Quantitative measurement of the stresses induced during polymerisation of bone cement

Full mapping tensile bond strength of luting in search for differences due to centripetal curing shrinkage

OBJECTIVES

testing if hypothetical transverse centripetal strains due to polymerization contraction of luting materials produce differential alterations in its bonding to luted structures, depending on distances to the center of the luting mass, and if this effect is C-factor related. Two hypotheses were tested: (1) there is a statistically significant decreasing relationship between the bonding strength and the transverse distances to the center of the luting material, and (2) there is a statistically significant difference between bonding strengths among luting spaces with different configuration factors.

METHODS

10 PMMA (15 mm Ø) pairs of cylinders were cemented (Scotchbond Universal adhesive & Relyx Universal, both chemically cured) in a compliant setup under two (20 and 70 N) luting forces forming 2 groups (5 samples each), resulting in different C-factors. Whole samples were sectioned in x and y directions obtaining non-trimmed beams from all along the luting surfaces. Their relative positions in each sample were assessed before separating and categorized (10 categories) according to their distances to the center of the sample. All beams were tested in tension and, because of their uneven bonding areas and to balance its influence, UTS results were transformed into UTS_res. First hypothesis was tested trough a linear relationship between UTS_res and distances to vertical centers per samples. Second hypothesis was tested using Mann-Whitney U tests to compare UTS_res between groups, along all categories. Further Weibull analysis was applied.

RESULTS

ANOVA's p of the regression UTS_res - categories were statistically significant for all samples in group 70 N and for all except one in group 20 N: first hypothesis is partially maintained. Although Mann-Whitney tests p comparing UTS_res of both groups for all categories but the first were statistically significant this hypothesis was maintained relying in Weibull analysis.

SIGNIFICANCE

bonded attachment of cemented materials decreases from centers to outbounds in plane, extensive surfaces, and this decrease is C-factor related.

Does vacuum mixing affect diameter shrinkage of a PMMA cement mantle during in vitro cemented acetabulum implantation?

Radiolucent lines on immediate postoperative cemented acetabular component radiographs between the PMMA bone cement mantle and bone are an indicator of an increased risk of early loosening. The cause of these lines has yet to be identified. Thermal and chemical necrosis, fluid interposition and cement shrinkage have all been suggested in the literature. The aim of the study reported here was to take an engineering approach - eliminating confounding variables present during surgery - to quantify the size of the interstice created by cement shrinkage when a 50 mm diameter flanged acetabular cup is implanted in a model acetabulum with a 52 mm hemispherical bore under controlled conditions using vacuum and non-vacuum mixed cement. Irrespective of the mixing method used, a significant interstice was created between the bone cement and the mock acetabulum. When the cement was mixed under vacuum the interstice created between the mock acetabulum and the cement mantle was 0.60 mm ± 0.09 mm; when the cement was mixed under non-vacuum conditions the interstice created was 0.39 mm ± 0.15 mm. Possible explanations for radiolucent lines are discussed.

Real-time synchronous measurement of curing characteristics and polymerization stress in bone cements with a cantilever-beam based instrument

An instrumentation capable of simultaneously determining degree of conversion (DC), polymerization stress (PS), and polymerization exotherm (PE) in real time was introduced to self-curing bone cements. This comprises the combination of an in situ high-speed near-infrared spectrometer, a cantilever-beam instrument with compliance-variable feature, and a microprobe thermocouple. Two polymethylmethacrylate-based commercial bone cements, containing essentially the same raw materials but differ in their viscosity for orthopedic applications, were used to demonstrate the applicability of the instrumentation. The results show that for both the cements studied the final DC was marginally different, the final PS was different at the low compliance, the peak of the PE was similar, and their polymerization rates were significantly different. Systematic variation of instrumental compliance for testing reveals differences in the characteristics of PS profiles of both the cements. This emphasizes the importance of instrumental compliance in obtaining an accurate understanding of PS evaluation. Finally, the key advantage for the simultaneous measurements is that these polymerization properties can be correlated directly, thus providing higher measurement confidence and enables a more in-depth understanding of the network formation process.

