Wear simulation of total knee prostheses using load and kinematics waveforms from stair climbing

Comparison of the Kinematics and Laxity of Total Knee Arthroplasty Bearing Designs Stabilized With Specimen-Specific Virtual Ligaments on a Joint Motion Simulator

A variety of total knee arthroplasty (TKA) designs offer increased congruency bearing options, primarily to compensate for a loss of posterior cruciate ligament (PCL) function. However, their efficacy in providing sufficient stability under different circumstances requires further investigation. The preclinical testing of prosthesis components on joint motion simulators is useful for quantifying how design changes affect joint stability. However, this type of testing may not be clinically relevant because surrounding ligaments are either ignored or greatly simplified. This study aimed to assess the kinematics and stability of TKA joints during various motions using condylar-stabilized (CS) bearings without a PCL versus cruciate-retaining (CR) bearings with an intact PCL. TKA prosthetic components were tested on a joint motion simulator while being stabilized with five different sets of specimen-specific virtual ligament envelopes. In comparison to CR knees, CS knees without a PCL exhibited a greater amount of posterior tibial displacement laxity, with a mean increase of 2.7±2.1 mm (p = 0.03). Additionally, significant differences were observed in the anterior-posterior kinematics of the knee joint during activities of daily living (ADL) between the two designs. These results were consistent with previous cadaveric investigations, which indicated that CS knees without a PCL are less resistant to posterior tibial displacement than CR knees with one. This study employing virtual ligaments confirms previous findings that the raised anterior lip of some CS bearings may not completely compensate for the absence of the PCL; however, as both studies used reduced joint contact forces, the contributions of this design feature may be attenuated.

The influence of implant design and limb alignment on in vivo wear rates of fixed-bearing and rotating-platform knee implant retrievals

Analysis of polyethylene (PE) wear in knee implants is crucial for understanding the factors leading to revision in total knee arthroplasty. Importantly, current experimental and computational methods for predicting insert wear can only be validated against true in vivo measurements from retrievals. This study quantitatively investigated in vivo PE wear rates in fixed-bearing (FB) (n = 21) and rotating-platform (n = 53) implant retrievals. 3D surface geometry of the retrievals was measured using a structured light scanner. Then, a reference surface that included the deformation, but not the wear that the retrievals had experienced in vivo, was constructed using a fully automatic surface reconstruction algorithm. Finally, wear volume was calculated from the deviation between the worn and reconstructed surfaces. The measurement and analysis techniques were validated and the algorithm was found to produce errors of only 0.2% relative to the component volumes. In addition to quantifying cohort-level wear rates, the effect of mechanical axis limb alignment on mediolateral wear distribution was examined for a subset of the retrievals (n = 14 + 26). Our results show that FB implants produce significantly (p = 0.04) higher topside wear rates (24.6 ± 10.1 mm3/year) than rotating-platform implants (15.3 ± 8.0 mm3/year). This effect was larger than that of limb alignment, which had a smaller and nonsignificant influence on overall wear rates (+4.5 ± 11.6 mm3/year, p = 0.43). However, increased varus alignment was associated significantly with greater medial compartment wear in both the FB and rotating-platform designs (+1.7 ± 1.3%/° and +1.8 ± 1.6%/°). Our findings emphasize the importance of implant design and limb alignment on wear outcomes, providing reference data for improving implant performance and longevity.

Development of Multibundle Virtual Ligaments to Simulate Knee Mechanics After Total Knee Arthroplasty

Preclinical evaluation of total knee arthroplasty (TKA) components is essential to understanding their mechanical behavior and developing strategies for improving joint stability. While preclinical testing of TKA components has been useful in quantifying their effectiveness, such testing can be criticized for lacking clinical relevance, as the important contributions of surrounding soft tissues are either neglected or greatly simplified. The purpose of our study was to develop and determine if subject-specific virtual ligaments reproduce a similar behavior as native ligaments surrounding TKA joints. Six TKA knees were mounted to a motion simulator. Each was subjected to tests of anterior-posterior (AP), internal-external (IE), and varus-valgus (VV) laxity. The forces transmitted through major ligaments were measured using a sequential resection technique. By tuning the measured ligament forces and elongations to a generic nonlinear elastic ligament model, virtual ligaments were designed and used to simulate the soft tissue envelope around isolated TKA components. The average root-mean-square error (RMSE) between the laxity results of TKA joints with native versus virtual ligaments was 3.5 ± 1.8 mm during AP translation, 7.5 ± 4.2 deg during IE rotations, and 2.0 ± 1.2 deg during VV rotations. Interclass correlation coefficients (ICCs) indicated a good level of reliability for AP and IE laxity (0.85 and 0.84). To conclude, the advancement of virtual ligament envelopes as a more realistic representation of soft tissue constraint around TKA joints is a valuable approach for obtaining clinically relevant kinematics when testing TKA components on joint motion simulators.

