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Department of Mechanical Engineering, University College London, UK
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Department of Mechanical Engineering, University College London, UK
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Royal National Orthopaedic Hospital, Stanmore, UK.
Cleveland Clinic London, London, UK
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Three-dimensional printing is a rapidly growing manufacturing method for orthopaedic implants and it is currently thriving in several other engineering industries. It enables the variation of implant design and the construction of complex structures which can be exploited in orthopaedics and other medical sectors.
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In this review, we develop the vocabulary to characterise 3D printing in orthopaedics from terms defined by industries employing 3D printing, and by fully examining a 3D-printed off-the-shelf acetabular cup (Fig. 1). This is a commonly used 3D-printed implant in orthopaedics, and it exhibits a range of prominent features brought about by 3D printing.
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The key features and defects of the porous and dense regions of the implant are clarified and discussed in depth to determine reliable definitions and a common understanding of characteristics of 3D printing between engineers and medical experts in orthopaedics.
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Despite the extensive list of terminology derived here, it is clear significant gaps exist in the knowledge of this field. Therefore, it is necessary for continued investigations of unused implants, but perhaps more significantly, examining those in vivo and retrieved to understand their long-term impact on patients and the effects of certain features (e.g. surface-adhered particles).
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Analyses of this kind will establish an understanding of 3D printing in orthopaedics and additionally it will help to update the regulatory approach to this new technology.
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Femoral version (FV) is more widely adopted with the definition as the angle between the long axis of the femoral neck and the tangent line of the posterior femoral condyles on the axial plane, and the normal range between 5 and 20°.
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FV can be measured by imaging and functional tests. Cross-sectional CT including both the hip and the knee is the typically used imaging technique, yet variation exists according to the different landmarks used. As MRI investigations are routinely performed preoperatively, and protocols can be easily adopted to include version measurement, they are frequently used as an alternative to CT and offers several advantages.
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Abnormal FV has adverse effects on the biomechanics and musculoskeletal health of the whole lower limb. It affects the lever arm of muscles and the forces that the hip and patellofemoral joints suffer, and can lead to disorders such as osteoarthritis and impingement.
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In adult hip preservation surgery for developmental dysplasia of the hip (DDH), abnormal FV is sometimes accompanied by other morphological abnormities of the hip, a more severe DDH, and can help predict postoperative range of motion (ROM), and postoperative impingement.
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Currently, the most frequently used surgical technique for abnormal FV is femoral derotational osteotomy.
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Many controversies are left to be solved, including the specific origin of FV, the indication for femoral derotational osteotomy, especially in patients with combined DDH and abnormal FV, and the explicit compensation mechanism of abnormal FV by tibial torsion.
Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Orthopedics-Traumatology and Prosthetic Surgery and Hip and Knee Revision, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Department of Biomedical and Neuromotor Science-DIBINEM, University of Bologna, Bologna, Italy
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Purpose
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Leg length discrepancy (LLD) is a common complication following total hip arthroplasty (THA). The direct anterior approach (DAA) for THA is gaining popularity due to its advantages, but there is limited research on the incidence and size of LLD. This systematic review aims to explore the differences in LLD between DAA and other approaches, as well as the techniques to control LLD in DAA.
Methods
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A comprehensive literature search was conducted to identify relevant studies comparing THA by DAA with other surgical approaches and investigating methods to control LLD in DAA, following PRISMA guidelines and a priori registration on PROSPERO (CRD42023412644). The quality of the included studies was assessed. Data on preoperative and postoperative LLD and other relevant outcomes were extracted and analyzed descriptively.
Results
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In total, 29 studies were included in this systematic review. The majority (86%) were classified as level IV evidence. Comparisons between DAA and posterior approach (PA) or anterolateral approach (ALA) showed DAA had lower rates of LLD >10 mm compared to PA and ALA. Different pre- and intra-operative techniques were evaluated, but no consensus on the best method for preventing LLD in DAA was reached.
Conclusion
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DAA shows comparable or superior results in the prevention of LLD compared to other surgical approaches. Supine patient placement, direct leg measurement, and the use of IF contribute to these outcomes. Intraoperative fluoroscopy with a grid and preoperative planning offers a good option, especially for training purposes, but its role in preventing LLD by experienced DAA surgeons needs further investigation.
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This paper discusses the existing literature in the field of metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), the background (why was it developed), the past (what was the evidence leading to its rise and fall in clinical use), the present situation (why a potential resurgence), and the future directions for potential improvements.
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All literature relevant to MoM HRA was reviewed and summarized to provide a comprehensive summary. Furthermore, a detailed literature search was performed on PubMeD, MEDLINE, and Google Scholar to identify all clinical studies reporting a minimum 10 years of outcomes for modern MoM HRA devices from February 2018 to February 2023.
