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      Strains on the human femur after revision total knee arthroplasty: An in vitro study using digital image correlation

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          Abstract

          Pain at the tip of the stem of a knee prosthesis (End-of-Stem Pain) is a common problem in revision total knee arthroplasty (TKA). It may be caused by a problematic interaction between stem and bone, but the exact biomechanical correlate is still unknown. On top of this, there is no biomechanical study investigating End-of-Stem Pain at the distal femur using human specimens. Aim of this study was to find out whether the implantation of a revision total knee implant leads to high femoral surface strains at the tip of the stem, which the authors expect to be the biomechanical correlate of End-of-Stem Pain. We implanted 16 rotating hinge knee implants into 16 fresh-frozen human femora using the hybrid fixation technique and comparing two reaming protocols. Afterwards, surface strains on these femora were measured under dynamic load in two different load scenarios (climbing stairs and chair rising) using digital image correlation (DIC) and fracture patterns after overcritical load were analysed. Peak surface strains were found at the tip of the stem in several measurements in both load scenarios. There were no significant differences between the two compared groups (different trial sizes) regarding surface strains and fracture patterns. We conclude that implantation of a long intramedullary stem in revision TKA can lead to high surface strains at the tip of the stem that may be the correlate of femoral End-of-Stem Pain. This finding might allow for a targeted development of future stem designs that can lead to lower surface strains and therefore might reduce End-of-Stem Pain. Digital Image Correlation proved valid for the measurement of surface strains and can be used in the future to test new stem designs in vitro.

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          Most cited references27

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          Standardized Loads Acting in Knee Implants

          The loads acting in knee joints must be known for improving joint replacement, surgical procedures, physiotherapy, biomechanical computer simulations, and to advise patients with osteoarthritis or fractures about what activities to avoid. Such data would also allow verification of test standards for knee implants. This work analyzes data from 8 subjects with instrumented knee implants, which allowed measuring the contact forces and moments acting in the joint. The implants were powered inductively and the loads transmitted at radio frequency. The time courses of forces and moments during walking, stair climbing, and 6 more activities were averaged for subjects with I) average body weight and average load levels and II) high body weight and high load levels. During all investigated activities except jogging, the high force levels reached 3,372–4,218N. During slow jogging, they were up to 5,165N. The peak torque around the implant stem during walking was 10.5 Nm, which was higher than during all other activities including jogging. The transverse forces and the moments varied greatly between the subjects, especially during non-cyclic activities. The high load levels measured were mostly above those defined in the wear test ISO 14243. The loads defined in the ISO test standard should be adapted to the levels reported here. The new data will allow realistic investigations and improvements of joint replacement, surgical procedures for tendon repair, treatment of fractures, and others. Computer models of the load conditions in the lower extremities will become more realistic if the new data is used as a gold standard. However, due to the extreme individual variations of some load components, even the reported average load profiles can most likely not explain every failure of an implant or a surgical procedure.
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            Zonal fixation in revision total knee arthroplasty.

            Revision knee arthroplasty presents a number of challenges, not least of which is obtaining solid primary fixation of implants into host bone. Three anatomical zones exist within both femur and tibia which can be used to support revision implants. These consist of the joint surface or epiphysis, the metaphysis and the diaphysis. The methods by which fixation in each zone can be obtained are discussed. The authors suggest that solid fixation should be obtained in at least two of the three zones and emphasise the importance of pre-operative planning and implant selection.
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              Pain at the end of the stem after revision total knee arthroplasty.

              A consecutive series of patients undergoing revision total knee arthroplasty was studied prospectively. Clinical and radiographic assessment was performed preoperatively, 6 and 12 months postoperatively, and annually thereafter. Evaluation consisted of a Knee Society clinical score and assessment of patient satisfaction. In addition, patients completed drawings of their lower extremity regarding the location and severity of the pain they experienced preoperatively and at minimum 2-year followup (mean, 36 months; range, 24-48 months). Pain that was localized to the diaphyseal region of the femur or tibia on the drawing was defined as pain at the end of the stem. Clinical, radiographic, and pain drawing data were completed for patients who had 66 of 78 revision total knee arthroplasties performed during the time of the study (85%). All procedures were performed with the same implant system and instrumentation and included fluted cobalt-chrome stems for all patients in whom the stem was implanted without cement and slightly underreamed (press fit). All femoral components had the surface cemented with the stems press fit. Sixteen of the tibial stems were cemented fully, whereas the remaining 50 tibial components were cemented on the surface only with the stems press fit. Localized pain at the end of the stem was present on the femoral side in seven of 66 patients (11%) and in seven of 50 patients with press fit tibial stems (14%). Patients with pain at the end of the stem at 2 to 4 years postoperatively had significantly lower preoperative function scores and overall Knee Society clinical score. Postoperatively, patients with pain at the end of the stem had a significantly lower clinical score; however the postoperative function score and Knee Society clinical score were not significantly different than scores of patients who did not have pain at the end of the stem. There was no correlation between the stem diameter and the occurrence of pain; however, there was a trend for percent canal fill to be higher on the tibial side in patients with pain (71% versus 63%), but this was not statistically significant. Three of the 16 patients with cemented tibial stems (19%) experienced pain at the end of the stem. Patients with press fit stems who had pain at the end of the stem were more likely to express dissatisfaction with the surgical procedure than patients without pain at the end of the stem.
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                Author and article information

