INTRODUCTION. Understanding bone morphology is essential for successful computer assisted orthopaedic surgery, where definition of normal anatomical variations and abnormal morphological patterns can assist in surgical planning and evaluation of outcomes. The proximal femur was the anatomical target of the study described here. Orthopaedic surgeons have studied femoral geometry using 2D and 3D radiographs for precise fit of bone-implant with biological fixation. METHOD. The use of a Statistical Shape Model (SSM) is a promising venue for understanding bone morphologies and for deriving generic description of normal anatomy. A SSM uses measures of statistics on geometrical descriptions over a population. Current SSM construction methods, based on Principal Component Analysis (PCA), assume that shape morphologies can be modeled by pure point translations. Complicated morphologies, such as the femoral head-neck junction that has non-rigid components, can be poorly explained by PCA. In this work, we showed that PCA was impotent for processing complex deformations of the proximal femur and propose in its place our Principal Tangent Component (PTC) analysis. The new method used the Lie algebra of affine transformation matrices to perform simple computations, in tangent spaces, that corresponded to complex deformations on the data manifold. RESULTS. Both PCA and PTC were applied to the proximal femur dataset, from which selected femurs were reconstructed using the accumulation of components. PCA was deemed to have failed to reconstruct the surfaces because it required 65 components to achieve high coverage of the dataset. An important observation was that the head-neck junction was the most difficult section in the femur, requiring more components than other anatomical regions to reconstruct. This finding is consistent with the surgical observation that deformations occur in this junction for abnormal hip morphologies. PTC was successful in recovering 100% of the medical data using the only the first 5 components. We note that the encoding of deformation in PTC accounting for the performance increase. PTC outperformed PCA on the dataset in descriptive compactness. CONCLUSION. A standard SSM construction method was not adequate for analysing proximal femur surfaces because it could not easily model the complexity of non-rigid deformations at the head-neck junction. Principal tangent components, a novel method for using exponential maps on manifolds, accurately reconstructed the anatomical surfaces with very few components. Future work may include extending these concepts to describe joint diseases based on the shape of surfaces derived from volumetric data, such as CT or MRI. In conclusion, we have shown that differential geometry may be provide new insights to computational anatomy applications

Introduction. The first carpometacarpal (CMC) joint is the second most common joint of the hand affected by degenerative osteoarthritis (OA). 1. Laxity of ligamentous stabilizers that attach the first metacarpal bone (MC1) and the trapezium bone (TZ), notably the volar anterior oblique ligament (AOL), has been associated with cartilage wear, joint space narrowing, osteophyte formation, and dorsal-radial CMC subluxation. 2. In addition, the proximal-volar end of the MC1 has a bony prominence known as the palmar lip (PL) that adds conformity to this double-saddle joint, and is thought to be a supplemental dorsal stabilizer. Currently, no study has looked at the changes to the 3D shape and relative positions of these structures with OA. Methods. CT scans of patients with clinically diagnosed CMC OA (n=11, mean age 73 [60–97], 8 females) and CT scans of ‘normal’ patients with no documented history of CMC OA (n=11, mean age 37 [20–51], 6 females) were obtained with the hand in a prone position. 3D reconstructions of the MC1 and TZ bones were created, and each assigned a coordinate system. 3. The long axis of the MC1 and the proximal-distal axis of the TZ were established, and the location where they intersected the CMC articular surface was defined as their articular center points, X and O, respectively (Figure 1). Using the TZ as a fixed reference, we calculated the relative position of X in the dorsal-ventral and radial-ulnar directions. A two sample t-test was performed to compare the normal and OA groups. In addition, the distal position of the PL relative to X was recorded. Results. The dorsal position of the MC1 relative to the TZ was significantly greater (p=0.002) in the OA group compared with the normal group, with mean dorsal positions of 7.1 and 3.2mm, respectively (Figure 2). The distal position of the PL relative to X was also significantly greater (p=0.001) in the OA group when compared with the normal group, with mean positions of 5.8 and 1.9mm, respectively (Figure 3). Discussion. Dorsal migration of the MC1 in the OA group would suggest a compromised AOL, known to be elongated or absent intraoperatively. Without a sufficient AOL, the PL was positioned more distally in the OA group, as the load on the PL during extension activities could possibly exceed cartilage strength resulting in subchondral bone remodeling and further joint degeneration. We did not observe radial migration of the MC1 bone possibly due to the presence of bony osteophytes that can reduce abduction-adduction function in OA patients. 4. The relationship discovered between OA and changes to bone morphology and relative bone positions of the CMC joint may provide further insight into the natural progression of this disease

