Contact mechanics of modular metal-on-polyethylene total hip replacement under adverse edge loading conditions

Postoperative posterior pelvic tilt progression is a risk factor for cup revision after total hip arthroplasty with a conventional polyethylene liner: a 25-year follow-up study

BACKGROUND

Whether postoperative posterior pelvic tilt progression is an independent risk factor for cup revision after total hip arthroplasty (THA) with a conventional polyethylene (PE) liner is unclear. This long-term follow-up study assessed the association between posterior pelvic tilt and cup revision after THA using the porous-coated anatomic (PCA) total hip system.

METHODS

This retrospective cohort study included 94 patients who underwent THA using the PCA total hip system and participated in postoperative follow-up for a mean of 25 years. The Japanese Orthopaedic Association (JOA) hip score was the clinical outcome, and prosthetic alignment and the change in pelvic tilt were measured as radiological outcomes. Prosthetic survival rates for revision as the endpoint were evaluated, and risk factors for cup revision were identified using a multivariate logistic regression analysis.

RESULTS

The JOA hip score improved significantly (p < 0.001) after THA (before THA: 41 ± 6.3 points; after THA: 86 ± 8.9 points). The postoperative posterior pelvic tilt progressed 3.6 ± 3.2°. Survival rates of the cup and stem at 27 years postoperatively were 60.8% and 87.5%, respectively (p < 0.001). The main reason for revision (81% of all revisions) was aseptic loosening. Postoperative posterior pelvic tilt progression was an independent risk factor for cup revision (odds ratio, 1.53; 95% confidence interval, 1.06-2.20; p = 0.022).

CONCLUSIONS

When the PCA total hip system was used, the stem exhibited good longevity during a mean follow-up period of 25 years; however, the cup was vulnerable because of aseptic loosening. Postoperative posterior pelvic tilt progression was an independent risk factor for cup revision.

Spinopelvic alignment and precise cup placement in total hip arthroplasty - A systematic review

Study Design

A systematic literature review and meta- analysis.

Objective

To extract and combine the available literature focused on normal and abnormal biomechanical principles of spine-pelvis-hip complex and to sum up the data in the application of THA both in the setting with and without spinal disorders.

Methods

An extensive search and analysis of the articles was done by 3 authors independently in 7 platforms based on PRISMA and MOOSE guidelines. Selection criteria 1. Articles that assessed spinopelvic parameters (SS, SPT, PI, and acetabular cup orientation) in patients undergoing THA, Articles that assessed balance in spinopelvic complex after THA, Randomized control studies, Systematic literature reviews, Meta-analyses, Clinical trials / original research studies, Review articles and Articles after 2015 were included. Cochrane's GRADE method was used to define the level of evidence. 2.Participants: Patients who underwent THA only (in asymptomatic spine), those who had ankylosing spondylitis and underwent THA and those who underwent THA with prior spinal arthrodesis. 3.Study parameters: Ante Inclination (AI), sacral slope (SS), pelvic Incidence (PI) and spinopelvic tilt (SPT) in both positions of standing and sitting. ΔAI, ΔSS and ΔSPT. Data were collected and analyzed, the means of the study parameters with SD were calculated and a meta-analysis is performed to evaluate the pooled means with optimal value range.

Results

From 218 abstracts extracted and after eligibility assessment and exclusion, 4 articles involving 439 patients were enrolled. The mean SS in standing and sitting calculated were 35.53±10.52 and 33.13±12.38. The mean of AI and SPT in standing /sitting positions are 29.7±12.29/34.69±12.96 (n = 242) and 19.56±8.9/21.22±12.53 (n=439) respectively. The ΔAI, ΔSS, and ΔSPT were 4.99,2.4 and 1.66 respectively.

Conclusion

There is a proportionate change between the spinopelvic tilt and the acetabular orientation in postural variations. Evaluation of spine, pelvis and hip becomes more critical in identifying these changes and thereby prompting the acetabular cup position in the functional safe zone.

Hip contact force pathways in total hip replacement differ between patients and activities of daily living

One of the main causes of implant failure and revision surgery in total hip replacement (THR) is aseptic loosening often caused by the accumulation of wear debris arising between the contact surfaces of the acetabular cup and femoral head during activities of daily living (ADL's). However, limited information is available regarding the contact force pathways between these two surfaces during specific ADL's. In this study, through musculoskeletal modelling, we aimed to estimate the orientation of the hip contact force pathway on the acetabular cup. One hundred and thirty-two THR patients underwent motion capture analysis whilst undertaking locomotor and non-locomotor ADL's. Musculoskeletal simulations were performed to calculate contact force pathways using inverse dynamics analysis. We then qualitatively compared differences in the contact force pathways between patients and between ADL's. Walking resulted in a typical figure-of-eight pattern, with the peak contact forces occurring in the superior-anterior area of the cup. The non-locomotive activities such as stand up, sit down and squat had a more linear shape, spanning across the superior-posterior quarter of the cup. Our results showed a large inter-patient variability in the shape and location of the contact force pathway. There is a distinct difference in the location and shape of the pathway between locomotor and non-locomotor activities and this could result in different wear accumulations. These results could enhance our understanding why revision rates vary across the population and could inform the development of personalised implant design.

Kinematic-kinetic compliant acetabular cup positioning based on preoperative motion tracking and musculoskeletal modeling for total hip arthroplasty

The invention of the surgical robot enabled accurate component implantation during total hip arthroplasty (THA). However, a preoperative surgical planning methodology is still lacking to determine the acetabular cup alignment considering the patient-specific hip functions during daily activities such as walking. To simultaneously avoid implant edgeloading and impingement, this study established a kinematic-kinetic compliant (KKC) acetabular cup positioning method based on preoperative gait kinematics measurement and musculoskeletal modeling. Computed tomography images around the hip joint and their biomechanical data during gait, including motion tracking and foot-ground reaction forces, were collected. Using the reconstructed pelvic and femur geometries, the patient-specific hip muscle insertions were located in the lower limb musculoskeletal model via point cloud registration. The designed cup orientation has to be within the patient-specific safe zone to prevent implant impingement, and the optimized value selected based on the time-dependent hip joint reaction force to minimize the risk of edgeloading. As a validation of the proposed musculoskeletal model, the predicted lower limb muscle activations for seven patients were correlated with their surface electromyographic measurements, and the computed hip contact force was also in quantitative agreement with data from the literature. However, the designed cup orientations were not always within the well-known Lewinnek safe zone, highlighting the importance of KKC surgical planning based on patient-specific biomechanical evaluations.

