Deformable acetabular cups

A biomechanical proof of concept

Joëll Magré
January 2020
2
Deformable acetabular cups
A biomechanical proof of concept

by

J. Magré

In partial fulfillment of the requirements for the degree of

Master of Science
in Biomedical Engineering

Delft University of Technology

To be defended on January 30th 2020

Supervisor: K. Willemsen, MD
Thesis committee: Prof. Dr. Ir. H.H. Weinans
Prof. Dr. Ir. P. Breedveld
Ir. H.M.A. Kolken

3
4
 Preface
This graduation project is part of a larger research project, focusing on developing the smart implant of
the future. The research project Prosperos (Printing Personalized Orthopaedic Implants) is a
collaboration between several universities and companies in the Netherlands and Belgium.

After my internship at the UMC Utrecht I started my thesis on deformable acetabular cups. An exciting
project I thoroughly enjoyed working on. Next to my graduation project I had the opportunity to work
on several clinical 3D cases. I would like to thank Harrie Weinans for the opportunity to do my
internship and thesis at the UMC Utrecht. Koen, thank you for being my supervisor during my time at
the UMC Utrecht. I enjoyed working with you on the clinical 3D cases.

Thanks to Aritz Fontecha from 3D Systems for manufacturing all samples and acetabular cups and to
Bart from the MTKF for assisting me in the workshop. I would like to thank Bart van der Wal and
Charles Vogely for their clinical input and enthusiasm.

During this project we had regular meetings with everyone working on this project. Thank you, Amir
Zadpoor, Eline Kolken, Lennart Scheys, Alexander Meynen and Christa de Jonge for all the constructive
meetings.

At last I would like to thank all my friends and family for their support during my studies. The
experiences I have gained during the past years are a great foundation for the future.

5
 Abstract
Introduction The management of large acetabular defects remains one of the most challenging aspects
of revision total hip arthroplasties. Failure of frequently used acetabular reconstruction components are,
among others, caused by the lack of biological fixation, a non-physiological stress distribution and stress-
shielding. Attempting to diminish these drawbacks of current implants a new acetabular cup with a
plastically deformable layer has been explored. The plastically deformable layer of this new acetabular cup
deforms during insertion and completely fills the acetabular defect. According to Wolff’s law this should
reduce stress shielding and stimulate bone ingrowth.
Methods Part one of this study explores the relationship between unit cell size and mechanical
properties for the body centred cubic unit cell. Three graded lattices using different unit cell sizes were
designed and 3D-printed out of commercially pure titanium (Grade 1) using selective laser melting. An
unconfined compression test with cylindrical samples as well as a confined compression test with
hemispherical samples were performed to obtain mechanical properties as well as assessing deformation
of the lattice structures. An additional finite element study was used to validate deformation observed in
the confined compression test. In part two the 4x4x4 mm unit cell size was chosen to be implemented as
deformable layer for the deformable cups. Acetabular defects were made in five Sawbones hemipelves
which served as the basis for the design of the ‘patient specific’ acetabular cups. Three triflange and two
unflanged acetabular cups were designed and 3D-printed out of commercially pure titanium (Grade 1)
using selective laser melting.
Results Mechanical properties were obtained from the unconfined compression tests. Elastic
moduli and yield strengths as low as 0.026 MPa and 0.076 MPa respectively were found. All acetabular
cups were inserted by two orthopaedic surgeons at the UMC Utrecht. Some loose struts were observed
after insertion. Segmented CT scans revealed deformation after insertion of the implants when registered
onto their original CAD (Computer Aided Design) files. Cyclic testing was performed up to 1000 cycles
to assess femoral head penetration under load after insertion. Additional penetration of the femoral head
was found to be between 0.1781 and 0.3793 mm.
Conclusion The concept of a deformable acetabular cups showed promising results in this study.
Future work is needed to prevent strut breakage upon insertion. Also, more research is needed in the
fatigue behaviour of these highly porous lattices and their biological effect on living bone tissue.

6
 Graphical abstract
Part one
Part two

7
 Contents
Preface 5

Abstract 6

Graphical abstract 7

Contents 8

1 Introduction 9

2 Part one 11

2.1 Introduction 11
2.2 Materials and methods 12
2.2.1 Lattice structure design ............................................................................................. 12
2.2.2 Cylindrical samples ................................................................................................... 12
2.2.3 Hemispherical samples and mould ........................................................................... 14
2.2.4 Material and production............................................................................................. 15
2.2.5 Mechanical testing..................................................................................................... 15
2.2.6 Finite element analysis............................................................................................... 16
2.3 Results 18
2.3.1 Cylindrical samples ................................................................................................... 18
2.3.2 Hemispherical samples ............................................................................................. 20
2.3.3 Finite element validation ............................................................................................ 21
2.4 Discussion 23
2.5 Conclusion 25

3 Part two 26

3.1 Introduction 26
3.2 Material and methods 26
3.2.1 Sawbones .................................................................................................................. 26
3.2.2 Implant design ........................................................................................................... 27
3.2.3 Insertion of the acetabular components .................................................................... 31
3.2.4 Mould and femoral head............................................................................................ 33
3.2.5 Mechanical testing..................................................................................................... 35
3.3 Results 36
3.3.1 Insertion of the acetabular components .................................................................... 36
3.3.2 Mechanical testing..................................................................................................... 37
3.4 Discussion 39
3.5 Conclusion 40

4 Future work 41

5 References 42

6 Appendix 45

8
 1
Introduction
The increasing number of primary total hip arthroplasties has led to an increasing number of revision
total hip arthroplasties.1 The main reason for revision surgery is aseptic loosening of the acetabular
component.2,3 The better the fixation of the component, the longer it will last without revision.
Long term fixation of the acetabular cup relies on bony ingrowth, which on its turn relies on
initial stability after implantation. Regular hemispherical acetabular cups have a high chance of failure
when initial stability cannot be obtained due to large acetabular bone defects.4 Micromotion at the bone-
implant interface may result in fibrous tissue formation instead of bone ingrowth, preventing biological
fixation.5,6 Biological fixation of a non-cemented hemispherical cup is unlikely when acetabular bone loss
exceeds 50%.7,8 One of the most challenging aspects of revision total hip arthroplasty is the management
of large acetabular defects.9
The Paprosky acetabular defect classification system is often used for describing acetabular
defects. The Paprosky type 3A and type 3B are considered large acetabular defects. For type 3A defects
acetabular bone loss is usual present from 10 to 2 o’clock if the acetabulum is imagined as a watch face.
For type 3B defects this is usually from 9 to 5 o’clock.10

Multiple off the shelf treatment options are available for revision total hip arthroplasty of the acetabular
component, including structural allografts, non-cemented hemispherical cups, oblong cups, jumbo cups,
antiprotrusio cages and Trabecular Metal augments and shells.11–15 For large acetabular defects surgeons
can also opt for a custom-made triflange acetabular implant.16 These custom-made implants have flanges
fixated with screws directed towards the ischium, pubis and ilium. However, many of these procedures
are associated with high revision rates due to loosening of the acetabular cup or implant migration.17 Due
to the large bone defects not all implants will be biologically fixated.
The screwed flanges on the custom-made triflange implants generate initial stability directly after
implantation. However, these flanges generate a non-physiological stress distribution within the pelvis.
The screwed flanges are stiffer than the bone it is connected to. With the implant distributing the load in
a non-physiological way, mainly through the flanges, the trabecular bone behind the implant becomes
unloaded. This effect is known as stress-shielding.18–20 According to Wolff’s bone remodels itself when
mechanically loaded. A lack of mechanical stimulus will eventually lead to bone resorbtion.21,22

These drawbacks of current procedures inspired us to develop a new acetabular cup which distributes
stresses in a more physiological way, resulting in less stress-shielding. Current advancements in additive
manufacturing, including SLM (selective laser melting) allow us to produce highly porous lattice
structures.23 The goal is to use these highly porous lattice structures to develop a deformable acetabular
cup for large acetabular bone defects.
The deformable highly porous lattice structure of the implant will plastically deform and precisely
fit into the acetabular cavity. Great host bone coverage should provide initial stability of the cup, the
porosity allows bone ingrowth for biological fixation. Since the implant fully covers the acetabular cavity
the implant actually transfers load into the acetabular cavity rather than via the flanges only. This load
transfer mechanically stimulates the bone, resulting in bone ingrowth and reduction of stress shielding by
the implant.

