Disc degeneration is a natural process and is widely prevalent. The severity of disc degeneration and the type of treatment varies from person to person. Fusion is a commonly chosen treatment option. However, clinical and biomechanical studies have shown that intervertebral discs adjacent to a fusion experience increased motion and higher stress which may lead to adjacent-segment disease. Cervical disc arthroplasty achieves similar decompression of the neural elements, but preserves the motion at the operated level and may potentially decrease the occurrence of adjacent segment degeneration. Computationally, a validated intact 3D finite element model of the cervical spine (C2-T1) was modified to simulate single (C5-C6) and bi-level (C5-C7) degeneration. The single level degenerative model was modified to simulate single level fusion and arthroplasty with the Bryan and Prestige LP artificial discs. The bi-level degenerative model was modified to simulate a bi-level fusion, bi-level arthroplasty with Bryan and Prestige LP discs and a disc replacement adjacent to fusion. An in-vitro biomechanical study was also conducted to address the effects of arthroplasty and fusion on the kinematics of the cervical spine. A total of 11 specimens (C2-T1) were divided into two groups (Bryan and Prestige LP). The specimens were tested in the following order; intact, single level TDR at C5-C6, bi-level TDR C5-C6-C7, fusion at C5-C6 and TDR at C6-C7 (Hybrid construct) and finally a bi-level fusion. The intact state was tested up to a moment of 2Nm. After surgical intervention, the specimens were loaded until the primary motion (C2-T1) matched the motion of intact state (hybrid control). In all cases; computational and experimental, an arthroplasty preserved motion at the implanted level and maintained normal motion at the nonoperative levels. A fusion, on the other hand, resulted in a significant decrease in motion at the fused level and an increase in motion at the un-fused levels. In the hybrid construct, the TDR adjacent to fusion preserved motion at that level, thus reducing the demand on the other levels. The computational models were used to analyze disc stresses at the adjacent levels and facet forces at the index and adjacent levels. The disc stresses followed the same trends as motion. Facet forces though, increased considerably at the index level following a TDR. There was a decrease in facet forces however at the adjacent levels. The adjacent level facet forces increased considerably with a fusion. The hybrid construct had adjacent level facet forces between the bi-level TDR and bi-level fusion models. To conclude, this study highlighted that cervical disc replacement with both the Bryan and Prestige LP discs not only preserved the motion at the operated level, but also maintained the normal motion at the adjacent levels. Under hybrid loading, the motion pattern of the spine with a TDR was closer to the intact motion pattern, as compared to the degenerative or fusion models. Also, in the presence of a pre-existing fusion, this study shows that an adjacent segment disc replacement is preferable to a second fusion.

Though the literature contains many computational models studying RSA, very few utilize finite element analysis to study stresses in the implant and the surrounding bone. The introductions section shows that many parameters (center of rotation lateralization, center of rotation superior or inferior position, tilt of the cut glenoid surface, glenosphere shape design, glenosphere size, humeral design, notch severity, etc.) have been studied independently utilizing many different methods (finite element modeling and non-FE computational modeling). However, the introduction section also detailed the current limitations in modern modeling as well as many examples of the heights to which finite element modeling can be taken to study RSA. Using these limitations as guidelines, the goal of this project is to create a robust FE model of RSA to study the effect of lateralization on scapular notching and shoulder function. In the following chapters, the development of the model is detailed. In addition, results produced by the incrementally advanced models are shown. In Chapter 2, the initial finite element model encompassing scapular and RSA hardware geometry is described. Chapter 3 contains description of incremental changes to the model including humeral geometry and muscle element incorporation. An anatomically realistic configuration of the finite element model with increased functionality is detailed in Chapter 4. Finally, Chapter 5 discusses the assets and limitations of the current model as a platform for future research. In addition, a proposed validation protocol is presented.