Knee laxity following anterior cruciate ligament (ACL) injury is a complex phenomenon influenced by various biomechanical and anatomical factors. The contribution of soft tissue injuries – such as ligaments, menisci, and capsule – has been previously defined, but less is known about the effects of bony morphology. (Tanaka et al, KSSTA 2012) The pivot shift test is frequently employed in the clinical setting to assess the combined rotational and translational laxity of the ACL deficient knee. In order to standardise the maneuver and allow for reproducible interpretation, the quantitative pivot shift test was developed. (Hoshino et al, KSSTA 2013) The aim of this study is to employ the quantitative pivot shift test to determine the effects of bone morphology as determined by magnetic resonance imaging (MRI) on rotatory laxity of the ACL deficient knee. Fifty-three ACL injured patients scheduled for surgical reconstruction (36 males and 17 females; 26±10 years) were prospectively enrolled in the study. Preoperative magnetic resonance imaging (MRI) scans were reviewed by two blinded observers and the following parameters were measured: medial and lateral tibial slope, tibial plateau width, femoral condyle width, bicondylar width, and notch width. (Musahl et al. KSSTA 2012). Preoperatively and under anaesthesia, a quantitative pivot shift test was performed on each patient by a single experienced examiner. An image analysis technique was used to quantify the lateral compartment translation during the maneuver. Subjects were classified as “high laxity” or “low laxity” based upon the median value of lateral compartment translation. (Hoshino et al. KSSTA 2012) Independent t-tests and univariate logistic regression were used to investigate the relationship between the pivot shift grade and various features of bone morphology. Statistical significance was set at p<0.05. A high inter-rater reliability was observed in all MRI measurements of bone morphology (ICC=0.72–0.88). The median lateral compartment translation during quantitative pivot shift testing was 2.8mm. Twenty-nine subjects were classified as “low laxity” (2.8mm). The lateral tibial plateau slope was significantly increased in “high laxity” patients (9.3+/−3.4mm versus 6.1+/−3.7mm; p<0.05). No other significant difference in bone morphology was observed between the groups. This study employed an objective assessment tool – the quantitative pivot shift test – to assess the contribution of various features of bone morphology to rotatory laxity in the ACL deficient knee. Increased lateral tibial plateau slope was shown to be a significant independent predictor of high laxity. These findings could help guide treatment strategies in patients with high grade rotatory laxity. Further research into the role of tibial osteotomies in this sub-group is warranted

Introduction. The ability to create patient-specific implants (PSI) at the point-of-care has become a desire for clinicians wanting to provide affordable and customized treatment. While some hospitals have already adopted extrusion-based 3D printing (fused filament fabrication; FFF) for creating non-implantable instruments, recent innovations have allowed for the printing of high-temperature implantable polymers including polyetheretherketone (PEEK). With interest in FFF PEEK implants growing, it is important to identify methods for printing favorable implant characteristics such as porosity for osseointegration. In this study, we assess the effect of porous geometry on the cell response and mechanical properties for FFF-printed porous PEEK. We also demonstrate the ability to design and print customized porous implants, specifically for a sheep tibial segmental defect model, based on CT images and using the geometry of triply periodic minimal surfaces (TPMS). Methods. Three porous constructs – a rectilinear pattern and gyroid/diamond TPMSs – were designed to mimic trabecular bone morphology and manufactured via PEEK FFF. TPMSs were designed by altering their respective equation approximations to achieve desired porous characteristics, and the meshes were solidified and shaped using a CAD workflow. Printed samples were mCT scanned to determine the resulting pore size and porosity, then seeded with pre-osteoblast cells for 7 and 14 days. Cell proliferation and alkaline phosphatase activity (ALP) were evaluated, and the samples were imaged via SEM. The structures were tested in compression, and stiffness and yield strength values were determined from resulting stress-strain plots. Roughness was determined using optical profilometry. Finally, our process of porous structure design/creation was modified to establish a proof-of-concept workflow for creating PSIs using geometry established from segmented sheep tibia CT images. Results. ALP activity measurements of the porous PEEK samples at 7 and 14 days were significantly greater than for solid controls (p < 0.001 for all three designs, 14 days). No difference between the porous geometries was found. SEM imaging revealed cells with flat, elongated morphology attached to the surface of the PEEK and into the pore openings, with filopodia and lamellipodia extensions apparent. mCT imaging showed average pore size to be 545 ± 43 µm (porosity 70%), 708 ± 64 µm (porosity 68%), and 596 ± 94 µm (porosity 69%) for the rectilinear, gyroid, and diamond structures, respectively. The average error between the theoretical and actual values was −16.3 µm (pore size) and −3.3 % (porosity). Compression testing revealed elastic moduli ranging from 210 to 268 MPa for the porous samples. Yield strengths were 6.6 ± 1.2 MPa for lattice, 14.8 ± 0.7 MPa for gyroid, and 17.1 ± 0.6 for diamond. Average roughness ranged from 0.8 to 3 µm. Finally, we demonstrated the ability to design and print a fully porous implant with the geometry of a sheep tibia segment. Assessments of implant geometrical accuracy and mechanical performance are ongoing. Discussion. We created porous PEEK with TPMS geometries via FFF and demonstrated a positive cellular response and mechanical characteristics similar to trabecular bone. Our work offers an innovative approach for advancing point-of-care 3D printing and PSI creation

