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Pitt CN, Ashkanfar A, English R, Naylor A, Öpöz TT, Langton DJ, Joyce TJ. Development of a bespoke finite element wear algorithm to investigate the effect of femoral centre of rotation on the wear evolution in total knee replacements. J Mech Behav Biomed Mater 2025; 163:106843. [PMID: 39647338 DOI: 10.1016/j.jmbbm.2024.106843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 11/01/2024] [Accepted: 11/29/2024] [Indexed: 12/10/2024]
Abstract
Total Knee Replacements (TKRs) are a commonly used treatment to help patients suffering from severely damaged knee joints, which is normally brought on by osteoarthritis. The aim of the surgery is to reduce pain and regain function of the joint, however, some of these implants fail prematurely with implant wear being one of the main factors of failure. Computational analysis is an efficient tool that can provide an in-depth insight on the evolution of wear, before utilising experimental techniques which are time-consuming and costly. In this study, a bespoke finite element (FE) based wear algorithm has been further developed for TKRs and was used to investigate how location of femoral centre of rotation (CoR) affects the evolution of wear at the bearing surfaces. Three locations of femoral CoR have been investigated: international standards (ISO) CoR, being the location defined in ISO 14243-3, distal CoR being the centre of the femoral component's distal radius, and reference CoR being the middle ground between the two. All investigations were setup in accordance with ISO 14243-3 for displacement-controlled wear testing conditions for knee simulators. The wear algorithm extracts contact pressure and sliding distance from the FE analysis to determine wear depth, wear pattern, volumetric wear, and wear rates on the polymeric insert and femoral component's bearing surfaces using Archard's wear law. The polymeric insert volumetric wear rate after 5 million cycles (Mc) for ISO, reference, and distal CoR are 4.37mm3/Mc, 5.40mm3/Mc, and 6.83mm3/Mc respectively. Furthermore, the wear pattern's location on the bearing surfaces is dependent on the femoral CoR, with ISO CoR wear pattern being positioned more posteriorly, distal CoR being more anteriorly, and reference CoR in between ISO and distal. The ISO CoR investigation showed a region of minimal wear between two wear regions at the middle of the femoral component's wear pattern, on both medial and lateral condyles. This region of minimal wear reduces for the reference CoR and further reduces for the distal CoR. After 5 Mc, the average polymeric insert-femoral component contact area changes with femoral CoR, with the average contact area being 66.53mm2, 68.35mm2, and 71.21mm2 for ISO, reference, and distal CoRs respectively, with distal having around 7% more contact area than ISO. The results from this study show that there is a wide range of wear values for different locations of femoral CoR. As such the choice of femoral CoR should be carefully considered when performing any wear investigation to ensure that the CoR location is consistent for all studies being compared.
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Affiliation(s)
- Ciaran Neil Pitt
- School of Engineering, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK.
| | - Ariyan Ashkanfar
- School of Engineering, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK
| | - Russell English
- School of Engineering, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK
| | - Andrew Naylor
- School of Engineering, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK
| | - Tahsin T Öpöz
- School of Engineering, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, UK
| | | | - Thomas J Joyce
- School of Engineering, Newcastle University, Newcastle Upon Tyne, NE1 7RU, UK
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Ting C, Weiguo M, Kaihui Z, Zilong H. Wear simulation of UHMWPE against the different counterface roughness in reciprocating unidirectional sliding motion. Sci Rep 2024; 14:15858. [PMID: 38982227 PMCID: PMC11233713 DOI: 10.1038/s41598-024-66613-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 07/02/2024] [Indexed: 07/11/2024] Open
Abstract
Wear simulations of UHMWPE can economically and conveniently predict the performance of wear resistant bushings used for sealing or other reciprocating unidirectional sliding motion. In this study, pin on plate tribological experiments and microscopic analysis was done to obtained the wear profiles, wear volume and wear mechanism of UHMWPE against the counterface with different surface roughness of which Ra range is 0.03 ~ 2 μm. Meanwhile, the 3D wear simulation model of the pin on plate tribological experiments was established to discuss the adaptability of the energy and Archard wear model by analyzing the difference of wear profiles and wear volume between the experiment and simulation. The results indicate that with an increase in the counterface roughness, the wear simulation of UHMWPE estimated by the energy model were more accurate in reciprocating unidirectional sliding motion.
