3D Printing Applications in Orthopaedic Surgery: Clinical Experience and Opportunities

Background: Three-dimensional (3D) printing is a technology capable of creating solid objects based on the reproduction of computerised images. This technology offers revolutionary impacts on surgical practice, especially in prosthetic and traumatological surgery. Methods: 20 patients with proximal humeral fractures were divided into two groups, one of which involved the processing of a 3D model. The model made it possible to plan the positioning and dimensions of the implants. The results were then compared with those obtained according to the usual procedures. We also reported the irreparable case of a custom revision implants acetabular bone loss treated with a 3D-printed, custom-made implant. Results: In the processed 3D proximal humeral fracture series, in the face of time and costs expenses, surgical and X-ray times were shorter than in the control group. On the other hand, there were no differences in terms of blood loss. The patient who underwent acetabular re-prosthetic surgery in a 3B Paprosky bone loss was managed and solved with a 3D-printed, custom-made implant and reported excellent outcomes at a 1 year follow-up. Conclusion: Three-dimensional printing made it possible to create better pre-operative planning in traumatology in order to optimise surgical procedures and outcomes. It also made it possible to deal with large losses of bone stock in prosthetic revision surgery, even when reconstruction may have appeared impossible with traditional implants.

The Diagnosis and Treatment of Acetabular Bone Loss in Revision Hip Arthroplasty: An International Consensus Symposium

Despite growing evidence supporting the evaluation, classification, and treatment of acetabular bone loss in revision hip replacement, advancements have not been systematically incorporated into a single document, and therefore, a comprehensive review of the treatment of severe acetabular bone loss is needed. The Stavros Niarchos Foundation Complex Joint Reconstruction Center at Hospital for Special Surgery held an Acetabular Bone Loss Symposium on June 21, 2019, to answer the following questions: What are the trends, emerging technologies, and areas of future research related to the evaluation and management of acetabular bone loss in revision hip replacement? What constitutes the optimal workup and management strategies for acetabular bone loss? The 36 international experts convened were divided into groups, each assigned to discuss 1 of 4 topics: (1) preoperative planning and postoperative assessment; (2) implant selection, management of osteolysis, and management of massive bone loss; (3) the treatment challenges of pelvic discontinuity, periprosthetic joint infection, instability, and poor bone biology; and (4) the principles of reconstruction and classification of acetabular bone loss. Each group came to consensus, when possible, based on an extensive literature review. This document provides an overview of these 4 areas, the consensus each group arrived at, and directions for future research.

Management of Spinal Bone Metastases With Radiofrequency Ablation, Vertebral Reinforcement and Transpedicular Fixation: A Retrospective Single-Center Case Series

Spine is a frequent site of bone metastases, with a 8.5 months median survival time after diagnosis. In most cases treatment is only palliative. Several advanced techniques can ensure a better Quality of Life (QoL) and increase life expectancy. Radiofrequency ablation (RFA) uses alternating current to produce local heating and necrosis of the spinal lesion, preserving the healthy bone. RFA is supported by vertebral reinforcement through kyphoplasty and vertebroplasty in order to stabilize the fracture with polymethylmethacrylate (PMMA) injection, restoring vertebral body height and reducing the weakness of healthy bone. The aim of this study is to demonstrate the efficacy and advantages of RFA plus vertebral reinforcement through PMMA vertebroplasty and fixation in patients affected by bone spinal metastases. We retrospectively analyzed 54 patients with thoraco-lumbar metastatic vertebral fractures admitted to our Unit between January 2014 and June 2020. Each patient underwent RFA followed by PMMA vertebroplasty and transpedicle fixation. We evaluated pain relief through the Visual Analogue Scale (VAS) Score and PMMA vertebral filling based on the mean Saliou filling score. Analysis of variance (ANOVA) was used to test pain relief with statistical significance for p<0.05. A total of 54 patients (median age 63,44 years; range 34-86 years), with a total of 63 infiltrated vertebrae, were treated with RFA, PMMA vertebroplasty and transpedicular screw fixation; average operative time was 60.4 min (range 51–72). The preoperative average VAS score decreased significantly from 7.81 to 2.50 (p < 0.05) after 12 months. Based on Saliou filling score, filling was satisfactory (12–18) in 20 vertebrae (31,7%), mediocre (6–11) in 33 vertebrae (52,4%), inadequate (0–5) in 10 vertebrae (15,9%). A consistent PMMA filling of vertebral bodies was successfully achieved with significant pain relief. Concomitant RFA, PMMA vertebroplasty and pedicle screw fixation represent a safe and effective technique for the management of spinal metastases, improving clinical outcome and pain control.

XR (Extended Reality: Virtual Reality, Augmented Reality, Mixed Reality) Technology in Spine Medicine: Status Quo and Quo Vadis

In recent years, with the rapid advancement and consumerization of virtual reality, augmented reality, mixed reality, and extended reality (XR) technology, the use of XR technology in spine medicine has also become increasingly popular. The rising use of XR technology in spine medicine has also been accelerated by the recent wave of digital transformation (i.e., case-specific three-dimensional medical images and holograms, wearable sensors, video cameras, fifth generation, artificial intelligence, and head-mounted displays), and further accelerated by the COVID-19 pandemic and the increase in minimally invasive spine surgery. The COVID-19 pandemic has a negative impact on society, but positive impacts can also be expected, including the continued spread and adoption of telemedicine services (i.e., tele-education, tele-surgery, tele-rehabilitation) that promote digital transformation. The purpose of this narrative review is to describe the accelerators of XR (VR, AR, MR) technology in spine medicine and then to provide a comprehensive review of the use of XR technology in spine medicine, including surgery, consultation, education, and rehabilitation, as well as to identify its limitations and future perspectives (status quo and quo vadis).

Medial Ball and Socket Total Knee Arthroplasty in Indian Population: 5-Year Clinical Results

Background

Medial pivot total knee arthroplasty aims to restore native knee kinematics through highly conforming medial tibiofemoral articulation with survival comparable to contemporary knee designs. The aim of this study was to report preliminary clinical results of medial pivot total knee arthroplasty in an Indian population.

Methods

A retrospective analysis of 45 patients (average age, 62 years; 40 women and 5 men) with end-stage arthritis (Kellgren-Lawrence grade 4) operated with a medial pivot prosthesis was done. All patients were assessed using Knee Society Score (satisfaction, expectation, and functional scores) and Oxford Knee Score, and range of motion was recorded at the end of 5-year postoperative follow-up. In addition, all patients underwent standardized radiological assessment.

Results

At the final follow-up, patients reported significant improvement in mean Knee Society Score (satisfaction, expectation, and functional scores) and Oxford Knee Score (p < 0.05). The mean range of motion achieved at the end of 5 years ranged from 0° (extension) to 118.4° (further flexion). There was no evidence of loosening or osteolysis at a minimum follow-up of 5 years.

Conclusions

These results demonstrated satisfactory clinical and radiological outcomes at 5 years after total knee arthroplasty with a medial pivot design, which may be related to better replication of natural knee kinematics with the medial pivot knee and inherent advantages of this design.

NO SIGNIFICANT EFFECT OF 3D MODELLING ON SURGICAL PLANNING IN SPINAL DEFORMITIES

ABSTRACT Objective: To evaluate the effect of 3d printed models on surgical pre-operative planning of complex spinal deformities. Methods: In our study, five orthopedic surgeons made surgical planning of 5 patients with severe spinal deformity in three conditions: X-ray with computer tomography (X-ray-CT), 3D-computed tomography (3dCT), and 3d printed spine models. Operation plans were examined according to the level and number of instrumentations, osteotomy level, and time required for decision-making. Results: X-ray-CT, 3dCT, and 3d modeling methods were compared, and no statistically significant difference was observed in the number of screws and osteotomy score to be used in operation. The time required for decision ranking is 3d Model, 3d CT, and Xray-CT. Conclusions: 3d printed models do not influence the operative plan significantly; however, it reduces surgical planning time at pre-op duration, and those models gave some opportunities to practice with implants on a patient’s 3d spine model. Level of Evidence III; Diagnostic Studies - Investigating a Diagnostic Test .

The use of a non-biological, bridging, antiprotrusio cage in complex revision hip arthroplasty and periacetabular reconstructive oncologic surgery. Is still today a valid option?: A mid/long-term survival and complications' analysis

INTRODUCTION

Burch-Schneider-like antiprotrusio cages (B-SlAC) still remain helpful implants to bridge severe periacetabular bone losses. The purpose of this study was to evaluate outcomes and estimate both cages' failures and complication risks in a series of B-SlAC implanted in revision of failed total hip arthroplasties (THA) or after resection of periacetabular primary or secondary bone malignancies. Risk factors enhancing the chance of dislocations and infections were checked.

