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

Assessment of Wear in Total Knee Arthroplasty Using Advanced Radiographic Techniques

Total knee arthroplasty (TKA) has become the gold standard approach for treating advanced osteoarthritis of the knee. Although the surgery continues to be very successful at relieving pain and restoring joint function, its longevity is challenged by wear and loosening of the implant components. This requires the patient to undergo a revision surgery to replace the implant, a much more challenging operation than primary arthroplasty. Wear of the polyethylene tibial inserts from TKA is assessed in vitro using mechanical wear simulator testing and by examining failed implants retrieved from patients during revision surgery, as well as with direct in vivo measurements. Current in vitro measurement tools provide only a global estimate of wear (failing to describe whether the wear has occurred on the articulating or backside surfaces, or stabilizing post), or are qualitative measurements, or lack resolution. Current in vivo measurement techniques are performed statically or quasi-statically, leading to the potential for an underestimation of wear volume as the contact area of the implant components change throughout flexion. The purpose of this thesis was to describe, validate, and utilize new advanced imaging techniques to measure TKA implant wear for both in vitro and in vivo applications. Micro-computed tomography (micro-CT), a non-destructive, high resolution imaging technique was utilized to provide detailed images of the geometry of tibial inserts used in wear simulator trials or retrieved from patients, and create surface deviation maps to accurately quantify wear. Ways to create an unworn reference geometry, for use in comparing to a worn retrieved tibial insert when the pre-wear geometry is unknown, were evaluated and a best practice approach was determined. These methods were then applied to study a group of tibial inserts retrieved from patients during revision surgery, which were found to be well functioning with a yearly wear rate equivalent to other contemporary implant designs. Finally, a pilot study to evaluate the use of dynamic single-plane flat panel digital radiography for use in measuring TKA implant wear in vivo was conducted. The system was determined to have a measurement accuracy and precision sufficient to begin a pilot clinical study with patients

Patient-Specific Implants in Musculoskeletal (Orthopedic) Surgery

Most of the treatments in medicine are patient specific, aren’t they? So why should we bother with individualizing implants if we adapt our therapy to patients anyway? Looking at the neighboring field of oncologic treatment, you would not question the fact that individualization of tumor therapy with personalized antibodies has led to the thriving of this field in terms of success in patient survival and positive responses to alternatives for conventional treatments. Regarding the latest cutting-edge developments in orthopedic surgery and biotechnology, including new imaging techniques and 3D-printing of bone substitutes as well as implants, we do have an armamentarium available to stimulate the race for innovation in medicine. This Special Issue of Journal of Personalized Medicine will gather all relevant new and developed techniques already in clinical practice. Examples include the developments in revision arthroplasty and tumor (pelvic replacement) surgery to recreate individual defects, individualized implants for primary arthroplasty to establish physiological joint kinematics, and personalized implants in fracture treatment, to name but a few

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

Spatial Sensors for Quantitative Assessment of Retrieved Arthroplasty Bearings

Evaluation of retrieved joint arthroplasty bearings provides unique evidence related to the physiological environment in which bearing materials are expected to perform. This dissertation describes the development of novel spatial sensors and measurement strategies for standardized, quantitative assessments of arthroplasty bearings, including total knee replacements, unicompartmental knee replacements, and total hip replacements. The approach is to assess bearings that endured a finite duration of function in patients, with particular emphasis on expanding our understanding of the biomechanical conditions specific to bearing function and wear in the physiological environment. Several quantifiable parameters are identified that prove comparable to pre-clinical in vitro tibological evaluations, including knee wear simulation and analytical modeling. These comparisons provide clinical relevance to the existing methodologies, helping to verify that the biomechanical simulations accurately represent the in vivo conditions they are meant to simulate. The broad objective of this dissertation is to improve the longevity and function of arthroplasty bearing materials and designs. Assessments from the retrieved prostheses are discussed within the context of developing comprehensive approaches for the prospective evaluation of new materials and designs in joint replacements

Tribological Investigation of Articular Cartilage Substitution in the Medial Compartmental Knee

In the development of any cartilage substitution device, an understanding of the tribological response of the natural joint, as well as the treated joint is of upmost importance. Many previous studies have investigated the tribology of potential cartilage substitution therapies, using small scale pin on plate experiments. The aim of the current study was to develop an anatomical and physiological simulation of the medial compartmental bovine knee joint and to use this simulation to investigate a number of cartilage substitution therapies for damaged or diseased knee joints. A pendulum friction simulator was used to apply physiological loading and motion to medial compartmental knees. The wear of the cartilage was characterised following the experiments using three different techniques: surface topography analysis, volumetric wear quantification using µMRI scans and histological assessment. Three main interventions were investigated using this novel anatomical simulation - the tribological response of meniscectomy, the effect of conformity of tibial hemiarthroplasty designs, and finally, a number of potential cartilage substitution materials were investigated as osteochondral repair devices in the femoral condyle. In the first two studies, the removal of the meniscus and a decrease of tibial hemiarthroplasty conformity, resulted in an elevation of the coefficient of friction, contact stress, friction shear stress and subsequently the wear and degradation of cartilage. In the defect repair study, biphasic defect repair materials (hydrogels) had a superior tribological performance to non-compliant single phase materials (stainless steel). Across the three studies, the use of non-biphasic materials and/or the loss of joint congruity resulted in a more rapid decrease of cartilage interstitial fluid pressurisation and biphasic fluid load support, resulting in increased cartilage solid-solid contact and increased wear. This tribological simulation can be used to investigate many potential knee joint intervention, from uni- or hemi-arthroplasty, cartilage defect repair, meniscus substitutes or tissue engineered substitutes. This simulation can be used to further our understanding of the tribological characteristics of more satisfactory and conservative therapies for damaged and diseased synovial joints

