The application of robotics in the operating theatre for knee arthroplasty remains controversial. As with all new technology, the introduction of new systems might be associated with a learning curve. However, guidelines on how to assess the introduction of robotics in the operating theatre are lacking. This systematic review aims to evaluate the current evidence on the learning curve of robot-assisted knee arthroplasty. An extensive literature search of PubMed, Medline, Embase, Web of Science, and Cochrane Library was conducted. Randomized controlled trials, comparative studies, and cohort studies were included. Outcomes assessed included: time required for surgery, stress levels of the surgical team, complications in regard to surgical experience level or time needed for surgery, size prediction of preoperative templating, and alignment according to the number of knee arthroplasties performed. A total of 11 studies met the inclusion criteria. Most were of medium to low quality. The operating time of robot-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is associated with a learning curve of between six to 20 cases and six to 36 cases respectively. Surgical team stress levels show a learning curve of seven cases in TKA and six cases for UKA. Experience with the robotic systems did not influence implant positioning, preoperative planning, and postoperative complications. Robot-assisted TKA and UKA is associated with a learning curve regarding operating time and surgical team stress levels. Future evaluation of robotics in the operating theatre should include detailed measurement of the various aspects of the total operating time, including total robotic time and time needed for preoperative planning. The prior experience of the surgical team should also be evaluated and reported. Cite this article:
Gait analysis systems have enjoyed increasing usage and have been validated to provide highly accurate assessments for range of motion. Size, cost, need for marker placement and need for complex data processing have remained limiting factors in uptake outside of what remains predominantly large research institutions. Progress and advances in deep neural networks, trained on millions of clinically labelled datasets, have allowed the development of a computer vision system which enables assessment using a handheld smartphone with no markers and accurate range of motion for knee during flexion and extension. This allows clinicians and therapists to objectively track progress without the need for complex and expensive equipment or time-consuming analysis, which was concluded to be lacking during a recent systematic review of existing applications. A smartphone based computer vision system was assessed for accuracy with a gold standard comparison using a validated ‘traditional’ infra-red motion capture system which had a defined calibrated accuracy of 0.1degrees. A total of 22 subjects were assessed simultaneously using both the computer vision smartphone application and the standard motion capture system. Assessment of the handheld system was made by comparison to the motion capture system for knee flexion and extension angles through a range of motion with a simulated fixed-flexion deformity which prevented full extension to assess the accuracy of the system, repeating movements ten times. The peak extension angles and also numerous discrete angle measurements were compared between the two systems. Repeatability was assessed by comparing several sequential cycles of flexion/extension and comparison of the maximum range of motion in normal knees and in those with a simulated fixed-flexion deformity. In addition, discrete angles were also measured on both legs of three cadavers with both skin and then bone implanted fiducial markers for ground truth reliability accounting for skin movement. Data was processed quickly through an automated secure cloud system.Introduction
Method
The objective of our study was to determine the extent to which the quality of the biomechanical reconstruction when performing hip replacement influences gait performances. We aimed to answer the following questions: 1) Does the quality of restoration of hip biomechanics after conventional THR influence gait outcomes? (question 1), and 2) Is HR more beneficial to gait outcomes when compared with THR? (question 2). we retrospectively reviewed 52 satisfied unilateral prosthetic hip patients (40 THRs and 12 HRs) who undertook objective gait assessment at a mean follow-up of 14 months. The quality of the prosthetic hip biomechanical restoration was assessed on standing pelvic radiograph by comparison to the healthy contralateral hip.Introduction
Methods
