Computational analysis of prosthesis production via topology optimization

This work investigates the use of Topology Optimization (TO) to support the design of femur prosthesis to obtain more efficient solutions from the point of view of material distribution and internal forces. Computational tests were performed by the Interior-Point OPTimizer (IPOPT) method, seeking to explore the elastic mechanical characteristics of three real scenarios of daily loads on the femur. Numerical examples are presented to verify the novelty of the proposed method. The results obtained indicate that it is possible to reduce the volume of material up to 30% of the customize human femoral prosthesis, respecting all the boundary conditions.

Updates in Surgical Oncology

New knowledge and data can influence the treatment options of dogs and cats affected by neoplasms. Partial limb amputation with the use of a prosthesis is possible in dogs. Newer studies attempt to define better and understand the complications and limb function associated with this approach. Limb sparing is an alternative to amputation, and three-dimensional printing allows the manufacturing of personalized endoprostheses. Finally, the recommended approach for the excision of cutaneous mast cell tumors (MCTs) is with proportional margins. In dogs, grade shifting might have occurred when removing a recurrent MCT or soft tissue sarcoma.

Indication and surgical approach for reconstruction with endoprosthesis in bone-associated soft tissue sarcomas: Appropriate case management is vital

It is important for surgeons performing sarcoma surgery to know that bone resection and tumor prosthesis applications in soft tissue sarcomas (STS) have unique features in terms of indication, surgical approach and follow-up, in terms of the management of these cases. Some STS are associated with bone and major neurovascular structures. Bone-associated STS are generally relatively large and relatively deep-seated. Additionally, the tendency for metastasis is high. In some cases, the decision about which structures to resect is difficult. These cases are often accompanied by poor oncological and surgical outcomes. Management of cases should be done by a multidisciplinary team in advanced centers specialized in this field. The surgical team must have sufficient knowledge and experience in the field of limb-sparing surgery. Preoperative evaluation and especially good planning of bone and soft tissue reconstruction are vital.

Ultra-high-resolution CT of the temporal bone: The end of stapes prosthesis dimensional error and correlation with patient symptoms

PURPOSE

To describe the reliability of ultra-high-resolution computed tomography (UHR-CT) in the measurement of titanium stapes prostheses using manufacturer data as a reference.

MATERIALS AND METHODS

This retrospective study included patients treated by stapedectomy with titanium prostheses who underwent UHR-CT between January 2020 and October 2023. Images were acquired using an ultra-high-resolution mode (slice thickness: 0.25 mm; matrix, 1024 × 1024). Two radiologists independently evaluated the length, diameter, and intra-vestibular protrusion of the prosthesis. Post-operative air-bone gaps (ABGs) were recorded.

RESULTS

Fourteen patients were enrolled (mean age, 44.3 ± 13.8 [SD] years, 9 females), resulting in 16 temporal bone UHR-CTs. The exact length was obtained in 81.3 % (n = 13/16) and underestimated by 0.1 to 0.3 mm in the remaining 18.7 % (n = 3/16) CT scans for both readers (mean misestimation: -0.02 ± 0.06 [SD] mm, overall underestimation of 0.43 %). The exact diameter was reported in 75 % (n = 12/16) and 87.5 % (n = 14/16) of the CT scans for readers 1 and 2, respectively, and was off by 0.1 mm in all discrepancies (mean misestimation: 0.01 ± 0.04 [SD] mm, overall overestimation of 2.43 %). Intravestibular prosthesis protrusion was of 0.5 ± 0.43 [SD] mm (range: 0-1) and 0.49 ± 0.44 [SD] mm (range: 0-1.1) for readers 1 and 2, respectively, and did not correlate with ABGs (r = 0.25 and 0.22; P = 0.39 and 0.47 for readers 1 and 2, respectively). Intra and interobserver agreements were excellent.

CONCLUSION

UHR-CT provides 99.6 % and 97.6 % accuracy for prosthesis length and diameter measurements, respectively.

De Quervain tendinitis after total trapeziometacarpal joint arthroplasty: Biomechanical evaluation of tendon excursion in the first extensor tendon compartment

De Quervain's tenosynovitis is the most common complication after total trapeziometacarpal joint replacement. Etiology is unclear. Implantation of a ball-in-socket implant changes the biomechanics of the normal trapeziometacarpal saddle joint and increases its range of motion. The present study demonstrates that this procedure also significantly increases excursion of the abductor pollicis longus and extensor pollicis brevis tendons during thumb flexion-extension, and not during thumb abduction-adduction. Increased tendon gliding under the retinaculum of the first extensor tendon compartment could predispose to the development frictional tenosynovitis and play a role in the development of de Quervain's syndrome after total trapeziometacarpal joint replacement. LEVEL OF EVIDENCE: Not applicable (laboratory study).

Surface replacing arthroplasty of a post-traumatic stiff and deviated proximal interphalangeal joint in an adolescent

This case report describes the 4-year outcomes of proximal interphalangeal joint arthroplasty in a 14-year-old girl with a stiff joint after trauma. At follow-up, active range of motion was 35°, she was pain-free and satisfied with the outcome. Implant arthroplasty seems to be a valuable option for young patients with persistent post-traumatic stiff and deviated PIP joints to-at least temporarily-increase quality of life.

The influence of pontic distribution on the marginal and internal gaps of CAD/CAM five-unit anterior zirconia framework

Background/purpose

Nowadays, zirconia-based framework has been used for longspan or full-arch fixed dental prostheses (FDPs). This study aimed to evaluate the effect of pontic distribution on marginal and internal gaps of five-unit anterior zirconiabased DPs.

Materials and methods

Right maxillary central incisor and second premolar were selected as terminal abutments and three different edentulous conditions with one nonterminal abutment were simulated. Marginal and internal gaps in each zirconia-based samples(n = 10) were examined by computer-aided replica technique. Five regions, including marginal gaps at mesial or distal finishing line, internal gaps at the mesial or distal axial wall, and occlusal surface, were statistically analyzed (α = .05).

Results

Most of marginal gaps and internal gaps at axial wall were clinically acceptable, but larger at occlusal surface. For the three experimental groups, clinically accepted percentage with qualified gaps were less than 30%.There were statistical differences at axial wall over pontic side and marginal gaps over non-pontic side between groups (P<0.05). For sum of gaps of all abutments in each group, statistical differences were found at marginal and axial wall (P < 0.05). As for those on terminal and non-terminal abutments, statistical differences were found on second premolar (P < 0.05).

Conclusion

Except for occlusal surface, the overall marginal gaps and internal gaps at axial wall of five-unit anterior zirconia-based FDPs with different pontic distribution were clinically acceptable. However, the percentage with qualified gaps were low (<30%). Greater gaps were noted when adjacent pontic existed. Different pontic size and distribution with curvature had an influence on the gaps.

Three Sliding Probes Placed on Forelimb Skin for Proprioceptive Feedback Differentially yet Complementarily Contribute to Hand Gesture Detection and Object-Size Discrimination

The purpose was to assess the effectiveness of three sliding tactile probes placed on the forelimb skin to provide proprioceptive feedback for the detection of hand gestures and discrimination of object size. Tactile contactors representing the first three fingers were driven along the proximodistal axis by linear servo motors. Twenty healthy subjects were involved in the gesture detection test, with 10 of them also participating in the object-size discrimination task. Motors were controlled by computer in the first four sessions of the gesture detection experiment, while the fifth session utilized a sensorized glove. Both the volar and dorsal sides of the forearm were examined. In the object-size discrimination experiment, the method was exclusively assessed on the volar surface under four distinct feedback conditions, including all fingers and each finger separately. The psychophysical data were further analyzed using a structural equation model (SEM) to evaluate the specific contributions of each individual contactor. Subjects consistently outperformed the chance level in detecting gestures. Performance improved up to the third session, with better results obtained on the volar side. The performances were similar in the fourth and fifth sessions. The just noticeable difference for achieving a 75% discrimination accuracy was found to be 2.90 mm of movement on the skin. SEM analysis indicated that the contactor for the index finger had the lowest importance in gesture detection, while it played a more significant role in object-size discrimination. However, all fingers were found to be significant predictors of subjects' responses in both experiments, except for the thumb, which was deemed insignificant in object-size discrimination. The study highlights the importance of considering the partial contribution of each degree of freedom in a sensory feedback system, especially concerning the task, when designing such systems.

