• International Journal of Technology (IJTech)
  • Vol 12, No 6 (2021)

Evaluation of the Contact Area in Total Knee Arthroplasty Designed for Deep Knee Flexion

Evaluation of the Contact Area in Total Knee Arthroplasty Designed for Deep Knee Flexion

Title: Evaluation of the Contact Area in Total Knee Arthroplasty Designed for Deep Knee Flexion
Joko Triwardono, Sugeng Supriadi, Yudan Whulanza, Agung Shamsuddin Saragih, Deva Ariana Novalianita, Muhammad Satrio Utomo, Ika Kartika

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Cite this article as:
Triwardono, J., Supriadi, S., Whulanza, Y., Saragih, A.S., Novalianita, D.A., Utomo, M.S., Kartika, I., 2021. Evaluation of the Contact Area in Total Knee Arthroplasty Designed for Deep Knee Flexion. International Journal of Technology. Volume 12(6), pp. 1312-1322

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Joko Triwardono 1. Department of Mechanical Engineering, Faculty of Engineering, Universitas Indonesia, Kampus Ui Depok, Depok 16424, Indonesia 2. National Research and Innovation Agency, Banten 15314, Indonesia
Sugeng Supriadi Department of Mechanical Engineering, Faculty of Engineering, Universitas Indonesia, Kampus Ui Depok, Depok 16424, Indonesia
Yudan Whulanza Department of Mechanical Engineering, Faculty of Engineering, Universitas Indonesia, Kampus Ui Depok, Depok 16424, Indonesia
Agung Shamsuddin Saragih Department of Mechanical Engineering, Faculty of Engineering, Universitas Indonesia, Kampus Ui Depok, Depok 16424, Indonesia
Deva Ariana Novalianita Department of Mechanical Engineering, Faculty of Engineering, Universitas Indonesia, Kampus Ui Depok, Depok 16424, Indonesia
Muhammad Satrio Utomo National Research and Innovation Agency, Banten 15314, Indonesia
Ika Kartika National Research and Innovation Agency, Banten 15314, Indonesia
Email to Corresponding Author

Abstract
Evaluation of the Contact Area in Total Knee Arthroplasty Designed for Deep Knee Flexion

Total knee arthroplasty (TKA) implants are becoming an interesting subject in implant design research and development activities due to their complexity. They should be able to facilitate knee movement while supporting body weight during daily usage. Meanwhile, incidents such as hyperflexion in TKA implants outside their designated configuration can lead to subluxation and dislocation in this study, a polyethylene component of a posterior-stabilized right knee joint implant was developed to facilitate a high range of motion (ROM). Finite element analysis (FEA) was used to analyze the contact area on the polyethylene component. FEA was used to simulate weight-bearing conditions at 0°, 30°, 60°, 90°, 120°, and 150° of knee flexion. The modified polyethylene component resulted in better performance in terms of contact area, especially at 120° of knee flexion. The two dominant contact areas on the polyethylene component were 733 mm² at 0° of knee flexion and 576 mm² at 120° of knee flexion. Furthermore, the current design of the polyethylene component can maintain a contact area of 65 mm² at 150° of knee flexion. The current design is expected to accommodate deep knee flexion movement in daily activities and reduce the possibility of subluxation and dislocation at the polyethylene component during deep knee flexion. In addition, a large contact area can reduce the potential wear on or fracture of the polyethylene component. Finally, the result of FEA was validated using a simulator of knee kinematic motion; there was no indication of subluxation and dislocation at any degree of knee flexion.

