Assessment of proximal femur microarchitecture using ultra-high field MRI at 7 Tesla.

PURPOSE: The purpose of this study was to investigate bone microarchitecture of cadaveric proximal femurs using ultra-high field (UHF) 7-Tesla magnetic resonance imaging (MRI) and to compare the corresponding metrics with failure load assessed during mechanical compression test and areal bone mineral density (ABMD) measured using dual-energy X-ray absorptiometry. MATERIALS AND METHODS: ABMD of ten proximal femurs from five cadavers (5 women; mean age=86.2±3.8 (SD) years; range: 82.5-90 years) were investigated using dual-energy X-ray absorptiometry and the bone volume fraction, trabecular thickness, trabecular spacing, fractal dimension, Euler characteristics, connectivity density and degree of anisotropy of each femur was quantified using UHF MRI. The whole set of specimens underwent mechanical compression tests to failure. The inter-rater reliability of microarchitecture characterization was assessed with the intraclass correlation coefficient (ICC). Associations were searched using correlation tests and multiple regression analysis. RESULTS: The inter-rater reliability for bone microarchitecture parameters measurement was good with ICC ranging from 0.80 and 0.91. ABMD and the whole set of microarchitecture metrics but connectivity density significantly correlated with failure load. Microarchitecture metrics correlated to each other but did not correlate with ABMD. Multiple regression analysis disclosed that the combination of microarchitecture metrics and ABMD improved the association with failure load. CONCLUSION: Femur bone microarchitecture metrics quantified using UHF MRI significantly correlated with biomechanical parameters. The multimodal assessment of ABMD and trabecular bone microarchitecture using UHF MRI provides more information about fracture risk of femoral bone and might be of interest for future investigations of patients with undetected osteoporosis.

Is anatomic acetabular orientation related to pelvic morphology? CT analysis of 150 healthy pelvises.

BACKGROUND: Links between sagittal spinal alignment and acetabular orientation attract considerable research attention with the goal of optimising prosthetic cup position. However, whether pelvic incidence (PI) is related to anatomic acetabular orientation remains unknown. We therefore conducted a radiological study with the following objectives: to look for correlations between PI and anatomic acetabular parameters; to describe the sacro-pubic angle (SPA), defined by fixed bony pelvic landmarks, and its relations with acetabular anteversion; and to determine whether anatomical parameters (PI and SPA) correlate with demographic characteristics. HYPOTHESIS: PI correlates with anatomical acetabular parameters. MATERIALS AND METHODS: We conducted a computed tomography (CT) study of the pelvises of 150 patients free of degenerative disease. Three parameters were measured: anatomic acetabular orientation in the Lewinnek reference plane, PI, and the SPA subtended by the line connecting the midpoint of the sacral endplate to the pubic symphysis and the anterior pelvic plane. Statistical tests were performed to look for correlations among these parameters. RESULTS: Intra-observer and inter-observer reproducibility was considered highly satisfactory (inter-class correlation coefficient, >86% and >82%, respectively). Mean PI was 58.6°±10.2° (range, 32.8°-97.6°), with no significant differences between genders or across age groups. Mean SPA was 34.7°±5.5° (range, 18.3°-49.8°). Mean anatomic acetabular anteversion (AAA) was greater in females (23.4°; range, 11.5°-34.5°) than in males (20°; range, 7.5°-34.5°) (P<0.001). PI did not correlate with any of the acetabular parameters (PI/AAA, r=0.8 and P=0.33; PI/acetabular inclination on the horizontal, r=-0.96 and P=0.24). SPA correlated significantly with both PI (r=0.33 and P<0.001) and AAA (r=0.33 and P<0.001). DISCUSSION: This CT study of normal pelvises showed that AAA was significantly greater in females and that SPA correlated significantly with both PI and acetabular anteversion. SPA could serve to define the "theoretical" AAA of each individual patient and could thus be incorporated into surgical planning protocols or intra-operative guidance methods for hip replacement surgery. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

The kinematic alignment technique for TKA reliably aligns the femoral component with the cylindrical axis.

