Objectives. The anteversion angle of the cup is important for achieving the stability and avoiding the dislocation after total hip arthroplasty (THA). We place the component considering with the change of inclination of pelvis with its posture change. We analyzed the perioperative pelvic inclination angles with posture change and the time course. Materials and Methods. We treated 40 hips in 40 patients (9 males and 31 females) with cementless THA that were performed from January 2007 to December 2008 in our hospital. 30 osteoarthritis hips, 3 rheumatoid arthritis hips and 7 idiopathic osteonecrosis hips were included. All patients were performed THA with VectorVision Hip 2.5.1 navigation system (BrainLAB, Feldkirchen, Germany). We used AMS HA cups and PerFix stems (KYOCERA Medical co., Osaka, Japan). The mean age of surgery was 59 years old (35–79 years old). The pelvic inclination angles (PIA) were measured with anteroposterior radiographic image in accordance with the Doiguchi's method. Results. The amount of change of the pelvic inclination angle between supine and standing position was 0.6 degrees prior to surgery, 0.7 degree at 1 year after surgery and 2.3 degrees at 3 years after surgery. 7 patients prior to surgery, 7 patient at 1 year after surgery and 13 patient at 3 year after surgery changed more than 5 degrees between supine and standing position. The pelvic inclination angles of 23 patients prior to surgery, 19 patients at 1 year after surgery and 29 patients at 3 years after surgery changed in the retroverted direction with posture change. It tended to increase after surgery. Discussion and Conclusions. When we place the acetabular component, it is important that the pelvic inclination angle in supine position according to preoperative planning and the change of pelvic inclination angle with posture change. The amount of change of PIA tended to increase at 3 year after surgery compared to 1 year after surgery. Moreover, we experienced some patients the amount of change of pelvic inclination angle between supine and standing position changed more than 10 degrees. If the pelvic inclination angle changes widely, it requires more attention because of a narrow safe margin for placing the acetabular component

Materials and Methods. We treated 60 hips in 60 patients (8 males and 52 females) with cementless THA that were performed from January 2007 to December 2009 in our hospital. 48 osteoarthritis hips, 5 rheumatoid arthritis hips and 7 idiopathic osteonecrosis hips were included. All patients were performed THA with VectorVision Hip navigation system (BrainLAB, Feldkirchen, Germany). We used AMS HA cups and PerFix stems (KYOCERA Medical co., Osaka, Japan). The mean age of surgery was 61 years old (35–79 years old). The pelvic inclination angles (PIA) were measured with anteroposterior radiographic image in accordance with the Doiguchi's method. Results. The amount of change of the pelvic inclination angle between supine and standing position was 0.6 degrees prior to surgery, 0.7 degree at 1 year after surgery and 2.4 degrees at 5 years after surgery. 7 patients prior to surgery, 7 patient at 1 year after surgery and 18 patient at 5 year after surgery changed more than 5 degrees between supine and standing position. The pelvic inclination angles of 23 patients prior to surgery, 19 patients at 1 year after surgery and 35 patients at 5 years after surgery changed in the retroverted direction with posture change. It tended to increase after surgery. Discussions and Conclusions. When we place the acetabular component, it is important that the pelvic inclination angle in supine position according to preoperative planning and the change of pelvic inclination angle with posture change. The amount of change of PIA tended to increase at 5 year after surgery compared to 1 year after surgery. Moreover, we experienced some patients the amount of change of pelvic inclination angle between supine and standing position changed more than 10 degrees. If the pelvic inclination angle changes widely, it requires more attention because of a narrow safe margin for placing the acetabular component

Restoration of ankle alignment is thought to be critical in total ankle arthroplasty (TAA) outcomes, but previous research is primarily focused on coronal alignment. The purpose of this study was to investigate the sagittal alignment of the talar component. The talar component inclination, measured by the previously-described gamma angle, was hypothesized to be predictive of TAA outcomes. A retrospective review of the Canadian Orthopaedic Foot and Ankle Society (COFAS) database of ankle arthritis was performed on all TAA cases at a single center over a 11-year period utilizing one of two modern implant designs. Cases without postoperative x-rays taken between 6 and 12 weeks were excluded. The gamma angle was measured by two independent orthopaedic surgeons twice each and standard descriptive statistics was done in addition to a survival analysis. The postoperative gamma angles were analyzed against several definitions of TAA failure and patient-reported outcome measures from the COFAS database by an expert biostatistician. 109 TAA cases satisfied inclusion and exclusion criteria. An elevated postoperative gamma angle higher than 22 degrees was associated with talar component subsidence, defined as a change in gamma angle of 5 degrees or more between postoperative and last available followup radiographs. This finding was true when adjusting for age, gender, body mass index (BMI), and inflammatory arthritis status. All measured angles were found to have good inter- and intraobserver reliability. Surgeons should take care to not excessively dorsiflex the talar cuts during TAA surgery. The gamma angle is a simple and reliable radiographic measurement to predict long-term outcomes of TAA and can help surgeons counsel their patients postoperatively

