1. Biomechanics Vol. 16. No. 6, pp. 385-409. 1983 0021 -9290,83 13.

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Printed I Char Bnram Pergamon Press Ltd.

A SURVEY OF FINITE ELEMENT ANALYSIS IN

ORTHOPEDIC BIOMECHANICS: THE FIRST DECADE
R. HUISKES*
Laboratory for Experimental Orthopedics. University of Nijmegen. 6500 HB, The Netherlands

and

E. Y. S. CHAO
Orthopedic Biomechanics Lab. Mayo Clinic/Mayo Foundation, Rochester. MN. U.S.A.

Abstract-The finite element method (FEM), an advanced computer technique of structural stress analysis
developed in engineering mechanics, was introduced to orthopedic biomechanics in 1972 to evaluate stresses
in human bones. Since then, this method has been applied with increasing frequency for stress analyses of
bones and bone-prosthesis structures, fracture fixation devices and various kinds of tissues other than bone.
The aims of these investigations were to assess relationships between load carrying functions and
morphology of the tissues, and to optimize designs and fixation techniques of implants.
Although the amounts of significant findings and useful concepts generated by the FEM during the first
decade of its application in this field were limited, many publications have served to illustrate its capabilities
and limitations. The method is now well established as a tool for basic research and for design analysis in
orthopedic biomechanics, and the number of publications in which it is used is increasing rapidly. In the
meantime, following developments in engineering mechanics, the capabilities of the method are augmented
which, together with an increasing sophistication of computers, guaranties exciting possibilities for the
future.
However, the biological structures and the clinical problems concerned are complex. Scientific progress in
this area requires a sound understanding of engineering mechanics on the one hand, and a profound
appreciation of the complex reality on the other. These features were not always apparent in the FEM work
reported during the first ten years.
In the following survey,the developments of FEM applications in orthopedic biomechanics during the first
decade are discussed. Special problem areas are indicated and future trends anticipated.

INTRODUCTION ation of the FEM in orthopedic biomechanics, and its

In 1972, about fifteen years after the finite element
method (FEM) initiated a revolution in stress analyses
of structures in engineering mechanics, this new
method to analyze the mechanical behavior of skeletal
parts (Brekelmans et al., 1972) was first introduced in
the orthopedic literature. Traditionally, interest ex-
isted in orthopedics and orthopedic-related sciences
with respect to stresses and strains in loaded bones,
specifically concerning the relationship between archi-
tecture and load-bearing function (e.g. Wolff, 1870;
Koch, 1917). The mathematical tools available for
stress analyses in classic mechanics, however, were not
very suitable for the highly irregular structural pro-
perties of bones. Hence, the powerful FEM became the
logical choice to fill the gap, due to its unique capability
to evaluate stresses in structures of complex shape,
loading and material behavior. Nevertheless, this ini-
tial application of the FEM could have gone relatively
unnoticed, due to its rather academic nature in ortho-
pedic basic sciences, were it not for a rapidly growing
interest in artificial joint replacement and new methods
of fracture fixation, New questions and new methods
have created a stimulating environment for the utiliz-
_.
Receiced 4 May 1982; in rerisedfbrm I January 1983.
*Author to whom reprint requests should be addressed.
applications have grown exponentially in the last
decade. Finite element analysis is presently being used
to investigate the stress-related architecture of bone
and bone remodeling processes, to test and to optimize
artificial joint designs and fracture fixation devices, and
to study the mechanical behavior of tissues such as
articular cartilage and intervertebral discs.
This survey article is not aimed at educating the lay person
in the principles of the FEM. Nonetheless, a brief explanation
may be helpful to the uninformed reader. The method is
treated in-depth by Zienkiewicz (1977), among others, and a
general description of its principles, possibilities and limi-
tations in orthopedic biomechanics specifically was published
by Huiskes (1983).
When a structure is loaded, stresses are generated in its
materials. The distribution of these stresses, their magnitudes
and orientations throughout the structure, depend not only
on the loading configuration, but also on the geometry of the
structure and the properties of its materials. In addition, the
stresses are influenced by the interaction of the structure with
its environment (kinematic and dynamic boundary con-
ditions) and by physical conditions at boundaries between
different materials (interface conditions). In a (theoretical)
stress analysis the stress distribution is evaluated by using a
mathematical model. In such a model, that mimics the real
structure to a certain degree of refinement, the structural
aspects (loading, geometry, material properties, boundary
and interface conditions) are described mathematically. The
mathematical descriptions can be more or less accurate,
depending on the level of refinement required, and are usually

