A numerically validated probabilistic model of a simplified total hip replacement construct

Hip replacement constructs are paradigms of uncertain systems, and as such are suited to the application of probabilistic methods to assess their structural integrity. In order to gain confidence in a probabilistic model, it would be useful to verify the findings with experimental data; however, this is difficult to achieve in practice because of the exhaustive number of parameter combinations that need to be tested. As an alternative to experimental testing, benchmarking can be carried out provided a known analytical solution is available. To this end, a simplified 2D two-beam model of the femoral part of a total hip replacement construct was utilised to analyse uncertainties and variability in the construct as it is subjected to load. The use of a simplified model enabled geometric parameters to be investigated; these are commonly not considered in probabilistic models due to the increased complexity involved. Analytical and finite element representations of the model were developed and compared. The probabilistic study used the Monte Carlo simulation technique and the first-order reliability method to look at the inducible displacement of a hip implant, a phenomenon that has been linked to the most common cause of hip implant failure, aseptic loosening. Excellent correlation was observed between the analytical and probabilistic solutions, and it was shown that probabilistic approaches could efficiently predict the response of the simplified beam model while readily identifying the parameters most likely to compromise the structural integrity of the construct.     

Probabilistic finite element analysis of the uncemented hip replacement—effect of femur characteristics and implant design geometry

In the present study, a probabilistic finite element tool was assessed using an uncemented total hip replacement model. Fully bonded and frictional interfaces were investigated for combinations of three proximal femurs and two implant designs, the Proxima short stem and the IPS hip stem prostheses. The Monte Carlo method was used with two performance indicators: the percentage of bone volume that exceeded specified strain limits and the maximum nodal micromotion. The six degrees of freedom of bone-implant relative position, magnitude of the hip contact force (L), and spatial direction of L were the random variables. The distal portion of the proximal femurs was completely constrained and some of the main muscle forces acting in the hip were applied. The coefficients of the linear approximation between the random variables and the output were used as the sensitivity values. In all cases, bone-implant position related parameters were the most sensitive parameters. The results varied depending on the femur, the implant design and the interface conditions. Values of maximum nodal micromotion agreed with results from previous studies, confirming the robustness of the implemented computational tool. It was demonstrated that results from a single model study should not be generalised to the entire population of femurs and that bone variability is an important factor that should be investigated in such analyses.     

Activity intensity,assistive devices and joint replacement influence predicted remodelling in the proximal femur

Bone morphology and density changes are commonly observed following joint replacement, may contribute to the risks of implant loosening and periprosthetic fracture and reduce the available bone stock for revision surgery. This study was presented in the ‘Bone and Cartilage Mechanobiology across the scales’ WCCM symposium to review the development of remodelling prediction methods and to demonstrate simulation of adaptive bone remodelling around hip replacement femoral components, incorporating intrinsic (prosthesis) and extrinsic (activity and loading) factors. An iterative bone remodelling process was applied to finite element models of a femur implanted with a cementless total hip replacement (THR) and a hip resurfacing implant. Previously developed for a cemented THR implant, this modified process enabled the influence of pre- to post-operative changes in patient activity and joint loading to be evaluated. A control algorithm used identical pre- and post-operative conditions, and the predicted extents and temporal trends of remodelling were measured by generating virtual X-rays and DXA scans. The modified process improved qualitative and quantitative remodelling predictions for both the cementless THR and resurfacing implants, but demonstrated the sensitivity to DXA scan region definition and appropriate implant–bone position and sizing. Predicted remodelling in the intact femur in response to changed activity and loading demonstrated that in this simplified model, although the influence of the extrinsic effects were important, the mechanics of implantation were dominant. This study supports the application of predictive bone remodelling as one element in the range of physical and computational studies, which should be conducted in the preclinical evaluation of new prostheses.     

