Accurate diagnosis of hip prosthesis loosening using a vibrational technique

Ultrasonic Interferometric Procedure for Quantifying the Bone-Implant Interface

The loosening of an artificial joint is a frequent and critical complication in orthopedics and trauma surgery. Due to a lack of accuracy, conventional diagnostic methods such as projection radiography cannot reliably diagnose loosening in its early stages or detect whether it is associated with the formation of a biofilm at the bone-implant interface. In this work, we present a non-invasive ultrasound-based interferometric measurement procedure for quantifying the thickness of the layer between bone and prosthesis as a correlate to loosening. In principle, it also allows for the material characterization of the interface. A well-known analytical model for the superposition of sound waves reflected in a three-layer system was combined with a new method in data processing to be suitable for medical application at the bone-implant interface. By non-linear fitting of the theoretical prediction of the model to the actual shape of the reflected sound waves in the frequency domain, the thickness of the interlayer can be determined and predictions about its physical properties are possible. With respect to determining the layer's thickness, the presented approach was successfully applied to idealized test systems and a bone-implant system in the range of approx. 200 µm to 2 mm. After further optimization and adaptation, as well as further experimental tests, the procedure offers great potential to significantly improve the diagnosis of prosthesis loosening at an early stage and may also be applicable to detecting the formation of a biofilm.

Multiscale Sensing of Bone-Implant Loosening for Multifunctional Smart Bone Implants: Using Capacitive Technologies for Precision Controllability

The world population growth and average life expectancy rise have increased the number of people suffering from non-communicable diseases, namely osteoarthritis, a disorder that causes a significant increase in the years lived with disability. Many people who suffer from osteoarthritis undergo replacement surgery. Despite the relatively high success rate, around 10% of patients require revision surgeries, mostly because existing implant technologies lack sensing devices capable of monitoring the bone–implant interface. Among the several monitoring methodologies already proposed as substitutes for traditional imaging methods, cosurface capacitive sensing systems hold the potential to monitor the bone–implant fixation states, a mandatory capability for long-term implant survival. A multifaceted study is offered here, which covers research on the following points: (1) the ability of a cosurface capacitor network to effectively monitor bone loosening in extended peri-implant regions and according to different stimulation frequencies; (2) the ability of these capacitive architectures to provide effective sensing in interfaces with hydroxyapatite-based layers; (3) the ability to control the operation of cosurface capacitive networks using extracorporeal informatic systems. In vitro tests were performed using a web-based network sensor composed of striped and interdigitated capacitive sensors. Hydroxyapatite-based layers have a minor effect on determining the fixation states; the effective operation of a sensor network-based solution communicating through a web server hosted on Raspberry Pi was shown. Previous studies highlight the inability of current bone–implant fixation monitoring methods to significantly reduce the number of revision surgeries, as well as promising results of capacitive sensing systems to monitor micro-scale and macro-scale bone–interface states. In this study, we found that extracorporeal informatic systems enable continuous patient monitoring using cosurface capacitive networks with or without hydroxyapatite-based layers. Findings presented here represent significant advancements toward the design of future multifunctional smart implants.

Modal Analysis of the Ancillary During Femoral Stem Insertion: A Study on Bone Mimicking Phantoms

The femoral stem primary stability achieved by the impaction of an ancillary during its insertion is an important factor of success in cementless surgery. However, surgeons still rely on their proprioception, making the process highly subjective. The use of Experimental Modal Analysis (EMA) without sensor nor probe fixation on the implant or on the bone is a promising non destructive approach to determine the femoral stem stability. The aim of this study is to investigate whether EMA performed directly on the ancillary could be used to monitor the femoral stem insertion into the bone. To do so, a cementless femoral stem was inserted into 10 bone phantoms of human femurs and EMA was carried out on the ancillary using a dedicated impact hammer for each insertion step. Two bending modes could be identified in the frequency range [400-8000] Hz for which the resonance frequency was shown to be sensitive to the insertion step and to the bone-implant interface properties. A significant correlation was obtained between the two modal frequencies and the implant insertion depth (R² = 0.95 ± 0.04 and R² = 0.94 ± 0.06). This study opens new paths towards the development of noninvasive vibration based evaluation methods to monitor cementless implant insertion.

Machine Learning-Based Diagnosis in Laser Resonance Frequency Analysis for Implant Stability of Orthopedic Pedicle Screws

Evaluation of the initial stability of implants is essential to reduce the number of implant failures of pedicle screws after orthopedic surgeries. Laser resonance frequency analysis (L-RFA) has been recently proposed as a viable diagnostic scheme in this regard. In a previous study, L-RFA was used to demonstrate the diagnosis of implant stability of monoaxial screws with a fixed head. However, polyaxial screws with movable heads are also frequently used in practice. In this paper, we clarify the characteristics of the laser-induced vibrational spectra of polyaxial screws which are required for making L-RFA diagnoses of implant stability. In addition, a novel analysis scheme of a vibrational spectrum using L-RFA based on machine learning is demonstrated and proposed. The proposed machine learning-based diagnosis method demonstrates a highly accurate prediction of implant stability (peak torque) for polyaxial pedicle screws. This achievement will contribute an important analytical method for implant stability diagnosis using L-RFA for implants with moving parts and shapes used in various clinical situations.

