Abstract

INTRODUCTION Bone resorption around hip stems, in particular periprosthetic bone loss, is a common observation post-operatively. A number of factors influence the amount of bone loss over time and the mechanical environment following total hip replacement (THR) is important; conventional long stem prostheses have been shown to transfer loads distally, resulting in bone loss of the proximal femur. More conservative, short stems have been recently introduced to attempt to better replicate the physiological load distribution in the femur. The aim of this study was to evaluate the bone mineral density (BMD) change over time, in a femur implanted with either a short or a long stem.

METHODS Finite element models of two implants, a short (Minihip, Corin, UK) and long (Metafix, Corin, UK) hip stem were used to simulate bone remodeling under a physiological load condition (stair climbing). The magnitudes and directions of the muscle forces and joint reaction force were obtained from Heller et al (2001, 2005). An unimplanted femur was also simulated.

A strain-adaptive remodelling theory (Scannel & Prendergast 2009) was utilised to simulate remodelling in the bone after virtual implantation. COMSOL Multiphysics software was used for the analysis. The strain component of the remodelling stimulus was strain energy density per unit mass. This was calculated in the continuum model from the strain energy density, and apparent density.

Bone mass was adapted using a site-specific approach in an attempt to return the local remodelling stimulus to the equilibrium stimulus level (calculated from the unimplanted femur). The minimal inhibitory signal proposed by Frost (1964), was included in the model and described by a ‘lazy zone’, where no bone remodelling occurred.

The three dimensional geometry of the femur was constructed from computed tomography data of the donor (female, 44 years old, right side). Elemental bone properties were assigned from the Hounsfield Unit values of the CT scans. The elastic modulus of the bone was assumed to be isotropic and was determined using a relationship to the apparent bone density (Frost 1964, Rho 1995). The Poisson's ratio for the bone regions varied between 0.2 and 0.32 depending on the apparent density of the bone (Stulpner 1997).

The period of implantation analysed was 2 years. The muscle forces and joint contact loads applied were ramped linearly from zero to full load over a period of two weeks, representing the estimated post operative rest period of a patient.

RESULTS AND DISCUSSION The overall percentage BMD change observed for Gruen zones 1 through to 7, were −14%, +4%, +40%, +12%, +4%, 0%, 12% respectively at 2 years for the Minihip. The corresponding overall percentage BMD change observed for Gruen zones 1 through to 7 for the Metafix were −8%, −2%, 18%, 26%, +12%, −9%, −42% respectively (Figure 1,2).

CONCLUSIONS Considerably more bone resorption occurs in Gruen zone 7 with the long stem. Long stem designs distrupt the mechanical environment more than short stems, and lead to a greater bone mineral reduction over time.