Advances in Implant Technologies for Spine Surgery

Spine implants are becoming increasingly diversified. Taking inspiration from other industries, three-dimensional modeling of the spinal column has helped meet the custom needs of individual patients as both en bloc replacements and pedicle screw designs. Intraoperative tailoring of devices, a common need in the operating room, has led to expandable versions of cages and interbody spacers.

Three-dimensional printed pure-titanium implantation for chest wall reconstruction involving the sternum and ribs: a novel approach

Chest wall reconstruction is challenging due to the complex shape and large defect size. The three-dimensional printing technology enables the fabrication of customized implants, and 3D-printed pure-titanium could provide superior mechanical properties to conventional materials. The aim of this study was to evaluate long-term outcomes of patients undergoing chest wall reconstruction with a 3D-printed pure-titanium implant. Between August 2018 and May 2021, 5 patients underwent surgery due to sternal metastasis (n = 3), postoperative sternal wound infection (n = 1) and deformity (n = 1). The customized implant was designed and constructed based on the size and shape of the chest wall defect measured on computed tomography. All patients demonstrated uneventful recovery without complications during the hospital course. During the median follow-up of 20 months, 1 patient underwent revision surgery due to implant breakage, and 1 removed the implant due to trauma-related chest wall infection. One patient died from cancer progression, while 3 patients are alive without any implant-related complications. Chest wall reconstruction using a 3D-printed pure-titanium implant could be a novel alternative for patients with various conditions affecting the sternum and ribs.

Modular intercalary prosthetic reconstruction for malignant and metastatic tumours of the proximal femur

To illustrate the surgical technique and explore clinical outcomes of the reconstruction for the malignant and metastatic bone tumour of proximal femur with metallic modular intercalary prosthesis. Sixteen patients who underwent modular intercalary prosthetic reconstruction after tumour resection were included from April 2012 and October 2020. Prosthesis and screws parameters, resected bone length and residual bone length, clinical outcomes and survivorship were analyzed. All patients were followed up for an average of 19 months (range 1-74). In our series, 12 patients died of the progression of the primary disease at the final follow-up. The cumulative survivorship since the treatment of proximal femoral metastasis was 78.6% (11 patients) at 6 months and 38.5% (5 patients) at 1 year. The mean MSTS score was 22.25 ± 4.55 among all patients. There were no cases of loosening or breakage of the prostheses, plates or screws, despite the various measurements of prostheses and residual bones. Modular intercalary prosthetic reconstruction was an effective method for malignant tumour of the proximal femur, including the advantages of providing early pain relief, quickly restoring postoperative function, required a short operation time, and preserving the adjacent joints.

The influence of prosthetic suspension on gait and cortical modulations is persons with a transfemoral amputation: socket-suspended versus bone-anchored prosthesis

BACKGROUND

Persons with a transfemoral amputation (TFA) often experience difficulties in daily-life ambulation, including an asymmetrical and less stable gait pattern and a greater cognitive demand of walking. However, it remains unclear whether this is effected by the prosthetic suspension, as eliminating the non-rigid prosthetic connection may influence stability and cortical activity during walking. Spatiotemporal and stability-related gait parameters, as well as cortical activity during walking, were evaluated between highly active individuals (MFC-level K3-4) with a TFA and able-bodied (AB) persons, and between persons with a bone-anchored prosthesis (BAP) and those with a socket-suspended prosthesis (SSP).

METHODS

18 AB persons and 20 persons with a unilateral TFA (10 BAP-users, 10 SSP-users) walked on a treadmill at their preferred speed. Spatiotemporal and margin of stability parameters were extracted from three-dimensional movement recordings. In addition, 126-channel electroencephalogram (EEG) was recorded. Brain-related activity from several cortical areas was isolated using independent component analysis. Source-level data were divided into gait cycles and subjected to time-frequency analysis to determine gait-cycle dependent modulations of cortical activity.

RESULTS

Persons with TFA walked with smaller and wider steps and with greater variability in mediolateral foot placement than AB subjects; no significant differences were found between BAP- and SSP-users. The EEG analysis yielded four cortical clusters in frontal, central (both hemispheres), and parietal areas. No statistically significant between-group differences were found in the mean power over the entire gait cycle. The event-related spectral perturbation maps revealed differences in power modulations (theta, alpha, and beta bands) between TFA and AB groups, and between BAP- and SSP-users, with largest differences observed around heel strike of either leg.

CONCLUSIONS

The anticipated differences in gait parameters in persons with TFA were confirmed, however no significant effect of the fixed suspension of a BAP was found. The preliminary EEG findings may indicate more active monitoring and control of stability in persons with TFA, which appeared to be timed differently in SSP than in BAP-users. Future studies may focus on walking tasks that challenge stability to further investigate differences related to prosthetic suspension.

Can99mTc-MDP-SPECT/CT Differentiate Loosening and Infection After Hip and Knee Replacements?

Background

Prosthetic loosening and infection are still common complications after joint replacement. Over the past few years, single-photon emission computed tomography-computed tomography (SPECT/CT) was widely used and showed unique value based on the combination of anatomic and metabolic information of foci. However, its performance in differentiating between prosthetic loosening and periprosthetic infection after joint replacement is still the focus of clinicians and deserves further investigation.

Purpose

This retrospective study was aimed to determine whether bone scintigraphy combined with SPECT/CT still can differentiate prosthetic infection from loosening in patients after joint replacement. The differential efficacy in hip and knee prosthesis was also analyzed. Blood biomarkers for the diagnosis of periprosthetic infection were also evaluated.

Patients and methods

Data sets of 74 prosthetic joints (including knees and hips), with suspected prosthetic loosening or infection between 2015 and 2021, were evaluated. Besides the results of nuclear imaging, X-ray images and serum biomarker were also recorded. Telephone follow-up and revision surgery after SPECT/CT were used as a gold standard. The sensitivity and accuracy of different imaging modalities were calculated by Chi-square test. The diagnostic efficacy of imaging methods and serum biomarkers were then analyzed by the area under curve (receiver operating characteristic curves, ROC) in SPSS 26.

Results

In all, 47 joints (14 knees and 33 hips) were confirmed as aseptic loosening, while 25 joints (18 knees and 7 hips) were confirmed as infection. The sensitivity and accuracy of SPECT combined with SPECT/CT imaging were the highest (92.86% and 87.84%, respectively). The differential efficacy of bone scintigraphy combined with SPECT/CT imaging was also better than any other single imaging modality. In the analysis of involved prosthesis, prosthetic loosening occurred more in hip prosthesis and knee prosthesis was easily infected (P < 0.05). Finally, the sensitivity of ESR and CRP were 80% and 84%, respectively.

Conclusions

Bone scintigraphy with hybrid SPECT/CT remains encouraging in differentiating prosthetic infection from loosening after joint replacement. The diagnostic efficacy of differentiation in hip prosthesis was better than knee. Serum biomarkers cannot be used alone to differentiate prosthetic infection from loosening.

User- and Speed-Independent Slope Estimation for Lower-Extremity Wearable Robots

Wearable robots can help users traverse unstructured slopes by providing mode-specific hip, knee, and ankle joint assistance. However, generalizing the same assistance pattern across different slopes is not optimal. Control strategies that scale assistance based on slope are expected to improve the feel of the device and improve outcome measures such as decreasing metabolic cost. Prior numerical methods for slope estimation struggled to estimate slopes at variable walking speeds or were limited to a single estimation per gait cycle. This study overcomes these limitations by developing machine-learning methods that yield continuous, user- and speed-independent slope estimators for a variety of wearable robot applications using an able-bodied wearable sensor dataset. In a leave-one-subject-out cross-validation (N = 9), four-phase XGBoost regression models were trained on static-slope (fixed-slope) data and evaluated on a novel subject's static-slope and dynamic-slope (variable-slope) data. Using all available sensors, we achieved an average error of 0.88° and 1.73° mean absolute error (MAE) on static and dynamic slopes, respectively. Ankle prosthesis, knee-ankle prosthesis, and hip exoskeleton sensor suites yielded average errors under 2° MAE on static and dynamic slopes, except for the ankle prosthesis and hip exoskeleton cases on dynamic slopes which yielded an average error of 2.2° and 3.2° MAE, respectively. We found that the thigh inertial measurement unit contributed the most to a reduction in average error. Our findings suggest that reliable slope estimators can be trained using only static-slope data regardless of the type of lower-extremity wearable robot.