Synthesis and Characterization of an Injectable and Hydrophilous Expandable Bone Cement Based on Poly(methyl methacrylate)

Poly(methyl methacrylate) (PMMA), the most common bone cement, has been used as a graft substitute in orthopedic surgeries such as vertebroplasty. However, an undesirable minor crack in the bone-cement interface provoked by shrinkage during polymerization and high elastic modulus of conventional PMMA bone cement dramatically increases the risk of vertebral body refracture postsurgery. Thus, herein, a hydrophilous expandable bone cement was synthesized based on a PMMA commercial cement (Mendec Spine Resin), acrylic acid (AA), and styrene (St). The two synthesized cements (PMMA-PAA, PMMA-PAA-PSt) showed excellent volumetric swelling in vitro and cohesive bone-cement contact in rabbit femur cavity defect. The elastic modulus and compressive strength of the new cements were lower than PMMA. Furthermore, the in vitro analysis indicated that the new cements had lower cytotoxicity than PMMA, including superior proliferation and lower apoptotic rates of Sprague-Dawly rat-derived osteoblasts. Western blotting for protein expression and RT-PCR analysis of osteogenesis-specific genes were conducted on SD rat-derived osteoblasts from both PMMA and new cements films; the results showed that new cements enhanced the expression of osteogenesis-specific genes. Scanning electron microscopy demonstrated improved morphology and attachment of osteoblast on new cement discs compared to the PMMA discs. Additionally, the histological morphologies of the bone-cement interface from the rabbit medial femoral condyle cavity defect model revealed direct and cohesive contact with the bone in the new cement groups in contrast to a minor crack in the PMMA cement group. The sign of a new bone growing into the cement has been found in the new cements after 12 weeks, thereby indicating the osteogenic capacity in vivo. In conclusion, the synthesized hydrophilous expandable bone cements based on PMMA and poly(acrylic acid) (PAA) are promising candidates for vertebroplasty.

Four decades of finite element analysis of orthopaedic devices: where are we now and what are the opportunities?

Finite element has been used for more than four decades to study and evaluate the mechanical behaviour total joint replacements. In Huiskes seminal paper "Failed innovation in total hip replacement: diagnosis and proposals for a cure", finite element modelling was one of the potential cures to avoid poorly performing designs reaching the market place. The size and sophistication of models has increased significantly since that paper and a range of techniques are available from predicting the initial mechanical environment through to advanced adaptive simulations including bone adaptation, tissue differentiation, damage accumulation and wear. However, are we any closer to FE becoming an effective screening tool for new devices? This review contains a critical analysis of currently available finite element modelling techniques including (i) development of the basic model, the application of appropriate material properties, loading and boundary conditions, (ii) describing the initial mechanical environment of the bone-implant system, (iii) capturing the time dependent behaviour in adaptive simulations, (iv) the design and implementation of computer based experiments and (v) determining suitable performance metrics. The development of the underlying tools and techniques appears to have plateaued and further advances appear to be limited either by a lack of data to populate the models or the need to better understand the fundamentals of the mechanical and biological processes. There has been progress in the design of computer based experiments. Historically, FE has been used in a similar way to in vitro tests, by running only a limited set of analyses, typically of a single bone segment or joint under idealised conditions. The power of finite element is the ability to run multiple simulations and explore the performance of a device under a variety of conditions. There has been increasing usage of design of experiments, probabilistic techniques and more recently population based modelling to account for patient and surgical variability. In order to have effective screening methods, we need to continue to develop these approaches to examine the behaviour and performance of total joint replacements and benchmark them for devices with known clinical performance. Finite element will increasingly be used in the design, development and pre-clinical testing of total joint replacements. However, simulations must include holistic, closely corroborated, multi-domain analyses which account for real world variability.

