INTRODUCTION. Additive manufacturing (3D printing) is used to create porous surfaces that promote bone ingrowth in an effort to improve initial stability and optimize long-term biological fixation. The acetabular cup that was studied is manufactured with titanium alloy powder via electron beam melting. Electron beam melting integrates the porous and solid substrate rather than sintering a porous coating to a solid surface. The 3D-printed acetabular cup's high surface coefficient of friction (up to 1.2), combined with its geometry, creates a predictable press-fit in the acetabulum, improving initial mechanical stability and ultimately leading to reproducible biologic fixation. The objective of this study was to evaluate the early clinical outcomes and implant fixation of this 3D-printed acetabular cup in total hip arthroplasty (THA). METHODS. Four hundred twenty-eight subjects from 8 US and international research sites underwent primary THA with the 3D-printed acetabular cup. All sites received IRB approval prior to conducting the study, and all participants signed the informed consent. Screw usage and number used during surgery were used as a surrogate measurement for initial implant fixation. Clinical performance outcomes included pre- and post-operative Harris Hip Scores (HHS) and Oxford Hip Scores (OHS), patient satisfaction, and revision assessment. 215 patients had a minimum 1-year post-operative follow-up visit. Student t-tests were used to identify significant mean differences (p<0.05). RESULTS. Acetabular screws were used in 206 of 428 cases (48.1%); 85.9% used 1 screw, 12.6% used 2 screws, and 1.5% used 3 screws. For patients with a 1-year post-operative visit, the HHS improved by 49.8 points to 91.9 from 42.1, and the OHS improved by 27.7 points to 44.4 from16.7. Patient satisfaction scores at the 1-year post-operative visit were 9.7±0.7 (n=94). There was no significant difference between genders with regard to BMI, the 1-year post-operative HHS, OHS, or patient satisfaction scores. However, the males were significantly younger (59.8 vs. 62.9 years) and had significantly higher pre-operative HHS (45.7 vs. 37.9) and OHS scores (17.8 vs. 15.3). There were 9 revisions reported. DISCUSSION. For initial implant fixation, compared to a similar, non-3D-printed acetabular cup in the same product line, the 3D-printed cup used significantly fewer screws per case (n=1 for 85.9% cases vs. n=2 for 85.7% of cases) in a fewer percentage of cases (48.1% vs. 70.4%), suggesting greater initial stability and “scratch fit”. The 3D-printed acetabular cup also displayed positive early clinical results as evidenced by the pronounced improvement in clinical outcome scores from the pre-operative visit to the 1-year post-operative visit. These 1-year improvements are better than moderate clinically important improvements reported in the literature (40.1 points for HHS). Patient satisfaction scores were also excellent (9.7/10). There were nine revisions; however, four of these were due to patient falls and one was due to infection. SIGNIFICANCE. The 3D-printed acetabular cup evaluated in this study demonstrated improved implant fixation and positive early clinical outcomes for THA

Background. Accurate acetabular cup positioning is considered to be essential to prevent postoperative dislocation and improve the long-term outcome of total hip arthroplasty (THA). Recently various devices such as navigation systems and patient-specific guides have been used to ensure the accuracy of acetabular cup positioning. Objectives. The present study evaluated the usefulness of CT-based three-dimensional THA preoperative planning for acetabular cup positioning. Methods. This study included 120 hips aged mean 68.3 years, who underwent primary THA using CT-based THA preoperative planning software ZedHip® (LEXI, Tokyo Japan) and postoperative CT imaging (Fig.1). The surgical approach adopted the modified Watson-Jones approach in the lateral decubitus position and Trident HA acetabular cups were used for all cases. Preoperatively the optimum cup size and position in the acetabular were decided using the ZedHip® software, taking into consideration femoral anteversion and to achieve the maximum range of motion in dynamic motion simulation. Radiographic inclination (RI) was selected in the range between 40°∼45° and radiographic anteversion (RA) in the range between 5°∼25°. Three-dimensional planning images of the cup positioning were obtained from the ZedHip® software, and the distances between the edge of the implant and anatomical landmarks such as the edge of the anterior or superior acetabular wall were measured on the three-dimensional images and recorded (Fig.2). Intraoperatively, the RI and RA were confirmed by reference to these distances and the acetabular cup was inserted. Relative positional information of the implant was extracted from postoperative CT imaging using the ZedHip® software and used to reproduce the position of the implant on preoperative CT imaging with the software image matching function. The difference between the preoperative planning and the actual implant position was measured to assess the accuracy of acetabular cup positioning using the ZedHip® software. Results. Actual cup size corresponded with that of preoperative planning in 95% of cases (114 hips). Postoperative mean RI was 42.3° ± 4.2° (95% confidence interval (CI), 41.5° ∼ 43.0°) and mean RA was 16.1° ± 5.9° (95%CI, 15.0° ∼ 17.1°). Deviation from the target RI was 4.2° ± 3.7° (95%CI, 3.5° ∼ 4.9°) and deviation from the target RA was 4.0° ± 3.6° (95%CI, 3.4° ∼ 4.7°). Overall 116 hips (96.7%) were within the RI safe zone (30° ∼ 50°) and 108 hips (90.0%) were within the RA safe zone (5° ∼ 25°), and 105 hips (87.5%) were within both the RI and RA safe zones (Fig.3). Mean cup shift from preoperative planning was 0.0mm ± 3.0mm to the cranial side in the cranio-caudal direction, 2.1mm ± 3.0mm to the anterior side in the antero-posterior direction, and 1.7mm ± 2.1mm to the lateral side in the medio-lateral direction. Conclusion. The accuracy of acetabular cup positioning using our method of CT-based three-dimensional THA preoperative planning was slightly inferior to reported values for CT-based navigation, but obviously superior to those without navigation and similar to those with portable navigation. CT-based three-dimensional THA preoperative planning is effective for acetabular cup positioning, and has better cost performance than expensive CT-based navigation. For any figures or tables, please contact the authors directly

