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Flashcards in Implant Technology Unit 3 Deck (136):
1

what are the main design difficulty for knee prostheses

- needs to have an acceptable replication of the motion of the natural joint

- sufficient stability w.out being so rigidly constratined in its motion that it resulst in high stresses at the bone-implant interfaces under lateral and twisting loads

2

what is the most successful knee protheses design to date

"total condylar" design

3

what keeps the knee joint stable

ligaments, posterior joint capsule and good musculature

soft tissues act together to hold the knee in place throughtout its range of motion

[knee prostheses must take in to account the ligaments]

4

what do the collateral and cruciate ligaments work together to prevent

subluxation

5

what are the main ligaments of the knee and their function

Anterior cruciate ligament (ACL): resists posterior subluxation of the femur

Posterior cruciate ligament (PCL): resists anterior subluxation of the femur

Lateral collateral ligament (LCL): resists adduction of the joint

Medial collateral ligament (MCL): resists abduction of the joint

All the ligaments act together to limit distraction of the knee

All the ligaments act together to limit long axis rotation of the joint

6

what is the function of the posterior capsule

resist hyper-extension

7

what are the ACL and PCL named in relation too

their attachment to the tibia

8

what would happen if there was no ACL and no PCL

no ACL = femur can slide backwards over tibia

no PCL = femur can slide excessively forward

9

what is important for the surgeon to do in a knee replacement

correct ligament imbalance and looseness

if ligaments are damaged or removed during knee replacements surgery, the resulsting loss of stability must be compensated for in the design of the prosthetic knee

10

what does subluxation of a joint mean

partial or complete dislocation of a joint

11

what type of knee subluxation does ACL prevent

anterior subluxation of the tibia

[posterior subluxation of the femur = same thing]

12

knee ligaments move isometrially, what does this mean

they keep the same lenght as they move and do not lengthen or shorten

13

what happens to the axis of rotation in the knee as it flexes

axis of rotation changes

known as instantaneous centre of rotation as it changes as every instant of motion

moves posteriorly as knee rotates

[screw-home mechanism which follows a spiral motion]

14

what is the shape of the tibia plateau

medial compartment is slightly concave [lower at the centre than at the edges]

lateral compartment is convex

15

what is the motion at the knee joint as it flexes and extends

knee extends - tibia rotates externally

knee flexes - tibia rotates internally

[at full extension rotation is restricted by interlocking femoral and tibial condyles]

16

what is the name of the mechanism that desribes the movement of the knee

screw home mechanism

17

what does the four bar linkage cruciate mechanism do

constrains the motion of the femur on the tibia so that there is a combo of rolling and sliding motion

18

if the radius of the posterior part of the femoral condule is 22mm and the knee flexion is 140 degrees - calculate the lenght of the arc

s = [2 x pie x radius] x 140/360

radius in this case would be 22mm

s = 54mm

19

what does the limit to rolling distance in the knee prevent

[Why does the femur not roll off the tibia as the knee flexes?]

controls the position of the most posterior point of the centre of rotation

so enabling the knee to flex fully w/out rolling up against the posterior capsule

[cruciate ligamenst and joint capsule prevents it from doing so]

20

How does the position of the instantaneous centre of rotation change as the knee moves from extension to flexion?

It moves posteriorly by upwards of 10 mm and distally by a few mm

21

what force is the knee joint normally under and why is the magnitude greater than that of the body weight

compression

forces much higher than the body weight due to the combined effect of these gravitational forces, the contracting forces of the muscle and the balancing loads of the ligaments

joint force ranges from 2 to 6 times body weight under normal daily activity

22

since the knee is under mainly compressive load, what does the mean for designs of prostheses

that cement is a good option as it is very effective in compression

23

during the STANCE phase of gait what forces are seen at the knee

[GRF = ground reaction force]

[BW = body weight]

- vertical component of GRF just exceeds body weight during stance phase

- transmitted to the knee

- compressive force due to the action of quadriceps acting via patellar ligament generates max force of about 3 x BW

- GRF is about 1 X BW

- Resultant joint reaction force = 4 x BW

24

there is a fore-aft ground reaction force component of up to 20% body weight which is also transmitted to the joint - what has to work to counter act this

the cruciate ligaments

[where the forward component of the load acting on the femur tends to push it forwards over the tibia and the PCL restrains this movement]