Dislocation; Finite element analysis; Hyperflexion; Polyethylene; Subluxation; Total knee arthroplasty

Introduction

    Fiber- Knee replacement surgery or total knee arthroplasty (TKA) for the treatment of chronic degenerative pathologies of the knee has been a successful method for 60 years. During this period, the collaboration between surgeons and engineers has resulted in many developments in prosthesis design (Karczewski et al., 2021). For example, the first TKA allowed a single degree of freedom, but now TKA offers multiple degrees of freedom (Murray, 1928). Almost all TKAs performed in the United States and Europe have a range of motion (ROM) of 120° for knee flexion. This satisfies the inhabitants of the West, as it accommodates the range of motion required for most of their daily activities. However, this is not true for people in East Asia and the Middle East, whose sociocultural background varies greatly, as does their normal range of joint motion. This therapy is frequently refused because the resulting ROM is restricted (Villar et al., 1989). Squatting is used to perform activities on the toilet or just to rest, and it can easily be done for hours (Ahlberg et al., 1988). A cross-legged sitting posture is popular in many regions of Asia for eating on the floor as well as for informal activities such as chatting. Furthermore, kneeling is a popular practice among Muslims during prayer as well as among Japanese people during traditional rituals. For example, it has been reported that Saudi men have a knee flexion difference of more than 15° compared to Scandinavians (Hefzy et al., 1998). Most of the population in the Middle East routinely bend their knees to 165°. At prayer, most Muslims kneel with their limbs fully extended (between 150° and 165°) and with the shaft of the heel erect, reaching the posterior surface of the upper thigh. Since most commercial TKAs available today are not designed to achieve knee flexion of more than 120°, commercial TKAs do not meet the needs of patients in predominantly Muslim countries and Asian countries who practice traditional kneeling and sitting poses. In addition, differences in morphometry data between populations around the globe require a specific implant design for each population (Utomo et al., 2019). Hyperflexion outside the design configuration of implants are can lead to subluxations and dislocations (Li et al., 2004).

According to Thiele et al. (2015), some causes for revising the design of total knee arthroplasty are aseptic loosening (34.7%), instability (18.5%), and polyethylene wear (18.5%) (Thiele et al., 2015). These failure mechanisms have been associated with thin polyethylene (Pijls et al., 2012; Massin, 2016; Garceau et al., 2020; Presti et al., 2020; Crawford et al., 2021; Tzanetis et al., 2021). Polyethylene wear may result in osteolysis and the subsequent loosening of the components (Pijls et al., 2012; Massin, 2016). A significant amount of contact stress in the posterior post region might explain polyethylene wear and fracture in posterior-stabilized (PS) TKA (Nor Izmin et al., 2020; Garceau et al., 2020; Crawford et al., 2021; Tzanetis et al., 2021). Therefore, it is necessary to be prepared for patient management following possible knee implant failure.

Finite element analysis (FEA) is a versatile tool for studying the contact area during the design of the polyethylene component (Ahmad et al., 2020). Evaluation by FEA of the contact area on the polyethylene component, particularly in the posterior region of the post, may assist in avoiding issues that develop after TKA. In previous studies (Ishikawa et al., 2015; Tanaka et al., 2016; Zhang et al., 2017; Azam et al., 2018; Kang et al., 2018; Tanaka et al., 2018), an FEA of weight-bearing deep knee flexion was performed for 0° to 120° of knee flexion. In this study, FEA was performed for 0° to 150° of knee flexion.

    In this study, the polyethylene component of posterior-stabilized right knee joint prostheses was developed from the benchmark product. Benchmarking is a systematic method or process of measuring product performance by comparing it with products from other companies that are considered the best in the same industry. Vanguard Posterior Stabilized Knee Zimmer Biomet was used as benchmark in this study. FEA was used to measure the contact area on the polyethylene component. We hypothesized that the geometric modification of the polyethylene component could improve the contact area and increase the distribution of contact stress; this may reduce subluxation and dislocation at the polyethylene during deep knee flexion and minimize the risk of implant failure. 

Conclusion

The current results were compared to the results of previous studies (Tanaka et al., 2016). For the FEA result using polyethylene, the largest contact areas were 329 mm² at 0° of knee flexion and 146 mm² at 120° with the knee bent (Tanaka et al., 2016).

