A Review of Virtual Reality Based Training Simulators for Orthopaedic Surgery

This review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 total hip replacement pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator

A review of virtual reality based training simulators for orthopaedic surgery

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this recordThis review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 hip replacements pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator.Wessex Academic Health Science Network (Wessex AHSN) Innovation and Wealth Creation Accelerator Fund 2014/15Bournemouth Universit

Personalized Hip and Knee Joint Replacement

This open access book describes and illustrates the surgical techniques, implants, and technologies used for the purpose of personalized implantation of hip and knee components. This new and flourishing treatment philosophy offers important benefits over conventional systematic techniques, including component positioning appropriate to individual anatomy, improved surgical reproducibility and prosthetic performance, and a reduction in complications. The techniques described in the book aim to reproduce patients’ native anatomy and physiological joint laxity, thereby improving the prosthetic hip/knee kinematics and functional outcomes in the quest of the forgotten joint. They include kinematically aligned total knee/total hip arthroplasty, partial knee replacement, and hip resurfacing. The relevance of available and emerging technological tools for these personalized approaches is also explained, with coverage of, for example, robotics, computer-assisted surgery, and augmented reality. Contributions from surgeons who are considered world leaders in diverse fields of this novel surgical philosophy make this open access book will invaluable to a wide readership, from trainees at all levels to consultants practicing lower limb surger

1st EFORT European Consensus: Medical & Scientific Research Requirements for the Clinical Introduction of Artificial Joint Arthroplasty Devices

Innovations in Orthopaedics and Traumatology have contributed to the achievement of a high-quality level of care in musculoskeletal disorders and injuries over the past decades. The applications of new implants as well as diagnostic and therapeutic techniques in addition to implementation of clinical research, have significantly improved patient outcomes, reduced complication rates and length of hospital stay in many areas. However, the regulatory framework is extensive, and there is a lack of understanding and clarity in daily practice what the meaning of clinical & pre‐clinical evidence as required by the MDR is. Thus, understanding and clarity are of utmost importance for introduction of new implants and implant-related instrumentation in combination with surgical technique to ensure a safe use of implants and treatment of patients. Therefore EFORT launched IPSI, The Implant and Patient Safety Initiative, which starting from an inaugural workshop in 2021 issued a set of recommendations, notably through a subsequent Delphi Process involving the National Member Societies of EFORT, European Specialty Societies as well as International Experts. These recommendations provide surgeons, researchers, implant manufacturers as well as patients and health authorities with a consensus of the development, implementation, and dissemination of innovation in the field of arthroplasty. The intended key outcomes of this 1st EFORT European Consensus on “Medical & Scientific Research Requirements for the Clinical Introduction of Artificial Joint Arthroplasty Devices”are consented, practical pathways to maintain innovation and optimisation of orthopaedic products and workflows within the boundaries of MDR 2017/745. Open Access practical guidelines based on adequate, state of the art pre-clinical and clinical evaluation methodologies for the introduction of joint replacements and implant-related instrumentation shall provide hands-on orientation for orthopaedic surgeons, research institutes and laboratories, orthopaedic device manufacturers, Notified Bodies but also for National Institutes and authorities, patient representatives and further stakeholders. We would like to acknowledge and thank the Scientific Committee members, all International Expert Delegates, the Delegates from European National & Specialty Societies and the Editorial Team for their outstanding contributions and support during this EFORT European Consensus

The measurement of wear in hip arthroplasties

Metal-on-metal (MOM) total hip replacement (THR) and resurfacing implants were designed to form a low friction bearing that would improve implant longevity, in response to the ever-aging population. However, the unanticipated release of cobalt chromium wear debris had a detrimental impact on periprosthetic tissue, resulting in many being revised and some designs being recalled. The aim of this thesis was to identify the surgeon, implant and patient factors that contributed to the increased wear of MOM hip arthroplasties and ultimately their failure. A developed software solution was found to provide improved accuracy during the quantification of volumetric wear from the bearing surface of retrieved hip implants, overcoming the limitations of current methods. Through its application, neither diametrical clearance nor manufacture dates were found to influence the wear performance of MOM Pinnacle hips, contrary to previous speculation. A high proportion of Pinnacle and ASR hips had a diametrical clearance below their specifications. Its detrimental impact on ASR bearing wear, further implicated its acetabular design in the increased prevalence of edge loading. The comparably high wear rates and whole blood metal ion levels of the ASR could explain their high revision rates. Nevertheless, the greater toxicity of taper junction debris was identified as the primary contributor to the disproportionately greater revision rates of the ASR XL, compared to its resurfacing form. Bearing wear was successfully located in vivo for the first time and predominantly isolated to the anterosuperior portion of the acetabular component, analogous to cartilage damage mapped in native hips. A potential relationship was also identified between component positioning and the location of this wear. These findings will help inform the management of a million patients worldwide that remain with implanted MOM hips, while influencing future design, quality control and the regulation of all orthopaedic implants