Striated Pattern on Worn Surface of a Retrieved TKR Tibial Insert Stems from Microstructural Changes in the UHMWPE

Polyethylene wear has been a concern for the longevity of total knee replacements (TKR). A characteristic wear feature often observed on the articular surfaces of retrieved polyethylene tibial inserts is a striated pattern of hills and troughs. This pattern is of interest because its surface area has been found to correlate with increased tibial insert wear. We therefore addressed the following two research questions: (1) What is the prevalence of the striated pattern on a contemporary tibial insert design made from conventional ultra-high-molecular-weight polyethylene (UHMWPE)? (2) Are the peaks and troughs of the striated pattern connected with differences in crystallinity developed during the wear process? The prevalence and area coverage of the striated patterns were determined on a set of 81 retrieved tibial inserts of a cruciate-retaining TKR design. The striated areas were mapped using an optical coordinate measuring machine. Differences in crystallinity between troughs and hills were determined on a representative tibial insert using Raman spectroscopy. The striated pattern was observed on 61 out of 81 (75%) of the retrieved tibial inserts, covering an average of 32% of the total articular area. In the representative insert that was evaluated, the hills exhibited higher crystallinity (68%) than the troughs (54%) (p = 0.001). Conversely, the troughs exhibited higher amorphous phase content (22%) than the hills (19%) (p = 0.04). In conclusion, this pattern of hills and troughs is another example of microstructural changes in UHMWPE stemming from tribological stresses.

Do hip resurfacing and short hip stem arthroplasties differ from conventional hip stem replacement regarding impingement-free range of motion?

Total hip joint replacement (THR) is clinically well-established. In this context, the resulting range of motion (ROM) is crucial for patient satisfaction when performing joint movements. However, the ROM for THR with different bone preserving strategies (short hip stem and hip resurfacing) raises the question of whether the ROM is comparable with conventional hip stems. Therefore, this computer-based study aimed to investigate the ROM and type of impingement for different implant systems. An established framework with computer-aided design 3D models based on magnetic resonance imaging data of 19 patients with hip osteoarthritis was used to analyse the ROM for three different implant systems (conventional hip stem vs. short hip stem vs. hip resurfacing) during typical joint movements. Our results revealed that all three designs led to mean maximum flexion higher than 110°. However, hip resurfacing showed less ROM (-5% against conventional and -6% against short hip stem). No significant differences were observed between the conventional and short hip stem during maximum flexion and internal rotation. Contrarily, a significant difference was detected between the conventional hip stem and hip resurfacing during internal rotation (p = 0.003). The ROM of the hip resurfacing was lower than the conventional and short hip stem during all three movements. Furthermore, hip resurfacing shifted the impingement type to implant-to-bone impingement compared with the other implant designs. The calculated ROMs of the implant systems achieved physiological levels during maximum flexion and internal rotation. However, bone impingement was more likely during internal rotation with increasing bone preservation. Despite the larger head diameter of hip resurfacing, the ROM examined was substantially lower than that of conventional and short hip stem.

Current Concepts in Diagnosis and Management of Patients Undergoing Total Hip Replacement with Concurrent Disorders of Spinopelvic Anatomy: A Narrative Review

Despite the high success rate of primary total hip replacement (THR), a significant early revision rate remains, which is largely attributed to instability and dislocations. Despite the implants being placed according to the safe zone philosophy of Lewinnek, occurrence of THR dislocation is not an uncommon complication. Large diagnostic and computational model studies have shown variability in patients' mobility based on the individual anatomic and functional relationship of the hip-pelvis-spine complex. The absolute and relative position of hip replacement components changes throughout motion of the patient's body. In the case of spinopelvic pathology such as spine stiffness, the system reaches abnormal positional states, as shown with computerized models. The clinical result of such pathologic hip positioning is edge loading, implant impingement, or even joint dislocation. To prevent such complications, surgeons must change the dogma of single correct implant positioning and take into account patients' individualized anatomy and function. It is essential to broaden the standard diagnostics and their anatomical interpretation, and correct the pre-operative surgical planning. The need for correct and personalized implant placement pushes forward the development and adaptation of novel technologies in THR, such as robotics. In this current concepts narrative review, we simplify the spinopelvic biomechanics and pathoanatomy, the relevant anatomical terminology, and the diagnosis and management algorithms most commonly used today.

Dynamic finite element analysis of hip replacement edge loading: Balancing precision and run time in a challenging model

An important aspect in evaluating the resilience of hip replacement designs is testing their performance under adverse conditions that cause edge loading of the acetabular liner. The representation of edge loading conditions in finite element models is computationally challenging due to the changing contact locations, need for fine meshes, and dynamic nature of the system. In this study, a combined mesh and mass-scaling sensitivity study was performed to identify an appropriate compromise between convergence and solution time of explicit finite element analysis in investigating edge loading in hip replacement devices. The optimised model was then used to conduct a sensitivity test investigating the effect of different hip simulator features (the mass of the translating fixture and mediolateral spring damping) on the plastic strain in the acetabular liner. Finally, the effect of multiple loading cycles on the progressive accumulation of plastic strain was then also examined using the optimised model. A modelling approach was developed which provides an effective compromise between mass-scaling effects and mesh refinement for a solution time per cycle of less than 1 h. This 'Recommended Mesh' model underestimated the plastic strains by less than 10%, compared to a 'Best Estimate' model with a run time of ∼190 h. Starting with this model setup would therefore significantly reduce any new model development time while also allowing the flexibility to incorporate additional complexities as required. The polyethylene liner plastic strain was found to be sensitive to the simulator mass and damping (doubling the mass or damping had a similar magnitude effect to doubling the swing phase load) and these should ideally be described in future experimental studies. The majority of the plastic strain (99%) accumulated within the first three load cycles.

Finite Element Analysis of Acetabulum Prosthesis' Lining Damage Zone with Different Implanting Angle

Objective

Research the acetabular component's construction method of a three-dimensional finite element model in THA with different angles and study the influence of polyethylene liner wearing with finite element analysis.

