Non-optimal clinical alignment of components in total hip replacements (THRs) may lead to edge loading of the acetabular cup liner. This has the potential to cause changes to the liner rim not accounted for in standard wear models. A greater understanding of the material behaviours could be beneficial to design and surgical guidance for THR devices. The aim of this research was to combine finite element (FE) modelling and experimental simulation with microstructural assessment to examine material behaviour changes during edge loading. A dynamic deformable FE model, matching the experimental conditions, was created to simulate the stress strain environment within liners. Five liners were tested for 4Mc (million cycles) of standard loading (ISO14242:1) followed by 3Mc of edge loading with dynamic separation (ISO14242:4) in a hip simulator. Microstructural measurements by Raman spectroscopy were taken at unloaded and highly loaded rim locations informed by FE results. Gravimetric and geometric measurements were taken every 1Mc cycles. Under edge loading, peak Mises stress and plastic deformation occur below the surface of the rim during heel strike. After 7Mc, microstructural analysis determined edge loaded regions had an increased crystalline mass fraction compared to unloaded regions (p<0.05). Gravimetric wear rates of 12.5mm. 3. /Mc and 22.3mm. 3. /Mc were measured for standard and edge loading respectively. A liner penetration of 0.37mm was measured after 7Mc. Edge loading led to an increase in gravimetric wear rate indicating a different wear mechanism is occurring. FE and Raman results suggest that changes to material behaviour at the rim could be possible. These methods will now be used to assess more liners and over a larger number of cycles. They have potential to explore the impact of edge loading on different surgical and patient variables

Variations in component positioning of total hip replacements can lead to edge loading of the liner, and potentially affect device longevity. These effects are evaluated using ISO 14242:4 edge loading test results in a dynamic system. Mediolateral translation of one of the components during testing is caused by a compressed spring, and therefore the kinematics will depend on the spring stiffness and damping coefficient, and the mass of the translating component and fixture. This study aims to describe the sensitivity of the liner plastic strain to these variables, to better understand how tests using different simulator designs might produce different amounts of liner rim deformation. A dynamic explicit deformable finite element model with 36mm Pinnacle metal-on-polyethylene bearing geometry (DePuy Synthes, Leeds, UK) was used with material properties for conventional UHMWPE. Setup was 65° clinical inclination, 4mm mismatch, 70N swing phase load, and 100N/mm spring. Fixture mass was varied from 0.5-5kg, spring damping coefficient was varied from 0-2Ns/mm. They were changed independently, and in combination. Maximum separation values were relatively insensitive to changes in the mass, damping coefficient, or both. The sensitivity of peak plastic strain, to this range of inputs, was similar to changing the swing phase load from 70N to approximately 150N – 200N. Increasing the fixture mass and/or damping coefficient increased the peak plastic strain, with values from 0.15-0.19. Liner plastic deformation was sensitive to the spring damping and fixture mass, which may explain some of the differences in fatigue and deformation results in UHMWPE liners tested on different machines or with modified fixtures. These values should be described when reporting the results of ISO14242:4 testing. Acknowledgements. Funded by EPSRC grant EP/N02480X/1; CAD supplied by DePuy Synthes

