Objectives. In this prospective cohort study, we investigated whether patient-specific finite element (FE) models can identify patients at risk of a pathological femoral fracture resulting from metastatic bone disease, and compared these FE predictions with clinical assessments by experienced clinicians. Methods. A total of 39 patients with non-fractured femoral metastatic lesions who were irradiated for pain were included from three radiotherapy institutes. During follow-up, nine pathological fractures occurred in seven patients. Quantitative CT-based FE models were generated for all patients. Femoral failure load was calculated and compared between the fractured and non-fractured femurs. Due to inter-scanner differences, patients were analyzed separately for the three institutes. In addition, the FE-based predictions were compared with fracture risk assessments by experienced clinicians. Results. In institute 1, median failure load was significantly lower for patients who sustained a fracture than for patients with no fractures. In institutes 2 and 3, the number of patients with a fracture was too low to make a clear distinction. Fracture locations were well predicted by the FE model when compared with post-fracture radiographs. The FE model was more accurate in identifying patients with a high fracture risk compared with experienced clinicians, with a sensitivity of 89% versus 0% to 33% for clinical assessments. Specificity was 79% for the FE models versus 84% to 95% for clinical assessments. Conclusion. FE models can be a valuable tool to improve clinical fracture risk predictions in metastatic bone disease. Future work in a larger patient population should confirm the higher predictive power of FE models compared with current clinical guidelines. Cite this article: F. Eggermont, L. C. Derikx, N. Verdonschot, I. C. M. van der Geest, M. A. A. de Jong, A. Snyers, Y. M. van der Linden, E. Tanck. Can patient-specific finite element models better predict fractures in metastatic bone disease than experienced clinicians? Towards computational modelling in daily clinical practice. Bone Joint Res 2018;7:430–439. DOI: 10.1302/2046-3758.76.BJR-2017-0325.R2

Abstract. Objectives. The aim of this study was to develop an open-source finite element model of the ankle for identification of the best clinical treatment to restore stability to the ankle after injury. Methods. The ankle geometry was defined from the Visible Human Project Female CT dataset available from the National Library of Medicine, and segmented using Dragonfly software (Object Research Systems, 2020). The finite element model was created with FEBio (University of Utah, 2021) using the dynamic nonlinear implicit solver. Linear isotropic material properties were assigned to the bones (E=7300MPa, ν=0.3, ρ=1730kg/m. 3. ) and cartilage (E=10MPa, ν=0.4, ρ=1100kg/m. 3. ). Spring elements were used to represent the ligaments and material properties were taken from Mondal et al. [1]. Lagrangian contact was defined between the cartilaginous surfaces with μ=0.003. A standing load case was modelled, assuming even distribution of load between the feet. A reaction force of 344.3N was applied to the base of the foot, a muscle force of 252.2N, and the proximal ends of the tibia and fibula were fully constrained. Results. The von Mises stresses closely matched those reported by Mondal et al. for the fibula (Present study: 1.00MPa, Mondal: 1.30MPa) and the talus (Present study: 2.20MPa, Mondal: 2.39MPa). However stresses within the tibia were underpredicted (Present study: 1.08MPa, Mondal: 5.86MPa). This was because the present study modelled a shorter tibial length because of a limitation in the CT slices available, which reduced the bending force. Conclusions. This first step in producing an open source ankle model for the orthopaedics community has shown the potential of the model to generate results comparable with those found in the literature. Future work is underway to examine the robustness of the model under different loading and explore alternative open-source CT datasets. [1] Mondal, S., & Ghosh, R. (2017). J Orthopaedics, 14(3), 329–335. . https://doi.org/10.1016/j.jor.2017.05.003

Finite element models of the musculoskeletal system have the possibility of describing the in vivo situation to a greater extent than a single in vitro experimental study ever could. However these models and the assumptions made must be validated before they can be considered truly useful. The object of this study was to validate, using digital image correlation (DIC) and strain gauging, a novel free boundary condition finite element model of the femur. The femur was treated as a complete musculoskeletal construct without specific fixed restraint acting on the bone. Spring elements with defined force-displacement relationships were used to characterize all muscles and ligaments crossing the hip and knee joints. This model was subjected to a loading condition representing single leg stance. From the developed model muscle, ligament and joint reaction forces were extracted as well as displacement and strain plots. The muscles with the most influence were selected to be represented in the simplified experimental setup. To validate the finite element model a balanced in vitro experimental set up was designed. The femur was loaded proximally through a construct representative of the pelvis and balanced distally on a construct representing the tibio-femoral joint. Muscles were represented using a cabling system with glued attachments. Strains were recorded using DIC and strain gauging. DIC is an image analysis technique that enables non-contact measurement of strains across surfaces. The resulting strain distributions were compared to the finite element model. The finite element model produced hip and knee joint reaction forces comparable to in vivo data from instrumented implants. The experimental models produced strain data from both DIC and strain gauging; these were in good agreement with the finite element models. The DIC process was also shown to be a viable method for measuring strain on the surface of the specimen. In conclusion a novel approach to finite element modeling of the femur was validated, allowing greater confidence for the model to be further developed and used in clinical settings

