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An arthritic or damaged joint is removed and replaced with an artificial joint, called a prosthesis or Total joint replacement. Total joint replacement has become a widely accepted treatment for many destructive joint diseases including osteoarthritis, rhematoid arthritis, osteonecrosis and very severe pathologic fractures. Of total joint replacments, the two most commonly replaced joints and most successfully replaced joints are the knee and the hip. Sir John Charnely, a British Orthopaedic surgeon who was knighted for his development of joint replacements, developed the fundamental principles of the artificial hip and designed a hip in the mid and late 1960's. Frank Gunston developed one of the first artificial knee joints in 1969. Since then, joint replacement surgery has become one of the most successful orthopaedic treatements. The goal is to relieve the pain in the joint caused by the damage done to the cartilage. A physical examination, and possibly some laboratory tests and X-rays, will show the extent of damage to the joint. Total joint replacement will be considered if other treatment options will not relieve the pain and disability. The number of hip replacements done in the world per year numbers between 500,000 and 1 million. The total number of knee replacements done in the world per year is less, but probably still numbers between 250,000 and 500,000. Of all the factors leading to total hip replacement, osteoarthritis or OA, is the most common, accounting for 65% of all total hips.


The basic idea of joint replacement surgery is to replace the diseased articular surface with one made from a synthetic material. This new joint surface must then be part of the artificial joint which itself is fixed to the bone near the joint. The major design issues in artificial joint replacement are 1) the geometric and material design of the articulating surfaces and 2) design of the interface between the artificial joint and the surrounding bone. Most joint replacements use a polyethylene for the bearing surface and either a titanium alloy or a chromecobalt alloy for the rest of the joint. It is the metal part of the joint in most cases that interfaces with the bone. The are two widely used methods for interfacing the joint with the bone: 1) using a Polymethylmethacrylate (PMMA) cement to adhere the metal to the bone or 2) using a porous metal surface to create a bone ingrowth interface. These two types of interfaces are illustrated below


Wear is now considered one of the most signficiant factors limiting the longevity of total joints. Improvements in implant metallurgy, surgical techniques, patient selection, and cementing techniques have boosted total joint lifetimes so that most moderately active patients in their 60's can expect 10 to 15 years of pain

free activity with a joint replacement. Beyond this however, or in a younger patient population, wear is a significant factor leading to joint revision. The two factors leading to wear debris that most affect joint replacements are foreign body wear and subsurface fatigue. Foreign body wear occurs when a piece of material comes between the articulating joint surfaces. The presence of the piece of material generates additional stress concentrations of the articulating surfaces. The second type of wear is sub-surface fatigue. High contact stresses in the polyethylene can cause cracks to form and propagate beneath the surface of the polyethylene. These cracks can cause material particles to break from the surface creating wear debris.The wear particles can track down the interface between the bone and implant. Macrophage cells will respond to the wear particles by engulfing the particles and resorbing bone at the interface. The bone is replaced by soft tissue, creating a more compliant interface. Over time, this will lead to implant loosening. Reduced wear from surface fatigue failure and delamination of polyethylene can be achieved by reducing the cyclic contact stresses on the polyethylene, improving the toughness and wear characteristics of polyethylene, or a combination of the two.


In addition to wear, the most frequent source of total joint failure is debonding of the implant bone interface due to fatigue failure of the bone implant interface or adverse bone adaptation around the total joint.

Load transfer in composite materials:

Just as all biological tissues are composite materials and structures, so are bone implant combinations composite structures. Because of the difference in material properties of the bone and the implant, an interface is created when the two materials are put together. One of the most important issues in bone implant interfaces is how load is transferred from the implant to the surrounding bone. If

the two materials are bonded and equal force is applied to both as illustrated in the figure:

then the strain in each bar must be equal:

If we use Hooke's law and also the fact that stress is force/area, we obtain:

which leads to the result

Next, we also know that the total force is the sum of the forces in each bar:

If we use the Hooke's law relationship given above, we can find a relationship between the forces defined in terms of area and Young's modulus:

We also know that deformation on parallel materials gives us Voight's model or the rule of mixtures:

which when substituted in for E and A in the immediately proceeding equation gives us:

Load transfer between the proximal femoral compoent and the surrounding bone is analagous to the case where there are two bars bonded together, but the first bar only is the site of load application, and it carries the total load as:

The first bar, in our case the implant, will take all of the intial force, in our case the contact force with the acetabulum. However, at the point where the prosthesis is imbedded in the bone, there must be load transfer between the implant and the bone. Based on our original analysis of load sharing in composite structures, we know that at some distance past the point where the implant meets the bone the force distribtution between the implant and the bone will be:

where the subscript i denotes implant and b denotes bone. Thus, the force in the implant drops from the total force F to a lesser force that depends on the stiffness ratio of the implant to the bone. Conversely, the force in the bone must rise from 0 to a greater force that depends on the stiffness ratio of the bone to the implant. The transfer of load must take place through shear stress at the bone implant interface. It is this shear stress repeated many cycles per day that determines the longevity of the bone implant interface. This shear stress distribution may be represented by a shear lag distribution function.

The above results indicate two major points. First, the stiffness ratio of the implant to the bone will determine how much load is borne by each. Since the ratio EA/(E1A1 + E2A2) is generally weighted much more towards the implant, this explains why the implant carries most of the load and leads to stress shielding of the bone. Second, the need of the interface to carry high stresses to create the transition between the implant and the bone load carrying explains the reason why the bone implant interface is the critical design feature of most implants. Another important determinant of interface stresses are the characteristics of the bond between the implant and bone. Bonding characteristics can range from completely bonded to non-bonded interfaces with no friction. On the latter, no interface shear stresses can be generated due to the lack of friction at the interface. In this case, significant compressive stresses must be generated to withstand the applied force. In an implant situation, these compressive stresses can only be generated when the implant subsides into the bone. If the interface is bonded, then significant shear stresses can be generated at the interface to support the implant. A bonded interface is characteristic of a cemented prosthesis, while a non-bonded interface is characteristic of a non-cemented press fit prosthesis.


A schematic of a hip replacement is shown below

In the above picture, you can see that both the acetabulum (the "socket") and the proximal femur (the "ball" of the hip joint) have been replaced. The femoral side is completely metal. The acetabular side is composed of the polyethylene bearing surface that may or may not have a metal backing. Both the components in this schematic are shown to be fixed to bone with PMMA cement. The hip joint is a common ball joint comprised of just two bones, the head of the femur (thigh bone) and the socket (acetabulum). The femur has a head, a neck and the trochanters, large on the outer side and lesser on the inner side below which is the shaft. The bones themselves have a hard outer shell, the cortex, with a cavity inside. There are two parts to a hip replacement acetabular preparation and femoral preparation. In the acetabular preparation, special mushroom-shaped reamers are used to remove the diseased and damaged cartilage and bone. The area is power washed to remove all blood, fat and debris and thoroughly dried. Once the bone is dry, cement (if used) is put in and pressure applied to force the cement into the honeycomb of the bone. Implants comprised of a metal shell and a liner are then inserted. Sometimes the shell is fixed in place with two or three screws through into the hip bone. For the femoral preparation, the femoral head is removed and ream the shaft out with specially shaped rasps. The area is power washed to remove all blood, fat and debris and thoroughly dried. Once the bone is dry, cement (if used) is put in and pressure applied to force the cement into the honeycomb of the bone. Implants comprised of a metal stem and a ball for the head are inserted. A two-dimensional biomechanical model of the juvenile hip joint was developed to describe the forces acting on the capital epiphysis and the greater trochanter apophysis in the one-legged stance. We showed that the apophysis of the greater trochanter is a pressure apophysis. If the muscular forces acting on the apophysis of the greater trochanter are added, the unit sum may be considered a resultant force acting from a craniolateral direction. The trochanteric resultant force near the end of the growth period is equivalent to approximately 1.7 times body weight. The trochanteric resultant force stimulates craniolateral growth of the greater trochanteric apophysis. This mechanism is responsible for the direction of