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Affiliation(s)
- Chen Ting
- School of Mechanical Engineering, Yangtze University, Jingzhou, 434023, China.
| | - Ma Weiguo
- School of Mechanical Engineering, Yangtze University, Jingzhou, 434023, China
| | - Zhu Kaihui
- SJS Petroleum Drilling & Production Equipment Co. LTD, Jingzhou, 434023, China
| | - Hu Zilong
- School of Mechanical Engineering, Yangtze University, Jingzhou, 434023, China
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Hörlesberger N, Smolle MA, Leitner L, Hauer G, Leithner A, Sadoghi P. Long-term clinical and radiological outcome of a cementless titanium-coated total knee arthroplasty system. Arch Orthop Trauma Surg 2024; 144:847-853. [PMID: 37831197 PMCID: PMC10822817 DOI: 10.1007/s00402-023-05091-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION To ensure a high-quality standard, it is important to frequently evaluate different prostheses models to avoid prostheses with high failure rates. Thus, the aim of the study was to evaluate the long-term outcome of the uncemented titanium-coated total knee arthroplasty (TKA) system (Advanced Coated System (ACS) III, Implantcast, GERMANY). We hypothesized that the ACS III would have a similar performance as other cemented TKA systems. MATERIALS AND METHODS A total of 540 ACS III mobile-bearing knee joint prostheses were implanted in 495 patients. The visual analogue scale (VAS) score, Tegner activity score (TAS), knee society score (KSS), Western Ontario and McMaster (WOMAC) score, and the Short Form 12 (SF-12) score for the evaluation of quality of life (QoL) were taken after at least 9 years of follow-up. In addition, we measured range of motion (ROM) and assessed potential sex differences. In addition, the survival analysis was calculated at a median follow-up of 16.7 years. RESULTS At the final follow-up, 142 patients had died, and 38 had been lost to follow-up. The rate of revision-free implant survival at 16.7 years was 90.0% (95% CI 87.1-92.2%) and the rate of infection-free survival was 97.0% (IQR 95.2-98.2%). The reasons for revision surgery were aseptic loosening (32.9%), followed by infection (27.1%), inlay exchange (15.9%), and periprosthetic fractures (5.7%). At the clinical follow-up visit, the mean VAS score was 1.9 ± 1.9, the median TAS was 3 (IQR 2-4), and the mean KSS for pain and function were 83.5 ± 15.3 and 67.5 ± 25.2, respectively. The mean WOMAC score was 81.1 ± 14.9, and the median SF-12 scores for physical and mental health were 36.9 (IQR 29.8-45.1) and 55.8 (IQR 46.2-61.0), respectively. The mean knee flexion was 102.0° ± 15.4°. Male patients had better clinical outcome scores than female patients [SF-12 mental health score, p = 0.037; SF-12 physical health score, p = 0.032; KSS pain score (p < 0.001), and KSS functional score (p < 0.001)]. CONCLUSION The ACS III TKA system is a suitable option for the treatment of end-stage osteoarthritis of the knee joint because of its adequate long-term survival. Our findings are in line with published data on similar TKA systems that have shown favourable clinical scores in males. LEVEL OF EVIDENCE Level III-Retrospective cohort study.
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Affiliation(s)
- Nina Hörlesberger
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Maria Anna Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Lukas Leitner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Georg Hauer
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Patrick Sadoghi
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
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Deroche E, Batailler C, Shatrov J, Gunst S, Servien E, Lustig S. No clinical difference at mid-term follow-up between TiN-coated versus uncoated cemented mobile-bearing total knee arthroplasty: a matched cohort study. SICOT J 2023; 9:5. [PMID: 36757220 PMCID: PMC9910165 DOI: 10.1051/sicotj/2023001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/05/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Nitride-based ceramic coating was introduced into surgical implants to improve hardness, reduce abrasion, and decrease the risk of metal-induced adverse reactions, especially for patients with suspected or identified metal hypersensitivity. The study aimed to evaluate the effectiveness and safety of a titanium nitride (TiN) coated prosthesis with a mobile bearing design. METHODS This was a retrospective matched-cohort study from a single center, comparing clinical outcomes between patients receiving either a TiN-coated versus an uncoated cobalt-chromium-molybdenum (CoCrMo) prostheses for primary total knee replacement. Seventeen patients received the TiN prosthesis between 2015 and 2019. These were matched 1:2 with patients receiving uncoated mobile-bearing knee prostheses with the same design manufacturer. RESULTS Fourteen patients in the TiN group had complete 5-year follow-up data and were compared with 34 patients from the CoCrMo group. The Knee Society Score was 170.6 ± 28.0 (Function subscore 83.7 ± 17.5 and Knee subscore 86.9 ± 13.8) in the TiN group and 180.7 ± 49.4 (Function subscore 87.5 ± 14.3 and Knee subscore 93.2 ± 9.6) in CoCrMo group, with no statistically significant difference (p = 0.19). One patient underwent a revision for instability requiring the removal of the implant in the TiN group and none in the CoCrMo group. The survival rates were 92.9% (CI95% 77.3-100.0) and 100.0% in the TiN group and CoCrMo group respectively (p = 1.0). DISCUSSION TiN-coated TKA with mobile bearing resulted in satisfactory clinical outcomes, and a low revision rate, and there was no complication related to the coated implant. The use of TiN-coated prostheses in case of confirmed or suspected metal allergy provides satisfactory short-term clinic outcomes.
