Reproduction of fretting wear at the stem-cement interface in total hip replacement

The stem-cement interface experiences fretting wear in vivo due to low-amplitude oscillatory micromotion under physiological loading, as a consequence it is considered to play an important part in the overall wear of cemented total hip replacement. Despite its potential significance, in-vitro simulation to reproduce fretting wear has seldom been attempted and even then with only limited success. In the present study, fretting wear was successfully reproduced at the stem-cement interface through an in-vitro wear simulation, which was performed in part with reference to ISO 7206-4: 2002. The wear locations compared well with the results of retrieval studies. There was no evidence of bone cement transfer films on the stem surface and no fatigue cracks in the cement mantle. The cement surface was severely damaged in those areas in contact with the fretting zones on the stem surface, with retention of cement debris in the micropores. Furthermore, it was suggested that these micropores contributed to initiation and propagation of fretting wear. This study gave scope for further comparative study of the influence of stem geometry, stem surface finish, and bone cement brand on generation of fretting wear.     

The influence of stem insertion rate on the porosity of the cement mantle of hip joint replacements

This study investigates the effect of stem insertion rate on the porosity of the cement mantle. An experimental protocol was developed to simulate the surgical technique of cementing a prosthetic stem into the medullary canal of the femur. Cement mantle specimens were produced for three different stem insertion rates. The presence of porosity in the cement mantle was investigated. Additionally, the mechanical strength of the bone cement was assessed. Increasing the stem insertion rate did not have a significant effect on the porosity distribution within the bulk cement mantle. However, for all stem insertion rates investigated, the porosity concentration increased significantly moving from the cement/pseudofemur interface through to the stem/cement interface. In all cases, the presence of porosity significantly decreased the mechanical behaviour of the bone cement. High porosity concentration at the stem/cement interface seems to be attributed also to the rheology of the cement during implant insertion. Nevertheless, the surgeon cannot influence the formation of porosity by changing the stem insertion rate.     

Radiographic assessment of the cement mantle thickness of the femoral stem in total hip replacement: a case study of 112 consecutive implants

The results are reported of a radiographic study of cement mantle thickness in 112 consecutive primary hip replacements. Measurements were made by three observers of the apparent cement thickness medially and laterally using standard anterior-posterior radiographs. The average cement thickness was 3.2 mm, which is 1.2 mm greater than the size difference between the broach and the prosthesis, and was in the range 2-5 mm in 67 per cent of all measurement points. This has significance for the design of instrumentation to prepare the femoral cavity to give a defined cement mantle thickness. There was a greater cement mantle thickness proximally than distally. In 95 cases it was possible to determine the orientation of the stem within the cement mantle, which showed an even distribution between varus and valgus orientation; 49 per cent were within 1 degree of neutral and only one case was more than 5 degrees from neutral.     

A novel test method for evaluation of the abrasive wear behaviour of total hip stems at the interface between implant surface and bone cement

After total hip replacement, some cemented titanium stems show above-average early loosening rates. Increased release of wear particles and resulting reaction of the peri-prosthetic tissue were considered responsible. The objective was to develop a test method for analysing the abrasive wear behaviour of cemented stems and for generating wear particles at the interface with the bone cement. By means of the novel test device, cemented hip stems with different designs, surface topographies and material compositions using various bone cements could be investigated. Before testing, the cemented stems were disconnected from the cement mantle to simulate the situation of stem loosening (debonding). Subsequently, constant radial contact pressures were applied on to the stem surface by a force-controlled hydraulic cylinder. Oscillating micromotions of the stem (+/- 250 microm; 3 x 10(6)cycles; 5 Hz) were carried out at the cement interface initiating the wear process. The usability of the method was demonstrated by testing geometrically identical Ti-6A1-7Nb and Co-28Cr-6Mo hip stems (n= 12) with definite rough and smooth surfaces, combined with commercially available bone cement containing zirconium oxide particles. Under identical frictional conditions with the rough shot-blasted stems, clearly more wear particles were generated than with the smooth stems, whereas the material composition of the hip stems had less impact on the wear behaviour.     