the forces exerted by the hip abductors and thus the direction and magnitude of Pauwels' hip-joint resultant, and finally influences the neck-shaft angle. The results confirmed quite strikingly two aspects of hip joint pressures that had been indicated from in vitro experiments and calculations. First, the pressure is not uniformly distributed within the joint, but varies significantly from point to point. Second,pressures are much higher (up to 18 MPa) than had been predicted from an assumption of uniform pressure distribution.The contact area is reproduced on the articular surface of the femoral head and its position determined by the attitude of the femur to the acetabulum during the walking cycle. The contact area includes the anterior,superior and posterior aspects of the femoral head.Incongruency of the opposed surface curvatures is then a feature of the human hip joint.In the terms of mechanical engineering the dome of the normal acetabulum is relieved, and the existence of this feature invites speculation upon its significance, if any, in normal joint function.


A schematic of a knee replacement is shown below :

There are three major components to a total knee: 1) the femoral component that replaces the distal femur, 2) the tibial component that is inserted into the proximal tibia, and 3) the patellar component that replaces the back of the patella. As with the hip joint, the articulating surface is metal on polyethylene, and the metal parts of the implant interface with bone.

The femur (the upper leg bone) and the tibia (the shinbone) are connected by the anterior and posterior cruciate ligaments. The joint is cushioned by the meniscus, a tough cartilage material, during movement. The patella (or kneecap) is a small bone, encased in tendons, that glides up and down in the groove on the top of the femur when the knee is flexed and extended. The load-bearing mode of the knee joint and the load-carrying capacity of the menisci were investigated by a load-deflection and load-contact study using stresses of as much as 3 times body weight. A flection angle of 00 was used. The average deflection and the average size of the contact area of the intact knees were 1.04 x 10(-1) cm and 14.1 cm2 respectively. when the knees were loaded to 1,500 N. The elastic modulus of the entire joint was 2.7 x 102 MPa over the load of 1,500 N. At first, the knee joint was not congruous at a low load under about 500 N; the joint contacts both menisci in conjunction with some part of the exposed cartilage. However, the joint became markedly congruous at higher loads, around 1,000 N. The joint was in contact with the menisci and the exposed cartilage, and as more load was applied, the areas of contact widened to the peripheral areas of both the compartments. After menisci were removed, the deflection increased. The size of the contact areas decreased significantly by a third to a half. Consequently, the average stress increased 2 to 3 times that of the intact knee. The elastic modulus was increased over 2 fold after menisci were removed. The results of the energy study indicate that the menisci gave more elastic stability to the joint. After the menisci were removed, more energy was dissipated during cyclic loading. Thus, the menisci provide surface compliance and serve to transmit stresses across the wider areas to the periphery, and, therefore, help to avoid stress concentration both in the articular cartilage and in the subchondral bone, especially under high loads over 1,000 N. At a load of 1000N the contact area of the knee was 11.5 x 102 mm2 with menisci and 5.2 x 102 mm2 without menisci, and the menisci occupied 70% of the total contact area. Peak pressure at 1000N was 3 MPa with the menisci and 6 MPa without them. The high pressure areas were located on the lateral meniscus as well as on the uncovered part of the articular cartilage of the lateral compartment, and on the uncovered cartilage in the medial compartment. After removal of the menisci the contact area decreased to below one half that of the intact knee and the contact pressure considerably increased. These facts imply that the menisci have load bearing and load spreading functions. The contact areas were also measured in two osteoarthrotic knees and they were significantly

larger than those in normal knees. In these arthrotic knees the menisci seemed to play a less significant role in transmission of weight than in the normal knees. At 30 of knee flexion, the femoro-patellar contact areas were located in the inferior part of the patellar articular cartilage. The contact was distributed across both patella facets, showing a broad transverse band.The average size of the contact areas was 134.560.5 mm2. At 90 of flexion, the contact areas migrated superiorly, the distribution still being a broad transversal band. The size of the contact areas increased significantly compared to 30 of flexion with a mean value of 205.496.6 mm2 (p<0.05).


