Shivani Sathasivam

A knee simulating machine for performance evaluation of total knee replacements

A knee simulating machine is required for the design and evaluation of total knee replacements, the kinematics and the long-term wear being aspects of particular importance. There are no generally agreed design criteria, such that existing designs of simulator have a wide variety of input and constraint conditions. In this study, it was postulated that in order to reproduce physiological wear patterns, the correct kinematics is required, on the basis that the wear will be a direct function of the sliding, rolling and tractive rolling conditions at the joint surfaces. In turn, the correct kinematics would only be achieved by the input of physiological forces, by the appropriate constraints on the fixtures holding the components, and by simulating the soft tissue restraints. A knee simulating machine based on these principles was constructed, and used to test the kinematics of a range of contemporary condylar replacement knees. The displacements and rotations varied over a range of almost two times, even with the soft tissue restraints. Without the restraints, the low constraint designs would have dislocated or moved unrealistically. It was concluded that a simulating machine should be based on the input of forces and moments, rather than on displacements and rotations, in order to provide data of kinematics and wear.

A computer model with surface friction for the prediction of total knee kinematics

A computer model was generated which modelled the bearing surfaces of total knees, and predicted the kinematics for a set of input forces and moments. The model included friction at the bearing surfaces and soft tissue restraint forces, including the effect of cruciate resection. Predictions from the model were compared with data from a Knee Simulating Machine. There was close agreement in the shapes of the curves and in the magnitudes of the displacements and rotations under most conditions. The model predicted major differences in kinematics when friction between metal and polyethylene was included, the differences being even greater at the friction levels associated with small embedded acrylic particles. Soft tissue restraint was shown to reduce the displacements and rotations for tibial surfaces of low constraint but for moderate to high constraint, the soft tissues affected the kinematics only slightly. When the model was used to predict the motions for different condylar geometries, widely different contact paths on the tibial surface were determined. This suggested that condylar geometries which appeared to be generally similar, could have important differences in kinematics, function and wear.

Optimization of the bearing surface geometry of total knees

Various design criteria were examined in combination to find the ideal geometry for a condylar knee replacement. The criteria were the contact stresses on the plastic, femoral-tibial size interchangeability, patella lever arm, laxity and stability and the amount of bone resection required. The variables were the radii of curvature of the femoral and tibial bearing surfaces in the sagittal and frontal planes. Metal toroidal indentors were loaded onto dished surfaces of UHMWPE covering a range of radii and the contact areas measured. Using elasticity equations, the apparent elastic modulus of UHMWPE ranged from 400 to 600 MPa for less conforming to closely conforming surfaces. Using a value of 600 MPa, contact stresses were predicted for a complete spectrum of radii of curvature. Finite element analysis was used to determine the stresses beneath the contact patches when different femoral-tibial sizes were interchanged. A computergraphics program was written to analyse the effects of flexion, rotation and femoral roll-back on the contact point locations. An influential variable was the sagittal curvature of the femoral component, notably the point of transition between the posterior curve of small radius and the distal curve of larger radius. This affected the patella lever arm, the stability, and the bone resection. Interchangeability was primarily dependent upon the relative frontal radii. Contact stresses and contact locations depended upon the combination of sagittal and frontal radii. The most suitable geometrical combinations overall were discussed.

The conflicting requirements of laxity and conformity in total knee replacement

Bearing surfaces of total condylar knees which are designed with a high degree of conformity to produce low stresses in the polyethylene tibial insert may be overconstrained. This study determines femoral and tibial bearing surface geometries which will induce the least destructive fatigue mechanisms in the polyethylene whilst conserving the laxity of the natural knee. Sixteen knee designs were generated by varying four parameters systematically to cover the range of contemporary knee designs. The parameters were the femoral frontal radius (30 or 70 mm), the difference between the femoral and tibial frontal radii (2 or 10 mm), the tibial sagittal radius (56 or 80 mm) and the posterior-distal transition angle (-8 or -20 degrees), which is the angle at which the small posterior arc of the sagittal profile transfers to the larger distal arc. Rigid body analyses determined the anterior-posterior and rotational motions as well as the contact points during the stance phase of gait for the different designs. In addition, a damage function which accumulated the fluctuating maximum shear stresses was used to predict the susceptibility to delamination wear of the polyethylene (damage score). This study predicted that of the 16 designs, the knee with a frontal radius of 70 mm, a difference in femoral and tibial frontal radii of 2 mm, a tibial sagittal radius of 80 mm and a posterior distal transition angle of -20 degrees would satisfy the conflicting needs of both resistance to delamination wear and natural kinematics.