INTRODUCTION. Unlike current acetabular cups, this novel ceramic cup has a Ti/HA coating which removes the requirement for assembly into a metal shell which avoiding potential chipping/misalignment and reducing wall thickness [Figure 1]. This study examines the resistance of novel thin-walled, direct to bone fixation ceramic cups to critical impact loads. METHODS. Samples of the smallest (Ø46mm) and largest (Ø70mm) diameter ReCerf. TM. acetabular cups and corresponding femoral head implants were implanted into Sawbones foam blocks considered representative of pelvic cancellous bone. Two different positional configurations were tested and were considered worst case and the extremes of surgical compromise; P1 simulates the cup fully supported by the acetabulum with a high inclination angle (70°) and a vertical impaction axis (worst case loading near the cup rim) and. P2 simulates the cup implanted with a lower inclination (55°) but with the superior section unsupported by acetabulum bone [Figure 2]. For each size, three acetabular cups were tested in each position. The impact fixture was positioned within a drop weight rig above a bed of sand and ≈22mm of pork belly representative of soft tissues damping effect and the implant components aligned to achieve the defined impact point on the cup [Figure 2]. Lateral falls were tested on all available samples applying impact energy of 140J [1] and 3m/s impact velocity [2]. After the lateral fall test, each sample was tested under impact conditions equivalent to a frontal car crash considering a peak impact force of 5.7kN occurring 40ms from initial contact (able to produce acetabular fracture)[3]. RESULTS. None of the testing simulating a lateral fall produced fracture or any other damage to the ceramic acetabular cup. In 7 of the 12 tests, the impact force was sufficient to fracture the foam block representing the periprosthetic bone. The cups showed a good stability within the blocks, with a maximum recorded cup spinning angle relative to the acetabulum of 4.5˚. Subsequent testing simulating a car crash resulted in the fracture of two samples out of 12, one of the largest and one of the smallest ReCerf. TM. cups. In both instances, failure occurred very close to the inner edge. Of the remaining 10 samples no cup fractures were observed. All foam acetabulum blocks were severely damaged and 5 blocks fractured. The maximum recorded cup spinning angle following the car crash impact was 5.8˚. SIGNIFICANCE. Extreme testing scenarios presented here are not a regulatory requirement for manufacturers and have not previously been considered for ceramic acetabular components. Fracture is a possible failure mode of ceramics but this testing has proven that modern ceramics can withstand lateral falls and the large majority can withstand subsequent loading equivalent to head on car-crash; loading under which pelvic bone fracture and significant injury is far more likely to occur than implant fracture

Introduction. Proper acetabular cup placement is very important factor for successful clinical results in total hip arthroplasty (THA). Malposition of acetabular cup has been linked to increased rates of dislocation, impingement, pelvic osteolysis, cup migration, leg length discrepancy and polyethylene wear. Recently, some authors reported usefulness of navigation systems to set the acetabular cups with correct position. The purpose of this study is to evaluate the accuracy of acetabular cup placement in THA using computed tomography (CT)-based navigation system. Material and Methods. Subjects were 235 hip joints we performed primary THA using CT based navigation system (Stryker® Navigation System, Stryker Corporation, Kalamazoo, MI, USA) from 2008 to 2014 and could assess the implant position by postoperative CT images. Their average age was 65.1 years (range 35–88). In all cases, non-cemented acetabular cups were implanted. TriAD cups (Stryker®) were used in 31 hips, and Tritanium cups (Stryker®) were used in 15 hips, and Trident cups (Stryker®) were used in 189 hips. Registration in this navigation system used surface matching system. We designed cup implantation using preoperative CT images and 3-dimensional (3-D) templates. The planned position of acetabular cup was in principle 40 degrees of inclination and 20 degrees of anteversion. However, we adjusted the better position of the cups according to pelvic tilt and femoral neck anteversion. When we placed acetabular cups, the position, inclination and anteversion, were measured by navigation system. After surgery, the positions of the cups were measured using postoperative CT images, navigation software and 3-D templates. Postoperative position using CT images were adjusted according to preoperative pelvic plane. The discrepancies between intraoperative navigation data and postoperative CT images data were analyzed as accuracy of navigation system in cup placement. Results. No complications related to navigation procedures were encountered. There was no case with acetabular cup displacement obviously. The discrepancies between intraoperative data and postoperative data were an average difference of 1.6 degrees (SD, 1.4 degrees) for inclination and 2.1 degrees (SD, 1.7 degrees) for anteversion. Discussion and Conclusions. In THA, cup position is very important factor of postoperative long-term success. However, it is not easy to place the acetabular cup with proper position using conventional devices. CT-based navigation system was reported that it had many advantages than previous techniques in preoperative planning, setting the implants and analysis of postoperative data. But in registration with surface matching, learning-curve was pointed out and might be a problem for proper placement of implants. Therefore, we performed this study after some navigation THA cases. In the results of this study, the discrepancies between intraoperative and postoperative data were average 1.6 degrees for inclination and 2.1 degrees for anteversion. The accuracy of navigation system was good in inclination and anteversion of the cups, and there was no complication related it. CT-based navigation system is very useful device