SUMMARY. The relationship between component position, wear rate and edge loading was investigated for 115 explanted current generation Metal-on-Metal (MoM) hips. Edge wear was detected in: 63% of all hips; and 48% of those with cups positioned within Lewinnek's box. BACKGROUND. The link between steeply inclined cups (>55 degrees) and edge loading is known for all common hip bearing couples. Edge loading is associated with high rates of wear, and has been linked to premature failure of hips. METHODS. The wear of failed hip joints was measured using a Taylor Hobson Talyrond 365. Edge loading was identified when the depth of the wear scar was maximum at the rim of the cup. The position of the cups was measured from plain radiographs or 3D CT. RESULTS. A total of 115 retrieved hips were available with position and wear analysis. The median age of patients was 58 years (25 – 87) and the median time before revision was 38 months (4 – 121). All hips were measured for inclination and 78 were measured for version. The median (range) of cup inclination was 51 degrees (15 – 82), and cup version was 18.5 degrees (-47 – 61). 63% of cups were found to be edge loaded. The median wear rate of the edge loaded cups was 12 μm per year compared to 1.88 μm per year for non-edge loaded cups. Edge loading was found in all components with an inclination steeper than 60°. Edge loading was found at inclination angles as low as 30°. 23 cups were placed within Lewinnek's safe zone: inclination of 40 ± 10degrees, and version of 15 ± 10 degrees. However, 11 of these “well positioned” components were edge loaded. Of the edge loaded components in Lewinnek's box, none had an inclination less than 40 degrees. CONCLUSIONS. Edge loading occurred at cup inclination angles lower than previously reported. It is believed that edge wear is related to the contact patch between head and cup, overlapping the edge of the cup, causing disruption to the lubrication regime and increased contact pressures at the edge of the cup. Work is progressing to calculate the size of contact patch for the explanted hips and position in the cup

Mismatch of bearing component centres and tension of soft tissues surrounding the hip joint can lead to component separation during gait cycle and cause the femoral head to contact the rim of an acetabular liner, which could increase wear and shorten lifespan of an implant. This study aims to investigate the contact and wear mechanics of a metal-on-polyethylene hip joint under dynamic separation by using Finite Element Analysis (FEA). A Pinnacle® cup with a Marathon neutral liner 36×56mm with a 45° inclination was constrained by a spring element in the medial-lateral axis. The spring was pre-compressed by 4mm to represent the corresponding translational mismatch of a simulator testing. Archard's law was used to predict wear over one ISO 14242-1 gait cycle. Contact pressure is proportional to the load input during the stance phase, associated with concentric contact condition; it increases threefold just before the swing phase (time C), reaching 46.2MPa, where edge loading occurs. Consequently, separation climbs to 3.54mm, which is comparable to the mathematical prediction (3.34mm) and dynamic FEA (3.2mm). The predicted volumetric wear after this gait cycle is 1.22 × 10–5 mm3. Dynamic separation between femoral head and acetabular liner can result in edge loading, consequently high contact pressure on the edge of a liner. In combination with cyclic loading, fatigue damage could take place and may be worth investigating in the future

Edge loading due to dynamic separation can occur due to variations in component positioning such as a steep cup inclination angle (rotational) or mismatch between the centres of rotation of the head and the cup (translational). The aim of this study was to determine the effect of variations in rotational and translational positioning of the cup on the magnitude of dynamic separation, wear and deformation of metal-on-polyethylene bearings. Eighteen 36mm diameter metal-on-polyethylene hip replacements were tested on an electromechanical hip simulator. Standard gait with concentric head and cup centres were applied for cups inclined at 45° (n=3) and 65° (n=3) for two million cycles. A further two tests with translational mismatch of 4mm applied between the head and cup bearing centres for cups inclined at 45° (n=6) and 65° (n=6) were run for three million cycles. Wear was determined using a microbalance and deformation by geometric analysis. Confidence intervals of 95% were calculated for mean values, and t-tests and ANOVA were used for statistical analysis (p<0.05). Under 4mm mismatch conditions, a steeper cup inclination angle of 65° resulted in larger dynamic separation (2.1±0.5mm) compared with cups inclined at 45° (0.9±0.2mm). This resulted in larger penetration at the rim under 65° (0.28±0.04mm) compared to 45° (0.10±0.09mm) cup inclination conditions (p<0.01). Wear rates under standard concentric conditions were 12.8±3.8 mm. 3. /million cycles and 15.4±5.0 mm. 3. /million cycles for cups inclined at 45° and 65° respectively. Higher wear rates were observed under 4mm of translational mismatch compared with standard concentric conditions at 45° (21.5±5.5 mm. 3. /million cycles, p<0.01) and 65° (23.0±5.7 mm. 3. /million cycles, p<0.01) cup inclination. Edge loading under dynamic separation conditions due to translational mismatch resulted in increased wear and deformation of the polyethylene liner. Minimising the occurrence and severity of edge loading through optimal component positioning may reduce the clinical failure rates of polyethylene

