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.

Can the radiopaque marker in surgical swabs scratch orthopaedic implant surfaces?

AIMS: To determine whether the radiopaque marker strip, which is woven in surgical swabs, causes measureable wear on metal implants at pressures typically used to wipe off fluid from their surface. MATERIALS AND METHODS: Finger pressure used to wipe a surface was measured and used as a reference pressure for further testing. A tribological wear rig was then used to analyse the wear caused on polished titanium plates by a cobalt chromium pin (the control test), the pin covered by a surgical swab and the pin covered by a radiopaque marker strip. RESULTS: It was found that the cotton part or the radiopaque marker of surgical swabs on polished medical grade titanium plates caused no significant wear. In contrast severe scratching was observed from the cobalt chromium pin on its own. CONCLUSION: To our knowledge, this is the first study in the literature analysing the wear caused by the surgical swabs and radiopaque strip on metal implants. The results suggest that surgical swabs are safe to use on metallic implants at pressures typical of a wiping motion.

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 3000s 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.

Spectral analysis of the sound produced during femoral broaching and implant insertion in uncemented total hip arthroplasty.

Preparation of the proximal femur using incremental broaches to create the ideal cancellous bone envelope is an important technique to perfect in uncemented hip arthroplasty. To guide broaching adequacy and final implant position, the surgeon can use audible pitch changes produced by the femoral broach and definitive implant. The aim of this study was to characterise these pitch changes by analysing the sound spectra created by the first broach, last broach and implant using spectral analysis software. The last broach and implant introduction spectra demonstrated low-frequency (400-1200 Hz) spectral peaks that were not detected when using the first broach. These frequencies corresponded to the natural resonant frequency of a standing sound wave within the femoral bone canal (approximately 894 Hz) that was estimated using acoustic physics theory. The remaining spectral peaks were associated with transverse vibration modes produced by striking the metal broach handle and implant introducer and were a function of the constructs geometry and material properties.

A review of symptomatic leg length inequality following total hip arthroplasty.

Leg length inequality (LLI) following total hip replacement is a complication which features increasingly in the recent literature. The definition of LLI is complicated by lack of consensus regarding radiological measurement, clinical measurement and the incomplete relationship between LLI and associated symptoms. This paper reviews 79 reports relating to LLI post hip replacement, detailing definitions and classification and highlighting patient populations prone to symptomatic LLI. While there is no universal definition of LLI, there is a broad consensus that less than 10 mm of difference on AP view plain radiographs is clinically acceptable. There are few techniques described that consistently produce a postoperative LLI of less than this magnitude. Where postoperative LLI exists, lengthening appears to cause more problems than shortening. In cases of mild LLI, non-surgical management produces adequate outcomes in the majority of cases, with functional LLI cases doing better than those with true LLI. Operative correction is effective in half of cases, even where nerve palsy is present, and remains an important option of last resort. Poor outcomes in patients with LLI may be minimised if individuals at risk are identified and counselled appropriately.

Assessing reproducibility for radiographic measurement of leg length inequality after total hip replacement.

Leg length inequality (LLI) as a result of total hip replacement can cause considerable morbidity. Although LLI was described when the technique was popularised in the 1960s, it remains a significant challenge to arthroplasty surgeons. This study reviews the established practice for the measurement of LLI on plain antero-posterior radiograph, and compares these techniques to two methods used locally. The radiographs of 35 patients were measured using four techniques. All four methods yielded an interclass correlation co-efficient of ≥0.90 for inter reader reliability. This study shows that the four methods are comparable for reliability, while a composite method, measuring from the centre of femoral rotation to the inferior teardrop and then to the lesser trochanter, has the added advantage of providing extra information on component position as well as an overall measure of LLI.

Characterization of worn alumina hip replacement prostheses.

Alumina hip replacement prostheses have been analyzed following in vitro simulated microseparation. The worn surfaces of the alumina acetabular cup and femoral head were investigated using scanning electron microscopy (SEM) and atomic force microscopy (AFM) which identified four different wear zones. Focused ion beam (FIB) cross-sectioning was used to section the worn surface and produce 3D reconstructions of the subsurface damage. This showed that the subsurface fracture was predominantly intergranular, with occasional intragranular fracture. Significantly, in all cases, fracture was restricted to the outer layer of grains. The wear mechanisms leading to the generation of the stripe wear region on the worn alumina hip prostheses are proposed and microseparation is believed to play a critical role.

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.