Journal of Personalized Medicine

Editorial

Jump to: Research, Review, Other

3 pages, 185 KiB

Open AccessEditorial

Taking the Next Step in Personalised Orthopaedic Implantation

by Maximilian Rudert

J. Pers. Med. 2022, 12(3), 365; https://doi.org/10.3390/jpm12030365 - 27 Feb 2022

Cited by 2 | Viewed by 1733

Abstract

Most of the treatments in medicine are patient specific, are they not [...] Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

Research

Jump to: Editorial, Review, Other

12 pages, 3379 KiB

Open AccessArticle

The Impact of Total Knee Replacement with a Customized Cruciate-Retaining Implant Design on Patient-Reported and Functional Outcomes

by Andre F. Steinert, Lennart Schröder, Lukas Sefrin, Björn Janßen, Jörg Arnholdt and Maximilian Rudert

J. Pers. Med. 2022, 12(2), 194; https://doi.org/10.3390/jpm12020194 - 31 Jan 2022

Cited by 9 | Viewed by 3659

Abstract

Purpose: To treat patients with tricompartimental knee osteoarthritis (OA), a customized cruciate-retaining total knee arthroplasty (CCR-TKA) system can be used, including both individualized instrumentation and implants. The objective of this monocentric cohort study was to analyze patient-reported and functional outcomes in a series [...] Read more.

Purpose: To treat patients with tricompartimental knee osteoarthritis (OA), a customized cruciate-retaining total knee arthroplasty (CCR-TKA) system can be used, including both individualized instrumentation and implants. The objective of this monocentric cohort study was to analyze patient-reported and functional outcomes in a series of patients implanted with the second generation of this customized implant. Methods: At our arthroplasty center, we prospectively recruited a cohort of patients with tricompartmental gonarthrosis to be treated with total knee replacement (TKA) using a customized cruciate-retaining (CCR) implant design. Inclusion criteria for patients comprised the presence of intact posterior cruciate and collateral ligaments and a knee deformity that was restricted to <15° varus, valgus, or flexion contracture. Patients were assessed for their range of motion (ROM), Knee Society Score (KSS), Western Ontario and McMaster University osteoarthritis index (WOMAC), and short form (SF)-12 physical and mental scores, preoperatively, at 3 and 6 months, as well as at 1, 2, 3, and 5 years of follow-up (FU) postoperatively. Results: The average age of the patient population was 64 years (range: 40–81), the average BMI was 31 (range: 23–42), and in total, 28 female and 45 male patients were included. Implant survivorship was 97.5% (one septic loosening) at an average follow-up of 2.5 years. The KSS knee and function scores improved significantly (p < 0.001) from, respectively, 41 and 53 at the pre-operative visit, to 92 and 86, respectively, at the 5-year post-operative time point. The SF-12 Physical and Mental scores significantly (p < 0.001) improved from the pre-operative values of 28 and 50, to 50 and 53 at the 5-year FU, respectively. Patients experienced significant improvements in their overall knee range of motion, from 106° at the preoperative visit to 122°, on average, 5 years postoperatively. The total WOMAC score significantly (p < 0.001) improved from 49.1 preoperatively to 11.4 postoperatively at 5-year FU. Conclusions: Although there was no comparison to other implants within this study, patients reported high overall satisfaction and improvement in functional outcomes within the first year from surgery, which continued over the following years. These mid-term results are excellent compared with those reported in the current literature. Comparative long-term studies with this device are needed. Level of evidence 3b (individual case–control study). Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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17 pages, 4495 KiB

Open AccessArticle

The Patient-Specific Combined Target Zone for Morpho-Functional Planning of Total Hip Arthroplasty

by Juliana Habor, Maximilian C. M. Fischer, Kunihiko Tokunaga, Masashi Okamoto and Klaus Radermacher

J. Pers. Med. 2021, 11(8), 817; https://doi.org/10.3390/jpm11080817 - 21 Aug 2021

Cited by 11 | Viewed by 3460

Abstract

Background Relevant criteria for total hip arthroplasty (THA) planning have been introduced in the literature which include the hip range of motion, bony coverage, anterior cup overhang, leg length discrepancy, edge loading risk, and wear. The optimal implant design and alignment depends on [...] Read more.

Background Relevant criteria for total hip arthroplasty (THA) planning have been introduced in the literature which include the hip range of motion, bony coverage, anterior cup overhang, leg length discrepancy, edge loading risk, and wear. The optimal implant design and alignment depends on the patient’s anatomy and patient-specific functional parameters such as the pelvic tilt. The approaches proposed in literature often consider one or more criteria for THA planning. but to the best of our knowledge none of them follow an integrated approach including all criteria for the definition of a patient-specific combined target zone (PSCTZ). Questions/purposes (1) How can we calculate suitable THA implant and implantation parameters for a specific patient considering all relevant criteria? (2) Are the resulting target zones in the range of conventional safe zones? (3) Do patients who fulfil these combined criteria have a better outcome score? Methods A method is presented that calculates individual target zones based on the morphology, range of motion and load acting on the hip joint and merges them into the PSCTZ. In a retrospective analysis of 198 THA patients, it was calculated whether the patients were inside or outside the Lewinnek safe zone, Dorr combined anteversion range and PSCTZ. The postoperative Harris Hip Scores (HHS) between insiders and outsiders were compared. Results 11 patients were inside the PSCTZ. Patients inside and outside the PSCTZ showed no significant difference in the HHS. However, a significant higher HHS was observed for the insiders of two of the three sub-target zones incorporated in the PSCTZ. By combining the sub-target zones in the PSCTZ, all PSCTZ insiders except one had an HHS higher than 90. Conclusions The results might suggest that, for a prosthesis implanted in the PSCTZ a low outcome score of the patient is less likely than using the conventional safe zones by Lewinnek and Dorr. For future studies, a larger cohort of patients inside the PSCTZ is needed which can only be achieved if the cases are planned prospectively with the method introduced in this paper. Clinical Relevance The method presented in this paper could help the surgeon combining multiple different criteria during THA planning and find the suitable implant design and alignment for a specific patient. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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17 pages, 2698 KiB