9
Previous research on porous structures (unpublished work by Groenewoud et al.) has demonstrated that
these lattice structures show desirable mechanical properties which are a low elastic modulus (9.15 MPa)
and large plastic deformations (61%).24 Research into different unit cells (unpublished work by de Jonge et
al.) demonstrated that the body centred cubic (BCC) unit cell was consistently the least stiff unit cell. This
is a desirable property when designing plastically deformable implants. However, when mechanically
testing highly porous hemispherical acetabular cups the push in forces were very high (3.33 kN to 14.8
kN).25 These forces were considered to be too high for complex acetabular revision surgery, especially
when the medial wall of the acetabulum is weak. Therefore, the push in force at which the scaffold
deforms should be lowered.

This thesis is divided into two main parts. Part one consists of experimental tests to obtain mechanical
properties of highly porous BCC (body centred cubic) lattice structures. Both the deformation in an
unconfined and confined environment will be assessed. The deformation in a confined environment will
also be evaluated using finite element modelling.
Part two is more focused on the clinical implication. Five porous deformable cups are designed and
inserted into a Sawbones pelvis by two orthopaedic surgeons. These cups will be cyclically tested,
simulating a walking motion, to assess additional penetration of the femoral head after insertion.

10
 2
Part one
2.1 Introduction
Understanding material properties of lattice structures is important when designing plastically deformable
acetabular cups. Since the deformable acetabular cup in previous experiments was rendered to be too
stiff, the porous structure needs to be re-designed to obtain a lower elastic modulus and a lower yield
strength. A couple of parameters can be adjusted to obtain these properties. Since the material of choice
is commercially pure titanium (CP-Ti grade 1) for its ductile behaviour, other parameters have to be
altered.26 Strut thickness is currently limited to 200 µm, which is also the minimal thickness used in the
previously printed deformable acetabular cups (unpublished work by de Jonge et al.).25 Strut length can be
increased by upsizing the unit cell.
The goal of these mechanical tests is defining the mechanical properties of porously graded
lattice structures constructed out of body centred cubic unit cells. It is expected that the elastic modulus
and the yield strength greatly decreas with increasing strut length. The relationship between the increasing
unit cell size and decreasing elastic modulus will also be looked into.
The BCC unit cell is characterized by its low compressive strength, as well as its space filling
capacities (lateral expansion) as described in both previous experiments and literature.25,27 The unit cell is
therefore suited for the design of intentionally compliant structures. This part consists of two
experiments and a finite element validation. In the first experiment cylindrical samples are used to assess
the mechanical properties of lattice structures (BCC unit cell) with larger unit cell sizes. In the second
experiment hemispherical samples and a mould are used to assess the behaviour of the lattice structure
when pressed into a confined space. Since the deformability of the lattice structure seems to be reliable
on the large lateral expansion of the structure the question is how the lattice structure behaves when
pushed into a confined space. The confined compression test is simulated in a finite element analysis to
asses internal deformability and stress distribution.

11
2.2 Materials and methods
2.2.1 Lattice structure design
Lattice structures are porous structures consisting of unit cells. Unit cells are the individual building
blocks that eventually form the lattice structure. The unit cell used in these experiments is the body
centred cubic (BCC) unit cell (Figure 1).

Figure 1: Design of the body centred cubic (BCC) unit cell with the representation of the strut length (L), strut diameter (D)
and unit cell size (U).

The body centred cubic unit cell is isotropic, it consists of eight struts of equal length and nine nodes.
The eight struts are all positioned with a 45° angle between them, all struts are connected in the centre.
The size of the unit cell (U) is described by the box the unit cell fits in. The unit cell size is related to the
strut length (L). The strut length can be described as a function of the unit cell size by the following
equation:

√3𝑈 &
𝐿=
2

2.2.2 Cylindrical samples

Three porous cylindrical samples were designed using the 3-Matic Medical software package (Version 13,
Materialise, Belgium). The samples were 81 mm in height and had a diameter of 40 mm. The BCC unit
cell was used to create the porous scaffold. Three types of samples were designed, each with a different
unit cell size. The infill with the BCC unit cells done via a direct patterning approach.28 The cylinders are
divided into three equal sections with each a different strut thickness to create a gradual porosity (Figure
2). This porosity gradient is chosen because the final implant will most likely also feature a porosity
gradient transitioning from the solid cup to the most porous outer layer.

12
Figure 2: Design of the porously graded cylinders. Unit cell size; left: 3x3x3 mm, middle: 4x4x4 mm, right: 5x5x5 mm. The
porosity gradient is obtained by adjusting the strut thickness; in all samples from top to bottom: 0.20 mm, 0.31mm and 0.45
strut thickness.

The theoretical densities of the sections are defined as the ratio between the volume of the lattice (VLattice)
structures (out of CAD) and the volume of a solid section (VSolid). The theoretical density can be
described by the following equation:

𝑉;<==>?@
𝑇ℎ𝑒𝑜𝑟𝑒𝑡𝑖𝑐𝑎𝑙 𝑑𝑒𝑛𝑠𝑖𝑡𝑦 [%] = ∙ 100
𝑉ABC>D

The theoretical porosity can subsequently be expressed as:

𝑇ℎ𝑒𝑜𝑟𝑒𝑡𝑖𝑐𝑎𝑙 𝑝𝑜𝑟𝑜𝑠𝑖𝑡𝑦 [%] = 100 − 𝑇ℎ𝑒𝑜𝑟𝑒𝑡𝑖𝑐𝑎𝑙 𝑑𝑒𝑛𝑠𝑖𝑡𝑦

13
The properties of the samples are displayed in Table 1.

Table 1: Properties of cylindrical samples

Strut Strut
Unit cell Theoretical Theoretical
diameter length
size [mm] density porosity
[mm] [mm]
3x3x3 0.45 2.598 21.7 % 78.3 %
Sample 1 3x3x3 0.31 2.598 10.4 % 89.6 %
3x3x3 0.20 2.598 4.3 % 95.7 %
4x4x4 0.45 3.464 12.4 % 87.6 %
Sample 2 4x4x4 0.31 3.464 6.0 % 94.0 %
4x4x4 0.20 3.464 2.5 % 97.5 %
5x5x5 0.45 4.330 8.1 % 91.9 %
Sample 3 5x5x5 0.31 4.330 1.9 % 98.1 %
5x5x5 0.20 4.330 0.8 % 99.2 %

2.2.3 Hemispherical samples and mould

Three porous samples were designed using the 3-Matic Medical software package (Version 13,
Materialise, Belgium). These samples were also lattice structures using the BCC unit cell and a direct
patterning approach.28 The three sample types all featured, as in the previous experiment, different unit
cell sizes. These samples do also have a porous gradient obtained by different strut thickness. The design
and dimensions of the samples can be seen in Figure 3. The porosity values, strut thicknesses and strut
lengths are the similar to the values of the cylindrical samples. Only these samples have a two-layer
gradient using the 0.20 mm and 0.31 mm strut thickness. These properties are shown in Table 1.
A mould was milled out of a solid block of aluminium by the MTKF (Medische Technologie & Klinische
Fysica) at the UMC Utrecht. The mould with its dimensions is shown in Figure 3.

Figure 3: Design parameters of the hemispherical samples and aluminium mould (top). Photographs of the manufactured
hemispherical samples and aluminium mould(bottom).

