Can a Computational Model Predict the Effect of Lesion Location on Cam-type Hip Impingement?

BACKGROUND

The Warwick consensus defined femoroacetabular impingement syndrome as a motion-related clinical disorder of the hip with a triad of symptoms, clinical signs, and imaging findings representing symptomatic premature contact between the proximal femur and acetabulum. Several factors appear to cause labral and cartilage damage, including joint shape and orientation and patient activities. There is a lack of tools to predict impingement patterns in a patient across activities. Current computational modeling tools either measure pure ROM of the joint or include complexity that reduces reliability and increases time to achieve a solution.

QUESTIONS/PURPOSES

The purpose of this study was to examine the efficacy of a low computational cost approach to combining cam-type hip shape and multiple hip motions for predicting impingement. Specifically, we sought to determine (1) the potential to distinguish impingement in individual hip shapes by analyzing the difference between a cam lesion at the anterior femoral neck and one located at the superior femoral neck; (2) sensitivity to three aspects of hip alignment, namely femoral neck-shaft angle, femoral version angle, and pelvic tilt; and (3) the difference in impingement measures between the individual activities in our hip motion dataset.

METHODS

A model of the shape and alignment of a cam-type impinging hip was created and used to describe two locations of a cam lesion on the femoral head-neck junction (superior and anterior) based on joint shape information available in prior studies. Sensitivity to hip alignment was assessed by varying three aspects from a baseline (typical alignment described in prior studies), namely, femoral neck-shaft angle, femoral version, and pelvic tilt. Hip movements were selected from an existing database of 18 volunteers performing 13 activities (10 male, eight female; mean age 44 ± 19 years). A subset was selected to maximize variation in the range of joint angles and maintain a consistent number of people performing each activity, which resulted in nine people per activity, including at least three of each sex. Activities included pivoting during walking, squatting, and golf swing. All selected hip motion cases were applied to each hip shape model. For the first part of the study, the number of motion cases in which impingement was predicted was recorded. Quantitative analyses of the depth of penetration of the cam lesion into the acetabular socket and qualitative observations of impingement location were made for each lesion location (anterior and superior). In the second part of the study, in which we aimed to test the sensitivity of the findings to hip joint orientation, full analysis of both cam lesion locations was repeated for three modified joint orientations. Finally, the results from the first part of the analysis were divided by activity to understand how the composition of the activity dataset affected the results.

RESULTS

The two locations of cam lesion generated impingement in a different percentage of motion cases (anterior cam: 56% of motion cases; superior cam: 13% of motion cases) and different areas of impingement in the acetabulum, but there were qualitatively similar penetration depths (anterior cam: 6.8° ± 5.4°; superior cam: 7.9° ± 5.8°). The most substantial effects of changing the joint orientation were a lower femoral version angle for the anterior cam, which increased the percentage of motion cases generating impingement to 67%, and lower neck-shaft angle for the superior cam, which increased the percentage of motion cases generating impingement to 37%. Flexion-dominated activities (for example, squatting) only generated impingement with the anterior cam. The superior cam generated impingement during activities with high internal-external rotation of the joint (for example, the golf swing).

CONCLUSION

This work demonstrated the capability of a simple, rapid computational tool to assess impingement of a specific cam-type hip shape (under 5 minutes for more than 100 motion cases). To our knowledge, this study is the first to do so for a large set of motion cases representing a range of activities affecting the hip, and could be used in planning surgical bone removal.

CLINICAL RELEVANCE

The results of this study imply that patients with femoroacetabular impingement syndrome with cam lesions on the superior femoral head-neck junction may experience impinging during motions that are not strongly represented by current physical diagnostic tests. The use of this tool for surgical planning will require streamlined patient-specific hip shape extraction from imaging, model sensitivity testing, evaluation of the hip activity database, and validation of impingement predictions at an individual patient level.

Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction

Aim and objective

This study was designed to test and compare the mechanical performance of the biplanar ArthroSave KneeReviver and a circular frame construct with the intended use of providing a mechanically favourable environment for cartilage regeneration across a knee joint.

Materials and methods

Three similar constructs of the two devices were applied to biomechanical testing sawbones, with the knee distracted by 8 mm. The constructs were vertically loaded to 800 N in an Instron testing machine at 20 mm/minute. Tests were conducted in neutral hip flexion and at 12° of hip flexion and extension, to mimic leg position in gait. Displacement measurements were taken from the Instron machine, and three-dimensional joint motion was recorded using an Optotrak Certus motion capture system.

Results

Overall axial rigidity was similar between the two devices (circular frame, 81.6 N/mm ± 5.9; and KneeReviver, 79.5 N/mm ± 25.1 with hip neutral) and similar in different hip positions. At the point of joint contact, the overall rigidity of the circular frame increased significantly more than the KneeReviver (491 N/mm ± 27 and 93 N/mm ± 32, respectively, p <0.001). There was more variability between models in the KneeReviver. There was more off-axis motion in the KneeReviver, mainly due to increasing knee flexion on loading. This was exacerbated with the hip in flexion and extension but remained small, with the maximal off-axis displacement being 7 mm/3°.

Conclusion

The circular frame provides a similar mechanical environment to the novel KneeReviver device, for which most clinical data are available. These findings suggest that both devices appear a viable option for knee joint distraction (KJD). Further clinical data will help inform mode of application.

Clinical significance

KJD is a relatively novel technique for use in osteoarthritis (OA), and it remains unclear which distraction devices provide appropriate mechanics. Our testing gives evidence to support either option for further use.

