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  • Journal article
    Doyle R, van Arkel R, Jeffers J, 2019,

    The effect of impaction energy on dynamic bone strains, fixation strength and seating of cementless acetabular cups

    , Journal of Orthopaedic Research, ISSN: 0736-0266
  • Journal article
    Barnes S, Clasper J, Bull A, Jeffers Jet al., 2019,

    Micromotion and push out evaluation of an additive manufactured implant for above-the-knee amputees

    , Journal of Orthopaedic Research, ISSN: 0736-0266

    In comparison to through knee amputees the outcomes for above‐the‐knee amputees are relatively poor; based on this novel techniques have been developed. Most current percutaneous implant based solutions for transfemoral amputees make use of high stiffness intramedullary rods for skeletal fixation which can have risks including infection, femoral fractures and bone resorption due to stress shielding. This work details the cadaveric testing of a short, cortical bone stiffness matched subcutaneous implant, produced using additive manufacture, to determine bone implant micromotion and push out load. The results for the micromotions were all less than 20 microns and the mean push out load was 2099 Newtons. In comparison to a solid control, the stiffness matched implant exhibited significantly higher micromotion distributions and no significant difference in terms of push out load. These results suggest that, for the stiffness matched implant at time zero, osseointegration would be facilitated and that the implant would be securely anchored. For these metrics, this provides justification for the use of a short stem implant for transfemoral amputees in this subcutaneous application.

  • Journal article
    Ghouse S, Reznikov N, Boughton O, Babu S, Ng KCG, Blunn G, Cobb J, Stevens M, Jeffers Jet al., 2019,

    The design and in vivo testing of a locally stiffness-matched porous scaffold

    , Applied Materials Today, Vol: 15, Pages: 377-388, ISSN: 2352-9407

    An increasing volume of work supports utilising the mechanobiology of bone for bone ingrowth into a porous scaffold. However, typically during in vivo testing of implants, the mechanical properties of the bone being replaced are not quantified. Consequently there remains inconsistencies in the literature regarding ‘optimum’ pore size and porosity for bone ingrowth. It is also difficult to compare ingrowth results between studies and to translate in vivo animal testing to human subjects without understanding the mechanical environment. This study presents a clinically applicable approach to determining local bone mechanical properties and design of a scaffold with similar properties. The performance of the scaffold was investigated in vivo in an ovine model.The density, modulus and strength of trabecular bone from the medial femoral condyle from ovine bones was characterised and power-law relationships were established. A porous titanium scaffold, intended to maintain bone mechanical homeostasis, was additively manufactured and implanted into the medial femoral condyle of 6 ewes. The stiffness of the scaffold varied throughout the heterogeneous structure and matched the stiffness variation of bone at the surgical site. Bone ingrowth into the scaffold was 10.73 ± 2.97% after 6 weeks. Fine woven bone, in the interior of the scaffold, and intense formations of more developed woven bone overlaid with lamellar bone at the implant periphery were observed. The workflow presented will allow future in vivo testing to test specific bone strains on bone ingrowth in response to a scaffold and allow for better translation from in vivo testing to commercial implants.

  • Journal article
    Boughton O, Ma S, Cai X, Yan L, Peralta L, Laugier P, Marrow J, Giuliani F, Hansen U, Abel R, Grimal Q, Cobb Jet al., 2019,

    Computed tomography porosity and spherical indentation for determining cortical bone millimetre-scale mechanical properties

    , Scientific Reports, Vol: 9, ISSN: 2045-2322

    The cortex of the femoral neck is a key structural element of the human body, yet there is not a reliable metric for predicting the mechanical properties of the bone in this critical region. This study explored the use of a range of non-destructive metrics to measure femoral neck cortical bone stiffness at the millimetre length scale. A range of testing methods and imaging techniques were assessed for their ability to measure or predict the mechanical properties of cortical bone samples obtained from the femoral neck of hip replacement patients. Techniques that can potentially be applied in vivo to measure bone stiffness, including computed tomography (CT), bulk wave ultrasound (BWUS) and indentation, were compared against in vitro techniques, including compression testing, density measurements and resonant ultrasound spectroscopy. Porosity, as measured by micro-CT, correlated with femoral neck cortical bone’s elastic modulus and ultimate compressive strength at the millimetre length scale. Large-tip spherical indentation also correlated with bone mechanical properties at this length scale but to a lesser extent. As the elastic mechanical properties of cortical bone correlated with porosity, we would recommend further development of technologies that can safely measure cortical porosity in vivo.Introduction

  • Journal article
    Amis AA, 2019,

    Editorial Commentary: Taking a Wider View During Anterior Cruciate Ligament Reconstruction? The Case for Doing More Than Just Reconstructing the Anterior Cruciate Ligament Itself

  • Journal article
    Kedroff L, Galea Holmes MN, Amis A, Newham DJet al., 2019,

    Effect of patellofemoral pain on foot posture and walking kinematics.