Evaluate precisely and reproducibly tridimensional positioning of bone tunnels in anterior cruciate ligament reconstructions (ACL). To propose biplanar stereoradiographic imaging as a new reference in tridimensional evaluation of ACL reconstruction (ACLR). Comparing knee 3D models issued from EOStm low-irradiation biplanar X-Ray with those issued from computed tomography (CT-Scan) high definition images will allow a bone morphological description of a previously unseen precision. We carried out the transfer of 3D models from EOStm X-Ray images obtained from 10 patients in the same reference frame with models issued from CT-Scan. Two evaluators reconstructed both pre-operative and post-operative knees, using two different stereoradiographic projections, for a total of 144 knee 3D models from EOStm. A surface analysis by distance mapping allowed us to know the differences or errors between the homologous points of the EOStm and CT reconstructions, the latter being our “bronze-standard”. At the femur, we obtained a mean (95% confidence level) error of 1.5 mm (1.3–1.6) between the EOStm models compared to the Arthro-CT segmentations when using AP-LAT incidences, compared to 1 mm (1.0 – 1.1) with oblique projections. For the tunnels placement analysis, the total radius difference between EOStm and Arthro-CT's femoral tunnel apertures was 0.8 mm (0.4–1.2) in AP-LAT and 0.6 mm (0.0–1.2) in oblique views. These femoral apertures positioning on EOStm models were within 4.3 mm (3.0–5.7) of their homologues on CT-Scan models, 4.6 mm (3.5–5.6) with the oblique views. Furthermore, 9.3o (7.2–11.4) of difference in direction between femoral tunnels from EOStm models and CT reconstructions is obtained with AP-LAT projections, 8.3o (6.6–10) with obliques views. Measures of these parameters were also performed at the tibia. According to the intra and inter-reproducibility analysis of our knee 3D models, EOStm biplanar X-Ray images prove to be fast, efficient and precise in the design of ACLR 3D models with respect to CT-Scan. Our results also propose the recourse of oblique stereoradiographic projections for the realization of knee 3D models. These models will be subjects of further analysis and will allow us eventually to propose a new frame of reference guiding the positioning of the tunnels in the ACLR

INTRODUCTION. It is generally accepted that strong hammering is necessary for the press fit fixation of a joint prosthesis. In this regard, large stress must remain within bone tissues for a long period. This residual stress is, however, some different from the feasible mechanical stimuli for bone tissues because that is stationary, continuous and directed from within outward unlike physiological conditions. The response on this residual stress, which may induce the disorder of the fixation of implant, has not been discussed, yet. In the present study, we designed an experimental method to exert a stationary load from inside of a femur of a rat by inserting a loop spring made from a super elastic wire of titanium alloy. Response of the femur was assessed by bone morphology mainly about the migration of the wire into the bone twelve weeks after the implantation. MATERIALS AND METHODS. We developed a method using a loop spring made of super elastic wire of titanium alloy, which can maintain sufficient magnitude of stress in a rat femur during the experimental period. The loop spring was fabricated with a wire of 0.4 mm diameter before the quenching process. Eleven Wistar rats of ten weeks old were used for the experiments. The loop spring was inserted the right femur, as shown in Figure 1. The left femur was remained intact. The compressive load was added from within outward of bone marrow when the spring was compressed with the insertion into a bone marrow of a rat femur, as shown in Figure 2. The average contact stress was calculated by dividing the elastic force by the spring and bone contact area. The contact stress was distributed from 62 to 94 MPa, which are sufficiently lower than the yield stress of cortical bone [1]. The assessment of bone morphology around the implanted loop spring was performed by micro-CT imaging after the twelve weeks of cage activity. RESULTS. To assess the migration of the spring in the femur, we measured the distance from the endocortical surface to the periphery of the spring, on the micro CT image, as shown in Figure 3. Apparent migration of the spring wire was observed on nine specimens among the eleven. Deep migration over 0.3 mm was observed at three cases. DISCUSSION. The migration of the wire in cortical bone was accompanied with the bone resorption on the surface of the wire toward outside. Therefore, the present findings suggest that stationary load at the implant surface can induce endosteal bone resorption and prosthesis dislocation and protrusion. CONCLUSION. We developed a method for configuring a stationary stress field in a rat femur using a loop spring with the super elasticity. It was found that stationary stress about 70 MPa can induce bone resorption

Introduction:. Although cementless total hip arthroplasty (THA) is well accepted, the optimal femoral component design remains unknown. Among early complications, loosening and periprosthetic fracture persist and are related to implant design. The purpose of this study is to compare the anatomic fit and early subsidence of two different stem designs: a modern, short taper-wedge design and a traditional fit-and-fill design. Methods:. A retrospective cohort study of 129 consecutive cementless THAs using two different femoral stems was performed. A modern taper-wedge stem was used in 65 hips and a traditional proximal fit-and-fill stem was used in 64 hips. Radiographic analysis was performed at preoperative, immediate postoperative and 1-month postoperative intervals. The radiographic parameters of bone morphology via the canal-flare index, implant subsidence at 1 month, sagittal alignment, and the “anatomic fit” metrics of canal fill and associated gaps were measured and recorded. Results:. There were no differences between groups in patient demographics (p > 0.4), and in bone morphology via the canal-flare index (p = 0.6) with numbers available. The mean subsidence was less in the taper-wedge design at 0.27 mm compared to 1.1 mm in the fit-and-fill stem (p < 0.0001). Subsidence greater than 2 mm occurred in 26 of 64 fit-and-fill stems (41%) compared to 1 of 65 taper-wedge implants (1.5%). The percentage fill at all levels measured was greater in the taper-wedge design (p < 0.0001). The taper-wedge design was inserted a mean of 2.7° sagittal extension compared to 0.4° in the fit-and-fill design (p < 0.0001). Conclusion:. Despite being shorter in length, the taper-wedge design demonstrates greater axial stability and less subsidence compared to a traditional fit-and-fill stem. The optimized proximal femoral fit inherent in this anatomic-based taper-wedge design is likely responsible for the minimal subsidence. The clinical implication of greater extension in the sagittal plane is unknown and longer-term clinical follow up is warranted

