Effect of joint laxity on polyethylene wear in total knee replacement

Experimental simulator studies are frequently performed to evaluate wear behavior in total knee replacement. It is vital that the simulation conditions match the physiological situation as closely as possible. To date, few experimental wear studies have examined the effects of joint laxity on wear and joint kinematics and the absence of the anterior cruciate ligament has not been sufficiently taken into account in simulator wear studies.The aim of this study was to investigate different ligament and soft tissue models with respect to wear and kinematics.A virtual soft tissue control system was used to simulate different motion restraints in a force-controlled knee wear simulator.The application of more realistic and sophisticated ligament models that considered the absence of anterior cruciate ligament lead to a significant increase in polyethylene wear (p=0.02) and joint kinematics (p<0.01). We recommend the use of more complex ligament models to appropriately simulate the function of the human knee joint and to evaluate the wear behavior of total knee replacements. A feasible simulation model is presented.     

Evaluating knee replacement mechanics during ADL with PID-controlled dynamic finite element analysis

Validated computational knee simulations are valuable tools for design phase development of knee replacement devices. Recently, a dynamic finite element (FE) model of the Kansas knee simulator was kinematically validated during gait and deep flexion cycles. In order to operate the computational simulator in the same manner as the experiment, a proportional–integral–derivative (PID) controller was interfaced with the FE model to control the quadriceps actuator excursion and produce a target flexion profile regardless of implant geometry or alignment conditions. The controller was also expanded to operate multiple actuators simultaneously in order to produce in vivo loading conditions at the joint during dynamic activities. Subsequently, the fidelity of the computational model was improved through additional muscle representation and inclusion of relative hip–ankle anterior–posterior (A–P) motion. The PID-controlled model was able to successfully recreate in vivo loading conditions (flexion angle, compressive joint load, medial–lateral load distribution or varus-valgus torque, internal–external torque, A–P force) for deep knee bend, chair rise, stance-phase gait and step-down activities.     

The influence of design, materials and kinematics on the in vitro wear of total knee replacements

Debris-induced osteolysis due to surface wear of ultra high molecular weight polyethylene (UHMWPE) bearings is a potential long-term failure mechanism of total knee replacements (TKR). This study investigated the effect of prosthesis design, kinematics and bearing material on the wear of UHMWPE bearings using a physiological knee simulator. The use of a curved fixed bearing design with stabilised polyethylene bearings reduced wear in comparison to more flat-on-flat components which were sterilised by gamma irradiation in air. Medium levels of crosslinking further improved the wear resistance of fixed bearing TKR due to resistance to strain softening when subjected to multidirectional motion at the femoral-insert articulating interface. Backside motion was shown to be a contributing factor to the overall rate of UHMWPE wear in fixed bearing components. Wear of fixed bearing prostheses was reduced significantly when anterior-posterior displacement and internal-external rotation kinematics were reduced due to decreased cross shear on the articulating surface and a reduction in AP displacement. Rotating platform mobile bearing prostheses exhibited reduced wear rates in comparison to fixed bearing components in these simulator studies due to redistribution of knee motion to two articulating interfaces with more linear motions at each interface. This was observed in two rotating platform designs with different UHMWPE bearing materials. In knee simulator studies, wear of TKR bearings was dependent on kinematics at the articulating surfaces and the prosthesis design, as well as the type of material.     

Simulating dynamic activities using a five-axis knee simulator

This work describes the design and capabilities of the Purdue Knee Simulator: Mark II and a sagittal-plane model of the machine. This five-axis simulator was designed and constructed to simulate dynamic loading activities on either cadaveric knee specimens or total knee prostheses mounted on fixtures. The purpose of the machine was to provide a consistent, realistic loading of the knee joint, allowing the kinematics and specific loading of the structures of the knee to be determined based on condition, articular geometry, and simulated activity. The sagittal-plane model of the knee simulator was developed both to predict the loading at the knee from arbitrary inputs and to generate the necessary inputs required to duplicate specified joint loading. Measured tibio-femoral compressive force and quadriceps tension were shown to be in good agreement with the predicted loads from the model. A controlled moment about the ankle-flexion axis was also shown to change the loading on the quadriceps.     

Simulation of a knee joint replacement during a gait cycle using explicit finite element analysis.