                Contributors
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: ResourcesRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLOS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                13 June 2024
                2024
                : 19
                : 6
                : e0305387
                Affiliations
                [1 ] Aesculap AG, Research & Development, Tuttlingen, Germany
                [2 ] Medical Department, Ludwig Maximilians University Munich, Munich, Germany
                [3 ] Orthopaedic Institute of Henderson, Henderson, Nevada, United States of America
                [4 ] Department of Orthopaedic Surgery, Medical University of Vienna, Vienna, Austria
                [5 ] Department of Orthopaedic and Trauma Surgery, Musculoskeletal University Center Munich (MUM), Ludwig Maximilians University Munich, Munich, Germany
                Gdańsk University of Technology: Politechnika Gdanska, POLAND
                Author notes

                Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Three of the authors (EMS, CS, TMG) are employees of Aesculap AG, a manufacturer of orthopedic implants. RT and AG are paid consultants for Aesculap AG. AG is receiving royalties from Aesculap AG and is an unpaid consultant for DePuy Synthes. He is member of the Austrian Orthopaedic Society and of ”AE – Arbeitsgemeinschaft Endoprothetik”. RT is receiving royalties from Conformis and is a paid consultant for this company. RT has stock or stock options in OnPoint Surgical and receives support from Conformis and ZimmerBiomet as Principal Investigator. TMG is scientific member of the working group „Evaluations & Studies“ of the German National Joint Registry „Endoprothesenregister Deutschland“ (EPRD), Advisory Board Member of the EU Consortium SPINNER “Next generation of repair materials & techniques for spine surgery” and Chair of working group I “Introduction of Innovations” of the ”European Federation of National Associations of Orthopaedics and Traumatology” (EFORT) “Implant & Patient Safety Initiative”. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                https://orcid.org/0000-0001-8443-8445
                Article
                PONE-D-23-39275
                10.1371/journal.pone.0305387
                11175519
                38870168
                46f5f9e1-cf72-4a77-bbce-408f6f3cdfde
                © 2024 Sporer et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 7 December 2023
                : 28 May 2024
                Page count
                Figures: 8, Tables: 2, Pages: 15
                Funding
                The author(s) received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Clinical Medicine
                Signs and Symptoms
                Pain
                Biology and Life Sciences
                Anatomy
                Musculoskeletal System
                Skeleton
                Femur
                Medicine and Health Sciences
                Anatomy
                Musculoskeletal System
                Skeleton
                Femur
                Biology and Life Sciences
                Bioengineering
                Biotechnology
                Medical Devices and Equipment
                Medical Implants
                Engineering and Technology
                Bioengineering
                Biotechnology
                Medical Devices and Equipment
                Medical Implants
                Medicine and Health Sciences
                Medical Devices and Equipment
                Medical Implants
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Trauma Medicine
                Traumatic Injury
                Bone Fracture
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Musculoskeletal System Procedures
                Arthroplasty
                Total Knee Arthroplasty
                Biology and Life Sciences
                Anatomy
                Musculoskeletal System
                Skeleton
                Skeletal Joints
                Knees
                Medicine and Health Sciences
                Anatomy
                Musculoskeletal System
                Skeleton
                Skeletal Joints
                Knees
                Biology and Life Sciences
                Anatomy
                Body Limbs
                Legs
                Knees
                Medicine and Health Sciences
                Anatomy
                Body Limbs
                Legs
                Knees
                Biology and Life Sciences
                Biomechanics
                Computer and Information Sciences
                Digital Imaging
                Custom metadata
                All relevant data are within the manuscript and its Supporting Information files.

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