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1.  Gait and lower limb muscle strength in women after triple innominate osteotomy 
In adult patients with developmental hip dysplasia, a surgical procedure (triple innominate osteotomy) of the pelvic bone can be performed to rotate the acetabulum in the frontal plane, establishing better acetabular coverage. Although common clinical hip scores demonstrate significant improvements after surgery, they provide only overall information about function. The purpose of this study was to quantify the long-term outcome of triple innominate osteotomy in more detail using gait analyses and muscle strength measurements.
We performed gait analyses at self-selected walking speed as well as isometric hip and knee muscle strength tests in twelve women who had undergone a unilateral triple innominate osteotomy (age: 34 ± 12 y, time post surgery: 80 ± 18 m). We compared the results to reference values obtained from eight healthy peers (age: 33 ± 10 y).
The patients exhibited slight asymmetries in step length (smaller steps) and stance time (longer stance) as well as lower hip abduction moments in the operated limb in early stance compared to the non-operated limb. However, there were no differences in gait compared to healthy controls, even though the patients showed reduced bilateral hip abduction strength compared to controls.
Our results indicate that the patients’ gait pattern had generally recovered very well, despite slight asymmetries in spatiotemporal parameters. Subtle deviations in hip abduction moments were observed during gait, whereas hip abduction strength was substantially reduced. Hence, the patients walked at a higher percentage of their maximal capacity. They may, therefore, be prone to fatigue and adopt compensatory gait strategies more quickly than healthy peers when walking long distances.
PMCID: PMC4391330  PMID: 25879958
Triple pelvic osteotomy; Hip joint; Walking; Congenital hip dislocation; Biomechanics
Bone  2013;58:160-167.
There is an urgent need to improve the prediction of fracture risk for cancer patients with bone metastases. Pathological fractures that result from these tumors frequently occur in the femur. It is extremely difficult to determine the fracture risk even for experienced physicians. Although evolving, fracture risk assessment is still based on inaccurate predictors estimated from previous retrospective studies. As a result, many patients are surgically over-treated, whereas other patients may fracture their bones against expectations.
We mechanically tested ten pairs of human cadaveric femurs to failure, where one of each pair had an artificial defect simulating typical metastatic lesions. Prior to testing, finite element (FE) models were generated and computed tomography rigidity analysis (CTRA) was performed to obtain axial and bending rigidity measurements. We compared the two techniques on their capacity to assess femoral failure load by using linear regression techniques, Student's t tests, the Bland-Altman methodology and Kendall rank correlation coefficients.
The simulated FE failure loads and CTRA predictions showed good correlation with values obtained from the experimental mechanical testing. Kendall rank correlation coefficients between the FE rankings and the CTRA rankings showed moderate to good correlations. No significant differences in prediction accuracy were found between the two methods.
Non-invasive fracture risk assessment techniques currently developed both correlated well with actual failure loads in mechanical testing suggesting that both methods could be further developed into a tool that can be used in clinical practice. The results in this study showed slight differences between the methods, yet validation in prospective patient studies should confirm these preliminary findings.
PMCID: PMC3908856  PMID: 24145305
Finite element analysis; CT-based structural rigidity analysis; lytic lesion; femur
3.  Porous titanium particles for acetabular reconstruction in total hip replacement show extensive bony armoring after 15 weeks 
Acta Orthopaedica  2014;85(6):600-608.
Background and purpose
— The bone impaction grafting technique restores bone defects in total hip replacement. Porous titanium particles (TiPs) are deformable, like bone particles, and offer better primary stability. We addressed the following questions in this animal study: are impacted TiPs osteoconductive under loaded conditions; do released micro-particles accelerate wear; and are systemic titanium blood levels elevated after implantation of TiPs?
Animals and methods —
An AAOS type-III defect was created in the right acetabulum of 10 goats weighing 63 (SD 6) kg, and reconstructed with calcium phosphate-coated TiPs and a cemented polyethylene cup. A stem with a cobalt chrome head was cemented in the femur. The goats were killed after 15 weeks. Blood samples were taken pre- and postoperatively.
Results —
The TiP-graft layer measured 5.6 (SD 0.8) mm with a mean bone ingrowth distance of 2.8 (SD 0.8) mm. Cement penetrated 0.9 (0.3–1.9) mm into the TiPs. 1 reconstruction showed minimal cement penetration (0.3 mm) and failed at the cement-TiP interface. There were no signs of accelerated wear, metallic particle debris, or osteolysis. Median systemic titanium concentrations increased on a log-linear scale from 0.5 (0.3–1.1) parts per billion (ppb) to 0.9 (0.5–2.8) ppb (p = 0.01).
