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Staunton P, Alhojailan K, Desgagne C, Epure L, Zukor D, Huk O, Antoniou J. Acute Periprosthetic Hip Fractures With Short, Uncemented Femoral Stems. J Arthroplasty 2024:S0883-5403(24)00572-2. [PMID: 38851408 DOI: 10.1016/j.arth.2024.05.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Uncemented femoral stems in hip arthroplasty have shown excellent long-term results, and several systematic studies indicate satisfactory performance of short stems. However, biomechanical and finite element analysis studies have suggested that shorter stems allow greater micromotion, producing greater strain at the implant-bone interface, which potentially increases the risk for periprosthetic fracture (PPF). We sought to assess this risk within our unit. METHODS Our institution's arthroplasty database was searched for all primary total hip arthroplasties using short femoral stems performed between July 14, 2009 and August 29, 2022. The overall PPF rate and the PPF rate for individual femoral stems were established. Preoperative X-rays for each case were analyzed to characterize individual proximal femoral geometry. A data analysis was performed to identify risk factors for PPF. RESULTS For the time period assessed, 3,192 short femoral stems were implanted. This included 1,561 of stem A and 1,631 of stem B. Women constituted 55.37% of the cohort. The average patient age was 66 years (range, 22 to 95). The PPF rate was 0.6%, with 19 PPFs identified at a follow-up of 3 months. There was a significantly higher fracture rate in stem A (0.96%) compared to stem B (0.25%) (P ≤ .01). Proximal femoral geometry, age, and sex were not determined to be risk factors for PPF in our cohort. Individual surgeons and surgical approaches appeared to confer no increased risk. There was no significant difference in average stem length, but multivariate analysis identified stem type and stem length as an independent risk factor for PPF. CONCLUSIONS Our study identified individual stem and stem length as independent risk factors for PPF within our cohort. PPF is a multifactorial issue, and consensus on emerging risk factors such as implant design will hopefully inform decisions that can provide further risk reduction for individual patients.
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Affiliation(s)
- Peter Staunton
- Department of Orthopedics, Jewish General Hospital, Montreal, Quebec, Canada; McGill University, Montreal, Quebec, Canada
| | - Khalifa Alhojailan
- Department of Orthopedics, Jewish General Hospital, Montreal, Quebec, Canada; McGill University, Montreal, Quebec, Canada
| | | | - Laura Epure
- Department of Orthopedics, Jewish General Hospital, Montreal, Quebec, Canada
| | - David Zukor
- Department of Orthopedics, Jewish General Hospital, Montreal, Quebec, Canada; McGill University, Montreal, Quebec, Canada
| | - Olga Huk
- Department of Orthopedics, Jewish General Hospital, Montreal, Quebec, Canada; McGill University, Montreal, Quebec, Canada
| | - John Antoniou
- Department of Orthopedics, Jewish General Hospital, Montreal, Quebec, Canada; McGill University, Montreal, Quebec, Canada
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Fontalis A, Yasen AT, Kayani B, Luo TD, Mancino F, Magan A, Plastow R, Haddad FS. Two-Dimensional Versus Three-Dimensional Preoperative Planning in Total Hip Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00526-6. [PMID: 38810812 DOI: 10.1016/j.arth.2024.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Preoperative planning in total hip arthroplasty (THA) involves utilizing radiographs or advanced imaging modalities, including computerized tomography scans, for precise prediction of implant sizing and positioning. This study aimed to compare 3-dimensional (3D) versus 2-dimensional (2D) preoperative planning in primary THA with respect to key surgical metrics, including restoration of the horizontal and vertical center of rotation (COR), combined offset, and leg length. METHODS This study included 60 patients undergoing primary THA for symptomatic hip osteoarthritis (OA), randomly allocated to either robotic arm-assisted or conventional THA. Digital 2D templating and 3D planning using the robotic software were performed for all patients. All measurements to evaluate the accuracy of templating methods were conducted on the preoperative computerized tomography scanogram, using the contralateral hip as a reference. Sensitivity analyses explored differences between 2D and 3D planning in patients who had superolateral or medial OA patterns. RESULTS Compared to 2D templating, 3D templating was associated with less medialization of the horizontal COR (-1.2 versus -0.2 mm, P = .002) and more accurate restoration of the vertical COR (1.63 versus 0.3 mm, P < .001) with respect to the contralateral side. Furthermore, 3D templating was superior for planned restoration of leg length (+0.23 versus -0.74 mm, P = .019). Sensitivity analyses demonstrated that in patients who had medial OA, 3D planning resulted in less medialization of horizontal COR and less offset reduction. Conversely, in patients who had superolateral OA, there was less lateralization of horizontal COR and less offset increase using 3D planning. Additionally, 3D planning showed superior reproducibility for stem, acetabular cup sizes, and neck angle, while 2D planning often led to smaller stem and cup sizes. CONCLUSIONS Our findings indicated higher accuracy in the planned restoration of native joint mechanics using 3D planning. Additionally, this study highlights distinct variances between the 2 planning methods across different OA pattern subtypes, offering valuable insights for clinicians employing 2D planning.