    , Gait Posture, Vol: 70, Pages: 361-369

    Background Excessive pronation has been implicated in patellofemoral pain (PFP) aetiology and foot orthoses are commonly prescribed for PFP patients. Pronation can be assessed using foot posture tests, however, the utility of such tests depends on their association with foot and lower-limb kinematics. Research questions Do PFP participants compared with healthy participants (1) have a more pronated foot measured with static foot tests and a kinematic multi-segmental foot model and (2) is there an association between static foot posture and foot and lower limb kinematics during walking? Methods A case-control study including 22 participants (n = 11 PFP, 5 females per group, aged 24 ± 3 (mean ± SD) years) was conducted. Foot posture measures included Arch Height Ratio, Navicular Drop (ND), and Foot Posture Index. Between-group comparisons of foot posture, segment and joint angle magnitudes, and associations between foot posture and kinematic data during gait were evaluated. Results There were no group differences in foot posture tests and mean joint angles. PFP participants had greater internal rotation of the shank and rearfoot segments, and adduction of the mid- and forefoot in the transverse plane (all p < 0.05). Greater ND was associated with increased forefoot abduction (rho=-0.68, p = 0.02) in healthy participants but no relationships were found between foot posture and kinematics in PFP participants. Significance Foot posture and kinematic data did not indicate excessive pronation in PFP participants questioning the use of orthoses to correct pronation. Larger studies are needed to determine the utility of foot posture tests as indicators of gait abnormalities in PFP.

  • Journal article
    Logishetty K, van Arkel RJ, Ng KCG, Muirhead-Allwood SK, Cobb JP, Jeffers JRTet al., 2019,

    Hip capsule biomechanics after arthroplasty THE EFFECT OF IMPLANT, APPROACH, AND SURGICAL REPAIR

    , BONE & JOINT JOURNAL, Vol: 101B, Pages: 426-434, ISSN: 2049-4394
  • Journal article
    Ng KCG, Daou HE, Bankes MJK, Rodriguez y Baena F, Jeffers JRTet al., 2019,

    Hip Joint Torsional Loading Before and After Cam Femoroacetabular Impingement Surgery

    , AMERICAN JOURNAL OF SPORTS MEDICINE, Vol: 47, Pages: 420-430, ISSN: 0363-5465
  • Journal article
    Reznikov N, Boughton OR, Ghouse S, Weston AE, Collinson L, Blunn GW, Jeffers JRT, Cobb JP, Stevens MMet al., 2019,

    Individual response variations in scaffold-guided bone regeneration are determined by independent strain- and injury-induced mechanisms

    , BIOMATERIALS, Vol: 194, Pages: 183-194, ISSN: 0142-9612
  • Journal article
    Doyle R, Boughton O, Plant D, Desoutter G, Cobb JP, Jeffers JRTet al., 2019,

    An in vitro model of impaction during hip arthroplasty

    , JOURNAL OF BIOMECHANICS, Vol: 82, Pages: 220-227, ISSN: 0021-9290
  • Journal article
    El Daou H, Ng KC, van Arkel R, Jeffers J, Rodriguez y Baena Fet al., 2019,

    Robotic hip joint testing: Development and experimental protocols

    , Medical Engineering and Physics, Vol: 63, Pages: 57-62, ISSN: 1350-4533

    The use of robotic systems combined with force sensing is emerging as the gold standard for in vitro biomechanical joint testing, due to the advantage of controlling all six degrees of freedom independently of one another. This paper describes a novel robotic platform and the experimental protocol used for hip joint testing. An experimental protocol implemented optical tracking and registration techniques in order to define the position of the hip joint centre of rotation (COR) in the coordinate system of the robot's end effector. The COR coordinates defined the origin of the task-related coordinate system used to control the robot, with a hybrid force/position law to simulate standard clinical tests. The axes of this frame were defined using the International Society of Biomechanics (ISB) anatomical coordinate system.Experiments were carried out on two cadaveric hip joint specimens using the robotic testing platform and a mechanical testing rig previously developed and described by our group. Simulated internal-external and adduction/abduction laxity tests were carried out with both systems and the resulting peak range of motion (ROM) was measured. Similarities and differences were observed in these experiments, which were used to highlight some of the limitations of conventional systems and the corresponding advantages of robotics, further emphasising their added value in vitro testing.