14
2.2.4 Material and production
Due to its high strength to weight ratio Ti6Al4V is an often-used material for load-bearing orthopaedic
implants. Although Ti6Al4V remains the strongest material for statically loaded applications, the non-
alloyed material; commercially pure titanium (CP-Ti), shows mechanical behaviour similar to tantalum.26
CP-Ti outperforms Ti6Al4V in terms of high cycle fatigue strength and could therefore be more suitable
for cyclically loaded implants such as acetabular components in hip arthroplasties.26
The goal of this study is to make highly deformable structures to design deformable acetabular
implants. The ductile behaviour of CP-Ti makes this the material of choice for the production of porous
deformable lattice structures and acetabular implants. The bulk properties of CP-Ti and Ti6Al4V are
shown in Table 2.29,30

All samples were manufactured by 3D Systems (Leuven, Belgium) using selective laser melting (SLM).
For these samples the ProX DMP 320 (3D Systems, Leuven, Belgium) SLM machine was used.31 The
material used to produce the samples is commercially pure titanium (Grade 1) in powder form.29 The
parts are build up layer by layer by laser scanning a powder bed. The laser melts the titanium powder
which binds together. A new layer of titanium powder is then placed onto the powder bed and the laser
scans the powder bed again, binding the powder. This layer by layer process eventually forms the part.32,33
Strut thickness of the lattice structure is currently limited to 200 µm.
Each sample type was produced three times resulting in a total of nine samples per experiment.

Table 2: Mechanical properties of CP-Ti (Grade 1) and Ti6Al4V (Grade 5). CP-Ti has an elastic modulus similar to Ti6Al4V but
a yield strength almost three times as low.

CP-Ti Ti6Al4V
(Grade 1) (Grade 5)
Density [g/cm3] 4.51 4.42
Young’s modulus [GPa] 105-120 105-120
Ultimate strength [MPa] 500 ±30 1180 ±30
Yield strength [MPa] 380 ±30 1090 ±30
Elongation at break [%]
Horizontal direction – XY 29 ±5 9 ±2
Vertical direction - Z 30 ±5 9 ±2

2.2.5 Mechanical testing

All samples were subjected to a static compression test on a Lloyd LS 5 universal test machine (Amatek,
Berwyn, United States) with a 5 kN load cell. The cylindrical samples were placed in between
compression plates, the hemispherical samples were placed into an upper vice grip while the mould was
placed on the lower compression plate (Figure 4). All cylindrical samples were subsequently compressed
with a compression rate of 2 mm/min up to a force of 5 kN. All nine cylindrical samples were tested in
the same manner and a video recording was made of the compression of each sample type.
The hemispherical samples were also compressed with a rate of 2 mm/min. These samples were
compressed until a machine extension of 10 mm was reached. This was to make sure the solid part of the
sample did not touch the mould.

15
The direct results from the static compression test are force-displacement curves. This data is used to
obtain stress-strain curves for the cylindrical samples. The stress (s) is calculated by dividing the applied
force by the initial cross-sectional area. The strain (e) is defined as the displacement divided by the
original sample height. The elastic moduli were calculated from the slope of the stress-strain curves in the
linear elastic regions of the cylindrical samples using the following formula:

𝜎
𝐸=
𝜀

The compressive yield strengths were determined from the stress-strain curves of the cylindrical samples
using the 0.2% offset method.
It is important to understand that the material properties described in these experiments describe a
different concept when concerning highly porous lattice structures. When referring to solid materials the
material properties describe the intrinsic properties of the material, when referring to highly porous lattice
structures it describes the macroscopic properties of the structure.34

(a) (b)
Figure 4: Test setup of the compression tests; cylindrical samples (a), hemispherical
samples (b).

2.2.6 Finite element analysis

A simplified two-dimensional FEM (finite element method) model was created in Abaqus (Version 6.14,
Dassault Systemes, France) to assess stress distribution and deformation of the hemispherical samples.
The cross sections of the porous sections of the hemispherical samples were created in Abaqus together
with a discrete rigid press (representing the solid part of the sample) and a discrete rigid mould.
For simplification the porous part of the sample was modelled as a solid using the material
properties found in the compression test with cylindrical samples. The average elastic modulus found in
the first experiment (Table 3) and a Poisson’s ratio of 0.48 was used to define the elastic material
behaviour. For isotropic solid materials the theoretical Poisson’s ration cannot exceed 0.5. However,
experiments have shown that highly porous lattice structures, including the BCC unit cell, can show
atypical behaviour and have a Poisson’s ratio higher than 0.5.25 A Poisson’s ratio higher than 0.5 is an
invalid input in Abaqus so a high Poisson’s ration of 0.48 was chosen to avoid computational errors. The
plastic material behaviour was described by fitting a polynomial through the plastic region of the data
points. This data was used to describe the plastic material behaviour. The Abaqus model and the data of
one of the plastic regions (4x4x4 mm unit cell size, 0.2 mm strut thickness) can be seen in Figure 5. The

16
elastic and plastic data of all samples and strut thicknesses can be found in appendix Figure A 1-Figure A
4. Density was calculated by using the theoretical density values shown in Table 1 as a percentage of the
bulk property density value shown in Table 2.
A displacement of 7 mm was exerted on the samples (Abaqus) to validate the stress distribution
and deformation within the printed titanium samples.

[4x4x4] 0.2 mm
6

Stress [Mpa]
4

0
0 5 10 15 20 25 30 35 40 45
Strain [%]
[4x4x4] 0.2 mm elastic [4x4x4] 0.2 mm plastic

Figure 5: Left: mesh of the samples used in Abaqus for the finite element method. The red coloured elements are the inner
struts with a thickness of 0.31 mm, the other elements are the outer more porous struts with a thickness of 0.2 mm. On the
right the elastic and plastic data extracted from the cylindrical sample compression test of the 4x4x4 mm sample with a 0.2
mm strut thickness.

17
2.3 Results
2.3.1 Cylindrical samples
All nine cylindrical samples were compressed until a force of 5 kN was reached. The resulting force-
displacement curves were converted into stress-strain curves. The smaller unit cell size samples (3x3x3
mm) results in a stiffer and stronger structure than the larger unit cell size samples (5x5x5 mm). The
stress-strain curves of the static compression test can be seen in Figure 6. The three linear elastic sections
with different porosities can clearly be differentiated in the 4x4x4 mm and 5x5x5 mm unit cell size
samples. In these plots the three plateau regions are clearly visible. The stress-strain curves of the 3x3x3
mm unit cell size does not show three, but two linear elastic sections indicating the least porous section
(0.45 mm strut thickness) did not deform under a 5 kN load. This is further illustrated in Figure 7.
Figure 7 shows the compression of all sample types at corresponding time intervals. At the latest
time interval the compression force is 5 kN and it can be seen that the less porous sample (3x3x3 mm)
has deformed considerably less than the more porous samples, as can also be seen from the stress-strain
curve (Figure 6).

4,5

3,5
Compressive stress [MPa]

2,5

1,5

0,5

0
0 10 20 30 40 50 60 70 80 90

Strain [%]
[3x3x3] 1 [3x3x3] 2 [3x3x3] 3 [4x4x4] 1 [4x4x4] 2

[4x4x4] 3 [5x5x5] 1 [5x5x5] 2 [5x5x5] 3

Figure 6: Stress-strain curves of the compression test of the cylindrical samples. Each sample type was produced three times,
hence the three lines that are grouped. The 3x3x3 mm samples are displayed in blue, the 4x4x4 mm samples in orange and
the 5x5x5 mm samples in yellow.

All samples show ductile behaviour characterized by the plateau region in the plastic region. The elastic
moduli found and compressive yield strengths for each porous section of the samples are show in Table
3. The elastic modulus and compressive yield strength could not be determined for the 0.45 mm strut
thickness section (3x3x3 mm sample) because the 5 kN compression force did not deform this section.

