Virtual interactive musculoskeletal system (VIMS) in orthopaedic research, education and clinical patient care

The ability to combine physiology and engineering analyses with computer sciences has opened the door to the possibility of creating the "Virtual Human" reality. This paper presents a broad foundation for a full-featured biomechanical simulator for the human musculoskeletal system physiology. This simulation technology unites the expertise in biomechanical analysis and graphic modeling to investigate joint and connective tissue mechanics at the structural level and to visualize the results in both static and animated forms together with the model. Adaptable anatomical models including prosthetic implants and fracture fixation devices and a robust computational infrastructure for static, kinematic, kinetic, and stress analyses under varying boundary and loading conditions are incorporated on a common platform, the VIMS (Virtual Interactive Musculoskeletal System). Within this software system, a manageable database containing long bone dimensions, connective tissue material properties and a library of skeletal joint system functional activities and loading conditions are also available and they can easily be modified, updated and expanded. Application software is also available to allow end-users to perform biomechanical analyses interactively. Examples using these models and the computational algorithms in a virtual laboratory environment are used to demonstrate the utility of these unique database and simulation technology. This integrated system, model library and database will impact on orthopaedic education, basic research, device development and application, and clinical patient care related to musculoskeletal joint system reconstruction, trauma management, and rehabilitation

Design and Development Towards a Novel Prosthesis for Total Shoulder Arthroplasty to Reduce Aseptic Glenoid Loosening

Total shoulder arthroplasty (TSA) is the most common surgical solution, that helps in restoring the structural and functional integrity of a diseased glenohumeral (GH) joint with intact rotator-cuff. A 300% increase in the usage of TSA has been observed since 2007, along with 2.5% increase in revision rate. Aseptic glenoid loosening accounts for 37% of postsurgical failures in TSA. Eccentric loading of the prosthetic glenoid cup, leading to the “rocking horse” effect, is one of the prevalent causes of aseptic glenoid loosening. Current anatomical total shoulder prosthesis (ATSP) geometry does not consider all the GH morphometric features, for example the elliptical shape of the humeral head. Moreover, the morphometric studies leading to the initial ATSP design did not consider the GH morphology of any sub-Saharan population. Hence, there exists a gap in understanding of the implications of certain morphometric features on the functionality of a post-TSA GH joint. This thesis had two primary aims to address this gap in knowledge. Firstly, to study the GH morphometric variations between cohorts representing native European (Swiss) and native sub-Saharan (South African) populations. Secondly, to develop anatomically inspired ATSP design concepts and test them using biomechanical and finite element (FE) models, insilico, under standardised testing protocols. The morphometric analysis suggested that an average Swiss humeral head radius of curvature was larger (P28mm or <19mm. Considering both the populations, the inherent shape of an average humeral head was found to be elliptical. The thickest region of the head was found to lie in the posterior region and not at the geometric center. Hertzian contact theory was applied to calculate the GH stresses produced by symmetric and asymmetric elliptical heads. Higher concentric stresses (P<0.001), within the acceptable limit for polyethylene, were observed to be imparted by the asymmetric heads. Population-specific musculoskeletal models were developed to study the post-TSA kinematic variation. When an identical range of motion (RoM) was performed by these models, population-specific variation in muscle moment arms was observed. The novel glenoid designs were not found to alter the post-surgical kinematics. FE models of the biradial, compartmental and pear-shaped glenoid implant designs were subjected to compressive and shear loading according to the American Society for Testing and Materials (ASTM). Using the bi-radial the glenoid cup, with thickened posterior-superior surface, anatomically relevant force distribution patterns could be replicated. Compartmentalising the glenoid prosthesis into concentric and eccentric regions with the gaps, proved to be highly beneficial. When compared to a commercially available glenoid prosthesis, the compartmental prosthesis was able to contain the GH forces to the concentric region for longer, delaying the eccentric loading and therefore potentially reducing the “rocking horse” effect. In the light of the above observations, two conclusions can be drawn from this thesis. Firstly, it would be beneficial if population-specific ATSP were made available for natives of certain geographic locations. Secondly, glenoid prosthesis designs could be compartmentalised to contain the GH joint forces within the concentric regions of the cup which might aid in the reduction of post-TSA complications

Finite Element Modeling of the Proximal Humerus to Compare Stemless, Short and Standard Stem Humeral Components of Varying Material Stiffness for Shoulder Arthroplasty