Pre-existing hip pathology such as femoroacetabular impingement is believed by some, to have a direct causal relationship with osteoarthritis of the hip. The strength of this relationship remains unknown. We investigate the prevalence of abnormal bone morphology in the symptomatic hip on the pre-operative anteroposterior pelvic radiograph of consecutive patients undergoing hip resurfacing. Rotated radiographs were excluded. One hundred patients, of mean age 53.5 years were included (range 33.4–71.4 years, 32% female). We examined the films for evidence of a cam-type impingement lesion (alpha angle >50.5°, a pistol grip, Pitt's pits, a medial hook, an os acetabuli and rim ossification), signs of acetabular retroversion or a pincer-type impingement lesion (crossover sign, posterior wall sign, ischial sign, coxa profunda, protrusio, coxa vara, Tonnis angle < 5°), and hip dysplasia (a Tonnis acetabular angle >14° and a lateral centre-edge angle of Wiberg <20°). Pre-existing radiographic signs of pathology were present in a large proportion of hips with low grade (Tonnis grade 1–2) arthritis. There is a group of patients who presented with more advanced osteoarthritis in which we suspect abnormal bone morphology to be a causative factor but, for example, neck osteophytes obscure the diagnosis of a primary cam lesion. Our findings corroborate those of Harris and Ganz. Impingement is radiographically detectable in a large proportion of patients who present with early arthritis of the hip, and therefore we agree that it is a likely pre-cursor for osteoarthritis. Treatments directed at reducing hip impingement may stifle the progression of osteoarthritis

Introduction. Trabecular Titanium is a biomaterial characterized by a regular three-dimensional hexagonal cell structure imitating trabecular bone morphology. Components are built via Electron Beam Melting technology in aone- step additive manufacturing process. This biomaterial combines the proven mechanical properties of Titanium with the elastic modulus provided by its cellular solid structure (Regis 2015 MRS Bulletin). Several in vitro studies reported promising outcomes on its osteoinductive and osteoconductive properties: Trabecular Titanium showed to significantly affect osteoblast attachment and proliferation while inhibiting osteoclastogenesis (Gastaldi 2010 J Biomed Mater Res A, Sollazzo 2011 ISRN Mater Sci); human adipose stem cells were able to adhere, proliferate and differentiate into an osteoblast-like phenotype in absence of osteogenic factors (Benazzo 2014 J Biomed Mater Res A). Furthermore, in vivo histological and histomorphometric analysis in a sheep model indicated that it provided bone in-growth in cancellous (+68%) and cortical bone (+87%) (Devine 2012 JBJS). A multicentre prospective study was performed to assess mid-term outcomes of acetabular cups in Trabecular Titanium after Total Hip Arthroplasty (THA). Methods. 89 patients (91 hips) underwent primary cementless THA. There were 46 (52%) men and 43 (48%) women, with a median (IQR) age and BMI of 67 (57–70) years and 26 (24–29) kg/m2, respectively. Diagnosis was mostly primary osteoarthritis in 80 (88%) cases. Radiographic and clinical evaluations (Harris Hip Score [HHS], SF-36) were performed preoperatively and at 7 days, 3, 6, 12, 24 and 60 months. Bone Mineral Density (BMD) was determined by dual-emission X-ray absorptiometry (DEXA) according to DeLee &Charnley 3 Regions of Interest (ROI) postoperatively at the same time-points using as baseline the measureat 1 week. Statistical analysis was carried out using Wilcoxon test. Results. Median (IQR) HHS and SF-36 improved significantly from 48 (39–61) and 49 (37–62) preoperatively to 99 (96–100) and 76 (60–85) at 60 mo. (p≤0.0001). Radiographic analysis showed evident signs of bone remodelling and biological fixation, with presence of superolateral and inferomedial bone buttress, and radial trabeculae in ROI I/II. All cups resulted radiographically stable without any radiolucent lines. The macro-porous structure of this biomaterial generates a high coefficient of friction (Marin 2012 Hip Int), promoting a firm mechanical interlocking at the implant-bone interface which could be already observed in the operating room. BMD initially declined from baseline at 7 days to 6 months. Then, BMD slightly increased or stabilized in all ROIs up to 24 months, while showing evidence of partial decline over time with increasing patient' age at 60 months, although without any clinical significance in terms of patients health status or implant stability. Statistical significant correlations in terms of bone remodeling were observed between groups of patients on the basis of gender and age (p≤0.05). No revision or implant failure was reported. Conclusions. All patients reported significant improvements in quality of life, pain relief and functional recovery. Radiographic evaluation confirmed good implant stability at 60 months. These outcomes corroborate the evidence reported on these cups by orthopaedic registries and literature (Perticarini 2015 BMC Musculoskelet Disord; Bistolfi 2014 Min Ortop)