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Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Adam T Yasen
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Babar Kayani
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tianyi David Luo
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK; Orthopaedics Northeast, Fort Wayne, Indiana
| | - Fabio Mancino
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ahmed Magan
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ricci Plastow
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, London, UK
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Park CW, Cho K, Jeong SJ, Jung IG, Lim SJ, Park YS. Mean 23-Year Outcomes of Total Hip Arthroplasty Using a Modular Femoral Stem With Metaphyseal Fixation Sleeve. J Arthroplasty 2024; 39:1007-1012. [PMID: 37852443 DOI: 10.1016/j.arth.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Although the modular sleeve concept for femoral implants has several advantages, studies reporting on greater than 20-year outcomes are limited. This study aimed to report the mean 23-year results of total hip arthroplasty (THA) using a modular stem with metaphyseal fixation sleeve. METHODS This study reviewed primary THAs performed using a modular stem between October 1994 and April 1998. Of the 272 hips (221 patients) identified, 220 hips (177 patients) satisfying the minimum 20-year follow-up were included. The Harris Hip Score was used for clinical evaluation. Final hip radiographs were analyzed to evaluate the implant stability and the extent of femoral osteolysis. The mean follow-up duration was 23 years (range, 20 to 28). RESULTS The mean Harris Hip Score improved from 38 points (range, 26 to 67) preoperatively to 90 points (range, 71 to 100) at the final follow-up (P < .001). Femoral osteolysis was observed in 146 hips (67.1%), but 145 were located proximal to the osseo-integrated sleeve. Overall, 4 femoral revisions were performed; 2 for chronic infection, one for aseptic loosening, and one for periprosthetic femoral fracture. Of the 19 (8.6%) periprosthetic femoral fractures, the most common type was Vancouver AG (13 hips). One (0.5%) asymptomatic distal stem fracture occurred, while no complications were identified at the stem-sleeve junction. Implant survivorship free of any femoral revision was 98.3% at 23 years. CONCLUSIONS A THA using a modular stem with metaphyseal fixation sleeve demonstrated 98.3% stem survivorship with excellent clinical outcomes at a mean follow-up of 23 years in non-obese patients.
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Affiliation(s)
- Chan-Woo Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyungjun Cho
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Jin Jeong
- Department of Orthopedic Surgery, Myongji hospital, Hanyang University School of Medicine, Goyang, Korea
| | - In Geol Jung
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Jae Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Youn-Soo Park
- Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Di Martino A, Ferri R, Bordini B, Brunello M, Rossomando V, Digennaro V, Traina F, Faldini C. Long-term survival and complication rate of cementless prosthetic stems in primary total hip arthroplasty categorized by types according to Mont classification: a regional registry-based study on 53,626 implants. Arch Orthop Trauma Surg 2024; 144:1423-1435. [PMID: 38112778 DOI: 10.1007/s00402-023-05144-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION The purpose of this retrospective registry-based study is to assess survival and causes of failure of cementless stem implants used in total hip arthroplasty (THAs), to ascertain if there are differences when these are categorized according to the six types described by Mont. METHODS Data collected from the regional registry regarding all primary THAs performed from 2000 to 2019 were analyzed. Femoral prosthetic stems were divided into the six types of Mont classification. For each stem type, number of implants, survival and causes of failure were evaluated and compared. RESULTS The most frequently implanted stem type was the 3c type (53.4%). Type 1 had the lowest stem failure rate (1.6%), and type 6 showed the highest (3.9%). Periprosthetic fracture was the most frequent complication in type 6, accounting for 34.5% of failures. Aseptic loosening was the main complication in type 2 stems, accounting for 36.4% of failures. Pairwise comparisons showed significant higher survival of type 1 compared to type 3c (p = 0.000026) and type 6 (p = 0.000076), and between type 3a compared to type 3c (p = 0.03) and type 6 (p = 0.026). CONCLUSION Significant variations in implant survival rates were found among the six Mont-types of cementless stems. These findings emphasize the paramount importance of stem design and fixation area in determining long-term survival, providing a guidance for orthopedic surgeons in the selection of the most appropriate stem for primary THA, contributing to our understanding of cementless stem performance, presenting invaluable insights to further improve patient outcomes in THA surgery.