25

what is the other component of GRF whilst walking

a horizontal component directed medially causing an adduction moment

this generates a turning moment on the knee

typically about 5% of body weight

[must be balanced by the muscles and ligaments]

26

what happens to the load distribution due to an adduction moment caused by medially acting horizontal GRF

the load distribution shifts such that the greater the horizontal force, the greater the load transferred from the lateral compartment to the medial compartment of the joint

27

what happens when it is a low magnitude sideways medial reaction force [like those that occur during gait]

the quadriceps muscle acting via the patellar tendon ligament, can pull the joint together hard enough to keep both condylar surfaces in contact with the tibial plateau

28

what happens when the horizontal force increases due to more strenuous activities

becomes necessary to use hamstrings as well, thus increasing joint reaction force

29

what happens as the load continues to increase

the muscles do not have strenght to maintain contact at both condylar surfaces

lateral side loses contact and all the load is taken by the MEDIAL condyle

stability of the joint relies on the LATERAL collateral ligament which is required to balance the turning moment due to sideways acting force

30

what implications does the high loads acting on the medial compartment of the knee have on joint replacement designs

the tibial component needs to be able to transfer high medial compartment loads on its upper surface to the underlying bone w/out causing high compressive stresses which could cause the bone to fail

31

what would be required if the collateral ligaments where absent or cannot be retained during surgery

the replacement joint would be required to provide all the lateral stability

linked prosthesis, such as a hinge, would be required

32

what other forces is the knee require to resist

axially generated torques which try to twist the knee axially and, if excessive can cause a meniscus to tear

[stability once again relies on ligaments, replacement joint would have to do the same]

33

why does the joint reaction force at the knee increases as the sideways horizontal component of the ground reaction force increases

as force increases, a greater patella tendon force and a greater hamstring force are required to balance its effects which adds to the joint reaction force

34

What adverse effect could a high contact force in the medial compartment of the knee have on a joint replacement

cause high local stresses medially which could cause the underlying cancellous bone to fail

35

what is the general criteria for knee implants

- Be tolerated within the human body with no short term and little long term risk of adverse toxic effects such as carcinogenesis

- Achieve its aim of relieving pain and restoring the activities of daily living.

- Last a reasonable length of time which ideally should extend beyond the expected life span of the individual patient without the need for revision

- Be insertable by a competent surgeon of average ability such that a predictable outcome can reasonably be guaranteed.

- cost-effective

36

what are most commerically avaliable knee replacements made of

femoral component - cobalt chrome

tibial component - HDP

37

what is the minimum functional kinematic requirements of a knee replacement

- should fully extend to 180° at which point the patient should be able to stand without the need for muscular effort by the quadriceps.

- collateral ligaments and posterior capsule must be intact to enable screw home mechanism or be designed with alternative stabilising mechanism

- should flex to 90 degrees [allows person to walk up/down stairs]

- should permit slight axial rotation as the knee extends to maintain natural ligamet tension throughout flexion and extension

38

what is essential for the surgeon to do in a knee replacement

[apart from balance the ligaments]

essential that the two bearing surfaces are cut parallel

means the tibial surface is maintained at right angles to the tibial shaft, parallel w/ the ground when weight bearing

femoral cut will have to be at an angle to compensate for the natural angulation of the femur relative to the tibia
[cut needs to be 6 or 7 degrees relative to axis of femur]

39

what needs to be removed to ensure that the replacement knee can fully extend

posterior capsule of the knee off the back of the femur

40

how should collateral ligaments be balanced

balanced in tension so that the bony cuts are parallel when the bones are stretched apart by the new joint and there is no tendency of the joint to open more medially than laterally or vice versa

41

what is the easiest method to balance the ligaments

lenghten tightened ligaments to match slack ones

42

what is the controversy of the cost of knee replacements compared to hips

they cost on average 5 times as much as hips

43

what is meant by the word "constraint" in context of modern knee replacement

relationship between tibial and femoral bearing surface geometrics

44

what are the functional design features of knee replacements

- to provide an acceptable ROM of joint combined with good stability under loading