A systematic investigation of sensorimotor mechanisms with intelligent prostheses in patients with ankle amputation while walking

It is thought that creating sensorimotor feedback in people with ankle joint amputation can affect motor biomechanics during gait, but there is little evidence or previous research. This study e aim ed to investigate the sensorimotor mechanism of smart prostheses in with ankle amputations while walking. Search in Google Scholar, Scopus, PubMed and Medline databases between April 2017 and February 2023, in addition to a detailed review in specialized clinical and engineering databases, 29 articles were selected based on the inclusion and exclusion criteria. Trials that mainly include; Proprioception, walking process in movement disorders, ankle amputation were included. Qualitative assessments of selected trials using PEDro' scale was used. The review of studies showed that the use of pressure sensors, neural stimulation through encoded algorithms can provide continuous tactile and positional information of the artificial leg in the direction of neural stimulation throughout the entire walking cycle. These findings indicate that restoration of intraneuronal sensory feedback leads to functional and cognitive benefits. With these definitions, different companies and research centers are trying to improve the mechanics of walking, however, movement strategies are unknown despite little research in creating sense and movement in the use of smart prostheses.

Validation of Proprietary and Novel Step-counting Algorithms for Individuals Ambulating With a Lower Limb Prosthesis

OBJECTIVE

To compare the accuracy and reliability of 10 different accelerometer-based step-counting algorithms for individuals with lower limb loss, accounting for different clinical characteristics and real-world activities.

DESIGN

Cross-sectional study.

SETTING

General community setting (ie, institutional research laboratory and community free-living).

PARTICIPANTS

Forty-eight individuals with a lower limb amputation (N=48) wore an ActiGraph (AG) wGT3x-BT accelerometer proximal to the foot of their prosthetic limb during labeled indoor/outdoor activities and community free-living.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Intraclass correlation coefficient (ICC), absolute and root mean square error (RMSE), and Bland Altman plots were used to compare true (manual) step counts to estimated step counts from the proprietary AG Default algorithm and low frequency extension filter, as well as from 8 novel algorithms based on continuous wavelet transforms, fast Fourier transforms (FFTs), and peak detection.

RESULTS

All algorithms had excellent agreement with manual step counts (ICC>0.9). The AG Default and FFT algorithms had the highest overall error (RMSE=17.81 and 19.91 steps, respectively), widest limits of agreement, and highest error during outdoor and ramp ambulation. The AG Default algorithm also had among the highest error during indoor ambulation and stairs, while a FFT algorithm had the highest error during stationary tasks. Peak detection algorithms, especially those using pre-set parameters with a trial-specific component, had among the lowest error across all activities (RMSE=4.07-8.99 steps).

CONCLUSIONS

Because of its simplicity and accuracy across activities and clinical characteristics, we recommend the peak detection algorithm with set parameters to count steps using a prosthetic-worn AG among individuals with lower limb loss for clinical and research applications.

Optimized reamer geometry for controlled reaming of the proximal femur

Preparation of the femoral proximal medullary cavity by reaming is essential for intramedullary nail osteosynthesis and hip revision arthroplasty. The use of reamers sometimes exerts high torsional forces on the bone. Design and direction of rotation of the reamer are potential influencing factors. The aim of this biomechanical study is to evaluate the best combination of a right- or left-cutting reamer with a clockwise- or counterclockwise-rotating insert in terms of preparation and safety. Right- and left-cutting reamers with conical design were each introduced into five synthetic femurs in both clockwise and counterclockwise rotation with constant feed force. A specially constructed test system was used for this series of tests, with which the respective intramedullary channel were reamed step by step. This was then used to determine the required torque. In addition, the feed rate measurement was analyzed using a modified digital caliper. The feed rates of the reamers with rotation in the same direction as the cutting direction were significantly increased compared to rotation in the opposite cutting direction (CCRLC vs. CCRRC 76.8 ± 9.0 mm/s vs. 25.2 ± 8.3 mm/s and CRRC vs. CRLC 54.3 ± 12.3 mm/s vs. 19.3 ± 0.6 mm/s; p < 0.01). In contrast, the mean torque during the reaming process was identical in all four groups. When preparing the proximal femoral medullary cavity, especially in cases with fragile bone structure, the available reamers should be introduced in opposite rotation to the cutting direction to achieve a more controllable feed of the reamer. Left-cutting reamers represent an alternative, using them in the usual clockwise-rotating technique to reduce the risk of complications during reaming.

Thumb basal joint arthritis in 2023

Thumb carpometacarpal or basal joint arthritis is the second most common location for osteoarthritis in the hand. It mainly affects women over 50years of age. Basal joint arthritis causes pain, loss of strength during pinch grips, and eventually stiffness and progressive deformity of the thumb column. Conservative treatment must be implemented first. It aims to spare the joint by using standardized methods. It must be initiated as soon as pain starts, not once the deformity has settled in. There is broad agreement that surgery is indicated when pain relief is not achieved after at least 6months of conservative treatment. The available surgical techniques can be classified as joint-sparing (extra-articular) and joint-sacrificing (intra-articular). The former consists of trapeziometacarpal stabilizing ligament reconstruction, subtraction osteotomy of the first metacarpal and thumb carpometacarpal denervation. The latter consists of trapeziometacarpal fusion, trapeziectomy (and its variants) and implant arthroplasty. Except in very specific cases, trapeziectomy and trapeziometacarpal implant arthroplasty with a total joint prosthesis or an interposition implant are the two main surgical techniques for treating basal joint arthritis. After reviewing the pathophysiology and the diagnosis of thumb basal joint arthritis, we will provide an overview of the available treatment options, with emphasis on the accepted surgical strategies in 2023. LEVEL OF EVIDENCE: III.

Does trapezium remodeling correlate with cup shape?

We investigated whether trapezium bone reaction was different following implantation of a trapeziometacarpal total joint replacement with a hemispheric or a conical cup. Fifty-three Keri Medical Touch implants with hemispheric cup and 53 with conical cup were prospectively followed up radiographically. We compared radiographs taken immediately and one year after surgery for cup subsidence, tilt, heterotopic ossification and loosening. Cup subsidence of at least 1 mm was detected in 4% of cases for both cup types. Additive bone reaction around the cup of more than 1 mm was present in 62% of conical cups and 47% of hemispheric cups. These were minor and there were no large ossifications with risk of impingement. Minor radiolucency was seen superficially at the implant-bone interface of 13% of the hemispheric cups and 9% of the conical cups. None of these bone reactions differed significantly according to cup design.

Transfemoral limb loss modestly increases the metabolic cost of optimal control simulations of walking

Background

In transtibial limb loss, computer simulations suggest that the maintenance of muscle strength between pre- and post-limb loss can maintain the pre-limb loss metabolic cost. These results are consistent with comparable costs found experimentally in select cases of high functioning military service members with transtibial limb loss. It is unlikely that similar results would be found with transfemoral limb loss, although the theoretical limits are not known. Here we performed optimal control simulations of walking with and without an above-knee prosthesis to determine if transfemoral limb loss per se increases the metabolic cost of walking.

Methods

OpenSim Moco was used to generate optimal control simulations of walking in 15 virtual "subjects" that minimized the weighted sum of (i) deviations from average able-bodied gait mechanics and (ii) the gross metabolic cost of walking, pre-limb loss in models with two intact biological limbs, and post-limb loss with one of the limbs replaced by a prosthetic knee and foot. No other changes were made to the model. Metabolic cost was compared between pre- and post-limb loss simulations in paired t-tests.

Results

Metabolic cost post-limb loss increased by 0.7-9.3% (p < 0.01) depending on whether cost was scaled by total body mass or biological body mass and on whether the prosthetic knee was passive or non-passive.

Conclusions

Given that the post-limb loss model had numerous features that predisposed it to low metabolic cost, these results suggest transfemoral limb loss per se increases the metabolic cost of walking. However, the large differences above able-bodied peers of ∼20-45% in most gait analysis experiments may be avoidable, even when minimizing deviations from able-bodied gait mechanics. Portions of this text were previously published as part of a preprint (https://www.biorxiv.org/content/10.1101/2023.06.26.546515v2.full.pdf).

Surgical aortic valve replacement etiologies, hemodynamics, and outcomes in 1346 patients from the Malaysian heart centre

BACKGROUND

This study examined the characteristics and outcomes of surgical aortic valve replacement (SAVR) both isolated and in combination with other cardiac surgery in Malaysia from 2015 to 2021.

