The Effects of Interlocking a Universal Hip Cementless Stem on Implant Subsidence and Mechanical Properties of Cadaveric Canine Femora.

ObjectiveTo determine if an interlocking bolt would limit subsidence of the biological fixation universal hip (BFX(®)) femoral stem under cyclic loading and enhance construct stiffness, yield, and failure properties.Study designEx vivo biomechanical study.AnimalsCadaveric canine femora (10 pairs).MethodsPaired femora implanted with a traditional stem or an interlocking stem (constructs) were cyclically loaded at walk, trot, and gallop loads while implant and bone motions were captured using kinematic markers and high-speed video. Constructs were then loaded to failure to evaluate failure mechanical properties.ResultsImplant subsidence was greater (P = .037) for the traditional implant (4.19 mm) than the interlocking implant (0.78 mm) only after gallop cyclic loading, and cumulatively after walk, trot, and gallop cyclic loads (5.20 mm vs. 1.28 mm, P = .038). Yield and failure loads were greater (P = .029 and .002, respectively) for the interlocking stem construct (1155 N and 2337 N) than the traditional stem construct (816 N and 1405 N). Version angle change after cyclic loading was greater (P = .020) for the traditional implant (3.89 degrees) than for the interlocking implant (0.16 degrees), whereas stem varus displacement at failure was greater (P = .008) for the interlocking implant (1.5 degrees) than the traditional implant (0.17 degrees).ConclusionAddition of a stabilizing bolt enhanced construct stability and limited subsidence of a BFX(®) femoral stem. Use of the interlocking implant may decrease postoperative subsidence. However, in vivo effects of the interlocking bolt on osseointegration, bone remodeling, and stress shielding are unknown

Biomechanical Analysis of Fixation and Bone

Long-term survivorship of a total knee replacement (TKR) relies on the strength of bone around the implant and its initial stability. Aseptic component loosening caused by mechanical factors is a recognised failure mode for knee prostheses. Bone resorption due to “stress-shielding” of the stiff stemmed implants will potentially lead to weakened bone strength, and presents a challenge for revision TKR surgery. The aim of this study was to develop analytical methodologies for the investigation of fixation performance of TKR, and to gain a better understanding of the prosthetic design requirements, addressing two major mechanical problems of bone remodelling and aseptic loosening. Patient-specific finite element (FE) modelling incorporated with a strain-adaptive bone remodelling theory was used to simulate bone remodelling responses of the postoperative tibial fixation. The choice of cementing technique was found to influence the remodelling behaviour; cemented fixationmodelled as a firm anchorage of the prosthesis onto the bone, was predicted to induce greater stress-shielding effect consequently leading to severe proximal bone resorption; for a fixation relying on biological attachment of bony ingrowthmodelled as a less firmly anchored boneprosthesis interface, lesser proximal bone resorption was predicted. The consideration of bone remodelling in FE simulations for fixation analyses is paramount as it influenced the risk prediction of aseptic loosening between prosthesis designs. The cement tensile stresses and bone-prosthesis interface micromotions predicted were different prior to and after bone adaptation. FE predictions of the MIS mini-keel and standard stemmed prosthesis fixations after simulating six months of bone adaptation correlated well with the RSA measurements at a similar period. A modified in-vitro technique of measuring bone-prosthesis relative micromotion was developed for relating initial stability of the cemented and cementless (press-fit) tibial prostheses fixations to late aseptic loosening. The developed computational and invitro methods should be applicable to other joint replacements

Influence of cementless hip stems on femoral cortical strain pattern depending on their extent of porous coating