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Affiliation(s)
- Etienne Deroche
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,Corresponding author:
| | - Cécile Batailler
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France
| | - Jobe Shatrov
- Sydney Orthopaedic Research Institute (SORI) at Landmark Orthopaedics 500 Pacific Hwy St. Leonards NSW Australia
| | - Stanislas Gunst
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France
| | - Elvire Servien
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,LIBM – EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University 69622 Lyon France
| | - Sébastien Lustig
- Orthopaedic Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France,University of Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
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Computational Wear Prediction of TKR with Flatback Deformity during Gait. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12073698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Loss of lumbar lordosis in flatback patients leads to changes in the walking mechanism like knee flexion. Such variations in flatback patients are predicted to alter the characteristics of total knee replacement (TKR) contact, so their TKR will show different wear characteristics with a normal gait. However, the relevant study is limited to predicting the wear depth of TKR for normal gait mechanisms or collecting and analyzing kinematic data on flatback gait mechanisms. The objective of this study was to compare wear in TKR of flatback patients with people without flatback syndrome. The main difference between the normal gait mechanism and the flat back gait mechanism is the knee flexion remain section and the tendency to change the vertical force acting on the knee. Thus, in this paper, A finite element-based computational wear simulation for the gait cycle using kinematic data for normal gait and flat gait were performed, and substituting the derived contact pressure and slip distance into the Archard formula, a proven wear model, wear depth was predicted. The FE analysis results show that the wear volume in flatback patients is greater. The results obtained can provide guidance on the TKR design to minimize wear on the knee implant for flatback patients.
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Serbaya SH, Abualsauod EH, Basingab MS, Bukhari H, Rizwan A, Mehmood MS. Structure and Performance Attributes Optimization and Ranking of Gamma Irradiated Polymer Hybrids for Industrial Application. Polymers (Basel) 2021; 14:polym14010047. [PMID: 35012073 PMCID: PMC8747675 DOI: 10.3390/polym14010047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 11/16/2022] Open
Abstract
The selection of suitable composite material for high-strength industrial applications, from the list of available alternatives, is a tedious task as it requires an optimized structural performance-based solution. This study aimed to optimize the concentration of fillers, i.e., vinyl tri-ethoxy silane and absorbed gamma-dose, to enhance the properties of an industrial scale polymer, i.e., ultra-high molecular weight polyethylene (UHMWPE). The UHMWPE hybrids, in addition to silane, were treated with (30, 65, and 100 kGy) gamma dose and then tested for ten application-specific structural and performance attributes. The relative importance of attributes based on an 11-point fuzzy conversation was used for establishing the material assessment graph and corresponding adjacency matrix. Afterwards, the normalized values of attributes were used to establish the decision matrix for each alternative. The normalization was performed after the identification of high obligatory valued (HOV) and low obligatory valued (LOV) attributes. After this, suitability index values (SIVs) were calculated for ranking the hybrids that revealed hybrids 65 kGy irradiated the hybrid as the best choice and ranked as first among the existing alternatives. The major responsible factors were higher oxidation strength, a dense cross-linking network, and elongation at break. The values of the aforementioned factors for 65 kGy irradiated hybrids were 0.24, 91, and 360 MPa, respectively, as opposed to 0.54, 75, and 324 MPa for 100 kGy irradiated hybrids, thus placing the latter in second place regarding higher values of Yield Strength and Young Modulus. Finally, it is believed that the reported results and proposed model in this study will improve preoperative planning as far as considering these hybrids for high-strength industrial applications including total joint arthroplasty, textile-machinery pickers, dump trucks lining ships, and harbors bumpers and sliding, etc.
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Affiliation(s)
- Suhail H. Serbaya
- Department of Industrial Engineering, Faculty of Engineering, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (S.H.S.); (M.S.B.)
| | - Emad H. Abualsauod
- Industrial Engineering Department, College of Engineering, Taibah University, Al MadinaAlmonawara 41411, Saudi Arabia;
| | - Mohammed Salem Basingab
- Department of Industrial Engineering, Faculty of Engineering, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (S.H.S.); (M.S.B.)
| | - Hatim Bukhari
- Department of Industrial and Systems Engineering, College of Engineering, University of Jeddah, Jeddah 21959, Saudi Arabia;
| | - Ali Rizwan
- Department of Industrial Engineering, Faculty of Engineering, King Abdulaziz University, Jeddah 21589, Saudi Arabia; (S.H.S.); (M.S.B.)