Laser resonance frequency analysis of pedicle screw stability: A cadaveric model bone study

There is no evaluation method currently available to assess intraoperative pedicle screw fixation (PSF) strength. In this study, we established a laser-based resonance frequency analysis (RFA) system with high-speed, noncontact, quantitative measurements of PSF. Clinical investigations in the future can assess surgical failure risk of implants. We investigated the characteristics of the laser RFA and compared them with the conventional methods. We inserted a pedicle screw in the vertebral pedicle of human cadaver or model bone, followed by screw pull-out, peak torque, implant stability quotient (ISQ) value obtained by the magnetic dental RFA system, and fixation force of laser RFA. We compared the outcomes using best-fit linear or logarithmic approximations. For the model bone study, the resonance frequency (RF) versus peak torque/pull-out force (POF) demonstrated strong correlations using logarithmic approximation (vs. peak torque: R = 0.931, p < .001, vs. POF: R = 0.931, p < .001). RF strongly correlated with the ISQ value using linear approximation (R = 0.981, p < .001). For the cadaveric vertebrae study, the correlation coefficients between RF and the peak torque/POF were significant regardless of approximation method (peak torque: logarithmic: R = 0.716 vs. linear: R = 0.811; p < .001) (POF: logarithmic: R = 0.644 vs. linear: R = 0.548; p < .05). Thus, the results of this study revealed a constant correlation between RFA and conventional methods as a measurement validation, predicting favorable support for intraoperative PSF. RFA has the potential to be a new index for evaluating the implant fixation force.

Ultrasonic assessment of osseointegration phenomena at the bone-implant interface using convolutional neural network

Although endosseous implants are widely used in the clinic, failures still occur and their clinical performance depends on the quality of osseointegration phenomena at the bone-implant interface (BII), which are given by bone ingrowth around the BII. The difficulties in ensuring clinical reliability come from the complex nature of this interphase related to the implant surface roughness and the presence of a soft tissue layer (non-mineralized bone tissue) at the BII. The aim of the present study is to develop a method to assess the soft tissue thickness at the BII based on the analysis of its ultrasonic response using a simulation based-convolution neural network (CNN). A large-annotated dataset was constructed using a two-dimensional finite element model in the frequency domain considering a sinusoidal description of the BII. The proposed network was trained by the synthesized ultrasound responses and was validated by a separate dataset from the training process. The linear correlation between actual and estimated soft tissue thickness shows excellent R² values equal to 99.52% and 99.65% and a narrow limit of agreement corresponding to [ -2.56, 4.32 μm] and [ -15.75, 30.35 μm] of microscopic and macroscopic roughness, respectively, supporting the reliability of the proposed assessment of osseointegration phenomena.

Simple Smart Implants: Simultaneous Monitoring of Loosening and Temperature in Orthopaedics With an Embedded Ultrasound Transducer

Implant failure can have devastating consequences on patient outcomes following joint replacement. Time to diagnosis affects subsequent treatment success, but current diagnostics do not give early warning and lack accuracy. This research proposes an embedded ultrasound system to monitor implant fixation and temperature - a potential indicator of infection. Requiring only two implanted components: a piezoelectric transducer and a coil, pulse-echo responses are elicited via a three-coil inductive link. This passive system avoids the need for batteries, energy harvesters, and microprocessors, resulting in minimal changes to existing implant architecture. Proof-of-concept was demonstrated in vitro for a titanium plate cemented into synthetic bone, using a small embedded coil with 10 mm diameter. Gross loosening - simulated by completely debonding the implant-cement interface - was detectable with 95% confidence at up to 12 mm implantation depth. Temperature was calibrated with root mean square error of 0.19°C at 5 mm, with measurements accurate to ±1°C with 95% confidence up to 6 mm implantation depth. These data demonstrate that with only a transducer and coil implanted, it is possible to measure fixation and temperature simultaneously. This simple smart implant approach minimises the need to modify well-established implant designs, and hence could enable mass-market adoption.

Ultrasonic Propagation in a Dental Implant

Ultrasound techniques can be used to characterize and stimulate dental implant osseointegration. However, the interaction between an ultrasonic wave and the implant-bone interface (IBI) remains unclear. This study-combining experimental and numerical approaches-investigates the propagation of an ultrasonic wave in a dental implant by assessing the amplitude of the displacements along the implant axis. An ultrasonic transducer was excited in a transient regime at 10 MHz. Laser interferometric techniques were employed to measure the amplitude of the displacements, which varied 3.2-8.9 nm along the implant axis. The results demonstrated the propagation of a guided wave mode along the implant axis. The velocity of the first arriving signal was equal to 2110 m.s^-1, with frequency components lower than 1 MHz, in agreement with numerical results. Investigating guided wave propagation in dental implants should contribute to improved methods for the characterization and stimulation of the IBI.

Differentiation between mechanically loose and fixed press-fit implants using quantitative acoustics and load self-referencing: A phantom study on shoulder prostheses in polyurethane foam

This study proposes to use cross-interface quantitative acoustics (ci-qA) and load self-referencing (LSR) to assess implant stability in a radiation-free, inexpensive, rapid, and quantitative manner. Eight bone analog specimens, made from polyurethane foam, were implanted with a cementless stemless shoulder implant—first in a fixed and later in a loose configuration—and measured using ci-qA under two load conditions. The loose implants exhibited higher micromotion and lower pull-out strength than their stable counterparts, with all values falling within the range of reported reference values. All acoustic characteristics differentiated between loose and fixed implants (maximum area-under-curve AUC = 1.0 for mean total signal energy, AUC = 1.0 for mean total signal energy ratio, AUC = 0.8 for harmonic ratio, and AUC = 0.92 for load self-referencing coefficient). While these results on bone substitute material will need to be confirmed on real bone specimen, ci-qA could ultimately facilitate the assessment of primary stability during implantation surgery and avoid unnecessary revision through quantitative evaluation of secondary stability during follow-up.