The stress distribution within the polyethylene insert of a total knee joint replacement is dependent on the kinematics, which in turn are dependent on the design of the articulating surfaces, the relative position of the components and the tension of the surrounding soft tissues. Implicit finite element analysis techniques have been used previously to examine the polyethylene stresses. However, these have essentially been static analyses and hence ignored the influence of the kinematics. The aim of this work was to use an explicit finite element approach to simulate both the kinematics and the internal stresses within a single analysis. A simulation of a total knee joint replacement subjected to a single gait cycle within a knee wear simulator was performed and the results were compared with experimental data.The predicted kinematics were in close agreement with the experimental data. Various solution-dependent parameters were found to have little influence on the predicted kinematics. The predicted stresses were found to be dependent on the mesh density. This study has shown that an explicit finite element approach is capable of predicting the kinematics and the stresses within a single analysis at relatively low computational cost.     

Dynamic finite element knee simulation for evaluation of knee replacement mechanics

In vitro pre-clinical testing of total knee replacement (TKR) devices is a necessary step in the evaluation of new implant designs. Whole joint knee simulators, like the Kansas knee simulator (KKS), provide a controlled and repeatable loading environment for comparative evaluation of component designs or surgical alignment under dynamic conditions. Experimental testing, however, is time and cost prohibitive for design-phase evaluation of tens or hundreds of design variations. Experimentally-verified computational models provide an efficient platform for analysis of multiple components, sizes, and alignment conditions. The purpose of the current study was to develop and verify a computational model of a dynamic, whole joint knee simulator. Experimental internal-external and valgus-varus laxity tests, followed by dynamic deep knee bend and gait simulations in the KKS were performed on three cadaveric specimens. Specimen-specific finite element (FE) models of posterior-stabilized TKR were created from magnetic resonance images and CAD geometry. The laxity data was used to optimize mechanical properties of tibiofemoral soft-tissue structures on a specimen-specific basis. Each specimen was subsequently analyzed in a computational model of the experimental KKS, simulating both dynamic activities. The computational model represented all joints and actuators in the experimental setup, including a proportional-integral-derivative (PID) controller to drive quadriceps actuation. The computational model was verified against six degree-of-freedom patellofemoral (PF) and tibiofemoral (TF) kinematics and actuator loading during both deep knee bend and gait activities, with good agreement in trends and magnitudes between model predictions and experimental kinematics; differences were less than 1.8 mm and 2.2° for PF and TF translations and rotations. The whole joint FE simulator described in this study can be applied to investigate a wide range of clinical and research questions.     

Predicting knee replacement damage in a simulator machine using a computational model with a consistent wear factor

Wear of ultrahigh molecular weight polyethylene remains a primary factor limiting the longevity of total knee replacements (TKRs). However, wear testing on a simulator machine is time consuming and expensive, making it impractical for iterative design purposes. The objectives of this paper were first, to evaluate whether a computational model using a wear factor consistent with the TKR material pair can predict accurate TKR damage measured in a simulator machine, and second, to investigate how choice of surface evolution method (fixed or variable step) and material model (linear or nonlinear) affect the prediction. An iterative computational damage model was constructed for a commercial knee implant in an AMTI simulator machine. The damage model combined a dynamic contact model with a surface evolution model to predict how wear plus creep progressively alter tibial insert geometry over multiple simulations. The computational framework was validated by predicting wear in a cylinder-on-plate system for which an analytical solution was derived. The implant damage model was evaluated for 5 million cycles of simulated gait using damage measurements made on the same implant in an AMTI machine. Using a pin-on-plate wear factor for the same material pair as the implant, the model predicted tibial insert wear volume to within 2% error and damage depths and areas to within 18% and 10% error, respectively. Choice of material model had little influence, while inclusion of surface evolution affected damage depth and area but not wear volume predictions. Surface evolution method was important only during the initial cycles, where variable step was needed to capture rapid geometry changes due to the creep. Overall, our results indicate that accurate TKR damage predictions can be made with a computational model using a constant wear factor obtained from pin-on-plate tests for the same material pair, and furthermore, that surface evolution method matters only during the initial "break in" period of the simulation.     