Comparison of in vivo measured loads in knee,hip and spinal implants during level walking

Walking is a task that we seek to understand because it is the most relevant human locomotion. Walking causes complex loading patterns and high load magnitudes within the human body. This work summarizes partially published load data collected in earlier in vivo measurement studies on 9 patients with telemeterized knee endoprostheses, 10 with hip endoprostheses and 5 with vertebral body replacements. Moreover, for the 19 endoprosthesis patients, additional simultaneously measured and previously unreported ground reaction forces are presented.The ground reaction force and the implant forces in the knee and hip exhibited a double peak during each step. The maxima of the ground reaction forces ranged from 100% to 126% bodyweight. In comparison, the greatest implant forces in the hip (249% bodyweight) and knee (271% bodyweight) were much greater. The mean peak force measured in the vertebral body replacement was 39% bodyweight and occurred at different time points of the stance phase.We concluded that walking leads to high load magnitudes in the knee and hip, whereas the forces in the vertebral body replacement remained relatively low. This indicates that the first peak force was greater in the hip than in the knee joint while this was reversed for the second peak force. The forces in the spinal implant were considerably lower than in the knee and hip joints.     

Animal models relevant to cementless joint replacement

This review focuses on animal models used to study certain aspects of 'cementless' joint replacement. Implants used in this application are designed to become attached to the host skeleton through either bone ingrowth into porous surfaces or bone apposition (ongrowth) onto other types of surfaces. Biological fixation of cementless joint replacement implants relies on intramembranous bone regeneration. We describe a framework for understanding research design in light of the type of research questions now being asked. In particular, species choice, implant design and placement, and experimental endpoints are described in some detail. We provide a summary of recent studies specifically focused on implant fixation, demonstrating that most work is still at the morphological and biomechanical levels with little understanding at the molecular level. We also provide a more comprehensive listing of studies using hip and knee replacement models, demonstrating that most work is focused on the interface, and responses of the immediately adjacent trabecular bone and the more distant cortical bone. We conclude by encouraging investigators to design their experiments so that there is enough power to answer a limited number of questions as opposed to providing limited data on a broader number of issues.     

Multiscale design and multiobjective optimization of orthopedic hip implants with functionally graded cellular material

Revision surgeries of total hip arthroplasty are often caused by a deficient structural compatibility of the implant. Two main culprits, among others, are bone-implant interface instability and bone resorption. To address these issues, in this paper we propose a novel type of implant, which, in contrast to current hip replacement implants made of either a fully solid or a foam material, consists of a lattice microstructure with nonhomogeneous distribution of material properties. A methodology based on multiscale mechanics and design optimization is introduced to synthesize a graded cellular implant that can minimize concurrently bone resorption and implant interface failure. The procedure is applied to the design of a 2D left implanted femur with optimized gradients of relative density. To assess the manufacturability of the graded cellular microstructure, a proof-of-concept is fabricated by using rapid prototyping. The results from the analysis are used to compare the optimized cellular implant with a fully dense titanium implant and a homogeneous foam implant with a relative density of 50%. The bone resorption and the maximum value of interface stress of the cellular implant are found to be over 70% and 50% less than the titanium implant while being 53% and 65% less than the foam implant.     

Method for the evaluation of factors influencing the dislocation stability of total hip endoprotheses]

Dislocation of the artificial joint is a serious complication of total hip replacement. Various factors with an influence on dislocation stability were determined clinically. Our goal was to develop a method for evaluating experimentally the parameters implant design, position and the load situation for their influence on joint stability. With the newly developed testing device the range of motion to impingement and to dislocation can be determined at different implant positions. In addition, the rotational moments on subluxation, i.e. the "levering out" of the femoral head, can be determined. By way of example several hip implants were examined during movements associated with dislocation, e.g. (internal-)rotation in 90 degrees flexion and 0 degrees adduction as well as with (external-)rotation in combination with 10 degrees extension and 15 degrees adduction. Irrespective of implant design and position, the following movement phases can be differentiated: undisturbed motion, impingement, subluxation and, finally, complete dislocation of the head. On the basis of the range of motion of the specific phases, the moments occurring and the direction of dislocation, different implant systems can be compared. In this study the influence of the head diameter on the dislocation stability of the hip endoprosthesis is shown. With the aid of the model presented herein, a data set showing the most favourable and/or most dislocation stable implant position can be acquired for different combinations of the implant components. Additionally, useful information for implant design can be deduced and applied to new developments and/or modifications of existing implant components.     