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Affiliation(s)
- Alberto Di Martino
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy.
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy.
| | - Riccardo Ferri
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
| | - Barbara Bordini
- Medical Technology Lab, IRCCS - Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli, 1, 40136, Bologna, Italy
| | - Matteo Brunello
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
| | - Valentino Rossomando
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
| | - Vitantonio Digennaro
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
| | - Francesco Traina
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
- Ortopedia, Traumatologia e Chirurgia Protesica e dei Reimpianti di Anca e Ginocchio, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via Giulio Cesare Pupilli 1, 40136, Bologna, Italy
- Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, 40136, Bologna, Italy
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Meisterhans M, Dimitriou D, Fasser MR, Hoch A, Jud L, Zingg PO. Influence of offset on osseointegration in cementless total hip arthroplasty: A finite element study. J Orthop Res 2024. [PMID: 38376065 DOI: 10.1002/jor.25808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/21/2024]
Abstract
Early aseptic loosening is caused by deficient osteointegration of the femoral stem due to increased micromotions and represents a common mode of failure in uncemented total hip arthroplasty (THA). This study hypothesized that a higher femoral offset, a smaller stem size and obesity increase femoral micromotion, potentially resulting in early aseptic loosening. A finite element analysis was conducted based on computed tomography segmented model of four patients who received a THA with a triple-tapered straight stem (Size 1, 3, 6). The influence of femoral stem offset (short neck, standard, lateral), head length (S to XXL), femoral anteversion and obesity during daily activities of fast walking and stair climbing was analyzed. The micromotions for the femoral stem zones were compared to a threshold representing a value above which only partial osseointegration is expected. The minimum femoral offset configuration compared to the maximum offset configuration (short neck stem, S head vs. lateral stem, XXL head) leads to a relative mean micromotion increase of 24% for the upper stem zone. Increasing the body weight (body mass index 30-35 kg/m2 ) increases the micromotion by 20% for all stem zones. The obese population recorded threshold-exceeding micromotions for stem sizes 1 and 3 for all offset configurations during stair climbing. Higher femoral offset, a smaller stem size, and higher loading due to obesity lead to an increase in micromotion between the prosthesis and proximal femur and represent a risk configuration for impaired osseointegration of a triple-tapered straight stem, especially when these three factors are present simultaneously.
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Affiliation(s)
- Michel Meisterhans
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dimitris Dimitriou
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marie-Rosa Fasser
- Institute of Biomechanics, Balgrist Campus, ETH Zurich, Zurich, Switzerland
- Spine Biomechanics, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armando Hoch
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Lukas Jud
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick O Zingg
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Robin JX, Huebschmann N, Villa JC, Schwarzkopf R. Staged Bilateral Total Hip Arthroplasty in a Patient With Larsen Syndrome. Arthroplast Today 2023; 21:101147. [PMID: 37274834 PMCID: PMC10238462 DOI: 10.1016/j.artd.2023.101147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/14/2023] [Accepted: 04/16/2023] [Indexed: 06/07/2023] Open
Abstract
Larsen syndrome is a rare genetic disorder characterized by weak connective tissues and various musculoskeletal abnormalities. This is a case report of a 39-year-old patient with Larsen syndrome who presented with over a decade of bilateral hip pain and difficulty ambulating. This patient has a prior history of bilateral congenital hip dislocations that were treated with open reduction and spica casting as a child with good result. Years later, she went on to develop bilateral hip osteoarthritis with significant remodeling of the proximal femur. The goal of this case presentation is to demonstrate the utility of total hip arthroplasty for this patient and discuss surgical challenges and considerations.
