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Bakhtiarinejad M, Gao C, Farvardin A, Zhu G, Wang Y, Oni JK, Taylor RH, Armand M. A Surgical Robotic System for Osteoporotic Hip Augmentation: System Development and Experimental Evaluation. IEEE TRANSACTIONS ON MEDICAL ROBOTICS AND BIONICS 2023; 5:18-29. [PMID: 37213937 PMCID: PMC10195101 DOI: 10.1109/tmrb.2023.3241589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Minimally-invasive Osteoporotic Hip Augmentation (OHA) by injecting bone cement is a potential treatment option to reduce the risk of hip fracture. This treatment can significantly benefit from computer-assisted planning and execution system to optimize the pattern of cement injection. We present a novel robotic system for the execution of OHA that consists of a 6-DOF robotic arm and integrated drilling and injection component. The minimally-invasive procedure is performed by registering the robot and preoperative images to the surgical scene using multiview image-based 2D/3D registration with no external fiducial attached to the body. The performance of the system is evaluated through experimental sawbone studies as well as cadaveric experiments with intact soft tissues. In the cadaver experiments, distance errors of 3.28mm and 2.64mm for entry and target points and orientation error of 2.30° are calculated. Moreover, the mean surface distance error of 2.13mm with translational error of 4.47mm is reported between injected and planned cement profiles. The experimental results demonstrate the first application of the proposed Robot-Assisted combined Drilling and Injection System (RADIS), incorporating biomechanical planning and intraoperative fiducial-less 2D/3D registration on human cadavers with intact soft tissues.
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Affiliation(s)
- Mahsan Bakhtiarinejad
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Cong Gao
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Amirhossein Farvardin
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Gang Zhu
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Yu Wang
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Julius K Oni
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Russell H Taylor
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Mehran Armand
- Laboratory for Computational Sensing and Robotics, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Computer Science, Johns Hopkins University, Baltimore, MD 21218, USA; Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD 21287, USA
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Farvardin A, Bakhtiarinejad M, Murphy RJ, Basafa E, Khanuja H, Oni JK, Armand M. A biomechanically-guided planning and execution paradigm for osteoporotic hip augmentation: Experimental evaluation of the biomechanics and temperature-rise. Clin Biomech (Bristol, Avon) 2021; 87:105392. [PMID: 34174676 PMCID: PMC8550980 DOI: 10.1016/j.clinbiomech.2021.105392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Augmentation of the proximal femur with bone cement (femoroplasty) has been identified as a potential preventive approach to reduce the risk of fracture. Femoroplasty, however, is associated with a risk of thermal damage as well as the leakage of bone cement or blockage of blood supply when large volumes of cement are introduced inside the bone. METHODS Six pairs of cadaveric femora were augmented using a newly proposed planning paradigm and an in-house navigation system to control the location and volume of the injected cement. To evaluate the risk of thermal damage, we recorded the peak temperature of bone at three regions of interest as well as the exposure time for temperature rise of 8 °C, 10 °C, and 12 °C in these regions. Augmentation was followed by mechanical testing to failure resembling a sideway fall on the greater trochanter. FINDINGS Results of the fracture tests correlated with those of simulations for the yield load (R2 = 0.77) and showed that femoroplasty can significantly improve the yield load (42%, P < 0.001) and yield energy (139%, P = 0.062) of the specimens. Meanwhile, temperature recordings of the bone surface showed that the areas close to the greater trochanter will be exposed to more critical temperature rise than the trochanteric crest and femoral neck areas. INTERPRETATION The new planning paradigm offers a more efficient injection strategy with injection volume of 9.1 ml on average. Meanwhile, temperature recordings of bone surfaces suggest that risk of thermal necrosis remains as a concern with femoroplasty using Polymethylmethacrylate.
