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2011, Copyright the Authors

Artificial Organs 2011, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Optimization of the Femoral Stem of a Cemented Total

Hip Arthroplasty

*Toshimasa Ishida, *Ikuya Nishimura, Hiromasa Tanino, Masaru Higa, Hiroshi Ito, and

Yoshinori Mitamura

*Graduate School of Information Schience and Technology, Hokkaido University, Sapporo; Department of Orthopaedic

Surgery, Asahikawa Medical College, Asahikawa; Graduate School of Engineering, University of Hyogo, Himeji; and

School of Biological Science and Engineering, Tokai University, Sapporo, Japan

Abstract: There are many designs of the femoral stem of a introduced to minimize these objective functions. The

cemented total hip arthroplasty, and mechanical failure of results showed that the geometry that leads to a decrease in

the stem is caused by several factors related to the cement, the proximal cement stress and the geometry that leads to

such as failure of the cement. Optimization of the shape of a decrease in the distal cement stress were not the same.

the stem, especially multiobjective optimization, is required However, the results of the walking and the stair climbing

to solve these design problems because a cement fracture is conditions matched. Five dominant stem designs were con-

caused by multiple factors. The objective of this study was sidered to be the Pareto solution, and one design was iden-

to determine a stem geometry considering multiple factors tified as the better design for all objective functions. It

at the same time. A three-dimensional finite element model was shown that multiobjective optimization using a genetic

of the proximal femur was developed from a composite algorithm may be used for optimizing the shape of the

femur. A total of four objective functionstwo objective femoral stem in order to avoid cement fracture. Key

functions, the largest maximum principal stress of proximal Words: Computer analysisFinite element analysis

and distal sections in the cement mantle, for each of the two OptimizationTotal hip replacementFemoral stem

boundary conditions, walking and stair climbingwere Cement failure.

used. The neighborhood cultivation genetic algorithm was

Failure of the femoral prosthesis component of a aided engineering, may help to reduce the frequency

cemented total hip arthroplasty (THA) is often of implant loosening. For example, finite element

attributed to failure of cement mantle associated with analysis (FEA), design sensitivity analysis (7), and

many stress patterns in the cement (1). shape optimization have been used to evaluate and

There have been many changes in the design of the create stem designs (811).

femoral stem of THA, with many of these changes Although optimization is a suitable technique for

being implicated in failure of the cement layer (2,3). developing femoral stems, there were many limita-

Many design and surgical factors may affect the tions in optimization procedure. Huiskes and Boek-

stress distribution related with aseptic loosening in lagen (8) and Yoon et al. (9) reported one of the

cemented femoral hip components (4,5). Therefore, earliest optimization studies. However, simple two-

proper preclinical testing (6), including computer- dimensional analysis models were used in both

reports because of lack of computer resources in the

1980s. A three-dimensional analysis cannot obtain

doi:10.1111/j.1525-1594.2010.01117.x dramatic parameter changes; however, these analyses

Received June 2009; revised July 2010. are important because of the asymmetric femoral

Address correspondence and reprint requests to Dr. Ikuya Nish- geometry. Katoozian et al. (10) reported the rela-

imura, Graduate School of Information Science and Technology,

Hokkaido University, Kita 14 Nishi 9, Kita-ku, Sapporo, Hokkaido tionship between objective functions, boundary con-

060-0814, Japan. E-mail: mura@bme.ist.hokudai.ac.jp ditions, and optimum geometries. These authors

404

aor_1117 404..410

OPTIMIZATION OF A CEMENTED FEMORAL STEM 405

to different results. Thus, the use of multiple condi-

tions and objective functions, called multiobjective

optimization, is one of the best methods for solving

complex optimization problems. Fernandes et al. (11)

analyzed the multiobjective optimization of a two-

dimensional cementless stem with a weighting

method. This method was useful in easily obtaining

the optimization direction. However, when there is a

large number of parameters or when detailed solu-

tions are sought, the calculation time increased

greatly because of the increase in the number of

parameter combinations.