Simulation of fretting wear at orthopaedic implant interfaces

Osteolysis due to wear debris is a primary cause of failure of total joint replacements. Although debris produced by the joint articulating surfaces has been studied and simulated extensively, fretting wear debris, produced at nonarticulating surfaces, has not received adequate attention. We developed a three-station fretting wear simulator to reproduce in vivo motion and stresses at the interfaces of total joint replacements. The simulator is based on the beam bending theory and is capable of producing cyclic displacement from 3 to 1000 microns, under varying magnitudes of contact stresses. The simulator offers three potential advantages over previous studies: The ability to control the displacement by load, the ability to produce very small displacements, and dynamic normal loads as opposed to static. A pilot study was designed to test the functionality of the simulator, and verify that calculated displacements and loads produced the predicted differences between two commonly used porous ingrowth titanium alloy surfaces fretting against cortical bone. After 1.5 million cycles, the simulator functioned as designed, producing greater wear of bone against the rougher plasma-sprayed surface compared to the fiber-mesh surface, as predicted. A novel pin-on-disk apparatus for simulating fretting wear at orthopaedic implant interfaces due to micromotion is introduced. The test parameters measured with the fretting wear simulator were as predicted by design calculations, and were sufficient to measure differences in the height and weight of cortical bone pins rubbing against two porous ingrowth surfaces, plasma-sprayed titanium and titanium fiber mesh.     

Probabilistic finite element prediction of knee wear simulator mechanics

Computational models have recently been developed to replicate experimental conditions present in the Stanmore knee wear simulator. These finite element (FE) models, which provide a virtual platform to evaluate total knee replacement (TKR) mechanics, were validated through comparisons with experimental data for a specific implant. As with any experiment, a small amount of variability is inherently present in component alignment, loading, and environmental conditions, but this variability has not been previously incorporated in the computational models. The objectives of the current research were to assess the impact of experimental variability on predicted TKR mechanics by determining the potential envelope of joint kinematics and contact mechanics present during wear simulator loading, and to evaluate the sensitivity of the joint mechanics to the experimental parameters. In this study, 8 component alignment and 4 experimental parameters were represented as distributions and used with probabilistic methods to assess the response of the system, including interaction effects. The probabilistic FE model evaluated two levels of parameter variability (with standard deviations of component alignment parameters up to 0.5mm and 1 degrees ) and predicted a variability of up to 226% (3.44mm) in resulting anterior-posterior (AP) translation, up to 169% (4.30 degrees ) in internal-external (IE) rotation, but less than 10% (1.66MPa) in peak contact pressure. The critical alignment parameters were the tilt of the tibial insert and the IE rotational alignment of the femoral component. The observed variability in kinematics and, to a lesser extent, contact pressure, has the potential to impact wear observed experimentally.     

An energy dissipation and cross shear time dependent computational wear model for the analysis of polyethylene wear in total knee replacements

The cost and time efficiency of computational polyethylene wear simulations may enable the optimization of total knee replacements for the reduction of polyethylene wear. The present study proposes an energy dissipation wear model for polyethylene which considers the time dependent molecular behavior of polyethylene, aspects of tractive rolling and contact pressure. This time dependent – energy dissipation wear model was evaluated, along with several other wear models, by comparison to pin-on-disk results, knee simulator wear test results under various kinematic conditions and knee simulator wear test results that were performed following the ISO 14243-3 standard. The proposed time dependent – energy dissipation wear model resulted in improved accuracy for the prediction of pin-on-disk and knee simulator wear test results compared with several previously published wear models.     

Comparison of long-term numerical and experimental total knee replacement wear during simulated gait loading

Pre-clinical experimental wear testing of total knee replacement (TKR) components is an invaluable tool for evaluating new implant designs and materials. However, wear testing can be a lengthy and expensive process, and hence parametric studies evaluating the effects of geometric, loading, or alignment perturbations may at times be cost-prohibitive. The objectives of this study were to develop an adaptive FE method capable of simulating wear of a polyethylene tibial insert and to compare predicted kinematics, weight loss due to wear, and wear depth contours to results from a force-controlled experimental knee simulator. Finite element-based computational wear predictions were performed to 5 million gait cycles using both force- and displacement-controlled inputs. The displacement-controlled inputs, by accurately matching the experimental tibiofemoral motion, provided an evaluation of the simple wear theory. The force-controlled inputs provided an evaluation of the overall numerical method by simultaneously predicting both kinematics and wear. Analysis of the predicted wear convergence behavior indicated that 10 iterations, each representing 500,000 gait cycles, were required to achieve numerical accuracy. Using a wear factor estimated from the literature, the predicted kinematics, polyethylene wear contours, and weight loss were in reasonable agreement with the experimental data, particularly for the stance phase of gait. Although further development of the simplified wear theory is important, the initial predictions are encouraging for future use in design phase implant evaluation. In contrast to the experimental testing which occurred over approximately 2 months, computational wear predictions required only 2h.     