- Correspondence:
| | - Malik Sajjad Mehmood
- Department of Basic Sciences, University of Engineering and Technology, Taxila 47050, Pakistan;
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Rothammer B, Marian M, Neusser K, Bartz M, Böhm T, Krauß S, Schroeder S, Uhler M, Thiele S, Merle B, Kretzer JP, Wartzack S. Amorphous Carbon Coatings for Total Knee Replacements-Part II: Tribological Behavior. Polymers (Basel) 2021; 13:1880. [PMID: 34198895 PMCID: PMC8201056 DOI: 10.3390/polym13111880] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/02/2021] [Accepted: 06/02/2021] [Indexed: 12/27/2022] Open
Abstract
Diamond-like carbon coatings may decrease implant wear, therefore, they are helping to reduce aseptic loosening and increase service life of total knee arthroplasties (TKAs). This two-part study addresses the development of such coatings for ultrahigh molecular weight polyethylene (UHMWPE) tibial inlays as well as cobalt-chromium-molybdenum (CoCr) and titanium (Ti64) alloy femoral components. While the deposition of a pure (a-C:H) and tungsten-doped hydrogen-containing amorphous carbon coating (a-C:H:W) as well as the detailed characterization of mechanical and adhesion properties were the subject of Part I, the tribological behavior is studied in Part II. Pin-on-disk tests are performed under artificial synovial fluid lubrication. Numerical elastohydrodynamic lubrication modeling is used to show the representability of contact conditions for TKAs and to assess the influence of coatings on lubrication conditions. The wear behavior is characterized by means of light and laser scanning microscopy, Raman spectroscopy, scanning electron microscopy and particle analyses. Although the coating leads to an increase in friction due to the considerably higher roughness, especially the UHMWPE wear is significantly reduced up to a factor of 49% (CoCr) and 77% (Ti64). Thereby, the coating shows continuous wear and no sudden failure or spallation of larger wear particles. This demonstrated the great potential of amorphous carbon coatings for knee replacements.
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Affiliation(s)
- Benedict Rothammer
- Engineering Design, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Martensstr. 9, 91058 Erlangen, Germany; (K.N.); (M.B.); (S.W.)
| | - Max Marian
- Engineering Design, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Martensstr. 9, 91058 Erlangen, Germany; (K.N.); (M.B.); (S.W.)
| | - Kevin Neusser
- Engineering Design, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Martensstr. 9, 91058 Erlangen, Germany; (K.N.); (M.B.); (S.W.)
| | - Marcel Bartz
- Engineering Design, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Martensstr. 9, 91058 Erlangen, Germany; (K.N.); (M.B.); (S.W.)
| | - Thomas Böhm
- Forschungszentrum Jülich GmbH, Helmholtz-Institute Erlangen-Nürnberg for Renewable Energy, Cauerstr. 1, 91058 Erlangen, Germany; (T.B.); (S.T.)
| | - Sebastian Krauß
- Department of Materials Science & Engineering, Interdisciplinary Center for Nanostructured Films (IZNF) Institute I, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Cauerstr. 3, 91058 Erlangen, Germany; (S.K.); (B.M.)
| | - Stefan Schroeder
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany; (S.S.); (M.U.); (J.P.K.)
| | - Maximilian Uhler
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany; (S.S.); (M.U.); (J.P.K.)
| | - Simon Thiele
- Forschungszentrum Jülich GmbH, Helmholtz-Institute Erlangen-Nürnberg for Renewable Energy, Cauerstr. 1, 91058 Erlangen, Germany; (T.B.); (S.T.)
- Department of Chemical and Biological Engineering, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Egerlandstr. 3, 91058 Erlangen, Germany
| | - Benoit Merle
- Department of Materials Science & Engineering, Interdisciplinary Center for Nanostructured Films (IZNF) Institute I, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Cauerstr. 3, 91058 Erlangen, Germany; (S.K.); (B.M.)
| | - Jan Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany; (S.S.); (M.U.); (J.P.K.)
| | - Sandro Wartzack
- Engineering Design, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Martensstr. 9, 91058 Erlangen, Germany; (K.N.); (M.B.); (S.W.)
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Lee JA, Koh YG, Kang KT. Effect of post-cam design on the kinematics and contact stress of posterior-stabilized total knee arthroplasty. Biomed Mater Eng 2021; 32:323-332. [PMID: 33967034 DOI: 10.3233/bme-201097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The post-cam mechanism in the posterior-stabilized (PS) implant plays an important role, such as durability and kinematic performances, in total knee arthroplasty (TKA). OBJECTIVE The purpose of this study was to evaluate the difference in the kinematics and contact stress of five post-cam designs, which are flat-and-flat, curve-and-curve (concave), curve-and-curve (concave and convex), helical, and asymmetrical post-cam designs, using three-dimensional finite element models. METHODS We designed the post-cam model with five different geometries. The kinematics, contact stress, and contact area were evaluated in the five post-cam designs under gait cycle loading conditions using the finite element method. RESULTS There were no differences in the contact stress and area on the tibial insert in all designs. The largest internal rotation was shown in the swing phase for the helical design, and the largest tibial posterior translation was observed for the curve-and-curve (concave) design. The curve-and-curve (concave) design showed the lowest contact stress and the largest posterior tibial translation during the gait cycle. CONCLUSIONS Considering the kinematics and contact stress, we found that the curve-and-curve (concave) design was more stable than other designs. From the results, we found the important factors of TKA implant considering stability and kinematics.