Introduction:. Subchondral bone density (SBD) distribution is an important parameter regarding that may be important when considering implant stability. This parameter is a reflection of the loading experienced by the joint throughout the lifetime and may be useful in pre-surgical planning and implant design. Clinically, the question of the glenoid surface preparation for TSA/RSA remains controversial, despite numerous published studies on glenoid bone morphology. To address this question, there exists a need to develop a 3D quantitative method capable of analyzing the complex glenoid bone morphology at different depths from the surface. Computed tomographic osteoabsoptiomery (CT-OAM) evaluates SBD based on the Housfield Unit (HU) value of each pixel. In this pilot study, we aimed to analyze SBD distribution of the glenoid at different depths by means of CT-OAM in male TSA subjects. Materials and Methods:. A study group of twenty male TSA patients (61–69y.o) were included in this study. Each subject obtained a pre-operative CT scan following a standardized protocol on the same CT scanner (1.25 mm slice thickness). Resultant DICOM 2D images were processed in custom-written program (VC++) and the surface of every glenoid was manually traced from the axial slices. Care was taken during the manual tracing process to exclude osteophytes and cyst formations from the resultant surface. Values of HU at every selected pixel on the surface of the glenoid were recorded. Subsequently, the layer of pixels at a 0.5 mm distance from the previous surface was virtually scraped and the HU values of new layer of pixels were recorded. This routine was repeated up to a depth of 5 mm from the glenoid surface, taking measurements on 11 virtual 3D surfaces with a thickness of 0.5 mm. Mean SBD distribution was reported for each layer and differences were compared using ANOVA and Fisher's post-hoc test. Results:. Apparent differences in mean SBD distribution were identified at every measured depth from the glenoid surface (Fig. 1). Significant differences (Tab.1) were identified between the middle range of studied surfaces (2.5–4.5 mm) when compared to the superficial (0–1.5 mm, p < 0.0001) and deep layers (5 mm, p < 0.0001). The maximum mean value of HU (1635.9 ± 35.5) was measured at 3.5 mm depth and the minimum value of HU was measured on the surface of the glenoid (1445.8 ± 31.3). Discussion:. The stability of the glenoid component in TSA prostheses is highly dependent on the SBD distribution. Controversy among orthopaedic surgeons exists regarding the depth of reaming required to prepare an arthritic glenoid. Extensive reaming may lead to the violation of the support provided by the denser subchondral bone; however, optimal match between the bone and glenoid component undersurface is highly desirable. This study demonstrates that the density of the bone is sustained up to a depth of approximately 4.5 mm from the glenoid surface, suggesting that an increased reaming may be favorable without compromising bony support

Periprosthetic fractures around the femur during and after total hip arthroplasty (THA) remain a common mode of failure. It is important therefore to recognise those factors that place patients at increased risk for development of this complication. Prevention of this complication, always trumps treatment. Risk factors can be stratified into: 1. Patient related factors; 2. Host bone and anatomical considerations; 3. Procedural related factors; and 4. Implant related factors. Patient Factors. There are several patient related factors that place patients at risk for development of a periprosthetic fracture during and after total hip arthroplasty. Metabolic bone disease, particularly osteoporosis increases the risk of periprosthetic fracture. In addition, patients that smoke, have long term steroid use or disuse, osteopenia due to inactivity should be identified. A metabolic bone work up and evaluation of bone mineralization with a bone densitometry test can be helpful in identifying and implementing treatment prior to THA. Pre-operative Host Bone and Anatomic Considerations. In addition to metabolic bone disease the “shape of the bone” should be taken into consideration as well. Dorr has described three different types of bone morphology (Dorr A, B, C), each with unique characteristics of size and shape. It is important to recognise that not one single cementless implant may fit all bone types. The importance of templating a THA prior to surgery cannot be overstated. Stem morphology must be appropriately matched to patient anatomy. Today, several types of cementless stem designs exist with differing shape and areas of fixation. It is important to understand via pre-operative templating which stem works best in what situation. Procedural Related Factors. There has been a resurgence in interest in the varying surgical approaches to THA. While the validity and benefits of each surgical approach remains a point of debate, each approach carries with it its own set of risks. Several studies have demonstrated increased risk of periprosthetic fractures during THA with the use of the direct anterior approach. Risk factors for increased risk of periprosthetic fracture may include obesity, bone quality and stem design. Implant Related Factors. As mentioned there are several varying cementless implant shapes and sizes that can be utilised. There is no question that cementless fixation remains the most common mode of fixation in THA. However, one must not forget the role of cemented fixation in THA. Published results on long term fixation with cemented stems are comparable if not exceeding those of press fit fixation. In addition, the literature is clear that cemented fixation in the elderly hip fracture patient population is associated with a lower risk of periprosthetic fracture and lower risk of revision. The indication and principles of cemented stem fixation in THA should not be forgotten