BACKGROUND. Abnormal glenoid version positioning has been recognized as a cause of glenoid component failure caused by the rocking horse phenomenon. In contrast, the importance of the glenoid inclination has not been investigated. MATERIALS AND METHODS. The computed tomography scans of 152 healthy shoulders were evaluated. A virtual glenoid component was positioned in 2 different planes: the maximum circular plane (MCP) and the inferior circle plane (ICP). The MCP was defined by the best fitting circle of the most superior point of the glenoid and 2 points at the lower glenoid rim. The ICP was defined by the best fitting circle on the rim of the inferior quadrants. The inclination of both planes was measured as the intersection with the scapular plane. We defined the force vector of the rotator force couple and calculated the magnitude of the shear force vector on a virtual glenoid component in both planes during glenohumeral abduction. RESULTS. The inclination of the component positioned in the MCP averaged 95° (range, 84°–108°) and for the ICP averaged 111° (range, 94°–126°). A significant reduction in shear forces was calculated for the glenoid component in the ICP vs the MCP: 98% reduction in 60° of abduction to 49% reduction in 90° of abduction. CONCLUSION. Shear forces are significantly higher when the glenoid component is positioned in the MCP compared with the ICP, and this is more pronounced in early abduction. Positioning the glenoid component in the inferior circle might reduce the risk of a rocking horse phenomenon. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved

Background. Virtual planning of shoulder arthroplasty has gained recent popularity. Combined with patients specific instrumentation, several systems have been developed that allow the surgeon to accurately appreciate and correct glenoid deformities in version and inclination. While each virtual software platform utilizes a consistent algorithm for calculating these measurements, it is imperative for the surgeon to recognize any differences that may exist amongst software platforms and characterize any variability. Methods. A case-control study of all CT scans of patients previously pre-operatively planned using MatchPoint SurgiCase® software were uploaded into the BluePrint software. The cohort represents surgical planning for total shoulder arthroplasty and reverse shoulder arthroplasty with varying degrees of glenoid deformity. Glenoid version and inclination will be recorded for each CT scan using both software platforms. Results. A total of 38 patient CT scans previously planned using MatchPoint Surgicase® software were uploaded into the BluePrint software. The mean difference for glenoid version between the two software programs was 2.497° (±1.724°) with no significant differences in measured glenoid version readings between BluePrint and SurgiCase software (p=0.8127). No significant differences were seen in the measured glenoid inclination between the two software programs (p=0.733), with a mean difference for glenoid inclination between the two software programs at 5.150° ± 3.733° (figure 1). A Bland-Altman plot determined the 95% limits of agreement between the two programs at −5.879 to 6.116 degrees of glenoid version and −12.05 to 12.75 degrees of glenoid inclination. There was a significant statistical agreement between the two software programs measuring glenoid version and inclination in relation to glenoid wear position for the centered (p=0.004), posterior (p<0.001, p=0.003), posterior-superior (p<0.001, p<0.001), and superior (p=0.027, p=0.034) positions, respectively. Conclusions. Both BluePrint and SurgiCase software platforms yield similar measurements for glenoid version and glenoid inclination. In the setting of glenoid wear in the posterior, posterior-superior or superior position, measurements of between two surgical platforms are in agreement

Background. Cup inclination is a major factor in the success of a total hip replacement. An open cup position can lead to dislocation or increased wear from rim loading and a closed cup position lead to impingement against the femoral neck or psoas. Although the ideal inclination for cup position is recommended as between 40 and 45 degrees, accurate positioning of the implant might be influenced by pelvic flexion and movement of the patient's pelvis during the procedure. We wanted to examine if the transvers acetabular ligament (TAL) could be used to determine cup inclination intra-operatively. Methods. 16 hips from 9 cadaveric specimens were used for the study. A computer navigation system (Brain lab) was used to measure and document the exact inclination and version of the acetabular trial component in three positions: flush with the transvers acetabular ligament (TAL), with the rim of the cup 5 mm from the TAL in a cranial direction and with the rim of the cup 5 mm caudally displaced. Statistical analysis of the results was performed by the Department of Biostatistics. Findings. With the cup positioned flush with the TAL, the average version was 43 degrees (range 37 to 47 degrees.) When there was a 5 mm gap between the TAL and the cup the average inclination was 28 degrees (21 to 35 degrees.) When the cup was opened so it covered the TAL by 5 mm the average inclination increased to 64 degrees (55 to 75 degrees.) The average anteversion angle was 18 degrees (range 15 to 25 degrees.). Conclusion. We found the transverse acetabular ligament to be an accurate landmark for positioning of the femoral implant as far as version and inclination was concerned. We recommend positioning the acetabular component flush with the TAL as cup inclination was shown to be ideal in all cases when we adhered to that principle. NO DISCLOSURES

