Generation of physiological parameter sets for hip joint motions and loads during daily life activities for application in wear simulators of the artificial hip joint

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.

Biomechanical Study of Three Cannulated Screws Configurations for Femur Neck Fracture: A Finite Element Analysis

Background

To improve the performance of cannulated screws (CSs) in the treatment of femoral neck fractures (FNF), a number of new screw configurations have been proposed. However, most of the studies have only analyzed the biomechanical performance of different screw configurations under static conditions. This study aimed to investigate the biomechanical performance of three cannulated screws configurations under different loadings through finite element analysis.

Methods

In this FEA study, nine numerical models of proximal femur were employed to analyze the mechanical response of various fracture types and different fixation strategies (three inverted triangular parallel cannulated screws (TCS), four non-parallel cannulated screws (FCS) and biplane double-supported screw fixation (BDSF) respectively). The maximum principal strain (MPS) on the proximal femur and the von Mises stress on the screws were compared for different models.

Results

In Pauwels I and II fractures, FCS had the lowest peak MPS on the proximal femur and the BDSF had highest peak MPS value. In Pauwels III fractures, BDSF performance in MPS is improved and better than FCS under partial loading conditions. FCS exhibits the lowest von Mises stress in all load conditions for all fracture types, demonstrating minimal risk of screws breakage.

Conclusions

FCS is an ideal screw configuration for the treatment of FNF. And BDSF has shown potential in the treatment of Pauwels type III FNF.

Moving fluoroscopy-based analysis of THA kinematics during unrestricted activities of daily living

Introduction: Knowledge of the accurate in-vivo kinematics of total hip arthroplasty (THA) during activities of daily living can potentially improve the in-vitro or computational wear and impingement prediction of hip implants. Fluoroscopy- based techniques provide more accurate kinematics compared to skin marker-based motion capture, which is affected by the soft tissue artefact. To date, stationary fluoroscopic machines allowed the measurement of only restricted movements, or only a portion of the whole motion cycle. Methods: In this study, a moving fluoroscopic robot was used to measure the hip joint motion of 15 THA subjects during whole cycles of unrestricted activities of daily living, i.e., overground gait, stair descent, chair rise and putting on socks. Results: The retrieved hip joint motions differed from the standard patterns applied for wear testing, demonstrating that current pre-clinical wear testing procedures do not reflect the experienced in-vivo daily motions of THA. Discussion: The measured patient-specific kinematics may be used as input to in vitro and computational simulations, in order to investigate how individual motion patterns affect the predicted wear or impingement.

Feature selection to classify lameness using a smartphone-based inertial measurement unit

Background and objectives

Gait can be severely affected by pain, muscle weakness, and aging resulting in lameness. Despite the high incidence of lameness, there are no studies on the features that are useful for classifying lameness patterns. Therefore, we aimed to identify features of high importance for classifying population differences in lameness patterns using an inertial measurement unit mounted above the sacral region.

Methods

Features computed exhaustively for multidimensional time series consisting of three-axis angular velocities and three-axis acceleration were carefully selected using the Benjamini–Yekutieli procedure, and multiclass classification was performed using LightGBM (Microsoft Corp., Redmond, WA, USA). We calculated the relative importance of the features that contributed to the classification task in machine learning.

Results

The most important feature was found to be the absolute value of the Fourier coefficients of the second frequency calculated by the one-dimensional discrete Fourier transform for real input. This was determined by the fast Fourier transformation algorithm using data of a single gait cycle of the yaw angular velocity of the pelvic region.

Conclusions

Using an inertial measurement unit worn over the sacral region, we determined a set of features of high importance for classifying differences in lameness patterns based on different factors. This completely new set of indicators can be used to advance the understanding of lameness.

