Malte Asseln

Evaluation of Biomechanical Models for the Planning of Total Hip Arthroplasty.

Musculoskeletal loading plays an important role in the primary stability of THA. There are about 210,000 primary THA interventions p.a. in Germany. Consideration of biomechanical aspects during computer-assisted orthopaedic surgery is recommendable in order to obtain satisfactory long-term results. For this purpose simulation of the pre- and post-operative magnitude of the resultant hip joint force R and its orientation is of interest. By means of simple 2D-models (Pauwels, Debrunner, Blumentritt) or more complex 3D-models (Iglic), the magnitude and orientation of R can be computed patient-individually depending on their geometrical and anthropometrical parameters. In the context of developing a planning module for computer-assisted THA, the objective of this study was to evaluate the mathematical models. Therefore, mathematical model computations were directly compared to in-vivo measurements obtained from instrumented hip implants. With patient-specific parameters the magnitude and orientation of R were model-based computed for three patients (EBL, HSR, KWR) of the OrthoLoad-database. Their patient-specific parameters were acquired from the original patient X-rays. Subsequently, the computational results were compared with the corresponding in-vivo telemetric measurements published in the OrthoLoad-database. To obtain the maximum hip joint load, the static single-leg-stance was considered. A reference value for each patient for the maximum hip load under static conditions was calculated from OrthoLoad-data and related to the respective body weights (BW). On average there are large deviations of the results for the magnitude (O=147%) and orientation (O=14.35° too low) of R obtained by using Blumentritt9s model from the in-vivo results/measurements. The differences might be partly explained by the supplemental load of 20% BW within Blumentritt9s model which is added to the input parameter BW in order to consider dynamic gait influences. Such a dynamic supplemental load is not applied within the other static single-leg-stance models. Blumentritt9s model assumptions have to be carefully reviewed due to the deviations from the in-vivo measurement data. Iglic9s 3D-model calculates the magnitude (O17%) and the orientation (O49%) of R slightly too low. For the magnitude one explanation could be that his model considers nine individual 3D-sets of muscle origins and insertion points taken from literature. This is different from other mathematical models. The patient-individual muscle origin and insertion points should be used. Pauwels and Debrunner9s models showed the best results. They are in the same range compared to in-vivo data. Pauwels9s model calculates the magnitude (O5%) and the orientation (O28%) of R slightly higher. Debrunner9s model calculates the magnitude (O1%) and the orientation (O14%) of R slightly lower. In conclusion, for the orientation of R, all the computational results showed variations which tend to depend on the used model. There are limitations coming along with our study: as our previous studies showed, an unambiguous identification of most landmarks in an X-ray (2D) image is hardly possible. Among the study limitations there is the fact that the OrthoLoad-database currently offers only three datasets for direct comparison of static single leg stance with in-vivo measurement data of the same patient. Our ongoing work is focusing on further validation of the different mathematical models.

Patient-specific musculoskeletal modeling of the hip joint for preoperative planning of total hip arthroplasty: A validation study based on in vivo measurements

Validation of musculoskeletal models for application in preoperative planning is still a challenging task. Ideally, the simulation results of a patient-specific musculoskeletal model are compared to corresponding in vivo measurements. Currently, the only possibility to measure in vivo joint forces is to implant an instrumented prosthesis in patients undergoing a total joint replacement. In this study, a musculoskeletal model of the AnyBody Modeling System was adapted patient-specifically and validated against the in vivo hip joint force measurements of ten subjects performing one-leg stance and level walking. The impact of four model parameters was evaluated; hip joint width, muscle strength, muscle recruitment, and type of muscle model. The smallest difference between simulated and in vivo hip joint force was achieved by using the hip joint width measured in computed tomography images, a muscle strength of 90 N/cm2, a third order polynomial muscle recruitment, and a simple muscle model. This parameter combination reached mean deviations between simulation and in vivo measurement during the peak force phase of 12% ± 14% in magnitude and 11° ± 5° in orientation for one-leg stance and 8% ± 6% in magnitude and 10° ± 5° in orientation for level walking.

Gender differences in knee morphology and the prospects for implant design in total knee replacement

BACKGROUND Morphological differences between female and male knees have been reported in the literature, which led to the development of so-called gender-specific implants. However, detailed morphological descriptions covering the entire joint are rare and little is known regarding whether gender differences are real sexual dimorphisms or can be explained by overall differences in size. METHODS We comprehensively analysed knee morphology using 33 features of the femur and 21 features of the tibia to quantify knee shape. The landmark recognition and feature extraction based on three-dimensional surface data were fully automatically applied to 412 pathological (248 female and 164 male) knees undergoing total knee arthroplasty. Subsequently, an exploratory statistical analysis was performed and linear correlation analysis was used to investigate normalization factors and gender-specific differences. RESULTS Statistically significant differences between genders were observed. These were pronounced for distance measurements and negligible for angular (relative) measurements. Female knees were significantly narrower at the same depth compared to male knees. The correlation analysis showed that linear correlations were higher for distance measurements defined in the same direction. After normalizing the distance features according to overall dimensions in the direction of their definition, gender-specific differences disappeared or were smaller than the related confidence intervals. CONCLUSIONS Implants should not be linearly scaled according to one dimension. Instead, features in medial/lateral and anterior/posterior directions should be normalized separately (non-isotropic scaling). However, large inter-individual variations of the features remain after normalization, suggesting that patient-specific design solutions are required for an improved implant design, regardless of gender.