385
386 R. HUISKESand E. Y. S. CHAO

based on experimentally determined data. In the solution dious, expensive and prone to error. Although these
procedure, the structural descriptions are combined in mathe- limitations are gradually improving through bio-
matical equations based on theories of solid mechanics and
these are solved to give the stresses.
mechanics research and computer software and hard-
Various theories and solution methods are available in ware advances respectively, the time and efforts this
classic mechanics for certain classes of structures. The FEM, would require were not fully appreciated during the
as a (theoretical) computer method of structural stress early stages.
analysis, however, is suitable in principle for any structure. In all fairness, however, it must be said that the
Geometries, material properties and loading of arbitrary
complexity can be accounted for. greater part of the efforts in this first decade of the
In using the method, the model as a geometric entity is FEM in orthopedic biomechanics were method-
defined first. This model is then (mathematically) divided into oriented rather than problem-oriented, and the work
a number of blocks (elements), connected at specific (e.g. must be judged in this light. Progress was made
corner) locations, called nodal points or nodes. The boundary
towards closer and more precise definitions of prob-
conditions and loading configurations are numerically de-
fined as displacements and forces, respectively, in boundary lems, and a more balanced multidisciplinary approach
nodes. Every element is assigned one or more parameters (e.g. to their solutions. Although many analyses have not
moduli of elasticity) that define its material (stiffness) be- led to solutions of realistic problems directly, they have
havior. The computer program calculates the stiffness charac- served indirectly in demonstrating advances in meth-
teristics of each element and assembles the element mesh
through mutual forces and displacements in each node. In
odology to the biomechanics field and in guiding
fact, the FEM program solves a large number of equations experimental biomechanics research as, for instance, in
that govern force equilibrium at element nodes. The com- the areas of materials testing and functional force
puter time needed (and thus the costs of the analysis) depends evaluation.
progressively on the number of elements applied, and on the
From an engineering mechanics point of view, the
element type.
The solution obtained with this method is approximate in present analyses in biomechanics may still be consid-
the sense that it converges to the exact solution for the model ered simple and straightforward. Although realistic
when the mesh density approximates infinity. Thus, the 3-D geometry has been modeled and used to a limited
accuracy of an FEM model can be checked by refining the extent, numerical (mesh) refinement was often poor in
mesh and comparing the results obtained with the refined
these studies. Nonlinear and anisotropic properties
mesh to the original one, which is called a convergency test.
In interpreting the FEM results we must differentiate were incorporated into some recent models, and they
between the validity of the model, the precision by which the have helped to demonstrate the capabilities of the
entity of mathematical descriptions of structural aspects FEM. Nonlinear interface conditions have been intro-
(loading, geometry, material properties, boundary and inter- duced lately in composite structures. These advances
face conditions) mimics the real structure, and the accuracy of
the model, the precision by which the FEM mesh can have no doubt helped to lay important groundwork
approximate the exact solution for the mode). Only the for future developments.
accuracy can be checked with a convergency test, the validity
must be assessed by experimental verification or other means.
A variety of element types are usually available for three-
dimensional (3-D) and two-dimensional (2-D) structures in
an FEM computer package (Fig. I), different in their number
of nodal points and their shapes. The computer time required
for 3-D elements is many times higher as compared to 2-D
elements. Because of cost efficiency, mesh accuracy is easier
obtained in a 2-D model.
FEM programs are usually applied in combination with
pre-processors and post-processors, computer programs that
handle the element division (mesh) and the graphical rep-
resentation of the results, respectively.
In its initial years of introduction to the orthopedic
biomechanics field, the FEM was sometimes regarded
as a magic tool to solve all problems. Few scientists in
the field were specialised in its use or aware of its
capabilities and limitations. Suspicion became evident
when a number of optimistic users appeared to rely on
it as a tool to generate solutions without carefully
formulating the problem. The complexity of biological
structures was often underestimated. In particular,
Fig. 1. A few examples of element types, (a) 20-node iso-
little was known about joint and muscle loading, and
parametric hexahedron, a 3-D element with curved sides and
the rheologic properties of bone and connective quadratic displacement field; (b) 6-node axisymmetric ring
tissues, let alone their stress failure mechanisms and element with quadratic displacement field in a plane section;
biologic reactions to stress. The practical potential of (c) 6-node and (d) 3-node triangles for 2-D analyses, with
the FEM for modeling complex structures adequately quadratic and linear displacement field, respectively; (e) 4-
node quadrilaterial with linear displacement field. Quadratic
was often overestimated. Suited in principle for struc- elements allow linear stress distributions within an element,
tures of arbitrary complexity, its application to three- linear elements allow constant stress only (reproduced from
dimensional and/or nonlinear structures is still te- Huiskes, 1983).
 The first decade of finite element analysis in orthopaedic biomechanics
The following review of the current literature in-
cludes 104 references to FEM applications in ortho-
pedic biomechanics research that appeared from 1972
to 1982 in archive journals, books and conference
proceedings. The list is by no means exhaustive. Many
authors have published their work in more than one
medium and in that case priority was given to the full
articles in journals or books, whereas the abstracts
were not mentioned. Reports and dissertations are
included only occasionally, when no other publication
of the work concerned could be found. Although a few
articles might have escaped our attention, an attempt
was made to fairly represent the contributions to this
field by the various institutions and individuals
concerned.
The aim of this survey is to record an inventory of
FEM applications in orthopedic biomechanics during
its first decade, and place its progress in a historical
perspective. Although this approach, in view of the
total numbers and the limited space, prohibits an
extensive treatment of each publication individually, a
few are discussed at length, while a general discussion
of quality and problem areas is included in the last part
of the article.
STRESS ANALYSES OF BONES
FEM analyses are based on theories of continuum
mechanics. The continuum materials involved in the
analyses of bones are cortical (or compact) bone, and
trabecular (or spongeous) bone. No material is con-
tinuous to any level, but trabecular bone is even
noncontinuous on a macroscopic level; hence, it is a
structure rather than a material. It is not clear at the
moment how this affects the results of the stress
analyses, but work with respect to this question is in
progress. In quasi-static loading (and probably in uiuo
loading) both cortical and trabecular bone, although
anisotropic and nonhomogeneous, behave linear elas-
tic by approximation. Their elastic properties depend
on such factors as age, species and mineral content;
hence, variability between subjects can be high. It must
be appreciated that bone is a biological tissue. Its
structure at any moment represents an equilibrium
between continuous processes of resorption and for-
mation, which may be affected by outside stimuli of a
chemical, mechanical and electrical nature. There are
many indications that bone architecture is influenced
by stresses or strains, a relation expressed in Wolffs
Law (Wolff, 1870; Koch, 1917), which is actually a
hypothesis (Hayes et al., 1982). Excellent reviews on
the biomechanics of bone were edited by Cowin (198 1).
Diaphyses, cortical shafts of the long bones, have
irregular beam-like geometries. The metaphyseal and
epiphyseal ends, consisting principally of trabecular
bone, are even less regular in shape. Bone loading (due
to muscle and gravitational forces) is dynamic and
relatively little is known regarding its real charac-
teristics and magnitudes (e.g. Chao and An, 1982a).
387
The femur (thigh bone) is the bone most frequently
analyzed due to historical developments (e.g. Wolff,
1870; Koch, 1917) and its common involvement in
orthopedic treatments, such as prosthetic replacement
of the hip joint. The early FEM was adopted for stress
analysis of the femur by Brekelmans ef ~1. (1972,
Fig. 2a) and Rybicki el al. (1972). As most of the early
efforts, their analyses were not so much directed at a
specific probtem, but aimed at demonstrating the
possibilities of the FEM. Both applied 2-D plane-stress
elements of uniform thickness, although Rybicki et al.
(1972) analyzing the proximal (upper) part of the bone
only, accounted for non-uniform thickness by varying
the Youngs moduli of the elements. Results were
compared with those of a 2-D beam model analysis,
yielding good agreement in the diaphyseal part only. A
comparable model was used by Wood et al. (1973).
who applied 2-D elements of variable thickness.
Early 3-D FEM models of the femur were those of
Scholten (1975) and Olofsson (1976), followed by
others (Valliappan et al., 1977; Harris et al., 1978:
Rohlmann et a[., 1982). The problems associated with
data manipulation, interpretation and representation,
frequently more demanding in 3-D FEM analysis,
were clearly demonstrated in these publications. Some
models contained a high degree of sophistication (e.g.
Fig. 2b), including realistic non-homogeneity of trabe-
cular bone based on experimental data (Scholten, 1975;
Rohlmann et al., 1982). These articles were, in fact, all
method-oriented, focusing on the application of the
FEM itself, with little emphasis on problem-oriented
solutions within a specific investigation. All in some
way compared results of different approaches such as
beam, 2-D. 3-D, or experimental analysis techniques.
The data generated for the shaft of the femur com-
pared favorably among different mathematical
models. Deviations were more extensive, however, in
the proximal region.
The early 3-D model by Scholten (1975) is a refined
one, even according to present standards, with prob-
ably the highest mesh density to date (approximately
10,000 degrees of freedom). The models presented by
Valliappan et uI. (1977) are rather rough in com-
parison, but consist of higher order elements. Only
these authors report an extensive convergency test to
check the adequacy of the mesh. Few authors have
correlated theoretical and experimental results in
detail. Valliappan el al. (1977) roughly compared FEM
results with those of stress-coat experiments, revealing
good agreement in a relative sense but poor in an
absolute sense. The same conclusion was reached by
Rohlmann ef al. (1982), based on a comparison
between 3-D FEM and strain-gauge experimental
results from paired femoral bones. It was shown by
Huiskes ef al. (1981a), through detailed experimental
and theoretical analyses on bilateral bones, that the
femoral shaft can be modeled rather refined when the
cortical bone is assumed to be transversely isotropic,
although local inhomogeneities produce deviations to
a certain degree in the experiment.
388 R. HUISKESand E. Y. S. CHAO

Fig. 2. Element meshesof the human femur; (a) 2-D mesh of 936 triangular 3-node elements (537 nodes), one
of the first applications of the FEM in orthopedic biomechanics (reproduced from Brekelmans et al., 1972);
(b) 3-D mesh of 1950 I-node isoparametric hexahedron elements (2532 nodes), shown from different sides
(reproduced from Rohlmann et al., 1982).

A 2-D FEM model of the femoral head alone was
developed by Brown and Ferguson (1978).
Nonhomogeneous elastic properties of trabecular bone
based on experimental data were included in this study,
that was initially aimed at investigating the influences of
trabecular bone nonhomogeneity and of geometrical
varus-valgus alterations on the stress distribution.
This model was later extended to the proximal femur;
anisotropy was included (giving minor changes in the
stress fields only) and the mechanics of the femoral
head in the presence of avascular necrosis (a local
degeneration of the trabecular bone) were studied
(Brown et al., 1980). This is a good example of a more
problem-oriented approach in which the FEM can
play a significant role whereas the models used need
not be very complicated. A comparable model was
used to investigate the stress alterations related to
growth in the normal juvenile (Brown et al., 1982a). A
recent 2-D FEM model of the proximal femur de-
veloped by this group to study the collapse phenom-
enon of trabecular bone in aseptic necrosis includes
(assumed) nonlinear elasto-plastic material behavior
(Brown et al., 1982b). The validity of this model has
been addressed only qualitatively with respect to
scattered clinical findings. However, the use of non-
linear FEM techniques is still rare in this field,
although many problems would lend themselves to
this approach. Hence, developments of this kind are
encouraging.
Other examples of problem-oriented studies, em-
ploying relatively simple FEM models, are those
pertaining to bone growth and remodeling. Hayes et al.
(1979, 1982), in an ongoing study, have attempted to
correlate the trabecular bone architecture of the
human patella and its stress distribution for the
quantification of Wolffs hypothesis (Fig. 3). Using a
2-D FEM model they found that high Von Mises
effective stress correlates with regions of high trabe-
cular density, and they re-established that the trabe-
cular structure aligns itself with principal stress orien-
tations. They also demonstrated that anisotropy of
trabecular bone hardly affects the stress distribution if
its nonhomogeneity is correctly accounted for. In this
investigation (as in all models previously discussed)
trabecular bone is still regarded as a continuum
material. Stresses in the trabeculae of the bone struc-
ture itself were studied with the FEM by Pugh et al.
(1973), using simple plate elements. The aim of this
Fig. 3. An FEM analysis to study stress-morphology relationships in trabecular bone; (a) trabecular bone
architecture in a midsection of a human patella is quantitatively described and compared with results of FEM
stress predictions. (b) 2-D FEM model, including boundary conditions; mesh of 16 8-node isoparametric
quadrilateral elements (reproduced from Hayes et al., 1982).