How to cite this article

Chowdhury JMY, Lineham B, Pallett M, et al. Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction. Strategies Trauma Limb Reconstr 2021;16(2):71–77.

Analysis of hip joint cross-shear under variable activities using a novel virtual joint model within Visual3D

Cross-shear forces occur between bearing surfaces at the hip and have been identified as a key contributor to prosthesis wear. Understanding the variation in relative motion paths between both individuals and activities, is a possible explanation for increased revision rates for younger patients and could assist in improved pre-clinical testing regimes. Additionally, there is little information for the pre-clinical testing of cartilage substitution therapies for younger more active individuals. The calculation of motion paths has previously relied on computational modelling software which can be complex and time-consuming. The aim of this study was to determine whether the motion paths calculations could be integrated into gait analysis software to improve batch processing, reduce analysis time and ultimately improve the efficiency of the analysis of cross-shear variation for a broader range of activities. A novel Virtual Joint model was developed within Visual3D for calculating motion paths. This model was compared to previous computational methods and found to provide a competitive solution for cross shear analysis (accuracy <0.01 mm error between methods). The virtual hip model was subsequently applied to 13 common activities to investigate local aspect ratio's, velocities and accelerations. Surprisingly walking produced the harshest cross shear motion paths in subjects. Within walking, of additional interest was that the localised change in acceleration for subjects was six times greater compared to the same point on an equivalent smoothed simulator cycle. The Virtual hip developed in Visual 3D provides a time saving technique for visualising and processing large data sets directly from motion files. The authors postulate that rather than focussing on a generalised smoothed cross-shear model that pre-clinical testing of more delicate structures should consider localised changes in acceleration as these may be more important in the assessment of cartilage substitutes sensitive to shear.

Foot trajectories and loading rates in a transfemoral amputee for six different commercial prosthetic knees: An indication of adaptability

BACKGROUND

The relationship between the functional loading rate and heel velocities was assessed in an active unilateral transfemoral amputee (UTFA) for adaptation to six different commercial prosthetic knees.

OBJECTIVE

To Investigate the short-term process of adaptability for UTFA for two types of prosthetic knees were evaluated, based on the correlation between heel vertical velocity and transient loading rate.

METHODS

The loading rate was calculated from the slope of ground reaction forces (GRF) and the corresponding time. The heel velocities and GRF were obtained by a motion analysis system.

RESULTS

Biomechanical adaptation was evident following a short period of prosthetic knee use based upon the mean transient impact (loading rate) and the heel vertical velocity in slow, normal and fast walking. Trend lines of transient impact versus vertical heel velocity for a set of actively controlled variable damping (microprocessor) and mechanically passive prosthetic knees were all negatively correlated, except for an amputated leg during normal pace and healthy leg during fast pace. For an amputee to adapt well to a prescribed prosthesis excellent coordination between the intact and amputated limbs is required to control placement of the amputated leg to achieve a gait comparable to healthy subjects.

CONCLUSION

There are many factors such as the hip, knee flexion/extension and the ankle plantarflexion/dorsiflexion contributing to the control of the transient impact of an amputee during walking. Therefore, for enhanced control of a prosthetic knee, a multifaceted approach is required. This study showed that UTFA adaption to different prosthetic knees in the short term with slower than self-selected speed is completely achievable based on the negative correlation of ground reaction forces versus linear velocity. Reduced speed may provide the prosthetists with the vision of the amputees' progression of adaptation with a newly prescribed prosthetic knee.

Hip surgeons and leg length inequality after primary hip replacement

BACKGROUND:

This study reports the results of 2 separate surveys of British Hip Society (BHS) members relating to leg length inequality (LLI) after primary total hip replacement (THR).

SURVEY 1:

Investigates the members' opinions on the effect of LLI on the outcome of THR and explores the acceptable limits of LLI.

SURVEY 2:

Reports on the intraoperative techniques currently used by BHS members to minimise LLI after THR.

RESULTS - SURVEY 1:

97% of all surgeons completing the survey believed that LLI can affect the outcome of THR.

RESULTS - SURVEY 2:

All surgeons reported using at least 1 intraoperative technique for assessing leg length with a median of 5 techniques. Over 50% of surgeons use 2 or more tests.

CONCLUSION - SURVEY 1:

89% of surgeons agreed that 15 mm of LLI after primary uncomplicated THR was always acceptable. 90% of surgeons felt that LLI more than 22.74 mm was never acceptable.

CONCLUSION - SURVEY 2:

Despite the multiple published papers on various methods of assessing leg length intraoperatively, the problem of LLI post THR persists. This study highlights the need for further research to develop a simple intraoperative technique with high accuracy and reproducibility.

Biomechanical analysis of walking gait when simulating the use of an Ilizarov external fixator

The Ilizarov frame is an external fixation device, primarily used for the treatment of complex fractures. The authors postulate that the size and weight of the frame may lead to biomechanical adaptations to gait, independent to any injury. Temporospatial characteristics, kinetics and kinematics were assessed when simulating the use of an Ilizarov frame. Fifteen healthy participants performed walking trials, with and without the simulated frame. Significant changes to temporospatial characteristics were identified, with a decreased mean walking speed (with: 1.24 m s–1; without: 1.29 m s–1) and increased mean step width (with: 0.14 m; without: 0.11 m). The push-off phase of gait differed significantly between test conditions with mean increases in ankle dorsiflexion angles (with: 90.4°; without: 89.0°) and extension moments (proportional to body weight or P BWT) at the knee and ankle (knee with: 0.8 P BWT·m; without: 0.7 P BWT·m; ankle with: 1.6 P BWT·m; without: 1.6 P BWT·m). Although changes were small and likely to be clinically insignificant, the size and weight of the frame led to adaptations which may be magnified for patient groups with associated injury and pain at the lower limb. Results provide an argument for the potential redesign of the frame.