Total knee replacements: design and pre-clinical testing methods

Total knee replacement (TKR) is a common and successful treatment for severe osteoarthritis of the knee. However, a large minority of people remain dissatisfied after the operation, despite adequate pain relief. Over 50 designs of TKR are used in the UK each year, but differentiating between these devices in terms of patient function and making the right choice for each patient remains challenging. The aim of this research was to characterise designs of TKR in the laboratory, using pre-clinical testing methods, in order to better understand TKR function, and make suggestions for improved implant design and testing. Conventional, medial-pivot, guided-motion and bicruciate retaining (BCR) TKRs were tested. Standard ASTM test methods used for CE-marking purposes were demonstrated to differentiate between devices, but did not produce enough information to adequately understand how a new device will behave clinically, or what the potential benefits of a new device would be to patients. Guided-motion devices are meant to replicate normal knee motion, but there has been concern that they might cause too much rotation of the knee, leading to anterolateral knee pain. Results from cadaveric testing suggest that they do not adequately mimic normal knee motion and small design changes may have little impact on performance. A BCR TKR, designed to improve stability in the replaced knee joint, was also tested. Knee kinematics were measured for three design phases and surgical feasibility was also assessed for this more complicated procedure. BCR TKR was shown to lead to more normal levels of anteroposterior tibiofemoral laxity, compared to a conventional, anterior-cruciate-ligament-sacrificing TKR. Inherent variability between people’s anatomy and osteoarthritis pathology suggests there will never be a single, perfect, TKR, but more comprehensive pre-clinical testing could improve the regulatory approval process and inform better device selection, leading to improved patient outcomes.Open Acces

The Developing of a Smart Elbow Prosthesis for Loosening Detection

Total Elbow Arthroplasty (TEA) is an effective surgical procedure for restoring elbow joint function and improve a patient's quality of life by relieving pain suffered from various musculoskeletal disorders. Despite new designs for prostheses and improved surgical procedures, TEA still suffers today from mid to-long-term complications such as aseptic loosening, infection, dislocation, and pre-prosthetic fractures. With aseptic loosening followed by infection being the most persistent reason for TEA revision, investigating methods for early diagnosis of implant loosening and differentiating between the infection and aseptic loosening is necessary to address this problem. This thesis aims to develop a novel diagnostic tool that can be embedded into the prosthetic and provide a quantitative measurement for early signs of the implant loosening without any usage of radiographs or any contact with the implant. In this study, three types of sensor configurations along with detection algorithms were developed, designed, and tested along with a functional prototype to detect the migration of the elbow prosthesis (Aseptic loosening). The detection system was validated under realistic conditions through experiments with a custom-designed mechanical testing rig. Finally, for infection detection, a biocompatible chemical sensor (Hydrogel) was synthesised and was linked with the aseptic loosening detection system to investigate the early signs of infection. Among the three sensor configurations, the single sensor configuration detected the implant migration at a resolution of 0.3 mm with a detection error of less than 3 %. The configuration was able to detect angular motion up to 3 degrees with a detection error of 5 %. The quad sensor configuration, an arrangement of four closely packed sensors, enhanced the overall detection performance by increasing system resolution to 0.15 mm in multiple axes along with increasing the signal to noise ratio, reducing root mean square error, and compensating the tilt effect of the single sensor. While the dual sensor configuration, two sensors arranged in-line but 42 mm apart, downgraded the detection performance by introducing a detection error of 30 %. The detection system showed negligible effect on the biomaterial used in TEA and was able to differentiate between different migrations types (Linear, Angular, Static and Dynamic). The difference in three fixation scenarios (grossly loose, partially loose, and fully fixed) was identified evidently by the detection system with the grossly loose fixation showed a displacement of 0.187 ± 0.061 mm on the x-axis and 0.387 ± 0.059 mm on the y-axis. The chemical sensor (Hydrogel) was able to detect the change in its surrounding pH level (highlighting the potential to detect infection) and by the amalgamation with the detection system, pH change was detected without the use of an imaging technique. Further improvement in the synthesis of the hydrogel and the optimisation of the detection system has also been suggested. The quad sensor system implies that it has the potential to be used to continually or intermittently monitor implant behaviour without hospital visitation or x-ray exposure. This could be applied more widely to other major joints such as the hips and knees, giving in-situ biomechanical insight into joint replacement behaviour over time