Finite element and experimental models of cemented hip joint reconstructions can produce similar bone and cement strains in pre-clinical tests

Finite element (FE) models could be used for pre-clinical testing of cemented hip replacement implants against the damage accumulation failure scenario. To accurately predict mechanical failure, the models should accurately predict stresses and strains. This should be the case for various implants. In the current study, two FE models of composite hip reconstructions with two different implants were validated relative to experimental bone and cement strains. The objective was an overall agreement within 10% between experimental and FE strains. Two stem types with different clinical results were analyzed: the Lubinus SPII and the Mueller Curved with loosening rates of 4% and 16% after 10 yr, respectively (Prognosis of total hip replacement. 63rd Annual Meeting of the American Academy of orthopaedic surgeons, Atlanta, USA). For both implant types, six stems were implanted in composite femurs. All specimens were subjected to bending. The Mueller Curved specimens were additionally subjected to torsion. Bone strains were recorded at 10 locations on the cortex and cement strains at three locations within the cement mantle. An FE model was built for both stem types and the experiments were simulated. Bone and cement strains were calculated at the experimental gauge locations. Most FE bone strains corresponded to the mean experimental strains within two standard deviations; most FE cement strains within one standard deviation. Linear regression between the FE and mean experimental strains produced slopes between 0.82 and 1.03, and R(2) values above 0.98. Particularly for the Mueller Curved, agreement improved considerably when FE strains were compared to the strains from the experimental specimen used to build the FE model. The objective of overall agreement within 10% was achieved, indicating that both FE models were successfully validated. This prerequisite for accurately predicting long-term failure has been satisfied.     

The role of patient, surgical, and implant design variation in total knee replacement performance

Clinical studies demonstrate substantial variation in kinematic and functional performance within the total knee replacement (TKR) patient population. Some of this variation is due to differences in implant design, surgical technique and component alignment, while some is due to subject-specific differences in joint loading and anatomy that are inherently present within the population. Combined finite element and probabilistic methods were employed to assess the relative contributions of implant design, surgical, and subject-specific factors to overall tibiofemoral (TF) and patellofemoral (PF) joint mechanics, including kinematics, contact mechanics, joint loads, and ligament and quadriceps force during simulated squat, stance-phase gait and stepdown activities. The most influential design, surgical and subject-specific factors were femoral condyle sagittal plane radii, tibial insert superior-inferior (joint line) position and coronal plane alignment, and vertical hip load, respectively. Design factors were the primary contributors to condylar contact mechanics and TF anterior-posterior kinematics; TF ligament forces were dependent on surgical factors; and joint loads and quadriceps force were dependent on subject-specific factors. Understanding which design and surgical factors are most influential to TKR mechanics during activities of daily living, and how robust implant designs and surgical techniques must be in order to adequately accommodate subject-specific variation, will aid in directing design and surgical decisions towards optimal TKR mechanics for the population as a whole.     

The primary stability of a cementless stem varies between subjects as much as between activities

The rehabilitation program adopted immediately after a cementless total hip replacement is a very important factor, because of the known relationship between osseointegration and implant micromotion. The present study was aimed to evaluate which type of task is the most critical in terms of bone-implant relative micromotion. Both inter-task and inter-subject variability were taken into account to verify if the movement strategy could be determinant on this assessment. A previously validated finite element model was used to predict the peak total micromovements over the entire bone-implant contact surface in four different patients, performing nine different tasks, using published data on joint forces recorded by instrumented hip prostheses. The results predicted by the various simulations suggest that while stair climbing is surely a critical task for primary stability, for some subjects other tasks may be as critical as stair climbing. From a variance analysis for simple crossover design on the predicted peak micromotion, the inter-subject variability had much more influence on the primary stability of cementless implant than the inter-task variability. Even if the results of Patient IBL, who was reported to have difficulties to perform any activities in a normal way, were excluded from the statistical analysis, the inter-subject variability remained still higher than the inter-task variability. The results obtained from simulations suggest that the strategy the hip replacement patient adopts to perform a given motor task, may be, for the implant stability, equally or even more critical than the type of motor task performed.     