Hip stem fatigue: : The implications of increasing patient mass

General trends of increasing body mass index have been observed in many western countries along with an increasing demand for joint replacement. Standards have been developed for testing the fatigue properties of femoral stems; however, the loads that these apply are based on a historic patient weight and may not be valid in the current patient population. Several fatigue tests were conducted using distally fixed titanium alloy stems positioned according to the ISO standard but with a cyclic load based on a current 75th percentile patient sample. Smaller sized stems (currently not weight restricted) fractured in; 30,000 cycles, while larger sized stems were found to have excellent durability under loads simulating walking and stumbling. The results suggest that while the fatigue properties of medical grade titanium are very good, the ISO pre-clinical durability testing standard does not represent the influence of femoral offset or stem size sufficiently to reflect safe design practice.

What Are the Biomechanical Properties of the Taylor Spatial Frame™?

BACKGROUND

The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixator. Although in widespread use, little comparative data exist to quantify the biomechanical effect of substituting the tried-and-tested Ilizarov construct for the TSF hexapod system.

QUESTIONS/PURPOSES

This study was designed to investigate the mechanical properties of the TSF system under physiologic loads, with and without the addition of a simulated bone model, with comparison to the standard Ilizarov frame.

METHODS

The mechanical behaviors of three identical four-ring TSF and Ilizarov constructs were tested under levels of axial compression, bending, and rotational torque to simulate loading during normal gait. An acrylic-pipe fracture model subsequently was mounted, using fine wires and 5 mm half pins, and the testing was repeated. Load-deformation curves, and so rigidity, for each construct were calculated, with statistical comparisons performed using paired t-tests.

RESULTS

Under axial loading, the TSF was found to be less rigid than the Ilizarov frame (645 ± 57 N/mm versus 1269 ± 256 N/mm; mean difference, 623 N/mm; 95% CI, 438.3-808.5 N/mm; p < 0.001), but more rigid under bending and torsional loads (bending: 42 ± 9 Nm/degree versus 78 ± 13 Nm/degree; mean difference, 37 Nm/degree; 95% CI, 25.0-47.9 Nm/degree; p < 0.001; torsion: 16 ± 2 Nm/degree versus 5 ± 0.35 Nm/degree; mean difference, 11 Nm/degree; 95% CI, 9.5-12.2 Nm/degree; p < 0.001). On mounting the bone models, these relationships broadly remained in the half-pin and fine-wire groups, however the half-pin constructs were universally more rigid than those using fine wires. This effect resulted in the TSF, using half pins, showing no difference in axial rigidity to the fine-wire Ilizarov (107 ± 3 N/mm versus 107 ± 4 N/mm; mean difference, 0.05 N/mm; 95% CI, -6.99 to 7.1 N/mm; p > 0.999), while retaining greater bending and torsional rigidity. Throughout testing, a small amount of laxity was observed in the TSF construct on either side of neutral loading, amounting to 0.72 mm (±0.37 mm) for a change in loading between -10 N and 10 N axial load, and which persisted with the addition of the synthetic fracture model.

CONCLUSIONS

This study broadly shows the TSF construct to generate lower axial rigidity, but greater bending and torsional rigidity, when compared with the Ilizarov frame, under physiologic loads. The anecdotally described laxity in the TSF hexapod strut system was shown in vitro, but only at low levels of loading around neutral. It also was shown that the increased stiffness generated by use of half pins produced a TSF construct replicating the axial rigidity of a fine-wire Ilizarov frame, for which much evidence of good clinical and radiologic outcomes exist, while providing greater rigidity and so improved resistance to potentially detrimental bending and rotational shear loads.

CLINICAL RELEVANCE

If replicated in the clinical setting, these findings suggest that when using the TSF, care should be taken to minimize the observed laxity around neutral with appropriate preloading of the construct, but that its use may produce constructs better able to resist bending and torsional loading, although with lower axial rigidity. Use of half pins in a TSF construct however may replicate the axial mechanical behavior of an Ilizarov construct, which is thought to be conducive to bone healing.

What Are the Biomechanical Effects of Half-pin and Fine-wire Configurations on Fracture Site Movement in Circular Frames?

BACKGROUND

Fine-wire circular frame (Ilizarov) fixators are hypothesized to generate favorable biomechanical conditions for fracture healing, allowing axial micromotion while limiting interfragmentary shear. Use of half-pins increases fixation options and may improve patient comfort by reducing muscle irritation, but they are thought to induce interfragmentary shear, converting beam-to-cantilever loading. Little evidence exists regarding the magnitude and type of strain in such constructs during weightbearing.

QUESTIONS/PURPOSES

This biomechanical study was designed to investigate the levels of interfragmentary strain occurring during physiologic loading of an Ilizarov frame and the effect on this of substituting half-pins for fine-wires.

METHODS

The "control" construct was comprised of a four-ring all fine-wire construct with plain wires at 90°-crossing angles in an entirely unstable acrylic pipe synthetic fracture model. Various configurations, substituting half-pins for wires, were tested under levels of axial compression, cantilever bending, and rotational torque simulating loading during gait. In total three frames were tested for each of five constructs, from all fine-wire to all half-pin.