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In addition, joint registry data over the same time period, available in the public domain, was examined to extract related information on MoM HRA.
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Metal ions are present in almost all types of hip replacement; on the whole, however, the risk of revision for resurfacing due to metal-related pathologies is very low, but higher than in other types of bearings.
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There are studies that show that some brands of MoM resurfacing prostheses have achieved excellent clinical outcomes in long-term follow-up studies and are still in use although less commonly than in early 2000s.
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Use of alternative bearing surfaces has demonstrated excellent results in the short-term and a very critical long-term follow-up of these cases still will help establish their place in the hip arthroplasty world.
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HRA deserves a permanent place in the armamentarium of orthopedic surgeons and in the hand of experienced surgeons.
Arts et Métiers Institute of Technology, Université Sorbonne Paris Nord, IBHGC-Institut de Biomécanique Humaine Georges Charpak, HESAM Université, Paris, France
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Periacetabular osteotomy is the gold standard treatment for acetabular dysplasia. The great variability of acetabular dysplasia requires a personalized preoperative planning improved by 3D reconstruction and computer-assisted surgery. To plan the displacement of the acetabular fragment by a pelvic osteotomy, it is necessary to define a reference plane and a method to characterize 3D acetabular orientation.
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A scoping review was performed on PubMed to search for articles with a method to characterize the acetabulum of native hips in a 3D reference frame. Ninety-eight articles out of 3815 reports were included. Three reproducible reference planes were identified: the anterior pelvic plane, the Standardization and Terminology Committee plane used in gait analysis, and the sacral base plane. The different methods for 3D analysis of the acetabulum were divided in four groups: global orientation, triplanar measurements, segmentation, and surface coverage of the femoral head.
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Two methods were found appropriate for reorientation osteotomies: the global orientation by a vector method and the triplanar method. The global orientation method relies on the creation of a vector from the acetabular rim, from the acetabular surface or from successive planes. Normalization of the global acetabular vector would correct acetabular dysplasia by a single alignment maneuver on an ideal vector. The triplanar method, based on angle measurements at the center of the femoral head, would involve correction of anomalies by considering axial, frontal, and sagittal planes. Although not directly fit for reorientation, the two others would help to candidate patients and verify both planning and postoperative result.
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Purpose
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Up to 90% of nonambulatory patients with cerebral palsy (CP) experience hip displacement during their lifetime. Reconstructive surgery is recommended. Redisplacement rate is an outcome parameter.
Methods
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In a systematic literature review (MEDLINE, Embase and CENTRAL databases) until January 2023 we searched for reports with redisplacement rates after bony hip reconstructive surgery in nonambulatory patients. Quantitative data synthesis, subgroup analysis and meta-regression with moderators were carried out.
Results
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The pooled mean redisplacement rate was 16% (95% CI: 12–21%) with a prediction interval of 3–51% (Q: 149; df: 32; P < 0.001; I 2: 78%; τ 2: 0.67 and τ: 0.82) in 28 studies (1540 hips). Varus derotation osteotomy (VDRO) alone showed a higher redisplacement rate than VDRO + pelvic osteotomy (30% vs 12%, P < .0001). Mean age in the VDRO-alone subgroup was 7.1 years and in the combined group 9.5 years (P = .004). In meta-regression, lower redisplacement rates were observed with higher preoperative migration index (MI) (correlation coefficient: −0.0279; P = .0137), where comprehensive surgery was performed. Variance in true effects are explained by type of bone surgery (57%), preoperative MI (11%), age (5%) and MI for definition of failure (20%). No significant reduction in the redisplacement rate could be observed over the mid-years of studies (1977-2015).
Conclusion
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Our pooled data support the more extensive surgical approach in patients with high preoperative MI and emphasize the superiority of combined surgery. Studies should report a coordinated set of parameters and outcome classifications according to internationally accepted gradings to reduce redisplacement in future.
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Purpose
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The aim of this study was to evaluate the development of the worldwide survival rate of primary total hip arthroplasty (THA). The hypothesis was that survival improved over the last decade in worldwide arthroplasty registers.
Methods
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THA registers were screened in 2022 and compared between different countries with respect to the number of primary implantations per inhabitant, age, fixation type, and survival rate, and compared to similar data from 2009. The data from these reports were analyzed in terms of number, age distribution, and procedure type of primary THAs. Survival curves and a comparative analysis with respect to the development over time were calculated.