Biomechanical, morphological, and histological analysis of early failures in hip resurfacing arthroplasty

The present revival of hip resurfacing arthroplasty may be related to an increase in early failures owing to the challenging technique of the procedure. Fifty-five retrieved implants were analysed with respect to wear, cement mantle and cement penetration, fracture and head morphology, as well as standard histology. Femoral neck fractures occurred in median after 102 days. The time to failure was shorter for older women. Major deviations from the suggested cement mantle thickness and cement penetration were found. Indications for high trauma during implantation leading to early failure due to weakening of the femoral neck were also observed. Some failures had signs of pseudarthrosis beneath the implant. Four different fracture patterns with different mean survival times were identified. Observed wear was minor with the exception of that due to alignment mistakes (rim loading). The cups were not damaged by the failures. Histological results indicate that avascular necrosis is not necessarily connected with this kind of endoprosthetic surgery. Most of the failures analysed can probably be attributed to the 'learning curve' effect, which is an unsatisfactory situation.     

Properties of composite specimens of old and new bone cement

The most common cause of failure of a total hip replacement is aseptic loosening of an implant. In a number of cases, the cement-bone interface of at least one component is not compromised. In cases of aseptic cup loosening, removal of a well-fixed femoral stem may be undertaken to facilitate exposure of the acetabulum for cup revision, and the surgeon may choose to leave the functional cement-bone interfaces in the femur undisturbed. After cup revision, new cement is pressurized within the old cement mantle and a stem is cemented into this 'old-new cement' composite. Retaining the old cement mantle is an attractive option as it reduces the duration of surgery, minimizes bleeding, and preserves the bone stock. Excellent results have been shown with this technique of 'in-cement femoral revision' using a double-tapered polished stem. While considerable literature is available on the short- and long-term properties of PMMA bone cement, very little is known about the mechanical properties of old-new composite cement specimens where the old cement is more than a few days old. This paper tests the properties of such old-new composite specimens where the 'old' cement is aged between 3.3 and 17.7 years, better reflecting clinical situations.     

Finite element analysis of the resurfaced femoral head

Failure of the resurfaced femoral head may occur in the short term owing to femoral neck fracture or in the long term owing to aseptic loosening as a result of strain shielding. Resurfacing arthroplasties are not all the same. In particular, there is considerable debate regarding the role of the metaphyseal stem and cementing technique. This study examines the influence of various metaphyseal stem configurations (diameter, percentage length in contact with bone, and bonded versus debonded) and cement mantle thickness on the load transfer within the femoral head. Resurfacing resulted in significant strain shielding in the superior femoral head and elevated strain in the superior femoral neck. Although the increase in strain in the femoral neck was significant, the mean strains were below the yield strain for cancellous bone. Peak strains were observed above the yield strain, but they accounted for less than 1 per cent of the total head-neck bone volume and therefore were unlikely to result in femoral neck fracture. Increasing the stem diameter and increasing the percentage stem length in contact with bone both increased the degree of strain shielding. Bonding the metaphyseal stem produced the most dramatic strain shielding, which also extended into the head-neck junction. In contrast, varying the cement mantle thickness had a negligible effect on the load transfer.     

Preclinical assessment of the long-term endurance of cemented hip stems. Part 2: in-vitro and ex-vivo fatigue damage of the cement mantle

Fatigue damage in the cement mantle surrounding hip stems has been studied in the past. However, so far no quantitative method has been validated for assessing ex-vivo damage and for predicting the in-vitro risk of cement fracture. This work presents a method for measuring cement damage; the cement mantle was sliced and sections were inspected with dye penetrants and an optical microscope. Cracks were counted, measured, and classified by type in each region of the cement mantle. Statistical indicators (in total and per unit volume of cement) were proposed that allow quantitative comparison. The method was first validated on two implant types with known clinical success rate, which were tested in vitro using a physiological loading profile (described in Part 1 of this work). The most relevant indicators were able to detect statistical differences between the two designs. Retrieved cement mantles (the same design as one of the in-vitro stems) from revision surgery were also processed with the same inspection method. Excellent qualitative and quantitative agreement was found between the in-vitro generated fatigue damage and the cracking pattern found in the ex-vivo retrieved cement mantles. This demonstrated the effectiveness of the cement inspection protocol and provided a further validation to the in-vitro testing method.     