METHODS

This was a retrospective study of 1346 patients analyzed on the basis of medical records, echocardiograms and surgical reports. The overall sample was both considered as a whole and divided into aortic stenosis (AS)/aortic regurgitation (AR)-predominant and similar-severity subgroups.

RESULTS

The most common diagnosis was severe AS (34.6%), with the 3 most common etiologies being bicuspid valve degeneration (45.3%), trileaflet valve degeneration (36.3%) and rheumatic valve disease (12.2%). The second most common diagnosis was severe AR (25.5%), with the most common etiologies being root dilatation (21.0%), infective endocarditis (IE) (16.6%) and fused prolapse (12.2%). Rheumatic valve disease was the most common mixed disease. A total of 54.5% had AS-predominant pathology (3 most common etiologies: bicuspid valve degeneration valve, degenerative trileaflet valve and rheumatic valve disease), 36.9% had AR-predominant pathology (top etiologies: root dilatation, rheumatic valve disease and IE), and 8.6% had similar severity of AS and AR. Overall, 62.9% of patients had trileaflet valve morphology, 33.3% bicuspid, 0.6% unicuspid and 0.3% quadricuspid. For AS, the majority were high-gradient severe AS (49.9%), followed by normal-flow low-gradient (LG) severe AS (10.0%), paradoxical low-flow (LF)-LG severe AS (6.4%) and classical LF-LG severe AS (6.1%). The overall in-hospital and total 1-year mortality rates were 6.4% and 14.8%, respectively. Pure severe AS had the highest mortality. For AS-predominant pathology, the etiology with the highest mortality was trileaflet valve degeneration; for AR-predominant pathology, it was dissection. The overall survival probability at 5 years was 79.5% in all patients, 75.7% in the AS-predominant subgroup, 83.3% in the AR-predominant subgroup, and 87.3% in the similar-severity subgroup.

CONCLUSIONS

The 3 most common causes of AS- predominant patients undergoing SAVR is bicuspid valve degeneration, degenerative trileaflet valve and rheumatic and for AR-predominant is root dilatation, rheumatic and IE. Rheumatic valve disease is an important etiology in our SAVR patients especially in mixed aortic valve disease. Study registration IJNREC/562/2022.

Performance of classical serum inflammatory markers in healed and unhealed treated patients with joint and prosthetic joint infections

BACKGROUND

Serum markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and D-dimer, are currently used by clinicians and orthopedic surgeons in diagnosing and managing joint infections (JI), although conflicting results exist on their performance. The aim of this study was to evaluate their performance in assessing healing or unhealing of patients with JI or with prosthetic joint infection (PJI).

METHODS

ESR, CRP and D-dimer serum levels were evaluated before, during and after antibiotic treatment in 61 patients (65.1 ± 12.6 years): 49 affected by PJI and 12 by JI, between 2020 and 2022. These patients had undergone orthopedic surgery and were treated with antibiotics.

RESULTS

ESR, CRP and D-dimer were significantly lower after treatment than before (p value: 0.001, 0.001 and 0.003, respectively) in healed and unhealed patients. A moderate correlation was found between the three inflammatory markers.

CONCLUSIONS

Using a cut off value of 25 mm/h for ESR, 0.5 mg/L for CRP, and 700 ng/ml for D-dimer, it might be possible to discriminate healed from unhealed patients (PPV and NPV: ESR 65.5% and 68.8%, CRP 71.9% and 79.3%, D-dimer 76.9% and 81.8%). The combined use of these three inflammatory markers might be useful in the management of joint infections.

[Current design and cement mantle thickness in hip arthroplasty : Theory and analysis of register data]

BACKGROUND

In this article, an overview and comparison of the most commonly used cemented hip stems, grouped into different stem types and cement mantle thickness, is given to see which combination performs well.

METHODOLOGY

Revision rates of cemented stem types were categorized from the Endoprosthesis Register-Germany, and 3‑ and 5‑year revision rates were reported and analyzed. For the research, the focus was on the Exeter, C‑Stem, MS-30, Excia, Bicontact, Charnley, Müller straight stem, Twinsys, Corail, Avenir, Quadra, and the Lubinus SP II stems. An important aspect was which stem is preferred to be implanted and which cementing technique is used with regard to the planned cement mantle thickness. In order to identify a trend in cemented hip arthroplasty, data from the Danish, Swedish, Norwegian, Swiss, New Zealand, English and Australian arthroplasty registers were also compared.

RESULTS AND CONCLUSION

Most countries use cemented prostheses according to the taper slip principle (Exeter, MS30, C‑Stem etc) or the composite beam (Charnley, Excia, Bicontact), which are implanted with a cement mantle thickness of 2-4 mm. However, a trend has emerged in Germany and Switzerland towards the line-to-line technique, with a planned cement mantle thickness of 1 mm (Twinsys, Corail, Avenir, Quadra), following the principle of the Müller straight stem prosthesis and the Kerboul-Charnley prosthesis, even though these are postulated to be "French paradoxes" in themselves. In the EPRD 5‑year results, the newer line-to-line prostheses seem to perform slightly worse. The best results are achieved by the "MS 30" in Germany and the "Exeter" in England. These are polished straight stems with centralizer and subsidence space at the apex with a 2-4 mm cement mantle in good cementing technique.

Intra-scrotal epidermoid cyst rupture misdiagnosed as a testicular prosthesis rupture: A case report

Testicular cancers represent about 5 % of all urological tumors. Most patients who undergo radical orchiectomy (RO) decide to place a testicular prosthesis, for a cosmetic result and to accept the testicular loss. Among all late complications, a spontaneous prosthesis rupture is a rare event contrary to penile prosthesis. The present study reported the case of a 53-year-old Italian man has presented to our department principally for a suspicious rupture of testicular implant, placed twenty years before after a RO. Despite the findings at scrotal ultrasonography, at final histology, the mass was identified as spontaneously broken intra-scrotal epidermoid cyst.

The reimbursement system can influence the treatment choice and favor joint replacement versus other less invasive solutions in patients affected by osteoarthritis

PURPOSE

The aim of this study was to assess how physicians perceive the role of the reimbursement system and its potential influence in affecting their treatment choice in the management of patients affected by osteoarthritis (OA).

METHODS

A survey was administered to 283 members of SIAGASCOT (Italian Society of Arthroscopy, Knee, Upper Limb, Sport, Cartilage and Orthopaedic Technologies), a National scientific orthopaedic society. The survey presented multiple choice questions on the access allowed by the current Diagnosis-Related Groups (DRG) system to all necessary options to treat patients affected by OA and on the influence toward prosthetic solutions versus other less invasive options.

RESULTS

Almost 70% of the participants consider that the current DRG system does not allow access to all necessary options to best treat patients affected by OA. More than half of the participants thought that the current DRG system favors the choice of prosthetic solutions (55%) and that it can contribute to the increase in prosthetic implantation at the expense of less invasive solutions (54%). The sub-analyses based on different age groups, professional roles, and places of work allowed to evaluate the response in each specific category, confirming the findings for all investigated aspects.

CONCLUSIONS

This survey documented that the majority of physicians consider that the reimbursement system can influence the treatment choice when managing OA patients. The current DRG system was perceived as unbalanced in favor of the choice of the prosthetic solution, which could contribute to the increase in prosthetic implantation at the expense of other less invasive options for OA management.

Hip joint and muscle loading for persons with bilateral transfemoral/through-knee amputations: biomechanical differences between full-length articulated and foreshortened non-articulated prostheses

BACKGROUND

Currently, there is little available in-depth analysis of the biomechanical effect of different prostheses on the musculoskeletal system function and residual limb internal loading for persons with bilateral transfemoral/through-knee amputations (BTF). Commercially available prostheses for BTF include full-length articulated prostheses (microprocessor-controlled prosthetic knees with dynamic response prosthetic feet) and foreshortened non-articulated stubby prostheses. This study aims to assess and compare the BTF musculoskeletal function and loading during gait with these two types of prostheses.

METHODS

Gait data were collected from four male traumatic military BTF and four able-bodied (AB) matched controls using a 10-camera motion capture system with two force plates. BTF completed level-ground walking trials with full-length articulated and foreshortened non-articulated stubby prostheses. Inverse kinematics, inverse dynamics and musculoskeletal modelling simulations were conducted.