A Vibrational Technique for In Vitro Intraoperative Prosthesis Fixation Monitoring

OBJECTIVE

In this paper, a new vibrational modal analysis technique was developed for intraoperative cementless prosthesis fixation evaluation upon hammering.

METHODS

An artificial bone (Sawbones)-prosthesis system was excited by sweeping of a sine signal over a wide frequency range. The exponential sine sweep technique was implemented to the response signal in order to determine the linear impulse response. Recursive Fourier transform enhancement (RFTE) technique was applied to the linear impulse response signal in order to enhance the frequency spectrum with sharp and distinguishable peak values indicating distinct high natural frequencies of the system (ranging from 15 kHz to 90 kHz). The experiment was repeated with 5 Sawbones-prosthesis samples. Upon successive hammering during the prosthesis insertion, variation of each natural frequency was traced.

RESULTS

Compared to classical Fast Fourier Transform, RFTE provided a better tracing and enhancement of frequency components during insertion. Three different types of frequency evolving trends (monotonically increasing, insensitive, and plateau-like) were observed for all samples, as confirmed by a new finite element simulation of the prosthesis dynamic insertion. Two main mechanical phenomena (i.e., geometrical compaction and compressive stress) were shown to govern these trends in opposite ways. Follow-up of the plateau-like trend upon hammering showed that the frequency shift is a good indicator of fixation.

CONCLUSION

Alongside the individual follow-up of frequency shifts, combinatorial frequency analysis provides new objective information on the mechanical stability of Sawbone-prosthesis fixation.

SIGNIFICANCE

The proposed vibrational technique based on RTFE can provide the surgeon with a new assistive diagnostic technique during the surgery by indicating when the bone-prosthesis fixation is acceptable, and beyond of which further hammering should be done cautiously to avoid bone fracture.

Altering the Course of Technologies to Monitor Loosening States of Endoprosthetic Implants

Musculoskeletal disorders are becoming an ever-growing societal burden and, as a result, millions of bone replacements surgeries are performed per year worldwide. Despite total joint replacements being recognized among the most successful surgeries of the last century, implant failure rates exceeding 10% are still reported. These numbers highlight the necessity of technologies to provide an accurate monitoring of the bone–implant interface state. This study provides a detailed review of the most relevant methodologies and technologies already proposed to monitor the loosening states of endoprosthetic implants, as well as their performance and experimental validation. A total of forty-two papers describing both intracorporeal and extracorporeal technologies for cemented or cementless fixation were thoroughly analyzed. Thirty-eight technologies were identified, which are categorized into five methodologies: vibrometric, acoustic, bioelectric impedance, magnetic induction, and strain. Research efforts were mainly focused on vibrometric and acoustic technologies. Differently, approaches based on bioelectric impedance, magnetic induction and strain have been less explored. Although most technologies are noninvasive and are able to monitor different loosening stages of endoprosthetic implants, they are not able to provide effective monitoring during daily living of patients.

Laser Resonance Frequency Analysis: A Novel Measurement Approach to Evaluate Acetabular Cup Stability During Surgery

Artificial joint acetabular cup stability is essential for successful total hip arthroplasty. However, a quantitative evaluation approach for clinical use is lacking. We developed a resonance frequency analysis (RFA) system involving a laser system that is fully contactless. This study aimed to investigate the usefulness of laser RFA for evaluating acetabular cup stability. First, the finite element method was performed to determine the vibration mode for analysis. Second, the acetabular cup was press-fitted into a reamed polyurethane cavity that replicated the human acetabular roof. The implanted acetabular cup was vibrated with pulse laser irradiation and the induced vibration was detected with a laser Doppler vibrometer. The time domain signal from the vibrometer was analyzed by fast Fourier transform to obtain the vibration frequency spectrum. After laser RFA, the pull-down force of the acetabular cup was measured as conventional implant fixation strength. The frequency of the first highest amplitude between 2 kHz and 6 kHz was considered as the resonance peak frequency, and its relationship with the pull-down force was assessed. The peak frequency could predict the pull-down force (R² = 0.859, p < 0.000). Our findings suggest that laser RFA might be useful to measure acetabular cup stability during surgery.

An Implantable Wireless Inductive Sensor System Designed to Monitor Prosthesis Motion in Total Joint Replacement Surgery

Currently, the most common method for detecting prosthetic implant loosening is imaging. Unfortunately, imaging methods are imprecise in detecting the early signs of implant loosening. This paper describes a new wireless inductive proximity sensor system for detecting early implant loosening. The loosening of the implant is accurately detected by analyzing the electromagnetic field generated by the passive sensors located around the implant. The sensor system was modeled and simulated using COMSOL, and then tested experimentally. The inductive proximity sensor and the metallic implant form a coupled circuit is tuned to oscillate at a designed frequency. The circuit's integrated controller measures and records specific sensor's parameters such as resistance and inductance of the sensor that are directly related to the distance between the sensor system and the implant. A prototype has been developed and the results show that the designed proximity sensor is capable of measuring the loosening of the hip implant at [Formula: see text]m resolution at distances of less than [Formula: see text], and of [Formula: see text]m resolution at a distance of [Formula: see text]. Furthermore, there is a good correlation between the simulated and experimental results.

