Jiann-Jong Liau

The effect of malalignment on stresses in polyethylene component of total knee prostheses – a finite element analysis

OBJECTIVE To investigate the effects of malalignment on stresses in tibial polyethylene component of total knee prostheses. DESIGN A three-dimensional finite element analysis was used to calculate the contact stress and von Mises stress in the tibial polyethylene component subjected to a compressive load, and the malalignment situations were simulated. BACKGROUND Many biomechanical studies to investigate the stresses in tibial polyethylene component were assumed at the ideal contact alignment. The effect of malalignment on stresses in tibial polyethylene component was not investigated extensively. METHODS Three-dimensional finite element models of the tibiofemoral joint of knee prostheses for three different designs were constructed. Three malalignment conditions including the medial translation (0.25, 0.5 and 1.0 mm), internal rotation (1 degree, 3 degree and 5 degree), and varus tilt (1 degree, 3 degree and 5 degree) of the femoral component relative to the tibial component were simulated. A compression load of 3000 N was applied to the tibiofemoral joint at 0 degree of flexion. The maximum contact stress and von Mises stress in the tibial component were compared to investigate the effects of malalignment. RESULTS In comparing with the neutral position, the greatest increase of maximum contact stress were 67.6%, 14.3% and 145.9% and the greatest increase of maximum von Mises stress were 92.5%, 22.7% and 120.6% in maltranslation, internal rotation and varus tilt simulations, respectively. CONCLUSION The greatest increase of contact stress and von Mises stress was occurred in the high conformity flat-on-flat design of knee prosthesis under the severest malalignment condition. The high conformity curve-on-curve design of knee prosthesis has the minimal risk of polyethylene wear under the malalignment conditions. RELEVANCE This study revealed the importance of malalignment effect on stresses in tibial polyethylene component. Polyethylene wear in surface replacement total knees will be minimal when a high conformity curve-on-curve knee design is used and the rotational line between the femoral and tibial components has the least effect on polyethylene wear but varus/valgus malalignment, even with the best designed prosthesis will still accelerate wear.

Evaluation of shoulder proprioception following muscle fatigue

OBJECTIVE To investigate the effect of shoulder muscle fatigue on glenohumeral proprioception. DESIGN A repeated proprioception test was performed. BACKGROUND The role of conditioning and fatigue in sport injuries remains controversial. It has been hypothesized that proprioceptive information plays an important role in joint stabilization and that muscle fatigue may alter proprioceptive ability. However, the effect of shoulder muscle fatigue on glenohumeral proprioception is still controversial. METHODS Eleven normal subjects (mean age 27.3 years) participated in this study. Proprioception tests (on the dominant shoulder) were performed in which proprioception of the active reproduced and passive reproduced shoulder position was measured using an isokinetic dynamometer and a proprioception testing apparatus, respectively. The speed of active repositioning was at 2 deg/s and passive repositioning was at 0.5 deg/s. The mean value of maximum voluntary contraction and the number of repetitions for muscle fatigue were recorded. Post-fatigue proprioception test was started within 3 min after muscle fatigue. RESULTS There was no significant difference of shoulder proprioception between pre- and post-fatigue determinations of passive repositioning in shoulder internal rotation, passive repositioning in external rotation and active repositioning in internal rotation. There was a significant difference between pre- and post-fatigue determination of active repositioning in external shoulder rotation (mean degrees: 2.57 (SD 1.02) vs. 4.96 (SD 1.73), P<0.05). CONCLUSION Shoulder proprioception in active repositioning in external rotation was major affected by muscle mechanoreceptors in the presence of muscle fatigue. RELEVANCE This study revealed that the shoulder proprioception after muscle fatigue in active repositioning in shoulder external rotation was affected more sensitively by the muscle mechanoreceptors than the joint mechanoreceptors. Increasing resistance of muscle fatigue would increase the shoulder proprioceptive ability.