Background. Several studies have reported that tibial component in varus alignment can worsen the survivorship of medial unicompartmental knee arthroplasty (UKA). On the other hand, Varus/valgus inclination of the tibial component can affect the location of the contact point between femoral and tibial component especially in round on flat bearing surface design. Along with the tibial component inclination, changes in the contact point may also alter the tibial condylar bone stress, which would affect the longevity or complications after UKA. Method. We constructed a validated three-dimensional finite element model of the tibia with a medial component and assessed stress concentrations by changing the tibial component coronal inclinations (squale inclination, 3° and 6° varus, 3° and 6° valgus inclination). We evaluated the Von Mises stress on the medial tibial metaphyseal cortex and the proximal resected surface when a load of 900N was applied on the tibial component surface by two conditions in each inclination models; one is that the loading site is fixed at the mediolateral center of the tibial component (fixed model), and the other is that the loading site is variable depending on the tibial component inclination (variable model) (Fig.1). Result. In variable models, the loading site moved medially 22.8% of the tibial component width as the tibial component inclination changed from 6°varus to 6°valgus. The Von Mises stress concentrations were observed on the medial tibial metaphyseal cortices and on the anterior and posterior corner of the resected surface in all models (Fig.2). Stress concentration was also observed along the medial cortical rim of the resected surface in valgus tibial component inclination of the fixed model and varus inclination of the variable model (Fig.2). The stress on the medial tibial metaphyseal cortices did not markedly change in any inclination of fixed models, but increased in variable models as the tibial component inclination changed from varus to valgus (Fig.3A). The stress on the medial cortical rim of the resected surface increased with varus inclination in the fixed model and decreased with varus inclination in the variable model (Fig.3B). Changes in the Von Mises stress on the anterior and posterior corner of the resected surfaces did not differ between the fixed and variable model. Discussion. Varus inclination of the tibial component has been considered to increase the bone stress in previous studies. However, in the current study, bone stress on the medial metaphyseal cortex and the medial cortical rim of the resected surface conversely decreased in varus inclination when the change of the femorotibial contact point was taken into consideration. Recent opinion has advocated that restoring the constitutive patient's anatomy by compensating cartilage wear is critical in producing the excellent clinical outcome after UKA. Therefore, three to five degrees of anatomical varus inclination of the tibial component would reduce the tibial condylar bone stress and protective against complications such as unknown postoperative pain or tibial component migration. For figures/tables, please contact authors directly.

Introduction. Navigation in total hip arthroplasty (THA) has the goal to improve accuracy of cup orientation. Measurement of cup orientation on conventional pelvic radiographs is susceptible to error due to pelvic malpositioning during acquisition. A recently developed and validated software using a postoperative radiograph in combination with statistical shape modelling allows calculation of exact 3-dimensional cup orientation independent of pelvic malpositioning. Objectives. We asked (1) what is the accuracy of computer-navigated cup orientation (inclination and anteversion) and (2) what is the percentage of outliers (>10° difference to aimed inclination and anteversion) using postoperative measurement of 3-dimensional cup orientation. Methods. We performed a retrospective comparative study including a single surgeon series with 114 THAs (109 patients). Surgery was performed through the anterolateral approach with the patient in supine position. An image-free navigation system (PiGalileo, Smith & Nephew) with a passive digital reference base for the pelvic wing and one for the distal femur was used. The anterior pelvic plane (APP) was registered manually using a pointer and used as anatomical reference. After implantation of the press-fit cup (EP-Fit plus, Smith & Nephew) the final cup orientation (inclination and anteversion) was registered with the navigation system. Postoperative orientation was calculated using validated software to calculate 3-dimensional cup orientation. The postoperative anteroposterior pelvic radiograph in combination with a statistical model of the pelvis allowed calculation of inclination and anteversion referenced to the APP. The software was previously validated using CT measurements and revealed a mean accuracy of 0.4° for inclination 0.6° for anteversion with a maximum error of 3.3° and 3.6°, respectively. The mean postoperative inclination in the current series was 46° ± 4° (range, 35° – 60°) and the mean anteversion was 23° ± 6° (range, 11° – 37°). Accuracy was calculated as the absolute difference of the intraoperative registered cup orientation and the postoperative calculated orientation. An outlier was defined if cup orientation was outside a range of ±10° of inclination and/or anteversion. Results. (1) The mean accuracy for inclination was 3 ± 3° (0 – 17°) and 6 ± 5° (0 – 22°) for anteversion. (2) Three out of 114 cups (3%) were outliers for inclination. An increased percentage of outliers was found for anteversion with 23 out of 114 cups (20%; p<0.001). In total, 25 cups (22%) were outliers (See Figure 1). Conclusions. Previous studies evaluating accuracy of cup orientation were limited in numbers of hips due to the use of CT or used measurements on conventional postoperative radiographs which are prone to error due to pelvic malpositioning. Novel and validated software allows accurate and anatomically referenced measurement of postoperative cup orientation. This study is the single largest case series with 3-dimensional measurement of cup orientation for validation of navigated THA. Computer-assisted image-free navigation of cup orientation showed a high accuracy of cup orientation with 78% within a narrow range of ±10° of inclination and anteversion. Accuracy of cup inclination was increased compared to cup anteversion. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Purpose. The aim of this study is to describe the influence of sitting and standing posture on sagittal pelvic inclination in preoperative total hip replacement patients to assist with correct acetabular component positioning. Methods. Lateral radiographs of the pelvis and lumbar spine in sitting and standing of preoperative hip arthroplasty patients with primary hip osteoarthritis were extracted. Pelvic tilt was measured using the vertical inclination of a line from the ASIS to pubic tubercle. Sacral inclination was measured as the angle between the anterior surface of the sacrum and a horizontal reference. Figure one is a representation of the pelvic tilt angle and sacrel inclination angle taken during standing. The Cobb angle of the lumbar spine was recorded represented for a sitting patient in figure 2. Hip flexion was recorded (figure 2). Results. 60 patients were identified. Mean age of the cohort was 63. Sacral inclination ranged from 1 to 55 degrees in standing with a mean of 25.7 degrees. In sitting, sacral inclination ranged from 0.3–84.5 degrees with a mean of 24.1 degrees. Pelvic tilt ranged from 30 degrees posteriorly to 21.5 degrees anteriorly in standing. Pelvic tilt in sitting and ranged from 48 posterior to 42 degrees anterior tiltLumbar lordosis ranged from 11.6 to 91.7 degrees in standing. Lumbar lordosis in sitting ranged from 29.5 degrees(kyphosis) to 42 degrees (lordosis). Total hip flexion was 107.4 degrees from standing to sitting. Conclusions. There is wide variability in pelvic orientation between individuals in both postures Orientating acetabular components for total hip arthroplasty should account for postural changes in native version