Multiscale characterization of acrylic bone cement modified with functionalized mesoporous silica nanoparticles

Acrylic bone cement is widely used to anchor orthopedic implants to bone and mechanical failure of the cement mantle surrounding an implant can contribute to aseptic loosening. In an effort to enhance the mechanical properties of bone cement, a variety of nanoparticles and fibers can be incorporated into the cement matrix. Mesoporous silica nanoparticles (MSNs) are a class of particles that display high potential for use as reinforcement within bone cement. Therefore, the purpose of this study was to quantify the impact of modifying an acrylic cement with various low-loadings of mesoporous silica. Three types of MSNs (one plain variety and two modified with functional groups) at two loading ratios (0.1 and 0.2wt/wt) were incorporated into a commercially available bone cement. The mechanical properties were characterized using four-point bending, microindentation and nanoindentation (static, stress relaxation, and creep) while material properties were assessed through dynamic mechanical analysis, differential scanning calorimetry, thermogravimetric analysis, FTIR spectroscopy, and scanning electron microscopy. Four-point flexural testing and nanoindentation revealed minimal impact on the properties of the cements, except for several changes in the nano-level static mechanical properties. Conversely, microindentation testing demonstrated that the addition of MSNs significantly increased the microhardness. The stress relaxation and creep properties of the cements measured with nanoindentation displayed no effect resulting from the addition of MSNs. The measured material properties were consistent among all cements. Analysis of scanning electron micrographs images revealed that surface functionalization enhanced particle dispersion within the cement matrix and resulted in fewer particle agglomerates. These results suggest that the loading ratios of mesoporous silica used in this study were not an effective reinforcement material. Future work should be conducted to determine the impact of higher MSN loading ratios and alternative functional groups.

Thermally induced strains and total shrinkage of the polymethyl-methacrylate cement in simplified models of total hip arthroplasty

An evaluation of transient and stabilized strains in the cement mantle during polymerization was carried out in simplified cemented total hip arthroplasty (THA) model. A mathematical approach combined with a simple finite element simulation was used to compare measured and calculated stabilized strain values and to provide the Von Mises stresses at the stem/cement interface due to shrinkage related to temperature decrease after exothermal reaction. A second similar model was carried out to measure stem/cement/mold interfacial shear strength and dimensional changes of the cement mantle to obtain total shrinkage due to temperature decrease plus cement polymerization. The results indicated that positive strain peaks found during the exothermic stage of polymerization have the potential to produce pre-loading cracking. After the initial expansion, it was observed a progressive strain decrease pattern down to stabilized values that takes place near 2h after the cementation. Even though there is a great deal of dispersion in the measured stabilized strain values, in average those values match quite well with the numerical simulations, indicating 4,7 MPa von Mises interfacial stress due to thermal shrinkage. The total cement shrinkage leads to a negative radial stress of 11 MPa and 14 MPa von Mises interfacial stress. Finally, total shrinkage has the potential to enhance gaps in the cement/mold interface.

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 interface morphology. In this study, we used a finite element (FE) approach to analyze the mixed-mode response of the cement-bone interface taken from postmortem retrievals. 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 FE-models of postmortem cement-bone interfaces 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 FE-simulations compare satisfactorily with experimental observations, albeit the magnitude of the strength and stiffness are somewhat overestimated. Surprisingly, the FE-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.

Using 'subcement' to simulate the long-term fatigue response of cemented femoral stems in a cadaver model: could a novel preclinical screening test have caught the Exeter matt problem?

Previously, cement was formulated with degraded fatigue properties (subcement) to simulate long-term fatigue in short-term cadaver tests. The present study determined the efficacy of subcement in a 'preclinical' test of a design change with known clinical consequences: the 'polished'-to-'matt' transition of the Exeter stem (revision rates for polished stems were twice those for matt stems). Contemporary stems were bead blasted to give Ra = 1 microm (matt finish). Matt and polished stems were compared in cadaver pairs under stair-climbing loads (three pairs of size 1; three pairs of size 3). Stem micromotion was monitored during loading. Post-test transverse sections were examined for cement damage. Cyclic retroversion decreased for polished stems but increased for matt stems (p < 0.0001). The implant size had a substantial effect; retroversion of (larger) size-3 stems was half that of size-1 stems, and polished size-3 stems subsided 2.5 times more than the others. Cement damage measures were similar and open through-cracks occurred around both stems of two pairs. Stem retroversion within the mantle resulted in stem-cement gaps of 50-150 microm. Combining information on cyclic motion, cracks, and gaps, it was concluded that this test 'predicted' higher revision rates for matt stems (it also implied that polished size-3 stems might be superior to size-1 stems).

