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1.  Early Experience With a Comprehensive Hip Preservation Service Intended to Improve Clinical Care, Education, and Academic Productivity 
Background
The field of hip preservation surgery has grown substantially over the past decade. Although open hip procedures reportedly relieve pain and restore function, arthroscopic treatment has increasingly become a reasonable alternative. In 2008, we formed a comprehensive hip preservation service (HPS) to address clinical, educational, and research needs.
Questions/Purposes
We compared (1) volume, type, and corresponding improvement in pain and function of open and arthroscopic treatments; (2) orthopaedic resident test performance; and (3) academic productivity before and after creation of the HPS.
Methods
We retrospectively reviewed 212 patients undergoing 220 open procedures from 1996 to 2007 (Group 1) and 260 patients undergoing 298 procedures (153 open, 145 arthroscopic) from 2008 to May 2010 (Group 2). At each clinic visit, we recorded Harris hip score (HHS) and conversion to THA. Minimum followup was 1 year for Group 1 (mean, 4 years; range, 1–13 years) and Group 2 (mean, 1.5 years; range, 1–3 years). We compared orthopaedic resident performance on two standardized tests and the number of academic works (publications, book chapters, electronic media) and peer-reviewed grants funded before and after creation of the HPS.
Results
Mean HHS improved from 63 to 90 in Group 1 and from 76 to 91 in Group 2. Rate of conversion to THA was similar between groups despite expansion of surgical volume. Standardized orthopaedic resident test performance improved. Academic productivity as measured by publications and grant funding was facilitated by the HPS.
Conclusions
Early experience with a multidisciplinary HPS was positive; it facilitated clinical volume expansion while maintaining improvement in pain and function in young adults. Additional benefits included educational and academic productivity gains.
Level of Evidence
Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-012-2549-3
PMCID: PMC3492621  PMID: 22926493
2.  Finite Element Prediction of Cartilage Contact Stresses in Normal Human Hips 
Journal of Orthopaedic Research  2011;30(7):1133-1139.
Our objectives were to determine cartilage contact stress during walking, stair climbing and descending stairs in a well-defined group of normal volunteers and to assess variations in contact stress and area among subjects and across loading scenarios. Ten volunteers without history of hip pain or disease with normal lateral center-edge angle and acetabular index were selected. Computed tomography imaging with contrast was performed on one hip. Bone and cartilage surfaces were segmented from volumetric image data, and subject-specific finite element models were constructed and analyzed using a validated protocol. Acetabular contact stress and area were determined for seven activities. Peak stress ranged from 7.52±2.11 MPa for heel-strike during walking (233% BW) to 8.66±3.01 MPa for heel-strike during descending stairs (261% BW). Average contact area across all activities was 34% of the surface area of the acetabular cartilage. The distribution of contact stress was highly non-uniform, and more variability occurred among subjects for a given activity than among activities for a single subject. The magnitude and area of contact stress were consistent between activities, although inter-activity shifts in contact pattern were found as the direction of loading changed. Relatively small incongruencies between the femoral and acetabular cartilage had a large effect on the contact stresses. These effects tended to persist across all simulated activities. These results demonstrate the diversity and trends in cartilage contact stress in healthy hips during activities of daily living and provide a basis for future comparisons between normal and pathologic hips.
doi:10.1002/jor.22040
PMCID: PMC3348968  PMID: 22213112
Hip; Finite Element; Biomechanics; Cartilage Contact Stresses; Cartilage Pressure
3.  Effects of Idealized Joint Geometry on Finite Element Predictions of Cartilage Contact Stresses in the Hip 
Journal of biomechanics  2010;43(7):1351-1357.
Computational models may have the ability to quantify the relationship between hip morphology, cartilage mechanics and osteoarthritis. Most models have assumed the hip joint to be a perfect ball and socket joint and have neglected deformation at the interface between bone/cartilage. The objective of this study was to analyze finite element (FE) models of hip cartilage mechanics with varying degrees of simplified geometry and a model with a rigid bone material assumption to elucidate the effects on predictions of cartilage stress. A previously validated subject-specific FE model of a cadaveric hip joint was used as the basis for the models. Geometry for the bone/cartilage interface was either: 1) subject-specific (i.e. irregular), 2) spherical, or 3) a rotational conchoid. Cartilage was assigned either a varying (irregular) or constant thickness (smoothed). Loading conditions simulated walking, stair climbing and descending stairs. FE predictions of contact stress for the simplified models were compared with predictions from the subject-specific model. Both spheres and conchoids provided a good approximation of native hip joint geometry (average fitting error ~0.5 mm). However, models with spherical/conchoid bone geometry and smoothed articulating cartilage surfaces grossly underestimated peak and average contact pressures (50% and 25% lower, respectively) and overestimated contact area when compared to the subject-specific FE model. Models incorporating subject-specific bone geometry with smoothed articulating cartilage also underestimated pressures and predicted evenly distributed patterns of contact. The model with rigid bones predicted much higher pressures than the subject-specific model with deformable bones. The results demonstrate that simplifications to the geometry of the bone/cartilage interface, cartilage surface and bone material properties can have a dramatic effect on the predicted magnitude and distribution of cartilage contact pressures in the hip joint.
