Adaptive glenoid bone remodeling simulation

Glenoid prosthesis loosening is the most common cause for revision total shoulder arthroplasty. Stress-induced bone remodeling may compromise long-term prosthesis fixation and significantly contribute to loosening. Realistic, robust analysis of bone-prosthesis constructs need to look beyond initial post-implantation mechanics provided by static finite element (FE) simulation. Adaptive bone remodeling simulations based on Wolff's law are needed for evaluating long-term glenoid prostheses fixation. The purpose of this study was to take a first step towards this goal and create and validate two-dimensional FE simulations, using the intact glenoid, for computing subject-specific adaptive glenoid remodeling. Two-dimensional glenoid FE models were created from scapulae computed tomography images. Two distinct processes, “element” and “node” simulations, used the forward-Euler method to compute bone remodeling. Initial bone density was homogeneous. Center and offset load combinations were iteratively applied. To validate the simulations we performed location-specific statistical comparisons between predicted and actual bone density, load combinations, and “element” and “node” processes. Visually and quantitatively “element” simulations produced better results (p>0.22), and correlation coefficients ranged 0.51–0.69 (p<0.001). Having met this initial work's goals, we expect subject-specific FE glenoid bone remodeling simulations together with static FE stress analyses to be effective tools for designing and evaluating glenoid prostheses.     

Stress analysis of cemented glenoid prostheses in total shoulder arthroplasty

Glenoid component loosening is the most-frequently encountered problem in the total shoulder arthroplasty. The purpose of the study was to investigate whether failure of the glenoid component is caused by stresses generated within the cement mantle, implant materials and at the various interfaces during humeral abduction, using 3-D FE analyses of implanted glenoid structures. FE models, one total polyethylene and the other, metal backed polyethylene, were developed using CT-scan data and submodelling technique, which was based on an overall solution of a natural scapula model acted upon by all the muscles, ligaments and joint reaction forces. Material interfaces were assumed to be fully bonded. Based on the FE stress analysis, the following observations were made. (1) The submodelling technique, which required a large-size submodel and the use of prescribed displacements at cut-boundaries located far away from the glenoid, was crucial for evaluations on glenoid component. (2) Total polyethylene results in lower-peak stresses (tensile: 10 MPa, Von-Mises: 8.31 MPa) in the cement as compared to a metal-backed design (tensile: 11.5 MPa, Von-Mises: 9.81 MPa). The maximum principal (tensile) stresses generated in the cement mantle for both the designs were below its failure strength, but might evoke crack initiation. (3) The cement-bone interface adjacent to the tip of the keel seemed very likely to fail for both the designs. In case of metal-backed design, this interface adjacent to the tip of the keel appears even more likely to fail. (4) High metal-cement interface stresses for a moderate load might indicate failure at higher load. (5) It appears that both the designs were vulnerable to failure in some ways or the other. A part of the subchondral bone along the longitudinal axis of the glenoid cavity should be preserved to strengthen the glenoid structure and to reduce the use of cement.     

Three-dimensional finite element analysis of glenoid replacement prostheses: a comparison of keeled and pegged anchorage systems

Glenoid component loosening is the dominant cause of failure in total shoulder arthroplasty. It is presumed that loosening in the glenoid is caused by high stresses in the cement layer. Several anchorage systems have been designed with the aim of reducing the loosening rate, the two major categories being "keeled" fixation and "pegged" fixation. However, no three-dimensional finite element analysis has been performed to quantify the stresses in the cement or to compare the different glenoid prosthesis anchorage systems. The objective of this study was to determine the stresses in the cement layer and surrounding bone for glenoid replacement components. A three-dimensional model of the scapula was generated using CT data for geometry and material property definition. Keeled and pegged designs were inserted into the glenoid, surrounded by a 1-mm layer of bone cement. A 90 deg arm abduction load with a full muscle and joint load was applied, following van der Helm (1994). Deformations of the prosthesis, stresses in the cement, and stresses in the bone were calculated. Stresses were also calculated for a simulated case of rheumatoid arthritis (RA) in which bone properties were modified to reflect that condition. A maximum principal stress-based failure model was used to predict what quantity of the cement is at risk of failure at the levels of stress computed. The prediction is that 94 percent (pegged prosthesis) and 68 percent (keeled prosthesis) of the cement has a greater than 95 percent probability of survival in normal bone. In RA bone, however, the situation is reversed where 86 percent (pegged prosthesis) and 99 percent (keeled prosthesis) of the cement has a greater than 95 percent probability of survival. Bone stresses are shown to be not much affected by the prosthesis design, except at the tip of the central peg or keel. It is concluded that a "pegged" anchorage system is superior for normal bone, whereas a "keeled" anchorage system is superior for RA bone.     