  • Journal article
    Correa T, Pal B, van Arkel R, Vanacore F, Amis AAet al., 2018,

    Reduced tibial strain-shielding with extraosseous total knee arthroplasty revision system

    , Medical Engineering and Physics, Vol: 62, Pages: 22-28, ISSN: 1350-4533

    BackgroundRevision total knee arthroplasty (RTKA) has poorer results than primary total knee arthroplasty (TKA), and the prostheses are invasive and cause strain-shielding of the bones near the knee. This paper describes an RTKA system with extracortical fixation. It was hypothesised that this would reduce strain-shielding compared with intramedullary fixation.MethodsTwelve replica tibiae were prepared for full-field optical surface strain analysis. They were either left intact, implanted with RTKA components with cemented intramedullary fixation stems, or implanted with a novel design with a tibial tray subframe supported by two extracortical fixation plates and screw fixation. They were loaded to simulate peak walking and stair climbing loads and the surface strains were measured using digital image correlation. The measurements were validated with strain gauge rosettes.ResultsCompared to the intact bone model, extracortical fixation reduced surface strain-shielding by half versus intramedullary fixation. For all load cases and bone regions examined, the extracortical implant shielded 8–27% of bone strain, whereas the intramedullary component shielded 37–56%.ConclusionsThe new fixation design, which offers less bone destruction than conventional RTKA, also reduced strain-shielding. Clinically, this design may allow greater rebuilding of bone loss, and should increase long-term fixation.

  • Journal article
    Stephen JM, Sopher R, Tullie S, Amis AA, Ball S, Williams Aet al., 2018,

    The infrapatellar fat pad is a dynamic and mobile structure, which deforms during knee motion, and has proximal extensions which wrap around the patella

    , Knee Surgery, Sports Traumatology, Arthroscopy, Vol: 26, Pages: 3515-3524, ISSN: 0942-2056

    PURPOSE: The infrapatellar fat pad (IFP) is a common cause of knee pain and loss of knee flexion and extension. However, its anatomy and behavior are not consistently defined. METHODS: Thirty-six unpaired fresh frozen knees (median age 34 years, range 21-68) were dissected, and IFP attachments and volume measured. The rectus femoris was elevated, suprapatellar pouch opened and videos recorded looking inferiorly along the femoral shaft at the IFP as the knee was flexed. The patellar retinacula were incised and the patella reflected distally. The attachment of the ligamentum mucosum (LMuc) to the intercondylar notch was released from the anterior cruciate ligament (ACL), both menisci and to the tibia via meniscotibial ligaments. IFP strands projecting along both sides of the patella were elevated and the IFP dissected from the inferior patellar pole. Magnetic resonance imaging (MRI) of one knee at ten flexion angles was performed and the IFP, patella, tibia and femur segmented. RESULTS: In all specimens the IFP attached to the inferior patellar pole, femoral intercondylar notch (via the LMuc), proximal patellar tendon, intermeniscal ligament, both menisci and the anterior tibia via the meniscotibial ligaments. In 30 specimens the IFP attached to the anterior ACL fibers via the LMuc, and in 29 specimens it attached directly to the central anterior tibia. Proximal IFP extensions were identified alongside the patella in all specimens and visible on MRI [medially (100% of specimens), mean length 56.2 ± 8.9 mm, laterally (83%), mean length 23.9 ± 6.2 mm]. Mean IFP volume was 29.2 ± 6.1 ml. The LMuc, attached near the base of the middle IFP lobe, acting as a 'tether' drawing it superiorly during knee extension. The medial lobe consistently had a pedicle superomedially, positioned between the patella and medial trochlea. MRI scans demonstrated how the space between the anterior tibia and patellar t

  • Journal article
    Hoogeslag RAG, Brouwer RW, Huis In 't Veld R, Stephen JM, Amis AAet al., 2018,

    Dynamic augmentation restores anterior tibial translation in ACL suture repair: a biomechanical comparison of non-, static and dynamic augmentation techniques

    , Knee Surgery, Sports Traumatology, Arthroscopy, Vol: 26, Pages: 2986-2996, ISSN: 0942-2056

    PURPOSE: There is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading. METHODS: Eleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles. RESULTS: Only static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation. CONCLUSION: In contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dyna

  • Journal article
    Inderhaug E, Stephen JM, Williams A, Amis AAet al., 2018,

    Effect of anterolateral complex sectioning and tenodesis on patellar kinematics and patellofemoral joint contact pressures