In patients with debilitating pain due to osteoarthritis, total shoulder arthroplasty can restore function and provide effective pain relief. Newer implant designs vary in length and material stiffness. Unfortunately, literature on these newer implants is limited. This thesis investigates the effect of stem length and implant material stiffness on proximal humeral bone stresses. 3D bone models with implants of various stem lengths (stemless, short, and standard) and different material stiffness’s (CoCr, Ti and PEEK) were generated using MIMICS, Solidworks and ABAQUS for varying abduction angles (15°, 45° and 75°). Cortical and trabecular stresses were contrasted with the intact bone state. As expected, the reduction in stem length and material stiffness yielded humeral stresses that better matched the intact stress distribution in cortical bone, but opposing trends presented in trabecular bone. Future work should continue to build on these models and investigate implant fixation through the analysis of micromotion

A Theoretical Model of the Effect of Bone Defects on Anterior Shoulder Instability: a Finite Element Approach

Presence of either a Hill Sachs or a Bony Bankart lesion has been indicated as a possible cause of subluxation and anterior shoulder dislocation. Previous studies have investigated only effects of these isolated lesions on the glenohumeral instability of the shoulder. The purpose of this thesis was to investigate the effect of both Bony Bankart lesion and Hill-Sachs lesion in the glenohumeral joint on the stability of the shoulder. We hypothesize that as the size of the lesion increases, the glenohumeral joint\u27s stability will decrease. We further hypothesize that the presence of both defects together will reduce the glenohumeral joint\u27s stability to an even greater extent. Finite element analysis approach was utilized to model the glenohumeral joint in combination with the intact humerus and the glenoid. The model was developed for the cartilage and the bone of the glenoid and the humerus, using the data from classical research papers. Different sets of simulation were run with both isolated and combined defects to analyze the reaction forces and calculate distance to dislocation. The experiments were analyzed using statistical analysis with displacement control. The results from the study predicted a theoretical model which explains the direct correlation between the anterior stability of glenohumeral joint and the size of the defect. It was found that, with the increase in size of the defect, the distance to dislocation decreased and so does the stability. Presence of both the lesions simultaneously further decreased the glenohumeral stability, for some cases it decreased to zero percent. This data was consistent with our second hypothesi

FEM Model an Effective Tool to Evaluate Von Mises Stresses in Shoulder Joint and Muscles for Adduction and Abduction

AbstractShoulder is one of the most complicated and critical joint. It consists of the clavicle, scapula and humerus. Studying individual functions of these structures is nearly unfeasible. In order to understand these relationships during different shoulder exercise, an attempt has been made to model, simulate and analyze the shoulder joint.The technique described in this paper utilizes the advanced 3D scanning; Computer Aided Design (CAD), DMU Kinematics Tool in CATIA V5 then Finite Element Analysis (FEA) to detect the stress points of the shoulder joints during adduction and abduction. FEM of the ligaments and the muscles are carried out using the hexa-penta mesh elements in Hyper Mesh and von mises stresses are analysed by LS DYNA software. The results for abduction and adduction are plotted and validated with the previous research papers as well as the limiting values of the different shoulder muscle for the range of motion 0° to 30°

The Effect of Implant Girth and Implant Collar on the Degree of Bone to Implant Contact and Bone Stresses in the Proximal Humerus

Stem design is a crucial element for the success of shoulder prostheses. Various components of stem design have been investigated; however, little research has been conducted on the effects of (1) implant girth and (2) an implant collar on load transfer. A generic implant model was designed and employed in a (FE) model to determine 3 outcome measures: changes in the degree of bone to implant contact (BIC), changes in cortical and trabecular bone stresses from the intact state, and changes in cortical and trabecular strain energy densities (SED). The variables examined were (1) implant girth (small, medium [generic base model], and large sizes), and (2) the implant collar and collarless. The small implant produced the overall greatest amount of BIC when compared to the other two sizes. The small implant also produced the lowest change in stress from the intact state in both cortical and trabecular bone, as well as the lowest amount of bone volume expected to resorb. Removing the implant collar caused an increase in the degree of BIC, when compared to the collared state. In terms of the changes in stress, removing the implant collar resulted in an increase in both the change in cortical and trabecular bone stresses, and resulted in an increased risk in the amount of cortical bone expected to resorb. Collectively, these findings suggest that a smaller sized implant may be beneficial, while the collar may be beneficial if less stress changes in bone relative to the native state are desired

Computer Aided Tools for the Design and Planning of Personalized Shoulder Arthroplasty