RESULTS

Full-length articulated prostheses introduced larger stride length (by 0.5 m) and walking speed (by 0.3 m/s) than stubbies. BTF with articulated prostheses showed larger peak hip extension angles (by 10.1°), flexion moment (by 1.0 Nm/kg) and second peak hip contact force (by 3.8 bodyweight) than stubbies. There was no difference in the hip joint loading profile between BTF with stubbies and AB for one gait cycle. Full-length articulated prostheses introduced higher hip flexor muscle force impulse than stubbies.

CONCLUSIONS

Compared to stubbies, BTF with full-length articulated prostheses can achieve similar activity levels to persons without limb loss, but this may introduce detrimental muscle and hip joint loading, which may lead to reduced muscular endurance and joint degeneration. This study provides beneficial guidance in making informed decisions for prosthesis choice.

[Financial and health impact of two models of providing prostheses in a public health systemImpacto econômico e sanitário de dois modelos de fornecimento de próteses em um sistema público de saúde]

Objective

Compare the health outcomes and financial outcomes of two systems for the procurement of prostheses: the traditional system, in which procurement is initiated when a product is requested; and the "Prosthesis Bank" model, based on a current inventory of supplies.

Methods

Descriptive-analytical study of users of Ministry of Health services in the province of Buenos Aires, Argentina. The patients belonged to two study groups: 1) prostheses were provided through the traditional computerized system for hospital procurement and contracting, known as SIPACH; and 2) prostheses were provided by the Prosthesis Bank. The study was limited to endovascular prostheses (coronary stents) and hip prostheses. Official government databases were used. The study period was from 01/01/2018 to 31/10/2022. The variables analyzed were: age, sex, diagnosis, hospital, type of implant or prosthesis, date of request, date received, unit price, direct and indirect costs, average cost of daily hospitalization, cost-effectiveness, and budgetary impact.

Results

A total of 4 106 applications were analyzed. In the traditional system: 13.5% of patients did not get their prostheses; it took 50 days longer than with the Prosthesis Bank; and total costs were higher in SIPACH (coronary stent, +463%; hip prosthesis, +133%). The Prosthesis Bank saved USD 3.2 million annually and prevented 22 deaths through early provision of endovascular prostheses.

Conclusions

The Prosthesis Bank proved to be superior to the traditional model for providing prostheses, both in terms of health-by achieving better access, shortening waiting times, and avoiding deaths-and financially-by significantly reducing unit and overall prices, achieving significant savings in allocated budgets.

Assessment and trends in the methodological quality of the top 50 most cited articles in shoulder arthroplasty

INTRODUCTION

Shoulder arthroplasty is increasingly frequent, and the associated literature is abundant. Citation rate is often considered a good means of assessing impact and scientific value. However, analysis of methodological quality is also essential in evidence-based medicine.

OBJECTIVES

(1) To identify the 50 most cited articles on shoulder arthroplasty, and (2) to assess the correlation between citation rate and methodological quality. The study hypothesis was that there is no correlation between citation rate and methodological quality.

METHOD

Articles were retrieved from PubMed and Google Scholar, identifying the 50 most cited articles on shoulder arthroplasty via the keywords "shoulder joint replacement", "shoulder arthroplasty", "anatomic shoulder prothesis", "reverse shoulder prothesis", and "glenohumeral arthritis". Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-Randomized Studies (MINORS) were calculated.

RESULTS

Mean citation rate for the 50 articles was 312.4±169.5 (range, 151-841.5), with a mean citation density of 18.8±10.6 (range, 4.7-46.7). 56% of the studies (28/50) were retrospective case series with level of evidence IV. There was no correlation between citation rate and methodological quality.

DISCUSSION

The 50 most cited articles on shoulder arthroplasty mostly showed low levels of methodological quality. There was no correlation between citation rate and methodological quality: the literature needs to be read with a critical eye.

LEVEL OF EVIDENCE

IV.

Development of low-cost and personalized external silicone breast prosthesis produced by additive manufacturing for women who have undergone mastectomy: A pilot study

BACKGROUND

The aim of this study was to develop a low-cost and personalized method for external breast prosthesis production.

METHODS

The projected light method was used for the acquisition of the 3D geometry of the left breast of a healthy 29-year-old woman, 69 kg and 1.69 m. The 3D modeling software Blender was used to make the prosthesis model and mold with adjustments to the model's mesh, such as smoothing, assigning thickness, and creating the walls of the prosthesis mold. Two counter-molds were created. The pieces were manufactured on the 3D printer Stella Lite 3 using polylactic acid filament. Finally, the silicone was pigmented, and the mold was filled.

FINDINGS

Prototype 1 of the prosthesis was produced using a mold without a counter-mold, which resulted in a prosthesis of 495 g, considered heavy compared to traditional prostheses for the same breast size. To solve this issue, a counter-mold with pins was used to produce prototype 2 with a mass of 393 g, 20.6% lighter than prototype 1. Prototype 3 was made with a central-volume counter-mold and presented a mass of 355 g, a reduction of 28.3% compared to prototype 1. The definitive breast prosthesis was made with the pin counter-mold with a different silicone. It has nipple and areola pigmentation and a mass of 294 g, 25.2% lighter than prototype 2.

INTERPRETATION

The results suggest that the projected light method and additive manufacturing are potential tools for developing external breast prostheses, which may improve the health conditions and quality of life of mastectomized women.

Functional and radiographic analysis of a cohort of 48 Tactys® prostheses with an average follow-up of 5 years: A retrospective study

OBJECTIVES

The Tactys® prosthesis is an anatomical unconstrained sliding implant with 4 modular components, designed for proximal interphalangeal arthroplasty. The main objective of our study was to evaluate medium-term functional outcomes at a minimum follow-up of 1 year.

MATERIALS AND METHODS

Forty-eight implants were studied, with a mean follow-up of 4.8 years. The study retrospectively analyzed functional, clinical and radiological results. Complications and re-interventions were also analyzed.

RESULTS

Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Patient-Rated Wrist Evaluation (PRWE) scores improved from 40.9 to 17.7 and from 47. 1 to 11 .2, respectively (p < 0.001) at last follow-up. Seventy-seven percent of patients rated their results as good or very good, and 83% were willing to undergo the procedure again. Pain on VAS improved significantly from 7.9 to 0.8/10 (p < 0.001). There was no significant difference in range of motion (53° vs 48°), grip strength (14.9 kgF vs 14.6 kgF), or pinch strength (3.4 kgF vs 3.4 kgF). There were no cases of fracture or loosening of implants. Periarticular ossification without functional impairment was observed in 31 patients. Axial deviation was generally corrected. Three surgical re-interventions were required, including 2 implant revisions using a silicone spacer. Five-year implant survival was 94%.

CONCLUSION

The Tactys® prosthesis was a reliable and effective option for the management of proximal interphalangeal osteoarthritis. Patient satisfaction was generally good, with improvement in pain and function; however, longer-term follow-up is needed.

Development of a Core Outcome Set for users and funders of lower-limb prosthetic interventions (PI-COS): a step to inform the benefits measured in prosthetic health economic evaluations

PURPOSE

Little is known about the outcomes that are most important to prosthesis users and funders. A Prosthetic Interventions Core Outcome Set (PI-COS) will help researchers and practitioners measure outcomes that are the most important to prosthesis users and funders.

MATERIALS AND METHODS

Prosthesis users and funders rated the importance of 121 International Classification of Functioning, Disability, and Health (ICF) second-level categories using a two-round Delphi survey. A Consensus Meeting using the nominal group technique resolved rating differences between groups. The ICF second-level categories were ranked according to importance and a K-Means Cluster Analysis helped establish the PI-COS.

RESULTS

65 users and 8 funders completed the Delphi surveys, followed by a Consensus Meeting. 26 ICF second-level categories were considered important to prosthesis users and funders and a PI-COS of 14 ICF second-level categories drawn predominantly from five ICF chapters was established: Sensory Functions and Pain (b2), Neuromusculoskeletal and Movement-related Functions (b7), General Tasks and Demands (d2), Mobility (d4), and Products and Technology (e1).

CONCLUSIONS

The PI-COS describes the outcomes that are most important to prosthesis users and funders. The PI-COS can help focus on the most important outcome measures in clinical practice and research, including future prosthetic health economic evaluations.

