recorded through a model 031 reflection polariscope. Observing the photoelastic coating through the polariscope, a series of fringes could be seen, which represented the difference in principal strain along the femur. The fringes were quantified using Fringe Order, N, as per the manufacturers technical notes. In order to analyze the strain distribution, the femur was separated into 6 zones, 3 lateral and 3 medial, and the maximum fringe order determined. Upon completion of testing of the intact femur, the short length femoral stem was inserted and tested, and finally the traditional length femoral stem was inserted and tested. Anterior and lateral radiographs were obtained of the femur with each femoral stem in order to confirm proper alignment. RESULTS:. Fringes formed in a similar pattern for all femurs, intact and with stems. The fringes first occurred medially and laterally in a proximal-distal direction and radiated outward, decreasing in fringe order, toward the neutral axis of bending (anterior and posterior). The magnitude of the fringe order, N, remained the same or increased in the proximal to distal direction. This became more prominent, particularly on the lateral side, with the traditional length femoral stem, when a distal migration of the fringes was seen compared to the intact femur (Figures 2 and 3). Medially, with the traditional length femoral stem, the fringes remained but were of a lower magnitude than the intact femur. The femoral strain pattern, resulting from implantation of the short length femoral stem, was found to closely match the intact femur. X-rays confirmed proper alignment of all implants. CONCLUSIONS:. The distal migration of strain seen with the traditional length femoral stem was indicative of potential stress shielding. As an alternative, this study suggests that the short length femoral stem most closely replicates the strain distribution of the intact femur and may limit this type of failure

Introduction. A new conservative hip stem has been designed to address the complex problem of total hip arthroplasty in the younger population. Objectives. To assess the stability and strain distribution of a new conservative hip stem. Materials and Methods. The prosthesis is tapered and collared and made from titanium (Ti6Al4V) with a titanium porous plasma spray to encourage bony ingrowth (Figure.1). It is circular-trapezoidal in cross-section to provide optimal ‘fit and fill’ in the femoral neck. (i) Finite Element Analysis (FEA). Computed tomography scans of an intact femur were modelled using MARC software and consisted of 161390 elements and 174881 nodes. The implant was modelled (Unigraphics) as a titanium alloy stem with a cobalt-chrome alloy head and consisted of 93440 hexahedral elements and 101133 nodes. This study compared the strains in the femoral calcar of an intact femur with a stem ‘implanted’ in neck shaft angles of 125°, 135°, and 145°. The head of all models received a load of 2.3KN at 7 degrees medially. (ii) Photoelastic Coating. A photoelastic coating was moulded around the medial cortices of ten third generation femora Sawbones. Strain before and after prosthesis insertion was measured at one-centimetre intervals down the medial cortex of the bones using a polariscope. The bones were positioned in a simplified single leg stance (7° physiological alignment), and loaded at 2.3 KN with strain recorded. (iii) Linear Variable Differential Transducers (LVDT's). Micromotion and migration of the prosthesis was measured using LVDT's. The femoral heads were cyclically loaded with 2.3KN at 1Hz for 2,500 cycles and held in a single leg stance. The bones were then repositioned at 70° of flexion to produce torsional (stair climbing) forces and loaded with 0.5KN for 2,500 cycles. Statistical analysis of non-parametric data was performed using a two-tailed Wilcox signed rank test (p<0.05). Results. The FEA analysis revealed strains in the neutral position most closely resembled that of an intact femur (Figure.2). Photoelastic strain readings for intact bone and following insertion were paired and statistically analysed using the Wilcox signed rank test (two tailed). The composite bones with prostheses inserted at 125° and 145° demonstrated a significant difference to the intact bones, whereas those at 135° showed no significant difference in the surface strain pattern of the femur following prosthetic insertion (Figure.3). Under single leg stance loading all prostheses produced axial micromotion of less than 200 µm and 50 µm in the varus-valgus direction. Implants inserted at 135° and 125° produced the least micromotion, the implants inserted at 145° had the greatest magnitude of motion and may be more susceptible to loosening. Under torsional load the same was true with the 135° and 125° producing the least micromotion while with the angulation of 145° micromotion increased over the test period – again suggesting loosening. Conclusion. This design transfers load in a physiological manner and the prosthesis is most stable in the neutral position. The findings from this study have been translated into clinical practice with the prosthesis implanted into two patients with promising results

