Problem

Total hip replacement (THA) is among the most common and highest total spend elective operations in the United States. However, up to 7% of patients have 90-day complications after surgery, most frequently joint dislocation that is related to poor acetabular component positioning. These complications lead to patient morbidity and mortality, as well as significant cost to the health system. As such, surgeons and hospitals value navigation technology, but existing solutions including robotics and optical navigation are costly, time-consuming, and complex to learn, resulting in limited uptake globally.

Introduction

Total Hip Arthroplasty has been shown to have excellent long term outcomes, yet early reoperation remains a risk. The current study assesses the incidence, causes, and cost associated with early revision following elective primary THA in the US Medicare population.

Background

Defining optimal coronal alignment in Total Knee Replacement (TKR) is a controversial and poorly understood subject. Tibial bone density may affect implant stability and functional outcomes following TKR. Our aim was to compare the bone density profile at the implant-tibia interface following TKR in mechanical versus kinematic alignment.

Tibial bone density may affect implant stability and functional outcomes following total knee replacement (TKR). Our aim was to characterise the bone density profile at the implant-tibia interface following TKR in mechanical versus kinematic alignment. Pre-operative computed tomography scans for 10 patients were obtained. Using surgical planning software, tibial cuts were made for TKR either neutral (mechanical) or 3 degrees varus (kinematic) alignment. Signal intensity, in Hounsfield Units (HU), was measured at 25,600 points throughout an axial slice at the implant-tibia interface and density profiles compared along defined radial axes from the centre of the tibia towards the cortices. From the tibial centre towards the lateral cortex, trabecular bone density for kinematic and mechanical TKR are similar in the inner 50% but differ significantly beyond this (p= 0.012). There were two distinct density peaks, with peak trabecular bone density being higher in kinematic TKR (p<0.001) and peak cortical bone density being higher in mechanical TKR (p<0.01). The difference in peak cortical to peak trabecular signal was 43 HU and 185 HU respectively (p<0.001). On the medial side there was no significant difference in density profile and a linear increase from centre to cortex. In the lateral proximal tibia, peak cortical and peak trabecular bone densities differ between kinematic TKR and mechanical TKR. Laterally, mechanical TKR may be more dependent upon cortical bone for support compared to kinematic TKR, where trabecular bone density is higher. This may have implications for surgical planning and implant design.

Background

The accurate positioning of the total knee arthroplasty affects the survival of the implants(1). Alignment of the femoral component in relation to the native knee is best determined using pre- and post-operative 3D-CT reconstruction(2). Currently, the scans are visualised on separate displays. There is a high inter- and intra-observer variability in measurements of implant rotation and translation(3). Correct alignment is required to allow a direct comparison of the pre- and post-operative surfaces. This is prevented by the presence of the prostheses, the bone shape alteration around the implant, associated metal artefacts, and possibly a segmentation noise.

BACKGROUND

Trochlear geometry of modern femoral implants is designed for the mechanical alignment (MA) technique for Total Knee Arthroplasty (TKA). The biomechanical goal is to create a proximalised and more valgus trochlea to better capture the patella and optimize tracking. In contrast, Kinematic alignment (KA) technique for TKA respects the integrity of the soft tissue envelope and therefore aims to restore native articular surfaces, either femoro-tibial or femoro-patellar. Consequently, it is possible that current implant designs are not suitable for restoring patient specific trochlea anatomy when they are implanted using the kinematic technique. This could cause patellar complications, either anterior knee pain, instability or accelerated wear or loosening. The aim of our study is therefore to explore the extent to which native trochlear geometry is restored when the Persona^® implant (Zimmer, Warsaw, USA) is kinematically aligned.

BACKGROUND

Conventional TKA surgery attempts to restore patients to a neutral alignment, and devices are designed with this in mind. Neutral alignment may not be natural for many patients, and may cause dissatisfaction [1]. To solve this, kinematical alignment (KA) attempts to restore the native pre-arthritic joint-line of the knee, with the goal of improving knee kinematics and therefore patient's function and satisfaction [1].

Proper prosthetic trochlea alignment is important to prevent patella complications such as instability or loosening. However, available TKA components have been designed for mechanical implantation, and concerns remain relating the orientation of the prosthetic trochlea when implants are kinematically positioned. The goal of this study is to investigate how a currently available femoral component restores the native trochlear geometry of healthy knees when virtually placed in kinematic alignment.

Trochlear geometry of modern femoral implants is designed for mechanical alignment (MA) technique for TKA. The biomechanical goal is to create a proximalised and more valgus trochlea to better capture the patella and optimize tracking. In contrast, Kinematic alignment (KA) technique for TKA respects the integrity of the soft tissue envelope and therefore aims to restore native articular surfaces, either femoro-tibial or femoro-patellar. Consequently, it is possible that current implant designs are not suitable for restoring patient specific trochlea anatomy when they are implanted using the kinematic technique, this could cause patellar complications, either anterior knee pain, instability or accelerated wear or loosening. The aim of our study is therefore to explore the extent to which native trochlear geometry is restored when the Persona^®implant (Zimmer, Warsaw, USA) is kinematically aligned.