Purpose. Cementless cup with structural allograft is one of option for acetabular revision in the cases which has severe bone loss. This study was performed to verify that the structural allograft with cementless cup could be one of good options for revision of acetabular cup with severe bone defect and to verify that the allograft resorption affect the stability of cementless acetabular cup. Materials and Methods. We reviewed 25 cases of 25 patients who underwent acetabular cup rvision using cementless porous coated hemispherical cup with structural allograft from May 1992 to July 2011 July 2011. There were nine males and sixteen females with an average age of 50.0 years. The average follow-up period was 76.7(28∼212) months. The clinical evaluation was performed using Harris Hip Score(HHS) and UCLA activity score. Radiologically, the degree of resorption of grafted bone, incorporation of allograft bone with normal bone, osteolysis and cup loosening were evaluated. Results. Clinically, the average Harris hip score was improved from 54 preoperatively to 93.4 at the last follow-up. The average UCLA activity score was also improved from 4.3 preoperatively to 6.4 at the last follow-up. Radiologically, the incorporation of allograft was accomplished in 11.4 months and the resorption of grafted bone was noted in 3 cases(12%), but the allograft resorption had not progressed to moderate degree even in long term follow-up. There was no cup loosening and average survivor rate was 100% in 6 years. There was no infection, allograft nonunion, osteolysis. Conclusion. Cementless cup with structural allograft in acetabular cup reconstruction can provide excellent mi-term results in both clinical and radiological aspects. Structural allograft can provide strong mechanical support for the bone ingrowth of cementless cup. The clinical result of this study auggest that cementless cup with structural allograft can be a good option for acetabular cup revision with severe bone defect. Resorption of structural allograft rarely occurred, and the resorption of structural allograft does not affect stablility of cup even in long term follow-up

Introduction. Ultra-high molecular weight polyethylene (UHMWPE) is the sole polymeric material currently used for weight- bearing surfaces in total joint replacement. However, the wear of UHMWPE in knee and hip prostheses after total joint replacement is one of the major restriction factors on the longevity of these implants. In order to minimize the wear of UHMWPE and to improve the longevity of artificial joints, it is necessary to clarify the factors influencing the wear of UHMWPE. A number of studies have investigated the factors influencing the wear of UHMWPE acetabular cup liner in hip prosthesis. Most of these studies, however, have focused on the main articulating surfaces between the femoral head and the polyethylene liner. Materials and Methods. In a previous study (Cho et al., 2016), the generations of cold flow into the screw holes in the metal acetabular cup were observed on the backside of the retrieved UHMWPE acetabular cup liners as shown in Figure 1. We focused on the screw holes in the metal acetabular cup (Figure 2) as a factor influencing the wear behavior of polyethylene liner in hip prosthesis. In this study, computer simulations of the generation of cold flow into the screw holes were performed using the finite element method (FEM) in order to investigate the influence of the screw holes in the metal acetabular cup on the mechanical state and wear behavior of polyethylene liner in hip prosthesis. Results. An example of the results of the FEM simulations performed in this study is shown in Figure 3. In the region which the cold flow into the screw holes occurred, it was found that locally high contact stresses which exceed the yield stress of UHMWPE and considerable plastic strains were generated throughout the overall thickness between the backside and top surface of the polyethylene liners. On the contrary, in the case of the polyethylene liner combined with the metal acetabular cup without screw hole, although the regions of high contact stress and high plastic strain had a tendency to be limited around contact surface compared with those of the combination with screw holes, the values of contact stress and plastic strain were lower than the combination with screw holes. Discussion and Conclusions. The results of this study suggest that the cold flow generated by the existence of the screw holes in the metal acetabular cup of hip prosthesis reduces the wear resistance of the UHMWPE acetabular cup liner. It would appear that the cold flow into the screw holes contributes to structural weakening of the UHMWPE and reduction of the polyethylene thickness, thus increase of internal stresses and plastic strains in and around the regions of cold flow. Therefore, it is required that improvement of the screw holes in the metal acetabular cup and/or improvement of fixation method of the metal acetabular cup to a pelvis in order to enhance the wear resistance of the polyethylene liner. For any figures or tables, please contact authors directly

Acetabular cup placement in total hip replacement surgery is often difficult to assess, especially in the lateral position and using the posterior approach. On table control X-Rays are not always accessible, especially in the government sector. Conventional techniques and computer assisted surgery (CAS), are currently the two most popular methods for proper placement of the acetabular cup in Lewinnek's safe zone of orientation (anteversion 15°–10° and lateral inclination 40°±10°). We developed a simple way to get accurate cup placement using Smartphone technology. Methods:. A spirit level application was downloaded to the Smartphone. The acetabulum inclination was measured on the pre-operative X-Rays. The phone is placed in a sterile bag and then used intra-operatively, to measure and set our acetabular cup orientation to our pre-operative measurements. The inclination level was measured before and after final placement of the acetabular cup. This was compared to the acetabular cup inclination in our post-operative X-Rays. Results:. In our series of 50 cup placements we found high accuracy. The results show less than 5° deviation between our pre-, intra- and post-operative measurements. Conclusions:. Smartphone technology proves to be good alternative to conventional methods and CAS, to improve Acetabular Cup placement in Total Hip Arthroplasty