Interpretation —
Adequate cement pressurization is advocated for impaction grafting with TiPs. After implantation, calcium phosphate-coated TiPs were osteoconductive under loaded conditions and caused an increase in systemic titanium concentrations. However, absolute levels remained low. There were no signs of accelerated wear. A clinical pilot study should be performed to prove that application in humans is safe in the long term.
PMCID: PMC4259031  PMID: 25238431
4.  Can Orthopedic Oncologists Predict Functional Outcome in Patients with Sarcoma after Limb Salvage Surgery in the Lower Limb? A Nationwide Study 
Sarcoma  2014;2014:436598.
Accurate predictions of functional outcome after limb salvage surgery (LSS) in the lower limb are important for several reasons, including informing the patient preoperatively and, in some cases, deciding between amputation and LSS. This study aimed to elucidate the correlation between surgeon-predicted and patient-reported functional outcome of LSS in the Netherlands. Twenty-three patients (between six months and ten years after surgery) and five independent orthopedic oncologists completed the Toronto Extremity Salvage Score (TESS) and the RAND-36 physical functioning subscale (RAND-36 PFS). The orthopedic oncologists made their predictions based on case descriptions (including MRI scans) that reflected the preoperative status. The correlation between patient-reported and surgeon-predicted functional outcome was “very poor” to “poor” on both scores (r2 values ranged from 0.014 to 0.354). Patient-reported functional outcome was generally underestimated, by 8.7% on the TESS and 8.3% on the RAND-36 PFS. The most difficult and least difficult tasks on the RAND-36 PFS were also the most difficult and least difficult to predict, respectively. Most questions had a “poor” intersurgeon agreement. It was difficult to accurately predict the patient-reported functional outcome of LSS. Surgeons' ability to predict functional scores can be improved the most by focusing on accurately predicting more demanding tasks.
PMCID: PMC4251794  PMID: 25484599
5.  Assessment of asymmetric leg loading before and after total hip arthroplasty using instrumented shoes 
Total hip arthroplasty is a successful surgical treatment in patients with osteoarthritis of the hip. Different questionnaires are used by the clinicians to assess functional capacity and the patient's pain, despite these questionnaires are known to be subjective. Furthermore, many studies agree that kinematic and kinetic parameters are crucial to evaluate and to provide useful information about the patient’s evolution for clinicians and rehabilitation specialists. However, these quantities can currently only be obtained in a fully equipped gait laboratory. Instrumented shoes can quantify gait velocity, kinetic, kinematic and symmetry parameters. The aim of this study was to investigate whether the instrumented shoes is a sufficiently sensitive instrument to show differences in mobility performance before and after total hip arthroplasty.
In this study, patients undergoing total hip arthroplasty were measured before and 6–8 months after total hip arthroplasty. Both measurement sessions include 2 functional mobility tasks while the subject was wearing instrumented shoes. Before each measurement the Harris Hip Score and the Traditional Western Ontario and McMaster Universities osteoarthritis index were administered as well.
The stance time and the average vertical ground reaction force measured with the instrumented shoes during walking, and their symmetry index, showed significant differences before and after total hip arthroplasty. However, the data obtained with the sit to stand test did not reveal this improvement after surgery.
Our results show that inter-limb asymmetry during a walking activity can be evaluated with the instrumented shoes before and after total hip arthroplasty in an outpatient clinical setting.
PMCID: PMC3975926  PMID: 24581227
Instrumented shoes; Gait parameters; Sit to stand parameters; Total hip replacement; Ground reaction forces
6.  Pre-operative ambulatory measurement of asymmetric lower limb loading during walking in total hip arthroplasty patients 
Total hip arthroplasty is a successful surgical procedure to treat hip osteoarthritis. Clinicians use different questionnaires to assess the patient’s pain and functional capacity. Furthermore, they assess the quality of gait in a very global way.
This clinical evaluation usually shows significant improvement after total hip arthroplasty, however, does not provide objective, quantifiable information about the movement patterns underlying the functional capacity, which can currently only be obtained in a gait laboratory. Instrumented force shoes can quantify gait velocity, ground reaction forces and the gait pattern easily in an outpatient setting.
The main goal of this study was to investigate how mobility characteristics during walking, relate to gait velocity and questionnaire outcomes of patients with hip osteoarthritis in an outpatient setting.
22 patients with primary osteoarthritis of the hip selected for a total hip arthroplasty participated in this study. For each patient the Harris Hip Score, the Traditional Western Ontario and the McMaster Universities osteoarthritis index were administered. Subsequently, the patients were instructed to walk through the corridor while wearing instrumented shoes. The gait velocity estimated with the instrumented force shoes was validated measuring the time required to walk a distance of 10 m using a stopwatch and a measuring tape as a reference system. A regression analysis between spatial, temporal, ground reaction force parameters, including asymmetry, and the gait velocity and the questionnaires outcomes was performed.