The effect on the fatigue strength of bone cement of adding sodium fluoride

New bone cements that include several additives are currently being investigated and tested. One such additive is sodium fluoride (NaF), which promotes bone formation, facilitating implant integration and success. The influence of NaF on the fatigue performance of the cement as used in biomedical applications was tested in this paper. In fact fatigue failure of the cement mantle is a major factor limiting the longevity of a cemented implant. An experimental bone cement with added NaF (12 wt%) was investigated. The fatigue strength of the novel bone cement was evaluated in comparison with the cement without additives; fatigue tests were conducted according to current standards. The load levels were arranged based on a validated, statistically based optimization algorithm. The curve of stress against number of load cycles and the endurance limit were obtained and compared for both formulations. The results showed that the addition of NaF (12 wt%) to polymethylmethacrylate (PMMA) bone cement does not affect the fatigue resistance of the material. Sodium fluoride can safely be added to the bone cement without altering the fatigue performance of the PMMA bone cement.     

The contribution of the micropores in bone cement surface to generation of femoral stem wear in total hip replacement

Although cemented total hip replacement has long been recognized as a situation that can lead to wear, the wear generated on the femoral stem has not been well documented, especially with regard to how this wear is initiated and propagated. This present work aimed to further investigate this issue based on a comprehensive study on surface morphology of the femoral stem and the bone cement, which were collected from seven in vitro wear simulations. It was shown that the wear locations on the stem surface compared well with the results of retrieval studies, and the boundaries of the worn areas matched well the edges of the micropores present in the bone cement surface. This indicated that the micropores could potentially contribute to the generation of femoral stem wear. In addition, metallic debris was detected around the micropores from the simulation with increased loading cycles. However, no evidence of macro-cracks was observed across the cement mantle in spite of the presence of micro-cracks initiated at the edge of the micropores. This study demonstrated a possible cause for progression of femoral stem wear and it may have an important bearing on the long term durability of cemented hip prosthesis.     

Design revision of a partially cemented hip stem.

In a previous preclinical study the prototype version of a partially cemented hip stem, cement-locked uncemented (CLU) prosthesis, showed optimal primary stability and moderate stress shielding. However, numerical analysis suggested that the prototype design would induce relatively high stresses in the cement and a significant relative motion between cement and metal. The present study aimed to verify if these problems could be eliminated once the CLU design is improved. The revised design was analysed using a complete finite element model of an implanted human femur. To further strengthen the predictions of the finite element analysis, the cement damage induced by a severe load history was assessed experimentally in synthetic femurs implanted with the improved CLU stem or with a clinically successful fully cemented stem. The modifications made to the CLU stem design did not reduce its good primary stability but decreased the metal-cement relative micromotion. The same load induced stresses in the cement mantle of the improved CLU stem that were significantly lower than those predicted for the prototype design. Although the presence of modelling artefacts produced a highly localized stress peak of 13 MPa. 99 per cent of the cement volume was subjected to a principal tensile stress lower then 4 MPa. These levels of stress compare favourably with the tensile fatigue limit of the acrylic cement used in this study (9.7 MPa). The experimental results further supported these findings. The cemented stem showed a number of cracks per volume unit approximately ten times higher than the partially cemented stem under investigation.     

Femoral stem wear in cemented total hip replacement

The great success of cemented total hip replacement to treat patients with endstage osteoarthritis and osteonecrosis has been well documented. However, its long-term survivorship has been compromised by progressive development of aseptic loosening, and few hip prostheses could survive beyond 25 years. Aseptic loosening is mainly attributed to bone resorption which is activated by an in-vivo macrophage response to particulate debris generated by wear of the hip prosthesis. Theoretically, wear can occur not only at the articulating head-cup interface but also at other load-bearing surfaces, such as the stem-cement interface. Recently, great progress has been made in reducing wear at the head-cup interface through the introduction of new materials and improved manufacture; consequently femoral stem wear is considered to be playing an increasingly significant role in the overall wear of cemented total hip replacement. In this review article, the clinical incidences of femoral stem wear are comprehensively introduced, and its significance is highlighted as a source of generation of wear debris and corrosion products. Additionally, the relationship between femoral stem surface finish and femoral stem wear is discussed and the primary attempts to reproduce femoral stem wear through in-vitro wear testing are summarized. Furthermore, the initiation and propagation processes of femoral stem wear are also proposed and a better understanding of the issue is considered to be essential to reduce femoral stem wear and to improve the functionality of cemented total hip replacement.     