Introduction. Recent gains in knowledge reveal that the ideal acetabular cup position is in a narrower range than previously appreciated and that position is likely different based on femoral component anteversion. For that reason more accurate acetabular cup positioning techniques will be important for contemporary THA. It is well known that malalignment of the acetabular component in THA may result in dislocation, reduced range of motion or accelerated wear. Up to 8% of THA patients have cups malaligned in version by more than ±10° outside of the Lewinnek safe zone. This type of malalignment may result in dislocation of the femoral head and instability of the joint within the first year, requiring reoperation. Reported incidences of reoperation are 1-9% depending on surgical skills and technique. In addition, cup malalignment is becoming increasingly important as adoption of hard on hard bearings increases as the success of large head hard on hard bearings seems to be more sensitive to cup positioning. This study reports the accuracy of a haptic robotic system to ream the acetabulum and impact an acetabular cup compared to manual instrumentation. Methods. Six fresh frozen cadaveric acetabula were CT scanned and three-dimensional templating of the center of rotation, anteversion and inclination of the cup was determined pre-operatively. Half of the specimens were prepared with manual instrumentation while half were prepared with robotic guidance. Haptic and visual feedback were provided through robotics and an associated navigation system to guide reaming and impaction of the cup. The robot constrained the orientation and position of the instruments thus constraining the inclination, anteversion and center of rotation of the reamer, trial and the final cup. Post-operative CT's were used to determine the achieved cup placement and compared to the pre-operative plans. Results. In all cases, robotic guidance resulted in placement of the acetabular cup within ±3° of anteversion, ±3° of relative to the pre-op plan. The average absolute inclination error was 1.5±1.2° and the average absolute anteversion error 1.3±1.4°. Cup placement with robotic assistance was significantly more accurate and precise than with manual instrumentation. With manual instrumentation the errors were, on average, 4.2 times higher in inclination and 4.8 times higher in anteversion compared to robotic instrumentation. Conclusion. This haptic robotic system substantially improved the accuracy of acetabular reaming and placement of the final cup compared to traditional manual techniques. With greater knowledge of ideal acetabular cup position, highly accurate techniques may allow surgeons to decrease the risk of dislocation, promote durability and improve the ability to restore appropriate leg length and offset. Haptic robotics has proven to be safe and effective in both knee and hip surgery and provides the potential to redefine the “instrument set” used for orthopedic procedures

Background. Supine positioning during direct anterior approach total hip arthroplasty (DAA THA) facilitates use of fluoroscopy, which has been shown to improve acetabular component positioning on plane radiograph. This study aims to compare 2- dimensional intraoperative radiographic measurements of acetabular component position with RadLink to postoperative 3- dimensional SterEOS measurements. Methods. Intraoperative fluoroscopy and RadLink (El Segundo, CA) were used to measure acetabular cup position intraoperatively in 48 patients undergoing DAA THA. Cup position was measured on 6-week postoperative standing EOS images using 3D SterEOS software and compared to RadLink findings using Student's t-test. Safe-zone outliers were identified. We evaluated for measurement difference of > +/− 5 degrees. Results. RadLink acetabular cup abduction measurement (mean 43.0°) was not significantly different than 3D SterEOS in the anatomic plane (mean 42.6°, p = 0.50) or in the functional plane (mean 42.7°, p = 0.61) (Fig. 1–2). RadLink acetabular cup anteversion measurement (mean 17.9°) was significantly different than 3D SterEOS in both the anatomic plane (mean 20.6°, p = 0.022) and the functional plane (mean 21.2°, p = 0.002) (Fig. 3–4). RadLink identified two cups outside of the safe-zone. However, SterEOS identified 12 (anatomic plane) and 10 (functional plane) outside of the safe-zone (Fig. 5–7). In the functional plane, 58% of anteversion and 92% of abduction RadLink measurements were within +/− 5° of 3D SterEOS. Conclusion. Intraoperative fluoroscopic RadLink acetabular anteversion measurements are significantly different than 3D SterEOS measurements, while abduction measurements are similar. Significantly more acetabular cups are placed outside of the safe- zone when evaluated with 3D SterEOS versus RadLink

Introduction. Modern acetabular cups require a convenient bone stock for sufficient cup fixation. Thereby, fixation stability is influenced by the chosen interference fit of the acetabular cup, the cup surface structure, circularity of the reamed acetabulum and by the acetabular bone quality. The ideal implantation situation of the cup is commonly compromised by joint dysplasia and acetabular bone defects. The aim of the present experimental study was to characterise implant fixation of primary acetabular cups in case of definite acetabular cavity defects. Materials and Methods. For the experimental determination bone substitute blocks (100 × 100 × 50 mm) made of polymethacrylimide (PMI) foam with a density of 7 pcf were used. The created acetabular defect situations were derived from the defect classification according to Paprosky. The defect geometries in the PMI foam blocks were realised by a CNC drilling machine. Thereby the defects are described in the dorso-ventral direction by the angle α and in medio-lateral direction by the angle β (given as angle combination α/β) related to the centre of rotation of the reamed cavity. For the lever-out tests the defect types IIb and IIIa (each with different α and β angles) were considered and compared to the intact fixation situation. Therefore, a macrostructured titanium cup (Allofit, Zimmer GmbH, Wintherthur, Switzerland) with an outer diameter of 56 mm were displacement-controlled (v = 20 mm/min) pushed into the 2 mm diametric under reamed PMI-foam cavities. Three cups were inserted until the cup overhang pursuant to surgical technique was reached. Subsequently the cups were displacement-controlled (v = 20 mm/min) levered out via a rod which was screwed into the implant pole by perpendicular displacement (U. axial. ) of the rod in direction of the defect aperture. The lever-out moments were calculated by multiplying the first occurring force maximum (F. max. ) with the effective lever arm length (l. lever. ), whereby moments caused by the deadweight of the rod were considered. Primary stability was defined by the first maximum lever-out moment. Results. The calculated lever-out moments were in a range from 15.5 ± 1.4 Nm to 1.4 ± 0.5 Nm. Defects with a 90° dorso-ventral opening angle showed 57 ± 17% lower lever-out moments. Defects with a 120° dorso-ventral opening angle showed 80 ± 6% lower lever-out moments compared to the cup fixation into intact cavities. Moreover, medio-lateral angles greater than 20° reduced the lever-out moment by 79 ± 12% compared to the intact cavities. Conclusion. The determined lever-out moments underline the reduction of fixation stability of acetabular cup by loss of circumferential rim and absent of superior wall support of the acetabular bone. Thereby, the fixation stability is influenced by the degree of dorso-ventral and medio-lateral defect manifestation. Hence, the fixation stability depends on the cavity surface and in particular the surface of the bone-implant interface in the fixation zone of the acetabular cup Thus, dorso-ventral defect sizes with greater opening angle than 60° and medio-lateral defect sizes greater than 20° are critically for sufficient fixation of primary acetabular cup implants