Bone remodelling around a cementless glenoid component

Post-operative change in the mechanical loading of bone may trigger its (mechanically induced) adaptation and hamper the mechanical stability of prostheses. This is especially important in cementless components, where the final fixation is achieved by the bone itself. The aim of this study is, first, to gain insight into the bone remodelling process around a cementless glenoid component, and second, to compare the possible bone adaptation when the implant is assumed to be fully bonded (best case scenario) or completely loose (worst case scenario). 3D finite element models of a scapula with and without a cementless glenoid component were created. 3D geometry of the scapula, material properties, and several physiological loading conditions were acquired from or estimated for a specific cadaver. Update of the bone density after implantation was done according to a node-based bone remodelling scheme. Strain energy density for different loading conditions was evaluated, weighted according to their frequencies in activities of daily life and used as a mechanical stimulus for bone adaptation. The average bone density in the glenoid increased after implantation. However, local bone resorption was significant in some regions next to the bone-implant interface, regardless of the interface condition (bonded or loose). The amount of bone resorption was determined by the condition imposed to the interface, being slightly larger when the interface was loose. An ideal screw, e.g. in which material fatigue was not considered, was enough to keep the interface micromotions small and constant during the entire bone adaptation simulation.     

Numerical analysis of an osseointegrated prosthesis fixation with reduced bone failure risk and periprosthetic bone loss

Currently available implants for direct attachment of prosthesis to the skeletal system after transfemoral amputation (OPRA system, Integrum AB, Sweden and ISP Endo/Exo prosthesis, ESKA Implants AG, Germany) show many advantages over the conventional socket fixation. However, restraining biomechanical issues such as considerable bone loss around the stem and peri-prosthetic bone fractures are present. To overcome these limiting issues a new concept of the direct intramedullary fixation was developed. We hypothesize that the new design will reduce the peri-prosthetic bone failure risk and adverse bone remodeling by restoring the natural load transfer in the femur. Generic CT-based finite element models of an intact femur and amputated bones implanted with 3 analyzed implants were created and loaded with a normal walking and a forward fall load. The strain adaptive bone remodeling theory was used to predict long-term bone changes around the implants and the periprosthetic bone failure risk was evaluated by the von Mises stress criterion. The results show that the new design provides close to physiological distribution of stresses in the bone and lower bone failure risk for the normal walking as compared to the OPRA and the ISP implants. The bone remodeling simulations did not reveal any overall bone loss around the new design, as opposed to the OPRA and the ISP implants, which induce considerable bone loss in the distal end of the femur. This positive outcome shows that the presented concept has a potential to considerably improve safety of the rehabilitation with the direct fixation implants.     

Multi-factorial analysis of variables influencing the bone loss of an implant placed in the maxilla: Prediction using FEA and SED bone remodeling algorithm

The aim of this study was to investigate the interactions of implant position, implant–abutment connection and loading condition influencing bone loss of an implant placed in the maxilla using finite element (FE) analysis and mathematical bone remodeling theory. The maxilla section contours were acquired using CT images to construct FE models containing RS (internal retaining-screw) and the TIS (taper integrated screwed-in) implants placed in SC (along the axis of occlusal force) and RA (along the axis of residual ridge) positions. The adaptive strain energy density (SED) algorithm was combined with FE approach to study the preliminary bone remodeling around implant systems under different load conditions. The simulated results showed that the implant position obviously influenced the bone loss. An implant placed in the RA position resulted in substantially increased bone loss. Implant receiving a lateral load slightly increased bone loss compared with an axial load. The implant type did not significantly influence bone loss. It was found that buccal site suffered the most bone loss around the implant, followed by distal, lingual and mesial sites. The implant position primarily influenced bone loss and it was found most obviously at the buccal site. Implant placed along the axial load direction of a proposed prosthesis could obtain less bone loss around the implant. Attaining proper occlusal adjustments to reduce the lateral occlusal force is recommended in implant–bone–prosthesis system. Abutments of internal engagement with or without taper-fit did not affect the bone loss in the surrounding bone.     