Effects of the medial and lateral tibial slope on knee joint kinematics in total knee arthroplasty

Abstract Implant design in total knee arthroplasty is a key factor for the recovery of function and mobility of the joint. However, there is a lack of knowledge on the complex relationship between design features and the biomechanical situation. The posterior inclination of the tibial plateau (tibial slope) has a known functional impact on knee joint kinematics. In the native knee it shows high inter-individual differences, which is inadequately considered in total knee arthroplasty. We investigated the effects of the separate and combined variation of the medial and lateral tibial slope on knee joint kinematics in an in vitro setup. Therefore, the medial and lateral inserts of a knee implant were parameterised and the initial slope was gradually varied to +4°, +2° (posterior) and -2°, -4° (anterior). The variations were manufactured by using polymer based rapid prototyping. The effects on semi-active tibiofemoral and patellofemoral kinematics were studied and quantified in terms of the Root Mean Square Error and Pearson’s Correlation coefficient. The overall largest effect was observed on tibiofemoral internal-external rotation by the variation of the lateral insert. The anterior-posterior translation was predominantly effected by the combined variation. Nevertheless, the lateral variation showed greater influence than medial. In contrast, changes in patellofemoral kinematics were small. Our findings suggest that in total knee arthroplasty the lateral tibial slope has a larger functional effect than the medial tibial slope. Thus, functional design optimization should focus on the lateral insert.

Impact of Simulated Knee Injuries on the Patellofemoral and Tibiofemoral Kinematics Investigated with an Electromagnetic Tracking Approach: A Cadaver Study

Purpose The purpose of this study was to evaluate the approach of using an electromagnetic tracking (EMT) system for measuring the effects of stepwise, simulated knee injuries on patellofemoral (PF) and tibiofemoral (TF) kinematics. Methods Three cadaver knees were placed in a motion rig. EMT sensors were mounted on the patella, the medial/lateral femoral epicondyles, the tibial condyle, and the tibial tuberosity (TT). After determining the motion of an intact knee, three injuries were simulated and the resulting bony motion was tracked. Results Starting with the intact knee fully extended (0° flexion) and bending it to approximately 20°, the patella shifted slightly in the medial direction. Then, while bending the knee to the flexed position (90° flexion), the patella shifted progressively more laterally. After transecting the anterior cruciate ligament (ACL), the base of the medial menisci (MM) at the pars intermedia, and the medial collateral ligament (MCL), individual changes were observed. For example, the medial femoral epicondyle displayed a medial lift-off in all knees. Conclusion We demonstrated that our EMT approach is an acceptable method to accurately measure PF joint motion. This method could also enable visualization and in-depth analysis of in vivo patellar function in total knee arthroplasty, if it is established for routine clinical use.

Rapid prototyping of replica knee implants for in vitro testing

Abstract The understanding of the complex biomechanics of the knee is a key for an optimal implant design. To easily investigate the influence of prosthetic designs on knee biomechanics a rapid prototyping workflow for knee implants has been developed and evaluated. Therefore, different manufacturing technologies and post-treatment methods have been examined and overall seven different replica knee implants were manufactured. For evaluation, the manufacturing properties such as surface accuracy and roughness were determined and kinematic behaviour was investigated in a novel knee testing rig. It was carried out that PolyJet-Modelling with a sanded surface resulted in changed kinematic patterns compared to a usual CoCr-UHMWPE implant. However, fused deposition modelling using ABS and subsequent surface smoothening with acetone vapor showed the lowest roughness of the manufactured implants and only minor kinematic differences. For this reason this method constitutes a promising approach towards an optimal implant design for improved patient-satisfaction and long lifetime of the implant. Finally the workflow is not only limited to the knee.

The Q-Angle and its Effect on Active Knee Joint Kinematics - a Simulation Study.

Improvements in design and implant alignment in total knee arthroplasty (TKA) remains a crucial factor in the function and lifetime of the implant. Therefore a comprehensive understanding of functional knee structures and their effects on biomechanics is essential. We hypothesized that the Q-angle has a substantial impact on active joint kinematics and should be taken into account in TKA. The results show that knee kinematics are strongly affected by the Q-angle. When active kinematics may differ significantly to passive kinematics, intraoperative ligament balancing may result in a suboptimal ligament situation during active motion. Therefore the individual situation should be considered in patient specific TKA.