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Affiliation(s)
- Amirhossein Farvardin
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA.
| | - Mahsan Bakhtiarinejad
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Ryan J Murphy
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Ehsan Basafa
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Harpal Khanuja
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Juluis K Oni
- Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
| | - Mehran Armand
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Rd, Laurel, MD 20723, USA; Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
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Horbach AJ, Staat M, Pérez-Viana D, Simmen HP, Neuhaus V, Pape HC, Prescher A, Ciritsis B. Biomechanical in vitro examination of a standardized low-volume tubular femoroplasty. Clin Biomech (Bristol, Avon) 2020; 80:105104. [PMID: 32712527 DOI: 10.1016/j.clinbiomech.2020.105104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/03/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteoporosis is associated with the risk of fractures near the hip. Age and comorbidities increase the perioperative risk. Due to the ageing population, fracture of the proximal femur also proves to be a socio-economic problem. Preventive surgical measures have hardly been used so far. METHODS 10 pairs of human femora from fresh cadavers were divided into control and low-volume femoroplasty groups and subjected to a Hayes fall-loading fracture test. The results of the respective localization and classification of the fracture site, the Singh index determined by computed tomography (CT) examination and the parameters in terms of fracture force, work to fracture and stiffness were evaluated statistically and with the finite element method. In addition, a finite element parametric study with different position angles and variants of the tubular geometry of the femoroplasty was performed. FINDINGS Compared to the control group, the work to fracture could be increased by 33.2%. The fracture force increased by 19.9%. The used technique and instrumentation proved to be standardized and reproducible with an average poly(methyl methacrylate) volume of 10.5 ml. The parametric study showed the best results for the selected angle and geometry. INTERPRETATION The cadaver studies demonstrated the biomechanical efficacy of the low-volume tubular femoroplasty. The numerical calculations confirmed the optimal choice of positioning as well as the inner and outer diameter of the tube in this setting. The standardized minimally invasive technique with the instruments developed for it could be used in further comparative studies to confirm the measured biomechanical results.
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Affiliation(s)
- Andreas J Horbach
- FH Aachen University of Applied Sciences, Institute of Bioengineering, Biomechanics Lab., Heinrich-Mußmann-Straße 1, 52428 Jülich, Germany.
| | - Manfred Staat
- FH Aachen University of Applied Sciences, Institute of Bioengineering, Biomechanics Lab., Heinrich-Mußmann-Straße 1, 52428 Jülich, Germany.
| | - Daniel Pérez-Viana
- FH Aachen University of Applied Sciences, Institute of Bioengineering, Biomechanics Lab., Heinrich-Mußmann-Straße 1, 52428 Jülich, Germany.
| | - Hans-Peter Simmen
- Universitätsspital Zürich, Trauma Unit, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Valentin Neuhaus
- Universitätsspital Zürich, Trauma Unit, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Hans-Christoph Pape
- Universitätsspital Zürich, Trauma Unit, Rämistrasse 100, 8091 Zürich, Switzerland.
| | - Andreas Prescher
- Institute of Anatomy and Cell Biology, Rheinisch-Westfälische Technische Hochschule Aachen University, Wendlingweg 2, 52074 Aachen, Germany.
| | - Bernhard Ciritsis
- Ente Ospedaliero Cantonale Ospedale di Bellinzona e Valli, Trauma Unit, Via Ospedale 12, 6500 Bellinzona, Switzerland; Centro Ortopedico di Quadrante, Lungolago Buozzi 25, 28887 Omegna (VB), Italy.
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Gao C, Farvardin A, Grupp RB, Bakhtiarinejad M, Ma L, Thies M, Unberath M, Taylor RH, Armand M. Fiducial-Free 2D/3D Registration for Robot-Assisted Femoroplasty. ACTA ACUST UNITED AC 2020; 2:437-446. [PMID: 33763632 DOI: 10.1109/tmrb.2020.3012460] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Femoroplasty is a proposed alternative therapeutic method for preventing osteoporotic hip fractures in the elderly. Previously developed navigation system for femoroplasty required the attachment of an external X-ray fiducial to the femur. We propose a fiducial-free 2D/3D registration pipeline using fluoroscopic images for robot-assisted femoroplasty. Intraoperative fluoroscopic images are taken from multiple views to perform registration of the femur and drilling/injection device. The proposed method was tested through comprehensive simulation and cadaveric studies. Performance was evaluated on the registration error of the femur and the drilling/injection device. In simulations, the proposed approach achieved a mean accuracy of 1.26±0.74 mm for the relative planned injection entry point; 0.63±0.21° and 0.17±0.19° for the femur injection path direction and device guide direction, respectively. In the cadaver studies, a mean error of 2.64 ± 1.10 mm was achieved between the planned entry point and the device guide tip. The biomechanical analysis showed that even with a 4 mm translational deviation from the optimal injection path, the yield load prior to fracture increased by 40.7%. This result suggests that the fiducial-less 2D/3D registration is sufficiently accurate to guide robot assisted femoroplasty.