Preliminary In Vitro Wear Assessment of Ceramic Cemented Femoral Components Coupled with Polyethylene Menisci

Success of total knee replacement (TKR) depends on the prosthetic design and materials. The use of metal components is well established with the disadvantage of allergic reactions. Ceramics have been recently proposed because of high wear resistance, excellent biocompatibility, wettability, and suitable mechanical properties. This study was aimed at investigating in vitro wear resistance of Zirconia Toughened Alumina (ZTA)/Ultra-high-molecular-weight polyethylene (UHMWPE) of TKR femoral components. An in vitro protocol was designed with the application of relevant load profile, 6-degrees-of-freedom knee simulator, and 8 × 10⁵ cycles on the ZTA/UHMWPE configuration under bovine calf serum. Before and after wear test, the femoral components were investigated by using the Scanning Electron Microscope (SEM) and the X-Ray Diffraction (XRD) analyses, and stylus surface roughness measurements. The proposed pre-clinical test yielded repeatable results. In particular, gravimetric results showed that, after 8 × 10⁵ cycles, the mean weight loss of the polyethylene mobile components is 5.3 ± 1.1 mg. The surface roughness measurements (Ra_max) performed after the wear test showed no significant variation on the UHMWPE menisci. A slight increase of roughness has been found on the ZTA (0.02 µm before wear test, 0.28 µm after the test). SEM observations did not show significant modification of the surface morphology. Tetragonal to monoclinic phase ratio was measured by XRD before and after wear test to evaluate stability of tetragonal ZrO₂ phase. Minimal conversion of tetragonal to monoclinic phase was found from 5.4 to 8%. Although this study is a preliminary evaluation limited to in vitro tests, it provides novel pre-clinical indications about the potential of ceramic TKR femoral components.

Graphene Oxide-Doped Gellan Gum-PEGDA Bilayered Hydrogel Mimicking the Mechanical and Lubrication Properties of Articular Cartilage

Articular cartilage (AC) is a specialized connective tissue able to provide a low-friction gliding surface supporting shock-absorption, reducing stresses, and guaranteeing wear-resistance thanks to its structure and mechanical and lubrication properties. Being an avascular tissue, AC has a limited ability to heal defects. Nowadays, conventional strategies show several limitations, which results in ineffective restoration of chondral defects. Several tissue engineering approaches have been proposed to restore the AC's native properties without reproducing its mechanical and lubrication properties yet. This work reports the fabrication of a bilayered structure made of gellan gum (GG) and poly (ethylene glycol) diacrylate (PEGDA), able to mimic the mechanical and lubrication features of both AC superficial and deep zones. Through appropriate combinations of GG and PEGDA, cartilage Young's modulus is effectively mimicked for both zones. Graphene oxide is used as a dopant agent for the superficial hydrogel layer, demonstrating a lower friction than the nondoped counterpart. The bilayered hydrogel's antiwear properties are confirmed by using a knee simulator, following ISO 14243. Finally, in vitro tests with human chondrocytes confirm the absence of cytotoxicity effects. The results shown in this paper open the way to a multilayered synthetic injectable or surgically implantable filler for restoring AC defects.

In vivo kinematical validated knee model for preclinical testing of total knee replacement

BACKGROUND AND OBJECTIVE

A computational knee model facilitates efficient component design evaluations and preclinical testing under various dynamic loadings. However, the development of a highly mimicked dynamic whole knee model with specified ligament constraints that provides high predictive accuracy with in-vivo experiments remains a challenge.

METHODS

In the present study, a musculoskeletal integrated force-driven explicit finite-element knee model with tibiofemoral and patellofemoral joints constrained with detailed soft tissue was developed. A proportional-integral-derivative controller was concurrently added to the knee model to track the boundary conditions. The actuations of the quadriceps and hamstrings were predicted via a subject-specific musculoskeletal model and matched with electromyography results.