Fig. 8. Experimental evaluation of strain data on the outside femur; 112 rosette strain-gauges are glued to the
bone, which is loaded in different ways. The tests are repeated with several kinds of hip prostheses. Although
such an experiment provides adequate data to evaluate the overall mechanical behavior of the intact femur,
the strains on the surface are rather unsensitive to structural details of a prosthetic design and the way in
which it is fixed in the bone. Hence, precise quantitative verification of FEM results is difficult (reproduced
from Huiskes et al., 1981a).

389
 The first decade of finite element analysis in orthopaedic biomechanics
analysis was to correlate local bone loading with
trabecular failure. A similar but more sophisticated
2-D FEM model was later proposed by Williams and
Lewis (1982), to predict the elastic constants of trabe-
cular bone as a continuum material from the non-
continuous trabecular structure and properties. The
theoretical results were verified by experimental data.
Stress-related remodeling of bone was investigated
by Hassler et at. (1980), who evaluated stress predic-
tions in a piece of rabbit skull, loaded locally by an
apparatus in an in uiuo experiment, applying 2-D and
3-D models. The stress distribution was evaluated at
particular time intervals and compared to histological
findings. A quantitative stress window for bone forma-
tion was proposed, based on the rest@.
A number of FEM stress analyses of bones have
been designed for problems of fracture and fracture
fixation (including problems of bone remodeling),
which will be discussed in the next section. Whole
bones other than the femur were investigated as well,
but to a lesser magnitude and frequency. The patella
was mentioned already. Using a 2-D FEM model and
an iterative algorithm the unbonded elastic contact
problem between femur and tibia in the knee joint was
analyzed by Chand et al. (1976). Results correlated
favorably with those of 2-D and 3-D photoelastic
analyses; the article was aimed specifically at de-
monstrating the technique. A simpler 2-D model of
both the tibia-femoral and the femur-patellar complex
was reported by Valenta et al. (198 1). In this study the
contact areas were presumed. Hayes et al. (1978a)
presented an axisymmetric FEM analysis (non-
axisymmetric loading) of the upper tibia. The ring
elements used in analyses of this kind are special in the
sense that the loads and displacement fields are
represented by Fourier series in the circumferential
direction. The solution is, in that case, a linear
combination of the solutions for each separate Fourier
term. Thus, the 3-D result is obtained by superimpos-
ing the results of a number of quasi 2-D calculations. If
a structure can be modeled as axisymmetric where its
geometry and material properties are concerned, the
application of this procedure saves computer time,
while the resulting stress distribution is truly three-
dimensional (Zienkiewicz, 1977). This analysis by
Hayes et al. (1978a) was effective in demonstrating the
load transmission mechanism in the upper tibia and
how it relates to the bone structure, qualitatively
speaking.
A 3-D FEM model of the lower femur and the upper
tibia was reported by Roehrle et al. (1980), but very
little information was provided. The whole tibia has
not been modeled with the FEM; however, Piziali et al.
(1976) used the FEM to solve Saint Venants warping
function for torsion in a cross-section of this bone. The
same method was reported by Huiskes et al. (198ta),
Carter et al. (1981) and Adamovich and Jansons (1981).
A 3-D FEM analysis of the pelvis, a very
complex structure in geometry and material non-
homogeneity, was reported by Goel et al. (1978).
391
FRACTURE FIXATION OF BONES
Traditionally, the interest in orthopedics regarding
the mechanisms of bone fractures has been rather
academic. Efforts in practice were focused more on
how to tix them to provide the best conditions for
fracture healing. However, because the use of fracture
fixation devices may weaken the bone through disuse
osteoporosis or bone resorption due to the application
of bone screws and pins, interest has been stimulated
recently to study fracture mechanisms for the purpose
of establishing preventive measures. As a result, the
bone weakening effects of various pathological con-
ditions, such as bone tumors, osteoporosis, fatigue
loading and surgically induced causes, can also be
better understood. Moreover, there have been sugges-
tions that bone-remodeling and bone-resorption
phenomena may be initiated by micro-fractures, which
would be of importance in implant design and fixation.
Obviously, research into bone-failure mechanisms is
becoming more important, since it governs a wide
domain of orthopedic problems. Naturally, the FEM
can serve as a logical tool to predict high-stressed
regions, as in analyses discussed in the previous
section. Fracture mechanics of bone have not been
studied with the FEM, although considerable ad-
vances in this area were reported for other materials in
engineering mechanics. An FEM simulation of a bone
fracture test was carried out by Vichnin et al. (1977).
Fracture fixation devices (internal and external) are
applied in enormous volumes in orthopedic and
general surgery. Their mechanical characteristics are
important due to strength requirements and the in-
fluence of their fixation rigidity on the fracture healing
process. Use of the FEM in an analysis of a bone-
fracture plate complex was first reported by Rybicki ef
al. (1974), although very little information was pro-
vided at that time. In a subsequent analysis (Rybicki
and Simonen, 1977) a 2-D FEM model of an oblique
fracture stabilized with bone plates was presented.
Stresses at the fracture site were evaluated for varying
circumstances, such as pretension in the plate, bone
screw orientation and bone loading.
An extensive comparison of beam, 2-D and 3-D
FEM model results, and experimental findings with
respect to the plated bone, was performed by Simon et
al. (1977). Although more detailed information was
obtained from the 3-D model at specific locations, all
three models gave comparable results in an overall
sense; thus, all models were useful, depending on the
information required. This is a good example of a
general rule. which states that the validity of a model
must be judged in the light of the analysis objectives.
The FEM beam model in this study was used sub-
sequently by Woo el al. (1977) to study bone remod-
eling, comparing FEM results to remodeling findings
in animal experiments. Further FEM studies of bone-
plated fractures were carried out by Levine and
Stoneking (1980) and Claes et al. (1982) applying 3-D
models, and by Carter et al. (1981). The latter studied
392 R. HIJISKESand E. Y. S. CHAO

bone remodeling in particular, by comparing stress
fields with in oivo bone resorption phenomena. The
FEM was applied for local cross-sections, to evaluate
shear-stresses in torsional loading.
Next to internal fixation devices, external fixation
was analyzed as well. Using 3-D FEM beam-elements
Chao and An (1982b) evaluated frame rigidity in several
configurations out of different materials, in combi-
nation with experimental analyses (Fig. 4). The sites at
which the pins of these frames are connected to bone
are usually heavily stressed, making the bone liable to
pressure necrosis. The stresses in these locations were
evaluated in local models, using 3-D (Chao and
Malluege, 1981) and axisymmetric elements (Crippen
el al., 1981), as illustrated in Fig. 5.
Fracture fixation by nailing has received some
attention where FEM analysis is concerned. A 3-D
nonlinear FEM model to study this procedure for
trochanteric femoral fractures has been announced by
Ghassemi er al. (1981). Previously, a numerically rather
refined but linear 2-D FEM model was applied with
comparable objectives by Valenta er al. (1976). In view
of the large variety in fracture types and surgical
procedures in patients, it is questionable whether an
anatomic (geometrically refined) 3-D model is really
helpful in analyzing these structures, specifically when
nonlinear effects are taken into account. To aim for
general information on a relative basis would seem
more realistic in this case.
ably lower than the number of fracture fixation devices
used, the mechanical problems involved in joint im-
plants are more demanding due to the long life ex-
pectancy and the severe loading conditions imposed
within the body. Progress is directed towards extend-
ing the functional life of these implants by reducing
mechanical failures. In these efforts, mechanical opti-
mization plays a key role. Mechanical failure mechan-
isms include plastic deformation and (fatigue) fracture
of metal and plastic components, breakdown of the
acrylic cement (polymethylmethacrylate, a filling ma-
terial to fixate the prosthesis to the bone), loosening at
the boundaries between different materials (interfaces),
and stress-related bone resorption.
Apart from the problems in assuming bone to be a
continuum material, as discussed previously, special
difficulties in modeling techniques are involved due to
the composite nature of the system. The 3-D geomet-
rical characteristics of each structural component have
to be dealt with, while the physical conditions at the
material interfaces are difficult, if not impossible, to
delineate. In prosthetic joint systems, there are usually
large dimensional differences among the composites.
Cement layers can be rather thin as compared to
prostheses and bone, thereby requiring a relatively
small element size (in view of the aspect ratio) and
increasing the degrees-of-freedom for the entire
system. Additional problems involve the unknown
loading and boundary conditions, the wide variation