Methods

Build a model in the 3D modeling software system HyperMesh according to the artificial hip joint prosthesis' entities and data. Using a finite element analysis system, ABAQUS 6.11 reconstitute acetabular prosthesis after hip replacement joints under different implanting position angles. Simulation and load the joint load when sheet foot touchdown state. Calculate the plastic volume strain and fatigue fracture.

Results

The two groups of combinations of abduction angle 50° vs. anteversion angle 10° and abduction angle 55° vs. anteversion angle 15° have been found to have relatively smaller interface plastic strain and fatigue fracture volume value (2.241 × 10^-7 m³, 2.443 × 10^-7 m³), respectively.

Conclusion

The groups of combinations of abduction angle 50° vs. anteversion angle 10° have been found to have relatively smallest interface plastic strain and fatigue fracture volume value in the total hip arthroplasty.

Importance of dynamics in the finite element prediction of plastic damage of polyethylene acetabular liners under edge loading conditions

After hip replacement, in cases where there is instability at the joint, contact between the femoral head and the acetabular liner can move from the bearing surface to the liner rim, generating edge loading conditions. This has been linked to polyethylene liner fracture and led to the development of a regulatory testing standard (ISO 14242:4) to replicate these conditions. Performing computational modelling alongside simulator testing can provide insight into the complex damage mechanisms present in hard-on-soft bearings under edge loading. The aim of this work was to evaluate the need for inertia and elastoplastic material properties to predict kinematics (likelihood of edge loading) and plastic strain accumulation (as a damage indicator). While a static, rigid model was sufficient to predict kinematics for experimental test planning, the inclusion of inertia, alongside elastoplastic material, was required for prediction of plastic strain behaviour. The delay in device realignment during heel strike, caused by inertia, substantially increased the force experienced during rim loading (e.g. 600 N static rigid, ∼1800 N dynamic elastoplastic, in one case). The accumulation of plastic strain is influenced by factors including cup orientation, swing phase force balance, the moving mass, and the design of the device itself. Evaluation of future liner designs could employ dynamic elastoplastic models to investigate the effect of design feature changes on bearing resilience under edge loading.

Selective Laser Melting of PA 2200 for Hip Implant Applications: Finite Element Analysis, Process Optimization, and Morphological and Mechanical Characterization

Polyamide 12 (PA 22000) is a well-known material and one of the most biocompatible materials tested and used to manufacture customized medical implants by selective laser sintering technology. To optimize the implants, several research activities were considered, starting with the design and manufacture of test samples made of PA 2200 by selective laser sintering (SLS) technology, with different processing parameters and part orientations. The obtained samples were subjected to compression tests and later to SEM analyses of the fractured zones, in which we determined the microstructural properties of the analyzed samples. Finally, an evaluation of the surface roughness of the material and the possibility of improving the surface roughness of the realized parts using finite element analysis to determine the optimum contact pressure between the component made of PA 2200 by SLS and the component made of TiAl6V4 by SLM was performed.

In vivo articular contact pattern of a total wrist arthroplasty design

Total wrist arthroplasty (TWA) designs suffer from relatively high complication rates when compared to other arthroplasties. Understanding the contact pattern of hip and knee replacement has improved their design and function; however, the in vivo contact pattern of TWA has not yet been examined and is thus the aim of this study. We hypothesized that the center of contact (CoC) is located at the geometric centers of the carpal component and radial component in the neutral posture and that the CoC moves along the principal arcs of curvature throughout primary anatomical motions. Wrist motion and implant kinematics of six patients with the Freedom® total wrist implant were studied during various tasks using biplanar videoradiography. The location of the CoC of the components was investigated by calculating distance fields between the articular surfaces. We found the CoC at the neutral posture was not at the geometric centers but was located 3.5 mm radially on the carpal component and 1.2 mm ulnarly on the radial component. From extension to flexion, the CoC moved 10.8 mm from dorsal to volar side on the carpal component (p < 0.0001) and 7.2 mm from volar to dorsal on the radial component (p = 0.0009). From radial to ulnar deviation, the CoC moved 12.4 mm from radial to ulnar on the carpal component (p < 0.0001), and 5.6 mm from ulnar to radial on the radial component (p = 0.009). The findings of this study may eventually improve TWA success by advancing future designs through a more accurate understating of their kinematic performance in vivo.

Influence of the Acetabular Cup Material on the Shell Deformation and Strain Distribution in the Adjacent Bone-A Finite Element Analysis

In total hip arthroplasty, excessive acetabular cup deformations and altered strain distribution in the adjacent bone are potential risk factors for implant loosening. Materials with reduced stiffness might alter the strain distribution less, whereas shell and liner deformations might increase. The purpose of our current computational study was to evaluate whether carbon fiber-reinforced poly-ether-ether-ketones with a Young´s modulus of 15 GPa (CFR-PEEK-15) and 23 GPa (CFR-PEEK-23) might be an alternative shell material compared to titanium in terms of shell and liner deformation, as well as strain distribution in the adjacent bone. Using a finite element analysis, the press-fit implantation of modular acetabular cups with shells made of titanium, CFR-PEEK-15 and CFR-PEEK-23 in a human hemi-pelvis model was simulated. Liners made of ceramic and polyethylene were simulated. Radial shell and liner deformations as well as strain distributions were analyzed. The shells made of CFR-PEEK-15 were deformed most (266.7 µm), followed by CFR-PEEK-23 (136.5 µm) and titanium (54.0 µm). Subsequently, the ceramic liners were radially deformed by up to 4.4 µm and the polyethylene liners up to 184.7 µm. The shell materials slightly influenced the strain distribution in the adjacent bone with CFR-PEEK, resulting in less strain in critical regions (<400 µm/m or >3000 µm/m) and more strain in bone building or sustaining regions (400 to 3000 µm/m), while the liner material only had a minor impact. The superior biomechanical properties of the acetabular shells made of CFR-PEEK could not be determined in our present study.

Finite element analysis of polyethylene wear in total hip replacement: A literature review

Evaluation and prediction of wear play a key role in product design and material selection of total hip replacements, because wear debris is one of the main causes of loosening and failure. Multifactorial clinical or laboratory studies are high cost and require unfeasible timeframes for implant development. Simulation using finite element methods is an efficient and inexpensive alternative to predict wear and pre-screen various parameters. This article presents a comprehensive literature review of the state-of-the-art finite element modelling techniques that have been applied to evaluate wear in polyethylene hip replacement components. A number of knowledge gaps are identified including the need to develop appropriate wear coefficients and the analysis of daily living activities.