Accurate and precise acetabular reaming is a requirement for the press-fit stability of cementless acetabular hip replacement components. The accuracy of reaming depends on the reamer, the reaming technique and the bone quality. Conventional reamers wear with use resulting in inaccurate reaming diameters, whilst the theoretical beneficial effect of ‘whirlwind’ reaming over straight reaming has not previously been documented. Our aim was to compare the accuracy and precision of single use additively-manufactured reamers with new conventional reamers and to compare the effect of different acetabular reaming techniques. Forty composite bone models, half high-density and half low-density, were reamed with a new 61 mm conventional acetabular reamer using either straight or ‘whirlwind’ reaming techniques. This was repeated with a 61 mm single use additively-manufactured reamer. Reamed cavities were scanned using a 3D laser scanner with mean diameters of reamed cavities compared using the Mann-Whitney U test to determine any statistically significant differences between groups (p<0.05) [Fig. 1).Aims
Materials and Methods
Osteoarthritis (OA) is a growing societal burden, due to the ageing population. Less invasive, less damaging, and cheaper methods for diagnosis are needed, and sound technology is an emerging tool in this field. The aim of the current research was to: 1) investigate the potential of visual scalogram analysis of Acoustic Emission (AE) frequencies within the human audible range (20–20000 Hz) to diagnose knee OA, 2) correlate the qualitative visual scalogram analysis of the AE with OA symptoms, and 3) to do this based on information gathered during gait.INTRODUCTION
AIMS
Accurate implant orientation is associated with improved outcomes after artificial joint replacement. We investigated if a novel augmented-reality (AR) platform (with live feedback) could train novice surgeons to orientate an acetabular implant as effectively as conventional training (CT). Twenty-four novice surgeons (pre-registration level medical students) voluntarily participated in this trial. Baseline demographics, data on exposure to hip arthroplasty, and baseline performance in orientating an acetabular implant to six patient-specific values on a phantom pelvis, were collected prior to training. Participants were randomised to a training session either using a novel AR headset platform or receiving one-on-one tuition from a hip surgeon (CT). After training, they were asked to perform the six orientation tasks again. The solid-angle error in degrees between the planned and achieved orientations was measured using a head-mounted navigation system.Background
Methods
Osteoarthritis (OA) is a growing societal burden, due to the ageing population. Less invasive, less damaging, and cheaper methods for diagnosis are needed, and sound technology is an emerging tool in this field. Some studies investigate ultrasound signals, while others look at acoustic signals in the audible range. The aim of the current research was to: 1) investigate the potential of visual scalogram analysis of Acoustic Emission (AE) frequencies within the human audible range (20–20000 Hz) to diagnose knee OA, 2) correlate the qualitative visual scalogram analysis of the AE with OA symptoms, and 3) to do this based on information gathered during gait.INTRODUCTION
AIMS
Complications such as dislocations, impingement and early wear following total hip arthroplasty (THA) increase with acetabular cup implant malorientation. These errors are more common with low-volume centres or in novice hands. Currently, this skill is most commonly taught during real surgery with an expert trainer, but simulated training may offer a safer and more accessible solution. This study investigated if a novel MicronTracker® enhanced Microsoft HoloLens® augmented reality (EAR) headset was as effective as one-on-one expert surgeon (ES) training for teaching novice surgeons hip cup orientation skill. Twenty-four medical students were randomly assigned to EAR or ES training groups. Participants used a modified sawbone/foam pelvis model for hip cup orientation simulation. A validated EAR headset measured the orientation of acetabular cup implants and displayed this in the participant”s field of view. The system calculated the difference between planned and achieved orientation as a solid-angle error. Six different inclination and anteversion combinations, related to hypothetical patient-specific anatomy, were used as target orientations. Learning curves were measured over four sessions, each one week apart. Error in orientations of non-taught angles and during a concealed pelvic tilt were measured to assess translation of skills. A post-test questionnaire was used for qualitative analysis of procedure understanding and participant experience.Background