Edge loading due to dynamic separation can occur due to variations in component positioning such as a steep cup inclination angle (rotational) or mismatch between the centres of rotation of the head and the cup (translational). The aim of this study was to determine the effect of variations in rotational and translational positioning of the cup on the magnitude of dynamic separation, wear and deformation of metal-on-polyethylene bearings. Eighteen 36mm diameter metal-on-polyethylene hip replacements were tested on an electromechanical hip simulator. Standard gait with concentric head and cup centres were applied for cups inclined at 45° (n=3) and 65° (n=3) for two million cycles. A further two tests with translational mismatch of 4mm applied between the head and cup bearing centres for cups inclined at 45° (n=6) and 65° (n=6) were run for three million cycles. Wear was determined using a microbalance and deformation by geometric analysis. Confidence intervals of 95% were calculated for mean values, and t-tests and ANOVA were used for statistical analysis (p<0.05). Under 4mm mismatch conditions, a steeper cup inclination angle of 65° resulted in larger dynamic separation (2.1±0.5mm) compared with cups inclined at 45° (0.9±0.2mm). This resulted in larger penetration at the rim under 65° (0.28±0.04mm) compared to 45° (0.10±0.05mm) cup inclination conditions (p<0.01). Wear rates under standard concentric conditions were 12.8±3.8 mm. 3. /million cycles and 15.4±5.0 mm. 3. /million cycles for cups inclined at 45° and 65° respectively. Higher wear rates were observed under 4mm of translational mismatch compared with standard concentric conditions at 45° (21.5±5.5 mm. 3. /million cycles, p<0.01) and 65° (23.0±5.7 mm. 3. /million cycles, p<0.01) cup inclination. Edge loading under dynamic separation conditions due to translational mismatch resulted in increased wear and deformation of the polyethylene liner. Minimising the occurrence and severity of edge loading through optimal component positioning may reduce the clinical failure rates of polyethylene

In vitro the introduction of microseparation and edge loading to hip simulator gait cycle has replicated clinically relevant wear rates and wear mechanisms in ceramic-on-ceramic bearings. [1]. , and elevated the wear rates of MoM surface replacements (SR) to levels similar to those observed in retrievals. [2]. The aim was to assess the wear of two different sized MoM total hip replacement bearings under steep cup inclination angles and adverse microseparation and edge loading conditions. Two tests were performed on the Leeds II hip joint simulator using two different size bearings (28mm and 36mm). Cups were mounted to provide inclination angles of 45 degrees (n=3) and 65 degrees (n=3). The first three million cycles were under standard gait conditions. Microseparation and edge loading conditions as described by Nevelos et al. [1]. were introduced to the gait cycle for the subsequent three million cycles. The lubricant was 25% new born calf serum. The mean wear rates and 95% confidence limits were determined and statistical analysis was performed using One Way ANOVA. Under standard gait conditions, when the cup inclination angle increased from 45 degrees to 65 degrees, the wear of size 28mm bearing significantly (p=0.004) increased by 2.7-fold, however, the larger bearings did not show any increase in wear (p=0.9). The introduction of microseparation conditions resulted in a significant (p=0.0001) increase in wear rates for both bearing sizes under both cup inclination angle conditions. Under microseparation conditions, the increase in cup inclination angle had no influence on the wear rate for both bearing sizes (Figure 1). With larger bearings, head-rim contact occurs at a steeper cup inclination angle providing an advantage over smaller bearings. The introduction of edge loading and microseparation conditions resulted in a significant increase in wear rates for both bearing sizes. The wear rates obtained in this study under combined increased cup inclination angle and microseparation were half of those obtained when SR MoM bearings were tested under similar adverse conditions. [2]. This study shows the importance of prosthesis design and accurate surgical positioning of the head and acetabular cup in MoM THRs

