Importance of trabecular anisotropy in finite element predictions of patellar strain after Total Knee Arthroplasty

Patellar fracture and anterior knee pain remain major complications after Total Knee Arthroplasty (TKA). Patient-specific finite element (FE) models should help improve understanding of these complications through estimation of joint and bone mechanics. However, sensitivity of predictions on modeling tech- niques and approaches is not fully investigated. In particular, the importance of patellar bone anisotropy, usually omitted in FE models, on strain prediction is still unknown. The objective of this study was thus to estimate the influence of modeling patellar trabecular anisotropy on prediction of patellar strain in TKA models. We compared FE-derived strain predictions with isotopic and anisotropic material properties using 17 validated FE models of the patella after TKA. We considered both non-resurfaced and resurfaced patellae, in a load-bearing TKA joint. We evaluated and compared the bone volume above a strain threshold and, in addition, estimated if the difference in isotopic and anisotropic predictions was consistent between patellae of different average bone volume fraction. Compared to the anisotropic reference, the isotropic prediction of strained volume was 3.7 ± 1.8 times higher for non-resurfaced patellae and 1.5 ± 0.4 times for resurfaced patellae. This difference was higher for patellae with lower average bone volume fraction. This study indicates that strain predictions acquired via isotropic patellar FE models should be inter- preted with caution, especially when patellae of different average bone volume fraction are compared.