INTRODUCTION: Kinematic alignment (KA) technique is an alternative technique for positioning a TKA, which aims a patient-specific implant positioning in order to reproduce the pre-arthritic knee anatomy. Because reliability in implant positioning is of interest to obtain reproducible good functional results, our study tests the hypothesis that the medial and lateral distal and posterior positions of the planned and surgically implanted kinematically aligned femoral component are similar. METHODS: Preoperative knee magnetic resonance imaging (MRI) and postoperative knee computed tomography (CT) of 13 patients implanted with a KA Persona® TKA (Zimmer, Warsaw, USA) using manual instrumentation (kinematically-aligned TKA procedure pack®, Zimmer Biomet, Warsaw, USA) were segmented to create 3D femoral models. The kinematic alignment position of the femoral component was planned on the 3D model created from the preoperative MRI. Differences in the positions of the planned and surgically implanted kinematically-aligned femoral component were determined with in-house analysis software. RESULTS: The average differences between the medial and lateral distal and posterior positions of the planned and surgically implanted kinematically-aligned femoral component were inferior to 1mm and no statistically significant. In terms of variability, 62% (8/13) of performed implants matched all four positions within 1.5mm, and the maximum difference was 3mm. CONCLUSION: In this small series, intraoperative kinematic positioning of the femoral component with the specific manual instrumentation closely matched the planned position, which suggests that this technique reliably aligned the flexion-extension axis of the femoral component to the cylindrical axis. LEVEL OF EVIDENCE: Level 3.

Biomechanical causes of trapeziometacarpal arthroplasty failure.

Trapeziometacarpal joint prosthesis revision has been widely reported, mainly due to loosening of the trapezium cup. Our hypothesis is that current prostheses do not sufficiently respect the kinematics of this joint. CT scan acquisitions enabled us to determine the position of the first metacarpal relative to the trapezium in three different characteristic postures, in subjects in different stages of arthrosis. A CAD model of a current prosthesis was inserted into the numerical 3D model of the joint under the different postures. In the numerical model, we observe penetration of the cup by the head of the prosthesis. This virtual penetration could, in vivo, amount to overstressing the prosthetic elements, which would lead to loosening of the cup or of the metacarpal stem and luxation of the prosthesis.

Can three-dimensional patient-specific cutting guides be used to achieve optimal correction for high tibial osteotomy? Pilot study.

INTRODUCTION: Treatment of medial tibiofemoral osteoarthritis with a high-tibial osteotomy (HTO) is most effective when the optimal angular correction is achieved. However, conventional instrumentation is limited when multiplanar correction is needed. HYPOTHESIS: Use of patient-specific cutting guides (PSCGs) for HTO provides an accurate correction (difference<2°) relative to the preoperative planning. MATERIALS AND METHODS: Between February 2014 and February 2015, 10 patients (mean age: 46 years [range: 31-59]; grade 1 or 2 osteoarthritis in Ahlbäck's classification) were included prospectively in this reliability and safety study. All patients were operated using the same medial opening-wedge osteotomy technique. Preoperative planning was based on long-leg radiographs and CT scans with 3D reconstruction. The PSGCs were used to align the osteotomy cut and position the screw holes for the plate. The desired correction was achieved in the three planes when the holes on the plate were aligned with the holes drilled based on the PSCG. Preoperatively, the mean HKA angle was 171.9° (range: 166-179°), the mean proximal tibial angle was 87° (86-88°) and the mean tibial slope was 7.8° (1-22°). The postoperative correction was compared to the planned correction using 3D CT scan transformations. Intraoperative and postoperative complications were assessed at a minimum follow-up of 1 year. RESULTS: The procedure was successfully carried out in all patients with the PSCGs. On postoperative long-leg radiographs, the mean HKA was 182.3° (180-185°); on the CT scan, the mean tibial mechanical angle was 94° (90-98°) and the mean tibial slope was 7.1° (4-11°). In 19 out of 20 postoperative HKA and slope measurements, the difference between the planned and achieved correction was <2° based on the 3D analysis of the three planes in space; in the other case, the slope was 13° instead of the planned 10°. The intra-class correlation coefficients between the postoperative and planned parameters were 0.98 [0.92-0.99] for the HKA and 0.96 [0.79-0.99] for the tibial slope. There were no surgical site infections; one patient had a postoperative hematoma that resolved spontaneously. DISCUSSION: The results of this study showed that use of PSCGs in HTO procedures helps to achieve optimal correction in a safe and reliable manner. LEVEL OF EVIDENCE: IV - Prospective cohort study.