Inherent differences in the laxity and stability between the intact knee and total knee replacements

Abstract To compare the laxity and stability characteristics between the natural knee and condylar replacements, tests were carried out in a knee simulating machine. The tests consisted of applying compressive forces and then applying cyclic AP force and cyclic torque. The magnitudes were similar to those of functional conditions. For the natural knee, the laxities were only reduced modestly by increases in compressive force, especially internal-external rotation. For a low conformity TKR soft tissue restraint was required under low compression in order to avoid anterior tibial subluxation and internal or external rotation in excess of 20 ° . As compression was increased, the rapidly increasing effect of the dishing and the frictional effects provided sufficient inherent stability, although on average, soft tissue restraint reduced the laxity by about 30%. A high conformity TKR still required soft tissue restraint at low compression, but as the compressive force was increased, the surfaces reduced the laxity to the point where, the laxities were only a few millimetres and a few degrees, and the soft tissues contributed little. This phenomenon, where the femoral component is constrained to be close to the bottom of the tibial dish, may not be fully recognised at surgery and may result in excessive PCL tensions and contact forces in function, as well as reduced mobility, especially when a deep-dished tibial component was used. Relatively shallow posterior tibial curvature and a steep anterior curvature were concluded to provide the most satisfactory combination of laxity and stability.

The design of guide surfaces for fixed-bearing and mobile-bearing knee replacements

In the natural knee, the femoral tibial contacts move posteriorly as the knee is flexed, guided primarily by the cruciate ligaments. This kinematic behaviour is important regarding muscle lever arms and in achieving a high flexion range. Most contemporary total knee designs use either posterior cruciate preservation or a cam system to produce posterior displacement with flexion, but there is no specific provision for anterior displacement. In this study, a method for the design of cams is described where the cams would guide the motion in both posterior and anterior directions, without requiring cruciate ligaments. The cams consist of a femoral Guide Surface interacting with a tibial Guide Surface while the main lateral and medial bearing surfaces carry the forces across the knee. It is shown that Guide Surfaces can be designed which provide the required motion, but with some laxity at different flexion ranges. It is then demonstrated that the Guide Surfaces can be applied to a range of possible knee designs including mobile-bearing types, rotating-platform types, and fixed-bearing types. The relative advantages of the different possibilities are discussed.

Custom constrained condylar total knees using CAD-CAM

Abstract There are a number of pathological conditions involving abnormal geometry, including extremely small sizes, where standard off-the-shelf total knees do not suffice. Usually, these conditions require total joints which provide varus–valgus stability. This report concentrates on condylar knees with intercondylar stability, namely the constrained condylar type. The design and manufacture of these custom implants can be time-consuming and expensive. In this study, a constrained condylar was designed with special attention to laxity, stability and strength. The design was parameterised such that for a custom case, only the A–P and M–L dimensions of the knee were required. Special software was then written and interfaced with CNC machines, such that the custom knees could be designed and manufactured simply, efficiently, and at low cost. Five case examples are reported, where constrained condylar knees were specially designed and manufactured to suit patient requirements. Follow-up examinations showed good geometrical fit and satisfactory function.

A comparison between cemented, press-fit, and HA-coated interfaces in Kinemax total knee replacement

There are possible advantages of using uncemented fixation in total knee replacement. In this prospective randomised multi-centre study, a comparison was made between cemented and two types of uncemented fixation for the Kinemax design. There were 12-14 cases in each group. Beads were inserted in the bones from which component migration was measured at time intervals up to 2 years. The axial migrations were significantly less for cemented and HA-coating, compared with press-fit, at all time intervals. The clinical data showed no differences at 2 years except for more cases of pain in the uncemented groups. Radiographically, the cemented interfaces showed the least change, press-fit showed a radiolucent line and a radiodense line, and HA showed a diffuse radiodensity adjacent to the components. It was concluded that for the Kinemax design of tibial component, press-fit was inferior to cemented, but that there was the potential for designing a special component for uncemented fixation for which HA-coating would be an advantage.