The current, most popular recommendation for cup orientation, namely the Lewinnek box, dates back to the 70's, that is to say at the stone age of hip arthroplasty. Although Lewinnek's recommendations have been associated with a reduction of dislocation, some complications, either impingement or edge loading related, have not been eliminated. Early dislocations are becoming very rare and most of them probably occur in “outlier” patients with atypical pelvic/hip kinematics. Because singular problems usually need singular treatments, those patients need a more specific personalised planning of the treatment rather than a basic systematic application of Lewinnek recommendations. We aim in this review to define the potential impacts that the spine-hip relations (SHRs) have on hip arthroplasty. We highlight how recent improvements in hip implants technology and knowledge about SHRs can substantially modify the planning of a THR, and make the « Lewinnek recommendations » not relevant anymore. We propose a new classification of the SHRs with specific treatment recommendations for hip arthroplasty whose goal is to help at establishing a personalized planning of a THR. This new classification gives a rationale to optimize the short and long-term patient's outcomes by improving stability and reducing edge loading. We believe this new concept could be beneficial for clinical and research purposes

Abstract. Objectives. Hip joint laxity after total hip arthroplasty (THA) has been considered to cause microseparation and lead to complications, including wear and dislocation. In the native hip, the hip capsular ligaments may tighten at the limits of range of hip motion and provide a passive stabilising force preventing edge loading and reduce the risk of dislocation. Previous attempts to characterise mechanical properties of hip capsular ligaments have been largely variable and there are no cadaveric studies quantifying the force contributions of each ligament in different hip positions. In this study we quantify the passive force contribution of the hip capsular ligaments throughout a complete range of motion (ROM). Methods. Nine human cadaveric hip specimens (6 males and 3 females) with mean age of (76.4 ± 9.0 years) were skeletonised, preserving the capsular ligaments. Prepared specimens were tested in a 6 degree of freedom system to assess ROM with 5 Nm torque applied in external and internal rotation throughout hip flexion and extension. Capsular ligaments were resected in a stepwise fashion to assess internal force contributions of the iliofemoral (superior and inferior), pubofemoral, and ischiofemoral ligaments during ROM. Results. In external rotation, the superior and inferior iliofemoral ligament minimum force contributions were (136.52 ± 27.15 N) in flexion and (82.40 ± 27.85 N) in extension, respectively. In internal rotation, the ischiofemoral ligament force contributions were dominant in adducted-flexion positions and abducted-extension positions. Conclusions. These findings provide insights into the primary capsular structures that stabilise the hip joint in different manoeuvres. This data allows for an improved understanding of which capsular ligaments contribute the most to hip stability and has important implications for choosing surgical approaches and repair strategies to minimise complications related to joint instability. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Trust in the validity of a measurement tool is critical to its function in both clinical and educational settings. Acetabular cup malposition within total hip arthroplasty (THA) can lead to increased dislocation rates, impingement and increased wear as a result of edge loading. We have developed a THA simulator incorporating a foam/Sawbone pelvis model with a modified Microsoft HoloLens® augmented reality (AR) headset. We aimed to measure the trueness, precision, reliability and reproducibility of this platform for translating spatial measurements of acetabular cup orientation to angular values before developing it as a training tool. Methods. A MicronTracker® stereoscopic camera was integrated onto a HoloLens® AR system. Trueness and precision values were obtained through comparison of the AR system measurements to a gold-standard motion capture system”s (OptiTrack®) measurements for acetabular cup orientation on a benchtop trainer, in six clinically relevant pairs of anteversion and inclination angles. Four surgeons performed these six orientations, and repeated each orientation twice. Pearson”s coefficients and Bland-Altman plots were computed to assess correlation and agreement between the AR and Motion Capture systems. Intraclass correlation coefficients (ICC) were calculated to evaluate the degree of repeatability and reproducibility of the AR system by comparing repeated tasks and between surgeons, respectively. Results. The trueness of the AR system was 0.24° (95% CI limit 0.92°) for inclination and 0.90° (95% CI limit 1.8°) for anteversion. Precision was 0.46° for inclination and 0.91° for anteversion. There was significant correlation between the two methods for both inclination (r = 0.996, p<0.001) and anteversion (r = 0.974, p<0.001). Repeatability for the AR system was 0.995 for inclination and 0.989 for anteversion. Reproducibility for the AR system was 0.999 for inclination and 0.995 for anteversion. Conclusion. Measurements obtained from the enhanced HoloLens® AR system were accurate and precise in regards to determining angular measurements of acetabular cup orientation. They exceeded those of currently used methods of cup angle determination such as CT and computer-assisted navigation. Measurements obtained were also highly repeatable and reproducible, therefore this platform is accurately validated for use in a THA training simulator