Metal ion release barrier function and biotribological evaluation of a zirconium nitride multilayer coated knee implant under highly demanding activities wear simulation

Total knee arthroplasty is a well established treatment for degenerative joint disease, which is also performed as a treatment in younger and middle-aged patients who have a significant physical activity and high life expectancy. However, complications may occur due to biological responses to wear particles, as well as local and systemic hypersensitivity reactions triggered by metal ions and particles such as cobalt, chromium and molybdenum. The purpose of the study was to perform a highly demanding activities (HDA) knee wear simulation in order to compare the wear characteristics and metal ion release barrier function of a zirconium nitride (ZrN) coated knee implant, designed for patients with suspected metal ion hypersensitivity, against an uncoated knee implant made out of CoCrMo. The load profiles were applied for 5 million HDA cycles, which represent 15–30 years of in vivo service depending on the activity level of the patient. Results showed a significant wear rate reduction for the coated group (1.01 ± 0.29 mg/million cycles) in comparison with the uncoated group (2.89 ± 1.04 mg/million cycles). The zirconium nitride coating showed no sign of scratches nor delamination during the wear simulation, whereas the uncoated femurs showed characteristic wear scratches in the articulation areas. Furthermore, the metal ion release from the coated implants was reduced up to three orders of magnitude in comparison with the uncoated implants. These results demonstrate the efficiency of zirconium nitride coated knee implants to reduce wear as well as to substantially reduce metal ion release in the knee joint.     

Influence of kinematics on the wear of a total ankle replacement

Total ankle replacement (TAR) is an alternative to fusion, replacing the degenerated joint with a mechanical motion-preserving alternative. Minimal pre-clinical testing has been reported to date and existing wear testing standards lack definition. Ankle gait is complex, therefore the aim of this study was to investigate the effect on wear of a range of different ankle gait kinematic inputs. Five Zenith (Corin Group) TARs were tested in a modified knee simulator for twelve million cycles (Mc). Different combinations of IR rotation and AP displacement were applied every 2Mc to understand the effects of the individual kinematics. Wear was assessed gravimetrically every Mc and surface profilometry undertaken after each condition. With the initial unidirectional input with no AP displacement the wear rate measured 1.2±0.6 mm³/Mc. The addition of 11° rotation and 9 mm of AP displacement caused a statistically significant increase in the wear rate to 25.8±3.1 mm³/Mc. These inputs seen a significant decrease in the surface roughness at the tibial articulation. Following polishing three displacement values were tested; 0, 4 and 9 mm with no significant difference in wear rate ranging 11.8–15.2 mm³/Mc. TAR wear rates were shown to be highly dependent on the addition of internal/external rotation within the gait profile with multidirectional kinematics proving vital in the accurate wear testing of TARs. Prior to surface polishing wear rates were significantly higher but once in a steady state the AP displacement had no significant effect on the wear.     

Effects of Forefoot Shoe on Knee and Ankle Loading during Running in Male Recreational Runners