INTRODUCTION. Poor acetabular cup orientation in total hip arthroplasty (THA) can cause dislocation and impingement, and lead to osteolysis (Little et al., 2009) and inflammatory soft tissue reactions (Haan et al., 2008). While the intrinsic accuracy of cup positioning in navigation is reported as low as 1° (Parratte et al., 2009), a large anterior pelvic tilt may lead to an offset of the same magnitude in the final cup anteversion (Wolf et al., 2005). The objectives of this study are to demonstrate feasibility of a new, non-invasive radiographic tool for accurate preoperative determination of a patient's specific pelvis angle, and intraoperative and postoperative assessment of the acetabular cup orientation with respect to boney landmarks. METHODS. The methodology stitches multiple radiographic views around the pelvis using a multi-planar radiography setup (Amiri et al., 2011) and reconstructs the reference boney landmarks and the acetabular cup in three dimensions using previously developed algorithms and software (Amiri et al., 2012). To validate the methodology, a Sawbone model of the pelvis and femur was implanted with a standard cementless metal-on-polyethylene THA, and was tracked and digitized by an Optotrak motion tracking system. Five radiographic views were acquired at the pubic tubercle (PT) and anterior-superior iliac spine (ASIS) levels (Views 1 to 5 in Fig 1). Imaging and analysis were repeated 10 times. Custom software (Joint 3D) was used to reconstruct the right and left PT and ASIS by fitting spheres to the corresponding pairs of images (Fig 1). The three-dimensional pose of the acetabular cup was reconstructed in the software by solving a back-projection equation of the elliptical shadow of the cup opening. Accuracies were measured as mean differences from the digitized references. A sample of the reconstructed graphical output for the anterior pelvic plane (APP) and the cup, in comparison to the digitized reference, is shown in Fig 2. Repeatability was estimated as standard deviation of the measures for the reconstructed locations of the boney landmarks and the APP (known as a standard reference plane for cup placement). RESULTS. Accuracy for the pelvis pose angles was <1.6°, with SD <0.8° (Fig 3). Pelvic tilt was the most accurate with accuracy of 0.1° and SD=0.4°. For the acetabular cup, accuracy was 2.5° or better, with SD <0.2°. Accuracies in the cup operative anteversion and inclination were 2.4° and 0.6°, with SD=0.4° and 0.9°, respectively. DISCUSSION. The measured accuracies were within an acceptable range, according to previous studies that recommended a 5° cut-off error for acetabular anteversion. The method shows accuracy and radiation dose advantages over current radiographic, fluoroscopic and computed tomography methods. These results suggest that the proposed method is feasible for assessing cup placement with reference to the functional and anatomical references. CONCLUSION. Use of this technique could improve acetabular cup placement and reduce the incidence of instability, wear and loosening, by providing tools to incorporate the individual's pelvic pose in preoperative planning of the surgery, and by serving as an accurate and reliable tool for intraoperative and postoperative assessment of the acetabular cup position

Introduction. Component positioning is of great importance in total hip arthroplasty (THA) and navigation systems can help guide surgeons in the optimal placement of the implants. We report on a newly developed navigation system which employs an inertial measurement unit (IMU) to measure acetabular cup inclination and anteversion. Aims. To assess the accuracy of the IMU when used for acetabular cup placement and compare this with an established optical navigation system (ONS). Methods. At the time of acetabular cup impaction, the IMU and ONS were separately mounted on the impactor handle. Cup inclination and anteversion as measured by each device were recorded. Post-operative CTs were acquired for all patients and used to determine the final cup position. Results. Data were recorded for a total of 100 patients undergoing THA; 51 had a direct anterior approach (DAA) and 49 had a posterior approach (PA). In the DAA group, the mean difference in IMU versus CT measured cup inclination was −0.7°(range −6 to 8º) compared with mean difference of ONS versus CT of −2° (range −8 to 5º). Mean difference in IMU versus CT measured anteversion was − 1.3° (range −10 to 10º) compared with a mean difference of −1.1° (range −23 to 20º) between ONS and CT. In the PA group, mean difference in IMU versus CT inclination was 1.3º (range −8 to 6º) compared with mean difference between ONS versus CT of 1.6° (range −5 to 7º). Mean difference in anteversion was 3.7° (range −7 to 16º) between IMU and CT and 7.3° (range −3 to 19º) between ONS and CT. Conclusion. The novel IMU can be used to accurately determine the position of the acetabular cup at the point of impaction, demonstrating comparable accuracy with an established navigation system in the direct anterior approach, and even greater accuracy in the posterior approach

