ADAPTIVE BONE REMODELLING OF ALL POLYETHYLENE
UNICOMPARTMENTAL TIBIAL BEARINGS
R.M. Gillies* **, M. Hogg*, L Kohan***, R Cordingley***
*WorleyParsons Services/Advanced Analysis, Sydney Australia
** Graduate School of Biomedical Engineering, UNSW,, Sydney, Australia.
***Joint Orthopaedic Centre, Sydney, Australia
Mark.Gillies@WorleyParsons.com
Abstract: Failure of unicompartmental knees is
either by progressive OA or by failure of the
prosthesis. Prosthesis failure can be either the actual
component itself or its fixation method. We have
modeled all polyethylene tibial components and
investigated the periprosthetic adaptive remodelling
of the bone. CT scans were used to reconstruct the
tibial geometry and then a 3D finite element mesh
was created. The tibia loading was at 45% of the
gait cycle. The distal end of the tibia as fixed.
Implant orientations were in accordance with the
manufacturers specifications. The bone mineral
density changes at 3 ROI was measured and plotted.
All ROI became stable at the 12 month time-point.
Predictive bone mineral changes where minimal in
both resorption and deposition. These findings are
consistent with the clinical experience of
unicompartmental knees, where the changes are
small and have little effect on the outcome of the
prosthesis. From a mechanical perspective, the
results are also consistent when a compliant material
is used to distribute loads. They do, however,
support the biomechanical theory that a change in
geometry will influence the loading environment and
as a consequence the adaptive response of the bone is
also influenced.
Introduction
Bone is a dynamic tissue known to respond to
imposed loads and remodel [1, 2]. Unicompartmental
knee replacement (UKR) clinical results are equivalent
to total knee replacement (TKR) results [3]. The reasons
for failure of UKR and TKR are similar and are
normally due to the reduction in bone mineral density
[4]. This has been hypothesised to occur due to a
reduction in the stress distribution [2, 5]. Van Loon et al
(1999) found that femoral and tibial bone loss is mainly
attributed to three etiological factors. Firstly, stress
shielding causing an osteopenia type of bone loss. They
used dual-energy x-ray absorptiometry (DEXA), and
found a decrease in bone mineral density. Secondly,
they found that polyethylene, cement and metal particles
are released by implant wear and may cause osteolysis
in regions at the anterior and posterior implant-cement
and cement-bone interfaces on the femur. The third
factor was that implant loosening lead to bone loss at
the cement-implant interface and resulted in "hollowing
out" of the distal femur in a stemmed TKA. UKR has
the additional risk of progressive osteoarthritis in the
retained compartments [6]. Khan et al. (2004)
investigated 30 patients three times by blind and
randomized assessment to measure the progression of
osteoarthritis within the remaining compartments. They
found evidence in 2 knees of the progression of
osteoarthritis within the patellofemoral joint and in
another 3 knees there was some progression of the
opposite tibiofemoral compartment. They concluded
that progression of arthritis in the unreplaced
compartments is not a significant problem after fixed
bearing UKR. Whiteside (1989) has shown that knee
alignment and soft tissue balancing along with
polyethylene geometric constraints may play an
important role in load distribution and ensuing bone
remodeling[1].
This study has examined the long-term effects of
strain adaptive bone remodeling due to the influence of
an all polyethylene (PE) unicomaprtmental (medial)
tibial replacement. It has used the algorithm put forward
by Husikes and Weinans (1987)[7].
Materials and Methods
Computed tomography (CT) scans of an intact tibia
were obtained from visual human data (VHD) set
(VHD, NLM, Bethesda, Maryland). The voxel slice
density was a 512x512 matrix. Each slice had
Houndsfield units (Hu) assigned to it that quantified the
relative attenuation to air. Slices were taken at 2mm
thick with no inter-slice distance through the distal
femur to the distal end of the tibia. The CT file was then
Figure 1. UKR reconstructed tibia
read into a contour extraction program. The contours are
then saved into an IGES file that is then read into the implant were analysed to determine the amount of bone
preprocessor PATRAN (MSC Software, Los Angeles, mineral density change.
CA). The IGES points cloud was then utilised to
develop the tibial geometry. The tibia was meshed with
10 noded modified tetrahedral elements. Each element
has 4 integration points. Two models for each implant
were developed since there is a need to have an intact
tibia and a reconstructed tibia (Fig. 1) for each case. The
implants used were all PE tibial implants (St Georg
Sled™, Waldermar Link, Hamburg, Germany and
Euis™, Stryker Inc, Mahwah, NJ, USA). The implant
contact conditions assumed interdigitisation of the bone
cement into the bone and locking mechanism of the
implant. The model was set-up so that the desired
remodeling elements retain the same element numbers
in both analyses (Intact and reconstructed). The Hu
values which were extracted from the CT data file are
Figure 3. Tri-linear remodeling curve used in the FEA
converted to an apparent density [8]. Young’s modulus,
E, was calculated according to Carter and Hayes[9]. A
pre-analysis of the intact tibia was then performed to
define the physiological normal stress and strain state. 3 2 1
The forces across the kneejoint developed by Taylor et.
al. [10] were used for both analyses. The heel strike
phase of gait was the load case simulation chosen for
the entire analysis (Fig. 2). Material properties were
read from the material file and applied to each element’s Figure 4.