 

Table 2 The contact areas (in mm²) on the polyethylene component during 0° to 150° of knee flexion from a comparable study by Tanaka et al. (2016) and the current study

 

 

30°

60°

90°

120°

150°

Tanaka et al. (2016)

Under maximum contact stress on the medial and lateral condyles, and on the ball

329

125

108

118

146

-

Current Study

Under average contact pressure on the polyethylene

733

218

510

469

576

65

 

In the current study, the largest contact areas were 733 mm2 at 0° of knee flexion and 576 mm2 at 120° with the knee bent. In previous studies, the contact area on the polyethylene was minimal at 60° of knee flexion. Meanwhile, in the current study, the contact area on the polyethylene was minimal at 150° of knee flexion. In the current study, the contact area was largest at 0° of knee flexion and decreased with increasing knee flexion. At approximately 90° of knee flexion, the posterior post region of the polyethylene began to come into contact with the femoral cam through the post-cam mechanism (Tanaka et al., 2016). This differs from the current results obtained, namely that the posterior post region of the polyethylene contacted the femoral cam at about 60° and that post-cam contact increases the contact area on knee flexion, as presented in Table 2.

According to Nakamura et al. (2015), In computer simulation research, the anteroposterior translation and geometric center of the femoral component were measured using the medial and lateral contact tool. Contact tools are important for evaluating the contact area and the contact stress (Nakamura et al., 2015) because a small contact area and a high contact stress are thought to induce significant problems such as polyethylene insert wear and fracture or severe post wear (Puloski, 2000; Reay et al., 2001; Mauerhan, 2003; Clarke et al., 2004; Casey et al., 2007).

In the current study, the contact area on the polyethylene was minimal at 150° knee flexion. This should be of particular concern because insufficient contact area might induce wear and fracture of polyethylene. The mean contact stress for arthroplasties is inversely proportional to the contact area. The contact area on the polyethylene component significantly increased during deep knee flexion. Many factors influence the site of the contact between the post and cam, including the form of the cam, the position of the attachment of the cam to the femoral component, and the curvature of the posterior femoral condyles (Utomo et al., 2020). The modification on polyethylene post feature is advantageous for reducing excessive tension at the bone-implant contact and preventing post fracture. In the current study, the design’s curved shape of the polyethylene post increased the contact area during deep flexion.

    The FEA was conducted under the assumption that all force was applied to the tibiofemoral articular surface and to the post’s polyethylene component. In our study, a relative force of 4 kN (Walker et al., 1997; Kuriyama et al., 2014; Azam et al., 2018) was applied. Despite this limitation, our research has provided vital information about the tibiofemoral joint and the post-cam mechanism. The design of the polyethylene component resulted in an increase in the contact area; this is expected to accommodate high flexion in daily activities and reduce the risk of subluxations and dislocations during deep knee flexion. 

Acknowledgement

    The author would like to thank the Indonesian Institute of Sciences (LIPI) for its financial support through a 2019 scientific scholarship (SK Number: B-4919/SU.3/HK.01/V/2019) and the TI-Bio Laboratory of the University of Indonesia, Depok, Indonesia, for providing all the facilities for this research. This research was funded by the University of Indonesia through the PUTI Saintekes 2020 program (NKB-4964/UN2.RST/HKP.05.00/2020). 

References

Ahlberg, A., Moussa, M., Al-Nahdi, M., 1988. On Geographical Variations in the Normal Range of Joint Motion. Clinical Orthopaedics and Related Research, Volume 234, pp. 229–231

Ahmad, M.A., Nadhirah, N., Elias, M., Shuib, S., Sulaiman, S.H., Abdullah, A.H., 2020. Finite Element Analysis of Proximal Cement Fixation in Total Hip Arthroplasty. International Journal of Technology, 2020, 11(5), pp. 1046–1055

Azam, N.M.A., Daud, R., Mas Ayu, H., Ramli, J., Hassan, M.F.B., Shah, A., 2018. The Effect of Knee Flexion Angle on Contact Stress of Total Knee Arthroplasty. MATEC Web of Conferences, Volume 225, pp. 2–7

Casey, D., Cottrell, J., Dicarlo, E., Windsor, R., Wright, T., 2007. PFC Knee Replacement. Clinical Orthopaedics and Related Research, Volume 464, pp. 157–163

Clarke, H.D., Math, K.R., Scuderi, G.R., 2004. Case Report Polyethylene Post Failure in Posterior Stabilized Total Knee Arthroplasty. The Journal of Arthroplasty, Volume 19(5), pp. 652–657

