Yu-Shu Lai

Biomechanical analysis of different types of pedicle screw augmentation: A cadaveric and synthetic bone sample study of instrumented vertebral specimens

This study aims to determine the pull-out strength, stiffness and failure pull-out energy of cement-augmented, cannulated-fenestrated pedicle screws in an osteoporotic cadaveric thoracolumbar model, and to determine, using synthetic bone samples, the extraction torques of screws pre-filled with cement and those with cement injected through perforations. Radiographs and bone mineral density measurements from 32 fresh thoracolumbar vertebrae were used to define specimen quality. Axial pull-out strength of screws was determined through mechanical testing. Mechanical pull-out strength, stiffness and energy-to-failure ratio were recorded for cement-augmented and non-cement-augmented screws. Synthetic bone simulating a human spinal bone with severe osteoporosis was used to measure the maximum extraction torque. The pull-out strength and stiffness-to-failure ratio of cement pre-filled and cement-injected screws were significantly higher than the non-cement-augmented control group. However, the cement pre-filled and cement-injected groups did not differ significantly across these values (p=0.07). The cement pre-filled group had the highest failure pull-out energy, approximately 2.8 times greater than that of the cement-injected (p<0.001), and approximately 11.5 times greater than that of the control groups (p<0.001). In the axial pull-out test, the cement-injected group had a greater maximum extraction torque than the cement pre-filled group, but was statistically insignificant (p=0.17). The initial fixation strength of cannulated screws pre-filled with cement is similar to that of cannulated screws injected with cement through perforations. This comparable strength, along with the heightened pull-out energy and reduced extraction torque, indicates that pedicle screws pre-filled with cement are superior for bone fixation over pedicle screws injected with cement.

Biomechanical evaluation of proximal tibial behavior following unicondylar knee arthroplasty: Modified resected surface with corresponding surgical technique

Persistent pain and periprosthetic fracture of the proximal tibia are troublesome complications in modern unicondylar knee arthroplasty (UKA). Surgical errors and acute corners on the resected surface can place excessive strains on the bone, leading to bone degeneration. This study attempted to lower strains by altering the orthogonal geometry and avoiding extended vertical saw cuts. Finite element models were utilized to predict biomechanical behavior and were subsequently compared against experimental data. On the resected surface of the extended saw cut model, the greatest strains showed a 50% increase over a standard implant; conversely, the strains decreased by 40% for the radial-corner shaped model. For all UKA models, the peak strains below the resection level increased by 40% relative to an intact tibia. There was no significant difference among the implanted models. This study demonstrated that a large increase in strains arises on the tibial plateau to resist a cantilever-like bending moment following UKA. Surgical errors generally weaken the tibial support and increase the risk of fractures. This study provides guidance on altering the orthogonal geometry into a radial-shape to reduce strains and avoid degenerative remodeling. Furthermore, it could be expected that predrilling a posteriorly sloped tunnel through the tibia prior to cutting could achieve greater accuracy in surgical preparations.

Influence of post-cam design of posterior stabilized knee prosthesis on tibiofemoral motion during high knee flexion

BACKGROUNDS The post-cam design of contemporary posterior stabilized knee prosthesis can be categorized into flat-on-flat or curve-on-curve contact surfaces. The curve-on-curve design has been demonstrated its advantage of reducing stress concentration when the knee sustained an anteroposterior force with tibial rotation. How the post-cam design affects knee kinematics is still unknown, particularly, to compare the difference between the two design features. Analyzing knee kinematics of posterior stabilized knee prosthesis with various post-cam designs should provide certain instructions to the modification of prosthesis design. METHODS A dynamic knee model was utilized to investigate tibiofemoral motion of various post-cam designs during high knee flexion. Two posterior stabilized knee models were constructed with flat-on-flat and curve-on-curve contact surfaces of post-cam. Dynamic data of axial tibial rotation and femoral translation were measured from full-extension to 135°. FINDINGS Internal tibial rotation increased with knee flexion in both designs. Before post-cam engagement, the magnitude of internal tibial rotation was close in the two designs. However, tibial rotation angle decreased beyond femoral cam engaged with tibial post. The rate of reduction of tibial rotation was relatively lower in the curve-on-curve design. From post-cam engagement to extreme flexion, the curve-on-curve design had greater internal tibial rotation. INTERPRETATION Motion constraint was generated by medial impingement of femoral cam on tibial post. It would interfere with the axial motion of the femur relative to the tibia, resulting in decrease of internal tibial rotation. Elimination of rotational constraint should be necessary for achieving better tibial rotation during high knee flexion.