Introduction. Traditional applied loading of the knee joint in experimental testing of RTKR components is usually confined to replicating the tibiofemoral joint alone. The second joint in the knee, the patellofemoral joint, can experience forces of up to 9.7 times body weight during normal daily living activities (Schindler and Scott 2011). It follows that with such high forces being transferred, particularly in high flexion situations such as stair climbing, it may be important to also represent the patellofemoral joint in all knee component testing. This research aimed to assess the inclusion of the patellofemoral joint during in vitro testing of RTKR components by comparing tibial strain distribution in two experimental rigs. The first rig included the traditional tibiofemoral joint loading design. The second rig incorporated a combination of both joints to more accurately replicate physiological loading. Five implanted tibia specimens were tested on both rigs following the application of strain gauge rosettes to provide cortical strain data through the bone as an indication of the load transfer pattern. This investigation aimed to highlight the importance of the applied loading technique for pre-clinical testing and research of knee replacement components to guide future design and improve patient outcomes. Methods. Five composite tibias (4th Generation Sawbones) were prepared with strain gauge rosettes (HBM), correctly aligned and potted using guides for repeatability across specimens. The tibias were then implanted with Stryker Triathlon components according to surgical protocol. The first experimental rig was developed to replicate traditional knee loading conditions through the tibiofemoral joint in isolation. The second experimental rig produced an innovative method of replicating a combination of the tibiofemoral and patellofemoral joint loading scenarios. Both rigs were used to assess the load distribution through the tibia using the same tibia specimens and test parameters for comparison integrity (Figure 1). The cortical strains were recorded under an equivalent 500 N cyclical load applied at 10° of flexion by a hydraulic test machine. Results. The average results comparing both experimental rigs at three strain gauge locations are shown in Figure 2. Paired t-tests were performed on all results and a p value of p<0.05 was considered significant. No significant differences were found between the rigs. There was a trend towards a reduction in proximal principal strain with the inclusion of the patellofemoral joint (p=0.058). Discussion. The results of this study indicate that there is no significant difference in tibial load transfer between the traditional and novel applied loading techniques at small flexion angles. There is a trend towards a reduction in proximal strain when including the patellofemoral joint. This reduction may be linked to the patella tendon force counteracting the effect of tibiofemoral loading at this small flexion angle. At high flexion angles the patellofemoral reaction load increases significantly relative to the tibiofemoral load. This will have a significant effect on tibial strains and so it is recommended that testing at higher flexion angles should be performed in a combined loading rig

Introduction. Revision total knee arthroplasy (TKA) has been often used with a metal block augmentation for patients with poor bone quality. However, bone resorption beneath metal block augmentation has been still reported and little information about the reasons of the occurrence of bone resorption is available. The aim of the current study is to identify a possibility of the potential occurrence of bone resorption beneath metal block augmentation, through evaluation of strain distribution beneath metal block augmentation in revision TKA with metal block augmentation, during high deep flexion. Materials and Method. LOSPA, revision TKA with a metal block augmentation (Baseplate size #5, Spacer size #5, Stem size Φ9, L30, Augment #5 T5) was considered in this study. For the test, the tibia component of LOSPA was implanted to the tibia sawbone (left, #3401, Sawbones EuropeAB, Malmö, Sweden), which was corresponded to a traditional TKR surgical guideline. The femoral component of LOSPA was mounted to a customized jig attached to the Instron 8872 (Instron, Norwood, MA, USA), which was designed specially to represent the angles ranged from 0° to 140° with consideration of a rollback of knee joint (Figure. 1). Here, a compressive load of 1,600N (10N/s) was applied for each angle. Strain distribution was then measured from rossete strain gauge (Half Bridge type, CAS, Seoul, Korea) together (Figure 1). Results and Discussions. The strain distribution on the cortical bone of the tibia was shown in Figure 2. The results showed that the strains on the posterior region were gradually increased from extension to high deep of the knee joint and generally larger than the other regions. In contrast to the results on the posterior region, the strains on the medial region were gradually decreased after 60° or 90° flexion position and relatively lower than the other regions. Particularly, the strains on the medial region were generally lower than 50–100 µstrain, which is known as critical value range able to inducing bone resorption, during high deep flexion. This fact indicate that a possibility of the potential bone resorption occurrence in revision TKA used with a metal block augmentation may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. This study may be valuable by identifying for the first time a possibility of the potential bone resorption occurrence through evaluation of the strain distribution beneath metal block augmentation in revision TKA used with a metal block augmentation during high deep flexion. Conclusion. A possibility of the potential bone resorption occurrence in revision TKA used with a metal block augmentation may be dependent on loading patterns applied on the knee joint related to personal lifestyle history. Particularly, it may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. Acknowledgements. This study was supported by a grant from the New Technology Product Evaluation Technical Research project, Ministry of Food and Drug Safety (MFDS), Republic of Korea

