Biomechanical Investigations on the Total Knee Arthroplasty (TKA)
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1 Fernando Fonseca, MD PhD Hospitais da Universidade de Coimbra Faculdade de Medicina / Universidade de Coimbra Faculdade de Ciências da Saúde / Universidade da Beira Interior pereirafonseca@gmail.com
2 KNEE ARTHROPLASTY Why do knee fail?
3 KNEE ARTHROPLASTY Why do knee fail?
4 KNEE ARTHROPLASTY Why do knee fail?
5 KNEE PROSTHESIS_What are the clinical solutions?
6 HISTORICAL EVOLUTION OF THE KNEE DESIGN 1958 Shier prosthesis Smith-Petersen FEMORAL INTERPOSITION Macintosh HALF TIBIAL PLATES 1974 Insall TOTAL CONDYLAR PROSTHESIS KINEMATIC II
7 NOWADAYS KNEE PROSTHESES UNICOMPARTIMENTAL PATELLO-FEMORAL Hinge prosthesis SLIDING TOTAL KNEE PROSTHESIS
8 COMPLEXICITY OF THE PROBLEM TO ADDRESS MATERIAL Biological reactions? debris? Compression, tension, shear? Muscle and ligament forces? which? Magnitudes and directions? Bone tissue quality? Patient physical activities? Tribology contact? Loads? Magnitudes and directions? GEOMETRY PATIENT SURFACE TEXTURE
9 CLINICAL STUDIES Radiographs Periodic patient evaluations RSA, Others EXPERIMENTAL STUDIES Strain gauges 3D and 2D photoelasticity Optical methods Others NUMERICAL SIMULATION Finite elements Finite differences Boundary elements Others SIMULATION CONTROL
10 THE MATERIALS OF KNEE PROSTHESES Patellar component Polyethelene Femoral component Co-Cr Tibial component Polyethelene Tibial plate Titanium Modular tibial stem Cr-Co or Titanium First prosthesis were made of Stainless Steel. Cobalt-Chrome (Co-Cr) is wear resistant and produces less debris, which are not well tolerated and induce loosening Titanium alloys are used for metallic tibial trays The sliding components are of ultra high density polyethelene (patella component and tibial tray) Ceramic femoral components Total Knee Prosthesis
11 TOTAL KNEE PROSTHESIS - SURGERY 1- Approach 2 Proximal tibial osteotomy 3 Femoral Osteotomy 4 Ligamentar balance 5 Definitive implants 6 Closing
12 KNEE PROSTHESIS_complications Pain Infection Wear Loosening / instability Why biomechanical studies of TKR? Correlate stresses and strains with clinical evidences The knowledge of the mechanical behaviour of TKR can support decisions on material selection, designs, fixation techniques to optimize mechanical performance of the knee prosthesis and provide higher life quality for the patient and postpone life service of the implant
13 Infection
14 Loosening
15 Loosening
16 Osteolysis / debris
17 Metal-back
18 Metal-back
19
20
21 NUMERICAL SIMULATION_The process Selection of model P.F.C Sigma Modular Knee System (Depuy/ Johnson & Johnson- Warsaw/Indiana) 3D geometry acquisition Roland LPX 250 Geometric modelling Catia V5 (Dassault Systèms). Finite Element mesh generation HyperWorks (Altair Engineering Inc.) Comparação Tensão Equivalente osso esponjoso Alternative proposals: optimization of geometry and materials Teq_colada Teq_atrito Numerical-clinical correlation Comparison of results Structural calculations (MEF)
22 KNEE PROSTHESIS_Numerical simulation_cad models
23 KNEE PROSTHESIS_von Mises stress on the tibial component
24 KNEE PROSTHESIS_Stresses (polyethelene and cement mantle)
25 KNEE PROSTHESIS_Cancellous bone von Mises stress
26 NUMERICAL EXPERIMENTAL VALIDATION: FEMORAL COMPONENT Medial side Reference Anterior side 60 M0 84 L0 M0 A1 M1 P1 L1 A1 M1 A2 M2 P2 135 L2 A2 M2 c b a Triaxial strain gauges (rosettes): measure strains (strain-stress shielding)
27 NUMERICAL EXPERIMENTAL VALIDATION: IN VITRO SURGERY
28 NUMERICAL EXPERIMENTAL VALIDATION: FEMORAL COMPONENT cancellous bone femur cement stemless stem cartilage cement cemented stem Press-fit stem Intact model Femoral component Cimented stem Non-cimented stem