Time-dependent functional maturation of scaffold-free cartilage tissue analogs

One of the most critical parameters in cartilage tissue engineering which influences the clinical success of a repair therapy is the ability to match the load-bearing capacity of the tissue as it functions in vivo. While mechanical forces are known to positively influence the development of cartilage matrix architecture, these same forces can induce long-term implant failure due to poor integration or structural deficiencies. As such, in the design of optimal repair strategies, it is critical to understand the timeline of construct maturation and how the elaboration of matrix correlates with the development of mechanical properties. We have previously characterized a scaffold-free method to engineer cartilage utilizing primary chondrocytes cultured at high density in hydrogel-coated culture vessels to promote the formation of a self-aggregating cell suspension that condenses to form a cartilage-like biomass, or cartilage tissue analog (CTA). Chondrocytes in these CTAs maintain their cellular phenotype and deposit extracellular matrix to form a construct that has characteristics similar to native cartilage; however, the mechanical integrity of CTAs had not yet been evaluated. In this study, we found that chondrocytes within CTAs produced a robust matrix of proteoglycans and collagen that correlated with increasing mechanical properties and decreasing cell-matrix ratios, leading to properties that approached that of native cartilage. These results demonstrate a unique approach to generating a cartilage-like tissue without the complicating factor of scaffold, while showing increased compressive properties and matrix characteristics consistent with other approaches, including scaffold-based constructs. To further improve the mechanics of CTAs, studies are currently underway to explore the effect of hydrodynamic loading and whether these changes would be reflective of in vivo maturation in animal models. The functional maturation of cartilage tissue analogs as described here support this engineered cartilage model for use in clinical and experimental applications for repair and regeneration in joint-related pathologies.     

The Phan-Thien and Tanner model applied to thin film spherical coordinates: applications for lubrication of hip joint replacement

The Phan-Thien and Tanner (PTT) model is one of the most widely used rheological models. It can properly describe the common characteristics of viscoelastic non-Newtonian fluids. There is evidence that synovial fluid in human joints, which also lubricates artificial joints, is viscoelastic. Modeling the geometry of the total hip replacement, the PTT model is applied in spherical coordinates for a thin confined fluid film. A modified Reynolds equation is developed for this geometry. Several simplified illustrative problems are solved. The effect of the edge boundary condition on load-carrying normal stress is discussed. Solutions are also obtained for a simple squeezing flow. The effect of both the relaxation time and the PTT shear parameter is to reduce the load relative to a Newtonian fluid with the same viscosity. This implies that the Newtonian model is not conservative and may overpredict the load capacity. The PTT theory is a good candidate model to use for joint replacement lubrication. It is well regarded and derivable from molecular considerations. The most important non-Newtonian characteristics can be described with only three primary material parameters.     

Pseudo-dynamic analysis of a cemented hip arthroplasty using a force method based on the Newmark algorithm

The main goal of this work was to develop an approached model to study dynamic behavior and prediction of the stress distribution in an in vitro Charnley cemented hip arthroplasty. An alternative version of the described pseudo-dynamic procedure is proposed by using the time integration Newmark algorithm. An internal restoring force vector is numerically calculated from the displacement, velocity, and acceleration vectors. A numerical model of hip replacement was developed to analyze the deformation of a dynamically stressed structure for all time steps. The experimental measurement of resulting internal forces generated in the structure (internal restoring force vector) is the second fundamental step of the pseudo-dynamic procedure. These data (as a feedback) are used by the time integration algorithm, which allows updating of the structure's shape for the next displacement, velocity, and acceleration vectors. In the field of Biomechanics, the potentialities of this method contribute to the determination of a dynamically equivalent in vitro stress field of a cemented hip prosthesis; implant fitted in patients with a normal mobility or practice sports. Consequences of the stress distribution in the implant zone that underwent cyclic fatigue loads were also discussed by using a finite element model. Application of this method in Biomechanics appears as a useful tool in the approximate stress field characterization of the peak stress state. Results show a peak value around two times the static situation, more for making possible the prediction of future damage and a programed clinical examination in patients using hip prosthesis.     