- screw home mechanism or some equilavent that allows standing up straight w/out the need to apply the quad muscle

- if 1 or more ligaments cannot be used, the prosthesis must be designed to compensate for the functional loss

45

what knee implant design is used if there is no ligaments intact

hinged prosthesis
- constrains the motion of the knee to a single axis of rotation with total stability

46

what is the problem with hinged joint prosthesis

has no give under lateral and long axis rotational loading

transmits the high shear forces associated w/ these loadings to the implant-cement and cement-bone interfaces

47

what condition often causes the destruction or degradation of the ACL

OA

- PCL is preserved more often that not

48

how does the preservation of the PCL influence the knee replacement design used

PCL controls rolling motion of the tibia

implant depends of whether PCL is retained or removed

if not retained it is necessary to substitute a mechanism within the prosthesis

49

why is it important to find some mechanism to replace PCL

enables the femur to rotate on the tibial plateau w/out sliding too far posteriorly

thus allowing a good range of knee flexion w/out restriction of movement due to soft tissue

50

what are the theoretical advantages of retaining the PCL

provides some degree of A-P knee stability and may preserve some proprioceptic activity

normal gait unaffected w/out PCL but walking on stairs more stable w/ PCL

51

what are disadv of retaining PCL

constricts a free surgical dissection of posterior capsule
- may limit full exntesion
- enourages femoral component to slide over tibial bearing which may have deterimental surface wear effects

removal of PCL allows the use of more congruent joint surfaces
- reduces HDP wear

removal may correct deformity also

[some surgeons prefer to remove PCL]

52

what is the design of prostheses that retain the PCL and what aspect of the surgery is difficult

have fairly flat tibial plateau like that on natural tibia

need to position tibial plataeu accurately to get the PCL to work as it should

if PCL is too loose - allows forward movement of the femur on the tibia so that normal rolling back motion no longer works

if PCL is too tight - there will be restricted degree of flexion, excessive rolling back of the femur on the tibia. Also compression of the 2 prothetic joint surfaces together posteriorly, causing high contact stresses

53

what problems are associated with PCL retaining prosthesis designs

HDP wear problems
Fatigue problems

54

Why does a replacement knee need to have a fairly flat tibial plateau when the PCL is retained

Because the PCL could otherwise become lax or too tight during flexion- extension movement.

55

what are the 3 important mechanical factors affecting surface shape and degree of motion

- effect of constraint on load transmission and generation of high shear stresses

- effect of surface contact on WEAR of HDP tibial component

- effect of surface contact area on the STRESSES of HDP tibial component

56

HDP is known for its adverse affects of its wear debris on bone tissue, leading to bone resorption - what is another of its side effects

surface becomes stiffer due to increase in density after sterilisation w/ gamma radiation and over time after implantation due to oxidisation

greater stiffness increases joint contact stress under loading therefore makes the HDP tibial component more prone to wear

57

how does the HDP (tibial component) and CoCr (femoral component) wear related to each other

HDP being softer material wears out first while CoCr is hardly affected by wear

HDP component is also prone to fatigue failure under loading >> eventually results in failure of the joint

HDP fatigue and wear are more of a problem in the knee than in the hip due to the smaller bearing surface contact area, so stresses in the material are higher

58

effect of degree of constraint on load transmission

Unit 3 page 15

59

what knee replacment joint designs are most representative of a natural knee joint

The femoral component should be fairly circular and the joint should only partially constrained.

60

if the prosthesis does not loosen or the components break, and there are no medical problems i.e. infection - then what determines the useful life of a prothesis

rate of wear of the HDP component

61

what is the equation for volume of wear

v = c.N.s / p

v = volume of wear
c = coefficient of wear/constant
N = applied load across bearing surface (normal load)
s = distance that the bearing slides
p = hardness of the surface being worn

62

what components of the equation for volume of wear in the cobalt chrome femoral component constant

c = coefficient of wear/constant

p = hardness of the surface being worn

63

for a given activity N is defined, so how can the formula be simplified for the purpose of comparing the wear rate of different surface geometries

v = K x s

K = some constant

thus, volume of wear material produced is proportional to the sliding distance moved