Introduction: Notching of the femoral neck during preparation of the femur during hip resurfacing has been associated with an increased risk of femoral neck fracture. We aimed to evaluate this with the use of a finite element model. Methods: A three dimensional femoral model was used and molded with a femoral component constructed from the dimensions of a Birmingham Hip Resurfacing. Multiple constructs were made with the component inferiorly translated in order to cause a notch in the superior femoral neck. The component angulation was kept constant. Once constructed the model was imported into the Ansys finite element model software for analysis. Elements within the femoral model were assigned different material properties depending on cortical and cancellous bone distributions. Von Misses stresses were evaluated near the notches and compared in each of the cases. Results: In the un-notched case the maximum Von Mises stress was only 40MPa. However, with the formation of a 1mm notch the stress rose to 144MPa and in the 4 mm notch the stress increased to 423MPa. These values demonstrated that a 1mm notch increased the maximum stress by 361% while a 4mm notch increased the maximum stress by 1061%. Discussion: This study demonstrated that causing a notch in the superior femoral neck dramatically increases the stress within the femoral neck. This may result in the weakening of the femoral neck and potentially predispose it to subsequent femoral neck fracture. The data suggests that even a small notch of 1mm may be detrimental in weakening the femoral neck by dramatically increasing the stress in the superior neck. This study suggests that any femoral neck notching should be avoided during hip resurfacing

Introduction. On the basis of a proposal by Noble, the marrow cavity form can be classified into three categories: stovepipe, normal, and champagne-fluted. In the present study, three typical finite element femoral models were created using CT data based on Noble's three categories. The purpose was to identify the relationship of stress distribution of the surrounding areas between femoral bone marrow cavity form and hip stem. The results shed light on whether the distribution of the high-stress area reflects the stem design concept. In order to improve the results of THA, researchers need to consider the instability of a stem design based on the pressure zone and give feedback on future stem selection. Methods. To develop finite element models, two parts (cortical bone and stem) were constructed using four-node tetrahedral elements. The model consisted of about 40,000 elements. The material characteristics were defined by the combination of mass density, elastic coefficient, and Poisson's ratio. Concerning the analysis system, HP Z800 Workstation(HP, Japan) was used as hardware and LS-DYNA Ver. 971 (Livermore Software Technology Corporation, USA) as software. The distal end of the femur was constrained in all directions. On the basis of ISO 7206 Part 4,8 that specifies a method of endurance testing for joint prostheses, the stem was tilted 10°, and a 500 N resultant force in the area around the hip joint was applied to the head at an angle of 25° with the long axis. Automatic contact with a consideration of slip was used. Von Mises stress during a 1.0 s period after loading was analyzed, and stress distribution in the stem and its maximum value were calculated. Result. The maximum stress at marrow cavity form of normal was shown to be 72 MPa. The stress of champagne-fluted was evenly distributed from proximal to distal, and the maximum stress was 67 MPa. For stovepipe, the maximum proximal stress was shown to be 120 MPa; moreover, stress concentration was observed. Discussion. The design concept for a Zweymüller-type stem can distribute load across a wide range of cortical bone from the middle position to the distal femur. It is determined using this concept that a wide range of stress was absorbed at the middle position and distal femur in the champagne-fluted and normal cases. On the other hand, the contact pressure zone of stovepipe could not meet the expected level at the distal femur. The method of this research involves controlling the stress conditions within the stem design. At this point, it is considered possible for the stability of various stem designs to be predicted and the stability to be assessed positively. On the basis of Noble's categories, three types of finite element model were made, and stress distribution measurement and finite element analyses were performed. The results indicate that Zweymüller stem has clinical validity for securing force in the champagne-fluted and stovepipe types from the stress distribution

Introduction. The performance of total hip replacement (THR) devices can be affected by the quality of the tissues surrounding the joint or the mismatch of the component centres during hip replacement surgery. Experimental studies have shown that these factors can cause the separation of the two components during walking cycle (dynamic separation) and the contact of the femoral head with the rim of the acetabular liner (edge loading), which can lead to increased wear and shortened implant lifespan. 1. There is a need for flexible pre-clinical testing tools which allow THR devices to be assessed under these adverse conditions. In this work, a novel dynamic finite element model was developed that is able to generate dynamic separation as it occurs during the gait cycle. In addition, the ability to interrogate contact mechanics and material strain under separation conditions provides a unique means of assessing the severity of edge loading. This study demonstrates these model capabilities for a range of simulated surgical translational mismatch values, for ceramic-on-polyethylene implants. Methodology. The components of the THR were aligned and constrained as illustrated in Figure 1. CAD models of commercially available implant geometries were used (DePuy Synthes, Leeds, UK) modified for model simplicity by removing anti-rotation features. The polyethylene cup liner was given elastic-plastic behaviour. An axial load following the Paul cycle pattern (5 repetitive cycles) with maximum of 3KN and swing phase load of 0.3KN, was applied through the cup holder. The effect of translational mismatch was implemented by using a spring element connected to the cup unit on the lateral side. The spring was compressed by a fixed amount to replicate a degree of medial-lateral mismatch of the components. The instantaneous resultant force vector dictated the dynamic sliding behaviour of the cup against the head. In this study, translational medial-lateral mismatch values of 1, 2, 3 and 4mm were used and the medial-lateral dynamic separation, contact pressure maps and plastic strain were recorded. Results. The highest level of dynamic separation is achieved when the minimum axial load (during swing phase) is applied. The dynamic separation increases as the surgical translation mismatch increases (figure 2), with values over 0.5mm (radial clearance) representing cases where the head is in contact with the rim of the cup. Maximum separation occurred towards the end of the swing phase. Plots of the shape of the contact pressure at that point can be seen in Figure 3. Only the 4mm mismatch created substantial plastic deformation. Conclusion. The finite element model was able to predict medial-lateral separation as it occurred dynamically in the gait cycle, including cases where the femoral head was in contact with the rim of the cup. The increase in medial-lateral separation with increased translational mismatch was in broad agreement with existing experimental data. 2. Substantial plastic deformation was only seen in cases where the translational mismatch caused the femoral head to be in contact with the rim of the polyethylene cup

