Osteoarthritis and Cartilage xxx (2016) 1e10

Review

Finite element analysis of mechanical behavior of human dysplastic

hip joints: a systematic review
B. Vafaeian y, D. Zonoobi z, M. Mabee z, A.R. Hareendranathan z, M. El-Rich y x,
S. Adeeb y a, J.L. Jaremko z *
y Department of Civil and Environmental Engineering, University of Alberta, 7-203 Donadeo Innovation Centre for Engineering, 9211-116 Street, Edmonton,
Alberta, T6G 1H9, Canada
z Department of Radiology and Diagnostic Imaging, University of Alberta, 2A2.41 WMC, 8440-112 Street, Edmonton, Alberta, T6G 2B7, Canada
x Department of Mechanical Engineering at Khalifa University (UAE), United Arab Emirates

a r t i c l e i n f o s u m m a r y

Article history: Developmental dysplasia of the hip (DDH) is a common condition predisposing to osteoarthritis (OA).
Received 8 April 2016 Especially since DDH is best identified and treated in infancy before bones ossify, there is surprisingly a
Accepted 28 October 2016 near-complete absence of literature examining mechanical behavior of infant dysplastic hips. We sought
to identify current practice in finite element modeling (FEM) of DDH, to inform future modeling of infant
Keywords: dysplastic hips. We performed multi-database systematic review using PRISMA criteria. Abstracts
Human dysplastic hip
(n ¼ 126) fulfilling inclusion criteria were screened for methodological quality, and results were analyzed
Finite element modeling
and summarized for eligible articles (n ¼ 12). The majority of the studies modeled human adult
Infant hip dysplasia
Systematic review
dysplastic hips. Two studies focused on etiology of DDH through simulating mechanobiological growth
of prenatal hips; we found no FEM-based studies in infants or children. Finite element models used
either patient-specific geometry or idealized average geometry. Diversities in choice of material prop-
erties, boundary conditions, and loading scenarios were found in the finite-element models. FEM of adult
dysplastic hips demonstrated generally smaller cartilage contact area in dysplastic hips than in normal
joints. Contact pressure (CP) may be higher or lower in dysplastic hips depending on joint geometry and
mechanical contribution of labrum (Lb). FEM of mechanobiological growth of prenatal hip joints revealed
evidence for effects of the joint mechanical environment on formation of coxa valga, asymmetrically
shallow acetabulum and malformed femoral head associated with DDH. Future modeling informed by
the results of this review may yield valuable insights into optimal treatment of DDH, and into how and
why OA develops early in DDH.
© 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Introduction cartilage contact pressure (CP), subluxation3e5, and OA3,5e7. In

Developmental dysplasia of the hip (DDH) is a common
anatomic deformity leading to hip dysfunction and osteoarthritis
(OA). Present in 1e3/1000 live births1, DDH accounts for one-third
of hip replacement surgeries in patients under 60 years old2. Un-
treated dysplastic hips are associated with mechanical instability,
limited mobility, muscle imbalance, abnormal joint load, increased
* Address correspondence and reprint requests to: J.L. Jaremko, Department of
Radiology and Diagnostic Imaging, University of Alberta, 2A2.41 WMC, 8440-112
Street, Edmonton, Alberta, T6G 2B7, Canada. Fax: 1-780-4073853.
E-mail addresses: vafaeian@ualberta.ca (B. Vafaeian), zonoobi@ualberta.ca
(D. Zonoobi), mmabee@ualberta.ca (M. Mabee), hareendr@ualberta.ca
(A.R. Hareendranathan), elrich@ualberta.ca (M. El-Rich), adeeb@ualberta.ca
(S. Adeeb), jjaremko@ualberta.ca (J.L. Jaremko).
a
Website: http://sameradeeb.srv.ualberta.ca.
addition to age, trauma, activity, weight, and genetics, OA in DDH
relates to anatomic hip abnormalities5e7. Since the mechanical
environment strongly affects bone growth and development6,8e13,
understanding hip mechanical behavior can provide insight into
how premature OA occurs6,7,14, and help optimize treatment10,15e18.
Hip mechanical behavior has been studied through experi-
mental measurements, theoretical models, and computational
methods including multibody dynamics (MBD), discrete element
analysis (DEA), and finite element modeling (FEM)19e21. Experi-
mental studies14,22e27 measure hip CP directly using sensors, but
these are invasive and it is difficult to maintain physiological con-
ditions during measurement20,21. Theoretical models6,14,28e33 esti-
mate articular surface CP with fundamental methodological
simplifications limiting their predictive validity20,34. MBD35,36 can

http://dx.doi.org/10.1016/j.joca.2016.10.023
1063-4584/© 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
2 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10

only estimate joint reaction force (JRF), not CP. DEA34,37e41 and
FEM19,20 are both capable of simulating articular surface CP, contact
area, and JRF. Although more computationally intensive, FEM can
also model the sliding contact mechanism inside the hip joint,
cartilage deformations in all directions, bone deformations, mate-
rial anisotropy, and stresses inside tissue layers19,20.
Mechanical behavior of adult normal hips has been well studied
through FEM, with generally good agreement with experimental
outcomes19e21,27. In contrast, FEM-based studies on dysplastic hips
have not been specifically reviewed. A dedicated review on this
complex topic can clarify the diverse methods in use to study DDH
from prenatal initiation to adult morbidity. Notably we could find
no published FEM of infant (post-birth) dysplastic hips. Since the
most important time to diagnose and treat DDH to prevent OA is in
infancy, this is an important gap in the literature. The objective of
this systematic review was to determine the state-of-the-art in FEM
of human dysplastic hips, with a view to making informed rec-
ommendations for future FEM of infant dysplastic hips.

Materials and methods

Search strategy

We performed a systematic review, searching PubMed, Medline

and Elsevier (ScienceDirect) for relevant peer-reviewed articles
with English-language abstracts published from 1946 to June 25th,
2016 based on these keywords: (“dysplasia” OR “hip dysplasia” OR
“dysplastic hip”) AND (“finite element” OR “computational” OR
“computer simulation” OR “mechanics”). Reference lists of relevant
publications were also reviewed to avoid missing relevant articles.

Selection criteria

Fig. 1. Study selection flow chart.

Titles and abstracts of all potentially relevant articles were
reviewed. Article selection was performed by an engineer/research
associate (BV) and confirmed in consensus with a radiologist/
biomedical engineer (JJ). Full-text articles were included when they
(1) demonstrated mechanical behavior of the human dysplastic hip
through FEM of full or partial three-dimensional (3D) geometries of
natural and/or post-acetabular-osteotomy dysplastic hip joints;
and/or (2) employed FEM to study formation of human dysplastic
hip morphology. We excluded articles related to total hip arthro-
plasty, and those in which hip mechanics were investigated by
methods other than FEM, i.e., theoretical models, MBD, and DEA.
However, noting that the closest alternative to FEM is DEA and to
capture merits of DEA in this area, we included a brief review on
applications of DEA for studying human dysplastic hips at the end
of this paper.
To better understand potential biases, we stratified studies by
data source (patient-specific or virtual) and structures modeled.
The summary measures reviewed were differences in model out-
puts between normal and dysplastic hips.
Results
We found 76 unique articles. 29 merited full-text review, and 12
met eligibility criteria (Fig. 1).
The included studies, published between 2004 and 2016, fell
into three groups. The first group42e46 compared mechanical
behavior of dysplastic vs normal hips (Tables IeIII). The second
group compared the behavior of dysplastic hips before and after
physical16 or virtual15,17,46e48 acetabular osteotomy (Tables IeIII).
The third group8,11 investigated DDH etiology by mechanobio-
logical prediction of patterns of prenatal hip growth (Table IV).
When an article also included FEM of joints with other pathology
(protrusio, femoroacetabular impingement44,46), we focused on the
results obtained in dysplastic hips. All studies contained FEM of
either adult hips or simplified prenatal hips. We found no studies
regarding post-birth pediatric hips.
Discussion
The following sections summarize methods and results from the
reviewed studies modeling dysplastic hips.
Geometry
Hip FEM requires computational geometries for the pelvis and
proximal femur (PF), from either (1) patient-specific volumetric
data, usually from computed tomography (CT) scan, or (2) idealized
computer-aided design (CAD) models (Table I). Patient-specific CT
data for both normal and dysplastic hips were employed in several
studies42,43,45. Others had only access to either normal17 or
dysplastic15,47,48 patient-specific CT data and generated models of
dysplastic or close-to-normal hips by deforming the acetabular rim
or changing morphological parameters of the acetabulum through
virtual osteotomy. One study employed patient-specific CT data of
dysplastic hips pre- and post-osteotomy16.
CT-based models demonstrate bony anatomy well, but gener-
ating accurate geometries of soft tissues (cartilage and ligaments) is
difficult since these structures are poorly seen on CT images. Some
studies42,43,45,48 used CT arthrography (CTA), which is invasive but
clearly demonstrates articular cartilage (AC) boundaries, to directly
model cartilage thickness (0.5e2.8 mm45, 0.8e2.0 mm42,43). Non-

Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10 3

Table I
Subjects and FEM specifications of adult hip joints

Study Simulated hips FEM

Normal Dysplastic Other Geometry Parts Bone material Soft tissue material

PB PF AC Lb CL Cortical (ILE) Cancellous (ILE) AC Lb

Russell (2006)45 1 11 N Patient-specific (CTA) Y Y Y N N E ¼ 2 GPa, n ¼ 0.3 E ¼ 120 MPa, ILE (E ¼ 12 MPa, NA
(Subchondral bone) n ¼ 0.3 n ¼ 0.42)
Zhao (2010) 17
1 3* 3 VPPAO Patient-specific (CT) Y Y Y Y N E ¼ 17 GPa, n ¼ 0.3 E ¼ 70 MPa, ILE (E ¼ 15 MPa, ILE (E ¼ 15 MPa,
n ¼ 0.2 n ¼ 0.45) n ¼ 0.45)
Henak (2011)43 1 1 N Patient-specific (CTA) Y Y Y Y N E ¼ 17 GPa, n ¼ 0.29 NA Neo-Hookean IHE Transversely IHEy
(K ¼ 1359 MPa,
G ¼ 13.6 MPa)
Zou (2013)15 N 5 24 VPPAO Patient-specific (CT) Y Y Y N Y E ¼ 17 GPa, n ¼ 0.3E ¼ 70 MPa, ILE (E ¼ 15 MPa, NA
n ¼ 0.2 n ¼ 0.45)
Henak (2014) 42
10 10 N Patient-specific (CTA) Y Y Y Y N E ¼ 17 GPa, n ¼ 0.29 NA Neo-Hookean IHE Transversely IHEy
(K ¼ 1359 MPa,
G ¼ 13.6 MPa)
Ike (2015)16 N 13 13 PRAO Patient-specific (CT) Y Y Y N N E: CT density-based ILE (E ¼ 10.35 MPa, NA
values, n ¼ 0.4 n ¼ 0.4)
Liu (2015) 47
N 4 4 VPPAO Patient-specific (CT) Y Y Y N N E ¼ 17 GPa, n ¼ 0.3 NA ILE (E ¼ 15 MPa, NA
n ¼ 0.45)
Liu (2016) 48
N 10z 40z VPPAO Patient-specific (CTA) Y Y Y N N E ¼ 17 GPa, n ¼ 0.3 NA ILE (E ¼ 15 MPa, NA
n ¼ 0.45)
Chegini (2009)44 4 4 NA CAD-based Yx Y Y Y N Rigid ILE (E ¼ 12 MPa, ILE (E ¼ 20 MPa,
n ¼ 0.45) n ¼ 0.4)
Liechti (2015)46 1 1 NA CAD-based Yx Y Y Y N Rigid ILE (E ¼ 12 MPa, ILE (E ¼ 20 MPa,
n ¼ 0.45) n ¼ 0.4)
Y: Yes, N: No, NA: not applicable, VPPAO: virtual post-periacetabular osteotomy, PRAO: post-rotational acetabular osteotomy, K: bulk modulus, G: shear modulus.
*
Dysplastic hip models were generated by deforming the acetabular rim of the normal hip model.
y
See ref. 43 for details.
z
The models (10 dysplastic and 40 VPPAO) were replicated but with constant cartilage thicknesses instead of the patient-specific cartilage thicknesses.
x
Includes only the acetabular cup.

Table II
Analysis conditions and finite element analysis specifications of adult hip joints

Study Analysis conditions Finite element analysis

(subjects' body weight)
Loading method Fixed boundary conditions Joint contact Direct output Software

Russell (2006)45 Gait JRF at femoral head centroid Medial pelvic wall Y CP and areay,z ABAQUS
(51e90 kgf)
Zhao (2010)17 One leg stance Vertical load on superior aspect Distal end of PF Y JRF MSC.Marc
(74 kgf) of sacrum Von-Mises stressy,z,x
Abductor force
Henak (2011)43 Gait (heel strike and mid- JRF by displacement control Pubis and the Sacro-iliac joints Y CP and areay,x NIKE3D
stance) technique Distal end of PF* Lb load support
Stair descent and ascent (heel Deflection of the Lb
strike)
(Female: 66 kgf; Male: 87 kgf)
Zou (2013)15 One leg stance JRF on pelvic bone Distal end of PF Y CP and areay ABAQUS
(70 kgf) Von-Mises stressy
42
Henak (2014) Gait (heel strike and mid- JRF by displacement control Pubis and the Sacro-iliac joints Y CP and areay,x NIKE3D
stance) technique Distal end of PF* Lb load support
Stair descent and ascent (heel
strike)
(70 ± 13.9 kgf)
Ike (2015)16 Nonphysiological load Vertical load on superior aspect Distal end of PF N Von-Mises stressy ANSYS
(Load: 183.5 kgf) of sacrum
47
Liu (2015) One leg stance JRF at femoral head centroid Pubis and top surface of pelvis Y CP and areay ABAQUS
(66.3 kgf) Distal end of PF*
Liu (2016)48 One leg stance JRF at femoral head centroid Pubis and top surface of pelvis Y CP and areay ABAQUS
(66.3 kgf) Distal end of PF*
Chegini (2009)44 Gait JRF at femoral head centroid Acetabulum Y CPy,x ABAQUS
Stance to sit Von-Mises stressy
(85 kgf)
Liechti (2015)46 Gait JRF at femoral head centroid Acetabulum Y CPy ABAQUS
Stance to sit Von-Mises stressy
(71.5 kgf)
*
Fixed or limited displacement only in lateral-medial and anterior-posterior directions.
y
Acetabular cartilage.
z
Femoral cartilage.
x
Lb.

Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
4 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10

Table III
Simulation results of adult hip joints

Study Significant model outputs Significant findings

Circumstances Output Normal Dysplastic Ratio*

Russell (2006)45 Gait Peak CP (MPa) 1.8 3.6e9.9 2.0e5.7 Bone irregularities in dysplastic hip models led to localized elevated
Contact area (mm2) 2265 215 0.1 cartilage CP. In dysplastic hip models, peak CP was not coincident
with maximum JRF during gait cycles as a consequence of
incongruous surfaces of dysplastic hips.
Zhao (2010)17 One-leg stance Peak svon (MPa) 15.2 22.7e30.7 1.5e2.0 Decrease in CE and vertical centre anterior (VCA) angles (from 25
to 10 ) of the simulated hips led to increase in the cartilage stress
and altered the uniform stress distribution of the normal joint to
stress concentration in the acetabular edge in the dysplastic joint
models..
Henak (2011)43 Gait Peak CP (MPa) 6e14 6e14 NR Due to shallow acetabulum in the dysplastic hip model, the Lb
Stair descent Average CP (MPa) 1.1e1.3 0.5e1.2 0.4e1.2 significantly contributed to the joint stability (lateral stability in
Stair ascent Contact area (mm2) 680e800 350e440 0.4e0.7 particular) and load transfer in the dysplastic hip model in
Lb load support 1e2% 4e11% 2e11 comparison with the normal hip model. Consequently, cartilage CP
did not substantially increase in the dysplastic hip model.
Zou (2013)15 One-leg stance Average CP (MPa) 3.59e6.07y 3.9e6.2 1.0e1.1 Average cartilage stresses (pressure and von-Mises) and contact
Contact Area (mm2) 319e531y 304e492 0.9e1.0 area were not linearly and monotonically correlated with CE angle
Average svon (MPa) 1.4e2.2y 1.5e2.4 1.0e1.1 (10 e45 ). However, patient-specific optimal CE angles minimizing
the cartilage stresses and maximizing the contact areas were found
for the dysplastic hip models.
Henak (2014)42 Gait Peak CP (MPa) 5.0e15.0 2.5e16.2 0.5e1.1 The load supported by the Lb (especially on the lateral side) was
Stair descent Average CP (MPa) 0.5e1.9 0.1e2.1 0.2e1.3 significantly higher in the dysplastic hip models than in normal hip
Stair ascent Lb load support 2.6e3.3% 8.2e10.3% 2.8e4.0 models. CPs in the dysplastic hip models were not elevated
compared with the normal hip models because the Lb provided
additional contact surface in the dysplastic hip models.
Ike (2015)16 Non-physiological Peak svon (MPa) 1.7e4.0y 1.2e6.5 0.7e1.8 Moderate correlations between von Mises stress in the joint and
morphological parameters, CE angle (R ¼ 0.65), acetabular head
index (R ¼ 0.60), acetabular angle (R ¼ 0.48), and acetabular roof
angle (R ¼ 0.57), were observed.
Liu (2015)47 One-leg stance Peak CP (MPa) 3.8e6.3y 5.5e18.9 1.5e3.6 Acetabular inclination and version, femoral head coverage ratio and
Contact Area (mm2) 834e1497y 503e1005 0.5e0.7 CE angle were morphological parameters engaged in the status of
CP and area of normal and dysplastic hips.
Liu (2016)48 One-leg stance Peak CP (MPa) 4.5e10y 5.5e15 1.1e2.9 Peak CP and contact area predicted by models using constant
Contact Area (mm2) 480e1198y 425e1166 0.6e1.0 thickness cartilage respectively had moderate (R ¼ 0.63) and strong
(R ¼ 0.87) correlations with their corresponding values resulted
from models employing varying-thickness cartilage obtained from
patient-specific data. An optimal range of CE angle minimizing the
peak CP and maximizing the contact area was found to be 23.5
e38.9 .
Chegini (2009)44 Gait Peak CP (MPa) 2.4e3.4 6.1e9.9 1.8e4.1 Activities with high load (gait) rather than with large range of
Stance to sit Peak CP (MPa) 3.3e3.7 3.5e3.6 0.9e1.1 motion (stance to sit) led to higher pressure and von Mises stress in
the dysplastic hip models. An optimal range of CE angle to minimize
the CP and von Mises stress was found to be 20 e30 .
Liechti (2015)46 Gait Peak CP (MPa) 1.4 2.0 1.4 During gait, the area of peak CP in the normal hip model was
Peak svon (MPa) 0.7 1.4 2.0 centered in the acetabular roof whereas this area shifted towards
Stance to sit Peak CP (MPa) 1.3 1.5 1.2 the lateral face of the acetabular cartilage in the dysplastic hip
Peak svon (MPa) 0.8 1.0 1.3 model. During stance to sit, the area of peak CP in both the normal
and the dysplastic hip models was located on the posterior aspect of
the lunate surface.

svon: Von-Mises stress in cartilage or the underneath cortical shell, NR: not reported, VCA: vertical center-anterior margin.
*
Ratio of the simulated values corresponding with dysplastic hips to those of normal hips.
y
The models of VPPAO and PRAO leading to minimized CP and maximized contact area are listed as normal hips.

arthrographic studies15e17,47,48 assumed constant AC thickness
(1.8e2 mm), simplifying FEM. However, Anderson et al.49 demon-
strated that use of constant-thickness cartilage in normal hip FEM
overestimated cartilage CP and underestimated contact areas. In
dysplastic hips, Liu et al.48 found 21 ± 19% and 17 ± 14% error in
simulated CP and area respectively when replacing patient-specific
cartilage thickness with a constant-thickness cartilage layer.
Therefore, utilizing patient-specific cartilage thickness likely en-
hances simulation accuracy49; especially in dysplastic hips in which
cartilage thickness is greater and more variable than in normal
hips50.
The cartilage-labrum (Lb) boundary is usually not visible even in
arthrograms. Studies either determine this based on morphology
and reader judgment17,42,43, or simply disregard the Lb15,16,45,47,48.
Several studies that included the Lb found its mechanical contri-
bution in hip stabilization and load transfer from cartilage was
greater (by 2e11 times) in dysplastic than normal hips. Not
including the Lb in FEM of dysplastic hips therefore notably affects
its simulated mechanical behavior42e44.
Defining capsular ligaments (CLs) on CT images is as difficult as
defining the Lb. Only one study (15) incorporated these ligaments
in FEM, however, in simple fashion with ligaments modeled as
discrete spring elements, with no report of the functionality and
effects of modeling these ligaments. The stabilizing contribution of
the hip capsule depends on the joint angular position and con-
gruency51e53, and is greater in dysplastic hips51. The circumstances
in which including the capsule may affect FEM results were not
discussed in the reviewed studies, and require further investigation
and experimental validation.
To investigate the effect of wide variations in hip geometry on
mechanical behavior, some studies used CAD-based rather than
patient-specific models44,46. Averaged anatomic measurements led

Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10 5

Table IV
FEM methodology and simulation results of prenatal hip joint growth

Study FEM specifications Significant findings

Model components Material (ILE) Boundary conditions Contact Stress output

(CAD-based) and load

Shefelbine PF (3D)* Bonez: Boundary conditions: N Hydrostatic Normal hip JRF loading history led to a convex shape of the
(2004)8 E ¼ 500 MPa, fixed distal end of PF pressure growth front, whereas dysplastic hip loading history resulted in
n ¼ 0.2 Load: varying angle JRF Octahedral formation of coxa valga.
Cartilagex: with arbitrary shear
G ¼ 2 MPa, magnitude
n ¼ 0.49
Giorgi PF Acetabular Cartilage: Boundary conditions: Y Hydrostatic Symmetric prenatal hip rotation within normal ranges
(2015)11 cup (2D)y E ¼ 1.1 MPa, Fixed acetabulum, pressure promoted normal formation of acetabulum, whereas reduced-
n ¼ 0.49 arbitrary distal- range rotations led to prediction of shallow acetabulum.
proximal displacement Asymmetric rotations simulated formation of asymmetrically
of distal end of the PF, shallow acetabulum and malformed femoral head associated
planar rotation of the with DDH.
femoral head
*
A 7-month fetal PF with a non-ossified head located above a thin cartilaginous growth region supported by a bony diaphysis.
y
Idealized 2D geometries of a non-ossified PF, and an acetabular cup associated with a fetus at 11th gestational week.
z
E ¼ 500 MPa distally, linearly decreasing toward the cartilaginous femoral head.
x
Young's modulus can be calculated as 5.96 MPa.