Background. Cup anteversion and inclination are important to avoid implant impingement and dislocation in total hip arthroplasty (THA). However, it is well known that functional cup anteversion and cup inclination also change as the pelvic sagittal inclination (PSI) changes, and many reports have been made to investigate the PSI in supine and standing positions. However, the maximum numbers of subjects studied are around 150 due to the requirement of considerable manual input in measuring the PSIs. Therefore, PSI in supine and standing positions were measured fully automatically with a computational method in a large cohort, and the factors which relate to the PSI change from supine to standing were analyzed in this study. Methods. A total of 422 patients who underwent THA from 2011 to 2015 were the subjects of this study. There were 83 patients with primary OA, 274 patients with DDH derived secondary OA (DDH-OA), 48 patients with osteonecrosis, and 17 patients with rapidly destructive coxopathy (RDC). The median age of the patient was 61 (range; 15–87). Preoperative PSI in supine and standing positions were measured and the number of cases in which PSI changed more than 10° posteriorly were calculated. PSI in supine was measured as the angle between the anterior pelvic plane (APP) and the horizontal line of the body on the sagittal plane of APP, and PSI in standing was measured as the angle between the APP and the line perpendicular to the horizontal surface on the sagittal plane of APP (Fig. 1). The value was set positive if the pelvis was tilted anteriorly and was set negative if the pelvis tilted posteriorly. Type of hip disease, sex, and age were analyzed with multiple logistic regression analysis if they were related to PSI change of more than 10°. For accuracy verification, PSI in supine and standing were measured manually with the previous manual method in 100 cases and were compared with the automated system used in this study. Results. The median PSI in the supine position was 5.1° (interquartile range [IQR]: 0.4 to 9.4°), and the median PSI in the standing position was −1.3° (IQR: −6.5 to 4.2°). There were 79 cases (19%) in which the PSI changed more than 10° posteriorly from supine to standing with a maximum change of 36.9° (Fig. 2). In the analysis of the factors, type of hip disease (p = 0.015) and age (p = 0.006, Odds Ratio [OR] = 1.035) were the significant factors. The OR of primary OA (p = 0.005, OR: 2.365) and RDC (p = 0.03, OR: 3.146) were significantly higher than DDH-OA. In accuracy verification, the automated PSI measurement showed ICC of 0.992 (95% CI: 0.988 to 0.955) for supine measurement and 0.978 (95% CI: 0.952 to 0.988) for standing measurement. Conclusions. PSI changed more than 10° posteriorly from supine to standing in 19% of the cases. Age and diagnosis of primary OA and RDC were related to having their pelvis recline more than 10° posteriorly. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

The purpose of this study was to examine the utility of the acetabular component introducer as a tool to intra-operatively predict implant inclination in total hip arthroplasty. This study investigated (1) the correlation between intra-operative photographic assessment of cup inclination using the acetabular introducer and that measured on post-operative radiograph; and (2) the accuracy of intra-operative prediction of abduction angle. For this study, we prospectively recruited 56 patients scheduled to receive primary hip arthroplasty from one of two senior surgeons. During the procedure, the lead surgeon provided a prediction of the abduction angle based on the alignment of the impactor attached to the cup in its final seated position. A standardized anteroposterior (AP) photograph was then taken of the acetabular impactor in situ. Abduction angles were measured by two observers on the photographs and post-operative AP pelvis radiographs. Linear regression was used to determine the correlation between the angle of the guide measured on the photographs and the actual position of the implant measured on the radiograph. Descriptive statistics were further used to analyze the accuracy of the intra-operative prediction as compared with the abduction angle measured on the photographs. Measurements of cup position made from post-operative radiographs were significantly correlated with the measurements as assessed by intra-operative photographs (r = 0.34, p = 0.00). Our findings demonstrate that radiological abduction angles tend to be greater than that assessed by intra-operative photographs by a mean of 5.6 degrees (SD = 6.6 degrees; 95% CI = 7.3 to 3.9 degrees). Conversely, surgeon prediction of cup inclination based on the acetabular introducer differed from the radiographic measurements by a mean of 6.8 degrees (SD = 8.7 degrees). There was good agreement between the two observers in both photographic and radiographic measurement (k = 0.95, k = 0.96, respectively). In conclusion, we found that the intra-operative photographic assessment of acetabular cup inclination by acetabular impactor alignment tends to underestimate the abduction angle by a mean of approximately 5 degrees. In addition, intra-operative surgeon estimation of acetabular inclination did not appear accurate in this study demonstrating that cup position should rely on additional visual cues beyond that captured in the anteroposterior view of the cup introducer