29 NUMERICAL EXPERIMENTAL VALIDATION: FEMORAL COMPONENT A1 A1 A2 A2 L0 L0 L1 L1 L2 L2 P1 P1 P2 P2 M0 M0 M1 M1 M2 M experimental model 1 friction model 1 bonded model 2 experimental model 2 friction model 2 bonded model
30 NUMERICAL EXPERIMENTAL VALIDATION: FEMORAL COMPONENT A1 A1 A2 A2 L0 L0 L1 L1 L2 L2 P1 P1 P2 P2 M0 M0 M1 M1 M2 2 1 M experimental model 1 friction model 1 bonded model 2 experimental model 2 friction model 2 bonded model
31 NUMERICAL EXPERIMENTAL VALIDATION: FEMORAL COMPONENT 400 y = x R 2 = FE strain ( strain) STANDARD IMPLANT Exp. Strain ( strain) Colado Atrito y = x R 2 = y = x INTACT FEMUR R 2 = FE strain ( strain) Exp. Strain ( strain)
32 NUMERICAL EXPERIMENTAL VALIDATION: FEMORAL COMPONENT Bonded case y = x R 2 = Friction case y = x R 2 = FE strain ( strain) PRESS-FIT STEM Exp. Strain ( strain) Colado Bonded case y = x R 2 = CEMENTED STEM Atrito Friction case y = x R 2 = FE strain ( strain) Exp. Strain ( strain)
33 NUMERICAL EXPERIMENTAL VALIDATION: TIBIAL COMPONENT Posterior side Reference Anterior side P L1 P1 AM1 L1 133 L2 P2 AM2 L2 202 L3 P3 AM3 L3 c b a Triaxial strain gauges (rosettes): measure strains (strain-stress shielding)
34 NUMERICAL EXPERIMENTAL VALIDATION: TIBIAL COMPONENT tibial tray cortical bone cortical bone standard stem stem tip cancellous bone pess-fit stem cemented stem Intact tibia Standard stem Cemented stem cement (PMMA) Press-fit stem
35 PHYSIOLOGICAL TIBIAL STRESSES 3 (Mpa) -0,5-0,4-0,3-0,2-0,1 0 A P M L Finite Element Model Minimal Principal Stresses A-anterior, P-posterior, M-medial, L-lateral
36 STRESS-SHIELDING EFFECT material & geometry role Stress-shielding Côndilo medial=1440n Côndilo lateral=880n 0% -20% -40% -34% -60% -52% -54% -63% -80% -70% -79% -82% -80% -100% Bone-cement interface stresses Haste 50mm em Ti Haste 110mm em Cr Haste 110mm em Ti Haste 95mm em Ti+ 15mm polietileno
37 INFLUENCE OF MATERIAL AND LENGTH TIBIAL STEM Medial -100% 0% 100% 200% 300% 400% 500% 600% 700% 800% Posterior -100% 0% 100% 200% 300% 400% 500% 600% 700% 800% Haste 110mm Ti Haste 110mm CrCo Haste 110mm Ti Haste 110mm CrCo Minimal principal stress deviation (intact tibia): Ti and CrCo stem of 110mm Bone-stem interface stresses
38 INFLUENCE OF MATERIAL AND LENGTH TIBIAL STEM Medial Posterior -100% 0% 100% 200% 300% 400% 500% 600% 700% 800% -100% 0% 100% 200% 300% 400% 500% 600% 700% 800% Haste 50mm Ti Haste 110mm Ti Haste 50mm Ti Haste 110mm Ti Minimal principal stress deviation (intact tibia): Ti stem of 50 and 110mm
39 INFLUENCE OF MATERIAL AND LENGTH polymeric tip Antero Posterior Radiograph Medial Posterior -100% 0% 100% 200% 300% 400% 500% 600% 700% 800% -100% 0% 100% 200% 300% 400% 500% 600% 700% 800% H 110mm Ti H 95mm Ti+15mm polietileno H 110mm Ti H 95mm Ti+15mm polietileno Minimal principal strain for stems of 110mm Ti and 95mm Ti, with a polyethelene tip of 15mm
40 INFLUENCE OF PROSTHESIS DESIGN Medial Lateral % 70% 60% 50% 40% 30% Cortical bone Cancellous bone Stem Strain (x10-6 ) Intact Base H_cim HPF_short HPF_long Cancellous bone minimal principal strains 20% 10% 0% Intact Base H_cim HPF_short HPF_long Axial load distribution at the cement-bone interface Strain (x10-6 ) Medial Base HPF_short Lateral H_cim HPF_long Cancellous bone shear strains
41 INFLUENCE OF PROSTHESIS DESIGN % -1% -2% -3% -4% -5% -6% -7% -8% -9% -10% H_cim HPF_short HPF_long Reduction of micromovement of the tibial tray-cortical bone relative to the non-stemmed implant Micromovement at cement-bone interface Micromovement at cement-bone interface
42 INFLUENCE OF PROSTHESIS DESIGN 0 Proximal Distal 0 Proximal Distal Intact Base H_Cim HPF_short HPF_long Intact Base H_Cim HPF_short HPF_long Cortical bone principal minimal strains (medial and lateral side)