Die Möglichkeiten der operativen Rekonstruktion degenerativ veränderter Hüftgelenke sind komplex und vielfältig. Bei den derzeit zur Verfügung stehenden operativen Behandlungsmassnahmen führen die Vor- und Nachteile immer wieder zur Diskussionen und Abwägung der Operationsverfahren. Hierbei stehen sich die rasche postoperative Mobilisierung sowie eine verminderte Rekonvaleszenzzeit mit den diskutierten Nachteilen einer schlechteren Übersichtlichkeit und damit verbundenen Fehlimplantationen gegenüber. Dies und die damit verbundene volkswirtschaftliche Bedeutung sind ein ständiger Ausgangspunkt für das Bemühen den optimalen Zugangsweg zu etablieren. Daher stellte das von Smith-Peterson 1949 publizierte Verfahren einen Meilenstein in der operativen Therapie dar. Hierdurch konnten zum einen die operationstechnischen Vorteile wie auch das volkswirtschaftliche Begehren nach kürzeren postoperativen Verweildauern vereint werden. Die Modifizierung dieses Zugangsweges hat sich bereits in einer großen Anzahl prospektiver Studien als zuverlässiges Rekonstruktionsverfahren etabliert und erfüllt zudem auch die Anforderungen der heutigen Medizin nach ästhetisch schönen Ergebnissen. In der vorliegenden Arbeit wurde eine prospektive Fallstudie des direkten anterioren Zugangs mit einem gesunden Vergleichskollektiv durchgeführt. Mit dem Ziel, die Aktivität ein Jahr postoperativ nach Implantation einer HTEP mit gesunden Probanden zu vergleichen. Von Januar 2009 bis Mai 2011 wurden insgesamt 77 Patienten und 59 Probanden in die Studie aufgenommen. Als Vergleichswerte wurde zum einen die klinische wie auch die radiologische Untersuchung herangezogen. In der klinischen Untersuchung zeigte sich insgesamt ein signifikanter Anstieg der untersuchten Scores im Vergleich mit den präoperativen Ergebnissen bei den Operierten. Im Vergleich zu den Probanden erzielen die Patienten ein Jahr nach HTEP teilweise noch schlechtere Werte in dem Bewegungsumfang und den Aktivitätsniveaus welche mittels der Auswertung des Stepwatches, des TWB und des Arzt-Patienten-Fragebogens erhoben wurden. Die radiologische Bewertung diente zur Feststellung der Positionierung der HTEP. Mit guten Positionierungen durch den direkten anterioren Zugang. Die Bewertung der Funktionalität zwischen den beiden Gruppen erfolgte durch den HHS, XSFMA- D und den Arzt-Patientenfragenbogen. Hierbei konnten ähnliche Ergebnisse, wie bereits oben beschrieben, verzeichnet werden mit guten Werten in der Gruppe der untersuchten Patienten, jedoch einer geringeren Funktionalität im Vergleich zu den Probanden. Die vorliegende Arbeit zeigt, dass der direkte anteriore Zugang die Wiederherstellung eines guten postoperativen Gesundheitszustandes mit erreichen eines hohen postoperativen Aktivitätslevels der Patienten ermöglicht. Ebenso erfüllt dieser Zugangsweg die Anforderungen der heutigen Medizin im Sinne einer schnellen postoperativen Mobilisation. Im Vergleich zu anderen minimal-invasiven Verfahren zeigen sich eine gute Implantierbarkeit, eine gute Positionierung und ein niedriges Komplikationsniveau. Prinzipiell hat der minimal-invasive anteriore Zugang das Potenzial sich als ein Standardverfahren in der operativen Rekonstruktion bei Hüftgelenksersatz zu etablieren, jedoch wäre ein direkter Vergleich mit dem lateralen Zugang erstrebenswert und sollte in weiteren Studien verglichen werden. / Background: The aim of this prospectve study was to evaluate the clinical results one year after total hip arthroplasty performed through a minimally invasive direct anterior approach versus a healthy volunteer group. Methods: 77 patients and 59 probands have been evaltuated applying the Stepwatch activity monitor (SAM), the Harris hip score (HHS), the SF 36, a daliy activity questionnaire (DAQ) and the XSFMA. Results: The average SAM showed significant differences of 5658 steps (patients) compared to 6417 steps (proband) (p=0,011). The same routcome can be seen in the DAQ with 4226 (patients) and 4686 (proband) cycles (p=0,327) respectively. No significant difference occured by using the average HHS reflecting an equal outcome of 90,7 points in the patient group compared to 90.8 points in the proband group (p=0,022). In contrast tot he afore-mentioned HHS, was a significant increase of the XSFMA reported with 10,9 (patients) and 5.0 (proband) (p=0,001). The SF -36 physical component scores were 45.8 (patients) and 50.6 (proband) while the psychometric properties added up to 56.6 (patients) and 55.9 (proband). While the physical component scores (p=0,001) showed a significant difference this couldnt be observed for the psychometric properties (p=0,511). Conclusion: In our study, good results have been obtained after the first year of the total hip arthroplasty, however these are not as beneficial as the outcomes in the healthy volunteer group.