Do component position and muscle strength affect the cup-head translation during gait after total hip arthroplasty?

INTRODUCTION

This study examined whether the component position or muscle strength affects the cup-head translation under in vivo weight-bearing conditions after total hip arthroplasty (THA). We hypothesized that there was a correlation between the hip offset or abductor strength and cup-head translation during gait.

MATERIALS AND METHODS

We prospectively evaluated 31 patients undergoing unilateral cementless primary THA. The cup height, cup/stem offset, and limb length discrepancy were measured on anterior-posterior bilateral hip radiographic images. The isometric muscle strength of the lower limbs was quantified using a handheld dynamometer. Continuous radiographic images were recorded during gait, and cup-head translation was analysed using a computer-assisted method.

RESULTS

The average cup height, cup/stem offset, and limb length discrepancy were - 3.8 ± 5.1 mm, 1.2 ± 5.2 mm/- 0.7 ± 7.7 mm, and - 2.1 ± 5.2 mm, respectively. The average hip abductor/flexor and knee extensor strength were 86% ± 18%/85% ± 17% and 88% ± 17% of the contralateral healthy hip, respectively. The average cup-head translation during swing phase of gait was - 0.003 ± 0.31 mm. Multiple regression analyses found no significant independent predictors of cup-head translation (p > 0.05).

CONCLUSIONS

The component position or muscle strength did not significantly influence cup-head translation during gait after well-positioned primary THA.

In vivo sliding distance on the metal-on-polyethylene total hip arthroplasty articulation using patient-specific gait analysis

Metal-on-polyethylene (MoP) is the most commonly used bearing surface in primary total hip arthroplasty (THA). Polyethylene wear debris remains a major concern. Studies investigating the wear performance based on patient-specific in vivo kinematics and component orientation remains largely lacking. The primary goal of this study was to identify patterns of the distribution of sliding distance and cross-shear ratio among THA patients. A validated approach combining dual fluoroscopic imaging system and computed-tomography was utilized to quantify in vivo gait kinematics and component orientations in 48 total hips. The distribution of accumulated sliding distance and cross-shear ratio over the polyethylene bearing surface was calculated and analyzed using principal component analysis (PCA). Strong patient-specific variation in sliding distance and cross-shear ratio was observed. PCA detected two principal components (PCs) of the sliding distance that together contribute to 94.8% of the total variation. PCA detected four PCs that together contribute to 86% of the total variation of the cross-shear ratio. Regression analysis identified a positive association between cross-shear magnitude and axial and frontal range of motion (RoM). Increased cup inclination, stem anteversion, and reduced cup anteversion may lead to superiorly distributed high cross-shear region, potentially accelerating wear. Our study investigated, in vivo sliding distance and cross-shear pattern using a comprehensive patient-specific dataset and detected several wear indicators under in vivo conditions. These findings provided useful reference values that may help to assess wear in MoP THA patients. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3151-3160, 2018.

A closed-form formulation for the conformal articulation of metal-on-polyethylene hip prostheses: Contact mechanics and sliding distance

Using Hertz contact law results in inaccurate outcomes when applied to the soft conformal hip implants. The finite element method also involves huge computational time and power. In addition, the sliding distance computed using the Euler rotation method does not incorporate tribology of bearing surfaces, contact mechanics and inertia forces. This study, therefore, aimed to develop a nonlinear dynamic model based on the multibody dynamic methodology to predict contact pressure and sliding distance of metal-on-polyethylene hip prosthesis, simultaneously, under normal walking condition. A closed-form formulation of the contact stresses distributed over the articulating surfaces was derived based upon the elastic foundation model, which reduced computational time and cost significantly. Three-dimensional physiological loading and motions, inertia forces due to hip motion and energy loss during contact were incorporated to obtain contact properties and sliding distance. Comparing the outcomes with that available in the literature and a finite element analysis allowed for the validation of our approach. Contours of contact stresses and accumulated sliding distances at different instants of the walking gait cycle were investigated and discussed. It was shown that the contact point at each instant was located within the zone with the corresponding highest accumulated sliding distance. In addition, the maximum contact pressure and area took place at the stance phase with a single support. The stress distribution onto the cup surface also conformed to the contact point trajectory and the physiological loading.

Biomechanical behavior of modular acetabular cups made of poly-ether-ether-ketone: A finite element study

After total hip arthroplasty, stress-shielding is a potential risk factor for aseptic loosening of acetabular cups made of metals. This might be avoided by the use of acetabular cups made of implant materials with lower stiffness. The purpose of this numerical study was to determine whether a modular acetabular cup with a shell made of poly-ether-ether-ketone or poly-ether-ether-ketone reinforced with carbon fibers might be an alternative to conventional metallic shells. Therefore, the press-fit implantation of modular cups with shells made of different materials (Ti6Al4V, poly-ether-ether-ketone, and poly-ether-ether-ketone reinforced with carbon fibers) and varying liner materials (ceramics and ultra-high-molecular-weight polyethylene) into an artificial bone cavity was simulated using finite element analysis. The shell material had a major impact on the radial shell deformation determined at the rim of the shell, ranging from 17.9 µm for titanium over 92.2 µm for poly-ether-ether-ketone reinforced with carbon fibers up to 475.9 µm for poly-ether-ether-ketone. Larger radial liner deformations (up to 618.4 µm) occurred in combination with the shells made of poly-ether-ether-ketone compared to titanium and poly-ether-ether-ketone reinforced with carbon fibers. Hence, it can be stated that conventional poly-ether-ether-ketone is not a suitable shell material for modular acetabular cups. However, the radial shell deformation can be reduced if the poly-ether-ether-ketone reinforced with carbon fiber material is used, while deformation of ceramic liners is similar to the deformation in combination with titanium shells.

A novel method to measure rim deformation in UHMWPE acetabular liners

Fluoroscopy studies of total hip replacement (THR) have shown that the femoral head and acetabular cup can separate in vivo, causing edge loading on the rim of the cup. Pre-clinical testing of THR involves ISO standard motion and loading parameters that are representative of a standard walking gait. However, a requirement for more robust testing of THR has been identified and protocols for edge loading in hip simulators have been developed. This technical note describes a method to measure rim wear and deformation on ultra-high molecular weight polyethylene acetabular liners using 2D contacting profilometry and Matlab^® analysis. The method is demonstrated on liners that have been subjected to edge loading in hip simulator tests and that have been retrieved at revision surgery. A quantitative and qualitative evaluation of the rim deformation was performed with good repeatability using the method.