Dependence of the primary stability of cementless acetabular cup implants on the biomechanical environment

Biomechanical phenomena occurring at the bone–implant interface during the press-fit insertion of acetabular cup implants are still poorly understood. This article presents a nonlinear geometrical two-dimensional axisymmetric finite element model aiming at describing the biomechanical behavior of the acetabular cup implant as a function of the bone Young’s modulus Eb, the diametric interference fit ( IF), and the friction coefficient µ. The numerical model was compared with experimental results obtained from an in vitro test, which allows to determine a reference configuration with the parameter set: μ*  = 0.3, [Formula: see text], and IF*  = 1 mm for which the maximal contact pressure tN = 10.7 MPa was found to be localized at the peri-equatorial rim of the acetabular cavity. Parametric studies were carried out, showing that an optimal value of the pull-out force can be defined as a function of μ, Eb, and IF. For the reference configuration, the optimal pull-out force is obtained for μ  = 0.6 (respectively, Eb = 0.35 GPa and IF = 1.4 mm). For relatively low value of µ ( µ < 0.2), the optimal value of IF linearly increases as a function of µ independently of Eb, while for µ > 0.2, the optimal value of IF has a nonlinear dependence on µ and decreases as a function of Eb. The results can be used to help surgeons determine the optimal value of IF in a patient specific manner.

Reflection of an ultrasonic wave on the bone-implant interface: Effect of the roughness parameters

Quantitative ultrasound can be used to characterize the evolution of the bone-implant interface (BII), which is a complex system due to the implant surface roughness and to partial contact between bone and the implant. The aim of this study is to derive the main determinants of the ultrasonic response of the BII during osseointegration phenomena. The influence of (i) the surface roughness parameters and (ii) the thickness W of a soft tissue layer on the reflection coefficient r of the BII was investigated using a two-dimensional finite element model. When W increases from 0 to 150 μm, r increases from values in the range [0.45; 0.55] to values in the range [0.75; 0.88] according to the roughness parameters. An optimization method was developed to determine the sinusoidal roughness profile leading to the most similar ultrasonic response for all values of W compared to the original profile. The results show that the difference between the ultrasonic responses of the optimal sinusoidal profile and of the original profile was lower to typical experimental errors. This approach provides a better understanding of the ultrasonic response of the BII, which may be used in future numerical simulation realized at the scale of an implant.

Design, Modeling, and Evaluation of the Eddy Current Sensor Deeply Implanted in the Human Body

Joint replacement surgeries have enabled motion for millions of people suffering from arthritis or grave injuries. However, over 10% of these surgeries are revision surgeries. We have first analyzed the data from the worldwide orthopedic registers and concluded that the micromotion of orthopedic implants is the major reason for revisions. Then, we propose the use of inductive eddy current sensors for in vivo micromotion detection of the order of tens of μ m. To design and evaluate its characteristics, we have developed efficient strategies for the accurate numerical simulation of eddy current sensors implanted in the human body. We present the response of the eddy current sensor as a function of its frequency and position based on the robust curve fit analysis. Sensitivity and Sensitivity Range parameters are defined for the present context and are evaluated. The proposed sensors are fabricated and tested in the bovine leg.

Reflection of an ultrasonic wave on the bone-implant interface: A numerical study of the effect of the multiscale roughness

Quantitative ultrasound is used to characterize and stimulate osseointegration processes at the bone-implant interface (BII). However, the interaction between an ultrasonic wave and the implant remains poorly understood. This study aims at investigating the sensitivity of the ultrasonic response to the microscopic and macroscopic properties of the BII and to osseointegration processes. The reflection coefficient R of the BII was modeled for different frequencies using a two-dimensional finite element model. The implant surface roughness was modeled by a sinusoidal function with varying amplitude h and spatial frequency L. A soft tissue layer of thickness W was considered between bone tissue and the implant in order to model non-mineralized fibrous tissue. For microscopic roughness, R is shown to increase from around 0.55 until 0.9 when kW increases from 0 to 1 and to be constant for kW > 1, where k is the wavenumber in the implant. These results allow us to show that R depends on the properties of bone tissue located at a distance comprised between 1 and 25 μm from the implant surface. For macroscopic roughness, R is highly dependent on h and this dependence may be explained by phase cancellation and multiple scattering effects for high roughness parameters.

A study on the use of the Osstell apparatus to evaluate pedicle screw stability: An in-vitro study using micro-CT

Pull-out force and insertion torque have not been generally used as intraoperative measures for the evaluation of pedicle screw stability because of their invasiveness. On the other hand, resonance frequency analysis is a non-invasive and repeatable technique that has been clinically used in dentistry to evaluate implant stability e.g. by the Osstell apparatus. In this study, the characteristics of the implant stability quotient (ISQ) value obtained by the Osstell apparatus in the field of spinal surgery were investigated. Biomechanical test materials simulating human bone were used to provide a comparative platform for evaluating each fixation strength measure, including pull-out force, insertion torque, and the ISQ value. To perform pull-out force measurement and to repeat pedicle screw insertion and removal, loosening was artificially created, and its effect was investigated. The grade of loosening was quantified on a micro-CT image after pedicle screw removal. In the comparison of the 3 fixation strength measures, the correlations of the ISQ value with the pull-out force (R² = 0.339 p <0.0001) and the insertion torque (R² = 0.337 p <0.0001) were lower than the correlation between pull-out force and insertion torque (R² = 0.918 p <0.0001). On a micro-CT study, the material volume of the internal threads disappeared after destruction of its integrity due to repeated pedicle screw insertion and removal. Material integrity destruction of the internal threads decreased only the pull-out force and the insertion torque, but it did not affect the ISQ value. The ISQ value only decreased when the material volume of the internal threads disappeared, probably because the ISQ value reflects the resistance against a force in the perpendicular direction of the screw, unlike the conventional measures of fixation strength, such as pull-out force and insertion torque, which reflect axial load.