Introduction A very specific group within the 80 percent of the population that suffers from low back pain at some stage in life are young cricket fast bowlers. Amongst them a high occurrence of unilateral L4 pars interarticularis fractures exists, which shows a strong statistical correlation to the presence of a contralateral volumetric increase in the Quadratus Lumborum (QL) muscle. However, there is no clear physical link between these two phenomena. To investigate this relationship, we have combined a mathematical model of the lumbar spine muscles with a finite element model of the fourth lumbar vertebra and analysed the stresses occurring in the L4 vertebra throughout the bowling motion. Methods A mathematical model of the lumbar spine muscles has been developed previously at QUT. It contains 170 fascicles representing all major muscles in the lumbar region and allows for analysis of the forces and moments on the intervertebral joints caused by these muscles in any given posture. A Finite Element Model (FEM) of an L4 vertebra and intervertebral disc (IVD) was developed based on one created by Theo Smit and obtainable from the Internet through the BEL Repository of the Istituti Ortopedici Rizzoli, Bologna, Italy. Material properties were obtained from literature, while muscle forces, directions and attachment locations in the different postures came from the mathematical model. Six postures occurring in right-handed fast bowling were modelled to determine the differences in stresses between having symmetric and asymmetric QL muscles. The asymmetric condition consisted of a 30% increase in Physiological Cross-Sectional Area (PCSA) on the right side. In all cases it was assumed the left facet joints were ‘locked up’, to create a presumed worst-case scenario for the stress build-up in the pars. Results It was found that when using muscle activation levels from literature an enlarged right-side QL did not increase the stresses in the left pars noticeably, in fact in some cases it even slightly reduced those stresses. When only the right-side QL muscle was activated, while all other muscles only provided passive muscle force, a 30% PCSA increase of this muscle produced an increase in maximum Von Mises and principal stresses in the left-side pars from typically 30 MPa to 40 MPa but only in the postures close to upright stance. In more extreme postures where the maximum stresses in the pars are higher, the increased PCSA of the right QL only led to small stress increases from typically 125 to 129 MPa. Discussion Even in the worst-case scenario where only the right-side QL is active and the left-side facet joint is locked up, a PCSA increase of that muscle does not cause a large increase in stresses in postures where the stresses are high. Hence, this study has not demonstrated a clear physical link between asymmetric hypertrophy of QL and pars fractures. It may even suggest the hypertrophy is a response to postural overload attempting to reduce stresses in the pars. To clarify this, an improved FEM of the L3 and L4 vertebrae and IVDs, including all ligaments, is currently being developed. We believe that in the future this combination of models can be used for many more purposes where the influence of posture and musculature on the lumbar spine biomechanics needs investigation

The primary fixation of cementless hip prostheses is related to the shape of the stem. When there is a complication of loading in several directions, the mechanical fixation of a hip stem is considered to provide good primary fixation. The purpose of this study was to evaluate whether the IMC stem with its characteristic fixation method, which was developed by a group at Kitasato University, contributes to primary fixation by finite element analysis. Analysis was performed at a friction coefficient of 0.1 with automatic contact, under the restriction of the distal femoral end. The following three loading conditions were applied:. step loading of the joint resultant force in the region around the hip stem,. loading in the rotational direction, simulating torsion, and. loading of the femoral head equivalent to that during walking. Micromotion of the IMC stem along the x-, y-, and z-axes direction was calculated by simulation, and the stress distributed on the stem and femur was determined. Micromotion along the z-axis, which is a clinical problem in hip prosthesis stems, was lower in the IMC stem than in other stems reported. Micromotion of the stem along the z-axis was low, indicating a low risk of sinking. The interlocking mechanism, which is a characteristic of the IMC stem, functioned to suppress its micromotion, indicating that the locking method of this stem contributed to the stability. Since no stress concentration was detected, it was considered that there are no risks of breakage of the IMC stem and femur. It was suggested that effective fixation of the finite element model of the IMC stem can be achieved because the micromotion and stress level are appropriate for primary fixation