INTRODUCTION. Retrieval and clinical studies of metal-on-metal (MoM) bearings have associated increased wear. 1. and elevated patient ion levels. 2. with steep cup inclination angles and edge loading conditions. The University of Leeds have previously developed a hip simulator method that has been validated against retrievals and shown to replicate clinically relevant wear rates and wear mechanisms. 3,4. This method involves introducing lateral microseparation to represent adverse joint laxity and offset deficiency. This study aimed to investigate the effect of microseparation representing translational malpostion, and increased cup inclination angle, representing rotational malposition, in isolation and combined on the wear of different sizes (28 and 36mm) MoM bearing in total hip replacement (THRs). MATERIALS AND METHODS. The wear of size 28mm and 36mm MoM THRs bearings was determined under different in vitro conditions using the Leeds II hip simulator. For each size bearing, two clinical cup inclination angles were considered, 45° (n=3) and 65° (n=3). The first three million cycles were run under standard gait conditions and subsequently three million cycles were run under microseparation conditions. Standard gait cycles included a twin peak load (300N–3000N), extension/flexion (−15°/+30°) and internal/external rotation (±10°). Microseparation. 4. was achieved by applying a 0.4–0.5mm medial displacement to the cup relative to the head during the swing phase of the standard gait cycle resulting in edge loading at heel strike. The lubricant was 25% (v/v) new-born calf serum. The wear volume was determined through gravimetric analysis every million cycles. One way ANOVA was performed (significance: p<0.05), and 95% confidence limits were calculated. RESULTS. Under standard gait conditions, the 28mm MoM bearing showed head-rim contact and increased wear rate with increased cup inclination angle but the 36mm bearing did not show any increase in wear. Microseparation and edge loading increased the wear rate of MoM bearings for all cup inclination angle conditions and bearing sizes (Figure 1). DISCUSSION. With the larger size bearings, head-rim contact occurred at a steeper cup inclination angle (>65°) providing an advantage over smaller bearings. Under standard gait conditions, where head-rim contact did not occur, wear was low, due to mixed lubrication and wear reduction through a protein boundary film. However, edge loading of the cup, with elevated stress, caused excess damage and wear. This effect was more dominant with microseparation conditions to that of head-rim contact due to increased cup inclination angle alone. Under microseparation conditions, there were no significant differences in the wear rates of the 28mm and the 36mm size bearings. However, the wear rates obtained in this study for 28mm and 36mm bearings were significantly lower than those obtained for size 39mm surface replacement MoM bearings (8.99 mm. 3. /million cycles) tested under the same adverse conditions. 5. . CONCLUSION. This study shows the importance of acetabular cup design and correct surgical positioning of the femoral head and acetabular cup and restoration of offset and cup centre. ACKNOWLEDGEMENT. This study was supported by the Furlong Research Charitable Foundation (FRCF) and the National Institute of Health Research (NIHR) as part of a collaboration with the Leeds Musculoskeletal Biomedical Research Unit (LMBRU). The components were custom made specifically for this project by Corin Ltd

Introduction. Wear plays a key role in the clinical outcome of total hip replacements (THR). In addition, increased frictional moment can stress the implant interfaces which may lead to high torsional loadings in the intermodular taper junction (fretting) and cup loosening and to the development of noise (squeaking). Against the background of larger head diameters (increased range of motion and decreased risk of dislocation), the friction induced by the joint articulation is of particular interest. As of now, the investigation of friction with the use of relevant joint kinematics and loadings are limited to numerical studies. Experimental approaches use simplified models which do not take into consideration complex activities. Thus, with the aim of this study is the identification of articular frictional moments that consider critical in vivo loading conditions and kinematics as well as the clinical cup inclination, head size and clearance of ceramic-on-ceramic hip bearings. Materials and Methods. A standard hip simulator (Minibionix 852 with 4 DOF Hip setup, MTS, Eden Prairie, USA) was modified in order to allow for high-precision friction measurements during head-insert articulation in all 6 DOF (MC2.5D-500, AMTI, Boston, USA). Disturbing systemic effects have been minimized by using quasi frictionless aerostatic lateral force compensation (Eitzenberger, Wessobrunn, Germany) and cross talk compensation. Beside the standard protocoll for in vitro wear assessment (ISO 14242-1), more complex profiles from in vivo patient data (Heidelberg Motion Lab and Orthoload database) have been used: normal walking with different walking speeds and patient's weights, stairs up/down and start-stop conditions. All-ceramic bearings (Biolox delta, Ceramtec, Plochingen, Germany) have been orientated in clinically relevant cup inclinations (30, 45, 60 and 75 deg). For each head diameter (28, 36 and 48 mm) n=8 specimens have been devided in two groups: small and large clearance according to the manufacturer's specification. All tests were run at 37°C in diluted bovine serum (20 g/l protein content). Results and Discussion. For all continuously running activities (normal walking, stairs up/down and ISO standard), increased resulting frictional moments have been measured with larger head diameters and smaller clearances in a range of less than 6 Nm. This data corresponds well to the results of a well-lubricated ceramic-on-ceramic bearing from numerical studies. In addition, the initial breakaway torque after a short resting period (start-stop initiation) was increased, where the highest maximal moments have been measured with increasing resting durations and larger head diameters (large clearance: up to 11 Nm, small clearance: up to 20 Nm). Interestingly enough, not in all cases a negative effect on the resulting moment was seen with increasing cup inclination, even though no subluxation was induced. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