La artroplastia de hombro es el tercer procedimiento de reemplazo articular más común, después de la artroplastia de rodilla y cadera, y actualmentees el de más rápido crecimiento en el campo ortopédico. Las principales opciones quirúrgicas incluyen la artroplastia total de hombro (TSA), en la quese restaura la anatomía articular normal, y, para pacientes con un manguito rotador completamente desgarrado, la artroplastia inversa de hombro (RSA), en la que la bola y la cavidad de la articulación glenohumeral se cambian. A pesar del progreso reciente y los avances en el diseño, las tasas de complicaciones reportadas para RSA son más altas que las de la artroplastia de hombro convencional. Un enfoque específico para el paciente, en el que los médicos adaptan el tratamiento quirúrgico a las características del mismo y al estado preoperatorio, por ejemplo mediante implantes personalizados y planificación previa, puede ayudar a reducir los problemas postoperatorios y mejorar el resultado funcional. El objetivo principal de esta tesis es desarrollar y evaluar métodos novedosos para RSA personalizado, utilizando tecnologías asistidas por ordenador de última generación para estandarizar y automatizar las fases de diseño y planificación.Los implantes personalizados son una solución adecuada para el tratamiento de pacientes con pérdida extensa de hueso glenoideo. Sin embargo, los ingenieros clínicos se enfrentan a muchas variables en el diseño de implantes (número y tipo de tornillos, superficie de contacto, etc.) y una gran variabilidad anatómica y patológica. Actualmente, no existen herramientas objetivas para guiarlos a la hora de elegir el diseño óptimo, es decir, con suficiente estabilidad inicial del implante, lo que hace que el proceso de diseño sea tedioso, lento y dependiente del usuario. En esta tesis, se desarrolló una simulación de Virtual Bench Test (VBT) utilizando un modelo de elementos finitos para evaluar automáticamente la estabilidad inicial de los implantes de hombro personalizados. A través de un experimento de validación, se demostró que los ingenieros clínicos pueden utilizar el resultado de Virtual Bench Test como referencia para respaldar sus decisiones y adaptaciones durante el proceso de diseño del implante.Al diseñar implantes de hombro, el conocimiento de la morfología y la calidad ósea de la escápula en toda la población es fundamental. En particular, se tienen en cuenta las regiones con la mejor reserva ósea (hueso cortical) para definir la posición y orientación de los orificios de los tornillos, mientras se busca una fijación óptima. Como alternativa a las mediciones manuales, cuya generalización está limitada por el análisis de pequeños subconjuntos de pacientes potenciales, Statistical Shape Models (SSMs) se han utilizado comúnmente para describir la variabilidad de la forma dentro de una población. Sin embargo, estos SSMs normalmente no contienen información sobre el grosor cortical.Por lo tanto, se desarrolló una metodología para combinar la forma del hueso escapular y la morfología de la cortical en un SSM. Primero, se presentó y evaluó un método para estimar el espesor cortical, a partir de un análisis de perfil de Hounsfield Unit (HU). Luego, utilizando 32 escápulas sanas segmentadas manualmente, se creó y evaluó un modelo de forma estadística que incluía información de la cortical. La herramienta desarrollada se puede utilizar para implantar virtualmente un nuevo diseño y probar su congruencia dentro de una población virtual generada, reduciendo así el número de iteraciones de diseño y experimentos con cadáveres.Las mediciones del alargamiento de los músculos deltoides y del manguito rotador durante la planificación quirúrgica pueden ayudar a los médicos aseleccionar un diseño y una posición de implante adecuados. Sin embargo, tal evaluación requiere la indicación de puntos anatómicos como referencia para los puntos de unión de los músculos, un proceso que requiere mucho tiempo y depende del usuario, ya que a menudo se realiza manualmente. Además, las imágenes médicas, que se utilizan normalmente para la artroplastia de hombro,contienen en su mayoría solo el húmero proximal, lo que hace imposible indicarlos puntos de unión de los músculos que se encuentran fuera del campo de visión de la exploración. Por lo tanto, se desarrolló y evaluó un método totalmente automatizado, basado en SSM, para medir la elongación del deltoides y del manguito rotador. Su aplicabilidad clínica se demostró mediante la evaluación del rendimiento de la estimación automatizada de la elongación muscular para un conjunto de articulaciones artríticas del hombro utilizadas para la planificación preoperatoria de RSA, lo que confirma que es una herramienta adecuada para los cirujanos a la hora de evaluar y refinar las decisiones clínicas.En esta investigación, se dio un paso importante en la dirección de un enfoque más personalizado de la artroplastia inversa de hombro, en el que el manejo quirúrgico, es decir, el diseño y la posición del implante, se adapta a las características específicas del paciente y al estado preoperatorio. Al aplicar tecnologías asistidas por computadora en la práctica clínica, el proceso de diseño y planificación se puede automatizar y estandarizar, reduciendo así los costos y los plazos de entrega. Además, gracias a los métodos novedosos presentados en esta tesis, esperamos en el futuro una adopción más amplia del enfoque personalizado, con importantes beneficios tanto para los cirujanos como para los pacientes.Shoulder arthroplasty is the third most common joint replacement procedure, after knee and hip arthroplasty, and currently the most rapidly growing one in the orthopaedic field. The main surgical options include total shoulder arthroplasty (TSA), in which the normal joint anatomy is restored, and, for patients with a completely torn rotator cuff, reverse shoulder arthroplasty (RSA), in which the ball and the socket of the glenohumeral