Biomechanical study of expandable pedicle screw fixation in severe osteoporotic bone comparing with conventional and cement-augmented pedicle screws

Pedicle screws are widely utilized to treat the unstable thoracolumbar spine. The superior biomechanical strength of pedicle screws could increase fusion rates and provide accurate corrections of complex deformities. However, osteoporosis and revision cases of pedicle screw substantially reduce screw holding strength and cause loosening. Pedicle screw fixation becomes a challenge for spine surgeons in those scenarios. The purpose of this study was to determine if an expandable pedicle screw design could be used to improve biomechanical fixation in osteoporotic bone. Axial mechanical pull-out test was performed on the expandable, conventional and augmented pedicle screws placed in a commercial synthetic bone block which mimicked a human bone with severe osteoporosis. Results revealed that the pull-out strength and failure energy of expandable pedicle screws were similar with conventional pedicle screws augmented with bone cement by 2 ml. The pull-out strength was 5-fold greater than conventional pedicle screws and the failure energy was about 2-fold greater. Besides, the pull-out strength of expandable screw was reinforced by the expandable mechanism without cement augmentation, indicated that the risks of cement leakage from vertebral body would potentially be avoided. Comparing with the biomechanical performances of conventional screw with or without cement augmentation, the expandable screws are recommended to be applied for the osteoporotic vertebrae.

Anatomic-like polyethylene insert could improve knee kinematics after total knee arthroplasty — A computational assessment

BACKGROUNDS Deficiencies in contemporary posterior crucitate retaining knee included inadequate femoral rollback and insufficient tibial rotation. Current study attempted to restore normal femoral rollback and tibial rotation to facilitate in knee flexion/extension and to achieve appropriate posture at deep knee bending after total knee arthroplasy by mimicking the morphology of convexly lateral tibial plateau of intact knee. METHODS Computational simulation was utilized to analyze motion of three-dimensional knee models, including intact, traditionally symmetrical posterior crucitate retaining and newly anatomic-like posterior crucitate retaining knees. Solid bones, attachments of ligaments and tendons of simulation models were reconstructed by magnetic resonance images of the subject. According to the representative literature, the distal femur was modeled to rotate about the specific axes and the motion of the proximal tibial was unconstrained except for the flexion/extension. Movements of the medial/lateral condyles and tibial rotation were recorded and analyzed. FINDINGS The newly anatomic-like posterior crucitate retaining knee improved the posterior movement of lateral condyle and tibial internal rotation significantly during full range of flexion. Compared with traditionally symmetrical posterior crucitate retaining knee, the improvements displayed by newly developed posterior crucitate retaining knee in posterior movement of lateral condyle and tibial internal rotation were 11.2mm and 9.3° at full flexion, respectively. INTERPRETATION The newly anatomic-like posterior crucitate retaining knee demonstrated that mimicking the morphology of convexly lateral tibial plateau can be expected to restore normal knee kinematics.

The Effect of Graft Strength on Knee Laxity and Graft In-Situ Forces after Posterior Cruciate Ligament Reconstruction

Surgical reconstruction is generally recommended for posterior cruciate ligament (PCL) injuries; however, the use of grafts is still a controversial problem. In this study, a three-dimensional finite element model of the human tibiofemoral joint with articular cartilage layers, menisci, and four main ligaments was constructed to investigate the effects of graft strengths on knee kinematics and in-situ forces of PCL grafts. Nine different graft strengths with stiffness ranging from 0% (PCL rupture) to 200%, in increments of 25%, of an intact PCL’s strength were used to simulate the PCL reconstruction. A 100 N posterior tibial drawer load was applied to the knee joint at full extension. Results revealed that the maximum posterior translation of the PCL rupture model (0% stiffness) was 6.77 mm in the medial compartment, which resulted in tibial internal rotation of about 3.01°. After PCL reconstruction with any graft strength, the laxity of the medial tibial compartment was noticeably improved. Tibial translation and rotation were similar to the intact knee after PCL reconstruction with graft strengths ranging from 75% to 125% of an intact PCL. When the graft’s strength surpassed 150%, the medial tibia moved forward and external tibial rotation greatly increased. The in-situ forces generated in the PCL grafts ranged from 13.15 N to 75.82 N, depending on the stiffness. In conclusion, the strength of PCL grafts have has a noticeable effect on anterior-posterior translation of the medial tibial compartment and its in-situ force. Similar kinematic response may happen in the models when the PCL graft’s strength lies between 75% and 125% of an intact PCL.