Nondestructive evaluation of bone cement and bone cement/metal interface failure

To quantify the failure mechanisms related to the loosening of cemented hip joint replacements, novel techniques, capable of monitoring, nondestructively, the initiation and progression of failure during in vitro fatigue tests, were employed. Fatigue testing of model cement and cement-stem test pieces was monitored using acoustic emission (AE) sensors. Once damage was detected, an ultrasonic imaging system was used to obtain an image of the damage site and to measure the stiffness of the affected region. This method of examination provided a detailed insight into the internal crack propagation and delamination patterns. Initial work was conducted on bulk cement specimens subjected to bending and tension. The second stage of the work examined a model stem-cement interface under tensile opening loading conditions. A novel ultrasonic technique was used to measure the bond quality at the cement-metal interface. Progressive delamination was identified over time, and the AE technique was able to identify critical areas of delamination before they could be identified conclusively by ultrasonic imaging. The work has demonstrated the potential of the AE technique as a tool for the preclinical assessment of total hip replacements.

Accounting for inclusions and voids allows the prediction of tensile fatigue life of bone cement

Previous attempts by researchers to predict the fatigue behavior of bone cement have been capable of predicting the location of final failure in complex geometries but incapable of predicting cement fatigue life to the right order of magnitude of loading cycles. This has been attributed to a failure to model the internal defects present in bone cement and their associated stress singularities. In this study, dog-bone-shaped specimens of bone cement were micro-computed-tomography (microCT) scanned to generate computational finite element (FE) models before uniaxial tensile fatigue testing. Acoustic emission (AE) monitoring was used to locate damage events in real time during tensile fatigue tests and to facilitate a comparison with the damage predicted in FE simulations of the same tests. By tracking both acoustic emissions and predicted damage back to microCT scans, barium sulfate (BaSO(4)) agglomerates were found not to be significant in determining fatigue life (p=0.0604) of specimens. Both the experimental and numerical studies showed that diffuse damage occurred throughout the gauge length. A good linear correlation (R(2)=0.70, p=0.0252) was found between the experimental and the predicted tensile fatigue life. Although the FE models were not always able to predict the correct failure location, damage was predicted in simulations at areas identified as experiencing damage using AE monitoring.

Computational modelling of bone cement polymerization: temperature and residual stresses

The two major concerns associated with the use of bone cement are the generation of residual stresses and possible thermal necrosis of surrounding bone. An accurate modelling of these two factors could be a helpful tool to improve cemented hip designs. Therefore, a computational methodology based on previous published works is presented in this paper combining a kinetic and an energy balance equation. New assumptions are that both the elasticity modulus and the thermal expansion coefficient depend on the bone cement polymerization fraction. This model allows to estimate the thermal distribution in the cement which is later used to predict the stress-locking effect, and to also estimate the cement residual stresses. In order to validate the model, computational results are compared with experiments performed on an idealized cemented femoral implant. It will be shown that the use of the standard finite element approach cannot predict the exact temporal evolution of the temperature nor the residual stresses, underestimating and overestimating their value, respectively. However, this standard approach can estimate the peak and long-term values of temperature and residual stresses within acceptable limits of measured values. Therefore, this approach is adequate to evaluate residual stresses for the mechanical design of cemented implants. In conclusion, new numerical techniques should be proposed in order to achieve accurate simulations of the problem involved in cemented hip replacements.