One way of overcoming all of these limitations is to

use a genetic algorithm (GA). GA is an algorithm for

solving large-scale optimization problems. Most of

the optimization algorithms consider only one solu-

tion, whereas GA considers many solutions as one

set and renews the solution sets during the

calculation. Therefore, a sufficient number of first-

solution parameters and renewal of solution sets can

easily solve large and complex problems.

The objective of this study was to optimize the

design of a cemented stem considering the several

simultaneous causes for cement failure. For this

purpose, GA was introduced in the optimization FIG. 1. Finite element model of the proximal femur.

calculation.

A three-dimensional finite element model of

the proximal femur was developed (Fig. 1). The

femoral geometry was determined on the basis of

the CAD data of the composite femur. Next, the

parametric stem model was developed using a CAD

program (Pro/Engineer, PTC, Inc.). The initial stem

shape was based on the results of our previous

study (12), and the 10 design parameters considered

were defined on the basis of the stem cross-sections

(Fig. 2). Later on, this initial model was used to

define the objective function. The design parameters

were defined as medial-lateral (ML) width and

anterior-posterior (AP) width of the stem proximal,

middle, and distal cross-sections. In particular, in the

case of the proximal sections, the ML width was

divided into two parameters considering the medial

and lateral sides along the stem neck axis. The stem

length was fixed at 140 mm and the head center

offset, at 38 mm.

All design parameters were labeled L1 to L10,

and the range of parameters is listed in Table 1.

These parameters are subjected to a set of constraints FIG. 2. Cross-section of the stem geometry.

406 T. ISHIDA ET AL.

TABLE 1. Default values and the range of design ler and the CAD and FEA programs. The FE models

parameters used in stem CAD model comprised 11 792 8-noded brick elements and 12 667

Initial Min Max nodes. The number of elements was the same for

all analysis models. The elastic modulii of the stem

Proximal ML L1 8 6 21

L2 14 12 15 material, bone cement (polymenthyl methacrylate

AP L3 6 4 6.5 [PMMA]), cortical bone, and cancellous bone were

L4 6 4 6.5 210, 2.2, 17, and 1 GPa, respectively (12). For each of

Middle ML L5 12.6 10 13.6

AP L6 6 4 6.5 these materials, Poissons ratio was taken to be 0.3.

L7 6 4 6.5 The cementbone interface was assumed to be fully

Distal ML L8 8.8 6 9 bonded. The cementstem interface was considered

AP L9 3.5 2.5 4.5

L10 3.5 2.5 4.5 to be a Coulomb frictional interface, with a coeffi-

cient of friction of 0.3 (16). We considered two

All dimensions are in millimeters.

loading cases to simulate a physiological condition.

One corresponded to walking whereas the other cor-

responded to stair climbing. For both cases, the mag-

in order to ensure that the cross-section size

nitudes and directions of the applied loads were

decreased from the middle cross-section to the distal

taken from the work of Stolk et al. (17).

cross-section,

g 2 = L6 L9 < 0

A schematic presentation of the complete optimi-

g 3 = L7 L10 < 0. zation procedure is shown in Fig. 3. Four objective

After that, a cement mantle, with a constant thick- functions are used: the largest maximum principal

ness of 2 mm was added around the stem and a stresses of the distal (walk-distal; F1, stair-distal; F2)

mantle, 30-mm thick (1315), was added below the tip and proximal (walk-proximal; F3, stair-proximal; F4)

of the stem. This model was fed into the FEA part in the cement mantle. These objective functions

program (ANSYS6.0, ANSYS, Inc., Cybernet were defined on the basis of the results of the static

Systems Co. Ltd., Tokyo, Japan) in the IGES format. stress analysis of the initial model. Therefore, all opti-

mization problems can be formulated as follows:

Static stress analysis

Minimize Fi ( x) i = 1 . . . 4

The values of all objective functions were calcu-

lated using a static stress analysis. All analysis models such that

and design parameters were automatically con-

structed or determined by the optimization control- (Lj )min < x j < (Lj )max g k (x) < 0 k = 1 . . . 3

OPTIMIZATION OF A CEMENTED FEMORAL STEM 407

(Lj)max are the upper and lower limits of the design

parameter xj.