Results

The remodeling algorithm used a dead zone width of

60% [12]. Von Mises stress distribution predicted an
altered loading environment in the proxiaml region of
the tibia (Fig. 5).
The remodeling
algorithm was
run until little or
no change was
occurring in the
BMD. The
change in BMD
was less than 1%
Figure 2. Gait cycle. Line at 45% between 30 and
illustrated model-loading time point. 40 steps
(equivalent to
integration points. The normal values of the remodeling Figure 5.
months 36 and 48
stimulus were written out to the stimulus file. In this
study, the remodelling signal was the equivalent strain St Georg Sled Uni Compartment Knee BMD change
stimulus [11](magnitude of the strain tensor).
The process of remodeling the bone required the Time [months]

material properties to be updated in the reconstructed -1% 0 10 20 30 40 50

tibia by iterating the model through a number of steps. -3%
This process involved obtaining the reconstructed
Change in BMD [%]

-5%
stimulus and comparing the difference between the
-7%
intact stimulus and the reconstructed stimulus with the
tri-linear remodeling curve (Fig. 3). This curve details -9%

the rate of bone resorption and deposition. The change -11%

in bone density was then applied to the element and the -13%
Zone 1 Zone 2 Zone 3

subsequent Young’s modulus recalculated; the updated -15%

element properties were then used in the next step of the
remodeling process. Regions of interest below each Figure 6
[12]) and was assumed to be asymptotic.
Figure 6 presents the change in BMD for the St
Georg Sled predicted using the finite element method.
The figures presented are an approximation to a
postoperative 48 month time-point. Zones 1 to 3 were
the regions that experienced the least amount of stress
shielding and lost a maximum of 5% BMD. Zone 4
experienced the maximum BMD loss (~11%). Figure 7
Eius Uni Compartment Knee BMD change
Zone 1 Zone 2
14%
Percentage change in BMD (%)
12%
10%
8%
6%
4%
2%
0%
0 5 10 15 20 25 30 35
Figure 7. Time (months)
presents the change in BMD for the Euis. It shows an
increase in BMD for all ROI. Again, all the figures
presented are an approximation to a postoperative 48
month time-point.
Discussion
There is no literature on the BMD changes under
unicompartmental tibial replacements. There is,
however, a large amount of literature [6, 13-34] on
radiographic and quality of life follow-up studies of
unicompartmental knees. These studies investigate the
expected life of the implants and it is clear that in
approximately 95% of the cases, with a 95 to 98%
survival, they are revised due to osteoarthritic changes
in the lateral compartment [6, 15, 18].
The finite element predictions illustrate that there is a
very small amount of resorption for the St Georg Sled™
due to the implant being in place. This small change
would lend itself to the fact that the implant’s survival
would not be affected by the resorption and that the
change in BMD change would not be clinically relevant.
SImilarily for the Euis™, an increase in BMD in the
proximal tibia is a positive change. As mentioned
above, the literature has the revision of the implants due
to arthrosis in the contralateral compartment.
This study has shown, by investigating the adaptive
bone remodeling and subsequent change in BMD that
the St Georg Sled™ and Euis™ unicompartmental knees
load the proximal tibia and maintain the supporting
subchondral bone density and structure. The bone model
development method is a validated process [8] and the
parameters in the remodelling algorithm were kept
constant. In this study, it is assumed that activity levels
are unchanged following surgery. Some other
limitations of the current study are that there is no
clinical DEXA data at the present time for any
unicompartmental knee replacement, including the St
Georg Sled™ and Euis™, to use as a comparison to the
predictions.
Conclusions
In conclusion, this study has shown that
computational bone remodelling theory is able to
produce a clinically relevant result with respect to the
literature [6, 13-34], and consequently would be a useful
tool for preclinical evaluation and validation of
Zone 3 periprosthetic bone adaptation.
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