    , American Journal of Sports Medicine, Vol: 46, Pages: 2922-2928, ISSN: 0363-5465

    Background:Anterolateral complex injuries are becoming more recognized. While these are known to affect tibiofemoral mechanics, it is not known how they affect patellofemoral joint behavior.Purpose:To determine the effect of (1) sectioning the anterolateral complex and (2) performing a MacIntosh tenodesis under various conditions on patellofemoral contact mechanics and kinematics.Study Design:Controlled laboratory study.Methods:Eight fresh-frozen cadaveric knees were tested in a customized rig, with the femur fixed and tibia free to move, with optical tracking to record patellar kinematics and with thin pressure sensors to record patellofemoral contact pressures at 0°, 30°, 60°, and 90° of knee flexion. The quadriceps and iliotibial tract were loaded with 205 N throughout testing. Intact and anterolateral complex–sectioned states were tested, followed by 4 randomized tenodeses applying 20- and 80-N graft tension, each with the tibia in its neutral intact alignment or left free to rotate. Statistical analyses were undertaken with repeated measures analysis of variance, Bonferroni post hoc analysis, and paired samples t tests.Results:Patellar kinematics and contact pressures were not significantly altered after sectioning of the anterolateral complex (all: P > .05). Similarly, they were not significantly different from the intact knee in tenodeses performed when fixed tibial rotation was combined with 20- or 80-N graft tension (all: P > .05). However, grafts tensioned with 20 N and 80 N while the tibia was free hanging resulted in significant increases in lateral patellar tilt (P < .05), and significantly elevated lateral peak patellofemoral pressures (P < .05) were observed for 80 N.Conclusion:This work did not find that an anterolateral injury altered patellofemoral mechanics or kinematics, but adding a lateral tenodesis can elevate lateral contact pressures and induce lateral patellar tilting if the tibia is pulled into external ro

  • Journal article
    Stephen J, Alva A, Lumpaopong P, Williams A, Amis AAet al., 2018,

    A cadaveric model to evaluate the effect of unloading the medial quadriceps on patellar tracking and patellofemoral joint pressure and stability

    , Journal of Experimental Orthopaedics, Vol: 5, ISSN: 2197-1153

    BackgroundVastus Medialis Muscles (VMM) damage has been widely identified following patellar dislocation. Rehabilitation programmes have been suggested to strengthen the VMM and reduce clinical symptoms of pain and instability. This controlled laboratory study investigated the hypothesis that reduced Vastus Medialis Obliquus (VMO) and Vastus Medialis Longus (VML) muscle tension would alter patellar tracking, stability and PFJ contact pressures.MethodsNine fresh-frozen dissected cadaveric knees were mounted in a rig with the quadriceps and iliotibial band loaded to 205 N. An optical tracking system measured joint kinematics and pressure sensitive film between the patella and trochlea measured PFJ contact pressures. Measurements were repeated for three conditions: 1. With all quadriceps heads and iliotibial band (ITB) loaded; 2. as 1, but with the VMO muscle unloaded and 3. as 1, but with the VMO and VML unloaded. Measurements were also repeated for the three conditions with a 10 N lateral displacement force applied to the patella.ResultsReduction of VMM tension resulted in significant increases in lateral patellar tilt (2.8°) and translation (4 mm), with elevated lateral and reduced medial joint contact pressures from 0.48 to 0.14 MPa, and reduced patellar stability (all p < 0.05).ConclusionsThese findings provide basic scientific rationale to support the role of quadriceps strengthening to resist patellar lateral maltracking and rebalance the articular contact pressure away from the lateral facet in patients with normal patellofemoral joint anatomy.

  • Journal article
    Zhao S, Arnold M, Ma S, Abel R, Cobb J, Hansen U, Boughton ORet al., 2018,

    Standardising compression testing for measuring the stiffness of human bone: a systematic review

    , Bone and Joint Research, Vol: 7, Pages: 524-538, ISSN: 2046-3758

    Objectives: The ability to determine human bone stiffness is of clinical relevance in many fields, including bone quality assessment and orthopaedic prosthesis design. Stiffness can be measured using compression testing; an experimental technique commonly used to test bone specimens in vitro. This systematic review aims to determine how best to perform compression testing of human bone. Methods: A keyword search of all English language articles up until December 2017 of compression testing of bone was undertaken in Medline, Embase, PubMed and Scopus databases. Studies using bulk tissue, animal tissue, whole bone or testing techniques other than compression testing were excluded. Results: 4712 abstracts were retrieved with a total of 177 papers included in the analysis. 20 studies directly analysed the compression testing technique to improve the accuracy of the testing technique. Several influencing factors should be considered when testing bone samples in compression. These include the method of data analysis, specimen storage, specimen preparation, testing configuration and loading protocol. Conclusions: Compression testing is a widely used technique for measuring the stiffness of bone but there is a great deal of inter-study variation in experimental techniques across the literature. Based on best evidence from the literature, suggestions for bone compression testing are made in this review, though further studies are needed to help establish standardised bone testing techniques to increase the comparability and reliability of bone stiffness studies.