RESULTS

Substitution of half-pins for wires was associated with increased overall construct rigidity and reduced planar interfragmentary motion, most markedly between all-wire and all-pin frames (axial: 5.9 mm ± 0.7 vs 4.2 mm ± 0.1, mean difference, 1.7 mm, 95% CI, 0.8-2.6 mm, p < 0.001; torsional: 1.4% ± 0.1 vs 1.1% ± 0.0 rotational shear, mean difference, 0.3%, 95% CI, 0.1%-0.5%, p = 0.011; bending: 7.5° ± 0.1 vs 3.4° ± 0.1, mean difference, -4.1°, 95% CI, -4.4° to -3.8°, p < 0.001). Although greater transverse shear strain was observed during axial loading (0.4% ± 0.2 vs 1.9% ± 0.1, mean difference, 1.4%, 95% CI, 1.0%-1.9%, p < 0.001), this increase is unlikely to be of clinical relevance given the current body of evidence showing bone healing under shear strains of up to 25%. The greatest transverse shear was observed under bending loads in all fine-wire frames, approaching 30% (29% ± 1.9). This was reduced to 8% (±0.2) by incorporation of sagittal plane half-pins and 7% (±0.2) in all half-pin frames (mean difference, -13.2% and -14.0%, 95% CI, -16.6% to 9.7% and -17.5% to -10.6%, both p < 0.001).

CONCLUSIONS

Appropriate use of half-pins may reduce levels of shear strain on physiologic loading of circular frames without otherwise altering the fracture site mechanical environment at levels likely to be clinically important. Given the limitations of a biomechanical study using a symmetric and uniform synthetic bone model, further clinical studies are needed to confirm these conclusions in vivo.

CLINICAL RELEVANCE

The findings of this study add to the overall understanding of the mechanics of circular frame fixation and, if replicated in the clinical setting, may be applied to the preoperative planning of frame treatment, particularly in unstable fractures or bone transport where control of shear strain is a priority.

Unilateral total hip replacement patients with symptomatic leg length inequality have abnormal hip biomechanics during walking

BACKGROUND

Symptomatic leg length inequality accounts for 8.7% of total hip replacement related claims made against the UK National Health Service Litigation authority. It has not been established whether symptomatic leg length inequality patients following total hip replacement have abnormal hip kinetics during gait.

METHODS

Hip kinetics in 15 unilateral total hip replacement patients with symptomatic leg length inequality during gait was determined through multibody dynamics and compared to 15 native hip healthy controls and 15 'successful' asymptomatic unilateral total hip replacement patients.

FINDING

More significant differences from normal were found in symptomatic leg length inequality patients than in asymptomatic total hip replacement patients. The leg length inequality patients had altered functions defined by lower gait velocity, reduced stride length, reduced ground reaction force, decreased hip range of motion, reduced hip moment and less dynamic hip force with a 24% lower heel-strike peak, 66% higher mid-stance trough and 37% lower toe-off peak. Greater asymmetry in hip contact force was also observed in leg length inequality patients.

INTERPRETATION

These gait adaptions may affect the function of the implant and other healthy joints in symptomatic leg length inequality patients. This study provides important information for the musculoskeletal function and rehabilitation of symptomatic leg length inequality patients.

Hip contact forces in asymptomatic total hip replacement patients differ from normal healthy individuals: Implications for preclinical testing

BACKGROUND

Preclinical durability testing of hip replacement implants is standardised by ISO-14242-1 (2002) which is based on historical inverse dynamics analysis using data obtained from a small sample of normal healthy individuals. It has not been established whether loading cycles derived from normal healthy individuals are representative of loading cycles occurring in patients following total hip replacement.

METHODS

Hip joint kinematics and hip contact forces derived from multibody modelling of forces during normal walking were obtained for 15 asymptomatic total hip replacement patients and compared to 38 normal healthy individuals and to the ISO standard for pre-clinical testing.

FINDINGS

Hip kinematics in the total hip replacement patients were comparable to the ISO data and the hip contact force in the normal healthy group was also comparable to the ISO cycles. Hip contact forces derived from the asymptomatic total hip replacement patients were comparable for the first part of the stance period but exhibited 30% lower peak loads at toe-off.

INTERPRETATION

Although the ISO standard provides a representative kinematic cycle, the findings call into question whether the hip joint contact forces in the ISO standard are representative of those occurring in the joint following total hip replacement.

Long-term results of a total knee prosthesis utilising an all polyethylene tibial component

INTRODUCTION

The aim of this study was to assess the long-term performance of a cemented total knee replacement utilising an All Polyethylene Tibial (APT) component and in addition to perform an engineering analysis of any failures to help refine surgical technique.

MATERIALS AND METHODS

A total of 26 patients had a total knee replacement performed using a cemented Depuy Press Fit Condylar (PFC) APT component and a cruciate retaining femoral component. At final review all patients were assessed using The Knee Society Score together with radiographs. An engineering analysis simulated loading conditions of the implants that failed and these were compared with the performance of a modular metal-backed Tibial (MBT) component.

RESULTS

A total of 20 patients were reviewed at mean time of 116 months following surgery. Knee Society Knee Scores and Function Scores in this cohort were 84/100 and 58/100, respectively. Two patients required revision for tibial component failure. Pre-operatively both had valgus deformities and in each case the tibial tray had been lateralised leaving a gap on the medial side where the APT component had no rigid support. The engineering analysis demonstrated that the volume of highly strained cancellous bone was greater in the APT design compared with the MBT design when a model with a 3 mm medial gap was loaded. The stiffer MBT base plate acted more rigidly and shielded the stress applied to the proximal tibial cancellous bone.

CONCLUSION

The APT component demonstrated satisfactory clinical and radiographic performance at long-term follow up. Appropriate cortical support of the APT component is important. The implant should be used with a degree of caution in patients with severe deformities and osteoporosis.