Worldwide, osteoporosis, causes more than 8.9 million fractures annually, resulting in an osteoporotic fracture every 3 seconds, where 1 in every 3 women and 1 in every 5 men aged over 50 will experience osteoporotic fractures at least once in their lifetime. Vertebral fractures, estimated at 1.4 million/year are among the most common fractures, posing enormous health and socioeconomic challenges to the individual and society at large. Considering that the great majority of individuals at high risk (up to 80%), who have already had at least one osteoporotic fracture, are neither identified nor treated, prediction of the risk factors for vertebral fractures can be of great value for prevention/early diagnosis. Recent studies show that finite element analysis of computed tomography (CT) scans provides noninvasive means to assess fracture risk and has the potential to be clinically implemented upon proper validation. The objective of this study was to develop a voxel-based finite element model using quantitative computed tomography (QCT) images in conjunction with in-vitro experiments to evaluate the strength of the vertebral bodies and predict the fracture risk criteria. A total of 10 vertebrae were dissected from juvenile sheep lumbar spines. The attached soft tissues and posterior elements and facet joints were completely removed, and the upper and lower vertebral bodies were polished using glass paper to provide smooth surfaces. The specimens were wrapped in phosphate buffer saline (PBS) soaked gauze, sealed in plastic bags, and stored in a refrigerator at −22°C. QCT scans of the specimens were captured using a bone density calibration phantom (QRM Co., Moehrendorf, Germany) with three 18 mm cylindrical inserts, providing 0, 100 and 200 mg HA/ccm, respectively. All the specimens, preserved hydrated in PBS solution, were mechanically tested at room temperature using a mechanical testing apparatus (Zwick/Roell, Ulm-Germany). The QCT images were then used to reconstruct the voxel-based FE model employing a custom-developed heterogeneous material mapping code. Five different equations for the correlation of the density and the elastic modulus were used to validate the efficiency of the FE model as compared to the in-vitro experiments. The results of the voxel-based FE models matched well with the in-vitro experiments, with an average error of 11.38 (±4.09)% based on the power law equation. A failure criterion was embedded in the FE models and the initiation of fracture was successfully predicted for all specimens. Further, typical kyphoplasty treatment was simulated in the 5 models to evaluate the application of the validated algorithm in the estimation of the failure patterns. Our novel voxel-based FE model can be used in future studies to predict the outcome of different types of therapeutic modalities/surgeries and estimate fracture risk including postoperative fractures

25–40% of unicompartmental knee replacement (UKR) revisions are performed for unexplained pain possibly secondary to elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on cancellous bone strain in a finite element model (FEM) of a cemented fixed bearing medial UKR, validated using previously published acoustic emission data (AE). FEMs of composite tibiae implanted with an all-polyethylene tibial component (AP) and a metal backed one (MB) were created. Polyethylene of thickness 6–10mm in 2mm increments was loaded to a medial load of 2500N. The volume of cancellous bone exposed to <−3000 (pathological overloading) and <−7000 (failure limit) minimum principal (compressive) microstrain (µ∊) and >3000 and >7000 maximum principal (tensile) microstrain was measured. Linear regression analysis showed good correlation between measured AE hits and volume of cancellous bone elements with compressive strain <−3000µ∊: correlation coefficients (R= 0.947, R2 = 0.847), standard error of the estimate (12.6 AE hits) and percentage error (12.5%) (p<0.001). AP implants displayed greater cancellous bone strains than MB implants for all strain variables at all loads. Patterns of strain differed between implants: MB concentrations at the lateral edge; AP concentrations at the keel, peg and at the region of load application. AP implants had 2.2 (10mm) to 3.2 (6mm) times the volume of cancellous bone compressively strained <−7000µ∊ than the MB implants. Altering MB polyethylene insert thickness had no effect. We advocate using caution with all-polyethylene UKR implants especially in large or active patients where loads are higher