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Affiliation(s)
- Jin-Ah Lee
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Yong-Gon Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, Republic of Korea
| | - Kyoung-Tak Kang
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, Republic of Korea
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Burchardt A, Abicht C, Sander O. An efficient and robust simulator for wear of total knee replacements. Proc Inst Mech Eng H 2020; 234:921-930. [PMID: 32579092 DOI: 10.1177/0954411920933022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Wear on total knee replacements is an important criterion for their performance characteristics. Numerical simulations of such wear have seen increasing attention over the last years. They have the potential to be much faster and less expensive than the in vitro tests in use today. While it is unlikely that in silico tests will replace actual physical tests in the foreseeable future, a judicious combination of both approaches can help making both implant design and pre-clinical testing quicker and more cost-effective. The challenge today for the design of simulation methods is to obtain results that convey quantitative information and to do so quickly and reliably. This involves the choice of mathematical models as well as the numerical tools used to solve them. The correctness of the choice can only be validated by comparing with experimental results. In this article, we present finite element simulations of the wear in total knee replacements during the gait cycle standardized in the ISO 14243-1 document, used for compliance testing in several countries. As the ISO 14243-1 standard is precisely defined and publicly available, it can serve as an excellent benchmark for comparison of wear simulation methods. We use comparatively simple wear and material models, but we solve them using a new wear algorithm that combines extrapolation of the geometry changes with a contact algorithm based on nonsmooth multigrid ideas. The contact algorithm works without Lagrange multipliers and penalty parameters, achieving unparalleled stability and efficiency. We compare our simulation results with the experimental data from physical tests using two different actual total knee replacements. Even though the model is simple, we can predict the total mass loss due to wear after 5-million gait cycles, and we observe a good match between the wear patterns seen in experiments and our simulation results. When compared with a state-of-the-art penalty-based solver for the same model, we measure a roughly fivefold increase of execution speed.
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Affiliation(s)
- Ansgar Burchardt
- Institut für Numerische Mathematik, Technische Universität Dresden, Dresden, Germany
| | | | - Oliver Sander
- Institut für Numerische Mathematik, Technische Universität Dresden, Dresden, Germany
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Koh YG, Park KM, Lee HY, Park JH, Kang KT. Prediction of wear performance in femoral and tibial conformity in patient-specific cruciate-retaining total knee arthroplasty. J Orthop Surg Res 2020; 15:24. [PMID: 31969195 PMCID: PMC6977248 DOI: 10.1186/s13018-020-1548-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/06/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Articular surface curvature design is important in tibiofemoral kinematics and the contact mechanics of total knee arthroplasty (TKA). Thus far, the effects of articular surface curvature have not been adequately discussed with respect to conforming, nonconforming, and medial pivot designs in patient-specific TKA. Therefore, this study evaluates the underlying relationship between the articular surface curvature geometry and the wear performance in patient-specific TKA. METHODS We compare the wear performances between conventional and patient-specific TKA under gait loading conditions using a computational simulation. Patient-specific TKAs investigated in the study are categorized into patient-specific TKA with conforming articular surfaces, medial pivot patient-specific TKA, and bio-mimetic patient-specific TKA with a patient's own tibial and femoral anatomy. The geometries of the femoral components in patient-specific TKAs are identical. RESULTS The anterior-posterior and internal-external kinematics change with respect to different TKA designs. Moreover, the contact pressure and area did not directly affect the wear performance. In particular, conforming patient-specific TKAs exhibit the highest volumetric wear and wear rate. The volumetric wear in a conforming patient-specific TKA is 29% greater than that in a medial pivot patient-specific TKA. CONCLUSION The findings in this study highlight that conformity changes in the femoral and tibial inserts influence the wear performance in patient-specific TKA. Kinematics and contact parameters should be considered to improve wear performance in patient-specific TKA. The conformity modification in the tibiofemoral joint changes the kinematics and contact parameters, and this affects wear performance.