MATERIALS AND METHODS

We evaluated 73 patients who received a B-SlAC from January 2008 to January 2018. Group A, 40 oncological cases (22 primary tumors; 18 metastases); Group B, 33 failed THAs. We compared both Kaplan-Meier estimates of risk of failure and complication with the cumulative incidence function, taking account the competing risk of death. Cox proportional hazards model was utilized to identify possible predictors of instability and infection. Harris hip score HHS was used to record clinical outcomes.

RESULTS

Medium follow-up was 80 months (24-137). Average final HHS was 61 (28-92), with no differences within the two groups (p > 0.05). The probabilities of failure and complications were 57% and 26%, respectively, lower in the oncologic group than in the rTHA group (p =0 .176; risk 0.43) (p = 0.52; risk 0.74). Extended ileo-femoral approach and proximal femur replacement (p =0.02, risk ratio = 3.2; p = 0.04, rr = 2.1) were two significant independent predictors for dislocations, while belonging to group B (p = 0.04, rr = 2.6) was predictable for infections.

CONCLUSION

Burch-Schneider-like antiprotrusio cages are a classical non-biological acetabular reconstruction method that surgeons should bear in mind when facing gross periacetabular bone losses, independently of their cause. However, dislocation and infection rates are high. Whenever possible, we suggest preserving the proximal femur in revision THA, and to use a less-invasive postero-lateral approach to reduce dislocation rates in non-oncologic cases.

The Use of Live Streaming Technologies in Surgery: A Review of the Literature

BACKGROUND

Live streaming surgery is a developing communication platform in medicine. To maximize the technological advances that allow for the live streaming of surgery, it is crucial to have an understanding of the various video-capturing devices that are available and their pros and cons of implementation. Possible barriers to the widespread use of live streaming surgery include cost, concerns about patient safety and privacy, and limited understanding of the current available resources. In this article, we present the results of our literature review of techniques for live streaming of surgery as a means to inform readers and promote their implementation.

METHODS

We conducted a literature review of the literature to identify previous articles indexed in PubMed and Ovid. We used the following search terms: [Surgery AND Streaming], which generated 32 articles for initial review. References were reviewed within each document to find similar articles that were not captured by the initial search. The article selection criteria were peer-reviewed publications, case reports, and case series describing the use of live surgical streaming technologies.

RESULTS

Literature review showed enhanced surgeon interaction with viewers and improved anatomy scores with the widespread use of live streaming. Surgeons reported positive feedback and wished to engage in more sessions in the future. The largest barriers to implementation of streaming technology are video quality through the Internet and patient information protection.

CONCLUSIONS

Live streaming of surgery for educational purposes has not been widely accepted in surgical training programs to date. Streaming accessibility has advanced over the past 2 decades with the availability of handheld mobile devices. However, little has been done to allow for live streaming of surgery to trainees in a manner compliant with the Health Portability Insurance and Accountability Act.

Clinical radiographic outcomes and survivorship of medial pivot design total knee arthroplasty: a systematic review of the literature

BACKGROUND

Total knee arthroplasty is a reliable procedure able to reduce pain and disability in patients suffering from osteoarthritis. However, a considerable percentage of patients still experiences unsatisfactory results. Medial pivot total knee arthroplasty has been introduced in the clinical practice to overcome problems related with classic design implants and better mimic native knee kinematics. The aim of this study was to analyze survivorship and clinical and radiographic outcomes of medial pivot implants.

METHODS

A systematic research was conducted in eight different databases. Thirty-four studies met the inclusion criteria and were included in the analysis. Data on objective and patients-reported outcomes, radiographic alignment, and survivorship were collected and analyzed. Revision rate was expressed as revision per 100 components years.

RESULT

A total of 3377 procedures were included. Mean follow-up was 85.7 months (range, 12-182). The revision per 100 components years was 0.19, which corresponds to a revision rate of 1.9% after 10 years. Mean post-operative range of motion was 117.3 ± 0.4°. Mean clinical and functional Knee Society Score were, respectively, 85.9 ± 1.1 and 84.7 ± 3.5 at final follow-up. Post-operative femorotibial alignment was 177.1 ± 0.5°. Alfa and beta angles were 95.7 ± 0.1° and 89.2 ± 0.1°, respectively. Gamma and delta angles were 2.3 ± 0.6° and 86.7 ± 0.4°.

CONCLUSION

Medial pivoting implants provided excellent survivorship and low revision rate, as well as good-to-excellent results in term of objective and patient-reported clinical outcomes, and reliable correction of radiographic parameters. More high-quality studies with long-term follow-up are needed to clarify the role of medial pivoting implants.

The Surgical Treatment of Brachymetatarsia

This article describes the 3 main surgical options for correction of congenital brachymetatarsia in childhood. The one-stage lengthening by lengthening osteotomy and lengthening with graft interposition are suitable for defects less than 10 mm. For the greater defects from 10 mm to more than 20 mm, gradual lengthening by callus distraction with an external or internal fixator is appropriate. Over the last years, callus distraction with an internal minifixator became commonly established because of the significantly improved aftercare with early full weight-bearing and high postoperative comfort for the child. All 3 surgical procedures are presented with comprehensive image material.

Complications and Outcomes Associated With a Novel, Prefabricated, Articulating Spacer for Two-Stage Periprosthetic Joint Infection Treatment

BACKGROUND

Various prefabricated articulating spacer options have been described for 2-stage treatment of chronic periprosthetic joint infection, but their results are poorly generalizable between designs due to differing antibiotic and material properties. This study reports outcomes for a novel, prefabricated, commercially available cement-on-cement articulating spacer.

METHODS

A retrospective review of prospectively collected data for patients undergoing treatment with a prefabricated articulating cement spacer was performed. Outcomes were categorized as spacer complications, reimplantation rates, function, reinfection, and mortality.

RESULTS

Seventy-six knees and 28 hips were analyzed. Spacer survival free of fracture, instability, or other implant-related complication until reimplantation was 100%. There were no bony or spacer fractures during the interstage or reimplantation. Reimplantation occurred in 84.6% of resected joints. Following spacer implantation, all but 1 patient was allowed to bear weight. The proportion of patients requiring an assistive device decreased from 67% prior to resection to 31% following reimplantation. Knee flexion improved from an average of 88.1° before resection to 111.9° following reimplantation. Eighty-seven percent of cases were infection free at mean follow-up of 16.6 ± 10.4 months.

CONCLUSION

Study results demonstrate that this novel, prefabricated, articulating antibiotic spacer is safe, allows for good interstage function, and results in reasonable infection eradication rates at early term follow-up.

LEVEL OF EVIDENCE

Therapeutic Level III.

3D imaging added value in the treatment and diagnosis of displaced intra-articular calcaneal fractures (DIACF): measuring the orientation of the posterior talo-calcaneal facet in the space

PURPOSE

Measure the reduction quality of calcaneal fractures on 3 D segmented images.

METHODS

The Ethics Review Board approved this study and written informed consent was collected from all patients. Bilateral CT scans of fifty-four patients with unilateral displaced calcaneal fracture were obtained before and after osteosynthesis. Orientation angle of the posterior subtalar joint facet (PTC) of displaced intra-articular calcaneal fractures of 54 patients was measured on segmented 3 D images before and after surgery and compared to the uninjured side. This orientation angle (OAC) is the average of every normal vector of each point of the PTC, as compared to the main calcaneal axis (calculated by first principal component analysis). The PTC is a well-known anatomical structure, relatively easy to identify on 3 D imaging.

RESULTS

This OAC angle was low before surgery (mean= 95°, std dev= 6°), statistically significantly different from the uninjured side value, p < 0.001. The OAC angle of the operated bone was nearly equal to the uninjured side (mean= 103°, std dev= 5°), without any statistically significant difference between postoperative values and uninjured side values. We found linear correlation between the quality of the reduction when assessed with this OAC and the functional score (AOFAS) (Adjusted R²=0.62, p = 0.04).

CONCLUSIONS

This angle seems to be useful to quantify the quality of the operative reduction of displaced intra-articular calcaneal fractures.

Efficacy of ethylene oxide-sterilized waterproof cases for handheld cameras as sterile barriers for intraoperative imaging and recording

OBJECTIVE

To evaluate the efficacy of ethylene oxide (EtOH) sterilization of 4 different waterproof camera cases and the ability of those sterilized cases to maintain a sterile barrier for intraoperative camera use.

SAMPLE

3 action cameras, 1 smartphone, and associated waterproof cases.

PROCEDURES

Cases were inoculated by immersion in medium containing Staphylococcus pseudintermedius, Escherichia coli, and Pseudomonas aeruginosa and then manually cleaned and subjected to EtOH sterilization. Cameras were disinfected, loaded into sterile cases, and sterilely operated for 2 hours. Samples were collected from cases after inoculation, EtOH sterilization, camera loading, and 1 and 2 hours of operation and from all cameras after 2 hours of operation. Procedures were repeated twice, followed by an additional challenge round wherein cameras were purposefully contaminated prior to loading. All samples underwent bacterial culture.