The velocity estimated with the instrumented shoes did not differ significantly from the velocity measured independently. Although gait parameters correlated significantly with velocity, symmetry index parameters were not correlated with velocity. These symmetry index parameters show significant inter-limb asymmetry during walking. No correlation was found between any of the variables studied and questionnaires outcomes.
Inter-limb asymmetry can be evaluated with the instrumented shoes supplying important additional information about the individual gait pattern, which is not represented by gait velocity and questionnaires usually used. Therefore, this new ambulatory measurement system is able to provide complementary information to gait velocity and questionnaires outcomes to assess the functional capacity of patients with hip osteoarthritis.
PMCID: PMC3637202  PMID: 23602092
Instrumented force shoes; Gait parameters; Hip osteoarthritis; Total hip replacement; Vertical ground reaction forces
7.  A New Approach to Quantify Trabecular Resorption Adjacent to Cemented Knee Arthroplasty 
Journal of Biomechanics  2012;45(4):711-715.
A new micro-computed tomography (μCT) image processing approach to estimate the loss of cement-bone interlock was developed using the concept that PMMA cement flows and cures around trabeculae during the total knee arthroplasty procedure. The initial mold shape of PMMA cement was used to estimate the amount of interdigitated bone at the time of implantation and following in vivo service using enbloc human postmortem retrievals. Laboratory prepared specimens, where there would be no biological bone resorption, were used as controls to validate the approach and estimate errors. The image processing technique consisted of identifying bone and cement from the μCT scan set, dilation of the cement to identify the cement cavity space, and Boolean operations to identify the different components of the interdigitated cement-bone regions. For laboratory prepared specimens, there were small errors in the estimated resorbed bone volume fraction (reBVfr = 0.11±0.09) and loss in contact area fraction (CAfr = 0.06±0.15). These values would be zero if there were no error in the method. For the postmortem specimens, the resorbed volume fraction (reBVfr = 0.85±0.16) was large, meaning that only 15% of the cement mold shape was still filled with bone. The loss of contact area fraction (CAfr = 0.84±0.17) was similarly large. This new approach provides a convenient method to visualize and quantify trabecular bone loss from interdigitated regions from postmortem retrievals. The technique also illustrates for the first time that there are dramatic changes in how bone is fixed to cement following in vivo service.
PMCID: PMC3278511  PMID: 22227315
8.  Morphology Based Cohesive Zone Modeling of the Cement-Bone Interface from Postmortem Retrievals 
In cemented total hip arthroplasty, the cement-bone interface can be considerably degenerated after less than one year in-vivo service; this makes the interface much weaker relative to the direct post-operative situation. It is, however, still unknown how these degenerated interfaces behave under mixed-mode loading and how this is related to the morphology of the interface. In this study, we used a finite element approach to analyze the mixed-mode response of the cement-bone interface taken from postmortem retrievals and we investigated whether it was feasible to generate a fully elastic and a failure cohesive model based on only morphological input parameters.
Computed tomography-based finite element analysis models of the postmortem cement-bone interface were generated and the interface morphology was determined. The models were loaded until failure in multiple directions by allowing cracking of the bone and cement components and including periodic boundary conditions. The resulting stiffness was related to the interface morphology. A closed form mixed-mode cohesive model that included failure was determined and related to the interface morphology.
The responses of the finite element simulations compare satisfactorily with experimental observations, albeit the magnitude of the strength and stiffness are somewhat overestimated. Surprisingly, the finite element simulations predict no failure under shear loading and a considerable normal compression is generated which prevents dilation of the interface. The obtained mixed-mode stiffness response could subsequently be related to the interface morphology and subsequently be formulated into an elastic cohesive zone model. Finally, the acquired data could be used as an input for a cohesive model that also includes interface failure.
PMCID: PMC3143371  PMID: 21783159
finite element; bone; bone cement; interface; cohesive modeling
9.  Differences in the stress distribution in the distal femur between patellofemoral joint replacement and total knee replacement: a finite element study 
Patellofemoral joint replacement is a successful treatment option for isolated patellofemoral osteoarthritis. However, results of later conversion to total knee replacement may be compromised by periprosthetic bone loss. Previous clinical studies have demonstrated a decrease in distal femoral bone mineral density after patellofemoral joint replacement. It is unclear whether this is due to periprosthetic stress shielding. The main objective of the current study was to evaluate the stress shielding effect of prosthetic replacement with 2 different patellofemoral prosthetic designs and with a total knee prosthesis.
We developed a finite element model of an intact patellofemoral joint, and finite element models of patellofemoral joint replacement with a Journey PFJ prosthesis, a Richards II prosthesis, and a Genesis II total knee prosthesis. For each of these 4 finite element models, the average Von Mises stress in 2 clinically relevant regions of interest were evaluated during a simulated squatting movement until 120 degrees of flexion.