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Affiliation(s)
- Cong Gao
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA 21211
| | - Amirhossein Farvardin
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA 21211
| | - Robert B Grupp
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA 21211
| | - Mahsan Bakhtiarinejad
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA 21211
| | - Liuhong Ma
- Department of Cranio-maxillo-facial Surgery Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, CHN,100144
| | - Mareike Thies
- Pattern Recognition Lab, Friedrich-Alexander-Universitt Erlangen-Nrnberg, Erlangen, Germany 91058
| | - Mathias Unberath
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA 21211
| | - Russell H Taylor
- Department of Computer Science, Johns Hopkins University, Baltimore, MD, USA 21211
| | - Mehran Armand
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA 21211; Department of Orthopaedic Surgery and Johns Hopkins Applied Physics Laboratory, Baltimore, MD, USA 21224
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Sas A, Tanck E, Sermon A, van Lenthe GH. Finite element models for fracture prevention in patients with metastatic bone disease. A literature review. Bone Rep 2020; 12:100286. [PMID: 32551337 PMCID: PMC7292864 DOI: 10.1016/j.bonr.2020.100286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/04/2020] [Accepted: 05/25/2020] [Indexed: 12/17/2022] Open
Abstract
Patients with bone metastases have an increased risk to sustain a pathological fracture as lytic metastatic lesions damage and weaken the bone. In order to prevent fractures, prophylactic treatment is advised for patients with a high fracture risk. Mechanical stabilization of the femur can be provided through femoroplasty, a minimally invasive procedure where bone cement is injected into the lesion, or through internal fixation with intra- or extramedullary implants. Clinicians face the task of determining whether or not prophylactic treatment is required and which treatment would be the most optimal. Finite element (FE) models are promising tools that could support this decision process. The aim of this paper is to provide an overview of the state-of-the-art in FE modeling for the treatment decision of metastatic bone lesions in the femur. First, we will summarize the clinical and mechanical results of femoroplasty as a prophylactic treatment method. Secondly, current FE models for fracture risk assessment of metastatic femurs will be reviewed and the remaining challenges for clinical implementation will be discussed. Thirdly, we will elaborate on the simulation of femoroplasty in FE models and discuss future opportunities. Femoroplasty has already proven to effectively relieve pain and improve functionality, but there remains uncertainty whether it provides sufficient mechanical strengthening to prevent pathological fractures. FE models could help to select appropriate candidates for whom femoroplasty provides sufficient increase in strength and to further improve the mechanical benefit by optimizing the locations for cement augmentation.
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Affiliation(s)
- Amelie Sas
- Biomechanics Section, KU Leuven, Leuven, Belgium
| | - Esther Tanck
- Orthopaedic Research Laboratory, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - An Sermon
- Department of Traumatology, University Hospitals Gasthuisberg, Leuven, Belgium and Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Farvardin A, Basafa E, Bakhtiarinejad M, Armand M. Significance of preoperative planning for prophylactic augmentation of osteoporotic hip: A computational modeling study. J Biomech 2019; 94:75-81. [PMID: 31371101 PMCID: PMC6736717 DOI: 10.1016/j.jbiomech.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 12/22/2022]
Abstract
A potential effective treatment for prevention of osteoporotic hip fractures is augmentation of the mechanical properties of the femur by injecting it with bone cement. This therapy, however, is only in research stage and can benefit substantially from computational simulations to optimize the pattern of cement injection. Some studies have considered a patient-specific planning paradigm for Osteoporotic Hip Augmentation (OHA). Despite their biomechanical advantages, customized plans require advanced surgical systems for implementation. Other studies, therefore, have suggested a more generalized injection strategy. The goal of this study is to investigate as to whether the additional computational overhead of the patient-specific planning can significantly improve the bone strength as compared to the generalized injection strategies attempted in the literature. For this purpose, numerical models were developed from high resolution CT images (n = 4). Through finite element analysis and hydrodynamic simulations, we compared the biomechanical efficiency of the customized cement-based augmentation along with three generalized injection strategies developed previously. Two series of simulations were studied, one with homogeneous and one with inhomogeneous material properties for the osteoporotic bone. The customized cement-based augmentation inhomogeneous models showed that injection of only 10 ml of bone cement can significantly increase the yield load (79.6%, P < 0.01) and yield energy (199%, P < 0.01) of an osteoporotic femur. This increase is significantly higher than those of the generalized injections proposed previously (23.8% on average). Our findings suggest that OHA can significantly benefit from a patient-specific plan that determines the pattern and volume of the injected cement.