The role of fretting-frequency on the damage modes of THR modular junction: In-vitro study

According to the National Center for Health Statistics, currently, more than 250,000 total hip replacements annually in the US alone, with an estimated increase to 500,000 by the year 2030. The usage of tapered junctions between the femoral neck and head gives the surgeon flexibility in implant assembly. However, these modular junctions are subjected to micro-motion that may cause chemical and fretting-corrosion at the modular junction. Therefore, it is imperative to study these forces to mitigate their effects. The current study aims to understand the effects of fretting-corrosion as a function of fretting frequencies caused by common physical activities in an in-vitro model of hip modular junctions. The fretting system has a tribological contact condition of flat-on-flat, mounted to a load frame. CoCrMo pins were polished and immersed in a synovial fluid-like electrolyte solution (Bovine calf serum 30 g/l). Electrochemical measurements were made using a potentiostat. Samples then undergo 3600 cycles at 50 μm (to simulate gross slips), with a horizontal load at 200 N, and a frequency of 0.5 Hz, 0.7 Hz, 1 Hz, and 1.5 Hz to simulate Sit Down-Stand Up, Stair Climb, Walking, and Jogging, respectively. Worn surfaces were then examined under optical and scanning electron microscopy. The evolution of free potential as a function of time for tested frequencies shows the initial potential drop and stabilized trend in the potential evolution. The sample group at a higher frequency displays a higher tendency of corrosion than a lower frequency; however, the dissipation energy decreases as a function of fretting frequency. Both electrochemical and mechanical responses correlate to the variation in the fretting frequencies. Organometallic complexes were found on the surfaces of the samples that were subjected to a slower frequency of fretting, whereas mechanical grooving was noticed on samples with a faster frequency. Hence, these preliminary studies suggest that implant failure rates may be altered based on fretting-frequencies induced by physical activity. Further studies will be required to verify the findings and explore the potential role of fretting frequency in the damage modes of the modular junction.

Effect of random variation of input and various daily activities on wear in a hip joint simulator

The ISO 14242-1 standard specifies fixed, simplified, sinusoidal motion and double-peak load cycles for wear testing of total hip prostheses. In order to make the wear simulation more realistic, random variation was added for the first time to the motion and load control signals of a hip joint simulator. For this purpose and for the simulation of various daily activities, computer-controlled, servo-electric drives were mounted on a biaxial hip simulator frame and successfully introduced. Random variation did not result in a statistically significant difference in the wear factor of large diameter VEXLPE liners compared with fixed sinusoidal waveforms. However, level walking according to biomechanical literature surprisingly resulted in a 134 per cent higher, and jogging in a 57 per cent lower wear factor compared with the fixed sinusoidal waveforms. These wear phenomena were likely to be caused by a variation in the lubrication conditions and frictional heating. Simplified motion waveforms may result in an underestimation of wear in walking.

Effects of Daily Activities and Position on Kinematics and Contact Mechanics of Dual Mobility Hip Implant

Dual mobility hip implants have been widely introduced to overcome dislocation in recent years. However, the potential influence of different gaits on kinematics and contact mechanics for dual mobility hip implants is still unclear. Furthermore, a large range of motion coupling with the implant position, especially high inclination or anteversion angle, may result in poor kinematics and contact mechanics. A previously developed dynamic finite element method was adopted in this study to examine the kinematics and corresponding stability of dual mobility hip implants under different gaits coupling with different inclinations or anteversion angles. The results showed only inner relative sliding under knee-bending for dual mobility hip implants under moderate inclination and anteversion angles, whereas an anteversion angle of 25° induced both impingement and consequent relative sliding of the outer articulation. However, the impingement (between the stem neck and the liner inner rim) indeed happened under stair-climbing and sitting-down/stand-up as well as combined movements when inclination and anteversion angles were set as 45° and 0°, respectively, and this finally led to relative sliding at the outer articulation. A high inclination angle did not worsen both the impingement and related outer sliding compared to modest inclination and anteversion angles of the liner, but a high anteversion angle prolonged the period of both the impingement and the outer relative sliding. The extreme motions and high anteversion angles are hardly inevitable, and they indeed lead to motions at both articulations for dual mobility hip implants.

Validation of two hybrid approaches for clustering age-related groups based on gait kinematics data

Age-associated changes in walking parameters are relevant to recognize functional capacity and physical performance. However, the sensible nuances of slightly different gait patterns are hardly noticeable by inexperienced observers. Due to the complexity of this evaluation, we aimed at verifying the efficiency of applied hybrid-adaptive algorithms to cluster groups with similar gait patterns. Based on self-organizing maps (SOM), k-means clustering (KM), and fuzzy c-means (FCM), we compared the hybrid algorithms to a conventional FCM approach to cluster accordingly age-related groups. Additionally, we performed a relevance analysis to identify the principal gait characteristics. Our experiments, based on inertial-sensors data, comprised a sample of 180 healthy subjects, divided into age-related groups. The outcomes suggest that our methods outperformed the FCM algorithm, demonstrating a high accuracy (88%) and consistent sensitivity also to distinguish groups that presented a significant difference (p < .05) only in one of the six observed gait features. The applied algorithms showed a compatible performance, but the SOM + KM required less computation cost and, therefore, was more efficient. Furthermore, the results indicate the overall importance of cadence, as a measurement of physical performance, especially when clustering subjects by their age. Such output provides valuable information to healthcare professionals, concerning the subject's physical performance related to his age, supporting and guiding the physical evaluation.