Objective. The purpose of this study was to investigate how rim poly locking scallop cutting depth could affect the rigidity of acetabular cup. Materials and Methods. (11) generic FEA models including (5) 50mm OD Ti6Al4VELI hemispherical acetabular shells with thicknesses of 3.0, 3.5, 4.0, 4.5 and 5.0mm, and (6) 4mm thick hemispherical shells with standard rim poly indexing scallops varied in cutting depths from inner diameter of the cup in 1.0, 1.5, 2.0, 2.5, 3.0 and 3.5mm. All cups were analyzed in ANSYS® Workbench™ FEA software with a loading condition of 2000N applied to the cup rim per V15 ISO/TC 150/SC 4 N. Verification was carried out by the physical test of a same generic Ti6Al4VELI 50mmOD and 5mm thick solid hemispherical shell under 2000N rim directed load. The cup deformation was compared with FEA results. The maximum deformation of FEA scalloped cups were compared with that of solid hemispherical cups with different shell thickness. Results. The average value for physical test was 0.265(0.282/0.268) mm. The FEA result of the same 50mm OD and 5mm thick shell was 0.2464mm representing a 7% difference. (Figure 1) FEA results for solid hemisphere cups and scalloped shells are shown in Figure 2 and Figure 3 respectively. Conclusion and Discussion. Cup deformation increased in the average of 40% for every 0.5mm shell thickness decrease from 5mm to 3mm for 50mm OD solid cup. The increase of rim scallop depth from 0 to 2.5mm was equivalent to a 0.5mm shell thickness reduction for 4mm thick 50mm OD cup. The higher deformation reading in physical test was likely caused by the accumulations of the fixture deformations. Intraoperative acetabular cup deformation is a clinical issue. It increases the risk of ceramic liner fracture when the liner is inserted in the out of round cup. The increase of shell thickness is a simple and effective way to reduce the cup deformation. However it also reduces the poly thickness and that puts the adverse effects to the poly wear property and poly rim fatigue strength. The common design of the indexing scallops in the rim of cup helps the rotational locking for the poly liner. But the drawbacks including the reduction of cup stiffness must be noticed. The shallower scallop design may be warranted to maximize the cup rigidity in a given cup thickness and maximize poly thickness in a given cup rigidity

Introduction. Robotic-assisted hip arthroplasty helps acetabular preparation and implantation with the assistance of a robotic arm. A computed tomography (CT)-based navigation system is also helpful for acetabular preparation and implantation, however, there is no report to compare these methods. The purpose of this study is to compare the acetabular cup position between the assistance of the robotic arm and the CT-based navigation system in total hip arthroplasty for patients with osteoarthritis secondary to developmental dysplasia of the hip. Methods. We studied 31 hips of 28 patients who underwent the robotic-assisted hip arthroplasty (MAKO group) between August 2018 and March 2019 and 119 hips of 112 patients who received THA under CT-based navigation (CT-navi group) between September 2015 and November 2018. The preoperative diagnosis of all patients was osteoarthritis secondary to developmental dysplasia of the hip. They received the same cementless cup (Trident, Stryker). Robotic-assisted hip arthroplasty were performed by four surgeons while THA under CT-based navigation were performed by single senior surgeon. Target angle was 40 degree of radiological cup inclination (RI) and 15 degree of radiological cup anteversion (RA) in all patients. Propensity score matching was used to match the patients by gender, age, weight, height, BMI, and surgical approach in the two groups and 30 patients in each group were included in this study. Postoperative cup position was assessed using postoperative anterior-posterior pelvic radiograph by the Lewinnek's methods. The differences between target and postoperative cup position were investigated. Results. The acetabular cup position of all cases in both Mako and CT-navi group within Lewinnek's safe zone (RI: 40±10 degree; RA: 15±10 degree) in group were within this zone. Three was no significant difference of RI between Mako and CT-navi group (40.0 ± 2.1 degree vs 39.7± 3.6 degree). RA was 15.0 ± 1.2 degree and 17.0 ± 1.9 degree in MAKO group and in CT-navi group, respectively, with significant difference (p<0.001). The differences of RA between target and postoperative angle were smaller in MAKO group than CT-navi group (0.60± 1.05 degree vs 2.34± 1.40 degree, p<0.001). The difference or RI in MAKO group was smaller than in CT-navi, however, there was no significance between them (1.67± 1.27 degree vs 2.39± 2.68 degree, p=0.197). Conclusions. Both the assistance of the robotic arm and the CT-based navigation system were helpful to achieve the acetabular cup implantation, however, MAKO system achieved more accurate acetabular cup implantation than CT-based navigation system in total hip arthroplasty for the patients with OA secondary to DDH. Longer follow-up is necessary to investigate the clinical outcome

Purposes. To compare the acetabular component size relative to the patient's native femoral head size between conventional THA (CTHA) approach and robotic-guided THA (RGTHA) to infer which of these techniques preserves more acetabular bone. Methods. Patients were included if they had primary osteoarthritis (OA) and underwent total hip replacement between June 2008 and March 2014. Patients were excluded if they had missing or rotated postoperative anteroposterior radiographs. RGTHA patients were matched to a control group of CTHA patients, in terms of pre-operative native femoral head size, age, gender, body mass index (BMI) and approach. Acetabular cup size relative to femoral head size was used as a surrogate for amount of bone resected. We compared the groups according to two measures describing acetabular cup diameter (c) in relation to femoral head diameter (f): (1) c-f, the difference between cup diameter and femoral head diameter and (2) (c-f)/f, the same difference as a fraction of femoral head diameter. Results. 57 matched pairs were included in each group. There were no significant differences between groups for demographic measures, femoral head diameter, or acetabular cup diameter (p>0.05). However, measures (1) and (2) did differ significantly between the groups, with lower values in the RGTHA group (p<0.02). Conclusion. Using acetabular cup size relative to femoral head size as an approximate surrogate measure of acetabular bone resection may suggest greater preservation of bone stock using RGTHA compared to CTHA. Further studies are needed to validate the relationship between acetabular cup size and bone loss in THA