Osteolysis in Failed Total Knee Arthroplasty: A Comparison of Mobile-Bearing and Fixed-Bearing Knees

Background: Osteolysis is an important complication associated with total knee arthroplasty. The purpose of this study was to compare the prevalence of osteolysis after failed total knee arthroplasty with a mobile-bearing prosthesis and after failed arthroplasty with a fixed-bearing prosthesis.Methods: Eighty revision total knee arthroplasties performed between 1995 and 1998 were included in this study. All had radiographic evidence of advanced polyethylene wear. The mobile-bearing group consisted of thirty-four knees with a Low Contact Stress implant, and the fixed-bearing group included forty-six knees. The average time (and standard deviation) from the primary operation to the revision was 102.8 ± 26.5 months in the mobile-bearing group and 96.0 ± 30.1 months in the fixed-bearing group. The prerevision radiographs and operative findings were reviewed.Results: The prevalence of osteolysis was significantly higher in the mobile-bearing group (47%; sixteen of thirty-four knees) than in the fixed-bearing group (13%; six of forty-six knees) (p = 0.003). The distal part of the femur was involved in thirteen knees in the mobile-bearing group and in four knees in the fixed-bearing group. Seventeen knees had osteolysis in the posterior aspect of the femoral condyle, which was the most common site of osteolysis; however, twelve of them had no evidence of osteolysis on prerevision radiographs.Conclusions: The prevalence of osteolysis was higher in the knees with a mobile-bearing prosthesis than in those with a fixed-bearing prosthesis. The osteolysis was predominantly on the femoral side, adjacent to the posterior aspect of the condyle. Radiographic evaluation of osteolysis in the distal part of the femur may not be reliable and usually leads to an underestimation of the degree of osteolysis.

Particle size and morphology of UHMWPE wear debris in failed total knee arthroplasties—a comparison between mobile bearing and fixed bearing knees

Osteolysis induced by ultrahigh molecular weight polyethylene wear debris has been recognized as the major cause of long‐term failure in total joint arthroplasties. In a previous study, the prevalence of intraoperatively identified osteolysis during primary revision surgery was much higher in mobile bearing knee replacements (47%) than in fixed bearing knee replacements (13%). We postulated that mobile bearing knee implants tend to produce smaller sized particles. In our current study, we compared the particle size and morphology of polyethylene wear debris between failed mobile bearing and fixed bearing knees. Tissue specimens from interfacial and lytic regions were extracted during revision surgery of 10 mobile bearing knees (all of the low contact stress (LCS) design) and 17 fixed bearing knees (10 of the porous‐coated anatomic (PCA) and 7 of the Miller/Galante design). Polyethylene particles were isolated from the tissue specimens and examined using both scanning electron microscopy and light‐scattering analyses. The LCS mobile bearing knees produced smaller particulate debris (mean equivalent spherical diameter: 0.58 μm in LCS, 1.17 μm in PCA and 5.23 μm in M/G) and more granular debris (mean value: 93% in LCS, 77% in PCA and 15% in M/G).

Late dislocation of rotating platform in New Jersey Low-Contact Stress knee prosthesis.

Five patients with late rotational dislocation of the rotating platform bearing in the New Jersey Low-Contact Stress total knee arthroplasty are reported. The prostheses had functioned well for 8 to 12 years before failure. Preoperative radiographs showed asymmetric femorotibial joint spaces. Entrapment of the dislocated bearing in three patients and spontaneous reduction of the dislocated bearing in another two patients were seen at revision. Femorotibial ligamentous instability was found after reduction. The retrieved polyethylene bearings showed advanced wear and cold flow deformities and the thickness was reduced. The revision arthroplasty was accomplished by replacement with a thicker bearing element. Progressive femorotibial ligament laxity and reduction of the thickness of polyethylene with wearing break down the originally well-balanced soft tissue tension of the knee. The rotational degree of the rotating platform bearing is unrestricted, which may result in late dislocation. Polyethylene wear is unavoidable in knee prostheses using metal contact with polyethylene even with a mobile-bearing design. Efforts to reduce polyethylene wear are mandatory.