RESULTS

Compared to in-vivo fluoroscopic results in a gait cycle, the predicted results of the kinematics of the tibiofemoral joint exhibited an agreement in terms of tendency and magnitude (anterior-posterior translation: RMSE = 1.1 mm, r² = 0.87; inferior-superior translation: RMSE = 0.83 mm, r² = 0.84; medial-lateral translation: RMSE = 0.82 mm, r² = 0.05; flexion-extension rotation: RMSE = 0.23°, r² = 1; internal-external rotation: RMSE = 1.85°, r² = 0.65; varus-valgus rotation: RMSE = 1.39°, r² = 0.08). Contact mechanics, including the contact area, pressure, and stress, were synchronously simulated on the tibiofemoral and patellofemoral joints.

CONCLUSIONS

The study provides a calibrated knee model and a kinematical validation approach that can be widely used in preclinical testing and knee prosthesis design.

Wear Behavior Characterization of Hydrogels Constructs for Cartilage Tissue Replacement

This paper aims to characterize the wear behavior of hydrogel constructs designed for human articular cartilage replacement. To this purpose, poly (ethylene glycol) diacrylate (PEGDA) 10% w/v and gellan gum (GG) 1.5% w/v were used to reproduce the superior (SUP) cartilage layer and PEGDA 15% w/v and GG 1.5% w/v were used to reproduce the deep (DEEP) cartilage layer, with or without graphene oxide (GO). These materials (SUP and DEEP) were analyzed alone and in combination to mimic the zonal architecture of human articular cartilage. The developed constructs were tested using a four-station displacement control knee joint simulator under bovine calf serum. Roughness and micro-computer tomography (µ-CT) measurements evidenced that the hydrogels with 10% w/v of PEGDA showed a worse behavior both in terms of roughness increase and loss of uniformly distributed density than 15% w/v of PEGDA. The simultaneous presence of GO and 15% w/v PEGDA contributed to keeping the hydrogel construct's characteristics. The Raman spectra of the control samples showed the presence of unreacted C=C bonds in all the hydrogels. The degree of crosslinking increased along the series SUP < DEEP + SUP < DEEP without GO. The Raman spectra of the tested hydrogels showed the loss of diacrylate groups in all the samples, due to the washout of unreacted PEGDA in bovine calf serum aqueous environment. The loss decreased along the series SUP > DEEP + SUP > DEEP, further confirming that the degree of photo-crosslinking of the starting materials plays a key role in determining their wear behavior. μ-CT and Raman spectroscopy proved to be suitable techniques to characterize the structure and composition of hydrogels.

Wear characterization and contact surfaces analysis of menisci and femoral retrieved components in bi-condylar knee prostheses

PURPOSE

Although total knee arthroplasty is a well-practiced surgical procedure, material properties and surface topography can contribute to the wear mechanisms and the implant failure. It has been advised that an increased femoral component's surface roughness of total knee prostheses may be a contributing factor to accelerated wear of the polyethylene menisci and eventually prosthesis failure. The aim of this study is to investigate the wear phenomena occurring on medial and lateral compartments of retrieved total knee arthroplasty in order to correlate the surface roughness vs. BMI, age at revision, and time in situ.

METHODS

Qualitative visual analyses were performed on all the retrieved knee components to assess the damage due to the wear phenomena. Quantitative analysis includes surface characterization performed using optical apparatus to describe surface roughness and morphology on the retrieved femoral, tibial and polyethylene component. The Mann-Whitney statistical test was performed to correlate the medial vs. lateral condyle surface roughness of all explants with BMI, age at revision, and time in situ.

RESULTS

Visual and topographical analysis showed damage along the entire zone of the sliding contact area. A statistical difference between medial and lateral condyle roughness was found on four prosthesis. No statistical significance was found between surface roughness measurements and patient BMI, age at revision, and time in situ. On the femoral components various scratches were observed in the anterior/posterior (AP) direction of all the fixed femoral components. A statistically significant difference between medial and lateral condyle was found on two mobile knee design (p = 0.03) and on two fixed design (p = 0.01). The results were discussed in the framework of the usual TKR loading conditions during the gait, and of knowledge on the bio-tribological behavior of the prosthetic joint.

CONCLUSIONS

The visual and topographical analysis showed consistent damage patterns with respect to the main movements to which the prosthetic components are subjected and no statistical significance was found between surface roughness measurements and patient BMI, age at revision, and time in situ.