Finite element and experimental cortex strains of the intact and implanted tibia

Finite Element (FE) models for the simulation of intact and implanted bone find their main purpose in accurately reproducing the associated mechanical behavior. FE models can be used for preclinical testing of joint replacement implants, where some biomechanical aspects are difficult, if not possible, to simulate and investigate in vitro. To predict mechanical failure or damage, the models should accurately predict stresses and strains. Commercially available synthetic femur models have been extensively used to validate finite element models, but despite the vast literature available on the characteristics of synthetic tibia, numerical and experimental validation of the intact and implant assemblies of tibia are very limited or lacking. In the current study, four FE models of synthetic tibia, intact and reconstructed, were compared against experimental bone strain data, and an overall agreement within 10% between experimental and FE strains was obtained. Finite element and experimental (strain gauge) models of intact and implanted synthetic tibia were validated based on the comparison of cortex bone strains. The study also includes the analysis carried out on standard tibial components with cemented and noncemented stems of the P.F.C Sigma Modular Knee System. The overall agreement within 10% previously established was achieved, indicating that FE models could be successfully validated. The obtained results include a statistical analysis where the root-mean-square-error values were always <10%. FE models can successfully reproduce bone strains under most relevant acting loads upon the condylar surface of the tibia. Moreover, FE models, once properly validated, can be used for preclinical testing of tibial knee replacement, including misalignment of the implants in the proximal tibia after surgery, simulation of long-term failure according to the damage accumulation failure scenario, and other related biomechanical aspects.     

Acromion-fixation of glenoid components in total shoulder arthroplasty

Successful design of components for total shoulder arthroplasty has proven to be challenging. This is because of the difficulties in maintaining fixation of the component that inserts into the scapula; i.e., the glenoid component. Glenoid components that are fixated to both the glenoid and acromion (a long process extending medially on the dorsal aspect of the scapula) have the possible advantage of greater stability over those that are fixated to the glenoid alone. In this study, a finite element analysis is used to investigate whether or not acromion fixation is advantageous for glenoid components. Full muscle loading and joint reaction forces are included in the finite element model. Reflective photoelasticity of five scapulae is used to obtain experimental data to compare with results from the finite element analysis, and it confirms the structural behaviour of the finite element model. When implanted with an acromion-fixated prosthesis, it is found that high unphysiological stresses occur in the scapula bone, and that stresses in the fixation are not reduced. Very high stresses are predicted in that part of the prosthesis which connects the acromion to the glenoid. It is found that the very high stresses are partly in response to the muscle and joint reaction forces acting at the acromion. It is concluded that, because of the relatively high forces acting at the acromion, fixation to it may not be the way forward in glenoid component design.     

Adaptive bone-remodeling theory applied to prosthetic-design analysis

The subject of this article is the development and application of computer-simulation methods to predict stress-related adaptive bone remodeling, in accordance with 'Wolff's Law'. These models are based on the Finite Element Method (FEM) in combination with numerical formulations of adaptive bone-remodeling theories. In the adaptive remodeling models presented, the Strain Energy Density (SED) is used as a feed-back control variable to determine shape or bone density adaptations to alternative functional requirements, whereby homeostatic SED distribution is assumed as the remodeling objective. These models are applied to investigate the relation between 'stress shielding' and bone resorption in the femoral cortex around intramedullary prostheses, such as used in Total Hip Arthroplasty (THA). It is shown that the amount of bone resorption depends mainly on the rigidity and the bonding characteristics of the implant. Homeostatic SED can be obtained when the resorption process occurs at the periosteal surface, rather than inside the cortex, provided that the stem is adequately flexible.     