Effect of Fuji pressure sensitive film on actual contact characteristics of artificial tibiofemoral joint

OBJECTIVE To investigate the effect of inserting a Fuji pressure sensitive film into an artificial tibiofemoral joint on the actual contact mechanics. DESIGN The experimental measurement and finite element analysis were used.Background. Although Fuji pressure sensitive film was widespread used for measuring the contact characteristics of artificial joint, how this measurement approaches actual contact characteristics has not yet been studied extensively. METHOD Two three-dimensional finite element models of an artificial tibiofemoral joint were constructed. The with-film-model was used to mimic the experimental setup and was verified by comparing the contact area and pressure on the simulated film calculated from finite element analysis to the measured one from the Fuji film (ultra-super low and medium grades) in the experimental test. Then the with-film-model was modified to the without-film-model in which the simulated film was removed. The contact characteristics on the film calculated from the with-film-model were represented to the measured one and the contact characteristics on the tibial component calculated from the without-film-model were represented to the actual one. The measured and actual contact characteristics were studied to investigate the effects of Fuji film on the actual contact characteristics in the tibiofemoral joint of knee prosthesis. RESULTS The contact characteristics calculated from with-film-model was reasonable agreement with measured one by Fuji film in the experimental test. The maximum difference is 13% in maximum contact pressure under a load of 3000 N. The maximum difference of contact area and pressure between the model simulating actual contact circumstance and the model with inserting a Fuji film between contacting surface are 2.4% and 14% respectively. CONCLUSION This study revealed that contact area and pressure of the tibiofemoral joint of knee prosthesis measured by Fuji pressure sensitive film could be simulated by finite element analysis. The measurement of contact area in the artificial joint by using ultra-super low grade Fuji film is overestimated its actual contact area by 1.2-2.4%, but the measurement of contact pressure by using medium grade Fuji film is underestimated its actual contact pressure by 8-14%. RELEVANCE This study revealed that the ultra-super low grade Fuji film is a reliable sensor to measure the contact area and the medium grade film would underestimate its actual contact pressure in the artificial tibiofemoral joint. This finding can provide a better understanding of the reliability of Fuji film to measure the contact characteristics of artificial joint in the experimental test.

The influence of surgical malalignment on the contact pressures of fixed and mobile bearing knee prostheses--a biomechanical study

OBJECTIVE To investigate the effect of surgical malalignment on contact pressures of fixed and mobile bearing knee prostheses. DESIGN An experimental set-up was used to measure contact pressure on the tibial component of fixed and mobile bearing knee prostheses subjected to a compression load and surgical malalignment situations were simulated. BACKGROUND Mobile bearing knee prostheses were designed to decrease tibiofemoral contact pressure by providing both high congruity and mobility. It was also assumed to accommodate surgical malalignment. However, few studies have reported the effect of malalignment of the tibiofemoral joint on contact pressure of fixed and mobile bearing knee prostheses. METHODS Surgical malalignment situations were simulated to evaluate contact characteristics of tibial component of fixed and mobile bearing knee prostheses. The simulated malalignment conditions include the medial-lateral translation (0.5 and 1 mm), anterior-posterior translation (2 and 4 mm) and internal-external rotation (1 degrees, 3 degrees, 5 degrees and 10 degrees ) of the femoral component relative to the tibial component. Fuji pressure sensitive film was used to measure the contact pressure. RESULTS The greatest increase of maximum contact pressure in the anterior-posterior maltranslation was 7.63% and 7.62% relative to the neutral contact situation in the fixed and mobile bearing designs respectively. In the medial-lateral maltranslation, there was 23.3% in the fixed bearing design and was 22.0% in the mobile bearing design. In the internal/external malrotation, the greatest increase of maximum contact pressure in the fixed bearing design was 27.1%, which was much higher than the mobile bearing design (22.4%). CONCLUSIONS The mobile bearing design can reduce maximum contact pressure more significantly than the fixed bearing design when malalignment conditions of the tibiofemoral joint occurs, especially in the internal/external malrotation. The mobile bearing design offers the advantage of self-adjusting over the fixed bearing design to accommodate surgical malalignment. RELEVANCE This study revealed that the mobile bearing design has smaller maximum contact pressures than the fixed bearing design in knee prosthesis under malalignment biomechanical tests. This result indicates that there is an advantage for a mobile bearing design over a fixed bearing design to accommodate malalignment conditions caused by surgical technique or soft tissues imbalance in total knee arthroplasty.