INTRODUCTION. Hip resurfacing offers a more bone conserving solution than total hip replacement (THR) but currently has limited clinical indications related to some poor design concepts and metal ion related issues. Other materials are currently being investigated based on their successful clinical history in THR such as Zirconia Toughened Alumina (ZTA, Biolox Delta, CeramTec, Germany) which has shown low wear rates and good biocompatibility but has previously only been used as a bearing surface in THR. A newly developed direct cementless fixation all-ceramic (ZTA) resurfacing cup offers a new solution for resurfacing however ZTA has a Young's modulus approximately 1.6 times greater than CoCr - such may affect the acetabular bone remodelling. This modelling study investigates whether increased stress shielding may occur when compared to a CoCr resurfacing implant with successful known clinical survivorship. METHODS. A finite element model of a hemipelvis constructed from CT scans was used and virtually reamed to a diameter of 58mm. Simulations were conducted and comparisons made of the ‘intact’ acetabulum and ‘as implanted’ with monobloc cups made from CoCr (Adept®, MatOrtho Ltd, UK) and ZTA (ReCerf ™, MatOrtho Ltd. UK) orientated at 35° inclination and 20° anteversion. The cups were loaded with 3.97kN representing a walking load of 280% for an upper bound height patient with a BMI of 35. The cup-bone interface was assigned a coulomb slip-stick function with a coefficient of friction of 0.5. The percentage change in strain energy density between the intact and implanted states was used to indicate hypertrophy (increase in density) or stress shielding (decrease in density). RESULTS. Implanting both cups changed the strain distribution observed in the hemipelvis, Figure 1. The change in strain distribution was similar between materials and indicated a similar response from the bone, Figure 2. In both implanted cases, the inferior peri-acetabular bone around the implant indicated a reduction in bone strain. The bone remodelling distribution charts show that regardless of threshold remodelling stimulus level (75% in elderly, 50% in younger patients) the CoCr and ZTA cups were expected to produce the same bone response with only a small percentage of the bone in the hemipelvis indicating stress shielding or hypertrophy, Figure 3. DISCUSSION. Currently only metal cups are used for cementless fixation but improvements in design and technology have made it possible to engineer a thin-walled, direct fixation, all-ceramic cup. Both CoCr and ZTA are an order of magnitude greater than the Young's modulus of cortical bone altering the bone strain but changing the material from CoCr to a stiffer ZTA did not change the expected bone remodelling response. Given the clinical history of metal cups without loosening due to bone remodelling, the study indicates that a ZTA cup should not lead to increased stress shielding and is potentially suitable for as a cementless cup for both resurfacing and THR. SIGNIFICANCE. An all-ceramic cup is unlikely to lead to increased stress shielding around the acetabulum due to the change in material. For any figures or tables, please contact the authors directly

It is nowadays widely recognized that patient satisfaction following knee arthroplasty strongly depends on ligament balancing. To obtain this balancing, the occurring ligament strain is assumed to play a crucial role. To measure this strain, a method is described in this paper that allows full field 3D evaluation of the strains. The latter is preferred over traditional measurement techniques, e.g. displacement transducers or strain gauges, as human soft tissue is not expected to deform uniformly due to its highly inhomogeneous and anisotropic properties. To facilitate full field strain measurements, the 3D digital image correlation (DIC) technique was adopted. This technique was previously validated by our research group on human tissue. First, a high contrast speckle pattern was applied on the sMCL. Therefore, the specimens are first coated with a small layer of methylene blue. Following, a random white speckle pattern is applied. During knee flexion, two cameras simultaneously take pictures of the deforming region at predefined flexion angles. Using dedicated software, the captured images are eventually combined and result in 3D full field strains and displacements. Using this method, the strain distribution was studied in six cadaveric knees during flexion extension movement. Therefore, the femur was rigidly fixed in a custom test rig. The tibia was left unconstrained, allowing the six degrees of freedom in the knee. A load was applied to all major muscles in physiological directions of each muscle by attaching a series of calibrated weights (Farahmand et al., J Orthop Res., 1998;16(1)). The direction of the pulling cables was controlled using a digital inclinometer for each specimen. As a result, a statically balanced muscle loading of the knee was obtained. From these cadaveric experiments, it is observed that on average the sMCL behaves isometrically between 0° and 90° of flexion. However, high regional differences in strain distribution are observed from the full field measurements. The proximal region of the sMCL experiences relatively high strains upon flexion. These strains are positive (tension) in the anterior part and negative (compression) in the posterior region. In contrast, the distal region remains approximately isometric upon knee flexion (see Figure 1). It is accordingly concluded that the sMCL behaves isometric, though large regional differences are observed. The proximal region experiences higher strains. Furthermore, the DIC technique provided valuable insights in the deformation of the sMCL. This technique will therefore be applied to study the impact of knee arthroplasty in the near future. Caption with figure 1: Full field strain distribution in the sMCL's longitudinal direction for specimen in 45° (a) and 90° (b) of knee flexion

Introduction. Revision total knee arthroplasty (TKA) has been often used with a metal block augmentation for patients with poor bone quality. However, bone defects are frequently detected in revision TKA used with metal block augmentation. This study focused on identification of a potential possibility of the bone defect occurrence through the evaluation of the strain distribution on the cortical bone of the tibia implanted revision TKA with metal block augmentation, during high deep flexion. Materials and Methods. Composite tibia finite element (FE) model was developed and revision TKA FE model with a metal block augmentation (Baseplate size #5 44AP/67ML, Spacer size #5 44AP/67ML, Stem size Φ9, L30, Augment #5 44AP/67ML thickness 5mm) was integrated with the composite tibia FE model. 0°, 30° 60°, 90°, 120° and 140° flexion positions were then considered with femoral rollback phenomenon [Fig 1.A]. A compressive load of 1,600N through the femoral component was applied to the composite tibia FE model integrated with the tibia component, sharing by the medial and lateral condyles, simulating a stance phase before toe-off [Fig 1.B]. Results and Discussions. The strain distribution on the cortical bone of the tibia was shown in [Fig 2]. The results showed that the strains on the posterior region were gradually increased from extension to high deep of the knee joint and generally larger than the other regions. This fact was favorably corresponded to the femoral rollback phenomenon in the knee joint, showing a good accuracy of our FE model. In contrast to the results on the posterior region, the strains on the medial region were gradually decreased after 60° or 90° flexion position and relatively lower than the other regions. Particularly, the strains on the medial region were generally lower than 50–100 µstrain, which is known as critical value range able to inducing bone loss, during high deep flexion. This fact indicate that a potential possibility of bone defect occurrence in revision TKA used with a metal block augmentation may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. This study may be valuable by identifying for the first time a potential possibility of the bone defect occurrence through evaluation of the strain distribution beneath metal block augmentation in revision TKA used with a metal block augmentation during high deep flexion. Conclusions. A potential possibility of bone defect occurrence in revision TKA used with a metal block augmentation may be dependent on loading patterns applied on the knee joint related to personal lifestyle history. Particularly, it may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. Acknowledgements. This study was supported by a grant from the New Technology Product Evaluation Technical Research project, Ministry of Food and Drug Safety (MFDS), Republic of Korea