RESULTS

All cases were successfully sterilized, and loading of nonsterile cameras into sterile cases caused no contamination when cameras had been disinfected beforehand. Nonpathogenic environmental contaminants were recovered from 6 of 64 culture samples and 2 of 4 room samples. During the challenge round, only the postload sample for 1 case yielded E coli, suggesting sterile glove contamination; however, postload, 1-hour, and 2-hour samples for the GoPro case yielded E coli and S pseudintermedius, suggesting major contamination.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that the evaluated cases can be safely sterilized with EtOH and used for image acquisition by aseptically prepared surgeons when cameras are disinfected prior to loading. Except for the GoPro camera, camera use did not jeopardize sterile integrity.

Modular or Monolithic Tapered Fluted Prostheses for Periprosthetic Fractures: Which One Could Work for You?

Periprosthetic fracture around a femoral component is a potentially devastating complication after total hip arthroplasty. Surgical treatment is often technically demanding and requires a thorough understanding of fracture care and revision joint reconstruction. Advancements in femoral component designs for revision total hip arthroplasty have improved management of this challenging complication. It is important for surgeons to understand which femoral component design might best suit their needs. We present an overview of revision total hip arthroplasty in the setting of periprosthetic fracture, focusing on comparing the 2 most popular femoral component revision models, the modular and monolithic tapered fluted conical prostheses.

Meta-Analysis of 3D Printing Applications in Traumatic Fractures

Background: Traumatic fracture is a common orthopaedic disease, and application of 3D printing technology in fracture treatment, which entails utilisation of pre-operative printed anatomic fracture model, is increasingly gaining popularity. However, effectiveness of 3D printing-assisted surgery lacks evidence-based findings to support its application.

Materials and Methods: Embase, PubMed and Cochrane Library databases were systematically searched until October, 2020 to identify relevant studies. All randomised controlled trials (RCTs) comparing efficacy of 3D printing-assisted surgery vs. conventional surgery for traumatic fractures were reviewed. RevMan V.5.3 software was used to conduct meta-analysis.

Results: A total of 12 RCTs involving 641 patients were included. Pooled findings showed that 3D printing-assisted surgery had shorter operation duration [standardised mean difference (SMD) = −1.52, 95% confidence interval (CI) – 1.70 ~ −1.34, P < 0.00001], less intraoperative blood loss (SMD = 1.34, 95% CI 1.74 ~ 0.94, P < 0.00001), fewer intraoperative fluoroscopies (SMD = 1.25, 95% CI 1.64 ~ 0.87, P < 0.00001), shorter fracture union time (SMD = −0.15, 95% CI −0.25 ~ −0.05, P = 0.003), and higher rate of excellent outcomes (OR = 2.40, 95% CI 1.07 ~ 5.37, P = 0.03) compared with conventional surgery. No significant differences in complication rates were observed between the two types of surgery (OR = 0.69, 95% CI 0.69 ~ 1.42, P = 0.32).

Conclusions: Indicators including operation duration, intraoperative blood loss, number of intraoperative fluoroscopies, fracture union time, and rates of excellent outcomes showed that 3D printing-assisted surgery is a superior alternative in treatment of traumatic fractures compared with conventional surgery. Moreover, the current study did not report significant differences in incidence of complications between the two approaches.

Systematic Review Registration: CRD42021239507.

3-D generated anatomic custom talar cement spacers: case reports, technical tips and literature review

Background

With today’s expanding use of total ankle arthroplasty, the ever-present trauma patient, and patients with uncontrolled comorbid conditions, surgeons face significant challenges for lower extremity reconstruction. These patients highlight some of those who may present with unique anatomy, bone loss, infection, and various other local and systemic factors that affect treatment options for successful outcomes. Three dimensional (3-D) printing for medical devices is allowing for new and customized ways to meet patient and surgeon goals of limb salvage and reconstruction.

Case presentations

While the majority of 3-D printing is done for the purpose of implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. With two case illustrations including a talus fracture nonunion and infected subtalar arthrodesis nonunion, we describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus.

Discussion

Case illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which are joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution.

Innovative 3-D printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients.

Touchless Control of Picture Archiving and Communication System in Operating Room Environment: A Comparative Study of Input Methods

Background

The advancement of computer information technology would maximize its potential in operating rooms with touchless input devices. A picture archiving and communication system (PACS) was compared with a touchless input device (LMC-GW), relaying to another person to control a mouse through verbal guidance, and directly controlling a mouse.

Methods

Participants (n = 34; mean age, 29.6 years) were prospectively enrolled and given nine scenarios to compare the three methods. Each scenario consisted of eight tasks, which required 6 essential functions of PACS. Time elapsed and measurement values were recorded for objective evaluation, while subjective evaluation was conducted with a questionnaire.

Results

In all 8 tasks, manipulation using the mouse took significantly less time than the other methods (all p < 0.05). Study selection, panning, zooming, scrolling, distance measuring, and leg length measurement took significantly less time when LMC-GW was used compared to relaying to another person (all p < 0.01), whereas there were no significant differences in time required for measuring the angles and windowing. Although the touchless input device provided higher accessibility and lower contamination risk, it was more difficult to handle than the other input methods (all p < 0.01).

Conclusions

The touchless input device provided superior or equal performance to the method of verbal instruction in the environment of operating room. Surgeons agreed that the device would be helpful for manipulating PACS in operating rooms with less contamination risk and disturbance of workflow. The touchless input device can be an alternative option for direct manipulation of a mouse in operation rooms in the future.

Clinical and Radiological Outcomes Following Medial Pivot Total Knee Arthroplasty: A Retrospective Chart Review Study

Medial pivot total knee arthroplasty (MP-TKA) is a relatively new design that simulates normal knee mechanics with the aim of enhancing postoperative recovery. Furthermore, it reduces postoperative complications in patients with end-stage osteoarthritis of the knee. No study has been done regarding this topic in Saudi Arabia yet, so we aimed to study the post-operative clinical and radiological outcomes of MP-TKA, as well as the postoperative complications. A retrospective cohort chart review study was conducted on 46 patients and 70 knees after applying our inclusion/exclusion criteria. The patients were followed up for an average period of two years. Clinical outcomes were assessed pre- and postoperatively by the validated Saudi Arabian version of the Knee Injury and Osteoarthritis Outcome Score (KOOS), as well as radiological outcomes and postoperative complications gathered from patients’ charts. The postoperative KOOS score showed a statistically significant improvement in pain, symptoms, and activities of daily living in comparison with the preoperative score (P-value < 0.0001). The mean time until ambulation and length of hospital stay were five and 14 days, respectively. Four patients (8.7%) showed radiological complications. Deep vein thrombosis was observed in only two knees (4.3%), and there were no revision cases. Thus, MP-TKA has been shown to improve pain, symptoms, and activities of daily living with a relatively short time until ambulation and length of hospital stay, in addition to a low incidence of postoperative and radiological complications.

Clinical outcomes of the use of 3D printing models in fracture management: a meta-analysis of randomized studies

PURPOSE

The use of three-dimensional printing models in medical practice has been booming recently and its application to orthopedic surgery is gaining popularity. When treating fractures by open reduction and internal fixation, potential benefits have been associated with the use of 3D printing models. This review aims to quantitatively analyze the effectiveness of using 3D printing models in fracture management.

MATERIALS AND METHODS

A structured systematic review was conducted, and multiple databases were searched using a combination of terms related to 3D printing in fracture management. The literature search was limited from inception to Nov 2020. Only comparative randomized studies were accepted for inclusion. Any software or material using 3D printing versus no technological assistance was included. All types of fracture treated by open reduction and internal fixation were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the Joanna Briggs Institute's critical appraisal tool used to assess the quality of the included studies. Quantitative analysis was performed.

RESULTS

Based on 13 RCTs including 673 patients (325 and 348 in the 3D and control groups, respectively), the weighted effect size outcomes were as follows: (a) operative duration - 1.47 (95% CI = - 1.759 to - 1.182), (b) intraoperative blood loss - 1.41 (95% CI = - 1.792 to - 1.029), (c) fluoroscopy use - 1.25 (95% CI = - 1.637 to - 0.867), in favor of the 3D group. The weighted Odds ratio outcomes were: (a) overall good or excellent result 2.05 (95% CI = 1.119 to 3.845) and (b) anatomic fracture reduction 2.64 (95% CI = 1.150 to 6.051) in favor of the 3D group. The mean residual displacement and time to union showed no significant difference. The mean JBI appraisal tool score for the randomized studies was of 9, out of a maximum of 13.