doi:10.1016/j.jbiomech.2010.01.010
PMCID: PMC2857573  PMID: 20176359
Hip; Finite Element; Biomechanics; Sphere; Conchoid; Boundary Conditions; Cartilage Pressures
4.  A New Discrete Element Analysis Method for Predicting Hip Joint Contact Stresses 
Journal of biomechanics  2013;46(6):1121-1127.
Quantifying cartilage contact stress is paramount to understanding hip osteoarthritis. Discrete element analysis (DEA) is a computationally efficient method to estimate cartilage contact stresses. Previous applications of DEA have underestimated cartilage stresses and yielded unrealistic contact patterns because they assumed constant cartilage thickness and/or concentric joint geometry. The study objectives were to: 1) develop a DEA model of the hip joint with subject-specific bone and cartilage geometry, 2) validate the DEA model by comparing DEA predictions to those of a validated finite element analysis (FEA) model, and 3) verify both the DEA and FEA models with a linear-elastic boundary value problem. Springs representing cartilage in the DEA model were given lengths equivalent to the sum of acetabular and femoral cartilage thickness and joint space in the FEA model. Material properties and boundary/loading conditions were equivalent. Walking, descending, and ascending stairs were simulated. Solution times for DEA and FEA models were ~7 seconds and ~65 minutes, respectively. Irregular, complex contact patterns predicted by DEA were in excellent agreement with FEA. DEA contact areas were 7.5%, 9.7% and 3.7% less than FEA for walking, descending stairs, and ascending stairs, respectively. DEA models predicted higher peak contact stresses (9.8–13.6 MPa) and average contact stresses (3.0–3.7 MPa) than FEA (6.2–9.8 and 2.0–2.5 MPa, respectively). DEA overestimated stresses due to the absence of the Poisson’s effect and a direct contact interface between cartilage layers. Nevertheless, DEA predicted realistic contact patterns when subject-specific bone geometry and cartilage thickness were used. This DEA method may have application as an alternative to FEA for pre-operative planning of joint-preserving surgery such as acetabular reorientation during peri-acetabular osteotomy.
doi:10.1016/j.jbiomech.2013.01.012
PMCID: PMC3623562  PMID: 23453394
Hip; cartilage; cartilage mechanics; contact stress; discrete element analysis; finite element analysis; computational modeling
5.  Role of the Acetabular Labrum in Load Support Across the Hip Joint 
Journal of biomechanics  2011;44(12):2201-2206.
The relatively high incidence of labral tears among patients presenting with hip pain suggests that the acetabular labrum is often subjected to injurious loading in vivo. However, it is unclear whether the labrum participates in load transfer across the joint during activities of daily living. This study examined the role of the acetabular labrum in load transfer for hips with normal acetabular geometry and acetabular dysplasia using subject-specific finite element analysis. Models were generated from volumetric CT data and analyzed with and without the labrum during activities of daily living. The labrum in the dysplastic model supported 4-11% of the total load transferred across the joint, while the labrum in the normal model supported only 1-2% of the total load. Despite the increased load transferred to the acetabular cartilage in simulations without the labrum, there were minimal differences in cartilage contact stresses. This was because the load supported by the cartilage correlated to the cartilage contact area. A higher percentage of load was transferred to the labrum in the dysplastic model because the femoral head achieved equilibrium near the lateral edge of the acetabulum. The results of this study suggest that the labrum plays a larger role in load transfer and joint stability in hips with acetabular dysplasia than in hips with normal acetabular geometry.
doi:10.1016/j.jbiomech.2011.06.011
PMCID: PMC3225073  PMID: 21757198
acetabular labrum; hip; cartilage mechanics; finite element; dysplasia
6.  An Algorithmic Approach to Surgical Decision-making in Acetabular Retroversion 
Orthopedics  2011;34(1):10.
