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Biomechanical evaluation of total ankle arthroplasty. Part II: Influence of loading and fixation design on tibial bone-implant interaction.

ABSTRACT: Finite element (FE) models to evaluate the burden placed on the interaction between total ankle arthroplasty (TAA) implants and the bone often rely on peak axial forces. However, the loading environment of the ankle is complex, and it is unclear whether peak axial forces represent a challenging scenario for the interaction between the implant and the bone. Our goal was to determine how the loads and the design of the fixation of the tibial component of TAA impact the interaction between the implant and the bone. To this end, we developed a framework that integrated robotic cadaveric simulations to determine the ankle kinematics, musculoskeletal models to determine the ankle joint loads, and FE models to evaluate the interaction between TAA and the bone. We compared the bone-implant micromotion and the risk of bone failure of three common fixation designs for the tibial component of TAA: spikes, a stem, and a keel. We found that the most critical conditions for the interaction between the implant and the bone were dependent on the specimen and the fixation design, but always involved submaximal forces and large moments. We also found that while the fixation design influenced the distribution and the peak value of bone-implant micromotion, the amount of bone at risk of failure was specimen dependent. To account for the most critical conditions for the interaction between the implant and the bone, our results support simulating multiple specimens under complex loading profiles that include multiaxial moments and span entire activity cycles.

SUBMITTER: Quevedo Gonzalez FJ

PROVIDER: S-EPMC7748995 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundJoint loading conditions have an effect on the development and management of ankle osteoarthritis and on aseptic loosening after total ankle arthroplasty (TAA). Apart from body weight, compressive forces induced by muscle action may affect joint loading. However, few studies have evaluated the influence of individual muscles on the intraarticular pressure distribution in the ankle.Question/purposesThe purpose of this study was to measure intraarticular pressure distribution and, in particular, (1) to quantify the effect of individual muscle action on peak-pressure magnitude; and (2) to identify the location of the center of pressure in the weightbearing native ankles and ankles that had TAA.MethodsPeak pressure and intraarticular center of pressure were quantified during force alterations of four muscle groups (peronei, tibialis anterior, tibialis posterior, and triceps surae) in 10 cadaveric feet. The pressure was measured with a pressure sensitive array before and after implantation of a three-component mobile-bearing TAA prosthesis. Linear mixed-effects models were calculated and the y-intercept (b0) and the slope (b1) of the regression were used to quantify the size of the effect.ResultsMean maximum peak pressures of 2 MPa (± 2.6 MPa) and 6.2 MPa (± 3.6 MPa) were measured for the native and TAA joint respectively. The triceps surae greatly affect the magnitude of peak pressure in the native ankle (slope b1 = 0.174; p = 0.001) and TAA joint (slope b1 = 0.416; p = 0.001). Furthermore, the force of most muscles caused a posterior and lateral shift of the center of pressure in both conditions.ConclusionsOur results suggest that muscle force production has the potential to alter the pressure distribution in the native ankles and those with and TAA.Clinical relevanceOur study results help us to understand the effect of muscle forces on joint loading conditions which could be used in muscle training strategies and the design of better prosthetic components. Physical therapy or guided exercises may provide the potential to relieve areas in the joint that show signs of early osteoarthritis or reduce the contact stress on prosthetic components, potentially reducing the risk of TAA failure attributable to wear.

Project description:IntroductionRevision total knee arthoplasty often requires modular implants to treat bone defects of varying severity. In some cases, it may not be clear which module size and implant combination (e.g. sleeve and stem) should be chosen for a specific defect. When balancing implant stability and osseointegration against stress-shielding, it is important to choose an appropriate implant combination in order to match the given level of bone loss. Therefore, the necessity of stems in less extensive tibial defects and the advantage of different stems (lengths and stiffnesses) in combination with large metaphyseal sleeves on implant fixation and bone flexibility using a modular tibial revision knee system, were analyzed.Materials and methodsFour different stem combinations for a tibial revision implant (Sigma TC3, DePuy) were compared to an intact bone. Standardized implantation with n = 4 synthetic tibial bones was performed after generating an Anderson Orthopaedic Research Institute (AORI) Type T1 bone defect. Axial torques around the longitudinal stem axis and varus-valgus torques were separately applied to the implant. Micromotions of bone and implant were tracked using a digital image correlation system to calculate relative micromotions at the implant-bone-interface and bone deformation.ResultsOverall, using stems reduced the proximal micromotions of tray and sleeve compared to no stem, while reducing bone deformation proximally at the same time, indicating some potential for proximal stress-shielding compared to no stem. The potential for increased proximal stress-shield due to reduced proximal deformation appeared to be greater when using the longer stems. The location of lowest relative micromotions was also more distal when using long stems as opposed to short stems. A short stem (especially a smaller diameter short stem which still achieves diaphyseal fixation) displayed less potential for stress-shielding, but greater bone deformation distal to the tip of the stem than in the natural model.DiscussionIn the case of tibial revision implants with metaphyseal sleeves in a simple fully contained Type I defect, the absence of a stem provides for more natural bone deformation. However, adding a stem reduces overall relative micromotions, while introducing some risk of proximal stress-shielding due to increased diaphyseal fixation. Increasing stem length intensifies this effect. Short stems offered a balance between reduced micromotions and more proximal bone deformation that reduced the potential for stress-shielding when compared to long stems. A short stem with slightly smaller diameter (simulating a less stiff stem which still has diaphyseal fixation) increased the proximal bone deformation, but also tended to increase the bone deformation even further at the distal stem's tip.ConclusionIn conclusion, further investigation should be conducted on fully contained Type I defects and the addition of a stem to offer better initial stability, taking into account stem length (i.e. shorter or more flexible stems) to support metaphyseal fixation and allowing bending found in intact bone. In addition, further study into more extensive tibial defects is required to determine if the stability/micromotion trends observed in this study with stems and sleeves in Type I defects still apply in cases of extensive proximal bone loss.