Methods
Trust in the validity of a measurement tool is critical to its function in both clinical and educational settings. Acetabular cup malposition within total hip arthroplasty (THA) can lead to increased dislocation rates, impingement and increased wear as a result of edge loading. We have developed a THA simulator incorporating a foam/Sawbone pelvis model with a modified Microsoft HoloLens® augmented reality (AR) headset. We aimed to measure the trueness, precision, reliability and reproducibility of this platform for translating spatial measurements of acetabular cup orientation to angular values before developing it as a training tool. A MicronTracker® stereoscopic camera was integrated onto a HoloLens® AR system. Trueness and precision values were obtained through comparison of the AR system measurements to a gold-standard motion capture system”s (OptiTrack®) measurements for acetabular cup orientation on a benchtop trainer, in six clinically relevant pairs of anteversion and inclination angles. Four surgeons performed these six orientations, and repeated each orientation twice. Pearson”s coefficients and Bland-Altman plots were computed to assess correlation and agreement between the AR and Motion Capture systems. Intraclass correlation coefficients (ICC) were calculated to evaluate the degree of repeatability and reproducibility of the AR system by comparing repeated tasks and between surgeons, respectively.Background
Methods
In robot-assisted orthopaedic surgery, registration is a key step, which defines the position of the patient in the robot frame so that the preoperative plan can be performed. Current registration methods have their limitations, such as the requirement of immobilisation of the limbs or the line of sight (LOS) issues. These issues cause inconvenience for the surgeons and interrupt the surgical workflow in the operating room. Targetting these issues of current registration methods, we propose a camera-robot registration system for joint replacement. The bone geometry, which is measured directly by a depth camera, is aligned to a preoperatively obtained bone model to calculate the pose of the target. Simultaneously, in order to avoid registration failure caused by LOS interruptions, the depth camera tracks objects that may occlude the target bone, and a robot manipulator is used to move the camera away from the nearest obstacle. The optimal camera motion is calculated based on the position and velocity of the obstacle, which avoids the occlusion efficiently without changing the target position in the camera frame. Inverse kinematics of the robot is used to project the Cartesian velocity of the end-effector into the joint space, with kinematic singularities considered for stable robotic control. An admittance controller is designed as the human-robot interface so that the surgeon can directly set the robot configuration by hand according to the actual environment. Simulations and experiments were conducted to test the performance. The results show that the proposed obstacle avoidance method can effectively increase the distance between the obstacle and the LOS, which lowers the risk of registration failure due to obstacle occlusion. This pilot study is promising in reducing distractions to the surgeon and can help achieve a fluent and surgeon-centred workflow.
The current, most popular recommendation for cup orientation, namely the Lewinnek box, dates back to the 70's, that is to say at the stone age of hip arthroplasty. Although Lewinnek's recommendations have been associated with a reduction of dislocation, some complications, either impingement or edge loading related, have not been eliminated. Early dislocations are becoming very rare and most of them probably occur in “outlier” patients with atypical pelvic/hip kinematics. Because singular problems usually need singular treatments, those patients need a more specific personalised planning of the treatment rather than a basic systematic application of Lewinnek recommendations. We aim in this review to define the potential impacts that the spine-hip relations (SHRs) have on hip arthroplasty. We highlight how recent improvements in hip implants technology and knowledge about SHRs can substantially modify the planning of a THR, and make the «Lewinnek recommendations» not relevant anymore. We propose a new classification of the SHRs with specific treatment recommendations for hip arthroplasty whose goal is to help at establishing a personalized planning of a THR. This new classification (figures 1 and 2) gives a rationale to optimize the short and long-term patient's outcomes by improving stability and reducing edge loading. We believe this new concept could be beneficial for clinical and research purposes.