Introduction. Periprosthetic bone remodelling after Total Knee Arthroplasty (TKA) may be attributed to local changes in the mechanical strain field of the bone as a result of the stiffness mismatch between high modulus metallic implant materials and the supporting bone. This can lead to significant loss of periprosthetic bone density, which may promote implant loosening, and complicate revision surgery. A novel polyetheretherketone (PEEK) implant with a modulus similar to bone has the potential to reduce stress shielding whilst eliminating metal ion release. Numerical modelling can estimate the remodelling stimulus but rigorous validation is required for use as a predictive tool. In this study, a finite element (FE) model investigating the local biomechanical changes with different TKA materials was verified experimentally using Digital Image Correlation (DIC). DIC is increasingly used in biomechanics for strain measurement on complex, heterogeneous anisotropic material structures. Methodology. DIC was used following a previously validated technique [1] to compare bone surface strain distribution after implantation with a novel PEEK implant, to that induced by a contemporary metallic implant. Two distal Sawbone® femora models were implanted with a cemented cobalt-chromium (CoCr) and PEEK-OPTIMA® femoral component of the same size and geometry. A third, unimplanted, intact model was used as a reference. All models were subjected to standing loads on the corresponding UHMWPE tibial component, and resultant strain data was acquired in six repeated tests. An FE model of each case, using a CT-derived bone model, was solved using ANSYS software. Results and Discussion. The sensitivity of DIC strain measurements was <+130με and experimental error was +230με, or 8.5% of the peak magnitude in the region of interest. High bone strain adjacent to the CoCr implant and low bone strain in the central metaphyseal region compared to the intact case (Fig.1) indicated that stress shielding may lead to resorption, a theory corroborated by bone density scans of implanted metallic TKRs [2]. Quantitatively, wider scatter and greater deviation was observed between the intact-vs-CoCr datasets (R. 2. : 0.425, slope = 0.508). A closer agreement was shown between the intact-vs-PEEK datasets (R. 2. : 0.771, slope = 1.270) (Fig.2). These strain distributions corroborated the predictions of the FE analysis (Fig.1). High bone strain in regions close to the CoCr implant can be attributed to the high stiffness mismatch between implant and bone, where the bone is constrained to the implant with cement. High strain gradients near the stiff CoCr could potentially compromise implant fixation, leading to loosening. The compressive strains in the PEEK implanted model were similar to those in the intact case, suggesting that bone would be maintained in these regions, and high strain gradients were not observed. Conclusion. Digital image correlation and FE analysis have been successfully employed for evaluation of a novel PEEK-OPTIMA® TKA implant in comparison to a metallic implant. The polymeric implant produced a strain distribution closer to that of the intact bone, and therefore would be expected to have less of a stress shielding effect, improving long term bone preservation

Introduction. The Rotational alignment is an important factor for survival total knee Arthroplasty. Rotational malalignment causes knee pain, global instability, and wear of the polyethylene inlay. Also, the anterior cortex line was reported that more reliable and more easily identifiable landmark for correct tibial component alignment. The aims of the current study is to identify effect of inserting the tibial baseplate of using anterior cortex line landmark of TKA on stress/strain distributions within cortical bone and bone cement. Through the current study, final aim is to suggest an alternative position of tibia baseplate for reduction of TKA failures with surgical convenience. Materials and Method. A three-dimensional tibia FE model with TKA was generated based on a traditional TKA surgical guideline. Here, a commercialized TKA (LOSPA, Corentc, Korea) was considered corresponded to a patient specific tibia morphology. Tibia baseplate was positioned at anterior cortex line. Alternative two positions were also considered based on tibia tuberosity 1/3 line and tibia tuberosity end line known as a gold standard (Fig. 1-A). Loading and boundary conditions for the FE analysis were determined based on five activities of daily life of persons with TKA (Fig. 1-B). FE model was additionally validated comparing with an actual mechanical test. Results and Discussions. The, through comparing with strain distribution on the cortical bone measured from the actual mechanical test considering 0°, 30° 60°, 90°, 120° and 140° flexion with femoral rollback phenomenon (Fig. 2). Stress/strain on the cortical bone (medial region) of the proximal tibia for the baseplate positioned at anterior cortex line were a little better distributed than those at tibia tuberosity 1/3 line and tibia tuberosity end line although the stress/stain values were similar to each other (Fig. 3-A). Potential fracture risk of the bone cement for the baseplate positioned at anterior cortex line was lower than that at tibia tuberosity 1/3 line and tibia tuberosity end line, considering safety factor (N=3). Particularly, Potential fracture risk of the bone cement for the baseplate positioned at tibia tuberosity 1/3 line known as a gold standard was highest (over 20MPa for stair down activity) (Fig. 3-B). Conclusion. Our results suggested that anterior cortex line landmark was feasible to apply positioning method on the tibial baseplate in terms of mechanical characteristics which were compared to tibia tuberosity 1/3 line and tibia tuberosity end line known as a gold standard. This study may be valuable by suggesting for the first time an alternative baseplate position for reduction of TKA failures with surgical convenience