  • Journal article
    Kedgley AE, Saw TH, Segal NA, Hansen UN, Bull AMJ, Masouros SDet al., 2018,

    Predicting meniscal tear stability across knee-joint flexion using finite-element analysis

    , Knee Surgery, Sports Traumatology, Arthroscopy, ISSN: 0942-2056

    Purpose: To analyse the stress distribution through longitudinal and radial meniscal tears in three tear locations in weight-bearing conditions and use it to ascertain the impact of tear location and type on the potential for healing of meniscal tears. Methods: Subject-specific finite-element models of a healthy knee under static loading at 0°, 20°, and 30° knee flexion were developed from unloaded magnetic resonance images and weight-bearing, contrast-enhanced computed tomography images. Simulations were then run after introducing tears into the anterior, posterior, and midsections of the menisci. Results: Absolute differences between the displacements of anterior and posterior segments modelled in the intact state and those quantified from in vivo weight-bearing images were less than 0.5 mm. There were tear-location-dependent differences between hoop stress distributions along the inner and outer surfaces of longitudinal tears; the longitudinal tear surfaces were compressed together to the greatest degree in the lateral meniscus and were most consistently in compression on the midsections of both menisci. Radial tears resulted in an increase in stress at the tear apex and in a consistent small compression of the tear surfaces throughout the flexion range when in the posterior segment of the lateral meniscus. Conclusions: Both the type of meniscal tear and its location within the meniscus influenced the stresses on the tear surfaces under weight bearing. Results agree with clinical observations and suggest reasons for the inverse correlation between longitudinal tear length and healing, the inferior healing ability of medial compared with lateral menisci, and the superior healing ability of radial tears in the posterior segment of the lateral meniscus compared with other radial tears. This study has shown that meniscal tear location in addition to type likely plays a crucial role in dictating the success of non-operative treatment of the menisci. T

  • Journal article
    Athwal K, Milner P, Bellier G, Amis AAet al., 2018,

    Posterior capsular release is a biomechanically safe procedure to perform in total knee arthroplasty

    , Knee Surgery, Sports Traumatology, Arthroscopy, ISSN: 0942-2056

    PurposeSurgeons may attempt to strip the posterior capsule from its femoral attachment to overcome flexion contracture in total knee arthroplasty (TKA); however, it is unclear if this impacts anterior–posterior (AP) laxity of the implanted knee. The aim of the study was to investigate the effect of posterior capsular release on AP laxity in TKA, and compare this to the restraint from the posterior cruciate ligament (PCL).MethodsEight cadaveric knees were mounted in a six degree of freedom testing rig and tested at 0°, 30°, 60° and 90° flexion with ± 150 N AP force, with and without a 710 N axial compressive load. After the native knee was tested, a deep dished cruciate-retaining TKA was implanted and the tests were repeated. The PCL was then cut, followed by releasing the posterior capsule using a curved osteotome.ResultsWith 0 N axial load applied, cutting the PCL as well as releasing the posterior capsule significantly increased posterior laxity compared to the native knee at all flexion angles, and CR TKA states at 30°, 60° and 90° (p < 0.05). However, no significant increase in laxity was found between cutting the PCL and subsequent PostCap release (n.s.). In anterior drawer, there was a significant increase of 1.4 mm between cutting the PCL and PostCap release at 0°, but not at any other flexion angles (p = 0.021). When a 710 N axial load was applied, there was no significant difference in anterior or posterior translation across the different knee states (n.s.).ConclusionsPosterior capsular release only caused a small change in AP laxity compared to cutting the PCL and, therefore, may not be considered detrimental to overall AP stability if performed during TKA surgery.Level of evidenceControlled laboratory study.

  • Journal article
    Ghouse S, Babu S, Nai K, Hooper PA, Jeffers JRTet al., 2018,

    The influence of laser parameters, scanning strategies and material on the fatigue strength of a stochastic porous structure

    , ADDITIVE MANUFACTURING, Vol: 22, Pages: 290-301, ISSN: 2214-8604

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