Background. As the number of ceramic THR bearings used worldwide is increasing, the number of implants that experience off-normal working conditions, e.g. edge loading, third bodies in the joint, soft tissues laxity, dislocation/subluxation of the joint, increases too. Under all such conditions the bearing surfaces can be damaged, leading eventually to a limitation of the expected performances of the implant. Methods. We characterised the damage resistance of different bearing surfaces (alumina matrix composite BIOLOXdelta, alpha-alumina BIOLOXforte, zirconia 3Y-TZP, oxidized zirconium alloy Zr-2.5Nb, CoCr-alloy) by scratch tests performed following the European standard EN 1071–3:2005. Also the scratch hardness of same materials has been assessed. Results. The Lc1 value (i.e., the load for the onset of a scratch) measured for BIOLOXdelta is about fivefold the one measured for the oxidized zirconium alloy (OXZr) surface and about tenfold the Lc1 measured for the CoCr alloy. The height of ridges along the scratch edges due to plastic flow in the composite ceramic BIOLOXdelta are only 21% in height than in CoCr, and only a small fraction (0.04%) of the height of ridges measured on OXZr surfaces. The scratch hardness of the metal samples tested (CoCr, OXZr) results one order of magnitude lower than the ones of ceramics. This behavior is not influenced by of the presence of the coating on OXZr surface. Conclusions. The transformation toughened ceramics tested (BIOLOXdelta, 3Y-TZP) are the materials that exhibit the higher resistance to scratching. Ridges at scratch edges are lower in ceramics than in coated or uncoated metals. The result show the superior scratch resistance behavior of toughened ceramics for THR wear couples with respect to coated or bare alloys. Level of Evidence. Level 1

Background. Fretting at modular junctions is thought to be a ‘mechanically assisted’ corrosion phenomenon, initiated by mechanical factors that lead to increased contact stresses and micromotions at the taper interface. We adopted a finite element approach to model the head-taper junction, to analyse the contact mechanics at the taper interface. We investigated the effect of assembly force and angle on contact pressures and micromotions, during loads commonly used to test hip implants, to demonstrate the importance of a good assembly during surgery. Methods. Models of the Bimetric taper and adaptor were created, with elastic-plastic material properties based on material tests with the actual implant alloy. FE contact conditions were validated against push-on and pull-off experiments. The models were loaded according to ISO 7206-4 and −6, after being assembled at 2-4-15kN, both axially and at a 30° angle. Average micromotions and contact pressures were analysed, and a wear score was calculated based on the contact pressures and micromotions. Results. The average contact pressure decreased when a higher assembly force was used, with loads being distributed over a larger contact area, but increased when tested at a 30° angle. Average micromotions reduced with a higher assembly load, except when assembled at a 30° angle. The wear score decreased with increasing assembly force, when applied perpendicularly, while when assembled at a 30° angle, the wear score did not reduce with assembly force. Conclusions. The location and patterns of micromotions were consistent with retrieved tapers and those generated in in-vitro test models. Increased impaction loads reduced the average amount of micromotion and fretting. We intend to apply more complex loading regimes in future analyses, enabling to study phenomena such as edge loading and frictional torque. Level of evidence. IIb - Experimental study. Disclosure. This study was financially supported by Biomet UK Healthcare Ltd