Effect of curing characteristics on residual stress generation in polymethyl methacrylate bone cements

Residual stresses resulting from the shrinkage of polymethyl methacrylate (PMMA) bone cement have been implicated in the formation of cracks in cement mantles following total hip arthroplasty. This study investigates whether two such cements, with differentiated solidification characteristics (i.e. working and setting times), display significant differences in their residual stress characteristics in an experiment designed to replicate the physical conditions of total hip arthroplasty. Experiments were performed using a representative femoral construct to measure and compare the temperatures and residual strains developed for standard PMMA cement mantles (CMW 1 Gentamicin) and slow curing cement mantles (SmartSet HV Gentamicin) during and following polymerization. These experimental results revealed no statistically significant difference (t-test, p > 0.05) for peak exotherm temperature and residual strain levels between the cements (measured after 3 h). The tailored polymerization characteristics of the slow-curing cement do not significantly affect residual stress generation, compared with the standard cement. It is often considered that residual stresses significantly relax following polymerization and before biomechanical loads are first applied during rehabilitation (up to 3 days later). This was examined for durations of 18 h to 3 days. Axial strains in the model femur and stem reduced by averages of 5.5 and 7.9 per cent respectively, while hoop strains in the stem exhibited larger reductions. An axisymmetric transient thermoelastic finite element model of the experiment was developed, allowing residual stresses to be predicted based on differential scanning calorimetry (DSC) measurements of the heat released throughout the exothermic curing reaction. The model predictions closely replicated the experimental measurements of both temperature and residual strain at 3 h, suggesting that residual strains can be fully accounted for by the thermal contraction mechanism associated with cooling after solidification.

Measurement of transient and residual stresses during polymerization of bone cement for cemented hip implants

The initial fixation of a cemented hip implant relies on the strength of the interface between the stem, bone cement and adjacent bone. Bone cement is used as grouting material to fix the prosthesis to the bone. The curing process of bone cement is an exothermic reaction where bone cement undergoes volumetric changes that will generate transient stresses resulting in residual stresses once polymerization is completed. However, the precise magnitude of these stresses is still not well documented in the literature. The objective of this study is to develop an experiment for the direct measurement of the transient and residual radial stresses at the stem-cement interface generated during cement polymerization. The idealized femoral-cemented implant consists of a stem placed inside a hollow cylindrical bone filled with bone cement. A sub-miniature load cell is inserted inside the stem to make a direct measurement of the radial compressive forces at the stem-cement interface, which are then converted to radial stresses. A thermocouple measures the temperature evolution during the polymerization process. The results show the evolution of stress generation corresponding to volumetric changes in the cement. The effect of initial temperature of the stem and bone as well as the cement-bone interface condition (adhesion or no adhesion) on residual radial stresses is investigated. A maximum peak temperature of 70 degrees C corresponds to a peak in transient stress during cement curing. Maximum radial residual stresses of 0.6 MPa in compression are measured for the preheated stem.

Femoral stem wear in cemented total hip replacement

The great success of cemented total hip replacement to treat patients with end-stage osteoarthritis and osteonecrosis has been well documented. However, its long-term survivorship has been compromised by progressive development of aseptic loosening, and few hip prostheses could survive beyond 25 years. Aseptic loosening is mainly attributed to bone resorption which is activated by an in-vivo macrophage response to particulate debris generated by wear of the hip prosthesis. Theoretically, wear can occur not only at the articulating head—cup interface but also at other load-bearing surfaces, such as the stem—cement interface. Recently, great progress has been made in reducing wear at the head—cup interface through the introduction of new materials and improved manufacture; consequently femoral stem wear is considered to be playing an increasingly significant role in the overall wear of cemented total hip replacement. In this review article, the clinical incidences of femoral stem wear are comprehensively introduced, and its significance is highlighted as a source of generation of wear debris and corrosion products. Additionally, the relationship between femoral stem surface finish and femoral stem wear is discussed and the primary attempts to reproduce femoral stem wear through in-vitro wear testing are summarized. Furthermore, the initiation and propagation processes of femoral stem wear are also proposed and a better understanding of the issue is considered to be essential to reduce femoral stem wear and to improve the functionality of cemented total hip replacement.