Clustering of Self-Organizing Maps as a means to support gait kinematics analysis and symmetry evaluation

Gait analysis is relevant for the functional diagnostic of several musculoskeletal disorders. Walking patterns can be analyzed using techniques such as video processing and inertial measurement units (IMU). In this work, a Self-Organizing Maps (SOM) algorithm is applied to reduce the complexity of kinematic features obtained by IMU sensors of a sample of 40 individuals. Our system provides a simpler data representation (2-D graphic) than conventional methods, which often applies statistical analysis. We have tested the proposed method to analyze typical and simulated limping gait pattern under well-controlled conditions. Based on kinematic parameters and symmetry-related features, SOM algorithm was able to organize the sample in groups of subjects with three different gait patterns, normal and limping with each lower limb. Moreover, our system may be used to evaluate the recovery of a patient, offering intuitive information of his walking pattern in an assessment report. However, further research with atypical-gait subjects is necessary before applying such method as a clinical tool.

Computational wear assessment of hard on hard hip implants subject to physically demanding tasks

Hip implants subject to gait loading due to occupational activities are potentially prone to failures such as osteolysis and aseptic loosening, causing painful revision surgeries. Highly risky gait activities such as carrying a load, stairs up or down and ladder up or down may cause excessive loading at the hip joint, resulting in generation of wear and related debris. Estimation of wear under the above gait activities is thus crucial to design and develop a new and improved implant component. With this motivation, this paper presents an assessment of wear generation of PCD-on-PCD (poly crystalline diamond) hip implants using finite element (FE) analysis. Three-dimensional (3D) FE model of hip implant along with peak gait and peak flexion angle for each activity was used to estimate wear of PCD for 10 million cycles. The maximum and minimum initial contact pressures of 206.19 MPa and 151.89 MPa were obtained for carrying load of 40 kg and sitting down or getting up activity. The simulation results obtained from finite element model also revealed that the maximum linear wear of 0.585 μm occurred for the patients frequently involved in sitting down or getting up gait activity and maximum volumetric wear of 0.025 mm³ for ladder up gait activity. The stair down activity showed the least linear and volumetric wear of 0.158 μm and 0.008 mm³, respectively, at the end of 10 million cycles. Graphical abstract Computational wear assessment of hip implants subjected to physically demanding tasks.

Three-dimensional friction measurement during hip simulation

Objectives

Wear of total hip replacements has been the focus of many studies. However, frictional effects, such as high loading on intramodular connections or the interface to the bone, as well as friction associated squeaking have recently increased interest about the amount of friction that is generated during daily activities. The aim of this study was thus to establish and validate a three-dimensional friction setup under standardized conditions.

Materials and methods

A standard hip simulator was modified to allow for high precision measurements of small frictional effects in the hip during three-dimensional hip articulation. The setup was verified by an ideal hydrostatic bearing and validated with a static-load physical pendulum and an extension-flexion rotation with a dynamic load profile. Additionally, a pendulum model was proposed for screening measurement of frictional effects based on the damping behavior of the angular oscillation without the need for any force/moment transducer. Finally, three-dimensional friction measurements have been realized for ceramic-on-polyethylene bearings of three different sizes (28, 36 and 40 mm).

Results

A precision of less than 0.2 Nm during three-dimensional friction measurements was reported, while increased frictional torque (resultant as well as taper torque) was measured for larger head diameters. These effects have been confirmed by simple pendulum tests and the theoretical model. A comparison with current literature about friction measurements is presented.

Conclusions

This investigation of friction is able to provide more information about a field that has been dominated by the reduction of wear. It should be considered in future pre-clinical testing protocols given by international organizations of standardization.