The influence of inserting a Fuji pressure sensitive film between the tibiofemoral joint of knee prosthesis on actual contact characteristics.

OBJECTIVE To investigate the influence of inserting a Fuji pressure sensitive film between the tibiofemoral joint of knee prosthesis on actual contact characteristics. DESIGN A finite element analysis was used to investigate the alteration of contact characteristics of the tibiofemoral joint due to inserting a pressure sensitive film between the contacting surfaces. BACKGROUND The discrepancy between actual contact behaviors of tibiofemoral joint of knee prosthesis and the measurement using Fuji pressure sensitive film was not discussed extensively. The change of direct contact circumstance of the tibiofemoral joint due to inserting a pressure sensitive film was not well reported. METHOD A two-dimensional finite element model of the tibiofemoral joint of knee prosthesis in the sagittal plane was constructed. Four different radii of the femoral component were used to investigate the conformity effect. Two-layers of plane strain element were used to model the pressure sensitive film. The influence of inserting a pressure sensitive film on the actual contact characteristics was analyzed by comparing the results of the change in contact radius. RESULTS Inserting a pressure sensitive film between contacting surfaces would disturb the original contact behaviors, especially in the lowest conformity design. The maximum difference of contact radius between the model simulating actual contact circumstance and the model with inserting a pressure sensitive film between contacting surface was 77% in the lowest conformity condition at the smallest load. CONCLUSIONS This study proposes a quantitative analysis of contact characteristics in the tibiofemoral joint of knee prosthesis between the models with and without inserting a pressure sensitive film into the contact surface. The measurement of contact area in artificial tibiofemoral joints by using Fuji pressure sensitive film is always overestimated its true contact area by 14-77%. RELEVANCE This study revealed the measurement of contact characteristics of artificial tibiofemoral joints by using Fuji pressure sensitive film which depends on not only the applied load, but also the conformity and material properties of the contact surface. Therefore, the information of the conformity and material properties of the contact surface should be provided as well as the applied load wherever a measurement of contact characteristics using Fuji pressure sensitive film is analyzed and interpreted.

Comparison of muscle strength of posterior cruciate-retained versus cruciate-sacrificed total knee arthroplasty

One of the most controversial issues in total knee arthroplasty is whether to retain or sacrifice the posterior cruciate ligament (PCL). Investigators have used various methods to evaluate the influence of the PCL after total knee arthroplasty, but muscle strength evaluation has not been reported. The purpose of this study is to compare the long-term effects of PCL retention or sacrifice on muscle strength. Isokinetic testings and isometric testings were studied in patients with three different types of prosthesis design: total condylar, low contact stress rotating platform (both sacrifice PCL), and low contact stress meniscal bearing (retains PCL). The results showed that in all testing conditions, the hamstring to quadriceps ratios did not significantly differ among the three prosthetic designs (P > .05) even after long-term (6-13 years) functional adaptation.

Mobile-bearing knees reduce rotational asymmetric wear.

Polyethylene wear of bearing components is the most common long-term complication in total knee arthroplasty. One would anticipate differing kinematics would generate different wear patterns (including wear type, degree, and symmetry) on the articulating surface of mobile-bearing and fixed-bearing inserts. Because mobile-bearing designs facilitate movement of the insert relative to the tray when the knee rotates, we hypothesized mobile-bearing designs would reduce the incidence of rotational asymmetric wear. We examined 51 worn tibial inserts, including 15 from mobile-bearing rotating-platform posterior-cruciate-sacrificing dished prostheses and 36 from fixed-bearing posterior-cruciate-retaining flat prostheses, which were retrieved at revision surgery with an average implantation time of 115 months. We divided wear types into low-grade wear (burnishing, abrasion, and cold flow) and high-grade wear (scratching, pitting, metal embedding, and delamination) to assess wear degree of polyethylene. To assess symmetry of wear, the insert surface was divided into medial and lateral sides and each side was further divided into three equal zones along the anteroposterior direction. Low-grade wear was more common in mobile-bearing knees, whereas high-grade wear was more common in fixed-bearing knees. We identified no internal/external rotational asymmetric wear or anteroposterior asymmetric wear in mobile-bearing knees.