Open AccessArticle

Wear Risk Prevention and Reduction in Total Hip Arthroplasty. A Personalized Study Comparing Cement and Cementless Fixation Techniques Employing Finite Element Analysis

by Carlos González-Bravo, Miguel A. Ortega, Julia Buján, Basilio de la Torre and Loreto Barrios

J. Pers. Med. 2021, 11(8), 780; https://doi.org/10.3390/jpm11080780 - 10 Aug 2021

Cited by 12 | Viewed by 3974

Abstract

The wear rate on Total Hip Arthroplasty (THA) entails a heavy burden for patients. This becomes more relevant with increased wear risk and its consequences such as osteolysis. In addition, osteolysis has been described in cemented and uncemented acetabular implants, and nowadays, controversy [...] Read more.

The wear rate on Total Hip Arthroplasty (THA) entails a heavy burden for patients. This becomes more relevant with increased wear risk and its consequences such as osteolysis. In addition, osteolysis has been described in cemented and uncemented acetabular implants, and nowadays, controversy remains as to whether or not to cement the acetabular component. A personalized theoretical study was carried out to investigate which parameters have an influence on wear risk and to determine the best fixation method. Liner wear risk was assessed for two different types of fixation (cemented vs uncemented) through Finite Elements Analysis (FEA). The intraoperative variables used to determine the wear risk (cervical-diaphyseal angle, Center of Rotation positioning -COR-, head material, head size, and liner thickness) are vital parameters in surgical planning. Two types of tridimensional liner models of Ultra High Molecular Weight Polyethene (UHMWPE) were simulated through finite element analysis (FEA—over 216 cases were the core of this research). A significant relationship was found between the cervical-diaphyseal angle and wear risk (p < 0.0001), especially in valgus morphology. The acetabular fixation technique (p < 0.0001) and liner thickness (p < 0.0001) showed a significant relationship with wear risk. According to our study, using a cemented fixation with a thick liner in the right center of rotation appears to be the proper stratagy for preventing polyethylene liner wear. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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8 pages, 913 KiB

Open AccessFeature PaperArticle

Augmented-Reality-Assisted K-Wire Placement for Glenoid Component Positioning in Reversed Shoulder Arthroplasty: A Proof-of-Concept Study

by Klaus Schlueter-Brust, Johann Henckel, Faidon Katinakis, Christoph Buken, Jörg Opt-Eynde, Thorsten Pofahl, Ferdinando Rodriguez y Baena and Fabio Tatti

J. Pers. Med. 2021, 11(8), 777; https://doi.org/10.3390/jpm11080777 - 10 Aug 2021

Cited by 38 | Viewed by 5802

Abstract

The accuracy of the implant’s post-operative position and orientation in reverse shoulder arthroplasty is known to play a significant role in both clinical and functional outcomes. Whilst technologies such as navigation and robotics have demonstrated superior radiological outcomes in many fields of surgery, [...] Read more.

The accuracy of the implant’s post-operative position and orientation in reverse shoulder arthroplasty is known to play a significant role in both clinical and functional outcomes. Whilst technologies such as navigation and robotics have demonstrated superior radiological outcomes in many fields of surgery, the impact of augmented reality (AR) assistance in the operating room is still unknown. Malposition of the glenoid component in shoulder arthroplasty is known to result in implant failure and early revision surgery. The use of AR has many promising advantages, including allowing the detailed study of patient-specific anatomy without the need for invasive procedures such as arthroscopy to interrogate the joint’s articular surface. In addition, this technology has the potential to assist surgeons intraoperatively in aiding the guidance of surgical tools. It offers the prospect of increased component placement accuracy, reduced surgical procedure time, and improved radiological and functional outcomes, without recourse to the use of large navigation or robotic instruments, with their associated high overhead costs. This feasibility study describes the surgical workflow from a standardised CT protocol, via 3D reconstruction, 3D planning, and use of a commercial AR headset, to AR-assisted k-wire placement. Post-operative outcome was measured using a high-resolution laser scanner on the patient-specific 3D printed bone. In this proof-of-concept study, the discrepancy between the planned and the achieved glenoid entry point and guide-wire orientation was approximately 3 mm with a mean angulation error of 5°. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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10 pages, 1614 KiB

Open AccessArticle

Patient Satisfaction, Functional Outcomes, and Implant Survivorship in Patients Undergoing Customized Unicompartmental Knee Arthroplasty

by Cyrus Anthony Pumilia, Lennart Schroeder, Nana O. Sarpong and Gregory Martin

J. Pers. Med. 2021, 11(8), 753; https://doi.org/10.3390/jpm11080753 - 30 Jul 2021

Cited by 5 | Viewed by 3168

Abstract

Customized unicompartmental knee arthroplasty (C-UKA) utilizes implants manufactured on an individual patient basis, derived from pre-operative computed tomography images in an effort to more closely approximate the natural anatomy of the knee. The outcomes from 349 medial and lateral fixed-bearing C-UKA were reviewed. [...] Read more.