18
Figure 7: Compression of the cylindrical samples at different time intervals. Top: 3x3x3 mm, middle: 4x4x4 mm and bottom:
5x5x5 mm. At t5 the maximum compression force of 5 kN is reached for the 4x4x4 mm and 5x5x5 mm samples. Note that at t3
a load of 5 kN is reached for the 3x3x3 mm sample.

All samples deformed significantly during compression, the largest unit cell size (5x5x5 mm) deformed
the most. The height of the 3x3x3 mm samples decreased 41.6% on average, for the 4x4x4 mm samples
this was 71.1% and for the 5x5x5 mm samples 79.2%. The average lateral expansion of the samples at the
fully deformed sections was 16.8% for the 3x3x3 mm samples, 16.8% for the 4x4x4 mm samples and
17% for the 5x5x5 mm samples.

Table 3: Mechanical and dimensional properties of the cylindrical samples extracted from the compression test

Unit cell Strut thickness Elastic modulus Compressive yield

Porosity
size [mm] [mm] [MPa] strength [MPa]

3x3x3 0.20 95.7 % 0.224 ±0.013 0.499 ±0.014

3x3x3 0.31 89.6 % 0.380 ±0.037 2.368 ±0.090
3x3x3 0.45 78.3 % - -
4x4x4 0.20 97.5 % 0.066 ±0.007 0.168 ±0.006
4x4x4 0.31 94.0 % 0.145 ±0.006 0.857 ±0.030
4x4x4 0.45 87.6 % 0.190 ±0.017 2.462 ±0.043
5x5x5 0.20 99.2 % 0.026 ±0.001 0.076 ±0.007
5x5x5 0.31 98.1 % 0.039 ±0.008 0.383 ±0.030
5x5x5 0.45 91.9 % 0.087 ±0.012 1.029 ±0.021

Plotting the elastic moduli against unit cell size for a given strut thickness gives a negative correlation
between increasing unit cell size and the decrease of the elastic modulus (Figure 8). An exponential trend
line appears to be a good fit through these data points demonstrating a negative exponential relationship
between the unit cell size and the elastic modulus for the BCC unit cell.

19
 0.2 mm 0.31 mm
0,5 0,5

0,45 0,45

0,4 0,4

0,35 0,35
Elastic modulus [MPa]

Elastic modulus [MPa]

0,3 0,3

0,25 0,25

0,2 0,2

0,15 0,15

0,1 0,1

0,05 0,05

0 0
1 2 3 4 5 6 7 1 2 3 4 5 6 7
Unit cell size [mm] Unit cell size [mm]

Figure 8: Unit cell size plotted against the elastic modulus demonstrating a negative exponential relationship between the unit
cell size and the elastic modulus for the BCC unit cell.

2.3.2 Hemispherical samples

The hemispherical samples were compressed into the aluminium moulds until a machine extension of 10
mm was reached. The 3x3x3 mm unit cell samples required the highest push-in force to compress the
samples into the mould. The machine extension is plotted against the force in Figure 9.

Force-displacement hemispherical samples

4000

3500

3000

2500
Force [N]

2000

1500

1000

500

0
0 2 4 6 8 10
Machine extension [mm]

[3x3x3] 1 [4x4x4] 1 [5x5x5] 1

[3x3x3] 2 [4x4x4] 2 [5x5x5] 2
[3x3x3] 3 [4x4x4] 3 [5x5x5] 3

Figure 9: Force-displacement curves of the compression test of the hemispherical samples. The 3x3x3 mm samples are
displayed in blue, the 4x4x4 mm samples in orange and the 5x5x5 mm samples in yellow.

When examining the samples after compression it is shows that the least porous (0.31 mm strut
thickness), and thus least stiff section appears to have deformed the most. Pictures of the deformed

20
samples are shown in Figure 10. The outer layer of the lattice structure seems to be more or less intact,
especially in the 3x3x3 mm and 4x4x4 mm unit cell size samples.

(a) (b) (c)

Figure 10: Hemispherical samples after compression. 3x3x3 mm unit cell size (a), 4x4x4 mm unit cell size (b) and 5x5x5 mm
unit cell size (c).

2.3.3 Finite element validation

A finite element simulation was done for each hemispherical sample type to visualize the stress
distribution and material displacement within the sample. A stress concentration is visible around the
edges of the solid part of the sample. Higher stresses are observed in the less porous section than in the
highest porous sections in all samples (Figure 11). Lower stresses are observed in the outer section (most
porous section) of the samples.

3x3x3 4x4x4

5x5x5

Figure 11: Stress distribution in the finite element models. Top left: 3x3x3 mm unit cell size, top right: 4x4x4 mm unit cell size,
bottom: 5x5x5 mm unit cell size.

21
Consistent with the observation of the compressed hemispherical samples the finite element models
show larger deformations in the less porous section of the samples than in the higher porous section.
This can be seen in the compressed finite element samples in Figure 12.

3x3x3 4x4x4

5x5x5

Figure 12: Deformation within the finite element models. Top left: 3x3x3 mm unit cell size, top right: 4x4x4 mm unit cell size,
bottom: 5x5x5 mm unit cell size.

22
2.4 Discussion
The experiments were conducted to evaluate the mechanical properties and behaviour using an increasing
unit cell size to optimize deformability. The body centred cubic (BCC) unit cell was evaluated since
previous experiment showed this was the most compliant unit cell.25 The first experiment with cylindrical
samples was performed to obtain the mechanical properties of increasing unit cell sizes. The compression
test with hemispherical samples was performed to assess deformability of the lattice structure in a
confined space. This experiment was also evaluated using a simplified finite element model in Abaqus.

The stress strain curves resulting from the compression test with cylindrical samples show a linear elastic
region and a plateau region as expected. The three porous sections are discernible in plots of both the
4x4x4 mm and 5x5x5 mm unit cell sizes. All samples show the same type stress-strain curves although
they represent different stiffnesses and compressive strengths. However, it is apparent from the stress
strain curves the samples with a higher porosity (thinner strut thicknesses or larger unit cell) show a larger
plateau region in the plastic deformation phase (Figure 6). Elastic moduli and compressive yield strengths
as low as 0.026 MPa and 0.076 MPa respectively were found in this experiment. The low elastic modulus
and large deformation capacity of the BCC unit cell found in this study are also described in literature.27
The stress-strain curves also show some spikes right after the plateau region, when material densification
is happening. These spikes indicate the breakage of struts. After compression no loose struts came out of
the samples. This indicates the struts broke at one end only, at this point the strut is no bearing part of
the lattice structure anymore. The samples deformed collapsing a layer by layer.
This is consistent with the failure mechanism described in literature, manufacturing irregularities
significantly affect the mechanical properties of the lattice structure.35 The lattice structure shows
heterogeneous behaviour while at strut level local strain concentrations accumulate at the weak spots,
resulting in strut failure.36

The elastic modulus and compressive yield strength were determined from the stress-strain curves of the
compression test. As shown in Figure 7 the samples showed significant lateral expansion during
compression. This is a desired property when designing the acetabular cups since this lateral expansion
fixates the cup in the acetabulum. This is due to geometrical properties of the BCC unit cell. The
deformability of the unit cell is highly dependent on the lateral expansion. The lateral expansion means
that the cross-sectional area increases during compression. When calculating the stress, the engineering
stress was calculated using the original cross-sectional area of 40 mm. The true compressive stress is
lower than the engineering compressive stress, this is also true for solid materials. However, the large
lateral expansion of these structures might result in a significant lower true stress.
The cylindrical samples were all a graded design, this was decided because the final acetabular cup will
most likely also feature a graded design to prevent stress shielding. This graded design is divided into
uniform sections. The mechanical properties obtained from a graded design in which there is a gradient
within the unit cell might not be exactly corresponding with the results obtained from a uniform design.34

Figure 8 demonstrates a negative exponential relationship between the unit cell size and the elastic
modulus. Increasing the unit cell size dramatically reduced the elastic modulus of the lattice structure.
Between the 3x3x3 mm unit cell size and the 5x5x5 mm unit cell size there is roughly a factor 10
difference in elastic modulus (0.224 MPa and 0.026 MPa respectively).
The exponential relationship is currently based on three unit cell sizes, to further analyse this relationship
experiments with more unit cell sizes are needed.