During deep knee flexion, in the anterior region of interest, the average Von Mises stress with the Journey PFJ design was comparable to the physiological knee, while reduced by almost 25% for both the Richards II design and the Genesis II total knee joint replacement design. The average Von Mises stress in the supracondylar region of interest was similar for both patellofemoral prosthetic designs and the physiological model, with slightly lower stress for the Genesis II design.
Patellofemoral joint replacement results in periprosthetic stress-shielding, although to a smaller degree than in total knee replacement. Specific patellofemoral prosthetic design properties may result in differences in femoral stress shielding.
PMCID: PMC3471009  PMID: 22704638
Patellofemoral joint replacement; Knee prosthesis; Finite element analysis; Stress shielding; Squat movement
10.  Interface micromechanics of transverse sections from retrieved cemented hip reconstructions: an experimental and finite element comparison 
In finite element analysis (FEA) models of cemented hip reconstructions, it is crucial to include the cement–bone interface mechanics. Recently, a micromechanical cohesive model was generated which reproduces the behavior of the cement–bone interface. The goal was to investigate whether this cohesive model was directly applicable on a macro level. From transverse sections of retrieved cemented hip reconstructions, two FEA-models were generated. The cement–bone interface was modeled with cohesive elements. A torque was applied and the cement–bone interface micromotions, global stiffness and stem translation were monitored. A sensitivity analysis was performed to investigate whether the cohesive model could be improved. All results were compared with experimental findings. That the original cohesive model resulted in a too compliant macromechanical response; the motions were too large and the global stiffness too small. When the cohesive model was modified, the match with the experimental response improved considerably.
PMCID: PMC3400762  PMID: 22678039
11.  Multi-axial Loading Micromechanics of the Cement-Bone Interface in Post-Mortem Retrievals and Lab-Prepared Specimens 
Maintaining adequate fixation between cement and bone is important for successful long term survival of cemented total joint replacements. Mixed-mode loading conditions (combination of tension/compression and shear) are present during in vivo loading, but the micromotion response of the interface to these conditions is not fully understood.
Non-destructive, multi-axial loading experiments were conducted on laboratory prepared (n=6) and post mortem (n=6) human cement-bone interfaces. Specimens were mounted in custom loading discs and loaded at 0, 30, 60, and 90° relative to the interface plane where 0° represents normal loading to the interface, and 90° represents shear loading along the longitudinal axis of the femur. Axial compliance did not depend on loading angle for laboratory prepared (p=0.96) or postmortem specimens (p=0.62). The cement-bone interface was more compliant under tensile than compressive loading at the 0° loading angle only (p=0.024). The coupled transverse to axial compliance ratio, which is a measure of the coupled motion, was small for laboratory prepared (0.115±0.115) and postmortem specimens (0.142±0.101). There was a moderately strong inverse relationship between interface compliance and contact index (r2 = 0.65).
From a computational modeling perspective, the results of the current study support the concept that the cement-bone interface could be numerically implemented as a compliant layer with the same initial stiffness in tension and shear directions. The magnitude of the compliance could be modified to simulate immediate post-operative conditions (using laboratory prepared data set) or long-term remodeling (using postmortem data set).
PMCID: PMC3077568  PMID: 21316624
12.  The behavior of the micro-mechanical cement-bone interface affects the cement failure in total hip replacement 
Journal of biomechanics  2010;44(2):228-234.
In the current study, the effects of different ways to implement the complex micro-mechanical behavior of the cement-bone interface on the fatigue failure of the cement mantle was investigated. In an FEA-model of a cemented hip reconstruction the cement-bone interface was modeled and numerically implemented in four different ways: (I) as infinitely stiff, (II) as infinitely strong with a constant stiffness, (III) a mixed-mode failure response with failure in tension and shear, and (IV) realistic mixed mode behavior obtained from micro FEA-models. Case II, III and IV were analyzed using data from a stiff and a compliant micro-FEA model and their effects on cement failure were analyzed. The data used for Case IV was derived from experimental specimens that were tested previously. Although the total number of cement cracks was low for all cases, the compliant Case II resulted in twice as many cracks as Case I. All cases caused similar stress distributions at the interface. In all cases, the interface did not display interfacial softening; all stayed the elastic zone. Fatigue failure of the cement mantle resulted in a more favorable stress distribution at the cement-bone interface in terms of less tension and lower shear tractions. We conclude that immediate cement-bone interface failure is not likely to occur, but its local compliancy does affect the formation of cement cracks. This means that at a macro-level the cement-bone interface should be modeled as a compliant layer. However, implementation of interfacial post-yield softening does seem to be necessary.
PMCID: PMC3019267  PMID: 21036358
Finite element; fatigue; bone; bone cement; interface
13.  Similar TKA designs with differences in clinical outcome 
Acta Orthopaedica  2011;82(6):685-691.