Introduction. 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. Methods and Materials. 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. Results. The cyclic load phase of the pull-off experiments revealed minimal migration for both CoCr and PEEK components, although after construct sectioning, debonding at the implant-cement interface was observed for the PEEK implants. During pull-off from Sawbones the ultimate failure load of the PEEK and CoCr components averaged 2552N and 3814N respectively. FEA simulations indicated that under more physiological loading, such as walking or squatting, the PEEK component had no increased risk of loss of fixation when compared to the CoCr component. Finally, the DIC experiments and FEA simulations confirmed closer resemblance of pre-operative strain distribution using the PEEK component. Discussion. The biomechanical consequences of changing implant material from CoCr to PEEK on implant fixation was studied using experimental and computational testing of cemented reconstructions. The results indicate that, although changes occur in implant fixation, the PEEK component had a fixation strength comparable to CoCr. The advantage of long term bone preservation, as the more compliant PEEK implant is able to better replicate the physiological loads occurring in the intact femur, may reduce stress shielding around the distal femur, a common clinical cause of TKA failure. For any figures or tables, please contact the authors directly

As an alternative to total hip arthroplasty (THA), hip resurfacing arthroplasty (HRA) provides the advantage of retaining bone stock. However, femoral component loosening and femoral neck fracture continue to be leading causes of revision in HRA. Surgical technique including cementation method and bone preparation, and patient selection are known to be important for fixation. This study was designed to understand if and to what extent compromise in bone quality and the presence of cysts in the proximal femur contribute to resurfacing component loosening. A finite element (FE) model of a proximal femur was used to calculate the stress in the cement layer. Bone density to Young's modulus relationship was used to calibrate the bone stiffness in the model using computed tomography. A contemporary resurfacing implant (BHR, Smith & Nephew) was used in the FE model. The effect of reduced bone quality (35% reduction relative to normal baseline; osteoporosis threshold) and presence of cysts on stress in the bone cement layer was then assessed using the same FE model. The center of the cyst (a localized spherical cavity 1 cm in diameter) was located directly under the contact patch. Simulations were run with two locations of the center of the cyst, on the surface of the resected bone and 1 cm below it. The surface cyst was filled with bone cement, but the inner cyst was empty. The contact force and location for the model were obtained from instrumented implant studies. Simulations were run representing the peak loads during two activities, jogging and stand-up from seated position. While density reduction of the bone reduced the stress in the CoCr femoral head, the Von-Mises stress in the cement layer was amplified. The peak Von-Mises stress in the cement layer under the contact patch increased more than six times for the jogging activity, and more than ten times for the stand-up activity, relative to values for normal bone density. The impact of cysts on the cement layer stress or the strain distributions in the bone were minimal. The results show a greater risk of failure of the cement layer under conditions of reduced bone density. In contrast cement stresses and bone strains appeared to be relatively immune to a surface cyst filled with bone cement or an empty inner cyst. Contraindications of hip resurfacing include severe osteopenia and multiple cysts of the femoral head, however no strict or quantitative criteria exist to guide patient selection. Research similar to the one presented herein, maybe key to developing better patient selection criteria to reduce risk associated with compromised femoral head fixation

Introduction. Unicompartmental Knee Replacement Arthroplasty (UKA) is a treatment option for early knee OA that appears under-utilised, partly because of a lack of clear guidance on how to best restore lasting knee function using such devices. Computational tools can help consider inherent uncertainty in patient anatomy, implant positioning and loading when predicting the performance of any implant. In the present research an approach for creating patient-specific finite element models (FEM) incorporating joint and muscle loads was developed to assess the response of the underlying bone to UKA implantation. Methods. As a basis for future uncertainty modelling of UKA performance, the geometriesof 173 lower limbs weregenerated from clinical CT scans. These were segmented (ScanIP, Simpleware Ltd, UK) to reconstruct the 3D surfaces of the femur, tibia, patella and fibula. The appropriate UKA prosthesis (DePuy, U.S.) size was automatically selected according to tibial plateau size and virtually positioned (Figure 1). Boolean operations and mesh generation were accomplished with ScanIP. A patient-specific musculoskeletal model was generated in open-source software OpenSim (Delp et al. 2007) based on the Gait2392 model. The model was scaled to a specific size and muscle insertion points were modified to corresponding points on lower limb of patient. Hip joint load, muscle forces and lower limb posture during gait cycle were calculated from the musculoskeletal model. The FE meshes of lower limb bones were transformed to the corresponding posture at each time point of a gait cycle and FE analyses were performed (Ansys, Inc. U.S) to evaluate the strain distribution on the tibial plateau in the implanted condition. Results. With the tibial component positioned above, along or below the joint line, the lower limb alignment was more varus, remained unaltered or more valgus respectively (Figure 2). With the tibial component positioned 3mm above the joint line, the peak strain in the underlying bone was 670 µstrain on medial (UKA) side and 6780 µstrain on the intact side. With the tibial component positioned 3mm below the joint line, the peak strain was 3010 µstrain on the medial side and 5330 µstrain on the intact side. Here, the strains on the medial side increased by 2640 µstrain whilst they were reduced by 1450 µstrain on the intact side compared to the unimplanted case. Conclusion. The present research has delivered a framework which can be exploited in future uncertainty modelling of UKA performance predictions. The patient-specific model incorporates loading, anatomical and material property variability, and can be applied to evaluate the performance of UKA prostheses for metrics such as stress/strain/micromotions in larger patient populations. For figures/tables, please contact authors directly.