43 SOME CONCLUSIONS It was possible to observe that load transferred at the bone-implant interface ranges from 3% to 24%, depending on the type of stem The cemented stem transfers higher degree of load, 24% of axial load to distal bone The non-cemented long stem transfers only 3% of the axial load to distal bone Stems have a more pronounced effect on load transferred to cortical bone than to cancellous bone, 19% difference of load transfer in cortical bone can be found between the stemless implant and the cemented stem Cemented stems can be beneficial for clinical cases were cortical bone is affected by bone tissue quality Considering the average of the micromotions in all aspects, the long press-fit stem presented similar performance to the cemented one Long stem produces high bone strains at the tip and do not depend on load transfer but on the resistance to moments generated at condilar the surfaces All commercial designs, cemented and non-cemented, produce high bone strains at the tip of the stems. Load transfer to the proximal and distal regions of the tibia is effectively achieved when cemented stems are used, but this type of the fixation presents a clinical inconvenient in surgical revision. Revisions of TKA are extremely difficult
44 Fracture estimation based on stress fields Intact femur Standard prosthesis
45 proximal distal 4 Intacto Tibia com protese de base Tibia com haste cimentada Tibia com haste não cimentada Interface von Mises stress implanted standard prosthesis Cemented stem (diam. 13mmx60mm) Intacto Tibia protese de base Tibia com haste cimentada Tibia com haste não cimentada Interface shear stress Non-cemented stem (diam. 14x115mm)
46 Cemented stem Press-fit stem LOAD SHARE Haste Cimento 18 Osso esponjoso Osso cortical 90% 80% cortical esponjoso haste 18 70% 60% 50% º % 30% 20% 10% Haste cimentada Haste press fit 0% Intacto Base H_cim HPF_longa Componente femoral cortical bone stem Vista anterior Vista medial cancellous bone
47 LOAD SHARE contact problem PRESS-FIT CEMENTED
48 MINIMAL PRINICIPAL BONE-CEMENT INTERFACE STRAIN: MEDIAL-LATERAL DIRECTION Medial Lateral Deformação (x10-6 ) Lateral Intacto Base H_Cim HPF_longa
49 CORTICAL STRAIN ENERGY - FEMUR M (x10-3 ) Joules 45 P L M (x10-3 ) Joules 35 P L DISTAL REGION AFTER FEMORAL COMPONENT Base H_Cim HPF_longa Intacto A Base H_Cim HPF_longa Intacto A POSITION OF THE CEMENTED STEM (90mm) (x10-3 ) Joules P (x10-3 ) Joules 60 P M 10 0 L M 10 0 L Base Base H_Cim H_Cim POSITION FROM THE PRESS-FIT STEM (175mm) HPF_longa Intacto A HPF_longa Intacto A 200mm FROM THE BONE-CEMENT INTERFACE (PROXIMAL REGION)
50 CONTACT REGIONS BETWEEN STEM AND CEMENT (CEMENTED STEM) Anterior Posterior Lateral Medial
51 CONTACT REGIONS BETWEEN STEM AND CEMENT (PRESS-FIT STEM) Anterior Posterior Lateral Medial
52 11.2 MPa CEMENT VON MISES STRESSES No stem (Standard) Cemented Stem (H_CEM) Press-Fit Stem (H_LONG)
53 VON MISES STRESSES AROUND THE STEM 13.4 MPa
54 RADIOGRAPHS (HIPERTROFY AND FRACTURE): can numerical simulations predict these?
55 5.0E-2 Joules 2.0E E-3 1.5E E-3 1.0E-3 7.5E-4 5.0E-4 2.5E PRESS-FIT CORTICAL STRAIN ENERGY Tip of press fit stem (cortical bone) Tip of cemented stem (cancellous bone) L LATERAL ANTERIOR MEDIAL (section)
56 F = 2100 N TOTAL KNEE PROSTHESIS FEMORAL + TIBIAL 7º Femur 245 mm Componente femoral Prato tibial polietileno Prato tibial 250 mm Tibia Zona de encastramento Vista posterior Vista Lateral Vista anterior
57 FINITE ELEMENT MESHES
58 TOTAL KNEE PROSTHESIS Vista anterior Base Componente femoral H_cim HPF_long a Componente tibial polietileno Prato tibial Haste 1 6 Sem haste de extensão Haste cimentada Haste press fit longa
59 MICROMOVEMENTS BETWEEN BONE AND FEMORAL COMPONENT 3.5% 3.0% 2.5% Posterior 0.0% -0.5% Anterior 2.0% -1.0% 1.5% 1.0% 0.5% -1.5% -2.0% 0.0% H_Cim HPF_longa -2.5% H_Cim HPF_longa 4% 3% Medial 1.0% 0.8% Lateral 2% 1% 0% 0.6% 0.4% -1% 0.2% -2% H_Cim HPF_longa 0.0% H_Cim HPF_longa
60 Questions
61 Or?
62
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