Development of a Novel in Silico Model to Investigate the Influence of Radial Clearance on the Acetabular Cup Contact Pressure in Hip Implants

A hip joint replacement is considered one of the most successful orthopedic surgical procedures although it involves challenges that must be overcome. The patient group undergoing total hip arthroplasty now includes younger and more active patients who require a broad range of motion and a longer service lifetime of the implant. The current replacement joint results are not fully satisfactory for these patients' demands. As particle release is one of the main issues, pre-clinical experimental wear testing of total hip replacement components is an invaluable tool for evaluating new implant designs and materials. The aim of the study was to investigate the cup tensional state by varying the clearance between head and cup. For doing this we use a novel hard-on-soft finite element model with kinematic and dynamic conditions calculated from a musculoskeletal multibody model during the gait. Four different usual radial clearances were considered, ranging from 0 to 0.5 mm. The results showed that radial clearance plays a key role in acetabular cup stress-strain during the gait, showing from the 0 value to the highest, 0.5, a difference of 44% and 35% in terms of maximum pressure and deformation, respectively. Moreover, the presented model could be usefully exploited for complete elastohydrodynamic synovial lubrication modelling of the joint, with the aim of moving towards an increasingly realistic total hip arthroplasty in silico wear assessment accounting for differences in radial clearances.

Risk factors for increased sagittal pelvic motion causing unfavourable orientation of the acetabular component in patients undergoing total hip arthroplasty

Aims

It is important to consider sagittal pelvic rotation when introducing the acetabular component at total hip arthroplasty (THA). The purpose of this study was to identify patients who are at risk of unfavourable pelvic mobility, which could result in poor outcomes after THA.

Patients and Methods

A consecutive series of 4042 patients undergoing THA had lateral functional radiographs and a low-dose CT scan to measure supine pelvic tilt, pelvic incidence, standing pelvic tilt, flexed-seated pelvic tilt, standing lumbar lordotic angle, flexed-seated lumbar lordotic angle, and lumbar flexion. Changes in pelvic tilt from supine-to-standing positions and supine-to-flexed-seated positions were determined. A change in pelvic tilt of 13° between positions was deemed unfavourable as it alters functional anteversion by 10° and effectively places the acetabular component outside the safe zone of orientation.

Results

For both men and women, the degree of lumbar flexion was a significant predictor of risk in hip flexion (p < 0.0001) with increased odds of unfavourable pelvic mobility in those with lumbar flexion of < 20° (men, odds ratio (OR) 6.74, 95% confidence interval (CI) 3.83 to 11.89; women, OR 2.97, 95% CI 1.87 to 4.71). In women, age and standing pelvic tilt were significant predictors of risk in hip extension (p = 0.0082 and p < 0.0001, respectively). The risk of unfavourable pelvic mobility was higher in those aged > 75 years (OR 2.28, 95% CI 1.56 to 3.32) and those with standing pelvic tilt of < -10° for extension risk (OR 7.10, 95% CI 4.10 to 10.29). In men, only standing pelvic tilt was significant (p < 0.0001) for hip extension with an increased risk of unfavourable pelvic mobility (OR 8.68, 95% CI 5.19 to 14.51).

Conclusion

Patients found to have unfavourable pelvic mobility had limited lumbar flexion and more posterior standing pelvic tilt in both men and women, as well as increasing age in women. We recommend that patients undergo preoperative functional radiographic screening to determine specific parameters that can affect the functional orientation of the acetabular component. Cite this article: Bone Joint J 2018;100-B:845–52.

A computational parametric study on edge loading in ceramic-on-ceramic total hip joint replacements

Edge loading in ceramic-on-ceramic total hip joint replacement is an adverse condition that occurs as the result of a direct contact between the head and the cup rim. It has been associated with translational mismatch in the centres of rotation of the cup and head, and found to cause severe wear and early failure of the implants. Edge loading has been considered in particular in relation to dynamic separation of the cup and head centres during a gait cycle. Research has been carried out both experimentally and computationally to understand the mechanism including the influence of bearing component positioning on the occurrence and severity of edge loading. However, it is experimentally difficult to measure both the load magnitude and duration of edge loading as it occurs as a short impact within the tight space of hip joints. Computationally, a dynamic contact model, for example, developed using the MSC ADAMS software for a multi-body dynamics simulation can be particularly useful for calculating the loads and characterising the edge loading. The aim of the present study was to further develop the computational model, and improve the predictions of contact force and the understanding of mechanism in order to provide guidance on design and surgical factors to avoid or to reduce edge loading and wear. The results have shown that edge loading can be avoided for a low range of translational mismatch in the centres of rotation of the cup and head during gait at the level of approximately 1.0 mm for a cup at 45° inclination, keeping a correct cup inclination at 45° is important to reduce the edge loading severity, and edge loading can be avoided for a certain range of translational mismatch of the cup and head centres with an increased swing phase load.

The effect of seated pelvic tilt on posterior edge-loading in total hip arthroplasty: A finite element investigation

Edge-loading of a ceramic-on-ceramic total hip replacement can lead to reproducible squeaking and revision. A patient’s functional acetabular cup orientation, driven by their pelvic tilt, has been shown to be a significant factor in squeaking during hip flexion. The aim of this study was to investigate the effect of seated pelvic tilt on the contact mechanics at the ceramic bearing surface. A finite element model of a ceramic-on-ceramic total hip replacement was created. The cup was orientated at 40° inclination and 15° anteversion relative to the anterior pelvic plane. The stem was flexed 90° to replicate sitting in a chair. The model was loaded using data from in vivo measurements taken during a sit-to-stand activity. The pelvis was modelled in seven different sagittal positions, ranging from −30° to 30° of pelvic tilt, where a positive value denotes anterior pelvic tilt. Three different head sizes were investigated: 32, 36 and 40 mm. The maximum contact pressure and contact patch to rim distance were determined for each of the 21 simulations. Edge-loading (contact patch to rim distance < 0 mm) occurred with all head sizes when seated pelvic tilt was ≥10° and induced a large increase in contact pressure on the liner, with a maximum pressure exceeding 500 MPa. Edge-loading initiated at seated pelvic tilts of 7°, 9° and 5° for the 32, 36 and 40 mm heads, respectively. Patients with anterior pelvic tilts in the seated position are susceptible to posterior edge-loading. As the position of the pelvis when seated is patient specific, cup orientation should be adjusted on an individual basis to minimise edge-loading.