Customized unicompartmental knee arthroplasty (C-UKA) utilizes implants manufactured on an individual patient basis, derived from pre-operative computed tomography images in an effort to more closely approximate the natural anatomy of the knee. The outcomes from 349 medial and lateral fixed-bearing C-UKA were reviewed. Implant survivorship analysis was conducted via retrospective chart review, and follow-up analysis was conducted via a single postoperative phone call or email. The rate of follow-up was 69% (242 knees). The average age at surgery was 71.1 years and the average body mass index was 28.8 kg/m². Seven revision arthroplasties (2.1%) had knowingly been performed at an average of 1.9 years postoperatively (range: 0.1–3.9 years), resulting in an implant survivorship of 97.9% at an average follow-up of 4.2 years (range: 0.1–8.7) and 97.9% at an average of 4.8 years (range: 2.0–8.7) when knees with less than two years of follow-up were excluded. The reasons for revision were implant loosening (one knee), infection (two knees), progression of osteoarthritis (two knees), and unknown reasons (two knees). The average KOOS, JR. interval score was 84 (SD: 14.4). Of those able to be contacted for follow-up analysis, 67% were “very satisfied,” 26% were “satisfied,” 4% were “neutral,” 2% were “dissatisfied,” and 1% were “very dissatisfied.” When asked if the knee felt “natural,” 60% responded with “always,” 35% responded with “sometimes,” and 5% responded with “never.” After analyzing a large cohort of C-UKA, we found favorable rates of survivorship, satisfaction, and patient-reported functional outcomes. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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13 pages, 6180 KiB

Open AccessFeature PaperArticle

Patient-Specific Implants for Pelvic Tumor Resections

by Kevin Döring, Kevin Staats, Stephan Puchner and Reinhard Windhager

J. Pers. Med. 2021, 11(8), 683; https://doi.org/10.3390/jpm11080683 - 21 Jul 2021

Cited by 6 | Viewed by 5161

Abstract

Introduction Limb salvage surgery for periacetabular malignancies is technically demanding and associated with a considerable likelihood of postoperative complications and surgical revision. Reconstruction using custom-made implants represents the treatment of choice. This study was conducted to analyze treatment outcomes of custom-made implants in [...] Read more.

Introduction Limb salvage surgery for periacetabular malignancies is technically demanding and associated with a considerable likelihood of postoperative complications and surgical revision. Reconstruction using custom-made implants represents the treatment of choice. This study was conducted to analyze treatment outcomes of custom-made implants in a single orthopaedic tumor center. Patients and Methods Twenty patients with a histologically verified periacetabular malignancy and a median follow up time of 5 (1–17) years were included. Results The median number of revision surgeries per patient was 1.5 (0–7). Complications were dislocations in 3 patients, aseptic loosening in 4 patients, deep infections in 9 patients, thromboembolic events in 5 patients and sciatic nerve lesions in 4 patients. Overall survival was 77% after one year, 69% after two years and 46% after five years. Median Harris Hip Score was 81 (37–92) points at last follow up. Conclusion Although internal hemipelvectomy and reconstruction using custom-made implants is linked with a high risk of postoperative complications, good functional outcomes can be regularly achieved. This information may help treating surgeons to find adequate indications, as eligible patients need to be critically selected and integrated into the decision-making process. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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11 pages, 1917 KiB

Open AccessArticle

True Kinematic Alignment Is Applicable in 44% of Patients Applying Restrictive Indication Criteria—A Retrospective Analysis of 111 TKA Using Robotic Assistance

by Kim Huber, Bernhard Christen, Sarah Calliess and Tilman Calliess

J. Pers. Med. 2021, 11(7), 662; https://doi.org/10.3390/jpm11070662 - 15 Jul 2021

Cited by 13 | Viewed by 3531

Abstract

Introduction: Image-based robotic assistance appears to be a promising tool for individualizing alignment in total knee arthroplasty (TKA). The patient-specific model of the knee enables a preoperative 3D planning of component position. Adjustments to the individual soft-tissue situation can be done intraoperatively. Based [...] Read more.