Wear particle-induced inflammation leading to periprosthetic osteolysis remains a major cause of hip implant failure. As polyethylene particles from conventional metal-on-polyethylene implants have been associated with these failures, an interest in lower wear metal-on-metal (MM) bearings has emerged. However, the biological effects of nanometer-size chromium oxide particles, predominant type of wear particles produced by MM implants, remain mostly unknown. Therefore, this study aimed to determine the cytotoxicity of nanometer-size Cr2O3 particles on macrophages in vitro, by analyzing their effects on cell mortality and cytokine release and comparing them with those of similarly-sized alumina (Al2O3) particles (known to be relatively bioinert). Results showed that at high concentrations, nanometer-size Cr2O3 particles can be cytotoxic to macrophages, inducing significant decreases in total cell numbers and increases in necrosis. Results also showed that, at high concentrations, the cytotoxicity of Cr2O3 particles was overall higher than that of Al2O3 particles, even though Cr2O3 and Al2O3 are both stable forms of ceramic materials. However, it appeared to be lower than that of previously reported conventional polyethylene and CoCrMo particles. Therefore, chromium oxide particles may not be the main culprit in initiating the inflammatory reaction in MM periprosthetic tissues.

Wear particle-induced inflammation leading to periprosthetic osteolysis remains a major cause of hip implant failure. As polyethylene particles from conventional metal-on-polyethylene implants have been associated with these failures, an interest in lower wear metal-on-metal (MM) bearings has emerged. However, the biological effects of nanometer-size chromium oxide particles, predominant type of wear particles produced by MM implants, remain mostly unknown. Therefore, this study aimed to determine the cytotoxicity of nanometer-size Cr2O3 particles on macrophages in vitro, by analyzing their effects on cell mortality and cytokine release and comparing them with those of similarly-sized alumina (Al2O3) particles (known to be relatively bioinert). Results showed that at high concentrations, nanometer-size Cr2O3 particles can be cytotoxic to macrophages, inducing significant decreases in total cell numbers and increases in necrosis. Results also showed that, at high concentrations, the cytotoxicity of Cr2O3 particles was overall higher than that of Al2O3 particles, even though Cr2O3 and Al2O3 are both stable forms of ceramic materials. However, it appeared to be lower than that of previously reported conventional polyethylene and CoCrMo particles. Therefore, chromium oxide particles may not be the main culprit in initiating the inflammatory reaction in MM periprosthetic tissues.

The purpose of this thesis was to explore the use of cost effectiveness for interventions in orthopaedics. This was done through three cost effectiveness articles that have been published by the author. In each of these articles, similar methodologies were used. Decision models were constructed for cost-effectiveness analyses of competing orthopaedic interventions. Outcome probabilities and effectiveness values were derived from the literature. Effectiveness was expressed in quality adjusted life years gained. Cost data were compiled and verified from either hospital cost data or from Medicare data. Costs and utilities were discounted in accord with the United States Panel on Cost Effectiveness in Health and Medicine. Principal outcome measures were average incremental costs, incremental effectiveness, incremental quality-adjusted life years, and, in the case of one article, net health benefits. In particular the articles compared the following: 1. Core decompression versus conservative management for osteonecrosis of the hip as a way to delay hip replacement; 2. Total knee arthroplasty versus unicompartmental knee arthroplasty; and 3. Periacetabular osteotomy versus total hip arthroplasty for a young adult with developmental dysplasia of the hip. The more cost effective intervention was identified in each case, along with implications of the results for clinical and operative decision-making. Cost effectiveness was found to be a useful tool in orthopaedic surgery under limited circumstances of either scarce data on new interventions or the need to use more resources to achieve greater effectiveness. It also can provide excellent insight into ways to direct future clinical research.

The aim of this thesis was to determine if the size of the femoral head can influ-ence corrosion at the head-neck taper interface of total hip arthroplasty (THA) prosthe-ses. A hypothesis was developed that large head sizes could result in a greater toggling torque at the head-neck taper interface by increasing the distance between the centre of the femoral head to the centre of the neck taper. This could result in increased micromotion and deteriorate the passive oxide film along the head-neck taper interface; thus, making the taper interface vulnerable to corrosion. A retrieval analysis of 74 THA prostheses studied the corrosion damage at the head-neck taper interface. This study revealed that prostheses featuring 36 mm femoral heads had significantly greater head taper corrosion than prostheses with a 28 mm head. Finite element analysis was performed afterwards to identify if the use of large femoral heads can increase the micromotion at the head-neck taper interface due to a greater toggling torque. This experiment demonstrated that with a larger head size the micromotion at the head-neck taper interface increases. An in vitro corrosion fatigue study was performed afterwards following ASTM F1875-98. When applying an off-axis fatigue load, prostheses featuring a 36 mm femoral head displayed significantly more corrosion damage at the head-neck taper interface than those with a 28 mm femoral head. Axial fatigue loading was also applied; negligible corrosion damage at the head-neck taper interface was discovered in comparison to the prostheses that received an out of axis load. This verifies that the use of large femoral heads can result in increased head-neck taper corrosion due to a greater toggling torque.