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. Create a novel method to automatically register pre- and post-operative femora for the direct comparison of the implant and the native bone.Background
Aim
Clear operative oncological margins are the main target in malignant bone tumour resections. Novel techniques like patient specific instruments (PSIs) are becoming more popular in orthopaedic oncology surgeries and arthroplasty in general with studies suggesting improved accuracy and reduced operating time using PSIs compared to conventional techniques and computer assisted surgery. Improved accuracy would allow preservation of more natural bone of patients with smaller tumour margin. Novel low-cost technology improving accuracy of surgical cuts, would facilitate highly delicate surgeries such as Joint Preserving Surgery (JPS) that improves quality of life for patients by preserving the tibial plateau and muscle attachments around the knee whilst removing bone tumours with adequate tumour margins. There are no universal guidelines on PSI designs and there are no studies showing how specific design of PSIs would affect accuracy of the surgical cuts. We hypothesised if an increased depth of the cutting slot guide for sawblades on the PSI would improve accuracy of cuts. A pilot drybone experiment was set up, testing 3 different designs of a PSI with changing cutting slot depth, simulating removal of a tumour on the proximal tibia (figure 1) A handheld 3D scanner (Artec Spider, Luxembourg) was used to scan tibia drybones and Computer Aided Design (CAD) software was used to simulate osteosarcoma position and plan intentioned cuts (figure 1). PSI were designed accordingly to allow sufficient tumour. The only change for the 3 designs is the cutting slot depth (10mm, 15mm & 20mm). 7 orthopaedic surgeons were recruited to participate and perform JPS on the drybones using each design 2 times. Each fragment was then scanned with the 3D scanner and were then matched onto the reference tibia with customized software to calculate how each cut (inferior-superior-vertical) deviated from plan in millimetres and degrees (figure 3). In order to tackle PSI placement error, a dedicated 3D-printed mould was used.Introduction
Methods
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. 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, BACKGROUND
METHODS
Hip resurfacing arthroplasty (HRA) is currently regaining positive attention as a treatment of osteoarthritis in young, active individuals[1]. The procedure is complex and has low tolerance for implant malpositioning [2]. ‘Precision tools', such as imageless navigation and patient specific instruments, have been developed to assist with implant positioning but have not been shown to be fully reliable [3]. The aim of this study is to present and validate the first step of novel quality control tool to verify implant position intra-operatively. We propose that, before reaming of the femoral head, a handheld structured light 3D scanner can be used to assess the orientation and insertion point of femoral guide wire. Guide wires were placed into the heads of 29 solid foam synthetic femora. A specially designed marker (two orthogonal parallelepipeds attached to a shaft) was inserted into the guide wire holes. Each bone (head, neck and marker) was 3D scanned twice (fig 1). The insertion point and guide wire neck angle were calculated from the marker's parameters. Reference data was acquired with an optical tracking system. The measurements calculated with the 3D scans were compared to the reference ones to evaluate the precision. The comparison of the test retest measurements done with the new method are used to evaluate intra-rater variability.Introduction
Methods
Across much of medicine, activity levels predict life expectancy, with low levels of activity being associated with increased mortality, and higher levels of activity being associated with longer healthier lives. Resurfacing is a technically demanding procedure that has suffered significant fallout from the failure of a couple of poorly performing designs. However strong evidence associates resurfacing with improved life expectancy in both the short and longer term following surgery. We wondered if there was any relationship between the function of hips following surgery and the extent of that surgery. Could a longer stem inside the femur be the reason for a slightly reduced step length? We proposed the nul hypothesis that there was no clinically relevant difference between stem length and gait. After informed consent each subject was allowed a 5 minute acclimatisation period at 4km/hr on the instrumented treadmill (Kistler Gaitway, Amherst, NY). Their gait performance on an increasing incline at 5, 10 and 15%. At all 0.5km incremental intervals of speed, the vertical component of the ground reaction forces, center of pressure and temporal measurements were collected for both limbs with a sampling frequency of 100Hz over 10sec. They were also asked to log onto our JointPRO website and report their function using Oxford, EQ5D, and Imperial scores. Owing to current restrictions in indications, the patient groups selected were not comparable. However, from our database of over 800 patients who have been through the gait lab. 82 subjects were tested from 2 diagnostic groups (29 conventional THR, 27 hip resurfacing) and compared with a slightly younger group of 26 healthy controls. Patients were excluded if less than 12 months postop, or with any other documented joint disease or medical comorbidities which might affect gait performance. Body weight scaling was also applied to the outputted mechanical data to correct for mass differences. All variables for each subject group were compared to each other using an analysis of variance (ANOVA) with Tukey post hoc test with significance set at α=0.05.Intro