ARTIFICIAL JOINT DESIGN AND FIXATION

Artificial joint design and fixation is probably the

most popular application of the FEM in orthopedic 19

biomechanics. It is estimated that a total volume of l2r 22 20 l23

31 7 32
more than 400,000 prosthetic joint implantations are
'ir 17 18
performed annually. Although this number is prob- '19 "a0
29 6 30
15 16
'I5 .I6 A"I7

27 5 28

.I4
11 33:
'I3
(12
25 26
4

Fig. 4. Stress and rigidity analyses of external fixation devices (a) for bone fractures; (b) FEM beam model of
a complete frame configuration, applied to a fractured bone, loaded in compression; division into 32 beam-
elements and one gap element (no. 33) to simulate the fracture (reproduced from Chao and An, 1982b).
 The first decade of finite element analysis in orthopaedic biomechanics 393

LOAD

(4 (4

Fig. 5. (a) Geometrical delineation of a 3-D FEM model of the local pinbone connection in external fixation
devices to study pin and bone stresses in relation to failure and bone necrosis (reproduced from Chao and
Malluege, 1981).(b) Axisymmetric FEM model of the pin-bone connection region (reproduced from Crippen
et al., 1981). The external loads for both models are obtained from the complete frame models (Fig. 4). The
3-D FEM model is used as a reference base for the axisymmetric model, which is better suited for extensive
parametric analysis.

among the patient population due to specific patho-
logies, and the variety of surgical procedures
performed.
The earliest and most common finite element analy-
ses reported in this area concern the femoral com-
ponent of total hip replacement (THR) which, in
general, consists of a spherical head connected to a
straight or curved stem fixed within the medullary
canal of the proximal femur, using acrylic cement as a
filler (Fig. 6a). Three-dimensional, 2-D and beam
analyses of this structure have been widely published.
When modeling this structure in two dimensions, only
three options are available (Fig. 6). Considering the
structure as it appears in a frontal section results in a
sandwich model, with no connection between the
lateral and the medial bone slabs (Fig. 6b). Applying
composite materials theory to calculate an apparent
Youngs modulus for the plane element by taking the
out-of-plane material into account (Fig. 6c) does not
improve the model in this respect. In addition, it
increases the cement-layer stiffness and decreases the
stem rigidity in the model. Thus, the overall rigidity of
the structure is represented adequately, but not the
rigidity ratios between the separate parts of the
composite structure. How this affects the results is
uncertain. Probably the best method to restore the 3-D
integrity of the bone in 2-D models is by using a layer
ofspanningelements or side plateelements (Fig. 6d).
Another way of accounting for the 3-D structural
integrity of the composite in simplified models is to
assume axisymmetric geometry. By using Fourier
analysis, 3-D loading and stress-state can be in-
corporated adequately in that case, as discussed pre-
viously (Fig. 6e).
Two-dimensional FEM models of the first kind (all
considering the femoral hip prosthetic component)
were analyzed by Andriacchi et al. (1976), Kwak et al.
(1979), Yettram and Wright (1979, 1980), Cook et al.
(1980), Sih et al. (1981) and Skinner et al. (1982).
Composite materials theory, the second kind, was
applied earlier in 2-D models by McNeice et al. (1976),
whereas others used the side-plate or spanning
element method (Hampton et al., 1976, 1981;
Svensson et al., 1977). Varying degrees of mesh refine-
ment were used, different prosthetic designs simulated,
several questions addressed. Influences of varus-valgus
placement, acrylic cement layer thickness, stem shape
and material were investigated principally. Due to the
variety in geometry and loading in particulac, the
results of these analyses can hardly, if at all, be
compared in a quantitative sense.
Axisymmetric geometry, applying 3-D elements, was
assumed by Bartel and Ulsoy (1975) and Bartel (,1977)
and by Huiskes et al. (1978). The latter also applied
axisymmetric ring elements (3-D loading and stress
state), FEM beam elements, 2-D plane-strain elements,
beam-on-elastic-foundation theory, and strain-gauge
analysis to compare modeling options and to obtain a
394 R. HUISKESand E. Y. S. CHAO

(4

- lateral; medial -

(4

Fig. 6. (a) Sectional, schematicview of a (Charnley type.) Total Hip Replacement In a 2-D FEM analysis the
femoral side can be modeled (b) as a sandwich construction, not taking the 3-D structural integrity of the
bone into account, (c) by using composite materials theory, calculating the plane element stiffness from the
3-D configuration; in fact again a sandwich construction with more realistic overall rigidity, and
(d) by accounting for the bone structural integrity through the use of side plates or a spanning element
layer. Another possibility of modeling this structure without the application of 3-D elements is by assuming
axisymmetry (e).

more generalized description of the intramedullary fix-
ation structure (Huiskes, 1979a; Huiskes et al., 1981a).
Anatomic models, applying the 3-D FEM with
varying degrees of refinement (e.g. Fig. 7) have been
investigated by Roehrle et al. (1977), Scholten et al.
(1978), Valhappan et al. (1980), Hampton er 01. (1980),
Crowninshield et al. (198Oa, 1980b, 1981), Lewis et al.
(1981), Tarr et al. (1982) and Vichnin and Batterman
(1982). Comparing the results obtained again is dif-
ficult, due to vast differences in mesh density,
geometry, material properties and loading.
Convergency tests were not reported in these 3-D
studies. Crownninshield et al. (1980a) tested con-
vergency with respect to deflection in a composite
cantilever beam, similar in principle to the hip stem
fixation. This does not guarantee local stress accuracy
in the real model, of course, but at least gives some
confidence in the overal model characteristics. A few
authors justify their mesh density by referring to the
total number of elements used, which guarantees
nothing at all. Experimental verification to some extent
was reported by several authors, applying stress-
coating and strain-gauge techniques. However, meas-
urements were usually taken at the outside bone
surface, where stresses are rather insensitive to design
details when compared to those in inner bone, acrylic
cement and at interfaces (Fig. 8).
In the majority of these FEM analyses, linear
elasticity, isotropy and homogeneity of cortical and
trabecular bone were assumed, whereas interfaces were
modeled as rigidly bonded. Realistic nonhomogeneity
of trabecular bone, based on experimental data, was
taken into account by Roehrle et al. (1977) and
Scholten et al. (1978). The effects of anisotropy in
cortical bone were investigated by Valliappan et al.
(1980) and Vichnin and Batterman (1982).
The (nonlinear) effects of cement-metal interface
loosening were studied by Svensson et al. (1977),
Huiskes and Schouten (198Oa) and Hampton et al.
(1981), in the latter case based on realistic (experimen-
tally determined) cement-metal bond failure charac-
teristics. It became evident from these 2-D analyses (all
three including side plates or spanningelements) that
slip and tensile loosening at the material connection
has a highly significant effect on cement and interface
stresses, whereas those in the stem and the boneare less
seriously affected.
An informative study was performed by Rohlmann
et al. (1980) to evaluate the accuracy of a 3-D FEM
model, as compared to experimental strain-gauge
measurements on a (physical) laboratory model, re-
lated to a femoral THR structure (Fig. 9). A prosthesis
was fixed with acrylic cement in a metal tube. This
experimental model was investigated with the 3-D
FEM, using a mesh of moderate refinement (232
hexahedron elements (&node?), half-structure) when
 The first decade of finite element analysis in orthopaedic biomechamcs 39s