Biomechanical Considerations in the Design of High-Flexion Total Knee Replacements

Typically, joint arthroplasty is performed to relieve pain and improve functionality in a diseased or damaged joint. Total knee arthroplasty (TKA) involves replacing the entire knee joint, both femoral and tibial surfaces, with anatomically shaped artificial components in the hope of regaining normal joint function and permitting a full range of knee flexion. In spite of the design of the prosthesis itself, the degree of flexion attainable following TKA depends on a variety of factors, such as the joints preoperative condition/flexion, muscle strength, and surgical technique. High-flexion knee prostheses have been developed to accommodate movements that require greater flexion than typically achievable with conventional TKA; such high flexion is especially prevalent in Asian cultures. Recently, computational techniques have been widely used for evaluating the functionality of knee prostheses and for improving biomechanical performance. To offer a better understanding of the development and evaluation techniques currently available, this paper aims to review some of the latest trends in the simulation of high-flexion knee prostheses.

Concave polyethylene component improves biomechanical performance in lumbar total disc replacement—Modified compressive-shearing test by finite element analysis

Failure of ultra-high molecular weight polyethylene components after total disc replacements in the lumbar spine has been reported in several retrieval studies, but immediate biomechanical evidence for those mechanical failures remained unclear. Current study aimed to investigate the failure mechanisms of commercial lumbar disc prostheses and to enhance the biomechanical performances of polyethylene components by modifying the articulating surface into a convex geometry. Modified compressive-shearing tests were utilized in finite element analyses for comparing the contact, tensile, and shearing stresses on two commercial disc prostheses and on a concave polyethylene design. The influence of radial clearance on stress distributions and prosthetic stability were considered. The modified compressive-shearing test revealed the possible mechanisms for transverse and radial cracks of polyethylene components, and would be helpful in observing the mechanical risks in the early design stage. Additionally, the concave polyethylene component exhibited lower contact and shearing stresses and more acceptable implant stability when compared with the convex polyethylene design through all radial clearances. Use of a concave polyethylene component in lumbar disc replacements decreased the risk of transverse and radial cracks, and also helped to maintain adequate stability. This design concept should be considered in lumbar disc implant designs in the future.

Morphometrical measurement of resected surface of medial and lateral proximal tibia for Chinese population

PurposeThe objective of this study was to analyze the morphology of the medial tibial plateau and lateral tibial plateau in Chinese knees and compared these measurements and features with those of commercial unicondylar tibial baseplates.MethodsThree-dimensional knee models were reconstructed from computed tomography slices of 81 subjects. Among the series, 27 knees were from male subjects and 54 knees from female subjects. The dimensions and shape of the medial and lateral tibial plateaus were measured and compared with six commercially available unicondylar tibial baseplates.ResultsThe results showed significant differences between the shapes of the medial and lateral tibial plateaus. For the lateral tibial plateau, the shape was symmetric about the mediolateral axis. The medial plateaus presented their widest mediolateral width in an obviously more posterior position than the lateral compartment. Additionally, the plateau aspect ratio decreased with increasing mediolateral dimensions, in contrast to the constant aspect ratio shown by conventional unicondylar knee prostheses.ConclusionCompartment-specific designs may optimize coverage between the prosthesis and resected tibial surface. The morphometrical measurements presented may allow manufacturers to design tibial baseplates that accommodate the structural variability between different ethnic groups.Level of evidenceProspective comparative study, Level II.

Effect of different radial hole designs on pullout and structural strength of cannulated pedicle screws

Cannulated pedicle screws are designed for bone cement injection to enhance fixation strength in severely osteoporotic spines. However, the screws commonly fracture during insertion. This study aims to evaluate how different positions/designs of radial holes may affect the pullout and structural strength of cannulated pedicle screws using finite element analysis. Three different screw hole designs were evaluated under torsion and bending conditions. The pullout strength for each screw was determined by axial pullout failure testing. The results showed that when the Von Mises stress reached the yield stress of titanium alloy the screw with four radial holes required a greater torque or bending moment than the nine and twelve hole screws. In the pullout test, the strength and stiffness of each screw with cement augmentation showed no significant differences, but the screw with four radial holes had a greater average pullout strength, which probably resulted from the significantly greater mean maximum lengths of cement augmentation. Superior biomechanical responses, with lower stress around the radial holes and greater pullout strength, represented by cannulated pedicle screw with four radial holes may worth recommending for clinical application.