Importance of preclinical evaluation of wear in hip implant designs using simulator machines

Total hip arthroplasty (THA) is a surgical procedure that involves the replacement of the damaged joint of the hip by an artificial device. Despite the recognized clinical success of hip implants, wear of the articulating surfaces remains as one of the critical issues influencing performance. Common material combinations used in hip designs comprise metal-on-polymer (MoP), ceramic-on-polymer (CoP), metal-on-metal (MoM), and ceramic-on-ceramic (CoC). However, when the design of the hip implant is concerned besides the materials used, several parameters can influence its wear performance. In this scenario, where the safety and efficacy for the patient are the main issues, it is fundamental to evaluate and predict the wear rate of the hip implant design before its use in THA. This is one of the issues that should be taken into account in the preclinical evaluation step of the product, in which simulated laboratory tests are necessary. However, it is fundamental that the applied motions and loads can reproduce the wear mechanisms physiologically observed in the patient. To replicate the in vivo angular displacements and loadings, special machines known as joint simulators are employed. This article focuses on the main characteristics related to the wear simulation of hip implants using mechanical simulators, giving information to surgeons, researchers, regulatory bodies, etc., about the importance of preclinical wear evaluation. A critical analysis is performed on the differences in the principles of operation of simulators and their effects on the final results, and about future trends in wear simulation.

Standardized Loads Acting in Hip Implants

With the increasing success of hip joint replacements, the average age of patients has decreased, patients have become more active and their expectations of the implant durability have risen. Thus, pre-clinical endurance tests on hip implants require defining realistic in vivo loads from younger and more active patients. These loads require simplifications to be applicable for simulator tests and numerical analyses. Here, the contact forces in the joint were measured with instrumented hip implants in ten subjects during nine of the most physically demanding and frequent activities of daily living. Typical levels and directions of average and high joint loads were extracted from the intra- and inter-individually widely varying individual data. These data can also be used to analyse bone remodelling at the implant-bone interface, evaluate tissue straining in finite element studies or validate analytical loading predictions, among other uses. The current ISO standards for endurance tests of implant stems and necks are based on historic analytical data from the 1970s. Comparisons of these test forces with in vivo loads unveiled that their unidirectional orientations deviate from the time-dependent in vivo directions during walking and most other activities. The ISO force for testing the stem is substantially too low while the ISO force for the neck better matches typical in vivo magnitudes. Because the magnitudes and orientations of peak forces substantially vary among the activities, load scenarios that reflect a collection of time-dependent high forces should be applied rather than using unidirectional forces. Based on data from ten patients, proposals for the most demanding activities, the time courses of the contact forces and the required cycle numbers for testing are given here. Friction moments in the joint were measured in addition to the contact forces. The moment data were also standardized and can be applied to wear tests of the implant. It was shown that friction only very slightly influences the stresses in the implant neck and shaft.

NUMERICAL AND STOCHASTIC ANALYSIS OF CORROSION IN MODULAR HIP IMPLANTS

The influence of localized corrosion on cementless titanium-alloy modular total hip arthroplasty was analyzed using numerical and stochastic modeling. Corrosion depth influences maximum stress significantly, thereby reducing the load carrying capacity. Numerical analysis revealed that the stress levels due to corrosion in the modular implants are influenced not only by the pit geometry, but also by the contact properties of the taper junctions. Subsequently, crevice corrosion was economically modeled with two parameters related to physical and chemical properties of the materials involved. The solution introduces a dimensionless number that determines whether anoxic conditions will be reached. The analysis confirms the power-law relationship for the exponent variation with the concentration gradient variation assumed by others. The results may be used in averting the progression to rapid corrosion growth through infusion of oxygen in the crevice at the appropriate time intervals. Stochastic modeling of crevice area and maximum depth shows a power-law increase in dispersion measures with exponent of 0.63–0.64 though the average increase follows a more modest exponent of 0.13–0.15. A holistic approach, and continuous research towards the development of robust corrosion models is warranted so as to predict and enhance the design life of otherwise successful modular arthroplasties. A better understanding of the phenomenon may help alleviate early and catastrophic fractures.