Selection of an animal model for implant fixation studies: anatomical aspects.

A number of different animal models have been employed by investigators to study the biology of the bone-cement interface as it relates to the problem of hip implant loosening in humans. This study compares to the human three species (baboon, dog, and sheep) currently under use as experimental animal models from an anatomical point of view. A number of parameters, important for the dimensional design of a femoral prosthesis, loads at the hip joint and its subsequent performance, were used for comparing external and internal femoral anatomy. The baboon and dog femora were found to be most similar to the human femur in their external anatomy. The quantification of cancellous bone distribution within the medullary canal revealed that, of the species studied, the sheep femur provided the least support to the prosthesis. The results suggest that the dog and baboon are anatomically appropriate for studying hip implant biomechanics experimentally. Thus, from an anatomical point of view, the current extensive use of the dog as an experimental animal appears appropriate.     

Construction of simplified models to simulate estrogenic disruptions by esters of 4-hydroxy benzoic acid (parabens)

Four parabens (methyl, n-butyl, benzyl and isobutylparaben) were theoretically studied in order to evaluate their estrogenic activity through simplified models. The experimental structure of the human estrogen receptor ligand-binding domain in complex with 17β-estradiol was used as the starting point to construct the models. The complex between 17β-estradiol and three fragments of the estrogenic receptor (Arg, Glu and His), resulted in a reasonable simplified model of interaction. The replacement of 17-β-estradiol by parabens was evaluated by conformational analyses and interaction energy calculations at BHandHLYP/cc-PVTZ(-f)+ level of theory. According with the calculated interaction energies, methylparaben is the paraben with higher estrogenic activity, which is in agreement with experimental studies of extraction and quantification of parabens in tumors. The antibacterial activity of parabens was also explored considering the formation of potassium salts in the phenolic OH groups. From the obtained relative energy values, methylparaben is the most active preservative.     

Frictional heating of total hip implants. Part 2: finite element study

Due to higher friction artificial hip joints warm up more than natural joints during walking and other continuous activities. This could lead to thermal damage in the surrounding tissues and be a reason for long-term implant loosening, an effect which has not yet been investigated. In vivo measurements with instrumented implants showed temperatures inside the prosthetic head up to 43.1 degrees C (Part 1 of this work). Based on the experimental data a finite element model was developed to calculate the temperatures in the tissues surrounding the hip implant to determine whether these tissues can heat up to critical levels. Various parameters were investigated which could account for the variations in the measured temperatures in the patients, including the perfusion rate in tissues, the volume of synovial fluid, and different implant materials. We found that the synovial fluid is most endangered by thermal damage and consequent deterioration of lubricating properties. Implants with a cobalt-chromium head and a polyethylene cup are unfavourable as they can elevate the temperature in the synovia to more than 46 degrees C. With regard to thermal properties stems made from cobalt-chromium alloys are superior to titanium stems, by better conducting heat to the femur and minimizing the synovial fluid temperature. Factors determining the temperatures during walking are insufficiently known or cannot be determined in the individual patient. Therefore, the risk of a thermally induced implant loosening cannot currently be estimated. Under unfavourable conditions such a risk exists, however. General improvements of implant materials and clinical studies on the possibility of implant loosening due to high temperatures are therefore required.     

A probabilistic network model for structural transitions in biomolecules

Biological macromolecules often undergo large conformational rearrangements during a functional cycle. To simulate these structural transitions with full atomic detail typically demands extensive computational resources. Moreover, it is unclear how to incorporate, in a principled way, additional experimental information that could guide the structural transition. This article develops a probabilistic model for conformational transitions in biomolecules. The model can be viewed as a network of anharmonic springs that break, if the experimental data support the rupture of bonds. Hamiltonian Monte Carlo in internal coordinates is used to infer structural transitions from experimental data, thereby sampling large conformational transitions without distorting the structure. The model is benchmarked on a large set of conformational transitions. Moreover, we demonstrate the use of the probabilistic network model for integrative modeling of macromolecular complexes based on data from crosslinking followed by mass spectrometry.     