The influence of size, clearance, cartilage properties, thickness and hemiarthroplasty on the contact mechanics of the hip joint with biphasic layers

Computational models of the natural hip joint are needed to examine and optimise tissue sparing interventions where the natural cartilage remains part of the bearing surfaces. Although the importance of interstitial fluid pressurisation in the performance of cartilage has long been recognized, few studies have investigated the time dependent interstitial fluid pressurisation in a three dimensional natural hip joint model. The primary aim of this study was to develop a finite element model of the natural hip incorporating the biphasic cartilage layers that was capable of simulating the joint response over a prolonged physiological loading period. An initial set of sensitivity studies were also undertaken to investigate the influence of hip size, clearance, cartilage properties, thickness and hemiarthroplasty on the contact mechanics of the joint. The contact stress, contact area, fluid pressure and fluid support ratio were calculated and cross-compared between models with different parameters to evaluate their influence. It was found that the model predictions for the period soon after loading were sensitive to the hip size, clearance, cartilage aggregate modulus, thickness and hemiarthroplasty, while the time dependent behaviour over 3000 s was influenced by the hip clearance and cartilage aggregate modulus, permeability, thickness and hemiarthroplasty. The modelling methods developed in this study provide a basic platform for biphasic simulation of the whole hip joint onto which more sophisticated material models or other input parameters could be added in the future.

Contact surface motion paths associated with leg length inequality following unilateral total hip replacement

In the past, there has been little research into leg length inequality (LLI) and its effect on hip arthroplasty bearing longevity. This investigation aimed to determine the effects of post-operative LLI on hip motions during gait and to postulate the subsequent influence on the wear of the artificial hip joint replacement. Motion data from a clinical gait analysis were processed with an in-house computational model to plot graphs showing the movement of loci of 20 points on the femoral head during one gait cycle for two cohorts: 19 LLI patients and 38 normal healthy patients. Loci paths were quantified by calculating the aspect ratio (AR) of the path shape. It was found that on average, LLI patients had a reduction in flexion/extension and abduction/adduction. Furthermore, the AR of LLI patients was found to be 8% smaller than the normal group. The shorter, more multidirectional, motion paths in LLI patients would suggest the potential for greater wear in a polyethylene bearing compared to an asymptomatic, non-LLI patient. The results have potential implications towards preclinical wear testing of joint replacements.

Influence of acetabular cup rim design on the contact stress during edge loading in ceramic-on-ceramic hip prostheses

The purpose of the study was to investigate the contact stresses in 3 different acetabular cup rim designs (new, worn, chamfer) during edge loading, after microseparation of ceramic on ceramic hip prostheses. A 3-dimensional finite element analysis was conducted for a 28-mm diameter alumina ceramic bearing with a radial clearance of 40 μm using a normal load of 2500 N under edge loading. At a separation distance of 250 μm, the maximum tensile stress in the "new" design was of similar magnitude to the flexural strength of the alumina material that supports the localized breakdown (stripe wear) of the acetabular cup surface observed clinically. Introducing a 2.5-mm radius chamfer should reduce the maximum tensile stress in the region of 60%.

Cement mantle stress under retroversion torque at heel-strike

The paper presents a theory of fixation failure and loosening in cemented total hip prostheses and proceeds to investigate this using an experimentally validated finite element model and two prosthesis types, namely the Charnley and the C-Stem. The study investigates the effects of retroversion torque occurring at heel-strike in combination with a loss of proximal cement/bone support and distal implant/cement support with a good distal cement/bone interface. A 3D finite element model was validated by comparison of femoral surface strains with those measured in an in vitro experimental simulation using an implanted Sawbone femur loaded in the heel-strike position and including a simplified representation of muscle forces. Results showed that the heel-strike position applies a high retroversion torque to the femoral stem that when combined with proximal debonding of the cement/bone interface and distal debonding of the implant/cement interface increases the strain transfer to the cement that may ultimately lead to the breakdown of the cement mantle leading on to osteolysis and loosening of the prostheses. Experimental fatigue testing of the implanted Charnley stem in a Sawbone femur produced cracks within the cement mantle that were located in positions of maximum stress supporting the finite element analysis results and theory of failure.

The wear and fracture behaviour of ultra high molecular weight polyethylene subjected to gamma-irradiation in an atmosphere of acetylene

The wear and mechanical properties of GUR 1020 (Perplas IMP 2000-2) Ultra High Molecular Weight Polyethylene (UHMWPE) subjected to gamma-irradiation in an atmosphere of acetylene, were evaluated for a range of processing conditions of irradiation, annealing and ageing. The results were compared with those obtained for the virgin UHMWPE material and material processed using conventional gamma-irradiation in nitrogen. Cross-linking produced by irradiation in acetylene, followed by subsequent annealing was found to be significantly more effective in improving the mechanical and wear properties of UHMWPE compared to when the material was irradiated in nitrogen. Gel fraction analysis on its own, while being able to detect the degree of cross-linking, was found to be insufficient in determining the effectiveness of the cross-links and the resulting mechanical properties of the UHMWPE material. The results suggest that gamma-irradiation in an atmosphere of acetylene may provide significant advantages over conventional UHMWPE processing and irradiation cross-linking techniques.