Fixation of Unicondylar Knee Prostheses

There is increasing use of Unicondylar or Unicompartmental Knee Replacements (UKR), especially following publication of good survival data and a trend towards ‘minimally invasive surgery’. The UKR preserves one of the femoral condyles and its meniscus, plus both of the cruciate ligaments. Therefore, the knee functions more normally following UKR than after Total Knee Replacement (TKR). However, the odds for failure of the UKR are higher than the TKR, and a principal reason is loosening of the tibial and femoral components. There is a need for the development of more reliable UKR fixation designs. The overall aim of this research was to understand fixation of UKR and make recommendations for improvement to designers and surgeons. Since the Oxford mobile-bearing UKR is most widely used in the UK, it was used as the benchmark in this study. To assess initial fixation, in-vitro bone-constructs were prepared from ten cadavers implanted with the Oxford mobile-bearing UKR and tested for bone strain and bone-implant interface motion with the implants fixed using first cementless and then cemented methods. Cementless fixation produced higher proximal tibia strain and bone-implant displacement than cemented fixation. Peak bone strain increased with reduced bone density, such that the lowest density specimen fractured when implanted with the cementless UKR. To assess long-term fixation, an in-vivo prospective follow-up study of 11 Oxford UKR patients was developed and conducted for one-year, taking measurements of bone density using Dual X-Ray Absorptiometry (DXA) scanning. The average bone resorption under the tibial implant was found to be low; while it was higher under the femoral component and very high under the tibial intercondylar eminence. The fixation of the Oxford UKR implant was considered to be adequate at 1-year. Finite Element (FE) simulation techniques were reviewed and developed to simulate the UKR knee for investigation of bone strain, bone-implant interface micromotion and bone remodelling to assess initial and long-term fixation performance. Computer simulations of the tibiae and femora of 2 patients and 4 cadaveric specimens (obtained from the in-vivo and in-vitro studies) were developed and validated for bone strain, bone-implant interface micromotion and bone remodelling. Comparative multi-specimen computational studies were conducted to understand how particular design features affected fixation. Good fixation was indicated for cementless UKRs when implanted in dense bone, but bone strains were very high in low density tibia. Cementation of the implants spread the loads more evenly and reduced bone strains. The cementless tibial implant caused less bone resorption (compared to the cemented equivalent) but the difference in the femur was small. Bone resorption was highest at the anterior tibia and posterior to the femoral peg. Bone density was an important factor in the fixation performance of implant design features. Less bulky fixation features reduced bone resorption, provided that the underlying bone was sufficiently dense to maintain bone strains below the failure limit of bone. For patients with dense bone, fixation could be improved with shorter tibial keels and less stiff femoral implants. For patients with low density bone, fixation could be improved with cementation and bone resection that avoids creating stress-raisers

Novel Research about Biomechanics and Biomaterials Used in Hip, Knee and Related Joints

Joint replacement is a very successful medical treatment. However, the survivorship of hip, knee, shoulder, and other implants is limited. The degradation of materials and the immune response against degradation products or an altered tissue loading condition as well as infections remain key factors of their failure. Current research in biomechanics and biomaterials is trying to overcome these existing limitations. This includes new implant designs and materials, bearings concepts and tribology, kinematical concepts, surgical techniques, and anti-inflammatory and infection prevention strategies. A careful evaluation of new materials and concepts is required in order to fully assess the strengths and weaknesses and to improve the quality and outcomes of joint replacements. Therefore, extensive research and clinical trials are essential. The main aspects that are addressed in this Special Issue are related to new material, design and manufacturing considerations of implants, implant wear and its potential clinical consequence, implant fixation, infection-related material aspects, and taper-related research topics. This Special Issue gives an overview of the ongoing research in those fields. The contributions were solicited from researchers working in the fields of biomechanics, biomaterials, and bio- and tissue-engineering

Tribological Performance of Artificial Joints

Joint replacement is a very successful medical treatment. However, the survivorship of the implants could be adversely affected due to the loss of materials in the form of particles or ions as the bearing surfaces articulate against earch other. The consequent tissue and immune response to the wear products, remain one of the key factors of their failure. Tribology has been defined as the science and technology of interacting surfaces in relative motion and all related wear products (e.g., particles, ions, etc.). Over the last few decades, in an attempt to understand and improve joint replacement technology, the tribological performance of several material combinations have been studied experimentally and assessed clinically. In addition, research has focused on the biological effects and long term consequences of wear products. Improvements have been made in manufacturing processes, precision engineering capabilities, device designs and materials properties in order to minimize wear and friction and maximize component longevity in vivo