Summary. A retrospective study on 98 patients shows that FE-based bone strength from CT data (using validated FE models) is a suitable candidate to discriminate fractured versus controls within a clinical cohort. Introduction. Subject-specific Finite element models (FEM) from CT data are a promising tool to non-invasively assess the bone strength and the risk of fracture of bones in vivo in individual patients. The current clinical indicators, based on the epidemiological models like the FRAX tool, give limitation estimation of the risk of femoral neck fracture and they do not account for the mechanical determinants of the fracture. Aim of the present study is to prove the better predictive accuracy of individualised computer models based a CT-FEM protocol, with the accuracy of a widely used standard of care, the FRAX risk indicator. Patients and Methods. This retrospective cohort is individually-matched case control study composed by 98 Caucasian women who were at least 5 years post menopause. The case group consisted of 49 patients who had sustained a hip fracture (36 intra-capsular and 13 extra-capsular fractures) within the previous 90 days due to low-energy trauma. The CT datasets were segmented (using the ITK-Snap software) in order to extract the periosteal bone surface. Unstructured meshes (10-node tetrahedral elements) were generated using ANSYS mesh morphing software. Each CT dataset was calibrated using the European Spine Phantom. The inhomogeneous material properties were mapped from CT datasets into the FEM with the BoneMat_V3 software. Bone strength was evaluated in quasi-axial loading conditions, for a set of 12 different configurations sampling the cone of recorded in vivo hip joint reactions, and was defined as the minimum load inducing on the femoral neck surface an elastic principal strain value greater than a limit value. Results. There were no statistically significant difference between the fracture and the control groups for age, height and weight (p<0.05). All indices of areal bone mineral density (aBMD) and the volumetric mineral density (vBMD) between fractured and controls showed on average a lower value for fractured respect of the controls, with similar mean difference (14% for aBMD and 13% for the vBMD). FEM-predicted strength differed between fractured and non-fractured on average for 20%. To evaluate its ability to identify patients at risk of hip fracture, FEM-based strength was compared to the FRAX predictor by computing for each predictor the Receiver Operating Characteristic (ROC) curve, and the Area Under the Curve (AUC). The individualised risk predictor based on FEM bone strength was found to perform significantly better (AUC=0.76) than FRAX (AUC=0.66). When the FEM-based strength indicator was combined with available clinical information in a logistic regression, the resulting predictor achieved in this retrospective study an excellent accuracy (AUC=0.82). Discussion. This study confirms that individualised, CT- FEM, when generated using to the state-of-the-art protocols, can provide a predictor of the risk of hip fracture more accurate than those based on clinical data alone. In the integrated workflow developed in the VPHOP Project (FP7-ICT-223865) CT-based risk prediction is requested only for those patients for whom the clinical decision is uncertain

Background. It is known that severe cases of intervertebral disc (IVD) disease may lead to the loss of natural intervertebral height, which can cause radiating pain throughout the lower back and legs. To this point, surgeons perform lumbar fusion using interbody cages, posterior instrumentation and bone graft to fuse adjacent vertebrae together, thus restoring the intervertebral height and alleviating the pain. However, this surgical procedure greatly decreases the range of motion (ROM) of the treated segment, mainly caused by high cage stiffness. Additive manufacturing can be an interesting tool to reduce the cage's elastic modulus (E), by adding porosity (P) in its design. A porous cage may lead to an improved osteointegration since there is more volume in which bone can grow. This work aims to develop a finite element model (FEM) of the L4-L5 functional spinal unit (FSU) and investigate the loss of ROM induced by solid and porous cages. Materials and Methods. The Intact-FEM of L4-L5 was created, which considered the vertebrae, IVD and ligaments with their respective material properties. 1. The model was validated by comparing its ROM with that of other studies. Moments of 10 Nm were applied on top of L4 while the bottom of L5 was fixed to simulate flexion, extension, lateral bending and axial rotation. 2. The lumbar cages, posterior instrumentation and bone graft were then modelled to create the Cage-FEMs. Titanium was chosen for the instrumentation and cages. Cages with different stiffness were considered to represent porous structures. The solid cage had the highest modulus (E. 0. =110 GPa, P. 0. =0%) whereas the porous cages were simulated by lowering the modulus (E. 1. =32.8 GPa, P. 1. =55%; E. 2. =13.9 GPa, P. 2. =76%; E. 3. =5.52 GPa, P. 3. =89%; E. 4. =0.604 GPa, P. 4. =98%), following the literature. 3. The IVD was removed in Cage-FEMs to allow the implant's insertion [Fig. 1] and the previous loading scenarios were simulated to assess the effects of cage porosity on ROM. Results. The Intact-FEM presents acceptable ROM according to experimental and numerical studies, as shown by the red line in Figure 2. After insertion, lower ROM values in Cage-FEMs are measured for each physiological movement [Fig. 3]. In addition, highly porous cages have greater ROM, especially in axial rotation. Discussion. Significant reduction of ROM is expected after cage insertion because the main goal of interbody fusion is to allow bone growth. As such, the procedure's success is highly dependent on segmental stability, which is achieved by using cages in combination with bone graft and posterior instrumentation. Furthermore, higher cage porosities seem to affect the FSU. In fact, ROM increases more as the cage modulus approaches that of the cancellous bone (E. canc-bone. =0.2 GPa. 1. ). Next step will be to assess the effects of cage design on the L4-L5 FSU mechanical behavior and stress distribution. To conclude, additive manufacturing offers promising possibilities regarding implant optimization, being able to create porous cages, thus reducing their stiffness. For any figures or tables, please contact the authors directly