to idealized ball-and-socket geometries of adult hips: hemispher-
ical femoral head and acetabulum. Articular surfaces were modeled
as portions of smooth spherical surfaces, including horseshoe-
shaped acetabular cartilage. Reducing the lateral center-edge (CE)
angle introduced dysplasia into these models. Although conve-
nient, this likely does not lead to reliable quantitative prediction of
hip mechanical behavior. In comparison with patient-specific
models of normal hips, CPs were underestimated by 25e50%49
from CAD-based FEM, due at least partly to contact area over-
estimation44,46,49. This error is likely greater in dysplastic hips,
where shape irregularities cause incongruent articulation and
locally increased CP45, not accounted for by CAD-based models
using simplified/smoothed geometry44,46. These stress concentra-
tions at the lateral acetabular roof may be important in OA devel-
opment. Use of patient-specific geometry is therefore preferred, as
it limits the risk of bias from anatomic assumptions.
The studies modeling prenatal hips (Table IV) utilized CAD-
based modeling of either a non-ossified fetal PF8, or an idealized
hip joint including non-ossified femoral and acetabular
components11.
Mechanical properties of materials
Deformations and stresses inside the hip depend on material
properties of its components including bone, cartilage and liga-
ments. Adult patient-specific FEM15e17,42,43,45,47,48 all assumed
homogeneous isotropic linear-elastic (ILE) materials for cortical
and cancellous bone. This simplifying assumption has been shown
to be appropriate for analyzing hip mechanical behavior54,55, and
requires only two mechanical constants, Young's modulus E and
Poisson's ratio n. For cortical bone most studies used E ¼ 17 GPa,
while those that modeled cancellous bone separately used
E ¼ 70e120 MPa (Table I). One study16 used location-dependent
values of E based on CT data. Because cortical bone is much
stiffer than cancellous bone and forms a sandwich shell over it55,
some consider cancellous bone to have only a minor effect on
CP27,49. Therefore, some FEM studies disregarded cancellous
bone42,43,47,48. Some CAD-based models use rigid material for
bone44,46, further simplifying FEM. One of these groups showed
this assumption to have no effect on predicted cartilage stresses,
since bone is much stiffer than AC44. However, the assumption
that bone is rigid may not be appropriate in patient-specific
models, where use of rigid bones led to a significant increase in
predicted CP49.
In a CAD-based prenatal femur model8, the bony part was
modeled as an elastic deformable material since simulation of
mechanical stress in the growth front within the diaphysis was
required (Table IV).
Unlike bone, cartilage exhibits time- and rate-dependent
behavior under physiological loads. Nevertheless, these complex
effects can be disregarded if external load on the cartilage is
instantaneous19,56e58, such as with loading time less than 150 ms56
or loading cycles less than 1 s (gait, stair descent/ascent, stance-to-
sit, onset of one-leg stance)57,58. Since cartilage is reportedly
incompressible under instantaneous load59, this simplified FEM of
adult hips allowing use of either nearly incompressible ILE15e17,44e48
or incompressible isotropic hyperelastic (IHE) models42,43 for
cartilage (Table I), with parameters determined based on fast-
loading experimental conditions. Cartilage in the prenatal hip
models8,11 was modeled as a nearly incompressible ILE material
(Table IV). Disregarding time and rate properties of the cartilage may
not be associated with physiological loading conditions inside the
uterus, however, it satisfies the minimum FEM requirements for
cross-comparison purposes between the simulation results.
The acetabular Lb consists primarily of type 1 collagen fiber
bundles extending around the acetabular rim60, and is therefore
highly anisotropic, having different mechanical response to loads
parallel vs perpendicular to the fibers. Assuming any direction
except circumferential has similar properties, the Lb can still be
considered transversely isotropic. Moreover, time- and rate-
dependent properties can be neglected under fast loading rates.
Thus, the Lb has been modeled as incompressible transversely IHE
material42,43, or as a nearly incompressible isotropic material with
linear elastic properties measured along the fibers17,44,46. Isotropic
labral material assumption reportedly overestimates the load
supported by the Lb by 2e11%43, since an isotropic Lb is unrealis-
tically stiff perpendicular to the fibers compared with the circum-
ferential direction.
Another simplification of material properties in adult hips was
employing the soft tissue material properties of the normal hips for
dysplastic hips. As noted by Henak et al.42, cartilage may be stiffer
and softer, respectively, in dysplastic than normal hips.
Contact mechanism
In a hip joint, the convex femoral articular surface slides against
the concave acetabulum. Articular friction is demonstrated to be
negligible (frictional coefficient of 0.002e0.02) when synovial fluid