An in vitro simulation model to assess the severity of edge loading and wear, due to variations in component positioning in hip joint replacements

The aim of this study was to develop a preclinical in vitro method to predict the occurrence and severity of edge loading condition associated with the dynamic separation of the centres of the head and cup (in the absence of impingement) for variations in surgical positioning of the cup. Specifically, this study investigated the effect of both the variations in the medial–lateral translational mismatch between the centres of the femoral head and acetabular cup and the variations in the cup inclination angles on the occurrence and magnitude of the dynamic separation, the severity of edge loading, and the wear rate of ceramic‐on‐ceramic hip replacement bearings in a multi‐station hip joint simulator during a walking gait cycle. An increased mismatch between the centres of rotation of the femoral head and acetabular cup resulted in an increased level of dynamic separation and an increase in the severity of edge loading condition which led to increased wear rate in ceramic‐on‐ceramic bearings. Additionally for a given translational mismatch, an increase in the cup inclination angle gave rise to increased dynamic separation, worst edge loading conditions, and increased wear. To reduce the occurrence and severity of edge loading, the relative positions (the mismatch) of the centres of rotation of the head and the cup should be considered alongside the rotational position of the acetabular cup. This study has considered the combination of mechanical and tribological factors for the first time in the medial–lateral axis only, involving one rotational angle (inclination) and one translational mismatch. © 2017 The Authors Journal of Biomedical Materials Research Part B: Applied Biomaterials Published by Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1897–1906, 2018.

Effects of working gas pressure on zirconium dioxide thin film prepared by pulsed plasma deposition: roughness, wettability, friction and wear characteristics

In joint arthroplasty one of the main issues related to the failure of prosthetic implants is due to the wear of the ultra-high molecular weight polyethylene (UHMWPE) component. Surface treatments and coatings have been recognized as enhancing methods, able to improve the tribological properties of the implants. Therefore, the main objective of this work was to investigate the possibility to fabricate yttria-stabilized zirconia (YSZ) coatings on a metal (AISI 316-L) substrate by means of Pulsed Electron Deposition, in order to improve the tribological behavior of the polymer-metal coupling, by reducing the initial wear of the UHMWPE component. In order to optimize the coating characteristics, the effects of working gas pressure on both its morphological and tribological properties were analyzed. Morphological characterization of the films was evaluated by Atomic Force Microscopy (AFM). Coating wettability was also estimated by contact angle (CA) measurement. Tribological performance (coupling friction and wear of UHMWPE) was evaluated by using a ball-on-disc tribometer during highly-stressing tests in dry and lubricated (i.e. NaCl and serum) conditions; friction and wear were specifically evaluated at the initial sliding distances - to highlight the main effect of coating morphology - and after 100m - where the influence of the intrinsic materials properties prevails. AFM analysis highlighted that the working pressure heavily affected the morphological characteristics of the realized films. The wettability of the coating at the highest and lowest deposition pressures (CA ~ 60°, closed to substrate value) decreased for intermediate pressures, reaching a maximum CA of ~ 90°. Regarding tribological tests, a strong correlation was found in the initial steps between friction coefficient and wettability, which decreased as the distance increased. Concerning UHMWPE wear associated to coated counterpart, at 100m a reduction rate of about 7% in dry, 12% in NaCl and 5% in presence of serum was obtained compared to the uncoated counterpart. Differently from what highlighted for friction, no correlation was found between wear rate and morphological parameters. These findings, in agreement with literature, underlined the effect of the deposition pressure on the morphological properties, but suggested that physical characteristics are influenced too. Further research on the deposition process will be required in order to improve the tribological performance of the coating at long distances, addressing - above all - orthopedic applications.

Dynamic virtual simulation of the occurrence and severity of edge loading in hip replacements associated with variation in the rotational and translational surgical position

Variation in the surgical positioning of total hip replacement can result in edge loading of the femoral head on the rim of the acetabular cup. Previous work has reported the effect of edge loading on the wear of hip replacement bearings with a fixed level of dynamic biomechanical hip separation. Variations in both rotational and translational surgical positioning of the hip joint replacement combine to influence both the biomechanics and the tribology including the severity of edge loading, the amount of dynamic separation, the force acting on the rim of the cup and the resultant wear and torque acting on the cup. In this study, a virtual model of a hip joint simulator has been developed to predict the effect of variations in some surgical positioning (inclination and medial-lateral offset) on the level of dynamic separation and the contact force of the head acting on the rim as a measure of severity of edge loading. The level of dynamic separation and force acting on the rim increased with increased translational mismatch between the centres of the femoral head and the acetabular cup from 0 to 4 mm and with increased cup inclination angle from 45° to 65°. The virtual model closely replicated the dynamics of the experimental hip simulator previously reported, which showed similar dynamic biomechanical trends, with the highest level of separation being found with a mismatch of 4 mm between the centres of the femoral head and acetabular cup and 65° cup inclination angle.

Hip joint geometry effects on cartilage contact stresses during a gait cycle

The cartilage surface geometry of natural human hip joint is commonly regarded as sphere. It has been widely applied in computational simulation and hip joint prosthesis design. Some new geometry models have been developed and the sphere assumption has been questioned recently. The objective of this study was to analyze joint geometry effects on cartilage contact stress distribution and investigate contact patterns during a whole gait cycle. Hip surface was reconstructed from CT data of a healthy volunteer. Three finite element (FE) models of hip joint were developed from different cartilage geometries: natural geometry, sphere and rotational ellipsoid. Loads at ten instants of gait cycle were applied to these models based on published in-vivo data. FE predictions of peak contact pressure during gait of natural hip were compared with sphere and rotational ellipsoid replaced hip joint. Contact occurs mainly in upper anterior region of both acetabulum and femur distributing along sagittal plane of human body. It moves towards inferolateral aspect as the resultant joint reaction force changes during walking for natural hip. Peak pressures at the instant with maximum contact force were 7.48 MPa, 14.97 MPa and 13.12 MPa for models with natural hip surface, sphere replaced and rotational ellipsoid replaced surface respectively. During the whole gait cycle, contact pressure of natural hip ranked lowest in most of the instants, followed by rotational ellipsoid replaced and sphere replaced hip. The results indicate that rotational ellipsoid is more consistent with natural hip cartilage geometry than sphere during normal walking. This means rotational ellipsoid prosthesis could give a better description of physiological structure compared with standard sphere prosthesis. Therefore, rotational ellipsoid would be a better choice for prosthesis design.