We prospectively collected clinical data during the period 2001–2006 on 60 hips with symptomatic femoroacetabular impingement that had radiographic evidence of acetabular retroversion defined as a crossover sign on an adequate anteroposterior radiograph or retroversion on magnetic resonance imaging or computed tomography. Our treatment algorithm for acetabular retroversion used measurements of acetabular coverage (lateral center edge angle and the posterior wall sign) and condition of acetabular cartilage to direct treatment of acetabular retroversion. The algorithm directed the surgeon to perform a periacetabular-osteotomy (PAO) in 30 hips and in 30 hips a surgical-dislocation and osteochondroplasty (SDO) of the femoral head-neck junction and acetabular rim. HHS and Tönnis radiographic grading were collected preoperatively and at latest followup. The HHS improved from 52 to 90 in the hips treated with SDO and 72 to 91 in the hips treated with PAO, with an overall survivorship of 96% at four years. Patient follow-up averaged 46 months (range 24–75). Elimination of the crossover sign and correction of the posterior wall sign occurred in over 90% of all patients when present. The results indicate that hips with acetabular retroversion, deficient posterior and/or lateral acetabular coverage and intact hyaline cartilage can be effectively treated with acetabular reorientation while retroverted hips with anterior over-coverage but sufficient posterior coverage are effectively treated with osteochondroplasty of the acetabulum and proximal femur.
doi:10.3928/01477447-20101123-07
PMCID: PMC3399593  PMID: 21210626
7.  Correlation between radiographic measures of acetabular morphology with 3D femoral head coverage in patients with acetabular retroversion 
Acta Orthopaedica  2012;83(3):233-239.
Background and purpose
Acetabular retroversion may result in anterior acetabular over-coverage and posterior deficiency. It is unclear how standard radiographic measures of retroversion relate to measurements from 3D models, generated from volumetric CT data. We sought to: (1) compare 2D radiographic measurements between patients with acetabular retroversion and normal control subjects, (2) compare 3D measurements of total and regional femoral head coverage between patients and controls, and (3) quantify relationships between radiographic measurements of acetabular retroversion to total and regional coverage of the femoral head.
Patients and methods
For 16 patients and 18 controls we measured the extrusion index, crossover ratio, acetabular angle, acetabular index, lateral center edge angle, and a new measurement termed the “posterior wall distance”. 3D femoral coverage was determined from volumetric CT data using objectively defined acetabular rim projections, head-neck junctions, and 4 anatomic regions. For radiographic measurements, intra-observer and inter-observer reliabilities were evaluated and associations between 2D radiographic and 3D model-based measures were determined.
Results
Compared to control subjects, patients with acetabular retroversion had a negative posterior wall distance, increased extrusion index, and smaller lateral center edge angle. Differences in the acetabular index between groups approached statistical significance. The acetabular angle was similar between groups. Acetabular retroversion was associated with a slight but statistically significant increase in anterior acetabular coverage, especially in the anterolateral region. Retroverted hips had substantially less posterior coverage, especially in the posterolateral region.
Interpretation
We found that a number of 2D radiographic measures of acetabular morphology were correlated with 3D model-based measures of total and regional femoral head coverage. These correlations may be used to assist in the diagnosis of retroversion and for preoperative planning.
doi:10.3109/17453674.2012.684138
PMCID: PMC3369147  PMID: 22553905
8.  Verification, Validation and Sensitivity Studies in Computational Biomechanics 
Computational techniques and software for the analysis of problems in mechanics have naturally moved from their origins in the traditional engineering disciplines to the study of cell, tissue and organ biomechanics. Increasingly complex models have been developed to describe and predict the mechanical behavior of such biological systems. While the availability of advanced computational tools has led to exciting research advances in the field, the utility of these models is often the subject of criticism due to inadequate model verification and validation. The objective of this review is to present the concepts of verification, validation and sensitivity studies with regard to the construction, analysis and interpretation of models in computational biomechanics. Specific examples from the field are discussed. It is hoped that this review will serve as a guide to the use of verification and validation principles in the field of computational biomechanics, thereby improving the peer acceptance of studies that use computational modeling techniques.
doi:10.1080/10255840601160484
PMCID: PMC3361760  PMID: 17558646
Verification; Validation; Sensitivity Studies; Computational Modeling; Biomechanics; Review
9.  Validation of Computational Models in Biomechanics 
The topics of verification and validation (V&V) have increasingly been discussed in the field of computational biomechanics, and many recent articles have applied these concepts in an attempt to build credibility for models of complex biological systems. V&V are evolving techniques that, if used improperly, can lead to false conclusions about a system under study. In basic science these erroneous conclusions may lead to failure of a subsequent hypothesis, but they can have more profound effects if the model is designed to predict patient outcomes. While several authors have reviewed V&V as they pertain to traditional solid and fluid mechanics, it is the intent of this manuscript to present them in the context of computational biomechanics. Specifically, the task of model validation will be discussed with a focus on current techniques. It is hoped that this review will encourage investigators to engage and adopt the V&V process in an effort to increase peer acceptance of computational biomechanics models.