The extent of porous coating of cementless total hip stems is held responsible for radiological periprosthetic changes, the rate of thigh pain, and even its long-term success. However, there is only sparse knowledge on how the biomechanical loading conditions of the femur are influenced by the extent of porous coating in the early phase after implantation of a cementless hip stem. Aiming to evaluate the effect of surface structuring on the strain pattern of the femur, we implanted three anatomic hip stems with different extents of porous coating (full, two-thirds proximal, and penguin type) in second-generation composite femora coated with a photoelastic layer. A cortical strain mapping was conducted before and after insertion of the implants under standardized loading conditions considering relevant muscle forces. The results of the statistical analysis of three different implantation sequences proved that composite femora are suitable for repeated measurements within the applied experimental setup. Cortical strain changes including stress-shielding effects medially (-60%) and laterally (-50%) were validated with a cadaver femur. The extent of porous coating had no significant influence on the surface strain pattern for an immediate postoperative situation

Probabilistic finite element analysis of the uncemented total hip replacement

There are many interacting factors affecting the performance of a total hip replacement(THR), such as prosthesis design and material properties, applied loads, surgical approach, femur size and quality, interface conditions etc. All these factors are subject to variation and therefore uncertainties have to be taken into account when designing and analysing the performance of these systems. To address this problem, probabilistic design methods have been developed.A computational probabilistic tool to analyse the performance of an uncemented THR has been developed. Monte Carlo Simulation (MCS) was applied to various models with increasing complexity. In the pilot models, MCS was applied to a simplified finite element model (FE) of an uncemented total hip replacement (UTHR). The implant and bone stiffness, load magnitude and geometry, and implant version angle were included as random variables and a reliable strain-based performance indicator was adopted. The sensitivity results highlighted the bone stiffness, implant version and load magnitude as the most sensitive parameters.The FE model was developed further to include the main muscle forces, and to consider fully bonded and frictional interface conditions. Three proximal femurs and two implants (one with a short and another with a long stem) were analysed. Different boundary conditions were compared, and convergence was improved when the distal portion of the implant was constrained and a frictional interface was employed. This was particularly true when looking at the maximum nodal micromotion. The micromotion results compared well with previous studies, confirming the reliability and accuracy of the probabilistic finite element model (PFEM). Results were often influenced by the bone, suggesting that variability in bone features should be included in any probabilistic analysis of the implanted construct.This study achieved the aim of developing a probabilistic finite element tool for the analysis of finite element models of uncemented hip replacements and forms a good basis for probabilistic models of constructs subject to implant position-related variability

Relative motion at the bone-prosthesis interface

Bone ingrowth in porous surfaces of human joint implants is a desired condition for long-term fixation in patients who are physically active (such as in sport or work). It is generally recognized that little actual bone ingrowth occurs. The best clinical results report between 10 and 20% of the total prosthetic surface in contact with bone will feature good bone ingrowth. One inhibiting factor is the relative motion of the bone with respect to the implant during load-bearing. This study investigated mathematically the interface micromotion (transverse reversible relative motion) between a flat metal tibial prosthetic surface of a prototype implant, and the bone at the resection site. The aim was to assess the effect of perimeter fixation versus midcondylar pin fixation and the effect of plate thickness and plate stiffness.\ud \ud Results showed that in the prototype design the largest reversible relative bone motion occurred at the tibial eminence. By design, the skirt fixation at the perimeter would prevent bone motion. A PCA (Howmedica Inc.) prosthesis has been widely used clinically and was chosen for a control because its fixation by two pegs beneath the condyles is a common variation on the general design of a relatively thick and stiff metal tibial support tray with pegs in each condylar area. The PCA tibial prosthesis showed the largest bone motion at the perimeter along the midcondylar mediolateral line, while being zero at the pegs. Maximum relative bone motion for the prototype was 37 ¿m and for the control was 101 ¿m. Averaged values showed the prototype to have 38% of the relative reversible bone motion of the control (PCA)

Catastrophic failure of an uncemented acetabular component due to high wear and osteolysis: An analysis of 154 Omnifit prostheses with mean 6-year follow-up