Influence of the optical system and anatomic points on computer-assisted total knee arthroplasty.

BACKGROUND: For over a decade, computer-assisted orthopaedic surgery for total knee arthroplasty has been accepted as ensuring accurate implant alignment in the coronal plane. HYPOTHESIS: We hypothesised that lack of accuracy in skeletal landmark identification during the acquisition phase and/or measurement variability of the infrared optical system may limit the validity of the numerical information used to guide the surgical procedure. METHODS: We built a geometric model of a navigation system, with no preoperative image acquisition, to simulate the stages of the acquisition process. Random positions of each optical reflector center and anatomic acquisition point were generated within a sphere of predefined diameter. Based on the virtual geometric model and navigation process, we obtained 30,000 simulations using the Monte Carlo statistical method then computed the variability of the anatomic reference frames used to guide the bone cuts. Rotational variability (α, ß, γ) of the femoral and tibial landmarks reflected implant positioning errors in flexion-extension, valgus-varus, and rotation, respectively. RESULTS: Taking into account the uncertainties pertaining to the 3D infrared optical measurement system and to anatomic point acquisition, the femoral and tibial landmarks exhibited maximal alpha (flexion-extension), beta (valgus-varus), and gamma (axial rotation) errors of 1.65° (0.9°); 1.51° (0,98°), and 2.37° (3.84°), respectively. Variability of the infrared optical measurement system had no significant influence on femoro-tibial alignment angles. CONCLUSION: The results of a Monte Carlo simulation indicate a certain level of vulnerability of navigation systems for guiding position in rotation, contrasting with robustness for guiding sagittal and coronal alignments. LEVEL OF EVIDENCE: Level IV.

Trabecular bone remodelling under pathological conditions based on biochemical and mechanical processes involved in BMU activity.

In adulthood, bone tissue is continuously renewed by processes governed by basic multicellular units composed of osteocytes, osteoclasts and osteoblasts, which are subjected to local mechanical loads. Osteocytes are known to be integrated mechanosensors that regulate the activation of the osteoclasts and osteoblasts involved in bone resorption and apposition processes, respectively. After collagen tissue apposition, a process of collagen mineralisation takes place, gradually increasing the effective stiffness of bone. This study presents a new model based on physicochemical parameters involved in spongy bone remodelling under pathological conditions. Our model simulates the transient evolution of both geometry and effective Young's modulus of the trabeculae, also taking turnover into account. Various loads were applied on a trabecula in order to determine the evolution of bone volume fraction under pathological conditions. A parametric study performed on the model showed that one key parameter here is the kinetic constant of hydroxyapatite crystallisation. We subsequently tested our model on a pathological case approaching osteoporosis, involving a decrease in the number of viable osteocytes present in bone. The model converges to a lower value (- 5%) for bone volume fraction than with a normal quantity of osteocytes. This useful tool offers new perspectives for predicting bone remodelling deficits on a local scale in patients with pathological conditions such as osteoporosis and in bedridden patients, as well as for astronauts subjected to weightlessness in space.

Fracture following lower limb lengthening in children: a series of 58 patients.