Introduction: Image-based robotic assistance appears to be a promising tool for individualizing alignment in total knee arthroplasty (TKA). The patient-specific model of the knee enables a preoperative 3D planning of component position. Adjustments to the individual soft-tissue situation can be done intraoperatively. Based on this, we have established a standardized workflow to implement the idea of kinematic alignment (KA) for robotic-assisted TKA. In addition, we have defined limits for its use. If these limits are reached, we switch to a restricted KA (rKA). The aim of the study was to evaluate (1) in what percentage of patients a true KA or an rKA is applicable, (2) whether there were differences regarding knee phenotypes, and (3) what the differences of philosophies in terms of component position, joint stability, and early patient outcome were. Methods: The study included a retrospective analysis of 111 robotic-assisted primary TKAs. Based on preoperative long leg standing radiographs, the patients were categorized into a varus, valgus, or neutral subgroup. Initially, all patients were planned for KA TKA. When the defined safe zone had been exceeded, adjustments to an rKA were made. Intraoperatively, the alignment of the components and joint gaps were recorded by robotic software. Results and conclusion: With our indication for TKA and the defined boundaries, “only” 44% of the patients were suitable for a true KA with no adjustments or soft tissue releases. In the varus group, it was about 70%, whereas it was 0% in the valgus group and 25% in the neutral alignment group. Thus, significant differences with regard to knee morphotypes were evident. In the KA group, a more physiological knee balance reconstructing the trapezoidal flexion gap (+2 mm on average laterally) was seen as well as a closer reconstruction of the surface anatomy and joint line in all dimensions compared to rKA. This resulted in a higher improvement in the collected outcome scores in favor of KA in the very early postoperative phase. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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10 pages, 19256 KiB

Open AccessArticle

Variation of the Three-Dimensional Femoral J-Curve in the Native Knee

by Sonja A. G. A. Grothues and Klaus Radermacher

J. Pers. Med. 2021, 11(7), 592; https://doi.org/10.3390/jpm11070592 - 23 Jun 2021

Cited by 11 | Viewed by 3115

Abstract

The native femoral J-Curve is known to be a relevant determinant of knee biomechanics. Similarly, after total knee arthroplasty, the J-Curve of the femoral implant component is reported to have a high impact on knee kinematics. The shape of the native femoral J-Curve [...] Read more.

The native femoral J-Curve is known to be a relevant determinant of knee biomechanics. Similarly, after total knee arthroplasty, the J-Curve of the femoral implant component is reported to have a high impact on knee kinematics. The shape of the native femoral J-Curve has previously been analyzed in 2D, however, the knee motion is not planar. In this study, we investigated the J-Curve in 3D by principal component analysis (PCA) and the resulting mean shapes and modes by geometric parameter analysis. Surface models of 90 cadaveric femora were available, 56 male, 32 female and two without respective information. After the translation to a bone-specific coordinate system, relevant contours of the femoral condyles were derived using virtual rotating cutting planes. For each derived contour, an extremum search was performed. The extremum points were used to define the 3D J-Curve of each condyle. Afterwards a PCA and a geometric parameter analysis were performed on the medial and lateral 3D J-Curves. The normalized measures of the mean shapes and the aspects of shape variation of the male and female 3D J-Curves were found to be similar. When considering both female and male J-Curves in a combined analysis, the first mode of the PCA primarily consisted of changes in size, highlighting size differences between female and male femora. Apart from changes in size, variation regarding aspect ratio, arc lengths, orientation, circularity, as well as regarding relative location of the 3D J-Curves was found. The results of this study are in agreement with those of previous 2D analyses on shape and shape variation of the femoral J-Curves. The presented 3D analysis highlights new aspects of shape variability, e.g., regarding curvature and relative location in the transversal plane. Finally, the analysis presented may support the design of (patient-specific) femoral implant components for TKA. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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12 pages, 4413 KiB

Open AccessFeature PaperArticle

Individual Revision Knee Arthroplasty Is a Safe Limb Salvage Procedure

by Peter Savov, Lars-Rene Tuecking, Henning Windhagen and Max Ettinger

J. Pers. Med. 2021, 11(6), 572; https://doi.org/10.3390/jpm11060572 - 18 Jun 2021

Cited by 10 | Viewed by 5075

Abstract

Introduction: Revision total knee arthroplasty after multiple pre-surgeries is challenging. Due to severe bone defects, standard implants for metaphyseal and diaphyseal anchoring may no longer be suitable. The primary aim of this case series is to evaluate the early complication rate for individual [...] Read more.

Introduction: Revision total knee arthroplasty after multiple pre-surgeries is challenging. Due to severe bone defects, standard implants for metaphyseal and diaphyseal anchoring may no longer be suitable. The primary aim of this case series is to evaluate the early complication rate for individual knee implants with custom-made cones and stems after two-stage revision with severe bone defects. Methods: Ten patients who were treated with custom-made 3D-printed knee revision implants were included. Inclusion criteria were a two-stage revision due to late-onset or chronic periprosthetic joint infection as well as aseptic loosening. All severe bone defects were AORI type III. All procedure-related complications were evaluated. Postoperative range of motion after one year was measured. The time between the two surgeries was evaluated. Results: The mean follow-up was 21 months (range: 12–40). The mean time between the two-stage surgeries was 71.6 days. No fractures were observed intra- and postoperatively. Two patients were revised without changing metal components due to persistent hematoma (three weeks post-surgery) and persistent PJI (three months post-surgery). The mean passive postoperative range of motion was 92° (range: 80–110°). Conclusions: Individual custom-made implants for rTKA provide a safe procedure for patients with huge bone defects after several pre-surgeries. If standard knee systems with standard cones or sleeves are not suitable anymore, custom-made treatment offers the patient the last option for limb preservation. However, this is associated with increased costs. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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7 pages, 1162 KiB