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Affiliation(s)
- Amirhossein Farvardin
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA.
| | - Ehsan Basafa
- Auris Health, Inc., 150 Shoreline Dr, Redwood City, CA 94065, USA
| | - Mahsan Bakhtiarinejad
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - Mehran Armand
- Department of Mechanical Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Laboratory for Computational Sensing and Robotics, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA; Johns Hopkins University Applied Physics Laboratory, 11100 Johns Hopkins Rd, Laurel, MD 20723, USA; Department of Orthopaedic Surgery, Johns Hopkins University, 601 N. Caroline Street, Baltimore, MD 21287, USA
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Stroncek JD, Shaul JL, Favell D, Hill RS, Huber BM, Howe JG, Bouxsein ML. In vitro injection of osteoporotic cadaveric femurs with a triphasic calcium-based implant confers immediate biomechanical integrity. J Orthop Res 2019; 37:908-915. [PMID: 30793358 PMCID: PMC6593990 DOI: 10.1002/jor.24239] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 01/21/2019] [Indexed: 02/04/2023]
Abstract
Current pharmaceutical therapies can reduce hip fractures by up to 50%, but compliance to treatment is low and therapies take up to 18 months to reduce risk. Thus, alternative or complementary approaches to reduce the risk of hip fracture are needed. The AGN1 local osteo-enhancement procedure (LOEP) is one such alternative approach, as it is designed to locally replace bone lost due to osteoporosis and provide immediate biomechanical benefit. This in vitro study evaluated the initial biomechanical impact of this treatment on human cadaveric femurs. We obtained 45 pairs of cadaveric femurs from women aged 77.8 ± 8.8 years. One femur of each pair was treated, while the contralateral femur served as an untreated control. Treatment included debridement, irrigation/suction, and injection of a triphasic calcium-based implant (AGN1). Mechanical testing of the femora was performed in a sideways fall configuration 24 h after treatment. Of the 45 pairs, 4 had normal, 16 osteopenic, and 25 osteoporotic BMD T-scores. Altogether, treatment increased failure load on average by 20.5% (p < 0.0001). In the subset of osteoporotic femurs, treatment increased failure load by 26% and work to failure by 45% (p < 0.01 for both). Treatment did not significantly affect stiffness in any group. These findings provide evidence that local delivery of the triphasic calcium-based implant in the proximal femur is technically feasible and provides immediate biomechanical benefit. Our results provide strong rationale for additional studies investigating the utility of this approach for reducing the risk of hip fracture. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society.
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Affiliation(s)
- John D. Stroncek
- AgNovos Healthcare7301 Calhoun Place Suite 100RockvilleMaryland 20855
| | - Jonathan L. Shaul
- AgNovos Healthcare7301 Calhoun Place Suite 100RockvilleMaryland 20855
| | - Dominique Favell
- AgNovos Healthcare7301 Calhoun Place Suite 100RockvilleMaryland 20855
| | - Ronald S. Hill
- AgNovos Healthcare7301 Calhoun Place Suite 100RockvilleMaryland 20855
| | - Bryan M. Huber
- Copley Hospital528 Washington HwyMorrisvilleVermont 05661
| | - James G. Howe
- AgNovos Healthcare7301 Calhoun Place Suite 100RockvilleMaryland 20855
| | - Mary L. Bouxsein
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center and Dept. of Orthopedic SurgeryHarvard Medical School330 Brookline AveBostonMassachusetts 02215
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Kok J, Širka A, Grassi L, Raina DB, Tarasevičius Š, Tägil M, Lidgren L, Isaksson H. Fracture strength of the proximal femur injected with a calcium sulfate/hydroxyapatite bone substitute. Clin Biomech (Bristol, Avon) 2019; 63:172-178. [PMID: 30903873 DOI: 10.1016/j.clinbiomech.2019.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/05/2019] [Accepted: 03/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Available interventions for preventing fragility hip fractures show limited efficacy. Injection of a biomaterial as bone substitute could increase the fracture strength of the hip. This study aimed to show the feasibility of injecting a calcium sulfate/hydroxyapatite based biomaterial in the femoral neck and to calculate the consequent change in strength using the finite element method. METHODS Five patients were injected with 10 ml calcium sulfate/hydroxyapatite in their femoral neck. Quantitative CT scans were taken before and after injection. Five additional patients with fragility hip fractures were also scanned and the images from the non-fractured contralateral sides were used. Finite element models were created for all proximal femora with and without injection and the models were tested under stance and sideways fall loading until fracture. The change in fracture strength caused by the injection was calculated. Additionally, perturbations in volume, location, and stiffness of the injected material were created to investigate their contribution to the fracture strength increase. FINDINGS The 10 ml injection succeeded in all patients. Baseline simulations showed theoretical fracture strength increases of 0-9%. Volume increase, change in location and increase in stiffness of the material led to increases in fracture strength of 1-27%, -8-26% and 0-17%, respectively. Altering the location of the injection to a more lateral position and increasing the stiffness of the material led to increases in fracture strength of up to 42%. INTERPRETATION This study shows that an injection of calcium sulfate/hydroxyapatite is feasible and can theoretically increase the hip's fracture strength.