Understanding initiation and propagation of fretting wear on the femoral stem in total hip replacement

The femoral stem–bone cement interface in total hip replacement is supposed to experience low amplitude oscillatory micromotion under physiological loading, consequently leading to fretting wear on the stem surface, which nowadays is considered to play an important part in the overall wear of cemented prosthesis. However, initiation and propagation of fretting wear has been poorly documented and a better understanding concerning this issue has not been established as yet. This present study, on the basis of a profound surface investigation of a polished Exeter V40? femoral stem and Simplex P bone cement obtained from an in vitro wear simulation, demonstrated that the edges of the micropores in the cement surface matched pretty well to the boundaries of the worn areas on the stem surface. This would indicate that these micropores contributed significantly to the fretting process at the stem–cement interface.     

Interfacial Stress and Failure Analysis for Piston Ring Coatings under Dry Running Condition

A two-dimensional thermomechanical finite element model was developed to analyze the sliding process of a piston ring with coating sliding on cylinder liner under dry running condition. Thermal and mechanical effects were considered simultaneously in the model. The aim of the current work is to study the mechanisms of scuffing, failure, and seizure occurrence in a piston ring-liner system. It is shown that coating thickness plays an important role in the thermal and mechanical stress status at the contact area, coating bulk body, and interface of the coating and piston ring substrate. The coating thickness also exhibits a significant influence on the temperature rising at the contact area and interface of the ring coating and substrate, which could cause failure at the interface of the coating and substrate before it happens at the contact surface under some specific conditions. The results also show that thinner coating thickness in some specific range could have a higher possibility of cracking or failure. Furthermore, it is found that the thermal loading is the key cause of scuffing or failure of the piston ring coating.     

Deformation of the cement mantle of tibial components following total knee arthroplasty: a laboratory study.

An in vitro model has been developed to measure in-plane strains of the cement mantle, sandwiched between the tibial component and the underlying cancellous bone following total knee arthroplasty. Maximal in-plane strains occurred in the cement mantle below the contact points between the femoral and tibial components. These strains were significantly reduced by increasing the thickness of the polyethylene and even more impressively by metal backing. Eccentric loading, by as little as 5 degrees, increased the strains in the loaded compartment by 26 per cent and decreased those in the unloaded compartment by 62 per cent. The addition of torsion to axial loading did not significantly alter the principal direct strains or the principal shear strains. Although surface-covering tibial components have been advocated, continuous support of the cortical rim did not appear to be important in reducing cement mantle strains. While other studies have emphasized the critical stresses that may occur in the polyethylene tibial components of total knee implants, this study highlights the potential for localized cement fatigue with improperly sized components or with eccentric loading.     

Re-design of the Exeter V40 long-stem femoral component for ease of removal

Clinical experience shows that removal of the Exeter long-stem femoral component (220 mm, 240 mm, 260 mm) of total hip arthroplasty is extremely difficult, often requiring splitting of the femur. To identify the reason for this, measurements of stem geometry and force required to pull the stems out of the cement mantle were conducted on three original Exeter long-stem and one standard femoral components. All implants required an initial force of approximately 4 kN for release from the cement. The long-stem components then required much larger forces and hence much higher expenditure of energy to pull them clear of the cement. This was attributed to the reverse taper seen on the nominally cylindrical distal section of the long-stem components. Following re-design of the manufacturing process to ensure the taper continued to the implant's distal tip, four further implants were tested. These demonstrated the requirement for initial cement release but then required no further energy expenditure similar to the standard stem. This study clearly demonstrated that the original difficulty in removing these long stems was owing to the manufacturing process resulting in a reverse taper on the distal stem. The adoption of recommended manufacturing changes to ensure the taper continues to the distal tip removed this difficulty.     

Assessment of cement introduction and pressurization techniques

The objective of this study was to measure the medullary pressures generated during bone cement injection, pressurization and femoral prosthesis insertion. The measurements were recorded throughout the length of an in vitro femoral model while implanting a series of prosthetic hip stems using different pressurization techniques. The prostheses used were a Charnley 40 flanged stem (Johnson & Johnson DePuy International Limited), an Exeter No. 3 stem (Stryker Howmedica Osteonics, Howmedica International Limited), and a customized femoral component (Johnson & Johnson DePuy International Limited). The following parameters were derived from the pressure data recorded: peak pressure, decay pressure and duration above optimum pressure of 76 kPa to predict adequate penetration. The custom and Exeter stems generated cement pressures throughout the length of the cavity model that were predicted to achieve adequate bone cement interdigitation into cancellous bone. For all the conditions investigated in this study, when using the Charnley femoral component, an adequate level of cement pressurization was generated in the medial-distal portion of the femoral cavity. It is postulated that this could result in reduced integration of the cement mantle with bone and less effective transmission of functional loads applied during a patient's normal activity, postoperatively.     