INTRODUCTION. Ceramic-on-ceramic hip replacements have generated great interest in recent years due to substantial improvements in manufacturing techniques and material properties. 1. Microseparation conditions that could occur due to several clinical factors such as head offset deficiency, medialised cup combined with laxity of soft tissue resulting in a translation malalignment, have been shown to cause edge loading, replicate clinically relevant wear mechanisms. 2,3. and increase the wear of ceramic-on-ceramic bearings. 3,4. The aim of this study was to investigate the influence of increasing the femoral head size on the wear of ceramic-on-ceramic bearings under several clinically relevant simulator conditions. MATERIALS AND METHODS. The wear of size 28mm and 36mm ceramic-on-ceramic bearings (BIOLOX® Delta, CeramTec, Germany) was determined under different in vitro conditions using the Leeds II hip simulator. For each size bearing, two clinical cup inclination angles were considered, 55° (n=3) and 65° (n=3) for the 28mm bearing and 45° (n=3) and 65° (n=3) for the 36mm bearing. The first two (28mm study) or three (36mm study) million cycles ran under standard gait conditions and a subsequent three million cycles ran under microseparation conditions. A standard gait cycle included a twin peak load (300N–3000N), extension/flexion (−15°/+30°) and internal/external rotation (±10°). Microseparation. 3. was achieved by applying a 0.4–0.5mm medial displacement to the cup relative to the head during the swing phase of the standard gait cycle resulting in edge loading at heel strike. The lubricant was 25% (v/v) new-born calf serum which was changed approximately every 333,000 cycles. The wear volume was ascertained through gravimetric analysis every million cycles. One way ANOVA was performed (significance: p<0.05), and 95% confidence limits were calculated. RESULTS AND DISCUSSION. The mean wear rate under standard gait conditions was 0.05mm. 3. / million cycles for the 28mm bearings and significantly lower (p=0.003) for the 36mm bearings (Figure 1) which could be due to improved lubrication regime. The wear of ceramic-on-ceramic bearings was not influenced by the increase in cup inclination angle for either bearing size (Figure 1). The introduction of microseparation into the gait cycle resulted in stripe wear on the femoral head with a corresponding wear area at the rim of the acetabular cup and significantly higher wear rates of the ceramic-on-ceramic bearings (Figure 2). The wear rate of BIOLOX® Delta bearings under microseparation conditions was still low (<0.25mm. 3. /million cycles) compared to the third generation alumina ceramic-on-ceramic bearings (1.84mm. 3. /million cycles). 4. under the same adverse conditions. Under microseparation conditions, the wear rate of size 36mm bearings was significantly higher (p=0.004) than that for size 28mm bearings. This was thought to be due to the larger contact area for the larger bearings and deprived lubrication under edge loading conditions. For both bearing sizes, the combination of both steep cup inclination angles and microseparation conditions did not increase the wear rates any further compared to microseparation conditions alone (Figure 3). This study shows the importance of surgical positioning of the femoral head and acetabular cup and the importance of testing new bearing materials and designs using these adverse simulator methods. ACKNOWLEDGEMENT. This study was supported by the Furlong Research Charitable Foundation (FRCF) and the National Institute of Health Research (NIHR) as part of a collaboration with the Leeds Musculoskeletal Biomedical Research Unit (LMBRU)

We present a study done to measure the change of angle of the acetabulum or cup, due to leg length discrepancy, deformity of hip and spine on standing. In 1998 a 3-dimensional reconstruction of hip model was prepared on CAD and the change of angle of the cup was measured as Functional Acetabular Inclination Angle (FAIA) with patient standing without squaring the pelvis. The FAIA on standing was compared with angle of the cup with patient in supine position with squared pelvis. The position of the cup changed on weight bearing due to multiple issues. The results showed that one centimetre of leg lengthening changed FAIA by 3°, 10° of abduction deformity resulted in apparent lengthening of 2.87 cm and loss of lordosis anteverted the cup on loading and vice-versa. We conclude that fixed hip deformities, leg length discrepancy and spine deformities can affect the angle of cup in hip replacement surgery and may prone to dislocations, impingement and segmental wear of the cup