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Affiliation(s)
- Joseph X. Robin
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
| | - Nathan Huebschmann
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
| | - Jordan C. Villa
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopedic Surgery, NYU Langone Health, New York, NY, 10003, USA
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Vio War AS, Kumar N, Chanda S. Does preclinical analysis based on static loading underestimate post-surgery stem micromotion in THA as opposed to dynamic gait loading? Med Biol Eng Comput 2023; 61:1473-1488. [PMID: 36763232 DOI: 10.1007/s11517-023-02801-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
The success of cementless hip stems depends on the primary stability of the implant quantified by the amount of micromotion at the bone-stem interface. Most finite element (FE)-based preclinical studies on post-surgery stem stability rely on static analysis. Hence, the effect of dynamic gait loading on bone-stem relative micromotion remains virtually unexplored. Furthermore, there is a paucity of research on the primary stability of grooved stems as opposed to plain stem design. The primary aim of this FE study was to understand whether transient dynamic gait had any incremental effect on the net micromotion results and to further draw insights into the effects of grooved texture vis-à-vis a plain model on micromotion and proximal load transfer in host bone. Two musculoskeletal loading regimes corresponding to normal walking (NW) and stair climbing (SC) were considered. Although marginally improved load transfer was predicted proximally for the grooved construct under static loading, the micromotion values (max: NW ~ 7 μm; SC ~ 10 μm) were found to be considerably less in comparison to plain stem (max: NW ~ 50 μm; SC ~ 20 μm). For both physiological load cases, a significant surge in micromotion values was predicted in dynamic analyses as opposed to static analyses for the grooved stem (~ 390% greater). For the plain model, the increase in these values from static to dynamic loading is relatively moderate yet clinically significant (~ 230% greater). This suggests that the qualitative similarities notwithstanding, there were significant dissimilarities in the quantitative trends of micromotion for different cases under both analyses.
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Affiliation(s)
- Adeline S Vio War
- Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, 781 039, Assam, India
| | - Neeraj Kumar
- Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, 781 039, Assam, India
| | - Souptick Chanda
- Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, 781 039, Assam, India.
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Yang J, Li Z, Zhan P, Li X, Wang K, Han J, Yang P. Proximal femur parameter measurement via improved PointNet+. Int J Med Robot 2022; 19:e2494. [PMID: 36527276 DOI: 10.1002/rcs.2494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 11/27/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Femoral morphological studies and parameter measurements play a crucial role in diagnosing hip joint disease, preoperative planning for total hip arthroplasty, and prosthesis design. Doctors usually perform parameter measurements manually in clinical practice, but it is time-consuming and labor-intensive. Moreover, the results rely heavily on the doctor's experience, and the repeatability is poor. Therefore, the accurate and automatic measurement methods of proximal femoral parameters are of great value. METHOD We collected 300 cases of clinical CT data of the femur. We introduced the adaptive function adjustment module to the neural network PointNet++ to strengthen the global feature extraction of the point cloud for improving the accuracy of femur segmentation. We used the improved PointNet++ network to segment the femur into three parts: femoral head, femoral neck, and femoral shaft. We evaluated the segmentation accracy using Dice Coefficient, MIoU, recall, and precision indicators. We achieved the automatic measurement of the proximal femoral parameters using the shape fitting algorithms, and compared the automatic and manual measurement results. RESULTS The Dice, MIoU, recall and precision indicator of the improved segmentation algorithm reached 98.05%, 96.55%, 96.63%, and 96.03%, respectively. The comparison between automatic and manual measurement results showed that the mean accuracies of all parameters were above 95%, the mean errors were less than 5 mm and 3°, and the ICC values were more than 0.8, indicating that the automatic measurement results were accurate. CONCLUSION Our improved PointNet++ network provided high-precision segmentation of the femur. We further completed automatic measurement of the femur parameters and verified its high accuracy. This method is of great value for the diagnosis and preoperative planning of hip diseases.
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Affiliation(s)
- Jiayu Yang
- School of Computer, Xi'an University of Posts and Telecommunications, Xi'an, Shaanxi, China
| | - Zhe Li
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Pengyu Zhan
- School of Computer, Xi'an University of Posts and Telecommunications, Xi'an, Shaanxi, China
| | - Xinghua Li
- Department of Radiology, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Kunzheng Wang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Jungang Han
- School of Computer, Xi'an University of Posts and Telecommunications, Xi'an, Shaanxi, China
| | - Pei Yang
- Department of Bone and Joint Surgery, The Second Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi, China
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