A retrospective study of a cohort of 15 patients with KA-TKA was performed with the Persona^®prosthesis (Zimmer, Warsaw, USA). Preoperative knee MRIs and postoperative knee CTs were segmented to create 3D femoral models. MRI and CT segmentation used Materialise Mimics and Acrobot Modeller software, respectively. Persona^®implants were laser scanned to generate 3D implant models. Those implant models have been overlaid on the 3D femoral implant model (generated via segmentation of postoperative CTs) to replicate, in silico, the alignment of the implant on the post-operative bone and to reproduce in the computer models the features of the implant lost due to CT metal artefacts. 3D models generated from post-operative CT and pre-operative MRI were registered to the same coordinate geometry. A custom written planner was used to align the implant, as located on the CT, onto the pre-operative MRI based model. In house software enabled a comparison of trochlea parameters between the native trochlea and the performed prosthetic trochlea. Parameters assessed included 3D trochlear axis and anteroposterior offset from medial facet, central groove, and lateral facet. Sulcus angle at 30% and 40% flexion was also measured. Inter and intra observer measurement variabilities have been assessed.

Varus-valgus rotation between the native and prosthetic trochleae was significantly different (p<0.001), with the prosthetic trochlear groove being on average 7.9 degrees more valgus. Medial and lateral facets and trochlear groove were significantly understuffed (3 to 6mm) postoperatively in the proximal two thirds of the trochlear, with greatest understuffing for the lateral facet (p<0.05). The mean medio-lateral translation and internal-external rotation of the groove and the sulcus angle showed no statistical differences, pre and postoperatively.

Kinematic alignment of Persona^®implants poorly restores native trochlear geometry. Its clinical impact remains to be defined.

Conventional TKA surgery attempts to restore patients to a neutral alignment, and devices are designed with this in mind. Neutral alignment may not be natural for many patients, and may cause dissatisfaction. To solve this, kinematical alignment (KA) attempts to restore the native pre-arthritic joint-line of the knee, with the goal of improving knee kinematics and therefore patient's function and satisfaction.

Proper prosthetic trochlea alignment is important to prevent patella complications such as instability or loosening. However, available TKA components have been designed for mechanical implantation, and concerns remain relating the orientation of the prosthetic trochlea when implants are kinematically positioned. The goal of this study is to investigate how a currently available femoral component restores the native trochlear geometry of healthy knees when virtually placed in kinematic alignment.

The healthy knee OAI (Osteoarthritis Initiative) MRI dataset was used. 36 MRI scans of healthy knees were segmented to produce models of the bone and cartilage surfaces of the distal femur. A set of commercially available femoral components was laser scanned. Custom 3D planning software aligned these components with the anatomical models: distal and posterior condyle surfaces of implants were coincident with distal and posterior condyle surfaces of the cartilage; the anterior flange of the implant sat on the anterior cortex; the largest implant that fitted with minimal overhang was used, performing ‘virtual surgery’ on healthy subjects.

Software developed in-house fitted circles to the deepest points in the trochlear grooves of the implant and the cartilage. The centre of the cartilage trochlear circle was found and planes, rotated from horizontal (0%, approximately cutting through the proximal trochlea) through to vertical (100%, cutting through the distal trochlea) rotated around this, with the axis of rotation parallel to the flexion facet axis. These planes cut through the trochlea allowing comparison of cartilage and implant surfaces at 1 degree increments. Trochlear groove geometry was quantified with (1) groove radial distance from centre of rotation cylinder (2) medial facet radial distance (3) lateral facet radial distance and (4) sulcus angle, along the length of the trochlea. Data were normalised to the mean trochlear radius. The orientation of the groove was measured in the coronal and axial plane relative to the flexion facet axis. Inter- and intra-observer reliability was measured.

In the coronal plane, the implant trochlear groove was oriented a mean of 8.7° more valgus (p<0.001) than the normal trochlea. The lateral facet was understuffed most at the proximal groove between 0–60% by a mean of 5.3 mm (p<0.001). The medial facet was understuffed by a mean of 4.4 mm between 0–60% (p<0.001).

Despite attempts to design femoral components with a more anatomical trochlea, there is significant understuffing of the trochlea, which could lead to reduced extensor moment of the quadriceps and contribute to patient dissatisfaction.