CONCLUSIONS

When compared to the non-use of 3D technology for open reduction and internal fixation of fractures, the review demonstrated evidence that 3D printing yielded significantly better perioperative results. Further studies are needed to evaluate the effect of 3D printing on union and long-term function.

LEVEL OF EVIDENCE

I.

A Mid-term Comparison of the Functional Outcomes of Medial Pivot and Rotating Platform Mobile-Bearing Total Knee Arthroplasty in the Indian Population

BACKGROUND

Both medial pivot (MP) and rotating platform (RP) mobile-bearing (MB) total knee arthroplasty (TKA) have been developed to better mimic the natural knee kinematics and femoral roll back in flexion. The purpose of this retrospective study was to compare the mid-term functional outcomes and range of motion (ROM) of MP and RP types of total knee arthroplasty.

METHODS

116 patients (mean age of 66.3 years) undergoing TKA (52 Medial pivot design and 64 Rotating Platform design) were evaluated retrospectively with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) knee score, knee society score (KSS) with its subgroups namely, Knee Score (KSKS) and Functional Score (KSFS) and forgotten joint score (FJS) at a mean follow-up of 7.1 years. Range of motion (ROM) and tibiofemoral anatomic angle on the radiographs were also compared.

RESULTS

Mean ROM, WOMAC and KSKS improved significantly from pre-operative to postoperative knees in both the groups. There was, however, no significant difference between the two groups at the final follow-up. In contrast, mean KSFS score improved to 89.5 ± 8.1 in MP group and 86.3 ± 7.1 in RP Group (p = 0.025), while mean FJS was 85.6 ± 4.1 and 80.9 ± 5.4 in the MP and RP groups, respectively (p = < 0.0001).

CONCLUSION

Satisfactory clinical and functional outcomes can be obtained using either a MP or RP knee joint in tricompartmental osteoarthritis of knee. The MP design scores better on the KSFS score and FJS than the RP-TKA.

Systemic Contact Dermatitis: The Routes of Allergen Entry

Systemic contact dermatitis (SCD) is a generalized reactivation of type IV hypersensitivity skin diseases in individuals with previous sensitization after a contact allergen is administered systemically. Patients with SCD may consider their dermatitis unpredictable and recalcitrant since the causative allergens are difficult to find. If a patient has a pattern of dermatitis suggestive of SCD but fails to improve with conventional treatment, SCD should be taken into consideration. If doctors are not familiar with the presentations of SCD and the possible routes of allergen sensitization and exposure, the diagnosis of SCD may be delayed. In this work, we summarized all of the routes through which allergens can enter the body and cause SCD, including oral intake, local contact (through skin, inhalation, nasal spray and anal application), implants, and other iatrogenic or invasive routes (intravenous, intramuscular, intraarticular, and intravesicular). This will provide a comprehensive reference for the clinicians to identify the culprit of SCD.

Aetiology, diagnosis, and treatment of brachymetatarsia: a narrative review

Brachymetatarsia (BM), or hypoplastic metatarsal, is an abnormal shortening of one or more metatarsal bones with a female-to-male ratio of 10.53:1. Different causes are described in the literature, such as congenital, acquired, or iatrogenic, associated with different conditions and syndromes. Its presence may develop deformity and pain; however, often feet are pain free and the major worries of patients are cosmetics. Non-operative treatments aim to improve the comfort of metatarsal heads and the possible dorsal conflict through comfortable shoes or the use of specific orthotics. The surgical treatment is anything but straightforward, with "one-stage" or "two stage" techniques, the latter better called "by gradual distraction". One-stage procedures are more rapid techniques but have limited ability to restore the desired length due to neurovascular compromise caused by acute lengthening. Insufficient correction is also possible. On the contrary, by gradual distraction procedures allow gradual distraction lengthening of more than 1.5 cm, but require the use of an external fixator, with a higher risk of complications in more than about 50% of surgeries. The adjacent metatarsal shortening should be considered in combination with other techniques, to diminish the excessive lengthening. In each case, surgeries should be always decided on each patient's concerns, deformities, and clinical needs.

Osmo Pocket© vs VITOM®: comparison of surgical educational video recording means in head and neck reconstructive surgery

PURPOSE

To highlight the needs for better intraoperative educational video recording in head and neck reconstructive surgery and to provide some information to standardize camera positioning in operative room.

METHODS

The Authors compared the Osmo Pocket© and the VITOM® 0° Telescope, evaluating the faculty and trainees point of view through specific questionnaires. The study was performed during two Masterclasses on Head and Neck Reconstructive Surgery that took place in the Hospital Casa Sollievo della Sofferenza in 2018 e 2019. Camera positioning in the Operative Room was also assessed.

RESULTS

In the faculty group, Osmo Pocket© was reported as frequently interfering with surgical intervention; the need for repositioning was reported more frequently in recording with VITOM®, that was evaluated as better in keeping a good "recording flow". In trainees' group, the perceived image quality with VITOM® was more appreciated, while Osmo Pocket© was considered superior in surgical field vision. Regarding the systems' positioning in the OR, in all the surgical procedures it was observed the need for the first operator and the trainees to have the HD monitor placed in front of them. Only during forearm flap harvesting the HD monitor was placed laterally to the first operator and the trainees.

CONCLUSIONS

The Osmo Pocket© is a cheap solution and allows a stable and continuous vision of the operative field, without the needing for stop and repositioning. The Vitom®, despite its major costs and the needing for periodic repositioning, allows a better view of anatomical details with less discomfort for the surgeon. Moreover it's important a standardization of the video means positioning in the operative room to reduce the pre-operative times and to aid in the choice of the most useful method for educational video recording.

Multicup reconstruction technique for the management of severe protrusio acetabular defects

Background

In revision hip arthroplasty, managing the large protrusio acetabular defects remains a challenge. The report described a novel technique which employs a trabecular metal revision shell as a super-augment to buttress the superior medial structure.

Methods

Between January 2015 and December 2018, the multicup reconstruction was performed in 21 patients with severe protrusio acetabular defects. The revision shell, plus two similar porous acetabular components was implanted into the initial shell to create a “multicup” construct. The functional outcomes were evaluated in terms of the Harris Hip Score. Acetabular loosening, restoration of hip center of rotation, and bone ingrowth etc., were radiographically assessed. The survival rate of the implants was also evaluated.

Results

A followup lasting a mean time of 31 months (range, 18–57 months) revealed that the average Harris Hip Score improved from preoperative 37.0 ± 7.1 to postoperative 76.4 ± 9.0. There were no revisions due to acetabular loosening. The horizontal offset increased by an average of 14 mm, and the vertical offset decreased by an average of 18 mm. Eighteen of the 21 patients (86 %) met at least 3 of 5 criteria associated with bone ingrowth. The survivorship free from re-revision for acetabular loosening after 2 years was 100 %.

Conclusions

The multicup reconstruction technique was a simplified re-revision procedure for managing the severe protrusio acetabular defects and could achieve a high survival rate.

Level of evidence

Therapeutic study, Level IVa.

The importance of Böhler's angle in calcaneus geometry: A finite element model study

OBJECTIVES

Calcaneal fractures are the most common tarsal fractures following a foot-ankle trauma. The Böhler's angle is an important measurable angle before, during, and after surgery. In this study, we aimed to investigate correlation between Böhler's angle, calcaneal strength, and subtalar joint stress using a finite element analysis (FEA).

PATIENTS AND METHODS

Between January 2016 and December 2016, computed tomography (CT) scans were used with MIMICS® software for FEA. The ankle and foot of a 23-year-old male person with a height of 180 cm and weighing 80 kg was modeled as reference. Raw coronal CT images were obtained in Digital Imaging and Communications in Medicine format with the resolution of 512X512 pixels and 0.3-mm slice intervals in 135 kV. The structures including tibia, fibula and 26 other bones (talus, calcaneus, cuboid, navicular, three cuneiforms, five metatarsals, and 14 components of phalanges), cartilage and ligamentous tissues were modeled to form ankle joint. After determining Böhler's angle as 35 degrees for the reference model, a fracture line was created on calcaneus. Calcaneus was remodeled with the Böhler's angle of 45, 40, 30, 25, 20, 10, and 0 degrees respectively. All models were transferred to ANSYS software for FEA and the loads on the lower extremities with normal posture were applied on models.

RESULTS

Analysis of all models based in the reference model revealed that maximum tension values on calcaneus increased, while the Böhler's angle decreased, indicating a statistically significant difference. The decreased Böhler's angle indicated statistically significantly higher maximum tension values (p=0.04). Action force in subtalar joint was evaluated by comparing with the forces in reference model. The increased Böhler's angle was found to be associated with statistically significantly decreased amount of load on subtalar joint. The decreased Böhler's angle was related to the statistically significantly increased amount of load on subtalar joint.

CONCLUSION

Our study results suggest that decreased Böhler's angle increases the possibility of subtalar arthrosis, although overcorrection of the Böhler's angle seems not to increase the risk of subtalar arthrosis.