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6 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10
becomes pressurized at the onset of loading and remains pressur-
ized for a prolonged duration61e63. Accordingly, the reviewed
studies accounting for the sliding mechanism of the joint assumed
a frictionless contact mechanism11,15,17,42e48. This allows the small
tangential (shear) component of the JRF to be neglected. One study,
however, modeled AC as one entity without considering the sliding
mechanism16. Ignoring the joint sliding contact mechanism over-
estimates cartilage stresses and does not permit evaluation of joint
CP. The studies that included the Lb also assumed frictionless
cartilage-Lb contact17,42e44,46.
Boundary conditions and loading
To analyze hip behavior, each bone should be in a state of force
equilibrium. Commonly the adult hip is analyzed assuming static
loads and immobilized bones. Generally42e48, the pelvic bone (PB)
was immobilized by applying fixed-displacement boundary con-
ditions (i.e., no motion), and a load exerted on the PF already ori-
ented within the hip according to the analysis conditions (Table II).
Boundary conditions may also be applied to the femur to fix or limit
its medial-lateral or antero-posterior displacements42,43,47,48.
Typically, the femur is initially mobile in distal-proximal direction,
and becomes immobilized and statically stable in the acetabular
socket once femoral-acetabular articular contact is completely
established. Other studies15e17 applied fixed-displacement
boundary conditions for the distal femur and applied load to the
PB to analyze natural anatomic posture, e.g., one-leg stance.
The reviewed studies investigated adult hip mechanical
behavior under different physiological (gait, stair descent/ascent,
stance-to-sit, one-leg stance) and non-physiological loading sce-
narios (Table II). Most studies consider the JRF vector obtained
experimentally23,64 to be the loading input for the FEM. JRF is the
balancing force transmitted at articular surfaces due to ligament
and muscle forces, and body weight. JRF can be used to avoid dif-
ficulties in locating, distributing and orienting individual muscle
forces in FEM, as long as analysis results near the joint (i.e., ace-
tabulum and femoral head including soft tissues) are the focus of
FEM. JRF can be applied either under load control or displacement
control. Under load control, JRF was applied at the femoral head
centroid44e48 or at the upper pelvis15. Applying JRF at the femoral
head centroid requires kinematic coupling of femoral head finite-
element nodes to the centroid, i.e., assumption of a rigid femoral
head, which induces a potentially undesirable approximation in the
results49. Applying JRF to the upper hemi-pelvis involves kinematic
coupling of upper pelvis finite-element nodes to a single point such
that the line of action of the force, applied at the reference point,
passes through the femoral head centroid, allowing the femoral
head model to remain deformable. Two reviewed studies employed
displacement-control loading42,43, in which the PF was pushed
against the acetabulum along the line of action of JRF until the
desired force was achieved. Since the displacement vector (as
boundary condition) was applied to the femoral shaft, the
deformable property of the femoral head was preserved. A meth-
odological limitation of employing JRF in the hip models is that the
JRF vectors in the reviewed studies were based on in vivo mea-
surement data from instrumented implants within hips after total
hip arthroplasty, scaled by patient weight. These estimates are not
necessarily equivalent to the JRF one might actually observe in
patient-specific models, especially in dysplastic hips.
Rather than loading along the line of action of JRF, some studies
instead applied a vertical load to the upper sacrum16,17, to assess
one-leg stance and non-physiological loading65. For one-leg
stance17, gluteus medius abductor muscle force was also applied
to the PB and the greater trochanter to maintain static force equi-
librium. Unlike the direct utilization of JRF in FEM, applying the
Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
loading conditions to the upper sacrum preserved patient-specific
effects of the joint geometry on the predicted JRF.
The prenatal studies employed both direct and displacement
control loading (Table IV). Applying fixed displacement boundary
conditions at the distal femur, Shefelbine et al.8 used a dynamically
varying-angle JRF vector distributed symmetrically on the carti-
laginous femoral head. The force angles assumed JRF angles in
normal (25 , 40 , 50 ) and dysplastic (60 , 85 , 105 ) joints. The
two-dimensional (2D) model by Giorgi et al.11 had an immobilized
acetabular cup and a freely rotating femur. The femur was proxi-
mally displaced towards the acetabulum for contact force initiation,
and dynamically rotated in-plane according to reported ranges of
motion from early to late gestation (±40 to ±5 respectively).
Symmetric and asymmetric rotations were tested. Contact forces in
both studies had an arbitrary magnitude, adequate for cross-
comparison but not necessarily physiologic.
Finite element analysis, outputs and results
Hip FEM can be categorized as a contact problem since loads are
transferred by the contact mechanism of the joint. In the reviewed
studies, FEM offered a choice of model outputs for adult hips.
Cartilage CP (distributed form of the JRF on the surfaces in contact)
and von Mises stress (indicator of internal distortion energy inside
the tissues) are parameters that reflect the status of the load
transfer mechanism and mechanical stresses inside the joint
respectively. High cartilage CP may lead to OA when accumulated
over years6,14 and elevated von Mises stress may be associated with
cartilage damage44.
The reviewed studies on adult hip joints show widely varying
ranges of CP and area, and von Mises stress in normal and
dysplastic hips under a variety of loading scenarios (Table III). Each
study performed mesh sensitivity analysis to minimize FEM error
and produce accurate results. Most of the studies (except Refs. 16
and 48) validated their FEM by showing that simulated CP and
contact area were comparable with or in range of available
measured experimental data. The numeric ranges of simulated
values are not directly comparable with each other because the
models are associated with different joint geometry, material
properties, and loading vectors, methods and scenarios. Fortu-
nately, the diversity of model design reduces the risk of bias in
results across studies. Qualitative comparisons between the FEM
results of dysplastic vs normal hips were performed.
Simulating gait cycles, some researchers44e46 found peak CP to
be 1.4e5.7 times higher in dysplastic hips than normal joints. In
contrast, Henak et al.42,43 found peak CP were actually larger in
normal hip models than dysplastic hips, because dysplastic hip
geometry shifted part of the JRF towards the Lb, engaging part of
the labral surface to contact femoral head cartilage. The extra labral
contact area helped redistribute JRF, sparing cartilage by increasing
load on the Lb. According to Henak et al.42, other studies predict
elevated CP during gait in dysplastic hips because they disregard
either the Lb45 or patient-specific joint geometry44,46. The fact that
the superior Lb was most affected by shift of JRF in the dysplastic
hip models may explain the high clinical prevalence of superior or
anterosuperior labral tears and adjacent cartilage damage. Cartilage
contact area during gait was reportedly smaller in dysplastic than
normal hips, whether or not the Lb was included in FEM43,45.
Groups investigating mechanical behavior of dysplastic hips
under one-leg stance conditions15,17,47,48 simulated acetabular
osteotomies to create close-to-normal hip models out of dysplastic
hips. They reported that maximizing contact area in dysplastic hips
via acetabular reorientation generally decreased CP and von Mises
stress. However, minimized peak CP may not be always concurrent
 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10 7

with the maximized contact area48, due to stress concentrations at
patient-specific bone irregularities45.
Two studies investigating stance-to-sit conditions44,46 both re-
ported higher CP and von Mises stress in dysplastic hips, accentu-
ated by activities with high load (gait) rather than with large range
of motion (stance-to-sit).
The reviewed prenatal studies recruited other FEM-simulated
stress components (Table IV). Shefelbine et al.8 evaluated the
mechanobiological theory that growth is accelerated by intermit-
tent octahedral shear stress and inhibited by intermittent hydro-
static pressure66. Giorgi et al.11 assessed the theory that growth is
accelerated by dynamic hydrostatic pressure and inhibited by static
pressure67. Growth in both studies was simulated through
computational expansion of finite elements with rates calculated
based on the growth theories. These simulations provided insights
on the effect of the mechanical environment on cartilage growth
within limited and idealized assumptions.
Shefelbine et al.8 found that in normal hips, hydrostatic pressure
was higher peripherally and octahedral shear stress was highest
centrally, promoting a convex shape of the growth front. In dysplastic
hips, octahedral shear stress was increased on the medial side of the
growth region, imbalancing the growth front toward coxa valga.
Giorgi et al.11 showed that asymmetric rotations of the femoral
head inside the acetabulum prenatally led to asymmetric joint
loading which eventually opened the acetabulum toward the di-
rection of the generated JRF, giving the asymmetrically shallow
acetabulum and malformed femoral head of DDH. Such asymmetric
rotations of a prenatal hip joint might result from fetal breech
position or increased joint laxity.
Limitations of, and alternatives to, FEM
The reviewed studies show that FEM provides a versatile tool to
assess etiology and effects of DDH. Nevertheless, FEM is time-
intensive and computationally expensive, especially with detailed
finite-element meshes, nonlinear material properties and non-
linear contact mechanism formulation20. This can paralyze the
method if analysis time is a critical factor, such as in large popu-
lation studies37e39,68e70, osteotomy surgical planning71,72 or real-
time intraoperative feedback73e75. Trading strict accuracy for
faster modeling in these settings, DEA can be regarded as the
closest alternative to FEM76. DEA (or rigid body-spring modeling)
considers bones as rigid bodies, and AC as one-dimensional springs
connecting the acetabulum and femoral head34,40. Ligaments are
represented by springs. Neglecting mechanical stresses inside
bones, DEA estimates joint CP from forces in compressive springs
distributed on the joint surfaces. This does not accurately model the
joint sliding contact mechanism, but can still demonstrate patterns
of contact area and CP distribution regardless of absolute magni-
tudes. This makes DEA appropriate for studies comparing me-
chanical behavior of normal vs dysplastic hips, and pre- vs post-
operative joints34,40 (Table V).
Recommendations for FEM of infant hips
We found no FEM-based studies in infants or children. Prenatal
FEM-based studies focus on DDH etiology. Pathological conse-
quences of the dysplastic mechanical environment in infant hips,
and optimal methods of DDH correction in children, have not, to
our knowledge, been modeled yet. Adult studies are likely not
directly applicable to infant hips, since unlike in adults most of the
infant/prenatal hip is composed of cartilage, including the femoral
head and the pubic rami. Given the extent to which small changes
in cartilage thickness affect results in patient-specific adult hip
models48, the proportionately thicker infant hip AC likely alters
infant hip mechanical behaviour compared to adults. It is also un-
clear to what extent infant cartilage mechanical properties differ
from adult cartilage77. Patient-specific computational geometries of
infant hips are challenging to produce via CT which poorly depicts
cartilage, and CT is not practical for this indication due to radiation
dose concerns in infants. Magnetic resonance imaging (MRI) shows
clearer boundaries of soft tissue structures78,79, without ionizing
radiation, but infants may require sedation, and spatial resolution is
lower than on CT. 3D ultrasound is an emerging modality offering
high spatial resolution with no ionizing radiation. Since early re-
sults show promising geometric accuracy80, this may be useful in
future patient-specific modeling.
Loading scenarios in adult hip FEM such as walking, climbing
stairs or one-leg standing are obviously not relevant in infants,
where more important loading scenarios include positioning
within a swaddle, sling, car seat or Pavlik harness. In-utero loading
scenarios are also uniquely challenging. Verbruggen81 evaluated
fetal movements, and reaction force of fetal kicking against the
uterine wall. Unlike in adults, infant load scenarios may involve
prolonged slow loading, as with corrective harnesses worn 24 h/
day. According to Hjelmstedt et al.12,13, long-duration moderate