F[g. 7. Element meshes for 3-D analyses (a evaluate the mechan& performance of direrent types of
femoral THR components on a relative basis. A typical mesh has 531 tetrahedral, quadratic elements; beam
elements are used as well, as shown in the right model. Stress patterns are also compared with those in the
natural femur (reproduced from Roehrle et al.. 1977).

compared to other analyses published in this area
(Fig. 9a). Although the trends established were more or
less equal in both cases where the most significant
stresses on the medial side of the tube were concerned,
they found considerable differences (up to 1bO~~,,)
between the experimental and theoretical stress results
at certain locations (Fig. 9b), specifically the lateral
side of the tube which simulates the bone. They
attribute these deviations mainly to interface loosen-
ing, occuring in the expertmental model and not
396 R. HUSKES and E. Y. S. CHAO

F - 20 kN

(4

Fig. 9. A 3-D FEM analysis of a physical (laboratory) model, simulating a femoral THR fixation structure;
the prosthesis is fixed in a metal tube, using acrylic cement. (a) Element mesh (232 hexahedron elements,
probably linear); for reasons of symmetry, only half of the structure is modeled; (b)comparison of
longitudinal strains on the tube as calculated in the FEM model (dashed curve) and as measured with strain-
gauges (solid columns); (c) stresses normal to the stem-cement interfaces as calculated in the FEM model for
the stem material (dashed curve) and for the acrylic cement material (dotted curve). In view of equilibrium
requirements these stresses must be continuous over the interface, hence equal on both sides. Because the
cement is softer, the stresses obtained in this material are the more dependable of the two. Interface continuity
is often difficult to reproduce in FEM models when the materials differ significantly in stiffness properties.
The discontinuities will improve by using higher order elements or by increasing the mesh density
(reproduced from Rohlmann et al., 1980).

simulated in the FEM model. In addition, they find
extremely poor continuity of normal interface stresses
in the FEM model which, according to the authors, is
caused by the coarseness of the element mesh (Fig. SC).
Such a check of normal (and shear) stress continuity at
material boundaries is rather informative for a judge-
ment of FEM mesh refinement, but was hardly ever
provided by other authors.
A comparable effort was carried out by Svensson et
al. (1980). Their experimental configuration was in
principle the same as described above, but strain
measurements were taken on the prosthesis in this
case. Their mesh density was somewhat less (167
elements), but their element more sophisticated (20-
node isoparametric hexahedrons). They compared
experimental stresses in the stem with those of theoret-
ical results, assuming bonded surfaces and later allow-
ing slip to occur at the cement-stem interface. In the
first case agreement was poor (up to 40% lower in the
FEM results), in the second case it was remarkably
good. It was found repeatedly by other authors,
however (as discussed previously), that stem stresses
are not very sensitive to interface loosening.
Particularly in analyses of this kind, which are aimed at
verifying the FEM modeling technique, convergency
tests would be most helpful to quantitatively assess the
accuracy of the mesh.
Anand et al. (1976) and Ducheyne et al. (1978)
studied the influences of bone ingrowth in porous
coatings of intramedullary fixated stems, using axisym-
metric FEM models in which the elastic moduli of the
coatings were adapted to account for the ingrown
material. Forte (1975), applying 2-D plane-strain ele-
ments, analyzed the femoral component stem only, not
taking into account its bone environment. Seidelmann
et al. (1982) investigated the head-stem connection in
prostheses with ceramic heads, using 2-D and axisym-
metric models. The biological environment is, in this
case, of no importance.
Stress analyses of the acetabular cup component in
 The first decade of finite element analysis in orthopaedic biomechanics 397

total hip replacement have become popular only
recently, probably due to the relatively late occurrence
of cup loosening and the complicated geometry of the
pelvis. Presently, however, it is envisioned by some that
the acetabular cup design has far more impact on long-
term survival of the THR structure than the femoral
component. A 2-D FEM model of this structure
was developed by Vasu et al. (1982) to de-
monstrate changes in the acetabular stress patterns
after joint replacement. Carter et al. (1982), using the
same model, studied effects of adding a metal encase-
ment (metal backing) over the plastic prosthetic
component and also evaluated the influences of acrylic
cement thickness. Metal backing was also investi-
gated by Pedersen et al. (1982) in an axisymmetric
FEM analysis taking 3-D loading and stress fields into
account. It is not certain whether these models can
adequately represent the essential 3-D structural stiff-
ness characteristics of the acetabulum; presumably the
axisymmetric model has more potential here than the
2-D model. Nonetheless, trends established with re-
spect to the relative advantages of the metal encase-
ment were agreeable in both studies. Three-
dimensional FEM models as reported by Oonishi
(1981) and by Goel et al. (1981) have better potential in
modeling the complicated acetabular geometry in
principle. However, local mesh refinement is notably
poor as yet in models of this kind, while their
complexity apparently prohibits an effective evalu-
ation of results.
A relatively new hip joint replacement, known as the
resurfacing prosthesis, contains a metal cup placed
over the femoral head to replace its articular surface.
The FEM was used to evaluate this procedure in a 2-D
model by Shybut et al. (1980) and in an axisymmetric
model (3-D loading and stress fields) by Huiskes and
Heck (1981b). The axisymmetric model (Fig. 10) better
represents the 3-D structural integrity of the metal cup;

Fig. 10. FEM analysis of the femoral component of a hip surfacereplacement. The structure (the head-neck
region) is assumed axisymmetric, but 3-D loading is taken into account. 646 6-node axisymmetric ring
element (quadratic displacement field) are used. To account for the 3-D stress state, loading, displacements
and stresses are expanded in Fourier series with respect to the &coordinate, one term of which is shown in the
inset; eieven Fourier terms are applied in total. Note the local mesh refinement in regions where high stress
gradients are expected, the cup-rim in particular (reproduced from Huiskes and Heck, 1981b).
398 R. HUISKES
and E. Y. S. CHAO
however, realistic inhomogeneity of trabecular bone
can only be included in the 2-D model. So, both models
are approximative in a different sense. Results cor-
respond in overall trends, but disagree in some details.
Whether this is caused by differences in cup geometry,
loading or model characteristics is as yet unresolved.
FEM analyses in artificial knee-joint design and
fixation became more frequent in the late seventies.
With some exceptions, all studies have dealt with the
tibia1 component fixation exclusively, which indeed is
the part giving the most problems in actual patients.
The tibia1 and femoral stem fixation of hinged pros-
theses were analyzed in 3-D models (Roehrle et al., 1980,
1982) and the tibia1 fixation alone in axisymmetric
models, taking 3-D loading into account (Campen et
al., 1979; Croon et al., 1982). The tibia1 plateau fixation
of non-hinged surface replacement prostheses was
investigated using 2-D models by Lewis (1977), Hayes
(1978b), Vichnin et al. (1979), and Askew and Lewis
(1981). Most of these studies were directed at the
function of the central post, used to fixate the plateau
in the tibia. Askew and Lewis (1981) performed an
extensive parametric analysis, including anisotropy
and nonhomogeneity of trabecular bone. It appears
that if the nonhomogeneity is taken into account
correctly, the effect of anisotropy is only minor, as was
also established by Hayes et al. (1982) for the intact
patella. Pissinou and Brook (1980) studied both the
femoral and the tibia1 knee component, addressing
mainly the contact stresses. An axisymmetric FEM
model of the tibia1 plateau fixation without central
post was reported by Shrivastava et al. (1980), whereas
axisymmetric geometry taking 3-D loading into ac-
count was studied by Murase et al. (1983). This last
study includes nonhomogeneous (but axisymmetric)
trabecular bone properties, while several loading cases
and plateau geometries were considered. An early 3-D
FEM model of the tibia1 component was reported by
Chao et al. (1977), later followed by Bartel et al. (1982)
and by Lewis et al. (1982). The last model (Fig. 11)
specifically is quite anatomical, including nonhomo-
Fig. 11. A 3-D FEM model of 768 I-node (linear) isoparametric hexahedron elements (1053 nodes in total)
to investigate the tibia1 plateau fixation of total knee replacements. The performance of several prosthetic
designs, shown in the figure, were evaluated (reproduced
geneous trabecular bone properties. Several loading
modes and tibia1 plateau geometries were investigated,
somewhat comparable to those in the study of
Murase et al. (1983). It is interesting to note
that, although both models are not truly comparable in
a quantitative sense, many of the trends established
agree, whereas some do not. Because both models are
approximative in a different sense (the axisymmetric
mode1 lacks geometric refinement in a global sense,
whereas the 3-D model is relatively rough in a local
sense), the question of which model is best cannot be
resolved at this point.
Convergency tests in the analyses of artificial knee-
joints were only reported by Murase et al. (1983).
Experimental verification (as far as feasible) was
conducted by Croon et al. (1982). Material connections
were always considered rigidly bonded. In a recent
study Hori et al. (1982) have investigated the effects of
a soft-tissue layer between the tibia1 implant and the
bone on the local stress distribution and fixation
strength, using a nonlinear FEM approach. Such a
soft-tissue line can often be seen to appear in postoper-
ative roentogenograms after some time. It was shown
to have a significant influence on interface shear
stresses in this study.
Analyses of prosthetic components other than in the
hip and knee joints have been rare. Joints that are also
replaced relatively frequently are those in the hand. An
axisymmetric FEM analysis (3-D loading) of a new
intramedullary fixation system for finger-joint pros-
theses was carried out by Huiskes et al. (1980b). Stress
results were compared in detail (but qualitatively) with
histological findings in animal experiments in a related
study, and some corresponding effects were found.
In revising failed total joint replacements with
extensive bone loss and for bone and joint reconstruc-
tion after tumor resection, the use of custom fit
prostheses is increasingly in demand. In the design and
selection of these devices, the FEM has been used by
Chao (1980) in an axisymmetric model to evaluate a
specific type of ceramic prosthesis based on extra-
from Lewis er al., 1982).
 The first decade of finite element analysis in orthopaedic biomechanics 399