A Perspective on Biotribology in Arthroplasty: From In Vitro toward the Accurate In Silico Wear Prediction

Nowadays hip arthroplasty is recognized as one of the most successful orthopedic surgical procedures, even if it involves challenges to overcome, such that lately, younger and more active patients are in need of total arthroplasty. Wear is still one of the main issues affecting joint prostheses endurance, and often causes loosening accompanied by implant failures. Actual in vitro wear tests executed by mechanical simulators have a long duration, are very expensive, and do not take into account all the possible daily activities of the patients; thus, the challenge to obtain a complete in silico tribological and dynamical model of (bio) tribo-systems could give the possibility to overcome the actual testing procedures and could contribute as a tool for a more accurate tribological design of human prostheses. This prospective paper is intended to underline actual research trends toward the challenge of having accurate numerical algorithms to be used both in preclinical testing and in the optimizations of the prostheses design. With this aim we depicted the possible in silico approach in artificial joints’ wear assessment over time, accounting for contact mechanics, numerical stress–strain analysis, musculoskeletal multibody, and synovial lubrication modelling (boundary/mixed, hydrodynamic, and elastohydrodynamic).

Wear Simulation of Ceramic-on-Crosslinked Polyethylene Hip Prostheses: A New Non-Oxide Silicon Nitride versus the Gold Standard Composite Oxide Ceramic Femoral Heads

The purpose of the present study was to compare the wear behavior of ceramic-on-vitamin-E-diffused crosslinked polyethylene (Vit-E XLPE) hip bearings employing the gold standard oxide ceramic, zirconia (ZrO₂)-toughened alumina (Al₂O₃) (ZTA, BIOLOX^®delta) and a new non-oxide ceramic, silicon nitride (Si₃N₄, MC^2®). In vitro wear test was performed using a 12-station hip joint simulator. The test was carried out by applying the kinematic inputs and outputs as recommended by ISO 14242-1:2012. Vitamin-E-diffused crosslinked polyethylene (Vit-E XLPE) acetabular liners (E1^®) were coupled with Ø28-mm ZTA and Si₃N₄ femoral heads. XLPE liner weight loss over 5 million cycles (Mc) of testing was compared between the two different bearing couples. Surface topography, phase contents, and residual stresses were analyzed by contact profilometer and Raman microspectroscopy. Vit-E XLPE liners coupled with Si₃N₄ heads produced slightly lower wear rates than identical liners with ZTA heads. The mean wear rates (corrected for fluid absorption) of liners coupled with ZTA and Si₃N₄ heads were 0.53 ± 0.24 and 0.49 ± 0.23 mg/Mc after 5 Mc of simulated gait, respectively. However, after wear testing, the ZTA heads retained a smoother topography and showed fewer surface stresses than the Si₃N₄ ones. Note that no statistically significant differences were found in the above comparisons. This study suggests that the tribochemically formed soft silica layer on the Si₃N₄ heads may have reduced friction and slightly lowered the wear of the Vit-E XLPE liners. Considering also that the toughness of Si₃N₄ is superior to ZTA, the present wear data represent positive news in the future development of long-lasting hip components.

Knee Wear Assessment: 3D Scanners Used as a Consolidated Procedure

It is well known that wear occurring in polyethylene menisci is a significant clinical problem. At this regard, wear tests on biomaterials medical devices are performed in order to assess their pre-clinical performance in terms of wear, durability, resistance to fatigue, etc. The objective of this study was to assess the wear of mobile total knee polyethylene inserts after an in vitro wear test. In particular, the wear behavior of mobile bearing polyethylene knee configurations was investigated using a knee joint wear simulator. After the completion of the wear test, the polyethylene mobile menisci were analyzed through a consolidated procedure by using 3D optical scanners, in order to evaluate the 3D wear distribution on the prosthesis surface, wear depths, wear rates, amount of material loss and contact areas. The results in terms of wear rates and wear volumes were compared with results of gravimetric tests, finding equivalent achievements.

The choice of the femoral center of rotation affects material loss in total knee replacement wear testing - A parametric finite element study of ISO 14243-3

A leading cause of long-term failure of total knee replacements (TKRs) is osteolysis caused by polyethylene wear particles. The current gold standard for preclinical wear testing of TKRs is mechanical knee simulators. The definition of the femoral center of flexion-extension rotation (CoR) has been identified as one possible source of variability within TKR wear tests, since the femoral curvature varies from distal to posterior. The magnitude of the influence on wear due to changes in location of femoral CoR has not been investigated in depth. During this study, a computational framework utilizing finite element analysis for modelling wear of TKRs was developed and used to investigate the influence of the location of femoral CoR on TKR polyethylene wear during standardized displacement controlled testing (ISO 14243-3:2014). The study was carried out using a 40-point Latin Hypercube Design of Experiments approach. Volumetric wear was highly correlated to femoral CoR in both the superior/inferior and anterior/posterior directions, with a stronger relationship in the superior/inferior direction. In addition, wear scars showing linear penetration were examined, with large differences in simulations at the extreme ends of the sampling region. In this study, it was found that variations in the location of the femoral center of rotation can represent a large source of variability in the preclinical testing and evaluation of the wear performance of total knee replacements. This study represents the first attempt at quantifying the effect on wear of different femoral center of rotations across a large sampling space.

