To overcome the limitations of the traditional 3D fluoroscopic analysis of the joint kinematics in TKA patients and to analyze more reliably contact patterns at these joints, an innovative technique was developed based on FE models. A sensitivity analysis and an experimental validation were performed and reported. In vivo 3D kinematics obtained by fluoroscopy during chair rising-sitting, stair climbing, and step up-down from five patients with a TKA were used as input for these models. The FE technique reproduced well the contact points displacement derived from fluoroscopy but with smoother, more credible and consistent patterns. In addition, for the first time, the models enabled the in vivo analysis of the contact between the femoral cam and the tibial post. Both the condylar and the post-cam contact patterns supported the design features of the analyzed knee implant.
A number of shortcuts were taken in FE modeling to make these calculations feasible and reliable at the same time. The 2-mm constant penetration was taken as a compromise solution between opposite factors after a series of preparatory tests: to avoid separation between the femoral component and insert (which produces no contact estimation during the analysis), a large depth would be required; to reduce vibration effects and the relevant large increase of computational time, a small depth would be recommended. With the penetration used, no relevant differences in the contact point locations were found. Two different criteria were adopted to determine contact between the post and the cam because we wanted to exclude numerical artifacts inherent to FE modeling where a continuous body is discretized in separate elements. This can lead either to virtual contact between single nodes, which is not realistic, or to extremely low pressure values, which are irrelevant. To exclude the former error, we defined a small area threshold; to exclude the latter error, we defined a lower contact pressure threshold. An additional weakness of the study is the limited size of the patient population, although the main aim was to propose and test the technique first; more consistent and robust clinical analyses can now follow. Furthermore, also the acquisition by means of single-plane fluoroscopy could represent a limitation to the study. Nevertheless, past and recent studies have demonstrated the reliability and repeatability of the fluoroscopic technique we utilized [7, 15, 16].
A sensitivity analysis of the technique used was performed. As expected, the intrinsic error of single-plane fluoroscopy in the prosthesis component positioning, particularly in the ML direction, resulted in a large difference of the condylar contact point locations. Therefore, a number of modifications were made. The complexity of the original shapes of the polyethylene insert was replaced by two independent boxes and a single post. Appropriate mechanical characteristics of the box material were chosen to avoid vibrational effects and distortion of elements and to reduce computational time. An experimental test proved the validity of this approach.
This study is innovative in its combination of in vivo kinematics and FE analysis. The relative motion of the components is the most critical input for the models, considerably affecting the final results. Relative movement data are usually taken from measurements performed with external markers, which are unreliable. On the other hand, fluoroscopy-based kinematics and contact analyses are performed frequently without the support of prosthesis-specific models for the contacts. Our results support the reliability of the traditional measurements based only on fluoroscopy. Nevertheless, the results also demonstrate the necessity of FE models for a more realistic estimation of the condylar contacts and for additional information about in vivo post-cam engagement.
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