Open AccessArticle

Comparison of Postoperative Coronal Leg Alignment in Customized Individually Made and Conventional Total Knee Arthroplasty

by Felix Wunderlich, Maheen Azad, Ruben Westphal, Thomas Klonschinski, Patrick Belikan, Philipp Drees and Lukas Eckhard

J. Pers. Med. 2021, 11(6), 549; https://doi.org/10.3390/jpm11060549 - 12 Jun 2021

Cited by 8 | Viewed by 3518

Abstract

Neutral coronal leg alignment is known to be important for postoperative outcome in total knee arthroplasty (TKA). Customized individually made implants (CIM) instrumented with patient-specific cutting guides are an innovation aiming to increase the precision and reliability of implant positioning and reconstruction of [...] Read more.

Neutral coronal leg alignment is known to be important for postoperative outcome in total knee arthroplasty (TKA). Customized individually made implants (CIM) instrumented with patient-specific cutting guides are an innovation aiming to increase the precision and reliability of implant positioning and reconstruction of leg alignment. We aimed to compare reconstruction of the hip–knee–ankle angle (HKA) of the novel CIM system iTotal™ CR G2 (ConforMIS Inc.) to a matched cohort of the off-the-shelf (OTS) knee replacement system Vanguard™ CR (Zimmer Biomet). Retrospective analysis of postoperative coronal full-leg weight-bearing radiographs of 562 TKA (283 CIM TKA, 279 OTS TKA) was conducted. Via a medical planning software, HKA and rotation of the leg were measured in postoperative radiographs. HKA was then adjusted for rotational error, and 180° ± 3° varus/valgus was defined as the target zone HKA. Corrected postoperative HKA in the CIM group was 179.0° ± 2.8° and 179.2° ± 3.1° in the OTS group (p = 0.34). The rate of outliers, outside of the ±3° target zone, was equal in both groups (32.9%). Our analysis showed that TKA using patient-specific cutting guides and implants and OTS TKA implanted with conventional instrumentation resulted in equally satisfying restoration of the coronal leg alignment with less scattering in the CIM group. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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8 pages, 1394 KiB

Open AccessArticle

Automatic Hip Detection in Anteroposterior Pelvic Radiographs—A Labelless Practical Framework

by Feng-Yu Liu, Chih-Chi Chen, Chi-Tung Cheng, Cheng-Ta Wu, Chih-Po Hsu, Chih-Yuan Fu, Shann-Ching Chen, Chien-Hung Liao and Mel S. Lee

J. Pers. Med. 2021, 11(6), 522; https://doi.org/10.3390/jpm11060522 - 7 Jun 2021

Cited by 15 | Viewed by 3119

Abstract

Automated detection of the region of interest (ROI) is a critical step in the two-step classification system in several medical image applications. However, key information such as model parameter selection, image annotation rules, and ROI confidence score are essential but usually not reported. [...] Read more.

Automated detection of the region of interest (ROI) is a critical step in the two-step classification system in several medical image applications. However, key information such as model parameter selection, image annotation rules, and ROI confidence score are essential but usually not reported. In this study, we proposed a practical framework of ROI detection by analyzing hip joints seen on 7399 anteroposterior pelvic radiographs (PXR) from three diverse sources. We presented a deep learning-based ROI detection framework utilizing a single-shot multi-box detector with a customized head structure based on the characteristics of the obtained datasets. Our method achieved average intersection over union (IoU) = 0.8115, average confidence = 0.9812, and average precision with threshold IoU = 0.5 (AP50) = 0.9901 in the independent testing set, suggesting that the detected hip regions appropriately covered the main features of the hip joints. The proposed approach featured flexible loose-fitting labeling, customized model design, and heterogeneous data testing. We demonstrated the feasibility of training a robust hip region detector for PXRs. This practical framework has a promising potential for a wide range of medical image applications. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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11 pages, 2547 KiB

Open AccessArticle

Restoring the Patient’s Pre-Arthritic Posterior Slope Is the Correct Target for Maximizing Internal Tibial Rotation When Implanting a PCL Retaining TKA with Calipered Kinematic Alignment

by Alexander J. Nedopil, Connor Delman, Stephen M. Howell and Maury L. Hull

J. Pers. Med. 2021, 11(6), 516; https://doi.org/10.3390/jpm11060516 - 4 Jun 2021

Cited by 14 | Viewed by 3632

Abstract

Introduction: The calipered kinematically-aligned (KA) total knee arthroplasty (TKA) strives to restore the patient’s individual pre-arthritic (i.e., native) posterior tibial slope when retaining the posterior cruciate ligament (PCL). Deviations from the patient’s individual pre-arthritic posterior slope tighten and slacken the PCL in flexion [...] Read more.