Introduction. The number of total hip replacements (THR) increased around 3.5% by year in last decade. Osteoarthritis is the most important disease in the hip, with a prevalence of 10% in the older population (>85 years), according to the Swedish THA Register. THR have been increasing in last years, mainly in young patients between 45 to 59 years old. This type of patients needs a long term solution to prevent hip revision. Two commercial solutions for young patients, the resurfacing prosthesis and press fit one, were analysed in the present study by experimental and numerical models. Methods. Two synthetic left models of composite femur (Sawbones. ®. , model 3403), which replicates the cadaveric femur, and two composite pelvic bones were used to introduce two Comercial models of Hip resurfacing (Birmingham model) and Press-fit stem (Laffit Selft –locking stem press-fit model). The commercial hip stems were chosen according to the femurs head size (resurfacing) and the femur size to press-fit Hip stem. Then, they were introduced by an experimented surgeon. The experimental set-up was applied according to a system defined previously by Ramos et al. (2013). Numerical models were implemented by replicating the experimental tests. A 3D scanning was used to identify the stem position in each model. The properties of cortical and cancel bone and hip prosthesis were also taken into account by these models. Contact was established in the interfaces for both press-fit solutions. The femur rotates distally and Pelvic moves up and down according model changes, in order to guarantee models with the same boundary conditions. Results. The numerical models were already validated experimentally using different loading conditions. Results from numerical models, present different distribution in the two commercial solutions in comparison to intact articulation (Figure 1). The medial aspect is the most critical in the femur. The resurfacing hip presents a closer behavior than the intact femur at proximal region. The press-fit hip presents a strain reduction in proximal region, which promotes the bone loss observed in clinical cases. The changes in the contact Hip joint for commercial solutions modify strain distribution distally, in all femur aspects. The press fit solution increase the bending in medial aspect

Purpose. As human soft tissue is anisotropic, non-linear and inhomogeneous, its properties are difficult to characterize. Different methods have been described that are either based on contact or noncontact protocols. In this study, three-dimensional (3D) digital image correlation (DIC) was adopted to examine the mechanical behaviour of the human Achilles tendon. Despite its wide use in engineering research and its great potential for strain and displacement measurements in biological tissue, the reported biomedical applications are rather limited. To our knowledge, no validation of 3D DIC measurement on human tendon tissue exists. The first goal of this study was to determine the feasibility to evaluate the mechanical properties of the human Achilles tendon under uniaxial loading conditions with 3D Digital Image Correlation. The second goal was to compare the accuracy and reproducibility of the 3D DIC against two linear variable differential transformer (LVDT's). Methods. Six human Achilles tendon specimens were prepared out of fresh frozen lower limbs. Prior to preparation, all limbs underwent CT-scanning. Using Mimics software, the volume of the tendons and the cross sectional area at each level could be calculated. Subsequently, the Achilles tendons were mounted in a custom made rig for uni-axial loading. Tendons were prepared for 3D DIC measurements with a modified technique that enhanced contrast and improved the optimal resolution. Progressive static loading up to 628,3 N en subsequent unloading was performed. Two charge-coupled device camera's recorded images of each loading position for subsequent strain analysis. Two LVDT's were mounted next to the clamped tendon in order to record the displacement of the grips. Results. 3D DIC strain measurement proved to be technical feasible on human tendon tissue if an adapted preparation protocol is used. A spatial resolution of 0,1 mm was reached. Accuracy analysis shows a very low scatter, comparable to that obtained in steel applications (0,03%). When compared to the LVDT measurements, DIC showed excellent correlation (R = 0.99). Apart from the longitudinal strain component, an important transverse strain component was revealed in all specimens (fig 1). Also a significant amount of slip was observed at the clamps. Through the non-contact nature of the measurement, this could be quantified and the analysis became independent of any slip (fig 2). The strain distribution was of a strongly inhomogeneous nature, both within the same specimen (fig 1) and amongst different specimens. Conclusion. 3D DIC is a very promising technique for strain measurement of human collagenous tissue. Accuracy analyses indicate a very low scatter, comparable to that obtained in traditional steel applications. The major advantages of the DIC technique over the LVDTs is the 3D, non-contact, full-field nature of the analysis and the possibility to analyse multidirectional strain, without disturbing slip effects in the grips