64

what is the sliding distance to achieve a rotation of theta degrees proportional to

the radius of the bearing,

as s = r x theta

[r = d / 2]

thus v = K x d/2 x theta

65

what does this relationship between radius and sliding distance mean for volume of wear

that a smaller diameter of bearing will reduce the volume of wear material

66

what value determines the life of the HDP bearing

the rate of DEPTH of wear

[not the rate of volume of wear]

67

what is the equation for depth of wear

v = A x t

v = volume of wear
A = area of contact
t = depth of wear

thus depth of wear can be reduced by having a large surface area of contact

68

what is the area of contact equal too

lenght of the arc x width of bearing

s x W

[s = d x theta]

69

why is the width of the bearing increased to increase area of contact rather than the lenght of the arc

increasing d [to increase s] increases the rate of wear so it is preferable to increase W

70

how is volume of rate of wear reduced and how is depth of wear reduced

to minimise rate of production of wear particles i.e. volume rate of wear, the SLIDING distance of the bearing surfaces is minimised


to reduce rate of depth of wear the contact area should be increased, by having a wide bearing

71

what can HDP fatigue cause

premature wear and subsurface lamination cracking at the joint

72

if a model knee prosthesis had a lower contact area than another, what would it be more at risk too

contact stresses much higher and therefore will be more prone to fatigue failure under the cyclical loading that occurs during flexion and extension of a loaded knee

[thus larger contact area superior]

73

the moment due to lateral GRF can cause one of the condyles to lift off and place all the load on the other one - what prostheses design is suited to deal with this

one with a curved edge to spread out the load

the curved surface maintains a higher contact area when horiztonal and tilted

74

why is the HDP tibial component prone to fatigue failure

Because it experiences repetitive loading / unloading and tensile / compressive loading cycles.

75

what are the important design features that influence prosthesis contact stress and load transfer [affecting the interface stresses between the tibial component and the underlying bone]

- HDP surface shape

- thickness of HDP component

- whether or not HDP has a metal backing plate

- whether the tibial component has a stem

- stiffness of the HDP material

76

how does the thickness of the HDP component and stress relate

the thinner the HDP component, the greater it is stressed

due to the stress being unable to be distribute evenly in the material

77

what is the minimum thickness of HDP tibial component w/out metal backing plate

8mm thickness

if a metal tray is used, HDP tibial component can be thinner to limit total thickness

78

when is metal backing of value

when the soft tissue tightness forces the choice of a prosthesis of minimum thickness upon the surgeon

79

why is the ability to vary the tibial height in a prosthesis important

essential to ligament balancing

[If the joint is to be compressed its ligaments must be tight, or at least maintained at a length that does not allow the joint to open up medially or laterally when loaded with a lateral turning moment]

80

how does the natural tibial plateau distribute load and how does this compare to the replacement tibial plateau

- takes most of the load on the medial side (at least 60% but sometimes more)

- replacement tibial plateau will be similarly loaded

- medial edge of the plateau will be more highly stressed thus transferring a higher load and stress to underlying bone than on the lateral side

- load is taken proximally by cancellous bone only and is transferred to cortical bone more distally

81

what is the tibial backing tray under the HDP tibial component function

to distribute high contact stresses under the condyles in order to provide an even loading on the bone beneath it

conc of load on the top surface of the HDP is spread out over the contact area w/ bone, due to the high stiffness of the metal plate

82

what is the main disadvantage seen in tibial backing metal trays

- occurs if knee is loaded unevenly

[normally it is the medial side that takes largest proportion of the load]

- stress concentration will be greater in the underlying medial bone

- also tensile stresses arising between the plate and the bone laterally [higher tensile stresses than using an all-HDP component]

- the bone cement will not tolerate the tensile stresses well

83

most tibial components have a small peg between 30-50mm long - what is the function of this

found that tibial components loosen mainly from sinkage in the bone, probably due to gradual done failure from high localised stresses

providing central peg reduces the incidence of loosening

[peg helps reduce the high contact stresses due to uneven loading that could cause the bone to fail and subside]

84

how does the young's modulus of the HDP component affect the contact stress

higher the young's modulus of HDP the greater the contact stress

85

4 design features of a tibial component that affect the magnitude of the stresses on the underlying bone.

thickness of HDP component

whether or not HDP has a metal backing plate

whether tibial component has a stem

stiffness of a material

86

advantage of a modular tibial component that can take different thicknesses of tibial insert.