Crawford, D.A., Lapsley, L., Hurst, J.M., Morris, M.J., Adolph, Jr. V.L., Berend, K.R., 2021. Impact of Polyethylene Thickness on Clinical Outcomes and Survivorship in Medial Mobile-Bearing Unicondylar Knee Arthroplasty. The Journal of Arthroplasty, Volume 36(7), pp. 2440–2444

Garceau, S.P., Warschawski, Y.S., Tang, A., Sanders, E.B., Schwarzkopf, R.M., Backstein, D.J., 2020. The Effect of Polyethylene Liner Thickness on Patient Outcomes and Failure After Primary Total Knee Arthroplasty. The Journal of Arthroplasty, Volume 35(8), pp. 2072–2075

Hefzy, M.S., Kelly, B.P., Cooke, T.D.V., 1998. Kinematics of the Knee Joint in Deep Flexion: A Radiographic Assessment. Medical Engineering and Physics, Volume 20(4), pp. 302–307

Ishikawa, M., Kuriyama, S., Ito, H., Furu, M., 2015. The Knee Kinematic Alignment Produces Near-Normal Knee Motion but Increases Contact Stress After Total Knee Arthroplasty: A Case Study on a Single Implant Design. The Knee, Volume 22(3), pp. 206–212

Kang, K., Son, J., Kwon, S.K., Kwon, O., 2018. Finite Element Analysis for the Biomechanical Effect of Tibial Insert Materials in Total Knee Arthroplasty. Composite Structures, Volume 201, pp. 141–150

Karczewski, A.M., Dingle, A.M., Poore, S.O., 2021. The Need to Work Arm in Arm: Calling for Collaboration in Delivering Neuroprosthetic Limb Replacements. Frontiers In Neurorobotics, Volume 12, pp. 1–26

Kuriyama, S., Ishikawa, M., Furu, M., Ito, H., Matsuda, S., 2014. Malrotated Tibial Component Increases Medial Collateral Ligament Tension in Total Knee Arthroplasty. Journal of Orthopaedic Research, Volume 32(12), pp. 1658–1666

Kurtz, S.M., Muratoglu, O.K., Evans, M., Edidin, A.A., 1999. Advances in the Processing, Sterilization, and Crosslinking of Ultra-High Molecular Weight Polyethylene for Total Joint Arthroplasty. Biomaterials, Volume 20, pp. 1659–1688

Li, G., Most, E., Sultan, P.G., Schule, S., Zayontz, S., Park, S.E., Rubash, H.E., 2004. Knee Kinematics with a High-flexion Posterior Stabilized Total Knee Prosthesis: An in Vitro Robotic Experimental Investigation. Journal of Bone and Joint Surgery - Series A, Volume 86(8), pp. 1721–1729

Massin, P., 2016. How Does Total Knee Replacement Technique Influence Polyethylene Wear?, Orthopaedics & Traumatology: Surgery & Research, Volume 103(1), pp. S21–S27

Mauerhan, D.R., 2003. Case Report Fracture of the Polyethylene Tibial Post in a Posterior Cruciate – Substituting Total Knee Arthroplasty Mimicking Patellar Clunk Syndrome A Report of 5 Cases. The Journal of Arthroplasty, Volume 18(7), pp. 942–945

Murray, D.G., 1928. History of Total Knee Replacement, Total Knee Replacement Books. Springer Link, 1991, 1, XVI, p. 268

Nakamura, S., Sharma, A., Ito, H., Nakamura, K., Zingde, S.M., Komistek, R.D., 2015. Kinematic Difference between Various Geometric Centers and Contact Points for Tri-Condylar Bi-Surface Knee System. Journal of Arthroplasty, Volume 30(4), pp. 701–705

Nor Izmin, N.A., Hazwani, F., Todo, M., Abdullah, A.H., 2020. Risk of Bone Fracture in Resurfacing Hip Arthroplasty at Varus and Valgus Implant Placements. International Journal of Technology, Volume 11(5), pp. 1025–1035