Objectives. Porous metal surfaces have been a popular option for acetabular component fixation in total hip arthroplasty (THA). New THA component designs are introduced periodically with the expectation of better wear properties and survivorship. Since its approval for use in 2002 there have been few clinical outcome studies published on the Pinnacle acetabular cup system. We hypothesised that the hemispherical porous coated Pinnacle acetabular cup system with a range of cup options and bearing surfaces would give us predictably good fixation and survivorship at five years post implantation. Materials and Methods. A total of 1391 Pinnacle acetabular cups (De Puy, a Johnson & Johnson company, Warsaw IN) were implanted between the period March 2003 to August 2011 by four senior surgeons. There were a total of 29 patients requiring revision surgery. Of these revisions, 23 were excluded from the final analysis. Sixteen were for early infection requiring debridement of the hip joint and exchange of the modular liner and femoral head. Five patients sustained femoral peri-prosthetic fractures requiring further surgery with retention of the acetabular component in all cases. Of the remaining 8 revision cases, only 6 had more than two years follow-up. All patients had pre and post-operative Harris hip scores, WOMAC and SF-12 scores. All patients were assessed with serial radiographs immediately post-operatively, 3 months, 1 year, 2 years, every 2 years thereafter. Component migration and revisions (excluding infection and peri-prosthetic fractures) are reported as failures. Post-operative radiographs were evaluated for component migration. Kaplan-Meier survivorship curves were drawn to show survivorship for cup type and bearing type. Results. A total of 894 Pinnacle acetabular components implanted into 796 patients were available for inclusion in the final analysis. There were 358 males with an average age of 63.70 years and 438 females with an average age of 64.55 years. The average period for follow-up was 44.95 months with 133 patients having more than five years of follow-up. Only one cup showed signs of aseptic loosening and component migration on plain radiographs, this patient had previously sustained an acetabular fracture requiring open reduction and internal fixation ans subsequently developed osteoarthritis. The cup failed to adequately in-grow and migrated medially to an intra-pelvic position, this was revised to a Trabelcular Metal cup with bone grafting to the acetabulum. There were two cases revised for instability. Three revisions were performed for aseptic loosening of the femoral components which were revised with retention of the acetabular cups. Conclusion. Published data on the performance of various porous coated cups have demonstrated varying degrees of osteolysis, however the Pinnacle cup has shown excellent midterm results postulated to be associated with the taper lock liner mechanism of the Pinnacle cups resulting in less micromotion and, therefore, reduced hydraulic pressure pumping polyethylene wear debris behind the cup. Our study confirms excellent overall survivorship of the Pinnacle acetabular porous coated cup system at a minimum of two years followup in over 790 patients

Total hip replacement (THR) is one of the most successful orthopedic operations, yet it continues to be plagued with problems despite the many advances in the procedure. Inconsistent placement of the acetabular cup persists even in the hands of most experienced surgeons, leading to early and late failure including instability, impingement, polyethylene wear, osteolysis, and component loosening. Cup mal-position is the single greatest cause of early instability and late polyethylene wear. Despite advent of recent technology including navigation and use of fluoroscopy cup mal-alignment persists. Several studies show 50% of experienced surgeons missing the target ranges using Lewinnnk desired safe zones. The act of impaction of the cup with a mallet is a crude and unreliable process. The surgeon's mallet imparts large and uncontrolled forces on the impaction rod creating variable torques, leading to inconsistent cup placement. Navigation and Fluoroscopy add precision to the operation however that level of precision is not maintained throughout the course of the operation. There is a market need for a tool that helps maintain “precision tolerance” through out the course of the operation. A new device is theoretically proposed and prototyped for this process (Patent Pending). The new paradigm involves elimination of impaction forces created by unpredictable blows of the mallet. A low energy and high frequency device is utilized to insert and position the acetabular cup without the use of the mallet. The cup is inserted (not impacted) with significantly less force than the typical 2000N forces created with a mallet. The cup is also simultaneously positioned to the desired alignment while the device is active with the surgeon effectively feeling minimal haptic resistance to the movement of the cup. The system therefore proposes to eliminate cup mal-alignment for all surgeons, removing the primary cause of hip dislocations as well as factors contributing to late failure. In addition the idea allows the academic surgeon to better study the relationship of the position of the cup and clinical outcomes eliminating the need to use “safe zone ranges”. As well, this process completely eliminates acetabular fractures as a complication of this operation. Two devices were prototyped with use of electrical and pneumatic energy. Both devices proved the concept. Both devices allowed modulation of the applied force and “effective” disarming of the frictional forces involved in cup impaction, allowing insertion and positioning of the acetbular cup to occur with smooth haptic control and without the use of violent force. The device can be used individually, with navigation and fluoroscopy, with robots and/or with any other intra-operative measurement device and can be a significant adjunct for THR. Cup Mal-Alignment is an unsolved problem in THR surgery causing poor outcomes for patients, anxiety and a sense of failure for the surgeons, and a great cost to society in general. A new device is described to solve this problem. The science involved is proposed and described in detail and primarily involves understanding and utilizing the mechanical properties of bone/pelvis and understanding and manipulating the complex frictional forces at play