Clinical Outcome in Patients With High-grade Soft-tissue Sarcoma Receiving Prosthetic Replacement After Tumor Resection of the Lower Extremities: Tokai Musculoskeletal Oncology Consortium Study

AIM

This multicenter retrospective study aimed to clarify the surgical and oncological outcomes of patients with high-grade soft tissue sarcoma (STS) who underwent prosthetic replacement reconstruction after lower extremity tumor resection.

PATIENTS AND METHODS

We retrospectively collected the data of 27 patients with high-grade STS. The mean follow-up duration after prosthetic replacement was 44.7 months.

RESULTS

The mean age at surgery was 63 years. The mean tumor size was 16 cm. For reconstruction, proximal femur replacement was performed in 15 patients, distal femur replacement in six, and total femur replacement in six. The major complications were infections in nine patients and aseptic loosening in four. Nine patients developed local recurrence. The cause of revision surgery was infection in five patients, aseptic loosening in three, and metal allergy in one. The 5-year prosthetic survival rate was 51.1%. At the final follow-up, amputation was performed in five patients. The 5-year limb salvage rate was 76.8%. The mean functional score of the 25 patients who could be assessed was 16.0 (53%). Of the 27 patients, five were excluded from the survival analysis because they underwent prosthetic replacement for local recurrence. The 5-year overall survival rate in the remaining 22 patients was 45.3%.

CONCLUSION

We identified a high rate of surgical complications and poor survival in patients with high-grade STS who underwent tumor resection and reconstruction using prosthetic replacement of the lower extremities, although limb salvage was achieved in 81.5% of the patients. Careful follow-up is needed for surgical complications and oncological events after surgery.

Lower limb amputation rehabilitation status in India: A review

Rehabilitation of lower limb amputation in developing countries is quite challenging. Though there are basic to highly advanced prostheses available in India, the set-up is still facing difficulties in developing countries. Prosthetic management is difficult due to lack of availability of prostheses and reduced affordability among low income populations. In this review we highlighted the lower limb amputation and prosthetic rehabilitation status in India. Currently, India is advancing well in the rehabilitation field, but further studies are required to provide more evidence and recommendation.

From rubber hands to neuroprosthetics: Neural correlates of embodiment

Our interaction with the world rests on the knowledge that we are a body in space and time, which can interact with the environment. This awareness is usually referred to as sense of embodiment. For the good part of the past 30 years, the rubber hand illusion (RHI) has been a prime tool to study embodiment in healthy and people with a variety of clinical conditions. In this paper, we provide a critical overview of this research with a focus on the RHI paradigm as a tool to study prothesis embodiment in individuals with amputation. The RHI relies on well-documented multisensory integration mechanisms based on sensory precision, where parietal areas are involved in resolving the visuo-tactile conflict, and premotor areas in updating the conscious bodily representation. This mechanism may be transferable to prosthesis ownership in amputees. We discuss how these results might transfer to technological development of sensorised prostheses, which in turn might progress the acceptability by users.

Life of an amputee: predictors of quality of life after lower limb amputation

Lower limb amputations (LLA) have a significant impact on global morbidity. Approximately 2 million people are living with lower limb amputation in the United States and this figure is expected to rise. LLA lead to physical disabilities and can cause restriction in functionalities in the everyday life of amputees. Patients lose their independence, which can be very debilitating and eventually causes physical, behavioral, and psychical changes. These changes after amputations should be properly addressed and must be incorporated into rehabilitation to improve and regain better adjustment to life among amputees. This article focuses on determining various factors and their effect on quality of life after lower limb amputations.

Sensorimotor function and standing balance in older adults with transtibial limb loss

BACKGROUND

Limited research has focused on older prosthesis users despite the expected compounded effects of age and amputation on sensorimotor function, balance, and falls. This study compared sensorimotor factors and standing balance between older individuals with and without transtibial amputation, hypothesizing that prosthesis users would demonstrate worse sensorimotor function. Secondarily we assessed the relationship between standing balance and somatosensation in prosthesis users.

METHODS

Thirteen persons with unilateral transtibial amputation (71.7 years) and 10 able-bodied controls (71.7 years) participated in this cross-sectional observational study. Passive joint range-of-motion, muscle strength, proprioception (joint position sense), tactile sensitivity, and standing balance (center-of-pressure sway) were compared between groups. A multiple linear regression analysis assessed the relationship between proprioception and balance (without vision) in prosthesis users.

FINDINGS

Our hypotheses were generally not supported, with the only differences being reduced joint range-of-motion and strength in prosthesis users (with large effect sizes), but comparable sensation and balance. Notably, prosthesis users demonstrated better proprioception than controls as reflected through better joint position sense when the limb was non-weight bearing. Worse amputated limb proprioception was associated with better standing balance in prosthesis users.

INTERPRETATION

Older prosthesis users have impaired passive joint motion and muscle strength compared to controls that could challenge their ability to position and control the amputated limb to avoid falls during daily activities. However, their better amputated limb proprioception might help counteract those limitations by leveraging sensory feedback from the suspended limb. The relationship between amputated limb proprioception and standing balance suggests a nuanced relationship that warrants further study.

Prosthesis Options for Proximal Interphalangeal Joint Arthroplasty in Osteoarthritis: A Systematic Review and Meta-Analysis

Background: Literature investigating the long-term outcomes of prosthesis options for proximal interphalangeal (PIP) joint arthroplasty is scarce, with most reports combining indications and underlying pathologies in analyses. In this study, we aim to compare silicone, pyrocarbon and metal prostheses in PIP joint arthroplasty for primary degenerative osteoarthritis (OA). Methods: A review of scientific literature published between 1990 and 2021 was conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Relevant studies were screened and the appropriate data was extracted. An evaluation of clinical outcomes (range of motion [ROM] and pain), complications (reoperation) and survival rates for each prosthesis was performed. Results: Twelve studies were included for analysis with a total of 412 PIP joints. ROM was 66.6°, 55.8° and 46.4° for metal, silicone and pyrocarbon implants, respectively. Silicone implants had the best pain score on the visual analogue scale (1.2) followed by the pyrocarbon (2.6) and metal (3.9) groups. Complication rates were lowest in silicone implants (11.3%) compared to 18.5% in pyrocarbon and 22.4% in metal prostheses. Survival did not differ significantly amongst the three groups. Conclusions: Our findings suggest that for patients with primary degenerative OA, PIP joint arthroplasty using a silicone prosthesis can provide greater pain relief with lower complication rates compared to other implant options. Level of Evidence: Level III (Therapeutic).

EMG feedback improves grasping of compliant objects using a myoelectric prosthesis

BACKGROUND

Closing the control loop in myoelectric prostheses by providing artificial somatosensory feedback is recognized as an important goal. However, designing a feedback interface that is effective in realistic conditions is still a challenge. Namely, in some situations, feedback can be redundant, as the information it provides can be readily obtained through hearing or vision (e.g., grasping force estimated from the deformation of a compliant object). EMG feedback is a non-invasive method wherein the tactile stimulation conveys to the user the level of their own myoelectric signal, hence a measurement intrinsic to the interface, which cannot be accessed incidentally.

METHODS

The present study investigated the efficacy of EMG feedback in prosthesis force control when 10 able-bodied participants and a person with transradial amputation used a myoelectric prosthesis to grasp compliant objects of different stiffness values. The performance with feedback was compared to that achieved when the participants relied solely on incidental cues.

RESULTS

The main outcome measures were the task success rate and completion time. EMG feedback resulted in significantly higher success rates regardless of pin stiffness, indicating that the feedback enhanced the accuracy of force application despite the abundance of incidental cues. Contrary to expectations, there was no difference in the completion time between the two feedback conditions. Additionally, the data revealed that the participants could produce smoother control signals when they received EMG feedback as well as more consistent commands across trials, signifying better control of the system by the participants.

CONCLUSIONS

The results presented in this study further support the efficacy of EMG feedback when closing the prosthesis control loop by demonstrating its benefits in particularly challenging conditions which maximized the utility of intrinsic feedback sources.

Modern Internet Search Analytics and Osseointegration: What are Patients Asking and Reading Online?

Background

Osseointegration (OI) limb has been performed for over 30 years and is an example of an advance in technology and surgical technique which has led to improvements in patient mobility and quality of life. An increasing number of patients seek information about osseointegration. The aim of this study was to categorise the most frequently asked questions by patients using the Google search engine and the most frequently accessed websites with the highest return on answers. The secondary aims of this study were to assess the quality of the information provided on those websites and to stratify, by category, which websites provide the best quality information.

