Standardized loads acting in knee implants

The loads acting in knee joints must be known for improving joint replacement, surgical procedures, physiotherapy, biomechanical computer simulations, and to advise patients with osteoarthritis or fractures about what activities to avoid. Such data would also allow verification of test standards for knee implants. This work analyzes data from 8 subjects with instrumented knee implants, which allowed measuring the contact forces and moments acting in the joint. The implants were powered inductively and the loads transmitted at radio frequency. The time courses of forces and moments during walking, stair climbing, and 6 more activities were averaged for subjects with I) average body weight and average load levels and II) high body weight and high load levels. During all investigated activities except jogging, the high force levels reached 3,372–4,218N. During slow jogging, they were up to 5,165N. The peak torque around the implant stem during walking was 10.5 Nm, which was higher than during all other activities including jogging. The transverse forces and the moments varied greatly between the subjects, especially during non-cyclic activities. The high load levels measured were mostly above those defined in the wear test ISO 14243. The loads defined in the ISO test standard should be adapted to the levels reported here. The new data will allow realistic investigations and improvements of joint replacement, surgical procedures for tendon repair, treatment of fractures, and others. Computer models of the load conditions in the lower extremities will become more realistic if the new data is used as a gold standard. However, due to the extreme individual variations of some load components, even the reported average load profiles can most likely not explain every failure of an implant or a surgical procedure

Is there a mechanical regulation of bone formation in spinal fusion?

Introduction Lumbar interbody fusion using cages is one of the most reliable treatment options for degenerative spinal diseases. Currently, many cage designs are available in the market; however none of them is completely successful, as reflected by non-union rates ranging from 7 to 30%. Cages are made of very different materials (e.g. metals, polymers) and they present a large range of morphological configurations (e.g. solid, ring), leading to distinct mechanical conditions within the fusion region. Mechanical conditions are known to largely influence bone regeneration [Klein, 2003] in long bones, however their role on spinal fusion remains largely unknown. The aim of this study was to investigate how the local mechanical conditions (strains, stress, fluid flow) created by different cage designs might influence bone tissue formation during the spinal fusion process. Methods We developed an iterative computer model to simulate the time course of tissue formation during spinal fusion. The model included the vertebral bodies, the intervertebral space and a spinal cage (Fig. 1). In each time step, tissue formation was regulated by the local mechanical conditions [Prendergast, 1997] within the regenerating region, determined using finite element techniques. The temporal and spatial evolution of tissue formation was investigated for two different cage designs (a solid and a ring cage) and two different levels of stiffness: 1 (soft) and 100 (stiff) GPa. Results Bone formation and maturation started in the most inner region of the intervertebral space and extended over time to the outer region, forming a defined callus shape (Fig. 1a). Model predictions showed a strong influence of cage stiffness and configuration on the fusion outcome (Fig 1b-e). A softer cage showed a more favourable mechanical stimulation for the regeneration of bone, leading to higher amounts of bone tissue formation. For the stiffer cage, better fusion outcome was predicted with a centered solid cage compared to a ring cage (Fig. 1c & e). Stress shielding was observed in the central hollow region of the ring cage, which was more pronounced for the stiffer cage (Fig. 1c). Discussion Mechanical conditions have an influence on bone regeneration. We investigated the effect of the mechanical environment created by different cage designs on the fusion outcome. We observed that cage design, both morphology and material properties, play a key role in the mechanical conditions within the fusion region and therefore the time course of the fusion process. In the future such understanding may be used to optimize the design of spinal fusion implants to guide and foster bone formation and inter-body fusion. References [1] Klein et al., J Orthop Res, 21: 662–669, 2003. [2] Prendergast et al., J Biomech, 30, 539-548, 1997.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