Constitutional knee varus increases the risk of medial OA disease due to increase in the knee adduction moment and shifting of the mechanical axis medially. Hueter-Volkmann’s law states that the amount of load experienced by the growth plate during development influences the bone morphology. For this reason, heightened sports activity during growth is associated with constitutional varus due to added knee adduction moment. In early OA, X-rays often show a flattened medial femoral condyle extension facet (EF). However, it is unknown whether this is a result of osteoarthritic wear, creep deformation over decades of use, or an outcome of Hueter-Volkmann’s law during development. A larger and flattened medial EF can bear more weight, due to increased load distribution. However, a flattened EF may also extrude the meniscus, leading meniscus degeneration and joint failure. Therefore, this study aimed to investigate whether varus knees have flattened medial EFs of both femur and tibia in a cohort of patients with no signs yet of bony attrition. Segmentation and morphology analysis was conducted using Materialise software (version 8.0, Materialise Inc., Belgium). This study excluded knees with bony attrition of the EFs based on Ahlbäck criteria, intraoperative findings, and operation notes history. Standard reference frames were used for both the femur and tibia to ensure reliable and repeatable measurements. The hip-knee-angle (HKA) angle defined varus or valgus knee alignment. Femur: The femoral EFs and flexion facets (FFs) had best-fit spheres fitted with 6 repetitions. Tibia: The slopes of the antero-medial medial tibial plateau were approximated using lines. Results 72 knees met the inclusion and exclusion criteria. The average age was 59 ± 11 years. The youngest was 31 and the oldest 84 years. Thirty-three were male and 39 were female. There was good intra- and inter-observer reliability for EF sphere fitting. Femur: The results demonstrated that the medial femoral condyle EF is flattened in knees with constitutional varus, as measured by the Sphere Ratios between the medial and lateral EF (varus versus straight: p = 0.006), and in the scaled values for the medial EF sphere radius (varus versus straight: p = 0.005). There was a statistically significant, moderate and positive correlation between the medial femoral EF radius, and the medial femoral EF-FF AP offset. Tibia: There was a statistically significant difference between the steepness of the slopes of the medial tibial plateau EF in varus and valgus knees, suggesting varus knees have a less concave (flatter) medial EF. Conclusions In comparison to straight knees, varus knees have flattened medial EFs in both femur and tibia. As this was the case in knees with no evidence of bony attrition, this could mean flattened medial EFs may be a result of medial physis inhibition during development, due to Hueter-Volkmann’s law. Flattened medial EFs may increase load distribution in the medial compartment, but could also be a potential aetiology in primary knee OA due to over extrusion of the medial meniscus and edge loading

There are several component position and design variables that increase the risk of edge loading and high wear in metal-on-metal hip resurfacing (MOM-HR). In this study we combined all of these variables to calculate the ‘contact patch to rim distance’ (CPRD) in patients undergoing revision of their MOM-HR. We then determined whether CPRD was more strongly correlated with component wear and blood metal ion levels, when compared to any other commonly reported clinical variable. This was a retrospective study of 168 consecutively collected MOM-HR retrieval cases. All relevant clinical data was documented, including pre-revision whole blood cobalt and chromium ion levels. Wear of the bearing surfaces was then measured using a roundness-measuring machine. We found four variables to be significantly (p < 0.05) correlated with component wear and blood metal ion levels: (1) cup inclination angle, (2) cup version angle, (3) arc of cover, and (4) CPRD. The correlations between CPRD and both wear and ion levels were significantly stronger than those seen with any other variable (all p < 0.0001). Our study has shown that CPRD is the best predictor of component wear and blood metal ion levels, and may therefore be a useful parameter to help determine those patients who are at risk of high wear and require more frequent clinical surveillance