206

Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
K ENNETH A. E GOL
EDITOR, VOL. 60

C OMMITTEE
K ENNETH A. E GOL
CHAIR
F REDERICK M. A ZAR
M ARY I. O’C ONNOR
M ARK P AGNANO
P AUL T ORNETTA III

E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of

Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academy’s Annual Meeting, will be available
in February 2011 in Instructional Course Lectures, Volume 60.
The complete volume can be ordered online at www.aaos.org,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).
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Principles of Biomechanics and

Biomaterials in Orthopaedic Surgery
By S. Raymond Golish, MD, PhD, and William M. Mihalko, MD, PhD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Advances in orthopaedic surgery have
been based on biomechanical principles
for years. Engineering advances in met-
allurgy, polymer science, ceramic tech-
nology, and manufacturing processes
lead to improvements in the devices that
orthopaedic surgeons use and thus to
better performance in the fields of or-
thopaedics, especially arthroplasty, spine
surgery, trauma, and arthroscopy.
Biomechanics and biomaterials
as broad topics may seem overwhelm-
ing, but they are manageable when
approached by reviewing applications
directly related to clinical practice. The
present review covers basic aspects of
biomaterials relevant to clinical practice,
including their mechanical properties
and uses for implants, and it outlines the
clinically relevant aspects, principles,
and facts that are germane to many
surgical decisions.
Basic Mechanics
The surgeon’s understanding of ortho-
paedic implant technology is enhanced
by a basic knowledge of mechanics.
Once one has an understanding of how
mechanical properties of materials are
determined, one has a better apprecia-
tion of why certain materials in ortho-
paedics are utilized rather than others.
The first concept to emphasize
is the stress-strain diagram, a useful
graphical tool for illustrating the static
behavior of systems that are elastic, vis-
coelastic, and plastic. The full meaning
of these terms is clarified in the follow-
ing sections.
Stress and Strain
Stress is defined as the applied force per
unit cross-sectional area of the test
piece (newtons per square millimeter
[N/mm2]). Strain is defined as the
increase in length (in millimeters) as
a fraction of the original length (in
millimeters)1. A servohydraulic mate-
rials testing machine allows for either
load or displacement control to test the
mechanical integrity of a specimen or
device. A standard materials test piece
uses a small volume with a constant
cross-sectional area loaded to failure
according to protocols that are stan-
dardized by ASTM International and
the International Organization for
Standardization (ISO). With use of
these testing protocols, the stress-
strain curve can be plotted and multi-
ple material properties of the specimen
can be calculated. A representative
stress-strain diagram is shown in
Figure 1.
Several features of the stress-strain
diagram in Figure 1 are important and
define the mechanical properties of
the material or device being tested.
These features are the linear elastic
region, yield point, plastic region, ulti-
mate strength, and failure. As a conven-
tion, the properties of materials are most
often illustrated with use of a longitu-
dinal force and measurement of the
material’s tensile strength. A similar
curve can be constructed for materials
subjected to other forces such as com-
pression or shear.
Linear Elastic Region
In the linear region of the stress-strain
diagram, the test piece behaves as a
simple spring. When the stress is in-
creased, the strain increases propor-
tionally2. If the same amount of stress
is let off, the strain decreases to the
previous length. No permanent defor-

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors,
or a member of his or her immediate family, received, in any one year, payments or other benefits or a commitment or agreement to provide such benefits
from commercial entities (Smith & Nephew, Stryker, Ethicon, B. Braun, Aesculap, and Elsevier [in excess of $10,000] and Cytonics, Inc. [less than
$10,000]).