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Affiliation(s)
- Yong-Gon Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, 06698, Republic of Korea
| | - Kyoung-Mi Park
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hwa-Yong Lee
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Joon-Hee Park
- Department of Anesthesiology & Pain Medicine, Hallym University College of Medicine and Kangdong Sacred Heart Hospital, 150 Seongan-ro, Gangdong-gu, Seoul, 05355, Republic of Korea.
| | - Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Koh YG, Lee JA, Lee HY, Kim HJ, Kang KT. Computational wear prediction of insert conformity and material on mobile-bearing unicompartmental knee arthroplasty. Bone Joint Res 2019; 8:563-569. [PMID: 31832176 PMCID: PMC6888736 DOI: 10.1302/2046-3758.811.bjr-2019-0036.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives Unicompartmental knee arthroplasty (UKA) is an alternative to total knee arthroplasty with isolated medial or lateral compartment osteoarthritis. However, polyethylene wear can significantly reduce the lifespan of UKA. Different bearing designs and materials for UKA have been developed to change the rate of polyethylene wear. Therefore, the objective of this study is to investigate the effect of insert conformity and material on the predicted wear in mobile-bearing UKA using a previously developed computational wear method. Methods Two different designs were tested with the same femoral component under identical kinematic input: anatomy mimetic design (AMD) and conforming design inserts with different conformity levels. The insert materials were standard or crosslinked ultra-high-molecular-weight polyethylene (UHMWPE). We evaluated the contact pressure, contact area, wear rate, wear depth, and volumetric wear under gait cycle loading conditions. Results Conforming design inserts had the lower contact pressure and larger contact area. However, they also had the higher wear rate and volumetric wear. The improved wear performance was found with AMD inserts. In addition, the computationally predicted volumetric wear of crosslinked UHMWPE inserts was less than half that of standard UHMWPE inserts. Conclusion Our results showed that increasing conformity may not be the sole predictor of wear performance; highly crosslinked mobile-bearing polyethylene inserts can also provide improvement in wear performance. These results provide improvements in design and materials to reduce wear in mobile-bearing UKA. Cite this article: Bone Joint Res 2019;8:563–569.
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Affiliation(s)
- Y-G Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, South Korea
| | - J-A Lee
- Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
| | - H-Y Lee
- Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
| | - H-J Kim
- Department of Sport and Healthy Aging, Korea National Sport University, Seoul, South Korea
| | - K-T Kang
- Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
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Optimal Design of Patient-Specific Total Knee Arthroplasty for Improvement in Wear Performance. J Clin Med 2019; 8:jcm8112023. [PMID: 31752389 PMCID: PMC6912647 DOI: 10.3390/jcm8112023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 11/17/2022] Open
Abstract
Life expectancy is on the rise and, concurrently, the demand for total knee arthroplasty (TKA), which lasts a lifetime, is increasing. To meet this demand, improved TKA designs have been introduced. Recent advances in radiography and manufacturing techniques have enabled the production of patient-specific TKA. Nevertheless, concerns regarding the wear performance, which limit the lifespan of TKA, remain to be addressed. This study aims at reducing the wear in patient-specific TKA using design optimization and parametric three-dimensional (3D) finite-element (FE) modelling. The femoral component design was implemented in a patient-specific manner, whereas the tibial insert conformity remained to be determined by design variables. The gait cycle loading condition was applied, and the optimized model was validated by the results obtained from the experimental wear tests. The wear predictions were iterated for five million gait cycles using the computational model with force-controlled input. Similar patterns for internal/external rotation and anterior/posterior translation were observed in both initial and optimal models. The wear rates for initial and optimal models were recorded as 23.2 mm3/million cycles and 16.7 mm3/million cycles, respectively. Moreover, the experimental wear rate in the optimal design was 17.8 mm3/million cycles, which validated our optimization procedure. This study suggests that tibial insert conformity is an important factor in influencing the wear performance of patient-specific TKA, and it is capable of providing improved clinical results through enhanced design selections. This finding can boost the future development of patient-specific TKA, and it can be extended to other joint-replacement designs. However, further research is required to explore the potential clinical benefits of the improved wear performance demonstrated in this study.