The accurate positioning of the total knee arthroplasty affects the survival of the implants(1). Alignment of the femoral component in relation to the native knee is best determined using pre- and post-operative 3D-CT reconstruction(2). Currently, the scans are visualised on separate displays. There is a high inter- and intra-observer variability in measurements of implant rotation and translation(3). Correct alignment is required to allow a direct comparison of the pre- and post-operative surfaces. This is prevented by the presence of the prostheses, the bone shape alteration around the implant, associated metal artefacts, and possibly a segmentation noise.

The aim is to create a novel method to automatically register pre- and post-operative femora for the direct comparison of the implant and the native bone.

The concept is to use post-operative femoral shaft segments free of metal noise and of surgical alteration for alignment with the pre-operative scan. It involves three steps. Firstly, using principal component analysis, the femoral shafts are re-oriented to match the X axis. Secondly, variants of the post-operative scan are created by subtracting 1mm increments from the distal femoral end. Thirdly, an iterative closest point algorithm is applied to align the variants with the pre-operative scan.

For exploratory validation, this algorithm was applied to a mesh representing the distal half of a 3D scanned femur. The mesh of a prosthesis was blended with the femur to create a post-operative model. To simulate a realistic environment, segmentation and metal artefact noise were added. For segmentation noise, each femoral vertex was translated randomly within +−1mm,+−2mm,+−3mm along its normal vector. To create metal artefact random noise was added within 50 mm of the implant points in the planes orthogonal to the shaft. The alignment error was considered as the average distance between corresponding points which are identical in pre- and post-operative femora.

These preliminary results obtained within a simulated environment show that by using only the native parts of the femur, the algorithm was able to automatically register the pre- and post-operative scans even in presence of the implant. Its application will allow visualisation of the scans on the same display for the direct comparison of the perioperative scans.

This method requires further validation with more realistic noise models and with patient data. Future studies will have to determine if correct alignment has any effect on inter- and intra-observer variability.

Patellofemoral joint (PFJ) arthroplasty is traditionally performed using mechanical jigs to align the components, and it is hard to fine tune implant placement for the individual patient. These replacements have not had the same success rate as other forms of total or partial knee replacement surgery1.

Our team have developed a computer assisted planning tool that allows alignment of the implant based on measurements of the patient's anatomy from MRI data with the aim of improving the success of patellofemoral joint arthroplasty.

When planning a patellofemoral joint arthroplasty, one must start from the premise that the original joint is either damaged as a result of osteoarthritis, or is dysplastic in some way, deviating from a normal joint. The research aimed to plan PFJ arthroplasty using knowledge of the relationship between a normal PFJ (trochlear groove, trochlea axis and articular surfaces) and other aspects of the knee2, allowing the plan to be estimated from unaffected bone surfaces, within the constraints of the available trochlea.

In order to establish a patient specific trochlea model a method was developed to automatically compute an average shape of the distal femur from normal distal femur STL files (Fig.1). For that MRI scans of 50 normal knees from osteoarthritis initiative (OAI) study were used. Mimics and 3-matic software (Materialise) packages were used for segmentation and analysis of 3D models. Spheres were fitted to the medial and lateral flexion facets for both average knee model and patient knee model. The average knee was rescaled and registered in order to match flexion facet axis (FFA) distance and FFA midpoint of the patient (Fig.2). The difference between the patient surface and the average knee surface allow to plan the patella groove alteration.

The Patella cut is planned parallel to the plane fitted to the anterior surface of the patella. The patella width/thickness ratio (W/T=2) is used to predict the post reconstruction thickness3. The position of the patella component (and its orientation if a component with a median ridge is used) is also planned.

The plan is next fine-tuned to achieve satisfactory PFJ kinematics4 (Fig.3). This will be complemented by intraoperative PFJ tracking which assists with soft tissue releases. PFJ kinematics is evaluated in terms of patella shift, tilt and deviation from the previously described circular path of the centre of the patella.

The effect of preoperative planning on PFJ tracking and soft tissue releases is being examined. Additional study is needed to evaluate whether planning and intraoperative kinematic measurements improve the clinical outcome of PFJ arthroplasty.

Introduction

The trochlea of a typical patellofemoral replacement or anterior flange of a total knee replacement usually extends past the natural trochlea and continues onto the femoral anterior cortex. One reason for this is that it allows a simple patella button to be permanently engaged in the trochlea groove in an attempt to ensure stability. On the natural patella, the apex helps to guide it into the trochlea groove as the knee moves from full extension into flexion.

The aim is to study whether a generalised patella can be created that is close in form to a healthy patella.

Introduction

Patient Specific Instrumentation (PSI) has the potential to allow surgeons to perform procedures more accurately, at lower cost and faster than conventional instrumentation. However, studies using PSI have failed to convincingly demonstrate any of these benefits clinically. The influence of guide design on the accuracy of placement of PSI has received no attention within the literature.