J Bone Joint Surg Am. 2011;93:207-12


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Fig. 1
A representative stress-strain diagram (for a ductile material).
mation of the test piece occurs. The
strain may be altered any number of
times with the same results. The slope of
the linear region equals the modulus of
elasticity (or Young’s modulus) of the
material. On the stress-strain curve,
stiffer materials have greater slope on the
linear portion of the curve.
Yield Point
The yield point is the stress at which
there is a change from elastic to plastic
deformation. Graphically, on the stress-
strain curve, the yield point occurs at the
transition of a straight line with constant
slope to a curved line of variable slope.
On the stress-strain diagram, the yield
point is not always visually apparent as
it is in Figure 1. Consequently, a stress
resulting in a 0.2% change in strain is
conventionally chosen as the numerical
definition of the yield point.
Plastic Region
In the plastic region, when the stress is
increased the strain increases in a more
complex way than it does in the elastic
region. The stress-strain curve may
decrease for a small interval or it may
continue to increase but at a lower or
more variable rate relative to that in the
linear elastic region.
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The essential feature of plastic
deformation is that it is not completely
reversible. If the stress is let off, the test
piece will not return to its original
length. The molecular mechanisms that
mediate plastic deformation are com-
plex. Plastic deformation may result in
a phenomenon known as work harden-
ing or strain hardening.
Ultimate Strength
The ultimate strength is the maximum
stress that a material can withstand
before impending failure. The ultimate
strength is not as important for ortho-
paedic implants as it is in other settings.
For orthopaedic implants, fatigue
strength is more important and is not
necessarily related to ultimate strength.
Failure
Failure occurs when the test piece or
material fractures. Numerous modes of
failure are possible3. Ductile materials
have a process of impending failure that
occurs immediately after the stress sur-
passes the material’s ultimate strength.
Brittle materials are the opposite of ductile
materials. Very brittle materials, such as
some ceramics, fail in the linear elastic
region, or after a very small amount of
plastic deformation. Brittle materials have
AND B I O M AT E R I A L S
a simple stress-strain diagram, and their
yield strength, ultimate strength, and
failure strength are the same.
Mechanical Properties
Modulus of Elasticity
The modulus of elasticity is the stress per
unit strain in the linear elastic portion of
the stress-strain curve. Young’s modulus
is the modulus of elasticity for tensile
strength (measured with use of a longi-
tudinal force). As a rule, the stress-strain
diagram is for tensile testing (demon-
strating Young’s modulus) unless stated
otherwise. The units for Young’s modu-
lus are megapascals (MPa)2.
Strength
The yield strength is the stress in MPa
at the yield point on the stress-strain
curve. This is the strength at the end
of linear elastic behavior and at the onset
of plastic deformation4. The ultimate
strength is the stress at the apex of the
stress-strain curve. This is the strength
at the end of the plastic deformation
portion of the curve if it is higher than
the yield point. This strength denotes
the end of work hardening and the be-
ginning of necking, which precedes
fracture. (See Figure 1 for graphical
illustrations.)

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Failure strength is defined as the
point of fracture, beyond the linear elastic
region and after plastic deformation. In
principle, one can measure the strength
at the failure or fracture point. In prac-
tice, there is rarely a distinction between
the ultimate strength and the strength
at failure. Since necking has begun, the
failure of the test piece is impending with
further strain after the ultimate strength.
Therefore, the ultimate strength is often
reported as the final strength measure-
ment of a material.
Fatigue Strength
Fatigue strength is defined as the maxi-
mum stress at which a material can
withstand ten million cyclic loading cycles
without failure. (The number ten million
is arbitrary but widely used.) In the stress-
strain diagram, the test piece is subjected
to a static load instead of a repetitive load.
Incremental increases in loading result in
elastic deformation, followed by plastic
deformation and eventual failure. In fa-
tigue failure, repetitive cyclic loading below
the yield strength produces failure after
numerous cycles.
Hardness
The most common measure of hard-
ness of orthopaedic implants involves
indentation of the material by a small
indenter made of a very hard material
(such as diamond)2 . The Rockwell C
scale is based on a test using a small
diamond indenter with nearly 1500 N of
force. The scratch resistance of materials
is a distinct but related concept of hard-
ness that is important for articulating
total joint components, although it is
less commonly reported as a materials
property.
Toughness
Toughness is defined as the amount of
energy (per unit volume) that a material
can absorb up to the failure strength.
Intuitively, toughness is a measure of the
fracture resistance of a material when it
is subjected to stress. The units are joules
per cubic meter (J/m3).
Roughness
Roughness is a measurement of the sur-
face finish of a test piece. As such, it is not
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I N O R T H O PA E D I C S U R G E RY
a property of the material alone; it is also
a property of the manufacturing pro-
cesses used to create the surface finish.
Ra is the average deviation of the peaks
and valleys on a microscopic level (in
micrometers or micro-inches). Ra is the
most common roughness measure used
for orthopaedic implant surfaces5 .
Roughness may impact the ultimate and
fatigue strength material properties of
an implant. The greater the roughness of
the material’s surface, the higher the
stress concentrations at the valleys of
the surface. Crack initiation and prop-
agation in a device can originate in the
valleys of the surface, and roughness has
an impact on the longevity of a device
that is loaded for millions of cycles dur-
ing its lifetime.
Static versus Dynamic Analysis
Stress-strain diagrams are usually an
illustration of static analysis, but materials
can also be studied with dynamic analysis.
Static analysis reveals the properties of
materials independent of time. For ex-
ample, a material in the linear region of
a stress-strain diagram is held at an initial
stress, with some deformation (strain).
If the stress is increased a small amount
and then held steady, a new strain is
measured without taking into account
what occurs during the time period when
the testing machine is adjusting the
applied stress. When measurements are
made during changes that are applied
very slowly, or when a substantial time
period elapses between changes and
remeasurement, the behavior of the test
piece and material appears static.
In reality, no practical situation is
truly independent of time (static). The
alternative to static analysis is dynamic
analysis, in which the time-dependent
behavior at all time points is considered.
If measurements are made when large
changes in stress are applied, when
changes are made very quickly, or when
very little time has elapsed between
changes and remeasurement, the be-
havior of the test piece and material will
appear time-dependent. A dynamic
system that reaches steady-state equi-
librium with respect to applied changes
appears static if measurements are made
only after equilibration.
AND B I O M AT E R I A L S
Linear Elastic Behavior
Assessment of linear elasticity is the sim-
plest type of static analysis and is useful
for materials in the linear elastic region of
the stress-strain diagram undergoing
slow changes in stress, especially metals
and alloys under static loading 2. In a
linear elastic system, the measured strain
is directly proportional to the applied
stress at the jig. The constant of pro-
portionality, or the slope of the stress-
strain diagram, is called Young’s modulus
for tensile testing. There are several
synonymous terms for linear elasticity,
such as Hooke’s law and simple spring.
The input-output diagrams for a
linear elastic system are illustrated in
Figure 2. When the input load changes
instantaneously in the testing of these
kinds of materials, the output also changes
instantaneously. This is an idealization:
the change only appears instantaneous at
an appropriately coarse time scale. If the
time scale is finer, the system may appear
dynamic and viscoelastic.
Linear Viscoelastic Behavior
Linear viscoelasticity is another rela-
tively simple type of dynamic analysis.
It is useful for materials in the linear
elastic region of the stress-strain dia-
gram undergoing rapid changes in
stress6, especially amorphous polymers
under dynamic loading. In a linear vis-
coelastic system, the measured strain is
directly proportional to the applied
stress at the jig at final equilibrium
but approaches the new steady state
exponentially.
Time-dynamic behavior of visco-
elastic systems can be described by the
terms stress relaxation and creep. Figure 2
illustrates creep, in which deformation
takes some time to reach a final value
after application of a new load. A com-
plementary view of the same phenom-
enon is stress relaxation, in which the
measured stress gradually approaches
some new final value when the test piece
is suddenly adjusted to a new length.
Other Behavior
An important exception to viscoelastic
behavior is plastic behavior beyond the
yield point, the point of transition from
elastic to plastic deformation, in the stress-
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I N O R T H O PA E D I C S U R G E RY