Background and purpose
To try to improve the outcome of our TKAs, we started to use the CKS prosthesis. However, in a retrospective analysis this design tended to give worse results. We therefore conducted a randomized, controlled trial comparing this CKS prosthesis and our standard PFC prosthesis. Because many randomized studies between different TKA concepts generally fail to show superiority of a particular design, we hypothesized that these seemingly similar designs would not lead to any difference in clinical outcome.
Patients and methods
82 patients (90 knees) were randomly allocated to one or other prosthesis, and 39 CKS prostheses and 38 PFC prostheses could be followed for mean 5.6 years. No patients were lost to follow-up. At each follow-up, patients were evaluated clinically and radiographically, and the KSS, WOMAC, VAS patient satisfaction scores and VAS for pain were recorded.
With total Knee Society score (KSS) as primary endpoint, there was a difference in favor of the PFC group at final follow-up (p = 0.04). Whereas there was one revision in the PFC group, there were 6 revisions in the CKS group (p = 0.1). The survival analysis with any reoperation as endpoint showed better survival in the PFC group (97% (95% CI: 92–100) for the PFC group vs. 79% (95% CI: 66–92) for the CKS group) (p = 0.02).
Our hypothesis that there would be no difference in clinical outcome was rejected in this study. The PFC system showed excellent results that were comparable to those in previous reports. The CKS design had differences that had considerable negative consequences clinically. The relatively poor results have discouraged us from using this design.
PMCID: PMC3247886  PMID: 22066559
14.  The effect of cement creep and cement fatigue damage on the micromechanics of the cement-bone interface 
Journal of biomechanics  2010;43(15):3028-3034.
The cement-bone interface provides fixation for the cement mantle within the bone. The cement-bone interface is affected by fatigue loading in terms of fatigue damage, or micro cracks, and creep, both mostly in the cement. This study investigates how fatigue damage and cement creep separately affect the mechanical response of the cement-bone interface at various load levels in terms of plastic displacement and crack formation. Two FEA models were created, which were based on micro-computed tomography data of two physical cement-bone interface specimens. These models were subjected to tensile fatigue loads with four different magnitudes. Three deformation modes of the cement were considered; ‘only creep’, ‘only damage’ or ‘creep and damage’. The interfacial plastic deformation, the crack reduction as a result of creep and the interfacial stresses in the bone were monitored. The results demonstrate that, although some models failed early, the majority of plastic displacement was caused by fatigue damage, rather than cement creep. However, cement creep does decrease the crack formation in the cement up to 20%. Finally, while cement creep hardly influences the stress levels in the bone, fatigue damage of the cement considerably increases the stress levels in the bone. We conclude that at low load levels the plastic displacement is mainly caused by creep. At moderate to high load levels, however, the plastic displacement is dominated by fatigue damage and is hardly affected by creep, although creep reduced the number of cracks in moderate to high load region.
PMCID: PMC2975749  PMID: 20692663
Finite element; fatigue; bone; bone cement; interface
15.  Evaluation of subsidence, chondrocyte survival and graft incorporation following autologous osteochondral transplantation 
The aim of this study was to evaluate subsidence tendency, surface congruency, chondrocyte survival and plug incorporation after osteochondral transplantation in an animal model. The potential benefit of precise seating of the transplanted osteochondral plug on the recipient subchondral host bone (‘bottoming’) on these parameters was assessed in particular.
In 18 goats, two osteochondral autografts were harvested from the trochlea of the ipsilateral knee joint and inserted press-fit in a standardized articular cartilage defect in the medial femoral condyle. In half of the goats, the transplanted plugs were matched exactly to the depth of the recipient hole (bottomed plugs; n = 9), whereas in the other half of the goats, a gap of 2 mm was left between the plugs and the recipient bottom (unbottomed plugs; n = 9). After 6 weeks, all transplants were evaluated on gross morphology, subsidence, histology, and chondrocyte vitality.
The macroscopic morphology scored significantly higher for surface congruency in bottomed plugs as compared to unbottomed reconstructions (P = 0.04). However, no differences in histological subsidence scoring between bottomed and unbottomed plugs were found. The transplanted articular cartilage of both bottomed and unbottomed plugs was vital. Only at the edges some matrix destaining, chondrocyte death and cluster formation was observed. At the subchondral bone level, active remodeling occurred, whereas integration at the cartilaginous surface of the osteochondral plugs failed to occur. Subchondral cysts were found in both groups.
In this animal model, subsidence tendency was significantly lower after ‘bottomed’ versus ‘unbottomed’ osteochondral transplants on gross appearance, whereas for histological scoring no significant differences were encountered. Since the clinical outcome may be negatively influenced by subsidence, the use of ‘bottomed’ grafts is recommended for osteochondral transplantation in patients.