Clinical and Radiological Outcome of Acetabular Reconstruction Rings in Complex Primary and Revision Total Hip Arthroplasty

BACKGROUND

Acetabular reconstruction in complex primary and revision total hip arthroplasty (THA) with bone loss poses a great challenge. We aim to evaluate the medium-term clinical and radiological outcome of reconstruction rings used in these difficult situations.

METHODS

We retrospectively reviewed a consecutive series of acetabular reconstructions with Muller ring or Bursh-Schneider cage from January 2009 to December 2016. The reconstruction rings were used in 66 hips (65 patients). There were 41 complex primary THA and 25 revision THA. The mean follow-up period was 76 months (range, 37-167 months). Clinical evaluation includes the assessment of Harris hip score, visual analogue scale (VAS) score, limb length discrepancy, and activities of daily living. The radiographs were analyzed for any signs of loosening, osteolysis, acetabular migration, and heterotopic ossification.

RESULTS

The overall survival rate was 95% for revision in aseptic loosening and 87% for any reason at an average follow-up of 6.3 years. Twelve patients died and 9 patients were lost to follow-up leaving 45 patients for final functional analysis. Among the 45 patients, excellent to good results were seen in 33 patients, fair results were seen in 5 patients, poor results were seen in seven patients. Two patients had aseptic loosening and another two patients developed deep chronic infection awaiting two-stage revision.

CONCLUSION

Reconstruction rings still place a role in the armamentarium for complex acetabular reconstruction. It helps to reliably restore the bone stock, have an acceptable survival rate and satisfactory functional outcome at medium to long-term follow-up.

High Rates of Spacer Fracture in the Setting of Extended Trochanteric Osteotomy With a Specific Thin-Core Articulating Antibiotic Hip Spacer

BACKGROUND

Two-stage revision remains the standard of care for prosthetic joint infection after total hip arthroplasty. However, there are substantial complications associated with articulating antibiotic hip spacers. Handmade and molded spacers have been shown to have higher rates of spacer fracture than antibiotic-coated prostheses (ACPs). The aim of this study is to review outcomes with an implant that is often categorized as an ACP spacer, the Zimmer-Biomet StageOne Select Femoral Spacer (ZBSO).

METHODS

A retrospective review was performed of 63 patients who underwent placement of a ZBSO. Patients were compared based on whether or not an extended trochanteric osteotomy (ETO) was performed using Fisher's exact and t-tests.

RESULTS

Five patients were excluded due to lack of follow-up or death shortly after stage 1 surgery, leaving 58 patients. Spacer fracture was noted in 5 of 58 patients (8.6%). Sixteen patients underwent ETO and 25.0% suffered a spacer fracture compared to 2.3% without ETO (odds ratio 13.7, P = .0248). There was no association between patient demographics or ETO length and spacer fracture. Two patients had periprosthetic fractures (3.4%) and 4 had dislocations (6.9%). Forty-nine patients (84.4%) went on to second-stage revision; of those 26.5% failed to clear the infection and required an average of 2.2 additional surgeries.

CONCLUSION

The ZBSO spacer has overall complication rates similar to previously reported spacer series. Although the ZBSO looks like an ACP spacer, in the setting of ETO, it behaves like a molded or handmade spacer with a high rate of spacer fracture (25%) due to the small diameter of the core. This implant should be used with caution in combination with an ETO.

A Contemporary Classification System of Femoral Bone Loss in Revision Total Hip Arthroplasty

BACKGROUND

Current femoral bone loss classification systems in revision total hip arthroplasty were created at a time when the predominant reconstructive methods used cylindrical porous-coated cobalt-chrome stems. As these stems have largely been replaced by fluted-tapered titanium stems, the ability of these classification systems to help guide implant selection is limited. The purpose of this study was to describe a novel classification system based on contemporary reconstructive techniques.

METHODS

We reviewed the charts of all patients who underwent femoral component revision at our institution from 2007 through 2019. Preoperative images were reviewed, and FBL was rated according to the Paprosky classification and compared to ratings using our institution's NCS. Rates of reoperation at the time of most recent follow-up were determined and compared.

RESULTS

Four-hundred and forty-two femoral revisions in 330 patients with a mean follow-up duration of 2.7 years were identified. Femoral type according to Paprosky and NCS were Paprosky I (36, 8.1%), II (61, 13.8%), IIIA (180, 40.7%), IIIB (116, 26.2%), and IV (49 11.1%) and NCS 1 (35, 7.9%), 2 (364, 82.4%), 3 (8, 1.8%), 4 (27, 6.1%), and 5 (8, 1.8%). Of the 353 nonstaged rTHAs, there were 42 cases requiring unplanned reoperation (11.9%), including infection (18, 5.1%), instability (10, 2.8%), femoral loosening (5, 1.4%), and various other causes (9, 2.5%). The NCS was more predictive of reoperation than the Paprosky classification (Fisher's exact test, P = .008 vs P = ns, respectively).

CONCLUSION

We present a novel femoral classification system that can help guide contemporary implant selection.

Early clinical and radiological outcomes of a new tapered fluted titanium monobloc revision stem in hip arthroplasty

PURPOSE

A new fluted, titanium, monobloc stem with a three degree taper has been designed in an attempt to overcome the challenges associated with femoral reconstruction in the setting of extensive bone loss. The aim of this study was to report its early clinical and radiographic outcomes.

METHODS

This is a retrospective review of prospectively collected data carried out at a single institution between Jan 2017 and Dec 2019. Forty-three femoral revisions were performed using a new tapered, fluted, titanium, monobloc (TFTM) revision stem. Complications, clinical and radiographic data were obtained from medical records and a locally maintained database. Clinical outcomes were assessed using the Oxford Hip Score (OHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). All post-operative radiographs were analysed for subsidence, osteolysis and femoral cortical bone remodelling.

RESULTS

Mean follow-up was 24 months (range 8-42 months). Subsidence of 1.2 mm was noted in one patient. No cases of clinically significant subsidence (> 10 mm) were observed. At final follow-up, a statistically significant improvement was noted in functional outcome scores. The mean OHS preoperatively and at final follow-up were 24 (SD 13) and 42 (SD15). p = 0.04 mean difference 18 (95% CI 15-22). The mean WOMAC scores preoperatively and at final follow-up were 62 (SD23) and 88 (SD7) respectively (p < 0.001, mean difference 26; 95% CI 21-34). No stem fractures were noted within the follow-up period.

CONCLUSION

Positive early clinical and radiological outcomes have been observed with this tapered, fluted, titanium, monobloc stem. Based on these results, this implant may be considered as a viable option in the majority of uncemented femoral revisions.

Long-Term Outcomes of 496 Anatomical Cementless Modular Femoral Stems: Eleven to Twenty Years of Follow-Up

BACKGROUND

The aim of the study is to assess the long-term outcomes of this specific stem (anatomical cementless modular stem ESOP), to review the survivorship, complication rate, and radiographic and clinical outcomes.

METHODS

Descriptive and analytical retrospective longitudinal observational study of patients was operated on total hip arthroplasty between 1998 and 2007. Four hundred ninety-six prostheses corresponding to 447 patients were reviewed, mean age was 65.8 years (standard deviation [SD] ±11.6 years), and median follow-up time was 13.4 years (range 1-20). The most used cups were cementless (75.8%). The most frequent friction pairs were metal-polyethylene (53.1%) and ceramic-polyethylene (24.2%). Main variables analyzed were stem survival, subsidence, coronal orientation, osteolysis, reintervention, and Oxford Hip Score.

RESULTS

From 496 implants, there were 22 lost to follow-up (4.4%). Stem revision was performed in 51 patients: 26 periprosthetic joint infections (2-stage revision), 16 periprosthetic fractures, and 8 one-stage revisions (6 real aseptic loosening with negative culture after revision). The stem survivorship at more than 15 years for any reason was 89.2% and for aseptic loosening 97.97%. No specific complications were found due to modularity. The mean subsidence and orientation was 2.06 mm (SD ±5.11 mm) and 0.41° varus (SD ±2.20°) respectively. Subsidence >5 mm or varus >5° was associated with a higher revision rate. Osteolysis was found in 110 patients (zone I = 79, VII = 57), associated with zirconium-polyethylene, without relationship to the stem revision rate or Oxford Hip Score.

CONCLUSION

To our knowledge, this study represents the largest series of this stem, revealing an excellent survival rate and long-term clinical outcomes similar to the best results of classical cementless stems published in the literature.