Background The purposes of this study were (1) to evaluate the wear pattern of the hydroxyapatite-coated "Dual Radius" Omnifit cup, (2) to investigate whether wear is correlated to any demographic or prosthesis-related factors, and (3) to describe micromotion of both the cup and the stem. Patients and methods 154 hips were implanted between 1990 and 1996 and followed for an average of 6 years. Wear was measured according to the "Charnley-duo" method and, in 79 hips, with radiostereometry (RSA). RSA was also used to evaluate micromotion. We analyzed the femoral heads using scanning electron microscopy, energy dispersive X-ray spectroscopy and an atomic force microscope. Result 66 cups were revised and had a mean annual wear of 0.32 mm compared to 0.12 mm in hips not revised. Osteolytic processes were observed in 35 hips but at revision osteolysis was present in 51 cases. 43/66 sockets were loose. Micromotion evaluated by RSA, weight, age, side, size of cup, screws, polyethylene thickness or shelf-life of the polyethylene did not correlate to wear, whereas male gender did. Interpretation It is still unclear why about half of our cases had an abnormal wear rate. Annual wear exceeding 0.2 mm is prognostic of late failure and should be considered a warning sign

Development of Optimal Total Hip Joint Replacement

Total hip replacement (THR) is a surgical process in which the hip joint is replaced by a hip prosthesis. It is one of the most popular and cost effective surgery. In particular in 2014, 83,125 primary procedures were recorded. Some of these operations need to be carried out again for different reasons after sometime. These are called revision (replacement of the prosthesis) procedures. Important studies and statistics suggest that the number of THR procedures is projected to increase by almost 175% by 2030. Aseptic loosening appears to be the most significant cause of failure in THR. Aseptic loosening might lead to revision surgery and in turn can be avoided by enhancing the stability and durability of the hip replacement. Primary stability attained after surgery is a determinant issue for the long-term stability of cementless hip arthroplasty. Primary stability is the level of relative micromotion between the femur and the prosthesis induced via the physiological joint forces following the surgery. The hip prosthesis is also exposed to dynamic loadings and activities of daily living, which can induce the stress distribution on the prosthesis of the hip joint model and affect the durability of the implant. The aim of this study is to develop an optimal total hip replacement (THR) implant with new and improved design features to achieve stability and durability. The micromotion between bone and implant interface and the stress distribution on the prosthesis and femur assembly has been reviewed and investigated. The laboratory testing were carried out on the femur including the compression, torsion and Brinell hardness testing. A compression testing using strain gauge technique done on the hip implant. Finite element analysis software used to simulate all compression and torsion testing assuming the same boundary and loading conditions and subsequently the computational results were compared with the earlier experimental data to verify the experiments and models used. 7 The comparative micromotion studies and findings of other researchers were used beside the clinical follow-up reports on success or failure rates of related hip designs, to justify the best solutions for design factors. In this computational approach researchers usually use finite element methodology to calculate micromotion of elements, sometimes known as migration. The elements exceeding the threshold limit would simulate the migration and subsequently eliminated from the assembly. This procedure recurs until reaching the convergence that derives a stable mechanical equilibrium. One of the restrictions of micromotion analysis was the inability to divide the final results into axial and rotational components. Therefore it would have been inappropriate to eventually conclude the best femoral stem, without considering the sustaining torsional loadings. Another limitation was that the micromotion analysis would not reflect the stress distribution on the hip prosthesis and consequently would ignore the potential high stress concentration that is associated with post operative pain as well as low durability and long-term stability. For these reasons stress analysis was carried out under dynamic loadings of nine different activities to examine the von Mises stress, shear stress and principal stress distribution of a cementless hip implant. In each activity realistic boundary and loading conditions of a complete assembly of femur and hip implant were investigated which includes defining of many variables including different geometry, material properties, boundary conditions, forces and moments of varying magnitude and orientation over specific time intervals. The critical points and areas that were developed in the entire 3D model were evaluated and explained. The finite element analysis which verified by experimental testing and hold the clinical relevance were used to decide the best optimal hip stem design amongst different presented design concepts. This was accompanied and improved with further stress analysis of different design factors to get the final optimal model. High offset stem option is a unique feature that helps tightening the abductor and boosts the hip implant stability with the ability to adjust neck and offset. It gives a surgeon more options to fix the most accurate offset and do the operation more effectively. The final optimal design and its advantages were presented in the last chapter