Finite element modelling of glenohumeral kinematics following total shoulder arthroplasty

Due to the shallowness of the glenohumeral joint, a challenging but essential requirement of a glenohumeral prosthesis is the prevention of joint dislocation. Weak glenoid bone stock and frequent dysfunction of the rotator cuff, both of which are common with rheumatoid arthritis, make it particularly difficult to achieve this design goal. Although a variety of prosthetic designs are commercially available only a few experimental studies have investigated the kinematics and dislocation characteristics of design variations. Analytical or numerical methods, which are predictive and more cost-effective, are, apart from simple rigid-body analyses, non-existent. The current investigation presents the results of a finite element analysis of the kinematics of a total shoulder joint validated using recently published experimental data for the same prostheses. The finite element model determined the loading required to dislocate the humeral head, and the corresponding translations, to within 4% of the experimental data. The finite element method compared dramatically better to the experimental data (mean difference=2.9%) than did rigid-body predictions (mean difference=37%). The goal of this study was to develop an accurate method that in future studies can be used for further investigations of the effect of design parameters on dislocation, particularly in the case of a dysfunctional rotator cuff. Inherently, the method also evaluates the glenoid fixation stresses in the relatively weak glenoid bone stock. Hence, design characteristics can be simultaneously optimised against dislocation as well as glenoid loosening.     

Bone remodelling of the scapula after a total shoulder arthroplasty

According to Wolff’s law, the changes in stress after a prosthesis implantation may modify the shape and internal structure of bone, thus compromising the long-term prosthesis fixation and, consequently, be a significant factor for glenoid loosening. The aim of the present study is to evaluate the changes in the bone adaptation process of the scapula after an anatomical and reverse total shoulder arthroplasty. Five finite element models of the implanted scapula are developed considering the implantation of three anatomical, cemented, all-polyethylene components; an anatomical, cementless, metal-backed component; and a reverse, all-metal component. The methodology followed to simulate the bone adaptation of the scapula was previously validated for the intact model, prior to the prosthesis implantation. Additionally, the influence of the bone quality on the adaptation process is also investigated by considering an osteoporotic condition. The results show that the stress shielding phenomenon is more concerning in cementless, metal-based components than in cemented, all-polyethylene components, regardless of the bone quality. Consequently, as far as the bone adaptation process of the bone is concerned, cemented, all-polyethylene components are better suited for the treatment of the shoulder joint.     

Bone ingrowth simulation for a concept glenoid component design

Glenoid component loosening is the major problem of total shoulder arthroplasty. It is possible that uncemented component may be able to achieve superior fixation relative to cemented component. One option for uncemented glenoid is to use porous tantalum backing. Bone ingrowth into the porous backing requires a degree of stability to be achieved directly post-operatively. This paper investigates the feasibility of bone ingrowth with respect to the influence of primary fixation, elastic properties of the backing and friction at the bone prosthesis interface. Finite element models of three glenoid components with different primary fixation configurations are created. Bone ingrowth into the porous backing is modelled based on the magnitude of the relative interface micromotions and mechanoregulation of the mesenchymal stem cells that migrated via the bonded part of the interface. Primary fixation had the most influence on bone ingrowth. The simulation showed that its major role was not to firmly interlock the prosthesis, but rather provide such a distribution of load, that would result in reduction of the peak interface micromotions. Should primary fixation be provided, friction has a secondary importance with respect to bone ingrowth while the influence of stiffness was counter intuitive: a less stiff backing material inhibits bone ingrowth by higher interface micromotions and stimulation of fibrous tissue formation within the backing.     

Experimental and probabilistic analysis of distal femoral periprosthetic fracture: a comparison of locking plate and intramedullary nail fixation. Part B: probabilistic investigation

The following is Part B of a two-part study. Part A evaluated, biomechanically, intramedullary (IM) nails versus locking plates for fixation of an extra-articular, metaphyseal wedge fracture in synthetic osteoporotic bone. Part B of this study introduces deterministic finite element (FE) models of each construct type in synthetic osteoporotic bone and investigates the probability of periprosthetic fracture of the locking plate compared with the retrograde IM nail using Monte Carlo simulation. Deterministic FE models of the fractured femur implanted with IM nail and locking plate, respectively, were developed and validated using experimental data presented in Part A of this study. The models were validated by comparing the load-displacement curve of the experimental data with the load-displacement curve of the FE simulation with a root-mean square error of less than 3?mm. The validated FE models were then modified by defining the cortical and cancellous bone modulus of elasticity as uncertain variables that could be assumed to vary randomly. Monte Carlo simulation was used to evaluate the probability of fracture (POF) of each fixation. The POF represents the cumulative probability that the predicted shear stresses in the cortical bone will exceed the expected shear strength of the cortical bone. This investigation provides information regarding the significance of post-operative damage accumulation on the POF of the implanted bones when the two fixations are used. The probabilistic analysis found the locking plate fixation to have a higher POF than the IM nail fixation under the applied loading conditions (locking plate 21.8% versus IM nail 0.019%).     