Pelvic discontinuity: a challenge to overcome

Pelvic discontinuity (PD) has been a considerable challenge for the hip revision arthroplasty surgeon. However, not all PDs are the same. Some occur during primary cup insertion, resembling a fresh periprosthetic fracture that separates the superior and inferior portions of the pelvis, while others are chronic as a result of gradual acetabular bone loss due to osteolysis and/or acetabular implant loosening.In the past, ORIF, various types of cages, bone grafts and bone cement were utilized with little success. Today, the biomechanics and biology of PD as well as new diagnostic tools and especially a variety of new implants and techniques are available to hip revision surgeons. Ultraporous cups and augments, cup-cage constructs and custom triflange components have revolutionized the treatment of PD when used in various combinations with ORIF and bone grafts. For chronic PD the cup-cage construct is the most popular method of reconstruction with good medium-term results.Dislocation continues to be the leading cause of failure in all situations, followed by infection. Ultimately, surgeons today have a big enough armamentarium to select the best treatment approach. Case individualization, personal experience and improvisation are the best assets to drive treatment decisions and strategies. Cite this article: EFORT Open Rev 2021;6:459-471. DOI: 10.1302/2058-5241.6.210022.

Surgical data recording in the operating room: a systematic review of modalities and metrics

INTRODUCTION

Operating room recording, via video, audio and sensor-based recordings, is increasingly common. Yet, surgical data science is a new field without clear guidelines. The purpose of this study is to examine existing published studies of surgical recording modalities to determine which are available for use in the operating room, as a first step towards developing unified standards for this field.

METHODS

Medline, EMBASE, CENTRAL and PubMed databases were systematically searched for articles describing modalities of data collection in the operating room. Search terms included 'video-audio media', 'bio-sensing techniques', 'sound', 'movement', 'operating rooms' and others. Title, abstract and full-text screening were completed to identify relevant articles. Descriptive statistical analysis was performed for included studies.

RESULTS

From 3756 citations, 91 studies met inclusion criteria. These studies described 10 unique data-collection modalities for 17 different purposes in the operating room. Data modalities included video, audio, kinematic and eye-tracking among others. Data-collection purposes described included surgical trainee assessment, surgical error, surgical team communication and operating room efficiency.

CONCLUSION

Effective data collection and utilization in the operating room are imperative for the provision of superior surgical care. The future operating room landscape undoubtedly includes multiple modalities of data collection for a plethora of purposes. This review acts as a foundation for employing operating room data in a way that leads to meaningful benefit for patient care.

Technical Note for Transfemoral Implantation of Tapered Revision Stems. The Advantage to Stay Short

Background

The aim was to test the hypothesis that during transfemoral implantation of a conical revision stem, the fixation of the stem at the distal tip leads to a low rate of periprosthetic fractures.

Material and Methods

Two hundred eighty-two stem revisions by a transfemoral approach in cases of Paprosky Type II and IIIA-defects (with a sufficient isthmus) were carried out and analyzed during and radiographically after the surgery for unintentional periprosthetic fractures below the osteotomy.

Results

In all cases, fixation was always achieved at the tip of the distal component in the isthmus of the femur. No periprosthetic fractures were observed.

Conclusions

When the isthmus of the femur is intact, a transfemoral implantation of a tapered revision stem at the distal end reduces the risk of periprosthetic fractures by preventing bypassing the isthmus with the stem. Knowing the difference between the nominal diameter and the diameter at the distal start of the conical zone can help to create this fixation technique resulting in short revision stems.

Bilateral Erecta Luxation: A Case Report and Literature Review

CASE

A 69-year-old man fell from a height, resulting in direct axial loading while both shoulders were fully abducted. He was referred to the surgical ward, and both shoulders were reduced by closed reduction using the traction-countertraction maneuver. After little improvement of complaints of pain in the right shoulder over 45 days, magnetic resonance demonstrated traumatic rupture of the supraspinatus.

CONCLUSION

Inferior dislocation (luxation erecta) is an uncommon event, with bilateral dislocation being even rarer. Treatment should be initiated urgently via closed reduction or, if this is not possible, through open reduction. The long-term prognosis is favorable after appropriate treatment.

Three-dimensional Printing in Orthopaedic Surgery: Current Applications and Future Developments

Three-dimensional (3D) printing is an exciting form of manufacturing technology that has transformed the way we can treat various medical pathologies. Also known as additive manufacturing, 3D printing fuses materials together in a layer-by-layer fashion to construct a final 3D product. This technology allows flexibility in the design process and enables efficient production of both off-the-shelf and personalized medical products that accommodate patient needs better than traditional manufacturing processes. In the field of orthopaedic surgery, 3D printing implants and instrumentation can be used to address a variety of pathologies that would otherwise be challenging to manage with products made from traditional subtractive manufacturing. Furthermore, 3D bioprinting has significantly impacted bone and cartilage restoration procedures and has the potential to completely transform how we treat patients with debilitating musculoskeletal injuries. Although costs can be high, as technology advances, the economics of 3D printing will improve, especially as the benefits of this technology have clearly been demonstrated in both orthopaedic surgery and medicine as a whole. This review outlines the basics of 3D printing technology and its current applications in orthopaedic surgery and ends with a brief summary of 3D bioprinting and its potential future impact.

Mid-term clinical outcomes and survivorship of medial-pivot total knee arthroplasty-a mean five year follow-up based on one thousand, one hundred and twenty eight cases

PURPOSE

The unique medial-pivot (MP) design of ADVANCE® system largely simulates the movement of a normal knee joint and a high mid- and long-term success rate has been reported in limited populations. The aims of this study are to investigate the mid-term clinical outcomes and survivorship based on a large cohort with 1128 cases.

METHODS

One thousand seven patients received 1276 ADVANCE® MP TKAs from January 2011 to April 2016 in our institution were retrospectively investigated. The range of motion (ROM), the Knee Society Score (KSS), the Knee Society Function Score (KSFS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score, and the Forgotten Joint Score (FJS) were used to evaluate clinical outcomes and Kaplan-Meier survival curve was used to calculate the survivorship.

RESULTS

In an averaged five year follow-up, the results of 879 patients (1128 knees) were successfully obtained and the clinical outcomes of 1107 knees were recorded. One hundred forty-eight knees (11.6%) were lost to follow-up. Excellent mid-term ROM, KSS, KSFS, and WOMAC score were recorded. A total of 53 complications were identified and most complications were related to the discordance of femoropatellar joint. Taking revision for any reason as end point, the overall survivorship was 99.2% at seven years. When taking all cases lost to follow-up as failures, the survivorship was 83.8% at five years and 50.6% at seven years.

CONCLUSION

For MP designs, the intermediate clinical outcomes are good to excellent and the mid-term survivorship related to reasons other than infection is also satisfactory.

Clinical outcomes and survivorship of two-stage total hip or knee arthroplasty in septic arthritis: a retrospective analysis with a minimum five-year follow-up

Purpose

Septic arthritis of the native joint is challenging for orthopedic surgeons because it may lead to wide bone defects and severe impairment of joint function. This study aimed to analyze clinical functional outcomes, the rate of infection eradication, and survival of implants of patients who underwent two-stage arthroplasty for septic arthritis of the hip and knee.

Methods

A retrospective single-centre analysis was conducted of patients treated for septic arthritis of the hip and knee joints through a two-stage surgery between 2012 and 2015. Clinical and radiological records were gathered from the prospectively collected Institutional Arthroplasty Registry. Patients’ pre-operative Harris hip scores and Knee Society scores were compared with those obtained at the latest follow-up. Kaplan–Meier curves were generated to assess survival of implants.

Results

Forty-seven patients were included. The mean follow-up was 85.2 ± 15.4 months. The Harris hip score improved from 39.4 ± 9.9 to 84.5 ± 10.8 points (p < 0.001). The Knee Society score improved from 40.7 ± 8.4 to 86.0 ± 7.8 points (p < 0.001). Knee Society score-function increased from 25.7 ± 14.2 to 85.4 ± 23.4 points (p < 0.001). The infection eradication rates were 92.0% and 90.9% in patients who underwent hip and knee operation, respectively (p = 0.891). Overall survivorship of implants after the second stage was 93.6%.

Conclusions

Two-stage arthroplasty provides good to excellent clinical outcomes in cases of active septic arthritis of the hip and the knee, high rates of infection control, and implant survival.

Safety and Performance of Titanium Suture Anchors Used in Knee Ligament Repair Procedures

Injuries to the knee ligaments can be particularly disabling in young patients, given the risk of long-term disability if adequate fixation is not achieved during initial repair. The TWINFIX™ titanium (Ti) suture anchor with ULTRABRAID™ Suture (Smith and Nephew, London, UK) was designed to secure tendon and ligament reconstructions with increased boney ingrowth at the anchor site with minimal invasive technique. This retrospective analysis looked at 33 patients (41 implants) operated with this device between 2015 and 2019 at a single institution. The average age of patients was 33.18 years (standard deviation [SD], 15.26), with an average body mass index of 24.88 (SD, 3.49). The indications were lateral extra-articular tenodesis during anterior cruciate ligament reconstruction, medial patellofemoral ligament reconstruction, quadriceps or patellar tendon repair and medial collateral ligament repair. After an average follow up of 24.3 + 6.53 months, there was no reports of clinical failure or radiographic evidence of implant failure or loosening. One patient experienced a complication unrelated to the study device, requiring manipulation under anesthesia with resolution of symptoms. This case series supports the safety and performance of this implants for the knee procedures in which its use is indicated. Additional follow-up will be required to determine whether these effects are sustained at medium- and long-term durations.