Knee Implant Loosening Detection: A Vibration Analysis Investigation

Knee implant loosening is mainly caused by the weakness of the prosthesis-bone interface and is the main reason for surgical revisions. However, pre-operative diagnosis is difficult due to lack of accurate tests. In this study, we developed a vibration-based system to detect the loosening of the tibial implant of an instrumented knee prosthesis. The proposed system includes an instrumented vibrator for transcutaneous stimulation of the bone in a repeatable manner, and accelerometer sensors integrated into the implants to measure the propagated vibration. A coherence-based detection technique was proposed to distinguish the loosened implants from the secure ones. Fourteen ex vivo lower limbs were used, on which the knee prosthesis was implanted, and harmonic-forced vibration was applied on the tibia. The input–output coherence measure provided 92.26% accuracy, a high sensitivity (91.67%) and specificity (92.86%). This technique was benchmarked against power spectrum based analysis of the propagated vibration to the implant. In particular, loosening detection based on new peak appearance, peak shift, and peak flattening in power spectra showed inferior performance to the proposed coherence-based technique. As such, application of vibration on our instrumented knee prosthesis together with input–output coherence analysis enabled us to distinguish the secure from loose implants.

Development of an acoustic measurement protocol to monitor acetabular implant fixation in cementless total hip Arthroplasty: A preliminary study

In cementless total hip arthroplasty (THA), the initial stability is obtained by press-fitting the implant in the bone to allow osseointegration for a long term secondary stability. However, finding the insertion endpoint that corresponds to a proper initial stability is currently based on the tactile and auditory experiences of the orthopedic surgeon, which can be challenging. This study presents a novel real-time method based on acoustic signals to monitor the acetabular implant fixation in cementless total hip arthroplasty. Twelve acoustic in vitro experiments were performed on three types of bone models; a simple bone block model, an artificial pelvic model and a cadaveric model. A custom made beam was screwed onto the implant which functioned as a sound enhancer and insertor. At each insertion step an acoustic measurement was performed. A significant acoustic resonance frequency shift was observed during the insertion process for the different bone models; 250 Hz (35%, second bending mode) to 180 Hz (13%, fourth bending mode) for the artificial bone block models and 120 Hz (11%, eighth bending mode) for the artificial pelvis model. No significant frequency shift was observed during the cadaveric experiment due to a lack of implant fixation in this model. This novel diagnostic method shows the potential of using acoustic signals to monitor the implant seating during insertion.

Non-invasive vibrometry-based diagnostic detection of acetabular cup loosening in total hip replacement (THR)

Total hip replacement is aimed at relieving pain and restoring function. Currently, imaging techniques are primarily used as a clinical diagnosis and follow-up method. However, these are unreliable for detecting early loosening, and this has led to the proposal of novel techniques such as vibrometry. The present study had two aims, namely, the validation of the outcomes of a previous work related to loosening detection, and the provision of a more realistic anatomical representation of the clinical scenario. The acetabular cup loosening conditions (secure, and 1 and 2 mm spherical loosening) considered were simulated using Sawbones composite bones. The excitation signal was introduced in the femoral lateral condyle region using a frequency range of 100-1500 Hz. Both the 1 and 2 mm spherical loosening conditions were successfully distinguished from the secure condition, with a favourable frequency range of 500-1500 Hz. The results of this study represent a key advance on previous research into vibrometric detection of acetabular loosening using geometrically realistic model, and demonstrate the clinical potential of this technique.

Determination of replicate composite bone material properties using modal analysis

Replicate composite bones are used extensively for in vitro testing of new orthopedic devices. Contrary to tests with cadaveric bone material, which inherently exhibits large variability, they offer a standardized alternative with limited variability. Accurate knowledge of the composite's material properties is important when interpreting in vitro test results and when using them in FE models of biomechanical constructs. The cortical bone analogue material properties of three different fourth-generation composite bone models were determined by updating FE bone models using experimental and numerical modal analyses results. The influence of the cortical bone analogue material model (isotropic or transversely isotropic) and the inter- and intra-specimen variability were assessed. Isotropic cortical bone analogue material models failed to represent the experimental behavior in a satisfactory way even after updating the elastic material constants. When transversely isotropic material models were used, the updating procedure resulted in a reduction of the longitudinal Young's modulus from 16.00GPa before updating to an average of 13.96 GPa after updating. The shear modulus was increased from 3.30GPa to an average value of 3.92GPa. The transverse Young's modulus was lowered from an initial value of 10.00GPa to 9.89GPa. Low inter- and intra-specimen variability was found.

Development of a non-invasive diagnostic technique for acetabular component loosening in total hip replacements

Current techniques for diagnosing early loosening of a total hip replacement (THR) are ineffective, especially for the acetabular component. Accordingly, new, accurate, and quantifiable methods are required. The aim of this study was to investigate the viability of vibrational analysis for accurately detecting acetabular component loosening. A simplified acetabular model was constructed using a Sawbones(®) foam block. By placing a thin silicone layer between the acetabular component and the Sawbones block, 2- and 4-mm soft tissue membranes were simulated representing different loosening scenarios. A constant amplitude sinusoidal excitation with a sweep range of 100-1500 Hz was used. Output vibration from the model was measured using an accelerometer and an ultrasound probe. Loosening was determined from output signal features such as the number and relative strength of observed harmonic frequencies. Both measurement methods were sufficient to measure the output vibration. Vibrational analysis reliably detected loosening corresponding to both 2 and 4 mm tissue membranes at driving frequencies between 100 and 1000 Hz (p < 0.01) using the accelerometer. In contrast, ultrasound detected 2-mm loosening at a frequency range of 850-1050 Hz (p < 0.01) and 4-mm loosening at 500-950 Hz (p < 0.01).