INTRODUCTION: Fracture is one of the main complications following external fixator removal used in cases of progressive lower limb lengthening; rates as high as 50% are found in the literature. The aim of this study was to determine the factors influencing this complication. MATERIALS AND METHODS: One hundred and eleven cases of lower limb lengthening were performed in 58 patients (40 femurs and 71 tibias). The mean age at surgery was 10.1years old. Lengthening was performed in all cases with an external fixator alone, associated in 39.6% of cases with intramedullary nailing. The patients were divided into three groups according to disease etiology (congenital, achondroplasia and other). The fractures were classified according to the Simpson classification. RESULTS: Twenty fractures were recorded (18%). Sixteen fractures were found in patients with congenital disease, four with achondroplasia and none in the group of other etiologies. The fracture was more often in the femur (27.5%) than in the tibia (12.7%). DISCUSSION: The rate of fracture is influenced by different factors depending on the etiology of disease. In congenital diseases, the fracture rate is higher when there is lengthening of more than 15% of the initial length and a delay between surgery and the beginning of lengthening of less than 7days. In patients with achondroplasia, the influence of a relative percentage of lengthening is less important than in those with congenital disease. However, to avoid fractures, lengthening should not be started in children under the age of nine. Moreover, lengthening should begin at least 7days after the fixator has been placed. TYPE OF STUDY: Retrospective. LEVEL OF EVIDENCE: Level IV.

Computed tomography, histological and ultrasonic measurements of adolescent scoliotic rib hump geometrical and material properties.

In Adolescent Idiopathic Scoliosis (AIS), numerical models can enhance orthopaedic or surgical treatments and provide reliable insights into the mechanism of progression. Computational methods require knowledge of relevant parameters, such as the specific geometrical or material properties of the AIS rib, about which there is currently a lack of information. The aim of our study was to determine the geometrical and material properties (Young's modulus [E] and Poisson's ratio [ν]) for AIS rib bones. Twelve ribs extracted during gibbectomy on 15 and 17 year old girls were tested using computed tomography (CT) scanner, histology and ultrasonic scanner. The mean porosity (± standard deviation (SD)) is 1.35 (±0.52)% and the mean (±SD) bone mineral density is 2188 (±19)mmHA/cc. The cortical part of the AIS rib hump is found to be thicker than physiological values in the literature. To mimic the rib hump for an AIS girl, our results suggest that ribs should be modeled as hollow circular cylinders with a 10.40 (±1.02)mm external radius and 7.56mm (±0.75) internal radius, and material properties with a mean E of 14.9GPa (±2.6) and a mean ν of 0.26 (±0.08).

Combination of texture analysis and bone mineral density improves the prediction of fracture load in human femurs.

UNLABELLED: Twenty-one excised femurs were studied using (1) a high-resolution digital X-ray device to estimate three textural parameters, (2) dual-energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD), and (3) mechanical tests to failure. Textural parameters significantly correlated with BMD (p < 0.05) and bone strength (p < 0.05). Combining texture parameters and BMD significantly improved the fracture load prediction from adjusted r(2) = 0.74 to adjusted r(2) =0.82 (p < 0.05). INTRODUCTION: The purpose of this study is to determine if the combination of bone texture parameters using a new high-resolution X-ray device and BMD measurement by DXA provided a better prediction of femoral failure load than BMD evaluation alone. METHODS: The proximal ends of 21 excised femurs were studied using (1) a high-resolution digital X-ray device (BMA, D3A Medical Systems) to estimate three textural parameters: fractal parameter Hmean, co-occurrence, and run-length matrices, (2) DXA to measure BMD, and (3) mechanical tests to failure in a side-impact configuration. Regions of interest in the femoral neck, intertrochanteric region, and greater trochanter were selected for DXA and bone texture analysis. Every specimen was scanned twice with repositioning before mechanical testing to assess reproducibility using intraclass correlation coefficient (ICC) with 95% confidence interval. The prediction of femoral failure load was evaluated using multiple regression analysis. RESULTS: Thirteen femoral neck and 8 intertrochanteric fractures were observed with a mean failure load of 2,612 N (SD, 1,382 N). Fractal parameter Hmean, co-occurrence, and run-length matrices each significantly correlated with site-matched BMD (p < 0.05) and bone strength (p < 0.05). The ICC of the textural parameters varied between 0.65 and 0.90. Combining bone texture parameters and BMD significantly improved the fracture load prediction from adjusted r(2) =0.74 to adjusted r(2) = 0.82 (p < 0.05). CONCLUSION: In these excised femurs, the combination of bone texture parameters with BMD demonstrated a better performance in the failure load prediction than that of BMD alone.