Project description:Accurate positioning of the total ankle arthroplasty implant components with the absence of any hindfoot deformity does not preclude the development of bony impingement. In cases of ankle stiffness after total ankle arthroplasty, the usual limitation is in dorsiflexion. If triceps surae contracture is excluded or persistent restriction remains in ankle dorsiflexion after gastrocnemius recession or tendo-Achilles lengthening, posterior ankle capsulectomy, debridement of posterior ankle gutter, and release of the deep posterior deltoid ligament and the posterior talofibular ligament are indicated. In this Technical Note, the technical details of endoscopic posterior ankle decompression and release after total ankle arthroplasty are described. Technique Video Video 1 Endoscopic posterior ankle decompression and release after total ankle arthroplasty of the left ankle. The patient is in the prone position. Posteromedial portal is the viewing portal and posterolateral portal is the working portal. The flexor hallucis longus (FHL) tendon is exposed. The arthroscope is switched to the posterolateral portal and the posterolateral ankle capsule is resected with arthroscopic instruments via the posteromedial portal. The FHL tendon is pushed medially by the instruments to facilitate resection of the more medial posterior ankle capsule. The arthroscope is switched back to the posteromedial portal and the most lateral part of the posterior ankle capsule is resected with arthroscopic shaver and radiofrequency wand via the posterolateral portal. Then, the FHL tendon is looped with a vascular sling via the posterolateral portal and the tendon is retracted laterally. The medial part of the posterior ankle capsule is resected with arthroscopic instruments via the posteromedial portal. The fibrous tissue of the posteromedial ankle gutter is also resected. The arthroscope is switched to the posteromedial portal and the fibrous tissue of the posterolateral ankle gutter is resected. The scarred posterolateral ankle ligamentous structure and fibrous band is released from its calcaneal insertion. The arthroscope is switched back to the posterolateral portal and the scarred posteromedial ankle ligamentous structure and fibrous band is carefully cut by a No. 15 scalpel with the cutting blade facing laterally.

Project description:BackgroundIt is unclear whether there is a clinical benefit to adding hydroxyapatite (HA) coatings to total knee implants, especially with the tibial component, where failure of the implant more often occurs. A systematic review of the literature was undertaken to identify all prospective randomized trials for determining whether the overall clinical results (as a function of durability, function, and adverse events) favored HA-coated tibial components.MethodsA comprehensive literature search was performed for the years 1990 to September 16, 2010. We restricted our search to randomized controlled trials involving participants receiving either an HA-coated tibia or other forms of tibial fixation. The primary outcome measures evaluated were durability, function, and acute adverse events.ResultsData from 926 evaluable primary total knee implants in 14 studies were analyzed. Using an RSA definition for durability, HA-coated tibial components (porous or press-fit) without screw fixation were less likely to be unstable at 2 years than porous and cemented metal-backed tibial components (RR = 0.58, 95% CI: 0.34-0.98; p = 0.04, I(2) = 39%, M-H random effects model). There was no significant difference in durability, as measured from revision and evaluated at 2 and 8-10 years, between groups. Also, functional status using different validated measures showed no significant difference at 2 and 5 years, no matter what measure was used. Lastly, there was no significant difference in adverse events. Limitations included small numbers of evaluable patients (≤ 50) in 7 of the 14 trials identified, and a lack of "hard" evidence of durability with need for replacement (i.e. frank failure, pain, or loss of functionality).InterpretationIn patients > 65 years of age, an HA-coated tibial implant may provide better durability than other forms of tibial fixation. Larger trials should be undertaken comparing the long-term durability, function, and adverse events of HA-coated implants with those of other porous-coated tibial implants in younger, more active OA patients.

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Biomechanical evaluation of total ankle arthroplasty. Part II: Influence of loading and fixation design on tibial bone-implant interaction.

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