Introduction: The calipered kinematically-aligned (KA) total knee arthroplasty (TKA) strives to restore the patient’s individual pre-arthritic (i.e., native) posterior tibial slope when retaining the posterior cruciate ligament (PCL). Deviations from the patient’s individual pre-arthritic posterior slope tighten and slacken the PCL in flexion that drives tibial rotation, and such a change might compromise passive internal tibial rotation and coupled patellofemoral kinematics. Methods: Twenty-one patients were treated with a calipered KA TKA and a PCL retaining implant with a medial ball-in-socket and a lateral flat articular insert conformity that mimics the native (i.e., healthy) knee. The slope of the tibial resection was set parallel to the medial joint line by adjusting the plane of an angel wing inserted in the tibial guide. Three trial inserts that matched and deviated 2°> and 2°< from the patient’s pre-arthritic slope were 3D printed with goniometric markings. The goniometer measured the orientation of the tibia (i.e., trial insert) relative to the femoral component. Results: There was no difference between the radiographic preoperative and postoperative tibial slope (0.7 ± 3.2°, NS). From extension to 90° flexion, the mean passive internal tibial rotation with the pre-arthritic slope insert of 19° was greater than the 15° for the 2°> slope (p < 0.000), and 15° for the 2°< slope (p < 0.000). Discussion: When performing a calipered KA TKA with PCL retention, the correct target for setting the tibial component is the patient’s individual pre-arthritic slope within a tolerance of ±2°, as this target resulted in a 15–19° range of internal tibial rotation that is comparable to the 15–18° range reported for the native knee from extension to 90° flexion. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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28 pages, 7831 KiB

Open AccessArticle

Artificial Intelligence-Based Recognition of Different Types of Shoulder Implants in X-ray Scans Based on Dense Residual Ensemble-Network for Personalized Medicine

by Haseeb Sultan, Muhammad Owais, Chanhum Park, Tahir Mahmood, Adnan Haider and Kang Ryoung Park

J. Pers. Med. 2021, 11(6), 482; https://doi.org/10.3390/jpm11060482 - 27 May 2021

Cited by 40 | Viewed by 4620

Abstract

Re-operations and revisions are often performed in patients who have undergone total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). This necessitates an accurate recognition of the implant model and manufacturer to set the correct apparatus and procedure according to the patient’s [...] Read more.

Re-operations and revisions are often performed in patients who have undergone total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). This necessitates an accurate recognition of the implant model and manufacturer to set the correct apparatus and procedure according to the patient’s anatomy as personalized medicine. Owing to unavailability and ambiguity in the medical data of a patient, expert surgeons identify the implants through a visual comparison of X-ray images. False steps cause heedlessness, morbidity, extra monetary weight, and a waste of time. Despite significant advancements in pattern recognition and deep learning in the medical field, extremely limited research has been conducted on classifying shoulder implants. To overcome these problems, we propose a robust deep learning-based framework comprised of an ensemble of convolutional neural networks (CNNs) to classify shoulder implants in X-ray images of different patients. Through our rotational invariant augmentation, the size of the training dataset is increased 36-fold. The modified ResNet and DenseNet are then combined deeply to form a dense residual ensemble-network (DRE-Net). To evaluate DRE-Net, experiments were executed on a 10-fold cross-validation on the openly available shoulder implant X-ray dataset. The experimental results showed that DRE-Net achieved an accuracy, F1-score, precision, and recall of 85.92%, 84.69%, 85.33%, and 84.11%, respectively, which were higher than those of the state-of-the-art methods. Moreover, we confirmed the generalization capability of our network by testing it in an open-world configuration, and the effectiveness of rotational invariant augmentation. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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16 pages, 6017 KiB

Open AccessArticle

The Orthopedic-Vascular Multidisciplinary Approach Improves Patient Safety in Surgery for Musculoskeletal Tumors: A Large-Volume Center Experience

by Andrea Angelini, Michele Piazza, Elisa Pagliarini, Giulia Trovarelli, Andrea Spertino and Pietro Ruggieri

J. Pers. Med. 2021, 11(6), 462; https://doi.org/10.3390/jpm11060462 - 24 May 2021

Cited by 11 | Viewed by 2536

Abstract

Objective: Wide-margin resection is mandatory for malignant bone and soft tissue tumors. However, this increases the complexity of resections, especially when vessels are involved. Patients in this high-risk clinical setting could be surgically treated using the multidisciplinary orthopedic-vascular approach. This study was carried [...] Read more.

Objective: Wide-margin resection is mandatory for malignant bone and soft tissue tumors. However, this increases the complexity of resections, especially when vessels are involved. Patients in this high-risk clinical setting could be surgically treated using the multidisciplinary orthopedic-vascular approach. This study was carried out in this healthcare organization to evaluate patient safety in term of oncologic outcomes and reduction of the complication rate. Materials and Methods: We retrospectively reviewed 74 patients (37 males, 37 females; mean age 46 years, range 9–88) who underwent surgical excision for bone/soft tissue malignant tumors closely attached to vascular structures from October 2015 to February 2019. Vascular surgery consisted of isolation of at least one vessel (64 patients), bypass reconstruction (9 patients), and end-to-end anastomosis (1 patient). Mean follow-up was 27 months. Patients’ demographics, tumor characteristics, adjuvant treatments, type of orthopedic and vascular procedures, and oncologic and functional outcomes and complications were recorded. Results: Overall survival was 85% at 3 years follow-up. In total, 22 patients experienced at least one major complication requiring further surgery and 13 patients experienced at least one minor complication, whereas 17 reported deviations from the normal postoperative course without the need for pharmacological or interventional treatment. Major complications were higher in pelvic resections compared to limb-salvage procedures (p = 0.0564) and when surgical time was more than 4 h (p = 0.0364) at univariate analysis, whereas the most important multivariate independent predictors for major complications were pelvic resection (p = 0.0196) and preoperative radiotherapy (p = 0.0426). Conclusions: A multidisciplinary ortho-vascular approach for resection of malignant bone and soft tissue tumors tightly attached to important vascular structures should be considered a good clinical practice for patient safety. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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10 pages, 2472 KiB