A finite element analysis of the vibration behaviour of a cementless hip system

An early diagnosis of aseptic loosening of a total hip replacement (THR) by plain radiography, scintigraphy or arthography has been shown to be less reliable than using a vibration technique. However, it has been suggested that it may be possible to distinguish between a secure and a loose prosthesis using a vibration technique. In fact, vibration analysis methods have been successfully used to assess dental implant stability, to monitor fracture healing and to measure bone mechanical properties. Several studies have combined the vibration technique with the finite element (FE) method in order to better understand the events involved in the experimental technique. In the present study, the main goal is to simulate the change in the resonance frequency during the osseointegration process of a cementless THR (Zweymüller). The FE method was used and a numerical modal analysis was conducted to obtain the natural frequencies and mode shapes under vibration. The effects were studied of different bone and stem material properties, and different contact conditions at the bone–implant interface. The results were in agreement with previous experimental and computational observations, and differences among the different cases studied were detected. As the osseointegration process at the bone–implant interface evolved, the resonance frequency values of the femur–prosthesis system also increased. In summary, vibration analysis combined with the FE method was able to detect different boundary conditions at the bone–implant interface in cases of both osseointegration and loosening.     

Implant Optimisation for Primary Hip Replacement in Patients over 60 Years with Osteoarthritis: A Cohort Study of Clinical Outcomes and Implant Costs Using Data from England and Wales

Background

Hip replacement is one of the most commonly performed surgical procedures worldwide; hundreds of implant configurations provide options for femoral head size, joint surface material and fixation method with dramatically varying costs. Robust comparative evidence to inform the choice of implant is needed. This retrospective cohort study uses linked national databases from England and Wales to determine the optimal type of replacement for patients over 60 years undergoing hip replacement for osteoarthritis.

Methods and Findings

Implants included were the commonest brand from each of the four types of replacement (cemented, cementless, hybrid and resurfacing); the reference prosthesis was the cemented hip procedure. Patient reported outcome scores (PROMs), costs and risk of repeat (revision) surgery were examined. Multivariable analyses included analysis of covariance to assess improvement in PROMs (Oxford hip score, OHS, and EQ5D index) (9159 linked episodes) and competing risks modelling of implant survival (79,775 procedures). Cost of implants and ancillary equipment were obtained from National Health Service procurement data.

Results

EQ5D score improvements (at 6 months) were similar for all hip replacement types. In females, revision risk was significantly higher in cementless hip prostheses (hazard ratio, HR = 2.22, p<0.001), when compared to the reference hip. Although improvement in OHS was statistically higher (22.1 versus 20.5, p<0.001) for cementless implants, this small difference is unlikely to be clinically important. In males, revision risk was significantly higher in cementless (HR = 1.95, p = 0.003) and resurfacing implants, HR = 3.46, p<0.001), with no differences in OHS. Material costs were lowest with the reference implant (cemented, range £1103 to £1524) and highest with cementless implants (£1928 to £4285).Limitations include the design of the study, which is intrinsically vulnerable to omitted variables, a paucity of long-term implant survival data (reflecting the duration of data collection), the possibility of revision under-reporting, response bias within PROMs data, and issues associated with current outcome scoring systems, which may not accurately reflect level of improvement in some patients.

Conclusions

Cement fixation, using a polyethylene cup and a standard sized head offers good outcomes, with the lowest risks and at the lowest costs. The most commonly used cementless and resurfacing implants were associated with higher risk of revision and were more costly, while perceptions of improved function and longevity were unsupported.     

A Biomimetic Hip Joint Simulator and its Application in in vitro Study of the Integrity of Replacement Cemented Hip

1IntroductionAseptic loosening is a major clinical probleminterfering with long term success of arthroplasty inhumans.When this occurs,the stem will migrate withinthe cortical bone.The migration of the stem after hiparthroplasty is an unavoidable phenomenon and is one ofthe major cause of late aseptic loosening of the hiparthroplasty[1-5].Many factors,such as cement mantle performance,stem type and surface finish,cementing and surgerytechniques affect the subsidence or migration of thefemoral …