INTRODUCTION:. Proximally coated femoral stems have been designed to address the shortcomings of fully coated femoral stems including proximal femoral stress shielding. The design improvements leading to more optimized proximal femoral loading condition in the “Neck preserving stems” have increased the popularity of such implants (e.g., Minihip). Neck preserving stems depict better biological outcomes compared to more traditional stems . 1. by utilizing more natural mechanical stress/strain distribution over the femur. These stems provide significant reduction in both torsional and bending moments at the stem/bone interface. This reduction may result in decreasing the micromotion and failure of osseointegration . 1. Figure 1 demonstrates the differences between the cutting areas of a neck preserving versus traditional stem. The Minihip stem demonstrate a curved structure that is designed to match the shape of the femoral neck. The stability of the implant is achieved in the femoral neck and intertrochanteric area of the proximal femur. Further investigations are needed to establish a solid ground for the outcome of these stem in total hip arthroplasty (THA). OBJECTIVES:. The current study was conducted to report the short-term clinical outcome of the THA by using Minihip neck preserving stem. METHODS:. In the current study the short-term clinical outcomes of the patients in the patients who were treated by Minihip THA is analyzed. All patients were evaluated via Hip Disability and Osteoarthritis Outcome Score (HOOS). In addition we explored the effect of obesity on the perceived difficulty of surgery performance. A multinomial logistic regression was used in addition to a multivariate repeated ANCOVA was performed to determine significance of the demographics (i.e., BMI, Height, Weight, Age, and Gender). The signed consent was obtained from each participant. RESULTS:. 26 of the patients reported their symptoms to evaluate the HOOS (20 male, 6 female, Age 61.7 ± 8.5 years and BMI of 27.5 ± 3.88). Six patients demonstrated obesity (BMI>30). Post-operative data were collected at a mean followup time of 3 months. The results indicated significantly higher HOOS in individuals during postop depicting better quality of life (F(1, 25) = 186.695, p < .001), lower pain (F(1,25) = 249.317, p < .001), and higher activity level (F(1,25) = 202.233, p < .001). The increase in the performance of the patients however was not affected by the obesity of the individuals. We have also explored the effect of BMI on the difficulty of the surgery perceived by the surgeon and found that the surgeries were more difficult in obese patients (p = .023). CONCLUSION:. In this pilot study we have demonstrated that Minihip has the potential to exhibit excellent short-term clinical outcome in THA. In our study all individuals reported better quality of life after receiving the surgery. Future study should be conducted on comparing the differences in the outcome of the THA between commonly used implants and neck preserving stems

BACKGROUND. In vitro tests have shown that when a force is applied to the proximal femur within the range of directions spanned during physiological activities, the direction of principal strain vary by a very narrow angle (Cristofolini et al, 2009, J. Engng. Med.). This shows that the anatomy and the distribution of inhomogeneous and anisotropic material properties of the bone tissue make the structure of the proximal femur optimized to withstand a wide range of loading directions. The increasing use of hip resurfacing is associated with early neck fractures of the implanted femur. The aim of this study was to elucidate if such fractures could be caused by a non-physiological state of stress/strain post-implantation. While the possible role of notching at the neck-implant interface has already been elucidated, it is not know whether a resurfacing implant could make the principal strain vary in magnitude and direction in a way that could compromise integrity of the proximal femur. METHODS. The aim of this study was to measure if the direction of the principal strain in the proximal femur was affected by the presence of a resurfacing prosthesis. Seven human cadaver femurs were instrumented with 12 triaxial strain gauges to measure the magnitude and alignment of principal strains in the head-neck region. Each femur was implanted with a typical resurfacing prosthesis (BHR). All femurs were tested in vitro before and after implantation with a range of loading conditions to explore the range of loading directions during daily activity (Fig. 1). FINDINGS. Comparison of the strain distribution before and after implantation showed that: . In the natural conditions the principal tensile strain was significantly larger where the cortical bone was thinner; the compressive strain was larger where the cortical bone was thicker. This should be considered when designing a resurfacing prosthesis. The strain magnitude varied greatly between loading configurations both in the intact and implanted condition: this suggests that different loading configurations must be simulated for the preclinical validation of a resurfacing prosthesis. In the natural conditions, the direction of the principal strain varied significantly between measurement locations, but varied little between loading configurations (less than 10° when the hip force spanned a 21° cone, Fig. 2). This confirms that the anatomy and the distribution of anisotropic material properties enable the proximal femur to respond adequately to the changing direction of daily loading. In the resurfaced femurs, when the force spanned the same 21° cone, the direction of principal strain at each measurement location varied by less than 10° (Fig. 3), similar to the natural condition. In the resurfaced femurs, the direction of principal strain lied within less than 10° from the direction in the natural conditions. INTERPRETATION. Our results show that resurfacing does not disturb the alignment of principal strain in the proximal femur. In other words, the most critical directions of stress/strain after implantation stay aligned with the same direction as in the intact femur, which is the direction for which the inhomogeneous and anisotropic structure of the proximal femur is optimized