After Total Knee Arthroplasty, contact stresses at the surface and stresses at the implant-cement-bone interface are directly related to the joint contact forces. These stresses are a major factor in wear and fatigue, aseptic loosening, stress shielding and osteoporosis. Implant contact stresses influence the wear and fatigue damage of the Ultra High Molecular Weight Polyethylene (UHMWPE) articulating surface, decreasing the longevity of the implant. The contact stresses are influenced by the kinematics, the bearing congruency of the articulating surfaces and insert thickness. Thus, various studies have focused on the prediction and optimization of kinematics at the joint interface, contact areas, and stresses in different knee implant designs. As a result, the successful total knee replacement designs depend on joint kinematics and the contact stresses. The objective of this study was to perform contact stress analysis on a newly designed surface guided knee implant, in order to evaluate the design with respect to the potential of polyethylene wear. In order to test the performance of this design, Finite Element Modeling (FEM) was used as a good medium to analyze the design’s specifications, and to evaluate the results of the stress analysis of the design. For validation and also comparison with previous studies, results of this study were compared with those of related work with similar loading and constraints. Based on the gathered data from FE analysis of the design, it can be concluded that the new surface guided knee implant shows lower peak contact pressure than other previously evaluated implants. / October 2015

Reverse shoulder arthroplasty (RSA) is a joint replacement procedure used mainly to treat patients with severe shoulder osteoarthritis combined with massive rotator cuff tears. It involves reversing the `ball and socket' orientation of the glenohumeral joint in the shoulder. While RSA has been largely successful in treating pain and improving function in these patients, complication rates remain high. Many of these complications, including joint instability and scapular notching (excessive bone wear), are caused or exacerbated by impingement of the humerus or the humeral component against the scapula. Adduction deficit refers to a patient's inability to fully adduct the arm due to impingement. Minimizing adduction deficit may improve RSA patients' functional outcomes. An existing mechanical shoulder simulator was further developed to model glenohumeral range of motion in RSA. The three heads of the deltoid were modelled using polyethylene cable and electric linear actuators with inline load cells. RSA components were implanted in Sawbones scapula and humerus bone models. The scapula was fixed in the frame of the simulator. Triads of optical tracking markers were attached to the humerus and simulator frame and used to track segment motion. A data analysis technique was developed to determine when joint impingement occurred. The convex and concave surfaces of the glenoid and humeral components were digitized, and a least-squares sphere fit was used to find their centres. The distance between these centres was then calculated during passive abduction and adduction of the humerus, and labeled d_GH. Impingement onset was defined as the point where d_GH was five standard deviations above its baseline value, indicating that the components were no longer concentric. This technique was used to determine the effects of humeral neck-shaft angle, socket depth, glenosphere diameter and eccentricity on range of motion and adduction deficit. A retentive humeral cup depth increased adduction deficit by 14 degrees and reduced range of motion by 26 degrees. A decreased neck-shaft angle reduced adduction deficit by 10 degrees but had little effect on overall range of motion. Diameter and eccentricity had no effect on either measure. / Thesis (Master, Mechanical and Materials Engineering) -- Queen's University, 2014-04-03 13:34:07.404

Total knee arthroplasty (TKA) is a common surgical procedure for the treatment of patients with pain and immobility as a result of osteoarthritis or rheumatoid arthritis. Pain-related interference, pain and nausea are recovery-limiting in these patients in the immediate postoperative period. Preoperative educational interventions that include pain communication and management information have been shown to decrease pain in joint replacement patients (McDonald & Molony, 2004). This randomized controlled trial compared usual preoperative education to an individually delivered preoperative education program. Participants (N=143) were randomized to intervention or usual care groups during routine preadmission testing. The usual care group received the usual preoperative teaching. The treatment group received the usual care teaching, a booklet containing content specific to symptom management after TKA, an individual teaching session during the preadmission testing visit and a telephone follow-up support call during the week before surgery. The primary outcome for this study was pain-related interference with activity and was measured using the Brief Pain Inventory Interference subscale (BPI-I) (Cleeland et al., 1994) on postoperative day three. Secondary outcomes were pain, nausea and expected postoperative activity and were measured on postoperative days one, two and three. There were no differences between groups in any of the outcomes for this study. BPI-I total scores were 24.4±14.4 in the intervention group and 22.4±15.1 in the usual care group (P=0.5) on the third postoperative day. Overall results demonstrated that although TKA patients had severe postoperative pain and severe nausea, they received inadequate doses of analgesia and anti-emetics. Available evidenced based protocols and practices in the health care environment were not followed Individualizing education content was not sufficient to produce a change in postoperative symptoms for these patients. Further research involving the modification of environmental and system factors affecting the provision of symptom management interventions is warranted.