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Affiliation(s)
- Joeri Kok
- Department of Biomedical Engineering, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Aurimas Širka
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, LT 44307 Kaunas, Lithuania
| | - Lorenzo Grassi
- Department of Biomedical Engineering, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Deepak Bushan Raina
- Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Šarūnas Tarasevičius
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, LT 44307 Kaunas, Lithuania
| | - Magnus Tägil
- Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden.
| | - Lars Lidgren
- Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden
| | - Hanna Isaksson
- Department of Biomedical Engineering, Lund University, Box 118, 221 00 Lund, Sweden; Department of Orthopedics, Clinical Sciences, Lund University, Box 118, 221 00 Lund, Sweden.
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Freitas A, Camargo WS, Aquino RJ, Giordano V, Bonavides AF, Shimano AC. PRELIMINARY MECHANICAL TEST OF PROXIMAL FEMUR REINFORCEMENT WITH CEMENTED X-SHAPED PMMA. ACTA ORTOPEDICA BRASILEIRA 2018; 26:231-235. [PMID: 30210250 PMCID: PMC6131274 DOI: 10.1590/1413-785220182604187691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To evaluate the mechanical behavior of the proximal end of the femur submitted to the X-shaped polymethylmethacrylate (PMMA) reinforcement technique. Methods: Fifteen synthetic femurs, with a Nacional® density of 10 PCF, were divided into two groups: the DX group, with 5 units that were submitted to PMMA reinforcement, and the DP group, with 10 units, which were evaluated intact. The volume of PMMA required, the maximum load, and the absorbed energy to fracture were analyzed by means of a static mechanical bending test simulating a fall on the greater trochanter. Results: A mean of 6 ml of PMMA was used to model the X-reinforcement; it was observed that the DX group presented significantly higher maximum load (median = 1553 N, p = 0.005) and absorbed energy to fracture (median = 9.7 J; p = 0.050) than the DP group (median = 905 N and 6.6 J). Conclusion: X-reinforcement of the proximal end of synthetic femurs showed a statistically significant increase in the maximum load and absorbed energy to fracture in the mechanical assay when compared to the control group. Level of Evidence III, Experimental study.
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Affiliation(s)
- Anderson Freitas
- Instituto de Pesquisa e Ensino do Hospital Ortopédico e Medicina Especializada (IPE-HOME), Brasília, DF, Brazil
| | | | | | | | | | - Antônio Carlos Shimano
- Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
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Discrete particle model for cement infiltration within open-cell structures: Prevention of osteoporotic fracture. PLoS One 2018; 13:e0199035. [PMID: 29898001 PMCID: PMC5999107 DOI: 10.1371/journal.pone.0199035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/30/2018] [Indexed: 11/19/2022] Open
Abstract
This paper proposes a discrete particle model based on the random-walk theory for simulating cement infiltration within open-cell structures to prevent osteoporotic proximal femur fractures. Model parameters consider the cement viscosity (high and low) and the desired direction of injection (vertical and diagonal). In vitro and in silico characterizations of augmented open-cell structures validated the computational model and quantified the improved mechanical properties (Young's modulus) of the augmented specimens. The cement injection pattern was successfully predicted in all the simulated cases. All the augmented specimens exhibited enhanced mechanical properties computationally and experimentally (maximum improvements of 237.95 ± 12.91% and 246.85 ± 35.57%, respectively). The open-cell structures with high porosity fraction showed a considerable increase in mechanical properties. Cement augmentation in low porosity fraction specimens resulted in a lesser increase in mechanical properties. The results suggest that the proposed discrete particle model is adequate for use as a femoroplasty planning framework.