Table V
DEA-based studies regarding human dysplastic hips

Study Modeling focus Significant findings

Genda (1995)37 Evaluating CP in normal and acetabular
dysplastic hip joints (loading scenarios:
heel strike and toe-off phases of gait)
Tsumura (1998)41 Simulating 3D CP distribution in normal
and dysplastic hips (loading scenario:
one-leg stance phase of gait)
Rab (2007)70 Investigating effects of different
acetabular rotations on hip subluxation
(loading scenario: one-leg stance)
Armiger (2009)69 Calculating pre- and post-operative CP
in hip joints of PAO patients (loading
scenarios: standing, gait, and sitting)
Niknafs (2013)72 Evaluating the effects of cartilage
thickness distribution and compressive
spring models of cartilage on optimal
alignment of acetabulum in PAO
patients (loading scenarios: standing,
gait, and sitting)
Even distribution of CP over the joint surface and low peak CP (averaged 2.6 MPa) in normal joints
(CE > 20 ). Concentration of CP on anterolateral edge of acetabulum and increasing peak CP (2.5
e17 MPa) with reduction of CE angle in dysplastic joints (1.75 < CE < 19.8 ).
The peak CP in dysplastic hips (15 < CE < 7 ) was located at the edge of the acetabulum. The peak CP
values in dysplastic hips (2.83e5.31 MPa) were higher in normal hips (1.83e2.51 MPa) with
24 < CE < 38 .
Progressive anterolateral subluxation associated with hip dysplasia occurred in the hip models with
CE < 20 . The subluxation was followed by dislocation in the models with CE < 0 . Models with CE  30
did not lead to lateral subluxation.
Calculated peak CP values in preoperative dysplastic hips (1.9e7.7 MPa) were reduced (1.4e3.2 MPa) by
an average factor of 1.7 after PAO. Reduction of the peak CP was not proportional with increase of CE
angle.
Choice of cartilage thickness distribution (patient-specific vs constant), or linear/non-linear spring
models of cartilage did not affect the predicted optimal alignment of acetabulum.

PAO: periacetabular osteotomy.

Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
8 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10
loads can provoke DDH due to time-dependent deformations of
cartilaginous femoral head and acetabulum. The rate- and time-
dependency of cartilage material properties may play a role in
FEM of infant hips.
Summary
FEM of adult dysplastic hips is most commonly performed using
patient-specific CT-based geometry, ILE models of bone, cartilage
and Lb, omission of most muscles and ligaments, and assumptions
of rapid loading to simplify cartilage mechanical properties. Load
conditions modeled simulate situations such as walking or stair-
climbing. Joint CPs and stresses are simulated. Most models
demonstrate increased stress on cartilage and/or increased reliance
on the Lb to bear load in dysplastic hips, correlating well to clinical
findings of premature OA and early labral tearing in dysplastic hips.
DEA offers a rapid alternative to FEM when computational time is
an issue. FEM of prenatal hips demonstrates ways in which in-utero
loading might produce DDH. FEM of infant dysplastic hips offers an
opportunity to understand the stress environment and factors
affecting it at a time when the dysplasia can still be corrected
conservatively. Models in infants do not yet exist, and have special
challenges, including the need to obtain accurate cartilage geom-
etry, consideration of rate-dependent cartilage material properties,
and infant-relevant loading scenarios.
Hip mechanical modeling through the human life cycle may
improve our understanding of the causes of DDH and of premature
hip OA, and ultimately help us optimize DDH treatment to reduce
its lifelong disability.
Author contributions
Author list:
BV: B. Vafaeian
DZ: D. Zonoobi
MM: M. Mabee
ARH: A. R. Hareendranathan
ME: M. El-Rich
SA: S. Adeeb
JJ: J. L. Jaremko
Contributions of authors (All authors should have made
substantial contributions to all three of sections (1), (2) and (3))
 (1) Conception and design: BV, DZ, MM, ARH, ME, SA, JJ
 (1) Analysis and interpretation of the data: BV, DZ, MM, ARH
 (2) Drafting of the article: BV, JJ
 (2) Critical revision of the article for important intellectual
content: BV, DZ, MM, ARH, ME, SA, JJ
 (3) Final approval of the article: BV, DZ, MM, ARH, ME, SA, JJ
 (.) Provision of study materials or patients: ME, SA, JJ
 (.) Statistical expertise: JJ
 (.) Obtaining of funding: JJ
 (.) Administrative, technical, or logistic support: DZ, ME, SA, JJ
 (1) Collection and assembly of data: BV, JJ
 Guarantor of overall integrity of the work: JJ
Conflict of interest
None of the co-authors has any competing interests to disclose that
could potentially and inappropriately influence the study.
Acknowledgements
Unrestricted funding support for this work was provided by the
Capital Health Endowed Chair in Diagnostic Imaging and the CIHR-
HSC Young Investigator Award (NI15-004).
Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
References
1. Schwend RM, Shaw BA, Segal LS. Evaluation and treatment of
developmental hip dysplasia in the newborn and infant.
Pediatr Clin North Am 2014;61:1095e107.
2. Furnes O, Lie SA, Espehaug B, Vollset SE, Engesaeter LB,
Havelin LI. Hip disease and the prognosis of total hip re-
placements. J Bone Joint Surg 2001;83:579e86.
3. Maquet P. Biomechanics of hip dysplasia. Acta Orthop Belg
1999;65:302e14.
4. Gulati V, Eseonu K, Sayani J, Ismail N, Uzoigwe C,
Choudhury MZ, et al. Developmental dysplasia of the hip in the
newborn: a systematic review. World J Orthop 2013;4:32e41.
5. Harris-Hayes M, Royer NK. Relationship of acetabular
dysplasia and femoroacetabular impingement to hip osteoar-
thritis: a focused review. PM R 2011;3. 1055.e1e1067.e1.
6. Hadley NA, Brown TD, Weinstein SL. The effects of contact
pressure elevations and aseptic necrosis on the long-term
outcome of congenital hip dislocation. J Orthop Res 1990;8:
504e13.
7. Brand RA. Joint contact stress: a reasonable surrogate for
biological processes? Iowa Orthop J 2005;25:82e94.
8. Shefelbine SJ, Carter DR. Mechanobiological predictions of
growth front morphology in developmental hip dysplasia.
J Orthop Res 2004;22:346e52.
9. Siffert RS. Patterns of deformity of the developing hip. Clin
Orthop Relat Res 1981:14e29.
10. LeVeau BF, Bernhardt DB. Developmental biomechanics. Effect
of forces on the growth, development, and maintenance of the
human body. Phys Ther 1984;64:1874e82.
11. Giorgi M, Carriero A, Shefelbine SJ, Nowlan NC. Effects of
normal and abnormal loading conditions on morphogenesis of
the prenatal hip joint: application to hip dysplasia. J Biomech
2015;48:3390e7.
12. Hjelmstedt A, Asplund S. Congenital dislocation of the hip a
biomechanical study in autopsy specimens. J Pediatr Orthop
1983;3:491e7.
13. Hjelmstedt A, Asplund S, Rauschning W. Cryodissection and
cryosectioning in biomechanical studies on congenital dislo-
cation of the hip. Anat Clin 1982;4:13e21.
14. Michaeli DA, Murphy SB, Hipp JA. Comparison of predicted and
measured contact pressures in normal and dysplastic hips.
Med Eng Phys 1997;19:180e6.
15. Zou Z, Cha
vez-Arreola A, Mandal P, Board TN, Alonso-
Rasgado T. Optimization of the position of the acetabulum in a
ganz periacetabular osteotomy by finite element analysis.
J Orthop Res 2013;31:472e9.
16. Ike H, Inaba Y, Kobayashi N, Yukizawa Y, Hirat Y, Tomioka M,
et al. Effects of rotational acetabular osteotomy on the me-
chanical stress within the hip joint in patients with develop-
mental dysplasia of the hip: a subject-specific finite element
analysis. Bone Joint J 2015;97-B:492e7.
17. Zhao X, Chosa E, Totoribe K, Deng G. Effect of periacetabular
osteotomy for acetabular dysplasia clarified by three-
dimensional finite element analysis. J Orthop Sci 2010;15:
632e40.
18. Schmitt J, Meiforth J, Lengsfeld M. Development of a hybrid
finite element model for individual simulation of inter-
trochanteric osteomies. Med Eng Phys 2001;23:529e39.
19. Stops A, Wilcox R, Jin Z. Computational modelling of the
natural hip: a review of finite element and multibody simu-
lations. Comput Methods Biomech Biomed Engin 2011;15:
963e79.
20. Bachtar F, Chen X, Hisada T. Finite element contact analysis of
the hip joint. Med Biol Eng Comput 2006;44:643e51.
 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10
21. Harris MD, Anderson AE, Henak CR, Ellis BJ, Peters CL, Weiss JA.
Finite element prediction of cartilage contact stresses in
normal human hips. J Orthop Res 2012;30:1133e9.
22. Brown TD, Shaw DT. In vitro contact stress distributions in the
natural human hip. J Biomech 1983;16:373e84.
23. Bergmann G, Deuretzabacher G, Heller M, Graichen F,
Rohlmann A, Strauss J, et al. Hip forces and gait patterns from
routine activities. J Biomech 2001;34:859e71.
24. Afoke NY, Byers PD, Hutton WC. Contact pressures in the hu-
man hip joint. J Bone Joint Surg Br 1987;69:536e41.
25. Krebs DE, Elbaum L, Riley PO, Hodge WA, Mann RW. Exercise
and gait effects on in vivo hip contact pressures. Phys Ther
1991;71:301e9.
26. Von Eisenhart R, Adam C, Steinlechner M, Muller-Gerbl M,
Eckstein F. Quantitative determination of joint incongruity and
pressure distribution during simulated gait and cartilage
thickness in the human hip joint. J Orthop Res 1999;17:532e9.
27. Anderson AE, Ellis BJ, Maas SA, Peters CL, Weiss JA. Validation
of finite element predictions of cartilage contact pressure in
the human hip joint. J Biomech Eng 2008;130:51008.
28. Ipavec M, Brand RA, Pedersen DR, Mav ci
c B, Kralj-Igli
c V,
Igli
c A. Mathematical modelling of stress in the hip during gait.
J Biomech 1999;32:1229e35.
29. Pompe B, Daniel M, Sochor M, Vengust R, Kralj-Iglic V, Igli c A.
Gradient of contact stress in normal and dysplastic human
hips. Med Eng Phys 2003;25:379e85.
30. Daniel M, Antolic V, Iglic A, Kralj-Iglic V. Determination of
contact hip stress from nomograms based on mathematical
model. Med Eng Phys 2001;23:347e57.
31. Brinckmann P, Frobin W, Hierholzer E. Stress on the articular
surface of the hip joint in healthy adults and persons with
idiopathic osteoarthrosis of the hip joint. J Biomech 1981;14:
149e56.
32. Maxian TA, Brown TD, Weinstein SL. Chronic stress tolerance
levels for human articular cartilage: two nonuniform contact
models applied to long-term follow-up of CDH. J Biomech
1995;28:159e66.
33. Hipp JA, Sugano N, Millis MB, Murphy SB. Planning acetabular
redirection osteotomies based on joint contact pressures. Clin
Orthop Relat Res 1999:134e43.
34. Abraham CL, Maas SA, Weiss JA, Ellis BJ, Peters CL, Anderson AE.
A new discrete element analysis method for predicting hip joint
contact stresses. J Biomech 2011;72:181e204.
35. Ardila OJ, Divo EA, Moslehy FA, Rab GT, Kassab AJ, Price CT.
Mechanics of hip dysplasia reductions in infants using the