Tribological characterization of zirconia coatings deposited on Ti6Al4V components for orthopedic applications

One of the most important issues leading to the failure of total joint arthroplasty is related to the wear of the plastic components, which are generally made of ultra high molecular weight polyethylene (UHMWPE). Therefore, the reduction of joint wear represents one of the main challenges the research in orthopedics is called to address nowadays. Surface treatments and coatings have been recognized as innovative methods to improve tribological properties, also in the orthopedic field. This work investigated the possibility to realize hard ceramic coatings on the metal component of a prosthesis, by means of Pulsed Plasma Deposition, in order to reduce friction and wear in the standard coupling against UHMWPE. Ti6Al4V substrates were coated with a 2 μm thick yttria-stabilized zirconia (YSZ) layer. The mechanical properties of the YSZ coatings were assessed by nanoindentation tests performed on flat Ti6Al4V substrates. Tribological performance was evaluated using a ball-on-disk tribometer in dry and lubricated (i.e. with fetal bovine serum) highly-stressing conditions, up to an overall distance of 10 km. Tribology was characterized in terms of coefficient of friction (CoF) and wear rate of the UHMWPE disk. After testing, specimens were analyzed through optical microscopy and SEM images, in order to check the wear degradation mechanisms. Progressive loading scratch tests were also performed in dry and wet conditions to determine the effects of the environment on the adhesion of the coating. Our results supported the beneficial effect of YSZ coating on metal components. In particular, the proposed solution significantly reduced UHMWPE wear rate and friction. At 10 km of sliding distance, a wear rate reduction of about 18% in dry configuration and of 4% in presence of serum, was obtained by the coated group compared to the uncoated group. As far as friction in dry condition is concerned, the coating allowed to maintain low CoF values until the end of the tests, with an overall difference of about 40% compared to the uncoated balls. In wet conditions, the friction values were found to be comparable between coated and uncoated materials, mainly due to a premature delamination of the coating. Scratch tests in wet showed in fact a reduction of the critical load required to a complete delamination due to a formation of blister, although no change or damage occurred at the coating during the soaking period. Although conditions of high values of contact pressure were considered, further analyses are however required to fully understand the behavior of YSZ coatings in wet environment and additional research on the deposition process will be mandatory in order to improve the coating tribological performance at long distances addressing orthopedic applications.

Patient-specific hip geometry has greater effect on THA wear than femoral head size

In vivo linear penetration in total hip arthroplasty (THA) exhibits similar values for 28mm and 32mm femoral head diameter with considerable variations between and within the studies. It indicates factors other than femoral head diameter influence polyethylene wear. This study is intended to test the effect of patient׳s individual geometry of musculoskeletal system, acetabular cup orientation, and radius of femoral head on wear. Variation in patient׳s musculoskeletal geometry and acetabular cup placement is evaluated in two groups of patients implanted with 28mm and 32mm THA heads. Linear wear rate estimated by mathematical model is 0.165-0.185mm/year and 0.157-0.205mm/year for 28 and 32mm THA heads, respectively. Simulations show little influence femoral head size has on the estimated annual wear rate. Predicted annual linear wear depends mostly on the abduction angle of the acetabular cup and individual geometry of the musculoskeletal system of the hip, with the latter having the greatest affect on variation in linear wear rate.

An Analytical Calculation of Frictional and Bending Moments at the Head-Neck Interface of Hip Joint Implants during Different Physiological Activities

This study predicts the frictional moments at the head-cup interface and frictional torques and bending moments acting on the head-neck interface of a modular total hip replacement across a range of activities of daily living. The predicted moment and torque profiles are based on the kinematics of four patients and the implant characteristics of a metal-on-metal implant. Depending on the body weight and type of activity, the moments and torques had significant variations in both magnitude and direction over the activity cycles. For the nine investigated activities, the maximum magnitude of the frictional moment ranged from 2.6 to 7.1 Nm. The maximum magnitude of the torque acting on the head-neck interface ranged from 2.3 to 5.7 Nm. The bending moment acting on the head-neck interface varied from 7 to 21.6 Nm. One-leg-standing had the widest range of frictional torque on the head-neck interface (11 Nm) while normal walking had the smallest range (6.1 Nm). The widest range, together with the maximum magnitude of torque, bending moment, and frictional moment, occurred during one-leg-standing of the lightest patient. Most of the simulated activities resulted in frictional torques that were near the previously reported oxide layer depassivation threshold torque. The predicted bending moments were also found at a level believed to contribute to the oxide layer depassivation. The calculated magnitudes and directions of the moments, applied directly to the head-neck taper junction, provide realistic mechanical loading data for in vitro and computational studies on the mechanical behaviour and multi-axial fretting at the head-neck interface.

The study of wear behaviors on abducted hip joint prostheses by an alternate finite element approach

An acetabular cup with larger abduction angles is able to affect the normal function of the cup seriously that may cause early failure of the total hip replacement (THR). Complexity of the finite element (FE) simulation in the wear analysis of the THR is usually concerned with the contact status, the computational effort, and the possible divergence of results, which become more difficult on THRs with larger cup abduction angles. In the study, we propose a FE approach with contact transformation that offers less computational effort. Related procedures, such as Lagrangian Multiplier, partitioned matrix inversion, detection of contact forces, continuity of contact surface, nodal area estimation, etc. are explained in this report. Through the transformed methodology, the computer round-off error is tremendously reduced and the embedded repetitive procedure can be processed precisely and quickly. Here, wear behaviors of THR with various abduction angles are investigated. The most commonly used combination, i.e., metal-on-polyethylene, is adopted in the current study where a cobalt-chromium femoral head is paired with an Ultra High Molecular Weight Polyethylene (UHMWPE) cup. In all illustrations, wear coefficients are estimated by self-averaging strategy with available experimental datum reported elsewhere. The results reveal that the THR with larger abduction angles may produce deeper depth of wear but the volume of wear presents an opposite tendency; these results are comparable with clinical and experimental reports. The current approach can be widely applied easily to fields such as the study of the wear behaviors on ante-version, impingement, and time-dependent behaviors of prostheses etc.

