A.M.R. New

Probabilistic finite element analysis of the uncemented hip replacement—effect of femur characteristics and implant design geometry

In the present study, a probabilistic finite element tool was assessed using an uncemented total hip replacement model. Fully bonded and frictional interfaces were investigated for combinations of three proximal femurs and two implant designs, the Proxima short stem and the IPS hip stem prostheses. The Monte Carlo method was used with two performance indicators: the percentage of bone volume that exceeded specified strain limits and the maximum nodal micromotion. The six degrees of freedom of bone-implant relative position, magnitude of the hip contact force (L), and spatial direction of L were the random variables. The distal portion of the proximal femurs was completely constrained and some of the main muscle forces acting in the hip were applied. The coefficients of the linear approximation between the random variables and the output were used as the sensitivity values. In all cases, bone-implant position related parameters were the most sensitive parameters. The results varied depending on the femur, the implant design and the interface conditions. Values of maximum nodal micromotion agreed with results from previous studies, confirming the robustness of the implemented computational tool. It was demonstrated that results from a single model study should not be generalised to the entire population of femurs and that bone variability is an important factor that should be investigated in such analyses.

Biological and mechanical enhancement of impacted allograft seeded with human bone marrow stromal cells: potential clinical role in impaction bone grafting

With the demographics of an aging population the incidence of revision surgery is rapidly increasing. Clinical imperatives to augment skeletal tissue loss have brought mesenchymal stem cells to the fore in combination with the emerging discipline of tissue engineering. Impaction bone grafting for revision hip surgery is a recognized technique to reconstitute bone, the success of which relies on a combination of mechanical and biological factors. The use of morsellized allograft is currently the accepted clinical standard providing a good mechanical scaffold with little osteoinductive biological potential. We propose that applying the principles of a tissue engineering paradigm, the combination of human bone marrow stromal cells (hBMSCs) with allograft to produce a living composite, offers a biological and mechanical advantage over the current gold standard of allograft alone. This study demonstrates that hBMSCs combined with allograft can withstand the forces equivalent to a standard femoral impaction and continue to differentiate and proliferate along the bony lineage. In addition, the living composite provides a biomechanical advantage, with increased interparticulate cohesion and shear strength when compared with allograft alone.

A numerical study of failure mechanisms in the cemented resurfaced femur:effects of interface characteristics and bone remodelling

Abstract Failure mechanisms of the resurfaced femoral head include femoral neck fracture in the short term and stress shielding and implant loosening in the long term. In this study, finite element simulations of the resurfaced femur considering a debonded implant—cement interface, variable stem—bone interface conditions, and bone remodelling were used to study load transfer within the resurfaced femur and to investigate its relationship with known failure mechanisms. Realistic three-dimensional finite element models of an intact and resurfaced femur were used. Various conditions at the interface between the stem of the prosthesis and the bone were considered. Loading conditions included normal walking and stair climbing. For all stem—bone contact conditions, the tensile stresses in the cement mantle varied between 1 MPa and 5.4 MPa, except near the distal rim of the resurfacing component where they reached 5.4—7 MPa. In the case of full stem—bone contact, high von Mises stresses (114—121 MPa) were generated in the implant at the stem—cup junction. These stresses were considerably reduced (maximum von Mises stress, 76 MPa) where a gap was present at the stem—bone interface. Resurfacing led to strain shielding of the bone of the femoral head (20—75 per cent strain reductions) and periprosthetic bone resorption (50—80 per cent bone density reductions) for all interface stem—bone contact conditions. In the lateral femoral head and the proximal femoral shaft around the trochantric region, bone density reductions varied between 10 per cent and 50 per cent. Bone apposition was observed in the inferior—medial part of the femoral head and proximal femoral neck region. For full stem—bone contact, more load was transferred through the stem to the surrounding bone, exacerbating strain shielding. Although femoral hip resurfacing conserves bone stock at the primary operation, strain shielding and periprosthetic bone resorption might lead to eventual loosening over time. Post-operatively, the resurfacing procedure generated elevated strains (0.50—0.75 per cent strain) in the proximal femoral neck—component junction irrespective of the variation in interface conditions, indicating an initial risk of femoral neck fracture. Subsequent to bone remodelling, this strain concentration was considerably reduced (0.35—0.50 per cent strain), lowering the risk of neck fracture. In order to reduce the potential risk of neck fracture, patients should avoid activities which might induce high loading of the hip during the early post-operative period to allow the bone around the proximal femoral neck to remodel and heal.