cortical fixation, which has been applied in shoulder have been carried out by Huiskes and Chao (1983).
prostheses. In order to optimize stem designs for the Using the FEM results as a reference base, analytical
intramedullary fixation type of custom-fit implants, guidelines for rapid stem size evaluations were de-
axisymmetric FEM studies (3-D loading and stresses) veloped from closed-form theories (Fig. 12).

1,SHOULDER AREA

&NTERFACE

q PROSTHESIS

3 BONE

1 -no shoulder contact

1 ---shoulder contact

(b)

Fig. 12. (a)Axisymmetric FEM representation of a custom fit hip-prosthesis fixation structure. The
numerical results are used as a reference base for simple, analytical design guidelines, derived from beams-
on-elastic-foundation theory. (b) In using this theory, the most significant internal loads can be characterized
by simple formulas, depending on lumped structural parameters (E,. I,) and the external load (bending M, in
this case) (reproduced from Huiskes and Chao, 1983).
400 R. HUISKES and E. Y. S. CHAO
OTHER APPLICATIONS
Finite element analyses of the soft tissues in the
musculoskeletal system have been limited to articular
cartilage and the intervertebral discs in the spine. The
latter structure is usually modeled as consisting of
three separate regions: vertebral body/endplates, an-
nulus fibrosus and nucleus pulposus. An early axisym-
metric FEM analysis was reported by Belytschko et al.
(1974), featuring linear and isotropic elastic properties,
but later including nonlinear characteristics of the
annulus (Kulak et al., 1976). A 3-D, rather coarse, FEM
model was applied by Lin et al. (1978) to identify
material properties by comparing experimental to
theoretical results. Spilker (1980) published a para-
metric analysis in a simplified axisymmetric FEM
model, applying linear elastic and isotropic properties
to investigate the influences of geometry and material
characteristics. All these investigations used exper-
imentally determined disc compliances for reference
and verification purposes.
Articular cartilage is an important connective tissue
with its known mechanical functions of lubrication
and load bearing. Due to its complex composite
structure and bi-phasic properties, precise mechanical
analysis has been difficult to pursue. The FEM was
used to characterize the elastic response of its solid
phase by Roth and Mow (1977). A semi-analytic FEM
model was used to study its electromechanical pro-
perties based on contemporary mixture theory by
Swenson et al. (1979). Rybicki et al. (1979) analyzed the
squeeze film lubrication theory, assuming cartilage as a
nonporous compliant material with a bony foundation
covered by a layer of synovial fluid. It is not certain
whether this mechanism indeed plays a significant role
in cartilage lubrication. The relations between struc-
ture and mechanical function of articular cartilage are
gradually becoming better understood through pre-
sent experimental and analytical research (e.g. Mow
et al., 1982).
FEM analyses of soft tissues other than those
mentioned are quite common in related fields, as for
instance cardiovascular biomechanics (e.g. Gallagher
et al., 1982). Where the musculoskeletal system is
concerned, the FEM has been used to some extent in
the fields of crash biomechanics and product liability
for modeling the spine, skull and rib cage. In ortho-
pedic biomechanics, a final area of the application of
the FEM as a universal numerical tool to solve
differential field equations lies in problems of heat and
mass transfer. An example is the nonsteady heat
generation and conduction that occurs in and around
acrylic cement during its curing phase while fixing an
implant. The bone close to the cement rises in tempera-
ture and may be necrotized. FEM non-steady heat
conduction analyses to evaluate chances of bone
necrosis and to study preventive measures have been
carried out with respect to the intramedullary stem
fixation (Huiskes, 1979b; Swenson et al., 1981), the
acetabular THR component fixation (Huiskes, 1979b),
and pressurized cement fixation in the tibia1 com-
ponent of the knee joint (Huiskes and Slooff, 1981~).
An example is shown in Fig. 13.
DISCUSSION
There is no question that the FEM has established
itself as an important research tool in orthopedic
biomechanics. Many of the publications discussed
have opened new fields of investigation, and even
triggered a renewed interest in the basic sciences of
orthopedics. Nevertheless, a number of favorable
exceptions notwithstanding, the amounts of useful and
unchallenged concepts developed and significant data
obtained with the FEM to date are small when
compared to the total efforts. It is evident that,
particularly in the early years, most work has been of
an exploring kind. In the footsteps of FEM progress in
engineering mechanics, the method was applied in
orthopedic biomechanics often without a full appreci-
ation of the vagaries and uncertainties involved in the
complex biological structures.
A clear perception on the nature of a problem is a
prerequisite for any investigation, and it forms the
basis on which practical and realistic goals can be
established. During the modeling process, the basic
aims involved in the study must be weighed carefully in
lieu of the inevitable compromises necessary for the
application of the FEM. No model is valid to an
infinite detail, and its adequacy must primarily be
judged in the light of the objectives of the analysis.
If analyses are aimed at design testing, to evaluate
the mechanical performance of actual designs on a
relative basis as in the examples in Figs 7 and 11,
detailed modeling is often necessary. But quite
frequently a more schematic and general representa-
tion of a structure is required, in particular when the
analysis is aimed at investigating general concepts.
To appreciate these differences in objectives and,
consequently, in model requirements, one must realize
that in biomechanics the FEM is commonly used as a
research tool, rather than purely a method for quan-
tifying stresses, as in many engineering applications.
Rarely is an absolute solution either needed or possible
because of many unknown conditions inherent to the
biological system. The large variety in structural details
discounts the value of specific case analysis and favors
solutions for classes of structures. Under such circum-
stances a higher degree of abstraction in simplified and
general models is often necessary.
Whereas in a number of publications realistic ob-
jectives were discussed explicitly, and the models
applied were carefully tailored to fit the aims, in many
others the relation between purpose and model charac-
teristics is unclear. Doubtful modeling assumptions
have sometimes been introduced and poor numerical
accuracy (mesh density) accepted for the sake of
progress towards 3-D, anatomical models, where
such a degree of geometrical specificity is not needed,
or not even advantageous. As a consequence, import-
 The first decade of finite element analysis in orthopaedic biomechanics 401

(4 (b)

time
CCIIC so (4

Fig. 13. Axisymmetric FEM model (b) simulating an acetabular cup fixation (a) with acrylic cement to
evaluate transient temperatures during and after cement curing. The elements used are 3-node triangies with
linear temperature distribution; the time domain is discretized using a backward difference method. (c) An
example of results, temperatures as function of time in several points of the structure (reproduced from
Huiskes, 1979b).