joint are switched. Despite the recent progress and advancement in design, the reported rates of complication for RSA are higher than those of conventional shoulder arthroplasty. A patient-specific approach, in which clinicians adapt the surgical management to patient characteristics and preoperative condition, e.g. through custom implants and pre-planning, can help to reduce postoperative problems and improve the functional outcome. The main goal of this thesis is to develop and evaluate novel methods for personalized RSA, using state-of-the-art computer aided technologies to standardize and automate the design and planning phases. Custom implants are a suitable solution when treating patients with extensive glenoid bone loss. However, clinical engineers are confronted with an enormous implant design space (number and type of screws, contact surface, etc.) and large anatomical and pathological variability. Currently, no objective tools exist to guide them when choosing the optimal design, i.e. with sufficient initial implant stability, thus making the design process tedious, time-consuming, and user-dependent. In this thesis, a Virtual Bench Test (VBT) simulation was developed using a finite element model to automatically evaluate the initial stability of custom shoulder implants. Through a validation experiment, it was shown that the virtual test bench output can be used by clinical engineers as a reference to support their decisions and adaptations during the implant design process. When designing shoulder implants, knowledge about bone morphology and bone quality of the scapula throughout a certain population is fundamental. In particular, regions with the best bone stock (cortical bone) are taken into account to define the position and orientation of the screw holes, while aiming for an optimal fixation. As an alternative to manual measurements, whose generalization is limited by the analysis of small sub-sets of the potential patients, Statistical Shape Models (SSMs) have been commonly used to describe shape variability within a population. However, these SSMs typically do not contain information about cortical thickness. Therefore, a methodology to combine scapular bone shape and cortex morphology in an SSM was developed. First, a method to estimate cortical thickness, starting from a profile analysis of Hounsfield Unit (HU), was presented and evaluated. Then, using 32 manually segmented healthy scapulae, a statistical shape model including cortical information was created and assessed. The developed tool can be used to virtually implant a new design and test its congruency inside a generated virtual population, thus reducing the number of design iterations and cadaver labs. Measurements of deltoid and rotator cuff muscle elongation during surgical planning can help clinicians to select a suitable implant design and position. However, such an assessment requires the indication of anatomical landmarks as a reference for the muscle attachment points, a process that is time-consuming and user-dependent, since often performed manually. Additionally, the medical images, which are normally used for shoulder arthroplasty, mostly contain only the proximal humerus, making it impossible to indicate those muscle attachment points which lie outside of the field of view of the scan. Therefore, a fully-automated method, based on SSM, for measuring deltoid and rotator cuff elongation was developed and evaluated. Its clinical applicability was demonstrated by assessing the performance of the automated muscle elongation estimation for a set of arthritic shoulder joints used for preoperative planning of RSA, thus confirming it a suitable tool for surgeons when evaluating and refining clinical decisions. In this research, a major step was taken into the direction of a more personalized approach to Reverse Shoulder Arthroplasty, in which the surgical management, i.e. implant design and position, is adapted to the patient-specific characteristics and preoperative condition. By applying computer aided technologies in the clinical practice, design and planning process can be automated and standardized, thus reducing costs and lead times. Additionally, thanks to the novel methods presented in this thesis, we expect in the future a wider adoption of the personalized approach, with important benefits both for surgeons and patients.<br /

The Design and Validation of a Computational Rigid Body Model of the Elbow.

The use of computational modeling is an effective and inexpensive way to predict the response of complex systems to various perturbations. However, not until the early 1990s had this technology been used to predict the behavior of physiological systems, specifically the human skeletal system. To that end, a computational model of the human elbow joint was developed using computed topography (CT) scans of cadaveric donor tissue, as well as the commercially available software package SolidWorks™. The kinematic function of the joint model was then defined through 3D reconstructions of the osteoarticular surfaces and various soft-tissue constraints. The model was validated against cadaveric experiments performed by Hull et al and Fern et al that measured the significance of coronoid process fractures, lateral ulnar collateral ligament ruptures, and radial head resection in elbow joint resistance to varus displacement of the forearm. Kinematic simulations showed that the computational model was able to mimic the physiological movements of the joint throughout various ranges of motion including flexion/extension and pronation/supination. Quantitatively, the model was able to accurately reproduce the trends, as well as the magnitudes, of varus resistance observed in the cadaveric specimens. Additionally, magnitudes of ligament tension and joint contact force predicted by the model were able to further elucidate the complex soft-tissue and osseous contributions to varus elbow stability