Ligament tension can be set correctly be selecting the right thickness of insert

87

advantage and one possible disadvantage of using a metal backed tibial component.

adv
- provides a more even loading distribution on the underlyning bone

disadv
- may cause excessively high stresses on the medial bone if the knee is unevenly loaded as the metal plate is stiff
- thus does not spread out a high contact load as the less stiff HDP

88

what are the headings for the priniciple features of knee prostheses

femoral component shape

tibial surface shape

methods of anchorage of components

89

how does the femoral component shape of the prostheses vary from the shape of the normal knee

left and right side of the prostheses are symmetrical

in a normal knee, the medial condyle is larger than the lateral condyle

90

what is the main disadvantage of trying to copy the knee's natural asymmetry

doubles the size of the required inventory of components required to carry out knee joint replacement

91

what does the anterior part of the femoral component curvature accommodate

the movement of the patella during flexion and extension

92

what largely determines the degree of constraint of a knee prosthesis

the surface shape design of the tibial component

93

what shape of tibial component is favoured and why

partially constrained shapes, used in total condylar prostheses

they provide the required degree of functional movement and do not suffer greatly from loosening due to overstressing and limit the range of sliding motion to help reduce wear

94

what tibial component shape is needed if the PCL is retained

flattish surface profile

95

what tibial component shape is required if the PCL is not retained

surface shape which is dished in all directions

96

what does the posterior stabilised design mechanism need to be able to do in knee prostheses

- prevent posterior femoral subluxation of the femur over the tibia

- cause the femur to "roll back" as it flexes

97

what is an example of a knee prostheses which has a posterior stabilised design mechanism

"cam" shaped designs
- employ more of a gradual curve on the tibial component
- produces a smoother transition to the roll back position in flexion

98

if a knee joint replacement is properly aligned and the ligaments balanced, how should the femoral and tibial component rest

the femoral and tibial components should be maintained in compression throughtout the range of joint motion

[if tibial component is loaded evenly]

[therefore use of PMMA cement should provide good anchorage]

99

what will happen to the tibial component if only one condyle is loaded

due to a lateral turning moment, the other side will tend to lift off and give rise to tensile stress in any bonding material between tibial tray and underlying bone

100

what can cause uneven loading in the tibial component

imbalance in the ligaments will result in uneven loading and greater stresses

101

what can be added to the undersurface of the tibial component to give additional rotatory control

projections built into the undersurface

102

when are cementless knee bone protheses used

PCL-retaining knee protheses

103

What is the difference between a standard total condylar prosthesis and a posterior stabilised prosthesis?

posterior stabilised version has a stability device to substitute for the lost PCL.

104

What features of a knee prosthesis provide rotational stability

Projections on the undersurface of the tibial or femoral components, the stem (if present), screws (if present).

105

What additional fixation methods are required for cementless knee prostheses

Tibial component
- requires screw fixation to a stem

Femoral Component
- press fit
- use of pegs

106

what part of the knee can be the principal source of pain in OA in the knee and how can this be solved in a TKR

patello-femoral joint
- a total knee replacement w/out specifically resurfacing patella can cause total pain relief

- in a TKR the patellar bearing surface of the femur is replaced, so may be regarded as a form of hemi-arthroplasty

107

what is the biomechanic function of the patella

provides a better leverage for patellar tendon, so flexion movement can be provided by lower patellar force than w/out

thus, causes lower joint reaction force, so component wear and loading are reduced

108

what needs to be taken in to account when designing a replacement patella

reaction force of the patella against the femur can be as high as 4-5 times body weight

fractures of replacement patella are not common but can occur in more active patients

109

how is the femoral component designed to accomodate the patella

anterior part is grooved in the frontal plane to better accommodate the patella and to encourage patellar tracking

110

what is the replacement patellar bearing surface made from

HDP
- so excessive wear needs to be taken into account

111

what can affect the wear rate

shape of the contact surface of the patella

conforming shapes that match the femur wear less than convex (non-conforming) shapes