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Santana Artiles ME, Venetsanos DT. Numerical investigation of the effect of bone cement porosity on osteoporotic femoral augmentation. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2018; 34:e2989. [PMID: 29603673 DOI: 10.1002/cnm.2989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/19/2018] [Accepted: 03/24/2018] [Indexed: 06/08/2023]
Abstract
Femoroplasty is the injection of bone cement into the proximal femur, enhances the bone load capacity, and is typically applied to osteoporotic femora. To minimize the required injected volume of bone cement and maximize the load capacity enhancement, an optimization problem must be solved, where the modulus of elasticity of the augmented bone is a key element. This paper, through the numerical investigation of a fall on the greater trochanter of an osteoporotic femur, compares different ways to calculate this modulus and introduces an approach, based on the concept of bone cement porosity, which provides results statistically similar to those obtained with other considerations. Based on this approach, the present paper quantifies the correlation between degree of osteoporosis and optimum volume of bone cement. It concludes with an exhaustive search that reveals the effect of the bone cement porosity on the optimum volume of PMMA, for various combinations of the frontal and transverse angles of the fall on the greater trochanter.
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Affiliation(s)
- María E Santana Artiles
- School of Engineering, Faculty of Science, Engineering and Computing, Kingston University, Friars Ave., Roehampton Vale Campus, SW15 3DW, London, UK
| | - Demetrios T Venetsanos
- School of Mechanical, Aerospace and Automotive Engineering, Faculty of Engineering, Environment & Computing, Coventry University, Gulson Road, CV1 2JH, Coventry, UK
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Varga P, Inzana JA, Schwiedrzik J, Zysset PK, Gueorguiev B, Blauth M, Windolf M. New approaches for cement-based prophylactic augmentation of the osteoporotic proximal femur provide enhanced reinforcement as predicted by non-linear finite element simulations. Clin Biomech (Bristol, Avon) 2017; 44:7-13. [PMID: 28282569 DOI: 10.1016/j.clinbiomech.2017.03.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 02/27/2017] [Accepted: 03/01/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND High incidence and increased mortality related to secondary, contralateral proximal femoral fractures may justify invasive prophylactic augmentation that reinforces the osteoporotic proximal femur to reduce fracture risk. Bone cement-based approaches (femoroplasty) may deliver the required strengthening effect; however, the significant variation in the results of previous studies calls for a systematic analysis and optimization of this method. Our hypothesis was that efficient generalized augmentation strategies can be identified via computational optimization. METHODS This study investigated, by means of finite element analysis, the effect of cement location and volume on the biomechanical properties of fifteen proximal femora in sideways fall. Novel cement cloud locations were developed using the principles of bone remodeling and compared to the "single central" location that was previously reported to be optimal. FINDINGS The new augmentation strategies provided significantly greater biomechanical benefits compared to the "single central" cement location. Augmenting with approximately 12ml of cement in the newly identified location achieved increases of 11% in stiffness, 64% in yield force, 156% in yield energy and 59% in maximum force, on average, compared to the non-augmented state. The weaker bones experienced a greater biomechanical benefit from augmentation than stronger bones. The effect of cement volume on the biomechanical properties was approximately linear. Results of the "single central" model showed good agreement with previous experimental studies. INTERPRETATION These findings indicate enhanced potential of cement-based prophylactic augmentation using the newly developed cementing strategy. Future studies should determine the required level of strengthening and confirm these numerical results experimentally.