Pavlik harness: a physics-based computational model.
J Biomech 2013;46:1501e7.
36. Huayamave V, Rose C, Serra S, Jones B, Divo E, Moslehy F, et al.
A patient-specific model of the biomechanics of hip reduction
for neonatal developmental dysplasia of the hip: investigation
of strategies for low to severe grades of developmental
dysplasia of the hip. J Biomech 2015;48:2026e33.
37. Genda E, Konishi N, Hasegawa Y, Miura T. A computer simu-
lation study of normal and abnormal hip joint contact pres-
sure. Arch Orthop Trauma Surg 1995;114:202e6.
38. Genda E, Iwasaki N, Li G, MacWilliams BA, Barrance PJ,
Chao EY. Normal hip joint contact pressure distribution in
single leg standing. J Biomech 2001;34:895e905.
39. Yoshida H, Faust A, Wilckens J, Kitagawa M, Fetto J, Chao EYS.
Three-dimensional dynamic hip contact area and pressure
distribution during activities of daily living. J Biomech
2006;39:1996e2004.
40. Chao EYS, Volokh KY, Yoshida H, Shiba N, Ide T. Discrete
element analysis in musculoskeletal biomechanics. Mol Cell
Biomech 2010;7:175e92.
Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
9
41. Tsumura H, Miura H, Iwamoto Y. Three-dimensional pressure
distribution of the human hip joint e comparison between
normal hips and dysplastic hips. Fukuoka Igaku Zasshi
1998;89:109e18.
42. Henak CR, Abraham CL, Anderson AE, Maas SA, Ellis BJ,
Peters CL, et al. Patient-specific analysis of cartilage and
labrum mechanics in human hips with acetabular dysplasia.
Osteoarthritis Cartilage 2014;22:210e7.
43. Henak CR, Ellis BJ, Harris MD, Anderson AE, Peters CL, Weiss JA.
Role of the acetabular labrum in load support across the hip
joint. J Biomech 2011;44:2201e6.
44. Chegini S, Beck M, Ferguson SJ. The effects of impingement and
dysplasia on stress distributions in the hip joint during sitting
and walking: a finite element analysis. J Orthop Res 2009;27:
195e201.
45. Russell ME, Shivanna KH, Grosland NM, Pedersen DR. Cartilage
contact pressure elevations in dysplastic hips: a chronic
overload model. J Orthop Surg Res 2006;1:6.
46. Liechti EF, Ferguson SJ, Tannast M. Protrusio acetabuli: joint
loading with severe pincer impingement and its theoretical
implications for surgical therapy. J Orthop Res 2015;33:106e13.
47. Liu L, Ecker T, Xie L, Schumann S, Siebenrock K, Zheng G.
Biomechanical validation of computer assisted planning of
periacetabular osteotomy: a preliminary study based on finite
element analysis. Med Eng Phys 2015;37:1169e73.
48. Liu L, Ecker TM, Schumann S, Siebenrock K. Evaluation of
constant thickness cartilage models vs. patient specific carti-
lage models for an optimized computer-assisted planning of
periacetabular osteotomy. PLoS One 2016;11:1e12.
49. Anderson AE, Ellis BJ, Maas SA, Weiss JA. Effects of idealized
joint geometry on finite element predictions of cartilage con-
tact stresses in the hip. J Biomech 2010;43:1351e7.
50. Nishii T, Sugano N, Sato Y, Tanaka H, Miki H, Yoshikawa H.
Three-dimensional distribution of acetabular cartilage thick-
ness in patients with hip dysplasia: a fully automated
computational analysis of MR imaging. Osteoarthritis Cartilage
2004;12:650e7.
51. Nepple JJ, Smith MV. Biomechanics of the hip capsule and
capsule management strategies in hip arthroscopy. Sports Med
Arthrosc 2015;23:164e8.
52. Martin HD, Savage A, Braly BA, Palmer IJ, Beall DP, Kelly B. The
function of the hip capsular ligaments: a quantitative report.
Arthrosc e J Arthrosc Relat Surg 2008;24:188e95.
53. Aspden RM, Rudman KE, Meakin JR. A mechanism for
balancing the human body on the hips. J Biomech 2006;39:
1757e9.
54. Dalstra M, Huiskes R. Load transfer across the pelvic bone.
Biomechanics 1995;28:715e24.
55. Dalstra M, Huiskes R, van Erning L. Development and valida-
tion of a three-dimensional finite element model of the pelvic
bone. J Biomech Eng 1995;117:272e8.
56. Shepherd DE, Seedhom BB. The “instantaneous” compressive
modulus of human articular cartilage in joints of the lower
limb. Ann Rheum Dis 1999;38:124e32.
57. Park S, Hung C, Ateshian GA. Mechanical response of bovine
articular cartilage under dynamic unconfined compression
loading at physiological stress levels. Osteoarthritis Cartilage
2004;12:65e73.
58. Henak CR, Kapron AL, Anderson AE, Ellis BJ, Maas SA, Weiss JA.
Specimen-specific predictions of contact stress under physio-
logical loading in the human hip: validation and sensitivity
studies. Biomech Model Mechanobiol 2014;13:387e400.
59. Wong M, Ponticiello M, Kovanen V, Jurvelin JS. Volumetric
changes of articular cartilage during stress relaxation in un-
confined compression. J Biomech 2000;33:1049e54.
10 B. Vafaeian et al. / Osteoarthritis and Cartilage xxx (2016) 1e10
60. Ferguson SJ, Bryant JT, Ito K. The material properties of the
bovine acetabular labrum. J Orthop Res 2001;19:887e96.
61. Caligaris M, Ateshian GA. Effects of sustained interstitial fluid
pressurization under migrating contact area, and boundary
lubrication by synovial fluid, on cartilage friction. Osteoar-
thritis Cartilage 2008;16:1220e7.
62. Schmidt TA, Sah RL. Effect of synovial fluid on boundary
lubrication of articular cartilage. Osteoarthritis Cartilage
2007;15:35e47.
63. Adeeb SM, Sayed Ahmed EY, Matyas J, Hart DA, Frank CB,
Shrive NG. Congruency effects on load bearing in diarthrodial
joints. Comput Methods Biomech Biomed Engin 2004;7:
147e57.
64. Pedersen R, Brand RA, Davy T. Pelvic muscle and acetabular
contact forces during gait. J Biomech 1997;30:959e65.
65. Macirowski T, Tepic S, Mann RW. Cartilage stresses in the
human hip joint. J Biomech Eng 1994;116:10e8.
66. Carter DR, Wong M. The role of mechanical loading histories in
the development of diarthrodial joints. J Orthop Res 1988;6:
804e16.
67. Giorgi M, Carriero A, Shefelbine SJ, Nowlan NC. Mechanobio-
logical simulations of prenatal joint morphogenesis. J Biomech
2014;47:989e95.
68. Tsumura H, Kaku N, Ikeda S, Torisu T. A computer simulation
of rotational acetabular osteotomy for dysplastic hip joint:
does the optimal transposition of the acetabular fragment
exist? J Orthop Sci 2005;10:145e51.
69. Armiger RS, Armand M, Tallroth K, Lepisto € J, Simon C. Three-
dimensional mechanical evaluation of joint contact pressure in
12 periacetabular osteotomy patients with 10-year follow-up.
Acta Orthop 2009;80:155e61.
70. Rab GT. Lateral acetabular rotation improves anterior hip
subluxation. Clin Orthop Relat Res 2007;456:170e5.
71. Armiger RS, Armand M, Lepisto J, Minhas D, Tallroth K,
Mears SC, et al. Evaluation of a computerized measurement
technique for joint alignment before and during periacetabular
osteotomy. Comput Aided Surg 2007;12:215e24.
Please cite this article in press as: Vafaeian B, et al., Finite element analysis of mechanical behavior of human dysplastic hip joints: a systematic
review, Osteoarthritis and Cartilage (2016), http://dx.doi.org/10.1016/j.joca.2016.10.023
72. Niknafs N, Murphy RJ, Armiger RS, Lepisto € J, Armand M.
Biomechanical factors in planning of periacetabular osteot-
omy. Front Bioeng Biotechnol 2013;1:1e10.
73. Lepisto€ J, Armand M, Armiger RS. Periacetabular osteotomy in
adult hip dysplasia e developing a computer aided real-time
biomechanical guiding system (BGS). Suom Ortoped Trauma-
tol 2008;31:186e90.
74. Murphy RJ, Armiger RS, Lepisto € J, Mears SC, Taylor RH,
Armand M. Development of a biomechanical guidance system
for periacetabular osteotomy. Int J Comput Assist Radiol Surg
2015;10:497e508.
75. Murphy RJ, Armiger RS, Lepisto € J, Armand M. Clinical evalua-
tion of a biomechanical guidance system for periacetabular
osteotomy. J Orthop Surg Res 2016:11e36.
76. Henak CR, Anderson AE, Weiss JA. Subject-specific analysis of
joint contact mechanics: application to the study of osteo-
arthritis and surgical planning. J Biomech Eng 2013;135:
21003.
77. Gannon AR, Nagel T, Bell AP, Avery NC, Kelly DJ. Postnatal
changes to the mechanical properties of articular cartilage are
driven by the evolution of its collagen network. Eur Cells
Mater 2015;29:105e23.
78. Assassi L, Magnenat-Thalmann N. Assessment of cartilage
contact pressure and loading in the hip joint during split
posture. Int J Comput Assist Radiol Surg 2016;11(5):745e56.
79. Windhagen H, Chincisan A, Choi HF, Thorey F. Soft-tissue
balance in short and straight stem total hip arthroplasty. Or-
thopedics 2015;38:S14e20.
80. Diederichs C, Heath A, Hareendranathan AR, Zonoobi D,
Kuntze G, Dulai S, et al. Cross-modality validation of acetabular
surface models using 3-D ultrasound versus magnetic reso-
nance imaging in normal and dysplastic infant hips. Ultra-
sound Med Biol 2016;42:2308e14.
81. Verbruggen SW, Loo JHW, Hayat TTA, Hajnal JV, Rutherford MA,
Phillips ATM, et al. Modeling the biomechanics of fetal move-
ments. Biomech Model Mechanobiol 2016;15(4):995e1004.