We previously demonstrated that cartilaginous tissue was induced on a reamed acetabular articulation in an ovine hemiarthroplasty model with three different femoral head sizes. At maximum loading during stance phase, the acetabular peak stresses immediately after reaming could reach approximately 80 MPa under direct implant-bone contact with in-vitro measurements. We aimed to establish finite element (FE) models of the ovine hip hemiarthroplasty which examine stress distribution on the reamed acetabula by three head sizes. We hypothesized that the stress distribution did not differ between different sizes when the joint is congruent and that the peak stresses in the acetabulum immediately after reaming occurred in the dorsal acetabulum. Three two-dimensional FE models of ovine hip hemi-arthroplasty were built; each comprised a head component, 25, 28, and 32 mm in diameter, and an acetabular component. The acetabular geometry was acquired from an ovine acetabular histological section. The head was moved to partly intersect with the acetabulum representing the reaming procedure and a congruent contact was confirmed. Cortical bone and cancellous bone were modelled as linear elastic, with moduli of 20 and 1.2 GPa, respectively. Variable moduli were also assessed. The finest mesh for each model consisted of over 100,000 four-node quadrilateral elements. Loading conditions were chosen to represent peak hip joint force developed during the stance phase. Stress distribution in the acetabular area in contact with the head was plotted against the articulating arc length. The results confirmed that the stress distribution between different prosthetic head sizes in a reamed hemiarthroplasty model did not change when the joint was congruent. The peak compressive stresses occurred in the dorsal acetabulum with the 32 mm model being the highest at approximately 69 MPa, the 28 mm model at 63 MPa, and the 25 mm model at 54 MPa. An increase in the cancellous modulus and a decrease in the cortical modulus increased the peak stresses in the dorsal acetabulum. This presents an indicative study into the effect of prosthetic femoral head sizes on the stress distribution in the acetabulum. The idealized 2-D models showed reasonable agreement when compared quantitatively with the in vitro study

Iterative finite element (FE) models are used to simulate bone remodelling that takes place due to the surgical insertion of an implant or to simulate fracture healing. In such simulations element material properties are calculated after each iteration of solving the model. New material properties are calculated based on the results derived by the model during the last iteration. Once the FE model has gone through a number of such iterations it is often necessary to assess the remodelling that has taken place. The method widely used to do this is to analyse element Young's modulus plots taken at particular sections through the model. Although this method gives relevant information which is often helpful when comparing different implants, the information is rather abstract and is difficult to compare with patient data which is commonly in the form of radiographs. The authors suggest a simple technique that can be used to generate synthetic radiograph images from FE models. These images allow relatively easy comparisons of FE derived information with patient radiographs. Another clear advantage of this technique is that clinicians (who are familiar with reading radiographs) are able to understand and interpret them readily. To demonstrate the technique a three dimensional (3D) model of the proximal tibia implanted with an Oxford Unicompartmental Knee replacement was created based on CT data obtained from a cadaveric tibia. The model's initial element material properties were calculated from the same CT data set using a relationship between radiographic density and Young's modulus. The model was subject to simplified loading conditions and solved over 365 iterations representing one year of in vivo remodelling. After each iteration the element material properties were recalculated based on previously published remodelling rules. Next, synthetic anteroposterior radiographs were generated by back calculating radiographic densities from material properties of the model after 365 iterations. A 3D rectangular grid of sampling points which encapsulated the model was defined. For each of the elements in the FE model radiographic densities were back calculated based on the same relationships used to calculate material properties from radiographic densities. The radiographic density of each element was assigned to all the sampling grid points within the element. The 3D array of radiographic densities was summed in the anteroposterior direction thereby creating a 2D array of radiographic densities. This 2D array was plotted giving an image analogous to anteroposterior patient radiographs. Similar to a patient radiograph denser material appeared lighter while less dense material appeared darker. The resulting synthetic radiographs were compared to patient radiographs and found to have similar patterns of dark and light regions. The synthetic radiographs were relatively easy to produce based on the FE model results, represented FE results in a manner easily comparable to patient radiographs, and represented FE results in a clinician friendly manner

Summary. At the clinical CT image resolution level, there is no influence of the image voxel size on the derived finite element human cancellous bone models. Introduction. Computed tomography (CT)-based finite element (FE) models have been proved to provide a better prediction of vertebral strength than dual-energy x-ray absorptiometry [1]. FE models based on µCTs are able to provide the golden standard results [2], but due to the sample size restriction of the µCT and the XtremeCT machines, the clinical CT-based FE models is still the most promising tool for the in vivo prediction of vertebrae's strength. It has been found [3] that FE predicted Young's modulus of human cancellous bone increases as the image voxel size increases at the µCT resolution level [3]. However, it is still not clear whether the image voxel size in the clinical range has an impact on the predicted mechanical behavior of cancellous bone. This study is designed to answer this question. Methods. For this study, 6 thoracolumbar vertebrae (Th12) obtained from the female donors were scanned in the non-dissected cadavers under 2 different resolutions – group A: 120 kVp, 100 mAs, with a resolution of 0.29×0.29×1.3 mm. 3. ; group B: 120 kVp, 360 mAs, with a resolution of 0.18×0.18×0.6 mm. 3. A solid calibration phantom (QRM-BDC) was placed beneath the cadavers during the scans. Cuboids with the size of 12.3×12.3×14.3 mm. 3. were cropped from the center of each vertebral body. The FE model was created by converting each image voxel into hexahedron (C3D8). Inhomogeneous material property was defined for the cuboid [4], i.e. the image greyscale value were firstly calibrated into the bone mineral density (BMD), then the Young's modulus and yield stress were calculated from the BMD [5] for each element. Statistical analysis was performed to compare the FE predicted mechanical properties between the groups and the significance level was set to 95% (α=0.05). Results. The trabecular structure is more clearly mimicked in the models from group B than those from group A. The modulus (mean ± SE) in group A is 5.9% higher than that in group B (193.33 ± 31.67 MPa vs. 182.50 ± 27.07 MPa). The yield strength (mean ± SE) in group A is 6.4% higher than that in group B (0.99 ± 0.21MPa vs. 0.93 ± 0.17MPa). However, the paired t-test shows there is no significant difference of the mechanical properties in the two groups (p=0.109 for the modulus and p=0.234 for the yield strength). Discussion. This study shows that there is no influence of the voxel size on the clinical CT derived FE cancellous bone models. This finding can help choose a better, less invasive CT protocol for the patient when creating a clinical CT image based FE model. Acknowledgements. This study is financially supported by the Federal Ministry of Education and Research and the state of Hamburg, Germany