Introduction. Recent concerns over adverse effects of metal ion release, have led to the development of alternative hip joint replacements. This study reports the performance of new hemispherical MOTIS® (milled pitch-carbon fibre reinforced polyetheretherketone) acetabular cups articulating against Biolox Delta® femoral heads with the aim of producing lower wear and more biologically compatible bearings. Materials and Methods. The wear performance of 40mm hemispherical MOTIS® cups articulating against Biolox Delta® heads has been investigated. The diametral clearance was 322±15.3nm (mean ± standard deviation). Wear tests were carried out on the Simplified Mark II Durham Hip Wear Simulator to 8 million cycles. New born bovine calf serum was used as the lubricant, diluted to give a protein content of 17g/l. Friction tests were carried out on the unworn joints and worn joints after 7.5 million cycles using lubricants containing protein (bovine serum based carboxymethyl cellulose (CMC) fluids) and without protein (water based CMC fluids). Temperature measured near every hip joint over a continuous wear testing period of 0.5 million cycles was recorded using PICO TC-08 data logger. One K-type thermocouple was placed carefully and consistently in each wear station and two were used to record the ambient room temperature. After stopping the wear test, the data logger continued recording the temperature for a further ten hours to indicate the cooling period. Additionally surface analyses were undertaken before and after wear testing using a non-contacting profilometer and atomic force (AFM) microscope. Results and Discussion. Throughout the wear testing, different degrees of fluid absorption were observed for the load control and soak control MOTIS® cups. After normalising the wear data in the post-processing analysis, the corresponding volumetric wear rates, averaged among five worn cups, were 0.551±0.115 mm. 3. /10. 6. cycles taking account of the load control and 0.493±0.107 mm. 3. /10. 6. cycles taking account of the soak control respectively. In contrast there was no difference in the fluid uptake for the ceramic heads between the load control and soak control. Normalised by the mass changes of the load control, the worn heads produced a volumetric wear rate of 0.243±0.031mm. 3. /10. 6. cycles. Interestingly, varying inclination angles had no effects on the wear of ceramic heads and statistically little effects for the MOTIS® cups. The mean lubricant temperature during wear testing varied from 40°C to 45°C with a mean of 43°C. However, friction testing on worn joints produced a mean friction factor of 0.089 which is relatively low for CFR-PEEK bearings. Further investigation is ongoing. Atomic Force Microscopy showed some partial grain pull-out on the ceramic heads. Compared with the literature, addressing the hard-on-soft hip bearings, the hemispherical MOTIS® cups assessed in the present study have produced the lowest wear [1-4]. Statistically, high inclination angles appeared to have little effect on the wear performance of the hemispherical MOTIS-PEEK-on-ceramic joints

Navigation in total hip arthroplasty has been shown to improve acetabular positioning and can decrease the incidence of mal-positioned acetabular components. The aim of this study was to assess two surgical guidance systems by comparing intra-operative measurements of acetabular component inclination and anteversion with a post-operative CT scan. We prospectively collected intra-operative navigation data from 102 hips receiving conventional THA or hip resurfacing arthroplasty through either a direct anterior or posterior approach. Two guidance systems were used simultaneously: an inertial navigation system (INS) and optical navigation system (ONS). Acetabular component anteversion and inclination was measured on a post-operative CT. The average age of the patients was 64 years (range: 24-92) and average BMI was 27 kg/m. 2. (range 19-38). 52% had hip surgery through an anterior approach. 98% of the INS measurements and 88% of the ONS measurements were within 10° of the CT measurements. The mean (and standard deviation) of the absolute difference between the post-operative CT and the intra-operative measurements for inclination and anteversion were 3.0° (2.8) and 4.5° (3.2) respectively for the ONS, along with 2.1° (2.3) and 2.4° (2.1) respectively for the INS. There was significantly lower mean absolute difference to CT for the INS when compared to ONS in both anteversion (p<0.001) and inclination (p=0.02). Both types of navigation produced reliable and reproducible acetabular cup positioning. It is important that patient-specific planning and navigation are used together to ensure that surgeons are targeting the optimal acetabular cup position. This assistance with cup positioning can provide benefits over free-hand techniques, especially in patients with an altered acetabular structure or extensive acetabular bone loss. In conclusion, both ONS and INS allowed for adequate acetabular positioning as measured on postoperative CT, and thus provide reliable intraoperative feedback for optimal acetabular component placement