PMCID: PMC3199551  PMID: 21904953
Autologous osteochondral transplantation; Osteochondral defect; Cartilage repair; Cartilage defect; Histology
16.  The effect of impaction and a bioceramic coating on bone ingrowth in porous titanium particles 
Acta Orthopaedica  2011;82(3):372-377.
Background and purpose
Porous titanium (Ti) particles can be impacted like cancellous allograft bone particles, and may therefore be used as bone substitute in impaction grafting. We evaluated the effect of impaction and of a thin silicated biphasic calcium phosphate coating on osteoconduction by Ti particles.
The bone conduction chamber of Aspenberg was used in goats and filled with various groups of coated or uncoated small Ti particles (diameter 1.0–1.4 mm). Impacted allograft bone particles and empty chambers were used in control groups. Fluorochromes were administered at 4, 8, and 12 weeks. Maximum bone ingrowth distance was evaluated by histomorphometric analysis.
Histology of Ti particle graft cylinders showed a dense matrix with narrow inter-particle and intra-particle pores (< 100 μm), occluding the lumen of the bone chamber. Bone ingrowth distances gradually increased with time in all groups. Maximum bone ingrowth distance was higher in originally empty chambers than those with allograft bone particles (p = 0.01) and Ti particles (p < 0.001). Maximum bone ingrowth in allograft bone particles was higher than in all Ti groups (p ≤ 0.001). Impaction reduced osteoconduction and the coating partially compensated for the negative effect of impaction, but these differences were not statistically significant. No osteolytic reactions were found.
Osteoconduction in the bone conduction chamber was reduced more by the insertion of small Ti particles than by insertion of small allograft bone particles. The osteoconductive potential of porous Ti particles should be studied further with larger-sized particles, which may allow bone ingrowth after impaction through larger inter-particle pores.
PMCID: PMC3235319  PMID: 21504310
17.  The mechanical effects of different levels of cement penetration at the cement-bone interface 
Journal of biomechanics  2010;43(6):1167-1175.
The mechanical effects of varying the depth of cement penetration in the cement-bone interface was investigated using finite element analysis (FEA) and validated using companion experimental data. Two FEA models of the cement-bone interface were created from microcomputed tomography data and the penetration of cement into the bone was varied over six levels each. The FEA models, consisting of the interdigitated cement-bone constructs with friction between cement and bone, were loaded to failure in tension and in shear. The cement and bone elements had provision for crack formation due to excessive stress. The interfacial strength showed a strong relationship with the average interdigitation (r2=0.97 and r2=0.93 in tension and shear, respectively). Also, the interface strength was strongly related with the contact area (r2=0.98 and r2=0.95 in tension and shear, respectively). The FEA results compared favorably to the stiffness-strength relationships determined experimentally. Overall, the cement-bone interface was 2.5 times stronger in shear than in tension and 1.15 times stiffer in tension than in shear, independent of the average interdigitation. More cracks occurred in the cement than in the bone, independent of the average interdigitation, consistent with the experimental results. In addition, more cracks were generated in shear than in tension. In conclusion, achieving and maintaining maximal infiltration of cement into the bone to obtain large interdigitation and contact area is key to optimizing the interfacial strength.
PMCID: PMC2849873  PMID: 20022010
bone; bone cement; interface; finite element; mechanics
18.  Assessment of bone ingrowth potential of biomimetic hydroxyapatite and brushite coated porous E-beam structures 
The bone ingrowth potential of biomimetic hydroxyapatite and brushite coatings applied on porous E-beam structure was examined in goats and compared to a similar uncoated porous structure and a conventional titanium plasma spray coating. Specimens were implanted in the iliac crest of goats for a period of 3 (4 goats) or 15 weeks (8 goats). Mechanical implant fixation generated by bone ingrowth was analyzed by a push out test. Histomorphometry was performed to assess the bone ingrowth depth and bone implant contact. The uncoated and hydroxyapatite-coated cubic structure had significantly higher mechanical strength at the interface compared to the Ti plasma spray coating at 15 weeks of implantation. Bone ingrowth depth was significantly larger for the hydroxyapatite- and brushite-coated structures compared to the uncoated structure. In conclusion, the porous E-beam surface structure showed higher bone ingrowth potential compared to a conventional implant surface after 15 weeks of implantation. Addition of a calcium phosphate coating to the E-beam structure enhanced bone ingrowth significantly. Furthermore, the calcium phosphate coating appears to work as an accelerator for bone ingrowth.
PMCID: PMC3085057  PMID: 21327405
19.  Frictional and bone ingrowth properties of engineered surface topographies produced by electron beam technology 
Electron beam melting (E-beam) is a new technology to produce 3-dimensional surface topographies for cementless orthopedic implants.
The friction coefficients of two newly developed E-beam produced surface topographies were in vitro compared with sandblasted E-beam and titanium plasma sprayed controls. Bone ingrowth (direct bone–implant contact) was determined by implanting the samples in the femoral condyles of 6 goats for a period of 6 weeks.