Biological response to wear debris generated in carbon based composites as potential bearing surfaces for artificial hip joints

UHMWPE wear particles have been implicated in osteolysis, implant loosening, and long-term failure of total hip arthroplasties in vivo. This study examined four carbon-based composite materials as alternatives for UHMWPE in joint bearings. These materials were HMU-CVD, SMS-CVD, P25-CVD, and CFR-PEEK. New bearing materials should satisfy certain criteria: they should have good wear properties that at least match UHMWPE, and produce wear particles with low levels of biological activity. Of the four materials tested in multidirectional pin-on-plate tribological tests, SMS-CVD, P25-CVD, and CFR-PEEK showed lower volumetric wear factors than UHMWPE. P25-CVD had the lowest wear factor of 0.54 +/- 0.34 x 10(-7) mm(3)/Nm. Analysis of P25-CVD wear particles by transmission electron microscopy showed that the debris was very small, with the vast majority of particles being under 100 nm in size, which was similar in size to metal wear particles. The P25-CVD particles were isolated and cultured with L929 fibroblasts and U937 monocytic cells to assess their effect on cell viability. P25-CVD particles were significantly less cytotoxic (p < 0.01, ANOVA) to both cell types than CoCr metal wear particles. This work suggests that carbon-carbon composite materials may have potential for use in total hip replacement bearings. Of the materials tested P25-CVD had the lowest wear factor, and produced very small wear debris that had minimal cytotoxic effect on L929 and U937 cells in vitro. Therefore carbon-carbon composites, such as P25-CVD, may be important in the development of next-generation implants with lower wear rates and reduced cytotoxic potential.

Wear of surface engineered metal-on-metal hip prostheses

The wear of existing metal-on-metal (MOM) hip prostheses (1 mm3/million cycles) is much lower than the more widely used polyethylene-on-metal bearings (30-100 mm3/million cycles). However, there remain some potential concerns about the toxicity of metal wear particles and elevated metal ion levels, both locally and systemically in the human body. The aim of this study was to investigate the wear, wear debris and ion release of fully coated surface engineered MOM bearings for hip prostheses. Using a physiological anatomical hip joint simulator, five different bearing systems involving three thick (8-12 microm) coatings, TiN, CrN and CrCN, and one thin (2 microm) coating diamond like carbon (DLC) were evaluated and compared to a clinically used MOM cobalt chrome alloy bearing couple. The overall wear rates of the surface engineered prostheses were at least 18-fold lower than the traditional MOM prostheses after 2 million cycles and 36-fold lower after 5 million cycles. Consequently, the volume of wear debris and the ion levels in the lubricants were substantially lower. These parameters were also much lower than in half coated (femoral heads only) systems that have been reported previously. The extremely low volume of wear debris and concentration of metal ions released by these surface engineered systems, especially with CrN and CrCN coatings, have considerable potential for the clinical application of this technology.

Carbon-carbon composite bearing materials in hip arthroplasty: analysis of wear and biological response to wear debris

Ultra-high molecular weight polyethylene wear particles have been implicated as the major cause of osteolysis, implant loosening and late aseptic failure in total hip arthroplasties in vivo. This study initially screened 22 carbon-carbon composite materials as alternatives for UHMWPE in joint bearings. New bearing materials should satisfy certain criteria--they should have good wear properties that at least match UHMWPE, and produce wear particles with low levels of cytotoxic and osteolytic activity. Initial screening was based on wear resistance determined in short-term tribological pin-on-plate tests. Three materials (HMU-PP(s), HMU-RC-P(s), and SMS-RC-P(s)) which had superior wear resistance were selected for long-term testing. All materials had very low wear factors and SMS-RC-P(s), which had a wear factor of 0.08 +/- 0.56 x 10(-7) mm3/Nm, was selected for the subsequent biological testing and particle size analysis. SMS-RC-P(s) showed good biocompatibility in bulk material form and also the wear particles had low cytotoxicity for L929 fibroblasts in culture compared to metal wear particles. Wear debris size analysis by transmission electron microscopy showed that the particles were very small, with the vast majority being under 100 nm in size, similar to metal wear particles. The potential osteolytic effect of SMS-RC-P(s) wear particles was investigated by culturing particles with human peripheral blood mononuclear cells and measuring TNFalpha production. SMS-RC-P(s) did not significantly stimulate TNFalpha production at a particle volume to cell number ratio of 80:1, indicating that the debris had a low osteolytic potential. The results of this study suggest that carbon-carbon composites, particularly those composed of PAN-based fibers may be important biomaterials in the development of next generation bearing surfaces for use in total joint replacements that have very low wear rates and reduced osteolytic and cytotoxic potential.

Metal-on-metal bearing wear with different swing phase loads

There is currently much discussion about the most clinically relevant testing methods for evaluating total hip replacements. This study examined the effect of different swing phase loads, including microseparation, on the wear, friction, and wear particles of metal-on-metal (MOM) hip replacements. MOM hip replacements were tested for 5 million cycles with the use of a hip simulator; prostheses were tested with a low (100-N) and ISO (280-N) swing phase load, and under microseparation conditions. Increasing the swing phase load from 100 to 280 N in the same hip simulator increased the wear of the MOM hip replacements by over tenfold. Introducing microseparation into the gait cycle increased wear further, and stripe wear was observed on the femoral heads, accompanied by corresponding rim damage on the acetabular cups. No significant difference in wear particle size was observed between wear particles produced by low load and microseparation hip simulator conditions. Introducing microseparation into the hip simulator gait cycle increased the wear of MOM prostheses. Joint laxity and separation may lead to increased wear rates of MOM prostheses in vivo. Additionally elevated positive swing phase loads may also increase wear. Variable swing phase load conditions in vivo may contribute to variations in clinical wear rates.