Fig. 2
Time course of changes in measured strain for an instantaneous change in applied stress for both linear
elastic (top) and linear viscoelastic (bottom) behavior. Because of its simplicity, linear elastic behavior may
be viewed as time-independent (static), whereas the more complex linear viscoelastic behavior is time-
dependent (dynamic). However, both models are abstractions. A system may appear to be static versus
dynamic depending on the time scale of measurements and the size of changes of applied stresses.

strain diagram. In plastic deformation,
changes in length are not reversible with
changes in load. The test piece is perma-
nently deformed, and neither static nor
dynamic elastic models describe the
behavior beyond the yield point. Many
biological tissues exhibit nonlinear visco-
elastic behavior that can be extremely
complex6. Nonlinear viscoelasticity is
dynamic behavior that is not described by
linear time-invariant differential equa-
tions. Cartilage has complex nonlinear
viscoelastic behavior. When a new load is
applied slowly, such as with slow walking,
the modulus of elasticity is lower, the
deformation is increased, and the time to
final deformation is increased. When a
new load is applied quickly with a sudden
weight-bearing impact, the modulus of
elasticity is higher, the deformation is
decreased, and the time to final defor-
mation is decreased. Although important
for biological tissues and some polymers,
nonlinear viscoelasticity does not need to
be taken into account for most engineer-
ing purposes involving materials.
Continuum Mechanics
Continuum mechanics is used in the
study of elastic, viscoelastic, and plastic
behaviors of structures containing a va-
riety of materials with different prop-
erties, often with complex geometry.
Although the principles of complex
systems are the same as those of simple
test geometries of a single material, the
practical situation is much more com-
plex. Computers are used to solve large
systems of equations in order to simu-
late the mechanics of complex designs
(e.g., finite element analysis)2.
Some features of continuum me-
chanics are important clinically. For
example, stress-shielding can result
when a mismatch in the elastic modulus
occurs between two adjacent materials,
such as a relatively stiff femoral stem
and the cortical/cancellous bone in the
proximal part of the femur. The prox-
imal femoral region experiences a rela-
tive decrease in stress due to the stiff
implant carrying stress to the cortical
bone of the femoral diaphysis. This may
result in relative osteopenia of the stress-
shielded bone visible on a radiograph7.
Corrosion
The corrosion resistance of an implant
has several components. The material
and surface finish combine with the
geometry of the test piece interacting
with the biological environment. Cor-
rosion varies widely among orthopaedic
implants, with some polymer implants,
such as bioabsorbable implants, being
designed to degrade completely and