Development of a computer model to predict pressure generation around hip replacement stems

Cemented fixation of hip replacements is the elective choice of many orthopaedic surgeons. The cement is an acrylic polymer which grouts the prostheses into the medullary cavity of the femur. Cement pressure is accepted as a significant parameter in determining the strength of cement/bone interfaces and hence preventing loosening of the prostheses. The aim of this work was to allow optimal design of the intramedullary stem of a hip prosthesis through knowledge of the flow characteristics of curing bone cement which can be used to predict pressures achieved during insertion of the femoral stem. The viscosity of the cement is a vital property determining the cement flow and hence cement interdigitation into bone. The apparent viscosities, nu(a), of three commercial bone cements were determined with respect to time by extrusion of the curing cement through a parallel die of known geometry under selected pressures. Theoretical models were developed and implemented in a computer program to describe cement flow in three models each of increasing complexity: (a) a simple parallel cylinder, (b) a tapered conical mandrel and (c) an actual femoral prosthesis, the latter models being complicated by extensional effects as annular areas increase. Predicted pressures were close to those measured experimentally, maximum pressures being in the range 10-160 kPa which may be compared with a threshold of 76 kPa proposed for effective interdigitation with cancellous bone. The theoretical model allows the prosthesis/bone geometry of an individual patient to be evaluated in terms of probable pressure distributions in the medullary cavity during cemented fixation and can guide stem design with reference to preparation of the medullary canal. It is proposed that these models may assist retrospective studies of failed components and contribute to implant selection, or to making informed selection from options in custom hip prosthesis designs to achieve optimum cement pressurization.     

Cementing techniques in hip resurfacing

The subject of the cementing technique in hip resurfacing has been poorly studied to date. The hip resurfacing prosthesis is unique in the family of cemented prostheses because the cement mantle is blind (hidden underneath the implant) and is radiographically obscured. This presents an immediate challenge to the surgeon at the time of surgery, but also has a longer-term implication in terms of lack of post-operative clinical observation. This should be compared with total hip replacement or total knee replacement where the cement mantle can at least be partially observed both intra- and post-operatively. With this in mind, the objective of this review is, firstly, to understand the cement mantles typically achieved in current clinical practice and, secondly, to identify those factors affecting the cement mantle and to consolidate them into an improved and reproducible cementing technique. The outcome of this work shows that the low-viscosity technique can commonly lead to excessive cement penetration in the proximal femoral head and an incompletely seated component, whereas a more consistent controlled cement mantle can be achieved with a high-viscosity cementing technique. Consequently, it is recommended that a high-viscosity technique should be used to minimize the build-up of excessive cement, to reduce the temperature created by the exothermic polymerization, and to help to ensure correct seating of the prosthesis. A combination of these factors is potentially critical to the clinical success of some articular surface replacement (ASR) procedures. It is important to note that we specifically studied the DePuy ASR system; therefore only the general principles (and not the specifics) of the cementing technique may apply to other resurfacing prostheses, because of differences in internal geometry, clearance, and surgical technique.     

Optimization of composite flywheel design

Composite flywheels are effective energy storage devices. The multi-rimmed flywheel configuration is first chosen for this study because of its superior operating characteristics and versatility. Then the Kevlar-49/epoxy system is adopted as the basic composite material, which is sandwiched between thin layers of rubber. A general stress analysis procedure is developed for the multi-rimmed structure and a computer routine is established to investigate the effects of various material and geometric parameters on the internal stress levels. A maximum stress criterion is used for failure of the composite flywheel. The basic goal of optimization is to achieve a stress distribution such that each ring in the multi-ringed structure will fail at approximately the same angular speed. The parameters varied in the optimization process include the thickness, Poisson's ratio, Young's modulus and density of the inter-ring material, the density and thickness of the composite material, and the thickness of the flywheel in the axial direction. The optimization process demonstrated that this procedure can be applied in general when other failure criteria or performance characteristics (such as maximum kinetic energy, kinetic energy per weight and kinetic energy per volume) are preferred.