ant mechanisms often remained hidden in the geomet-
ric complexity of the models, whereas sometimes the
significance of the conclusions reached hardly justified
the efforts.
A problem that has received far too little attention in
this field is that of model validity. The degree of
numerical empiricism displayed in some of the publi-
cations is disturbing. Results of FEM analyses are
often presented at their face value, with very little
correlation to physical observation of the system and
the underlying mechanisms that can affect the per-
formance of the models as a whole. These factors are
the more important where the models are more
complex. The audience is often impressed by an
anatomic mesh configuration, but unfortunately it is
commonly forgotten that a visual agreement between
FEM model and reality does not guarantee the validity
of the results produced by that model.
Again, the validity of a mode1 must be regarded in
the light of the analysis objectives, and the question is
always whether the results, given the mode1 assump-
tions, justify the conclusions reached. The results of
simplified, general models should be stated in qualitat-
ive terms, and in this case the question of validity too, is
of a qualitative nature. Whereas detailed models of
specific structures have more capabilities for quantitat-
ive validity, it is doubtful at this point in time whether
this potential can be made fully operational, in view of
the many uncertain aspects of the biological materials.
Although most authors do agree that in view of all the
simplifying assumptions only the trend of the results
produced by their model is important, absolute num-
bers are often presented, discussed and passed on. As a
consequence, misinterpretation of the data has
frequently occurred, particularly among lay persons.
The validity of a model can be addressed in several
402 R. HUISKESand E. Y. S. CHAO
ways. Very little attention has been devoted to exper-
imental verification in this area, and where it was, the
experiments were not always satisfactory. The prob-
lems, of course, are difficult. For example in the area of
hip-joint prosthesis analysis (Fig. 8) strains can be
measured at the outside surface of the bone and
transformed to stresses. However, these stresses are, on
the one hand, rather insensitive to the prosthetic stem
design and, on the other hand, these stresses are usually
not of real interest. The analyses are usually aimed at
the much more sensitive stresses in the acrylic cement
layer, the endosteal bone, and the interfaces. Hence,
agreement in outside bone stresses is no guarantee at
all for the validity of a model where it concerns the
more significant results in other locations.
Other ways possible to address questions of model
validity include in-depth investigations of the structure
by parametric analysis. Without in-depth analysis, no
fundamental understanding can be derived and no
general concepts can be established with respect to the
mechanical behavior of the model in question.
Consequently, the influences of the parameters on its
functional performance are often difficult to define
quantitatively. Individual assumptions as for instance
bone homogeneity and isotropy, interface bonding,
were assessed as to their effects by refining the model in
these respects (e.g. Hayes et al., 1982; Brown and
Ferguson, 1978; Valliappan et al., 1980; Vichnin and
Batterman, 1982; Hampton et al., 1981; and Askew and
Lewis, 1981). Other modeling aspects can be evaluated
in the same way, by changing the descriptions of
loading, material properties and boundary conditions
and repeating the calculations. These parametric
analyses need not necessarily be carried out with
expensive, anatomic models, but can often be limited
to simplified, general representations (e.g. Huiskes.
1979a).
Although a number of authors have addressed
problems of model validity, particularly in recent
years, more work in this direction needs to be done
before a complete understanding and assessment of
the several models reported can be obtained.
The accuracy of FEM models is, in principle, less
difficult to assess. The question is here how well the
chosen element types and meshes can approximate the
exact solution for the structure, under the assumed
simplified conditions. The most important factor is the
element mesh density, in relation to the element type
chosen. The mesh density can be assessed objectively
for each individual model by convergency tests (repeat-
ing the calculations for increased mesh refinement and
checking the convergence of the stress results). These
tests can, for 3-D structures specifically, be very
expensive and time-consuming, and very few have
been reported in this field. A 2-D element mesh can be
intuitively evaluated relatively easily by FEM special-
ists, provided the element characteristics are given
(element displacement field and/or nodal points per
element), which is not always the case. Specific signs to
judge are mesh density, particularly in the neighbor-
hood of material discontinuities and in other regions
of high stress gradients, and distorted elements (un-
favorable aspect ratios). Boundary conditions too, are
of importance.
For axisymmetric finite element meshes the same
applies. If 3-D loading and stress state is incorporated
in an axisymmetric analysis, then the number of
Fourier terms must be considered as well.
Three-dimensional meshes are not that easily in-
spected. It is quite possible that a great number of the
3-D models reported in this field lack adequate mesh
refinement to justify at least a part of the conclusions
generated from the analyses. Unfortunately, very little
is usually done by the authors to justify their models
objectively, and quite often the articles lack essential
information. Important data to be included are, apart
from a graphic representation of the element mesh, the
number of elements, the number of degrees of freedom
(or number of nodal points), the number of nodal
points per element, and the element type. The 20-node
isoparametric hexahedrons (quadratic elements) for
instance, require a much lower mesh density than the
8-node isoparametric hexahedrons (linear elements)
which, in a sense, are superior to the non-isoparametric
hexahedrons and tetrahedrons (Zienkiewicz, 1977).
For example, in the present survey, 34 publications
applying the 3-D FEM have been included. Of these
seven are abstracts. In only 11 of the remaining 27 full
papers do the authors provide complete information
on element mesh characteristics. The use of 20-node
isoparametric hexahedrons is reported five times, 8-
node hexahedrons seven times, and other specified
elements twice. Unspecified tetrahedrons and hexa-
hedrons are mentioned five and four times respectively;
the remaining four authors do not give any element
information at all. In ten publications neither the total
number of degrees of freedom, nor the total number of
nodal points is given.
An example of element mesh data with respect to
3-D FEM analyses of the femoral hip component
fixation structure is given in Table 1, as provided in the
articles concerned. It is apparent from this table that
essential information is often lacking, so that a relative
assessment of model accuracy is hardly possible.
Evidently, an inaccurate 3-D model is less helpful in
obtaining useful results than an accurate 2-D model
whereas, to the lay person the first would appear more
refined and thus valid for detailed information. The
field of orthopedic biomechanics FEM analysis as a
whole would certainly gain in credibility if the in-
dividual authors would explicitly address these matters
of model accuracy, if only to the satisfaction of their
peers.
Apart from convergency tests, model accuracy can
be addressed by other means. Examples are the use of
closed-form solutions to check first-order tendencies
(e.g. Huiskes, 1979a; Askew and Lewis, 1981), control
of equilibrium conditions at specific locations in the
model, and the investigation of stress continuity across
interfaces (e.g. Rohlmann et al., 1980): although a
Table 1. Finite element mesh characteristics of 3-D FEM analyses of the femoral (intramedullary) THR tixationas far as published in journal articles or book chapters. Number
ofelements,number of degrees of freedom (3 x number of nodal points), number of nodal points per element (or displacement field characterization), and element type, as far as
could be found in the publications. If a half structure is modeled (indicated under symmetry), using structural symmetry in a frontal, longitudinal plane, the effective mesh density
is about twice that suggested by the number given, if compared to the full-structure models. The publications of Crowninshield et al. (1980b, 1981) and Scholten ef al. (1978)are not
included, since they report on essentially the same models as Crowninshield Ed ul. (1980a) and Roehrle et al. (1977), respectively, while providing no additional information in this
respect.