Method
Financial and human cost effectiveness is an increasing evident outcome measure of surgical innovation. Considering the human element, the aim is to restore the individual to their “normal” state by sparing anatomy without compromising implant performance. Gait lab studies have shown differences between different implants at top walking speed, but none to our knowledge have analysed differing total hip replacement patients through the entire range of gait speed and incline to show differences. The purpose of this gait study was to 1) determine if a new short stem femoral implant would return patients back to normal 2) compare its performance to established hip resurfacing and long stem total hip replacement (THR) implants. 110 subjects were tested on an instrumented treadmill (Kistler Gaitway), 4 groups (short-stem THR, long-stem THR, hip resurfacing and healthy controls) of 28, 29, 27, and 26 respectively. The new short femoral stem patients (Furlong Evolution, JRI) were taken from the ongoing Evolution Hip trial that have been tested on the treadmill minimum 12months postop. The long stem total hip replacements and hip resurfacing groups were identified from our 800+ patient treadmill database, and only included with tests minimum 12 months postop and had no other joint disease or medical comorbidities which would affect gait performance. All subjects were tested through their entire range of gait speeds and incline after having a 5 minute habituation period. Speed were increased 0.5kmh until maximum walking speed achieved and inclines at 4kmh for 5,10,15%. At all incremental intervals of speed 10seconds ere collected, including vertical ground reaction forces (normalized to body mass), center of pressure and temporal measurements were for both limbs (fs=100Hz). Symmetry Index(SI) were calculated on a range of features comparing leg with implanted hip to the contralateral normal hip. Group means for each feature for each subject group were compared using an analysis of variance (ANOVA) with Tukey post-hoc test with significance set at α=0.05.Introduction
Method
Because of the low cost and easy access, surgical video has become a popular method of acquiring surgical skills outside operating rooms without disrupting normal surgical flow. However, currently existing video systems all use a single point of view (POV). Some complex orthopedic procedures, such as joint replacement, require a level of accuracy in several dimensions. So single and fixed POV video may not be enough to provide all the necessary information for educational and training purposes. The aim of our project was to develop a novel multiple POV video system and evaluate its efficacy as an aid for learning joint replacement procedure compared with traditional method. Based on the videos of a hip resurfacing procedure performed by an expert orthopedic surgeon captured by 8 cameras fixed all around the operating table, we developed a novel multiple POV video system which enables users to autonomously switch between optimal viewpoints (Figure 1). 30 student doctors (undergraduate years 3–5 and naive to hip resurfacing procedure) were recruited and randomly allocated to 2 groups: experiment group and control group, and were assigned to learn the procedure using multiple or single POV video systems respectively. Before learning they were first asked to complete a multiple choicetest designed using a modified Delphi technique with the advice and feedback sought from 4 experienced orthopedic surgeons to test the participants' baseline knowledge of hip resurfacing procedure. After video learning, they were asked to answer the test again to verify their gained information and comprehension of the procedure, followed by a 5-point Likert-scale questionnaire to demonstrate their self-perception of confidence and satisfaction with the learning experience. The scores in the 2 tests and in the Likert-scale questionnaire were compared between 2 groups using Independent-Samples t-test (for normally distributed data) or Mann-Whitney U test (for non-normally distributed data). Statistical significance was set as p<0.05.Introduction
Materials and Methods
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. 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 - (fig.1). 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.BACKGROUND
METHODS
Osteoarthritis and the pain associated with it result in gait pattern alteration, in particularly gait asymmetry when the disease is unilateral [1–2]. The quantification of such asymmetry could assist with the diagnosis and follow up. Various asymmetry indices have been proposed to compare the spatiotemporal, kinematic and kinetic parameters of lower limbs during the gait cycle. One, the Continuous Relative Phase [3] compares the joints angle and its derivatives to assess the gait asymmetry during the gait cycle. However, the indices rely on marker based gait measurement systems that are costly and generally require manual examination, calibration procedures and the precise placement of sensors/markers on the body of the patient. Create an automatic method to assess gait asymmetry with low cost depth camera system like Kinect.Background
Aim