Severe wear and fracture of zirconia heads against alumina inserts in hip simulator studies with microseparation

The wear of zirconia femoral heads against alumina acetabular inserts with swing-phase microseparation was investigated in a hip joint simulator. Under mild microseparation conditions, the wear was very low, with an average wear rate of 0.05 mm(3)/million cycles reported over 5 million cycles of testing. However, under severe microseparation conditions representative of greater joint laxity, the wear rate of zirconia against alumina increased by 2 orders of magnitude, producing severe wear and, in one case, femoral head fracture. The adverse results of this study indicate that the combination of a zirconia femoral head articulating against an alumina acetabular insert is not recommended for clinical use. The results further raise concerns over the suitability of conventional simulators in evaluating the wear of ceramic hip prostheses.

Long-term wear of ceramic matrix composite materials for hip prostheses under severe swing phase microseparation

The purpose of this study was to evaluate the long-term wear performance of alumina matrix composite (AMC) heads against alumina matrix composite inserts and alumina matrix composite heads against alumina (Al) inserts with the use of a hip-joint simulator incorporating severe swing phase joint microseparation. The wear of AMC on Al produced an average wear rate of 0.61 mm3/million cycles over the 5-million-cycle test duration. The wear of AMC on AMC produced an average wear rate of 0.16 mm3/million cycles over the 5-million-cycle test duration. Both the AMC on alumina and AMC on AMC produced significantly lower wear than previously tested HIPed alumina, where an average wear rate of 1.84 mm3/million cycles was reported over 5 million cycles. The wear mechanisms and wear debris of AMC on AMC and AMC on Al were similar to those observed in previous alumina retrieval studies with stripe wear caused by intragranular fracture and wear debris consisting of predominantly uniform 10-20-nm-sized particles and a few irregular particles up to 3 microm in size.

An in vitro study of the reduction in wear of metal-on-metal hip prostheses using surface-engineered femoral heads

Although the wear of existing metal-on-metal (MOM) hip prostheses (1 mm3/10(6) cycles) is much lower than the more widely used polyethylene-on-metal bearings, there are concerns about the toxicity of metal wear particles and elevated metal ion levels, both locally and systemically, in the human body. The aim of this study was to investigate the possibility of reducing the volume of wear, the concentration of metal debris and the level of metal ion release through using surface-engineered femoral heads. Three thick (8-12 microm) coatings (TiN, CrN and CrCN) and one thin (2 microm) coating (diamond-like carbon, DLC), were evaluated on the femoral heads when articulating against high carbon content cobalt-chromium alloy acetabular inserts (HC CoCrMo) and compared with a clinically used MOM cobalt-chromium alloy bearing couple using a physiological anatomical hip joint simulator (Leeds Mark II). This study showed that CrN, CrCN and DLC coatings produced substantially lower wear volumes for both the coated femoral heads and the HC CoCrMo inserts. The TiN coating itself had little wear, but it caused relatively high wear of the HC CoCrMo inserts compared with the other coatings. The majority of the wear debris for all half-coated couples comprised small, 30 nm or less, CoCrMo metal particles. The Co, Cr and Mo ion concentrations released from the bearing couples of CrN-, CrCN- and DLC-coated heads articulating against HC CoCrMo inserts were at least 7 times lower than those released from the clinical MOM prostheses. These surface-engineered femoral heads articulating on HC CoCrMo acetabular inserts produced significantly lower wear volumes and rates, and hence lower volumetric concentrations of wear particles, compared with the clinical MOM prosthesis. The substantially lower ion concentration released by these surface-engineered components provides important evidence to support the clinical application of this technology.

Syndrome X, depression, and chaos: relevance to medical practice

The low detection rate and undertreatment of depression in general medical practice is pervasive. The persistence of this problem suggests that doubt remains within elements of the medical profession that depression is a medical condition meriting medical treatment, as opposed to an existential state, inevitable for the human condition. Depression is a physical and psychological clinical disorder which affects every aspect of human physiology. As such it deserves consideration as a comorbid medical illness requiring treatment as does hypertension in relation to diabetes. This article will illustrate how clinical depression is a comorbid medical illness requiring detection and treatment through the analysis of depression's impact on two conditions called Syndrome X. Conditions labeled Syndrome X in endocrinology and cardiology demonstrate how depression amplifies the pathophysiology of endocrine and cardiac disease and diminishes functional variability (regularizes variance) found in normal physiology.

Anomalous morphologic formation of deciduous and permanent teeth in a 5-year-old 15th century child: a variant of the Ekman-Westborg-Julin syndrome

A gross morphologic anomaly affecting both the primary and secondary teeth of unknown cause is presented. A 5-year-old American Indian child exhibited macrodontia, extreme shovel-shaping, agenesis, three-rooted deciduous molars, dens invaginatus, and other less striking dental features. This case represents the earliest example of a variant of the Ekman-Westborg-Julin syndrome reported in the New World.

Twenty neuroleptic rechallenges after neuroleptic malignant syndrome in 15 patients

Neuroleptic medication was reintroduced to 15 patients who had suffered an episode of neuroleptic malignant syndrome (NMS). Thirteen (87%) were eventually able to take neuroleptics again, indicating that they did not have an inherent intolerance. The authors analyzed the ability of patients to tolerate rechallenge according to the time of reintroduction after resolution of a previous episode and the relative neuroleptic potency and dosage compared with the initial episode. Successful rechallenge was highly significantly related to the time that had elapsed following resolution of the previous episode. The choice of a neuroleptic lower in potency and dosage than that which precipitated the original NMS episode was not significantly related to successful outcome.