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Total knee arthroplasty application of polyetheretherketone and carbon-fiber-reinforced polyetheretherketone: A review. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 100:70-81. [DOI: 10.1016/j.msec.2019.02.082] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 12/31/2022]
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Koh YG, Park KM, Lee HY, Kang KT. Influence of tibiofemoral congruency design on the wear of patient-specific unicompartmental knee arthroplasty using finite element analysis. Bone Joint Res 2019; 8:156-164. [PMID: 30997041 PMCID: PMC6444019 DOI: 10.1302/2046-3758.83.bjr-2018-0193.r1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives Unicompartmental knee arthroplasty (UKA) is an alternative to total knee arthroplasty for patients who require treatment of single-compartment osteoarthritis, especially for young patients. To satisfy this requirement, new patient-specific prosthetic designs have been introduced. The patient-specific UKA is designed on the basis of data from preoperative medical images. In general, knee implant design with increased conformity has been developed to provide lower contact stress and reduced wear on the tibial insert compared with flat knee designs. The different tibiofemoral conformity may provide designers the opportunity to address both wear and kinematic design goals simultaneously. The aim of this study was to evaluate wear prediction with respect to tibiofemoral conformity design in patient-specific UKA under gait loading conditions by using a previously validated computational wear method. Methods Three designs with different conformities were developed with the same femoral component: a flat design normally used in fixed-bearing UKA, a tibia plateau anatomy mimetic (AM) design, and an increased conforming design. We investigated the kinematics, contact stress, contact area, wear rate, and volumetric wear of the three different tibial insert designs. Results Conforming increased design showed a lower contact stress and increased contact area. In addition, increased conformity resulted in a reduction of the wear rate and volumetric wear. However, the increased conformity design showed limited kinematics. Conclusion Our results indicated that increased conformity provided improvements in wear but resulted in limited kinematics. Therefore, increased conformity should be avoided in fixed-bearing patient-specific UKA design. We recommend a flat or plateau AM tibial insert design in patient-specific UKA. Cite this article: Y-G. Koh, K-M. Park, H-Y. Lee, K-T. Kang. Influence of tibiofemoral congruency design on the wear of patient-specific unicompartmental knee arthroplasty using finite element analysis. Bone Joint Res 2019;8:156–164. DOI: 10.1302/2046-3758.83.BJR-2018-0193.R1.
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Affiliation(s)
- Y-G Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, Seoul, South Korea
| | - K-M Park
- Department of Mechanical Engineering, Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
| | - H-Y Lee
- Department of Mechanical Engineering, Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
| | - K-T Kang
- Department of Mechanical Engineering, Department of Mechanical Engineering, Yonsei University, Seoul, South Korea
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Park CH, Kang SG, Bae DK, Song SJ. Mid-term clinical and radiological results do not differ between fixed- and mobile-bearing total knee arthroplasty using titanium-nitride-coated posterior-stabilized prostheses: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2019; 27:1165-1173. [PMID: 30088030 DOI: 10.1007/s00167-018-5095-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 08/03/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE This study was performed to prospectively compare the clinical and radiographic results between mobile-bearing (MB) and fixed-bearing (FB) TKAs using ceramic titanium nitride (TiN)-coated prostheses. METHODS Seventy MB and 70 FB TKAs using TiN-coated prostheses (ACS®) were prospectively evaluated. There were no differences in demographic characteristics between the two groups. Clinically, the Knee Society knee and function scores, WOMAC, and range of motion (ROM) were compared. Considering the possibility of a kinematic change in the polyethylene (PE) insert and a decrease in ROM following MB TKA, serial changes in the ROM were also compared. The thickness of the PE insert was compared according to the size of the femoral component. Radiographically, the alignment and positions of the components were compared. RESULTS There were no differences between the two groups in clinical scores or ROM (n.s.). The maximum flexion increased from 133.5° ± 8.3° to 137.6° ± 5.5° across all time points in the MB group. The serial maximum flexion angles did not differ between the two groups over time (n.s.). The average thickness of the PE insert was greater in the MB group (12.0 ± 1.9 vs. 11.2 ± 1.6 mm, respectively, p = 0.008), especially when a large femoral component was used (12.7 ± 1.9 vs. 11.0 ± 1.5 mm, p = 0.005). The pre- and postoperative mechanical axes and positions of the components did not differ between the two groups (n.s.). CONCLUSIONS TiN-coated MB TKA showed no significant advantage over FB TKA. The selection of bearing design would be clinically insignificant when using the TiN-coated TKA prosthesis. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Cheol Hee Park
- Department of Medicine, Graduate School, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea
| | - Se Gu Kang
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea
| | - Dae Kyung Bae
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea
| | - Sang Jun Song
- Department of Medicine, Graduate School, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea. .,Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, 24 Kyunghee-daero, Dongdaemun-gu, Seoul, 02453, South Korea.