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other implants being designed to resist
corrosion as completely as possible8.
Chemical Corrosion
Chemical corrosion is a process by which
there is a chemical reaction of a material
with the biological environment. The
chemical reaction results in new com-
pounds at the surface of the implant,
which can change the mechanical prop-
erties. Metals often undergo oxidation,
which may be catalyzed by other chem-
icals in the biological milieu, especially
halide ions such as chloride (Cl2). Poly-
mers undergo a variety of corrosive
and degradative processes, including
hydrolysis of the polymer bonds into
shorter-chain polymers by thermal and
enzymatic processes. The process of
chemical corrosion can be altered by al-
terations in the chemistry of the biolog-
ical environment, such as the decrease in
pH that may be present with bacterial
infection.
Crevice and Pitting Corrosion
These two distinct but related processes
occur when local chemistry established
in a small feature of the test piece causes
increased corrosion in a small area.
Crevice corrosion occurs when a small
machined feature on the surface traps
the local chemical environment and
results in increased corrosion. Pitting
corrosion is caused by a small pit, which
can exist even on a smooth surface, with
an altered chemical environment due to
an impurity resulting from statistical
variation. This local pit sets up a cata-
lytic process that leads to a larger pit
with even more altered chemistry. Even
a tiny pit can ultimately lead to cata-
strophic failure.
Galvanic Corrosion
Galvanic corrosion is due to differences
in electrochemical potential between two
distinct metals in an electrolyte solution,
creating an electric current between the
two metals. This battery effect results in
physical migration of metal ions. There
is concern that galvanic corrosion in
mixed-metal implants (especially cobalt-
chromium and stainless-steel combina-
tions) can change the geometry of the
implant and weaken it over time. The
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PRINCIPLES OF BIOMECHANICS
I N O R T H O PA E D I C S U R G E RY
evidence that this phenomenon repre-
sents a clinically relevant problem with
commonly used metal combinations is
limited9. Nevertheless, informed deci-
sions that include an understanding of
galvanic and other corrosion modes
should be made regarding the use of
mixed-metal implants.
Fretting
Fretting is a chemical and mechanical
process in which corrosion occurs be-
tween two mating surfaces in micro-
motion. It includes both the chemical
corrosion of freshly exposed surfaces
and wear due to mechanical friction of
corrosion products. Fretting is an im-
portant issue with articulating compo-
nents of total joint arthroplasties, such
as tibial trays articulating with poly-
ethylene inserts in total knee arthro-
plasty, which can produce polyethylene
debris affecting the tibial side10.
Corrosion and Biocompatibility
Ti-6Al-4V alloy is highly resistant to
corrosion in biological environments.
Commercially pure titanium has a high
affinity for oxygen; however, Ti-6Al-4V
forms a stable, adherent oxide layer in
aqueous environments in a process
termed self-passivation. The resultant
film stabilizes the alloy to resist further
oxidation and chemical corrosion, in-
cluding that due to halide ions such as
chloride. Passivation is a key to the
corrosion resistance of Ti-6AL-4V8 .
Materials that resist corrosion by pas-
sivation are subject to pitting corrosion
and crevice corrosion, in which an
altered local chemistry in small pits or
crevices inhibits the passivation layer,
leading to progressive corrosion. This
can be influenced by small scratches,
pits, or design features and contributes
to notch sensitivity induced by intra-
operative handling and metal-metal
interfaces.
Ti-6Al-4V is regarded as a highly
biocompatible alloy. There is virtually
no nickel in this alloy, so it is useful in
patients with documented nickel sensi-
tivity11. Corrosion modes, resistance,
and biocompatibility are distinct for all
orthopaedic metals and biomaterials,
including 316L stainless steel, Co-Cr-Mo
AND B I O M AT E R I A L S
alloy, highly cross-linked ultra-high
molecular weight polyethylene, poly-
L-lactic acid polymer, and other com-
monly used materials. However, the
considerations listed here for titanium
alloys are representative of the consider-
ations and reasoning for all materials11.
Alloys in Use
ASTM International is an interna-
tional standards organization respon-
sible for standardization of materials in
industrial use. Previously known as the
American Society for Testing and Ma-
terials (ASTM), the organization now
has a global scope and charter. The
existence of standards allows for trade of
materials with known engineering per-
formance among international ven-
dors 12. The society for medical devices
is designated F-04, and the breadth and
number of standards applicable to the
field of orthopaedic surgery are as-
tounding. The following are a few
examples of standards used for titanium
alloys commonly used in orthopaedic
surgery today.
ASTM F-136: This alloy is Ti-6Al-
4V and is used in many orthopaedic
applications in North America13.
ASTM F-67: This alloy is com-
mercially pure (CP) titanium and is
used for spinal rods, plasma-spray
coatings on Ti-6Al-4V implants, and
some other applications.
ASTM F-1295: This alloy contains
titanium, aluminum, and niobium and
has been used for applications similar to
ASTM F-136 in the European and North
American markets.
ASTM F-2063: This alloy is com-
monly called Nitinol and contains nickel
and titanium in nearly equal ratios. It
has the peculiar property of being
a shape memory alloy (SMA), in which
heating after deformation restores the
material to its prior shape. It has found
wide application for intraluminal stents
and arthroscopic suture passers, but
only scant application for orthopaedic
implants.
Mechanical Properties of Common
Materials in Orthopaedics
With an understanding of how me-
chanical properties of materials are