Our experience has suggested that surgeons gain greater benefit from PSI when undertaking procedures they are less familiar with. Lateral unicompartmental knee replacement (UKR) is relatively infrequently performed and may be an example of an operation for which PSI would be of benefit. We aimed to investigate the impact on accuracy of PSI with respect to the area of contact, the nature of the contact (smooth or studded guide surfaces) and the effect of increasing the number of contact points in different planes.

Introduction

We report 10-year clinical outcomes of a prospective randomised controlled study on uni-compartmental knee arthroplasty using an active constraint robot.

Measuring the clinical impact of CAOS systems has generally been based around surrogate radiological measures with currently few long-term functional follow-up studies reported. We present 10 year clinical follow up results of robotic vs conventional surgery in UKA.

Large heads offer substantial advantages over small ones in hip arthroplasty, as they are far less likely to dislocate. This feature is of particular benefit in very dysplastic females who often have a degree of joint laxity making dislocation a real possibility. Large metal heads have a range of problems, so registries report that they are now being substituted by large ceramic heads, typically reducing in diameter by 15% or more from the native size.

All current designs of the femoral ball heads, whether for resurfacing of replacement share a unique design characteristic: a subtended angle of 120° defining the proportion of a sphere that the head represents. A novel design has recently been proposed that might reduce conflict between the femoral ball head rim and the iliopsoas tendon. This paper explains the problem of iliopsoas impingement on femoral heads of native diameter, and the consequences.

Outcome measures are an essential element of our industry: comparing a novel procedure against an established one requires a reliable set of metrics that are comprehensible to both the technologist and the layman.

We surmised that a detailed assessment of function before and after knee arthroplasty, combined with a detailed set of personal goals would enable us to test the hypothesis that less invasive joint and ligament preserving operations could be demonstrated to be more successful, and cost effective. We asked the simple question: how well can people walk following arthroplasty, and can we measure this?

INTRODUCTION:

The 3D shape of the normal proximal femur is poorly described in current designs of proximal femur prosthesis. Research has shown that in current implant designs with small diameter femoral heads the moment arm of the ilio-psoas tendon is reduced causing weakness in full extension, while large femoral heads cause psoas tendon impingement on the femoral head neck junction [1]. The femoral head-neck junction thus directly influences the hip flexor muscles' moment arm. Mathematical modeling of proximal femoral geometry allowed a novel proximal femur prosthesis to be developed that takes into account native anatomical parameters. We hypothesized that it is possible to fit a quadratic surface (e.g. sphere, cylinder…) or combinations of them on different bone surfaces with a relatively good fit.

Introduction:

Varus alignment of the knee is common in patients undergoing unicondylar knee replacement. To measure the geometry and morphology of these knees is to know whether a single unicondylar knee implant design is suitable for all patients, i.e. for patients with varus deformity and those without. The aim of this study was to identify any significant differences between normal and varus knees that may influence unicondylar implant design for the latter group.

Introduction:

Cam type femoroacetabular impingement (FAI) may lead to osteoarthritis (OA)[1]. In 2D studies, an alpha angle greater than 55° was considered abnormal however limitations of 2D alpha angle measurement have led to the development of 3D methods [2–4]. Failure to completely address the bony impingement lesions during surgery has been the most common reason for unsuccessful hip arthroscopy surgery [5]. Robotic technology has facilitated more accurate surgery in comparison to the conventional means. In this study we aim to assess the potential application of robotic technology in dealing with this technically challenging procedure of cam sculpting surgery.

Acetabular and pelvic fractures are amongst the most challenging to treat, still requiring major open surgery. The operations to reduce and fix them entail lengthy operative time, significant blood loss and use of ionising radiation.

We report on the initial stages of developement of a minimally invasive method for navigated reduction and percutaneous fixation of acetabular fractures (NRFA). A commercial navigation platform (Acrobot Ltd.) will be adapted for use with this technique. CT based planning will be used to identify the correct realignment of the the bone fragments, which will then be reduced percutaneously with the aid of two tracked arms attached to the navigation system. Schanz pins, which are inserted in pre-operatively planned sites in each fragment using safe trajectories, are handled as joysticks to manipulate the fracture under computer assistance. Registration of the fragments after insertion of the joysticks will be carried out by means of fluoroscopic images of the AP and Judet views of the fractured acetabulum. Once reduction is achieved by following on-screen instructions, the joysticks are held in place by a custom clamping system connected to one of the arms, while the other is used for percutaneous insertion of column screws.

This technique is potentially suitable for a number of acetabular fractures which include transverse, anterior column, posterior column, T-fractures and some associated both columns fractures. These constitute over 50% of Letournel’s and 60% of Matta’s original series of acetabular fractures. Furthermore, this percutaneous technique could reduce bleeding, wound complications, hospital stay and cost of treatment. Intra operative ionising radiation would be greatly reduced for both patients and the surgeons.

Adequate training with the use of this software may provide a greater number of surgeons the capability to surgically treat these complex fractures.