The hemispherical samples were all compressed into an aluminium mould until a deformation of 10 mm
was reached. Where the three porous sections were clearly discernible in the unconfined compression test

23
with cylindrical samples, this is not the case with the hemispherical samples. Where the cylindrical
samples showed significant lateral expansion, this was not possible since the samples were confined by
the mould. The confined space seems to stiffen the lattice structure in a way deformation happens mostly
in the stiffer, les porous, section of the sample. Still the push-in forces for the hemispherical 4x4x4 mm
unit cell size samples are considerably lower than the push-in forces of the 3x3x3 mm unit cell size
samples.
The plateau stresses appear to be less constant for the confined compression test than for the unconfined
compression test (Figure 9 and Figure 6). This is probably caused by the restriction in the lateral
directions causing the BCC unit cells to collapse within the parameters of the confinement.

The finite element analysis showed larger deformations in the least porous/stiffer section of the samples.
This is in line with the observations from the hemispherical samples. This finite element model is a
simplification of the real samples and therefore has limitations. One of the biggest limitations is the
simplification as a solid. As seen in the samples the structure deforms by collapsing layer by layer meaning
there is a space filling volume reduction happening. The mechanical properties found in de unconfined
cylindrical compression test were used as mechanical properties for the modelled solid, however, a
reduction of volume cannot take place in a solid material. This is the reason only 7 mm of deformation
was possible in the finite element model versus the 10 mm used in the real samples. Another limitation is
the simplification to a two-dimensional model.
A more accurate representation can be created by modelling the entire lattice structure. Though
manufacturing irregularities affect the mechanical properties of the lattice structure model based on
straight trusses will not give an accurate representation. It is described in literature that these
manufacturing irregularities can be implemented in finite element models.35

Though it is possible to create strut lengths up to 4.33 mm using SLM, some limitations were found when
removing the samples from the build plate. The large strut lengths make it not possible to directly grow
the scaffold on the build and are therefore printed on a solid block of titanium. The samples are removed
from the solid blocks using wire EDM (Electrical Discharge Machining) method.37 The inaccuracies of
the process make it difficult to remove the structures. For the 5x5x5 mm unit cell size with its 4.33 mm
strut length this resulted in damaged and open-ended struts. Therefore, the 5x5x5 mm unit cell size is
considered a non-viable scaffold geometry for real production.

In these experiments, samples featuring a porosity gradient were designed and used. The final acetabular
cups will feature some sort of porosity gradient. Previous experiments (unpublished work by de Jonge et
al.) have shown that the transition between a solid titanium layer and very thin struts (0.20 mm strut
thickness) might lead to strut failure at the interface.25
The current samples are tested as manufactured without any post processing. Post processing can
further optimize mechanical properties of the lattice structures. A recommended post processing step is
HIP (Hot Isostatic Pressing) treatment.38 For CP-Ti HIP treatment will further reduce the yield strength
of the bulk material and increase ductility.29 In theory this should mean greater deformability and less
strut breakage in the lattice structures.

24
2.5 Conclusion
Increasing the unit cell size considerably reduces the elastic modulus and compressive yield strength of
lattice structures constructed out of the body centred cubic (BCC) unit cell. This experiment shows a
relationship that is negatively exponential.
The large deformability of the BCC unit cell is desirable for designing deforming acetabular cups.
However, it was observed that in a confined space the lattice structure becomes stiffer. In the graded
design the least porous (stiffest) section deformed the most. This was also observed in a finite element
validation where also most deformation took place in the least porous section. Also, the highest stresses
within the material were in the least porous section.

For the design of the acetabular cups the 4x4x4 mm body centred cubic unit cell will be used. For now,
the 5x5x5 mm unit cell size is not a viable option for production. The 3x3x3 mm unit cell size has an
elastic modulus more than three times higher than the elastic modulus of the 4x4x4 mm unit cell size.
The push-in forces required to deform the 3x3x3 mm lattice structure were considered too high for
complex acetabular revision surgery in previous experiments.
The deformable parts on the acetabular cups will be filling a solid volume using a direct patterning
approach. In terms of geometry retainment, the 4x4x4 mm unit cell size is also more favourable as
opposed to the larger 5x5x5 mm unit cell size.

25
 3
Part two
3.1 Introduction
In part one the mechanical properties of BCC unit cell lattice structures were obtained. The 4x4x4 mm
unit cell size was chosen to be used for the deformable part of the implants. The goal of part two is
implementing the knowledge gained in previous experiments in designing plastically deformable
acetabular cups for large acetabular defects.
One of the most important aspects of the deformable acetabular cup is that the deformable part
deforms during insertion. The challenging aspect is that no additional deformation occurs when the
implant is under load, during walking for example. These aspects of the deformable acetabular cup will be
investigated in this second part.
Acetabular defects are made in five Sawbones hemipelves which will be the basis for the
acetabular cups. Five acetabular cups featuring deformable layers are designed for the corresponding
hemipelves. All acetabular cups are inserted into their corresponding hemipelves by two orthopaedic
surgeons at the UMC Utrecht. After insertion the hemipelves with acetabular cups are cyclically tested to
assess additional penetration of the femoral head, which could be an indication of additional deformation.

3.2 Material and methods

3.2.1 Sawbones
Five Sawbones biomechanical composite hemipelves (right side) were ordered from Sawbones Sweden.
Sawbones biomechanical bones are a validated alternative to cadaveric bones.39,40 The used composite
hemipelves consist of a 10 PCF solid foam inner core simulating trabecular bone and a short fibre filled
epoxy as simulated cortical bone.41 The mechanical properties of the 10 PCF solid foam and short fibre
epoxy as well as the mechanical properties of human bone are shown in Table 4 Mechanical properties of
the Sawbones hemipelves are from the Sawbones data sheet.41 The properties of the human bone are
based on literature.42–45

Table 4: Mechanical properties of the Sawbones hemipelvis and the human pelvic bone.

Sawbones Human pelvic bone

10 PCF solid Short fibre Trabecular Cortical
foam epoxy bone bone
Elastic modulus
58 16.700 49.7 - 96 18.600
(compression) [MPa]
Yield strength
2.2 157 0.22 – 0.64 161 - 183
(compression) [MPa]

In all five hemipelves acetabular defects were made according to the Paprosky acetabular defect
classification system.10,46 In two hemipelves a Paprosky type 3A defect was created and type 3B defects
were created in the other three hemipelves.

26
After the defects were made a CT-scan was made of all hemipelves using a 0.8 mm slice thickness (Philips
IQon Spectral CT, UMC Utrecht). The DICOM files of the scans were segmented using the Mimics
Medical software package (Version 24, Materialise, Leuven, Belgium) to create three-dimensional
computer models. The rendered images of the created Paprosky type 3A and 3B defect are shown in
Figure 13.

(a) (b)
Figure 13: Rendered images of the acetabular defects created in the Sawbones hemipelves. Paprosky
type 3A (a), Paprosky type 3B (b).