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.

In vivo kinematics of knee replacement during daily living activities: Condylar and post-cam contact assessment by three-dimensional fluoroscopy and finite element analyses

In total knee replacement, the investigation on the exact contact patterns at the post-cam in implanted patients from real in vivo data during daily living activities is fundamental for validating implant design concepts and assessing relevant performances. This study is aimed at verifying the restoration of natural tibio-femoral condylar kinematics by investigating the post-cam engagement at different motor tasks. An innovative validated technique, combining three-dimensional fluoroscopic and finite element analyses, was applied to measure joint kinematics during daily living activities in 15 patients implanted with guided motion posterior-stabilized total knee replacement. Motion results showed physiological antero-posterior translations of the tibio-femoral condyles for every motor task. However, high variability was observed in the position of the calculated pivot point among different patients and different motor tasks, as well as in the range of post-cam engagement. Physiological tibio-femoral joint rotations and contacts at the condyles were found restored in the present knee replacement. Articular contact patterns experienced at the post-cam were found compatible with this original prosthesis design. The present study reports replaced knee kinematics also in terms of articular surface contacts, both at the condyles and, for the first time, at the post-cam. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1396-1403, 2017.

Quantification of Wear and Deformation in Different Configurations of Polyethylene Acetabular Cups Using Micro X-ray Computed Tomography

Wear is currently quantified as mass loss of the bearing materials measured using gravimetric methods. However, this method does not provide other information, such as volumetric loss or surface deviation. In this work, we validated a technique to quantify polyethylene wear in three different batches of ultrahigh-molecular-polyethylene acetabular cups used for hip implants using nondestructive microcomputed tomography. Three different configurations of polyethylene acetabular cups, previously tested under the ISO 14242 parameters, were tested on a hip simulator for an additional 2 million cycles using a modified ISO 14242 load waveform. In this context, a new approach was proposed in order to simulate, on a hip joint simulator, high-demand activities. In addition, the effects of these activities were analyzed in terms of wear and deformations of those polyethylenes by means of gravimetric method and micro X-ray computed tomography. In particular, while the gravimetric method was used for weight loss assessment, microcomputed tomography allowed for acquisition of additional quantitative information about the evolution of local wear and deformation through three-dimensional surface deviation maps for the entire cups’ surface. Experimental results showed that the wear and deformation behavior of these materials change according to different mechanical simulations.

The Influence of Component Alignment and Ligament Properties on Tibiofemoral Contact Forces in Total Knee Replacement

The study objective was to investigate the influence of coronal plane alignment and ligament properties on total knee replacement (TKR) contact loads during walking. We created a subject-specific knee model of an 83-year-old male who had an instrumented TKR. The knee model was incorporated into a lower extremity musculoskeletal model and included deformable contact, ligamentous structures, and six degrees-of-freedom (DOF) tibiofemoral and patellofemoral joints. A novel numerical optimization technique was used to simultaneously predict muscle forces, secondary knee kinematics, ligament forces, and joint contact pressures from standard gait analysis data collected on the subject. The nominal knee model predictions of medial, lateral, and total contact forces during gait agreed well with TKR measures, with root-mean-square (rms) errors of 0.23, 0.22, and 0.33 body weight (BW), respectively. Coronal plane component alignment did not affect total knee contact loads, but did alter the medial-lateral load distribution, with 4 deg varus and 4 deg valgus rotations in component alignment inducing +17% and -23% changes in the first peak medial tibiofemoral contact forces, respectively. A Monte Carlo analysis showed that uncertainties in ligament stiffness and reference strains induce ±0.2 BW uncertainty in tibiofemoral force estimates over the gait cycle. Ligament properties had substantial influence on the TKR load distributions, with the medial collateral ligament and iliotibial band (ITB) properties having the largest effects on medial and lateral compartment loading, respectively. The computational framework provides a viable approach for virtually designing TKR components, considering parametric uncertainty and predicting the effects of joint alignment and soft tissue balancing procedures on TKR function during movement.