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Farvardin A, Bakhtiarinejad M, Murphy RJ, Basafa E, Khanuja H, Oni JK, Armand M. A biomechanically-guided planning and execution paradigm for osteoporotic hip augmentation: Experimental evaluation of the biomechanics and temperature-rise. Clin Biomech (Bristol, Avon) 2021; 87:105392. [PMID: 34174676 PMCID: PMC8550980 DOI: 10.1016/j.clinbiomech.2021.105392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Augmentation of the proximal femur with bone cement (femoroplasty) has been identified as a potential preventive approach to reduce the risk of fracture. Femoroplasty, however, is associated with a risk of thermal damage as well as the leakage of bone cement or blockage of blood supply when large volumes of cement are introduced inside the bone. METHODS Six pairs of cadaveric femora were augmented using a newly proposed planning paradigm and an in-house navigation system to control the location and volume of the injected cement. To evaluate the risk of thermal damage, we recorded the peak temperature of bone at three regions of interest as well as the exposure time for temperature rise of 8 °C, 10 °C, and 12 °C in these regions. Augmentation was followed by mechanical testing to failure resembling a sideway fall on the greater trochanter. FINDINGS Results of the fracture tests correlated with those of simulations for the yield load (R2 = 0.77) and showed that femoroplasty can significantly improve the yield load (42%, P < 0.001) and yield energy (139%, P = 0.062) of the specimens. Meanwhile, temperature recordings of the bone surface showed that the areas close to the greater trochanter will be exposed to more critical temperature rise than the trochanteric crest and femoral neck areas. INTERPRETATION The new planning paradigm offers a more efficient injection strategy with injection volume of 9.1 ml on average. Meanwhile, temperature recordings of bone surfaces suggest that risk of thermal necrosis remains as a concern with femoroplasty using Polymethylmethacrylate.
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Affiliation(s)
- Amirhossein Farvardin
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA.
| | - Mahsan Bakhtiarinejad
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Ryan J Murphy
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Ehsan Basafa
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Harpal Khanuja
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Juluis K Oni
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Mehran Armand
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Rd, Laurel, MD 20723, USA; Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
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Sas A, Tanck E, Sermon A, van Lenthe GH. Finite element models for fracture prevention in patients with metastatic bone disease. A literature review. Bone Rep 2020; 12:100286. [PMID: 32551337 PMCID: PMC7292864 DOI: 10.1016/j.bonr.2020.100286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/04/2020] [Accepted: 05/25/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with bone metastases have an increased risk to sustain a pathological fracture as lytic metastatic lesions damage and weaken the bone. In order to prevent fractures, prophylactic treatment is advised for patients with a high fracture risk. Mechanical stabilization of the femur can be provided through femoroplasty, a minimally invasive procedure where bone cement is injected into the lesion, or through internal fixation with intra- or extramedullary implants. Clinicians face the task of determining whether or not prophylactic treatment is required and which treatment would be the most optimal. Finite element (FE) models are promising tools that could support this decision process. The aim of this paper is to provide an overview of the state-of-the-art in FE modeling for the treatment decision of metastatic bone lesions in the femur. First, we will summarize the clinical and mechanical results of femoroplasty as a prophylactic treatment method. Secondly, current FE models for fracture risk assessment of metastatic femurs will be reviewed and the remaining challenges for clinical implementation will be discussed. Thirdly, we will elaborate on the simulation of femoroplasty in FE models and discuss future opportunities. Femoroplasty has already proven to effectively relieve pain and improve functionality, but there remains uncertainty whether it provides sufficient mechanical strengthening to prevent pathological fractures. FE models could help to select appropriate candidates for whom femoroplasty provides sufficient increase in strength and to further improve the mechanical benefit by optimizing the locations for cement augmentation.