Friction coefficients of the new structures were comparable to the titanium plasma sprayed control. The direct bone–implant contact was 23.9 and 24.5% for the new surface structures. Bone–implant contact of the sandblasted and titanium plasma sprayed control was 18.2 and 25.5%, respectively.
The frictional and bone ingrowth properties of the E-beam produced surface structures are similar to the plasma-sprayed control. However, since the maximal bone ingrowth had not been reached for the E-beam structures during the relatively short-term period, longer-term follow-up studies are needed to assess whether the E-beam structures lead to a better long-term performance than surfaces currently in use, such as titanium plasma spray coating.
PMCID: PMC3078515  PMID: 21161665
Electron beam melting; Bone ingrowth; Friction; Surface characteristics; Prosthesis
20.  Fatigue creep damage at the cement-bone interface: an experimental and a micro-mechanical finite element study 
Journal of biomechanics  2009;42(15):2513-2519.
The goal of this study was to quantify the micromechanics of the cement-bone interface under tensile fatigue loading using finite element analysis (FEA) and to understand the underlying mechanisms that play a role in the fatigue behavior of this interface. Laboratory cement-bone specimens were subjected to a tensile fatigue load, while local displacements and crack growth on the specimen's surface were monitored. FEA models were created from these specimens based upon micro-computed tomography data. To accurately model interfacial gaps at the interface between the bone and cement, a custom-written erosion algorithm was applied to the bone model. A fatigue load was simulated in the FEA models while monitoring the local displacements and crack propagation. The results showed the FEA models were able to capture the general experimental creep damage behavior and creep stages of the interface. Consistent with the experiments, the majority of the deformation took place at the contact interface. Additionally, the FEA models predicted fatigue crack patterns similar to experimental findings. Experimental surface cracks correlated moderately with FEA surface cracks (r2=0.43), but did not correlate with the simulated crack volume fraction (r2=0.06). Although there was no relationship between experimental surface cracks and experimental creep damage displacement (r2=0.07), there was a strong relationship between the FEA crack volume fraction and the FEA creep damage displacement (r2=0.76). This study shows the additional value of FEA of the cement-bone interface relative to experimental studies and can therefore be used to optimize its mechanical properties.
PMCID: PMC2783955  PMID: 19682690
bone; bone cement; interface; finite element; damage
21.  Posterior cruciate ligament recruitment affects antero-posterior translation during flexion gap distraction in total knee replacement 
Acta Orthopaedica  2010;81(4):471-477.
Background and purpose
Because of the oblique orientation of the posterior cruciate ligament (PCL), flexion gap distraction could lead to anterior movement of the tibia, which would influence the tibiofemoral contact point. This would affect the kinematics of the TKR. We assessed the flexion gap parameters when the knee is distracted during implantation of a PCL-retaining TKR. Furthermore, the effects of PCL elevation (steep or flat) and collateral ligament releases on the flexion gap parameters were determined.
During a ligament-guided TKR procedure in 50 knees, the flexion gap was distracted with a double-spring tensor with 200N after the tibia had been cut. The flexion gap height, anterior tibial translation, and femoral rotation were measured intraoperatively using a CT-free navigation system.
During flexion gap distraction, the greatest displacement was seen in anterior-posterior direction. Mean ratio between increase in gap height and tibial translation was 1 to 1.9, and was highest for knees with a steep PCL (1 to 2.3). Knees with a flat PCL and knees with a ligament release had a larger increase in PCL elevation when the gap was distracted.
When the PCL is tensioned, every extra mm that the flexion gap is distracted can be expected to move the tibia anteriorly by at least 1.7 mm (flat PCL), or more if there is a steep PCL. This changes the tibiofemoral contact point, which may have consequences for polyethylene wear.
PMCID: PMC2917571  PMID: 20809745
22.  Functional interface micromechanics of 11 en-bloc retrieved cemented femoral hip replacements 
Acta Orthopaedica  2010;81(3):308-317.
Background and purpose
Despite the longstanding use of micromotion as a measure of implant stability, direct measurement of the micromechanics of implant/bone interfaces from en bloc human retrievals has not been performed. The purpose of this study was to determine the stem-cement and cement-bone micromechanics of functionally loaded, en-bloc retrieved, cemented femoral hip components.
11 fresh frozen proximal femurs with cemented implants were retrieved at autopsy. Specimens were sectioned transversely into 10-mm slabs and fixed to a loading device where functional torsional loads were applied to the stem. A digital image correlation technique was used to document micromotions at stem-cement and cement-bone interfaces during loading.