Introduction. Range of motion (ROM) simulation of the hip is useful to understand the maximum impingement free ROM in total hip arthroplasty (THA). In spite of a complex multi-directional movement of the hip in daily life, most of the previous reports have evaluated the ROM only in specific directions such as flexion-extension, abduction-adduction, and internal - external rotation at 0° or 90° of hip flexion. Therefore, we developed ROM simulation software (THA analyzer) to measure impingement free ROM in any positions of the hip. Recent designs of the hip implants give a wider ROM by increasing the head diameter and then, bone to bone impingement can be a ROM limit factor particularly in a combination of deep flexion, adduction and internal rotation of the hip. Therefore, the purpose of this study were to observe an individual variation in the pattern of the bone impingement ROM in normal hip bone models using this software, to classify the bone impingement ROM mapping types and to clarify the factors affecting the bone impingement type. Methods. The subjects were 15 normal hips of 15 patients. Three dimensional surface models of the pelvis and femur were reconstructed from Computer tomography (CT) images. We performed virtual hip implantation with the same center of rotation, femoral offset, and leg length as the original hips. Subsequently, we created the ROM mapping until bone impingement using THA analyzer. We measured the following factors influenced on the bone impingement map patterns; the neck shaft angle, the femoral offset, femoral anteversion, pelvic tilt, acetabular anteversion, sharp angle, and CE angle. These factors were compared between the two groups. Statistical analysis was performed with Mann-Whitney U test, and statistical significance was set at P<0.05. Results. According to the borderline of ROM at the flexion-internal rotation corner on the bone impingement map, the hips were classified into two groups; group-A showed more than 45° of the borderline slope at the flexion-internal rotation corner and the remaining hips were group-B. (Fig.1). There were 7 hips in group-A and 8 hips in group-B. Femoral offset was 36.8±2.2 mm in group-A and 30±2.7 mm in group-B. Femoral anteversion was 32±6.4° in-group A and 43 ±4.8° in group-B. There were statistically significant differences in the femoral offset and femoral anteversion between the groups. There were no significant differences in the other factors. Discussion. The results of this study showed various ROM map patterns even in normal hips and we classified them into two groups. An increased femoral offset or a decreased femoral anteversion revealed an early impinge in internal rotation. ROM until bone impingement is affected by the individual bone morphology. However, it is not easy to evaluate bony ROM in complex hip positions. THA analyzer shows the impingement position visually on the map and it is easy to understand the hip positions with reduced ROMs. Conclusion. There are two patterns on the bony ROM map in normal hips, and an early impinge in internal rotation occurred by increasing the femoral offset or decreasing the femoral anteversion. For figures/tables, please contact authors directly.

Osteoarthritic (OA) changes to the bone morphology of the proximal tibia may exhibit load transfer patterns during total knee arthroplasty not predicted in models based on normal tibias. Prior work highlighted increased bone density in transverse sections of OA knees in the proximal-most 10mm tibial cancellous bone. Little is known about coronal plane differences, which could help inform load transfer from the tibial plateau to the tibial metaphysis. Therefore, we compared the cancellous bone density in OA and cadaveric (non-OA) subjects along a common coronal plane. This study included nine OA patients (five women, average age 59.1 ± 9.4 years) and 18 cadaver subjects (four women, average age 39.5 ± 14.4 years). Patients (eight with medial OA and one with lateral OA) received pre-operative CT scans as standard-of-care for a unicompartmental knee replacement. Cadavers were scanned at our institution and had no history of OA which was confirmed by gross inspection during dissection. 3D reconstructions of each proximal tibia were made and an ellipse was drawn on the medial and lateral plateau using a previously published method. A coronal section (Figure 1) to standardize the cohort was created using the medial ellipse center, lateral ellipse center, and the tibial shaft center 71.5mm from the tibial spine. On this section, profile lines were drawn from the medial and lateral ellipse centers, with data collected from the first subchondral bone pixel to a length of 20mm. The Hounsfield Units (HU) along each profile line was recorded for each tibia; a representative graphical distribution is shown in Figure 2. The Area Under the Curve (AUC) was calculated for the medial and lateral sides, which loosely described the stiffness profile through the region of interest. To determine differences between the medial and lateral subchondral bone density, the ratio AUC[medial] / AUC[lateral] was compared between the OA and cadaver cohorts using a two-sample t-test. Data from the sole lateral OA patient was mirror-imaged to be included in the OA cohort. The majority of the OA patients appeared to have higher subchondral bone density on the affected side. Figure 3 compares the medial and laterals sides of each group using the AUC ratio method described above. For the cadaver group the AUC was 1.2 +/− 0.22, with a median of 1.1 [0.9 1.6], smaller than the mean AUC for the OA group, which was 1.4 +/− 0.39, with a median of 1.6 [0.93 2.1]. The p-value was 0.06. The increased density observed in OA patients is consistent with asymmetric loading towards the affected plateau, resulting in localized remodeling of cancellous bone from the epiphysis to metaphysis. From the coronal plane, bone was often observed in OA patients bridging the medial plateau to the metaphyseal cortex. Although the cadaver subjects were normal from history and gross inspection, some subjects exhibited early bone density changes consistent with OA. Future work looks to review more OA scans, extend the work to the distal femur, and convert the HU values to bone elastic moduli for use in finite element modelling