3.2.2 Implant design

Using the CAD (Computer Aided Design) models of the Sawbones hemipelves five ‘patient specific’
acetabular cups were designed using the 3-Matic software package.
To determine the correct position of the acetabular cup without the contralateral hemipelvis (left
side) present, the hemipelvis was mirrored around the articular surface of the pubis. A fitting sphere was
fitted in the acetabular cavity to determine the centre of rotation. Using this centre of rotation, a 44 mm
hemispherical acetabular cup designed in SolidWorks (version 2017, Dassault Systemes, France) was
imported and placed at 55° inclination and 20° anteversion.47

Five different acetabular cups were designed, these cups can be divided into two major concepts;
acetabular cups without flanges and acetabular cups with flanges. The cups with flanges feature two
design concepts, a version with the deformable outer layer attached and an undersized version that
requires a separate deformable mesh. The porous layers of the cups are constructed out of BCC unit cells
using a direct patterning approach.28 The lattice structure is oriented in the direction of insertion,
favourable to the direction of lateral expansion of the BCC unit cell. The specifications of the acetabular
cups are shown in Table 5.
The three oversized cups with attached deformable layer have a graded porosity. They consist of
a porous non-deformable section with a strut thickness of 0.5 mm and a deformable outer layer with a
strut thickness of 0.2 mm. The cups are 4 mm oversized in the direction of insertion. The deformable
layer has a thickness of 8 mm. One of the oversized cup features three flanges directed towards the

27
ischium, pubic and ilium. The solid part of the cups without flanges is designed to lay flush with the
cortical shell of the Sawbones hemipelves.
The two undersized cups are 6 mm undersized and require the 10 mm generic mesh. Both these
cups feature three flanges directed towards the ischium, pubis and ilium. SB2 has a smaller unit cell size
which is more comparable to the currently available aMace cups.48 The SB4 cup has a slightly larger
2.5x2.5x2.5 mm unit cell size. The strut thickness of the non-deformable porous sections is 0.3 mm.
Undercuts were removed of all implants to ensure a proper fit. The design of the five acetabular cups is
shown in Figure 14.
Five 28 mm liners were produced using SLS (Selective Laser Sintering) out of PA12 (Oceanz,
Ede, Netherlands).

Two types of generic deformable meshes were designed in SolidWorks (version 2017, Dassault Systemes,
France). A circular mesh and an elongated mesh, both with cut-outs to improve deformability (Figure 14).
The elongated part of the mesh could for instance fill the defect in the direction of the ilium. The meshes
are 10 mm thick and are constructed out of the 4x4x4 mm BCC unit cell using direct patterning.28 Both
mesh types were produced in three diameter sizes; 53 mm, 63 mm and 73 mm. The designs of the
deformable meshes are shown in Figure 14.

Table 5: Properties of the designed acetabular cups

Flanged/no
Acetabular cup Type Defect type Unit cell size [mm]
flanges
SB1 Oversized Paprosky 3A No flanges 4x4x4
SB2 Undersized Paprosky 3A Flanged 1.5x1.5x1.5
SB3 Oversized Paprosky 3B No flanges 4x4x4
SB4 Undersized Paprosky 3B Flanged 2.5x2.5x2.5
SB5 Oversized Paprosky 3B Flanged 4x4x4

28
(a)

(b)

(c)

29
(d)

(e)

(f)

Figure 14: Rendered images of the designed acetabular cups; SB1 (a), SB2 (b), SB3 (c), SB4 (d), SB5 (e), deformable meshes (f).
30
Each cup was produced once by 3D Systems (Leuven, Belgium) using selective laser melting. For these
cups the ProX DMP 320 (3D Systems, Leuven, Belgium) SLM machine was used.31 The material is
commercially pure titanium (Grade 1) in powder form.29 The generic deformable meshes were produced
two times each. The cups were tested as manufactured, the only post processing was support removal.
The printed acetabular cups and meshes are shown in Figure 15, more pictures can be found in appendix
Figure A 6.

3.2.3 Insertion of the acetabular components

(a)

(b)

(c)

(f)

31
 (d)

(e)

(f)

Figure 15: Photographs of the manufactured acetabular cups; SB1 (a), SB2 (b), SB3 (c), SB4 (d), SB5 (e), deformable
meshes (f).

The acetabular cups were inserted into their corresponding Sawbones hemipelves by Dr. H.CH. Vogely
and Dr. B.C.H. van der Wal, two orthopaedic surgeons at the UMC Utrecht. To insert the cups, a
standard hip insertion set from the operating room was used. The oversized acetabular cups were placed
into position and subsequently inserted using an inserter and hammer. The two undersized cups needed a
mesh to fill the medial gap between the implant and Sawbones interface. All three sizes circular and
generic meshes were available to the surgeons to be used in combination with the undersized acetabular
cups. For these cups the generic mesh was placed into position first and partially deformed using a
hammer and inserter. Then the acetabular cup was placed and inserted with the inserter and hammer,
further deforming the generic mesh underneath.

After insertion of the acetabular cups the liners were cemented into the cups using Zimmer Biomet
Refobacin Râ bone cement.49 The Sawbones hemipelves with inserted acetabular cups and cemented
liners are shown in Figure 16.

32
 Since the deformability of the oversized cups cannot be assessed during insertion, a CT scan was made
after insertion (Philips IQon Spectral CT, metal artefact reduction protocol, UMC Utrecht). The slice
thickness of the scan was 0.8 mm. To assess deformation of the oversized cups the DICOM files were
segmented using the Mimics Medical software package (Version 24, Materialise, Belgium). The registered
scans were positioned on the original CAD (Computer Aided Design) file using a point to point
registration method, this was done using the 3-Matic software package (Version 13, Materialise, Belgium).
All registered points were positioned at the solid (non-deformable) part of the acetabular cups.

(a) (b) (c)

(d) (e)

Figure 16: Photographs of the inserted acetabular cups. SB1 (a), SB2 (b), SB3 (c), SB4 (d) and SB5 (e).

3.2.4 Mould and femoral head

To position the hemipelves during mechanical testing a mould was designed to place them in 180°
anterior pelvic plane. The force vector acting on the hemipelves, described by Bergmann et al. is in line
with the direction of compression when placed in the mould.50 The mould was designed using the 3-
Matic software package (Version 13, Materialise, Leuven, Belgium). This mould was then hollowed in
CAD with a wall thickness of 4 mm. This part was 3D printed (Oceanz, Ede, Netherlands) out of PA12
using selective laser sintering (SLS). To ensure rigidity of the mould the hollow cavity was filled with

33
epoxy resin. (Polyservice, Amsterdam, Netherlands) The mould is designed in a way that the Sawbones
hemipelves can be inserted into the mould in the direction of compression testing. The mould and
direction of insertion of the hemipelves is shown in Figure 17.
A 28 mm femoral head was fitted to a solid metal connection bar by the MTKF (UMC Utrecht,
Netherlands) which can be clamped in the upper vice of the testing machine.

Figure 17: Rendered images of the mould for cyclic testing with the placement of the Sawbones hemipelves.

34
3.2.5 Mechanical testing
All Sawbones hemipelves with acetabular cups were cyclically tested on a Lloyd LS 5 universal testing
machine (Amatek, Berwyn, United States). The mould was clamped onto the lower compression plate,
then a hemipelvis with prior inserted acetabular cup was placed into the mould. The acetabular head was
placed into the upper clamp and positioned into the liner. A preload of 100 N was used to keep pressure
on the pelvis. A picture of the test setup can be seen in Figure 18.
All acetabular cups were first tested up to 1000 cycles with a force altering between 100 N and 1800 N to
simulate a walking motion. A minimum load of 100 N was used to ensure the acetabular head did not
lose contact with the liner. The maximum compressive force of 1800 N is based on the average peak load
for walking.50 The extension speed of the machine was kept constant at 60 mm/min. After 1000 cycles a
second test of 50 cycles was performed.
The output of the cyclic compression test is a time-extension curve. The difference in machine
extension between the first cycle and the last cycle gives the extra penetration of the femoral head.

Figure 18: Test setup of the cyclic tests for the acetabular cups.

35
3.3 Results
3.3.1 Insertion of the acetabular components
All five acetabular cups were implanted into the matching Sawbones hemipelves. Subjectively, according
to both surgeons none of the cups did require a noticeably larger impact force to insert them than a
regular hemispherical acetabular cup. Only the smallest generic meshes (53 mm) were used with the
undersized cups, one circular and one elongated mesh. The elongated mesh was cut to size with plain
scissors to fit the defect.
In both cups without flanges the deformation was less than planned in the ischium direction, evident
from a small gap between the solid part of the cup and the Sawbones cortex.
One generic mesh (Paprosky type 3B defect) broke when deformed with an inserter. Also broken
titanium struts fell through the defect in the medial wall when the undersized flanged cup was inserted.
Some broken and loose struts were observed in other cups judged by the sound of rattling metal in the
porous section of the cup.
Only one acetabular cup needed additional fixation with screws after insertion, this was the cup
with the broken generic mesh (Paprosky type 3B defect). None of the other cups could be removed by
hand after insertion.