Influence of cyclic bending loading on in vivo skeletal tissue regeneration from periosteal origin.

INTRODUCTION: Periosteum osteogenic and chondrogenic properties stimulate the proliferation then differentiation of mesenchymal precursor cells originating from its deeper layers and from neighboring host tissues. The local mechanical environment plays a role in regulating this differentiation of cells into lineages involved in the skeletal regeneration process. HYPOTHESIS: The aim of this experimental animal study is to explore the influence of cyclic high amplitude bending-loading on skeletal tissue regeneration. The hypothesis is that this mechanical loading modality can orient the skeletogenesis process towards the development of anatomical and histological articular structures. MATERIAL AND METHODS: A vascularised periosteal flap was transferred in close proximity to each knee joint line in 17 rabbits. On one side, the tibiofemoral joint space was bridged and loading occurred when the animal bent its knee during spontaneous locomotion. On the other side, the flap was placed 12 mm distal to the joint line producing no loading during bending. Tissue regeneration was chronologically analyzed on histologic samples taken from the 4th day to the 6th month. RESULTS: The structure and mechanical behavior of regenerating tissue evolved over time. As a result of the cyclic bending-loading regimen, cartilage tissue was maintained in specific areas of the regenerating tissue. When loading was discontinued, final osteogenic and fibrogenic differentiation occurred in the neoformed cartilage. Fissures developed in the cartilage aggregates resulting in pseudo-gaps suggesting similar processes to embryonic articular development. Ongoing mesenchymal stem cells stimulation was identified in the host tissues contiguous to the periosteal transfer. DISCUSSION: These results suggest that the pseudarthrosis concept should be reconsidered within the context of motion induced articular histogenesis.

A micromechanical model to predict damage and failure in biological tissues. Application to the ligament-to-bone attachment in the human knee joint.

Computational models are developed in injury biomechanics to assess lesions in biological tissues based on mechanical measurements. The linear mechanics of fracture theory (LMFT) is a common approach to establish injuries based on thresholds (such as force or strain thresholds) which are straightforward to implement and computationally efficient. However, LMFT does not apply to non-linear heterogeneous materials and does not have the ability to predict failure onset. This paper proposes the cohesive zone model theory (CZMT) as an alternative. CZMT focuses on the development of behaviour laws for crack initiation and propagation at an interface that apply within a fibrous material or at the interface between materials. With the view of evaluating CZMT for biological tissues, the model developed by Raous et al. [1999. A consistent model coupling adhesion, friction and unilateral contact. Comput. Methods Appl. Mech. Eng., 177, 383-399] was applied to the ligament-to-bone interface in the human knee joint. This model accounts for adhesion, friction and damage at the interface and provides a smooth transition from total adhesion to complete failure through the intensity of adhesion variable. A 2D finite element model was developed to mimic previous experiments, and the model parameters were determined using a dichotomy method. The model showed good results by its ability to predict damage. The extension to a 3D geometry, with an inverse problem approach, is, however, required to better estimate the model parameters values. Although it is computationally costly, CZMT supplements the improvements achieved in microimaging techniques to support the development of micro/macro approaches in biomechanical modelling.

Design parameters dependences on contact stress distribution in gait and jogging phases after total hip arthroplasty.

We have developed a mathematical model to calculate the contact stress distribution in total hip arthroplasty (THA) prosthesis between the articulating surfaces. The model uses the clearance between bearing surfaces as well as the inclination and thickness of the Ultra High Molecular Weight Poly-Ethylene (UHMWPE) cup to achieve this. We have used this mathematical model to contrast the maximal force during normal gait and during jogging. This is based on the assumption that the contact stress is proportional to the radial deformation of the cup. The results show that the magnitude of the maximal contact stress remains constant for inclination values in the range of [0-35 degrees ] and increase significantly with the cup clearance and liner thickness for inclination values in the range of [35-65 degrees ]. A major use for this model would be the calculation of spatial contact stress distribution during normal gait or jogging for different couples of bearing surfaces.