Objectives: Although overuse running injury risks for the ankle and knee are high, the effect of different shoe designs on Achilles tendon force (ATF) and Patellofemoral joint contact force (PTF) loading rates are unclear. Therefore, the primary objective of this study was to compare the ATF at the ankle and the PTF and Patellofemoral joint stress force (PP) at the knee using different running shoe designs (forefoot shoes vs. normal shoes). Methods: Fourteen healthy recreational male runners were recruited to run over a force plate under two shoe conditions (forefoot shoes vs. normal shoes). Sagittal plane ankle and knee kinematics and ground reaction forces were simultaneously recorded. Ankle joint mechanics (ankle joint angle, velocity, moment and power) and the ATF were calculated. Knee joint mechanics (knee joint angle velocity, moment and power) and the PTF and PP were also calculated. Results: No significant differences were observed in the PTF, ankle plantarflexion angle, ankle dorsiflexion power, peak vertical active force, contact time and PTF between the two shoe conditions. Compared to wearing normal shoes, wearing the forefoot shoes demonstrated that the ankle dorsiflexion angle, knee flexion velocity, ankle dorsiflexion moment extension, knee extension moment, knee extension power, knee flexion power and the peak patellofemoral contact stress were significantly reduced. However, the ankle dorsiflexion velocity, ankle plantarflexion velocity, ankle plantarflexion moment and Achilles tendons force increased significantly. Conclusions: These findings suggest that wearing forefoot shoes significantly decreases the patellofemoral joint stress by reducing the moment of knee extension, however the shoes increased the ankle plantarflexion moment and ATF force. The forefoot shoes effectively reduced the load on the patellofemoral joint during the stance phase of running. However, it is not recommended for new and novice runners and patients with Achilles tendon injuries to wear forefoot shoes.     

Combined measurement and modeling of specimen-specific knee mechanics for healthy and ACL-deficient conditions

Quantifying the mechanical environment at the knee is crucial for developing successful rehabilitation and surgical protocols. Computational models have been developed to complement in vitro studies, but are typically created to represent healthy conditions, and may not be useful in modeling pathology and repair. Thus, the objective of this study was to create finite element (FE) models of the natural knee, including specimen-specific tibiofemoral (TF) and patellofemoral (PF) soft tissue structures, and to evaluate joint mechanics in intact and ACL-deficient conditions. Simulated gait in a whole joint knee simulator was performed on two cadaveric specimens in an intact state and subsequently repeated following ACL resection. Simulated gait was performed using motor-actuated quadriceps, and loads at the hip and ankle. Specimen-specific FE models of these experiments were developed in both intact and ACL-deficient states. Model simulations compared kinematics and loading of the experimental TF and PF joints, with average RMS differences [max] of 3.0° [8.2°] and 2.1° [8.4°] in rotations, and 1.7 [3.0] and 2.5 [5.1] mm in translations, for intact and ACL-deficient states, respectively. The timing of peak quadriceps force during stance and swing phase of gait was accurately replicated within 2° of knee flexion and with an average error of 16.7% across specimens and pathology. Ligament recruitment patterns were unique in each specimen; recruitment variability was likely influenced by variations in ligament attachment locations. ACL resections demonstrated contrasting joint mechanics in the two specimens with altered knee motion shown in one specimen (up to 5 mm anterior tibial translation) while increased TF joint loading was shown in the other (up to 400 N).     

Material and surface factors influencing backside fretting wear in total knee replacement tibial components

Retrieval studies have shown that the interface between the ultra-high molecular weight polyethylene insert and metal tibial tray of fixed-bearing total knee replacement components can be a source of substantial amounts of wear debris due to fretting micromotion. We assessed fretting wear of polyethylene against metal as a function of metal surface finish, alloy, and micromotion amplitude, using a three-station pin-on-disc fretting wear simulator. Overall, the greatest reduction in polyethylene wear was achieved by highly polishing the metal surface. For example, highly polished titanium alloy surfaces produced nearly 20 times less polyethylene wear compared with blasted titanium alloy, whereas, decreasing the micromotion amplitude from 200 to 50 μm produced approximately four times less polyethylene wear for the same blasted titanium alloy surface. Although the effect of the metal alloy was much smaller than the effect of metal surface roughness or the micromotion amplitude, CoCr discs produced slightly greater polyethylene fretting wear than titanium alloy discs under each condition. The results are essential in design and manufacturing decisions related to fixed-bearing total knee replacements.     