Loosening detection of the femoral component of hip prostheses with extracorporeal shockwaves: a pilot study

The diagnosis of aseptic loosening of hip implants is often challenging. A vibrational analysis of the bone-implant interface could be an alternative method to analyze the fixation of endoprostheses. We assessed an innovative and new approach for excitation by using extracorporeal shockwaves in this study. In three cadaver specimens total hip arthroplasty was performed bilaterally. Four different states of implant loosening were simulated. Three accelerometers were fixed at the medial condyle, the greater trochanter, and the crest of the ilium. The bone-implant compound was excited with highly standardized extracorporeal shock waves. Resonance spectra between 100 Hz and 5000 Hz were recorded. This technique permitted a good adaptation to varying soft tissue conditions. The main resonance frequency of the hip joints occurred at about 2000 Hz. The analysis of the measured spectra showed an interrelation between the state of loosening and the frequency values of the resonances. In case of a stem loosening, there were significant shifts of the resonance into the lower frequency area between 386 Hz and 847 Hz. With this novel technique the degree of stem loosening could be assessed in a soft tissue considering configuration. This study forms a first step for future establishment of a non-invasive, non-radiological and fast applicable diagnostic procedure for early detection of endoprostheses loosening before manifest presence of clinical signs.

Investigation of a passive sensor array for diagnosis of loosening of endoprosthetic implants

Currently, imaging methods are used to diagnose loosening of endoprosthetic implants, but fail to achieve 100% accuracy. In this study, a passive sensor array which is based on the interaction between magnetic oscillators inside the implant and an excitation coil outside the patient was investigated. The excited oscillators produce sound in the audible range, which varies according to the extent of loosening. By performing several experimental tests, the sensor array was optimized to guarantee reproducible and selective excitation of the sound emission. Variation in the distance between the oscillators demonstrated a definite influence on the quality of the generated sound signal. Furthermore, a numerical design analysis using the boundary element method was generated for consideration of the magnetic field and the selectivity of the oscillators during excitation. The numerical simulation of the coil showed the higher selectivity of a coil with a C-shape compared to a cylindrical coil. Based on these investigations, the passive sensor system reveals the potential for detection of implant loosening. Future aims include the further miniaturization of the oscillators and measurements to determine the sensitivity of the proposed sensor system.

Nonlinear ultrasound: potential of the cross-correlation method for osseointegration monitoring

Recently the concept of probing nonlinear elasticity at an interface prosthesis/bone has been proposed as a promising method to monitor the osseointegration/sealing of a prosthesis. However, the most suitable method to achieve this goal is a point of debate. To this purpose, two approaches termed the scaling subtraction method and the cross-correlation method are compared here. One nonlinear parameter derived from the cross-correlation method is as sensitive as a clinical device based on linear elasticity measurement. Further, this study shows that cross-correlation based methods are more sensitive than those based on subtraction/addition, such like pulse inversion and similar methods.

Time reversed elastic nonlinearity diagnostic applied to mock osseointegration monitoring applying two experimental models

This study broadens vibration-like techniques developed for osseointegration monitoring to the nonlinear field. The time reversed elastic nonlinearity diagnostic is applied to two mock models. The first one consists of tightening a dental implant at different torques in a mock cortical bone; the second one allows one to follow glue curing at the interface between a dental implant and a mock jaw. Energy is focused near the implant interface using the time reversal technique. Two nonlinear procedures termed pulse inversion and the scaling subtraction method, already used successfully in other fields such as contrast agents and material characterization, are employed. These two procedures are compared for both models. The results suggest that nonlinear elasticity can provide new information regarding the interface, complementary to the linear wave velocity and attenuation. The curing experiment exhibits an overall low nonlinear level due to the fact that the glue significantly damps elastic nonlinearity at the interface. In contrast, the torque experiment shows strong nonlinearities at the focus time. Consequently, a parallel analysis of these models, both only partially reflecting a real case, enables one to envisage future in vivo experiments.

A finite element analysis of the vibration behaviour of a cementless hip system

An early diagnosis of aseptic loosening of a total hip replacement (THR) by plain radiography, scintigraphy or arthography has been shown to be less reliable than using a vibration technique. However, it has been suggested that it may be possible to distinguish between a secure and a loose prosthesis using a vibration technique. In fact, vibration analysis methods have been successfully used to assess dental implant stability, to monitor fracture healing and to measure bone mechanical properties. Several studies have combined the vibration technique with the finite element (FE) method in order to better understand the events involved in the experimental technique. In the present study, the main goal is to simulate the change in the resonance frequency during the osseointegration process of a cementless THR (Zweymüller). The FE method was used and a numerical modal analysis was conducted to obtain the natural frequencies and mode shapes under vibration. The effects were studied of different bone and stem material properties, and different contact conditions at the bone-implant interface. The results were in agreement with previous experimental and computational observations, and differences among the different cases studied were detected. As the osseointegration process at the bone-implant interface evolved, the resonance frequency values of the femur-prosthesis system also increased. In summary, vibration analysis combined with the FE method was able to detect different boundary conditions at the bone-implant interface in cases of both osseointegration and loosening.