A Study of 323 Asymptomatic Volunteers

Background The understanding of the individual shape and mobility of the lumbar spine are key factors for the prevention and treatment of low back pain. The influence of age and sex on the total lumbar lordosis and the range of motion as well as on different lumbar sub-regions (lower, middle and upper lordosis) in asymptomatic subjects still merits discussion, since it is essential for patient-specific treatment and evidence-based distinction between painful degenerative pathologies and asymptomatic aging. Methods and Findings A novel non-invasive measuring system was used to assess the total and local lumbar shape and its mobility of 323 asymptomatic volunteers (age: 20–75 yrs; BMI <26.0 kg/m2; males/females: 139/184). The lumbar lordosis for standing and the range of motion for maximal upper body flexion (RoF) and extension (RoE) were determined. The total lordosis was significantly reduced by approximately 20%, the RoF by 12% and the RoE by 31% in the oldest (>50 yrs) compared to the youngest age cohort (20–29 yrs). Locally, these decreases mostly occurred in the middle part of the lordosis and less towards the lumbo- sacral and thoraco-lumbar transitions. The sex only affected the RoE. Conclusions During aging, the lower lumbar spine retains its lordosis and mobility, whereas the middle part flattens and becomes less mobile. These findings lay the ground for a better understanding of the incidence of level- and age-dependent spinal disorders, and may have important implications for the clinical long-term success of different surgical interventions

Methods for Avoiding or Reducing High Spinal Loads in Everyday Life

Background: High loads on an anterior spinal implant can cause an implant to subside into the vertebral body. This alteration may endanger the clinical output of the treatment and can result in back pain. The aim of this paper is to show the possibilities for avoiding or reducing high spinal loads in daily life.&nbsp;Methods: The loads on a telemeterized vertebral body replacement were measured in 5 patients for a variety of different activities. The effects of the ways an exercise was performed on implant loads were evaluated.Results: Following a physiotherapist’s instructions reduced implant loads by approximately 60% when changing from one body position to another or when performing physiotherapeutic exercises. Supporting the upper body with one hand can reduce loads by approximately 30% when washing the face in front of a washing basin. Leaning against a backrest in a sitting position reduced implant loads by an average of 38%. If possible, weight should be carried in a backpack or spilt bilaterally and evenly between both hands. Generally, any weight should be held close to the body.Conclusions: Patients should follow their physiotherapists’ instructions. Spinal loads are generally reduced by reducing the lever arm of the upper body’s center of mass relative to the lumbar spine and by supporting the upper body, for example, with the hands.&nbsp;</p

Spinal loads during post-operative physiotherapeutic exercises.

After spinal surgery, physiotherapeutic exercises are performed to achieve a rapid return to normal life. One important aim of treatment is to regain muscle strength, but it is known that muscle forces increase the spinal loads to potentially hazardous levels. It has not yet been clarified which exercises cause high spinal forces and thus endanger the surgical outcome. The loads on vertebral body replacements were measured in 5 patients during eleven physiotherapeutic exercises, performed in the supine, prone, or lateral position or on all fours (kneeling on the hands and knees). Low resultant forces on the vertebral body replacement were measured for the following exercises: lifting one straight leg in the supine position, abduction of the leg in the lateral position, outstretching one leg in the all-fours position, and hollowing the back in the all-fours position. From the biomechanical point of view, these exercises can be performed shortly after surgery. Implant forces similar or even greater than those for walking were measured during: lifting both legs, lifting the pelvis in the supine position, outstretching one arm with or without simultaneously outstretching the contralateral leg in the all-fours position, and arching the back in the all-fours position. These exercises should not be performed shortly after spine surgery

Spinal loads during cycling on an ergometer.

Cycling on an ergometer is an effective exercise for improving fitness. However, people with back problems or previous spinal surgery are often not aware of whether cycling could be harmful for them. To date, little information exists about spinal loads during cycling. A telemeterized vertebral body replacement allows in vivo measurement of implant loads during the activities of daily living. Five patients with a severe compression fracture of a lumbar vertebral body received these implants. During one measurement session, four of the participants exercised on a bicycle ergometer at various power levels. As the power level increased, the maximum resultant force and the difference between the maximum and minimum force (force range) during each pedal revolution increased. The average maximum-force increases between the two power levels 25 and 85 W were 73, 84, 225 and 75 N for the four patients. The corresponding increases in the force range during a pedal revolution were 84, 98, 166 and 101 N. There were large variations in the measured forces between the patients and also within the same patient, especially for high power levels. In two patients, the maximum forces during high-power cycling were higher than the forces during walking measured on the same day. Therefore, the authors conclude that patients with back problems should not cycle at high power levels shortly after surgery as a precaution