Clinical investigations show that the cervical spine presents wide inter-individual variability, where its motion patterns and load sharing strongly depend on the anatomy. The magnitude and scope of cervical diseases, including disc degeneration, stenosis, and spondylolisthesis, constitute serious health and socioeconomic challenges that continue to increase along with the world”s growing aging population. Although complex exact finite element (FE) modeling is feasible and reliable for biomechanical studies, its clinical application has been limited as it is time-consuming and constrained to the input geometry, typically based on one or few subjects. The objective of this study was twofold: first to develop a validated parametric subject-specific FE model that automatically updates the geometry of the lower cervical spine based on different individuals; and second to investigate the motion patterns and biomechanics associated with typical cervical spine diseases. Six healthy volunteers participated in this study upon informed consent. 26 parameters were identified and measured for each vertebra in the lower cervical spine from Lateral and AP radiographs in neutral, flexion and extension viewpoints in the standing position. The lower cervical FE model was developed including the typical vertebrae (C3-C7), intervertebral discs, facet joints, and ligaments using ANSYS (PA, USA). In order to validate the FE model, the bottom surface of C7 was fixed, and a 73.6N preload together with a 1.8 N.m pure moment were input into the model in both flexion and extension. The results were compared to experimental studies from literature. Disc degeneration disease (DDD) was used as an example, where the geometry of C5-C6 disc was changed in the model to simulate 3 different grades of disc degeneration (mimicking grades 1 to 3), and the resulting biomechanical responses were evaluated. The average ranges of motion (ROM) were found to be 4.84 (±0.73) degrees and 5.36 (±0.68) degrees for flexion and extension for C5-C6 functional unit, respectively, in alignment with literature. The total ROM of the model with disc generation grades 2 and 3 was found to have decreased significantly as compared to the intact model. In contrast, the axial stresses on the degenerated discs were significantly higher than the intact discs for all 3 degeneration grades. Our preliminary results show that this novel validated subject-specific FE model provides a potential valuable tool for noninvasive time and cost effective analyses of cervical spine biomechanical (kinematic and kinetic) changes associated with various diseases. The model also provides an opportunity for clinicians to use quantitative data towards subject-specific informed therapy and surgical planning. Ongoing and future work includes expanding the studied population to investigate individuals with different cervical spine afflictions

Adult Spine Deformity (ASD) is a degenerative condition of the adult spine leading to altered spine curvatures and mechanical balance. Computational approaches, like Finite Element (FE) Models have been proposed to explore the etiology or the treatment of ASD, through biomechanical simulations. However, while the personalization of the models is a cornerstone, personalized FE models are cumbersome to generate. To cover this need, we share a virtual cohort of 16807 thoracolumbar spine FE models with different spine morphologies, presented in an online user-interface platform (SpineView). To generate these models, EOS images are used, and 3D surface spine models are reconstructed. Then, a Statistical Shape Model (SSM), is built, to further adapt a FE structured mesh template for both the bone and the soft tissues of the spine, through mesh morphing. Eventually, the SSM deformation fields allow the personalization of the mean structured FE model, leading to generate FE meshes of thoracolumbar spines with different morphologies. Models can be selectively viewed and downloaded through SpineView, according to personalized user requests of specific morphologies characterized by the geometrical parameters: Pelvic Incidence; Pelvic Tilt; Sacral Slope; Lumbar Lordosis; Global Tilt; Cobb Angle; and GAP score. Data quality is assessed using visual aids, correlation analyses, heatmaps, network graphs, Anova and t-tests, and kernel density plots to compare spinopelvic parameter distributions and identify similarities and differences. Mesh quality and ranges of motion have been assessed to evaluate the quality of the FE models. This functional repository is unique to generate virtual patient cohorts in ASD.