Cement mantle fatigue failure in total hip replacement: Experimental and computational testing

One possible loosening mechanism of the femoral component in total hip replacement is fatigue cracking of the cement mantle. A computational method capable of simulating this process may therefore be a useful tool in the preclinical evaluation of prospective implants. In this study, we investigated the ability of a computational method to predict fatigue cracking in experimental models of the implanted femur construct. Experimental specimens were fabricated such that cement mantle visualisation was possible throughout the test. Two different implant surface finishes were considered: grit blasted and polished. Loading was applied to represent level gait for two million cycles. Computational (finite element) models were generated to the same geometry as the experimental specimens, with residual stress and porosity simulated in the cement mantle. Cement fatigue and creep were modelled over a simulated two million cycles. For the polished stem surface finish, the predicted fracture locations in the finite element models closely matched those on the experimental specimens, and the recorded stem displacements were also comparable. For the grit blasted stem surface finish, no cement mantle fractures were predicted by the computational method, which was again in agreement with the experimental results. It was concluded that the computational method was capable of predicting cement mantle fracture and subsequent stem displacement for the structure considered.

The effect of water uptake on the behaviour of hydrophilic cements in confined environments

Physiological fluids will be in contact with the implant components from the first moments after a surgery. Therefore, the study of the effect of water on the properties of the bone cements that are part of the arthroplasty procedure is of critical importance to predict the long-term performance of the whole system. In our research group, we have developed a novel concept, the hydrophilic, partially degradable and bioactive cements which uptake considerably more water than standard bone cements. In this paper, we aimed to study the effect of water uptake (WU) by these cements on their behaviour. The tests were carried out in confined cavities, which represent more accurately the in vivo situation the cement will face (constrained by the bone and prosthesis surfaces). We observed that the equilibrium WU decreased up to 60% (as compared to non-confined situations), depending of the formulation. This decrease resulted in a latent tendency of the cements to swell, and the hindering of such swelling generated a swelling pressure against the constraining walls. The pressure, and consequent press-fitting effect, could be controlled by a number of mechanisms, and resulted in higher stability of the hydrophilic cements, expressed as an increase in the push-out force, required to extract the specimens from such constrained cavities. This effect was only observed in hydrophilic cements, not in commercial, hydrophobic ones used as controls. We conclude that such cements will provide an additional and very useful source of immediate adhesion in the short-term after surgery: water induced press fitting.

A comparison of the shrinkage of commercial bone cements when mixed under vacuum

The outcome of a cemented hip arthroplasty is partly dependent on the type of cement which is used. The production of an interface gap between the stem and the cement mantle as a result of shrinkage of the cement, may be a factor involved. Palacos R, Palacos LV (both with gentamicin), CMW 1, CMW 2, CMW Endurance (CMWE) and Simplex were prepared under vacuum and allowed to cure overnight in similar cylinders. The next day this volume was determined by the displacement of water. Shrinkage varied between 3.82% and 7.08% with CMWE having the lowest and Palacos LV the highest. This could be a factor to consider when choosing a cement for a shape-closed stem.

Microtomography assessment of failure in acrylic bone cement

Micromechanical studies of fatigue and fracture processes in acrylic bone cement have been limited to surface examination techniques and indirect signal analysis. Observations may then be mechanically unrepresentative and/or affected by the presence of the free surface. To overcome such limiting factors the present study has utilised synchrotron X-ray microtomography for the observation of internal defects and failure processes that occurred within a commercial bone cement during loading. The high resolution and the edge detection capability (via phase contrast imaging) have enabled clear microstructural imaging of both strongly and weakly absorbing features, with an effective isotropic voxel size of 0.7 microm. Detailed assessment of fatigue damage processes in in vitro fatigue test specimens is also achieved. Present observations confirm a link with macroscopic failure and the presence of larger voids, at which crack initiation may be linked to the mechanical stress concentration set up by adjacent beads at pore surfaces. This study does not particularly support the suggested propensity for failure to occur via the inter-bead matrix; however crack deflections at matrix/bead interfaces and the incidence of crack arrest within beads do imply locally increased resistance to failure and potential improvements in global crack growth resistance via crack tip shielding.