PMCID: PMC2941217  PMID: 20839648
biomechanics; computation; validation; verification; modeling
10.  Factors Influencing Cartilage Thickness Measurements with Multi-Detector CT: A Phantom Study 
Radiology  2008;246(1):133-141.
PURPOSE
To prospectively assess in a phantom the reconstruction errors and detection limits of cartilage thickness measurements from MDCT arthrography as a function of contrast agent concentration, imaging plane, spatial resolution, joint space and tube current, using known measurements as the reference standard.
MATERIALS AND METHODS
A phantom with nine chambers was manufactured. Each chamber had a nylon cylinder encased by sleeves of aluminum and polycarbonate to simulate trabecular bone, cortical bone, and cartilage. Variations in simulated cartilage thickness and joint space were assessed. The phantom was scanned with and without contrast agent on three separate days, with chamber axes both perpendicular and parallel to the scanner axis. Images were reconstructed at intervals of both 1.0 and 0.5 mm. Contrast agent concentration and tube current were varied. Simulated cartilage thickness was determined from image segmentation. Root mean squared and mean residual errors were used to characterize the measurements. CT scanner and image segmentation reproducibility were determined.
RESULTS
Simulated cartilage was reconstructed with < 10% error for thicknesses >1.0 mm when no contrast agent or a low concentration of contrast agent (25%) was used. Errors grew as concentration of contrast agent increased. Decreasing the simulated joint space to 0.5 mm caused slight increases in error; below 0.5 mm errors grew substantially. Measurements from anisotropic image data had errors greater than those for isotropic data. Altering tube current did not affect reconstruction errors.
CONCLUSION
Our study establishes lower bounds and repeatability of simulated cartilage thickness measurement using MDCT arthrography, and provides data pertinent to choosing contrast agent concentration, joint spacing, scanning plane, and spatial resolution to reduce reconstruction errors.
doi:10.1148/radiol.2461062192
PMCID: PMC2881220  PMID: 18096534
CT arthrography; phantom; reconstruction error; cartilage; thickness
11.  Validation of Finite Element Predictions of Cartilage Contact Pressure in the Human Hip Joint 
Methods to predict contact stresses in the hip can provide an improved understanding of load distribution in the normal and pathologic joint. The objectives of this study were to develop and validate a three-dimensional finite element (FE) model for predicting cartilage contact stresses in the human hip using subject-specific geometry from computed tomography image data, and to assess the sensitivity of model predictions to boundary conditions, cartilage geometry, and cartilage material properties. Loads based on in vivo data were applied to a cadaveric hip joint to simulate walking, descending stairs and stair-climbing. Contact pressures and areas were measured using pressure sensitive film. CT image data were segmented and discretized into FE meshes of bone and cartilage. FE boundary and loading conditions mimicked the experimental testing. Fair to good qualitative correspondence was obtained between FE predictions and experimental measurements for simulated walking and descending stairs, while excellent agreement was obtained for stair-climbing. Experimental peak pressures, average pressures, and contact areas were 10.0 MPa (limit of film detection), 4.4-5.0 MPa and 321.9-425.1 mm2, respectively, while FE predicted peak pressures, average pressures and contact areas were 10.8-12.7 MPa, 5.1-6.2 MPa and 304.2-366.1 mm2, respectively. Misalignment errors, determined as the difference in root mean squared error before and after alignment of FE results, were less than 10%. Magnitude errors, determined as the residual error following alignment, were approximately 30% but decreased to 10-15% when the regions of highest pressure were compared. Alterations to the cartilage shear modulus, bulk modulus, or thickness resulted in ±25% change in peak pressures, while changes in average pressures and contact areas were minor (±10%). When the pelvis and proximal femur were represented as rigid, there were large changes, but the effect depended on the particular loading scenario. Overall, the subject-specific FE predictions compared favorably with pressure film measurements and were in good agreement with published experimental data. The validated modeling framework provides a foundation for development of patient-specific FE models to investigate the mechanics of normal and pathological hips.
doi:10.1115/1.2953472
PMCID: PMC2840996  PMID: 19045515
Hip; Finite Element; Biomechanics; Pressure Film

Results 1-11 (11)