To assess the deformation of the oversized acetabular cups a CT scan was made (Philips IQon Spectral
CT, metal artefact reduction protocol, UMC Utrecht). Registration of the CT scan onto the original CAD
file shows the deformation of the outer porous layer of all three oversized acetabular cups, this can be
seen in Figure 19.

(a) (b)

(c)

Figure 19: Rendered images of the CT-CAD registration; SB1 (a), SB3 (b), SB5 (c). The red part is the segmented cup after
insertion, the grey part is the original CAD file.

36
3.3.2 Mechanical testing
All five acetabular cups, inserted in Sawbones hemipelves, were cyclically tested up to 1000 cycles. With
this cyclic compression a walking motion was simulated. The time-extension plot for SB1 is shown in
Figure 20. The time-extension curves for the other cups can be found in appendix Figure A 8-Figure A
11. The curves show that the machine extension increases during the first cycles to reach 1800 N,
indicating a displacement. The more cycles performed the more the curve flattens. This is true for all
acetabular cups. The second test of 50 cycles shows this behaviour to a lesser extent.
The machine extension needed to reach 1800 N at the first, second and last compression are
visualised in Figure 20. The extension of the first compression is indicated by the lower red line, the
second compression by the yellow line the last compression by the upper red line. The difference in
extension between the first and last compression and the second and last compression is shown in Table
6. This is the additional penetration of the femoral head. The same is done for the second test of 50
cycles for the first and last compression, indicated by the red lines.

SB1 [1000 cycles]

4

3,5
Machine extension [mm]

2,5

1,5

1
0 500 1000 1500 2000 2500 3000 3500
Time [s]

SB1 [50 cycles]

4

3,5
Machine extension [mm]

2,5

1,5

1
0 50 100 150
Time [s]

Figure 20: Time-extension curves for the 1000 and 50 cycles test for SB1. The extension of the first compression is indicated
by the lower red line, the second compression by the yellow line the last compression by the upper red line. For the second
test of 50 cycles only the first and last compression are shown.

37
When comparing the deformation between the first and last compression SB1 showed the most
additional femoral head penetration (0.3793 mm) under cyclic compression. SB4 showed the lowest
additional femoral head penetration (0.1781 mm). During the second test with 50 cycles all cups showed
less femoral head penetration than during the first test. However, SB1 still showed the most penetration
(0.0726 mm) and SB4 the least (0.0197 mm).

Table 6: Values of the femoral head penetration for both the 1000 and 50 cycles test. The differences are measured between
the first and last compression and the second and last compression.

1000 cycles 50 cycles

Acetabular First-last Second-last First-last
cup compression [mm] compression [mm] compression [mm]
SB1 0.3793 0.3120 0.0726
SB2 0.2190 0.1973 0.0264
SB3 0.2281 0.1867 0.0260
SB4 0.1781 0.1406 0.0197
SB5 0.2610 0.2193 0.0275

38
3.4 Discussion
Five ‘patient specific’ acetabular cups were designed and inserted in Sawbones hemipelves with Paprosky
type 3A and 3B acetabular defects. A mould was designed to position the hemipelves in 180° anterior
pelvic plane for cyclic testing. The acetabular cups were cyclically tested up to 1000 cycles (simulating a
walking motion) to assess additional femoral head penetration under cyclic loading.

During the cyclic tests all implants showed additional penetration of the femoral head between the first
and last compression up to 1800 N. This happened in both the first and second cyclic test. However, the
penetration was about a factor 10 less during the second compression test of 50 cycles. We hypothesize
the implants ‘settle’ during the first cycles in which some extra deformation takes place. In literature this
is also described as ‘bedding-in’ of the implant.51 The extra penetration of the femoral head between the
first compression and last compression is between 0.1781 and 0.3793 mm in this test. Saffarini et al.
describes values between 0.05 and 0.27 mm of femoral head penetration for cementless hemispherical
cups.52 Also the graphical illustration of femoral head penetration over time in this study is consistent
with the curves from our experiments.

Insertion of the acetabular cups was performed without major complications. Subjectively, both surgeons
did not use noticeably more force to insert the deformable cups than regular hemispherical cups. The
solid part of the cups without flanges was designed to be flush with the cortical shells of the Sawbones
hemipelves. However, in the direction of the ilium there still was a small gap between the solid part of the
cup and the cortical shell. This indicates the acetabular cup did not deform as anticipated. This can be
explained by the fact that the cup is inserted using a hemispherical inserter which is positioned in the cup,
which is not the centre of the implant. The impact of the hammer is therefore not evenly distributed.
A way to resolve this is creating a second impact point, directed towards the ilium. Another
solution could be to reduce the thickness of the deformable layer in the ilium direction. Also, the
deformable mesh in SB3 penetrated the defect in the medial wall. This can be easily resolved in the design
of the cup.

In SB4, an undersized flanged cup with separate deformable mesh, the mesh broke during insertion of
the mesh. The decision was made to not replace the mesh but to use the already inserted, broken one.
The SB4 cup was the only cup that needed additional fixation with screws. It cannot be said if the cup
was not fixed properly because the mesh was broken or that a separate mesh doesn’t work in
combination with defects in the medial wall.

After insertion of the acetabular cups with attached deformable layer (SB1, SB3, SB5), there were two
possibilities; either the deformable layer deformed and filled the acetabular defect or the struts penetrated
the Sawbones solid foam which represents the trabecular bone. The CT scan that was made after
insertion showed that the deformable layer indeed deformed. However, this is only a global deformation
since the spatial resolution of the CT scan does not allow for segmentation of individual struts due to the
partial volume effect.53 A µCT scan, also used to show three-dimensional trabecular bone structures, has
a spatial resolution ranging from 20 to 100 µm which would be suitable to show individual struts.54,55
However, there is limited physical space in the µCT scanner and the Sawbones hemipelves with inserted
acetabular cups were too large to scan at once.

After insertion of the acetabular cups broken struts could be shaken out of the Paprosky type 3B defect
hemipelves through the defect in the medial wall. Broken struts could be heard rattling in the Paprosky
type 3A defect hemipelves when shaken. There is no doubt that the implant should remain one construct

39
when clinically used. Also, these acetabular cups were tested as manufactured without additional post
processing, except for support material removal. HIP treatment would increase ductility for CP-Ti.29,38
Greater ductility should theoretically reduce the chance of strut breakage. Another method to prevent
broken struts could be decreasing the thickness of the deformable layer.

All acetabular cups were cyclically tested after insertion with two cyclic tests. The first test consisted of
1000 cycles and the second test of 50 cycles. During the first test of SB3 the testing machine had an
unintentional error at ±900 cycles and stopped. The remaining cycles were performed directly after
resetting the machine before the second test was conducted. As far as we can tell this had no noticeable
influences on the results.

The use of Sawbones hemipelves comes with its limitations. The inner solid foam that represents
trabecular bone is isotropic, where trabecular bone in the human pelvis can be considered as largely
transversely isotropic.42 Also the yield strength of human pelvic trabecular bone is a factor 3 to 10 lower
than the yield strength of the Sawbones solid foam (Table 4). However, next to cadaveric in-vivo testing
this is the nearest resemblance of the physiological situation.

SB1 showed the most additional femoral head penetration of all acetabular cups, this is not in line with
the expectations since this cup was inserted in an acetabular defect with an intact medial wall. An
explanation for this could be that this was the first cup inserted, suggesting some sort of learning curve in
insertion. SB4, the cup with the broken deformable mesh, was the acetabular cup that showed the least
additional femoral head penetration. This cup was additionally fixated with screws and thus stiffened the
whole pelvis with implant. This could have played a part in the fact that SB4 showed the least additional
femoral head penetration during the cyclic test.