Materials and methods

Ten permutations and conjugations of the word 'osseointegration' were entered into Google. The first fifty 'People also ask' and associated websites by Google's machine learning and natural language processing engine were collected for each search term. The Rothwell classification system of questions by topic (Fact, Value, Policy) and websites by category was used (Commercial, Academic, Medical Practice, Single Surgeon Personal, Government, Social Media). Website quality was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (Likert-style rating 0-4). Pearson's Chi-squared and Student's t-tests were performed for statistical analysis as appropriate (significance, p < 0.05).

Results

The 10 search terms generated 454 questions and referenced 408 websites. Of the 454 questions generated, the most common question categories were fact (70.8%), value (19.2%), and policy (10%). The most common website type was social media (37.4%). The most common question types were technical details (30.4%), specific activity (20.6%), and cost (14.1%). Only 1.6% of questions related to risks and complications. Generally, website quality was poor with 64.1% having a JAMA score of 0 or 1. Websites that were categorised as 'Government' had the highest overall JAMA scores: 71.4% had a score of 4.

Conclusion

Based on Google search engine's results, the most commonly asked questions about osteointegration related to technical details, specific activities and cost; only 1.6% related to risks and complications. Interestingly, social media websites represented the highest volume of search result referrals. Overall, the quality of websites was poor with the most factual information coming from governmental websites.

How to cite this article

Murphy EP, Sheridan GA, Page BJ, et al. Modern Internet Search Analytics and Osseointegration: What Are Patients Asking and Reading Online? Strategies Trauma Limb Reconstr 2023;18(3):163-168.

EyeCee One preloaded intraocular lens: are patients with glaucoma more at risk?

OBJECTIVE

The Medicine and Healthcare products Regulatory Agency reported links of raised intraocular pressure (IOP) with recently implanted EyeCee One intraocular lens (IOL). This work investigates if glaucomatous eyes were more susceptible to these postoperative IOP rises and if they required more intensive management.

METHODS

Retrospective observational study of all phacoemulsification surgery with implanted EyeCee One IOL, performed between 1 October 2022 and 26 January 2023 inclusive.

ANALYSIS

A significant IOP elevation was defined as an IOP rise of 10 mm Hg or more from preoperative to maximal postoperative IOP reading. The management of all patients who had a significant IOP elevation was reviewed. Glaucoma/ocular hypertension cases were identified and analysed against non-glaucomatous eyes and statistical analysis performed.

RESULTS

112 glaucoma and 671 non-glaucoma cases identified; 19.6% of the glaucoma cohort had a significant postoperative IOP rise compared with 8.9% of patients without glaucoma (OR 2.49 (95% CI 1.45 to 4.20) p=0.0014). In the glaucoma cohort, 12.5% had an increase in the number of topical IOP-lowering agents (mean increase 1.65±1.58), 6.3% required systemic treatment and 2.7% surgical intervention. In the non-glaucoma group, 3.3% required topical treatment (mean number of agents 0.88±1.34), 0.8% required systemic treatment and 0.2% surgical intervention.

CONCLUSION

This study shows that during the time frame in question, patients with glaucoma or ocular hypertension who had an EyeCee One IOL were almost two and a half times more likely to have a postoperative rise of 10 mm Hg or more in IOP following routine cataract surgery, requiring more aggressive management.

A framework for understanding prosthetic embodiment for the plastic surgeon

Plastic surgeons play a critical role in the management of amputations and are uniquely positioned to improve the lives and functional abilities of patients with limb loss. The embodiment of a prosthesis describes how effectively it replaces a missing limb and is an important aspect of patient care. Despite its importance, the current prosthetics literature lacks a formal definition of embodiment, and descriptions are often vague or incomplete. In this narrative review, we assess the current literature on prosthetic embodiment to explore the main mechanisms of embodiment and how each allows a prosthesis to interface with the human body. In doing so, we provide a comprehensive, holistic framework for understanding this concept.

Retrospective and Prospective Outcomes of Distal Radioulnar Joint Prosthesis Arthroplasty at a Single Center

Purpose

Distal radioulnar joint (DRUJ) arthritis can cause painful and limited motion of the forearm leading to decreased function. When conservative treatment options are exhausted, surgical treatments are the next step. The purpose of this study was to retrospectively and prospectively evaluate outcomes of Scheker DRUJ total arthroplasty at a single center and add to the limited data on this procedure.

Methods

In a retrospective and prospective cohort of 12 patients, 13 DRUJ prosthetics implanted from 2014 to 2021 were evaluated from a single center. The primary outcome was patient satisfaction with the procedure, including comparisons of preoperative and postoperative visual analog scale, Disabilities of the Arm, Shoulder, and Hand, and willingness to repeat the procedure. Secondary outcomes included range of motion, subjective grip strength, need for hardware revision, subsequent procedures, and postoperative complaints.

Results

Out of 12 patients that were at least 1-year after surgery from DRUJ arthroplasty, 1 was deceased at the time of final survey and 1 underwent bilateral DRUJ arthroplasty. Seven of 12 available patients were surveyed over the phone. On average, patient range of motion after surgery was 76° in each direction for pronation and supination. There was a clinically significant improvement in the Disabilities of the Arm, Shoulder, and Hand score and a statistically significant improvement in visual analog scale pain rating. Seventy-five percent of patients surveyed were satisfied with their outcomes and would undergo the surgery again. Only one patient required additional surgery, and there were no instances of hardware failure at an average follow-up of 40 months.

Conclusions

Our study has shown positive outcomes with decrease in pain, improvement in function via Disabilities of the Arm, Shoulder, and Hand evaluation, and subjective patient satisfaction, with a 100% prosthesis survival rate. The DRUJ arthroplasty prosthesis is a viable alternative to other DRUJ salvage procedures.

Type of study/level of evidence

Therapeutic Level III.

How to Perform Better on Oxford UKA? A Technical Note from over 500 Surgical Experiences

Oxford unicompartmental knee arthroplasty (UKA) has been particularly prevalent because the concept of knee preservation is deeply rooted in people's minds. Mobile bearing UKA is a surgical type of UKA with considerable advantages. This note describes some surgical techniques, including patient position, surgical field exposure, selection of the size of the prosthesis, sagittal tibial osteotomy, placement of the femoral prosthesis and gap balance, to assist surgeons with less experience in performing these operations successfully. The techniques described in this note have been used in over 500 Oxford UKA cases, and nearly 95% patients achieved good prosthesis position and satisfactory postoperative outcome. We hope that the empirical summaries from numerous cases will help surgeons to learn Oxford UKA quickly and effectively, driving the spread of the technique and benefiting more patients.

The impact of walking on the perception of multichannel electrotactile stimulation in individuals with lower-limb amputation and able-bodied participants

BACKGROUND

One of the drawbacks of lower-limb prostheses is that they do not provide explicit somatosensory feedback to their users. Electrotactile stimulation is an attractive technology to restore such feedback because it enables compact solutions with multiple stimulation points. This allows stimulating a larger skin area to provide more information concurrently and modulate parameters spatially as well as in amplitude. However, for effective use, electrotactile stimulation needs to be calibrated and it would be convenient to perform this procedure while the subject is seated. However, amplitude and spatial perception can be affected by motion and/or physical coupling between the residual limb and the socket. In the present study, we therefore evaluated and compared the psychometric properties of multichannel electrotactile stimulation applied to the thigh/residual limb during sitting versus walking.

METHODS

The comprehensive assessment included the measurement of the sensation and discomfort thresholds (ST & DT), just noticeable difference (JND), number of distinct intervals (NDI), two-point discrimination threshold (2PD), and spatial discrimination performance (SD). The experiment involved 11 able-bodied participants (4 females and 7 males; 29.2 ± 3.8 years), 3 participants with transtibial amputation, and 3 participants with transfemoral amputation.