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Koh YG, Son J, Kwon OR, Kwon SK, Kang KT. Tibiofemoral conformity variation offers changed kinematics and wear performance of customized posterior-stabilized total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2019; 27:1213-1223. [PMID: 29974167 DOI: 10.1007/s00167-018-5045-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/27/2018] [Indexed: 01/17/2023]
Abstract
PURPOSE Posterior-stabilized (PS)-total knee arthroplasty (TKA) can be applied in any of several variations in terms of the tibiofemoral conformity and post-cam mechanism. However, previous studies have not evaluated the effect of the condylar surface radii (tibiofemoral conformity) on wear in a customized PS-TKA. The present study involved evaluating the wear performance with respect to three different conformities of the tibiofemoral articular surface in a customized PS-TKA by means of a computational simulation. METHODS An adaptive computational simulation method was developed that conduct wear simulation for tibial insert to predict kinematics, weight loss due to wear, and wear contours to results. Wear predictions using computational simulation were performed for 5 million gait cycles with force-controlled inputs. Customized PS-TKA designs were developed and categorized as conventional conformity (CPS-TKA), medial pivot conformity (MPS-TKA), and anatomical conformity (APS-TKA). The post-cam design in the customized PS-TKA is identical. We compared the kinematics, contact mechanics, and wear performance. RESULTS The findings revealed that APS-TKA exhibited the highest internal tibial rotation relative to other TKA designs. Additionally, the higher contact area led to there being less contact stress although it did not directly affect the wear performance. Specifically, MPS-TKA exhibited the lowest volumetric wear. CONCLUSIONS The results of the present study showed that tibiofemoral articular surface conformity should be considered carefully in customized PS-TKA design. Different wear performances were observed with respect to different tibiofemoral conformities. Even though APS-TKA exhibited an inferior wear performance compared to MPS-TKA, it proved to be better in terms of kinematics so its functionality may be improved through the optimization of the tibiofemoral articular surface conformity. Additionally, it should be carefully designed since any changes may affect the post-cam mechanism.
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Affiliation(s)
- Yong-Gon Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, 06698, Republic of Korea
| | - Juhyun Son
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Oh-Ryong Kwon
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, 06698, Republic of Korea
| | - Sae Kwang Kwon
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, 06698, Republic of Korea
| | - Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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Prediction of Wear on Tibial Inserts Made of UHMWPE, PEEK, and CFR-PEEK in Total Knee Arthroplasty Using Finite-Element Analysis. LUBRICANTS 2019. [DOI: 10.3390/lubricants7040030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The wear of tibial inserts in total knee arthroplasty (TKA) remains a major limitation of longevity. However, wear tests are expensive and time-consuming. Computational wear prediction using a finite-element (FE) model followed by validation through comparison with experimental data is effective for assessing new prosthetic designs or materials prior to functional testing and surgical implementation. In this study, the kinematics, volumetric wear, and wear depth of tibial inserts made of different materials (ultrahigh-molecular weight polyethylene (UHMWPE), polyetheretherketone (PEEK), and carbon fiber-reinforced PEEK (CFR–PEEK)) in TKA were evaluated by employing FE models and analysis. The differences among the materials were evaluated using adaptive wear modeling to predict the wear depth, volumetric wear, and kinematics under a gait loading condition. The volumetric wear and wear depth of the CFR–PEEK decreased by 87.4% and 61.3%, respectively, compared with those of the UHMWPE, whereas the PEEK exhibited increased volumetric wear and wear depth. These results suggest that CFR–PEEK is a good alternative to UHMWPE as a promising and suitable material for tibial inserts used in TKA. However, orthopedic research should be performed to evaluate the threshold conditions and appropriate applications for the newly developed and introduced biomaterial.
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Grieco PW, Pascal S, Newman JM, Shah NV, Stroud SG, Sheth NP, Maheshwari AV. New alternate bearing surfaces in total hip arthroplasty: A review of the current literature. J Clin Orthop Trauma 2018; 9:7-16. [PMID: 29628677 PMCID: PMC5884051 DOI: 10.1016/j.jcot.2017.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 10/26/2017] [Indexed: 01/01/2023] Open
Abstract
As indications for total hip arthroplasty (THA) have expanded, the incidence of THA has increased among younger patients, who live longer and tend to place more strain on implants via higher activity levels. This demographical shift accentuates the importance of advancing innovation to ensure implant longevity for younger and more active patients. Future innovation, as it pertains to THA components, is likely to focus on modifying implant designs and tribology in conjunction with identification and application of newer biomaterials. By reviewing the literature for development status of various materials and novel design advancements in THA component outside of the standard highly cross-linked polyethylene, this investigation provided an update on the current and future status of design initiatives as they pertain to THA. Though the highlighted alternative bearing surfaces have shown promising in vitro and limited, yet encouraging clinical data, they lack larger and longer-term clinical trial results. Further research and innovation is warranted to identify the optimal bearing surface to most effectively accommodate for the trend of younger and more active patients undergoing THA. Implant longevity is crucial if the clinical success of THA is to be maintained.
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Affiliation(s)
- Preston W. Grieco
- Department of Orthopaedic Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Scott Pascal
- Department of Orthopaedic Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Jared M. Newman
- Department of Orthopaedic Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Neil V. Shah
- Department of Orthopaedic Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Sarah G. Stroud
- Department of Orthopaedic Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA
| | - Neil P. Sheth
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 1 Cathcart 800 Spruce Street, Philadelphia, PA 19107, USA
| | - Aditya V. Maheshwari
- Department of Orthopaedic Surgery, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA,Corresponding author at: Adult Reconstruction and Musculoskeletal Oncology Divisions SUNY Downstate Medical Center 450 Clarkson Ave., Box 3 Box 3 Box 30 Brooklyn, NY 11203, USA.
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