GA parameter settings

The neighborhood cultivation genetic algorithm

(NCGA) (18) was introduced to minimize these

objective functions. NCGA is an example of a multi-

objective GA and can optimize several objective

functions while maintaining the diversity of solutions.

The GA requires the encoding of design parameters

to bit strings in order to obtain the gene parameters.

In this study, it was mounted as follows:

1 Minimum value of a design parameter is defined as

000 . . . 0 on a gene parameter.

2 Maximum value is defined as 111 . . . 1.

3 A design parameter is encoded to the nearest bit- FIG. 4. Maximum principal stress in the cement mantle, load

string area that is defined in (1) and (2). case of the walking (a) and stair-climbing (b) conditions.

parameter used in this calculation. The population 1 solution number;

size was set to 50 in a single generation, and the 2 value of all design parameters L1 . . . L10, and

number of generations was set to 20. Therefore, a value of objective functions F1 . . . F4;

total of 1000 calculations were performed. During 3 where the solution number contains the generation

each successive generation, 50% of the existing popu- data.

lation was selected to determine the next generation Therefore, these charts provide the relationship

according to the fitness function. Double crossover between the objective functions.

points on both parents organism strings were

selected. In NCGA, individuals who were close to Stem design for each Pareto front

each other were chosen as the mated pair. Further- Several Pareto solutions are shown in Fig. 5 and

more, mutation took place at a probability of 0.01 in Table 2. Figure 5a shows the resulting Pareto solu-

the case of all generations. After the analysis of each tions in the two-dimensional objective function

generation, the values of objective functions were spaces. These solutions were based on an approxi-

plotted as a two-dimensional scatter chart. mate trade-off line of two objective functions (F1

and F2). In this chart, the strongest geometry for the

RESULTS proximal region is (1). At the same time, (1) is a

relatively worse geometry on the Pareto front for

Static stress analysis of pre-optimization the distal region. From this scatter chart (Fig. 5a),

The distribution of the maximum principal stress five dominant designs were selected that were on

acting in the coronal midplane of the cement mantle the Pareto front ([1][5]). Figure 5b shows the lin-

in the initial design is shown in Fig. 4. It was found earity of objective functions of F2 and F3. Clearly,

that the largest maximum principal stress in the these two objective functions are correlated and not

cement mantle was found near the tip of the stems for a trade-off. Figure 5c also shows the trade-off line of

both the walking (12.9 Mpa) and the stair-climbing two objective functions (F3 and F4). Each number

(15 Mpa) conditions, and another stress concentra- in the figure represents the same design as that in

tion was found in the proximal region of the cement another figure.

mantle. Note that these results were all bases of

objective functions.

DISCUSSION

Optimization and scatter diagram

Results of optimization are shown in Fig. 5. On all This study was an initial attempt to use a GA for the

charts, the direction of optimization is the lower left multiobjective optimization of the femoral stem of a

one. On each diagram, each point has the following cemented THA. Compared with a mathematical

properties: optimization method such as the steepest-descent

408 T. ISHIDA ET AL.

a b

optimization results. (a) The relationship

between walk-distal and walk-proximal, (b)

c walk-distal and stair-distal, and (c) stair-

distal and stair-proximal.

method, a searching method such as the GA has an long. Even with the simplified analysis performed in

advantage for complex multiparameter analysis this study, a searching method required more than

because it searches the optimum values without using 2 months of CPU time to complete all the calculations

a derivative function. Therefore, the GA will never (Intel Xeon 2.4 GHz, Windows 2000 PC). An attrac-

converge to a local extreme, and the solutions will tion of a searching method is that the individual cal-

cover a wide range. Searching methods, however, culation of each genetic parameter can easily be

could not be used until recently, because the calcula- carried out in parallel. Unlike in a mathematical opti-

tion time required to obtain good solutions was very mization method, in a searching method, each gene

(1) (2) (3) (4) (5)