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Affiliation(s)
| | | | - Jakob Schwiedrzik
- Institute of Surgical Technology and Biomechanics, University of Bern, Switzerland
| | - Philippe K Zysset
- Institute of Surgical Technology and Biomechanics, University of Bern, Switzerland
| | | | - Michael Blauth
- Department for Trauma Surgery, Medical University Innsbruck, Austria
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Santana Artiles ME, Venetsanos DT. A new evolutionary optimization method for osteoporotic bone augmentation. Comput Methods Biomech Biomed Engin 2017; 20:691-700. [DOI: 10.1080/10255842.2017.1291805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Varga P, Hofmann-Fliri L, Blauth M, Windolf M. Prophylactic augmentation of the osteoporotic proximal femur-mission impossible? BONEKEY REPORTS 2016; 5:854. [PMID: 28018586 DOI: 10.1038/bonekey.2016.86] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/01/2016] [Indexed: 11/09/2022]
Abstract
The high incidence of secondary hip fractures and the associated markedly increased mortality call for preventive actions that could help to avoid these injuries. By providing immediate strengthening and not relying on patient compliance, internal prophylactic augmentation of the osteoporotic proximal femur may overcome the main limitations of systemic bone drugs and wearable protective pads. However, such a method would have to provide sufficient and reliable strengthening effect with minimal risks and side effects to justify the need of an invasive treatment. The requirements for an internal reinforcement approach are thus strict and include mechanical, biological, clinical, ethical and financial criteria. Here we first attempt to describe the properties of an ideal augmentation method. Previously published methodologies and techniques developed at our research institute, including approaches using cements, metals, other materials or combined approaches, are then reviewed and evaluated according to these aspects. We conclude that none of the discussed methodologies appears to be able to deliver a sufficiently high gain-versus-risk ratio that could justify the clinical application and thus augmentation of the osteoporotic proximal femur remains a challenge. Finally, we provide suggestions for the development and evaluation of future strategies.
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Affiliation(s)
- Peter Varga
- AO Research Institute Davos , Davos Platz, Switzerland
| | | | - Michael Blauth
- Department for Trauma Surgery, Medical University Innsbruck , Innsbruck, Austria
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Basafa E, Murphy RJ, Otake Y, Kutzer MD, Belkoff SM, Mears SC, Armand M. Subject-specific planning of femoroplasty: an experimental verification study. J Biomech 2014; 48:59-64. [PMID: 25468663 DOI: 10.1016/j.jbiomech.2014.11.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/01/2014] [Accepted: 11/03/2014] [Indexed: 11/25/2022]
Abstract
The risk of osteoporotic hip fractures may be reduced by augmenting susceptible femora with acrylic polymethylmethacrylate (PMMA) bone cement. Grossly filling the proximal femur with PMMA has shown promise, but the augmented bones can suffer from thermal necrosis or cement leakage, among other side effects. We hypothesized that, using subject-specific planning and computer-assisted augmentation, we can minimize cement volume while increasing bone strength and reducing the risk of fracture. We mechanically tested eight pairs of osteoporotic femora, after augmenting one from each pair following patient-specific planning reported earlier, which optimized cement distribution and strength increase. An average of 9.5(±1.7) ml of cement was injected in the augmented set. Augmentation significantly (P<0.05) increased the yield load by 33%, maximum load by 30%, yield energy by 118%, and maximum energy by 94% relative to the non-augmented controls. Also predicted yield loads correlated well (R(2)=0.74) with the experiments and, for augmented specimens, cement profiles were predicted with an average surface error of <2 mm, further validating our simulation techniques. Results of the current study suggest that subject-specific planning of femoroplasty reduces the risk of hip fracture while minimizing the amount of cement required.
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Affiliation(s)
- Ehsan Basafa
- Laboratory for Computational Sensing & Robotics, Johns Hopkins University, Baltimore, MD, USA.
| | - Ryan J Murphy
- Laboratory for Computational Sensing & Robotics, Johns Hopkins University, Baltimore, MD, USA; Research and Exploratory Development Department, Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA
| | - Yoshito Otake
- Graduate School of Information Science, Nara Institute of Science and Technology, Ikoma, Nara, Japan
| | | | - Stephen M Belkoff
- International Center for Orthopaedic Advancement, Bayview Medical Center, Johns Hopkins University, Baltimore, MD, USA
| | - Simon C Mears
- Total Joint Replacement Center, Baylor Regional Medical Center, Plano, TX, USA
| | - Mehran Armand
- Laboratory for Computational Sensing & Robotics, Johns Hopkins University, Baltimore, MD, USA; Research and Exploratory Development Department, Johns Hopkins University Applied Physics Laboratory, Laurel, MD, USA
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