Biomechanics of Knee Replacement Mujda Hakime, Paul Malcolm 1
Table of contents Knee Anatomy Movements of the Knee Knee conditions leading to knee replacement Materials Alignment and Joint Loading Knee Implant failure Future development 2
Knee Anatomy: Bones of the knee Knee joint capsule Ligaments of the knee Tendons of the knee Muscles around the knee Knee Cartilage (Menisci) 3
Knee Anatomy: Bones of the Knee Four Major Bones: Tibia Patella Femur Fibula 4
Knee Anatomy: Ligaments of the Knee Medial collateral ligament Lateral collateral ligament Anterior cruciate ligament Posterior cruciate ligament Patellar ligament 5
Knee Anatomy: Cartilage of the Knee Articular cartilage Lateral meniscus Medial meniscus 6
Knee Anatomy: Muscles of the Knee Quadriceps: composed of four major muscles in front of thigh which allows you to straighten your the leg from a bent position Hamstrings: composed of 3 major muscles on the back of the thigh which allows you to bend your knee from a straight position 7
Knee Anatomy: Knee joint capsule 8
Knee Anatomy: Other features Tendons Bursae Arteries and veins 9
Movement of the Knee Knee Extension: The Normal range of knee extension is 0-10 degrees. Knee Flexion: The Normal range of knee flexion is 135-150 degrees. 10
Movement of the Knee 11
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Reasons for Knee replacement Arthritis : Osteoarthritis, rheumatoid arthritis and traumatic arthritis 14
Reasons for Knee replacement Severe Knee pain limiting daily activity Knee pain even when resting Chronic knee inflammation and swelling Knee Stiffness Avascular necrosis (AVN) results from an inadequate supply of blood to the bone end inside the joint. Malalignment of the knee joint: bowing in or out also known as knock-knees or bowlegs 15
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Fundamentals General idea is to replace the diseased surface with one made of a synthetic material Joint is interfaced with the bone using one of two methods; PMMA cement or bone ingrowth ACL is removed, sometimes PCL as well Plastic surface is inserted between femoral and tibial component, so weight is transferred metal-plastic-metal
Four Components of a Knee Replacement 1. Femoral component 2. Tibial component 3. Plastic insert 4. Patellar component Total or partial (sometimes called unicompartmental) Mobile-bearing or fixed-bearing regarding the plastic insert Cruciate-retaining (allows PCL to help support knee joint) Posterior-stabilized (when PCL has been removed) 18
Design Challenges and Requirements Lifespan patient age vs. artificial knee durability 85-90% of replacement knees are still functional after 10 years, has a lot to do with experience of surgeon Geometric design of the surfaces Interface between artificial joint and the surrounding bone 19
Materials and Their Properties Cobalt-chromium alloys are most commonly used since they are tough, corrosion resistant and bio-compatible Metal components are anchored using PMMA cement, which has good tissue compatibility Sometimes patients have an allergic reaction to the nickel in the Co-Cr alloy, in which case titanium can be used Polyethylene is usually used for the plastic spacer and allows for maximum joint mobility while minimizing surface wear (coeff. of friction 0.07, wear rate of 0.25mm/year) 20
Gait Analysis 1. Knee flexion angle about the axis from the lateral to medial condyle of the femur 2. Adduction moment about the posterioranterior axis (line of progression) 3. Moment about the distal-proximal axis of the limb (Deluzio et al. 708) 21
Alignment The effectiveness of a knee replacement greatly depends on having the proper alignment of the components, to maximize stability and decrease discomfort mechanical alignment only considers the 2-d alignment of the knee, lining them up to give a 0-degree hip-knee-ankle angle However, in reality only 2% of humans have this 0-degree setup naturally kinematic alignment takes into account the 3-d alignment and has been clinically shown to result in better motion and patient satisfaction 22
Tibiofemoral Joint Loadings Heel strike at 0, toe off at 100. Forces exerted on the knee joint can be up to 8x body weight walking downhill, and 4x body weight while walking on a level surface These forces are difficult to measure, and are greater than designers originally calculated 23
Contact Area of Replacement Knees in a natural knee, the average contact area ranges from 765mm 2 to 1150mm 2 Assuming a uniform load distribution and a load of 8x BW for a 70kg person, the stress on the cartilage of a healthy knee is less than 5MPa The contact area of a typical knee prostheses anywhere from 80-300mm 2, leading to a stress on the polyethylene inlay that could be up to 60MPa The polyethylene inlay has a yield point of 20MPa Designers typically use 4x BW during the testing phase of a knee replacement Shows the importance of being able to measure kinematics accurately 24
Knee Implant Failure Wear and loosening: Friction Infection Fracture Instability: A sensation of the knee giving away Stiffness: Loss of range Osteolysis: long term when tiny particles of worn-out plastic or cement from the implant that may potentially migrate into the bone and cause localized damage to the bone Thrombosis: blood cloth inside blood vessel obstructing blood flow through circulatory system 25
Future Advances Biologic Knee Replacement DeNovo ET Living Cartilage Implant smart or intelligent orthopedic implants 26
References DeNovo ET Living Cartilage Implant. ISTO Technologies, Inc. Web. 8 October 2012. <http://www.istotech.com/denovo-et-orthopedics.html> Fischer S., Knee Injuries and Conditions. UConn Health Care Center. Web. 8 October 2012. < http://uconnsportsmed.uchc.edu/injury/knee/total_knee.html> Knee Joint Anatomy, Function and Problems. Health Pages.org. 6 July 2010. Web. 8 October 2012. <http://healthpages.org/anatomy-function/knee-joint-structure-function-problems/#bones-of-the-knee> Knee Anatomy. Sportsinjuryclinic.net. Web. 8 October 2012. <http://www.sportsinjuryclinic.net/anatomy/knee-anatomy> Deluzio, Kevin, U. Wyss, P. Costigan, C. Sorbie, B. Zee. Gait Assessment in unicompartmental knee arthroplasty patients: Principal component modeling of gait waveforms and clinical status. Human Movement Science 8 (1999): 701-711. Kinematic vs. mechanical alignment: What is the difference?. Orthopedics Today. 11 Oct. 2010. <http://www.healio.com/orthopedics/knee/news/print/orthopedics-today/%7bca0f9a6b-d1bf-4d84-8437- c324d5cc0ad9%7d/kinematic-vs-mechanical-alignment-what-is-the-difference>. Types of Knee Replacement Prosthetics. Livestrong. 30 Mar. 2011. <http://www.livestrong.com/article/263154-types-of-knee-replacement-prosthetics/> Joint Load Considerations in Total Knee Replacement. M. Kuster, G. Wood, G. Stachowiak, A. Gachter. 1 Jan. 1997. <http://www.bjj.boneandjoint.org.uk/content/79-b/1/109.full.pdf> 27