A Novel Sensor Concept for Optimization of Loosening Diagnostics in Total Hip Replacement

The main reason for the revision of total hip replacements is aseptic loosening, caused by stress shielding and wear particle induced osteolysis. In order to detect an implant loosening early, the osseointegration of endoprosthetic implants must be measured exactly. Currently applied diagnostic methods, such as standard radiographs and clinical symptomatology, often result in an imprecise diagnosis. A novel radiation-free method to improve the diagnostic investigation of implant loosening is presented. The osseointegration of an implant can be identified using mechanical magnetic sensors (oscillators), which impinge on small membranes inside an implant component, e.g., the femoral hip stem. The maximum velocity after impingement of the oscillator depends on the osseointegration of the implant. Excitation of the oscillator is realized by a coil outside the human body. Another external coil is used to detect the velocity of the oscillator. To demonstrate the principle of the novel loosening sensor, an overdimensioned test device was designed to measure simulated loosening phases in the first experimental tests with different material layers. The overdimensioned test device of the loosening sensor showed significant differences in the various phases of fixation. Analysis of the membrane without any material layer in the case of advanced loosening resulted in a 23% higher maximum velocity compared to an attached artificial bone layer. Based on these preliminary results, the sensor system shows potential for the detection of implant loosening. Moreover, the proposed system could be used in experimental applications to determine the quality of bioactive coatings and new implant materials.

The efficacy of using vibrometry to detect osteointegration of the Agility total ankle

Arthritis is a chronic, debilitating disease affecting one in six people in the United States annually. One of the most promising surgical treatments is total joint replacement. After decades of development, some joint replacement (arthroplasty) systems such as the hip and knee enjoy high success rates while others, particularly newer ones for the ankle, have disappointing survival rates. The goal of this study was to investigate, develop, and test a methodology to assess implant osteointegration, specifically for the talar component of a total ankle prosthesis. A vibrometry technique using Doppler ultrasound was developed to non-invasively determine osteointegration clinically. This methodology was evaluated via preliminary experimentation, along with another validation methodology, to access whether design criteria have been met in order to initiate a clinical study of the technique. Bench-top and cadaveric testing demonstrated that the Doppler ultrasound technique could distinguish the level of osteointegration between loose and fixed implant components. The laser vibrometry technique, used for the validation of the ultrasound technique intraoperatively, was also shown to be functional and indicative of the ultrasound technique's testing results. This methodology can provide a much needed tool to determine the integration of implants non-invasively in the clinical and surgical setting, thus allowing each patient's rehabilitation program to be monitored and tailored to maximize the osteointegration and survival rate of their total joint replacement.

Acoustic monitoring (RFM) of total hip arthroplasty - Results of a cadaver study

Introduction

At present there are no reliable non-traumatic and non-invasive methods to analyse the healing process and loosening status after total hip replacement. Therefore early as well as late loosening of prosthesis and interface component problems are difficult to be found or diagnosed at any time.

Methods

In a cadaver study the potential application of Resonance Frequency Monitoring (RFM) will be evaluated as a non-invasive and non-traumatic method to monitor loosening and interface problems in hip replacement. In a 65 year old female cadaver different stability scenarios for a total hip replacement (shaft, head/modular head and cup, ESKA, Luebeck, Germany) are simulated in cemented and cement less prosthesis and then analysed with RFM. The types of stability vary from secure/press-fit to interface-shaft disruption.

Results

The RFM shows in cemented as well as cement less prosthesis significant intra-individual differences in the spectral measurements with a high dynamic (20 dB difference corresponding to the factor 100 (10000%)), regarding the simulated status of stability in the prosthesis system.

Conclusion

The results of the study demonstrate RFM as a highly sensitive non-invasive and non-traumatic method to support the application of RFM as a hip prosthesis monitoring procedure. The data obtained shows the possibility to use RFM for osteointegration surveillance and early detection of interface problems, but will require further evaluation in clinical and experimental studies.

In vivo evaluation of a vibration analysis technique for the per-operative monitoring of the fixation of hip prostheses

Background

The per-operative assessment of primary stem stability may help to improve the performance of total hip replacement. Vibration analysis methods have been successfully used to assess dental implant stability, to monitor fracture healing and to measure bone mechanical properties. The objective of the present study was to evaluate in vivo a vibration analysis-based endpoint criterion for the insertion of the stem by successive surgeon-controlled hammer blows.

Methods

A protocol using a vibration analysis technique for the characterisation of the primary bone-prosthesis stability was tested in 83 patients receiving a custom-made, intra-operatively manufactured stem prosthesis. Two groups were studied: one (n = 30) with non cemented and one (n = 53) with partially cemented stem fixation. Frequency response functions of the stem-femur system corresponding to successive insertion stages were compared.

Results

The correlation coefficient between the last two frequency response function curves was above 0.99 in 86.7% of the non cemented cases. Lower values of the final correlation coefficient and deviations in the frequency response pattern were associated with instability or impending bone fracture. In the cases with a partially cemented stem an important difference in frequency response function between the final stage of non cemented trial insertion and the final cemented stage was found in 84.9% of the cases. Furthermore, the frequency response function varied with the degree of cement curing.

Conclusion

The frequency response function change provides reliable information regarding the stability evolution of the stem-femur system during the insertion. The protocol described in this paper can be used to accurately detect the insertion end point and to reduce the risk for intra-operative fracture.

Intra-operative evaluation of cementless hip implant stability: A prototype device based on vibration analysis

Cementless implants are mechanically stabilized during surgery by a press-fitting procedure. Good initial stability is crucial to avoid stem loosening and bone cracking, therefore, the surgeon must achieve optimal press-fitting. A possible approach to solve this problem and assist the surgeon in achieving the optimal compromise, involves the use of vibration analysis. The present study aimed to design and test a prototype device able to evaluate the primary mechanical stability of a cementless prosthesis, based on vibration analysis. In particular, the goal was to discriminate between stable and quasi-stable implants; thus the stem-bone system was assumed to be linear in both cases. For that reason, it was decided to study the frequency responses of the system, instead of the harmonic distortion. The prototype developed consists of a piezoelectric exciter connected to the stem and an accelerometer attached to the femur. Preliminary tests were performed on four composite femurs implanted with a conventional stem. The results showed that the input signal was repeatable and the output could be recorded accurately. The most sensitive parameter to stability was the shift in resonance frequency of the stem-bone system, which was highly correlated with residual micromotion on all four specimens.