Pijls, B.G., der Zwag, H.M.J.V.D.L-V., Nelissen, R.G.H.H., 2012. Polyethylene Thickness is a Risk Factor for Wear Necessitating Insert Exchange. International Orthopaedics (SICOT), Volume 36, pp. 1175–1180

Puloski, S., 2000. Post Wear In Posterior Stabilized TKA: An Unrecognized Source of Polyethylene Debris. In: 46th Annual Meeting, Orthopaedic Research Society, March 12-15, 2000, Orlando, Florida, 403, 7709

Presti, M.L., Costa, G.G., Grassi, A., Agrò, G., Cialdella, S., Vasco, C., Neri, M.P., Cucurnia, I., Zaffagnini, S., 2020. Orthopaedics & Traumatology?: Surgery & Research Bearing Thickness of Unicompartmental Knee Arthroplasty is a Reliable Predictor of Tibial Bone Loss during Revision to Total Knee Arthroplasty. Orthopaedics & Traumatology: Surgery & Research, Volume 106(3), pp. 429–434

Reay, E., Wu, J., Holland, J., Deehan, D., 2001. Premature Failure of Kinemax Plus Total Knee Replacements. The Journal of Bone and Joint Surgery, Volume 91-B, pp. 604–611

Sulong, A.B., Arifin, A., Harun, Z., 2016. Jig Prototype For Computer-Assisted Total Knee Replacement and Its Flow Simulation. International Journal of Technology, Volume 7(1), pp. 132–140

Tanaka, Y.D.M., Nakamura, S., Kuriyama, S., Ito, H., Furu, M., Komistek, R.D., Matsuda, S., 2016. How Exactly Can Computer Simulation Predict the Kinematics and Contact Status after TKA?? Examination in Individualized Models. Clinical Biomechanics, Volume 39, pp. 65–70

Tanaka, Y., Nakamura, S., Kuriyama, S., Nishitani, K., Ito, H., Furu, M., Watanabe, M., Matsuda, S., 2018. Clinical Biomechanics Medial tilting of the Joint Line in Posterior Stabilized Total Knee Arthroplasty Increases Contact Force and Stress. Clinical Biomechanics, Volume 53, pp. 54–59

Thiele, K., Perka, C., Matziolis, G., Mayr, H.O., Sostheim, M., Hube, R., 2015. Wear Is Less Common in Revision Surgery. The Journal of Bone and Joint Surgery, Volume 97, pp. 715–720

Tzanetis, P., Marra, M.A., Fluit, R., Koopman, B., Verdonschot, N., 2021. Biomechanical Consequences of Tibial Insert Thickness after Total Knee Arthroplasty?: A Musculoskeletal Simulation Study. Applied. Sciences, Volume 11(5), pp. 1–11

Utomo, M.S., Amal, M.I., Supriadi, S., Malau, D., Annur, D., Pramono, A.W., 2019. Design of Modular Femoral Implant based on Anthropometry of Eastern Asian. In: AIP Conference Proceedings 2088, https://doi.org/10.1063/1.5095285

Utomo, M.S., Malau, D.P., Annur, D., Asmaria, T., Amal, M.I., Supriadi, S., Rahyussalim, A.J., 2020. The Effect of Patellar Groove on Mechanical Performance of Femoral Component. In: AIP Conference Proceedings 2227, pp. 1–7

Villar, R.N., Solomon, V.K., Rangam, J., 1989. Knee Surgery and the Indian Knee. Tropical Doctor, Volume 19(1), pp. 21–24

Walker, P.S., Blunn, G.W., Broome, D.R., Perry, J., Watkins, A., Sathasivam, S., Dewart, M.E., Paul, J.P., 1997. A Knee Simulating Machine for Performance Evaluation of Total Knee Replacements, Journal Biomechanics, Volume 30(1), pp. 83–89

Zhang, J., Chen, Z., Wang, L., Li, D., 2017. Load Application for the Contact Mechanics Analysis and Wear Prediction of Total Knee Replacement. Journal of Engineering in Medicine, Volume 231(5), pp. 444–454