Functional orientation of the acetabular component in ceramic-on-ceramic total hip arthroplasty and its relevance to squeaking

Aims

Long-term clinical outcomes for ceramic-on-ceramic (CoC) bearings are encouraging. However, there is a risk of squeaking. Guidelines for the orientation of the acetabular component are defined from static imaging, but the position of the pelvis and thus the acetabular component during activities associated with edge-loading are likely to be very different from those measured when the patient is supine. We assessed the functional orientation of the acetabular component.

Patients and Methods

A total of 18 patients with reproducible squeaking in their CoC hips during deep flexion were investigated with a control group of 36 non-squeaking CoC hips. The two groups were matched for the type of implant, the orientation of the acetabular component when supine, the size of the femoral head, ligament laxity, maximum hip flexion and body mass index.

Results

The mean functional anteversion of the acetabular component at the point when patients initiated rising from a seated position was significantly less in the squeaking group than in the control group, 8.1° (-10.5° to 36.0°) and 21.1° (-1.9° to 38.4°) respectively (p = 0.002).

Conclusion

The functional orientation of the acetabular component during activities associated with posterior edge-loading are different from those measured when supine due to patient-specific pelvic kinematics. Individuals with a large anterior pelvic tilt during deep flexion might be more susceptible to posterior edge-loading and squeaking as a consequence of a significant decrease in the functional anteversion of the acetabular component. Cite this article: Bone Joint J 2016;98-B:910–16.

Wear simulation strategies for reverse shoulder arthroplasty implants

Reverse total shoulder arthroplasty is a clinically accepted surgical procedure; however, its long-term wear performance is not known. The purpose of this work is to review wear simulator testing of reverse total shoulder arthroplasty, to develop a wear simulator protocol for reverse total shoulder arthroplasty, and to test it by performing a pilot study. The review of wear simulator testing in the literature revealed considerable variation in protocols. A combination of our own cadaveric testing and those of other research groups helped in determining the magnitude and direction of joint loading for the development of the present protocol. A MATCO orbital-bearing simulator was adapted using custom fixtures to simulate a circumduction motion of the shoulder under mildly adverse conditions, and a pilot study gave wear rates within the wide range found in the literature. Arguments were presented in support of the currently developed protocol, but it was also suggested that, rather than rely on one protocol, a series of simulator wear protocols should be developed to fully test the implant wear performance in reverse total shoulder arthroplasty.

Contact mechanics of reverse total shoulder arthroplasty during abduction: the effect of neck-shaft angle, humeral cup depth, and glenosphere diameter

BACKGROUND

Implant design parameters can be changed during reverse shoulder arthroplasty (RSA) to improve range of motion and stability; however, little is known regarding their impact on articular contact mechanics. The purpose of this finite element study was to investigate RSA contact mechanics during abduction for different neck-shaft angles, glenosphere sizes, and polyethylene cup depths.

METHODS

Finite element RSA models with varying neck-shaft angles (155°, 145°, 135°), sizes (38 mm, 42 mm), and cup depths (deep, normal, shallow) were loaded with 400 N at physiological abduction angles. The contact area and maximum contact stress were computed.

RESULTS

The contact patch and the location of maximum contact stress were typically located inferomedially in the polyethylene cup. On average for all abduction angles investigated, reducing the neck-shaft angle reduced the contact area by 29% for 155° to 145° and by 59% for 155° to 135° and increased maximum contact stress by 71% for 155° to 145° and by 286% for 155° to 135°. Increasing the glenosphere size increased the contact area by 12% but only decreased maximum contact stress by 2%. Decreasing the cup depth reduced the contact area by 40% and increased maximum contact stress by 81%, whereas increasing the depth produced the opposite effect (+52% and -36%, respectively).

DISCUSSION

The location of the contact patch and maximum contact stress in this study matches the area of damage seen frequently on clinical retrievals. This finding suggests that damage to the inferior cup due to notching may be potentiated by contact stresses. Increasing the glenosphere diameter improved the joint contact area and did not affect maximum contact stress. However, although reducing the neck-shaft angle and cup depth can improve range of motion, our study shows that this also has some negative effects on RSA contact mechanics, particularly when combined.

The effect of cup outer sizes on the contact mechanics and cement fixation of cemented total hip replacements

One important loosening mechanism of the cemented total hip arthroplasty is the mechanical overload at the bone-cement interface and consequent failure of the cement fixation. Clinical studies have revealed that the outer diameter of the acetabular component is a key factor in influencing aseptic loosening of the hip arthroplasty. The aim of the present study was to investigate the influence of the cup outer diameter on the contact mechanics and cement fixation of a cemented total hip replacement (THR) with different wear penetration depths and under different cup inclination angles using finite element (FE) method. A three-dimensional FE model was developed based on a typical Charnley hip prosthesis. Two acetabular cup designs with outer diameters of 40 and 43 mm were modelled and the effect of cup outer diameter, penetration depth and cup inclination angle on the contact mechanics and cement fixation stresses in the cemented THR were studied. The results showed that for all penetration depths and cup inclination angles considered, the contact mechanics in terms of peak von Mises stress in the acetabular cup and peak contact pressure at the bearing surface for the two cup designs were similar (within 5%). However, the peak von Mises stress, the peak maximum principal stress and peak shear stress in the cement mantle at the bone-cement interface for the 43 mm diameter cup design were predicted to be lower compared to those for the 40 mm diameter cup design. The differences were predicted to be 15-19%, 15-22% and 18-20% respectively for different cup penetration depths and inclination angles, which compares to the clinical difference of aseptic loosening incidence of about 20% between the two cup designs.

Finite element analysis of sliding distance and contact mechanics of hip implant under dynamic walking conditions

An explicit finite element method was developed to predict the dynamic behavior of the contact mechanics for a hip implant under normal walking conditions. Two key parameters of mesh sensitivity and time steps were examined to balance the accuracy and computational cost. Both the maximum contact pressure and accumulated sliding distance showed good agreement with those in the previous studies using the implicit finite element analysis and analytical methods. Therefore, the explicit finite element method could be used to predict the contact pressure and accumulated sliding distance for an artificial hip joint simultaneously in dynamic manner.