Fatigue effects on the coordinative pattern during cycling: Kinetics and kinematics evaluation

The aim of the present study was to analyze the net joint moment distribution, joint forces and kinematics during cycling to exhaustion. Right pedal forces and lower limb kinematics of ten cyclists were measured throughout a fatigue cycling test at 100% of PO_MAX. The absolute net joint moments, resultant force and kinematics were calculated for the hip, knee and ankle joint through inverse dynamics. The contribution of each joint to the total net joint moments was computed. Decreased pedaling cadence was observed followed by a decreased ankle moment contribution to the total joint moments in the end of the test. The total absolute joint moment, and the hip and knee moments has also increased with fatigue. Resultant force was increased, while kinematics has changed in the end of the test for hip, knee and ankle joints. Reduced ankle contribution to the total absolute joint moment combined with higher ankle force and changes in kinematics has indicated a different mechanical function for this joint. Kinetics and kinematics changes observed at hip and knee joint was expected due to their function as power sources. Kinematics changes would be explained as an attempt to overcome decreased contractile properties of muscles during fatigue.     

Development of computational wear simulation of metal-on-metal hip resurfacing replacements

As one of the alternatives to traditional metal-on-polyethylene total hip replacements, metal-on-metal hip resurfacing prostheses demonstrating lower wear have been introduced for younger and more active patients during the past decade. However, in vitro hip simulator testing for the predicted increased lifetime of these surface replacements is time-consuming and costly. Computational wear modelling based on the Archard wear equation and finite element contact analysis was developed in this study for artificial hip joints and particularly applied to metal-on-metal resurfacing bearings under simulator testing conditions to address this issue. Wear factors associated with the Archard wear equation were experimentally determined and based on the short-term hip simulator wear results. The computational wear simulation was further extended to a long-term evaluation up to 50 million cycles assuming that the wear rate stays constant. The prediction from the computational model shows good agreement with the corresponding simulator study in terms of volumetric wear and the wear geometry. The simulation shows the progression of linear wear penetrations, and the complexity of contact stress distribution on the worn bearing surfaces. After 50 million cycles, the maximum linear wear was predicted to be approximately 6 and 8 microm for the cup and head, respectively, and no edge contact was found.     

Stretched polyethylene (UHMWPE)--a new substance modification for minimizing wear in artificial knee joint replacement]

Polyethylene wear is a major cause of aseptic loosening of knee endoprostheses. With the aim of minimizing this mechanical wear, we stretch-modified the structure of polyethylene. From plates of UHMWPE, stretched PE samples were produced under defined conditions, and subsequently submitted to friction tests in a fluid environment (cycles 5 x 10(5), frequency 1.5 Hz, load 500 N, contact stress 10 MPa). After load testing, the stretched samples revealed a 70% reduced wear rate in comparison with non-stretched samples. Microscopic examination (light microscopy, scanning electron microscopy) showed abrasive scratches in all test samples, but only in the non-stretched specimens were signs of pitting found. Translating these results to unidirectional tractive rolling on the tibial plateau in the knee joint suggests that a significant reduction in polyethylene wear can be expected. However, further experimental investigations need to be carried out to confirm this highly promising possibility.     

Computational wear prediction of artificial knee joints based on a new wear law and formulation

Laboratory joint wear simulator testing has become the standard means for preclinical evaluation of wear resistance of artificial knee joints. Recent simulator designs have been advanced and become successful at reproducing the wear patterns observed in clinical retrievals. However, a single simulator test can be very expensive and take a long time to run. On the other hand computational wear modelling is an alternative attractive solution to these limitations. Computational models have been used extensively for wear prediction and optimisation of artificial knee designs. However, all these models have adopted the classical Archard's wear law, which was developed for metallic materials, and have selected wear factors arbitrarily. It is known that such an approach is not generally true for polymeric bearing materials and is difficult to implement due to the high dependence of the wear factor on the contact pressure. Therefore, these studies are generally not independent and lack general predictability. The objective of the present study was to develop a new computational wear model for the knee implants, based on the contact area and an independent experimentally determined non-dimensional wear coefficient. The effects of cross-shear and creep on wear predictions were also considered. The predicted wear volume was compared with the laboratory simulation measurements. The model was run under two different kinematic inputs and two different insert designs with curved and custom designed flat bearing surfaces. The new wear model was shown to be capable of predicting the difference of the wear volume and wear pattern between the two kinematic inputs and the two tibial insert designs. Conversely, the wear factor based approach did not predict such differences. The good agreement found between the computational and experimental results, on both the wear scar areas and volumetric wear rates, suggests that the computational wear modelling based on the new wear law and the experimentally calculated non-dimensional wear coefficient should be more reliable and therefore provide a more robust virtual modelling platform.