RESULTS

In able-bodied participants, the results were consistent for all the measured parameters, and they indicated that both amplitude and spatial perception became worse during walking. More specifically, ST and DT increased significantly during walking vs. sitting (2.90 ± 0.82 mA vs. 2.00 ± 0.52 mA; p < 0.001 for ST and 7.74 ± 0.84 mA vs. 7.21 ± 1.30 mA; p < 0.05 for DT) and likewise for the JND (22.47 ± 12.21% vs. 11.82 ± 5.07%; p < 0.01), while the NDI became lower (6.46 ± 3.47 vs. 11.27 ± 5.18 intervals; p < 0.01). Regarding spatial perception, 2PD was higher during walking (69.78 ± 17.66 mm vs. 57.85 ± 14.87 mm; p < 0.001), while the performance of SD was significantly lower (56.70 ± 10.02% vs. 64.55 ± 9.44%; p < 0.01). For participants with lower-limb amputation, the ST, DT, and performance in the SD assessment followed the trends observed in the able-bodied population. The results for 2PD and JND were however different and subject-specific.

CONCLUSION

The conducted evaluation demonstrates that electrotactile feedback should be calibrated in the conditions in which it will be used (e.g., during walking). The calibration during sitting, while more convenient, might lead to an overly optimistic (or in some cases pessimistic) estimate of sensitivity. In addition, the results underline that calibration is particularly important in people affected by lower-limb loss to capture the substantial variability in the conditions of the residual limb and prosthesis setup. These insights are important for the implementation of artificial sensory feedback in lower-limb prosthetics applications.

Exploring the relationship between oral health and multiple health conditions: An outcome-wide approach

PURPOSE

A growing body of evidence suggests that oral health is associated with a wide range of health outcomes; however, opinions tend to vary because of inconsistent findings. This study aimed to simultaneously examine the association between oral health status and multiple health and well-being indicators using outcome-wide epidemiology.

METHODS

Data were obtained from the Japan Gerontological Evaluation Study. Oral health status was categorized as: ≥20 teeth, 10-19 teeth with dental prosthesis, 0-9 teeth with prosthesis, 10-19 teeth without prosthesis, and 0-9 teeth without prosthesis. We examined the associations between oral health status in 2013 and 35 health and well-being outcomes in 2019, including physical/cognitive health, psychological distress, subjective health, social well-being, prosocial/altruistic behaviors, and health behaviors, using two databases (n=32,827 and 15,905).

RESULTS

Compared to individuals with ≥20 teeth, those with <20 teeth had a 10-33% higher risk of mortality and a 7-10% higher risk of functional disability six years later. Additionally, individuals with fewer than 20 teeth tended to go out less frequently and eat fewer vegetables and fruits. Furthermore, individuals with 0-9 teeth without a prosthesis were more likely to have severe functional disability (risk ratio (RR):1.17, 95% confidence interval (CI):1.05-1.31), engage in fewer intellectual activities (standardized difference: 0.17, 95% CI: 0.10-0.24), and feel more hopeless (RR: 1.21, 95% CI: 1.04-1.41).

CONCLUSIONS

The prevention of tooth loss and prosthodontic treatment may be associated with reduced mortality and functional disability, as well as maintenance of intellectual ability, frequency of going out, and improvements in dietary lifestyle.

Dosimetric evaluation of high-Z inhomogeneity with modern algorithms: A collaborative study

PURPOSE

To evaluate modern dose calculation algorithms with high-Z prosthetic devices used in radiation treatment.

METHODS

A bilateral hip prosthetic patient was selected to see the effect of modern algorithms from the commercial system for plan comparisons. The CT data with dose constraints were sent to various institutions for dose calculations. The dosimetric parameters, D98%, D90%, D50% and D2% were compared. A water phantom with an actual prosthetic device was used to measure the dose using a parallel plate ionization chamber.

RESULTS

Dosimetric variability in PTV coverage was significant (>10%) among various treatment planning algorithms. The comparison of PTV dosimetric parameters, D98%, D90%, D50% and D2% as well as organs at risk (OAR) have large discrepancies compared to our previous publication with older algorithms (https://doi.org/10.1016/j.ejmp.2022.02.007) but provides realistic dose distribution with better homogeneity index (HI). Backscatter and forward scatter attenuation of the prosthesis was measured showing differences <15.7% at the interface among various algorithms.

CONCLUSIONS

Modern algorithms dose distributions have improved greatly compared to older generation algorithms. However, there is still significant differences at high-Z-tissue interfaces compared to the measurements. To ensure accuracy, it's important to take precautions avoiding placing any prosthesis in the beam direction and using type C algorithms.

Recent trends and challenges of surface electromyography in prosthetic applications

Surface electromyography (sEMG) meets extensive applications in the field of prosthesis in the current period. The effectiveness of sEMG in prosthesis applications has been verified by numerous revolutionary developments and extensive research attempts. A large volume of research and literature works have explored and validated the vast use of these signals in prostheses as an assistive technology. The objective of this paper is to conduct a systematic review and offer a detailed overview of the work record in the prosthesis and myoelectric interfaces framework. This review utilized a systematic search strategy to identify published articles discussing the state-of-the-art applications of sEMG in prostheses (including upper limb prosthesis and lower limb prostheses). Relevant studies were identified using electronic databases such as PubMed, IEEE Explore, SCOPUS, ScienceDirect, Google Scholar and Web of Science. Out of 3791 studies retrieved from the databases, 188 articles were found to be potentially relevant (after screening of abstracts and application of inclusion-exclusion criteria) and included in this review. This review presents an investigative analysis of sEMG-based prosthetic applications to assist the readers in making further advancements in this field. It also discusses the fundamental advantages and disadvantages of using sEMG in prosthetic applications. It also includes some important guidelines to follow in order to improve the performance of sEMG-based prosthesis. The findings of this study support the widespread use of sEMG in prosthetics. It is concluded that sEMG-based prosthesis technology, still in its sprouting phase, requires significant explorations for further development. Supplementary investigations are necessary in the direction of making a seamless mechanism of biomechatronics for sEMG-based prosthesis by cohesive efforts of robotic researchers and biomedical engineers.

Functional Outcome of Above-Knee Amputation After Infected Total Knee Arthroplasty

Background

Periprosthetic joint infection is a serious complication of total knee arthroplasty (TKA). Management usually involves irrigation and debridement, polyethylene liner exchange, one-stage revision, two-stage revision, knee arthrodesis, or ultimately above-knee amputation (AKA). We present our experience with 21 patients who underwent AKA as a sequela of unresolved infected TKA, highlighting their etiology and functional outcomes.

Methods

A retrospective chart review was performed for all cases of infected TKA treated with AKA at 1 institute from January 2007 to December 2020, with a minimum follow-up of 1 year. Patient demographics, Charlson comorbidity index, culture results, ambulation status, prosthesis fitting, and functional outcomes were collected. Short Form-36 and activities of daily living questionnaires were used for functional outcome assessment.

Results

Twenty-one patients were identified, 7 of whom were male (33.3%). Mean ± standard deviation follow-up was 5.7 ± 3.1 years (range, 1-11 years). Mean ± standard deviation age was 57.9 ± 10.7 years (range, 38-87 years), and the mean body mass index was 33.5 ± 6.4 kg/m2 (range, 25.4-46 kg/m2). Gram-positive organisms were identified in 15 cases (66.7%). Prosthesis fitting was successful in 17 patients (81%). Post-AKA ambulation was achieved in 12 patients (57.1%). The ambulating group showed higher Short Form-36 and activities of daily living scores when compared with patients who did not ambulate (60.2 vs 43.3, P = .041, and 67.2 vs 52.7, P = .029, respectively).

Conclusions

AKA should be considered solely as the final recourse for infected TKA. Despite the low-to-moderate patient-reported postoperative outcomes, prosthesis fitting and maintaining ambulation can improve postoperative functional outcomes.

New perspectives in prosthetic reconstruction in chest wall resection

The extension of chest wall resection for the treatment of primary and secondary tumours is still widely debated. The reconstructive strategy after extensive surgery is challenging as well as chest wall demolition itself. Reconstructive surgery aims to avoid respiratory failure and to guarantee intra-thoracic organs protection. The purpose of this review is to analyse the literature on this issue focusing on the planning strategy for chest wall reconstruction. This is a narrative review, reporting data from the most interesting studies on chest wall demolition and reconstruction. Representative surgical series on chest wall thoracic surgery were selected and described. We focused to identify the best reconstructive strategies analyzing employed materials, techniques of reconstruction, morbidity and mortality. Nowadays the new "bio-mimetic" materials in "rigid" and "non-rigid" chest wall systems reconstructive represent new horizons for the treatment of challenging thoracic diseases. Further prospective studies are warranted to identify new materials enhancing thoracic function after major thoracic excisions.