Taking tissue-engineering principles into theater: augmentation of impacted allograft with human bone marrow stromal cells

Human bone marrow contains bone progenitor cells that arise from multipotent mesenchymal stem cells. Seeding bone progenitor cells onto a scaffold can produce a 3D living composite with significant mechanical and biological potential. This article details laboratory and clinical findings from two clinical cases, where different proximal femoral conditions were treated using impacted allograft augmented with marrow-derived autogenous progenitor cells. Autologous bone marrow was seeded onto highly washed morselized allograft and impacted. Samples of the impacted graft were also taken for ex vivo analysis. Both patients made an uncomplicated clinical recovery. Imaging confirmed defect filling with encouraging initial graft incorporation. Histochemical and alkaline phosphatase staining demonstrated that a live composite graft with osteogenic activity had been introduced into the defects. These studies demonstrate that marrow-derived cells can adhere to highly washed morselized allograft, survive the impaction process and proliferate with an osteoblastic phenotype, thus creating a living composite.

Finite element analysis of unicompartmental knee arthroplasty.

Concerns over accelerated damage to the untreated compartment of the knee following unicompartmental knee arthroplasty (UKA), as well as the relatively poor success rates observed for lateral as opposed to the medial arthroplasty, remain issues for attention. Finite element analysis (FEA) was used to assess changes to the kinematics and potential for cartilage damage across the knee joint in response to the implantation of the Oxford Mobile Bearing UKA. FE models of lateral and medial compartment arthroplasty were developed, in addition to a healthy natural knee model, to gauge changes incurred through the arthroplasty. Varus-valgus misalignments were introduced to the femoral components to simulate surgical inaccuracy or over-correction. Boundary conditions from the Stanmore knee simulator during the stance phase of level gait were used. AP translations of the tibia in the medial UKA models were comparable to the behaviour of the natural knee models (+/-0.6mm deviation from pre-operative motion). Following lateral UKA, 4.1mm additional posterior translation of the tibia was recorded than predicted for the natural knee. IE rotations of the medial UKA models were less consistent with the pre-operative knee model than the lateral UKA models (7.7 degrees vs. 3.6 degrees deviation). Varus misalignment of the femoral prosthesis was more influential than valgus for medial UKA kinematics, whereas in lateral UKA, a valgus misalignment of the femoral prosthesis was most influential on the kinematics. Resection of the cartilage in the medial compartment reduced the overall risk of progressive OA in the knee, whereas removing the cartilage from the lateral compartment, and in particular introducing a valgus femoral misalignment, increased the overall risk of progressive OA in the knee. Based on these results, under the conditions tested herein, both medial and lateral UKA can be said to induce kinematics of the knee which could be considered broadly comparable to those of the natural knee, and that even a 10 degrees varus-valgus misalignment of the femoral component may not induce highly irregular kinematics. However, elevated posterior translation of the tibia in lateral UKA and large excursions of the insert may explain the higher incidence of bearing dislocation observed in some clinical studies.

Adult mesenchymal stem cells and impaction grafting: a new clinical paradigm shift

The demographic challenges of an increasingly aging population emphasize the need for innovative approaches to skeletal reconstruction to augment and repair skeletal tissue lost as a consequence of implant loosening, trauma, degeneration or in situations involving revision surgery requiring bone stock. These clinical imperatives to augment skeletal tissue loss have brought mesenchymal stem cells to the fore in combination with the emerging discipline of tissue engineering. To date, impaction bone grafting for revision hip surgery is a recognized technique to reconstitute bone utilizing morselized allograft to provide a good mechanical scaffold, although with little osteoinductive biological potential. This review details laboratory and clinical examples of a paradigm shift in the application of mesenchymal stem cells with allograft to produce a living composite using the principles of tissue engineering. This step change creates a composite that offers a biological and mechanical advantage over the current gold standard of allograft alone. This translation of tissue engineering concepts into clinical practice offers enormous input into the field of bone regeneration and has implications for translation and future change in skeletal orthopedic practice in an increasingly aging population.