Background. Constitutional knee varus increases the risk of medial OA disease due to increase in the knee adduction moment and shifting of the mechanical axis medially. Hueter-Volkmann's law states that the amount of load experienced by the growth plate during development influences the bone morphology. For this reason, heightened sports activity during growth is associated with constitutional varus due to added knee adduction moment. In early OA, X-rays often show a flattened medial femoral condyle extension facet (EF). However, it is unknown whether this is a result of osteoarthritic wear, creep deformation over decades of use, or an outcome of Hueter-Volkmann's law during development. A larger and flattened medial EF can bear more weight, due to increased load distribution. However, a flattened EF may also extrude the meniscus, leading meniscus degeneration and joint failure. Therefore, this study aimed to investigate whether varus knees have flattened medial EFs of both femur and tibia in a cohort of patients with no signs yet of bony attrition. Methods. Segmentation and morphology analysis was conducted using Materialise software (version 8.0, Materialise Inc., Belgium). This study excluded knees with bony attrition of the EFs based on Ahlbäck criteria, intraoperative findings, and operation notes history. Standard reference frames were used for both the femur and tibia to ensure reliable and repeatable measurements. The hip-knee-angle (HKA) angle defined varus or valgus knee alignment. Femur: The femoral EFs and flexion facets (FFs) had best-fit spheres fitted with 6 repetitions. (Fig1). Tibia: The slopes of the antero-medial medial tibial plateau were approximated using lines. (fig2). Results. 72 knees met the inclusion and exclusion criteria. The average age was 59 ± 11 years. The youngest was 31 and the oldest 84 years. Thirty-three were male and 39 were female. There was good intra- and inter-observer reliability for EF sphere fitting. Femur: The results demonstrated that the medial femoral condyle EF is flattened in knees with constitutional varus, as measured by the Sphere Ratios between the medial and lateral EF (varus versus straight: p = 0.006), and in the scaled values for the medial EF sphere radius (varus versus straight: p = 0.005). There was a statistically significant, moderate and positive correlation between the medial femoral EF radius, and the medial femoral EF-FF AP offset. (fig3). Tibia: There was a statistically significant difference between the steepness of the slopes of the medial tibial plateau EF in varus and valgus knees, suggesting varus knees have a less concave (flatter) medial EF. (fig3). Conclusions. In comparison to straight knees, varus knees have flattened medial EFs in both femur and tibia. As this was the case in knees with no evidence of bony attrition, this could mean flattened medial EFs may be a result of medial physis inhibition during development, due to Hueter-Volkmann's law. Flattened medial EFs may increase load distribution in the medial compartment, but could also be a potential aetiology in primary knee OA due to over extrusion of the medial meniscus and edge loading

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant however without attending to releases and extra-articular correction may not suffice. Certain myths in deformity correction will be presented. Technical tips with regard to preoperative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Technique of performing TKA with concomitant extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain-free motion, and stability without necessarily using more constrained implants

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant, however, without attending to releases and extra-articular correction may not suffice. Pre-operative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Results of a large series of TKA with extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain-free motion, and stability without necessarily using more constrained implants

Introduction. Migration of the trial femoral head is a rarely occurring complication of total hip arthroplasty (THA) performed using the anterolateral approach (ALA). This migration of the trial femoral head under the rectus femoris is extremely risky because of the anatomical situation. Analyzing the morphological character of a case of migration may help us to avoid this risk. Objective. We analyzed the three-dimensional bone morphology using computed tomography (CT) scan images to investigate the physiological characteristics of five migration cases. Methods. We examined 108 patients (21 men, 87 women, 113 hips) who underwent THA via the ALA. The average patient age was 62.9 (range: 30–87) years and average body mass index was 24.4 (range: 18.0–36.0) kg/m2. The exclusion criteria were dysplastic coxarthroses greater than Crowe type II, previous fractures, previous hip operations, and muscle disease. Three-dimensional models of the pelvis and femur were made using ZedHip software® (Lexi, Tokyo, Japan). The anterior superior iliac spine on the affected side (A) and contralateral side (A’), anterior inferior iliac spine (I), and greater trochanter tip (G) were noted in these models. The distances A–I, I–G, and A–G and the angle formed by AA’ and AI were measured (Figure 1, 2). Each hip was classified by the presence (group M) or absence (group N) of migration during surgery. A Fisher's exact probability test, Student's t-test, and Welch's t-test were used to compare the two groups, and p-values less than 0.05 were considered significant. Results. In 5 of the 113 hips, the trial femoral heads migrated under the rectus femoris and were removed safely. No significant differences were found between the gender, height, weight, or BMI of the groups. The average A–I distance was 32.3±3.0 mm (mean±SD) in group M and 39.4±10.4 mm in group N; I–G was 52.2±8.2 mm in group M and 59.7±10.6 mm in group N; and A–G was 64.3±10.3 mm in group M and 76.3±12.3 mm in group N. The average angle formed by AA’ and AI was 50.5±5.8°. Significant differences between the two groups were found for the distances A–I and A–G. Conclusions. In 4.4% of cases, the trial femoral heads migrated under the rectus femoris, which creates a risk for serious complications because major nerve and blood vessels are located nearby. The tendency for migration was expected to be related to the balance between soft tissues. In this study, we found that migration tends to occur in patients with shorter distances between A and I, and A and G. The trial head should be dislocated more carefully in those patients

Deformity can be associated with significant bone loss, ligament laxity, soft-tissue contractures, distortion of long bone morphology, and extra-articular deformity. Correction of varus, valgus, or flexion deformity requires soft tissue releases in conjunction with bone cuts perpendicular to the long axes of the femur and tibia. Cruciate-retaining or -substituting implants can be used based on surgeon preference if the ligaments are well balanced. However, in presence of severe deformity, additional measures may be warranted to achieve alignment and balance. TKA then becomes a more challenging proposition and may require the surgeon to perform extensive releases, adjunct osteotomies and deploy more constrained implants. Merely enhancing constraint in the implant however without attending to releases and extra-articular correction may not suffice. Preoperative planning, i.e., whether intra-articular correction alone will suffice or extra-articular correction is required, will be highlighted. Surgical principles and methods of performing large releases, reduction osteotomy, lateral epicondylar sliding osteotomy, sliding medial condylar osteotomy, and closed wedge diaphyseal/metaphyseal osteotomy concomitantly with TKA will be illustrated with examples. Results of a large series of TKA with extra-articular deformity resulting from coronal bowing of femoral or tibial diaphysis, malunited fractures, prior osteotomies, and stress fractures will be presented. The techniques reported can successfully restore alignment, pain free motion, and stability without necessarily using more constrained implants