Depression: a possible complication of orthognathic surgery

Advances in the field of orthognathic surgery as well as increased experience on the part of surgeons have led to successful treatment of greater numbers of patients with maxillofacial deformities. Consequently, greater insight has been gained into not only the technical effects of surgery, but also into the psychological impact on the patients. This paper describes a small pilot study designed to evaluate possible psychiatric effects that may occur during the recuperative period of orthognathic surgery.

Penile prostheses: potential value of medical psychiatric assessment and psychotherapy

Impotence is often the expression of complex psychological and physiological dysfunction. Proper medical psychiatric assessment is essential to assure that treatment addresses the real problems. Advances in materials technology and surgical methods have made penile implants an increasingly popular solution for impotence. There are, however, other treatments which may provide relief. These include correction of endocrine dysfunction, change in medications, and psychotherapy. This article reviews the content of a proper medical work-up, prosthesis options, psychiatric assessment, and psychotherapeutic considerations in addressing this problem.

Use of projective testing on a consultation-liaison service

Projective psychological testing is a valuable but underrated tool in consultation-liaison psychiatry. By reviewing psychiatric consultations with supporting psychological testing done over a 12-month period at the Beth Israel Hospital, the authors pinpointed clinical problems where projective testing was particularly helpful. The authors found suicidality, depression, and regression to be diagnostic dilemmas in which use of the Rorschach and TAT was decisive in the crisis setting of some consultations. The psychodynamic information offered by these tests guided both proper medication selection and verbal interventions as well as facilitated medical education. 4 cases were selected to illustrate the relevance of projective testing to consultation-liaison work.

Pathologic changes in aging sacroiliac joints. A study of dissecting-room skeletons

Pathologic changes of the sacroiliac joints were observed in 1986 skeletons from dissecting rooms in St. Louis, Missouri and Johannesburg, South Africa. In addition to being the largest population samples ever studied from this standpoint, these samples are the first to include blacks. Para-articular osteophytosis culminating in ankylosis is considered first, followed by the less common intraarticular changes that also occasionally culminate in ankylosis. Expressed as "average involvement" by decade, sex, laterality, and ethnic group, these joint changes are shown clearly to worsen progressively from the age of about 40 years. Osteophytosis especially becomes more common in black males, both American and African Bantu, than in American white males, and generally more common in males than in females. When occurring only (or mainly) unilaterally, the changes average out in favor of the right side, but only slightly. Joint mobility, or lack thereof, is assigned a large etiologic role.

The points of attachment of the palpebral ligaments: their use in facial reconstructions on the skull

The discovery in the Smith College Archives of a reference to Whitnall's little-known "malar tubercle" points up the fact that H. H. Wilder used this point of attachment of the lateral palpebral ligament in positioning the lateral canthus of the eye in his face reconstructions on the skull. The present paper offers an equally sure means of positioning the medial canthus.

Hysterical conversion reactions: some patient characteristics and treatment team reactions

Paralysis due to an hysterical conversion reaction may require an active rehabilitation program to prevent complications such as contractures and adhesions. The delivery of this care can create an emotional burden on the rehabilitation staff due to their awareness of the psychiatric etiology of this condition. Good patient care may be undermined by the thought that the patient is malingering. This paper explores features of hysteria--its relation to emotional stress, absence of organic pathology and symbolism--and contrasts it to malingering. The impact of this condition on the treatment staff is explored with two case studies. An understanding of hysteria could make the delivery of proper care to these troubled patients less stressful.

Pioneer contributions of Harris Hawthorne Wilder, Ph.D., to forensic sciences

In his youth Harris Hawthorne Wilder developed interests in both zoology and human anatomy. Following graduate study in Germany (1886-1891), he was appointed professor of zoology at Smith College but retained his dual interests throughout his career. As a result, he was instrumental in introducing to American audiences two new European developments in human identification; dermatoglyphics and face reconstruction on skulls. The details of his contributions in these two areas, summarized here, establish him as an important pioneer in American forensic sciences.

Responses of the human skeleton to changes in the quality of life

Americans have been getting taller for more than a century, and within this century their life expectancy has risen markedly. Descendants of some of the immigrants who arrived from Europe early in this century have heads with shapes that differ from those of relatives back in the Old World. Before they were born head shape was assumed to be one of mankind's most stable features. These examples of population change reflect the fact that in America the quality of life has improved more rapidly and widely than elsewhere. Forensic anthropologists have been adjusting their identification techniques to compensate for these population changes. Among other things, they have used data collected in connection with the military programs to repatriate the American dead of World War II and the Korean War.

Coping behaviour and the moratorium following spinal cord injury

Coping with severe traumatic injury involves three interwoven processes--denial, depression and restitution. Denial and depression are seen as adaptive processes in the appropriate context. A moratorium during the coping process is described; its duration and implications for patient care are discussed.

Spinal cord injury: a role for the psychiatrist

The initial psychiatric evaluation of individuals with spinal cord injuries should focus on the patients' coping strategies; this information is an essential part of the treatment and rehabilitation plan. Psychiatrists can also work effectively with staff members in groups designed to ease the strain of working with severely disabled patients. Such patients may have psychiatric illnesses that are not secondary to the injury; careful selection of antidepressant or antipsychotic medication is essential. The author points out that the psychiatrist has much to offer in the treatment of individuals with spinal cord and other severely disabling injuries.

Psychotherapy and physical therapy common grounds

Psychotherapy and physical therapy involve charged emotional relationships with many common features. Understanding of these common elements can help physical therapists to work with their patients, to utilize the healing aspects of the relationship, and to reduce the tensions within the relationships that can interfere with job satisfaction. The importance of separation and its management are emphasized.