Long-term study of bone remodelling after femoral stem: a comparison between dexa and finite element simulation

A hip replacement with a cemented or cementless femoral stem produces an effect on the bone called adaptive remodelling, attributable to mechanical and biological factors. The objective of all of cementless prostheses designs has been to achieve a perfect transfer of loads in order to avoid stress-shielding, which produces an osteopenia. In order to quantify this, the long term and mass-produced study with dual energy X-ray absorptiometry (DEXA) is necessary. Finite element (FE) simulation makes possible the explanation of the biomechanical changes which are produced in the femur after stem implantation. The good correlation obtained between the results of the FE simulation and the densitometric study allow, on one hand, to explain from the point of view of biomechanical performance the changes observed in bone density in the long-term, where it is clear that these are due to a different transfer of load in the implanted model compared to the healthy femur; on the other hand, it validates the simulation model, in a way that it can be used in different conditions and at different time periods, to carry out a sufficiently precise prediction of the evolution of the bone density from the biomechanical behaviour in the interaction between the prosthesis and femur.     

Wear analysis in anatomical and reversed shoulder prostheses

This paper describes the development of a computational model to calculate wear rates in total shoulder prostheses, for a 5–150 degrees arm abduction. Anatomical keeled and pegged prosthesis as well as reversed prosthesis were the studied implants. The bone models were built based on computed tomography (CT) images and using a computer aided design-based modelling pipeline. The finite element method was used to solve the contact problem between the surface of the polyethylene (PE) components and the corresponding articular component. The aim of this work was to determine linear and volumetric PE wear, for several radial mismatches, in conditions of pathological (rheumatoid arthritis) and non-pathological bone. Results showed that contact pressures and linear wear developed in anatomical prosthesis were higher than those visualised in reversed prosthesis. However, anatomical prosthesis exhibited a better volumetric wear performance. Moreover, our findings indicated higher values of volumetric wear in higher congruent models and on pathological bone conditions.     

Wear analysis in anatomical and reversed shoulder prostheses

This paper describes the development of a computational model to calculate wear rates in total shoulder prostheses, for a 5-150 degrees arm abduction. Anatomical keeled and pegged prosthesis as well as reversed prosthesis were the studied implants. The bone models were built based on computed tomography (CT) images and using a computer aided design-based modelling pipeline. The finite element method was used to solve the contact problem between the surface of the polyethylene (PE) components and the corresponding articular component. The aim of this work was to determine linear and volumetric PE wear, for several radial mismatches, in conditions of pathological (rheumatoid arthritis) and non-pathological bone. Results showed that contact pressures and linear wear developed in anatomical prosthesis were higher than those visualised in reversed prosthesis. However, anatomical prosthesis exhibited a better volumetric wear performance. Moreover, our findings indicated higher values of volumetric wear in higher congruent models and on pathological bone conditions.     

Femoral strength is better predicted by finite element models than QCT and DXA.

Clinicians and patients would benefit if accurate methods of predicting and monitoring bone strength in-vivo were available. A group of 51 human femurs (age range 21-93; 23 females, 28 males) were evaluated for bone density and geometry using quantitative computed tomography (QCT) and dual energy X-ray absorptiometry (DXA). Regional bone density and dimensions obtained from QCT and DXA were used to develop statistical models to predict femoral strength ex vivo. The QCT data also formed the basis of a three-dimensional finite element (FE) models to predict structural stiffness. The femurs were separated into two groups; a model training set (n = 25) was used to develop statistical models to predict ultimate load, and a test set (n = 26) was used to validate these models. The main goal of this study was to test the ability of DXA, QCT and FE techniques to predict fracture load non-invasively, in a simple load configuration which produces predominantly femoral neck fractures. The load configuration simulated the single stance phase portion of normal gait; in 87% of the specimens, clinical appearing sub-capital fractures were produced. The training/test study design provided a tool to validate that the predictive models were reliable when used on specimens with "unknown" strength characteristics. The FE method explained at least 20% more of the variance in strength than the DXA models. Planned refinements of the FE technique are expected to further improve these results. Three-dimensional FE models are a promising method for predicting fracture load, and may be useful in monitoring strength changes in vivo.     