On the design evolution of hip implants: A review

This manuscript reviews the development of femoral stem prostheses in the biomedical field. After a brief introduction on the development of these prostheses and the associated problems, we describe the standard design of these systems. We review the different materials, constructions, and surfaces used in the development of femoral stems, in order to solve and avoid various problems associated with their use. Femoral stem prostheses have undergone substantial changes and design optimizations since their introduction. Common materials include stainless steel, cobalt–chromium alloy, titanium alloy, and composites. The structural development of femoral stem prostheses, including their length, shape, porosity, and functional gradient construction, is also reviewed. The performance of these prostheses is affected not only by individual factors, but also by the synergistic combination of multiple effects; therefore, several aspects need to be optimized. The main purpose of this study is to summarize various strategies for the material and construction optimization of femoral stem prostheses, and to provide a reference for the combined optimization of their performance. Substantial research is still needed to develop prostheses emulating the behavior of a real human femoral stem

The Use of Hydroxyapatite-coated Collars Enhances Osteointegrated Extra-cortical Bone Formation and Improves Long Term Survival of Distal Femoral Endoprostheses

The fixation of massive segmental prostheses is more problematic than standard joint replacements. The aims of this study are: 1) To evaluate the long-term survival of cemented and uncemented distal femoral bone tumour endoprostheses in adults and skeletally immature patients. 2) To investigate the relationship between the degree of osteointegration onto the hydroxyapatite (HA) coated collar located at the boneimplant junction and relate this to aseptic loosening (ASL) of these endoprostheses. The hypothesis is that a hydroxyapatite collar at the shoulder of bone and implant junction enhances osteointegration and extra-cortical bone formation, reducing aseptic loosening of the endoprostheses. Three separate studies to evaluate the long-term survival of distal femoral endoprosthetic replacements (DFR) implanted at our institute since 1992 were carried out. The first included 61 adult patients with cemented DFR, the second study involved 69 uncemented DFR in adults and the third comprised 24 cemented, non-invasive and expandable DFR in skeletally immature patients. For the first time, the degree of osteointegration at the bone-implant junction was evaluated and the amount of extracortical bone formation was evaluated. Finally the effect of osteointegration of the HA collar on the rate of aseptic loosening (ASL) and on implant survival was investigated. Uncemented, custom made distal femoral endoprostheses have a higher rate of aseptic loosening compared to cemented fixation but this was associated with early loosening and implants that survived for greater than two years, were well fixed for the duration of follow-up. Initial fixation of uncemented DFR is crucial as most cases of loosening occur early. The use of grooved HA coated collar located at the shoulder of distal femoral massive prostheses resulted in increased formation and attachment of the extra-cortical bone and showed a reduced rate of revision due to aseptic loosening. However in cases where osteointegration could not be identified on radiographs, the loosening was higher than in those cases which were well osteointegrated. Survivorship at 10 and 15 years was 98% for those patients with well osteoinetgrated implants but only 75% for those without osteointegration. In paediatric cases, the use of a HA collar reduces the progression of radiolucent lines and results indicate that implants with osteointegrated HA collars, inserted into adolescent patients remain more firmly attached to the skeleton than nonosteoinegrated HA collars. This suggests that HA collars can enhance the survival of the prosthesis inserted when these patients achieve skeletally maturity. These results suggest that HA collars are beneficial when they are osteointegrated as they allow load distribution onto the adjacent cortical bone in a more physiological manner resulting in a reduced load on the intramedullary stem leading to a reduction of aseptic loosening