Combined anteversion angle of acetabular component and femeral neck is an important factor for total hip arthroplasty (THA) as it may affect impingement and dislocation. Previous studies have collected data mainly from direct measurements of bone morphology or manual measurements from 2D or 3D radiolographic images. The purpose of this study was to electronically measure the version angles in native acetabulum and femur in matured normal Caucasion population using a novel virtual bone database and analysis environment named SOMA™. 221 CT scans from a skeletally mature, normal Caucasian population with an age range of 30–95 years old. The population included 135 males and 86 females. CT data was converted to virtual bones with cortical and cancellous boundaries using custom CT analytical sofware. (SOMA™ V.3.2) Auxillary reference frames were constructed and measurements were performed within the SOMA™ design environment. Acetabular Anteversion (AA) angle as defined by Murray. 1. was measured. The acetabular rim plane was constructed by selecting 3 bony land marks from pubis, ilium and ischium. A vector through acetabular center point and normal to the rim plane defined the plane for the AA measurement. The AA was defined as the angle of this plane relative to the frontal (Coronal) plane of the pelvis. The Femoral Neck Anteversion (FNA) angle was measured from the neck axis plane to the frontal (Coronal) plane as defined by the posterior condyles. The neck axis plane was constructed to pass through femoral neck axis perpendicular to the transverse plane. The combined anteversion angle was computed as the summation of acetabular and femoral anteversion angles. Student's t tests were performed to compare gender difference with an assumed 95% confidence level. The mean AA angle for total population was 25.8°, SD=7.95°. The mean AA for male was 24.8°, SD=5.93° and for female was 27.3°, SD=7.14°. P=0.009. The mean FNA angle for total population was 14.3°, SD=6.52°. The mean FNA for male was 13.5°, SD=7.97° and for female was 15.5°, SD=7.80°. P=0.058. The mean combined anteversion angle for total population was 40.1°, SD=10.76°. The mean combined anteversion angle for male was 38.3° SD=10.39 ° and for female was 42.8° SD=10.83 °. P=.0002. The plot of AA as a function of FNA shows weak correlation for both male and female. (Figure 1) The frequency distribution is shown in Figure 2. The results showed the both AA, FNA and combined anteversion angles were significantly smaller in male population than that in female population. The FNA angle of the cementless femoral stem can be smaller than with the natural femur, therefore a higher AA or higher posterior build up may be required for the acetabular component for optimal function of a THA

INTRODUCTION. Immediate post-operative stability of a cementless hip design is one of the key factors for osseointegration and therefore long-term success [1]. This study compared the initial stability of a novel, shortened, hip stem to a predicate standard tapered wedge stem design with good, long-term, clinical history. The novel stem is a shortened, flat tapered wedge stem design with a shape that was based on a bone morphology study of 556 CT scans to better fit a wide array of bone types [2]. METHODS. Test methods were based on a previous study [3]. Five stems of the standard tapered wedge design (Accolade, Stryker Orthopaedics, Mahwah, NJ) and the novel stem (Accolade II, Stryker Orthopaedics, Mahwah, NJ) were implanted into a homogenous set of 10 synthetic femora (Figure 1) utilizing large left fourth generation. composite femurs (Sawbones, Pacific Labs, Seattle, WA). The six degrees-of-freedom (6 DoF) motions of the implanted stems were recorded under short-cycle stair-climbing loads. Minimum head load was 0.15 kN and the maximum load varied between 3x Body Weights (BW) and 6 BW. Loading began with 100-cycles of “normal” 3 BW and was stepped up to 4 BW, 5 BW & 6 BW for 50-cycles each. Prior to each load increase, 50 cycles of 3 BW loading was applied. This strategy allowed a repeatable measure of cyclic stability after each higher load was applied. The 6 DoF micromotion data, acquired during the repeated 3 BW loading segments, were reduced to four outcome measures: two stem migrations (retroversion and subsidence at minimum load) and two cyclic motions (cyclic retroversion and cyclic subsidence). Data were analyzed using repeated measures ANOVA with a single between-subjects factor (stem type) and repeated measures defined by load-step (3 BW, 4 BW, 5 BW 6 BW). RESULTS. Both stems retroverted under increasing load (p = 0.0011, Fig 2). Retroversion of the novel stem was significantly smaller than that of the standard tapered wedge stem (p = 0.023). The rate of increase in retroversion with increasing load was significantly lower for the novel stem (p = 0.026). In addition, both stems subsided under increasing load (p = 0.0015, Fig 3). Subsidence of the novel stem was significantly smaller than that of the standard tapered wedge stem (p = 0.016). The rate of increase in subsidence with increasing load was significantly lower for the novel stem (p = 0.022). With regard to cyclic motions, both cyclic retroversion and cyclic subsidence were significantly lower for the novel stems (p = 0.0033 & p = 0.0098). In addition, the rate of increase in cyclic motion was significantly lower for the novel stems for both cyclic retroversion (p = 0.0021) and cyclic subsidence (p = 0.023). DISCUSSION. In this study, the novel tapered wedge stem demonstrated an improved stability compared to the clinically successful predicate design. It appears that through optimization of the proximal geometry, a reduction in the length of the stem can be accomplished without jeopardizing initial stability