Proximal ML L1 (mm) 8.47 10.93 18.61 19.45 19.45

L2 (mm) 14.7 12.43 14 14.73 13.99

AP L3 (mm) 5.28 4.81 5.1 5.12 5.78

L4 (mm) 6.33 6.2 5.1 6.39 6.42

Middle ML L5 (mm) 13.1 13.46 13.2 13.48 10

AP L6 (mm) 6.18 5.15 6.47 6.31 6.32

L7 (mm) 5.95 6.27 4.63 4.67 4.66

Distal ML L8 (mm) 8.77 6.6 6.66 6.6 6.1

AP L9 (mm) 3.24 4.07 3.3 3.43 3.55

L10 (mm) 2.54 2.78 2.66 2.55 2.51

12.4 12.2 9.3 8.6 7

Walk-distal (Mpa)

Walk-proximal (Mpa) 3.3 3.5 3.7 3.8 4.9

Stair-distal (Mpa) 12.8 13.7 10.6 9.9 8.5

Stair-proximal (Mpa) 4.9 5.4 7.6 5.5 7.5

OPTIMIZATION OF A CEMENTED FEMORAL STEM 409

parameter is independent from the others belonging this is the reason for the synchronized optimization

to the same generation. Thus, in this study, a 50-CPU direction.

PC cluster was used to perform all calculations in less The main limitation of this study was that the

than 2 days. failure criteria related to the boundary conditions.

For general single objective optimization, the We used the largest maximum principal stress as the

optimal implant is only one particular case, the one objective function. In some clinical reports, it has

represented in the FE model. In most cases, because of been suggested that the failure of the femoral stem is

the variations in shape and properties, the optimal attributable not only to the failure of the cement

implant will be suboptimal (19). Hence, a multiobjec- mantle but also to the failure of the cementimplant

tive approach was used for considering biomechanical interface (21,22). Another limitation was the accu-

conditions.With respect to the Pareto solutions shown racy of the finite element method model. Most prop-

in Fig. 5a, the geometries of (1) and (5) were the best erties and model shapes were derived from our

results for the two objective functions (Sp-walk and previous study (12) as a continued work. Therefore,

Sd-walk). However, both geometries have a risk for the model in this study did not include the latest

the other objective function. Therefore, geometries methods in modeling and material properties. Con-

(2), (3), and (4) were well balanced for the two objec- sidering these limitations, we can propose a new opti-

tive functions. In contrast, in the case of the stair- mization method in a future work.

climbing condition (Fig. 5c), (2) and (3) did not exist

on the Pareto front. Then, geometry (4) was the best-

balanced geometry for this analysis condition. Geom- CONCLUSION

etries (3) and (4) were almost the same except in the This study is the first report of the use of a genetic

case of the proximal cross-section. Therefore, the algorithm for optimizing the shape of the femoral

dimensions of the stem of the proximal cross-section stem in a cemented total hip arthroplasty. The opti-

should be carefully designed. mized shape was obtained considering multiobjective

Resolution of the genetic parameter was one of the functions. This design is not the best design for all

important factors that affected the accuracy of the objective functions, but it is better than the existing

solution. We used 10-bit strings as the genetic designs for all conditions because of the trade-off

parameters. The resolution of these strings was between the objective functions. Stem designers

approximately 1.5 10-2 mm in the case of the design should find the method presented in this study useful

parameter L1 (15/210). These resolutions had to be when modifying the shape of the stem.

varied according to the accuracy of stem casting.

Low-resolution bit strings increase the calculation Acknowledgment: This research was partially

speed but adversely affect the accuracy of the supported by Engineous Japan, Inc., Yokohama,

solution. In the future work, the relationship between Japan.

the lengths of the genetic bit strings and the accuracy

of the solution has to be investigated.

From Fig. 5b, it is seen that the optimization direc- REFERENCES

tion of the two boundary conditions is the same. In 1. Jasty M, Maloney WJ, Bragdon CR, OConnor DO, Haire T,

this study, the original values of all the loads were Harris WH. The initiation of failure in cemented femoral com-

obtained in an experimental study (20). In the case of ponents of hip arthroplasties. J Bone Joint Surg 1991;73-

B:5518.

stair climbing, the load was higher than that in the 2. Dall D, Learmonth I, Solomon M, Miles A, Davenport J. Frac-

case of the walking condition for the purpose of ture and loosening of Charnley femoral stems. J Bone Joint

rotation. Therefore, the cement stress value in the Surg 1993;75-B:25965.