Open AccessArticle

Highly Cancellous Titanium Alloy (TiAl₆V₄) Surfaces on Three-Dimensionally Printed, Custom-Made Intercalary Tibia Prostheses: Promising Short- to Intermediate-Term Results

by Wiebke K. Guder, Jendrik Hardes, Markus Nottrott, Lars E. Podleska and Arne Streitbürger

J. Pers. Med. 2021, 11(5), 351; https://doi.org/10.3390/jpm11050351 - 28 Apr 2021

Cited by 20 | Viewed by 3369

Abstract

Custom-made, three-dimensionally-printed (3D) bone prostheses gain increasing importance in the reconstruction of bone defects after musculoskeletal tumor resections. They may allow preservation of little remaining bone stock and ensure joint or limb salvage. However, we believe that by constructing anatomy-imitating implants with highly [...] Read more.

Custom-made, three-dimensionally-printed (3D) bone prostheses gain increasing importance in the reconstruction of bone defects after musculoskeletal tumor resections. They may allow preservation of little remaining bone stock and ensure joint or limb salvage. However, we believe that by constructing anatomy-imitating implants with highly cancellous titanium alloy (TiAl₆V₄) surfaces using 3D printing technology, further benefits such as functional enhancement and reduction of complications may be achieved. We present a case series of four patients reconstructed using custom-made, 3D-printed intercalary monobloc tibia prostheses treated between 2016 and 2020. The mean patient age at operation was 30 years. Tumor resections were performed for Ewing sarcoma (n = 2), high-grade undifferentiated pleomorphic bone sarcoma (n = 1) and adamantinoma (n = 1). Mean resection length was 17.5 cm and mean operation time 147 min. All patients achieved full weight-bearing and limb salvage at a mean follow-up of 21.25 months. One patient developed a non-union at the proximal bone-implant interface. Alteration of implant design prevented non-union in later patients. Mean MSTS and TESS scores were 23.5 and 88. 3D-printed, custom-made intercalary tibia prostheses achieved joint and limb salvage in this case series despite high, published complication rates for biological and endoprosthetic reconstructions of the diaphyseal and distal tibia. Ingrowth of soft tissues into the highly cancellous implant surface structure reduces dead space, enhances function, and appears promising in reducing complication rates. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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9 pages, 7251 KiB

Open AccessArticle

Custom Made Monoflange Acetabular Components for the Treatment of Paprosky Type III Defects

by Sebastian Philipp von Hertzberg-Boelch, Mike Wagenbrenner, Jörg Arnholdt, Stephan Frenzel, Boris Michael Holzapfel and Maximilian Rudert

J. Pers. Med. 2021, 11(4), 283; https://doi.org/10.3390/jpm11040283 - 8 Apr 2021

Cited by 14 | Viewed by 3585

Abstract

Purpose: Patient-specific, flanged acetabular components are used for the treatment of Paprosky type III defects during revision total hip arthroplasty (THA). This monocentric retrospective cohort study analyzes the outcome of patients treated with custom made monoflanged acetabular components (CMACs) with intra- and extramedullary [...] Read more.

Purpose: Patient-specific, flanged acetabular components are used for the treatment of Paprosky type III defects during revision total hip arthroplasty (THA). This monocentric retrospective cohort study analyzes the outcome of patients treated with custom made monoflanged acetabular components (CMACs) with intra- and extramedullary iliac fixation. Methods: 14 patients were included who underwent revision THA with CMACs for the treatment of Paprosky type III defects. Mechanism of THA failure was infection in 4 and aseptic loosening in 10 patients. Seven patients underwent no previous revision, the other seven patients underwent three or more previous revisions. Results: At a mean follow-up of 35.4 months (14–94), the revision rate of the implant was 28.3%. Additionally, one perioperative dislocation and one superficial wound infection occurred. At one year postoperatively, we found a significant improvement of the Western Ontario and McMaster Universities Arthritis Index (WOMAC) score (p = 0.015). Postoperative radiographic analysis revealed good hip joint reconstruction with a mean leg length discrepancy of 3 mm (−8–20), a mean lateralization of the horizontal hip center of rotation of 8 mm (−8–35), and a mean proximalization of the vertical hip center of rotation of 6 mm (13–26). Radiolucency lines were present in 30%. Conclusion: CMACs can be considered an option for the treatment of acetabular bone loss in revision THA. Iliac intra- and extramedullary fixation allows soft tissue-adjusted hip joint reconstruction and improves hip function. However, failure rates are high, with periprosthetic infection being the main threat to successful outcome. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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Review