Probabilistic analysis of an uncemented total hip replacement.

This paper describes the application of probabilistic design methods to the analysis of the behaviour of an uncemented total hip replacement femoral component implanted in a proximal femur. Probabilistic methods allow variations in factors which control the behaviour of the implanted femur (the input parameters) to be taken into account in determining the performance of the construct. Monte Carlo sampling techniques were applied and the performance indicator was the maximum strain in the bone. The random input parameters were the joint load, the angle of the applied load and the material properties of the bone and the implant. Two Monte Carlo based simulations were applied, direct sampling and latin hypercube sampling. The results showed that the convergence of the mean value of the maximum strain improved gradually as a function of the number of simulations and it stabilised around a value of 0.008 after 6200 simulations. A similar trend was observed for the cumulative distribution function of the output. The strain output was most sensitive to the bone stiffness, followed very closely by the magnitude of the applied load. The application of latin hypercube sampling with 1000 simulations gave similar results to direct sampling with 10,000 simulations in a much reduced time. The results suggested that the number of simulations and the selection of parameters and models are important for the reliability of both the probability values and the sensitivity analyses.

Acetabular cementing technique in THA—flanged versus unflanged cups, cadaver experiments

Background There are few studies on the effect of acetabular cup design on cement penetration.Material and methods We evaluated the effects of an acetabular flange on cement pressurization and cement penetration in 12 cadavers. Flanged or unflanged cups were implanted in paired human acetabula with simulated intraosseous bleeding pressure but without cement pressurization before insertion of the cup. Three pressure transducers were used to record intra-acetabular peak and average pressures during cup insertion. Following implantation, the whole specimens were AP-radiographed and standardized sections through the acetabula were microradiographed to evaluate cement penetration.Results Flanged cups produced greater intra-acetabular peak pressures than unflanged cups, but did not increase the average intra-acetabular pressure. Cement penetration did not differ significantly between the two groups.Interpretation Our findings do not support the use of flanged cups as the sole means of cement pressurization in the acetabulum.

Vibration-assisted bone-graft compaction in impaction bone grafting of the femur

The complications of impaction bone grafting in revision hip replacement includes fracture of the femur and subsidence of the prosthesis. In this in vitro study we aimed to investigate whether the use of vibration, combined with a perforated tamp during the compaction of morsellised allograft would reduce peak loads and hoop strains in the femur as a surrogate marker of the risk of fracture and whether it would also improve graft compaction and prosthetic stability. We found that the peak loads and hoop strains transmitted to the femoral cortex during graft compaction and subsidence of the stem in subsequent mechanical testing were reduced. This innovative technique has the potential to reduce the risk of intra-operative fracture and to improve graft compaction and therefore prosthetic stability.

Effect of bone material properties on the initial stability of a cementless hip stem: a finite element study.

Abstract In previous finite element studies of cementless hip stems reported in the literature, the effect of bone quality on the initial micromotion and interface bone strain has been rarely reported. In this study, the effect of varying cortical and cancellous bone modulus on initial stem micromotion and interface bone strain was examined and the potential consequence of these changes on bone ingrowth and implant migration was reported. A finite element (FE) model of a total hip replacement (THR) was created and the Youngs moduli of cortical and cancellous bone were systematically varied to study the relative effect of the quality of both types of bone on the initial stability of a cementless THR. It was found that the initial micromotion and interface bone strain in a THR was significantly affected by the overall stiffness of the femur. In other words, both the reduction of the modulus of cortical and cancellous bone caused an increase in the initial micromotion and interface bone strain. This suggests that for FE studies to be truly predictive, a range of bone quality must be examined to study the performance envelope of a particular stem and to allow comparison with clinical results.