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TABLE I Mechanical Properties of Commonly Used Alloys
Property
Modulus of elasticity (GPa)
Yield strength (MPa)
Ultimate strength (MPa)
Hardness (on Rockwell C scale)
Fatigue strength (MPa at 107 cycles)
Mass density (g/cm3)
determined, one has a better appre-
ciation of why certain materials in
orthopaedics are utilized over others.
Comparing these properties (Table I) to
bone allows a better comparison of the
material’s properties and use in ortho-
paedics. The more similar a material’s
mechanical properties are to bone, the
less stress shielding is created. For ex-
ample, if the properties of a femoral
component in a total hip replacement are
more similar to bone, there will be less
stress shielding of proximal femoral bone
and a lower stress riser at the tip of the
femoral stem, thereby decreasing the risk
of periprosthetic fracture. This is just one
of multiple examples of how a better
understanding of biomechanics and
1. Özkaya N, Nordin M. Fundamentals of biome-
chanics: equilibrium, motion, and deformation. 2nd
ed. New York: Springer; 1999. Stress and strain;
p 125-52.
2. Ratner B, Hoffman AS, Schoen FI, Lemons JE,
editors. Biomaterials science: an introduction to
materials in medicine. 2nd ed. San Diego: Elsevier
Academic Press; 2004. Properties of materials;
p 23-66.
3. Ratner B, Hoffman AS, Schoen FI, Lemons JE,
editors. Biomaterials science: an introduction to
materials in medicine. 2nd ed. San Diego: Elsevier
Academic Press; 2004. Implants, devices, and bio-
materials: issues unique to this field; p 753-82.
4. Özkaya N, Nordin M. Fundamentals of biome-
chanics: equilibrium, motion, and deformation. 2nd
ed. New York: Springer; 1999. Multiaxial deforma-
tions and stress analyses; p 153-94.
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I N O R T H O PA E D I C S U R G E RY
Porous Tantalum Ti-6Al-4V
2.5-3.9 106-115
35-51 860
50-110 780-1050
36
18-20 480-590
4.4
material properties enhances a surgeon’s
ability to make an educated decision
concerning the products utilized in the
treatment of his or her patients.
Overview
The terminology and principles in-
volved in mechanics, materials, and
engineering for orthopaedic surgery are
manageable. Having sources to review to
better their understanding of applica-
tions to orthopaedic surgery is para-
mount to enable surgeons to better treat
their patients and comprehend the
rationale behind many surgical proce-
dures. Our hope is that this review can
serve as a source to aid orthopaedic sur-
geons in obtaining this goal.
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8.3 8.0
S. Raymond Golish, MD, PhD
Department of Orthopaedic Surgery,
Stanford University,
450 Broadway Street,
Redwood City, CA 94063
William M. Mihalko, MD, PhD
Campbell Clinic Orthopaedics,
1458 West Poplar Avenue,
Memphis, TN 38017.
E-mail address: wmihalko@campbellclinic.com
Printed with permission of the American
Academy of Orthopaedic Surgeons. This article,
as well as other lectures presented at the
Academy’s Annual Meeting, will be available in
February 2011 in Instructional Course Lectures,
Volume 60. The complete volume can be
ordered online at www.aaos.org, or by calling
800-626-6726 (8 A.M.-5 P.M., Central time).
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