Acknowledgements: European Commission (MSCA-TN-ETN-2020-Disc4All-955735, ERC-2021-CoG-O-Health-101044828)

INTRODUCTION. Growth-guidance constructs are an alternative to growing rods for the surgical treatment of early onset scoliosis (EOS). In growth-guidance systems, free-sliding anchors preserve longitudinal spinal growth, thereby eliminating the need for surgical lengthening procedures. Non-segmental constructs containing ultra-high molecular weight polyethylene (UHMWPE) sublaminar wires have been proposed as an improvement to the traditional Luque trolley. In such a construct, UHMWPE sublaminar wires, secured by means of a knot, serve as sliding anchors at the proximal and distal ends of a construct, while pedicle screws at the apex prevent rod migration and enable curve derotation. Ideally, a construct with the optimal UHMWPE sublaminar wire density, offering the best balance between providing adequate spinal fixation and minimizing surgical exposure, is designed preoperatively for each individual patient. In a previous study, we developed a parametric finite element (FE) model that potentially enables preoperative patient-specific planning of this type of spinal surgery. The objective of this study is to investigate if this model can capture the decrease in range of motion (ROM) after spinal fixation as measured in an experimental study. MATERIALS AND METHODS. In a previous in vitro study, the ROM of an 8-segment porcine spine was measured before and after instrumentation, using different instrumentation constructs with a sequentally decreasing number of wire fixation points. In the current study, the parametric FE model of the thoracolumbar spine was first validated relative to ROM values reported in the literature. The rods, screws, and sublaminar wires were implemented, and the model was subsequently used to replicate the in vitro tests. The experimental and simulated ROM”s for the different instrumentation conditions were compared. RESULTS. Good agreement between in vitro biomechanical tests and FE simulations was observed in terms of the decrease in ROM for the complete construct with wires at each level. The stepwise increase in total ROM with decreasing number of wires at the construct ends was less prominent in silico in comparison to in vitro. CONCLUSION. Important first steps in the implementation and validation of a growth-guidance construct for EOS patients in a patient-specific FE model of the spine have been made in this study. The parametric nature of the FE model allows for rapid personalization. Although further improvements to the model will be necessary to better distinguish between different spinal instrumentation constructs, we conclude that the model can well capture essential aspects of spinal motion and the overall effect of instrumentation

A recently developed parametric geometrical finite element model (p-FEM) was adapted to the specific hip geometric measurements of a group of patients with slipped capital femoral epiphysis (SCFE). The objective was to analyze the stress distribution in the growth plate of these patients and to evaluate differences for those patients who developed bilateral disease. Different geometric parameters were measured in the healthy proximal femur of 18 adolescents (mean age, 12,1 yr) with unilateral SCFE and in 23 adolescents matched in age without hip disease (control group). Five patients developed SCFE in the contralateral side during follow-up. Different geometric measurements were taken from hip conventional X-ray studies. The p-FEM of the proximal femur permits modifications of different geometrical parameters, therefore the X-ray measurements taken from each patient were applied to the model obtaining a subject-specific model for each case. In each model, different mechanical situations such as walking, stairs climbing and sitting were simulated by applying loads on the femoral head corresponding to each own weight. The risk for growth plate failure was estimated by the Tresca, von Misses and Rankine stresses. In summary, the models shows important differences between the stresses computed at the healthy femurs of patients with unilateral SCFE and femurs that further underwent bilateral SCFE. So, the 95% confidence interval of the percentage of volume of the growth plate subjected to stresses higher than 2MPa was almost similar for the control group and patients with unilateral SCFE. However, those patients who developed bilateral disease had statistically significant large physeal areas with more than 2.0 MPa (p< 0.005). Stresses were also strongly dependent on the geometry of the proximal femur, especially on the posterior sloping angle of the physis and the physeal sloping angle. In spite of simplifications of the developed p-FEM, this tool has been able to show the influence of femur geometry in growth plate stresses and to predict the sites where growth plate starts to fail

Finite element (FE) analysis is widely used to calculate stresses and strains within human bone in order to improve implant designs. Although validated FE models of the human femur have been created (Lengsfeld et al., 1998), no equivalent yet exists for the tibia. The aim of this study was to create such an FE model, both with and without the tibial component of a knee replacement, and to validate it against experimental Results: A set of reference axes was marked on a cleaned, fresh frozen cadaveric human tibia. Seventeen triaxial stacked strain rosettes were attached along the bone, which was then subjected to nine axial loading conditions, two four-point bending loading conditions, and a torsional loading condition using a materials testing machine (MTS 858). Deflections and strain readings were recorded. Axial loading was repeated after implantation of a knee replacement (medial tibial component, Biomet Oxford Unicompartmental Phase 3). The intact tibia was CT scanned (GE HiSpeed CT/i) and the images used to create a 3D FE mesh. The CT data was also used to map 600 transversely isotropic material properties (Rho, 1996) to individual elements. All experiments were simulated on the FE model. Measured principal strains and displacements were compared to their corresponding FE values using regression analysis.

Experimental results were repeatable (mean coefficients of variation for intact and implanted tibia, 5.3% and 3.9%). They correlated well with those of the FE analysis (R squared = 0.98, 0.97, 0.97, and 0.99 for axial (intact), axial (implanted), bending, torsional loading). For each of the load cases the intersects of the regression lines were small in comparison to the maximum measured strains (< 1.5%). While the model was more rigid than the bone under torsional loading (slope =0.92), the opposite was true for axial (slope = 1.14 (intact) 1.24 (implanted)) and bending (slope = 1.06) loads. This is probably due to a discrepancy in the material properties of the model.