3. Middleton R, Howie D, Costi K, Sharpe P. Effects of design

case of the stair-climbing condition was also higher changes on cemented tapered femoral stem fixation. Clin

than that in the case of the walking condition, but the Orthop 1998;355:4756.

tendency of results was the same in both cases. The 4. Mann KA, Bartel DL, Wright TM, Burstein AH. Coulomb

frictional interfaces in modeling cemented total hip

largest maximum principal stress value in the cement replacements. J Biomech 1995;28:126778.

mantle, which can lead to the fracture of the bulk of 5. Barrack RL. Early failure of modern cemented stems. J

the cement mantle, was higher in the case of the Arthroplasty 2000;15:103650.

6. Stolk J, Verdonschot N, Cristofolini L, Toni A, Huiskes R.

stair-climbing condition than in the case of the Finite element and experimental models of cemented

walking condition (Fig. 5). This tendency was hip joint reconstructions can produce similar bone and

observed only in the proximal region. Therefore, the cement strains in pre-clinical tests. J Biomech 2002;35:499

510.

stair-climbing condition was detrimental to the 7. Yang RJ, Choi KK, Crowninshfield RD, Brand RA. Design

cement around the proximal region. We suggest that sensitivity analysis: a new method for implant design and ad

410 T. ISHIDA ET AL.

comparison with parametric finite analysis. J Biomech 1984;17: oral stem design and centralizer. J Arthrop 2001;16-5:648

84954. 57.

8. Huiskes R, Boeklagen R. Mathematical shape optimization of 15. Mann KA, Gupta S, Race A, Miller MA, Cleary RJ, Ayers DC.

hip prosthesis design. J Biomech 1989;22:793804. Cement microcracks in thin-mantle regions after in vitro

9. Yoon SY, Jang GH, Kim YY. Shape optimal design of the fatigue loading. J Arthrop 2004;19-5:60512.

stem of a cemented hip prosthesis to minimize stress con- 16. Mann KA, Bartel DL, et al. Mechanical characteristics of the

centration in the cement layer. J Biomech 1989;22:1279 stem-cement inteface. J Orthop Res 1991;9:798808.

84. 17. Stolk J, Verdonschot N, Huiskes R. Stair climbing is more

10. Katoozian H, Davy DT. Effects of loading conditions and detrimental to the cement in hip replacement than walking.

objective function on three-dimensional shape optimization of Clin Orthop 2002;405:294305.

femoral components of hip endoprostheses. Med Eng Physics 18. Watanabe S, Hiroyasu T, et al. Neighborhood cultivation

2000;22:24351. genetic algorithm for multi-objective optimization problems.

11. Fernandes PR, Folgardo J, Ruben RB. Shape optimization of a IPSJ J 2002;43:No.SIG10 (TOM7);18398.

cementless hip stem for a minimum of interface stress and 19. Huiskes R, Hollister SJ. From structure to process, from organ

displacement. Comput Methods Biomech Biomed Engin to cell: recent developments of FE-analysis in orthopaedic

2004;7:5161. biomechanics. Trans ASME J Biomech Engin 1993;115:52027.

12. Tanino H, Ito H, Higa M, et al. Three-dimensional computer- 20. Bergmann G, Deuretzbacher G, Heller M, et al. Hip contact

aided design based design sensitivity analysis and shape opti- forces and gait patterns from routine activities. J Biomech

mization of the stem using adaptive p-method. J Biomech 2001;34:85972.

2006;39:194853. 21. Mohler CG, Callaghan JJ, Collis DK, Johnston RC. Early loos-

13. Estok DM, Orr TE, Harris WH. Factors affecting cement ening of the femoral component at the cement-prosthesis

strains near the tip of a cemented femoral component. J interface after total hip replacement. J Bone Joint Surg

Arthrop 1997;12-1:408. 1995;77-A:131522.

14. Breusch SJ, Lukoschek M, Kreutzer J, Brocai D, Gruen 22. Gardiner RC, Hozack WJ. Failure of the cement-bone

TA. Dependency of cement mantle thickness on fem- interface. J Bone Joint Surg 1994;76-B:4952.

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