The influence of tibial component malalignment on bone strain in revision total knee replacement

Abstract

Revision total knee replacement is a challenging surgical procedure typically associated with significant loss of bone stock in the proximal tibia. To increase the fixation stability, extended stems are frequently used for the tibial component in revision surgery. The design of the tibial stem influences the load transfer from tibial component to the surrounding bone and is cited as a possible cause for the clinically reported pain in the location of the stem-end. This study aimed to analyse the strain distribution of a fully cemented revision tibial component with a validated finite element model. The model was developed from a scanned composite tibia (Sawbones), with an implanted, fully cemented stemmed tibial component aligned to the mechanical axis of the tibia. Loading was applied to the tibial component with mediolateral compartment load distributions of 60:40 and 80:20. Three strain gauged composite tibias with implanted tibial components of the same design using the same loading distribution were tested to obtain experimental strains at five locations in the proximal tibia. The finite element model developed was validated against strain measurements obtained in the experimental study. The strains displayed similar patterns (R² = 0.988) and magnitudes with those predicted from the finite element model. The displacement of the stem-end from the natural mechanical axis in the finite element model demonstrated increased strains in the stem-end region with a close proximity of the distal stem with the cortical bone. The simulation of a mediolateral compartment load of 80:20 developed peak cortical strain values on the posterior-medial side beneath the stem. This may possibly be related to the clinically reported pain at the stem-end. Furthermore, stem positioning in close proximity or contact with the posterior cortical bone is a contributory factor for an increase in distal strain.

Keywords

Revision total knee replacement arthroplasty finite element experimental validation cemented implant

Get full access to this article

View all access options for this article.

References

National Joint Registry of England, Wales and Northern Ireland. 10th annual report 2013, http://www.njrcentre.org.uk/njrcentre/Portals/0/Documents/England/Reports/10th_annual_report/NJR%2010th%20Annual%20Report%202013%20B.pdf (accessed 12 May 2014).

Carr

Robertsson

Graves

. Knee replacement. Lancet 2012; 379(9823): 1331–1340.

Daines

Dennis

. Management of bone defects in revision total knee arthroplasty. J Bone Joint Surg Am 2012; 94(12): 1131–1139.

Huten

. Femorotibial bone loss during revision total knee arthroplasty. Orthop Traumatol Surg Res 2013; 99(1): S22–S33.

Barrack

Rorabeck

Burt

. Pain at the end of the stem after revision total knee arthroplasty. Clin Orthop Relat Res 1999; 367: 216–225.

Barrack

Stanley

Burt

. The effect of stem design on end-of-stem pain in revision total knee arthroplasty. J Arthroplasty 2004; 19(7): 119–124.

Peters

Erickson

Kloepper

. Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement. J Arthroplasty 2005; 20(3): 302–308.

Kim

Kwon

Kim

. Analysis of biomechanical effect of stem-end design in revision TKA using Digital Korean model. Clin Biomech 2008; 23(7): 853–858.

Completo

Talaia

Fonseca

. Relationship of design features of stemmed tibial knee prosthesis with stress shielding and end-of-stem pain. Mater Design 2009; 30(4): 1391–1397.

10.

Completo

Fonseca

Simões

. A new press-fit stem concept to reduce the risk of end-of-stem pain at revision TKA: a pre-clinical study. Knee 2012; 19(5): 537–542.

11.

Gray

Taddei

Zavatsky

. Experimental validation of a finite element model of a human cadaveric tibia. J Biomech Eng 2008; 130(3): 031016.

12.

Heiner

. Structural properties of fourth-generation composite femurs and tibias. J Biomech 2008; 41(15): 3282–3284.

13.

Wright

. Strain distribution in the tibia as a function of applied loading through a revision total knee replacement. PhD Thesis, University of Bath, Bath, 2015.

14.

Halloran

Petrella

Rullkoetter

. Explicit finite element modeling of total knee replacement mechanics. J Biomech 2005; 38(2): 323–333.

15.

Bellemans

Ries

Victor

. Total knee arthroplasty: a guide to get better performance. Berlin, Heidelberg: Springer-Verlag, 2005, p.27.

16.

Hashemi

Chandrashekar

Gill

. The geometry of the tibial plateau and its influence on the biomechanics of the tibiofemoral joint. J Bone Joint Surg Am 2008; 90(12): 2724–2734.

17.

Sawbones, Pacific Research Laboratories, Inc. Biomechanical test materials, http://www.sawbones.com/UserFiles/Docs/biomechanical_catalog.pdf (accessed 23 August 2014).

18.

Cawley

Kelly

Simpkin

. Full and surface tibial cementation in total knee arthroplasty: a biomechanical investigation of stress distribution and remodeling in the tibia. Clin Biomech 2012; 27(4): 390–397.

19.

Polgar

Viceconti

O’Connor

. A comparison between automatically generated linear and parabolic tetrahedra when used to mesh a human femur. Proc IMechE, Part H: J Engineering in Medicine 2001; 215(1): 85–94.

20.

Completo

Fonseca

Simões

. Finite element and experimental cortex strains of the intact and implanted tibia. J Biomech Eng 2007; 129(5): 791–797.

21.

Mach

Rogers

Sabino

. Origins of skeletal pain: sensory and sympathetic innervation of the mouse femur. Neuroscience 2002; 113(1): 155–166.

22.

Mørch

Hennings

Andersen

. Estimating nerve excitation thresholds to cutaneous electrical stimulation by finite element modeling combined with a stochastic branching nerve fiber model. Med Biol Eng Comput 2011; 49(4): 385–395.

23.

Bono

Scott

. Revision total knee replacement. New York: Springer-Verlag, 2005, p.143.

24.

Bäthis

Perlick

Tingart

. Alignment in total knee arthroplasty: a comparison of computer-assisted surgery with the conventional technique. J Bone Joint Surg Br 2004; 86(5): 682–687.

25.

Jeffcote

Shakespeare

. Varus/valgus alignment of the tibial component in total knee arthroplasty. Knee 2003; 10(3): 243–247.