Bone vibration measurement using ultrasound: application to detection of hip prosthesis loosening

Hip prosthesis loosening can be determined in vivo using a vibration-based technique called vibrometry. In this technique, a low frequency (<1000Hz) sinusoidal vibration is applied to the femoral condyles and the resulting vibration is measured at the greater trochanter. If the prosthesis is securely fixed, the output vibration signal matches that of the input vibration, whereas if the prosthesis is loose, the output vibration signal is distorted and shows the marked presence of harmonics of the input frequency. One of the main problems with this application of this technique is in measuring the output vibration where significant amounts of soft tissue cover the measurement site. In order to circumvent this problem, an ultrasound probe, normally used for the measurement of blood flow, has been used to measure the output vibration. This has been evaluated by comparing the results obtained from the ultrasound probe with those from a conventional accelerometer in models representing a tight and loose hip prosthesis under simulated clinical conditions. The ultrasound probe was able to consistently detect the output vibration, for both the loose and secure prostheses. Under the test conditions used (which attempted to simulate a large thickness of soft tissue), the ultrasound probe was able to produce a greatly enhanced output vibration signal compared to the accelerometer. This suggests that the use of an ultrasound probe to detect mechanically induced vibration through significant amounts of soft tissue appears to be viable and could lead to enhanced detection of prosthesis loosening using this technique.

Natural Frequency Analysis of Osseointegration for Trans-femoral Implant

Osseointegration trans-femoral implants are a new orthopaedic anchoring method to attach prosthetic limbs. The clinical success of this promising technique depends on the effectiveness of osseointegration achieved after implantation. The aim of this study is to use the resonant characteristics of the implant system to determine the changes in stability as a reflection of boundary condition of the implant. With a small mechanical excitation, Vibration responses of the trans-femoral implant to a small mechanical excitation were measured using an accelerometer and the vibration signal was analyzed using Fast Fourier Transform (FFT) software to obtain the fundamental natural frequency (NF) of the implant system. In-vitro study was conducted using different silicone rubbers to simulate the interface condition. The result showed that a high NF corresponded to a high elastic modulus of the interface material between the implant and bone. A preliminary in-vivo study with one osseointegration trans-femoral implant patient showed that there was a decrease of NF after initial weight bearing rehabilitation. After continued weight bearing, the NF gradually returned to the pre-loading level at around day 24 and the general trend of the NF reached a stable state 38 days after the first weight bearing exercise.

The resonance frequencies and mode shapes of dental implants: Rigid body behaviour versus bending behaviour. A numerical approach

The purpose of this study was to evaluate the modal behaviour of the bone-implant-transducer (Osstell) system by means of finite element analyses. The influence of different parameters was determined: (1) the type of implant anchorage being trabecular, cortical, uni-cortical, or bi-cortical, (2) the implant diameter, (3) the length of the implant embedded in the bone, and (4) the bone stiffness. The type of anchorage determines the resulting modal behaviour of the implant-transducer system. A rigid body behaviour was found for a uni-cortical anchoring and for a homogeneous anchoring with low bone stiffness (< or =1000 MPa), whereas a bending behaviour was found for a homogeneous anchoring with a high bone stiffness (> or =5000 MPa) and for a bi-cortical anchorage. The implant dimensions influence the values for the resonance frequencies. Generally, an increase in implant diameter or implant length (in bone) results in higher resonance frequencies. This study also showed that resonance frequencies in case of rigid body behaviour of the implant-transducer system are more sensitive to changes in bone stiffness than resonance frequencies in case of bending behaviour. In conclusion, it seems that the Osstell transducer is suited for the follow-up in time of the stability of an implant, but not for the quantitative comparison of the stability of implants.

How much can a vibrational diagnostic tool reveal in total hip arthroplasty loosening?

OBJECTIVE

To investigate how much information a vibrational technique can reveal regarding the loosening of the femoral component of a total hip arthroplasty.

DESIGN

Numerical modal analysis using finite element method and computer simulation.

BACKGROUND

Existing work suggested that this technique is capable of revealing total hip arthroplasty loosening. However, the potentials of this technique are not fully studied yet. There is a need to establish the limitation of this technique.

METHODS

Numerical modal analysis was conducted to obtain the natural frequencies and mode shapes of femoral models under free vibration. An absent interface portion was hypothesized at specified locations the data from modal analysis were then used in a computer simulation to visualize the vibration diagnosis.

RESULTS

The effects of interface failure on the femoral component stiffness vary with the locations and sizes of failure. Nominal critical, reliable, and nondetectable levels of interface failure are found.

CONCLUSION

When the size of failure is more than one-third of the stem length, this tool is able to provide a reliable diagnosis. The critical detectable interface failure size is one-fifth of the stem length. It was found that the motion at higher harmonics is the most sensitive to the interface failure. This tool is unlikely to differentiate the slight differences in natural frequencies that occur when the interface failure length is less than one-sixth of the stem length. It is likely to fail in detecting failures located at the stem central portion regardless of their length.

RELEVANCE

A numerical study of the vibration tool is important prior to pursuing clinical trials of the tool and may guide the characterizations involved in the trials.