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14 pages, 511 KiB

Open AccessReview

Clinical and Radiological Outcomes after Knee Arthroplasty with Patient-Specific versus Off-the-Shelf Knee Implants: A Systematic Review

by Céline Saphena Moret, Benjamin Luca Schelker and Michael Tobias Hirschmann

J. Pers. Med. 2021, 11(7), 590; https://doi.org/10.3390/jpm11070590 - 22 Jun 2021

Cited by 16 | Viewed by 2993

Abstract

Customised, patient-specific implants (PSI) manufactured based on computed tomography data are intended to improve the clinical outcome by restoring more natural knee kinematics as well as providing a better fit and a more precise positioning. The aim of this systematic review is to [...] Read more.

Customised, patient-specific implants (PSI) manufactured based on computed tomography data are intended to improve the clinical outcome by restoring more natural knee kinematics as well as providing a better fit and a more precise positioning. The aim of this systematic review is to investigate the effect of these PSI on the clinical and radiological outcome compared to standard, off-the-shelf (OTS) implants. Thirteen comparative studies including a total of 2127 knee implants were identified. No significant differences in clinical outcome assessed with the range of motion, the Knee Society Score (KSS), and the Forgotten Joint Score (FJS-12) were found between PSI and OTS implants. PSI showed fewer outliers from the neutral limb axis and a better implant fit and positioning. Whether these radiological differences lead to long-term advantages in terms of implant survival cannot be answered based on the current data. Patients receiving PSI could be discharged home earlier at the same or at an even lower total cost. The effective overall superiority of PSI has yet to be proven in long-term studies. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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20 pages, 33889 KiB

Open AccessReview

Complex Bone Tumors of the Trunk—The Role of 3D Printing and Navigation in Tumor Orthopedics: A Case Series and Review of the Literature

by Martin Schulze, Georg Gosheger, Sebastian Bockholt, Marieke De Vaal, Tymo Budny, Max Tönnemann, Jan Pützler, Albert Schulze Bövingloh, Robert Rischen, Vincent Hofbauer, Timo Lübben, Niklas Deventer and Helmut Ahrens

J. Pers. Med. 2021, 11(6), 517; https://doi.org/10.3390/jpm11060517 - 4 Jun 2021

Cited by 23 | Viewed by 4446

Abstract

The combination of 3D printing and navigation promises improvements in surgical procedures and outcomes for complex bone tumor resection of the trunk, but its features have rarely been described in the literature. Five patients with trunk tumors were surgically treated in our institution [...] Read more.

The combination of 3D printing and navigation promises improvements in surgical procedures and outcomes for complex bone tumor resection of the trunk, but its features have rarely been described in the literature. Five patients with trunk tumors were surgically treated in our institution using a combination of 3D printing and navigation. The main process includes segmentation, virtual modeling and build preparation, as well as quality assessment. Tumor resection was performed with navigated instruments. Preoperative planning supported clear margin multiplanar resections with intraoperatively adaptable real-time visualization of navigated instruments. The follow-up ranged from 2–15 months with a good functional result. The present results and the review of the current literature reflect the trend and the diverse applications of 3D printing in the medical field. 3D printing at hospital sites is often not standardized, but regulatory aspects may serve as disincentives. However, 3D printing has an increasing impact on precision medicine, and we are convinced that our process represents a valuable contribution in the context of patient-centered individual care. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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Other

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11 pages, 1907 KiB

Open AccessFeature PaperOpinion

Opinion Piece: Patient-Specific Implants May Be the Next Big Thing in Spinal Surgery

by Tajrian Amin, William C.H. Parr and Ralph J. Mobbs

J. Pers. Med. 2021, 11(6), 498; https://doi.org/10.3390/jpm11060498 - 2 Jun 2021

Cited by 5 | Viewed by 4235

Abstract

The emergence of 3D-Printing technologies and subsequent medical applications have allowed for the development of Patient-specific implants (PSIs). There have been increasing reports of PSI application to spinal surgery over the last 5 years, including throughout the spine and to a range of [...] Read more.

The emergence of 3D-Printing technologies and subsequent medical applications have allowed for the development of Patient-specific implants (PSIs). There have been increasing reports of PSI application to spinal surgery over the last 5 years, including throughout the spine and to a range of pathologies, though largely for complex cases. Through a number of potential benefits, including improvements to the implant–bone interface and surgical workflow, PSIs aim to improve patient and surgical outcomes, as well as potentially provide new avenues for combating challenges routinely faced by spinal surgeons. However, obstacles to widespread acceptance and routine application include the lack of quality long-term data, research challenges and the practicalities of production and navigating the regulatory environment. While recognition of the significant potential of Spinal PSIs is evident in the literature, it is clear a number of key questions must be answered to inform future clinical and research practices. The spinal surgical community must selectively and ethically continue to offer PSIs to patients, simultaneously allowing for the necessary larger, comparative studies to be conducted, as well as continuing to provide optimal patient care, thereby ultimately determining the exact role of this technology and potentially improving outcomes. Full article

(This article belongs to the Special Issue Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery)

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