Introduction. Total Knee Replacement (TKR) is a highly effective treatment providing pain relief and improved function to patients experiencing advanced stage osteoarthritis. Tray fit or bone coverage is a critical design feature for both cemented and cementless designs affecting stability, load transfer and potential for infection. Many authors have attempted to characterise the relationship between the profile of the proximal tibia and gender and ethnicity. 1–3. As a consequence, a number of manufacturers have commercialised devices designed for specific gender and racial demographics. This study was initiated to compare the effect of the fixed minimum tibial resection depth prescribed by existing surgical instruments with that of a proportionate resection based on the size of the tibia. Method. A dataset consisting of 30 donor scans from a US cadaver tissue bank (ScienceCare, Memphis, US) was used for this study. The dataset consisted of 12 male and 18 female specimens. Due to the limited view of the diaphysis for most scans, the natural slope of the lateral compartment was used as a guide for orienting the resection. All scans were resected with a 3° posterior slope. For the first part of this study, an equal mediolateral (ML) resection of 9.5 mm, reflecting the minimum resection for the Unity TKR tibia (Corin, UK), was performed on all specimens (Figure 1). Following this, two proportionate resection depths (13.5 mm and 6.7 mm) were calculated based on the ML relationship between the smallest and largest available Unity components (59.5 mm: 84.5 mm). Two further resection depths (11.3 mm and 8.0 mm) were calculated based on a mid size (71.0 mm). Three resection depths (8.0 mm, 9.5 mm & 11.3 mm) were applied to four medium sized specimens. In addition to this two larger specimens were resected at 9.5 mm and 13.5 mm and two smaller specimens at 6.7 mm and 9.5 mm. A grid was applied to all cut surfaces and oriented using the posterior axis. The cut surface was divided based on lines drawn at 10%, 25%, 50%, 75% and 90% of the overall ML dimension and 10%, 25%, 50%, 75% and 90% of the overall anteroposterior (AP) dimension. Measurements were taken from the medial side and recorded from the points at which lines intersected the external profile of the cut tibia (Figure 2). Results. Results were presented as percentages relative to the AP and ML enabling the generation of 2D curve plots of the proposed profile (Figure 3). Discussion. Results from the fixed resection (9.5 mm) data depicted a good trend (R. 2. = 0.71–0.72) for the progression of the anterior profile as the tibia size increases. Similarly as the resection depth increased the same trend was observed. A weaker trend of R. 2. = 0.5 was also evident for the posterior profile. This methodology was applied to the development of the Unity tibia size range to optimise bone coverage and strain distribution

Introduction. Aligning the tibial tray is a critical step in total knee arthroplasty (TKA). Malalignment, (especially in varus) has been associated with failure and revision surgery. While the link between varus malalignment and failure has been attributed to increased medial compartmental loading and generation of shear stress, quantitative biomechanical evidence to directly support this mechanism is incomplete. We therefore constructed and validated a finite element model of knee arthroplasty to test the hypothesis that varus malalignment of the tibial tray would increase the risk of tray subsidence. Methods. Cadaver Testing. Fresh human knees (N = 4) were CT scanned and implanted with TKA cruciate-retaining tibial tray (Triathlon CR, Stryker Orthopaedics, New Jersey). The specimens were subjected to ISO-recommended knee wear simulation loading for up to 100,000 cycles. Micromotion sensors were mounted between the tray and underlying bone to measure micromotion. In two of the specimens, the application of vertical load was shifted medially to generate a load distribution ratio of 55:45 (medial:lateral) to represent neutral varus-valgus alignment. In the remaining two specimens, a load distribution ratio of 75:25 was generated to represent varus alignment. Finite element analysis. qCT scans of the tested knees were segmented using MIMICS (Materialise, Belgium). Material properties of bone were spatially assigned after converting bone density to elastic modulus. A finite element model of the tibia implanted with a tibial tray was constructed (Abaqus 6.8, Simulia, Dassault Syst`mes). Boundary conditions were applied to simulate experimental mounting conditions and the tray was subjected to a single load cycle representing that applied during cadaver loading. Results. The two cadaver specimens tested at 55:45 medial:lateral (M:L) force distribution survived the 100,000 cycle test, while both cadaver specimens tested at 75:25 M:L force distribution failed. The finite element model generated distinct differences in compressive strain distribution patterns in the proximal tibia. A threshold of 2000 microstrain was used for fatigue damage in bone under cyclic loading. Both specimens loaded under 75:25 M:L distribution demonstrated substantially larger cortical bone volumes in the proximal tibial cortex that were greater than this fatigue threshold. Discussion & Conclusion. We validated a finite element model of tibial loading after TKA. Local compressive strains directly correlated with subsidence and failure in cadaver testing. A significantly greater volume of proximal tibial cortical bone was compressed to a strain greater than the fatigue threshold in the varus alignment group, indicating an increased risk for fatigue damage. This model is extremely valuable in studying the effect of surgical alignment, loading, and activity on damage to proximal bone. Emerging techniques that customize tibial tray placement to the individual patient's pre-arthritic alignment run counter to the traditional recommendations for coronal alignment to the mechanical axis of the knee. A method that determines the risk of bone damage in a patient-specific manner can provide the surgeon with a safe range for component alignment and may even be applicable in preoperative planning