The data obtained in part one was a good basis for designing the acetabular cups. Both the elastic
modulus and yield strength of the 4x4x4 mm unit cell size (0.2 mm strut thickness), which was used for
the deformable section, are lower than the respective moduli of human pelvic trabecular bone. Since the
oversized cups did deform upon insertion and are almost positioned as planned, we can assume there is 4
mm deformation in the deformable layer. This is about 50% strain in the deformable layer. According to
the data in Figure 6 this means all deformation of the plateau region took place and material densification
is taking place. This extend of material densification could be the cause of the broken struts, µCT images
will be relevant to accurately visualize the deformation.

3.5 Conclusion
The aim of this study was design and evaluate a new concept of acetabular cup with a highly porous
plastically deformable component to fill large bone defects. This acetabular cup has the potential of
diminishing stress shielding and stimulating the formation of bone.18–22 The acetabular cups designed and
tested in this study showed promising results. The deformable layer of the acetabular cups deformed
during insertion, filling the acetabular cavity. Though insertion resulted in some broken struts. The cyclic
test resulted in some additional penetration of the femoral head; the values found in the experiments are
mostly in line with literature.52 The concept of a deformable acetabular cup seems a feasible solution for
treating large acetabular defects. The results of these experiments are a validation for further development
of these implants.

40
 4
Future work
Future work is needed to further develop the deformable acetabular cup concept. Though the Sawbones
hemipelves were the best option available for these experiments, cadaveric experiments are recommended
for further tests. The trabecular bone in the human pelvis has a lower yield strength than the solid foam
used in the Sawbones hemipelves. Since the implants are very likely to be used in osteoporotic patients,
cadaveric experiments are needed to validate the deformability of the porous layer in human pelvic bone.
All current acetabular cups are tested as manufactured. For further development of these
implants it is recommended perform post processing to further optimize ductility.29,38

In this study a cyclic test was performed up to 1000 cycles due to machine and time constraints. Further
cyclic testing is needed to assess the fatigue behaviour of these highly porous lattice structures. Some
research on fatigue behaviour of CP-Ti lattice structures is already described in literature. Li et al. studied
fatigue behaviour of titanium lattice structures with a porosity up to 70%.56 Yavari et al. studied fatigue
behaviour of higher porosity samples, up to 84%, but used samples manufactured of Ti6Al4V.57 The
samples used in this study have a porosity up to 97.5%, considerably higher than what is used in
literature. It is important to remind that bone will grow into the porous part of the implant and will form
a solid construct. This means that most of the cyclic loading is performed on the bone-lattice structure
composite rather than the lattice structure alone.

This brings up one of the most important factors in implant longevity; biological fixation. It is important
to evaluate the biological effects of these highly porous lattices on living bone. The outer layer of these
highly porous lattices often-end in open ended struts due to the direct patterning approach used to create
the lattices.28 These open-ended struts are sharp. The interaction between these open-ended struts and
the living bone tissue is something that requires further research.

41
 5
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44
 6
Appendix
[3x3x3] 0.2 mm
10

7
Stress [MPa]

0
0 5 10 15 20 25 30 35 40
Strain [%]

[3x3x3] 0.2 elastic [3x3x3] 0.2 plastic

[3x3x3] 0.31 mm
30

25

20
Stress [MPa]

15

10

0
0 5 10 15 20 25 30 35 40 45 50
Strain [%]

[3x3x3] 0.31 elastic [3x3x3] 0.31 plastic

Figure A 1: The elastic and plastic data extracted from the cylindrical sample compression test of the 3x3x3 mm sample with a
0.2 mm (top) and 0.31 mm (bottom) strut thickness.

45
 [4x4x4] 0.2mm
6

4
Stress [Mpa]

0
0 5 10 15 20 25 30 35 40 45
Strain [%]

[4x4x4] 0.2 mm elastic [4x4x4] 0.2 mm plastic

[4x4x4] 0.31 mm
8

5
Stress [MPa]

0
0 5 10 15 20 25 30 35 40 45
Strain [%]

[4x4x4] 0.31 elastic [4x4x4] 0.31 plastic

Figure A 2: Figure A 3: The elastic and plastic data extracted from the cylindrical sample compression test of the 4x4x4 mm
sample with a 0.2 mm (top) and 0.31 mm (bottom) strut thickness.

46
 [5x5x5] 0.2 mm
0,4

0,35

0,3

0,25
Stress [MPa]

0,2

0,15

0,1

0,05

0
0 5 10 15 20 25 30 35
Strain [%]

[5x5x5] 0.2 elastic [5x5x5] 0.31 plastic

[5x5x5] 0.31 mm
1,8

1,6

1,4

1,2
Stress [MPa]

0,8

0,6

0,4

0,2

0
0 5 10 15 20 25 30 35 40 45 50
Strain [%]

[5x5x5] 0.31 elastic [5x5x5] 0.31 plastic

Figure A 4: Figure A 5: The elastic and plastic data extracted from the cylindrical sample compression test of the 5x5x5 mm
sample with a 0.2 mm (top) and 0.31 mm (bottom) strut thickness.

47
(a)

(b)

(c)

(d)

48
 (e)

Figure A 6: Photographs of the manufactured acetabular cups; SB1 (a), SB2 (b), SB3 (c), SB4 (d), SB5 (e).

49
 SB1 [1000 cycles]
4

3,5
Machine extension [mm]

2,5

1,5

1
0 500 1000 1500 2000 2500 3000 3500
Time [s]

SB1 [50 cycles]

4

3,5
Machine extension [mm]

2,5

1,5

1
0 20 40 60 80 100 120 140 160 180
Time [s]

Figure A 7: Time-extension curves for the 1000 and 50 cycles test for SB1. The extension of the first compression is indicated
by the lower red line, the second compression by the yellow line the last compression by the upper red line. For the second
test of 50 cycles only the first and last compression are shown.

50
 SB2 [1000 cycles]
4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 500 1000 1500 2000 2500 3000 3500
Axis Title

SB2 [50 cycles]

4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 20 40 60 80 100 120 140 160 180
Time [s]

Figure A 8: Time-extension curves for the 1000 and 50 cycles test for SB2. The extension of the first compression is indicated
by the lower red line, the second compression by the yellow line the last compression by the upper red line. For the second
test of 50 cycles only the first and last compression are shown.

51
 SB3 [1000 cycles]
4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 500 1000 1500 2000 2500 3000
Time [s]

SB3 [50 cycles]

4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 20 40 60 80 100 120 140 160 180
Time [s]

Figure A 9: Time-extension curves for the 1000 and 50 cycles test for SB3. The extension of the first compression is indicated
by the lower red line, the second compression by the yellow line the last compression by the upper red line. For the second
test of 50 cycles only the first and last compression are shown.

52
 SB4 [1000 cycles]
4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 500 1000 1500 2000 2500 3000
Time [s]

SB4 [50 cycles]

4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 20 40 60 80 100 120 140
Time [s]

Figure A 10: Time-extension curves for the 1000 and 50 cycles test for SB4. The extension of the first compression is indicated
by the lower red line, the second compression by the yellow line the last compression by the upper red line. For the second
test of 50 cycles only the first and last compression are shown.

53
 SB5 [1000 cycles]
4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 500 1000 1500 2000 2500 3000 3500
Time [s]

SB5 [50 cycles]

4

3,5

3
Machine extension [mm]

2,5

1,5

0,5

0
0 20 40 60 80 100 120 140 160 180
Time [s]

Figure A 11: Time-extension curves for the 1000 and 50 cycles test for SB5. The extension of the first compression is indicated
by the lower red line, the second compression by the yellow line the last compression by the upper red line. For the second
test of 50 cycles only the first and last compression are shown.

54