112

why is wear shown to be worse in metal backed patella

as HDP is insufficiently thick to distribute the loads and is prone to higher contact stresses than the less rigid all-HDP component

113

some studies have shown that patella replacements have what benefits

patients complained of less pain

also found the knee to be stronger in flexion for demanding activities such as stair climbing

114

why would the patella be made thinner in some cases

to achieve closure of the surgical wound after TKR

use of an HDP patellar replacement component can help make it thinner

115

how might RA and OA differ in regards to the whether to replace the patella

RA preferable to replace all joint surfaces due to involvement of whole joint

OA, patella resurface may be appropriate for some stiff OA knees with deformed patellae

116

how does absence of patella affect knee extension force

The patella tendon lever arm is reduced, requiring a greater quadriceps force. This adds to the patello-femoral joint reaction force.

117

why is metal backed patella replacement not used

The HDP is too thin to prevent high stresses in the material, which can result in extremely fast wear.

118

what do replacement mescius bearing consist of

a metal femoral component, a metal tibial component and an HDP meniscus

119

why is the metal meniscal bearing designed the way it is

large contact area to reduce contact stresses

low degree of constraint to avoid high stresses, other than compression, during load transfer

[actual designs of meniscal bearings vary]

120

how does the meniscus move during flexion/extension and long axis rotation/lateral movement

extension
- moves forward

flexion
- moves backwards

long axis rotation and lateral movement
- meniscus slides at the lower bearing surface

121

what is the principle disadvantage of meniscal designs

increased technical difficulty in achieving ligamentous balance and overall alignment w/out risking dislocation of the moving bearing

[newer designs reduce the risk of dislocation by limiting sliding motion of the menisci]

122

what does a hemi-arthroplasty consist of in the knee

replacing only one side of the tibio-femoral joint - either medial or lateral side

123

when is a hemi-athroplasty done

as an alternative to osteotomy in younger patients who have painful and deformed joints that is not severe enough to warrant TKR but too advanced disease process to permit osteotomy

124

what are both osteotomy and hemi-athroplasty surgeries designed to do

restore joint aligment to normal so to balance the forces on the medial and lateral sides of the joint

125

what is the design of a hemi-athroplasty

1) femoral component
- must be broad enough to cap damaged condyle
- small pegs or lugs are used to limit loss of bone stock in case of need of revision op

2) two lugs are required to counter any tendency to rotate

3) unicompartmental meniscal bearings
- require removal of more bone in order to fit

4) HDP thickness of at least 8mm to prevent excessive wear

126

TKR fail through wear, loosening and infection - why are revision knee surgeries difficult

same problem as seen in hip revision surgeries
- loss of bone stock for anchoring the revision prosthesis

problems trying to achieve ligamentous balance especially when ligaments may have been destroyed in loosening process

127

what is the design of revision knee prostheses

bearing surface w/ high degree of constraint built into the tibio-femoral bearing

can be provided by having high peg projection above tibial plateau which is partially captured by a central groove in the femoral component

128

why are linked hinged designs unsatisfactory

their inability to accommodaet axially generated torque w/out putting great strain on the bone prosthesis interface

129

what is the function of the central peg in revision knee prostheses

secondary constraint - fail safe mechanism - to offer stability only if the joint is loaded heavily either medially or laterally

130

if there is considerbale bone loss, what is needed in knee revision prostheses

modular components which are flat or wedge shaped that can be added to prosthesis to fill the gaps and allow prosthesis to rest on the bone

- called augmentation blocks

131

what can be done for knee revision prostheses if there is gross bone loss

intramedullary stems may be needed to get some degree of anchorage

stems need to be fixed initimately within the long bone medullae of the femur and tibia

132

one advantage and one disadvantage of using meniscal bearing knee prostheses.

Advantage
- lowers contact stresses.

Disadvantages
- requires removal of more bone, more difficult operation to perform.

133

why are two pegs commonly used on unicompartmental surface replacement

resist the tendency to rotate under torsional loading.

134

what is the main problem with knee replacements

HDP wear particles limit the knee replacement longevity

135

what does anchorage depend on

converting the axial loads into hoop stresses at the stem-bone interface

136

why is HDP fatigue and wear more of a problem in the knee than in the hip

smaller bearing surface contact area
so stresses in the material are higher