The effect of the loading condition corresponding to functional shoulder activities on trabecular architecture of glenoid

There is little information on bone morphology as it relates to shoulder activities. This study investigated how loads corresponding to functional shoulder activities affect the trabecular architecture of the glenoid. Two different protocols were used. Protocol 1 investigated the material and morphological characteristics of the glenoid by analyzing digitized trabecular bone images obtained from 12 cadaver scapula specimens. Protocol 2 used a finite element analysis (FEA) to compute the principal stress trajectories acting within the glenoid. The principal stresses were derived for five loading conditions, which represent typical functional shoulder activities. The study showed that shoulder activity involved in carrying a light load makes the greatest contribution to the trabecular architecture compared with other shoulder activities considered in this study (p<0.05). With all of the activities considered in this study, the lateral region, particularly in the anterior and posterior portions, showed greater deviation and greater sensitivity to variation under loading conditions than did the other regions (p<0.05). These results suggest that owing to the extra sensitivity of the anterior and posterior parts of the lateral region, these regions may be more informative in the analysis of the trabecular architecture following shoulder musculoskeletal injuries. These results may provide essential design information for shoulder prostheses and contribute to an understanding of morphological changes resulting from injury.     

Concept and development of an orthotropic FE model of the proximal femur

PURPOSE: In contrast to many isotropic finite-element (FE) models of the femur in literature, it was the object of our study to develop an orthotropic FE "model femur" to realistically simulate three-dimensional bone remodelling. METHODS: The three-dimensional geometry of the proximal femur was reconstructed by CT scans of a pair of cadaveric femurs at equal distances of 2mm. These three-dimensional CT models were implemented into an FE simulation tool. Well-known "density-determined" bony material properties (Young's modulus; Poisson's ratio; ultimate strength in pressure, tension and torsion; shear modulus) were assigned to each FE of the same "CT-density-characterized" volumetric group.In order to fix the principal directions of stiffness in FE areas with the same "density characterization", the cadaveric femurs were cut in 2mm slices in frontal (left femur) and sagittal plane (right femur). Each femoral slice was scanned into a computer-based image processing system. On these images, the principal directions of stiffness of cancellous and cortical bone were determined manually using the orientation of the trabecular structures and the Haversian system. Finally, these geometric data were matched with the "CT-density characterized" three-dimensional femur model. In addition, the time and density-dependent adaptive behaviour of bone remodelling was taken into account by implementation of Carter's criterion. RESULTS: In the constructed "model femur", each FE is characterized by the principal directions of the stiffness and the "CT-density-determined" material properties of cortical and cancellous bone. Thus, on the basis of anatomic data a three-dimensional FE simulation reference model of the proximal femur was realized considering orthotropic conditions of bone behaviour. CONCLUSIONS: With the orthotropic "model femur", the fundamental basis has been formed to realize realistic simulations of the dynamical processes of bone remodelling under different loading conditions or operative procedures (osteotomies, total hip replacements, etc).     

Experimental validation of intact and implanted distal femur finite element models

Four finite element (FE) models of intact and distal femur of knee replacements were validated relative to measured bone strains. FE models of linear tetrahedrons were used. Femoral replacements with cemented stemless, cemented and noncemented femoral stems of the PFC Sigma Modular Knee System were analyzed. Bone strains were recorded at ten locations on the cortex. The magnitude of the FE bone strains corresponded to the mean measured strains, with an overall agreement of 10%. Linear regression between the FE and mean experimental strains produced slopes between 0.94 and 1.06 and R(2) values between 0.92 and 0.99. RSME values were less than 12%. The FE models were able to adequately replicate the mechanical behavior of distal femur reconstructions.