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Affiliation(s)
- Amelie Sas
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - An Sermon
- Department of Traumatology, University Hospitals Gasthuisberg, Leuven, Belgium and Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Farvardin A, Basafa E, Bakhtiarinejad M, Armand M. Significance of preoperative planning for prophylactic augmentation of osteoporotic hip: A computational modeling study. J Biomech 2019; 94:75-81. [PMID: 31371101 PMCID: PMC6736717 DOI: 10.1016/j.jbiomech.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 12/22/2022]
Abstract
A potential effective treatment for prevention of osteoporotic hip fractures is augmentation of the mechanical properties of the femur by injecting it with bone cement. This therapy, however, is only in research stage and can benefit substantially from computational simulations to optimize the pattern of cement injection. Some studies have considered a patient-specific planning paradigm for Osteoporotic Hip Augmentation (OHA). Despite their biomechanical advantages, customized plans require advanced surgical systems for implementation. Other studies, therefore, have suggested a more generalized injection strategy. The goal of this study is to investigate as to whether the additional computational overhead of the patient-specific planning can significantly improve the bone strength as compared to the generalized injection strategies attempted in the literature. For this purpose, numerical models were developed from high resolution CT images (n = 4). Through finite element analysis and hydrodynamic simulations, we compared the biomechanical efficiency of the customized cement-based augmentation along with three generalized injection strategies developed previously. Two series of simulations were studied, one with homogeneous and one with inhomogeneous material properties for the osteoporotic bone. The customized cement-based augmentation inhomogeneous models showed that injection of only 10 ml of bone cement can significantly increase the yield load (79.6%, P < 0.01) and yield energy (199%, P < 0.01) of an osteoporotic femur. This increase is significantly higher than those of the generalized injections proposed previously (23.8% on average). Our findings suggest that OHA can significantly benefit from a patient-specific plan that determines the pattern and volume of the injected cement.
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Affiliation(s)
- Amirhossein Farvardin
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA.
| | - Ehsan Basafa
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Mahsan Bakhtiarinejad
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Mehran Armand
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Rd, Laurel, MD 20723, USA; Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
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Discrete particle model for cement infiltration within open-cell structures: Prevention of osteoporotic fracture. PLoS One 2018; 13:e0199035. [PMID: 29898001 PMCID: PMC5999107 DOI: 10.1371/journal.pone.0199035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/30/2018] [Indexed: 11/19/2022] Open
Abstract
This paper proposes a discrete particle model based on the random-walk theory for simulating cement infiltration within open-cell structures to prevent osteoporotic proximal femur fractures. Model parameters consider the cement viscosity (high and low) and the desired direction of injection (vertical and diagonal). In vitro and in silico characterizations of augmented open-cell structures validated the computational model and quantified the improved mechanical properties (Young's modulus) of the augmented specimens. The cement injection pattern was successfully predicted in all the simulated cases. All the augmented specimens exhibited enhanced mechanical properties computationally and experimentally (maximum improvements of 237.95 ± 12.91% and 246.85 ± 35.57%, respectively). The open-cell structures with high porosity fraction showed a considerable increase in mechanical properties. Cement augmentation in low porosity fraction specimens resulted in a lesser increase in mechanical properties. The results suggest that the proposed discrete particle model is adequate for use as a femoroplasty planning framework.
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Santana Artiles ME, Venetsanos DT. Numerical investigation of the effect of bone cement porosity on osteoporotic femoral augmentation. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2018; 34:e2989. [PMID: 29603673 DOI: 10.1002/cnm.2989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/19/2018] [Accepted: 03/24/2018] [Indexed: 06/08/2023]
Abstract
Femoroplasty is the injection of bone cement into the proximal femur, enhances the bone load capacity, and is typically applied to osteoporotic femora. To minimize the required injected volume of bone cement and maximize the load capacity enhancement, an optimization problem must be solved, where the modulus of elasticity of the augmented bone is a key element. This paper, through the numerical investigation of a fall on the greater trochanter of an osteoporotic femur, compares different ways to calculate this modulus and introduces an approach, based on the concept of bone cement porosity, which provides results statistically similar to those obtained with other considerations. Based on this approach, the present paper quantifies the correlation between degree of osteoporosis and optimum volume of bone cement. It concludes with an exhaustive search that reveals the effect of the bone cement porosity on the optimum volume of PMMA, for various combinations of the frontal and transverse angles of the fall on the greater trochanter.
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Affiliation(s)
- María E Santana Artiles
- School of Engineering, Faculty of Science, Engineering and Computing, Kingston University, Friars Ave., Roehampton Vale Campus, SW15 3DW, London, UK
| | - Demetrios T Venetsanos
- School of Mechanical, Aerospace and Automotive Engineering, Faculty of Engineering, Environment & Computing, Coventry University, Gulson Road, CV1 2JH, Coventry, UK
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