Besides relative implant bone stiffness, another important parameter affecting cemented implant interfaces is the bonding between the implant and the cement. If we loose bonding between the implant and the cement, then this interface cannot carry shear stresses, only compressive stresses. If this happens, then we have the situation, where the implant will subside in the bone to generate compressive stresses capable of bearing the applied load. In addition to implant subsidence, debonding of the implant from the cement will lead to higher cement mantle stresses. There are two types of debonding that can occur. The first type of debonding is separation of the metal stem from the cement. Debonding of the metal from the cement occurs in many cemented implants. If debonding occurs, the amount of shear stress that can be borne at the metal-cement interface is reduced, an the interface must withstand the applied load through compressive forces. The figure,shows how shear stresses at the interface change when the stem becomes unbonded from the cement:

As expected, debonding drastically reduces shear stress at the cement metal interface. This shows that shear stresses are a significant mode of load transfer for bonded implants. Likewise, progressive debonding states from completely bonded, to unbonded with friction transfers compressive loads and shear stress under compression via Coulomb's friction law

where to frictionless unbonded that can only carry compressive stress and the effects of these bonding states on tensile stresses in the cement mantle. The second type of debonding that can occur is between the cement and the bone. Again, using continuum finite element models, this debonding is represented as a change in contact conditions. If the contact conditions at the the bone-cement interface are changed from completely bonded to unbonded, there is an increase in stresses at the implant cement interface, as shown below:

Left part of figure shows cement stem stresses with bonded bone cement interface while the middle part of the figure shows increased stresses at the cement stem interface. Avoiding debonding depends both on prosthesis design and surgical experience with cement pressurization.Removing voids in cement during mixing is critical to avoid fatigue failure of cement, as is designing stems that avoid stress concentrations in the cement.

In addition to bonding affects, the stem material stiffness can have a significant affect on both interface motion and stress shielding, in contradictory ways. Comparing a titanium stem with an isoelastic stem (has the same stiffness as bone), it is shown that the titanium stem produces less interface motion. This is important since reduce interface motion will reduce cement stresses and cement metal debonding. In addition, as expected, higher friction (indicative of better bonding) also reduces interface motion. A disadvantage of a stiff stem, however, is stress shielding. As seen in the simple stem analysis above, a stiffer implant to bone stiffness ration means that the stem will carry more load. This means that the bone stresses will likely be much lower than stresses in the intact bone and will lead to bone resorption through excessive bone remodeling. These resorption affects can be predicted using numerical bone adaptation simulations. In sum, these analyses suggest that successful total hip stem design is a tradeoff among many factors. Stiff stems will reduce interface motion, but will lead to more bone resorption. Increasing surface roughness of the metal will increase the friction coefficient of the metal cement interface, but this will also increase the localized stress concentrations within the cement, possibly creating wear debris. The design of tibial components of knee protheses may also affect stress shielding. The next figure, shows the effect of stem length and stem material (polyethylene vs. metal backed) on stresses in the tibia. Longer stems and metal stems produce more stress shielding than all polyethylene components. However, polyethylene components may be more at risk for fatigue failure and wear.


An alternative to cemented implant interface is a porous coated implant interface. The theory behind porous coating is that bone will grow into 300 to 500 micron pores on the implant surface. This will eliminate the poor mechanical properties of the cement. However, porous coated implants have not overtaken cemented implants in terms of clinical usage. That may be for two reasons 1) porous coated implants rely on a biological (osteogenesis) process that is not as predictable as an immediate cemented interface. The interface bond develops over time and 2) porous coated implant interface is much more dependent on precise surgical fit to obtain an implant bone. In hip stems, porous coating is most often limited to the proximal portion of the implant. This is because an implant completely covered with porous coating will most likely have ingrowth at the tip. This leads to extreme stress shielding. Finally, the stability of porous coated implants is more dependent on the location of ingrowth than on the depth of ingrowth. This means that the ability to control ingrowth location is perhaps the most critical aspect of porous coated implants, but the one aspect most difficult to control.

REFERENCES: http://bonesmart.org/joint-replacement-surgery http://www.engin.umich.edu/class/bme456/artjoint/artjoint.htm http://www.ncbi.nlm.nih.gov/pubmed/7408313 http://www.pnas.org/content/83/9/2879.short