Imageless computer navigation systems have the potential to improve acetabular cup position in total hip arthroplasty (THA), thereby reducing the risk of revision surgery. This study aimed to evaluate the accuracy of three alternate registration planes in the supine surgical position generated using imageless navigation for patients undergoing THA via the direct anterior approach (DAA). Fifty-one participants who underwent a primary THA for osteoarthritis were assessed in the supine position using both optical and inertial sensor imageless navigation systems. Three registration planes were recorded: the anterior pelvic plane (APP) method, the anterior superior iliac spines (ASIS) functional method, and the Table Tilt (TT) functional method. Post-operative acetabular cup position was assessed using CT scans and converted to radiographic inclination and anteversion. Two repeated measures analysis of variance (ANOVA) and Bland-Altman plots were used to assess errors and agreement of the final cup position. For inclination, the mean absolute error was lower using the TT functional method (2.4°±1.7°) than the ASIS functional method (2.8°±1.7°, ρ = .17), and the ASIS anatomic method (3.7°±2.1, ρ < .001). For anteversion, the mean absolute error was significantly lower for the TT functional method (2.4°±1.8°) than the ASIS functional method (3.9°±3.2°, ρ = .005), and the ASIS anatomic method (9.1°±6.2°, ρ < .001). All measurements were within ± 10° for the TT method, but not the ASIS functional or APP methods. A functional registration plane is preferable to an anatomic reference plane to measure intra-operative acetabular cup inclination and anteversion accurately. Accuracy may be further improved by registering patient location using their position on the operating table rather than anatomic landmarks, particularly if a tighter target window of ± 5° is desired

Introduction. Reverse shoulder Arthroplasty is a successful treatment for gleno-humeral osteoarthritis. However, components loosening and painful prostheses, related to components wrong positioning, are still a problem for those patients who underwent this kind of surgery. Several new technology has been developed the improve the implant positioning. CT-based intraoperative navigation system is a suitable technology that allow the surgeon to prepare the implant site exactly as planned with preoperative software. Method. Thirty reverse shoulder prostheses were performed at Modena Polyclinic using GPS CT-based intraoperative navigation system (Exactech, Gainsville, Florida). Walch classification was used to assess glenoid type. Planned version and inclination of the glenoid component, planned seating, final version and inclination of the reamer were recorded. Intraoperative and perioperative complication were recorded. Planned positioning was conducted aiming to the maximum seating, avoiding retroversion >10° and superior inclination. Results. Eight patients were male, 22 were female. Mean age was 75 years old (range 58–87). 4 glenoid were type B3, four were B2, 10 cases were B1, 12 case were A1/A2. Posterior or superior augment was used in 15 cases. Mean planned seating was 93%. Mean preoperative version was -7.5±6.9°; Mean planned version was -2±2.8°; Mean intraoperative measured version was -1.9±2.8°; no statistical difference was found between planned and intraoperative version (p=0.16). Mean preoperative inclination was 1.8±6.°; Mean planned inclination was -2.2±2.4°; Mean intraoperative measured inclination was -2.1.9±2.3°; no statistical difference was found between planned and intraoperative version or inclination (respectively p=0.16 and p=0.32). Mean surgical time was 71 minute (range 51–82). Three cases of coracoid ruptures were reported, 1 failure of the system occurred. Discussion. GPS navigation system allows the surgeon to prepare the implant site as planned on Preoperative software in Reverse shoulder arthroplasty, with no statistical difference between planned orientation and intraoperative measured orientation. That means that even in the most difficult cases the surgeon is able to find a good positioning (93% seating)and to replicate it in the operative room. Only one failure of the system occurred, because too much time was passed between CT scan and surgery (9 months). Three coracoid fractures occurred in the first 10 cases: these could be addressed to a lack of confidence with the double lateralization of this prosthesis which increase tensioning on the coracoid and a lack of confidence in tracker positioning, which should be made as proximal as it is possible. Finally, the system needs several improvements to be considered a breakthrough technology, such as humeral component positioning and final control of the implant, but by now is a useful way to improve our surgery, especially in difficult cases

Glenoid baseplate orientation in reverse shoulder arthroplasty (RSA) influences clinical outcomes, complications, and failure rates. Novel technologies have been produced to decrease performance heterogeneity of low and high-volume surgeons. This study aimed to determine novice and experienced shoulder surgeon's ability to accurately characterise glenoid component orientation in an intra-operative scenario. Glenoid baseplates were implanted in eight fresh frozen cadavers by novice surgical trainees. Glenoid baseplate version, inclination, augment rotation, and superior-inferior centre of rotation (COR) offset were then measured using in-person visual assessments by novice and experienced shoulder surgeons immediately after implantation. Glenoid orientation parameters were then measured using 3D CT scans with digitally reconstructed radiographs (DRRs) by two independent observers. Bland-Altman plots were produced to determine the accuracy of glenoid orientation using standard intraoperative assessment compared to postoperative 3D CT scan results. Visual assessment of glenoid baseplate orientation showed “poor” to “fair” correlation to 3D CT DRR measurements for both novice and experienced surgeon groups for all measured parameters. There was a clinically relevant, large discrepancy between intra-operative visual assessments and 3D CT DRR measurements for all parameters. Errors in visual assessment of up to 19.2 degrees of inclination and 8mm supero-inferior COR offset occurred. Experienced surgeons had greater measurement error than novices for all measured parameters. Intra-operative measurement errors in glenoid placement may reach unacceptable clinical limits. Kinesthetic input during implantation likely improves orientation understanding and has implications for hands-on learning