Number of Number of degrees Nodes/ or Displacement Element

Author Remarks elements Symmetry of freedom elements field type
______ _____
Bartel (1977) 1 42 112 * 20 quadratic isoparametric hexahedron
Roehrle et 01. (1977) 4 531 l/l 2650 * quadratic tetrahedron
Huiskes et al. (1978) 1 212 112 3588 20 quadratic isoparametric hexahedron
Valliappan et al. (1980) 4 * 1080 * quadratic isoparametric
l/l
Hampton ef al. (1980) 2 31 111 600 * * isoparametric hexahedron
Crowninshield et al. 4 400 111 * * * tetrahedron
(198Oa)
Rohlmann et al. (1980) 3 232 112 1182 * * hexahedron
Svensson et al. (1980) 3 167 * 20 quadratic isoparametric hexahedron
l/l
Tarr el al. (1982) 4 1032 l/l 4185 * * isoparametric hexahedron

* = no information provided,
1 = axisymmetric geometry,
2 = model suited for stem stresses only,
3 = FEM models of physical models.
4 = Anatomic models.
404 R. HUISKESand E. Y. S. CHAO
number of stress-components are by necessity dis-
continuous in different materials, normal stresses on
and shear stresses in the interface planes must be
continuous. That this condition is sometimes difficult
to obtain was illustrated in Fig. 9(c). It is well known
that numerical accuracy is more easily obtained with
respect to the highest stress components in a specific
region when compared to the less significant com-
ponents; however, in composite (biological) structures
the latter may still be of importance.
Another important aspect of FEM analyses con-
cerns the significance of results: what do they actually
imply for the structure investigated. Where it concerns
the probabilities of failure of technical materials,
conclusions can usually be drawn relatively easily.
However, the significance of stress predictions in
orthopedic biomechanics problems is often inter-
related with biological and clinical phenomena. These
relations must be investigated for a correct assessment
of the significance of the FEM results. This implies that
the responsibilities of the biomechanician do not end
by delivering the stress data, and requires an active
involvement in research efforts on a larger scale,
including non-engineering methods and techniques.
Several investigations have successfully combined
FEM analysis with experimental and clinical observa-
tions of biological bone behavior (e.g. Woo et al., 1977;
Hassler et al., 1980; Brown et al., 1980, 1982a, 1982b;
Carter et al., 1981; Hayes et al., 1982). In areas of bone-
prosthesis structural analysis, however, such an ap-
proach has been less common. The lack of data in this
respect seriously reduces the validity of predictions
that pertain to the long-term performance of pros-
thetic devices. Although these matters are quite com-
plicated and foreign to the engineering field, progress
in that direction is badly needed.
Finally, an interesting question is to what extent the
FEM has affected clinical orthopedics, in terms of the
everyday surgical practice after ten years of its use.
Although the answer to this question should be
provided by a surgeon, it is relatively safe to predict
that many of them would argue that there has been no
influence whatsoever. Sadly enough, this is quite often
used as an argument to discourage the application of
highly advanced and abstract methods like the FEM,
even by research oriented individuals. It is obvious,
however, that even the most significant and relevant
FEM result reaches the greater part of the orthopedic
community only through a filter of more clinically
oriented publications. A good example of results that
have been spread among the orthopedic community
are those of McNeice et al. (1976) who, through an
FEM analysis, established modes of cement failure in
total hip replacement that are widely used in several
clinics to evaluate postoperative roentgenograms. In
other cases, FEM analysis is used in direct collabor-
ation with clinical efforts to develop new prosthetic
and fracture fixation designs and techniques of which
the results sooner or later will reach the greater
orthopedic community in one form or another.
Although it is true, as discussed earlier, that many
FEM applications have, at the most, only served to
illustrate FEM capabilities or advances in FEM analy-
sis itself, others have contributed in general to a better
understanding of orthopedic related structures, with-
out the orthopedic community perhaps being explicitly
aware of it.
The FEM is a tool that, if used correctly, may lead to
information that is eventually applied to the benefit of
patients. Information and concepts which in many
cases cannot be obtained in any other way. This is a
pleasant thought for individuals working in this area;
however, it also charges them with the corresponding
responsibilities in the execution and interpretation of
their analyses.
FUTURE TRENDS
In considering the future of FEM analysis in
orthopedic biomechanics research one has to ap-
preciate that this (relatively) new method is not just a
versatile vehicle for stress analysis, but represents a
completely new approach to quantitative analysis of
structures and systems, based on the use of computers.
It allows us to evaluate the behavior of a complex and
incomprehensible system by discretizing it into an
amount of small parts, if the properties of these parts
and their boundary connections can be described
mathematically. Time-dependent processes too can be
divided in small time intervals and described step-by-
step. Numerical methods such as the FEM have been
introduced to kinematics, solid-, gas-, fluid- and
thermo-dynamics where mechanics is concerned, and
also to analysis in electricity, electromechanics, chemi-
cal technology and other areas. There should be little
doubt that this trend will continue in the future. Many
sciences other than biomechanics that bear a relation
to orthopedics will experience the introduction of
computer-based analysis. And this will not occur only
in basic research, but also in clinical measuring devices;
the roentgen computer scanner is a good example.
These developments will be accompanied by the
production of better and faster computers, at relatively
lower prices, and computer programs of increasing
sophistication.
The FEM for stress analysis of structures has
experienced an enormous progress in engineering
mechanics during the last decade. Already at this point
in time, not in the least through the application of
extremely powerful 2-D element mesh generators and
computer graphics packages, the solution of a
straightforward 2-D, linear elastic stress analysis prob-
lem has become no more than a routine programmers
job. The opportunities for 3-D, nonlinear and dynamic
analysis have been tremendously improved and will,
eventually, follow the same road although, at this point
in time, these applications still require considerable
skill and knowledge.
How orthopedic biomechanics, and eventually clini-
cal orthopedics, will profit from these developments is
 The first decade of finite element analysis in orthopaedic biomechanics 405

less easy to predict. Research takes place, as in other
areas, in a tension field between technical feasibilities,
personal capabilities, and the needs of the market.
During the last decade the technical feasibilities have
pulled (if not overwhelmed) the field, and there seems
to be no reason to assume that this will change in the
future. Progress will depend on the capabilities of this
field to attract skilled young mechanics engineers, and
to interest the clinicians (the market) for an ongoing
dialogue on realistic problem definitions and the
application of results.
The greatest challenge for the next decade is prob-
ably to generate enough dependable data to put into
the computer models. When capabilities for refined
modeling increase toward nonlinear and dynamically
loaded structures, more precise formulations of ma-
terial properties, boundary conditions and loading
characteristics will become an even greater priority. In
these formulations, the influences of biological reac-
tions of tissues to stress stimuli will be of grave
importance for the validity of model predictions. This
emphasizes the need for refined experimental tech-
niques, to assess mechanical and biological material
behavior as well as for direct verification purposes of
models. The experiments required include animal
experiments and patient evaluation studies, in close
interaction with FEM analysis to quantitatively inter-
relate the experimental findings, evaluate general mech-
anisms and develop fundamental concepts.
The immediate future calls for a closer look at model
validity and accuracy on the one hand, and an
evaluation of stress-related bone remodeling mechan-
isms on the other. Emphasis should be put on exper-
imental verification and interaction, including clinical
evaluations, and multiple modeling. No model can be
valid to any level of refinement, and in view of the
detailed local stress information often required, a
multiple model approach can be used. The stresses (or
deformations) obtained in rough, global models can be
used in such a scheme as the boundary conditions of a
localized and more refined model, as illustrated in
Fig. 14. In the process of multiple modeling and model
accuracy evaluations and in the development of simple
design guidelines for implants, the power of analytical
closed-form solution methods must not be under-
estimated in their capabilities to amplify and inter-
relate the complex numerical FEM results.
In a way, one can say that the future in this area of
biomechanics started ten years ago. The FEM, or the
computer in a more general sense, has created an
exciting environment with potential applications pre-
viously undreamed off. However, future progress will
only occur at the cost of considerable efforts that, even
more so than in the first decade, will require a sound
understanding of applied mechanics and numerical
pitfalls on the one hand, and a realistic appreciation of
the biological and clinical complexities on the other.
Acknowledgements-The positive criticism and useful com-
ments of Richard A. Brand, Dick H. van Campen, and Wilson

(a)

INTAZ I931 elem I 99L nodes

(4
Fig. 14. (a) An axisymmetric model of a new finger-joint prosthesis fixation system (Huiskes et al., 1980b), in
which a few local plug-bone interface regions are delineated. (b) The boundary conditions of such a region
follow from an overall analysis of the structure, where the interfaces are assumed straight and smooth.
(c) These conditions are applied on FEM models that simulate a more realistic interface shape and, for
instance, the influences of bone apposition within the grooves, as shown. (d) FEM mesh for a local model
with some bone ingrowth; the stresses evaluated in this model are compared with histological findings in
animal experiments to study relations between stresses and bone interface remodeling (Huiskes and
Nunamaker, unpublished data).
406 R. HUISKESand
C. Hayes during the completion of this survey article are
gratefully acknowledged. During the initial stages of the
literature search underlying this survey article, the principal
author was partly sponsored by the Netherlands
Organization for the Advancement of Pure Research (ZWO,
Stipend No. S95/118). We thank the various authors and
publishers concerned for giving permission for the reproduc-
tion of their figures.
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408 R. HUISKESand E. Y. S. CHAO
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