Results
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We identified nine hip arthroplasty registers that contained sufficient data to be included. A large variation was found in the annual number of primary THA implantations per inhabitant, with more than the factor 4 for all age groups across regions. The procedure type varied strongly as well, e.g. in Sweden, 50% were cemented THAs, whereas in Emilia-Romagna (Italy), 96% of THAs were implanted cementless. We found an improved survival rate of 5%, with 90% of survival after 15 years in the cohorts from 2021 compared to 85% in the cohorts from 2009.
Conclusion
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The present study revealed a significant improvement in the survival of THA in worldwide arthroplasty registers within different countries and regions over the period of one decade. We believe that it is safe to state that the success of THA is still rising with respect to this main outcome.
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Orthopedics, Faculty of Medicine, Department of Clinical Sciences, Lund University, Malmö, Sweden
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BG Kliniken – Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
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Purpose
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To assess utility, benefits, and risks of 4th-generation alumina–zirconia ceramic pairings in elective total hip arthroplasty (THA).
Methods
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A comprehensive mixed-methods best-evidence synthesis using data from systematic reviews, randomized controlled trials (RCTs), prospective and retrospective cohort studies, as well as joint replacement registries, was conducted to estimate overall revision and survival rates, periprosthetic infection, bearing fractures, and noise phenomena with 4th-generation alumina–zirconia ceramic versus other tribological couplings in elective THA. The systematic review part across multiple databases was registered with PROSPERO (CRD42023418076), and individual study data were extracted for statistical re-analysis.
Results
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Twenty overlapping systematic reviews, 7, 17, and 8 references from RCTs, cohort studies, and joint replacement registries form the basis of this work. According to current best evidence, it is (i) 15–33 times more likely that 4th-generation alumina–zirconia pairings avoid a revision for infection than causing a revision for audible noise, (ii) 38–85 times more likely that 4th-generation alumina–zirconia pairings avoid a revision for infection than causing a revision for ceramic head fractures, and (iii) three to six times more likely that 4th-generation alumina–zirconia pairings avoid a revision for infection than cause a revision for ceramic liner fractures.
Conclusion
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Fourth-generation alumina–zirconia pairings in THA show a favorable benefit–risk ratio, with rare compound-specific adverse events and complications significantly outbalanced by long-term advantages, such as a markedly lower incidence of revision for infection.
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Acetabular revision arthroplasty, a demanding field of reconstructive hip surgery, calls for innovative strategies to deal with challenging bone defects and implant failure seen in revision cases.
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Conventional implant solutions might fall short of adequately addressing severe bone loss and ensuring stable fixation, highlighting the necessity of customized strategies.
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Personalized megaimplants, distinguished by their tailor-made design and large-scale construction, present a viable option to overcome these challenges.
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The present article provides an elaborate analysis of custom-made megaimplants in acetabular revision arthroplasty, shedding light on the underlying principles, design complexities, manufacturing methods, applications in the clinical setting, and outcome assessment.
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The aim of this review is to present a comprehensive insight into personalized megaimplants and their contribution to the advancement of orthopedic surgery.
Artro Institute, 8, rue du Pont de Thé, Annecy Le Vieux, France
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Artro Institute, 8, rue du Pont de Thé, Annecy Le Vieux, France
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Purpose
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to systematically review comparative studies reporting revision rates, clinical outcomes, or radiographic outcomes of total hip arthroplasty (THA) using collared versus collarless conventional-length uncemented hydroxyapatite (HA)-coated stems.
Methods
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In adherence with PRISMA guidelines, a literature search was performed on Medline, Embase, and Scopus. Comparative clinical studies were eligible if they reported outcomes of collared versus collarless uncemented HA-coated stems for primary THA. Two reviewers screened titles, abstracts, and full-texts to determine eligibility; then performed data extraction; and assessed the quality of studies according to Joanna Briggs Institute (JBI) checklist.
Results
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The search returned 972 records, 486 were duplicates, and 479 were excluded after title/abstract/full-text screening. Three further studies were included from the references of eligible studies and from discussions with subject matter experts, resulting in 11 included studies. The JBI checklist indicated six studies scored ≥7 points and four studies ≥4 points. Pooled data revealed collared stems had significantly lower revision rates (OR = 0.45; 95% CI = 0.31–0.64) and subsidence (MD = −1 mm; 95% CI = −1.6–-0.3), but no significant difference in intraoperative complication rates (OR = 0.94; 95% CI = 0.67–1.32) in the short term to mid-term. Unpooled data indicated that collared stems provide equivalent survival, equivalent or better outcomes, and equivalent or lower complication rates.
Conclusion
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In comparative studies, collared stems have lower revision rates than collarless stems, as well as equivalent or better clinical and radiographic outcomes. Differences could be due to a protective effect that the collar offers against subsidence, particularly in undersized or misaligned stems. Further studies are warranted to confirm long-term results and better understand differences between registry data and clinical studies.