Introduction:. The lateral radiographs are useful in evaluation of the acetabular cup anteversion. However, this method was affected by variations in pelvic position and radiographic technique. In this study, we employed the ischial axis (IA) as an anatomical landmark on the lateral radiographs, and we investigated a relationship between IA and the anterior pelvic plane (APP) using three-dimensional computed tomography (3D-CT). Using these findings, we report a new method for accurate measurement of the acetabular cup anteversion on plain lateral radiographs using IA as an anatomical reference. Materials and Methods:. At first, preoperative3D-CT images were obtained in 109 patients who underwent total hip arthroplasty. The diagnosis was osteoarthritis in all patients. The angle between the IA (defined by a line connecting the anterior edge of the greater sciatic notch and the lesser sciatic notch) and APP (defined by the bilateral anterosuperior iliac spine and the symphysis) was measured on 3D-CT (Fig. 1). Secondly, postoperative lateral radiographs were obtained at 2 weeks, 4 weeks, 12 weeks, 24 weeks, and 52 weeks after surgery in 15 patients. The angle between a line tangential to the opening of the cup and a line perpendicular to APP was measured (Fig. 2). Three methods of acetebular cup position assessment were compared: 1) the present method, 2) Woo and Morrey method, and 3) software (2D template, Kyocera) method. Results:. The mean angle between IA and APP was 18.0 ± 3.5°. The mean acetabular cup anteversion measured using present method was 21.3°, Woo and Morrey method was 26.6°, and software method was 21.2°. The mean SDs of present method was 0.64°, Woo and Morrey method was 1.17°, and software method was 0.46°. Conclusions:. APP, considered as vertical in weight bearing, has a relatively consistent relationship between IA. The findings of this study provide a more consistent measurement of acetabular cup by reducing variation due to pelvic position

Initial stability of cementless components in bone is essential for longevity of Total Hip Replacements. Fixation is provided by press-fit: seating an implant in an under-reamed bone cavity with mallet strikes (impaction). Excessive impaction energy has been shown to increase the risk of periprosthetic fracture of bone. However, if implants are not adequately seated they may lack the stability required for bone ingrowth. Ideal fixation would maximise implant stability but would minimise peak strain in bone, reducing the risk of fracture. This in-vitro study examines the influence of impaction energy and number of seating strikes upon implant push-out force (indicating stability) and peak dynamic strain in bone substitute (indicating likelihood of fracture). The ratio of these factors is given as an indicator of successful impaction strategy. A custom drop tower with simulated hip compliance was used to seat acetabular cups in 30 Sawbone blocks with CNC milled acetabular cavities. 3 impaction energies were selected; low (0.7j), medium (4.5j) and high (14.4j), representing the wide range of values measured during surgery. Each Sawbone was instrumented with strain gauges, secured on the block surface close to the acetabular cavity (Figure 1). Strain gauge data was acquired at 50 khz with peak tensile strain recorded for each strike. An optical tracker was used to determine the polar gap between the cup and Sawbone cavity during seating. Initially 10 strikes were used to seat each cup. Tracking data were then used to determine at which strike the cups progressed less than 10% of the final polar gap. This value was taken as number of strikes to complete seating. Tests were repeated with fresh Sawbone, striking each cup the number of times required to seat. Following each seating peak push-out forces of the cups were recorded using a compression testing machine. 10, 5 and 2 strikes were required to seat the acetabular cups for the low, medium and high energies respectively. It was found that strain in the Sawbone peaked around the number of strikes to complete seating and subsequently decreased. This trend was particularly pronounced in the high energy group. An increase in Sawbone strain during seating was observed with increasing energy (270 ± 29 µε [SD], 519 ± 91 µε and 585 ± 183 µε at low, medium and high energies respectively). The highest push-out force was achieved at medium strike energy (261 ± 46N). The ratio between push-out and strain was highest for medium strike energy (0.50 ± 0.095 N/µε). Push-out force was similar after 5 and 10 strikes for the medium energy strike. However push-out recorded at ten strikes for the high energy group was significantly lower than for 2 strikes (<40 ± 19 N, p<0.05). These results indicate that a medium strike energy with an appropriate number of seating strikes maximizes initial implant stability for a given peak bone strain. It is also shown that impaction with an excessive strike energy may greatly reduce fixation strength while inducing a very high peak dynamic strain in the bone. Surgeons should take care to avoid an excessive number of impaction strikes at high energy. For any figures or tables, please contact the authors directly

Introduction. Durable bone fixation of uncemented porous-coated acetabular cups can be observed at a long-term, however, polyethylene (PE) wear and osteolysis may affect survivorship. Accurate wear measurements correlated with clinical data may offer unique research information of clinical interest about this highly debated issue. Objetive. We assessed the clinical and radiological outcome of a single uncemented total hip replacement (THR) after twenty years analysing polyethylene wear and the appearance of osteolysis. Materials and Methods. 82 hips implanted between 1992 and 1995 were prospectively evaluated with a mean follow-up of 20.6 years (range, 18 to 23). A hemispherical porous-coated acetabular cup matched to a proximally hydroxyapatite-coated anatomic stem and a 28 mm standard PE liner, sterilised by gamma irradiation in air, was used in all hips. Radiological position and the possible appearance of loosening and osteolysis were recorded over time. Penetration of the prosthetic head into the liner was measured by the Roentgen Monographic Analysis (ROMAN) Tool at 6 weeks, 6 months, one year and yearly thereafter. Results. Six cups were revised due to wear and four due to late dislocation. All cups were radiographically well-fixed and all stems showed radiographic ingrowth. Six un-revised hips showed osteolysis on the acetabular side and two on the proximal femoral side. Creep at one year was 0.30 (±0.23) mm. Mean total femoral head penetration was 1.23 mm at 10 years, 1.52 mm at 15 years and 1.92 mm at 23 years. Overall mean wear was 0.12 (± 0.1) mm/year and 0.09 (±0.06) mm/year after the creep period. Mean wear was 0.08 (± 0.06) mm/year in hips without osteolysis and 0.14 (±0.03) mm/year in revised hips or with osteolysis (p<0.001). Conclusions. Although continued durable fixation can be observed with a porous-coated cups and a proximally hydroxyapatite-coated anatomic stem, true wear continues to increase at a constant level over time. PE wear remains as the main reason for revision surgery and osteolysis in uncemented THR after twenty years