There was a wide range of responses with stem-cement micromotions ranging from 0.0006 mm to 0.83 mm (mean 0.17 mm, SD 0.29) and cement-bone micromotions ranging from 0.0022 mm to 0.73 mm (mean 0.092 mm, SD 0.22). There was a strong (linear-log) inverse correlation between apposition fraction and micromotion at the stem-cement interface (r2 = 0.71, p < 0.001). There was a strong inverse log-log correlation between apposition fraction at the cement-bone interface and micromotion (r2 = 0.85, p < 0.001). Components that were radiographically well-fixed had a relatively narrow range of micromotions at the stem-cement (0.0006–0.057 mm) and cement-bone (0.0022–0.029 mm) interfaces.
Minimizing gaps at the stem-cement interface and encouraging bony apposition at the cement-bone interface would be clinically desirable. The cement-bone interface does not act as a bonded interface in actual use, even in radiographically well-fixed components. Rather, the interface is quite compliant, with sliding and opening motions between the cement and bone surfaces.
PMCID: PMC2876832  PMID: 20367421
23.  A sliding stem in revision total knee arthroplasty provides stability and reduces stress shielding 
Acta Orthopaedica  2010;81(3):337-343.
Background and purpose
In the reconstruction of unicondylar femoral bone defects with morselized bone grafts in revision total knee arthroplasty, a stem extension appears to be critical to obtain adequate mechanical stability. Whether stability is still assured by this reconstruction technique in bicondylar defects has not been assessed. The disadvantage of relatively stiff stem extensions is that bone resorption is promoted due to stress shielding. We therefore designed a stem that would permit axial sliding movements of the articulating part relative to the intramedullary stem.
This stem was used in the reconstruction with impaction bone grafting (IBG) of 5 synthetic distal femora with a bicondylar defect. A cyclically axial load was applied to the prosthetic condyles to assess the stability of the reconstruction. Radiostereometry was used to determine the migrations of the femoral component with a rigidly connected stem, a sliding stem, and no stem extension.
We found a stable reconstruction of the bicondylar femoral defects with IBG in the case of a rigidly connected stem. After disconnecting the stem, the femoral component showed substantially more migrations. With a sliding stem, rotational migrations were similar to those of a rigidly connected stem. However, the sliding stem allowed proximal migration of the condylar component, thereby compressing the IBG.
The presence of a functional stem extension is important for the stability of a bicondylar reconstruction. A sliding stem provides adequate stability, while stress shielding is reduced because compressive contact forces are still transmitted to the distal femoral bone.
PMCID: PMC2876836  PMID: 20450422
24.  Micro-mechanics of Post-mortem Retrieved Cement-Bone Interfaces 
The cement-bone interface plays an important role in load transfer between cemented implant systems and adjacent bone, but little is known about the micro-mechanical behavior of this interface following in vivo service. Small samples of post-mortem retrieved cement-bone specimens from cemented total hip replacements were prepared and mechanically loaded to determine the mechanical response to tensile and compressive loading. The morphology of the cement-bone interface was quantified using a CT-based stereology approach. Laboratory prepared specimens were used to represent immediate post-operative conditions for comparison. The stiffness and strength of the cement-bone interface from post-mortem retrievals was much lower than that measured from laboratory prepared specimens. The cement-bone interfaces from post-mortem retrievals were very compliant (under tension and compression) and had a very low tensile strength (0.21 ± 0.32 MPa). With a linear regression model, including interface contact fraction and intersection fraction between cement and bone could explain 71% (p<0.0001) of the variability in experimental response. Bony remodeling following an arthroplasty procedure may contribute to reduced contact between cement and bone and this is associated with weaker and more compliant interfaces.
PMCID: PMC2796700  PMID: 19658167
25.  Finite element simulation of cement-bone interface micromechanics; a comparison to experimental results 
Recently, experiments have been performed to determine the micromechanical behavior of the cement-bone interface under tension-compression loading conditions. These experiments were simulated using finite element analysis (FEA) to test whether the micromechanical response of the cement-bone interface could be captured in micro-models. Cement-bone interface models were created of experimental specimens based upon micro-computed tomography data, including the complex interdigitated bone-cement morphology and simulated frictional contact at the interface. The models were subjected to a fully reversible tension-compression load, mimicking the experimental protocol. Similar to what was found experimentally, the simulated interface was stiffer in compression than in tension and the majority of displacement localized to the cement-bone interface. There was a weak correlation between the FEA predicted stiffness and the stiffness found experimentally, with average errors of 8.3 and 29.8% in tension and compression, respectively. The hysteresis behavior found experimentally was partially reproduced in the simulation by including friction at the cement-bone interface. Furthermore, stress analysis suggested that cement was more at risk of fatigue failure than bone, concurring with the experimental observation that more cracks were formed in the cement than in the bone. The current study provides information that may help to better understand the load transfer mechanisms taking place at the cement-bone interface.
PMCID: PMC2802538  PMID: 19340877
bone; bone cement; interface; finite element

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