The Divergence of Wear Propagation and Stress at Steep Acetabular Cup Positions Using Ceramic Heads and Sequentially Cross-Linked Polyethylene Liners

The aim of the present wear simulator study was to assess the effect of steep acetabular cup positions on the wear propagation of highly cross-linked-PE (HX-PE) liners. Furthermore, a finite element analysis (FEA) was performed in order to calculate the stress within the HX-PE material in case of steep cup positions under physiological loadings. The higher stress in the HX-PE at a steep acetabular cup position did not result in increased wear in the present wear simulator study. The gravimetrical wear rates at normal (45°) and steep cup inclinations (75°) showed wear amounts of 3.15±0.27mg and 2.18±0.31mg per million cycles (p=0.028), respectively. However, FEA revealed clear increase in stress at the HX-PE liners with respect to steep cup positions.

Wear testing of total hip replacements under severe conditions

Controlled wear testing of total hip replacements in hip joint simulators is a well-established and powerful method, giving an extensive prediction of the long-term clinical performance. To understand the wear behavior of a bearing and its limits under in vivo conditions, testing scenarios should be designed as physiologically as possible. Currently, the ISO standard protocol 14242 is the most common preclinical testing procedure for total hip replacements, based on a simplified gait cycle for normal walking conditions. However, in recent years, wear patterns have increasingly been observed on retrievals that cannot be replicated by the current standard. The purpose of this study is to review the severe testing conditions that enable the generation of clinically relevant wear rates and phenomena. These conditions include changes in loading and activity, third-body wear, surface topography, edge wear and the role of aging of the bearing materials.

Articulating Biomaterials

This chapter examines the importance of surface characteristics such as microstructure, composition, crystallographic texture, and surface free energy in achieving desired biocompatibility and tribological properties thereby improving in vivo life of artificial articulating implants. Current implants often fail prematurely due to inadequate mechanical, tribological, biocompatibility, and osseointegration properties, apart from issues related to design and surgical procedures. For long-term in vivo stability, artificial implants intended for articulating joint replacement must exhibit long-term stable articulation surface without stimulating undesirable in vivo effects. Since the implant's surface plays a vital and decisive role in their response to biological environment, and vice versa, surface modification of implants assumes a significant importance. Therefore, overview on important surface modification techniques, their capabilities, properties of modified surfaces/implants are presented in the chapter. The clinical performance of surface modified implants and new surfaces for potential next-generation articulating implant applications are discussed at the end.

A new protocol from real joint motion data for wear simulation in total knee arthroplasty: stair climbing

In its normal lifespan, a knee prosthesis must bear highly demanding loading conditions, going beyond the sole activity of level walking required by ISO standard 14243. We have developed a protocol for in vitro wear simulation of stair climbing on a displacement controlled knee simulator. The flexion/extension angle, intra/extra rotation angle, and antero/posterior translation were obtained in patients by three-dimensional video-fluoroscopy. Axial load data were collected by gait analysis. Kinematics and load data revealed a good consistence across patients, in spite of the different prosthesis size. The protocol was then implemented and tested on a displacement controlled knee wear simulator, showing an accurate reproduction of stair climbing waveforms with a relative error lower than 5%.

Self-centering dual-mobility total hip systems: Prediction of relative movements and realignment of different intermediate components

The increased jump distance against dislocation and the large range of motion due to the enlarged effective head diameter substantiate the use of dual-mobility systems in cases of total hip joint instability. For this type of total hip endoprostheses, an eccentric design of the outer bearing is assumed in order to provide a force-dependent self-centering mechanism and an improved joint stability against dislocation. The purpose of this study was to determine the relative movements and realignment of different intermediate components during various motion cycles as a result of the eccentric design. We established a validated mathematical model for eccentric dual-mobility systems, which allowed a comparison of relative movements, self-centering torque and overall frictional torque during four different activities in order to analyze their motion behavior in everyday life. In addition, the impact of different radial clearances on the dynamic performance of the self-centering mechanism was investigated. According to torque patterns and the validation experiment, the main articulation of eccentric dual-mobility systems was limited to the smaller inner bearing for the most daily life activities, i.e. the eccentric intermediate component remained in its current position and only with changing activity did the intermediate component realign clearly. However, an inappropriate dimensioning of the radial clearance could lead to a permanent realignment of the intermediate component during the motion cycles. In general, the self-centering mechanism of the intermediate component seems to have no negative influence on relative movements and wear propagation of dual-mobility cup systems if the clearance and eccentricity are appropriately dimensioned.