Mid-term survivorship and clinical outcomes of the medial stabilized systems in primary total knee arthroplasty: A systematic review

INTRODUCTION

Medial Pivot Total Knee Arthroplasty was introduced in clinical practice in 1990s to reproduce the in vivo-natural knee kinematics. This design is characterized by an asymmetric constraint profile, with aa highly congruent medial compartment, and a less congruent lateral compartment. Short-term outcomes of the medial pivot systems in primary knee arthroplasty have been widely reported in the current literature, however, only few studies have described results beyond 5-year follow-up.

OBJECTIVES

The primary objectives of this systematic review of the literature is to analyze the mid-term studies on medial pivot total knee arthroplasty focusing on the reoperation rate, survivorship and clinical outcome scores.

METHODS

The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications from January 1980 to December 2019 utilizing the following keywords: "medial pivot", "medial stabilized", "medial rotating", "medial congruent", medial ball and socket", "arthroplasty", "TKA", "TKR", and "knee surgery".

RESULTS

18 articles met the inclusion criteria for the present study. The average quality was 11.4 for non-comparative studies and 21.7 for comparative studies based on MINORS criteria. A total 2832 knee arthroplasties were included for the final analysis with an average age of 69 years, and an average follow-up of 8.1 years (minimum 5 years). The overall reoperation rate was 2.4%, with periprosthetic joint infection as the leading cause of revision in 0.9% of cases, followed by aseptic loosening in 0.4% of cases. The average Knee Society Score improved to a mean preoperative score of 40.1 to a mean postoperative score of 89.2. The functional knee society score improved from a mean preoperative score of 44.8 to an average postoperative score of 82.9. The global range of motion improved from 104.8° preoperatively to 115.6° postoperatively.

CONCLUSION

We found that medial pivot system in primary total knee arthroplasty provide overall mid-term survivorship comparable to other standard implasnts. In addition, medial pivot system is associated with better high-end function compared to standard implants.

The Nottingham radiation protocol for O-arm navigation in paediatric deformity patients: a feasibility study

BACKGROUND

O-arm assisted pedicle screw placement has been proven to be more accurate than free-hand technique. Radiation exposure remains the primary drawback. We determined the feasibility and safety of a reduced radiation protocol in paediatric patients undergoing scoliosis correction.

METHODS

A reduced radiation protocol for a medtronic O-arm navigational system was devised. 3D CT reconstructions of an anthropomorphic pelvic phantom indicated adequate image quality after reduction to 14% of current manufacturer default factors. A feasibility study to test the image quality was undertaken on four patients, one with syndromic and three with idiopathic scoliosis each receiving progressively reducing radiation exposure of 60%, 50%, 40% and 14% of what would have been delivered using the manufacturer default protocol. This represented 32% of the mayo clinic protocol. It was achieved by reducing the x-ray tube current to 10 mA while keeping the tube potential at 90 kVp.

RESULTS

A low dose O-arm protocol was able to generate adequate image quality while delivering as little as 14% (for lumbar region reconstructions) of the recommended protocol radiation dose. The total radiation dose delivered with this protocol was approximately 0.8 milliSieverts for a single spin. This effective dose represents < 1/3 of average UK and < 1/6 average US annual radiation exposure. There were no neurological or implant-related complications.

CONCLUSIONS

Our low dose O-arm radiation protocol significantly reduces the radiation exposure compared to the manufacturer recommended Mayo clinic protocol providing operational image quality to allow accurate screw placement in spinal deformity.

3D printing-assisted fabrication of patient-specific antibacterial radial head prosthesis with high periprosthetic bone preservation

We present a novel fabrication and surgical approach for anatomical reconstruction of a fractured radial head using patient-specific radial head prosthesis made of polymethylmethacrylate (PMMA) bone cement. To this end, the use of PMMA bone cement for prosthesis fabrication was initially investigated using computational modeling and experimental methods. The radial head prosthesis was fabricated through casting of PMMA bone cement in silicone mold in the operation room before implantation. To enhance the precision of bony preparation for replacement of the radial head, patient-specific surgical guide for accurate resection of the radial neck with the desired length was developed. Post-surgical clinical examinations revealed biomechanical restoration of elbow function, owing to the use of patient-specific radial head prosthesis and surgical guide. Importantly, follow-up radiographs after a mean follow-up of 18 months revealed bone preservation at the bone-prosthesis interface without any signs of erosion of the capitellum. Taken together, our method demonstrated the safety and efficacy of the PMMA radial head prosthesis in restoring elbow biomechanics. This also provides a very safe and cost-effective method for making various patient-specific prostheses with localized antibacterial delivery and close mechanical properties to native bone for improved periprosthetic bone regeneration.

Survival Analysis of Allografting and Antiprotrusio Cage in Treating Massive Acetabular Bone Defects

BACKGROUND

Massive acetabular bone defects reconstructed with allografting and antiprotrusio cage in revision hip arthroplasty is less reported in the literature. We here report a series of 84 antiprotrusio cages and analyze the risk factors associated with failure.

METHODS

All instances of use of an antiprotrusio cage for massive acetabular defect (Paprosky type IIc, III, and pelvic discontinuity) between 2002 and 2017 in the authors' institute were reviewed after institutional review board's approval. Survival analyses based on clinical data, bone defect (Paprosky system), type of allograft, size of cage, fixation quality, and position of cage were performed. Failure was defined as cage loosening or breakage, poor hip function, or cage revision for any reason.

RESULTS

A total of 84 cages in 77 patients (mean age, 62.9 years), with a mean follow-up period of 6.2 years, had a survival rate of 82.1%. Failure was noted in 15 hips, including mechanical failure in 8 hips, recurrent dislocation in 1 hip, poor hip function in 1 hip, and periprosthetic joint infection in 5 hips. Pelvic discontinuity, reconstruction with morselized allograft alone, and fewer than 4 fixation points to the host bone were associated with higher failure rates (hazard ratios, 4.02, 3.42, and 9.9, respectively).

CONCLUSION

We found that an antiprotrusio cage combined with strut allografts, fixed securely to the host bone (>4 fixation points), are beneficial for the management of massive acetabular bone defects. However, pelvic discontinuity remains a challenge that warrants the further study of technical or prosthetic innovations, such as triflange implants, cup cage, and 3D-printed implants.

Quasi-static analysis of hip cement spacers

The use of temporary hip prosthesis made of orthopedic cement (spacer) in conjunction with antibiotics became a widespread method used for treating prosthetic infections despite the fact that this method makes bone cement (PMMA) more fragile. The necessity to incorporate reinforcement is therefore crucial to strengthen the bone cement. In this study, a validated Finite Element Modelling (FEM) was used to analyze the behavior of spacers. This FEM model uses a non-linear dynamic explicit integration to simulate the mechanical behavior of the spacer under quasi-static loading. In addition to this FEM, Extended Finite Element Method (XFEM) was also used to investigate the fracture behavior of the spacers reinforced with titanium, ceramic and stainless-steel spacer stems. The effect of the material on the performance of the reinforced spacers was also analyzed. The results showed that numerical modelling based on explicit finite element using ABAQUS/Explicit is an effective method to predict the different spacers' mechanical behavior. The simulated crack initiation and propagation were in a good agreement with experimental observations. The FEM models developed in this study can help mechanical designers and engineers to improve the prostheses' quality and durability.

Modular tapered conical revision stem in hip revision surgery: mid- term results

BACKGROUND

The aim of this paper is to evaluate the clinical and radiological outcomes of a fluted tapered modular distal-fixation stem at medium to long-term follow-up. The hypothesis of this investigation was to verify if the use of this implant design may have provided potential advantages in femoral revisions and post-traumatic instances where the restoration of the anatomy was the prime concern.

METHODS

We retrospectively reviewed 62 cases of femoral revision surgeries, performed in Paprosky type IIIA and IIIB bone defects between January 2001 and December 2011 with a mean follow-up of 8.5 ± 1.5 years (range 5.1-15.9 years) where a modular fluted stem was used. The clinical assessment was performed with the Harris Hip Score (HHS), and the radiographic evaluation was carried in order to assess the stability of the femoral component. Intra-operative and postoperative complications were recorded, and the rates of complications and revisions for any cause were determined.

RESULTS

Mean HHS improved 35.4 points from the preoperative assessment. Radiographic evaluation showed a stable stem anchorage in 90.3% of the cases at the last follow-up. Five (8%) implants required additional surgery. Neither breakage of the stem nor loosening of the taper junction were recorded. Kaplan-Meier survivorship was 89.4% (CI: 88.8-90%) for any complication and 92.3% (CI: 91.8-92.7%) according to revision for any causes at 81 months follow-up.

CONCLUSIONS

Our findings suggest that this stem design is a reliable option in cases of complex femoral bone defects, as well as in cases with high functional deficiencies, with promising survivorship.

Comparing cost and print time estimates for six commercially-available 3D printers obtained through slicing software for clinically relevant anatomical models

Background

3D printed patient-specific anatomical models have been applied clinically to orthopaedic care for surgical planning and patient education. The estimated cost and print time per model for 3D printers have not yet been compared with clinically representative models across multiple printing technologies. This study investigates six commercially-available 3D printers: Prusa i3 MK3S, Formlabs Form 2, Formlabs Form 3, LulzBot TAZ 6, Stratasys F370, and Stratasys J750 Digital Anatomy.

Methods

Seven representative orthopaedic standard tessellation models derived from CT scans were imported into the respective slicing software for each 3D printer. For each printer and corresponding print setting, the slicing software provides a print time and material use estimate. Material quantity was used to calculate estimated model cost. Print settings investigated were infill percentage, layer height, and model orientation on the print bed. The slicing software investigated are Cura LulzBot Edition 3.6.20, GrabCAD Print 1.43, PreForm 3.4.6, and PrusaSlicer 2.2.0.

Results

The effect of changing infill between 15% and 20% on estimated print time and material use was negligible. Orientation of the model has considerable impact on time and cost with worst-case differences being as much as 39.30% added print time and 34.56% added costs. Averaged across all investigated settings, horizontal model orientation on the print bed minimizes estimated print time for all 3D printers, while vertical model orientation minimizes cost with the exception of Stratasys J750 Digital Anatomy, in which horizontal orientation also minimized cost. Decreasing layer height for all investigated printers increased estimated print time and decreased estimated cost with the exception of Stratasys F370, in which cost increased. The difference in material cost was two orders of magnitude between the least and most-expensive printers. The difference in build rate (cm³/min) was one order of magnitude between the fastest and slowest printers.

Conclusions

All investigated 3D printers in this study have the potential for clinical utility. Print time and print cost are dependent on orientation of anatomy and the printers and settings selected. Cost-effective clinical 3D printing of anatomic models should consider an appropriate printer for the complexity of the anatomy and the experience of the printer technicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41205-020-00091-4.

Revision Hip Arthroplasty Using a Porous-coated or Taper ZMR Implant: Minimum 10-year Follow-up of Implant Survivorship

INTRODUCTION

The Zimmer Modular Revision hip (ZMR) system is available in two stem options, a porous-coated cylindrical (PCM) and a taper (TM) stem. Several concerns have been reported regarding modular implants. Specifically, because of early junctional fractures, the ZMR system was redesigned with a wider modular interface. As such, we designed a study assessing long-term ZMR survivorship and functional and radiographic outcomes.

METHODS AND MATERIALS

A search of our institutional research database was performed. A minimum 10-year follow-up was selected. The following two cohorts were created: PCM and TM stems. The Kaplan-Meier survival analysis was performed, and causes of stem failure requiring revision surgery were collected. Functional outcomes as per the Harris Hip Score and radiographic stem stability were assessed as per the Engh classification.

RESULTS

A total of 146 patients meeting the inclusion criteria were available for follow-up (PCM = 68, TM = 78). The mean follow-up was 13.4 years clinically and 11.1 years radiographically for the PCM cohort. Similarly, the TM cohort had a follow-up of 11.1 years clinically and 10.5 years radiographically. The Kaplan-Meier survivorships were 87.1% and 87.8% at 15 years for the PCM and TM cohorts, respectively. The most common cause of failure requiring revision surgery overall was aseptic loosening (PCM = 1.4%, TM = 5.6%). The mean postoperative Harris Hip Score was as follows: PCM = 71.2 and TM = 64.7. Engh type I or II stem ingrowth was as follows: PCM = 85% and TM = 68%.

DISCUSSION

Good survivorship using the ZMR stem system can be expected at up to 15 years. Aseptic loosening remains the most commonly encountered problem for both PCM and TM stems. Previously identified modular junctional weakness seem to have been addressed.

Controlling Antibiotic Release from Polymethylmethacrylate Bone Cement

Bone cement is used as a mortar for securing bone implants, as bone void fillers or as spacers in orthopaedic surgery. Antibiotic-loaded bone cements (ALBCs) have been used to prevent and treat prosthetic joint infections by providing a high antibiotic concentration around the implanted prosthesis. High antibiotic concentrations are, on the other hand, often associated with tissue toxicity. Controlling antibiotic release from ALBCS is key to achieving effective infection control and promoting prosthesis integration with the surrounding bone tissue. However, current ALBCs still need significant improvement in regulating antibiotic release. In this review, we first provide a brief introduction to prosthetic joint infections, and the background concepts of therapeutic efficacy and toxicity in antibiotics. We then review the current state of ALBCs and their release characteristics before focusing on the research and development in controlling the antibiotic release and osteo-conductivity/inductivity. We then conclude by a discussion on the need for better in vitro experiment designs such that the release results can be extrapolated to predict better the local antibiotic concentrations in vivo.

Computer-assisted open reduction internal fixation of intraarticular radius fractures navigated with patient-specific instrumentation, a prospective case series

BACKGROUND

Intra-articular fractures are associated with posttraumatic arthritis if inappropriately treated. Exact reduction of the joint congruency is the main factor to avoid the development of arthrosis. Aim of this study was to evaluate feasibility of computer-assisted surgical planning and 3D-printed patient-specific instrumentation (PSI) for treatment of distal intraarticular radius fractures.

METHOD

7 Patients who suffered a distal intraarticular radius fracture were enrolled in this prospective case series. Preoperative CT-scan was recorded, whereupon a 3D model was computed for surgical planning and design of PSI for surgical navigation. Postoperative accuracy and joint congruency were assessed. Patients were followed-up 3, 6 and 12 months postoperatively.

RESULTS

Mean follow-up was 16 months. Over all range of motion was restored and flexion, extension and pronation showed significant recovery, p < 0.05. Biggest intraarticular joint step-off and gap reduced from average 2.49 (± 1.04) to 0.8 mm (± 0.44), p < 0.05 and 6.12 mm (± 1.04) to 2.21 mm (± 1.16), p < 0.05. Average grip strength restored (3-16 months) from 20.33 kg (± 7.12) to 39.3 kg (± 19.55) p < 0.05, 100% of the healthy contralateral side. 3D-accuracy for guided fragments was 2.07 mm (± 0.64) and 8.59° (± 2.9) and 2.33 mm (± 0.69) and 12.86° (± 7.13), p > 0.05 for fragments reduced with ligamentotaxis.

CONCLUSION

Computer-assisted and PSI navigated intraarticular radius fracture treatment is feasible, safe and accurate. The benefits of this method, however, do not outstand the additional effort.

LEVEL OF EVIDENCE

IV.

The Recent Progress and Applications of Digital Technologies in Healthcare: A Review

BACKGROUND

The implementation of medical digital technologies can provide better accessibility and flexibility of healthcare for the public. It encompasses the availability of open information on the health, treatment, complications, and recent progress on biomedical research. At present, even in low-income countries, diagnostic and medical services are becoming more accessible and available. However, many issues related to digital health technologies remain unmet, including the reliability, safety, testing, and ethical aspects.

PURPOSE

The aim of the review is to discuss and analyze the recent progress on the application of big data, artificial intelligence, telemedicine, block-chain platforms, smart devices in healthcare, and medical education. Basic Design. The publication search was carried out using Google Scholar, PubMed, Web of Sciences, Medline, Wiley Online Library, and CrossRef databases. The review highlights the applications of artificial intelligence, "big data," telemedicine and block-chain technologies, and smart devices (internet of things) for solving the real problems in healthcare and medical education. Major Findings. We identified 252 papers related to the digital health area. However, the number of papers discussed in the review was limited to 152 due to the exclusion criteria. The literature search demonstrated that digital health technologies became highly sought due to recent pandemics, including COVID-19. The disastrous dissemination of COVID-19 through all continents triggered the need for fast and effective solutions to localize, manage, and treat the viral infection. In this regard, the use of telemedicine and other e-health technologies might help to lessen the pressure on healthcare systems. Summary. Digital platforms can help optimize diagnosis, consulting, and treatment of patients. However, due to the lack of official regulations and recommendations, the stakeholders, including private and governmental organizations, are facing the problem with adequate validation and approbation of novel digital health technologies. In this regard, proper scientific research is required before a digital product is deployed for the healthcare sector.